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Surgery 6th year, Tutorial (Dr. Hamid)


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Jan. 8th, 2012

Published in: Health & Medicine
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Surgery 6th year, Tutorial (Dr. Hamid)

  1. 1. Surgical Management of Lumbar Disc Herniation
  2. 2. Objectives <ul><ul><li>Absolute and Relative Indications for Surgery </li></ul></ul><ul><ul><li>Timing of Surgery </li></ul></ul><ul><ul><li>List of Available Surgical Interventions </li></ul></ul><ul><ul><li>Complications of Surgery </li></ul></ul><ul><ul><li>Results of Surgery </li></ul></ul>
  3. 3. Indications for Surgery <ul><li>Absolute </li></ul><ul><ul><li>Cauda Equina Syndrome </li></ul></ul><ul><ul><li>Recent Onset, Severe and Progressive Motor Deficit </li></ul></ul><ul><li>Relative </li></ul><ul><ul><li>Failure of adequate trial of non operative treatment for radicular pain </li></ul></ul><ul><ul><li>Severe intractable radicular pain </li></ul></ul><ul><ul><li>Herniation into an already stenotic spinal or nerve root canal </li></ul></ul><ul><ul><li>Significant motor deficits with positive nerve root tension signs </li></ul></ul><ul><ul><li>Large extruded fragments </li></ul></ul><ul><ul><li>Recurrent radicular pain after successful trial of non operative treatment </li></ul></ul><ul><ul><li>The presence of a mild or moderate motor deficit does not necessarily affect the indication for operative or non operative treatment </li></ul></ul>
  4. 4. Timing of Surgery <ul><li>Cauda Equina Syndrome </li></ul><ul><ul><li>ASAP </li></ul></ul><ul><li>Relative Indications </li></ul><ul><ul><li>Lack of scientific evidence on optimal timing </li></ul></ul><ul><ul><li>Rarely <6 weeks </li></ul></ul><ul><ul><ul><li>Period in which improvement in symptoms generally known to occur </li></ul></ul></ul><ul><ul><li>Should not be delayed beyond 3-4 months </li></ul></ul><ul><ul><ul><li>Chances of improvement in radicular pain are slight and decrease further after 6 months </li></ul></ul></ul>
  5. 5. Available Surgical Interventions <ul><li>Open Discectomy-open,fenstration,flavectomy,tailor </li></ul><ul><li>-- Microdiscectomy </li></ul><ul><li>-- Chemonucleolysis with Ozon, Chymopapain </li></ul><ul><li>---- Automated Percutaneous Nucleotomy </li></ul><ul><li>Manual Percutaneous Discectomy </li></ul><ul><li>Percutaneous Endoscopic Discectomy </li></ul><ul><li>Endoscopic or Percutaneous Laser Discectomy </li></ul><ul><li>Dskectomy plus fusion </li></ul><ul><li>Vertebral arthroplasty </li></ul>
  6. 6. Complications of Surgery <ul><li>Wrong Level 1.2 – 3.3 % </li></ul><ul><li>Durotomy 0.8 – 7.2 % </li></ul><ul><li>Nerve Root Lesions 0.2 % </li></ul><ul><li>Infection 2 – 3 % </li></ul><ul><li>Recurrent Herniations 5 – 15 % </li></ul><ul><li>Epidural Fibrosis </li></ul><ul><ul><li>Difficult to distinguish from recurrent herniation </li></ul></ul><ul><ul><li>Contrast MRI investigation of choice </li></ul></ul><ul><ul><li>No correlation between extent and symptoms </li></ul></ul><ul><ul><li>No intervention or material shown to alter incidence </li></ul></ul><ul><li>Epidural Haematoma </li></ul><ul><li>Cauda Equina Syndrome </li></ul><ul><li>Iatrogenic Instability </li></ul>
  7. 7. Results of Surgery <ul><li>85 – 95 % good to excellent short term results </li></ul><ul><li>Long Term good to excellent results diminish to 55 – 70 % </li></ul><ul><ul><li>10 – 18 % having required additional surgery </li></ul></ul><ul><ul><li>Lower back pain usually the cause of dissatisfaction </li></ul></ul><ul><ul><ul><li>No difference between surgery or conservative </li></ul></ul></ul><ul><li>Microdiscectomy </li></ul><ul><ul><li>Shorter hospital stay </li></ul></ul><ul><ul><li>Faster return to sedentary work </li></ul></ul><ul><ul><li>No difference c/w open discectomy after 8 –12 weeks </li></ul></ul><ul><li>No statistically significant difference in recovery of established motor deficits with or without surgery </li></ul>
  8. 8. Patient Factors Predicting Favourable Outcomes <ul><li>Absence of Lower Back Pain </li></ul><ul><li>Radicular pain distribution with positive tension sign </li></ul><ul><li>Higher socioeconomic status </li></ul><ul><li>Minimal psychosocial stress </li></ul>
  9. 9. Summary <ul><li>Open (and probably micro) Discectomy Gold Standard </li></ul><ul><li>Adhere to indications for surgery </li></ul><ul><li>Patient selection influences outcome </li></ul><ul><li>Chymopapain has a role to play </li></ul><ul><li>Other interventions remain experimental </li></ul><ul><li>Bear in mind Natural History of LDH </li></ul>
  10. 10. Questions