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Women with pelvic floor complaints experience restrictions and distress in their daily, social, and sexual functioning, and their intimate relationships. We interviewed forty-eight women to unravel differences between women receiving and not receiving pelvic physical therapy and between pregnant, parous, and nulliparous women in preparation for theory development. We analyzed data in a mixed-method design using NVivo and Leximancer. sexual dysfunction, relationship dynamics, the nature and severity of restrictions and distress, and coping strategies appear to vary between women receiving and not receiving therapy. specific combinations of restrictions and distress are present in pregnant, parous, and nulliparous women, and might influence women’s decision to seek help.

Aim To evaluate low back pain (LBP) incidence and impact throughout pregnancy in terms of women’s well-being and delivery outcomes. Material and methods Cross-sectional prospective study conducted on singleton pregnancies at ≥37th gestational age admitted for delivery. Localization of LBP, intensity and frequency as well as derived functional disability status were assessed with a self-reported questionnaire. Main delivery outcomes including mode of delivery, and maternal or neonatal complications were recorded. Results A total of 229 women participated in the study. LBP prevalence amounted to 55.9%, with the pain already present before pregnancy in 14.0% of the cases. The pain was mostly localized in the lower back (40.6%), symphysis (23.3%), and coccyx (20.5%). Both the frequency and intensity of pain gradually increased significantly during pregnancy, reaching 20 days/month (IQR=10–30) and 6/10 points (IQR=5–8) on a visual analog scale in the 3rd trimester (p Conclusions LBP is a common issue in pregnant women, accounting for increasing morbidity and invalidity, and leading to an increased cesarean section risk during labor.

Objective. To develop a conceptual model of patho- and sanogene­sis of the sacroiliac joint (SIJ) osteoarthritis on base of the known data about the SIJ, the results of our own biomechanical studies of this joint, its ligaments and stabilizing muscles by finite element modelling, data of clinical verification of these results. Methods. The object of the model is the SIJ as a link, which connects thespine and pelvis. The proposed conceptual model is based on the M.Panjabi hypothesis of chronic lumbar pain in the case of partial dama­ge to ligaments, which leads to muscle dysfunction. Results. Anew conceptual model of SIJ osteoarthritis was developed. In this model we tried to take into account the limitations of the existing SIJ stability hypotheses and models of the appearance ofthepelvic girdle pain, SIJ dysfunction and SIJ arthrosis. Themodel is based on theresults of our own research. It was proved, that patients with SIJ osteoarthritis have an asymmetry of the width ofthejoint slits, theinclination of the sacrum and pelvis, sacral rotation, hyperlordosis in the LV–SI segment. These factors lead toa shift ofthehorizontal axis of sacral rotational mobility relative tothe pelvic bones. This horizontal axis shift leads to the instabili­ty oftheSIJ on one side of the joint, and to the functional block on another side. Theresults of these functional changes were damage ofthe SIJ ligaments-stabilizers, dysfunction of the SIJ muscles-stabilizers, degenerative changes ofSIJ elements and pain. The deve­loped model allows toexplain the distortion of muscular response pattern in patients with improper SIJ biomechanics in conditions ofSIJ osteoarthritis. The increase of the SIJ biomechanics changes enlarges thethemuscle response pattern distortion. Conclusions. The developed conceptual model explains many clinical manifestations oftheSIJ osteoarthritis and will help to understand better themechanics ofthepelvic girdle pain in such conditions, will improve theresults ofdiagnosis and treatment., Мета. На підставі відомих уявлень про крижово-клубовий суглоб (ККС), результатів власних біомеханічних досліджень методом скінченних елементів особливостей цього суглоба, його зв’язок і м’язів-стабілізаторів, їхньої клінічної верифікації розробити концептуальну модель пато- ісаногенезу артрозу ККС. Методи. Об’єктом моделювання була система ККС як ланка, що з’єднує хребет ітаз. За основу передбачуваної концептуальної моделі взято модель М. Panjabi виникнення хронічного поперекового болю в разі часткового ушкодження зв’язок, що призводить до порушення функції м’язів. Результати. Розроблено нову концептуальну модель розвитку артрозу ККС, в якій ми намагалися врахувати обмеження наявних моделей стабільності ККС і появу хребтово-тазового болю, виникнення дисфункції та розвитку артрозу ККС. Модель побудована за результатами власних досліджень. Доведено, що у хворих на артроз ККС є асиметрія ширини суглобових щілин, нахил крижів і таза, ротація крижів, гіперлордоз ухребтовому руховому сегменті LV–SІ. Це призводить до зсуву горизонтальної осі ротаційної рухомості крижів щодо тазових кісток і, відповідно, виникнення, з одного боку, нестабільності ККС, а з іншого, — функціонального блока. Унаслідок цього виникають ушкодження зв’язок-стабілізаторів ККС, біль іпорушення функції м’язів-стабілізаторів суглоба і дегенеративні зміні в його елементах. Розроблена модель дає змогу пояснити зміну патерна м’язової відповіді в пацієнтів із порушенням біомеханіки ККС за умов артрозу. Чим більше змінюється біомеханіка ККС, тим більше спотворюється патерн м’язової відповіді. Висновки. Розроблена концептуальна модель пояснює багато клінічних проявів артрозу ККС і допоможе кращому розумінню механізму виникнення хребтово-тазового болю за таких умов, дозволить поліпшити результати діагностики та лікування.

