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PHTH 7212 Pathophysiology > Lumbar Surgeries PowerPoint - Dr Wofford > Flashcards

Lumbar Surgeries PowerPoint - Dr Wofford Flashcards

1
Q

What happens to the piece of free-floating NP that is present in a sequestration HNP?

A

body will do phagocytosis which will take care of it but it takes a long time and most people don’t want to sit through the pain for that long

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2
Q

Explain DJD (5 things)

A
  • Wear and tear on the joints
  • Most commonly in the lumbar facet joints
  • Osteophyte formation is significant
  • Can have genetic components
  • Can have activity level play a role (like too much activity from military career)
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2
Q

Explain DDD (6 things)

A
  • It is wear and tear on the disks
  • Disc loses water content and gets shorter
  • Can have fissuring and tearing of the annulus
  • “black disk” is very indicative on T2 MRI (water is white)
  • Can have genetic components
  • Can have activity level play a role (like too much activity from military career)
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3
Q

What is a scottie dog fracture?

A

Same as spondylolysis

Collar is where you look for the fracture on the x-ray

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4
Q

What percent of LBP patients have s/s lasting for longer than 2 weeks?

A

7-14%

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4
Q

What are Schmorl’s Nodes?

A

A protrusion of intervertebral cartilage through the vertebral endplate into an adjacent vertebrae.

A term we will see a lot when we look at MRI reports

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4
Q

What is Spondylolysis?

A

A fracture of the pars articularis in the vertebrae.

Can be degenerative (older pop) or traumatic (younger pop).

Pt may not know it has happend

It must be present bilaterally for spondylolisthesis to occur

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4
Q

What condition is the ligamentum flavum usually in when a surgeon performs a Lumbar Laminectomy?

A

Typically there is a lot of hypertrophy of the ligamentum flavum

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4
Q

What is Tietze Syndrome?

A

About the same thing as Costocondritis

Inflammation of the costal cartilage. If swelling accompanies it, it is called Tietze Syndrome

Usually caused by something repetitive (coughing, laughter, push-ups)

Treatment: rib mobs and thoracic manips, and other stuff I forgot to listen to

By far the most common musculoskeletal reason to have chest pain.

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5
Q

Disc Replacement: Advantages and disadvantages

A

Advantages (sort of best of both worlds of fusion and discectomy):

  • Ability to restore full motion to the intervertebral segment
  • Protect adjacent segments from increased “wear and tear

Disadvantages

  • No long term outcome studies in the US- only gained FDA approval 8 years ago
  • Possibility of subluxation/dislocation and implant failures
  • Very few pts are candidates
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6
Q

Four Lumbar Surgeries:

A
  1. Diskectomy
  2. Lumbar fusion
  3. Laminectomy
  4. Total Disc Replacement
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7
Q

Lumbar Dicectomy: what is it?

A

Like ACDF in C-spine

In lumbar spine it is more analgolous to a meniscectomy

They go in and shave off part sticking out?

They can have open or closed (microdiscectomy)

It is for HNP

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8
Q

What is facet joint syndrome?

A

A bucket term, sort of like HNP is, which doesn’t tell you much.

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9
Q
A

pars interarticularis

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9
Q

Lumbar Discectomy, general rehab guidelines

A
  • Limit flexion and rotation for 8-12 weeks
  • ** No joint mobilizations of surgical segments for 3 months**
  • ** Use modalities as needed and be sure to address scar**

No joint mobs TO THAT SEGMENT. We can do mobs in other spinal regions/segments. Don’t get close to the surgical level.

WE MUST ADDRESS the scar. Most pts don’t see or touch low back often if at all.

Scar massage when wound is fully healed. X-friction massage every day for 3-5 minutes with vitamin e cream. Prevents adhesions and hypersensitivity.

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10
Q

What are the two biggest pain generators in the low back?

A

By a long shot, most people say the disk is the primary generator, followed by facet joints

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11
Q

What are the only reasons to do a Lumbar MRI?

