1/16. Unilateral osseous bridging between the arches of atlas and axis after trauma.STUDY DESIGN: This is a case report. OBJECTIVE: To present a case of osseous bridging between C1 and C2 of posttraumatic origin and with an associated closed head injury and to discuss its pathogenesis and clinical outcome after surgical resection. SUMMARY OF BACKGROUND DATA: Heterotopic ossifications of posttraumatic origin in the spine are rare. To the authors' knowledge, no cases have been reported of spontaneous bony bridging between C1 and C2 with a posttraumatic origin. methods: Heterotopic ossifications were detected when pain and limited axial rotation (left/right 10 degrees/0 degree/20 degrees) were persistent, despite intensive physical therapy. Because heterotopic ossifications were ankylosing C1 and C2, the decision was to resect the osseous bridge in combination with a careful mobilization of the cervical spine. Functional computed tomography was performed for analysis of the postoperative results. RESULTS: Four months after surgery, clinical examination showed asymptomatic increased axial rotation. Functional computed tomography indicated that left C1-C2 axial rotation was reduced, possibly related to impingement caused by residual bony spurs. Pathologic changes in the surrounding soft tissue may be another important factor in the persistent limitation of rotation. CONCLUSIONS: Osseous bridging between C1 and C2 may be considered when persistent pain and limited axial rotation are observed after trauma. Operative resection, together with careful intraoperative and postoperative mobilization, may be the treatment of choice.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
2/16. Coexistent Marfan's syndrome and ankylosing spondylitis: a case report.We report on a 46-year-old man with a 4-year history of predominantly nocturnal pain at the thoracic and lumbar spine as well as accompanying morning stiffness and episodes of alternating buttock pain. At physical examination the patient presented with the typical traits for Marfan's syndrome (MFS), along with limitation of both chest expansion and movement in all planes of the lumbar spine. Pelvic and lumbar spine radiographs showed findings consistent with ankylosing spondylitis (AS). Laboratory tests were consistent with an inflammatory state and HLA typing was positive for the B27 antigen. Transthoracic echocardiography showed prolapse of the posterior mitral leaflet and mild aortic insufficiency. We diagnosed co-existent MFS and AS. The association of these two pathologies is particularly interesting, owing to the co-existence of hypermobility of peripheral joints due to MFS ligamentous hyperlaxity, and the reduction of both axial skeleton motility and chest expansion related to AS. As both of these diseases may damage the cardiovascular system over time, follow-up with echocardiography monitoring is indispensable.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
3/16. Opioids in non-cancer pain: a life-time sentence?There is continuing reluctance to prescribe strong opioids for the management of chronic non-cancer pain due to concerns about side-effects, physical tolerance, withdrawal and addiction. Randomized controlled trials have now provided evidence for the efficacy of opioids against both nociceptive and neuropathic pain. However, there is considerable variability in response rates, possibly depending on the type of pain, the type of opioid and its route of administration, the time to follow-up, compliance and the development of tolerance. Five patients were selected with nociceptive or neuropathic pain in whom other pharmacological or physical therapies had failed to provide satisfactory pain relief. They received transdermal fentanyl (starting dose 25 microg/h) for at least 6 weeks. Transdermal fentanyl dosage was titrated upwards as required. Transdermal fentanyl provided adequate pain relief in patients with nociceptive pain (diabetic ulcer, osteoporotic vertebral fracture, ankylosing spondylitis) or neuropathic pain with a nociceptive component (radicular pain due to disc protrusion, herpetic neuralgia). The duration of treatment ranged from 6 weeks to 6 months for four cases. In the case of ankylosing spondylitis, treatment was carried out for 2 years, stopped and then restarted successfully. There were no withdrawal effects or addictive behaviour on treatment cessation, regardless of duration of the treatment. In conclusion, strong opioids may provide prolonged effective pain relief in selected patients with nociceptive and neuropathic non-cancer pain. Transdermal fentanyl treatment can often be temporary and can easily be stopped following adequate pain relief without withdrawal effects or any evidence of addictive behaviour.- - - - - - - - - - ranking = 2keywords = physical (Clic here for more details about this article) |
4/16. The effect of chiropractic care for a 30-year-old male with advanced ankylosing spondylitis: a time series case report.BACKGROUND: Manipulative treatment for ankylosing spondylitis is a controversial subject, and no literature on using this therapy for advanced cases with fusion of the spine could be found. OBJECTIVE: To discuss the case presentation of a patient with advanced ankylosing spondylitis who was treated with chiropractic manipulation and mobilization.Clinical features The patient was a 30-year-old Asian male who was first diagnosed with ankylosing spondylitis at age 12. Despite medical intervention, a series of exacerbations had fused his sacroiliac joints and the facet joints in his lumbar and cervical spine. He presented with local moderate-to-severe pain in his low back and neck and lack of mobility.Intervention and outcome The patient was treated with grade 5 manipulation of his thoracic spine and grade 3 mobilization of his lumbar and cervical spine, along with physical therapy and stretches for a period of 12 weeks. He reported some improvement of his condition as measured by the SF-36 health Survey and several measures of spinal flexibility. CONCLUSIONS: This case shows that even advanced cases of ankylosing spondylitis may show a favorable response to chiropractic manipulative therapy.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
