DOCSLIB.ORG

Interventional Chronic Pain Treatment in Mature Theaters of Operation

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Interventional Chronic Pain Treatment in Mature Theaters of Operation 28. INTERVENTIONAL CHRONIC PAIN pain, nonradicular arm pain, groin pain, noncardiac spinal and myofascial pain); and anticonvulsants TREATMENT IN MATURE THEATERS chest pain, and neck pain. The most common diag- and tricyclic antidepressants (usually prescribed for OF OPERATION noses conferred on these patients were lumbosacral radicular and other forms of neuropathic pain). The radiculopathy, recurrence of postsurgical pain, large majority of patients received at least one inter- IMPACT OF NONBATTLE-RELATED INJURIES lumbar facetogenic pain, myofascial pain, neuro- ventional procedure. The most frequently employed AND TREATMENT pathic pain, and lumbar degenerative disc disease. nerve blocks were lumbar transforaminal epidural The most common noninterventional treatments steroid injections (ESIs), trigger point injections, Acute nonbattle injuries (NBIs) and chronic pain have been nonsteroidal antiinflammatory drugs cervical ESIs, lumbar facet blocks, various groin conditions that recur during war have been termed (NSAIDs; > 90%); physical therapy referral (for back blocks, and plantar fascia injections. Table 28-1 lists the “hidden epidemic” by the former surgeon pain, neck pain, and leg pain); muscle relaxants (for procedures for common nerve blocks conducted in general of the US Army, James Peake. Since statistics have been kept, the impact of NBIs on unit readiness TABLE 28-1 has increased. In World War I, NBI was the fourth leading cause of soldier attrition. In World War II PROCEDURES FOR COMMON NERVE BLOCKS CONDUCTED IN THEATER and the Korean conflict, NBIs were the third leading cause of morbidity. By the Vietnam War, NBIs had Injection Injectate Need for Comments become the leading cause of hospital admissions, Volume* (mL) Fluoroscopy? where they have remained ever since. However, increasing evidence demonstrates that in-theater Cervical ESI 2–4 Yes Use of local anesthetic controversial. Cervical TFESI may management of NBIs and recurrent chronic pain result in death or paraplegia and should not be done in austere environment. syndromes can improve return-to-duty rates. The current system of military treatment levels, Interlaminar lumbar ESI 3–5 Strongly Performing blind ESI associated with a high likelihood of advised injectate failing to reach targeted area. designed to facilitate the rapid evacuation of wounded soldiers based on their medical condi- Transforaminal lumbar 2–3 Yes Superior outcomes compared to interlaminar ESI. tion and needs, was developed in World War ESI II—predating the establishment of pain management Intraarticular facet blocks Cervical: 1 Yes Likelihood of relief higher in patients with acute as a medical specialty. No personnel are currently Lumbar: 1–2 inflammatory process. deployed specifically for pain management (acute or Trochanteric bursa 3–5 No Similar outcomes for fluoroscopically and landmark- chronic) at level-III combat support hospital (CSH) injection guided injections. facilities in either Iraq or Afghanistan. Instead, anes- Sacroiliac joint block 2–4 Yes < 25% chance of intraarticular spread in landmark-guided thesiologists and other pain specialists are deployed injections. in their primary specialties and are expected to Lateral epicondylar 0.5–1.5 No Mixed results for treatment. provide pain management services as needed in ad- injection dition to their regular full-time duties. This situation Subacromial bursa 4–10 Advised May use posterior or anterolateral approach; 50%–80% has resulted in a varying standard of pain manage- injection accuracy rate for blinded injections. ment care in theaters of operation. The modern CSH has key infrastructure such as radiology services (eg, Piriformis muscle 3–8 Yes May use nerve stimulator to locate sciatic nerve (adjacent injection to muscle) if fluoroscopy is not available. Injection of local fluoroscopy, radiography, computed tomography) anesthetic may cause sciatic