Neurosurgical Updates 2016 Brain & Spine Symposium: Presented by: Mary L. Dombovy, MD, MHSA Paul K. Maurer, MD Anthony L. Petraglia, MD Patrick J. Reid, MD Matthew L. Dashnaw, MD, Pharm D M. Gordon Whitbeck, Jr., MD

Putting Your Back Front and Center Lumbar Disc Disease Putting Your Back Front and Center Presented by Anthony L. Petraglia, MD Neurosurgeon Executive Director, Concussion Program Rochester Regional Health

Lumbar Disc Disease Low Back Pain: major public health concern 60 – 90% of adults experience back pain at some point in their life.  incidence age 35 - 55 y.o. 90% resolve in 1 - 2 months 7% become chronic Most patients with LBP improve on their own in time (even without treatment). LBP is extremely common; a majority of individuals will experience at least one episode of it in their life Second leading cause of physician visit behind common cold

Discogenic LBP v. ??? Evaluation of patients with LBP should be geared towards identification of those patients with a potentially serious underlying etiology. Cancer Infection – osteo, abscess Fracture Cauda Equina Syndrome Previous hx of cancer, unexplained weight loss Immunosuppression, hx of steroid use, hx of IV drug abuse, hx of skin/other infection(s) Hx of recent falls or trauma (including surgery) Bladder dysfunction (usually urinary retention or overflow incontinence) or fecal incontinence, “saddle anesthesia”, leg weakness Pain that doesn’t improve with rest; failure to improve after 4 weeks conservative management

Degenerative Disc Disease (DDD) DDD sort of a “wastebasket term” While the changes are indeed “degenerative,” this happens as we age Is not necessarily indicative of any significant underlying pathology or condition Overwhelming majority of individuals > 60 will show some type of degenerative change(s) on lumbar imaging Back pain is strongly associated with degeneration of the intervertebral disc DJD is often used to describe age-related changes on MRI, etc.

Hydrostatic, load bearing structure between the vertebral bodies Nucleus pulposus + annulus fibrosus No blood supply ----------------------------- Annulus Fibrosis -- Type 1 collagen fibers (wrap) and Nucleus pulposus Type 2 collagen and hydrophilic proteoglycan (hydrated mostly made up of water)

Disc Degeneration loss of disc height loss of water content fibrosis and end plate sclerosis

Also mechanical stressors affect nutrient supply

Herniated Nucleus Pulposus Classic presentation is radiculopathy The disc herniation impinges upon a nerve root, causing characteristic pain. Aggravating and alleviating factors May be assoc. with numbness/tingling Also as a part of this --- patients can develop disc herniation Pain may be worsened by sitting, straining, coughing or sneezing, and may be relieved upon standing or flexing the knee and thigh. There may also be associated numbness and weakness of the affected leg.

Clinical Story Is Everything Evaluation Motor/Dermatomal patterns L3-4 (5%) L4-5 (40-45%) L5-S1 (45-50%) Root usually compressed L4 L5 S1 Weakness Quadriceps, ant tib (knee extension, dorsiflexion) EHL (big toe extension) Gastrocnemius, soleus (plantar flexion) Sensory loss Medial foot, medial calf Big toe, dorsum of foot Lateral foot, bottom foot Reflex diminished Patellar --- Achilles

Role of Imaging An integral part of the evaluation of the patient with signs and symptoms of spine disorder The studies (MRI,CT etc) VERIFY the plan, should not drive it Abnormalities in more than 30% of asymptomatic volunteers Boden SD et al: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am 1990;72:403-408. Morbidity ?? Costs ?? Findings do not always = symptoms Findings do not always = surgery Will find most recommendations are to not obtain imaging prior to 4-6 weeks - unless red flag of some sort

Bulge v. Protrusion v. Extrusion Bulge – generalized disc displacement involving 50-1005 circumference --- is not considered a disc herniation; can be symmetrical or assym Intravertebral disc herniation aka Schmorls node Annular tear

Lumbar HNP 90% of herniated discs are paracentral (slightly off to one side) affect the nerve root that corresponds to the lower vertebral level. Example: a typical L4-5 disc herniation would cause symptoms referrable to the L5 nerve root. As many as 10% of herniated discs, however, are “far lateral” and impinge upon the nerve root that corresponds to the upper vertebral level. A far lateral disc hernation at L4/5, then, would be expected to cause symptoms relative to the L4 root.

Woman with Anterolateral thigh, medial calf pain; Dorsiflexion weak

Conservative Treatment Pharmacologic NSAIDs Muscle Relaxants Opiates/Non-Opiate Pain Rx Neuromodulators Steroid taper Topical Analgesic Non-Pharmacologic Heat/Ice Physical Therapy Chiropractic Therapy Acupuncture Massage Therapy Epidural Injections - The overwhelming majority of people with a herniated disc will get better TOPICAL: gels creams lotions, lidocaine patches, salonpas, biofreeze Neuromodulators: gabapentin, lyrica, TCAs, cymbalta Patient Education!!!

Surgery In the carefully chosen patient … “Surgery provides faster pain relief and perceived recovery in patients with herniated disc.” Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. Jama. 2006;296:2451–9. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. Jama. 2006;296:2441–50. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine. 1983;8:131–40. Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1- year outcomes of surgical and nonsurgical management of sciatica. Spine. 1996;21:1777–86. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245– 56. Several randomized trials and large prospective cohorts have demonstrated that ….

Surgery Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT) Spine 2014 Jan 1; 39(1): 3–16. “ In patients with a herniated disc confirmed by imaging and leg symptoms persisting for at least 6 weeks, surgery was superior to non-operative treatment in relieving symptoms and improving function. In the as-treated analysis, the treatment effect for surgery was seen as early as 6 weeks, appeared to reach a maximum by 6 months and persisted over 8 years; it is notable that the non-operative group also improved significantly and this improvement persisted with little to no degradation of outcomes in either group (operative and non-operative) between 4 and 8 years.” Long term analysis holds up

Laminectomy

Goals of Surgery Free up nerve from compression Allow nerve chance to heal Early mobilization

Personal Philosophy Patient Centered Approach Informed and shared decision-making Complete evaluation Thorough explanation of symptoms Discussion of non-operative and operative tx options Develop personal relationship with good communication and empathy committed to listening to and guiding the patient, with respect and compassion. Only Through this process, we empower our patients to make the best decision for their treatment.