The importance of fear, beliefs, catastrophizing and kinesiophobia in chronic low back pain rehabilitation.

AIM: To evaluate fear, beliefs, catastrophizing and kinesiophobia in chronic low back pain patients about to begin a training programme in a rehabilitation centre. PATIENTS AND METHODS: Fifty chronic low back pain patients (including both males and females) were assessed in our physical medicine department. We used validated French-language scales to score the patients' pain-related disability, quality of life and psychosocial factors. RESULTS: Seventy percent of the patients had a major functional disability (i.e., a Roland-Morris Scale score over 12) and nearly 73% reported an altered quality of life (the daily living score in the Dallas Pain Questionnaire). Pain correlated with functional impairment and depression but not with catastrophizing or kinesiophobia. Disability was correlated with catastrophizing and kinesiophobia. CONCLUSION: Psychosocial factors are strongly associated with disability and altered quality of life in chronic low back pain patients. Future rehabilitation programs could optimizing patient management by taking these factors into account.

Osteoporotic fracture of the sacrum: sacroplasty and physical medecine.

CONTEXT: Traditional treatment of sacrum osteoporotic fractures is mainly based on antalgics and rest in bed. But complications are frequent, cutaneous, respiratory, thrombotic or digestive and mortality at 1 year significant. THE AIMS: We wanted to define the interest of sacroplasty when treating osteoporotic fracture of sacrum. METHOD: We reviewed literature while studying a clinical case in an elderly patient. RESULTS: Sacroplasty was efficient at short and mean delay to control the pain due to osteoporotic sacrum fracture. Rate of complications is low in the centers mastering the procedure. CONCLUSION: Sacroplasty is of evident interest for elderly patients suffering of an osteoporotic fracture of sacrum. It reduces decubitus complications, secondary effects of antalgics and allows an early reeducation.

[Prospective evaluation of fracture risk in osteoporotic patients after low cement volume vertebroplasty]. / Suivi prospectif du risque fracturaire après vertébroplastie utilisant un faible volume de ciment chez des patients ostéoporotiques.

PURPOSE: To prospectively compare the incidence of new fractures (as demonstrated on MR) within the first 3 months after an initial fracture in a population treated with low cement volume vertebroplasty and a population treated conservatively. MATERIALS AND METHODS: From 49 patients admitted for osteoporotic vertebral compression fracture, 22 underwent CT guided vertebroplasty with injection of 1-3 ml of PMMA, and 27 were treated conservatively. All patients underwent MR at presentation and at 3 months to detect new compression fractures. RESULTS: Twelve patients (54%) treated with vertebroplasty showed new fractures at 3 months compared to 10 (37%) in the control group. This was not statistically different (p=0.049). In the vertebroplasty group, the new fractures involved vertebrae adjacent to the treated vertebra in 77% of cases (p=0.009) compared to only 15% in the control group. During the 3-month period, 3 patients, including 2 treated with vertebroplasty, required hospital admission due to fracture related acute lumbar back pain. CONCLUSION: The small amount of injected cement does not prevent fractures of adjacent vertebrae but does reduce the extravasation of PMMA in adjacent tissues.

EULAR evidence-based recommendations for the management of fibromyalgia syndrome.

OBJECTIVE: To develop evidence-based recommendations for the management of fibromyalgia syndrome. METHODS: A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation. RESULTS: 146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made. CONCLUSIONS: Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

Predictive factors of efficacy of periradicular corticosteroid injections for lumbar radiculopathy.