nerve weakness. and full surgical, laboratory, and pharmacy support, which can facilitate chronic pain clinical services if Carpal tunnel injection 1–2 No Not superior to NSAID treatment after 2 months. properly staffed. Greater occipital nerve 2–4 No Difficult to clinically distinguish from referred cervical The most common presenting complaints of NBI injection pain. during Operation Iraqi Freedom have been radicular ESI: epidural steroid injection. NSAID: nonsteroidal antiinflammatory drug. TFESI: transforaminal epidural steroid injection. leg pain, axial low back pain (LBP), nonradicular leg *Volume of injectate consists of 1 to 2 mL of depot (long-acting) corticosteroid plus local anesthetic. 107 28 INTERVENTIONAL CHRONIC PAIN TREATMENT IN MATURE THEATERS OF OPERATION theater. Significantly, when treated in theater, 94.7% A mainstay interventional treatment for LBP Zygapophyseal Joint Pain. Lumbar zygapophyseal of soldiers returned to their units. Differences in is ESI. ESIs exert their beneficial effects through (facet) joint pain accounts for approximately 15% of return-to-duty rates support aggressive pain man- their antiinflammatory properties, inhibition of patients with chronic axial LBP. Typical presentation is agement in forward-deployed areas. the enzyme phospholipase A2, and suppression of a dull aching pain, usually bilateral, that radiates from ectopic discharges from injured neurons. Although the low back into the buttocks and thigh. Although TRIAGING PATIENTS FOR TREATMENT ESIs have been successfully used to treat axial back the history and physical examination can be sugges- As a result of limited pain management pain, ideal candidates for the procedure are those tive of facet joint pain, an analgesic response to fluo- resources, coupled with the risk involved with with pain of less than 6 months’ duration, leg pain roscopically guided low-volume diagnostic blocks, soldier transport, healthcare providers must triage greater than back pain, young age, intermittent of either the zygapophyseal joints themselves or the NBI pain patients based on the anticipated risk– pain, and absence of concomitant spinal stenosis. medial branches that innervate them, is the gold stan- benefit ratio. Soldiers with acute or recurrent The use of fluoroscopic guidance is highly recom- dard for diagnosis. The interventional treatment of overuse injuries (eg, tendonitis or bursitis) can mended for interlaminar ESIs and is required for facetogenic pain consists of either intraarticular injec- usually be handled at a level I facility such as a transforaminal ESIs. ESIs performed without the tions with corticosteroid, which may benefit a small battalion aid station. For soldiers who require more fluoroscope have a high technical failure rate, even percentage of patients with an acute inflammatory sophisticated interventions, the battalion or brigade when performed by experienced practitioners. component, or more frequently radiofrequency dener- surgeon must decide whether a medical evacuation Transforaminal ESIs, although technically more vation of the nerves that innervate the painful joints. to a CSH is warranted. This decision is based upon challenging than interlaminar ESIs, are generally Because of the lack of radiofrequency capability, com- several factors: the likelihood of quick resolution of associated with superior outcomes because medica- bination diagnostic/therapeutic intraarticular facet the pain issue, the soldier’s motivation to remain in tion is deposited directly over the affected nerve injections are recommended in theater. In patients theater, the soldier’s military occupational specialty, root (Figure 28-1). with radiological evidence of an acute inflammatory the probability of recurrence, the commander’s Patients suspected of radicular pain should process, intraarticular corticosteroids may afford up to desire to keep the soldier in theater, the treatment receive computed tomography (CT) scans of the 3 months of excellent pain relief (Figure 28-2). capabilities at the CSH, and the risk of medical appropriate spine evacuation. level. Whereas magnetic