1
|
Xu X, Chen Q, Oliveira CB, Maher CG, Machado GC. Emergency department length of stay and re-presentation rates in patients with low back pain: A medical record review study. Am J Emerg Med 2024; 84:33-38. [PMID: 39067198 DOI: 10.1016/j.ajem.2024.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/15/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND Low back pain (LBP) is ranked in the top 10 conditions presenting to emergency departments (ED) in Australia. We aimed to investigate ED re-presentation rates and length of stay (LOS) of patients with LBP, including associated factors. METHODS We reviewed medical records of three EDs in Sydney, Australia from January 2016 to October 2021. The primary outcome was the proportion of episodes of non-serious LBP with at least one re-presentation within 12 months. Secondary outcomes were re-presentation rates within 3-days, 1-week, 1-month, 3-months, 6-months, and mean LOS. Multivariable logistic regression analyses were performed to investigate the associated factors with re-presentation and prolonged stay (>4 h) and reported as adjusted odds ratios (aORs) and 95% confidence intervals (95% CI). RESULTS Of 8289 episodes of non-serious LBP, 7.7% included at least one re-presentation within 12 months. There were only 14 re-presentations (0.2%) where the diagnosis changed from non-serious LBP at the index visit to serious spinal pathology at the repeat visit. The overall mean LOS was 4.1 h, and 26.9% of patients stayed in the ED for >4 h. Those who received opioids (aOR: 1.31; 95% CI: 1.08-1.59) were more likely to re-present. In contrast, patients receiving imaging were less likely to re-present (aOR: 0.78, 95% CI: 0.65-0.94). Receiving imaging (aOR: 2.83; 95% CI: 2.56-3.13) and opioids (aOR: 1.64; 95% CI: 1.47-1.82) increased the odds of prolonged stay. CONCLUSION A re-presentation within 12 months occurs in 7.7% of episodes of LBP in ED. Over one-quarter of patients stayed longer than 4 h.
Collapse
Affiliation(s)
- Xiaotian Xu
- Institute for Musculoskeletal Health, Sydney Local Heath District, Sydney, NSW, Australia; Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Qiuzhe Chen
- Institute for Musculoskeletal Health, Sydney Local Heath District, Sydney, NSW, Australia; Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Crystian B Oliveira
- Institute for Musculoskeletal Health, Sydney Local Heath District, Sydney, NSW, Australia; Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney Local Heath District, Sydney, NSW, Australia; Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, Sydney Local Heath District, Sydney, NSW, Australia; Sydney Musculoskeletal Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
2
|
Yilmaz Muluk S, Olcucu N. Comparative Analysis of Artificial Intelligence Platforms: ChatGPT-3.5 and GoogleBard in Identifying Red Flags of Low Back Pain. Cureus 2024; 16:e63580. [PMID: 39087174 PMCID: PMC11290316 DOI: 10.7759/cureus.63580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Low back pain (LBP) is a prevalent healthcare concern that is frequently responsive to conservative treatment. However, it can also stem from severe conditions, marked by 'red flags' (RF) such as malignancy, cauda equina syndrome, fractures, infections, spondyloarthropathies, and aneurysm rupture, which physicians should be vigilant about. Given the increasing reliance on online health information, this study assessed ChatGPT-3.5's (OpenAI, San Francisco, CA, USA) and GoogleBard's (Google, Mountain View, CA, USA) accuracy in responding to RF-related LBP questions and their capacity to discriminate the severity of the condition. METHODS We created 70 questions on RF-related symptoms and diseases following the LBP guidelines. Among them, 58 had a single symptom (SS), and 12 had multiple symptoms (MS) of LBP. Questions were posed to ChatGPT and GoogleBard, and responses were assessed by two authors for accuracy, completeness, and relevance (ACR) using a 5-point rubric criteria. RESULTS Cohen's kappa values (0.60-0.81) indicated significant agreement among the authors. The average scores for responses ranged from 3.47 to 3.85 for ChatGPT-3.5 and from 3.36 to 3.76 for GoogleBard for 58 SS questions, and from 4.04 to 4.29 for ChatGPT-3.5 and from 3.50 to 3.71 for GoogleBard for 12 MS questions. The ratings for these responses ranged from 'good' to 'excellent'. Most SS responses effectively conveyed the severity of the situation (93.1% for ChatGPT-3.5, 94.8% for GoogleBard), and all MS responses did so. No statistically significant differences were found between ChatGPT-3.5 and GoogleBard scores (p>0.05). CONCLUSIONS In an era characterized by widespread online health information seeking, artificial intelligence (AI) systems play a vital role in delivering precise medical information. These technologies may hold promise in the field of health information if they continue to improve.
Collapse
Affiliation(s)
| | - Nazli Olcucu
- Physical Medicine and Rehabilitation, Antalya Ataturk State Hospital, Antalya, TUR
| |
Collapse
|
3
|
Capsey M, Ryan C, Mankelow J, Martin D. Utilisation and experience of emergency medical services by patients with back pain: A scoping review. Musculoskelet Sci Pract 2024; 71:102928. [PMID: 38574578 DOI: 10.1016/j.msksp.2024.102928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 01/16/2024] [Accepted: 03/07/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Back pain is recognised as a common reason for people to access emergency medical services (EMS). EMS focus on identifying and treating serious and life-threatening conditions. Back pain frequently has a non-specific cause, however back pain is also a symptom for potentially serious pathology best suited for management by EMS. OBJECTIVES This scoping review explores how and why patients with back pain access EMS, the care provided, and patients' and clinicians' perceptions of EMS. METHODS The established methodology advocated by the Joanna Briggs Institute was followed. Literature was identified via a comprehensive search of six databases as well as grey literature searching. Data was extracted to form a narrative review supported by summary tables and figures. RESULTS The review included 144 papers across the last 36 years, with half the papers published since 2018, the majority from the USA and Australia. Rates of back pain presentation range from 1 to 9% depending on the definition used, with the rate of serious pathology higher than in primary care. Patients present due to concerns about their condition, positive perceptions of the care provided by EMS and difficulty in accessing primary care. Imaging and opioids are widely used, blood markers may aid diagnosis of serious pathology, whilst physiotherapists in Emergency Departments may support management of patients without serious pathology. CONCLUSIONS Back pain is a common reason for EMS presentation. Whilst non-specific back pain is the most common diagnosis further research to support the recognition and care of serious cases would be beneficial.
Collapse
Affiliation(s)
- Matt Capsey
- Institute of Health, University of Cumbria, Bowerham Road, Lancaster, LA1 3JD, UK; School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX , UK.
| | - Cormac Ryan
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX, UK.
| | - Jagjit Mankelow
- School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX , UK.
| | - Denis Martin
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX, UK.
| |
Collapse
|
4
|
Schlicht F, Vosshenrich J, Donners R, Seifert AC, Fenchel M, Nickel D, Obmann M, Harder D, Breit HC. Advanced deep learning-based image reconstruction in lumbar spine MRI at 0.55 T - Effects on image quality and acquisition time in comparison to conventional deep learning-based reconstruction. Eur J Radiol Open 2024; 12:100567. [PMID: 38711678 PMCID: PMC11070664 DOI: 10.1016/j.ejro.2024.100567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024] Open
Abstract
Objectives To evaluate an optimized deep leaning-based image post-processing technique in lumbar spine MRI at 0.55 T in terms of image quality and image acquisition time. Materials and methods Lumbar spine imaging was conducted on 18 patients using a 0.55 T MRI scanner, employing conventional (CDLR) and advanced (ADLR) deep learning-based post-processing techniques. Two musculoskeletal radiologists visually evaluated the images using a 5-point Likert scale to assess image quality and resolution. Quantitative assessment in terms of signal intensities (SI) and contrast ratios was performed by region of interest measurements in different body-tissues (vertebral bone, intervertebral disc, spinal cord, cerebrospinal fluid and autochthonous back muscles) to investigate differences between CDLR and ADLR sequences. Results The images processed with the advanced technique (ADLR) were rated superior to the conventional technique (CDLR) in terms of signal/contrast, resolution, and assessability of the spinal canal and neural foramen. The interrater agreement was moderate for signal/contrast (ICC = 0.68) and good for resolution (ICC = 0.77), but moderate for spinal canal and neuroforaminal assessability (ICC = 0.55). Quantitative assessment showed a higher contrast ratio for fluid-sensitive sequences in the ADLR images. The use of ADLR reduced image acquisition time by 44.4%, from 14:22 min to 07:59 min. Conclusions Advanced deep learning-based image reconstruction algorithms improve the visually perceived image quality in lumbar spine imaging at 0.55 T while simultaneously allowing to substantially decrease image acquisition times. Clinical relevance Advanced deep learning-based image post-processing techniques (ADLR) in lumbar spine MRI at 0.55 T significantly improves image quality while reducing image acquisition time.
Collapse
Affiliation(s)
- Felix Schlicht
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Jan Vosshenrich
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Ricardo Donners
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Alina Carolin Seifert
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Matthias Fenchel
- Siemens Healthcare GmbH, Magnetic Resonance, Allee am Röthelheimpark 2, Erlangen 91052, Germany
| | - Dominik Nickel
- Siemens Healthcare GmbH, Magnetic Resonance, Allee am Röthelheimpark 2, Erlangen 91052, Germany
| | - Markus Obmann
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Dorothee Harder
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| | - Hanns-Christian Breit
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel 4031, Switzerland
| |
Collapse
|
5
|
Tanner L, Saywell NL, Adams T, Niazi IK, Hill J. Factors influencing imaging clinical decision-making in low back pain management. A scoping review. Musculoskeletal Care 2024; 22:e1898. [PMID: 38862275 DOI: 10.1002/msc.1898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The use of diagnostic imaging in low back pain (LBP) management is often inappropriate, despite recommendations from clinical practice guidelines. There is a limited understanding of factors that influence the imaging clinical decision-making (CDM) process. AIM Explore the literature on factors influencing imaging CDM for people with LBP and consider how these findings could be used to reduce inappropriate use of imaging in LBP management. DESIGN Scoping review. METHOD This review followed the Preferred Reporting Items for Systematic Review extension for scoping reviews. A digital search was conducted in Medline, the Cumulative Index of Nursing and Allied Health Literature, Scopus, and the Cochrane Central Register of Controlled Trials for eligible studies published between January 2010-2023. Data reporting influences on imaging CDM were extracted. Data were then analysed through an inductive process to group the influencing factors into categories. RESULTS After screening, 35 studies (5 qualitative and 30 quantitative) were included in the review, which reported factors influencing imaging CDM. Three categories were developed: clinical features (such as red flags, pain, and neurological deficit), non-modifiable factors (such as age, sex, and ethnicity) and modifiable factors (such as beliefs about consequences and clinical practice). Most studies reported non-modifiable factors. CONCLUSIONS The results of this scoping review challenge the perception that imaging CDM is purely based on clinical history and objective findings. There is a complex interplay between clinical features, patient and clinician characteristics, beliefs, and environment. These findings should be considered when designing strategies to address inappropriate imaging behaviour.
