Lumbar Disc Disease

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CHAPTER Lower Back Pain and Disorders 39 of Intervertebral Discs

Keith D. Williams ◆ Ashley L. Park

Epidemiology, ••• Psychological testing, ••• Nonoperative treatment, ••• General disc and spine anatomy, ••• Cervical disc disease, ••• Epidural steroids, ••• Neural elements, ••• Signs and symptoms, ••• Operative treatment, ••• Anatomical proportions, ••• Differential diagnosis, ••• General principles for open disc Natural history of disc disease, ••• Confirmatory testing, ••• surgery, ••• Nonspecific lumbar pain, ••• Myelography, ••• Ruptured lumbar disc excision, ••• Diagnostic studies, ••• Nonoperative treatment, ••• Microlumbar disc excision, ••• Roentgenography, ••• Operative treatment, ••• Endoscopic techniques, ••• Myelography, ••• Removal of posterolateral herniations Additional exposure techniques, ••• Computed tomography, ••• by posterior approach (posterior Lumbar root anomalies, ••• Magnetic resonance imaging, ••• cervical foraminotomy), ••• Results of open (micro or standard) Positron emission tomography, ••• Anterior approach to cervical disc, ••• surgery for disc herniation, ••• Other diagnostic tests, ••• Thoracic disc disease, ••• Complications of open disc Injection studies, ••• Signs and symptoms, ••• excision, ••• Epidural cortisone injections, ••• Confirmatory testing, ••• Dural repair augmented with fibrin Cervical epidural injection, ••• Treatment results, ••• glue, ••• Thoracic epidural injection, ••• Operative treatment, ••• Free fat grafting, ••• Lumbar epidural injection, ••• Costotransversectomy, ••• Chemonucleolysis, ••• Zygapophyseal (facet) joint injections, ••• Anterior approach for thoracic disc Spinal instability from degenerative disc Cervical facet joint, ••• excision, ••• disease, ••• Lumbar facet joint, ••• Thoracic endoscopic disc excision, ••• Disc excision and fusion, ••• Sacroiliac joint, ••• Lumbar disc disease, ••• Lumbar vertebral interbody fusion, ••• Discography, ••• Signs and symptoms, ••• Anterior lumbar interbody fusion, ••• Lumbar discography, ••• Physical findings, ••• Posterior lumbar interbody fusion, ••• Thoracic discography, ••• Differential diagnosis, ••• Failed spine surgery, ••• Cervical discography, ••• Confirmatory imaging, ••• Repeat lumbar disc surgery, •••

Humans have been plagued by back and leg pain since the Several physical maneuvers were devised to isolate the true beginning of recorded history. Primitive cultures attributed problem in each patient. The most notable of these is the such pain to the work of demons. The early Greeks recognized Lase`gue sign, or straight leg raising test, described by Forst in the symptoms as a disease and prescribed rest and massage for 1881 but attributed to Lase`gue, his teacher. This test was the ailment. The Edwin Smith papyrus, the oldest surgical text devised to distinguish hip disease from sciatica. Although dating to 1500 BC, includes a case of back strain. Unfortunately, sciatica was widespread as an ailment, little was known about the text does not include the treatment rendered by the ancient it because only rarely did it result in death, allowing Egyptians. In the fifth century AD, Aurelianus clearly described examination at autopsy. Virchow (1857), Kocher (1896), and the symptoms of sciatica. He noted that sciatica arose from Middleton and Teacher (1911) described acute traumatic either hidden causes or observable causes, such as a fall, a ruptures of the intervertebral disc that resulted in death. The violent blow, pulling, or straining. In the eighteenth century correlation between the disc rupture and sciatica was not Cotugnio (Cotunnius) attributed the pain to the sciatic nerve. appreciated by these examiners. Goldthwait in 1911 attributed Gradually, as medicine advanced as a science, the number of back pain to posterior displacement of the disc. Oppenheim and specific diagnoses capable of causing back and leg pain Krause in 1909 performed the first successful surgical excision increased dramatically. of a herniated intervertebral disc. Unfortunately, they did not

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 1/74 Pg: 1955 Team: 1956 PART XII ◆ The Spine recognize the excised tissue as disc material and interpreted it Epidemiology as an enchondroma. Oil-contrast myelography was serendipi- tously introduced when iodized poppy seed oil, injected to treat Back pain, the ancient curse, is now an international health sciatica in 1922, was inadvertently injected intradurally and issue of major significance. Hult estimated that up to 80% of was noted to flow freely. Dandy in 1929 and Alajouanine in the people are affected by this symptom at some time in their lives. same year reported removal of a ‘‘disc tumor,’’ or chondroma, Impairments of the back and spine are ranked as the most from patients with sciatica. The commonly held opinion of that frequent cause of limitation of activity in people younger than time was that the disc hernia was a neoplasm. Mixter and Barr 45 years by the National Center for Health Statistics. in their classic paper published in 1934 attributed sciatica to Physicians who treat patients with spinal disorders and lumbar disc herniation. This report also included a series of spine-related complaints must distinguish the complaint of four patients with thoracic disc herniations, and four patients back pain, which several epidemiological studies reveal to be with cervical disc herniations. They suggested surgical treat- relatively constant, from disability attributed to back pain. In ment. Myelography was not used for confirmation of disc 1984, disability was noted by Waddell to be exponentially disease because of toxicity of the agents used in the years that increasing in the United Kingdom (Fig. 39-1). Conversely, an followed. Myelography was refined with the development of insurance industry study revealed a trend toward decreasing nonionic contrast media, and the test was combined with CT; claim rates for low back pain in the United States from 1987 to however, even this appears to have been supplanted by MRI of 1995. the spine. Although back pain as a presenting complaint may account The standard procedure for disc removal was a total for only 2% of the patients seen by a general practitioner, laminectomy followed by a transdural approach to the disc. In Dillane, Fry, and Kalton reported that in 79% of men and 89% 1939 Semmes presented a new procedure to remove the of women the specific cause was unknown. Svensson and ruptured intervertebral disc that included subtotal laminectomy Andersson noted the lifetime incidence of low back pain to be and retraction of the dural sac to expose and remove the 61% and the prevalence to be 31% in a random sample of 40- ruptured disc with the patient under local anesthesia. Love in to 47-year-old men. They noted that 40% of those reporting the same year also described this same technique indepen- back pain also reported sciatica. In women 38 to 64 years of age dently. This procedure, now the classic approach for the the lifetime incidence of low back pain was 66% with a removal of an intervertebral disc, has been improved with the prevalence of 35%. Svensson and Anderson noted psycholog- use of microscopic and video imaging. Kambin, Onik, and ical variables associated with low back pain to be dissatisfac- Helms and others have popularized minimally invasive tion with the work environment and a higher degree of worry techniques for selected disc hernias. and fatigue at the end of the workday. The cost to society and As more people were treated for herniated lumbar discs, it the patient in the form of lost work time, compensation, and became obvious that surgery was not universally successful. treatment is staggering. Snook reported that Liberty Mutual Over the past several decades, studies of patients with back or Insurance Company paid $247 million for compensable back leg pain have led to improved treatment of those in whom a specific diagnosis was possible. Unfortunately, this group remains the minority of patients who are evaluated for low back 105 or leg pain. Complex psychosocial issues, depression, and 95 secondary gain are but a few of the nonanatomical problems that must be considered when evaluating these patients. In 85 addition, the number of anatomical causes for these symptoms 75 has increased as our understanding and diagnostic capabilities 65 have increased. In an attempt to identify other causes of back 55 pain Mooney and Robertson popularized facet injections, thus ays (per year) 45 resurrecting an idea proposed originally in 1911 by Goldthwait. d 35

Smith et al. in 1963 approached the problem by suggesting a ion ll 25

radical departure in treatment—enzymatic dissolution of the Mi disc by injection of chymopapain. Although this technique is 15 still used in Europe, it rarely is used in the United States 5 because of medicolegal concerns. The anatomical dissections and clinical observations of 55 60 65 70 75 80 85 90 95 Kirkaldy-Willis and associates identiﬁed pathological pro- Year cesses associated with or complicating the process of spinal Fig. 39-1 Forty-year trends in chronic low back disability. aging as primary causes of disc disease. Additional information United Kingdom statistics for sickness and invalidity beneﬁts for about this process and its treatment continues to be collected. back incapacities from 1953-1954 to 1993-1994 (based on A thorough and complete history of all aspects of lumbar statistics supplied by the Department of Social Security). (From spinal surgery was compiled by Wiltse in 1987. Waddell G: Spine 21:2820, 1996.)

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 2/74 Pg: 1956 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 1957 pain in 1980. Because this company represents only 9% of the ever, have found no relationship between obesity and back insured workers’ compensation market, Webster and Snook pain. Svensson and Anderson associated low back pain with estimated the compensable costs of low back pain in the United cardiovascular risk factors, including calf pain on exertion, States to be $11.1 billion in 1989. They reported that the mean high physical activity at work, smoking, frequent worry, cost of each reported claim of low back pain at Liberty Mutual tension, and monotonous work. had increased from $6807 in 1986 to $8321 in 1989, although The incidence of back pain appears to be constant. Efforts they suggested that an increase in premiums sold, not an are being made to decrease the physical risk factors that may increase in low back pain claims, was the reason for this rise. lead to low back pain. However, as shown by Boos et al., More recent data from Liberty Mutual estimates that $8.8 nonanatomical factors, specifically work perception and psy- billion was paid annually in the United States for claims related chosocial factors, are intimately intertwined with physical to low back pain. Of the billions of dollars spent annually in the complaints. Compounding diagnostic and treatment difficulties United States because of back complaints, it was estimated that is the high incidence of significant abnormalities demonstrated only about 39% was spent for medical treatment; the remaining by imaging studies, which in asymptomatic matched controls is costs were for disability payments. This did not include the as high as 76%. losses from absenteeism. Although absenteeism because of General Disc and Spine Anatomy back pain varies with the type of work, it rivals the common cold in total workdays lost. General Disc and Spine Anatomy Saal and Saal noted an 18% incidence of chronic back pain in 1135 adults; 80% of those reporting chronic pain did not The development of the spine begins in the third week of report limitation of activity, and fewer than 4% reported gestation and continues until the third decade of life. Forma- significant limitation of activity. Females reported back pain tion of the primitive streak marks the beginning of spinal more frequently than males. There were no racial differences, development, which is followed by the formation of the but the lower the educational level of those interviewed the notochordal process. This process induces neurectodermal, greater the proportion of those reporting back pain. In 1992 ectodermal, and mesodermal differentiation. Carey et al. interviewed 4437 North Carolinians by telephone Somites form in the mesodermal tissue adjacent to the and noted an incidence of 3.9% chronic low back pain. Of those neural tube (neurectoderm) and notochord. They number 42 to who reported having chronic low back pain, 34% said that they 44 in humans. The somites begin to migrate in preparation for were permanently disabled. These authors concluded that the formation of skeletal structures. At the same time, the chronic back pain is common and associated with high costs. portion of the somites around the notochord separates into a In the Netherlands van Doorn noted that the low back pain sclerotome with loosely packed cells cephalad and densely disability claims for self-employed dentists, veterinarians, packed cells caudally. Each sclerotome then separates at the physicians, and physical therapists increased 211% from 1977 junction of the loose and densely packed cells. The caudal to 1989, and the cost increased 13% over that same time period. dense cells migrate to the cephalad loose cells of the next more Frymoyer and Cats-Baril noted an increase of 2500% in awards caudal sclerotome (Fig. 39-2). for back pain disability by the Social Security Disability The space where the sclerotome separates eventually forms Insurance from 1957 to 1976. They estimated that the total cost the intervertebral disc. Vessels that originally were positioned of low back pain was $25 billion to $100 billion per year, with between the somites now overlie the middle of the vertebral 75% of those costs attributed to the 5% who became body. As the vertebral bodies form, the notochord that is in the permanently disabled. center degenerates. The only remaining notochordal remnant Multiple factors affect the development of back pain. forms the nucleus pulposus. Pazzaglia, Salisbury, and Byers Frymoyer et al. noted that risk factors associated with severe reviewed the involution of the notochord in fetal and lower back pain include jobs requiring heavy and repetitive embryonic spines by several histological methods and con- lifting, the use of jackhammers and machine tools, and the cluded that all chordal cells disappear by early childhood. operation of motor vehicles. They also noted that patients with Notochordal remnants usually are not distinguishable in the severe pain were more likely to be cigarette smokers and had adult nucleus pulposus. a greater tobacco consumption. In an earlier study Frymoyer The intervertebral disc in adults is composed of the annulus et al. noted that patients complaining of back pain reported fibrosus and the nucleus pulposus. The annulus fibrosus is more episodes of anxiety and depression; they also had more composed of numerous concentric rings or layers of fibrocar- stressful occupations. Women with back pain had a greater tilaginous tissue. Fibers in each ring cross diagonally, and the number of pregnancies than those who did not. Jackson, rings attach to each other with additional radial fibers. The rings Simmons, and Stripinis noted that adult patients with scoliosis are thicker anteriorly (ventrally) than posteriorly (dorsally). are more likely to have back pain and that the pain persists and The nucleus pulposus, a gelatinous material, forms the center of progresses. Deyo and Bass noted a strong relationship between the disc. Because of the structural imbalance of the annulus, the smoking and back pain in patients younger than 45 years of nucleus is slightly posterior (dorsal) in relation to the disc as a age. They also noted a greater tendency for back pain in those whole. The discs vary in size and shape with their position in patients who were the most obese. Other investigators, how- the spine. Discs also decrease in volume, resulting in a 16% to

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Fig. 39-2 Schematic representation of development of vertebrae and discs. (From Rothman RH, Simeone FA: The spine, vol 1, Philadelphia, 1982, WB Saunders.)

21% loss in disc height after 6 hours of standing or sitting. T2-weighted MRI signals increase as much as 25% after a night of bed rest. This diurnal variation has been substantiated by Botsford et al. and Paajanen et al. The nucleus pulposus is composed of a loose, nonoriented, collagen fibril framework supporting a network of cells resembling fibrocytes and chondrocytes. This entire structure is embedded in a gelatinous matrix of various glucosaminogly- cans, water, and salts. This material usually is under considerable pressure and is restrained by the crucible-like annulus. Inoue demonstrated that the cartilage endplate contains no fibrillar connection with the collagen of the sub- chondral bone of the vertebra. This lack of interconnection between the endplate and the vertebra may render the disc biomechanically weak against horizontal shearing forces. Inoue also demonstrated that the collagen fibrils in the outer two thirds of the annulus fibrosus are firmly anchored into the Fig. 39-3 Schematic representation of orientation of fibers in disc and endplate. AF, Annulus fibrosus; NP, nucleus pulposus; vertebral bodies (Fig. 39-3). CP, cartilaginous plate. (From Inoue H: Spine 6:139, 1981.) The intervertebral disc in the adult is avascular. Rudert and Tillmann were able to demonstrate blood vessels in the annulus until the age of 20 years and within the cartilage endplates until the age of 7 years. The cells within the disc are sustained by diffusion of nutrients into the disc through the porous central of the disc is relatively high when its avascularity is considered concavity of the vertebral endplate. Histological studies have but slow compared with other tissues. The glycosaminoglycan shown regions where the marrow spaces are in direct contact turnover in the disc is quite slow, requiring 500 days. Inoue with the cartilage and that the central portion of the endplate is postulated that the degeneration of the disc may be prompted permeable to dye. Motion and weight-bearing are believed to by decreased permeability of the cartilage endplate, which is be helpful in maintaining this diffusion. The metabolic turnover normally dense.

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Dorsal root ganglion C6 C5 Dorsal L4 C6 ramus L4 C7 Ventral Fig. 39-4 Discs are named for vertebral level immediately cephalad. Pathology C7 ramus C8 L5 most commonly affects nerve root one segment caudal. T1 L5 T1

NEURAL ELEMENTS pars interarticularis. Three branches from the dorsal ramus innervate the structures dorsal to the neural canal. The lateral The organization of the neural elements is strictly maintained and intermediate branches provide innervation to the posterior throughout the entire neural system, even within the conus musculature and skin. The medial branch separates into three medullaris and cauda equina distally. Wall et al. noted that the branches to innervate the facet joint at that level and the orientation of the nerve roots in the dural sac and at the conus adjacent levels above and below (Fig. 39-5). medullaris follows a highly organized pattern, with the most Pedersen, Blunck, and Gardner noted that the clinically cephalad roots lying lateral and the most caudal lying centrally. significant function of the sinu-vertebral nerves and the The motor roots are ventral to the sensory roots at all levels. posterior rami is the transmission of pain. The proprioceptive The arachnoid mater holds the roots in these positions. functions of these nerves are not known but assumed. The pedicle is the key to understanding surgical spinal Studies by Bogduk and others demonstrated neural fibers in anatomy. The relation of the pedicle to the neural elements the outer layers of the annulus. These fibers are branches of the varies by region within the spinal column. In the cervical sinu-vertebral nerve dorsally. Ventral branches arise from region, there are seven vertebrae but eight cervical roots. the sympathetic chain that courses anterolaterally over the Therefore, accepted nomenclature allows each cervical root to vertebral bodies. Rhalmi et al., using histological methods, exit cephalad to the pedicle of the vertebra for which it is demonstrated neural elements in all spinal ligaments. In the named (e.g., the C6 nerve root exits above or cephalad to the C6 ligamentum flavum the nerve fibers are close to blood vessels pedicle). This relationship changes in the thoracic spine and fat globules. because the eighth cervical root exits between the C7 and T1 ANATOMICAL PROPORTIONS pedicles, requiring the T1 root to exit caudal or below the ANATOMICAL PROPORTIONS pedicle for which it is named. This relationship is maintained throughout the remaining more caudal segments. Of impor- Variation in the ratio of the cross-sectional area of the neural tance, the naming of the disc levels is different, in that all levels elements to the cross-sectional area of the spinal canal at where discs are present are named for the vertebral level various levels is relatively large. This is particularly true in immediately cephalad (i.e., the C6 disc is immediately caudal patients with developmental stenosis in whom otherwise to the C6 vertebra and disc pathology at that level typically relatively minor intrusion into the spinal canal by pathological would involve the C7 nerve root). In the lumbar spine anatomy may cause compression of the neural structures. Many classically a similar relationship exists in that disc pathology studies have documented that the changes in the foraminal most commonly affects the nerve root one segment caudal (e.g., dimensions increase with flexion and decrease with extension. an L4 disc herniation would be expected to cause L5 root Also, disc space narrowing causes significant volumetric symptoms and findings) (Fig. 39-4). decreases in the neural foramen at all levels. At the level of the intervertebral foramen is the dorsal root Natural History of Disc Disease ganglion. The ganglion lies within the outer confines of the foramen. Distal to the ganglion three distinct branches arise; the Natural History of Disc Disease most prominent and important is the ventral ramus, which supplies all structures ventral to the neural canal. The second The natural process of spinal aging has been studied by branch, the sinu-vertebral nerve, is a small filamentous nerve Kirkaldy-Willis and Hill and by others through observation of that originates from the ventral ramus and progresses medially clinical and anatomical data. One theory of spinal degeneration over the posterior aspect of the disc and vertebral bodies, assumes that all spines degenerate and that our current methods innervating these structures and the posterior longitudinal of treatment are for symptomatic relief, not for a cure. ligament. The third branch is the dorsal ramus. This branch The degenerative process has been divided into three courses dorsally, piercing the intertransverse ligament near the separate stages with relatively distinct findings. The first stage

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A B

Fig. 39-5 A, Dorsal view of lumbar spinal segment with lamina and facets removed. On left side, dura and root exiting at that level remain. On right side, dura has been resected and root is elevated. Sinu-vertebral nerve with its course and innervation of posterior longitudinal ligament is usually obscured by nerve root and dura. B, Cross-sectional view of spine at level of endplate and disc. Note that sinu-vertebral nerve innervates dorsal surface of disc and posterior longitudinal ligament. Additional nerve branches from ventral ramus innervate more ventral surface of disc and anterior longitudinal ligament. Dorsal ramus arises from root immediately on leaving foramen. This ramus divides into lateral, intermediate, and medial branches. Medial branch supplies primary innervation to facet joints dorsally.

is dysfunction, which is seen in those 15 to 45 years of age. It ing neural tissue in the late instability and early stabilization is characterized by circumferential and radial tears in the disc stages. Mayoux-Benhamou et al. noted that a 4-mm collapse of annulus and localized synovitis of the facet joints. Varlotta et al. the disc produces sufficient narrowing of the foramen to noted a familial predisposition to lumbar disc herniation in threaten the nerve. patients who had disc herniation before the age of 21 years. In The stages and progression of degeneration have been this group the familial incidence was 32% compared with a confirmed by histological studies. Miller, Schmatz, and Schultz matched control group of asymptomatic individuals in whom noted that disc degeneration progresses histologically as age the rate was only 7%. A case control study of familial increases. Males were found to have more degeneration than degenerative disc disease revealed a similar incidence of females. L4-5 and L3-4 disc levels showed the greatest degree degenerative changes between first-order relatives of those with of disc degeneration. Urban and McMullin noted that the documented lumbar disc herniations and those without such a hydration of disc material decreased with age. The relationship family history. However, the first-order relatives did have between the change in hydration and swelling pressure was statistically significant more severe degenerative change. dependent on the composition of the disc rather than on the age The next stage is instability. This stage, found in 35- to of the patient or the degree of degeneration. In their study L1-2 70-year-old patients, is characterized by internal disruption of and L5-S1 discs had the lowest hydration. Yasuma et al. noted the disc, progressive disc resorption, degeneration of the facet progressive histological changes in the prolapsed discs when joints with capsular laxity, subluxation, and joint erosion. The compared with protruded discs. Urovitz and Fornasier were final stage, present in patients older than 60 years, is unable to detect any evidence of autoimmune reaction in stabilization. In this stage the progressive development of human disc tissue, but they did detect evidence of the response hypertrophic bone about the disc and facet joints leads to to mechanical injury. Using postmyelogram CT scans, Takata segmental stiffening or frank ankylosis (Table 39-1). et al. found that the cauda equina and affected nerve roots were Each spinal segment degenerates at a different rate. As one swollen in 17 of 28 patients studied. The affected roots returned level is in the dysfunction stage, another may be entering the to normal size after disc excision. Ziv et al. reported coarsely stabilization stage. Disc herniation in this scheme is considered fibrillated and ulcerated spinal facet joints in young patients, a complication of disc degeneration in the dysfunction and and this finding continued through progressive aging. The instability stages. Spinal stenosis from degenerative arthritis in cartilage of the superior facets is thicker and has a higher water this scheme is a complication of bony overgrowth compromis- content than the inferior facets, indicating more frequent

