Objectives. Identify and differentiate appropriate surgical cases. Good Surgical Outcomes

Transcription

1 ECHO February 5 th, 2015 Surgical Selection for Low Back Pain Objectives Identify and differentiate appropriate surgical cases Disclosures Medical director for UHN Rehabilitations Solution Back and Neck Speciality Program Consultant for Medtronic Minimally Invasive Spine Surgery Y. Raja Rampersaud, MD, FRCS(C) Medical Director Back and Neck Clinic Altum Health Associate Professor, Divisions of Orthopaedic and Neurosurgery, Spinal Program, Toronto Western Hospital,, University of Toronto, Canada Non-Emergent Surgical Scenarios < 10% of patients end up in surgery Trail of conservative care always recommended Surgeon practice variability Good Surgical Outcomes Radiculopathy Arm / Leg Neurogenic Claudication Leg Dominant Myelopathy - Neurology Back / Neck Dominant Pain Spondylolisthesis / Deformity DDD -??? Best Evidence! 1

2 Durability of Outcome Back Pain and Surgery Surgical outcomes for patients with back dominant pain, in the absence of deformity or instability (i.e. spondylolisthesis) has not been proven to be more beneficial then appropriate non-surgical care. Majority of negative outcomes and perception of surgery = LBP Surgical MGMT: Recommendations Controversial No diff with comprehensive non-op LBP due to DDD Back Pain and Surgery Chronic LBP Mixed bag that predominates poor surgical outcomes. Exception Single level disease Mechanical pain Motivated patient No pain disorder Poor / unpredictable active third party issues significant psychosocial comorbidities such as chronic pain disorder, regional complex pain syndrome, depression etc (regardless of underlying organic clinical or structural diagnosis). Centralization? Initial Pain Pain Disorder 2

3 Back and / or Leg Pain (e.g. 50/50) Mechanical Pain (i.e. intermittent pain with loading /movement ) No psychosocial Surgical Back and / or Leg Pain (e.g. 50/50) Constant Pain / +++ Psychosocial Tend to have high level of resting pain (e.g. 8/10 at rest and 10/10 with activity) NON SURGICAL unless objective surgical red flags History Red Flags Fever, Chills, Sweats Infection IV drug use, Immune compromised Weight-loss, Night Pain Malignancy Significant Trauma - Fracture Myelopathy (UMN) Cauda Equina Syndrome (LMN) If any of the above are positive in the setting of neck /back and/or arm/leg pain emergently refer patient to ER for investigation and surgical assessment. Cauda Equina Syndrome Symptomatic Compression of the Cauda Equina Bowel/Bladder/Erectile Dysfunction Including Hx of retention, frequency (no other cause ID d), incontinence Need to do a post void residual PVR catheterization (> 100cc abnormal) Saddle Anaesthesia / Dysesthesia Motor Disturbance Myelopathy Symptomatic Compression of the spinal cord Upper Motor Neuron screening Hyper-reflexia Babinski response Clonus > 4 beats / Sustained clonus Spasticity Bowel/Bladder Including Hx of retention, frequency (no other cause ID d), incontinence Need to do a post void residual PVR catheterization (> 100cc abnormal) Primary Care Challenges Understanding Primary Care Physicians Challenges, Barriers and Priorities in Caring for Patients with Low Back Pain. Rampersaud R, Alleyne J Systematic Review, small focus group and a survey of family physicians (n=325) across Ontario 3

4 What do patients want? MRI and the Lumbar Spine Imaging test to tell them what is wrong Funded physiotherapy Note for work activity restrictions 90% of MRIs for LBP are abnormal < 2% of CTs for Headache are abnormal Value of a negative test is nearly nonexistent for LBP Modality of choice in evaluation of most spinal disorders. o Incidental abnormal findings common within asymptomatic individuals. o 57-80% abnormalities for those over the age of 60 o Poor correlation with patient symptoms, therapeutic decision-making and patient outcome. Modic & Ross. Radiology. 2007; 245(1): Boden et al. JBJS. 1990; 72(3): Beattie et al, Spine 2000; 25(7): MRI and Spine Descriptive MRI reports are often concerning large disc herniation indentation of the cauda equina severe diffuse degenerative disc etc Rationale for referral to spinal surgeon: Investigations 45 yo male with 9 mths of LBP: No leg pain. Diffuse degenerative disc disease L5-S1 herniated disc impinging on the S1 nerve root Diagnosis? Now what? 23 4

