Slide 1: Lumbar Spine Disorders interactive session
LUMBAR SPINE DISORDERS interactive session Ben OKAFOR FRCS FRCS.orth Consultant orthopaedic/spine/trauma surgeon
Slide 2: Certainties of life
Certainties of life Death Taxes Back pain
Slide 3: Case 1
CASE 1 25 year old male Postal worker ?lifting? LBP- 2 wks BMI 35 Mx?- Dx? Ix? Rx?
Slide 4: Conservative Rx
Conservative Rx Time Relative rest Analgesia/NSAIDS Reassurance Weight loss General fitness
Slide 5: Conservative Rx
Conservative Rx Physical therapy – Physiotherapy – Chiropractic – Osteopathy – Hydrotherapy – Massage
Slide 6: Case 2
CASE 2 35 year old builder LBP + Leg pain (proximal) – 4 months Mx?- Dx? Ix? Rx?
Slide 7: Leg pain
LEG PAIN LOCAL PATHOLOGY VASCULAR REFERED NEURAL COMPRESSION • DISC PROLAPSE • STENOSIS
Slide 8: Facet joint syndrome
FACET JOINT SYNDROME
Slide 9: SI joint syndrome
Sil JOINT SYNDROME
Slide 10: Case 3
CASE 3 43 year old office worker Recurrent sciatica 1 year Mx?- Dx? Ix? Rx?
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Slide 12: Case 4
CASE 4 50 year old Generalised back pain Sleep disturbance Mx?- Dx? Ix? Rx?
Slide 13: Red flags conditions
Red flags conditions Spine fracture Cancer or Infection Cauda equina syndrome
Slide 14: Red flags indicators for cancer or infection
Red flags indicators for cancer or infection Age > 50 years and new back pain, or age <20 years History of cancer Constitutional symptoms (fever, unexplained wt. loss) Recent bacterial infection (e.g. UTI) IVDU Immune suppression Pain that worsens when supine; severe night-time pain; thoracic pain
Slide 15: Rx – suspected cancer or infection
Rx –suspected cancer or infection Check FBC,ESR, Bence jones protein CRP, Biochemistry, Urine analysis If still concerned, consider -referral -Note that a negative X-ray alone does not rule out disease. MRI scan’, bone scan
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Slide 17: Case 5
CASE 5 25 year old lady Leg pain -1 week Odd feeling crotch area? Mx?- Dx? Ix? Rx?
Slide 18: Red flags for cauda equina syndrome
Red flags for cauda equina syn. Perianal/perineal sensory loss (Saddle anaes.) Bladder dysfunction (e.g. urine retention, increased frequency, overflow incontinence) Faecal incontinence Neurological deficit in the lower extremities Unexpected laxity of the anal sphincter Bilateral sciatica Cross ove
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Slide 20: Case 6
CASE 6 50 year old male Leg weakness Mx?- Dx? Ix? Rx?
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Slide 22: Stenosis
STENOSIS SCIATICA NEUROGENIC CLAUDICATION STANDING LEG INTOLERANCE BACK PAIN NEUROLOGICAL SYMPTOMS
Slide 23: Stenosis
STENOSIS DIRECT DECOMPRESSION • LAMINOTOMY • LAMINECTOMY • MEDIAL FACECTOMY • FORAMINOTOMY • +- FUSION
Slide 24: Case 7
CASE 7 80 year old LBP Leg pain Weakness COAD Mx?- Dx? Ix? Rx?
Slide 25: X STOP
X STOP
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Slide 27: Case 8
CASE 8 75 year female Fall Thoracolumbar pain Mx?- Dx? Ix? Rx?
Slide 28: Red flags for spine fracture
Red flags for spine fracture Major trauma Minor trauma, or even just strenuous lifting, in people with osteoporosis Suspicion of secondaries
Slide 29: Osteoporotic fractures
OSTEOPOROTIC FRACTURES BACK PAIN PROGESSIVE DEFORMITY IMMOBILTY Rx MEDICAL THERAPY BRACING KYPHOPLASTY
Slide 30: Indications
Indications Balloon Kyphoplasty is designed for patients with Vertebral Compression Fractures caused by: • Primary Osteoporosis • Secondary Osteoporosis • Multiple Myeloma • Bone Metastasis
Slide 31: Balloon Kyphoplasty Procedure
Balloon Kyphoplasty Procedure
Slide 32: Step 1 Insertion of two balloons
Step 1 Insertion of two balloons into the fractured vertebral body.
Slide 33: Step 2 Inflation of the balloons
Step 2 Inflation of the balloons to create a cavity and perform fracture reduction.
