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Background Sacroiliac joint (SIJ) pathology is a cause of low back pain that may be difficult to diagnose and challenging to treat. Open and minimally invasive (MI) lateral approach fusions have been used to treat sacroiliitis over the past two decades. A novel MI posterior approach SIJ fusion technique utilizes a posteriorly placed transfixing device with single point S1/S2 level or mid-segment SIJ fixation (LinQ procedure). Current efficacy and safety data for this novel procedure are lacking. Objective To review multicenter retrospective 12 months or greater outcomes data in patients receiving the LinQ procedure, with sub-analysis of patients with prior lumbar fusions. Methods Patients with sacroiliitis refractory to conservative care with short-term benefit from diagnostic local anesthetic SIJ injections receiving MI posterior approach SIJ fusion with allograft were included from different centers including both academic and private practice. Numeric rating scale (NRS) scores at baseline (pre-procedural) and most recent follow-up were reviewed across three institutions. Results Of 110 patients who received MI SIJ fusion, 50 patients had sufficient data for evaluation of outcomes at least 12 months post-implant. The average time out from implant at follow-up was 612.2 days for all unique patients. The average NRS was 6.98 pre-fusion and 3.06 at last follow-up. Twenty-four patients had prior lumbar surgery of which 17 had prior lumbar fusions. Average NRS for this subset was 6.85 at baseline and 2.86 at last follow-up with an average follow-up of 613.2 days out from implant. No major adverse events or complications were associated with any of the 50 implants. Conclusion Real-world evidence suggests that MI posterior SIJ fusion with the LinQ procedure is a viable approach for medically refractory sacroiliitis management with long-term efficacy and safety. Further prospective studies are needed to fully evaluate this technique.

Author(s): Barash, Ashley; Stern, Evan; Hoelle, Robyn | Abstract: Introduction: Acute bacterial prostatitis is characterized by acute inflammation of the prostate gland accompanied by the presence of pain and other urinary tract or systemic symptoms. Prostatitis is a relatively common disease of the urinary tract in men, However, this case reports a man diagnosed with acute bacterial prostatitis with an unusual presentation, as well as an unusual pathogen and a unique mechanism of colonization.Case Report: A 52-year-old male with no past medical history presented to our facility for right-sided buttock pain associated with dysuria, diarrhea, and perianal burning. The patient was diagnosed with sepsis secondary to acute bacterial prostatitis, and the pathogen identified in his urine was Aeromonas hydrophila/A. caviae. His disease process was later recognized as a complication of the use of a P-valve condom catheter while freshwater cave diving.Conclusion: This is the first documented case of prostatitis as a result of the use of a P-valve condom catheter while diving. Furthermore, the pathogen identified is of particular interest as there are very few documented cases of urosepsis secondary to Aeromonas hydrophila or A. caviae.

Objective: In recent years, there has been an increase in research on the therapeutic effects of exergaming, but there have been few studies on these types of interventions for chronic low back pain. In this study, we hypothesized that the Nintendo Ring Fit Adventure (RFA) exergame would be effective for patients with chronic low back pain, and we conducted a randomized prospective longitudinal study. Materials and Methods: Patients with chronic low back pain were included in this study. Twenty randomly selected patients (9 males and 11 females, mean age 49.3 years) were included in the RFA group, and RFA exergaming was performed once a week for 40 minutes for 8 weeks. Twenty patients (12 males and 8 females, mean age 55.60 years) served as the control group and received oral treatment for 8 weeks. Pain and psychological scores (pain self-efficacy, pain catastrophizing, and kinesiophobia) were measured and analyzed before and after 8 weeks of treatment in both groups. Results: In the RFA group, low back pain, buttock pain, and pain self-efficacy were significantly improved after 8 weeks of RFA exergaming, but there was no significant improvement in lower limb numbness, pain catastrophizing, or kinesiophobia. In the control group, no significant improvement was observed after 8 weeks of oral treatment. Conclusion: RFA exergaming increased pain self-efficacy and reduced pain in patients with chronic low back pain. Future treatment protocols should be developed to improve pain self-efficacy. Approval code: 2894, School of Medicine, Chiba University.

Entrapment of the middle cluneal nerve (MCN), a peripheral nerve in the buttock, can elicit low back pain (LBP). We examined the epidemiology, clinical course, and treatment of MCN entrapment (MCN-EN). Among 383 LBP patients who visited our institute, 105 were admitted for intractable LBP. They were 42 men and 63 women; their average age was 64 years. Based on clinical symptoms, palpation, and the effects of MCN block, we suspected MCN-EN in these 105 patients, 50 of whom are our study subjects. Their treatment outcomes were assessed at the time of discharge and at follow-up visits. MCN-EN was diagnosed in 50 of the 383 patients (13.1%) and they were hospitalized. In 43 (11.2%), MCN-EN was associated with other diseases (superior cluneal nerve entrapment, n = 21, sacroiliac joint pain, n = 9, other, n = 13). At the time of discharge, the symptoms of patients with LBP due to MCN-EN were significantly improved by repeat MCN blocks. In 7 of the 383 patients (1.8%), LBP was improved by only MCN blocks; 5 of them had reported leg symptoms in the dorsal part of the thigh. After discharge, 22 of the 50 hospitalized patients required no additional treatments after 2–5 blocks; 19 required only conservative treatment, and 9 underwent microsurgical release of the MCN. We confirmed MCN-EN in 50 of 105 patients admitted for intractable LBP. Repeat MCN blocks were effective in 22 patients; 19 required additional conservative treatment, and 9 underwent surgery. Buttock pain radiating to the posterior thigh was an MCN-EN symptom that has been diagnosed as pseudo-sciatica. Before subjecting patients with intractable LBP to surgery, the presence of MCN-EN must be ruled out.

Axial spondyloarthritis (axSpA) is an important cause of chronic low back pain and affects approximately 1% of the US population. The back pain associated with axSpA has a characteristic pattern referred to as inflammatory back pain (IBP). Features of IBP include insidious onset before age 45 years, association with morning stiffness, improvement with exercise but not rest, alternating buttock pain, and good response to treatment with nonsteroidal anti-inflammatory drugs. In patients with IBP, it is essential to look for other features associated with spondyloarthritis (SpA), such as enthesitis, dactylitis, peripheral arthritis, extra-articular manifestations (eg, psoriasis, uveitis, or inflammatory bowel disease), human leukocyte antigen B27 positivity, and a family history of SpA. Axial SpA is underrecognized, and a delay of several years between symptom onset and diagnosis is common. However, with new and effective therapies available for the treatment of active axSpA, early recognition and diagnosis are of critical importance. For this narrative review, we conducted a literature search of English-language articles using PubMed. Individual searches were performed to identify potential articles of interest related to axSpA (search terms: ["axSpA" OR "axial SpA" OR "axial spondyloarthritis" OR "ankylosing spondylitis"]) in combination with terms related to IBP ("inflammatory back pain" OR "IBP" OR "chronic back pain" OR "CBP" OR "lower back pain" OR "LBP"), diagnosis (["diagn∗" OR "classification"] AND ["criteria" OR "recommend∗" OR "guidelines"]), and referral ("refer∗"). No date range was formally selected, as we were interested in providing an overview of the evolution of these concepts in clinical practice. We supplemented the review with insights based on our clinical expertise. Patients with chronic back pain should be screened for IBP and other SpA features; suspicion for axSpA should trigger referral to a rheumatologist for further evaluation.

Hip preservation surgery is now an established part of orthopedic surgery and sports medicine. This report describes the key findings of the 11th Annual Scientific Meeting of International Society for Hip Arthroscopy—the International Hip Preservation Society—in Madrid, Spain from 16 to 19 October 2019. Lectures, seminars and debates explored the most up-to-date and expert views on a wide variety of subjects, including: diagnostic problems in groin pain, buttock pain and low back pain; surgical techniques in acetabular dysplasia, hip instability, femoroacetabular impingement syndrome, labral repair and reconstruction, cartilage defects, adolescent hips and gluteus medius and hamstring tears; and new ideas about femoral torsion, hip–spine syndrome, hip capsule surgery, impact of particular sports on hip injuries, registries, robotics and training for hip preservation specialists. Surgeons, sports physicians, radiologists and physiotherapists looking after young people with hip problems have an increasingly sophisticated armoury of ideas and techniques with which to help their patients. The concept of hip preservation has developed incredibly fast over the last decade; now it is clear that the best results can only be achieved by a multidisciplinary team working together. The 2020s will be the decade of ‘Teamwork in Hip Preservation’.

