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Cervical Radiculopathy: Diagnosis and Management

Teaser: 

Heidi Godbout, MD,1 Sean Christie, MD, FRCSC,2

1Dalhousie University, Dept. Surgery (Neurosurgery), Dept. Medical Neurosciences.
2Associate Professor, Dalhousie University, Dept. Surgery (Neurosurgery).

CLINICAL TOOLS

Abstract: Neck and arm pain are common reasons to seek medical attention, especially in the working population. However, there are several diagnostic pitfalls that must be avoided. Appropriate, conservative management will lead to improvement in a significant number of patients. Knowing when to refer a patient as well as what imaging modalities are indicated is crucial to managing cervical radiculopathy in the primary care setting. The purpose of this review is to help primary care physicians diagnose, investigate and treat cervical radiculopathy and to know when a surgical referral is appropriate.
Key Words: Cervical radiculopathy, neurological exam, imaging, conservative treatment, surgery.

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1. Cervical pain is a common clinical problem; pure cervical radiculopathy is much less frequent.
2. The natural history of cervical radiculopathy is favorable; most patients improve within 3 months.
3. Imaging is only required if there are indications of sinister, non-mechanical pathology or when surgery is being contemplated.
4. Surgery produces beneficial results in 85-90% of cases.
1. A well-constructed musculoskeletal and neurological history and physical examination can distinguish between mechanical neck pain, cervical radiculopathy, cervical myelopathy or shoulder pathology.
2. C5-6 and C6-7 are the most common levels affected.
3. C6 radiculopathy leads to numbness in the thumb and weakness in wrist extension.
4. C7 radiculopathy leads to numbness in the middle finger and triceps weakness.
5. Spurling's manoeuver can be used to reproduce radicular symptoms. It should not be used when myelopathy is suspected.
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Managing Back Dominant Pain

Managing Back Dominant Pain

Teaser: 

Hamilton Hall, MD, FRCSC,1 Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,2 Yoga Raja Rampersaud, MD, FRCSC,3

1Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.
2Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.
3Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Immediate Past President Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: Back dominant pain is either intensified by flexion or is not aggravated by bending forward. The most common pattern, probably discogenic, subdivides into two groups: one with pain on flexion but relief on extension, the other with pain in both directions. The second pattern has symptoms with extension only. Treatment begins with education about the true benign nature of the problem. Mechanical pain responds to posture adjustment and pattern-specific movement. Medication has a secondary role. Imaging is not required for the responding patient. The inability to detect a pattern or a lack of anticipated response combined with non-mechanical findings indicates the need for appropriate referral.
Key Words:back dominant pain, education, medication, imaging, specialist referral.

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Back Dominant pain can be divided into two presentations: pain that is predominantly reproduced with flexion or pain that is reduced or unaffected by flexion.
The recognition of mechanical low back pain is based on a precise history, a validating physical examination and a positive treatment result.
Referred pain to the leg may occur with back dominant pain but, unlike radicular pain, the neurological examination will be normal.
Facilitating the patient to engage in activity that does not aggravate pain is the key to pain management and recovery.
The goal is control, not cure. Anything that relieves the pain and helps to restore mobility is valuable.
Medication has a limited and secondary role. There is no place for the routine use of narcotics or psychotropic drugs.
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Radiology on the front lines

Author(s): 
Teaser: 

I am currently preparing to present two talks at the Ontario College of Family Physicians Annual Scientific Assembly in Toronto, on November 25th.

I am currently preparing to present two talks at the Ontario College of Family Physicians Annual Scientific Assembly in Toronto, on November 25th:
 

1. Radiology on the front lines - Emergency Medicine. “An Introduction to Stroke Imaging. Saving the Brain. “

Keyword: 
Section: 

Things that fascinate me about radiology

Author(s): 
Teaser: 

I was a family physician for 7 years before becoming a radiologist. There are some things ...

I was a family physician for 7 years before becoming a radiologist. There are some things I miss about family practice. I miss the longitudinal relationship that I often had with multiple generations of family members.

Section: 

Diagnosis and Management of Progressive Supranuclear Palsy

Diagnosis and Management of Progressive Supranuclear Palsy

Teaser: 

Amitabh Gupta, MD, Clinical Fellow, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.
Susan Fox, MD, Assistant Professor, Movement Disorders Centre, Toronto Western Hospital, University of Toronto, ON.

Progressive supranuclear palsy (PSP) is a rare, fatal neurodegenerative disease with limited treatment options that is characterized by gait and postural instability and a classical vertical supranuclear gaze palsy. Initially often misdiagnosed as idiopathic Parkinson’s disease (IPD), proper patient care in PSP may be delayed until late into the disease course, after dopaminergic medication fails to improve symptoms. Here, we review the diagnostic criteria that help to separate PSP from IPD and rarer forms of parkinsonian diseases to help clinicians with earlier recognition. We discuss current treatment concepts as well as ongoing experimental approaches that are derived from an emerging pathological understanding.
Key words: progressive supranuclear palsy, clinical diagnosis, imaging, differential diagnosis, management.

