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

3. No conflict of interest.
No disclosures.

4. 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

9. Neurogenic claudication Stenosis Spondylosis Spondylolisthesis
Terms
Radiculopathy
Neurogenic claudication
Stenosis
Spondylosis
Spondylolisthesis
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10. Ligamentum flavum removal Microdiscectomy Neuroforaminotomy
Surgical Terms
Laminectomy
Laminotomy
Ligamentum flavum removal
Microdiscectomy
Neuroforaminotomy
Medial facetectomy
Minimal Invasive Surgery (MIS)
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12. Example of degenerative processes of spine – spondylosis ad spondylolisthesis

13. 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.
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14. 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
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15. 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
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16. Low Back Pain
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17. 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)

18. 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)

19. 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)

21. Yoga! (Yoga Lite)

22. 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
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23. 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
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24. 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

26. 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
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29. 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.

32. 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.

35. 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.
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36. 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
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37. Neurogenic claudication

38. 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

39. 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

40. 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).

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

42. 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.

43. 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

44. L 4/5

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

46. 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%).
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47. 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

48. 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

49. 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
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50. CES, large L5/S1 disc

51. 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):
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52. Thank you