BACKGROUND AND PURPOSE: Steroid periradicular infiltration is a common nonsurgical sciatic pain treatment of inconsistent efficacy. The purpose of this study was to identify factors for predicting the efficacy or failure of this procedure. METHODS: Two hundred twenty-nine patients with lumbar radiculopathy were prospectively followed up at 2 weeks and 1 year after percutaneous periradicular steroid infiltration. The intensity of radicular pain was scored on the visual analog scale (VAS). Pain relief was classified as "excellent" when the pain was completely resolved or had diminished by 75% or more, "good" for a diminution of 50% to 74%, "fair" for a diminution of 25% to 49%, or "poor" for a diminution of less than 25% or an increase in pain. RESULTS: The mean VAS scores were 6.5 (range, 3.1-9.5) before and 4.2 (range, 0-9.5) 2 weeks after the procedure. Pain relief was graded as excellent in 45 patients (19.7%), good in 48 patients (21%), fair in 45 patients (19.7%), and poor in 91 patients (39.7%). Cause of pain, conflict location, and pain intensity were not predictive factors of radicular pain relief, whereas the symptom duration before the procedure was highly correlated with the pain relief outcome. Patients with excellent results 2 weeks after the procedure had a mean duration of symptoms of 3.04 months (SD 3.28) versus 7.96 months (DS 9.04) in the group with poor pain relief. CONCLUSIONS: Periradicular infiltration is a simple, safe, and effective nonsurgical procedure that should be performed quite early in the course of the illness to provide radicular pain relief, because corticosteroid infiltration is less beneficial for patients with more chronic radicular pain.

Awareness and knowledge of fibromyalgia among French rheumatologists and general practitioners.

OBJECTIVES: Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain and fatigue. Its prevalence is estimated to be at 3.4% in women and 0.5% in men. It is a major cause of morbidity. Our objective was to evaluate, using a self-questionnaire sent by mail, the level of knowledge of French physicians, general practitioners, and rheumatologists on fibromyalgia and to analyse their therapeutic approach. METHODS: The demographic characteristics of a sample of general practitioners and rheumatologists were compared to those of the overall data available. This comparison demonstrated the good representativeness of our sample. RESULTS: Fibromyalgia was considered as a disease by 23% of rheumatologists and 33% of general practitioners. While on average, each rheumatologist followed 30 fibromyalgia patients, each general practitioner followed 6.1 patients (i.e., 2 to 5% of their practice's patient base). Among rheumatologists, 6.4% made no distinction between this disease and depression vs. 13.1% of general practitioners. The diagnosis of fibromyalgia was made based on tenderness that occurs in precise, localized areas of the body (trigger points) by 94% of rheumatologists and 79.1% of general practitioners. Of general practitioners and rheumatologists, 93.7% and 73.7% respectively, have not received any medical school training on fibromyalgia or chronic fatigue syndrome. CONCLUSION: Given the lack of medical school training and continuing professional education concerning fibromyalgia (rare use of pain rating scales, confusion in the classification of rheumatic diseases), there is an urgent need to initiate an explicit teaching effort on chronic pain, and on fibromyalgia in particular.

Efficacy of transforaminal versus interspinous corticosteroid injectionin discal radiculalgia - a prospective, randomised, double-blind study.

A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months' duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober's index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland-Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.

Metastatic pudendal nerve compression presenting as atypical sciatica.

A rare case of Alcock's syndrome caused by tumoral compression of the pudendal nerve is reported. Spine surgeons must be aware of the possibility of Alcock's syndrome in patients presenting with atypical sciatica.

Normal vertebral body dimensions: a new measurement method using MRI.

Much clinical research on osteoporosis is aimed at documenting a reduction in vertebral fracture rates, but there is considerable disagreement about defining normality. Most methods for measuring vertebral body dimensions use lateral radiographs. In the present paper, we investigate the reliability of magnetic resonance imaging (MRI) for normal reference determination. A validation study was performed on a cadaver by comparing vertebral body volume measured both with MRI (sagittal acquisition in T1 weighted sequence) and with immersion. MRI was then performed with the same protocol from T4 to L5 in a standard population of 80 women with no history of vertebral fractures. Then all vertebral measurements were standardized relative to each other, and means and standard deviations were calculated using a statistical fitting procedure derived from volume and medial area. The validation study confirmed the reproducibility and accuracy of MRI (intraclass correlation coefficient 0.95). There was a strong correlation between volume and medial area of vertebral bodies (Pearson correlation coefficient 0.95) and a constant relationship between the medial area of vertebral bodies for each subject (coefficient of variation 5.6%). The variations in vertebral body dimensions will allow comparison with pathologic vertebral fractures in further studies. This could be useful for monitoring osteoporosis treatments.

