Mechanical Low Back Pain Joshua Scott Will, DO; David C
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Opioid-Induced Hyperalgesia in Humans Molecular Mechanisms and Clinical Considerations
SPECIAL TOPIC SERIES Opioid-induced Hyperalgesia in Humans Molecular Mechanisms and Clinical Considerations Larry F. Chu, MD, MS (BCHM), MS (Epidemiology),* Martin S. Angst, MD,* and David Clark, MD, PhD*w treatment of acute and cancer-related pain. However, Abstract: Opioid-induced hyperalgesia (OIH) is most broadly recent evidence suggests that opioid medications may also defined as a state of nociceptive sensitization caused by exposure be useful for the treatment of chronic noncancer pain, at to opioids. The state is characterized by a paradoxical response least in the short term.3–14 whereby a patient receiving opioids for the treatment of pain Perhaps because of this new evidence, opioid may actually become more sensitive to certain painful stimuli. medications have been increasingly prescribed by primary The type of pain experienced may or may not be different from care physicians and other patient care providers for the original underlying painful condition. Although the precise chronic painful conditions.15,16 Indeed, opioids are molecular mechanism is not yet understood, it is generally among the most common medications prescribed by thought to result from neuroplastic changes in the peripheral physicians in the United States17 and accounted for 235 and central nervous systems that lead to sensitization of million prescriptions in the year 2004.18 pronociceptive pathways. OIH seems to be a distinct, definable, One of the principal factors that differentiate the use and characteristic phenomenon that may explain loss of opioid of opioids for the treatment of pain concerns the duration efficacy in some cases. Clinicians should suspect expression of of intended use. -
Download the Herniated Disc Brochure
AN INTRODUCTION TO HERNIATED DISCS This booklet provides general information on herniated discs. It is not meant to replace any personal conversations that you might wish to have with your physician or other member of your healthcare team. Not all the information here will apply to your individual treatment or its outcome. About the Spine CERVICAL The human spine is comprised 24 bones or vertebrae in the cervical (neck) spine, the thoracic (chest) spine, and the lumbar (lower back) THORACIC spine, plus the sacral bones. Vertebrae are connected by several joints, which allow you to bend, twist, and carry loads. The main joint LUMBAR between two vertebrae is called an intervertebral disc. The disc is comprised of two parts, a tough and fibrous outer layer (annulus fibrosis) SACRUM and a soft, gelatinous center (nucleus pulposus). These two parts work in conjunction to allow the spine to move, and also provide shock absorption. INTERVERTEBRAL ANNULUS DISC FIBROSIS SPINAL NERVES NUCLEUS PULPOSUS Each vertebrae has an opening (vertebral foramen) through which a tubular bundle of spinal nerves and VERTEBRAL spinal nerve roots travel. FORAMEN From the cervical spine to the mid-lumbar spine this bundle of nerves is called the spinal cord. The bundle is then referred to as the cauda equina through the bottom of the spine. At each level of the spine, spinal nerves exit the spinal cord and cauda equina to both the left and right sides. This enables movement and feeling throughout the body. What is a Herniated Disc? When the gelatinous center of the intervertebral disc pushes out through a tear in the fibrous wall, the disc herniates. -
Vertebral Column and Thorax
Introduction to Human Osteology Chapter 4: Vertebral Column and Thorax Roberta Hall Kenneth Beals Holm Neumann Georg Neumann Gwyn Madden Revised in 1978, 1984, and 2008 The Vertebral Column and Thorax Sternum Manubrium – bone that is trapezoidal in shape, makes up the superior aspect of the sternum. Jugular notch – concave notches on either side of the superior aspect of the manubrium, for articulation with the clavicles. Corpus or body – flat, rectangular bone making up the major portion of the sternum. The lateral aspects contain the notches for the true ribs, called the costal notches. Xiphoid process – variably shaped bone found at the inferior aspect of the corpus. Process may fuse late in life to the corpus. Clavicle Sternal end – rounded end, articulates with manubrium. Acromial end – flat end, articulates with scapula. Conoid tuberosity – muscle attachment located on the inferior aspect of the shaft, pointing posteriorly. Ribs Scapulae Head Ventral surface Neck Dorsal surface Tubercle Spine Shaft Coracoid process Costal groove Acromion Glenoid fossa Axillary margin Medial angle Vertebral margin Manubrium. Left anterior aspect, right posterior aspect. Sternum and Xyphoid Process. Left anterior aspect, right posterior aspect. Clavicle. Left side. Top superior and bottom inferior. First Rib. Left superior and right inferior. Second Rib. Left inferior and right superior. Typical Rib. Left inferior and right superior. Eleventh Rib. Left posterior view and left superior view. Twelfth Rib. Top shows anterior view and bottom shows posterior view. Scapula. Left side. Top anterior and bottom posterior. Scapula. Top lateral and bottom superior. Clavicle Sternum Scapula Ribs Vertebrae Body - Development of the vertebrae can be used in aging of individuals. -