Collapse
Affiliation(s)
- Luke Tanner
- Clinical Physiotherapist, Auckland, New Zealand
| | - Nicola L Saywell
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
| | - Thomas Adams
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Imran Khan Niazi
- Research Innovation Centre, Auckland University of Technology, Auckland, New Zealand
- Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland, New Zealand
| | - Julia Hill
- Physiotherapy Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
- Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| |
Collapse
|
6
|
Giroux D, Branconnier C, Bussières A, Théroux J, Blanchette MA. Frequency and indication of non-musculoskeletal examinations: a cross-sectional survey of Quebec chiropractors. Chiropr Man Therap 2024; 32:6. [PMID: 38419063 PMCID: PMC10903024 DOI: 10.1186/s12998-023-00522-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/07/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Approximately 1% of low back pain is estimated to be caused by serious systemic diseases, including cancer, infection, or abdominal aortic dissection. This study aimed to determine the frequency of execution of non-MSK physical examination procedures among Quebec chiropractors and to identify the clinical context that prompts them to use these physical examination procedures. METHODS Cross-sectional survey containing 44 questions administered to a random sample of Quebec chiropractors using a succession of online, postal and phone questionnaires. The 4-part survey questionnaire contained six demographic questions, 28 single-choice questions to determine the frequency of execution of non-MSK physical examination procedures, seven short clinical vignettes for which the respondents had to select the non-MSK examinations that would be required, and two questions inquiring about the proportion of new patients for which participants' felt non-MSK examinations were necessary and whether appropriate assessments were performed. The questionnaire was pilot tested, and feedback received integrated prior to administration. We conducted descriptive statistics, Pearson correlations, and an ANOVA. RESULTS The survey was completed by 182 chiropractors (response rate: 36.4%). The most commonly non-musculoskeletal examination performed daily were blood pressure (12.1%) and cranial nerves (4.9%). The most common tests never performed were oxygen saturation (68.7%), cardiac auscultation (69.2%), tibio-brachial index (71.4%), breast (86.8%), rectal (96.7%), testicular (95.6%), and vaginal (99.9%) exams. Female chiropractors and Quebec University in Trois-Rivières graduates reported that a significantly higher proportion of their new patients required a non-musculoskeletal physical examination compared to male participants (37.2% vs 28.3%) or Canadian Memorial Chiropractic College graduates (33.9% vs 19.9%). Reason for not performing a physical examination included the belief that another healthcare professional was better positioned to perform and/or interpret the related tests (76.4%). CONCLUSIONS Vital signs and cranial nerve examinations were the most frequency performed non-musculoskeletal examinations reported by chiropractors. Apart from the genitourinary exam almost never performed, most participants chose non-musculoskeletal examinations deemed appropriate for the patient's presentation.
Collapse
Affiliation(s)
- Danikel Giroux
- Departement de Chiropratique, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada.
| | - Chloé Branconnier
- Departement de Chiropratique, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada
| | - André Bussières
- Departement de Chiropratique, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Jean Théroux
- School of Allied Health, Chiropractic Discipline, Murdoch University, Perth, WA, Australia
| | - Marc-André Blanchette
- Departement de Chiropratique, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, QC, Canada
| |
Collapse
|
7
|
Werthman AM, Jolley BD, Rivera A, Rusli MA. Emergency Department Management of Low Back Pain: A Comparative Review of Guidelines and Practices. Cureus 2024; 16:e53712. [PMID: 38455774 PMCID: PMC10919314 DOI: 10.7759/cureus.53712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
This narrative review examines the current best practices and guidelines for integrating pharmacologic interventions, imaging, and physiotherapy in the management of low back pain. The review also explores how patient factors such as age, sex, comorbidities, and prevalent pathologies/diagnoses influence the choice and effectiveness of these treatment approaches.
Collapse
Affiliation(s)
- Alec M Werthman
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| | - Brayden D Jolley
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| | - Andrew Rivera
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| | - Melissa A Rusli
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| |
Collapse
|
8
|
Shu S, Garrison GM. Spinal Gout: An Unusual Cause of Low Back Pain. J Prim Care Community Health 2024; 15:21501319241271907. [PMID: 39135504 PMCID: PMC11320678 DOI: 10.1177/21501319241271907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 08/15/2024] Open
Abstract
Low back pain is the most common musculoskeletal complaint accounting for over 30 million visits to primary care physicians annually. Serious pathology is found in less than 1% of these visits. Therefore it is often a challenge to distinguish worrisome findings requiring further workup and treatment from common complaints of pain. Gout is an inflammatory arthritis that most commonly affects the appendicular skeleton. It is characterized by the saturation of uric acid and deposition of monosodium urate crystals in joints and tissues. Spinal involvement is rare and is not typically considered on the differential diagnosis for a patient presenting with acute low back pain. We present such a case of a 35-year-old male who presented with intractable back pain, highlighting the need to recognize signs and symptoms that raise suspicion for spinal gout.
Collapse
|
9
|
Cattrysse E, den Broeck JV, Petroons R, Teugels A, Scafoglieri A, van Trijffel E. Impact of direct access on the quality of primary care musculoskeletal physiotherapy: a scoping review from a patient, provider, and societal perspective. Arch Physiother 2024; 14:20-28. [PMID: 38962745 PMCID: PMC11220609 DOI: 10.33393/aop.2024.3023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 06/05/2024] [Indexed: 07/05/2024] Open
Abstract
Introduction Worldwide many countries provide direct access in physiotherapy. The aim of this scoping review was to synthesize the available evidence on the quality of primary care musculoskeletal physiotherapy from different perspectives. Methods Systematic searches were conducted in three databases up to September 2022. Studies were included when regarding assessment of at least one of the following perspectives: patient (quality of Life, patient satisfaction, pain, functioning, adverse events), provider (treatment compliance, responsibility, liability, status, prestige, job satisfaction), and society (number of referrals, amount of medical imaging, medication use, number of sessions needed for rehabilitation, and overall costs and cost-effectiveness). Selection and methodological quality assessment of systematic reviews were performed. Data extraction and analysis were performed separately for systematic reviews and individual primary studies. Results Five systematic reviews as well as 17 primary studies were included. From a patient perspective, no significant effect of direct access was found for pain and a tendency in favour of direct access was found for quality of life, functioning, and well-being. Concerning providers, higher treatment compliance was found in direct access to physiotherapy and decision-making was more accurate. From a societal perspective, significant differences in favour of direct access physiotherapy were found for waiting time, prescribed medication, and medical imaging. In addition, there was a tendency towards lower health care costs. Conclusions Emerging evidence suggests that direct access physiotherapy could provide at least equal quality of care for patients and better opportunities for providers and the society on selected outcomes.
Collapse
Affiliation(s)
- Erik Cattrysse
- Experimental Anatomy Research group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
| | - Jona Van den Broeck
- Experimental Anatomy Research group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
| | - Robin Petroons
- Experimental Anatomy Research group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
| | - Amber Teugels
- Experimental Anatomy Research group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
| | - Aldo Scafoglieri
- Experimental Anatomy Research group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
| | - Emiel van Trijffel
- Experimental Anatomy Research group (EXAN), Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels - Belgium
- Ziekenhuisgroep Twente, ZGT Academy, Almelo - The Netherlands
| |
Collapse
|
10
|
Ellem R, Pickering R, Marks D, Todd J, Brown J, Roberts S, Michaleff ZA. Emergency presentations for older persons with low back pain: An increasing clinical and economic challenge. Australas J Ageing 2023; 42:742-750. [PMID: 37799007 DOI: 10.1111/ajag.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 08/07/2023] [Accepted: 08/23/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To determine whether differences exist for older persons presenting to Emergency Departments (EDs) with lower back pain (LBP) in terms of management, health service resource use and cost when compared to younger patients with LBP. METHODS Retrospective analysis of routinely collected electronic medical record data from January 2015 to July 2021. Data from 11,098 adults presenting with LBP to two large regional Australian EDs were analysed over a 5-year period. Rates of presentation, investigation, medication use, spinal surgery and cost were assessed for all participants with respect to age groups (over or under 65 years of age), diagnosis and time. Multivariable logistic regression analysis was employed to assess the contribution of presentation characteristics to the risk of inpatient admission and to investigate the variable effect of patient age. RESULTS Older people represented 23% (n = 2565) of all LBP presentations, with a growing proportion of presentations over time. More than 1 in 4 patients over 65 were admitted (n = 703, 27%), with CT imaging being proportionately three times more prevalent (24% vs. 6%), and average cost double (AU$3973 vs. $1671) that of the younger population. Consultation by an ED physiotherapist was associated with lower admission risk across all adult presentations (OR 0.52, 95% CI [0.40 to 0.67]). CONCLUSIONS Older persons are over-represented amongst gradually increasing rates of LBP presentations to EDs and associated with escalating cost of care and hospital resource use. Older patients present a different clinical and economic profile to younger patients, supporting the provision of individualised management recommendations.
