Brad Elder, MD - - Neurosurgery Neurosurgery Brad Elder, MD Greg - PowerPoint PPT Presentation

Brad Elder, MD - - Neurosurgery Neurosurgery Brad Elder, MD Greg Weidner, MD - - Anesthesia Anesthesia Greg Weidner, MD Jennifer Belu, PT, MPH - - Physical Therapy Physical Therapy Jennifer Belu, PT, MPH Elizabeth Yu, MD - - Orthopedics Orthopedics Elizabeth Yu, MD

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 YU

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/Lower- Back-Surgery/Lumbar-Discectomy/a~410/article.html http://www.siddiqimd.com/technology/technology-in-treatment.htm YU

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 YU

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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 YU

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. YU

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 YU

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 YU

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/ YU