5/16. Late esophageal perforation complicating anterior cervical plate fixation in ankylosing spondylitis: a case report and review of the literature.esophageal perforation in ankylosing spondylitis (AS) is a rare complication in anterior cervical spine surgery and has not been reported before. A 50-year-old patient with AS developed incomplete tetraplegia after minimal trauma. C5 pedicle fracture was diagnosed and treated predominantly by physical therapy until neurological symptoms progressed. Cervical spine MRI showed C6/7 fracture and spinal cord compression. The patient underwent dorsal laminectomy, C5-7 anterior cervical fusion using allograft iliac crest and CASPAR-plate fixation. Delayed esophageal perforation appeared 10 months postoperatively when he came first to our hospital. He complained of dysphagia and developed acute dyspnea. Posterior stabilization with two plates was performed followed by removal of the ventral plate and screws. The esophageal laceration was sutured. The patient was treated with antibiotics and percutaneous endoscopic gastrostomy. Position of fracture and implants were accurate at 18 months postoperatively. The patient had persistent minor neurological deficits (Frankel D) at last follow-up. We conclude that esophageal perforation after anterior spinal fusion is a rare complication. Minor traumas in patients with AS are unstable and can result in significant spinal injury. Dorsoventral stabilization should be performed to avoid further complications.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
6/16. Injuries of the cervical spine in patients with ankylosing spondylitis: experience at two trauma centers.OBJECT: The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine's poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment. methods: Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior-posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed. Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences. CONCLUSIONS: The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior-posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10--a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
7/16. The triggering role of physical injury in the onset of peripheral arthritis in seronegative spondyloarthropathy.Three more cases of B27-positive patients who developed peripheral arthritis immediately after trauma are reported. The first had an exacerbation of arthritis in the right hip after falling from her motor-bike. The second had arthritis of the distal interphalangeal (DIP) joint of the right forefinger after shutting his finger in the door of his car. The third had arthritis of the right sternoclavicular joint after a road-accident while fastening her safety belt.- - - - - - - - - - ranking = 4keywords = physical (Clic here for more details about this article) |
8/16. Trauma and seronegative spondyloarthropathy: rapid joint destruction in peripheral arthritis triggered by physical injury.Two B27 positive patients developed peripheral arthritis immediately after a significant musculoskeletal injury. Unlike previously reported peripheral arthritis precipitated by trauma in B27 positive subjects the arthritis was rapidly destructive.- - - - - - - - - - ranking = 4keywords = physical (Clic here for more details about this article) |
9/16. Diagnostic value of HLA-B27 testing ankylosing spondylitis and Reiter's syndrome.Typing for histocompatibility antigen (HLA)-B27 has been suggested as a clinically valuable diagnostic test for ankylosing spondylitis and Reiter's syndrome, although some decry its use for this purpose. Diagnoses can be made in most patients with these diseases on the basis of the history, physical examination, and roentgenographic findings. The B27 test cannot be used to screen an asymptomatic population to detect these diseases and should not be thought of as a routine diagnostic test. We present probability graphs derived from Bayes' theorem, which show that for certain patients the B27 test, when used properly, is of clinical value as an aid to diagnosis. Proper application of the B27 test in clinical medicine is discussed. The test result does not absolutely confirm or exclude the presence of these diseases; it merely provides a probability statement on their existence in the patient. The test is therefore most useful to physicians who understand the use of probability reasoning in clinical decision making.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
10/16. Cephalgia secondary to neuroma in a patient with ankylosing spondylitis: a case report.A case is presented in which a 26-year-old male with intermittent headaches of many years duration, presents to the Arlington chiropractic Clinic for evaluation and therapy. Routine palpation of the painful area reveals a small mass in the region of the greater occipital nerve. Microscopic examination of the tumor after surgical removal suggests neuroma formation. Headaches did not recur. This patient also experienced exacerbations and remissions of vague low back pain with no radiation. A sacroiliitis was both clinically and radiographically evident. These findings, a positive HLA B27 and the consistent symptom complex allowed a diagnosis of ankylosing spondylitis to be ascertained. It is concluded that palpation of the painful area is a vital portion of the physical examination and must be included in all evaluations. This case also demonstrates that the diagnosis of one problem does not preclude the presence of others. When one condition is diagnosed and therapy is instituted, diagnostic suspicion must not be relaxed.- - - - - - - - - - ranking = 1keywords = physical (Clic here for more details about this article) |
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