The ABC’s of LUMBAR SPINE DISEASE - cdn.ymaws.com · spondylolisthesis Lumbar Spondylosis Spondylolisthesis. 12 MyelogramViewsDyeColumn Cut-Off Lumbar Stenosis NORMAL STENOSIS Lateral

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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

Susan O. Smith ANP-BC

University of Rochester

Department of Neurological Surgery

Diagnosis/Imaging/Surgery of Lumbar Spine Disorders

ObjectivesObjectives

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

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

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Conflicts of InterestConflicts of Interest

none none

AJNR addition to reportsAJNR addition to reports

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FACET JOINT

LAMINA

SPINOUS PROCESS

Diagnosis & Imaging of Common Causes of Back Pain

Lumbar Disc HerniationLumbar Disc Herniation


Nerve Sac

Disc & Pinched Nerve

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Low Back Pain & Radiculopathy (“Sciatica”)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

#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

LBP and RadiculopathyLBP and RadiculopathyMechanical LBP

Strain muscles, ligaments, facetsDisc degenerationLumbar Instability

Radiculopathy

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


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Differential Diagnosis: LBPDifferential Diagnosis: LBP

• Mechanical LBP majority of patients

• Radiculopathy 1%, only 1-3% HNP

• “Red Flags” neurogenictumorinfection fracture




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Exam FindingsExam Findings

L4 - quadricep weakness, iliopsoas

L5 – Foot dorsiflexion, eversion, EHL (great toe)

S1 – Plantar flexion, foot inversion

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 BackDiagnosis & Imaging of Common Causes of Back Pain

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Conservative TreatmentConservative Treatment

NSAIDS

Physical Therapy

Chiropractic Care

Aqua Therapy

Epidural/trigger point steroid injections

NSAIDS

Physical Therapy

Chiropractic Care

Aqua Therapy

Epidural/trigger point steroid injections

SURGERY INDICATIONSSURGERY INDICATIONSLumbar Disc Herniation

(laminectomy/discectomy)Lumbar Stenosis

(lumbar decompression/bilateral laminectomy, foraminotomies

Spondylolisthesis = slippage of alignmentSpondylolysis = pars fracture/pedicle fractureRX - Fusion if dynamic movement

Lumbar Disc Herniation(laminectomy/discectomy)

Lumbar Stenosis(lumbar decompression/bilateral laminectomy, foraminotomies

Spondylolisthesis = slippage of alignmentSpondylolysis = pars fracture/pedicle fractureRX - Fusion if dynamic movement


6 months of conservative treatment, severe pain, unable to work, WHY?

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Surgical approaches


Foraminal stenosis


Spinal stenosis-central and foraminal

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NORMAL LATERAL RECESS STENOSIS

NORMAL STENOSIS

Laminectomy – unilateral and bilateral

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LUMBAR STENOSISLUMBAR 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 hypesthesiafrom ankles to toes, KJ tr/0, AJ0/0

MYELO/CT: Congenital stenosis, diffuse disc bulging, ligamentum flavum hypertrophy, severe facet hypertrophy

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 hypesthesiafrom ankles to toes, KJ tr/0, AJ0/0

MYELO/CT: Congenital stenosis, diffuse disc bulging, ligamentum flavum hypertrophy, severe facet hypertrophy

Myelogram - Lumbar StenosisMyelogram - Lumbar Stenosis

Post Myelo CT - Lumbar StenosisPost Myelo CT - Lumbar Stenosis

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LUMBAR SPONDYLOSISLUMBAR 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

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 SpondylosisLumbar Spondylosis

SpondylolisthesisSpondylolisthesis

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Myelogram ViewsDye Column Cut-OffMyelogram ViewsDye Column Cut-Off

Lumbar StenosisLumbar Stenosis

NORMAL

STENOSIS

Lateral Recess StenosisLateral Recess StenosisMRI CT SCAN

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Lumbar Congenital StenosisLumbar Congenital Stenosis

Lumbar DecompressionPedicle Screw Fusion Interbody Graft

Lumbar DecompressionPedicle Screw Fusion Interbody Graft

SpondylolysisSpondylolysis 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

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

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PARS DEFECT IS A SPONDYLOLYSIS

SpondylolysisSpondylolysis

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Pedicle Screw FusionPedicle Screw Fusion

Minimally Invasive Spine SurgeryMinimally Invasive Spine Surgery

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MISSMISS

MISSMISS

Cauda Equina SyndromeCauda 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.

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): 2004

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Post op AssessmentPost 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

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

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Thank you, any Questions?Thank you, any Questions?

Scarlett, Sherman, Simon, Samson, Spencer, Sophie, Sydney

Documents

The ABC’s of LUMBAR SPINE DISEASE - cdn.ymaws.com · spondylolisthesis Lumbar Spondylosis Spondylolisthesis. 12 MyelogramViewsDyeColumn Cut-Off Lumbar Stenosis NORMAL STENOSIS Lateral