CBBLE PaJR participatory learning action research disclaimer

 

Greetings, 

I'm TELLA SHRUTHI, a medical student hailing from India. Within this blog, I aspire to present a compilation of captivating medical cases that I have meticulously examined, guided by the expertise of my esteemed seniors. The essence of this platform lies in expounding upon these cases, their corresponding treatments, and ultimately deepening our comprehension of patient care during our formative years as undergraduates. So, let us embark upon this enlightening voyage together, as we unravel the intricacies of clinical medicine.

Welcome, and I encourage you to immerse yourself in these insightful chronicles.

CBBLE PaJR participatory learning action research disclaimer

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.  

As a young medical learner eager to gain valuable insights, I was assigned to the medicine ward, ready to immerse myself in the realities of patient care. 

My first case in the medicine ward was an encounter that left me both intrigued and concerned. Sitting in the post-hemodialysis ward, I observed a middle-aged man, approximately 55 years old, accompanied by his worried wife. The patient appeared visibly unwell, with a noticeable yellowish discoloration of his skin, known as icterus. His legs were swollen, exhibiting significant pedal edema, which extended from the ankles to above the knees.

As I approached the patient, I couldn't help but notice the fatigue etched on his face. The puffiness around his eyes and cheeks further emphasized the severity of his condition. It was evident that he was experiencing significant discomfort, as he struggled to catch his breath. Even simple activities, such as talking or walking to the washroom, seemed to exacerbate his shortness of breath, which was classified as grade 3 on the scale.

During my conversation with the patient, I learned that these symptoms had been persisting for the past 20 days. His appetite had significantly diminished, and he had noticed a decrease in urine output over the last 10 days. These distressing developments prompted him to seek medical attention, and it was this very situation that had led him to our care.

Delving into his medical history, I discovered that he had been previously diagnosed with hypertension (HTN) approximately one year ago. Despite receiving a prescription for antihypertensive medications, he had never taken them. This revelation struck me as a potential contributory factor to his current deteriorating health. It was a stark reminder of the importance of medication compliance and the consequences that can arise from neglecting treatment.

Beyond his medical history, the patient had been married for 32 years and had experienced infertility. This detail shed light on the additional emotional and psychological burden he had carried throughout his life.

the exact etiology of his condition remained unknown.

As I reviewed the patient's medical records and test results, a wave of concern washed over me. The laboratory findings revealed elevated levels of serum creatinine, urea, and alkaline phosphatase, coupled with low protein levels. These abnormalities hinted at a severe renal dysfunction and disruption in the body's normal metabolic processes.

https://tellashruthi159.blogspot.com/2022/01/a-55-year-old-male-patient-with-bl.html?m=1

I learned that the elevated serum creatinine and urea indicated a significant impairment in his kidney function, resulting in the accumulation of waste products and toxins in his body. This, in turn, contributed to the development of pedal edema, facial puffiness, and decreased urine output.

Moreover, the low protein levels raised concerns about the patient's nutritional status and the potential impact on various bodily functions. Proteins play a vital role in maintaining fluid balance, regulating immune responses, and supporting tissue repair. Their deficiency could further exacerbate his symptoms and hinder the body's ability to heal.

As I concluded my initial assessment, I couldn't help but feel a mix of emotions—compassion for the patient's suffering and a deep sense of responsibility to find a way to alleviate his distress. This encounter marked the beginning of my journey as a medical professional, reminding me of the immense impact our work can have on the lives of those in need. It solidified my commitment to provide the best care possible and find answers for patients like him.

Case of a 55 year old female with low back ache since 15 years 

https://tellashruthi159.blogspot.com/2023/04/58f-with-low-back-ache-since-15-years.html?m=1

One particular case left an indelible mark on me, as it opened my eyes to the profound challenges faced by individuals seeking medical attention. Allow me to recount my encounter with a patient who presented with a complex medical history.

