Low Back Pain: Mechanical Vs. Inflammatory

Total Page:16

File Type:pdf, Size:1020Kb

Low Back Pain: Mechanical Vs. Inflammatory Low Back Pain: Mechanical vs. Inflammatory Thomas A. Rennie, MD, FACR Rheumatology Associates of South Texas Disclosure • Dr. Rennie has disclosed that he is on the speaker’s bureau for Flexion Pharmaceuticals. Game Plan • Overview • Mechanical vs. Inflammatory Low Back Pain • Spondyloarthropathies – Ankylosing Spondylitis – Psoriatic Arthritis – Reactive Arthritis – Enteric Arthritis • Treatment Low Back Pain Overview • 31 million Americans have low back pain • Affects men and women equally • Average age of onset: 30 - 50 years old • Over 50% will have recurrence • 5-10% will develop chronic LBP Low Back Pain Overview • Accounts for 2-6% of visits to Primary Care Physicians – Ranks 2nd to upper respiratory symptoms • 80% of the population will experience back pain at some point in their lifetime • Leading cause of work-related disability worldwide – People older than 45 • Evidence for excessive imaging and surgery in U.S. Low Back Pain Overview • $50-100 billion annually • Direct costs – Office visits – Imaging – Labs – Treatment • Indirect costs: – Absenteeism: 20 million sick days – Loss of productivity – Employer health care – Worker’s compensation benefits – 85% of costs incurred by only 5-10% patients Causes of Low Back Pain • Mechanical • Inflammatory / Spondylarthritis – Degenerative disk disease – Ankylosing spondylitis – Degenerative joint disease • Non-radiographic axial spondyloarthropathy – Muscle strain – Psoriatic arthritis – Pregnancy – Reactive arthritis – Spondylolisthesis – Enteric arthritis – Spondylolysis – Fracture • Referred pain – Spinal stenosis – Abdominal aneurysm – Cholecystitis • Infiltrative – Nephrolithiasis – Cancer – Pancreatitis – Infection • Osteomyelitis • Abscess • Diskitis Why is it important to distinguish between inflammatory vs. mechanical low back pain? Inflammatory vs. Mechanical Back Pain FEATURE INFLAMMATORY MECHANICAL Morning stiffness > 1 hour ≤ 30 minutes Fatigue Significant Minimal Nocturnal pain Moderate Mild Activity ↓ symptoms ↑ symptoms Rest ↑ symptoms ↓ symptoms Systemic symptoms Yes No Inflammatory Back Pain • Do you have low back stiffness in the morning? • Does the back pain get worse or better with activity? • Does the pain wake you up at night? • Have you noticed increased fatigue? • Have you noticed any unexplainable weight loss? Spondyloarthropathies Screening Questions • Peripheral joint pain / arthritis • Acute diarrhea preceding the arthritis • Family history • History of STDs –AS • Urethritis or cervicitis preceding the –Psoriasis arthritis – Uveitis • Enthesitis – Reactive Arthritis – Achilles' tendinitis – Inflammatory bowel disease – Plantar fasciitis • Rashes • Alternating buttock pain •Psoriasis • Iritis / uveitis • Inflammatory bowel disease • Sausage digit / dactylitis – Recurrent diarrhea • Unexplainable weight loss – Hematochezia – Abdominal pain • History of GI infections Inflammatory Back Disease • Spondyloarthropathies – Ankylosing spondylitis • Non-radiographic axial spondyloarthropathy – Psoriatic arthritis – Reactive arthritis – Enteric arthritis • Crohn’s • Ulcerative colitis Ankylosing Spondylitis Ankylosing Spondylitis Epidemiology • Late adolescence – early adulthood • Onset after age 40 uncommon • Male:Female 3:1 • Manifestations in females less pronounced Physical Exam • Sacroiliac joint involvement – Pelvic compression – Gaenslen’s test – Patrick’s test • Progression of spinal disease / ankylosis – Schober’s test – Occiput to wall test – Chest expansion Sacroiliac Pain Pelvic Compression Test