Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case-control study of 120 patients.

PURPOSE: To compare, in a case-control study, clinical characteristics of patients with low back pain (LBP) with and without Modic 1 signal changes on MRI. METHODS: Patients with chronic non-specific LBP and a recent (<6 months) MRI were prospectively screened and included in Modic 1 group or control group. Patients in control group were age- and gender-matched with patients with Modic 1 group. Pain characteristics, including night pain and worse pain on waking and morning stiffness, were recorded. The presence of at least one of these three characteristics indicated an inflammatory pain pattern. Patients were evaluated by questionnaires and physical examination (including lumbar range of motion). Data were analyzed by univariate and multivariate analyses. RESULTS: 120 patients were included (60 in each group). The groups did not differ in sedentary work (p = 0.25), morning stiffness for >60 min (p = 0.19), waking at night (p = 0.08), worse pain on waking (p = 0.09), back stiffness (p = 0.12), or pain with flexion (p = 0.87). Modic 1 patients more frequently exhibited an inflammatory pain pattern (p = 0.006), worse pain with lumbar extension (p < 0.005) and responded better to oral steroids (p = 0.004) than did controls. On multivariate analysis, Modic 1 changes were associated with sedentary work [odds ratio 0.22 (95% confidence interval 0.05-0.93)], pain with lumbar extension [11.2 (3.1-40.4)] and an inflammatory pain pattern [4.5 (1.2-16.9)]. CONCLUSIONS: Characteristics of patients with LBP and Modic 1 changes on MRI consist of an inflammatory pain pattern and pain with lumbar extension. Level of evidence 3b.

Postpartum coccydynia: a case series study of 57 women.

BACKGROUND: Although childbirth is a well-known cause of coccydynia, this condition has not been studied previously. AIM: To explore the characteristics of postpartum coccydynia and identify risk factors. DESIGN: A case series study. SETTING: A specialist coccydynia clinic in a department of physical medicine in a university hospital. METHODS: A series of 57 women suffering from postpartum coccydynia was analyzed and compared with a control group of 192 women suffering from coccydynia due to other causes. Dynamic radiography enabled a comparison of the coccygeal mobility in the two groups. RESULTS: 7.3% of the cases of coccydynia in female patients seen in our clinic were related to childbirth. The pain appeared as soon as the patient adopted the sitting position after delivery. The deliveries had often been performed with instruments (forceps deliveries: 50.8%; vacuum-assisted deliveries: 7.0%) or were spontaneous but described as "difficult" (12.3%). Luxation of the coccyx was observed in 43.9% of the cases and 17.0% of the controls. Fracture of the coccyx was involved in 5.3% of the cases. A body mass index >27 and ≥2 vaginal deliveries were associated with a higher prevalence of luxation of the coccyx. CONCLUSION: Postpartum coccydynia is often associated with a difficult delivery, with the use of forceps in 50.8% of cases. Luxation and fracture of the coccyx are the two most characteristic lesions. CLINICAL REHABILITATION IMPACT: Our results bring a better knowledge and should allow a better management of this specific etiology of coccydynia.

Lower back pain and neck pain: is it possible to identify the painful side by palpation only?

OBJECTIVES: Back pain is often attributed to increased tension in the back muscles, regardless of whether the tension is primary or related to a disc/facet pathology. We hypothesized that when either lower back pain or neck pain is unilateral, the muscle tension would be more pronounced on the painful side and could be detected by palpation alone (i.e., without the need to apply pain-triggering manoeuvres). METHODS: Patients with unilateral neck or lower back pain were enrolled in the study. Participants with scoliosis, obesity, a history of spinal surgery or pain radiating below the knee or the elbow were excluded. The patients were examined by comparative muscle palpation only. The examiner was unaware of which body side was painful and the patient was told to remain still and silent. The spinal muscles were examined bilaterally, with superficial and deep palpation. The examiner had to determine on which side the tension was greater. The patients' age, body mass index, time since onset of symptoms and Rolland Morris (lower back pain) and INDIC (neck pain) functional disability questionnaire scores were recorded. RESULTS: Ninety-one patients with unilateral lower back pain (35 males, 56 females; mean±SD age: 45.2±15 yrs) and 94 patients with unilateral neck pain (26 males, 68 females, 49.1±15 yrs) were enrolled in the study. The lower back pain and neck pain were right-sided in 50 (54.9%) and 53 (56.4%) of cases, respectively. The examiners correctly identified the painful side in 64.8% of the cases of lower back pain (a significantly better percentage than chance alone (i.e. 50%), P=0.02) and 58.5% (P=0.10) of the cases of neck pain. In lower back pain patients, the results were better for right-side pain than for left-side pain (70.0% and 58.5% of correct answers, respectively, ns). In neck pain patients, the results were better for left-side pain than right-side pain (61% and 56.6%, respectively, ns). There were no significant differences between the two examiners' respective performance levels. The patients' clinical parameters did not appear to influence successful detection of the painful side. CONCLUSION: Our findings suggest that palpation can detect increased muscle tension in a limited proportion of cases.