Collapse
Affiliation(s)
- Rod Ellem
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Rowan Pickering
- Bond Institute of Health Sciences, Bond University, Gold Coast, Queensland, Australia
| | - Darryn Marks
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- Bond Institute of Health Sciences, Bond University, Gold Coast, Queensland, Australia
| | - James Todd
- Bond Institute of Health Sciences, Bond University, Gold Coast, Queensland, Australia
| | - Jarryd Brown
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Shelley Roberts
- Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- School of Health Science and Social Work, Griffith University, Nathan, Queensland, Australia
| | - Zoe A Michaleff
- Faculty of Health Sciences and Medicine, Bond University, Robina, Queensland, Australia
- New South Wales Health, St. Leonards, New South Wales, Australia
| |
Collapse
|
11
|
Truter P, Attwooll L, Flanagan P, McGinty C, Taylor R, Hince D, Wand BM. Comparing multi-disciplinary low back pain care in the ED to the Australian clinical care standard: The possible influence of profession, experience and back pain beliefs. Int Emerg Nurs 2023; 71:101351. [PMID: 37757581 DOI: 10.1016/j.ienj.2023.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/12/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Piers Truter
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia; School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA 6160, Australia.
| | - Lydia Attwooll
- School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA 6160, Australia
| | - Pippa Flanagan
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia; School of Allied Health, Curtin University, Perth, WA 6845, Australia
| | - Casey McGinty
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia
| | - Rosalind Taylor
- Fiona Stanley Hospital, Emergency Department, Perth, Murdoch, WA 6150, Australia
| | - Dana Hince
- Institute of Health Research, The University of Notre Dame Australia, Fremantle, WA 6160, Australia
| | - Benedict M Wand
- School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, WA 6160, Australia
| |
Collapse
|
12
|
Breit HC, Vosshenrich J, Hofmann V, Rusche T, Kovacs BK, Bach M, Manneck S, Harder D. Image Quality of Lumbar Spine Imaging at 0.55T Low-Field MRI is Comparable to Conventional 1.5T MRI - Initial Observations in Healthy Volunteers. Acad Radiol 2023; 30:2440-2446. [PMID: 36841743 DOI: 10.1016/j.acra.2023.01.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/29/2023] [Accepted: 01/29/2023] [Indexed: 02/27/2023]
Abstract
RATIONALE AND OBJECTIVES To assess the potential of 0.55T low-field MRI system in lumbar spine imaging with and without the use of additional advanced postprocessing techniques. MATERIALS AND METHODS The lumbar spine of 14 volunteers (32.9 ± 3.6 years) was imaged both at 0.55T and 1.5T using sequences from clinical routine. On the 0.55T scanner system, additional sequences with simultaneous multi-slice acquisition and artificial intelligence-based postprocessing techniques were acquired. Image quality of all 28 examinations was assessed by three musculoskeletal radiologists with respect to signal/contrast, resolution, and assessability of the spinal canal and neuroforamina using a 5-point Likert scale (1 = non-diagnostic to 5 = perfect quality). Interrater agreement was evaluated with the Intraclass Correlation Coefficient and the Mann-Whitney U test (significance level: p < 0.05). RESULTS Image quality at 0.55T was rated lower on the 5-point Likert scale compared to 1.5T regarding signal/contrast (mean: 4.16 ± 0.29 vs. 4.54 ± 0.29; p < 0.001), resolution (4.07 ± 0.31 vs. 4.49 ± 0.30; p < 0.001), assessability of the spinal canal (4.28 ± 0.13 vs. 4.73 ± 0.26; p < 0.001) and the neuroforamina (4.14 ± 0.28 vs. 4.70 ± 0.27; p < 0.001). Image quality for the AI-processed sagittal T1 TSE and T2 TSE at 0.55T was also rated slightly lower, but still good to perfect with a concomitant reduction in measurement time. Interrater agreement was good to excellent (range: 0.60-0.91). CONCLUSION While lumbar spine image quality at 0.55T is perceived inferior to imaging at 1.5T by musculoskeletal radiologists, good overall examination quality was observed with high interrater agreement. Advanced postprocessing techniques may accelerate intrinsically longer acquisition times at 0.55T.
Collapse
Affiliation(s)
- Hanns-Christian Breit
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Jan Vosshenrich
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
| | - Verena Hofmann
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Thilo Rusche
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Balázs K Kovacs
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Michael Bach
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Sebastian Manneck
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Radiology, Gesundheitszentrum Fricktal AG, Rheinfelden, Switzerland
| | - Dorothee Harder
- Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| |
Collapse
|
13
|
Osterhoff G, Rappert D, Scheyerer MJ, Disch AC, Ullrich BW, Spiegl UA, Schnake KJ. [Value of routine transpedicular biopsies in kyphoplasty and vertebroplasty for vertebral compression fractures : A survey among 250 spine surgeons]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:873-879. [PMID: 35838762 PMCID: PMC10627954 DOI: 10.1007/s00113-022-01210-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Transpedicular cement augmentation is an established therapeutic option in the treatment of pathologic compression fractures of the spine. In addition to osteoporosis, underlying metastatic diseases or, more rarely, a primary bone tumor are recurrent causes of vertebral compression fractures without adequate trauma. OBJECTIVE To obtain a current opinion among spine surgeons in Germany, Switzerland, and Austria on the value of transpedicular biopsy during kyphoplasty and vertebroplasty of vertebral body fractures. MATERIAL AND METHODS A web-based (UmfrageOnline®) questionnaire with 11 questions was created and sent to the email distribution lists of the German Spine Society (DWG), the Austrian Society for Spine Surgery (spine.at), and the Swiss Society for Spinal Surgery (SGS), as well as to the email distribution list of the Spine Section of the German Society for Orthopedics and Trauma Surgery (DGOU). RESULTS Of a total of 2675 spine surgeons contacted 250 (9.3%) responded to the survey. Approximately one third (29.8%) of respondents regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Reasons cited for biopsy were image morphology (79.7%) or history of suspected (66.0%) or present (71.4%) tumor disease. Reasons cited against routine biopsy were the associated costs and the limited informative value of the biopsies obtained. DISCUSSION Nearly one third of the spine surgeons surveyed regularly perform a transpedicular biopsy with each kyphoplasty or vertebroplasty. Almost all respondents perform biopsies at least when there is an imaging morphologic suspicion of tumor disease or tumor disease is known or suspected based on risk factors. Future studies need to further clarify the cost-effectiveness of transpedicular biopsy.
Collapse
Affiliation(s)
- Georg Osterhoff
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - Denis Rappert
- Interdisziplinäres Zentrum f. Wirbelsäulen- und Skoliosetherapie, Malteser Waldkrankenhaus St., Marien Rathsberger Str. 57, 91054, Erlangen, Deutschland
| | - Max J Scheyerer
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Medizinische Fakultät und Uniklinik Köln, Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Alexander C Disch
- UniversitätsWirbelsäulenzentrum (UCSC), UniversitätsCentrum für Orthopädie, Unfall- & Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Fiedlerstraße 19, 01307, Dresden, Deutschland
| | - Bernhard W Ullrich
- Klinik für Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost GgmbH Halle, Merseburger Straße 165, 06112, Halle (Saale), Deutschland
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Jena, Friedrich Schiller Universität Jena, 07747, Jena, Deutschland
| | - Ulrich A Spiegl
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland
| | - Klaus J Schnake
- Interdisziplinäres Zentrum f. Wirbelsäulen- und Skoliosetherapie, Malteser Waldkrankenhaus St., Marien Rathsberger Str. 57, 91054, Erlangen, Deutschland
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Nürnberg Süd, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg, Deutschland
| |
Collapse
|
14
|
Cai AG, Zocchi MS, Carlson JN, Bedolla J, Pines JM. Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess. Acad Emerg Med 2023; 30:995-1001. [PMID: 37326026 DOI: 10.1111/acem.14765] [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: 01/12/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Spinal epidural abscess (SEA) is a rare, catastrophic condition for which diagnostic delays are common. Our national group develops evidence-based guidelines, known as clinical management tools (CMT), to reduce high-risk misdiagnoses. We study whether implementation of our back pain CMT improved SEA diagnostic timeliness and testing rates in the emergency department (ED). METHODS We conducted a retrospective observational study before and after implementation of a nontraumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (January 2016-June 2017) and after (January 2018-December 2019) with 95% confidence intervals (CIs) clustered by facility. We graphed monthly testing rates. RESULTS In 59 EDs, pre versus post periods included 141,273 (4.8%) versus 192,244 (4.5%) back pain visits and 188 versus 369 SEA visits, respectively. After implementation, SEA visits with prior related visits were unchanged (12.2% vs. 13.3%, difference +1.0%, 95% CI -4.5% to 6.5%). Mean number of days to diagnosis decreased but not significantly (15.2 days vs. 11.9 days, difference -3.3 days, 95% CI -7.1 to 0.6 days). Back pain visits receiving CT (13.7% vs. 21.1%, difference +7.3%, 95% CI 6.1% to 8.6%) and MRI (2.9% vs. 4.4%, difference +1.4%, 95% CI 1.0% to 1.9%) increased. Spine X-rays decreased (22.6% vs. 20.5%, difference 2.1%, 95% CI -4.3% to 0.1%). Back pain visits receiving erythrocyte sedimentation rate or C-reactive protein increased (1.9% vs. 3.5%, difference +1.6%, 95% CI 1.3% to 1.9%). CONCLUSIONS Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.
Collapse
Affiliation(s)
- Angela G Cai
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- US Acute Care Solutions, Canton, Ohio, USA
| | - Mark S Zocchi
- Department of Health Policy, Heller School for Social Policy and Management, Waltham, Massachusetts, USA
| | - Jestin N Carlson
- US Acute Care Solutions, Canton, Ohio, USA
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - John Bedolla
- US Acute Care Solutions, Canton, Ohio, USA
- Department of Emergency Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Jesse M Pines
- US Acute Care Solutions, Canton, Ohio, USA
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Jermini-Gianinazzi I, Blum M, Trachsel M, Trippolini MA, Tochtermann N, Rimensberger C, Liechti FD, Wertli MM. Management of acute non-specific low back pain in the emergency department: do emergency physicians follow the guidelines? Results of a cross-sectional survey. BMJ Open 2023; 13:e071893. [PMID: 37541755 PMCID: PMC10407374 DOI: 10.1136/bmjopen-2023-071893] [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] [Received: 01/20/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVES Clinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED). SETTING We invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations. RESULTS In total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions. CONCLUSION Management of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.
