low back pain

GLA:D® Back

Teaser:

Brandyn Powelske, PhD Candidate, ¹ Greg Kawchuk, ² Ted Findlay,³

¹ Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta.
² Professor, Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta.
³Medical Staff, Calgary Chronic Pain Centre at Alberta Health Services, Calgary. Alberta.

CLINICAL TOOLS

Abstract: While low back pain is one of the most common clinical conditions seen in a family physician's office, there remains a lack of low or no cost initial treatment options that are concordant with recognized best practice guidelines. As a result, many patients are offered investigations and treatments that have limited value and/or significant risks but are readily available through publicly funded provincial health care systems. GLA:D® Back builds upon the successful GLA:D model (initially developed for hip and knee osteoarthritis patients) by using the same established methodology to deliver a patient education and targeted rehabilitation program for low back pain.

Key Words: low back pain; best practice; guidelines; education; rehabilitation.

Pre-test CME Quiz Post-test CME Quiz

1. Low Back Pain remains one of the most seen conditions in a family medical practice, and chronic low back pain the leading cause of ongoing disability

2. There are significant patient financial and access barriers to treatment modalities most consistently recommended in practice guidelines: education and activity/rehabilitation-based therapies.

3. GLA:D Back presents a validated option that can help close the gap between recommended treatments for low back pain and access through a primary care practice.

4. GLA:D Back is an extension of the well-recognized and widely used GLA:D program for hip and knee osteoarthritis.

In the absence of clinical "Red Flags", avoid ordering unnecessary imaging when the results are not needed for investigating an established clinical diagnosis or to initiate a therapeutic procedure.

When considering pharmacotherapeutic options, remember that the Institute for Safe Medical Practices (Canada Institute for Safe Medication Practices Canada notes that opioids should generally be avoided in the treatment of low back pain, headache and fibromyalgia.

The Covid-19 Pandemic has taught us that many group based education and rehabilitation-based programs can be effectively delivered in a virtual format.

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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

Authors' Affiliations

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.

Pre-test CME Quiz Post-test CME Quiz

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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Anatomy of a Lumbar Spine MRI: Indications for Imaging and Interpretation of Imaging for Surgical Referral

Teaser:

¹Samuel Yoon MD, MSc, ²Tiffany Lung MD, BKin, ³ Albert Yee MD, MSc, FRCSC, FIOR,

Authors' Affiliations

¹Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.²Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada. ³ Professor of Surgery, Department of Surgery, University of Toronto, Marvin Tile Chair Division Chief of Orthopaedic Surgery, Division of Spine Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

CLINICAL TOOLS

Abstract: Despite guidelines from multiple medical organizations including Choosing Wisely Canada, routine screening for low back pain symptoms with advanced imaging modalities such as Magnetic Resonance Imaging (MRI) persists. While sensitive, the high prevalence of asymptomatic or non-correlative degenerative findings limits their usefulness for routine screening. Given the constraints on Canadian healthcare resources this is a cause for significant concern. Lumbar MRI examinations should be ordered only with clear clinical indications and never for simple triage. Suitable indications include patients with symptoms of Cauda Equina Syndrome, suspected spinal malignancies, vertebral infections, or a progressive neurologic deficit correlating to a dermatomal and/or myotomal distribution.

Key Words: Appropriateness in diagnostic imaging, lumbar MRI, low back pain, surgical indications.

Pre-test CME Quiz Post-test CME Quiz

Lumbar spine MRI is not a useful screening tool as incidental degenerative findings are extremely common.

Routine lumbar MRI usage to investigate low back pain is inappropriate and can cause harm to patients through wasted time and resources, as well as possible nocebo effects.

Lumbar spine MRI is indicated if accompanying Red Flag symptoms, such as recent systemic illness, high suspicion for tumour, or progressive/severe neurological symptoms/signs are present with the back pain.

Elective referrals to spine surgical specialists should confirm that the patient's clinical spinal condition aligns with advanced imaging findings.

The majority of patients with low back pain will improve with conservative management modalities.

Understanding clinical patterns of lumbar related axial pain and lower extremity referred neurologic symptoms is a more useful guide for determining whether or not patients are surgical candidates than obtaining images of structural change.

