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A Practical Guide to Managing Low Back Pain in the Primary Care Setting: Imaging, Diagnostic Interventions and Treatment—Part 2

Teaser: 

Conner Joseph Clay1, José M. Orenday-Barraza, MD2, María José Cavagnaro MD2, Leah Hillier MD CCFP (SEM)3, Leeann Qubain1, Eric John Crawford MD MSc(c) FRCSC4, Brandon Hirsch MD5, Ali A. Baaj MD2, Robert A. Ravinsky MDCM MPH FRCSC5

1 University of Arizona College of Medicine – Phoenix, Phoenix, AZ.
2Department of Neurosurgery, University of Arizona College of Medicine – Phoenix, Phoenix, AZ.
3Department of Family Medicine & Community Medicine, Banner University Medical Center Phoenix, University of Arizona College of Medicine – Phoenix, Phoenix, AZ.
4Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
5Department of Orthopaedic Surgery, University of Arizona College of Medicine – Phoenix, Phoenix, AZ.

CLINICAL TOOLS

Abstract: Low back pain (LBP) is one of the most common presenting complaints in the primary care setting with significant economic implications and impairment of quality of life. Effective treatment of LBP can frequently be delivered in the primary care setting. Knowledge of common pain generators and recognition of pain patterns based on the history and physical exam helps guide the treatment of LBP without the need for excessive resource utilization. The majority of patients presenting with LBP can be confidently managed with targeted conservative management; when this fails further investigation may be warranted. Part 2 of this review focuses on imaging and diagnosis of LBP, as well as a detailed review of treatment modalities.
Key Words: low back pain, imaging, diagnostic interventions, treatment.

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

www.cfpc.ca/Mainpro_M2

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Patients presenting with lumbar-related complaints, in the absence of red flags or neurological deficits, can safely undergo a course of conservative treatment prior to ordering imaging studies.
Nonsurgical treatment modalities that can be attempted in patients with LBP include oral medications, topical medications, passive modalities, active physical therapy and cognitive interventions.
Diagnostic interventions such as selective nerve root blocks, diagnostic facet joint injections, medial branch blocks and provocative discography can be useful in confirming that a particular anatomical structure is a clinically relevant pain generator.
Surgery, in the absence of red flags or neurological deficits, should only be considered after the patient fails a thorough course of conservative treatment.
Images of the spine are not necessary to initiate management of mechanical low back pain; they may even be counterproductive.
When required, initial radiological evaluation of the lumbar spine involves upright plain radiographs. Further investigation may include use of MRI or CT myelography.
Diagnostic interventions can aid in establishing the dominant pain-generating anatomical structure but are not required if the patient is improving as anticipated.
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Choosing Wisely Canada and Low Back Imaging: The view from Alberta

Teaser: 

Dr. Ted Findlay, D.O., CCFP,

is a Clinical Assistant Professor in the Department of Medicine at the University of Calgary and he is on the Medical Staff at Alberta Health Services, Calgary Zone in Calgary, Alberta.

CLINICAL TOOLS

Abstract: The Choosing Wisely Canada (CWC) initiative is a partner in a global effort to increase the efficiency and effectiveness of medical care by stimulating conversations between patients and care givers about the benefits and risks of commonly done tests and treatments. One of the earliest and broadly publicized recommendations was to stop routine lumbar spine imaging in the absence of clinical red flags. The rationale for discouraging this practice, including the quantification of associated harm, is not as widely known. The CWC initiative includes "Toolkits" for a number of clinical conditions, which extend the conversation beyond what should be avoided to include recommendations for appropriate care. The Alberta CWC partners have developed a Toolkit for low back pain for use by individual clinicians, physician groups, and at the systems level.
Key Words: Low back pain, imaging, overuse, red flags.

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.

In the absence of red flags and/or significant chronicity don't order x-rays or advanced imaging for low back pain.
Be cautious about attributing any findings from imaging as the "cause" of low back pain in a particular patient; recognize normal age related changes.
Low back imaging is required in the presence of clinical Red Flags for which invasive intervention is planned. Clinical correlation of the images is mandatory.
The indications for specific interventional treatments either surgical or image guided must be determined by history and physical examination.
Most low back pain patients need treating, not testing.
Patients presenting with low back pain are often anxious and worried that they may have a serious underlying anatomical cause. This anxiety is not relieved by discussions of abnormalities found on routine imaging.
Patients respond to a treatment plan that is supported by pertinent handouts and clear explanations including discussions about when imaging could be considered and when a referral might be the correct course.
Treatment for low back pain should not be delayed until the cause has been "established" by investigation; appropriate treatment can be determined by the history and physical examination and supported by the anticipated positive clinical response.
A successful back school educates the patient about the benign nature of back pain and provides the tools to transfer knowledge about back hygiene into practice in the patient's life.
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Disclaimer: 
Disclaimer at the end of each page

Clinical Disorders of the Aging Spine

Clinical Disorders of the Aging Spine

Teaser: 
Edward P Abraham, MD, FRCSC,
Associate Professor of Surgery, Department of Orthopaedics, Dalhousie University Medical School, Saint John Campus, Saint John NB Canada Canada East Spine Centre, Horizon Health Network.

