SURGERY FOR LOW BACK PAIN Paul Licina
SURGERY FOR LOW BACK PAIN
Paul Licina
Not all spine surgery is the same…
DISCECTOMY FOR DISC HERNIATION
DISCECTOMY FOR DISC HERNIATION
tear in outer discmigration of inner gel
What causes it ?
nerve pressureleg pain (sciatica)
What does it cause ?
DISCECTOMY FOR DISC HERNIATION
cauda equina syndrome
unremitting pain
When do we operate ?
relief of leg painWhy do we operate ?
DISCECTOMY FOR DISC HERNIATION
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
DISCECTOMY FOR DISC HERNIATION
Outcome
• Day Surgery procedure• back to sedentary duties in 3 weeks• back to sport in 6 weeks• good or excellent result in 90-95%
•small incision • interlaminar space exposed
•adequate retraction •laminotomy
FUSION FOR LOW BACK PAIN
FUSION FOR LOW BACK PAIN
What is fusion good for?
FUSION FOR LOW BACK PAIN
What about low back pain?
FUSION FOR LOW BACK PAIN
Results not as good as for deformity or instability
Results not as good as for discectomy surgery
WRONG diagnosisWRONG patient
FUSION FOR LOW BACK PAIN
DISEASE DIAGNOSIS
symptoms and signs
Hx, Ex & Ix
TREATMENTCURE
directed at pathology
The medical model
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
CHRONICSPECIFIC
ACUTESPECIFIC
CHRONICNON
SPECIFIC
ACUTENONSPECIFIC
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
UNSUITABLE CANDIDATE
• Employee undertaking 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
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’s new?
When is fusion good for LBP?
•specific diagnosis•clearly defined pain source
•suitable candidate•no negative psychosocial factors
•appropriate technique for pathology•some surgeon variation