Objective There is currently no consensus regarding surgical indications for symptomatic sacral perineural cysts. Methods Nine patients with symptomatic sacral perineural cysts underwent microsurgery. All patients fulfilled the following criteria: (1) cyst sizes larger than 15 mm; (2) cysts show the “delayed inflow” and/or “delayed outflow” of contrast on myelographic computed tomography (CT), and (3) neurological symptoms correlate with the primary cyst. Results On myelographic CT, all primary cysts showed the “delayed inflow” of contrast; the average cyst/thecal sac Hounsfield units (HU) ratio was 0.17. In 7 patients, the primary cyst showed “delayed outflow”; the average cyst/thecal sac HU ratio increased to 3.12 on images obtained 24 hours after contrast injection. Regarding the modified Rankin Scale, 67% of patients reported that their overall symptoms improved to normal activities after surgery. The most improved symptom was coccydynia (75% improvement, P = 0.017), followed by leg radiation pain (67% improvement, P = 0.027) and buttock pain (50% improvement, P = 0.068). Bowel/bladder dysfunction improved in 100% of patients, but newly developed in 1 patient (P = 0.32). Perineal pain only decreased in 33% (P = 0.41). Conclusions To the best of our knowledge, this is the first study to have performed a quantitative analysis of the dynamics of cerebrospinal fluid in sacral perineural cysts using myelographic CT. Sixty-seven percent of patients benefited from surgery; however, our criteria may not be a necessary and sufficient condition for patient selection because 33% did not respond to surgery despite the successful elimination of the check-valve.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To evaluate the efficacy of the postoperative single-shot bolus of epidural Fentanyl and Bupivicaine in providing pain relief postlumbar decompression surgery. SUMMARY OF BACKGROUND DATA: Despite lumbar decompression's success in alleviating symptoms of sciatica, radiculopathy, and neurogenic claudication, transient back and buttock pain has been a common complaint postoperatively. Providing good postoperative pain alleviation predicts patient's quality of recovery. METHODS: We performed a randomized, double-blinded, clinical trial. Forty-five patients scheduled for lumbar decompression for a year's period who were randomly assigned to receive a postoperative bolus of 10-mL solution of 50 mcg of Fentanyl, 0.125% Bupivacaine, and 0.9% saline solution via an intraoperatively placed epidural catheter immediately after wound closure, before dressing application. Facial pain scale scores (from 0 to 10) were measured at three time points after surgery (fully awake at recovery room, transfer to ward, first postoperative day). Postoperative need for oral analgesics, time to independent ambulation, associated adverse events, and time to hospital discharge were also evaluated. RESULTS: Pain scores were noted to be significantly lower at all time points in the epidural group (P 

A 73-year-old woman underwent deformity correction surgery (anterior lumbar interbody fusion of L2-L3-L4-L5-S1, pedicle subtraction osteotomy at L4, and posterior screw fixation from T10 to the pelvis) due to lumbar degenerative flat-back. Following the operation, the patient experienced pain in her back and buttocks, for which she regularly took medications. She reported frequently feeling a heavy and stretched sensation of pain after the operation in those areas, which made her regret undergoing the operation. However, at 33 months postoperatively, she reported that one day, while getting up from a chair, she felt a crack in her back, which was followed by an improvement in her back and buttock pain; thereafter, she stopped taking pain medications. Follow-up radiography revealed a bilateral rod fracture at the L4–5 level on the right side and at the L3–4 level on the left side. The overall pelvic parameters, except pelvic incidence, slightly changed after the rod fracture. Therefore, the broken rod was replaced and another rod was added to the broken rod area; however, the changed pelvic parameters were not corrected further during the reoperation. Following the reoperation, the patient showed improvements and she no longer required pain medication.

ObjectiveTo evaluate the clinical characteristics of juvenile-onset non-radiographic axial spondyloarthritis (nr-axSpA) and to investigate risk factors associated with progression to juvenile-onset ankylosing spondylitis (JoAS).MethodsA nested case–control study was conducted using the retrospectively collected data of 106 patients with juvenile-onset nr-axSpA (age at disease onset, ResultsOverall, 58.5% of patients with juvenile-onset nr-axSpA presented with peripheral symptoms at disease onset. In 82.1% of these patients, axial with peripheral involvement occurred during the disease course. The rate of disease onset at >12 years and disease duration of ≤10 years were significantly higher in those with progression to JoAS than in those without progression to JoAS (83.0% vs 52.8%, p=0.001; 92.5% vs 56.6%, pConclusionPeripheral involvement was prevalent in juvenile-onset nr-axSpA. IBP, buttock pain, enthesitis, elevated baseline CRP levels and SIJ-MRI positivity in patients with the disease are associated with higher risk of progression to JoAS.

Psoriatic arthritis is chronic inflammatory condition affecting multiple tissues including skin and joints. Axial psoriatic arthritis (axPsA) forms part of the SpA spectrum, may occur in the form of spondylitis with or without sacroiliitis. Spondylitis presents clinically with spinal stiffness and pain, while sacroiliitis causes alternating buttock pain. Although different classification criteria have been used for axPsA, a clear distinction is still not available. Spondylitis occurs in 40% of patients with PsA and may result in fusion of the vertebrae. These manifestations may be present on radiological examination without symptoms or signs. Some patients had silent axial disease, thus it was suggested that in order to identify axPsA, recognition of which has prognostic value, rheumatologists should consider conducting axial imaging for all patients with PsA regardless the presence of back pain. Aim of the work: To study spinal involvement in patients with psoriatic arthritis clinically and radiographically.Patients and MethodsPatients:Fifty patients diagnosed with PsA according to the classification criteria for psoriatic arthritis (CASPAR) were enrolled. Patients were classified into three groups based on the absence or presence of spinal involvement clinically and/or radiographically: Group (Ι): patients with peripheral PsA (pPsA) only.Group (ΙI): PsA patients with radiographic axial involvement (AxPsA-R) Group (ΙII): PsA patients with clinical and radiographic axial involvement (AxPsA-CR). Patients with orthopedic diseases or other rheumatic disorders affecting the spine and psychiatric and neurological disorders were excluded.

Dengue virus infection is an arthropod-born infection with high global prevalence. A spectrum of clinical syndromes and complications were recognized following dengue fever that can range from undifferentiated fever to dengue shock syndrome. Neurological complications following dengue fever can extend to various sequelae, including transverse myelitis. We report a 20-year-old pregnant woman with a recent diagnosis of dengue hemorrhagic fever (DHF) at the period of amenorrhea (POA) of 28 weeks, presenting with left-sided severe buttock pain. Following extensive investigations, we found left-sided sacroiliitis to be the cause of the buttock pain. She completely recovered with appropriate management.

A retrospective analysis of prospectively collected data from patients aged 12-30 years, operated for AIS in our hospital from 2005 to 2014 and registered in our local patient outcomes database linked to EUROSPSINE's Spine Tango Registry.To investigate whether in patients with AIS and notable back pain surgery is associated with significant pain relief and whether age influences outcome.Few studies have investigated the association between adolescent idiopathic scoliosis and back pain and the influence of age on the relief of back pain after surgical correction of the deformity.Preoperatively and up to two years' postoperatively, patients completed the Core Outcome Measures Index, which includes two 0-10 scales for back pain and leg/buttock pain. A score of 4/10 or more is considered "relevant pain."We identified 85 patients with AIS (74 (87%) females) in the database; 60 were aged 12-18 years (mean 15.5 ± 1.7 years) and 25 were 19-30 years (mean 22.5 ± 3.1 years). There were no significant differences (p.05) between the age groups for coronal Cobb angles of the main curves or Lenke curve types, and these curves showed no correlation with pain intensity (p.05). Back pain was correlated with age (r = 0.31, p = .004). Preoperatively, 42% patients had a back pain score of ≥4/10 (52% in adults, 38% in adolescents). Just 8% patients had a leg pain score of ≥4/10 (16% in adults, 5% in adolescents). Those with notable back pain showed a significant (p.0001) improvement two years after surgery. However, 24% of patients with no back pain at baseline showed a worsening of pain by 2 (out of 10) points or more two years postoperatively. There was no significant difference in the extent of improvement in older and younger patients (p = .22).In patients undergoing surgery for correction of AIS, back pain is correlated with age. In those with relevant back pain at baseline, surgery is associated with a statistically significant and clinically relevant reduction of pain 24 months later, in skeletally mature young adults and adolescents alike.Level III.

