ABSTRACT
Background: With increased restrictions following the COVID-19 pandemic, use of virtual care has shown an appreciable rise in clinical practice. Use of self-administrated surveys in triaging patients with low back pain assists with prioritizing care. The objective of this study was to assess the diagnostic value of a self-administrated, self-reported history questionnaire (SSHQ) in diagnosing patients with lumbar spinal stenosis (LSS), using combined clinical and imaging results as the gold standard. The SSHQ has 4 questions that all need to be true for a positive diagnosis of LSS. Methods: Patients with low back pain with and without leg symptoms who had a telephone interview with an advanced practice physiotherapist as a part of a new virtual care initiative were included. A score of 4 points on Q1-Q4 was indicative of the presence of LSS. The relationship between the SSHQ and the Oswestry Disability Index (ODI), the STarT Back questionnaire and the 5-repetition sit-to-stand Test was explored. Results: Data for 57 patients, of whom 26 were female (46%), with a mean age of 57 (standard deviation 17) years were analyzed. The majority of the patients had a diagnosis of radiculopathy (19 [33%] claudication type and 19 [33%] disc related). Of the remaining patients, 9 (16 %) had a mechanical low back pain, 5 (9%) had neurogenic claudication with bilateral symptoms, 3 (5 ) had degenerative disc disease and 2 (4 %) had peripheral joint involvement with referred pain. The SSHQ score did not correlate with the ODI, STarT Back or performance measure scores. The SSHQ did not differentiate the claudication-type radiculopathy or neurogenic claudication from the disc-related radiculopathy or other diagnoses. Patients whose symptoms were reduced by bending forward as the typical sign of LSS had a significantly lower STarT Back score (p = 0.015), indicating less risk of physical or psychological disability. Conclusion: The SSHQ did not clearly identify patients with and without LSS, potentially because 3 out of 4 SSHQ questions refer to symptoms that overlap with other diagnostic categories. The STarT Back risk categories appear to be more informative in the diagnosis of LSS.
ABSTRACT
The international standard treatment for mucopolysaccharidosis type I - Hurler syndrome (MPS1H) is haemopoietic stem cell transplant (HSCT) preceded by intravenous enzyme replacement therapy (ERT), with HSCT ideally undertaken before 18 months age to achieve best outcome. The invasive nature and high risk of morbidity and mortality associated with HSCT, in addition to a complex patient cohort, demands an extensive pre-transplant work-up to minimise risks where avoidable. This is achieved by collaboration between transplant and specialist paediatric LD-metabolic services. Transplant may be delayed due to clinical complications pre-transplant, but non-clinical disruptions have also been encountered in practice causing delays from time of diagnosis to transplantation. This work aimed to identify clinical complications and non-clinical disruptions in this process, and to identify areas of improvement for clinical practice, ultimately to achieve timely intervention and optimise clinical outcomes. A single-centre prospective clinical and procedural analysis of 7 MPS1H patients undergoing HSCT between April 2020 - January 2021 was completed. Age at diagnosis (median(range)) was 10 (1.5–25) months. Time from diagnosis to starting ERT (median(range)) was 10 (3–26) days. Time from diagnosis to transplant (median(range)) was 158 (101–189) days, with age at transplant 14 (6.5–30) months. Multiple reasons causing delay were identified. Clinical factors included presence of dilated cardiomyopathy, requirement for adenotonsillectomy to treat obstructive sleep apnoea, Covid-19 infection, vascular device infection, and acute neurosurgical issues including hydrocephalus requiring ventriculoperitoneal shunt and cervical spine stenosis requiring decompression. Non-clinical factors identified included late cancellation of required investigations, missed clinic appointments, and issues with accessing HSCT donors due to UK/European political situation and Covid-19 restrictions. Clear communication between teams was found to be a key identifying factor in ensuring timely completion of the pre-HSCT.
