Clinical Guidelines for the Evaluation and Treatment of Lumbar Disc Herniations: How Accurate is the Internet?

OBJECTIVE: To compare information online regarding lumbar disc herniation (LDH) on commonly searched websites and compare those findings with the evidence-based recommendations listed in the North American Spine Society (NASS) clinical practice guidelines. METHODS: NASS Clinical Practice Guidelines, Internet searches were performed utilizing three common search engines (Google, Bing, Yahoo) and keywords associated with LDH. The top 20 websites from each search were selected. The content regarding diagnosis and treatment of LDH was compared to the NASS clinical practice guidelines. RESULTS: On average, websites mentioned only 59% of recommendations supported by Level I evidence. Websites included an average of 3 recommendations not discussed in the NASS guidelines out of an average of 12 total recommendations. Muscle and sensory testing and physical therapy were the most frequent recommendations, appearing on over 80% of websites. Websites were equally likely to contain recommendations backed by high-quality evidence as recommendations not included in NASS guidelines. CONCLUSIONS: This study demonstrates that websites regarding LDH contain a mix of information, with only a fraction of recommendations aligning with NASS clinical guidelines. Patients who use these websites are presented with unsubstantiated information, conceivably impacting their understanding, expectations and decision-making in physician offices.

Team Approach: Safety and Value in the Practice of Complex Adult Spinal Surgery.

Surgical management of complex adult spinal deformities is of high risk, with a substantial risk of operative mortality. Current evidence shows that potential risk and morbidity resulting from surgery for complex spinal deformity may be minimized through risk-factor optimization. The multidisciplinary team care model includes neurosurgeons, orthopaedic surgeons, physiatrists, anesthesiologists, hospitalists, psychologists, physical therapists, specialized physician assistants, and nurses. The multidisciplinary care model mimics previously described integrated care pathways designed to offer a structured means of providing a comprehensive preoperative medical evaluation and evidence-based multimodal perioperative care. The role of each team member is illustrated in the case of a 66-year-old male patient with previous incomplete spinal cord injury, now presenting with Charcot spinal arthropathy and progressive vertebral-body destruction resulting in lumbar kyphosis.

Helping spine surgeons detect pre-surgical psychological distress in complex spine patients: an observational pilot study.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: Analysis of a standardized, pre-surgical psychological evaluation program for complex spine surgery. Adult spinal deformity (ASD) patients have a high rate of comorbid mental health conditions. Although there is a body of literature demonstrating the impact of psychological factors, including anxiety and depression, on spine surgery outcome, it is estimated that spine surgeons utilize a psychological assessment only about one third of the time prior to a patient's spine surgery. At this time, there is not a widely reported pre-surgical psychological evaluation program for ASD patients. METHODS: 129 consecutive complex spine surgery candidates receiving a pre-surgical psychological evaluation were analyzed between January 1st 2014 and December 31st 2018. Based on the available literature and professional experience in our facility, a color code for patients was developed from Green (low psychological or psychosocial co-morbidity) to Red (high psychological or psychosocial co-morbidity). Univariate analysis was used to evaluate between color grades and demographics, mental health disorders and outcomes. RESULTS: 83% of complex spine patients had at least one psychological disorder or psychosocial barrier. Only 17% had a combination of realistic expectations for surgery, a good support plan, and were without a history of mental illness. The pre-surgical psychological color criteria were validated in showing higher rates of major depression, anxiety disorder, and bipolar disorder in moderate to severe color grades (p < .001) in addition to higher PHQ-9 and GAD-7 scores (p < .001). Patients having a more severe color grade had lower rates of a discharge home and were taking higher morphine equivalent dosages (MEDs) at their six-month follow-up, though both did not reach statistical significance (p = .07 and p = .08; respectively). CONCLUSION: A comprehensive pre-surgical psychological evaluation may be beneficial to risk stratify and counsel patients being evaluated for surgical reconstruction of adult spinal deformities. LEVEL OF EVIDENCE: 3.

