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Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev 2023; 8:CD014461. [PMID: 37615643 PMCID: PMC10448864 DOI: 10.1002/14651858.cd014461.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Low back pain is a common presentation across different healthcare settings. Clinicians need to confidently be able to screen and identify people presenting with low back pain with a high suspicion of serious or specific pathology (e.g. vertebral fracture). Patients identified with an increased likelihood of having a serious pathology will likely require additional investigations and specific treatment. Guidelines recommend a thorough history and clinical assessment to screen for serious pathology as a cause of low back pain. However, the diagnostic accuracy of recommended red flags (e.g. older age, trauma, corticosteroid use) remains unclear, particularly those used to screen for vertebral fracture. OBJECTIVES To assess the diagnostic accuracy of red flags used to screen for vertebral fracture in people presenting with low back pain. Where possible, we reported results of red flags separately for different types of vertebral fracture (i.e. acute osteoporotic vertebral compression fracture, vertebral traumatic fracture, vertebral stress fracture, unspecified vertebral fracture). SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 26 July 2022. SELECTION CRITERIA We considered primary diagnostic studies if they compared results of history taking or physical examination (or both) findings (index test) with a reference standard test (e.g. X-ray, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computerised tomography (SPECT)) for the identification of vertebral fracture in people presenting with low back pain. We included index tests that were presented individually or as part of a combination of tests. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data for diagnostic two-by-two tables from the publications or reconstructed them using information from relevant parameters to calculate sensitivity, specificity, and positive (+LR) and negative (-LR) likelihood ratios with 95% confidence intervals (CIs). We extracted aspects of study design, characteristics of the population, index test, reference standard, and type of vertebral fracture. Meta-analysis was not possible due to heterogeneity of studies and index tests, therefore the analysis was descriptive. We calculated sensitivity, specificity, and LRs for each test and used these as an indication of clinical usefulness. Two review authors independently conducted risk of bias and applicability assessment using the QUADAS-2 tool. MAIN RESULTS This review is an update of a previous Cochrane Review of red flags to screen for vertebral fracture in people with low back pain. We included 14 studies in this review, six based in primary care, five in secondary care, and three in tertiary care. Four studies reported on 'osteoporotic vertebral fractures', two studies reported on 'vertebral compression fracture', one study reported on 'osteoporotic and traumatic vertebral fracture', two studies reported on 'vertebral stress fracture', and five studies reported on 'unspecified vertebral fracture'. Risk of bias was only rated as low in one study for the domains reference standard and flow and timing. The domain patient selection had three studies and the domain index test had six studies rated at low risk of bias. Meta-analysis was not possible due to heterogeneity of the data. Results from single studies suggest only a small number of the red flags investigated may be informative. In the primary healthcare setting, results from single studies suggest 'trauma' demonstrated informative +LRs (range: 1.93 to 12.85) for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture' (+LR: 6.42, 95% CI 2.94 to 14.02). Results from single studies suggest 'older age' demonstrated informative +LRs for studies in primary care for 'unspecified vertebral fracture' (older age greater than 70 years: 11.19, 95% CI 5.33 to 23.51). Results from single studies suggest 'corticosteroid use' may be an informative red flag in primary care for 'unspecified vertebral fracture' (+LR range: 3.97, 95% CI 0.20 to 79.15 to 48.50, 95% CI 11.48 to 204.98) and 'osteoporotic vertebral fracture' (+LR: 2.46, 95% CI 1.13 to 5.34); however, diagnostic values varied and CIs were imprecise. Results from a single study suggest red flags as part of a combination of index tests such as 'older age and female gender' in primary care demonstrated informative +LRs for 'unspecified vertebral fracture' (16.17, 95% CI 4.47 to 58.43). In the secondary healthcare setting, results from a single study suggest 'trauma' demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 2.18, 95% CI 1.86 to 2.54) and 'older age' demonstrated informative +LRs for 'osteoporotic vertebral fracture' (older age greater than 75 years: 2.51, 95% CI 1.48 to 4.27). Results from a single study suggest red flags as part of a combination of index tests such as 'older age and trauma' in secondary care demonstrated informative +LRs for 'unspecified vertebral fracture' (+LR: 4.35, 95% CI 2.92 to 6.48). Results from a single study suggest when '4 of 5 tests' were positive in secondary care, they demonstrated informative +LRs for 'osteoporotic vertebral fracture' (+LR: 9.62, 95% CI 5.88 to 15.73). In the tertiary care setting, results from a single study suggest 'presence of contusion/abrasion' was informative for 'vertebral compression fracture' (+LR: 31.09, 95% CI 18.25 to 52.96). AUTHORS' CONCLUSIONS The available evidence suggests that only a few red flags are potentially useful in guiding clinical decisions to further investigate people suspected to have a vertebral fracture. Most red flags were not useful as screening tools to identify vertebral fracture in people with low back pain. In primary care, 'older age' was informative for 'unspecified vertebral fracture', and 'trauma' and 'corticosteroid use' were both informative for 'unspecified vertebral fracture' and 'osteoporotic vertebral fracture'. In secondary care, 'older age' was informative for 'osteoporotic vertebral fracture' and 'trauma' was informative for 'unspecified vertebral fracture'. In tertiary care, 'presence of contusion/abrasion' was informative for 'vertebral compression fracture'. Combinations of red flags were also informative and may be more useful than individual tests alone. Unfortunately, the challenge to provide clear guidance on which red flags should be used routinely in clinical practice remains. Further research with primary studies is needed to improve and consolidate our current recommendations for screening for vertebral fractures to guide clinical care.