ABSTRACT
Introduction: To investigate the effects of the COVID-19 pandemic on epidural steroid injection treatment in elderly patients and to inform our colleagues to take possible precautions concerning treatment strategies. Materials and Methods: Retrospectively, patients who received lumbar epidural steroid injections between January 2019 and March 2021 were included in the study. The procedures performed between January 2019 and January 2020 before the pandemic were classified as Group A, and those performed during the pandemic period between March 2020 and March 2021 were classified as Group B. Demographic data, baseline pain scores, and waiting times for procedures and medical treatments in both groups were compared. Results: There were 186 and 81 patients in groups A and B, respectively. The mean age was 74 in Group B and 73 in Group A. Lumbar spinal stenosis and disc herniation were the most common diagnoses in both groups. The waiting time for epidural steroid injection was 39.4 days (0–160) in group B and 23.4 days (0–149) in group A. There was no significant difference between the two groups in terms of medical treatment for neuropathic pain. Conclusions: COVID-19 has caused a significant decrease and delay in the number of epidural procedures related to lower back pain in elderly patients. In the future, this decrease may create a burden on the health system. However, more observational and prospective studies are needed to inform our colleagues about the possible effects of COVID-19 on the elderly.
ABSTRACT
Introduction: COVID-19 occurred in late 2019 and subsequently spread globally, resulting in the declaration of the pandemic by the World Health Organization in March 2020. As a results, the increase in patients with COVID-19 affected general practice and reduced the number of outpatients due to patients' avoidance of consultation. The purpose of this study was investigating the influence of COVID-19 on patients underwent lumbar spine surgery at our hospital. Material and Methods: We retrospectively reviewed the medical records of patients who underwent thoracolumbar and lumbar spine surgery in our hospital from April 2019 to March 2021. The cohort was divided into two group according to before or after the pandemic of COVID-19. The number of outpatients and surgeries were counted in each group. From the medical records, information about age, gender, waiting period to the surgery and diseases for which surgery is required. The low back pain and leg pain were assessed using visual analogue scale (VAS) at the admission and discharge, respectively. Oswestry Disability Index (ODI) was measured to evaluate the functional disability at the admission and discharge. Results: The total number of outpatients and surgeries decreased after the pandemic of COVID-19, respectively (Pre-pandemic group: 17635 and 588, post-pandemic group: 15407 and 530). The mean ages in the pre-pandemic group and post-pandemic group were 64.5 years and 63.9 years, respectively, and there was no significant difference between two groups (P = 0.51). The waiting period to the surgery was significantly shorter in the post-pandemic group (35.8 days) than the pre-pandemic (45.6 days) (p < 0.01). The rate of patients with the lumbar herniation increased from 32% to 37% after the pandemic. In the total cohort, the averages of the VAS for the lower back pain, the VAS for the leg pain and ODI were higher in the post-pandemic group, however, there was no significant difference between two groups (Table 1). The VAS and ODI categorized by the disease are summarized in the (Tables 2 and 3) In patients with the lumbar herniation, the post-pandemic group had the significantly higher score in the preoperative VAS for leg pain (P = 0.02). On the other hand, the degenerative diseases included lumbar spinal canal stenosis and degenerative spondylolisthesis had no significant difference in VAS and ODI between the pre-pandemic and post-pandemic group. Conclusion: The number of outpatients in our hospital decreased due to the impact of COVID-19, resulting in the decrease of the lumber surgeries. Although the total cohort had no significant difference in VAS and ODI between the pre-pandemic and post-pandemic group, the patient with lumbar herniation had higher score of the preoperative VAS for the leg pain in post-pandemic group, indicating that COVID-19 could influenced the patients with lumbar herniation than the degenerative diseases. However, according to the postoperative VAS and ODI, it was considered that the COVID-19 didn't affect the prognosis after the surgery in the field of lumbar spine diseases. Table 1 Pre-Post Pandemic VAS and ODI.Table 1 Pre-Post Pandemic VAS and ODI. View larger version Table 2 Pre-Post Pandemic VAS and ODI in Lumbar Herniation Group.Table 2 Pre-Post Pandemic VAS and ODI in Lumbar Herniation Group. View larger version Table 3 Pre-Post Pandemic VAS and ODI in Degenerative Diseases.Table 3 Pre-Post Pandemic VAS and ODI in Degenerative Diseases. View larger version.
