Low Back Pain and Sciatica: A New Pathogenetic Model and Treatment Principles

Foreword
Introduction
	The “Back Pain”: a Cold Case
	Narrowing the Field
	Text Style and Instructions for Use
Contents
Part I: Observing the Patient
	1: Lower Back Pain and its Contradictions
		1.1	 The Two Main Clinical Types: The Patient with Flexor Relief and the Patient with Extensor Relief
	2: The Flexor-Type Patient: Low Back Pain, Sciatica, Lumbar Radiculopathy
		2.1	 Medical History
		2.2	 The Pain: Which and Where
		2.3	 The Temporal and Spatial Distribution of Pain
			2.3.1	 The Distribution: Referred Pain and Radiating Pain
		2.4	 Subjective Description of Pain
		2.5	 Therapies: Which (Did Not) Work
		2.6	 The Diagnostic History
		2.7	 Pain and Daily Movements
		2.8	 Not Just Low Back Pain: Painless Claudication (claudicatio spinalis)
			2.8.1	 The Syndrome of the Narrow Lumbar Canal (Spinal Stenosis)
			2.8.2	 When Is the Canal “Narrow”?
			2.8.3	 History and Characteristics of the Syndrome
			2.8.4	 Two Syndromes or One? Stenosis and “Restless” Legs
		2.9	 Considering Instrumental Examinations
			2.9.1	 The Electromyographic Examination: Rarely Necessary
		2.10	 The Objective Clinical Examination
			2.10.1	 Segmental Examination at the Bedside
			2.10.2	 Behavioural Motor Examination
			2.10.3	 Clinical Evaluation of Imaging Exams of the Lumbosacral Spine
			2.10.4	 (In)congruence Between Anamnesis, Neuromotor Examination and Imaging
			2.10.5	 Why There Can Be a Contradiction Between Imaging and Clinical Picture
		References
	3: The Extensor-Type Patient: Typical Clinical Picture
Part II: The Foundations of Lumbosciatic Pain
	4: Neurology of Lumbosciatic Pain
		4.1	 Where Are the Pain Receptors? An Anatomical Reminder
			4.1.1	 The Spinal Nerve
			4.1.2	 The Mechanisms of Pain: “traditional” Compressive Pathogenesis
			4.1.3	 Protrusion or Disc Herniation
			4.1.4	 Why Hernias of the Fourth or Fifth Lumbar Disc Prevail
			4.1.5	 Paralysing Sciatica
			4.1.6	 Osteophytosis of the “facets” (Interapophyseal or Zygapophyseal Arthritis)
		4.2	 Muscle Pain
		4.3	 Meningeal Pain
		References
	5: The Missing Link: Epidural Venous stasis
		5.1	 Batson’s Epidural Venous Plexus: Brief History and Anatomy
		5.2	 Lumbar Pain and Dilation of the Epidural Venous Plexus: some Clinical Conditions
			5.2.1	 Pregnancy
			5.2.2	 Inferior Vena Cava Obstruction
			5.2.3	 Heart Failure and Pulmonary Hypertension
		5.3	 The Venous Theory of “simple” Lumbar or Sciatic pain: An Unfinished Story
			5.3.1	 Narrow Lumbar Canal and Epidural Venous Stasis
			5.3.2	 An Interesting Corollary: Cervical Pain and Headache
			5.3.3	 A Suspicious Association: Low Back Pain and Erectile Dysfunction Therapy
			5.3.4	 Evidence of Critical Circulation in the Ganglia and Roots of the Cauda
			5.3.5	 From Stasis to Phlebitis to Fibrosis, We Broaden the Field of Observation
		References
Part III: Explaining the Contradictions
	6: Explaining the (Few) Different Clinical Pictures
		6.1	 Disc Mechanics
			6.1.1	 Disc Pressure: The Nucleus Pulposus Does Not Tell the Whole Story
			6.1.2	 The Mechanics of the Disc in Relation to Spine Movements
			6.1.3	 The Yellow Ligaments: Not to be Overlooked
			6.1.4	 The “Facet Syndrome” (“Facet Joint Syndrome”)
			6.1.5	 Spondylolisthesis and “Instability” in Chronic Low Back Pain
			6.1.6	 The Overall Section of the Vertebral Canal in Flexion and Extension
			6.1.7	 The Mechanics of the Dural Sac
		References
	7: Explained Mysteries
