Dr. Ankur Saxena, FRCS (Neuro. Surg), Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom, talks about, how, given the rising spinal issues in our country, delivery of the spinal services be improved effectively.
Spinal pain is an extremely common problem that would affect most individuals at some point in their life. In about 85 per cent of patients, no conclusive diagnosis can be made. A vast majority of these patients would recover without any serious consequences in a short period of time. However, this problem can have severe disabling effects on others that might or might not get better with treatment. By far the commonest location for spinal pain is in the lower back. In fact if a patient suffers from cervical or thoracic spinal pain, investigations are warranted almost in every case.
There has been a massive change in the attitude towards back pain over the last few decades. People today are living a longer, healthier life and the expectations from one’s own body have gone up. On the other hand, the younger population is being subjected to stress that certainly contributes to the general wear and tear of the spine. Medically too, with more awareness and increasing availability of imaging, more and more people are being diagnosed with spinal problems.
A wide range of spinal disorders comes under the remit of specialised services. Apart from non-specific back pain that is treated majority of the time in the community inconsequentially, specialist services are required to manage a plethora of specific spinal conditions. According to the NHS in the United Kingdom, spinal services that are commissioned for specialist treatment are sub divided into radicular pain (mainly cervical and lumbar), potentially serious pathology (cauda equina compression, spinal infection, tumours), deformity (adult and paediatric), trauma and other spinal pathologies like inflammatory disorders, fragility fractures, coccydynia etc. While a lot of these pathologies were under diagnosed and treated in a conservative manner, aggressive intensive management now seems to be helping such patients much more. I remember the teaching at medical school where patients with lumbar disc prolapse were prescribed bed rest for 6 weeks sometimes with traction on their legs. There is enough new evidence now that being in bed for more than 4 days could be detrimental for the patient and aggressive pain management with physiotherapy should be encouraged.
The management of spinal disorders is complex and gathering consensus about a particular treatment plan is difficult. It is for this reason that spinal services were fragmented in the past. This is the case in the majority of the world now. Being a very industry driven specialty doesn’t help too. It is very difficult to define an ideal spinal setup and there would be very few of these in the world. Having said that, more and more healthcare organisations are aiming towards the establishment of specialist spinal care centres that are adept in dealing with most complex spinal pathologies through a more holistic approach, with involvement of medical and allied medical professionals.
In our centre in Sheffield, we have tried to conceive such a service. A spinal multi-disciplinary team meeting consisting of surgeons, radiologists, microbiologists, theatre nurses, ward-based nurse practitioners, physiotherapists, occupational health therapists and rehabilitation service professionals takes place every week. The surgeons involved are both from neurosurgical and orthopaedic backgrounds. The management of all spinal cases (referrals, inpatients and cases to be done in future) are discussed and plans are made for the further care of the patients. Outcomes are recorded and entered in the British Spine Registry. Such a service is supported by an infrastructure with dedicated spinal theatres, spinal ward, neurophysiological support for intraoperative monitoring and a spinal injuries unit. Detailed management plans are made for most patients from the very beginning, including the patients’ rehabilitation requirements, which, according to me, is as important as the original medical / surgical treatment in the first place.
I must say that such a service is exemplary and not only it provides a brilliant quality of care for our patients but also is a very effective teaching tool for all the professionals who train through / visit our department. There are many similar spinal centres in the country and the other ones try to emulate such centres.
From an Indian perspective, access to healthcare is so variable but some of the big establishments are very ambitious towards delivery of very good quality services in various parts of the country. The delivery of spinal services is still fragmented and scattered primarily as various problems come within the remit of various (sometimes unrelated) specialities. Bringing them to a common platform so as to discuss the best possible management will automatically generate the best possible outcomes. Due to the massive catchment area of each establishment in India, the individual experience and expertise is immense. Contribution of this experience in concordance with other therapies adds so much more to the experience and learning of each individual practitioner. This is something every spinal centre in the world aspires for so why should such a place in India lag behind?
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