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17 Surgical Managem ent of Lum bar Degene rat ive Disk Disease
Fi g . 1 7 . 1 Sin g le-p ho t on e m issio n co m p u t e d t om og ra p h y (SPECT/CT).
3. The combination of pain with disk injection and ndings of disk
degeneration on CT-diskography increases the likelihood that a particular
disk is involved with the patient’s pain.
a. Remains controversial, especially without a control.
4. Important ndings:
a. Re-creation of similar pain with injection (concordance).
b. Pain at low pressurization.
(1) High pressurization may result in a false positive.
c. Disk accepts > 2 mL of dye.
5. Highly controversial:
a. In 2009, Carragee et al reported that diskography was associated with
accelerated disk degeneration, disk herniation, and loss of disk height in
patients without serious lower back pain.
b. The validity of this diagnostic intervention has not been proven.
(1) The lack of a gold standard diagnostic study for diskogenic back pain
lim its the assessm ent of the diagnost ic validit y.
(2) Carragee et al reported that nearly 50% of patients who had surgery
after a positive diskography reported signi cant pain.
(a) Thus a positive diskography was not highly predictive in
identifying a disk lesion that was responsible for the patient ’s
symptoms.
c. Diskography is associated w ith a variable false-positive rate in patients
without low back pain.
(1) Pain-free patients—10%.
17 Surgical Managem ent of Lum bar Degene rative Disk Disease 187
Fi g . 1 7 . 2 A fa c e t in j e c t io n i s p e r f o r m e d in t h e lu m b a r sp in e .
(2) Chronic pain (not in lower back)—40%.
(3) Som atization disorder—75%.
d. In carefully selected patients with normal psychosomatic states (not
involved in litigation), diskography m ay provid e useful diagnostic
inform ation in the set t ing of non speci c lower back pain.
IV. General surgica l ind icatio n s.
A. Me ch an ica l in st a b ilit y.
B. Ne u r o lo g ic a l d e cit s.
C. In d i c a t io n s fo r p a t ie n t s w it h lo w b ack p a in w it h ou t r a d ic u la r s y m p t om s
1. Unremitting back pain and disability for more than 1 year.
2. Failure of physical therapy and nonoperative treatment modalities.
a. Nonsteroidal anti-in ammatory drugs (NSAIDs), heat, ice, weight loss,
activity modi cation.
188
17 Surgical Managem ent of Lum bar Degene rat ive Disk Disease
a b
Fi g . 1 7 . 3 ( a , b ) Co nt ra s t d ye in je ct io n in t o t he n uc le u s p ulp osu s .
3. Absence of psychiatric disorders and compensation or ligation issues.
4. Isolated single-level disk degeneration on MRI with concordant pain on
diskography or single-level static or dynamic instability.
V. S u r g i c a l p r o c e d u r e s .
A. Ge n e r a l p r in cip le s.
1. Low back pain management largely focuses on spinal fusion.
2. Decompression is indicated in the setting of leg pain and nerve root
compression.
3. Motion preservation procedure with lumbar total disk arthroplasty.
B. Sp in a l fu sio n p r in cip le s.
1. Prevents further segmental motion.
a. More appropriate for spinal instability.
C. Keys t o a t t ain in g a s o lid a r t h r o de sis .
1. Meticulous preparation of the graft site (decortication).
2. Supplementation with appropriate type and amount of bone graft.
3. Consideration of lumbar spine biomechanics.
a. Maintaining or restoring the normal lordosis in the sagittal alignment of
the lumbar spine.
4. Optimizing systemic conditions that in uence bone healing.
a. Nicotine, corticosteroids, NSAIDs, nutrition, and infection.
b. Concern for new or progressive degeneration of adjacent levels to the
fused segm en t s m an dates th at m inim um num bers of levels be fused,
especially in younger individuals.
VI. Lu m bar fu s ion t e ch n iq u es (Table 17.3).
A. Po st e r o la t e ra l (in te r t r a n sve rs e p ro ce ss ) fu sio n (PLF).
1. Involves either a posterior or a posterolateral muscle-splitting approach.
190
17 Surgical Managem ent of Lum bar Degene rat ive Disk Disease
2. Involves decortication of transverse processes and placement of an
autogenous bone graft along the transverse processes.
3. The pseudarthrosis rate without instrumentation is estimated to be between
25 and 45%.
4. Instrumentation lowers the pseudarthrosis rate (15–25%).
5. There is still some preserved motion after this procedure because of the
intact disk an teriorly.
a. If the disk is the main source of pain, patients may demonstrate
persistent back pain (controversial).
B. In t er bo d y fu sio n .
1. Principles.
a. Resection of diseased intervertebral disk:
(1) In appropriately selected patients with diskogenic back pain,
removing the intervertebral disk should resolve patient symptoms.
b. Rigid instrumentation and bone grafts provide initial stability to the
anterior column.
