Sacral Giant Cell Tumor Presenting as Low Back Pain in the Chiropractic Office: A Case Report.

Sacral giant cell tumors are a rare cause of low back pain and may be challenging to identify via routine clinical examination and radiography. A 47-year-old woman presented to a chiropractor with a one-month history of worsening low back pain with radiation to the posterior thighs, worsened with ambulation, and used a cane to walk. She previously saw an orthopedic surgeon and was diagnosed with lumbar spondylosis, having tried anti-inflammatory medications, exercises, and acupuncture without success. The chiropractor ordered lumbar magnetic resonance imaging which revealed an aggressive sacral lesion and referred the patient to an oncologist. The oncologist performed positron emission tomography/computed tomography and biopsy, confirming a sacral giant cell tumor. A surgical team recommended tumor resection, lumbosacral fusion, radiotherapy, and zoledronic acid infusion. Sacral giant cell tumors are rare and may be challenging to identify via routine radiography. These tumors are an important differential to consider for patients with unexplained lumbosacral symptoms unresponsive to care.

Lumbar Schwannoma as a Rare Cause of Radiculopathy in the Chiropractic Office: A Case Report.

Cauda equina tumors are rare, slow-growing, and typically benign. These tumors present with low back pain resembling disc displacement with radiculopathy and thus may go undiagnosed for months. A 52-year-old, otherwise healthy man presented to a chiropractor with a one-year history of worsening low back pain radiating to the right lower extremity, rated an 8/10 in severity and aggravated by recumbency. Previously, his primary care physician had ordered radiographs revealing mild lumbar degenerative changes, prescribed a non-steroidal anti-inflammatory medication, and referred him to an orthopedist and physical therapist. There had been no change in symptoms. Upon examination by the chiropractor, the patient had neurologic deficits, and due to progressive worsening, the chiropractor recommended magnetic resonance imaging (MRI), which the patient deferred due to cost. The chiropractor initiated a trial of care, with initial success; however, the patient's symptoms recurred, and he consented to an MRI. MRI revealed an intradural extramedullary lumbar tumor, and the chiropractor referred the patient to an oncologist, who referred the patient to a neurosurgeon. The neurosurgeon surgically removed the mass, with a biopsy confirming a schwannoma. The patient had significantly improved six weeks after surgery. This case highlights a patient with chronic low back pain for whom a chiropractor identified a cauda equina tumor and referred him for further evaluation and surgery. Clinicians should consider night pain and persistent symptoms, despite conservative care, as red flags warranting further investigation in those with low back pain. Providers should refer for neurosurgical evaluation when clinical and radiological findings suggest a cauda equina tumor.

Concurrent Spinal and Intracranial Subdural Hematomas as a Cause of Near-Fatal Low Back Pain in the Chiropractic Office: A Case Report.

In older individuals, minor trauma may cause potentially fatal intracranial subdural hematoma (SDH). Rarely, these patients present with only low back and radicular pain as gravity redistributes the SDH to the lumbar spine. A 69-year-old male presented to a chiropractor with a 10-day history of acute on chronic low back pain, which radiated into his lower extremities bilaterally, involving weakness and difficulty walking, and a ground-level fall onto his elbows 16 days prior. He had visited his primary care provider, orthopedist, and traditional Chinese medicine practitioner, received oral analgesics and three ketorolac injections, and had lumbar radiographs, followed by acupuncture, cupping, and spinal manipulation without lasting relief. Considering the patient's concerning presentation, the chiropractor ordered lumbar magnetic resonance imaging (MRI) on the first visit, revealing findings suggestive of late subacute lumbar SDH, and recommended urgent brain MRI and neurosurgical referral. The patient went to an orthopedic surgeon at a nearby hospital, becoming disoriented upon presentation, prompting admission. Brain MRI confirmed bilateral chronic intracranial SDH, prompting emergency hematoma evacuation via burr hole craniostomy. The patient's gait rapidly improved, and the pain subsided over the following two weeks. This case highlights an older male identified as having spinal SDH by a chiropractor, leading to referral and surgery for concurrent life-threatening intracranial SDH. Clinicians should be aware that spinal SDH may stem from asymptomatic intracranial SDH and should be suspicious of SDH in older individuals after a fall, signs of which warrant emergency referral for MRI and surgical evaluation.