I vividly remember the day when a 55-year-old woman from Casba, Assam, arrived at the hospital, burdened by years of lower backache. 

She spoke and understood only Bengali ,which I did not this made me use google translate to take her detailed history and to communicate with her about her general well being ,Her chief complaint resonated with me, as she had been grappling with this condition for an astounding 15 years. This resilient individual and her journey immediately sparked my curiosity.

Upon delving into her presenting illness, I discovered that her lower back pain had gradually emerged 15 years ago over time  the pain intensified and began radiating to both of her lower limbs. What surprised me further was the presence of tingling and numbness, predominantly affecting her right side.

Sitting for extended periods had become unbearable for her, aggravating the pain. Even the simple act of transitioning from a bent-forward position to standing caused her significant discomfort. The absence of any relieving factors only added to her frustration.

What struck me most was the profound impact this condition had on her daily life. As someone who had toiled in the fields, engaging in physically demanding tasks she had found solace in her work. However, due to the relentless progression of her symptoms, she was forced to abandon her livelihood eight years ago. It was a testament to the physical and emotional toll chronic pain can exact on an individual.

What amazed me was her unwavering resilience in the face of such challenging circumstances.

Adding to the complexity of her case, she had been grappling with neck pain and headaches for a decade. Seeking relief, she had consulted a healthcare professional who prescribed medications and exercises. However, her persistence in adhering to the treatment yielded no respite from her symptoms.

The patient has been taking Tablet hilcam plus for the past five years to help with her sleep at bedtime. Interestingly, she has developed a habit of frequently taking medications for unknown complaints.

She sought medical attention, and after various investigations, it was determined that changes were observed in her vertebrae in the lumbar region, resulting in compression and radiating pain. Painkillers were prescribed, and since then, she has been taking them almost daily. Although her sleep disturbances are primarily caused by her lower back pain, she finds relief once she manages to fall asleep. The patient used to work as a farmer but had to stop due to the increasing pain and financial support provided by her children. She currently manages daily chores in her house and maintains self-care and hygiene.

Despite consulting numerous doctors over the past 10 to 15 years, the patient's symptoms have not subsided, and no definitive diagnosis has been made. She has tried various medications, but no treatment has provided complete relief. The patient experiences anxiety and tension if she is unable to access her medications, which is evident when she misses taking them for a few days. She believes that medication is necessary for her to have a normal life, as it alleviates her pain and makes her feel better.

She constantly ruminates about her health, pain, and the impact it has on her ability to lead a normal life. Over the past 10 years, she has felt increasingly low regarding her condition and has noticed a decrease in her energy levels, perceiving her body as fragile. Additionally, she constantly worries about her family members. She has developed sensitivity to loud noises over the past 5 to 6 years, which causes her to feel sick and intensifies her pain.

Digging deeper into her medical history, I discovered that she had been managing hypertension for the past ten years, and she had also been diagnosed with cervical spondylitis eight years ago. she had undergone a hysterectomy at the age of 35 due to amenorrhea, which further highlighted the challenges she had faced throughout her life.

As I reflected on her personal history, I couldn't help but empathize with the struggles she had endured. Married at a young age, she started working in the fields four years into her marriage. The physically demanding nature of her work, which required hours of bending forward and leaning, undoubtedly contributed to the development and progression of her backache.

This case appeared to involve the spine, likely attributed to degenerative disc pathology, possibly lumbar spondylosis. Considering the symptoms and the location of the pain, a potential intervertebral disc prolapse at the L5-S1 level seemed plausible. I couldn't ignore the fact that her early menopause might have played a role in exacerbating her condition.

The symptoms she presented with were indicative of S1 nerve compression, possibly resulting from the intervertebral disc prolapse. Additionally, her ankle reflex appeared to be "hung up," further supporting the involvement of the S1 nerve.

As I delved deeper into her medical history, I couldn't help but reflect on the various risk factors that might have contributed to her condition. The physical demands of her occupation, combined with early menopause, seemed to amplify the likelihood of developing lumbar spine issues and subsequent nerve compression.

