Shoulder pain due to cervical radiculopathy: an underestimated long-term complication of herpes zoster virus reactivation?

Purpose To evaluate if herpes zoster virus (HZV) reactivation may be considered in the aetiology of cervical radiculopathy. Methods The study group was composed of 110 patients (52 M-58F;mean age ± SD:46.5 ± 6.12; range:40-73) with a clinical diagnosis of cervical radiculopathy. Patients with signs of chronic damage on neurophysiological studies were submitted to an X-ray and to an MRI of the cervical spine in order to clarify the cause of the cervical radiculopathy and were investigated for a possible reactivation of HZV; HZV reactivation was considered as “recent” or “antique” if it occurs within or after 24 months from the onset of symptoms, respectively. Data were submitted to statistics. Results Thirty-eight patients (34,5%,16 M-22F) had a history of HZV reactivation: four (2 M-2F) were “recent” and 34 (14 M-20F) were “antique”. In 68 of 110 participants (61,8%,30 M-38F), pathological signs on X-ray and/or MRI of the cervical spine appeared; in the remaining 42 (38,2%,22 M-20F) X-ray and MRI resulted as negative. Among patients with HZV reactivation, seven (18,4%) had a “positive” X-ray-MRI while in 31 (81,6%) the instrumental exams were considered as negative. The prevalence of “antique” HZV reactivations was statistically greater in the group of patients with no pathological signs on X-ray/MRI of the cervical spine with respect to the group with a pathological instrumental exam (p < 0.01). Conclusions It may be useful to investigate the presence of a positive history of HZV reactivation and to consider it as a long-term complication of a cervical root inflammation especially in patients in which X-ray and MRI of the cervical spine did not show pathological findings

Spinal manipulation or mobilization for lumbar disc herniation with radiculopathy : a protocol for a systematic review and meta-analysis

Introduction: The purpose of this study is to conduct a systematic review and meta-analysis into the effects of spinal manipulation or mobilization for Lumbar Disc Herniation with Radiculopathy (LDHR). Methods: An electronic database search of titles and abstracts of articles published in English will be conducted in the following databases: PEDro (Physiotherapy Evidence Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PubMed, Science Direct, Google Scholar, and The Cochrane Library. The specific search strategies will be dependent on the particular database being searched and hand searches of the reference lists of the included articles will also be performed. Studies will be included if they reported an acceptable comparison group, and also reported at least one of the main clinically relevant outcome measures for LDHR. Two independent reviewers will screen the identified records, and all disagreements will be resolved. The internal and external validities of the included studies will be assessed using the PEDro scale and the External Validity Assessment Tool (EVAT) respectively. The clinical relevance and risk of bias of the studies will be determined using the 5-Criteria developed by the Cochrane Back Review Group and the Cochrane Risk of Bias Assessment Tool respectively. Studies will be pooled into meta-analysis where appropriate using RevMan software and the outcomes will be reported using the PRISMA guidelines. Discussion: This review will summarize the current evidence about the effects of spinal manipulation or mobilization compared with other interventions in the management of individuals with Lumbar Disc Herniation with Radiculopathy (LDHR). A meta-analysis will also be conducted where appropriate in this review to compare the effects of spinal manipulation or mobilization with other interventions with a view to finding out which technique is better in the management of individuals with LDHR. Review Registration: This review has been registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42019131292). Keywords: Spinal manipulation; spinal mobilization; lumbar disc herniation; systematic review; meta-analysi

Outcome of low back pain patients referred to orthopeadic outpatient clinic

Background: Musculoskeletal complaints are the commonest encounters in primary care. Low back pain management is commonly initiated by the family practitioner. Guidelines are limited as to when patients should be referred for specialist treatment by the orthopaedic department. Objectives: Evaluate the justification of low back pain referrals to Orthopedic outpatients (OOP), Mater Dei Hospital, Malta and assess whether these merited specialist consultation. Method: Anonymous data was collected over a 3- month period, where 100 low back pain new case referrals were evaluated during OOP. Data collection was based on routine questions normally brought forward during a consultation and a management plan which was documented in a spreadsheet. Data was analyzed using the same software. Results: Out of the total number of patients reviewed, 57 had been referred for the first time to OOP. Out of these, only 10 required an MRI with a scheduled follow up appointment. The remainder were referred for physiotherapy or pain clinic and discharged to follow-up in the community by the primary care physician. Out of 43 patients who had had previous OOP appointments complaining of lower back pain, 5 patients required an MRI and follow up appointment, remainder were discharged with physiotherapy or pain clinic appointments. Conclusion: The majority of patients seen at OOP could have been managed in primary care. It reflects the importance of developing local management guidelines for low back pain, which would assist general practitioners. It is indicative that referral to OOP should only be triggered when all treatment options available in the primary care are exhausted. This would lead to patients achieving targeted treatment timely within the community, resulting in shorter waiting time for outpatient visits.peer-reviewe