Sacroiliac Pain Patrick’s Test (FABER’s Test) Gaenslen’s Test Progression of Spine Disease / Ankylosis Schober’s Test Occiput-to-Wall Test Physical Exam • Peripheral arthritis: 30% of patients with AS – Hips and shoulders common – Rare involvement • Sternoclavicular • Temporomandibular • Cricoarytenoid • Symphysis pubis • Enthesitis – Ligamentous structures of the intervertebral discs – Achilles enthesitis / tendinitis – Plantar fasciitis Extra-articular Manifestations • Cardiac • Renal – Aortic insufficiency – Secondary amyloidosis – Aortitis – IgA Nephropathy – Pericarditis (10%) • Ocular • Neurologic – Anterior uveitis (25-30%) – Atlantoaxial subluxations • Pulmonary – Cauda equina syndrome – Upper lobe fibrosis • Osteoporosis – Restrictive lung disease Apical Pulmonary Fibrosis Audience Polling Question 1 How many white ankylosing spondylitis patients have a positive HLA-B27? 1. 10% 2. 50% 3. 75% 4. 90% Audience Polling Question 2 How many non-white patients have a positive HLA-B27? 1. 0-5% 2. 20-40% 3. 50-80% 4. 90-100% Audience Polling Question 3 A positive HLA-B27 is seen in approximately 8% of healthy white people. What percentage of this population will develop ankylosing spondylitis? 1. 2% 2. 20% 3. 75% 4. 90% Laboratory Data •HLA –B27 – 90% of white AS patients – 50-80% of non-white patients – 8% healthy whites • 2% will develop AS • 15 – 20% if they have a 1st degree relative with AS – 3% healthy North American Blacks • ESR and CRP – Elevated in 70% of patients with AS – Normal ESR and/or CRP does not exclude the presence of clinically active AS Radiographic Findings • Sacroiliitis – Bilateral and symmetric – Involves lower 2/3 of SI joints – Earliest changes on the iliac side of the SI joint • Sclerosis • Pseudo-widening • Erosions • Complete ankylosis / fusion – If x-rays are normal •MRI Radiographic Findings • Spinal disease – Shiny corners – Squaring of the vertebrae – Ossification of the outer layers of the annulus fibrosis – Syndesmophytes •Thin • Marginal – Fusion of the vertebral body • Bamboo spine Radiographic Findings Enteric Arthritis Enteric Arthritis Epidemiology • Any age • Male = Female ULCERATIVE COLITIS CROHN’S DISEASE Peripheral arthritis 10% 20% Sacroiliitis 15% 15% Sacroiliitis/spondylitis 5% 5% Physical Exam Peripheral Arthritis Ulcerative Colitis Crohn’s Disease Shoulder 20% 20% Elbow 30% 10% Wrist 15% 15% MCP 25% 10% Hip 20% Knee 70% 80% Ankle 50% 40% MTP / Toes 10% Extra-intestinal Manifestations • Pyoderma gangrenosum (< 5%) • Aphthous stomatitis (< 10%) • Acute anterior uveitis ( 5 – 15%) • Erythema nodosum (< 10%) Frequency of HLA-B27 in IBD ULCERATIVE COLITIS CROHN’S DISEASE Sacroiliitis/spondyliti 70% 55% s Peripheral arthritis Same as normal Same as normal healthy control healthy control population population Laboratory Data • ESR and CRP elevated • ANA and RF negative • Iron deficiency anemia • Leukocytosis • Thrombocytosis • pANCA in 50 – 60% of UC patients Radiographic Findings • Same findings as with AS – Bilateral symmetric sacroiliitis – Bamboo spine • Activity of inflammatory spine disease does not correlate with IBD activity Psoriatic Arthritis Psoriatic Arthritis Epidemiology • 35 – 50 years old • Juvenile psoriatic arthritis: 9 – 12 years • Prevalence – Any arthritis: Male:Female 1:1 – Spinal involvement: Male:Female 3:1 • Less than 30% of patients with psoriasis will develop arthritis • Psoriasis precedes arthritis: 67% • Arthritis precedes psoriasis: 33% Occult Psoriasis • Umbilicus •Scalp • Anus / cleft of the buttocks •Ears Psoriatic Arthritis Subtypes SUBTYPE PERCENTAGE TYPICAL JOINTS Asymmetric 15-20% DIPs, PIPs, MCPs, MTPs, Knees, Hips, oligoarticular