Background Music gtgt The JAMA Network. Silence gtgt Hello, I’m Dr. Harley Goldberg, the Director of the Spine Care Program at Kaiser Permanente, Northern California. We, of course, have a lot of patients with spine problems including herniated discs and acute radiculopathy. And over the years we have moved, as many have, from the surgical treatment to the interventional treatment. And it has been my observation clinically that people would get better with oral Prednisone as well as, perhaps, epidural steroid injections. So because of that we underwent the randomized double blind clinical trial of oral Prednisone.
Versus placebo for acute radiculopathy associated with a herniated lumbar disc. We randomized nearly 300 patients. It was 269 patients that were adult patients enrolled in the Kaiser Permanente Program, who presented with clinical acute radiculopathy and who were found also to be confirmed with a positive MRI that matched clinically their clinical presentation. They had a physical exam and then we used outcome instruments that included the Oswestry Disability Index and the Visual Analog Scale as well as subsets of the SF36 and other global questionnaires as well. We studied whether or not oral Prednisone, in a two to one randomization with placebo,.
Would improve pain and increase function in this patient population. The results were no different between the randomized patients to placebo and those with Prednisone in terms of pain over the first three weeks and in fact at any point in the time course out of 52 weeks. We did find a statistically significant benefit in functional improvement but it was of minimal clinical improvement, that is to say it was less than seven points on a 100 point Oswestry scale. While our dataset contains a lot more data for us to evaluate.
And determine perhaps other aspects of noninvasive treatment of their medications or other methods of care that may or may not be appropriate for this population, what was surprising to us was that the oral Prednisone did not in fact decrease the pain as we expected. Our next steps will be to evaluate how these patients rolled over to an epidural steroid injection to a surgical outcome andor the use of other concomitant pain medications throughout the course of this study, to let us infer what would be the next studies needed.
Why Do I Have Pain in My Kidney Area
Why do I have pain in my kidney area Part of it depends on what might be causing the pain. My kidney. You could feel pain if there is a kidney infection. That’s more likely if you have a fever and blood or pus in your urine. I’m not usually checking the quality of my urine. Pain in the kidney area isn’t necessarily your kidneys. It might come from back muscle strain, a spine fracture, arthritis of the back or even shingles. What are shingles Aside from those you put on a roof, of course.
If you had chicken pox as a kid, the virus still lingers in your nervous system. If it flares up, you’ll have severe pain before any lesions show up. I thought the first outbreak was bad enough. You can get a shingles vaccine to try to prevent that. What else could cause this If you have kidney stones, you could get kidney pain. Then again, so could polycystic kidney disease. Sometimes this is as bad as appendicitis. If you think you have appendicitis or another serious condition like that, get to an ER.
Appendicitis and other internal infections are life threatening. It could just be a urinary tract infection. If the pain is in the kidneys, it is now a kidney infection. And that’s serious. What if it is not serious Then all you have is a compressed nerve in your back or misaligned spine. I don’t want to bend myself all out of shape, but that sounds like I am bent all out of shape. Sciatic nerve pain occurs in the lower spine, but it can run down the leg, buttocks and even the calf. Some people mistake it for a kidney problem if it doesn’t radiate along.
Inflammatory, Autoimmune, Infectious Diseases Part 2 Lower Back Pain Spine Expert in Colorado
Parkinson’s disease occurs in elderly it is noted to be one percent in population over the age of sixty it’s associated with tremor muscle rigidity bradykinesia and akinesia difficulty with muscle motion akinesia is the loss of normal automatic motion such as eye blinking swallowing so patients can drool and have a decreased arms swing when walking many patients will have a pil rolling maneuver at rest motor strength will be normal even though the motion is slow and seventy five percent of patients may have unilateral symptoms there is rest tremor present that is a pill rolling.
