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PubMed2001

Undifferentiated spondyloarthropathies: a 2-year follow-up study.

The aim of the study was to analyse the 2-year follow-up of a series of patients with the diagnosis of undifferentiated spondyloarthropathy (uSpA). A prospective study was carried out analysing 68 patients with symptomatic uSpA who fulfilled the European Spondylarthropathy Study Group (ESSG) criteria for seronegative spondyloarthropathies (SpA) and were aged between 18 and 50 years. Inclusion criteria included inflammatory low back pain (ILBP) (without radiographic sacroiliitis), asymmetric oligoarthritis (predominantly affecting large joints in the lower limbs) and heel enthesopathies (Achilles tendinitis and/or plantar fasciitis). Imaging methods included pelvic radiography (at study entry and after 2 years) and calcaneal radiography (at study entry). There was a predominance of male gender (78%), caucasoid race (72%) and positive HLA-B27 (54%), with a mean age of 31 years and mean disease duration of 5 years. The first disease manifestations were ILBP (49%), asymmetric oligoarthritis (35%) and heel enthesopathies (16%). A positive family history of a definite SpA was mentioned by 9% of the patients. Seventeen patients (25%) scored 5 points in the Amor set of SpA criteria; logistic regression analysis showed that HLA-B27, heel enthesopathy and asymmetric oligoarthritis were significantly associated with Amor criteria > or = 6, whereas ILBP was associated with Amor criteria <6. Male sex was associated with heel enthesopathies (p = 0.041) and ankle involvement (p = 0.015). Caucasoid race was associated with ILBP (p=0.015) and buttock pain (p = 0.047). Positive HLA-B27 was associated with wrist involvement (p=0.019) and Amor criteria > or = 6 (p=0.001). After a 2-year follow-up the following outcomes were observed: uSpA 75%; disease remission 13%; ankylosing spondylitis 10%; psoriatic arthritis 2%. Logistic regression analysis showed that buttock pain and positive HLA-B27 (trend) were statistically associated with progression to a definite SpA. In conclusion, uSpA can represent a provisional diagnosis in the group of SpA and a systematic follow-up is necessary in order to better establish the different patterns of the disease.

Adult↗
PubMed1983

Changes in the somatotopic organization of the cat lumbar spinal cord following peripheral nerve transection and regeneration.

Glass microelectrodes were used to record the activity of neurones in the left dorsal horn of the L6 segment of the spinal cord of normal cats and cats in which the left sciatic and saphenous nerves had been cut 1 or 9 months previously. In the normal animals the receptive fields of L6 dorsal horn neurons excited by tactile stimulation of the leg were somatotopically organized, with neurones in the medial and central dorsal horn having receptive fields on the distal parts of the leg, particularly the toes, and neurones in the lateral dorsal horn having receptive fields on the proximal parts of the leg, buttock and lower back. This somatotopy has been shown before. One month after nerve section no cells responded to tactile stimulation of the distal leg and cells in the medial and central parts of the dorsal horn now had receptive fields on the proximal leg, buttock and back. There did not appear to be any somatotopic organization of these new receptive fields. Lateral dorsal horn neurones had normal receptive fields. Nine months after nerve section neurones in the medial and central parts of the lumbar dorsal horn had receptive fields on the distal leg but they showed several abnormal features and there was no evidence of a return of the somatotopic organization seen in normal animals. Lateral dorsal horn cells still had normal receptive fields.

Animals↗
PubMed1990

The redistribution of collagen in expanded pig skin.

Silicone tissue expanders were inserted subcutaneously in the buttocks of nine young pigs and gradually inflated to maximum capacity over 5 weeks. On the control side the expanders were left uninflated. Island buttock flaps were then raised, the expanders removed and the flaps spread into the same sites for 10 days. The tissue was harvested. Area measurements and full thickness skin biopsies were taken 10 days after flap inset in order to study the changes in collagen composition and isotypes in the skin layers. Ten days after inset of the flap the expanded skin had a mean 47% increase in surface area, was 9% thinner (from surface to implant), mostly due to thinning of the subcutaneous zone, but was not significantly different in water content, relative to the control skin. The expanded skin had a significant 9.3% increase (p less than 0.01, t test) in collagen content of the dermis. The relative proportions of Types I and III were not significantly changed by skin expansion in either the dermal/epidermal or subcutaneous/capsular zones. It is speculated that tensile factors during expansion stimulate the biosynthetic activity and/or mitotic activity of fibroblasts in the dermis to produce this gain in collagen in the expanded compared with unexpanded tissue.