(1) Posterior xation with pedicle screws provides additional xation for
selected cases.
c. A solid interbody fusion generally occurs at 6 months to 1 year follow ing
surgery.
2. Techniques.
a. Posterior lumbar interbody fusion (PLIF) (Fig. 17.4 and Fig. 17.5).
(1) Extraction of the disk through a posterior approach via a wide
lam in ectom y with preser vation of the facet joint.
(2) The approach can be widened with the rem oval of the lower third of
the inferior facet and medial two-thirds of the superior facet.
(3) This is followed by posterior instrum entation.
a b
Fi g . 1 7 . 4 Bo n y re s e c t i o n r e q u i r e d i n a (a) posterior lum bar inte rbody fusion and (b) transforam inal
lum ba r inte rb o d y fusion.
17 Surgical Managem ent of Lum bar Degene rative Disk Disease 191
a b
Fi g . 1 7 . 5 Working zones of the (a) posterior lum b ar interbo d y fusion an d (b) tra nsfo ram inal lum bar
int e rbo d y fu sion in re la t ion t o t he n e urovascu la r st ru ct ure s.
b. Transforaminal lumbar interbody fusion (TLIF) (Fig. 17.6 and Fig. 17.7).
(1) Decreased/m inimal manipulation of neural elem ents when compared
with PLIF.
(2) A partial or complete facetectomy is perform ed to enable access to
the disk space.
(3) Can be perform ed bilaterally.
c. Anterior lum bar interbody fusion (ALIF) (Fig. 17.8 and Fig. 1 7 .9 ).
(1) Indirect decom pression of the exiting roots with the restoration of
disk space and foraminal height.
(2) Limited decompression of posterior elem ents when compared with
PLIF a n d TLIF p roced u res.
(3) Fusion occurs readily w ith this approach because of compression on
the graft.
(4) Can be used in a revision setting after a previous posterior surgery to
avoid dissection of scar tissue.
(5) Approaches:
(a) Open left retroperitoneal approach.
(b) Open transperitoneal approach.
(c) Laparoscopic approach.
d. Lateral lumbar interbody fusion (Fig. 17.10).
(1) Lateral retroperitoneal approach.
(2) Considered a variant of ALIF.
(3) Can be used for thoracic and lum bar interbody fusion.
(4) Associated with a signi cantly reduced risk of injury to the great
vessels.
192
17 Surgical Managem ent of Lum bar Degene rat ive Disk Disease
Fi g . 1 7 . 6 In t ra o pe ra t ive p h ot o g ra p h o f t h e L4 – L5 in t er s p a ce d e m o nst ra t in g t he d o rs al ro ot g a ng lio n
of the L4 nerve root (exiting).
a b
c d
Fi g . 1 7 . 7 ( a – d ) Re m o v a l o f t h e d i s k m a t e r i a l a n d p l a c e m e n t o f t h e i n t e r b o d y c a g e w i t h b o n e g r a f t
material.
17 Surgical Managem ent of Lum bar Degene rative Disk Disease 193
Fig . 1 7 . 8 Po sto pe rat ive lat e ra l radiograp h o f an
anterior LT Cage (Medtronic) at L5–S1.
Fi g . 1 7 . 9 An t e r io r l u m b a r in t e r b o d y fu s io n p r o ce d u r e .
194
17 Surgical Managem ent of Lum bar Degene rat ive Disk Disease
Fi g . 1 7 . 1 0 Exp o s u r e f o r t h e la t e r a l
lum ba r inte rb o d y fu sion.
(5) The disk space is reached through a transpsoas approach.
(a) Risk of injury to the lum bar plexus.
(b) The gen itofem oral nerve is m ost com m only inju red
(postoperat ive groin and thigh paresth esia).
(c) Intraoperative neurom onitoring is critical during passage
through the psoas.
e. Axial lumbar interbody fusion (AxiaLIF).
(1) Minimally invasive technique that uses the presacral space to create a
surgical working plane.
(2) Can only address L4 to S1 disk pathology.
(3) Risk of rectal injury, sacral fracture, and pelvic hematom a.
(4) Special im plants provide axial compression between vertebral bodies.
(5) Limited evidence in the published literature has dem onstrated
variable ou tcom es and fusion rates.
VII. M o t io n - p r e se r vin g p roce d u re s (t o t al d isk a r th ro p la st y).
A. Pr in cip le s.
B. Bio m e ch a n ic a l s t u d ie s h ave d e m o n s t r at e d t h a t m o t io n - p re s er va t io n d ev ice s
are associated with lower stresses on adjacent segments when compared
with traditional fusion techniques in an e ort to reduce adjacent segment
degeneration.
