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Objective Conservative management of cervical radiculopathy (CR) is a first treatment option because the risk–benefit ratio for surgery is less favorable. Systematic reviews and clinical practice guidelines reporting on the effectiveness of nonsurgical management have not considered the timing of management. The aim of this study was to establish consensus on effective nonsurgical treatment modalities at different stages (ie, acute, subacute, or chronic) of CR using the Delphi method approach. Methods Through an iterative multistage process, experts within the field rated their agreement with a list of proposed treatment modalities according to the stage of CR and could suggest missing treatment modalities. Agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round. Consensus for Round 3 was based on ≥2 of the following: a median Likert scale value of ≥4, interquartile range value of ≤1, and/or a percentage of agreement ≥70%. Results Data analysis produced a consensus list of effective treatment modalities in different stages of recovery. Conclusion According to experts, the focus of multimodal management in the acute stage should consist of patient education and spinal manipulative therapy, specific (foraminal opening) exercises, and sustained pain-relieving positions. In the subacute stage, increasing individualized physical activity including supervised motor control, specific exercises, and/or neurodynamic mobilization could be added. In the chronic stage, focus should shift to include general aerobic exercise as well as focused strength training. Postural education and vocational ergonomic assessment should also be considered. Impact Multimodal conservative management of individuals with CR should take the stage of the condition into consideration. The focus of therapeutic interventions should shift from passive pain-relieving intervention in the acute stage to increasingly more individualized physical activity and self-management in the chronic stage. [ABSTRACT FROM AUTHOR]

Objectives: Facial palsy is the most common manifestation of Lyme neuroborreliosis (LNB) in the United States. This study aimed to describe features of patients with early LNB presenting with facial palsy and to determine if corticosteroids in addition to antibiotic therapy was associated with unfavorable outcome. Methods: Retrospective analysis of participants enrolled in clinical studies investigating Lyme disease (N = 486) identified 44 patients who had facial palsy from LNB. The House–Brackmann scale was used to quantify the facial nerve dysfunction. Results: Most patients presented in the summer months. Erythema migrans, frequently associated with systemic symptoms, occurred in 29 patients. Thirteen patients presented with bilateral facial palsy, usually with sequential involvement. Fourteen patients had painful radiculopathy. Of the 38 patients treated with antibiotics before the resolution of the palsy who had complete follow‐up, 24 received both antibiotics and corticosteroids. Of these 38 patients, 34 recovered completely, 3 had nearly complete recovery, and 1 had moderate dysfunction. There were no differences between the treatment groups in achieving complete resolution of the palsy at 12 months or in time to complete recovery. Interpretation: A history of rash compatible with erythema migrans or febrile illness in the weeks preceding the palsy are helpful clues pointing toward LNB and should be actively sought when evaluating patients with acute‐onset peripheral facial palsy, particularly bilateral facial palsy. Treatment with antibiotic therapy is highly effective and most patients will fully recover facial nerve function. Adjunctive corticosteroid therapy appears to not affect the speed of recovery or overall outcome in this retrospective observational study. [ABSTRACT FROM AUTHOR]

Objective Pain in fibromyalgia (FM) and chronic fatigue syndrome (CFS) is assumed to originate from central sensitization. Perineural cysts or Tarlov cysts (TCs) are nerve root dilations resulting from pathologically increased cerebrospinal fluid pressure. These cysts initially affect sensory neurons and axons in dorsal root ganglia and produce sensory symptoms (pain and paresthesia). Symptomatic TC (STC) patients often complain about widespread pain and fatigue. Consequently, STC patients may initially be diagnosed with FM, CFS, or both. The objective of this study was to document the prevalence of TCs in patients diagnosed with FM or CFS. Design A retrospective study. Setting An outpatient clinic for musculoskeletal disorders. Subjects Patients diagnosed with FM according to the 1990 American College of Rheumatology criteria or with CFS according to the 1994 Centers for Disease Control criteria were selected. Methods Review of lumbar and sacral magnetic resonance imaging scans including TCs ≥5 mm in size. Results In total, 197 patients with FM, CFS, or both underwent magnetic resonance imaging. Ninety-one percent were women. The mean age was 48.1 (±11.9) years. TCs were observed in 39% of patients, with a mean size of 11.8 (±5.2) mm. In males, the prevalence was 12%, vs. 42% in females. Conclusions In patients diagnosed with FM or CFS, the prevalence of TCs was three times higher than that in the general population. This observation supports the hypothesis that STCs, FM, and CFS may share the same pathophysiological mechanism, i.e. moderately increased cerebrospinal fluid pressure, causing irritation of neurons and axons in dorsal root ganglia. [ABSTRACT FROM AUTHOR]

