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Management of Lumbar Radiculopathy Secondary to Lumbar Intervertebral Disc Herniation

Teaser: 

Patrick Thornley, MD, MSc, FRCSC,1, Christopher S. Bailey, MD, MSc, FRCSC,2,

1 London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, Ontario, Canada.
2 London Health Science Centre Combined Neurosurgical and Orthopaedic Spine Program, Schulich School of Medicine, Western University, Ontario, Canada.

CLINICAL TOOLS

Abstract: Lumbar intervertebral disc herniations (IVH) carry a high lifetime prevalence and are the most common cause of sciatica. The vast majority of symptomatic lumbar IVH improve with conservative management though adjuncts such as physiotherapy and epidural steroid injections may play a role in short-term symptom relief. For patients with unresponsive lumbar IVH, discectomy reliably improves symptoms more rapidly than continued conservative care, though there is inconsistent evidence that clinical differences between operative and conservative care are no different at one-year after symptom onset.
Key Words: lumbar radiculopathy, intervertebral disc herniation; lumbar intervertebral disc herniation; lumbar disc herniation; sciatica.

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

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1. The natural history of lumbar intervertebral disc herniations causing lumbar radiculopathy is favourable with conservative care in the vast majority of patients.
2. Advanced imaging for patients with lumbar radiculopathy is indicated only in the setting of “red flag” neurologic symptoms or a concerning clinical history for infection, neoplastic or traumatic etiology or the absence of symptom improvement after six-weeks of conservative care.
3. Long-term follow-up demonstrates most patients with lumbar intervertebral disc herniation causing lumbar radiculopathy achieve comparable clinical improvement with surgery or conservative management, with surgery leading to earlier symptom resolution.
4. The high-quality evidence for surgery is weak given the high cross over rate but observational studies show a benefit of surgery after failed non-operative care.
1. The diagnosis is made on the patient’s history including leg dominant pain and confirmed by the physical examination.
2. A combination of a detailed motor and sensory neurologic examination, including supine straight leg raise in addition to cross leg straight leg raise, increases the clinical sensitivity and specificity of a diagnostic examination for lumbar radiculopathy.
3. Analgesics should be used to manage function and not just to reduce pain, taking into account response to the specific analgesic on an individual basis including the known side effect profiles.
4. Microdiscectomy surgery for patients with refractory lumbar radiculopathy lasting greater than four months can lead to a significant reduction in leg pain compared to continued conservative management.
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Related Terms: Back Health, lumbar radiculopathy, intervertebral disc herniation, lumbar intervertebral disc herniation, Lumbar disc herniation, sciatica

Public–Medicine Dissonance: Why in a World of Evidence-based Medicine?

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Emeritus Professor of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: The evolution of medicine is quite remarkable and astounding. Modern medicine is successfully treating or providing long-term control of conditions which in the not-so-distant past were lethal or resulted in permanent disability. The strong emphasis on evidence-based medicine in today's medical profession has led to a more organized approach toward evaluating the safety and efficacy of new medical treatments. Despite attempts to meet the complex needs of an ever-aging population, an almost cynical or inherent distrust of physicians in general and their medical claims is being increasingly noted. For many physicians this has led to an uncomfortable sense of professional frustration as doubt is cast on themselves or the medical profession in general when the expectations and goals of patients or their families are not achieved. The causes of this apparent malady of contemporary medicine are myriad and may be explored from various perspectives, depending on the particular issue. To understand better the issues and challenges involved, today's medical practitioner needs to be aware of the complex mix of organizational, professional, ethical, and at times anthropological perspectives contributing to this dissonance between medical professionals and the public. Improving our insight into the forces at work in this dissonance will help medical professionals improve medical services to the public and contribute to the preservation of medicine's admirable historical legacy.
Key Words: Anti-vaccination movement, conspiracy theories, evidence-based medicine, medical quackery, trust in physicians.
Evidence-based medicine asks questions, finds and appraises the relevant data, and harnesses that information for everyday clinical practice. Evidence-based medicine follows four steps:
• Formulate a clear clinical question from a patient’s problem
• Search the literature for relevant clinical articles
• Evaluate (critically appraise) the evidence for its validity and usefulness
• Implement useful findings in clinical practice.
The growing mistrust undermines the patient-doctor relationship, as well as the public’s perspective of health care professionals and the system in general.
If the medical dissonance is left unresolved, the future of health care will become increasingly onerous for those wishing to enter its professions, ultimately impacting those in need of medical services.
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Related Terms: Law and Ethics, anti-vaccination movement, conspiracy theories, evidence-based medicine, medical quackery, trust in physicians

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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Related Terms: Back Health, low back pain, imaging, diagnostic, intervention, treatment

A Practical Guide to Managing Low Back Pain in the Primary Care Setting: Epidemiology, Pathoanatomy, Clinical Evaluation and Triage—Part 1

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 low back pain 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 treated with targeted conservative management, frequently obviating the need for advanced imaging and diagnostic investigations.
Key Words: low back pain, mechanical low back pain, lumbar pain, degenerative disease, clinical evaluation, triage.

