Low Back Pain in a Teenage Baseball Player

Background: In this article, we present the results of 50 patients whom we treated with epidural steroid injection, and our experience on the subject. Methods: Fifty patients who were followed in our clinic between January 2011 and August 2011 were assessed retrospectively. These were the patients who had chronic low back and leg pain due to lomber spinal degeneration and for whom operation was not recommended and lomber caudal epidural steroid was applied. Results: In our study, 50 patients having low back pain or leg pain or low back and leg pain together were assessed, and regression at rVAS score of 86% of the patients was detected for a short period after the intervention. VAS scores of 14% of the patients were not different. On long-term follow-up rVAS score analysis of the patients showed regression at 74% of the cases. Conclusion: Caudal steroid injection is a safe and efficient treatment method for the patients who have radicular pain, who do not respond to conservative treatment and for whom surgery is not recommended. Randomized double blind studies are needed to assess its superiority to other conservative methods. J Neurol Res. 2013;3(6):173-178 doi: http://dx.doi.org/10.4021/jnr212w

Background Chronic mechanical low back pain is a common clinical condition encountered by physical therapists. It has a mechanical origin that lasts more than 3 months. Aim The aim of this study was to investigate the effects of the suboccipital muscle inhibition technique on pain intensity, range of motion (ROM), and functional disability in patients with chronic mechanical low back pain. Patients and methods Thirty female patients with a mean age of 23.8±0.86 years who had chronic mechanical low back pain were randomly assigned to two equal groups. Group A received exercise training (stretching and strengthening) and the suboccipital muscle inhibition treatment for five consecutive sessions. Group B received only exercise training (stretching and strengthening) for five consecutive sessions. Both groups were assessed using the visual analog scale for pain intensity, Modified–Modified Schober’s test for ROM of lumbar flexion and extension, and the Oswestary functional disability questionnaire for functional disability. Patients were assessed before and after treatment. Results The results of this study showed that there were significant improvements in pain, ROM in the lumbar region (flexion and extension), and functional disability in both groups A and B (P Conclusion It was concluded that the suboccipital muscle inhibition technique combined with exercises have better clinical effects than exercises alone in patients with chronic mechanical low back pain.

Epidural steroid injection has been used to treat low back pain for many decades. Numerous randomized trials have examined the efficacy of this approach. This review details the findings of older systematic reviews, newer randomized controlled trials, and two recent systematic reviews that examine the effectiveness of this treatment. Collectively, studies in acute radicular pain due to herniated nucleus pulposus have failed to show that epidural steroid injection reduces long-term pain or obviates the need for surgery. Similarly, there is scant evidence that epidural steroids have any beneficial effect in those with acute low back pain without leg pain or in those with chronic low back or leg pain. However, most studies have demonstrated more rapid resolution of leg pain in those who received epidural steroid injections versus those who did not. The role of epidural steroid injections in the management of acute radicular pain due to herniated nucleus pulposus is simply to provide earlier pain relief.

Dear Editor, We appreciate the interest in our work and for the opportunity to focus on detailed aspects of chronic mechanical low back pain. The reader attempted to emphasize the importance of pelvic incidence as a predictive factor for chronic low back pain. We should mention that concordant with this valuable comment there are several studies considering sagittal imbalance as a potential contributing factor for developing low back pain [1,2,3]. Pelvic incidence, a pelvic anatomic parameter that is specific and constant for each person determines the size of lumbar lordosis. Changes in this parameter either through relation with back muscle degeneration or other spine conditions might play a role in chronic mechanical low back pain [2,3,4]. The main focus of our study was lumbar lordosis and its effect on functional status measured by Oswestry disability index (ODI) that is not a simple pain score. According to this index, no significant correlation between the degree of lumbar lordosis and the score of functional disability was found [5]. Also, in a recent study using ODI, osteoarthritis of the facet joints as specific locations of degenerative changes to the lumbar spine, was not definitely correlated with ODI scores [6]. On the other hand, 2 studies investigating the relationship between spinopelvic parameters and clinical symptoms of severe isthmic spondylolisthesis used ODI and found a significant correlation between degree of lumbar lordosis and the Oswestry score. However, there was no correlation between pelvic incidence and the Oswestry score [7,8]. Disability is the main consequence of low back pain that should be prevented or treated once occurred. Thus, for more clarification we suggest randomized trials to evaluate possible relationships between the various spinopelvic alignment parameters such as pelvic incidence and the level of functional disability in patients with chronic mechanical low back pain.

