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Background

Psychological models predict behaviour in a wide range of settings. The aim of this study was to explore the usefulness of a range of psychological models to predict the health professional behaviour 'referral for lumbar spine x-ray in patients presenting with low back pain' by UK primary care physicians.

Methods

Psychological measures were collected by postal questionnaire survey from a random sample of primary care physicians in Scotland and north England. The outcome measures were clinical behaviour (referral rates for lumbar spine x-rays), behavioural simulation (lumbar spine x-ray referral decisions based upon scenarios), and behavioural intention (general intention to refer for lumbar spine x-rays in patients with low back pain). Explanatory variables were the constructs within the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-Regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Weinstein's Stage Model termed the Precaution Adoption Process (PAP), and knowledge. For each of the outcome measures, a generalised linear model was used to examine the predictive value of each theory individually. Linear regression was used for the intention and simulation outcomes, and negative binomial regression was used for the behaviour outcome. Following this 'theory level' analysis, a 'cross-theoretical construct' analysis was conducted to investigate the combined predictive value of all individual constructs across theories.

Results

Constructs from TPB, SCT, CS-SRM, and OLT predicted behaviour; however, the theoretical models did not fit the data well. When predicting behavioural simulation, the proportion of variance explained by individual theories was TPB 11.6%, SCT 12.1%, OLT 8.1%, and II 1.5% of the variance, and in the cross-theory analysis constructs from TPB, CS-SRM and II explained 16.5% of the variance in simulated behaviours. When predicting intention, the proportion of variance explained by individual theories was TPB 25.0%, SCT 21.5%, CS-SRM 11.3%, OLT 26.3%, PAP 2.6%, and knowledge 2.3%, and in the cross-theory analysis constructs from TPB, SCT, CS-SRM, and OLT explained 33.5% variance in intention. Together these results suggest that physicians' beliefs about consequences and beliefs about capabilities are likely determinants of lumbar spine x-ray referrals.

Conclusions

The study provides evidence that taking a theory-based approach enables the creation of a replicable methodology for identifying factors that predict clinical behaviour. However, a number of conceptual and methodological challenges remain.

Study Design

Cross-sectional survey.

Objective

Our primary objective was to describe spine and pain clinics serving North Carolina residents with respect to organizational characteristics. Our secondary objective was to assess the multidisciplinary nature of the clinics surveyed.

Summary of Background Data

Pain clinics have become common in the United States, and patients with chronic back pain have increasingly been seeking services at these clinics. Little is known about the organizational characteristics of spine and pain clinics.

Methods

We identified and surveyed spine and pain clinics serving North Carolina residents with chronic back and neck pain. Practice managers at 46 clinics completed a 20-minute questionnaire about the characteristics of their clinic, including providers on staff and services offered. Descriptive and exploratory analyses were conducted to summarize the data. Several variables were constructed to assess the multidisciplinary nature of the clinics.

Results

The response rate was 75%. There was marked heterogeneity among the clinics surveyed. Fifty-nine percent of practices were free-standing (n = 27) and 61% were physician-owned (n = 28). Twenty-five clinics (54%) had an anesthesiologist. Other common physician providers were physiatrists and surgeons. Less than one third of sites had mental health providers (n = 12; 26%); only 26% employed physical therapists. Seventy-six percent of sites offered epidural injections, 74% long-term narcotic prescriptions, and 67% antidepressants. The majority of clinics (30 of 33) prescribing narcotics provided monitoring of therapy using periodic urine toxicology testing. Forty-eight percent of sites (n = 22) offered exercise instruction. Few clinics were multidisciplinary in nature. Only 3 (7%) met the criteria of having a medical physician, registered nurse, physical therapist, and mental health specialist.

Conclusion

Clinics varied widely in their organizational characteristics, including providers and scope of services available. Few clinics were multidisciplinary in nature. This information should be used to determine how pain clinics can better serve patients and improve outcomes.

Abstract

Objective

This case study reports the findings of an upper gastrointestinal hemorrhage in a patient with thoracic spine pain reporting to a chiropractic clinic. The purpose of this article is to highlight the importance of identifying a patient's medication history as well as reviewing the signs and symptoms of gastrointestinal bleeding from a nonvariceal lesion.

