3. SIGNS AND SYMPTOMS
• In many instances, the back pain is relatively
fleeting and This pain often is brought on by
heavy exertion, repetitive bending, twisting,
or heavy lifting.
• In other instances, an inciting event cannot be
elicited
3
4. Lumbar disc herniation
• Most people in the third and
fourth decades of life.
• Pain often is brought on by
heavy exertion, repetitive
bending, twisting, or heavy
lifting.
• It usually begins in the lower
back, radiating to the sacroiliac
region and buttocks.
• The pain can radiate down the
posterior thigh. & relieved by
rest.
4
5. • Back and posterior thigh pain
From:the facet joints, longitudinal
ligaments, and the periosteum of
the vertebra.
• Radicular pain, usually extends
below the knee and follows the
dermatome of the involved nerve
root.
5
8. The usual history of lumbar disc
herniation
•
Repetitive lower back & buttock
pain, relieved by a short period of rest.
This pain is suddenly
exacerbated, often by a
flexion episode, with the
appearance of leg pain.
8
9. radicular pain= nerve root compression
• Most radicular pain from
nerve root compression
caused by a herniated
nucleus pulposus is
evidenced by leg pain
equal to, or in many cases
much greater than, the
degree of back pain.
9
leg pain>>>> back pain
10. No leg pain
• Whenever leg pain is minimal and back pain
is predominant
• strongly suggests NO herniated intervertebral
disc.??????
10
11. Pattern of pain
• The pain from disc herniation
usually is intermittent, increasing
with activity, especially sitting.
• The pain can be relieved by rest,
especially in the semi Fowler
position, and can be exacerbated
• by straining, sneezing, or coughing.
(Louvel Sign)
11
shooting pain
12. Bizarre or uniform pain
• Whenever the pattern of pain is bizarre, or the
pain is uniform in intensity, a diagnosis of
symptomatic herniated disc
• should be viewed with some skepticism
12
13. Weakness
• Other symptoms of disc herniation include
weakness and paresthesias.
• In most patients the weakness is intermittent,
variable with activity, and localized to the
neurological level of involvement.
13
14. paresthesia
• Paresthesias also are variable and limited to
the dermatome of the involved nerve root.
• Whenever these complaints are generalized,
the diagnosis of a simple unilateral disc
herniation should be questioned.
14
15. High or midline lumbar disc
• Numbness and weakness in the involved leg and
occasionally pain in the groin or testicle can
be associated with a high or midline lumbar disc
herniation.
• If a fragment is large or the herniation is high,
symptoms of pressure on the entire cauda equina
can be elicited. These include numbness and
weakness in both legs, rectal pain, numbness in the
perineum, and paralysis of the sphincters.
15
16. Cauda equina syn
• This diagnosis should be the primary
consideration in patients who complain of
sudden loss of bowel or bladder control.
• Whenever the diagnosis of a cauda equina
syndrome or acute midline herniation is
suspected, evaluation and treatment should
be aggressive.
16
18. Anatomy
• The caudal end of the spinal
cord is the conus medullaris
and is attached to the coccyx
by a thin non-neural filament,
the filum terminale.
• The cauda equina is a
collection of peripheral
nerves (L1 to S5) in a common
dural sac within the lumbar
spinal canal.
•
18
19. The spinal cord
• Terminates as the conus medullaris
• L2 in Adult & L3 in neonates.
• From the conus, a fibrous cord called
• the filum terminale extends to the dorsum of
the first coccygeal segment(C1)
19
21. Limb atrophy
• If the leg pain has persisted for any length of
time. atrophy of the involved limb may be
present.
21
22. • 1.Radicular pain(leg pain>>>> back pain&NO
Bizarre or uniform pain)
• 2. Weakness(intermittent& localized NO
generalized)
• 3. paresthesia(limited to the dermatome&NO
generalized)
• 4. Cauda equina syn
• 5. Limb atrophy( the leg pain persisted for
prolong time)
22
23. PHYSICAL FINDINGS
• .
• .
23
paraspinal spasm during walking
or motion
A scoliosis or a list and in many pts
the normal lumbar lordosis is lost
Point tenderness may be present
over the spinous process at the
level of the disc involved. and in
some patients pain may extend
laterally.
25. PHYSICAL FINDINGS
• 1. paraspinal spasm
•
• 2. A scoliosis or a list
• 3. lost of normal lumbar lordosis
• 4. Point tenderness over the spinous process
at the level of the disc involved
25
26. As the acute episode subsides
• degree of spasm
• the loss of normal lumbar lordosis
• the only telltale
sign.
26
27. • A positive Lasègue sign or straight-leg
• raising should elicit buttock and leg pain
distal to the knee.
• A Lasegue sign usually is positive on the
involved side.
27
28. Lasègue sign or straight-leg
raising
Pain reproduced between 30°
and 70° passive flexion of the
straight leg. Dorsiflexion of the
foot exacerbates the pain
Pain below the knee at less than 70 degrees of
straight leg raising, aggravated by dorsiflexion
of the ankle and relieved by ankle plantar
flexion or external limb rotation, is most
suggestive of tension on the L5 or S1 nerve
root related to disc herniation. Reproducing
back pain alone with SLR testing does not
indicate significant nerve root tension.
28
29. Contralateral straight leg raising
• Contralateral leg pain produced by straight leg
raising should be regarded as pathognomonic
of a herniated intervertebral disc.
29
30. flip test
Occasionally, if leg pain is
significant, the patient leans
back from an upright sitting
position and assumes the
tripod position to relieve the
pain. This is referred to as the
“flip sign.”
30
31. • The absence of a positive Lasègue sign
should make one skeptical of the diagnosis,
although older individuals may not have a
positive Lasègue sign.
31
32. The neurological examination varies
as determined by the level of root
involvement
unilateral rupture of the disc
32
33. • Spinal nerves C2-7 exit above the pedicle for
which they are named (the C6 nerve root exits
the foramen between the C5 and C6 pedicles).