ABSTRACT
BACKGROUND: Transforaminal epidural injections have been used since the late 1990s to treat lumbar radicular pain. They have been the subject of considerable attention, with varying conclusions from systematic reviews as to their efficacy. Transforaminal injections have been associated with rare but major complications. Further, the use of transforaminal injections has increased since the passage of the Affordable Care Act. Finally, with the SARS-CoV-2 pandemic, there has been heightened concern regarding the risk associated with steroid injections. OBJECTIVES: To evaluate and update the effectiveness of transforaminal injections for 4 indications: radicular pain;from spinal stenosis;from failed back surgery syndrome;and for axial low back pain;and to evaluate the safety of the procedure. STUDY DESIGN: A systematic review and meta-analysis of the efficacy of transforaminal injections. METHODS: The available literature on transforaminal injections was reviewed and the quality assessed. The level of evidence was classified on a 5-point scale based on the quality of evidence developed by the US Preventive Services Task Force (USPSTF) and modified by the American Society of Interventional Pain Physicians (ASIPP). Data sources included relevant literature from 1966 to April 2020, and manual searches of the bibliographies of known primary and review articles. Pain relief and functional improvement were the primary outcome measures. A minimum of 6 months pain relief follow-up was required. RESULTS: For this systematic review, 66 studies were identified. Eighteen randomized controlled trials met the inclusion criteria. No observational studies were included. Eleven randomized controlled trials dealt with various aspects of transforaminal injections for radicular pain owing to disc herniation. Based on these studies, there is Level 1 evidence supporting the use of transforaminal injections for radicular pain owing to disc herniation. A meta-analysis showed that at both 3 and 6 months, there was highly statistically significant improvement in both pain and function with both particulate and nonparticulate steroids. For radicular pain from central stenosis there is one moderate quality study, with Level IV evidence. For radicular pain caused by failed back surgery syndrome there is one moderate quality study, with Level IV evidence. For radicular pain from foraminal stenosis and for axial pain there is Level V evidence, opinion-based/consensus, supporting the use of transforaminal injections. Transforaminal injections are generally safe. However, they have been associated with major neurologic complications related to cord infarct. Causes other than intraluminal injection of particulates appear to be at play. The use of an infraneural approach and of blunt needles appear to offer the greatest patient safety. Because of concern over the role of particulate steroids, multiple other injectates have been evaluated, including nonparticulate steroids, tumor necrosis factor alpha (TNF-a) inhibitors, and local anesthetics without steroids. No injectate has been proven superior. If there is concern about immunosuppression because of risk of COVID-19 infection, either the lowest possible dose of steroid or no steroid should be used. LIMITATIONS: The study was limited by the paucity of literature for some indications. CONCLUSIONS: There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations.
ABSTRACT
The new coronavirus disease, which started in Wuhan, quickly transformed into a pandemic and a life-threatening global infection. Understanding Covid-19-specific views can facilitate defining more accurate CT scan diagnostic criteria for this disease. These views include ground-glass opacity (GGO), consolidation, interlobular septal thickening, reticular, and crazy paving. This case series aimed to assess six Covid-19 patients displaying the target sign view in lung CT scans.
ABSTRACT
Coronavirus disease 2019 (COVID-19) has led to a global pandemic with the recent demonstration of several neurological manifestations. While there are limited reports of neurologic involvement in the context of COVID-19 infection, recent evidence has established the neuroinvasive potential of the virus. A 57-year-old man was diagnosed with COVID-19 via a polymerase chain reaction test and treated as an outpatient with a combination of prednisone and azithromycin. Nine days after his initial diagnosis, he was admitted to the intensive care unit for acute respiratory failure where he required high-flow oxygen support at a maximum of 60 L/minute. Ten days after his admission to the intensive care unit, he was discharged requiring no oxygen at rest, but 2-3 L/minute with exertion. Nine days after his discharge, he was readmitted with a six-day history of bilateral lower extremity weakness, low back pain, diminished sensation, bowel and bladder incontinence, and decreased rectal sensation and tone. Evaluation for cauda equina syndrome was unremarkable; however, cervical magnetic resonance imaging revealed severe central cervical stenosis of C3-4 and C4-5 with spinal cord flattening and intraparenchymal T2 hyperintensity. The examination was notable for muted reflexes in the bilateral lower extremities, T10 sensory level, decreased rectal tone, and ambulation with a walker. Cerebrospinal fluid analysis revealed an albuminocytologic dissociation. Treatment with intravenous dexamethasone and immunoglobulin resulted in partial motor resolution and complete resolution of his bowel and bladder incontinence within three days of treatment. In the face of this novel global pandemic, surgeons and clinicians should carefully evaluate patients presenting with neurologic deficits and ensure a thorough examination to accurately identify the appropriate etiology for a neurologic deficit.