[Diagnosis and prognosis of low back pain: contribution and limitations of the clinical approach]. / Diagnostic et pronostic des douleurs lombaires : apport et limites de la clinique.

The label « non-specific ¼ that applies to 85% of patients complaining of low back pain is an heterogeneous group including different phenotypes. The identification of the anatomic origin of pain is often impossible in a primary care encounter. However, the physician can identify several elements that are useful to establish some diagnosis, foresee the evolution and tailor therapeutic decisions.

Le diagnostic de lombalgie « non spécifique ¼, attribué à 85% des patients avec maux de dos, ne reflète pas une réalité homogène. Cet article passe en revue les différentes approches existantes visant à identifier des sous-groupes utiles aux cliniciens. L'accent souvent porté sur l'identification anatomique des causes de la douleur est en réalité une mission quasiment impossible et rarement utile. Par contre, le médecin de premier recours a à sa disposition des éléments susceptibles de lui permettre d'identifier certaines pathologies, d'estimer le risque de chronicité et de personnaliser les décisions thérapeutiques. Les résultats récents obtenus dans ce dernier domaine laissent présager pour l'avenir la possibilité d'un meilleur ciblage, en particulier dans le choix des traitements physiothérapeutiques, qui devrait améliorer l'efficacité thérapeutique globale.

No kidding: low back pain and type of container influence adolescents' perception of load heaviness.

PURPOSE: The relationship between low back pain (LBP) and the lifting/carrying of loads is still a matter of great discussion. In teenagers, the weight of the school bag has been considered to play a pathogenic role in LBP but the relationship between the actual weight of the school bag and LBP symptoms does not seem to be a straightforward one. Numerous factors have been identified that influence the perception of weight. This study aimed to evaluate the influence of low back pain and the type of container on the perception of load heaviness by healthy teenagers. METHODS: A convenience sample of 80 healthy teenage males (mean ± SD age 13.9 ± 2.1 years) was recruited from the members of two local sports clubs. The volunteers were evaluated during one of their training sessions. Information about a history of consequential LBP was gathered by questionnaire. Subjects were invited to estimate the weight of three bags (a typical school bag, a sports bag with the logo of a well-known brand, and a neutral bag) containing two different loads (total weights approximately 3 and 5 kg). RESULTS: Consequential LBP (i.e., LBP requiring medical attention and/or interfering with usual sports activities) was reported by 26.2% of them. The majority of the LBP episodes occurred ≥3 months before the tests. Overall, teenagers significantly (p ≤ 0.05) underestimated the weight of the sports bag compared with the school bag and the neutral bag. Compared with those with no LBP, subjects with a history of LBP overestimated the weight of the heavier load. CONCLUSIONS: Our results suggest that several subjective variables significantly influence the perception of load heaviness. Until we have a better understanding of the mechanical role of the backpack weight versus the perception of its weight in the aetiology of LBP, any recommendations about the schoolbag weight limit should be viewed with caution.

Non-specific low back pain.

Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 23%, with 11-12% of the population being disabled by low back pain. Mechanical factors, such as lifting and carrying, probably do not have a major pathogenic role, but genetic constitution is important. History taking and clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted. The mechanism of action of many treatments is unclear, and effect sizes of most treatments are low. Both patient preferences and clinical evidence should be taken into account for pain management, but generally self-management, with appropriate support, is recommended and surgery and overtreatment should be avoided.

Rehabilitation following surgery for lumbar spinal stenosis.