Clinical Features

A 61-year–old woman presented with worsening middle thoracic spine pain of 3 months' duration along with recent abdominal pain. Medications, physical therapy, and spinal manipulation did not provide considerable improvement. The patient was taking ibuprofen daily to cope with her back pain.

Intervention and Outcome

The initial physical examination demonstrated mild increased tissue tension in the thoracic paraspinal muscles with mild restriction of thoracic spine range of motion secondary to the patient's pain. There was pain on palpation of the T4-5 and T7-8 spinal segments. The physical examination findings did not correlate to the patient's pain presentation, and she was referred back to her primary care physician. Two days after the initial examination, the patient experienced an upper gastrointestinal hemorrhage and underwent emergency surgery. It was determined postoperatively that she had a medication-induced duodenal ulcer that subsequently ruptured.

Conclusion

An upper gastrointestinal bleed should be considered in the differential diagnosis of a patient with a history of prolonged aspirin or nonsteroidal anti-inflammatory drug use with nonspecific abdominal symptoms.

Chondrosarcoma is the third most common primary malignant bone tumor. Yet the spine represents the primary location in only 2% to 12% of these tumors. Almost all patients present with pain and a palpable mass. About 50% of patients present with neurologic symptoms. Chemotherapy and radiotherapy are generally unsuccessful while surgical resection is the treatment of choice. Early diagnosis and careful surgical staging are important to achieve adequate management. This paper provides an overview of the histopathological classification, clinical presentation, and diagnostic procedures regarding spinal chondrosarcoma. We highlight specific treatment modalities and discuss which is truly the most suitable approach for these tumors. Abstracts and original articles in English investigating these tumors were searched and analyzed with the use of the PubMed and Scopus databases with “chondrosarcoma and spine” as keywords.

Mechanical disorders of the lumbar spine have been given much attention in the literature. Short of an acute cauda equina syndrome, few reports exist detailing the findings and clinical course of patients with pelvic and disorders of bladder, bowel and gynecologic/sexual function of spinal origin. Two uncomplicated representative cases of mechanically induced pelvic pain and organic dysfunction (PPOD) in patients presenting with low back pain are detailed. These patients typically reveal a wide range of individual symptoms and demonstrate clinical features characteristic of a mechanical disorder of the lumbar spine as the cause of their PPOD. The clinical features of the mechanically induced PPOD syndrome are reviewed and the response to distractive decompressive manipulation of the lumbar spine is presented.

The purpose of our report is to describe a new application of kyphoplasty, the percutaneous anterolateral balloon kyphoplasty that we performed in two cases of metastatic osteolytic lesions in cervical spine. The first patient, aged 48 years, with primary malignancy in lungs had two metastatic lesions in C2 and C6 vertebrae. Patient’s complaints were about pain and restriction of movements (due to the pain) in the cervical spine. The second patient, aged 70 years, with primary malignancy in stomach, had multiple metastatic lesions in thoracolumbar spine and C3, C4 and C5 vertebrae without neurological symptoms. The main symptoms were from cervical spine with severe pain even in bed rest and systematic use of opiate-base analgesis. The preoperative status was evaluated with X-rays, CT scan, MRI scan and with Karnofsky score and visual analogue pain (VAS) scale. Both patients underwent percutaneous anterolateral balloon kyphoplasty via the anterolateral approach in cervical spine under general anaesthesia. No clinical complications occurred during or after the procedure. Both patients experienced pain relief immediately after balloon kyphoplasty and during the following days. The stiffness also resolved rapidly and cervical collars were removed. VAS score significantly improved from 85 and 95 preoperatively to 30 in both patients. Karnofsky score showed also improvement from 40 and 30 preoperatively to 80 and 70, respectively, at the final follow-up (7 months after the procedure). Fluoroscopy-guided percutaneous anterolateral ballon kyphoplasty proved to be safe and effective minimally invasive procedure for metastatic osteolytic lesions of the cervical spine, reducing pain and avoiding vertebral collapse. Experience and attention are necessary in order to avoid complications.

