Dr. Kshitij Chaudhary, MS, DNBConsultant Spine Surgeon

Sir HN Reliance Foundation HospitalMumbai

@kcspine

I N D I C AT I O N S F O R S U R G E R YH O W T O C H O O S E T H E R I G H T PAT I E N T ?

A N O N .

"If operating on the wrong leg is a medical error, what do we call operating on a someone who doesn't

need it.”

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Asymptomatic Subjects

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No correlation with symptoms

- I M M A N U E L K A N T ( 1 8 0 0 )

“Physicians think that they do a lot for a patient when they give his disease a name”

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Fail-safe system

1. Is pain a diagnostic trap? Non-spondylogenic ?2. If spondylogenic - Any red flags?3. Is pain mechanical? If so, which syndrome? 4. Is pain a true physical disability? Yellow Flags?5. After history, PE, imaging and tests – what is

structural lesion? 6. Does clinical picture fit with structural lesion?

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Is the back pain from the spine ?

Viscerogenic

Vascular

Psychogenic

1

ViscerogenicKidney, Retroperitoneal tumor, pelvic viscera

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VascularAortic aneurysm, Peripheral Vascular d/s

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Spondylogenic back painis the most common

Are there any red flags?

Degeneration

Inflammatory

Tumor

Infections

Trauma

Osteoporosis

2 @kcspine

Which mechanical pain syndrome?

Axial Back Pain

Referred Leg Pain

Neurogenic Leg Pain

3 @kcspine

Leg pain - Referred@kcspine

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Leg pain

Radicular Claudicatory

Back pain or leg pain predominant ?

Pearson, A., Blood, E., Lurie, J., Abdu, W., Sengupta, D., Frymoyer, J. F., & Weinstein, J. (2011). Predominant Leg Pain Is Associated With Better Surgical Outcomes in Degenerative Spondylolisthesis and Spinal Stenosis. Spine, 36(3), 219–229.

90%

10%

50%

50% 90%

10%

Vascular claudications

Pain relief on STANDING !

D/D Leg pain

Hip joint, Knee OA

Pelvis / SI

PVD / Varicose veins

Muscle pulls (Hamstrings)

Neuropathy (Diabetes)

Is pain a true physical disability?4

@kcspine

Listen to the patient !

80% History

10% Physical examination

5% Imaging, Labs etc

What is structural lesion? 56 Does it explain the clinical picture?

Is there a nonoperative option?7

Paracetamol / NSIADSPregabalin

Physical therapyManipulation

TENSBrace

Traction

No studies: Workgroup Consensus Statement - NASS

Is there a nonoperative option?7

Epidural steroid injections

Small or no benefit

Chou R et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015.Friedly JL, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014;371:11-21.

Controversial

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Epidural steroid injection

Diagnostic Value ?

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Co-morbidities

AgeObesitySmokingDiabetes

OsteoporosisCardiac etc.

de Kleuver et.al. (2012). Optimizing Outcomes in the Management of Degenerative Spondylolisthesis. Spine Deformity, 1–9.

8 @kcspine

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What is the functional limitation?

Dissatisfied with their symptoms

Pearson et.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21), 1799–1811.

9

Oswestry Disability Index

• 0 to 20: Minimal disability• 21-40: Moderate Disability• 41-60: Severe Disability• 61-80: Crippling disability• 81-100: Bed-bound or exaggeration

Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000 Nov 15;25(22):2940-52

Patient expectations

“Patient expectation can be a self fulfilling prophecy”

Pearson et.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21), 1799–1811.

10

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DECISION > INCISION

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www.orthotimes.com

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