L22: Surgical Interventions Flashcards
Where do referral patients come from in terms of surgery?
- Privately
- Physio referral (2-3)
- Massage referral
- GP referral (1-2)
- They have come because they are confused and have been told conflicting information
- Public
- Screening service
What is the role of physio in spinal surgery in a timeline of Day 0, 2 weeks and 6 weeks post?
- Seen on day of surgery –> HEP (give plan)
- Seen after 2 weeks –> walking and gentle mobilisation
- Seen after 6 weeks –> more progressions
What causes a disc herniation?
tear in outer disc migration of inner gel
Nucleus is solid like –> not a gel • When removed
What does a disc herniation cause? What are the 2 stages?
nerve pressure leg pain (sciatica)
2 stages:
- Tingling feeling
- Pain due to inflammatory response (after a few days)
How can we treat a disc herniation?
observe (physiotherapy) nerve root block surgery
Very little you can do –> ease symptoms and make them feel better) –> MAIN ROLE: advice and support
What are 6 characteristics of a nerve root block?
- injection of local anaesthetic (Marcain) and steroid (Dexamethasone)
- into nerve root foramen
- under CT guidance
- usually temporary
- Not change any natural physiology (just help with pain)
- good if surgery not indicated
- good for diagnosis if in doubt
- When the pain to very severe and is used very commonly
When can we operate on a disc herniation?
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)
Why do we operate on a disc herniation?
relief of leg pain
What is the surgery for a disc herniation called?
Discectomy
What are 6 prerequisites for a disctectomy?
- symptoms > 4-6 weeks
- Long enough that you know that the pain won’t go away with time (naturally)
- leg pain > back pain
- leg pain in radicular distribution- cannot be diffused and vague pain
- nerve tension signs (reduced SLR)
- nerve compression signs (weakness, numbness, reflex loss)
- confirmed on imaging
What are 5 outcomes post discectomy?
- Day Surgery procedure
- back to sedentary duties in 3 weeks
- back to sport in 6 weeks
- good or excellent result in 95%
- recurrence rate 6% at 2 years
Hole in the annulus to let it heal naturally –> cannot seal
What does a disc herniation look like?
What does a nerve root injection look like?
What causes spinal stenosis?
narrowing of the spinal canal with nerve compression
What does spinal stenosis cause?
Gradual development of symptoms (nerve have more time to accommodate) leg pain neurogenic claudication
What relieves spinal stenosis symptoms?
Need to stoop forward to get relieve –.> flexion based positions
What else could spinal stenosis look like?
- osteoarthritis of the hip
- vascular claudication (Pain around the buttock and when you walk (due to the deficiency of blood supply)
How do you treat spinal stenosis?
observe / physiotherapy epidural injection surgery
What are 6 characteristics of an epidural injection?
- injection of local anaesthetic (Marcain) and cortisone (Celestone)
- via epidural or caudal approach
- usually temporary
- can be long-lasting
- can be repeated
- good if surgery not indicated
When do we operate on spinal stenosis?
intolerable pain; neurological deficit (uncommon –> usually no neuro deficits)
Why do we operate on spinal stenosis?
relief of leg/back symptoms
What do we call surgery for spinal stenosis?
Laminectomy
What happens in a laminectomy?
Why is it important to be careful with a laminectomy, while it is a common operation?
Spinous process removed from 4 levels
- Need to be careful not to damage the nerves (quite delicate)
Common operation, usually goes well
When do we add a fusion in spinal stenosis?
presence of instability
What is spondylolysis?
Stress fracture of pars interarticularis
What are 3 characteristics of degenerative spondylolisthesis?
- due to degeneration of facet joint
- facet joint stability fails and L4 slips forward on L5
- leads to spinal stenosis
How common is degenerative spondylolisthesis?
More common -> almost universal once reaching 80yrs old
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
Degenerated Spondylolisthesis with association with spinal stenosis
What does the fusion/stabilisation of the vertebrae look like?
Stabilise and decompression (screws)
What are 3 characteristics of degenerative scoliosis?
- due to asymmetric degeneration of disc and facet joint
- vertebral tilt leads to spinal deformity and accelerated degeneration
- associated spinal stenosis
What does scoliosis look like on a x-ray?
What is the problem with scoliosis?
Leg symptoms due to compression of nerves (from the curvature of the spine)
How can scoliosis be fixed surgically?
- Screws are placed all down the spine (huge operation)
- Quite hesitant to be done –> sometimes have to be done if symptoms so are severe
In LBP, the Decision whether to operate is _____. Why?
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
Why does surgery for LBP not have as good prognosis that discectomy or laminectomy?
We don’t know where the pain is coming from (eg. which structure)
When is surgery done for LBP?
Young middle aged –> still need to be able to very functional activities
How to you do surgery from anterior rather than posterior?
Surgery from anteriorly rather than from posteriorly
- Split the skin and rectus abdominis
- Move the organs • Look straight into the spine
What is added when the surgery is done from anteriorly?
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
If a patient has pyshological issue involved, what is the course of action? Surgery?
- 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
discectomy is effective for _____ and for severe _____
disc herniation; radiculopathy
laminectomy is good for _____ and _____symptoms improve
spinal stenosis; claudication
Is a discectomy a first or last resort for disc herniation?
This is a first resort (not last resort)
Fusion ______ (is/is not) usually indicated for back pain
is not
right diagnosis / right patient