A
  1. You think something is non-musculoskeletal problems (such as kidney symptoms)
  2. If they have completely failed conservative treatment
  3. If we do our clinical scan and they have full radiculopathy and they have impaired reflexes and myotomes (because they may need someone besides us, maybe surgery).

Anything but these, the MRI results will not change your POC or treatment. If results of MRI will not change your treatment approach, ordering it will not help and is unnecessary. If it may change your plan of care, then ordering the imaging would likely be appropriate. But we treat the symptoms, not the image. MRIs are over-ordered all the time.

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11
Q

Two main cauda equina symptoms

A
  1. Bowel and bladder symptoms
  2. Saddle paresthesia
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11
Q

Two big things that Dr. Wofford wanted us to get out of her Lumbar Surgeries lectures:

A
  1. MRI’s are majorly over utilized (and there is only 3 reasons to do them)
  2. There have been plenty of studies where they have looked at pts who in the absence of red-flags, but have low back pain and found 5 years down the road the outcome is the same if pt does surgery or conservative treatment. That is what research shows.
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12
Q

PLIF: Advantages and disadvantages

A

Advantages:

  • Will not recur
  • Can do in pts with instability

Disadvantages

  • Herniation cannot recur
  • Longer Rehab
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14
Q

What is one of the most common causes of disability?

A

LBP

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15
Q

Possible symptoms with an anteriordisc bulge or herniation:

A

LBP, but no radicular symptoms or pain.

Could have referred pain, but not radicular pain.

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16
Q

How long have lumbar disc replacements been performed in Europe?

A

over a decade

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17
Q

When does initial fusion occur with lumbar fusion?

A

12 weeks (3 months)

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18
Q

What is Failed Back Syndrome?

A

Failed Back Syndrome: pts go in and the have L4-5 HNP, PCP sends to Neurosurgeon who does surgery, Discectomy fails so fused, then other joints have more wear and tear and end up with fusions, and progressively more levels need fusion. Unfortunately we will see this a lot. This is a BIG reason pts should try conservative treatment first!!!

pt that doesn’t exercise may want to choose the 45 min surgery over exercise. PT is not as instant, but doesn’t cause long term problems. It can actually help long term outcomes.

It makes a HUGE difference how you education your patients.

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19
Q

______ & ________ commonly go together so we will see that many ________ have LBP

A

LBP

Disability

Workers Comp Patients

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19
Q

More about capsular entrapment

A

Capsular entrapment is usually triggered by quick awkward movement. Will be limited in Extension, Lateral Flexion, and rotation. An acute problem. It responds very well to manual therapy.

Could see them with Capsular entrapment as primary issue depending on how soon you see patients. Sometimes pts will go to doctor for this.

Could also see pt with this

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19
Q

Lumbar Fusion, general rehab guidelines (all types of lumbar fusion)

A
  1. No impact loading for at least 3 months
  2. Avoid endrange rotation, extension, repetitive/prolonged flexion for at least 3 months
  3. Avoid intensive abdominal strengthening for 3 months
  4. Equivocal research regarding post-opguidelines
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21
Q

Spondylolisthesis Grades

A
  1. Grade I: 0-25%, treated conservatively (pt may have no pain)
  2. Grade II: 25-50%, treated conservatively (pt may have no pain)
  3. Grade III: 50-75%, sometimes surgery (at least eval)
  4. Grade IV: 75-100%, always surgery, send to neuro MD if we see first
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22
Q

Describe clinical relevance of Lumbar Strain/Sprain

A

There must be some sort of traumatic event (macro or micro) that causes this, and it must be some sort of motion (cannot be slept wrong). MDs often refer with strain/sprain on order, but pt doesn’t recall any event that could cause it.

Very common for the traumatic event to be that pt leaned over to pick something up off the floor.

She doesn’t see much of either one (true versions). She sees muscle guarding and contraction a lot to protect lumbar structures).

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23
Q

What percent of LBP patients eventually undergo lumbar surgery? (this may be the figure for the percent of the people with LBP lasting longer than 2 weeks, I can’t tell from the slide and I didn’t write it down)

A

1-2%

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23
Q

What is the take home about chronic LBP and fear-avoidance behavior?