Collapse
Affiliation(s)
- Ilaria Jermini-Gianinazzi
- Emergency Department, Ospedale Regionale di Bellinzona e Valli Bellinzona, Bellinzona, Ticino, Switzerland
| | - Manuel Blum
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria Trachsel
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maurizio Alen Trippolini
- School of Health Professions, Berne University of Applied Sciences, Bern, Switzerland
- Evidence-based Insurance Medicine (EbIM), Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Nicole Tochtermann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Caroline Rimensberger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabian Dominik Liechti
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, Kantonsspital Baden AG, Baden, Aargau, Switzerland
| |
Collapse
|
17
|
Oliveira CB, Coombs D, Machado GC, McCaffery K, Richards B, Pinto RZ, O'Keeffe M, Maher CG, Christofaro DGD. Process evaluation of the implementation of an evidence-based model of care for low back pain in Australian emergency departments. Musculoskelet Sci Pract 2023; 66:102814. [PMID: 37421758 DOI: 10.1016/j.msksp.2023.102814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND The Sydney Health Partners Emergency Department (SHaPED) trial targeted ED clinicians and evaluated a multifaceted strategy to implement a new model of care. The objective of this study was to investigate attitudes and experiences of ED clinicians as well as barriers and facilitators for implementation of the model of care. DESIGN A qualitative study. METHODS The EDs of three urban and one rural hospital in New South Wales, Australia participated in the trial between August and November 2018. A sample of clinicians was invited to participate in qualitative interviews via telephone and face-to-face. The data collected from the interviews were coded and grouped in themes using thematic analysis methods. RESULTS Non-opioid pain management strategies (i.e., patient education, simple analgesics, and heat wraps) were perceived to be the most helpful strategy for reducing opioid use by ED clinicians. However, time constraints and rotation of junior medical staff were seen as the main barriers for uptake of the model of care. Fear of missing a serious pathology and the clinicians' conviction of a need to provide something for the patient were seen as barriers to reducing lumbar imaging referrals. Other barriers to guideline endorsed care included patient's expectations and characteristics (e.g., older age and symptoms severity). CONCLUSIONS Improving knowledge of non-opioid pain management strategies was seen as a helpful strategy for reducing opioid use. However, clinicians also raised barriers related to the ED environment, clinicians' behaviour, and cultural aspects, which should be addressed in future implementation efforts.
Collapse
Affiliation(s)
- Crystian B Oliveira
- Faculty of Medicine, University of Western São Paulo (Unoeste), Presidente Prudente, Sao Paulo, Brazil; Departamento de Fisioterapia, Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista, Presidente Prudente, Brazil; Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia.
| | - Danielle Coombs
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kirsten McCaffery
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Bethan Richards
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; Department of Rheumatology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rafael Z Pinto
- Departamento de Fisioterapia, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Diego G D Christofaro
- Departamento de Educação Física, Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista, Presidente Prudente, Brazil
| |
Collapse
|
18
|
Meidinger P, Kéchichian A, Pinsault N. A Model of Triage of Serious Spinal Pathologies and Therapeutic Options Based on a Delphi Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1283. [PMID: 37512094 PMCID: PMC10383224 DOI: 10.3390/medicina59071283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: The relevance of red flags in serious spinal pathology (SSP) has evolved throughout the last years. Recently, new considerations have been proposed to expand the consideration of red flags. The purpose of this study was to determine, approve and test a model for the triage and management process of SSPs based on the latest data available in the literature. Materials and Methods: The SSP model was initially built on the basis of a literature review. The model was further determined and approved by an expert panel using a Delphi process. Finally, clinical scenarios were used to test the applicability of the model. Results: After three rounds of the Delphi process, panellists reached a consensus on a final version of the model. The use of clinical scenarios by experts brought about reflexive elements both for the determined model and for the SSPs depicted in the clinical cases. Conclusions: The validation of the model and its implementation in the clinical field could help assess the skills of first-line practitioners managing spinal pain patients. To this end, the development of additional clinical scenarios fitting the determined model should be further considered.
Collapse
Affiliation(s)
- Philippe Meidinger
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| | - Amélie Kéchichian
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| | - Nicolas Pinsault
- TIMC-IMAG UMR CNRS 5525, ThEMAS Team, Université Grenoble Alpes, Domaine de la Merci, 5 Avenue du Grand Sablon, 38700 La Tronche, France
| |
Collapse
|
19
|
Miękisiak G. Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1255. [PMID: 37512066 PMCID: PMC10384667 DOI: 10.3390/medicina59071255] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/25/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain.
Collapse
Affiliation(s)
- Grzegorz Miękisiak
- Institute of Medicine, University of Opole, 45-040 Opole, Poland
- Vratislavia Medica Hospital, 51-134 Wrocław, Poland
| |
Collapse
|
20
|
Mathieu J, Pasquier M, Descarreaux M, Marchand AA. Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews. J Clin Med 2023; 12:jcm12103581. [PMID: 37240687 DOI: 10.3390/jcm12103581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 05/28/2023] Open
Abstract
Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.
Collapse
Affiliation(s)
- Janny Mathieu
- Department of Anatomy, Université du Québec à Trois-Rivières, 3351, Boul. des Forges, C.P. 500, Trois-Rivieres, QC G8Z 4M3, Canada
| | - Mégane Pasquier
- Institut Franco-Européen de Chiropraxie, 72 Chemin de la Flambère, 31300 Toulouse, France
| | - Martin Descarreaux
- Department of Human Kinetics, Université du Québec à Trois-Rivières, 3351, Boul. des Forges, C.P. 500, Trois-Rivières, QC G8Z 4M3, Canada
| | - Andrée-Anne Marchand
- Department of Chiropractic, Université du Québec à Trois-Rivières, 3351, Boul. des Forges, C.P. 500, Trois-Rivières, QC G8Z 4M3, Canada
| |
Collapse
|
21
|
Kimber D, Pigott T. Cauda equina screening in Physiotherapy: A qualitative study of physiotherapists in a community musculoskeletal service: Are we asking the right questions and are we asking the questions right? Musculoskelet Sci Pract 2023; 65:102773. [PMID: 37201228 DOI: 10.1016/j.msksp.2023.102773] [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: 01/11/2023] [Revised: 04/11/2023] [Accepted: 05/03/2023] [Indexed: 05/20/2023]
Abstract
Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition. Thirty physiotherapists working in a community musculoskeletal service were purposively sampled and participated in semi-structured interviews. Data was transcribed and thematically analysed. All participants routinely asked bladder, bowel function and saddle anaesthesia screening questions although only 9 routinely asked about sexual function. Whether questions are asked in the correct way has never been studied. Sufficient depth of questioning, using lay terminology and explicit language was achieved by two-thirds of participants. Less than half of the participants framed the questions before asking them and only 5 participants combined all four dimensions. Whilst most clinicians felt comfortable asking general CES questions, half reported feeling uncomfortable when asking about sexual function. Issues around; gender, culture and language were also highlighted. Four main themes emerged from this study; i) Physiotherapists ask the right questions but frequently omit sexual function questions, ii) mostly, Physiotherapists ask CES questions in a way that patients understand however, there needs to be improvement in framing the context of the questions, iii) Physiotherapists generally feel comfortable with CES screening but there is some awkwardness surrounding discussion of sexual function and iv) Physiotherapists perceive there to be barriers to effective CES screening caused by culture and language.
Collapse
Affiliation(s)
- Damien Kimber
- MSK Service, Birmingham Community Healthcare NHS Trust, 1 Priestley Wharf, Holt Street, Aston, Birmingham, B7 4BN, UK.
| | - Tim Pigott
- Trauma & Orthopaedics, University of Salford School of Health & Society, The Crescent, Salford, M5 4WT, UK
| |
Collapse
|
22
|
Osterhoff G, Kreinest M, Kuhnt T, Pohlenz C, Müller-Broich J, Röllig C, Teipel R, Scheyerer MJ, Schnake KJ, Spiegl UJA, Disch AC. Management of Pathological Thoracolumbar Vertebral Fractures in Patients With Multiple Myeloma: Multidisciplinary Recommendations. Global Spine J 2023; 13:85S-93S. [PMID: 37084345 PMCID: PMC10177308 DOI: 10.1177/21925682221143732] [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] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Mutlidisciplinary consensus recommendations for patients suffering from multiple myeloma (MM) involvement of the spinal column by the Spine Section of the German Association of Orthopaedic and Trauma Surgeons. OBJECTIVE To provide a comprehensive multidisciplinary diagnostic and therapeutic approach and to summarize the current literature on the management of pathological thoracolumbar vertebral fractures in patients with multiple myeloma. METHODS Multidisciplinary recommendations using a classical consensus process provided by radiation oncologists, medical oncologists, orthopaedic- and trauma surgeons. A narrative literature review of the current diagnostic and treatment strategies was conducted. RESULTS Treatment decision has to be driven by a multidisciplinary team of oncologists, radiotherapists and spine surgeons. When considering surgery in MM patients, differing factors compared to other secondary spinal lesions have to be included into the decision process: probable neurological deterioration, the stage of the disease and prognosis, patient's general condition, localization and number of the lesions as well as patient's own wishes or expectations. Aiming to improve quality of life, the major goal of surgical treatment is to preserve mobility by reducing pain, secure neurological function and stability. CONCLUSION The goal of surgery is primarily to improve quality of life by restoring stability and neurological function. Interventions with an increased risk of complications due to MM-associated immunodeficiency must be avoided whenever feasible to allow early systemic treatment. Hence, treatment decisions should be based on a multidisciplinary team that considers patient's constitution and prognosis.
Collapse
Affiliation(s)
- Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | | | - Thomas Kuhnt
- Department of Imaging and Radiation Medicine, Clinic of Radiooncology, University of Leipzig, Leipzig, Germany
| | - Claudia Pohlenz
- Department of Imaging and Radiation Medicine, Clinic of Radiooncology, University of Leipzig, Leipzig, Germany
| | | | - Christoph Röllig
- Medizinische Klinik und Poliklinik I, Universitätsklinikum, Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Raphael Teipel
- Medizinische Klinik und Poliklinik I, Universitätsklinikum, Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Max J Scheyerer
- Department of Orthopaedics and Trauma Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Klaus John Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Ulrich J A Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Alexander C Disch
- University Comprehensive Spine Center, University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at the TU Dresden, Dresden, Germany
| |
Collapse
|
23
|
Osterhoff G, Scheyerer MJ, Spiegl UJA, Schnake KJ. The role of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures in the detection of malignant diseases: a systematic review. Arch Orthop Trauma Surg 2023; 143:1887-1893. [PMID: 35233719 PMCID: PMC10030449 DOI: 10.1007/s00402-022-04392-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 02/12/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Procedures like kyphoplasty or vertebroplasty have become an established treatment option for vertebral compression fractures (VCF). The transpedicular approach used during these procedures allows to take biopsies from the affected vertebral body. The aim of this study was to systematically summarize the existing knowledge on the value of routine transpedicular biopsies during kyphoplasty or vertebroplasty for vertebral compression fractures. METHODS A systematic review of the literature using PubMed/Medline databases with the goal of finding all articles describing the value trans-pedicular biopsies for detecting primary bone tumors, metastases, bone diseases, or spondylitis in patients with vertebral compression fractures was performed. Search terms were (*biopsy/ OR biops*.ti,ab.) AND (vertebral compression fracture*.ti,ab.). RESULTS Sixteen articles met the inclusion criteria, among these were six prospective and ten retrospective case series. Publication dates ranged from 2005 to 2020. A total of 3083 patients with 3667 transpedicular biopsies performed were included. Most biopsies confirmed osteoporosis as the dominant underlying pathology of VCFs. Transpedicular biopsies revealed an unexpected malignant diagnosis in 0.4-6% of the cases. CONCLUSION Routine transpedicular biopsies during kyphoplasty or vertebroplasty detect unexpected malignant lesions in 0.4-6% of the patients, even though the definition of "unexpected" varies among the analyzed studies. The evidence to support a routine biopsy is inconsistent. Nevertheless, routine biopsies can be considered, especially when sufficient preoperatvie imaging is not available or radiological findings are unclear.
