Surgery for back pain
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Presented by: Dr Paul Licina — Spine Surgeon Event: Mackay GP & Allied Health Education Day - 2014
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Surgery for low back pain
The document discusses different types of spine surgery for low back pain, including discectomy for disc herniation and fusion surgery. Discectomy has good outcomes, with patients typically able to return to sedentary duties in 3 weeks and sports in 6 weeks, and a 90-95% success rate. Fusion surgery results are not as good for low back pain compared to discectomy or when done for deformities or instability. Fusion may be suitable for patients with a specific diagnosis, clearly defined pain source, who are otherwise healthy candidates and have no psychosocial issues. The technique used should match the underlying pathology.
Surgery for back pain
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Surgery for Lower Back Pain
This document discusses different types of back surgery for low back pain, including discectomy and spinal fusion. It provides details on discectomy for disc herniation, including causes, symptoms, prerequisites for surgery, expected outcomes, and the surgical procedure. For spinal fusion, it notes the procedure is generally only good for low back pain if there is a specific diagnosis, clearly defined pain source, suitable patient candidate without psychosocial factors, and an appropriate surgical technique is used to address the underlying pathology. Results are not as good for fusion compared to discectomy or for non-specific low back pain. The document also discusses factors that make a patient suitable or unsuitable for fusion surgery.
Causation and decision making
The document discusses factors that contribute to spinal compensation issues and determining whether back pain is work-related or requires surgery. It notes that genetics play a dominant role in disc degeneration, explaining 74% of cases, rather than physical loading as previously thought. When evaluating work-relatedness, multiple factors are considered like the injury mechanism, pain onset relationship, preexisting issues, current pathology, and presentation consistency. For surgery approval, considerations include the treated condition, nonoperative treatment effectiveness, surgery effectiveness, return to work likelihood, and surgeon capability.
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This document discusses common lumbar spine conditions like disc herniations and spinal stenosis. It provides 5 facts about disc herniations including what causes them, typical symptoms, and treatment options like steroid injections or surgery. It also outlines 5 facts about spinal stenosis including what it is, typical symptoms, and potential surgical treatment. The document seeks to address 3 common misconceptions about spinal fusion surgery, noting risks are low, it is often successful when combined with decompression, and adjacent level degeneration is usually due to preexisting conditions, not the fusion itself.
Surgery for low back pain
This document discusses spinal fusion surgery for low back pain. It begins by noting that fusion has caused "more tragic human wreckage" when performed incorrectly. It then outlines specific diagnoses that may warrant fusion, including facetogenic pain, discogenic pain, and spondylolisthesis. The document describes suitable and unsuitable surgery candidates. It details common fusion techniques like posterolateral fusion and interbody fusion. Finally, it states that fusion is appropriate when there is a clear diagnosis, identified pain source, suitable patient without psychosocial issues, and the technique matches the pathology.
Case Presentation
Dave, a 38-year old factory worker, sees a doctor for worsening back pain that radiates down his left leg. Imaging reveals chronic pars defects, grade 1 spondylolisthesis, and disc degeneration. He is referred to specialists, prescribed medications, and advised to file a workers compensation claim to receive treatment including epidural injections and physical rehabilitation with the goal of a gradual return to work.
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Surgery for low back pain
The document discusses different types of spine surgery for low back pain, including discectomy for disc herniation and fusion surgery. Discectomy has good outcomes, with patients typically able to return to sedentary duties in 3 weeks and sports in 6 weeks, and a 90-95% success rate. Fusion surgery results are not as good for low back pain compared to discectomy or when done for deformities or instability. Fusion may be suitable for patients with a specific diagnosis, clearly defined pain source, who are otherwise healthy candidates and have no psychosocial issues. The technique used should match the underlying pathology.
Surgery for back pain
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Dr Paul Licina – Spine Surgeon
Event:
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Surgery for Lower Back Pain
This document discusses different types of back surgery for low back pain, including discectomy and spinal fusion. It provides details on discectomy for disc herniation, including causes, symptoms, prerequisites for surgery, expected outcomes, and the surgical procedure. For spinal fusion, it notes the procedure is generally only good for low back pain if there is a specific diagnosis, clearly defined pain source, suitable patient candidate without psychosocial factors, and an appropriate surgical technique is used to address the underlying pathology. Results are not as good for fusion compared to discectomy or for non-specific low back pain. The document also discusses factors that make a patient suitable or unsuitable for fusion surgery.
