Spinal Surgery 2. Teaching Aims. Common Spinal Pathologies. Disc Degeneration. Disc Degeneration. Causes of LBP 8/2/13. Common Spinal Conditions

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1 Teaching Aims Spinal Surgery 2 Mr Mushtaque A. Ishaque BSc(Hons) BChir(Cantab) DM FRCS FRCS(Ed) FRCS(Orth) Hunterian Professor at The Royal College of Surgeons of England Consultant Orthopaedic Spinal Surgeon Senior Clinical Academy Teacher Common Spinal Conditions Important Spinal Conditions Be Safe Common Spinal Pathologies Degenerative disc disease Lumbar and Cervical disc herniation Spinal canal stenosis Spondylolysis Spondylolisthesis Disc Degeneration Affects everyone Age at onset is determined genetically and by environmental influence Variably symptomatic Disc Degeneration Causes of LBP Progressive and irreversible Probably increases with age Presents typically with low back pain Unfortunately, there are lots of causes of low back pain Mechanical Rheumatological Infection Tumours Systemic disease Neuro/Psychiatric 1

2 Natural History LBP 90% improve within 4/52 of seeking care At 1 month 66% mild LBP 33% moderate LBP 20% substantial limitation of activity At 1 year 14% severe back pain Patterns of LBP Back only Back and posterior thigh Back and lower leg pain Back and anterior thigh pain Causes of LBP Diagnosis Disc degeneration Bony endplate Facet joint Facet capsule Tendon Muscles Combination of all of the above Pain History Site Onset Character Radiation Alleviating factors Timing Exacerbating factors Severity SOCRATES Diagnosis Examination Posture (Listing) Movement Cadence Flexion increment Pain on extension Tenderness Neurological examination Perineal examination Investigations Plain radiographs MRI Discography Facet joint block Psychological assessment 2

3 Treatment Conservative Physiotherapy Core stability exercises Surgical Fusion Posterolateral uninstrumented Transforaminal Lumbar Interbody Posterior Lumbar Interbody Indications for fusion Incapacitating back pain Failure of conservative treatment for at least 6/12 Correlating clinical findings and imaging Patient accepting of risks and success rates RED FLAGS Age under 20 or over 55 Non-mechanical back pain Thoracic back pain Structural deformity Recent unexplained weight loss RED FLAGS Night pain Prior Malignancy Constitutional symptoms Sphincter symptoms Neurological abnormality Lumbar Disc Herniation Lumbar Disc Herniation Presents with leg pain Radicular pain in a dermatomal distribution May have associated back pain Pain is Dermatomally sited Sudden with obvious time of onset Sharp, burning or lancinating Radiates down the leg below the knee Mildly relieved with NSAID s Constant Exacerbated by any movement Severe in nature 3

4 Anatomy Pathophysiology Sacrum Root Root Disc Root Leg Pain is secondary to Mechanical radiculitis Chemical radiculitis Back pain is due to From the disc itself From the bony endplate Anatomy Natural History Broad based herniation 80% settle spontaneously within 6 weeks Traversing vs Exiting Nerve Root Focal herniation Surgery is no more effective in the long term than conservative management Surgery does however provide pain relief earlier and facilitates earlier return to normal activities and work MRI Investigation Indications for surgery Absolute Sphincter compromise Major Motor radiculopathy Relative Failed conservative management Only after a minimum of 6 weeks Neurological deficit Stenotic spinal canal 4

5 Management Conservative Nerve Root Block Lumbar Epidural Surgical Microdiscectomy Success Rate in excess of 93% Spinal Stenosis Also known as neurogenic claudication Narrowing of the spinal canal Multiple aetiologies Pathophysiology uncertain Definition Spinal Stenosis Claudication with evidence of chronic nerve root compression or irritation in the presence of a spinal canal lesion on imaging and absence of vascular insufficiency Aetiology Facet joint degeneration Osteophyte overgrowth Facet joint capsular laxity Ligamentum flavum oedema or buckling Characteristics MRI Insidious onset Age over 50 years old Numb aching cramp-like leg pain Brought on by standing or walking Relieved by sitting, leaning forward or simply stopping walking Back pain Weakness and sphincter disturbance if severe Spinal Stenosis 5

6 Management Targeted Decompression Conservative Lumbar or caudal epidurals Surgical Targeted decompression Decompression and fusion Spondylolysis Imaging Spondyl = Vertebra Lysis = Break Unilateral or bilateral pars interarticularis defect Usually L3 to L5, commonest at L5 Imaging Spondylolisthesis Spondyl = vertebra Listhesis = slip Classification Dysplastic Isthmic Degenerative Traumatic (other than a pars defect) Pathological 6

7 Imaging Management Decompress the nerve roots Reduce the spondylolisthesis Spondylolisthesis Obtain a fusion at the level of the spondylolisthesis Post Op Imaging Reduce and Fuse 7