Chronic coccydynia in adolescents. A series of 53 patients.

BACKGROUND: Little is known about coccydynia in adolescents. AIM: The aim of this study was to explore causes, clinical and imaging features and response to treatment of chronic coccydynia in adolescents. DESIGN: This was a cohort study. SETTING: The study included patients followed up at a specialized consultation in a university hospital. METHODS: A series of 53 adolescent patients with chronic coccydynia were followed for 1-4 years. Investigations included dynamic X-ray films, with a magnetic resonance imaging scan of the coccyx in 26/53. Treatment was by coccygeal steroid injection or non-steroidal anti-inflammatory drugs (NSAIDs). Amitriptyline or coccygectomy were used as second-line treatment. Outcomes were assessed at a consultation two months after the treatment, then between one to four years later, by telephone interview, questionnaires and by a visual analogue scale (VAS). Fifty-one adult patients with coccydynia formed the control group. RESULTS: In 20 cases (37.7%) the coccydynia was subsequent to trauma. Obesity was not a risk factor. Abnormal mobility was rarer and spicules more frequent compared to adult patients (P<0.001); 11/27 MRI scans showed a hypersignal within the disc or adjacent bone and 6/27 a hypersignal surrounding the tip of the coccyx (bursitis). Initial treatment was a coccygeal steroid injection for 41 patients and NSAIDs for 12. Ten were given amitriptyline and 3 a coccygectomy. At final assessment, there was no pain or almost no pain in 32/53 (60.4%), moderate pain and functional impairment in 12/53 (22.6%) and severe pain and functional impairment in 9/53 (17%). CONCLUSION: Coccydynia in adolescents differs from coccydynia in adults. A MRI scan is helpful and should be obligatory for diagnosis. Prognosis is relatively good. CLINICAL REHABILITATION IMPACT: Our results should help clinicians manage this rare and debilitating condition.

Interexaminer agreement of clinical examination of the neck in manual medicine.

OBJECTIVES: To assess interexaminer agreement in a structured, manual, clinical examination of the neck. To correlate these data with the score in a functional questionnaire (a validated, French-language version of the neck pain and disability scale). PATIENTS: Fifty-nine ambulatory patients (26 males and 33 females, mean+/-SD age: 46.3+/-12 yrs) with common neck pain but no radiation below the elbow. METHODS: Two medical practitioners (a junior and a senior consultant) assessed neck rotation (in degrees) and the presence of pain during maximum neck flexion and extension, muscle palpation trapezius, levator scapulae, splenius cervicis, semispinalis) and cervical spine palpation. Cohen's kappa coefficient was calculated for qualitative variables. Angular rotational values (as a continuous variable) were compared using the p coefficient. Pearson coefficient was used to correlate the number of tender spots to the results of the questionnaire. RESULTS: There was no significant interexaminer difference (+/-10 degrees) in the neck rotation measurement. Kappa was (i) 0.71 and 0.76 for pain in flexion or extension, respectively, (ii) 0.44 on average for palpation of various muscles and (iii) 0.53 on average for cervical spine palpation. The number of tender spots correlated strongly with the questionnaire score (Pearson's coefficient: 0.35; p=0.007). CONCLUSION: The interexaminer agreement for our clinical examination was moderate. The number of tender spots correlated strongly with the functional impairment. Pain at the lower attachment of the levator scapulae was associated with dysfunction of the median or upper cervical spine.

[Is systematic radiography needed before spinal manipulation? Recommendations of the SOFMMOO]. / Faut-il faire des radiographies systématiques avant manipulation vertébrale? Recommandations de la Société française de médecine manuelle orthopédique et ostéopathique (SOFMMOO).

