Medication recommendations for treatment of lumbosacral radiculopathy: A systematic review of clinical practice guidelines.

OBJECTIVE: The purpose of this systematic review was to ascertain guideline-recommended pharmaceutical approaches to lumbosacral radicular symptoms, assess the quality of the clinical practice guidelines (CPGs) with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool, and qualitatively synthesize the guideline recommendations. LITERATURE SURVEY: Literature searches were performed in PubMed, Cochrane Database of Systematic Reviews, Index to Chiropractic Literature, Allied and Complementary Medicine Database (AMED), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence Database (PEDro). We included guidelines published between January 1, 2017, and January 9, 2022, written in the English language, related to radiculopathy, sciatica, and/or low back pain with leg pain, and that provided recommendations on oral medication. METHODOLOGY: The review was performed in accordance with Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) and the protocol was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO). Eligibility screening, full-text review, extraction of information pertaining to pharmacological management, and synthesis of results were performed independently by two authors and a third investigator was recruited to arbitrate any disagreements. The AGREE II tool was administered by four authors to appraise CPG quality. SYNTHESIS: After screening 413 citations and assessing 37 full-text articles, 11 CPGs met the inclusion criteria. They represented seven countries (Belgium, Canada, England, France, Japan, Korea, and United States) and three continents (Asia, Europe, and North America), as well as the Global Spine Care Initiative aimed at a worldwide presence. The mean overall AGREE II score was 87.1% (standard deviation [SD] 12.6%), generally reflecting high-quality CPGs. The highest domain mean score was for Clarity of Presentation (96.7%, SD 4.4%), and the lowest was Applicability (75.6%, SD 22.8%). Five classes of medications were recommended by at least one CPG: anticonvulsants, antidepressants, oral corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids. CONCLUSIONS: The most common medication class recommended by the CPGs for lumbar radiculopathy was antidepressants. No CPGs recommended prescribing acetaminophen, benzodiazepines, muscle relaxants, or antibiotics. There was very little agreement between the CPGs, and all the medication classes had at least one CPG recommended against its use. Three guidelines reviewed did not recommend any medications due to lack of supporting literature, and instead recommended nonpharmacologic therapy.

Symptoms of Patients With Vertebral Artery Dissection Presenting to Chiropractors: A Systematic Review and Meta-Analysis.

Early symptoms of vertebral artery dissection (VAD) may be nonspecific, including neck pain and headache. Neck pain and headache are also common reasons for patients to seek chiropractic care. We hypothesized that neck pain and/or headache would be the most prevalent symptoms among patients with undiagnosed VAD presenting to chiropractors compared to dizziness or other symptoms. We searched PubMed, Ovid, the Index to Chiropractic Literature, Google Scholar, and gray literature through September 2023 for observational studies describing patients aged ≥10 with previously undiagnosed VAD presenting to a chiropractor. Article selection, data extraction, and quality assessment were performed in duplicate. We synthesized the point prevalence of symptoms and other clinical features. We included 10 case reports describing 10 patients (mean age = 37, SD = 7, 60% female). All patients had either neck pain or headache (100%; 95% confidence interval (CI) = 100%-100%). The most prevalent individual symptoms were neck pain (90%; 95% CI = 71%-100%), headache (80%; 95% CI = 55%-100%), visual disturbance (50%; 95% CI = 19%-81%), and dizziness (40%; 95% CI = 10%-70%). The certainty of results was very low due to publication bias. While our findings suggest that neck pain and/or headache are the most prevalent symptoms among patients with undiagnosed VAD visiting a chiropractor, the small sample size and reliance on case reports preclude any definitive conclusions. Further research with larger sample sizes, control groups, and better control of confounders is required to corroborate these results. Chiropractors should be aware of VAD features and refer suspected patients for emergency care.

The ambiguity of sciatica as a clinical diagnosis: A case series.

Sciatica as a clinical diagnosis is nonspecific. A diagnosis of sciatica is typically used as a synonym for lumbosacral radiculopathy. However, the differential for combined low back and leg pain is broad, and the etiology can be one several different conditions. The lifetime prevalence of sciatica ranges from 12.2% to 43%, and nonsuccessful outcomes of treatment are prevalent. Nurse practitioners and other primary care clinicians often have minimal training in differential diagnosis of the complex causes of lower back and leg pain, and many lack adequate time per patient encounter to work up these conditions. Differentiating causes of low back and leg pain proves challenging, and inadequate or incomplete diagnoses result in suboptimal outcomes. Chiropractic care availability may lessen demands of primary care with respect to spinal complaints, while simultaneously improving patient outcomes. The authors describe three patients referred from primary care with a clinical diagnosis of sciatica despite differing underlying pathologies. More precise clinical terminology should be used when diagnosing patients with combined low back and leg pain. Nurse practitioners and other clinicians' triage, treat, and determine appropriate referrals for low back and leg pain. Multidisciplinary care including chiropractic may add value in settings where patients with lower back and leg pain are treated.

Post-traumatic Scapholunate Advanced Collapse of the Wrist: A Case Report.

OBJECTIVE: The purpose of this report is to describe a patient with scapholunate advanced collapse (SLAC) of the wrist. CLINICAL FEATURES: A 38-year-old man presented to a chiropractic teaching clinic with right wrist pain after falling off of the tailgate of a truck 7 years prior. The mechanism of injury was a fall on an outstretched hand. Ultrasonography and radiography were performed, which demonstrated abnormal lunate kinematics and scapholunate interval diastasis associated with a clenched-fist maneuver. These findings were consistent with SLAC. INTERVENTION AND OUTCOME: Following the diagnosis of SLAC, the wrist was splinted. Conservative care consisting of physical therapy included paraffin dips, therapeutic ultrasound, and stretching. The patient received only minimal alleviation of pain, and a surgical consultation was obtained. The patient elected surgical intervention, utilizing the proximal row carpectomy procedure. CONCLUSION: This case demonstrates a patient with chronic wrist pain, with progression to carpal instability, which ultimately manifested as SLAC. We demonstrate, utilizing multiple imaging modalities, both preoperative and postoperative findings. To our knowledge, this is the first case to describe the use of diagnostic ultrasonography in the evaluation of the proximal row carpectomy procedure.