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Purpose of Review: The present investigation evaluates clinical uses and roles of platelet rich plasma in the management of vetrebrogenic and discogenic mediated pain states., Recent Findings: Back pain is a common and significant condition that affects millions of people around the world. The cause of back pain is often complex and multifactorial, with discogenic and vertebrogenic pain being two subtypes of back pain. Currently, there are numerous methods and modalities in which back pain is managed and treated such as physical therapy, electrical nerve stimulation, pharmacotherapies, and platelet-rich plasma. To conduct this systematic review, the authors used the keywords "platelet-rich plasma", "vertebrogenic pain", and "discogenic pain", on PubMed, EuroPMC, Who ICTRP, and clinicaltrials.gov to better elucidate the role of this treatment method for combating vertebrogenic and discogenic back pain. In recent decades, there has been a rise in popularity of the use of platelet-rich plasma for the treatment of numerous musculoskeletal conditions. Related to high concentration of platelets, growth factors, cytokines, and chemokines, platelet-rich plasma is effective in reducing pain related symptoms and in the treatment of back pain. Platelet-rich plasma use has evolved and gained popularity for pain related conditions, including vertebrogenic and discogenic back pain. Additional well-designed studies are warranted in the future to better determine best practice strategies to provide future clinicians with a solid foundation of evidence to make advancements with regenerative medical therapies such as platelet-rich plasma., (© 2024. The Author(s).)

Background: Spinal tuberculosis (TB) may have a variable, non-specific presentation including back pain with- or without- constitutional symptoms. Further tools are needed to aid early diagnosis of this potentially severe form of TB and immunological biomarkers may show potential in this regard. The aim of this study was to investigate the utility of host serum biomarkers to distinguish spinal TB from mechanical back pain., Methods: Patients with suspected spinal TB or suspected mechanical back pain were recruited from a tertiary hospital in the Western Cape, South Africa, and provided a blood sample for biomarker analysis. Diagnosis was subsequently confirmed using bacteriological testing, advanced imaging and/or clinical evaluation, as appropriate. The concentrations of 19 host biomarkers were evaluated in serum samples using the Luminex platform. Receiver Operating Characteristic (ROC) curves and General Discriminant Analysis were used to identify biomarkers with the potential to distinguish spinal TB from mechanical back pain., Results: Twenty-six patients with spinal TB and 17 with mechanical back pain were recruited. Seven out of 19 biomarkers were significantly different between groups, of which Fibrinogen, CRP, IFN-γ and NCAM were the individual markers with the highest discrimination utility (Area Under Curve ROC plot 0.88-0.99). A five-marker biosignature (CRP, NCAM, Ferritin, CXCL8 and GDF-15) correctly classified all study participants after leave-one-out cross-validation., Conclusion: This study identified host serum biomarkers with the potential to diagnose spinal TB, including a five-marker biosignature. These preliminary findings require validation in larger studies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Mann, Davis, Walzl, Beltran, du Toit, Lamberts and Chegou.)

Primary Sjögren's syndrome (pSS) is a chronic slowly progressive autoimmune disease characterised by lymphocytic infiltration of salivary and lacrimal glands with varying degree of systemic involvement. Renal involvement, a recognised extraglandular manifestation of pSS, is commonly related to tubular dysfunction and generally manifests as distal renal tubular acidosis (RTA), proximal RTA, tubular proteinuria and nephrogenic diabetes insipidus. Untreated long-standing RTA is known to cause metabolic bone disease. Here, we present the report of a patient with sclerotic metabolic bone disease related to pSS with combined distal and proximal RTA and negative workup for other causes of sclerotic bone disease. A significant clinical and biochemical improvement, including recovery of proximal tubular dysfunction, was noted with alkali therapy. This case suggests the need to consider pSS in the diagnostic algorithm of a patient presenting with sclerotic bone disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Back pain is the leading cause of disability worldwide and is associated with obesity and chronic low-grade inflammation. Alterations in intestinal microbiota may contribute to the pathogenesis of back pain through metabolites affecting immune and inflammatory responses. Aims and Methods: We compared the gut microbiota composition in a cohort of 36 overweight or obese individuals with or without self-reported back pain in the preceding month. Participants were characterized for anthropometry; bone health; metabolic health; inflammation; dietary intake; and physical activity. Results: Demographic, clinical, biochemical characteristics, diet and physical activity were similar between participants with ( n = 14) or without ( n = 22) back pain. Individuals with back pain had a higher abundance of the genera Adlercreutzia ( p = 0.0008; FDR = 0.027) , Roseburia ( p = 0.0098; FDR = 0.17), and Uncl. Christensenellaceae ( p = 0.02; FDR = 0.27) than those without back pain. Adlercreutzia abundance remained higher in individuals with back pain in the past 2 weeks, 6 months, and 1 year. Adlercreutzia was positively correlated with BMI (rho = 0.35, p = 0.03), serum adipsin (rho = 0.33, p = 0.047), and serum leptin (rho = 0.38, p = 0.02). Conclusions: Our findings suggest that back pain is associated with altered gut microbiota composition, possibly through increased inflammation. Further studies delineating the underlying mechanisms may identify strategies for lowering Adlercreutzia abundance to treat back pain., (Copyright © 2020 Dekker Nitert, Mousa, Barrett, Naderpoor and de Courten.)

Vertebral endplate bone marrow lesions, visualized on magnetic resonance imaging (MRI) as Modic changes (MC), are associated with chronic low back pain (cLBP). Since guidelines recommend against routine spinal MRI for cLBP in primary care, MC may be underdiagnosed. Serum biomarkers for MC would allow early diagnosis, inform clinical care decisions, and supplement treatment monitoring. We aimed to discover biomarkers in the blood serum that correlate with MC pathophysiological processes. For this single-site cross-sectional study, we recruited 54 subjects with 38 cLBP patients and 16 volunteers without a history of LBP. All subjects completed an Oswestry Disability Index (ODI) questionnaire and 10-cm Visual Analog Score (VAS) for LBP (VASback) and leg pain. Lumbar T1-weighted and fat-saturated T2-weighted MRI were acquired at 3T and used for MC classification in each endplate. Blood serum was collected on the day of MRI. Biomarkers related to disc resorption and bone marrow fibrosis were analyzed with enzyme-linked immune-absorbent assays. The concentration of biomarkers between no MC and any type of MC (AnyMC), MC1, and MC2 were compared. The Area Under the Curve (AUC) of the Receiver Operating Characteristics were calculated for each biomarker and for bivariable biomarker models. We found that biomarkers related to type III and type IV collagen degradation and formation tended to correlate with the presence of MC ( p = 0.060-0.088). The bivariable model with the highest AUC was PRO-C3 + C4M and had a moderate diagnostic value for AnyMC in cLBP patients (AUC = 0.73, specificity = 78.9%, sensitivity = 73.7%). In conclusion, serum biomarkers related to the formation and degradation of type III and type IV collagen, which are key molecules in bone marrow fibrosis, correlated with MC presence. Bone marrow fibrosis may be an important pathophysiological process in MC that should be targeted in larger biomarker and treatment studies., Competing Interests: The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Objective: As a minimally invasive intervertebral fusion technique popularized in recent years, extreme lateral interbody fusion (XLIF) has various advantages. In this study, we describe the application and efficacy of XLIF for the treatment of thoracic tuberculosis (TB), as this may be an emerging treatment option for thoracic TB in the future., Methods: We present the case of a 75-year-old man who had suffered from chest and back pain for 1 month. Imaging studies showed destruction of the T12 and L1 vertebral bodies and the T12-L1 intervertebral disc, accompanied by formation of a paravertebral abscess. After 2 weeks of standard anti-TB treatment, the patient underwent debridement of the lesions, XLIF, and percutaneous pedicle screw fixation., Results: The patient's chest and back pain were significantly alleviated after the operation. The patient recovered well, and as of the most recent follow-up had no obvious limitation in thoracolumbar spine function., Conclusions: XLIF combined with percutaneous pedicle screw fixation for the treatment of thoracic TB can allow for TB lesion debridement, discectomy, and interbody fusion under direct visualization, and can effectively improve patient prognosis.