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Table 39-1 Spectrum of Pathological Changes in Facet Joints and Discs and the Interaction of These Changes

Phases of Spinal Degeneration Facet Joints Pathological Result Intervertebral Disc

 Synovitis → Dysfunction ← Circumferential tears  Dysfunction Hypermobility ↓ %   Continuing degeneration # Herniation ← Radial tears  Capsular laxity → Instability ← Internal disruption Instability   Subluxation → Lateral nerve entrapment ← Disc resorption  Enlargement of articular → One-level stenosis ← Osteophytes Stabilization   processes & Multilevel spondylosis and $ stenosis

Modiﬁed from Kirkaldy-Willis WH, ed: Managing low back pain, New York, 1983, Churchill Livingstone.

damage. Neumann et al. suggested that the amount of bone Also, our understanding of certain pathophysiological entities tissue in the spine may be functionally related to the structural must be juxtaposed to other entities of which we have only a properties of the spinal ligaments. rudimentary understanding. It is doubtful if there is any other Long-term follow-up studies of lumbar disc herniations by area of orthopaedics in which accurate diagnosis is as difficult Hakilius in 1970, Weber in 1983, and Seal in 1996 consistently or the proper treatment as challenging as in patients with documented several principles, the foremost being that persistent neck and arm or low back and leg pain, despite generally symptomatic lumbar disc herniation (which is only appropriate evaluation and care. Although there are many one of the consequences of disc degeneration) has a favorable patients with clear diagnoses properly arrived at by careful outcome in most patients. This was pointed out by Weber, who history and physical examination with confirmatory imaging noted that the primary benefit of surgery was early on in the studies, more patients with pain have absent neurological first year, but that with time the statistical significance of findings other than sensory changes and have normal imaging the improvement was lost. In addition, the review by Saal studies or studies that do not support the clinical complaints supported an active care approach, minimizing centrally acting and findings. Inability to easily demonstrate an appropriate medications. The judicious use of epidural steroids also is diagnosis in a patient does not relieve the physician of the supported. Nonprogressive neurological deficits (except cauda obligation to recommend treatment or to direct the patient to a equina syndrome) can be treated nonoperatively with expected setting where such treatment is available. Careful assessment of improvement clinically. If surgery is necessary, it usually can these patients to determine if they have problems that can be be delayed 6 to 12 weeks to allow adequate opportunity for orthopaedically treated (nonsurgically or surgically) is imper- improvement. These principles are consistent with clinical ative to avoid overtreatment as well as undertreatment. Surgical findings and treatment practices at this clinic. Clearly, some treatment can benefit a patient if it corrects a deformity, corrects patients are best treated surgically, and this is discussed in the instability, or relieves neural compression, or treats a combi- section dealing specifically with lumbar disc herniation. nation of these problems. Obtaining a history and completing a Similar principles are valid regarding cervical disc herniations, physical examination to determine a diagnosis that should be which also generally can be treated nonoperatively. The supported by other diagnostic studies is a very useful approach; important exceptions are patients with cervical myelopathy, conversely, matching the diagnosis and treatment to the results who are best treated surgically. of diagnostic studies, as is done in other subspecialties of The natural history of disc disease is one of recurrent orthopaedics, is fraught with difficulty. episodes of pain followed by periods of significant or complete As pointed out by Waddell, most patients with nonspecific relief. Biering-Sørensen and Hilden noted that the memory of complaints and findings are best treated by their primary care painful low back episodes was short. At initial evaluation and physicians. For those with significant findings, evaluation and at 6 months’ follow-up the question of ever having had low treatment by a specialist is appropriate. For a small minority of back pain was answered by patients with a yes or no and 84% patients (although they are responsible for a much more answered consistently on the two occasions. However, in a significant portion of health care utilization) a multidisciplinary questionnaire at 12 months only two fifths of those interviewed approach is best. answered consistently. They questioned the long-term analysis NONSPECIFIC LUMBAR PAIN of data from this standpoint and noted that the clinician should NONSPECIFIC LUMBAR PAIN be aware of the potential vagueness and unreliability of a history of previous back injury. Nonspecific low back pain occurs at some point in the lives of Before a discussion of diagnostic studies, axial spine pain most people. In Western societies a lifetime incidence of with radiation to one or more extremity must be considered. approximately 80% has been documented. A study of 1389

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Table 39-2 Selective Indications for 100 Roentgenography in Acute Low 90 Back Pain 80 Age >50 years 70 Signiﬁcant trauma Neuromuscular deﬁcits 60 Unexplained weight loss (10 pounds in 6 months) 50 Suspicion of ankylosing spondylitis

Drug or alcohol abuse Percentage 40 History of cancer 30 Use of corticosteroids 20 Temperature ≥37.8° C (100.0° F) Recent visit (within 1 month) for same problem and no 10 improvement 0 Patient seeking compensation for back pain 012 Time off work (yr) Adapted from Deyo RA, Diehl AK: J Gen Intern Med 1:20, 1986. Fig. 39-6 Diminishing chance of return to work with increasing time out of work resulting from low back pain (based on data from adolescents aged 13 to 16 years recorded low back pain in Clinic Standards Advisory Group). (From Waddell G: Spine nearly 60%. The incidence and severity of this problem has 21:2820, 1996.) remained fairly constant since the early 1980s. Appropriate treatment for what can be at times excruciating pain generally should begin with evaluation for significant spinal pathology. some patients. Another finding that is evident from the This being absent, a brief (1 to 3 days) period of bed rest with literature is the inability of physicians to detect psychosocial institution of an antiinflammatory regimen and rapid progres- factors adequately without using specific instruments designed sion to an active exercise regimen with an anticipated return to for this purpose in patients with back pain. In one particular full activity should be expected and encouraged. Diagnostic study by Grevitt et al. experienced spinal surgeons were able to studies, including roentgenograms, often are unnecessary identify distressed patients only 26% of the time based on because they add little information. More sophisticated patient interviews. Given the difficulty of identifying patients imaging with CT scans and MRI or other studies have even less with psychosocial distress, being aware of the high incidence of utility initially. An overdependence on the diagnosis of disc incidental abnormal findings on imaging studies underscores herniation occurred with early use of these diagnostic studies the need for critical individual review of these studies by that show disc herniations in 20% to 36% of normal volunteers. treating physicians. Severe nerve compression demonstrated by This incidence increased to 76% of asymptomatic controls MRI or CT correlates with symptoms of distal leg pain; when they were matched to a population at risk for work- however, mild to moderate nerve compression (Table 39-3), related lumbar pain complaints. Imaging guidelines have been disc degeneration or bulging, and central stenosis do not set forth by Bigos et al. (Table 39-2). Generally, patients treated significantly correlate with specific pain patterns. in this manner improve significantly in 4 to 8 weeks. Patients A review of the pertinent literature reveals that similar should understand that persistence of some pain is not psychological factors are important in patients with neck pain. indicative of treatment failure, necessitating further measures; As confounding as these psychological risk factors are, however, it is important for treating physicians to recognize that reasonable and logical measures are available that assist in the longer a person is limited by pain, the less likely is a return evaluation and treatment. to full activity. Once a patient is out of work for 6 months, there Diagnostic Studies is only a 50% chance that he will return to his previous job ROENTGENOGRAPHY (Fig. 39-6). Diagnostic Studies For patients who do not respond to treatment regimens, early recognition that other issues may be involved is essential. ROENTGENOGRAPHY Careful reassessment of complaints and reexamination for new information or findings as well as inconsistencies are necessary. The simplest and most readily available diagnostic tests for Many studies of occupational back pain have revealed that back or neck pain are anteroposterior and lateral roentgeno- depression, occupational mental stress, job satisfaction, inten- grams of the involved spinal segment. These simple roentgeno- sity of concentration, anxiety, and marital status can be related grams show a relatively high incidence of abnormal findings. to complaints of pain and disability. The role of these factors as Ford and Goodman reported only 7.3% normal spine roent- causal or consequential of the symptoms remains an area of genograms in a group of 1614 patients evaluated for back pain. continued study; however, there is certainly some evidence that Scavone, Latshaw, and Rohrer reported a 46% incidence of the psychological stresses occur before complaints of pain in abnormal incidental findings in lumbar spine films taken over

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 8/74 Pg: 1962 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 1963

Table 39-3 Classification for Spinal Nerve facet syndrome and hypertrophic arthritis of the lumbar spine. and Thecal Sac Deformation Conversely, in the cervical spine hypertrophic changes about the foramina are easily outlined. Lateral flexion and extension SPINAL NERVE DEFORMATION IN LATERAL RECESS roentgenograms may reveal segmental instability. Hayes et al. OR INTERVERTEBRAL FORAMEN attempted to identify the pathological level of abnormal lumbar 0—Absent No visible disc material contacting or spine flexion, but they found a wide range of motion in deforming nerve asymptomatic patients. They also found that translational I—Minimal Contact with disc material deforming nerve movements of 2 to 3 mm were frequent, which means that there but displacement less than 2 mm II—Moderate Contact with disc material displacing 2 or is little correlation between abnormal motion and pathological more mm. The nerve is still visible and instability. No standards are available to make this distinction. not obscured by disc material Unfortunately, the interpretation of these views depends on III—Severe Contact with disc material completely patient cooperation, patient positioning, and reproducible obscuring the nerve technique. Knutsson, Farfan, Kirkaldy-Willis, Stokes et al., Macnab, and Bigos are excellent references on this topic. The THECAL SAC DEFORMATION IN VERTEBRAL CANAL Ferguson view (20-degree caudocephalic anteroposterior roent- 0—Absent No visible disc material contacting or genogram) has been shown by Wiltse et al. to be of value in deforming thecal sac the diagnosis of the ‘‘far out syndrome,’’ that is, fifth root I—Minimal Disc material in contact with thecal sac compression produced by a large transverse process of the fifth II—Moderate Disc material deforming thecal sac, antero- lumbar vertebra against the ala of the sacrum. Abel, Smith, and posterior distance of thecal sac ≥7mm III—Severe Disc material deforming thecal sac, antero- Allen note that angled caudal views localized to areas of posterior distance of thecal sac <7mm concern may show evidence of facet or laminar pathological conditions. From Beattie PF, Meyers SP, Strafford P, et al: Spine 25:819, 2000. MYELOGRAPHY ◆ MYELOGRAPHY 1 year in a university hospital. Unfortunately, when these The value of myelography is the ability to check all disc levels roentgenographic abnormalities are critically evaluated with for abnormality and to define intraspinal lesions; it may be respect to the patients’ complaints and physical findings, the unnecessary if clinical and CT findings are in complete correlation is very low. Fullenlove and Williams clearly agreement. The primary indications for myelography are identified the lack of definition between roentgenographic suspicion of an intraspinal lesion or questionable diagnosis findings in symptomatic, asymptomatic, and operated patients. resulting from conflicting clinical findings and other studies. In Rockey et al. and Liang and Komaroff concluded that spinal addition, myelography is of value in a previously operated roentgenograms on the initial visit for acute low back pain do spine and in patients with marked bony degenerative change not contribute to patient care and are not cost effective. They that may be underestimated on MRI. Myelography is improved recommended that plain roentgenograms be taken only after the by the use of postmyelography CT scanning in this setting, initial therapy fails, especially in patients younger than 45 years as well as in evaluating spinal stenosis. Bell et al. found of age. myelography more accurate than CT scanning for identifying There is insignificant correlation between back pain and the herniated nucleus pulposus and only slightly more accurate roentgenographic findings of lumbar lordosis, transitional than CT scanning in the detection of spinal stenosis. Szypryt vertebra, disc space narrowing, disc vacuum sign, and claw et al. found myelography slightly less accurate than MRI in spurs. In addition, the entity of disc space narrowing is detecting spinal abnormalities. extremely difficult to quantify in all but the operated backs or Several contrast agents have been used for myelography: air, in obviously abnormal circumstances. Frymoyer et al. in a oil contrast, and water-soluble (absorbable) contrast including study of 321 patients found that only when traction spurs or metrizamide (Amipaque), iohexol (Omnipaque), and iopamidol obvious disc space narrowing or both were present did the (Isovue-M). Since these nonionic agents are absorbable, the incidence of severe back and leg pain, leg weakness, and discomfort of removing them and the severity of the post- numbness increase. These positive findings had no relationship myelographic headache have been decreased. to heavy lifting, vehicular exposure, or exposure to vibrating Isophendylate (Pantopaque) was the contrast agent of choice equipment. Other studies have shown some relationship be- from 1944 to the late 1970s (Fig. 39-7). This agent required tween back pain and the findings of spondylolysis, spondylolis- aspiration at the conclusion of the study and was more of a thesis, and adult scoliosis, but these findings also can be meningeal irritant than the nonionic materials currently observed in spine roentgenograms of asymptomatic patients. available. Occasionally, older patients are seen with small Special roentgenographic views can be helpful in further amounts of residual Pantopaque within the subarachnoid space. defining or disproving the initial clinical roentgenographic Rarely, patients have severe reactions such as transient impression. Oblique views are useful in further defining paralysis, cauda equina syndrome, or focal neurological spondylolisthesis and spondylolysis but are of limited use in deficits.

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Fig. 39-7 A, Anteroposterior roentgenogram of iophendyl- Fig. 39-8 A, Anteroposterior roentgenogram of metrizamide ate (Pantopaque) myelogram showing lumbar disc herniation. lumbar myelogram showing lumbar disc herniation. B, Oblique B, Oblique roentgenogram showing large L4-5 disc herniation. roentgenogram showing large L4-5 disc herniation.

Arachnoiditis is a severe complication that has been incidence of the more common reactions. Likewise, mainte- attributed on occasion to the combination of isophendylate and nance of at least a 30-degree elevation of the patient’s head blood in the cerebrospinal fluid (CSF). Unfortunately, this until the contrast is absorbed also should help prevent reactions. diagnosis usually is confirmed only by repeat myelography. Complete information about these agents and the dosages Attempts at surgical neurolysis have resulted in only short-term required is found in their package inserts. relief and a return of symptoms within 6 to 12 months after the Iohexol (Omnipaque) is a nonionic contrast medium procedure. Fortunately, time may decrease the effects of this approved for thoracic and lumbar myelography. The incidence serious problem in some patients, but progressive paralysis of reactions to this medium is low. The most common reactions has been reported in rare instances. Arachnoiditis also can are headache (less than 20%), pain (8%), nausea (6%), and be caused by tuberculosis and other types of meningitis. vomiting (3%). Serious reactions are very rare and include Arachnoiditis has not been noted to be related to the use of mental disturbances and aseptic meningitis (0.01%). Good water-soluble contrast, with or without injection, in the hydration is essential to minimize the common reactions. The presence of a bloody tap. Myelography remains the best use of phenothiazine antinauseants is contraindicated when this diagnostic study to evaluate arachnoiditis. medium is employed. Management before and after the Water-soluble contrast media are now the standard agents procedure is the same as for metrizamide. for myelography (Fig. 39-8). Their advantages include Air contrast is used rarely and probably should be used only absorption by the body, enhanced definition of structures, in situations in which myelography is mandatory and the tolerance, absorption from other soft tissues, and the ability to patient is extremely allergic to iodized materials. The resolution vary the dosage for different contrasts. Like isophendylate they from such a procedure is poor. Air epidurography in con- are meningeal irritants, but they have not been associated with junction with CT has been suggested in patients in whom arachnoiditis. The complications of these agents include further definition between postoperative scar and recurrent disc nausea, vomiting, confusion, and seizures. Rare complications material is required. include stroke, paralysis, and death. Iohexol and iopamidol Myelographic technique begins with a careful explanation have significantly lower complication rates than metrizamide. of the procedure to the patient before its initiation. Hydration of The more common complications appear to be related to patient the patient before the procedure may minimize postmyelo- hydration, phenothiazines, tricyclics, and migration of contrast graphic complaints. Heavy sedation rarely is needed. Proper into the cranial vault. Many of the reported complications can equipment, including a fluoroscopic unit with a spot film be prevented or minimized by using the lowest possible dose to device, image intensification, tiltable table, and television achieve the desired degree of contrast. Adequate hydration and monitoring, is useful. The type of needle selected also discontinuation of phenothiazines and tricyclic drugs before, influences the risk of postdural puncture headaches (PDPH), during, and after the procedure should also minimize the which can be severe. Smaller gauge needles (22 or 25 gauge)

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 10/74 Pg: 1964 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 1965 have been found to result in a lower incidence of PDPH. Also, use of a Whitacre-type needle with a more blunt tip and side contrast to proceed cranially. Extend the neck and head port opening results in fewer PDPH complaints. maximally to prevent or minimize intracranial migration of the contrast medium. TECHNIQUE 39-1 If isophendylate (oil contrast) was used, remove the Place the patient prone on the fluoroscopic table. Use of an contrast medium by extracting through the original needle abdominal pillow is optional. Prepare the back in the usual or a multiholed stylet inserted through the original needle or surgical fashion. Determine needle placement by the by inserting another needle if extraction through the first suspected pathological level. Placement of the needle needle is difficult. A small amount of medium occasionally cephalad to L2-3 is more dangerous because of the risk of is retained, but remove as much as possible. damaging the conus medullaris. If blood is present in the initial tap, abandon the Infiltrate the selected area of injection with a local procedure if oil contrast is to be used. It can be attempted anesthetic. Use the smallest-gauge needle that can be well again in several days if the patient has no symptoms related placed. If a Whitacre-type needle is used, a 19-gauge needle to the first tap and is well hydrated. If the proper needle may be placed through the skin, subcutaneous tissue, and position is confirmed in the anteroposterior and lateral views fascia to form a track, since this relatively blunt needle may and CSF flow is minimal or absent, suspect a neoplastic not penetrate these structures well. Midline needle place- process. Then place the needle at a higher or lower level as ment usually minimizes lateral nerve root irritation and indicated by the circumstances. If attempts to obtain CSF epidural injection. Advance the needle with the bevel continue to fail, abandon the procedure and reevaluate the parallel to the long axis of the body. Subarachnoid clinical situation. placement can be enhanced by tilting the patient up to increase intraspinal pressure and minimize the epidural space. The most common technical complications of myelography Once the dura and arachnoid have been punctured, turn are significant retention of contrast medium (oil contrast only), the bevel of the needle cephalad. A clear continuous flow of persistent headache from a dural leak, and epidural injection. CSF should continue with the patient prone. Manometric These problems usually are minor. Persistent dural leaks studies can be performed at this time if desired or indicated. usually are responsive to a blood patch. With the use of a Remove a volume of CSF equal to the planned injection water-soluble contrast medium, the persistent abnormalities volume for laboratory evaluation as indicated by the clinical caused by retained medium and epidural injection are suspicions. In most patients a cell count, differential white eliminated. cell count, and protein analysis are performed. COMPUTED TOMOGRAPHY Inject a test dose of the contrast material under COMPUTED TOMOGRAPHY fluoroscopic control to confirm a subarachnoid injection. If a mixed subdural-subarachnoid injection is suspected, Computed tomography revolutionized the diagnosis of spinal change the needle depth; occasionally a lateral roentgeno- disease (Fig. 39-9). Most clinicians now agree that CT is an gram may be required to confirm the proper depth. If flow extremely useful diagnostic tool in the evaluation of spinal is good, inject the contrast material slowly. disease. Be certain of continued subarachnoid injection by The current technology and computer software have made occasionally aspirating as the injection continues. The usual possible the ability to reformat the standard axial cuts in almost dose of iohexol for lumbar myelography in an adult is 10 to any direction and magnify the images so that exact measure- 15 ml with a concentration of 170 to 190 mg/ml. Higher ments of various structures can be made. Software is available concentrations of water-soluble contrast are required if to evaluate the density of a selected vertebra and compare higher areas of the spine are to be demonstrated. Consult the it with vertebrae of the normal population to give a numer- package insert of the contrast used. The needle can be ically reproducible estimate of vertebral density to quantitate removed if a water-soluble contrast (iohexol) is used. The osteopenia. needle must remain in place and be covered with a sterile Numerous types of CT studies for the spine are available. towel if isophendylate is used. These studies vary from institution to institution and even Allow the contrast material to flow caudally for the best within institutions. One must be careful in ordering the study to views of the lumbar roots and distal sac. Make spot films in be certain that the areas of clinical concern are included. the anteroposterior, lateral, and oblique projections. A full Several basic routines are used in most institutions. The lumbar examination should include thoracic evaluation to most common routine for lumbar disc consists of making serial about the level of T7 because lesions at the thoracic level cuts through the last three lumbar intervertebral discs. If the may mimic lumbar disc disease. Take additional spot films equipment has a tilting gantry, an attempt is made to keep the as the contrast proceeds cranially. axis of the cuts parallel with the disc. However, frequently If a total or cervical myelogram is desired, allow the the gantry cannot tilt enough to allow a parallel beam through the lowest disc space. This technique does not allow demon-