Ankles Predominant DIP 2-5% DIPs Involvement Arthritis Mutilans 5% DIPs, PIPs Polyarthritis (RA like) 50-60% MCPs, PIPs, Wrists Axial 2-5% Sacroiliitis, Spondylitis Clinical Features Associated with Subtypes • Asymmetric oligoarthritis: Dactylitis • Predominant DIP involvement: Nail changes • Arthritis mutilans: Osteolysis • “RA” like disease: Fusion of wrists • Axial involvement: Asymmetric sacroiliitis Asymmetric oligoarthritis: Dactylitis Predominant DIP Involvement: Nail Changes Arthritis Mutilans: Osteolysis Laboratory Data • ESR and CRP may be elevated • ANA, RF and CCP typically negative – Positive RF in 5 – 10% of patients – Positive CCP in 8 - 16% • Anemia Radiographic Data • Sacroiliitis – Unilateral – Asymmetric • Spinal disease – Asymmetric involvement – Syndesmophytes • Large • Non-marginal Radiographic Data Audience Polling Question 4 1. Normal 2. Ankylosing spondylitis 3. Degenerative arthritis 4. Psoriatic arthritis Audience Polling Question 5 1. Normal 2. Ankylosing spondylitis 3. Degenerative arthritis 4. Psoriatic arthritis Audience Polling Question 6 1. Normal 2. Ankylosing spondylitis 3. Degenerative arthritis 4. Psoriatic arthritis Audience Polling Question 7 1. Normal 2. Ankylosing spondylitis 3. Degenerative arthritis 4. Psoriatic arthritis Radiographic Data Radiographic Data Reactive Arthritis Reactive Arthritis Epidemiology • 20 – 40 years of age • Enterogenic: Male = Female – Campylobacter – Salmonella – Shigella – Yersinia • Urogenital: Male > Female – Chlamydia trachomatis – Ureaplasma urealyticum Sacroiliitis / Spondylitis • Similar to psoriatic arthritis – Sacroiliitis: Unilateral or asymmetric – Spondylitis: Nonmarginal syndesmophytes • 5% of patients with reactive arthritis develop x-ray changes in the SI joints Peripheral Arthritis • Asymmetric • Oligoarticular • Joints involved – Knees –Ankles – Feet –Wrists – Digits • Enthesitis Extra-articular Manifestations • Low-grade fever • Urethritis • Sterile conjunctivitis – Sterile • Anterior uveitis – Infectious • Colitis • Prostatitis – Infectious • Salpingitis – Sterile • Vulvovaginitis • Heart block • Keratoderma blennorrhagicum • Pericarditis • Circinate balanitis • Painless oral ulcers Keratoderma Blennorrhagicum Circinate Balanitis Laboratory Data • Many patients are HLA-B27 (-) • HLA-B27 (+) correlates with increased disease – Severity – Chronicity – Frequency
Recommended publications
  • Evicore Spine Imaging Guidelines
    CLINICAL GUIDELINES Spine Imaging Policy Version 1.0 Effective February 14, 2020 eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’s Primary Care Physician (PCP) may provide additional insight. CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. © 2019 eviCore healthcare. All rights reserved. Spine Imaging Guidelines V1.0 Spine Imaging Guidelines Procedure Codes Associated with Spine Imaging 3 SP-1: General Guidelines 5 SP-2: Imaging Techniques 14 SP-3: Neck (Cervical Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma 22 SP-4: Upper Back (Thoracic Spine) Pain Without/With Neurological Features (Including Stenosis) and Trauma 26 SP-5: Low Back (Lumbar Spine) Pain/Coccydynia without Neurological Features 28 SP-6: Lower Extremity Pain with Neurological Features (Radiculopathy, Radiculitis, or Plexopathy and Neuropathy) With or Without Low Back (Lumbar Spine) Pain 32 SP-7: Myelopathy 36 SP-8: Lumbar Spine Spondylolysis/Spondylolisthesis 39 SP-9: Lumbar Spinal Stenosis 42 SP-10: Sacro-Iliac (SI) Joint Pain, Inflammatory Spondylitis/Sacroiliitis and Fibromyalgia 44 SP-11: Pathological Spinal Compression Fractures 47 SP-12: Spinal Pain in Cancer Patients 49 SP-13: Spinal Canal/Cord Disorders (e.g.
