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PubMed1995

Liver laceration in an intercollegiate football player.

Serious abdominal injuries in athletics, including liver trauma, are relatively rare. When they do occur, the athletic trainer and the team physician must be able to recognize the signs and symptoms and employ the appropriate first aid and follow-up care. In this paper, we present a case study of a football player who suffered a lacerated liver as a result of a forceful blow to the right side of the chest. Although his case was typical of most isolated liver injuries and he did not experience massive internal bleeding, the potential for life-threatening exsanguination exists and must be recognized by by sports health care practitioners. Most isolated liver injuries can be treated nonsurgically. However, those patients with multiple organ trauma, deteriorating vital signs, or diminishing hemodynamic stability generally require immediate surgery. Athletes with persistent right upper quadrant pain, especially when accompanied by referred pain to the right shoulder, abdominal rigidity, guarding, or rebound pain should be considered to have a liver injury until ruled out by CT scan and liver enzyme studies. Our subject was typical of most athletic liver patients and he was able to resume light exercise after 5 weeks and full activity after 3 months.

Journal Article↗
PubMed1986

"Bony sciatica"--the value of thermography, electromyography, and water-soluble myelography.

With an increased interest in sporting activity, particularly among the older population, together with the appreciation of the importance of "bony entrapment" as a cause of sciatica, so the need has arisen to develop a simple, noninvasive, reliable, and reproducible method of determining whether leg pain is of radicular or referred origin. In our experience, liquid crystal thermography has proved unsatisfactory but electromyography appears to be of value in distinguishing root from referred pain in approximately 70 per cent of patients within this group. Our experience with radiculography within this context is also presented and is shown to be currently unsatisfactory.

Athletic Injuries↗
PubMed2004

[Clinical manifestations and late complications of the hepatic hydatid cyst: report of 4 cases].

INTRODUCTION: Hepatic hydatid cyst (HHC) may appear and remain free of symptoms for a long time, require treatment of its syptoms or relapse after an adequate treatment. The HHC relapse after a medical and surgical treatment is considered a complication of the disease as well as the infection, breakup or other complications. OBJECTIVES: Describe four patients with HHC whose complication or relapse symptoms appeared between 13 and 26 years after the disease was known or adequately treated. CASE REPORT: Four patients with previously diagnosed HHC and symptoms associated to its relapse or infection were retrospectively studied. Patient 1: woman, 48 years old, with diagnosis of HHC during a cholecistectomy in 1977, who showed a touchable mass in 1998. Patient 2: woman, 45 years old, with HHC surgery in 1973, who referred pain and HHC relapse in 1996. Patient 3: woman, 43 years old, with HHC diagnosed in 1980, who referred abdominal pain with increase of HHC volume in 1996. Patient 4: man, 60 years old, with HHC diagnosed in 1981, who referred fever in 1996 related to an abscess of the HHC. The four patients presented HHC relapse and symptoms due to its complications. Medical and surgical treatment was needed in all the cases. CONCLUSIONS: We observed that HHC disease may present complications many years after its surgical treatment with late symptomatic relapses and that the non-treated disease may also develop complications many years after remaining asymptomatic.

Adult↗
PubMed1986

Spine x-ray abnormalities in idiopathic limb pain problems. Study notes possibility pain may be referred.

Five hundred and thirty-eight cases of spine (298) and limb (240) pain problems were coded for spine x-ray abnormality (congenital, scoliosis, straightening, and degenerative joint disease). Analysis reveals that the limb pain cases (97 upper and 143 lower) when compared with the spine pain cases (45 cervical and 253 lumbar) have fewer normal spine x-rays with a greater incidence of degenerative joint disease in the limb pain cases and a greater incidence of straightening in younger spine and limb pain cases. Excluding 107 disability cases increases these tendencies. A group of 191 women who have had x-rays every five years are studied for controls and show a much lower incidence of x-ray changes. These data support a diagnosis of referred pain from the spine as a significant possibility in the idiopathic limb pain problem case.

Adult↗
PubMed2006

Multiple dose gabapentin attenuates cutaneous pain and central sensitisation but not muscle pain in healthy volunteers.

