for Low Back Conditions Barry Landau MD Fourth Corner Neurosurgical - PowerPoint PPT Presentation

Surgical Decision Making for Low Back Conditions Barry Landau MD Fourth Corner Neurosurgical Associates

Acute Lumbar Herniated Disc • Steve - age 44 • 6 weeks of leg > back pain • Numbness, weakness plantar flexion

Acute Lumbar Herniated Disc • NSAIDs – short term narcotics • Avoid bed rest • Physical Therapy • MRI if red flags or failing above treatments

Acute Lumbar Herniated Disk Right L5-S1 herniation

Acute Lumbar Herniated Disc surgery • SPORT Study 8 year follow up 1,195 patients • Surgery superior to non-operative care • Treatment effect lasted full 8 years • Non-operated patients also improved but not as much •

Acute lumbar herniated disc Surgical indications Rapidly progressive neurological deficit • Rapid resolution of pain can indicate more severe neurological • damage Persistent disabling pain and/or neurological deficit lasting 6 weeks • Recurring episodes of pain • Cauda Equina Syndrome • Surgical success rate starts to decline at 3-4 months •

Lumbar Discectomy Outpatient procedure • Driving in a few days • Sedentary work 1-2 weeks • Post-operative Physical • Therapy Unrestricted activity in 8-12 • weeks

Lumbar discectomy Complications Dural tear 2-4% (reoperation rarely needed) • Infection, bleeding < 1% • Nerve injury • Recurrent herniation 4% within 1 year, 4-8% long term • Persistent pain (most common problem) •

Stenosis with Degenerative Spondylolisthesis Dorothy - age 77 • 1 year history of Neurogenic claudication • DM, Hypertension • Numbness in feet – diabetic neuropathy?

Stenosis with Degeneretive Spondylolisthesis Stenosis with Degenerative Spondylolisthesis associated conditions: • Knee and Hip problems • Vascular Claudication • Peripheral Neuropathy • Cervical Spinal Stenosis with Myelopathy • Fibromyalgia – pre-existing chronic pain syndromes

Stenosis with Degeneretive Spondylolisthesis conservative care: • Physical therapy • Epidural Steroids • SPORT Study: Patients treated surgically maintain substantial greater pain • relief and improvement in function than those treated conservatively at 4 years

Stenosis with Degeneretive Spondylolisthesis Medical - Surgical considerations Cardiac Obesity Diabetes disease Smoking Sleep Apnea Osteoporosis Vitamin D Depression Anemia deficiency and Anxiety

Surgical Options • Stenosis with spondylolisthesis

Stenosis with Degenerative Spondylolisthesis Surgical options Laminectomy • Open • Minimally invasive Fusion • Posterior • Lateral trans-psoas

Stenosis with Degenerative Spondylolisthesis Surgical options Laminectomy with non-fusion stabilization Coflex device

Chronic Low Back Pain Chuck, age 54 • Long term narcotics • Financial issues, L&I claim • Smoking, cannabis • Residual neck pain after cervical fusion • Anxiety, depression •

Asymptomatic middle aged Adults 4% nerve compression 10% disc extrusions 29% contained herniation 38% disc bulges 60% disc degeneration

Chronic Low Back Pain Surgery for scoliosis, flat back • syndrome Surgery for radiculopathy only • Degenerative disc disease, Facet • pain, Stenosis Non-spine anatomical causes • Depression and Anxiety • Avoid surgical disasters •