Gilles Chatellier

Vertebral metastases: a critical appreciation of the preoperative prognostic tokuhashi score in a series of 71 cases.

Study Design. The utility of the Tokuhashi score was assessed in a retrospective study in 71 patients with vertebral metastases. Objectives. To study the importance of the site of the primary tumor as a parameter in the preoperative prognostic Tokuhashi score. Summary of Background Data. A preoperative score composed of six parameters, each rated from zero to two, has been proposed by Tokuhashi for the prognostic assessment of patients with metastases to the spine. Methods. Seventy‐one patients with vertebral metastases were studied. There were 34 cases of thyroid cancer metastases, 28 cases of renal cancer metastases, and nine cases of metastases of unknown origin. In each patient, a local and a systemic tumor search were performed. Patients were divided into groups based on the primary site of the tumor, and each group was analyzed separately. Results. In cases of vertebral metastases of thyroid cancers, surgery to excise single metastases was found to provide good results, as was palliative surgery of multiple metastases. Vertebral metastases of renal tumors were rarely single, and the results of palliative surgery were less satisfactory. Vertebral metastases of unknown primary tumors had a poor outcome, regardless of whether surgery was excisional or palliative. The median survival period in patients with metastases of unknown primary tumors was significantly shorter than that in patients with renal or thyroid cancer metastases. Conclusion. The Tokuhashi preoperative score is successful as a prognostic tool. However, it attributes the same one‐point rating to metastases of renal cancer and to those of unknown primary tumors. In the case of metastases of unknown primary tumors, this rating is too high and should be reduced to 0.

Causes and Mechanisms of Common Coccydynia: Role of Body Mass Index and Coccygeal Trauma

Study Design. A total of 208 consecutive coccydynia patients were examined with the same clinical and radiologic protocol. Objectives. To study radiographic coccygeal lesions in the sitting position, to elucidate the influence of body mass index on the different lesions, and to establish the effect of coccygeal trauma. Summary of Background Data. A protocol comparing standing radiographs and radiographs subsequently taken in the painful sitting position in coccydynia patients and in controls has shown two culprit lesions: posterior luxation and hypermobility. Obesity and a history of trauma have been identified as risk factors for luxation. Methods. Dynamic radiographs were obtained. The body mass index was compared with the coccygeal angle of incidence, sagittal rotation of the pelvis when sitting down, and the presence and time of previous trauma. The patients with the newly described lesions were examined after an anesthetic block under fluoroscopic guidance. Results. Two new coccygeal lesions are described (anterior luxation and spicules). Obesity was found to be a risk factor. The body mass index determines the way a subject sits down, and lesion patterns were different in obese, normal-weight, and thin patients (posterior luxation: 51%, 15.2%, 3.7%; hypermobility: 26.5%, 30.3%, 14.8%; spicules: 2%, 15.9%, 29.6%; normal: 16.3%, 32.6%, 48.1%, respectively;P < 0.0001). Trauma affected the type of lesion only if it was recent (<1 month before the onset of coccydynia), in which case the instability rate increased from 55.6% to 77.1%. Backward-moving coccyges were at greatest risk of trauma. Conclusions. This protocol allows identification of the culprit lesion in 69.2% of cases. The body mass index determines the causative lesion, as does trauma sustained within the month preceding the onset of the pain.

Comparison of three manual coccydynia treatments: a pilot study.