Various muscle pains constitute a large clinical problem, both for patients and clinicians. Gabapentin is an established therapy in neuropathic pain and reduces cutaneous pain in healthy volunteers. Gabapentin in combination with other analgesics reduces post-operative pain. No data exist on the effect of gabapentin on muscle pain. This study investigates the effect of gabapentin on muscle and cutaneous pain in healthy volunteers. Sixteen healthy volunteers, 8 male/8 female, were included in this double-blind three-session crossover study comparing the effects of 0, 1200, 1800 and 2600 mg (pre-treatment, titrated over 4 doses) gabapentin and placebo. Muscle pain was induced by infusing 0.5 ml of hypertonic saline into the anterior tibial muscle. Simultaneously, subjects graded pain on a computerized visual analog scale (VAS, 0-10). Total (AUC, VAS*duration in s) and maximal pain (VAS(max)) were assessed. Areas of local and referred pain were measured. Further, continuous intracutaneous electrical stimulation was applied to the forearm. Current was increased until pain intensity 5/10 or until subjects reached a cut-off of 70 mA. Spontaneous pain (VAS 0-10), areas of secondary hyperalgesia to pinprick (cm2) and mechanical pain threshold (g) within this area were assessed. Gabapentin pre-treatment reduced sensitivity to electrical induction of skin pain by 14%, p=0.016. Secondary hyperalgesia was induced, but areas were reduced after pre-treatment, p<0.05. Mechanical pain thresholds were unaffected. Pain induced by intramuscular infusion of hypertonic saline was not affected by gabapentin. In conclusion, single or repeated dosing of gabapentin reduced cutaneous but not muscle pain in healthy volunteers.

Adult↗
PubMed2003

[Pathophysiology and clinical manifestation of cervicogenic headache].

Cervicogenic headache (CH) originates from disorders of the neck but is recognized as a referred pain in the head. Primary sensory afferents from the cervical roots C1-C3 converge with afferents from the occiput and trigeminal afferents on the same second-order neuron in the upper cervical spine. Consequently, the anatomical structures innervated by the cervical roots C1-C3 are potential sources of CH. In normal volunteers, the painful stimulation of different anatomical structures of the neck produced headache. In CH, particular structures have been selectively anesthetized in order to identify possible sources of pain. In summary, CH can origin from different muscles and ligaments of the neck, from intervertebral discs,and, particularly, from the atlantooccipital, atlantoaxial, and C2/C3 zygapophyseal joints. Diagnosis of CH should adhere strictly to the published diagnostic criteria to avoid misdiagnosis and confusion with primary headache disorders such as migraine and tension type headache.

Afferent Pathways↗
PubMed2004

Piriformis syndrome: Correlation of muscle morphology with symptoms and signs.

OBJECTIVE: To determine the relation of symptoms and pain provocation tests to abnormal piriformis morphology among people with chronic buttock pain. DESIGN: Each of 2 clinical symptoms and 2 clinical signs were compared with the abnormal morphology found on ultrasound. The pain-free side was used as an internal control. SETTING: A tertiary referral center. PARTICIPANTS: A series of 27 consecutive patients (26 women, 1 man; average age, 48 y) with chronic low lumbosacral or buttock pain, who presented to a musculoskeletal clinic over a 12-month period, underwent ultrasound assessment of piriformis muscle morphology. Four patients were excluded because their body mass index was in excess of 30 kg/m 2 . INTERVENTION: The symptomatic piriformis muscle was injected with bupivacaine after pain was assessed on a visual analog scale (VAS), using the resisted abduction test. MAIN OUTCOME MEASURE: A 70% reduction of pain on the VAS was considered positive for pain in the piriformis muscle. RESULTS: Odds ratios (ORs) and 95% confidence intervals were calculated comparing each of the signs and symptoms with normal morphology. The highest ORs were found for pain on walking up inclines (10.8), referred pain (5.3), and pain on needling the piriformis muscle (6.0). CONCLUSIONS: This study did not provide a criterion standard for the diagnosis of piriformis syndrome, but it did support the syndrome as a contributing factor in chronic buttock pain and very low back pain.

Anesthetics, Local↗
PubMed2001

The clinical picture of neuropathic pain.