resonance Figure 28-1. Lateral fluoroscopic view demonstrat- Figure 28-2. Antero-posterior fluoroscopic view CHRONIC PAIN CONDITIONS ENCOUNTERED imagery (MRI) is the ing needle position for L4-5 transforaminal epidural demonstrating needle position for bilateral L3 and steroid injection. L4 facet joint (medial branch) nerve blocks. IN THE FIELD gold standard for imaging soft tissue Low Back Pain. LBP is the most common complaint and disc anatomy, CT likely to be encountered by the pain practitioner scans are sensitive deployed to the CSH. Its high incidence is probably at determining caused by a combination of factors encountered the presence of in theater: the heavy loads service members must disc pathology. carry, frequent transportation over rough terrain in Although ESIs are military vehicles with stiff suspensions, heavy indi- considered by many vidual body armor, sleep deprivation, and the high practitioners to be the degree of psychosocial stressors faced by soldiers best interventional deployed to combat zones. Among the various therapy for radicular causes of LBP, radiculopathy from nerve root ir- pain, controversy ritation may be the most commonly encountered exists regarding their condition. long-term efficacy. 108 INTERVENTIONAL CHRONIC PAIN TREATMENT IN MATURE THEATERS OF OPERATION 28 Sacroiliac Joint Pain. Sacroiliac (SI) joint pain is a 28 frequent source of axial LBP, accounting for roughly 15%to 20% of cases. Compared to other causes of back pain, SI joint pain is more likely to result from
Load more

Recommended publications
  • Shoulder Pain – Complexity to Simplicity
    Shoulder Pain – Complexity to Simplicity A Regional Approach to Shoulder Pain The best way to approach a problem of shoulder pain is to look at the pain from a regional point of view. This allows for easy identification of specific pathological problems that occur at each region. In this talk, we look at the patterns of pain that occur with the different regions around the shoulder. From this, we will focus on the pathological problems that can be expected in each region and then look at specific physical examination findings that can be used to confirm a diagnosis or help further clarify the problem. Although this talk is focused on the diagnosis of causes of shoulder pain, we also take a look at some updates and salient features of treatment. In general, pain in the region of the shoulder can be grouped into 4 main types. These relate to specific patterns of pain that allow history taking to help us focus on the likely cause(s) before moving on to examination. A fairly clear-cut diagnosis is almost always achievable without the need to resort to special tests to help make the diagnosis. Of course, this does not include all possible causes of pain. The uncommon problem will still need a thorough and complete approach to determining cause, often with the requirement for special investigations. Remember that this is a good guide. Don't neglect other causes of referred pain that may cause pain in and around the shoulder. Included here is cardiac pain, diaphragmatic pain, apical lung disease and malignant bone pain.
    [Show full text]
  • Management of Radicular Pain
    Management of Radicular Pain Mel Cusi MBBS, FACSP, FFSEM (UK) Sport & Exercise Medicine Physician Dr Mel Cusi Sport & Exercise Medicine Physician Management of Radicular Pain A. Background B. Epidemiology C. Diagnosis D. Treatment Dr Mel Cusi Sport & Exercise Medicine Physician A. Background • Names and concepts – Radicular pain – Radiculopathy • Structures that can produce radicular Sx – Sinu‐vertebral nerve – Nerve root • Mechanisms of pain – Direct toxic effect of disc material – Chemical substances Dr Mel Cusi Sport & Exercise Medicine Physician B. Epidemiology • Occurs in 3‐5% of the population – More frequent in males in their 40’s – More frequent in females in their 50’s • In sporting population – More frequent in sports that combine spinal flexion/extension with rotation – Fast bowlers, gymnasts, dancers, RU backrowers, golfers, weightlifters, baseball pitchers Dr Mel Cusi Sport & Exercise Medicine