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A BC

DE F

Fig. 39-9 A, CT scan ‘‘scout view’’ of lumbar disc herniation at lumbar disc level showing angled gantry technique. B, CT scan ‘‘scout view’’ of straight gantry technique. C, CT scan of lumbar disc herniation at L4-5 disc level showing cross-sectional anatomy with gantry straight. D, CT scan of L4-5 disc herniation at lumbar disc level showing cross-sectional, sagittal, and coronal anatomy using computerized reformatted technique. E, CT scan of L4-5 disc herniation at lumbar disc level showing cross-sectional anatomy 2 hours after metrizamide myelography. F, CT scan of lumbar disc herniation at L4-5 disc level showing cross-sectional anatomy after intravenous injection for greater soft tissue contrast. stration of the canal at the pedicles. Another method involves of cuts. Several sections of the axial cuts should include the making cuts through the discs without tilting the gantry. Once local soft tissue and contiguous abdominal contents. Finally, a again, the entire canal is not demonstrated, and the lower cuts set of images adjusted for improved bony detail should be frequently have the lower and upper endplates of adjacent included for evaluation of the facet joints as well as the lateral vertebrae superimposed in the same view. recesses. Naturally this study should be centered on the level of The final and most complex method consists of making greatest clinical concern. The study can be enhanced further if multiple parallel cuts at equal intervals. This allows computer done after water contrast myelography or with intravenous reconstruction of the images in different planes—usually contrast medium. Enhancement techniques are especially sagittal and coronal. These reformatted views allow an almost useful if the spine being evaluated has been operated on three-dimensional view of the spine and most of its structures. previously. The greatest benefit of this technique is the ability to see This noninvasive, painless, outpatient procedure can supply beyond the limits of the dural sac and root sleeves. Thus the more information about spinal disease than was previously diagnosis of foraminal encroachment by bone or disc material available with a battery of invasive and noninvasive tests can now be made in the face of a normal myelogram. The usually requiring hospitalization. Unfortunately, CT does not proper procedure can be chosen that fits all the pathological demonstrate intraspinal tumors or arachnoiditis and is unable to conditions involved. differentiate scar from recurrent disc herniation. Bell et al. Optimal reformatted CT should include enlarged axial and compared myelography with CT scanning and noted that sagittal views with clear notation as to laterality and sequence myelography was more accurate. They did not compare the

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 12/74 Pg: 1966 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 1967

A B combined accuracy was 94%. MRI is clearly superior in the detection of disc degeneration, tumors, and infections. Most MRI scans allow evaluation of a complete spinal region (such as cervical, thoracic, or lumbar) rather than three segments. They also can clearly view areas in the foramen and the paraspinal soft tissues. MRI is so accurate that a significant number of lesions can be identified in asymptomatic patients. Gibson et al. found disc degeneration in all symptomatic adolescent patients and in 4 of 20 asymptomatic adolescents. Boden et al. found cervical spinal abnormalities in 14% of asymptomatic patients younger than 40 years of age and in 28% of asymptomatic patients over the age of 40 years. Cervical disc degeneration was found in 25% of those younger than 40 years of age and in 60% of those 60 years and older. They studied lumbar MRI scans of 67 asymptomatic patients and found that 20% of those younger than 60 years of age had herniated nuclei pulposi, which were also present in 36% of those over the age of 60 years. Asymptomatic abnormalities were found in 57% of those 60 Fig. 39-10 Magnetic resonance imaging of lumbar spine. years of age or older. Lumbar disc degeneration was found in A, Normal T2-weighted image. B, T2-weighted image showing 35% of those from 20 to 39 years of age and in 100% of those degenerative bulging and/or herniated discs at L3-4, L4-5, and over 50 years of age. Therefore the demonstrated findings must L5-S1. be carefully correlated with the clinical impression. POSITRON EMISSION TOMOGRAPHY POSITRON EMISSION TOMOGRAPHY results of postmyelogram CT scanning. Weiss et al. and Teplick and Haskin in separate reports suggested that the use of Positron emission tomography (PET) and single photon intravenous contrast medium (Fig. 39-9, E) followed by CT can emission CT (SPECT) are other similar techniques that may improve the definition between scar and disc herniation. offer additional diagnostic information. Collier et al. and others Myelography is still required to demonstrate intraspinal tumors reported that SPECT is more sensitive than planar bone and to ‘‘run’’ the spine to detect occult or unsuspected lesions. scintigraphy in the identification of symptomatic sites in The development of low-dose metrizamide or iohexol myelog- spondylolysis. PET scanners are considered experimental by raphy with reformatted CT done as an outpatient procedure most third-party payers at this time. Their use currently is allows a maximum of information to be obtained with a limited to relatively few centers. minimum of time, risk, discomfort, and cost. Currently, imaging capabilities exceed clinical abilities to MAGNETIC RESONANCE IMAGING identify the source of pain. However, some patients may have MAGNETIC RESONANCE IMAGING nonanatomical causes for their pain and there is no imaginable explanation for their symptoms. In these patients, imaging Magnetic resonance imaging (MRI) is the newest technological studies are useful to rule out significant pathology that may advance in spinal imaging. This technique uses the interaction explain their symptoms, such as with spinal cord tumors, of an unpaired electron with an external oscillating electromag- infections, polyradiculopathies, or myeloradiculopathies. netic field that is changing as a function of time at a particular OTHER DIAGNOSTIC TESTS frequency. Energy is absorbed and subsequently released by OTHER DIAGNOSTIC TESTS selected nuclei at particular frequencies after excitation with radiofrequency electromagnetic energy. The released energy is Numerous diagnostic tests have been used in the diagnosis of recorded and formatted by computer in a pattern similar to CT. intervertebral disc disease in addition to roentgenography, Current MRI techniques concentrate on imaging the proton myelography, and CT. The primary advantage of these tests is

(hydrogen) distribution present as H2O primarily. The advan- to rule out diseases other than primary disc herniation, spinal tages of this technique include the ability to demonstrate stenosis, and spinal arthritis. intraspinal tumors, examine the entire spine, and identify Electromyography is the most notable of these tests. One degenerative discs based on decreased H2O content. Unfortu- advantage of electromyography is in the identiﬁcation of nately, the equipment required for this procedure is costly and peripheral neuropathy and diffuse neurological involvement requires specially constructed facilities (Fig. 39-10). indicative of higher or lower lesions. Electromyography and Szypryt et al. found MRI slightly better than myelography in nerve conduction velocity can be helpful if a patient has a the identiﬁcation of spinal lesions. The accuracy of MRI history and physical examination suggestive of radiculopathy at in their study was 88% and that of myelography was 75%; either the cervical or lumbar level with inconclusive imaging

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 13/74 Pg: 1967 Team: 1968 PART XII ◆ The Spine studies. Macnab et al. reported that denervation of the epidurally and intradurally. The use of bupivacaine should be paraspinal muscles is found in 97% of previously operated limited to low concentrations and low volumes because of lumbar spines as a result of the surgery. Therefore paraspinal reports of death after epidural anesthesia using concentrations muscles in a patient with a previous posterior operation usually of 0.75% or higher. are abnormal and are not a reliable diagnostic finding. Steroids prepared for intramuscular injection also have been The somatosensory evoked potentials (SSEP) test is another used frequently in the epidural space with few and usually diagnostic tool that can identify the level of root involvement. transient complications. Spinal arachnoiditis in years past was Unlike electromyography this test can only indicate a problem associated with the use of epidural methylprednisolone acetate between the cerebral cortex and the end organs; the test cannot (Depo-Medrol). This complication was thought to be caused by pinpoint the level of the lesion. This procedure is of benefit the use of the suspending agent, polyethylene glycol, which has during surgery to avoid neurological damage. Both electromy- since been eliminated from the Depo-Medrol preparation. For ography and SSEP depend on the skill of the technician and epidural injections, we prefer the use of Celestone Soluspan, interpreter. Delamarter et al. used cortical evoked potentials to which is a mixture of betamethasone sodium phosphate and monitor experimentally induced spinal stenosis. They noted betamethasone acetate. Celestone Soluspan provides both changes in the cortical response at 25% constriction. This was immediate and long-term duration of action, is highly soluble, the only change noted in this group. Higher degrees of and contains no harmful preservatives. Isotonic saline is the constriction were accompanied by much more significant only other injectable medium used frequently about the spine changes. The SSEP is an extremely sensitive monitoring with no reported adverse reactions. technique. When discrete, well-controlled injection techniques directed Bone scans are another procedure in which positive findings at specific targets in and around the spine are used, grading the usually are not indicative of intervertebral disc disease, but they degree of pain before and after selective spinal injection is can confirm neoplastic, traumatic, and arthritic problems in the helpful in determining the location of the pain generator. The spine. Various laboratory tests such as a complete blood count, patient is asked to grade the degree of pain ona0to10scale differential white cell count, biochemical profile, urinalysis, before and at various intervals after the selective spinal and sedimentation rate are extremely good screening pro- injection (Box 39-1). If a selective spinal injection done under cedures for other causes of pain in the spine. Rheumatoid fluoroscopic control results in a 50% or more decrease in the screening studies such as rheumatoid arthritis latex, antinuclear level of pain, which corresponds to the duration of action of the antibody, lupus erythematosus cell preparation, and HLA-B27 anesthetic agent used, then the target area injected is presumed also are useful when indicated by the clinical picture. to be the pain generator. Some tests that were developed to enhance the diagnosis of EPIDURAL CORTISONE INJECTIONS intervertebral disc disease have been surpassed by the more EPIDURAL CORTISONE INJECTIONS advanced technology. Lumbar venography and sonographic measurement of the intervertebral canal are two examples. Epidural injections in the cervical, thoracic, and lumbosacral Injection Studies spine were developed to diagnose and treat spinal pain. Information obtained from epidural injections can be helpful in Injection Studies confirming pain generators that are responsible for a patient’s discomfort. Structural abnormalities do not always cause pain Whenever a diagnosis is in doubt and the complaints appear and diagnostic injections can help to correlate abnormalities real or the pathological condition is diffuse, identificationofthe seen on imaging studies with associated pain complaints. In source of pain is problematic. The use of local anesthetics or addition, epidural injections can provide pain relief during the contrast media in various specific anatomical areas can be recovery of disc or nerve root injuries and allow patients to useful. These agents are relatively simple, safe, and minimally increase their level of physical activity. Because severe pain painful. Contrast media such as diatrizoate meglamine from an acute disc injury with or without radiculopathy often is (Hypaque), iothalamate meglumine (Conray), iohexol (Omni- time-limited, therapeutic injections help to manage pain and paque), iopamidol, and metrizamide (Amipaque) have been may alleviate or decrease the need for oral analgesics. used for discography and blocks with no reported ill effects. Epidural injections were first done in the lumbar region. In Reports of neurological complications with contrast media used 1901 the first reports were published of epidural injections of for discography and subsequent chymopapain injection are well cocaine for low back pain and sciatica. In 1930 Evans reported documented. The best choice of a contrast medium for good results in 22 of 40 patients treated with procaine and documenting structures outside the subarachnoid space is an saline injection into the sacral epidural space for unilateral absorbable medium with low reactivity because it might be sciatica, and in the early 1950s Robecchi and Capral were the injected inadvertently into the subarachnoid space. Iohexol and first to report epidural injection of cortisone into the first sacral metrizamide are the least reactive, most widely accepted, and neuroforamen for the treatment of low back pain. The earliest best tolerated of the currently available contrast media. Local references for cervical epidural injections were published by anesthetics such as lidocaine (Xylocaine), tetracaine (Pon- Catchlove and Braha and Shulman et al. No historical tocaine), and bupivacaine (Marcaine) are used frequently both information on thoracic epidural injections has been published.

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BOX 39-1 • Pain Scale and Diary

0 No pain 1 Mild pain that you are aware of but not bothered by 2 Moderate pain that you can tolerate without medication 3 Moderate pain that is discomforting and requires medication 4-5 More severe and you begin to feel antisocial 6 Severe pain 7-9 Intensely severe pain 10 Most severe pain; you might contemplate suicide over it

Activity Comments Location of Pain Time Severity of Pain (0 to 10)

From White AH: Back school and other conservative approaches to low back pain, St Louis, 1983, Mosby.

The efficacy of epidural injections is not reliably known include nonpositional headaches, fascial flushing, insomnia, because of the lack of well-controlled studies. Inconsistencies low-grade fever, and transient increased back or lower in indications and protocols are striking among reports, and extremity pain. Epidural corticosteroid injections are contrain- many epidural steroid injection studies were done without dicated in the presence of infection at the injection site, fluoroscopic-guided needle placement to confirm correct systemic infection, bleeding diathesis, uncontrolled diabetes positioning, adding another variable to the interpretation of the mellitus, and congestive heart failure. results. Nevertheless, more than 40, mostly uncontrolled, We do epidural corticosteroid injections in a fluoroscopy studies on more than 4000 patients have been published on the suite equipped with resuscitative and monitoring equipment. efficacy of lumbar and caudal epidural corticosteroid injec- Intravenous access is established in all patients with a 20-gauge tions, and according to Bogduk, only 4 recommended against angiocatheter placed in the upper extremity. Mild sedation is the use of lumbosacral epidural corticosteroids in the man- achieved through intravenous access. We recommend the use of agement of radicular pain in the lumbosacral spine. Kepes and fluoroscopy for diagnostic and therapeutic epidural injections Duncalf calculated the average favorable response rate ob- for several reasons. Epidural injections performed without tained with lumbar epidural steroid injections to be 60%, fluoroscopic guidance are not always made into the epidural whereas White calculated the favorable response rate to be space or the intended interspace. Even in experienced hands, 75%. Several studies reported the usefulness of transforaminal needle misplacement occurs in up to 40% of caudal and 30% of epidural corticosteroid injections (selective epidural or selec- lumbar epidural injections when done without fluoroscopic tive nerve root block) to identify or confirm a specific nerve guidance. Accidental intravascular injections also can occur, root as a pain generator when the diagnosis is not clear based and the absence of blood return with needle aspiration before on clinical evidence. injection is not a reliable indicator of this complication. In the Few serious complications occur in patients receiving presence of anatomical anomalies, such as a midline epidural epidural corticosteroid injections; however, epidural abscess, septum or multiple separate epidural compartments, the desired epidural hematoma, durocutaneous fistula, and Cushing syn- flow of epidural injectants to the presumed pain generator will drome have been reported as individual case reports. The most be restricted and remain undetected without fluoroscopy. In adverse immediate reaction during an epidural injection is a addition, if an injection fails to relieve pain, it would be vasovagal reaction. Dural puncture has been estimated to occur impossible without fluoroscopy to determine whether the in 0.5% to 5% of patients having cervical or lumbar epidural failure was caused by a genuine poor response or by improper steroid injections. The anesthesiology literature reported a needle placement. 7.5% to 75% incidence of postdural puncture (positional) headaches, with the highest estimates associated with the use of Cervical Epidural Injection 16- and 18-gauge needles. Headache without dural puncture Cervical epidural steroid injections have been used with has been estimated to occur in 2% and is attributed to air some success to treat cervical spondylosis associated with acute injected into the epidural space, increased intrathecal pressure disc disruption and radiculopathies, cervical strain syndromes from fluid around the dural sac, and possibly an undetected with associated myofascial pain, postlaminectomy cervical dural puncture. Some of the minor, more common complaints pain, reflex sympathetic dystrophy, postherpetic neuralgia, caused by corticosteroid injected into the epidural space acute viral brachial plexitis, and muscle contraction headaches.

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The best results with cervical epidural steroid injections have been in patients with acute disc herniations or well-defined vertical fashion until contact is made with the upper edge of radicular symptoms and in patients with limited myofas- the T1 lamina 1 to 2 mm lateral to the midline. cial pain. Anesthetize the lamina with 1 to 2 ml of 1% preservative-free Xylocaine without epinephrine. Then anesthetize the soft tissues with 2 ml of 1% preservative-free ◆ Interlaminar Approach Xylocaine without epinephrine as the spinal needle is withdrawn. Insert a 31⁄2-inch, 18-gauge Tuohy epidural TECHNIQUE 39-2 needle and advance it vertically within the anesthetized soft Place the patient prone on a pain management table. We use tissue track until contact is made with the T1 lamina under a low-attenuated carbon fiber table top that allows better fluoroscopy. ‘‘Walk off’’ the lamina with the Tuohy needle imaging and permits unobstructed C-arm viewing. For onto the ligamentum flavum. Remove the stylet from the optimal placement and comfort, place the patient’s face in a Tuohy needle and attach a 10-ml syringe filled halfway with cervical prone cutout cushion. Cervical epidural injections air and sterile saline. Advance the Tuohy needle into the using a paramedian approach should be done routinely at the epidural space using the loss of resistance technique. Once C7-T1 interspace unless previous surgery of the posterior loss of resistance has been achieved, aspirate to check for cervical spine has been done at that level, in which case the blood or spinal fluid. If neither is evident, remove the C6-C7 or T1-T2 level is injected. Aseptically prepare the syringe from the Tuohy needle and attach a 5-ml syringe skin area with isopropyl alcohol and povidone-iodine containing 1.5 ml of nonionic contrast dye. Confirm several segments above and below the laminar interspace to epidural placement by producing an epidurogram with be injected. If the patient is allergic to povidone-iodine, then the nonionic contrast agent (Fig. 39-11). To further con- substitute with chlorhexidine gluconate (Hibiclens). Drape firm proper placement adjust the C-arm to view the area the patient in sterile fashion. Using anteroposterior fluoro- from a lateral perspective. A spot roentgenogram can scopic imaging, identify the target laminar interspace. With be obtained to document placement. Inject a test dose of the use of a 27]-gauge needle, anesthetize the skin so that 1 to 2 ml of 1% preservative-free Xylocaine without a skin wheal is raised over the target interspace on the side epinephrine and wait 3 minutes. If the patient is without of the patient’s pain with 1 to 2 ml of 1% preservative-free complaints of warmth, burning, significant paresthesias, or Xylocaine without epinephrine. To diminish the burning signs of apnea, place a 10-ml syringe on the Tuohy needle discomfort of the anesthetic, mix 3 ml of 8.4% sodium and slowly inject 2 ml of 1% preservative-free Xylocaine bicarbonate in a 30-ml bottle of 1% preservative-free without epinephrine and 2 ml of 6 mg/ml Celestone Xylocaine without epinephrine. Nick the skin with an Soluspan slowly into the epidural space. If Celestone 18-gauge hypodermic needle. Under fluoroscopic control Soluspan cannot be obtained, 40 mg/ml of triamcinolone is insert and advance a 31⁄2-inch, 22-gauge spinal needle in a a good substitute.

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◆ Transforaminal Approach ◆ Interlaminar Approach

TECHNIQUE 39-3 TECHNIQUE 39-4 Place the patient in a modified lateral decubitus position A paramedian rather than a midline approach is used with the painful side up on a pain management table. because of the angulation of the spinous processes. Place the Aseptically prepare the skin area with isopropyl alcohol and patient prone on a pain management table. The preparation povidone-iodine several segments above and below the of the patient and equipment is identical to that used for neuroforamen to be injected. Drape the patient in sterile interlaminar cervical epidural injections. Aseptically pre- fashion. Identify the foramen level to be injected under pare the skin area several segments above and below the fluoroscopy, orienting the beam so that it is slightly tilted interspace to be injected. Drape the patient in sterile fashion. caudal to cephalad and anterior to posterior to maximize Identify the target laminar interspace using anteroposterior the view of the neuroforamen. Insert and slowly advance a visualization under fluoroscopic guidance. Anesthetize the 31⁄2-inch 25-gauge spinal needle until contact is made with skin over the target interspace on the side of the patient’s the lower aspect of the superior articular process under pain. Under fluoroscopic control, insert and advance a fluoroscopy. Stay posterior to the foramen to avoid the 31⁄2-inch, 22-gauge spinal needle to the superior edge of the vertebral artery. To maximize posterior positioning of the target lamina. Anesthetize the lamina and the soft tissues as spinal needle bevel, orient the needle notch anteriorly. the spinal needle is withdrawn. Mark the skin with an 18- Orient the C-arm so that the fluoroscopy beam is in an gauge hypodermic needle and then insert a 31⁄2-inch, anteroposterior projection. Redirect the spinal needle and 18-gauge Tuohy epidural needle and advance it at a 50- to ‘‘walk off’’ bone into the foramen 3 to 4 mm but no farther 60-degree angle to the axis of the spine and a 15- to 30-degree medially than the midpoint of the articular pillar on angle toward the midline until contact with the lamina is anteroposterior imaging. Remove the stylet. After a negative made. To better view the thoracic interspace, position the aspiration, inject 0.5 ml of nonionic contrast dye under C-arm so that the fluoroscopy beam is in the same plane as fluoroscopy. Once an acceptable dye pattern is seen (filling the Tuohy epidural needle. ‘‘Walk off’’ the lamina with the of the oval neuroforamen and flow of contrast along the Tuohy needle into the ligamentum flavum. Remove the stylet exiting nerve root), inject slowly a 1-ml volume, containing from the Tuohy needle and, using the loss of resistance 0.5 ml of 2% to 4% preservative-free Xylocaine without technique, advance it into the epidural space. Once loss of epinephrine and 0.5 ml of 6 mg/ml Celestone Soluspan. resistance has been achieved, aspirate to check for blood or spinal fluid. If neither is evident, inject 1.5 ml of nonionic contrast dye to confirm epidural placement. To further Thoracic Epidural Injection confirm proper placement, adjust the C-arm to view the area Epidural steroid injections in the thoracic spine have been from a lateral projection (Fig. 39-12). A spot roentgenogram shown to provide relief from thoracic radicular pain secondary or epidurogram can be obtained. Inject 2 ml of 1% to disc herniations, trauma, diabetic neuropathy, herpes zoster, preservative-free Xylocaine without epinephrine and 2 ml of and idiopathic thoracic neuralgia, although reports in the 6 mg/ml Celestone Soluspan slowly into the epidural space. literature are few.

A B

Fig. 39-12 A, Anteroposterior view of thoracic interlaminar epidurogram demonstrating characteristic contrast ﬂow pattern. B, Lateral roentgenogram of thoracic interlaminar epidurogram. Copyright 2003. Elsevier Science (USA). All Rights Reserved.

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Fig. 39-13 Anteroposterior and lateral view of lumbar interlaminar epidurogram demonstrating characteristic contrast ﬂow pattern.