Lower Back Pain in Athletes EXPERT CONSULTANTS: Timothy Hosea, MD, Monica Arnold, DO
SPORTS TIP Lower Back Pain in Athletes EXPERT CONSULTANTS: Timothy Hosea, MD, Monica Arnold, DO How common is low back pain? What structures of the back Low back pain is a very common can cause pain? problem in industrialized countries, Low back pain can come from all the affecting over 70 percent of the working spinal structures. The bony elements population. Back pain is also common of the spine can develop stress fractures, in such sports as football, soccer, or in the older athlete, arthritic changes golf, rowing, and gymnastics. which may pinch the nerve roots. The annulus has a large number of pain What are the structures fibers, and any injury to this structure, of the back? such as a sprain, bulging disc, or disc The spine is composed of three regions herniation will result in pain. Finally, the from your neck to the lower back. surrounding muscles and ligaments may The cervical region corresponds also suffer an injury, leading to pain. to your neck, the thoracic region is the mid-back (or back of the chest), How is the lower back injured? and the lumbar area is the lower back. Injuries to the lower back can be the The lumbar area provides the most result of improper conditioning and motion and works the hardest in warm-up, repetitive loading patterns, supporting your weight, and enables excessive sudden loads, and twisting you to bend, twist, and lift. activities. Proper body mechanics and flexibility are essential for all activities. Each area of the spine is composed To prevent injury, it is important to learn of stacked bony vertebral bodies with the proper technique in any sporting interposed cushioning pads called discs. -
Guidline for the Evidence-Informed Primary Care Management of Low Back Pain
Guideline for the Evidence-Informed Primary Care Management of Low Back Pain 2nd Edition These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making. Guideline Disease/Condition(s) Targeted Specifications Acute and sub-acute low back pain Chronic low back pain Acute and sub-acute sciatica/radiculopathy Chronic sciatica/radiculopathy Category Prevention Diagnosis Evaluation Management Treatment Intended Users Primary health care providers, for example: family physicians, osteopathic physicians, chiro- practors, physical therapists, occupational therapists, nurses, pharmacists, psychologists. Purpose To help Alberta clinicians make evidence-informed decisions about care of patients with non- specific low back pain. Objectives • To increase the use of evidence-informed conservative approaches to the prevention, assessment, diagnosis, and treatment in primary care patients with low back pain • To promote appropriate specialist referrals and use of diagnostic tests in patients with low back pain • To encourage patients to engage in appropriate self-care activities Target Population Adult patients 18 years or older in primary care settings. Exclusions: pregnant women; patients under the age of 18 years; diagnosis or treatment of specific causes of low back pain such as: inpatient treatments (surgical treatments); referred pain (from abdomen, kidney, ovary, pelvis, -
Inflammatory Back Pain in Patients Treated with Isotretinoin Although 3 NSAID Were Administered, Her Complaints Did Not Improve
Inflammatory Back Pain in Patients Treated with Isotretinoin Although 3 NSAID were administered, her complaints did not improve. She discontinued isotretinoin in the third month. Over 20 days her com- To the Editor: plaints gradually resolved. Despite the positive effects of isotretinoin on a number of cancers and In the literature, there are reports of different mechanisms and path- severe skin conditions, several disorders of the musculoskeletal system ways indicating that isotretinoin causes immune dysfunction and leads to have been reported in patients who are treated with it. Reactive seronega- arthritis and vasculitis. Because of its detergent-like effects, isotretinoin tive arthritis and sacroiliitis are very rare side effects1,2,3. We describe 4 induces some alterations in the lysosomal membrane structure of the cells, cases of inflammatory back pain without sacroiliitis after a month of and this predisposes to a degeneration process in the synovial cells. It is isotretinoin therapy. We observed that after termination of the isotretinoin thought that isotretinoin treatment may render cells vulnerable to mild trau- therapy, patients’ complaints completely resolved. mas that normally would not cause injury4. Musculoskeletal system side effects reported from isotretinoin treat- Activation of an infection trigger by isotretinoin therapy is complicat- ment include skeletal hyperostosis, calcification of tendons and ligaments, ed5. According to the Naranjo Probability Scale, there is a potential rela- premature epiphyseal closure, decreases in bone mineral density, back tionship between isotretinoin therapy and bilateral sacroiliitis6. It is thought pain, myalgia and arthralgia, transient pain in the chest, arthritis, tendonitis, that patients who are HLA-B27-positive could be more prone to develop- other types of bone abnormalities, elevations of creatine phosphokinase, ing sacroiliitis and back pain after treatment with isotretinoin, or that and rare reports of rhabdomyolysis. -
