54Non-invasive positive pressure ventilation (NIPPV) has become the accepted standard of care for the initial management of respiratory insufficiency in amyotrophic lateral sclerosis (ALS) 1,2 . A series of prospective studies have shown that when tolerated for greater than four hours per day, NIPPV therapy prolongs survival, increases quality of life and reduces decline in pulmonary function [3][4][5][6][7] . In addition, a recent randomized controlled trial has supported NIPPV's survival and quality of life benefit in a subset of ALS patients with good bulbar function 8 . Nevertheless, considerable variability in the prevalence of NIPPV use has been documented in the international ALS patient population. A survey of 265 British neurologists reported that approximately 2.6 -3.5% of patients were utilizing NIPPV, with 30% of all referrals coming from three physicians 9 . In addition, a questionnaire completed by 110 ABSTRACT: Objective: The purpose of this study was to evaluate Canadian amyotrophic lateral sclerosis (ALS) centres with respect to: 1) the prevalence of Non-invasive positive pressure ventilation (NIPPV) and invasive mechanical ventilation via tracheostomy (TV) utilization, 2) the approach to NIPPV use, focusing upon the currently employed initiation criteria and 3) the barriers influencing NIPPV administration. Methods: A descriptive survey research design aimed to obtain quantitative data and open-ended responses from an active physician at each of the 15 multidisciplinary Canadian ALS centres. Results: The principal findings of this study were: 1) NIPPV and TV are used in 18.3% and 1.5% of patients at Canadian ALS centres, respectively, 2) symptoms of respiratory insufficiency, namely orthopnea (clinical significance rated at 9.00/10 ± 1.48), dyspnea (8.27 ± 1.95) and morning headache (7.55 ± 1.21) are the most significant indicators for NIPPV initiation, 3) the primary barriers to NIPPV utilization are patient intolerance (70% of centres) and inaccessibility of respirologists and ventilation technologists (50% of centres). Conclusions: Variability in NIPPV use has an impact upon the management of Canadian ALS patients. The establishment of more definitive NIPPV initiation criteria, emphasizing respiratory symptoms, and the attenuation of barriers to NIPPV use should be targeted so as to ensure optimal care for all ALS patients.RÉSUMÉ: La NIPPV : prévalence, approche et freins à son utilisation dans les centres canadiens de traitement de la SLA. Objectif : Le but de cette étude était d'examiner dans les centres canadiens de traitement de la SLA : 1) la prévalence de NIPPV (ventilation non invasive en pression positive) et de l'utilisation de la ventilation mécanique avec trachéotomie (VT); 2) l'approche à l'utilisation de NIPPV ciblant les critères utilisés actuellement pour la commencer et 3) les freins à son utilisation. Méthodes : Nous avons utilisé un plan d'enquête descriptive dont le but était d'obtenir des données quantitatives et des réponses ouvertes des médecins pratiquant dans chacun d...

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Background:The beneficial treatment effect surgery demonstrates over conservative care for radiculopathy secondary to acute lumbar disc herniation (LDH), occurs in the first 3 to 6 months; thereafter outcomes are recognized to be similar. This is not surprising given the favourable natural history; 90% will experience gradual resolution of their symptoms within 4 months. In Canada, owing to the inherent wait time to see a surgeon and the referring physician's expectation that most patients will improve without surgery, symptomatic patients presenting to surgeons are often the 10% that have remained symptomatic longer than the expected 4 months. The purpose is to determine whether surgery is superior to conservative care in a patient population that has had persistent symptoms for more than 4 months, and therefore create a study population which is generalizable to the Canadian health care experience. Methods: This single blinded (assessor) RCT enrolled 18-to 60-year-old patients with a unilateral, single radiculopathy from a posterolateral L4-5 or L5-S1 disc herniation. Radiculopathy duration was longer than 4 months but less than 12 months. Patients on a waiting list to see surgeons at 1 academic hospital centre were randomized to early microdiscectomy or standardized nonoperative care, including medications, education, physiotherapy and steroid injections. Patients were excluded if they had previously received these conservative modalities. The primary outcome was intensity of sciatica (scale 0-10) measured at 6 months following randomization. Secondary outcome measures included back pain, Oswestry Disability Index (ODI), SF-36, work status and satisfaction. Results: This interim analysis reports on 40 nonoperative and 39 surgical patients. No difference existed between their demographic or preoperative data. At 6 months follow-up 32 of 39 surgical patients and 36 of 40 nonoperative patients had data available. Treatment effect for all outcome measures favoured surgery for the intent-to-treat, as-treat and last-value carried forward analysis (p < 0.05). To date 13 of 40 nonoperative patients have undergone microdiscectomy (performed after the primary outcome measure of 6 mo); they have had persistent inferior scores than early surgical patients (p < 0.05). Conclusion: At the interim analysis microdiscectomy is superior to nonoperative care for patients presenting with sciatica secondary to LDH. This study will continue to confirm robustness and validity of results.

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