Lumbar burner and stinger syndrome in an elderly athlete

Burner or stinger syndrome is a rare sports injury caused by direct or indirect trauma during high-speed or contact sports mainly in young athletes. It affects peripheral nerves, plexus trunks or spinal nerve roots, causing paralysis, paresthesia and pain. We report the case of a 57-year-old male athlete suffering from burner syndrome related to a lumbar nerve root. He presented with prolonged pain and partial paralysis of the right leg after a skewed landing during the long jump. He was initially misdiagnosed since the first magnet resonance imaging was normal whereas electromyography showed denervation. The insurance company refused to pay damage claims. Partial recovery was achieved by pain medication and physiotherapy. Burner syndrome is an injury of physically active individuals of any age and may appear in the cervical and lumbar area. MRI may be normal due to the lack of complete nerve transection, but electromyography typically shows pathologic results.

Can denosumab be a substitute, competitor, or complement to bisphosphonates?

Osteoblasts, originating from mesenchymal cells, make the receptor activator of the nuclear factor kappa B ligand (RANKL) and osteoprotegerin (OPG) in order to control differentiation of activated osteoclasts, originating from hematopoietic stem cells. When the RANKL binds to the RANK of the pre-osteoclasts or mature osteoclasts, bone resorption increases. On the contrary, when OPG binds to the RANK, bone resorption decreases. Denosumab (AMG 162), like OPG (a decoy receptor), binds to the RANKL, and reduces binding between the RANK and the RANKL resulting in inhibition of osteoclastogenesis and reduction of bone resorption. Bisphosphonates (BPs), which bind to the bone mineral and occupy the site of resorption performed by activated osteoclasts, are still the drugs of choice to prevent and treat osteoporosis. The merits of denosumab are reversibility targeting the RANKL, lack of adverse gastrointestinal events, improved adherence due to convenient biannual subcutaneous administration, and potential use with impaired renal function. The known adverse reactions are musculoskeletal pain, increased infections with adverse dermatologic reactions, osteonecrosis of the jaw, hypersensitivity reaction, and hypocalcemia. Treatment with 60 mg of denosumab reduces the bone resorption marker, serum type 1 C-telopeptide, by 3 days, with maximum reduction occurring by 1 month. The mean time to maximum denosumab concentration is 10 days with a mean half-life of 25.4 days. In conclusion, the convenient biannual subcutaneous administration of 60 mg of denosumab can be considered as a first-line treatment for osteoporosis in cases of low compliance with BPs due to gastrointestinal trouble and impaired renal function.

Should We Start Treating Chronic Low Back Pain with Antibiotics Rather than with Pain Medications?

For those of us who have read the 2 recently published articles by a Danish - British research group, it might appear that we are observing an impending paradigm shift on the origins of chronic low back pain. The results of this research indicate, that chronic low back pain associated with bone marrow edema in vertebral endplates that are adjacent to herniated intervertebral discs may be caused by infections with anaerobic bacteria of low virulence. According to these articles, treatment with certain antibiotics is significantly more effective than placebo against this low back pain. If these findings are to hold true in repeat studies by other researchers, they stand to fundamentally change our concepts of low back pain, degenerative disc disease and in consequence the suitable therapies for these entities. It may in fact require pain specialists to become familiarized with the details of antibiotic treatments and their specific risks in order to be able to properly counsel their patients. While this seems hard to believe at first glance, bacteria have been implicated in the pathogenesis of other conditions that do not primarily impose as infectious diseases such as gastric ulcers. While the authors refer to a few previous studies pointing into the same direction, the relevant research is really only from one group of collaborating scientists. Therefore, before we start prescribing antibiotics for chronic low back pain, it is imperative that other researchers in different institutions confirm these results.