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.

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The lumbar spine is designed to be both strong and flexible, but disruption or degeneration of the supporting structures of the spine can result in low back pain without major pathology.
Low back pain can be characterized into one of four pain patterns using a focused history supported by a relevant physical exam.
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.
The presence of "red flag" signs and symptoms must be carefully interpreted as a group and not individually.
Most adults will experience LBP sometime during their life.
Knowledge of common pain generators, and recognition of pain patterns based on the history and physical exam help guide treatment without the need for excessive resource utilization.
The goal of triaging LBP is to determine which cases arise from sinister pathology, and which cases can be safely managed conservatively.
Diagnostic investigations and specialist referral are warranted only when there is suspicion of a specific disease process that would be managed differently than mechanical LBP.
When clearly identified, the four LBP pain patterns should be treated in the primary care setting before undergoing advanced imaging.
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Related Terms: Back Health, low back pain, mechanical low back pain, lumbar pain, degenerative disease, clinical evaluation, triage
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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,

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.

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.

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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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Related Terms: Back Health, Appropriateness in diagnostic imaging, lumbar MRI, low back pain, surgical indications
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Social Determinants of Health and Low Back Pain

Teaser: 

1Ted Findlay, DO, CCFP, FCFP, 2Dr. Eugene Wai, MD, MSc, CIP, FRCSC,

1Medical Staff, Calgary Chronic Pain Centre at Alberta Health Services, Calgary, Alberta. 2Associate Professor, University of Ottawa Division of Orthopaedic Surgery, Cross Appointment to School of Epidemiology and Public Health, Ottawa, ON.

CLINICAL TOOLS

Abstract: It has long been recognized that, following an intervention, two patients with very similar or even identical pathophysiology can have dramatically different outcomes. There is increasing recognition of the role and importance of the social determinants of health as a factor in explaining these differences. This article reviews a number of recent studies that explain the impact of these social determinants, specifically in chronic pain and low back pain. It includes commonly used screening tools and advice for interventions.
Key Words: Social determinants of health, chronic pain, low back pain, screening, social prescription.

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.

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1. According the World Health Organization, the impact of the social determinants of health on health and illness may outweigh that of health care or lifestyle choices.
2. The social determinants of health identified as being of the most importance specifically for low back pain include education and job position.
3. Most communities across Canada will include a number of resources that can be readily accessed as part of a "Social Prescription".
1. Incorporating social work support at an early stage may have the potential to improve treatment compliance and outcomes for those low back pain patients who have notable challenges related to the social determinants of health.
2. Well validated and easily utilized screening tools already exist for the routine screening of social determinants of health.
3. Sleep disorders are shown to affect nearly half of all people reporting chronic pain, with a bidirectional relationship.
Proper patient selection and pre-operative optimization of all modifiable factors improve outcomes and decrease the possibility of FBSS.
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Related Terms: Back Health, social determinants of health, chronic pain, low back pain, screening, social prescription
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Exercise and Dementia: A Step-by-Step Approach to Prescribing Exercise

Teaser: 

Dr. Alykhan Abdulla, BSC, MD, LMCC, CCFP, DipSportMed CASEM, FCFP, CTH (ISTM), CCPE, Masters Cert Phys Leader, ICD.D

Assistant Professor University of Ottawa Faculty of Medicine, Academic Clinical Professor University of Ottawa Faculty of Nursing Medical Director The Kingsway Health Centre, The Kingsway Travel Clinic, The Kingsway Cosmetic Clinic, Editor in Chief/Author Journal of Current Clinical Care SPORTS MEDICINE, Past Chair Section of General and Family Practice Ontario Medical Association, Bruyere Foundation

CLINICAL TOOLS

Abstract: Dementia is a threat to the aging population. Although dementia cannot be reversed there is evidence that physical exercise can improve activities of daily living, balance, quality of life, funtion, strength, and mental function through various parameters. This article will focus on aerobic training, resistance training, and flexibility training.
Key Words: dementia, exercise, aerobic training, resistance training, flexibility training, exercise prescription.
Approach to Exercise Prescription includes asking questions during a patient's routine visit.
1. Ask about a patient's level of physical fitness.
2. Review their activities, assessing intensity, duration, and frequency.
3. Develop a fitness goal.
Prescribing exercise to patients with dementia that includes focus on aerobic training, resistance training, and flexibility for the prevention of injuries will help reduce the symptoms of dementia and improve function.
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Related Terms: Sports Medicine, dementia, exercise, aerobic training, resistance training, flexibility training, exercise prescription
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Repetitive Strain Injuries: Featuring Trish the Typist

