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 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 Degenerative scoliosis – connected with spinal stenosis Pain unsuccessfully treated conservatively, with neural deficit Pain unsuccessfully treated conservatively, with neural deficit University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Spondylolysis isthmus reparation isthmus reparation posterolateral fusion with instrumentation posterolateral fusion with instrumentation University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Spondylolisthesis 1. Decompression 2. Posterolateral fusion w/wo instrument. 2. Posterolateral fusion w/wo instrument. 3. PLF, decompression, instrumentation 3. PLF, decompression, instrumentation 4. partial – complete reduction, post. instrum. 4. partial – complete reduction, post. instrum ° fusion: PLIF - TLIF, ALIF + 360° fusion: PLIF - TLIF, ALIF 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 deficit - restoring spine stability - pain relief - improving quality of life

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 - Prodisc (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) (L2 - S1) - normal i.v. joints - without spondylolisthesis - spinal stenosis - disc narrowing (4 mm)

University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Dynamic stabilization - DYNESYS 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 - lateral recessus - radicular canal - radicular canal - foraminum - foraminum University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Etiology, pathomechanism Theory of nerve structures compression (ischemia, oedema, inflammation) Theory of nerve structures compression (ischemia, oedema, inflammation) Theory of vascular compression – multilevel stenosis (venous congestion) Theory of vascular compression – multilevel stenosis (venous congestion) University Hospital Brno, Orthopaedic Dept Brno-Bohunice

clinical cases 3 – 13% congenital stenosis 3 – 13% acquired 75% acquired 75% combined others combined others University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Radiological definition of LS stenosis Verbiest – AP canal diameter - relative 10 – 12 mm - relative 10 – 12 mm - absolute bellow 10 mm - absolute bellow 10 mm Dural sac area bellow 75 mm² two levelsbellow 100 mm² two levelsbellow 100 mm² Lateral recessus bellow 3 mm University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Clinical symptoms = LS stenosis ( 20% pts. above 60 yrs. ) none ( 20% pts. above 60 yrs. ) = „narrow spine canal“ = „narrow spine canal“ radicular syndrome radicular syndrome cauda equina syndrome cauda equina syndrome neurogenic claudication neurogenic claudication University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Neurogenic claudication standing, gait – pain, parestesia, weak lower extremities lower extremities worsening – extension, downhill gait worsening – extension, downhill gait improvement – sitting, squatting, flexion improvement – sitting, squatting, flexion gait omezena - fluctuate gait omezena - fluctuate University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Neurogenic claudication - stenosis of minimum 2 levels - intermitent hypoxia of cauda equina - intermitent hypoxia of cauda equina - disorder of venous drainage - disorder of venous drainage - mild back pain - mild back pain - 1/3 of pts. with paresis - 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

X-rays of L spine - plain: AP and lateral - functional ( flexion / extension ) - functional ( flexion / extension ) University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Wiltse and Winter method University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Dupuis et al. method University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Instability: flexion/extension translational  8% translational  8% Wood et al Wood et al rotational > 11° rotational > 11° Louis 1985 Louis 1985 Wood et al.1994 Wood et al.1994 University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Instability surgery: fusion and instrumentation fusion and instrumentation dynamic stabilization DYNESYS, other methods dynamic stabilization DYNESYS, other methods University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Radicular deficit of L yrs University Hospital Brno, Orthopaedic Dept Brno-Bohunice

MRI examination false positive 7-21% functional MRI flexion/extension functional MRI flexion/extension MRI myelography MRI myelography University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Contrast perimyelography standard? functional X-rays functional X-rays University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Management of mild and middle forms orthotics, analgetics, NSAIR drugs physiotherapy, orthotics, analgetics, NSAIR drugs psychofarm. / antidepresive psychofarm. / antidepresive kalcitonin ? kalcitonin ? epidural corticosteroids ? epidural corticosteroids ? University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Pain clinic drugs nerve blocks, injections nerve blocks, injections psychologist psychologist invasive implants technologies invasive implants technologies University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Spinal cord / epidural stimulation neuropathic pain careful selection of patients careful selection of patients failed back surgery syndrome failed back surgery syndrome - only partial pain relief - only partial pain relief University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Spinal cord stimulation - percutaneous implantation (electrodes 4 – 8 polar) epidural (electrodes 4 – 8 polar) epidural - laminotomy in loc.anesthesia, - laminotomy in loc.anesthesia, testing period of 1 month testing period of 1 month pain relief more than 50%, pain relief more than 50%, then definitive implantation then definitive implantation University Hospital Brno, Orthopaedic Dept Brno-Bohunice

- symptoms more than 3 months, unsuccessful conservative treatment - gait m - Oswestry quest % - VAS dural sac area bellow 100 mm 2 University Hospital Brno, Orthopaedic Dept Brno-Bohunice Middle form of LSS – surgery indication

Treatment of severe, progressive forms PosteroLat. Decompression PL. Dec. + fusion (F) PL. Dec. + fusion (F) PLD + F + instrumentation (translaminar screws) PLD + F + instrumentation (translaminar screws) PLD + F + instrumentation PLD + F + instrumentation (transpedicular screws) (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

Decompression, fusion, translam. screws 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

Complications dural sac tears, root injury wound infection wound infection urinary infection, lung embolism urinary infection, lung embolism ament delirant syndrome ament delirant syndrome late - instability above fusion late - instability above fusion University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Results of surgeries Katz et al improved 85% Airaksinen et al improved 62% University Hospital Brno, Orthopaedic Dept Brno-Bohunice

Conclusion onservative management conservative management surgery – clear diagnosis surgery – clear diagnosis University Hospital Brno, Orthopaedic Dept Brno-Bohunice