Neurosurgical Options for Back Problems

Osama Nezar Kashlan, MD MPHClinical Assistant Professor of Neurosurgery

University of MichiganNAAMA International Summer Conference

July 3rd, 2019

Knoeller SM, Seifried C. Historical perspective: history of spinal surgery. Spine (Phila Pa 1976). 2000; 25(21):2838-43.

Low Back Pain (LBP)

• One of the leading causes of disability worldwide

• Possible risk factors:– Previous episode of back pain

– Age

– Sex

– Socioeconomic class

– Psychosocial factors

– Physical work demands

• Vast personal and societal impact

• No clear pain generator most of the time

Vassilaki M, Hurwitz EL. Perspectives on Pain in the low back and Neck: Global Burden, Epidemiology, and Management. Hawaii J Med Public Health. 2014. 73(4):122-126.

• Basic Anatomy

• Work-up of LBP Patients

• Types of Surgery

• New Technologies in Spine Surgery

• Basic Anatomy

• Work-up of LBP Patients

• Types of Surgery

• New Technologies in Spine Surgery

http://www.brainandspinalinjuries.co.uk/LeighDayBrainAndSpinalInjury/media/Images/News/Spine/Spinal-cord-anatomy.jpg

https://classconnection.s3.amazonaws.com/544/flashcards/666544/png/spinal_cord1317791249636.png

http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/Root.htm

Central Canal

Lateral Recess

Foramen

Extraforaminal Space

• Basic Anatomy

• Work-up of LBP Patients

• Types of Surgery

• New Technologies in Spine Surgery

Work-up of LBP

• History

• Physical Exam

• If axial pain with no worrying past medical history, symptoms or signs, conservative measures recommended with no imaging needed.

What Makes a Lesion Worrisome?

• Etiology: Infection/Mass vs. Degenerative

• Level of compression: Conus or above

• Site within canal: Central

• Symptoms: Saddle anesthesia, bowel/bladder issues, or weakness

What Makes a Lesion Worrisome?

• Etiology: Infection/Mass vs. Degenerative

• Level of compression: Conus or above

• Site within canal: Central

• Symptoms: Saddle anesthesia, bowel/bladder issues, or weaknes

What Makes a Lesion Worrisome?

• Etiology: Infection/Mass vs. Degenerative

• Level of compression: Conus or above

• Site within canal: Central

• Symptoms: Saddle anesthesia, bowel/bladder issues, or weaknes

• Basic Anatomy

• Work-up of LBP Patients

• Types of Surgery

• New Technologies in Spine Surgery

Compression of Neural Structures

Decompression Surgery (Laminectomy, Diskectomy, etc.)

Instability Present?

Decompression + Instrumentation/Fusion

Risk of Instability After Decompression Surgery?

Decompression + Instrumentation/Fusion

https://www.mayoclinic.org/tests-procedures/laminectomy/about/pac-20394533

• Basic Anatomy

• Work-up of LBP Patients

• Types of Surgery

• New Technologies in Spine Surgery

New Technologies in Spine Surgery

Improving decompression surgery:• Endoscopic spine surgery

Substituting fusion surgery with decompression surgery:• Endoscopic spine surgery• Facet replacement• Disk replacement

Improving fusion surgery:• Cortical screws• Porous cages/ technology• Anterior/lateral approaches for cage placement• Biologics• Robotics

New Technologies in Spine Surgery

Improving decompression surgery:• Endoscopic spine surgery

Substituting fusion surgery with decompression surgery:• Endoscopic spine surgery• Facet replacement• Disk replacement

Improving fusion surgery:• Cortical screws• Porous cages/ technology• Anterior/lateral approaches for cage placement• Biologics• Robotics

Improving Decompression Surgery

https://www.pauljeffordsmd.com/endoscopic-spine-surgery

Improving Decompression Surgery

https://www.pauljeffordsmd.com/endoscopic-spine-surgery

New Technologies in Spine Surgery

Improving decompression surgery:• Endoscopic spine surgery

Substituting fusion surgery with decompression surgery:• Endoscopic spine surgery• Facet replacement• Disk replacement

Improving fusion surgery:• Cortical screws• Porous cages/ technology• Anterior/lateral approaches for cage placement• Biologics• Robotics

Endoscopic Spine Surgery

https://www.pauljeffordsmd.com/endoscopic-spine-surgery

Facet Replacement

https://www.youtube.com/watch?v=QAvuMXhHTlk

Lumbar Disk Replacement

https://chelsielamie.com/artificial-disc-replacement-after-a-crash/

New Technologies in Spine Surgery

Improving decompression surgery:• Endoscopic spine surgery

Substituting fusion surgery with decompression surgery:• Endoscopic spine surgery• Facet replacement• Disk replacement

Improving fusion surgery:• Minimally-invasive fusion• Cortical screws• Robotics/ Navigation• Anterior/lateral approaches for cage placement• Porous cages/ metallurgy• Biologics

Take Home Points

• Back pain is a prevalent condition.

• Pain generator is difficult to pinpoint.

• Unless accompanied by neurologic symptoms, surgical outcomes for treatment of back pain are average at best.