Spinal Cord Stimulator Inequities Within the US Military Health System.

OBJECTIVES: Although studies have described inequities in spinal cord stimulation (SCS) receipt, there is a lack of information to inform system-level changes to support health care equity. This study evaluated whether Black patients exhaust more treatment options than do White patients, before receiving SCS. MATERIALS AND METHODS: This retrospective cohort study included claims data of Black and non-Latinx White patients who were active-duty service members or military retirees who received a persistent spinal pain syndrome (PSPS) diagnosis associated with back surgery within the US Military Health System, January 2017 to January 2020 (N = 8753). A generalized linear model examined predictors of SCS receipt within two years of diagnosis, including the interaction between race and number of pain-treatment types received. RESULTS: In the generalized linear model, Black patients (10.3% [8.7%, 12.0%]) were less likely to receive SCS than were White patients (13.6% [12.7%, 14.6%]) The interaction term was significant; White patients who received zero to three different types of treatments were more likely to receive SCS than were Black patients who received zero to three treatments, whereas Black and White patients who received >three treatments had similar likelihoods of receiving a SCS. CONCLUSIONS: In a health care system with intended universal access, White patients diagnosed with PSPS tried fewer treatment types before receiving SCS, whereas the number of treatment types tried was not significantly related to SCS receipt in Black patients. Overall, Black patients received SCS less often than did White patients. Findings indicate the need for structured referral pathways, provider evaluation on equity metrics, and top-down support.

Sacroiliac Joint Dysfunction: Diagnosis and Treatment.

Sacroiliac (SI) joint dysfunction is a common cause of low back pain and accurate diagnosis can be challenging. A complete history and physical examination are critical in differentiating other diagnoses that may have similar signs and symptoms. Positive responses to at least three physical provocation tests suggest SI joint dysfunction, and local anesthetic SI joint blocks can also be useful for confirming the SI joint as the source of pain. Conservative treatment consists of a multimodal program combining patient education, pelvic girdle stabilization with focused stretching, and manipulative therapy. These programs can be performed by physical therapists or clinicians trained in manipulative therapy. Pelvic belts may be beneficial in affected postpartum patients. Patients with symptoms that do not improve with conservative management may benefit from interventional treatment options including intra-articular corticosteroid injections, cooled radiofrequency ablation, or SI joint fusion.

Back Pain in Outer Space.

Space travel has grown during the past 2 decades, and is expected to surge in the future with the establishment of an American Space Force, businesses specializing in commercial space travel, and National Aeronautics and Space Administration's planned sustained presence on the moon. Accompanying this rise, treating physicians are bracing for a concomitant increase in space-related medical problems, including back pain. Back pain is highly prevalent in astronauts and space travelers, with most cases being transient and self-limiting (space adaptation back pain). Pathophysiologic changes that affect the spine occur during space travel and may be attributed to microgravity, rapid acceleration and deceleration, and increased radiation. These include a loss of spinal curvature, spinal muscle atrophy, a higher rate of disc herniation, decreased proteoglycan and collagen content in intervertebral discs, and a reduction in bone density that may predispose people to vertebral endplate fractures. In this article, the authors discuss epidemiology, pathophysiology, prevention, treatment, and future research.

A Novel Approach to Assessing and Conservatively Treating Anterior Cutaneous Nerve Entrapment Syndrome: A Case Study.

Anterior cutaneous nerve entrapment syndrome (ACNES) is a common source of chronic abdominal pain and is often underdiagnosed despite numerous and potentially invasive diagnostic evaluations and tests. We present a case report describing a novel, conservative, and non-invasive approach to diagnose and treat recurrent ACNES in a young and active patient. We describe a treatment-based diagnostic approach to confirm potential ACNES pain generators while recording pre- and post-treatment pain scores. After each maneuver, the patient was reassessed which allowed the working diagnosis to clinically evolve demonstrating the pathologic interrelationship between different skeletal structures and myofascial tissues contributing to irritation of the anterior cutaneous nerve. This treatment-based technique also made it possible to identify referred pain from a condition with overlapping symptoms originating from a different anatomic site. Treatment consisted of sequenced osteopathic manipulation techniques, active release techniques, instrument-assisted soft tissue mobilization, directional cupping, stretching, and strengthening exercises. The combination of sequenced treatments over the course of six physical therapy visits spanning 10 weeks resulted in 100% pain reduction and complete resolution of functional limitations. The patient was able to complete all work requirements and physical activity without pain. A sequenced treatment-based diagnostic approach to this case allowed us to more accurately identify all involved anatomic regions of pain and anatomic segments of pathology that were contributing to the abdominal pain or referring pain. No diagnostic imaging, invasive test, or injection was needed to properly diagnose and treat this case of ACNES. A proper understanding and application of osteopathic manipulation, active release techniques, instrument-assisted soft tissue mobilization, cupping, and exercises successfully resolved the contributing pain conditions and provided the patient important and useful tools and strategies to prevent recurrence.

Successful Resolution of Chronic Testicular Pain With an Impairment-Based Treatment Program: A Case Study With One-Year Follow-Up.

Chronic testicular pain is a condition commonly experienced by males. Potential causes of testicular pain can be pathology localized within the testicle or referred pain from surrounding tissues or spinal conditions. The diagnostic differential is extensive and can be seen as a diagnosis of exclusion after structural disorders specific to the testicle are ruled out. In approximately 50% of the cases, the cause of pain is undetermined. Patients with testicular and inguinal pain may undergo extensive workup that overlooks potential neuropathic and musculoskeletal causes remote to the testicle. This case study describes the application of a conservative treatment program targeting presumptive chronic genitofemoral and/or ilioinguinal nerve entrapment along the course of the inguinal canal for the treatment of chronic testicular pain. By combining sacroiliac joint osteopathic manipulation, iliopsoas stretching, and soft tissue mobilization utilizing a vacuum suction cup, the patient was symptom-free on the fourth visit after suffering from testicular pain for a year. At a one-year follow-up, the patient remains pain-free.