Cauda Equina Syndrome Following Lumbar Disc Herniation at L5-S1: A Case Report.

Objective: The purpose of this article is to describe a patient presenting to a chiropractic clinic with rapidly progressing cauda equina symptoms. Clinical Features: A 30-year-old woman presented to a chiropractic clinic with the onset of saddle distribution sensory loss and urinary retention. The patient had worsening symptoms 48 hours following evaluation at local emergency and radiology departments. Intervention and Outcomes: After a brief history and evaluation, the patient was immediately referred back to the emergency department. Based on the rapidly progressive clinical presentation and previous magnetic resonance study of the lumbar spine, immediate decompressive surgery was performed the same day. Low back pain and neurogenic symptoms persisted following surgery, and that prompted a trial of epidural injections and pelvic floor therapy with minimal relief. One year later, the patient returned with back pain for chiropractic treatment to include cupping, cold laser therapy, Cox flexion-distraction, and McKenzie-based at-home exercises for post-laminectomy syndrome. Chiropractic treatment provided a mild decrease in symptoms and severity over the course of 3 months. Conclusion: This case demonstrates that chiropractic physicians should be aware of the clinical manifestations and possible rapid progression of cauda equina symptoms to avoid a delay in diagnosis. The patient responded well to postoperative chiropractic care.

Radiographically Occult Manifestation of Rheumatoid Arthritis in a Patient With Prolonged Clinical and Laboratory Evidence of Rampant Disease: A Case Report.

OBJECTIVE: The purpose of this case report is to present a case of rampant rheumatoid synovitis and arthritis of a patient with a long duration of symptoms and no radiographic abnormalities of rheumatoid arthritis at the initial diagnosis. CLINICAL FEATURES: A 49-year-old Hispanic woman presented to a chiropractic teaching clinic with an 8-month history of bilateral, symmetrical hand pain and stiffness noted specifically in her second and third metacarpophalangeal joints. The patient has reported no other health changes and no history of rheumatoid arthritis in the family. INTERVENTION AND OUTCOME: Based on this patient's complaint, initial bilateral 3-view radiographic examination of the hands using computed radiography was performed. Despite prolonged history of inflammatory joint pain and rheumatoid arthritis confirmed by abnormally high levels of rheumatoid factor, C-reactive protein, and anti-cyclic citrulline peptide antibodies, the patient had no radiographic evidence of rheumatoid arthritis during the initial and repeat radiographic studies. CONCLUSION: Some patients with rheumatoid arthritis may present with rampant clinical and laboratory abnormalities despite an apparent lack of radiographically detectable rheumatoid arthritis. This case demonstrates that astute clinicians should primarily rely on the results of clinical and laboratory abnormalities of rheumatoid arthritis and not be deterred or mislead by an apparent lack of radiographic changes at diagnosis. If the diagnosis of rheumatoid arthritis requires diagnostic imaging confirmation, then magnetic resonance imaging or diagnostic ultrasound of the hands should be used, especially if the initial radiographic assessment remains unrewarding.

Reliability of Human Lumbar Facet Joint Degeneration Severity Assessed by Magnetic Resonance Imaging.

OBJECTIVE: The purpose of this study was to determine the reliability of the assessment of lumbar facet joint degeneration severity by analyzing degeneration subscales using magnetic resonance imaging (MRI) in human participants. METHODS: The reliability of articular cartilage degeneration, subchondral bone sclerosis, and osteophyte formation subscales of lumbar facet joint degeneration severity was assessed in MRI images from n = 10 human participants. Each scale was applied to n = 20 lumbar facet joints (L4/5 level). Three examiners were trained. A first assessment of MRI images was provided by the examiners followed by a second assessment 30 days later. Intraobserver and interobserver reliability were determined using percent agreement, the weighted kappa coefficient κw for paired comparisons, and the overall weighted kappa κo. The minimum threshold for reliability was set at moderate levels of agreement, κw > 0.40, based upon previous recommendations. RESULTS: The articular cartilage subscale had acceptable intraobserver (κo = 0.51) and interobserver (κo = 0.41) reliability. Scales for subchondral bone sclerosis (intraobserver κo = 0.28; interobserver κo = 0.10) and osteophyte formation (intraobserver κo = 0.26; interobserver κo = 0.20) did not achieve acceptable reliability. CONCLUSION: Of the 3 subcategories of lumbar facet joint degeneration, only articular cartilage degeneration demonstrated acceptable reliability. Subscales of lumbar facet joint degeneration should be considered independently for reliability before combining subscales for a global degeneration score. Owing to the inherent difficulty of assessing lumbar facet joint degeneration, the use of multiple examiners independently assessing degeneration with reliable scales and then coming to a consensus score upon any disagreements is recommended for future clinical studies.

Spinous process apophysitis: a cause of low back pain following repetitive hyperextension in an adolescent female dancer.

We report a case of a 13-year-old female dancer with spinous process apophysitis following repetitive microtrauma during end-range hyperextension movements. Following appropriate rest and limitation of hyperextension, she was able to return to her previous level of training. It is important to recognize that numerous diagnostic possibilities arise when presented with a young dancer with back pain. The intention of this case report is to compare and contrast the pertinent clinical and radiologic findings of spinous process apophysitis and its more common and debilitating mimic, spondylolysis. The correct diagnosis is paramount in cases of this sort due to the variable treatment requirements of each disorder.

Acromial apophysitis in a 13-year-old adolescent boy: a common condition in an uncommon location.

OBJECTIVE: Traction apophysitis is a common condition in physically active and skeletally immature adolescents. This case study describes the clinical presentation and plain film imaging of traction apophysitis of the acromion process of the scapula. CLINICAL FEATURES: A physically active 13-year-old adolescent boy presented to a chiropractic physician with an acute onset of moderate shoulder pain. Plain film radiographs of the shoulder were performed that revealed fragmentation, sclerosis, and irregularity of the left acromial apophysis. INTERVENTION AND OUTCOME: The patient was treated with conservative therapy for 10 weeks, with complete resolution of symptoms. Follow-up radiographs 9 weeks later revealed no radiographic change in the appearance of the apophysis; however, clinical symptoms were absent. The apophyseal growth cartilage is the most vulnerable site in the muscle-tendon unit in the skeletally immature patient and is more susceptible to very small avulsion fractures. Repetitive microtrauma following chronic overuse at a tendon insertion site in a skeletally immature patient may result in traction apophysitis. CONCLUSIONS: Acromial apophysitis should be included in the differential diagnosis when presented with a young active patient with shoulder pain. Early treatment with restriction of activities is important in the prevention of permanent injury to the acromial cartilaginous growth plate. This case demonstrates that a prompt diagnosis can be made with a careful history, physical examination, and conventional imaging.