BACKGROUND: Lumbar spinal stenosis is a common cause of back pain that can also give rise to pain in the buttock, thigh or leg, particularly when walking. Several possible treatments are available, of which surgery appears to be best at restoring function and reducing pain. Surgical outcome is not ideal, and a sizeable proportion of patients do not regain good function. No accepted evidence-based approach to postoperative care is known-a fact thathas prompted this review. OBJECTIVES: To determine whether active rehabilitation programmes following primary surgery for lumbar spinal stenosis have an impact on functional outcomes and whether such programmes are superior to 'usual postoperative care'. SEARCH METHODS: We searched the following databases from their first issues to March 2013: CENTRAL (The Cochrane Library, most recent issue), the Cochrane Back Review Group Trials Register, MEDLINE, EMBASE, CINAHL and PEDro. SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that compared the effectiveness of active rehabilitation versus usual care in adults (> 18 years of age) with confirmed lumbar spinal stenosis who had undergone spinal decompressive surgery (with or without fusion) for the first time. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included trials by using a predeveloped form. We contacted authors of original trials to request additional unpublished data as required. We recorded baseline characteristics of participants, interventions, comparisons, follow-up and outcome measures to enable assessment of clinical homogeneity. Clinical relevance was independently assessed by using the five questions recommended by the Cochrane Back Review Group (CBRG), and risk of bias within studies was determined by using CBRG criteria.We pooled individual study results in a meta-analysis when appropriate. For continuous outcomes, we calculated the mean difference (MD) when the same measurement scales were used in all studies and the standardised mean difference (SMD) when different measurement scales were used. Whenreported means and standard deviations of the outcomes showed that outcome data were skewed, we log-transformed data for all studies in the comparison and performed a meta-analysis on the log-scale. Results of analyses performed on the log-scale were converted back to the original scale. We used a fixed-effect inverse variance model to measure treatment effect when no substantial evidence of statistical heterogeneity was found. When we detected substantial statistical heterogeneity, we used a random-effects inverse variance model.The primary outcome measure was functional status as measured by a back-specific functional scale. Secondary outcomes included measures of leg pain, low back pain and global improvement/general health. We considered statistical significance and clinical relevance of outcomes. We used the GRADE approach to assess the overall quality of evidence for each outcome on the basis of five criteria, for which evidence was ranked from high to very low quality, depending on the number of criteria met. MAIN RESULTS: Our searches yielded 1,726 results, and a total of three studies (N = 373 participants) were included in the review and meta-analysis. All studies were deemed to have low risk of bias; no study had unacceptably high dropout rates. Also, no unacceptably unbalanced dropout rates, unacceptably low adherence rates or non-adherence to the protocol or clearly significant unbalanced baseline differences were noted for the primary outcome. Outcomes in the short term (within six months postoperative)Evidence of moderate quality from three RCTs (N = 340) shows that active rehabilitation is more effective than usual care for functional status (log SMD -0.22, 95% confidence interval (CI) -0.44 to 0.00, corresponding to an average percentage improvement (reduction in standardised functional score) of 20%, 95% CI 0% to 36%) and for reported low back pain (log MD -0.18, 95% CI-0.35 to -0.02, corresponding to an average percentage improvement (reduction in VAS score) of 16%, 95% CI 2% to 30%). In contrast, evidence of low quality suggests that rehabilitation is no more effective than usual care for leg pain (log MD -0.17, 95% CI -0.52 to 0.19, corresponding to an average percentage improvement (reduction in VAS score) of 16%, 95% CI 21% worsening to 41% improvement). Low-quality evidence from two RCTs (N = 238) indicates that rehabilitation has no additional benefit on general health status as compared to usual care (MD 1.30, 95% CI -4.45 to 7.06). Outcomes in the long term (at 12 months postoperative)Evidence of moderate quality from three RCTs (N = 373) shows that rehabilitation is more effective than usual care for functional status (log SMD -0.26, 95% CI -0.46 to -0.05, corresponding to an average percentage improvement (reduction in standardised functional score) of 23%, 95% CI 5% to 37%), for reported low back pain (log MD -0.20, 95% CI -0.36 to -0.05, corresponding to an average percentage improvement (reduction in VAS score) of 18%, 95% CI 5% to 30%]. Evidence of moderate quality (N = 373) and for leg pain (log MD -0.24, 95% CI -0.47 to -0.01, corresponding to an average percentage improvement (reduction in VAS score) of 21%, 95% CI 1% to 37%). In contrast, evidence of low quality from two studies (N = 273) suggests that rehabilitation is no more effective than usual care with respect to improvement in general health (MD -0.48, 95% CI -6.41 to 5.4).None of the included papers reported any relevant adverse events. AUTHORS' CONCLUSIONS: Evidence suggests that active rehabilitation is more effective than usual care in improving both short- and long-term (back-related) functional status. Similar findings were noted for secondary outcomes, including short-term improvement in low back pain and long-term improvement in both low back pain and leg pain, although limited impact was observed in relation to improvements in general health status. The clinical relevance of these effects is medium to small. Our evaluation is limited by the small number of relevant studies identified, and further research is required.

