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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

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.

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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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Spinal Lesion: Benign or Malignant? When should you worry?

Teaser: 

Raphaële Charest-Morin, MD, FRCSC,1
Nicolas Dea, MD, MSc, FRCSC,2

1Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Québec, Laval University, QC.
2Spine Surgeon, Clinical Associate Professor of Neurosurgical and Orthopedic Spine Program, Vancouver General Hospital, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: General practitioners are occasionally confronted to unknown lesions of the spine. Recognition of imaging characteristics and anatomic details from the different imaging modalities generally provides sufficient information to generate an appropriate differential diagnosis. Importantly, first line clinicians should recognize worrisome imaging characteristics and initiate timely referral when indicated. On the other hand, lesions expressing benign features should also be identified to avoid anxiety for the patient and overuse of diagnosis imaging studies. In a public health-care system, judicious utilization of imaging is of paramount importance. This article will review an approach to unknown bony lesions of the spine.
Key Words: Spinal lesion, tumour, imaging characteristics, primary bone tumours.

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A solitary spinal lesion warrants a careful investigation. Most of the time, local imaging and systemic staging provide diagnosis.
In patients over 40 years old, most tumours are malignant with metastases and multiple myeloma being the most frequent. Benign and incidental lesions such as bony islands and hemangiomas are, however, also frequently encountered in this age group.
In patients under 30 years old, tumours of the spine are uncommon and are generally benign with the exception of Ewing Sarcoma and Osteosarcoma.
Primary bone tumours of the spine are rare and should be referred to specialized centers.
Worrisome features on imaging include aggressive bony destruction, spinal canal invasion, soft tissue mass and multiple level involvement.
Pyogenic infections usually start in the disc space, whereas tumours generally spare the intervertebral disc.
Most aggressive lesions will initially present with non-specific clinical complaints and as such, a high level of suspicion is warranted. Systemic symptoms are rare with primary bone tumours.
Most incidental findings do not require any follow-up or further investigation.
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Chronic Neuropathic Pain in Primary Care—The Role of Neuromodulation

Teaser: 

Philippe Magown, MD CM, PhD, FRCSC,

Caleo Health, Calgary, Alberta.

CLINICAL TOOLS

Abstract: Neuropathic pain is a severe pain condition characterized by burning, tingling, or lancinating pain in the distribution of a nerve, dermatome, or sclerotome and affects patient function, quality of life, mood, and employment. Neuropathic pain is generally refractory to pain medications but amenable to gabapentinoids and antidepressants. When neuropathic pain is refractory to conservative medical management, neuromodulation is the next strategy. Neuromodulation is the modulation of neural signals, most commonly performed with electrical stimulation, such as spinal cord stimulation. Spinal cord stimulation can provide clinically significant pain relief, improve quality of life and function for neuropathic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.
Key Words: Spinal cord stimulation, failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, refractory angina.

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1. Neuromodulation outcomes for neuropathic pain are best if performed early upon confirmation of pain refractoriness to multimodal and multi-pharmacological management.
2. Level 1 and 2 evidences support the use of neuromodulation for neuropathic pain conditions such as failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.
3. Neuromodulation can provide 50% or more pain relief in a significant proportion of patients with neuropathic pain conditions refractory to pharmacotherapy.
1. Neuropathic pain is a severe pain condition along a nerve, dermatome, or sclerotome that is characterized by burning, lancinating, prickling, or shocking-like pain generally refractory to pain medications.
2. Neuropathic pain refractory to four or more pharmacological agents among TCAs, SNRIs, gabapentinoids, and tramadol can benefit from neuromodulation, even more so if performed within two years of onset.
3. Neuromodulation can provide 50% or more pain relief in a significant proportion of patients with failed back surgery syndrome, complex regional pain syndrome, painful diabetic neuropathy, and refractory angina.
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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The Need for Obstructive Sleep Apnea Screening: A Wake-Up Call to Physicians

Teaser: 

Sharon A. Chung, PhD1and Colin M. Shapiro, MBBCh, PhD, MRCPsych, FRCP(C)1-3

1Youthdale Treatment Centres, Toronto, Ontario, Canada. 2International Sleep Clinic, Parry Sound, Canada and the 3University of Toronto, Department of Psychiatry, Canada.

