Back and Pelvic Pain

Back and Pelvic Pain

  • Gustavo Zanoli added an answer:
    Any new treatment suggestions for a patient with FBSS, updated MRI & EMG and has had an L5-S1 right hemilaminectomy in 2010 with increased pain ?

    33 yr old male, works full time as a motor equipment mechanic, who reports low back pain with the intermittent feeling of weakness in the legs. He has had showing increasing pain in the low back. All nerve conduction studies were within normal limits with no evidence of lumbar motor radiculopathy, large fiber peripheral polyneuropathy, or a peripheral nerve entrapment. MRI findings: minimal modic endplate degenerative changes are seen at the L5-S1 level, remote right hemilaminectomy changes are seen at L5-S1, few endplate Schmorl's nodes are noted, minimal disc desicciation is seen at L1-L2, L4-L5, and L5-S1 levels. There is a slight loss of intervertebral disc height at L5-S1. At L4-L5 and L5-S1, a very mild broad-based central disc protrusion is seen with a small annular fissure. There is no significant central spinal canal stenosis or neural foraminal narrowing. Remote Right L5-S1 hemilaminectomy changes with no evidence of significant recurrent disc herniation.A mild broad-based Right paracentral disc protrusion is again seen at this level. Patient declines more surgery, has tried 4 nerve blocks that have failed , a failed trial neurostimulator, physical therapy, is going to pursuit chiropractic therapy, declines massage therapy as it makes the patient nauseous.List of active medications: Tizanidine 4mg 1-2 tab @ bed, ooxycodone 7.5-325mg 1-2 tab q BID - TID PRN. These medications help mildly with pain for patient to get through the day. Patient would like to be off opioids and find another solution as he has been on this medication for approx 5 years. Has tried a large list of other medications that have all failed to help. If anyone has any suggestions on how to help this patient, I would greatly appreciate it. If you would like to know any other treatments and/or medications he has tried in the past just ask.Thank you for your time.


    Gustavo Zanoli

     No good surgeon could ever promise 100% solution of the problem. In spinal surgery even less than in other types of orthopaedic surgery. In this cases chances are probably 50-50 that nothing will change, and even if you get some improvement it will never be 100%, 60-80% at the best. I would not advise for surgery, and in any case not having tried some form of prediction of the result of a stabilization (external fixation, or at lest bracing etc.) To advise for a better treatment information on weight, BMI, posture, pain history (continuous, only standing etc; inflammatory or mechanic; widespread or metameric distribution, etc...) would be important. Anyway, such a long story of pharmacologic treatment makes it very difficult to find a solution. If the problem, as it seems, is originally mechanical, manual therapy and exercises along with lifestyle changes should have been offered in the first place. Now, with such a strong drug addiction profile, it will take a long time and consistency both from patients and physicians/physical therapist to restore a "normality" or at least an acceptable compromise. With so many yellow flags, cognitive behavioral approach should probably be integrated in the process. If inflammatory and/or neuropathic pain is suspected to be superimposed on the mechanical problem (likely at this stage) pharmacological support should be aimed at reducing that, and thus enabling better work for the therapists with exercises, manual therapy, occupational therapy etc. It is not going to be a quick process (at least 3-6 months to see some progress) and it will require active involvement and high motivation of the patient, as well as competent physiotherapists. Not always easy...

  • Richard Dontigny added an answer:
    Does anyone know of any case studies or relevant articles on manual therapy in lumbo-sacral dysfunction?

    I happened to treat a case with lumbosacral dysfunction (AS ilum) with spinal lateral shift, differently.... and had unexpected results.... need the study to be published... not finding enough literature support... also it would be great if anyone could suggest a good journal for such a case!!

    Richard Dontigny

    This was from a competent chiropractor who has investigated his own body for some time for the source of his problem.  I am not familiar with the piece of equipment that he used although it is simple enough to correct this joint without any equipment.  This is all available on  How it works, why it hurts and how to fix it. 
    I discovered and published on the sacral axis in 2007 and dysfunction at this axis is prevalent just distal to the PSIS and easily self-corrected with a posterior innominate rotation.

