Distinguishing between sequestered disc fragments and tumours remains a diagnostic challenge, but one of paramount importance given the surgical management of these two clinical entities varies dramatically. Our experience over the last 3 years in managing this clinical challenge was analyzed. Patients referred to the regional neurosurgical unit for evaluation of possible spinal tumours whose imaging and clinical findings were atypical, were prospectively identified and the medical notes, operative records and MR imaging reviewed.Purpose
Methods
To quantify the duration of symptoms and the treatment modalities employed prior to surgery in patients undergoing lumbar and cervical nerve root decompression and to assess the evidence of these non-surgical treatments. Pre- and post operative questionnaires completed by consecutive patients. 514 people undergoing consecutive cervical or lumbar nerve root decompression between March 2007 to October 2009. Pre-operative severity and duration of pain, functional limitations and treatment received. Post-operative pain severity and change in functional limitations. Evidence in the literature for efficacy of treatment modalities employed. Mean duration of pre-operative symptoms was 23 months (range 1 to 360). 91% took regular medication for pain, 83% received one or more physical therapy, 24% received injection therapy. There was improvement in both pain scores (mean pre-op 7.3; post-op 3.0) and 78% of the commonly reported functional limitations, walking, sleep and work. We found extremely limited evidence to support the other treatment modalities employed. Patients spend many months unnecessarily in pain, consuming considerable resources and may suffer significant side effects from ineffective treatment for pain emanating from nerve root compression. Surgical nerve root decompression relieves pain and restores function. Despite this a specialist opinion is often delayed. Early referral for specialist opinion is almost certainly more humane, cost effective, and time-limits the journey on the not so magic roundabout.
We have examined how many and which potential complications (PCs) are recorded on the consent form by a group of consultant surgeons performing common spinal procedures - anterior cervical discectomy and fusion (ACDF) and posterior lumbar discectomy and/or medial facetectomy (PLD). Email survey Consultant spinal surgeons performing ACDF and/or PLD practicing in Southwest England Identification of the PCs each surgeon listed on the consent form for the specified procedures. There were 23 responses from 28 Consultant surgeons approached. 21 surgeons performed both ACDF and PLD, 2 performed only PLD. Surgeons quoted 5 to 17 (mode 10) PCs for ACDF and 4 to 15 (mode 13) for PLD. These did not necessarily represent the most common or most dangerous PCs recorded in the literature1,2. Small difference in PCs mentioned by Neurosurgeons and Orthopaedic surgeons was seen (ACDF mode: 12vs10, PLD mode: 12vs13). There was a strong correlation between the number of PCs recorded by surgeons for ACDF and PLD. We have found a wide variation in consenting practice amongst a group of surgeons performing common spinal operations. Issues of consent are common causes of formal complaints and potential litigation, causing anxiety for both patient and surgeon. A more homogenous consent process, employing objective measures where possible, may help reduce this burden and may be achieved by setting a national standard.
To determine if the term “back pain” has uniform meaning to spinal surgeons. A survey of specialists attending an international meeting on spinal surgery. Participants were shown 5 schematic pain drawings and then asked to categorize the pain as either back or leg pain. An international cohort of neurosurgeons, orthopaedic surgeons and trauma surgeons (n=104) attending a European spinal meeting. 67% of participants were orthopaedic surgeons and 22% neurosurgeons. 42% were in full time spinal practice. 50% had been in independent practice for 7 years or more. There was no statistical difference in the responses of neuro- and orthopaedic surgeons (Fisher's test, p>0.05). The more rostral the pain, the more likely it was to be deemed “back pain”. However, unilateral pain was more likely to be deemed “leg pain” than its bilateral symmetrical equivalent no matter how rostral the distribution. Unilateral mid-lumbar pain was considered “back pain” by 48%, symmetrical bilateral mid-lumbar pain in 87%. Pain in the buttocks was considered “back pain” in 50% whether unilateral or bilateral. This study demonstrates significant discrepancy in what is considered to be back pain and leg pain by a broad spectrum of spinal surgeons. Back pain and leg pain are often investigated and managed in different ways. This differentiation is difficult to justify until we know the answer to the question, what is back pain?