OBJECTIVES: The French National Health Authority recommends systematic radiography before lumbar manipulation. However, current research shows radiography to have more disadvantages than advantages. For the cervical spine, in cases of complication following cervical manipulation, the lack of prior radiography is a fault, even if such x-ray results would have advised manipulation. To establish clear recommendations on this topic, we searched in the literature for complications of spinal manipulations that could have been prevented had preliminary radiography been performed to determine whether these complications were anticipated or not by the international guidelines. MATERIAL AND METHODS: Literature search. RESULTS: For the lumbar and thoracic spine, the international guidelines are sufficient, except in cases of aneurysmal bone cyst, which can appear until the age of 25 years. For the cervical spine, despite a lack of data in the literature, prudence and medicolegal issues justify the performance of systematic radiography. CONCLUSION: The SOFMMOO recommends systematic radiography prior to cervical manipulation and in case of back or neck pain in patients of less than 25 years of age. In all other cases, the international guidelines provide sufficient recommendations.

Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks.

Low back pain persisting or appearing after a technically successful lumbar fusion challenges clinicians. In this context, the sacroiliac joint could be a possible source of pain, but the frequency of its responsibility is not really known. We used sacroiliac anesthetic blocks, the gold standard for diagnosis, to determine this frequency. Our second goal was to search predictive factors for a positive block. Our prospective series consisted of 40 patients with persistent low back pain after a technically successful fusion who received a sacroiliac anesthetic block under fluoroscopic control. The diagnostic criterion was a relief of more than 75% of the pain on a visual analog scale. We found a 35% rate of positive blocks. The only criterion that characterized these patients was a postoperative pain different from the preoperative pain in its distribution ( p =0.017). A free interval of more than 3 months between surgery and appearance of the pain had an indicative value ( p =0.17). An increased uptake in the sacroiliac on bone scintigraphy or a past history of posterior iliac bone-graft harvesting had no significant value ( p =0.74 and p =1.0, respectively). The sacroiliac joint is a possible source of pain after lumbar fusion. The anesthetic block under fluoroscopic control remains the gold standard.

Telomere dynamics determine episodes of anticancer drug resistance in rat hepatoma cells.

Clinical and experimental observations indicate that resistance to anticancer drugs may be spontaneously reversible over time, but the mechanisms of this reversal are unknown. The resistance of cultured hepatoma cells to methotrexate (MTX) and cisplatin was followed for 9 months. Cells were exposed to three treatments: MTX 200 nM for 24 h or 15 nM continuously and cisplatin 50 microM for 2 h. We investigated the relation between the temporal pattern of cell resistance and the previously reported fluctuations in cell proliferation rate, telomere length and telomerase activity. Spontaneous major peaks in resistance to each drug fell in time windows of 2-3 months (60-70 population doublings) and were at different times for each drug. The frequency of the fluctuations in drug resistance was the same as that of variations in cell growth rate, but amplitudes were unrelated. By contrast, resistance was directly related to telomere length dynamics in the same cells. MTX resistance occurred when telomeres shortened and cisplatin resistance when they were elongated. Furthermore, peaks of resistance to the continuous treatment with MTX were observed at 350-bp intervals of mean telomere length (9.06, 9.41, and 9.76 kbp) during the two 2-month phases of telomere shortening. Statistical analysis demonstrates the sinusoidal relationship between intermittent MTX resistance and telomere length. Possibly, erosion of telomeres encroaches on periodically spaced nucleosomal proteins, defining the onset of resistance phases. This evidence that resistance of tumoral cells to anticancer drugs may be intermittent and that onset of resistance is dictated by telomere length has major implications for clinical practice.

Towards a model of back pain. The 3 circles of pain.

A new model for back pain is introduced. Three major groups (or ''circles'') of pain are described for the use of clinicians. The 1(st) circle is comprised of patients with pain from genuine spinal (mainly discs or facets) origin. The main feature identifying this group is the organic pattern of pain, a concept which is described and discussed, and which is based on the history, the clinical signs, imaging tests and response to treatments. The 2(nd)circle consists in patients with diffuse and permanent back pain, without any organic pattern. The pain, presumed to be not spinal in origin, is attributed to a dysfunction in the pain pathways. The 3(rd) circle is comprised of patients with clear psychosocial risk factors and no evidence for a spinal origin of their pain. This model applies for lumbar or cervical pain, with or without radiculopathy. Classifying a given patient in one of the 3 circles is relatively easy. It should allow an easier management of the back pain patients.

[Cervical spine manipulation: risks--benefit--assessment]. / Manipulations du rachis cervical: risques--bénéfices--précautions.

Cervical manipulation is a widely used method indicated in non-specific mechanical neck pain and cervicogenic headache. Cervical manipulation can cause severe neurologic complications which are both rare and generally unpredictable, which can be compared with the accidents occurring with other treatments (nonsteroidal anti-inflammatory drugs...). To decrease this risk, we propose five recommendations developed by consensus: --unwanted effects, however minor (e.g. nausea or vertigo), of prior manipulation should be searched for routinely and taken as contraindications for future spinal manipulations; --a thorough physical examination, including a neurological evaluation should be performed prior to manipulation; --all know indications and contraindications should be followed; -- manipulations should be performed only by physicians experienced in this technique; --special caution should be exercised when performing first-line cervical manipulation and simple, honest and easily understandable information about these risks should be included when informed consent is obtained.

