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Interventional Radiology Procedures for Chronic Low Back Pain

Teaser: 

Dr. Ted Findlay, D.O., CCFP,1 Amar Suchak, MD, FRCP(C), 2

1is a Clinical Assistant Professor in the Department of Medicine at the University of Calgary. He is also in a Private Family Medicine practice. In addition he is on Medical Staff at Alberta Health Services, Calgary Zone in Calgary, Alberta.
2Clinical Assistant Professor Department of Radiology, Department of Nuclear Medicine, University of Calgary, Calgary, Alberta.

CLINICAL TOOLS

Abstract: There is an increasing availability and clinical use of interventional radiological techniques for patients with low back pain. This can be a valuable additional tool in the management of low back pain that has not responded to conservative treatment. However, the clinical indications and appropriate uses as well as cautions that apply to this treatment modality are in many cases less well understood by the primary care practitioner. The objective of this article is to review clinical scenarios in which these procedures are commonly considered, as well as their limitations. The field of interventional radiology is one that is rapidly evolving and an area of active clinical research. It is important for the primary care practitioner to have a basic understanding of the current state of the art in order to have an informed discussion with their patients who may be seeking advice on this treatment option.
Key Words: Low back pain; treatment; interventional radiology definitions; interventional radiology indications; interventional radiology complications.

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1. In patients carefully selected by clinical and radiological examination, there can be satisfying clinical gains from the use of currently available interventional radiologic procedures.
2. One must not assume that abnormal findings on radiologic imaging immediately explains the anatomical cause of a patient's low back pain; a corresponding accurate history and physical examination is ideal prior to commencing injections.
3. When successful, the gains from radiological interventions should be considered one portion of a broader clinical treatment plan, rather than the entire plan of management.
4. Unsuccessful interventional procedures should not be repeated.
1. Do not apply repeated interventional procedures with an expectation that one of them will find the target source of the patient's low back pain.
2. Although they may be uncommon, interventional radiology risks can occur and the referring physician should be cognizant of these dangers that accumulate with repeated interventions.
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Dealing with Family Strife

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One always hopes that as medical practitioners, we will be able to focus our attention on the medical issues faced by seniors and help families cope with the fears, disappointments and tragedies that are faced by loved ones in the midst of what are often life-altering illnesses.

Throughout our initial medical training, and most often during post-graduate training programs, the primary focus in general is: what is the "best of medicine" and what does "evidence-based medicine" tell us about treatment decisions and their ultimate impact on health, well-being and, often, the likelihood of death? This is particularly the case in the care of the older adult—whether in geriatric medicine or eldercare.

What is often surprising and baffling, especially to younger physicians, is the situation where the core of what appears to be the challenge in care provision is negatively tinged by what might be called family "strife." At times, however, a more appropriate term would be venomous, hateful actions—actions that ultimately will be destructive to the family fabric.

This should not be surprising to anyone who has even a modest understanding and familiarity with the world of literature—whether limited to English works, or more broadly including European or other literature.

Those medical trainees who have worked with me have in all likelihood heard me either seriously or humorously say, "If I were king, all first degrees would be in English literature." Or when there is a complex family dynamic playing out, I might say, "It's King Lear—if you have not read it ever or lately, read it or read it again—it's all there."
Sometimes I feel like that great American comic Jimmy Durante, who was quoted as saying, "I have a million of them, a million of them," referring to his often delectable jokes. According to an online biographical history, it has been said that "I've got a million of 'em" is what Durante (1893-1980) often said after telling a corny joke. Durante was credited with "I've got a million of 'em" in a 1929 newspaper story.

I say this when referring to complex family situations in which what appears to be the worst in human interactions seems to be playing out. Often the issue is related to money (or property), and if one is in a position to hear the story from all the parties, it often becomes clear that, for whatever reason, the pot has come to a boil at this juncture of life. This is usually because the flame heating the water that's not boiling has been on for what appears to have been many years.

Most of us know of such stories, hopefully not in our own families, but it is unlikely that there is a family who is not familiar with a "Lear-like" scenario in someone close to them. Greed, jealousy, hurtful memories, mean-spirited personalities, events that occurred—sometimes decades earlier—that were never resolved or left indelible scars are often the reasons cited for the enmity.

I have had the good fortune to observe that, on some occasions, especially when a parent, in particular, is dying, though it could be another relative, there is the possibility of repairing longheld animosities and bringing long-estranged family members back together. It does not always succeed, but I have witnessed the monumental efforts of health-care staff—especially those in social work, nursing and medicine, although any and all of the health-care staff can be key—in bridging the emotional moat that often separates family members.

It may not always work, but I believe it is always worth the effort. Living with the result of lifelong family strife is often disabling, and the scars that occur and that are left can have long-lasting negative effects on people's lives and their own abilities to have meaningful and binding relationships with their siblings and offspring.

This article was originally published online at http://www.cjnews.com/perspectives/opinions/dealing-family-strife

Beyond Medications for Dementia

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Physicians usually become adept at choosing medications for the complaints and illnesses that patients bring to their attention. Doctors have to become familiar with the common medications that are indicated for the most prevalent illnesses they see, and there are many resources available to keep physicians as up to date as possible on the most effective drugs and what the medical evidence says about indications, side effects, drug interactions and priorities of care at various points in the progression of a patient’s illness. In the elderly, there are often a number of illnesses competing for possible medical attention and intervention.