CLINICAL TOOLS

Abstract: Obstructive Sleep Apnea (OSA), where patients stop breathing numerous times during sleep, is a disorder linked to serious medical, socioeconomic, and psychological morbidity, yet most patients with OSA remain undetected. Physicians should consider symptoms of frequent/loud snoring, complaints of daytime sleepiness or fatigue, high blood pressure and obesity or excessive body fat distribution in the neck or upper chest area as possible indications of untreated OSA.
Key Words: obstructive sleep apnea, screening, management.
Untreated OSA is associated with significant morbidity and mortality and results in increased healthcare utilization.
OSA is more prevalent in individuals with a chronic medical illness.
Almost 90% of individuals with OSA remain undiagnosed.
Treatment of OSA improves medical outcome; this is particularly relevant in medically ill patients.
Evidence-based medicine supports screening for OSA as part of routine clinical care.
Newer technology allows doctors to 'skip the waiting line' and obtain quick and accurate sleep testing for their patients.
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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.

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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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Clinical Images: Cercarial Dermatitis

Clinical Images: Cercarial Dermatitis

Teaser: 

Kerry Gardner, MD,1 Joseph M. Lam, MD, FRCPC,2

1Resident, Department of Dermatology and Skin Science, University of British Columbia, BC.
2Clinical Assistant Professor, Department of Pediatrics and Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Cercarial dermatitis (swimmers' itch) consists of urticarial papules that form when the larvae of avian parasitic flatworms penetrate the skin. Cercarial dermatitis is common in the summer months where heaviest recreational swimming occurs, and when the temperature is ideal for amplified schistosome development.
Key Words: cercarial dermatitis (swimmers' itch), non-communicable, water-borne disease.
Cercarial dermatitis usually occurs with exposure to fresh water, but can occur with shallow salt water exposure as well.
The eruption typically occurs on uncovered skin 12-24 hours (up to 8 days) after exposure.
The eruption is self-limited, lasting 4-10 days (up to 20 days).
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Clearing Up Acne Treatment for the Primary Care Physician

Teaser: 

Darcy Russell,1 Joseph M. Lam, MD, FRCPC,2

1Medical Undergraduate Program, University of British Columbia, Vancouver, BC.
2Clinical Assistant Professor, Department of Pediatrics and Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Acne vulgaris is a common skin condition encountered in family practice and can cause significant distress during adolescence. Treatment options discussed include topical benzyl peroxide, topical retinoids, oral and topical antibiotics, hormonal therapy, and isotretinoin. The following review article provides up-to-date recommendations for treating mild to severe pediatric acne.
Key Words: acne vulgaris, adolescence, treatment, pathogenesis.
The differential diagnosis for acne in adolescence includes corticosteroid induced acne, folliculitis, keratosis pilaris, papular sarcoidosis, perioral dermatitis, pseudofolliculitis barbae, and tinea faceie.
Acne may be classified as mild, moderate or severe based on the number and type of lesions involved as well as the total surface area involved.
Acne therapy is targeted at treating as many pathogenic factors as possible.
Topical fixed-dose combination therapies can be used for all types and severities of acne in children 9 years of age and older.
Both topical and oral antibiotics work by inhibiting P acnes protein synthesis and decreasing inflammation.
Do not be afraid of isotretinoin. It can be used first line in patients with severe nodular and/or inflammatory acne, acne conglobata, and recalcitrant acne.12 It is the only treatment that targets all four pathogenic factors implicated in acne vulgaris and can permanently decrease acne.
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Five Things to Know about Cauda Equina Syndrome

Teaser: 