This study is primarily aimed at assessing serum changes on a large panel of proteins in patients with chronic back pain following spa therapy, as well as evaluating different spa therapy regimens as a preliminary exploratory clinical study. Sixty-six patients with chronic back pain secondary to osteoarthritis were randomly enrolled and treated with daily mud packs and bicarbonate-alkaline mineral water baths, or a thermal hydrotherapy rehabilitation scheme, the combination of the two regimens or usual medication only (control group), for two weeks. Clinical variables were evaluated at baseline, after 2 and 12 weeks. One thousand serum proteins were tested before and after a two-week mud bath therapy. All spa treatment groups showed clinical benefit as determined by improvements in VAS pain, Roland Morris disability questionnaire and neck disability index at both time points. The following serum proteins were found greatly increased (≥2.5 fold) after spa treatment: inhibin beta A subunit (INHBA), activin A receptor type 2B (ACVR2B), angiopoietin-1 (ANGPT1), beta-2-microglobulin (B2M), growth differentiation factor 10 (GDF10), C-X-C motif chemokine ligand 5 (CXCL5), fibroblast growth factor 2 (FGF2), fibroblast growth factor 12 (FGF12), oxidized low density lipoprotein receptor 1 (OLR1), matrix metallopeptidase 13 (MMP13). Three proteins were found greatly decreased (≤0.65 fold): apolipoprotein C-III (Apoc3), interleukin 23 alpha subunit p19 (IL23A) and syndecan-1 (SDC1). Spa therapy was confirmed as beneficial for chronic back pain and proved to induce changes in proteins involved in functions such as gene expression modulation, differentiation, angiogenesis, tissue repair, acute and chronic inflammatory response.

Background: Back pain is a leading reason for patients to seek medical attention. Although musculoskeletal causes are common, patients can also present with rarer etiologies., Case Description: A 50-year-old man presented with 2 months of isolated upper back pain initially suspected to be secondary to overuse muscular strain. During the next 3 months, his pain worsened, and he developed lower extremity dysesthesia and subjective weakness, despite normal neurological examination findings. Nonrevealing laboratory workup included normal muscle enzymes, C-reactive protein, urinalysis, and human leukocyte antigen B27. Magnetic resonance imaging revealed a normal brain but a hypointense C7-T5 epidural mass, prompting a neurosurgical recommendation for laminectomy with evacuation of the suspected hematoma. His symptoms fully and promptly resolved after a 5-day course of prednisone 40 mg. When his symptoms recurred within 2 months, he underwent T4-T5 laminectomy with biopsy of a mass confluent with the dura mater. Initial pathological examination revealed fibrotic tissue of unclear etiology with polyclonal lymphoid infiltrate but no malignant cells, vasculitis, or granulomas. After months of recurrent, steroid-responsive symptoms, he presented to the rheumatology clinic. Repeat spinal magnetic resonance imaging demonstrated progression of epidural thickening with suspected spinal cord compression. Previous biopsy samples were then immunostained for IgG4, revealing focally dense IgG4-positive plasma cells, up to 29 cells per high power field, consistent with spinal IgG4-related hypertrophic pachymeningitis. He began rituximab therapy with a prednisone taper and demonstrated symptomatic and neurologic improvement with successful withdrawal from corticosteroids., Conclusions: To the best of our knowledge, the present case represents the 12th reported case of spinal IgG4-related hypertrophic pachymeningitis. An early diagnosis and treatment could prevent progression to permanent neurological impairment and functional disability., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Monoaminergic pathways are involved in the process of pain inhibition and facilitation. The objective of this study was to investigate the role of blood monoamines as biomarkers of conditioned pain modulation (CPM) efficacy., Methods: One hundred and five paediatric patients with chronic back pain were enrolled in this observational study. The protocol involved dosage of plasma monoamines (dopamine, DOPA; serotonin, 5-HT; epinephrine, Epi; norepinephrine, NE; metanephrine, ME; and normetanephrine, NME) and clinical assessment (CPM, functional disability, pain, sleep quality, anxiety and depression)., Results: 5-HT and DOPA were positively correlated among each other and were both negatively correlated with Epi, ME, NE and NME. CPM presented a positive correlation with DOPA and 5-HT. On the other hand, Epi, ME, NE and NME correlated negatively with CPM. Different correlation coefficients were observed between genders, with stronger coefficients being observed in the male subpopulation. Stepwise regression controlling for age and gender indicated that ME (B = -0.987, SE(B) = 0.299, p = 0.002) was the only significant predictor for CPM efficacy. Higher blood ME was associated with poorer CPM efficacy. ME explained 53% of variation of CPM in males (R 2  = 0.536, p < 0.0001) and 7% in females (R 2  = 0.074, p = 0.014). In males, blood ME >15 pg/ml predicted inefficient CPM with 88.9% sensitivity and 83.3% specificity., Conclusions: Our findings suggest that ME can be a potential biomarker for CPM efficacy in paediatrics. Future studies are needed to assess the efficacy of tailored treatments for pain according to blood ME., Significance: We were able to demonstrate an association between CPM and circulating monoamines. In the clinical setting, sampling ME could provide the clinician an idea of the individual's pain modulation potential. This may be particularly important for children with cognitive impairment, for whose CPM paradigm cannot be used., (© 2018 European Pain Federation - EFIC®.)

Competing Interests: Conflict-of-interest disclosure: S.Z.U. has received research funding from Amgen, Array Biopharma, BMS, Celgene, Janssen, Pharmacyclics, Sanofi, and Takeda; consulted for Abbvie, Amgen, BMS, Celgene, Janssen, Takeda, Sanofi, and SkylineDx; and been affiliated with the Speaker’s Bureau for Amgen, Celgene, Janssen, and Takeda.

With the advent new proteasome inhibitors (carfilzomib, ixazomib), new immune-modulatory drugs (pomalidomide), and new monoclonal antibodies (elotuzimab, daratumumab) as approved treatments for myeloma, the therapeutic landscape for this disease has changed. In this chapter, using a case-based approach, I will provide a personal guide of how I approach myeloma therapy in a transplant eligible patient in 2018., Competing Interests: Conflict-of-interest disclosure: S.G. has received research funding and honoraria from Celgene, Sanofi, Amgen, Takeda, Novartis, Miltenyi, Pfizer, JAZZ, and Johnson & Johnson., (© 2018 by The American Society of Hematology. All rights reserved.)

