Spine
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A systematic approach to low-back pain is presented that relies on the classification of patients according to their symptoms. Rational systems of physiotherapy are proposed for each group and incorporated into an algorithmn. One hundred forty-two patients with mechanical low-back pain have been treated, and their response has been assessed by means of a postal questionnaire. ⋯ Eighteen percent of patients became completely free of pain, and 59% experienced a reduction in pain level. The most effective treatment was education in back care, followed closely by an exercise program. The responses were different in the various subgroups, and a series of revised flow charts is presented.
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Some of the chronic pains that follow disc rupture, myelography, and discectomy may be due to injury to peripheral nerves or nerve roots. The neural mechanisms underlying these pain syndromes are discussed and possible etiologies examined. The roles of peripheral and central changes in neuronal activity and connectivity are explored: plasticity in the nervous system may either be the cause of pain in the 5% of people who develop chronic pain after nerve injury or what prevents pain in the 95% who do not become painful after nerve injury. More research on the behavior of damaged nerves and their central connections is essential.
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The effect of experimental trauma on the blood flow in the central (essentially gray matter) and peripheral (essentially white matter) regions of the sheep's spinal cord was studied using a radioactive microsphere technique. In seven out of eight animals, a progressive fall in blood flow occurred in both the peripheral and central regions of the cord within 2 hours following injury and remained reduced over the period of recording (up to 12 hours). Changes in local vascular resistance indicated that in approximately 60% of our animals, changes in arterial pressure alone contributed highly significantly to the decreased spinal blood flow. There remains the possibility that early therapeutic intervention could sustain neuronal function where local blood flow would otherwise be inadequate in the damaged spinal cord.
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Comparative Study
Ethnic and sex differences in response to clinical and induced pain in chronic spinal pain patients.
There is widely held clinical opinion and some tentative research justification for stereotypic or ethnic and sex differences in response to pain. To more adequately test this notion, 60 chronic spinal pain patients (black, Mexican American, and Caucasian, with ten men and ten women per group), all having persistent spinal pain for over 1 year, were studied. They were administered the ischemic pain test, a numerical estimate of spinal pain, and two independent raters scaled the amount of pain emphasis, based upon the patient's physical condition and pain behaviors. ⋯ They also indicated that they more nearly approached their pain tolerance. It was concluded that while ethnic and sex differences were found, stereotypic responses were not uniform, and tended to be related to the manner in which that pain was assessed. These results are discussed in light of cultural differences.
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From this literature, we have made the following conclusions: (1) Complete cord lesions do not recover cord functional motor control. (2) Complete lesions recover one nerve root level of function at the fracture site. (3) Partial lesions recover partially. (4) The less the injury, the greater the recovery. (5) Brown-Sequard lesions recover more than central cord syndromes, which recover more than anterior cord syndromes. (6) Reduction of dislocated facets facilitates nerve root recovery. (7) Better documentation of specific pathology and recovery rates are necessary to determine the surgical benefits in complete lesions, incomplete lesions, and nerve root recovery.