More than just back pain

 A 68-year-old man attended A&E with the ambulance. Prior to admission, he had experienced acute pain in the lower lumbar spine when getting up from bed during a twisting motion. Subsequently, he was unable to move due to pain. He complained of neurological symptoms with reduced sensation in the left thigh.

There is no previous medical history. He smokes 20 cigarettes per day. He has been experiencing chronic back pain for 2 years. Six weeks ago, he saw an orthopaedic specialist who ordered an MRI. He was informed that "cysts" were observed. Based on these findings, an appointment was made at a nearby university hospital.

Findings:

The 63-year-old patient is in good nutritional condition and has an age-appropriate general condition. Mobilization from the stretcher to a seated position cannot be tolerated. Rotation of the spine in a supine position is indicated as painful. There is tenderness on palpation of the spinous processes of the lower lumbar spine during a log-roll manoeuvre. Peripheral circulation and neurological status are normal.

Given the previous abnormal MRI findings, a CT scan of the lumbar spine is being request. It reveals a large lytic lesion in the L5 vertebral body with infiltration of the adjacent soft tissues, suggestive of an unstable fracture.

 In the absence of a known tumor, staging is performed to determine the primary site. Liver metastases are identified on ultrasound. A CT scan of the thorax shows a central bronchial carcinoma with additional rib metastases. Bronchoscopy reveals infiltration of the right main bronchus, from which a histological sample is taken. The histology confirms a mucinous adenocarcinoma.

Therapy and Course:

After an oncological consultation, the patient was transferred to a neurosurgical department for stabilization with spinal fusion of the lumbar vertebral metastasis and initiation of chemotherapy. Local postoperative radiation therapy for the metastasis was discussed.

 Discussion:

The patient had been experiencing back pain for 2 years without any trauma. Diagnostic evaluation at this time revealed the presence of metastatic bronchial carcinoma.

According to guidelines, in the absence of acute treatment-requiring conditions based on history and examination, further diagnostic measures are not indicated for back pain. They are only recommended after a duration of 4 to 6 weeks with guideline-compliant treatment and then only once. Imaging is recommended only if there are indications of a specific condition, e.g.  trauma, tumor in older age, steroid therapy, neurological symptoms, spondylarthritis, general symptoms like recent onset of fever or chills, loss of appetite, rapid fatigue, recent bacterial infection, intravenous drug abuse, immunosuppression, consuming underlying diseases, recent spinal infiltration treatment, or severe nocturnal pain. This was not done for our patient. The symptoms were managed with analgesia as needed but not further investigated.

The guidelines do not consider the patient's age. It can be interpreted that age can be used to rule out specific causes and initiate imaging even at the initial contact. In young patients under 20 and in "older" patients over 55, back pain may indicate a specific origin. Imaging should be used in conjunction with additional investigations depending on the underlying suspected diagnosis. From the age of 20 to under 50, the incidence of back pain is very high, and the course is usually benign and self-limiting (Chou 2011).

However, with increasing age, the causes of extraspinal back pain also increase. This includes mainly abdominal and visceral processes, e.g.  cholecystitis, pancreatitis; vascular changes, particularly aortic aneurysms (Takeyachi 2008), gynecological causes, e.g.  endometriosis, urological causes, e.g.  urolithiasis, kidney tumors, perinephric abscesses, neurological diseases, e.g.  polyneuropathies, and psychosomatic and psychiatric diseases. Their share is estimated at 2% (Deyn 2001). Therefore, a significant portion of these diseases can be promptly detected through additional abdominal ultrasound and urinalysis.

In malignant underlying diseases, back pain is usually a late manifestation due to metastasis, particularly from the stomach, lungs, prostate, kidneys, lymphomas, gastrointestinal tumors, and breast. They account for 80% (Greenberg 2016). Back pain due to metastasis occurs in approximately 10% of cancer patients. Patients in middle age (40-65 years) are particularly affected. In contrast, metastases are very rare in childhood and usually occur intramedullary with brain tumors.