Collapse
Affiliation(s)
- Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany.
| | - Max J Scheyerer
- Department of Orthopedics and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ulrich J A Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103, Leipzig, Germany
| | - Klaus J Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| |
Collapse
|
24
|
Capsey M, Ryan C, Mankelow J, Alexanders J, Martin D. Emergency department use by people with back pain: An investigation. Br J Pain 2023; 17:28-35. [PMID: 36815064 PMCID: PMC9940253 DOI: 10.1177/20494637221119924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Demand on emergency departments (EDs) is rising, at least in part due to patients with conditions suitable for management in primary care. Pain experienced in the back region is a common reason for patients to seek help and much of the established literature on back pain suggests serious pathologies are rare and the majority of patients can be safely treated in primary care. Emerging international data suggests that patients who present to ED complaining of back pain do not reflect those in primary care, with a higher rate of serious pathologies and non-spinal causes. This exploratory study seeks to quantify the prevalence of people attending ED with back pain, to describe their characteristics and the characteristics of their attendance. Methods This observational study is a retrospective analysis of patients attending EDs within an NHS Trust in the North East of England presenting with back pain from 1/10/2017 to 30/09/2018. Results Of 212,020 attendances, 3872 (2%) patients presented complaining of back pain on arrival. 36% of patients had no official diagnosis recorded, 5% were categorised as having a potentially serious spinal pathology, 22% had a non-spinal pathology diagnosis and 23% were categorised as simple backache. The majority (56%) had no recorded investigations, 19% received plain radiography, 5% received either CT/MRI, 18% had blood investigations and 17% had cardiac monitoring or electrocardiogram. Most individuals self-presented. NHS 111, primary care and community care referrals accounted for 24% of attendances. Conclusion Back pain was a relatively common ED attendance and represented a variety of conditions including non-spinal causes. This suggests that the population of patients with back pain attending ED are a different subgroup to those presenting to primary care. Care should be taken applying primary care guidance to this group and there may be a need for emergency care specific back pain guidelines.
Collapse
Affiliation(s)
- Matt Capsey
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK,Matt Capsey, School of Health and Life Sciences, Teesside University, Southfield Road, Middlesbrough, Tees Valley TS1 3BX, UK.
| | - Cormac Ryan
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Jagjit Mankelow
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Jenny Alexanders
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Denis Martin
- Centre for Rehabilitation, School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| |
Collapse
|
25
|
Thalmann NF, Rimensberger C, Blum MR, Liechti FD, Wertli MM. [Internal differential diagnoses in acute back pain : An internal perspective on the possible causes of acute back pain]. Z Rheumatol 2023; 82:3-9. [PMID: 36094629 PMCID: PMC9894948 DOI: 10.1007/s00393-022-01257-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 02/06/2023]
Abstract
The majority of patients with acute back pain have no serious underlying disease; however, many internal diseases can be manifested as acute or chronic back pain. Therefore, in the assessment of patients with back pain the clinical history and clinical examination are important in order to detect indications for a possible underlying disease. Particularly red flags that indicate an acute or life-threatening disease should not be missed. In most cases where such red flags, risk factors or clinical indications are not present, no systematic search for internal underlying diseases is necessary. This article summarizes the most relevant differential diagnoses and clinical indications as well as warning symptoms.
Collapse
Affiliation(s)
- Nicolas F Thalmann
- Allgemeine Innere Medizin, Universitätsspital Bern, Inselspital, Freiburgstr. 18, 3010, Bern, Schweiz.
| | - Caroline Rimensberger
- Allgemeine Innere Medizin, Universitätsspital Bern, Inselspital, Freiburgstr. 18, 3010, Bern, Schweiz
| | - Manuel R Blum
- Allgemeine Innere Medizin, Universitätsspital Bern, Inselspital, Freiburgstr. 18, 3010, Bern, Schweiz
- Berner Institut für Hausarztmedizin (BIHAM), Universität Bern, Mittelstr. 43, 3012, Bern, Schweiz
| | - Fabian D Liechti
- Allgemeine Innere Medizin, Universitätsspital Bern, Inselspital, Freiburgstr. 18, 3010, Bern, Schweiz
| | - Maria M Wertli
- Allgemeine Innere Medizin, Universitätsspital Bern, Inselspital, Freiburgstr. 18, 3010, Bern, Schweiz
- Departement Innere Medizin, Kantonsspital Baden, Im Ergel 1, 5404, Baden, Schweiz
| |
Collapse
|
26
|
Jia J, Chen C, Wang P. Evaluation of biopsy results during vertebral augmentation in patients with a known history of malignancy. Eur Radiol 2022; 33:4422-4428. [PMID: 36478121 DOI: 10.1007/s00330-022-09291-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate biopsy results during vertebral augmentation in vertebral compression fracture (VCF) patients with a known history of malignancy. METHODS An analysis of vertebral augmentation between 2012 and 2021 was performed retrospectively. Each level of VCF was biopsied, and all biopsies were sent for histopathological analyses. Imaging evaluation was performed in collaboration with an oncologist, a spine surgeon, and a radiologist. Patients were divided into two groups based on the preoperative imaging findings. Malignant VCF (MVCF) was presumed in group A, while osteoporotic VCF (OVCF) was presumed in group B. RESULTS One hundred and fifty-six VCF patients with a known history of malignancy were included. Group A included 91 patients with preoperative imaging findings suspicious for MVCF. And 73 patients were finally diagnosed as MVCF, with biopsy results confirming imaging findings. The incidence of MVCF was 46.8%. Group B included 65 patients with imaging evidence of OVCF. And all biopsy results were negative for malignancy. The sensitivity of imaging evaluation for finding MVCF was 100%, and the specificity was 78.3%. CONCLUSION A combination of X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) is sufficient to distinguish MVCF from OVCF. Biopsy is not required to confirm the diagnosis during vertebral augmentation, if the imaging findings do not indicate MVCF in patients with a known history of malignancy. It is recommended to perform a biopsy in patients with preoperative imaging findings suspicious for MVCF. KEY POINTS • A combination of X-ray, CT, and MRI is sufficient to distinguish MVCF from OVCF. • Biopsy is not required in patients without imaging signs of MVCF. • Biopsy is recommended in patients with imaging findings suspicious for MVCF.
Collapse
|
27
|
Andreoletti F, Maselli F, Storari L, Vongher A, Erbesato M, Testa M, Turolla A. Screening for Referral of Serious Pathology by Physical Examination Tests in Patients with Back or Chest Pain: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192416418. [PMID: 36554298 PMCID: PMC9779291 DOI: 10.3390/ijerph192416418] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/16/2022] [Accepted: 11/24/2022] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To investigate the most common physical examination tests (PET) for the screening for referral of patients with back or chest pain caused by serious pathology. METHODS A systematic review was conducted. Searches were performed on seven electronic databases between June 2020 and December 2021. Only studies evaluating patients with back and/or chest pain with clear reporting of PETs and prompt patient referrals were included. RESULTS 316 full texts were included, and these studies had a total of 474/492 patients affected by a serious disease. Only 26 studies of them described suspicion of serious disease due to at least one positive PET. Cardiac/pulmonary auscultation and heartbeats/blood pressure measurements were the most frequently reported tests. None of the reported studies included physiotherapists and chiropractors who reported the use of various tests, such as: cardiac and pulmonary auscultation, lung percussion, costovertebral angle tenderness, and lymph node palpation, highlighting a lack of attention in measuring vital parameters. On the contrary, doctors and nurses reported the assessment of the range of motion of the thoracolumbar spine and hip less frequently. CONCLUSIONS Appropriate reporting of PETs is sparse, and their utilization is heterogeneous among different healthcare professionals. Further primary studies are needed to describe PETs results in patients suffering from back and/or chest pain.
Collapse
Affiliation(s)
- Federico Andreoletti
- Departement of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genova-Campus of Savona, 17100 Savona, Italy
| | - Filippo Maselli
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence:
| | - Lorenzo Storari
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Andrea Vongher
- Departement of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genova-Campus of Savona, 17100 Savona, Italy
| | - Monica Erbesato
- Departement of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genova-Campus of Savona, 17100 Savona, Italy
| | - Marco Testa
- Departement of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genova-Campus of Savona, 17100 Savona, Italy
| | - Andrea Turolla
- Division of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, 40126 Bologna, Italy
| |
Collapse
|
28
|
Pennella D, Giagio S, Maselli F, Giovannico G, Roncone A, Fiorentino F, Brindisino F. Red flags useful to screen for gastrointestinal and hepatic diseases in patients with shoulder pain: A scoping review. Musculoskeletal Care 2022; 20:721-730. [PMID: 35229444 DOI: 10.1002/msc.1628] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION In most patients, shoulder pain has a neuromusculoskeletal cause. However, it might conceal other types of disorders, hiding a non-neuromusculoskeletal condition. The main aim of this scoping review is to map and summarise findings to identify red flags for gastrointestinal and hepatic diseases in the assessment of patients with shoulder pain. METHODS Five databases were searched up to 31 May 2021. Additional studies have been identified through grey literature, and the reference lists of the included studies have been screened. Any study design and publication type have been considered to be eligible for inclusion. No time, geographical setting and language restrictions have been applied. RESULTS A total of 157 records have been identified, with 40 studies meeting the inclusion criteria (37 case reports, 2 retrospective studies and 1 systematic review with meta-analysis). The most prevalent red flags associated with shoulder pain were abdominal pain (14 cases) and abdominal discomfort (3 cases), reported by 47% of patients. As for comorbidities, hepato-gastric, cardiac, visceral and systemic diseases were the most common ones. CONCLUSION Abdominal pain, right and left hypochondriac pain, and epigastric pain represent the most prevalent symptoms in patients with an abdominal disease that could mimic a shoulder problem. Clinicians should be encouraged to screen for red flags when assessing patients with shoulder pain.