But the voice tremor typically does not occur and there is a typical gait called a festianation gait the patient tends to take short steps with the upper body traveling faster than the lower body and a walk will typically turn into a run in advanced diseases charcot marie tooth disease is an inherited disease of peripheral nerves there’s actually a number of different types it’s also called peroneal muscle atrophy the myelin sheath and the nerve itself are both affected and it’s both motor and sensory the hallmark of this disease.
Is a cavovarus foot a fancy way of saying a very high arch turned in foot with arched toes the picture on the side is significant for this some individuals have a quote stork leg appearance unquote where they have lower leg muscle atrophy but the upper muscles in the thighs are still intact ten percent of patients with charcot marie tooth will have a spinal deformity and intrinsic muscles of the hand can also be involved lyme disease lyme disease is in infectious neurologic diesease caused by the bite of the deer tick.
This deer tick will carry the bacteria borrelia burgdorferi which is a spirochete the onset from the tick bite is about three to thirty two days and eighty percent of patients will experience a rash called in erythema migrans what they’ll see is a small central erythematuous macula or papule that spreads into a larger red ring with central clearing called the target lesion seen on the lady on the right the symptoms will initially be headaches fever chills myalgias and fatigue fifteen percent of these patients will develop frank nerve.
Abnormalities such as meningitis encephalitis cranial neuritis such as bell’s palsy plexitis or momoneuritis multiplex individual nerves which all become involved in months to years later the patient can develop chronic nerve manifestations which include mood memory sleep patterns spinal and even radicular pain and eight percent will develop cardiac manifestations the treatment is doxycyclin and erythromycin if caught early guillain barre syndrome is called ascending paralysis it’s an autoimmune disorder associated with myelin destruction onset can be days or weeks after a viral prodrome it starts always in the foot it works up the leg and then ascends up the.
Spine the ascent can take two to three weeks but some aggressive cases have noted to see three to four hours of ascent the mildest form of guillain barre is simple fatigue and typically won’t be recognized when the ascent goes to the diaphragm lifesupport it’s necessary and the affestc typically disappear within months but fifteen percent of patients can have lasting impairment herpes zoster as most people know herpes zoster or shingles is the varicella virus or the chicken pox virus if a patient hasn’t had chicken pox they won’t develop herpes zoster.
The virus typically lies dormant in the spinal dorsal root ganglion and for some reason a unknown stressor will activate the virus the symptoms are unilateral pain down the dermatome of the nerve and two to three days later a rash will develop these are small reddish fluid filled blisters called vesicles the rash increases from onset for three days and then dries up and small scars can permanently form there is a very painful condition that can occur to an injured nerve called postherpetic neuralgia which is painful scarring of a nerve.
And a permanent painful condition if steroids are given during the beginning of the attack this will typically prevent nerves scarring parsonage turner syndrome is a brachial plexopathy an involvement of the lower motor neurons of the brachial plexus it will be an onset somewhat similar to a herniated disc in the neck it’s one sided unilateral shoulder pain which is severe and crescendos in a day or two it’s associated with significant weakness of the shoulder and the upper extremities the paralysis can last months to a year and typically there’s full recovery in about seventy five percent.
But this is prolonged males are noted to be much more common than females at 21 to 41 the diagnosis is made by exclusion and an EMG as this is a plexopathy an EMG should not show any involvement of the pair of vertebral muscles autoimmune vertebral involvement or spondyloarthropathies most of these disorders start with the sacroiliac joint involvement except for rheumatoid arthritis and lupus most are unilateral SI involvement except ankylosing spondylitis which is typically bilateral involvement stiffness in the morning that gets better with motion is a typical indicator of.
The autoimmune vertebral involvement fatigue is also very common the types of spondyloarthropathies are rheumatoid arthritis psoriatic arthritis ulcerative colitis crohns reiter’s syndrome ankylosing spondylitis and lupus DISH is diffuse idiopathic skeletal hyperostosis or forestier’s disease this is a typically non painful disease and associated with diabetes ten percent of patients with diabetes will have this disease it’s characterized by these non marginal very large osteophytes sites where the spine starts becoming stiff and the spine can eventually fuse together unilateral SI involvement as noted before are typically the seronegative spondyloarthropathies.