• The C8 nerve root exits the foramen between the
C7
• and T1 pedicles
• . All spinal nerves caudal to C8 exit the
• foramen below the pedicle for which they are
named (the L4 nerve root exits the foramen
between the L4 and L5 pedicles).
33
35. L4 root Compression
• Unilateral disc herniation between L3 and
L4 usually compresses the L4 root .
• 1.Pain may be localized around the medial
side of the leg.
• 2.Numbness present over the anteromedial
aspect of the leg
35
39. Sensory testing the L4 dermatome
, the isolated portion of which is the
medial leg & the autonomous zone
of which is at the level of the medial
malleolus.
39
42. L5 root compression
• Numbness, the anterolateral aspect of the leg
and the dorsum of the foot, including the
• great toe.
• The autonomous zone for this nerve is the
dorsal first web of the foot and the dorsum of
the third toe.
42
44. • Weakness
• -the extensor hallucis longus (L5),
• - gluteus medius (L5),
• -extensor digitorum longus and brevis (L5).
• Reflex change usually is not found. A
diminished posterior tibial reflex is possible
but difficult to elicit.
44
49. S1 Root Compression
• Pain and numbness
• -over the lateral aspect of the leg and, more
important, over the lateral aspect of the foot,
including the lateral three toes.&the heel.
• The autonomous zone for this root is the
dorsum of the fifth toe.
49
52. • Weakness
• -the peroneus longus and brevis (S1)
• -, gastrocnemius-soleus (S1),
• - gluteus maximus (S1).
52
53. • In general, weakness is not a usual finding in
• S1 radiculopathy.
• Occasionally, mild weakness may be shown
• by asymmetrical fatigue with exercise of these
motor groups.
• The ankle jerk usually is reduced or absent
53
56. • more than 95% of
the ruptures of the
lumbar
intervertebral discs
occur at L4 or L5.
56
57. higher levels Disc Ruptures
• not associated with a positive straight-leg
• raising test.
• In these instances, a positive femoral stretch
test can be helpful.
57
58. • The sciatic nerve is formed from the L4 to S3
• The Femoral Nerve is formed from the L2 to
L4
58
59. Femoral Nerve Stretch Test
Prone and acutely flexing the knee,
while placing the hand in the
popliteal fossa. With anterior thigh
pain, the result is positive, and a
high lesion should be suspected.
Tests for nerve root impingement
at L2, L3, L4
59
60. Femoral Nerve Stretch Test
• In addition, these lesions may occur with a
more diffuse neurological complaint without
significant localizing neurological signs.
60
61. • Early symptoms or signs suggesting
• cauda equina syndrome
• or severe progressive neurological deficit
• should be treated aggressively from the onset.
61
62. DIFFERENTIAL DlAGNDSIS
• include diseases of the urogenital system.
Gastrointestinal system , vascular system, endocrine
system, nervous system not localized to the spine,
and the extrinsic musculoskeletal system.
• They include diseases of the spinal musculoskeletal
system,the local hematopoietic system, and the local
neurological system.
• These conditions include trauma,tumors, infections
diseases of aging and immune diseases affecting the
spine or spinal nerves.
62
63. Diseases mimic disc disease
• Common diseases that can mimic disc disease
include ankylosing spondylitis, multiple myeloma,
vascular insufficiency, arthritis of the hip,
osteoporosis with stress fractures ,extradural
tumors, peripheral neuropathy, and herpes zoster.
• Infrequent but reported causes of sciatica not
related to disc hernia include synovial cysts, rupture
of the medial head of the gastrocnemius, sacroiliac
joint dysfunction, lesions in the sacrum and pelvis,
and fracture of the ischial tuberosity.
63
65. Types of disc herniation. A, Normal bulge.
B, Protrusion. C, Extrusion. D, Sequestration
65
66. Plain radiographs
• Plain radiographs are of limited use in the
diagnosis because they do not show disc
herniations or other intraspinal lesions, but
they can show infection, tumors, or
• other anomalies and should be obtained,
especially if surgery is planned.
66
67. • Currently, the most useful test for diagnosing
a herniated lumbar disc is MRI.
• (myelography is used much less frequently),
67
75. 1. Vertebral body
2. Spinal cord
3. Conus medullaris
4. Intervertebral disc
5. Filum terminale
(internum)
6. Subarachnoid
space
Lower Third of Spinal Cord, MRI
75
76. Sagittal Section through the Spinal Cord
1. Intervertebral disc
2. Vertebral body
3. Dura mater
4. Extradural or epidural
space
5. Spinal cord
6. Subarachnoid space
7, The pia mater
76
The pia and arachnoid membranes
are separated by the subarachnoid space
77. NONOPERATIVE TREATMENT
• The simplest treatment
for acute back pain is
rest.
• 2 days of bed rest were
better than a longer
period.
• lying in a semi- Fowler
position (i.e., on the
side with the hips and
knees flexed) with a
pillow between the legs
77
78. • Muscle spasm can be controlled by the
application of ice, preferably with a massage
over the muscles in spasm.
• Pain relief and antiinflammatory effect can be
achieved with nonsteroidal antiinflammatory
drugs (NSAIDs).
78
80. As the pain diminishes
• 1.the patient begin isometric abdominal and
lower extremity exercises.
• 2.Walking within the limits of comfort also is
encouraged.
• 3.Sitting, especially riding in a car, is discouraged.
• 4. Continuation of ordinary activities within the
limits permitted by pain has been shown to lead
to a quicker recovery.
80
81. medications
• Oral steroids used briefly can be beneficial as potent
antiinflammatory agents.
• The many types of NSAIDs also are helpful when
aspirin is not tolerated or is of little help.
• When depression is prominent, mood elevators
such as nortriptyline can be beneficial in reducing
sleep disturbance and anxiety without increasing
depression. Nortriptyline also decreases the need for
narcotic medication.
81
The current trend seems to be moving away from the use of
strong narcotics and muscle relaxants in the outpatient treatment of
subacute and chronic back and leg pain syndromes.
