Spine surgical referrals are considered by many to be the apex medical referral for a chronic neck or back injured patient. The reality is that it is, and it is not. On the one hand, severe or non-improving patients should definitely be considered for an effective and more invasive option. On the other hand, some persistent problems are not surgical at all.
Severe neurological symptoms
Some patients should be referred to a spine surgeon before they ever become chronic. General orthopedists, primary care physicians and chiropractors should all be able to recognize spinal fractures, neurological weakness or myelopathy (spinal cord dysfunction). In these cases, it is appropriate to order an MRI and a surgical consultation as soon as the condition is discovered.
Unremitting or relapsing pain
Patients with persistent symptoms will be the 10% of patients who have persistent severe pain. Those with recurrent or relapsing symptoms will be the 33% of patients who improve only to be in severe pain again. Ideally, all these patients will have run the gamut of conservative care before being deemed non-responders. In these cases, a surgical referral makes sense. It would be the job of the surgeon to use his/her training and expertise to determine if an operation can be performed that would have an overwhelming likelihood of improving the patient’s condition. It’s important not to wait too long in considering surgery in these cases. In the case of discectomy, guidelines recommend surgery within the first 6 months of symptom onset.
Apex interventional referrals
Merely having persistent complaints despite conservative care does not always merit a spine surgery consultation. In some cases, persistent pain can best be addressed by a physician with interventional expertise. In this case, the interventional physician is the apex referral, not the surgeon. Commonly, this is the case with an injury to the cervical facet joint. This is a small, paired joint that is on either side of the disc and joins adjacent vertebra together. About 80% of persistent neck pain cases after whiplash are caused by a facet injury. In all cases, the MRI is essentially negative (degenerative changes are considered negative). Diagnosis requires a medial branch nerve injection. If positive, a radiofrequency neurotomy of the joint follows. Both are outpatient procedures. In the absence of a clear disc herniation on MRI, the patient should not be considered for more invasive treatment, like a cervical fusion or disc replacement, until a cervical facet injury can be ruled out by diagnostic injection.
Conclusion
It is important to know when the personal injury patient should be referred for a higher level of consultation. When there are severe neurological problems or a chronic pain condition that persists despite conservative care, a recommendation for surgery is appropriate. However, some of these persistent pain conditions will be more amenable to an apex interventional referral and one should recognize those cases.
Ferdinand Bardamu, MD
The views expressed are the personal views of the author and do not represent the views of The Brain, Spine and Joint Group, its managers, affiliates, partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.
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