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In disseminated infection, hepatic and splenic abscesses can occur, and relapses are common without prolonged therapy. Additional members of the complex con- Burkholderia include Burkholderia pseudomallei, Burkholderia gladioli, and Burkholderia mallei (the agent responsible for glanders). Burkholderia thailandensis and Burkholderia oklahomensis are rare human pathogens. Depending on the species, transmission may occur from other people (person to person), from contact with contaminated fomites, and from exposure to environmental sources. In areas with highly endemic infection, B pseudomallei is acquired early in life, with the with more than 75% of cases occurring during the rainy season. Disease can be acquired by direct inhalation of aerosolized organisms or dust particles containing organisms, by percutaneous or wound inoculation with contaminated soil or water, or by ingestion of contaminated soil, water, or food. People also can become infected as a result of laboratory exposures when proper techniques and/or proper personal protective equipment guidelines are not followed. Symptomatic infection can occur in children 1 year or younger, with pneumonia and parotitis reported in infants as young as 8 months; in addiB pseudomallei also has been reported to cause pulmonary infection in the incubation period can be prolonged (years). A direct polymerase chain reaction assay may provide a more rapid result than culture but is less sensitive, especially when performed on blood, and is not recommended for routine use as a diagnostic assay. Some experts recommend combinations of antimicrobial agents that provide synergistic activity against B cepacia complex. In neonates and young infants, bloody diarrhea without fever can be the only manifestation of infection. Pronounced fevers in children can result in febrile seizures that can occur before gastrointestinal tract symptoms. Other Campylobacter species, including Campylobacter upsaliensis, Campylobacter lari, and Campylobacter hyointestinalis, can cause similar diarrheal or systemic illnesses in children. The gastrointestinal tracts of domestic and wild birds and animals are reservoirs of the bacteria. C jejuni and C coli have been isolated from feces of 30% to 100% of healthy chickens, turkeys, and water fowl. Many farm animals, pets, and meat sources can harbor the organism and are potential sources of infection. Transmission of C jejuni and C coli occurs by ingestion of contaminated food or water or by direct contact with fecal material from infected animals or people. Improperly cooked poultry, untreated water, and unpasteurized milk have been the main vehicles of transmission. Person-to-person transmission also has occurred in neonates of infected mothers and has resulted in health care-associated outbreaks in nurseries. In perinatal infection, C jejuni and C coli usually cause neonatal gastroenteritis, whereas C fetus often causes Campylobacter as 7 weeks. Direct-examination, cultureindependent methods also are available, in addition to culture, but all have the major drawback of not providing an opportunity to determine antibiotic susceptibilities for the infecting organism. The presence of motile curved, spiral, or S-shaped rods resembling Vibrio cholerae tive evidence for Campylobacter performed routinely. C jejuni and C coli can be detected directly (but not differentiated) by commercially available enzyme immunoassays. These immunologic assays provide rapid diagnosis of enteric infection with C jejuni and C coli but have variable performance. C fetus generally is susceptible to aminoglycosides, extended-spectrum cephalosporins, meropenem, imipenem, ampicillin, and erythromycin. Antimotility agents should not be used, because they have been shown to prolong symptomatology and may be associated with an increased risk of death. People with diarrhea should be excluded from food handling, care of patients in hospitals, and care of people in custodial care and child care centers. Chronic or recurrent oral candidiasis can be the presenting sign of human laryngeal candidiasis can occur in immunocompromised patients. Candidemia can occur with or without systemic disease in patients with indwelling central vascular catheters, especially patients receiving prolonged intravenous infusions with parenteral alimentation or lipids. Peritonitis can occur in patients undergoing peritoneal dialysis, especially in patients receiving prolonged broad-spectrum antimicrobial therapy.