[Imaging in low back pain: limits and reflexions]. / Place de l'imagerie dans la douleur lombaire: limites et réflexions.

Lumbar imaging is frequently requested in patients with low back pain for various reasons. However, the prevalence of severe lesions, including neoplastic, is only about 1%. Imaging in the absence of clinical suspicion performs poorly. Similarly, the imagery is no more likely to identify the anatomical structures that are the source of pain for patients with low back pain. Finally, the literature shows that the impact on treatment decisions and the effect on quality of life of patients cannot justify an indiscriminate use of these investigative techniques. Without questioning the value of imaging, the practitioner must keep in mind these limitations in order to optimize the use of this resource.

Assessing the association between low back pain, quality of life, and life events as reported by schoolchildren in a population-based study.

Low back pain (LBP) is prevalent in teenagers but not necessarily detrimental to their quality of life (QoL). This population-based study evaluated a global QoL score and the association between LBP and life events and/or health problems affecting QoL. Schoolchildren were investigated in Fribourg-Switzerland and Barcelona-Spain. In addition to the KIDSCREEN, a health-related QoL questionnaire, two Numerical Rating Scales were used to assess QoL in general, and the influence of LBP on QoL. Open questions explored life events and health problems affecting QoL; responses were submitted to content analysis. Adolescents were stratified: Pain-free, Other pain (OP), isolated LBP (IsoLBP), LBP + other pains (LBP + OP), and LBP + whole-body pain (LBP + WBP). Between-group comparisons were performed using Chi-squared tests and ANOVA. Linear regression analysis was performed to assess between-group differences in the impact of LBP on QoL. Schoolchildren (1,470) (mean age = 15.05 years, 52.6% = boys) completed the questionnaire. LBP lasting >1 day in the last month was reported by 39.8% (N = 560): of them, 242 (43.2%) reported IsoLBP, 268 (47.9%) LBP + OP, and 50 (9.1%) LBP + WBP. QoL was lower in LBP + WBP (mean = 6.44 vs. LBP + OP = 7.8; IsoLBP = 7.6, OP = 7.96, Pain-free = 8.1; p < 0.001). There were 18.5% who reported health problems and 15.3% life events with a perceived impact on QoL. Prevalence was higher in LBP + WBP with >30% of this group identifying life events and/or health problems vs. 10-12% in PFree or IsoLBP groups (p < 0.001). IsoLBP affected QoL marginally (mean = 2.4 ± 2.2) compared to LBP + WBP (mean = 4.9 ± 2.4) (p < 0.001). LBP affected QoL marginally. These results stress the distinction between disease and common life experience. They also indicate the potential value of global QoL assessments in clinical settings.

Reliability and validity of the cross-culturally adapted French version of the Core Outcome Measures Index (COMI) in patients with low back pain.

