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Dr. Kshitij Chaudhary, MS, DNB
Consultant Spine Surgeon
Sir HN Reliance Foundation Hospital
Mumbai
@kcspine
I N D I C A 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
need it.”
@kcspine
@kcspine
Asymptomatic Subjects
@kcspine
No correlation with symptoms
- I M M A N U E L K A N T ( 1 8 0 0 )
“Physicians think that they do a lot for a patient when
they give his disease a name”
@kcspine
Fail-safe system
1. Is pain a diagnostic trap? Non-spondylogenic ?
2. If spondylogenic - Any red flags?
3. Is pain mechani...
@kcspine
Is the back pain from the spine ?
Viscerogenic
Vascular
Psychogenic
1
Viscerogenic
Kidney, Retroperitoneal tumor, pelvic viscera
@kcspine
Vascular
Aortic aneurysm, Peripheral Vascular d/s
@kcspine
@kcspine
Spondylogenic back pain
is the most common
Are there any red flags?
Degeneration
Inflammatory
Tumor
Infections
Trauma
Osteoporosis
2
@kcspine
Which mechanical pain syndrome?
Axial Back Pain
Referred Leg Pain
Neurogenic Leg Pain
3
@kcspine
Leg pain - Referred
@kcspine
@kcspine
Leg pain
Radicular Claudicatory
Back pain or leg pain predominant ?
D., Frymoyer, J. F., & Weinstein, J. (2011). Predominant Leg Pain Is Associated With B...
Vascular claudications
Pain relief on STANDING !
D/D Leg pain
Hip joint, Knee OA
Pelvis / SI
PVD / Varicose veins
Muscle pulls (Hamstrings)
Neuropathy (Diabetes)
Is pain a true physical disability?4
@kcspine
Listen to the patient !
80% History
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
Pregabalin
Physical therapy
Manipulation
TENS
Brace
Traction
No stud...
Is there a nonoperative option?7
Epidural steroid injections
Small or no benefit
Chou R et al. Epidural Corticosteroid Inj...
Epidural steroid injection
Diagnostic Value ?
@kcspine
Co-morbidities
Age
Obesity
Smoking
Diabetes
Osteoporosis
Cardiac etc.
de Kleuver et.al. (2012). Optimizing Outcomes in the...
@kcspine
@kcspine
What is the functional limitation?
Dissatisfied with their symptoms
t.al. (2013). Who Should Undergo Surgery for Degenerat...
Oswestry Disability Index
• 0 to 20: Minimal disability
• 21-40: Moderate Disability
• 41-60: Severe Disability
• 61-80: C...
Patient expectations
“Patient expectation can be a self fulfilling prophecy”
n et.al. (2013). Who Should Undergo Surgery f...
@kcspine
DECISION > INCISION
@kcspine
www.orthotimes.com
@kcspine
Indications for Surgery in Adult Spondylolisthesis
Indications for Surgery in Adult Spondylolisthesis
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Indications for Surgery in Adult Spondylolisthesis

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How to choose the right patient for surgery?

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Indications for Surgery in Adult Spondylolisthesis

  1. 1. Dr. Kshitij Chaudhary, MS, DNB Consultant Spine Surgeon Sir HN Reliance Foundation Hospital Mumbai @kcspine 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 ?
  2. 2. 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 need it.”
  3. 3. @kcspine
  4. 4. @kcspine Asymptomatic Subjects
  5. 5. @kcspine No correlation with symptoms
  6. 6. - I M M A N U E L K A N T ( 1 8 0 0 ) “Physicians think that they do a lot for a patient when they give his disease a name”
  7. 7. @kcspine
  8. 8. Fail-safe system 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 lesion? 6. Does clinical picture fit with structural lesion?
  9. 9. @kcspine
  10. 10. Is the back pain from the spine ? Viscerogenic Vascular Psychogenic 1
  11. 11. Viscerogenic Kidney, Retroperitoneal tumor, pelvic viscera @kcspine
  12. 12. Vascular Aortic aneurysm, Peripheral Vascular d/s @kcspine
  13. 13. @kcspine Spondylogenic back pain is the most common
  14. 14. Are there any red flags? Degeneration Inflammatory Tumor Infections Trauma Osteoporosis 2 @kcspine
  15. 15. Which mechanical pain syndrome? Axial Back Pain Referred Leg Pain Neurogenic Leg Pain 3 @kcspine
  16. 16. Leg pain - Referred @kcspine
  17. 17. @kcspine Leg pain Radicular Claudicatory
  18. 18. Back pain or leg pain predominant ? D., Frymoyer, J. F., & Weinstein, J. (2011). Predominant Leg Pain Is Associated With Better Surgical Outcomes in Degenerative Spondyl 90% 10% 50% 50% 90% 10%
  19. 19. Vascular claudications Pain relief on STANDING !
  20. 20. D/D Leg pain Hip joint, Knee OA Pelvis / SI PVD / Varicose veins Muscle pulls (Hamstrings) Neuropathy (Diabetes)
  21. 21. Is pain a true physical disability?4
  22. 22. @kcspine
  23. 23. Listen to the patient ! 80% History 10% Physical examination 5% Imaging, Labs etc
  24. 24. What is structural lesion?5 6 Does it explain the clinical picture?
  25. 25. Is there a nonoperative option?7 Paracetamol / NSIADS Pregabalin Physical therapy Manipulation TENS Brace Traction No studies: Workgroup Consensus Statement - NASS
  26. 26. 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. Controversial @kcspine
  27. 27. Epidural steroid injection Diagnostic Value ? @kcspine
  28. 28. Co-morbidities Age Obesity Smoking Diabetes Osteoporosis Cardiac etc. de Kleuver et.al. (2012). Optimizing Outcomes in the Management of Degenerative Spondylolisthesis. Spine Deformity, 1–9. 8 @kcspine
  29. 29. @kcspine
  30. 30. @kcspine
  31. 31. 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 9
  32. 32. 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
  33. 33. Patient expectations “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) 10
  34. 34. @kcspine DECISION > INCISION
  35. 35. @kcspine www.orthotimes.com @kcspine

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