1. Spinal Surgery Algorithms

2. Low Back Patient Consider Surgical Diagnoses General Approach to the Elective Lumbar Patient – Goals of History / Physical Last updated Sept. 10, 2009 Consider Differentials Guide Management Neurological Impingement Segmental Instability Multifactorial Neoplasm Infection Fractures Inflammatory Intra-abdominal / Pelvic Psychological Referred Pain Leg Pathology Spinal Cord Goals Back Pain Leg Pain Both/Either Severity Past Treatments Yellow Flags Physical General Neurological Sensory / Motor / Reflex Nerve Root Tension Spinal Cord +/- rectal Back Look (Inspection) Feel (Tender) Move (Directionality) Hips / Legs Vascular +/- Abdominal HPI Duration Onset Course Characteristics Location/dominance Aggravating/relieving Disability Past Treatments Red / Yellow Flags Medical/Surgical Allergies Social Cauda Equina Red Flags 30 Second Summary

3. Low Back Patient History / Physical Consider / Rule Out Differential Diagnosis / Red Flags Back DominantLeg Dominant Reassure, Educate, Analgesics, Exercise, Physiotherapy, Lifestyle, ? Alternative Consider Spinal Manipulation Advise Re: Cauda Equina Syndrome Flexion (Discogenic) Extension (Facet) Flexion (Sciatica – Disc Herniation) Extension (Claudication – Spinal Stenosis) Facet Injections / Rhizolysis Epidural Fusion DiscectomyLaminectomy +/- Fusion General Approach to the Elective Lumbar Patient – Surgical Options Non-Operative Interventional Surgical Assess Patient Last updated October 18, 2007 Appropriate Imaging to Confirm Diagnosis

4. Acute Sciatica Non-op MRI, Myelogram P2 Laminectomy (absolute indication) CT, MRI P3 Discectomy (relative indication) Meds (OTC, NSAID, Lyrica, Opiods, Prednisone) Physio Stay Active Reassure Advise of CES Subacute / Chronic Sciatica Epidural Elective Discectomy Encourage daily exercise Better MRI or CT Cauda Equina Syndrome Severe Pain/ Weakness (< grade 3) DDX Hip OA / Fracture Vascular Non-spinal neural compression / pathology Herpes DVT, etc. Rule Out Not better Yes Clinical Correlation ? Pt. Choice Medical Comorbidity Unsure of Diagnosis Willing to wait Predictors of Good Surgical Outcome +ve SLR Leg Dominant Pain Clinical Correlation (dermatomal distribution, neuro exam) WSIB / Disability No Blame Hysteria < 6 months pain Baseline fitness Surgery for pain as opposed to for neuro deficit Not in foramen ? Size of disc ? Sequesterd Epidural response No CES Mild or no neuro deficit Pt. Choice Able to stay active If able to tolerate pain then similar long term outcomes to surgery Pt. Choice No Not Better Better CT, MRI P2-3 Discectomy (absolute indication) Progressive Weakness Last Updated: Sept. 14, 2007 Sciatica / Disc Herniation

5. Claudication and Spinal Stenosis Non-op Educate, Analgesia, Exercise (Core, Aerobic), Physio, Lifestyle, Advise CES Epidural Posterior Decompression (Laminectomy, Foraminotomy) Leg DominantSignif. Back Pain No Instability Instability Degen. Spondylolisthesis, Lat. Listhesis, Scoliosis No Instability Fusion (All Decompressed Levels + ? Additional Levels) Non-instrumented, Instrumented (Pedicle Screws, TLIF, PLIF) Pt. Choice Medical Comorbidity Unsure of Diagnosis Willing to wait Assess Additional Fusion Levels Bone Scan, MRI, Discogram Relative Indication Claudication Spinal Stenosis Last Updated: Oct 18, 2007 Predictors of Good Surgical Outcome Leg Dominant Pain Not Foraminal ? Degree of Stenosis ? # of Levels ? No scoliosis No WSIB / Disability No Blame No Hysteria No Comorbidity < 6 months pain Baseline fitness ? Surgery for pain as opposed to for neuro deficit (Surgery as P3 to Within Weeks) (Note: Facet Sparing, If No Fusion) Cauda Equina Syndrome (Acute: Surgery as a P2, Chronic: Surgery Within Weeks) Progressive Weakness ? No Surgery

