New Clinical Consult Feature on the Blog

We would like to experiment with a new feature on the blog called 'Clinical Consult'. The idea is for readers to submit real clinical questions that can be posted on the blog for input from other readers. The process for posting a question is very simple. When you encounter cognitive dissonance (the fancy EBP term describing that moment in the clinic when you scratch your head an go, 'Huh...I dunno...'), send an email with your question to clinicalconsult@evidenceinmotion.com. Obviously remove any patient-specific identifying information. We will post to the blog within 24-48 hours under the 'Clinical Consult' category. Readers can collaborate by posting their responses as a comment. The individual asking the question can monitor the responses, add additional information that is requested, etc.

We have set up a typelist on the left hand side of the blog (just underneath the FeedBlitz subscription) to promote this new feature. Depending on the feature's popularity, we may have to offer this feature in a separate blog that is linked to this primary blog. We will keep you posted on any developments. Let us know if you have ideas for how we can continue to improve the feature.

To start things off, here is the first question. I received this via email from another colleague last week:

"A doctor that I have close contact with reviews medical records.  The Dr. is reviewing a patients' record that shows a disc bulge on the left but has radicular symptoms on the right.  Are you aware of any articles that may refute or support this as a possible scenario."

Post any responses as a comment to this post.

Open collaboration will provide real answers for the clinician's question, hone our critical thinking skills, and generally facilitate an evidence-based dialogue on real questions that confront clinicians everyday in clinical practice. Looking forward to watching this feature evolve. Let us know if you have any questions.

John

Comments

[Ben]

I would refer anyone looking to bone up on clinical significance of MRI/imaging findings to the Jarvik/Deyo 02 article:

"Diagnostic evaluation of low back pain with emphasis on imaging". Annals of Internal Medicine 2002; 137(7):586-597.

And also, Jon Lurie's review in Best Practice and Research Clinical Rheumatology, "What diagnostic tests are useful for low back pain?"-2004.

As far as bulges specifically; Deyo reports that disc bulges occur in over 50% of asymptomatic adults and should probably be considered a normal finding. Disc extrusions are another matter.

I would want to know more from the clinical exam before I gave any more thought to the MRI.

Just 2 cents to think about...

Another great idea from EIM folks--thanks!

Ben

Also--I'd post the articles if I could, but I don't think you can from a comment.

[Charles Sheets]

There is strong evidence that there can be annular tears on the side opposite the painful side (Slipman CW, Patel RK, Zhang L, Vresilovic E, Lenrow D, Shin C, Herzog R. Side of symptomatic annular tear and site of low back pain: is there a correlation? Spine. 2001 Apr 15;26(8):E165-9.), as well as slight variability in the direction of sciatic scoliosis as it relates to a herniation (Matsui H, Ohmori K, Kanamori M, Ishihara H, Tsuji H. Significance of sciatic scoliotic list in operated patients with lumbar disc herniation. Spine. 1998 Feb 1;23(3):338-42.)
Neither of these, however, specifically address a radiculopathy, traditionally defined as myotomal or dermatomal changes, or reflex changes.

The closest I could get was the following:

Lumbar disk herniation with contralateral symptoms
European Spine Journal
Hasan Kamil Sucu and Fazimathl Gela
Published online: 18 October 2005
Abstract The aim of the study is to determine if leg pain can be caused by contralateral lumbar disk herniation and if intervention from only the herniation side would suffice in these patients. Five patients who had lumbar disk herniations with predominantly contralateral symptoms were operated from the side of disk herniation without exploring or decompressing the symptomatic side. Patients were evaluated pre- and postoperatively. To our knowledge, this is the first reported series of such patients who were operated only from the herniation side. The possible mechanisms of how contralateral symptoms predominate in these patients are also discussed. In all patients, the shape of disk herniations on imaging studies were quite similar: a broad-based posterior central–paracentral herniated disk with the apex deviated away from the side of the symptoms. The symptoms and signs resolved in the immediate postoperative period. Our data clears that sciatica can be caused by contralateral lumbar disk herniation. When operation is considered, intervention only from the herniation side is sufficient. It is probable that traction rather than direct compression is responsible from the emergence of contralateral symptoms.

I don't have full-text access to this paper, but the abstract seems to answer the question pretty well.

Charlie

[Paul Beattie]

I wanted to reply to the question regarding the MRI finding of a disc bulge
on the left with contralateral symptoms. The following article might be
helpful:

Beattie PF., Meyers S., Stratford P, Millard R, Hollenbeck G. Associations
Between Patient Report of Symptoms and Anatomic Impairment Visible on Lumbar
Magnetic Resonance. Spine 2000;25:819-828. In this study (N=408) we found
no association between the lumbar MRI finding of "disc bulge" and symptom
location. Severe nerve compression and/or large disc extrusion were the
only findings that predicted symptom location. The MRI finding of "disc
bulge" is extremely common in asymptomatic people (Boden et al. 1990;
Buirski et al. 1993; Jensen et al. 1994) and, in my opinon, is typically a
normal anatomic variation. These findings often look impressive on MRI and
fit nicely into some of our treatment algorithmns but I am unaware of any
solid evidence that supports the MRI finding of disc bulge as being specific
for LBP and/or radiculopathy.

Hope this is helpful, Paul

[Britt Smith]

An interesting image study was Jarvik et al. three-yr incidence of LBP in an initial asymptomatic cohort, Clinical & imaging risk factors. Spine. 2005.20:1541-1548. They calculated the Hazard Ratio for back pain predictors: Nerve root contact (H.R.=2.2) and Central Stenosis (1.9) were the strongest correlation of MRI findings at the start of the study and future LBP. DEPRESSION (hx, treatment), had the highest correlation with future LBP (H.R.=2.3).
None of the imaging findings were statistically significantly associated with new LBP.
Britt

[Rick Jemmett]

Two things come to mind on this question. First, using Bogduk's definitions of radiculopathy (signs of neural compromise), radicualr pain (pain along a well-defined path) and referred pain (diffuse 'spready' pain) I would ask again what the patient complained of. Second, it is interesting how many of us continue to fall into the pathoanatomical toilet from time to time. Bogduk makes a strong argument that nerve root compression does not, in and of itself, result in pain. The inflammation associated with all manner of segmental dysfunction does. Thus, the clinician might conceptualize this as a segmental dysfunction which happpens to include what may or may not be a clinically significant protrusion on one side and an inflammation-based irritation of the root on the other side (if this is radicualr pain we are speaking of). The key though is to appreciate that a variety of structural faults have likely developed (see Panjabi, various papers thru the 90's). My advice would be to give up the search for a guilty 'structure', understand the stiffness, motor control and psychosocial issues at play and manage from there.

Cheers,

Rick

[garyceg]

Emm.. Sometimes I can't help but show you my sketchy license Do you want a joke? :) What do you get if you cross a hippo and a blackbird? Lots of broken telephone poles!