SANDEEP KONDURU M.B.B.S, FRCSED (TR & ORTH)CONSULTANT ORTHOPAEDIC SPINE SURGEON

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 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

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 3Chronic back pain

Education, analgesia, CBT, Physiotherapy, Functional rehabilitation programme, acupuncture, osteopathic manipulations

Improvement

Yes No

Address yellow, orange flags

Discharge Referral 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

DischargeRefer 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 UrgentSpinal 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 <20 and >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)

www.spineconsultant.co.uk

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

Sandeep Konduru

Non academic pursuits Travel Racquet sports Aasha Charity (www.aasha.org.uk)

www.spineconsultant.co.uk

Charity Cricket match(for tickets contact Sandeep: 07515379010)

9th September 2011

Okamoor Cricket Club

Cricket and curry

Other entertainment and activities

Children’s cricket

THANK YOU