Headache and Chronic Pain in Primary Care
FAMILY PRACTICE GRAND ROUNDS Headache and Chronic Pain in Primary Care Thomas Greer, MD, MPH, Wayne Katon, MD, Noel Chrisman, PhD, Stephen Butler, MD, Dee Caplan-Tuke, MSW Seattle, W a s h in g t o n R. THOMAS GREER (Assistant Professor, Depart automobile accident while vacationing in another state Dment of Family Medicine): The management of pa and suffered multiple contusions and rib fractures. Oral tients with chronic headaches is difficult and often a source methadone had been prescribed at her second clinic visit of discord between the patient and his or her physician. when other oral narcotics failed to control her pain. She The patient with chronic headaches presented in this con also had a long history of visits for headaches, treated with ference illustrates most of the common problems encoun injections of a narcotic, usually meperidine, and oral co tered in the diagnosis, treatment, and management of pa deine. tients with other kinds of chronic pain as well. As her acute injuries healed and she was tapered off the methadone, her chronic headaches emerged as a signifi cant problem. Within a few months the patient was reg EPIDEMIOLOGY ularly requesting oral codeine for the management of her severe, intractable headaches. More than 40 million Americans consult physicians each In early September she was brought to our emergency year for complaints of headache.1 The National Ambu department by ambulance following an apparent seizure. latory Medical Care Survey, which gathered information Witnesses reported that the patient had “jerking move on approximately 90,000 patient visits to a nationally ments.” There was no incontinence; and the ambulance representative sample of physicians, determined that personnel found the patient to be irritable and disoriented headache was the second most common chronic pain but with stable vital signs. -
5. Vertebral Column
5. Vertebral Column. Human beings belong to a vast group animals, the vertebrates. In simple terms we say that vertebrates are animals with a backbone. This statement barely touches the surface of the issue. Vertebrates are animals with a bony internal skeleton. Besides, all vertebrates have a fundamental common body plan. The central nervous system is closer to the back than it is to the belly, the digestive tube in the middle and the heart is ventral. The body is made of many segments (slices) built to a common plan, but specialised in different regions of the body. A “coelomic cavity” with its own special plan is seen in the trunk region and has a characteristic relationship with the organs in the trunk. This is by no means a complete list of vertebrate characteristics. Moreover, some of these features may be shared by other animal groups in a different manner. Such a study is beyond the scope of this unit. Vertebrates belong to an even wider group of animals, chordates. It may be difficult to imagine that we human beings are in fact related to some the earlier chordates! However, we do share, at least during embryonic development, an important anatomical structure with all chordates. This structure is the notochord. The notochord is the first stiff, internal support that appeared during the evolutionary story. As we have seen in early embryology, it also defines the axis of the body. The vertebral column evolved around the notochord and the neural tube, and we see a reflection of this fact during our embryonic development. -
Surgery for Lumbar Radiculopathy/ Sciatica Final Evidence Report
Surgery for Lumbar Radiculopathy/ Sciatica Final evidence report April 13, 2018 Health Technology Assessment Program (HTA) Washington State Health Care Authority PO Box 42712 Olympia, WA 98504-2712 (360) 725-5126 www.hca.wa.gov/hta [email protected] Prepared by: RTI International–University of North Carolina Evidence-based Practice Center Research Triangle Park, NC 27709 www.rti.org This evidence report is based on research conducted by the RTI-UNC Evidence-based Practice Center through a contract between RTI International and the State of Washington Health Care Authority (HCA). The findings and conclusions in this document are those of the authors, who are responsible for its contents. The findings and conclusions do not represent the views of the Washington HCA and no statement in this report should be construed as an official position of Washington HCA. The information in this report is intended to help the State of Washington’s independent Health Technology Clinical Committee make well-informed coverage determinations. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients). This document is in the public domain and may be used and reprinted without permission except those copyrighted materials that are clearly noted in the document. Further reproduction of those copyrighted materials is prohibited without the specific permission of copyright holders. -
Anatomic Mapping of Lumbar Nerve Roots During a Direct Lateral Transpsoas Approach to the Spine a Cadaveric Study
