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surgery

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.

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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.
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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.

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. 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 Leg Dominant Pain

Managing Leg Dominant Pain

Teaser: 

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

1Associate 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.
2Associate Professor, Department of Family and Community Medicine, University of Toronto, Medical Director, Sport CARE, Women’s College Hospital, Toronto, ON.
3Professor, Department of Surgery, University of Toronto; Medical Director, Canadian Back Institute; Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: Leg dominant pain suggests direct nerve root involvement: radicular, not referred symptoms. Constant pain associated with positive neurological findings usually results from an acute disc herniation. Symptoms are the result of mechanical compression but principally reflect an inflammatory response, properly designated sciatica. Intermittent leg dominant pain triggered by activity in extension and relieved by rest in flexion probably represents neurogenic claudication: nerve root ischemia secondary to spinal stenosis. Except for acute cauda equina syndrome, acute sciatica is initially managed with scheduled rest, adequate medication, and time. Non-responsive cases may require surgery. Surgery also shows superior outcomes for disabling neurogenic claudication.
Key Words:leg dominant pain, sciatica, neurogenic claudication, cauda equina syndrome, surgery.

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True spine-generated, leg dominant pain is consistently reproduced by particular spinal movements or positions.
No imaging investigation is required for a patient presenting an unequivocal clinical picture and exhibiting steady predictable improvement.
Of the four back pain syndromes, only neurogenic claudication is consistently best treated by surgery.
In contrast to the back dominant cases, in sciatica there is a definite role for short-acting narcotics or psychotropic drugs for uncontrolled pain.
Criteria for Surgical Referral
Emergency Referral The symptoms of Cauda Equina Syndrome are: - Urinary retention followed by insensible urinary overflow. - Unrecognized fecal incontinence. - Loss or decrease in saddle/perineal sensation. Acute Cauda Equina Syndrome is a surgical emergency.
Consider Elective Referral Failure to respond to a trial of conservative care: - Unbearable constant leg dominant pain. - Worsening nerve irritation tests (SLR or femoral nerve stretch). - Expanding motor, sensory or reflex deficits. - Recurrent disabling sciatica. - Disabling neurogenic claudication.
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Surgical Treatment of Diabetic Foot Complications

Surgical Treatment of Diabetic Foot Complications

Teaser: 


Timothy Daniels, MD, FRCSC, Associate Professor, University of Toronto, Toronto, ON.
Eran Tamir, MD, Department of Orthopaedic Rehabilitation, Sheba Medical Center, Tel-Hashomer, Israel.

Neuropathic foot complications are increasing in frequency, and surgery is becoming recognized as an important adjunct to their treatment and prevention.
The development of a diabetic foot ulcer is a multifactorial process; however, the presences of obvious and/or subtle foot deformities are being recognized as a significant contributing factor.
Off-loading of the affected area is the standard of care and commonly results in healing the noninfected neuropathic ulcer. Methods of off-loading can be broadly categorized as external (nonweightbearing, casting, braces, orthotics, and shoes) or internal (surgical intervention to correct the deformity).
Reconstructive surgery can prevent foot complications when conservative methods fail. By correcting the musculoskeletal deformity, the areas at risk are off-loaded so that the prevention of ulcer becomes less dependent on protective footwear and patient compliance.
Key words: Diabetic foot, ulceration, off-loading, surgery, reconstruction.

Prevention, Diagnosis, and Management of Prostate Cancer: An Update

Prevention, Diagnosis, and Management of Prostate Cancer: An Update

Teaser: 


S. Gogov, MD, Department of Medicine, University Health Network, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCPC, Department of Medicine, University Health Network; Departments of Medicine and Health Policy, Management, and Evaluation, University of Toronto, ON.

Prostate cancer remains the most common malignancy in men. Screening remains controversial due to a lack of evidence from randomized trials that it decreases mortality. Treatment decisions are based on assigning patients to one of three risk groups (low, intermediate, or high) based on stage, tumour grade, and prostate-specific antigen level, and considering remaining patient life expectancy (affected by age and comorbidity). Men with low-risk disease can consider expectant management, surgery, or radiotherapy (either external beam or brachytherapy). In intermediate-risk patients, all options except expectant management are associated with excellent long-term survival. In high-risk patients, combining either radiation or surgery with androgen deprivation has emerged as the best option. There is no role for primary androgen deprivation for most patients.
Key words: prostate cancer, screening, treatment, surgery, radiotherapy.

Diagnosis and Management of Lung Cancer in Older Adults

Diagnosis and Management of Lung Cancer in Older Adults

Teaser: 

Natasha B. Leighl, MD, FRCPC, Assistant Professor of Medicine, Division of Medical Oncology, Princess Margaret Hospital/University Health Network; Department of Medicine, University of Toronto, Toronto, ON.

Lung cancer is the leading cause of cancer-related mortality in North America and most commonly affects older patients. Patterns of investigation and treatment in older individuals differ, which may compromise outcome. Older patients should be carefully evaluated, using comprehensive geriatric assessment, to assess for function, functional reserve, comorbidities, polypharmacy, and other issues. Fit patients with few or no comorbidities should be offered standard treatments such as surgical resection for early-stage lung cancer with adjuvant chemotherapy, combined modality treatment (chemotherapy and radiation) for locally advanced disease, and systemic chemotherapy with supportive care for metastatic disease. Frail patients should be reviewed to optimize function and comorbid illnesses, and then considered for other treatment alternatives aimed at minimizing toxicity while still trying to maximize the curative or palliative potential of lung cancer therapy depending upon disease stage.
Key words: lung cancer, aging, chemotherapy, surgery, radiation, treatment.

