I think the correct answer is 2 although the treatment for acute cholecystitis is cholecystectomy, for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention. In these cases cholecystostomy can cure cholecystitis; and after recovery, assess scheduled surgery according to the patient's situation.

I think [HIDDEN] although the treatment for acute cholecystitis is cholecystectomy, for this it is necessary that the patient is a surgical candidate, in this case it is an elderly patient, with previous diseases that increase the surgical risk and would be an ASA IV for an urgent intervention. In these cases cholecystostomy can cure cholecystitis; and after recovery, assess scheduled surgery according to the patient's situation.

An 87-year-old patient with a history of chronic bronchitis and heart failure, has been diagnosed with acute calculous cholecystitis . After four days of treatment with absolute diet, serum therapy and piperacillin/tazobactam, the patient continues with fever, persistent abdominal pain and leukocytosis. The most appropriate attitude at this time would be:

Surgical treatment (urgent cholecystectomy).

Biliary drainage by percutaneous cholecystostomy.

Substitute metronidazole + cefotaxime for piperacillin/tazobactam.

Replace piperacillin/tazobactam with amikacin+clindamycin.

InternalMed_Harrison

for 14 days) also is effective for treatment of acute uncomplicated pyelonephritis if the uropathogen is known to be susceptible. If the pathogen’s susceptibility is not known and TMPSMX is used, an initial IV 1-g dose of ceftriaxone is recommended. Oral β-lactam agents are less effective than the fluoroquinolones and should be used with caution and close follow-up. Options for parenteral therapy for uncomplicated pyelonephritis include fluoroquinolones, an extended-spectrum cephalosporin with or without an aminoglycoside, or a carbapenem. Combinations of a β-lactam and a β-lactamase inhibitor (e.g., ampicillin-sulbactam, ticarcillinclavulanate, piperacillin-tazobactam) or imipenem-cilastatin can be used in patients with more complicated histories, previous episodes of pyelonephritis, or recent urinary tract manipulations; in general, the treatment of such patients should be guided by urine culture results. Once the patient has responded clinically, oral therapy should be substituted

Piperacillin

Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as initial empiric treatment for people with suspected neutropenic sepsis. Piperacillin is used to treat patients diagnosed with various internal infections such as abdominal, bacteremia, gynecological, respiratory, and urinary, mainly caused by Pseudomonas aeruginosa and other infectious bacteria. They are primarily used in current and former neutropenic patients, and patients with biliary tract infections. Other uses include applications in surgical infection prophylaxis; in biliary surgery, a single dose of piperacillin is administered intravenously to inhibit the development of acute cholangitis and prevent wound infections. The combination of piperacillin and an aminoglycoside is commonly used to treat severe infections, but due to the incompatibilities in drug interaction, they are administered separately.

Spanish conquest of the Aztec Empire

WHO Model List of Essential Medicines

Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquineα Cysticidal medicines Albendazoleα Mebendazoleα Praziquantelα Antibacterials Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Spectinomycin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Trimethoprim Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidimeα Meropenemα Vancomycinα

[Comparative clinical studies of the effectiveness of the most frequently used antibiotics in the period of 1961-1970].

The results from the treatment of 1086 patients, treated at the Therapeutic Clinic, HMI- Sofia were followed up for the period 1961-1970 incld. Acute bacterial and vuris-bacterial pneumonias were found in 318 patients, 475 of the patients were with exacerbated chronic bronchitis and bronchiectasis, with exacerbated chronic pyelo-nephritis -216 patients and with exacerbated chronic cholecystitis and cholangiohepatitis --92 patients. The effect of the treatment was determined according to a three-stage scale "good" with complete clinical healing (in acute pneumonia), with "improvement"--with complete clinical remission (in chronic infections) and "without effect". Clinical and paraclinical indices were used as criteria in the determination of the effectiveness. The data are statistically processed according to the method of variation analysis. In patients with acute pneumonia the- best effectiveness was manifested by tetraolean (88,7 per cent), tetracylins (77,8 per cent), chloramphenicol (76,8 per cent), penicillin (72,5 per cent), the combination penicillin-streptomycin (71,9 per cent); in patients with exacerbated chronic bronchitis--tetraolean (88,0 per cent), chloramphenicol (73,2 per cent), tetracylins (65,3 per cent); in patients with exacerbated chronic pyelonephritis - chloramphenicol (65,5 per cent); in patients with exacerbated chronic cholecystitis and cholecysto-cholangiohepatitis-tetraolean (70,7 per cent), tetracyclins (66,7 per cent), chloramphenicol (66,1 per cent).

Piperacillin/tazobactam

Piperacillin/tazobactam was approved for medical use in the United States in 1993. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication. Medical uses Its main uses are in intensive care medicine (pneumonia, peritonitis), some diabetes-related foot infections, and empirical therapy in febrile neutropenia (e.g., after chemotherapy). The drug is administered intravenously every 6 or 8 hr, typically over 3–30 min. It may also be administered by continuous infusion over four hours. Prolonged infusions are thought to maximize the time that serum concentrations are above the minimum inhibitory concentration (MIC) of the bacteria implicated in infection. Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as first-line therapy for the treatment of bloodstream infections in neutropenic cancer patients.

Spanish conquest of the Aztec Empire

WHO Model List of Essential Medicines for Children

Antifilarials Albendazole Diethylcarbamazine Ivermectin Antischistosomals and other antinematode medicines Praziquantel Triclabendazole Oxamniquine Antibiotics Access group antibiotics Amikacin Amoxicillin Amoxicillin/clavulanic acid (amoxicillin + clavulanic acid) Ampicillin Benzathine benzylpenicillin Benzylpenicillin Cefalexin Cefazolin Chloramphenicol Clindamycin Cloxacillin Doxycycline Gentamicin Metronidazole Nitrofurantoin Phenoxymethylpenicillin (penicillin V) Procaine benzylpenicillin Sulfamethoxazole/trimethoprim (sulfamethoxazole + trimethoprim) Watch group antibiotics Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Clarithromycin Piperacillin/tazobactam (piperacillin + tazobactam) Vancomycin Ceftazidime Meropenem Vancomycin Reserve group antibiotics Ceftazidime/avibactam (ceftazidime + avibactam) Colistin Fosfomycin Linezolid Polymyxin B Antileprosy medicines Clofazimine Dapsone Rifampicin