Study Design: A nationwide cross-sectional study., Objectives: To measure the associations between cigarette smoking (defined as serum cotinine concentration >15 ng/mL) and the 3-month prevalence of spinal pain (neck pain, low back pain, low back pain with pain below knee, and self-reported diagnosis of arthritis/rheumatism) and related limitations, and to verify whether these associations are mediated by serum concentrations of vitamin C., Summary of Background Data: Cigarette smoking has been consistently associated with back pain, but this association has never been explained. Because vitamin C has recently been reported to be associated with spinal pain and related functional limitations, and the metabolism of vitamin C differs between smokers and nonsmokers, we hypothesized that the prevalence of spinal pain and related limitations might be greater among smokers because they are more susceptible to be in a state of hypovitaminosis C., Methods: We conducted secondary analyses of National Health and Nutrition Examination Survey (NHANES) 2003 to 2004 data on 4438 individuals aged ≥20 years., Results: Serum concentrations of vitamin C and cotinine were strongly and inversely correlated (r = -0.35, P < 0.0001). Smoking was statistically associated with the prevalence of neck pain [adjusted odds ratio: aOR: 1.25; 95% confidence interval (95% CI): 1.06-1.47], low back pain (aOR: 1.20; 95% CI: 1.04-1.39), and low back pain with pain below knee (aOR: 1.58; 95% CI: 1.13-2.22) and related limitations, with a dose-response relationship (P < 0.05). However, the associations between smoking and spinal pain were not mediated by concentrations of vitamin C., Conclusion: These results confirm the relationship between smoking and spinal pain, but they do not support a mediating effect of vitamin C on this relationship., Level of Evidence: 2.

Background: Inflammatory back pain is a condition characterized by inflammation of the sacroiliac joints and lower spine. It is frequently seen in patients with spondyloarthropathies like ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis and reactive arthritis. Inflammatory back pain can be caused by many other conditions like infection and crystal deposition such as gout. In this case, it is difficult to specifically identify gout as a cause by ordinary imaging like magnetic resonance imaging (MRI) or ultrasound., Case Presentation: This case report describes a young man with severe psoriasis, presumptive psoriatic spondyloarthropathy and chronic extensive tophaceous gout which was difficult to treat because of non-compliance with medications and lifestyle. He presented with inflammatory type low back and buttocks pain with raised inflammatory markers. MRI of the lower back and sacroiliac joints showed features of active sacroiliitis. He was subsequently treated with a Tumor Necrosis Factor (TNF) alpha inhibitor for presumed axial psoriatic arthritis and had no significant benefit. Two attempts DECT of the lumbar spine was not executed correctly. CT lumbar spine and SIJs showed L2/3 endplate and left SIJ erosions mostly related to gout. Rasburicase was introduced. The tophi decreased in size peripherally with marginal improvement in back pain. From this study, we want to bring to the attention of physicians that gout can lead to back pain with inflammatory changes on MRI. We also want to address the importance of other imaging modalities if the cause of the back pain is not clear., Conclusion: This case is meant to highlight an important but overlooked cause of active sacroililitis and inflammatory type back pain in patients who have gout, and to bring to the attention that plain X-ray, MRI and ultrasound cannot differentiate between inflammatory sacroiliitis caused by seronegative arthritis versus gouty arthritis. CT scan can add more information but DECT is the preferred method for differentiation and identification of axial tophaceous gout.

Objectives: Burst spinal cord stimulation (SCS) has been reported to reduce back pain and improve functional capacity in Failed Back Surgery Syndrome (FBSS). However, its mechanism of action is not completely understood. Systemic circulating cytokines have been associated with the development of chronic back pain., Methods: This prospective, feasibility study enrolled 12 refractory FBSS patients with predominant back pain (70% of overall pain) suitable for Burst SCS. Back and leg pain intensity (back pain [VAS B ]/leg pain [VAS L ]), functional capacity (sleep quality [PSQI]), depressive symptoms (BDI), body weight, stimulation parameters, and plasma levels of pro-inflammatory (Il-1b; TNF; HMGB1)/anti-inflammatory (Il-10) cytokines were collected at baseline and after three months of Burst SCS and compared to healthy controls., Results: Pain intensity (pre VAS B : 8.25 ± 0.75 vs. post 1.42 ± 1.24) and functional capacity (PSQI: pre 7.92 ± 3.92 vs. post 3.42 ± 1.24; BDI: pre 20.83 ± 3.56 vs. post 10.92 ± 0.75) significantly improved compared to baseline. Pro-inflammatory HMGB1 remained unchanged (preburst: 3.35 ± 3.25 vs. postburst: 3.78 ± 3.83 ng/mL; p = 0.27; W = -30) versus the HC group (2.53 ± 2.6 ng/mL; p = 0.47; U = 59), while anti-inflammatory IL-10 levels were significantly elevated after burst SCS as compared to baseline (preburst 12.54 ± 22.95 vs. postburst 43.16 ± 74.71 pg/mL; p = 0.03; W = -48) and HC group (HC: 7.03 ± 11.6 vs. postburst 43.16 ± 74.71 pg/mL; p = 0.03; W = -48; p = 0.04). Baseline preburst IL-10 values and preburst VAS B significantly correlated (Spearman correlation r = -0.66; p = 0.05; 95 CI -0.86 to -0.24), while correlation was not significant between postburst IL-10 values and postburst VAS B (Spearman correlation r = -0.49; p = 0.18; 95 CI -0.83 to -0.15). Postburst IL-10 values correlated significantly with postburst PSQI scores (Spearman correlation r = -0.66; p = 0.05; 95 CI -0.86 to -0.24), while no correlation was found between preburst and postburst changes related to the BDI., Conclusions: Burst SCS increased systemic circulating anti-inflammatory IL-10, improved FBSS back pain and back pain associated co-morbidities like disrupted sleep architecture and depressive symptoms in FBSS patients. Thus, suggesting a possible relationship between burst SCS and burst-evoked modulation of peripheral anti-inflammatory cytokine IL-10 in chronic back pain., (© 2017 International Neuromodulation Society.)

Aim: To compare immunochemical and clinical parameters in patients with chronic radicular and myofascial back pain., Material and Methods: A study included 92 patients (55 men and 37 women) with radicular pain syndrome and 97 patients (33 men and 64 women) with myofascial pain syndrome. Pain status was assessed with the differential visual analogous scale (at rest, on movement, at night and during spontaneous pain). Tensor algometry was used to measure pain intolerance thresholds at day and night. Levels of natural antibodies (nAB) to endogenous pain regulators (β-endorphin, orphanin, serotonin, dopamine, histamine and angiotensin) were determined in the blood serum by ELISA. Patients were examined at admission to the hospital, on 10th and 21st days of treatment., Results and Conclusion: There was a significant decrease in pain syndrome in all patients to the 21st day. Pain intensity was higher in patients with radicular pain syndrome (р<0.05) in all functional states. Pain intolerance thresholds were initially reduced in both groups. No significant between-group differences in the dynamics were not found either in men or women. Women had lower pain intolerance thresholds compared to men. An analysis of nAB profiles to pain regulators showed that they were correlated with higher and high indices, with the predominance of nAB to β-endorphin, orphanin and histamine in both groups. The increased levels of antibodies circulate in the blood serum of patients with dorsalgia for a long time can further be a factor of pain chronification.