    1.  DonTigny, RL:  A detailed and critical biomechanical analysis of the sacroiliac joints and relevant kinesiology: the implications for lumbopelvic function and dysfunction.  In Vleeming A, Mooney V, Stoeckart R (eds): Movement, Stability & Lumbopelvic Pain: Integration of research and therapy. Churchill Livingstone (Elsevier). Edinburgh, 2007, pp 265-279

    2.  Gracovetsky S: Stability or controlled instability.  In Vleeming A, Mooney V, Stoeckart R (eds) Movement, Stability & Lumbopelvic Pain: Integration of research and therapy. Churchill Livingstone (Elsevier), Edinburgh, 2007, pp 279-293

    3.  DonTigny, RL: Sacroiliac 101; Form and Function; A biomechanical study.  Journal of Prolotherapy  3:561-567, 2011    Available in full text from

    4.  DonTigny, RL: Sacroiliac 201; Dysfunction and Management: A biomechanical solution.  Journal of Prolotherapy 3:644-652, 2011   Available in full text from

    5.  . DonTigny, RL:  Measuring PSIS movement. Clinical Management 10:43-44, 1990

  • Marco Campello added an answer:
    How often is a questionnaire used in CLBP? Outcome measures in CLBP in clinics?

    How many times a physiotherapist use a questionnaire in clinics to change his behaviour towards a patient with chronic low back pain? What are mostly used questionnaire in CLBP clinically? Which one of these tells us patient is "feeling or getting better"?

    Marco Campello


    This is an interesting question. As you can see we may at times agree in the constructs to be measured but not always in the instrument to measure them. Our experience with Oswestry for example, in a clinical setting has shown that repeating it every two weeks was enough to detect changes. However, we have to be mindful of the patient burden. And if I can recall we never had more than three data points during treatment.  

  • Liviana De Michiel added an answer:
    Management of PROM after acl reconstruction. What do you do in your clinical practice and do you know literature on this topic?

    Does anyone know exercises or passive techniques to restore knee extension in early acl postoperative rehabilitation without giving too much strain on the new graft? In my clinical practice I often manage patients with incomplete extension (PROM) and I'm in doubt how to manage this problem in the best way. What do you do in your clinical practice? Is there any literature about this topic? In particular I'm interested in early rehab after acl reconstruction with semitendinosus-gracilis autograft, p.o. weeks 1st to 6th.

    Liviana De Michiel

    Dear Daniel and dear Anibarn, thak you so much for your answers. Indeed I think passive PROM is the best way to reach full extension avoiding any risk of excessive anterior tibial traslation. I agree that prone lying stretching is probably not a very comfortable method for patients (even for surgical sutures and edema) but it's probably the most effective and sure one. Perhaps a pillow under patients thigh can improve tibial posterior traslation. 

  • Hugo F Soares added an answer:
    Can the results of physical examination predict the clinical outcomes of patients with low back pain?
    Based on my literature search, it is apparent that depression and fear avoidance are the most important predictors for the development of chronic low back pain while the results of medical imaging or physical examination do not contribute much to the prediction of clinical outcomes of patients with low back pain. Have you read any articles that support the roles of physical factors (morphology or physical exam) in predicting the clinical outcomes of patients with low back pain?
    Hugo F Soares

    All biopsychosocial aspects must be taken into consideration in the treatment of low back pain.

    The theory proposes that may be different in practice.

  • Krzysztof Korbel added an answer:
    Does anybody have experience with a quality of life questionnaire (idiopathic scoliosis)?

    Does anybody have experience with quality of live questionairre in treatment of idiopathic scoliosis?

    Krzysztof Korbel

    Dear Prof. Tanchev

    Thank You for Your answer.

  • Taher Jarafa added an answer:
    Does anyone have an experience using isokinetic exercise for low back pain?

    I have not got various researches that have been written in English, so could anyone give me a hand?

