Lumbar Surgeries PowerPoint - Dr Wofford Flashcards
What happens to the piece of free-floating NP that is present in a sequestration HNP?
body will do phagocytosis which will take care of it but it takes a long time and most people don’t want to sit through the pain for that long
Explain DJD (5 things)
- Wear and tear on the joints
- Most commonly in the lumbar facet joints
- Osteophyte formation is significant
- Can have genetic components
- Can have activity level play a role (like too much activity from military career)
Explain DDD (6 things)
- It is wear and tear on the disks
- Disc loses water content and gets shorter
- Can have fissuring and tearing of the annulus
- “black disk” is very indicative on T2 MRI (water is white)
- Can have genetic components
- Can have activity level play a role (like too much activity from military career)
What is a scottie dog fracture?
Same as spondylolysis
Collar is where you look for the fracture on the x-ray
What percent of LBP patients have s/s lasting for longer than 2 weeks?
7-14%
What are Schmorl’s Nodes?
A protrusion of intervertebral cartilage through the vertebral endplate into an adjacent vertebrae.
A term we will see a lot when we look at MRI reports
What is Spondylolysis?
A fracture of the pars articularis in the vertebrae.
Can be degenerative (older pop) or traumatic (younger pop).
Pt may not know it has happend
It must be present bilaterally for spondylolisthesis to occur
What condition is the ligamentum flavum usually in when a surgeon performs a Lumbar Laminectomy?
Typically there is a lot of hypertrophy of the ligamentum flavum
What is Tietze Syndrome?
About the same thing as Costocondritis
Inflammation of the costal cartilage. If swelling accompanies it, it is called Tietze Syndrome
Usually caused by something repetitive (coughing, laughter, push-ups)
Treatment: rib mobs and thoracic manips, and other stuff I forgot to listen to
By far the most common musculoskeletal reason to have chest pain.
Disc Replacement: Advantages and disadvantages
Advantages (sort of best of both worlds of fusion and discectomy):
- Ability to restore full motion to the intervertebral segment
- Protect adjacent segments from increased “wear and tear
Disadvantages
- No long term outcome studies in the US- only gained FDA approval 8 years ago
- Possibility of subluxation/dislocation and implant failures
- Very few pts are candidates
Four Lumbar Surgeries:
- Diskectomy
- Lumbar fusion
- Laminectomy
- Total Disc Replacement
Lumbar Dicectomy: what is it?
Like ACDF in C-spine
In lumbar spine it is more analgolous to a meniscectomy
They go in and shave off part sticking out?
They can have open or closed (microdiscectomy)
It is for HNP
What is facet joint syndrome?
A bucket term, sort of like HNP is, which doesn’t tell you much.
pars interarticularis
Lumbar Discectomy, general rehab guidelines
- Limit flexion and rotation for 8-12 weeks
- ** No joint mobilizations of surgical segments for 3 months**
- ** Use modalities as needed and be sure to address scar**
No joint mobs TO THAT SEGMENT. We can do mobs in other spinal regions/segments. Don’t get close to the surgical level.
WE MUST ADDRESS the scar. Most pts don’t see or touch low back often if at all.
Scar massage when wound is fully healed. X-friction massage every day for 3-5 minutes with vitamin e cream. Prevents adhesions and hypersensitivity.
What are the two biggest pain generators in the low back?
By a long shot, most people say the disk is the primary generator, followed by facet joints
What are the only reasons to do a Lumbar MRI?
- You think something is non-musculoskeletal problems (such as kidney symptoms)
- If they have completely failed conservative treatment
- If we do our clinical scan and they have full radiculopathy and they have impaired reflexes and myotomes (because they may need someone besides us, maybe surgery).
Anything but these, the MRI results will not change your POC or treatment. If results of MRI will not change your treatment approach, ordering it will not help and is unnecessary. If it may change your plan of care, then ordering the imaging would likely be appropriate. But we treat the symptoms, not the image. MRIs are over-ordered all the time.
Two main cauda equina symptoms
- Bowel and bladder symptoms
- Saddle paresthesia
Two big things that Dr. Wofford wanted us to get out of her Lumbar Surgeries lectures:
- MRI’s are majorly over utilized (and there is only 3 reasons to do them)
- There have been plenty of studies where they have looked at pts who in the absence of red-flags, but have low back pain and found 5 years down the road the outcome is the same if pt does surgery or conservative treatment. That is what research shows.
PLIF: Advantages and disadvantages
Advantages:
- Will not recur
- Can do in pts with instability
Disadvantages
- Herniation cannot recur
- Longer Rehab
What is one of the most common causes of disability?
LBP
Possible symptoms with an anteriordisc bulge or herniation:
LBP, but no radicular symptoms or pain.
Could have referred pain, but not radicular pain.
How long have lumbar disc replacements been performed in Europe?
over a decade
When does initial fusion occur with lumbar fusion?
12 weeks (3 months)
What is Failed Back Syndrome?
Failed Back Syndrome: pts go in and the have L4-5 HNP, PCP sends to Neurosurgeon who does surgery, Discectomy fails so fused, then other joints have more wear and tear and end up with fusions, and progressively more levels need fusion. Unfortunately we will see this a lot. This is a BIG reason pts should try conservative treatment first!!!
pt that doesn’t exercise may want to choose the 45 min surgery over exercise. PT is not as instant, but doesn’t cause long term problems. It can actually help long term outcomes.
It makes a HUGE difference how you education your patients.
______ & ________ commonly go together so we will see that many ________ have LBP
LBP
Disability
Workers Comp Patients
More about capsular entrapment
Capsular entrapment is usually triggered by quick awkward movement. Will be limited in Extension, Lateral Flexion, and rotation. An acute problem. It responds very well to manual therapy.
Could see them with Capsular entrapment as primary issue depending on how soon you see patients. Sometimes pts will go to doctor for this.
Could also see pt with this
Lumbar Fusion, general rehab guidelines (all types of lumbar fusion)
- No impact loading for at least 3 months
- Avoid endrange rotation, extension, repetitive/prolonged flexion for at least 3 months
- Avoid intensive abdominal strengthening for 3 months
- Equivocal research regarding post-opguidelines
Spondylolisthesis Grades
- Grade I: 0-25%, treated conservatively (pt may have no pain)
- Grade II: 25-50%, treated conservatively (pt may have no pain)
- Grade III: 50-75%, sometimes surgery (at least eval)
- Grade IV: 75-100%, always surgery, send to neuro MD if we see first
Describe clinical relevance of Lumbar Strain/Sprain
There must be some sort of traumatic event (macro or micro) that causes this, and it must be some sort of motion (cannot be slept wrong). MDs often refer with strain/sprain on order, but pt doesn’t recall any event that could cause it.
Very common for the traumatic event to be that pt leaned over to pick something up off the floor.
She doesn’t see much of either one (true versions). She sees muscle guarding and contraction a lot to protect lumbar structures).
What percent of LBP patients eventually undergo lumbar surgery? (this may be the figure for the percent of the people with LBP lasting longer than 2 weeks, I can’t tell from the slide and I didn’t write it down)
1-2%