Lumbar Problems and their Surgical Results Mats Agren, M.D.

Lumbar Diagnosis Lumbar Disk Herniation (DH) Lumbar Spinal Stenosis (SS) Lumbar Degenerative Spondylolisthesis (DS)

Lumbar Diagnosis Lumbar Degenerative Disk Disease (DDD) Lumbar Degenerative Scoliosis (DSc)

Lumbar Diagnosis Rules Symptomatic not radiographic Bad enough? Going on long enough? Predicable enough? Limiting enough? Progressive enough?

DDD Natural History Genetic, not activity Small effect of smoking Twin studies Small effect of smoking Increased load in adolescents MRI + >30% in asymptomatic 10%/decade

DDD Diagnosis difficult Exam Radiographic vs clinical Focal pain Sitting intolerant Better staying active Focal MRI

DDD Treatment Conservative Surgical Aggressive PT/Exercise program Emotional/Psychological care Rare Injection Surgical >6 month agressive care Fusion vs Disk replacement

DSc Natural History ~70% elderly ~70% Left curve ~55% Spondylolisthesis ~40% Lateral Lishthesis >80% present with radicular pain

DSc Conservative care Surgery PT: Aerobic and core Tricyclics for night ? Gabapentin Brace: symptoms not curve Surgery Rare for curve Common for radicular pain

DH Disc Bulge Disk Protrusion Disk Extrusion Disk Sequestration “normal” degeneration Disk Protrusion Large base Disk Extrusion Small waist Disk Sequestration “free fragment”

DH Chemical Inflammation Mechanical Compression Pain +/- Neurological findings Less neurological tension Mechanical Compression Neurological Tension

DH Presentation Leg pain> back pain Dermatomal symptoms +/- Valsalva SLR Ipsilateral sensitive, not specific Contralateral specific, not sensitive Femoral Stretch Test(anterior thigh pain) L4 and above

DH Cauda Equina Conus Medullaris Rare Saddle Anesthesia Overflow Incontinence

DH Conservative Care 90% improve in 6 weeks Does not alter natural history Symptomatic relief NSAID ? Steroids ? Narcotics ESI Avoid 50% of surgery

DH Surgical Care Discectomy Micro vs regular >75% success Age Dependent Expectations % leg pain Neurologic Tension Signs

SS Symptoms Neurogenic Claudication Pain- >90% Numbness ~60% Standing Walking Extending Better Flexing Pain- >90% Numbness ~60% Weakness <50%

SS Natural History 9% of population 6th decade >90% at L4-L5 Radiographic severity poor clinical correlation 20% in asymptomatic

SS Natural History (>4 years) 70% unchanged 15% worse 15% improved

SS Work Up MRI CT/CT Myelogram +/- Xrays (Standing)

SS Central Lateral Only fair interobserver correlation Lateral recess Foraminal Extra Foraminal Usually DH Only fair interobserver correlation Surgical/Injection planning

SS Conservative Care PT: <60% improved in 6 weeks NSAIDS Older Population ? Narcotics ESI: <60% improved ? Number of shots ? Osteoporosis Diagnostic Test

SS Surgical Care Laminectomy Laminotomy >70% Improved Gold Standard Instability Laminotomy Less destruction >70% Improved 4% Instability

DS Common Usually L4-L5 More common in Women Most present with SS Back pain if instability Treat symptoms

DS Work Up Follow the symptoms Xrays with Dynamic views MRI/CT/CT Myelogram

DS Most Grade 1 or 2 Uncommon to progress Unstable or not? Young Tall disk Unstable or not?

DS Conservative care PT: Core and Aerobic program ESI (SS) Facet Injections (back pain) Diagnostic

DS Surgical Care Decompression Fusion 80% if stable If Unstable- Intrumentation +/- Interbody High fusion rate If Stable- ? In Situ High Psudoarthrosis rate, good outcomes Lower cost Lower complication rates

DS SPORT >80 Satisfaction ODI Cost Decreased 23 points with surgery Decreased 9 points with conservative care Cost QALY similar to THA/TKA

Questions? Mats Agren, M.D.