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As children age, there is a higher incidence of rheumatologic conditions diagnosis. Any diagnoses of a rheumatologic condition accounted for just under 3% of hospitalizations for any musculoskeletal condition diagnosis, and 0. Age and sex were not significant factors in length of hospital stay and average charges for a rheumatologic condition diagnosis. Total hospital charges for primary rheumatologic condition diagnosis discharges in 2012 were $203. This section discusses some of the more common of those diagnoses, including hemophilia, sickle cell disease, and endocrine and metabolic disorders such as rickets and lysosomal storage disorders. It may result in musculoskeletal problems by way of hemophilic arthropathy and intramuscular hemorrhage. Hemophilic arthropathy occurs through spontaneous bleeding into a weight-bearing joint, resulting in cartilage degeneration and arthrosis as well as asymmetric growth stimulation and deformity. Sickle cell disease is inherited in an autosomal dominant fashion and is characterized by production of abnormal hemoglobin. This results in reduced oxygen delivery to tissues and can lead to multiple musculoskeletal manifestations, including painful bone infarcts, osteomyelitis, avascular necrosis, and vertebral compression fractures. Metabolic bone diseases, such as rickets, occur due to abnormal calcium and phosphate metabolism. Rickets occurs in many forms, including vitamin D deficiency, vitamin D resistance, hypophosphatemic rickets, and renal osteodystrophy. Regardless of the cause, the result is inadequate calcification of bone and cartilage, resulting in bone pain and deformity. This results in musculoskeletal manifestations that include bone deformity secondary to bone marrow infiltration, avascular necrosis, bone pain, pathologic fracture, and osteomyelitis. More than one in ten (12%) children and adolescents with any medical problem diagnoses were hospitalized (55,300), while 2% (4,800) with a primary diagnosis had a hospital discharge. However, this age group tends to have a higher rate of musculoskeletal hospitalizations overall. Any diagnoses of a medical problem with musculoskeletal implications accounted for 11% of hospitalizations for any musculoskeletal condition diagnosis, and less than 1% of all hospitalizations for any health care condition. Hospitalizations with a primary diagnosis of a medical problem were 1% of all musculoskeletal diagnoses and 0. When hospitalized with any diagnosis of a medical problem with musculoskeletal implications along with other medical conditions, males had slightly longer hospital stays and charges than females did. Infants under the age of 1 year had significantly longer stays and higher charges than other age groups, primarily due to cases of rickets. However, for primary medical diagnoses of musculoskeletal implications along with another medical condition, sex and age were not major factors in length of hospital stay and mean charges. Total hospital charges for primary medical problem with musculoskeletal implications diagnosis discharges in 2012 were $151. Watkins-Castillo, PhD Musculoskeletal pain syndromes, including amplified musculoskeletal pain, juvenile primary fibromyalgia syndrome, reflex sympathetic dystrophy, benign hypermobility, and benign limb pains, are common diagnoses in the pediatric population. A systematic review examining the prevalence of chronic musculoskeletal pain found a range of prevalence rates between 4% and 40% in children. Patients also typically have sleep disturbance and other somatic complaints, such as headaches and abdominal pain. The affected limb becomes swollen and discolored and the area can be very painful with light touch (allodynia). The recommended treatment for these conditions includes restoring normal sleep patterns, a therapy program with a focus on exercise and desensitization, and cognitive behavioral therapy. Children with benign limb pains tend to complain of pain at night, often awaking from sleep due to pain. Benign hypermobility is diagnosed in patients who have hypermobile joints4, without an underlying connective disuse disorder. Anterior knee pain and back pain are more common in hypermobile vs nonhypermobile individuals. Hypermobile joints extend easily and painlessly beyond the normal range of motion.

