Symposia - The Spine

transcript

The Spine - what can a

neurosurgeon offer?

Mr Sinan Barazi FRCS(NeuroSurgery) B.Sc MB BS

Consultant Neurosurgeon

King's College Hospital NHS

Foundation Trust

Bupa Cromwell Hospital

Clinics: Thursday pm/eve

Mon - Weds, Fri, Sat ad hoc

Bupa Cromwell Hospital Private and Confidential

There are a lot of surgeons out there who really like to operate - but I can tell

you that I see quite a few post surgical problems after people have had back

surgery so if I were in your situation I would not want to pursue any operation

before a trial of non-operative management, and I would be asking the

surgeon:

'Would it be reasonable to try a non operative approach for 3 months and then

re-assess'?

'What is the likelihood that I will be able to avoid an operation based on the

size of this disc'?

Natural History of Spinal Degeneration

• Spondylosis: progressive, age-related degenerative changes- usually asymptomatic

• Mid cervical & lower lumbar regions particularly affected because of the distribution of mechanical stresses due to spinal motion & loading

Natural History of Spinal Degeneration

• Syndromes relating to neural impingement

– Radiculopathy: brachialgia, sciatica

– Myelopathy

– Cauda equina syndrome

– Neurogenic claudication

• Axial spinal pain pathology

– Disc related

– Vertebral body related

– Musculo-ligamentous

Axial low back pain

• Lifetime prevalence of 84%

• 70% patients have recurrent episodes

• 40% of adults >1 day LBP last 12 months

• 150 million days/annum lost

– £3.5 billion lost production

• NHS cost of treatment > £500 million

– All types back pain > £1.5 billion

• Musculo-ligamentous disruption

• Most relates to the lumbar spine

• Prompt ∆ required

• Identification of the pain

generator

• Pro-active management

– Anti-inflammatories

– Physiotherapy/ osteopathy/

chiropractic

– Pain physician

– Other treatments

• Back pain & off work > 1 year→ poor outcome

• Plain x ray

– Unexpected findings occur 1:2500, < 50 years

– 60% bone loss before lytic lesion evident

– Dynamic imaging possible

SPECT CT

Back pain- red flags

• History

– Age

– History of cancer, infection, trauma

– Unexplained weight loss

– Immunosuppression, steroids

– Pain > 1 month

– History of drug abuse

– Pain worse at rest/night

– Neurological symptoms eg. cauda equina syndrome

• Examination

– Limited movement

– Spinal tenderness

– Fever (not common in discitis)

– Neurological signs

Disc herniation- natural history

6/52→

Endoscopic discectomy

Cauda Equina Syndrome

• Relates to a central lumbar disc protrusion

• 1-2% of all lumbar disc herniations

• Bilateral sciatica, sphincter disturbance,

sexual dysfunction, saddle anaesthesia

• Constitutes a surgical emergency

Pars defect (spondylolysis)

• 3-7% general population

• Hyper-extension & hyper-flexion manoevres likely to be

causative

• Physiotherapy

• Bracing

• Injections

• Surgery

Percutaneous pedicle screws

Syrinx 16♀- presenting as side strain

Cervical myelopathy & cord contusion 51♂

Radiculopathy

• Posterolateral protrusion

• Majority settle with non-operative treatment within 1-2 months

Surgery-ACD/disc replacement

Osteoporosis & vertebral column fracture

• 40% lifetime risk of caucasian female > 50

• Vertebral compression # is commonest

• May occur in absence of trauma

• After 1st VCF risk of subsequent # is 5 fold

• ↑ morbidity

• ↑ mortality

– 23-34% increased mortality

– pulmonary disease is most common cause of death

Metastatic spinal cord compression

3600 posterior approach to tumour

Thank you!

How to refer?

Call 0800 783 9229

Clinic: Thursday pm/eve

Mon - Weds, Fri, Sat ad hoc

Symposia - The Spine

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