82. Prevention
• Back school approach-
– Causes of HNP
– Learn how to prevent
– Good body mechanics
– Exercises to strengthen leg and abdominal muscles
• Change in life-style or occupation
82
84. Physical therapy
• Physical therapy should be used judiciously
• The exercises should be fitted to the
symptoms and not forced as an absolute
group of activities.
84
85. • Patients with acute back and thigh pain eased by
passive extension of the spine in the prone position
can benefit from extension exercises rather than
flexion exercises.
• Improvement in symptoms with extension is
indicativc of a good prognosis with conservative care.
• On the other hand. patients whose pain is increased
• by passive extension may be improved by fllexion
exercises.
• These exercises should not be forced in the face of
increased pain.
85
90. • Although low-back pain can result in
significant disability, approximately 95% of
• patients return to their previous employment
within 3 months of symptom onset.
• Failure to return to work within 3 months
• has been identified as a poor prognostic sign.
90
91. • Obesity and smoking have been shown to
correlate unfavorably with low back pain and
may adversely affect the progression of
• symptoms.
91
92. OPERATIVE TREATMENT
• 1.Before this step is taken, the surgeon must be
sure of the diagnosis
• 2.The patient must be certain that the degree of
pain and impairment warrants such a step.
• 3. The surgeon and the patient must realize
• that disc surgery is not a cure but may provide
symptomatic relief.( It neither stops the pathological
processes that allowed the herniation to occur nor restores
the disc to a normal state.)
92
93. • 4. The patient still must practice good posture
and body mechanics after surgery.
• 5. Activities involving repetitive bending,
twisting, and lifting with the spine in flexion may
have to be curtailed or eliminated.
• 6. If prolonged relief is to be expected, some
permanent modification in the patient’s lifestyle
• may be necessary, although often no specific
limitations are applied.
93
99. • The key to good results in disc
surgery is appropriate patient
selection.
99
100. OPERATIVE TREATMENT
• The optimal patient is
• 1.one with predominant, unilateral leg pain
extending below the knee that has been
present for at least 6 weeks.
• 2.The pain should have been decreased by
rest, antiinflammatory medication, or even
epidural steroids but should have returned to
the initial levels after a minimum of 6 to 8
weeks of conservative care
100
101. • CT, lumbar MRI, or myelography should
confirm the level of involvement consistent
with the patient’s examination.
101
102. Urgent vs elective
• Operative disc removal is mandatory and
urgent only in patients with cauda equina
syndrome;
• other disc excisions should be considered
elective
102
103. • Frequently, if there is a rush to the
operating room to relieve pain without
proper investigation, the patient and the
physician later regret the decision.
103
104. the patient aware
• Regardless of the method chosen to treat a
disc rupture surgically, the patient should be
aware that ;
• 1.the procedure is predominantly for the
symptomatic relief of leg pain.
• 2.Patients with predominantly back pain may
not experience relief.
104
107. Knee-chest position
To position the patient in a
modified kneeling position,
.Positioning the patient in this
manner allows the abdomen to
hang free, minimizing epidural
venous dilation and bleeding
107
108. Micro lumbar disc excision
• Micro lumbar disc excision has replaced the
standard open laminectomy as the procedure
of choice for herniated lumbar disc.
• This procedure can be done on an
outpatient& less postoperative pain and a
shorter postoperative stay.
108
109. • 1.Make the incision from the midspinous
process
• 2.hemostasis with electrocautery
• 3.Infiltrate the operative field with 30 mL of
0.25% bupivacaine with epinephrine
• 4. Incise the fascia at the midline using
electrocautery
109
111. • 5. elevate the deep fascia and muscle
• subperiosteally from the spinous processes
and lamina, on the involved side only.
• 6. Obtain a lateral radiograph with a metal
clamp attached to the spinous process to
verify the level.
111
112. • 7. Using a Cobb elevator exposing the
• interlaminar space and the edge of each
lamina
• 8. Identify the ligamentum flavum and
lamina. Use a pituitary rongeur to remove the
superficial leaf of the ligamentum.
112
114. • 9. Detach the lateral portion of the
ligamentum flavum from the caudal edge of
the superior lamina and the cephalad
• edge of the inferior lamina by Kerrison
rongeur(Care should be maintained
• to orient the Kerrison rongeur parallel to the nerve
root as much as possible.)
114
116. • 10. The lamina, facet, and facet capsule
should remain intact. Remove the ligamentum
• flavum and bone from the lamina as needed,
• however, to identify the nerve root clearly
116
118. • 11. When the nerve root is identified,
carefully mobilize the root medially; this may
require some bony removal.(If the root is
difficult to
• mobilize, consider that a conjoined root may be
present.)
• 12. Follow the root to the pedicle if
necessary to be certain of its location
118
120. • 13. With the nerve root retracted, the disc now
is visible .
• 14. Enlarge the annular tear, and remove the disc
material with the microdisc forceps
• (Do not insert the instrument into the
• disc space beyond the angle of the jaws, which
usually is about 15 mm, to minimize the risk of
anterior perforation and vascular injury.)
120
123. • 15. Forcefully irrigate the disc space using a
Luer-Lok syringe and 18-gauge spinal
• needle inserted into the disc space.
• 16. Close the fascia and the skin in the usual
fashion, using absorbable sutures
123
124. If the expected pathological process is
not found
• Review preoperative imaging studies for the
correct level and side.
• Also obtain a repeat radiograph with a
metallic marker at the disc level to verify the
level.
• Be aware of bony anomalies that may alter
the numbering of the vertebrae on imaging
studies.
124
126. POSTOPERATIVE CARE
• Postoperative care is similar to that after
standard open disc surgery.
• Typically, this procedure is done on an
outpatient basis
126
127. RUPTURED LUMBAR DISC EXCISION
• This procedure is most often used for
recurrent herniation but can be used in
primary disc excisions.
127
the standard open laminectomy
128. the standard open laminectomy
• The lumbosacral interspace (L5-S1)commonly
is large enough to permit exposure and
removal of a herniated nucleus pulposus
without removal of any bone.
