Brad Elder, MD Brad Elder, MD -- NeurosurgeryNeurosurgeryGreg Weidner, MD Greg Weidner, MD -- AnesthesiaAnesthesia

Jennifer Belu, PT, MPH Jennifer Belu, PT, MPH -- Physical TherapyPhysical TherapyElizabeth Yu, MD Elizabeth Yu, MD -- OrthopedicsOrthopedics

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, MDAssistant 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

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Disk herniation

Physical examination Motor Sensory Reflexes Straight leg raise

History “cough effect” No precipitating

event

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Disk herniation

Lumbar 95% at L4/5 or L5/S1

Cervical C5/6 and C6/7

Thoracic Much less common

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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

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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 TechniquesTransforaminal highly effective for short term relief Surrounds the nerve root with combination of steroid and local anestheticIntralaminar approach best suited for patient with minimal radicular complaints, e.g., the central disc herniation

WEIDNER

The Patient with a Herniated Disc

Transforaminal ESIBelieved to be effective by lowering phospholipase levels –PL A2 the rate limiting step in production of leukotriene's and prostaglandinsCombining image guided injections with physical therapy described as 90% effective in one study

WEIDNER

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The Patient with a Disc herniation

Side-Effects Insomnia, transient hyperglycemia, local irritation,

leg cramps

Contraindications to Interventional TechniquesAnti-Coagulant therapyInfection

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Controlling pain

Centralization of symptoms

Therapeutic exercise

Return to activities

BELU

Low Back Pain: Physical Therapy Perspective – Jennifer Belu, PT, MPH

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”

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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/IM01274Bono, CM. Instructional Course Lectures: Spine 2. 2010.

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Disc Herniations: Surgical Intervention – Elizabeth Yu, MD

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/Lower-Back-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_INFORMATION-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

dischttp://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