Surgical Treatment of Low Back Pain & Sciatics
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Surgical Treatmentof Low Back Pain &
SciaticsLEFLOT Jean-Louis
Lieutenant ColonelOrthopaedic Surgeon
Military Hospital Queen Astrid BrusselsBelgian Back Society
10-11 december 2010
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Disc Herniation
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Disc Herniation
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Disc Herniation
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Facet joints « Overloading »
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Failure of the conservative treatment
• Medical treatment• Physiotherapy• Infiltration « Pain Clinic »
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DISCECTOMY
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DISCECTOMYFibrosis
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DISCECTOMYThinning of the disc
• Recurrence of disc herniation• Foramenal stenosis• Facet joints « overloading »
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DIAM
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DIAM
Man 42Y
Chronic Low Back Pain and Irritation L4 Left
Intra- and Extraforamenal Disc Herniation
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Device Intervertebral for Assisted Motion
6 months after discectomy and DIAM L4L5
No more leg pain and good relief of the lumbagosNormal height of the intervertebral disc
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DIAM ou INTRASPINEINDICATIONS
DISCECTOMY
- Massive herniated disc leadingto substantial loss of disc material
- Recurrence of herniated disc
- Herniation of a transitional disc withsacralization of L5
DEGENERATIVE DISC DISEASE
- Topping off above or below the fusedsegment, to support newly created loads.
- Isolated Modic I lesion leading to chroniclow-back pain.
HYPERLORDOSIS
- Facet joints overloading
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Disc Arthroplasty
Man 39Y (Infantery)
Chronic Low Back Pain and Sciatic L5 right
Disc Hernia L4L5 rightDiscopathy from levels L3L4, L4L5, L5S1
Severe L4L5 and L5S1
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Disc Arthroplasty
ALIF L5S1 + TDA L4L5Only 1 approach (RetroPeritoneal) !
Control after 6 monthsNo more lumbago & sciatic
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Disc Arthroplasty
Goals of Lumbar TDA ?
• Pain relief• Improved function• Restoration of the sagittal balance• Increased foramenal height• Avoidance of adjacent level breakdown• Longevity
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Disc Arthroplasty
The retroperitonealapproach is very
little dilapidating
•It preserves the lumbar muscles
•It avoids the intraspinal fibrosis
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Disc ArthroplastyRetroperitoneal Approach
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Disc Arthroplasty
« Minimal invasive surgery »
A very good view of the intervertebral space ispossible with a mini-access (5 cm)
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Disc Arthroplasty
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NO …
BUT …
Accelerated degenerationof the adjacent segments
Disorder of thesagittal balance ?
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Dynamic Instability
Disc degeneration L4L5 (L3L4)
Facet osteoarthritis
Disc protrusion
Spinal and foramenal stenosis
DynamicInstability
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HIGH RISK after PLIF !
Hypermobility above fusion !
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ALIF is beter than PLIF
Man 32 Y(Infantery)
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ALIF is beter than PLIF
ALIFrestore :
• Disc Space & Lumbar Lordosis• Foramenal Height• Facet Decompression
Combined Anterior & Posterior Fusionpermits :
• Circonferential Fusion• No intra-canalaire intrusion• No risk of peri-neural fibrosis
N.B. We can perform a DIAM stabilization above thefusion to avoid the hypermobility
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ALIF
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AXIALIF
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AXIALIF
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AXIALIFIndications- Discopathy L5S1
without hernia
- Spondylolisthesis L5S1grade 1
+ Posterior fixation
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Conclusion
• Disc Hernia• Disc Height• Foramenal Height• Fibrosis• Sagitall Balance