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Given the large number of interventions to consider, those with insufficient evidence are not discussed in detail in this Executive Summary. Domains considered in grading the strength of evidence included study limitations, consistency, directness, precision, and reporting bias, with the body of evidence assigned a strength-of-evidence grade of high, moderate, or low. Applicability We assessed applicability by analyzing study eligibility criteria, characteristics of the enrolled population compared with the target population, characteristics of the interventions, comparators compared with care models currently in use, and clinical relevance and timing of the outcome measures. Results the results of our searches and the selection of articles are summarized in the study flow diagram (Figure B). Our review of abstracts led to retrieval and dual assessment of 389 full-text articles. The factors used to determine the overall strength-ofevidence grades are summarized in Appendix J of the full report. Changes in overall prescribing were reported in all studies, while attempts to measure changes in appropriate or inappropriate prescribing were reported in nine studies (7%) and antibiotic resistance was reported in one study. In addition to the sparseness of reporting on the outcome of appropriate prescribing, the few studies that attempted to assess appropriate prescribing had important limitations in outcome definition and ascertainment methods, and lack of consistency in methods across studies. Reporting on actual patient use of antibiotics was also rare; only studies of delayed prescribing report patient self-report of filling the prescription, with use assumed. This executive summary highlights interventions based on the direction and strength of evidence for benefits (prescribing and/or resistance) and adverse consequences (e. Although we sought to determine whether strategies differed based on various patient, clinical, and contextual factors, this was not possible for any outcome because of the potential confounding influences of a wide variety of other factors. Given the large number of interventions to consider, those with insufficient evidence are not discussed in the Executive Summary. Evidence of Improved or Reduced Antibiotic Prescribing and No Increase in Adverse Consequences Table C summarizes the evidence for these interventions. Four interventions (2 types of education programs, procalcitonin tests, and electronic decision support systems) had moderatestrength evidence for benefits and low-strength evidence for not causing adverse consequences. Education Interventions Clinic-based education interventions for parents of pediatric patients (e. Point-of-Care Tests Point-of-care tests are meant to be a rapid way to determine the likelihood that a given patient has a particular type of bacterial or viral infection, or to determine if an infection is more likely to be bacterial rather than viral. Procalcitonin was the only point-of-care test with evidence of benefit, and this benefit was restricted to adults. Data were not available on appropriate antibiotic prescribing or on antibiotic resistance. Rapid multiviral pointof-care testing in adults had low-strength evidence of improving prescribing outcomes compared with usual care but no evidence on adverse consequences. We did not attempt to weigh the various adverse consequences against the benefits of improved antibiotic prescribing because the balance depends on clinical, economic, and patient values. Evidence on reconsultations, patient satisfaction, and hospitalizations was insufficient. Delayed Prescribing There are multiple methods of implementing delayed prescribing, as well as multiple possible comparison groups. The comparison for delayed prescribing is not with usual care, in which some patients get a prescription, some do not, and some may get a delayed prescription. Hence, the reductions seen based on the delayed prescribing comparison cannot be compared with the evidence on other interventions (for which the comparison is usual care). A single study reported on patientlevel antibiotic resistance, finding a lower rate with delayed prescribing. Together, we found this to be low-strength evidence of a potential increase in risk of hospitalization within 1 month. Studies were not combinable; therefore, this evidence was low strength for a small absolute increase in risk. The reasons for even a small increased risk of hospitalization were unclear in these two trials with over 4,000 patients. For influenza testing, this finding was not surprising, as clinicians were likely using the test to confirm suspected viral illness. This suggests that procalcitonin should not be used to guide antibiotic prescribing in children without further study. Head-to-Head Comparisons of Interventions Single Interventions the evidence from studies that directly compared different interventions with each other was sparse, and few studies reported outcomes other than prescribing of antibiotics.