    [Show full text]
  • Juvenile Spondyloarthropathies: Inflammation in Disguise
    PP.qxd:06/15-2 Ped Perspectives 7/25/08 10:49 AM Page 2 APEDIATRIC Volume 17, Number 2 2008 Juvenile Spondyloarthropathieserspective Inflammation in DisguiseP by Evren Akin, M.D. The spondyloarthropathies are a group of inflammatory conditions that involve the spine (sacroiliitis and spondylitis), joints (asymmetric peripheral Case Study arthropathy) and tendons (enthesopathy). The clinical subsets of spondyloarthropathies constitute a wide spectrum, including: • Ankylosing spondylitis What does spondyloarthropathy • Psoriatic arthritis look like in a child? • Reactive arthritis • Inflammatory bowel disease associated with arthritis A 12-year-old boy is actively involved in sports. • Undifferentiated sacroiliitis When his right toe starts to hurt, overuse injury is Depending on the subtype, extra-articular manifestations might involve the eyes, thought to be the cause. The right toe eventually skin, lungs, gastrointestinal tract and heart. The most commonly accepted swells up, and he is referred to a rheumatologist to classification criteria for spondyloarthropathies are from the European evaluate for possible gout. Over the next few Spondyloarthropathy Study Group (ESSG). See Table 1. weeks, his right knee begins hurting as well. At the rheumatologist’s office, arthritis of the right second The juvenile spondyloarthropathies — which are the focus of this article — toe and the right knee is noted. Family history is might be defined as any spondyloarthropathy subtype that is diagnosed before remarkable for back stiffness in the father, which is age 17. It should be noted, however, that adult and juvenile spondyloar- reported as “due to sports participation.” thropathies exist on a continuum. In other words, many children diagnosed with a type of juvenile spondyloarthropathy will eventually fulfill criteria for Antinuclear antibody (ANA) and rheumatoid factor adult spondyloarthropathy.
    [Show full text]
  • Etiopathogenesis of Sacroiliitis
    Korean J Pain 2020;33(4):294-304 https://doi.org/10.3344/kjp.2020.33.4.294 pISSN 2005-9159 eISSN 2093-0569 Review Article Etiopathogenesis of sacroiliitis: implications for assessment and management Manuela Baronio1, Hajra Sadia2, Stefano Paolacci3, Domenico Prestamburgo4, Danilo Miotti5, Vittorio A. Guardamagna6, Giuseppe Natalini1, and Matteo Bertelli3,7,8 1Dipartimento di Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Fondazione Poliambulanza, Brescia, Italy 2Atta-ur-Rahman School of Applied Biosciences, National University of Science and Technology, Islamabad, Pakistan 3MAGI’s Lab, Rovereto, Italy 4Ortopedia e Traumatologia, Ospedali Civili di Legnano e Cuggiono, Cuggiono, Italy 5Cure Palliative e Terapia del Dolore, ICS Maugeri, Pavia, Italy 6Cure Palliative e Terapia del Dolore, IRCCS IEO, Milano, Italy 7MAGI Euregio, Bolzano, Italy 8EBTNA-LAB, Rovereto, Italy Received January 16, 2020 Revised March 17, 2020 The sacroiliac joints connect the base of the sacrum to the ilium. When inflamed, Accepted April 16, 2020 they are suspected to cause low back pain. Inflammation of the sacroiliac joints is called sacroiliitis. The severity of the pain varies and depends on the degree of Handling Editor: Kyung Hoon Kim inflammation. Sacroiliitis is a hallmark of seronegative spondyloarthropathies. The presence or absence of chronic sacroiliitis is an important clue in the diagnosis of Correspondence low back pain. This article aims to provide a concise overview of the anatomy, physi- Stefano Paolacci ology, and molecular biology of sacroiliitis to aid clinicians in the assessment and MAGI’s Lab, Via delle Maioliche, 57/D, management of sacroiliitis. For this narrative review, we evaluated articles in Eng- Rovereto, Trentino 38068, Italy lish published before August 2019 in PubMed.