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Affiliation(s)
- Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Mark J Hancock
- Department of Health Sciences, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Aron Downie
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Jeffrey G Jarvik
- Departments of Radiology and Neurological Surgery, and the UW Clinical Learning, Evidence And Research (CLEAR) Center for Musculoskeletal Disorders, University of Washington School of Medicine, Seattle, USA
| | - Bart W Koes
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
- Department of General Practice, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Arianne P Verhagen
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney (UTS), Sydney, Australia
| | | | - Qiuzhe Chen
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Zeb J, Zaib J, Khan A, Farid M, Ambreen S, Shah SH. Characteristics and clinical features of cauda equina syndrome: insights from a study on 256 patients. SICOT J 2023; 9:22. [PMID: 37470755 DOI: 10.1051/sicotj/2023019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/23/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE To determine the frequency, clinical presentation, and etiological factors of cauda equina syndrome (CES). MATERIALS AND METHOD This retrospective study was done on 256 participants, and aimed to analyze the frequency and patterns of clinical presentation in suspected cases of CES. The inclusion criteria included participants aged 18 or older with medical records available for review and having red-flagged symptoms for CES. The study collected information on various factors such as age, gender, confirmation of CES on MRI, neurological deficits, etiological factors, duration of symptoms, and more. The data collected was analyzed using descriptive statistics and logistic regression to identify significant variables between MRI-proven CES and suspected CES. RESULTS The mean age was 58.05 ± 19.26 years, with 151 females (58.98%) and 105 males (41.02%). The majority (50.78%) had a neurological deficit, while other symptoms included difficulty initiating micturition or impaired sensation of urinary flow (17.58%), loss of sensation of rectal fullness (3.12%), urinary or faecal incontinence (35.16%), bilateral sciatica (21.88%), neurological symptoms in the lower limbs (25.00%), anaesthesia or any leg weakness (24.22%), and bilateral sciatica as the predominant symptom (21.88%). Symptoms were chronic in 47.27% and acute in 21.88%. The odds of MRI-proven CES increase by 3% per year of age. Neurological deficit was strongly associated with MRI-proven CES (OR = 14.97), while loss of sensation of rectal fullness increased the odds by 10-fold (OR = 10.62). CONCLUSION CES can present with various symptoms, including the bilateral neurological deficit, urinary and faecal incontinence, and bilateral sciatica, with age, severe bilateral neurological deficit, and loss of sensation of rectal fullness being associated with MRI-proven CES. Early diagnosis and treatment are crucial for better outcomes.