Spanish conquest of the Aztec Empire

Secondary sources

Chorioamnionitis

Treatment The American College of Obstetricians and Gynecologists' Committee Opinion proposes the use of antibiotic treatment in intrapartum mothers with suspected or confirmed chorioamnionitis and maternal fever without an identifiable cause. Intrapartum antibiotic treatment consists of: Standard Ampicillin + gentamicin Alternative Ampicillin/sulbactam Ticarcillin/clavulanate Cefoxitine Cefotetan Piperacillin/tazobactam Ertapenem Cesarean delivery Ampicillin and gentamicin plus either clindamycin or metronidazole Penicillin-allergy Vancomycin + gentamicin Gentamicin + clindamycin

Aztec Empire

Goddesses

Piperacillin

Following two studies conducted in 1986 and 2006, piperacillin was found to inhibit the removal of methotrexate in animal kidneys. Furthermore, in the presence of piperacillin-tazobactam, the decay time for methotrexate triples in comparison to the normal half-life, leaving the patient exposed to cytotoxic effects produced by the chemical agent. While penicillin antibiotics generally work synergistically with aminoglycosides by enhancing their penetration of bacterial membranes, they can also work adversely by inactivating them. A reformulation of ethylenediaminetetraacetic acid and piperacillin-tazobactam has produced results showing an increase in their affinity with amikacin and gentamicin in vitro, enabling the process of simultaneous Y-site infusion to occur. However, tobramycin was found to be incompatible as a combination through Y-site infusion.

[A trial of using augmentin (amoxicillin/clavulanate) in surgical practice].

The experience with the use of augmentin (amoxycillin/clavulane) in abdominal surgery for prophylaxis of postoperative purulent complications was analyzed. The drug was used in 44 patients after relatively pure operations, 37 of them having various risk factors. In 2 patients (4.5 per cent) of that group postoperative pyoinflammatory complications were recorded. For comparison the results of the prophylactic use of cefoperazone, cefamandole or ceftazidime in the group of 78 patients after relatively pure operations on the abdominal cavity organs were analyzed. Postoperative complications in the latter group amounted to 7.4 per cent (4 patients). The results of the treatment of patients in two groups after contaminated operations were also compared. The patients of one group (41 patients) were treated prophylactically with augmentin in a dose of 1200 mg intraoperatively followed by the drug use in a dose of 600 mg thrice daily for 1 to 2 days after the operation. Postoperative pyoinflammatory complications were recorded in 4 patients of that group (9.7 per cent). 78 patients of the other group were treated prophylactically with ceftazidime or cefoperazone in a dose of 2 g and metronidazole intraoperatively or cefoperazone in a dose of 2 g twice daily and metronidazole in a dose of 500 mg twice daily for 1 to 2 days after the operation. Postoperative infectious complications were recorded in 8 patients of that group (10 per cent). In the group of patients with acute cholecystitis treated with ciprofloxacin in a dose of 400 mg in combination, with metronidazole before the operation and for 1 to 2 days after the operation postoperative complications were recorded in 4 patients (17 per cent).

Febrile neutropenia

In 2010, updated guidelines were issued by the Infectious Diseases Society of America, recommending use of cefepime, carbapenems (meropenem and imipenem/cilastatin), or piperacillin/tazobactam for high-risk patients and amoxicillin-clavulanic acid and ciprofloxacin for low-risk patients. Patients who do not strictly fulfill the criteria of low-risk patients should be admitted to the hospital and treated as high-risk patients. Research to compare antibiotic treatments currently recommended in consensus guidelines identified 44 studies comparing different antibiotics. Significantly higher mortality was reported for cefepime compared to all other antibiotics combined. Piperacillin/tazobactam resulted in lower mortality than other antibiotics. Piperacillin/tazobactam might be the preferred antibiotic for the treatment of cancer patients with fever and neutropenia, while cefepime should not be used.

History of the Later Roman Empire

Divided empire

Cholecystitis

Other Supportive measures may be instituted prior to surgery. These measures include fluid resuscitation. Intravenous opioids can be used for pain control. Antibiotics are often not needed. If used they should target enteric organisms (e.g. Enterobacteriaceae), such as E. coli and Bacteroides. This may consist of a broad spectrum antibiotic; such as piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate (Timentin), a third generation cephalosporin (e.g.ceftriaxone) or a quinolone antibiotic (such as ciprofloxacin) and anaerobic bacteria coverage, such as metronidazole. For penicillin allergic people, aztreonam or a quinolone with metronidazole may be used.

Piperacillin

Adverse effects Common side effects associated with the administration of piperacillin-tazobactam include: Gastrointestinal: constipation, diarrhea, nausea, vomiting Dermatologic: erythema, pain, phlebitis, rash Neurologic: headaches, insomnia Prolonged periods of piperacillin-tazobactam therapy have been associated with the potential development of hematologic adversities such as leukopenia (16.3%), neutropenia (10%), and eosinophilia (10%) in adult patients. The combination of piperacillin-tazobactam with other antibiotics was found to be a major risk factor for leukopenia as well. Additionally, the chances of developing these illnesses increases in younger patients suffering from fewer conditions, prolonging their time to recover.

InternalMed_Harrison

For outpatient management, amoxicillin (1 g every 8 h) provides effective treatment for virtually all cases of pneumococcal pneumonia. Neither cephalosporins nor quinolones, which are far more expensive, offer any advantage over amoxicillin. Levofloxacin (500–750 mg/d as a single dose) and moxifloxacin (400 mg/d as a single dose) also are highly likely to be effective in the United States except in patients who come from closed populations where these drugs are used widely or who have themselves been treated recently with a quinolone. Clindamycin (600–1200 mg/d every 6 h) is effective in 90% of cases and azithromycin (500 mg on day 1 followed by 250–500 mg/d) or clarithromycin (500–750 mg/d as a single dose) in 80% of cases. Treatment failure resulting in bacteremic disease due to macrolide-resistant isolates has been amply documented in patients given azithromycin empirically. As noted above, rates of resistance to all these antibiotics are relatively low in some countries and much

[Controlled, open, parallel-group study of the clinical and microbiological efficacy of piperacillin-tazobactam versus metronidazole + gentamicin in urgent colorectal surgery].

Antibiotic treatment is an important element in infection control after urgent abdominal surgery. The aim of this study was to determine the therapeutic efficacy of piperacillin-tazobactam versus a combination of 2 antibiotics (metronidazole and gentamicin) in patients undergoing urgent appendicular and/or colorectal surgery. The study period comprised December 1998 to December 2002. A total of 183 patients who required urgent surgery for colon disease and/or severe acute appendicitis were prospectively and randomly included. Patients were randomly distributed in 2 groups. Group A received piperacillin-tazobactam (4/0.5/8 h/i.v.) and group B received metronidazole (500 mg/i.v./8 h) plus gentamicin (5 mg/kg/i.v./24 h). Treatment was started between 30 and 60 minutes prior to surgery and was continued for at least 3 days. The incidence of wound infection in patients who underwent surgery for colon disease and acute appendicitis was lower when they were treated with piperacillin-tazobactam (P< .05). The incidence of intraperitoneal abscess in the group of patients who underwent surgery for severe acute appendicitis was lower when they were treated with piperacillin-tazobactam. Microbiological analyses revealed that there was a predominance of infection due to Escherichia coli. The association of piperacillin-tazobactam was more effective than that of metronidazole and gentamicin in the prevention and treatment of local infection in the treated groups. Therapeutic failure was mainly related to the presence of gram-negative bacteria.