Back pain brings about one of the heaviest burden of disease. Despite much research, this condition remains poorly understood, and effective treatments are frustratingly elusive. Thus, researchers in the field need to consider new hypotheses. Vitamin C (ascorbic acid) is an essential cofactor for collagen crosslinks, a key determinant of ligament, tendon, and bone quality. Recent studies have reported high frequency of hypovitaminosis C in the general population. We hypothesized that lack of vitamin C contributes to poor collagen properties and back pain. We conducted this study to examine the associations between serum concentration of vitamin C and the prevalence of spinal pain and related functional limitations in the adult general population. This study used nationwide cross-sectional data from the U.S. National Health and Nutrition Examination Survey (NHANES) 2003-2004. Data were available for 4742 individuals aged ≥20 years. Suboptimal serum vitamin C concentrations were associated with the prevalence of neck pain (adjusted odds ratio [aOR]: 1.5; 95% confidence interval [CI]: 1.2-2.0), low back pain (aOR: 1.3; 95% CI: 1.0-1.6), and low back pain with pain below knee (aOR: 1.3; 95% CI: 1.0-1.9) in the past 3 months, self-reported diagnosis of arthritis/rheumatism (aOR: 1.4; 95% CI: 1.2-1.7), and related functional limitations' score (adjusted difference of means [aB]: 0.03; 95% CI: 0.00-0.05). The prevalence of hypovitaminosis C in the general population is high. Our study shows associations between vitamin C and spinal pain that warrant further investigation to determine the possible importance of vitamin C in the treatment of back pain patients.

Conventional reversed clinicopathological conference (RCPC) is an educational method to interpret labora- tory data. In this RCPC, physicians and several specialists in laboratory medicine discussed laboratory data of a patient with tuberculous spondylitis who complained of back pain and general fatigue. Then, they and the moderators held a question-and-answer session with an audience in a hall, and they tried to understand the detailed state of the patient. This discussion revealed the usefulness of RCPC to elucidate the clinical state of patient. At the same time, we can understand the limits of laboratory data analysis. [Review].

Aims: To investigate the relationship between omentin-1 levels and painful temporomandibular disorders (TMD)., Methods: In a case-control design, chronic painful TMD cases (n = 90) and TMD-free controls (n = 54) were selected from participants in the multisite OPPERA study (Orofacial Pain: Prospective Evaluation and Risk Assessment). Painful TMD case status was determined by examination using established Research Diagnostic Criteria for TMD (RDC/TMD). Levels of omentin-1 in stored blood plasma samples were measured by using an enzyme linked immunosorbent assay. Binary logistic regression was used to calculate the odds ratios (ORs) and 95% confidence limits (CLs) for the association between omentin-1 and painful TMD. Models were adjusted for study site, age, sex, and body mass index., Results: The unadjusted association between omentin-1 and chronic painful TMD was statistically nonsignificant (P = .072). Following adjustment for covariates, odds of TMD pain decreased 36% per standard deviation increase in circulating omentin-1 (adjusted OR = 0.64; 95% CL: 0.43, 0.96; P = .031)., Conclusion: Circulating levels of omentin-1 were significantly lower in painful TMD cases than controls, suggesting that TMD pain is mediated by inflammatory pathways.

To investigate the association between smoking and clinical, inflammatory and radiographic parameters in patients with ankylosing spondylitis (AS). One hundred and six tumour necrosis factor inhibitor naïve patients with AS were included in the study. The erythrocyte sedimentation rate, C-reactive protein, Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI) and modified Stroke AS Spine Score (mSASSS) were assessed cross-sectionally for each patient. Smoking history was obtained, and smoking pack years were calculated. Current smokers had significantly higher BASDAI (p < 0.001) and a trend for higher BASFI (p = 0.059). Ever smokers had significantly higher BASFI (p = 0.035) and a trend for higher mSASSS (p = 0.063) compared to never smokers. Pack years (smoking intensity) were positively correlated with duration of inflammatory back pain (r = 0.628, p < 0.001), BASFI (r = 0.443, p < 0.001) and mSASSS (r = 0.683, p < 0.001). Multivariate regression analyses showed that current smoking was independently associated with a higher BASDAI score [regression coefficient (B) = 14.75, p < 0.001] and increasing pack years were independently associated with higher mSASSS (B = 0.26, p = 0.005). In patients with AS, current smoking was strongly and independently associated with higher disease activity, and cumulative smoking exposure with more radiographic spinal damage. In AS smokers, smoking cessation should be strongly recommended.

Objectives: To investigate DKK-1 and SOST serum levels among patients with recent inflammatory back pain (IBP) fulfilling ASAS criteria for SpA and associated factors., Methods: The DESIR cohort is a prospective, multicenter French cohort of 708 patients with early IBP (duration >3 months and <3 years) suggestive of AxSpA. DKK-1 and SOST serum levels were assessed at baseline and were compared between the subgroup of patients fulfilling ASAS criteria for SpA (n = 486; 68.6%) and 80 healthy controls., Results: Mean SOST serum levels were lower in ASAS+ patients than healthy controls (49.21 ± 25.9 vs. 87.8 ± 26 pmol/L; p<0.0001). In multivariate analysis, age (p = 5.4 10-9), CRP level (p<0.0001) and serum DKK-1 level (p = 0.001) were associated with SOST level. Mean DKK-1 serum levels were higher in axial SpA patients than controls (30.03 ± 15.5 vs. 11.6 ± 4.2 pmol/L; p<0.0001). In multivariate analysis, DKK-1 serum levels were associated with male gender (p = 0.03), CRP level (p = 0.006), SOST serum level (p = 0.002) and presence of sacroiliitis on radiography (p = 0.05). Genetic association testing of 10 SNPs encompassing the DKK-1 locus failed to demonstrate a significant contribution of genetics to control of DKK-1 serum levels., Conclusions: DKK-1 serum levels were increased and SOST levels were decreased among a large cohort of patients with early axial SpA compared to healthy controls. DKK-1 serum levels were mostly associated with biological inflammation and SOST serum levels.