Collapse
Affiliation(s)
- Denis Pennella
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Silvia Giagio
- Division of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Filippo Maselli
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile, Sciences (DINOGMI), Campus of Savona, University of Genova, Savona, Italy
| | - Giuseppe Giovannico
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Antonella Roncone
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Fabio Fiorentino
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| | - Fabrizio Brindisino
- Department of Medicine and Health Science "Vincenzo Tiberio", University of Molise, Campobasso, Italy
| |
Collapse
|
29
|
Whalen WM, Hawk C, Farabaugh RJ, Daniels CJ, Taylor DN, Anderson KR, Crivelli LS, Anderson DR, Thomson LM, Sarnat RL. Best Practices for Chiropractic Management of Adult Patients With Mechanical Low Back Pain: A Clinical Practice Guideline for Chiropractors in the United States. J Manipulative Physiol Ther 2022; 45:551-565. [PMID: 37341675 DOI: 10.1016/j.jmpt.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 02/12/2023] [Accepted: 04/12/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVE The purpose of this paper was to update the previously published 2016 best-practice recommendations for chiropractic management of adults with mechanical low back pain (LBP) in the United States. METHODS Two experienced health librarians conducted the literature searches for clinical practice guidelines and other relevant literature, and the investigators performed quality assessment of included studies. PubMed was searched from March 2015 to September 2021. A steering committee of 10 experts in chiropractic research, education, and practice used the most current relevant guidelines and publications to update care recommendations. A panel of 69 experts used a modified Delphi process to rate the recommendations. RESULTS The literature search yielded 14 clinical practice guidelines, 10 systematic reviews, and 5 randomized controlled trials (all high quality). Sixty-nine members of the panel rated 38 recommendations. All but 1 statement achieved consensus in the first round, and the final statement reached consensus in the second round. Recommendations covered the clinical encounter from history, physical examination, and diagnostic considerations through informed consent, co-management, and treatment considerations for patients with mechanical LBP. CONCLUSION This paper updates a previously published best-practice document for chiropractic management of adults with mechanical LBP.
Collapse
Affiliation(s)
| | - Cheryl Hawk
- Clinical Sciences, Texas Chiropractic College, Pasadena, Texas
| | | | - Clinton J Daniels
- Rehabilitation Care Services, VA Puget Sound Health Care System, Tacoma, Washington
| | - David N Taylor
- Clinical Sciences, Texas Chiropractic College, Pasadena, Texas
| | | | | | - Derek R Anderson
- Rehabilitation Care Services, VA Puget Sound Health Care System, Tacoma, Washington
| | | | | |
Collapse
|
30
|
C-reactive Protein-to-albumin Ratio in Spinal Epidural Abscess: Association with Post-treatment Complications. J Am Acad Orthop Surg 2022; 30:851-857. [PMID: 35984080 DOI: 10.5435/jaaos-d-22-00172] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Spinal epidural abscess (SEA) is a complex medical condition with high morbidity and healthcare costs. Clinical presentation and laboratory data may have prognostic value in forecasting morbidity and mortality. C-reactive protein-to-albumin ratio (CAR) demonstrates promise for the prediction of adverse events in multiple orthopaedic and nonorthopaedic surgical conditions. We investigated the relationship between CAR and outcomes after treatment of SEA. METHODS We retrospectively evaluated adult patients treated within a single healthcare system for a diagnosis of SEA (2005 to 2017). Laboratory and clinical data included age at diagnosis, sex, race, body mass index, smoking status, history of intravenous drug use, Charlson Comorbidity Index, and CAR. The primary outcome was the occurrence of any complication; mortality and readmissions were considered secondarily. We used logistic regression to determine the association between baseline CAR and outcomes, adjusting for confounders. RESULTS We included 362 patients with a 90-day mortality rate of 13.3% and a 90-day complication rate of 47.8%. A reduced complication rate was observed in the lowest decile of CAR values compared with the remaining 90% of patients, a threshold value of 2.5 (27.0% versus 50.2%; odds ratio [OR] 2.66, 95% confidence interval [CI] 1.22 to 5.81). CAR values in the highest two deciles experienced significantly increased odds of complications compared with the lowest decile (80th: OR 3.44; 95% CI 1.25 to 9.42; 90th: OR 3.28; 95% CI 1.19 to 9.04). DISCUSSION We found elevated CAR to be associated with an increased likelihood of major morbidity in SEA. We suggest using a CAR value of 2.5 as a threshold for enhanced surveillance and recognizing patients with values above 73.7 as being at exceptional risk of morbidity. LEVEL OF EVIDENCE Level III observational cohort study.
Collapse
|
31
|
Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Maher CG. Red flags to screen for vertebral fracture in patients presenting with low back pain. Hippokratia 2022. [DOI: 10.1002/14651858.cd014461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christopher S Han
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| | - Mark J Hancock
- 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
- Radiology and Neurological Surgery, Clinical Learning, Evidence And Research (CLEAR) Center; University of Washington School of Medicine; Seattle USA
| | - Bart W Koes
- Center for Muscle and Health; University of Southern Denmark; Odense Denmark
| | - 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 Australia
| | | | - Christopher G Maher
- Institute for Musculoskeletal Health; The University of Sydney and Sydney Local Health District; Sydney Australia
| |
Collapse
|
32
|
Emergency department evaluation, treatment, and functional outcomes among patients presenting with low back pain. Am J Emerg Med 2022; 59:37-41. [PMID: 35777258 DOI: 10.1016/j.ajem.2022.06.048] [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: 03/16/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Low back pain (LBP) leads to more than 4.3 million emergency department (ED) visits annually. Despite the number of ED visits for LBP, emergency medicine societies have not established clear guidelines for the evaluation and care of these patients. This study aims to describe patterns in the evaluation, treatment, and outcomes of patients presenting to an urban, academic ED for atraumatic LBP. METHODS We prospectively identified a convenience sample of patients presenting with LBP to the University of Utah Hospital ED between January 2017 and June 2018. We collected baseline demographic information and calculated the Patient-Reported Outcomes Measurement Information System Physical Function Short Form 12a (PROMIS PFSF-12a) score to assess patient function and mobility (50 = average PROMIS PFSF-12a score, with higher scores indicating better function). We contacted patients 6 weeks after the ED visit to assess outpatient follow-up and functional outcomes. RESULTS Over the 18-month study period, 103 patients presented with a chief complaint of LBP and agreed to participate in the study. Average age of the cohort was 48.5 years (SD = 18.3) and 55 (53.4%) were female. Notably, 61 patients (59.2%) had been seen previously in the ED for LBP and 32 (31.1%) had received an opioid for LBP in the preceding 3 months. In the ED, 35.9% of patient received an opioid while 18.5% had an opioid prescription at discharge. While in the ED, 37 (35.9%) had an x-ray and 47 (45.6%) underwent computed tomography or magnetic resonance imaging. At 6-week follow-up, 22 of 68 (32.4%) patients reported having missed work due to pain. PROMIS PFSF-12a score improved from 32.2 ("low" range) at time of ED visit to 42.0 ("low-average" range) at the 6-week follow up. Regarding outpatient follow-up after the ED visit, 22 patients (21.4%) saw a primary care provider, 12 patients (17.8%) saw orthopedics or neurosurgery, and 8 patients (11.8%) attended physical therapy. CONCLUSIONS Patients receiving ED care for LBP had a significant improvement in PROMIS PFSF-12a scores 6 weeks after the ED but return to function continued to lag despite interventions. Imaging patterns, medication prescriptions, and outpatient follow-up varied widely, emphasizing the needs for clear guidelines and treatment pathways for ED patients with LBP.
Collapse
|
33
|
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
| |
Collapse
|
34
|
Melman A, Maher CG, Needs C, Machado GC. Many people admitted to hospital with a provisional diagnosis of nonserious back pain are subsequently found to have serious pathology as the underlying cause. Clin Rheumatol 2022; 41:1867-1871. [PMID: 35015190 PMCID: PMC9119888 DOI: 10.1007/s10067-022-06054-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 12/30/2021] [Accepted: 01/03/2022] [Indexed: 11/27/2022]
Abstract
To determine the proportion of patients admitted to the hospital for back pain who have nonserious back pain, serious spinal, or serious other pathology as their final diagnosis. The proportion of nonserious back pain admissions will be used to plan for future 'virtual hospital' admissions. Electronic medical record data between January 2016 and September 2020 from three emergency departments (ED) in Sydney, Australia were used to identify inpatient admissions. SNOMED-CT-AU diagnostic codes were used to select ED patients aged 18 and older with an admitting diagnosis related to nonserious back pain. The inpatient discharge diagnosis was determined from the primary ICD-10-AM codes by two independent clinician-researchers. Inpatient admissions were then analysed by sociodemographic and hospital admission variables. A total of 38.1% of patients admitted with a provisional diagnosis of nonserious back pain were subsequently diagnosed with a specific pathology likely unsuitable for virtual care; 14.2% with a serious spinal pathology (e.g., fracture and infection) and 23.9% a serious pathology beyond the lumbar spine (e.g., pathological fracture and neoplasm). A total of 57% of admissions were identified as nonserious back pain, likely suitable for virtual care. A challenge for implementing virtual care in this setting is screening for patients with serious pathology. Protocols need to be developed to reduce the risk of patients being admitted to virtual hospitals with serious pathology as the cause of their back pain. Key Points • Among admitted patients provisionally diagnosed in ED with non-serious back pain, 38.1% were found to have 'serious spinal pathologies' or 'serious pathologies beyond the lumbar spine' at discharge. • Spinal fractures were the most common serious spinal pathology, accounting for 9% of all provisional 'non-serious back pain' admissions from ED. • 57% of back pain admissions were confirmed to be non-serious back pain and may be suitable to virtual hospital care; the challenge is discriminating these patients from those with serious pathology.
