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JCCC 2018 Issue 2

Table of Contents

JCCC 2018 Issue 1

Table of Contents

JCCC 2018 Issue 1

Table of Contents

The Canadian Spine Surgeon’s Perspective: Avoiding Opioid Use in Spine Patients

Teaser: 

Alexandra Stratton, MD, MSc, FRCSC,1
Dr. Darren Roffey, PhD,2
Dr. Erica Stone, MD, FRCPC,3
Mohamed M. El Koussy, BSc,4
Dr. Eugene Wai, MD,5

1Orthopaedic Spinal Surgeon, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
2University of Ottawa Spine Program, The Ottawa Hospital, Ottawa, ON, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON.
3Anesthesiology, PGY 6 Pain Medicine, The Ottawa Hospital, Ottawa, ON.
4Clinical Research Assistant, University of Ottawa Combined Adult Spinal Surgery Program, Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, ON.
5is an orthopedic surgeon who specializes in the care of adult spinal disorders. He is also an Associate Professor in the Department of Surgery at the University of Ottawa. In addition he is the Research Chair for the Canadian Spine Society. Department of Orthopaedic Surgery, Centre Hospitalier Universitaire de Québec, Laval University, QC.

CLINICAL TOOLS

Abstract: Opioids are drugs with pain relieving properties; however, there is evidence that opioids are no more effective than non-opioid medications in treating low back pain (LBP), and opioid use results in higher adverse events and worse surgical outcomes. First line treatment should emphasize non-pharmacological modalities including education, self-care strategies, and physical rehabilitation. Non-steroidal anti-inflammatory drugs (NSAIDs) are generally considered an appropriate introduction into pharmacological treatment when deemed necessary. Non-opioid adjunct medications can be considered for specific features related to LBP such as neuropathic leg pain. Primary care providers should exhaust first and second line treatments before considering low-dose opioids, and only then in consultation with evidence-based clinical practice guidelines.
Key Words: Pharmacological; low back pain; radiculopathy; opioids; analgesia.

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1. First line treatment for low back and radicular leg pain is non-pharmacological.
2. Second line treatment includes NSAIDs (with or without proton pump inhibitor), and muscle relaxants (3 weeks maximum), gabapentinoids and antidepressants.
3. Exhausting non-opioid analgesics includes trialing different medications within the same class and at different doses since many of these medications have wide therapeutic dose ranges.
A "start low and go slow" approach is recommended for initiating pharmacological treatments for low back and radicular leg pain, especially when using neuroleptics and antidepressants.
When treating low back pain with neuropathic leg pain, patients who fail a trial of pregabalin may tolerate gabapentin, or vice versa.
Antidepressants have a role in managing low back pain, particularly chronic, even in the absence of mood disorder.
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Spinal Lesion: Benign or Malignant? When should you worry?

Teaser: 

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

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

CLINICAL TOOLS

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

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

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