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15
Surgical Management of Axial
Back Pain
Introduction
I. Lifetime incidence of low back pain estimated at 80% of general population
A. Fourteen percent of new patient visits to physicians are related to lower
back pain.
B. Second only to respiratory infections as the most common cause of work
absence
II. One hundred sixty-five lumbar spine operations per 100,000 individuals
occur each year in United States
A Lumbar fusion for discogenic pain and lumbar laminectomies for radicu-
lar symptoms are the most common spine surgeries performed.
III. Risk factors for low back pain
A. Previous history of low back pain
B. Increasing age
C. Smoking
D. Medical comorbidities
E. Lower socioeconomic status
F. Psychological distress
G. Heavy occupational demands
Etiologies
I. Idiopathic or nonspecific
A. Up to 85% without specific diagnosis
II. Degenerative disc disease
A. Discogenic pain
B. Disc herniation
158
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Chapter 15 Surgical Management of Axial Back Pain 159
C. Degenerative scoliosis
III. Developmental
A. Isthmic spondylolisthesis
B. Idiopathic scoliosis
IV. Congenital
V. Traumatic
VI. Infectious
A. Osteomyelitis
B. Discitis
VII. Inflammatory
A. Ankylosing spondylitis
VIII. Neoplastic
IX. Metabolic
A. Osteoporosis
X. Referred
A. Dissecting aortic aneurysm
B. Renal vein thrombosis
C. Acute myocardial infarction
D. Pancreatitis
E. Duodenal ulcer
XI. Red flags in clinical presentation that require further investigation
A. History of significant trauma
B. History of previous malignancy
C. Age 50 years
D. Systemic symptoms (fever, chills, anorexia, recent weight loss)
E. Severe progressive neurological deficit
1. Especially saddle anesthesia or bowel/bladder dysfunction
F. Ongoing infection
G. History of immunosuppression
Diagnostic Tools
I. Establishing a pathoanatomic diagnosis is the key to successful surgical out-
comes (Table 15–1).
II. Arriving at a conclusive diagnosis is not possible in as many as 85% of
patients who are categorized as having “idiopathic low back pain.”
III. Plain Radiographs
A. Flexion-extension films
1. May demonstrate dynamic instability
B. Oblique films
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160 III Degenerative Spinal Conditions
1. Helpful in evaluating the integrity of the pars intra-articularis in the
setting of a spondylolisthesis
C. Lumbar spine films unnecessary for at least 4 weeks in a patient with new
onset of low back pain without any of the previously mentioned red flags
IV. Computed tomography
A. Excellent visualization of the bony anatomy of the vertebral column
B. Not as good as magnetic resonance imaging (MRI) for visualization of soft
tissue structures
C. Computed tomographic myelography is an excellent imaging modality for
spinal stenosis, but MRI is used because it is less invasive.
V. MRI
A. Excellent axial, coronal, and sagittal visualization of soft tissues and neu-
ral structures both surrounding and within the vertebral column
B. Great for evaluation of neural compression within the canal and foramen
C. T2-weighted MRI shows darkening of the discs in disc degeneration due
to loss of water, but this finding does not predict development of back
pain in an asymptomatic patient.
Table 15–1 Anatomic Sources of Lumbar Spine Pain
Intervertebral disks Primary pain generator in setting of degenerative disk
disease.
Pain fibers present in the outer third of the anulus
fibrosus.
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 anulus fibrosus
and even into nucleus.
Facet joints Extensively innervated with pain fibers.
Synovial folds of the joint lining also possess pain fibers.
Proprioceptive nerve endings also present, which
mediate protective muscular reflexes.
Musculoligamentous structures Both anterior and Posterior Longitudinal Ligaments
(PLL) possess sensory innervation.
PLL has been found to have substance
P-containing fibers.
Unencapsulated nerve fibers found in paraspinal
musculature respond to metabolites accumulated
during prolonged muscle contraction or spasm.
Neural structures Pain from mechanical nerve root compression is
thought to require the presence of inflammation.
Dorsal root ganglion sensitive to direct pressure and
vibratory forces.
Increase in genetic expression of neuropeptides
(substance P) in response to mechanical nerve root
compression.
Chapter 15 Surgical Management of Axial Back Pain 161
VI. Facet injections
A. Rationalized by the hypothesis that facet arthrosis contributes to low back
pain
B. Not many well-designed studies to evaluate efficacy, and thus the use of
injections to predict surgical outcomes for patients with low back pain is
not supported.