• If not, remove a small part of the inferior
margin of the L5 lamina..(L5-S1)
128
129. the standard open laminectomy
• Exposure of the disc at higher levels usually
requires removal of a portion of the inferior
lamina. L2&L3 laminectomy L3
• the root is more posterior than is normal
because of the displacement caused by the
herniated disc fragment
129
131. the standard open laminectomy
• If the herniated fragment is especially large,
it is much better to sacrifice a portion of the
facet to obtain a more lateral exposure than to
risk injury to the root or cauda equina by
excessive medial retraction
131
132. the standard open laminectomy
• If the fragment is very large, as with cauda
equina lesions typically, a bilateral
laminectomy is preferred to allow safer
removal.
• If the disc cannot be teased from under the
root, make a cruciate incision in the disc
laterally.
132
133. the standard open laminectomy
Unilateral
laminectomy
Facetectomy
Bilateral
laminectomy
133
136. the standard open laminectomy
• Close the wound with absorbable sutures in
the supraspinous ligament and subcutaneous
tissue.
• Staples are avoided for patient comfort.
• After closure of the lumbodorsal fascia, inject
an additional 25 mL of 0.25% bupivacaine into
the paraspinal musculature
136
137. POSTOPERATIVE CARE
• Neurological function is closely monitored
after surgery.
• The patient is allowed to turn in bed at will
and to select a position of comfort, such as a
semi-Fowler position.
137
138. the standard open laminectomy
• The patient is allowed to stand with
assistance after surgery to go to the
bathroom.
• Discharge is permitted when the patient is
able to walk and void
138
139. The patient is instructed
• 1.to minimize sitting and riding in a vehicle to
comfort.
• 2. Increased walking on a daily basis is
recommended.
• 3.Lifting, bending, and stooping are limited
• for the first several weeks.
• 4.As the patient’s strength increases, gentle
isotonic leg exercises and stretching are
• started.
139
140. • Lifting, bending, and stooping are
gradually restarted after the third week.
• Increased sitting is allowed as pain
• permits, but long trips are to be avoided for at
least 4 to 6 weeks.
140
141. return to work
• 1. jobs requiring much walking without
lifting return to work within 2 to 3 weeks.
• 2. jobs requiring prolonged sitting return to
work within 4 to 6 weeks
• 3. jobs requiring heavy labor or long
periods of driving return to work until 6 to 8
weeks.
• 4. jobs requiring heavy manual labor modify
their occupation permanently or seek a lighter
occupation.
141
142. • Keeping the patient out of work
beyond 3 months rarely improves recovery or
• pain relief.
142
144. ADDITIONAL EXPOSURE TECHNIQUES
• 1.hemilaminectomy,(is required when
identifying the root as a problem.e.p
conjoined root..)
• 2.total laminectomy(spinal stenoses that are
central, which occur typically in cauda equina
syndrome.)
• 3.facetectomy.(foraminal stenosis or severe
lateral recess stenosis.)
144
146. Spinal Stenosis
• Grouped as “spinal
stenosis”
– Central stenosis
• Narrowing of the central
part of the spinal canal
– Foraminal stenosis
• Narrowing of the foramen,
resulting in pressure on the
exiting nerve root
– lateral recess stenosis
• Narrowing of the lateral part
of the spinal canal
146
151. When fusion?
• 1.If more than one facet is removed, a
fusion should be considered in addition.
• (removal of facets and the disc at
• the same interspace in a young, active
individual with a normal disc height at that
level.)
151
152. TRANSDURAL APPROACH
Rarely, disc herniation has been reported to be
intradural.
An extremely large disc that cannot be dissected
from the dura or the persistence of an
intradural mass after dissection of the disc
should alert one to this potential problem.
Excision of an intradural disc requires a
transdural approach.
152
153. Sagittal Section through the Spinal Cord
1. Intervertebral disc
2. Vertebral body
3. Dura mater
4. Extradural or epidural
space
5. Spinal cord
6. Subarachnoid space
7, The pia mater
153
The pia and arachnoid membranes
are separated by the subarachnoid space
154. far lateral disc
• may require exposure outside the spinal canal
by removing the intertransverse lig between
the superior and inferior
• transverse processes
• lateral to the spinal canal.
The disc hernia usually is anterior to the nerve
root that I found in a mass of fat below the
intertransverse ligament. microsurgical
approach is a good method for dealing with
this problem.
154
156. The far lateral approach
The far lateral
(Wiltse) approach involves resection
of the lateral aspect of the pars
interarticularis and facet joint at the
L4-5 level on the left side of the
spinal canal. This approach also
requires removal of the
intertransverse ligament and fascia.
This exposure provides
visualization of the foraminal, far
laterally exiting, superior L4 nerve
root and dorsal root ganglion that
typically overlie the sequestrated
disk herniation.
156
157. Intertransverse approach
Intertransverse approach involving the left L4-5
level. Specifically, this warrants anextended L4
laminotomy, routine Inferior laminotomy, medial
facetectomy-foraminotomy, and
partial resection of the lateral
aspect of the L4-5 facet, including
shaving down of the pars
interarticularis. This provides
visualization of both the foraminal,
far laterally exiting L4 nerve root
superiorly and the inferiorly exiting
L5 nerve root and thecal sac.
157
159. the far lateral compartment
• superiorly by the pedicle,
• anteriorly by the disk,
• medially by the vertebral body and superior
articular facet,
• laterally by fat
159
160. LUMBAR ROOT ANOMALIES
• Several different types of nerve root
anomalies
• are relatively common in anatomical studies
• but less common with imaging studies,
160
161. types of nerve root anomalies
• 1.Conjoined nerve roots(the most common
type of anomaly.)
• 2.furcal nerve root(bifurcation of a single
nerve root)
161
162. • These congenital anomalies may account for a
portion of the poor results from lumbar disc
surgery because the abnormal
• and unrecognized roots may be injured.
• Conjoined nerve roots are the most common
type of anomaly.