Collapse
Affiliation(s)
- Alla Melman
- Institute for Musculoskeletal Health, Sydney Local Health District and University of Sydney, Level 10N, King George V Building, Royal Prince Alfred Hospital PO Box M179, Missenden Road Camperdown, NSW, 2050, Sydney, Australia.
| | - Chris G Maher
- Institute for Musculoskeletal Health, Sydney Local Health District and University of Sydney, Level 10N, King George V Building, Royal Prince Alfred Hospital PO Box M179, Missenden Road Camperdown, NSW, 2050, Sydney, Australia
| | - Chris Needs
- Rheumatology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Gustavo C Machado
- Institute for Musculoskeletal Health, Sydney Local Health District and University of Sydney, Level 10N, King George V Building, Royal Prince Alfred Hospital PO Box M179, Missenden Road Camperdown, NSW, 2050, Sydney, Australia
| |
Collapse
|
35
|
Krasin E, Schermann H, Snir N, Tudor A, Behrbalk E. A Quick and Comprehensive Guide to Differential Diagnosis of Neck and Back Pain: a Narrative Review. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 4:232. [PMID: 36320816 PMCID: PMC9610337 DOI: 10.1007/s42399-022-01321-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
Abstract
The list of diagnostic options when approaching a patient with axial pain is impressively complex. Many offer limited diagnostic workups, but we could not find a truly comprehensive diagnostic guide to assist in the diagnostic evaluation. In this short paper, we briefly described a long list of medical conditions, each of which can manifest as back or neck pain, and whose prevalence ranges from common to very rare. We then proposed an algorithm for classifying them into subgroups. Further referral to diagnostic tests and specialist consultations, after assignment to one of those subgroups, could save time and unnecessary tests. We believe that this review and the proposed diagnostic algorithm can be valuable for medical education and for use in the primary care setting for the diagnostic evaluation of any type of back or neck pain in all patient groups.
Collapse
Affiliation(s)
- Elisha Krasin
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haggai Schermann
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nimrod Snir
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adrian Tudor
- Division of Orthopedic Surgery at Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Behrbalk
- Department of Orthopedic Surgery at Hillel Yaffe Medical Center, Hadera, Israel, affiliated with the Rappaport Faculty of Medicine, Technion, Haifa, Israel
| |
Collapse
|
36
|
Kioh SH, Pooke TG, Chong SV. Use of Radiography for New Patients Presenting to a Chiropractic Teaching Clinic: A Cross-sectional Analysis. JOURNAL OF CHIROPRACTIC HUMANITIES 2021; 28:9-14. [PMID: 35002573 PMCID: PMC8720650 DOI: 10.1016/j.echu.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The aim of this study was to identify the number and type of indications for radiographs ordered in a chiropractic teaching clinic in Malaysia. METHODS A cross-sectional retrospective analysis was conducted using the medical health records of new patients who presented to the International Medical University Bukit Jalil teaching clinic for chiropractic care between August 2018 and July 2019. Data about sociodemographic characteristics, region of presenting complaint, radiography ordering rates, and referral indications were collected. We compared indications reported in the patient records with those listed in the International Medical University Chiropractic Clinical Manual. We conducted χ2 and logistic regression analysis to identify the association between radiography indications and the number of radiographs ordered. RESULTS Data were collected for 1451 patients (741 [51.1%] women and 700 [48.9%] men). The most common body region for the presenting complaint was the lumbar/pelvic region (39.0%), and the overall radiograph use rate was 2.7%, with the highest number of radiographs for the lumbar spine. CONCLUSION For the patient files sampled in this study, the overall radiograph order rate in the International Medical University Bukit Jalil Chiropractic teaching clinic was 2.7%.
Collapse
Affiliation(s)
- Sheng Hui Kioh
- Corresponding author: Sheng Hui Kioh, Department of Chiropractic, International Medical University, 126, Jln Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Federal Territory of Kuala Lumpur, Kuala Lumpur, Malaysia
| | | | | |
Collapse
|
37
|
Shroyer SR, Davis WT, April MD, Long B, Boys G, Mehta SG, Mercaldo SF. A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection. West J Emerg Med 2021; 22:1156-1166. [PMID: 34546893 PMCID: PMC8463051 DOI: 10.5811/westjem.2021.5.52007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/15/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions. Methods We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool. Results In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38–70 and 51.5 (42–59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100–100%); 56% (95% CI, 48–64%), and 40% (95% CI, 36–46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829–0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84–98%), and 98% (95% CI, 94–100%), respectively. Conclusion The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.
Collapse
Affiliation(s)
- Steven R Shroyer
- Methodist Hospital System, Greater San Antonio Emergency Physicians, San Antonio, Texas
| | - William T Davis
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland
| | - Michael D April
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland.,Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| | - Brit Long
- Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, Bethesda, Maryland
| | - Greg Boys
- Methodist Hospital System, Department of Radiology, San Antonio, Texas
| | - Sumeru G Mehta
- Methodist Hospital System, Greater San Antonio Emergency Physicians, San Antonio, Texas
| | - Sarah F Mercaldo
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts
| |
Collapse
|
38
|
Traeger AC, Machado GC, Bath S, Tran M, Roper L, Oliveira C, Peek A, Coombs D, Hall A, Tcharkhedian E, Maher CG. Appropriateness of imaging decisions for low back pain presenting to the emergency department: a retrospective chart review study. Int J Qual Health Care 2021; 33:6321318. [PMID: 34260690 DOI: 10.1093/intqhc/mzab103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/03/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Imaging for low back pain is widely regarded as a target for efforts to reduce low-value care. OBJECTIVE We aimed to estimate the prevalence of the overuse and underuse of lumbar imaging in patients presenting with low back pain to the emergency department (ED). METHODS This was a retrospective chart review study of five public hospital EDs in Sydney, Australia, in 2019-20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse). RESULTS Six hundred and forty-nine patients presented with a complaint of low back pain, of which 158 (24.3%) were referred for imaging. Seventy-nine (12.2%) had a combination of features suggesting that lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95% CI 6.8-11.2%) and 4.3% (28 of 649 cases, 95% CI 3.0-6.1%), respectively. Thirteen cases were classified as underuse because the patients were referred for uninformative imaging modalities (e.g. referred for radiography for suspected cauda equina syndrome). CONCLUSION In this study of emergency care, there was evidence of not only overuse of lumbar imaging but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse.
Collapse
Affiliation(s)
- Adrian C Traeger
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Gustavo C Machado
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Sally Bath
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Martin Tran
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Lucinda Roper
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Crystian Oliveira
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia.,Physical Therapy Department, Faculty of Science and Technology, Sao Paulo State University, Presidente Prudente, R. Roberto Símonsen, 305 - Centro Educacional, Pres. Prudente - SP 19060-900, Brazil
| | - Aimie Peek
- Faculty of Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Susan Wakil Building, Western Ave, Camperdown NSW 2050, Australia
| | - Danielle Coombs
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| | - Amanda Hall
- Faculty of Medicine, Memorial University, 300 Prince Philip Dr, St. John's, NL A1B 3V6, Canada
| | - Elise Tcharkhedian
- Physiotherapy Department, Liverpool Hospital, Southwest Sydney Local Health District, Liverpool, 75 Elizabeth St, Liverpool NSW 2170, Australia
| | - Chris G Maher
- Faculty of Medicine and Health, Institute for Musculoskeletal Health, Sydney School of Public Health, The University of Sydney, Level 10 North, King George V Building, Royal Prince Alfred Hospital (C39), PO Box M179, Missenden Road, Sydney, NSW 2050, Australia
| |
Collapse
|
39
|
Carman MJ. CE: Assessing Back Pain in Patients Presenting to the ED. Am J Nurs 2021; 121:26-30. [PMID: 34117133 DOI: 10.1097/01.naj.0000756520.85864.c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Although back pain is common, most often benign, and generally resolves in a few days with self-care, nonspecific low back pain that does not resolve with self-care and prompts patients to seek treatment in an ED may result from a serious underlying pathology. In this article, the first in a series on clinical red flags-indicators that can be used in the clinical setting to screen for an elevated risk of severe underlying conditions-the author considers back pain manifestations that may signal the presence of a debilitating or even fatal disease process. Detecting such red flags and communicating their presence to the attending provider can facilitate appropriate diagnosis and management.
Collapse
Affiliation(s)
- Margaret J Carman
- Margaret J. Carman is an associate professor in the School of Nursing, University of North Carolina at Chapel Hill. Contact author: . The author and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the author is available at www.ajnonline.com
| |
Collapse
|
40
|
Christe G, Darlow B, Pichonnaz C. Changes in physiotherapy students' beliefs and attitudes about low back pain through pre-registration training. Arch Physiother 2021; 11:13. [PMID: 33993879 PMCID: PMC8126429 DOI: 10.1186/s40945-021-00106-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/17/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Implementation of best-practice care for patients with low back pain (LBP) is an important issue. Physiotherapists' who hold unhelpful beliefs are less likely to adhere to guidelines and may negatively influence their patients' beliefs. Pre-registration education is critical in moving towards a biopsychosocial model of care. This study aimed to investigate the changes in 2nd year physiotherapy students' beliefs about LBP after a module on spinal pain management and determine whether these changes were maintained at the end of academic training. METHODS During three consecutive calendar years, this longitudinal cohort study assessed physiotherapy students' beliefs with the Back Pain Attitudes Questionnaires (Back-PAQ) in their 1st year, before and after their 2nd year spinal management learning module, and at the end of academic training (3rd year). Unpaired t-tests were conducted to explore changes in Back-PAQ score. RESULTS The mean response rate after the spinal management module was 90% (128/143 students). The mean (± SD) Back-PAQ score was 87.73 (± 14.21) before and 60.79 (± 11.44) after the module, representing a mean difference of - 26.95 (95%CI - 30.09 to - 23.80, p < 0.001). Beliefs were further improved at the end of 3rd year (- 7.16, 95%CI - 10.50 to - 3.81, p < 0.001). CONCLUSIONS A spinal management learning module considerably improved physiotherapy students' beliefs about back pain. Specifically, unhelpful beliefs about the back being vulnerable and in need of protection were substantially decreased after the module. Improvements were maintained at the end of academic training one-year later. Future research should investigate whether modifying students' beliefs leads to improved clinical practice in their first years of practice.