Background: Low back pain after either post lumbar surgery syndrome or spinal stenosis in the absence of surgery is a vexing problem. Post lumbar surgery syndrome can occur in any age group, while low back and radicular pain from spinal stenosis is a disease of aging. As the population ages, the incidence of symptomatic spinal stenosis will increase. There are currently limited treatment options for either group. Further surgery is not uniformly effective in relieving pain after previous surgery. While therapies are being developed to treat pain due to spinal stenosis, no therapy other than adhesiolysis will treat pain due to scarring. Adhesiolysis was developed as a means of removing epidural scarring leading directly or indirectly to compression, inflammation, swelling, or a decreased nutritional supply of nerve roots. Adhesiolysis utilizes a number of modalities in the effort to break up epidural scarring, including the use of a wirebound catheter for mechanical adhesiolysis, placement of the catheter in the ventro-lateral aspect of the epidural space at the site of the exiting nerve root, and the use of high volumes of injectate, including local anesthetics and saline, either hypertonic or isotonic, along with steroids. Study Design: A systematic review of percutaneous adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. Objective: To evaluate the effectiveness of percutaneous adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. The severity of risks and adverse events associated with percutaneous adhesiolysis were also evaluated. Methods: The available literature on percutaneous adhesiolysis for the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief of at least 6 months. Secondary outcome measures were improvement in functional status, change in psychological status, return to work, and reduction in opioid use or interventions. Results: For this systematic review, 15 studies were identified and selected for review. Of these, 5 randomized controlled trials and 2 observational studies met the inclusion criteria. Applying the USPSTF criteria, these studies indicate that there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain caused by post lumbar surgery syndrome and that there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/ or leg pain caused by spinal stenosis The incidence of complications from percutaneous adhesiolysis is low and the complications are generally minimal and self-limited. The procedure should be considered to be low risk for serious adverse events when performed by well-trained physicians. Limitations: The limitations of this systematic review include the paucity of literature. Conclusion: In summary, there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain due to post lumbar surgery syndrome or spinal stenosis. Key words: Spinal pain, chronic low back pain, leg pain, adhesiolysis, Racz procedure, post lumbar surgery syndrome, spinal stenosis

The low back and the lower limb are generally viewed as two isolated regions, however, there are many authors who believe that these two regions are functionally related. This is due to the two regions being connected to each other through the kinematic chain of the lower extremity. The lumbar spine is the link between the lower extremities and the trunk, and plays a significant role in the transfer of forces through the body via the kinematic chain. The physical link between the low back and the lower limb is supplied by the thoracolumbar fascia, which plays an important role in the transfer of forces between the spine, pelvis and legs. Although a relationship between the lower extremity and low back pain is often assumed, little research has been published to demonstrate the association. Most of the evidence so far has been anecdotal, without scientific research to support it. This study was designed to compare the relative effectiveness of lumbar spine manipulation, compared to combined lumbar spine and subtalar manipulation for the treatment of chronic mechanical low back pain, using subjective and objective measures, for the management of chronic mechanical low back pain. The study design was a quantitative clinical trial, using purposive sampling. It consisted of forty voluntary participants with chronic mechanical low back pain. There were two groups of twenty participants each, each of whom received six treatments within a three week period. Group A received manipulation of the lumbar spine only, whilst Group B received manipulation of both the lumbar spine and subtalar joint. The outcome measures included the response of the participants to the Numerical Pain Rating Scale-101 and the Quebec Low Back Pain and Disability Questionnaire. Objective data was obtained from three digital Algometer measures. Data was collected prior to the initial, third and sixth treatment. iv Statistically both groups showed improvements, subjectively and objectively, with regards to chronic mechanical low back pain. Inter-group testing for NRS over time showed no significant effect for both treatment groups. There was a significant treatment effect for Algometer Average TP1 while the treatment effect for Algometer Average TP2 was not significant. However, inter-group testing for the Quebec LBP over time showed no significant effect for both treatment groups. Inter-group analysis demonstrated no statistical significance between the two groups for subjective and objective measurements, thus suggesting that there is no additional benefit in treating the subtalar joint in the management of mechanical low back pain. Further studies will also benefit greatly from the use of larger sample sizes to improve statistical relevance of data.

