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Cauda Equina Syndrome: a review of all you need to know

Teaser: 

Vega-Arroyo Miguel, MD,1 Perry Dhaliwal, MD, MPH, FRCSC,2

1 Section of Neurosurgery, Department of Surgery, University of Manitoba.
2 Assistant Professor of Neurosurgery, Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba.

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Abstract: Cauda equina syndrome (CES) is the collection of signs and symptoms produced by severe compression of the lumbar spinal nerves that form the cauda equina. The compression can be caused by lumbar degenerative changes, intraspinal tumors, epidural hematoma, and infections. Rapid diagnosis and treatment are paramount as CES requires emergent surgical decompression. With delay, the patient could develop permanent neurological deficits including loss of lower limb sensorimotor function, bladder, bowel, and/or sexual dysfunction. Unfortunately, even with expeditious surgery, neurological improvements remain unpredictable. Failure to fully explain the possible prognoses can involve all the healthcare providers in medicolegal consequences.
Key Words:Cauda Equina Syndrome, Spine Emergency, Urinary retention, MRI scanning, Saddle Anesthesia.

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1. Cauda Equina Syndrome results from pathologies that compress the nerves in the lumbosacral spinal canal, most commonly due to an acute lumbar disc herniation.
2. Early diagnosis is crucial and is made clinically by distinctive symptoms of saddle anesthesia, acute urinary incontinence combined with acute back and leg pain.
3. The most consistent early clinical sign of CES is urinary retention, and the prognosis is worse when present.
4. Urgent MRI is the study of choice and should be performed to confirm or rule out CES.
5. Surgery is highly recommended within 24 hours after CES is identified.
1. Cauda Equina Syndrome is caused by a large space-occupying lesion within the central canal of the lumbosacral spine, most commonly a large disc herniation. However, compression can also be caused by lumbar degenerative changes, intraspinal tumors, epidural hematoma, and infections.
2. Cauda equina syndrome generally presents with varying degrees of sensory loss and motor weakness in the lower extremities, saddle anesthesia, and bowel/bladder dysfunction (these last 2 are required to establish the diagnosis of CES).
3. The main clinical feature between differentiating Cauda Equina Syndrome vs Conus Medullaris Syndrome, is the absence of UPPER MOTOR NEURONS findings in CES).
4. About 70% of patients with cauda equina syndrome have a previous history of lower back pain and/or sciatica.
5. Although the prognosis is largely determined by the preoperative severity of neurological deficits, early surgery improves the chance of significant recovery so patients with CES require urgent surgical intervention.
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Related Terms: Back Health, cauda equina syndrome, spine emergency, urinary retention, MRI scanning, Saddle Anesthesia

An Ethics Journey: From Kant to Assisted Suicide

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Emeritus Professor of Medicine, Member, Joint Centre for Bioethics, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: Most of us would agree with the almost trite saving that "life is a journey". Of course it is, unless it ends tragically at birth, and even then it is a very short journey. All of us can describe how we got from one stage in life to another, whether personal, family, education or career. Many journeys seem to be in an almost straight line while others meander from one place to another, changing direction and alternating goals, sometimes zigging back and forth. I have had many wonderful journeys in my life; the choice to change career aspirations from engineering to medicine, the choice to study in medicine in Scotland, the choice to focus on geriatrics and then the choice to branch out into medical ethics to add more depth to clinical medicine. The early undergraduate study of philosophy planted the seed that eventually grew into my completing a Master's in Medical Ethics; and then expanding my teaching and practice to include palliative care and end-of-life decision-making, to most recently participating in the assessment of those requesting medical assistance in dying (MAiD in Canada).
Key Words: Kant, medical ethics, MAiD, assisted suicide, medicine.
The controversy in Canada about the evolution of MAiD legislation is an example of how polar opposite views can affect the law and the citizen’s views about end-of-life options.
One of the contemporary pillars of medical ethics is autonomy.
Doctors have to describe the benefits and risks of medications in order to get the proper consent to use the prescription.
MAiD is a complex concept. It will take time until the right balance is achieved.
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Related Terms: Law and Ethics, Kant, medical ethics, MAiD, assisted suicide, medicine

Acute Management of Cervical Spine Trauma and Spinal Cord Injury

Teaser: 

Mohamed Sarraj, MD,1 Brian Drew, MD FRCSC,2

1 Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario.
2 Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario.

