The Three-Tier Referral System: When Back and Neck Pain Needs a Spine Surgeon

If there is no significant back pain and no instability, we prefer decompression alone, either bipartal endoscopy through two ports of 4 to 5 millimeters to 1 centimeter, or an MIS tubular approach through a single 2.5 centimeter incision, adding a discectomy at the same sitting if the disc is large. If there is significant back pain and the dynamic X-ray shows instability, lysis, or discal collapse with foraminal stenosis, he will need a TLIF with a cage and screws to restore disc height and decompress both foramina. If he is already exhausted by medication and physiotherapy and still suffering, he almost certainly needs surgery; that is exactly why he is still hanging around doctors trying to find another way.

Spinal surgery takes most of the surgical case volume in neurosurgery at my center in Nigeria. We were expecting to see the procedures Dr. Girdhar uses and how they aid recovery, not only the traditional open decompression we already practice, but also how he performs minimally invasive spine surgery, since it is still an emerging area for us.

I would request that we spend time together if you are planning to come to India, please come to Delhi to our center. I tried my best, but that is all you can cover in an hour when it represents twenty years of work with a lot of technology behind it. You need to observe more, and that would let you move on to minimally invasive work. It is not difficult, but everything new you start in your practice is a steep curve at first, though very achievable, looking at how many MIS centers exist in the world today.

My availability is never really an issue. I usually reply the same day, before going to bed, to most of the queries I get, and I hear from 30 to 40 people a day from all over the place. We look forward to working together and helping your patients from Zambia, at the very least by providing an opinion.

Thank you for a very impressive, interesting presentation.

Spine disorders are second only to headache in frequency among patients seen in general practice, though very few of these cases ever need surgery.

Severe radicular pain such as sciatica or brachialgia with neurological signs, tumors of the spinal meninges like neurofibroma or lipoma pressing on a nerve, spondylolisthesis with gait disturbance, and disabling pain that has already resisted six to eight weeks of physiotherapy, medication, or nerve blocks.

When it has not improved after twelve weeks of therapy and there is no radicular pain or nerve root compression, prompting evaluation for desiccated or degenerated discs, sacralization, spina bifida occulta, or spondylolysis.

Neurological compression (disc herniation with a deficit, progressive stenosis with claudication, myelopathy from cord compression), structural instability (degenerative, lytic, or isthmic spondylolisthesis, unstable fractures, deformity needing osteotomy and fusion), and space-occupying pathology (epidural abscess, osteomyelitis, tumors causing neurological progression).

Because the alternative to surgery in these groups is progressive and often permanent neurological loss.