C. In d i c a t io n s:
1. Indicated for one- or two-level diskogenic back pain without radiculopathy.
17 Surgical Managem ent of Lum bar Degene rative Disk Disease 195
D. Ou tcom es com p ared w it h lu m bar ar th r odesis:
1. Mid- and long-term data are now available to compare lumbar total disk
replacement (TDR) w ith fusion procedures.
a. TDR has demonstrated comparable safety and e cacy to lumbar fusion
procedures at 7 years.
b. Early experience with TDR has demonstrated satisfactory clinical
outcomes with acceptable complication (14.4%) and reoperation (7.2%)
rates.
c. Superiority of TDR over lumbar fusion has not been proven with regard
to adjacent-level degeneration.
d. Studies have reported revision rates between 7.7 and 32.1% at 5 years (up
to 39.3% at 10 years), depending upon the device.
VIII. Con clu sio n s.
A. Low b a ck p a in is a m u lt ifa ct o r ia l issu e .
B. Ca r e fu l p at ie n t s e le ct io n is t h e ke y t o s u cce ssfu l c lin ic a l o u t co m e s in p at ie n t s
with nonspeci c low back pain.
1. Pathological ndings in imaging studies must be carefully assessed and
correlated w ith the patient’s histor y and physical exam ndings.
2. Psychosomatic evaluation may play an important role in selecting patients
who undergo surgery for lower back pain.
C. No n sp e ci c lo w b a ck p a in r e m a in s a co n t rove rs ia l a re a w it h lim it e d
understanding of the pathoanatomy and bene ts of the available treatment
options.
D. Num erous su rgical tech n iques exist for t h e att ainm en t of lu m ba r arth rod esis.
E. Mot ion p re se r v in g d e v ice s (TDR) h ave b e e n d em o n st rat e d t o b e a s a fe a n d
e ective alternative to lumbar fusion surgery. However, the theoretical
advantage of reducing adjacent-segment degeneration remains unproven.
Sugg este d Reading
Anderson PA, Sasso RC, Hipp J, Nor vell DC, Raich A, Hashim oto R. Kin em at ics of th e cervical
adjacent segments after disc arthroplasty compared with anterior discectomy and fusion: a system atic review and meta-analysis. Spine 2012;37(22, Suppl):S85–S95
Ca r r a g e e EJ, Do n AS, H u r w it z EL, Cu ella r JM, Ca r r in o JA, He rzo g R. 2 00 9 ISSLS Pr iz e W in -
ner: Does discography cause accelerated progression of degeneration changes in
the lumbar disc: a ten-year matched cohort study [published correction appears
in Spine 2010 15;35(14):1414; Carrin o, Joh n corrected to Carrino, John A]. Spine
2009;34(21):2338–2345
Ca r r a g e e EJ, Lin co ln T, Pa r m a r VS, Ala m in T. A g o ld s t a n d a r d e va lu at io n o f t h e “d is co ge n -
ic pain ” diagn osis as deter m in ed by provocative discograp hy. Sp in e 2006 ;31 (18):
2115–2123
Ca r r a g e e EJ, Tan n e r CM, Kh u r a n a S, et a l . Th e r a t es o f fa ls e -p os it ive lu m b a r d is co g r a-
phy in select patients without low back symptoms. Spine 2000;25(11):1373–1380,
discu ssion 13 81
196
17 Surgical Managem ent of Lum bar Degene rat ive Disk Disease
Ja c o b s W, Va n d e r Ga a g NA, Tu s c h e l A, e t a l . To t a l d is c r e p l a c e m e n t fo r ch r o n i c b a c k p a i n i n
the presence of disc degeneration. Cochrane Database Syst Rev 2012;9:CD008326
Phillip s FM, Slosar PJ, You ssef JA, And ersso n G, Pap ath e o fan is F. Lu m bar spin e fu sion for
chronic low back pain due to degenerative disc disease: a system atic review. Spine
2013;38(7):E409–E422
Ro d g e r s W B, Ge r b e r EJ, Pa t t e r so n J. In t r a o p e r a t ive a n d e a r ly p o st o p e r at ive co m p l i ca -
tions in extreme lateral interbody fusion: an analysis of 600 cases. Spine 2011;36(1):
26–32
Sie p e CJ, He id e r F, W ie ch e r t K, Hit z l W, Is h a k B, Ma ye r MH. Mi d - t o lo n g - t e r m r e su lt s of
total lumbar disc replacement: a prospective analysis with 5- to 10-year follow-up.
Spine J 2014;14(8):14 17–1431
Wei J, Son g Y, Sun L, Lv C. Com p arison of arti cial total disc replacem en t versu s fusion for
lum bar degenerative disc disease: a meta-analysis of random ized controlled t rials. Int
Orthop 2013 ;37(7):1315 –1325
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