A

Take home: if people have chronic LBP, we really need to address fear-avoidance behavior in our therapy in order to make any improvement.

24
Q

Chou Study: things to consider

A
  • surgery for spinal stenosis and radiculopathy secondary to HNP may have short-term benefits, but that the tendency is for patients to improve with or without surgery
    • Intensive vs. nonintensive therapy
    • Several of the “surgery” groups in these studies include patients who have already failed conservative therapy. Nonsurgical group may include treatment options that have already proved noneffective
    • Wide variety of therapy performed for nonsurgical spinal patients
25
Q

Posterior Lumbar Interbody Fusion

A
  1. May be used for the treatment of the following conditions:
    a. lumbar degenerative disease
    b. spondylolisthesis (often)
    c. discogenic back pain
  2. Generally indicated for patients who have persistent, disabling pain after an aggressive and prolonged bout of conservative therapy
26
Q

When Is lumbar surgery indicated?

A
  1. Patients who present with s/s of cauda equina syndrome**
  2. Patients who present with progressive motor deficits**
  3. Patients who have failed conservative measures

** urgent referral

27
Q

ALIF

A

Anterior Lumbar Interbody Fusion

29
Q

What percent of the population will have some type of low back pain within their lifetime?

A

estimated 80%

31
Q

What is Spondylolisthesis?

A

It is the slippage of one vertebra on the other that can occur after bilateral spondylolysis occurs a the pars interarticularis (articularis).

Can be degenerative (older pop) or traumatic (younger pop). Pt may not know it has happend

It has four grades:

  • Grade I: 0-25%, treated conservatively (pt may have no pain)
  • Grade II: 25-50%, treated conservatively (pt may have no pain)
  • Grade III: 50-75%, sometimes surgery (at least eval)
  • Grade IV: 75-100%, always surgery, send to neuro MD if we see first
32
Q

The whole spine has to be held together like a ________ ?

A

Slinky

33
Q

What is the most common imaging technique for discogenic pain?

A

MRI (most common by far)

34
Q

When will we encounter the term schmorl’s nodes?

A

A term we will see a lot when we look at MRI reports

35
Q

Discectomy: difficulty level, time for procedure, inpatient or outpatient, length of rehab?

A

Fairly easy

~45 minutes

Outpatient – home same day

4-6 weeks of rehab

Anagoluos to menisectomy in knee

36
Q

What is the phrase to help remember the types of MRIs?

A

T2 = H2O

37
Q

Lumbar Laminectomy: How to perform

A

(it opens up the space).

  1. Midline incision is made with patient in prone position
  2. Central canal is decompressed by removing laminae and ligamentum flavum
  3. Hypertrophied tissues is removed from the lateral recesses
  4. Individual neuroforamen are decompressed- bone spurs and soft tissue removed
  5. Wound is closed
39
Q

Meniscectomy

A

the surgical removal of all or part of a torn meniscus in the knee

40
Q

What is very indicative of DDD on an MRI?

A

“black disk” in a T2 MRI (water is light) because there is a decrease in water in the disc.

41
Q

When can step-off deformity be felt?

A

not until at least grade 3 spondylolisthesis is present

42
Q

What is the difference between Tietze Syndorme and Costocondritis?

A

It is about the same thing

43
Q

3 main Types of grafts that could be used in a PLIF

A
  1. Autograft bone
  2. Allograft bone
  3. Metal and carbon cages filled with cancellous bone
44
Q

Two Degenerative lumbar Disorders

A

DDD (Degenerative disc disease)

DJD (Degenerative joint disease)

45
Q

Lumbar Discectomy vs PLIF;

advantages and disadvantages:

A

Disectomy advantages: Disectomy Disadvantages:

  • shorter Rehab * HNP may recur
  • maintain full ROM * Cannot do in pts with instability

PLIF advantages: PLIF disadvantages:

  • HNP won’t recur * longer rehab
  • can do in pts with instibility * potential for wear and tear on adjacent joints
47
Q

At a typical outpatient ortho clnic, hat percent of your patient clients will come to you for LBP?

A

About 60%

48
Q

What are 5 common Lumbar Pathologies?

