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Surgical Management of Spondyloarthropathies in the Age of Disease Altering Drugs

Teaser: 

1Mosaab Alsuwaihel, MD, 2Sean Christie, MD,

1PGY4 Dalhousie Neurosurgery Program, Dalhousie University, Halifax, NS. 2Professor, Department of Surgery (Neurosurgery), Faculty of Medicine, Vice-Chair and Director of Research , Division of Neurosurgery, Dalhousie University.

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Abstract: Inflammatory spondyloarthropathies produce synovitis of the spinal joints in rheumatoid arthritis (RA), or enthesitis in ankylosing spondylitis (AS). In RA, progressive disease leads to synovial destruction, ligamentous laxity, pannus formation and deformity. In AS progressive enthesitis results in ascending ossification, kyphotic deformity and rigidity which increase the risk of fracture. Although pain is the common presentation, spinal cord compression can produce neurological deficits. Although the need for surgery has decreased with the advent of new disease altering drugs, there remains a number of indications when surgical consultation remains important.
Key Words: Spondyloarthropathy and spondyloarthritis, Synovium and synovitis, Enthesis and enthesitis, Pannus.

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1. Inflammatory arthritis from multiple etiologies may affect the spine with different patterns and pathophysiology.
2. Rheumatoid arthritis is a disease of synovial inflammation and in advanced disease leads to synovitis within the atlanto-dental articulation and the facet joints of the spine.
3. If left untreated atlantoaxial subluxation, cranial settling and pannus formation may lead to spinal cord and lower medullary compression.
4. Seronegative arthropathies leads to an enthesitis of the spine, usually starting in the sacroiliac spine and ascending with progressive ossification.
5. As a consequence of pathological alteration of the spine biomechanics, trauma in the setting of ankylosing spondylitis leads to different fracture patterns with a high chance of instability even after minimal trauma.
1. Early and adequate treatment of rheumatoid arthritis can prevent advanced atlanto-axial disease, deformity and neurological injury.
2. Even minimal trauma to the spine in a patient with ankylosing spondylitis has a high risk of instability and neurological injury; detailed imaging is always warranted.
3. With the advent of modern disease modifying agents for the treatment of spondyloarthropathies, the requisite for surgery has decreased but there remain important indications.
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Related Terms: Back Health, Spondyloarthropathy and spondyloarthritis, Synovium and synovitis, Enthesis and enthesitis, Pannus
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Athletes and their Hearts: What the Primary Care Physician Should Recognize

Teaser: 

Dr. Marina Abdel Malak

is a Family Medicine Resident at the University of Toronto. She graduated and completed her Bachelor of Science in Nursing and went on to study Medicine. She has a passion for medical education, patient empowerment, and increasing awareness about the relationship between mental, emotional, and physical health.

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Abstract: Physicians will undoubtedly follow athletic patients in their practice, and must therefore be aware of the cardiac adaptations that occur in these patients. Athletic heart syndrome (AHS) is a term used to describe the physiologic adaptation (leading to cardiac hypertrophy and/or dilation) that the heart undergoes in response to intense physical activity. Although these are adaptive responses, physicians need to ensure that these changes are not due to pathological causes such as hypertrophic cardiomyopathy, other genetic or congenital disorders, etc. To do so, physicians must take a through history from the athlete (including family history), conduct a physical exam, and order investigations (such as ECGs, an echocardiograph, etc.) as appropriate. If a pathologic cause is not identified and AHS is noted to be the sole cause of these changes, the athlete should still be counselled on how to safely participate in physical activity.
Key Words: Athletes, cardiovascular care, sports medicine, primary care, screening.
Athletic heart syndrome (AHS) is a physiologic adaptation hypertrophy and/or dilation of the heart that allows for increased stroke volume, decreased heart rate, and increased blood flow and oxygen delivery
The hypertrophy and/or dilation that occurs in AHS can mimic serious illnesses that must be ruled out
To differentiate between AHS and pathological causes of AHS, the physician should take a history and conduct a physical exam. Echocardiography and an ECG are also important
A family history of sudden cardiac death (SCD) is a 'red flag' that must be investigated further
Inquire and investigate for symptoms such as syncope, shortness of breath, connective tissue changes, lab abnormalities, etc. It is important to keep the differential diagnosis broad to ensure a serious cardiovascular condition isn't missed
An echocardiogram should be ordered to assess cardiac function and look for structural changes in the heart
When other causes have been ruled out, AHS may be diagnosed. Although this is not inherently dangerous in itself, all athletes engaging in strenuous activity require counselling and advice around warming up, pacing activity, etc.
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Related Terms: Cardio-Cerebrovascular, athletes, cardiovascular care, sports medicine, primary care, screening
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Primary Care Approach to Degenerative Cervical Myelopathy

Teaser: 

1Ali Moghaddamjou, MD,2Jetan H. Badhiwala, MD,3Michael G. Fehlings. MD, Phd, FRCSC, FACS,

1Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. 2Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. 3Division of Neurosurgery, Department of Surgery, University of Toronto, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.