Background Context: Cervical disc replacement (CDR) has increased in popularity over the past decade based on published outcomes from FDA IDE studies with narrowly defined inclusion and exclusion criteria. A low rate of complications was noted in these studies. The broader complication profile for CDR in widespread clinical practice has yet to be described.Purpose: To outline the complications reported to the FDA regarding commonly used CDR products STUDY DESIGN/SETTING: Retrospective database review PATIENT SAMPLE: Nationwide database of reported complications related to CDR products from patients across the country OUTCOME MEASURES: Complications related to CDR METHODS: We queried the MAUDE database and Alternative Summary Reporting (ASR) data files submitted between January 2005 to March 2020. The complications listed for seven FDA-approved CDR implants were analyzed. The entries in the databases were cataloged for complication type, date of entry, source of report, and whether the investigation was "complete". Reports that had too little information to extract relevant data were excluded.Results: There were 1,517 entries identified in the MAUDE database. After removal of duplicate entries and entries without sufficient information, there were 1,347 entries analyzed. The top five complications were (1) migration of implant (338 entries, 25.2%) (2) insertion problem/failure (312 entries, 23.3%) (3) neck pain (203 entries, 15.2%) (4) heterotopic ossification (108 entries, 8.1%) and (5) radiculopathy (90 entries, 8.1%). The number of analyzed implant-related MAUDE entries and most common implant-related complication for each implant was 209 entries for insertion problem/failure for Mobi-C; 158 entries for migration of implant for ProDisc-C; 154 entries for insertion problem/failure for Bryan cervical disc; 130 entries for migration of implant for Prestige cervical disc; 49 entries for migration of implant for PCM cervical disc; 12 entries for migration of implant for M6 and 10 entries for migration of implant for Secure-C. Only 263 entries (19.5%) were deemed "complete". Most entries were from the manufacturer/company representative/distributor (923 entries, 70%). There were no entries related to cervical disc replacement devices within the ASR data.Conclusions: The MAUDE database highlights complications related to CDR implants that may not be emphasized in currently published studies. It is important to understand this broad complication profile for CDR to ensure safe utilization of this new technology. [ABSTRACT FROM AUTHOR]

Spinal epidural lipomatosis (SEL) is a rare pathologic growth of histologically normal nonencapsulated adipose tissue in the epidural space. It can cause myelopathy or radiculopathy. Etiologies include chronic exposure to endogenous or exogenous steroids and obesity. Idiopathic forms are much infrequent. We present a case of lumbar SEL compressing the thecal sac in a 50-year-old female patient. [ABSTRACT FROM AUTHOR]