Presumptive Prostate Cancer Presenting as Low Back Pain in the Chiropractic Office: Two Cases and Literature Review.

Prostate cancer is a common type of cancer in men and may metastasize to the spine and pelvis, causing back and/or radicular pain that appears to be musculoskeletal. This presents a diagnostic challenge and can be complicated by a lack of routine screening for prostate cancer. In two similar cases, elderly males (ages 78 and 82) with no known history of cancer and no previous prostate-specific antigen screening presented to a chiropractor with chronic, worsening radiating low back pain. In each case, a previous provider obtained radiographs and ascribed symptoms to a non-cancerous etiology (i.e., lumbar spondylosis, osteoporotic compression fracture), treated with nonsteroidal anti-inflammatory medications and physiotherapy. Given each patient's progressive worsening and neurologic deficits, the chiropractor ordered lumbar magnetic resonance imaging, revealing potential spinal metastasis. The chiropractor referred each patient to an oncologist who performed additional testing, making a presumptive diagnosis of prostate cancer. A literature review identified seven cases of previously undiagnosed prostate cancer presenting to a chiropractor. Including the current cases, patients were often older, presenting with thoracolumbar pain caused by spine or pelvic metastasis. The current cases and literature review illustrate that men with undiagnosed metastasis from prostate cancer may present to chiropractors complaining of spinal pain. Chiropractors should be aware of red flags warranting imaging such as older age and new or progressive symptoms and should refer patients to an oncologist when suspecting prostate cancer.

Adjacent segment pathology of the cervical spine: A case report.

Adjacent segment pathology (ASP) refers to degenerative changes at segments immediately contiguous to previous spinal fusion. Its pathophysiology is hypothesized as being possibly due to altered biomechanical stresses on adjacent levels following spinal fusion or due to patient propensity to develop progressive degenerative change. This case report describes a 61-year-old female who presented with neck pain and cervical radiculopathy attributed to an anterior cervical discectomy and spinal fusion performed for degenerative disc disease 30 years earlier. ASP was seen on magnetic resonance imaging (MRI) and radiograph. Treatment consisted of cervical manipulation, soft-tissue mobilization, flexion-distraction decompression, and therapeutic ultrasound to release restriction and restore muscle strength. Following 34 sessions of chiropractic intervention, her symptoms were resolved. Patients with ASP will have ongoing shared care between general practitioners and secondary or tertiary care pain units. This report aims to build a shared understanding from the wider vision of ASP and help primary practitioners to manage ASP effectively.

Spontaneous Cervical Epidural Hematoma Following COVID-19 Illness Presenting to a Chiropractor: A Case Report.

Cervical epidural hematoma (CEH) is a rare and potentially fatal condition in which blood accumulates in the epidural space of the cervical spine. A 64-year-old man presented to a chiropractor with a two-week history of sudden-onset neck pain, shoulder pain, occipital headache, and numbness in the shoulders and upper extremities. He had recovered from a mild course of coronavirus disease 2019 (COVID-19) illness one month prior. The patient's primary care provider had previously prescribed a nonsteroidal anti-inflammatory drug for his neck pain. However, his symptoms worsened, and he visited the emergency department where he had unremarkable cervical spine radiographs and was discharged with a diagnosis of neck strain. The chiropractor ordered cervical spine magnetic resonance imaging (MRI), revealing a ventral CEH extending from C2 to C5. The chiropractor referred the patient to a nearby hospital for urgent management. The patient was admitted and observed, progressively improved, and did not require surgery. After 10 weeks in the hospital the patient was asymptomatic, a follow-up MRI revealed resolution of the CEH, and the patient was discharged. While the current case highlights a temporal relationship between COVID-19 and CEH, further research is needed to determine if COVID-19 is a risk factor for this condition. Clinicians who encounter patients with spinal disorders must be able to recognize the clinical features of CEH and refer these patients for emergency care and/or neurosurgical evaluation.

Use of Thrust Cervical Spinal Manipulative Therapy for Complicated Neck Pain: A Cross-Sectional Survey of Asia-Pacific Chiropractors.