Patients suspected of having Cauda Equina Syndrome or exhibiting rapid progressive neurological decline in a dermatomal/myotomal distribution should be referred immediately for surgical evaluation.

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Refractory Back Pain after Surgery: an Overview of the Failed Back Surgery Syndrome (FBSS)

Teaser:

¹Zhi Wang BSc, MSc MD FRCSC, ²Ali Ghoul MD, ³Jesse Shen MD, PhD Candidate, ⁴Amer Sebaaly MSc, MD,

Authors' Affiliations

¹Associate Professor, Montreal University (CHUM), Montreal, Quebec. ²PGY 3 Orthopaedic Resident, Saint Joseph University, Beirut Lebanon. ³PGY 5 Montreal University, Montreal Quebec. ⁴Orthopedic Lecturer, Saint Joseph University, Beirut, Lebanon.

CLINICAL TOOLS

Abstract: “Lumbar spinal pain of unknown origin, either persisting despite surgical intervention or appearing after surgical intervention for spinal pain, originating in the same topographical location” is a description widely used to describe Failed Back Surgery Syndrome (FBSS). In reality, the syndrome is more often a mismatch between the patient’s expectations and the surgical results. This review will describe the possible causes and presentation of FBSS and highlight the role of the multidisciplinary team approach in its management involving non-operative and surgical interventions. The most important objective is correct patient selection for surgery before the first operation.

Key Words: Failed Back Surgery Syndrome, multi-disciplinary approach, spine surgery, low back pain, patient expectations.

Pre-test CME Quiz Post-test CME Quiz

1. Fusing even a short segment of the spine can have significant, possibly deleterious effects, on the complex spinal functions.

2. The Failed Back Syndrome is often a mismatch between the patient's expectations and the final result rather than a failure of surgical technique.

3. The poor result may be the result of preoperative, intraoperative or postoperative factors. All three areas must be assessed.

4. Correct patient selection is as important or even more important than the surgical approach.

The incidence of Failed Back Surgery Syndrome ranges from 10-40% after a major spinal operation.

Setting the preoperative expectations with a full discussion between the patient, referring physician and operating surgeon plays a key role.

There are three periods – pre-operative, intra-operative, post-operative–in which FBSS can arise.

Proper patient selection and pre-operative optimization of all modifiable factors improve outcomes and decrease the possibility of FBSS.

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Virtual Care for Low Back Pain Patients

Teaser:

Ted Findlay, DO, CCFP, FCFP,¹ Dr. Hamilton Hall, MD, FRCSC,²

Authors' Affiliations

¹ is on Medical Staff with the Calgary Chronic Pain Centre at Alberta Health Services, Calgary Zone in Calgary, Alberta.
² is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

CLINICAL TOOLS

Abstract:The COVID-19 global pandemic has had a rapid and massive impact on health care delivery worldwide. Two of the first public health measures applied in Canada and most other developed nations have been some variety of social distancing and "stay at home" orders, which limit the ability of patients to access non-urgent health care services. Patients with chronic pain including low back pain comprise some of the most disadvantaged populations where ongoing support from their family physician is an essential aspect of management. Virtual patient care has rapidly become one of the primary means to deliver of non-urgent management and is, in many ways, ideally suited for the support of chronic low back pain patients. It will continue to be used not only until face to face appointments are again permitted but may become a permanent feature of continuing care.

Key Words: COVID-19; virtual care; video appointments; low back pain; communication.

Pre-test CME Quiz Post-test CME Quiz

1. Virtual patient care is not a new concept, but its use has been accelerated due to the COVID-19 pandemic.

2. Even pre-dating the COVID-19 pandemic, organized medicine in Canada has come out strongly in favor of the delivery of health care by virtual means.

3. There are many on-line resources that can be accessed by patients to help manage their low back pain during pandemic limitations on direct patient contact.

4. Positive patient identification and documentation of consent are requirements for virtual care delivery.

5. Both the physician and the patient have a role to play in ensuring appropriate privacy for the virtual visit.

Have your patient download and test any required communications software prior to their virtual appointment.

Commercial video communication software can be compliant with provincial personal privacy and information protection laws, check with your provincial medical association and/or provincial College of Physicians and Surgeons to be certain that approved software is being used.

Have the patient perform any required clinical measurements and list current medications and any required refills prior to the start of the virtual appointment.