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Affiliation(s)
- Junaid Zeb
- Registrar Trauma and Orthopaedics, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Pensnett Rd, Dudley DY1 2HQ, United Kingdom
| | - Jehan Zaib
- Registrar Trauma and Orthopaedics, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Pensnett Rd, Dudley DY1 2HQ, United Kingdom
| | - Arshad Khan
- Associate Specialist, Trauma and Orthopaedics, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Pensnett Rd, Dudley DY1 2HQ, United Kingdom
| | - Mehreen Farid
- SHO Trauma and Orthopaedics, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Pensnett Rd, Dudley DY1 2HQ, United Kingdom
| | - Seemab Ambreen
- SHO Trauma and Orthopaedics, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Pensnett Rd, Dudley DY1 2HQ, United Kingdom
| | - Syed Hussaini Shah
- Clinical Attachment Trauma and Orthopedics, Russells Hall Hospital, The Dudley Group NHS Foundation Trust, Pensnett Rd, Dudley DY1 2HQ, United Kingdom
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Blokzijl J, Lee H, Cullen L, Coggins A, Golding M, Gillett M, Middleton PM, Ferreira GE, Machado GC, Maher CG, Traeger AC. Diagnoses and trends in use of imaging for low back pain in four Australian emergency departments between 2012 and 2019. Emerg Med Australas 2022; 34:539-546. [DOI: 10.1111/1742-6723.13928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Johan Blokzijl
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
- Physical Therapy Sciences, Program in Clinical Health Sciences, University Medical Center Utrecht Utrecht University Utrecht The Netherlands
| | - Hopin Lee
- Centre for Statistics in Medicine, Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences University of Oxford Oxford UK
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital The University of Queensland Brisbane Queensland Australia
| | - Andrew Coggins
- Emergency Department Westmead Hospital Sydney New South Wales Australia
| | - Michael Golding
- Emergency Department Prince of Wales Hospital Sydney New South Wales Australia
| | - Mark Gillett
- Emergency Department Royal North Shore Hospital Sydney New South Wales Australia
| | - Paul M Middleton
- Emergency Department Liverpool Hospital Sydney New South Wales Australia
- South Western Emergency Research Institute Liverpool Hospital Sydney New South Wales Australia
| | - Giovanni E Ferreira
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health Sydney Local Health District and The University of Sydney Sydney New South Wales Australia
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Curtis Lopez C, Berg AJ, Clayton B, Siddique I, Carrasco R, Horner D, Angus M. Evaluation of the role of anal tone and perianal sensation examination in the assessment of suspected cauda equina syndrome. Br J Neurosurg 2021:1-5. [PMID: 34796788 DOI: 10.1080/02688697.2021.2005775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/25/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Cauda equina syndrome (CES) can present with a varied constellation of clinical signs and symptoms, which together with the time-sensitive nature of the condition and risk of catastrophic clinical outcome, presents a significant challenge to those assessing patients with this suspected diagnosis. Anal tone is commonly tested during initial assessment using a digital rectal examination (DRE). This study aims to evaluate the diagnostic value of anal tone and perianal sensation assessment in patients with suspected CES and report modern prevalence data on CES within a neurosciences centre. MATERIALS AND METHODS Consecutive patients with suspected CES presenting over three years to the Emergency Department (ED) of a busy tertiary centre were included in the study. History and examination findings, documented in the ED notes, were assessed and these variables were correlated with the presence or absence of cauda equina compression on subsequent magnetic resonance imaging (MRI). RESULTS Out of 1005 patients with suspected CES, 117 (11.6%) had MRI confirmed cauda equina compression (MRI + ve CES). 35% of MRI + ve patients and 31% of MRI -ve patients had reduced anal tone. Using univariate and multivariable logistic regression analyses, no associations were found between abnormal anal tone and MRI + ve CES for patients of all ages. The univariate logistic regression analysis identified altered perianal sensation to be significantly associated with MRI + ve CES in patients ≤42 years old. This association was no longer present when an adjusted multivariable logistic regression was performed. CONCLUSION The prevalence of MRI + ve CES was 11.6%. Our findings suggest that the clinical finding of reduced anal tone has no demonstrable diagnostic value for those with suspected CES, either in itself or in combination with other clinical findings. Further studies are needed to confirm the diagnostic efficacy of assessing perianal sensation in this context.
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Affiliation(s)
- Carlos Curtis Lopez
- University of Manchester, Manchester, England
- Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Bethan Clayton
- University of Manchester, Manchester, England
- Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Roberto Carrasco
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Daniel Horner
- Division of Population Health, Health Services Research & Primary Care, School of Biological Sciences, The University of Manchester, Manchester, UK
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Barbaro K, Midgley J. Priapism, a symptom of claudication of the cauda equina in spinal stenosis. Musculoskelet Sci Pract 2021; 52:102337. [PMID: 33549525 DOI: 10.1016/j.msksp.2021.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 11/30/2022]
Abstract
Priapism is defined as a persistent penile erection in the absence of sexual arousal. This symptom has been documented in patients with spinal stenosis although it is considered a rare finding. The European Association of Urology guidelines on priapism [Salonia et al., 2014] list cauda equina syndrome and spinal stenosis as causative factors for ischemic priapism although the literature describing this phenomenon appears sparse. Priapism can be a rare symptom of lumbar spine stenosis/transient cauda equina compression. This presentation is complex and believed to be a parasympathetic mediated autonomic disorder. This article discusses the relationship between spinal stenosis, cauda equina syndrome and priapism using available literature. Greater awareness of this clinical finding may help clinicians in their clinical decision making. In patients with suspected cauda equina syndrome, subjective enquiry regarding the symptom priapism may add to the patients overall clinical picture.
