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

3. 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.

4. 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

5. Emergency Referral 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). Cauda Equina Syndrome

6. Emergency Referral  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 Cauda Equina Syndrome – Signs & Symptoms

7. Emergency Referral Symptom Sensitivity  Urinary retention0.90  Unilateral or bilateral sciatica>0.80  Sensory / motor deficit and reduced SLR >0.80  Saddle anaesthesia 0.75 Objective Assessment  Reduced anal tone and power 60-80%  Sacral sensory loss 85% cases (Jalloh & Minhas 2007)  Bladder scan (post void) >150ml Cauda Equina Syndrome

8. Emergency Referral 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). Spinal Cord Compression

9. Emergency Referral  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. Spinal Cord Compression - Signs

10. 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. Infection/Discitis

11. 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

12. Urgent/GP Referral  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). Possible Tumour

13. Urgent/GP Referral 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 Possible Fracture

14. 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). Urgent/GP Referral Acute Radiculopathy

15. 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 Chronic Radicular Symptoms

16. 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 Structural Deformity

17. 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. Routine/GP Referral Mechanical Low Back Pain