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The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states. Evidence based medicine: how to practice and teach evidence based medicine, 2nd ed. Periodic Health Examination Monograph: report of the task force to the Conference of Deputy Ministers of Health. Ottawa: Health Services and Promotion Branch, Department of National Health and Welfare, 1980. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Revised definition of neuropathic pain and its grading system: an open case series illustrating its use in clinical practice. The effects of dorsal column stimulation on measures of clinical and experimental pain in man. Widespread pain in fibromyalgia is related to a deficit of endogenous pain inhibition. High-frequency spinal cord stimulation for the treatment of chronic back pain patients: results of a prospective multicenter European clinical study. The recommendations made by this consensus panel are intended to improve safety, selection of implant candidates, efficacy, and cost-effectiveness. We encourage implanting physicians to strive to provide the best and most informed care possible in this quickly evolving and exciting area of medicine. Acknowledgements Our thanks to Mary Bockman Price, Michelle Byers, Jeffrey Peterson, Tia Sofatzis, and Sarah Staples, whose hard work and dedication to detail supported our authors during manuscript preparation. The remaining authors contributed sections of the manuscript or provided critical reviews. Flexibility in lead placement for the treatment of failed back surgery syndrome with spinal cord stimulation of the dorsal root ganglion: a case series. A multicenter, prospective trial to assess the safety and performance of the Spinal Modulation dorsal root ganglion neurostimulator system in the treatment of chronic pain. Analysis of the selective nature of sensory nerve stimulation using different sinusoidal frequencies. Long term results of peripheral conditioning stimulation as an analgesic measure in chronic pain. Sustained effectiveness of 10 kHz high-frequency spinal cord stimulation for patients with chronic, low back pain: 24-month results of a prospective multicenter study. Analgesic efficacy of high-frequency spinal cord stimulation: a randomized double-blind placebo-controlled study. Conventional and kilohertz-frequency spinal cord stimulation produces intensity- and frequency-dependent inhibition of mechanical hypersensitivity in a rat model of neuropathic pain. Spinal cord stimulation for axial low back pain: a prospective controlled trial comparing 16-contact insulated electrodes with 4-contact percutaneous electrodes. Epidural spinal cord stimulation for treatment of chronic pain-some predictors of success. Could automatic position-adaptive stimulation be useful in spinal cord stimulation? Assessing the quality of reports of randomized clinical trials: is blinding necessary? Effectiveness of cervical spinal cord stimulation for the management of chronic pain. Spinal cord stimulation for relief of chronic pain in vasospastic disorders of the upper limbs. Neuroaugmentation in the treatment of complex regional pain syndrome of the upper extremity. Spinal cord stimulation in complex regional pain syndrome: cervical and lumbar devices are comparably effective. Four-limb neurostimulation with neuroelectrodes placed in the lower cervical epidural space. Spinal cord stimulation is effective in management of complex regional pain syndrome I: fact or fiction.

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Aspiration of osteoprogenitor cells for augmenting spinal fusion: comparison of progenitor cell concentrations from the vertebral body and iliac crest. Aspiration to obtain osteoblast progenitor cells from human bone marrow: the influence of aspiration volume. Mesenchymal progenitor cells and their orthopedic applications: forging a path towards clinical trials. Therapeutic potential of adult bone marrow-derived mesenchymal stem cells in diseases of the skeleton. Practical modeling concepts for connective tissue stem cell and progenitor compartment kinetics. Role of mesenchymal stem cells in regenerative medicine: application to bone and cartilage repair. Treating osteoarthritic joints using dextrose Prolotherapy and direct bone marrow aspirate injection therapy. Regenerative injection therapy with whole bone marrow aspirate for degenerative joint disease: A case series. Evidence-based use of dextrose Prolotherapy for musculoskeletal pain: a scientific literature review. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review. A randomized, placebo controlled trial of bupropion sustained release in chronic low back pain. Intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. An intact facet capsular ligament modulates behavioral sensitivity and spinal glial activation produced by cervical facet joint tension. The biology of Prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study. Neurootological contributions to the diagnostic follow-up after whiplash injuries. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Identifiers Suggestive of Clinical Cervical Spine Instability: A Delphi Study of Physical Therapists. Dynamic motion analysis of normal and unstable cervical spines using cineradiography. The value of functional computed tomography in the evaluation of soft-tissue injury in the upper cervical spine. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. Upper cervical instability of traumatic origin treated with dextrose Prolotherapy: a case report. Head-turned postures increase the risk of cervical facet capsule injury during whiplash. Axial head rotation increases facet joint capsular ligament strains in automotive rear impact. Non-operative treatment of cervical radiculopathy: a three part article from the approach of a physiatrist, chiropractor, and physical therapist. The efficacy of dextrose Prolotherapy for temporomandibular joint hypermobility: a preliminary perspective, randomized, double-blind, placebocontrolled clinical trial.

