A Case of Worsened Pain with Improved Posture
By Gregg Carb, D.C.
CASE STUDY
A young, heavy-set adult male reported lower back pain after working at
his computer for prolonged periods. The severity of his pain seemed to
be in direct relation to how long he sat. At the time of his initial
visit in the office, he was not particularly symptomatic. Standing and
sitting postural observation revealed that the patient had a habit of
slumping, but was otherwise unremarkable. Active ROM, orthopedic testing
and x-ray findings were mostly benign. On palpation, some tenderness was
present centrally at the lower sacrum. This presentation may sound like
an uncomplicated case of postural lower back strain, usually improved by
correcting bad posture habits. Unfortunately, improving his sitting
posture only seemed to worsen the lower back pain.
BACKGROUND
During WWII, a condition referred to as “Jeep Rider’s” disease was
responsible for hospitalizing over 80,000 US army soldiers, accounting
for 4.2 million sick days. The actual name of the condition is pilonidal
disease (pilus-hair, nidal-nest). Pilonidal disease consists of a
hair-containing sinus or abscess, usually in the sacrococcygeal area.
The clinical presentations range from asymptomatic pits in the
intergluteal or “natal cleft” region (Figure 1), to painful draining
lesions. Pilonidal disease has a male predominance (2.2 to 1.0 male to
female ratio) and usually affects patients from the mid-teens into the
thirties (the average age is 21). A family history of the disease is
found in 38% of the patients. In the US, the incidence is 26 cases per
100,000 people.
CAUSATION
At first, it was believed that pilonidal disease was congenital. The
current understanding is that pilonidal disease is an acquired condition
involving midline pits in the natal cleft. These holes or pits are
enlarged hair follicles in the skin. It has been suggested that gravity
and motion of the gluteal folds create a vacuum that pulls on the
follicle. A pilonidal cyst contains hair that has grown down into the
skin instead of up as it normally does. Pilonidal cysts are more common
in those who have an abundance of body hair and / or those who have
considerable rubbing of the skin in the fold of the buttocks.
Overweight, hairy men account for 85 percent of the cases.
It was once thought that every pilonidal lesion contained a nest of
hair. However, only 50% of cysts and sinuses are found to have hair
during surgical exploration. This does not diminish the role hair plays
in pilonidal disease. In the affected area, any distended hair follicles
are not shed like their normal counterparts but can remain in the
follicle during their expansion, contributing to local irritation and
inflammation once the follicle ruptures. External hairs growing out of
normal, adjacent follicles can act as secondary invaders, and contribute
to a foreign body reaction through penetration and growth of the hairs
into subcutaneous tissue. Neighboring hair found in the surrounding skin
can also act as mechanical irritators, creating friction and adversely
affecting wound healing of the damaged area.
CYST vs. ABSCESS
While a pilonidal cyst doesn’t actually become an abscess until bacteria
invade and cause infection, the terms pilonidal cyst and pilonidal
abscess are sometimes used interchangeably. A pilonidal abscess is an
infection that the body has been unable to quickly subdue. The body
sends many white blood cells to the infected area to destroy invading
bacteria. This battle creates the red-colored, swollen area that is
characteristic of an infection. If the microscopic conflict is
prolonged, an accumulation of infectious debris forms. This collection
of worn out white blood cells, bacteria, body fluids and blood stretches
and fills the tissue inside the pilonidal cyst, forming an abscess.
CLINICAL PRESENTATION
Most patients with pilonidal disease seek attention due to a history of
progressive tenderness after physical activity or a period of prolonged
sitting, such as computer data entry or after a long drive. Patients may
seek advice for asymptomatic dimples or pits they notice in the gluteal
fold region. There may be no symptoms or minimal symptoms when the area
is not infected. When infected, it causes local pain, redness,
tenderness, and swelling in the area. A discharge of pus may be present.
Eighty percent of symptomatic presentations are exacerbations or
manifestations of chronic disease, and twenty percent are due to acute
abscess. Close physical inspection of the affected area will typical
show lower sacral midline puffiness/ edema with or without redness. If
infected, the area will be warm and tender, and discharge may be present
from one or more lesions.
CONSERVATIVE MANAGEMENT
The presence of an acute, infected abscess is an absolute indication for
medical referral/co-management. If the cyst is not infected,
conservative therapy can effectively control pilonidal disease. The
patient should be advised as follows: Keep the area clean and dry. Bathe
or shower daily and wash the area well with a germ-killing soap. Taking
hot tub baths helps prevent re-infection. The affected area should be
dried well with a towel. Light, loose-fitting clothing should be worn.
Avoid tight-fitting garments as heavy perspiration and friction in the
area of the cyst should be avoided. Weight loss is indicated for obese
patients (diet control). Weekly shaving of the area has been shown to
decrease recurrence rates. Rubbing in the sacral region should be
minimized, which means sitting flush against a seatback with a lumbar
support in place can be a source of irritation. The back-less ergonomic
chairs with the sloping seatpans and ankle rests are a good alternative.
A sit/stand workstation for patients with computer-intensive occupations
would also be helpful. In summary, most painful recurrences can be
avoided by practicing good hygiene, preventing the re-accumulation or
re-growth of hair, and avoiding local mechanical irritation to the area.
SURGICAL CASES
For patients suffering from recurrent or acute pilonidal abscess,
drainage or excision by a surgeon may become necessary. Studies have
reported that these cases are typically one-day inpatient procedures,
using a general or spinal anaesthetic, averaging 2-3 weeks off work,
with a recurrence rate of 17.5%. Following surgery, these patients
should be managed in the same manner as the chronic, non-operative
outpatient cases described above.
SUMMARY
Patients with pilonidal disease may be unaware of the exact nature of
their condition. They may seek out chiropractic care, as many patients
do, because of lower back discomfort. It is helpful to be able to
identify the pilonidal lesion, explain its cause, and guide these
patients through a conservative care approach or refer them to the
appropriate specialist, while tending to their chiropractic needs.
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