Low back pain is one of the causes of Piriformis syndrome. Low back pain is the second most common medical complaints encountered by physicians. More than 50% of the population will complain of low back pain at the same time. Piriformis syndrome may constitute up to 5% of cases of low back pain, buttock pain, and lower limb pain. This is a prospective and case–control study. In this study, we study 268 cases with low back pain; in 268 cases, seven cases had Piriformis syndrome. We studied pain, severity pain, radicular pain, limping, and painful sitting. Evaluation of musculoskeletal, BMI, and physical examination of Piriformis sign, Freiberg sign, and pace sign. Neurological evaluation was taken by paraclinical examination elevated through X-ray, computed tomography scan, magnetic resonance imaging, and electromyography. Data as mean + standard deviation. And SPSS software for analysis. In 268 cases with conservative method, 100% of cases were cure treatment after 4 months, in contrast to surgery methods after 1 month. The result illustrated the significantly improved between two methods of treatment (P < 0.0025). In seven cases, four cases had a history of blunt trauma and one case had a history of surgery that after 6 months had complication of surgery and scare tissue that with the second surgery release of scare was done with 100% cure. Anomaly of Piriformis muscle was seen in one case that surgery was done. Tumor was seen in one case that had pressure effect on sciatic nerve that surgery was done. Heterotopic ossification was seen in two cases. BMI of all cases was in normal range. All cases with diagnosis of disc herniation were excluded from the study. They were need to surgical operation for herniated disc. Piriformis syndrome is differentiated primary from secondary type, in which it is done according to history and physical examination. According to the etiology of Piriformis syndrome, the treatments are different. If you see mass that compressed the sciatic nerve, you must remove it. If the patient had sacroiliitis, it must be treated in early phase. Surgery of Piriformis is not accepted by all surgeons. It is limited to release Piriformis tendon and insertion to femur.

BACKGROUND Leg pain associated with walking is sometimes incorrectly attributed to hip osteoarthritis (OA) or lumbar spinal stenosis (LSS). PURPOSE This study compared physicians' values of signs and symptoms for diagnosing and differentiating hip OA and LSS to their clinical utility. STUDY DESIGN/SETTING Musculoskeletal physicians were surveyed with online questionnaires. Patients were recruited from hip and spine specialty practices. PATIENT SAMPLE Seventy-seven hip OA and 79 LSS patients. OUTCOME MEASURES Signs and symptoms of hip OA and LSS. METHODS Fifty-one of 66 invited musculoskeletal physicians completed online surveys about the values of 83 signs and symptoms for diagnosing hip OA and LSS. Of these, the most valued 32 symptoms and 13 physical examination items were applied to patients with symptomatic hip OA or LSS. Positive likelihood ratios (+LR) were calculated for each items' ability to differentiate hip OA from LSS, with a +LR>2 set as indicating usefulness for favoring either diagnosis. Positive LRs were compared with surveyed physicians' values for each test. RESULTS All symptoms were reported by some patients with each diagnosis. Only 11 of 32 physician-valued symptoms were useful for discriminating hip OA from LSS. Eight symptoms favored hip OA over LSS: groin pain (+LR=4.9); knee pain (+LR=2.2); pain that decreased with continued walking (+LR=3.9); pain that occurs immediately with walking (+LR=2.4); pain that occurs immediately with standing (+LR=2.1); pain getting in/out of a car (+LR=3.3); pain with dressing the symptomatic leg (+LR=3.1); and difficulty reaching the foot of the symptomatic leg while dressing (+LR=2.3). Three symptoms favored LSS over hip OA: pain below the knee (+LR=2.3); leg tingling and/or numbness (+LR=2.7); and some pain in both legs (+LR=2.5). Notable symptoms that did not discriminate hip OA from LSS included: pain is less while pushing a shopping cart (+LR=1.0); back pain (+LR=1.1); weakness and/or heaviness of leg (+LR=1.1); buttocks pain (+LR=1.2); poor balance or unsteadiness (+LR=1.2); pain that increased with weight-bearing on the painful leg (+LR=1.3), and step to gait on stairs (+LR=1.7). Consistent with physicians' expectations, 7 of 13 physical examination items strongly favored hip OA over LSS: limited weight-bearing on painful leg when standing (+LR=10); observed limp (+LR=9); and painful and restricted range-of-motion with any of five hip maneuvers (+LR range 21–99). Four of five tested neurological deficits (+LR range 3–8) favored the diagnosis of LSS over hip OA. CONCLUSIONS There is substantial crossover of symptoms between hip OA and LSS, with some physician-valued symptoms useful for differentiating these disorders whereas others were not. Physicians recognize the value of the examination of gait, the hip, and lower extremity neurological function for differentiating hip OA from LSS. These tests should be routinely performed on all patients for which either diagnosis is considered. Awareness of these findings might reduce diagnostic errors.

Background: Minimally invasive sacroiliac joint (SIJ) fusion (SIJF) has become an increasingly accepted surgical option for chronic SI joint dysfunction, a prevalent cause of chronic low back/buttock pain. Objective: To report clinical and functional outcomes of SIJF using 3D-printed triangular titanium implants (TTI) for patients with chronic SI joint dysfunction. Methods: A total of 28 subjects with SIJ dysfunction at 8 centers underwent SIJF with 3D TTI and had scheduled follow-up to 6 months (NCT03122899). Results: Mean preoperative SIJ pain score was 79.1 and mean preoperative Oswestry Disability Index (ODI) was 49.9. At 6 months, pain scores decreased by 51 points and ODI decreased by 23.6 points (both p

Sacroiliac joint (SIJ)-related pain is associated with low back- and buttock pain and the SIJ score is diagnostically useful because it helps to differentiate between SIJ-related pain and pain due to other factors such as lumbar disc herniation and lumbar spinal canal stenosis. Middle cluneal nerve (MCN) entrapment (MCN-E) can produce pain involving the lower back and buttocks. Therefore, the origin of the pain must be identified. We successfully treated patients with a high SIJ score whose pain was attributable to MCN-E. Between August 2016 and June 2017, we treated 40 patients with non-specific low back pain. Among them, 18 (45%) presented with a positive SIJ score. Although SIJ treatment was unsuccessful in 4 of these patients, they responded to MCN-E treatment. All 4 patients reported tenderness at the site of the sacrotuberous ligament (STL); 3 were positive for the one-finger test and experienced pain while sitting in a chair. The effect of SIJ block was inadequate in the 4 patients. As they reported severe pain at the trigger point in the area of the MCN, we performed MCN blockage. It resulted in pain control. However, in 1 patient, the effect of MCN block was transient and required MCN neurolysis. At the last visit, our patients’ symptoms were significantly improved; their average numerical rating scale score fell from 8.3 to 1.0, their Roland-Morris Disability Questionnaire score fell from 12.8 to 0.3, and their average Japanese Orthopaedic Association score rose from 12.5 to 19.5. In patients with suspected SIJ-related pain, the presence of MCN-E must be considered when the effect of SIJ block is unsatisfactory.

Intradural disk herniation is a rare entity with0.3%-1% of all disk herniations and at an L2-L3 level even rarer. The dural defects repairs on ventral aspect are technically challenging and may not be possible after durotomy, so many authors have placed fascia, muscle, or plugging by the hemostatic material. The surgical treatment of intradural disk herniation is usually posterior open surgery with formal durotomy to remove the disk fragments with good to fair results. Poorer outcome occurs in late-presenting cases.We report on a 78-year-old man who presented with spontaneous low back pain and bilateral buttock pain aggravated for 1 month with severe walking difficulty without bowel and bladder symptoms. Magnetic resonance imaging revealed disk herniation at the L2-L3 level. He underwent a transforaminal endoscopic removal of intradural disk fragments via the original rent in the anterolateral aspect of the dura, and sealing was performed with dural patch and Gelfoam without any lumbar drain. The patient's symptom significantly improved postoperatively with muscle power improved to grade 5 on day 1 with no cerebrospinal fluid leakage, and he was mobilized with a lumbar orthosis on the first postoperative day. Postoperative and at 6-month follow-up, magnetic resonance imaging revealed adequate decompression and successful sealing of the ventral dural defect.To our knowledge, this is the first case of transforaminal endoscopic treatment of intradural disk herniation at an L2-L3 level in which good clinical outcomes were obtained and maintained until recent follow-up of 8 months.