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Affiliation(s)
- Karl Barbaro
- Musculoskeletal Department, York Teaching Hospital NHS Foundation Trust, York, United Kingdom.
| | - James Midgley
- Musculoskeletal Department, York Teaching Hospital NHS Foundation Trust, York, United Kingdom.
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6
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Ali A, Manzoor K, Chang YM, Mehta PJ, Brook A, Hackney DB, Edlow JA, Bhadelia RA. Role of C-reactive protein in effective utilization of emergent MRI for spinal infections. Emerg Radiol 2021; 28:573-580. [PMID: 33449259 DOI: 10.1007/s10140-020-01892-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Emergent spinal MRI is recommended for patients with back pain and red flags for infection. However, many of these studies are negative due to low prevalence of spinal infections. Our purpose was to assess if C-reactive protein (CRP) can be used to guide effective utilization of emergent MRI for spinal infections. METHODS 316/960 (33%) MRIs performed for infection by the emergency department over 75-month period had CRP levels obtained at presentation, after excluding patients receiving antibiotic or had spinal surgery in < 1 month. An MRI was considered positive when there was imaging evidence of spinal infection confirmed on follow-up by surgery/biopsy/drainage or definitive therapy. A CRP of ≤ 10 mg/L was considered normal and > 100 mg/L as highly elevated. RESULTS CRP was normal in 95/316 (30%) and abnormal in 221/316 (70%) patients. MRI was positive in 43/316 (13.6%) patients, all of whom had abnormal CRP. CRP (p < 0.001) and intravenous drug use (IVDU; p = 0.002) were independently associated with a positive MRI. Receiver operator characteristic (ROC) analysis showed AUC of 0.76 for CRP, slightly improving with IVDU. Sensitivity, specificity, and negative predictive values for CRP level cut-off: 10 mg/L, 100%, 35%, and 100%, and 100 mg/L, 58%, 70% and 91%, respectively. CONCLUSION Abnormal CRP, although extremely sensitive, lacks specificity in predicting a positive MRI for spinal infection unless highly elevated. However, a normal CRP (absent recent antibiotic or surgery) makes spinal infection unlikely, and its routine use as a screening test can help reducing utilization of emergent MRI for this purpose.
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Affiliation(s)
- Aamir Ali
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Komal Manzoor
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Pritesh J Mehta
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - David B Hackney
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
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Implementation of musculoskeletal specialists in the emergency department at a level A1 VA Hospital during the SARS-CoV-2 pandemic. Am J Emerg Med 2020; 46:722-723. [PMID: 33127186 PMCID: PMC7544733 DOI: 10.1016/j.ajem.2020.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 12/29/2022] Open
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Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE To investigate the 30-day recurrence rate after emergency lumbar discectomy. Secondary aims were to investigate the factors affecting the 30-day recurrence and readmission rates and clinical outcome. SUMMARY OF BACKGROUND DATA Excluding cauda equine syndrome (CES) due to massive intervertebral disc herniation, emergency surgery for lumbar disc herniation (LDH) is rarely required. The operation may, however, be performed for other reasons such as persistent or progressive motor paresis associated with radiculopathy or uncontrolled pain. Literature on these topics is scarce. METHODS All patients admitted for inpatient care after a visit to the emergency department (ED) due to acute low back pain and who had subsequently undergone an emergency lumbar discectomy during the 4-year study period were included in the study. Patients attending the ED who subsequently had a delayed discectomy formed the control group. Recurrence and readmission rates were analyzed and clinical outcome at 30 days post-surgery was assessed with the Oswestry Disability Index (ODI) and the visual analog pain scale (VAS). RESULTS One hundred thirty patients were admitted to the hospital after visiting the ED and underwent an emergency discectomy after a median of 1.0 days from admittance. Six patients in the study group [4.6% (95% CI: 2.1-9.7)] had recurrent LDH and nine patients in total [6.9% (95% CI: 3.9-12.6)] were readmitted within 30 days. None of the baseline variables clearly predicted recurrence. Mean ODI difference between the study group and controls was 8.1 (95% CI: -6.7-23.2). BMI and surgery by a non-spine surgeon were associated with higher ODI values. CONCLUSION An emergency discectomy is associated with a higher rate than expected of both recurrent LDHs and 30-day readmissions. Surgeon experience and patient-related factors had minor effects on the 30-day clinical outcome. LEVEL OF EVIDENCE 4.
