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176
16 Lum bar Disk Disease: Pat hoge nesis and Treat m ent Options
III. Clin ical e va lu at ion .
A. His t o r y.
1. Sciatica or radiculopathy.
a. Frequently becomes greater than back pain in large extruded or
sequestered disk herniations.
b. Typically resolves with time in most protruded disk herniations.
c. Derm atom al distribution.
(1) Pain is classically worse with sitting, coughing, sneezing, and forward
exion.
(2) Pain is usually alleviated by lying and rest.
B. Ph ys i c a l e x a m in at io n .
1. Observation of the patient’s behavior, pain response, spine balance, gait,
muscle spasm, muscle atrophy is important.
2. Bony and soft tissue palpation:
a. Midline tenderness is frequent at the involved level.
b. Sciatic notch and tenderness along the course of the sciatic nerve may be
present in radiculopathy.
c. Paraspinal muscle spasm may be palpable.
3. Range of motion:
a. Normal range of motion is extremely variable among individuals and
even changes from morning to evening.
(1) Pain reproduction at extrem es of m otion is a helpful sign.
(a) Painful lum bar exion suggests diskogenic etiology.
(b) Painful lum bar extension suggests facet disease.
b. Lateral bending may cause ipsilateral lower extremity pain in patients
with posterolateral or lateral herniated disks.
(1) Lateral bending away from the symptom atic limb may aggravate pain
in patients w ith an axillary herniated disk.
c. Painful dysrhythm ic range of m otion may indicate mechanical instability,
particularly when straightening from forward exion.
4. Neurological examination:
a. Motor, sensory, and re ex de cits may be present along a speci c nerve
root distribution.
b. Special tests:
(1) Straight leg raise.
(a) Elevation of a painful limb causes radicular lim b pain.
i. Record the degree of elevation th at reproduces pain .
(b) Dorsi exion of the foot while raising the leg also stretches the
sciatic nerve and causes pain.
(2) Contralateral leg raise test.
(a) Positive if elevation of a nonpainful lim b causes back and lim b
pain on the opposite side.
i. Usually im p lies sequestered or large ext ruded hern iated disk.
(3) Reverse straight leg raise test (fem oral nerve stretch test).
(a) Fem oral extension in a prone position stretches the fem oral
nerve reproducing pain in the L3 or L4 distribution.
5. Di erential diagnosis of low back pain (Table 16.2):
16 Lum bar Disk Disease: Pat hog e nesis and Treat m ent Options 177
Ta b l e 1 6 . 2 Di e re ntial diagno sis of low b ack p a in
Ty p e Di erential
Vis ce r o g e n ic Ab d o m in a l a n d re n a l
Ne o p last ic Prim ar y a n d m et ast at ic bo n e t um ors
Ne uro g enic Spin a l co rd t um ors o r cyst s
In a m m at o r y
diseases
An k ylo s in g sp o n d ylit is , Re it e r ’s syn d r o m e , in a m m a t o r y b o w e l
diseases, and psoriatic arthritis (sacroiliitis)
In fe ct io u s Diskit is , o st e o m ye lit is , p so as a bsce ss
Spo ndylo g e n ic Myofascia l syn drom e s
Ilio lu m b ar syn d ro m e , p irifo rm is s yn dro m e , q u ad ra t us
lum bo rum synd rom e, an d b rosit is (t rig ge r p oint syn d rom e )
Mot ion s e gm en t d iso rd e rs
Disk d ise ase, facet syn d rom e, spinal st e nosis
Bo n y p r o b le m s
Fr a c t u r e s , in c l u d i n g o s t e o p o r o t i c c o m p r e s s io n fr a c t u r e s
Spo nd ylo list he sis
Sacral le sio ns, co ccyx p ain
Psychogenic
6. Distinguishing spondylogenic causes of low back pain:
a. Diskogenic.
(1) HNP.
(a) Leg pain, tension signs, neurological de cits.
b. Annular tears.
(1) Back pain and referred pain to the buttock (controversial).
(2) Midline tenderness, painful forward exion, back pain increased with
straight leg raising test.
c. Myofascial syndrom es.
(1) Tenderness on the a ected muscles rather than in the midline.
(2) Pain with active contraction and with passive stretch (contralateral
bending).
d. Posterior elements.
(1) Spondylolysis.
(a) Painful extension and rotation toward opposite side.
(2) Facet syndrom e.
(a) Tenderness unilaterally over the joint.
(b) Painful hyperexten sion an d ben ding.
(3) Spinal stenosis.
(a) Neurogenic claudication.
(b) Painful extension of the back.
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16 Lum bar Disk Disease: Pat hoge nesis and Treat m ent Options
7. Diagnostic studies:
a. Plain X-rays.
(1) Detect spondylolysis/spondylolisthesis.
(2) Disk space narrow ing.