PURPOSE: To conduct a cross-cultural adaptation of the Core Outcome Measures Index (COMI) into French according to established guidelines. METHODS: Seventy outpatients with chronic low back pain were recruited from six spine centres in Switzerland and France. They completed the newly translated COMI, and the Roland Morris disability (RMQ), Dallas Pain (DPQ), adjectival pain rating scale, WHO Quality of Life, and EuroQoL-5D questionnaires. After ~14 days RMQ and COMI were completed again to assess reproducibility; a transition question (7-point Likert scale; "very much worse" through "no change" to "very much better") indicated any change in status since the first questionnaire. RESULTS: COMI whole scores displayed no floor effects and just 1.5% ceiling effects. The scores for the individual COMI items correlated with their corresponding full-length reference questionnaire with varying strengths of correlation (0.33-0.84, P < 0.05). COMI whole scores showed a very good correlation with the "multidimensional" DPQ global score (Rho = 0.71). 55 patients (79%) returned a second questionnaire with no/minimal change in their back status. The reproducibility of individual COMI 5-point items was good, with test-retest differences within one grade ranging from 89% for 'social/work disability' to 98% for 'symptom-specific well-being'. The intraclass correlation coefficient for the COMI whole score was 0.85 (95% CI 0.76-0.91). CONCLUSIONS: In conclusion, the French version of this short, multidimensional questionnaire showed good psychometric properties, comparable to those reported for German and Spanish versions. The French COMI represents a valuable tool for future multicentre clinical studies and surgical registries (e.g. SSE Spine Tango) in French-speaking countries.

Adalimumab in severe and acute sciatica: a multicenter, randomized, double-blind, placebo-controlled trial.

OBJECTIVE: Based on several experimental results and on a preliminary study, a trial was undertaken to assess the efficacy of adalimumab, a tumor necrosis factor alpha inhibitor, in patients with radicular pain due to lumbar disc herniation. METHODS: A multicenter, double-blind, randomized controlled trial was conducted between May 2005 and December 2007 in Switzerland. Patients with acute (duration of <12 weeks) and severe (Oswestry Disability Index score of >50) radicular leg pain and imaging-confirmed lumbar disc herniation were randomized to receive as adjuvant therapy either 2 subcutaneous injections of adalimumab (40 mg) at 7-day intervals or matching placebo. The primary outcome was the score for leg pain, based on a visual analog scale (0-100 mm), which was recorded every day for 10 days and at 6 weeks and 6 months. RESULTS: Of the 265 patients screened, 61 were enrolled; 31 patients were assigned to receive adalimumab, and 4 patients in the placebo group were lost to followup. Over time, the course of leg pain was more favorable in the adalimumab group than in the placebo group (P = 0.002). However, the effect size was relatively small, and at the last followup visit the difference was 13.8 (95% confidence interval -11.5, 39.0). Compared with patients in the placebo group, approximately twice as many patients in the adalimumab group fulfilled the criteria for "responders" and for "low residual disease impact" (P < 0.05), and fewer surgical discectomies were performed (6 versus 13 in the placebo group; P = 0.04). CONCLUSION: The addition of a short course of adalimumab to the treatment regimen of patients experiencing acute and severe sciatica resulted in a small decrease in leg pain and in significantly fewer surgical procedures.

Low Back Pain in Adolescent and Geriatric Populations.

Spinal pain is the most common form of musculoskeletal pain. Chronic low back pain may contain nociceptive, neuropathic, and central components. Children are at risk of developing spinal pain. An increasing proportion of children develop low back pain as they become adolescents. In most adolescents, no specific diagnosis is identified. Psychological factors play a role in adolescents with back pain. Lumbar spinal stenosis causes neurogenic claudication in older patients. Magnetic resonance imaging is the best radiographic technique to detect nerve compression. Surgical decompression with or without fusion may offer greater short-term benefit but may not be significantly better than medical therapy.

The association between isoinertial trunk muscle performance and low back pain in male adolescents.