Metastasis primarily occurs hematogenously in the vertebral bodies. With increasing infiltrative growth, the pedicles can also be affected, and the spinal canal can be compressed. Rarely does the tumor invade the dura and spread intradurally (Abeloff 2008).

The thoracic spine is most commonly affected, accounting for 50-60% of cases. The segments affected are T4 to T7. In prostate cancer, on the other hand, metastasis in the lumbar spine is predominant. In more than half of the patients, multiple levels of the spine are affected.

Therapy

The choice of therapy depends primarily on the underlying primary tumor. The treatment of vertebral metastases is determined by the localization, remaining stability, duration and severity of neurological symptoms, and the overall condition of the patient. Classification systems such as the Tomita Score, Tokuhashi Score, or Spinal Instability Neoplastic Score can help in the decision-making process, but they have limited practical applicability and serve more as aids.

The primary goal of therapy is tumor reduction or, ideally, resection to relieve the spinal canal and nerve roots and achieve pain relief.

-        Medical Treatment

Corticosteroids can reduce acute swelling and pressure on the nerve structures.

Bisphosphonates are used to prevent bone loss and thus provide pain relief.

Some tumors grow in a hormone-dependent manner, so hormone preparations can also be used.

-        Radiation Therapy

Radiation therapy reduces tumor cells. This can be done as monotherapy or in combination after surgery.

            - Surgery

- Kyphoplasty or vertebroplasty

- Laminectomy and spinal fusion

During laminectomy, parts of the bony vertebral body are removed to relieve the spinal canal. The tumor may not always be completely removed. The surgery can create instability, which can be supplemented with spinal fusion. Classification systems such as the SINS score are used for assessment. These systems consider the localization of the metastasis, extent of damage, and position of the vertebral bodies relative to each other (Fisher 1976).

 

Prognosis

The overall prognosis depends significantly on the primary tumor and the tumor stage. Pain control is a crucial component of the treatment plan, as well as the stability of the spine to prevent further neurological complications, e.g.  spinal cord compression.

Favorable prognostic factors include solitary metastasis to the spine and primary tumors e.g.  breast cancer, kidney cancer, lymphomas, or multiple myeloma. Unfavorable factors include multiple metastases, the occurrence of pathological fractures, and lung cancer as the primary tumor, as well as neurological symptoms or their loss (Bauer 1996). The location of the metastasis does not have a prognostic value in principle, but it significantly determines the possibilities of surgical intervention.

The preoperative status of neurological functions or other therapies also plays a crucial role in the outcome. In particular, ambulation and sphincter function are important, as complete loss of sphincter function is an unfavorable prognostic factor and is usually irreversible (Greenberg 2016).

Impingement symptoms after low velocity car accidents: Is there a whiplash of the shoulder joint?

Impingement symptoms after low velocity car accidents: Is there a whiplash of the shoulder joint?

After low-velocity rear-end accidents, a plethora of symptoms can arise. In addition to neck pain, there are particularly complaints radiating into the shoulder, which can either radiate from the trapezius or be localized in the shoulder joint, which in turn can radiate back into the neck.

In 9% of cases, signs of impingement can be present. We examined patients with impingement signs from an expert clinic. In their case, clinical criteria for impingement had to be fulfilled.

It was found that patients are generally older and female. Manual laborers recovered from complaints faster. MRI and ultrasound showed pre-existing degenerative changes up to tears in the rotator cuff. Signs of a seatbelt injury could not be found.

The examiner and expert can assume that the type of accident is not suitable for causing bodily harm. Studies have shown that patients develop an altered scapulothoracic rhythm.

We argue that acceleration/deceleration alters proprioception and thus muscular guidance. This, in turn, leads to functional impingement, which makes pre-existing changes clinically apparent. This would also explain why complaints can develop on both sides or only on the non-seatbelted shoulder.

The therapy consists of targeted physiotherapy aimed at stabilizing the shoulder girdle muscles rather than focusing on the neck muscles.