Age of Empires

Historical elements

Piperacillin

Pneumonia The piperacillin-tazobactam (piptaz) antibiotic commonly used with an aminoglycoside retains similar levels of drug safety and efficacy as other antibiotic combinations such as ceftazidime with the aminoglycoside tobramycin in the treatment of patients with hospital acquired pneumonia. In a clinical comparison primarily targeting patients not initially placed in intensive care units, piperacillin-tazobactam was found to produce higher clinical and microbiological rates of success. By contrast, the drug efficacy of ceftazidime and piperacillin-tazobactam resulted in similar response rates (61.5% and 63.9 respectively) when tobramycin was added into both groups. Identical evaluations are shown when compared to the imipenem and tobramycin combination, where the administration of piperacillin-tazobactam on patients (especially those under mechanical ventilation) was only consisted of a slightly higher response rate.

History of penicillin

Early scientific evidence

Anaerobic infection

Empiric antibiotic therapy for health care-associated intra-abdominal should be driven by local microbiologic results. Empiric coverage of likely pathogens may require multidrug regimens that include agents with expanded spectra of activity against gram-negative aerobic and facultative bacilli. These include meropenem, imipenem-cilastatin, doripenem, piperacillin-tazobactam, or ceftazidime or cefepime in combination with metronidazole. Aminoglycosides or colistin may be required. Antimicrobial regimens for children include an aminoglycoside-based regimen, a carbapenem (imipenem, meropenem, or ertapenem), a beta-lactam/beta-lactamase-inhibitor combination (piperacillin-tazobactam or ticarcillin-clavulanate), or an advanced-generation cephalosporin (cefotaxime, ceftriaxone, ceftazidime, or cefepime) with metronidazole.

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Empire Galloper

Results of the North American trial of piperacillin/tazobactam compared with clindamycin and gentamicin in the treatment of severe intra-abdominal infections. Investigators of the Piperacillin/Tazobactam Intra-abdominal Infection Study Group.

A total of 192 men and 139 women aged 15 to 89 years with diagnosed intra-abdominal infection were randomised in a 2:1 ratio to treatment with either intravenous piperacillin/tazobactam (3 g/375 mg every six hours) or clindamycin (600 mg every six hours) plus gentamicin (2.5 mg to 5.0 mg/kg every eight to 12 hours) in a multicentre trial. Of 147 evaluable patients with microbiologically confirmed infections, 104 were treated with piperacillin/tazobactam and 43 with clindamycin plus gentamicin. The diagnoses of perforated appendicitis (n = 79), other peritonitis (n = 32), cholecystitis/cholangitis (n = 18), intraabdominal abscess (n = 14), and diverticulitis (n = 3), were distributed proportionately between the two therapeutic groups. Ninety one of 104 patients (88%) in the piperacillin/tazobactam group and 33 of 43 patients (77%) in the clindamycin plus gentamicin group were considered cured or improved (p = 0.13). In the piperacillin/tazobactam group, 80 of 88 (91%) Bacteroides fragilis group organisms and 68 of 74 (92%) E coli isolates were eradicated; in the clindamycin plus gentamicin group, 21 of 25 (84%) Bacteroides fragilis group isolates and 23 of 30 (76%) E coli isolates were eradicated. Eleven evaluable patients in the piperacillin/tazobactam group had beta-lactamase-producing organisms that were resistant to piperacillin but susceptible to piperacillin/tazobactam; in 10 of these patients (91%) bacteria were eradicated. We conclude that piperacillin/tazobactam is an effective antimicrobial drug for monotherapy of intra-abdominal infections, with efficacy similar to or better than standard aminoglycoside/anti-anaerobe combinations.

[Our experience in introducing current antibiotic prophylaxis into abdominal surgery--the initial results].

Over a one-year period (Nov. 1996-Nov. 1997), a total of 154 patients are admitted on an emergency basis, with deferred emergency and for routine treatment in the Clinic of Emergency Surgery. They are distributed in three groups, as follows: patients not requiring perioperative antibiotic prophylaxis and postoperative antibiotic therapy--27, patients subjected to perioperative parenteral antibiotic prophylaxis under adequate hospital conditions--121, and patients undergoing antibiotic prophylaxis in conditions inappropriate for its application--six. The drug schemes elaborated are in conformity with worldwide and Bulgarian experience along this line, and with the concrete hospital and economical conditions in this country. In all patient indicated for antibiotic prophylaxis the listed below antibacterial agents (presented as drug schemes) are administered i.v. a single time prior to anesthesia induction: in operations on the gastrointestinal tract except for interventions in acute appendicitis: cephalotin/cefazolin 2.0 g and metronidazole 0.5 g i.v.; in operations for acute appendicitis: amoxicillin/clavulanate 1.2 g and petronidazole 0.5 f i.v.; biliary surgery free of extrahepatic cholestasis: cephalotin/cefazolin 2.0 g i.v.; biliary surgery with present or preceding extrahepatic cholestasis: cefotetan 2 g i.v.; contaminated liver cysts (parasitic and nonparasitic): cefotetan 2 g i.v.; abdominal trauma without perforation of a hollow organ: cefotetan 2 g i.v.; in plastic repair of the anterior abdominal wall (congenital defects, postoperative eventration) and in poor risk patients (local and general status: cephalotin/cefazolin 2.0 g i.v. In 135 patients the postoperative period runs a course free of complications worthy of notice. Complications directly linked to introduction of the method proposed are recorded in ten cases: operative wound suppuration (4) and hospital infection (6). Complications not related directly to the procedure are observed in nine cases: urinary tract infection (4), bronchopneumonia (2), fever with unknown source of infection (including negative hemoculture) necessitating additional antibiotic therapy (2) and secondary infection (within a week of intervention) necessitating further therapy with antibiotics. The specific features of antibiotic prophylaxis used in the various types of operative interventions are discussed from microbiological, clinical and pharmacotherapeutic viewpoints. The obtained results are compared with pertinent literature data on the issue with a special reference to the clinical efficacy attained. They mirror the approach against the background of the concrete hospital conditions in this country. The method developed is fully consistent with the level of surgical expertise in Bulgaria. All efforts should be aimed at intrahospital environment improvement by means of meticulous asepsis and antisepsis.

