Other treatment
Treatment of Cauda Equina Syndrome
Cauda equina syndrome is a neurosurgical emergency and urgent referral by the emergency physician will be required once the diagnosis has been made on MRI scanning.
Treatment of sciatica
Epidural injection therapy is commonly used, relatively straightforward and safe. There is a suggestion that it may be of benefit to some patients with sciatica but most of the studies have been in patients with subacute or chronic pain.
Trials of surgery provide suggestive rather than conclusive results. Overall, surgical discectomy for carefully selected patients with sciatica due to a prolapsed lumbar disc appears to provide faster relief from the acute attack than non-surgical management. However, any positive or negative effects on the lifetime natural history of the underlying disc disease are unclear. Microdiscectomy gives broadly comparable results to standard discectomy. There is insufficient evidence on other surgical techniques to draw firm conclusions. Trials showed that discectomy produced better outcomes than chemonucleolysis, which in turn was better than placebo. For various reasons including concerns about safety, chemonucleolysis is not commonly used today to treat prolapsed disc.25
One study has shown that discectomy gives more rapid relief of leg pain than conservative treatment and earlier return to normal activities but the differences between the groups were not statistically different by six months. There was no significant difference in back pain and surgery did not decrease the risk of an unsatisfactory outcome at two years. However, 44% of patients allocated to the conservative arm of the trial eventually required surgery.26
Treatment of vertebral compression fractures
Conventional treatment for vertebral compression fractures is not evidence-based and is focused on the alleviation of symptoms with analgesia medication. Spinal support may help the pain but patients also need to mobilize to regain back movement. The majority of patients become symptom free through these measures. Patients who continue to have pain should be followed up and have repeat lateral standing lumbar spine X-rays to ensure that they are not developing progressive deformity. Surgery may be considered in patients in whom there is continued vertebral collapse and severe pain.
Osteoporosis will also need to be investigated and managed. Postmenopausal women with an initial fracture are at much greater risk of subsequent fractures,27 so this is very important and may help to prevent a future attendance with a hip fracture.
Treatment of metastatic disease
Patients with bone metastases and patients at high risk of developing bone metastases should be given information explaining what to do and who to contact if they develop symptoms of spinal metastases or spinal cord compression or if their symptoms progress while waiting for investigation.
Spinal cord compression is an oncological emergency and treatment should be started within 24 hours. Most patients will be given steroids and will need radiotherapy or surgery. Patients with a risk of spinal instability should be nursed flat in neutral alignment.
NICE has recommended (for England and Wales) that every centre should have a coordinator for patients with spinal metastases and metastatic spinal cord compression, to whom such patients should be referred.28