Seronegative because the serum is negative there is no HLA B27 here and again noted ulcerative colitis and crohn’s psoratic arthritis reiter’s syndrome but not ankylosing spondylitis as there is bilateral involvement in this CT scan we can see the right SI joined is not involved and the left SI joint is fused indicating a unilateral SI involvement or seronegative spondyloarthropathies seronegative spondyloarthropathies develop non marginal syndesmophytes these are spurs that join the vertebra together that are not right on the margin they actually swing out here marginal syndesmophytes that go right edge to edge are typical of ankylosing spondylitis.
And again these diseases have sacroiliac involvement fatigue and lethargy and typically not common HLA B27 but they can have that this is compared to ankylosing spondylitis the prototype for these diseases it first starts with bilateral joint sacroiliac involvement the incidence is considered to be one in a thousand in patients there’s periods of remission and aggravation it’s typical to have back pain that wakes the patient up at night morning stiffness it is relieved with exercise anterior uveitis and unlike the others marginal syndesmophytes it’s typically called a bamboo spine in ninety five percent of patients.
Are positive for HLA B27 it’s also a typical to have a kyphosis and as we can see this patient’s bent forward with a few spine and we look at the brow chin angle ankylosing spondylitis starts on xrays with an initial squaring of the vertebra as you can see here the vertebra should typically be cut but they start to square and marginal syndesmopkytes are the most common findings physical exam findings and ankylosing spondylitis will first be noted with chest excursion if you measure inspiration and exploration of the chest.
Inflammatory, Autoimmune, Infectious Diseases Part 1 Mimics of Low Back Pain CO Spine Surgeon
Hello this is doctor corenman we’re going to talk about inflammatory autoimmune infectious diseases and chronic pain and mimics of low back pain and leg pain these are essentially neurologic diseases or chronic pain diseases that we will discuss again my favorite comment was from the physician famous doctor osler you find what you know and you see what you look for if you don’t understand it something can happen and you don’t know that a condition can occur you won’t look for it I think this quote is very valuable.
We’re going to start with retroperitonal pain referral to the lower back these are structures organs essentially and the retroperitonal area that will refer pain to the lower back embroyologically the structures are all supplied by similar nerve endings as found in the lumbar spine it’s thought that there’s possible feedback from the afferent autonomics that goes through the same track as the somatic sensory system this is why you get referral pain into the lower back the retroperitonal structure of course are the abdominal aorta the kidneys the pancreas the gallbladder.
The urinary bladder the ovaries and the uterus the quality of pain can very commonly be identified by what structure is affected kidneys normally will cause a unilateral costovertebral pain and tenderness if you percuss the area right below the lowest unilateral rib you can get significant reproduction of pain endometriosis and ovarian cysts of course are cyclical pain that are associated with the patient’s period pelvic inflammatory diseases are not cyclical there’s something called the hanging chandelier sign the cervix is so tender that the patient has severe pain with any palpation of this.
Ectopic pregnancy of course is a surgical emergency you need a good history normally seven weeks after the last period and the patient should have a prior pelvic inflammatory disease causing scarring of the fallopian tubes diverticulitis commonly can cause a steady type of abdominal pain cancer of bone or organ can cause different types of pain normally night pain and gallbladder is a right sided pain after a fatty meal anatomy of the nerve is relatively simple you have the cell body with the nucleus that produces many of the substances necessary to quote run the nerve unquote.
You have the myelin sheath and many higher order nerves these are schwann cells in the peripheral nervous system and oligodendrocytes in the central nervous system the speed of conduction of the nerve is increased by something called ephaphtic conduction where the signal jumps from the node of Ranvier to the next node and this is as you can see part of the myelin sheath where we have the schwann cell that is surrounding the nerve and the node of Ranvier the exposed nerve in between you have actually jumping from one node to the next which increases conduction.
