Dolor de espalda. Generalidades en su diagnóstico y tratamiento / Generalities of Back Pain in Diagnosis And Treatment

Introducción: El dolor de espalda es un síntoma frecuente y de distribución universal que afecta a personas de cualquier edad y de ambos sexos. El 80 % de la población presentará un dolor de espalda en algún momento de su vida. Los procesos agudos son autolimitados y se resuelven en el plazo de unas semanas, excepto algunos casos que se cronifican y requieren asistencia médica continuada. Los cuadros crónicos son más frecuentes en edades comprendidas entre 45 y 65 años y en el sexo femenino. Objetivo: Actualizar los elementos generales relacionados con el diagnóstico y tratamiento del dolor de espalda. Métodos: Se realizó una revisión detallada en la literatura en relación al dolor de espalda en cuanto a su diagnóstico y tratamiento. Se obtuvo literatura actualizada en las bases de datos Cumed, Ibec, Lilac, Pubmed/Medline, Scopus y Wholis. Se hizo una revisión del tema fundamentalmente de los últimos 5 años. Conclusiones: El dolor de espalda es un síntoma frecuente y de distribución universal que afecta a personas de cualquier edad y de ambos sexos. Las recomendaciones presentadas están basadas en la mejor evidencia disponible, con la intención de estandarizarlas para el tratamiento del dolor de espalda en la Atención Primaria de Salud y para el tratamiento farmacológico y no farmacológico(AU)

Introduction: Back pain is a frequent and universally distributed symptom that affects people of any age and of both sexes. 80% of the population will experience back pain at some point in their lives. Acute processes are self-limiting and resolve within a few weeks, except for some cases that become chronic and require continued medical care. Chronic symptoms are more frequent in ages between 45 and 65 years and in the female sex. Objective: To update the general elements related to the diagnosis and treatment of back pain. Methods: A detailed review of the literature was carried out in relation to back pain in terms of diagnosis and treatment. Updated literature was retrieved from Cumed, Ibec, Lilac, Pubmed/Medline, Scopus, and Wholis databases. A review of the subject was made fundamentally of the last 5 years. Conclusions: Back pain is a frequent and universally distributed symptom that affects persons of any age and both sexes. The recommendations are based on the best available evidence, with the intention of standardizing them for treating back pain in Primary Health Care and for pharmacological and non-pharmacological treatment(AU)

Baseline characteristics of postmenopausal women with osteoporosis treated with teriparatide in a real-world setting in Latin America: a subregional analysis from the Asia and Latin America Fracture Observational Study (ALAFOS)

Abstract Background: Osteoporosis is a major healthcare concern in Latin America. Factors such as changing demographics, fragmented healthcare systems, and financial considerations may result in a huge increase in the burden of osteoporosis in this region. The aim of this article is to describe the baseline clinical characteristics and fracture history of patients who are prescribed teriparatide in normal clinical practice in Latin America. Methods: We conducted a prospective, multinational, observational study (the Asia and Latin America Fracture Observational Study [ALAFOS]) in 20 countries worldwide to assess the incidence of fractures in postmenopausal women with osteoporosis receiving teriparatide as a part of routine clinical practice in a real-world setting. In this subregional analysis of the ALAFOS study, we report the clinical characteristics, fracture history, risk factors for osteoporosis, comorbidities, previous osteoporosis therapies and health-related quality of life measures at baseline for patients from the four participant Latin American countries: Argentina, Brazil, Colombia, and Mexico. Results: The Latin America subregional cohort included 546 postmenopausal women (mean [SD] age: 71.0 [10.1] years; range: 40-94 years), constituting 18% of the ALAFOS total population. The baseline mean (SD) bone mineral density T-scores were - 3.02 (1.23) at the lumbar spine and - 2.31 (0.96) at the femoral neck; 62.8% of patients had a history of low trauma fracture after the age of 40 years and 39.7% of patients had experienced ≥1 fall in the past year. Osteoporosis medications were used by 70.9% of patients before initiating teriparatide. The median (Q1, Q3) EQ-5D-5 L Visual Analog Scale (VAS) scores for perceived health status at baseline was 70 (50, 80). The mean (SD) worst back pain numeric rating scale score for the overall Latin American cohort was 4.3 (3.4) at baseline. Conclusions: This baseline analysis of the Latin America subregion of the ALAFOS study indicates that patients who are prescribed teriparatide in the four participant countries had severe osteoporosis and high prevalence of fractures. They also had back pain and poor health-related quality of life. The proportions of patients with severe or extreme problems on the EQ-5D-5 L individual domains were lower than those in the overall ALAFOS study population.