Study Objective: To provide a contemporary medicolegal analysis of claims brought against anesthesia providers in the United States related to neuraxial blocks for surgery and obstetrics.Design: In this retrospective analysis, we analyzed closed claims data from the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System (CBS) database between 2007 and 2016.Setting: Closed claims from inpatient and outpatient settings related to neuraxial anesthesia for surgical procedures and obstetrics.Patients: Forty-five claims were identified for analysis. These patients underwent a variety of surgical procedures, included both children and adults, and with ages ranging from 6 to 82.Interventions: Patients receiving neuraxial anesthesia (spinals, epidurals) for surgery or obstetrics.Measurements: Data collected includes patient demographics, alleged injury type/severity, surgical specialty, likely contributors to the alleged damaging event, and case outcome. Some of the data were drawn directly from coded variables in the CRICO database, and some were gathered from narrative case summaries.Main Results: Settlement payments were made in 20% of claims. Reported adverse outcomes ranged from temporary minor to permanent major injuries. Most closed claims were classified as permanent minor injuries. The greatest number of claims involved residual weakness and radiculopathy resulting from epidurals. The largest contributing factor to these injuries was noted to be "Technical Knowledge/Performance" of the anesthesia provider followed by "Missing or Documentation Error." Over half of the claims arose from obstetric patients (31%) and patients undergoing orthopedic surgery (27%).Conclusions: Patients with pre-existing radiculopathy or comorbidities may warrant more thorough informed consent about the increased risk of injury. Additionally, prompt follow-up, monitoring, and documentation of post-operative symptoms, such as weakness or radiculopathy, are crucial for improving patient safety and satisfaction. More timely communication with the patient and the surgical team regarding residual neurologic symptoms is important for earlier diagnosis of injury. [ABSTRACT FROM AUTHOR]

Background Context: Posterior cervical fusion (PCF) with decompression is a treatment option for patients with conditions such as spondylosis, spinal stenosis, and degenerative disc disorders that result in myelopathy or radiculopathy. The annual rate, number, and cost of PCF in the United States has increased. Far fewer studies have been published on PCF outcomes than on anterior cervical fusion (ACF) outcomes, most likely because far fewer PCFs than ACFs are performed.Purpose: To evaluate the patient-reported and clinical outcomes of adult patients who underwent subaxial posterior cervical fusion with decompression.Study Design/setting: Systematic review and meta-analysis.Patient Sample: The total number of patients in the 31 articles reviewed and included in the meta-analysis was 1,238 (range 7-166).Outcome Measures: Preoperative to postoperative change in patient-reported outcomes (visual analog scales for arm pain and neck pain, Neck Disability Index, Japanese Orthopaedic Association [JOA] score, modified JOA score, and Nurick pain scale) and rates of fusion, revision, and complications or adverse events.Methods: This study was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a preapproved protocol. PubMed and Embase databases were searched for articles published from January 2001 through July 2018. Statistical analyses for patient-reported outcomes were performed on the outcomes' raw mean differences, calculated as postoperative value minus preoperative value from each study. Pooled rates of successful fusion, revision surgery, and complications or adverse events, and their 95% confidence intervals, were also calculated. Two subgroup analyses were performed: one for studies in which only myelopathy or radiculopathy (or both) were stated as surgical indications and the other for studies in which only myelopathy or ossification of the posterior longitudinal ligament (or both) were stated as surgical indications. This study was funded by Providence Medical Technology, Inc. ($32,000).Results: Thirty-three articles were included in the systematic review, and 31 articles were included in the meta-analysis. For all surgical indications and for the 2 subgroup analyses, every cumulative change in patient-reported outcome improved. Many of the reported changes in patient-reported outcome also exceeded the minimal clinically important differences. Pooled outcome rates with all surgical indications were 98.25% for successful fusion, 1.09% for revision, and 9.02% for complications or adverse events. Commonly reported complications or adverse events were axial pain, C5 palsy, transient neurological worsening, and wound infection.Conclusions: Posterior cervical fusion with decompression resulted in significant clinical improvement, as indicated by the changes in patient-reported outcomes. Additionally, high fusion rates and low rates of revision and of complications and adverse events were found. [ABSTRACT FROM AUTHOR]

Neck pain from cervical spine disorders is the second-leading cause of musculoskeletal disorders. Neck pain can exist alone or with the presence of upper extremity symptoms. This review of evidence-based guidelines assists the provider in identifying and treating various cervical disorders. [ABSTRACT FROM AUTHOR]