Piperacillin/tazobactam

Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as first-line therapy for the treatment of bloodstream infections in neutropenic cancer patients. For β-lactam antipseudomonal antibiotics, including piperacillin/tazobactam, prolonged intravenous infusion is associated with lower mortality than bolus intravenous infusion in persons with sepsis due to Pseudomonas aeruginosa. Adverse effects The most common adverse effect is diarrhea (7–11%). Another adverse effect is inhibition of platelets (thrombocytopenia). Society and culture Trade names Apart from Tazocin and Zosyn, the drug is marketed in various countries under other trade names such as Tazact, Biopiper TZ, Brodactam, Piptaz, Maxitaz, Kilbac, Trezora, Du-Tazop, Tazopen, Sytaz, Tazin, and Inzalin TZ.

Gajapati Empire

History

Piperacillin/tazobactam in comparison with clindamycin plus gentamicin in the treatment of intra-abdominal infections.

Concerned about the inactivation of piperacillin by beta-lactamase and the risk of aminoglycoside-induced nephrotoxicity and clindamycin-induced enterocolitis, we conducted the following phase III clinical trial. Between November 1991 and March 1993, 77 surgical patients with intraabdominal infections were enrolled and randomly assigned in a 3:2 ratio to receive either piperacillin/tazobactam or clindamycin plus gentamicin to compare safety, tolerance and efficacy between both two treatment groups. There were 76 clinically and 50 bacteriologically evaluable patients with 80 isolated pathogens. The demographic data were comparable in both groups. There was no statistically significant difference of clinical response at any time-point of treatment, with 97.8% favorable clinical response rate in piperacillin tazobactam group and 96.6% in clindamycin plus gentamicin group at endpoint. The bacteriological eradication rates were similar, with 97.7% in piperacillin/tazobactam group and 94.4% in clindamycin plus gentamicin group at pathogen level, and 96.7% in piperacillin/tazobactam group and 95.0% in clindamycin plus gentamicin group at patient level. By susceptibility tests, only 3 (4%) isolated pathogens were resistant to piperacillin/tazobactam, which was much superior to the use of piperacillin, clindamycin or gentamicin alone in antimicrobial activity. The piperacillin tazobactam-related adverse experiences included 1 (2.1%) urticaria and 2 (4.3%) diarrhea. However, there were no significant differences in the adverse experiences between these two groups. This study has demonstrated that piperacillin/tazobactam is comparable with clindamycin plus gentamicin in efficacy, safety and tolerance in the treatment of surgical patients with intra-abdominal infections. The combination of piperacillin/tazobactam could potentially be the treatment of choice in adjunt to surgical management in intra-abdominal infection.

Phenoxymethylpenicillin

History

Piperacillin

Medical uses Piperacillin is used almost exclusively in combination with the beta lactamase inhibitor tazobactam for the treatment of serious, hospital-acquired infections. This combination is among the most widely used drug therapies in United States non-federal hospitals, accounting for $388M in spending in spite of being a low-cost generic drug. Piperacillin-tazobactam is recommended as part of a three-drug regimen for the treatment of hospital-acquired pneumonia suspected as being due to infection by multi-drug resistant pathogens. It is also one of several antibacterial drugs recommended for the treatment of infections known to be caused by anaerobic Gram-negative rods. Piperacillin-tazobactam is recommended by the National Institute for Health and Care Excellence as initial empiric treatment for people with suspected neutropenic sepsis.

Grampian 23

Operational history


Positive Lasegue's sign, reappearance of the symptoms when performing the extension maneuver of the affected limb, compatible with involvement of nerve roots at the lumbosacral spine level.

A 61-year-old woman, administrative, with a history of overweight, hypertension, dyslipidemia and metabolic syndrome, who consults for pain in both buttocks, left trochanteric region, lateral aspect of the left thigh up to the knee and left leg up to the middle third. The pain appears when the lower limb is lifted with the knee extended, but is relieved when the knee is flexed. What is the first clinical suspicion?

Sacroiliac joint

Signs and symptoms The following are signs and symptoms that may be associated with an SI joint (SIJ) problem: Mechanical SIJ dysfunction usually causes a dull unilateral low back pain. The pain is often a mild to moderate ache around the dimple or posterior superior iliac spine (PSIS) region. The pain may become worse and sharp while doing activities such as standing up from a seated position or lifting the knee towards the chest during stair climbing. Pain is typically on one side or the other (unilateral PSIS pain), but the pain can occasionally be bilateral. When the pain of SIJ dysfunction is severe (which is infrequent), there can be referred pain into the hip, groin, and occasionally down the leg, but rarely does the pain radiate below the knee. Pain can be referred from the SIJ down into the buttock or back of the thigh, and rarely to the foot. Low back pain and stiffness, often unilateral, that often increases with prolonged sitting or prolonged walking.

Greater trochanteric pain syndrome

More often the lateral hip pain is caused by disease of the gluteal tendons that secondarily inflames the bursa. This is most common in middle-aged women and is associated with a chronic and debilitating pain which does not respond to conservative treatment. Other causes of trochanteric bursitis include uneven leg length, iliotibial band syndrome, and weakness of the hip abductor muscles. Greater trochanteric pain syndrome can remain incorrectly diagnosed for years, because it shares the same pattern of pain with many other musculoskeletal conditions. Thus people with this condition may be labeled malingerers, or may undergo many ineffective treatments due to misdiagnosis. It may also coexist with low back pain, arthritis, and obesity. Signs and symptoms The primary symptom is hip pain, especially hip pain on the outer (lateral) side of the joint. This pain may appear when the affected person is walking or lying down on that side. Diagnosis

Sciatica -- History and Physical

Further, a straight leg raise (SLR) test is a neurological maneuver performed while examining a patient presenting with lower back pain. This test is conducted with the patient lying supine while keeping the symptomatic leg straight by flexing the quadriceps. The examiner elevates the leg progressively at a slow pace. The test is deemed positive if it reproduces the patient's symptoms (pain and paresthesia) at an angle lower than 70° with radiation below the knee (Lasegue sign). This test is most helpful in diagnosing L4, L5, and S1 radiculopathies. The patient is asked to dorsiflex the foot while the examiner raises the leg (Bragaad sign) to increase the test's sensitivity. When executing the straight leg raise test, the examiner will slightly bend the patient's knee by 20° to 30°, which will lessen the pain. Then, manual pressure is applied in the popliteal fossa. The Bowstring sign is considered positive if it causes the same level of discomfort that the patient feels during a straight leg raise. [8] The Naffziger test involves reproducing pain via coughing. [9]

The piriformis muscle syndrome: a simple diagnostic maneuver.