[Association of Kaposi sarcoma--multiple myeloma. A new case]. / Association maladie de Kaposi--myélome multiple. Un nouveau cas.

INTRODUCTION: Kaposi's disease is an angiogenic multifocal cancer process that has several forms, namely Mediterranean, African, HIV-associated, and secondary to a preexisting immunodepressive state (hematological disorder, corticosteroid therapy, immunodepressive treatment). Whatever its form, Kaposi's sarcoma is probably associated with a chronic viral human herpes type 8 infection (HHV8). EXEGESIS: This virus has been implicated in the pathogenesis of multiple myeloma (17 cases recorded to date). In the present study, a further case of Kaposi's sarcoma associated with multiple myeloma has been reported. However, Epstein-Barr virus, cytomegalovirus, hepatitis B and C, HIV and HHV8 serologies were negative. Radiotherapy on the lower limbs was initiated. CONCLUSION: It is concluded that HHV8 does not appear to play a pathogenic role in cases of multiple myeloma, given the rarity of the association between Kaposi's sarcoma/multiple myeloma/HHV8.

Motor cortical dysfunction disclosed by single and double magnetic stimulation in patients with fibromyalgia.

OBJECTIVE: To investigate the motor cortex by single and double magnetic stimulation, in patients with fibromyalgia. METHODS: Thirteen patients with fibromyalgia and 13 age-matched healthy subjects were examined. We evaluated, in both limbs, motor evoked potential (MEP) latency and amplitude and the MCA/MPA ratio, i.e. MEP cortical amplitude (MCA) /maximal peripheral amplitude of the M response (MPA), the central conduction time (TCC) and the length of the silent period (SP). With double magnetic stimulation, different time intervals between shocks were used: with delays between shocks of 4, 25, 55 and 85 ms, the intensities of the conditioning shock were 80% the relaxed threshold. With delays between shocks of 55, 85, 100, 155, 200, 255 and 355 ms, the intensities of the conditioning shocks were set at 150% the relaxed threshold. In all cases, the intensity of the test shock was 150% the relaxed threshold. The results were also compared with those obtained in 5 women affected by rheumatoid arthritis (RA). RESULTS: As compared to control, the cortical relaxed threshold was enhanced on both sides and limbs (P<0.05). The cortical silent period recorded with single magnetic stimulation was reduced in the upper limbs (P = 2.7x10(-11)) and lower limbs (both sides P = 3.6x10(-5)). The other parameters investigated were normal. With double magnetic stimulation, facilitatory phenomena were absent in fibromyalgic patients and the inhibitory responses recorded with a delay of 155 ms were reduced (P = 0.0052). No significant differences were noted between FM and RA patients. CONCLUSION: This study demonstrated motor cortical dysfunction in patients with fibromyalgia involving excitatory and inhibitory mechanisms. This indicates motor cortical involvement and supports the hypothesis of aberrant central pain mechanisms. The absence of differences between FM and RA suggest that the lesions were not specific and could be related to chronic pain disorders within the central nervous system.

Acute osteoporotic vertebral collapse: open study on percutaneous injection of acrylic surgical cement in 20 patients.