Animals↗
PubMed1991

Microbiological studies of decubitus ulcers in children.

Specimens from 58 children with decubitus ulcers were cultured for aerobic and anaerobic bacteria. Aerobic bacteria only were present in 29 (50%) ulcers, anaerobic bacteria only were recovered in 5 (9%), and mixed aerobic and anaerobic flora were present in 24 (41%). A total of 132 isolates (79 aerobes, 53 anaerobes) were recovered, an average of 2.3 isolates per specimen (1.4 aerobes, 0.9 anaerobes). The smallest number of isolates was recovered in ulcers of the skull (1.7 per site), and the highest number of isolates was found in ulcers of the buttocks (4.1 per site). The predominant isolates were Staphylococcus aureus (25 isolates), Peptostreptococcus species (22), Bacteroides fragilis group (10), and Pseudomonas aeruginosa (7). Forty-two of the organisms isolated from 38 (66%) patients produced the enzyme beta-lactamase. Most of the S aureus isolates were recovered from ulcers of the hand and the leg. Organisms that resided in the mucous membranes close to the ulcer predominated in the wounds next to these areas. Enteric gram-negative rods, group D streptococci, and B fragilis group predominated in ulcers of the buttocks. Group A streptococci, Haemophilus influenzae, Bacteroides melaninogenicus group, and Fusobacterium species were most frequently recovered in ulcers of the skull. The polymicrobial etiology of decubitus ulcers in hospitalized children and the association of bacterial flora with the anatomical site of the ulcer are demonstrated.

Adolescent↗
PubMed1994

Early one-stage surgical reconstruction of the extremely high vagina in patients with congenital adrenal hyperplasia.

High vaginal atresia is a very rare anomaly seen in the most severely masculinized females with congenital adrenal hyperplasia. These children have a foreshortened vagina conjoining the urogenital sinus proximal to the external urethral sphincter. In the past, they have undergone early clitoral recession and labioscrotal reduction, followed by vaginal pull-through at 2 to 4 years of age. Cumulative experience with repair of this anomaly has led us to attempt earlier one-stage intervention and to develop techniques that circumvent previously encountered vaginal stenoses. One-stage reconstruction of three older children (ages 2 to 9 years) involved: closure of the urethrovaginal fistula, mobilization of the vagina from the rectum and urethra, use of bilateral buttock flaps to augment the anterior vaginal wall, augmentation of the posterior wall with an inverted perineal U flap, clitoral recession, and advancement of labioscrotal and clitoral shaft flaps inferiorly to create labia majora and minora (respectively). The introiti were quite capacious after employing such flaps, did not require postoperative dilatation, and were free of strictures or urethrovaginal fistulae during long-term follow-up. Three younger patients were seen for initial evaluation at 8 to 12 months of age, when early one-stage reconstruction was undertaken. Paradoxically, these repairs were technically less difficult and did not require buttock flap augmentation because an island of anterior perineal skin could be rotated in to reach the anterior vaginal wall. A nerve stimulator was used to identify the external urethral sphincter, while the vagina was aggressively mobilized and advanced forward beyond the site of fistula closure on the urethra to avert formation of a urethro-vaginal fistula.2 +

Adrenal Hyperplasia, Congenital↗
PubMed1995

Sacroiliitis associated with pyelonephritis in pregnancy.

BACKGROUND: Sacroiliitis is a rare infection and an unusual cause of back pain during pregnancy. Because pregnancy and infections commonly associated with pregnancy are risk factors, this diagnosis should be considered in the gravida with sacroiliac pain. CASE: A 17-year-old woman at 24 weeks' gestation, with a history of illicit drug use, presented to a local emergency room with back and buttock pain. Bacteriuria and pyuria were diagnosed, and cefazolin was initiated. Blood cultures grew Staphylococcus aureus and Escherichia coli. Despite prolonged antibiotic therapy for possible endocarditis, she had persistent debilitating lower back and buttock pain. Radiographic studies detected sacroiliitis, and broadened antibiotic therapy effected cure. CONCLUSION: When sacroiliitis is suspected, diagnostic imaging with either computed axial tomography, or, preferably, magnetic resonance imaging may be helpful. Antibiotic therapy should be tailored to the specific organism involved and continued for 3-6 weeks.