5 Case Wrong Care at the Wrong Time Wrong Care at the Wrong Time 45 y.o. male now at 9mths of LBP Holy crap, all that is going on in my back, no wonder why it hurts so much Can it be fixed? I have to see a Specialist! Surgical referral stream Dx Back and Leg pain, S1root compression 6-12 wait (if agree to see) Worsening symptoms Not working No ongoing treatment wait to see what specialist says 26 Non-surgical, I can t help you Advice given (if surgeon takes the time) Surgeons typically unwilling or unable to do non-op care Referral back to PCP/ PMR/Pain/Rheumatology Psychosocial issues well established No singular provider ownership We have to do better! 27 When to get Imaging? Imaging LBP > 6 weeks (ACR and CAR) Not needed if manageable X-ray will rule out most surgical disorders # / spondylolisthesis / deformity etc Leg pain > 6 weeks or intractable MRI /CT If functionally significant neurological findings, suspicion of tumor, infection etc MRI Alberta LBP Guidelines Nov

6 MRI report that needs surgical assessment. Key Message: Good Surgical Outcomes Even the Americans don t recommend imaging unless a serious underlying issue is suspected. Fracture (non-fragility / acute trauma) Tumor Infection Structural abnormality of the spinal cord Signal change in the spinal cord e.g. edema, myelomalacia Radiculopathy Arm / Leg Neurogenic Claudication Leg Dominant Myelopathy - Neurology Mechanical Back Dominant Pain Spondylolisthesis / Deformity DDD -??? 31 Key Message: Where is the dominant pain? Key Message: Nature of pain? Rest = 0-2 vs. 8 with activity Remember MRI has to correlate with history of symptoms! Rest = 7 vs. 8 with activity 6

7 MRI Symptom Correlation Case 1 Case 1 35 y.o. female, labourer, single mother Atraumatic low back and progressive constant leg dominant pain times 3 weeks Pain = left buttock, lateral thigh and dorsum of foot (L5) Associated with numbness, no weakness No Red Flags Most likely diagnosis? Treatment Options - Which one(s)? Drugs Physiotherapy Injections (e.g.selective nerve root block) Alternative Medicine Activity / Job Modification Surgery Follow-up Case 1- MRI Lumbar Disc Herniation HNP - Surgery L4 Disc Herniation doesn t always cause symptoms 80-90% will resolve with non-operative management Reassure patient (i.e. pain will go away in the majority) Can be horrible pain! 10-20% may recur at same level Refer to surgeon after 6-12 weeks, or if intractable Medial L 5 7

8 Case 2 65 y.o. male, retired Atraumatic bilateral leg dominant pain times 6 months, no back pain Pain = diffuse bilateral below the knee, associated with numbness, no weakness Occurs with walking or standing Relieved by sitting or lying down No Red Flags Case 2 Most likely diagnosis? DDx? Case 2- MRI L4/5 Case 2 - Surgery Traditional laminectomy Case 2 - Surgery Less invasive options L4-5 Outcomes QOL 70-80% surgical success >> 30% conservative care Sport study results for Stenosis / Spondylolisthesis 2 and 4 year follow-up. 8

9 Case 3 Case 3 Case 4 40 y.o. female, married, lawyer Progressive low back pain for 5 years, following an MVA. Pain - radiates to left leg in mostly a L5 pattern, but is diffuse and nondermatomal(?) 8/10 at rest, 10/10 with activity Not working for 1 year, active ligation Physical exam Limited Lumbar ROM, pain in all directions Tender to palpation, allodynia Diffuse giving way Treatment Options? Case 3 40 y.o. female, married, lawyer Progressive low back pain for 5 years, following an MVA. No leg pain 0-2/10 at rest, 10/10 with activity Not working for 1 year Surgery? Dependent on imaging i.e. instability, deformity or focal disease Diffuse DDD Retrolisthesis Case 3a - MRI L3/4, L4/5 Foraminal stenosis Case 3b -MRI L5-S1 severe DDD No nerve root compression 9

10 Case 3c -MRI L4-5 grade 2 spondylolisthesis Severe stenosis with 5mm canal Surgical referral suggested 10