With this provisional diagnosis in mind, I realized the significance of formulating a comprehensive treatment plan tailored to her specific needs. It was essential to address her pain, enhance her quality of life, and potentially explore interventions such as physiotherapy, pain management, or even surgical options, depending on the severity of her condition.

On examination

 her vital signs were within normal limits, with a blood pressure of 110/70 mmHg, pulse rate of 84 beats per minute, respiratory rate of 19/minute, and no fever.

 

Based on the information gathered, my impression is that the patient has a persistent somatoform disorder in the background of her physical illness, lumbar spondylosis. Additionally, she is experiencing a mild depressive episode.

For the management plan

1. Provide psychoeducation to the patient.

2. Initiate treatment with Tab Pregabalin plus Duloxetine (30 mg) (Pregalin-D-30) to address her pain and depressive symptoms.

3. Prescribe Tab Clonazepam (0.25

As I concluded my narrative, I couldn't help but be inspired by this patient's resilience and fortitude in the face of debilitating pain. Her story reminded me of the profound impact chronic conditions can have on individuals from all walks of life. It was a humbling experience that would forever shape my understanding of patient care and motivate me to advocate for effective management strategies for those who suffer from chronic pain.

PJAR discussion 

Project: Clinical complexity in patients with chronic low back ache 

https://chat.whatsapp.com/IuiZ9ziiRI7INXH4YiCDxW

[4/30, 10:54 PM] Rakesh Biswas: Please elaborate on how to score our patient's joa score @⁨Kshitij 2018 Kims⁩

[4/30, 11:08 PM] Kshitij 2018 Kims: https://www.researchgate.net/figure/The-Japanese-Orthopaedic-Associations-scoring-system-JOA-Score_tbl1_268790894

[5/1, 8:52 AM] Rakesh Biswas: What is this patient's score?

[5/1, 8:54 AM] Rakesh Biswas: Also please let us know by reviewing the literature, what's the best way to capture the apd spinal canal diameter and area on MRI

[5/1, 9:01 AM] 2018 Tella Shruthi Kims: Lower back pain -1 

Leg pain or tingling -1 

Gait -0 

straight leg rasing -1

Sensory loss -2 

Motor loss-2

Restrictions of daily activities -1

Bladder function -3

[5/1, 9:02 AM] Himaja Kims Med Pg 2022: What is the interpretation of score 11?

[5/1, 9:05 AM] Kshitij 2018 Kims: The score is 5! Considering mild dysuria indicates (-3)

[5/1, 9:07 AM] Himaja Kims Med Pg 2022: Score more than 7 can be conservatively treated

[5/1, 9:08 AM] Kshitij 2018 Kims: Yes ma'am! But our pt score being 5! Can't be managed just conservatively!

[5/1, 9:13 AM] 2018 Tella Shruthi Kims: ma’am the patient had injection administered to her lower back 8 years ago and she only felt a relief for 1-2 months after it later she complained of similar symptoms ,also she’s on drug therapy since then …isn’t it a failed conservative management

[5/1, 9:24 AM] Rakesh Biswas: What would be a successful treatment for backache? 

Is the success duration dependent (for example the 2 month success with injection) or is it possible to attain low backache nirvana from surgical interventions? 

We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying 'completely recovered' and 'much better' patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline. The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS.

Conclusion: For estimating a 'success' rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.

https://pubmed.ncbi.nlm.nih.gov/30658613/

Can you share literature around "failed back pain surgery syndrome" as well as randomized controlled trials of trials for discectomy v placebo sham surgery?

Reviewed by Tella Shruthi 

Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index.

Results: At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.

https://pubmed.ncbi.nlm.nih.gov/12973134/

[05/05/23, 9:10:21 PM] Rakesh Biswas: What are our learning points from this patient that may have influenced our decisions and subsequent outcomes of this patient (which can only be gathered on follow up for another year)?