* BACKGROUND: Thoracic spine thrust manipulation has been shown to improve patient-rated outcomes for individuals with neck pain. However, there is limited evidence of Its effectiveness in patients with cervical radiculopathy. * OBJECTIVES: To compare the immediate and short-term effects of thoracic manipulation to those of a sham thoracic manipulation in patients with cervical radiculopathy. * METHODS: In this multicenter randomized controlled trial, participants with cervical radiculopathy were randomized to receive either manipulation (n = 22) or sham manipulation (n = 21) of the thoracic spine. Outcomes were measured at baseline, immediately after treatment, and at a follow-up 48 to 72 hours after manipulation. A repeated-measures analysis of variance was used to analyze neck and upper extremity pain (numeric pain-rating scale), disability (Neck Disability Index), cervical range of motion (ROM), and endurance (deep neck flexor endurance test). The chi-square test was used to analyze changes in neck and upper extremity pain, centralization of symptoms, and beliefs about receiving the active manipulation treatment using a global rating of change scale. * RESULTS: Neck and upper extremity pain, cervical ROM, disability, and deep neck flexor endurance all showed significant interactions between group and time (P<.01). Immediately after treatment and at the 48-to-72-hour follow-up, the manipulation group had lower neck pain (P<.01), better cervical ROM (P<.01), lower disability (P<.01), and better deep neck flexor endurance (P = .02) compared to the sham manipulation group. The manipulation group had moderate to large effect-size changes over time. No between group differences for upper extremity pain were found immediately following the intervention (P = .34) and at 48 to 72 hours after the intervention (P = .18). At 48 to 72 hours after treatment, a greater proportion of participants in the manipulation group reported improvement (global rating of change scale score of 4 or greater) in neck and upper extremity symptoms (P<.01), centralization of symptoms (P<.01), and beliefs about receiving an active manipulation (P = .01) compared to the sham manipulation group. CONCLUSION: One session of thoracic manipulation resulted in improvements in pain, disability, cervical ROM, and deep neck flexor endurance in patients with cervical radiculopathy. Patients treated with manipulation were more likely to report at least moderate change in their neck and upper extremity symptoms up to 48 to 72 hours following treatment. [ABSTRACT FROM AUTHOR]

Purpose: Lumbar disc surgery is a common procedure in the USA. It is frequently performed with good or excellent results in most patients. This article reviews common causes of persistent radiculopathy after surgical intervention.Methods: We performed an extensive review of the literature as well as applying our own experience.Results: Common causes of persistent leg pain following operative intervention include re-herniation, epidural fibrosis, biochemical/physiologic changes in the nerve root, and psychosocial issues.Conclusions: Patients with persistent leg pain after surgical treatment of lumbar disc herniation can pose a challenging clinical problem. Summary of these topics and available treatment options are reviewed. [ABSTRACT FROM AUTHOR]