Background/Aims Hypophosphatasia is a metabolic bone disease caused by mutations in the gene encoding tissue-nonspecific alkaline phosphate (TNSALP). Adults present with a variety of manifestations including musculoskeletal pain, calcium pyrophosphate disease (CPPD), dental problems and low trauma fractures. The characteristic finding in hypophosphatasia is a persistently low ALP. Due to the non-specific presentation, hypophosphatasia diagnoses are often delayed and this can result in misdiagnosis and incorrect treatment decisions. This is particularly significant in patients presenting with musculoskeletal pain. Methods Here we present 12 adults diagnosed with hypophosphatasia after referral to our general rheumatology clinic with musculoskeletal pain over the past decade. A persistently low ALP was established in all patients. Hypophosphatasia was diagnosed by an elevated fasting vitamin B6 and/or a positive genetic test. All patients had a normal DEXA scan. Results 11 patients were female and 1 was male.The average age at presentation to rheumatology clinic was 42 years. All patients had a consistently low ALP. This was first documented at the mean age of 39 years. Mean ALP across all patients was 24 U/L (normal range 60-35). ALP range for all patients was Conclusion Our patients experienced a significant diagnostic delay even after the establishment of a persistently low ALP. Various musculoskeletal symptoms were seen and a diagnosis of CPPD was common, affecting 7 of 12 patients (58%). Patients with hypophosphatasia, presenting to rheumatology clinic with musculoskeletal pain, experience significant diagnostic delay. This can be shortened by considering their pain in conjunction with a persistently low ALP, a history of pain earlier in life, dental problems, fractures, CPPD and a positive family history of dental problems, fractures or arthritis. Disclosure A. Rauf: None. K.E. Moss: None.

Cellulitis and abscess are common skin infections in military populations. Although complications of necrotizing soft tissue infections (NSTIs) such as Fournier Gangrene (FG) are rare, they are associated with significant morbidity and mortality. Laboratory and radiological studies may aid in the evaluation of NSTI; however, focus should remain on physical examination and prompt surgical consultation, as these infections can spread rapidly with significant increases in mortality with delayed management. We present the case of a 37-year-old male soldier with reported history of two distant left inguinal hernia repairs, complaining of increasing buttock pain despite outpatient antibiotic therapy for perineal cellulitis from his primary clinician. Despite normal vital signs and low risk from established NSTI calculator scores, examination revealed crepitus and severe tenderness extending from the buttock through the perineum and scrotum characteristic of FG. Preoperative computed tomography found additional spread of subcutaneous air from these areas into the lower abdomen, likely facilitated by the previously repaired left inguinal hernia. Surgical management necessitated debridement, multiple washouts, and ileostomy. Follow-up evaluations revealed previously undiagnosed Crohn’s disease with fistula-in-ano as the inciting factor.

The gluteus medius muscle is located in the buttock; it connects the iliac bone and the femoral head. It partially runs under the gluteus maximus muscle; its surface is covered by a hard gluteal aponeurosis. This muscle may elicit buttock pain on the affected side without paresis. Gluteus medius muscle loading exacerbates the pain that radiates to the lateral or posterior thigh. Patients may experience intermittent claudication. Gluteus medius muscle pain may be misdiagnosed as lumbar spine disease. The diagnosis is based on clinical symptoms. There is a trigger point at the gluteus maximus muscle edge at the same distance from the greater trochanter and the iliac crest. Symptom alleviation by gluteus medius muscle block confirms the diagnosis. The specific treatment for gluteus medius muscle pain is muscle block and decompression surgery under local anesthesia. The etiology of gluteus medius muscle pain is still unknown; chronic compartment syndrome of the gluteus medius muscle due to overloading may be involved. In some patients, gluteus medius muscle pain coexists with other diseases, and combined treatment for concurrent diseases is required.

The middle cluneal nerve (MCN), a pure sensory nerve, originates from the dorsal root nerves of S1–S4. As its entrapment around the sacroiliac joint can produce low back pain (LBP), it may often be the cause of LBP of unidentified origin. Symptoms of MCN entrapment (MCN-E) are medial buttock pain and, in some cases, leg symptoms. They are exacerbated by lumbar movements. Because they are similar to the symptoms of lumbar spine disease, they are easily attributed to that disease. The symptoms of MCN-E and sacroiliac joint pain are also similar, and a differential diagnosis is important. The diagnosis of MCN-E is based on clinical symptoms. Trigger point pain at the entrapment point (approximately 35 mm caudal from the posterior superior iliac spine at slightly lateral point at the edge of the iliac crest) and symptom improvement by MCN blockage are diagnostically useful. Specific treatments for MCN-E are MCN blockage and MCN neurolysis; the latter is less invasive and can be performed under local anesthesia.

This is a case of a 4-year-old healthy male who presented with abdominal pain that evolved into abdominal and right buttock pain. This pain was initially thought to be from constipation but failed to respond to typical treatment. His parents reported low-grade fever, loss of appetite, no weight gain in 2 months, and pain that woke him from his sleep. The pain became so severe that he was refusing to walk or even to bear weight. He would frequently cry while grasping his abdomen and right buttock. Erythrocyte sedimentation rate was 44 mm/hr, and the urinalysis was unremarkable.

Chronic buttock pain is a common and debilitating symptom, which severely impacts daily activities, sleep, and may affect athletic performance. Lumbar spine, posterior hip, or hamstring pathology are usually considered as the primary diagnoses; however, pelvic neural pathology may be a significant cause of chronic buttock pain, particularly if there are prolonged (>6 months) buttock and/or radicular symptoms. The subgluteal space is the site of most pelvic causes of neural-mediated buttock pain, primarily relating to entrapment neuropathy of the sciatic nerve (deep gluteal syndrome), although other nerves within the subgluteal space including the gluteal nerves, pudendal nerve, and posterior cutaneous nerve of thigh may also be involved. Additionally, cluneal nerve entrapment at the iliac crest may result in "pseudo-sciatica". Anatomical variants of the pelvic girdle muscles and functional factors, including muscle spasm and pelvic instability, may contribute to development of deep gluteal syndrome, along with neural senescence. Imaging findings primarily relate to the presence of sciatic neuritis and peri-sciatic pathology, including neural compression and peri-neural adhesions or fibrosis. This imaging review describes the causes, magnetic resonance imaging and ultrasound imaging findings and imaging-guided treatment of pelvic neural causes of chronic buttock pain and sciatica.

Background Gluteal compartment syndrome is an uncommon condition and can be difficult to diagnose. It has been diagnosed after trauma, vascular injury, infection, surgical positioning, and prolonged immobilization from drug or alcohol intoxication. The diagnosis is based on clinical findings and, in most cases, recognizing these symptoms and making a diagnosis early is critical to a complete recovery. Case presentation A 53-year-old male who underwent left foot surgery had severe pain to his contralateral hip and posterior gluteal compartment radiating to the right lower extremity immediately postoperative. He was positioned supine with a “bump” placed under his right hip to externally rotate his operative leg during the surgery. Due to the patient’s complex past medical history, a presumptive diagnosis of a herniated disc and/or compression of the sciatic nerve was made as a cause for the patient’s pain. This resulted in a misdiagnosis period of 36 h until the patient was diagnosed with unilateral gluteal compartment syndrome. Performing a fasciotomy was decided against due to the increased risk of complications. The patient was treated with administration of IV fluids and closely monitored. On post-op day 6, the patient was discharged. At three months post-op, the patient was walking without a limp and he had no changes in his peripheral neurologic examination compared to his preoperative baseline. Conclusion Gluteal compartment syndrome is a surgical emergency that must be considered postoperatively especially in obese patients with prolonged operation times who experience acute buttock pain. The use of positional bars or “bumps” in the gluteal area should be used with caution and raise awareness of this complication after orthopedic surgeries.

