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radiculopathy

Current Management of Symptomatic Lumbar Disc Herniation

Teaser: 

Parham Rasoulinejad, MD, FRCSC, MSc, 1 Jennifer C. Urquhart, PhD,2 Christopher S. Bailey, MD, FRCSC, MSc, 2

1Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Assistant Professor, Dept. of Surgery, University of Western Ontario, London, ON.
2Research Associate, Division of Orthopaedic Surgery, London Health Sciences Center, and Lawson Health Research Institute, London, ON.
3Orthopaedic Surgeon, Division of Orthopaedic Surgery, London Health Sciences Center, and Associate Professor, Dept. of Surgery, University of Western Ontario, London, ON.

CLINICAL TOOLS

Abstract: Lumbar disc herniation is a common cause of low back pain and radiculopathy (sciatica). Diagnosis is initially made based on history and physical examination and ruling out red flags, particularly surgical emergencies such as Cauda Equina Syndrome. A trial of conservative treatment consisting of physical rehabilitation and oral medication is usually successful for back dominant pain. When persistent radiculopathy indicates lumbar discectomy the diagnosis must be confirmed by imaging but, due to very high rates of asymptomatic disc herniation, imaging cannot replace clinical diagnosis. For disabling leg dominant pain discectomy results in faster recovery but has a similar long-term outcomes compared to conservative treatment.
Key Words: lumbar disc herniation, lower back pain, sciatica, radiculopathy.

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Lumbar disc herniation is common and frequently asymptomatic.
Lumbar disc herniation may result in back pain. Much less frequently, when the adjacent nerve root is involved it can cause radiculopathy (sciatica).
Under most circumstances, the symptoms of lumbar disc herniation can be managed conservatively with physical rehabilitation and oral medications.
Red flags and surgical emergencies such as Cauda Equina Syndrome must be considered and should lead to urgent imaging and surgical referral.
Imaging, particularly MRI, has high rates of false positives and should only be used to confirm a diagnosis made based on history and physical examination.
For disabling persistent radiculopathy with good radiological correlation, surgical intervention in the form of a discectomy can be considered.
Lumbar disc herniation (LDH) is common and in most cases asymptomatic. Findings on MRI of lumbar disc herniation are not predictive of future back related disability. MRI findings should be interpreted along with history and physical exam findings to determine the appropriate diagnosis.
LDH can result in back pain and, when the adjacent nerve root is involved, radicular leg pain. The first line of treatment for back dominant pain should be education, lifestyle modification, mechanical therapy and oral medications in the form of acetaminophen, non-steroidal anti-inflammatories.
Radicular leg dominant pain may require opioids and/or epidural corticosteroid injections. The majority of patients will improve without further intervention.
For persistent symptoms of sciatica, surgical intervention can be considered. Lumbar discectomy is the most common procedure performed and has good to excellent outcomes.
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Current Concepts in the Surgical Treatment of the Degenerative Spine

Teaser: 

Dr. Safraz Mohammed1 Dr. Robert Ravinsky2 Dr. Albert Yee3

1University of Ottawa, Neurosurgery, Ottawa Civic Hospital, Ottawa, ON.
2,3University of Toronto, Division of Orthopaedics, Department of Surgery; Holland Musculoskeletal Program and Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON.

CLINICAL TOOLS

Abstract: Degenerative conditions of the spine are a major cause of disability, and represent a large economic burden on the health care system. In this review, we have described some of the most common degenerative pathologies of the lumbar spine—low back pain, spinal stenosis, degenerative spondylolisthesis, lumbar disc herniation and cauda equina syndrome—and the diagnostic approach and immediate management from the perspective of the primary care physician. We have emphasized clinical pearls seen in these conditions and specific indications for surgical referral, as well as red flags that should prompt urgent referral for life-threatening entities, such as malignancy and infection.
Key Words: degenerative spine, surgery, lumbar disc herniation, spinal stenosis, spondylolisthesis, radiculopathy.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. Evaluate for hip and knee joint pathology, and vascular pathology, especially in older patients presenting with unilateral radiating leg symptoms.
2. Spine surgery is more successful in treating leg dominant pain symptoms than back dominant mechanical pain symptoms.
3. Screen every patient presenting with a lumbar spine complaint for concomitant cervical and thoracic stenosis, in particular looking for evidence of cord compression (i.e. myelopathy). Be suspicious in patients with bilateral leg symptoms.
Clinicians should ensure that a focused history and a thorough physical examination is performed to help place patients with low back pain into several key categories: (a) nonspecific low back pain (Pattern I or II), (b) back pain potentially associated with radiculopathy leg symptoms (Pattern III) or leg claudication from structural spinal stenosis (Pattern IV), or (c) back pain potentially associated with another specific spinal cause (i.e. red flags). The history should also include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.3
Unless there are red flag symptoms or signs, routine imaging or other diagnostic tests in patients with acute nonspecific low back pain is not required.3
Diagnostic imaging and special investigations in patients with low back pain in the presence of severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination.
Surgery can be helpful for patients with leg dominant symptoms (sciatica/radiculopathy, Pattern III) or leg claudication from spinal stenosis (Pattern IV). There is a limited role for surgery for back pain dominant symptoms in the absence of specific structural correlative pathology (i.e. Pattern I or II).3
Approximately 15% of patients with lumbar spinal stenosis will have concurrent cervical or thoracic canal stenosis. One must screen for the presence of upper motor neuron signs and symptoms. Degenerative lumbar stenosis always presents without upper motor findings but may occasionally have focal root compression signs.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is only $20 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Numbness and Paresthesias in the Elderly

Numbness and Paresthesias in the Elderly

Teaser: 

Anahita Deboo, MD, Assistant Professor of Neurology, Drexel University College of Medicine, Philadelphia, PA, USA.

The evaluation of numbness and paresthesias in geriatric patients can present a particular challenge to the primary care physician. Careful sensory examination, in combination with recognition of motor and reflex involvement, will suggest a pattern that aids in neuroanatomic localisation. This article reviews the common patterns seen in polyneuropathies, focal neuropathies, plexopathies and radiculopathies. Central nervous system etiologies also are mentioned. The differential diagnosis and further evaluation of sensory disturbances in the elderly population are discussed.
Key words: paresthesias, numbness, neuropathy, radiculopathy, plexopathy.