    Taher Jarafa

    abstract refers to an optimistic research,it was really helpful


  • Ali Fahir Ozer added an answer:
    Can herniated nucleus pulposus be cleaned by the body in some cases?
    Many studies have indicated that the immune cells, which infiltrate around the degenerated disc, could impact the situation. While these immunocytes can cause damage such as inflammation, can they also clean the herniated nucleus pulposus and reduce nerve root stress? At least to some degree?
    Ali Fahir Ozer

    Dear Sun,

    It is well known  if herniated disc contact epidural fat tissue, it is removed by fagocytes for a while. The problem is herniation occured among the annullar layers. Because of poor vascularisation of annulus, fagocytes can not easly reach to death nuclear material among the annullar layers . Most of the patient who were operated due the disc herniation have this kind of herniation( Carrage classification type III, IV). Rarely it is seen spontenous regression in these type of hernations.  In my opinion in these rare cases, paravertebral muscle support is very important. If the patient has enough muscle support, spontenous regression incidance is increased. We notticed this reality after transpedicular dynamic stabilisation of the spine.We have a lot of such cases. Briefly in my opinion , there is strong relationship between the stabil spine( muscle support or enstrumantation) and spontaneous regression of a disc herniation.

    Ali Fahir Ozer

  • Nelson Elias added an answer:
    Can anyone cite a good article that reviews the pathophysiology and/or neuroscience regarding pain associated with menstruation?
    I'm thinking specifically about back pain but any article on the topic would be great.
    Nelson Elias
    Dear Fred
    This article may be useful for you
    J Vasc Interv Radiol. 2014 May;25(5):725-33.
    Pelvic congestion syndrome: etiology of pain, diagnosis, and clinical management.
    Phillips D1, Deipolyi AR2, Hesketh RL3, Midia M4, Oklu R
  • Panayot Tanchev added an answer:
    What are behind Modic changes?
    While Modic changes are familar with most spine doctors, what is this phenomenon reflect? What exactly causes them?
    Panayot Tanchev
    To Dr. Duntsch: You state that MC on MRI are a common phenomenon "linked with low back pain". Is that always so ? I think there are patients with MC who are absolutely symptomless. On the other hand, you are right that "the etiology of MC remains poorly understood" . The clinical significance of MC is not clear.
  • Panayot Tanchev added an answer:
    Does diagnosis affect therapy treatment?
    When I see patients I really try to not look at any imaging or notes until I evaluate them first. I personally feel it adds too much bias into the picture and I don't want it to affect my clinical judgment.

    Are there any studies that show whether or not knowing the diagnosis changes the approach? It's obviously different here in the US because a diagnosis has to be coded by somebody so it's hard to be truly blind. Are there studies out there that look at whether being blinded to diagnosis affects treatment / therapy approach?
    Panayot Tanchev
    This question strives to complicate the general diagnostic and therapeutic algorithm.
    I would recommend to follow the classic formula which works for thousands of years: "Qui bene interrogat bene diagnostic, qui bene diagnostic bene curat". Unfortunately, many doctors of today look at the MRI-pictures, then at the CT-images, then at the X-rays, and at the end ask the patient about complaints, perform inspection, palpation, percussion, auscultation, etc. This is a vicious approach.
  • Sergio Lerma Lara added an answer:
    Why there is a prevalence of hamstring tightness in subjects with anterior pelvic tilt?
    In anterior pelvic tilt, lower cross syndrome exists, where hipflexors and spinal extensors get shortened while abdominals and hip extensors lengthen. This is what theory explains, but contradictorily I had seen hamstring shortening in subjects with anterior pelvic tilt. Can somebody clear this up for me?
    Sergio Lerma Lara
    We used to add kinematic and kinetic data for decission making. If you are familiar with Dynamic Muscle Length graphs psoas or rectors femoris spasticity or contracture could be in relation with "false hamstrings thigthness". Try with Modified Popliteal Angle test. (Keenan,WN et al. J Ped Othop, 2004).
    In other populations neural tissue tension mut be taken in consideration (SLR test).

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To facilitate discussion on issue of prevention, diagnosis and treatment of acute and chronic lumbar and lumbopelvic pain.

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