CLINICAL TOOLS

Abstract: Cervical spine injury can have life-changing consequences. At every stage of injury, we can intervene to meaningfully change patients' outcomes. On the field, a high index of suspicion is critical. Spinal immobilization prevents secondary injury, but immobilization, particularly use of a hard board, must be kept to a minimum. In the trauma bay, perfusion of the spinal cord is a priority to help prevent secondary spinal cord injury. This means addressing any cause of hypotension and understanding how to manage neurogenic shock. In the spinal-cord injured patient, hemodynamic management is an important adjunct.
Key Words:Spinal Cord Injury; Trauma; Cervical; Ankylosing Spondylitis.

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.

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1. Minimize time in rigid immobilization as much as feasible.
2. Spinal shock is temporary flaccid paralysis and loss of reflexes. You cannot give a prognosis for a spinal cord-injured patient in spinal shock.
3. Recognize patients with stiff spines (such as in ankylosing spondylitis) and immobilize them in their natural position of comfort to avoid secondary injury.
4. What we can do to improve neurologic outcomes in spinal cord injury: Maintain spinal cord perfusion through oxygenation and blood pressure management, avoid secondary injury through immobilization, and facilitate early surgical decompression (<24hr)
1. The Canadian C-spine Rule is the preferred algorithm to clear the cervical spine after trauma.
2. X-rays are not sufficient to rule out cervical spine injury. CT scan is the gold standard.
3. Neurogenic shock is a distributive syndrome characterized by the triad of hypotension, bradycardia, and peripheral vasodilation. First line treatment is fluid resuscitation, then vasopressors.
4. Patients with stiff spines (ankylosing spondylitis or DISH) have high rates of spine fractures and non-contiguous injuries. Full spine CT scans should be obtained.
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Related Terms: Back Health, spinal cord injury, trauma, cervical, ankylosing spondylitis

Pediatric Warts: 2023 Update

Teaser: 

Mahan Maazi, MEng,1 Joseph M. Lam, MD, FRCPC,2

1 Faculty of Medicine, University of British Columbia.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Cutaneous warts or verruca are benign growths of the skin that affect 30 to 70% of school-age children and has a lifetime prevalence of 10 to 22% in children. It is caused by human papillomavirus (HPV) which spreads from skin-to-skin contact or fomites and infects squamous cell in areas like the hands and feet. There are different HPV subtypes that cause different types of warts including common warts (verruca vulgaris), plantar warts (verruca plantaris), flat warts (verruca plana), mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis, and condyloma acuminata (genital or venereal warts). Most warts will spontaneously clear within 2 years. Diagnosis is based on history and physical examination features which may include dermoscopy and rarely, histological confirmation. Management includes treatment with topical salicylic acid and cryotherapy, the two most common and effective modalities.
Key Words: warts (verruca), human papillomavirus (HPV), common warts (verruca vulgaris), plantar warts (verruca plantaris), flat warts (verruca plana), mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis (EV), condyloma acuminata (genital or venereal warts).
Cutaneous warts are a benign growth caused by human papillomavirus (HPV) infection that can cause discomfort. These are most common in school-aged children and in adolescents.
HPV infection is acquired through skin-to-skin contact, contact with fomites, or through maternal transmission during birth. The virus infects squamous cells on the skin and inserts its viral genome into the cells causing survival and proliferation of the virus.
History and physical examination help diagnose warts in children. Dermoscopy and histology may also aid in diagnosis, especially in more challenging presentations. A history of genital warts in children mandates ruling out sexual abuse.
There is a wide range of treatment modalities that can be used for warts. The most well-studied are destructive therapies such as salicylic acid and cryotherapy. There are side effects from treatments such as pain, blistering, scarring and dyspigmentation from cryotherapy. HPV vaccination in children is useful in preventing certain subtypes of genital warts and those that may cause cancer.
Warts often spontaneously resolve with 33% clearing within the first 6 months, 66% within the first 2 years, and 90% within the first 5 years.
Treatment can hasten resolution of warts and often involve destructive therapies such as salicylic acid and cryotherapy.
HPV subtypes causing cancer are rare. Vaccination can significantly decrease the chance of acquiring HPV subtypes that cause genital warts and cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancer.
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Related Terms: Dermatology, warts, common warts, plantar warts, flat warts, mosaic warts, filiform/digitate warts, epidermodysplasia verruciformis, condyloma acuminata
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Spine Infections