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Duan K, Qin Y, Ye J, Zhang W, Hu X, Zhou J, Gao L, Tang Y. Percutaneous endoscopic debridement with percutaneous pedicle screw fixation for lumbar pyogenic spondylodiscitis: a preliminary study. INTERNATIONAL ORTHOPAEDICS 2020; 44:495-502. [PMID: 31879810 PMCID: PMC7026210 DOI: 10.1007/s00264-019-04456-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/21/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To access the feasibility and efficacy of percutaneous endoscopic debridement (PED) combined with percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar pyogenic spondylodiscitis. METHODS Forty-five patients diagnosed as pyogenic spondylodiscitis underwent PPSF followed by PED. A drainage catheter was left in place for negative pressure drainage. Adequate systematic antibiotics were administered empirically or based on bacterial culture results. Clinical outcomes were assessed by physical examination, regular serologic testing, visual analog scale (VAS), Oswestry Disability Index (ODI), and imaging studies. RESULTS The mean operative time was 110.1 ± 21.2 minutes (range 80-165 minutes), with intra-operative blood loss 47.8 ± 21.0 ml (range 20-120 ml). All patients reported relief of back pain, able to sit up, and partially ambulate the next day. Causative pathogens were identified in 32 of 45 biopsy specimens, staphylococcal bacteria being the most prevalent strain. However, there were 13 patients with post-operative complications. During 6-12 months' follow-up, inflammatory markers showed infection controlled. VAS and ODI values were significantly improved. DISCUSSION Satisfactory clinical and functional outcomes were achieved in our patients post-operatively. It is recommended that PED plus PPSF can be another alternative for spondylodiscitis. CONCLUSION PED supplementing PPSF offers a valid option in treating spondylodiscitis, as it is minimally invasive, shortens hospital stay, and avoids prolonged bed rest with an optimistic outcome.
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Affiliation(s)
- Kaidi Duan
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Yi Qin
- Dept. of Orthopedics, Zhuhai People’s Hospital, 79 Kangning Road, Zhuhai, China
| | - Jichao Ye
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Wei Zhang
- Dept. of Orthopedics, Xinsteel Center Hospital, Tuanjie West Road, Xinyu, China
| | - Xumin Hu
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Jinlang Zhou
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Liangbin Gao
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
| | - Yong Tang
- Dept. of Spine Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, China
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10
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Hoeritzauer I, Wood M, Copley PC, Demetriades AK, Woodfield J. What is the incidence of cauda equina syndrome? A systematic review. J Neurosurg Spine 2020; 32:832-841. [PMID: 32059184 DOI: 10.3171/2019.12.spine19839] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cauda equina syndrome (CES) is a surgical emergency requiring timely operative intervention to prevent symptom progression. Accurately establishing the incidence of CES is required to inform healthcare service design and delivery, including out-of-hours imaging arrangements. METHODS A systematic literature search of MEDLINE, EMBASE, and Scopus was undertaken to identify original studies stating the incidence of CES, and the estimates were combined in a meta-analysis as described in the protocol registered with PROSPERO (registration no. CRD42017065865) and reported using the PRISMA guidelines. RESULTS A total of 1281 studies were identified, and 26 studies were included in the review. Data about CES incidence were available from 3 different populations: asymptomatic community populations, patients with nontraumatic low-back pain, and patients presenting as an emergency with suspected CES. The incidence of CES was 0.3-0.5 per 100,000 per year in 2 asymptomatic community populations, 0.6 per 100,000 per year in an asymptomatic adult population, and 7 per 100,000 per year in an asymptomatic working-age population. CES occurred in 0.08% of those with low-back pain presenting to primary care in 1 study, and a combined estimate of 0.27% was calculated for 4 studies of those with low-back pain presenting to secondary care. Across 18 studies of adults with suspected CES, 19% had radiological and clinical CES. Difficulties in comparison between studies resulted from the heterogeneous definitions of CES and lack of separation of more advanced CES with retention, which is unlikely to be reversible. In the studies of patients with suspected CES, the small sample size, the high number of single-center studies (18/18), the high number of studies from the United Kingdom (17/18), the retrospective nature of the studies, and the high number of abstracts rather than full texts (9/18) reduced the quality of the data. CONCLUSIONS From current studies, it appears that CES occurs infrequently in asymptomatic community populations and in only 19% of those presenting with symptoms. Determining accurate incidence figures and designing a bespoke service for investigation of patients with suspected CES would require a consensus clinical and radiological definition of CES and international multisite studies of patient pathways of investigation and management.
