L22: Surgical Interventions

Question 1

Where do referral patients come from in terms of surgery?

Answer 1

1. Privately
   
   • Physio referral (2-3)
   • Massage referral
   • GP referral (1-2)
   • They have come because they are confused and have been told conflicting information
2. Public
   
   • Screening service

Question 2

What is the role of physio in spinal surgery in a timeline of Day 0, 2 weeks and 6 weeks post?

Answer 2

• Seen on day of surgery –> HEP (give plan)
• Seen after 2 weeks –> walking and gentle mobilisation
• Seen after 6 weeks –> more progressions

Question 3

What causes a disc herniation?

Answer 3

tear in outer disc migration of inner gel

Nucleus is solid like –> not a gel • When removed

Question 4

What does a disc herniation cause? What are the 2 stages?

Answer 4

nerve pressure leg pain (sciatica)

2 stages:

1. Tingling feeling
2. Pain due to inflammatory response (after a few days)

Question 5

How can we treat a disc herniation?

Answer 5

observe (physiotherapy) nerve root block surgery

Very little you can do –> ease symptoms and make them feel better) –> MAIN ROLE: advice and support

Question 6

What are 6 characteristics of a nerve root block?

Answer 6

1. injection of local anaesthetic (Marcain) and steroid (Dexamethasone)
2. into nerve root foramen
3. under CT guidance
4. usually temporary
   
   • Not change any natural physiology (just help with pain)
5. good if surgery not indicated
6. good for diagnosis if in doubt
   
   • When the pain to very severe and is used very commonly

Question 7

When can we operate on a disc herniation?

Answer 7

cauda equina syndrome unremitting pain

Severe dysfunction of the LL (bilaterally) (eg. unable to stand or walk, can’t move

• When they say they are incontinence (not to do with bladder/bowel) –> more about being unable to move (due to symptoms)

Question 8

Why do we operate on a disc herniation?

Answer 8

relief of leg pain

Question 9

What is the surgery for a disc herniation called?

Answer 9

Discectomy

Question 10

What are 6 prerequisites for a disctectomy?

Answer 10

1. symptoms > 4-6 weeks
   
   • Long enough that you know that the pain won’t go away with time (naturally)
2. leg pain > back pain
3. leg pain in radicular distribution- cannot be diffused and vague pain
4. nerve tension signs (reduced SLR)
5. nerve compression signs (weakness, numbness, reflex loss)
6. confirmed on imaging

Question 11

What are 5 outcomes post discectomy?

Answer 11

1. Day Surgery procedure
2. back to sedentary duties in 3 weeks
3. back to sport in 6 weeks
4. good or excellent result in 95%
5. recurrence rate 6% at 2 years

Hole in the annulus to let it heal naturally –> cannot seal

Question 12

What does a disc herniation look like?

Answer 12

Question 13

What does a nerve root injection look like?

Answer 13

Question 14

What causes spinal stenosis?

Answer 14

narrowing of the spinal canal with nerve compression

Question 15

What does spinal stenosis cause?

Answer 15

Gradual development of symptoms (nerve have more time to accommodate) leg pain neurogenic claudication

Question 16

What relieves spinal stenosis symptoms?

Answer 16

Need to stoop forward to get relieve –.> flexion based positions

Question 17

What else could spinal stenosis look like?

Answer 17

• osteoarthritis of the hip
• vascular claudication (Pain around the buttock and when you walk (due to the deficiency of blood supply)

Question 18

How do you treat spinal stenosis?

Answer 18

observe / physiotherapy epidural injection surgery

Question 19

What are 6 characteristics of an epidural injection?

Answer 19

1. injection of local anaesthetic (Marcain) and cortisone (Celestone)
2. via epidural or caudal approach
3. usually temporary
4. can be long-lasting
5. can be repeated
6. good if surgery not indicated

Question 20

When do we operate on spinal stenosis?

