brad elder, md - neurosurgery greg weidner, md ... 7.pdf · brad elder, md - neurosurgery greg...
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Brad Elder, MD Brad Elder, MD -- NeurosurgeryNeurosurgeryGreg Weidner, MD Greg Weidner, MD -- AnesthesiaAnesthesia
Jennifer Belu, PT, MPH Jennifer Belu, PT, MPH -- Physical TherapyPhysical TherapyElizabeth Yu, MD Elizabeth Yu, MD -- OrthopedicsOrthopedics
Case Presentation – Herniated Lumbar Disc A 36 year old male was lifting at work and felt a
twinge in his back. That evening, he felt more severe low back pain. The pain was so severe, he found it difficult to get
out of bed. He could flex minimally. On the fifth day the back pain improved and he
began to have pain down the left leg. The pain was into the posterior thigh and into the left
heel. He had numbness in the small toe and outside of the
right foot. When he sneezed or had a bowel movement the leg
pain was increased.
Case Presentation – Herniated Lumbar Disc (cont)
His exam showed an absent left AJ, a positive SLR on the left and had no tenderness or weakness. With flexion he had pain into the left buttock and
with extension had minimal back pain.
Disk herniation - Anatomy Tear in the annulus
fibrosus Extrusion of nucleus
pulposus Disk ‘bulge’ or
‘protrusion’ No extrusion of nucleus
pulposus outside the borders of the annulus
Locations Posterolateral Central Far lateral
ELDER
Disk herniation
Physiology Symptoms: Radiculopathy Back pain Neurologic deficits
Inflammatory reaction to annular tear can irritate nerve root Direct compression of
disk
ELDER
Disk herniation
Physical examination Motor Sensory Reflexes Straight leg raise
History “cough effect” No precipitating
event
ELDER
Disk herniation
Natural history Most patients will improve without surgical
intervention (85% in 6 weeks) Urgent surgery – cauda equina, progressive
neurologic deficit, severe motor weakness Symptom control Activity modifications Injections Oral medications (pain, steroids, muscle relaxants) Surgery
ELDER
The Patient with a Herniated Disc
Medical management Oral Steroids NSAIDS Muscle relaxants Opiates Bowel regimen
Interventional techniques
WEIDNER
The Patient with a Herniated Disc
Medical Management NSAIDS may need to cycle for efficacy Opiates Start with mild opiates, limit number,
combine with NSAID, careful with acetaminophen Muscle relaxants Carisprodol highly euphoric
inducing Gabapentin May help with sleep Topical Creams or OTC agents Heat and Ice Bowel regimen
WEIDNER
The patient with a Herniated Disc
Interventional TechniquesTransforaminal highly effective for short term relief Surrounds the nerve root with combination of steroid and local anestheticIntralaminar approach best suited for patient with minimal radicular complaints, e.g., the central disc herniation
WEIDNER
The Patient with a Herniated Disc
Transforaminal ESIBelieved to be effective by lowering phospholipase levels –PL A2 the rate limiting step in production of leukotriene's and prostaglandinsCombining image guided injections with physical therapy described as 90% effective in one study
WEIDNER
The Patient with a Disc herniation
Side-Effects Insomnia, transient hyperglycemia, local irritation,
leg cramps
Contraindications to Interventional TechniquesAnti-Coagulant therapyInfection
WEIDNER
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Controlling pain
Centralization of symptoms
Therapeutic exercise
Return to activities
BELU
Low Back Pain: Physical Therapy Perspective – Jennifer Belu, PT, MPH
Lumbar HNP: controlling symptoms
Back “First Aid” “neutral spinal position” lumbar taping to promotion neutral position avoid peripheralization of symptoms medication as recommended by primary care
provider Positions to alleviate radiculopathy
BELU
Lumbar HNP: Centralization of symptoms
Assessed at Physical Therapy evaluation: flexion versus extension bias (typically extension) Repeated motions: if result in centralization of
symptoms would utilize in treatment (i.e. McKenzie approach) Utilize positional motion/therapeutic exercise to
alleviate symptoms throughout patient’s day
BELU
Lumbar HNP: therapeutic exercise
Strengthen musculature effected by injury: spinal “stabilizers” Morphologic changes with disc injury in porcine
subjects on ipsilateral lumbar mulitifidi Start in positions of most support/least symptoms
(prone, supine knees flexed) Move to less supportive, more functional
positions
BELU
Lumbar HNP: return to activities
Work modifications (standing desk set up for varying positions) Look at home set up (lumbar support when
sitting) Walk before jog Taming the “weekend warrior”
BELU
INDICATIONS
Progressive neurological deficit Caudal equina Failure of improvement of
extremity symptoms after 6-8 weeks of conservative treatment Intractable extremity pain
http://www.mayoclinic.com/health/medical/IM01274Bono, CM. Instructional Course Lectures: Spine 2. 2010.
