Medication is one of the basic conservative treatments for low back pain. The most popular medicines used for low back pain are nonsteroidal anti-inflammatory drugs (NSAIDs). In addition to NSAIDs, depending on the patient symptoms, muscle relaxants, tranqulizer, or antidepressants are also used. When medication is done, we should take into account the effects and the side effects of each drug, patient pathology, complaints, age, degree of pain, and/or the general conditions. In this article, the author discussed the characteristics of the drugs for low back pain and future perspectives of medical treatment.
To help in the clinical diagnosis of lumbar spinal stenosis, we have developed a self-report instrument based on the clinical diagnosis support tool. Here we report the clinical validation of the unmodified tool and examine the usefulness of the new instrument. The new instrument, and also the unmodified tool were used for 201 outpatients (aged 50 years or older) with unknown diagnosis. The data obtained from the new instrument were analyzed using the tree model. The resulting sensitivity was 89.7% (compared to 97.4% for the unmodified tool), and the specificity was 70.6% (compared to 53.6% for the unmodified tool). The 201 outpatients included 116 with lumbar spinal stenosis, and 85 with no stenosis. These results suggested that both the unmodified tool and the new instrument may be useful for initial screening in clinical diagnosis of lumbar spinal stenosis and the new one is more simple and easy.
We investigated the correlation between sagittal spinal alignment and clinical symptoms in lumbar canal stenosis. Whether the presence of cauda equina intermittent claudication or not, the ninety three patients except combined type were classified into two groups (cauda equina group and radicular group) and we compared the results of lumbosacral and pelvic alignment in the two groups. We used the parameters of distance B (the distance between C7 plumb line and the posterior superior corner of S1), lumbar lordotic angle (LLA) and pervic angle (PA) on standing lateral radiographs. The averaged values of distance B, PA, LLA were as follows: cauda equina group 57.6 mm, 27.2°and 18.8°, radicular group 40.3 mm, 22.7°and 22.4°.In cauda equina group, the both of distance B and PA were larger than radicular group. LLA was smaller in cauda equina group. Sagittal spinal alignment of cauda equina group might be posterior tilt of pelvis and trunk forward shift in compared with radicular group.
Somatosensory evoked potentials evoked with tibial nerve stimulation were analyzed in patients of central type lumbar spinal canal stenosis. Analysis was performed according the guidelines for evoked potentials described by American electroencephalographic society. Average Lp peak latency recorded with surface electrodes applied on the skin on T12 or L1 spinatus process were 23.8ms in patients group and 22.0ms in control group. Lp peak latency had positive correlation with patients' height. Significant result was obtained by discrimination analysis performed using Lp latency and patients' height as parameters. According the result of the analysis, both groups were divided with the sensitivity of 72% and the specificity of 80%. The delay of Lp latency in patients group is thought to reflect pathophysiological change of cauda equina caused by narrow lumbar spinal canal. Lp peak latency is thought to be useful as a noninvasive examination in diagnosis of lumbar spinal canal stenosis.
The neurological findings tend to be aggravated, according to severity of for lumbar spinal canal stenosis. We sometimes experience the case that the level of the stenosis on the image does not correspond with neurological findings. The cause is thought to be the specific anatomical structure of the lumbar dural tube which is an aggregate of nerve roots.The purpose of the current study was to evaluate the discrepancy of responsible level for neurological findings between image findings retrospectively. We selected 38cases with operative severe spinal canal stenosis which presented total block or subtotal block by myelogram. The comparison and analysis between the responsible level of neurological findings and image findings were performed the discrepancy between neurological and image findings were noted with 13 cases (34.2%), and most of them were L3/4 stenosis accompanied with L5 disorder. The result was thought to be important clinically.