Adolescent↗
PubMed1976

Sacral agenesis. Analysis of 22 cases.

Sacral agenesis is a rare congenital anomaly of the spine and is usually associated with urologic abnormalities. Twenty-two patients are reviewed. Twenty-one had other congenital and developmental abnormalities in addition to sacral agenesis. Physical examination showed flattening of the buttocks, loss of the gluteal cleft, widely spaced buttock dimples, and a palpable sacral defect. Lateral views of the spine are essential when anteroposterior views suggest an absence of sacral segments. Seven patients had a significant familial history of diabetes mellitus. All patients with involvement of more than one sacral segment had neurogenic bladder dysfunction with incontinence. The degree of neurologic deficit could not be predicted from the radiologic appearance of the sacrum.

Abnormalities, Multiple↗
PubMed1993

Repeatability of subject/bed interface pressure measurements.

The repeatability of a technique for measuring interface pressures has been assessed. Pressure was measured using a Talley SA500 Pressure Evaluator under six anatomical sites (occiput, scapula, elbow, sacrum, buttock, and heel) of six healthy subjects lying supine on a Clinifloat mattress (trademark, SSI). For each site of each subject, four repeat readings were taken per day on four separate days. Mean pressures varied significantly between subjects (p < 0.02), though differences in mean pressures between sites were greater. Pressure was not significantly related to subject mass. The overall repeatability of the technique was +/- 0.77 kPa (+/- 5.8 mm Hg) which was much smaller than the range of pressures found under different sites (2.72 kPa or 20.4 mm Hg at the sacrum to 9.00 kPa or 67.5 mm Hg at the heel). Repeatability varied from site to site, from +/- 0.47 kPa (+/- 3.5 mm Hg) at the buttocks to +/- 1.20 kPa (+/- 9.0 mm Hg) at the heel. Measurements were found to vary significantly more between days than between repeats on the same day (p < 0.02).

Adult↗
PubMed1996

The UVR wavelength dependence for lomefloxacin photosensitization of human skin.

Lomefloxacin is a new fluoroquinolone with effective broad-spectrum antimicrobial activity. However, in common with other structurally related drugs, skin photosensitization reactions have been reported. The wavelength dependence for such photosensitization has been investigated on the previously unexposed buttock skin of 12 normal healthy human volunteers of skin types I and II. Using geometric square root of 2 dose increments, baseline 24 h minimal erythema doses were assessed at 300, 320, 330, 340, 350 and 360 nm, and with broad-band UVA. In addition, dose-response curves were constructed for erythema as measured by a reflectance device. Subjects received single daily oral doses of 400 mg lomefloxacin at specified times for 4 days. At 2 h after the final dose, new areas of buttock skin were irradiated to assess changes in minimal erythema dose and erythema dose-response. Convolution of the erythema action spectra obtained pre- and on-drug with a terrestrial solar spectrum showed that, although the UVA sensitivity on-drug was enhanced, most of the erythemally effective solar energy was still in the UVB region. An action spectrum derived for lomefloxacin skin photosensitization showed peak activity at 320 nm, the same spectral region as that for maximal absorption of the drug. There was no evidence of skin photosensitization at 300 nm.

Adult↗
PubMed2006

Sensory nerve injury after uterosacral ligament suspension.

OBJECTIVE: Uterosacral ligament suspension is a technique that is performed commonly to suspend the prolapsed vaginal apex. This case series describes our experience with the clinical evaluation and management of lower extremity sensory nerve symptoms after uterosacral ligament suspension. STUDY DESIGN: Hospital and office medical records from our 2 institutions were reviewed from January 2002 to August 2005, and all women who underwent uterosacral ligament suspension through a vaginal approach were identified. Women with symptoms of buttock and posterior thigh pain during the 6-week postoperative period were identified, and detailed clinical information was abstracted from the charts. RESULTS: From 182 uterosacral ligament suspension procedures, 7 women were identified. The age range was 42 to 70 years. Concurrent procedures included 6 vaginal hysterectomies, 5 anterior repairs, 4 posterior repairs, 2 slings, and 1 bilateral salpingo-oophorectomy. Within 24 hours of the surgical procedure, all the women experienced similar, substantial sharp buttock pain and numbness that radiated down the center of the posterior thigh to the popliteal fossa in 1 or both lower extremities. The ipsilateral uterosacral ligament suture was removed within 2 days of the procedure in 3 women who had immediate subjective reduction in their pain and complete resolution of pain by 6 weeks. The remaining 4 women were treated with gabapentin and narcotics. Three women had resolution of the pain by 12 to 14 weeks after the operation, and the last woman's pain resolved gradually by 6 months. CONCLUSION: Women who undergo uterosacral ligament suspension are at risk of postoperative pain and numbness in a S2-4 distribution. These symptoms appear to be related to the placement of uterosacral ligament sutures and may be relieved either by prompt removal of the ipsilateral uterosacral ligament suture or with prolonged medical therapy.

