8/2/13

1

Spinal Surgery 2

Mr Mushtaque A. Ishaque BSc(Hons) BChir(Cantab) DM FRCS FRCS(Ed) FRCS(Orth)

Hunterian Professor at The Royal College of Surgeons of England Consultant Orthopaedic Spinal Surgeon

Senior Clinical Academy Teacher

Teaching Aims

Common Spinal Conditions

Important Spinal Conditions

Be Safe

Common Spinal Pathologies

Degenerative disc disease Lumbar and Cervical disc herniation

Spinal canal stenosis Spondylolysis

Spondylolisthesis

Disc Degeneration

• Affects everyone

• Age at onset is determined genetically and by environmental influence

• Variably symptomatic

Disc Degeneration

•  Progressive and irreversible

•  Probably increases with age

•  Presents typically with low back pain

•  Unfortunately, there are lots of causes of low back pain

Causes of LBP

• Mechanical • Rheumatological •  Infection • Tumours • Systemic disease • Neuro/Psychiatric

8/2/13

2

Natural History LBP

•  90% improve within 4/52 of seeking care

•  At 1 month – 66% mild LBP – 33% moderate LBP – 20% substantial limitation of activity

•  At 1 year – 14% severe back pain

Patterns of LBP

• Back only

• Back and posterior thigh

• Back and lower leg pain

• Back and anterior thigh pain

Causes of LBP

•  Disc degeneration •  Bony endplate •  Facet joint •  Facet capsule •  Tendon •  Muscles

•  Combination of all of the above

Diagnosis

•  Pain History – Site – Onset – Character – Radiation – Alleviating factors – Timing – Exacerbating factors – Severity

“SOCRATES”

Diagnosis

• Examination – Posture (Listing) – Movement

• Cadence • Flexion increment • Pain on extension

– Tenderness – Neurological examination – Perineal examination

Investigations

•  Plain radiographs

•  MRI

•  Discography

•  Facet joint block

•  Psychological assessment

8/2/13

3

Treatment

• Conservative – Physiotherapy

• Core stability exercises

• Surgical – Fusion

• Posterolateral uninstrumented • Transforaminal Lumbar Interbody • Posterior Lumbar Interbody

Indications for fusion

•  Incapacitating back pain

•  Failure of conservative treatment for at least 6/12

•  Correlating clinical findings and imaging

•  Patient accepting of risks and success rates

RED FLAGS

Age under 20 or over 55

Non-mechanical back pain

Thoracic back pain

Structural deformity

Recent unexplained weight loss

RED FLAGS

Night pain

Prior Malignancy

Constitutional symptoms

Sphincter symptoms

Neurological abnormality

Lumbar Disc Herniation

•  Presents with leg pain

•  Radicular pain in a dermatomal distribution

•  May have associated back pain

Lumbar Disc Herniation

Pain is – Dermatomally sited – Sudden with obvious time of onset – Sharp, burning or lancinating – Radiates down the leg below the knee – Mildly relieved with NSAID’s – Constant – Exacerbated by any movement – Severe in nature

8/2/13

4

Anatomy

Sacrum

Root Root

Disc

Root

Pathophysiology

• Leg Pain is secondary to – Mechanical radiculitis – Chemical radiculitis

• Back pain is due to – From the disc itself – From the bony endplate

Anatomy

Broad based herniation

Focal herniation

Traversing vs Exiting

Nerve Root

Natural History

•  80% settle spontaneously within 6 weeks

•  Surgery is no more effective in the long term than conservative management

•  Surgery does however provide pain relief earlier and facilitates earlier return to normal activities and work

MRI Investigation Indications for surgery

•  Absolute • Sphincter compromise • Major Motor radiculopathy

•  Relative • Failed conservative management • Only after a minimum of 6 weeks • Neurological deficit • Stenotic spinal canal

8/2/13

5

Management

• Conservative • Nerve Root Block • Lumbar Epidural

• Surgical • Microdiscectomy • Success Rate in excess of 93%

Spinal Stenosis

•  Also known as neurogenic claudication

•  Narrowing of the spinal canal

•  Multiple aetiologies

•  Pathophysiology uncertain

Spinal Stenosis

• Definition

– Claudication with evidence of chronic nerve root compression or irritation in the presence of a spinal canal lesion on imaging and absence of vascular insufficiency

Aetiology

•  Facet joint degeneration

•  Osteophyte overgrowth

•  Facet joint capsular laxity

•  Ligamentum flavum oedema or buckling

Characteristics

•  Insidious onset •  Age over 50 years old •  Numb aching cramp-like leg pain •  Brought on by standing or walking •  Relieved by sitting, leaning forward or

simply stopping walking •  Back pain •  Weakness and sphincter disturbance if

severe

MRI

Spinal Stenosis

8/2/13

6

Management

• Conservative • Lumbar or caudal epidurals

• Surgical • Targeted decompression • Decompression and fusion

Targeted Decompression

Spondylolysis

•  Spondyl = Vertebra

•  Lysis = Break

•  Unilateral or bilateral pars interarticularis defect

•  Usually L3 to L5, commonest at L5

Imaging

Imaging Spondylolisthesis

•  Spondyl = vertebra •  Listhesis = slip

•  Classification – Dysplastic –  Isthmic – Degenerative – Traumatic (other than a pars defect) – Pathological

8/2/13

7

Imaging

Spondylolisthesis

Management

• Decompress the nerve roots

• Reduce the spondylolisthesis

• Obtain a fusion at the level of the spondylolisthesis

Post Op Imaging

Reduce and Fuse