Physician C. Diagnosis • Radicular pain is only a descriptive symptom • Diagnosis is made on the usual basis of – History – Clinical examination – Appropriate investigations (when required) Dr Mel Cusi Sport & Exercise Medicine Physician History • Acute LBP radiating to buttock / lower limb • Worse with flexion, sneezing, coughing. Sitting worse than standing • Some pointers – Referred pain from L1‐3 does not reach the knee – Unusual Symptoms (weight loss, fever, chills) point to something else – Beware of cauda equina: surgical emergency Dr Mel Cusi Sport & Exercise Medicine Physician Neurological Examination • Sensation – Subjective
    [Show full text]
  • Study Guide Medical Terminology by Thea Liza Batan About the Author
    Study Guide Medical Terminology By Thea Liza Batan About the Author Thea Liza Batan earned a Master of Science in Nursing Administration in 2007 from Xavier University in Cincinnati, Ohio. She has worked as a staff nurse, nurse instructor, and level department head. She currently works as a simulation coordinator and a free- lance writer specializing in nursing and healthcare. All terms mentioned in this text that are known to be trademarks or service marks have been appropriately capitalized. Use of a term in this text shouldn’t be regarded as affecting the validity of any trademark or service mark. Copyright © 2017 by Penn Foster, Inc. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner. Requests for permission to make copies of any part of the work should be mailed to Copyright Permissions, Penn Foster, 925 Oak Street, Scranton, Pennsylvania 18515. Printed in the United States of America CONTENTS INSTRUCTIONS 1 READING ASSIGNMENTS 3 LESSON 1: THE FUNDAMENTALS OF MEDICAL TERMINOLOGY 5 LESSON 2: DIAGNOSIS, INTERVENTION, AND HUMAN BODY TERMS 28 LESSON 3: MUSCULOSKELETAL, CIRCULATORY, AND RESPIRATORY SYSTEM TERMS 44 LESSON 4: DIGESTIVE, URINARY, AND REPRODUCTIVE SYSTEM TERMS 69 LESSON 5: INTEGUMENTARY, NERVOUS, AND ENDOCRINE S YSTEM TERMS 96 SELF-CHECK ANSWERS 134 © PENN FOSTER, INC. 2017 MEDICAL TERMINOLOGY PAGE III Contents INSTRUCTIONS INTRODUCTION Welcome to your course on medical terminology. You’re taking this course because you’re most likely interested in pursuing a health and science career, which entails ­proficiency­in­communicating­with­healthcare­professionals­such­as­physicians,­nurses,­ or dentists.
    [Show full text]
  • Studies on Brain and Spinal Cord Tumors
    Studies on Brain and Spinal Cord Tumors Chapter 1 Osteochondroma of the Spine Iraj Lotfinia Professor of Neurosurgery, Tabriz Universsity of medical science, Tabriz, Iran. Fax: 00984113340830; Email: [email protected] Abstract Osteochondroma (OC) is the most common benign tumor of the bones, and it remains the most common precursor for secondary chondrosarcoma, which often occurs in the long bones’ metaphyseal areas. Rarely, it is also found in the spine. This tumor comprises a cartilage capped bone projection and is observed in both solitary and multiple forms. In many cases, the lesion can be definitively diagnosed according to radiological characteristics, but the rarity of these lesions in the spine, gradual onset of symptoms, and the frequent lack of observation of lesions in plain radiography may delay the diagnosis or cause misdiagnosis. These lesions are be- nign and do not risk the patient’s life; however, they rarely may be found to be a malignant degeneration that transformed into chondrosarcoma. When the lesion has led to clinical symptoms or has faced the patient with cosmetic challenges, or when definitive diagnosis is unknown, treatment is required. The primary treatment is the surgical removal of the lesion. Timely diagnosis and complete resection of the le- sion using surgery lead to complete recovery and prevent recurrence. 1. Introduction According to the World Health Organization’s (WHO’s) definition in 2002, osteocar- tilaginous exostosis are benign bone neoplasms covered by a cartilaginous cap created at the outer surface of the bone by endochondral ossification [1]. Osteochondroma (OC) is the most common benign primary tumor of the bone.
