Indications for Surgery in Adult Spondylolisthesis
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How to choose the right patient for surgery?
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Indications for Surgery in Adult Spondylolisthesis
- 1. Dr. Kshitij Chaudhary, MS, DNB Consultant Spine Surgeon Sir HN Reliance Foundation Hospital Mumbai @kcspine I N D I C A T I O N S F O R S U R G E R Y H O W T O C H O O S E T H E R I G H T P A T I E N T ?
- 2. A N O N . "If operating on the wrong leg is a medical error, what do we call operating on a someone who doesn't need it.”
- 5. @kcspine
- 7. @kcspine No correlation with symptoms
- 8. - I M M A N U E L K A N T ( 1 8 0 0 ) “Physicians think that they do a lot for a patient when they give his disease a name”
- 9. @kcspine
- 10. Fail-safe system 1. Is pain a diagnostic trap? Non-spondylogenic ? 2. If spondylogenic - Any red flags? 3. Is pain mechanical? If so, which syndrome? 4. Is pain a true physical disability? Yellow Flags? 5. After history, PE, imaging and tests – what is structural lesion? 6. Does clinical picture fit with structural lesion?
- 11. @kcspine
- 12. Is the back pain from the spine ? Viscerogenic Vascular Psychogenic 1
- 13. Viscerogenic Kidney, Retroperitoneal tumor, pelvic viscera @kcspine
- 14. Vascular Aortic aneurysm, Peripheral Vascular d/s @kcspine
- 15. @kcspine Spondylogenic back pain is the most common
- 16. Are there any red flags? Degeneration Inflammatory Tumor Infections Trauma Osteoporosis 2 @kcspine
- 17. Which mechanical pain syndrome? Axial Back Pain Referred Leg Pain Neurogenic Leg Pain 3 @kcspine
- 18. Leg pain - Referred @kcspine
- 20. Back pain or leg pain predominant ? D., Frymoyer, J. F., & Weinstein, J. (2011). Predominant Leg Pain Is Associated With Better Surgical Outcomes in Degenerative Spondyl 90% 10% 50% 50% 90% 10%
- 21. Vascular claudications Pain relief on STANDING !
- 22. D/D Leg pain Hip joint, Knee OA Pelvis / SI PVD / Varicose veins Muscle pulls (Hamstrings) Neuropathy (Diabetes)
- 23. Is pain a true physical disability?4
- 24. @kcspine
- 25. Listen to the patient ! 80% History 10% Physical examination 5% Imaging, Labs etc
- 26. What is structural lesion?5 6 Does it explain the clinical picture?
- 27. Is there a nonoperative option?7 Paracetamol / NSIADS Pregabalin Physical therapy Manipulation TENS Brace Traction No studies: Workgroup Consensus Statement - NASS
- 28. Is there a nonoperative option?7 Epidural steroid injections Small or no benefit Chou R et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015. Friedly JL, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014;371:11-21. Controversial @kcspine
- 29. Epidural steroid injection Diagnostic Value ? @kcspine
- 30. Co-morbidities Age Obesity Smoking Diabetes Osteoporosis Cardiac etc. de Kleuver et.al. (2012). Optimizing Outcomes in the Management of Degenerative Spondylolisthesis. Spine Deformity, 1–9. 8 @kcspine
- 31. @kcspine
- 32. @kcspine
- 33. What is the functional limitation? Dissatisfied with their symptoms t.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21), 17 9
- 34. Oswestry Disability Index • 0 to 20: Minimal disability • 21-40: Moderate Disability • 41-60: Severe Disability • 61-80: Crippling disability • 81-100: Bed-bound or exaggeration Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000 Nov 15;25(22):2940-52
- 35. Patient expectations “Patient expectation can be a self fulfilling prophecy” n et.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21) 10
Notes de l'éditeur
- Most important presentation, not because I am giving it. Because I believe choosing the right patient for surgery is more important that surgery itself and the outcome of the surgery is heavily dependent on this decision.
- But the wisdom to choose the right patient is important. Decision is more important than the incision.
- 61y woman with L4-5 spondylolisthesis. How will you evaluate? Before starting out you have to know two facts about degenerative lumbar spine problems
- First: One famous study (Boden). Took normal people with healthy backs and did their MRI. Found that 2/3 of patients had degenerated discs.
- An algorithm is defined by Webster as an “organized method for solving a problem in a finite number of steps”.
- Have to go sequentially. Do not try to answer question 6 before answering questions 1,2 and 3
- Big mistake
- Spondylogenic - origin from the spinal column and associated structures. Aggravated by activities and relieved or reduced by rest Neurogenic - tension, irritation, compression of lumbar nerve roots (usually cause referral of pain to legs) Viscerogenic pain - Kidneys, retroperitoneal organs, pelvic viscera. Back pain alone is rarely the sole symptom. Usually other associated symptoms. Not related to activity. Vascular pain - AAA - deep boring back pain unrelated to activity. PVD, Varicose veins - Vascular claudication mimic pain produced by root irritation. We will discuss this more in detail later. Psychogenic pain - Rare, Never forget that emotional illness does not protect patient against organic disease. Investigate thoroughly and don’t be lazy and say that it is all in the patient’s mind.
- Beware!
- indicate psychological barriers to recovery
- If you are a music lover who like Indian classical music you will instantly recognize rag bharavi. On history, Now I can recognize the pain pattern PE, I will verify the suspicion and the anatomic level of involvement Also I know everything there is to know about other systems, such as vascular system, viscera, other joints such as hips, SI joints which can mimic spondylogenic back pain. After all this I am now ready to review the images. If there is perfect marriage between what I see on the images and the presentation of the patient then I have a diagnosis. If not then, maybe I have made a mistake or missed something and should return to the patient and start over. The problem is that degenerative changes in the spine are so ubiquitous, that frequently non spondylogenic back pain gets blamed on the disc degeneration. So one has to be very careful.
- Better outcomes in patients who are optimistic about surgery.