Langerhans cell histiocytosis (LCH) is extremely rare in the lumbar spine of adults. The radiological features typically manifest as vertebral tumors. The exact etiology of LCH remains unknown. Langerhans cells may cause local or systemic effects. The most frequent sites of these bony lesions are the skull, femur, mandible, pelvis and spine. To date, only 3 spinal LCH cases treated by percutaneous vertebroplasty (PVP) have been reported. The present study reports a case of LCH of the fourth lumbar vertebra (L4) in a 51-year-old male with a 10-day history of low back pain, limited waist motion and right lower limb numbness. The patient was treated using PVP. The use of PVP for treating LCH of the spine was successful. The present study provides an up-to-date literature overview of LCH.

Objective

The purpose of this case report is to describe a case of metastatic non-Hodgkin lymphoma in the lumbar spine presenting as lumbar radiculopathy.

Clinical Features

A 46-year-old man sought care from his doctor of chiropractic for low back pain and right leg radiculopathy. The patient was referred for a magnetic resonance imaging (MRI) scan to evaluate for a suspected disk herniation. The MRI scan revealed 2 lumbar pathologic compression fractures with cauda equina compression, and MRI short tau inversion recovery (STIR) sagittal image of the lumbar spine showed high signal in T12 and S2.

Intervention and Outcome

The patient was referred for an immediate consultation with his medical physician with the preliminary diagnosis of metastatic bone lesions or primary bone lesions of unknown etiology. The patient underwent bone biopsy, computed tomography, and positron emission tomography scanning and was diagnosed with small cell non-Hodgkin lymphoma with osseous metastasis. The patient underwent chemo- and radiation therapy, and the lymphoma is now in remission 18 months later.

Conclusion

This case describes the presentation of metastatic non-Hodgkin lymphoma as a possible contributing cause in a patient presenting with lumbar radiculopathy, a common musculoskeletal condition. As well, this case highlights the importance of STIR sequences as part of a routine lumbar spine MRI examination. Without the STIR sequences, the additional deposits in T12 and S1 would not have been readily appreciated. Although metastatic non-Hodgkin lymphoma of the spine is rare, it should be remembered in the differential diagnoses.

Chronic low back pain is the most common cause of disability in individuals between the ages of 45 and 65. Given the variety of anatomic and pathophysiologic causes of persistent low back pain, it is a difficult diagnosis for clinicians to treat. Discography is a diagnostic option that may link a patient’s subjective complaints of spinal pain to symptomatic disk disease when non-invasive imaging, such as magnetic resonance imaging (MRI), does not find structural abnormalities. A controversial procedure, discography is only necessary to assess painful discs prior to surgical interventions. For accurate discogram interpretation an experienced spine interventionalist must be careful to exclude false positive results and be aware of the patient’s underlying psychological state. This literature review will discuss the following: anatomy and function of the spine and intervertebral disc, intervertebral disc degeneration and discogenic pain, history of discography, indications and contraindications, a description of the procedure, complications, and the current debate regarding its outcomes.

Chondrosarcoma is a rare malignant tumor of bone. This family of tumors can be primary malignant tumors or a secondary malignant transformation of an underlying benign cartilage tumor. Pain is often the initial presenting complaint when chondrosarcoma involves the spine. In the mobile spine, chondrosarcoma commonly presents within the vertebral body and shows a predilection for the thoracic spine. Due to the resistance of chondrosarcoma to both radiation and chemotherapy, treatment is focused on surgery. With en bloc excision of chondrosarcoma of the mobile spine and sacrum patients can have local recurrence rates as low as 20%.

Background

To describe the evaluation, treatment, management and referral of two patients with back pain with an eventual malignant etiology, who were first thought to have a non-organic biomechanical disorder.

Clinical features

The study was a retrospective review of the clinical course of two patients seen by a chiropractor in a multi-disciplinary outpatient facility, who presented with what was thought to be non-organic biomechanical spine pain. Clinical examination by both medical and chiropractic physicians did not indicate the need for radiography in the early course of management of either patient. Upon subsequent re-evaluation, it was decided that certain clinical factors required investigation with advanced imaging.