STUDY DESIGN A prospective pilot study with independent assessment and a 2-year follow-up period was conducted. OBJECTIVES To compare and assess the efficacy of three manual coccydynia treatments, and to identify factors predictive of a good outcome. SUMMARY OF BACKGROUND DATA Various manual medicine treatments have been described in the literature. In an open study, the addition of manipulation to injection treatment produced a 25% increase in satisfactory results. Dynamic radiographs of the coccyx allow breakdown of coccydynia into four etiologic groups based on coccygeal mobility: luxation, hypermobility, immobility, and normal mobility. These groups may respond differently to manual treatments. METHODS The patients were randomized into three groups, each of which received three to four sessions of a different treatment: levator anus massage, joint mobilization, or mild levator stretch. Assessment with a visual analog scale was performed by an independent observer at 7 days, 30 days, 6 months, and 2 years. RESULTS The results of the manual treatments were satisfactory for 25.7% of the cases at 6 months, and for 24.3% of the cases at 2 years. The results varied with the cause of the coccydynia. The patients with an immobile coccyx had the poorest results, whereas those with a normally mobile coccyx fared the best. The patients with luxation or hypermobility had results somewhere between these two rates. Levator anus massage and stretch were more effective than joint mobilization, which worked only for patients with a normally mobile coccyx. Pain when patients stood up from sitting and excessive levator tone were associated with a good outcome. However, none of the results was significant because of the low success rate associated with manual treatment. CONCLUSIONS There is a need for a placebo-controlled study to establish conclusively whether manual treatments are effective. This placebo must be an external treatment. A sample size of 190 patients would be required for 80% confidence in detecting a difference.

The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study.

Study Design. Randomized open study. Objective. To evaluate the efficacy of intrarectal manual treatment of chronic coccydynia; and to determine the factors predictive of a good outcome. Summary of Background Data. In 2 open uncontrolled studies, the success rate of intrarectal manipulation of the coccyx was around 25%. Methods. Patients were randomized into 2 groups of 51 patients each: 1 group received three sessions of coccygeal manipulation, and the other low-power external physiotherapy. The manual treatment was guided by the findings on stress radiographs. Patients were assessed, at 1 month and 6 months, using a VAS and (modified) McGill Pain, Paris (functional coccydynia impact), and (modified) Dallas Pain questionnaires. Results. At baseline, the 2 groups were similar regarding all parameters. At 1 month, all the median VAS and questionnaire values were modified by −34.7%, −36.0%, −20.0%, and −33.8%, respectively, in the manipulation group, versus −19.1%, −7.7%, 20.0%, and −15.7%, respectively, in the control (physiotherapy) group (P = 0.09 [borderline], 0.03, 0.02, and 0.02, respectively). Good results were twice as frequent in the manipulation group compared with the control group, at 1 month (36% vs. 20%, P = 0.075) and at 6 months (22% vs. 12%, P = 0.18). The main predictors of a good outcome were stable coccyx, shorter duration, traumatic etiology, and lower score in the affective parts of the McGill and Dallas questionnaires. Conclusions. We found a mild effectiveness of intrarectal manipulation in chronic coccydynia.

Pain immediately upon sitting down and relieved by standing up is often associated with radiologic lumbar instability or marked anterior loss of disc space.

Study Design. Comparison of functional radiographs in consecutive patients with low back pain with or without pain on sitting down and relieved by standing up. Objectives. To detect radiologic signs possibly associated with a clinical symptom. Summary of Background Data. No link has been established between increased vertebral mobility and a specific pain pattern or a clinical symptom. Methods. Forty-two patients seen consecutively with low back pain occurring immediately on sitting down and relieved on standing up were compared with 32 controls whose low back pain did not show this pattern. Dynamic radiographs were taken in extension, erect, flexion, and sitting in the painful position. The segments thought to be responsible for the pain were identified by comparing clinical, radiographic, and magnetic resonance data. Endplate angles, rotation, and translation were measured. The radiographs were read twice each by two independent observers. Results. Eighty-six percent (95% confidence interval, 72–99%) of the patients with the symptom were female. The segments identified as the source of pain were as follows: L4–L5 in 20 cases and L1–L2 to L3–L4 in 22 cases. Mean rotation of these segments was 13.9 ± 4.5° in the patient group versus 7.5 ± 4.3° in the control group (P < 0.001). In 14% of the patients (vs. 3% of controls), it exceeded 20° (P = 0.13). Anterior or posterior translation >10% was seen in 31% of the patients (vs. 0% of controls;P < 0.001). In flexion, the endplate angle was −5.2 ± 3.6° (patients) versus 1.2 ± 5.7° (controls) (P < 0.01) and <−5° in 55% of patients versus 12.5% of controls (P < 0.001). This value of <−5° was associated with marked anterior loss of disc space. Conclusion. Low back pain occurring immediately on sitting down and relieved on standing up was statistically associated with instability (specificity 100%, sensitivity 31%) or marked anterior loss of disc space in flexion (specificity 87%, sensitivity 55%).