Dementia is the umbrella term used commonly to describe the cognitive decline that affects many older individuals. It may be due to a number of recognized conditions of which Alzheimer’s is the most commonly recognized, but the effects of blood vessel (vascular) disease are also very common factors in the aging population.

There are some medications for these conditions that affect memory, judgment and behaviour, the symptoms of which may cause great strife in the individuals affected as well as their families. The symptoms often cause immense challenges when it comes to the use of possibly helpful medications. The pharmaceutical products available for improvement of memory and judgment are often helpful in some individuals, but even when they are effective, they do not “cure” the cognitive impairment. They may, however, provide some improvement in certain aspects of cognition and especially socialization and interactive abilities.

Most challenging are the medications available for what are called behavioural manifestations of dementia, so much so that decisions to transfer to protective living environments such as nursing homes may be the result of such behavioural processes. These events may occur periodically and in what appear to be unpredictable outbursts. Although there are medications that are often used under such circumstances, which may be effective in decreasing the intensity of the disturbing symptoms, they—as do all medications—have potentially bothersome side-effects that may limit their efficacy.

During the past few years, the medical and non-medical health-care professionals involved in such care decisions have discovered that a number of non-medication interventions may be very effective and helpful without the risk of medication side-effects. Probably the most well-acknowledged and studied has been the use of individualized music, which has been shown to quell some of the agitations and disruptive behaviour associated with dementia. There are programs through the Alzheimer societies that provide personalized music on small iPods that can be used during episodes of behavioural outbursts.

In addition, there has been an expanding experience of using a range of alternative treatments such as pet therapy and doll therapy. In the latter, agitation, primarily in women, can be calmed by providing a life-like infant doll that brings out the calming and nurturing reactions many older women experienced during their earlier maternal days. Massage therapy and aroma therapy have also been used with good results in certain individuals.

The importance of these alternative therapies is that, unlike medications, they usually do not have side effects that might limit their effectiveness. They often tap into aspects of the person’s residual abilities that bring out what might otherwise be hidden aspects of his or her personality. Of greatest benefit is that these therapies are often provided by concerned and loving family members or dedicated health-care professionals, thus enhancing the social aspects of care that have been identified as being important through the course of conditions responsible for cognitive impairment.

Just imagine listening to one’s favourite music with an affectionate cat on one’s lap, while someone who cares enough provides a hand massage, rather than a dose of a medication that may cause drowsiness, increase the risk of falls and impair the person’s ability to walk securely. It may not always work, but it is always worth a try. So it’s important to be persistent and see what might work.

This article was originally published online at http://www.cjnews.com/perspectives/opinions/beyond-medications-dementia

A New Approach for the Excision of a Vallecular Cyst Using a Zero-Degree Nasal Endoscope

Teaser: 

Dr. Pradeep Shenoy, MD, FRCS, FACS, DLO,

ENT & Neck Surgeon, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.

CLINICAL TOOLS

Abstract: This case study reviews the clinical presentation and treatment of a patient’s vascular cyst. Though it is a rare diagnosis/condition, it could be a medical emergency for an individual of any age. Described here is a new approach for the complete excision of the vallecular cyst.
Key Words: vallecular cyst, excision, zero-degree nasal endoscope
Vallecular cysts are retention cysts in the Vallecular—a space between the base of the tongue, epiglottis and lateral pharyngeal wall.
They are triggered by acid reflux and smoking.
Vallecular cyst can be seen in CT Scan and laryngoscopy examination.
The access is difficult trans-orally. Here we are describing New approach using a zero-degree endoscope.
Vallecular cysts are rare in the paediatric and adult age groups.
Vallecular cysts can present as asymptomatic when small, however, when big they can present as a feeling of some food stuck in the throat or pain.
In emergency situation can block the food and airway passage and require emergency treatment.
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Median Raphe Cysts

Teaser: 

Mary Tong, BHSc, MD Candidate,1 Joseph M. Lam, MD, FRCSC,2

1McMaster University, Hamilton, ON.
2Clinical Associate Professor, Department of Pediatrics, Clinical Associate Professor, Department of Dermatology University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Median raphe cysts are rare congenital lesions caused by a defect in embryological development of the male genitalia. They can present as solitary or multiple papules along the median raphe from urethral meatus to the anus. Although they are asymptomatic during childhood, they can cause problems later on as they increase in size. Surgical excision of the lesion is not necessary unless the patient becomes symptomatic.
Key Words: median raphe cysts, congenital lesions, treatment, management.
Median raphe cysts are benign cysts that can be present at birth, or acquired due to trauma or infection in the genitalia area.
Histologically, the cysts can have pseudo stratified columnar, squamous cell, or glandular epithelium, or a mixture of these cells.
Although these cysts are asymptomatic during childhood, they should be monitored overtime because they may cause problems as they increase in size with time.
Because these are benign malformations, median raphe cysts do not require excision unless they cause problems such as pain, problems with urination or sexual activity, or for cosmetic reasons.
Median raphe cysts are benign lesions that may be caused be a defect in the embryological development of the male genitalia.
The differential diagnoses of median raphe cyst include glomus tumor, dermoid cyst, pilonidal cyst, epidermal inclusion cyst, urethral diverticulum, and steatocystoma.
Treatment for asymptomatic median raphe cyst is not necessary but surgical excision can be considered if the cyst is causing problems or for cosmetic reasons.
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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 $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.