Neuropathic pains refer to a heterogeneous group of pain conditions characterised by lesion or dysfunction of the normal sensory pathways. Clinical characteristics include: delayed onset of pain after nervous system lesion, pain in area of sensory loss, spontaneous and different evoked types of pains. It has so far only been possible to classify these pains on basis of underlying cause or on anatomical location. The mechanisms underlying neuropathic pain are not yet clear, but neuronal hyperexcitability in those neurons that have lost their normal patterned input seems to be a common denominator for many, if not all types, of neuropathic pains. Along these lines, a mechanism-based classification has recently been proposed, which is an attractive approach because it provides a frame for a rationally based therapy of neuropathic pains. The clinical manifestations of neuronal hyperexcitability due to nervous system lesions is described.

Animals↗
PubMed1996

Cervicogenic headache: the influence of mental load on pain level and EMG of shoulder-neck and facial muscles.

The relationship between pain and EMG levels was studied in 17 cervicogenic headache patients and 17 group-matched healthy controls. All subjects performed a 1-hour, complex, two-choice, reaction time test. Every 10 minutes before, during, and also for 20 minutes after the test, they reported pain levels (using visual analogue scales) in the forehead, both temples, neck, and shoulders. Electromyographic activity, using superficial electrodes, was also recorded from the frontal, temporal, neck (splenius), and trapezius muscles. Maximal voluntary contractions were performed in all the muscles. Increased pain levels before, during, and after the test were found on the symptomatic side in the temple, shoulder area, and neck in the patient group compared with nonsymptomatic side and controls (neck only compared with controls). Electromyographic amplitudes from the trapezius muscle on the symptomatic side were significantly higher before and during the test, compared with the nonsymptomatic side, but most markedly during the test. Pretest EMG amplitudes from the frontal muscle on the symptomatic side in patients were also significantly higher than those in controls, but the difference vanished during the test. There are indications that the temporal pain, ie, the headache, is a referred pain. These observations may point to a "muscular" involvement in the pathogenesis of cervicogenic headache, either primarily or, which seems more plausible, secondarily.

Adult↗
PubMed2006

Gout, have we met before? No, not like this...

LEARNING OBJECTIVES: Extra-articular symptoms could be the first manifestation of gouty arthritis (GA); polyarticular GA can mimic an infectious arthritis; infection can complicate GA. CASE: A 66-year-old male with a history of gout presented with high fever and excruciating bilateral calf pain for 1 day. Examination revealed chronic knee effusions; range of motion in both knees was limited by calf pain. Joint aspiration showed negatively birefringent intracellular crystals and normal gram stain. HOSPITAL COURSE: While receiving empiric antibiotics fever continued and he developed bilateral knee, right ankle, and shoulder pain. After demonstration of urate crystals and exclusion of infection, antibiotics were discontinued and steroids initiated. Fever, calf pain, and polyarthritis quickly resolved. DISCUSSION: Polyarticular gouty attack is an uncommon presentation of gout, and can mimic several other conditions. An exceptional presentation of this entity is excruciating calf pain, probably caused by tenosynovitis or referred pain preceding an acute polyarticular gouty attack.

Administration, Oral↗
PubMed2006

Slipped capital femoral epiphysis: the importance of early diagnosis.

Slipped capital femoral epiphysis typically occurs in adolescents. Presentation may include limp or vague pain in the hip, thigh or knee. Knee pain, in particular, is a common complaint among adolescents and may be due to patello-femoral syndromes, Osgood-Schlatter disease, patellar tendonitis, or chondromalacia patella, to name a few. However, it is vital to remember that the complaint of knee pain may be present because of referred pain from pathology at the hip. Every child presenting with a complaint of hip, thigh or knee pain must undergo a hip examination. Likewise, a "groin pull" is exceedingly rare in children and must be a diagnosis of exclusion. Any child with complaints of hip, thigh, or knee pain, or physical examination findings of out-toeing, decreased internal rotation, or obligate external rotation with flexion, should be presumed to have SCFE until proven otherwise. There is a high rate of delay in diagnosis of SCFE, which leads to opportunities for progression of deformity, which in turn leads to increased risk of arthritis. Delay in diagnosis also may allow a stable SCFE to become an unstable one, with a much higher risk of development of AVN. When suspected, the diagnosis is confirmed with x-rays (AP and frog-lateral of the pelvis). Therefore, a high index of suspicion for this disorder, and the attainment of appropriate radiographs, should allow for prompt diagnosis and referral for treatment. Treatment is urgent and surgical. Early diagnosis and proper treatment are the mainstays of prevention of adverse sequelae.