[05/05/23, 9:22:07 PM] Tella Shruthi: 1.she has urinary hestitancy ,can it be cauda eqina syndrome ? 

since cauda equina is LMN lesion it will usually present with symptoms of incontinence rather than frequency and urgency hestitancy ,beside CES is an emergency condition 

2.Based on antero-posterior diameter of spinal canal or on the cross sectional area of the dural sac, lumbar canal stenosis can be diagnosed. Cross sectional area of dural sac >100 mm2 at the narrowest point is normal and 76–100 mm2 is moderately stenotic and <76 mm2 are severely stenotic

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501532/#:~:text=Based%20on%20antero%2Dposterior%20diameter,mm2%20are%20severely%20stenotic.

3.JOA score to assess the need for surgery 

Lower back pain -1 

Leg pain or tingling -1 

Gait -0 

straight leg rasing -1

Sensory loss -2 

Motor loss-2

Restrictions of daily activities -1

Bladder function (-3)

1+1+0+1+2+2+1-3= 5

Score more than 7 can be conservatively treated

3. What would be a successful treatment for backache? 

Is the success duration dependent (for example the 2 month success with injection) or is it possible to attain low backache nirvana from surgical interventions? 

A study compared lumbar fusion surgery with cognitive intervention and exercises in 64 patients with low back pain and evidence of disc degeneration. The main outcome measure was the Oswestry Disability Index. Results showed that the Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.

https://pubmed.ncbi.nlm.nih.gov/30658613/

4.failed back pain surgery

Failed back surgery syndrome (FBSS) is a term used to describe persistent or recurrent low back pain following spinal surgery. It is a complex condition that can have a significant impact on the quality of life of patients. The reasons why surgery may fail are multifactorial and can include incorrect diagnosis, inadequate surgical technique, complications during surgery, and underlying medical conditions. 

Some common symptoms of FBSS include chronic pain, numbness, tingling, and weakness in the back and legs. Treatment options for FBSS may include physical therapy, medications, nerve blocks, spinal cord stimulation, or revision surgery. It is important to consult with a healthcare provider to determine the best treatment plan for individual cases of FBSS.

5.why was our patient on sulfasalazine 

In the case of lower back ache, Sulfasalazine may have been prescribed if the patient is suspected to have an inflammatory condition, such as ankylosing spondylitis or psoriatic arthritis

6.discectomy vs sham surgery 

https://pubmed.ncbi.nlm.nih.gov/12973134/

This study compared two treatments for long-term low back pain. One group received surgery, and the other group received exercises and education. After one year, both groups had improved, but the surgery group improved slightly more. However, the differences were not significant, meaning they could have happened by chance. The surgery group had more complications than the exercise group. Overall, both treatments were helpful for most patients, but surgery had more risks.

[05/05/23, 9:27:54 PM] Tella Shruthi: Surgery is not always the best option: Clinical trials have shown that low back pain surgery may not always be the best treatment option for patients with chronic low back pain. In some cases, non-operative treatments such as cognitive intervention and exercises may provide similar outcomes to surgery.

[05/05/23, 9:32:07 PM] Rakesh Biswas: How much of these can be translated to our patient's outcomes?

[05/05/23, 9:43:53 PM] Tella Shruthi: The JOA score can be used to assess the need for surgery in our patients with low back pain. A score of more than 7 can be conservatively treated, while a lower score may indicate the need for surgery.

2. Since the clinical trial have shown that low back pain surgery is not best treatment option always ,

Non operative methods can be used and follow up can be done using owswestry disability index 

3.currently since our patient reports the pain is reduced , continuation of conservative methods would be best choice 

4.MRI with spinal canal diameters can be used for follow up by comparing her MRI’s from 2016,2023 and in future

[05/05/23, 10:38:04 PM] Rakesh Biswas: What was our patient's score?

[05/05/23, 10:43:39 PM] Kshitij Sharma: 5 sir?

