Surgical referrals

[Tramadeezy]

Quick question... been out in practice about a year now. I see a lot of chronic neck and low back pain. I find myself almost never sending patient's for a surgical evaluation. If they have a radiculopathy with concordant MRI findings and evidence of weakness etc. I'll refer out for 2nd opinion. Otherwise my surgical referrals are almost nil. I've always had the impression that surgery was never a great option and I just see continued/worsened pain. Can all of these different types of fusions, discectomies, sacroplasties etc. actually be helpful? Am I missing the boat on this and doing a disservice to my patient's? Curious what you guys would consider definite surgical referrals. Thanks a bunch in advance.

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[DODOCSS]

surgery is not for pain

 

[lobelsteve]

I sent out 10 spines and 5 joints on average per week. Lots depends on your referral sources. I am usually first referral for the pcps.

 

[Tramadeezy]

surgery is not for pain

Agree with this. Surgery as an option I guess just never seems to cross my mind as a helpful tool.

 

[willabeast]

It really depends on your surgeon (s). There are really good spine surgeons and really poor spine surgeons and lots of skill levels in between. I would have absolutely no hesitation sending almost anything to a really good surgeon. I would not send my worst enemy to a poor surgeon. In general, looking at all spine surgeons across the USA, the patient is (99% of the time) going to be better off not having surgery for pain. In order to become a really good spine surgeon you have to be really smart, really dedicated, gotten really good training and have a whole lot of cases done in your past (say about 10,000 hours worth of surgery). This is such a rare thing to find. Sometimes people you know win the lottery. It happens.

 

[drrosenrosen]

I have one nsg group in town, and we're in the same building. We refer back and forth to each other a lot. I don't bother them with a referral except for real radiculopathy, never for back pain. And, to their credit, they wouldn't operate on someone for just back pain.

 

[NJPAIN]

I think many of us leave fellowships thinking that spine surgery is a never event. Then you get to know a few talented and reasonably conservative surgeons and you realize that there is a place for surgery. My great eye opener was doing some spine surgery assists and following those patients postop. It gave me an appreciation for what they do, how they do it and what their logic is. I have seen MANY patients do well after lumbar discectomy and ACDF after failing more conservative management. The ACDF's, many I never see or hear from them again because they do so well.

 

[IN2B8R]

Obviously this depends on the exact pathology. In general, if the pain is mostly axial (neck or lower back), then surgery will not help—often worsens the pain. Otherwise, severe stenosis with neurogenic claudications and the patient cannot walk, tumors or infections or instability, refractory radiculopathy not responsive to conservative measures/ESIs, patient becoming myelopathic, adjacent level disease (stenosis) after a prior fusion and very FEW other indications to warrant a surgical approach. For the most part, all else that goes to surgery ends up with worse pain. And if you ever find a conservative spine surgeon, make sure you take’em out to dinner, ‘cause that is a rare breed indeed.


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[Ronin1]

A conservative surgeon can be one your best referral sources. And yes some people do need surgery so I do refer our 1-2 patients a week.

 

[Ducttape]

one of the best reasons to get a spine referral is to show that you are invested in "making them better".

also, i tell patients that the referral is not to help the pain but to help with myelopathic or potential future myelopathic changes. its about functioning...

 

[lobelsteve]

one of the best reasons to get a spine referral is to show that you are invested in "making them better".

also, i tell patients that the referral is not to help the pain but to help with myelopathic or potential future myelopathic changes. its about functioning...

See the post in Neurology forum under functional Neurology. Ugh.

 

[Ronin1]

Also it is nice to have someone to help you out in the case of any potential issues especially if you are an implanter. And yes someday you will need a hand.

 

[Ducttape]

See the post in Neurology forum under functional Neurology. Ugh.

i read the posts, and it is not quite what i am looking for from a spine consultation. rather, the development of true myelopathic findings that require urgent evaluation and possible surgical intervention, not psychologically based functional disorders.

and Ronin also raises a good point. referrals and communication with Spine about appropriate patients helps engender good working relationships.

 

[nvrsumr]

Patients and pcps self select certain patients to go to surgery without you in the loop.

I worked for an ortho spine group for a year and saw a lot of patients get better with acdf for cervical radics

If patients aren’t better after a few pokes I usually send out for a second opinion to conservative surgeons who then tell them more pt and injections.