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.

1. Surgery for common
degenerative conditions of
the lumbar spine
Dr Paul Licina – Spine Surgeon

2. DISC HERNIATION
When do we
operate ?

3. THE PERFECT INDICATION
HISTORY
• pain for six weeks
• leg pain > back pain
• radicular pain
EXAMINATION
• nerve compression signs
• nerve tension signs
INVESTIGATIONS
• MRI shows concordant herniation

5. Discectomy
video

6. DISC HERNIATION
When do we
operate earlier ?

7. INDICATIONS FOR EARLIER SURGERY
HISTORY
• intolerable pain
EXAMINATION
• significant neurological deficit
INVESTIGATIONS
• MRI shows huge herniation

8. • 33 y.o. female
• 6 week history of severe sciatica
• bladder dysfunction and perineal
numbness for 2 days
• too painful for complete
assessment
• reduced bilateral SLR

9. INDICATIONS FOR STEROID INJECTION
HISTORY
• moderate pain for less than six weeks
• nonradicular pain
• recurrent pain
EXAMINATION
• no positive supporting findings
INVESTIGATIONS
• MRI shows small herniation

10. • 42 y.o. female
• 4 week history of sciatica
• initially incapacitating, now
improving
• no numbness, weakness or reflex
loss
• right SLR limited to 45°

13. MISCONCEPTIONS
surgery is a
last resort
weakness
doesn’t
improve
more trouble
in the future
these get
better by
themselves

14. SPINAL STENOSIS
When do we
operate ?

17. Laminectomy video

19. SPINAL STENOSIS
When do we
add fusion ?
SPONDYLOLISTHESIS SCOLIOSIS

20. DEGENERATIVE SPONDYLOLISTHESIS

24. DEGENERATIVE SCOLIOSIS

29. 1. Occurs in 1 in 50 people, usually age 25 to 55
2. Is a result of the aging process, not necessarily an injury
3. Usually starts to settle within 4 weeks
4. Steroid injection may speed up recovery
5. If doesn’t improve, best treated with microdiscectomy (keyhole
day surgery operation)
Disc herniation
a tear of the outer
annulus allows
prolapse of the inner
nucleus causing nerve
pressure and leg pain
1. Due to degeneration, usually in people over age 60
2. Commonly seen on scans but often causes no problems
3. Usual symptoms are leg heaviness and pain when walking
4. May improve temporarily with an epidural steroid injection
5. If symptoms are severe, may need a laminectomy operation
(where bone is removed to free the nerves)
1. Usually occurs in childhood but often only painful in later life
2. Pars stress fractures are common (1 in 10 people) and due to
bone weakness (developmental) and/or repetitive strain
(sport)
3. May lead to premature disc degeneration (back pain) and
nerve compression (leg pain)
4. Usually improves with time and appropriate exercises
5. Occasionally requires fusion surgery
Spinal stenosis
narrowing of the spinal
canal resulting in nerve
compression
Isthmic
spondylolisthesis
forward slip of a
vertebra due to stress
fractures in the pars,
usually occurring in L5
5 facts about common lumbar conditions…

30. 3 misconceptions about spinal fusion surgery…
Spinal fusion is dangerous
“I could end up in a wheelchair” is a common comment when patients are presented the option of a
spinal fusion. Although technically possible, severe damage to all the spinal nerves is exceedingly
rare. A subtle injury to one of the nerves is more common, but results in partial weakness or
numbness of one leg and this usually recovers. Other uncommon spinal risks include infection, and
there are general risks of any surgery including DVT and anaesthetic problems. However, the most
common adverse outcome is incomplete relief of pain. Fortunately, making people worse after a
spinal fusion does not often occur.
Spinal fusion doesn’t work
A fusion can be performed for many reasons. When it is part of a procedure to stabilise the spine (eg
for fracture or deformity) or decompress the nerves (eg for stenosis or spondylolisthesis) it is almost
always a very successful procedure. The problem comes with fusions for back pain only. The source
of pain can be hard to identify and there can be many contributors to chronic pain. For this reason,
only a small proportion of patients with back pain are good candidates for a spinal fusion. In this
group, a fusion usually gives good pain relief.
Spinal fusion means more surgery in the future
In most cases, lumbar spine problems involve multiple levels. It is not feasible to fuse all the levels and
it is therefore expected that the other nonfused levels may have problems in the future. It is
like a cavity in a tooth – after a filling, it is likely that other teeth will develop cavities in the future and
also need fillings. There is a theory that fusing one level puts more load on other levels. This does
occur, but the main reason adjacent segments degenerate is that they already have degeneration
present. If a disc is normal, fusing the disc next to it usually doesn’t lead to any long-term problems.

31. GOOD OUTCOMES FROM
FUSION SURGERY

32. ISTHMIC SPONDYLOLISTHESIS

33. POST-DISCECTOMY

34. ODI 36% BACK 6.9 LEG 6.4

36. ODI 6% BACK 0 LEG 0

37. NEXT LEVEL DEGENERATION
AFTER FUSION SURGERY

38. 2012

39. 2012

40. 2016

41. 2016

42. Thank you