Download Back Pain - Mercy Health System

Back Pain
Christopher D. Sturm, M.D., F.A.C.S
Medical Director
Mercy Institute of Neuroscience &
Mercy Regional Neurosurgery Center
Back Pain
• Extremely common
• Often accompanied by leg pain or
numbness
• Adversely affects quality of life
• Lost time, work & money
• Can vary in intensity and duration, leading
to significant frustration
Back Pain
But……THERE IS HOPE!
You Do NOT have to just “live with it”
Back Pain
• Can lead to nerve damage
• Permanent loss of some functions
– Movement
– Sensory
– Bowel and Bladder control
• In some instances earlier treatment can lead
to better outcomes
What to Do?
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“So, what the heck is going on?”
“Can anything be done to fix it?”
“What are my options?”
“When should I start?”
“What are the success rates?”
Causes of Back Pain
• Muscle spasm/inflammation/strain
• Degeneration or inflammation of the disc
• Degeneration or inflammation of the back (facet)
joints
• Loss of normal alignment or instability
• Fracture
• Infection
• Tumor
Evaluation of Back Pain/Leg Pain
• Symptom history and physical exam
findings
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What makes it worse or better?
Location?
Duration?
Associated pain/numbness/weakness?
Bowel and bladder control?
Past medical history?
Evaluation of Back Pain/Leg Pain
• MRI imaging
– Optimal to evaluate discs, nerves, alignment
• CT scan
– Better visualization of the bone
• Plain X-rays
– Screening test
• Bone Density study
– Osteopenia/osteoporosis?
“So, what to do?”
• Depends on the cause of the pain
• Is there any associated loss of function?
• Are the symptoms significantly interfering
with your quality of life?
• Any indication they are getting better?
• Have conservative therapies failed?
Conservative Therapy
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Symptom improvement without surgery
Activity modification
Pain medication
Physical therapy
Chiropractic intervention
Injectional therapy
When is Surgery Appropriate?
• If the symptoms are significantly interfering
with your quality of life, and have not
improved with conservative therapy
measures, for an appropriate period of time
• Any presence, or high risk of functional loss
• Instability
• Tumor
• Infection
Spinal Tumors - L1 Schwannoma
Myxopapillary Ependymoma
Advancements in Spine
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Improved imaging techniques
Pathophysiology of degenerative disease
Biomechanical advancements
Image guidance
Minimally Invasive techniques
Mechanical implantation devices
Mercy Regional Neurosurgery
Multi-Center National Studies
• CODA study
– Posterior lumbar
fusions
• In-Fix study
– Anterior lumbar
fusions
• Fortitude study
– Cervical discectomy
and fusions
Lumbar Degenerative Disease
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Initial desiccation of the disc
Loss of structural integrity of the disc
Loss of disc space height/potential HNP
Abnormal loading and laxity of the facet
joints
• Neuroforaminal compromise
• Malalignment and abnormal motion
Multi-level Lumbar Spondylosis
Surgical Options
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Lumbar discectomy
Lumbar laminectomy
Anterior lumbar interbody fusion (ALIF)
Posterior lumbar interbody fusion (PLIF)
Vertebroplasty/Kyphoplasty
Lumbar Discectomy
• Leg pain unresponsive to conservative
therapy
• Progressive deficit
• Cauda equina syndrome
• Small incision
• Outpatient or next day discharge
Right L5-S1 Discectomy
Lumbar laminectomy
• Leg pain secondary to lumbar
stenosis/lateral recess stenosis
• Failure of conservative therapy
• Older patients, slightly larger incision,
longer stay
• Approximate 10% incidence of subsequent
lumbar instability
Lumbar laminectomy
Anterior Lumbar Interbody Fusion
(ALIF)
• Lumbar degenerative disc disease producing
mechanical LBP & minimal radicular pain
• Localized concordant discogenic pain with
discography at level(s) abnormal on MRI
• Anterior approach avoids injury to posterior
lumbar musculature
• Suboptimal to address neural compression
Provocative discography
Anterior Lumbar Interbody Fusion
L4-5 ALIF
• 37 year old female
with progressive
mechanical LBP
• Right leg
psuedoradicular pain
• Concordant L4-5
discogenic pain
• Failed conservative
therapy
L4-5 In-Fix Cage
3 Level ALIF with InFix Cages
Posterior Lumbar Interbody Fusion
(PLIF)
• Mechanical LBP with associated radicular
pain and/or neurological deficit
– Degenerative disc disease/collapse/herniation
– Facet joint hypertrophy with foraminal stenosis
– Lateral recess and/or central spinal stenosis
• Spondylolysis/spondylolisthesis
• Lumbar instability
L4-5, L5-S1 PLIF
• 50 year old female with progressive LBP and
bilateral radicular pain w/dysesthesia
• Intensifying pain despite previous L4-5
hemilaminectomy/discectomy
• Lumbar MRI – L4-5, L5-S1 DDD & NFS
• Concordant discogenic pain L4-5, L5-S1
Pre operative MRI
Cadence Cage
PEEK Lordotic Lumbar Cages
3 Level PLIF w/PEEK Lordotic
Cages
L5-S1 PLIF
• 49 year old female with progressive LBP
and left leg radicular pain
• Dysesthesia left leg/foot
• MRI – L5-S1 DDD with left NFS
• Failed conservative therapy
• Concordant discogenic pain L5-S1
Pre-operative MRI
CODA Expandable Implant
Pre- and Post-operative Lateral
Views
L5-S1 PLIF – CODA Cages
Minimally Invasive Spine Surgery
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Achieve same goals as “open” procedures
Smaller incisions
Less muscle trauma
Utilization of image guidance
Less post-operative pain
Shorter hospitalization
360 degree Lumbar revision – stand
alone cages
360 degree Lumbar revision –
titanium mesh
360 degree Lumbar revision –
titanium mesh
Results
• Review of 5 years of
practice data
• Using the treatment
approach outlined here
• Improved or not?
• Fusion?
• Approximately 500
surgery patients
• 93% reported
improvement as a
result of their surgery
• 99% fusion rate
Multi-level Cervical Spondylosis
ACDF utilizing structural allografts
Remodeling Cervical Allograft
ACDF C4-5, C5-6
• 47 year old right handed female with
posterior cervical pain and right arm
radicular pain
• Right deltoid and biceps weakness
• Failed conservative therapy
• Cervical spondylosis C4-5, C5-6
Fortitude Ti Cages packed with
Cerasorb, AcuFix Plate
Fortitude Cages and AcuFix
Plate
PEEK Cervical Lordotic Cages
packed with Cerasorb
Posterior cervical revision –
allograft pseudoarthrosis & kyphosis