Ensuring Appropriate Surgical Referrals

January 29, 2018 | Author: Anonymous | Category: Science, Health Science, Urology
Share Embed Donate


Short Description

Download Ensuring Appropriate Surgical Referrals...

Description

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

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.

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 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

Emergency Referral Cauda Equina Syndrome Symptom Sensitivity Urinary retention Unilateral or bilateral sciatica Sensory / motor deficit and reduced SLR Saddle anaesthesia

0.90 >0.80 >0.80 0.75

Objective Assessment Reduced anal tone and power Sacral sensory loss Bladder scan (post void)

60-80% 85% cases (Jalloh & Minhas 2007) >150ml

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).

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.

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.

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

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).

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

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).

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).

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.

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.

View more...

Comments

Copyright � 2017 NANOPDF Inc.
SUPPORT NANOPDF