Primary Bone and Soft Tissue Tumours in the Geriatric Population

Primary Bone and Soft Tissue Tumours in the Geriatric Population

Teaser: 

Michelle A. Ghert, MD, Clinical Fellow in Musculoskeletal Oncology, University of Toronto, ON, Mount Sinai Hospital, Toronto, ON. and Peter C. Ferguson, MD, MSc, FRCSC, Assistant Professor of Surgery, University of Toronto, Division of Orthopaedic Surgery, Mount Sinai Hospital, Department of Surgical Oncology, Princess Margaret
Hospital, Toronto, ON.

Primary bone and soft tissue tumours are rare in the general population. While bone malignancies in the geriatric age group are most often due to metastases or multiple myeloma, primary tumours can occur. These are treated with surgical resection and occasionally chemotherapy. Soft tissue sarcomas are more common and are usually treated with a combination of radiation and surgery. The outcome of treatment for bone sarcomas is poorer in the geriatric age group, but this is not true of soft tissue sarcomas. Patients with both primary bone and soft tissue malignancies should be referred to regional cancer centres for management.

Key words: sarcoma, surgery, radiotherapy, chemotherapy, cancer

Introduction
Musculoskeletal complaints are common in the geriatric population, but rarely are these complaints attributable to malignancies.

Surgical Management of Osteoarthritis of the Hand and Wrist

Surgical Management of Osteoarthritis of the Hand and Wrist

Teaser: 

Herbert P. von Schroeder, MD, MSc, FRCSC, University of Toronto Hand Program and Toronto Western Hospital, University Health Network, Toronto, ON.

Osteoarthritis is a highly prevalent and disabling condition of the hand in the geriatric population. It is commonly and effectively managed by surgical means. The interphalangeal joints and base of the thumb are most frequently involved, particularly in women, whereas post-traumatic osteoarthritis of the wrist is more common in men. Surgical procedures include simple debridement, soft tissue stabilization or osteotomies for milder cases. Joint arthroplasty, including excision procedures, and joint arthrodesis (fusion) are indicated for more severe arthritis. The type of procedure used depends on the location of the affected joint, patient age and physical demands placed on the hand. Surgery can effectively alleviate pain and improve hand function to improve an individual's quality of life.
Key words: osteoarthritis, hand, arthrodesis, arthroplasty, surgery.

Cataract Surgery May Cut Crash Risk

Cataract Surgery May Cut Crash Risk

Teaser: 

Cataracts are the leading cause of blindness in the world and account for 15% of blindness in Canada. The condition, which results in deficits in acuity and contrast sensitivity and increased disability glare, is present in half of adults over the age of 65 years. Older drivers with cataract are more likely to have a history of recent driving accidents compared with older drivers without impaired vision, yet it has not been determined whether the surgical removal of cataracts--a highly successful treatment--reduces the likelihood of crashing. Investigators set out to determine the impact of cataract surgery on the crash risk for older adults in the years following surgery, compared with that of older adults with cataracts but who opted not to have surgery.

The prospective cohort study recruited 277 patients aged 55 to 84 with cataract, 174 of whom elected to undergo surgery. Researchers followed the patients for four to six years and compared vehicle crash occurrence involving patients who elected to have surgery versus those who did not.

Results showed that people who underwent surgery were 53% less likely to be involved in a car crash than those who did not have surgery, which translated to five crashes per million miles of travel among recipients of surgery compared to nine crashes per million miles for those who declined surgery. However, the authors, aware of the study's limitations, caution against the inference that surgery can make people better drivers. Patients who opted out of surgery may have had other medical risk factors that influenced both their decision to avoid the procedure and their risk of car crashes. Therefore, while the study may indicate that driving performance of older drivers with cataracts might improve after surgery, the threat of selection bias prevents more firm conclusions.

Source

  1. Owsley C, McGwin G, Sloane M, et al. Impact of cataract surgery on motor vehicle crash involvement by older adults. JAMA 2002;288:841-9.

Does the Risk of Surgery Increase with Age

Does the Risk of Surgery Increase with Age

Teaser: 

 

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Staff Physician, University Health Network,
Instructor, University of Toronto,
Toronto, ON.

 

The last few decades have seen major advances in the surgical management of numerous illnesses. As the proportion of the elderly in the general population continues to increase, the prevalence of many chronic conditions also increases. Given the number of available surgical therapeutic options to cure or palliate these chronic conditions, more and more elderly patients are undergoing surgery. Conventional wisdom suggests that, compared to younger or middle-aged patients, older individuals have a higher risk of perioperative and postoperative complications, including death. This increased risk has been attributed to aging itself. This article will examine this relationship in greater detail.

Dozens of studies have suggested that advanced age leads to an increased risk of experiencing surgical complications. This includes an increased risk of postoperative complications such as deep venous thrombosis, infections (including wound, urinary tract, and lung), delirium and mortality.1 In preoperative assessment clinics, internists and anesthetists utilize risk indices or algorithms to determine an individual patient's surgical risk and potentially modifiable risk factors.