Coccygectomy for instability of the coccyx

Between 1993 and 2000, 61 patients with instability-related coccygodynia were operated on by a single surgeon using the same technique. There were 49 women and 12 men, mean age 45.3 (18–72) years. Twenty-seven patients had hypermobility of the coccyx and 33 subluxation. In all cases, the unstable portion was removed through a limited incision directly over the coccyx. The outcome was assessed using a detailed questionnaire. Follow-up was between 12 months and more than 30 months. The outcome was rated excellent or good in 53 patients, fair in one, and poor in seven. There were nine patients with infection requiring reoperation.RésumeEntre 1993 et 2000, 61 malades avec une coccygodynie lié à une instabilité ont été opérés par un seul chirurgien, en utilisant la même technique. Il y avait 49 femmes et 12 hommes, d’âge moyen âge 45.3 ans (18–72). Vingt-sept malades avaient une hypermobilité du coccyx et 33 une subluxation. Dans tous les cas, la portion instable a été enlevée par une incision limitée, directement sur le coccyx. Le résultat a été apprécié en utilisant un questionnaire détaillé. Le suivi était entre 12 mois et plus de 30 mois. Le résultat a été estimé excellent ou bon pour 53 malades, moyen pour un, et mauvais pour sept. Il y avait neuf malades avec une infection qui a nécessité une réintervention.

Assessment of sexual activity in patients with back pain compared with patients with neck pain.

Recent research has shown significant adverse effects of chronic low back pain on sexual activity in 46% of patients. To establish whether and how chronic low back pain adversely affects sexual activity, a questionnaire-based study was conducted on a patient group (low back pain) and a comparison group (neck pain). Patients were administered a visual analog scale, a series of conventional questionnaires, and a specifically designed sexual activity questionnaire covering frequency of intercourse before and since onset of pain, discomfort during intercourse, satisfaction with sexual life, and comfortable and uncomfortable basic coital positions. Patients with low back pain reported more interference than did patients with neck pain, and women with low back pain were more affected than men. Compared with the other groups, women with low back pain had greater reduction in frequency of intercourse, more marked discomfort during intercourse, and more interference with their sexual lives. The most pain generating position was prone for both genders, and the most comfortable one was supine. Sexual impairment, more marked in women, seems to be related to the triggering of pain by intercourse and to psychologic factors.

Altered lower limb vascular perfusion in patients with sciatica secondary to disc herniation.

Study Design The present study attempts to document deep vascular abnormalities of the lower extremity in cases of sciatica secondary to discal herniation using Tc‐99m methylene diphosphonate angiography. Objectives Vascular abnormalities are studied compared with the contralateral extremity and normal control subjects. An attempt is made to determine the clinical usefulness of the current technique. Summary of Background Data Thermography has occasionally evidenced a decreased cutaneous temperature in patients with sciatica. There have been no studies to date looking at the total vascular flow in this condition, mainly constituted by the muscular perfusion. Methods Thirty patients with sciatica secondary to discal herniation, 16 patients with chronic low back pain referred to the thigh, and 31 control subjects were examined by isotopic angiography of the posterior aspect of the thigh after intravenous injection of Tc‐99m methylene diphosphonate. The affected side was compared with the nonpainful side, and the difference was expressed as a percentage. Control subjects were used as reference values. Results Abnormality in vascularization of the lower extremity was found in 24(80%) of patients with sciatica and in 11 (68.7%) of the patients with low back pain. The median blood flow difference was, respectively, ‐12.5% and +4% in these two groups versus +2.9% in the control group. The differences between the sciatica group and the other two groups were statistically significant. No correlation was found with the clinical parameters studied. Conclusion Vascular perfusion abnormalities observed in patients with sciatica secondary to disc herniation may be more important than previously considered and possibly result from alteration in sympathetic vascular autoregulation.