Significantly the synapse is the area where you communicate either with the next nerve or with the muscle there are synaptic vesicles which can key the neuro transmitter these are made in the nucleus and then dug down through the cell body and then through the actual dendrite and the axon there’s a pre synaptic membrane and these will be released there are ligand gated ion channels which will allow sodium and potassium to flow in and change the voltage of the nerve and possibly reaching the action potential history and physical examination is one of the cores to determine.
What the neurologic problem is upper motor neuron lesion symptoms are imbalance paresthesias in a non dermatomal pattern L’hermittes problems with fine motor skills possible bowel and bladder involvement upper motor neuron lesion signs or hyperreflexia release signs such as hoffman’s and invertebral reflex and incoordination lower motor neuron lesion signs are weakness reflex deficit and sensory loss symptoms of course of motor neuron lesions in the lower aspect our pain parasthesias and weakness sensation can be increased decreased or altered allodynia and hyperalgesia are two of the common altered sensations.
Of course you check motor strength reflexes endurance fatigue and also check for depression reactive depression is not uncommon in patients with significant pain one of my favorite quotes other than osler’s is voltaire’s quote the lower back is at the crossroads where the psyche meets the soma and there’s no place truer than in the lumbar spine where low back pain can really cause significant psyche issues pain perception with depression becomes amplified and this is noted to be chemically a depletion of serotonin neuro transmitters the treatment many times can be a SSRI.
And remember the four signs of depression insomnia anhydonia irritability and lethargy these are now specific diseases multiple sclerosis is an autoimmune disease the body will produce antibodies against the myelin sheath it’s noted to be greater in females than males in a twotoone ratio an onset is typically is twenty two forty years of age the actual problem is attack and destruction of the myelin sheath and this creates a conduction block as you can see in the diagram to the right common symptoms are a unilateral vision loss double vision or diplopia.
Paresthesias of the upper or lower extremities fatigue dizziness and incoordination the type of multiple sclerosis could be mild or progressive it is interestingly found more commonly in lightskinned northern europeans physical exam will note upper motor neuron findings such as motor blocks and sensory disturbances polio thank goodness is not seen much anymore but it is still around it’s an infectious viral disease that attacks the anterior horn cells in the spinal cord and brain if it attacks in the brain it’s called bulbar polio diaphragm paralysis can be fatal.
And the old iron lungs back in the thirties were quite common a vaccine confers immunity as this viral coat doesn’t change unlike in HIV paralysis of muscles is associated with obviously the nerve cell damage in the anterior horn tabes dorsalis is not seen commonly this is essentially the last part of syphilis the third stage of course syphilis is a sexually transmitted spirochete bacteria normally you see certain symptoms and the patient will receive antiobiotics immediately and the disease is cured however if the initial stages are not noticed and the patient advances to secondary and.
Especially tertiary syphilis this is where we get the neurologic damage the tertiary form is associated with damage to the posterior columns of the spinal cord the gracile and cuneate tracts which are responsible for proprioception so with damage of those tracks the symptoms are instability with gait patients will say they walk with a drunken gait and of course the causes and inflammatory destruction of the neurons which causes a temporarily increased output of the brain and there are stories in the middle ages of middle aged geniuses and these gentlemen have brilliant discoveries before they lead.
To insanity the disease amyotrophic lateral sclerosis is also called lou gerhig’s disease it’s a disease of only the peripheral motor nerve cells therefore there’s no sensory involvement and it is a painless disease somebody who has pain associated with weakness typically does not have lou gerhig’s disease the symptoms are loss of strength and weakness as well as clumsiness one of the hallmarks of this particular disease is the fasciculations or non purposeful twitching this does differentiate from other types of neurologic diseases the disease advances leads to loss of speaking swallowing and breathing.
