The ABC s of LUMBAR SPINE DISEASE

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Brittney Casey
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Neurosurgery APP s Objectives Identify the most common pathology that leads to

1 The ABC s of LUMBAR SPINE DISEASE Susan O. Smith ANP-BC University of Rochester Department of Neurological Surgery URMC Neurosurgery APP s Objectives Identify the most common pathology that leads to spine surgery Describe the key exam findings that will be assessed pre and post op Describe the most common elective surgery techniques 1

Conflicts of Interest none AJNR addition to reports Spine Pain is the Highest Cost Chronic Condition 80% of Americans having back pain at some point in their lives 30% of US adults

2 Conflicts of Interest none AJNR addition to reports Spine Pain is the Highest Cost Chronic Condition 80% of Americans having back pain at some point in their lives 30% of US adults experienced low back pain within last 3 months Main reason for missed work days and clinician visits, 1 next to colds Total direct healthcare cost exceeding $ billion dollars a year. 2

3 Diagnosis & Imaging of Common Causes of Back Pain Low Back Pain & Radiculopathy ( Sciatica ) #2 reason to seek medical attention 15% of all sick leave #1 cause of disability <45 yo 80-90% resolved in 1 month with no treatment Conservative Treatment NSAIDS Physical Therapy Chiropractic Care Aqua Therapy Epidural/trigger point steroid injections Ketamine Centers IMAGING LUMBAR FILMS - FLEX/EXTENSION CT SCAN CT MYELOGRAM MRI SCAN 3

Diagnosis & Imaging of Common Causes of Back Pain Mechanical LBP LBP and Radiculopathy

Nerve root dysfunction Exam: strength, reflex, sensation, provocative pain (SLR test)

Diagnosis: LBP MECHANICAL BACK PAIN RADICULOPATHY RED FLAGS MAJORITY OF PATIENTS 1%,

4 Diagnosis & Imaging of Common Causes of Back Pain Mechanical LBP LBP and Radiculopathy Strain muscles, ligaments, facets Disc degeneration Lumbar Instability Radiculopathy Nerve root dysfunction Exam: strength, reflex, sensation, provocative pain (SLR test) Contralateral SLR test Diagnosis & Imaging of Common Causes of Back Pain Differential Diagnosis: LBP MECHANICAL BACK PAIN RADICULOPATHY RED FLAGS MAJORITY OF PATIENTS 1%, 1-3% HNP, 95% BETTER IN 3 MONTHS NEUROGENIC TUMOR-NIGHT TIME PAIN INFECTION-Discitis FRACTURE 4

5 When to refer? Weakness Retention or incontinence Failed conservative treatment Ambulatory incapacity Pain not controlled 5

6 LAMINA FACET JOINT SPINOUS PROCESS Diagnosis & Imaging of Common Causes of Back Pain Diagnosis & Imaging of Common Causes of Back Pain Lumbar Disc Herniation Disc & Pinched Nerve Nerve Sac 6

quadricep weakness, iliopsoas L5 Foot dorsiflexion, eversion,

7 Diagnosis & Imaging of Common Causes of Back Pain Diagnosis & Imaging of Common Causes of Back Pain Exam Findings L4 - quadricep weakness, iliopsoas L5 Foot dorsiflexion, eversion, EHL (great toe), heel walking S1 Plantar flexion, foot inversion, toe walking 7

(lumbar decompression/bilateral laminectomy,

$fracture/pedicle fracture (Fusion if dynamic$

8 Diagnosis & Imaging of Common Causes of Back Pain Nerve Roots in the Lower Back SURGERY INDICATIONS Lumbar Disc Herniation (laminectomy/discectomy) Lumbar Stenosis (lumbar decompression/bilateral laminectomy, foraminotomies) Spondylolisthesis = slippage of alignment Spondylolysis = pars fracture/pedicle fracture (Fusion if dynamic movement and significant malalignment) 8

9 Diagnosis & Imaging of Common Causes of Back Pain 6 months of conservative treatment, severe pain, unable to work, WHY? Diagnosis & Imaging of Common Causes of Back Pain Lumbar Laminectomy, Discectomy 9

10 Diagnosis & Imaging of Common Causes of Back Pain Foraminal stenosis Lumbar Disc Herniation Unable to sit for 1 month Brother ( MD) gave her an injection so she could dance with her son at his wedding Lying on the floor to work on her lap top Physical Therapy, NSAIDS no relief MRI requested Lumbar Disc Herniation 10

Sent home from ED don t worry about the pain.