Team-Based Medicine: Incorporating a Clinical Pharmacist into Pain and Opioid Practice Management.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) reports that death from opioids has increased by more than five times since 1999. In response, federal and state organizations have released guidelines recommending best practice standards to combat the opioid epidemic. OBJECTIVE: To evaluate the impact of a clinical pharmacist in a team-based care model on the adherence to best practice standards and access to care for management of patients prescribed chronic opioid therapy (COT). DESIGN: Retrospective chart review study. SETTING: An outpatient physical medicine and rehabilitation clinic in a tertiary hospital. PATIENTS: Three hundred eighty-three patients presenting to the clinic between January 2012 and August 2016 with chronic, noncancer pain. METHODS: Comparison of adherence to best practice standards-including changes in morphine equivalent dose (MED), compliance with urine drug screenings, documentation of medication agreements, initiation of nonopioid medications, and the impact of comorbidities-was analyzed before and after a clinical pharmacist was added to the team. Data were gathered from the electronic medical record and the Prescription Monitoring Program. A control group of patients who did not see the pharmacist and were managed only by the physician section head was also compared to the group of patients managed by a clinical pharmacist. OUTCOME MEASUREMENTS: The primary outcome measurement evaluates the change in MED values over time. Secondary outcome measurements are to review compliance with annual urine drug screening, documentation of the medication agreement, initiation of nonopioid medications by the pharmacist, and assessment of the access to care for patients with chronic opioid therapy needs. RESULTS: A clinically significant reduction in MED with an average decrease of 207 mg was seen after five or more visits with the pharmacist. The pharmacist initiated nonopioid medications at 209 unique patient visits (19.5%). The pharmacist completed 1197 visits during the study time frame, increasing physician access by at least two additional visits per patient per year. Completion of urine drug screens and medication agreement reviews improved over time (P < .001). There was an increase in MED for patients who did not complete this monitoring, whereas the MED remained stable in patients who did complete the monitoring. CONCLUSIONS: The addition of a clinical pharmacist to an interdisciplinary team managing COT patients resulted in a MED reduction after five or more visits with the pharmacist, improved adherence to best practice standards, optimization of opioid and nonopioid medication therapy, and increased patient access. Developing a role for advanced practitioners, such as clinical pharmacist providers, working with patients on COT can result in significant improvements in patient access to care, adherence to best practice standards, and patient safety. LEVEL OF EVIDENCE: III.

Cosmic Bell Test Using Random Measurement Settings from High-Redshift Quasars.

In this Letter, we present a cosmic Bell experiment with polarization-entangled photons, in which measurement settings were determined based on real-time measurements of the wavelength of photons from high-redshift quasars, whose light was emitted billions of years ago; the experiment simultaneously ensures locality. Assuming fair sampling for all detected photons and that the wavelength of the quasar photons had not been selectively altered or previewed between emission and detection, we observe statistically significant violation of Bell's inequality by 9.3 standard deviations, corresponding to an estimated p value of ≲7.4×10^{-21}. This experiment pushes back to at least ∼7.8 Gyr ago the most recent time by which any local-realist influences could have exploited the "freedom-of-choice" loophole to engineer the observed Bell violation, excluding any such mechanism from 96% of the space-time volume of the past light cone of our experiment, extending from the big bang to today.

Patient-Reported Outcome Measures: Utility for Predicting Spinal Surgery in an Integrated Spine Practice.

BACKGROUND: For the majority of patients, spinal surgery is an elective treatment. The decision as to whether and when to pursue surgery is complicated and influenced by myriad factors, including pain intensity and duration, impact on functional activities, referring physician recommendation, and surgeon preference. By understanding the factors that lead a patient to choose surgery, we may better understand the decision-making process, improve outcomes, and provide more effective care. OBJECTIVE: To investigate the relationship between patient-reported outcome measures (PROMs) at initial physiatry clinic consultation and subsequent decision to pursue surgical treatment. We hypothesized that measures of function, pain, and mental health might identify which patients eventually elect to pursue surgical management. DESIGN: Retrospective chart review study. SETTING: Physiatry spine clinic in a tertiary hospital. PATIENTS: A total of 395 consecutive patients meeting our inclusion criteria were assessed for the presence of chronic pain, self-perceived disability, history of prior spinal surgery, and provision of chronic opioid therapy at the time of their initial visit to the integrated spine clinic. METHODS: Retrospective chart review of all patients presenting to our spine clinic between August 1, 2014, and July 31, 2015, was performed. At the initial spine clinic consultation, patients were asked to complete the General Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-8 (PHQ-8), Oswestry Disability Index (ODI), and Patient-Reported Outcomes Measurement Information System (PROMIS) 10-item short-form questionnaire. The primary outcome was surgical intervention within 18 months from their first visit to the integrated spine clinic. We surveyed all patient records until February 2017 for CPT codes associated with spinal surgery, excluding from analysis those patients who were lost to follow-up within 1 year of the index visit. Analysis focused on the risk of spinal surgery, with data points treated as both continuous and categorical variables. We used logistic regression models to determine whether PROMs, either alone or in combination, predicted later decision to pursue surgical intervention. MAIN OUTCOME MEASUREMENTS: Decision to pursue spinal surgery. RESULTS: The baseline PROM scores spanning functional, mental health, and pain domains were collected for 94% of the patients presenting to our spine program during the interval of this study. In total, 146 patients were excluded because of missing patient-reported outcome data or less than 1 year of follow-up, leaving 395 patients for analysis. Of these, 40.3% were male with a median age of 58 years, 4.6% presented with a history of prior spinal surgery, and 3.8% were being treated with chronic opioids at their initial consultation. Male gender (P = .01) and older age (P = .05) were associated with subsequent surgery, but no relationship was observed between measured patient-reported outcomes and decision to undergo spinal surgery within 18 months of the index visit. CONCLUSIONS: Contrary to our hypothesis, this analysis demonstrates that the PROMs evaluated in this study, alone are insufficient to identify patients who may elect to pursue spinal surgery. Male gender and increasing age correlate with decision for later spinal surgery. LEVEL OF EVIDENCE: II.