OBJECTIVE: The aim of this study was to determine the efficacy of percutaneous vertebroplasty in treating painful spinal osteoporotic collapse. SUBJECTS AND METHODS: Twenty-three cases of vertebral collapse were evaluated with CT and MR imaging to determine osteoporotic origin and recent evolution. Percutaneous vertebroplasties were performed using CT guidance. The 20 patients included in the study (17 women, 3 men; 62-92 years old) had acute pain of less than 1 month's duration that hindered ambulation and required treatment with narcotic drugs. They underwent this procedure for analgesic purposes. The analogic visual scale of Huskisson was used for pain when scoring assessment. RESULTS: In 15 patients (75%), pain relief was complete within 24 hr after injection. Analgesic administration was stopped in 14 patients. Mild pain persisted in three (15%) of the remaining five patients. In one other patient (5%), crural pain was observed with cement leakage in the psoas muscle. In the fifth patient (5%), pain recurred after the patient was lifted. The pain was related to a new acute collapse of an adjacent vertebrae. CONCLUSION: Vertebroplasty for the treatment of osteoporotic vertebral collapse is a minimally invasive procedure that provides immediate pain relief and enables the patient to become quickly mobile.

Fibromyalgia as a national issue: the French example.

Fibromyalgia has been known by French rheumatologists for more than 15 years. However, only recently have teaching and basic, clinical and epidemiological research been developed on this topic in France. Management of the fibromyalgia patient should benefit from this recent evolution, all the more so since the French government took action to facilitate the medical treatment of chronic pain and to support the development of algology in France.

Inhospital management of common lumbosciatic syndrome. An opinion survey among French rheumatologists.

To determine which treatments are most commonly offered to patients younger than 70 years of age admitted for uncomplicated lumbosciatica suggestive of disk herniation, we sent a 43-item questionnaire to 106 rheumatology departments in France. The questionnaire collected information on hospital stay duration, modalities of rest, drug treatments, local glucocorticoid injections, physical treatments, sick leave duration and advice given to the patients. The response rate was 77% (84 questionnaires). Substantial variations were found across departments. Hospital stay duration ranged from five to 20 days and nonsteroidal antiinflammatory drug treatment duration from five to 30 days. Local glucocorticoid therapy was given as one to four injections at intervals of two to seven days. Spinal traction was used in 38% and a corset in 50% of study centers. Neither was there any consensus regarding immediate or delayed physiotherapy. Most respondents recommended bedrest for no longer than 15 days, a nonsteroidal antiinflammatory drug, a level I or II analgesic, local glucocorticoid injections and, in the event of persistent pain at the end of the hospital stay, a lumbar corset.

Validation of the French version of the Dallas Pain Questionnaire in chronic low back pain patients.

OBJECTIVES: To translate and to validate the metrological properties of the Dallas Pain Questionnaire, an instrument designed to evaluate the impact of low back pain on four aspects of patients' lives: daily activities, work and leisure activities, anxiety/depression and social interest. METHODS: The Dallas Pain Questionnaire, originally in English, was translated into French. The metrological properties of the French version were investigated in a cohort of 59 patients with chronic low back pain due to degenerative disk disease. Duration of the pain was between three and 24 months. Treatment consisted of nonsteroidal antiinflammatory drugs and/or analgesics, local corticosteroid injections and a plaster lumbar corset. Patients were evaluated at baseline, after ten days (under the same treatment), and at completion of the treatment. RESULTS: Results were reproducible for all four areas of the questionnaire (CCI > 0.75). Internal structural validity was satisfactory for the four areas (Cronbach alpha test = 0.89 to 0.91). At baseline, the pain score on a visual analog scale was significantly correlated with the Dallas scores for daily activities, anxiety/depression and social interest (external structural validity). The daily activities, work/leisure and anxiety/depression scores were sensitive to change (P < 0.001, P < 0.001, and P = 0.003, respectively), whereas the social interest score was not (P = 0.11). CONCLUSION: The French version of the Dallas Pain Questionnaire is valid, reproducible, and sensitive to change in chronic low back pain patients.

Tophaceous gout of the navicular bone as a cause of medial inflammatory tumor of the foot.

A case of tophaceous gout of the navicular bone in a 24-year-old woman is reported. Emphasis is placed on the conditions that might have been precipitating, i.e., anorexia nervosa and alcoholism, and the mechanisms by which increased uric acid level may be explained. The main radiographic patterns of tophaceous gout of the foot are recalled to avoid unnecessary surgery in future cases.