Slide 34: Step 3 Filling the cavity with bone cement
Step 3 Filling the cavity, created by the balloons, with bone cement to obtain fracture fixation.
Slide 35: Step 4 Fracture stabilised
Step 4 The fracture is stabilised which facilitates patient mobility and gives fast pain relief.
Slide 36: Fast pain relief, stabilisation/correction deformity
Fast pain relief Stabilisation/correction deformity
Slide 37: Case 9
CASE 9 40 year old healthcare assistant Recurrent LBP Giving way/spasms Numerous sick leave? Mx?- Dx? Ix? Rx?
Slide 38: Disc bulge/degeneration - Significant?
Disc bulge/degeneration - Significant?
Slide 39: Pain source?
PAIN SO | Ligamentum * Anterior = -* P flavum gitudi | we 8, longitudin al Ne arias ligament—>) | * Zygapophyseal joint * Supraspinous To ligament longitudinal ligament FP | Interspinous —+——+— ligament * Vertebral body Fig. 1 * indicates pain-sensing dructures
Slide 40: Doubt? Discogram
DOUBT? DISCOGRAM
Slide 41: Recalcitrant discogenic back pain
Recalcitrant discogenic Back pain Failed conservative Rx At least 2 year LBP Recurrent time off work Options?
Slide 42: Soft stabilisation
SOFT STABILISATION @) zimmer | spine
Slide 43: Disc tear/good disc height
•Back +- leg pain •Disc tear/good disc height •Similar or better than fusion
Slide 44: Fusion?
FUSION? INSTABILITY ADJUNCT TO DECOMPRESSION BONE DESTRUCTIVE LESIONS RECALCITRANT DISCOGENIC PAIN
Slide 45: Isthmic spondylolisthesis
ISTHMIC SPONDYLOLISTHESIS
Slide 46: Isthmic spondylolisthesis
MN | MN = a= => ails = DL) mal = > (an) Z. © A MN
Slide 47: Spine fusion
SPINE FUSION
Slide 48: Disc replacement
DISC REPLACEMENT Motion preservation? Good early results Long term results no better than fusion?
Slide 49: Intradiscal therapy/IDET/Coblation
INTRADISCAL THERAPY/ IDET/COBLATION •Heat annular defect •Disorganise and shrink protein •Destroy nociceptive fibres GOOD SHORT TERM RESULTS BETTER FOR LEG PAIN BETTER FOR SMALL DISC PROLAPSE LONG TERM RESULTS NOT MAINTAINED
Slide 50: Prosthetic Disc Replacements
Prosthetic Disc Replacements Intact facets Good disc height Nucleus pulposus deficient Annular tear Prolapse
Slide 51: Yellow Flags
Yellow Flags Belief that pain and activity are harmful Sickness behaviours (extended rest) • Social withdrawal Emotional problems Problems and/or dissatisfaction at work Problems with claims or compensation or time off work Overprotective family; Lack of support Inappropriate expectations of treatme
Slide 52: Anatomy
REHOMBOQIDEUS MINOR MM, (CUT) TRAPEFIUS A. LEVATOR SOAPULAE AA, BELTORD AA PHOMPOIDELS ! MAJOR M. (CUT) a ~~ LATCSSIAGLES EXTERNAL ——— DORE! M. FLRDHOAL A AL OELIOUE AL ERECTOR SPIMAE FA, INTERMAL "a AU DOA AL SS GLUTELS OBUQUE AM ALAXIALS AA.
Slide 53: Ligamentum Flavum
Ligamentum Flavum Supraspinous Ligament
Slide 54: ii ¢ Ligamentum
ii ¢ Ligamentum * Anterior = » flavum longitudinal ||\) og A, ad ligament—>) | * Zygapophyseal joint * Supraspinous To ligament longitudinal ligament FP | Interspinous —+——+— ligament * Vertebral body Fig. 1 * indicates pain-sensing dructures
Slide 55: Normal Discs
Normal Discs
Slide 56: Fear of progression?
FEAR OF PROGRESSION?
Slide 57: Surgical management Decompression Fusion
Surgical management Decompression Fusion Leg Pain Back Pain
Slide 58: New Advances
New “Advances” Distraction Intradiscal therapy Stabilisation Disc replacement Fusion techniques Minimal access surgery kyphoplasty
Slide 59: Distraction devices
Distraction devices
Slide 60: X STOP
X STOP
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Slide 62: Spine surgery – results?
Spine surgery – results? RIGHT TIME RIGHT PATIENT RIGHT DIAGNOSIS RIGHT OPERATION RIGHT REHABILITATION
Slide 63: Thank you