In one instance, the patient responded to conservative care of low back pain for nine weeks, after which she developed severe pain in the pelvis. In the second case, the patient presented with signs and symptoms consistent with uncomplicated musculoskeletal pain that failed to respond to a course of conservative care. He was referred for medical therapy which also failed to relieve his pain. In both patients, malignancy was eventually discovered with magnetic resonance imaging and both patients are now deceased, resulting in an inability to obtain informed consent for the publication of this manuscript.

Conclusion

In these two cases, the prudent use of diagnostic plain film radiography did not significantly alter the appropriate long-term management of patients with neuromusculoskeletal signs and symptoms. The judicious use of magnetic resonance imaging was an effective procedure when investigating recalcitrant neuromusculoskeletal pain in these two patients.

Objective

The purpose of this case series is to describe the chiropractic management of 21 patients with daily stress and occasional total urinary incontinence (UI).

Clinical Features

Twenty-one case files of patients 13 to 90 years of age with UI from a chiropractic clinic were reviewed. The patients had a 4-month to 49-year history of UI and associated muscle dysfunction and low back and/or pelvic pain. Eighteen wore an incontinence pad throughout the day and night at the time of their appointments because of unpredictable UI.

Intervention and Outcome

Patients were evaluated for muscle impairments in the lumbar spine, pelvis, and pelvic floor and low back and/or hip pain. Positive manual muscle test results of the pelvis, lumbar spine muscles, and pelvic floor muscles were the most common findings. Lumbosacral dysfunction was found in 13 of the cases with pain provocation tests (applied kinesiology sensorimotor challenge); in 8 cases, this sensorimotor challenge was absent. Chiropractic manipulative therapy and soft tissue treatment addressed the soft tissue and articular dysfunctions. Chiropractic manipulative therapy involved high-velocity, low-amplitude manipulation; Cox flexion distraction manipulation; and/or use of a percussion instrument for the treatment of myofascial trigger points. Urinary incontinence symptoms resolved in 10 patients, considerably improved in 7 cases, and slightly improved in 4 cases. Periodic follow-up examinations for the past 6 years, and no less than 2 years, indicate that for each participant in this case-series report, the improvements of UI remained stable.

Conclusion

The patients reported in this retrospective case series showed improvement in UI symptoms that persisted over time.

Facet joint septic arthritis is a rare but severe infection with the possibility of significant morbidity resulting from local or systemic spread of the infection. Pain is the most common complaint on presentation followed by fever, then neurologic impairment. While the lumbar spine is involved in the vast majority of cases presented in the literature, the case presented here occurred in the cervical spine. The patient presented with a three week history of neck and left shoulder pain and was diagnosed by MRI when his pain did not respond to analgesics and muscle relaxants. The only predisposing factor was a history of diabetes mellitus and the infection most likely resulted from hematogenous spread. MRI is highly sensitive in diagnosing septic arthritis and it is the preferred modality for demonstrating the extent of infection and secondary complications including epidural and paraspinal abscesses as seen in this case. Without familiarity with this entity's predisposing factors, clinical symptoms and appropriate lab/ imaging work up, many patients experience a delay in diagnosis. Treatment involves long term parenteral antibiotics or percutaneous drainage. Surgical debridement is reserved for cases with severe neurologic impairment. The incidence of facet joint septic arthritis is increasing likely related to patient factors (increasing number of patients >50 yo, immunosuppressed patients, etc), advancement in imaging technology, availability of MRI, and heightened awareness of this rare infection which is the aim of this case presentation.

The clinical presentation of spinal tumors is known to vary, in many instances causing a delay in diagnosis and treatment, especially with benign tumors. Neck or back pain and sciatica, with or without neurological deficits, are mostly caused by degenerative spine and disc disease. Spinal tumors are rare, and the possibility of concurrent signs of degenerative changes in the spine is high. We report a series of ten patients who were unsuccessfully treated for degenerative spine disease. They were subsequently referred for operative treatment to our department, where an initial diagnosis of a tumor was made. Two patients had already been operated on for disc herniations, but without long-lasting effects. In eight patients the diagnosis of a tumor was made preoperatively. In two cases the tumor was found intraoperatively. All patients showed radiological signs of coexisting degenerative spine disease, making diagnosis difficult. MRI was the most helpful tool for diagnosing the tumors. A frequent symptom was back pain in the recumbent position. Other typical settings that should raise suspicion are persistent pain after disc surgery and neurological signs inconsistent with the level of noted degenerative disease. Tumor extirpation was successful in treating the main complaints in all but one patient. There was an incidence of 0.5% of patients in which a spinal tumor was responsible for symptoms thought to be of degenerative origin. However, this corresponds to 28.6% of all spine-tumor patients in this series. MRI should be widely used to exclude a tumor above the level of degenerative pathology.

