Back Pain

Christopher D. Sturm, M.D., F.A.C.SMedical Director

Mercy Institute of Neuroscience &Mercy Regional Neurosurgery Center

Back Pain

• Extremely common

• Often accompanied by leg pain or numbness

• Adversely affects quality of life

• Lost time, work & money

• Can vary in intensity and duration, leading to significant frustration

Back Pain

But……THERE IS HOPE!

You Do NOT have to just “live with it”

Back Pain

• Can lead to nerve damage

• Permanent loss of some functions– Movement– Sensory– Bowel and Bladder control

• In some instances earlier treatment can lead to better outcomes

What to Do?

• “So, what the heck is going on?”

• “Can anything be done to fix it?”

• “What are my options?”

• “When should I start?”

• “What are the success rates?”

Causes of Back Pain

• Muscle spasm/inflammation/strain• Degeneration or inflammation of the disc • Degeneration or inflammation of the back (facet)

joints • Loss of normal alignment or instability• Fracture• Infection• Tumor

Evaluation of Back Pain/Leg Pain

• Symptom history and physical exam findings– What makes it worse or better?– Location?– Duration?– Associated pain/numbness/weakness?– Bowel and bladder control?– Past medical history?

Evaluation of Back Pain/Leg Pain

• MRI imaging– Optimal to evaluate discs, nerves, alignment

• CT scan– Better visualization of the bone

• Plain X-rays– Screening test

• Bone Density study– Osteopenia/osteoporosis?

“So, what to do?”

• Depends on the cause of the pain

• Is there any associated loss of function?

• Are the symptoms significantly interfering with your quality of life?

• Any indication they are getting better?

• Have conservative therapies failed?

Conservative Therapy

• Symptom improvement without surgery

• Activity modification

• Pain medication

• Physical therapy

• Chiropractic intervention

• Injectional therapy

When is Surgery Appropriate?

• If the symptoms are significantly interfering with your quality of life, and have not improved with conservative therapy measures, for an appropriate period of time

• Any presence, or high risk of functional loss• Instability• Tumor• Infection

Spinal Tumors - L1 Schwannoma

Myxopapillary Ependymoma

Advancements in Spine

• Improved imaging techniques

• Pathophysiology of degenerative disease

• Biomechanical advancements

• Image guidance

• Minimally Invasive techniques

• Mechanical implantation devices

Mercy Regional Neurosurgery Multi-Center National Studies

• CODA study – Posterior lumbar

fusions

• In-Fix study– Anterior lumbar

fusions

• Fortitude study– Cervical discectomy

and fusions

Lumbar Degenerative Disease

• Initial desiccation of the disc

• Loss of structural integrity of the disc

• Loss of disc space height/potential HNP

• Abnormal loading and laxity of the facet joints

• Neuroforaminal compromise

• Malalignment and abnormal motion

Multi-level Lumbar Spondylosis

Surgical Options

• Lumbar discectomy

• Lumbar laminectomy

• Anterior lumbar interbody fusion (ALIF)

• Posterior lumbar interbody fusion (PLIF)

• Vertebroplasty/Kyphoplasty

Lumbar Discectomy

• Leg pain unresponsive to conservative therapy

• Progressive deficit

• Cauda equina syndrome

• Small incision

• Outpatient or next day discharge

Right L5-S1 Discectomy

Lumbar laminectomy

• Leg pain secondary to lumbar stenosis/lateral recess stenosis

• Failure of conservative therapy

• Older patients, slightly larger incision, longer stay

• Approximate 10% incidence of subsequent lumbar instability

Lumbar laminectomy

Anterior Lumbar Interbody Fusion (ALIF)

• Lumbar degenerative disc disease producing mechanical LBP & minimal radicular pain

• Localized concordant discogenic pain with discography at level(s) abnormal on MRI

• Anterior approach avoids injury to posterior lumbar musculature

• Suboptimal to address neural compression

Provocative discography

Anterior Lumbar Interbody Fusion

L4-5 ALIF

• 37 year old female with progressive mechanical LBP

• Right leg psuedoradicular pain

• Concordant L4-5 discogenic pain

• Failed conservative therapy

L4-5 In-Fix Cage

3 Level ALIF with InFix Cages

Posterior Lumbar Interbody Fusion (PLIF)

• Mechanical LBP with associated radicular pain and/or neurological deficit– Degenerative disc disease/collapse/herniation– Facet joint hypertrophy with foraminal stenosis– Lateral recess and/or central spinal stenosis

• Spondylolysis/spondylolisthesis

• Lumbar instability

L4-5, L5-S1 PLIF

• 50 year old female with progressive LBP and bilateral radicular pain w/dysesthesia

• Intensifying pain despite previous L4-5 hemilaminectomy/discectomy

• Lumbar MRI – L4-5, L5-S1 DDD & NFS

• Concordant discogenic pain L4-5, L5-S1

Pre operative MRI

Cadence Cage

PEEK Lordotic Lumbar Cages

3 Level PLIF w/PEEK Lordotic Cages

L5-S1 PLIF

• 49 year old female with progressive LBP and left leg radicular pain

• Dysesthesia left leg/foot

• MRI – L5-S1 DDD with left NFS

• Failed conservative therapy

• Concordant discogenic pain L5-S1

Pre-operative MRI

CODA Expandable Implant

Pre- and Post-operative Lateral Views

L5-S1 PLIF – CODA Cages

Minimally Invasive Spine Surgery

• Achieve same goals as “open” procedures

• Smaller incisions

• Less muscle trauma

• Utilization of image guidance

• Less post-operative pain

• Shorter hospitalization

360 degree Lumbar revision – stand alone cages

360 degree Lumbar revision – titanium mesh

360 degree Lumbar revision – titanium mesh

Results

• Review of 5 years of practice data

• Using the treatment approach outlined here

• Improved or not?• Fusion?

• Approximately 500 surgery patients

• 93% reported improvement as a result of their surgery

• 99% fusion rate

Multi-level Cervical Spondylosis

ACDF utilizing structural allografts

Remodeling Cervical Allograft

ACDF C4-5, C5-6

• 47 year old right handed female with posterior cervical pain and right arm radicular pain

• Right deltoid and biceps weakness

• Failed conservative therapy

• Cervical spondylosis C4-5, C5-6

Fortitude Ti Cages packed with Cerasorb, AcuFix Plate

Fortitude Cages and AcuFix Plate

PEEK Cervical Lordotic Cages packed with Cerasorb

Posterior cervical revision – allograft pseudoarthrosis &

kyphosis