Diagnostic pitfalls in spine surgery: masqueraders of surgical spine disease

A qualitative study to explore the experiences of first contact physiotherapy practitioners in the NHS and their experiences of their first contact role

PURPOSE

First Contact Practitioner (FCP) roles have been developed for health professionals with advanced practice skills to take on many of the musculoskeletal responsibilities currently carried out by general practitioners. FCP roles are new and still developing. Currently there is little research that has investigated the experiences of FCPs. This knowledge could help stakeholders and other clinicians gain an understanding into what makes a successful FCP role. The aim of this research was to explore the experiences of FCP working in North West England to gain insight into the first point of contact service, and their experiences of this developing full time FCP role.

METHODS

A qualitative design using in-depth semi-structured, face-to-face interviews was undertaken to explore the experiences of FCP providing a first point of contact service. The study took place in an economically deprived and ethnically diverse location in North West England.

FINDINGS

Ten FCPs were recruited, four were appointed from Band 6 posts to FCP training posts, 9 were male. The mean years qualified was 12.8. Five themes were identified: 1. 'It's the level of clinical complexity that you're dealing with', 2. FCP role - rewards and challenges, 3. Own wellbeing, 4. Professional development and education, 5. Realities of working in practice governed by business.

CONCLUSION

FCP roles are an exciting development for people with MSK conditions, the physiotherapy profession, primary care providers and MSK physiotherapists. Mentorship support, workload and standards of training and practice are important when considering future expansion for the sustainability of these roles.

Comparison of the history and physical examination for hip osteoarthritis and lumbar spinal stenosis

BACKGROUND

Leg pain associated with walking is sometimes incorrectly attributed to hip osteoarthritis (OA) or lumbar spinal stenosis (LSS).

PURPOSE

This study compared physicians' values of signs and symptoms for diagnosing and differentiating hip OA and LSS to their clinical utility.

STUDY DESIGN/SETTING

Musculoskeletal physicians were surveyed with online questionnaires. Patients were recruited from hip and spine specialty practices.

PATIENT SAMPLE

Seventy-seven hip OA and 79 LSS patients.

OUTCOME MEASURES

Signs and symptoms of hip OA and LSS.

METHODS

Fifty-one of 66 invited musculoskeletal physicians completed online surveys about the values of 83 signs and symptoms for diagnosing hip OA and LSS. Of these, the most valued 32 symptoms and 13 physical examination items were applied to patients with symptomatic hip OA or LSS. Positive likelihood ratios (+LR) were calculated for each items' ability to differentiate hip OA from LSS, with a +LR>2 set as indicating usefulness for favoring either diagnosis. Positive LRs were compared with surveyed physicians' values for each test.

RESULTS

All symptoms were reported by some patients with each diagnosis. Only 11 of 32 physician-valued symptoms were useful for discriminating hip OA from LSS. Eight symptoms favored hip OA over LSS: groin pain (+LR=4.9); knee pain (+LR=2.2); pain that decreased with continued walking (+LR=3.9); pain that occurs immediately with walking (+LR=2.4); pain that occurs immediately with standing (+LR=2.1); pain getting in/out of a car (+LR=3.3); pain with dressing the symptomatic leg (+LR=3.1); and difficulty reaching the foot of the symptomatic leg while dressing (+LR=2.3). Three symptoms favored LSS over hip OA: pain below the knee (+LR=2.3); leg tingling and/or numbness (+LR=2.7); and some pain in both legs (+LR=2.5). Notable symptoms that did not discriminate hip OA from LSS included: pain is less while pushing a shopping cart (+LR=1.0); back pain (+LR=1.1); weakness and/or heaviness of leg (+LR=1.1); buttocks pain (+LR=1.2); poor balance or unsteadiness (+LR=1.2); pain that increased with weight-bearing on the painful leg (+LR=1.3), and step to gait on stairs (+LR=1.7). Consistent with physicians' expectations, 7 of 13 physical examination items strongly favored hip OA over LSS: limited weight-bearing on painful leg when standing (+LR=10); observed limp (+LR=9); and painful and restricted range-of-motion with any of five hip maneuvers (+LR range 21-99). Four of five tested neurological deficits (+LR range 3-8) favored the diagnosis of LSS over hip OA.

CONCLUSIONS

There is substantial crossover of symptoms between hip OA and LSS, with some physician-valued symptoms useful for differentiating these disorders whereas others were not. Physicians recognize the value of the examination of gait, the hip, and lower extremity neurological function for differentiating hip OA from LSS. These tests should be routinely performed on all patients for which either diagnosis is considered. Awareness of these findings might reduce diagnostic errors.

Mimickers of lumbar radiculopathy

Orthopaedic surgeons frequently treat patients who report pain that radiates from the back into the lower extremity. Although the most common etiology is either a herniated disk or spinal stenosis, a myriad of pathologies can mimic the symptoms of radiculopathy, resulting in differences in the clinical presentation and the workup. Therefore, the clinician must be able to distinguish the signs and symptoms of lumbar radiculopathy from pathologies that may have a similar presentation. Being cognizant of these other possible conditions enables the physician to consider a breadth of alternative diagnoses when a patient presents with radiating lower extremity pain.