Current maneuvers to diagnose the piriformis syndrome are less than ideal. Freiberg's maneuver of forceful internal rotation of the extended thigh elicits buttock pain by stretching the piriformis muscle, and Pace's maneuver elicits pain by having the patient abduct the legs in the seated position, which causes a contraction of the piriformis muscle. This report describes a maneuver performed by the patient lying with the painful side up, the painful leg flexed, and the knee resting on the table. Buttock pain is produced when the patient lifts and holds the knee several inches off the table. The maneuver produced deep buttock pain in three patients with piriformis syndrome. In 100 consecutive patients with surgically documented herniated lumbar discs, the maneuver often produced lumbar and leg pain but not deep buttock pain. In 27 patients with primary hip abnormalities, pain was often produced in the trochanteric area but not in the buttock. The maneuver described in this report was helpful in diagnosing the piriformis syndrome. It relies on contraction of the muscle, rather than stretching, which the author believes better reproduces the actual syndrome.

Sciatica -- History and Physical

A straight-leg raise has variable sensitivity and specificity and may or may not be present depending on the underlying cause. The straight-leg test is a passive examination where the patient first lies in a relaxed, supine position. The examiner then lifts the leg from the posterior aspect, flexing at the hip joint and keeping the knee in full extension or keeping the leg straight. Typically, pain that is reproduced between 30° to 70° of hip flexion and experienced primarily in the back is likely due to a lumbar disc herniation. Pain and parenthesis felt in the leg are possible due to lateralizing compression of a peripheral nerve. While not absolute, musculoskeletal causes of the pain usually reproduce pain above 70° of flexion and below 30° of flexion.

Lumbar Disc Herniation -- History and Physical

A straight leg raise test is a neurological maneuver performed while examining a patient presenting with lower back pain. It is conducted with the patient lying supine while keeping the symptomatic leg straight by flexing the quadriceps. The examiner slowly elevates the leg progressively at a slow pace. The test is positive when it reproduces the patient's symptoms (pain and paresthesia) at an angle lower than 45 degrees with radiation below the knee (Lasegue sign). It is most helpful in diagnosing L4, L5, and S1 radiculopathies. The patient is asked to dorsiflex the foot while the examiner is raising the leg (Bragaad's sign) to increase the sensitivity of the test.

Disc Herniation -- History and Physical -- Physical Examination

L5 Nerve - back, radiating into buttock, lateral thigh, lateral calf, and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, webspace between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex. S1 Nerve - back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on the posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction. S2-S4 Nerves - sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex.

[Diagnosis and treatment of lumbar spinal canal stenosis].

Lumbar spinal canal stenosis (LSCS) was first described in 1954 by Verbiest, followed by the currently accepted international classification of LSCS in 1976 by Arnoldi. Briefly, LSCS is a nervous system syndrome that is characterized by neural symptoms in the lower extremities due to tightened cauda equina and spinal nerve root involvement. LSCS international classification consists of: (1) degenerative, (2) congenital developmental, (3) combined, (4) spondylolytic spondylolisthesis, (5) iatrogenic and (6) post traumatic stenosis. Degenerative stenosis-the most common type of LSCS-is caused by disc degeneration, osteoarthritis of the facet joint and hypertrophy of the ligamentum flavum. LSCS may also be the result of intervertebral disc degeneration, protruded intervertebral disc and/or bony spur compress cauda equina and spinal nerve root anteriorally, while degenerated facet joint and hypertrophied the ligamentum flavum compress cauda equina and spinal nerve root posteriorally? Most often, spondylolytic spondylolisthesis occurs at the fourth lumbar vertebrae in middle-aged women. As a result of a slipping forward of the vertebra, cauda equina and spinal nerve roots can be tightened between the edge behind the top of lower vertebra and frontal edge of the lower part of upper lamina. Typical clinical symptoms of LSCS are low back pain, leg pain and intermittent claudication. Low back pain is chronic with secondary radiating pain in the buttock. The leg pain is called "sciatica", which tends to appear on the back of thigh, in the lateral aspect of lower leg and calf muscles, and which intensifies when the patient is fatigued. Intermittent claudication is a symptom associated with this syndrome. Often, patients with LSCS find it impossible to walk because of increased numbness and pain in their leg. Many patients report that after squatting for a few minutes they are able to resume walking. LSCS patients may also report dysaesthesia in the perineum area, and may also report urinary dysfunction ranging from extreme urgency to urinary delay. Patients who present with symptoms of LSCS should be seen by an orthopedic surgeon. Correct diagnosis by imaging and clinical examination, with appropriate conservative or operative treatment in a timely fashion should be encouraged in order to prevent irreversible nerve damage.

Low back pain

Low back pain may be classified based on the signs and symptoms. Diffuse pain that does not change in response to particular movements, and is localized to the lower back without radiating beyond the buttocks, is classified as nonspecific, the most common classification. Pain that radiates down the leg below the knee, is located on one side (in the case of disc herniation), or is on both sides (in spinal stenosis), and changes in severity in response to certain positions or maneuvers is radicular, making up 7% of cases. Pain that is accompanied by red flags such as trauma, fever, a history of cancer or significant muscle weakness may indicate a more serious underlying problem and is classified as needing urgent or specialized attention.

GALS screen

Now ask the patient to do the following noting any painful, restricted or asymmetrical movements: Test rotation of the thoracic and lumbar spine. Gently hold the patient's hips still and ask them to: "Turn your shoulders round as far as you can to the left, then do the same to the right." Test lateral flexion of the thoracic and lumbar spine: "Stand up straight and then slide the palm of your right hand down your thigh towards your knee, bending your shoulder down to the side." "Now do the same with your left hand down your left leg." "Bend your left ear down towards your left shoulder and then your right ear down towards your right shoulder" to test for pain free cervical spine lateral flexion. Now test for stiffness or pain flexing or extending the cervical spine: "bend your neck forwards to try to touch your chin against your chest." "bend your neck back to lift your chin."

Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment.

Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.

