Articles: back-pain.
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Nerve growth factor (NGF) is a key regulator of nociceptive pain and thus appears to be an interesting target molecule for an innovative class of analgesic medication. We set out to review the principles of neurogenic inflammation and results of anti-NGF regimens in animal studies as well as clinical trials with patients with back pain and osteoarthritis (OA). ⋯ Anti-NGF agents either alone or in combination with non-steroidal anti-inflammatory agents (NSAIDs) were more efficacious for the treatment of pain in a number of trials of knee and hip pain compared to NSAIDs alone. However, adverse effects that included rapidly progressive OA and joint replacement were more common in patients treated with anti-NGF and NSAIDs than either treatment alone. Anti-NGF treatment related neurologic symptoms including paresthesias, and potentially other types of adverse effects were usually transient but warrant additional investigation.
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Next to conventional x-ray examinations, modern imaging modalities as computed tomography (CT) and magnetic resonance imaging (MRI) play an important role in the assessment of back pain. Guidelines and recommendations should be helpful for the - not always simple - indication for imaging for back pain. However, the latter have to be individually adapted regarding clinical symptoms and appearance for every patient. Choosing the adequate imaging modality depends on several criteria, as the suspected- and differential diagnosis, the acuteness, age of patient and the temporal availability of the examination.
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The differential diagnosis of back pain in children and adolescents is wide. The prevalence of low back pain is increasing with age and after puberty is similar to what is known from the adult population, but in smaller children a structural cause for the pain is more common. Careful history taking and physical examination will help with the decision of when to perform further investigations. This article lists the most common differential diagnoses of back pain in children.
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The treatment of chronic, non-malignant low-back pain is based on the patients' history and the clinical examination. It can be assumed that half of the cases present with a neuropathic pain component which needs to be treated with antidepressive and antiepileptic drugs instead of "pure" analgesics. Opioids should be considered with extreme caution because of their toxicity. ⋯ Their indication must be considered carefully, especially if the invasive diagnostic intervention has no therapeutic consequences. The interventional procedures should only be used as part of a multimodal approach in patients without any psychological problem. The sole use of interventions supports the purely somatic orientation of many patients and thus leads us in the wrong direction.
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Case Reports
[Patient careers in the orthopedic pain treatment : Sociological studies on pain behavior.]
Based on case histories the following study raises the question why some pain patients remain permanently on the path of specialist pain treatment after initial treatment whereas other patients with similar pain reports do not. ⋯ Conceptions of pain and pain behavior are formed in the course of patient careers while this is not necessarily a conscious or reflected process. As an unintended consequence it evolves into pain acting within the patient that integrates patients into distinct care milieus and holds them tight in the respective pain care. In these cases pain patients and their doctors fall so to say into a pain trap.