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Affiliation(s)
- Ingrid Hoeritzauer
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
- 3Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, United Kingdom
| | - Matthew Wood
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
| | - Phillip C Copley
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
- 3Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, United Kingdom
| | - Andreas K Demetriades
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 3Edinburgh Spinal Surgery Outcome Studies Group, Department of Clinical Neurosciences, Edinburgh, United Kingdom
| | - Julie Woodfield
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
- 2Centre for Clinical Brain Sciences, University of Edinburgh; and
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11
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Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags. Am J Med 2020; 133:60-72.e14. [PMID: 31278933 DOI: 10.1016/j.amjmed.2019.06.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Very little evidence is available on the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting to the emergency department (ED). This systematic review aims to investigate the prevalence of serious spinal pathologies and the diagnostic accuracy of red flags in patients presenting with low back pain to the ED. METHODS We systematically searched MEDLINE, PUBMED, EMBASE, Cochrane Library, and SCOPUS from inception to January 2019. Two reviewers independently reviewed the references and evaluated methodological quality. RESULTS We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess). CONCLUSION We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings. As the diagnostic accuracy of most red flags was reported only by a single study, further validation in high-quality prospective studies is needed.
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Bouri F, El Ansari W, Mahmoud S, Elhessy A, Al-Ansari A, Al-Dosari MAA. Orthopedic Professionals' Recognition and Knowledge of Pain and Perceived Barriers to Optimal Pain Management at Five Hospitals. Healthcare (Basel) 2018; 6:E98. [PMID: 30104518 PMCID: PMC6165346 DOI: 10.3390/healthcare6030098] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 12/17/2022] Open
Abstract
Pain is a challenge for orthopedic healthcare professionals (OHCP). However, pain studies examined the competencies of a single OHCP category, did not consider various pain management domains or barriers to optimal pain service, and are deficient across the Arabic Eastern Mediterranean region. We surveyed OHCP's recognition and knowledge of pain and perceived barriers to optimal pain service (361 OHCP, five hospitals). Chi square compared doctors' (n = 63) vs. nurses/physiotherapists' (n = 187) views. In terms of pain recognition, more nurses had pain management training, confidently assessed pediatric/elderly pain, were aware of their departments' pain protocols, and felt that their patients receive proper pain management. More doctors comfortably prescribed opiate medications and agreed that some nationalities were more sensitive to pain. For pain knowledge, more nurses felt patients are accurate in assessing their pain, vital signs are accurate in assessing children's pain, children feel less pain because of nervous system immaturity, narcotics are not preferred due respiratory depression, and knew pre-emptive analgesia. As for barriers to optimal pain service, less nurses agreed about the lack of local policies/guidelines, knowledge, and skills; time to pre-medicate patients; knowledge about medications; complexity of the clinical environment; and physicians being not comfortable prescribing pain medication. We conclude that doctors required confidence in pain, especially pediatric and geriatric pain, using vital signs in assessing pain and narcotics use. Their most perceived barriers were lack of local policies/guidelines and skills. Nurses required more confidence in medications, caring for patients on narcotics, expressed fewer barriers than doctors, and the complexity of the clinical environment was their highest barrier. Educational programs with clinical application could improve OHCPs' pain competencies/clinical practices in pain assessment and administration of analgesics.
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Affiliation(s)
- Fadi Bouri
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha 3050, Qatar.
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha 3050, Qatar.
- College of Medicine, Qatar University, Doha 2713, Qatar.
| | - Shady Mahmoud
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha 3050, Qatar.
| | - Ahmed Elhessy
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha 3050, Qatar.
| | - Abdulla Al-Ansari
- Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha 3050, Qatar.
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