During 2017, opioids were associated with 47,600 deaths in the United States, approximately one third of which involved a prescription opioid (1). Amid concerns that overprescribing to patients with acute pain remains an essential factor underlying misuse, abuse, diversion, and unintentional overdose, several states have restricted opioid analgesic prescribing (2,3). To characterize patterns of opioid analgesic use for acute pain in primary care settings before the widespread implementation of limits on opioid prescribing (2,3), patients filling an opioid analgesic prescription for acute pain were identified from a 2014 database of commercial claims. Using a logistic generalized additive model, the probability of obtaining a refill was estimated as a function of the initial number of days supplied. Among 176,607 patients with a primary care visit associated with an acute pain complaint, 7.6% filled an opioid analgesic prescription. Among patients who received an initial 7-day supply, the probability of obtaining an opioid analgesic prescription refill for nine of 10 conditions was <25%. These results suggest that a ≤7-day opioid analgesic prescription might be sufficient for most, but not all, patients seen in primary care settings with acute pain who appear to need opioid analgesics. However, treatment strategies should account for patient and condition characteristics, which might alternatively reduce or extend the anticipated duration of benefit from opioid analgesic therapy. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective analysis of national insurance billing database.Objective: To examine trends in reoperation after single-level lumbar discectomy.Summary Of Background Data: Lumbar discectomy is the most commonly performed procedure for treatment of radiculopathy caused by disc herniation. Randomized clinical trials have demonstrated the advantage of discectomy over nonsurgical treatment options, allowing for a more rapid reduction in symptoms. However, population-level data regarding reoperation after single level discectomy is limited.Methods: Data were collected using the commercially available PearlDiver software for patients billed with the Current Procedural Terminology code for our index procedure, hemilaminotomy and removal of disc material, between January 2007 and September 2014. The index group was then followed for up to 4 years for recurrent lumbar surgery, including spinal fusion, laminectomy, and additional discectomy.Results: Analysis of data obtained from 13,654 patient records revealed a rate of additional lumbar surgeries after single-level discectomy of 3.95% (539/13654) within 3 months and 12.2% (766/6274) within 4 years of the index procedure. Lumbar spinal fusion was performed on 5.9% (370/6274) of patients within 4 years. Patients who received a re-exploration discectomy within 2 years of the index procedure went on to receive lumbar fusion at a rate of 38.4% (48/125) within the 4 years after the re-exploration discectomy. The average additional cost of lumbar reoperation, as measured by insurance reimbursement, was approximately $11,161 per-patient per year.Conclusion: We report an overall 4-year reoperation rate of 12.2% after single-level discectomy. In addition, we report a rate of progression to lumbar fusion following re-exploration discectomy of 38.4% within 4 years of reoperation. Further studies are needed regarding the best treatment algorithm in patients with reherniation or iatrogenic instability after lumbar discectomy. This study should enhance the shared decision making process by providing surgeons and patients with valuable data regarding the frequency and nature of reoperations after discectomy.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: Cross-sectional survey, * OBJECTIVE: To examine the use of traction by physical therapists for patients with neck pain, including how and when traction is used, the delivery modes and parameters, supplemental interventions, and influence of professional demographics on usage. * BACKGROUND: Systematic reviews provide little support for traction in managing neck pain. While traction usage among physical therapists in other countries has been described, usage in the United States has not been examined. * METHODS: A random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association were surveyed. Associations among respondents' professional demographics and survey responses were explored with chi-square analyses (α = .05). * RESULTS: The response rate was 25.5% (n = 1001); 76.6% (n = 767) of respondents reported using traction, and 93.1% reported that they would use traction for a patient presenting with signs of nerve root compression. Common delivery modes included manual methods (92.3%) and mechanical traction tables (88.3%). Using traction is often supplemented with other interventions (exercise, postural education, joint mobilization). A higher proportion of physical therapists with American Board of Physical Therapy Specialties orthopaedic certification reported using traction (88.6%) than did those without specialty certification (73.0%). * CONCLUSION: Most respondents reported that their use of cervical traction was consistent with proposed criteria that identify patients who are likely to benefit. They use various traction delivery modes/parameters within comprehensive plans of care incorporating multiple interventions. Professional demographics (clinical specialist credentialing) were associated with traction usage. [ABSTRACT FROM AUTHOR]

Background: A bundled payment represents a single payment for services during an episode of care for a surgical procedure. Anterior cervical discectomy and fusion (ACDF) and associated 90-day costs have been suggested as a bundle amenable to such a payment structure; however, to our knowledge, there are limited available data with regard to costs related to this procedure and subsequent care.Methods: The Medicare 5% National Sample Administrative Database was used to catalog clinical and financial data associated with the day of the surgical procedure and the 90-day postoperative period for patients undergoing a one to two-level ACDF procedure from 2005 to 2012. We simultaneously queried the database for total knee replacement as a means to compare the payments and to verify the reliability of our analysis.Results: A total of 4,506 patients underwent an ACDF procedure for cervical radiculopathy. The total 90-day reimbursement was $69,469,550 or a mean cost per patient (and standard deviation) of $15,417 ± $947 (median, $15,589). As a comparison, the mean reimbursement for patients who had undergone a total knee replacement amounted to $17,451 per patient. The physician reimbursement for ACDF represented 20.42% of the total, with the surgeon receiving 18.07% of the total reimbursement. Revision surgery, readmission, and emergency department reimbursement accounted for 0.71% of the total reimbursement. Reimbursement for rehabilitation services, including physical therapy, skilled nursing facilities, and home care, represented 3.11% of the total reimbursement. There was a significant variation in reimbursement among geographic regions in the United States (p < 0.001), with the highest in the West.Conclusions: To our knowledge, this study is the first report on 90-day reimbursement per patient for one to two-level ACDF procedures in a Medicare cohort. Payments varied significantly among geographic locations. Our study provides a reimbursement benchmark for one to two-level ACDF procedures. Clarifying the payments relative to costs will help providers to understand whether a bundled payment for the ACDF procedure is economically viable. [ABSTRACT FROM AUTHOR]

