Surgical Treatment of Low Back Pain and Radiculopathy Andy Nemecek, MD

No conflict of interest. No disclosures.

Introduction Anatomy / Terms Cases Low back pain (work comp) HNP w/ radiculopathy Lumbar stenosis w/ neurogenic claudication Lumbar spondylolisthesis w/ radiculopathy Cauda Equina Syndrome OHSU Spine Center

Neurogenic claudication Stenosis Spondylosis Spondylolisthesis Terms Radiculopathy Neurogenic claudication Stenosis Spondylosis Spondylolisthesis OHSU Neurological Surgery

Ligamentum flavum removal Microdiscectomy Neuroforaminotomy Surgical Terms Laminectomy Laminotomy Ligamentum flavum removal Microdiscectomy Neuroforaminotomy Medial facetectomy Minimal Invasive Surgery (MIS) OHSU Neurological Surgery

Example of degenerative processes of spine – spondylosis ad spondylolisthesis

Low Back Pain at Work (Workman’s Compensation) 36 yo M HPI: New onset LBP after lifting heavy at 8 weeks ago (has not worked since). Has failed NSAIDs, rest, PT. Exam: Tender low lumbar paraspinous musculature. Full strength, except give-away weakness hip flexion due to pain. OHSU Neurological Surgery

Low Back Pain at Work (Workman’s Compensation) Red Flags: Bowel or bladder dysfunction Weakness Increasing pain despite time (rest, NSAIDs) Imaging workup: X-rays, r/o fracture, instability, spondylolisthesis MRI, r/o herniated disc OHSU Neurological Surgery

Low Back Pain at Work (Workman’s Compensation) Imaging: X-rays, degenerative L5/S1 disc MRI, degenerative L5/S1 disc Treatment: ACP guidelines for LBP NSAIDs Non-invasive treatments OHSU Neurological Surgery

Low Back Pain OHSU Neurological Surgery

Low Back Pain: ACP Clinical Practice Guidelines Recommendation 1: Acute or Subacute LBP Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Low Back Pain: ACP Clinical Practice Guidelines Recommendation 2: Chronic LBP, nonpharmacologic For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

Low Back Pain: ACP Clinical Practice Guidelines Recommendation 3: Chronic LBP, pharmacologic In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

Yoga! (Yoga Lite)

Low Back Pain at Work (Workman’s Compensation) F/U Patient returns in 4 wks without improvement (Now, 12 weeks from injury) Unable to work d/t LBP Return to Work: PT: Functional Capacity Exam Work limitations for APF / WC form PT: Work Hardening OHSU Neurological Surgery

Low Back Pain at Work (Workman’s Compensation) F/U Patient returns after work hardening by able to return to work 4 months after injury. Notes: W/C difficult Confidence in returning full duty Secondary gain issues (conscious / subconscious) The longer a patient is off work, less likely patient will return OHSU Neurological Surgery

Lumbar Herniated Disc with Radiculopathy 25 yo M HPI: New onset left leg pain and foot drop after lifting dresser. Exam: L plantar flexion weakness 2/5 (S1) Diminished L ankle jerk (S1) OHSU Neurological Surgery

Lumbar Herniated Disc with Radiculopathy Treatment Options: NSAIDs Solu-Medrol dose pack Neurontin / Lyrica Physical Therapy Chiropractor (traction) Inversion table Acupuncture (2d relief) Epidural steroid injection Surgery, discectomy OHSU Neurological Surgery

SPORT, patient randomized 13 centers, 2500 patients 501 surgical candidates with lumbar disc herniation, w/ 6 weeks of radiculopathy. Randomized “standard open discectomy” vs. non-operative treatment Trial contaminated by patient crossover surgical (50%) to non-surgical (30%) groups. Treatment superiority was inconclusive. F/U 4 year study of “as-treated” showed surgical superiority.

SPORT, 4 yr f/u “as-treated” lumbar disc herniation. 501 original cohort, 743 observational cohort. “Standard open discectomy” vs. non-operative treatment. Surgical group maintained greater improvement in all categories, except for work status.