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Alcohol-based hand sanitizers are the most effective products for reducing the number of bacteria on the hands. Soap and water are recommended when hands are visibly dirty, before eating, after using a restroom, or after known or suspected exposure to Clostridium difficile, norovirus, or Bacillus anthracis. When hands are cleaned with soap and water, they should be rubbed together vigorously for at least 15 seconds, and the soap and water should cover all surfaces of the hands and fingers. When alcohol-based hand sanitizer is used, the product should cover all surfaces as hands are rubbed together. For example, an active error occurs when a nurse accidentally administers a full dose of heparin rather than a heparin flush; an associated latent condition might be the fact that the two vials appear virtually identical and both are routinely stocked near each other in the same cabinet at the point of care. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (active errors) and underlying conditions that contributed to the event (latent conditions). It should be recognized that serious adverse events are almost never the result of a single cause, and often are associated with numerous contributing factors. In the setting of a serious adverse event, immediate interventions may be implemented to quickly reduce the risk of recurrence of a similar error. However, such quickly generated solutions typically do not address the root cause and should only serve as a placeholder until more reliable and sustainable solutions can be developed, tested, and implemented. PracticalQualityandSafetyApplicationsinHealthcare 20 Practical Safety Applications in Radiology 4. This zone should be clearly demarcated and marked as potentially hazardous because of the strong magnetic field. There have been reports of projectile injuries from anesthetic gas or oxygen cylinders, and even patient deaths. Screening is more difficult when the patient is unconscious or otherwise unable to provide a reliable history. In such cases, screening should be performed as effectively as possible from other sources, such as family members and the medical record, and the urgency of the examination should be bal-anced with the level of uncertainty of the screening process. The 5 Gauss line is the point at which the magnetic field begins to affect electromagnetic devices such as pacemak-ers. Thus, the restricted area may extend through the floor and/or ceiling to adjacent floors. While many devices are composed of nonferromagnetic materials and do not pose a risk, some, such as aneurysm clips and cardiac implantable electronic devices, require caution. Physical contact alone with the inner surface of the bore can produce burns, and insulating pads are necessary to keep skin at least 1 to 2 centimeters from the surface. In a large patient, tightly wedging a sheet in place of a pad between the skin and the bore, not maintaining the requisite distance, creates a distinct risk of burns. If there is only a small surface area of skin-to-skin contact, greater current density and resistive heating can lead to burns. Skinto-skin burns have also occurred when overhanging abdominal panniculus in an obese patient contacts the upper thigh. Commercial pads are available that have notches in them to keep thighs separated, minimizing this skin-to-skin contact risk. Other sources of heating can be associated with metallic fibers in clothing, especially undergarments, and burns 22 PracticalSafetyApplicationsinRadiology related to this have been reported. To minimize this risk, it is recommended (and required at most sites) that patients change out of street clothes into hospital gowns or similar attire. Certain transdermal patches may contain aluminum and other metals that may cause burns. Occasionally, large tattoos may undergo heating and cause burns; application of an ice pack may be necessary to reduce the risk of skin burning. A "quench" occurs when heating of a segment of the electromagnetic coils makes them no longer superconducting. This produces further heat in the coils, and collectively, these events produce a rapid change of state of the liquid helium into a gas (with a 760-fold increased volume). A specifically designed quench pipe accommodates the explosive force of the rapidly boiling helium gas, by allowing it to escape into the atmosphere. Iodinated contrast media can be classified as ionic or nonionic and monomeric or dimeric. Ionic contrast media dissociate into two particles in solution (an anion, which contains the tri-iodinated benzene ring, and a cation, consisting of sodium or methylglucamine [meglumine]).