11 50 yo female with acute onset of left thigh pain and numbness. MRI 7 months earlier revealed degenerative disc disease, no large disc herniation. Sent home from ED don t worry about the pain. Crying, unable to bear weight on Left leg, son carried her into office On exam severe Left iliopsoas (L1,L2) and quadricep (L3,L4) weakness Differential Diagnosis? March 2017 MRI 11

5/3+, Bilateral hypesthesia from ankles to toes, KJ tr/0, AJ 0/0 MYELO/CT: Congenital

12 NORMAL LATERAL RECESS STENOSIS NORMAL STENOSIS LUMBAR STENOSIS R.O. 72 yo male with 3 year history of LBP and L > R LE pain; epidural steroids X12 ineffective EXAM: LEFT EHL 5/3+, Bilateral hypesthesia from ankles to toes, KJ tr/0, AJ 0/0 MYELO/CT: Congenital stenosis, diffuse disc bulging, ligamentum flavum hypertrophy, severe facet hypertrophy 12

13 Myelogram - Lumbar Stenosis Post Myelo CT - Lumbar Stenosis Lumbar Decompression 13

POST OP COURSE Leg pain resolved within 8 hours Incisional back pain for 2 weeks, gone by 1 month Numbness persisted in legs; EMG at 8 weeks, chronic peripheral neuropathy r/t ETOH, DM LUMBAR

14 POST OP COURSE Leg pain resolved within 8 hours Incisional back pain for 2 weeks, gone by 1 month Numbness persisted in legs; EMG at 8 weeks, chronic peripheral neuropathy r/t ETOH, DM LUMBAR SPONDYLOSIS A.H. 62 yo female, with severe LBP and bilateral thigh pain Exam: Diffuse hypesthesia Left foot, LROM elicited buttock and thigh pain LUMBAR MRI: severe stenosis L4/5 MYELO/CT: Right L4/5 HNP, severe stenosis L4/5, lateral slip and Grade 1 spondylolisthesis Lumbar Spondylosis 14

15 Spondylolisthesis Myelogram Views - Dye Column Cut-Off Lumbar Stenosis NORMAL STENOSIS 15

16 Lateral Recess Stenosis MRI CT SCAN Lumbar Decompression EPIDURAL LIPOMATOSIS T2 T1 16

17 Treatment Options Weight loss Exercise Surgery avoided due to lack of symptom resolution with decompression of the nerve roots. Damage likely irreversible. Lumbar Congenital Stenosis Congenital Stenosis 17

18 History of severe Congenital Stenosis Recurrent stenosis above fusion Synovial Cyst/Facet Joint Cyst 18

$Spondylolysis Repetitive exposure to simultaneous forces of muscle contraction, gravity and rotational forces Repeated micro fractures of the pars interarticularis Classic imaging -$

19 Spondylolysis Repetitive exposure to simultaneous forces of muscle contraction, gravity and rotational forces Repeated micro fractures of the pars interarticularis Classic imaging - discontinuity of the neck of the scotty dog, extra facets on CT Often associated with spondylolisthesis 10-15% unilateral defects Can be congenital PARS DEFECT IS A SPONDYLOLYSIS Spondylolysis 19

with compression of the thecal sac (1-2% of disc herniations) Cauda Equina syndrome outcome following

20 Pedicle Screw Fusion Cauda Equina Syndrome Sphincter disturbance - Anal 60-80%, urinary retention 90% sensitivity Saddle Anesthesia - sensitivity 75% Significant Motor Weakness *Large Central Disc Herniation with compression of the thecal sac (1-2% of disc herniations) Cauda Equina syndrome outcome following surgery is clearly correlated with timing of surgery within 48 hours of syndrome onset. Neurosurg Focus 16 (6):

21 Post op Assessment Any new weakness? Urinary retention? Muscle relaxants can contribute to high PVR Pain control meds are only meant to take the edge off of pain, not to have pain freedom Wound drainage that is excessive SOB or low O2 Sat that could signify PE or respiratory distress Lumbar Fusions Insurance approval challenges Nicotine metabolite Reoperation challenges Dural tear/csf leak Infection Poor bone quality 21

22 Minimally Invasive Spine Surgery MISS 22

23 MISS Thank you, any Questions? Scarlett, Sherman, Simon, Samson, Spencer, Sophie, Sydney 23

The ABC s of LUMBAR SPINE DISEASE

The ABC s of LUMBAR SPINE DISEASE Susan O. Smith ANP-BC University of Rochester Department of Neurological Surgery Diagnosis/Imaging/Surgery of Lumbar Spine Disorders Objectives Identify the most common