Degenerative Disc Diseases: A Brief Review

Back pain of different etiology is a common encountered symptoms in daily practice. Several factors were associated with the development of degenerative disease (DDD) of the intervertebral disc (IVD). The intervertebral disc, usually asymptomatic but once became symptomatic it will be presented as a low back pain with is consider the main complain among the patient with IVD. Both genetic as well as environmental factors lead to progressive redaction in extracellular matrix (ECM) composition which resulted overtime in weak IVD. Clinically back pain divided into two main categories: Inflammatory versus mechanical back pain, DDD typically present with mechanical type lower back pain. In patient with compatible history and physical exam findings, diagnosis of DDD can be confirmed by computed tomography (CT) scan, magnetic resonance imaging (MRI), or provocative discography. The DDD can be manage with several treatment strategies such as conservative therapy which aim to relief the pain, on the other hand, surgical approach which aim to definitely treat the DDD. The current study aims to provide a brief review about degenerative disc diseases.

Candidate Biomarkers to Distinguish Spinal Tuberculosis From Mechanical Back Pain in a Tuberculosis Endemic Setting

BackgroundSpinal tuberculosis (TB) may have a variable, non-specific presentation including back pain with- or without- constitutional symptoms. Further tools are needed to aid early diagnosis of this potentially severe form of TB and immunological biomarkers may show potential in this regard. The aim of this study was to investigate the utility of host serum biomarkers to distinguish spinal TB from mechanical back pain.MethodsPatients with suspected spinal TB or suspected mechanical back pain were recruited from a tertiary hospital in the Western Cape, South Africa, and provided a blood sample for biomarker analysis. Diagnosis was subsequently confirmed using bacteriological testing, advanced imaging and/or clinical evaluation, as appropriate. The concentrations of 19 host biomarkers were evaluated in serum samples using the Luminex platform. Receiver Operating Characteristic (ROC) curves and General Discriminant Analysis were used to identify biomarkers with the potential to distinguish spinal TB from mechanical back pain.ResultsTwenty-six patients with spinal TB and 17 with mechanical back pain were recruited. Seven out of 19 biomarkers were significantly different between groups, of which Fibrinogen, CRP, IFN-γ and NCAM were the individual markers with the highest discrimination utility (Area Under Curve ROC plot 0.88-0.99). A five-marker biosignature (CRP, NCAM, Ferritin, CXCL8 and GDF-15) correctly classified all study participants after leave-one-out cross-validation.ConclusionThis study identified host serum biomarkers with the potential to diagnose spinal TB, including a five-marker biosignature. These preliminary findings require validation in larger studies.

Unstable Bony Chance Fracture Successfully Treated With Teriparatide in Patient With Ankylosed Spine: A Case Report and Review of the Literature

Background: Ankylosed spines with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis (DISH) are prone to fractures due to osteoporosis and fracture instability from long lever arm. In such cases, surgical management is the main treatment option. Case presentation: We report a first case of successful treatment of unstable bony Chance fracture at thoracolumbar junction in DISH patient using teriparatide and review previous literature on ankylosed spine fractures treated with teriparatide. An 82-year-old male patient presented with back pain after falling from a 3 m height 3 months ago. Imaging studies showed L1 unstable flexion-distraction injury (bony Chance fracture) and intravertebral vacuum cleft in ankylosed spine due to DISH. Conservative treatment, teriparatide and orthosis, was determined as the most appropriate approach because the patient declined surgery and presented with tolerable mechanical back pain without any neurologic deficits. Solid bony union was successfully achieved without any complications after 1-year treatment. Conclusion: Although surgical management is strongly recommended for unstable fracture in ankylosed spine, non-surgical treatment including teriparatide and orthosis might be safer and effective options in bony Chance fracture without neurologic deficits and intractable mechanical pain.

P143: The use of the erector spinae plane block to decrease pain and opioid consumption in the emergency department: A literature review