Lumbar Epidural Injection Certain clinical trends are apparent with lumbar epidural 1% Xylocaine as the spinal needle is withdrawn. Nick the steroid injections. When nerve root injury is associated with a skin with an 18-gauge hypodermic needle and then insert a disc herniation or lateral bony stenosis, most patients who 31⁄2-inch, 17-gauge Tuohy epidural needle and advance it received substantial leg pain relief from a well-placed trans- vertically within the anesthetized soft tissue track until foraminal injection, even if temporary, will benefit from contact with the lamina has been made under fluoroscopy. surgery for the radicular pain. Patients who do not respond and ‘‘Walk off’’ the lamina with the Tuohy needle onto the who have had radicular pain for at least 12 months are unlikely ligamentum flavum. Remove the stylet from the Tuohy to benefit from surgery. Patients with back and leg pain of an needle and attach a 10-ml syringe filled halfway with air and acute nature (less than 3 months) respond better to epidural sterile saline to the Tuohy needle. Advance the Tuohy needle corticosteroids. Unless a significant reinjury results in an acute into the epidural space using the loss of resistance disc or nerve root injury, postsurgical patients tend to respond technique. Avoid lateral needle placement to decrease the poorly to epidural corticosteroids. likelihood of encountering an epidural vein or adjacent nerve root. Remove the stylet once loss of resistance has been achieved. Aspirate to check for blood or spinal fluid. If ◆ Interlaminar Approach neither is present, remove the syringe from the Tuohy needle and attach a 5-ml syringe containing 2 ml of nonionic TECHNIQUE 39-5 contrast dye. Confirm epidural placement by producing an Place the patient prone on a pain management table. epidurogram with the nonionic contrast agent (Fig. 39-13). Aseptically prepare the skin area with isopropyl alcohol and A spot roentgenogram can be taken to document placement. povidone-iodine several segments above and below the Remove the 5-ml syringe and place on the Tuohy needle a laminar interspace to be injected. Drape the patient in a 10-ml syringe containing 2 ml of 1% preservative-free sterile fashion. Under anteroposterior fluoroscopy guidance, Xylocaine and 2 ml of 6 mg/ml Celestone Soluspan. Inject identify the target laminar interspace. Using a 27]-gauge the corticosteroid preparation slowly into the epidural space. needle, anesthetize the skin over the target interspace on the side of the patient’spainwith1to2mlof1% preservative-free Xylocaine without epinephrine. Insert a 31⁄2-inch, 22-gauge spinal needle vertically until contact is ◆ Transforaminal Approach made with the upper edge of the inferior lamina at the target interspace, 1 to 2 cm lateral to the caudal tip of the inferior TECHNIQUE 39-6 spinous process under fluoroscopy. Anesthetize the lamina Place the patient prone on a pain management table. with 2 ml of 1% preservative-free Xylocaine without Aseptically prepare the skin area with isopropyl alcohol and epinephrine. Then anesthetize the soft tissue with 2 ml of povidone-iodine several segments above and below the

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medial edge of the pedicle. Adjust the C-arm to a lateral projection to conﬁrm the position and then return it to the anteroposterior view. Remove the stylet. Inject 1 ml of nonionic contrast slowly to produce a perineurosheatho- gram. After an adequate dye pattern of the S1 nerve root is obtained, insert a 2-ml volume containing 1 ml of 0.75% preservative-free Marcaine and 1 ml of 6 mg/ml Celestone Soluspan.

◆ Caudal Approach

TECHNIQUE 39-7 Place the patient prone on a pain management table. Aseptically prepare the skin area from the lumbosacral Fig. 39-14 Right L5 selective nerve root injection contrast junction to the coccyx with isopropyl alcohol and povidone- pattern. iodine. Drape the patient in sterile fashion. Try to identify by palpation the sacral hiatus, which is located between the two horns of the sacral cornu. The sacral hiatus can best be observed by directing the fluoroscopic beam laterally. Anesthetize the soft tissues and the dorsal aspect of the interspace to the injected. Drape the patient in sterile sacrum with 2 to 3 ml of 1% preservative-free Xylocaine fashion. Under anteroposterior fluoroscopic guidance, iden- without epinephrine. Keep the C-arm positioned so that tify the target interspace. Anesthetize the soft tissues over the fluoroscopic beam remains lateral. Insert a 31⁄2-inch, the lateral border and midway between the two adjacent 22-gauge spinal needle between the sacral cornu at about 45 transverse processes at the target interspace. Insert a degrees, with the bevel of the spinal needle facing ventrally 43⁄4-inch, 22-gauge spinal needle and advance it within the until contact with the sacrum is made. Using fluoroscopic anesthetized soft tissue track under fluoroscopy until contact guidance, redirect the spinal needle more cephalad, hori- is made with the lower edge of the superior transverse zontal and parallel to the table, advancing it into the sacral process near its junction with the superior articular process. canal through the sacrococcygeal ligament and into the Retract the spinal needle 2 to 3 mm and redirect it toward epidural space. Remove the stylet. Aspirate to check for the base of the appropriate pedicle and advance it slowly to blood or spinal fluid. If neither is evident, inject 2 ml of the 6-o’clock position of the pedicle under fluoroscopy. nonionic contrast dye to confirm placement. Move the C-arm Adjust the C-arm to a lateral projection to confirm the into the anteroposterior position and look for the character- position then return the C-arm to the anteroposterior view. istic ‘‘Christmas tree’’ pattern of epidural flow (Fig. 39-15). Remove the stylet. Inject 1 ml of nonionic contrast slowly to If a vascular pattern is seen, reposition the spinal needle and produce a perioneurosheathogram (Fig. 39-14). After an again confirm epidural placement with nonionic contrast adequate dye pattern is observed, inject slowly a 2-ml dye. Once the correct contrast pattern is obtained, inject volume containing 1 ml of 0.75% preservative-free bupiva- slowly a 10-ml volume containing 3 ml of 1% preservative- caine and 1 ml of 6 mg/ml Celestone Soluspan. free Xylocaine without epinephrine, 3 ml of 6 mg/ml The S1 nerve root also can be injected using the Celestone Soluspan, and 4 ml of sterile normal saline. transforaminal approach. Place the patient prone on the pain management table. After appropriate aseptic preparation, ZYGAPOPHYSEAL (FACET) JOINT INJECTIONS direct the C-arm so that the fluoroscopy beam is in a ZYGAPOPHYSEAL (FACET) JOINT INJECTIONS cephalocaudad and lateral-to-medial direction so that the anterior and posterior S1 foramina are aligned. Anesthetize The facet joint can be a source of back pain; the exact cause the soft tissues and the dorsal aspect of the sacrum with 2 to of the pain remains unknown. Theories include meniscoid 3 ml of 1% preservative-free Xylocaine without epineph- entrapment and extrapment, synovial impingement, chondro- rine. Insert a 31⁄2-inch, 22-gauge spinal needle and advance malacia facetae, capsular and synovial inflammation, and it within the anesthetized soft tissue track under fluoroscopy mechanical injury to the joint capsule. Osteoarthritis is another until contact is made with posterior sacral bone slightly cause of facet joint pain; however, the incidence of facet joint lateral and inferior to the S1 pedicle. ‘‘Walk’’ the spinal arthropathy is equal in both symptomatic and asymptomatic needle off the sacrum into the posterior S1 foramen to the patients. As with other osteoarthritic joints, roentgenographic changes correlate poorly with pain.

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C1 g laaj C2vr ton

mb a

Fig. 39-15 Anteroposterior view of caudal epidurogram dem- Fig. 39-16 Proper needle placement for posterior approach to onstrating characteristic contrast flow pattern. C4 and C6 medial branch blocks. Second cervical ganglion (g), third occipital nerve (ton), C2 ventral ramus (C2vr) and lateral atlantoaxial joint (laaj) are noted. (Redrawn from Boduk N: Back Although the history and physical examination may suggest pain: Zygapophyseal blocks and epidural steroids. In Cousins MJ, that the facet joint is the cause of spine pain, no noninvasive Bridenbaugh PO, eds: Neural blockade in clinical anesthesia and pathognomonic findings distinguish facet joint–mediated pain management of pain, ed 2, Philadelphia, 1988, JB Lippincott.) from other sources of spine pain. Fluoroscopically guided facet joint injections therefore are commonly considered the gold standard for isolating or excluding the facet joint as a source of spine or extremity pain. directed fluoroscopy. Each cervical facet joint from C3-4 to Clinical suspicion of facet joint pain by a spine specialist C7-T1 is supplied from the medial nerve branch above and remains the major indicator for diagnostic injection, which below that joint which curves consistently around the should be done only in patients who have had pain for more ‘‘waist’’ of the articular pillar of the same numbered than 4 weeks and only after appropriate conservative measures vertebrae (Fig. 39-16). For example, to block the C6 facet have failed to provide relief. Facet joint injection procedures joint nerve supply, anesthetize the C6 and C7 medial may help to focus treatment on a specific spinal segment and branches. Insert a 22- or 25-gauge, 31⁄2-inch spinal needle provide adequate pain relief to allow progression in therapy. perpendicular to the pain management table and advance it Either intraarticular or medial branch blocks can be used for under fluoroscopic control ventrally and medially until diagnostic purposes. Although injection of cortisone into the contact is made with periosteum. Direct the spinal needle facet joint was a popular procedure through most of the 1970s laterally until the needle tip reaches the lateral margin of the and 1980s, many investigators have found no evidence that this waist of the articular pillar and then direct the needle until effectively treats low back pain caused by a facet joint. The it rests at the deepest point of the articular pillar’s concavity only controlled study on the use of intraarticular corticosteroids under fluoroscopy. Remove the stylet. If there is a negative in the cervical spine found no added benefit from intraarticular aspirate, inject 0.5 ml of 0.75% preservative Marcaine. betamethasone over bupivacaine.

Cervical Facet Joint Lumbar Facet Joint ◆ Medial Branch Block Injection ◆ Intraarticular Injection

TECHNIQUE 39-8 TECHNIQUE 39-9 Place the patient prone on the pain management table. Place the patient prone on a pain management table. Rotate the patient’s neck so that the symptomatic side is Aseptically prepare and drape the patient. Under ﬂuoro- down. This allows the vertebral artery to be positioned scopic guidance, identify the target segment to be injected. farther beneath the articular pillar, creates greater accentu- Upper lumbar facet joints are oriented in the sagittal ation of the cervical waists, and prevents the jaw from being (vertical) plane and often can be seen on direct anteropos- superimposed. Aseptically prepare and drape the side to be terior views, whereas the lower lumbar facet joints, injected. Identify the target location using anteroposterior- especially at L5-S1, are obliquely oriented and require an

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ipsilateral oblique rotation of the C-arm to be seen. Position the C-arm under fluoroscopy until the joint silhouette first appears. Insert and advance a 22- or 25-gauge, 31⁄2-inch spinal needle toward the target joint along the axis of the fluoroscopy beam until contact is made with the articular processes of the joint. Enter the joint cavity through the softer capsule and advance the needle only a few milli- meters. Capsular penetration is perceived as a subtle change of resistance. If midpoint needle entry is difficult, redirect the spinal needle to the superior or inferior joint recesses. a Confirm placement with less than 0.1 ml of nonionic contrast dye with a 3-ml syringe to minimize injection mb pressure under fluoroscopic guidance. Once intraarticular a placement has been verified, inject a total volume of 1 ml of mb injectant (local anesthetic with or without corticosteroids) into the joint.

Fig. 39-17 Posterior view of lumbar spine demonstrating ◆ Medial Branch Block Injection location of medial branches of dorsal rami, which innervate lumbar facet joints (a). Needle position for L3 and L4 medial branch blocks shown on left half of diagram would be used to anesthetize TECHNIQUE 39-10 the L4-5 facet joint. Right half of diagram demonstrates L3-4, Place the patient prone on a pain management table. L4-5, and L5-S1 intraarticular facet joint injection positions. Aseptically prepare and drape the patient. Because there is (Redrawn from Boduk N: Back pain: zygapophyseal blocks and dual innervation of each lumbar facet joint, two medial epidural steroids. In Cousins MJ, Bridenbaugh PO, eds: Neural branch blocks are required. It is important to remember that blockade in clinical anesthesia and management of pain, ed 2, the medial branches cross the transverse processes below Philadelphia, 1988, JB Lippincott.) their origin (Fig. 39-17). For example, the L4-5 facet joint is anesthetized by blocking the L3 medial branch at the transverse process of L4, and the L4 medial branch at the transverse process of L5. In the case of the L5-S1 facet joint, mately 5 mm below the superior junction of the sacral ala anesthetize the L4 medial branch as it passes over the L5 with the superior articular process of the sacrum under transverse process and the L5 medial branch as it passes fluoroscopy. Rest the spinal needle on the periosteum and across the sacral ala. Using anteroposterior fluoroscopic position the bevel of the spinal needle medial and away from imaging, identify the target transverse process. For L1 the foramen to minimize flow through the L5 or S1 foramen. through L4 medial branch blocks, penetrate the skin using a Slowly inject 0.5 ml of 0.75% Marcaine. 22- or 25-gauge, 31⁄2-inch spinal needle lateral and superior to the target location. Under fluoroscopic guidance, advance the spinal needle until contact is made with the dorsal ◆ Sacroiliac Joint superior and medial aspects of the base of the transverse The sacroiliac joint remains a controversial source of primary process so that the needle top rests against the periosteum. low back pain despite validated scientific studies. It often is To ensure optimal spinal needle placement, reposition the overlooked as a source of low back pain because its anatomical C-arm so that the fluoroscopy beam is ipsilateral oblique and location makes it difficult to examine in isolation and many the ‘‘Scotty dog’’ is seen. Position the spinal needle in the provocative tests place mechanical stresses on contiguous middle of the ‘‘eye’’ of the ‘‘Scotty dog.’’ Slowly inject structures. In addition, several other structures may refer pain (over 30 seconds) 0.5 ml of 0.75% Marcaine. to the sacroiliac joint. To inject the L5 medial branch (more correctly, the L5 The sacroiliac joint, like other synovial joints, moves; dorsal ramus), position the patient prone on the pain however, sacroiliac joint movement is involuntary and is management table with the fluoroscopic beam in the caused by shear, compression, and other indirect forces. anteroposterior projection. Identify the sacral ala. Rotate the Muscles involved with secondary sacroiliac joint motion C-arm 15 to 20 degrees ipsilateral obliquely to maximize include the erectae spinae, quadratus lumborum, psoas major exposure between the junction of the sacral ala and the and minor, piriformis, latissimus dorsi, obliquus abdominis, superior process of S1. Insert a 22- or 25-gauge, 31⁄2-inch and gluteal. Imbalances in any of these muscles as a result of spinal needle directly into the osseous landmarks approxi- central facilitation may cause them to function in a shortened state that tends to inhibit their antagonists reflexively.

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Fig. 39-18 Pain diagram. A, Patient reported pain diagram Fig. 39-19 Sacroiliac joint injection showing medial (A) and consistent with sacroiliac joint dysfunction. B, Patient reported lateral (B) joint planes (silhouettes). Entry into joint is achieved diagram inconsistent with sacroiliac joint dysfunction. (From above most posterior-inferior aspect of joint. Fortin JD, Dwyer AP, West S, Pier J: Spine 19:1475, 1994).

Theoretically, dysfunctional movement patterns may result. tory conditions, such as ankylosing spondylitis, psoriatic Postural changes and body weight also can create motion arthritis, and Reiter’s disease. The diagnosis of sacroiliac joint through the sacroiliac joint. pain can be confirmed if symptoms are reproduced upon Because of the wide range of segmental innervation (L2-S2) distention of the joint capsule by provocative injection and of the sacroiliac joint, there is a myriad of referral zone subsequently abated with an analgesic block. patterns. In studies of asymptomatic subjects, the most constant referral zone was localized to a 3 × 10 cm area just inferior to TECHNIQUE 39-11 the ipsilateral posterior superior iliac spine (Fig. 39-18); Place the patient prone on a pain management table. however, pain may be referred to the buttocks, groin, posterior Aseptically prepare and drape the side to be injected. Rotate thigh, calf, and foot. the C-arm until the medial (posterior) joint line is seen. Use Sacroiliac dysfunction, also called sacroiliac joint mechan- a27]-gauge needle to anesthetize the skin of the buttock 1 ical pain or sacroiliac joint syndrome, is the most common to 3 cm inferior to the lowest aspect of the joint. Using painful condition of this joint. The true prevalence of mediated fluoroscopy insert a 31⁄2-inch, 22-gauge spinal needle until pain from sacroiliac joint dysfunction is unknown; however, the needle rests 1 cm above the most posteroinferior aspect several studies indicated that it is more common than expected. of the joint (Fig. 39-19). Rarely, a larger spinal needle is Because no specific or pathognomonic historical facts or required in obese patients. Advance the spinal needle into physical examination tests accurately identify the sacroiliac the sacroiliac joint until capsular penetration occurs. Con- joint as a source of pain, diagnosis is one of exclusion. firm intraarticular placement under fluoroscopy with 0.5 ml However, sacroiliac joint dysfunction should be considered if of nonionic contrast dye. A spot roentgenogram can be taken an injury was caused by a direct fall on the buttocks, a rear-end to document placement. Inject a 2-ml volume containing motor vehicle accident with the ipsilateral foot on the brake at 1 ml of 0.75% preservative-free Marcaine and 1 ml of the moment of impact, a broadside motor vehicle accident with 6 mg/ml Celestone into the joint. a blow to the lateral aspect of the pelvic ring, or a fall in a hole with one leg in the hole and the other extended outside. Lumbar DISCOGRAPHY rotation and axial loading that can occur during ballet or ice DISCOGRAPHY skating is another common mechanism of injury. Although somewhat controversial, the risk of sacroiliac joint dysfunction Discography has been used since the late 1940s for the may be increased in individuals with lumbar fusion or hip experimental and clinical evaluation of disc disease in both the pathology. Other causes include insufficiency stress fractures, cervical and lumbar regions of the spine. Since that time fatigue stress fractures, metabolic processes, such as deposition discography has had a limited but important role in the diseases, degenerative joint disease, infection, and inflamma- evaluation of suspected disc pathology.

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The clinical usefulness of the data obtained from discogra- ing which disc is affected and will require surgery. Discography phy remains controversial. In 1968 Holt published a landmark also may be justified in medicolegal situations to establish a study that showed a 37% false-positive rate. He concluded that definitive diagnosis even though treatment may not be planned lumbar discography was an unreliable diagnostic tool. How- on that disc. ever, Holt’s studies had numerous design flaws, including Compression of the spinal cord, stenosis of the roots, suboptimal imaging equipment, neurotoxic contrast agents, bleeding disorders, allergy to the injectable material, and active inadequate needle placement, and failure to determine if pain infection are contraindications to diagnostic discography responses were concordant or discordant with patients’ typical procedures. Although the risk of complications from discogra- pain patterns. Using modern techniques, Walsh et al. in 1990 phy is low, potential problems include discitis, nerve root published a well-controlled prospective study that, unlike injury, subarachnoid puncture, chemical meningitis, bleeding, Holt’s study, required an abnormal nucleogram and a con- and allergic reactions. In addition, in the cervical region, cordant pain response to indicate a positive provocative retropharyngeal and epidural abscess can occur. Pneumothorax discogram. The investigators of this study found a 0% is a risk in both the cervical and thoracic regions. false-positive rate for discography compared with 37% reported by Holt. These authors concluded that, with current technique and standardized protocol, discography was a highly ◆ Lumbar Discography reliable test. Lumbar discography originally was done using a transdural In independent studies, Cloward and Smith emphasized that technique in a manner similar to myelography with a lumbar reproduction of a patient’s pain was the key feature of cervical puncture. The difference between lumbar myelography and discography. In 1964 Holt reported that cervical discography discography was that the needle used for the latter was had no diagnostic value because pain reproduction and advanced through the thecal sac. The technique later was fissuring were features of cervical discs in normal volunteers. modified, consisting of an extradural, extralaminar approach Later investigative work by Simmons and Segil demonstrated that avoided the thecal sac, and it was refined further to enable the importance of discriminating between painful and nonpain- entry into the L5-S1 disc using a two-needle technique to ful discs, while avoiding pain reproduction and disc morphol- maneuver around the iliac crest. ogy as absolute entities. Carrying this idea further, Roth in 1976 A patient’s response during the procedure is the most introduced analgesic cervical discography with the rationale important aspect of the study. Pain alone does not determine if that once a painful disc is identified, pain relief should occur by a disc is the cause of the back pain. The concordance of the pain injecting a local anesthetic into the disc. He reported a high in regard to the quality and location are paramount in success rate for anterior disc excision and fusion using this determining whether the disc is a true pain generator. A control form of precision diagnostic testing. disc is necessary to validate a positive finding on discography. The most important aspect of discography is provocative testing for concordant pain (that which corresponds to a TECHNIQUE 39-12 (Falco) patient’s usual pain) to provide information regarding the Place the patient on a procedure or fluoroscopic table. Insert clinical significance of the disc abnormality. Although difficult an angiocatheter into the upper extremity and infuse to standardize, this distinguishes discography from other intravenous antibiotics to prevent discitis. Some physicians anatomical imaging techniques. If the patient is unable to prefer to give antibiotics intradiscally during the procedure distinguish customary pain from any other pain, the procedure in lieu of the intravenous route. Place the patient in a is of no value. In patients who have a concordant response modified lateral decubitus position with the symptomatic without evidence of a radial annular fissure on discography, CT side down to avoid having the patient confuse the pain should be considered because some discs that appear normal on caused by the needle with the actual pain on that same side. discography show disruption on CT scan. This position also allows for easier fluoroscopic imaging of Indications for lumbar discography include surgical plan- the intervertebral discs and mobilizes the bowel away from ning of spinal fusion, testing of the structural integrity of an the needle path. Lightly sedate the patient with an intra- adjacent disc to a known abnormality such as spondylolisthesis venous opioid and short-acting benzodiazepine. Prepare and or fusion, identifying a painful disc among multiple degener- drape the skin sterilely, including the lumbosacral region. ative discs, ruling out secondary internal disc disruption or Under fluoroscopic control, identify the intervertebral suspected lateral or recurrent disc herniation, and determining discs. Adjust the patient’s position or the C-arm so that the the primary symptom-producing level when chemonucleolysis lumbar spine is in an oblique position with the superior is being considered. Thoracic discography is a useful tool in the articular process, dividing the intervertebral space in half investigation of thoracic, chest, and upper abdominal pain. (Fig. 39-20). Anesthetize the skin overlying the superior Degenerative thoracic disc disease, with or without herniation, articular process with 1 to 2 ml of 1% lidocaine if necessary. has a highly variable clinical presentation, frequently mimick- Advance a single 6-inch spinal needle (or longer, depending ing visceral conditions, as well as causing back or musculo- on the patient’s size) through the skin and deeper soft tissues skeletal pain. In the cervical spine, discography is an important to the outer annulus of the disc. The disc entry point is just adjunct for diagnosing primary discogenic pain and determin- continued Copyright 2003. Elsevier Science (USA). All Rights Reserved.