Background Chiropractors often use manual thrust cervical spinal manipulative therapy (thrust-cSMT) to treat musculoskeletal neck conditions. We hypothesized <50% of surveyed Asia-Pacific chiropractors would report using thrust-cSMT given potential contraindications, and secondarily explored predictors of thrust-cSMT use. Materials and methods We designed, validated, achieved sufficient reliability, and disseminated a survey to explore thrust-cSMT use. The survey queried chiropractors' characteristics (e.g., years in practice, education level, time with patients, importance of subluxation), and use of thrust-cSMT for uncomplicated neck pain and vignettes describing vertebral artery disorders, Arnold-Chiari malformation, and anterior cervical discectomy and fusion (ACDF). We performed logistic regression for each vignette with thrust-cSMT as the dependent variable and chiropractor characteristics as covariates. Results There were 241 respondents, having 12.8±10.9 years in practice, representing >15 countries. Less than 50% of chiropractors reported the use of thrust-cSMT for each vignette, including vertebral artery insufficiency (14%) and stenosis (17%), Arnold-Chiari type I (18%) and type II (5%), C5/6 ACDF (39%) and C3-6 ACDF (27%). Regressions identified significant predictors of increased or decreased use of thrust-cSMT including time spent with new patients, focus on subluxation, degree, group practice environment, use of thrust-cSMT on a healthy patient, and hours reading scientific literature (P<.05 for each). Conclusions This study was the first to chiropractors' use of thrust-cSMT for complicated neck pain and found that most Asia-Pacific chiropractors reported avoiding this treatment in the presence of a potential treatment contraindication. The use of thrust-cSMT in complicated neck pain may be related to practice characteristics. However, further research is needed to identify specific reasons why chiropractors use or avoid thrust-cSMT.

Cervicogenic dysphagia associated with cervical spondylosis: A case report and brief review.

Dysphagia (swallowing difficulty) is most often related to another health problems, including brain or spinal cord injury, neurological damage, neuromuscular disorders, and anatomical conditions. Dysphagia can have detrimental effects on pulmonary health and also impact nutritional intake. The right treatment depends on the cause established. Cervicogenic dysphagia is a cervical cause of difficulty in swallowing. This report describes a 53-year-old female patient with sore throat, swallowing difficulty for solids, and acid reflux for 2 years. Radiographs revealed anterior osteophytic lipping and kyphosis of the cervical spine and thoracolumbar (right convex) scoliosis. After 6 months of chiropractic treatment, her complaints and spinal deformity were obviously resolved. Our case report is unique in that the patient had an unusual presentation, i.e. cervical osteophytes, cervical kyphosis, and thoracolumbar scoliosis, which are all contributable causes of dysphagia. Correction of spinal deformity could result in positive treatment outcomes in selected patients with symptoms of cervicogenic dysphagia.

Plausible impact of forward head posture on upper cervical spine stability.

The cervical spine is responsible for allowing mobility and stability to the head and neck. Any deviation to the center of gravity of the head results in an increase in cantilever loads, which can be particularly damaging to the upper cervical joints. Excessive neck bending also exaggerates stretching through the cervical spine and all of the spinal structures below. It has been reported that forward head posture (FHP) can cause a multitude of disorders including cervical radiculopathy, cervicogenic headaches and cervicogenic dizziness. Most of these conditions manifest with clusters of painful symptoms and spine dysfunctions. The purpose of this case study is to describe the radiographic imaging considerations and to illustrate the potential impacts in symptomatic adults with FHP. We randomly selected radiographs of three individuals with FHP who had undergone cervical adjustment for cervical pain. The occipito-axial (C0-C2) and atlanto-axial (C1-C2) joints were assessed via the C0-2 distance from the C2 base to the McGregor line (Redlund-Johnell criterion) and the Ranawat C1-2 index, in addition to subjective radiographic parameters. By comparing the radiographs of before-and-after intervention of each patient, a regressive joint spacing was observed from both indices. Such a long-lasting stretching concordant with FHP was assumed to be hazardous to joint stability. A definite conclusion, however, cannot be drawn due to the small sample size and a lack of convincing measurements.

