Brad Elder, MD - Neurosurgery Greg Weidner, MD

Brad Elder, MD - Neurosurgery
Greg Weidner, MD - Anesthesia
Jennifer Belu, PT, MPH - Physical Therapy
Elizabeth Yu, MD - Orthopedics
Case Presentation – Herniated Lumbar Disc
 A 36 year old male was lifting at work and felt a
twinge in his back.
 That evening, he felt more severe low back pain.
 The pain was so severe, he found it difficult to get
out of bed. He could flex minimally.
 On the fifth day the back pain improved and he
began to have pain down the left leg.
 The pain was into the posterior thigh and into the left
heel.
 He had numbness in the small toe and outside of the
right foot.
 When he sneezed or had a bowel movement the leg
pain was increased.
Case Presentation – Herniated Lumbar Disc (cont)
 His exam showed an absent left AJ, a positive
SLR on the left and had no tenderness or
weakness.
 With flexion he had pain into the left buttock and
with extension had minimal back pain.
Disk Herniation
J. Bradley Elder, MD
Assistant Professor
Department of Neurological Surgery
Disk herniation - Anatomy
 Tear in the annulus
fibrosus
 Extrusion of nucleus
pulposus
 Disk ‘bulge’ or
‘protrusion’
 No extrusion of nucleus
pulposus outside the
borders of the annulus
 Locations
 Posterolateral
 Central
 Far lateral
ELDER
Disk herniation
 Physiology
 Symptoms:
 Radiculopathy
 Back pain
 Neurologic deficits
 Inflammatory reaction
to annular tear can
irritate nerve root
 Direct compression of
disk
ELDER
Disk herniation
 Physical examination




Motor
Sensory
Reflexes
Straight leg raise
 History
 “cough effect”
 No precipitating
event
ELDER
Disk herniation
 Lumbar
 95% at L4/5 or L5/S1
 Cervical
 C5/6 and C6/7
 Thoracic
 Much less common
ELDER
Disk herniation
 Natural history
 Most patients will improve without surgical
intervention (85% in 6 weeks)
 Urgent surgery – cauda equina, progressive
neurologic deficit, severe motor weakness
 Symptom control
 Activity modifications
 Injections
 Oral medications (pain, steroids, muscle relaxants)
 Surgery
ELDER
Disk herniation
ELDER
The Patient with a Herniated Disc
 Medical management





Oral Steroids
NSAIDS
Muscle relaxants
Opiates
Bowel regimen
 Interventional techniques
WEIDNER
The Patient with a Herniated Disc
 Medical Management
 NSAIDS may need to cycle for efficacy
 Opiates Start with mild opiates, limit number,
combine with NSAID, careful with acetaminophen
 Muscle relaxants Carisprodol highly euphoric
inducing
 Gabapentin May help with sleep
 Topical Creams or OTC agents
 Heat and Ice
 Bowel regimen
WEIDNER
The patient with a Herniated Disc
 Interventional Techniques
Transforaminal highly effective for short term
relief
Surrounds the nerve root with
combination of steroid and local anesthetic
Intralaminar approach best suited for patient with
minimal radicular complaints, e.g., the central
disc herniation
WEIDNER
The Patient with a Herniated Disc
 Transforaminal ESI
Believed to be effective by lowering
phospholipase levels –PL A2 the rate limiting
step in production of leukotriene's and
prostaglandins
Combining image guided injections with physical
therapy described as 90% effective in one study
WEIDNER
WEIDNER
The Patient with a Disc herniation
 Side-Effects
 Insomnia, transient hyperglycemia, local irritation,
leg cramps
 Contraindications to Interventional Techniques
Anti-Coagulant therapy
Infection
WEIDNER
Low Back Pain: Physical Therapy Perspective – Jennifer Belu, PT, MPH
 Controlling pain
 Centralization of symptoms
 Therapeutic exercise
 Return to activities
BELU
18
Lumbar HNP: controlling symptoms
 Back “First Aid”