Background There is continued debate on the effectiveness, indications, and medical necessity of epidural injections in managing pain and disability from lumbar disc herniation, despite extensive utilization. There is paucity of literature on interlaminar epidural injections in managing lumbar disc herniation or radiculitis in contemporary interventional pain management settings utilizing fluoroscopy. Methods A randomized, double-blind, active-control trial was undertaken to assess the effectiveness of lumbar interlaminar epidural injections with or without steroids for disc herniation and radiculitis. The primary outcome was defined as pain relief and functional status improvement of ≥ 50%. One hundred twenty patients were randomly assigned to 1 of the 2 groups. Group I patients received lumbar interlaminar injections containing a local anesthetic (lidocaine 0.5%, 6 mL), whereas Group II patients received lumbar interlaminar epidural injections of 0.5% lidocaine, 5 mL, mixed with 1 mL of non-particulate betamethasone. Results In the patients who responded with initial 2 procedures with at least 3 weeks of relief, significant improvement was seen in 80% of the patients in the local anesthetic group and 86% of the patients in the local anesthetic and steroid group. The overall average procedures per year were 3.6 in the local anesthetic group and 4.1 in the local anesthetic and steroid group, with an average relief of 33.7 ± 18.1 weeks in the local anesthetic group and 39.1 ± 12.2 weeks in the local anesthetic and steroid group over a period of 52 weeks in the overall population. Conclusions Lumbar interlaminar epidural injections of local anesthetic with or without steroids might be effective in patients with disc herniation or radiculitis, with potential superiority of steroids compared with local anesthetic alone at 1 year follow-up. [ABSTRACT FROM AUTHOR]

Objective Epidural steroid injections ( ESI) are the most commonly performed pain procedures. Despite numerous studies, controversy continues to surround their effectiveness. The purpose of this study is to determine whether a standard, clinical local anesthetic injection can predict outcomes for ESI. Study Design In this multicenter study, 103 patients received two ESI 2 weeks apart. Prior to their first injection, subjects rated the pain intensity of a standardized subcutaneous ( SQ) injection of lidocaine prior to the full dose. Numerical rating scale pain scores were correlated with leg and back pain relief, and functional improvement, through 3-month follow-up. Outcome Measures A composite successful outcome was predetermined to be a ≥2-point decrease in leg pain score, coupled with a positive global perceived effect. Results A small but significant relationship was found between SQ pain score and reduction in leg ( r = −0.21, 95% CI −0.38 to −0.04; P = 0.03) and back pain ( r = −0.22, 95% CI −0.36 to −0.07; P = 0.03). Subjects with a positive outcome at 1 month had a mean SQ pain score of 2.5 ( SD 1.9) vs 4.1 ( SD 2.7) in those with a negative outcome ( P = 0.04). Subjects with SQ pain scores <4/10 had lower leg and back pain scores than those with pain scores ≥4 at 1-month (mean 3.2, SD 2.6 vs 5.1, SD 2.7 for leg, P < 0.01; mean 3.7, SD 2.6 vs 5.0, SD 3.0 for back, P = 0.02) and 3-month (mean 3.8, SD 2.7 vs 5.2, SD 3.1 for leg, P = 0.01; mean 4.0, SD 2.6 vs 4.9, SD 3.1 for back; P = 0.14) follow-up. Conclusions The results of this study found a weak positive correlation between SQ pain scores and treatment results. Further research should consider whether pain perception in conjunction with other variables might prove to be a reliable predictor for ESI and other procedural outcomes. [ABSTRACT FROM AUTHOR]