Make sure that unidentified number call blocking does not prevent the virtual appointment from being completed.

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Cannabinoids and Low Back Pain

Teaser:

Ted Findlay, DO, CCFP, FCFP

Authors' Affiliations

is on Medical Staff with the Calgary Chronic Pain Centre at Alberta Health Services, Calgary Zone in Calgary, Alberta.

CLINICAL TOOLS

Abstract:There is a great deal of interest in the use of cannabis-based products including medically authorized marijuana for the treatment of almost any pain condition including low back pain. There are many anecdotal reports of patients who found it an effective treatment for chronic low back pain, one that has allowed them in some cases to discontinue other treatments such as continuing opioid therapy. There is now easy legal access to cannabis-based preparations in Canada with or without medical authorization. However, with some notable exceptions, the evidence that would allow physicians to have a high degree of confidence in selecting this treatment modality is lacking.

Key Words: cannabis; chronic pain; low back pain; evidence.

Pre-test CME Quiz Post-test CME Quiz

1. Compared to medically authorized cannabis, street sourced products are at high risk of contamination including insect remains, fungi, chemical fertilizers and herbicides.

2. Unlike most plant-sourced medications, the active ingredients are located on the cannabis leaf, which raises the risk of contaminant exposure.

3. Cannabis leaves by themselves are inert until heated in a process known as decarboxylation.

4. While inhaled cannabis has a rapid onset of action, ingested products have a delayed onset producing a risk of overdose if continuing to consume while waiting for an expected effect.

5. Little is yet known about potential drug interactions with cannabis use.

Cannabis authorizing physicians will often recommend a higher THC:CBD ratio product for evening or bedtime use, and a higher CBD:THC ratio or pure CBD for daytime use.

As is true for any potential intoxicant, patients need to be cautioned about the risks of operating a motor vehicle or any machinery while under the influence of cannabinoids, especially higher THC ratio products.

Because it is a lipid soluble chemical, urine, blood, or hair tests can detect THC for many days after use. Standardized tools and principles exist for the appraisal of credible eHealth resources.

Physicians in Canada provide medical "authorization" for cannabis use, verifying that the patient has a medical condition for which cannabis could be a valid therapeutic option. This authorization then allows the patient to purchase from a licensed producer up to a recommended quantity in grams per day. Although the basic patient demographics and birthday are required, unlike a prescription, the exact component percentage and potency, method of ingestion, and frequency are not components of the authorization.

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The Impact of Depressive Symptoms: Considerations for Clinicians Treating Patients with Low Back Pain

Teaser:

Jessica Wong, DC, MPH,¹
Linda Carroll, PhD, ²
Pierre Côté, DC, PhD, ³

Authors' Affiliations

¹ Research Associate, UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC).
²Professor Emeritus, School of Public Health, University of Alberta.
³ Professor and Canada Research Chair in Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Director, UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC).

CLINICAL TOOLS

Abstract: A considerable proportion of patients with low back pain (LBP) experience depressive symptoms. A clinical case is used to highlight potential steps that clinicians can take to help manage depressive symptoms in these patients: 1) Assess for depressive symptoms using a valid and reliable questionnaire; 2) Provide education, reassurance, and self-management strategies to initiate the program of care; 3) Adjust care plans if patients also present with depressive symptoms (e.g., ongoing support and education); and 4) Provide ongoing assessment of depressive symptoms, and consider referrals to a specialist or other health care providers (e.g., counselors, clinical psychologists, or psychiatrists) for further evaluation if symptoms are worsening.

Key Words: Low back pain, depressive symptoms, depression, depressive disorder.

