SURGERY  FOR    LOW  BACK  PAIN    Paul  Licina  

Not  all  spine  surgery  is  the  same…  

DISCECTOMY FOR DISC HERNIATION

DISCECTOMY FOR DISC HERNIATION

Outcome

•  Day  Surgery  procedure  •  back  to  sedentary  duHes  in  3  weeks  •  back  to  sport  in  6  weeks  •  good  or  excellent  result  in  90-­‐95%  

FUSION FOR LOW BACK PAIN

FUSION FOR LOW BACK PAIN

What  is  fusion  good  for?  

FUSION FOR LOW BACK PAIN

What  about  low  back  pain?  

FUSION FOR LOW BACK PAIN

   Results  not  as  good  as  for  deformity  or  instability  

 Results  not  as  good  as  for  

discectomy  surgery    

WRONG  diagnosis  WRONG  paHent  

FUSION FOR LOW BACK PAIN

   Results  not  as  good  as  for  deformity  or  instability  

 Results  not  as  good  as  for  

discectomy  surgery    

WRONG  diagnosis  WRONG  paHent  

FUSION FOR LOW BACK PAIN

DISEASE DIAGNOSIS symptoms and signs

Hx, Ex & Ix

TREATMENT CURE directed at pathology

The medical model

DISEASE DIAGNOSIS symptoms and signs

Hx, Ex & Ix

The medical model

back pain is a complex symptom rather than a

discrete illness

structural lesion cannot be identified in many

cases

does not account for individual variation in

human response

15%

FUSION FOR LOW BACK PAIN

CHRONIC  SPECIFIC  

ACUTE  SPECIFIC  

CHRONIC  NON  

SPECIFIC  

ACUTE  NONSPECIFIC  

FUSION FOR LOW BACK PAIN

   Results  not  as  good  as  for  deformity  or  instability  

 Results  not  as  good  as  for  

discectomy  surgery    

WRONG  diagnosis  WRONG  paHent  

SUITABLE  CANDIDATE  •  Self-­‐employed  •  Successful  business  •  No  specific  injury  •  No  compensa5on  or  li5ga5on  •  Works  with  some  difficulty  •  Has  given  up  some  of  more  acHve  sports  •  Uses  intermiCent  over-­‐the-­‐counter  analgesics  •  Non-­‐smoker  •  Normal  body  weight  •  Goal  is  to  be  able  to  return  to  ac5ve  lifestyle  •  No  abnormal  illness  behaviour  

UNSUITABLE  CANDIDATE  •  Employee  undertaking  manual  work  •  DissaHsfied  with  employment  •  UnremiYng  pain  aZer  liZing  at  work  •  Unresolved  WorkCover  claim  with  civil  ac5on  pending  

•  Failed  aCempts  at  return  to  work  •  Has  given  up  all  social  acHviHes  •  Uses  regular  narco5c  analgesia  •  Smoker  •  Unfit  and  overweight  •  Goal  is  for  someone  to  get  rid  of  their  pain  •  Abnormal  illness  behaviour  on  examina5on  

Techniques  

FUSION FOR LOW BACK PAIN

FUSION FOR LOW BACK PAIN

Noninstrumented fusion

Instrumented fusion

FUSION FOR LOW BACK PAIN

FUSION FOR LOW BACK PAIN

Interbody fusion

remove the disc

Interbody fusion

• remove the pain source • stop the movement

FUSION FOR LOW BACK PAIN

benefits

Anterior interbody

• anterior muscle-splitting only

• minimal tissue trauma

indications

•  isolated degeneration • L5-S1 (L4-5) • no need to enter canal • thin, no previous major abdominal surgery

FUSION FOR LOW BACK PAIN

benefits

Transforaminal interbody

• allows nerve decompression

• allows all levels • familiarity

indications

• not suitable for ALIF • nerve compression esp foraminal compression

• correction of deformity

What’s  new?  

When  is  fusion  good  for  LBP?  • specific  diagnosis  

• clearly  defined  pain  source  

• suitable  candidate  • no  negaHve  psychosocial  factors  

• appropriate  technique  for  pathology  • some  surgeon  variaHon