Introduction: As demand for orthopaedic care increases, the orthopaedic community must preserve access to skilled physicians. Workplace hazards and related injuries or conditions contribute to musculoskeletal (MSK) stress on orthopaedic surgeons, which can lead to undesirable medical leaves of absence or early retirement. The purpose of this study was to identify and characterize work-related and non-work-related MSK conditions that affect orthopaedic surgeons and differential injury patterns among male and female surgeons. This study hypothesized that MSK conditions would be exacerbated by work, correlate with age, and show gender-based disparities. Identifying MSK conditions and associated workplace hazards may ultimately help guide preventive or protective efforts., Methods: Following IRB and society approvals, a modified 15-question physical discomfort survey was emailed to a randomized selection of American Academy of Orthopaedic Surgeons (AAOS) members and all Ruth Jackson Orthopaedic Society members. Data were deidentified and merged by AAOS; analyses were performed by the authors., Results: Most surgeons reported at least one MSK condition (86%; 95% male versus 82% female, P = 0.317), with an average of two conditions per surgeon. Low back pain (56%) and neck pain (42%) were the two most common conditions reported. Male surgeons were more likely to report medial epicondylitis (P = 0.040), lateral epicondylitis (P ≤ 0.001), low back pain (P = 0.001), and lumbar radiculopathy (P = 0.001); however, male respondents were significantly older than female respondents (57 versus 43 years, P ≤ 0.0001), and some conditions were age-correlated. Most respondents reported at least one work-attributed MSK condition (64%; 68% male versus 62% female, P = 0.806). Caseload was not associated with an increased number of work-related MSK conditions; yet, 60% of surgeons reported that work worsened symptoms. Surgical treatment was sought most often for lumbar radiculopathy (6%) and carpal tunnel syndrome (6%). Sixty-nine leaves of absence were reported; most less than 1 month (55%). Exacerbating workplace factors included positioning (patient/surgeon), instruments, and personal protective equipment., Discussion: Work-related MSK conditions are common among orthopaedic surgeons. Greater awareness of potential workplace-related hazards and conditions is needed to address and mitigate negative MSK health effects on orthopaedic surgeons., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

In the United States, acute low back pain, with or without radiculopathy, is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life-years. Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, fracture, or infection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

This article reviews the available literature for novel cervical total disc replacement devices, including ones which are available inside and outside of the United States. It includes biomechanical consideration as well as design characteristics and clinical data when available., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: To report the occurrence of tophaceous gout in the cervical spine and to review the literature on spinal gout., Case Presentation: This report details the occurrence of a large and clinically significant finding of tophaceous gout in the atlantoaxial joint of the cervical spine in an 82-year-old Caucasian man with a 40-year history of crystal-proven gout and a 3-month history of new-onset progressive myelopathy. The patient's American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria score was 15.0., Conclusion: Spinal gout is more common than previously thought, and it should be considered in patients who present with symptoms of myelopathy. Diagnosis can be made without a tissue sample of the affected joint(s) with tools like the ACR/EULAR criteria and the use of the "diagnostic clinical rule" for determining the likelihood of gout. Early conservative management with neck immobilization and medical management can avoid the need for surgical intervention.

Description: In September 2017, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved the joint Clinical Practice Guideline (CPG) for Diagnosis and Management of Low Back Pain. This CPG was intended to provide healthcare providers a framework by which to evaluate, treat, and manage patients with low back pain (LBP)., Methods: The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through September 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. A patient focus group was also convened to ensure patient values and perspectives were considered when formulating preferences and shared decision making in the guideline., Recommendations: The VA/DOD LBP CPG provides evidence-based recommendations for the diagnostic approach, education and self-care, non-pharmacologic and non-invasive therapy, pharmacologic therapy, dietary supplements, non-surgical invasive therapy, and team approach to treatment of low back pain.

Cites a study reporting on the failure of sensory rhizotomy to provide a lasting relief for patients with chronic radicular pain. Cutting of spinal nerve fibers to interrupt the transmission of pain impulses; Complications associated with the procedure.