Pre-test CME Quiz Post-test CME Quiz

A considerable proportion of patients with low back pain present with depressive symptoms

Depressive symptomatology includes depression that has not been formally diagnosed and symptoms that do not meet the criteria for depression

The presence of depression may indicate poorer recovery from low back pain

Patients experiencing low back pain and concomitant depressive symptoms may benefit from ongoing assessments, education, reassurance, and self-management strategies

Assess for depressive symptoms in patients with LBP using a valid and reliable questionnaire (e.g., Patient Health Questionnaire-9)

Provide education, reassurance, and self-management strategies to all patients with LBP to initiate the program of care

Adjust the care plan accordingly if patients also present with depressive symptoms, including additional support and education (e.g., addressing misconceptions, encouraging activity) on an ongoing basis

Provide ongoing assessment of depressive symptoms, and consider referrals for further evaluation if symptoms are worsening

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The Canadian Spine Surgeon’s Perspective: Avoiding Opioid Use in Spine Patients

Teaser:

Alexandra Stratton, MD, MSc, FRCSC,¹
Dr. Darren Roffey, PhD,²
Dr. Erica Stone, MD, FRCPC,³
Mohamed M. El Koussy, BSc,⁴
Dr. Eugene Wai, MD,⁵

Authors' Affiliations

¹Orthopaedic Spinal Surgeon, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
²University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
³Anesthesiology, PGY 6 Pain Medicine, The Ottawa Hospital, Ottawa, ON.
⁴Clinical Research Assistant, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
⁵is an orthopedic surgeon who specializes in the care of adult spinal disorders. He is also an Associate Professor in the Department of Surgery at the University of Ottawa. In addition he is the Research Chair for the Canadian Spine Society. Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Québec, Laval University, QC.

CLINICAL TOOLS

Abstract: Opioids are drugs with pain relieving properties; however, there is evidence that opioids are no more effective than non-opioid medications in treating low back pain (LBP), and opioid use results in higher adverse events and worse surgical outcomes. First line treatment should emphasize non-pharmacological modalities including education, self-care strategies, and physical rehabilitation. Non-steroidal anti-inflammatory drugs (NSAIDs) are generally considered an appropriate introduction into pharmacological treatment when deemed necessary. Non-opioid adjunct medications can be considered for specific features related to LBP such as neuropathic leg pain. Primary care providers should exhaust first and second line treatments before considering low-dose opioids, and only then in consultation with evidence-based clinical practice guidelines.

Key Words: Pharmacological; low back pain; radiculopathy; opioids; analgesia.

Pre-test CME Quiz Post-test CME Quiz

1. First line treatment for low back and radicular leg pain is non-pharmacological.

2. Second line treatment includes NSAIDs (with or without proton pump inhibitor), and muscle relaxants (3 weeks maximum), gabapentinoids and antidepressants.

3. Exhausting non-opioid analgesics includes trialing different medications within the same class and at different doses since many of these medications have wide therapeutic dose ranges.

A "start low and go slow" approach is recommended for initiating pharmacological treatments for low back and radicular leg pain, especially when using neuroleptics and antidepressants.

When treating low back pain with neuropathic leg pain, patients who fail a trial of pregabalin may tolerate gabapentin, or vice versa.

Antidepressants have a role in managing low back pain, particularly chronic, even in the absence of mood disorder.

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Choosing Wisely Canada and Low Back Imaging: The view from Alberta

Teaser:

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

Authors' Affiliations

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.

Pre-test CME Quiz Post-test CME Quiz

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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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

Authors' Affiliations

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.

Pre-test CME Quiz Post-test CME Quiz

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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GLA:D® Back

Authors' Affiliations

CLINICAL TOOLS

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

Authors' Affiliations

CLINICAL TOOLS

Anatomy of a Lumbar Spine MRI: Indications for Imaging and Interpretation of Imaging for Surgical Referral

Authors' Affiliations

CLINICAL TOOLS

Refractory Back Pain after Surgery: an Overview of the Failed Back Surgery Syndrome (FBSS)

Authors' Affiliations

CLINICAL TOOLS

Virtual Care for Low Back Pain Patients

Authors' Affiliations

CLINICAL TOOLS

Cannabinoids and Low Back Pain

Authors' Affiliations

CLINICAL TOOLS

The Impact of Depressive Symptoms: Considerations for Clinicians Treating Patients with Low Back Pain

Authors' Affiliations

CLINICAL TOOLS

The Canadian Spine Surgeon’s Perspective: Avoiding Opioid Use in Spine Patients

Authors' Affiliations

CLINICAL TOOLS

Choosing Wisely Canada and Low Back Imaging: The view from Alberta

Authors' Affiliations

CLINICAL TOOLS

Current Management of Symptomatic Lumbar Disc Herniation

Authors' Affiliations

CLINICAL TOOLS