Adolescent↗
PubMed2000

[The clinical history and physical examination in patients with chronic lumbar pain. Patient classification by a decision tree].

AIM: To analyze the correlation between clinical symptoms and physical examination signs in diagnostic groups of low back pain patients; making a spanning tree. MATERIAL AND METHOD: A prospective longitudinal study of 485 low back pain patients was carried. We assess the type of pain and its irradiation, evolution in time, duration of the episodes, timetable, intensity and morning stiffness. A complete physical examination with specific tests for sacroiliac joints and neurologic examination was carried. We carried out a study of absolute and relative frequencies; calculating the rates with the chi 2 Pearson test and having a confidence of 95%. RESULTS: We found a significant relation (p < 0.0001) between the type of pain and the diagnosis groups. Proximal irradiation with functional disorders (p < 0.01) and metabolic bone diseases (p < 0.0001); the radicular irradiation and the disorders by physical agents (p < 0.001). The flare-up back pain with disorders by physical agents and metabolic bone diseases (p < 0.001). The morning stiffness was exclusive in the inflammatory diseases. In the physical examination, was found a significant relation (p < 0.0001) between the different tests with the diagnostic groups. CONCLUSION: The history and the physical examination provide us symptoms and signs which let us direct towards the above diagnostic. The type of pain with its characteristics and the referred pain as a main symptoms, give us some information, which complemented with the physical examination tests, providing the base on which we support our diagnostic hypothesis, allow us the first classification of the patients; at the same time we understand as a low back pain patients suffer its problem.

Chi-Square Distribution↗
PubMed1986

Intradural lumbar disc hernia. Case report.

The authors report a case of intradural disc hernia at L2-L3 in a woman aged 72 years. It presented clinically as chronic lumbar pain associated from the beginning with referred pain in the thighs, later with severe paraparesis and disturbance of bladder function. The myelogram showed a partial block suggestive of an intradural neoplasm. With a view to obtaining a more precise diagnosis, a CT lumbar scan was advised, but surgical intervention could not be deferred. Despite the gravity of the symptoms, the case reports in the literature showed that surgery carried out immediately offers a more than average chance of neurological recovery or improvement. This was in fact the outcome in the present case.

Aged↗
PubMed1994

Squirrel monkey lateral thalamus. II. Viscerosomatic convergent representation of urinary bladder, colon, and esophagus.

The response properties of 106 visceroceptive lateral thalamic neurons were investigated in anesthetized squirrel monkeys. Most neurons were located in the ventral posterior lateral nucleus (VPL), and a smaller number of cells was also found in a variety of thalamic nuclei around VPL. Ninety (85%) of these cells responded to distension of the urinary bladder, the distal colon, and/or the lower esophagus. The majority of the visceral-responsive cells also had convergent somatic and multivisceral responses (71% of the 85%). A small population (6%) was visceral specific; that is, these neurons were not activated with somatic stimuli. Visceral responses were excitatory, inhibitory, or mixed, and most were either visceral nociceptive specific (65%) or visceral wide-dynamic-range type (34%). Very few visceral responses (1%) could be classified as low threshold. The incidence of these response types were highly dependent on the specific viscus stimulated. Most visceral responses were able to code stimulus duration and intensity. The majority (69%) of the visceroceptive neurons had somatic low-threshold convergent input mainly from the surface of the lower body. The somatic receptive field locations and the somatic response properties seem unrelated to the convergent visceral input and the visceral response properties, although there were some exceptions. No obvious viscerotopical organization was found in VPL. The results lead us to propose two different modes of representation for processing of and distinguishing between visceral and somatic inputs: a distributed population code for visceral inputs, and a local code for somatic inputs. Based on these codes, we discuss a new hypothesis for referred pain.

Animals↗
PubMedDate not supplied

The use of the Varney brace for subluxating shoulders in stroke and upper motor neuron injuries.

Applying the Varney shoulder brace for painful subluxating shoulders in stroke and head injury patients with or without spasticity has proved to be an extremely effective means of reducing the subluxed shoulder. Other causes for painful shoulders in these patients must be ruled out. Not every shoulder which subluxes with or without spasticity is painful. Correct diagnosis of the etiology of the pain is essential to help the patient. Rotator cuff tendinitis, reflex sympathetic dystrophy, glenohumeral arthritis, shoulder contracture, pain due to central nervous system origin (thalmic pain) and other intrinsic causes of referred pain must be ruled out. Once the subluxed shoulder is proven to be the cause of pain, the Varney brace is an excellent orthosis for the reduction and maintenance of position. Pain usually subsides completely within 5 to 7 days.