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Abstract: Degenerative cervical myelopathy is an umbrella term describing all degenerative conditions that present with cervical myelopathy due to compression of the spinal cord. The role of primary care physicians (PCPs) in early identification is vital as delayed diagnosis can lead to irreversible neurological impairment. Patients often present with subtle neurological deficits associated with neck or upper extremity pain. Screening for upper motor neuron signs, gait disturbances, fine motor abnormalities and bowel bladder symptoms is critical. Currently, surgical decompression is the treatment of choice but with future advancements in non-operative treatments, PCPs are expected to play a larger role in treatment plans.
Key Words: degenerative cervical myelopathy, primary care, cervical spondylotic myelopathy, degenerative disc disease.

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

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PCPs play a vital role in the management of DCM as a delayed diagnosis can lead to irreversible neurological impairment.
A heightened level of awareness with a comprehensive history and a focused physical examination are essential.
With advancements in biomarkers and emerging neuroprotective and regenerative agents, we can expect an increased role in the primary care medical management of DCM patients soon.
The approach to DCM management is multidisciplinary and generally will involve PCPs, spinal surgeon, physiotherapist, pain specialist, and neurologist.
Patients with query bilateral carpal tunnel syndrome should be assessed for DCM.
Patients with moderate to severe DCM or unequivocal progression of mild DCM require surgical treatment while there exists clinical equipoise between structured non-operative therapies and surgical decompression for mild non-progressive cases of DCM.
Clinically monitor patients with mild DCM frequently and carefully for subtle signs of neurological progression
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Related Terms: Back Health, degenerative cervical myelopathy, primary care, cervical spondylotic myelopathy, degenerative disc disease
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Frailty in Adult Spine Surgery—A Clinical Update

Teaser: 

1Eryck Moskven, MD,2Raphaële Charest-Morin, MD, FRCSC,

1PGY 1, Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC. 2Clinical Assistant Professor, Combined Neurosurgical and Orthopaedic Spine Program, Vancouver General Hospital, University of British Columbia, Vancouver, BC.

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Abstract: Purpose: Frailty is a state of increased vulnerability. This paper reviews the definitions and applicability of frailty tools and discusses the impact of frailty in patients with spinal disease.
Recent Findings: Frailty is a significant risk factor for postoperative adverse-events (AEs), prolonged postoperative length of stay (LOS), adverse discharge disposition, and mortality following spine surgery. Cumulative deficit measures such as the mFI are appropriate risk stratification tools, while phenotypic measures are sensitive to capturing the relationship between spine disease and spine surgery on the frailty trajectory.
Summary: Frailty in patients with spinal disorders is predictive of postoperative adverse outcomes. The role of spine surgery to reverse frailty requires investigation.
Key Words: frailty, spine surgery, adverse outcomes, geriatric.

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

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Frailty is a state of decreased reserve and increased vulnerability associated with adverse health outcomes.
Clinical frailty measures derived from the cumulative deficit model of frailty such as the mFI are appropriate risk stratification tools for identifying patients at an increased risk of postoperative AEs following spine surgery.
Frailty tools with phenotypic constructs are the most sensitive measures in capturing the relationship between spinal pathology and surgical intervention on the frailty trajectory.
When assessing an elderly patient, the FRAIL acronym is a helpful guide to screen for frailty - F (fatigue), R (resistance/muscular weakness), A (ambulatory difficulty), I (illness and comorbidities), and L (unintentional loss of weight).
Access to a readily available clinical frailty assessment tool on a mobile device, such as the Clinical Frailty Scale (CFS), reduces the need for extensive chart review to calculate and determine frailty severity.
When assessing for surgical candidacy the clinician should evaluate the impact of spinal pathology on health-related quality of life, the magnitude of the proposed surgical intervention and the frailty status.
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Related Terms: Back Health, frailty, spine surgery, adverse outcomes, geriatrics
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Common Myths about mRNA COVID-19 Vaccine

Teaser: 

Zainab Abdurrahman, BSc, MMath, MD, FRCPC (Paediatrics), FRCPC (Clinical Immunology and Allergy)

Assistant Clinical Professor (Adjunct) of Paediatrics, McMaster University, Hamilton, ON.