Comparison of three manual coccydynia treatments: a pilot study.

STUDY DESIGN: A prospective pilot study with independent assessment and a 2-year follow-up period was conducted. OBJECTIVES: To compare and assess the efficacy of three manual coccydynia treatments, and to identify factors predictive of a good outcome. SUMMARY OF BACKGROUND DATA: Various manual medicine treatments have been described in the literature. In an open study, the addition of manipulation to injection treatment produced a 25% increase in satisfactory results. Dynamic radiographs of the coccyx allow breakdown of coccydynia into four etiologic groups based on coccygeal mobility: luxation, hypermobility, immobility, and normal mobility. These groups may respond differently to manual treatments. METHODS: The patients were randomized into three groups, each of which received three to four sessions of a different treatment: levator anus massage, joint mobilization, or mild levator stretch. Assessment with a visual analog scale was performed by an independent observer at 7 days, 30 days, 6 months, and 2 years. RESULTS: The results of the manual treatments were satisfactory for 25.7% of the cases at 6 months, and for 24.3% of the cases at 2 years. The results varied with the cause of the coccydynia. The patients with an immobile coccyx had the poorest results, whereas those with a normally mobile coccyx fared the best. The patients with luxation or hypermobility had results somewhere between these two rates. Levator anus massage and stretch were more effective than joint mobilization, which worked only for patients with a normally mobile coccyx. Pain when patients stood up from sitting and excessive levator tone were associated with a good outcome. However, none of the results was significant because of the low success rate associated with manual treatment. CONCLUSIONS: There is a need for a placebo-controlled study to establish conclusively whether manual treatments are effective. This placebo must be an external treatment. A sample size of 190 patients would be required for 80% confidence in detecting a difference.

Assessment of sexual activity in patients with back pain compared with patients with neck pain.

Recent research has shown significant adverse effects of chronic low back pain on sexual activity in 46% of patients. To establish whether and how chronic low back pain adversely affects sexual activity, a questionnaire-based study was conducted on a patient group (low back pain) and a comparison group (neck pain). Patients were administered a visual analog scale, a series of conventional questionnaires, and a specifically designed sexual activity questionnaire covering frequency of intercourse before and since onset of pain, discomfort during intercourse, satisfaction with sexual life, and comfortable and uncomfortable basic coital positions. Patients with low back pain reported more interference than did patients with neck pain, and women with low back pain were more affected than men. Compared with the other groups, women with low back pain had greater reduction in frequency of intercourse, more marked discomfort during intercourse, and more interference with their sexual lives. The most pain generating position was prone for both genders, and the most comfortable one was supine. Sexual impairment, more marked in women, seems to be related to the triggering of pain by intercourse and to psychologic factors.

Highlighting of intervertebral movements and variations of intradiskal pressure during lumbar spine manipulation: a feasibility study.

OBJECTIVES: To demonstrate relative movement of the vertebrae and variations in intradiskal pressure during 2 different lumbar spinal manipulations, in flexion or extension, in 2 unembalmed cadavers. DESIGN: A pressure sensor was inserted into the L3-4 disk in cadaver 1 and into the L1-2 to L4-5 disks in cadaver 2. Two adjacent vertebrae (L3 and L4 in cadaver 1, and L4 and L5 in cadaver 2) were each equipped with 2 monoaxial accelerometers to record acceleration in the caudocranial axis and a biaxial accelerometer to record acceleration in the "horizontal" anatomic plane. SETTING: Laboratory study. RESULTS: During the thrust, relative intervertebral movements were demonstrated; movements differed with the type of manipulation (in flexion or extension). Intradiskal pressure initially increased, then decreased. CONCLUSIONS: Lumbar spinal manipulations have a biomechanical effect on the intervertebral disks, producing a brief but marked change in intradiskal pressure. This effect, which differs slightly with the different types of manipulation studied, is the consequence of movements of the adjacent vertebrae.

Instability of the coccyx in coccydynia.

