The document discusses common lumbar spine conditions including disc herniation, spinal stenosis, and chronic low back pain. It describes the causes, symptoms, treatments including surgery, and outcomes. For disc herniation, surgery in the form of discectomy is recommended for severe or unremitting leg pain and can provide relief in 90% of cases. Spinal stenosis is treated initially with physiotherapy or epidural injections, with surgery as an option for severe, unresolved symptoms. Fusion surgery is not usually indicated for chronic low back pain alone but may be used for instability or certain structural deformities.

1. The role of surgery
in common
lumbar conditions
Paul Licina

4. disc herniation
discogenic pain
spinal stenosis

5. WHAT CAUSES IT?
WHO YOU
ARE
WHAT YOU
DO
WHAT
HAPPENED

6. genetics
weight
fitness psychology
age
WHO YOU ARE
WHAT CAUSES IT?

7. WHAT YOU DO
occupation
pastimes
WHAT CAUSES IT?
previous injuries
smoking

8. WHAT HAPPENED
injury
repetitive load
WHAT CAUSES IT?

9. WHO YOU
ARE
WHAT YOU
DO
WHAT
HAPPENED
WHAT CAUSES IT?

10. WHAT CAUSES IT?
The once commonly held view that disc degeneration is primarily a
result of aging and “wear and tear” from mechanical insults and
injuries was not supported by this series of studies. Instead, disc
degeneration appears to be determined in great part by genetic
influences. Although environmental factors also play a role, it is not
primarily through routine physical loading exposures (eg, heavy vs.
light physical demands) as once suspected.
Previously, heavy physical loading was the main suspected risk factor
for disc degeneration. Recent research indicates that heredity has a
dominant role in disc degeneration, explaining 74% of the variance in
adult populations studied to date.
The Twin Spine Study – Battie et al.

11. WHO YOU
ARE
WHAT YOU
DO
WHAT
HAPPENED
WHAT CAUSES IT?

12. Age (yr)
20 40 60 80
Disc degeneration 37% 68% 88% 96%
Disc protrusion 29% 33% 38% 43%

13. DISC HERNIATION
tear in outer disc (brittle)
migration of inner gel (lumpy)
not usually traumatic
does not occur in a normal disc
What causes
it ?
nerve pressure
leg pain (sciatica)
What does it
cause ?

14. What happens
to it ?
• two phases of pain
•inflammation
•compression
• inflammation can be reversed
• fragment can be resorbed
• rough guide
•50% better in 4 wks
•90% resolve eventually
DISC HERNIATION

15. radicular pain
parasthesiae
back pain
What are the
symptoms?
reduced straight leg raise
weakness
reflex loss
sensory loss
What are the
signs ?
DISC HERNIATION

16. observe (physiotherapy)
nerve root block
Nerve root block
• injection of local anaesthetic (Marcain)
and cortisone (Celestone)
• into nerve root foramen
• under CT guidance
• usually temporary
• good if surgery not indicated
• good for diagnosis if in doubt
How do we
treat it?
surgery
DISC HERNIATION

17. cauda equina syndrome
unremitting pain
Prerequisites
•symptoms > 6 weeks (?4 weeks)
•leg pain > back pain
•leg pain in radicular distribution
•nerve tension signs (reduced SLR)
•nerve compression signs
•confirmed on imaging
When do we
operate ?
SURGERY IN THE FORM OF DISCECTOMY
relief of leg pain
Why do we
operate ?
Outcome
satisfactory result in 90%
DISC HERNIATION
functional weakness
decompression of nerve

18. Patient information
discectomy video

20. Outcome
• Day Surgery procedure
• Back to sedentary duties by 3 weeks
• Back to sport by 6 weeks
• Good or excellent result in 90%
• Recurrence rate 6%
• Disabling low back pain <5%
DISC HERNIATION

21. • 35 y.o. male
• 6 week history of severe sciatica
• numbness in S1 distribution
• unable to single heel raise on right
• right calf wasting
• right SLR limited to 15°

24. • 42 y.o. female
• 4 week history of sciatica
• initially incapacitating, now improving
• absent ankle jerk
• mild calf weakness
• right SLR limited to 45°