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Disc Herniations: Surgical Intervention – Elizabeth Yu, MD
CASE EXAMPLE: 43 year old female with left L5 radiculopathy Left lower extremity pain > back pain
Underwent left L5 TFESI Failed medication Medrol dose pack, NSAIDs
Failed physical therapy Developing dynamic foot drop
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Procedure
Traditional open microdiscectomy Midline incision
Minimally invasive microdiscectomy 1.5 cm lateral midline Muscle splitting technique
Goals Minimal removal of bone to gain entry into the spinal canal Subtotal versus limited discectomy
http://www.davisandderosa.com/Injuries-Conditions/Lower-Back/Lower-Back-Surgery/Lumbar-Discectomy/a~410/article.html
http://www.siddiqimd.com/technology/technology-in-treatment.htm
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Procedure Traditional open microdiscectomy Direct visualization
Minimally invasive microdiscectomy Range from use of tubular retractors To endoscopic technique
http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-FlexMember-Show_Public_HFFY_1105110033945.html
http://www.jedpwebermd.com/procedures.html
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Outcomes: Open versus MIS
Similar regardless of approach: Lau et. al. 2011 – no difference in open versus MIS
operative time, length of stay, neurological outcome, complication rate, or change in pain score (pain improvement).
Harrington et. al. 2008 – no difference in open versus MIS Surgical times, blood loss, complications, and outcome Pain medication and hospital stay less in MIS group
German et. al. 2008 – similar perioperative results Smith et. al. 2010 – comparable results with
microendoscopic discectomy and open discectomy pain, disability, and functional health
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Outcomes
Successful procedure Profound improvement of pain when awaken Followed by strength and paresthesias
SPORTs trial 2 year follow up: Patient improvement
Physical function Satisfaction
4 year follow up: No statistical difference between improvement in nonoperative and operative group Maintenance of improvement in operative group
•"Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial: A Randomized Trial" JAMA 296(20):2441-2450, 2006.•"Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial Observational Cohort" JAMA 296(20):2451-2459, 2006.•"Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: Four-Year Results from the Spine Patient Outcomes Research Trial (SPORT)" Spine 33(25):2789-2800, 2008.
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Outcomes: Patient factors Psycological factors influence patient perception of successful
outcomes ODI or Oswestry Disability Index SF-36 or Short Form-36
Smokers: Vogt, et. al. – Smokers have baseline significantly lower function
on SF-36. 1 year postoperative: no significant improvement in SF-36 scores
compared to nonsmoker counterparts
Education level and self reported health: Independent predictor of poor self-reported function at baseline
ODI and SF-36
Other studies have implicated: Depression, unemployment, legal status
Obesity: Negative influence on SF-36 and ODI scores Greater pain than nonobese patients
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Complications
Risk of reherniation: occurs in 5-15% of patients Surgical intervention not necessary required Surgical approach no different
Infection Dural tear Long term outcomes the same as no dural tear
http://www.dartmouth.edu/sport-trial/whatissport.htm#WhatResults
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Laser spine surgery
Misnomer Incision 1” to 2” Laser to ablate tissue
Studies Review of the literature 2013 by Singh et. al.
found little RCTs (1966 to 2012) Limited evidence for percutaneous laser disc
decompression Usually used for broad based discs to shrink the
dischttp://health.howstuffworks.com/medicine/modern-treatments/laser-spine-surgery.htm
http://www.laserspineinstitute.com/about/lsi_history/
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Most commonly thought of…
Use the word MISS with use of endoscope Laser or thermal ablation is used to denervate the
sensory nerves
http://www.laserspineinstitute.com/about/lsi_history
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