Spinal injection of local anesthetic during cervical facet joint injection / Injeção espinhal de anestésico local durante injeção em facetas articulares cervicais

Abstract Introduction: Facet joint pain is a common source of non-radicular back pain worldwide. Non-surgical interventional modalities remain the mainstay in the treatment of facetogenic back pain and comprise the second most commonly performed interventional pain procedures in the USA. Case: A 36 year-old man with chronic cervical pain secondary to C6-C7 facet arthrosis radiographically, underwent diagnostic local anesthetic bilateral facet joint injection under fluoroscopic guidance. The left side was injected uneventfully; however, 1-2 min following injection of the right side the patient complained of unwellness and became very anxious. He referred paresthesias of the bilateral upper extremities, chest and upper abdomen. Physical examination showed sensory deficits roughly from C5 to T7 without motor deficits; resuscitation measures were not warranted. The deficits were completely resolved by 35-40 min in the recovery area. Discussion: Facet joint injections are a common and safe method of treating back pain secondary to facet arthropathy. Despite excellent safety profiles, rare and sometimes, life-threatening complications can occur. Our case hypothesizes intrathecal injection of local anesthetic during facet joint injection. Few reports have described similar situations. We hypothesize a mechanism of entry through the facet joint, given the proximity of the ligamentum flavum, and the intrathecal space to the anterior aspect of the facet joint. This report reinforces the need for resuscitation and airway management equipment to be readily available where interventional procedures are performed, as well as the need for adequate proficiency in airway management and resuscitation techniques in Pain Medicine training.

Resumo Introdução: A dor nas articulações facetárias é uma fonte mundialmente comum de dores nas costas não radiculares. As modalidades de intervenções não cirúrgicas continuam sendo os pilares no tratamento da dorsalgia facetária e ocupam o segundo lugar entre os procedimentos mais comumente feitos nos EUA para o manejo da dor. Relato de caso: Paciente do sexo masculino, 36 anos, com dor cervical crônica secundária à artrose facetária em C6-C7 (confirmada por radiografia), submetido a exame diagnóstico bilateral das facetas com injeção de anestésico local sob orientação fluoroscópica. O lado esquerdo foi injetado sem intercorrências; porém, um-dois minutos após a injeção do lado direito, o paciente queixou-se de mal-estar e ficou muito ansioso. Mencionou parestesia nos braços, no tórax e no abdome superior. O exame físico revelou déficits sensoriais de, aproximadamente, C5 a T7, sem déficit motor; medidas de reanimação não eram justificáveis. Os déficits foram completamente resolvidos em 35-40 minutos na área de recuperação. Discussão: A aplicação de injeções nas articulações facetárias é um método comum e seguro de tratar a dor nas costas secundária à artropatia facetária. Apesar dos excelentes perfis de segurança, complicações raras e, às vezes, com risco de morte podem ocorrer. Nosso caso relata a injeção intratecal de anestésico local durante injeção nas facetas articulares. Poucos relatos descreveram situações semelhantes. Levantamos a hipótese de um mecanismo de entrada através da faceta articular, por causa da proximidade do ligamento amarelo e do espaço intratecal com o aspecto anterior da faceta articular. Esse relato reforça a necessidade de reanimação e de equipamentos para o manejo das vias aéreas estarem prontamente disponíveis quando procedimentos intervencionistas são feitos, bem como a necessidade de estabelecer o domínio do conhecimento no manejo das vias aéreas e das técnicas de reanimação e treinamento em medicina da dor.