Introduction: Thoracic myelopathy is relatively uncommon because few degenerative changes occur as a result of the restricted range of motion surrounding the rib cage. Methods: A retrospective study was performed in 300 consecutive surgical cases of thoracic disorders with myelopathy treated in our department from 2000 to 2015. Girdle pain, back pain, low back pain, leg numbness, leg pain, gait disturbance, leg paresis, and bowel bladder disturbance as initial and preoperative symptoms; patellar tendon reflex, ankle tendon reflex, and ankle clonus as preoperative neurologic findings; MRI and CT findings; and surgical procedure, intraoperative findings, and postoperative recovery were investigated. Results: The disease distribution included ossification of the ligamentum flavum (OLF) (n = 48), ossification of the posterior longitudinal ligament (OPLL) (n = 30), OPLL with OLF (n = 27), intradural extramedullary tumor (n = 98), intramedullary spinal cord tumor (n = 64), vertebral tumor (n = 17), spinal cord herniation (n = 7), vertebral fracture (n = 4), and thoracic disk herniation (n = 5). There were notable associations of gait disturbance with OPLL and OPLL + OLF; back pain at initial diagnosis with disease at upper levels; and low back pain with disease at a lower level. Conclusion: These findings suggest that patients with gait disturbance, back pain, and low back pain on physical examination may have thoracic disease that results in myelopathy.

The possibility that polymyalgia rheumatica (PMR) can be diagnosed when both ESR and CRP are normal at the time of diagnosis and before therapy with glucocorticoids, has been often discussed in the literature. We present a case report of a 100-year-old Caucasian man referred to our outpatient clinic, complaining of chronic pain in the shoulder and hip girdle associated with normal values of both ESR (21 mm/1st hour) and CRP (4 mg/dL). In the previous four months, several anti-inflammatory drugs and painkillers associated with physiotherapy treatments gave no significant improvement in pain and self-care. After an ultrasound (US) and an 18-fluorodeoxyglucose positron emission tomography associated with total body computed tomography (18-FDG PET/CT) examination, PMR was diagnosed and he started therapy with 17.5 mg prednisone, obtaining a fast improvement in pain and self-care. After 10 months of tapering, he stopped prednisone without relapse. During a 3-year follow-up, no alternative diagnosis was done. When a patient complains of chronic bilateral shoulder and hip girdle pain associated with normal inflammatory indices, it is reasonable to think in the first instance that this person is not suffering from PMR. Moreover, the possibility that PMR may onset in a centenarian person, is exceptional. In our patient, when we piece the puzzle together, the diagnosis of PMR was the most possible one.

Capillary hemangiomas are benign tumors found in the skin and soft tissues in younger people. They occur in the central nervous system only rarely, and intradural occurrence is extremely rare. We report here a 60-year-old man presenting with thoracic girdle pain and progressive gait disturbance. Magnetic resonance images of the thoracic spine showed a12×8×20 mm, well-defined intradural mass at the T2 level, compressing the spinal cord laterally. Relative to the spinal cord, the mass was hypo- to isointense on T1-weighted images and relatively hyperintense on T2-weighted images, with strong enhancement on contrast-enhanced T1-weighted images. The patient underwent T1-2 hemilaminectomy with resection of the intradural extramedullary tumor, which showed characteristics of a capillary hemangioma on histologic examination. The patient’s symptoms improved following the surgery and no clinical or radiological evidence of recurrence was noted at the 2-year follow-up. We present this case with a review of the literature, highlighting features for differential diagnosis.

Data on the severity of signs and symptoms of lumbopelvic pain (LPP) during pregnancy are scarce. Therefore, this cross-sectional study examines the severity of LPP and pain-related signs and symptoms. Women with an uncomplicated pregnancy of 20-30 weeks were invited to participate. They rated their pain and fatigue on a numerical rating scale, and pain location was indicated on a drawing. Disability was scored on the Quebec Back Pain Disability Scale (QBPDS) and urine incontinence on a Likert scale. Physical examination consisted of the Active Straight Leg Raise (ASLR) test, the Posterior Pelvic Pain Provocation (PPPP) test and pain score, and force during isometric bilateral hip adduction. Of all 182 participants, 60.4% reported LPP. Mean pain level was 3.6 (SD 2.2); in 20.0% of the women the score was >5. The mean score on the QBPDS was 27 (SD 16); in 20.9% the score was >40. Compared to women without LPP, women with LPP more frequently suffered back pain in the past (p

Background: Discogenic, facet joint, and sacroiliac joint mediated axial low back pain may be associated with overlapping pain referral patterns into the lower limb. Differences between pain referral patterns for these three structures have not been systematically investigated. Objective: To examine the individual and combined relationship of age, hip/girdle pain, leg pain, and thigh pain and the source of internal disc disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP) in consecutive chronic low back pain (CLBP) patients. Design: Retrospective chart review. Setting: Community based interventional spine practice. Patients: 378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed. Methods: Charts of consecutive low back pain patients who underwent definitive diagnostic spinal procedures were retrospectively reviewed. Patients underwent provocation lumbar discography, dual diagnostic medial branch blocks, or intra-articular diagnostic sacroiliac joint injections based on clinical presentation. Some subjects underwent multiple diagnostic injections until the source of their chronic low back pain (CLBP) was identified. Main Outcome Measurements: Based on the results of diagnostic injections, subjects were classified as having IDD, FJP, SIJP, or other. The mean age/standard deviation and the count/percentage of patients reporting hip girdle pain, leg pain, or thigh pain were estimated for each diagnostic group and compared statistically among the IDD, FJP, SIJP, and other source groups. Next, the 4 predictor variables were simultaneously modeled with a single multinomial logistic regression model to explore the adjusted relationship between the predictors and the source of CLBP. Results: The mean age was significantly different among the source groups. IDD cases were significantly younger than FJP, SIJP, and other source groups and FJP cases were significantly younger than other sources. The age by thigh pain interaction effect was statistically significant (P = 0.021), indicating that the effect of age on the source of CLBP depends on thigh pain, and similarly, that the effect of thigh pain on the source of CLBP depends on age. Limitations: Retrospective study design. Conclusions: The presence or absence of thigh pain possesses a significant correlation on the source of CLBP for varying ages, whereas the presence of hip/girdle pain or leg pain did not significantly discriminate among IDD, FJP, or SIJP as the etiology of CLBP. Younger age was predictive of IDD regardless of the presence or absence of thigh pain. Key words: low back pain, intervertebral disc, zygapophyseal joint, sacroiliac joint, pain referral patterns