Background

Patients with Parkinson’s disease have higher risk of complications and revision surgery following spine surgery. Spinal fracture in an ankylosed spine is also difficult to treat. We recently treated a case of thoracic spine fracture in a patient with Parkinson’s disease complicating a severely ankylosed spine. There is no report describing surgical treatment of spine fracture in such a difficult condition, thus, we firstly report the case and discuss the reasons for a successful result.

Case presentations

A 68-year-old man with Parkinson’s disease had a pathologic thoracic spine fracture at T11. Four days after onset, he was referred to a local hospital because of gradually increasing back pain, but no spinal fracture was pointed out at that time. Because he developed lower extremity bilateral numbness and weakness, he was transported to our hospital, eight days after onset. When referred to our hospital, he exhibited severe back pain and paralysis of the lower extremities due to spinal cord involvement. Emergency surgery was performed. Decompression of T10-11 was performed followed by instrumented spinal fusion from T8 to L2. A dramatic neurological improvement was observed following surgery, and complete bony fusion was achieved. At the final two-year postoperative follow-up, the patient had no pathological symptoms related to spinal fracture and no instrument failure was observed.

Conclusion

This patient had Parkinson’s disease and a severely ankylosed spine, both of which may lead to unsatisfactory surgical results from spinal surgery. Generally, patients with Parkinson’s disease have an increased risk for adjacent segment disease and instrument failure. In this patient, fusion surgery did not change the number of fused segments because operated segments were already ankylosed. Because no stress force exists between adjacent vertebral bodies, a severely ankylosed spine may help prevent screw pullout. Thus, treatment of a spinal fracture in an ankylosed spinal segment is a less adverse condition for patients with Parkinson’s disease. Our experience led us to think that a combination of Parkinson’s disease with severely ankylosed spine does not necessarily suggest unsatisfactory outcomes after surgical treatment of spinal fracture.

Objective

Prostate cancer remains the second leading cause of cancer-related deaths, and African American men are affected with this disease disproportionately in terms of incidence and mortality. The purpose of this article is to present a case report that illustrates the importance of a careful evaluation, including a comprehensive historical review and appropriate physical and laboratory assessment, of a patient with back pain and seemingly unrelated symptoms.

Clinical Features

A 65-year-old African American man presented to a chiropractic clinic after experiencing lower back pain for 1 month. The digital rectal examination was unremarkable, but the serum prostate-specific antigen was markedly elevated. A suspicion of metastatic prostate cancer resulted in subsequent referral, further diagnostic evaluation, and palliation.

Intervention and Outcome

The patient was referred for medical evaluation and palliation of his condition. Spinal decompression surgery of the thoracic spine was initiated, resulting in weakness and paresthesia in the lower limbs bilaterally. The patient died because of the complications associated with the medical interventions and the disease about 12 months after the referral.

Conclusion

Chiropractic physicians should maintain a high degree of suspicion for catastrophic causes of back-related complaints, such as metastatic prostate cancer. The Prostate Cancer Prevention Trial Risk Calculator, a research validated instrument, should be used in the assessment of prostate cancer risk. Performance of the digital rectal examination and of the prostate-specific antigen determination remains integral in the clinical assessment of the health status in aging men, with or without back pain.

