Ensuring Appropriate Surgical Referrals

September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
Thought Process & Progression
 As with all cases, there has to be a clear and logical rationale supporting decision
 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
 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.
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
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).
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
 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
Emergency Referral
Cauda Equina Syndrome
Symptom Sensitivity
Urinary retention
Unilateral or bilateral sciatica
Sensory / motor deficit and reduced SLR
Saddle anaesthesia
Objective Assessment
Reduced anal tone and power
Sacral sensory loss
Bladder scan (post void)
85% cases (Jalloh & Minhas 2007)
Emergency Referral
Spinal Cord Compression
 Significant Disc Bulge
 Spinal mets can cause MSCC
 5% of patients with cancer present with MSCC (Levack et al,
 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).
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
 Cervical signs – more than one nerve root affected.
Urgent/GP Referral
 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.
Urgent/GP Referral
 Insidious onset
 Pain on movement & may affect mobility
 Fever &/or weight loss
 Neurological deficit
 Blood tests – ESR, CPR, WBC
 MRI – most sensitive
 Sputum & urine cultures – to identify source of infection
 Antibiotics – IV/oral
 Analgesia
 Surgical intervention
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
 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).
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
 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
Urgent/GP Referral
Acute Radiculopathy
 Radicular leg pain > back pain not responding to conservative
 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).
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
Routine/GP Referral
Structural Deformity
 Not previously diagnosed & associated with the back
 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.
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.

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