Sciatica: When to image When to refer

Sciatica: When to image When to refer
Presentation by:Juanita Halls M.D.
Internal Medicine


Objectives

* Understand when to perform imaging on patients presenting with sciatica
* Understand when to refer patients with sciatica to a spine surgeon

Case 1
PMH

* Hypertension on lisinopril/HCTZ
* s/p hysterectomy
* Takes MVI and Calcium/vitamin D
* Otherwise healthy, non-smoker
* Screening:
o Routine PE 10/06
o mammogram 10/05, ordered 10/06 but not done
o Flex sig negative 1999, FOBT negative 10/06 (colonoscopy not covered by insurance)
Exam

* No spinal tenderness or deformity
* Mild decrease extension with pain
* Mild decrease flexion without pain
* Positive SLR bilaterally at 60o
* DTR: 2+ knee and 1+ ankle bilaterally
* Motor: 5/5 in LE
* Sensory: Intact

Imaging

* L/S spine films: multilevel degenerative disk and joint disease
* “Sciatica with no worrisome symptoms and negative spine X-ray”
* Home exercises
* PT referral
* Ice or heat
* No lifting
* Naproxen and Tylenol #3
* RTC 2 months, sooner if not improving
2 months later

* Had cancelled PT because pain resolved with home exercises and Naproxen
* Now 3 week history of increased right sided LBP radiating to right foot
* Paresthesia of right ankle
* No weakness or bladder/bowel dysfn
* ↑ with sitting and at night
Exam

* No spinal tenderness
* SLR negative on left, positive at 60o on right
* DTR: symmetrical
* Motor: 5/5
Plan

* MRI offered but patient declined
* Diclofenac (was having side effects with naproxen)
* PT referral
* Spine clinic referral
4 weeks later (3 months after initial presentation)

* Seen in Spine clinic:
o Pain had gotten better, now worse again and interfering with sleep
o No systemic symptoms
* Exam:
o No change except minimal tenderness
o Positive SLR/Lasegue maneuver
* DX: Probable HNP
* Plan: MRI
2 Weeks later
(3 ½ months after presentation)
* MRI competed and I am paged by the Spine clinic physician late Friday afternoon
MRI case 1
MRI reading

* Large osseous mass involving right iliac wing and central and right portions of S1 and S2 vertebra with soft tissue extension obliterating right L5, S1 and S2 neural foramen.
* Second osseous mass in body of T12
* Most likely represents metastatic disease
10 days later

* CT guided biopsy:
o Large B cell lymphoma
Low Back Pain

* Low back pain
o 84% of adults experience LBP
o 2.5% of medical visits
o Total cost in US: $100 Billion per year
o <5% have serious pathology
o 5% have sciatica
+ Annual incidence of sciatica is 5 per 1000
Definition of sciatica

* Pain, numbness, tingling in distribution of sciatic nerve
* Radiation down posterior or lateral leg to foot or ankle
* If radiation below knee – more likely radiculopathy with impingement of nerve root
Etiology of sciatica

* Mechanical
* Neoplastic (0.7% of LBP)
* Infectious (0.01% of LBP)

Questions to ask
* Is there evidence of systemic disease?
* Is there evidence of neurological compromise?
Clues on history to suggest systemic disease
Testing for lumbar nerve root compromise
Straight leg raising
Dorsiflexion of the foot (Lasegue's test) will exacerbate these symptoms
SLR with Lasegue test
Sensitivity/specificity for radiculopathy, in patients with sciatica
Imaging indications
Imaging – L/S spine films
Imaging - MRI
Malignancy and sciatica
Case 2
Previous history
Exam
Treatment
5 weeks later
MRI Case 2
MRI reading
Spine clinic visit next day
Spine clinic treatment
8 weeks later (3 months after initial presentation)
Spine surgeon
When to refer to spine surgeon
Timing of referral for diskectomy
Surgery vs Prolonged Conservative Treatment for Sciatica
Outcomes of study
Conclusions of study
SPORT study
Surgical vs Nonoperative Treatment for Lumbar Disk Herniation
BOTTOM LINE