Causation and decision making
The document discusses factors that contribute to spinal compensation issues and determining whether back pain is work-related or requires surgery. It notes that genetics play a dominant role in disc degeneration, explaining 74% of cases, rather than physical loading as previously thought. When evaluating work-relatedness, multiple factors are considered like the injury mechanism, pain onset relationship, preexisting issues, current pathology, and presentation consistency. For surgery approval, considerations include the treated condition, nonoperative treatment effectiveness, surgery effectiveness, return to work likelihood, and surgeon capability.
Operative treatment for common back conditions
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Dr Paul Licina — Spine Surgeon
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This document discusses common lumbar spine conditions like disc herniations and spinal stenosis. It provides 5 facts about disc herniations including what causes them, typical symptoms, and treatment options like steroid injections or surgery. It also outlines 5 facts about spinal stenosis including what it is, typical symptoms, and potential surgical treatment. The document seeks to address 3 common misconceptions about spinal fusion surgery, noting risks are low, it is often successful when combined with decompression, and adjacent level degeneration is usually due to preexisting conditions, not the fusion itself.
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This document discusses spinal fusion surgery for low back pain. It begins by noting that fusion has caused "more tragic human wreckage" when performed incorrectly. It then outlines specific diagnoses that may warrant fusion, including facetogenic pain, discogenic pain, and spondylolisthesis. The document describes suitable and unsuitable surgery candidates. It details common fusion techniques like posterolateral fusion and interbody fusion. Finally, it states that fusion is appropriate when there is a clear diagnosis, identified pain source, suitable patient without psychosocial issues, and the technique matches the pathology.
Case Presentation
Dave, a 38-year old factory worker, sees a doctor for worsening back pain that radiates down his left leg. Imaging reveals chronic pars defects, grade 1 spondylolisthesis, and disc degeneration. He is referred to specialists, prescribed medications, and advised to file a workers compensation claim to receive treatment including epidural injections and physical rehabilitation with the goal of a gradual return to work.
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Dave is a 38-year old factory worker who presents with worsening back pain that has failed to improve with rest, over-the-counter medications, and a prescription for Endone. He wants advice on his diagnosis, pain management options, submitting a workers' compensation claim, and the possibility of surgery. A comprehensive assessment and multidisciplinary approach is needed to properly manage Dave's chronic back pain.
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An Accredited Exercise Physiologist (AEP) specializes in prescribing exercise programs for chronic disease and injury prevention and management. They work with Spine Plus to provide individually tailored rehabilitation and exercise programs for pre- and post-surgical patients, as well as those with chronic back pain. The AEP assists patients by designing progressive rehabilitation programs that incorporate core and functional strength training while avoiding exercises that involve high compression or lumbar extension. Cardiovascular options like walking, cycling, and modified swimming are also prescribed.
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This document provides an overview of pain control and postoperative analgesia. It begins with defining different types of pain such as nociceptive and neuropathic pain. It then discusses factors that influence pain and the physiological and psychological effects of uncontrolled pain. The document outlines principles of pain assessment and various pain assessment tools. It discusses pharmacological and non-pharmacological pain control strategies including the WHO analgesic ladder and principles of multimodal analgesia. The document provides details on specific drug classes and routes of administration for pain management. It concludes with discussing a multidisciplinary approach to pain management.
Pain Management 2017
This document discusses pain management strategies for various types of pain. It provides an overview of acute and chronic pain, as well as specific types of pain like kidney stone pain, stent pain, and post-procedure pain. The document outlines an interdisciplinary approach to pain management using both drug and non-drug interventions. It emphasizes the importance of comprehensive pain assessment, treatment, and education of patients. Key goals are reducing acute pain, enhancing patient comfort, and preventing severe or long-term chronic pain.