Mechanical low back pain is a common indication for Nuclear Medicine imaging. Whole-body bone scan is a very sensitive but poorly specific study for the detection of metabolic bone abnormalities. The accurate localisation of metabolically active bone disease is often difficult in 2D imaging but single photon emission computed tomography/computed tomography (SPECT/CT) allows accurate diagnosis and anatomic localisation of osteoblastic and osteolytic lesions in 3D imaging. We present a clinical case of a patient referred for evaluation of chronic lower back pain with no history of trauma, spinal surgery, or cancer. Planar whole-body scan showed heterogeneous tracer uptake in the lumbar spine with intense localisation to the right lateral aspect of L3. Integrated SPECT/CT of the lumbar spine detected active bone metabolism in the right L3/L4 facet joint in the presence of minimal signs of degenerative osteoarthrosis on CT images, while a segment demonstrating more gross degenerative changes was more quiescent with only mild tracer uptake. The usefulness of integrated SPECT/CT for anatomical and functional assessment of back pain opens promising opportunities both for multi-disciplinary clinical assessment and treatment for manual therapists and for research into the effectiveness of manual therapies.

The high prevalence of neck and low back pain in the rapidly aging population is associated with significant increases in health care expenditure. While spinal imaging can be useful to identify less common causes of neck and back pain, overuse and misuse of imaging services has been widely reported. This narrative review aims to provide primary care providers with an overview of available imaging studies with associated potential benefits, adverse effects, and costs for the evaluation of neck and back pain disorders in the elderly population. While the prevalence of arthritis and degenerative disc disease increase with age, fracture, infection, and tumor remain uncommon. Prevalence of other conditions such as spinal stenosis and abdominal aortic aneurysm (AAA) also increase with age and demand special considerations. Radiography of the lumbar spine is not recommended for the early management of non-specific low back pain in adults under the age of 65. Aside from conventional radiography for suspected fracture or arthritis, magnetic resonance imaging (MRI) and computed tomography (CT) offer better characterization of most musculoskeletal diseases. If available, MRI is usually preferred over CT because it involves less radiation exposure and has better soft-tissue visualization. Use of subspecialty radiologists to interpret diagnostic imaging studies is recommended.

The following paper is a case study of a patient with a history of chronic headaches (originally diagnosed as migraine without aura) who was being treaded at the Macquarie University Chiropractic Outpatients Clinic for cervical spine dysfunction. The treatments successfully reduced the upper neck and thoracic pain that the patient was experiencing and for which they had initially presented at the clinic. During the treatments, the patient also showed a significant subjective reduction in prevalence and intensity of headaches over a four month period. Analysis of the outcome is complicated by the fact that it is not clear whether the patient’s headaches were initially misdiagnosed as common migraine when in fact, they were cervicogenic. There may be some overlap between the two conditions, and a possible causative relationship between cervical spine dysfunction and common migraine. Furthermore, this case study discusses the validity of chiropractic treatment of organic disorders such as chronic headache or migraine.

Objective

Lumbosacral transitional vertebrae (LSTV) are relatively common skeletal anomalies with a debated role in low back pain. There are few documented cases of conservative care being used to address LSTV-associated symptomatology. The current report discusses chiropractic management of 2 patients with unilateral sacralization.

Clinical Features

Two patients with LSTV involving unilateral sacralization of L5, a Castellvi type IIIa variant, presented with back pain to a chiropractic clinic. Each case presented with symptomatology similar to piriformis syndrome.

Intervention and Outcome

Manual therapy, including spinal manipulation soft tissue therapies and exercise/stretching, was used to address the presenting symptoms. Approximately 2 weeks after initial treatment, the first patient subjectively reported a 70% improvement in symptoms, with lumbar extension increased to full in active range of motion at the lumbar spine but with continued tenderness and hypertonicity at the left piriformis and gluteus medius. After 4 weeks of treatment, the second patient reported improvement in pain and perceived mobility, although prolonged standing remained an aggravating factor. Although both showed improvement, neither case resulted in complete resolution of symptoms.

Conclusion

The presenting cases demonstrated partial resolution of symptoms after chiropractic management. It is proposed that sacralization is a possible cause of back pain in these cases.

Objective

To test the hypothesis that radiography of the lumbar spine in patients with low back pain is not associated with improved clinical outcomes or satisfaction with care.

Design

Randomised unblinded controlled trial.

Setting

73 general practices in Nottingham, north Nottinghamshire, southern Derbyshire, north Lincolnshire, and north Leicestershire. 52 practices recruited participants to the trial.

Subjects

421 patients with low back pain of a median duration of 10 weeks.

Intervention

Radiography of the lumbar spine.