(3) Scoliosis.
(4) Tumors.
(5) Infection.
b. Magnetic resonance imaging (MRI).
(1) Imaging modality of choice for herniated disks and for spinal stenosis.
(2) Use of gadolinium contrast increases accuracy when evaluating
postoperative disk herniations and may be helpful in evaluating for
tumor or infection (Fig. 16.5).
(3) Gadolinium (on T1-w eighted images) enhances in vascular scar tissue
and does not enhance in a recurrent disk herniation.
(4) Com puted tom ographic (CT) scan or CT myelography:
(a) If MRI is contraindicated.
(b) CT m ay be bet ter in pat ients w ith degenerative scoliosis or in
patients with metal implants.
c. Diskography.
(1) Perform ed in patients with suspected diskogenic back pain without
radiculopathy.
(2) Reproduction of back pain w ith injection of dye into the suspected
disk and evidence of an annular tear are considered positive ndings.
(a) Positive ndings must take into context the patient’s symptom s
and psychosocial status (e.g., somatization, chronic pain).
(b) Controversial as the accuracy also depends on th e physician
performing diskography, and the needle puncture of the disk may
accelerate degeneration over time.
Fi g . 1 6 . 5 Sag it t a l T1-we igh t ed m ag netic resonance imaging demonstrating e nh a n ce ment of le sio ns fo llo win g
administration of gadolinium contrast.
(From Chen C, Chen WL, Yen H. Ca n d i d a
albicans lumbar spondylodiscitis in an
int rave n o u s d ru g use r: a case re p or t .
BMC Re s N o t e s 2 0 1 3 ; 6 : 5 2 9 . Re p r o duced with permission.)
d. Bone scan.
(1) Perform a bone scan if suspicious for tum or or infection.
IV. Con servat ive t reat m en t .
A. Pr ove n m e t h o d s.
1. Patient education (“back school”).
a. Decreased mechanical stress and expectation.
2. Cardiovascular tness programs.
3. Smoking cessation.
4. Maintenance of ideal body weight.
B. Un p r o ve n m et h od s.
1. Prolonged bed rest, muscle relaxants, traction, bracing, and manipulation
16 Lum bar Disk Disease: Pat hog e nesis and Treat m ent Options 179
2. Narcotics and tranquilizers have not been shown to improve outcomes.
a. They may be used for acute symptoms (1–5 days).
3. Epidural steroids have not been proven to be helpful.
a. Use in selected patients with persistent leg pain to help with
rehabilitation.
V. O p e r a t i v e m a n a g e m e n t .
A. In d icat ion s .
1. Failure of conservative treatment for at least 6 weeks.
2. Progressive neurological de cits.
3. Presence of neurological ndings.
a. Radicular pain.
b. Positive tension sign or neurological de cits.
c. Positive im aging study with clinical correlation.
B. Su r gica l t ech n iq u e s (Fig. 16.6 and Fig. 16.7) (Table 16.3).
VI. SPORT.
A. Pa t ie n t p o p ula t io n s.
1. Clinical and radiographic diagnosis of HNP.
a. Persistent symptoms despite 6 weeks of nonoperative treatment.
b. Randomly assigned to operative and nonoperative cohorts.
B. Op e r at ive ve r s u s n o n op e r at ive t r e at m e n t o u tco m e s .
1. Intent-to-treat analysis: both operative and nonoperative treatment
demonstrated similar improvement of symptoms at 1 and 2 years.
a. Surgical treatment was associated with a faster recovery, better physical
funct ion, and overall sat isfaction .
2. As-treated analysis: patients treated surgically demonstrated greater
improvem ent in pain an d fun ction after 2 years com pared with those
treated nonoperatively.
C. Con t ro ve rs i e s.
1. High crossover rate.
a. Forty- ve percent of patients in the nonoperative cohort underwent surgery.
b. Forty percent of patients in the surgical cohort did not undergo surgery.
2. Nonoperative management.
a. Not standardized.
b. Patients were required to have had a 6-week course of nonoperative
management for enrollment, which likely a ected the crossover rate.
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16 Lum bar Disk Disease: Pat hoge nesis and Treat m ent Options
a b
c
Fi g . 1 6 . 6 A t yp i c a l L5 – S1 la m in o t o m y a n d d is ke c t o m y. (a) The interlaminar exposure starts with
removal of the ligam entum avum . (b) Additional removal of laminar bone is performed until the
lat eral portion o f t he n e r ve root is visu a lize d . (c) The nerve root is gently retracted medially, and the
herniated disk is rem oved with the aid of a pituitary rongeur.