Adnexa Uteri↗
PubMedDate not supplied

Surgical experience and cosmetic outcomes in children with sacrococcygeal teratoma.

To determine the extent of progress in the treatment of sacrococcygeal teratomas (SCTs), the experience of 25 patients over a period of 30 years between 1972 and 2002 was evaluated. The medical records of the children were reviewed for demographics, histology, clinical course, bladder, anorectal and sexual function, and outcome. In particular, analysis of long-term cosmetic results after surgery for SCT was performed. The follow-up period ranged from 1 day to 396 months (median, 212 months). In more than half of the cases, unsatisfactory cosmetic long-term results after surgery for SCT were found. This study demonstrates that poor cosmetic results in the buttock region were the most common long-term complication after surgery for SCT, possibly leading to further corrective operations in later life. A better surgical procedure for closing the buttock region in the treatment of SCT should be discussed. Early assessment of bladder, anorectal, and sexual function along with long-term cosmetic results should be integrated into the well-established long-term oncology follow-up program. Moreover one has to keep in mind that cesarean section could become necessary as the primary delivery technique in female patients who have had surgery for SCT. More evaluations concerning this aspect are necessary.

Comorbidity↗
PubMed2005

Systematic diagnostic approach to proximal-without-distal claudication in a vascular population.

BACKGROUND: Very few observations of proximal-without-distal claudication have been reported in the literature. This is likely due to the use of questionnaires limiting vascular claudication to the calves and to the problems encountered in attributing unexplained "buttock" claudication to a vascular origin. METHODS: During a 2 1/2-year period, we searched for proximal-without-distal exercise-related pain with the San Diego claudication questionnaire among some 2000 patients referred for lower limb arterial investigations. Of these patients, 97 presented no contraindication to treadmill testing and were investigated with exercise transcutaneous oxygen pressure (tcpO2). We used buttock tcpO2 (DROP index<-15 mm hg) to argue for the presence of ischemia on the corresponding side. RESULTS: Ischemia consistent with symptoms was found in 61 patients, whereas pain on one or both sides without underlying ischemia was found in 36 patients, suggesting a non-arterial origin of the symptoms. More than half of the patients with proximal-without-distal claudication and underlying exercise-related ischemia had been suffering for more than 2 years before they were referred to the laboratory. Eleven of the patients were treated. The treatment was successful in all but one of them. CONCLUSIONS: An important delay before diagnosis is frequently observed in proximal-without-distal claudication. TcpO2 is useful in attributing proximal exercise-related pain to a vascular origin. Given the number of detected and successfully treated patients in this small monocentric study, it is surprising that so few observations have been published to date, suggesting that proximal-without-distal arterial claudication is most likely an underestimated diagnosis.

Journal Article↗
PubMedDate not supplied

Chiropractic high-velocity low-amplitude spinal manipulation in the treatment of a case of postsurgical chronic cauda equina syndrome.

OBJECTIVE: To present an evidence-based case report on the use of chiropractic high-velocity low-amplitude spinal manipulation in the treatment a postsurgical, chronic cauda equina syndrome patient. CLINICAL FEATURES: A 35-year-old woman presented with complaints of midback pain, low-back pain, buttock pain, saddle anesthesia, and bladder and bowel incontinence, all of 6 months duration. The patient was 6 months post emergency surgery for acute cauda equina syndrome due to lumbar disc herniation. She had been released from neurosurgical care with the current symptoms considered to be residual and nonprogressive. INTERVENTION AND OUTCOME: The patient was treated with high-velocity low-amplitude spinal manipulation and ancillary myofascial release. After 4 treatments, the patient reported full resolution of midback, low back, and buttock pain. The patient was seen another 4 times with no improvement in her neurologic symptoms. No adverse effects were noted. CONCLUSION: This appears to be the first published case of chiropractic high-velocity low-amplitude spinal manipulation being used for a patient with chronic cauda equina syndrome. It seems that this type of spinal manipulation was safe and effective for reducing back pain and had no effect on neurologic deficits in this case.

