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Surgery for Lower Back Pain
- 1. SURGERY FOR LOW BACKPAIN Paul Licina
- 2. Not all spinesurgery is the same…
- 3. DISCECTOMY FOR DISCHERNIATION
- 4. DISCECTOMY FOR DISCHERNIATION tear in outer disc migration of inner gel What causes it ? nerve pressure leg pain (sciatica) What does it cause ?
- 5. DISCECTOMY FOR DISCHERNIATION cauda equina syndrome unremitting pain When do we operate ? relief of leg pain Why do we operate ?
- 6. DISCECTOMY FOR DISCHERNIATION Prerequisites • symptoms > 6 weeks • leg pain > back pain • leg pain in radicular distribution • nerve tension signs (reduced SLR) • nerve compression signs (weakness, numbness, reflex loss) • confirmed on imaging
- 7. DISCECTOMY FOR DISCHERNIATION Outcome • Day Surgery procedure • back to sedentary duties in 3 weeks • back to sport in 6 weeks • good or excellent result in 90-95%
- 8. •small incision •interlaminar space exposed •adequate retraction •laminotomy
- 13. FUSION FOR LOWBACK PAIN
- 14. FUSION FOR LOWBACK PAIN What is fusion good for?
- 18. FUSION FOR LOWBACK PAIN What about low back pain?
- 19. FUSION FOR LOWBACK PAIN Results not as good as for deformity or instability Results not as good as for discectomy surgery WRONG diagnosis WRONG patient
- 20. FUSION FOR LOWBACK PAIN DISEASE DIAGNOSIS symptoms and signs Hx, Ex & Ix TREATMENTCURE directed at pathology The medical model
- 21. DISEASE DIAGNOSIS symptoms andsigns 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
- 22.
- 25. 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
- 26. UNSUITABLE CANDIDATE • Employeeundertaking 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
- 27. Techniques FUSION FOR LOWBACK PAIN
- 28. FUSION FOR LOWBACK PAIN Noninstrumented fusion
- 29. Instrumented fusion FUSION FOR LOWBACK PAIN
- 30. FUSION FOR LOWBACK PAIN Interbody fusion
- 31. remove the disc Interbody fusion •remove the pain source • stop the movement FUSION FOR LOW BACK PAIN
- 32. 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
- 35. benefits Transforaminal interbody • allows nerve decompression •allows all levels • familiarity indications • not suitable for ALIF • nerve compression esp foraminal compression • correction of deformity
- 38.
- 46. When is fusiongood for LBP? •specific diagnosis •clearly defined pain source •suitable candidate •no negative psychosocial factors •appropriate technique for pathology •some surgeon variation