Lumbosacral Facet Syndrome -- History and Physical

In most presentations, facetogenic lumbosacral pain often presents secondary to chronic pain alone. It should, however, be noted that facet joint pain may be referred distally into the lower limb, thus mimicking sciatica. In these cases of "pseudo-radicular" lumbar pain, patients typically experience radiation into the unilateral or bilateral buttocks and the trochanteric region (from L4 and L5 levels), the groin and thighs (from L2 to L5), ending above the knee, and without any neurologic deficits. At times, pain may radiate further down the lower extremity reaching the foot, thus mimicking sciatic pain. This may occur especially in the setting of rather large synovial cysts causing direct mechanical compression and creating ensuing inflammation to further irritate the surrounding nerve roots. [15] Facet joint pain is typically worse in the mornings and following periods of inactivity. Stress exercise, lumbar spinal extension or rotary motions, standing or sitting positions, and facet joint palpation may also elicit lumbar facetogenic pain. [2]

Radicular Back Pain -- History and Physical

L2, L3, and L4 lumbar radiculopathies are considered a group. This group has a marked overlap of the innervation of the anterior thigh muscles. [1] An acute injury in the distribution of L2, L3, and L4 will most commonly present with the patient experiencing radiating back pain to the anterior aspect of the thigh, which may progress into their knee, and possibly radiate to the medial aspect of the lower leg, into the foot. On examination, patients can have weakness during knee extension, hip adduction, and or hip flexion. There is often a loss of sensation over the anterior thigh along the area of pain. The patient may show a reduced patellar reflex (L4). [1] Activities that can make the symptoms worse include coughing, leg straightening, or sneezing.

InternalMed_Harrison

2692 LATERAL FEMORAL CUTANEOUS NEUROPATHY (MERALGIA PARESTHETICA) The lateral femoral cutaneous nerve arises from the upper lumbar plexus (spinal levels L2/3), crosses through the inguinal ligament near its attachment to the iliac bone, and supplies sensation to the anterior lateral thigh. The neuropathy affecting this nerve is also known as meralgia paresthetica. Symptoms and signs consist of paresthesias, numbness, and occasionally pain in the lateral thigh. Symptoms are increased by standing or walking and are relieved by sitting. There is normal strength, and knee reflexes are intact. The diagnosis is clinical, and further tests usually are not performed. EDx is only needed to rule out lumbar plexopathy, radiculopathy, or femoral neuropathy. If the symptoms and signs are classic, EMG is not necessary. Symptoms often resolve spontaneously over weeks or months, but the patient may be left with permanent numbness. Treatment consists of weight loss and avoiding tight belts. Analgesics

Greater Trochanteric Pain Syndrome -- History and Physical

Patients with greater trochanteric pain syndrome usually have lateral hip pain, tenderness over and around the greater trochanter, pain at end-range hip rotation, abduction or adduction, pain with resisted hip abduction, and a positive Patrick-FABER (flexion abduction external rotation) test. Patients usually suffer from chronic back pain radiating to the posterolateral aspect of the thigh, leg paresthesias, and tenderness over the iliotibial tract. [6] They will often complain of the inability to lay on the affected hip. The mean duration of symptoms before treatment ranges from 7.1 weeks to 4.4 years. Young adults (18 to 35 years old) with hip pain often present with non-specific symptoms and vague findings from the history and physical examination, which may lead to a misdiagnosis of GTPS or trochanteric bursitis. [1] [4]

Neurology_Adams

The most characteristic syndrome affects the lumbar roots. Pain, which can be severe, begins in the low back or hip and spreads to the thigh and knee on one side; the discomfort has a deep, aching character with superimposed lancinating jabs and there is a propensity for pain to be most severe at night. Weakness and later atrophy are evident in the pelvic girdle and thigh muscles, although the distal muscles of the leg may also be affected. The weakness can progress for days or weeks (rarely, months). The patellar reflex is lost on the affected side. Curiously, we have found the opposite patellar reflex to be absent in some patients, without explanation. Deep and superficial sensation may be intact or mildly impaired, conforming to either a multiple nerve or multiple adjacent root distribution (i.e., L2 and L3, or L4 and L5). The pain lasts for several days and then gradually abates. Motor recovery is the rule although months and even years may elapse before it is complete. The same

Surgery_Schwartz

heavy-muscled athletesVenous claudicationEntire leg, but usually worse in thigh and groinTight, bursting painAfter walkingSubsides slowlyRelief speeded by elevationHistory of iliofemoral deep venous thrombosis, signs of venous congestion, edemaNerve root compression (e.g., herniated disk)Radiates down leg, usually posteriorlySharp lancinating painSoon, if not immediately after onsetNot quickly relieved (also often present at rest)Relief may be aided by adjusting back positionHistory of back problemsSymptomatic Baker’s cystBehind knee, down calfSwelling, soreness, tendernessWith exercisePresent at restNoneNot intermittentIntermittent claudication (hip, thigh, buttock)Hip, thigh, buttocksAching discomfort, weaknessAfter same degree of exerciseQuickly relievedNoneReproducibleHip arthritisHip, thigh, buttocksAching discomfortAfter variable degree of exerciseNot quickly relieved (and may be present at rest)More comfortable sitting, weight taken off legsVariable, may relate to activity

Spinal Stenosis -- History and Physical

Stenosis in the lumbar spine can lead to neurogenic claudication, myeloradiculopathy symptoms, sensory disturbances, motor weakness, and pathologic reflexes. Patients will present with complaints of cramping pain in the leg, calf, and or buttocks. They might report an increase in pain with walking or standing for prolonged periods and relief when sitting or leaning forward while using a shopping cart. [9] Disk herniation is most common at the L4-5 and L5-S1 levels. A herniated disk at L5-S1 can lead to plantarflexion weakness, decrease sensation in the lateral foot, and cause pain in the posterior leg. A disk herniation at L4-5 can lead to a foot drop and numbness in the large toe web and dorsal aspect of the foot. Lastly, an L3-4 disk herniation can lead to knee extension weakness, numbness in the medial foot, and pain in the anterior thigh.

Spinal gouty tophus presenting as an epidural mass lesion - A case report.

Gout is a metabolic disease secondary to an increased body pool of urate with hyperuricemia. Gout typically affects the peripheral joints and rarely involves the intra-spinal area. A 43-year-old man, who had metabolic syndrome s/p bariatric surgery and gout suffered from severe left low back pain with radiation to the lateral side of his left thigh and anterior side of his left leg for more than 7 days. His L-spine MRI showed an abnormal posterior epidural space occupying lesion at L4-L5 level. For tissue diagnosis and neural structures decompression, he underwent surgical removal of the epidural mass lesion. The surgical specimen showed a picture of gout and he got a good recovery after operation. The differential diagnoses of an epidural mass includes synovial cysts, ligament cyst, cystic neuromas, tumors, hematomas and abscesses. Gout in the spinal canal is difficult to diagnosis before surgery because it is rare and its clinical presentation and radiologic findings mimic tumor, abscess, tuberculosis, and degenerative spinal diseases. Patients with spinal gout may present with axial pain and a variety of neurological symptoms. Spinal gouty tophus should be considered in the different diagnoses of spinal epidural masses especially in patients with systemic gout. Surgery is needed for final diagnosis. If spinal gouty tophus is highly suspected during the surgery, the specimen should not be preserved with Formalin because birefringent crystals under polarized light is a unique feature for gouty tophus but they dissolve in Formalin.

