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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk PowerPoint Presentation
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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk. Ensuring Appropriate Surgical Referrals. Thought Process & Progression. As with all cases, there has to be a clear and logical rationale supporting decision making.

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Presentation Transcript
slide1

September 5th – 8th 2013

Nottingham Conference Centre, United Kingdom

www.nspine.co.uk

thought process progression
Thought Process & Progression
  • As with all cases, there has to be a clear and logical rationale supporting decision making.
  • Information from case history will raise or lower index of suspicion.
  • Thorough neurological investigation will determine course of action.
  • Always keep an open mind to potential for things to change.
  • Keep asking/checking if change has occurred if you have suspicion that it might have done.
  • Red flags are important factor, however some “red flags” such as insidious onset, age > 50, and failure to improve after one month have high false positive rates. Some evidence that previous history of cancer meaningfully increases the probability of malignancy.(1)
  • Remember serious spinal pathology is rare (< 1 % of cases).

1. Henschke N, Maher CG, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD008686. DOI: 10.1002/14651858.CD008686.pub2.

indications for referral
Indications for Referral
  • Emergency Referral
    • Cauda Equina Syndrome
    • Spinal Cord Compression
  • Urgent/GP Referral
    • Infection/Discitis
    • Possible Tumour
    • Possible Fracture
    • Acute Radiculopathy
  • Routine GP Referral
    • Chronic Radicular Symptoms
    • Structural Deformity
    • Mechanical Low Back Pain
slide5

Emergency Referral

Cauda Equina Syndrome

  • The Cauda Equina is the bundle of nerve roots which descend within the spinal canal, distal to the conus medullaris, approx. L1-L2 (Williams et al, 2003).
  • Compression can cause various motor and sensory problems of LEX, pelvic viscera and pelvic floor dysfunction (Wiesel et al, 1996).
  • Most significant is compromise of S4 which leads to bowel/bladder disturbance (Brier, 1999).
slide6

Emergency Referral

Cauda Equina Syndrome – Signs & Symptoms

  • Saddle anaesthesia
  • Faecal incontinence/loss of anal sphincter tone
  • Bladder retention/incontinence
  • Sexual dysfunction
  • Widespread neurological impairment which may include:
    • Bilateral neurological impairment
    • More than 2 lumbar nerve roots affected
    • Large area of anaesthesia – not just one nerve root
    • Gait disturbance e.g. foot drop
slide7

Emergency Referral

Cauda Equina Syndrome

  • Symptom Sensitivity
  • Urinary retention 0.90
  • Unilateral or bilateral sciatica >0.80
  • Sensory / motor deficit and reduced SLR >0.80
  • Saddle anaesthesia 0.75
  • Objective Assessment
  • Reduced anal tone and power 60-80%
  • Sacral sensory loss 85% cases (Jalloh & Minhas 2007)
  • Bladder scan (post void) >150ml
slide8

Emergency Referral

Spinal Cord Compression

  • Causes:
  • Significant Disc Bulge
  • Spinal mets can cause MSCC
  • 5% of patients with cancer present with MSCC (Levack et al, 2002).
  • Symptoms:
  • First symptom is pain (Levack et al, 2002).
  • Reduced control of legs, foot drop, dragging legs can be early signs but are often under reported as it is vague & patient unaware of significance (Greenhalgh & Selfe, 2008).
slide9

Emergency Referral

Spinal Cord Compression - Signs

  • Widespread neurological impairment.
  • Up going plantar response/positive Babinski sign.
  • Clonus/increased tone/brisk reflexes.
  • Positive Rhomberg’s, heel-toe gait, or Hoffmann’s.
  • Bilateral, quadrilateral or hemilateral neurological impairment.
  • Cervical signs – more than one nerve root affected.
slide10

Urgent/GP Referral

Infection/Discitis

  • Inflammation of intervertebral disc, often associated with infection, & can co-exist with vertebral osteomyelitis.
  • Lumbar > Cervical > Thoracic.
  • Usually haematogenous spread of infection – urinary tract, lungs and soft tissues are common primary sites.
  • Staphylococcus Aureus is the most common pathogen.
  • Most common in males >50yrs.
  • Risk factors include immunosuppressed, lifestyle, substance misuse.
slide11

Urgent/GP Referral

Infection/Discitis

  • Presentation:
  • Insidious onset
  • Pain on movement & may affect mobility
  • Fever &/or weight loss
  • Neurological deficit
  • Investigations:
  • Blood tests – ESR, CPR, WBC
  • MRI – most sensitive
  • Sputum & urine cultures – to identify source of infection
  • Treatment:
  • Antibiotics – IV/oral
  • Analgesia
  • Surgical intervention
slide12

Urgent/GP Referral

Possible Tumour

  • Pain associated with rest, severe night pain, weight loss, constant thoracic pain.
  • Constant progressive non-mechanical pain.
  • Deteriorating neurological signs/symptoms.
  • Patients over 55yrs with first episode of back pain.
  • Previous malignancy - any patient with previous breast, prostate or lung cancer.
    • Venous drainage from the breast is via azygos veins into thoracic paravertebral venous plexus, therefore commonly leads to thoracic mets (Frymoyer 1997).
    • Up to 85% of women with breast cancer develop skeletal mets before death (Centre for Chronic Disease Prevention and Control 2007).
slide13

Urgent/GP Referral

Possible Fracture

  • Risk factors:
  • Trauma – urgent referral
  • Previous pathological fractures
  • Diagnosis of osteoporosis
  • Factors to consider:
  • Post-menopausal women – age at menopause & years since menopause
  • Exercise status
  • Loss of height
  • Difficulty lying in bed (Bennell et al, 2000)
  • Altered bone absorption – coeliac disease, eating disorder, hyperthyroidism, gastrectomy
  • Corticosteroid use – RA, weightlifters
slide14

Urgent/GP Referral

Acute Radiculopathy

  • Radicular leg pain > back pain not responding to conservative treatment.
  • Identify limitation of walking as a significant symptom.
  • Two main groups:
    • Younger patients (20 – 55 years) with suspected disc pathology - refer if not responding to conservative treatment and pain hard to control with analgesia. N.B. Consider referring young patients with severe radiculopathy as early as 2-3 weeks of onset. Less severe cases within 6 weeks of onset.
    • Older patients (over 55 years) with suspected neurogenic claudication due to spinal stenosis - refer if have symptoms
  • Patients need to be open to the possibility of either injection (root blocks, epidural) or surgery (decompression, discectomy).
slide15

Routine/GP Referral

Chronic Radicular Symptoms

  • Patients with chronic (>12 months) low back pain associated with radicular pain, who:
    • have noticed a gradual deterioration in leg symptoms
    • have not responded to conservative treatment
    • wish to consider injection therapy or surgery
  • These patients should have:
    • limited yellow flags/psychosocial pain drivers
    • be in work or looking to return to work
    • Oswestry score of less than 50
  • Referred for consideration of injection or surgery (decompression/discectomy).
slide16

Routine/GP Referral

Structural Deformity

  • Not previously diagnosed & associated with the back pain.
  • Scoliosis – AIS and degenerative.
  • Spondylolisthesis - if presenting with significant pain, radiculopathy and/or neurological impairment and not responding to conservative management, usually grades II and above.
slide17

Routine/GP Referral

Mechanical Low Back Pain

  • Patients with predominantly back pain (more than leg pain), who have tried a range of evidence-based conservative approaches.
  • These patients should have:
    • limited yellow flags/psychosocial pain drivers
    • be in work or looking to return to work if applicable
    • Oswestry score of less than 50
  • Referred for consideration of spinal fusion.