Remission of recalcitrant dermatomyositis following a chiropractic adjustment.

Dermatomyositis (DM) is an idiopathic inflammatory myopathy characterized by progressive muscle weakness and pathognomonic skin eruptions. Systemic corticosteroid with or without an immunosuppressive agent is the current treatment of choice in most cases. Cutaneous disease in DM is often refractory and can become the most challenging component to manage effectively. Here, we report a case of recalcitrant DM in a 66-year-old female who sought chiropractic attention for recent episodes of pain and paresthesia in the neck and exacerbation of joint pain. As expected, the musculoskeletal complaints including neck pain, peripheral arthralgia, and muscle weakness that resolved within 1 month after starting treatment. Unexpectedly, dramatic remission of the characteristic skin rashes occurred concurrently. The underlying therapeutic mechanisms of chiropractic remain elusive. This case highlights the importance of family physicians becoming familiar with diagnosing the condition and using a multidisciplinary team approach to treat recalcitrant DM.

Application of the Seattle Heart Failure Model in ambulatory patients presented to an advanced heart failure therapeutics committee.

BACKGROUND: We sought to assess the predictive value of the Seattle Heart Failure Model (SHFM) when applied to ambulatory patients with advanced heart failure (HF) presented to an advanced HF therapeutics committee at a tertiary care US institution. METHODS AND RESULTS: We evaluated model discrimination and calibration in 215 consecutive ambulatory patients who were presented to the Cleveland Clinic advanced HF therapeutics committee between 2004 to 2007 for evaluation for advanced options including transplantation and ventricular assist device (VAD). Analyses were stratified by committee decision (not listed versus listed United Network of Organ Sharing [UNOS] Status 2). Eighty-five percent had 1 or no missing SHFM variables. The primary outcome was a composite of all-cause mortality, VAD, or urgent (UNOS Status 1) transplantation. During a median follow-up of 24 months, 68 died, 18 received VAD support, and 81 underwent heart transplantation. Discrimination was modest both for those not listed (c-index, 0.683 at 1 year and 0.648 at 2 years), and for those listed UNOS status 2 (c-index, 0.629 at 1 year and 0.628 at 2 years). Calibration was acceptable among those patients not listed for heart transplantation but with substantial underestimation of risk (ie, overestimation of survival free of VAD or urgent transplantation) among UNOS status 2 patients. CONCLUSIONS: In ambulatory patients presented to an advanced HF therapeutics committee for evaluation for heart transplantation, the SHFM offers modest discrimination of risk for the primary composite outcome of mortality, VAD, or urgent transplantation, with underestimation of risk in those patients listed for nonurgent transplantation. Interpretation of risk prediction by the SHFM in this patient population must be done with caution.

Prognosis on chronic dobutamine or milrinone infusions for stage D heart failure.

BACKGROUND: There are no published clinical trials comparing dobutamine with milrinone in outpatients with stage D heart failure on continuous inotropes. METHODS AND RESULTS: In a retrospective analysis of 112 inotrope-dependent patients with stage D heart failure who were not transplant candidates at enrollment, we investigated the relationship between choice of dobutamine or milrinone and mortality. Half the patients were on dobutamine (mean dose, 5.4+/-2.5 microg/kg per minute) and half on milrinone (mean dose, 0.4+/-0.2 microg/kg per minute). Those on dobutamine tended to be older (63 years old versus 54 years old), male (86% versus 79%), and fewer had implantable cardioverter-defibrillators (57% versus 74%). During a median follow-up time of 130 days (range, 2 to 2345 days), there were 85 deaths (76% of cohort) and 55 rehospitalizations. Use of dobutamine compared with milrinone was associated with higher all-cause mortality in an unadjusted analysis (hazard ratio [HR], 1.63; 95% CI, 1.06 to 2.52; P<0.03). However, this association was not significant after adjustment for baseline characteristics in the full cohort (N=112; HR, 0.99; 95% CI 0.5 to 1.97; P=0.98) or propensity-matched cohort (N=70; HR, 0.94; 95% CI 0.48 to 1.85; P=0.86). CONCLUSIONS: In this single-center retrospective study, there were no mortality differences between chronic intravenous dobutamine or milrinone in patients with stage D heart failure being discharged from the hospital. The high mortality in this group selected for inotrope dependence warrants careful consideration of all options and priorities for further care.