    [Show full text]
  • Pars Injection for Lumbar Spondylolysis
    Pars Injection for Lumbar Spondylolysis Issue 4: March 2016 Review date: February 2019 Following your recent investigations and consultation with your spinal surgeon, a possible cause for your symptoms may have been found. Your X-rays and / or scans have revealed that you have a lumbar spondylolysis. This is a stress fracture of the narrow bridge of bone between the facet joints (pars interarticularis) at the back of the spine, commonly called a pars defect. There may be a hereditary aspect to spondylolysis, for example an individual may be born with thin vertebral bone and therefore be vulnerable to this condition; or certain sports, such as gymnastics, weight lifting and football can put a great deal of stress on the bones through constantly over-stretching the spine. Either cause can result in a stress fracture on one or both sides of the vertebra (bone of the spine). Many people are not aware of their stress fracture or experience any problems but symptoms can occasionally occur including lower back pain, pain in the thighs and buttocks, stiffness, muscle tightness and tenderness. vertebra facet joint pars interarticularis sacrum spondylolysis (pars defect) intervertebral disc If the stress fracture weakens the bone so much that it is unable to maintain its proper position, the vertebra can start to shift out of place. This condition is called spondylolisthesis. Page 3 There is a forward slippage of one lumbar vertebra on the vertebra below it. The degree of spondylolisthesis may vary from mild to severe but if too much slippage occurs, the nerve roots can be stretched where they branch out of the spinal canal.
    [Show full text]
  • New ASAS Criteria for the Diagnosis of Spondyloarthritis: Diagnosing Sacroiliitis by Magnetic Resonance Imaging 9
    Document downloaded from http://www.elsevier.es, day 10/02/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Radiología. 2014;56(1):7---15 www.elsevier.es/rx UPDATE IN RADIOLOGY New ASAS criteria for the diagnosis of spondyloarthritis: ଝ Diagnosing sacroiliitis by magnetic resonance imaging ∗ M.E. Banegas Illescas , C. López Menéndez, M.L. Rozas Rodríguez, R.M. Fernández Quintero Servicio de Radiodiagnóstico, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain Received 17 January 2013; accepted 10 May 2013 Available online 11 March 2014 KEYWORDS Abstract Radiographic sacroiliitis has been included in the diagnostic criteria for spondy- Sacroiliitis; loarthropathies since the Rome criteria were defined in 1961. However, in the last ten years, Diagnosis; magnetic resonance imaging (MRI) has proven more sensitive in the evaluation of the sacroiliac Magnetic resonance joints in patients with suspected spondyloarthritis and symptoms of sacroiliitis; MRI has proven imaging; its usefulness not only for diagnosis of this disease, but also for the follow-up of the disease and Axial spondy- response to treatment in these patients. In 2009, The Assessment of SpondyloArthritis inter- loarthropathies national Society (ASAS) developed a new set of criteria for classifying and diagnosing patients with spondyloarthritis; one important development with respect to previous classifications is the inclusion of MRI positive for sacroiliitis as a major diagnostic criterion. This article focuses on the radiologic part of the new classification. We describe and illustrate the different alterations that can be seen on MRI in patients with sacroiliitis, pointing out the limitations of the technique and diagnostic pitfalls.