[05/05/23, 10:45:57 PM] Rakesh Biswas: Was there something wrong with our scoring? Can we run it again sharing the details

[05/05/23, 10:47:24 PM] Kshitij Sharma: 1+1+0+1+2+2+1-3

[05/05/23, 10:50:03 PM] Rakesh Biswas: How did we test her gait? 

Did we make her do a 6 minute walk test?

[05/05/23, 10:52:30 PM] Rakesh Biswas: Mild Dysuria -3?

How do you know it's related to her backache causing spinal cord dysfunction?

[05/05/23, 10:52:53 PM] Rakesh Biswas: Score is 9

[05/05/23, 10:53:33 PM] Kshitij Sharma: How sir?

[05/05/23, 10:59:27 PM] Kshitij Sharma: Occam's razor sir! That's the cause that fits!

[05/05/23, 11:02:21 PM] Kshitij Sharma: Like what's the split-up?

[05/05/23, 11:03:14 PM] Rakesh Biswas: Is occam's razor supposed to be blunt?

It is supposed to represent sharper minds who look for the optimal fits. Just because a person has dysuria and backache doesn't make it a neurogenic bladder

[05/05/23, 11:07:54 PM] Kshitij Sharma: 1+1+1+1+2+2+1+0 ??

[06/05/23, 10:35:40 AM] Rakesh Biswas: @918179510603 Can you summarize the successful learning points (that helped the patient) and the failed learning points (that didn't help the patient although they improved our understanding)? 

@8801316197024 Can we classify the AJND learning outcomes also in the same manner?

[06/05/23, 12:02:42 PM] Tella Shruthi: SUCCESSFUL LEARNING POINTS 

1.Based on antero-posterior diameter of spinal canal or on the cross sectional area of the dural sac, lumbar canal stenosis can be diagnosed. Cross sectional area of dural sac >100 mm2 at the narrowest point is normal and 76–100 mm2 is moderately stenotic and <76 mm2 are severely stenotic

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501532/#:~:text=Based%20on%20antero%2Dposterior%20diameter,mm2%20are%20severely%20stenotic. 

2.Patient was advised by neurosurgeon to undergo L4-L5 ,L5,S1 discectomy and laminectomy 

In view of this we researched and found a clinical trial 

https://pubmed.ncbi.nlm.nih.gov/12973134/

This study compared two treatments for long-term low back pain. One group received surgery, and the other group received exercises and education. After one year, both groups had improved, but the surgery group improved slightly more. However, the differences were not significant, meaning they could have happened by chance. The surgery group had more complications than the exercise group. Overall, both treatments were helpful for most patients, but surgery had more risks.

Hence we went forth with cognitive interventions consisting  lumbar back support painkillers (pregabalin ,duloxetin ),pyscho education 

3.JOA score to assess the need for surgery 

Lower back pain -1 

Leg pain or tingling -1 

Gait -1

straight leg rasing -1

Sensory loss -2 

Motor loss-2

Restrictions of daily activities -1

Bladder function -0 

1+1+1+1+2+2+1+0=9

Score more than 7 can be conservatively treated

FAILED LEARNING POINTS 

1.she has urinary hestitancy ,can it be cauda eqina syndrome ? 

since cauda equina is LMN lesion it will usually present with symptoms of incontinence rather than frequency and urgency hestitancy ,beside CES is an emergency condition 

2. What would be a successful treatment for backache? 

Is the success duration dependent (for example the 2 month success with injection) or is it possible to attain low backache nirvana from surgical interventions? 

A study compared lumbar fusion surgery with cognitive intervention and exercises in 64 patients with low back pain and evidence of disc degeneration. The main outcome measure was the Oswestry Disability Index.

https://pubmed.ncbi.nlm.nih.gov/30658613/

3.Failed back surgery syndrome (FBSS) is a term used to describe persistent or recurrent low back pain following spinal surgery. It is a complex condition that can have a significant impact on the quality of life of patients. The reasons why surgery may fail are multifactorial and can include incorrect diagnosis, inadequate surgical technique, complications during surgery, and underlying medical conditions. 