Autoimmune, Inflammatory, Infectious Diseases Part 3 Mimic Lower Back Pain CO Spine Surgeon
Reiter’s syndrome is associated with a sexually transmitted disease with clamydia and occasionally with enterocolic infections such as dysentery the infection ceases and the syndrome begins as an autoimmune disease the hallmarks are urethritis conjunctivitis and arthritis there’s also significant heel pain in seventy percent from achilles tendonosis and there’s also SI pain associated forty percent of patients will develop conjunctivitis as noted in this eye exam seen on the right myalgias are common sausage digits or large swollen fingers are very rare and circinate balanitis is a painless sore on the glans penis which is quite common.
With reiter’s psoriatic arthritis is a typical disease estimated at three percent of the population has psoriasis and it’s a skin disease normally seen with silvery erythematous patches over extensor surfaces patients with the nail bed changes as seen on the right have a higher correlation with the arthritic components of psoriasis twenty three percent of patients with nail bed changes will develop arthritis and five percent will have spondyloarthropathy enteropathic arthritis as crohn’s and ulcerative colitis and possibly even irritable bowel ten to twenty percent will develop sacroilitis and ten percent.
Will develop spondylitis here we see a CT scan of a normal right SI joint and a fused left SI joint rheumatoid arthritis is noted for the destruction of synovial joints throughout the body you develop enthesopathy as we note on the right picture of an inflamed joint with worn cartilage versus the normal joint the rheumatoid arthritis problem is typically symmetrical there’s painful subcutaneous nodules and spinal involvement is almost always exclusively cervical very uncommon to have a lumbar spine involved patients with rheumatoid arthritis can develop mononeuritis multiplex and even.
Vasculitis rheumatoid arthritis of course is an immune system which destroys the synovium of the joints the hands are the most commonly affected and in fact the picture that we see here shows the typical intra articular absorption and windswept deformity of the fingers spinal involvement is also noted in there can be a dislocation or translocation of C one and two causing significant spinal cord compression neuropathic pain is from the damage from the nerve itself the pain signals relentlessly and becomes amplified by facilitation and memory neuropathic pain tends to be a big.
Burning quality those patients will talk about crushing gnawing and crawling type of pain neuropathic pain typically is worse at night and generally not affected by activity but that’s not always the case patients will develop allodynia or pain generated from innocuous stimulation a simple brush of a feather against the skin can be painful patients with neuropathic pain commonly develop reactive depression polyneuropathy is a compartment of the fiber link dependent diseased nerves typically found in both feet the times that it starts it will be more in the evening.
It’ll be a burning sensation and it can ascend up the legs to the knees by the time numbness gets to the knees the hands become involved because the hands are at about the same length of nerves as the length of nerves going down to the knees acquired peripheral neuropathies patients with acquired peripheral neuropathies have many disease processes which could be associated diabetes alcoholism autoimmuned diseases infectious diseases and even inherited diseases as we talked about normally the diseases attack the myelin sheath but can destroy the nerves themselves.
Sensory nerves are the most commonly involved but peripheral neuropathies these can affect motor nerves it starts distally in the longest nerves which of course go to the feet and ascends slowly as noted before burning numbness is the first symptoms again as noted before symptoms are intensified at night and there’s allodynia asso a lot of patients with this problem can’t tolerate bed sheets on their feet with advanced peripheral neuropathies there’s a loss of proprioception and gait disturbance it’s diagnosed with a EMG and NCV can be treated with the use of physical therapy.
And medication such as membrane stabilizers there are metabolic peripheral neuropathies such as hypothyroidism which causes carpal tunnel syndrome and hung up reflexes when the reflexes typically tested such as a biceps the muscle will contract but release very slowly B12 deficiencies cause a disease process called subacute combined deficiency of the cord there’s degeneration of the posterior and lateral columns intial symptoms are numbness of the limbs and trunk which are an early sign and then unsteadiness and gait imbalance as a delayed sing the complex regional pain syndrome CRPS used to be called reflex sympathetic dystrophy.