    [Show full text]
  • Spondylolysis and Spondylolisthesis. Congenital Anomalies of the Spine
    Spondylolysis and spondylolisthesis. Congenital anomalies of the spine. Scheurmann’s disease and its treatment. Degenerative changes of the spine. Spinal stenosis. Disc generation and prolapse. Sciatica. Ankylosing spondylitis. University of Debrecen Department of Orthopaedic Surgery 1 Anatomy DE OEC 2 Ortopédiai Klinika Vertebrae • 7 Cervical • 12 Thoracic • 5 Lumbar • 5 Sacral • 4-6 Coccygeal • Same structure, but different localisation, shape and function! • Anatomical – functional segment 3 Joints of the vertebrae ALL JOINT TYPES CAN BE FOUND • SYNDESMOSIS (ligamentous) • SYNCHONDROSIS (fibro cartilage) • SYNOSTOSIS (bone) • REGULAR JOINT (joint capsule, hyalin cartilage, synovial membrane, synovial fluid) 4 DE OEC 5 Ortopédiai Klinika SYNDESMOSIS • Anterior and posterior longitudinal ligament • Yellow ligament • Interspinous ligament • Intertransversal ligament 6 DE OEC 7 Ortopédiai Klinika SYNCHONDROSIS INTERVERTEBRAL DISC (anulus fibrosus, nucleus pulposus) 8 SYNOSTOSIS SACRUM 9 REGULAR JOINTS FACET JOINTS Joint capsule, hyaline cartilage, synovial membrane and fluid! 10 DE OEC 11 Ortopédiai Klinika Movements of the spine • Anteflexion • Retroflexion • Lateralflexion (left and right) • Torsion (left and right) • Pairs of wertebrae –anatomical and functional segment 12 Functions of the vertebral disc • Stability - Stabilizing role (Keeps the ligaments tight by keeping the distance between the vertebrae constant) • Flexibility - Buffer role. 13 Degenerative changes • CAUSE: disc prolapse and protrusion. • Disc flattening causes pain.
    [Show full text]
  • Rheuma.Stamp Line&Box
    Arthritis Mutilans: A Report from the GRAPPA 2012 Annual Meeting Vinod Chandran, Dafna D. Gladman, Philip S. Helliwell, and Björn Gudbjörnsson ABSTRACT. Arthritis mutilans is often described as the most severe form of psoriatic arthritis. However, a widely agreed on definition of the disease has not been developed. At the 2012 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members hoped to agree on a definition of arthritis mutilans and thus facilitate clinical and molecular epidemiological research into the disease. Members discussed the clinical features of arthritis mutilans and defini- tions used by researchers to date; reviewed data from the ClASsification for Psoriatic ARthritis study, the Nordic psoriatic arthritis mutilans study, and the results of a premeeting survey; and participated in breakout group discussions. Through this exercise, GRAPPA members developed a broad consensus on the features of arthritis mutilans, which will help us develop a GRAPPA-endorsed definition of arthritis mutilans. (J Rheumatol 2013;40:1419–22; doi:10.3899/ jrheum.130453) Key Indexing Terms: OSTEOLYSIS ANKYLOSIS PENCIL-IN-CUP SUBLUXATION FLAIL JOINT ARTHRITIS MUTILANS Psoriatic arthritis (PsA) is an inflammatory musculoskeletal gists as a severe destructive form of PsA, a precise disease specifically associated with psoriasis. Moll and definition has not yet been universally accepted. The earliest Wright defined PsA as “psoriasis associated with inflam- definition of arthritis mutilans was provided
    [Show full text]
  • Brown Tumors, Presenting with a Degenerative Lumber Disc Like Pain
    Open Access Archives of Pathology and Clinical Research Case Report A great mimicker of Bone Secondaries: Brown Tumors, presenting with a ISSN 2640-2874 Degenerative Lumber Disc like pain Zuhal Bayramoglu1*, Ravza Yılmaz1 and Aysel Bayram2 1Department of Radiology, Istanbul Medical Faculty, Istanbul University, Capa, Fatih, 34093, Istanbul, Turkey 2Department of Pathology, Istanbul Medical Faculty, Istanbul University, Capa, Fatih, 34093, Istanbul, Turkey *Address for Correspondence: Dr. Zuhal ABSTRACT Bayramoglu, Department of Radiology, Istanbul Medical Faculty, Istanbul University, Capa, Fatih, 34093, Istanbul, Turkey, Tel: +90-212- 414-20-00, This report presents an adult patient suffering from sacroiliitis like low back pain, lumbosacral radiculopathy Fax: +90-212-631-07-28; Email: and elbow swelling. Multimodality imaging revealed multiple lytic bone lesions located in supra acetabular [email protected] iliac bone, sacrum, and distal end of radius. Painful numerous lesions due to the extension to the articular Submitted: 06 June 2017 surfaces are not expected for Brown tumors. Less than ten cases with multiple Brown tumor due to primary Approved: 14 July 2017 hyperparathyroidism has been reported. Although Brown tumors are mostly diagnosed incidentally, this case Published: 17 July 2017 would awake the physicians about rheumatological symptoms in the presentation of Brown tumors. Since Brown tumors are non-touch bone lesions that are expected to regress after parathyroid adenoma removal, it is Copyright: 2017 Bayramoglu Z. This is an important to distinguish Brown tumors from the giant cell tumors. open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in CASE PRESENTATION any medium, provided the original work is properly cited.
