SURGERIES IN BACK PAIN MANAGEMENT Chaloupka R., Repko M. University Hospital Brno, Orthopaedic Dept Brno-Bohunice Variability of spinal canal shape University Hospital Brno, Orthopaedic Dept Brno-Bohunice Management of back pain 1. diagnosis - 1% organic origin 2. conservative 3. surgery only in known and clear diagnosis University Hospital Brno, Orthopaedic Dept Brno-Bohunice Spine deformities Degenerative scoliosis – connected with spinal stenosis Pain unsuccessfully treated conservatively, with neural deficit University Hospital Brno, Orthopaedic Dept Brno-Bohunice Spondylolysis  isthmus reparation  posterolateral fusion with instrumentation University Hospital Brno, Orthopaedic Dept Brno-Bohunice Spondylolisthesis 1. Decompression 2. Posterolateral fusion w/wo instrument. 3. PLF, decompression, instrumentation 4. partial – complete reduction, post. instrum. + 360° fusion: PLIF - TLIF, ALIF University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice Spine tumours - imminent/present vert body colaps - imminent/present neural deficit - neural deficit progression Life expectancy more than 3 months (6 weeks?) University Hospital Brno, Orthopaedic Dept Brno-Bohunice Indication of surgery type - tumour localisation - tumour extent - age - condition of patient University Hospital Brno, Orthopaedic Dept Brno-Bohunice Posterior surgery - posterolateral decompression - decompression+instrumentation - decompr., instrum., fusion University Hospital Brno, Orthopaedic Dept Brno-Bohunice Anterior surgery - decompression, vertebral body replacement - bone cement with K-wires - pelvic autograft - allograft - cages - Harms - expansive – Synex, X-tens University Hospital Brno, Orthopaedic Dept Brno-Bohunice Combined surgeries University Hospital Brno, Orthopaedic Dept Brno-Bohunice - 2 simultaneous surgeries - one day with turning the patient - 2 stages – one week interval (bleeding during surgery) Goals of surgical treatment University Hospital Brno, Orthopaedic Dept Brno-Bohunice -improvement/prevention of neural deficit - restoring spine stability - pain relief - improving quality of life University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice Osteomyelitis of spine University Hospital Brno, Orthopaedic Dept Brno-Bohunice - unsuccessful antibiotic treatment (2 weeks) - fistula, abscesus formation - neural deficit and its worsening Anterior surgeries - removal of involved tissues - autograft replacement - instrumentation (anterior - posterior) University Hospital Brno, Orthopaedic Dept Brno-Bohunice Degenerative disc disease (osteochondrosis) - dysfunction - instability - stabilization University Hospital Brno, Orthopaedic Dept Brno-Bohunice Disc herniation University Hospital Brno, Orthopaedic Dept Brno-Bohunice - only clear cases (symptoms, MRI, exam) - radicular symptoms, unsuccessful conservative treatment - 6 weeks - cauda equina syndrome !! Disc protrusion - no indication of surg !! Discectomy - decompression University Hospital Brno, Orthopaedic Dept Brno-Bohunice - conventional - open - with microscope – less invasive - endoscopic Total disc endoprosthesis (titanium plates - PE) University Hospital Brno, Orthopaedic Dept Brno-Bohunice -conservative treatment of back pain more than 6 months (L2 - S1) - normal i.v. joints - without spondylolisthesis - spinal stenosis - disc narrowing (4 mm) University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice Dynamic stabilization University Hospital Brno, Orthopaedic Dept Brno-Bohunice Titanium screws connected with cord and plastic spacer (without fusion) - angle, translational instability - connected with disc herniation - spinal stenosis University Hospital Brno, Orthopaedic Dept Brno-Bohunice Spinal stenosis 2. Lateral - lateral recessus - radicular canal - foraminum University Hospital Brno, Orthopaedic Dept Brno-Bohunice Etiology, pathomechanism Theory of nerve structures compression (ischemia, oedema, inflammation) Theory of vascular compression – multilevel stenosis (venous congestion) University Hospital Brno, Orthopaedic Dept Brno-Bohunice clinical cases  congenital stenosis 3 – 13%  acquired 75%  combined others University Hospital Brno, Orthopaedic Dept Brno-Bohunice Radiological definition of LS stenosis Verbiest – AP canal diameter - relative 10 – 12 mm - absolute bellow 10 mm Dural sac area bellow 75 mm² two levels bellow 100 mm² Lateral recessus bellow 3 