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Vertebral Metastatic Disease: A Practice Guideline for the General Practitioner

Vertebral Metastatic Disease: A Practice Guideline for the General Practitioner

Teaser: 

Michael S. Taccone,1 Markian Pahuta,2 Darren M.Roffey,3,4Eugene K. Wai,2,3,4

1Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
2Division of Orthopedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
3Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.
4Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

CLINICAL TOOLS

Abstract: Vertebral metastatic disease afflicts a significant proportion of cancer patients, most commonly those with breast and lung disease. Symptoms can include tumor-related pain, neurological deficit from spinal cord or nerve compression and pathological fracture with mechanical instability. Appropriate workup includes identifying the primary disease, defining the extent of spinal and extra-spinal pathology and classifying spinal stability based on the pattern of osseous involvement. Specific therapy for the vertebral metastatic disease can include pharmacologic therapy to deliver analgesia, steroids, bisphosphonate, anti-neoplastic therapy, radiation therapy as either primary or adjuvant therapy and surgical intervention for mechanical or neurologic instability.
Key Words: Vertebral metastatic disease, metastatic epidural spinal cord compression, spinal instability, spine surgery, spinal radiation therapy, pathologic fracture.

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

www.cfpc.ca/Mainpro_M2

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Pre-test CME Quiz Post-test CME Quiz
Red flags are non-specific and unreliable means of determining spinal malignancy in patients with back pain. Clinical suspicion combined with history and physical exam are best for increasing pre-test probability of imaging studies.
Initial evaluation and referral to definitive management should be made within 24 hours of detection of significant neurological deficit, significant metastatic epidural spinal cord compression or instability.
MRI is the imaging modality of choice for initial evaluation and assessment of overall spinal tumor burden.
Vertebral metastatic disease is very common in patients with cancer.
SINS, ESCCS, Tomita score, Tokuhashi score and the Modified Bauer scores are all important tools for determining the most appropriate referral.
In eligible candidates, surgery with adjuvant radiotherapy yields faster and more sustainable neurologic stability and recovery.
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Related Terms: Back Health, Vertebral metastatic disease, metastatic epidural spinal cord compression, spinal instability, spine surgery, spinal radiation therapy, pathologic fracture

Error in Radiology: Negligence or Human Nature

D'Arcy Little, MD CCFP FRCPC, Chief of Diagnostic Imaging, Orillia Soldiers' Memorial Hospital,
Adjunct Clinical Lecturer, Department of Medical Imaging, University of Toronto, Toronto, ON,
Forensic Radiologist, Forensic Sciences and Coroners' Complex, Toronto, ON,
2015 Resident in Scientific Communications, Banff Centre, Banff, AB.

Related Terms: Radiology, radiology, errors

Tales of Heartache and Woe

Teaser: 

“Momma has been dead just over a year. Doesn’t he have any pride, any respect?” Sandy, short for Sandra, the next to youngest of the three brothers and two sisters was trying to calm Norman.

...

A Reticulate Hyperpigmented Abdominal Patch Associated with Chronic Abdominal Pain

A Reticulate Hyperpigmented Abdominal Patch Associated with Chronic Abdominal Pain

Teaser: 

Julie Man, MD,1 Joseph M. Lam, MD, FRCPC,2

1Department of Family Medicine, University of Alberta, Edmonton, AB.
2Assistant Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: A 13-year-old girl presented with a 3-month history of a reticulate hyperpigmented patch over the lower abdomen. Her past medical history was significant for recurrent abdominal pain, Ehlers-Danlos syndrome, a mild learning disability, and multiple allergies. On physical examination, she had a reticulate, hyperpigmented patch distributed diffusely over the lower abdomen (Figure 1). The remainder of her exam was unremarkable. Upon questioning, it was revealed that the patient had been applying a hot water bottle to the lower abdomen for the last 4 months to help relieve the discomfort associated with the abdominal pain. This history led to the diagnosis.
Key Words: Erythema ab igne, hyperpigmentation, reticulate, thermal injury.
Erythema ab igne may present as a transient erythematous eruption, or as a reticulate hyperpigmentation.
Erythema ab igne is a clinical diagnosis which rarely requires biopsy confirmation.
Direct questioning about heat sources, such as prolonged laptop computer use, aids the diagnosis.
Treatment consists of patient education and removal of the heat source.
1. Erythema ab igne is a recognizable condition associated with chronic exposure to heat sources such as heating pads, hot water bottles, electric blankets, space heaters and laptop computers.
2. The differential diagnosis for erythema ab igne includes livedo reticularis, livedoid vasculitis, cutis marmorata telangiectatica congenita, a reticulate port-wine stain and poikiloderma.
3. The most important treatment for erythema ab igne is recognition and removal of the source of infrared radiation.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Dermatology, erythema ab igne, hyperpigmentation, reticulate, thermal injury

Anticipatory Conversations: Is there a connection to Ice Cream?

Anticipatory Conversations: Is there a connection to Ice Cream?

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: Advance care planning has become a much touted and potentially very important addition to the new operative structure of meeting the many challenges of an ever increasingly older population. From what used to be discussions about CPR and DNR the process has evolved into what many expect might become the basis of end-of-life decision-making that may assist family members and health care providers to meet the needs, wishes and priorities of the elderly population, particularly when they are nearing that last trajectory of life.
Key Words: Artificial nutrition and hydration, advance care planning, living wills, end-of-life planning.
1. Planning before there is a medical crises can help avoid medical decisions that may not be in keeping with your wishes and values.
2. Artificial nutrition and hydration may not be what you really want, even though in its simplest form it may seem desirable as a way of avoiding death.
Communication with those who will be responsible for decision-making when you are no longer able to do so is key to having your end-of-life wishes fulfilled and should not be left to crises situations.
If you have favorite foods, make sure your substitute decision-makers know about them so that when the time comes you will not be deprived of your most enjoyed foods, because some health care provider deems them to be "unhealthy" or not in keeping with an "optimal diet".
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Dementia, artificial nutrition and hydration, advanced care planning, living wills, end-of-life planning