Women with pregnancy-related pelvic girdle pain (PPP), or athletes with groin pain, may have trouble with the active straight leg raise (ASLR), for which a pelvic belt can be beneficial. How the problems emerge, or how the belt works, remains insufficiently understood. We assessed muscle activity during ASLR, and how it changes with a pelvic belt. Healthy nulligravidae (N=17) performed the ASLR, and walked on a treadmill at increasing speeds, without and with a belt. Fine-wire electromyography (EMG) was used to record activity of the mm. psoas, iliacus and transversus abdominis, while other hip and trunk muscles were recorded with surface EMG. In ASLR, all muscles were active. In both tasks, transverse and oblique abdominal muscles were less active with the belt. In ASLR, there was more activity of the contralateral m. biceps femoris, and in treadmill walking of the m. gluteus maximus in conditions with a belt. For our interpretation, we take our starting point in the fact that hip flexors exert a forward rotating torque on the ilium. Apparently, the abdominal wall was active to prevent such forward rotation. If transverse and oblique abdominal muscles press the ilia against the sacrum (Snijders' "force closure"), the pelvis may move as one unit in the sagittal plane, and also contralateral hip extensor activity will stabilize the ipsilateral ilium. The fact that transverse and oblique abdominal muscles were less active in conditions with a pelvic belt suggests that the belt provides such "force closure", thus confirming Snijders' theory. © 2009 Elsevier Ltd. All rights reserved.

Evaluation of an athlete's report of "hip pain" is challenging. Many conditions involving the pelvic girdle can present with overlapping pain distributions, and athletes often may have coexisting disorders. Appropriate evaluation requires thorough, systematic consideration of intra-articular hip disease, extra-articular local causes of hip pain, and referred pain from other musculoskeletal or even visceral sources. Although our understanding of intra-articular hip disorders has been greatly enhanced in recent decades through advances in hip arthroscopy, gaps still exist in our understanding of appropriate treatment, including effective nonsurgical protocols and when to consider surgical intervention. For instance, we have a better understanding of hip dysfunction related to structural changes that occur prior to the onset of arthritis, but we are also learning that correction of the structural changes does not always guarantee a correction of dysfunction and pain. Furthermore, athletes need instruction and guidance in retraining appropriate movement patterns after a surgical intervention. Risk stratification regarding which athletes need surgical intervention and what their needs are after specific surgical procedures remain undefined. In this review we will describe the differential diagnosis of hip and pelvic girdle pain in the athlete and then discuss how to use a history, physical examination, and appropriate imaging and diagnostic injections to arrive at a proper diagnosis. Lastly, a brief discussion is included of key concepts and controversies involved in treating some of the most common hip disorders experienced by athletes.

Erasmus syndrome is defined as the association of silica exposure and subsequent development of systemic sclerosis. The limited number of cases reported in the literature mainly involves miners and only sporadically other professionals. We describe a case of Erasmus syndrome in a marble worker. A 68 year old man came to our observation complaining pelvic and scapular girdle pain, evening fever, intense weakness and emaciation for about 1 month. He also reported to have had Raynaud’s phenomenon in his hands for the last 13 years. Also, his occupational history revealed a chronic exposure to silica dust. The patient presented pain in his shoulders and hips, moderate skin thickening and sclerosis in his hands and fingers extending proximally to his wrists. The diagnosis of systemic sclerosis was determined according to his clinical and medical history, the positivity of anti-Scl 70 antibodies, the nailfold capillaroscopy suggestive of an active scleroderma pattern and the detection of a mild restrictive pulmonary syndrome. The evaluation of the organbased complications excluded a gastroenterological and cardiovascular involvement, while the chest computed tomography (CT) detected multiple small nodules with a mantle distribution and enlarged lymph nodes with no signs of interstitial lung disease and fibrosis. Additional tests (positron emission tomography-CT, flexible bronchoscopy and broncho-alveolar lavage) excluded infectious diseases and cancer. However, given the pulmonary involvement, we performed a histological examination of the parenchyma and lymph nodes, which revealed a picture of pneumoconiosis. In the end, the occupational history and the findings from the diagnostic procedures led to the diagnosis of pulmonary silicosis. The precise definition of the pulmonary involvement was essential to the therapeutic approach to this patient.

