Degenerative Lumbar Spine Mark F. Kurd, MD Associate Professor, - - PowerPoint PPT Presentation

Mark F. Kurd, MD

Associate Professor, Sidney Kimmel Medical College Thomas Jefferson University The Rothman Institute

Degenerative Lumbar Spine

Disclosures

• Duratap, LLC: Shareholder

History of Present Illness

• CC:

– 51 year old automotive plant employee, presents to the

• ffice with low back pain and a crooked spine
• HPI:

– Pain: sharp/constant predominately in upper lumbar midline – worse when walking and standing – Increasingly hunched over – Starting to use a cane for ambulating – Attempted TLSO brace and physical therapy – No bowel or bladder deficits – No leg/gluteal pain

Physical Examination

• PE:

– Lumbar EXT: 30 deg, FLEX: 45 deg – Left sided lumbar hump and global kyphotic deformity – Negative Long Tract Signs: Hoffmann’s Babinski’s, Reflexes, Clonus – Lower Extremity and Upper Extremity Strength 5/5 – Sensation is intact to pin prick from c4-T1 and L2-S1. – Negative Straight Leg raise bilaterally.

Radiographs

Radiographs

• History
• PE
• Compensatory Mechanism
• Retrovert pelvis
• Flex Knees
• Hyperextend mobile spine
• Fixed vs. Flexible
• Imaging
• Radiographs: Balance
• MRI: Stenosis

Evaluation Determine Pain Generator

Radiographic Evaluation – Sagittal Imbalance

• 36 inch Lateral Long-Cassette
• Identify key vertebral landmarks
• Measure Sagittal Vertical Axis
• Measure Pelvic Incidence
• Measure Sacral Slope and Pelvic Tilt
• Measure Lumbar Lordosis
• Measure Thoracolumbar Sagittal Alignment
• Measure Thoracic Kyphosis

Joseph et al. J Am Acad Orthop Surg. 2009;17:378-388.

Spinopelvic Parameters

• Pelvic Incidence is a Constant Anatomic

Parameter

• Sacral Slope and Pelvic Tilt are Position

Dependant

Schwab et al. Spine. 2010. 35(25):2224-31. Legaye et al. Eur Spine J. 1998;7:99-103.

PI = SS + PT PI = LL +/- 9°

Radiographic Evaluation – Coronal Imbalance

• 36 inch PA Long-Cassette
• Measure the Fractional curve in the lumbosacral jxn
• Find the apical vertebrae
• Find the neutral vertebrae
• Find the stable vertebrae
• Measure the main curve Cobb angle
• Measure the secondary curve Cobb angle
• Tribus. J Am Acad Orthop Surg. 2003. 11:174-183.
• Measure trunk shift

Provocative Discography

• 8 patients no previous LBP with previous

ICBG for reasons other than lumbar surgery

– Majority of patients unable to distinguish discogram pain from ICBG site pain.

• “The ability of a patient to separate spinal

from non-spinal sources of pain on discography is questioned”

Discography

Most frequently used tool to diagnose discogenic LBP & select surgical candidates has High false positive rate Unproven benefit in predicting surgical

• utcomes

Pain Generator Discogenic Nonsurgical PT NSAIDS ESI RFA Deformity Sagittal Coronal Stenosis Decompression Decompression/F usion Other

Algorithm for Back Pain

Algorithm for Sagittal Imbalance

Sagittal Imbalance Fixed Flexible Anterior and Posterior Fusion with Structural Grafting Anteriorly and Decompression where needed Pedicle Subtraction Osteotomy and Decompression where needed

Joseph et al. J Am Acad Orthop Surg. 2009. 17:378-388.

Sagittal Correction Goals

Schwab et al. Spine. 2010. 35(25):2224-31.

Coronal Deformity Global Balance Nonsurgical Stenosis Decompression/Fusi

• n

Global Imbalance/Trunk Shift Decompression/F usion c Correction

Algorithm for Coronal Deformity

Conclusion

• Diagnosis

–Identify pain generator

• Treatment

–Nonsurgical –Surgical

• Stenosis
• Sagittal Imbalance

– PI = LL +/- 9 deg

• Coronal deformity with stenosis or trunk shift

Thank You