mm University Hospital Brno, Orthopaedic Dept Brno-Bohunice Clinical symptoms = LS stenosis  none ( 20% pts. above 60 yrs. ) = „narrow spine canal“  radicular syndrome  cauda equina syndrome  neurogenic claudication University Hospital Brno, Orthopaedic Dept Brno-Bohunice Neurogenic claudication  standing, gait – pain, parestesia, weak lower extremities  worsening – extension, downhill gait  improvement – sitting, squatting, flexion  gait limited - fluctuate University Hospital Brno, Orthopaedic Dept Brno-Bohunice Neurogenic claudication - stenosis of minimum 2 levels - intermitent hypoxia of cauda equina - disorder of venous drainage - mild back pain - 1/3 of pts. with paresis University Hospital Brno, Orthopaedic Dept Brno-Bohunice - anamnesis, Oswestry quest. - neurological examination - treadmill gait - EMG 50% pts. radiculopathy bilat. 20% monoradiculopathy - EMG after stress University Hospital Brno, Orthopaedic Dept Brno-Bohunice Diagnostics University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice X-rays of L spine - plain: AP and lateral - functional ( flexion / extension ) University Hospital Brno, Orthopaedic Dept Brno-Bohunice X-rays: Wiltse and Winter method of measurement University Hospital Brno, Orthopaedic Dept Brno-Bohunice Dupuis et al. method University Hospital Brno, Orthopaedic Dept Brno-Bohunice Instability: flexion/extension  translational  8% Wood et al. 1994  rotational > 11° Louis 1985 Wood et al. 1994 University Hospital Brno, Orthopaedic Dept Brno-Bohunice Instability surgery:  fusion and instrumentation  dynamic stabilization University Hospital Brno, Orthopaedic Dept Brno-Bohunice Radicular deficit of L5 - 51 yrs University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice MRI examination  false positive 7-21%  functional MRI flexion/extension  MRI myelography University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice Contrast perimyelography in the past  now MRI is standard  functional X-rays University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice Management of mild and middle forms  physiotherapy, orthotics, analgetics, NSAIR drugs  psychofarm. / antidepresive drugs  kalcitonin ?  epidural corticosteroids ? University Hospital Brno, Orthopaedic Dept Brno-Bohunice Pain clinic  drugs  nerve blocks, injections  psychologist  invasive implants technologies University Hospital Brno, Orthopaedic Dept Brno-Bohunice Spinal cord / epidural stimulation  neuropathic pain  careful selection of patients  failed back surgery syndrome - only partial pain relief University Hospital Brno, Orthopaedic Dept Brno-Bohunice Spinal cord stimulation - percutaneous implantation (electrodes 4 – 8 polar) epidural - laminotomy in loc. anesthesia, testing period of 1 month pain relief more than 50%, then definitive implantation University Hospital Brno, Orthopaedic Dept Brno-Bohunice - symptoms more than 3 months, unsuccessful conservative treatment - gait 20 - 200 m - Oswestry quest. 40 - 65 % - VAS 4 - 7 - dural sac area bellow 100 mm2 University Hospital Brno, Orthopaedic Dept Brno-Bohunice Middle form of LSS – surgery indication Treatment of severe, progressive forms  PosteroLat. Decompression  PL. Dec. + fusion (F)  PLD + F + instrumentation (transpedicular screws) University Hospital Brno, Orthopaedic Dept Brno-Bohunice decompression posterolateral – laminectomy University Hospital Brno, Orthopaedic Dept Brno-Bohunice Selective decompression undercutting laminoplasty University Hospital Brno, Orthopaedic Dept Brno-Bohunice Decompression + PL fusion University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice Posterolateral fusion 360° fusion - PLIF (grafts, cages) TLIF (combined surgery + anterior fusion) University Hospital Brno, Orthopaedic Dept Brno-Bohunice Decompr., fusion, transped. screws University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice University Hospital Brno, Orthopaedic Dept Brno-Bohunice Complications  dural sac tears, root injury  wound infection  urinary infection, lung embolism  ament delirant syndrome  late - instability above fusion University Hospital Brno, Orthopaedic Dept Brno-Bohunice Results of surgeries Katz et al. 1997 improved 85% Airaksinen et al. 1977 improved 62% University Hospital Brno, Orthopaedic Dept Brno-Bohunice Conclusion  conservative management  surgery – clear diagnosis University Hospital Brno, Orthopaedic Dept Brno-Bohunice