Can an anomalous lumbo-sacral or lumbo-iliac articulation cause low back pain? A retrospective study of 12 cases.

UNLABELLED: Although anomalous lumbo-sacral articulations are present in 5 to 7% of the population at large, their clinical relevance remains a matter of debate. Articulation between the L5 transverse process and the sacrum or ilium has been implicated as a cause of low back pain. OBJECTIVE: To define symptoms and effects of steroid injections in patients with an articulation between a L5 transverse process and the sacrum or ilium. PATIENTS AND METHODS: Patients with low back pain and an expanded L5 transverse process articulating with the sacrum or ilium were studied retrospectively. Patients with an expanded transverse process that did not articulate with the sacrum or ilium were excluded. Demographic data, symptoms, physical findings and results of investigations were recorded. Efficacy of steroid injections into the anomalous articulation performed under fluoroscopic monitoring was evaluated in the short, medium and long term. RESULTS: Twelve patients (seven men and five women) with a mean age of 41.1 years (17-90 years) and a mean time since symptom onset of 1.9 years (0.2-4 years) were studied. All 12 patients reported pain on the side of the anomalous articulation (left, n = 10), either in the low back (n = 6) or in the buttock (n = 6). Eight patients had pain radiation to all (n = 1) or part (n = 7) of the lower limb on the same side. One patient had mild motor loss (4/5) and another had paresthesia in the foot. Radiographs were obtained in all 12 patients, computed tomography in six, magnetic resonance imaging in two, myelography in two, a bone scan in two and an electromyogram in one. Three of the 11 patients treated by steroid injection experienced pain during the procedure. Ten patients were improved in the short term and nine reported a 50% decrease in their pain after one month. Of the eight patients who were reevaluated after six to 24 months, seven were improved or free of symptoms and one was unchanged. CONCLUSION: An anomalous transitional articulation should be considered as a possible factor in the genesis of low back pain in patients who do not have the degenerative lesions classically responsible for this symptom. Local steroid injections should be tried before surgery is considered.

Fourteen cases of sarcomatous degeneration in Paget's disease.

OBJECTIVE: To describe characteristics of cases of sarcomatous degeneration in Paget's disease (SDP) recorded over 10 years in 2 French university hospitals, with particular emphasis on the pattern of this entity on magnetic resonance imaging (MRI). METHODS: Fourteen cases are described. Epidemiological, clinical, radiological, histological, and MRI features (in 3 cases) are compared to others in the literature. RESULTS: Nine men and 5 women (mean age 75.2+/-7.7 yrs) were studied. Paget's disease was monostotic in 5 cases and polyostotic in 9. Neurological complications were present in 10 cases. The mean interval between the first clinical signs and diagnosis was 4.4+/-4.7 months. The locations were: limbs 2, skull 2, pelvis 7, sacrum 3. The radiological pattern was lytic in 9 cases, sclerotic in 3, and mixed in 2. MRI revealed a similar pattern in all 3 cases studied (heterogeneous low signal intensity of the tumor on T1 weighted images increased after intravenous gadolinium administration and high signal intensity on T2 weighted images), whereas the radiological pattern was lytic in 2 cases and sclerotic in one case. The diagnosis was proved by histological investigation in 11/14 patients (osteogenic sarcoma of different appearance in 7 patients, fibroblastic sarcoma in one, fibrous histiocytoma-like sarcoma in one, and undifferentiated sarcoma in 2). Four patients had pulmonary metastases and 4 patients are still alive with followup ranging from 5 months to 5 years. CONCLUSION: Paget sarcomas remain the most threatening sarcomas of bone, their prognosis being far more negative than primary sarcomas. Improvement in therapy strategies including surgery, radiation therapy, and chemotherapy might together provide better prognosis for SDP.

Cervical spine involvement in psoriatic arthritis.

UNLABELLED: The clinical and radiographic manifestations of cervical spine involvement in psoriatic arthritis remain incompletely described. Only one case-control study has been reported. OBJECTIVE: To conduct a case-control study of the clinical and radiographic manifestations of cervical spine involvement in psoriatic arthritis. PATIENTS AND METHODS: 30 psoriatic arthritis patients (mean age, 53.3 years (21-78); sex ratio, 1; mean disease duration, 80.4 months (12-204); and mean Ritchie's index, 9.3 (2-30)) were compared with 30 controls with common low back pain (mean age, 53.8 years (21-78)). Each patient underwent a physical examination, completed a questionnaire on function, underwent cervical spine radiography (anteroposterior and lateral views and views in flexion and extension). All radiographs were evaluated by an independent observer. RESULTS: Patients were more likely than controls to have neck pain (22/30 (73%) vs 8/30 (26%) P < 0.001). Among subjects with neck pain, the time pattern was more likely to be inflammatory in the patients than in the controls (14/22 vs 1/8, P < 0.001). Functional impairment and pain severity were significantly greater in the patients. On radiographs, facet joint abnormalities (osteophytes, joint space loss, sclerosis) were significantly more common (P < 0.01) in the patients, particularly at C3-C4 and C4-C5. Also more common in the patients were signs of spondylitis (7 vs 0) and of facet joint arthritis (7 vs 2). No subjects had syndesmophytes. Three (10%) patients had anterior C1-C2 subluxation with an atlas-dens interval greater than 4 mm. Within the patient group, no correlations were found between clinical patterns and radiographic findings. CONCLUSION: Our data confirm that psoriatic arthritis frequently involves the cervical spine, with the facet joints being a preferred target, and can cause anterior C1-C2 subluxation.

Influence of psychological factors on the response to clomipramine in hospitalized chronic low back pain patients. Preliminary data from a psychometric study.

BACKGROUND: Chronic low back pain is a complex condition produced by multiple factors. Psychological disturbances have been found in previous studies using a variety of psychological tests. The most widely used self-administered questionnaire was the Minnesota Multiphasic Personality Inventory (MMPI). OBJECTIVE: To assess the response to clomipramine in chronic low back pain patients according to baseline MMPI scores. PATIENTS AND METHODS: Thirty chronic low back pain patients were given clomipramine intravenously during a ten-day hospital stay, then orally for 20 days. The dose was gradually brought up to 150 mg/d. The MMPI was administered on the day before treatment initiation. MMPI scores were not looked at until the end of the study. The Saint Antoine Questionnaire, a visual analog scale for pain, Schöber's maneuver, and the global result as assessed by the patients (success or failure) were evaluated on days 0 (D0), 4 (D4), 10 (D10), and 30 (D30). RESULTS: The initial mean MMPI scores for hypochondria, depression, and hysteria were significantly lower in the 23 patients (76%) who considered their treatment successful on D30. Among the 13 patients with high hypochondria and hysteria scores, five improved during hospitalization then had a relapse after returning home. CONCLUSION: The response to treatment with clomipramine was better in nondepressive patients. The hypochondria and hysteria scores were the best predictors of the response to clomipramine. These results may provide a basis for selecting those chronic low back pain patients most likely to benefit from clomipramine therapy.