“neutral spinal position”
lumbar taping to promotion neutral position
avoid peripheralization of symptoms
medication as recommended by primary care
provider
 Positions to alleviate radiculopathy
BELU
Lumbar HNP: Centralization of symptoms
 Assessed at Physical Therapy evaluation: flexion
versus extension bias (typically extension)
 Repeated motions: if result in centralization of
symptoms would utilize in treatment (i.e.
McKenzie approach)
 Utilize positional motion/therapeutic exercise to
alleviate symptoms throughout patient’s day
BELU
Lumbar HNP: therapeutic exercise
 Strengthen musculature effected by injury: spinal
“stabilizers”
 Morphologic changes with disc injury in porcine
subjects on ipsilateral lumbar mulitifidi
 Start in positions of most support/least symptoms
(prone, supine knees flexed)
 Move to less supportive, more functional
positions
BELU
Lumbar HNP: return to activities
 Work modifications (standing desk set up for
varying positions)
 Look at home set up (lumbar support when
sitting)
 Walk before jog
 Taming the “weekend warrior”
BELU
Disc Herniations: Surgical Intervention – Elizabeth Yu, MD
INDICATIONS
 Progressive neurological
deficit
 Caudal equina
 Failure of improvement of
extremity symptoms after
6-8 weeks of conservative
treatment
 Intractable extremity pain
http://www.mayoclinic.com/health/medical/IM01274
Bono, CM. Instructional Course Lectures: Spine 2. 2010.
YU
CASE EXAMPLE:
 43 year old female with left L5 radiculopathy
 Left lower extremity pain > back pain
 Underwent left L5 TFESI
 Failed medication
 Medrol dose pack, NSAIDs
 Failed physical therapy
 Developing dynamic foot drop
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Procedure
 Traditional open microdiscectomy
 Midline incision
 Minimally invasive microdiscectomy
 1.5 cm lateral midline
 Muscle splitting technique
 Goals
 Minimal removal of bone to gain entry into the spinal canal
 Subtotal versus limited discectomy
http://www.davisandderosa.com/Injuries-Conditions/Lower-Back/LowerBack-Surgery/Lumbar-Discectomy/a~410/article.html
http://www.siddiqimd.com/technology/technology-in-treatment.htm
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Procedure
 Traditional open microdiscectomy
 Direct visualization
 Minimally invasive microdiscectomy
 Range from use of tubular retractors
 To endoscopic technique
http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFO
RMATION-FlexMember-Show_Public_HFFY_1105110033945.html
http://www.jedpwebermd.com/procedures.html
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Outcomes: Open versus MIS
 Similar regardless of approach:
 Lau et. al. 2011 – no difference in open versus MIS
 operative time, length of stay, neurological outcome,
complication rate, or change in pain score (pain
improvement).
 Harrington et. al. 2008 – no difference in open versus MIS
 Surgical times, blood loss, complications, and outcome
 Pain medication and hospital stay less in MIS group
 German et. al. 2008 – similar perioperative results
 Smith et. al. 2010 – comparable results with
microendoscopic discectomy and open discectomy
 pain, disability, and functional health
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Outcomes
 Successful procedure
 Profound improvement of pain when awaken
 Followed by strength and paresthesias
 SPORTs trial
 2 year follow up: Patient improvement
 Physical function
 Satisfaction
 4 year follow up: No statistical difference between
improvement in nonoperative and operative group
 Maintenance of improvement in operative group
•"Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes
Research Trial: A Randomized Trial" JAMA 296(20):2441-2450, 2006.
•"Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes
Research Trial Observational Cohort" JAMA 296(20):2451-2459, 2006.
•"Surgery Vs Non-Operative Treatment for Lumbar Disk Herniation: Four-Year Results from the Spine
Patient Outcomes Research Trial (SPORT)" Spine 33(25):2789-2800, 2008.
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Outcomes: Patient factors
 Psycological factors influence patient perception of successful
outcomes
 ODI or Oswestry Disability Index
 SF-36 or Short Form-36
 Smokers:
 Vogt, et. al. – Smokers have baseline significantly lower function
on SF-36.
 1 year postoperative: no significant improvement in SF-36 scores
compared to nonsmoker counterparts
 Education level and self reported health:
 Independent predictor of poor self-reported function at baseline
 ODI and SF-36
 Other studies have implicated:
 Depression, unemployment, legal status
 Obesity:
 Negative influence on SF-36 and ODI scores
 Greater pain than nonobese patients
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Complications
 Risk of reherniation: occurs in 5-15% of patients
 Surgical intervention not necessary required
 Surgical approach no different
 Infection
 Dural tear
 Long term outcomes the same as no dural tear
http://www.dartmouth.edu/sport-trial/whatissport.htm#WhatResults
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Laser spine surgery
 Misnomer
 Incision 1” to 2”
 Laser to ablate tissue
 Studies
 Review of the literature 2013 by Singh et. al.
found little RCTs (1966 to 2012)
 Limited evidence for percutaneous laser disc
decompression
 Usually used for broad based discs to shrink the
disc
http://health.howstuffworks.com/medicine/modern-treatments/laser-spine-surgery.htm
http://www.laserspineinstitute.com/about/lsi_history/
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Most commonly thought of…
 Use the word MISS with use of endoscope
 Laser or thermal ablation is used to denervate the
sensory nerves
http://www.laserspineinstitute.com/about/lsi_history
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Discussion and Questions

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