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Abstract: There are many concerns the general population has over the new mRNA vaccines that have been produced and are now being distributed in countries around the world to help curb the spread of COVID-19. This review helps to debunk the myths around some of the more common concerns.
Key Words: COVID-19, vaccines, mRNA, trials, studies.
The mRNA vaccine is safe and effective for the prevention of COVID-19.
The two mRNA vaccines approved for use in Canada are the Pfizer-Biontech and the Moderna vaccine.
The Ministry of Health updated their guidelines indicating that the vaccine is still recommended for those with allergies.
It is important to discuss and dispel the myths that patients may have surrounding the mRNA vaccines.
The vaccine is safe and effective for the prevention of COVID-19.
Despite the safety and efficacy of the vaccine, patients who receive it should be reminded to continue wearing a mask and physically distance and follow public health guidelines.
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Related Terms: Infectious Diseases, COVID-19, vaccines, trials, studies, mRNA
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The COVID-19 Vaccine: Communicating with Patients

Teaser: 

Dr. Marina Abdel Malak

is a Family Medicine Resident at the University of Toronto. She graduated and completed her Bachelor of Science in Nursing and went on to study Medicine. She has a passion for medical education, patient empowerment, and increasing awareness about the relationship between mental, emotional, and physical health.

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Abstract: The COVID-19 pandemic has challenged providers and patients in several ways. The news of a vaccine has sparked both hope and doubt among our communities. Healthcare providers are in optimal positions to educate patients about the COVID-19 vaccine, and to dispel myths. This article aims to provide quick facts about the vaccine, tips to navigate around vaccine hesitancy, and resources to share with patients.
Key Words: COVID-19, vaccine, pandemic, resilience.
The COVID-19 vaccine is available and indicated for most patients > 16 years old, in a 2-dose series (with 21 days between first and second dose)
There is a spectrum of 'vaccine hesitancy' among individuals. Tailoring conversations to patients is essential in helping to navigate discussions around receiving vaccines
Data shows that the COVID-19 vaccine is about 95% effective in preventing the virus, with side effects similar to 'routine' vaccines
It is the responsibility of healthcare providers to dispel myths about vaccines, and to empower patients to understand the importance of vaccination when indicated
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: Caregiving, COVID-19, vaccines, pandemic, resilience
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When to Scratch Beyond the Surface of the Diagnosis—A look at Atopic Dermatitis Mimickers and Their Response to Topical Corticosteroids

Teaser: 

Briar Findlay1Joseph M. Lam, MD, FRCPC,2

1 Paediatric Resident, BC Children's Hospital, Vancouver, BC.
2Associate Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia.

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Abstract: Many dermatoses occur in the pediatric population that can mimic atopic dermatitis based on their morphology or their propensity for triggering itch. This review will highlight some of the common skin conditions that can mimic atopic dermatitis, their typical response to topical corticosteroids and helpful features that can help distinguish these conditions from atopic dermatitis.
Key Words: atopic dermatitis mimickers, topical corticosteroids, chronic inflammatory skin disease, paediatrics.
Many dermatitic eruptions can mimic atopic dermatitis but features such as their typical response to topical corticosteroids can be a helpful distinguishing feature.
Some atopic dermatitis mimickers can worsen with topical corticosteroids and these include periorificial dermatitis and tinea corporis.
Some atopic dermatitis mimickers will only partially improve with topical corticosteroids alone and these include allergic contact dermatitis and molluscum dermatitis.
Other atopic dermatitis mimickers such as psoriasis and seborrheic dermatitis can respond to topical corticosteroids and the correct diagnosis can be made using other morphological or historical features.
AD is a prevalent, chronic and relapsing condition in infancy and childhood.
Morphology, distribution and age of onset can be important in distinguishing between AD and common mimickers.
Response to corticosteroids is not diagnostic for AD as many mimickers may have an initial or complete response to topical corticosteroids; however, corticosteroid usage in some mimickers of AD may lead to complications and unnecessary side effects of topical corticosteroids.
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Related Terms: Dermatology, atopic dermatitis mimickers, topical corticosteroids, chronic inflammatory skin disease, paediatrics
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Community Resources for Management of Back Pain

Teaser: 

1Naazish Shariff, BHSc. Candidate, 2Eugene K. Wai, MD, MSc, CIP, FRCSC,

1Faculty of Health Science, University of Ottawa, Ottawa, ON. 2Head—University of Ottawa Combined Adult Spinal Surgery Program, Associate Professor—Division of Orthopaedic Surgery, University of Ottawa, Cross Appointment to School of Epidemiology and Public Health, Ottawa, ON.