    [Show full text]
  • CMA Psychiatry Profile, 2018
    Psychiatry Profile Updated December 2019 1 Table of Contents Slide . General Information 3-7 . Total number & number/100,000 population by province, 2019 8 . Number/100,000 population, 1995-2019 9 . Number by gender & year, 1995-2019 10 . Percentage by gender & age, 2019 11 . Number by gender & age, 2019 12 . Percentage by main work setting, 2019 13 . Percentage by practice organization, 2017 14 . Hours worked per week (excluding on-call), 2019 15 . On-call duty hours per month, 2019 16 . Percentage by remuneration method 17 . Professional & work-life balance satisfaction, 2019 18 . Number of retirees during the three year period of 2016-2018 19 . Employment situation, 2017 20 . Links to additional resources 21 2 General information Psychiatry is the medical specialty that deals with the diseases of the mind. Psychiatric patients manifest illnesses and problems that require a comprehensive biological, psychological and social evaluation to understand their illnesses and their needs. Central to the psychiatrist’s role is a comprehensive assessment, leading to a diagnosis and a treatment plan for the care and rehabilitation of patients with mental illness, and emotional and behavioural disorders. Psychiatrists use a combination of biological, psychological and social treatment modalities. They must be comfortable in working with the patient, as opposed to working on the patient. To do this successfully, they must possess the skills and comfort level to work and lead a team that includes the patient, their family and other mental health professionals and agencies. Source: Pathway evaluation program 3 General information Most psychiatrists work in multiple settings and their role may vary somewhat in these different settings, including: .
    [Show full text]
  • 2019‐2020 Internal Medicine Residency Handbook Table of Contents Contacts
    2019‐2020 Internal Medicine Residency Handbook Table of Contents Contacts ............................................................................................................................................ 1 Introduction ...................................................................................................................................... 2 Compact ............................................................................................................................................ 2 Core Tenets of Residency ……………………………………………………………………………………………………………3 Program Requirements ……………………………………………………………………………………………………………….6 Resident Recruitment/Appointments .............................................................................................. 9 Background Check Policy ................................................................................................................ 10 New Innovations ............................................................................................................................. 11 Social Networking Guidelines ......................................................................................................... 11 Dress Code ...................................................................................................................................... 12 Resident’s Well Being ...................................................................................................................... 13 Academic Conference Attendance ................................................................................................
    [Show full text]
  • Your Path to Becoming a Medical Doctor at the University of Iowa Types of Doctors Medicine Offers a Lot of Career Choices
    Your Path to Becoming a Medical Doctor at the university of iowa Types of Doctors Medicine offers a lot of career choices. Many doctors treat patients full-time, while others also teach, conduct research, manage hospitals and clinics, or help develop health policy. There is no single road to becoming a doctor, but most our mission is simple: changing medicine. changing lives. at the carver college medical career paths share key characteristics. of medicine, we do that by inspiring and educating students to become Doctors fall into two main groups: primary care world-class health care providers and scientists for iowa and the world. doctors and specialists. Primary Care Doctors The term “primary care” refers to the medical What Makes Us Different? fields that treat most common health problems: family medicine, general internal medicine, Our Curriculum pediatrics (children’s health), and in some cases obstetrics and gynecology (women’s health). As a medical student at Iowa, you’ll get a lot of hands-on experience, including opportunities to learn from real doctors—and real patients—in hospital or clinic setting. Specialists Specialists concentrate on diseases or problems Our Distinction Tracks that affect specific parts of the body. They may Six distinction tracks allow you to follow your own personal interests and career goals. treat patients with complicated illnesses who are sent to them by primary care doctors or other We’re an Academic Medical Center specialists. Being an academic medical center means that we teach and train future doctors and scientists, take care of patients, and do Types of Degrees medical research.
    [Show full text]
  • A Guide for Diagnosis and Therapy [Version 1; Peer
    F1000Research 2016, 5(F1000 Faculty Rev):1530 Last updated: 17 JUL 2019 REVIEW Mechanisms of low back pain: a guide for diagnosis and therapy [version 1; peer review: 3 approved] Massimo Allegri1,2, Silvana Montella1, Fabiana Salici1, Adriana Valente2, Maurizio Marchesini2, Christian Compagnone2, Marco Baciarello1,2, Maria Elena Manferdini2, Guido Fanelli1,2 1Department of Surgical Sciences, University of Parma, Parma, Italy 2Anaesthesia, Intensive Care and Pain Therapy Service, Azienda Ospedaliera Universitaria Parma Hospital, Parma, Italy First published: 28 Jun 2016, 5(F1000 Faculty Rev):1530 ( Open Peer Review v1 https://doi.org/10.12688/f1000research.8105.1) Latest published: 11 Oct 2016, 5(F1000 Faculty Rev):1530 ( https://doi.org/10.12688/f1000research.8105.2) Reviewer Status Abstract Invited Reviewers Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back 1 2 3 region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last version 2 decade and continues to increase dramatically in the aging population, published affecting both men and women in all ethnic groups, with a significant impact 11 Oct 2016 on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given version 1 this complexity, the diagnostic evaluation of patients with CLBP can be very published challenging and requires complex clinical decision-making. Answering the 28 Jun 2016 question “what is the pain generator” among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes.