162
163. • Type 1 occurs when two roots exit the dura
with one common sheath
• type 1A anomalies, the cephalad root departs
• the conjoined stalk at an acute angle to exit
below the appropriate pedicle
• type 1B anomaly the cephalad root
• exits at 90 degrees from the conjoined
portion, this is a type
163
165. • Type 2 anomalies occur when two roots exit
through a single foramen.
• Type 2A anomalies have one vacant foramen;
type 2B anomalies have a portion of one of
the roots exiting via the other foramen, which
may be cephalad to the foramen occupied by
the two nerve roots.
165
168. • Type 3 anomalies occur when there is an
anastomosing branch between two
• adjacent nerve roots.
• This branch crosses the disc space and
• can easily be injured during discectomy.
168
170. • The most common
location for conjoined
roots involves the L5
and S1 levels
170
171. • These root anomalies can cause false-positive
interpretations of imaging studies and can be
confused with disc bulges or herniations
• Also, if a patient presents with a history of
failed disc surgery, this diagnosis should be
• considered.
171
172. FURCAL NERVE ROOT
• A second type of
anomaly that may be as
common as conjoined
roots is a furcal nerve
root.
• this refers to a
bifurcation of a single
nerve root. Often furcal
roots are bilateral and
can occur at multiple
levels 172
176. factors affecting final outcome
• 1.low educational level is significantly
• correlated to poor results of surgery
• 2.The duration of the current episode,
• 3.the age of the patient,
• 4. the presence or absence of predominant
• back pain,
• 5. the number of previous hospitalizations
• 6.the presence or absence of compensation for a
work injury
176
177. Operative vs nonoperative
• Patients treated operatively had far less pain,
better physical function, and less disability
than patients who did not have surgery
177
178. COMPLICATIONS OF DISC EXCISION
• The complications associated with standard
disc excision and micro lumbar disc excision
are similar
• 1.Mortality(0.1%)
• 2.thromboembolism (1%, )
• 3.postoperative infection(3.2%)
• 4.deep disc space infection (1.1%)
• 5. Postoperative cauda equina lesions
178
179. complications after reoperation
• 1.Dural tears with CSF leaks,
2.pseudomeningocele formation,
• 3.CSF fistula formation,
• 4. meningitis
• This complications in micro lumbar disc
excision seem to be less than with standard
• laminectomy.
179
180. Dural tears& repair
• 1. The operative field must be unobstructed,
dry, and well exposed.
• 2. Dural suture of a 4-0 or 6-0 gauge with a
tapered or reverse cutting needle is used in a
simple or a running locking stitch.( If the leak is
large or inaccessible, a free fat graft or fascial graft can be
sutured to the dura. Fibrin glue applied to the repair also is
helpful but used alone does not seal a significant leak)
180
181. Dural tears& repair
• 3. All repairs should be tested by using the
reverse Trendelenburg position and Valsalva
maneuvers.
• 4. Paraspinous muscles and overlying fascia
should be closed in two layers with
nonabsorbable suture used in a watertight
fashion. Drains should not be used.
181
182. Dural tears& repair
• 5. Bed rest in the supine position should be
maintained for 4 to 7 days after the repair of
lumbar dural defects.
• 6. A lumbar drain should be placed if the
integrity of the closure is questionable
182
183. Dural tears& repair
Dural repair using running-locking dural
suture on taper or reverse-cutting,
one-half-circle needle. Smaller sized
suture should be used. Use of suction
with sucker and small cotton pledgets is
essential to protect nerve roots while
operative field is kept dry of
cerebrospinal fluid.
183
184. leak is large
Single dural stitches can be used to achieve
closure, each suture end being left
long. Second needle is attached to free
suture end, and ends of suture are passed
through piece of muscle or fat, which is tied
down over repaired tear to help achieve
watertight closure.
Whenever dural material is inadequate to
allow closure without placing excessive
pressure on underlying neural tissues, free
graft of fascia or fascia lata or freeze-dried
dural graft should be secured to margins of
dural tear using simple sutures of
appropriate size.
184
185. inaccessible areas
For small dural defects in relatively inaccessible
areas, transdural approach can be used to
pull small piece of muscle or fat into defect from
inside out, sealing CSF leak. Central durotomy should
be large enough to expose defect from dural sac.
Durotomy is closed in standard watertight fashion
185
186. Fibrin glue
• Fibrin glue also can be used in areas of
troublesome bleeding or difficult access for
closure, such as the ventral aspect of the
• dura.
186
187. postoperative headache??
• The development of headaches on standing
and a stormy postoperative period should
alert one to the possibility of an undetected
CSF leak. This can be confirmed by MRI
• The presence of glucose in drainage fluid is an
unreliable diagnostic test.
187
188. • Rarely, a pseudomeningocele has been
implicated as a cause of persistent pain from
pressure on a nerve root by the cystic mass.
• With good closure, patients can be mobilized
the day after surgery.
• If closure is not watertight, extended bed rest
with a drain may be helpful.
188
190. FREE FAT GRAFTING
• Fat grafting for prevention of postop epidural
scarring superior to Gelfoam .
• Neither the benefit of reduced scarring
• nor the prevention of postoperative pain
• nor increased ease of reoperation
• whom fat grafting was performed has been
established
190
191. large laminar defect?
• Caution should be taken in applying a fat
graft to a large laminar defect
• This has been reported to result in an acute
cauda equina syndrome in the early
postoperative period.
191
because
192. Indication fat graft (or fascial grafts)
• We currently reserve the use of a fat graft (or
fascial grafts) for dural repairs and
• small laminar defects where the graft is
supported by the bone.
192
193. FAT GRAFTING
• A study by Jensen et al. found that fat grafts
decreased dural scarring but not radicular scar
formation. The clinical outcome was not
improved.
193
194. Recurrent lumbar disc
• Incidence 3% to 7% of patients.
• Making the diagnosis of recurrent disc
herniation is significantly more difficult than
that of primary disc herniation
• The clinical presentation identical primary
herniation but larger component of axial pain.
194
195. Recurrent lumbar disc
• Most recurrences happen in the relatively early
postoperative period—primarily the first 6
months after surgery.