Low back pain or Backache
Low back pain is very common, affecting over 80% of people at some point in their lifetime. While the exact cause is often unclear, imaging is usually not needed and most cases resolve within a few weeks with conservative treatment. Serious underlying causes that may require imaging or surgery include infection, cancer, fractures, or progressive neurological deficits. Physical therapy, medications, and avoiding prolonged bed rest can help acute low back pain, while cognitive behavioral therapy may help chronic cases influenced by psychological factors. Surgery is usually only indicated for severe or progressive neurological problems or cases resistant to other treatments.
Pain management
This document provides an overview of pain management for long-term care facilities. It describes different types of pain, tools for assessing pain, and pharmacological and non-pharmacological treatment approaches. Effective pain management requires recognizing pain, assessing it regularly using tools, treating it with scheduled and as-needed medications, and involving all staff members to help improve patients' quality of life. Regulatory requirements mandate that facilities address pain as part of comprehensive resident assessments and care plans.
Non-operative management for common back conditions
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target the lumbar spine, hips, and core muscles while avoiding positions that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription managed by a physiotherapist or exercise physiologist.
Non-operative treatment for common back conditions
Lumbar disc herniation and stenosis are common causes of low back pain that often improve without surgery. Post-surgery rehabilitation focuses on education, low-impact exercises, and a gradual return to normal activities. Key goals include reducing pain and improving function to allow patients to return to work and daily life. Appropriate exercises target areas like the lumbar spine, hips, and core to improve mobility and reduce recurrence, while avoiding movements that increase pain. Outcomes are best with a multidisciplinary approach including exercise prescription tailored to individual needs and abilities.
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This document presents a case study of a 55-year-old female patient who presented with 6 months of progressive back pain and lower limb weakness. On examination, she had reduced muscle bulk and increased tone in the lower limbs with weakness. Imaging revealed compressive dorsal myelopathy at the D11 level due to Pott's disease. The provisional diagnosis was spastic paraparesis due to compressive dorsal myelopathy. Surgery was planned to address the compressive lesion.
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Case based presentation of pain management in an older patient
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Non-operative management for common back conditions
Non-operative management for common back conditions
Non-operative treatment for common back conditions
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Some WorkCover fusions work
- The study examined outcomes of 42 WorkCover fusion patients compared to 465 privately insured patients over 10 years
- WorkCover patients showed less improvement in ODI and VAS scores postoperatively, especially those with significant back pain preoperatively
- However, WorkCover patients with dominant leg pain preoperatively had similar outcomes to privately insured patients with leg pain
- The presence of leg pain may predict better outcomes for WorkCover fusion patients than significant back pain
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This document discusses interventional procedures for chronic pain, specifically in the lumbar back region. It describes common origins of lumbar pain such as degenerative discs and stenosis. Invasive treatment options are then outlined, including various injection procedures like epidural, facet joint, and medial branch nerve ablation using radiofrequency. The document provides details on how these procedures are performed and their goals in potentially providing temporary pain relief and allowing rehabilitation. Maximum recommended opioid doses and conversions between opioids are also presented.
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This document discusses several issues related to spine imaging. It covers the importance of radiation exposure from various imaging modalities like CT and highlights strategies to reduce radiation dose. Guidelines for imaging low back pain recommend no imaging for non-specific back pain but imaging if neurological deficits are present or specific causes are suspected. The document reviews imaging modalities like X-ray, bone scan, CT and MRI and what each shows. It provides details on MRI sequences and appearances of common spine findings.
Surgery for common lumbar conditions
This document discusses common degenerative conditions of the lumbar spine, including disc herniation, spinal stenosis, and spondylolisthesis. It provides details on symptoms, treatments like steroid injections or surgery, and outcomes. It aims to dispel misconceptions about spinal fusion surgery, noting that while risks exist, severe damage is rare and fusion is usually successful when performed for the right reasons. Fusion may not necessarily lead to more problems at adjacent levels in the future. The document includes examples of patients who had good outcomes from fusion surgery for conditions like isthmic spondylolisthesis and post-discectomy.
Pain management
This document discusses interventional pain procedures for chronic pain, including epidural injections, facet joint injections, medial branch blocks, and radiofrequency nerve ablation. It provides details on how each procedure is performed, when they are appropriate, and their potential benefits which include temporary pain relief and allowing patients to progress in rehabilitation. It also covers guidelines for opioid prescribing for chronic pain, including maximum recommended doses, conversion between opioid medications, requirements for authorities to prescribe, and factors to consider in opioid trials and maintenance therapy.
