1. Evaluation of back pain and other disorders of the Spine

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

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

4. 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

5. Case 1

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

7. Traditional approach for treatment of spondylolisthesis

8.  5-7 days post op stay  Increased post op pain  Longer recovery

12. 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

13. Case 2 - 30 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

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

15. Lumbar disc prolapse

16. Lumbar discectomy –  Wait for 12 months before offering surgery

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

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

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

20. 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

22. 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

23. Degenerative Disc Disease

24. Identify pain source  Discography  Facet joint injections

25. MIS treatment of DDD

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

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

29.  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

30. 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

31. 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

32. Vertebroplasty for osteoporotic vertebral compression fractures

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

34. Cervical radiculopathy  History

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

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

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

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

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

40. Neck pain

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

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

43. 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

44. Summary Don’t forget the red flags

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

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

47. 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 www.spineconsultant.co.uk

48. Sandeep Konduru  Non academic pursuits  Travel  Racquet sports  Aasha Charity (www.aasha.org.uk)www.aasha.org.uk www.spineconsultant.co.uk

49. Charity Cricket match ( for tickets contact Sandeep: 07515379010 )  9 th September 2011  Okamoor Cricket Club  Cricket and curry  Other entertainment and activities  Children’s cricket