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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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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. |
Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.
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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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Abandoning Treatment Due to Age Alone
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When caring for older adults with comorbidities, especially those at the extreme upper limits of life…
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When caring for older adults with comorbidities, especially those at the extreme upper limits of life, it may be easy for providers to lessen the intensity of their curiosity and medical investigation. For some older individuals’ chronic conditions, the odds of a positive outcome may seem too distant or the patient’s discomfort—or, in many jurisdictions, the financial burden—may act as a barrier to the pursuit of answers.
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Editor's Note, Volume 7 Issue 6
D’Arcy Little, MD, CCFP, FRCPC Medical Director, JCCC and HealthPlexus.NET
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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. |
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. 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. |
| 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. |
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