Efficacy of gabapentin in the improvement of pruritus and quality of life of patients with notalgia paresthetica

BACKGROUND: notalgia paresthetica is a subdiagnosed sensory neuropathy presenting as a condition of intense itching and hyperchromic macule on the back that interferes with daily habits. OBJECTIVES: To determine the efficacy of treatment of notalgia paresthetica using oral gabapentin, assessing the degree of improvement in itching and influence on quality of life. Moreover, to evaluate the signs and symptoms associated with notalgia paresthetica. METHODS: We conducted an experimental, non-randomized, parallel, non-blinded study including 20 patients with clinical and histopathological diagnosis of notalgia paresthetica. After application of the visual analogue scale of pain adapted for pruritus and of the questionnaire of dermatology life quality index (DLQI), ten patients with visual analogue scale > 5 were given treatment with gabapentin at the dose of 300 mg/day for four weeks. The other ten were treated with topical capsaicin 0.025% daily for four weeks. After the treatment period, patients answered again the scale of itching. RESULTS: The use of gabapentin was responsible for a significant improvement in pruritus (p=0.0020). Besides itching and hyperchromic stain on the back, patients reported paresthesia and back pain. It was observed that the main factor in the worsening of the rash is heat. CONCLUSION: Gabapentin is a good option for the treatment of severe itching caused by nostalgia paresthetica. .

Pancreatite autoimune / Autoimmune pancreatitis

Pancreatite autoimune é uma entidade caracterizada por processo inflamatório autoimune, no qual há proeminente infiltrado linfocitário associado à fibrose do pâncreas, com disfunção orgânica. Nas últimas quatro décadas, várias descrições morfológicas foram propostas para caracterizar a doença. Recentemente, o termo pancreatite autoimune se tornou largamente aceito, embora, aparentemente, a pancreatite autoimune seja uma doença heterogênea.

Autoimmune pancreatitis is a entity characterized by an autoimmune inflammatory process where there is an outstanding lymphocytic infiltrated associated with fibrosis of pancreas with organic dysfunction. The last four decades, many morphological descriptions have been proposed in order to characterized the disease. Recently, autoimmune pancreatitis term became widely accepted, however, autoimmune pancreatitis is a heterogeneous disease.

Transforaminal epidural steroid injection for the treatment of severe back pain caused by cement leakage during kyphoplasty procedure

Kyphoplasty is a minimally invasive procedure that is increasingly used to treat pain caused by compression fractures of vertebral bodies. A 56-year-old woman who had a compression fracture on the vertebral body of L5 vertebra was admitted to the Algology Department with a severe low back and leg pain. Kyphoplasty was planned for pain relief. She suffered severe pain in her back and left leg immediately after the procedure because of a leakage of injected cement through the fracture line. After injection of triamcinolone and bupivacaine transforaminally into the L5-S1 anterior epidural space, her pain complaints ended. If radicular pain symptoms caused by cement leakage are secondary to a chemically mediated non-cellular inflammatory reaction, transforaminal epidural steroid injection should be useful

Comparison of Effect of Treatment with Etidronate and Alendronate on Lumbar Bone Mineral Density in Elderly Women with Osteoporosis

The purpose of this open-labeled prospective study was to compare the treatment effects of cyclical etidronate and alendronate on the lumbar bone mineral density (BMD), bone resorption, and back pain in elderly women with osteoporosis. Fifty postmenopausal women with osteoporosis, age ranging from 55 to 86 years (mean: 70.7 years), were randomly divided into two groups with 25 patients in each group: the cyclical etidronate group (etidronate 200 mg daily for 2 weeks every 3 months) and the alendronate group (5 mg daily). The BMD of the lumbar spine (L1-L4) measured by DXA, the urinary cross-linked N-terminal telopeptides of type I collagen (NTX) level measured by the enzyme-linked immunosorbent assay, and back pain evaluated by the face scale score were assessed at baseline, 6 months, and 12 months. There were no significant differences in baseline characteristics including age, body mass index, years since menopause, lumbar BMD, urinary NTX level, and face scale score between the two treatment groups. Etidronate treatment sustained the lumbar BMD following a reduction in the urinary NTX level and improved back pain, while alendronate treatment reduced the urinary NTX level more significantly, resulting in an increase in the lumbar BMD, and similarly improved back pain. No serious adverse events were observed in either group. This study confirmed that alendronate treatment had a greater efficacy than etidronate treatment in increasing the lumbar BMD through the reduction of bone resorption in elderly women with osteoporosis.

