surgery for lower back pain
TRANSCRIPT
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SURGERY FOR LOW BACK PAIN
Paul Licina
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Not all spine surgery is the same…
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DISCECTOMY FOR DISC HERNIATION
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DISCECTOMY FOR DISC HERNIATION
tear in outer discmigration of inner gel
What causes it ?
nerve pressureleg pain (sciatica)
What does it cause ?
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DISCECTOMY FOR DISC HERNIATION
cauda equina syndrome
unremitting pain
When do we operate ?
relief of leg painWhy do we operate ?
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DISCECTOMY FOR DISC HERNIATION
Prerequisites
• symptoms > 6 weeks• leg pain > back pain• leg pain in radicular distribution• nerve tension signs (reduced SLR)• nerve compression signs (weakness,
numbness, reflex loss)• confirmed on imaging
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DISCECTOMY FOR DISC HERNIATION
Outcome
• Day Surgery procedure• back to sedentary duties in 3 weeks• back to sport in 6 weeks• good or excellent result in 90-95%
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•small incision • interlaminar space exposed
•adequate retraction •laminotomy
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FUSION FOR LOW BACK PAIN
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FUSION FOR LOW BACK PAIN
What is fusion good for?
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FUSION FOR LOW BACK PAIN
What about low back pain?
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FUSION FOR LOW BACK PAIN
Results not as good as for deformity or instability
Results not as good as for discectomy surgery
WRONG diagnosisWRONG patient
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FUSION FOR LOW BACK PAIN
DISEASE DIAGNOSIS
symptoms and signs
Hx, Ex & Ix
TREATMENTCURE
directed at pathology
The medical model
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DISEASE DIAGNOSIS
symptoms and signs
Hx, Ex & Ix
The medical model
back pain is a complex symptom rather than a
discrete illness
structural lesion cannot be identified in many
cases
does not account for individual variation in
human response
15%
FUSION FOR LOW BACK PAIN
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CHRONICSPECIFIC
ACUTESPECIFIC
CHRONICNON
SPECIFIC
ACUTENONSPECIFIC
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SUITABLE CANDIDATE
• Self-employed
• Successful business
• No specific injury
• No compensation or litigation
• Works with some difficulty
• Has given up some of more active sports
• Uses intermittent over-the-counter analgesics
• Non-smoker
• Normal body weight
• Goal is to be able to return to active lifestyle
• No abnormal illness behaviour
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UNSUITABLE CANDIDATE
• Employee undertaking manual work
• Dissatisfied with employment
• Unremitting pain after lifting at work
• Unresolved WorkCover claim with civil action pending
• Failed attempts at return to work
• Has given up all social activities
• Uses regular narcotic analgesia
• Smoker
• Unfit and overweight
• Goal is for someone to get rid of their pain
• Abnormal illness behaviour on examination
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Techniques
FUSION FOR LOW BACK PAIN
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FUSION FOR LOW BACK PAIN
Noninstrumentedfusion
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Instrumented fusion
FUSION FOR LOW BACK PAIN
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FUSION FOR LOW BACK PAIN
Interbodyfusion
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remove the disc
Interbodyfusion
• remove the pain source• stop the movement
FUSION FOR LOW BACK PAIN
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benefits
Anterior interbody
• anterior muscle-splitting only
• minimal tissue trauma
indications
• isolated degeneration• L5-S1 (L4-5)• no need to enter canal• thin, no previous major
abdominal surgery
FUSION FOR LOW BACK PAIN
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benefits
Transforaminalinterbody
• allows nerve decompression
• allows all levels• familiarity
indications
• not suitable for ALIF• nerve compression esp
foraminal compression• correction of deformity
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What’s new?
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When is fusion good for LBP?
•specific diagnosis•clearly defined pain source
•suitable candidate•no negative psychosocial factors
•appropriate technique for pathology•some surgeon variation