Common conditions of the lumbar spine
Common conditions of the lumbar spine include:
1. Degenerative disc disease, which occurs in nearly everyone over 50 due to disc degeneration and affects the lower lumbar spine the most.
2. Disc herniations, where a tear in the disc allows the nucleus to migrate and press on nerves, commonly causing leg pain.
3. Spinal stenosis, a narrowing of the spinal canal from bone spurs or thickened ligaments that compresses nerves and causes leg symptoms improved by sitting or bending forward.
4. Spondylolisthesis, the slipping of one vertebra over another, most often affecting L4 on L5 due to degeneration.
Lumbar Stabilisation
The document outlines an exercise program for lumbar stabilization rehabilitation. It provides 15 different exercises that involve contracting the transversus abdominis muscle to stabilize the spine. Each exercise lists instructions on positioning, muscle activation, and repetitions. The goal is to perform the full series of exercises while maintaining control of the lower back and pelvis.
Discectomy Activity Guide
Presented by:
Stephen Boyd — Physiotherapist
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GP Education Day - 2013
6 week discectomy
The document provides instructions for a 6-week lumbar rehabilitation exercise program following back surgery. It includes over 20 different exercises targeting the lower back, core, and legs. Exercises should be done 2-3 times per day and include stretches, strengthening moves using balls, bands, and body weight as well as exercises done in standing, kneeling, and various positions on the floor or ball. The full range of motion and correct form are emphasized to protect the back during rehabilitation.
3 week discectomy
This exercise program outlines rehabilitation exercises over 3 weeks following a lumbar discectomy surgery. The goals by 6 weeks include exercising 2-3 times per day, increasing walking, and lifting up to 10kg. The document provides detailed instructions for 20 different core-focused exercises involving positions like lying on the back or side, kneeling, and standing. Each exercise describes muscle activation and movements to help recovery while avoiding movements that could cause pain.
Initial Discectomy
This document outlines an exercise program for patients who have undergone a lumbar discectomy. The goals within 3 weeks are to do 2-3 exercise sessions per day, walk for a total of 5km split into two sessions, and lift weights up to 5kg. The program focuses on core stabilization exercises using a ball and includes exercises to do lying down, kneeling, sitting, and standing to strengthen the back and abdomen. Proper form is emphasized by engaging the transversus abdominis muscle and maintaining a neutral spine alignment throughout. Exercises are to be done in sets of 10-15 repetitions and held for 3-10 seconds, progressing to weight added as tolerated.
Pain diagram and questionnaire
The document contains a pain diagram and questionnaire for a patient to report their back pain. The pain diagram has the patient mark areas of pain and tingling. Two pain scales have the patient rate their average back and leg pain in the past week from 0 to 10. The back pain questionnaire has 10 sections for the patient to select the statement that best describes how their back pain affects daily activities like personal care, lifting, walking, sitting, standing, sleeping, social and work life, and traveling.
Rehabilitation for back pain
This document provides guidance on rehabilitation for non-operative and operative back pain. It discusses assessing abnormalities and treating to correct them. For severe back pain, it recommends reducing pain and inflammation through comfort positions, movement, medications, modalities, and exercise away from aggravation. For sub-acute back pain, it recommends manual therapy, restoring range of motion and flexibility/strength training. Post-episode, it recommends modifying activities, correcting biomechanical abnormalities, and implementing a home exercise regime. Core stability and stabilization exercises are emphasized for retraining deep muscles to maintain functional stability. Post-operative rehabilitation focuses on early mobility, exercises in neutral spine, and functional control prior to discharge with a home program.
Interventional Procedures and Opioids
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This Unbearable Pain
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Discectomy Patient Pathway
Dr. Paul Licina will perform a lumbar discectomy surgery on the patient. The patient will be admitted the morning of surgery and should expect to stay in the hospital for one day. Before surgery, the patient must stop taking certain medications and supplements. During the procedure, the surgeon will make an incision in the patient's back to remove a herniated disc putting pressure on a nerve root. After surgery, the patient will recover in the hospital before being discharged home, where they will do exercises and slowly resume normal activities over several weeks as pain improves.