The literature reports inconsistent findings regarding the association between low back pain (LBP) and trunk muscle function, in both adults and children. The strength of the relationship appears to be influenced by how LBP is qualified and the means by which muscle function is measured. The aim of this study was to examine the association between isoinertial trunk muscle performance and consequential (non-trivial) low back pain (LBP) in male adolescents. Healthy male adolescents underwent anthropometric measurements, clinical evaluation, and tests of trunk range of motion (ROM), maximum isometric strength (STRENGTH) and peak movement velocity (VEL), using an isoinertial device. They provided information about their regular sporting activities, history and family history of LBP. Predictors of "relevant/consequential LBP" were examined using multivariable logistic regression. LBP status was reassessed after 2 years and the change from baseline was categorised. At baseline, 33/95 (35%) subjects reported having experienced consequential LBP. BMI, a family history of LBP, and regularly playing sport were each significantly associated with a history of consequential LBP (p < 0.05). 85/95 (89%) boys participated in the follow-up: 51 (60%) reported no LBP at either baseline or follow-up (never LBP); 5 (6%) no LBP at baseline, but LBP at follow-up (new LBP); 19 (22%) LBP at baseline, but none at follow-up; and 10 (12%) LBP at both time-points (recurrent/persistent LBP). The only distinguishing features of group membership in these small groups were: fewer sport-active in the "never LBP" group); worse trunk mobility, in the "persistent LBP" group, lower baseline sagittal ROM in the "never LBP" and "new LBP" (p < 0.05). Regular involvement in sport was a consistent predictor of LBP. Isoinertial trunk performance was not associated with LBP in adolescents.

[Juvenile low back pain: clinical approach in 2010]. / Lombalgies juvénitles: quelle attitude en 2010?

The first part of this article reviews the evolution of diagnostic issues regarding low back pain (LBP) in children and adolescents in recent years. The attitude recommended in the literature has been adapted to current epidemiological data showing that non specific LBP is largely prevalent in these age groups, much like in adult populations. Thus, it seems reasonable to avoid an overly aggressive therapeutic attitude, especially in the adolescent population. The second part of the article is devoted to non specific LBP and summarizes recent studies. These data show that the impact of LBP on the quality of life in children and adolescents is very low, with the exception, however, of a small subgroup of adolescents suffering generalized pain in conjunction with LBP.

Low back pain rehabilitation in 2020: new frontiers and old limits of our understanding.

Low back pain (LBP) is the most common musculoskeletal condition affecting the quality of life of individuals, especially if persistent. Over the decades, a lot of work has been done in an attempt to reduce the negative impact of back pain, and help patients recover and maintain a better quality of life. New insights are coming from different fields of research, with a lot of work being done in searching for the etiology of LBP, describing the different phenotypes of symptomatic spines, and identifying factors involved in the persistence of the disease. Nevertheless, still a lot remains to be done to fully understand the problem of back pain and its causes. Even today, there appears to be a wide gap between basic science and applied rehabilitation research on LBP. The first is still searching in many different ways for the "holy grail" of the pain generator and providing very interesting results with particular relevance to surgical, drug-related and other biological approaches, while the second is pragmatically focusing on modifiable factors that may influence back pain outcomes. Yet, personalized, effective spine care has not been fully realized. While we recognize the potential of basic science advances, there is an immediate need for more translational rehabilitation research, as well as studies focused on the effectiveness of rehabilitation approaches.

Revisiting Radiographic L5-S1 Parallelism Using MRI T1 Mapping.

PURPOSE: Thirty years ago, we reported that parallel aspect of the L5-S1 disc on a lateral view of the spine might be considered to be an initial stage of disk degeneration. The current study represents an attempt to increase the validity of parallel sign on conventional radiograph using MR real T1 mapping. METHODS: Forty-four young asymptomatic volunteers (mean age 21.6 ± 2.3) underwent lumbar spine MRI, twice the same day, morning and afternoon. Dedicated sequences using the inversion-recovery technique were used to calculate the T1 relaxation time. A region of interest (ROI) representing the nucleus pulposus was defined in each disk. The volunteers were stratified according to the presence or absence of a parallel morphology of L5-S1. Correlation between endplates angles, sacral slopes and T1 values were then evaluated. RESULTS: L5-S1 space looks parallel for angles <10° (mean value 6.9° ± 1.4°). Sacral slope was lower in parallel disks (31.7 ± 4.9° vs. 40.1 ± 5.6°), showing a significant difference of 8.4° (p < 0.05). The T1 relaxation values show a significant difference between the two groups (p < 0.05) with a difference of 96 ms for the morning (1090.9 ± 33.3 ms for the parallel group and 1186.9 ± 41.2 ms for the non-parallel) and 121.9 ms for the afternoon (respectively 1004.7 ± 22.2 ms and 1126.6 ± 12.9 ms). CONCLUSION: The difference between the two groups suggests that parallel morphology of the L5-S1 disk is associated with lower water content.