Ta b l e 1 6 . 3 Va r i o u s t e c h n i q u e s o f d i s k t r e a t m e n t
Surg ical te chnique Finding s
Open diskectomy – Bet ter visualization of nerve
– More muscle dissection
– Longer hospital stay
– Potential for iatrogenic instability
Mic ro sco pic a lly a s sist ed
diskectomy
– Limited muscle dissection
– Improved visualization and lighting
Percu t ane o u s d iskect o m y – Te ch n iq u e s includ e ch e m o n ucleolysis, pe rcu tane o us
diskectomy, and laser diskotomy
– Inferior results when compared with microscopically
assisted diskectomy
In t ra d is ka l e le c t ro t h e rm a l
therapy
– Intradiskal procedure for primary diskogenic back pain
– Results demonstrate equivocal results when compared
with placebo
3. Intent-to-treat versus as-treated analysis.
a. Intent-to-treat analysis compared patients according to their assigned
cohort.
(1) This dem onstrated no di erence in prim ary outcom es between
groups in patients w ith disk herniation; that is, patients assigned to
nonoperative treatment were counted as nonoperative patients if
they crossed over and had surgical intervention.
b. As-treated analysis compared patients according to the treatment
ultimately received.
(1) Patients who underwent surgery dem onstrated improved and
sustained outcomes compared w ith those treated nonoperatively.
16 Lum bar Disk Disease: Pat hog e nesis and Treat m ent Options 181
Fi g . 1 6 . 7 ( a ) A W il t s e p a r a s p in a l
approach for excision of a lateral
disk herniation. (b) Intermuscular
dissection is between the multi dus and longissimus.
a
b
182
16 Lum bar Disk Disease: Pat hoge nesis and Treat m ent Options
Sugg este d Reading
Ba t t ié M C, Vi d e m a n T, Ka p r io J, e t a l. Th e Tw i n Sp in e St u d y: co n t r i b u t io n s t o a ch a n gi n g
view of disc d egen erat ion . Sp in e J 200 9;9(1): 47–59
Ba t t ié M C, Vi d e m a n T. Lu m b a r d is c d e ge n e r at io n : e p i d e m io lo g y a n d ge n e t ic s . J Bo n e Jo in t
Surg Am 2006;88 (Sup pl 2):3–9
Lu r ie JD, Tosteson TD, Tost eson AN, et al. Surgical versus n on operat ive treat m e n t for lu m -
bar disc herniation: eight-year results for the spine patient outcomes research trial.
Spine 20 14;39(1):3–16
Mazanec D, Okereke L. Interpreting the Spine Patient Outcom es Research Trial. Medical vs
surgical t reatm ent of lum bar disk h er n iat ion : im plicat ion s for fut u re trials. Cleve Clin
J Med 2007;74(8):5 77–583
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lum -
bar disc herniation: four-year results for the Spine Patient Outcomes Research Trial
(SPORT). Spin e 2008;33(2 5):2789–2800
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatm ent for lumbar
disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized
trial. JAMA 2006;296(20):2441–245 0
17 Surgical Management of Lumbar
Degene rative Disk Disease
17.1 General Considerations
I. In t r o d u ct ion .
A. Life t im e in cid e n ce o f low b ack p a in is e st im at e d t o a e c t 8 0 % o f t h e ge n e ra l
population.
1. Fourteen percent of new patient visits to physicians are related to low back pain.
2. Second only to respiratory infections as the most common cause of work absence.
B. On e h u n d r e d s i x t y- ve lu m b a r sp in e o p e r at io n s p e r 1 00 ,0 0 0 in d iv i d u als o cc u r
each year in the United States.
C. Lu m b a r fu s io n fo r d is ko g e n i c p a i n a n d lu m ba r l a m in ec t om ie s fo r r a d ic u la r
symptoms are the most common spine surgeries performed.
D. Risk factor s for low back p ain :
1. Prior history of low back pain.
2. Increasing age.
3. Smoking (nicotine consumption).
4. Medical comorbidities.
5. Lower socioeconomic status.
6. Psychological distress (depression).
II. Etiologie s (Table 17.1).
A. Re d a gs in clin ic a l p re se n t at io n t h a t r e q u ir e fu r t h e r in ve st igat ion .
1. History of signi cant trauma.
2. History of previous malignancy.
3. Age > 50 years.
4. Systemic symptoms (fever, chills, anorexia, recent weight loss).
5. Severe progressive neurological de cit.
a. Especially saddle anesthesia or bowel/bladder dysfunction.
6. Ongoing infection.
7. History of immunosuppression.
III. Diagn o st ic t ools.
A. Est a b lis h in g a p at h o a n at om ica l d ia g n os is is t h e ke y t o s u cce ssfu l s u rgica l
outcomes (Table 17.2).
B. Ar r iv i n g a t a co n cl u s iv e d ia gn o sis m ay b e d i c u lt ; a s m a n y a s 8 5 % o f p a t ie n t s
are categorized as having idiopathic low back pain.