It’s an involvement of the autonomic nervous system and there’s probably a deep sensory component to the sympathetic system which causes pain and sympathetic postganglionic system afferent pathways RSD onset is very commonly after a simple injury or surgery there is severe burning pain and eventually trophic changes of the skin such as loss of skin texture and swelling there’s two essential stages the initial stage where there’s increase circulation swelling and color change and later three to six months swelling disappears but the extremities cool and pale with contracted joins.
Brittle nails and continuing pain pictures of early RSD here noted and late RSD myopathies are not uncommon it’s a primary disorder of skeletal muscle there’s associated weakness cramping and myoglobinuria generally there is proximal weakness difficulty from rising from a chair is noted patients cannot climb stairs because of quid and buttocks weakness and they can’t work with their arms overhead it’s typically symmetric and there’s no sensory loss this is purely a muscle disorder polymyositis is muscle pain and tenderness neck flexor and proximal limb weakness there’s noted to be typically a high ESR.
And creatine kinase and this is treated with steroids finally fibromyalgia fibromyalgia is a syndrome it’s a constellation of symptoms found in a group of individuals but they cannot be identified by any marker there’s no lab test there’s no EMG finding there’s no type of specific test that can identify this patients with chronic pain and this chronic pain is diffuse and nonspecific and found throughout the body are typically patients with fibromyalgia there must be four areas or four quadrants with discrete tender points to make the diagnosis thank you for your attention.
Severe Leg Pain During Pregnancy
Are you suffering from severe leg pain during pregnancy You are not alone. Severe leg pain during pregnancy is a condition that is as common as morning sickness and fatigue are. The main cause of severe leg pain during pregnancy is a condition called sciatica. It is just as painful as it sounds. This condition is caused when the uterus is growing, it may push against the sciatic nerve. It could also be just leg cramps that could be happening in your legs. There are some more complex causes like DVT and also uterine fibroids.
First, do not get alarmed, it is not anything to feel panicked over. These are all issues that many pregnant women face. This is why you should let your doctor know in case you experience discomfort in your legs. He or she may be able to give you some much needed relief. You should inform your doctor of any pain that you experience, however small or big it is. A DVT, or deep vein thrombosis, is a blood clot that is in your leg and it is the most severe cause of leg pain.
You should be careful, when you have traveled for a long period of time, for this is the period that the clot is likely to develop. Take walks as often as you can to help keep the blood flowing. If you won’t be able to go walking as often as you would like, wear some compression socks or stockings. Treatment of severe leg pain during pregnancy starts with finding out the main causes of it. If the pain is cause by thrombosis, you will be given some anticoagulation meds. If you want to prevent blood clots from developing in your leg, make sure to eat healthy food.
Bacteria Cause of Chronic Lower Back Pain
Andrea Gerlin writing in Bloomberg News reported , As many as four in 10 cases of chronic lower back pain are probably caused by bacteria, and treatment with antibiotics may cure them, according to a 162patient study published in the European Spine Journal. The study found that as many as 80 percent of the participants with persistent back pain following a herniated disc and swelling in the spine reported an improvement after taking antibiotics three times daily for 100 days. The back pain is caused by an infection of Proprione acne.
Neurontin To Treat Adults with Nerve Pain Caused by Shingles Overview
Neurontin, the brand name form of gabapentin, is a prescription medication used to treat adults with nerve pain caused by shingles. Shingles is a painful rash that is caused by the varicellazoster virus, the virus that also causes chickenpox. Neurontin is also used in combination with other medications to treat partial seizures. Neurontin belongs to a group of drugs called anticonvulsants, which help treat seizures by decreasing abnormal excitement in the brain. It also works by altering the way the body senses pain. This medication comes in tablet, capsule, and oral by mouth solution forms and is taken up.