Braces↗
PubMed1996

Altered lower limb vascular perfusion in patients with sciatica secondary to disc herniation.

STUDY DESIGN: The present study attempts to document deep vascular abnormalities of the lower extremity in cases of sciatica secondary to discal herniation using Tc-99m methylene diphosphonate angiography. OBJECTIVES: Vascular abnormalities are studied compared with the contralateral extremity and normal control subjects. An attempt is made to determine the clinical usefulness of the current technique. SUMMARY OF BACKGROUND DATA. Thermography has occasionally evidenced a decreased cutaneous temperature in patients with sciatica. There have been no studies to date looking at the total vascular flow in this condition, mainly constituted by the muscular perfusion. METHODS: Thirty patients with sciatica secondary to discal herniation, 16 patients with chronic low back pain referred to the thigh, and 31 control subjects were examined by isotopic angiography of the posterior aspect of the thigh after intravenous injection of Tc-99m methylene diphosphonate. The affected side was compared with the nonpainful side, and the difference was expressed as a percentage. Control subjects were used as reference values. RESULTS: Abnormality in vascularization of the lower extremity was found in 24 (80%) of patients with sciatica and in 11 (68.7%) of the patients with low back pain. The median blood flow difference was, respectively, -12.5% and +4% in these two groups versus +2.9% in the control group. The differences between the sciatica group and the other groups were statistically significant. No correlation was found with the clinical parameters studied. CONCLUSION: Vascular perfusion abnormalities observed in patients with sciatica secondary to disc herniation may be more important than previously considered and possibly result from alteration in sympathetic vascular autoregulation.

Aged↗
PubMedDate not supplied

Centralization as a predictor of provocation discography results in chronic low back pain, and the influence of disability and distress on diagnostic power.

BACKGROUND CONTEXT: The "centralization phenomenon" (CP) is the progressive retreat of referred pain towards the spinal midline in response to repeated movement testing (a McKenzie evaluation). A previous study suggested that it may have utility in the clinical diagnosis of discogenic pain and may assist patient selection for discography and specific treatments for disc pain. PURPOSE: Estimation of the diagnostic predictive power of centralization and the influence of disability and patient distress on diagnostic performance, using provocation discography as a criterion standard for diagnosis, in chronic low back pain patients. STUDY DESIGN/SETTING: This study was a prospective, blinded, concurrent, reference standard-related validity design carried out in a private radiology clinic specializing in diagnosis of chronic spinal pain. PATIENT SAMPLE: Consecutive patients with persistent low back pain were referred to the study clinic by orthopedists and other medical specialists for interventional radiological diagnostic procedures. Patients were typically disabled and displayed high levels of psychosocial distress. The sample included patients with previous lumbar surgery, and most had unsuccessful conservative therapies previously. OUTCOME MEASURES DIAGNOSIS: results of provocation discography. INDEX TEST: The CP. Psychometric evaluation: Roland-Morris, Zung, Modified Somatic Perception questionnaires, Distress Risk Assessment Method, and 100-mm visual analog scales for pain intensity. METHODS: Patients received a single physical therapy examination, followed by lumbar provocation discography. Sensitivity, specificity, and likelihood ratios of the CP were estimated in the group as a whole and in subgroups defined by psychometric measures. RESULTS: A total of 107 patients received the clinical examination and discography at two or more levels and post-discography computed tomography. Thirty-eight could not tolerate a full physical examination and were excluded from the main analysis. Disability and pain intensity ratings were high, and distress was common. Sensitivity, specificity, and positive likelihood ratios for centralization observed during repeated movement testing for pain distribution and intensity changes were 40%, 94%, and 6.9 respectively. In the presence of severe disability, sensitivity, specificity, and positive likelihood ratios were 46%, 80%, 3.2 and for distress, 45%, 89%, 4.1. In the subgroups with moderate, minimal, or no disability, sensitivity and specificity were 37%, 100% and for no or minimal distress 35%, 100%. CONCLUSIONS: Centralization is highly specific to positive discography but specificity is reduced in the presence of severe disability or psychosocial distress.

Chronic Disease↗