27. • 48 y.o. male accountant
• gradual onset of severe right thigh
and knee pain
• right quadriceps wasting and
weakness
• absent right knee jerk

30. acute LBP ≠ chronic LBP
LOW BACK PAIN
• acute tissue trauma
• self-limiting
• stay active, be positive
• dysfunction in nervous system
• long-lasting
• multidisciplinary interventions
genetic
psychosocial

31. What causes
back pain ? SEGMENTAL INSTABILITY
DISCOGENIC PAIN
FACETOGENIC PAIN
SOFT-TISSUE RELATED
UNKNOWN CAUSE
CHRONIC LOW BACK PAIN

32. SEGMENTAL INSTABILITY
DISCOGENIC PAIN
FACETOGENIC PAIN
SOFT TISSUE/
UNKNOWN
CAUSE
CHRONIC LOW BACK PAIN
What causes
back pain ?
What can we
treat
surgically ?

33. DECISION
WHETHER TO
OPERATE IS
DIFFICULT
surgery is not universally effective
DEGENERATION
DOES NOT ALWAYS
EQUAL PAIN
incidence of degenerative changes on x-ray
back pain population = normal population
CHRONIC LOW BACK PAIN

34. FUSION FOR LOW BACK PAIN
WRONG diagnosis
WRONG patient

35. SUITABLE CANDIDATE
• Self-employed
• Successful business
• No specific injury
• No compensation or litigation
• Works with some difficulty
• Has given up some of more active sports
• Uses intermittent over-the-counter analgesics
• Non-smoker
• Normal body weight
• Goal is to be able to return to active lifestyle
• No abnormal illness behaviour

36. UNSUITABLE CANDIDATE
• Employee undertaking manual work
• Dissatisfied with employment
• Unremitting pain after lifting at work
• Unresolved WorkCover claim with civil action pending
• Failed attempts at return to work
• Has given up all social activities
• Uses regular narcotic analgesia
• Smoker
• Unfit and overweight
• Goal is for someone to get rid of their pain
• Abnormal illness behaviour on examination

37. Techniques
FUSION FOR LOW BACK PAIN

38. Noninstrumented
fusion
FUSION FOR LOW BACK PAIN

39. Instrumented
fusion
FUSION FOR LOW BACK PAIN

40. Interbody
fusion
FUSION FOR LOW BACK PAIN

45. • 38 year old female
• 18/12 of worsening low back pain
• Conservative treatment for past year
• Simple analgesics
• Flares of back pain becoming more frequent
• Fit, active lifestyle
• Recently ceased running and regular sport
• Working but with difficulty
• No WorkCover/legal claim
• Mild restriction of forward flexion
• Normal neurological examination

49. • 32 year old manual worker
• Sudden back pain with repetitive lifting
• Off work since injury, 9 months ago
• WorkCover claim, considering litigation
• High narcotic intake
• Spends majority of time in bed, resting
• Very restricted ROM in all directions
• Marked abnormal illness behaviour

53. SPINAL STENOSIS
What is it ?
What does it
cause ?
narrowing of the spinal canal
with nerve compression
leg pain and
neurogenic claudication

54. SPINAL STENOSIS
observe (physiotherapy)
epidural injection
Epidural injection
• injection of local anaesthetic (Marcain)
and cortisone (Celestone)
• via epidural or caudal approach
• usually temporary
• can be long-lasting
• can be repeated
• good if surgery not indicated
How do we
treat it?
surgery

55. SPINAL STENOSIS
When do we
operate ?
when symptoms severe
SURGERY IN THE FORM OF DECOMPRESSION
nonoperative treatment
unsuccessful

60. SPINAL STENOSIS
When do we
add fusion ?
SPONDYLOLISTHESIS SCOLIOSIS
stenosis with instability
•degenerative spondylolisthesis
•degenerative scoliosis

64. DEGENERATION
• is largely genetically determined
• is not necessarily the cause of pain
DISCECTOMY
• is a successful day surgery procedure
• is the first choice for severe pain or weakness
FUSION
• is not often indicated for back pain
• is successful for the right diagnosis and patient
LAMINECTOMY
• is effective for symptomatic stenosis
• is often combined with fusion for instability
KEY POINTS