		7.1	 Why the Flexor Picture: Non-meningeal Compression
		7.2	 Why the Extensor Picture: Meningeal Irritation
		7.3	 Pain at Rest
		7.4	 Pain in Pregnancy
		7.5	 Risk Factors
		7.6	 Radicular Signs that Disappear: Algogenic Inhibition More than Radicular Damage
		7.7	 Persistence of Results with Mechanical Therapies
		7.8	 Why Lumbar Pain Instead of Radiated or Referred Pain
		7.9	 Spontaneous Healing, Recurring Episodes, Chronicity
		References
Part IV: An Integrated Pathogenetic Model and Some Particular Cases
	8: The Compressive-Venous-Inflammatory Model
		8.1	 Model Synthesis
		8.2	 How and What the Model Explains
		8.3	 A Pragmatic Proposal: From “Lumbosciatica” to “CoVin Lumbosciatica”
		References
	9: Cases that Are Compatible with the CoVIn Model
		9.1	 Post-surgical Cases
			9.1.1	 Premise
			9.1.2	 Surgery, Not Always the Right Solution: It Doesn’t Always Work
			9.1.3	 Instability and “Surgical Stabilisation”: A Controversial Rationale
			9.1.4	 Repeated Surgical Interventions
		References
	10: Cases at the Boundaries or Outside the CoVIn Model
		10.1	 Lower Back or Sciatic Pain in Bone Deformity of the Spine
			10.1.1	 Pain in Idiopathic or Acquired Scoliosis
			10.1.2	 Pain in Malformations of Individual Vertebral Tracts
			10.1.3	 Pain in Cases with “Transitional” Vertebrae
			10.1.4	 Pain in Transverse-iliac or Sacro-transverse Malformation
			10.1.5	 Pain in Case of Abnormal Orientation of an Interapophyseal Joint
		10.2	 Pathogenesis in “Causeless” Pain
			10.2.1	 Theoretical Premise
			10.2.2	 Pain Has Mainly Mechanical Causes; However, It Is Never Only Mechanical
		References
Part V: Macro-rationale of Non-surgical Therapy
	11: Pain Therapies: Why They Are Not the First Choice
		Reference
	12: Exercise Therapies and Manual, Instrumental Physical or Pharmacological Therapies
		12.1	 Treatment Rationale for the Flexion Pattern
		12.2	 How to Decompress Without Surgery
			12.2.1	 The Flexion Exercise
		12.3	 How to Decongest Without Surgery
			12.3.1	 Still, the Flexion Exercises
			12.3.2	 Extensor Exercises: No Thanks
			12.3.3	 Exercise in Water
			12.3.4	 Associating Other Manual or Instrumental Therapies
		12.4	 The Whole Model in One Method: Active Lumbar Traction (or Autotraction)
			12.4.1	 The Active Lumbar Traction Bench
			12.4.2	 How Treatment Is Performed
			12.4.3	 Indications and Contraindications
			12.4.4	 The Results
			12.4.5	 How the Technique of ALT/Autotraction Was Born (And Why it Did Not Spread)
			12.4.6	 Too Many Paradoxes?
			12.4.7	 The Mechanism of Action: No Longer Paradoxical
			12.4.8	 Venous Pathogenesis: It’s Time for Imaging
			12.4.9	 Let’s Not Forget Drugs
				12.4.9.1	 Drugs “For Pain”
			12.4.10	 “Vascular” Drugs: From Pain to its Causes. Why Not?
		12.5	 Treatment Rationale for the Extensor Picture
			12.5.1	 Rest and Dexamethasone
		References
	13: Reflections on Conservative Therapy
		13.1	 Diagnosis: From Descriptive to Pathophysiological
		13.2	 Therapeutic Deductions: Three Model-compatible Techniques
		13.3	 From the CoVin Model to Clinical Decision: The Step Is Short
		Reference
Appendix - Some Treacherous Causes of Low Back Pain
	When the Numbers Don’t Add Up
	Lower Back Pain in Adolescents or Children
		Osteoid Osteoma
		Spondylolysis-spondylolisthesis
	Suffering of the Piriformis and the Internal Obturator Muscle
	“Primitive” Gluteal Pain
	Pain at the Iliac Crest
	Sacroiliac Pain
	Hyperacute Pain with Different Antalgic Positions
	References