Sciatica: When to image When to refer.ppt

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Safety in the Microbiology Lab

Safety in the Microbiology Lab

An Introduction to Principles and Practices at Biosafety Levels 1, 2 & 3

Pre-Test

Some Category A agents pose limited to moderate risk to the laboratory worker (BSL-2) while others (BSL-3) pose a greater risk.

o What does this tell you about the:
1. ease or difficulty for bioterrorists to produce BSL-2 and BSL-3 agents?
2. ease or difficulty to control BSL-2 and BSL-3 agents if used for bioterrorism?
* Why is Anthrax (a BSL-2) agent considered a very likely biothreat agent?
* What microbiology clues would implicate tularemia as a bioterror event?
* How do microbiologists protect themselves form accidental exposure to pathogenic microorganisms?

Learning Objectives

* By the end of the lesson the student will understand:
o The need for and use of biosafety designations
o Standard (or Good) Laboratory Practices
o The basic principles and practices for working in Labs designated BSL 1, BSL 2 or BSL 3
o CDC Priority Categories and the Select Agents Act
o Examples of microorganisms designated by their Biosafety Level

Microorganism Categories

* How are microorganisms categorized?
o By genetics to show how they are related
o By tissues they infect to show how they cause disease
o By pathogenicity and communicability (also known as their BioSafety Level)

Guidelines for Microorganism Use

* Besides federal law and regulations other guidelines exist for the use and control of microorganisms:
o CDC/NIH Biosafety in Microbiological and Biomedical Laboratories (BMBL)
o WHO (World Health Organization) Biosafety Manual
o USDA (United States Department of Agriculture) protocols

Guidelines for Microorganism Use

* All the afore mentioned agencies use the same system to categorize microorganisms based on the organisms danger to the laboratory worker and other research personnel.

* The microbes are placed into 4 categories called : Biosafety Levels (BSL 1-4)

BSL Labs

* Microbiology Laboratories are set up and maintained to meet a specific containment level. The designated level conveys information about infection potential and engineering controls implemented to protect workers.

Dangerous/exotic agents which pose high risk of life-threatening disease, aerosol-transmitted lab infections; or related agents with unknown risk of transmission Indigenous or exotic agents with potential for aerosol transmission; disease may have serious or lethal consequences

Associated with human disease, hazard = percutaneous injury, ingestion, mucous membrane exposure
Not known to consistently cause disease in healthy adults
Biosafety Levels for Infectious Agents
BSL = Containment
BSL-3 practices plus: Clothing change before entering, Shower on exit, All material decontaminated on exit from facility
BSL-2 practice plus: Controlled access, Decontamination of all waste, Decontamination of lab clothing before laundering,
Baseline serum antibody analysis
BSL-1 practice plus: Limited access, Biohazard warning signs, "Sharps" precautions, Biosafety manual defining any needed waste decontamination or medical surveillance policies
Standard Microbiological Practices
Engineering Controls by Biosafety Level
CDC Categories of Diseases/Agents
Select Agents Act
Biological Agent
Toxin
What are the Select Agents?

* Abrin
* Bacillus anthracis
* Cercopithecine herpesvirus 1 (Herpes B virus)
* Coccidioides posadasii
* Conotoxins
* Crimean-Congo haemorrhagic fever virus
* Diacetoxyscirpenol
* Ebola viruses
* Lassa fever virus
* Marburg virus
* Monkeypox virus
* Ricin
* Rickettsia prowazekii
* Rickettsia rickettsii
* Saxitoxin
* Shiga-like ribosome inactivating proteins
* South American Haemorrhagic Fever viruses
* Tetrodotoxin
* Tick-borne encephalitis complex viruses
* Variola major virus (Smallpox virus)
* Variola minor virus
* Yersinia pestis

Bioterrorism Agents: Laboratory Risk
High-priority agents include organisms that pose a risk to national security because they:

o can be easily disseminated or transmitted from person to person;
o result in high mortality rates and have the potential for major public health impact;
o might cause public panic and social disruption; and
o require special action for public health preparedness.