Literature

E Pietsch. “Shoulder Impingement after Low Velocity Car Accidents - Is there a "Whiplash" for the Shoulder Joint?” EC Orthopaedics 10.10 (2019): 816-822.

What is effective in chronic lower back pain?

A 2007 American College of Physicians guideline addressed pharmacologic options for low back pain. Now, new evidence and medications have now become available.

The number of trials ranged from 9 (benzodiazepines) to 70 (nonsteroidal anti-inflammatory drugs). New evidence found that acetaminophen was ineffective for acute low back pain, nonsteroidal anti-inflammatory drugs had smaller benefits for chronic low back pain than previously observed, duloxetine was effective for chronic low back pain, and benzodiazepines were ineffective for radiculopathy. For opioids, evidence remains limited to short-term trials showing modest effects for chronic low back pain; trials were not designed to assess serious harms. Skeletal muscle relaxants are effective for short-term pain relief in acute low back pain but caused sedation. Systemic corticosteroids do not seem to be effective. For effective interventions, pain relief was small to moderate and generally short-term; improvements in function were generally smaller. Evidence is insufficient to determine the effects of antiseizure medications.

Conclusion:Several systemic medications for low back pain are associated with small to moderate, primarily short-term effects on pain. New evidence suggests that acetaminophen is ineffective for acute low back pain, and duloxetine is associated with modest effects for chronic low back pain.

Literature:
Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, et al. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. [Epub ahead of print 14 February 2017] doi: 10.7326/M16-2458

http://annals.org/aim/article/2603229/systemic-pharmacologic-therapies-low-back-pain-systematic-review-american-college

The Break Pedal Injury - Always not too obvious

Injuries to the foot in connection with traffic accidents are difficult to diagnose. The linked case report gives an overview on injuries to the midfoot. This injury, better known as brake peadl injury, is easily missed.

Read more on EC Orthopaeics:

https://www.ecronicon.com/ecor/pdf/ECOR-03-000072.pdf

Frustrating: Back schools without reliable benefit in low back pain

Back schools are interventions comprised of exercise and education components. We aimed to systematically review the randomized controlled trial evidence on back schools for the treatment of chronic low back pain.

By searching MEDLINE, EMBASE and COCHRANE CENTRAL as well as bibliographies we identified 31 studies for inclusion in our systematic review and five of these for inclusion in meta-analyses.

Meta-analyses for pain scores and functional outcomes revealed statistical superiority of back schools versus no intervention for some comparisons but not others. No meta-analysis was feasible for the comparison of back schools versus other active treatments. Adverse events were poorly reported so that no reliable conclusions regarding the safety of back schools can be drawn, although some limited reassurance in this regard may be derived from the fact that few adverse events and no serious adverse events were reported in the back school groups in the studies that did report on safety.

Overall, the evidence base for the use of back schools to treat chronic low back pain is weak; in nearly a half-century since back schools were first trialled no unequivocal evidence of benefit has emerged.




Read more:

Straube S, Harden M, Schröder H, Arendacka B, Fan X, Moore RA, Friede T: Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research - systematic review and meta-analysis. Pain:Post Acceptance: June 01, 2016 doi: 10.1097/j.pain.0000000000000640

 

Medical errors are the third leading cause for death (in the US)

Medical error is the third leading cause of death in the United States, after heart disease and cancer, according to findings published today in BMJ.

Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient. Patient harm from medical error can occur at the individual or system level. The taxonomy of errors is expanding to better categorize preventable factors and events. The autors focussed on preventable lethal events to highlight the scale of potential for improvement.

As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine in Baltimore, Maryland.

But accurate, transparent information about errors is not captured on death certificates, which are the documents the Centers for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them.
And it's not just the US. According to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary health status indicator.
The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it.

