1. “What to refer to Orthopaedics – A Surgeon’s perspective”
Mr Rajiv Bajekal
MCh(Orth), FRCS(Orth)
Consultant Orthopaedic Surgeon
Highgate Private Hospital
&
Royal Free London
NHS Foundation Trust
(Barnet Hospital)

2. What are we worried about and why?
Harm to patient by missing potentially serious diagnosis
Serious neurological deficit
Early signs of cancer
Infection, with long term consequences
Fractures (fragility) with long term consequences
Harm to us as a result of the above
Not good for our standing
Many organisations watching our practice, Defence unions, GMC etc

3. The plan 5 serious conditions Dissect out symptoms
Cauda equina syndrome
Myelopathy
Malignancy
Infection
Osteoporotic fracture
Dissect out symptoms
Useful investigtions

4. Red Flag symptoms- identify serious causes
Pain- out of proportion
Night pain
Rapid escalation of analgesia ladder
Thoracic pain
Extremes of age
Neurological deficit
Bladder bowel involvement
History of malignancy
Systemic symptoms such as weight loss, fever etc.

5. Sciatica

6. Definition of Sciatica
Radicular pain, nerve root pain in the leg
Onset-Often attributed to a ‘traumatic event’
Buttock, thigh or leg pain usually with back pain
Aggravated by bending, coughing, sneezing, straining
Relieved by rest
Commonest cause- lumbar disc herniation

7. Natural History of disc herniation
75% better in 6 weeks
90% better in 12 weeks
93% better in 6 months
Quite likely that if symptoms have lasted 12 weeks, good chance of no improvement without intervention

8. Lumbar disc herniation and cauda equina syndrome
2% of all lumbar disc herniations
Bilateral symptoms
Pain out of proportion classically bilaterally in the legs
Perianal numbness
Bladder/ bowel dysfunction
Erectile dysfunction
Patulous sphincter on rectal examination

10. Urinary problems in disc herniation
Pain is the commonest cause of not being able to pass urine
Analgesia esp codeine based drugs lead to constipation
Earliest symptom of Cauda equina syndrome is lack of awareness of bladder filling up
Also incomplete voiding
If patients have a lack of sensation in perianal area- suspect CES
Rectal examination is a must

11. Commonest cause of incorrect referral

12. Cauda equine syndrome- full blown
Cauda equine syndrome – complete (CESR)
Numbness in perianal area
Painless retention of urine
Overflow incontinence
Bilateral leg pain
Profound motor weakness in lower limbs
Irreversible although most surgeons would still operate within hours

13. High risk patient Bilateral radicular pains Bilateral motor weakness
Bilateral absent ankle reflexes
Bilateral sensory disturbance
High risk of developing a cauda equina syndrome
Need urgent MRI

15. Cauda equina syndrome-incomplete
In the context of discogenic back problems with bilateral leg pain, back pain, numbness in perineal area
If bladder scan shows more than 100 ml urine in bladder after voiding
REFER URGENTLY to A and E not to RMS!!!

16. Urgent referral of disc herniation
New onset of neurological deficit e.g. foot drop with continuing radicular pain
Foot drop which is painless- too late
Consider referral of very severe sciatica as treatment can be gratifying and quick recovery

17. Treatment options
Ice- reduces swelling and spasm – therefore pain- good in acute LBP
Heat-  circulation- not for acute phase
Traction- generally ineffective
Manipulation and mobilization- large placebo effect
Cox’s distraction technique
No evidence that it reduces the disc herniation

18. Assumptions for injection treatment
Needle placement near symptomatic structure will reproduce pain
Anaesthetic will reduce pain at least temporarily
Pain secondary to inflammation may respond to steroid injection
If the painful phase of the Natural History is made painless=good outcome

19. Causation
Mechanical pressure on normal nerve – radiculopathy – no pain
Mechanical stimulation of abnormal nerve is painful
Chemical irritation- phospholipase A2, TNF-Alpha, free glutamate

20. What would I have? Pain killers/NSAID’s
Massage? Chiropractic? Osteopathy
Time off work?
Epidural steroids
Nerve root blocks – if typical root pain without hesitation

21. Neck pain

22. What do we not want to miss
Myelopathy
Why?
Usually progressive
Never gets better
Can be arrested surgically if picked up early

23. HISTORY Fine movements of fingers Broad based gait Radicular or axial
Pain
Radicular or axial
Diffuse/vague
May be in conjunction with radiculopathy- careful examination can reveal problem
Shooting down back
Fine movements of fingers
Broad based gait 23

24. 24

25. Radiculopathy 25

26. Myelopathy Hoffman’s Inverted radial Finger escape Grip and release
Babinski 26

27. Rule of 10 Watch gait over 10 steps
Watch fatiguing of grip and release over 10 seconds

28. BACK PAIN

31. Malignancy in the spine
Commonest- secondaries
Commonest symptom is pain out of proportion in the back
Wakefulness at night
Atypical pain e.g. thoracic pain
Extremes of age
younger than 18
older than 60
Past or remote history of cancer

32. Single red flag
Remote history of malignancy in the past

33. Investigations FBC, ESR, CRP, Serum electrophoresis LFT, CEA, CA 125
Plain x rays
CT scan, abdomen, pelvis and chest
Bone scan
MRI scan

36. Case discussion CS/ Caucasian, blue collar job aged 56
Sudden onset sharp severe back pain
Keen runner
Very fit and well
Loss of weight- unexplained

37. Infection diagnosis Night pain Rest pan Weight loss
Systemic symptoms- weight loss, fever
Blood tests
FBC
ESR
CRP
Serum electrophoresis

40. Fragility fractures of the spine
Very often asymptomatic
Sharp unbearable pain in the elderly
X ray can help but one cannot be sure whether fracture is fresh or old
STIR sequence MRI
Early correction gratifying
Late deformity- untreatable

44. Balloon kyphoplasty
wfwhuk

46. Summary slide 5 serious conditions
Cauda equine syndrome
myelopathy
Infection of the spine
Malignancy in the spine
Osteoporotic fractures
Vital clinical signs that cause worry
Few useful Orthopaedic blood tests

47. Thank you
Highgate Private Hospital Clinics: Thursday PM & Saturday AM (weekly) T: E: Other queries: (medical secretary)