Background: Careful interpretation of discordant results in high-sensitivity troponin measurements is necessary in cases of suspect immunoassay interferences. We describe several procedures taken in a case of a polymorbid patient with chest pain, without clear evidence of myocardial necrosis and with increased high-sensitivity cardiac troponin T (hs-cTnT). We checked the Vafaie's algorithm for the evaluation of suspect interference in troponin measurements., Methods: We conducted a case report analysis, additional measurements, a dilution test and pretreatment of plasma with blocking agents., Results: Concentration of hs-cTnT (99 th percentile of "healthy" population 14 ng/L) increased from 120.1 ng/L to 280.4 ng/L during an 8-month period and decreased to 216.3 ng/L during the following month with repeatedly negative troponin I (TnI), hs-cTnI, myoglobin and creatine kinase MB (CK-MB). Suspected false positivity of hs-cTnT was further confirmed by treatment of plasma with an antiheterophile blocking agent (hs-cTnT before treatment 280.4 ng/L, after 16.53/16.23 ng/L). This outcome was further confirmed by the manufacturer's experiments., Conclusions: The false-positive results of hs-cTnT were caused by the presence of extremely rare high molecular weight protein, presumably IgM, most likely HAMA (human anti-mouse antibody). Only the pre-treatment of plasma with a blocking agent provided a reliable indication of the interference. Cooperation among clinicians, laboratory personnel and the manufacturer is essential., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: To evaluate the diagnotic value of the Assessment of Spondyloarthritis International Society (ASAS) classification criteria for axial spondyloarthritis (SpA) in Chinese patients with chronic back pain and without radiographic sacroiliitis in a 2-year follow-up study., Methods: Patients with chronic back pain ≥ 3 months, onset age ≤ 45 years and without radiographic sacroiliitis were enrolled, and then received 2-year follow-up. All the clinical parameters associated with SpA were recorded. The patients were followed for 2 years and the final diagnosis of axial SpA or non-SpA was confirmed by rheumatologists. Diagnostic concordance between the initial classification according to three classification criteria (ASAS criteria for axial SpA, European Spondylarthropathy Study Group (ESSG) criteria and Amor criteria) and final diagnosis was compared. Diagnostic sensitivity and specificity were compared between the two subsets of ASAS criteria (set 1: sacroiliitis plus more than one SpA feature; set 2: HLA-B27 plus two more SpA features)., Result: One thousand and sixty-eight patients entered the study and 867 completed the 2-year follow-up (455 axial SpA and 412 non-SpA). The concordance of ASAS criteria was better than ESSG and Amor criteria. Three hundred and thirty-three patients and 335 patients were classified as axial SpA according to the ASAS set 1 and set 2 of criteria, respectively. Further, set 1 of criteria (318/333) showed higher specificity than set 2 critera (279/335) (P = 0.000)., Conclusion: The ASAS classification criteria for axial SpA showed good concordance in diagnosing Chinese axial SpA patients in this prospective study. Set 1 criteria involving sacroiliitis plus more than one SpA feature had better diagnosing value., (© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Context: Normeperidine accumulates in patients with impaired renal function and may cause central neurotoxicity. However, some uremic patients still undergo meperidine treatment for chronic pain., Objectives: To prevent normeperidine side effects and complications, we investigated the clearance rate and extraction ratio of meperidine and normeperidine in hemodialysis patients with chronic pain., Methods: Three hemodialysis patients, with diagnoses of chronic pancreatitis, chronic back pain, and intractable intra-abdominal pain, received long-term (more than six months) administration of meperidine for chronic noncancer pain. During regular hemodialysis, 72 blood samples in total were collected from the afferent port, efferent port, and ultradiafiltrate port at eight time points. The plasma concentrations of meperidine and normeperidine were determined by high-performance liquid chromatography., Results: The prehemodialysis plasma concentrations of meperidine and normeperidine were 2963 ± 315 and 2369 ± 1974 ng/mL, which declined to 591 ± 109 and 853 ± 765 ng/mL, with 80% and 65% reduction, respectively. The plasma clearance and extraction ratios of meperidine were 22.7 ± 9.8 mL/minute and 10.1 ± 5.6% and for normeperidine 26.0 ± 11.4 mL/minute and 10.8 ± 2.5%, respectively., Conclusion: Hemodialysis can efficiently remove meperidine and its active metabolite, normeperidine, in uremic patients receiving long-term meperidine therapy for chronic noncancer pain., (Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to investigate the relationship between Spondyloarthritis Research Consortium of Canada (SPARCC) enthesitis index and disease activity and health-related quality of life in patients with ankylosing spondylitis (AS)., Methods: Eighty-six AS patients not receiving antitumour necrosis factor (TNF) therapy were included in the study. Spinal pain by visual analogue scale (pain VAS rest and activity), disease activity by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), functional capacity by Bath Ankylosing Spondylitis Functional Index (BASFI), enthesitis severity by SPARCC index, quality of life by Short Form-36 (SF-36), and Bath Ankylosing Spondylitis Metrology Index (BASMI) were assessed in patients. In the laboratory evaluations, the erythrocyte sedimentation rates and serum C-reactive protein levels of the patients were determined., Results: All participants were aged between 18 and 65 years, with a mean age of 36.9 ± 11.13 years. The most frequent region of enthesitis was Achilles tendon insertion into calcaneum (55.8%). Pain VAS rest and activity, BASFI and all parameters of SF-36 were significantly different in AS patients with and without enthesitis. SPARCC index was significantly correlated with pain VAS activity (P < 0.05), pain VAS rest, BASDAI, BASFI and all parameters of SF-36 (P < 0.001). There were no correlations between SPARCC index and BASMI, disease duration and laboratory parameters (P > 0.05)., Conclusion: The clinical assessment of enthesitis in AS is an important outcome measure, and enthesitis indexes such as SPARCC enthesitis index can be valuable tools in the evaluation of disease activity in AS patients not receiving anti-TNF therapy., (© 2013 The Authors International Journal of Rheumatic Diseases © 2013 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd.)

Objectives: To investigate the relationships between inflammation, nocturnal back pain and fatigue in ankylosing spondylitis (AS) and the impact of 12 weeks' etanercept treatment versus sulfasalazine or placebo., Methods: Data were combined from four clinical trials for patients with AS who received at least one dose of etanercept, sulfasalazine or placebo and had at least one postbaseline assessment value. Linear regression was performed (controlling for site, protocol and demographics), to explore the relationship between inflammation (C-reactive protein [CRP]), nocturnal back pain (visual analog scale [VAS] 0-100 mm) and fatigue (VAS 0-100 mm Bath AS Disease Activity Index fatigue item)., Results: Out of 1283 patients (etanercept, n = 867; sulfasalazine, n = 187; placebo, n = 229), improvement in nocturnal back pain was a significant predictor of improvement in fatigue. Significant correlations were found between nocturnal back pain and fatigue, but not CRP levels. Etanercept provided significantly greater pain/fatigue improvement than sulfasalazine or placebo. Improvements in nocturnal back pain and fatigue had weak relationships with improvement in inflammation (CRP level)., Conclusions: AS patients treated with etanercept demonstrated superior improvement in nocturnal back pain and fatigue versus sulfasalazine or placebo. Decrease in nocturnal back pain can improve fatigue. Assessing treatment response using CRP levels alone may be misleading without also examining patient-reported outcomes such as back pain and fatigue.

Background: Back pain is a major public health problem due to its high frequency, to the resulting activity constraint, and the need for surgery in many cases. Back pain is more frequent in women than men, mainly in postmenopausal women. High prevalence of hypovitaminosis D has been detected in postmenopausal women, and it is associated with decreased bone mass, sarcopenia, vertebral fractures, and inflammation, which can be related to back pain., Methods: The relation between back pain and hypovitaminosis D was evaluated in this study, as well the difference regarding the number of bedridden days, number of days away from work, and daily activities limitation between women with and without hypovitaminosis D. This study reviewed baseline data from an interventional phase III multicenter trial in low bone mass postmenopausal women. The study included demographic data, 25OHD determinations, Newitt/Cummings questionnaire on back pain, and vertebral fracture identified thought X-ray evaluation., Results: The trial included 9354 participants, but only 9305 underwent all the evaluations. The age median was 67 (60 - 85 years old) and age at menopause was 49 (18 - 72 years). Hypovitaminosis D was found in 22.5% of the subjects, 15.3% of them had vertebral fractures, 67.5% with back pain, and 14.8% reduced their daily activities in the previous six months. Subjects with hypovitaminosis D, compared to those without hypovitaminosis D, reported more back pain (69.5 v 66.9%, p: 0.022), more cases of severe back pain (8.5% v 6.8%, p: 0,004), higher limitation in their daily activities (17.2 v 14.0%, p: 0.001), and more fractures (17.4 v 14.6%, p: 0,002); also, they had more trouble to perform daily activities addressed in the Newwit/Cummings questionnaire., Conclusion: Hypovitaminosis D was related to back pain, to its severity, and to difficulty in perform daily activities., Trial Registration: ClinicalTrial.gov: NCT00088010.