    [Show full text]
  • Chapter 4: Massage and Sciatica: an In-Depth Study 2 CE Hours
    Chapter 4: Massage and Sciatica: An In-Depth Study 2 CE Hours By: Kerry Davis, LMT, CIMT, CPT Learning objectives Define the characteristics of sciatica. Discuss how to construct a treatment plan. Recognize the causes of sciatica. Discuss how to assess the client’s posture and gait. Compare sciatica with other conditions of the low back. Describe the evaluation of the client’s pain patterns and symptoms. Distinguish the muscle imbalance patterns attributing to sciatica. Demonstrate practice of test assessments to rule out other Understand the pattern of referred pain resulting from sciatica. conditions of the low back. Illustrate application of massage techniques to treat the client. Overview Low back pain affects more than three million people in the United encounter multiple cases during the course of their practice due to the States each year (Werner, 2002). According to a 2010 survey, low back impact that low back pain has on society. This course will educate the pain was listed as the third most oppressive condition afflicting people. massage therapist about how to identify sciatica. It will also familiarize Low back pain does not discriminate between men and women and the therapist with the most common causes of sciatica, discuss usually presents as early as the age of thirty; in fact, the prevalence differences between sciatica from piriformis syndrome and sacroiliac increases in correlation with age (National Institute of Neurological joint dysfunctions, examine the proper evaluation of the condition, as Disorders and Stroke, 2015). It is likely that massage therapists will well as develop the treatment protocols for sciatica. UNDERSTANDING SCIATICA Sciatica, or lumbar radiculopathy, is characterized as an inflammation in the feet and toes.
    [Show full text]
  • Spondylolysis and Spondylolisthesis in Children and Adolescents: I
    Spondylolysis and Spondylolisthesis in Children and Adolescents: I. Diagnosis, Natural History, and Nonsurgical Management Ralph Cavalier, MD Abstract Martin J. Herman, MD Spondylolysis and spondylolisthesis are often diagnosed in children Emilie V. Cheung, MD presenting with low back pain. Spondylolysis refers to a defect of Peter D. Pizzutillo, MD the vertebral pars interarticularis. Spondylolisthesis is the forward translation of one vertebral segment over the one beneath it. Isth- Dr. Cavalier is Attending Orthopaedic mic spondylolysis, isthmic spondylolisthesis, and stress reactions Surgeon, Summit Sports Medicine and involving the pars interarticularis are the most common forms seen Orthopaedic Surgery, Brunswick, GA. Dr. Herman is Associate Professor, in children. Typical presentation is characterized by a history of Department of Orthopaedic Surgery, activity-related low back pain and the presence of painful spinal Drexel University College of Medicine, mobility and hamstring tightness without radiculopathy. Plain ra- St. Christopher’s Hospital for Children, Philadelphia, PA. Dr. Cheung is Fellow, diography, computed tomography, and single-photon emission Department of Orthopaedic Surgery, computed tomography are useful for establishing the diagnosis. Mayo Clinic, Rochester, MN. Dr. Symptomatic stress reactions of the pars interarticularis or adjacent Pizzutillo is Professor, Department of vertebral structures are best treated with immobilization of the Orthopaedic Surgery, Drexel University College of Medicine, St. Christopher’s spine and activity restriction. Spondylolysis often responds to brief Hospital for Children. periods of activity restriction, immobilization, and physiotherapy. None of the following authors or the Low-grade spondylolisthesis (≤50% translation) is treated similarly. departments with which they are The less common dysplastic spondylolisthesis with intact posterior affiliated has received anything of value elements requires greater caution.