VII. Discography
A. Highly controversial
B. Performed by the introduction of a needle into the nucleus pulposus and
injection of contrast to visualize internal fissures or tears
C. Saline may also be injected into the disc to see if it provokes the pain that
the patient has previously experienced.
D. Combination of pain with disc injection and findings of disc degeneration
on post CT-Discography increase the likelihood that a particular disc is in-
volved in patient’s pain.
E. Important findings
1. Re-creation of pain with injection
2. Pain at low pressure
3. Disc accepts greater than 2 mL of dye
4. Dye extravasation from disc space
General Surgical Indications
I. Mechanical instability
II. Neurological deficits
III. Indications for patients with low back pain without radicular symptoms
A. Unremitting pain and disability for more than 1 year
B. Failure of physical therapy and nonoperative treatment modalities
1. Nonsteroidal antiinflammatory drugs (NSAIDs), heat, ice, weight loss,
activity modification
C. Absence of psychiatric disorders and compensation or ligation issues
D. Isolated single-level disc degeneration on MRI with concordant pain on
discography or single-level static or dynamic instability
Surgical Procedures
I. General principles
A. Low back pain management largely focuses on spinal fusion.
B. Decompression indicated in setting of leg pain and nerve root compression
C. Nucleus pulposus or intervertebral disc degeneration arthroplasty
1. Emerging options that are still being investigated
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162 III Degenerative Spinal Conditions
II. Spinal fusion principles
A. Prevents further segmental motion
1. More appropriate for spinal instability
B. Keys to attaining a solid arthrodesis
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 align-
ment of the lumbar spine
4. Optimizing systemic conditions that influence bone healing
a. Nicotine, corticosteroids, NSAIDs, nutrition, and infection
b. Concern for degeneration of adjacent levels to the fused segments
mandates that minimum numbers of levels be fused, especially in
younger individuals.
III. Techniques for achieving fusion in the lumbar spine
A. Summary of fusion techniques (Table 15–2)
B. Posterolateral intertransverse process fusion
1. Involves either posterior or posterolateral muscle-splitting approach
2. Involves decortication of transverse processes and placement of an
autogenous bone graft along the transverse processes
3. Pseudarthrosis rate without instrumentation is estimated to be be-
tween 5 and 25%.
4. Instrumentation lowers pseudarthrosis rate to 5 to 10% but without ac-
companied improvement in clinical outcomes.
5. There is still some motion anteriorly that occurs after this procedure
because of the intact disc anteriorly. Pain may persist if it is due to
movement at the disc joint.
C. Posterior lumbar interbody fusion (Figs. 15–1, 15–2)
1. Extraction of much of the disc through posterior approach and wide
laminectomy
Figure 15–1 Schematic demonstrating the bony resection required in a PLIF and TLIF.
Table 15–2 Surgical Arthrodenis options for Discogenic Pain
Technique Advantages Disadvantages Notes
Posterolateral intertransverse • Technically straightforward with • Leaves intervertebral disk intact, allowing it • Most common
process fusion ± pedicle reasonable fusion rates that to potentially remain as the source of pain method of
screw instrumentation are enhanced slightly by addition • Posterior approach inflicts damage lumbar fusion
of instrumentation to dorsal paraspinal soft tissues
PLIF • Excises much of the disk • Access to disk requires significant retraction of • Pedicle screw
instrumentation • Places bone graft in compression neural elements, which may cause radiculopathy fixation commonly
• Increases disk height secondary to epineural or perineural fibrosis used to enhance
• Wide posterior exposure stability of
• Technically demanding the segment
• Incomplete disk excision
TLIF • Similar to PLIF but more lateral • Technically demanding
instrumentation approach, which requires less • Lower extremity dysesthesia
retraction of neural elements
• Near total disk removal
ALIF • More tolerated than posterior approach • Risk of vascular or intra–abdominal injury
• Can be accomplished with • Risk of damaging autonomic fibers in presacral
minimally invasive technology plexus leading to retrograde ejaculation
• Circumferential stabilization • Relative lack of stability because
increases fusion rates it depends on compressive fit of
interbody device or graft
• No direct decompression of neural
elements posteriorly
Circumferential • Combined benefits of wide surface area • Theoretically increased risk of
(anterior and posterior) for interbody fusion (ALIF) with ability to complications and morbidity compared
decompress and fuse posteriorly with with a single–stage procedure
instrumentation
ALIF, anterior lumbar interbody fusion; PLIF, posterior lumbar interbody fusion; TLIF, transforaminal lumbar fusion.