    [Show full text]
  • Spinal and Radicular Pain Syndromes of the Cervical and Thoracic Regions N.B
    D. SPINAL PAIN, SECTION 2: SPINAL AND RADICULAR PAIN SYNDROMES OF THE CERVICAL AND THORACIC REGIONS N.B. For explanatory material on this section and on section G, Spinal and Radicular Pain Syndromes of the Lumbar, Sacral, and Coccy eal Re ions, see pp. 11-16 in the list of Topics and Codes. Please also note the comments on codin on p. 17. GROUP IX: CERVICAL OR RADICULAR SPINAL PAIN SYNDROMES Cervica Spina or Radicu ar Pain Attributab e to a Fracture (IX-1) Definition Cervical spinal pain occurrin in a patient with a history of in(ury in whom radio raphy or other ima in studies demonstrate the presence of a fracture that can reasonably be interpreted as the cause of the pain. C inica Features Cervical spinal pain with or without referred pain. Dia.nostic Features Radio raphic or other ima in evidence of a fracture of one of the osseous elements of the cervical vertebral column. Schedu e of Fractures IX- 1.1(S,(R, Fracture of a -ertebral Body Code 1...X1eS/C 0...X1eR IX- 1.0(S, Fracture of a Spinous Process (Synonym1 2clay-shovelers fracture3, Code 1...XIfS IX-1..(S,(R, Fracture of a Transverse Process Code 1...Xl S/C 0...X1fR IX- 1.4(S,(R, Fracture of an Articular Pillar Code 1...XIhS/C 0...X1 R IX-1.5(S,(R, Fracture of a Superior Articular Process Code 1...X1iS/C 0...X1hR IX- 1.6(S,(R, Fracture of an Inferior Articular Process Code 1...X1(S/C 0...X1iR IX-1.7(S,(R, Fracture of Lamina Code 1...X17S/C 0...X1uR IX-1.8(S,(R, Fracture of the Odontoid Process Code 1...XIIS/C 0...X1vR IX-1.9(S,(R, Fracture of the Anterior Arch of the Atlas Code 1...X1mS/C 0...X1pR IX-1.10(S,(R, Fracture of the Posterior Arch of the Atlas Code 1...XlnS/C 0...XIqR IX- 1.11(S,(R, Burst Fracture of the Atlas Code 1...X1oS/C 0...XlwR Cervica Spina or Radicu ar Pain Attributab e to an Infection (IX-2) Definition Cervical spinal pain occurrin in a patient with clinical or other features of an infection, in whom the site of infection can be specified and which can reasonably be interpreted as the source of the pain.
    [Show full text]
  • Tips on Choosing the Specialty That's Right For
    page 1 of 2 Tips on Choosing the Specialty That’s Right for You • Where should you be in the specialty to work in? How many patients will you see in a selection process right now? Careers in day? As you go through the rotation, reconcile your Medicine (http://www.aamc.org/students/cim/) expectations with what you actually experience. is a valuable resource. It divides specialty Also use your journal to keep track of your feelings. choice into four phases corresponding with At the end of the rotation, summarize the things the four years of medical school. Designed by you learned about yourself. What challenged you the Association of American Medical Colleges the most? What were your biggest strengths and (AAMC) and the American Medical Association weaknesses? What did you enjoy the most? The (AMA), this program is implemented on many answers will help you focus on the specialties that medical school campuses. suit you best. • What if you haven’t narrowed your specialty • Identify a resident, attending physician and choices at all? The first step is self-assessment. community physician from each rotation who Go to the Careers in Medicine Web site inspire you. To gain an insider’s perspective of (http://www.aamc.org/students/cim/). Phase 1 the specialty, ask these individuals the following includes self-evaluation tools to help you define questions: What do you like most about your your personality, values and goals. Once you’ve specialty? What do you like least? What is your completed the exercises, you can begin thinking typical daily schedule? What skills or talents are about which specialties complement your most important for someone in your specialty? interests and goals.