Adult↗
PubMed2004

Improved skin flap survival after local heat preconditioning in pigs.

BACKGROUND: Preconditioning induces the expression of heat shock proteins (HSPs), which can help a cell survive an acute episode of stress. Similar to the induction of HSP expression, the cell protection is independent of the type of stress. The aim of this study was to test in a large, randomized animal model, if skin flap survival may be improved by local heat preconditioning and induction of HSP 70. MATERIALS AND METHODS: Twenty-four hours before surgery, a heating blanket was laid on the buttocks of large white pigs. In the preconditioned group (n = 6), the blanket was warmed up to 43 degrees C for 3 x 30 min, whereas it was kept at room temperature in between the heating episodes as well as in the control animals (n = 6). A random pattern skin flap was raised on both sides of the buttocks. Flap survival was measured clinically. Induction of HSP and apoptosis were assessed quantitatively by immunohistochemistry and TUNEL assay, respectively. RESULTS: Preconditioning reduced flap necrosis from 40 +/- 8% of the total flap surface to 7 +/- 14% (P < 0.01). Induction of HSP was significantly higher in the experimental group (79 +/- 12% versus 42 +/- 13%, P < 0.01), whereas apoptosis in healthy flap tissue was reduced from 30 +/- 11 to 11 +/- 6 cells/visual field (P < 0.01). CONCLUSION: In the present study, necrosis and apoptosis rate of skin flaps could be reduced significantly due to local heat preconditioning. Our results suggest that ischemia-related wound healing complications could be diminished with local heat application, a most simple and least invasive method of preconditioning.

Animals↗
PubMed2004

Ischemic complications after endovascular abdominal aortic aneurysm repair.

OBJECTIVES: Limb and pelvic ischemia are known complications after endovascular abdominal aortic aneurysm repair (EVAR). The objective of this paper is to present our experience with the incidence, presentation, and management of such complications. METHODS: Over 9 years 311 patients with aortic aneurysms underwent EVAR. A retrospective review identified 28 patients (9.0%) with ischemic complications. RESULTS: Among 28 patients with ischemic complications, 21 had lower extremity ischemia and 7 had pelvic ischemia: colon (n = 4), buttock (n = 2), and spinal cord (n = 2). Of the 21 patients with lower extremity ischemia, 15 had limb occlusions (71.4%), 3 due to embolization (14.7%) and 3 the result of common femoral artery thromboses (14.7%). Limb occlusions were manifested as severe acute arterial ischemia (n = 6), rest pain (n = 3), intermittent claudication (n = 5), and decreased femoral pulse (n = 1). Limb occlusions were managed with thrombectomy and stent placement (n = 4), femorofemoral bypass (n = 7), eventual explantation because of persistent endoleak (n = 1), and expectant management (n = 3). The 3 patients with occlusions managed expectantly all had intermittent claudication, which has subsequently improved. In the 6 patients with lower extremity ischemia due to embolization or common femoral artery injury presentation was acute, and embolectomy was performed, followed by femoral artery endarterectomy and patch angioplasty or placement of an interposition graft. One patient who had a prolonged postoperative course including cardiac arrest subsequently required distal bypass and ultimately above- knee amputation. Among the 7 patients with pelvic ischemia, 2 patients had unilateral hypogastric artery embolization before the original surgery. Among the patients with colonic ischemia, 3 were seen immediately postoperatively, and required colectomy and colostomy. Two patients who required urgent colectomy subsequently had multiple organ failure, and died in the perioperative period. One patient had abdominal pain 1 week after surgery, which was managed with bowel rest, with subsequent improvement. In 2 patients spinal cord ischemia developed immediately after surgery, which resulted in persistent paraplegia. Buttock ischemia developed in 2 patients, 1 of whom required fasciotomy because of gluteal compartment syndrome, and had transient renal failure. CONCLUSIONS: Ischemic complications are not uncommon after EVAR, and may exceed the incidence with open surgical repair. Limb ischemia is most often a result of limb occlusion, and can be successfully managed with standard interventions. Pelvic ischemia often results from atheroembolization despite preservation of hypogastric arterial circulation. Colonic and spinal ischemia are associated with the highest morbidity and mortality.

Aged↗
PubMed2004

Effects of bilateral hypogastric artery interruption during endovascular and open aortoiliac aneurysm repair.