Introduction: Piriformis syndrome (PS) is one of the most commonly misdiagnosed neuromuscular conditions characterized by buttock pain which radiates down the ipsilateral lower extremity. This case report describes the use of integrated neuromuscular inhibition technique (INIT) in the management of a patient with piriformis syndrome (PS). Case Presentation: A 40-year-old man presented with a complaint of right buttock pain which radiated to the ipsilateral lower limb. The patient was diagnosed as having PS. The treatment of the patient included INIT followed by stretching exercises for 6-weeks. Outcome measurements included visual analogue scale (VAS), Rolland-Morris disability questionnaire (RMDQ), Sciatica bothersome index (SBI), Sciatica frequency index (SFI), and global rating of change scale (GROC) and were assessed at baseline (T0), at 3 (T1) and 6-weeks (T2) of intervention, and then at 12-weeks (T3) follow-up. Conclusions: At 12-weeks follow-up (T3), the outcomes indicated improvement in all symptoms (VAS = 0, RMDQ = 0, SBI = 0, SFI = 0, and GROC = +7). Integrated neuromuscular inhibition technique is effective in the management of a patient with piriformis syndrome.

Middle cluneal nerve entrapment (MCN-E) around the sacroiliac joint can elicit low back pain (LBP). Pain control can be obtained with anesthetic nerve blocks; however, when their effectiveness is transient, surgical release may be necessary. We investigated the efficacy of radiofrequency thermocoagulation (RFTC) in patients with MCN-E. Between December 2018 and August 2019, 11 consecutive patients (4 men, 7 women; mean age 76.4 years) with intractable medial buttock pain due to MCN-E underwent MCN RFTC. The mean symptom duration was 49.5 months; pre-RFTC local MCN blocks provided pain relief for a mean of 7.7 days. The severity of pain in the medial buttock due to MCN-E was recorded before and 2, 6, 12, and 24 weeks after RFTC on the numerical rating scale (NRS) and the Roland-Morris Disability Questionnaire (RDQ). All patients reported pain alleviation; there were no complications. While there was a significant difference in the pre- and post-RFTC treatment NRS (p

Background Piriformis muscle syndrome (PMS) is a condition that can causes local buttock pain and tenderness. The symptoms of PMS are related to the hip joint position and may affect repetitive daily tasks such as walking. Objectives What is the difference between the gait characteristics of patients with PMS and those of matched-healthy controls? Design Observational study. Methods Thirty patients with PMS and 30 age-, sex-, and height-matched healthy participants underwent three-dimensional walking analysis. Results The results showed no significant differences in the spatiotemporal characteristics of gait between the groups (p > 0.1). The PMS group flexed the hip joint significantly more (−7.2 [–11.9 to −2.2], p = 0.003) and extended the hip joint to a lesser degree (−2.48 [–4.91 to −0.5], p = 0.04) than the control group. Patients with PMS needed a statistically significantly longer time to reach the peak angles of hip internal (1.3 [1 to 1.9], p = 0.003) and external (5.5 [0.9 to 10.1], p = 0.01) rotations during the gait cycle. Further, the results showed that the sagittal range of motion of the knee joint was significantly lesser in patients with PMS than in controls (3.45 [0.4 to 6.4], p = 0.02). Conclusions Patients with PMS seem to have different kinematic changes during level walking. Changing the peak flexion and extension of the hip joint is considered a strategy to enable pain-free gait in patients with PMS. Further, the knee kinematics are modified consequent to the change of hip joint kinematics.

OBJECTIVE: To evaluate whether different types of sacroiliac (SI) joint lesions identified by magnetic resonance imaging (MRI) could differentiate axial spondyloarthritis (SpA) from conditions with buttock or pelvic pain attributable to other reasons, including postpartum women and healthy subjects.METHODS: The study was designed as a prospective, cross-sectional study involving 204 participants, comprising patients with axial SpA (n = 41) and control groups of subjects with or without SI joint pain, including patients with lumbar disc herniation (n = 25), women with (n = 46) or without (n = 14) postpartum buttock/pelvic pain (having given birth within the preceding 4-16 months), hospital cleaning staff (n = 26), long-distance runners (n = 23), and healthy men (n = 29). Participants underwent clinical examination and MRI, and MRIs were evaluated in a blinded manner by 2 readers according to the Spondyloarthritis Research Consortium of Canada (SPARCC) SI joint inflammation and structural lesion scores. SPARCC score cutoff levels were defined as scores above a certain threshold. Primary analyses were based on reader agreement with regard to the presence of SI joint pathologic features on MRI ("concordant reads"). Sensitivity, specificity, and positive and negative predictive values were calculated.RESULTS: SI joint ankylosis and backfill were detected by MRI only in patients with axial SpA (32% and 37%, respectively), while bone marrow edema (BME) and fat lesions were seen in all non-axial SpA control groups (3-39% with BME and 4-14% with fat lesions). SI joint erosion was present only in patients with axial SpA and in women with postpartum buttock/pelvic pain (at erosion score cutoffs of >1 and >4, 61% and 34%, respectively, in patients with axial SpA, and 9% and 2%, respectively, in women with postpartum buttock/pelvic pain). A SPARCC BME score of ≥5 was present only in patients with axial SpA (56%) and in women with postpartum buttock/pelvic pain (24%), while fat lesions were present, albeit rarely, at high SPARCC cutoff scores in nearly all groups. Of the 38 women from the non-postpartum control groups who had given birth (mean time since birth 9.7 years), 2 (5%) had BME, whereas none had SI joint erosion or fat lesions, and none had a BME score of ≥4.CONCLUSION: BME and fat lesions were most pronounced in patients with axial SpA, but also occurred in other groups, particularly women with postpartum buttock/pelvic pain. Erosion above a certain SPARCC score threshold as well as backfill and ankylosis were highly specific for axial SpA.

OBJECTIVEThe etiology of low-back pain (LBP) is heterogeneous and is unknown in some patients with chronic pain. Superior cluneal nerve entrapment has been proposed as a causative factor, and some patients suffer severe symptoms. The middle cluneal nerve (MCN) is also implicated in the elicitation of LBP, and its clinical course and etiology remain unclear. The authors report the preliminary outcomes of a less invasive microsurgical release procedure to address MCN entrapment (MCN-E).METHODSThe authors enrolled 11 patients (13 sites) with intractable LBP judged to be due to MCN-E. The group included 3 men and 8 women ranging in age from 52 to 86 years. Microscopic MCN neurolysis was performed under local anesthesia with the patient in the prone position. Postoperatively, all patients were allowed to walk freely with no restrictions. The mean follow-up period was 10.5 months. LBP severity was evaluated on the numerical rating scale (NRS) and by the Japanese Orthopaedic Association (JOA) and the Roland-Morris Disability Questionnaire (RDQ) scores.RESULTSAll patients suffered buttock pain, and 9 also had leg symptoms. The symptoms were aggravated by standing, lumbar flexion, rolling over, prolonged sitting, and especially by walking. The numbers of nerve branches addressed during MCN neurolysis were 1 in 9 patients, 2 in 1 patient, and 3 in 1 patient. One patient required reoperation due to insufficient decompression originally. There were no local or systemic complications during or after surgery. Postoperatively, the symptoms of all patients improved statistically significantly; the mean NRS score fell from 7.0 to 1.4, the mean RDQ from 10.8 to 1.4, and the mean JOA score rose from 13.7 to 23.6.CONCLUSIONSLess invasive MCN neurolysis performed under local anesthesia is useful for LBP caused by MCN-E. In patients with intractable LBP, MCN-E should be considered.

