“What to refer to Orthopaedics – A Surgeon’s perspective” Mr Rajiv Bajekal MCh(Orth), FRCS(Orth) Consultant Orthopaedic Surgeon Highgate Private Hospital & Royal Free London NHS Foundation Trust (Barnet Hospital)

What are we worried about and why? Harm to patient by missing potentially serious diagnosis Serious neurological deficit Early signs of cancer Infection, with long term consequences Fractures (fragility) with long term consequences Harm to us as a result of the above Not good for our standing Many organisations watching our practice, Defence unions, GMC etc

The plan 5 serious conditions Dissect out symptoms Cauda equina syndrome Myelopathy Malignancy Infection Osteoporotic fracture Dissect out symptoms Useful investigtions

Red Flag symptoms- identify serious causes Pain- out of proportion Night pain Rapid escalation of analgesia ladder Thoracic pain Extremes of age Neurological deficit Bladder bowel involvement History of malignancy Systemic symptoms such as weight loss, fever etc.

Sciatica

Definition of Sciatica Radicular pain, nerve root pain in the leg Onset-Often attributed to a ‘traumatic event’ Buttock, thigh or leg pain usually with back pain Aggravated by bending, coughing, sneezing, straining Relieved by rest Commonest cause- lumbar disc herniation

Natural History of disc herniation 75% better in 6 weeks 90% better in 12 weeks 93% better in 6 months Quite likely that if symptoms have lasted 12 weeks, good chance of no improvement without intervention

Lumbar disc herniation and cauda equina syndrome 2% of all lumbar disc herniations Bilateral symptoms Pain out of proportion classically bilaterally in the legs Perianal numbness Bladder/ bowel dysfunction Erectile dysfunction Patulous sphincter on rectal examination

Urinary problems in disc herniation Pain is the commonest cause of not being able to pass urine Analgesia esp codeine based drugs lead to constipation Earliest symptom of Cauda equina syndrome is lack of awareness of bladder filling up Also incomplete voiding If patients have a lack of sensation in perianal area- suspect CES Rectal examination is a must

Commonest cause of incorrect referral

Cauda equine syndrome- full blown Cauda equine syndrome – complete (CESR) Numbness in perianal area Painless retention of urine Overflow incontinence Bilateral leg pain Profound motor weakness in lower limbs Irreversible although most surgeons would still operate within 24-48 hours

High risk patient Bilateral radicular pains Bilateral motor weakness Bilateral absent ankle reflexes Bilateral sensory disturbance High risk of developing a cauda equina syndrome Need urgent MRI

Cauda equina syndrome-incomplete In the context of discogenic back problems with bilateral leg pain, back pain, numbness in perineal area If bladder scan shows more than 100 ml urine in bladder after voiding REFER URGENTLY to A and E not to RMS!!!

Urgent referral of disc herniation New onset of neurological deficit e.g. foot drop with continuing radicular pain Foot drop which is painless- too late Consider referral of very severe sciatica as treatment can be gratifying and quick recovery

Treatment options Ice- reduces swelling and spasm – therefore pain- good in acute LBP Heat-  circulation- not for acute phase Traction- generally ineffective Manipulation and mobilization- large placebo effect Cox’s distraction technique No evidence that it reduces the disc herniation

Assumptions for injection treatment Needle placement near symptomatic structure will reproduce pain Anaesthetic will reduce pain at least temporarily Pain secondary to inflammation may respond to steroid injection If the painful phase of the Natural History is made painless=good outcome

Causation Mechanical pressure on normal nerve – radiculopathy – no pain Mechanical stimulation of abnormal nerve is painful Chemical irritation- phospholipase A2, TNF-Alpha, free glutamate

What would I have? Pain killers/NSAID’s Massage? Chiropractic? Osteopathy Time off work? Epidural steroids Nerve root blocks – if typical root pain without hesitation

Neck pain

What do we not want to miss Myelopathy Why? Usually progressive Never gets better Can be arrested surgically if picked up early

HISTORY Fine movements of fingers Broad based gait Radicular or axial Pain Radicular or axial Diffuse/vague May be in conjunction with radiculopathy- careful examination can reveal problem Shooting down back Fine movements of fingers Broad based gait 23

24

Radiculopathy 25

Myelopathy Hoffman’s Inverted radial Finger escape Grip and release Babinski 26

Rule of 10 Watch gait over 10 steps Watch fatiguing of grip and release over 10 seconds

BACK PAIN

Malignancy in the spine Commonest- secondaries Commonest symptom is pain out of proportion in the back Wakefulness at night Atypical pain e.g. thoracic pain Extremes of age younger than 18 older than 60 Past or remote history of cancer

Single red flag Remote history of malignancy in the past

Investigations FBC, ESR, CRP, Serum electrophoresis LFT, CEA, CA 125 Plain x rays CT scan, abdomen, pelvis and chest Bone scan MRI scan

Case discussion CS/ Caucasian, blue collar job aged 56 Sudden onset sharp severe back pain Keen runner Very fit and well Loss of weight- unexplained

Infection diagnosis Night pain Rest pan Weight loss Systemic symptoms- weight loss, fever Blood tests FBC ESR CRP Serum electrophoresis

Fragility fractures of the spine Very often asymptomatic Sharp unbearable pain in the elderly X ray can help but one cannot be sure whether fracture is fresh or old STIR sequence MRI Early correction gratifying Late deformity- untreatable

Balloon kyphoplasty wfwhuk

Summary slide 5 serious conditions Cauda equine syndrome myelopathy Infection of the spine Malignancy in the spine Osteoporotic fractures Vital clinical signs that cause worry Few useful Orthopaedic blood tests

Thank you Highgate Private Hospital Clinics: Thursday PM & Saturday AM (weekly) T: 020 8341 4182 E: enquiries@highgatehospital.co.uk Other queries: bajekalsec@aol.com (medical secretary)