low back pain

1. low back pain Siddharth Shetgeri DO, MS Neurosurgeon Complex spine specialist Kettering Physician Network

2. Disclosures None

3. Low Back pain 

4.  Epidemiology:

5. Regions of the Spine • Cervical • Thoracic • Lumbar • Sacral

6. History

7. History • Mechanism of injury Fall/MVA/Work Injury • Associated symptoms:   • radicular distribution L2-S1 • Numbness / Tingling /Weakness • Most important is Bowel or Bladder incontinence • Prior injuries, treatment and outcomes • Medications • Family history • Social history: • Vocational • Education • Tobacco / ETOH / Illicit drugs • Litigation Personal Injury or Workman’s Compensation Claim

8. Pain Specifics • Quality:sharp, dull, shooting, burning, etc. • Location / Distribution: • Radicular:Dermatomal distribution, dysesthesias • Onset: • Gradual: DDD • Acute: Disc abnormality, strain, compression fractures • Severity / Intensity on a VAS (0-10) • Frequency: Constant vs. Intermittent • Duration • Exacerbating and Alleviating Factors

9. Red Flags • Significant trauma history • Any complaint in children, adolescence or adults <20 • Bladder or bowel incontinence or dysfunction • Major motor weakness

10. Radiographic Imaging

11. X-ray Views • Standard/Plain Films • Anteroposterior (AP) or Posteroanterior (PA)

12. X-ray Views • Special Views • Flexion: forward bend • Extension: backward bend • Purpose: evaluate motion segment instability

13. CT • Purpose:  • Detect bony tissue pathologies • Ideal for  • Spinal stenosis • Foraminal stenosis • Radiation Exposure

14. MRI • Purpose: • Detect soft tissue pathologies Best diagnostic tool for: • Soft tissue abnormalities: • Spinal canal and neural foraminal contents • Lumbar Herniated Disc • Lumbar Spinal Stenosis • Lumbar Degenerative Disc Disease  • Benign vs. malignant compression fractures • Evaluation with prior spinal surgery • Scar tissue evaluation  • Best for diagnosing degenerative disc disease

15. MRI • MRI should be done early in the diagnostic phase • Rules out dangerous pathology: Cauda Equina Syndrome • Allows following the health of the spine

16. Myelography • Purpose: • Show compression or displacement of neural elements • Reading: • Neural structures are dark • Contrast material white • Myelogram is indicated if patient has a pacemaker, defibrillator, foreign metallic body, cochlear implant.  

17. Lumbosacral Pathology

18. Lumbar Degenerative Disc Disease

19. Overview - cont. • The motion segment is the functional unit of the spine and consists of • Muscle • Ligaments • Adjacent vertebral bodies • A 3-joint complex of two facet joints and a disc (pivots) • Degeneration can begin in one or more of these joints, but ultimately all three will be affected

20. Anatomy and Degenerative Change • The Intervertebral Disc • Two major components of IVD • Annulus fibrosus: thick, fibrous “radial tire” • Nucleus pulposus: ball-like gel • Significant changes to IVD are: • Water and proteoglycan content decreases • Results in: • Disc loses height and volume • Loses resistance to loading forces • No longer acts as a shock absorber

21. Anatomy and Degenerative Change The Vertebral Body (VB) • Key Roles • Carry 80% of the axial loads through VB and disc • Endplates enable nutrition to diffuse to disc • Degenerative Changes • Sclerosis: Increased bone formation adjacent to endplates • Osteophytes: Formation of small bony spurs • Can project into nerves

22. Lumbar Spinal Stenosis • Narrowing of the spinal canal and/or lateral foramen through which the nerves travel • Two types: • Central stenosis • Lateral recess stenosis • Most frequent in  lower lumbar spine L4-L5

23. Lumbar Spinal Stenosis

24. Lumbar Spinal Stenosis Treatment • Conservative options include: • Physical Therapy • Epidural steroid injections • Severe stenosis / intractable pain candidates for surgery