SPINE Volume 36, Number 11, pp E687–E691 ©2011, Lippincott Williams & Wilkins ANATOMY Anatomic Mapping of Lumbar Nerve Roots During a Direct Lateral Transpsoas Approach to the Spine A Cadaveric Study Kelley Banagan , MD, Daniel Gelb , MD, Kornelis Poelstra , MD, PhD, and Steven Ludwig , MD longitudinal ligament at the level of the disc to the sympathetic chain Study Design. Cadaveric study. averaged 9.25 mm. The nerve roots and genitofemoral nerve were Objective. Identifying anatomic structures at risk for injury during placed at risk in all dissections in which the approach was recreated. direct lateral transpsoas approach to the spine. Damage secondary to K-wire placement occurred in 25% of cases Summary of Background Data. Direct lateral transpsoas at L3–L4 and L4–L5; in one case, L4 nerve root was pierced, and approach is a novel technique that has been described for anterior in another, genitofemoral nerve was pierced. K-wire was posterior lumbar interbody fusion. Potential risks include damage to to the nerve roots in 25% of cases at L3–L4 and in 50% of cases genitofemoral nerve and lumbar plexus, which are not well visualized at L4–L5. The lumbar plexus was placed under tension because of during small retroperitoneal exposure. Previous cadaveric studies did sequential dilator placement. not evaluate the direct lateral transpsoas approach, and considering Conclusion. On the basis of our results, there is no zone of absolute the approach being used in clinical practice, the current study was safety when using the direct lateral transpsoas approach. The potential undertaken in an effort to identify the structures at risk during direct for nerve injury exists when using this approach, and consequently, we lateral transpsoas approach. -
AAFP Chronic Pain Toolkit
AAFP Chronic Pain Toolkit PAIN ASSESSMENT | Section 1 OVERVIEW Assessment of chronic pain should be multidimensional. Consideration should be given to several domains, including the physiological features of pain and its contributing factors, with physicians and other clinicians assessing patients for function, quality of life, mental health, and emotional health. In addition to a complete medical and medication history typically obtained at an office visit, documentation should be obtained about pain intensity, location, duration, and factors that aggravate or alleviate pain. A physical exam should include musculoskeletal and neurological components, as appropriate. Diagnostic testing and imaging may also be considered for some types of chronic pain. Many organizations, including the AAFP, recommend against imaging for low back pain within the first six weeks of treatment unless there are reasons for the imaging. These reasons may include concerns of underlying conditions, such as severe or progressive neurological deficits, or if osteomyelitis is suspected.1 Periodic reassessments of chronic pain and treatment should focus on evaluating improvements in physical health; mental and emotional health; progress towards functional treatment goals; and effectiveness and tolerability of medications for chronic pain treatment. Currently, there are no universally adopted guidelines or recommendations for assessment of chronic pain. The use of appropriate assessment tools can assist in diagnostic assessment, management, reassessment, and monitoring of treatment effects. Multiple tools are available, with many embedded in electronic health record (EHR) systems. Pain Assessment Tools The table on the next page includes selected tools for pain assessment included in this toolkit, along with links and reference to additional tools. Assessments about other relevant domains are covered in Functional and Other Assessments (Section 2). -
Anesthetic Or Corticosteroid Injections for Low Back Pain
Anesthetic or Corticosteroid Injections for Low Back Pain Examples Trigger point injections. Sometimes, putting pressure on a certain spot in the back (called a trigger point) can cause pain at that spot or extending to another area of the body, such as the hip or leg. To try to relieve pain, a local anesthetic, either alone or combined with a corticosteroid, is injected into the area of the back that triggers pain (trigger point injection). Facet joint injections. A local anesthetic or corticosteroid is injected into a facet joint, which is one of the points where one vertebra connects to another. Epidural injections. A corticosteroid is injected into the spinal canal where it bathes the sheath that surrounds the spinal cord and nerve roots. These injections can be done by an orthopedist, an anesthesiologist, a neurologist, a physiatrist, a pain management specialist, or a rheumatologist. How It Works Local anesthesia is believed to break the cycle of pain that can cause you to become less physically active. Muscles that are not being exercised are more easily injured. Then the irritated and injured muscles can cause more pain and spasm and can disrupt sleep. This pain, spasm, and fatigue, in turn, can lead to less and less activity. Steroids reduce inflammation. So a corticosteroid injected into the spinal canal can help relieve pressure on nerves and nerve roots. Why It Is Used Injections may be tried if you have symptoms of nerve root compression or facet inflammation and you do not respond to nonsurgical therapy after 6 weeks. How Well It Works Research has not shown that local injections are effective in controlling low back pain that does not spread down the leg.footnote1 Side Effects All medicines have side effects.