Cancer and Heart Disease Get the Attention
"Top-ranked causes of death as reported by the CDC inform our country's research funding and public health priorities," Dr Makary said in an university press release. "Right now, cancer and heart disease get a ton of attention, but since medical errors don't appear on the list, the problem doesn't get the funding and attention it deserves."

He adds: "Incidence rates for deaths directly attributable to medical care gone awry haven't been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used."
The researchers examined four studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that, based on 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error.
That number of deaths translates to 9.5% of all deaths each year in the US — and puts medical error above the previous third-leading cause, respiratory disease.
In 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease, according to the CDC.
The new estimates are considerably higher than those in the 1999 Institute of Medicine report "To Err Is Human." However, the authors note that the data used for that report "is limited and outdated."
Strategies for Change
The authors suggest several changes, including making errors more visible so their effects can be understood. Often, discussions about prevention occur in limited and confidential forums, such as a department's morbidity and mortality conference.
Another is changing death certificates to include not just the cause of death, but an extra field asking whether a preventable complication stemming from the patient's care contributed to the death.
The authors also suggest that hospitals carry out a rapid and efficient independent investigation into deaths to determine whether error played a role. A root cause analysis approach would help while offering the protection of anonymity, they say.
Standardized data collection and reporting are also needed to build an accurate national picture of the problem.

Jim Rickert, MD, an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics, told Medscape Medical News he was not surprised the errors came in at number 3 and that even those calculations don't tell the whole story.

"That doesn't even include doctors' offices and ambulatory care centers," he notes. "That's only inpatient hospitalization resulting in errors."

"I think most people underestimate the risk of error when they seek medical care," he said.
He agrees that adding a field to death certificates to indicate medical error is likely the way to get medical errors the attention they deserve.

"It's public pressure that brings about change. Hospitals have no incentive to publicize errors; neither do doctors or any other provider," he said.

However, such a major step as adding error information to death certificates is unlikely if not accompanied by tort reform, he said.

Still, this study helps emphasize the prevalence of errors, he said.

Human error is inevitable, the authors acknowledge, but "we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences."

They add that most errors aren't caused by bad doctors but by systemic failures and should 'not be addressed with punishment or legal action.





BMJ. Published online May 3, 2016.

Whiplash and High Heels: How does one affect the other?

Wearing high heels is associated with chronic pain of the neck, lower back and knees. A lot of whiplash Clients complain that the most significant impact is not to be able to go out with their high heels. The mechanisms behind this have not been fully understood. The purpose of a study by Weitkunat was to investigate the influence of high-heeled shoes on the sagittal balance of the spine and the whole body in non-habitual wearers of high heels.

Methods

Lateral standing whole body low-dose radiographs were obtained from 23 female participants (age 29 ± 6 years) with and without high heels and radiological parameters describing the sagittal balance were quantified. These were analyzed for differences between both conditions in the total sample and in subgroups.

Results

Standing in high heels was associated with an increased femoral obliquity angle [difference (Δ) 3.0° ± 1.7°, p < 0.0001], and increased knee (Δ 2.4° ± 2.9°, p = 0.0009) and ankle flexion (Δ 38.7° ± 3.4°, p < 0.0001). The differences in C7 and meatus vertical axis, cervical and lumbar lordosis, thoracic kyphosis, spino-sacral angle, pelvic tilt, sacral slope, and spinal tilt were not significant. Individuals adapting with less-than-average knee flexion responded to high heels by an additional increase in cervical lordosis (Δ 5.8° ± 10.7° vs. 1.8° ± 5.3°).

Conclusions

In all participants, wearing high heels led to increased flexion of the knees and to more ankle flexion. While some participants responded to high heels primarily through the lower extremities, others used increased cervical lordosis to adapt to the shift of the body’s center of gravity. This could explain the different patterns of pain in the neck, lower back and knees seen in individuals wearing high heels frequently.

Read more:

Weitkunat T et al. Influence of high-heeled shoes on the sagittal balance of the spine and the whole body. Eur Spine J 2016; online 20. Mai; doi: 10.1007/s00586-016-4621-2