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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? • • • • • “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 – – – – – – 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 • • • • • • 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 • • • • • • 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 • • • • 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 • • • • • 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 • • • • • • 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