Collapse
Affiliation(s)
- Guillaume Christe
- Department of Physiotherapy, HESAV School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
- Swiss BioMotion Lab, Department of Musculoskeletal Medicine, University Hospital and University of Lausanne (CHUV-UNIL), Lausanne, Switzerland
| | - Ben Darlow
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| | - Claude Pichonnaz
- Department of Physiotherapy, HESAV School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
- Department of Musculoskeletal Medicine, University Hospital and University of Lausanne (CHUV-UNIL), Lausanne, Switzerland
| |
Collapse
|
41
|
Yeung CM, Lightsey HM, Isaac S, Isaac Z, Gilligan CJ, Zaidi H, Ludwig SC, Kang JD, Makhni MC. Improving Spine Models of Care. JBJS Rev 2021; 9:e20.00183. [PMID: 33982981 DOI: 10.2106/jbjs.rvw.20.00183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Caleb M Yeung
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harry M Lightsey
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean Isaac
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zacharia Isaac
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher J Gilligan
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hasan Zaidi
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Steven C Ludwig
- Department of Orthopaedic Surgery, University of Maryland Medical System, Baltimore, Maryland
| | - James D Kang
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Melvin C Makhni
- Departments of Orthopaedic Surgery (C.M.Y., H.M.L., J.D.K., and M.C.M.), Physical Medicine and Rehabilitation (S.I. and Z.I.), Anesthesiology (C.J.G.), and Neurosurgery (H.Z.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
42
|
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.
Collapse
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.
| |
Collapse
|
43
|
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
|
44
|
Stubbs PW, Verhagen AP. Estimating Prevalence of Serious Spinal Pathology in Patients Presenting to the Emergency Department With Low Back Pain: Misrepresentation of Prospective Studies. Am J Med 2020; 133:e613. [PMID: 33004186 DOI: 10.1016/j.amjmed.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Peter W Stubbs
- Graduate School of Health, Discipline of Physiotherapy, University of Technology Sydney, Sydney, Australia.
| | - Arianne P Verhagen
- Graduate School of Health, Discipline of Physiotherapy, University of Technology Sydney, Sydney, Australia
| |
Collapse
|
45
|
Borges LF, Cisneros LL, Silva DA, Borges Dario A, Ferreira M, Ferreira PH. Profile and management of patients with low back pain complaints in a Brazilian Emergency Department: a cross-sectional retrospective study. REVISTA CIÊNCIAS EM SAÚDE 2020. [DOI: 10.21876/rcshci.v10i3.953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Objective: To describe the demographic profile and the management of patients with low back pain (LBP) complaints presenting to the Emergency Department (ED) of a Brazilian public hospital. Methods: Retrospective, cross-sectional study using a convenience sample of patients with LBP triaged at the studied ED through the Manchester Triage System along a year. Data were extracted from electronic medical records. LBP presentations were classified as non-traumatic, traumatic, and non-spinal related pain according to the signs and symptoms reported. Data included patients’ demographic profile, pain severity and management (e.g., imaging exams, medication prescription and hospitalization). Results: Data from 2016 patients was analyzed. Most were middle-aged adults (mean age = 40.5years, SD 15.7), female (n = 1043, 51.7%) and presented moderate pain intensity (score range 4 to 7 on the Visual Analogue Scale, n=1,471; 74.1%). Non-traumatic pain (n = 1,016; 50.4%) was the main cause of care-seeking. A total of 36.9% (n = 743) underwent imaging exams and 42.2% (n = 850) received medication. Patients with non-spinal related pain were three times more likely to receive opioid medication (OR = 2.96; 95%CI 2.30 to 3.79). Conclusion: Non-traumatic LBP (i.e., no history of trauma or red flags) was the main cause of LBP care-seeking in a Brazilian ED. Most patients were treated conservatively and without hospitalization. Opioids prescription and imaging exams, although performed on a smaller scale, were still used for of the management of this type of LBP.
Collapse
|
46
|
Abstract
Low back pain is a frequent complaint of patients seeking care at private offices, ambulatory clinics, and EDs. Key signs and symptoms can guide clinicians in differentiating acute and persistent mechanical low back pain from back pain resulting from a specific cause. Awareness of these findings can reduce the number of missed or incorrect diagnoses that lead to poor patient outcomes. The ability to recognize the red flag findings of serious causes of low back pain ensures prompt diagnosis and initiation of appropriate treatment. This article highlights the history and physical examination findings that will improve identification of red flags associated with emergency or serious causes.
Collapse
|
47
|
Machado GC, Ghinea N, Rogan E, Day RO, Maher CG. Emergency department care for low back pain: Should we adopt recommendations from primary care guidelines? Emerg Med Australas 2020; 32:890-892. [PMID: 32743874 DOI: 10.1111/1742-6723.13593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 12/13/2022]
Abstract
ED visits for low back pain are increasing, but the lack of specific guidance for emergency physicians impedes evidence-based care, and adopting primary care recommendations may not be appropriate. The ED sees a different spectrum of low back pain presentations, where physicians are likely to encounter a larger proportion of patients with an underlying serious pathology or non-spinal diseases than in primary care. Current low back pain guidelines do not adequately cover screening for these conditions, but making a differential diagnosis is crucial in emergency patients with low back pain. In this article, we also discuss the challenges in developing specific ED guidelines for low back pain, the limited evidence on the profile of these patients and the surprising dearth of randomised trials.
Collapse
Affiliation(s)
- Gustavo C Machado
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Narcyz Ghinea
- Sydney Health Ethics, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Eileen Rogan
- Emergency Department, Canterbury Hospital, Sydney, New South Wales, Australia
| | - Richard O Day
- Clinical Pharmacology and Toxicology Department, St Vincent's Hospital, Sydney, New South Wales, Australia.,St Vincent's Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia.,Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
48
|
Neff SM, Roecker CB, Okamoto CS, Holguin SL, Napuli JG, Mattox R, Hinkeldey NA, Paris DJ. Guidance concerning chiropractic practice in response to COVID-19 in the U.S.: a summary of state regulators' web-based information. Chiropr Man Therap 2020; 28:44. [PMID: 32631385 PMCID: PMC7336092 DOI: 10.1186/s12998-020-00333-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/30/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic led to unprecedented changes, as many state and local governments enacted stay-at-home orders and non-essential businesses were closed. State chiropractic licensing boards play an important role in protecting the public via regulation of licensure and provision of guidance regarding standards of practice, especially during times of change or uncertainty. OBJECTIVE The purpose of this study was to summarize the guidance provided in each of the 50 United States, related to chiropractic practice during the COVID-19 pandemic. METHODS A review of the public facing websites of governors and state chiropractic licensing boards was conducted in the United States. Data were collected regarding the official guidance provided by each state's chiropractic licensing board as well as the issuance of stay-at-home orders and designations of essential personnel by state governors. Descriptive statistics were used to report the findings from this project. RESULTS Each of the 50 state governor's websites and individual state chiropractic licensing board's websites were surveyed. Stay-at-home or shelter-in-place orders were issued in 86% of all states. Chiropractors were classified as essential providers in 54% of states, non-essential in one state (2%), and no guidance was provided in the remaining 44% of all states. Fourteen states (28%) recommended restricting visits to only urgent cases and the remaining states (72%) provided no guidance. Twenty-seven states (54%) provided information regarding protecting against infectious disease and the remaining states (46%) provided no guidance. Twenty-two states (44%) provided recommendations regarding chiropractic telehealth and the remaining states (56%) provided no guidance. Seventeen states (34%) altered license renewal requirements and eight states (16%) issued warnings against advertising misleading or false information regarding spinal manipulation and protection from COVID-19. CONCLUSION State guidance during the COVID-19 pandemic was heterogenous, widely variability in accessibility, and often no guidance was provided by state chiropractic licensing boards. Some state chiropractic licensing boards chose to assemble guidance for licensees into a single location, which we identified as a best practice for future situations where changes in chiropractic practice must be quickly communicated.
Collapse
Affiliation(s)
- Shawn M Neff
- Martinsburg Veterans Affairs Medical Center, Martinsburg, WV, USA.
| | | | - Casey S Okamoto
- Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Samuel L Holguin
- Martinsburg Veterans Affairs Medical Center, Martinsburg, WV, USA
| | - Jason G Napuli
- St Louis Veterans Affairs Health Care System, St Louis, MO, USA
| | - Ross Mattox
- St Louis Veterans Affairs Health Care System, St Louis, MO, USA
| | | | - David J Paris
- Veterans Affairs Northern California Health Care System, Redding, CA, USA
| |
Collapse
|
49
|
Magel J, Kim J, Fritz JM, Freburger JK. Time Between an Emergency Department Visit and Initiation of Physical Therapist Intervention: Health Care Utilization and Costs. Phys Ther 2020; 100:1782-1792. [PMID: 32478851 PMCID: PMC7530572 DOI: 10.1093/ptj/pzaa100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 05/26/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of this study was to examine the association between the length of time between an emergency department (ED) visit and the subsequent initiation of physical therapist intervention for low back pain (LBP) on 1-year LBP-related health care utilization (ie, surgery, advanced imaging, injections, long-term opioid use, ED visits) and costs. METHODS This retrospective cohort study focused on individuals who consulted the ED for an initial visit for LBP. Claims from a single statewide, all-payers database were used. LBP-related health care use and costs for the 12 months after the ED visit were extracted. Poisson and general linear models weighted with inverse probability treatment weights were used to compare the outcomes of patients who attended physical therapy early or delayed after the ED visit. RESULTS Compared with the delayed physical therapy group (n = 94), the early physical therapy group (n = 171) had a lower risk of receiving lumbar surgery (relative risk [RR] = 0.47, 95% CI = 0.26-0.86) and advanced imaging (RR = 0.72, 95% CI = 0.55-0.95), and they were less likely to have long-term opioid use (RR = 0.45, 95% CI = 0.28-0.76). The early physical therapy group incurred lower costs (mean = $3,806, 95% CI = $1,998-$4,184) than those in the delayed physical therapy group (mean = $8,689, 95% CI = $4,653-$12,727). CONCLUSION Early physical therapy following an ED visit was associated with a reduced risk of using some types of health care and reduced health care costs in the 12 months following the ED visit. IMPACT STATEMENT The ED is an entry point into the health care system for patients with LBP. Until now, the impact of the length of time between an ED visit and physical therapy for LBP has not been well understood. This study shows that swift initiation of physical therapy following an ED visit for LBP is associated with lower LBP-related health utilization for some important outcomes and lower LBP-related health care costs.
Collapse
Affiliation(s)
- John Magel
- Address all correspondence to Dr Magel at:
| | - Jaewhan Kim
- Department of Physical Therapy and Athletic Training, University of Utah
| | | | - Janet K Freburger
- Department of Physical Therapy, School of Health & Rehabilitation Sciences, University of Pittsburg, Pittsburgh, Pennsylvania
| |
Collapse
|