C. Pla in r ad io gr a p h s :
1. Flexion-extension lms.
D. May dem on strat e d yn am ic in st abilit y (sp o n dylolist h esis):
1. Oblique lms.
E. He lp fu l in e va lu at in g t h e in t e g r it y o f t h e p a r s in te ra r t ic u la r is in t h e se t t in g o f
an isthmic spondylolisthesis:
1. Lumbar spine lms are unnecessary for at least 4 weeks in a patient with
new-onset low back pain without any of the previously mentioned red ags.
183
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17 Surgical Managem ent of Lum bar Degene rat ive Disk Disease
Ta b l e 1 7 . 1 Et i o l o g ie s a n d d i e r e n t ia l d i a g n o s i s f o r l o w e r b a c k p a i n
Ty p e Di erential
Id io p a t h ic o r n o n sp ecif c (8 5 %)
Deg e nerat ive d isk d ise a se Disko g e nic pain
Disk h e rniat ion
Dege n e rat ive scoliosis
Develop m e nt a l Ist hm ic sp ondylolist hesis
Id io p a t hic sco lio sis
Co n g e n i t a l
Tr a u m a t i c
In fe c t io u s Ost e om ye lit is
Diskit is
In a m m at o ry An k y lo s in g s p o n d y li t is
Psoriat ic spondylitis
Re i t e r ’s s y n d r o m e
Neop la st ic
Me t a b olic Os t e op oro sis
Pag et ’s d isease of b one
Re f e r r e d D is s e c t i n g a o r t i c a n e u r y s m
Re n a l ve i n t h r o m b o s i s
Re n a l s t o n e s
Ac u t e m yo c a r d ia l i n f a r c t i o n
Pancreat it is
Duo denal ulcer
Pelvic disease
F. Co m p u t e d t o m o g r a p h y ( CT) :
1. Allows excellent visualization of the bony anatomy of the vertebral column.
2. Not as sensitive as magnetic resonance imaging (MRI) for visualization of
soft tissue structures.
3. CT myelography is an excellent imaging modality for evaluating spinal
stenosis, but MRI is used because it is less invasive.
G. MRI:
1. Excellent axial, coronal, and sagittal visualization of the soft tissues and
neural structures both within and surrounding the vertebral column.
2. Excellent for the evaluation of neural compression within the canal and
foram en .
3. With disk degeneration, T2-weighted MRI demonstrates darkening of the
disks due to loss of water, but this nding does not predict the development
of back pain in asymptomatic patients.
17 Surgical Managem ent of Lum bar Degene rative Disk Disease 185
Ta b l e 1 7 . 2 An a t o m ic a l s o u r ce s o f lu m b a r s p in e p a in
In t e r ve r t e b ra l d isks – Pr im a r y p a in g e ne ra t o r in s et t in g o f d e g e n e ra t ive d is k
disease; pain bers present in the outer third of the annulus
brosus
– Biochemical factors that can mediate painful stimuli:
prostaglandins, lactic acid, substance P
– During disk degeneration, nerve ingrowth has been
observed into deeper aspects of the annulus brosus and
even into the nucleus
Fa c e t j o i n t s – Extensively innervated with pain bers.
– Synovial folds of the joint lining also possess pain bers.
– Proprioceptive nerve endings also present, which mediate
protective muscular re exes.
Mu s cu lo lig a m e nt ou s
structures
– Both anterior and posterior longitudinal ligaments (PLL)
possess sensory innervation. PLL has been found to have
bers containing substance P. Unencapsulated nerve bers
found in p a rasp ina l m uscu lat ure resp o nd t o m e t ab o lit es
accumulated during prolonged muscle contraction or
spasm.
Neura l st ruct u re s – Pain fro m m e chanical n erve ro o t co m p re ssio n is t hought t o
require the presence of in ammation.
– Dorsal root ganglion is sensitive to direct pressure and
vibrat ory forces.
– Increase in genetic expression of neuropeptides (substance P)
in re sp onse t o m e ch an ical n e rve ro ot co m p ression
H. Single-p hoton em ission CT (SPECT/CT):
1. Combination of SPECT (high sensitivity and speci city) and CT (high
resolution).
2. Physiological imaging that can detect in ammatory changes in the lumbar
spine.
3. SPECT imaging detects gamma rays from radioisotopes injected into the
patient.
4. Useful in detecting facet joint arthropathy (Fig. 17.1).
5. Facet injections (Fig. 17.2):
a. Rationalized by the hypothesis that facet arthritis contributes to low back
pain.
b. There are few well-designed studies to evaluate e cacy; thus the use of
injection s to predict surgical outcom es for patients w ith low back pain is
not supported.
I. Diskogr a p hy (Fig. 17.3):
1. Performed by the introduction of a needle into the nucleus pulposus and
injection of contrast to visualize internal ssures or tears.
2. Saline may also be injected into the disk to reproduce pain.
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