Conclusion: Lumbar Herniated Disc with Radiculopathy Most patients improve. Discectomy offered: Incapacitating radicular pain at any time point. Radicular pain > 6 wks. Worsening motor weakness. Not offered (in general): Back pain only. Improving symptoms. Sensation loss only. OHSU Neurological Surgery

Lumbar Stenosis w/ Neurogenic Claudication 76 yo F HPI Burning pain into anterior thighs after walking 1 block Better with lumbar flexion. Exam Hunched posture Full strength OHSU Neurological Surgery

Neurogenic claudication

Lumbar Stenosis w/ Neurogenic Claudication Treatment Options: NSAIDs Solu-Medrol dose pack Neurontin / Lyrica Physical Therapy Chiropractor (traction) Inversion table Acupuncture (2d relief) Epidural steroid injection Surgery, laminectomy OHSU Neurological Surgery

2015, 4-year outcomes of surgery vs 2015, 4-year outcomes of surgery vs. conservative treatment for patients with symptomatic lumbar stenosis. Treatment standard decompressive laminectomy vs typical non-operative care. Outcomes wSF-36 Bodily Pain, Physical Function scales and the modified ODI

70% of those randomized to surgery and 52% of those randomized to non-operative (group) had undergone surgery by 8 years. 4-yr benefit of surgery, appeared disappear by the 6th to 8th postoperative year. (many patients lost f/u).

Insurance: Surgery Authorization Criteria Molina utilizes McKesson InterQual - Evidence Based Clinical Criteria Surgery algorithms Example: Surgery approval algorithm for spinal stenosis

Lumbar Stenosis w/ Neurogenic Claudication SPORT study, 2015, spinal stenosis treated with/without surgery showed improvement in short term 4-year outcomes; however, the two arm-results (surgical vs. non-surgical) converged at 8 years. Surgical Recommendations: Severe stenosis w/ neurogenic claudication symptoms for > 3 months. Moderate stenosis w/ Incapacitating neurogenic claudication.

Lumbar Spondylolisthesis w/ Radiculopathy 72 yo M HPI Right L4 radiculopathy Better after ESI for few weeks Exam Right dorsiflexion 4+/5 strength (L4) Absent L knee jerk (L4) OHSU Neurological Surgery

L 4/5

Lumbar Spondylolisthesis w/ Radiculopathy Tx: NSAIDs / Tyelonel Medrol dose pak Physical Therapy Chiropractic manipulation Spine Yoga Surgery, decompression plus/minus fusion. OHSU Neurological Surgery

OHSU Neurological Surgery 13 centers in 11 states (SPORT) 380 pts, > 12 wks symptoms Surgical procedures: decompressive laminectomy with posterolateral in situ fusion (21%; PLF 80 patients) posterolateral instrumented fusion with pedicle screws (56%; Pedicle Screws (PS) 213 patients) pedicle screws plus interbody fusion (17%; 63 patients 360 degree surgery) laminectomies alone (6%). OHSU Neurological Surgery

Surgery showed significant improvement over non-surgical. Outcomes were assessed at 1.5, 3, 6 months, and yearly up to 4 years utilizing the SF-36 and the modified ODI. 2 years, 360 fusions showed better outcomes, but “no consistent differences in clinical outcomes were seen among fusion groups over 4 years.” Surgery showed significant improvement over non-surgical. Non-instrumented and instrumented fusions yielded comparable results

Conclusion: Lumbar Spondylolisthesis w/ Radiculopathy Symptomatic degenerative spondylolisthesis have improvement long-term with surgery. SPORT trial did not show significant difference in decompression alone vs. non-instrumented vs. instrumented fusion. OHSU Neurological Surgery

Cauda Equina Syndrome 32 yo F HPI Exam Acute onset LBP, foot weakness, numb bottom, difficulty voiding. Exam B plantar flexion weakness 1/5 strength, saddle anesthesia, flaccid sphincter tone, absent ankle jerks OHSU Neurological Surgery

CES, large L5/S1 disc

Cauda Equina Syndrome Tx: Outcome: Surgery: Discectomy <48, best (controversial) Level of neurological dysfunction at surgery (incomplete CES vs. CES w/ retention) is most significant Bečulić H, Skomorac R, Jusić A, et al. Impact of timing on surgical outcome in patients with cauda equina syndrome caused by lumbar disc herniation. Med Glas (Zenica). 2016;13(2):136-41. OHSU Neurological Surgery

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