    [Show full text]
  • Sacroiliitis Mimics: a Case Report and Review of the Literature Maria J
    Antonelli and Magrey BMC Musculoskeletal Disorders (2017) 18:170 DOI 10.1186/s12891-017-1525-1 CASE REPORT Open Access Sacroiliitis mimics: a case report and review of the literature Maria J. Antonelli* and Marina Magrey Abstract Background: Radiographic sacroiliitis is the hallmark of ankylosing spondylitis (AS), and detection of acute sacroiliitis is pivotal for early diagnosis of AS. Although radiographic sacroiliitis is a distinguishing feature of AS, sacroiliitis can be seen in a variety of other disease entities. Case presentation: We present an interesting case of sacroiliitis in a patient with Paget disease; the patient presented with inflammatory back pain which was treated with bisphosphonate. This case demonstrates comorbidity with Paget disease and possible ankylosing spondylitis. We also present a review of the literature for other cases of Paget involvement of the sacroiliac joint. Conclusions: In addition, we review radiographic changes to the sacroiliac joint in classical ankylosing spondylitis as well as other common diseases. We compare and contrast features of other diseases that mimic sacroiliitis on a pelvic radiograph including Paget disease, osteitis condensans ilii, diffuse idiopathic skeletal hyperostosis, infections and sarcoid sacroiliitis. There are some features in the pelvic radiographic findings which help distinguish among mimics, however, one must also rely heavily on extra-pelvic radiographic lesions. In addition to the clinical presentation, various nuances may incline a clinician to the correct diagnosis; rheumatologists should be familiar with the imaging differences among these diseases and classic spondylitis findings. Keywords: Case report, Ankylosing spondylitis, Clinical diagnostics & imaging, Rheumatic disease Background We conducted a search in PubMed including combi- The presence of sacroiliitis on an anterior-posterior (AP) nations of the following search terms: sacroiliitis, sacro- pelvis or dedicated sacroiliac film is a defining feature of iliac, and Paget disease.
    [Show full text]
  • Psoriatic Arthritis Howard Duncan
    Henry Ford Hospital Medical Journal Volume 13 | Number 2 Article 6 6-1965 Psoriatic Arthritis Howard Duncan Darrell Oberg William R. Eyler Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Duncan, Howard; Oberg, Darrell; and Eyler, William R. (1965) "Psoriatic Arthritis," Henry Ford Hospital Medical Bulletin : Vol. 13 : No. 2 , 173-181. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol13/iss2/6 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. For more information, please contact [email protected]. Henry Ford Hosp. Med. Bull. Vol. 13, June, 1965 PSORIATIC ARTHRITIS* HOWARD DUNCAN, M.D.,** DARRELL OBERG, M.D.,** AND WILLIAM R. EYLER, M.D.*** Dr. Howard Duncan. It is apparent from these meetings that rheumatologists are not alone in having troubles with dissension amongst the hierarchy in arriving at a decision as to whether a disease exists or not. The problem is the relationship between arthritis and psoriasis. Our first approach will be to demonstrate that there is an entity "psoriatic arthritis" which is distinct from rheumatoid arthritis with psoriasis. I'll ask Dr. Oberg to illustrate the situation. Dr. Darrell Oberg. Our patient is a 49 year old white female who was first .seen in this hospital in 1960, at which time she was admitted with malignant hypertension, which has subsequently been controlled by treatment prescribed in the Hypertension Division.
    [Show full text]