In 23 patients with intermittent claudication due to both lumbar spinal canal stenosis (LCS) and peripheral arterial disease (PAD), we evaluated effects of lumbar nerve root block (RB) by skin temperature difference, claudication distance and ABI (ankle brachial pressure index) between before and after RB. The skin temperature (℃) before and after RB were 28.9±2.6 and 31.4±2.5, a statistically significant difference (p<0.01). In conservative treatment group (n=15), claudication distance (m) before and three months after treatments were 242±153 and 350±285, a statistically significant difference (p<0.01). There were no statistically significant differences in ABI. These results suggest that RB is one of effective and reasonable treatments for intermittent claudicants due to both LCS and PAD.
This paper reviews the basic researches for discogenic low back pain. The review revealed the following findings. The lumbar intervertebral disc may be innervated non-segmentally through the paravertebral sympathetic nerve and segmentally through the sinuvertebral nerves. The lumbar intervertebral disc may be innervated by dichotomizing sensory fibers. Exposure of the nucleus pulposus to the outside of the anulus fibrosus may induce nerve injury and ingrowth into the disc. NGF-dependent neurons are predominant in the rat intervertebral disc, indicating hyperalgegic responses can be induced by inflammation. NGF in the NP may promote the axonal growth. Lumbar fusion may inhibit nerve ingrowth into the degenerated disc, and reduce percentage of CGRP-immunoreactive neurons. Discogenic low back pain has a character of visceral pain.
Low back pain and associated spinal diseases are significant problem. Disc degeneration is believed to be one of the causes of low back pain, but patho-mechanisms are unknown. Recent report showed that the disc is an immune-privileged organ and Fas ligand expression may play important roles to maintain the immune privilege. It has been demonstrated that the expression of the Fas ligand is decreased in degenerated discs. On the other hands, symptoms associated with disc herniation are partially due to the production of the inflammatory mediators. The phenomenon of disc herniation can be recognized as a situation that an immune-privileged tissue is suddenly exposed to the host immune system. Therefore, we conducted the interaction of macrophage and the disc tissue and co-culture of them resulted in a stimulation of the IL-6 production. These observations indicate that the deep relationship between immune privilege of the disc and low back pain.
AGEs accumulate in all human tissues during aging and diabetes, thereby decreasing proteoglycan synthesis in articular cartilage. It was therefore hypothesized that AGE accumulation in nucleus pulposus cells might decrease the proteoglycan production, similar to that seen in articular cartilage. Our findings show that AGEs and RAGE were present in the nucleus pulposus of intervertebral discs. We have also demonstrated that AGEs suppress aggrecan expression at both the mRNA and protein levels. We propose the hypothesis that AGEs can accumulate over time in the nucleus pulposus and subsequently bind to the specific AGE receptor, thereby inhibiting the secretion of aggrecan. This might play an important role in the onset and progression of disc degeneration, similar to that seen in articular cartilage.
Feasibility of cell transplantation has been tried in various parameters as a new treatment for intervetebral disc degeneration and is being prepared for clinical application. In this study, beagles were used as a final stage animal model for clinical application in vivo. Eleven beagles were divided into three groups. No treatment (NC) group, degeneration (D) group and cell transplantation (Tx) group. Induction of disc degeneration was performed in D and Tx groups. In only Tx group, activated nucleus pulposus cells were injected into the degenerative disc and all group beagles were evaluated by XP, MRI and histology. Intervertebral disc degeneration of Tx group was inhibited compared with that of D group. The current study using large animal models suggests feasibility and effectiveness of cell transplantation therapy for intervertebral disc degeneration.
The cause of low back pain is multi-factorial. It has been suggested that lumbar disc disease (LDD) is one of the cause of low back pain. Recently, many data suggests that genetic background contributes to lumbar disc disease. In our previous study, we showed that a functional single nucleotide polymorphism (SNP) (1184T→C) in CILP (cartilage intermediate layer protein) acts as a modulator of LDD susceptibility. We also indicated the mechanism how the susceptibility gene in CLIP cause LDD. Through the genetic approach, the cause of low back pain has been elucidated. In this manuscript, we have reviewed the genetic approach for low back pain.