PURPOSE: Hypogastric artery interruption is sometimes required during aortoiliac aneurysm repair. We have not experienced some of the life-threatening complications of pelvic ischemia reported by others. Therefore we analyzed our experience to identify factors that help minimize pelvic ischemia with unilateral and bilateral hypogastric artery interruption. METHODS: From 1995 to 2003, 48 patients with aortoiliac aneurysm required interruption of both hypogastric arteries as part of endovascular (n = 32) or open surgical (n = 16) repair. During endovascular aneurysm repair coils were placed at the origin of the hypogastric arteries, and bilateral hypogastric artery interruptions were staged at 1 to 2 weeks when possible. Open surgery necessitated oversewing or excluding the origins of the hypogastric arteries and extending the prosthetic graft to the external iliac or femoral artery. Collateral branches from the external iliac and femoral arteries were preserved, and patients received systemic heparinization (50 units/kg). RESULTS: There was no buttock necrosis, ischemic colitis requiring colon resection, or death with the bilateral hypogastric artery interruption. Initially buttock claudication developed in 20 patients (42%), but persisted in only 7 patients (15%) at 1 year. New onset of impotence occurred in 4 of 28 patients (14%), and there were no neurologic deficits. CONCLUSIONS: Bilateral hypogastric artery interruptions can be accomplished with limited morbidity. When hypogastric artery interruption is needed during endovascular aneurysm repair, certain principles help minimize pelvic ischemia. These include hypogastric artery interruption at its origin to preserve the pelvic collateral vessels, staging bilateral hypogastric artery interruptions when possible, preserving collateral branches from the femoral and external iliac arteries, and providing adequate heparinization of the patient during these procedures.

Aged↗
PubMed2000

Sacroiliac joint pain referral zones.

OBJECTIVE: To determine the patterns of pain referral from the sacroiliac joint. STUDY DESIGN: Retrospective. PARTICIPANTS/METHODS: Fifty consecutive patients who satisfied clinical criteria and demonstrated a positive diagnostic response to a fluoroscopically guided sacroiliac joint injection were included. Each patient's preinjection pain description was used to determine areas of pain referral, and 18 potential pain-referral zones were established. OUTCOME MEASURES: Observed areas of pain referral. RESULTS: Eighteen men (36.0%) and 32 women (64.0%) were included with a mean age of 42.5 years (range, 20 to 75 yrs) and a mean symptom duration of 18.2 months (range, 1 to 72 mo). Forty-seven patients (94.0%) described buttock pain, and 36 patients (72.0%) described lower lumbar pain. Groin pain was described in 7 patients (14.0%). Twenty-five patients (50.0%) described associated lower-extremity pain. Fourteen patients (28.0%) described leg pain distal to the knee, and 6 patients (14.0%) reported foot pain. Eighteen patterns of pain referral were observed. A statistically significant relationship was identified between pain location and age, with younger patients more likely to describe pain distal to the knee. CONCLUSIONS: Pain referral from the sacroiliac joint does not appear to be limited to the lumbar region and buttock. The variable patterns of pain referral observed may arise for several reasons, including the joint's complex innervation, sclerotomal pain referral, irritation of adjacent structures, and varying locations of injury with the sacroiliac joint.

Adult↗
PubMed2003

Treatment of testicular pain using conservative management of the thoracolumbar spine: a case report.

Unsuccessful recognition of the origin of testicular pain and a high failure rate of surgical interventions lead to poor outcomes, psychologic distress, and increased costs of care. A frequently overlooked cause of testicular and buttock pain is irritation of the T10-L1 sensory nerve roots, the genitofemoral nerve, and the ilioinguinal nerve. We present the case of a 36-year-old policeman with a 5-year history of back pain and testicular pain of unknown origin. Physical examination of the thoracolumbar region revealed that active movement provoked the patient's buttock symptoms, and local mobility restrictions were present in the thoracolumbar region. A central disk protrusion at T12-L1 was noted on upper lumbar spine magnetic resonance imaging, which supports dysfunction of this region. The diagnosis of thoracolumbar stiffness led to implementation of passive and active mobilization of that region and to specific hip stretching and strengthening exercises. After a course of direct and guided physical therapy, the patient attained complete symptom resolution. The patient returned to full work duties as a police officer and resumed his full recreational activity. The excellent outcome achieved in managing this patient was attributed to identifying the origin of referred pain from the thoracolumbar junction.

Adult↗