The pattern of acute illness was determined in 102 adolescents and adults with sickle cell anaemia who presented to the emergency unit of a Lagos hospital. The patients had a mean age of 20.5 years (SD 13.1) and a male-female ratio of 1.5. The symptoms included fever (72%), fatigue and weakness (59%), anorexia (59%) and pain (57.5%) while major clinical signs were pallor (100%), jaundice (71%) and hepatomegaly (68%). Sixty-eight per cent of patients had sickle cell crises, including one with hemiplegic stroke, 10% with combined anaemia and pain crises, 33% with anaemia crises only and 23.5% with pain crises only. Sixty-three per cent had infection which was malaria in 24.5%, bacterial in 17% and viral in 6%. Of 16 patients with pyrexia of unknown origin, seven responded to treatment with chloroquine and eight to antibiotics. Infection was detected in 50% of the patients with sickle cell crises. The association between anaemia crises and malaria was significant (P < 0.05). Of the eight deaths, seven (88%) had anaemia crises. In contrast to studies conducted two decades ago in the same hospital, the prevalence of anaemia crises now exceeds that of pain crises and malaria now exceeds that of bacterial infection. Severe symptomatic anaemia (anaemia crisis) was more frequently associated with infection (mostly malaria) than was bone pain crisis. The Girdle pain crisis more frequently resulted in a fatal outcome than the uncomplicated bone pain crisis.

Operative cases in thoraco-lumbar fracture-dislocations were investigated. Nine males underwent surgical reduction, decompression and posterior instrumentations using ISOLA in 7 patients and VSP in 2 from June 1993 to July 1998. The age at the surgery ranged from 24 to 49 years old (average 33 years old) and follow-up period from 4 months to 65 months (average 17 months). The dislocated vertebrae ranged from T9 to L2 and 3.4 vertebrae on average were included into fusion area. Four patients underwent urgent operations and 5 patients elected operations.The duration of bed rest averaged 2 weeks. Six patients represented complete paraplesia preoperatively and no one improved postoperatively. Three patients with incomplete paraparesis improved completely (2 patients D→E, 1 patient B→E). After surgery the mean kyphotic angle before, justafter, at follow-up were 12°, 0°, and 4° respectively. Therefore good reduction was achieved and the correction loss was small. Three patients complained of persistent girdle pain of the torso but there was no relation with the correction loss of the kyphosis after surgery.

Diplopia may be a sign of giant cell arteritis (GCA). Polymyalgia rheumatica (PMR) is a systemic rheumatic inflammatory disease characterized by shoulder and hip girdle pain, and PMR can be associated in some patients with GCA. The authors report diplopia in two patients with treated PMR and biopsy-proven GCA, and review the literature on diplopia in GCA.

Background Polymyalgia rheumatica (PMR) is an inflammatory disorder of the elderly characterized by girdle pain and stiffness, constitutional symptoms and elevation of inflammatory indexes. Glucocorticoid (GC) treatment is effective but often prolonged, with associated side effects. Data on risk factors of poor prognosis are scanty: in particular it is not known if the pattern of clinical presentation can influence PMR outcome. Objectives To test the hypothesis that clinical presentation of PMR can predict its outcome. Methods 394 patients (251 women, median age 73 yrs, range 47–92 yrs) with PMR diagnosed according to Bird9s criteria, visited between 1990 and 2014 by the same clinician were studied. Median follow up was 13.8 months (range 1–250 months). Clinical features recorded at disease presentation included involvement of: i) the shoulder girdle; ii) the pelvic girdle; iii) the column; vi) two or more of the previous locations; v) with giant cell arteritis (GCA); or vi) with acute onset, defined as completion of full symptoms and signs in ≤72h. PMR outcome was evaluated by considering: i) duration of follow-up; ii) appearance of peripheral arthritis; iii) appearance of GCA; iv) number of exacerbations/ relapses; v) cumulative dosage of GC; vi) use of methotrexate (MTX); and vii) death. Results At multivariate analysis, acute onset predicted a longer follow-up duration (p=0.007) and death (p=0.037); involvement of the spine predicted longer follow up duration (p=0.001) and use of MTX (p=0.018); presentation at the pelvic girdle predicted a high number of exacerbations/relapses (p=0.034) and association therapy with MTX (p=0.009); onset in multiple locations predicted a high number of exacerbations/relapses (p=0.03); presentation with GCA predicted a higher cumulative dosage of GC (p=0.0001) and use of MTX (p=0.027). Conclusions Apart from the obvious association between concomitant GCA and negative prognosis of PMR, other clinical characteristics at disease onset influence outcome. In particular, the initial presentation with multiple locations, including spine and pelvic girdle, resulted in longer follow-up, more relapses, and need of MTX treatment, whereas the classic one with only shoulder girdle involvement was associated with a milder disease. An acute onset was also a negative prognostic factor. Clinicians should consider the pattern of disease presentation when evaluating the burden of PMR. Disclosure of Interest None declared