Cardiovascular Imaging and Noninvasive Diagnosis for Older Adults

Cardiovascular Imaging and Noninvasive Diagnosis for Older Adults

Teaser: 


Sherryn Rambihar, MD, Internal Medicine Resident, Schulich School of Medicine, University of Western Ontario, London, ON.
Beth Abramson, MD, MSc, FRCP(C), FACC, Assistant Professor of Medicine, University of Toronto; Director, Cardiac Prevention Centre and Women’s Cardiovascular Health, Department of Cardiology, St. Michael’s Hospital, Toronto, ON.

Coronary heart disease (CHD) is the leading cause of death among men and women at all ages, and older adults are at increased risk. In assessing an older adult at risk for CHD, Bayes’ theorem guides rational clinical decision-making. Physicians should consider a diagnosis of CHD for older adults, who have a high prevalence of disease but may present with atypical symptoms and multiple risk factors. In clinical presentation, older women may be more similar than dissimilar to men. Exercise treadmill testing is the recommended first-line noninvasive strategy in most symptomatic older adults. Risk factor optimization is imperative in all patients.
Key words: imaging, diagnostic, women, geriatrics, clinical practice patterns, delivery of health care.

Morphological and Cellular Aspects of the Aging Brain

Morphological and Cellular Aspects of the Aging Brain

Teaser: 

John R. Wherrett, MD, PhD, FRCPC, Department of Medicine (Neurology), Toronto Western Hospital and University of Toronto, Toronto, ON.

Contemporary technologies, including digital imaging of the brain during life and quantative microscopy (unbiased stereology) for estimating histological features postmortem, have resulted in important new knowledge about changes in the brain that accompany healthy aging, including evidence that grey matter atrophies with an anterior-posterior gradient. Neurons shrink but numbers are preserved; however, there is moderate reduction in dendritic spines and in synapses that have altered function. This is to be interpreted in the light of evidence for neurogenesis continuing into late life. White matter volume increases into maturity, but in aging there is a marked reduction due mostly to a loss of small myelinated fibres. Cell inclusions characteristic of neurodegenerative disease are commonly found postmortem in the healthy aged.
Key words: brain, aging, morphometry, imaging.

Cerebrovascular Pathologies in Alzheimer Disease

Cerebrovascular Pathologies in Alzheimer Disease

Teaser: 

John Wherrett, MD, FRCPC, PhD, Division of Neurology, Toronto Western Hospital and the University of Toronto, Toronto, ON.

This commentary addresses current views about the interaction of vascular disorders and Alzheimer disease, including vascular pathologies that may be intrinsic to the Alzheimer process as identified through demonstration of amyloid plaques and neurofibrillary tangles. The common cerebrovascular pathologies accompanying aging, mainly atherosclerosis and arteriosclerosis, will coincide in varying proportions with the Alzheimer pathology, also a concomitant to aging. Because interventions are available to modify both risks and complications of these vasculopathies, an important goal of dementia research is to develop means to characterize the contribution of cerebrovascular disease in Alzheimer and other dementias. Realization of this goal is confounded by the recognition that Alzheimer pathology, usually considered a parenchymal process, involves important vascular changes.
Key words: Alzheimer disease, dementia, cerebrovascular, pathology, imaging.

Breakthrough in Cellular Level Functional Imaging--Broad Implications for Medical and Aging Research

Breakthrough in Cellular Level Functional Imaging--Broad Implications for Medical and Aging Research

Teaser: 

Anna Liachenko, BSc, MSc
Managing Editor,
Geriatrics & Aging

In a stunning presentation at the National Academy of Engineering meeting, Thomas J. Meade of the California Institute of Technology presented frog embryos unfolding from egg to tadpole stages. The images provided an unprecedented degree of cellular resolution, allowing one to see a cell reacting to alterations in a single gene. The technique perfected by Meade and his colleagues represents a major advance in functional nuclear magnetic resonance (NMR) technology.

Positron Emission Tomography (PET) and functional magnetic resonance imaging (fMRI) are both known to reveal sites in the living brain or other tissues that are active when a person is engaged in performing a particular task. These techniques have provided an extraordinary amount of biological information and are among the most important advances in medical science.

The Meade technique uses a novel contrast agent that identifies specific cells when their genes are turned on. NMR relies on the detection of vibrations in hydrogen atoms of water that are induced by a magnetic field. Contrast agents, such as gadolinium, are often added to enhance hydrogen's signal emission. This technique provides a powerful means to image the topography of soft tissue, but cannot provide a deeper level of resolution.

Meade has discovered an elegant and economical solution to one of the most significant problems in biological science: how to provide functional images of cellular level activity. He solved this problem by constructing a 'molecular basket' for each gadolinium ion. The basket consists of claw-like molecules called chelators. He then created a lid for the basket made out of galactopyranose. The 'closed basket' was injected into both cells of a two-cell frog embryo. One of the two cells was also injected with the gene for galactopyranose-digesting enzyme. Upon synthesis of the galactopyranose-digesting enzyme, the galactopyranose 'lid' was digested, exposing gadolinium to water, resulting in a bright signal. The principle of this technique can potentially be used for detecting any enzyme. Thus, one can create a general method for tracking the changes in any cell, or cellular pathway. Even more exciting is research aimed at finding a way of attaching a drug to the 'basket' and activating it with a particular enzyme within a cell. The potential for this new delivery system is enormous.

Advances in aging research will require understanding the activities and interactions of hundreds of genes. The ability to resolve functional NMR images down to the cellular level will have enormous implications for this research.