Introduction: Acute pain represents one of the most common reasons for emergency department (ED) visits. In the opioid epidemic that North America faces, there is a significant demand for novel pain control modalities that are both safe and effective. Regional anesthesia techniques have revolutionized perioperative pain management, and they are currently thought to be indicated for acute pain relief in the ED. The erector spinae plane block (ESPB) is a novel regional block that has the ability to block multidermatomal sensation, including cervical, thoracic and lumbar regions, depending on the vertebral level at which the anesthetic is injected along the erector spinae muscle. Under ultrasound guidance, the landmarks involved are easy to identify, and there are no vital structures in the immediate vicinity of the site of injection. By reviewing the literature on ESPB, this review aims to summarize all its indications and efficacy for acute pain management in the ED. Methods: In April 2019, PUBMED, EMBASE, MEDLINE as well as CINAHL databases were systematically searched for articles discussing the use of ESPB in the ED. In compliance with the PRISMA guidelines, the search results were selected against inclusion and exclusion criteria. Due to the novelty of the block, all types of articles were included. Results: Ten studies on 7 different indications have been published on the use of ESPB in the ED. It is currently most commonly used for rib and spine fractures. Other indications include, mechanical back pain, burn injuries, herpes zoster, renal colic, and acute pancreatitis. ESPB was administered at the vertebral level of region of most pain, unilaterally or bilaterally for complete dermatomal block. It was injected as a single or continuous block - in the seated, lateral, or prone position. All of the studies demonstrate a significant reduction in pain. Furthermore, it has been reported to improve respiratory function, and it has not been associated with any complications following administration. Conclusion: This review shows initial data on the promising effect of ESPB in acute pain management in the ED. Current evidence shows its effectiveness and safety for the most common presenting cases of pain, such as rib and spine fracture, mechanical back pain, burn injuries, herpes zoster, renal colic, as well as acute pancreatitis. ESPB is flexible in administration and relatively easy to perform under ultrasound guidance.

Pathological fractures of the spine in children (review of the literature and clinical and morphological monocenter cohort analysis)

Background. Pathological vertebral fractures are rare and occur in inflammatory, tumor, and dystrophic lesions. Aim. This study aimed to analyze clinical features and morphological structure of pathological fractures of the spine in children. Materials and methods. The authors examined and operated 62 children aged 217 years for pathological vertebral fractures. We investigated the clinical, radiological, and morphological features. Results. The average age of children at the time of hospitalization was 10 years. Lesions of thoracic vertebrae prevailed (78%) with the maximum frequency of occurrence at the apex of physiological kyphosis Th78. In 10 cases, multiple lesions were noted, including the pathology of other parts of the skeleton. In 69% of observations, clinical symptoms were not dominated by mechanical back pain. Palpation pain (34%) and local spinal deformation (27%) were noted. On average, local kyphosis was 24. Eleven patients (18%) manifested a neurological deficiency, of which nine fractures were a consequence of the tumor process. In 16% of observations, the fracture of the vertebra was detected to be an accidental Х-ray finding. Among the radiation manifestations, all cases (12 patients) registered the decrease in the height of the vertebral body in the form of collapse. Destruction was manifested by various options other than blastic. Therapeutic and diagnostic interventions were performed in 56 patients, and in six children, manipulation was limited to trepan biopsy. The pathological fracture was caused by an inflammatory process in 50% of observations and tumors in 42%, of which 31% is malignant. Conclusions. Pathological spinal fracture in children should be considered as a syndrome, which in most cases is based on an inflammatory or tumor process. The high frequency of neoplastic, including malignant processes, requires active invasive diagnosis. Therapeutic tactics are determined by the clinical, radiation, and morphological characteristics of pathology.

Detectability of the peripheral and axial manifestations of psoriatic arthritis in patients with psoriasis in dermatological practice

Psoriatic arthritis (PsA) is a heterogeneous disease manifested by peripheral arthritis, dactylitis, spondylitis, and enthesitis. PsA is often undiagnosed by dermatovenerologists because of the difficulty in identifying a variety of clinical signs. The early diagnosis of PsA and the accurate assessment of all its symptoms are necessary for the timely choice of optimal therapy.Objective: to assess the detectability of clinical signs of PsA in patients with psoriasis in dermatological practice.Patients and methods. The investigation enrolled 103 patients (47 men and 56 women) (mean age, 44.0±13.7 years) with psoriasis (its mean duration, 10.7±10.2 years), the average prevalence and severity according to the Body Surface Area (BSA) and the Psoriasis Area and Severity Index (PASI) were 9.3±13.6% and 15.4±12.5 scores, respectively. All the patients completed the Psoriasis Epidemiology Screening Tool (mPEST) and were examined by a dermatovenerologist and a rheumatologist. The diagnosis of PsA was based on the Classification Criteria for Psoriatic Arthritis (CASPAR). The investigators evaluated arthritis, dactylitis, enthesitis, and inflammatory back pain (IBP) according to the rheumatological standards: IBP by the Assessment of SpondyloArthritis International Society (ASAS) criteria, and enthesitis by the Leeds Enthesitis Index (LEI).Results and discussion. Sixty-one (59.2%) of the 103 patients with psoriasis were found to have PsA on the basis of the CASPAR criteria and the rheumatologist's examination. The dermatovenerologist diagnosed arthritis in a significantly smaller number of cases than did the rheumatologist: in 15 (24.6%) and 35 (57.4%) of the 61 patients (p<0.001), respectively. The dermatovenerologist and the rheumatologist demonstrated no significant differences in their clinical evaluation of dactylitis: it was detected in 37 (60.7%) and 40 (65.6%) of the 61 patients, respectively (p=0.32). Based on patient complaints and mPEST findings, the dermatovenerologist recorded pain in the calcaneal region in 32 (52.5%) patients. The rheumatologist identified ulnar, knee, and calcaneus enthesitis in 11 (18%), 8 (13.1%), and 25 (41%) patients, respectively. Based on complaints and mPEST findings, the dermatovenerologist detected back pain in 30 (49.2%) of the 61 patients. The rheumatologist diagnosed IBP in 21 (70%) of these 30 patients and mechanical back pain in 9 (30%). Thus, IBP was noted in 34.4% of PsA patients. Tendonitis was undiagnosed by the dermatovenerologist; the rheumatologist identified wrist tendonitis in 13 (21.3%) of the 61 patients with PsA.Conclusion. Dermatovenerologists frequently underestimate damage to the spine and entheses in patients with psoriasis. The introduction of the ASAS criteria for IBP and methods for assessing enthesitis in dermatological practice can improve the early diagnosis of axial lesion in PsA in patients with psoriasis.