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Fig. 39-20 Lumbar spine in an oblique position with superior Fig. 39-21 Disc entry point is just anterior (arrow) to base of articular process (arrow) dividing disc space (d) in half. (Courtesy superior articular process (s) and just above superior endplate of Frank JE Falco, MD) vertebral body. (Courtesy Frank JE Falco, MD)

anterior to the base of the superior articular process and just above the superior endplate of the vertebral body, which allows the needle to safely pass by the exiting nerve root (Fig. 39-21). Advance the needle into the central third of the disc, using anteroposterior and lateral fluoroscopic imaging. Confirm the position of the needle tip within the central third of the disc with anteroposterior and lateral fluoroscopic imaging. Inject either saline or nonionic contrast dye into each disc. Record any pain that the patient experiences during the injection as none, dissimilar, similar, or exact in relationship to the patient’s typical low back pain. Record intradiscal pressures to assist in determining if the disc is the cause of the pain. Obtain roentgenograms of the lumbar spine upon completion of the study, paying particular attention to the contrast-enhanced disc. Obtain a CT scan if necessary to assess disc anatomy further. An alternative method is a two-needle technique in Fig. 39-22 Curved procedure needle (c) passing through straight which a 6- or 8-inch spinal needle is passed through a introducer needle (n). (Courtesy Frank JE Falco, MD) shorter introducer needle (typically 31⁄2 inches in length) into the disc in the same manner as a single needle. This approach may reduce the incidence of infection by allowing the procedure needle to pass into the disc space without ever places the needle tip in a position that does not line up with penetrating the skin. The introducer needle also may assist the L5-S1 disc space, which makes it difficult if not in more accurate needle placement, reducing the risk of impossible for a straight procedure needle to advance into injuring the exiting nerve root. The two-needle approach the L5-S1 disc. A curved procedure needle, on the other may require more time than the single-needle technique, and hand, allows the needle tip to align with the L5-S1 disc as the larger introducer needle could cause more pain to the it is advanced towards and into the disc adjusting for patient. malalignment. The two-needle technique often is used to enter the L5-S1 disc space with one modification. The procedure needle typically is curved (Fig. 39-22). To bypass the iliac ◆ Thoracic Discography crest, the introducer needle is advanced at an angle that Thoracic discography has been refined to provide a technique that is reproducible and safe. A posterolateral extralaminar

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Fig. 39-23 Oblique position with superior articular process Fig. 39-24 Thoracic endplates (e), superior articular process (s), (arrow) dividing thoracic intervertebral space in half. p, Pedicle. and rib head (r) form ‘‘box.’’ (Courtesy Frank JE Falco, MD) r, rib head. (Courtesy Frank JE Falco, MD)

approach similar to lumbar discography is used with a single-needle technique. The significant difference between of 1% lidocaine if necessary. Advance a single 6-inch spinal thoracic and lumbar discography is the potential for complica- needle (a shorter or longer needle can be used, depending on tions because of the surrounding anatomy of the thoracic spine. the patient’s size) through the skin and the deeper soft tissues In contrast to lumbar discography, which typically is performed into the outer annulus within the ‘‘box’’ just anterior to the in the mid to lower lumbar spine below the spinal cord and base of the superior articular process and just above the lungs, thoracic discography has the inherent risk of pneumo- superior endplate. Continue into the central third of the disc, thorax and direct spinal cord trauma; other complications using anteroposterior and lateral fluoroscopic guidance. include discitis and bleeding. Inject either saline or a nonionic contrast dye into each Essentially the same protocol is used for thoracic discogra- disc in the same manner as for lumbar discography. Record phy as for lumbar discography. any pain response and analyze for reproduction of concordant pain using the same protocol as for lumbar TECHNIQUE 39-13 (Falco) discography. Obtain roentgenograms and CT imaging of the Place the patient in a modified lateral decubitus position on thoracic spine upon completion of the study. the procedure table with the symptomatic side down. Begin antibiotics through the intravenous catheter. Alternatively, intradiscal antibiotics may be given during the procedure. ◆ Cervical Discography Lightly sedate the patient and prepare and drape the skin in The approach to the cervical spine is distinctly different from a sterile manner. the approaches used for discography of the lumbar and thoracic Using fluoroscopic imaging, identify the intervertebral spine. The cervical spine is approached anteriorly rather than thoracic discs. Move the patient or adjust the C-arm posteriorly. Complications associated with cervical discogra- obliquely to position the superior articular process so that it phy because of the surrounding anatomy include injury to the divides the intervertebral space in half (Fig. 39-23). At this trachea, esophagus, carotid artery, and jugular veins, as well as point, the intervertebral discs and endplates, subjacent spinal cord injury and pneumothorax. As with lumbar and superior articular process, and adjacent rib head should be in thoracic discography, discitis also is a concern in the cervical clear view. The endplates, the superior articular process, and spine, although the disc infection often originates from the the rib head form a ‘‘box’’ (Fig. 39-24) that delineates a safe gram-negative and anaerobic flora of the esophagus as opposed pathway into the disc, avoiding the spinal cord and lung. to the gram-positive skin flora seen in lumbar discography. Keep the needle tip within the confines of this ‘‘box’’ while Traditionally, the approach to the cervical intervertebral advancing it into the annulus. discs has been via a paralaryngeal route that requires displace- After proper positioning and exposure, anesthetize the ment of the trachea and esophagus away from the site of entry. skin overlying the superior articular process with 1 to 2 ml A more lateral approach that is gaining popularity bypasses these structures and does not require such displacement.

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After needle placement with either technique, the rest of the procedure is essentially the same as that described for thoracic or lumbar discography. Inject either saline or a nonionic contrast dye into each disc. Record any pain response and analyze for concordance using the same protocol employed for lumbar and thoracic discography. Obtain roentgenograms and CT imaging of the cervical spine upon completion of the study.

Psychological Testing Psychological Testing As discussed previously in this section, pain in some patients is the result of nonanatomical causes. Many, but not all, patients report the onset of their symptoms after a work-related incident, Fig. 39-25 Foraminal position for performing cervical discog- which may have been relatively minor. Some patients present raphy with anterolateral approach. f, Foramen; v, vertebral body; acutely, and for these patients treatment as outlined for d, intervertebral disc. (Courtesy Frank JE Falco, MD) nonspecific back pain should be followed. It is known that patients who do not return to work in 6 months are at increased risk for long-term disability. Patients with acute injuries or with history of chronic pain require closer evaluation. Increasing The same protocol for lumbar and thoracic discography is evidence suggests that the preeminence of psychosocial factors used in cervical discography. over physical variables is responsible for prolonged disability. Over the past several decades extensive studies have been TECHNIQUE 39-14 (Falco) done on various evaluation tools for patients with ‘‘abnormal Place the patient supine on the procedure table. Insert an illness behavior.’’ Waddell et al. defined this as ‘‘maladaptive angiocatheter into the upper extremity and begin intrave- overt illness-related behavior which is out of proportion to the nous antibiotic infusion. Alternatively, intradiscal antibiotics underlying physical disease and more readily attributable to can be given during surgery. Sedate the patient and prepare associated cognitive and affective disturbances.’’ Waddell et al. and drape the skin sterilely, including the anterolateral also developed clinical tools designed to detect the presence of aspect of the neck. ‘‘abnormal illness behavior’’ by identifying physical signs or Under fluoroscopic imaging, identify the intervertebral symptoms and descriptions that are nonorganic in nature. Five discs with aligned endplates and sharp margins of the nonorganic signs and seven nonorganic symptom descriptions intervertebral discs. Approach the paralaryngeal area from (Table 39-4) have been identified. Waddell initially described the right, using a finger to displace the esophagus and these for use in patients with chronic pain and suggested that trachea to the left and the carotid artery to the right side. the presence of three signs was required to determine With the other hand, insert a 2- or 31⁄2-inch spinal needle ‘‘abnormal illness behavior.’’ Several studies evaluated the over the finger through the skin and into the outer annulus ability of these signs and symptom descriptions to predict of the disc. Advance the needle into the center of the disc, return to work but have proved inconclusive; nevertheless, they using anteroposterior and lateral fluoroscopic guidance. appear to be useful in detecting patients at increased risk for An alternative method is a more lateral approach to the poor outcome with surgical intervention. cervical spine using a single needle. This approach may The Minnesota Multiphasic Personality Inventory (MMPI) reduce the incidence of infection by passing the needle has been used for psychological assessment in many previous posterior to the trachea and esophagus en route to the disc studies and has been demonstrated to be a reasonable predictor space. Position the patient or the C-arm to place the cervical of surgical and conservative treatment results regardless of the spine in an oblique position for optimal foraminal exposure spinal pathological condition. Unfortunately, the MMPI is and continue adjusting until the endplates, disc space, and lengthy and difficult to administer in an orthopaedic clinical uncovertebral process are in sharp focus (Fig. 39-25). Insert setting and probably is best given by a psychiatrist or a2-or31⁄2-inch needle into the skin and advance it until the psychologist. By comparison, the Distress and Risk Assessment tip makes contact with the subjacent uncovertebral process. Method (DRAM) is relatively easily administered and scored ‘‘Walk off’’ the needle just anterior to the uncovertebral and has been validated in clinical settings with regard to process. Advance the needle into the center of the disc, using patients with back pain. The DRAM consists of the Modified anteroposterior and lateral fluoroscopic guidance. Somatic Perception Questionnaire (MSPQ) and the Zung Depression Index (ZDI). With this simplified method, patients

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Table 39-4 Signs and Symptoms for Table 39-5 Result Expectancy Related Diagnosis of ‘‘Abnormal Illness to Hs and Hy T Scores on the Behavior’’ MMPI Test

Nonorganic Signs Organic Signs Chances of Good or Excellent Regional disturbances A widespread region of sensory Hs and Hy T Number Functional changes or weakness that is Scores of Patients Recovery (%) divergent from accepted neuroanatomy 85 and above 10 10 Superficial/nonanatomical Tenderness of the skin to light 75 to 84 32 16 tenderness touch (superficial) or deep ten- 65 to 74 31 39 derness felt over a widespread 55 to 64 36 72 area not localized to one struc- 54 and below 21 90 ture (nonanatomical) Prediction from 63 48 Simulation base rate Axial loading Low back pain reported with From Wiltse LL, Rocchio PD: J Bone Joint Surg 57A:478, 1975. pressure on the patient’s head while standing Rotation Low back pain reported when the shoulders and pelvis are rotated in the same plane as the patient and well-documented tests used for this purpose. This test is stands predictive of preinjury susceptibility to back injury and the Distraction potential for failure of conservative and surgical treatment. Straight leg raising Inconsistent limitation of straight Wiltse and Rocchio demonstrated that elevations of the hysteria leg raising in supine and seated (Hs) and hypochondriasis (Hy) T scores above 75 are indicative positions of a poor postoperative response (16% good results). Their Overreaction Disproportionate verbalization, study evaluated patients treated with chymopapain, and their facial expression, muscle tension, collapsing, sweating, and clinical results are illustrated in Tables 39-5 and 39-6. so forth during examination Table 39-5 indicates the rate of good or excellent results using the MMPI test Hs and Hy scores alone in the study by Nonorganic Symptom Descriptors Wiltse and Rocchio. Table 39-6 illustrates the lack of statistical 1. Do you get pain in your tailbone? significance between the MMPI scores and the presence of the 2. Do you have numbness in your entire leg (front, side, and following objective findings: reflex changes, motor weakness, back of leg at the same time?) sensory deficits, positive myelogram, positive electromyogram, 3. Do you have pain in your entire leg (front, side, and back and elevated CSF protein. of the leg at the same time?) Similar studies of surgically and conservatively treated 4. Does your whole leg ever give way? patients have had similar findings. Written reports are helpful, 5. Have you had any time during this episode when you have but the raw T score read on the far right or left side of the had very little back pain? standard test result sheet is the simplest guide to postoperative 6. Have you had to go to the emergency room because of outcome. If surgery is necessary in a patient with an elevated back pain? Hs or Hy score, then psychiatric or psychological assistance 7. Has all treatment for your back made your pain worse? before and after the procedure can be helpful, but a poor result From Fritz JM, Wainner RS, Hicks GE: Spine 25:1925, 2000. should be anticipated. Gentry observed a group of patients with objective evidence of psychological disturbance as indicated by the MMPI. Those patients who had surgery were less likely to return to work, less likely to have a reduction in their pain, and identified as psychologically distressed are three to four times more likely to have greater disability than similar patients more likely to have a poor outcome after any form of treatment. who did not have surgery. Wiltse and Rocchio recommended It is our recommendation that some type of formal psycholog- restraint and conservative treatment in these patients. Elevation ical evaluation be used preoperatively in patients who have of the Hs and Hy scores on the MMPI should be a relative chronic pain but no clear cause of their symptoms; whether the contraindication to elective spinal surgery. MMPI or the DRAM is used is less important. Additional material on this test can be found in the excellent The experience at this clinic has been primarily with the articles by Dennis et al., Wiltse and Rocchio, and Southwick MMPI, which we routinely use for assessment of patients who and White. Numerous other tests are available, but none has have symptoms seemingly out of proportion to their anatomical been shown to be as predictive of surgical outcome as the Hs abnormalities and are being evaluated for surgical treatment, and Hy scores on the MMPI. Riley et al. investigated a MMPI-2 especially spinal fusion. The MMPI is one of the most reliable and found that the results replicated those of the older MMPI.

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Table 39-6 Hs and Hy T Scores of Patients with Good or Excellent Results Versus Number of Preexisting Objective Deﬁcits

Percentage with the No. of Preinjection Objective Deﬁcits Indicated* Percentage Good Hs and Hy T scores Number of Patients or Excellent Results 1؉ 2؉ 3؉ 4؉ 5؉

75 and over 42 25 95.0 57.5 30.0 7.5 2.5 64 and below 57 87 95.2 64.4 32.6 8.7 2.2

From Wiltse LL, Rocchio PD: J Bone Joint Surg 57A:478, 1975. *X2 <0.001.

Patients with MMPI and MMPI-2 findings of depressed- anatomical location of cervical disc herniation in 1928 but pathological profile and a conversion V profile reported greater attributed the lesion to a cervical chondroma. Mixter and Barr dissatisfaction with surgical outcome. reported lumbar disc herniation in 1934 and included four Similar outcomes have been noted for nonoperative cervical disc protrusions. treatment of these patients. Gatchel et al. noted similar The classic approach to discs in this region has been problems in patients with acute back pain who were questioned posteriorly with laminectomy. This approach had been used as 6 months later. a standard exposure for extradural tumors. In 1943 Semmes and The main problem with the MMPI is that it requires the Murphey reported four patients in whom cervical disc rupture ability to read and comprehend the material. Pincus et al. also simulated coronary disease and introduced the concept that noted that the MMPI questions may be in line with natural cervical disc disease usually manifested itself in root symptoms disease processes such as rheumatoid arthritis. Patients with and not cord compression symptoms. Bailey and Badgley, chronic diseases may, by the nature of their disease symptoms, Cloward, and Smith and Robinson in the 1950s popularized the have MMPI elevations. Chronic back pain without a specific anterior approach coupled with interbody fusion. Robertson in disease association should not be considered as similar to 1973, after the initial report by Hirsch in 1960, reported anterior chronic disease such as rheumatoid arthritis. Chapman and cervical discectomy without fusion. He showed that simple Pemberton noted that the MMPI failed to predict the subjective anterior disc excision without fusion can give results similar to outcome as reported by patients with chronic back pain who anterior cervical disc excision with anterior interbody fusion. were in an interdisciplinary pain-management program. More recently, Yamamoto et al. reported the long-term (2 to 13 A simple test that is a good screening aid is the pain year) results of anterior cervical disc excision without fusion. drawing. The pain drawing correlates well with the Hs and Hy They noted 81% improvement in patients with soft disc hernias scores. This test also requires some ability to follow simple but only 47% improvement in patients with spondylosis; 49% directions (Fig. 39-26). Additional information can be found in had neck and scapular pain as new postoperative symptoms for the articles by Rainsford, Cairns, and Mooney and by Dennis the first 4 weeks after surgery (Table 39-7). Spontaneous fusion et al. Udeń and Landin found that the pain drawing correlated was noted in 79% at 29 months. Currently, anterior cervical well with clinical results. Ohnmeiss reported that the pain discectomy with fusion is the procedure of choice when the disc drawing remained consistent over 8 months in patients who is removed anteriorly to avoid disc space collapse, prevent reported no change in their symptoms. Also, the intraevaluator painful and abnormal cervical motion, and to speed interver- repeatability was found to be high in this as in other studies. tebral fusion. Foraminotomy is the procedure of choice when Patients with low Rainsford scores were most likely to have the disc fragment is removed posteriorly. definite pathological conditions and those with high Rainsford In an epidemiological study of acute cervical disc prolapse, scores were least likely to have a demonstrable pathological Kelsey et al. indicated that cervical disc rupture was more condition. Cummings and Routan warned that the pain drawing common in men by a ratio of 1.4 to 1. Factors associated with should not be used to identify areas of somatic disturbance in the injury were frequent heavy lifting on the job, cigarette chronic pain patients. smoking, and frequent diving from a board. The use of Cervical Disc Disease vibrating equipment and time spent in motor vehicles were not positively associated with this problem. Participation in sports Cervical Disc Disease other than diving, frequent wearing of shoes with high heels, frequent twisting of the neck on the job, time spent sitting on Herniation of the cervical intervertebral disc with spinal cord the job, and smoking of cigars and pipes were not associated compression has been identified since Key detailed the with cervical intervertebral disc collapse. Horal reported that pathological findings of two cases of cord compression by 40% of the population in Sweden were sometimes affected by ‘‘intervertebral substance’’ in 1838. During the late 1800s and neck pain during their lives. Patients with cervical disc disease early 1900s there were many reports of chondromas of the are also likely to have lumbar disc disease. MRI studies have cervical spine. Stookey described the clinical findings and shown increasing cervical disc degeneration with age.

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Fig. 39-26 A, Pain drawing and corresponding MMPI raw score sheet of patient with ‘‘conversion V’’ who was unrelieved of pain after disc surgery. B, Pain drawing and corresponding MMPI raw score sheet of patient with normal ﬁndings who was relieved of pain after disc surgery.

Table 39-7 Postoperative Neck proceeds, hypermobility of the segment can result in instability or Scapular Pain or degenerative arthritic changes or both. Unlike in the lumbar spine, these hypertrophic changes are predominantly at the Follow-up Soft Spondy- uncovertebral joint (uncinate process) (Fig. 39-27). Hypertro- Period Disc Percentage losis Percentage phic changes eventually develop about the facet joints and 1 month 4/11 36 8/34 53 vertebral bodies. As in lumbar disease, progressive stiffening of 1 year 1/11 9 10/29 34 the cervical spine and loss of motion are the usual result in 2 years 0/10 0 6/24 25 the end stages. Hypertrophic spurring anteriorly occasionally 4 years 0/5 0 4/21 19 results in dysphagia. Kang et al. identiﬁed the production of

From Yamamoto I, Ikeda A, Shibuya N, et al: Spine 16:272, 1991. increased amounts of matrix metalloproteinases, nitric oxide, prostaglandin E2, and interleukin-6 in disc material removed from cervical disc hernias. They suggested that these products The pathophysiology of cervical disc disease is the same as are involved in the biochemistry of disc degeneration. These degenerative disc disease in other areas of the spine. Disc substances also are implicated in pain production. These swelling is followed by progressive annular degeneration. ﬁndings are similar to those in the lumbar spine. Kauppila and Frank extrusion of nuclear material can occur as a complication Penttila reported the presence of degenerative changes in the of this normal degenerative process. Kramer postulated that common arteries that supply the cervicobrachial area, and they hydraulic pressure on the disc rather than excessive motion suggested that impaired blood ﬂow may play a part in produces traumatic disc herniation. As the disc degeneration cervicobrachial disorders.