To investigate the purported relationship between sciatic nerve variant anatomy and piriformis syndrome. Over 49 months, 1039 consecutive noncontrast adult hip MRIs were completed for various clinical indications. Repeat and technically insufficient studies were excluded. Radiologists categorized sciatic nerve anatomy into Beaton and Anson anatomical types. Chart review using our institution’s cohort search and navigation tool determined the prevalence of the explicit clinical diagnosis of piriformis syndrome (primary endpoint) and sciatica and buttock pain (secondary endpoints). A Z-test compared the prevalence of each diagnosis in the variant anatomy and normal groups. Seven hundred eighty-three studies were included, with sciatic nerve variants present in 150 hips (19.2%). None of the diagnoses had a statistically significant difference in prevalence between the variant and normal hip groups. Specifically, piriformis syndrome was present in 11.3% of variant hips compared with 9.0% of normal hips (p = 0.39). There were no significant differences in the prevalence of piriformis syndrome, buttock pain, or sciatica between normal and variant sciatic nerve anatomy. This large-scale correlative radiologic study into the relationship between sciatic nerve variants and piriformis syndrome calls into question this purported relationship. • Large retrospective study relating variant sciatic nerve anatomy, present in 19.2% of hip MRIs, and piriformis syndrome • While sciatic nerve variant anatomy has previously been implicated in piriformis syndrome in small studies, no relationship was identified between sciatic nerve variants and piriformis syndrome

Objective To define clinical screening criteria for spondyloarthritis (SpA) in patients with inflammatory bowel disease (IBD) and vice versa, which can be used as a reference for referring them to the rheumatology or gastroenterology service. Method Systematic literature review and a two-round Delphi method. The scientific committee and the expert panel were comprised of 2 rheumatologists and 2 gastroenterologists, and 7 rheumatologists and 7 gastroenterologists, respectively. The scientific committee defined the initial version of the criteria, taking into account sensitivity, specificity, standardisation and ease of application. Afterwards, members of the expert panel assessed each item in a two-round Delphi survey. Items that met agreement in the first or second round were included in the final version of the criteria. Results Positive screening for SpA if at least one of the following is present: onset of chronic low back pain before 45 years of age; inflammatory low back pain or alternating buttock pain; HLA-B27 positivity; sacroiliitis on imaging; arthritis; heel enthesitis; dactylitis. Positive screening for IBD in the presence of one of the major criteria or at least two minor criteria. Major: rectal bleeding; chronic diarrhoea with organic characteristics; perianal disease. Minor: chronic abdominal pain; iron deficiency anaemia or iron deficiency; extraintestinal manifestations; fever or low grade fever, of unknown origin and duration >1week; unexplained weight loss; family history of IBD. Conclusion Screening criteria for IBD in patients with SpA, and vice versa, have been developed. These criteria will be useful for early detection of both diseases.

Endometriosis is a common gynecological condition which affects 5-10% of women of reproductive age and up to 50% of women with pelvic pain and infertility. The most commonly affected areas are the pelvic peritoneum, ovaries and rectovaginal septum. Isolated endometriosis of the sciatic nerve is very rare. Our patient suffered from worsening right hip and buttock pain with severe exacerbation during menstruation. Several different imaging modalities (ultrasound of her pelvis and right hip, as well as X-rays and computed tomography scans of her right hip and lumbosacral spine) failed to identify any pathology. Magnetic resonance imaging scans of her pelvis revealed a 3.5 cm endometriotic lesion over the pelvic segment of her right sciatic nerve. Following a multidisciplinary discussion, the patient underwent laparoscopic excision of endometriosis. The patient recovered well from her surgery. She successfully conceived with in vitro fertilization 3 years after her surgery, following a failed course of Clomid (Clomiphene citrate) for ovulatory dysfunction.

Objective To investigate the diagnostic accuracy of patient history associated with hip pain. Data Sources A systematic, computerized search of electronic databases (PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science), a search of the gray literature, and review of the primary author's personal library was performed. Hip-specific search terms were combined with diagnostic accuracy and subjective or self-report history-based search terms using the Boolean operator “AND.” Study Selection This systematic review was conducted and reported according to the protocol outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria were: (1) patients with hip pain; (2) the statistical association of at least 1 patient history item was reported; (3) study designs appropriate for diagnostic accuracy; (4) adults aged ≥18 years; (5) written in English; and (6) used an acceptable reference standard for diagnosed hip pathology. Titles and abstracts of all database-captured citations were independently screened by at least 2 reviewers. Data Extraction Two reviewers independently extracted information and data regarding author, year, study population, study design, criterion standard, and strength of association statistics associated with the subjective findings. Data Synthesis For hip osteoarthritis (OA), a family history of OA (positive likelihood ratio [+LR], 2.13), history of knee OA (+LR, 2.06), report of groin or anterior thigh pain (+LR, 2.51-3.86), self-reported limitation in range of motion of 1 or both hips (+LR, 2.87), constant low back pain or buttock pain (+LR, 6.50), groin pain on the same side (+LR, 3.63), and a screening questionnaire (+LR, 3.87-13.29) were the most significant findings. For intra-articular hip pathology, crepitus (+LR, 3.56) was the most significant finding. Conclusions Patient history plays a key role in differential diagnosis of hip pain and in some cases can be superior to objective tests and measures.

Dislocation of the sacrococcygeal joint is a rare injury from trauma to the buttocks, most often from falling backwards. Standard of care for this injury has not been determined because it is rare. Left untreated this can cause coccydynia in the long-term. Here we present a case report to describe the treatment of an anterior sacrococcygeal dislocation with closed manual reduction. A 13-year-old female presented to the emergency department with buttock pain after slipping backwards down the stairs. On X-ray the coccyx was in bayonette apposition to the anterior distal sacrum and shortened by 6 mm. To manage the injury, closed manual reduction of the sacrococcygeal joint was performed. To our knowledge, this is the first successful case of sacrococcygeal dislocation treated with closed manual reduction, resulting in complete relief of symptoms at 36 months follow-up. Sacrococcygeal dislocations can be treated with closed manual reduction, resulting in lower morbidity and faster recovery compared to surgical treatment.

Objective To determine associations between magnetic resonance imaging (MRI) lesions originating from either axial spondyloarthritis (SpA) or from degeneration and pain in patients with chronic back pain of

Objectives The purpose of this study is to describe the clinical history leading up to and the outcomes after vaginal mesh removal surgery at an academic hospital. Methods A retrospective case series of patients who underwent vaginal mesh removal from 2008 to 2015 was conducted. Demographics, clinical history, physical examination, pre- and postoperative symptoms, and number and type of reoperations were abstracted. Results Between February 2008 and November 2015, 83 patients underwent vaginal mesh removal surgery at our hospital. The median time interval from initial mesh placement to removal was 58 months (range, 0.4-154 months). The most common preoperative symptoms were vaginal pain (n = 52, 62%), dyspareunia (n = 46, 55%), and pelvic pain (n = 42, 50%). Intraoperative complications were infrequent (n = 3, 4%). Of patients presenting for follow-up within 4 to 6 weeks postoperatively, the most common symptoms were urinary incontinence (n = 15, 28%), vaginal pain (n = 7, 13%), buttock pain (n = 5, 9%), and urinary tract infection (n = 5, 9%). There were no identifiable risk factors to predict which patients would have persistent postoperative symptoms or who would require more than 1 mesh removal surgery. After vaginal mesh removal, 29 patients (35%) required 1 or more reoperations, with 3 being the highest number of reoperations per patient. The total number of reoperations was 43, with a total of 63 individual procedures performed. Forty-four percent (n = 28) of the procedures were graft removals, 40% (n = 25) were pelvic organ prolapse surgeries (only native tissue repairs), and 16% (n = 10) were stress incontinence surgeries. More than 1 procedure was performed in 49% (n = 21) of the reoperations. Conclusions Vaginal mesh removal surgery is safe; however, some patients require more than 1 procedure, and the risk factors for reoperations are unclear.

Piriformis syndrome (PS) is an underdiagnosed but common cause of chronic buttock pain and sciatica. Anatomical variants of the piriformis muscle and sciatic nerve have not been thought to be significant in the pathophysiology of PS however, recent description of the piriformis musculotendinous junction has identified a common variant that we believe frequently results in dynamic sciatic nerve entrapment at the infra-piriformis fossa. We performed ultrasound guided low-dose Botulinum Toxin-A (BTX-A) injection to the lower piriformis muscle belly in an elite Australian Rules football player with PS and Type A piriformis muscle to relieve symptomatic sciatic nerve compression. Positive response to targeted BTX-A piriformis muscle injections support the hypothesis that sciatic nerve compression by Type A piriformis muscles may contribute to the pathophysiology of neuropathic PS, along with other functional factors. Sciatic nerve compression due to Type A piriformis at the infra-piriformis fossa has not been described previously and is a potentially common cause of neuropathic PS, especially when combined with other functional factors such as piriformis muscle spasm/hypertrophy and sacroiliac joint counternutation.

