POTENTIAL TRIAGING OF LUMBAR SPINAL SURGERY CONSULTS

Abstract

The wait times between referral and initial consultation for a spinal surgeon are amongst the highest in the country. Moreover, the vast majority of patients seen by spinal surgeons are not considered appropriate surgical candidates and hence do not benefit from the surgeon’s expertise in surgical management. Identifying inappropriate patients as a method of “triage” may help reduce the wait times. This paper examines two possible “triage” mechanisms – (i.) questionnaire and (ii.) screening by an acute spine pain centre.

Phase I identified three simple questions, which were reliable at identifying leg and back dominant pain. These questions were independently administered to a consecutive cohort of fifty-two lumbar patients prior to consultation with one of four spinal surgeons at a tertiary academic centre. Phase II involved an acute spinal pain centre, staffed by pain specialists, who have been orientated on appropriate indications for referral. The mandate of this clinic was to assess patients with acute or subacute back pain within two weeks of referral. A similar questionnaire as the one used in Phase I was independently administered to the first ninety lumbar patients attending the clinic in Phase II. All patients were followed independently to determine if surgery was recommended or performed and compared against the baseline questionnaires, findings on CT/MRI scan or pain specialist’s referrals.

The questionnaire identified twenty (38.5%) patients with clearly back dominant pain in Phase I and 56 (62.2%) patients in Phase II. Of the eighteen patients that had surgery or were recommended to have surgery, none had clearly back dominant pain as identified by the questionnaire for a combined sensitivity of 100%. When compared against the patient’s CT/MRI scans in phase I and the pain specialists referrals in Phase II, the questionnaire was more accurate at identifying surgical candidates.

This study has demonstrated in multiple settings that a simple questionnaire of three questions can identify patients requiring surgery and may be more specific than standard referrals, CT/MRI scans, or pain specialist’s assessments. Further work is required to refine this screening process and evaluate it prospectively.