Pain measurement in patients with low back pain.

Pain is a multidimensional experience that is a prominent feature of many musculoskeletal disorders. Despite its subjective nature, pain is a highly relevant complaint; hence, nothing should deter physicians from attempting to formally assess it. This Review summarizes the main aspects of pain measurement from a practical standpoint, with a specific focus on low back pain. On balance, for the assessment of pain intensity, categorical scales with verbal descriptors or numerical rating scales seem to be preferable to traditional visual analogue scales, although no single best measure can be recommended. Pain per se should be assessed, rather than surrogate measures such as analgesic use. Back and leg pain should be evaluated separately in patients in whom these conditions coexist. For assessing change, prospective measurements are preferable to retrospective reports. Pain is not synonymous with function or quality of life, and other tools covering these important outcome dimensions should complement the assessment of pain, especially in patients with chronic symptoms. Clinicians should be aware of the psychometric properties of the tool to be used, including its level of imprecision (random measurement error) and its minimum clinically important difference (score difference indicating meaningful change in clinical status).

Adolescent idiopathic scoliosis and back pain.

This broad narrative review addresses the relationship between adolescent idiopathic scoliosis (AIS) and back pain. AIS can be responsible for low back pain, particularly major cases. However, a linear relationship between back pain and the magnitude of the deformity cannot be expected for any individual patient. A large number of juvenile patients can remain pain-free. The long-term prognosis is rather benign for many cases and thus a tailored approach to the individual patient seems mandatory. The level of evidence available does not allow stringent recommendations for any of the disorders included in this review.

Fear of impending fractures: when to refer? A case-based review.

Impending fractures and spinal cord compression are frequent complications of bone metastasis with debilitating consequences. The issue of impending fracture of the femurs and risk of spinal cord compression was raised in an 83-year-old woman with multiple myeloma. Some type of prophylactic treatment would appear suitable, usually surgical, for this condition. While criteria for prophylactic treatment exist in the orthopedic literature, most patients present to rheumatologists, oncologists, or internists. This article reviews the various scoring systems available to evaluate the risk of these very serious complications. We also discuss the current limitations of such tools and the need for a research agenda to address this common problem.

What is the rational diagnostic approach to spinal disorders?

A problem that is encountered in patients with low back pain is that a definite diagnosis is rare. The heart of our clinical dilemma is how best to diagnose those rare patients with severe disease as early as possible. The main reasons for diagnostic errors have been summarized in this chapter. Numerous guidelines have been developed to help in the approach to this difficult problem. However, the limitations of such an approach are highlighted. History and clinical examination are the best single test for diagnostic purposes and neither questionnaires nor computers can replace the clinician. However, the values of clinical abilities should not be overestimated. Finally, the clinical application of guidelines needs to be re-evaluated for each individual patient.

Muscular metastatic infiltration from pulmonary epidermoid carcinoma.

The localisation of metastasis in muscle is rare and is discovered mainly during autopsy. Skeletal muscle metastasis may occur in the case of leukaemia, lymphoma, melanoma, thyroid, gastrointestinal tract and breast carcinoma. However the most frequent aetiology is lung cancer. We describe the case of a 67-year-old woman, suffering from epidermoid lung carcinoma localised in both upper right lobes, treated surgically with success. Two months after surgery, she complained of pain and a sensation of swelling in the adductor muscles of the left hip with important restriction of mobility. A MRI scan of the hip showed an ovoid mass between the obturator extemus and the adductors muscles on the left side. Biopsy of the infiltrated muscles showed proliferation of carcinomatous tissue.