Background The aim of this study was to investigate the correlation between radiographic measurement in lumbar spine and clinical information including symptoms or results of functional testing using a baseline data of longitudinal cohort study. Methods A total of 314 elderly subjects were recruited from 5 orthopedic clinics or affiliated facilities. Data for the present investigation were collected via an interviewer-administered questionnaire, which included questions on past medical history, drug history, pain area. And also results of functional testing and X-ray imaging of the lumbar spine were collected. Analysis was carried out to determine any correlation between results of X-ray imaging of the lumbar spine and other collected data, and sorted regarding Akaike Information Criterion (AIC). The correlations among these variables and odds ratio were also analyzed. Results T12/L1% disc height showed a minimum AIC value with buttock pain (− 4.57) and history of vertebral fracture (− 4.05). The L1/L2, L2/L3, and L3/L4% disc height had a minimal AIC value with knee pain (− 4.11, − 13.3, − 3.15, respectively), and odds ratio of knee pain were 3.5, 3.8, and 2.7, respectively. Conclusions Correlation was recognized between the T12/L1% disc height and both buttock pain and previous vertebral fractures, and the L1/L2, L2/L3, and L3/L4% disc height showed a correlation with knee pain. Especially the L2/L3% disc height and knee pain had a strong correlation. It was suggested that these findings may provide additional basis to the concept that lumbar spinal lesion associates with knee pain clinically. Electronic supplementary material The online version of this article (10.1186/s12891-019-2755-1) contains supplementary material, which is available to authorized users.

Piriformis syndrome is a form of sciatica caused by compression of the sciatic nerve by the piriformis muscle. It is a relatively uncommon, but not insignificant, cause of sciatica. The diagnosis of piriformis syndrome is complicated by the large differential diagnosis of low back and buttock pain with many diagnoses having overlapping symptoms. This narrative review highlights the relevant anatomy, history, physical exam maneuvers, electrodiagnostic findings, and imaging findings that are used to diagnose piriformis syndrome. Also discussed are posterior gluteal myofascial pain syndromes that mimic piriformis syndrome. The review then outlines the different treatment options for piriformis syndrome including conservative treatment, injections, and surgical treatment. In addition, it provides the reader with a clinical framework to better understand and treat the complex, and often misunderstood, diagnosis of piriformis syndrome.

Background: Stress fractures of the sacrum are an uncommon cause of low back and buttock pain in athletes. They have been described in a few case reports, with the injury occurring most often in female distance runners. Given the rarity of this condition, there is a general lack of awareness of this injury, which may lead to a missed or delayed diagnosis. Study Design: Case series. Level of Evidence: Level 5. Methods: The 5 cases were identified by performing a medical records search within the practices of the senior authors over a 3-year period from January 2016 to December 2018. Results: Three of 5 patients (1 male, 2 females) returned to regular activity after diagnosis and treatment. Two (1 male, 1 female) have yet to return to regular activity. Magnetic resonance imaging was the key modality in all diagnoses. All 3 female patients had components of the female athlete triad—menstrual irregularity, disordered eating, and decreased bone mineral density. Conclusion: A high index of suspicion is required to make the correct diagnosis and initiate treatment for this rare condition given its association with low body mass index, vitamin D insufficiency, disordered eating, and malabsorption disorders. Appropriate treatment includes rest from the causative activity, nutritional support, and biomechanical optimization. In severe, chronic, or recurrent cases, referral for nutritional counseling, hormonal replacement therapies, and mental health support may be necessary. Clinical Relevance: Sacral stress fractures, though uncommon, should be included prominently in the differential diagnosis for runners with low back pain, especially if the athlete has a history of prior stress fracture or the female athlete triad.

Background Acupuncture is commonly used to treat degenerative lumbar spinal stenosis in Asian countries. However, rigorous data regarding the efficacy and safety of acupuncture for aging patients are currently lacking. Methods Eighty patients older than 50 years were assigned randomly to the acupuncture group or the noninsertive sham acupuncture for 24 treatments over an 8-week period. Measurements were obtained at baseline and 4 and 8 weeks of treatment; and 3 and 6 months after completion of treatment. The primary outcome was a change in the 24-point Roland Morris Disability Questionnaire scores at the end of treatment. The secondary outcomes included disability, pain intensity, symptoms, and dysfunction. Results At the end of treatment, mean changes in the Roland Morris Disability Questionnaire were −4.1 (95% CI, −4.9 to −3.3) in the acupuncture group and −1.5 (95% CI, −2.3 to −0.7) in the sham group, with a statistically significant between-group difference: −2.6 (95% CI, −3.7 to −1.4). Acupuncture was superior to sham acupuncture in reducing pain intensity (between-group difference: −2.9 [95% CI, −3.8 to −2.0] in leg and buttock pain, vs −2.3 [95% CI, −3.0 to −1.5] in back pain), symptoms and dysfunction (between-group difference: −0.9 [95% CI, −1.2 to −0.6] in symptom subscale, and −0.8 [95% CI, −1.1 to −0.5] in dysfunction subscale). Conclusions Acupuncture provides immediate functional recovery and pain relief for degenerative lumbar spinal stenosis. However, current evidence is insufficient to support the suggestion that acupuncture could offer clinical benefits as compared with noninsertive sham acupuncture for degenerative lumbar spinal stenosis.

Background: In the light of new therapeutic strategies, it has become essential to detect spondyloarthritis (SpA) in its earliest stages in order to initiate treatment as early as possible. Magnetic resonance imaging (MRI), with its ability to detect active lesions, is usually considered as a key tool for early recognition of sacroiliitis. However, a growing number of studies reported the lack of specificity of bone marrow edema (BME) leading sometimes to a false “positive MRI” of sacroiliac joints (SIJ). In addition, many recent studies have pointed out the utility of detecting structural lesions, especially erosions, reported as the earliest structural change on SIJ in the course of sacroiliitis. Objectives: We aimed to assess the reliability of early recognition of erosions in patients with suspected SpA. Methods: Consecutive patients, aged 16 and over, consulting from February 2014 to February 2017 for symptoms suggestive of SpA (inflammatory back pain, enthesitis or dactylitis…) were enrolled in this cohort. They were referred for computed tomography (CT) and MRI of the SIJ. The CT and MR images were reviewed for the presence of erosions by 2 musculoskeletal radiologists blinded to clinical findings. After a follow-up of 2 years, 2 experienced rheumatologists confirmed or excluded the diagnosis of SpA. Diagnostic utility of erosions for diagnosis of SpA was determined by calculating sensitivity, specificity, positive and negative likelihood ratio with final clinical diagnosis made by rheumatologists as golden standard. Results: Fifty-four patients were included, 13 men and 41 women. The mean age was 39 years [17-71]. The mean duration of symptoms was 75 months (6 years). Cervical, thoracic, lumbar and buttock pain were noted respectively in 46.3%, 37%, 87%, and 57.4% of the studied patients. Morning stiffness was noted in 55.5% of patients. The prevalence of HLA–B27 was 23.4%. After a follow-up of 2 years, the referring rheumatologists made a diagnosis of SpA in 77.8% of patients, whereas SpA was excluded in 22.2%. Among the 42 patients classified as having a confirmed SpA, erosions were detected on SIJ by CT in 64.3% (n=27) and by MRI in (n=18) 42.85% of patients. Among the 12 patients in whom Spa was excluded, erosions were detected on SIJ by CT in 25% (n=3) of patients and were not detected by MRI in any patient. Sensitivity, specificity, positive and negative likelihood ratio of erosions detected by CT were respectively estimated at 64.3%, 75%, 90% and 37.5%. Those of erosions detected by MRI were estimated at 42.9%, 100%, 100%, 33.33%. A statistically significant association was observed between erosions and rheumatologists’ diagnosis of SpA (p= 0.05 for CT and p= 0.012 for MRI). The likehood ratio was estimated respectively for CT and MRI at 3.8 and 7.6. Conclusion: In our study, detection of erosions showed a high specificity for recognition of sacroiliitis, especially when detected by MRI. This study highlights the utility of structural SIJ lesions, particularly erosions, to reduce the number of false positives. Disclosure of Interests: None declared

