Ensuring Appropriate Surgical Referrals
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Transcript Ensuring Appropriate Surgical Referrals
September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
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
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
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).
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
Emergency Referral
Cauda Equina Syndrome
Symptom Sensitivity
Urinary retention
Unilateral or bilateral sciatica
Sensory / motor deficit and reduced SLR
Saddle anaesthesia
0.90
>0.80
>0.80
0.75
Objective Assessment
Reduced anal tone and power
Sacral sensory loss
Bladder scan (post void)
60-80%
85% cases (Jalloh & Minhas 2007)
>150ml
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).
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.
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.
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
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).
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
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).
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).
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.
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.