Background Polymyalgia rheumatica (PMR) is an inflammatory disorder of the elderly characterized by girdle pain and stiffness, constitutional symptoms and elevation of inflammatory indexes. In its classical form, the shoulder girdle is affected, associated or not with pelvic and spinal pain. The latter two locations can occasionally precede shoulder involvement. It is not known if the pattern of clinical presentation is related to disease severity at onset. Objectives In this study, disease severity of PMR has been correlated with clinical characteristics at presentation. Methods 394 patients (251 women, median age 73 yrs, range 47–92 yrs) with PMR diagnosed according to Bird9s criteria, visited between 1990 and 2014 by the same clinician were studied. Clinical features recorded at disease presentation included initial involvement of: i) the shoulder girdle; ii) the pelvic girdle; iii) the column; iv) two or more of the previous locations; v) presence of giant cell arteritis (GCA); vi) acute onset, defined as completion of full symptoms and signs in ≤72h; or vii) peripheral arthritis. Disease severity of PMR was evaluated by considering: i) weight loss; ii) fever; iii) morning stiffness (MS); iv) ESR; v) CRP; and vi) initial dose of prednisone. Results Acute onset and classical involvement of the shoulder girdle were not associated with our indicators of PMR severity. By contrast, onset in the pelvic girdle (p=0.002), simultaneous onset in multiple locations (p=0.006), peripheral arthritis (p=0.045) and GCA (p=0.0004) were associated with a higher initial dose of prednisone; multiple locations onset correlated also with MS (p=0.044). Conclusions The presentation with multiple locations, including column and pelvic girdle, peripheral arthritis, and GCA resulted in a more severe onset at least in the perception of the clinician who used a higher initial dose of prednisone. Clinicians should consider the pattern of disease presentation when evaluating the burden of PMR. Disclosure of Interest None declared

Supraclavicular nerve entrapment syndrome, although rare, should be considered among the causes of anterior shoulder girdle pain. This syndrome is usually related to anatomic variants (involving the bone structures, fibrous bands, or muscles and tendons). Computed tomography is the most useful investigation. Medications used to treat neuropathic pain may provide relief. Otherwise, a local glucocorticoid injection or even surgical decompression should be considered.

A 46-year-old female was admitted complaining of progressive, severe girdle pain consistent with the left Th3 dermatome. Neurological examination on admission revealed dysesthesia and radiating pain in the left Th3 territory. Plain X-rays and tomograms of the thoracic spine revealed a beak-like bony excrescence arising from the lamina and projecting moderately to the Th3/4 intervertebral foramen, suggesting ossification of the thoracic ligamentum flavum (OYL). Myelography showed the dural sac compressed from laterally just below the left Th3 pedicle, which suggested that the Th3 nerve root was compressed by the OYL. After Th3 nerve root decompression through hemilaminectomy and foraminotomy, the girdle pain disappeared. OYL is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare. The authors review the literature and stress the importance of myelography for diagnosis.

Polymyalgia rheumatica (PMR) is an inflammatory disease of the elderly characterized by the nonspecific findings of girdle pain and stiffness and constitutional symptoms: as a result its differential diagnosis ranges from rheumatic, to infective and neoplastic diseases. PMR patients also often show peripheral arthritis, which fact further complicates the diagnosis. The main differential diagnosis in patients with suspected PMR is EORA, which also may present with girdle pain and raised inflammation. Both conditions also share a common genetic background and patients with cured PMR can relapse as EORA. Many studies have addressed clinical and laboratory discriminating clues, with only peripheral arthritis being effective. However, peripheral arthritis, being present in up to 40% of PMR patients, has a poor predictive value. In a recent study, US clues for the diagnosis of PMR were the presence of subacromial-subdeltoid bursitis, low frequency of knee menisci chondrocalcinosis and low power Doppler scores at the wrist. Conversely, effusion and synovitis of wrist, metacarpophalangeal joints, metatarsophalangeal joints, and tendinous calcaneal calcifications or Achilles enthesitis were more frequent in patients with diagnoses other than PMR. In a study with 18F-FDG positron emission/computed tomography (PET/CT), PMR patients showed higher uptake of the ischiatic, trochanteric and interspinous bursae compared to EORA patients. Shoulders were not evaluated because of their anatomical complexity and the difficulty of precisely localizing inflammation. In the clinic, follow-up over time is often the only way to help differential diagnosis: if glucocorticoid treatment is effective despite its tapering and peripheral arthritis does not become chronic, the diagnosis of PMR is likely to be correct. Disclosure of Interest None declared

Object The author describes a technique of thoracic discectomy that has evolved from the posterolateral transfacet and the transpedicular approaches but that spares the pedicle and most of the facet joint. Methods This approach was used to remove a total of 11 discs (T6–12) in seven patients. The follow-up period ranged from 8 months to 3 years. In four patients with axial and/or girdle pain significant improvement was demonstrated. The paraparesis in one patient with myelopathy improved postoperatively; that in another patient improved but recurred 8 months postoperatively. In one patient who experienced preoperative leg weakness, the weakness was slightly increased postoperatively, but this sequela was only transient. There were no other complications, and there were no deaths. Conclusions This technique appears safe and effective. It can be adapted to the conventional laminectomy known to spine surgeons and requires no specialized instruments. Further trials appear warranted.

Acupuncture has been used in numerous diseases and for many types of symptoms. It has been also used for obstetric complaints, such as nausea and vomiting, insomnia and low back and girdle pain. There has long been concern that some points—called forbidden—might harm pregnancy owing to a potential abortifacient effect, but it is difficult to confirm this proposition. The small number of available publications on this topic seems to show that this is not correct. Animal research examining possible harmful effects and a systematic review would be welcome to throw some light on this question.