    [Show full text]
  • Hip-Spine Syndrome
    Review Article Hip-spine Syndrome Abstract Clinton J. Devin, MD The incidence of symptomatic osteoarthritis of the hip and Kirk A. McCullough, MD degenerative lumbar spinal stenosis is increasing in our aging population. Because the subjective complaints can be similar, it is Brent J. Morris, MD often difficult to differentiate intra- and extra-articular hip pathology Adolph J. Yates, MD from degenerative lumbar spinal stenosis. These conditions can James D. Kang, MD present concurrently, which makes it challenging to determine the predominant underlying pain generator. A thorough history and physical examination, coupled with selective diagnostic testing, can be performed to differentiate between these clinical entities and help prioritize management. Determining the potential benefit from surgical intervention and the order in which to address these conditions are of utmost importance for patient satisfaction and adequate relief of symptoms. ubjective reports of pain in the cases. The prevalence of radio- From the Vanderbilt Orthopaedic Sbuttock, thigh, and/or knee, with graphic hip OA is 27% in adults Institute, Nashville, TN (Dr. Devin, or without a limp, are common in aged ≥45 years.6 However, not all Dr. McCullough, and Dr. Morris) and patients with degenerative changes patients with radiographic hip OA the Department of Orthopaedic 1-3 Surgery, University of Pittsburgh of the hip and spine. Failure to ap- are symptomatic. Symptomatic hip Medical Center, Pittsburgh, PA propriately diagnose the primary OA is reported in 9.2% of adults (Dr. Yates and Dr. Kang). source of pain can result in delayed aged ≥45 years.6 Thus, the treating Dr. Devin or an immediate family relief of symptoms and patient frus- physician must correlate the radio- member has received research or tration.
    [Show full text]
  • All Pain Comes to an End, Eventually
    All Pain Comes To An End, Eventually Low Back Pain From Youth To Grave Michael Jaffe MD Physical Medicine and Rehabilitation 2017 CME-n-Ski 1 Low back pain age <5 Very uncommon Discitis (refuse to walk, avoid bending, back and abdominal pain, fever, usually staph aureus) Tumor (night pain, red flags) Osteomyelitis (Staph/TB) Labs CBC, ESR, CRP, blood Cx, peripheral smear, CMP Xray 2017 CME-n-Ski Adolescence LBP Spondylolyisis Discogenic Fracture Spondyloarthropathy Scoliosis Scheuermann’s kyphosis (thoracic) Posterior element overuse syndrome Pain amplification syndrome Slipped vertebral apophesis Hyperlaxity Infection Tumor 2017 CME-n-Ski 2017 CME-n-Ski Spondylolysis Common (4% age 6, 6% adults, 15% elite adolescent athletes) Overuse disorder Risk factor hyperlordosis PE: tight hamstrings, pain with lumbar extension, hyperlordosis Preferred work up… 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Spondylolysis +/- Spondylolisthesis- Diagnosis MRI with pars edema is best imaging. CT and bone scan are discouraged to limit radiation exposure. If a gap exists on CT or Xray the lysis can’t be healed. 2017 CME-n-Ski 2017 CME-n-Ski Treatment Spondylolysis Rehabilitate rest Posterior pelvic tilts Stabilization Stretching- quad and psoas Muscle imbalances Sports specific exercises Return to sport when asymptomatic Bracing Surgery 2017 CME-n-Ski If MRI normal but exam extension based Posterior overuse syndrome Treatment: relative rest Core stabilization- neutral to flexion biased Stretching- quads and psoas 2017 CME-n-Ski 2017 CME-n-Ski Spondylolytic
    [Show full text]