A
  1. Degenerative disorders
  2. Discal Disorders
  3. Instability (bony)
  4. Lumbar strain/sprain
  5. Facet disorders
50
Q

Will the presence of a Schmorl’s node change your treatment?

A

Nope

51
Q

Lumbar Disc Replacement rehab, general guidelines

A
  1. Avoid endrange rotation, extension, and flexion for at least 6 weeks
  2. No impact loading for at least 3 months
  3. Currently no evidence published in a peer-reviewed literature for post-op guidelines
52
Q

Chou Study, Results

A
  • NonradicLBP w/common degen chng: fair evid frm RCTs fusion no Î effect than intense rehab w/a cogn/behav emp; but is slight to mod Î effect than stand (nonint) non-surg ther.

Radiculopathy with HNP: good evidence open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improv pain & function, but only through 2-3 mo. Evidence of longer term benefits after 2-3 months is inconsistent

  • Spinal stenosis with/without degen spondylolisthesis: good evid that laminectomy (with or w/o fusion) is mod superior to nonsurgtherapy for pain & function, but only thru 1-2 yrs
  • TDR: fair evidence it is as effective as fusion w/pts who have nonradic LBP w/single level degen disc dz. Insufficient data to assess long-term benefits & harms
54
Q

Imaging in the spine and how it relates to treatment (precautions and considerations)

A

Patho anatomical approach is treating according to imaging. In the spine, this is a very dangerous and not a good approach. It is best to use imaging as adjunct. Treat according to symptoms, regardless of what structure is causing it. Treat according to clinical exam and findings there, not according to imaging. Use imaging as an adjunct.

Study with >30years old with no symptoms. 80% of these pts had HNP on imaging. But they had no pain, so if you have someone with spine pain and their MRI shows HNP, then if you treat HNP it still may hurt since people can have HNP with no pain. In appendicular skeleton, you look to the diagnostic imaging more than in the spine, but still be careful. You do not have to have an MRI before you do mobs

56
Q

PLIF

A

Posterior Lumbar Interbody Fusion

57
Q

What are three imaging techniques used for discogenic pain?

A
  1. MRI (most common by far)
  2. CT scan
  3. Provocative discography: invasive procedure. Image-guided procedure that injects the nucleus propulsus with a contrast agent. Evaluate pain response. (inject stuff, see if it reproduces pain)
58
Q

Treatment approaches with Spondylolisthesis

A
  • Grade I & II are treated coservatively (pt may not have pain)
  • Grade III, sometimes surgery (at least evaluation)
  • Grade IV, always surgery (if we do see them be for they see neurosurgeon, send emmediately to surgeon)
59
Q

Chou Study, intro and inclusion criteria

A
  • Conducted search for randomized controllled trials and systematic reviews from 2000-July 2008.
  • Included articles from Ovid MEDLINE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials
  • nInclusion criteria included:
    • All trials/reviews were in English and included nonpregnant adults >18 years old
    • Reported at least on of the following: back specific function, generic health status, pain, work disability, or patient satisfaction
    • Evaluated surgery for nonradicular LBP with common degenerative changes, radiculopathy with HNP, or symptomatic
61
Q

How to perform a discectomy?

A
  • Small midline incision is generally made with patient in prone position (on the lateral side where the herniation is)
  • Correct level is identified and laminectomy is performed on the affected side
  • Nerve root is retracted to expose with underlying disc herniation
  • Herniated diskal material is excised
  • Wound is closed
62
Q

Lumbar Laminectomy: Indications

A
  1. Usually used for patients with spinal stenosis with/without degenerative spondylolisthesis
    1. Generally people in their 6th/7th decades
    2. intractable pain not responsive to conservative treatment
    3. patients with neurological deficits that significantly impair function/lifestyle
  2. Laminectomy without stabilization is used for patients without instability (no degenerative spondylolisthesis)
  3. If degenerative spondylolisthesis is present, then instrumentation may be used
63
Q

Lumbar Discectomy: indications

A

(in the absence of cauda equina or progressive motor deficits):

a. unilateral radicular s/s
b. imaging confirms correlating disc herniation
c. failure of at least 6-8 weeks of non-operative treatment

All three must be be present to be indicated.