25. Minimally invasive laminectomy

26. Lumbar Herniated Disc • Often called “ruptured disc” or “slipped disc” • L4-5, L5-S1 common locations 26

27. Treatment • Medications 1st Tier • NSAIDS - Naprosyn • Muscle relaxers Skelaxin, Flexeril or Robaxain • Neuropathic Pain meds Neurontin or Zonegran • Non-narcotic analgesics: Ultram • Narcotics: • Steroids: temporary relief for inflamed nerve root • Medrol Dose Pak • Physical therapy 1st Tier • Stretching / body work • Exercise / strengthening • Traction • Injections 2nd Tier • Epidural Facet blocks • Nerve blocks

28. Minimally invasive lumbar microdiscectomy

29. Degenerative Disc Disease Most common presentation of lumbosacral pain or low back pain • Those patients who present with degenerative disc disease without any central stenosis or disc herniations • Essentially minimal to mild spondylosis • Black Disc Disease on MRI • Source of back pain is the degenerative disc-discogram

30. Spondylolisthesis • Slippage of the L4 on the L5 vertebra • Translation best seen on a flexion / extension Xray • During normal daily routine there is essentially a grinding action leading to L4 and L5 radiculopathy

31. Degenerative Disc Disease treatment: spinal Fusion • lumbar fusion or essentially replace the disc material with a interbody device with pedicle screws. • Posterior Lumbar Interbody Fusion PLIF • Large incision • More blood loss, more pain

32. Minimally invasive spine surgery

33. Modern lumbar fusion

34. TLIF

35. TLIF • 1 level: 2-3 hour surgery • 2-3 day hospital stay • Disadvantage: smaller graft size, less fusion area

36. ALIF/OLIF • Powerful Minimally Invasive technique for fusion of lower lumbar levels (L4-5, L5-S1) • Powerful reduction of spondylolisthesis  • Great indirect foraminal decompression • Approach performed by vascular surgeon

37. ALIF/OLIF • 1 level: 2-3 hour surgery • 2-3 day hospital stay • Large graft size, good fusion potential inbuilt screws • Can be used standalone or supplemented with posterior screws

38. DLIF/XLIF • Direct lateral approach to upper lumbar levels (L2-3, L3-4) • ALIF cannot access upper lumbar levels due to great vessel anatomy • 1 level: 2-3 hour surgery • 2-3 day hospital stay • Can be used standalone or supplemented with posterior screws

39. DLIF/XLIF • 1 level: 2-3 hour surgery • 2-3 day hospital stay • Large graft size, good fusion potential inbuilt screws

40. Choice of minimally invasive lumbar fusion approach • Goal is to create smaller incisions • Less exposure • Less dissection • Less time in the hospital • Can mobilize, get involved in PT/OT faster • Less need for pain medications • Much less pain • Lower chance of needing future surgery • Less violation/devascularization of adjacent levels

41. Degenerative Disc DiseaseNON FUSION DEVICE •  Artificial Disc  • FDA approved for single level either L4-5 or L5-S1 • Symptoms are mainly from DDD back pain with minimal amount of leg pain due to disc bulging • Spine is able to maintain the six degrees of motion • Indications are limited

42. Degenerative Disc DiseaseNonfusion Device • Coflex device • Gives the spine some mobility and some stability • Off loads the disc space by transmitting the load through the metal spring 

43. Spinal cord stimulation • Used to treat neuropathic pain, where nerves are dysfunctional • Patient have failed conservative care and surgery • Non spine surgical candidates

44. Spinal cord stimulation • "Tricks" spinal cord into reducing the feeling of pain • Needs an SCS trial and if successful, permanent SCS placement • Most effective for 5 years • Outpatient minimally invasive surgery, patient goes home • 2 hours

45. Adult Spinal Deformity • Deformity of the adult spine • Mismatch of specific spinal deformity measurements & parameters • Severe back pain due to loss of compensatory mechanisms to keep • Head over pelvis • Horizontal gaze

46. Adult Spinal Deformity: goals of surgery

47. Robotic spine surgery Future directions

48. Robotic spine surgery

49. robotic spine surgery