Background Polymyalgia rheumatica (PMR) is an inflammatory disease of the elderly characterized by girdle pain and systemic symptoms. Imaging techniques, such as 18F-fluorodesoxyglucose (FDG)-PET/CT, have demonstrated that inflammation is localized mainly in the joint capsule and in bursae, with occasional large vessel vasculitis. However, the correspondence between FDG uptake and subjective symptoms is unclear. We have recently demonstrated that interspinous bursitis is typical of PMR, although it does not associate with pain. Objectives To test if FDG uptake, which is frequently seen in the girdles of PMR patients, is associated with the clinical experience of pain in the individual patients. Methods Eighty-four patients affected by PMR according to the ACR/EULAR criteria were studied. A standardized clinical examination, including pain at pressure of the long head of the biceps (LHB), the subacromial area (SA), the ischiatic (IB) and trochanteric (TB) bursae, and at mobilization of the shoulder and hip girdles, was performed immediately before PET/CT. After a minimum of six hours fasting, a dose of 4.8-5.2 MBq of FDG per kilogram body weight was injected through a peripheral vein catheter. Data acquisition started between 60 and 90 minutes after tracer administration. Patients underwent simultaneous FDG-PET and CT imaging from the skull base to the knee using an integrated PET/CT scanner (Hirez; Siemens Medical Solutions, Knoxville TN, USA). PET raw data were reconstructed by means of ordered subset expectation maximization and attenuation correction was performed using the CT raw data. The entire CT dataset was fused with the 3-dimensional PET images using an integrated software interface (Syngo Image Fusion; Siemens Erlangen, Germany) to create superimposed anatomical images. Joint uptake was scored relative to liver uptake as 0=no uptake present, 1=lower than liver uptake, 2=similar to liver uptake, 3=higher than liver uptake. Results A history of shoulder pain was present in all patients, whereas that of the pelvic girdle was present in 42/84 (50%). The concordance between pain elicited in the different areas and FDG uptake is shown in the table for the right (R) and left (L) sides. At clinical examination, 11/84 (13.1%) patients reported spontaneous pain or pain on passive motion which was clearly more intense in one shoulder. In these cases, tracer uptake was more intense in the symptomatic side in only 2, whereas in the remaining ones it was symmetrically distributed (bilaterally absent in 1 and bilaterally present in 8). Pelvic pain side was discordant in only 1 patient. The TB and IB were involved more often at PET than clinically. Conclusions The concordance between pain and FDG uptake in the girdles of PMR patients is only modest, except for shoulder capsulitis/synovitis, suggesting that factors other than inflammation visible at PET could contribute to clinical presentation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3011

Background Polymyalgia rheumatica (PMR) is an inflammatory condition characterized by aching and morning stiffness in the shoulders, hip girdle, and neck. The initial goal of therapy is to rapidly achieve symptomatic control using a relatively low dose of glucocorticoids although most patients require long duration treatment and relapses are common with tapering dosage. Recently musculoskeletal ultrasound (MUS) has been proposed as part of PMR classification criteria. Objectives To assess if a positive MUS pattern of the shoulder (presence of subdeltoid bursitis and/or biceps tenosynovitis) at the diagnosis may represent a predictive marker of response to standard therapy at after 12 months follow-up and may correlate with an higher maintenance dosage of steroid at 6 and 12 months follow-up. Methods 66 consecutive outpatients (51 (77,3%) female) with PMR underwent a shoulder MUS at the time of diagnosis before starting therapy, and after 12 months follow-up. Clinical and laboratory assessment of age, girdle pain, 44 swollen and tender joint count, inflammatory markers was performed. Glucocorticoids at low doses were the mainstay of treatment. Clinical remission was defined as lack of girdle pain and as levels of eritrosedimentation rate (ESR)≤40 mm/h and c-reactive protein (CRP)≤4 mg/l. Results At the study entry, PMR patients had a mean age of 72±6.9 years. All patients presented aching shoulder and 16 (24,2%) had peripheral arthritis. A positive MUS pattern of the shoulder was present in 46 (69,7%) patients of whom 33 (71,8%) patients became negative after 12 months follow-up. 13 (28,2%) patients remains still positive at MUS evaluation after 12 months. All patients rapidly achieve a symptomatic persistent control due to prednisone at the initial mean dosage of 16,29±8,19mg/die of prednisone gradually tapered until a maintenance dose. At 6 months follow-up, 30 (45,5%) patients were treated with prednisone >5 mg/die, of whom 22 (73.3%) had positive MUS pattern and 8 (26.7%) had negative MUS pattern at the study entry. Among the general cohort, after 12 months follow-up, 7 (10,6%) patients were treated with prednisone >5 mg/die, of whom 3 (42.8%) showed positive and 4 (57.2%) a negative MUS pattern at baseline. No significant difference was found for the mean dosage of steroid at 6 and 12 months follow-up (p=0,37 and p=0,35 respectively) comparing PMR patients with positive and negative MUS at the study entry. Moreover no difference was found in the remission rate between patients with positive and negative MUS pattern at the baseline (50,0% of MUS positive patients vs 45,0% of MUS negative patients in disease remission, p=0,46). Conclusions In conclusion in PMR patients, ultrasonographic presence of shoulder bursitis or tenosynovitis at the time of diagnosis is not a predicting marker of higher corticosteroid maintenance dose in the long-term glucocorticoid therapy nor of clinical remission after 12 month of therapy. Normalization of the initial ultrasonographic changes in patients with persistent control of the disease suggests that MUS can add specificity to the diagnosis. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5028