[Acromegaly and spinal canal stenosis].

A rare case of acromegaly with radiculomyelopathy due to spinal canal stenosis is reported. A long history of acromegalic deformity was seen on this 55 years old acupuncture therapist for the last 18 years, while he had developed unusually increased appetite, profuse perspiration and gained weight. Fifteen years ago, acromegalic tendency became prominent and was accompanied by low back and knee pain. In 1974 CB-154 was administered in several occasions beside 4000 rads irradiation to the sella. After radiation therapy was completed his outlook was somewhat improved, although low back pain was aggravated and associated with atrophy of the left lower extremity. The neurological examination at admission in 1980 revealed acromegalic feature, increased DTRs on both upper and lower extremities, dysesthesia of feet and atrophy of the leg muscles in general, mainly due to diffuse atrophy. Patient bended knees due to pain and unable to walk. He had radiating pain in the postero-lateral aspect of the left lower extremity and some dysesthesia of feet, although no specific root lesion was identifiable. Spinal roentgenograms disclosed diffuse ossification of anterior and posterior longitudinal ligaments, and marked spondylotic changes. Although the low back pain was impending complaint of the patient, the hypophyseal tumor was advised to remove and transsphenoidal hypophyseal adenomectomy was performed. A good amount of softend tumor tissue was removed however, adenoma found markedly fibrotic. Low back pain and knee were decreased gradually, but intermittent claudication was evident. Acromegaly in association with spinal canal stenosis were reviewed in literature, and the relationship of growth hormone and therapeutic problems were discussed.

A straight leg raising can be helpful in lumbosacral radiculopathy. The mechanism of pain during a straight leg raise is increased dural tension placed upon the lumbosacral spine during the test. Patients lay supine during the test. The physician will flex the patient's quadriceps with the leg in extension as well as dorsiflex the patient's foot on the symptomatic side. Pain or reproduction of paresthesias is considered a positive test (Lasegue's sign). A Bowstring sign relieves this underlying radicular pain with flexion of the patient's knee on the affected side. The straight leg raising test is most helpful in the diagnosis of L4 and S1 radiculopathies. [11] [3]

Diabetic amyotrophy, not your typical back pain.

A 49-year-old man presented to the hospital for spinal cord decompression surgery with left buttock and left leg pain. The patient described an acute burning pain radiating down from his left buttock to left lateral leg. He also noted a 13.6 kg weight loss in recent months. Physical examination showed decreased muscle bulk of the left thigh, decreased strength of the left hip, left knee flexors and extensors. Recent MRI spine showed mild canal narrowing and cord flattening in the lower thoracic spine. Serologic testing showed an elevated glucose of 17.9 mmol/L and haemoglobin A1c of 9.8%. Electromyography showed denervation of scattered muscles of the left knee flexors, hip flexors and adductors. In the setting of newly diagnosed diabetes mellitus, he was diagnosed with diabetic amyotrophy, started on insulin therapy, and his surgery was cancelled.

Comparison of the history and physical examination for hip osteoarthritis and lumbar spinal stenosis.

Leg pain associated with walking is sometimes incorrectly attributed to hip osteoarthritis (OA) or lumbar spinal stenosis (LSS). This study compared physicians' values of signs and symptoms for diagnosing and differentiating hip OA and LSS to their clinical utility. Musculoskeletal physicians were surveyed with online questionnaires. Patients were recruited from hip and spine specialty practices. Seventy-seven hip OA and 79 LSS patients. Signs and symptoms of hip OA and LSS. 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. 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. 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.

Pudendal tumor mimicking cauda equina syndrome and acute radiculopathy: case report.

Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts. A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved. CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc.

Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis?

The clinical syndrome of lumbar spinal stenosis (LSS) is a common diagnosis in older adults presenting with lower extremity pain. To systematically review the accuracy of the clinical examination for the diagnosis of the clinical syndrome of LSS. MEDLINE, EMBASE, and CINAHL searches of articles published from January 1966 to September 2010. Studies were included if they contained adequate data on the accuracy of the history and physical examination for diagnosing the clinical syndrome of LSS, using a reference standard of expert opinion with radiographic or anatomic confirmation. Two authors independently reviewed each study to determine eligibility, extract data, and appraise levels of evidence. Four studies evaluating 741 patients were identified. Among patients with lower extremity pain, the likelihood of the clinical syndrome of LSS was increased for individuals older than 70 years (likelihood ratio [LR], 2.0; 95% confidence interval [CI], 1.6-2.5), and was decreased for those younger than 60 years (LR, 0.40; 95% CI, 0.29-0.57). The most useful symptoms for increasing the likelihood of the clinical syndrome of LSS were having no pain when seated (LR, 7.4; 95% CI, 1.9-30), improvement of symptoms when bending forward (LR, 6.4; 95% CI, 4.1-9.9), the presence of bilateral buttock or leg pain (LR, 6.3; 95% CI, 3.1-13), and neurogenic claudication (LR, 3.7; 95% CI, 2.9-4.8). Absence of neurogenic claudication (LR, 0.23; 95% CI, 0.17-0.31) decreased the likelihood of the diagnosis. A wide-based gait (LR, 13; 95% CI, 1.9-95) and abnormal Romberg test result (LR, 4.2; 95% CI, 1.4-13) increased the likelihood of the clinical syndrome of LSS. A score of 7 or higher on a diagnostic support tool including history and examination findings increased the likelihood of the clinical syndrome of LSS (LR, 3.3; 95% CI, 2.7-4.0), while a score lower than 7 made the diagnosis much less likely (LR, 0.10; 95% CI, 0.06-0.16). The diagnosis of the clinical syndrome of LSS requires the appropriate clinical picture and radiographic findings. Absence of pain when seated and improvement of symptoms when bending forward are the most useful individual findings. Combinations of findings are most useful for identifying patients who are unlikely to have the diagnosis.

L5 nerve root exits at the L5-S1 foramina. When compressed by a herniated disc, it causes back pain that radiates into the buttock, lateral thigh, lateral calf, the dorsum of the foot, and the great toe. Sensory loss is present on the web space between the big toe and second toe, the dorsum of the foot, and lateral calf. There is a weakness in hip abduction, knee flexion, foot dorsiflexion, big toe dorsiflexion, foot inversion, and eversion. Patients present with decreased semitendinosus/semimembranosus reflex. Weakness in foot dorsiflexion makes it challenging to walk on the heels. Chronic L5 radiculopathy may cause atrophy of the extensor digitorum brevis and the tibialis anterior of the anterior leg.

