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Institute
- Fakultät WiSo (32)
Background and Aims
Early identification of nerve lesions and associated neuropathic pain in spine-related pain disorders is important for tailored treatment. Management may consist of surgical intervention for compressive neural lesions.
With a growing waitlist for public surgical outpatient clinics in Western Australia and wait times exceeding the recommended wait time for initial assessment (Category 1 – assessment within 1 months, Category 2 within 3 months, category 3 within 12 months), a call to support new models of care has been made1, including the evaluation and expansion of workforce models supporting advanced skills in allied health.1
An Advanced Scope Physiotherapy (ASP) led Neurosurgery Spinal Clinic operates at Sir Charles Gairdner Hospital in Western Australia. The ASPs (2FTE) examine patients from the neurosurgery waitlist for their suitability for spinal surgery. Recommendation of either further investigation and possible assessment by a neurosurgeon or appropriate non-surgical management of the patients’ pain condition is suggested. Patient assessment is conducted either ‘in person’ at the hospital or via telehealth due to the remoteness of some rural patients. Patient cases are discussed with a neurosurgery consultant on a weekly basis. The aim of this project is to evaluate the ASP service in the year 2022.
Method
A retrospective descriptive analysis of patient data captured in 2022 was performed.
Results
In 2022, 1337 new patient referrals were managed plus 267 follow-ups from the previous year. Category 1 patients (n=81) waited on average 31 days for their first appointment, Category 2 patients (n=394) waited 76 days and Category 3 patients (n=854) waited 376 days.
287 (18%) referrals were discharged without physical assessment of the patient (DNA, cancellations, declined). Of the 1317 patients physically assessed by the ASPs (57%) were discharged directly after assessment, for 290 patients (22%) their outcome was still pending at time of analysis (March 2023) and 281 (22%) patients were referred for review with a neurosurgeon. Of the 229 patients assessed by a neurosurgeon (including patients from 2022), 103 patients (45%) were offered surgery, 52 (23%) were not offered surgery, 46 ( 20%) patients had to be reviewed, and for the remaining (n=18) their outcome was unknown.
Conclusion
Of the 1604 patients managed in the Neurosurgery Spinal Clinic, only 17% needed to see a neurosurgeon. The conversion rate to surgery of 45% is higher compared to an estimated 5%-10% in a non-triaged clinic.
The ASP model of care has proved invaluable to (i) provide access of patient care within the recommended wait times (ii) optimize neurosurgeons’ time, (iii) educate patients and, in case of non-suitability for surgery, advise and refer them for alternative appropriate management.
Relevance for Patient Care
The Advanced Scope Physiotherapy model of care at the Neurosurgery Spinal Clinic allows timely assessment of patients with spine-related disorders and supports targeted management of their condition.
Ethical Permissions
This project is registered as a Quality Improvement Project at Sir Charles Gairdner Hospital (QI35728) and as per the National Statement on Ethical Conduct in Human Research was exempt from review by the Sir Charles Gairdner Hospital Human Research and Ethics Committee
References
1Sustainable Health Review (2019). Sustainable Health Review: Final report to the Western Australian Government of Health, Western Australia
Workshop: “‘Sciatica’: neuropathic or not and does it matter? Outcomes from a NeuPSIG working group”
(2023)
The identification of neuropathic pain in persons with spine-related leg pain is important as this information guides treatment and management, including self-management. The NeuPSIG neuropathic pain grading system was developed to assist clinicians and researchers in determining whether patients have neuropathic pain and the level of confidence associated with that decision. Based on clinical and laboratory examination findings, patients are classified as having no neuropathic pain, possible, probable or definite neuropathic pain. Whereas this grading system works nicely in people with systemic neuropathies where sensory findings and diagnostic tests are mostly present, its application in patients with spine-related leg pain, particular in radicular pain, can be challenging. For example, in the absence of sensory changes and MRI findings, patients with radicular pain would at best reach a classification of possible neuropathic pain according to the current neuropathic pain grading system.
In this presentation I will explain the adaptations to the neuropathic pain grading system for spine-related leg pain recommended by the NeuPSIG working group. I will demonstrate its application in clinical practice using case studies and provide clarity for how the system can be incorporated in clinical trials. This will be an interactive session with audience participation.
Neurotension – Gestern und Heute. Wie ist der momentane Kenntnisstand, und wie setze ich ihn um?
(2018)
Differentiating nociceptive and neuropathic components of clinical pain presentations matters!
(2016)
Comparison of quantitative sensory testing profles between people living in Germany and Australia
(2021)
Objectives
The aims of the present study were to provide back pain (BP) point prevalence data from inpatients at an Australian tertiary hospital on one day, and compare this with Australian non-hospitalized population prevalence data; to collect data around the development of BP throughout hospital admission; and to analyse the association between BP and past history of BP, gender, age, admission specialty and hospital length of stay (LOS).
Methods
This was a single-site, prospective, observational study of hospitalized inpatients on one day during 2016, with a subsequent survey over the following 11 days (unless discharge or death occurred sooner).
Results
Data were collected from 343 patients (75% of the hospitalized cohort). A third of patients (n = 108) reported BP on admission, and almost a fifth (n = 63) developed new BP during their hospitalization. Patients who described BP at any time during their hospital stay had a higher chance of having had a history of BP, with odds increasing after adjustment for age and gender (odds ratio 5.89; 95% confidence interval (CI) 3.0 to 11.6; p < 0.001). After adjusting for age and gender, those experiencing BP had a significantly longer LOS (median 13 days; CI 10.8 to 15.3) than those who did not (median 10 days; CI 8.4 to 11.6; p = 0.034).
Conclusions
Hospital LOS for patients who complained of BP at any time during their admission was 3 days longer than those who had no BP, and a history of BP predicted a higher likelihood of BP during admission. Screening of patients on admission to identify any history of BP, and application of a package of care including early mobilization and analgesia may prevent the onset of BP and reduce LOS.
Characterisation of pain in people with hereditary neuropathy with liability to pressure palsy
(2017)
Hereditary neuropathy with liability to pressure palsy (HNPP) has historically been considered a pain-free condition, though some people with HNPP also complain of pain. This study characterised persistent pain in people with HNPP. Participants provided cross-sectional demographic data, information on the presence of neurological and persistent pain symptoms, and the degree to which these interfered with daily life. The painDETECT and Central Sensitization Inventory questionnaires were used to indicate potential neuropathic, central sensitisation and musculoskeletal (nociceptive) pain mechanisms. Additionally, participants were asked if they thought that pain was related to/part of HNPP. 32/43 (74%) subjects with HNPP had persistent pain and experience this pain in the last week. Of those with pain, 24 (75%) were likely to have neuropathic pain and 27 (84%) were likely to have central sensitisation. All 32 participants felt that their pain could be related to/part of their HNPP. Significant negative impact of the pain was common. Pain characterisation identified neuropathic pain and/or central sensitisation as common, potential underlying processes. Pain may plausibly be directly related to the underlying pathophysiology of HNPP. Further consideration of including pain as a primary symptom of HNPP is warranted.
Entrapment neuropathies are the most prevalent type of peripheral neuropathy and often a challenge to diagnose and treat. To a large extent, our current knowledge is based on empirical concepts and early (often biomechanical) studies. This Viewpoint will challenge some of the current beliefs with recent advances in both basic and clinical neurosciences.