An unexpected cause of palmar paraesthesia in a soldier : a case report

Athletes presenting with neurological symptoms merit thorough assessments that in most cases will include investigations with one or more imaging modality. Imaging is especially useful in atypical presentations of neurological pathology (both acute and chronic) as was the instance in the presented case report. The case of a 22-year-old male soldier is presented who presented with a two week history of paraesthesia involving his right hand. After being assessed by the military medical officer, a presumptive diagnosis of cervical radiculopathy was made and appropriate treatment was prescribed. Symptoms persisted despite treatment and following an inconclusive cervical X-Ray, a magnetic resonance scan was booked that confirmed the diagnosis of multiple sclerosis. The patient was admitted to hospital and started on intravenous methylprednisolone and beta-interferon therapy with resolution of his symptoms. This case highlights the usefulness of imaging in confirming diagnosis, especially in atypical presentations of pathology afflicting the neurological system. Atypical symptoms, lack of response to standard therapy and inconclusive initial radiological investigations, should prompt the physician to carry out further detailed imaging modalities. The choice of the latter will need to reflect the working differential diagnoses. With reference to the presented case, imaging plays a role not only in diagnosis but also in assessing response to treatment and disease progression.peer-reviewe

Diagnostic Prediction Using Discomfort Drawings with IBTM

In this paper, we explore the possibility to apply machine learning to make diagnostic predictions using discomfort drawings. A discomfort drawing is an intuitive way for patients to express discomfort and pain related symptoms. These drawings have proven to be an effective method to collect patient data and make diagnostic decisions in real-life practice. A dataset from real-world patient cases is collected for which medical experts provide diagnostic labels. Next, we use a factorized multimodal topic model, Inter-Battery Topic Model (IBTM), to train a system that can make diagnostic predictions given an unseen discomfort drawing. The number of output diagnostic labels is determined by using mean-shift clustering on the discomfort drawing. Experimental results show reasonable predictions of diagnostic labels given an unseen discomfort drawing. Additionally, we generate synthetic discomfort drawings with IBTM given a diagnostic label, which results in typical cases of symptoms. The positive result indicates a significant potential of machine learning to be used for parts of the pain diagnostic process and to be a decision support system for physicians and other health care personnel.Comment: Presented at 2016 Machine Learning and Healthcare Conference (MLHC 2016), Los Angeles, C

C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases.

STUDY DESIGN: A multicenter, retrospective review of C5 palsy after cervical spine surgery. OBJECTIVE: Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery. METHODS: We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. P values were calculated using 2-sample t test for continuous variables and χ(2) tests or Fisher exact tests for categorical variables. RESULTS: Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%). CONCLUSION: C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date

Radiculopathy as Delayed Presentations of Retained Spinal Bullet.

Bullet injuries to the spine may cause injury to the anatomical structures with or without neurologic deterioration. Most bullet injuries are acute, resulting from direct injury. However, in rare cases, delayed injury may occur, resulting in claudication. We report a case of intradural bullet at the L3-4 level with radiculopathy in a 30-year-old male. After surgical removal, radicular and claudicating pain were improved significantly, and motor power of the right leg also improved. We report the case of intradural bullet, which resulted in delayed radiculopathy

Tapentadol extended release for the management of chronic neck pain

BACKGROUND: The role of opioids in the management of chronic neck pain is still poorly investigated. No data are available on tapentadol extended release (ER). In this article, we present 54 patients with moderate-to-severe chronic neck pain treated with tapentadol ER. PATIENTS AND METHODS: Patients received tapentadol ER 100 mg/day; dosage was then adjusted according to clinical needs. The following parameters were recorded: pain; Douleur Neuropathique 4 score; Neck Disability Index score; range of motion; pain-associated sleep interference; quality of life (Short Form [36] Health Survey); Patient Global Impression of Change (PGIC); Clinician GIC; opioid-related adverse effects; and need for other analgesics. RESULTS: A total of 44 of 54 patients completed the 12-week observation. Tapentadol ER daily doses increased from 100 mg/day to a mean (standard deviation) dosage of 204.5 (102.8) mg/day at the final evaluation. Mean pain intensity at movement significantly decreased from baseline (8.1 [1.1]) to all time points (P<0.01). At baseline, 70% of patients presented a positive neuropathic component. This percentage dropped to 23% after 12 weeks. Tapentadol improved Neck Disability Index scores from 55.6 (18.6) at baseline to 19.7 (20.9) at the final evaluation (P<0.01). Tapentadol significantly improved neck range of motion in all three planes of motion, particularly in lateral flexion. Quality of life significantly improved in all Short Form (36) Health Survey subscales (P<0.01) and in both physical and mental status (P<0.01). Based on PGIC results, approximately 90% of patients rated their overall condition as much/very much improved. Tapentadol was well tolerated: no patients discontinued due to side effects. The use of other analgesics was reduced during the observed period. CONCLUSION: Our results suggest that tapentadol ER, started at 100 mg/day, is effective and well tolerated in patients with moderate-to-severe chronic neck pain, including opioid-naïve subjects. Patients can expect a decrease in pain, an improvement in neck function, and a decrease in neuropathic symptoms