The objective of this study was to evaluate posterolateral fusion (PLF) without spinal instrumentation for lumbar spinal diseases. Thirty-six patients were followed. There were 28 male and 8 female patients ranging in age from 21 to 78 years, with a mean age of 53.2 years. The postoperative period ranged from 7 months to 18 years and 2 months, mean period of 4 years and 3 months. Radiographically, the fusion rate was 86.1%. The fusion rate of unilateral cases was signicantly lower than that of bilateral cases. Posterolateral fusion is a useful technique for avoiding instrumentation and associated complications.
Lumbar spinal canal stenosis is important as a cause of lower back pain in the aging society, and the symptoms can be improved by appropriate treatment. The incidence and characteristics of the clinical symptoms of this disease in elderly outpatients undergoing treatment in the department of internal medicine remain unclear. We performed a questionnaire survey, based on the principle of the support tool for diagnosis of lumbar spinal canal stenosis established by the ‘Study Group for Diagnostic Criteria of Lumbar Spinal Canal Stenosis and QOL Assessment‘, in 51 elderly patients with chronic diseases undergoing treatment at the Senior Outpatient Clinic, Diabetes/Metabolism/Endocrinology, Chiba University Hospital. The score was 7 or higher, which corresponds to suspected lumbar spinal canal stenosis, in 24 patients (47.1%), and 57.1% of patients with a score of 7 or higher who underwent examination at the Orthopedic Department were definitely diagnosed with lumbar spinal canal stenosis. The most frequent clinical symptoms in the patients with the definite diagnosis were intermittent claudication (87.5%) and reduction of lower limb symptoms in anteflexion (62.5%), and 55.6% of patients exhibiting both major symptoms had lumbar spinal canal stenosis. It may be possible to screen for spinal canal stenosis by a relatively simple method in elderly patients undergoing treatment at internal medicine outpatient clinics.
Male patients (n=106) with low back pain (LBP) were divided into 2 groups; the flexion-provoked LBP group (n=61) and the extension-provoked LBP group (n=45). After the 4 weeks McKenzie exercise, JOA-score, VAS, SF-36 and intramuscular oxygenation using near-infrared spectroscopy (NIRS) on the paraspinal muscle during lumbar extension and flexion were evaluated. Parameters such as oxygenated hemoglobin (Oxy-Hb), deoxygenated hemoglobin (Deoxy-Hb), and tissue oxygen saturation index (SdO2) were compared. Deoxy-Hb and SdO2 during lumbar flexion were significantly lower in the flexion-provoked LBPs than in the extension-provoked LBPs before exercise. VAS and PF, RP, BP in SF-36 were significantly better in extension-provoked LBPs after exercise. The group whose Oxy-Hb during lumbar extension increased after exercise in the flexion-provoked LBP group showed better clinical results than the non-increased group. The increased blood flow in the muscle was thought to cause pain relief, therefore, muscle strengthening exercise and/or agents for the increase of muscle blood flow may alternate the treatment in the flexion-provoked LBP group.
This review sought papers on the straight-leg-raising (SLR) test to summarize and assess the means-ends of the test procedure. The procedure is classified into active and passive components, while the objective is classified into three types; pain assessment, muscle assessment and flexibility assessment. Regarding pain assessment, there is no agreement in the papers reviewed regarding criteria for pain location (e.g. sciatica, a combination of low back pain and leg pain). It is therefore considered unacceptable to conclude that the SLR test is positive without describing the examination and the patient's responses. However, observed variations in the means-ends of the test procedure indicate that the SLR test is highly-sensitive test of various forms of pain in the lower body and it is therefore thought to be useful for assessing various clinical states associated with the standardization of the SLR test including a structured examination.