Teaser: 

Jessica Albanese, MD,1 Brett Rocos, MB, ChB, MD, FRCS (Tr & Orth),2

1 Adult Spine Fellow, Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.
2 Assistant Professor of Orthopaedic Surgery, Division of Spine Surgery, Department of Orthopaedic Surgery, Duke University, Durham, NC, USA.

CLINICAL TOOLS

Abstract: Though they have significant morbidity and mortality, spine infections are a rare cause of back pain. Because they are uncommon, it is important to recognize the signs and symptoms of a spine infection, to establish the diagnosis, and to treat appropriately, guided by culture results, with antibiotic therapy. Surgical intervention is indicated in cases of significant neurologic deficit, significant spinal deformity, instability, and/or failed medical management.
Key Words:spinal infection, spondylodiscitis, discitis, vertebral osteomyelitis, epidural abscess, back pain.

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.

Pre-test CME Quiz Post-test CME Quiz
Patients with spine infections often present with back pain and may have radicular pain, neurologic deficits, or constitutional signs and symptoms of infection
Workup begins with laboratory studies including, CBC, CRP, and ESR
The gold standard for imaging is MRI
Definitive diagnosis may require CT-guided biopsy and culture
The mainstay of treatment is at least 6 weeks of antibiotic therapy guided by culture results
Surgical intervention is indicated in cases of progressive neurologic deficit or spinal deformity, instability, or failed medical management
Spinal infections can present insidiously
Refer early if patients present with back pain and unexplained fever
Prompt identification with MRI improves likelihood of recovery
Antibiotic treatment for 6 weeks is recommended
Surgery is useful for neurological deficit or instability
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Related Terms: Back Health, spinal infection, spondylodiscitis, discitis, vertebral osteomyelitis, epidural abscess, back pain

Dermatological Findings in Body-focused Repetitive Behaviours

Teaser: 

Amir Gohari1 Joseph M. Lam, MD, FRCPC,2

1 University of British Columbia, Vancouver, British Columbia, Canada.
2Department of Pediatrics, Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada.

CLINICAL TOOLS

Abstract: Body-focused repetitive behaviours (BFRBs) are common yet poorly understood conditions with significant mental and physical implications. Dermatological findings associated with BFRBs can be atypical, and recognizing them can be very beneficial. This paper reviews the dermatological findings associated with BFRBs, including habit-tic nail deformity, onychophagia, onychotillomania, trichotillomania, lip/cheek biting, dermatillomania, and compulsive washing. Recognition of these classic dermatological signs can help clinicians differentiate them from other common dermatological conditions. Body-focused repetitive behaviours require multidisciplinary management, and dermatology can contribute to their recognition and treatment.
Key Words:body-focused repetitive behaviours, dermatological findings, nail, hair, oral mucosa, skin.

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.

Pre-test CME Quiz Post-test CME Quiz
BFRBs are common yet poorly understood conditions with significant mental and physical implications.
Recognition of classic dermatological signs can help clinicians differentiate BFRBs from other common dermatological conditions.
Dermatological findings associated with BFRBs can be atypical, and recognizing them can be very beneficial.
BFRBs require multi-disciplinary management, and dermatology can contribute to their recognition and treatment.
Recognizing dermatological findings associated with BFRBs can help clinicians make an accurate diagnosis and develop an effective treatment plan.
BFRBs can cause significant physical and psychological harm and require a multi-disciplinary approach to management.
Early recognition and treatment of BFRBs can prevent long-term physical and psychological complications.
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Related Terms: Dermatology, body-focused repetitive behaviours, dermatological findings, nail, hair, oral mucosa, skin
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Principles of Geriatric Palliative Care

Teaser: 

Albert J. Kirshen, MD, FRCPC,

(Internal, Geriatric, Palliative Medicine), Emeritus Associate Professor, Dept. of Family and Community Medicine, Faculty of Medicine, University of Toronto, formerly consultant palliative care physician, The Temmy Latner Centre for Palliative Care, Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON.