The concept of inflammatory back pain (IBP) evolved in the 1970s, coincident with the discovery of the HLA-B27 association with ankylosing spondylitis (AS), leading to the development of criteria to determine the presence of IBP. The concept of IBP and it relationship with AS and axial spondyloarthritis (AxSpA) has further evolved, and an instrument developed (the Spondylitis Association of America Back Pain Tool), which was further modified and field tested for use in the 2009 to 2010 National Health and Nutrition Examination Survey (NHANES). This has shown the frequency of chronic back pain to have risen to 19.4%, with nearly one third having IBP. The prevalence of AxSpA has been defined at 1.0% to 1.4% and AS at 0.52% to 0.55%. The national prevalence of HLA-B27 in the United States is 6.1%, and intriguing data from NHANES 2009 suggest a decreasing frequency with increasing age. From this arise new questions and a work agenda ahead.

Recent theories have suggested that chronic pain could be partly maintained by maladaptive physiological responses of the organism facing a recurrent stressor. The present study examined the associations between basal levels of cortisol collected over seven consecutive days, the hippocampal volumes and brain activation to thermal stimulations administered in 16 patients with chronic back pain and 18 healthy control subjects. Results showed that patients with chronic back pain have higher levels of cortisol than control subjects. In these patients, higher cortisol was associated with smaller hippocampal volume and stronger pain-evoked activity in the anterior parahippocampal gyrus, a region involved in anticipatory anxiety and associative learning. Importantly, path modelling-a statistical approach used to examine the empirical validity of propositions grounded on previous literature-revealed that the cortisol levels and phasic pain responses in the parahippocampal gyrus mediated a negative association between the hippocampal volume and the chronic pain intensity. These findings support a stress model of chronic pain suggesting that the sustained endocrine stress response observed in individuals with a smaller hippocampii induces changes in the function of the hippocampal complex that may contribute to the persistent pain states.

Purpose: To assess the association of serum 25-hydroxy-calciferol levels with pain and low back function in patients with failed back surgery syndrome., Methods: Records of 6 men and 3 women aged 25 to 54 (mean, 39.2) years who had failed back surgery syndrome after pedicular screw and rod instrumentation for lower lumbar degenerative diseases were reviewed. They had moderate-to-severe pain (visual analogue scale [VAS] score of >6) and low back function disability (Japanese Orthopaedic Association [JOA] back score of <10). In all patients, the serum 25-hydroxy-calciferol level was <30 ng/ ml, indicating vitamin D deficiency. Vitamin D2 (20 000 IU per day) was given for 10 days, and vitamin D3 (600 IU per day) was given for maintenance. Patients were followed up at months 3 and 6. Three men and 4 women aged 27 to 55 (mean, 41.3) years who were age- and disease-matched but achieved good outcomes (VAS score of 0-1 and mean JOA low back score of 14.7) were used as indirect referents. All 7 matched patients except one had a normal serum 25-hydroxy-calciferol level (mean, 40.6 ng/ml)., Results: In the 9 patients with failed back surgery syndrome, the mean duration of chronic pain was 2.6 years; the mean VAS score for pain was 7.7; the mean JOA low back score was 7.6; the mean number of reoperations was 2.2; and the mean serum 25-hydroxy-calciferol level was 17.0 ng/ml. Two male patients had grade-IV motor weakness and decreased sensory function based on the pin prick test. One patient had a history of prolonged (>3 months) antibiotic use after primary surgery, but had no evidence of infection. Six months after vitamin D2 and vitamin D3 supplementation, the mean serum 25-hydroxy-calciferol level improved significantly (17.0 vs. 42.5 ng/ml), as did the mean pain score (7.7 vs. 4.2) and mean JOA back score (7.6 vs. 11.1). Seven of the patients had a pain score of <6 and a JOA back score of >10, the remaining 2 patients had neurological deficits and only slight improvement., Conclusion: Vitamin D supplementation may be used as an adjuvant treatment for patients with failed back surgery syndrome.

Ms TS is a 66-year-old woman who receives warfarin for prevention of systemic embolization in the setting of hypertension, diabetes, and atrial fibrillation. She had a transient ischemic attack about 4 years ago when she was receiving aspirin. Her INR control was excellent; however, over the past few months it has become erratic, and her average dose required to maintain an INR of 2.0 to 3.0 appears to have decreased. She has had back pain over this same period and has been taking acetaminophen at doses at large as 650 mg four times daily, with her dose varying based on her symptoms. You recall a potential interaction and wonder if (1) her acetaminophen use is contributing to her loss of INR control, and (2) does this interaction place her at increased risk of warfarin-related complications?

Background: Deficiency of vitamin D has been reported in patients with many types of musculoskeletal pain. The present study was designed to determine the association between serum 25-hydroxyvitamin D [25-(OH)D] deficiency and nonspecific skeletal pain., Methods: A total of 276 patients with nonspecific skeletal pain at different regions of the skeletal system diagnosed as leg pain, widespread pain, arthralgia, rib pain, back pain and fibromyalgia were compared with 202 matched controls with regard to mean serum 25-(OH)D level and 25-(OH)D deficiency. Serum 25-(OH)D was measured by enzyme-linked immunosorbent assay method and levels < 20 ng/mL were considered as deficient. Nonparametric one-way analysis of variance, Kruskal Wallis and Wilcoxon tests were used for group comparisons. Multiple logistic regression analysis with calculation of adjusted odds ratio (OR) and 95% confidence interval (95% CI) were performed to determine associations., Results: In patients with nonspecific skeletal pain the mean 25-(OH)D was significantly lower (P = 0.0001) and the proportion of 25-(OH)D deficiency was significantly higher (63.4%vs. 36.1%, P = 0.0001) compared with controls. There was a significantly positive association between 25-(OH)D deficiency and skeletal pain (OR = 2.94, 95% CI = 1.01-4.3, P = 0.0001). The strength of association varied across the groups with strongest association observed with leg pain (OR = 7.4; 95% CI = 3.9-13.9, P = 0.0001) followed by arthralgia (OR = 3.9, 95% CI = 2.1-7.1, P = 0.0001) and widespread pain (OR = 2.8, 95% CI = 1.1-6.6, P = 0.020) but no association with back pain and fibromyalgia. There was a greater positive associations in women compared with men (OR = 2.1, 95% CI = 1.1-4.3, P = 0.001)., Conclusion: The results of this study indicate a positive association of vitamin D deficiency with a variety of nonspecific bone pain, particularly in women. More studies with larger samples are required to confirm these findings. Increasing serum vitamin D to sufficient levels and longitudinal follow-up of patients may provide further evidence in relation to vitamin D deficiency and skeletal pain.