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The subject was then asked to lower the trunk back to the bed and asked to extend the hip causing a contraction of the gluteal muscles lying lateral to the ligament. The area in between these two structures where no movement occurred was assumed to be the target structure but this was confirmed by comparing the ultrasound findings with the markings on the skin. The purpose of including light brush and pin-prick to the protocol was to account for potential sensory disturbances (hyper/hyposensitivity) of superficial structures (Treede et al. It must however be acknowledged that most of the force from the algometer is absorbed in the upper most layers of subcutaneous tissue (Finocchietti et al. The results of quantitative sensory testing may also be affected by a range of cognitive, emotional and sleep-related problems (see section 2. Manual clinical tests the sacroiliac joint pain provocation tests are traditionally performed in prone, side-lying or supine depending on which test is being performed (Laslett et al. Therefore, a modified version of the test was performed in side lying in the following manner: the hips and knees were placed in a comfortably flexed position, maintaining the curvature (lordosis) of the lumbar spine as close as possible to what was seen in standing position. The examiner placed the thumb over the facet joints of the upper most L5/S1 segment and applied an anteriorly directed force. The test was considered positive as per usual clinical best practice based on whether it provoked a painful response (muscle guarding, apprehension). Whilst applying the pressure the subject was asked whether any pain was detected at the stimulation site and/or at sites adjacent or distant to the stimulation site. This was repeated for the L4/L5 segment and then for the consecutive segments above, running the length of the lumbar spine up to the thoracolumbal junction and then repeated on the other side after the subject had switched sides. The first instance the stimulation caused pain, the pressure was relieved and the test registered as being positive but this was done to avoid unnecessary discomfort for the participants during and/or after the test. Pain provocation tests for the low back have been shown to have excellent sensitivity and specificity when a verbal response is given (Phillips and Twomey, 1996). This was done to ensure that the movement created by the prime movers (hip flexors) and the work load of the stabilizing muscles (trunk muscles and the posterior thigh muscles on the contralateral side) was comparable between subjects. The hip angle was determined with a goniometer and a bar was positioned so that the anterior part of the talocrural joint would touch it at 20 degrees of hip flexion. During the test, the subjects were instructed to lift the leg up to the bar, at a self-selected speed and hold it steady for approximately 5 seconds. This was done three times consecutively with approximately 1 second stop between lifts and then repeated for the opposite side. In clinical samples the added value of both sides represents the outcome of the test (Mens et al. Finally, the quality of pain was assessed using the English (Melzack and Torgerson, 1971) or Danish (Drewes et al. This is not a universal finding in clinical conditions although it has been reported of (Slipman et al. The mechanisms underlying pain referral in general are not fully understood but are considered to relate to a convergence of nociceptive input from various anatomically unrelated structures (somatic and visceral) onto the same spinal segment (Mense, 1994). In chronic low back pain, an extensive pain area is well described (Ohnmeiss et al. The reason for this may be an ongoing bombardment of incoming signals from nociceptive fibres on to the second-order neurones of the dorsal horn (Hoheisel et al. In pregnancy, it is difficult to determine the exact origin of pain but from studies using intraarticular blocking protocols in non-pregnant populations (see above) it is evident that the origin of pain lies in the deeper structures of the low back and pelvic girdle e. The small discrepancy in pain areas when comparing the clinical group with experimental pain (Fig. Pregnant subjects reported both areas of pregnancy related pain and other preexisting pain areas. No increase was found in deep tissue sensitivity distal to the stimulation area despite the large area of pain referral which is in accordance with what has been demonstrated previously (Graven-Nielsen et al. Interestingly, a decrease in pain sensitivity (hypoalgesia) was found on the side contralateral to the injection site (I) which has been seen before after hypertonic saline injections (Ge et al. The onset of widespread hyperalgesia has been shown to occur soon after the initiating painful episode in a clinical sample (Sterling et al. Experimental pain studies have shown that in healthy subjects, low-intensity nociceptive activity can cause spreading of pain and hyperalgesia (Andersen et al. A spreading in sensitivity as a result of an initiating localized painful stimulus may potentially indicate a system where central processing is facilitated (Graven-Nielsen et al. In the third study, the pregnant subjects where included solely due to their pregnancy and therefore they had varying degrees of pain and disability.