Answer 20

intolerable pain; neurological deficit (uncommon –> usually no neuro deficits)

Question 21

Why do we operate on spinal stenosis?

Answer 21

relief of leg/back symptoms

Question 22

What do we call surgery for spinal stenosis?

Answer 22

Laminectomy

Question 23

What happens in a laminectomy?

Answer 23

Question 24

Why is it important to be careful with a laminectomy, while it is a common operation?

Answer 24

Spinous process removed from 4 levels

• Need to be careful not to damage the nerves (quite delicate)

Common operation, usually goes well

Question 25

When do we add a fusion in spinal stenosis?

Answer 25

presence of instability

Question 26

What is spondylolysis?

Answer 26

Stress fracture of pars interarticularis

Question 27

What are 3 characteristics of degenerative spondylolisthesis?

Answer 27

1. due to degeneration of facet joint 2. facet joint stability fails and L4 slips forward on L5 3. leads to spinal stenosis

Question 28

How common is degenerative spondylolisthesis?

Answer 28

More common -\> almost universal once reaching 80yrs old

Question 29

What does spinal stenosis look like in a patient: * 75 y.o. female * long history of back pain * gradual onset of leg heaviness and tingling (ants crawling on skin) * comes on with standing and walking * starting to stoop and lean on trolley * normal neurological examination

Answer 29

Degenerated Spondylolisthesis with association with spinal stenosis

Question 30

What does the fusion/stabilisation of the vertebrae look like?

Answer 30

Stabilise and decompression (screws)

Question 31

What are 3 characteristics of degenerative scoliosis?

Answer 31

1. due to asymmetric degeneration of disc and facet joint 2. vertebral tilt leads to spinal deformity and accelerated degeneration 3. associated spinal stenosis

Question 32

What does scoliosis look like on a x-ray?

Answer 32

Question 33

What is the problem with scoliosis?

Answer 33

Leg symptoms due to compression of nerves (from the curvature of the spine)

Question 34

How can scoliosis be fixed surgically?

Answer 34

* Screws are placed all down the spine (huge operation) * Quite hesitant to be done --\> sometimes have to be done if symptoms so are severe

Question 35

In LBP, the Decision whether to operate is \_\_\_\_\_. Why?

Answer 35

difficult * Results not as good as for discectomy or laminectomy * Degeneration ≠ pain * Incidence of degenerative changes on x-ray in back pain population = normal population * BP is not a disease --\> is a combination of symptoms (many factors eg. psychological) which affect pain WRONG diagnosis WRONG patient

Question 36

Why does surgery for LBP not have as good prognosis that discectomy or laminectomy?

Answer 36

We don’t know where the pain is coming from (eg. which structure)

Question 37

When is surgery done for LBP?

Answer 37

Young middle aged --\> still need to be able to very functional activities

Question 38

How to you do surgery from anterior rather than posterior?

Answer 38

Surgery from anteriorly rather than from posteriorly * Split the skin and rectus abdominis * Move the organs • Look straight into the spine

Question 39

What is added when the surgery is done from anteriorly?

Answer 39

Bone graft + screws which is done from anteriorly * Elegant and works well Bone has grown through L4-5 --\> bone graft healed (after 12 weeks) • Pain source stabilised

Question 40

If a patient has pyshological issue involved, what is the course of action? Surgery?

Answer 40

* Will not be a viable candidate for surgery * This patient needs education, exercise, psychological care and injections rather than surgery * This patient needs education, exercise, psychological care and injections rather than surgery

Question 41

discectomy is effective for _____ and for severe \_\_\_\_\_

Answer 41

disc herniation; radiculopathy

Question 42

laminectomy is good for _____ and \_\_\_\_\_symptoms improve

Answer 42

spinal stenosis; claudication

Question 43

Is a discectomy a first or last resort for disc herniation?

Answer 43

This is a first resort (not last resort)

Question 44

Fusion ______ (is/is not) usually indicated for back pain

Answer 44

is not right diagnosis / right patient