4.why was our patient on sulfasalazine 

if the patient is suspected to have an inflammatory condition, such as ankylosing spondylitis or psoriatic arthritis

[06/05/23, 2:45:42 PM] Tella Shruthi: spl 2 -says joa score of more than 7 should be conservatively managed and 

Spl- proves that indeed there was no need for surgery since surgery vs placebo after year yielded same results

[06/05/23, 2:46:42 PM] Tella Shruthi: Slp-1 is only telling us when to call it moderately or severe lumbar canal stenosis

[30/04/23, 3:47:19 PM] Rakesh Biswas: Please share her clinical images of visceral fat and muscle mass @918790889907. Did you check @918897799393 's image links to how can get eyeball estimates of body fat?

 Please share your eyeball estimate of her body fat after going through the links in Pavan's projr. 

A fat muscle ratio would be great if you could share

[30/04/23, 3:56:18 PM] Himaja Gen Med Madam: To my eyeball estimation it is 35% sir

[30/04/23, 4:08:39 PM] Kshitij Sharma: Then my estimation would be 30%

[30/04/23, 10:13:26 PM] Rakesh Biswas: 30-40%?

Although again this estimation is based on eyeballing absence of muscle such as six packs in the abdomen.

Discussion 

My questions regarding this case 

1.did hysterectomy at the age of 35 years cause this denegerative condition 

2.she has urinary hestitancy ,can it be cauda eqina syndrome ? 

3.if L5-S1 level compression is present then y sensory manifestations of S1 not seen 

4.cause for cervical spondylosis

Patient tried explaining in Bangla but google translant could not pick up properly

2A-since cauda equina is LMN lesion it will usually present with symptoms of incontinence rather than frequency and urgency hestitancy ,beside CES is an emergency condition 

Criteria based on AP diameters for lumbar stenosis 

https://emedicine.medscape.com/article/344171-overview#a1

The AP diameter of the normal lumbar spinal canal varies widely, from 15 to 27 mm. Lumbar stenosis results from an AP spinal canal diameter of less than 12 mm in some patients; a diameter of 10 mm is definitely stenotic and may be a primary source of symptoms.

Ours patients diameters 

L4/L5-11.2 mm 

L5/S1-8.6 mm in 2015

Criteria used for surgery requirement 

Score more than 7 can be conservatively treated

In our patient 

Lower back pain -1 

Leg pain or tingling -1 

Gait -0 

straight leg rasing -1

Sensory loss -2 

Motor loss-2

Restrictions of daily activities -1

Bladder function (-3)

1+1+0+1+2+2+1-3= 5

https://www.researchgate.net/figure/The-Japanese-Orthopaedic-Associations-scoring-system-JOA-Score_tbl1_268790894

What is the role of Sulfasalazine in rheumatology and why do you think this was given to our patient?

Sulfasalazine is a disease-modifying anti-rheumatic drug (DMARD) that is commonly used in the treatment of rheumatoid arthritis and other inflammatory rheumatic conditions, such as ankylosing spondylitis and psoriatic arthritis. It works by suppressing the activity of the immune system, thereby reducing inflammation and preventing joint damage.

In the case of lower back ache, Sulfasalazine may have been prescribed if the patient is suspected to have an inflammatory condition, such as ankylosing spondylitis or psoriatic arthritis. These conditions can cause inflammation in the joints of the spine, leading to pain and stiffness in the lower back. By suppressing the immune system and reducing inflammation, Sulfasalazine can help to relieve these symptoms and slow the progression of joint damage.

1.What would be a successful treatment for backache? 