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C2-3

C3-4 C4-5 A C5-6

C6-7

Fig. 39-28 Composite map of the results in all volunteers depicting characteristic distribution of pain from facet joints at segments C2-3 to C6-7. (Redrawn from Dwyer A, Aprill C, Bogduk N: Spine 15:456, 1990.) B

control to the point of pain production, a topographical map was produced. Although the number of volunteers was small, the ﬁndings were consistent (Fig. 39-28). The second stage of the study included a small number of patients who had Fig. 39-27 A, Comparison of points at which nerve roots emerge therapeutic injections based on the location of their pain, as it from cervical and lumbar spine. B, Cross-sectional view of cervical related to the previously constructed pain map. Pain relief spine at level of disc (D). Uncinate process (U) forms ventral wall occurred immediately and completely in 9 of 10 patients who of foramen. Root (N) exits dorsal to vertebral artery (A). (A from had had prior evaluation and failed other treatments. These pain Kikuchi S, Macnab I, Moreau P: J Bone Joint Surg 63B:272, patterns are not predicted by accepted dermatomal maps. 1981.) Symptoms of root compression usually are associated with pain radiating into the arm or chest with numbness in the ﬁngers and motor weakness. Cervical disc disease also can SIGNS AND SYMPTOMS mimic cardiac disease with chest and arm pain. Usually the radicular symptoms are intermittent and combined with the The signs and symptoms of intervertebral disc disease are best more frequent neck and shoulder pain. separated into symptoms related to the spine itself, symptoms The signs of midline cervical spinal cord compression related to nerve root compression, and symptoms of myelopa- (myelopathy) are unique and varied. The pain is poorly thy. Several authors reported that, when the disc is punctured localized and aching in nature; pain may be only a minor anteriorly for the purpose of discography, pain is noted in the complaint. Occasional sharp pain or generalized tingling may neck and shoulder. Complaints of neck pain, medial scapular be described with neck extension. This is not unlike the pain, and shoulder pain are therefore probably related to Lhermitte sign in multiple sclerosis. The pain can be in both the primary pain about the disc and spine. Anatomical studies have shoulder and pelvic girdles; it is occasionally associated with a indicated cervical disc and ligamentous innervations. This has generalized feeling of weakness in the lower extremities and a been inferred to be similar in the cervical spine to that of the feeling of instability. lumbar spine with its sinu-vertebral nerve. Tamura noted In patients with predominant cervical spondylosis, symp- cranial symptoms such as headache, vertigo, tinnitus, and toms of vertebral artery compression also may be found. These ocular problems associated with C3-4 root sleeve defects on symptoms consist of dizziness, tinnitus, intermittent blurring of myelography. Dwyer, Aprill, and Bogduk completed a two- vision, and occasional episodes of retroocular pain. stage investigation of the facet joints of the cervical spine as The signs of lateral root pressure from a disc or osteophytes possible sources of pain. By injecting contrast medium into are predominantly neurological (Boxes 39-2 to 39-6). By the facet joints of normal volunteers under roentgenographic evaluating multiple motor groups, multiple levels of deep

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BOX 39-2 • C5 Nerve Root Compression* BOX 39-5 • C8 Nerve Root Compression*

Sensory Deficit Sensory Deficit Upper lateral arm and elbow Ring finger, little finger, and ulnar border of palm

Motor Weakness Motor Weakness Deltoid Interossei Biceps (variable) Finger flexors (variable) Flexor carpi ulnaris (variable) Reflex Change Biceps (variable) Reflex Change None *Indicative of C4-5 disc rupture or other pathological condition at that level. *Indicative of C7-T1 disc rupture or other pathological condition at that level.

BOX 39-3 • C6 Nerve Root Compression* BOX 39-6 • T1 Nerve Root Compression*

Sensory Deficit Sensory Deficit Lateral forearm, thumb, and index finger Medial aspect of elbow

Motor Weakness Motor Weakness Biceps Interossei Extensor carpi radialis longus and brevis Reflex Change Reflex Change None Biceps Brachioradialis *Indicative of T1-2 disc rupture or other pathological condition at that level. *Indicative of C5-6 disc herniation or other local pathological condition at that level. diminished with injury to this nerve root, although it also has a C6 component, and this must be considered. Sensory testing BOX 39-4 • C7 Nerve Root Compression* should show a patch on the lateral aspect of the proximal arm to be diminished (Fig. 39-29). Sensory Deficit Rupture of the C5-6 disc with compression of the C6 root Middle finger (variable because of overlap) can be confused with other root levels because of dual innervation of structures. Weakness may be noted in the biceps Motor Weakness Triceps and extensor carpi radialis longus and brevis. As mentioned Wrist flexors (flexor carpi radialis) above, the biceps is dually innervated by C5 and C6, whereas Finger flexors (variable) the long extensors are dually innervated by C6 and C7. The brachioradialis and biceps reflexes also may be diminished at Reflex Change this level. Sensory testing usually indicates a decreased Triceps sensibility over the lateral proximal forearm, thumb, and index

*Indicative of C6-7 disc rupture or other pathological condition at that finger. level. Rupture of the C6-7 disc with compression of the C7 root frequently results in weakness of the triceps. Weakness of the wrist flexors, especially the flexor carpi radialis, also is more tendon reflexes, and sensory abnormalities, the level of the indicative of C7 root problems. Extensor digitorum communis lesion can be localized as accurately as any other lesion in the weakness also can indicate C7 root involvement and may be nervous system. The multiple innervation of muscles can more readily apparent because of the normal relative weakness sometimes lead to confusion in determining the exact root of this muscle compared to the triceps. Weakness of the flexor involved. For this reason, myelography or other studies done carpi ulnaris usually is caused more by C8 lesions. As for roentgenographic confirmation of the clinical impression mentioned above, finger extensors also may be weakened in usually are helpful. that they have both C7 and C8 innervation. The triceps reflex Rupture of the C4-5 disc with compression of the C5 nerve may be diminished. Sensation is lost in the middle finger. C7 root should result in weakness in the deltoid and biceps sensibility is variable because it is so narrow and overlap is muscles. The deltoid is almost entirely innervated by C5, but prominent. Strong sensibility change can be difficult to the biceps has dual innervation. The biceps reflex may be document.

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Fig. 39-29 C5 neurological level. (After Hoppenfeld S: Physical examination of the spine and extremities, Norwalk, Conn, 1976, Appleton- Century-Crofts.)

Rupture between C7 and T1 with compression of the C8 Metzmaker described the shoulder abduction relief sign. This nerve root results in no reflex changes. Weakness may be noted can be helpful in the diagnosis of cervical root compression in the finger flexors and in the interossei of the hand. Sensibility syndromes. The test consists of shoulder abduction and elbow is lost on the ulnar border of the palm, including the ring and flexion with placement of the hand on the top of the head. This little fingers. Compression of T1 produces weakness of the should relieve the arm pain caused by radicular compression. It interosseus muscles, decreased sensibility about the medial is interesting to note that if this position is allowed to persist for aspect of the elbow, and no reflex changes. a minute or two and pain is increased, then more distal The clinical series of Odom, Finney, and Woodhall noted compressive neuropathies such as a tardy ulnar nerve syndrome considerable variability in the level of compression and the (cubital tunnel syndrome) or primary shoulder pathological neurological findings. Change in the triceps reflex was the conditions often are the cause. Viikari-Juntura, Porras, and predominant reflex change with compression of the sixth Laasonen noted that the shoulder abduction, axial compression, cervical root (56%). It also was the predominant reflex change and manual axial traction tests are related to disc disease, but in seventh root compression (64%). Similarly the index finger the sensitivity of these tests is low. was the predominant digit with sensory change, with evidence Cervical paraspinal spasm and limitation of neck motion are of hypalgesia in both sixth (68%) and seventh (70%) cervical frequent findings of cervical spine disease but are not indicative root compression. of a specific pathological process. Special maneuvers involving Care should be taken in the examination of the extremity neck motion can be helpful in the selection of conservative when radicular problems are encountered to rule out more treatment and identification of pathological processes. The distal compression syndromes in the upper extremities such as distraction test, which involves the examiner placing his hands thoracic outlet syndrome, carpal tunnel syndrome, and cubital on the occiput and jaw and distracting the cervical spine in the tunnel syndrome. The lower extremities should be examined neutral position, can relieve root compression pain but also can with special attention to long tract signs indicative of increase pain caused by ligamentous injury. Neck extension and myelopathy. flexion with or without traction can be helpful in selecting No tests for the upper extremity correspond with straight conservative therapies. leg raising tests in the lower extremity. Davidson, Dunn, and Patients relieved of pain with the neck extended, with or

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 32/74 Pg: 1986 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 1987 without traction, usually have hyperextension syndromes with Odom et al. reported that most of the soft disc herniations in ligamentous injury posteriorly, whereas patients relieved of their series occurred at the sixth cervical interspace (70%) and pain with distraction and neck flexion are more likely to have fifth cervical interspace (24%). Only six occurred at the seventh nerve root compression caused by either a soft ruptured disc or interspace. Foraminal spurs also were found predominantly at most likely hypertrophic spurs in the neural foramina. Pain the sixth interspace (48%). The fifth interspace (39%) and usually is increased in any condition with compression. One seventh interspace (13%) accounted for the remaining levels must be careful before applying compression or distraction to where foraminal spurs were found. They also noted the be sure no cervical instability or fracture is present. One must incidence of medial soft disc protrusion with myelopathy to be also be careful in interpreting the distraction test to be certain rare (14 of 246 patients). the temporomandibular joint is not diseased or injured because Disc material sometimes is extruded into the midline of the distraction also will increase the pain in this area. spinal canal anteriorly, with compression of the spinal cord and The signs of midline disc herniation are those of spinal cord without nerve root involvement. Occasionally this is caused compression. If the lesion is high in the cervical region, by a violent injury to the cervical spine, with or without paresthesias, weakness, atrophy, and occasionally fascicula- fracture-dislocation, and at times it is associated with imme- tions may occur in the hands. Also present may be a Hoffman’s diate quadriplegia. However, in some instances the symptoms sign (upper cervical spinal cord) or the inverted radial reflex are progressive and may be suggestive of spinal cord tumor or (typically indicating C5-6 pathology). Most commonly, how- degenerative diseases of the spinal cord, such as amyotrophic ever, the first and most prominent symptoms are those of lateral sclerosis, posterolateral sclerosis, and multiple sclerosis. involvement of the corticospinal tract; less commonly the In most of these ailments no block of the spinal canal has been posterior columns are affected. The primary signs are sustained reported, and for many years the mechanism causing the clonus, hyperactive reflexes, and the Babinski reflex. Lesser cervical cord compression was not understood. However, in the findings are varying degrees of spasticity, weakness in the legs, rare patients whom we have observed, spinal fluid block could and impairment of proprioception. Equilibrium may be grossly be produced by hyperextending the neck, although with the disturbed, but sense of pain and temperature sense rarely are neck in the neutral or flexed position the canal was completely lost and usually are of little localizing value. open. This finding has been previously reported. It has since DIFFERENTIAL DIAGNOSIS been observed that during operation on such patients when the DIFFERENTIAL DIAGNOSIS neck is hyperextended, the superior edge of the lamina compresses the cord against the herniated disc, and it is The differential diagnosis of cervical disc disease is best therefore probable that repeated hyperextension of the neck separated into extrinsic and intrinsic factors. Extrinsic factors over a period of weeks, months, or years gradually damages the generally include disease processes extrinsic to the neck spinal cord. resulting in symptoms similar to primary neck problems. In view of the disturbances of the spinal fluid dynamics just Included in this group are tumors of the chest, nerve mentioned, jugular compression should be carried out during compression syndromes distal to the neck, degenerative lumbar puncture with the neck in the flexed, neutral, and processes such as shoulder and upper extremity arthritis, hyperextended positions. Roentgenographically there is more temporomandibular joint syndrome, and lesions about the often than not little or no alteration in the cervical curve. MRI shoulder such as acute and chronic rotator cuff tears and usually demonstrates the abnormality without the need for impingement syndromes. Intrinsic problems primarily consist myelography. of lesions directly associated with the cervical spine, the most CONFIRMATORY TESTING common being cervical disc degeneration with a concomitant CONFIRMATORY TESTING complication of disc herniation and later development of hypertrophic arthritis. Congenital factors such as spinal Roentgenographic evaluation of the cervical spine frequently stenosis in the cervical region also may produce symptoms. shows loss of normal cervical lordosis. Disc space narrowing Primary and secondary tumors of the cervical spine and and hypertrophic changes frequent increase with age but are not fractures of the cervical vertebrae also should be considered as indicative of cervical disc rupture. Usually roentgenograms intrinsic lesions. are most helpful to rule out other problems. Oblique roent- Cervical disc disease has been categorized by Odom et al. genograms of the cervical spine may reveal foraminal into four groups: (1) unilateral soft disc protrusion with nerve encroachment. root compression, (2) foraminal spur, or hard disc, with nerve MRI of the cervical spine has rapidly become the major root compression, (3) medial soft disc protrusion with spinal diagnostic procedure for neck, arm, and shoulder symptoms. cord compression, and (4) transverse ridge or cervical Maruyama evaluated the cervical discs in 36 cadavers using spondylosis with spinal cord compression. Soft disc herniations MRI and anatomical dissection and concluded that degenera- usually affect one level, whereas hard disc herniations can tion appeared to parallel T2 low intensity, but the incidence of affect multiple levels. Central lesions usually result in cord false-positive posterior protrusion on MRI was remarkably compression symptoms, and lateral lesions usually result in high. MRI should confirm the objective clinical findings. radicular symptoms. Asymptomatic findings should be expected to increase with the

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 33/74 Pg: 1987 Team: 1988 PART XII ◆ The Spine age of the patient. Cervical myelography usually is indicated cervical spine and associated musculature is to support and only after noninvasive evaluation by MRI fails to reveal the mobilize the head while providing a conduit for the nervous cause or level of the lesion. If MRI is inconclusive, system. The forces on the cervical spine are therefore much electromyography or nerve conduction velocity may be smaller than on the lower spinal levels. The cervical spine is indicated to demonstrate active radiculopathy before proceed- vulnerable to muscular tension forces, postural fatigue, and ing with myelography, especially if the history and physical excessive motion. Most nonoperative treatments focus on one examination are not strongly supportive of the presence of or more of these factors. The best primary treatment is short radiculopathy. Cervical myelography usually is more precise periods of rest, massage, ice, and antiinflammatory agents with than lumbar myelography, regardless of the contrast medium active mobilization as soon as possible. The position of the used. Postmyelogram CT scanning with block imaging and thin neck for comfort is essential for relief of pain. The position of cuts is very helpful. greatest relief may suggest the offending pathological process Cervical discography is a highly controversial technique or mechanism of injury. Patients with hyperflexion injuries with limited benefits. It is not indicated in frank disc rupture, usually are more comfortable with the neck in extension over spondylosis, or spinal stenosis. The primary use is in patients a small roll under the neck. No specific position is indicative of with persistent neck pain without localized neurological lateral disc herniation, although most tolerate the neutral findings in whom standard MRI, myelographic, and CT scan position best. Patients with spondylosis (hard disc) are most studies are negative. Some investigators maintain that isolated comfortable with the neck in flexion. painful discs can be identified in some patients by discography. Cervical traction can be helpful in selected patients. Care Certainly a degenerative disc without pain on injection is not must be exercised in instructing the patient in the proper use of the source of the patient’s complaint. Cervical discography the traction. It should be applied to the head in the position of requires considerable care and caution. It should be considered maximal pain relief. Traction never should be continued if it a preoperative test in those patients in whom an anterior disc increases pain. The weights should rarely exceed 10 pounds excision and interbody fusion are considered for primary neck (weight of the head). The proper head halter and duration of and shoulder pain. Assessing the psychosocial well-being of a traction sessions should be chosen to prevent irritation of the patient is recommended before proceeding with surgical temporomandibular joint. Traction applied by a patient- treatment. Great care is required both in the technique and controlled pneumatic force, which is more mobile than interpretation if reproducible results are desired. Cervical root halter-type units, avoids irritation of temporomandibular joint. blocks also have been suggested for the localization and Traction also should allow general relaxation of the patient. confirmation of symptomatic root compression when used in ‘‘Poor man’s’’ traction is a simple method of evaluating the conjunction with cervical discography. Facet joint injections efficacy of cervical traction. It uses the weight of the also should be considered before fusion as a therapeutic as well unsupported head for the traction weight (about 10 pounds). as diagnostic procedure. For extension traction, the patient is supine and the head is allowed to gently extend off the examining table or bed. For Myelography flexion the same procedure is repeated in the prone position. When a component of dynamic cord compression is present, The patient continues the exercise in the position that is most myelography remains a valuable tool, although dynamic MRI comfortable for 5 to 10 minutes several times daily. has reduced the role of myelography. Myelography is The postural aspects of neck pain can be treated with more performed in the same way as for ruptured lumbar discs except frequent changes in position and ergonomic changes in the that considerable attention must be paid to the flow of the work area to prevent fatigue and encourage good posture. column of contrast medium with the neck in hyperextended, Techniques to minimize or relieve tension also are helpful. neutral, and flexed positions. One cannot conclude that spinal Cervical braces usually limit excessive motion. Like trac- cord compression is not present until one is certain that the tion, they should be tailored to the most comfortable neck cephalad flow of the medium is not obstructed with the neck position. They may be most helpful for patients who are very acutely hyperextended. The neck should be hyperextended active. carefully because of the danger of further damage to the Neck and shoulder exercises are most beneficial as the acute spinal cord. pain subsides. Isometric exercises are helpful in the acute NONOPERATIVE TREATMENT phase. Occasionally, shoulder problems such as adhesive NONOPERATIVE TREATMENT capsulitis may be found concomitantly with cervical spondylosis; therefore complete immobilization of the painful As discussed earlier, most patients with symptomatic cervical extremity should be avoided. disc herniations respond well to nonoperative treatment, OPERATIVE TREATMENT including some patients with nonprogressive radicular weak- OPERATIVE TREATMENT ness. Reasonably good evidence shows that acute disc herniations actually decrease in size over time in the cervical The primary indications for operative treatment of cervical disc region. Many conservative treatment methods for neck pain are disease are (1) failure of nonoperative pain management, used for multiple diagnoses. The primary purpose of the (2) increasing neurological deficit, and (3) cervical myelopathy

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 34/74 Pg: 1988 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 1989 that will predictably progress, based on natural history studies. In most patients the persistence of pain is the primary cephalad edge of the lateral portion of the caudal lamina is indication. Intuitively, the level of persistent pain should be needed. Only a small amount of the medial portion of the severe enough to consistently interfere with the patient’s facet needs to be removed in most patients. A small Kerrison desired activity and greater than would reasonably be expected rongeur (1 to 2 mm) can be used to enlarge this keyhole as after operative treatment. The choice of approach should be needed. Sharply excise the ligamentum flavum with a small determined by the position and type of lesion. Soft lateral discs Kerrison rongeur and identify the nerve root, which is are easily removed from the posterior approach, whereas soft commonly displaced posteriorly and flattened by pressure central or hard discs (central or lateral) probably are best treated from the underlying disc fragments. Removal of additional with an anterior approach. Any controversy that existed relative bone along the dorsal aspect of the foramen and immedi- to the need for fusion with anterior discectomy essentially has ately above and below the nerve root often is beneficial at been resolved with long-term follow-up studies of patients this point. Once the bony removal has been completed, we without fusion, such as that by Yamamoto et al. mentioned prefer to use the operative microscope for the remainder of previously. Osteophytes that were not removed at surgery have the procedure. This allows more delicate work around the been shown frequently to be reabsorbed at the level of fusion. neural elements while minimizing additional bone removal The use of a graft also prevents the collapse of the disc space and allows better hemostasis. and maintains adequate foraminal size. The herniated nucleus pulposus most often lies slightly caudal to the center of the nerve root but occasionally cephalad. Gently retract the nerve root superiorly to expose ◆ Removal of Posterolateral Herniations the extruded nuclear fragments or a distended posterior by Posterior Approach (Posterior Cervical longitudinal ligament. The nerve root should not be Foraminotomy) retracted in a caudal direction. If additional exposure is needed, remove more bone rather than risk nerve root or TECHNIQUE 39-15 spinal cord injury from traction on the root. To control With the patient under general endotracheal anesthesia in troublesome venous oozing at this point use bipolar cautery the prone position and the face in a Mayfield positioner, flex if possible. Otherwise, place tiny pledgets of cotton and the neck to obliterate the cervical lordosis as much as thrombin-soaked Gelfoam above and below the nerve root. possible. The upright position for surgery decreases venous Take care not to pack the pledgets tightly around the nerve. bleeding, but concern regarding the possibility of air The nerve root then can be retracted slightly in a cephalad embolism and cerebral hypoxia in the event of a significant direction to allow incision of the posterior longitudinal drop in blood pressure makes us reluctant to recommend its ligament over the herniated nucleus pulposus in a cruciate use. Usually a slight reverse Trendelenburg position works manner to permit the removal of the disc fragments. well in posterior cervical surgery coupled with careful After removal of all visible loose fragments, it is dissection to minimize bleeding. The shoulders are retracted imperative to make a thorough search for additional inferiorly with tape if roentgenograms of the lower cervical fragments, both laterally and medially. It is equally levels are contemplated. important to be sure that the nerve root is thoroughly Appropriately prepare and drape the operative field. decompressed by inserting a probe in the intervertebral Make a midline incision 2.5 cm lower than the interspace to foramen. If the nerve root still seems to be tight, remove be explored (Fig. 39-30). Retract the edges of this incision more bone from the articular facets until the nerve root is and the skin will withdraw in a cephalad direction so that the completely free. Since recurrence is so rare, do not curet wound becomes properly placed. Divide the ligamentum the intervertebral space. Remove any cotton pledgets and nuchae longitudinally to expose the tips of the spinous Gelfoam after meticulous hemostasis has been achieved. processes above and below the designated area. The correct Hemostasis must be complete because postoperative hem- position is reasonably well ensured by palpation of the last orrhage can produce cord compression and quadriplegia. bifid spine, which usually is the sixth cervical vertebra. Close the wound by suturing the fascia to the supraspinous However, it should be verified intraoperatively by a marker ligament with interrupted sutures and then suturing the attached to the spinous process and documented on the subcutaneous layers and skin. lateral cervical spine roentgenogram. Dissect subperiosteally the paravertebral muscles from the laminae on the side of the lesion and retract them with a self-retaining AFTERTREATMENT. Neurological function is closely mon- retractor or with the help of an assistant using a Hibbs itored after surgery. Discharge is permitted when the patient can retractor. walk and void. Pain should be controlled with oral medication. With a small high-speed drill, grind away the caudal edge Currently most patients are discharged within 24 hours after of the lateral portion of the lamina cephalad to the surgery. Radicular pain relief usually is dramatic and prompt, interspace. Usually minimal bone removal from the although hypesthesia can persist for weeks or months. The patient is allowed to return to clerical work when comfortable

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A B C

E F

Fig. 39-30 Technique of removal of disc between fifth and sixth cervical vertebrae. A, Midline incision extending from spinous process of fourth cervical vertebra to that of first thoracic vertebra. B, Paraspinal muscles have been dissected from laminae and retracted laterally. Hole is to be drilled with Hudson burr (see text). C, Ligamentum flavum is being dissected. D, Defect measuring about 1.3 cm has been made (see text) to expose nerve root and lateral aspect of dura. E, Nerve root has been separated from nucleus and retracted superiorly to expose herniated disc. F, Longitudinal ligament has been incised, and loose fragment of nucleus is being removed.