163
164 III Degenerative Spinal Conditions
2. Insertion of bone graft into intervertebral space to fuse anterior
column
3. Approach can be widened by removal of lower one third of the inferior
facet and medial two thirds of superior facet. This increases risk of ia-
trogenic instability.
a. Instrumentation is placed posteriorly to increase stability.
D. Transforaminal interbody fusion (Fig. 15–3)
1. Decreased manipulation of neural elements during interbody fusion
compared with posterior lumbar interbody fusion (PLIF)
2. Pars interarticularis and half of the facet are removed unilaterally in-
stead of wide laminectomy as seen in PLIF.
3. Can be done bilaterally to improve the disc excision and to decompress
exiting and traversing nerve roots on both sides
E. Anterior lumbar interbody fusion (Fig. 15–4)
1. Used more for pain associated with degenerative discs and not for
radicular pain associated with posteriorly located neural elements
2. May indirectly decompress exiting roots due to restoration of disc
space and foraminal height but decompression of posterior structures
is better achieved with PLIF and transforaminal lumbar fusion (TLIF).
3. Anterior approaches
a. Open left-sided retroperitoneal approach
b. Open transperitoneal approach
c. Laparoscopic approach
4. Fusion occurs readily with this approach because of compression on
the graft.
5. Can be used after a previous posterior approach surgery has been used
to avoid dissecting through the scarred area.
Figure 15–2 Diagram demonstrating the working zones of the PLIF and TLIF in relation to the
neurovascular structures.
Chapter 15 Surgical Management of Axial Back Pain 165
Figure 15–3 An intraoperative photograph of the L4–L5 interspace demonstrating the dorsal root
ganglion of the L4 nerve root (exiting).
Figure 15–4 A postoperative lateral radiograph of an anterior LT Cage (Medtronic, Memphis, TN,
USA) at L5–S1.
166 III Degenerative Spinal Conditions
F. Circumferential (anterior and posterior) fusion
1. Combination of anterior lumbar interbody fusion (ALIF) with pedicle
screws and PLIF or 360-degree fusion
2. Two hundred seventy-degree fusion is when PLIF is eliminated.
3. Often applied to patients with previously failed lumbar surgery as a
last-resort procedure
G. Motion preserving procedures (total disc arthroplasty)
1. Same indications as ALIF
2. Allows preservation of motion
a. Potentially may decrease rate of adjacent-level degeneration
3. Only one device currently approved by the Food and Drug Administra-
tion (Charite, Depuy Spine, Raynhzm, MA)
a. Single-level disease L4–L5 or L5–S1
b. Minimal evidence of facet arthritis
c. Minimal neurological compression
Conclusions
I. Low back pain is a multifactorial problem.
II. Surgical management is controversial because of limited understanding of
the pathoanatomy of low back pain.
III. Numerous surgical techniques exist for the attainment of lumbar arthrodesis.
IV. Careful patient selection is the key to successful clinical outcomes.
Suggested Reading
Abraham I, Killackey-Jones B. Lack of evidence-based research for idiopathic low back pain; the impor-
tance of a specific diagnosis. Arch Intern Med 2002;162:1442–1444
Andersson GB. Diagnostic considerations in patients with back pain. Phys Med Rehabil Clin N Am
1998;9:309–322
Borenstein DG, O’Mara JW Jr, Boden SD, et al. The value of magnetic resonance imaging of the lumbar
spine to predict low back pain in asymptomatic subjects: a 7- year follow-up study. J Bone Joint Surg Am
2001;83-A:1306–1311
Carette S, Marcoux S, Truchon R, et al. (1991) A controlled trial of corticosteroid
Fritzell P. Hagg O, Wessberg P, et al. Chronic low back pain and fusion: a comparison of three surgical
techniques-a prospective, multicenter, randomized study from the Swedish Lumbar Spine Study Group.
Spine 2002;26:1131–1141
Leufven C, Nordwall A. Management of chronic disabling low back pain with 360 degrees fusion: results
from pain provocation test and concurrent posterior lumbar interbody fusion, posterolateral fusion, and
pedicle screw instrumentation in patients with chronic disabling low back pain. Spine 1999;24:2042–2045
Turner JA, Ersek M, Herron L, et al. Patient outcomes after lumbar spinal fusions. JAMA 1992;268:907–911
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IV
Deformity
16 Lumbar Spondylolisthesis
17 Scoliosis
18 Kyphotic Spinal Deformities in Children and Adults