Hamilton Hall, MD, FRCSC,
Professor, Department of Surgery, University of Toronto, Executive Director, Canadian Spine Society, Toronto, ON.

CLINICAL TOOLS

Abstract: In spite of the slightly increased incidence of infections, malignancies and systemic illnesses affecting the older spine, about 90% of back pain in the elderly, as in younger patients, is mechanical. This article covers several of the common problems: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity and osteoporotic compression fractures. Treatment is both non-operative and surgical and the decisions about which to choose and therefore when to refer depend as much on the age and functional capacity of the patient as upon the specific pathology.
Key Words: neurogenic claudication, degenerative disc disease, degenerative spondylolisthesis, disc herniation, spinal deformity, osteoporotic fractures, imaging.

The diagnosis of neurogenic claudication is made on the history of intermittent leg dominant pain brought on by activity, usually walking, and relieved by rest in flexion, usually by sitting down. The physical examination while the patient is at rest is often normal.
Mechanical back pain associated with disc degeneration is seldom an indication for surgery and can usually be adequately managed through a combination of education, activity modification, general fitness and exercises selectively tailored to improve the pain-producing positons and movements.
Disc herniation producing acute sciatica is uncommon in the older patient and the diagnosis should be made with caution. True radicular pain is constant and leg dominant. Referred, intermittent leg pain frequently accompanies back dominant pain and should not be treated as sciatica.
Enduring spine surgery is a major challenge for the elderly patient. The decision to operate must be made after comprehensive consultation, emphasizing the prolonged recovery and weighing the potential benefits against the inevitable risks, including the risk to life.
Osteoporotic vertebral body compression fractures frequently occur without a recognized history of trauma. The pain, often in the thoracic or upper lumbar area, appears suddenly, is aggravated by movement (particularly bending forward) and is reduced but not eliminated by lying down. The acute phase can last several weeks but usually subsides without specific treatment. Multiple compression fractures over time will produce a kyphotic spine.
Back pain in the elderly should be managed with a minimum of medication. Mechanical pain can usually be controlled with the appropriate mechanical measures and additional analgesia is not required. Recourse to pain medication as a first line of treatment is not recommended and when employed should be limited to non-narcotic formulations. With the possible exceptions of acute sciatica and recent vertebral compression fractures, opioids should not be used.
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Disclaimer: 
This article was published as part of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource. The development of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource was supported by an educational grant from Medtronic Canada.

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 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.

HealthPlexus is offering an eCME in support of the Back Pain Management Resource

eCME: The Latest in Back Pain Management

This CME activity offers interactive Videos, Animations, Pre- and Post-test Quizzes and you will be able to download a Certificate of Participation upon completion.

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.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 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.

Radiology on the front lines

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. “

2. Radiology - Focus on the family physician's office ;"What tests to order and what to do with incidental findings".

If you are there, please drop by and say hello. I hope to see you there!

D’Arcy

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Things that fascinate me about radiology

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.

There are also some things that fascinate me about radiology. For instance, improving computer and imaging technology has translated into imaging developments that can be used to benefit patients. Just a few years ago, we wouldn’t have thought we could adequately screen the colon for colon cancer and pre-cancerous lesions such as polyps. Now, in patients who cannot have a colonoscopy, we routinely perform CT colonoscopy (CTC), giving an alternative means of screening and diagnosis in these patients.

An article in the New England Journal of Medicine suggests that CTC could be used for primary screening, however, we mainly use it for patients who have failed colonoscopy – often because of a redundant sigmoid colon which cannot be navigated by the scope. We can even do the study the same day, as the patient has already undergone a bowel preparation. We do give them contrast to tag any residual fluid and stool in the colon to be able to differentiate it from colonic pathology.

We perform CT prone and supine to allow us to exam all the walls of the colon without any overlying fluid. Then we use computer software to generate 3 dimensional images of the colon that we can “fly through” to assess for mucosal lesions. Of course, the CT images are also examined for any extra- mucosal findings. I have diagnosed an unsuspected renal cell carcinoma on a patient being screened for colon cancer.

Below is a picture from my practice. It shows the colon distended with carbon dioxide – we use a small rectal tube and a regulated pump to inflate the colon. The technique readily shows the “napkin-ring” constricting lesion in the cecum. The 3D images show the lesion as it would be seen by the scope!

I would love to hear how imaging has affected your practice, both positive and negative.

Reference:
CT Colonography versus Colonoscopy for the Detection of Advanced Neoplasia
David H. Kim, M.D., Perry J. Pickhardt, M.D., Andrew J. Taylor, M.D., Winifred K. Leung, M.D., Thomas C. Winter, M.D., J. Louis Hinshaw, M.D., Deepak V. Gopal, M.D., Mark Reichelderfer, M.D., Richard H. Hsu, M.D., and Patrick R. Pfau, M.D.
N Engl J Med 2007; 357:1403-1412; October 4, 2007

 


Axial view with the “Napkin-ring” mass seen in the region of the cecum-ascending colon.

 


Coronal Image showing the lesion.

 


3D image showing the lesion almost identical to how it would appear on Colonoscopy, had this patient been able to have colonoscopy.

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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.