and to manual labor after 6 weeks. As a rule, neither support nor soft extrusions on the opposite side at another level, also physical therapy is necessary, and the patient’s future activity is requiring a second operation. not restricted. Isometric neck exercises, upper extremity range- Murphey, Simmons, and Brunson analyzed the results in a of-motion exercises, and posterior shoulder girdle exercises can series of 150 patients who returned questionnaires concerning be useful for patients in whom atrophy or inactivity has been the success or failure of the operation. They were asked to state considerable. A soft cervical collar can help relieve immediate the percentage of benefit they derived from the procedure postoperative pain. (Table 39-8), whether they were performing the same work as they had done preoperatively, and if not, whether the change of Results. In few if any operations in orthopaedic surgery are work had resulted from neck trouble. Approximately 90% had the results better than after the removal of a lateral herniated extremely good results, and there were none who were not cervical disc. In the series of 250 operations reported by significantly improved, as the data concerning work done Simmons there were no deaths or major complications confirm. Only 7 (6%) of the 125 patients who answered this involving the brain or spinal cord. Three patients had reflex part of the questionnaire found a change of work necessary sympathetic dystrophy postoperatively. Two of these com- because of neck trouble. pletely recovered and one almost so. Two patients continued to have arm pain after operation and were reexplored during the Anterior Approach to Cervical Disc initial hospital stay; in each, several more fragments of disc Smith and Robinson in 1955 were the first to recommend were found and removed. It is assumed that these fragments an anterior approach to the cervical spine in the treatment were overlooked at the initial operation. One patient had a of cervical disc disease. They described an anterolateral recurrent extrusion at the same level. Two other patients had discectomy with interbody fusion (Fig. 39-31). This pro-

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Table 39-8 Results of Removal of Lateral Type I (50.9) KP/cm2 Herniated Discs in Cervical Region (Patient’s Estimate of Percent Improvement) A

Patients Number Relief (%) Improved (%) of Patients Anteroposterior Lateral 95-100 65.3 98 90-94 23.3 35 Type II (41.6) KP/cm2 75-89 8.0 12 50-74 3.3 5 Total 100.0 150 B Murphey F, Simmons JCH, Brunson B: J Neurosurg 38:679, 1973. Anteroposterior Lateral

2 cedure attained widespread acceptance and application after Type III (35.2) KP/cm Cloward in 1958 modified the procedure and introduced new instrumentation. Three basic techniques are used for anterior cervical disc C excision and fusion. The Cloward technique involves making a round hole centered at the disc space. A slightly larger, round Anteroposterior Lateral iliac crest plug is then inserted into the disc space hole. The Smith-Robinson technique involves inserting a tricortical plug of iliac crest into the disc space after removing the disc and cartilaginous endplate. The graft is inserted with the cancellous side facing the cord (posterior). Bloom and Raney modified this technique by fashioning the tricortical graft to be thicker in its midportion and then inserting the graft with the cancellous D portion facing anteriorly. The Bailey-Badgley technique involves the creation of a slot in the superior and inferior vertebral bodies. This technique is most applicable to reconstruction when one or more vertebral bodies are excised for tumor, stenosis, or other extensive pathological conditions. Fig. 39-31 Types of anterior cervical fusion. A, Smith-Robinson Simmons and Bhalla modified this technique by using a fusion. B, Cloward fusion. C, Bailey-Badgley fusion. D, Bloom- keystone graft that increases the surface area of the graft by Raney modification of Smith-Robinson fusion. (A to C redrawn 30% and allows more complete locking of the graft. Bio- from White AA, Jupiter J, Southwick WO, Panjabi MM: Clin mechanically, the Smith-Robinson technique provides the Orthop 91:21, 1973; D redrawn from Bloom MH, Raney FL: greatest stability and least risk of extrusion, compared to the J Bone Joint Surg 63A:602, 1981.) Cloward or Bailey-Badgley type fusions. White et al. reported relief of pain in 90% of 65 patients undergoing anterior cervical spine fusion for spondylosis with who use it to be a significant deterrent to choosing this the technique of Smith and Robinson. Analysis of 90 patients exposure. Exposure from the left is more inconvenient for a with anterior cervical discectomies and fusion for cervical right-handed surgeon but decreases the risk of recurrent spondylosis with radiculopathy using the Cloward technique laryngeal nerve injury. This nerve on the left consistently showed good or excellent results in 82% in the study by Jacobs, descends with the carotid sheath and exits from the carotid Krueger, and Levy. These investigators did not use discogra- sheath and vagus nerve intrathoracically. The nerve then phy. Others also have found that discography does not courses under the arch of the aorta and ascends in the neck statistically improve the results. The Smith-Robinson technique beside the trachea and esophagus. The course of the nerve on is used almost exclusively at this clinic for anterior cervical the right is not as consistent. The nerve usually descends with discectomy procedures. the carotid sheath and then loops around the subclavian artery The choice of right- or left-sided approach to the cervical and ascends between the trachea and esophagus. Occasionally spine is somewhat controversial. The right side of the neck is the right recurrent laryngeal nerve exits the carotid sheath early preferred by some right-handed surgeons because of the ease of and crosses anteriorly behind the thyroid. A large series of dissection. The reported increased risk of recurrent laryngeal anterior cervical procedures implicated the endotracheal tube nerve trauma when operating on the right is not judged by those in combination with self-retaining retractors as the cause of

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 37/74 Pg: 1991 Team: 1992 PART XII ◆ The Spine recurrent laryngeal nerve injuries. The recommendation made was to deflate the cuff of the endotracheal tube after retractor processes of the upper and lower vertebrae (Fig. 39-32, B). placement to allow the tip of the tube to reposition itself. This Expose the vertebral artery anterior to the C7 transverse significantly decreased the incidence of recurrent laryngeal process. When operating at C6-7 take care not to injure the nerve palsy in a series of 600 patients. See Chapter 36 for a vertebral artery while removing the medial portion of complete description of anterior cervical discectomy and the longus colli muscle. For operations above C6-7, the fusion. vertebral artery is not exposed purposely at this point. Anterior Foraminotomy. Recently there have been several Once the medial parts of the transverse processes of reports of microsurgical anterior foraminotomy to treat the upper and lower vertebrae have been identified, the unilateral foraminal nerve compression from soft disc hernia- ipsilateral uncovertebral joint between them can be seen. tions or uncovertebral joint degenerative change. Verbiest first The interface of the uncovertebral joint is angled approxi- described this technique; Jho reported a modification, and mately 30 degrees cephalad from the horizontal line of the Johnson reported a small clinical series. This technique appears intervertebral disc. Make a sharp vertical incision of the disc to allow adequate decompression of the ventral aspect of the at the medial margin of the ipsilateral uncovertebral joint to foramen unilaterally while removing the lateral portion of the prevent inadvertent internal disruption of the remaining disc, thus preserving the remaining disc. The long-term results disc. While drilling the bone, repeated sharp cutting of the are not yet available to compare this technique with anterior deeper disc may be required. Remove the thin layer of disc discectomy with fusion. We do not have any clinical experience material located at the uncovertebral joint. with this technique. Drill between the transverse processes of the uncovertebral joint using a high-speed microdrill attached to an angled handpiece (Fig. 39-32, B). To prevent injury to the vertebral ◆ Microsurgical Anterior Cervical Foraminotomy artery, leave the thin cortical bone attached to the ligamentous tissue covering the medial portion of this artery. TECHNIQUE 39-16 (Jho) Continue drilling down to the posterior longitudinal liga- After anesthesia has been administered by means of ment (Fig. 39-32, C). While drilling posteriorly, gently endotracheal intubation, place the patient supine, with a incline medially. When the posterior longitudinal ligament bolster placed behind both shoulders to maintain gentle is exposed, a piece of thin cortical bone remains attached extension of the cervical spine. Position the head with the lateral to the ligamentous tissue covering the vertebral midline upright. Gently pull both shoulders caudally and fix artery. Dissect the lateral remnant of the uncinate process with tape for a good lateral view of the cervical spine on from the ligamentous tissue and fracture it at the base of the intraoperative roentgenogram. Do not use a cervical traction uncinate process (Fig. 39-32, D). Further dissect it from the device. Prepare the anterior neck with antiseptic solution surrounding soft tissue and remove it. The vertebral artery and drape. can be identified by its pulsation between the transverse Make a 3- to 5-cm long transverse incision in a skin processes of the vertebrae. Drilling at the base of the crease ipsilateral to the radiculopathy. The first two thirds uncinate process must proceed cautiously because the nerve of the incision should be medial to the sternocleidomas- root lies just behind it. After the uncinate process becomes toid muscle and the remainder should be lateral to the loosened at its base, remove the remaining thin bone of the medial border of that muscle. Incise the subcutaneous uncinate process by fracturing it from its base rather than by tissue and platysma muscle along the line of the skin continued drilling. Once the remaining piece of uncinate incision. Cleanly undermine the loose connective tissue process is removed, the compressed nerve root will be layer under the platysma muscle to provide space in which distended forward by bone decompression (Fig. 39-32, E). to work. Use a combination of sharp and blunt dissection The size of the hole that is made by drilling at the to access the anterior column of the cervical spine. Keep uncovertebral joint usually is approximately 5 to 8 mm wide the carotid artery and the sternocleidomastoid muscle transversely and 7 to 10 mm wide vertically. If there is no lateral and the strap muscle, trachea, and esophagus ruptured herniated disc fragment behind the posterior medial. Open the prevertebral fascia and expose the anterior longitudinal ligament, this will end the nerve root column of the cervical spine. Confirm the correct level decompression. roentgenographically. At this point the posterior longitudinal ligament still Use an anterior cervical discectomy retractor system to covers the nerve root and the lateral margin of the spinal expose the ipsilateral longus colli muscle (Fig. 39-32, A). cord. If the disc fragment has ruptured through the posterior Use only smooth-tipped retractor blades to avoid injury to longitudinal ligament, the tail of the disc material will be the trachea and esophagus medially and the carotid artery visible. Remove this disc fragment at this time. To avoid and vagus nerve laterally. Use the operating microscope at overlooking a hidden disc fragment, use a no. 15 blade knife this stage and excise the medial portion of the longus colli or micro scissors to incise the ligament and remove any muscle to expose the medial parts of the transverse fragment with a 1- or 2-mm foot-plated bone punch. The

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A BC

Fig. 39-32 Anterior foraminotomy. (Redrawn from Johnson JP, Filler AG, McBride DQ, Batzdorf U: Spine 25:906, DE2000.)

ipsilateral one third to one half of the spinal cord is thus minimize postoperative incisional pain, inject a few exposed and the nerve root can be seen laterally as it exits milliliters of local anesthetic subcutaneously. behind the vertebral artery (Fig. 39-32, F). Jho reported excision of the posterior longitudinal ligament in selected cases because it is unlikely that a Thoracic Disc Disease hidden ruptured disc fragment could be present without Thoracic Disc Disease disruption of this ligament. Removal of the ligament sometimes is complicated by epidural bleeding. If the ligament The thoracic spine is the least common location for disc is not removed, the procedure is much simpler and the pathology. C.A. Key has been credited with the first report of a operating time is shorter. If epidural bleeding occurs during spinal cord injury caused by thoracic disc herniation, which removal of the posterior longitudinal ligament, use bipolar appeared in 1838 in the Guy’s Hospital Report. In the early coagulation. To avoid any potential compressive material twentieth century several reports of enchondromata, chondro- coming into contact with the nerve root or spinal cord, do mata, or echondromata appeared. In their study in 1934 Mixter not use hemostatic agents. Although epidural bleeding and Barr included four patients with a thoracic location of the usually is not a problem, removing the posterior longitudinal herniated nucleus pulposus. Of the four patients in this series, ligament is the most difficult part of this procedure. The disc three were treated operatively and one nonoperatively. The within the intervertebral space remains untouched and patient with nonoperative treatment died soon after diagnosis. preserved. Of the surgical group, two had complete paraplegia postopera- Close the platysma with interrupted 3-0 absorbable tively. The third surgical patient died several months later for stitches and approximate the skin with subcuticular sutures. unknown reasons. These three were treated with posterior The operation can be performed at multiple levels. To laminectomy. This initial report not only described the condition, but also revealed some of the difficulties of treatment.

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Since the 1960s many other approaches have been described and validated through clinical experience. It is apparent that posterior laminectomy has no role in the surgical treatment of this problem. Other posterior approaches, such as costotransversectomy, have good indications. Fessler and Sturgill, as well as Vanichkachorn and Vaccaro, chronicled the history and treatment evolution for thoracic disc disease. T4 Symptomatic thoracic disc herniations remain relatively T8 rare, with an estimated incidence of 1 in 1,000,000 persons per year. They represent 0.25% to 0.75% of the total incidence of symptomatic disc herniations. The most common age of onset T10 is between the fourth and sixth decades. As with the other areas of the spine, the incidence of asymptomatic disc herniations is T12 high. Wood et al. reviewed MRI studies in 90 asymptomatic patients and found thoracic disc abnormalities in 73%. Of these, 37% had frank herniations and 29% showed cord compression. At a mean follow-up of 26 months with repeat MRI of some of these patients none had become symptomatic. Fig. 39-33 Sensory dermatomes of trunk region. (Redrawn from Also, Wood et al. noted that small herniations often increased, Klein JD: Clinical evaluation of patients with spinal disorders. In whereas the larger herniations often regressed. Operative Garfin SR, Vaccaro AR, eds: Orthopaedic knowledge update: treatment of thoracic disc herniations is indicated in the rare spine, Rosemont, Ill, 1997, American Academy of Orthopaedic patient with acute disc herniation with myelopathic findings Surgeons.) attributable to the lesion, especially progressive neurological symptoms. SIGNS AND SYMPTOMS radicular pattern is more common with upper thoracic and SIGNS AND SYMPTOMS lateral disc herniations. Some axial pain often occurs with this pattern as well. Associated sensory changes of paresthesias Fortunately, the natural history of symptomatic thoracic disc and dysesthesia in a dermatomal distribution also occur. disease is similar to that in other areas, in that symptoms and (Fig. 39-33). High thoracic discs (T2 to T5) can present function typically improve with conservative treatment and similarly to cervical disc disease with upper arm pain, time. However, the clinical course can be quite variable, and a paresthesias, radiculopathy, and even Horner’s syndrome. high index of suspicion must be maintained to make the correct Myelopathy also may occur. Complaints of weakness, which diagnosis. The differential diagnosis for the symptoms of may be generalized by the patient, typically involving both thoracic disc herniations is fairly extensive and includes lower extremities present in the form of mild paraparesis. The nonspinal causes occurring with the cardiopulmonary, gastro- presence of sustained clonus, a positive Babinski sign, and intestinal, and musculoskeletal systems. Spinal causes of wide-based and spastic gait are all signs of myelopathy. Bowel similar symptoms can occur with infectious, neoplastic, and bladder dysfunction occur in only about 15% to 20% of degenerative, and metabolic problems within the spinal column these patients. The neurological evaluation of patients with as well as the spinal cord. thoracic disc herniations must be meticulous because there are Two general patient populations have been documented in few localizing findings. Abdominal reflexes, cremasteric reflex, the literature. The smaller group of patients is younger and has dermatomal sensory evaluation, rectus abdominis contraction a relatively short history of symptoms, often with a history of symmetry, lower extremity reflex, strength, and sensory exami- trauma. Typically, an acute soft disc herniation with either acute nations, as well as determination of long tract findings, are all spinal cord compression or radiculopathy is present. Outcome important. generally is favorable with operative or nonoperative treatment. CONFIRMATORY TESTING The larger group of patients has a longer history, often more CONFIRMATORY TESTING than 6 to 12 months of symptoms, which result from chronic spinal cord or root compression. Disc degeneration, often with Plain roentgenograms are of some help to evaluate traumatic calcification of the disc, is the underlying process. injuries and to determine potential osseous morphological Pain is clearly the most common presenting feature of variations that may help to localize findings, especially on thoracic disc herniations. There appear to be two patterns of intraoperative films, if these become necessary. MRI is the most pain: one is axial and the other is bandlike radicular pain along important and useful imaging method to demonstrate thoracic the course of the intercostal nerve. The T10 dermatomal level disc herniations. In addition to the disc herniation, neoplastic or is the most commonly reported distribution, regardless of the infectious pathology can be seen. The presence of intradural level of involvement. This is a band extending around the lower pathology, including disc fragments, also usually is demon- lateral thorax and caudally to the level of the umbilicus. This strated on MRI. The spinal cord signal may indicate the

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 40/74 Pg: 1994 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 1995 presence of inflammation or myelomalacia as well. Despite all ◆ Costotransversectomy these advantages, MRI may underestimate the thoracic disc Costotransversectomy is probably best suited for thoracic disc herniation, which often is calcified and thus has low signal herniations that are predominantly lateral or herniations that are intensity on T1 and T2 sequences. suspected to be extruded or sequestered. Central disc Myelography followed by CT scanning also can be useful herniations are probably best approached transthoracically. in evaluating the bony anatomy, as well as more accurately Some surgeons have recommended subsequent fusion after disc assessing the calcified portion of the herniated thoracic disc. removal anteriorly or laterally. Regardless of the imaging methods used, the appearance and presence of a thoracic disc herniation must be carefully TECHNIQUE 39-17 considered and correlated with the patient’s complaints and The operation usually is done with the patient under general detailed examination findings. anesthesia with a cuffed endotracheal tube or a Carlen tube TREATMENT RESULTS to allow lung deflation on the side of approach. Place the TREATMENT RESULTS patient prone and make a long midline incision or a curved incision convex to the midline centered over the side of As mentioned previously, nonoperative treatment usually is involvement. Expose the spine in the usual manner out to effective. Brown reported that 63% of patients improved using the ribs. Remove a section of rib 5 to 7.5 cm long at the level a combination of nonoperative treatments. A specific regimen of involvement, taking care to avoid damage to the cannot be recommended for all patients; however, the prin- intercostal nerve and artery. Carry the resection into the ciples of short-term rest, pain relief, antiinflammatory agents, lateral side of the disc, exposing it for removal. Additional and progressive directed activity restoration appear most exposure can be made by laminectomy and excision of the appropriate. These measures generally should be continued at pedicle and facet joint. Fusion is unnecessary unless more least 6 to 12 weeks if feasible. If neurological deficits progress than one facet joint is removed. Close the wound in layers. or present as myelopathy, or if pain remains at an intolerable level, surgery should be recommended. The initial procedure recommended for this lesion was posterior thoracic laminec- AFTERTREATMENT. The aftertreatment is similar to that for tomy and disc excision. At least half of the lesions have been lumbar disc excision without fusion (Technique 39-21). identified as being central, making the excision from this approach extremely difficult, and the results were somewhat disheartening. Most series reported fewer than half of the ◆ Anterior Approach for Thoracic Disc Excision patients improving, with some becoming worse after posterior Because of the relative age of patients with thoracic disc laminectomy and discectomy. Most recent studies suggest that ruptures, special care must be taken to identify those with lateral rachiotomy (modified costotransversectomy) or an pulmonary problems. In these patients the anterior approach anterior transthoracic approach for discectomy produces con- can be detrimental medically, making a posterolateral approach siderably better results with no evidence of worsening after the safer. Patients with midline protrusions probably are best procedure. Video-assisted thoracic surgery (VATS) has been treated with the transthoracic approach to ensure complete disc used in several series to successfully remove central thoracic removal. disc herniations without the need for a thoracotomy or fusion. Bohlman and Zdeblick reported the results of anterior thoracic TECHNIQUE 39-18 disc excision in 19 patients: 16 patients had excellent or good The operation is done with the patient under general results, and 3 had fair or poor results. Pain was relieved in 10, anesthesia, using a cuffed endotracheal tube or Carlen tube decreased in 8, and unchanged in 1. None had worsening of for lung deflation on the side of the approach. Place the neurological symptoms. Regan, BinYashay, and Mack reported patient in a lateral recumbent position. A left-sided anterior a series of 29 thoracoscopic disc excisions with 76% sat- approach usually is preferred, making the operative pro- isfactory results. cedure easier. Make a skin incision along the line of the rib OPERATIVE TREATMENT that corresponds to the second thoracic vertebra above the OPERATIVE TREATMENT involved intervertebral disc except for approaches to the upper five thoracic segments, where the approach is through The best surgical approach for these lesions depends on the the third rib. Choose the skin incision by inspection of the specific characteristics of the disc herniation, as well as on the anteroposterior roentgenogram. Cut the rib subperiosteally particular experience of the surgeon. Simple laminectomy at its posterior and anterior ends and then insert a rib really has no role in the treatment of thoracic disc herniations. retractor. Save the rib for grafting later in the procedure. One Posterior approaches, including costotransversectomy, trans- can then decide on an extrapleural or transpleural approach pedicular approach, and the lateral extracavitary approach, depending on familiarity and ease. Exposure of the thoracic have all been used successfully. Anterior approaches via vertebrae should give adequate access to the front and thoracotomy, a transsternal approach, or VATS also have been opposite side. Dissect the great vessels free of the spine. used successfully (Fig. 39-34). continued Copyright 2003. Elsevier Science (USA). All Rights Reserved.

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Fig. 39-34 Exposure of thoracic disc provided by standard lami- Laminectomy nectomy (A), transpedicular approach (B), costotransversectomy approach (C), lateral extracavitary approach (D), and anterolateral thoracotomy (E). (Redrawn from Fessler RG, Sturgill M: Surg Neurol 49:609, 1998.)

