SPINE SURGERY

1. Massive disc herniation
Discectomy Vs Fusion ?
DEPARTMENT OF SPINE SURGERY AND ORTHOPAEDICS
SANJAY GANDHI INSTITUTE OF TRAUMA AND ORTHOPAEDICS ,
BANGALORE.
Dr. MOHAN N S
Professor Spine surgery

2. REVIEW
Anatomy
Classification of Disc Herniation
Clinical Features and Cauda-equina syndrome
 Indications for Fusion
Approaches
Complications of Discectomy
Complications of Fusion
Conclusions

3. Anatomy
 The Intervertebral
disc is composed of
a central nucleus
pulposus surrounded
circumferentially by
the annulus fibrosus.
 The annulus fibrosus
is composed of
multiple concentric
lamellae made up of
fibers oriented in
alternating directions
to create maximal
tension resistance.

4. Innervation of the intervertebral disc.
• The sinuvertebral nerve is formed from branches of the ventral primary ramus
and the gray ramus communicans.
• Divides into a Larger superior division and a lesser inferior division.
• Provides sensation to the dorsal and dorsolateral annulus and PLL.

5. Classification of Disc Displacements

7. Massive Disc prolapse?
Massive disc prolapse is defined on MRI
Herniated disc material occupies 50% or more
antero-posterior diameter of spinal canal.

8. T2-WI Mid-sagittal and Axial cuts
L4-L5 Massive IVDP

9. Clinical Features
Axial back pain : Nociceptors along annulus and posterior
longitudinal ligament thought to contribute to axial pain with
annular tears.
Radiculopathy: Radiating pain in distribution of affected
nerve root dermatome.
Can be associated with sensory or motor deficits of
compressed nerve root.
Decreased reflexes of involved nerve root

11. CES is rare: Incidence rates ranging from 1 in 33,000 - 1 in
100,000 have been reported in Lumbar disc herniation .
Incidence of cauda equina
syndrome ?

12. Common clinical Features in CES
1.Severe Low Back Pain
2.Saddle anesthesia
3.Unilateral/ Bilateral sensory or motor radiculopathy of lower extremities
4.Loss of visceral function which may lead to
• Urinary incontinence
• Decreased or absent rectal tone
• Erectile dysfunction
5.Absent deep tendon reflexes in lower extremities

13. CES in Massive disc Herniation?
• The majority of patients do not display a cauda equina
syndrome (CES).
• Low lumbar disc sites are mostly affected
• Disc fragments are more likely to be central uncontained.

14. Discectomy?
V/s
Lumbar Interbody Fusion?

15. Surgeons in favor of Discectomy
Believe :
 Reduces Risk of Adjacent segment disease
 Preserves Spine motion
 Reduced Risk of Infection and Implant Failure
 Lumbar fusion surgery to be done in cases where disc herniation
is associated with :
Instability of the spine.
Lumbar canal stenosis.
Loss of disc height and diameter

16. Surgeons in Favor of Fusion
They believe that after Discectomy:
Residual low back pain .
Recurrent herniation.
Lumbar Instabilty
Cartilage end plate avulsion

17. Complications after Discectomy ?

18. Studies have shown that there are
3%- 18% incidence of recurrent
disc herniation

19. Evidence suggests 30 % patients
following discectomy continue to
experience pain in long term follow-up

20. Approximately 14% of patients required
Revision surgery in the UK

21. Severe Endplate changes result in poor
efficacy and damage the lumbar stability
after discectomy
Thus, for patients with severe endplate changes,
internal fixation surgery should be considered.

22. Indications –Lumbar Fusion
 Recurrent disc herniation
 Lumbar spinal stenosis
 Degenerative disk disease
 Postlaminectomy kyphotic instability
 Pseudarthrosis
 Synovial cysts with associated spinal instability.

24. Complications after Fusion
Surgery?

25. The rate of Symptomatic Adjacent segment disease is higher in
patients with transpedicular instrumentation (12.2–18.5%)

26. Incidence of infection after lumbar
discectomy or laminectomy is
approximately 1%

27. Deep infections were found in 4.7%, all
successfully cured by debridement and
antibiotics.

28. Functional Outcome?
Discectomy
V/s
Lumbar Interbody Fusion in
Massive disc herniation

29. Both the groups were found comparable in terms for back and
leg pain of Visual Analogue score

30. Among both groups for Modified Oswestry Disability Index, which
showed better functional outcome in discectomy

31. McNab’s criterion- Patients in both groups have satisfactory
outcome
In discectomy group, excellent result was obtained in 80% of
patients
In TLIF group only 68.42% of patients have excellent results.

32. PELD has the advantages
1.Less trauma and bleeding,
2.Rapid postoperative recovery
3. Curative effect and recurrence rate are similar with TLIF.
Therefore, PELD is an effective method for the treatment of
upper lumbar disc herniation.

33. Conclusion
Recurrent herniation and instability were noticed more with
discectomy and ASD was more common after fusion
surgeries.
 The choice of procedure should be individualized, and it also
depends on surgical expertise.
Where resources are constrained, discectomy should be
preferred.

34. THANK YOU