Background Polymyalgia rheumatica (PMR) is a common inflammatory disease of the elderly characterized by girdle pain and cervical and lumbar aching. Interspinous bursitis has been suggested as potential cause of the symptoms at the lumbar spine level in a study performed with MRI (1). In rheumatology, 18F-fluorodeoxyglucose (FDG) positron emission tomography integrated with computed tomography (PET/CT) is used mainly for the demonstration of large-vessel vasculitis. Characteristic uptake patterns are also seen in PMR, where bursal and joint involvement is highlighted in shoulders, hips, column, and ischium (2). Objectives To evaluate the spine structures involved in PMR by FDG-PET/CT in a cohort of consecutive, untreated patients. Methods Sixty-five consecutive patients (44 women, median age 73 years, range 50-87 years), fulfilling Bird’s criteria for PMR were studied. After a standardized physical exam, which included pain and tenderness of the spine, they underwent simultaneous FDG-PET and CT imaging from the skull base to the knee using an integrated PET/CT scanner (Hirez; Siemens Medical Solutions, Knoxville TN, USA), after injection of 4.8-5.2 MBq of F18-FDG per kg body weight. FDG-uptake was scored according to liver uptake as 0=no uptake present, 1=lower than liver uptake, 2=similar to liver uptake, 3=higher than liver uptake. These values were further subdivided into “positive” (scores 2 and 3) and “negative” (scores 0 and 1). Sites of pathological uptake in the column were recorded. Results Table 1 shows the clinical and PET/CT results. FDG uptake was more frequent in the lumbar spine than in the other locations, and in the cervical than in the dorsal spine (p rd and 6 th cervical vertebrae and between the 4 th and 5 th lumbar vertebrae. Spontaneous pain was more frequent in the cervical and lumbar spine than in the dorsal spine (p Conclusions Interspinous bursitis is a frequent finding in the lumbar spine of patients with PMR. It is however not associated with the presence of clinical symptoms and can hardly explain the spinal pain reported by the patients. Cervical pain is more frequent than lumbar pain in PMR patients and might be caused by shoulder girdle involvement. References Salvarani C, Barozzi L, Cantini F, Niccoli L, Boiardi L, Valentini M, et al. Cervical interspinous bursitis in active polymyalgia rheumatica. Ann Rheum Dis 2008;67:758–61. Camellino D, Cimmino MA. Imaging of polymyalgia rheumatica: indications on its pathogenesis, diagnosis and prognosis. Rheumatology (Oxford) 2012; 51: 77-86. Disclosure of Interest : None Declared

We describe a case of dumbbell hydatid cyst of the T(10) pedicle. This cyst had both extradural and retroperitoneal components,leading to spinal cord compression and abdominal pain. Following surgical excision and irrigation with hypertonic saline the patient made a full recovery, and is recurrence-free after 18 months follow-up.

Tumours arising from the paraganglia (paragangliomas) are characteristically of low malignant potential, with only 10% developing distant metastases (North et al, 1990). Malignancy in paragangliomas is defined either by local invasion or spread to distant sites normally devoid of paraganglia (Irons et al, 1977; Jackson et al, 1982). We present a case with several unusual features: (1) the primary site of the tumour is in the extradural space at D7 and L3 levels (lesion at L3 not biopsied), (2) multiple skeletal metastases at a short interval after primary diagnosis, and (3) absence of mitoses both in the original specimen and the metastatic deposit. A 29-year-old man presented in December 1989 with girdle pain in the upper abdomen for 3 months, descending numbness and paraparesis for 3 weeks and incontinence for 1 week.

Calcified psoas abscesses are a characteristic feature of tuberculosis of the thoraco-lumbar spine. We present a case in which well established calcification has almost completely disappeared, several years after any antituberculous treatment. A review of the English literature has revealed no previous report of this finding. The patient, now a 48-year-old woman, first presented at the age of 6 with back pain and radiographic features of spinal tuberculosis at T12/L1. Bilateral calcined psoas abscesses developed over thenext few months. Management was first by bed rest and later, at the age of 12, by postero-lateral drainage with spinal fusion. By this time abscess calcification was well established. The patient then remained relatively well until the age of 33, when she developed girdle pain due to further vertebral destruction at a higher level (T8–T12).

This report deals with a case with a myelopathy of Brown-Sequard type due to ossification of the posterior longitudinal ligament (OPLL) in the cervico-thoracic spine. The patient, 59-year-old male was admitted on February 1, 1977, with complaints of disturbance of gait, girdle pain in the chest, cold dysesthesia of the left half of trunk below papilla, with progressive aggravation for the last two years. Neurological examination revealed weakness of the right leg with pyramidal tract signs, hypesthesia to pin-prick, and temperature on the left leg below Li with cold dysesthesia and impaired vibration sense on both legs. X-ray examinations showed the OPLL from C6 down to Th4 vertebral bodies and myelographic block at the level of C6-7; blocked mainly on the right side of the spinal cannal. (Fig. 1, 2). Decompressive laminectomy from Th 1 upto CS and bilateral facetectomy at C6-7 disclosed an extradural osseous bulge on the right side of the spinal canal most marked at level of Th 1 to C7, compressing the dural tube from right lateral to the midline with distortion of the tube away from the right. The exposed cord at this level showed marked atrophy; almost 1/2 of normal diameter. No intradural pathology noted. Dentatotomy was added. Following closure of the dura, the osseous bulge was drilled away. Postoperatively, the girdle chest pain disappeared on the next morning, cold dysesthesia improved for 50%, hypesthesia to pain and temperature for 80%. With 11 months' follow-up, the patient showed good recovery of muscle strength of legs; walking by himself and running by bicycle. The clinical course, X-ray examinations and surgical exploration revealed the OPLL as the sole cause of this syndrome in this case.

