Property:Has featured journal abstract
From WikiMSK
This is a property of type Text.
F
Most diseases of the spine disproportionately impact older persons, with the modal (i.e., commonest) patient a female in their 8th decade of life. We examined the corpus of spinal RCTs to determine how many included "average" spine patients. We searched PubMed for randomized clinical trials published in the top 7 spine journals over a period of 5 years from 2016 to 2020 and extracted nominal upper age cut-offs and the distribution of ages actually recruited. We identified 186 trials of 26,238 patients. We found that only 4.8% of trials could be applied to an "average" 75-year-old patient. This age-based exclusion was not dependent on funding source. Age-based exclusion was exacerbated by explicit upper age cut-offs, however, the age-based exclusion went beyond explicit age cut-offs. Only few trials were applicable to older patients even amongst trials with no age cut-off specified. Age-based exclusion from clinical trials starts at late middle age. The mismatch between spinal patient's age seen in clinical practice and spinal patient's age in trials was so severe that over the 5 years (2016-2020) almost no RCT evidence was produced applicable to the "average" aged-patient across the body of literature available. In conclusion, age-based exclusion is ubiquitous, multifactorial, and happens on a supratrial level. Eliminating age-based exclusion involves more than an arbitrary lifting of explicitly stated upper age cut-offs. Instead, recommendations include increasing input from geriatricians and ethics committees, establishing updated or new models of cares, and creating new protocols to facilitate further research. +
Trigeminal neuralgia (TN) is a highly disabling disorder characterised by very severe, brief and electric shock like recurrent episodes of facial pain. New diagnostic criteria, which subclassify TN on the basis of presence of trigeminal neurovascular conflict or an underlying neurological disorder, should be used as they allow better characterisation of patients and help in decision-making regarding medical and surgical treatments. MR imaging, including high-resolution trigeminal sequences, should be performed as part of the diagnostic work- up. Carbamazepine and oxcarbazepine are drugs of first choice. Lamotrigine, gabapentin, pregabalin, botulinum toxin type A and baclofen can be used either alone or as add-on therapy. Surgery should be considered if the pain is poorly controlled or the medical treatments are poorly tolerated. Trigeminal microvascular decompression is the first-line surgery in patients with trigeminal neurovascular conflict while neuroablative surgical treatments can be offered if MR imaging does not show any neurovascular contact or where patients are considered too frail for microvascular decompression or do not wish to take the risk +
Patients with weakness or abnormal posture of their lower leg may benefit greatly from appropriate orthoses. This paper describes the sorts of problems that can be helped in
neurological practice and the range of devices commonly used, and also highlights some of the factors influencing selection. With greater understanding of their use, clinicians will feel more confident about referring patients for early orthotic assessment. +
This comprehensive review article revisits the validity and utility of comparative local anesthetic blocks, specifically in the diagnosis of spine pain. These blocks have provided an effective alternative to placebo controls. The discussion includes biostatistical principles involved in assessing the validity and clinical utility of diagnostic tests in relation to existing empirical studies. The review refutes recent claims questioning the clinical utility of these blocks, and highlights the need for studies that correctly test and compare the durations of action of the two anesthetic agents. It concludes that the validity of diagnostic tests is measured by likelihood ratios, and the clinical utility is measured by the diagnostic confidence provided by these likelihood ratios according to the prevalence of the condition being diagnosed. +
There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for “better research.” This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of “elder statesman” researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the “Budapest” criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient. +
This study compared the clinical and cost-effectiveness of transforaminal epidural steroid injection (TFESI) and surgical microdiscectomy for treating sciatica secondary to herniated lumbar discs. The randomized controlled trial involved 163 patients across 11 UK spinal units. At 18 weeks, the primary outcome of Oswestry Disability Questionnaire (ODQ) scores showed no significant difference between the TFESI and surgery groups. However, surgery had a higher rate of serious adverse events and was less cost-effective compared to TFESI. The researchers concluded that for patients with sciatica secondary to herniated lumbar discs and symptom duration up to 12 months, TFESI should be considered as the first invasive treatment option. +
