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Background: Spinal epidural lipomatosis (SEL) is a rare contributor of low back pain (LBP) that can present with or without radicular symptoms. Case Presentation: A 51-year-old and 65-year-old male presented with chronic LBP to the Veterans Affairs chiropractic clinic for a trial of care. One had a moderate degree of lumbar spinal stenosis with known SEL and the other had severe. The patient with moderate grade stenosis responded favorably with weeks of transient benefit after visits and the patient with severe grade did not find benefit with care. Summary: SEL is a condition that conservative care providers should be aware of as a potential cause of central canal stenosis or neuroforaminal narrowing. Chiropractic management of SEL has been scarcely reflected in the published literature, but may be a viable option for transient symptom management.
ABSTRACT
OBJECTIVE: The purpose of this systematic review was to ascertain guideline-recommended pharmaceutical approaches to lumbosacral radicular symptoms, assess the quality of the clinical practice guidelines (CPGs) with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool, and qualitatively synthesize the guideline recommendations. LITERATURE SURVEY: Literature searches were performed in PubMed, Cochrane Database of Systematic Reviews, Index to Chiropractic Literature, Allied and Complementary Medicine Database (AMED), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence Database (PEDro). We included guidelines published between January 1, 2017, and January 9, 2022, written in the English language, related to radiculopathy, sciatica, and/or low back pain with leg pain, and that provided recommendations on oral medication. METHODOLOGY: The review was performed in accordance with Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) and the protocol was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO). Eligibility screening, full-text review, extraction of information pertaining to pharmacological management, and synthesis of results were performed independently by two authors and a third investigator was recruited to arbitrate any disagreements. The AGREE II tool was administered by four authors to appraise CPG quality. SYNTHESIS: After screening 413 citations and assessing 37 full-text articles, 11 CPGs met the inclusion criteria. They represented seven countries (Belgium, Canada, England, France, Japan, Korea, and United States) and three continents (Asia, Europe, and North America), as well as the Global Spine Care Initiative aimed at a worldwide presence. The mean overall AGREE II score was 87.1% (standard deviation [SD] 12.6%), generally reflecting high-quality CPGs. The highest domain mean score was for Clarity of Presentation (96.7%, SD 4.4%), and the lowest was Applicability (75.6%, SD 22.8%). Five classes of medications were recommended by at least one CPG: anticonvulsants, antidepressants, oral corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. CONCLUSIONS: The most common medication class recommended by the CPGs for lumbar radiculopathy was antidepressants. No CPGs recommended prescribing acetaminophen, benzodiazepines, muscle relaxants, or antibiotics. There was very little agreement between the CPGs, and all the medication classes had at least one CPG recommended against its use. Three guidelines reviewed did not recommend any medications due to lack of supporting literature, and instead recommended nonpharmacologic therapy.
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Background: Distal bimelic amyotrophy (DBMA) also known as Hirayama disease, is a rare, self-limiting motor neuron disease manifesting as atrophy of C7-T1 innervated muscles. We present a case report describing the chiropractic management of neck and thoracic pain in a patient with known DBMA. Case presentation: A 30 year-old black male U.S. veteran with DBMA presented with myofascial pain of the neck, shoulder, and back. A trial of chiropractic care was undertaken involving spinal manipulation of the thoracic spine and cervicothoracic region, manual and instrument-assisted soft tissue mobilization, and home exercise prescription. The patient reported modest improvement in pain intensity and did not experience any adverse events. Summary: This case presents the first documentation of chiropractic services in musculoskeletal pain management of a patient with concurrent DBMA. At this time there is no guidance in the existing body of literature for the safety and effectiveness of manual therapy in this population.
Contexte: La myélopathie cervicale basse, également connue sous le nom de maladie d'Hirayama, est une maladie rare et spontanément résolutive du motoneurone qui se manifeste par une atrophie des muscles innervés C7-T1. Nous présentons un rapport de cas décrivant la prise en charge chiropratique de douleurs cervicales et thoraciques chez un patient atteint d'une maladie d'Hirayama connue. Présentation du cas: Un vétéran américain noir de 30 ans, atteint de myélopathie cervicale basse, s'est présenté avec des douleurs myofasciales au cou, aux épaules et au dos. Un essai de soins chiropratiques a été entrepris comprenant des manipulations vertébrales de la colonne thoracique et de la région cervicothoracique, des mobilisations manuelles et instrumentales des tissus mous, et la prescription d'exercices à domicile. Le patient a fait état d'une amélioration modeste de l'intensité de la douleur et n'a pas ressenti d'effets indésirables. Résumé: Ce cas présente la première documentation des services chiropratiques dans la gestion de la douleur musculo-squelettique d'un patient souffrant d'une myélopathie cervicale basse. À l'heure actuelle, il n'existe pas d'orientation dans la littérature existante sur la sécurité et l'efficacité de la thérapie manuelle dans cette population.
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Objective: The purpose of this case report is to describe the conservative treatment of a patient with musculoskeletal knee pain associated with a benign femoral osteochondroma. Clinical Features: An 11-year-old boy with acute left knee pain for 1 week's duration presented for chiropractic evaluation. He attributed the pain to nontraumatic provocation during football and a pre-existing benign osteochondroma located in his left femoral epiphysis. He had pain throughout his posteromedial knee and distal thigh, attributed to acute irritation of the surrounding adductor and medial hamstring musculature. His orthopedic surgeon had recommended delaying surgical excision. The patient presented for conservative pain management to continue participating in football. Intervention and Outcome: A trial of conservative care was performed for 3 visits throughout 6 days. It consisted of therapeutic exercise in the form of end-range isometric exercises and gentle manual therapy, with self-management strategies including Kinesio Taping and cryotherapy. After 3 visits the patient's acute pain declined and his function and ranges of motion returned to baseline, which allowed him to continue participating in youth football unrestricted. Conclusion: A young athlete with knee pain, likely associated with a distal femoral osteochondroma, was managed with a short course of chiropractic care. The patient was able to continue participating in youth football and required no further care.
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OBJECTIVE: To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG). METHODS: We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP. RESULTS: 316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids. CONCLUSIONS: Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.
