1. Back Pain Christopher D. Sturm, M.D., F.A.C.S Medical Director Mercy Institute of Neuroscience & Mercy Regional Neurosurgery Center

2. Back Pain Extremely common Often accompanied by leg pain or numbness Adversely affects quality of life Lost time, work & money Can vary in intensity and duration, leading to significant frustration

3. Back Pain But……THERE IS HOPE! You Do NOT have to just “live with it”

4. Back Pain Can lead to nerve damage Permanent loss of some functions –Movement –Sensory –Bowel and Bladder control In some instances earlier treatment can lead to better outcomes

5. What to Do? “So, what the heck is going on?” “Can anything be done to fix it?” “What are my options?” “When should I start?” “What are the success rates?”

6. Causes of Back Pain Muscle spasm/inflammation/strain Degeneration or inflammation of the disc Degeneration or inflammation of the back (facet) joints Loss of normal alignment or instability Fracture Infection Tumor

7. Evaluation of Back Pain/Leg Pain Symptom history and physical exam findings –What makes it worse or better? –Location? –Duration? –Associated pain/numbness/weakness? –Bowel and bladder control? –Past medical history?

8. Evaluation of Back Pain/Leg Pain MRI imaging –Optimal to evaluate discs, nerves, alignment CT scan –Better visualization of the bone Plain X-rays –Screening test Bone Density study –Osteopenia/osteoporosis?

9. “So, what to do?” Depends on the cause of the pain Is there any associated loss of function? Are the symptoms significantly interfering with your quality of life? Any indication they are getting better? Have conservative therapies failed?

10. Conservative Therapy Symptom improvement without surgery Activity modification Pain medication Physical therapy Chiropractic intervention Injectional therapy

11. When is Surgery Appropriate? If the symptoms are significantly interfering with your quality of life, and have not improved with conservative therapy measures, for an appropriate period of time Any presence, or high risk of functional loss Instability Tumor Infection

12. Spinal Tumors - L1 Schwannoma

13. Myxopapillary Ependymoma

14. Advancements in Spine Improved imaging techniques Pathophysiology of degenerative disease Biomechanical advancements Image guidance Minimally Invasive techniques Mechanical implantation devices

15. Mercy Regional Neurosurgery Multi-Center National Studies CODA study –Posterior lumbar fusions In-Fix study –Anterior lumbar fusions Fortitude study –Cervical discectomy and fusions

16. Lumbar Degenerative Disease Initial desiccation of the disc Loss of structural integrity of the disc Loss of disc space height/potential HNP Abnormal loading and laxity of the facet joints Neuroforaminal compromise Malalignment and abnormal motion

17. Multi-level Lumbar Spondylosis

18. Surgical Options Lumbar discectomy Lumbar laminectomy Anterior lumbar interbody fusion (ALIF) Posterior lumbar interbody fusion (PLIF) Vertebroplasty/Kyphoplasty

19. Lumbar Discectomy Leg pain unresponsive to conservative therapy Progressive deficit Cauda equina syndrome Small incision Outpatient or next day discharge

20. Right L5-S1 Discectomy

21. Lumbar laminectomy Leg pain secondary to lumbar stenosis/lateral recess stenosis Failure of conservative therapy Older patients, slightly larger incision, longer stay Approximate 10% incidence of subsequent lumbar instability

22. Lumbar laminectomy

23. Anterior Lumbar Interbody Fusion (ALIF) Lumbar degenerative disc disease producing mechanical LBP & minimal radicular pain Localized concordant discogenic pain with discography at level(s) abnormal on MRI Anterior approach avoids injury to posterior lumbar musculature Suboptimal to address neural compression

24. Provocative discography

25. Anterior Lumbar Interbody Fusion

26. L4-5 ALIF 37 year old female with progressive mechanical LBP Right leg psuedoradicular pain Concordant L4-5 discogenic pain Failed conservative therapy

27. L4-5 In-Fix Cage

28. 3 Level ALIF with InFix Cages

29. Posterior Lumbar Interbody Fusion (PLIF) Mechanical LBP with associated radicular pain and/or neurological deficit –Degenerative disc disease/collapse/herniation –Facet joint hypertrophy with foraminal stenosis –Lateral recess and/or central spinal stenosis Spondylolysis/spondylolisthesis Lumbar instability

30. L4-5, L5-S1 PLIF 50 year old female with progressive LBP and bilateral radicular pain w/dysesthesia Intensifying pain despite previous L4-5 hemilaminectomy/discectomy Lumbar MRI – L4-5, L5-S1 DDD & NFS Concordant discogenic pain L4-5, L5-S1

31. Pre operative MRI

32. Cadence Cage

33. PEEK Lordotic Lumbar Cages

34. 3 Level PLIF w/PEEK Lordotic Cages

35. L5-S1 PLIF 49 year old female with progressive LBP and left leg radicular pain Dysesthesia left leg/foot MRI – L5-S1 DDD with left NFS Failed conservative therapy Concordant discogenic pain L5-S1

36. Pre-operative MRI

37. CODA Expandable Implant

38. Pre- and Post-operative Lateral Views

39. L5-S1 PLIF – CODA Cages

40. Minimally Invasive Spine Surgery Achieve same goals as “open” procedures Smaller incisions Less muscle trauma Utilization of image guidance Less post-operative pain Shorter hospitalization

41. 360 degree Lumbar revision – stand alone cages

42. 360 degree Lumbar revision – titanium mesh

44. Results Review of 5 years of practice data Using the treatment approach outlined here Improved or not? Fusion? Approximately 500 surgery patients 93% reported improvement as a result of their surgery 99% fusion rate

45. Multi-level Cervical Spondylosis

46. ACDF utilizing structural allografts

47. Remodeling Cervical Allograft

48. ACDF C4-5, C5-6 47 year old right handed female with posterior cervical pain and right arm radicular pain Right deltoid and biceps weakness Failed conservative therapy Cervical spondylosis C4-5, C5-6

49. Fortitude Ti Cages packed with Cerasorb, AcuFix Plate

50. Fortitude Cages and AcuFix Plate

51. PEEK Cervical Lordotic Cages packed with Cerasorb

52. Posterior cervical revision – allograft pseudoarthrosis & kyphosis