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Abstract:Back pain is a community level health problem because of the high prevalence and burden on patients, health care and society. Many aspects of back management, such as exercise and psychosocial stress management, are suitable for a community model of care. Community models for back pain are in their infancy but lessons learned from other chronic diseases can be applied and will be discussed. This review will discuss existing evidence-based community programs, such as Exercise is Medicine® and the Stanford Model, that support exercise and self-management, and their relevance to low back pain.
Key Words: back pain, community model of care, self-management, exercise, lifestyle risk factors.

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

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Many aspects of back management such as exercise and promotion of self-management are more suited for a community model of care.
Physicians and other health care providers are important catalysts for change and must support patient engagement.
Health care practitioners should identify resources within their community as well as develop their own local creative solutions.
Evidence-supported models for community involvement in managing chronic diseases are available. This article provides resources enabling practitioners to identify these programs in their community and tailor them for their back pain patients.
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Related Terms: Back Health, back pain, community model of care, self-management, exercise, lifestyle risk factors
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Spinal Injuries among Paediatric Patients

Teaser: 

Dr. Khaled Almansoori, MD, M.Ed, FRCSC,

Adult & Paediatric Spine Surgeon, Department of Orthopaedic Surgery, Advocate Christ Medical Center, Illinois, USA.

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Abstract:Due to the distinctive anatomic and biomechanical features of the growing paediatric spine, children are susceptible to unique patterns of spinal injuries. Although clinical examination can help guide management, physicians are often required to rely on advanced imaging. Imaging interpretation can be challenging when considering that abnormal parameters among adults, are often within normal physiological limits in children. In general, spinal injuries in children younger than nine years of age are often managed non-operatively, while adolescents are typically managed by adult treatment principles. With the exception of neurologic injuries, most paediatric spinal injuries demonstrate good to excellent prognosis and outcomes.
Key Words: fracture, injury, spine, paediatric, children.

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

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Due to the unique properties of the growing spine, including greater elasticity, osseous plasticity, presence of growth centers, relatively strong ligaments, and greater joint mobility, paediatric patients are susceptible to unique fracture patterns and injuries.
There are absolute contraindications regarding return to play decisions.
Children under 13 years of age with vertebral body compression fractures can progressively restore their vertebral height until skeletal maturity.
The vast majority of spine injuries among children under nine years of age, even when relatively unstable, can be managed non-operatively.
Pre-adolescent patients with complete spinal cord injuries are at high risk for developing progressive scoliosis and have not been shown to demonstrate any better neurological outcomes when compared to adults.
The cervical spine is the commonest area of spine injuries with the C1-3 vertebral levels being more commonly seen in children under eight years of age.
A standard immobilization board should not be used for children under eight years of age without an occipital recess or 2-3cm of padding to elevate their body relatively to their head.
Adult radiographic spinal parameters are often unreliable in children and severe neurologic injuries can be sustained in spite of normal imaging results.
Clinical examination is fairly unreliable for identifying spinal column injuries among pre-school patients and it is often necessary to rely on advanced imaging.
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Related Terms: Back Health, fracture, injury, spine, paediatric, children
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Epiglottitis: An Under-recognized, Life-Threatening Infection

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Teaser: 

Dr. Pradeep Shenoy, MD, FRCS, FACS, DLO,1
Marah Mansour2

1ENT & Neck Surgeon, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.
2Faculty of Medicine, Tartous University, Tartous, Syrian Arab Republic.

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Abstract:Acute Epiglottitis is a potentially life threatening infection of the supraglottic structures, epiglottis and aryepiglottic folds causing fatal airway obstruction. Historically described in adults before the 1960s and after the 1960s in the paediatric group causing more mortality and morbidity until the introduction of the H. influenza type B vaccine in 1993. Since then the incidence was described again more in the adult group.6 Prompt diagnosis and treatment will save the patients if failed mortality is as high as 80% in children and 20% in adults.2
Key Words: Epiglottis, H. Influenza Type B, Aspergillus, Kliebsiella, Candida, Fibroptic laryngoscopy, Humidified oxygen therapy, orotracheal intubation, naso-tracheal intubation, tracheostomy thumb sign.
Epiglottits is an acute emergency in ENT practice as mortality is high in children at about 80% and 20% in adults.
Before the 1960s epiglottitis was not seen in the paediatric group.
Since the invention of H. influenza type B vaccine the numbers in the paediatric group has declined though in adults it remains the same as there are other bacteria and fungus involved in immune compromised patients .
Acute epiglottitis is potentially life threatening both in children and adults. Prompt diagnosis with clinical examination complimented with radiographic investigation depending on the severity of cases and early treatment could save the patient
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Related Terms: Otolaryngology, epiglottis, H. Influenza Type B, Aspergillus, Kliebsiella, Candida, Fibroptic laryngoscopy, Humidified oxygen therapy, orotracheal intubation, naso-tracheal intubation, tracheostomy thumb sign
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