Myelopathy management
This document discusses cervical myelopathy, including its causes, symptoms, tests, treatment options, and surgical procedures. It provides details on:
- Common causes of cervical myelopathy like spinal stenosis, disc protrusions, and osteophyte formation.
- Typical symptoms like clumsy hands, leg stiffness, and gait imbalance and signs like hyperreflexia on examination.
- MRI as the best test to identify cord compression and changes, and CT myelogram as also useful.
- Surgical treatment options include anterior discectomy and fusion or corpectomy for one to two levels, and corpectomy with possible posterior fixation for three or more levels. Posterior laminectomy, laminectomy with fusion
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Surgery for back pain
- 1. SURGERY FOR LOW BACK PAIN Paul Licina
- 2. Not all spine surgery is the same…
- 3. DISCECTOMY FOR DISC HERNIATION
- 5. DISCECTOMY FOR DISC HERNIATION Outcome • Day Surgery procedure • back to sedentary duHes in 3 weeks • back to sport in 6 weeks • good or excellent result in 90-‐95%
- 6. FUSION FOR LOW BACK PAIN
- 7. FUSION FOR LOW BACK PAIN What is fusion good for?
- 11. FUSION FOR LOW BACK PAIN What about low back pain?
- 12. FUSION FOR LOW BACK PAIN Results not as good as for deformity or instability Results not as good as for discectomy surgery WRONG diagnosis WRONG paHent
- 13. FUSION FOR LOW BACK PAIN Results not as good as for deformity or instability Results not as good as for discectomy surgery WRONG diagnosis WRONG paHent
- 14. FUSION FOR LOW BACK PAIN DISEASE DIAGNOSIS symptoms and signs Hx, Ex & Ix TREATMENTCURE directed at pathology The medical model
- 15. DISEASE DIAGNOSIS symptoms and signs Hx, Ex & Ix The medical model back pain is a complex symptom rather than a discrete illness structural lesion cannot be identified in many cases does not account for individual variation in human response 15% FUSION FOR LOW BACK PAIN
- 16. CHRONIC SPECIFIC ACUTE SPECIFIC CHRONIC NON SPECIFIC ACUTE NONSPECIFIC
- 20. FUSION FOR LOW BACK PAIN Results not as good as for deformity or instability Results not as good as for discectomy surgery WRONG diagnosis WRONG paHent
- 21. SUITABLE CANDIDATE • Self-‐employed • Successful business • No specific injury • No compensa5on or li5ga5on • Works with some difficulty • Has given up some of more acHve sports • Uses intermiCent over-‐the-‐counter analgesics • Non-‐smoker • Normal body weight • Goal is to be able to return to ac5ve lifestyle • No abnormal illness behaviour
- 22. UNSUITABLE CANDIDATE • Employee undertaking manual work • DissaHsfied with employment • UnremiYng pain aZer liZing at work • Unresolved WorkCover claim with civil ac5on pending • Failed aCempts at return to work • Has given up all social acHviHes • Uses regular narco5c analgesia • Smoker • Unfit and overweight • Goal is for someone to get rid of their pain • Abnormal illness behaviour on examina5on
- 23. Techniques FUSION FOR LOW BACK PAIN
- 24. FUSION FOR LOW BACK PAIN Noninstrumented fusion
- 25. Instrumented fusion FUSION FOR LOW BACK PAIN
- 26. FUSION FOR LOW BACK PAIN Interbody fusion
- 27. remove the disc Interbody fusion • remove the pain source • stop the movement FUSION FOR LOW BACK PAIN
- 28. benefits Anterior interbody • anterior muscle-splitting only • minimal tissue trauma indications • isolated degeneration • L5-S1 (L4-5) • no need to enter canal • thin, no previous major abdominal surgery FUSION FOR LOW BACK PAIN
- 31. benefits Transforaminal interbody • allows nerve decompression • allows all levels • familiarity indications • not suitable for ALIF • nerve compression esp foraminal compression • correction of deformity
- 34. What’s new?
- 42. When is fusion good for LBP? • specific diagnosis • clearly defined pain source • suitable candidate • no negaHve psychosocial factors • appropriate technique for pathology • some surgeon variaHon
- 43. END