CLINICAL TOOLS

Abstract: Palliative care aims to relieve suffering and enhance the quality of life for those with chronic, progressive or life-threatening illnesses. However, seniors' palliative care needs are often poorly recognized, assessed, or managed, resulting in adverse outcomes. This article explores the importance of recognizing, assessing, and managing symptoms for older adults needing palliative care. It offers insights into how physicians and healthcare providers can improve the quality of life for seniors by addressing their pain and symptom management needs.
Key Words: palliative care, symptom management, older adults, geriatrics, pain management, quality of life, recognition, assessment.
Palliative care aims to improve the quality of life for seniors with chronic, progressive or life-threatening illnesses.
Healthcare providers need to tailor symptom management to the unique characteristics of older adults, including cognitive and sensory impairments.
Recognition, assessment, and management of symptoms are critical components of palliative care.
A comprehensive approach that includes communication, pharmacological and non-pharmacological interventions can improve the quality of life for seniors in need of palliative care.
Communication with patients, caregivers, and other healthcare professionals is key to recognizing seniors’ palliative care needs.
Assessment of seniors’ symptoms should be tailored to their unique characteristics, including cognitive and sensory impairments.
A comprehensive approach that includes pharmacological and non-pharmacological interventions is essential for optimal symptom management in seniors.
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Related Terms: Caregiving, palliative care, symptoms, management, older adults, geriatric, pain management, quality of life, recognition, assessment

Diabetes Complications: Erectile Dysfunction

Teaser: 

Dean Elterman, MD, MSc, FRCSC,

Associate Professor, Division of Urology, University Health Network, University of Toronto, Toronto, ON.

CLINICAL TOOLS

A clear relationship, with shared risk factors, exists between diabetes, ED and CVD.
Use of ED as a harbinger of CVD is most predictive in younger men (ED may precede CVD by 2-5 yrs, 3 avg).
The identification of ED may allow for risk reduction and preventative measures in large numbers of men.
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Related Terms: Diabetes-Endocrine Disorders, diabetes, diabetic management, treatment, erectile dysfunction
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Diabetes Complications: Diabetic Nephropathy

Teaser: 

Louis-Philippe Girard, MD, MBT, FRCSC,

Clinical Nephrologist, Associate Professor, University of Calgary, Calgary, AB.

CLINICAL TOOLS

The hallmark of Diabetic Nephropathy is albuminuria. Albuminuria is a marker of poor renal and CV prognosis and should be identified in all patients where CKD is suspected.
Organ protection should be a priority in patients with DN. Very solid evidence exists for the SGTL2i class as it pertains to renal protection. Patients with DN are at very high risk of CV disease and its complications. There are robust data demonstrating CV protection when SGLT2i and GLP-1RAs are used in patients with DKD.
A1C control remains a critical component of preventing the progression of DN and can now be achieved in a safe manner with newer agents that do not cause hypoglycemia.
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Related Terms: Diabetes-Endocrine Disorders, diabetes, diabetic management, treatment, nephropathy
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Diabetes Complications: Diabetic Neuropathy

Teaser: 

Aaron Izenberg, MD, FRCSC,

Neurologist, Sunnybrook Health Sciences Centre, Assistant Professor, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Neuropathy is a very common complication of diabetes with sensorimotor neuropathy being the most common subtype of diabetic neuropathy
Other types of diabetic neuropathies include autonomic, treatment-induced, diabetic lumbosacral radiculoplexus, and mononeuropathies
Diagnostic testing for sensorimotor neuropathy includes bedside testing (e.g., Monofilament) and electrodiagnostic methods
Treatment of sensorimotor diabetic neuropathy includes achieving good glycemic control and appropriate use of pain medications
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Related Terms: Diabetes-Endocrine Disorders, diabetes, neuropathy, diabetic management, treatment
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