Background Bi-Digital O-Ring Test (BDORT) has been used by medical practitioners worldwide with diagnostic and therapeutic purposes. Its role as an important and affordable tool in diagnosing and treating chronic pain has been shown by the originator of the test, Prof. Y. Omura. Abjectives To assess the results of the application of BDORT in patients with chronic pain due to spinal column problems; and to evaluate the effects of medicines used for the treatment of chronic pain including unconventional treatment such as acupuncture, mixtures of EPA and DHA, Cilantro and propolis among others. Methods Forty-two patients with chronic low back and cervical pain were selected from a large database of the first author. Patients included were previously treated using conventional therapies with unsatisfactory results. Approximately 10% of patienLs with chronic low back and cervical pain in the database accepted to be diagnosed and treated by using information gathered by BDORT at least on two different occasions. Data about the age, gender, number of BDORTs, main health problem, co-morbidities, prescribed treatment and follow-up by at least six months were collected for each patient. All patients included within this study were examined, diagnosed and treated by the first author using BDORT and standard Western medical diagnostic methods. BDORT was performed for each patient in every visit using standard plates with samples of the materials to be investigated. A systemic test was done for detection of virus, bacteria, heavy metals, fungi, tumor markers and some biochemical substances in all attended patients. All patients were instructed to perform the “Drug Uptake Enhancement Method” with massage in areas of the hands in correspondence to the affected organs following the Omura’s map of organ representation areas of the hands and by using “+” Qi-gong energy stored paper on painful areas. Results The mean age of patients was 60 years (18-85 years) and 90% of them were female. Bi-Digital O-Ring Test was performed every time for patients attended the surgery each visit (mean number of 5.2 times). Co-morbidities included hypertension, depression, osteoarthrosis, inrervertebral disk herniation and obesity. According to BDORT, Mercury was detected in all patients, Aluminium (98%), Lead (93%), Chlamydia trachomatis (93%) and Human Cytomegalovirus (93%), Herpes Simplex Virus Type 1(86%), Copper (83%), Herpes Simplex Virus Type 11(81 %) and Borrelia burgdorferi (81 %). Mixtures of EPA and DHA, and Cilantro were given to all the patients and propolis to 90% of the patients. Doxycycline (lOOmg twice day for 2 weeks) was prescribed 70% of patients who were Chlamydia trachomatis positive and Azithromycin (500mg once day for one week) for 36%. Conventional anti-inflammatory drugs were used in half of the patients. Acupuncture was applied in 21% of the patients. There was a large improvement in most patients which was not observed in previous treatments using conventional medicines. Whole-body improvement together with clinical progress was noted in 12% of patients, 36% of the patients became asymptomatic, 24% reported a significant improvement and 19% of patients got moderate progress after doing BDORT and using the indicated medicines. For 9% of our sample the results were poor, with intermittent pain episodes or irregular course, but no deterioration of the original clinical symptomatology. Quality of life, assessed by the first author, was considered to the optimal for 29% of patients, good for 62% and not improvement for 9%. Conclusion The use of Bi-Digital O-Ring Test in patients with chronic low back and cervical pain was found to be a very useful and powerfill diagnostic tool and also helps to identify effective medicines and treatments.

Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache.

Background: Low back pain (LBP) is a prevalent musculoskeletal disorder that significantly affects quality of life and incurs considerable costs. Transforaminal epidural steroid injections (TFESI) and trigger point injections (TPI) are widely utilised in interventional pain management treatments. Nonetheless, their relative efficacy for sustained pain relief is not well comprehended. Aim: This research assesses the efficacy of TFESI compared to TPI in managing chronic LBP by analysing pain alleviation and functional outcomes at a six-month follow-up. Methodology: A prospective, comparative interventional study was undertaken at Aditi mother and Child Care Centre, Patna, Bihar, India, involving 96 patients with chronic low back pain. Patients were randomly assigned to two groups: Group A (n=48) underwent transforaminal epidural steroid injection (TFESI), and Group B (n=48) received trigger point injection (TPI). Pain intensity was evaluated using the Visual Analogue Scale (VAS) during the initial consultation and at follow-up appointments at 1, 3, and 6 months. The Mann-Whitney U test was employed for statistical analysis, with p<0.05 indicating statistical significance. Results: Both therapies considerably decreased pain scores over time. TFESI provide more substantial alleviation in the long term. The mean VAS score for Group A at 3 months (3.2 ± 1.1) was considerably lower than that of Group B (3.8 ± 1.3, p=0.04). Group A (2.9 ± 1.0) exhibited superior pain management compared to Group B (3.6 ± 1.2, p=0.02) at the six-month mark. Conclusion: Although both TFESI and TPI effectively mitigate LBP, TFESI provides longer prolonged pain relief, making it preferable for long-term application.

Secular Mindfulness-Based Interventions: Efficacy and Neurobiology.