• To date, no operative technique has been shown
to reduce the incidence of recurrent disc
herniations
• Specifically, more aggressive disc removal
• does not reduce this complication and may be
detrimental to the function of the motion
segment
195
196. diagnosis
• MRI with intravascular contrast material
has been helpful in identifying recurrent
• herniations.
• It is difficult, however, to distinguish a
peridural scar from a small recurrent
herniation
196
197. 197
Axial T1-weighted image without contrast of
recurrent disc herniation. It is difficult to
differentiate between scar and disc fragment
in this image
Contrastenhancedimage demonstrating lack
of enhancement of soft-tissue suggestive of
recurrent disc herniation.
200. • The accuracy of imaging studies in
distinguishing whether the mass
• is disc or scar tissue is of some concern,
because the results of reoperation for
excision of scar tissue are generally poor
200
202. surgery for recurrent herniation
• principles of are the same as for a primary
• discectomy. But exposure generally should be
larger.(No microsurgery)
• Spinal fusion is not done unless an unstable
spine is created by the dissection or was
identified preoperatively as a correctable and
symptomatic problem.
202
203. DISC EXCISION AND FUSION
• The indications for lumbar fusion should be
independent of the indications
• for disc excision for radiculopathy.
• Some studies indicate that spinal fusion
increases the complication rate and lengthens
recovery
203
205. • Current research shows that genetic factors
are more important than the mechanical
stresses that have long been emphasized.
• the degenerative process is fundamental to
the development of disc herniations
• The development of a disc herniation is only
one of the pathways that the degenerative
disc may follow.
205
206. The pathways of the degenerative disc
DEGENERATIVE DISC
DISEASE(spondylosis) Disc
herniations
Spinal
Stenosis
NL
DISC
INTERNAL DISC
DERANGEMENT
genetic
factors
The Aging
Root Nerve
Compression
206
207. Degenerative Disease
• Occurs at all levels of
the spine
• Asymptomatic degeneration
in majority of the
population
Normal Degenerative
207
208. Degenerative Disease
• The spinal structures
most affected by
degenerative
disease are
– Intervertebral discs
– Articular facet joints
• These conditions is
referred to as
“spondylosis
208
209. Degenerative Disease
• A diagnosis of spondylosis
usually requires confirmation by radiologic
examination, but biochemical and
histological changes occur long before
symptoms or identifiable anatomic changes
are present Based on radiologic findings,
degenerative disc disease (DDD) may be
classified into stages of progression
209
210. I
II
III
IV
V
V
The Aging Disc
– Loss of cells
– Loss of H20/ proteoglycans
– Type II/ Type I collagen
– Annular fissures
– Mechanical incompetence
– Bony changes
210
212. Discogenic Pain
• Alternatively, the disc may become the
primary source of pain, rather than the
• nerve root, as is the case with herniations.
• This discogenic type of pain is most
attributable to the internal disc derangement
• (IDD) that accompanies the degenerative
process.
212
213. The internal disc derangement
Discogenic Pain
• Discogenic pain is pain
originating from the disc
itself; an internally
disrupted disc may result in
disc material causing
chemical irritation of nerve
fibers
213
214. The pathways of the degenerative disc
DEGENERATIVE DISC
DISEASE(spondylosis) Disc
herniations
Spinal
Stenosis
NL
DISC
INTERNAL DISC
DERANGEMENT
genetic
factors
The Aging
Root Nerve
Compression
214
215. • Correct diagnosis and treatment of
painful degenerative discs are difficult and
controversial.
215
217. • The indication for most of fusions in US
• is IDD.
• The sole indication for disc replacement
prostheses or nucleoplasty currently is to treat
symptomatic degenerative disc disease.
• There are multiple devices and models for
“dynamic stabilization,” only some of which
are for the treatment of IDD.
217
218. diagnosis
• Treatment is controversial because no
consensus of diagnostic criteria exists.& few
prospective randomized data exist on
• outcomes for the numerous operative or
nonoperative treatment options.
218
219. • The understanding of pain and mechanisms
• that lead to inflammatory and mechanical
pain is continually improving
219
220. Degenerative Disc Disease
• Surgical care
– Failure of nonoperative treatment
• Minimum of 6 weeks
– Fusion or dynamic stabilization procedures
• Removal of disc and replacement with bone graft, or a cage-
filled bone graft, or a bone graft substitute
– Anterior approach
– Posterior approach
– Combined approach
– Arthroplasty or nucleoplasty
• Articulating disc replacement
220
223. technique of localizing the pedicle
• The intersection technique is perhaps the
most
• commonly used method of localizing the
pedicle. It involves dropping a line from the
lateral aspect of the facet joint, which
intersects a line that bisects the transverse
process at a
• spot overlying the pedicle
223
224. • The pars interarticularis is the area of bone
where the pedicle connects to the lamina.
• Because the laminae and the pars
interarticularis can be identified easily at
surgery, they provide landmarks
• by which a pedicular drill starting point can be
made.
224
225. • The mammillary process technique is based
on a small prominence of bone at the base of
the transverse process.
• This mammillary process can be used as a
starting point for transpedicular
• drilling
225
226. Posterior Lumbar Fusion
• Posterolateral fusion (PLF)
– spondylolysis
without disc involvement
– Usually includes the use of
screws/rods for stabilization
until the fusion occurs
dynamic stabilization procedures
226
227. Posterior Lumbar Fusion
• Posterior lumbar interbody fusion (PLIF)
– Used with disc involvement in conjunction with PLF
– Usually includes the use of screws/rods for stabilization until the
fusion occurs
– Bone graft
– Cages
PLIF
PLF
227
228. Posterior Lumbar Fusion
• Transforaminal lumbar interbody fusion (TLIF)
– Used with disc involvement with or without PLF
– Usually includes the use of screws/rods
for stabilization until the fusion occurs
– Bone graft/cages
– Less soft-tissue and bone trauma
228
229. Anterior Lumbar Fusion
• Anterior lumbar interbody fusion (ALIF)
– Used with disc involvement primarily with, but sometimes without,
PLF
– Bone graft/cages
229
231. Lumbar Arthroplasty
• Total disc replacement (TDR)
– DDD(The sole indication symptomatic degenerative disc
disease.)