Study Design: Cross sectional and prospective observational study in Japanese postmenopausal women., Objective: The aim of the study was 2-fold. The first was to investigate what kind of comorbidities could be found in conjunction with back pain in Japanese postmenopausal women. The second was to investigate whether significant relationship between baseline back pain and future fracture exists or not., Summary of Background Data: Back pain has been reported to be associated with vertebral degeneration or vertebral fracture. However, there has been no available data that indicates the relationship between back pain and future fracture risks., Methods: The subjects who visited their practitioner were examined for their prevalent back pain or pains in other site. Bone mineral density, body height, body weight, and serum parameter were measured at baseline, and comorbidities were investigated by interview. Fragility fractures were also assessed at baseline and then followed up with 1- to 2-year intervals. The correlation between back pain and baseline characteristics was investigated by logistic regression analysis. The hazard ratio of back pain to future vertebral fracture was estimated by multivariate Cox regression analysis., Results: A total of 899 postmenopausal ambulatory women (62.5 +/- 10.3 years old) were enrolled and 81 subjects were dropped out from the study within 1 year. The remaining 818 postmenopausal women (62.1 +/- 10.3 years) were followed-up for 5.7 +/- 3.5 years. Compared to the group without pain, the group with back pain had significantly higher age, lower bone mineral densities at lumbar spine and hip, and higher number of prevalent vertebral fractures. The back pain was significantly associated with rheumatic arthritis (odds ratio [OR]: 2.01, P < 0.05), prevalent vertebral fracture (OR: 4.60, P < 0.001) and osteoporosis (OR: 2.14, P < 0.001). A total of 189 future fractures were observed, of which the most frequent was vertebral fractures (78.3%). The fact that baseline back pain was a significant risk factor for time-dependent vertebral fractures (hazard ratio: 1.62, 95% confidence interval: 1.16-2.27, P = 0.005) was demonstrated by the Cox hazards model after adjusting for traditional risk factors, such as age, bone mineral density, and prevalence of vertebral fractures., Conclusion: The data obtained in this study indicated that the back pain is significantly associated with osteoporosis and rheumatoid arthritis and that it can be useful predictor for future vertebral fracture risk in Japanese postmenopausal women in clinical settings.

Introduction: The back pain associated to intervertebral prolapsed disc is a frequent pathology, that produces in many cases severe work-disability. The mechanisms of pain generation are controversial, the mechanical theories of nerve compression have been weak for explaining severe pain in patients with low protrusion grades., Development: In the last years several studies have been accomplished in order to determinate the contribution of inflammatory phenomena into the intervertebral disc disease's evolution. Abnormal values of cytokines like TNF-alpha, IL-1 beta, IL-6, and other molecules related with the immune system have been found, although the available studies are inconsistent. The analysis of immune cells in the intervertebral disc is in the same way contradictory, but the presence of macrophages appears constantly. The variability might be originated by the self-heterogeneity of the immune system in a disease with repeated episodes of injury-reparation that could conduce to deregulation and progressive tissular damage., Conclusion: Until now it seems clear the association of macrophages in the pathologic degeneration of the intervertebral disc, but the interaction of these in this microenvironment not totally. The understand of the cellular and molecular networks is fundamental for explaining the poor correlation between clinical and radiological findings, in addition to the potential impact on the actual management applied.

We evaluated bone turnover using biochemical markers in 273 women over 60 years of age with suspected osteoporosis. Their age range was 60-96 years, with an average of 72.7 years. Patients with disorders that might affect bone metabolism were excluded. Those complaining of back pain within 6 months before or after examination were assigned to the back-pain group. Serum bone-specific alkaline phosphatase (BAP) was measured as a bone formation marker, and the urinary N-terminal telopeptide of type I collagen (NTX) was measured as a bone resorption marker. Both BAP and NTX levels increased in individuals over 60 years of age; moreover, these markers were significantly higher in subjects aged over 80 years. Among elderly patients, both BAP and NTX levels were significantly higher in those with back pain than in those without, and in a similar way were observed to increase in parallel with age from the 60-year point. We found that both NTX and BAP increased with aging, and that the increase in these bone turnover markers was closely related to back pain. We also showed that NTX and BAP levels increased significantly in women over 80 years, and specifically in patients with back pain.

Objectives: Sarcoidosis is a chronic granulomatous multisystem disease in which arthritis is relatively common. Arthritis of the sacroiliac joints (sacroiliitis) has been described in sarcoidosis but is thought to be rare. The objective of this study was to determine the prevalence of sacroiliitis in a secondary-care population of patients with sarcoidosis., Methods: Patients attending a specialist secondary-care sarcoidosis clinic underwent evaluation of spinal symptoms using a standard back pain questionnaire, examination of spinal mobility, and laboratory measurements of erythrocyte sedimentation rate, C-reactive protein, serum angiotensin-converting enzyme, and neopterin/creatinine ratio. Tissue typing for the presence of the human leukocyte antigen (HLA)-B27 allele was undertaken. Radiographs of the sacroiliac joints were obtained in each patient and reviewed independently by two observers; a further observer reviewed disputed radiographs., Results: Sixty-one patients completed the assessments (80.3% of all patients invited to participate). Forty-nine of 61 patients (80.3%) reported having back pain at some point in their lives. Thirty-one of 61 patients (50.8%) had a score on the back pain questionnaire suggestive of inflammatory spinal disease, but only 3 of these patients had erosive damage of the sacroiliac joints on radiography indicating sacroiliitis. One further patient had erosive damage on radiography, making a total of four individuals with evidence of sacroiliitis, a prevalence of 6.6%. Four patients (one patient with sacroiliitis) were positive for HLA-B27. The back pain questionnaire had a sensitivity of 75% and a specificity of 51% for sacroiliitis in this population., Conclusion: The prevalence of spondyloarthropathy in the normal population has been estimated to be 1.9%. In the sarcoid population studied the prevalence was 6.6% suggesting a possible association between these two conditions. The standard back pain questionnaire for the identification of inflammatory spinal disease had a low sensitivity and specificity in this population.

Serum magnesium and calcium was examined in 70 patients with chronic dorsalgias. Values of calcium were stabilized, but values of magnesium were unstable and exceeded the 2SD lines, being more often over than under these lines. Lability of serum magnesium levels is considered a secondary consequence, caused by the stress of pain. These symptoms may be alleviated by Mg administration, by local application of Mg through transdermic iontophoresis or sonophoresis, or by hydropathy of the paravertebral muscles.

Study Design: One-dimensional polyacrylamide gel electrophoresis was used to study serum esterase enzymatic activity in three groups of patients and one group of normal volunteers., Objectives: To determine whether there is a statistically significant correlation between variations of serum pseudocholinesterase and the perception of pain in patients with chronic spinal pain., Summary of Background Data: Changes in levels of cholinesterase in the extracellular space of the brain and in the cerebral spinal fluid have been found to be associated in animal pain experimentation., Methods: Ninety-three surgical patients with chronic spinal pain, six surgical control subjects operated for conditions not associated with pain, 21 normal control volunteers, and nine disabled patients receiving monetary benefits were studied. The patients were analyzed for a period of time by rating the perception of their pain with a visual assessment score at the time venous blood was drawn. Serum samples were prepared, serum pseudocholinesterase was monitored, separated, and quantified according to Allen et al.5 Paired sample t tests were used to statistically evaluate the data., Results: A trend of correlation was noted between preoperative serum pseudocholinesterase levels and visual assessment score: serum pseudocholinesterase levels increased as visual assessment score increased. The mean preoperative serum pseudocholinesterase level of chronic spinal pain patients (1313; SE = 26), which was significantly higher than the mean levels of the normal control volunteers (941; SE = 24; P<0.001) and that of surgical control subjects (1018; SE = 63; P <0.01), decreased significantly with anesthesia (P<0.005). The mean preoperative serum pseudocholinesterase level of the surgical controls, however, remained unchanged with anesthesia. A correlation demonstrated between visual assessment score and serum pseudocholinesterase in chronic spinal pain patients was not observed in six of nine patients receiving disability payments for more than a year., Conclusions: Measurements of quantitative alterations of serum pseudocholinesterase levels may be useful in the treatment of patients with chronic spinal pain.

We report on an elderly woman suffering from an acutely bleeding duodenal ulcer. Apart from old age and a history of gastrointestinal ulcer there were no risk factors detectable. However, clinical examination revealed that the patient had put a diclofenac hydroxyethylpyrrolidine plaster, which had been prescribed for lower back pain, inadvertently on a large ulcus cruris. The diclofenac serum concentration was 80 mu/l corresponding to a therapeutic serum level. This case demonstrates that false application of new pharmaceutical formulation may lead to inadvertent side-effects.

