Evaluation of back pain and
other disorders of the Spine
SANDEEP KONDURU
M.B.B.S, FRCSED
(TR & ORTH)
CONSULTANT ORTHOPAEDIC SPINE
SURGEON
 What to refer
 When to refer
 Where to refer
 Recent advances in Spine surgery – Minimally
invasive surgery
Elective cases
 Back pain
Spinal stenosis
 Neck pain
Lumbar/Cervical disc prolapse
 Leg pain
Degenerate disc/facet joint disease
 Arm pain
Myelopathy
 Neurological
symptoms
Case 1 – 50 year old gentleman
Back pain with bilateral leg pain, heaviness
Leg symptoms get worse on walking, relieved by sitting
Distal pulses and vascular exam
Abnormal
Normal
Spinal stenosis
Vascular referral
Spinal referral
Case 1
Treatment for spinal
stenosis
 Non operative
 Operative
 Limited role for medical therapy
Traditional approach for
treatment of
spondylolisthesis
 5-7 days post op stay
 Increased post op pain
 Longer recovery
Minimally invasive spine
surgery
 Small incisions
 Less muscle and tissue damage
 Decreased blood loss
 Less post op pain, early discharge and
recovery, improved early and long term
function
 Cost effective
Case 2 - 30 yr old self employed
joiner
Sciatica +/- Back pain
Cauda equina symptoms
No
Yes
Analgesia, exercises, education
Urgent referral to
spine surgeon
Improvement in 4-6 weeks
No
Referral to Spine surgeon
Yes
Discharge
Examination
 History
 Physical Examination
 Nerve root tension signs
 Straight leg raise
 Bowstring sign
 Femoral stretch test
 Neurological exam
 P.R exam
Lumbar disc prolapse
Lumbar discectomy –
 Wait for 12 months before offering surgery
 Effectiveness of surgery decreases in patients
with symptoms longer than 12 months
Lumbar microdiscectomy
 Early surgery gives better clinical results
 Early surgery is cost effective
 Decreasing incidence of complications (much
safer than a THR)
Lumbar microdiscectomy –
A day case procedure
 Go home the same day of surgery
 High patient satisfaction
 Quicker recovery
 Minimally invasive approach – operating
microscope
Lumbar disc prolapse causing
radiculopathy – my approach
 Advice and analgesia for 6 weeks
 Persistent pain after 6-8 weeks
 Conservative management
 Nerve root blocks
 Microdiscectomy
Case 3
R/o Red flags
Chronic back pain
Education, analgesia, CBT, Physiotherapy,
Functional rehabilitation programme,
acupuncture, osteopathic manipulations
Address
yellow,
orange flags
Improvement
Yes
Discharge
No
Referral to Spinal surgeon
Degenerative Disc Disease
Identify pain source
 Discography
 Facet joint injections
MIS treatment of DDD
 ‘‘No, this
won’t help
your back,
but I’m
getting
great
reception
for the big
game!’’
Case 4
 65 year old lady with
back pain following
minor fall
 Radiograph
 Osteoporotic vertebral
fracture
 1 in 2 women above age of 50 years
 1 in 4 men above age of 50 years
 Vast majority unrecognised
 Persistent pain in a third of cases
Clinical consequences of
vertebral compression fractures
 Acute and chronic pain
 Impairment in activities of daily living
 Loss of mobility
 Depression
 Progressive kyphosis
 Shortness of breath
 Increased mortality
Case 4
65 year old lady with back pain following minor fall
Osteoporotic vertebral compression fractures
Analgesia, +/brace, treatment for
osteoporosis
Improvement in 6 weeks
Yes
No
Discharge
Refer to spine surgeon
Vertebroplasty for osteoporotic
vertebral compression fractures
Case 5
Neck pain
Red flags
Yes
Urgent
Spinal referral
No
Arm pain
Myelopathy
Neck pain
Cervical radiculopathy
 History
Cervical radiculopathy
 Nerve root tension signs
 Spurling’s test
 Axial compression test
 Upper limb tension test
Cervical disc prolapse
 Treatment
 Conservative
 Nerve root block
 Surgical (Anterior
cervical discectomy and
fusion)
Cervical myelopathy
 High index of suspicion
especially in the elderly
 Natural history
 Treatment
 Observation
 Surgery
Cervical myelopathy
 Hoffman’s sign
 Walking Rhomberg’s
 Grip and release
 Inverted supinator and inverted biceps
reflexes
 Brisk reflexes
 Upgoing plantars
 Sustained clonus
Neck pain
 Second most frequent musculoskeletal cause
for consultation in primary care.
 Aetiology
 Muscular, postural, stress, depression,
degenerative discs and facets
Neck pain
Neck pain - treatment
 Surgery usually ineffective unless for
instability
 Conservative treatment
 Exercise based therapy
 Manual therapy, manipulation
More urgent problems
 Trauma
 Tumour
 Infection
 Cauda equina / Spinal cord compression
Red flags
 New onset back pain in patients <20 and >55





years old
Mid thoracic back pain
Past history of cancer
Back pain with fever, chills, rigors, weight
loss, etc
Progressive neurology
Bladder / bowel symptoms, perineal
numbness
Summary
Don’t forget the red flags
Summary
 Most elective conditions are self limiting
 Early surgery efficacious and cost effective
 Trend towards minimally invasive techniques
 Osteoporotic vertebral compression fractures
Where to refer?
 University Hospital of North Staffordshire
 Nuffield Health North Staffordshire Hospital,
Newcastle-under- Lyme
 Private referrals
 Choose and book (NHS)
www.spineconsultant.co.uk
Sandeep Konduru
 Full time Orthopaedic Spine Surgeon
 Combined Neurosurgical and Orthopaedic Spine
Fellowship
 Consultant Orthopaedic Spinal Surgeon – UHNS
 Special interests
 degenerative pathology of the entire spine
 cervical spine surgery
 Minimally invasive spine surgery
www.spineconsultant.co.uk
Sandeep Konduru
 Non academic pursuits
 Travel
 Racquet sports
 Aasha Charity (www.aasha.org.uk)
www.spineconsultant.co.uk
Charity Cricket match
(for tickets contact Sandeep: 07515379010)
 9th September 2011
 Okamoor Cricket Club
 Cricket and curry
 Other entertainment and
activities
 Children’s cricket
THANK YOU