Is the success duration dependent (for example the 2 month success with injection) or is it possible to attain low backache nirvana from surgical interventions? 

https://pubmed.ncbi.nlm.nih.gov/30658613/

We analysed 3859 patients with Lumbar Spinal Stenosis [(LSS); mean age 66; female gender 50%] and 617 patients with Lumbar Degenerative Spondylolisthesis [(LDS); mean age 67; 72% female gender]. The accuracy of identifying 'completely recovered' and 'much better' patients was generally high, but lower for EQ-5D than for the other PROMs. For all PROMs the accuracy was lower for the change score than for the follow-up score and the percentage change score, especially among patients with low and high PROM scores at baseline. The optimal threshold for a clinically important outcome was ≤24 for ODI, ≥0.69 for EQ-5D, ≤3 for NRS leg pain, and ≤ 4 for NRS back pain, and, for the percentage change score, ≥30% for ODI, ≥40% for NRS leg pain, and ≥ 33% for NRS back pain. The estimated cut-offs were similar for LSS and for LDS.

Conclusion: For estimating a 'success' rate assessed by a PROM, we recommend using the follow-up score or the percentage change score. These scores reflected a clinically important outcome better than the change score.

2.Can you share literature around "failed back pain surgery syndrome" 

Failed back pain surgery syndrome (FBPSS) is a term used to describe persistent or recurrent low back pain following spinal surgery. It is a complex and multifactorial condition that can have a significant impact on the quality of life of patients. There are several reasons why surgery may fail, including incorrect diagnosis, inadequate surgical technique, complications during surgery, and underlying medical conditions.

3. randomized controlled trials of trials for discectomy v placebo sham surgery?

https://pubmed.ncbi.nlm.nih.gov/12973134/

Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index.

Results: At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.

SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) of the patient's case:

Strengths:

1. The patient is maintaining self-care and hygiene.

2. She has a supportive family who provides financial stability and assistance.

3. The patient has been able to manage her pain with the help of medications.

4. She is able to sleep better with the use of medication.

5. The patient is oriented to time, place, and person.

Weaknesses:

1. The patient experiences chronic pain in her lower back and other areas of the body, leading to difficulty sitting for long periods.

2. She has become dependent on medication and experiences anxiety when unable to access them.

3. The patient has been unable to find relief or a definitive diagnosis for her symptoms despite consulting multiple doctors.

4. She has been experiencing sleep disturbances.

5. The patient feels low regarding her condition and has become less energetic.

Opportunities:

1. Further evaluation and psychiatric referral provide an opportunity for a comprehensive assessment and management of her condition.

2. Psychoeducation can help the patient understand the relationship between physical illness, pain, and psychological factors.

3. Stopping the use of HICALM plus may allow for the assessment of its effectiveness and potential alternatives.

4.gained understating over failed back ache surgeries and the effectiveness of the back ache surgery 

Threats:

1. The patient's dependence on medication and anxiety when unable to access them may pose a risk to her well-being.

2. The chronic pain and lack of relief may lead to frustration, further exacerbating her depressive symptoms.

3. The patient's perception of herself as having a less normal life compared to others may contribute to a negative self-image and decreased motivation.

4. The inability to sit for long periods and increasing pain sensation may limit the patient's physical functioning and overall quality of life.

References 

1.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501532/#:~:text=Based%20on%20antero%2Dposterior%20diameter,mm2%20are%20severely%20stenotic

2.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431053/#:~:text=Following%20lumbar%20laminectomy%2C%20patients%20experienced,a%20postoperative%20cerebrospinal%20fluid%20leak

3.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431053/#:~:text=Following%20lumbar%20laminectomy%2C%20patients%20experienced,a%20postoperative%20cerebrospinal%20fluid%20leak

4. https://jorthoptraumatol.springeropen.com/articles/10.1007/s10195-005-0099-0

5. https://www.researchgate.net/figure/The-Japanese-Orthopaedic-Associations-scoring-system-JOA-Score_tbl1_268790894

6. https://pubmed.ncbi.nlm.nih.gov/30658613/

7. https://pubmed.ncbi.nlm.nih.gov/12973134/