Improvements in technology and a push toward value-based health care have poised the telemedicine industry for growth; however, despite the benefits of virtual care, widespread implementation had not occurred until the coronavirus 2019 (COVID-19) pandemic. Powerful barriers have hindered the widespread adoption of telemedicine, including lack of awareness, implementation costs, inefficiencies introduced, difficulty performing physical examinations, overall lack of perceived benefit of virtual care, negative financial implications, concern for medicolegal liability, and regulatory restrictions. Some of these challenges have been addressed with temporary state and federal mandates in response to the COVID-19 pandemic; however, continued investment in systems and technology as well as refinement of regulations around telemedicine are needed to sustain widespread adoption by patients and providers.
IMPORTANCE Lumbar spinal stenosis is a prevalent and disabling cause of low back and leg pain in older persons, affecting an estimated 103 million persons worldwide. Most are treated nonoperatively. Approximately 600 000 surgical procedures are performed in the US each year for lumbar spinal stenosis.OBSERVATIONS The prevalence of the clinical syndrome of lumbar spinal stenosis in US adults is approximately 11% and increases with age. The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI). Nonoperative treatment includes activity modification such as reducing periods of standing or walking, oral medications to diminish pain such as nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. In a series of patients with lumbar spinal stenosis followed up for up to 3 years without operative intervention, approximately one-third of patients reported improvement, approximately 50% reported no change in symptoms, and approximately 10% to 20% of patients reported that their back pain, leg pain, and walking were worse. Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated. Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management. For example, in a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis, decompressive laminectomy improved symptoms more than nonoperative therapy (difference, 7.8 points; 95% CI, 0.8-14.9; minimum clinically important difference, 10-12.8) on the Oswestry Disability Index (score range, 0-100). Among persons with lumbar spinal stenosis and concomitant spondylolisthesis, lumbar fusion increased symptom resolution in 1 trial (difference, 5.7 points; 95% CI, 0.1 to 11.3) on the 36-Item Short Form Health Survey physical dimension score (range, 0-100), but 2 other trials showed either no important differences between the 2 therapies or noninferiority of lumbar decompression alone compared with lumbar decompression plus spinal fusion (MCID, 2-4.9 points). In a noninferiority trial, 71.4% treated with lumbar decompression alone vs 72.9% of those receiving decompression plus fusion achieved a 30% or more reduction in Oswestry Disability Index score, consistent with the prespecified noninferiority hypothesis. Fusion is associated with greater risk of complications such as blood loss, infection, longer hospital stays, and higher costs. Thus, the precise indications for concomitant lumbar fusion in persons with lumbar spinal stenosis and spondylolisthesis remain unclear.CONCLUSIONS AND RELEVANCE Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term bene...
The relationship between radiographic and functional outcomes in older patients with distal radius fractures is controversial. We explored this relationship by assessing the influence of radiographic displacement and fracture comminution on the functional outcomes of these fractures. We also asked whether operative intervention and demographic factors (age, gender, duration of followup) influenced outcome. We examined 53 patients older than 55 years with distal radius fractures with various functional assessments: range of motion (ROM) and strength measurements, three subjective surveys (Disabilities of the Arm, Shoulder, and Hand; Patient-rated Wrist Evaluation; Modernized Activity Subjective Survey of 2007), a Gartland and Werley score, and an objective, standardized hand performance test (Jebsen-Taylor). We measured angulation, articular gap/stepoff, and radial shortening on final radiographs and fracture comminution of preoperative radiographs. We observed no effect of radiographic displacement on subjective or objective outcome assessments, including standardized hand performance timed testing. Surgically treated fractures were less likely to display residual dorsal angulation and radial shortening, but surgical intervention did not independently predict functional outcome. Fracture comminution, patient gender, and months of followup similarly had no effect on outcome. We found no relationship between anatomic reduction as evidenced by radiographic outcomes and subjective or objective functional outcomes in this older patient cohort.
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