Bilateral periprosthetic stress fractures in a juvenile chronic arthritis patient secondary to bilateral genu valgum.

Lateral insufficiency fractures following total hip replacement have been reported with the femoral stems positioned in varus, together with osteopenia of the lateral femoral cortex. Any abnormal alignment of the lower limbs, such as genu valgum, will alter the load distribution across the femoral cortices, and repetitive loading during walking will predispose the bones to stress fractures at any stress riser point, such as the tip of a femoral component. Bilateral femoral stress fractures post total hip replacements have not been previously described. We present a 55-year-old woman, diagnosed with juvenile idiopathic arthritis, who had undergone bilateral total hip replacements and bilateral knee replacements. The knees 15 years postoperatively were in valgus and the left knee was extremely stiff, flexing to just 5. The patient presented with bilateral thigh pain, with plain radiographs confirming bilateral periprosthetic fractures of the femur at the tip of well-fixed femoral components. There was no history of injury and her hips were functioning well up to this time. The patient required revision of both hips to long-stem uncemented components, bypassing the fractures, and revision of both knees to stemmed semi-constrained implants, thereby correcting the alignment of both lower limbs. Both fractures healed and the patient is currently pain-free and mobile with walking aids. Surgeons must remain aware that when implants are in situ, abnormal alignments will lead to abnormal forces, and stress fractures are likely to occur at any stress riser around the implant. Avoiding malalignment will avoid this complication.

Plantar Heel Pain -- History and Physical -- S1 Radiculopathy

Patients with heel pain may have a history of chronic lower back pain. Clinically, radicular involvement will present as pain and numbness radiating from the lower back down to the heel of the foot. Patients may have decreased sensation over the skin of the sole, heel, or lateral foot and weakness of the gastrocnemius, gluteus maximus, hamstring, peroneal, and foot muscles with a diminished ankle reflex. Perform the positive straight leg raise test (Lasègue test) with the patient in the supine position. Pain with passive hip flexion while lifting the leg suggests stretching the lower lumbar and sacral roots. [21] Perform a crossed straight leg raise test, eliciting pain on the contralateral side with the same motion. Results from new studies suggest that these exams may not be as reliable as we once thought. [22]

Neurogenic claudication

Knee to chest stretch - Laying down on the back, bring one leg up and pull it towards the chest and hold for 30–45 seconds. Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5–10 seconds and relax. Neural Stretching of the legs - Laying on the back, bring one leg up with a stretching band until a stretch is felt in the legs. Ensure your legs are straight. Once the stretch is felt, hold for 30–45 seconds and relax. Hip-flexor stretch - To stretch the right hip-flexor, bring the left leg forward, and kneel on the right knee. Push the pelvis forward (lean forward), whilst keeping the upper body straight. Hold the position for 30–45 seconds and relax. To stretch the left hip-flexor, bring swap the positions of the legs.

Deep vein thrombosis in an athletic military cadet.

Resident's case problem. A 21-year-old healthy athletic male military cadet with complaint of worsening diffuse left knee pain was evaluated 4 days after onset. The knee pain began 2 hours after completing a long car trip, worsened over the subsequent 3 days, and became almost unbearable during the return trip. The patient reported constant pain, limited knee motion, and difficulty ambulating. In addition, he was unable to perform physical military training or attend academic classes due to the severe left knee pain. Past medical history revealed a mild left lateral calf strain 21/2 weeks prior, which completely resolved within 24 hours of onset. Our physical examination led us to either monoarticular arthritis, pseudothrombophlebitis (ruptured Baker's cyst), or a lower leg deep vein thrombosis (DVT) as the cause of knee pain. Diagnostic imaging of this patient revealed a left superficial femoral vein thrombosis and popliteal DVT, with bilateral pulmonary emboli (PE). A systematic differential diagnosis was undertaken to rule out a potentially fatal DVT diagnosis as the cause of knee pain, despite minimal DVT risk factors. The physical therapist in a direct-access setting must ensure timely evaluation and referral of a suspected DVT, even when patient demographics cause the practitioner to question the likelihood of this diagnosis. The physical examination findings, clinical suspicion, and established clinical prediction rules can accurately dictate the appropriate referral action necessary.

What was the disease of the legs that afflicted King Asa?

The elderly have suffered from pain in their legs, which may be associated with various diseases, for thousands of years. This report analyzes the disease that afflicted the biblical King Asa (the third king of the house of Judah who reigned between 867 and 906 BCE). The sentence 'Nevertheless in the time of his old age he was diseased in his legs' indicates that King Asa suffered from disease in his legs. Among numerous diseases, peripheral vascular disease, gout, and degenerative osteoarthritis were most likely to affect the King's legs. And among these diseases, the diagnosis of peripheral vascular disease is the most acceptable. This report shows that the roots of contemporary modern gerontology can be traced back to biblical times.

Multiple Venous Thromboses Presenting as Mechanical Low Back Pain in an 18-Year-Old Woman.

The purpose of this case report is to describe a patient who presented with acute musculoskeletal symptoms but was later diagnosed with multiple deep vein thrombosis (DVT). An 18-year-old female presented to a chiropractic clinic with left lumbosacral pain with referral into the posterior left thigh. A provisional diagnosis was made of acute myofascial syndrome of the left piriformis and gluteus medius muscles. The patient received 3 chiropractic treatments over 1 week resulting in 80% improvement in pain intensity. Two days later, a sudden onset of severe abdominal pain caused the patient to seek urgent medical attention. A diagnostic ultrasound of the abdomen and pelvis were performed and interpreted as normal. Following this, the patient reported increased pain in her left leg. Evaluation revealed edema of the left calf and decreased left lower limb sensation. A venous Doppler ultrasound was ordered. Doppler ultrasound revealed reduction of the venous flow in the femoral vein area. An additional ultrasonography evaluation revealed an extensive DVTs affecting the left femoral vein and iliac axis extending towards the vena cava. Upon follow-up with a hematologist, the potential diagnosis of May-Thurner syndrome was considered based on the absence of blood dyscrasias and sustained anatomical changes found in the left common iliac vein at its junction with the right common iliac artery. A week following discharge, she presented with chest pain and was diagnosed with venous thromboembolism. The patient was successfully treated with anticoagulation therapy and insertion of a vena cava filter. Although DVTs are common in the general population, presence in low-risk individuals may be overlooked. In the presence of subtle initial clinical signs such as those described in this case report, clinicians should keep a high index of suspicion for a DVT. Rapid identification of such clinical signs in association with a lack of objective examination findings warrants further evaluation due to potentially negative outcomes.