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In the past, patients in this latter group were indiscriminately subjected to coccygectomy, but more recent studies have demonstrated that most cases respond favorably to injections of local anesthetic and methylprednisolone or to manipulation of the coccyx under anesthesia (Wray et al) Obscure Types of Low Back Pain and the Question of Psychiatric Disease It is a safe clinical rule that most patients who complain of low back pain have some type of primary or secondary disease of the spine and its supporting structures or of the abdominal or pelvic viscera However, even after careful examination, there remains a sizable group of patients in whom no pathologic basis for the back pain can be found Two categories can be recognized: one with postural back pain and another with aggravating psychiatric illness, but there are always cases where the diagnosis remains obscure.

So-called occupational cramps or spasms should be mentioned here, since the prevailing opinion is that they are restricted or focal

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Of these, trichinosis is of greatest importance to neurologists Infections with other roundworms, such as Angiostrongylus, cause an eosinophilia-like meningitis, as discussed further on Trichinosis This disease is caused by the intestinal nematode Trichinella spiralis Infection in humans results from the ingestion of uncooked or undercooked pork (occasionally bear meat) containing the encysted larvae of T spiralis The larvae are liberated from their cysts by the gastric juices and develop into adult male and female worms in the duodenum and jejunum After fertilization, the female burrows into the intestinal mucosa, where she deposits several successive batches of larvae These make their way via the lymphatics, regional lymph nodes, thoracic duct, and bloodstream into all parts of the body The new larvae penetrate all tissues but survive only in muscle, where they become encysted and eventually calcify.

Postural Back Pain Many slender, asthenic individuals and some fat, middle-aged ones have chronic discomfort in the back, and the pain interferes with effective work The physical examination is unrevealing except for slack musculature and poor posture The pain is diffuse in the middle or lower region of the back; characteristically, it is relieved by bed rest and induced by the maintenance of a particular posture over a period of time Spinal manipulation is said to have helped a number of these patients Pain in the neck and between the shoulder blades is a common complaint among thin, tense, active women and seems to be related to taut trapezius muscles Adolescent girls and boys are subject to a form of epiphysial disease of the spinal vertebrae (Scheuermann disease), which, over a period of 2 to 3 years, may cause low back pain upon exercise.

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Animals are infected in the same way as humans, and the cycle can be repeated only if a new host ingests the encysted larvae Gould has written an authoritative review of this subject The early symptoms of the disease, beginning a day or two after the ingestion of pork, are those of a mild gastroenteritis Later symptoms coincide with invasion of muscle by larvae The latter begin about the end of the rst week and may last for 4 to 6 weeks Low-grade fever, pain and tenderness of muscles, edema of the conjunctivae and particularly of the eyelids, and fatigue are the usual manifestations The myopathic aspects of Trichinella infestation are considered fully on page 1202 Particularly heavy infestation may be associated with a CNS disorder Headache, stiff neck, and a mild confusional state are the usual symptoms Delirium, coma, hemiplegia, and aphasia have also been observed on occasion.

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Some of these individuals are predisposed to kyphoscoliosis Also in this age group, spondylolysis, described earlier in this chapter, should be excluded as a cause of persistent back pain Psychiatric Illness Low back pain may be a major symptom in patients with hysteria, malingering, anxiety neurosis, depression, and hypochondriasis as well as in many nervous persons whose symptoms do not conform to any of these psychiatric illnesses Again, it is good practice to assume that pain in the back in such patients may signify disease of the spine or adjacent structures, and this should always be carefully sought However, even when some organic factors are found, the pain may be exaggerated, prolonged, or woven into a pattern of invalidism because of coexistent primary or secondary psychologic factors This is especially true when there is the possibility of secondary gain (notably workers compensation or settlement of personal injury claims).

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