The ABC s of LUMBAR SPINE DISEASE

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Diagnosis/Imaging/Surgery of Lumbar Spine Disorders Objectives Identify the most common

1 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 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

2 Conflicts of Interest none AJNR addition to reports 2

3 LAMINA FACET JOINT SPINOUS PROCESS Lumbar Disc Herniation Disc & Pinched Nerve Nerve Sac 3

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 Mechanical LBP

4 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 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) 4

5 Differential Diagnosis: LBP Mechanical LBP Radiculopathy Red Flags majority of patients 1%, only 1-3% HNP neurogenic tumor infection fracture 5

6 Exam Findings L4 - quadricep weakness, iliopsoas L5 Foot dorsiflexion, eversion, EHL (great toe) S1 Plantar flexion, foot inversion Nerve Roots in the Lower Back Nerve Roots in the Lower Back 6

$Stenosis (lumbar decompression/bilateral laminectomy, foraminotomies Spondylolisthesis = slippage of alignment Spondylolysis = pars fracture/pedicle fracture RX - Fusion if dynamic movement 6 months$

7 Conservative Treatment NSAIDS Physical Therapy Chiropractic Care Aqua Therapy Epidural/trigger point steroid injections SURGERY INDICATIONS Lumbar Disc Herniation (laminectomy/discectomy) Lumbar Stenosis (lumbar decompression/bilateral laminectomy, foraminotomies Spondylolisthesis = slippage of alignment Spondylolysis = pars fracture/pedicle fracture RX - Fusion if dynamic movement 6 months of conservative treatment, severe pain, unable to work, WHY? 7

8 Surgical approaches Foraminal stenosis Spinal stenosis-central and foraminal 8

9 NORMAL LATERAL RECESS STENOSIS NORMAL STENOSIS Laminectomy unilateral and bilateral 9

10 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, AJ0/0 MYELO/CT: Congenital stenosis, diffuse disc bulging, ligamentum flavum hypertrophy, severe facet hypertrophy Myelogram - Lumbar Stenosis Post Myelo CT - Lumbar Stenosis 10

hypesthesia L foot, LROM elicited buttock and thigh pain LUMBAR MRI: severe

11 LUMBAR SPONDYLOSIS A.H. 62 yo female, with severe LBP and bilateral thigh pain Exam: Diffuse hypesthesia L foot, LROM elicited buttock and thigh pain LUMBAR MRI: severe stenosis L 4/5 MYELO/CT: R L 4/5 HNP, severe stenosis L 4/5, lateral slip and slight spondylolisthesis Lumbar Spondylosis Spondylolisthesis 11

12 Myelogram ViewsDye Column Cut-Off Lumbar Stenosis NORMAL STENOSIS Lateral Recess Stenosis MRI CT SCAN 12

$Repeated micro fractures of the pars interarticularis Classic imaging - discontinuity of the neck of the scotty dog, extra facets on CT Often associated with spondylolisthesis 10-15% unilateral$

13 Lumbar Congenital Stenosis Lumbar Decompression Pedicle Screw Fusion Interbody Graft 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 13

14 PARS DEFECT IS A SPONDYLOLYSIS Spondylolysis 14

15 Pedicle Screw Fusion Minimally Invasive Spine Surgery 15

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

16 MISS MISS 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):

meant to take the edge off of pain, not to have pain freedom.

17 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 17

18 Thank you, any Questions? Scarlett, Sherman, Simon, Samson, Spencer, Sophie, Sydney 18

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 URMC Neurosurgery APP s Objectives Identify the most common pathology that leads to spine