A case of spinal cord compression from an intradural arachnoid cyst in the thoracic region is reported. The patient was a 59-year-old female. She had noted thoracic girdle pain and urinary trouble for 2 years. Neurologically, she showed muscle atrophy and weakness of the right leg, and loss of all sensory modalities below the 7th thoracic cord (Th7) level bilaterally. Metrizamide myelography showed no abnormal findings, but computed tomography (CT) following the metrizamide myelography demonstrated marked enlargement of the subarachnoid space and remarkable rightward and ventral displacement of the spinal cord. During surgery it was noted that the spinal cord was severely compressed by an arachnoid cyst from Th4 through Th6. After this operation, neurological deficits disappeared completely. Most spinal intradural arachnoid cysts arise in the region of the septum posticum in the thoracic portion. Various etiologies have been postulated. Although conventional myelogram has been the most important form of examination, intradural arachnoid cysts may be filled incompletely or not at all in the myelography performed in a prone position, because they mostly locate on the dorsal aspect of the spinal cord. There are some reported cases in which intradural arachnoid cysts were found a few hours after myelography. Therefore it is not so easy to diagnose intradural arachnoid cysts with conventional myelography. With metrizamide CT myelography, intradural arachnoid cysts can be visualized more easily.

Summary 1. We are reporting here a case of spinal lues, which showed clinically an attack of gastric crisis (peristaltic unrest and abdominal distress) accompanied simultaneously with hypersensibility (girdle pain sensation). 2. The autopsy findings revealed that the pathological changes are found in the spinal cord, meninges and spinal root fibers extending between the 5.-10. thoracic segments. Nerve fibers in the sglanchnic nerve are also found partly degenerated. These findings correspond exactly to the clinical symptoms of motor and sensory disturbances. 3. There is no change in the vagus nerve, so the cause of the gastric crisis can not be attributed to lesion of the vagus nerve. We would rather ascribe the crisis symptom to the lesin of the posterior root of the spinal cord. We believe that the lesion of the Fosterior roots causes simultaneous appearance of sensory irritation (girdle pain) and peristaltic unrest of the stomach.

Brucellosis in Britain is usually caused by Bruceila abortus and mainly affects those in direct contact with cattle or their un pasteurised milk products.1 2 Bone and joint brucellosis consti? tutes about 9% of brucellosis infections and the spine is the commonest site of skeletal infection.1 3 Brucellar spondylitis most often presents with back pain and leg pain, resembling an inter vertebral disc protrusion. Girdle pain has been reported.1 2 4 Para vertebral abscesses are uncommon in brucellosis.4 It is most unusual for brucellar spondylitis to present as right upper quadrant pain. A paravertebral abscess could produce nerve root and diaphragmatic irritation, resulting in right hypochondrial pain with radiation to the right shoulder tip. In skeletal brucel? losis the cultures are frequently negative in keeping with the late stage of the disease.3 4 Early serological studies may be crucial to the diagnosis. Treatment with tetracylines and streptomycin is successful in most cases.1-4 Surgery is indicated for spinal brucellosis only if there is instability, vertebral collapse with cord compression, or failure of a thick walled paravertebral abscess to respond to medical treatment.4

Reports have been made on anterior chordotomy with reference to the location and disposition of the fibers of the spinothalamic tract1; anterior chordotomy as a cure for the pain and vomiting of gastric crises2; the influence of the anterior columns on hyperreflexia3; the effect of chordotomy on existing motor abnormalities,4and the effect of chordotomy on thermoregulatory sweating.5 PRESENT INVESTIGATION The present report consists of an analysis of further studies, with particular reference to the physiology of the anterior and anterolateral columns and deductions concerning the location and manner of performance of chordotomy for optimum results. The material is presented according to the following outline: Influence on sensory system Tickle and itch Girdle pain Visceral pain—importance of splanchnic mediation Testicular pain and renal pelvic pain Effect of complete transverse lesion on testicular and renal pain Influence on motor system Shivering Superficial and deep reflexes Reenforcement

Patient. —J. C., aged 37, single, admitted Oct. 6, 1910, to the Buffalo General Hospital. Family history, negative. Usual diseases of childhood. Railroad accident at the age of 7 leaving right ankle ankylosed. Typhoid at 17; recovery complete. At 19, acute rheumatism of joints of legs for six months; another attack at the age of 21, which lasted nine months; recovery. Two attacks of gonorrhea at ages of 23 and 25, leaving moderate stricture; chancre at age of 35; patient had been treated for that and for the stricture. Present Illness. —For some time past, patient had a sensation about the body like a girdle pain and some numbness of the legs; had some trouble in walking. Sept. 25, 1910, he felt a sudden shock like an electric current go through the body; abdominal muscles grew tense; patient had to be taken home and later entered the General Hospital. Complaint

Pain has been considered rather uncommon in multiple sclerosis, as a survey of textbooks will reveal. Yet in a necropsy study of 46 cases, Carter et al 1 recorded pain in 42% of them and it was the first symptom in 11%. Their patients had a severe form of the disease, having reached the hospital and remained there until death. McAlpine et al 2 found that pain, especially in the low back, may be early or late in the course of the disease. They noted that Abb and Schaltenbrand defined a pseudorheumatic type of multiple sclerosis characterized by muscle and joint pains or by neuralgia, but without fever. Pain in the limbs occurred in about one third of the patients of McAlpine et al with the spinal form of the disease, but girdle pain and neck pain were rarer. Head pain or trigeminal neuralgia are unusual in multiple sclerosis. However