Lumbo-sacral radiculopathy referral decision-making and primary care management. A case report

Recognition and Management of Emergent Spinal Pathology Among First-Line Providers

Spinal emergencies require prompt identification, management, and surgical referral (if needed) from first-line providers. Diagnostic delays from a failure to recognize emergency conditions can lead to adverse patient outcomes. The objective of this study was to understand the proficiency with which first-line providers can recognize and manage spinal conditions, particularly spinal emergencies. This was a cross-sectional analysis of 143 internal medicine, family medicine, emergency care, and neurology questionnaires collected at a single-site academic center. Participants were predominantly physicians (88.1%, n=126), with a smaller percentage of midlevel providers (11.9%, n=17). Only 35.0% (n=50) of respondents felt "very prepared" to handle spinal emergencies. Bivariate analyses revealed interdepartmental differences in clinical knowledge pertaining to the management of lumbar radiculopathy (P<.0001), epidural abscess (P=.0002), and cervical myelopathy (P<.0001). Following pairwise comparisons of interdepartmental differences, emergency medicine statistically outperformed internal medicine (P=.0007) and neurology (P<.0001) on initial management of lumbar radiculopathy, while also having markedly higher success in identifying and managing epidural abscess with respect to family medicine (P<.0001). The likelihood of appropriate initial treatment of cervical myelopathy was significantly higher for neurology than for emergency medicine (P<.0001). A minority of first-line providers reported being very prepared to handle spinal emergencies. Disparities exist between first-line provider specialties regarding clinical knowledge in managing and proficiently identifying emergent and nonemergent spinal conditions. Because appropriate handling of emergent spinal pathologies is essential to patient outcomes and optimal resource use, measures should be taken to further educate first-line providers regarding the spinal conditions they will be treating. [Orthopedics. 2020;43(4):e244-e250.].

Development of an Evidence-Based Practical Diagnostic Checklist and Corresponding Clinical Exam for Low Back Pain

OBJECTIVE

The purpose of this study was to use scientific evidence to develop a practical diagnostic checklist and corresponding clinical exam for patients presenting with low back pain (LBP).

METHODS

An iterative process was conducted to develop a diagnostic checklist and clinical exam for LBP using evidence-based diagnostic criteria. The checklist and exam were informed by a systematic review focused on summarizing current research evidence for office-based clinical evaluation of common conditions causing LBP.

RESULTS

Diagnostic categories contained within the checklist and exam include nociceptive pain, neuropathic pain, and sensitization. Nociceptive pain subcategories include discogenic, myofascial, sacroiliac, and zygapophyseal (facet) joint pain. Neuropathic pain categories include neurogenic claudication, radicular pain, radiculopathy, and peripheral entrapment (piriformis and thoracolumbar syndrome). Sensitization contains 2 subtypes, central and peripheral sensitization. The diagnostic checklist contains individual diagnostic categories containing evidence-based criteria, applicable examination procedures, and checkboxes to record clinical findings. The checklist organizes and displays evidence for or against a working diagnosis. The checklist may help to ensure needed information is obtained from a patient interview and exam in a variety of primary spine care settings (eg, medical, chiropractic).

CONCLUSION

The available evidence informs reasonable working diagnoses for many conditions causing or contributing to LBP. A practical diagnostic process including an exam and checklist is offered to guide clinical evaluation and demonstrate evidence for working diagnoses in clinical settings.