Teaser: 

Dr. Alykhan Abdulla, BSC, MD, LMCC, CCFPC, DipSportMed CASEM, FCFCP, CTH (ISTM), CCPE, Masters Cert Phys Leader, ICD.D

Assistant Professor University of Ottawa Faculty of Medicine, Academic Clinical Professor University of Ottawa Faculty of Nursing Medical Director The Kingsway Health Centre, The Kingsway Travel Clinic, The Kingsway Cosmetic Clinic, Beechwood Medical Cosmetic Physio Pharmacy, Editor in Chief/Author Journal of Current Clinical Care SPORTS MEDICINE, Vice Chair Section of General and Family Practice Ontario Medical Association, Board Director Eastern Ontario Regional Lab Association, Bruyere Foundation

CLINICAL TOOLS

Abstract: A Repetitive strain injuries are a group of medical conditions that are caused by prolonged repetitive, awkward, or forceful movements that overstress particular muscles, nerves, tendons, or bones. It is most common in the forearms and hands, but can also affect the eyes, neck, shoulders, or back.
Key Words: repetitive strain injuries, good posture, typing technique, regular stretching.
The key to RSI is prevention and that includes the following items:
1. Good Posture: feet flat on the floor, knees at right angles, pelvis rocked forward, lower back slightly arched, upper back naturally rounded, shoulder arms and hands naturally relaxed at the side, head middle of shoulders.
2. Typing technique: wrists straight, let your hands float and your strokes light, and don't strain your fingers for the hard keys like CTRL or ALT.
3. Regular stretching: get up every 15-20 and stretch out your wrists, fingers, elbows, shoulders, neck and upper back.
Repetitive strain injuries are common and can be treated with good posture, proper typing techniques and regular stretching.
Setting up an ergonomic work station at home and taking regular breaks that include strengthening the hands and forearms.
Working with a physiotherapist and/or massage therapist can be helpful in conquering repetitive strain injuries.
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Related Terms: Sports Medicine, repetitive strain injuries, good posture, typing technique, regular stretching
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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,

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.

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.

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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Related Terms: Back Health, failed back surgery syndrome, low back pain, multidisciplinary approach, spine surgery, patient expectations
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Surgical Management of Spondyloarthropathies in the Age of Disease Altering Drugs

Teaser: 

1Mosaab Alsuwaihel, MD, 2Sean Christie, MD,

1PGY4 Dalhousie Neurosurgery Program, Dalhousie University, Halifax, NS. 2Professor, Department of Surgery (Neurosurgery), Faculty of Medicine, Vice-Chair and Director of Research , Division of Neurosurgery, Dalhousie University.

CLINICAL TOOLS

Abstract: Inflammatory spondyloarthropathies produce synovitis of the spinal joints in rheumatoid arthritis (RA), or enthesitis in ankylosing spondylitis (AS). In RA, progressive disease leads to synovial destruction, ligamentous laxity, pannus formation and deformity. In AS progressive enthesitis results in ascending ossification, kyphotic deformity and rigidity which increase the risk of fracture. Although pain is the common presentation, spinal cord compression can produce neurological deficits. Although the need for surgery has decreased with the advent of new disease altering drugs, there remains a number of indications when surgical consultation remains important.
Key Words: Spondyloarthropathy and spondyloarthritis, Synovium and synovitis, Enthesis and enthesitis, Pannus.

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.

Pre-test CME Quiz Post-test CME Quiz
1. Inflammatory arthritis from multiple etiologies may affect the spine with different patterns and pathophysiology.
2. Rheumatoid arthritis is a disease of synovial inflammation and in advanced disease leads to synovitis within the atlanto-dental articulation and the facet joints of the spine.
3. If left untreated atlantoaxial subluxation, cranial settling and pannus formation may lead to spinal cord and lower medullary compression.
4. Seronegative arthropathies leads to an enthesitis of the spine, usually starting in the sacroiliac spine and ascending with progressive ossification.
5. As a consequence of pathological alteration of the spine biomechanics, trauma in the setting of ankylosing spondylitis leads to different fracture patterns with a high chance of instability even after minimal trauma.
1. Early and adequate treatment of rheumatoid arthritis can prevent advanced atlanto-axial disease, deformity and neurological injury.
2. Even minimal trauma to the spine in a patient with ankylosing spondylitis has a high risk of instability and neurological injury; detailed imaging is always warranted.
3. With the advent of modern disease modifying agents for the treatment of spondyloarthropathies, the requisite for surgery has decreased but there remain important indications.
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Related Terms: Back Health, Spondyloarthropathy and spondyloarthritis, Synovium and synovitis, Enthesis and enthesitis, Pannus
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