Conservative and Surgical Management of Thoracolumbar Intervertebral Disc Herniation

Question 1

Fill the blank: In cases of disc extrusion around [blank] of patients may deteriorate or relapse when conservative management is used.

Answer 1

1/3

Question 2

Conservative treatment options? (7)

Answer 2

NSAIDS for 7 to 14 days

And/or Paracetamol (10 mg/kg q12hrs for 7 to 10 days)

Gabapentin (10-20 mg/kg q8h for 2 weeks then q12hrs for 2 weeks)

Cage rest 4 weeks and lead walks only for 5-10 minutes with sling support if required

Physiotherapy

Pain clinic

Weight control

Question 3

A re-examination is recommended in the first week after starting a conservative management followed by rechecks. How often should rechecks be performed?

Answer 3

In the first week, after two weeks and at four weeks

Question 4

What needs to be considered re health with spinal surgery?

Answer 4

Health co-morbidities

Question 5

Use of steroids in spinal dx?

Answer 5

Contraindicated; high risk of side effects

Question 6

Common complications of spinal surgery include? (6)

Answer 6

Venous sinus bleed,
Redistribution of disc material,
Incomplete decompression,
Relapse of intervertebral disc disease,
Approaching the wrong disc space
Intra-operative trauma.

Question 7

Two important factors to ensure a satisfactory outcome in spinal cases are (2)

Answer 7

Regular assessment of the patient
Good communication with the client

Question 8

Pre-medication?

Answer 8

Opioid and ACP

Question 9

ABx for spinal surgery?

Answer 9

(e.g. amoxicillin or cephalosporins) can be initiated at induction and continued during surgery (every 2 hours).

• Not usually needed post op

Question 10

In which recumbency should the patient be positioned during hemilaminectomy?

Answer 10

The patient is positioned in ventral recumbency with a mild tilt away from the surgeon.

Question 11

Hemilaminectomy
A) what blade is used for the skin?
B) What blade is used to incise fascia adjacent to spinous process?

Answer 11

A) 10
B) 11

Question 12

Hemilaminectomy:
A) What muscle is retracted with periosteal elevator?
B) What is exposed after inciding muscle, and using periosteal elevators and cautery?

Answer 12

A) paraspinal muscles
B) articular facet

Question 13

Hemilamenectomy;
On the approach use gelpi retractors to exposure and expose what process?

Answer 13

Mammillary process

Question 14

Hemilamenectomy;
What tendon is cut close to its insertion on the accessory process.?

Answer 14

longissimus tendon

Question 15

Hemilaminectomy;
Once the surgical site is identified, remove what with rongeurs?

Answer 15

the articular facet

Question 16

Hemilaminectoyl use a spinal burr to remove what? (3)

Answer 16

cranial and caudal articular facets,
mammillary process
dorsal aspect of articular facet.

Question 17

Once a fine osseous window is achieved, open the window and remove the fine cortical bone with(3)

Answer 17

small rongeurs, a curette or Kerrison bone punch

Question 18

Hemilamenectomy:
In cases of a chronic disc, material can be removed using? (2)

Answer 18

forceps
haemostats.

Question 19

Following hemilamenectomy where to check the window for remaining disc material?

Answer 19

Dorsal
Cranial
Caudal
Ventral

Question 20

What is performed on the disc Following hemilamenectomy?

Answer 20

Fenestration

Question 21

Following hemilamenectomy what happens prior to closing? (2)

Answer 21

Flush
Check for haemorrhage

Question 22

Hemilamenectomy;
A) Suture the fascia with?
B) Close subcut with?
C) Skin closure?

Answer 22

A) PDS
B) monocryl
C) Ethilon or staples

Question 23

With a hemilamenectomy; ensure the incision is ventral enough; what landmark is used?

Answer 23

The accessory process as a ventral landmark

Question 24

Why does the hemilamenectomy need to be ventral enough? (2)

Answer 24

explore the vertebral canal below the spinal cord
identify the nerve root and venous sinus.

Question 25

If the disc is not properly fenestrate; what is the risk?

Answer 25

Relapse

Question 26

What is used as a marker to confirm surgical site?

Answer 26

Needle for localization of the intervertebral disc space. The needle can be inserted into a spinous process and radiographs performed prior to surgery to confirm positioning.

Question 27

What are the most common complications following a laminectomy? (8)

Answer 27

Incorrect surgical site

Venous sinus bleed

Redistribution of disc material

Incomplete decompression

Post-operative haematoma

Further intervertebral disc extrusion

Trauma during surgery

Development of post surgical seroma.

Question 28

T or F:
Make your hemilaminectomy ventral enough (using the accessory process as a ventral landmark) to be able to explore the vertebral canal above the spinal cord.

Answer 28

False

Question 29

T or F
Make your hemilaminectomy ventral enough (using the accessory process as a ventral landmark) to identify the nerve root and venous sinus.

Answer 29

True

Question 30

T or F
The risk of relapse without fenestration is 70% vs 4% if fenestrated.

Answer 30

False

Question 31

T of F
For localisation of the intervertebral disc space, a marker needle can be inserted in a spinous process.

Answer 31

True