SLIDE 1
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
for Low Back Conditions Barry Landau MD Fourth Corner Neurosurgical - - PowerPoint PPT Presentation
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
SLIDE 2
SLIDE 3
Acute Lumbar Herniated Disc
- NSAIDs – short term narcotics
- Avoid bed rest
- Physical Therapy
- MRI if red flags or failing above treatments
SLIDE 4
Acute Lumbar Herniated Disk
Right L5-S1 herniation
SLIDE 5
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
SLIDE 6
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
SLIDE 7
Lumbar Discectomy
- Outpatient procedure
- Driving in a few days
- Sedentary work 1-2 weeks
- Post-operative Physical
Therapy
- Unrestricted activity in 8-12
weeks
SLIDE 8
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)
SLIDE 9
Stenosis with Degenerative Spondylolisthesis
Dorothy - age 77
- 1 year history of Neurogenic claudication
- DM, Hypertension
- Numbness in feet – diabetic neuropathy?
SLIDE 10
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
SLIDE 11
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
SLIDE 12
Stenosis with Degeneretive Spondylolisthesis
Medical - Surgical considerations
Obesity Diabetes Cardiac disease Smoking Sleep Apnea Osteoporosis Anemia Vitamin D deficiency Depression and Anxiety
SLIDE 13
Surgical Options
- Stenosis with spondylolisthesis
SLIDE 14
Stenosis with Degenerative Spondylolisthesis
Surgical options
Laminectomy
- Open
- Minimally invasive
Fusion
- Posterior
- Lateral trans-psoas
SLIDE 15
Stenosis with Degenerative Spondylolisthesis
Surgical options Laminectomy with non-fusion stabilization Coflex device
SLIDE 16
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
SLIDE 17
Asymptomatic middle aged Adults
4% nerve compression 10% disc extrusions 29% contained herniation 38% disc bulges 60% disc degeneration
SLIDE 18
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