Tratamento de dor em paciente com tumor sacral inoperável: relato de caso / Management of pain in patient with inoperable sacral tumor: case report

JUSTIFICATIVA E OBJETIVOS: Diversas técnicas podem ser utilizadas no controle de dor em pacientes oncológicos. O objetivo deste relato é mostrar o uso de algumas medidas terapêuticas empregadas para tratar um paciente com quadro doloroso importante de difícil controle. RELATO DO CASO: Paciente do sexo masculino, 70 anos, com cordoma sacral e com possibilidade terapêutica muito difícil. Apresentava quadro de dor importante associado ao tumor. São relatadas diversas técnicas utilizadas no seu tratamento e os resultados obtidos. CONCLUSÕES: Os bloqueios neurolíticos, para o controle da dor em paciente com tumores cuja possibilidade terapêutica é difícil, constituem técnica eficaz quando bem indicados e realizados dentro de critérios estabelecidos.

Dextropropoxyphene dependence: a cautionary note.

Drug abuse and dependence is common in patients with chronic pain. Of concern are the opioid analgesics prescribed commonly, and its availability over the counter. Often the cause of dependence is iatrogenic. We report a case of a patient with chronic back pain and dextropropoxyphene dependence. With chronic pain being a significant risk factor for drug dependence, increased caution by the prescribing physicians is advisable while treating such patients using opioid analgesics. The dangers of opioid dependence, associated risk factors, and issues regarding the prescription of such medication are discussed to aid prevention of prescription drug abuse seen in general practice.

Calidad de la atención primaria para lumbalgia aguda. Estudio multicéntrico / Quality of care in low back pain. Comparative survey

Objetivo. Evaluar la calidad de atención para pacientes con lumbagia aguda proporcionada por médicos de atención primaria y estudiantes de medicina de 4 ciudades de México. Tipo de studio. Encuesta comparativa. Material y métodos. Se interrogó sobre acciones diagnóstico terapéuticas en lumbalgia aguda a médicos de atención primaria y a estudiantes de medicina. Las acciones consideradas como aciertos se tomaron de las guías emitidas por la Quebec Task Force on Spinal Disorders (QTFSD). Resultados. Fueron evaluables los datos de 211 de 213 pacientes (30 Cd. Obregón, 43 Morelia, 80 León y 60 Mérida); 79 por ciento de los participantes habrían proporcionado calidad de atención no adecuada generalmente debida a sobresolicitud de estudios de imagen. No hubo asociación entre haber cursado reumatología en la carrera de medicina y el tipo de atención proporcionadas; sin embargo, el tener la especialidad de Medicina Familiar se asocició con proporcionar atención adecuada y en contraste, el ser estudiante de medicina estuvo asociado con proporcionar atención no adecuada. Conclusiones. Parece existir una elevada prevalencia de calidad de atención no adecuada para pacientes con lumbalgia aguda por parte de médicos de atención primaria; ésto parece ser mas frecuente en médicos en formación

Uso de esteroides intravenosos como tratamiento de la lumbociática aguda / Intravenous steroids for treatmente of acute lumbosciatic pain

Se realizó un estudio prospectivo de marzo de 1992 a junio de 1993 en 25 pacientes adultos, de 24 a 45 años, con cuadro de lumbociatalgia aguda secundaria a radiculopatía por hernia de disco intervertebral lumbar, que se trataron en forma intra-hospitalaria con un succinato sódico de metil-prednisolona en dosis de 500 mg por vía intravenosa, a intervalos de 8 a 12 horas durante un periodo de tres a cinco días. De los 25 pacientes tratados, en 14 desapareció del dolor y en 10 de esos 14 desaparecieron las alternaciones neurológicas. De los 11 restantes en tres hubo mejoría significativa con fisioterapia y reposo. Finalmente ocho no mejoraron, de los cuales solamente cinco aceptaron someterse a cirugía. El porcentaje de pacientes que mejoró en forma primaria con este tratamiento fue de 56 por ciento, el cual se considera de valor clínico