Main outcome measures

Roland adaptation of the sickness impact profile, visual analogue scale for pain, health status, EuroQol, satisfaction with care, use of primary and secondary care services, and reporting of low back pain at three and nine months after randomisation.

Results

The intervention group were more likely to report low back pain at three months (relative risk 1.26, 95% confidence interval 1.00 to 1.60) and had a lower overall health status score and borderline higher Roland and pain scores. A higher proportion of participants consulted their doctor in the three months after radiography (1.62, 1.33 to 1.97). Satisfaction with care was greater in the group receiving radiography at nine but not three months after randomisation. Overall, 80% of participants in both groups at three and nine months would have radiography if the choice was available. An abnormal finding on radiography made no difference to the outcome, as measured by the Roland score.

Conclusions

Radiography of the lumbar spine in primary care patients with low back pain of at least six weeks' duration is not associated with improved patient functioning, severity of pain, or overall health status but is associated with an increase in doctor workload. Guidelines on the management of low back pain in primary care should be consistent about not recommending radiography of the lumbar spine in patients with low back pain in the absence of indicators for serious spinal disease, even if it has persisted for at least six weeks. Patients receiving radiography are more satisfied with the care they received. The challenge for primary care is to increase satisfaction without recourse to radiography.

A 50-year-old multiparous woman presented with a 3 month history of back pain. She was initially treated for non-mechanical back pain by her primary care physician, but was subsequently discovered to have a right sided clinical breast cancer and palpable axillary lymphadenopathy. An oestrogen/progesterone receptor positive invasive ductal carcinoma with axillary metastatic disease was confirmed on breast clinic triple assessment. Magnetic resonance imaging of the spine revealed an L1 vertebral body metastatic fracture with cord compression and other axial and non-axial stable skeletal metastases. The patient underwent immediate orthopaedic spinal stabilisation with full resolution of her back pain, and began primary endocrine breast cancer therapy with outpatient spinal radiotherapy planned.

Centralization of referred pain or failure to centralize has in earlier studies been shown to be a predictor of low back pain prognosis. Research suggests that there are differences in how males and females experience pain. The aim of this study was to evaluate the outcome after 1 year, and to evaluate the prognostic value of the pain response in a mechanical test at the first consultation at a spine clinic, and the influence of gender, in order to identify patients with especially high risk of chronicity. The patients in this study were low back pain patients, included consecutively from a spine clinic in Northern Denmark. The criteria for entering this spine clinic were neck or low back pain with radiating symptoms and a duration of 4–26 weeks, without satisfactory improvement after treatment in the primary care system. The 793 patients were categorised into four subgroups according to their pain response in a mechanical test performed at the initial examination: centralization, non-lasting centralization, peripheralization and no effect. The patients were instructed in doing specific exercises according to the test results. The four subgroups were compared after 1 year with regard to changes in back and leg pain, disability and return-to-work status. The statistical evaluation was undertaken for the study group as a whole and stratified according to gender. A significant improvement in all outcome measures was found in all the subgroups, among both men and women. There were no systematic or statistically significant differences in the prognosis between the four subgroups of patients. The proportion of Centralizers in this study was 18%. The mechanical test at baseline is important for deciding the subject-specific exercises, but when treated according to test results, the prognostic value of the test seems limited.

Objective: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis.

Clinical presentation: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department.

Intervention: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion.

Conclusion: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.

Chronic neck pain is widely prevalent and a common source of disability in the working-age population. Etiology of chronic neck pain includes neck sprain, mechanical or muscular neck pain, myofascial pain syndrome, postural neck pain as well as pain due to degenerative changes.

We report the case of a 42 year old secretary, complaining about a longer history of neck pain and limited movement of the cervical spine. Surprisingly, the adequate radiologic examination revealed a bilateral ossification of the stylohyoid ligament complex. Her symptoms remained intractable from conservative treatment consisting of anti-inflammatory medication as well as physical therapy. Hence the patient was admitted to surgical resection of the ossified stylohyoid ligament complex. Afterwards she was free of any complaints and went back to work.

Therefore, ossification of the stylohyoid ligament complex causing severe neck pain and movement disorder should be regarded as a rare differential diagnosis of occupational related neck pain.