– Contraindicated for spondylolisthesis and
spondylolysis
The CHARITÉ Artificial Disc is
indicated for spinal arthroplasty in
skeletally mature patients with
DDD at one level from L4-S1.
231
232. Total disc replacement
TDR:The facets should be essentially
normal & NO significant disc space
narrowing(spondylolysis ) &NO
osteoporosis
Contraindicated for spondylolisthesis
and spondylolysis& osteoporosis 232
233. INTERNAL DISC DERANGEMENT
• Current understanding of IDD defines
this as a pathological condition resulting in
axial spine pain with no or minimal
deformation of spinal alignment or disc
contour.
• There are no defined criteria for IDD,
• however.
233
234. Discogenic Pain
• Discogenic pain is pain
originating from the disc
itself; an internally
disrupted disc may result in
disc material causing
chemical irritation of nerve
fibers
234
235. DX
• Because there are no pathognomonic
findings for IDD, the diagnosis requires a
compilation of findings consistent with IDD
and elimination of other diagnostic
possibilities.
• Foremost among the consistent findings is the
history.
235
236. history
• 1.Patients usually are relatively young, in the
third to sixth decades of life.
• 2.Pain usually is chronic with symptoms
present for several years, (although the pain may
have become constant or very frequent only in the previous
several months. )
236
237. history
• 3.The pain is axial primarily, often with
buttock and posterior thigh (sclerotomal)
pain.(Pain distal to the knee indicates either
different or coexistent pathology.)
• 4. Positions and activities that increase
intradiscal pressure, such as sitting or flexion,
should exacerbate the symptoms
237
238. history
• 5.Likewise, recumbency, especially in the
• fetal position, often decreases the pain.
• 6.This pattern of variable pain intensity is
important and must be elicited carefully because
the patient usually describes the pain only as
constant.(Pain that is constant but has little or no variation
• in intensity or only random fluctuations probably is not
• caused by IDD)
238
239. Examination
• 1.Examination reveals no weakness or reflex
changes if IDD is the only diagnosis.
• 2.Straight-leg raising typically causes
• back and buttock pain but no pain distal to the
knee.
239
240. Examination
• 3.There is no spasm in the paraspinal
musculature, and extension usually gives
some relief temporarily.
• 4.The patient often has a depressed mood
and should be questioned about changes or
• stresses at work and at home.( If the patient has
identified significant stresses, anger, or anxiety, the
diagnosis of IDD is in question.)
240
241. Examination
• 5.Also, examination for Waddell signs
should be included and if three or more are
present, an alternative diagnosis is more likely.
241
243. Imaging studies
• lumbar spine series and dynamic films to
assess deformities, measurable instability,
• or destructive lesions.
• Additionally, MRI of the lumbar spine should
show diminished water content in the
• nucleus of one or more lumbar discs
243
244. • Decreased water content leads to decreased
signal intensity best seen on T2-weighted
sagittal images.
• This finding alone has no diagnostic value,
unless the appropriate history and physical
examination also are present and there is no
other discernible diagnosis.
244
246. treatment options
• Most patients can be treated without
operative intervention.
• especially if they are educated their pain, is
not relentlessly progressive generally, and
that continued pain does not equate with
progressive deterioration or disability
246
247. • A small group may benefit from operative
intervention
• Before operative the pt should be informed
that surgery leads to improvement in
• only 65%, leaving about 35% no better or
possibly worse with respect to axial spine
pain.
247
248. “abnormal illness behaviors
• patients with chronic pain and suggested that
the presence of three or more was required to
show abnormal illness behavior.
248
250. PATIENT SELECTION PROCESS
• Although these signs and symptoms cannot
• be used to predict return to work, the
presence of multiple Waddell signs
correlates with poor operative outcome and
• may temper the decision to offer a particular
patient operative consideration.
250
251. IDD treatment
• We recommend that patients being
considered for operative treatment with the
diagnosis of IDD have formal psychological
testing, which at our clinic consists of the
MMPI
DIFFERENTIAL SPINAL ANESTHETIC
251
252. IDD treatment
• The current version of this test has predictive
• value for failure of operative treatment but
has no predictive value for successful
operative treatment.
DIFFERENTIAL SPINAL ANESTHETIC
252
253. DIFFERENTIAL SPINAL ANESTHETIC
• Is based anatomically on the relationship
between nerve fiber size,conduction velocity,
and fiber function.
253
255. • The fiber diameter is the most critical physical
dimension.
• The type A fibers are myelinated and
subdivided into alpha, beta, gamma, and delta
subtypes, each with different functions.
• Also, the unmyelinated B and C fibers serve
different functions.
255
256. DIFFERENTIAL SPINAL ANESTHETIC
• The basic concept of the differential spinal is
• that by sequentially administering a local
anesthetic agent, a predictable sequence of
functional loss, beginning with sympathetic,
• then sensory, and finally motor blockade, is
seen.
256
258. • The solutions should be referred to as “A”
through “D” to avoid the term “placebo”
• in front of the patient.
258
259. • Solution A—contains no local anesthetic and
serves as placebo.
• Solution B—contains 0.25% procaine,
Sympathetic blockage
• Solution C10 mL of 0.5% procaine Sensory
blockage
• Solution D 4 mL of 5% procaine Motor
blockage(block all fiber types.)
259
260. PSYCHOGENIC PAIN
• If solution A relieves the patient’s
pain(Clinically, be differentiated From the
placebo reaction is short lived and self-
limiting, whereas pain relief provided by an
inactive agent in a patient with true
• psychogenic pain usually is long lasting, if not
permanent.)
260
261. SYMPATHETIC PAIN(B (unmyelinated))
• If solutionB relieves the patient’s pain is
classified as sympathetic(without signs of
sensory block.)
• This fortunate dx because it may be
• treatable with sympathetic blocks, especially if
diagnosis and treatment are started early.