Cosmic Bell Test: Measurement Settings from Milky Way Stars.

Bell's theorem states that some predictions of quantum mechanics cannot be reproduced by a local-realist theory. That conflict is expressed by Bell's inequality, which is usually derived under the assumption that there are no statistical correlations between the choices of measurement settings and anything else that can causally affect the measurement outcomes. In previous experiments, this "freedom of choice" was addressed by ensuring that selection of measurement settings via conventional "quantum random number generators" was spacelike separated from the entangled particle creation. This, however, left open the possibility that an unknown cause affected both the setting choices and measurement outcomes as recently as mere microseconds before each experimental trial. Here we report on a new experimental test of Bell's inequality that, for the first time, uses distant astronomical sources as "cosmic setting generators." In our tests with polarization-entangled photons, measurement settings were chosen using real-time observations of Milky Way stars while simultaneously ensuring locality. Assuming fair sampling for all detected photons, and that each stellar photon's color was set at emission, we observe statistically significant ≳7.31σ and ≳11.93σ violations of Bell's inequality with estimated p values of ≲1.8×10^{-13} and ≲4.0×10^{-33}, respectively, thereby pushing back by ∼600 years the most recent time by which any local-realist influences could have engineered the observed Bell violation.

Diagnosis and Treatment of Work-Related Ulnar Neuropathy at the Elbow.

Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome and occurs most commonly at the elbow due to mechanical forces that produce traction or ischemia to the nerve. The primary symptom associated with UNE is diminished sensation or dysesthesias in the fourth or fifth digits, often coupled with pain in the proximal medial aspect of the elbow. Treatment may be conservative or surgical, but optimal management remains controversial. Surgery should include exploration of the ulnar nerve throughout its course around the elbow and release of all compressive structures.

Work-Related Carpal Tunnel Syndrome: Diagnosis and Treatment Guideline.

Carpal tunnel syndrome is the most common entrapment neuropathy, and its risk of occurrence in the presence of repetitive, forceful angular hand movements, or vibration, is common. It is critical to make the diagnosis based on appropriate clinical history and findings and with corroborating electrodiagnostic studies. Conservative management should be undertaken with the goal of maintaining employment; surgical decompression can be highly effective, particularly if undertaken early on.

Testing Bell's inequality with cosmic photons: closing the setting-independence loophole.

We propose a practical scheme to use photons from causally disconnected cosmic sources to set the detectors in an experimental test of Bell's inequality. In current experiments, with settings determined by quantum random number generators, only a small amount of correlation between detector settings and local hidden variables, established less than a millisecond before each experiment, would suffice to mimic the predictions of quantum mechanics. By setting the detectors using pairs of quasars or patches of the cosmic microwave background, observed violations of Bell's inequality would require any such coordination to have existed for billions of years-an improvement of 20 orders of magnitude.

Electrical stimulation for treating chronic poststroke shoulder pain using a fully implanted microstimulator with internal battery.

This case report describes the first stroke survivor with chronic poststroke shoulder pain treated with electrical stimulation delivered via a fully implanted microstimulator containing a rechargeable internal battery. In light of existing efficacy data for similar types of treatment, the investigational system described in this report was developed to address the limitations of previously evaluated electrical stimulation devices. A 58-yr-old male stroke survivor with chronic hemiparesis and chronic shoulder pain received up to 6 hrs of stimulation daily over 12 wks. The microstimulator was implanted percutaneously near the axillary nerve at the quadrilateral space, under local anesthesia during an outpatient procedure. The implantation procedure was well tolerated. There were no adverse events related to the implantation procedure or treatment (implanted peripheral nerve stimulation). Outcomes were obtained before treatment, after 12 wks of treatment, and at 3-mo follow-up. Question no. 12 of the Brief Pain Inventory was used as the primary outcome measure to evaluate response to treatment. Shoulder pain decreased from 8/10 before treatment to 4/10 after treatment and decreased further to 3/10 at 3-mo follow-up. Passive range of motion and motor function also improved after treatment. Sensation, shoulder subluxation, activities, and quality-of-life did not change. The feasibility, safety, and efficacy of implanted peripheral nerve stimulation to treat poststroke shoulder pain should be evaluated further in clinical trials already underway.