Drew A. Bednar, MDCM, FRCS(C), FAAOS,

Clinical Professor of Orthopedic Surgery, Adult Spine Surgeon, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: Cauda Equina Syndrome (CES) is a rare progressive syndrome of pain and neurological deficits below the waist caused by massive central lumbar disc prolapse. The most common clinical presentation is highly variable with multifocal mixed polyradicular deficits. Loss of bladder and/or bowel control can be subtle and is frequently not the patient' chief complaint. These symptoms must be aggressively sought by the assessing physician. While delays of a few hours in the diagnosis and management may not be deleterious, definitive lumbar MRI imaging and (if positive) surgical care referral are emergent.
Key Words: Cauda Equina Syndrome; Presentation; Diagnosis; Outcome.

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The CES patient often presents with rapidly escalating, poorly controlled pain. There may be daily or even more frequent physician visits.
While standing, the CES patient commonly adopts a "sciatic scoliosis": forward bending at the waist and leaning to either side as they attempt to decompress themselves. They may limp or need walking aids. These features help distinguish them from drug-seekers or malingerers.
Since patients are distracted by extreme pain, they may not reliably volunteer a history of bladder/bowel disturbance.
Cauda Equina Syndrome is an acute or subacute pathology caused specifically by massive central prolapse of a lumbar disc. Decompensation lumbar spinal stenosis is not Cauda Equina Syndrome.
Cauda Equina Syndrome most commonly presents with complaints of back or leg pain. These differ from common sciatica in being rapidly progressive, difficult to control with analgesics and often associated with considerable locomotor impairment.
The neurological examination in Cauda Equina Syndrome most commonly finds a mixed pattern of incomplete polyradicular deficits in the distribution of multiple lumbar and sacral nerve roots involving either of the legs and/or the saddle (perineum). The classically described complete flaccidity with loss of all motor control from the waist down is extremely rare.
Patients presenting with CES will not commonly volunteer complaints of incontinence or urinary retention as they are often overwhelmed by the magnitude of their pain. The assessor must specifically ask about bowel/bladder function and when indicated, test these by bladder scanning or catheterizing and a digital rectal examination.
As a rapidly evolving syndrome of neurological deterioration, CES warrants emergent imaging investigation and referral. Although the literature is not precise on the critical time point, it is widely accepted that patients should receive surgical intervention within 24 to 48 hours.
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Faits en bref : Aperçu de la nycturie

Faits en bref : Aperçu de la nycturie

Teaser: 

Références

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  5. InterAct Consortium, Scott RA, Langenberg C, et al. The link between family history and risk of type 2 diabetes is not explained by anthropometric, lifestyle or genetic risk factors: the EPIC-InterAct study. Diabetologia. 2013;56(1):60-9.
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Movement as Medicine in Osteoarthritis

Teaser: 

Dr. Zahra Bardai MD CCFP (COE) MHSc FCFP,

Community Family Physician, Lecturer, University of Toronto, Assistant Clinical Professor (Adjunct), Department of Family Medicine, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: Osteoarthritis is a prevalent health condition that affects millions of people worldwide. Increasingly, there has been a growing body of international recommendations emphasizing non-pharmacologic interventions using physical activity to modify joint mechanics. Discussion will focus on pathophysiology of joint mechanics as it relates to physical activity as well as the use of specific clinical strategies that can be incorporated into physical activity counseling in osteoarthritis management.
Key Words: Osteoarthritis, Physical Activity, Exercise Vital Sign, Exercise Prescription.
Osteoarthritis is a leading source of nonfatal health burden
Non-pharmacologic treatments of osteoarthritis focus on modifiable factors in joint mechanics
Osteoarthritis is a structural and functional failure of joints
Movement and physical activity have protective effects on osteoarthritic joints
The Exercise Vital Sign should become incorporated into assessments for preventative health and chronic disease including osteoarthritis.
The Exercise Prescription tool can help clinicians formally prescribe exercise as a treatment for their patients.
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