Background Kummell’s Disease has insidious progression. Neurological deficit is usually slow in onset and progression and only few cases of acute neurological deficit have been reported. We came across a case of Kummell’s disease which progressed to burst fracture, developed neurological deficit within two weeks. We managed patient with “pivot ligamentotaxis” and Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation. Case presentation Eighty-three years old woman following fall was on conservative management at another hospital. She had no neurological deficit. A week later her back pain aggravated and two weeks later developed bilateral buttock pain, bilateral lower limb weakness and diminished sensation in the sacral area. Radiological investigations (X-rays, Magnetic resonance imaging and Computed tomography) showed L1 vertebral body fracture with vacuum cleft and fracture fragment retropulsed into the spinal canal. A diagnosis of Kummell’s disease with burst fracture of L1 vertebra & neurological deficit was made. Patient was managed with Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation. The reduction of the retropulsed fragment was achieved by virtue of “Pivot ligamentotaxis”. The patient got relieved of the symptoms (Preoperative VAS 8 and postoperative VAS 3) and was allowed brace assisted ambulation on first postoperative day. Conclusion This study reports acute occurrence of the burst fracture in unstable vertebra inflicted by Kummell’s disease and role of spinal stability in recovery. We achieved closed reduction of the fracture fragments and relief of the cord compression by posterior compression with “pivot ligamentotaxis”.

Background: The sacroiliac joint dysfunction (SIJD) has been found to be the primary culprit for lower back pain (LBP), but it is still overlooked and treated as LBP. There are no guidelines or appropriate therapeutic protocols for SIJD. Thus, there is a need for an effective treatment strategy for SIJD. Objective: To compare exercise therapy (ET), manipulation therapy (MT), and a combination of the 2 (EMT) in terms of their effectiveness in treating SIJD. Study Design: A comparative, prospective, single-blind randomized controlled trial . Setting: Sports Medicine Department of Rasoul Akram Hospital. Methods: A total of 51 patients with lower back or buttock pain resulting from SIJD were randomly assigned to 1 of 3 study groups: ET, MT, or EMT. The ET group received posterior innominate self-mobilization, sacroiliac joint stretching, and spinal stabilization exercises. The MT group underwent posterior innominate mobilization and SIJ manipulation. Lastly, the EMT group received manipulation maneuvers followed by exercise therapy. Pain and disability were assessed at 6, 12, and 24 weeks after the interventions. Results: All 3 groups demonstrated significant improvement in pain and disability scores compared to the baseline (P < 0.05). The difference among these therapeutic protocols was found to be a function of time. At week 6, MT showed notable results, but at week 12, the effect of ET was remarkable. Finally, at week 24, no significant difference was observed among the study groups. Limitations: A major limitation of the present study is lack of a control group receiving a type of intervention other than the experimental protocols. Another limitation is the short duration of follow-ups. Conclusions: Exercise and manipulation therapy appear to be effective in reducing pain and disability in patients with SIJD. However, the combination of these 2 therapies does not seem to bring about significantly better therapeutic results than either approach implemented separately. Key words: Exercise therapy, manipulation therapy, sacroiliac joint dysfunction

External iliac artery endofibrosis is an uncommon, nonatherosclerotic disease seen in endurance cyclists. It is poorly identified by providers. These otherwise healthy patients usually present with symptoms of arterial insufficiency, such as thigh or buttock pain, loss of power, or weakness occurring during strenuous exercises. These symptoms subside rapidly with rest. As these patients lack traditional risk factors of peripheral artery disease, their symptoms are often overlooked or are attributed to other etiologies, resulting in mismanagement and delayed treatment. In this case study, we report our experience with the successful management of a 48-year-old male who is a longstanding, avid cyclist. He self-referred to our institution after extensive research of providers familiar with his problem and at the recommendation of other cyclists with similar experiences. The patient underwent a successful left external iliac to common femoral artery endarterectomy and patch angioplasty. Three months after operation, he returned to cycling and, for the most part, has remained without symptoms.

Study Objective Sciatic Nerve Endometriosis is rarely observed. Symptoms include sciatica, gluteal pain, and sometimes, locomotion problems without bladder dysfunction or Pudendal pain. Clinical gynecological pelvic examination in these patients is usually unremarkable. Design Case report with surgical technical details and anatomical landmark discussion. Setting Gynecologic Endoscopic Unit in a Tertiary Care Private Clinic. Patients or Participants 46-year-old patient with multiple leiomyomas and chronic pelvic pain. 3 years with progressive sciatic pain (right hip and buttock pain), alteration of sensation along L5 and S1 dermatomes with a perceived reduced power in the right ankle. All showed severe exacerbation during menstruation. Besides uteromegaly, her pelvic gynecological examination was normal. Pelvic MRI showed a 3.4 cm endometriotic lesion over the pelvic segment of her right sciatic nerve, before exiting the great sciatic foramen. Interventions Laparoscopic access to the Lumbosacral space and sciatic nerve cold scissors shaving. Measurements and Main Results The patient recovered well from her surgery. She complained of exacerbation of neurological symptoms immediately after surgery, specifically lower limb paresthesia over the first few days. After a week she had significant improvement of pain and after one year she is asymptomatic. Conclusion Exploration of lumbosacral space should not be undertaken lightly due to its complex anatomy and potential for serious injury to the major neurovascular structures. Once the procedure is started, resection of the lesions must be fully completed to avoid further surgical interventions which are always more challenging than the preceding one.

Aims: To describe a series of piriformis syndrome patient among Bangladesh people with literature review. Methods: Consecutive 31 piriformis syndrome patients were enrolled. Besides history and clinical examination, piriformis muscle thickness was also measured with diagnostic ultrasound (3.5 MHZ). MRI of lumbar spine, X-rays of lumbo-sacral spine, and pelvis were performed in all patients. Statistical Package for the Social Sciences (SPSS), Windows 8.0, was used for statistical calculation, and univariate analysis of primary data was done. Data present with frequency table. For literature review concerning piriformis syndrome we used Embase, Pubmed, Medline, and Cochrane database. Results: A total of 31 patients (21 female) with PS were enrolled, 21 housewives. Mean age 42.2 ± 14.5 years. All presented with buttock pain, aggravating with long sitting (31), lying on the affected side (31), during rising from a chair(24), and forward bending (28). Six reported pain improvement while walking. Gluteal tenderness, positive FAIR test, and Pace sign were elicited in all patients. A palpable gluteal mass was found in 8 cases, gluteal atrophy in 5 other patients. The mean piriformis muscle thickness on the diseased side was more than on the healthy side (13.6 ± 3.7 vs 10.9 ± 1.9, (p > 0.05). Common conditions associated with PS were: preceding fall (9, 29 %), overuse of piriformis muscle, lumbar spinal stenosis, fibromyalgia, intra-muscular gluteal injection, blunt trauma over the buttock, leg length discrepancy and use of rear pocket’s wallet. Conclusions: In Bangladesh piriformis syndrome is more syndrome should be considered as possible diagnosis when sciatica occurs without a clear spine pathology.common in female, especially among housewives. A fall often precedes the condition. Piriformis

STUDY DESIGN A cross-sectional study of 1804 consecutive patients. OBJECTIVE The aim of this study was to investigate the prevalence of pathological pain and its distribution features in patients with chronic lumbar spinal disorders. SUMMARY OF BACKGROUND DATA Clinical spinal disorders can involve pathological neuropathic pain (NeP) as well as physiological nociceptive pain (NocP), as they have varied pathology, including spinal cord injury, stenosis, and compression. A study conducted by the Japanese Society for Spine Surgery and Related Research (JSSR) has determined a prevalence of 29.4% for NeP in patients with lumbar spinal disorder. However, the data did not include information on pain location. METHODS Patients aged 20 to 79 years with chronic lower back pain (≥3 months, visual analog scale score ≥30) were recruited from 137 JSSR-related institutions. Patient data included an NeP screening questionnaire score and pain location (lower back, buttock, and legs). The association between the pain pathology and its location was analyzed statistically using the unpaired t test and Chi-square test followed by Fisher test. P