Imaging is taken after failed conservative treatment

64
Q

How long will we keep pts in PT for all the surgeries we have talked about?

A

Discectomy: 1-2 months

Fusion: 3-4 months

TDR: 2-3 months (not as established )

Laminectomy without fusion: Similar time to discectomy

Laminectomy with fusion: similar to fusion

65
Q

ALIF: Indications and approach

A

Similar to PLIF, execpt without neural compression

  1. lumbar degenerative disease
    1. spondylolisthesis
    2. discogenic back pain
  2. Generally indicated for patients who have persistent, disabling pain after an aggressive and prolonged bout of conservative therapy

Approach is through abdomen

66
Q

Is LBP easy or hard to treat, and is chronic and acute versions different in difficulty?

A

It can be very difficult to treat in some respects, especial chronic.

67
Q

PLIF: how to perform

A
  1. Patient is lying prone and longitudinal midline incision is made
  2. Portion of the lamina and superior/inferior facets are removed to be able to expose the spinal canal. (also clean up osteophytes)
  3. Diskal material is removed (entire disk)
  4. Grafts are placed in the interspace (autograft or allograph). Autograph uncommon but it is usually from iliac crest (pain there
  5. Instrumentation is added

Cannot reherniate like a discectomy

69
Q

pars articularis

A

the part of vertebra located between the inferior and superior articular processes of the facet joint.[1]

70
Q

Lumbar Discectomy: advantages and disadvantages

A

Advantages:

  • Shorter Rehab
  • maintain full ROM

Disadvantages

  • Herniation may recur
  • cannot do in pts with instability
71
Q

Four Facet Disorders

A
  1. Degenerative facet disorders
  2. Capsular entrapment
  3. Facet joint sprain
  4. Facet Joint syndrome
72
Q

Chou Study: Types of comparisons

A
  • Types of comparisons include:
    • Surgery for nonradicular back pain with common degenerative changes
  • a. Fusion vs. nonsurgical
    • Articifial disc replacement
  • a. disc replacement vs. fusion
    • Radiculopathy with HNP
                 a. discectomy vs. nonsurgical
            b. microdiscectomy vs. standard open discectomy
    • Surgery for symptomatic spinal stenosis with/without degenerative spondylolisthesis
      a. laminectomy with/without fusion vs. nonsurgical
      b. laminectomy + posteriorlateral fusion vs. laminectomy alone
73
Q

When did lumbar TDR start in the USA (FDA approval)?

A

FDA granted approval for lumbar disc replacement in Oct 2004

74
Q

What are some reasons that MRIs are not great for helping treat a patient, and what is a problematic reason PTs sometimes want them?

A

Usually it doesn’t add anything useful.

MRIs only give a static picture of one point of time when not moving. What is this really going to tell us?

Some PT’s are not confident in their own clinical exam skills, so they want MRI so they can treat off that. But she guaruntees us we won’t get pt better off MRI. We NEED to have good clinical exam skills/abilities.

75
Q

What are two bony lumbar instabilities?

A

Spondylolysis

Spondylolisthesis

76
Q

What is Costocondritis?

A

About the same thing as Tietze Syndrome

Inflammation of the costal cartilage. If swelling accompanies it, it is called Tietze Syndrome

Usually caused by something repetitive (coughing, laughter, push-ups)

Treatment: rib mobs and thoracic manips, and other stuff I forgot to listen to

By far the most common musculoskeletal reason to have chest pain.

77
Q

Who is a candidate for a Lumbar Total Disc Replacement?

A
  1. 18-60 years old
  2. failed >6 months of nonoperative treatment
  3. single level degenerative disease confirmed by MRI or discography
  4. no previous lumbar fusion
  5. no instability
  6. no extruded disc material

**only 5% of patients considered for surgical intervention meet this criteria (only 1% of back patients are considered for surgery)

78
Q

LBP

A

Low Back Pain

PHTH 7212 Pathophysiology (12 decks)

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