Category A Definition
Category A Disease/Agents

* Anthrax (Bacillus anthracis)
* Botulism (Clostridium botulinum toxin)
* Plague (Yersinia pestis)
* Smallpox (Variola major)
* Tularemia (Francisella tularensis)
* Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])
Category B Definition
Category B Disease/Agents

* Brucellosis (Brucella species)
* Epsilon toxin of Clostridium perfringens
* Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella)
* Glanders (Burkholderia mallei)
* Melioidosis (Burkholderia pseudomallei)
* Psittacosis (Chlamydia psittaci)
* Q fever (Coxiella burnetii)
* Ricin toxin from Ricinus communis (castor beans)
* Staphylococcal enterotoxin B
* Typhus fever (Rickettsia prowazekii)
* Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis])
* Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

Category C Definition
Category C Disease/Agents


Safety in the Microbiology Lab.ppt

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Food Safety & Microbiology

Food Safety & Microbiology
Presentation lecture by:Dr. Hirsch
Department of Food Science

Food Processing
Food Safety and Microbiology
* Defining Food Illness
* Bad and Good Microorganisms
o Pathogens and Outbreaks
o Spoilage
o Probiotics
* Outbreaks
* Food Safety: Safe food storage and preservation

Food Safety: Foodborne Illness

o Infectious agents
+ Bacteria
+ Viruses
+ Parasites
o A toxin or chemical
+ Bacterial toxin
+ Pesticides
+ Heavy metals
+ Other chemical contaminants

Illness occurring as a result of ingesting food or water contaminated with:
Food Processing
Bad and Good of Microorganisms
Harmful effects:
Beneficial effects:

* Fermentation
o Cheese
o Yogurt
o Fermented sausages
o Wine
o Beer
o Pickles
o Sour kraut
* Probiotics

Pathogens
Harmful: Food Infection vs. Food Poisoning

Food infection

* Live cells delivered by contaminated food; organism multiply once food is ingested
o Salmonella; E. coli

Food poisoning (intoxication)

* Caused by preformed toxin in the food; organism may or may not be alive and growing
o Clostridium botulinum; Staphylococcus aureus

Harmful: Pathogens of Public Health Concern

* Clostridium botulinum
* Escherichia coli
* Listeria monocytogenes
* Salmonella
* Staphylococcus aureus
* Aeromonas hydrophila
* Bacillus cereus
* Campylobacter jejuni
* Clostridium perfringens
* Shigella
* pathogenic Vibrio spp.
* Yersinia enterocolitica

Specific Product Concerns

* Produce
* Imported foods
* Juice
* Eggs

Peanut Salmonella Recall More than 31 million pounds 125 items affected in salmonella probe
2006 Nationwide Outbreak of E. coli
Food Processing
Timeline of Foodborne Illness
Preventive measures
Spoilage Microorganisms: NOT Harmful
Food Spoilage Microorganisms bacteria, yeasts, molds
Microbial Food Spoilage = Changes in Food Quality
The Good Microorganisms: Probiotics

Human probiotics: where?

• Gastro-intestinal
• Skin
• Scalp
• Oral cavity
• Underarm and feet
• Urogenital
including vaginal

Expected Benefits with Consumption

• Increased tolerance to infections
• Control of diarrhea
• Reduction of blood pressure
• Cholesterol reduction
• Allergy control
• Immunomodulation
• Cancer reduction
Probiotics species
Prevention of Deleterious Microbes
Knowledge and Action
Food Handling and Food Processing
Safe Food Storage and Preparation
Major Risk Factors of Food Safety
A day in the life of…fresh Produce
Washing produce would not have prevented the E-coli spinach outbreak
Proper food storage starts at the store
Food Processing
Guidelines for Leftovers

Food Safety & Microbiology.ppt

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