Sandeep konduru M.B.B.S, FRCS Ed (Tr & Orth ) consultant orthopaedic Spine surgeon
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Transcript of Sandeep konduru M.B.B.S, FRCS Ed (Tr & Orth ) consultant orthopaedic Spine surgeon
SANDEEP KONDURU M.B.B.S, FRCSED (TR & ORTH)CONSULTANT ORTHOPAEDIC SPINE SURGEON
Evaluation of back pain and other disorders of
the Spine
What to refer When to refer Where to refer Recent advances in Spine surgery –
Minimally invasive surgery
Elective cases
Back pain Neck pain Leg pain Arm pain Neurological
symptoms
Spinal stenosis
Lumbar/Cervical disc prolapse
Degenerate disc/facet joint disease
Myelopathy
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
Vascular referral
Normal
Spinal referral
Spinal stenosis
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
Analgesia, exercises, education
Cauda equina symptoms
Yes
Urgent referral to spine surgeon
No
Improvement in 4-6 weeks
Yes
Discharge
No
Referral to Spine surgeon
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 3Chronic back pain
Education, analgesia, CBT, Physiotherapy, Functional rehabilitation programme, acupuncture, osteopathic manipulations
Improvement
Yes No
Address yellow, orange flags
Discharge Referral to Spinal surgeon
R/o Red flags
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
Osteoporotic vertebral compression fractures
Analgesia, +/- brace, treatment for osteoporosis
Improvement in 6 weeks
Yes No
DischargeRefer to spine surgeon
65 year old lady with back pain following minor fall
Vertebroplasty for osteoporotic vertebral compression fractures
Neck pain
Red flags
Arm pain Myelopathy
Yes UrgentSpinal referral
No
Neck pain
Case 5
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