Dismetría de los miembros inferiores como causa de lumbalgia / Lower limb unequality as a cause of low back pain

Se estudian 500 pacientes que presentan lumbalgia crónica de más de cuatro meses de evolución de los cuales pacientes 298 fueron hombres (59.6 por ciento) y 202 mujeres (40.4 por ciento); la edad varió de 15 a 75 años como promedio 30 años; se excluyeron a los que a su ingreso presentaban radiculopatía. Talla 1.60 m. El rango de normalidad de la dismetría varió de 4-24 mm. Se encontró en 394 pacientes (79 por ciento) y la izquierda 106 pacientes (21 por ciento). En todos los pacientes se les realizó proyecciones radiológicas anteroposterior y lateral de columna lumbosacra de pie y descalzo en placas de 14 x 17 pulg. y una escanometría para efectuar la medición de la dismetría. Radiológicamente en todos predominaba el basculamiento pélvico y una escoliosis no mayor a los ocho grados. A todos los pacientes con dismetría mayor de 4 mm, se les indicó tratamiento conservador a base de analgésicos, antinflamatorios, medidas higienico-dietéticas, y la corrección de la dismetría por medio de una talonera que equilibrara el acortamiento, (menos 4mm) y posteriormente con aplicación de ejercicios para la reeducación muscular, se integraron a sus actividades cotidianas, el seguimiento de los pacientes es de seis a 18 meses de evolución, siendo cada vez más satisfactoria la misma. Unicamente el 5 por ciento de los pacientes evolucionaron mal cuando se agregó otra patología extra-articular

Coccigodínia: tratamento com carbamazepina - relato de caso / Coccygodynia: treatment with carbamazepine - report of case

Os autores relatam um caso de coccigodínia em uma paciente de 44 anos, do sexo feminino, rotulada como idiopática após extensa avaliaçao radiológica. Foi submetida a tratamento clínico com carbamazepina (800 mg/dia), com excelente resultado. Após extensa revisao bibliográfica, nao foi encontrado nenhum relato similar. Os autores chamam a atençao para o uso da carbamazepina no tratamento clínico da coccigodínia idiopática.

Estudo multicêntrico nacional com tenoxicam em ortopedia / Brazilian multicenter trial with tenoxicam in orthopedics

Säo relatados os resultados obtidos em um estudo multicêntrico com o tenoxim, novo agente antiinflamatório näo-esteróide em patologias diversas. Participam da investigaçäo 185 pacientes e 50 investigadores. Foram registrados resultados satisfatórios em 96,2 por cento dos casos. Os eventos adversos, de leve intensidade em sua maioria, foram registrados em 14,1 por cento dos pacientes e só constituíram causa de abandono em cinco casos. A boa tolerabilidade da droga, aliada a uma eficácia superior com apenas uma dose diária, recomendam seu emprego nas afecçöes ortopédicas.

Epidural steroid injection in non-specific low backache.

Effect of epidural steroid injection has been studied in 107 cases (50 males and 57 females, mostly above 20 years of age) with non-specific low backache. Out of 42 cases with acute syndrome 20(47.6%) showed good response, 10(23.8%) showed fair response and 12(28.6%) showed poor response, whereas similar responses were found in 5(7.7%), 10(15.4%) and 50(76.9%) cases respectively among 65 cases of chronic syndrome (p less than 0.001). Agewise, 23(32.9%), 9(12.9%) and 38(54.2%) cases among 70 patients below 40 years of age and 2(5.4%), 11(29.8%) and 24 (69.8%) cases among 37 patients above 40 years of age showed good, fair and poor responses to epidural steroid respectively (p less than 0.001). Hence epidural steroid injection has been shown to be a useful adjunct to conservative treatment of low backache in young patients with acute syndrome.

Importância do ângulo lombo-sacro na síndrome do compartimento posterior / Importance of the lumbosacral angle in posterior compartment syndrome

Analisa-se a impôrtancia do ângulo lombo-sacro, nas lombalgias do compartimento posterior em 80 indivíduos. Considerados os valores referidos por Ferguson e Kapandji conclui-se pela importância do aumento do ângulo lombo-sacro como fator colaborador das lombalgias do compartimento posterior