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

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'?

Bupa Cromwell Hospital

Private and Confidential

Natural History of Spinal Degeneration

Spondylosis: progressive, age-related degenerative changesusually asymptomatic

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

Bupa Cromwell Hospital

Private and Confidential

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

Bupa Cromwell Hospital

Private and Confidential

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

Bupa Cromwell Hospital

Private and Confidential

Musculo-ligamentous disruption
Most relates to the lumbar spine

Bupa Cromwell Hospital

Private and Confidential

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

Bupa Cromwell Hospital

Private and Confidential

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

Bupa Cromwell Hospital

Private and Confidential

Disc herniation- natural history

6/52

Bupa Cromwell Hospital

Private and Confidential

Endoscopic discectomy

Bupa Cromwell Hospital

Private and Confidential

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

Bupa Cromwell Hospital

Private and Confidential

Pars defect (spondylolysis)

3-7% general population

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

Bupa Cromwell Hospital

Private and Confidential

Physiotherapy
Bracing
Injections
Surgery

Bupa Cromwell Hospital

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Percutaneous pedicle screws

Bupa Cromwell Hospital

Private and Confidential

Syrinx 16- presenting as side strain

Bupa Cromwell Hospital

Private and Confidential

Cervical myelopathy & cord contusion 51

Bupa Cromwell Hospital

Private and Confidential

Radiculopathy

Posterolateral protrusion
Majority settle with non-operative treatment within 1-2 months

Bupa Cromwell Hospital

Private and Confidential

Surgery-ACD/disc replacement

Bupa Cromwell Hospital

Private and Confidential

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

Bupa Cromwell Hospital

Private and Confidential

Bupa Cromwell Hospital

Private and Confidential

Metastatic spinal cord compression

Bupa Cromwell Hospital

Private and Confidential

3600 posterior approach to tumour

Bupa Cromwell Hospital

Private and Confidential

Thank you!
How to refer?
Call 0800 783 9229
Clinic:
Thursday pm/eve
Mon - Weds, Fri, Sat ad hoc