SURGERY  FOR    

LOW  BACK  PAIN  

Paul  Licina  Spine  Surgeon  

SPINAL  PROBLEMS  -­‐  ANSWERING  THE  HARD  QUESTIONS  

Is  fusion  warranted  for  LBP?  

“spinal  fusion  has  leG  more  tragic  human  wreckage  in  its  wake  than  any  

other  operaLon  in  history”  

   WRONG  diagnosis      WRONG  paLent      WRONG  operaLon  

FACETOGENIC PAIN

DISCOGENIC PAIN

SPONDYLOLISTHESIS

PAIN OF UNCLEAR CAUSE

SUITABLE  CANDIDATE  •  Self-­‐employed  •  Successful  business  •  No  specific  injury  •  No  compensa@on  or  li@ga@on  •  Works  with  some  difficulty  •  Has  given  up  some  of  more  acLve  sports  •  Uses  intermiJent  over-­‐the-­‐counter  analgesics  •  Non-­‐smoker  •  Normal  body  weight  •  No  abnormal  illness  behaviour  •  Goal  is  to  be  able  to  return  to  ac@ve  lifestyle  

UNSUITABLE  CANDIDATE  •  Employee  undertaking  manual  work  •  DissaLsfied  with  employment  •  UnremiRng  pain  aGer  liGing  at  work  •  Unresolved  WorkCover  claim  with  civil  ac@on  pending  

•  Failed  aJempts  at  return  to  work  •  Has  given  up  all  social  acLviLes  •  Uses  regular  narco@c  analgesia  •  Smoker  •  Unfit  and  overweight  •  Abnormal  illness  behaviour  on  examina@on  •  Goal  is  for  someone  to  get  rid  of  their  pain  

back  pain  

suitable  for  surgery  

TYPES OF SURGERY

Posterolateral fusion

pars

facet joint

transverse processes transverse processes

sacrum

STEPS • decortication • graft insertion

leave out

Grafting

decortication & grafting

screw insertion

rod insertion

sleeve & nut

Instrumentation

TYPES OF SURGERY

remove the disc

Interbody fusion

• remove the pain source • stop the movement

TYPES OF SURGERY

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

L5-S1 no leg pain thin no abdo surgery

My ALIF indications

TYPES OF SURGERY

benefits

Transforaminal interbody

• allows nerve decompression

• allows all levels • familiarity

indications

• not suitable for ALIF • nerve compression esp foraminal compression

• correction of deformity

ALIF contraindicated nerve compression L4-5 level wrong shape young male

My TLIF indications

FUSION TECHNIQUES

What’s new?

When  is  fusion  good  for  LBP?  

• specific  diagnosis  • clearly  defined  pain  source  

• suitable  candidate  • no  negaLve  psychosocial  factors  

• appropriate  technique  for  pathology  • some  surgeon  variaLon