Spinal Conditions - DRAFT

Overview

The information on this page has been produced in partnership with James Pendle, Olivier Sluijters and Adam Williams at NBT.

Please also consider the following pages:

• Back pain/ Spinal pathway
• Spinal Imaging in Primary Care

Radiology queries - if you require further clarification on radiology reports then please contact the trust concerned. See the Radiology Advice & Queries page.

Atlantoaxial Instability

Atlantoaxial Instability is a finding often associated with degenerative / inflammatory conditions affecting the craniocervical junction, such as rheumatoid arthritis.

Please consider the following referral options:

• MSK Interface service

Cervical Myelopathy

Cervical Myelopathy is a common degenerative condition of the cervical spine that leads to progressive narrowing of the spinal canal with subsequent compression of the spinal cord. This can lead to progressive upper and lower limb weakness, incoordination, sensory disturbances and sphincter dysfunction. Surgical intervention aims to prevent further deterioration by decompressing the spinal cord and when required, stabilise the cervical spine.

If the patient is neurologically deteriorating over the course of days, please refer urgently via Referapatient and the on-call team can assess the urgency of the case. 

If the patient is stable or progressively worsening over weeks to months, please refer via the Musculoskeletal Interface (MSKI) Service

Chiari Malformation

Chiari malformations describe abnormalities in the hindbrain, where the contents of the posterior fossa are herniating downwards into the foramen magnum. There are several types, with type 1 being the most common. they can be associated with a spinal syrinx. the symptoms are a consequence of disturbed CSF flow around the craniocervical junction.

Typical symptoms include pressure headaches that are exacerbated by valsalva manoeuvres, visual disturbances, dizziness and nausea. Symptoms associated with a cervical syrinx are similar to those of cervical myelopathy.

There is a separate entity called benign cerebellar ectopia, which is often reported on CT imaging. This is not a chiari 1 malformation and is an incidental finding.

Patients with a chiari malformation should be referred to the MSK spinal interface service

Disc Herniation

Cauda Equina Syndrome (CES)

If there is clinical suspicion of Cauda Equina Syndrome, please see the Cauda Equina Syndrome page. 

Progressive Foot Drop

If there is progressive foot drop with associated leg pain over the course of days, please refer urgently to the on-call team via Referapatient, as there may be a role for early surgical intervention. If the patient presents with painless foot drop, please discuss the case with neurology.  

Disc Herniation in non-lumbar sites

Please note that a disc herniation in the cervical spine will cause symptoms of cervical myelopathy or radiculopathy - please refer to those sections. In the thoracic spine, it will cause similar symptoms but spare the upper limbs.

Disc Herniation (lumbar)

For all other cases, where there is no sudden significant neurological decline, please refer via the Musculoskeletal Interface (MSKI) Service.

Metastatic Spinal Cord Compression

If you suspect your patient has MSCC, please direct them to the nearest emergency department for urgent assessment and imaging. They will liaise with neurosurgery services as required.

Osteoporotic Spinal Fractures

If the patient presents with a suspected osteoporotic spinal fracture and new neurological deficit, please direct them to the nearest Emergency Department for urgent assessment and imaging. They will liaise with neurosurgery services as required.

If there is a significant deformity associated with the fracture reported on x-ray imaging, please refer to the on-call neurosurgery team via Referapatient.

If this is an incidental finding or the patient’s only presenting complaint is pain, please ensure they are on adequate bone protection, whether specialist input for osteoporosis is required and consider alternative causes for the fracture. Whilst osteoporosis / fragility fractures are common, other causes such as myeloma and other malignancies should be considered.

If the patient has persistent pain at 6 weeks, please consider referring for cement vertebroplasty by interventional radiology.

See the Osteoporotic Vertebral Fracture page for further details..

Spinal Stenosis (lumbar)

Degenerative changes in the lumbar spine can lead to progressive narrowing of the spinal canal and pressure on the lumbosacral nerve roots in the cauda equina. Symptoms include back pain, neurogenic claudication (leg pains that worsen after walking and settle with rest), balance disturbances, weakness and sphincter dysfunction.

If you have clinical suspicion of Cauda Equina Syndrome please visit the page.

Please refer to MSKI for patients with longstanding symptoms - patients will be seen and assessed by an ESP and referred to a spinal surgeon if this is required / appropriate.

Please note the GIRFT guidance for patients with CES symptoms present for >14 days that require an urgent MSKi referral and imaging- has a pathway been agreed?

Spondylodiscitis

Patients with spondylodiscitis are managed by the medical team, with spinal team involvement in specific circumstances, such as progressive neurological deficit, progressive deformity, epidural collections or failed medical management.  

In the first instance, please refer these patients to the medical team. If you suspect the patient needs spinal team involvement according to the above criteria, you can refer via Referapatient to ensure neurosurgical early involvement - the medical team can use the same referral link for continued input.

Syringomyelia

If the patient has recent imaging suggestive of a spinal syrinx / other central CSF cavity and presents with an acute neurological deterioration, please refer urgently to our on-call via Referapatient. 

If this is an incidental finding or symptoms are mild and longstanding, please refer to the neurospine MDT by emailing a completed form (do we have a form?) to neurospinemdt@nbt.nhs.uk.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.