The outcome of long-term treatment in patients with low back pain was evaluated at our ‘Lumbago Pain Clinic‘. Evaluations of responses were based on questionnaire mailed to out-patients who have been treated at our clinic for the first time and for more than 1 year period; symptomatic changes (visual analog scale or VAS; activity of daily living or ADL scores) and recurrent low back pain were monitored. The response rate was 63.1% (89/141 cases). The mean age and treatment period of the 89 patients were 45.2 (22-78) and 3 years, respectively. Patients suffered from disc disorder (77.5%) indicated significant symptomatic changes after the treatment period, with both VAS and ADL showing improvements in the scores. The post-treatment outcome was well managed thereafter. Of 70% (62/89 cases) with recurrent low back pain, 14 cases (16%) sought treatment at our clinic while the remaining 75 (84%) cases appeared to have self-managed the pain well. Self-management of post-treatment low back pain was established in a majority of cases treated at our Low Back Pain Clinic, and the present treatment might have yielded long-term useful outcome.
We assessed changes in the intensity (from low to high) of the multifidus muscles on T2 weighted MRI images after performing surgery by the spinous process splitting approach for LCS. The changes in the intensity of these muscles were classified into 4 grades. Grade 0: almost no change; Grade 1: Less than 50% of the muscle area showed a change in intensity; Grade 2: Between 50 and 80% of the muscle area showed a change in intensity; Grade 3: High intensity extended throughout the whole (over 80%) muscle. As a result, the ratio indicating Grade 2 or 3 was 25% for one intervertebral procedure, 32.5% for two intervertebral procedures, and 46.7% for three intervertebral procedures. It is thought that the change in signal intensity increases with the number of intervertebral procedures.
The purpose of this study was to assess a relation between efficacy of the McKenzie exercise and the direction of motion pain at the initial examination among patients with acute low back pain. At the first examination 79 patients had backward motion pain among 80 patients whose extension exercise was effective. Twenty three patients had forward motion pain in 24 patients whose flexion exercise was effective. This study suggests that McKenzie exercise is very effective to be done as the direction which pain occurs for patients with acute low back pain.
The purpose of this study is to find out the association between pelvic movement with or without lower back pain (LBP) during extension movements while seated on a chair. The sample of this experiment is 10 patients who had LBP during extension movements (LBP group) while seated and a control group of 10. There was no significant difference in the pelvis anteversion angle when they sat down. As for the pelvic anteversion angle during extension movements, the LBP group had a significantly lower degree of movement in comparison with the control group. Furthermore, all the control group experienced a lean of more than 5 degrees, compared with the LBP group, where 7 of 10 patients had a lean of less than 5 degrees. In conclusion, it was suggested that it was useful to evaluate the pelvic anteversion angle in those experiencing LBP during extension movements when investigating LBP.
We examined the difference for the muscle activity patterns of the trunk muscles during gait between the healthy persons and two chronic low back pain patients diagnosed lumbar disc herniation using electromyography. In the patient A, the characteristics of the muscle activity pattern in the obliquus internal abdominis had low activity at all times through gait cycle. The muscle activity patterns in the paravertebral muscles were characterized by high activity at the middle stance phase and swing phase. The high activity in the paravertebral muscles during gait correlated to the restriction of the ROM in the spine. In the patient B, the characteristics of the paravertebral muscles had flat activity in comparison with healthy persons. After the therapy, the muscle activity pattern in the longissimus and iliocostalis were approximately normalized. However the multifidus remained high activity at the swing phase during gait. Lasegue sign positive and restricted SLR (Straight Leg Raising) angle correlated to the knee extension and the hip flexion at the swing phase. Therefore the high activity in the multifidus at the swing phase may avoid redundant nerve extension. The evaluation of the trunk function using surface electromyography was importance for the chronic low back pain patients.
The purpose of this study is that the evaluation of clinical findings and spinal list. We classified spinal list and investigated the lumbo-pelvic sagittal alignment. In cases of spinal forward list, the clinical findings were severe and the alignment was less lumbar lordosis and had more vertical tilt of pelvic bone. From these results, spinal forward list in lumbar disc herniation seems to be affected by both sciatic pain and hyper tonus in lumbo-pelvic muscles.