Objective: Our purpose was to study the relationship between serum relaxin levels and back pain during pregnancy., Study Design: A prospective clinical cohort study with repeated examinations was performed., Results: There was an initial increase of relaxin levels until a peak value at the twelfth week followed by a decline until the seventeenth week. Thereafter stable serum levels around 50% of the peak value were recorded. Three months after delivery serum relaxin was not detectable. There was a significant correlation between mean serum relaxin levels during the pregnancy and symphyseal pain or low back pain occurring during late pregnancy as measured by medical history or pain-provoking test., Conclusion: Relaxin is known to remodel pelvic connective tissue in several mammalian species during pregnancy. The current data suggest that relaxin might be involved in the development of pelvic pain in pregnant women.

We prospectively studied the prevalence of lupus anticoagulant, anticardiolipin antibodies (aCL) and various haemostatic parameters in 71 patients with migraine and compared the results with a control group of 32 subjects with back pain never having experienced migraine. The patients with migraine were divided into two groups: group I with migraine without (n = 18) and with aura lasting less than 60 min (n = 24) and group II with migraine with prolonged aura or migrainous infarction (complicated migraine, n = 29). The following results were obtained: a) no difference in aCL positivity was noted between migrainous patients and controls and between common migraine and complicated migraine patients and b) no statistically significant difference in haemostatic parameters (except for thrombin-antithrombin III complexes) was found between the two groups of migraine and between aCL positive and negative migrainous patients. These data suggest that anticardiolipin antibodies are not involved in the pathogenesis of migraine complications.

A critical need in assessing the clinical utility of manipulative therapy for back pain is the identification of biological changes associated with the forces applied by spinal manipulation. Such changes could then serve as markers for both sham treatment and manipulation. We determined the priming of polymorphonuclear neutrophils for an enhanced respiratory burst and its duration, the priming of mononuclear cells for enhanced endotoxin-stimulated tumor necrosis factor production and plasma levels of substance P following a single thoracic spine manipulation. There was a significant difference in the respiratory burst of polymorphonuclear neutrophils in response to a particulate challenge, depending on the time of blood sample collection. The response of polymorphonuclear neutrophils isolated from blood collected 15 min after manipulation was significantly higher than the response of cells isolated from blood collected 15 min before and 30 and 45 min after manipulation. Mononuclear cells were also primed for enhanced endotoxin-stimulated tumor necrosis factor production by spinal manipulation. Both of these priming effects were accompanied by a slight, but significant elevation in plasma substance P. The mean manipulation force associated with these biological effects was 878 +/- 99 N. These biological effects may provide a means of monitoring the delivery of both sham and manipulative treatment and, therefore, provide a crucial tool for understanding the efficacy of manipulative therapy.

We analyzed the fibrinolytic system in patients with chronic low back pain using a venous occlusion test to stimulate fibrinolysis, and we subsequently determined the levels of tissue plasminogen activator (TPA) and fast-acting inhibitor of TPA (PAI). There were 20 patients with a mean age of 50 years. Two thirds had radiographically spinal stenosis. Scar tissue around the spinal nerves was seen in 11 cases. Thirteen patients had undergone back surgery, whereas 21 healthy subjects served as controls. In the basal samples, TPA activity was decreased in the patients while TPA antigen level was increased compared with the controls. No clear explanation for this defective function of TPA in the patients was obtained, because no difference was seen in PAI level in basal samples. After the venous occlusion, no difference was observed in TPA activity between the two groups excluding the constitutionally defective fibrinolytic system in the patients. However, our results confirm low basal fibrinolytic activity in patients with chronic low back pain with manifest spinal pathology.

Clinical features, contrast-enhanced lumbar tomographic findings, and biochemical plasma fibrinolytic parameters were critically assessed in 70 patients suffering severe, chronic postsurgical low-back and radicular pain to determine the cause of their persisting symptoms. Patients exhibited gross functional disability and significant impairment of plasma fibrinolytic activity, compared with 84 normal control subjects. This fibrinolytic defect appeared attributable to disproportionate increases in circulating plasminogen activator inhibitor-1 levels. Clinical features were slightly worse in patients with radiologic epidural fibrosis, whereas the frequency of radiologic abnormalities, including epidural fibrosis, was higher in patients with fibrinolytic abnormalities. The results, however, demonstrated no significant associations between patients' symptoms and signs and their biochemical and radiologic abnormalities.

Commercial sources for neuropeptide radioimmunoassays have made this sensitive tool available to clinical investigators for monitoring the potential involvement of neuropeptides in pain modulation. We measured substance P-like immunoreactivity in the plasma, saliva, and pericardial fluid of subjects with and without pain (chronic and acute) to determine if substance P levels are altered. Some recent studies have suggested that substance P in various body fluids may be a correlate of chronic pain. To test this correlation it is important to ensure that the assay is measuring what it was designed to measure. Therefore, the influence of three tachykinins on the analysis of substance P concentrations was assessed with a commercially available radioimmunoassay kit. A small (approximately 2 to 6%), apparently nonspecific elevation in measured substance P was found when alpha-neurokinin, beta-neurokinin, or eledoisin was incubated with substance P and its antibody. Our results also indicate an apparent specific affinity of the substance P antibody for alpha-neurokinin (above 1,000 pg/ml) and beta-neurokinin (above 5,000 pg/ml). Substance P levels in the body fluids we tested ranged from 0.47 to 62.88 pg/mg protein (47.4 to 230.8 pg/ml). Levels of the tested tachykinins have not been determined in body fluids. If alpha-neurokinin or beta-neurokinin is found to be present in high concentrations in these fluids, this commercially available substance P kit may overestimate substance P levels. The concentrations of tachykinins necessary to interfere specifically with the assay are 10- to 100-fold higher than substance P in body fluids.(ABSTRACT TRUNCATED AT 250 WORDS)

We measured beta-endorphin concentrations in peripheral blood mononuclear cells and mitogen-induced T-lymphocyte proliferation in patient who underwent treatment with traditional acupuncture. Traditional acupuncture increased both the concentrations of the opioid in the immune cells and lymphocyte proliferation. Our data are consistent with the hypothesis that traditional acupuncture modulates immune responses in man.

The purpose of this study was to evaluate pain scores and plasma beta-endorphin levels following a single spinal adjustive manipulation in subjects with acute low back pain. Eighteen subjects were randomly assigned to either a control group, which received no treatment; a sham group, which received only light physical contact (touch); or an experimental group, which received an adjustive manipulation at a specific lumbar segment. Following a standard protocol, all subjects were administered visual analog pain scales and venous blood was drawn 5 min prior to, 5 min after, and 30 min after intervention. Analysis of the pain scores indicated that there was a slight, but significant, reduction of pain in the experimental group, but no similar reduction in the control or sham groups. Furthermore, this reduction of pain in the experimental group was not accompanied any significant change in the plasma beta-endorphin concentration.

Serum pepsinogen I was determined radioimmunologically in 18 patients suffering from lumbar backache syndromes. These patients were then treated with lornoxicam 4 mg twice daily over a period of 2 weeks. No significant increase in the serum pepsinogen I level was found in 17 (94.4%) of cases. Using the serum pepsinogen I as a parameter for the integrity of the gastric mucosa, this suggests good gastric tolerance of lornoxicam.