Iliac Crest Pain Syndrome in Low Back Pain. A Double Blind, Randomized Study of Local Injection Therapy
Collée G, Dijkmans BA, Vandenbroucke JP, Cats A.
J Rheumatol. 1991 Jul;18(7):1060-3. PubMed PMID: 1833543.
From the department of rheumatology and Clinical Epidemiology, University Hospital, Leiden, The Netherlands.
In a 2-week, double blind, randomized study we compared the efficacy of a single local injection of 5 ml lignocaine, 0.5% (L) with 5 ml isotonic saline (S) in 41 patients with the iliac crest pain syndrome (ICPS), recruited from a rheumatology clinic and from a general practice. For the purpose of comparing both treatment, 2 major outcome variables at the end of the study were defined at the outset: (1) Pain score. In the L group the mean pain score at Day 14 was 30.5, in the S group 43.8; the difference between both treatment groups was significant (p less than 0.05). On subgroup analysis similar results were found in the rheumatology setting (p less than 0.05) but not in the general practice setting (NS). (2) Pain severity compared with baseline. In the L group 52% of patients improved and in the S group 30% (NS). In the general practice clinic there was no significant difference (44 vs 62%); however, in the rheumatology setting 58% of those treated with L were improved compared with 8% in the S group (p less than 0.01). Our data demonstrate an effect of a local injection with lignocaine that is somewhat larger than an injection with saline, which also has some beneficial effect. The difference is evident in the rheumatology setting but not in the general practice setting.
Collée et al. start with the epidemiology of low back pain (LBP)
They stated that:
-Low back pain is so common that affects half of all people during their life.
-One fourth of general population at any moment.
-In the majority of cases that the cause is UNKNOWN, it is called nonspecific LBP.
The management of LBP lacks proper studies
The LBP is managed mainly by conservative therapies: rest, drugs, exercises, massage, manipulation, traction, heat, cold, ultrasound, transcutaneous nerve stimulation, corsets, acupuncture, and local injection therapy.
But there aren’t proper studies and it depends on the physician experience to choose one treatment or the other.
PREVIOUS Collée et al. studies
They described a SPECIFIC REGIONAL PAIN SYNDROME…. “THE ICPS” ILIAC CREST PAIN SYNDROME in 40% of the patients with LBP.
They configured a more homogenous group by identifying this subgroup.
They mentioned previous works about LOCAL INJECTION management (Bourne, Bauwens, Fairbank…see references).
THEY DESIGNED A PROSPECTIVE, RANDOMIZED, DOUBLE BLIND study to compare treatment with local injection with lignocaine vs isotonic saline.
NOTES ABOUT PATIENT SELECTION METHOD from COLLÉE et al. study
-They included 41 CONSECUTIVE patients with LBP with a diagnosis of UNILATERAL ICPS confirmed by 2 independent observers.
-ICPS was defined as TYPICAL LOCAL TENDERNESS over the medial part of the iliac crest.
-Excluded patients: patients that had sciatica, ankylosing spondylitis, malignancy, infection, spondylolisthesis, severe degenerative disc disease or fibromyalgia syndrome. Patients that were treated previously (one year) with local injections for LBP. Patients with adverse reactions from LIGNOCAINE.
-There were 2 recruiting settings: Rheumatology clinic (R) (mainly with long lasting low back pain) and general practice area (GP) (mainly with LBP of shorter period).
NOTES ABOUT DESIGN STUDY METHOD from Collée et al. study
-Patients were randomly allocated to 2 groups.
-Both treated with a SINGLE local injection… 5 ml isotonic saline or 5 ml lignocaine 0.5%.
-Patient was injected with prone position in the point of maximum tenderness of the ICPS.
-All injections were performed by same physician.
-The physician and the patients were blinded to the solution content.
-During study no other treatment was started.
-They assessed pain in 4 occasions: baseline, after 7 min from injection and on day 7 and day 14.
Patient characteristics: 41 patients (29 women, 12 men; average 42 years). 21 received lignocaine and 20 saline injections.
The two groups didn’t have clinical and demographic differences.
There were differences between the two groups on day 14 pain score, patients that received the lignocaine injection had less pain score that the ones that received saline injection on day 14. But not after 10 min or 7 days. Pain severity decrease was especially significant in the lignocaine group from the rheumatology clinic subgroups (that are the ones with pain for longer period).
The main conclusion from this short study in ICPS is that a single injection of LIGNOCAINE was slightly more effective than local injection with isotonic saline especially after 14 days.
The outcomes for lignocaine were better in the R group (from LBP patients with the long period in the rheumatology clinic).
It is NOT WELL UNDERSTOOD why an injection of a short acting anesthetic should provide prolonged pain relief. Some explanations are “breaking reflex mechanisms”, “CLOSING THE PAIN GATE” AND OTHERS…
COLLÉE ET AL. suggested that further studies had to be done.
Published in June 2018 by Marta Cañis Parera
Some references from Collée
- Collée G, Dijkmans BA, Vandenbroucke JP, Cats A. Iliac crest pain syndrome in low back pain. A double blind, randomized study of local injection therapy. J Rheumatol. 1991 Jul;18(7):1060-3. PubMed PMID: 1833543.
- BAUWENS P, COYER AB. The multifidus triangle syndrome as a cause of recurrent low-back pain. Br Med J. 1955 Nov 26;2(4951):1306-7. PubMed PMID: 13269857;
- Fairbank JC, O’Brien JP. The iliac crest syndrome. A treatable cause of low-back pain. Spine (Phila Pa 1976). 1983 Mar;8(2):220-4. PubMed PMID: 6222490.
- Hirschberg GG, Froetscher L, Naeim F. Iliolumbar syndrome as a common cause of low back pain: diagnosis and prognosis. Arch Phys Med Rehabil. 1979 Sep;60(9):415-9. PubMed PMID: 159027.
- Broudeur P, Larroque CH, Passeron R, Pellegrino J. [Iliolumbar syndrome. A syndesmoperiostitis of the iliac crest. Clinical, radiologic and therapeutic summary. Diagnosis with lumbar sciatica. 440 cases]. Rev Rhum Mal Osteoartic. 1982