Coccygectomy is a controversial operation. Some authors have reported good results, but others advise against the procedure. The criteria for selection are ill-defined. We describe a study to validate an objective criterion for patient selection, namely radiological instability of the coccyx as judged by intermittent subluxation or hypermobility seen on lateral dynamic radiographs when sitting. We enrolled prospectively 37 patients with chronic pain because of coccygeal instability unrelieved by conservative treatment who were not involved in litigation. The operation was performed by the same surgeon. Patients were followed up for a minimum of two years after coccygectomy, with independent assessment at two years. There were 23 excellent, 11 good and three poor results. The mean time to definitive improvement was four to eight months. Coccygectomy gave good results in this group of patients.

Cervical spine manipulation and the precautionary principle.

Cervical manipulations can cause severe neurologic complications, which are both exceedingly rare and generally unpredictable. To meet the requirements of the principles of prevention and precaution, we believe the number of cervical manipulations should be reduced. To this end, we suggest that five recommendations developed by consensus be followed: unwanted effects, however minor, of previous manipulation should be looked for routinely and taken as absolute contraindications to further manipulation; a thorough physical examination, including a neurological evaluation, should be performed prior to manipulation; all known contraindications and indications should be followed; manipulation should be performed only by physicians experienced in this technique; and special caution should be exercised when performing first-line cervical manipulation.

Evidence for deterministic chaos in aperiodic oscillations of proliferative activity in long-term cultured Fao hepatoma cells.

The proliferative activity of long-term cultured mammalian cells exhibits traits of a complex dynamic system, with a succession of spontaneous rises and falls in proliferation rate. We analyzed three successive series of proliferation data for the Fao hepatoma cell line in long-term cultures. In the three series the proliferation rate displayed apparently disordered oscillations, which each lasted about 3-5 passages, with variable amplitude and were therefore unpredictable. Such non-linear kinetics raises the major issue of whether these fluctuations are random, or determined and coordinated. We used a graphical method of analysis of the data, which demonstrated that all troughs of proliferation were mathematically related to a common value in each series. This common value was itself related to the maximum level of proliferation of the cell line. Non-linear analysis thus confirmed that the fluctuations in proliferation rate of tumoral Fao cells are, at least in part, determined. This pattern evokes chaotic dynamics and is evidence for the flexible coordination of the complex system linking positive and negative growth regulators in long-term cultured cells.

Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma.

STUDY DESIGN: A total of 208 consecutive coccydynia patients were examined with the same clinical and radiologic protocol. OBJECTIVES: To study radiographic coccygeal lesions in the sitting position, to elucidate the influence of body mass index on the different lesions, and to establish the effect of coccygeal trauma. SUMMARY OF BACKGROUND DATA: A protocol comparing standing radiographs and radiographs subsequently taken in the painful sitting position in coccydynia patients and in controls has shown two culprit lesions: posterior luxation and hypermobility. Obesity and a history of trauma have been identified as risk factors for luxation. METHODS: Dynamic radiographs were obtained. The body mass index was compared with the coccygeal angle of incidence, sagittal rotation of the pelvis when sitting down, and the presence and time of previous trauma. The patients with the newly described lesions were examined after an anesthetic block under fluoroscopic guidance. RESULTS: Two new coccygeal lesions are described (anterior luxation and spicules). Obesity was found to be a risk factor. The body mass index determines the way a subject sits down, and lesion patterns were different in obese, normal-weight, and thin patients (posterior luxation: 51%, 15.2%, 3.7%; hypermobility: 26.5%, 30.3%, 14.8%; spicules: 2%, 15.9%, 29.6%; normal: 16.3%, 32.6%, 48.1%, respectively; P < 0.0001). Trauma affected the type of lesion only if it was recent (<1 month before the onset of coccydynia), in which case the instability rate increased from 55.6% to 77.1%. Backward-moving coccyges were at greatest risk of trauma. CONCLUSIONS: This protocol allows identification of the culprit lesion in 69.2% of cases. The body mass index determines the causative lesion, as does trauma sustained within the month preceding the onset of the pain.

Value of quantitative radionuclide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain.

A prospective study was performed to compare the results of quantitative radionuclide bone scanning with those of sacroiliac joint anesthetic block in patients with unilateral low back pain. Thirty-four subjects, forming the control group, underwent quantitative radionuclide bone scanning of the sacroiliac joints. The normal values in sacroiliac uptake difference were taken to be between -1.7% and +6.2%. Thirty-two patients with chronic unilateral low back pain underwent sacroiliac bone scanning and sacroiliac joint block. Six of the seven patients with increased uptake > 6.2% on the painful side had at least 75% pain reduction in response to the block. The sensitivity, specificity, and positive and negative predictive values of the quantitative bone scanning in the unilateral mechanical sacroiliac joint syndrome were 46.1%, 89.5%, 85.7%, and 72%, respectively.