Evaluation of back pain and other disorders of the Spine

 What to refer  When to refer  Where to refer  Recent advances in Spine surgery – Minimally invasive surgery

Elective cases  Back pain  Neck pain  Leg pain  Arm pain  Neurological symptoms Spinal stenosis Lumbar/Cervical disc prolapse Degenerate disc/facet joint disease Myelopathy

Case 1 – 50 year old gentleman Back pain with bilateral leg pain, heaviness Leg symptoms get worse on walking, relieved by sitting Distal pulses and vascular exam Abnormal Vascular referral Normal Spinal referral Spinal stenosis

Case 1

Treatment for spinal stenosis  Non operative  Operative  Limited role for medical therapy

Traditional approach for treatment of spondylolisthesis

 5-7 days post op stay  Increased post op pain  Longer recovery

Minimally invasive spine surgery  Small incisions  Less muscle and tissue damage  Decreased blood loss  Less post op pain, early discharge and recovery, improved early and long term function  Cost effective

Case yr old self employed joiner Sciatica +/- Back pain Analgesia, exercises, education Cauda equina symptoms Yes Urgent referral to spine surgeon No Improvement in 4-6 weeks Yes Discharge No Referral to Spine surgeon

Examination  History  Physical Examination  Nerve root tension signs  Straight leg raise  Bowstring sign  Femoral stretch test  Neurological exam  P.R exam

Lumbar disc prolapse

Lumbar discectomy –  Wait for 12 months before offering surgery

 Effectiveness of surgery decreases in patients with symptoms longer than 12 months

Lumbar microdiscectomy  Early surgery gives better clinical results  Early surgery is cost effective  Decreasing incidence of complications (much safer than a THR)

Lumbar microdiscectomy – A day case procedure  Go home the same day of surgery  High patient satisfaction  Quicker recovery  Minimally invasive approach – operating microscope

Lumbar disc prolapse causing radiculopathy – my approach  Advice and analgesia for 6 weeks  Persistent pain after 6-8 weeks  Conservative management  Nerve root blocks  Microdiscectomy

Case 3 Chronic back pain Education, analgesia, CBT, Physiotherapy, Functional rehabilitation programme, acupuncture, osteopathic manipulations Improvement Yes No Address yellow, orange flags DischargeReferral to Spinal surgeon R/o Red flags

Degenerative Disc Disease

Identify pain source  Discography  Facet joint injections

MIS treatment of DDD

 ‘‘No, this won’t help your back, but I’m getting great reception for the big game!’’

Case 4  65 year old lady with back pain following minor fall  Radiograph  Osteoporotic vertebral fracture

 1 in 2 women above age of 50 years  1 in 4 men above age of 50 years  Vast majority unrecognised  Persistent pain in a third of cases

Clinical consequences of vertebral compression fractures  Acute and chronic pain  Impairment in activities of daily living  Loss of mobility  Depression  Progressive kyphosis  Shortness of breath  Increased mortality

Case 4 Osteoporotic vertebral compression fractures Analgesia, +/- brace, treatment for osteoporosis Improvement in 6 weeks Yes No Discharge Refer to spine surgeon 65 year old lady with back pain following minor fall

Vertebroplasty for osteoporotic vertebral compression fractures

Neck pain Red flags Arm pain Myelopathy Yes Urgent Spinal referral No Neck pain Case 5

Cervical radiculopathy  History

Cervical radiculopathy  Nerve root tension signs  Spurling’s test  Axial compression test  Upper limb tension test

Cervical disc prolapse  Treatment  Conservative  Nerve root block  Surgical (Anterior cervical discectomy and fusion)

Cervical myelopathy  High index of suspicion especially in the elderly  Natural history  Treatment  Observation  Surgery

Cervical myelopathy  Hoffman’s sign  Walking Rhomberg’s  Grip and release  Inverted supinator and inverted biceps reflexes  Brisk reflexes  Upgoing plantars  Sustained clonus

Neck pain  Second most frequent musculoskeletal cause for consultation in primary care.  Aetiology  Muscular, postural, stress, depression, degenerative discs and facets

Neck pain

Neck pain - treatment  Surgery usually ineffective unless for instability  Conservative treatment  Exercise based therapy  Manual therapy, manipulation

More urgent problems  Trauma  Tumour  Infection  Cauda equina / Spinal cord compression

Red flags  New onset back pain in patients 55 years old  Mid thoracic back pain  Past history of cancer  Back pain with fever, chills, rigors, weight loss, etc  Progressive neurology  Bladder / bowel symptoms, perineal numbness

Summary Don’t forget the red flags

Summary  Most elective conditions are self limiting  Early surgery efficacious and cost effective  Trend towards minimally invasive techniques  Osteoporotic vertebral compression fractures

Where to refer?  University Hospital of North Staffordshire  Nuffield Health North Staffordshire Hospital, Newcastle-under- Lyme  Private referrals  Choose and book (NHS)

Sandeep Konduru  Full time Orthopaedic Spine Surgeon  Combined Neurosurgical and Orthopaedic Spine Fellowship  Consultant Orthopaedic Spinal Surgeon – UHNS  Special interests  degenerative pathology of the entire spine  cervical spine surgery  Minimally invasive spine surgery

Sandeep Konduru  Non academic pursuits  Travel  Racquet sports  Aasha Charity (

Charity Cricket match ( for tickets contact Sandeep: )  9 th September 2011  Okamoor Cricket Club  Cricket and curry  Other entertainment and activities  Children’s cricket