[Rhizomelic pseudopolyarthritis: update]. / Pseudopolyarthrites rhizoméliques: mise au point.

PURPOSE: Update of recent works on polymyalgia rheumatica (PMR). CURRENT KNOWLEDGE ANS KEY POINTS: In polymyalgia rheumatica (PMR) unassociated with giant cell arteritis (GCA) (twice as frequent as GCA without PMR) several recent works demonstrated by MRI or echography that synovitis and/or subacromial bursitis accounted for most of the painful shoulders and could be relieved by steroid injections. Peripheral synovitis can also occur in 10-20% of PMR, and lead to consideration of other diagnoses, mostly RA or the RS3PE syndromes for those cases of PMR with peripheral edema. PMR with asymmetrical onset are often difficult to diagnose early, and the classification criteria for PMR are not widely accepted. When clinical signs suggestive of GCA are lacking, temporal biopsy is positive in only 1 to 5% of PMR cases. Several studies on PMR with so-called 'normal' ESR (below 30 mm, first hour) have cast doubts on the value of this biological sign (although 'normal ESR' should only stand for values below 11 mm). Hence it would be worthwhile to study whether CRP and even SAA deserve to be added to future sets of criteria for PMR. A defect in hypothalamic axis response is often noticed and could play a part in PMR pathogenesis, thus explaining why PMR is quite exclusively noticed after ages 50 or 60. Two-thirds of patients can stop prednisone within 2 years after the onset of treatment. The lack of a prompt response within the first days should suggest differential diagnoses, including some myelodysplastic disorders. FUTURE PROSPECTS AND PROJECTS: The search for genetic factors common or specific to PMR and GCA could enhance our understanding of these overlapping syndromes. Studies of the transcriptosomes of lymphocytes infiltrating the target tissues (arterial wall in GCA, synovium in PMR) might also prove informative. Controlled studies of new biological treatments like cytokine inhibitors (anti-TNF-alpha, anti-interferon gamma) could demonstrate a clear sparing effect in steroids, a goal not yet achieved by the use of current DMARDs, including MTX.

Intraarticular glucocorticosteroid injection into the lateral atlantoaxial joint under fluoroscopic control. A retrospective comparative study in patients with mechanical and inflammatory disorders.

OBJECTIVES: To evaluate the overall efficacy in various disorders of glucocorticoid injection into the lateral atlantoaxial joints, performed via the posterior route under fluoroscopic control. METHODS: Retrospective study of 26 patients including 16 (19 injections) with mechanical disorders and ten (16 injections) with inflammatory disorders. RESULTS: The response rate was 69.3%, the mean pain scale score decrease was 52.3 +/- 40.1%, and the mean duration of pain relief was 8.1 +/- 11.8 months. All three parameters were significantly (P < 0.005) better in the subgroup with inflammatory disorders than in the subgroup with mechanical disorders (response rate, 100% vs 50%; pain scale score decrease, 80 +/- 27% vs 34.2 +/- 40%, and pain relief duration, 16.9 +/- 14.9 months vs 24.5 months). A single patient developed a side effect (moderately severe hypertension). CONCLUSION: Glucocorticoid injection into the lateral atlantoaxial joints is a valid treatment alternative in patients who fail to respond to conventional noninvasive therapy.

Reasons for rheumatology department admission in 125 patients with disk-related sciatica.

OBJECTIVES: To identify medical and nonmedical reasons for admission of disk-related sciatica patients. PATIENTS AND METHODS: 125 patients were evaluated prospectively using a 25-items questionnaire, including seven items on medical reasons, four on psychological reasons, four on work-related reasons, six on social and family reasons, and four on miscellaneous reasons. RESULTS: Severe nerve root pain (34%), motor loss (17%), atypical clinical manifestations (13%), severe low back pain (8%), and/or sphincter dysfunction (4%) were recorded in only 55% of patients, and only 16% had at least two of these reasons. A minority of patients were admitted to avoid premature surgery (13%) or to try one more conservative approach prior to surgery (15%). Seventy-five per cent of patients reported at least one of the psychological reasons listed in the questionnaire (irritability/fatigue, 66%; anxiety, 42%; depression, 26%; panic disorder, 21%), 50% reported at least one work-related reason (workaholism, 21%; job offer, 16%; self-employed, 14%; fear of losing their job, 11%), 66% reported at least one social or family reason (living alone, 34%; one or more dependents younger than seven years of age, 32%; too many demands from household members, 22%; one or more dependents older than seven years of age, 8%; need to care for another person, 9%; important upcoming family or personal event, 6%), and 26% reported at least one miscellaneous reason (firm belief that sciatica can be cured only by inhospital treatment, 10%; desire to put pressure on the employer or on an expert, 7% and 6%, respectively; admission via the emergency room without prior medical advice, 6%). CONCLUSION: In France, the reason for admission of patients with disk-related sciatica is frequently a mixture of physical, psychological, and social problems, with only 55% of patients having a symptom requiring inhospital management.

Is it possible to predict the efficacy at discharge of inhospital rheumatology department management of disk-related sciatica? A study in 150 patients.

OBJECTIVES: To identify criteria for predicting the outcome at discharge in patients scheduled for inhospital treatment of disk-related sciatica. PATIENTS AND METHODS: We studied 150 rheumatology department patients admitted for disk-related sciatica with a mean duration of 88 +/- 127 days to determine the impact on treatment outcomes of 50 parameters. RESULTS: After complete bed and 2.2 +/- 1.1 epidural glucocorticoid injections during a mean hospital stay of 9.9 +/- 4.3 days, 80% of patients reported either complete or partial pain relief (19% and 61%, respectively). The remaining 20% reported little (9%) or no (11%) change. Surgery was performed in 13% of cases. A tighter straight-leg raising test angle was correlated with treatment failure (P = 0.01). Complete bed rest duration prior to admission was shorter in the 80% of responders (P = 0.036) than in the 20% of nonresponders; in the overall population, patients spent on average 64% +/- 33% of daytime hours in bed. Patient predictions about their own outcomes were unreliable (P = 0.926). Patients who believed strongly that sciatica requires surgical treatment were more likely to be nonresponders (P = 0.06), as were patients with a family history of surgically-treated sciatica (P = 0.055). Outcomes were not correlated with any of the other parameters studied, including sciatica duration (P = 0.13), bedrest duration prior to admission (P = 0.52; mean duration, 18 +/- 29 days), the specialty of the physicians seen, investigations done prior to admission, or a history of sciatica (noted in 65% of cases and treated surgically in 16%). CONCLUSIONS: Eighty percent of patients benefited from their hospital stay. Patient opinions on the merits of nonsurgical and surgical treatments in their own case were not correlated with their own outcomes. A tight straight leg-raising test angle was correlated with a poorer outcome. Neither sciatica duration nor rest duration prior to admission had an influence on outcome. Absence of complete bed rest prior to admission was correlated with a greater likelihood of a therapeutic benefit from the hospital stay.