261
262. SOMATIC PAIN(A delta and C type
fibers)
• If solution C relieves the patient’s pain.
• This is important because if the patient had a
decreased sensitivity for B fibers, pain relief at
the 0.5% concentration is from delayed
• sympathetic block rather than sensory block.
262
263. CENTRAL PAIN
• If the 5% dose(Solution D) gives pain relief,
the mechanism is still considered somatic and
it is presumed that the patient
• has a decreased sensitivity for A delta and C
fibers.
• If the patient fails to obtain relief despite
complete blockade, the pain is classified as
“central” in origin.
263
264. SOMATIC PAIN VS CENTRAL PAIN
• Solution D relieves the patient’s pain
• (SOMATIC PAIN decreased sensitivity for A
delta and C fibers.)
• Solution D NO relieves the patient’s pain
• (CENTRAL PAIN)
264
265. CENTRAL PAIN
• This is not a specific diagnosis and may
indicate one of four possibilities,
• (1) a central lesion
• (2) psychogenic pain,
• (3) encephalization,
• (4) malingering
265
267. central mechanism VS malingering
• Empirically previous placebo reaction from
solution A followed by no relief from solution
D strongly suggests a central mechanism
is not malingering .
267
268. Spinal Blockade
sympathetic sensory motor
Solution B
Solution C Solution D
Solution A (placebo)
SYMPATHETIC PAIN(B (unmyelinated)) SOMATIC PAIN(A delta and C type fibers)
SOMATIC PAIN decreased sensitivity for A delta and C fibers
Solution D
CENTRAL PAIN
PSYCHOGENIC PAIN
+ +
+
_
+
fortunate dx
_
_
268
269. MODIFIED TECHNIQUE
• The modified technique requires only two
solutions: normal saline and 5% procaine
• FIRST , 2 mL N/S is injected & observations.
• If no or only partial relief
• SECOND 2 mL of 5% procaine is
injected,&placed supine
269
270. INTERPRETATION
• 1.If the pain is relieved with the
saline(psychogenic)
• 2. If the patient does not obtain relief with the
5% procaine,(central)
• 3. If the patient obtains complete pain relief
• after the 5% procaine, (organic OR somatic)
(decreased sensitivity for A delta and C fibers)
270
271. • 4. If the pain returns when the patient again
appreciates pinprick as sharp (recovered from
analgesia), somatic
• 5. If pain relief persists for a prolonged time
after recovery from analgesia(sympathetic.)
271
272. benefit of this procedure
(DIFFERENTIAL SPINAL ANESTHETIC)
• Identification of a patient with true
psychogenic or central mechanism of pain
and avoiding any further operative
interventions is very advantageous to a
patient who is highly likely to have a poor
outcome ..
272
273. FAILED SPINE SURGERY
• One of the greatest problems in orthopaedic
surgery and neurosurgery is the treatment of
failed spine surgery.
• The best results from repeat surgery in pts who
• 1. have 6 months or more of complete pain relief
after the first procedure
• 2. when leg pain exceeds back pain
• 3.when a definite recurrent disc can be identified.
273
274. total disc replacement VS solid arthrodesis
• The reason for TDR interest is
• motion-preserving technique reduces
adjacent motion segment degeneration.
• BUT Serious questions remain in regard to
this technology, however??
274
275. solid arthrodesis
anterior lumbar antibody fusion with
radiolucent threaded cages
Posterolateral fusion with autologous bone
and pedicle screw
The ultimate goal in each type of surgery is a solid
arthrodesis. no superiority between various
techniques for spinal arthrodesis
275
276. Total disc replacement
TDR:The facets should be
essentially normal & NO significant
disc space narrowing &NO
osteoporosis
276
278. • Satisfactory results from reoperation 31% to
• 80%
• complications three to five times higher than
for primary surgeries.
278
279. • Patients should expect improvement in the
severity of symptoms, rather than complete
relief of pain.
279
280. • The recurrence or intensification of pain
in the subacute or late period after disc
surgery should be treated with the usual
conservative methods initially.
280
281. • If these methods fail to relieve the pain, the
patient should be completely reevaluated.
• 1.repeat history and physical examination
• 2.psychological testing
• 3., myelography
• 4. MRI to check for tumors or a higher disc
herniation
• 5. CT scans to check for areas of foraminal
stenosis or for lateral herniation
281
282. Cosider in reoperation
• Psychological problem
• anatomical problem(imoprtant)
• Pseudarthrosis, instability,
• recurrent herniations
282
283. COCCYGEAL PAIN
• Pain in the region of the coccyx is referred to
as coccydynia or coccygodynia.
• The most common causes direct axial
trauma &a subtle form of cumulative trauma
that occurs due to long periods of sitting.
283
287. • Obese patients have mainly posterior
subluxation,
• normal-weight patients have mainly a
hypermobile or radiographically normal
coccyx,
• thin patients have mainly anterior
subluxation and spicules.
287
288. • The most common presenting complaint is
pain in and around the coccyx without
significant low-back pain or radiation
• or referral of pain.
• Typically, the pain is associated with
• sitting and is exacerbated when rising from a
seated position.
288
289. • Although coccydynia is a clinical
• diagnosis, imaging studies are helpful in the
evaluation
• Radiographs obtained with the patient sitting
and standing are most useful because they
allow measurement of the sagittal rotation of
the pelvis and the coccygeal angle of
incidence
289
291. treatment for coccydynia
• Nonsurgical methods such as NSAIDs and use
of a donut cushion remain the standard initial
treatment for coccydynia and are successful in
approximately 90% of patients.
291
292. • When these methods fail to relieve pain,
we have had success in reducing or
eliminating coccygeal pain with the injection
of a local anesthetic and corticosteroids under
fluoroscopic guidance (target
• the distal third of the coccyx.)
292
293. • Excision of the mobile segment or total
coccygectomy may be indicated for patients in
whom conservative management fails.
• Outcomes of surgery are good those with
radiographic evidence of hypermobility or
subluxation; but not as good in patients with
normal coccygeal mobility
293