6. Acute Back Pain < 6- 12 weeks Non-op Acute Back Pain Last Updated: Nov 8, 2007 Red Flags Age > 50, Trauma, Fever, Night Pain, Weight Loss, Cancer History Rheum Workup Differential Diagnosis Consider non-spinal diagnosis if: Atypical or unable to elicit pain on physical AM Stiffness X-ray Appropriate Workup Blood work, Abdo U/S CT, Urinalysis, etc. Reassure Stay Active Avoid Bedrest If Cauda Equina Syndrome go to ER First general low impact aerobic. Add core strengthening (Pilates, yoga, Physio) when able Multi-Modalities (in order): 1.Tylenol 2.Advil 3.Robaxacet 4.NSAID 5.Opiod 6.Lyrica if leg pain as well Chiro / Physio Spinal Manipulation / Mobilization Positional Care Exercise EducationExerciseAnalgesia Referral Yellow Flags (High risk of poor outcomes) WSIB Blame on Injury Lawyer Insurance Poor Expectations Multiple Areas Previous Episodes Changing Positions Difficulty Sleeping Intensity of Pain Bad Temper / Irritable Focus on Pain Believes Hurt = Harm Fear Avoidance Prefers Passive Tx. Cauda Equina MRI Rule Out Consider

7. Chronic Back Pain Standard Conservative Care Educate, Analgesia, Exercise (Core, Aerobic), Active Physio, Lifestyle Facet Back PainDiscogenic Back Pain Chronic Back Pain Last Updated: Dec 6, 2007 Atypical Pain Rule out DDx (Bone Scan, Abdo US/CT, ESR, CRP, CBC, Renal, LFT, Protein Electro- phoresis, Bence Jones, PSA, TSH, Ferritin, B12) Bone Scan with SPECT Facet Injection Repeat Facet Injection Radio- frequency Rhizotomy MRI Discogram Myofascial Pain Trigger Point Injection High Emotional Stress Psychologist / GP Extension Pain (Older) 1-2 Inflamed Facet(s) Short relief but recurrent pain Long relief but recurrent pain Flexion Pain (Younger) Understands Risks / Expected Outcomes of OR 1-2 level(s) degeneration Fusion Concordant Pain Understands Risks / Expected Outcomes of OR recurrent pain Relative Absence of Yellow Flags Trigger Points Chronic Multidisciplinary Pain Clinic A lot of Yellow Flags Diffuse Pain Non-mechanical Pain Educate, Analgesia, Exercise (Core, Aerobic), Active Physio, Lifestyle, Cognitive Behavioural

8. Acute Spinal Cord Injury Standard Emergency Care ABC, C-spine Precautions (Aspen Collar, NOT ambulance collar) CTL spine X-rays (Rule out other fractures) Get off backboard, NG Tube, Foley, Keep Warm,? Steroids Acute Spinal Cord Injury Last Updated: Jan 24, 2008 Monitor for: Admit to 1:1 Nursing: Neurogenic Shock Intra-abdominal Injury Atelectasis Neurological Deterioration Ascending Paralysis Document Neurological Exam Motor (Myotomes), Sensory (Dermatomes), Reflexes, Rectal, Bulbocavernosus ASIA Classification Appropriate Imaging MRI Better to image spinal cord Can still see most bony anatomy Important if prior imaging does not explain neuro exam CT Better to see bony anatomy Easier to get Definitive Management Observation, Closed Reduction or Surgery (Open Reduction / Decompression / Stabilization)

9. Acute Central Cord Syndrome Complete (Irreversible) Spinal Cord Injury Central Cord Syndrome Last Updated: Jan 24, 2008 Incomplete Spinal Cord Injury / Still in Spinal Shock Non-operative Urgent Decompression Progressive Neurological Deterioration Observation / Collar Delayed Decompression No Improvement Non-Progressive Neurology Physiologically Younger Acute Disc Herniation Patient Wishes Physiologically Older Medical Comorbidities Osteophytic Compression Multiple levels Patient Wishes Delay in Diagnosis