Back pain and functional status in patients with ankylosing spondylitis during pregnancy

Inflammatory rhythm back pain and enthesitis are one of the main clinical manifestations of ankylosing spondylitis (AS), which increase in severity during pregnancy. However, addition of back pain and, possibly, enthesis in the second half of gestation, which is associated with normal pregnancy, needs to make a differential diagnosis for clarifying the genesis of pain and choosing the right management tactics, which determines the relevance of this study.Objective: to investigate the course of pain in the back, enthesis, and inguinal region, as well as the functional status in AS patients during pregnancy and to reveal clinical signs that most accurately reflect inflammatory activity during gestation.Patients and methods. A study included 36 pregnant women with a reliable diagnosis of AS according to the modified New York criteria (1984). Their mean age was 31.6±4.8 years, the mean age at the onset of AS was 21.8±10.9 years; the duration of the disease was 134.9±89.3 months. A control group comprised 30 healthy pregnant women with no history of back pain and arthritis; their mean age was 28.2±4.5 years. The pregnant women of both groups were matched for parity. They made visits at 10–11, 20–21, and 31–32 weeks of pregnancy. Pain intensity was estimated using the numerical pain rating scale (NPRS) and the functional status was assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI). The Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) was used to assess enthesitis.Results and discussion. During pregnancy, 94% of AS patients had back pain; its intensity by trimesters was 3 [2; 4], 4 [3; 5.5], 3 [2; 7] and was higher than in healthy pregnant women (p<0.0001). In the study group, there was a rise in pain intensity at night with increasing gestational age (n=23–28): 2 [1; 4] in the first trimester; 3 [0; 5] II in the second trimester; 3 [1; 6] in the third trimester (p< when comparing the first, second, and third trimesters) and an increase in the duration of morning stiffness (n= ): 10 [5; 20], 15 [10; 55], and 15 [5; 60] min, respectively. Moreover, the number of women who reported improvements after exercise (85–63%) and no improvement at rest (88–56%) declined (p<0.05 when comparing the first, second, and third trimesters).In the control group, 1 and 3 patients had morning back stiffness and night pain, respectively. The healthy pregnant women more frequently reported a reduction in back pain after exercise in the third trimester (66.7% of those with pain) than in the first trimester (20% of those with pain) (p<0.05).By the third trimester, the patients with AS showed a change in the nature of back pain: 43.7% of the patients reported an improvement at rest; 42.4% noted an increase in pain after exercise, while the frequency of elements of mechanical back pain was less than that in the control group (p < 0.05).The intensity of groin pain (2.4±1.9, 3.3±2.4, and 4.3±3.0 in the first, second, and third trimesters, respectively) did not differ in AS patients with and without coxitis or pelvic enthesitis. The frequency of enthesitis and MASES scores in the study group were higher than in the control group (p<0.05), the MASES scores increased with gestational age, amounting to 0 [0; 1] in the first trimester and 2 [0; 3] in the third trimester (p<0.05).Functional disorders during pregnancy increased in both groups; there was a difference in BASFI scores between the groups only in the third trimester: 3.5±2.8 and 1.7±1.2, respectively (p<0.05).Conclusion. Back pain and functional disorders increase in AS patients during gestation. Night back pain, morning stiffness, and enthesitis reflect the inflammatory activity of AS during pregnancy. Mechanical back pain joins in 40% of women with AS in the third trimester. The criteria for inflammatory back pain and BASFI require adaptation when used in pregnant women.