Most important presentation, not because I am giving it. Because I believe choosing the right patient for surgery is more important that surgery itself and the outcome of the surgery is heavily dependent on this decision.
But the wisdom to choose the right patient is important.
Decision is more important than the incision.
61y woman with L4-5 spondylolisthesis. How will you evaluate?
Before starting out you have to know two facts about degenerative lumbar spine problems
One famous study (Boden). Took normal people with healthy backs and did their MRI. Found that 2/3 of patients had degenerated discs.
An algorithm is defined by Webster as an “organized method for solving a problem in a finite number of steps”.
Have to go sequentially. Do not try to answer question 6 before answering questions 1,2 and 3
Spondylogenic - origin from the spinal column and associated structures. Aggravated by activities and relieved or reduced by rest Neurogenic - tension, irritation, compression of lumbar nerve roots (usually cause referral of pain to legs) Viscerogenic pain - Kidneys, retroperitoneal organs, pelvic viscera. Back pain alone is rarely the sole symptom. Usually other associated symptoms. Not related to activity. Vascular pain - AAA - deep boring back pain unrelated to activity. PVD, Varicose veins - Vascular claudication mimic pain produced by root irritation. We will discuss this more in detail later. Psychogenic pain - Rare, Never forget that emotional illness does not protect patient against organic disease. Investigate thoroughly and don’t be lazy and say that it is all in the patient’s mind.
indicate psychological barriers to recovery
If you are a music lover who like Indian classical music you will instantly recognize rag bharavi. On history, Now I can recognize the pain pattern PE, I will verify the suspicion and the anatomic level of involvement Also I know everything there is to know about other systems, such as vascular system, viscera, other joints such as hips, SI joints which can mimic spondylogenic back pain.
After all this I am now ready to review the images. If there is perfect marriage between what I see on the images and the presentation of the patient then I have a diagnosis. If not then, maybe I have made a mistake or missed something and should return to the patient and start over.
The problem is that degenerative changes in the spine are so ubiquitous, that frequently non spondylogenic back pain gets blamed on the disc degeneration. So one has to be very careful.
Better outcomes in patients who are optimistic about surgery.
Indications for Surgery in Adult Spondylolisthesis
Dr. Kshitij Chaudhary, MS, DNB
Consultant Spine Surgeon
Sir HN Reliance Foundation Hospital
I N D I C A T I O N S F O R S U R G E R Y
H O W T O C H O O S E T H E R I G H T P A T I E N T ?
A N O N .
"If operating on the wrong leg is a medical error,
what do we call operating on a someone who doesn't
1. Is pain a diagnostic trap? Non-spondylogenic ?
2. If spondylogenic - Any red flags?
3. Is pain mechanical? If so, which syndrome?
4. Is pain a true physical disability? Yellow Flags?
5. After history, PE, imaging and tests – what is structural
6. Does clinical picture fit with structural lesion?
Listen to the patient !
10% Physical examination
5% Imaging, Labs etc
What is structural lesion?5
6 Does it explain the clinical picture?
Is there a nonoperative option?7
Paracetamol / NSIADS
No studies: Workgroup Consensus Statement - NASS
Is there a nonoperative option?7
Epidural steroid injections
Small or no benefit
Chou R et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015.
Friedly JL, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014;371:11-21.
Epidural steroid injection
Diagnostic Value ?
de Kleuver et.al. (2012). Optimizing Outcomes in the Management of Degenerative Spondylolisthesis.
Spine Deformity, 1–9.
What is the functional limitation?
Dissatisfied with their symptoms
t.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21), 17
Oswestry Disability Index
• 0 to 20: Minimal disability
• 21-40: Moderate Disability
• 41-60: Severe Disability
• 61-80: Crippling disability
• 81-100: Bed-bound or exaggeration
Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000 Nov 15;25(22):2940-52
“Patient expectation can be a self fulfilling prophecy”
n et.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21)