Common Lumbar Surgical Procedures

Question 1

Describe the degernative cascade

Answer 1

• phase 1: circumferntial tears
• phase 2: radial/HNP tears
• phase 3: spondlyosis/stenosis

Question 2

Microdisectomy incidence of procedure

Answer 2

• removal of bulging portion
• 90% of all spinal surgeries involved DDD
• 90% of all lumbar Herniated Nucleus pulpus occur at L4-5 and L5-S1 level
• microdisectomy is gold standard for HNP with radicular symptoms

Question 3

What are strong indications for having a microdisectomy

Answer 3

• bowel and bladder invovlement
• progressive neurological deficits

Question 4

What are the relative indiciations for

a microdisectomy

Answer 4

• more of an elective procedure
• failure to respond to an active rehab program for 6 weeks
• severe, incapaciting pain that eludes pain control
• recurrent episodes of sciatica
• significant neural deficits (+SLR less than 30)

Cross over SLR => go to uninvolved side and do a SLR (sciatic neural tension) and a positive result is symptoms down the other leg

Question 5

What is the goal of a microdiscectomy

Answer 5

• decompress nerve root
• minimize scar formation that could bind down the nerve
• avoid iatrogenic nerve damage
• typically discharged same down/next day

Question 6

Microdiscectomy procedure

Answer 6

• goes down to the lamina
• ligamentum flava is cut

Question 7

What is an annulus repair with a microdiscectomy

Answer 7

• reduced reoccurrence rate with sutured repair
• concern is suture may now irritating the nerve root

Question 8

Bone Anchored ACD

Annular Closure Device

Answer 8

• plugs the breech of annulus
• prevents reoccurance of disc bulging

Question 9

Post op rehab overal goals with microdiscectomy

Answer 9

• reduce pain (happens almost immediately)
• prevent reoccurence
• Controled motion with avoiding end range flexion
• maintain dural mobility (dont want to scar down the nerve)
• improve function
• safe, early return to functional activities

Question 10

Microdiscectomy outcomes

Answer 10

• 90-95% success rate
• smaller incision does not reduce hospital stay
• 25% persistent pain with repeat surgery
• better short term outcomes

keep in mind that in most people the disc couldve reaborbed over time

Question 11

Potential complications of microdiscectomy

Answer 11

• inadequate decompression
• iatrogenic injuries
• post op infections
• reoccurence of herniation
• impaired multifidii recovery

Question 12

Percutaneous Endoscopic lumbar discectomy (PELD)

Answer 12

• newer procedure
• smaller incision
• less muscule trauma
• less post-op soreness
• better outcomes

however

• surgeon’s visual of herniation is more difficult
• more expensive tools, increase cost of procedure

Question 13

Lumbar fusions incidence

Answer 13

• 137% increase in lumbar fusions performed
• typically with stage 3 patients
• average age is 52
• male = female
• 2-3 days average hospital length of stay

Question 14

lumbar fusions indications

Answer 14

• severe disabiling back or leg pain (2nd pahse of DDD)
• post-traumatic instability
• spondylolesthesis

Question 15

Goals of

a lumbar fusion

Answer 15

• successful unions of two or more segments
• preserve lordosis

Question 16

Posterior fusion

approach

Answer 16

• SP and lamina are removed
• pt can donate bone graft from iliac crest
• 6 screws and 2 rods
• go through pedicle into bodies

Question 17

Procedures for fusions

interbody fusion

Answer 17

• clears out disc => threads the screws to provide a spacer
• packed with bone graft = bone grows through perforation

Question 18

Fusions procedures

PEEK lumbar interbody cages

Answer 18

• cage can be put in anteriorly or posteriorly
• if cage is in by itself they must be immobilized

Question 19

potential complications of lumbar fusions

Answer 19

• non-union rates up to 50% (bone doesnt take = more stress on hardware)
• long term donor site pain up to 30%
• accelerated adjacent level degeneration
• iatrogenic cauda equina injruy 0.2-1%
• impaired multifidii recovery
• fusion will accelerate degeneration above and below

Question 20

Fusion outcomes

Answer 20

• stand-alone ALIF demonstrated a shorter operative time and less blood loss
• hospitalization time reduce with ALIF compared to TLIF
• patient reported outcome measures were equal with ALIF or TLIF
• VAS and ODI scores mainly favoured ALIF over PLF
• adverse events were equal between ALIF and posterior fusion approaches

TFIL= Transforamenal lumbar interbody fusion

Question 21

Total posterior spinal arthroplasty (TOPS)

Answer 21

• non-rigid fusion without bone graft
• objective: stabilization with adjacent site perservation
• allows movement but primary there for stabilizer and spacer
• two titanium plates connected by a polycarbonate urethane boot
• SP is removed and pedicle screws are used to anchor

Question 22

lumbar total disc arthroplasty

what does it do

Answer 22

• maintain disc space
• perserves motion
• mid-term outcomes equal rigid fusion
• must exceed gold standard
• FDA approaved Charite disc in 2004
• prodisc 2006

Question 23

Outcomes

lumbar total disc arthroplasty

Answer 23

• prodisc-L is safe and effective treatment for chronic back pain caused by lumbar DDD as assessed at more than 5 years post-op
• however outcome scores were slightly though significantly lower at last follow up visits than at 1 and 2 years post op

Question 24

what is lookin to happen in the future: molecular biology

Answer 24

• cell based tissue replacement
• re-grow chondroblast and fibroblast for disc injeciton