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