Among 29 patients, there were 15 lumbar spinal canal stenoses (LCS), 6 lumbar disc herniation (LDH), 5 cervical spondylotic myelopathy (CSM), one lumbar spondylolysis (SL), and 2 idiopathic scoliosis (SC). The items investigated in the spinal fluid consisted of TNF-alpha, IL-1beta, IL-6, IL-8, and MMP3. The concentration of each cytokine was investigated according to disease and severity of the narrowing of the dural tube. The concentrations of MMP3, IL-6 and IL-8 could be assessed. However, those of TNF-alpha and IL-1beta were below the threshold of determination. The concentrations of MMP3, IL-6, and IL-8 were significantly higher in LCS than in SC. The concentrations of these were significantly higher in the group with leg pain than in that without leg pain. The concentrations of cytokines were associated with the severity of narrowing of the dural tube. In this study, since spinal fluid investigation was not performed in the acute stage after conservative treatment, TNF-alpha and IL-1beta associated with the acute inflammation was not increased in the group with leg pain. However, there was a tendency toward increase of IL-6, IL-8 and MMP3. The authors suggested IL-6, IL-8 and MMP3 were induced by mechanical pressure on the spinal nerve.
This study examined surgical outcomes in five lumbar spondylolysis patients treated by posterior lumbar fusion using pedicle screw and hook. Patients were evaluated pre- and post-operatively using Japan Orthopedic Association (JOA) scores and lumbar pain score in JOA scores, and post-operatively using Hirabayashi recovery rate, bony fusion rates and activities of daily living. The average JOA scores improved from 17.6 points to 26.4 points, average lumbar pain from 1 point to 2.4 points, and the Hirabayashi recovery rate was 78.7%. Four of five patients returned to their pre-operative activity levels for sports and work. In one 28-year-old potient with L5 spondylolysis facet joint extension caused right buttock pain due to poor fitting of the facet joint at the lower level. We should therefore be careful to pull the hook down using forceps when using the pedicle and hook for posterior lumbar fusion.
Lumbar belt provide support to the spinal column by continuously raising the abdominal pressure. We developed a lumbar belt that could apply pressure to the abdominal wall along the plane that was larger than the upper quadrant. We measured pressure the belt of a conventional belt (D) and that of our newly developed belt (RF), in eight healthy men and ten healthy women. RF was able to press the abdominal wall with D at the same level. When it was assumed that RF and D could raise abdominal pressure at the same level, it was thought that pressure a wide over range reduced the burden on the person who wearing the belt. It was thought that RF could prevent the whole belt from slipping off when the belt was applied to the lower abdominal area, in the case of the type girth of the abdomen was large.
Finger-floor distance (FFD), which represents trunk flexibility, is a reliable assessment of lumbar impairment. Although this measurement is easy to test, it is difficult to adopt in a large, epidemiological study because it requires examiners. As an alternative, we developed a simple self-assessment bending scale (SABS). The purpose of the present study was to investigate the validity and reliability of the SABS. The SABS has 7-point grading scheme: (1) Fingertips can not reach beyond the knees; (2) Fingertips can reach beyond the knees but the wrists can not; (3) Wrists can reach beyond the knees, but fingertips can not reach the ankles; (4) Fingertips can reach the ankles, but not the floor; (5) Fingertips can touch the floor; (6) All of the fingers can reach the floor; and (7) Palms can reach the floor. We measured the FFD and SABS in 55 healthy volunteers. SABS assessments were made and documented independently by the subject and examiner. The SABS highly correlated with the FFD (r =0.95). Kappa statistics for the SABS grades given independently by the subjects and the examiner were high at 0.98. These findings suggest that the SABS may be used as an alternative to FFD measurements in epidemiological studies.