September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

1. September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

2. Ensuring Appropriate Surgical Referrals

3. 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.

4. 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

5. 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).

6. 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

7. 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

8. 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).

9. 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.

10. 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.

11. 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

12. 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).

13. 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

14. 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).

15. 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).

16. 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.

17. 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.