Fast-acting subperception therapy in spinal cord stimulation (FAST-SCS) uses low-frequency, subthreshold stimulation to engage the dorsal column-mediated surround inhibition mechanism and thereby relieve pain. Our study was performed to better characterize the multidimensional long-term clinical outcomes of FAST-SCS therapy in patients with chronic low back and/or leg pain. Our prospective, multicenter, single-arm, open-label trial, conducted at 12 pain management centers across the USA, included male and female patients with chronic low back pain with/without leg pain refractory to conservative therapy. All eligible patients received an SCS implant. Outcomes evaluated included pain relief, disability, mobility, health-related quality of life, sleep quality, depression, pain catastrophizing, and global impression of change. Fifty-six patients received a permanent SCS implant and 55 were activated with FAST-SCS therapy. At 12months, 89% and 59% of patients achieved ≥ 50% and ≥ 80% pain relief, respectively (p < 0.0001), and pain intensity (verbal numerical rating scale) decreased by 4.9 ± 2.2 points (p < 0.0001). Significant improvements were observed in disability (Oswestry Disability Index - 24 ± 16 points, p < 0.0001) and endurance (6-Minute Walk Test + 73 ± 96m, p < 0.0001), while mobility and balance improved without reaching statistical significance (Timed Up-and-Go test - 7.5 ± 37.5s, p = 0.17). All psychosocial measures improved significantly at 12months compared to baseline, with an increase in the EQ5D-5L index (+ 0.200 ± 0.182, p < 0.0001) and decreases in the Pittsburgh Sleep Quality index (- 3.96 ± 4.31, p < 0.0001), Pain Catastrophizing Score (- 13.3 ± 11.4, p < 0.0001), and Beck Depression Index (- 7.9 ± 10.0, p < 0.0001). At 12months, 87% of patients reported being "much" or "very much" improved. Responses to FAST-SCS were at or above the minimal clinically important differences across all measured clinical dimensions. This prospective study demonstrated that FAST-SCS provided statistically significant, multidimensional benefits across pain, disability, mobility, and psychosocial outcomes over 12months in patients with chronic low back and/or leg pain. These findings support the use of FAST-SCS in this patient population. ClinicalTrials.gov (NCT04618471). https://www. gov/study/NCT04618471 .

Objective To observe the prevalence and risk factors of chronic low back pain in puerperas after childbirth. Methods Eight hundred and eighty-one puerperas were selected, among whom 459 cases had uterine-incision delivery, and 422 cases had spontaneous delivery. The age, height and weight of pregnant women, birth weight of newborn, history of preoperative low back pain, parity and mode of delivery were recorded. The rate of chronic low back pain occurring within 1 month after childbirth and continuing for 3 months was recorded by telephone. The factors with P values less than 0.05 would enter the Logistic regression analysis to screen the risk factors of chronic low back pain. Results Two hundred and fifty-nine puerperas (259/881, 29.4%) appeared chronic low back pain, of whom 157 puerperas (157/459, 34.2%) delivered by uterine-incision and 102 puerperas (102/422, 24.2%) delivered spontaneously, and the difference was statistically significant (P<0.01). Six hundred and fifty-eight puerperas had no history of preoperative low back pain, and 150 puerperas (150/658, 22.8%) appeared newly developed chronic low back pain. Logistic regression analysis showed that mode of delivery, parity and history of preoperative low back pain were the risk factors of chronic low back pain. Conclusions The rate of chronic low back pain in puerperas after childbirth is 29.4%, and the newly developed chronic low back pain is 22.8%. Uterine-incision delivery, multiparity and history of preoperative low back pain are the risk factors of chronic low back pain for puerperas after childbirth. Key words: Low back pain; Pregnancy; Risk factors; Cesarean section

Intradiscal electrothermal treatment for chronic discogenic low back pain: a prospective outcome study with minimum 1‐year follow‐up. (SOAR, Physiatry Medical Group, Menlo Park, CA) <i>Spine</i> 2000;25:2622–2627.

Subcutaneous Stimulation as an Additional Therapy to Spinal Cord Stimulation for the Treatment of Lower Limb Pain and/or Back Pain: A Feasibility Study

Low back pain is a common and causes functional limitations, decreased quality of life, loss of workforce, and economic burden. Aim : Our aim is to evaluate to what extent patients with chronic mechanical low back pain use Complementary Alternative Treatment methods, which methods they frequently use, through which channels they use these methods, and their relationship with sociodemographic characteristics. Materials and Methods: 500 randomly selected male and female patients with chronic mechanical low back pain were included in this cross-sectional descriptive study. Sociodemographic characteristics and diagnoses of the patients who signed informed consent were recorded. The severity of back pain was evaluated with a visual analog scale, and their use of complementary alternative treatments was questioned. Conclusion : It is common to use complementary alternative treatments for low back pain. For this reason, it has revealed the need for comprehensive scientific research with high patient participation by physicians on this subject. Key Words: Back Pain, Physiotherapy Alternative Treatment