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Neurophysiologically, the essential feature is that it arises as a result of the stimulation of nerve endings in a bone, ligament, joint or muscle. Referred pain occurs because of a misperception of the origin of the signal which reaches the brain by a convergent sensory pathway. These features underlie the distinction between somatic referred pain and radicular pain. As such, referred pain may be perceived in areas relatively remote from the source of pain, but often the distinction is blurred when the regions of local pain and referred pain are contiguous and the two pains appear to be confluent. A knowledge of the innervation of the affected regions, however, serves to make the distinction. Conduction block in sensory axons results in numbness; conduction block in motor axons results in weakness. An important realisation is that radiculopathy does not cause pain, either in the back or in the lower limbs. If radiculopathy is associated with pain, the mechanism of that pain may not necessarily be the same as the cause of the racticulopathy. Radiculopathy may be associated with somatic referred pain, in which case the mechanisms of pain and the cause of radiculopathy will be distinctly different. On the other hand, racticulopathy may be associated with radicular pain, in which case the aetiology may be the same for both features, but the mechanisms of each will not be exactly the same. Radicular pain is shooting and band like, whereas somatic referred pain is constant in position but poorly localised and diffuse, and is aching in quality. The implied basis for sciatica is nerve root compression or nerve root irritation, whereupon sciatica must be considered a form of radicular pain. However, the available physiological evidence dictates that radicular pain has a characteristic quality and distribution, and therefore the term sciatica should be restricted to this type of pain in the lower limb. The only type of pain that has ever been produced experimentally by stimulating nerve roots is shooting pain in a band-like distribution. There is no physiological evidence that constant, deep aching pain in the lower limb arises from nerve root irritation. Neurophysiological experiments have shown that compression of a nerve root does not evoke nociceptive activity; at best it evokes a brief discharge at the time of application of the compression stimulus, but thereafter the root becomes silent. Clinical experiments have shown that compressing normal nerve roots with urinary catheters evokes paraesthesia and numbness but not pain. I It is only when previously damaged nerve roots are squeezed by forceps35 or pulled with sutures,34 or when nerve roots are stimulated electrically,36 that a characteristic pain is evoked. Indeed, on cLinjcal grounds it has been estimated that fewer than 5% or 1 %, of presentations of low back pain are associated with nerve root irritation due to disc 30%, and perhaps as few as herniation. Inflammation was implicated initially on the grounds that surgeons have often seen signs of nerve root inflammation when operating on herniated discs. Nevertheless, belief in some form of inflammation has persisted and has been explored. In animal studies, compression of lumbar nerve roots causes oedema and increased intraneural pressure,b. For any structure to be deemed a cause of back pain: and produces hyperalgesia and pain behaviour? The structure should have a nerve supply, for without access to the nervous system it could not evoke pain. The structure should be capable of causing pain similar to that seen clinically, Ideally, this should be demonstrated in normal volunteers, for inferences drawn from clinical studies may be compromised by observer bias or poor patient reliability, 3. The structure should be susceptible to diseases or injuries that are known to be painful. Ideally, such disorders should be evident upon investigation of the patient but this may not always be possible. Certain conditions may not be detectable using currently available imaging techniques, whereupon the next line of evidence stems from post-mortem studies or biomechanical studies which can provide at least prima facie evidence of the types of disorders or injuries that might affect the structure, 4.


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