SURGERY FOR LOW BACK PAIN Paul Licina
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SURGERYFORLOWBACKPAIN
PaulLicina
Notallspinesurgeryisthesame…
DISCECTOMY FOR DISC HERNIATION
DISCECTOMY FOR DISC HERNIATION
Outcome
• DaySurgeryprocedure• backtosedentarydutiesin3weeks• backtosportin6weeks• goodorexcellentresultin90-95%
FUSION FOR LOW BACK PAIN
FUSION FOR LOW BACK PAIN
Whatisfusiongoodfor?
FUSION FOR LOW BACK PAIN
Whataboutlowbackpain?
FUSION FOR LOW BACK PAIN
Resultsnotasgoodasfordeformityorinstability
Resultsnotasgoodasfordiscectomysurgery
WRONGdiagnosisWRONGpatient
FUSION FOR LOW BACK PAIN
DISEASE DIAGNOSISsymptoms and signs
Hx, Ex & Ix
TREATMENTCUREdirected at pathology
The medical model
DISEASE DIAGNOSISsymptoms 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
CHRONICSPECIFIC
ACUTESPECIFIC
CHRONICNON
SPECIFIC
ACUTENONSPECIFIC
FUSION FOR LOW BACK PAIN
Resultsnotasgoodasfordeformityorinstability
Resultsnotasgoodasfordiscectomysurgery
WRONGdiagnosisWRONGpatient
SUITABLECANDIDATE• Self-employed• Successfulbusiness• Nospecificinjury• Nocompensationorlitigation• Workswithsomedifficulty• Hasgivenupsomeofmoreactivesports• Usesintermittentover-the-counteranalgesics• Non-smoker• Normalbodyweight• Goalistobeabletoreturntoactivelifestyle• Noabnormalillnessbehaviour
UNSUITABLECANDIDATE• Employeeundertakingmanualwork• Dissatisfiedwithemployment• Unremittingpainafterliftingatwork• UnresolvedWorkCover claimwithcivilactionpending
• Failedattemptsatreturntowork• Hasgivenupallsocialactivities• Usesregularnarcoticanalgesia• Smoker• Unfitandoverweight• Goalisforsomeonetogetridoftheirpain• Abnormalillnessbehaviour onexamination
Techniques
FUSION FOR LOW BACK PAIN
FUSION FOR LOW BACK PAIN
Noninstrumentedfusion
Instrumented fusion
FUSION FOR LOW BACK PAIN
FUSION FOR LOW BACK PAIN
Interbodyfusion
remove the disc
Interbodyfusion
• remove the pain source• stop the movement
FUSION FOR LOW BACK PAIN
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
benefits
Transforaminalinterbody
• allows nerve decompression
• allows all levels• familiarity
indications
• not suitable for ALIF• nerve compression esp
foraminal compression• correction of deformity
What’snew?
WhenisfusiongoodforLBP?•specificdiagnosis
•clearlydefinedpainsource
•suitablecandidate•nonegativepsychosocialfactors
•appropriatetechniqueforpathology•somesurgeonvariation
Thankyou
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