Mice with a deletion in the gene for CCAAT/enhancer-binding protein beta are protected against diet-induced obesity.

The CCAAT/enhancer-binding protein beta (C/EBPbeta) is required for adipocyte differentiation and maturation. We have studied the role of the transcription factor, C/EBPbeta, in the development of diet-induced obesity. Mice with a deletion in the gene for C/EBPbeta (C/EBPbeta(-/-)) and wild-type mice were fed a high-fat diet (60% fat) for 12 weeks. The C/EBPbeta(-/-) mice lost body fat, whereas the wild-type mice increased their total body fat on a high-fat diet. The C/EBPbeta(-/-) mice had lower levels of blood triglycerides, free fatty acids, cholesterol, and hepatic triglyceride accumulation compared with the wild-type mice, thus protecting them from diet-induced obesity and fatty liver on a high-fat diet. Deletion of C/EBPbeta gene resulted in greatly reducing hepatic lipogenic genes, acetyl CoA carboxylase, and fatty acid synthase and increasing the expression of beta-oxidation genes in the brown adipose tissue. CO(2) production was significantly higher in the C/EBPbeta(-/-) mice as was the level of uncoupling protein (UCP)-1 and UCP-3 in the muscle. In conclusion, the transcription factor C/EBPbeta is an important regulator in controlling lipid metabolism and in the development of diet-induced obesity.

PTEN regulatory functions in tumor suppression and cell biology.

PTEN is a dual-specificity phosphatase with both protein phosphatase and lipid phosphatase activity. PTEN is the first phosphatase identified as a tumor suppressor. Not since the discovery of p53 has a tumor suppressor generated such interest. Initial studies performed on cancer cell lines suggested that PTEN may be responsible for almost all types of cancer, both solid tumors and hematological malignancies. Biallelic deletion of PTEN has been associated with advanced stage tumors or metastatic disease. PTEN has been shown to play a pivotal role in apoptosis, cell cycle arrest, and possibly cell migration. Emerging data suggest that this may be an oversimplification of PTEN's role, and that PTEN may be haploinsufficient for tumor progression and may play important roles in other cellular functions such as angiogenesis and MAP kinase signaling.

NSAIDs activate PTEN and other phosphatases in human colon cancer cells: novel mechanism for chemopreventive action of NSAIDs.

Studies on chemoprevention of colorectal cancer have generated increasing interest. The mechanisms involved in NSAIDs chemopreventive action are not fully elucidated. In this study, we examined in human colon cancer cells the effect of indomethacin and NS-398 (a pre-clinical selective COX-2 inhibitor) on expression of 96 genes of the EGF/PDGF signaling pathways essential for cell proliferation, migration, and survival. We found that indomethacin and NS-398 treatment significantly upregulated expression of the tumor suppressor gene, PTEN, the MAP kinase phosphatase-3, MKP-3, and the protein tyrosine phosphatase, SHP2. Additionally, NS-398 treatment increased expression of apoptotic genes such as BAD, STAT1, and CASP3. These results suggest that as a consequence of increased expression of phosphatases such as PTEN and the resulting dephosphorylation of kinases, NSAIDs can negatively regulate the EGF/PDGF pathways in colon cancer cells-a novel mechanism for NSAIDs' chemopreventive actions.

Fatal spontaneous gallbladder variceal bleeding in a patient with alcoholic cirrhosis.

Gallbladder varices are unusual ectopic varices that may develop in patients with portal hypertension, particularly in those with portal vein occlusion. In rare instances, these varices may cause hemobilia, life-threatening bleeding, or even rupture of the gallbladder. We report the first case of a 41-year-old man with alcoholic cirrhosis and patent portal vein who developed massive hemoperitoneum from spontaneous rupture of varices in the gallbladder fossa. The diagnosis of gallbladder varices eluded conventional imaging and was made only at autopsy. Gallbladder variceal hemorrhage is a rare, but potentially catastrophic complication of cirrhosis.