Transpedicular Costotransversectomy

B C

Lateral extracavitary

D E

Transthoracic

Ligate the intersegmental vessels near the great vessels and microscope or loupe magnification eases the removal of the not near the foramen. One should be able to insert the tip of disc near the posterior longitudinal ligament. Use curets and a finger against the opposite side of the disc when the nibbling instruments to remove the disc up to the posterior vascular mobilization is complete. Exposure of the interver- longitudinal ligament. Then place a finger on the opposite tebral disc without disturbing more than three segmental side of the disc to avoid penetration when removing disc vessels is preferable to avoid ischemic problems in the material on the more distant side. Carefully inspect the spinal cord. In the thoracolumbar region strip the diaphragm posterior longitudinal ligament for tears and extruded from the eleventh and twelfth ribs. The anterior longitudinal fragments. Remove the posterior longitudinal ligament only ligament usually is sectioned to allow spreading of the if necessary. Significant bleeding can occur if the venous intervertebral disc space. Remove the disc as completely plexus near the dura is torn. After removal of the disc, strip as possible if fusion is planned. The use of the operating the endplates of their cartilage. Make a slot in one vertebral

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S S Fig. 39-35 Position on operating table and operating room setup. Surgeons (S) and nurse with instruments (I) stand in A front of patient. Monitor (M) placed at back. ‘‘Working channels’’ (1,2,3) con- 4 verge toward spine. Channel for opti- cal system (4) situated ventrally. (From 1 2 3 Rosenthal D, Rosenthal R, de Simone A: Spine 19:1087, 1994.)

stability of the graft is questionable. The graft usually is stable body and a hole in the body on the opposite side of the disc without support if only one disc space is removed. Postopera- space to accept the graft material. Make the hole large tive care is the same as for anterior corpectomy and fusion if enough to accept several sections of rib, but make the slot more than one disc level is removed. If no fusion is done, the large enough to accept only one rib graft at a time. Then patient is mobilized as pain permits without a brace. insert iliac, tibial, or rib grafts into the disc space. Tie the grafts together with heavy suture material when the maximal number of grafts have been inserted. Close the ◆ Thoracic Endoscopic Disc Excision wound in the usual manner and employ standard chest Microsurgical and endoscopic surgical techniques are being drainage. As an alternative, if fusion is not desired a more applied to the anterior excision of thoracic disc herniation. limited resection using the operating microscope can be Rosenthal et al. and Horowitz et al. first performed these done. After the vascular mobilization, resect the rib head to procedures on cadavers to perfect the technique. Because these allow observation of the pedicle and foramen caudal to the methods are highly technical, they should be performed by a disc space. The pedicle can be removed with a high-speed surgeon who is proficient in this technique and in the use of burr and Kerrison rongeurs, thus exposing the posterolateral endoscopic equipment and with the assistance of an experi- aspect of the disc. This allows careful, blunt development of enced thoracic surgeon. Ideally the procedure should be done the plane ventral to the dura with removal of the disc on cadavers or live animals first. Regan et al. also described this herniation and preservation of the anterior majority of the technique, with different portal positions. disc, as well as limiting the need for fusion. A similar technique using VATS is described in Technique 39-19. TECHNIQUE 39-19 (Rosenthal et al.) The transthoracic approach removing a rib two levels (Figs. 39-35 and 39-36) above the level of the lesion can be used up to T5. The Place the patient in the left lateral decubitus position to transthoracic approach from T2 to T5 is best made by allow a right-sided approach and displacement of the aorta excision of the third or fourth rib and elevation of the and heart to the left. Insert four trocars in a triangular scapula by sectioning of attachments of the serratus anterior fashion along the middle axillary line converging on the disc and trapezius from the scapula. The approach to the T1-2 space. Introduce a rigid endoscope with a 30-degree optic disc is best made from the neck with a sternal splitting angle attached to a video camera into one of the trocars, incision. leaving the other three as working channels. Deflate the lung using a Carlin tube or similar method. Split the parietal pleura starting at the medial part of the intervertebral space AFTERTREATMENT. Postoperative care is the same as for a and extending up to the costovertebral process. Preserve and thoracotomy. The patient is allowed to walk after the chest mobilize the segmental arteries and sympathetic nerve out tubes are removed. Extension in any position is prohibited. A of the operating field. Drill away the rib head and lateral brace or body cast that limits extension should be used if the continued Copyright 2003. Elsevier Science (USA). All Rights Reserved.

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decades of life. Most people relate their back and leg pain to a traumatic incident, but close questioning frequently reveals that the patient has had intermittent episodes of back pain for many months or even years before the onset of severe leg pain. In many instances the back pain is relatively fleeting and is relieved by rest. This pain often is brought on by heavy exertion, repetitive bending, twisting, or heavy lifting. In other instances an exacerbating incident cannot be elicited. The pain usually begins in the lower back, radiating to the sacroiliac region and buttocks. The pain can radiate down the posterior thigh. Back and posterior thigh pain of this type can be elicited from many areas of the spine, including the facet joints, longitudinal ligaments, and the periosteum of the vertebra. Radicular pain, on the other hand, usually extends below the knee and follows the dermatome of the involved nerve root. The usual history of lumbar disc herniation is of repetitive lower back and buttock pain, relieved by a short period of rest. This pain is then suddenly exacerbated by a flexion episode, with the sudden appearance of leg pain much greater than back pain. Most radicular pain from nerve root compression caused by a herniated nucleus pulposus is evidenced by leg pain equal Fig. 39-36 Endoscopic removal of thoracic disc. Horizontal to, or in many cases much greater than, the degree of back pain. view at T6 level. Patient is in left lateral decubitus position. Whenever leg pain is minimal and back pain is predominant, A, Right lung (collapsed). B, Heart and pericardium. C, Esoph- great care should be taken before making the diagnosis of a agus. D, Aorta. E, Forceps and endoscope. F, Left lung. (From Rosenthal D, Rosenthal R, de Simone A: Spine 19:1087, 1994.) symptomatic herniated intervertebral disc. The pain from disc herniation usually is intermittent, increasing with activity, especially sitting. The pain can be relieved by rest, especially in the semi-Fowler position, and can be exacerbated by straining, sneezing, or coughing. Whenever the pattern of pain is bizarre portion of the pedicle. Remove the remaining pedicle with or the pain itself is constant, a diagnosis of symptomatic Kerrison rongeurs to improve exposure to the spinal canal. herniated disc should be viewed with some skepticism. Removing the superior posterior portion of the vertebra Other symptoms of disc herniation include weakness and caudal to the disc space allows safer removal of the disc paresthesias. In most patients the weakness is intermittent, material, which then can be pulled anteriorly and inferiorly variable with activity, and localized to the neurological level of away from the spinal canal to be removed. Use endoscopic involvement. Paresthesias also are variable and limited to the instruments for surgery in the portals. Remove the disc dermatome of the involved nerve root. Whenever these posteriorly and the posterior longitudinal ligament, restrict- complaints are generalized, the diagnosis of a simple unilateral ing bone and disc removal to the posterior third of the disc herniation should be questioned. intervertebral space and costovertebral area to maintain Numbness and weakness in the involved leg and occasion- stability. Insert chest tubes in the standard fashion and set ally pain in the groin or testicle can be associated with a high them to water suction; close the portals. or midline lumbar disc herniation. If a fragment is large or the herniation is high, symptoms of pressure on the entire cauda equina can be elicited. These include numbness and weakness AFTERTREATMENT. The patient is rapidly mobilized as in both legs, rectal pain, numbness in the perineum, and tolerated by the chest tubes. Discharge is possible once the paralysis of the sphincters. This diagnosis should be the chest tubes have been removed and the patient is ambulat- primary consideration in patients who complain of sudden loss ing well. of bowel or bladder control. Whenever the diagnosis of a cauda Lumbar Disc Disease equina syndrome or acute midline herniation is suspected, evaluation and treatment should be aggressive. SIGNS AND SYMPTOMS Lumbar Disc Disease PHYSICAL FINDINGS PHYSICAL FINDINGS SIGNS AND SYMPTOMS The physical findings in back pain with disc disease are Although back pain is common from the second decade of life variable because of the time intervals involved. Usually on, intervertebral disc disease and disc herniation are most patients with acute pain show evidence of marked paraspinal prominent in otherwise healthy people in the third and fourth spasm that is sustained during walking or motion. A scoliosis or

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BOX 39-7 • L4 Root Compression* BOX 39-8 • L5 Root Compression*

Sensory Deﬁcit Sensory Deﬁcit Posterolateral thigh, anterior knee, and medial leg Anterolateral leg, dorsum of the foot, and great toe

Motor Weakness Motor Weakness Quadriceps (variable) Extensor hallucis longus Hip adductors (variable) Gluteus medius Extensor digitorum longus and brevis Reflex Changes Patellar tendon Reflex Change Tibialis anterior tendon (variable) Usually none Tibialis posterior (difficult to elicit) *Indicative of L3-4 disc herniation or pathological condition localized to the L4 foramen. *Indicative of L4-5 disc herniation or pathological condition localized to the L5 foramen. a list in the lumbar spine may be present, and in many patients BOX 39-9 • S1 Root Compression* the normal lumbar lordosis is lost. As the acute episode subsides, the degree of spasm diminishes remarkably, and the Sensory Deficit loss of normal lumbar lordosis may be the only telltale sign. Lateral malleolus, lateral foot, heel, and web of fourth and Point tenderness may be present over the spinous process at the fifth toes level of the disc involved, and in some patients pain may extend Motor Weakness laterally. Peroneus longus and brevis If there is nerve root irritation, it centers over the length of Gastrocnemius-soleus complex the sciatic nerve, both in the sciatic notch and more distally Gluteus maximus in the popliteal space. In addition, stretch of the sciatic nerve at Reflex Change the knee should reproduce buttock, thigh, and leg pain (i.e., Tendo calcaneus (gastrocnemius-soleus complex) pain distal to the knee). A Lase`gue sign usually is positive on the involved side. A positive Lase`gue sign or straight leg raising *Indicative of L5-S1 disc herniation or pathological condition localized should elicit buttock or leg pain distal to the knee or both on the to the S1 foramen. side tested. Occasionally if leg pain is significant the patient will lean back from an upright sitting position and assume the tripod stance to relieve the pain. Contralateral leg pain atrophic. Reflex testing may reveal a diminished or absent produced by straight leg raising should be regarded as patellar tendon reflex (L2, L3, and L4) or tibialis anterior pathognomonic of a herniated intervertebral disc. The absence tendon reflex (L4). Sensory testing may show diminished of a positive Lase`gue sign should make one skeptical of the sensibility over the L4 dermatome, the isolated portion of diagnosis, although older individuals may not have a positive which is the medial leg (Fig. 39-37), and the autonomous zone Lase`gue sign. Likewise, inappropriate findings and inconsis- of which is at the level of the medial malleolus. tencies in the examination usually are nonorganic in origin (see Unilateral disc herniation between L4 and L5 results in discussion of nonspecific back pain). If the leg pain has compression of the fifth lumbar root. Fifth lumbar root persisted for any length of time, atrophy of the involved limb radiculopathy should produce pain in the dermatomal pattern. may be present, as demonstrated by asymmetrical girth of the Numbness, when present, follows the L5 dermatome along the thigh or calf. The neurological examination will vary as anterolateral aspect of the leg and the dorsum of the foot, determined by the level of root involvement (Boxes 39-7 to including the great toe. The autonomous zone for this nerve is 39-9). Smith et al. examined the motion of the spinal roots in the dorsal first web of the foot and the dorsum of the third toe. cadavers. They observed 0.5 to 5 mm of linear motion and 2% Weakness may involve the extensor hallucis longus (L5), to 4% strain on the nerves at L4, L5, and S1. With increased gluteus medius (L5), or extensor digitorum longus and brevis strain, the roots moved lateral to the pedicle. (L5). Reflex change usually is not found. A diminished tibialis Unilateral disc herniation between L3 and L4 usually posterior reflex is possible but difficult to elicit. compresses the fourth lumbar root as it crosses the disc before With unilateral rupture of the disc between L5 and S1 the exiting at the L4 intervertebral foramen. Pain may be localized findings of an S1 radiculopathy are noted. Pain and numbness around the medial side of the leg. Numbness may be present involve the dermatome of S1. The S1 dermatome includes the over the anteromedial aspect of the leg. The tibialis anterior lateral malleolus and the lateral and plantar surface of the foot, may be weak as evidenced by inability to heel walk. The occasionally including the heel. There is numbness over the quadriceps and hip adductor group, both innervated from L2, lateral aspect of the leg and, more important, over the lateral L3, and L4, also may be weak and, in extended ruptures, aspect of the foot, including the lateral three toes. The

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Fig. 39-37 L4 neurological level. (After Hoppenfeld S: Physical examination of the spine and extremities, Norwalk, Conn, 1976, Appleton-Century-Crofts.)

autonomous zone for this root is the dorsum of the fifth toe. result is positive and a high lesion should be suspected. In Weakness may be demonstrated in the peroneus longus and addition, these lesions may occur with a more diffuse brevis (S1), gastrocnemius-soleus (S1), or gluteus maximus neurological complaint without significant localizing neurolog- (S1). In general, weakness is not a usual finding in S1 ical signs. radiculopathy. Occasionally, mild weakness may be demon- Often the neurological signs associated with disc disease strated by asymmetrical fatigue with exercise of these motor vary over time. If the patient has been up and walking for a groups. The ankle jerk usually is reduced or absent. period of time, the neurological findings may be much more Massive extrusion of a disc involving the entire diameter of pronounced than if he has been at bed rest for several days, thus the lumbar canal or a large midline extrusion can produce pain decreasing the pressure on the nerve root and allowing the in the back, legs, and occasionally perineum. Both legs may be nerve to resume its normal function. In addition, various paralyzed, the sphincters may be incontinent, and the ankle conservative treatments can change the physical signs of disc jerks may be absent. Tay and Chacha in 1979 reported that the disease. combination of saddle anesthesia, bilateral ankle areflexia, and Comparative bilateral examination of a patient with back bladder symptoms constituted the most consistent symptoms of and leg pain is essential in finding a clear-cut pattern of signs cauda equina syndrome caused by massive intervertebral disc and symptoms. It is not uncommon for the evaluation to extrusion at any lumbar level. In these instances a cystomet- change. Adverse changes in the examination may warrant more rogram may show bladder denervation. aggressive therapy, whereas improvement of the symptoms More than 95% of the ruptures of the lumbar intervertebral or signs should signal a resolution of the problem. Early discs occur at L4 or L5. Ruptures at higher levels in many symptoms or signs suggestive of cauda equina syndrome or patients are not associated with a positive straight leg raising severe or progressive neurological deficit should be treated test. In these instances, a positive femoral stretch test can be aggressively from the onset. McLaren and Bailey warn that the helpful. This test is carried out by placing the patient prone and cauda equina syndrome is more frequent when disc excision is acutely flexing the knee while placing the hand in the popliteal performed in the presence of an untreated spinal stenosis at the fossa. When this procedure results in anterior thigh pain, the same level.

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DIFFERENTIAL DIAGNOSIS few have been evaluated scientifically. In addition, the natural history of disc disease is characterized by exacerbations and The differential diagnosis of back and leg pain is extremely remissions with eventual improvement regardless of treatment. lengthy and complex. It includes diseases intrinsic to the spine Finally, several distinct symptom complexes appear to be and those involving adjacent organs but causing pain referred to associated with disc disease. Few if any studies have isolated the back or leg. For simplicity, lesions can be categorized as the response to specific and anatomically distinct diagnoses. being extrinsic or intrinsic to the spine. Extrinsic lesions The simplest treatment for acute back pain is rest. Deyo, include diseases of the urogenital system, gastrointestinal Diehl, and Rosenthal reported that 2 days of bed rest were system, vascular system, endocrine system, nervous system not better than a longer period. Biomechanical studies indicate that localized to the spine, and the extrinsic musculoskeletal system. lying in a semi- Fowler position (i.e., on the side with the hips These lesions include infections, tumors, metabolic distur- and knees flexed) with a pillow between the legs should relieve bances, congenital abnormalities, and the associated diseases of most pressure on the disc and nerve roots. Muscle spasm can be aging. Intrinsic lesions involve those diseases that arise controlled by the application of ice, preferably with a massage primarily in the spine. They include diseases of the spinal over the muscles in spasm. Pain relief and antiinflammatory musculoskeletal system, the local hematopoietic system, and effect can be achieved with nonsteroidal antiinflammatory the local neurological system. These conditions include trauma, drugs (NSAIDs). Most acute exacerbations of back pain tumors, infections, diseases of aging, and immune diseases respond quickly to this therapy. As the pain diminishes, the affecting the spine or spinal nerves. patient should be encouraged to begin isometric abdominal and Although the predominant cause of back and leg pain in lower extremity exercises. Walking within the limits of comfort healthy people usually is lumbar disc disease, one must be also is encouraged. Sitting, especially riding in a car, is extremely cautious to avoid a misdiagnosis, particularly given discouraged. Malmivaara et al. compared the efficacy of bed the high incidence of disc herniations present in asymptomatic rest alone, back extension exercises, and continuation of patients as discussed previously. Therefore a full physical ordinary activities as tolerated in the treatment of acute back examination must be completed before making a presumptive pain. They concluded that continuation of ordinary activities diagnosis of herniated disc disease. Common diseases that can within the limits permitted by pain led to a more rapid recovery. mimic disc disease include ankylosing spondylitis, multiple Education in proper posture and body mechanics is helpful myeloma, vascular insufficiency, arthritis of the hip, osteopo- in returning the patient to the usual level of activity after the rosis with stress fractures, extradural tumors, peripheral acute exacerbation is eased or relieved. This education can take neuropathy, and herpes zoster. Infrequent but reported causes of many forms, from individual instruction to group instruction. sciatica not related to disc hernia include synovial cysts, rupture Back education of this type is now usually referred to as ‘‘back of the medial head of the gastrocnemius, sacroiliac joint school.’’ Although the concept is excellent, the quality and dysfunction, lesions in the sacrum and pelvis, and fracture of quantity of information provided may vary widely. The work of the ischial tuberosity. Bergquist-Ullman and Larsson and others indicates that patient CONFIRMATORY IMAGING education of this type is extremely beneficial in decreasing the CONFIRMATORY IMAGING amount of time lost from work initially but does little to decrease the incidence of recurrence of symptoms or length of Although the diagnosis of a herniated lumbar disc can be time lost from work during recurrences. Certainly the suspected from the history and physical examination, imaging combination of back education and combined physical therapy studies are necessary to rule out other causes, such as a tumor is superior to placebo treatment. Cohen et al. reviewed 13 or infection. Plain roentgenograms are of limited use in the studies on group back education and concluded that the diagnosis because they do not show disc herniations or other evidence was insufficient to recommend group education. intraspinal lesions, but they can demonstrate infection, tumors, A study by Galm et al. regarding sacroiliac joint dysfunction in or other anomalies and should be obtained, especially if surgery patients with image-proven herniated nucleus pulposus and is planned. Currently, the most useful test for diagnosing a sciatica but without motor or sensory deficits found that 75% herniated lumbar disc is MRI. Since the advent of MRI, improved with respect to sciatic and back pain with intensive myelography is used much less frequently, although in some physiotherapy. situations it may help to demonstrate subtle lesions. When Numerous medications have been used with varied results in myelography is used, it should be followed with a CT scan. subacute and chronic back and leg pain syndromes. The current NONOPERATIVE TREATMENT trend appears to be moving away from the use of strong NONOPERATIVE TREATMENT narcotics and muscle relaxants in the outpatient treatment of these syndromes. This is especially true in the instances of The number and variety of nonoperative therapies for back and chronic back and leg pain where drug habituation and increased leg pain are overwhelming. Treatments range from simple rest depression are frequent. Oral steroids used briefly can be to expensive traction apparatus. All these therapies are reported beneficial as potent antiinflammatory agents. The many types with glowing accounts of miraculous ‘‘cures’’; unfortunately, of NSAIDs also are helpful when aspirin is not tolerated or is

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 47/74 Pg: 2001 Team: 2002 PART XII ◆ The Spine of little help. Numerous NSAIDs are available for the treatment patients with motor or reflex abnormalities (12% to 14% good of low back pain. When depression is prominent, mood results). A negative myelogram also was associated with a elevators such as amitriptyline can be beneficial in reducing better result. Cuckler et al. in a double-blind, randomized study sleep disturbance and anxiety without increasing depression. In of epidural steroid treatment of disc herniation and spinal addition, amitriptyline also decreases the need for narcotic stenosis found no difference in the results at 6 months between medication. placebo and a single epidural injection. Our experience Physical therapy should be used judiciously. The exercises parallels that of Berman et al. We agree that epidural steroids should be fitted to the symptoms and not forced as an absolute are not a cure for disc disease, but they do offer relatively group of activities. Patients with acute back and thigh pain prolonged pain relief without excessive narcotic intake if eased by passive extension of the spine in the prone position conservative care is elected. Hopwood and Abram observed can benefit from extension exercises rather than flexion that factors associated with poor surgical outcome also were exercises. Improvement in symptoms with extension is associated with a poor outcome from epidural steroid injection. indicative of a good prognosis with conservative care. On the These factors included lower educational levels, smoking, lack other hand, patients whose pain is increased by passive of employment, constant pain, sleep disruption, nonradicular extension may be improved by flexion exercises. These diagnosis, prolonged duration of pain, change in recreational exercises should not be forced in the face of increased pain. activities, and extreme values on psychological scales. This may avoid further disc extrusion. Any exercise that In experienced hands the complication rate from this increases pain should be discontinued. Lower extremity procedure should be small. White, Derby, and Wynne reported exercises can increase strength and relieve stress on the back, that the most common problem is a 25% rate of failure to place but they also can exacerbate lower extremity arthritis. The true the material in the epidural space. Renfrew et al. and el-Khoury benefit of such treatments may be in the promotion of good et al. observed that the use of fluoroscopic control dramatically posture and body mechanics rather than of strength. Hansen decreased the failure rate. Another technique-related problem is et al. compared intensive, dynamic back muscle exercises, intrathecal injection with inadvertent spinal anesthesia. Other conventional physiotherapy (manual traction, flexibility, iso- reported complications include transient hypotension, difficulty metric and coordination exercises, and ergonomics counseling), in voiding, severe paresthesias, cardiac angina, headache, and and placebo-control treatment in a randomized, observer blind transient hypercorticoidism. Kushner and Olson reported trial. Regardless of the method used, patients who completed retinal hemorrhage in several patients who had epidural steroid therapy reported a decrease in pain. However, physiotherapy injection for chronic back pain. They recommended careful appeared to have better results in men, and intensive back consideration of this procedure in patients who have bleeding exercises gave better results in women. Patients with hard problems and in patients who have only one eye. DeSio et al. physical occupations responded better to physiotherapy, reported facial flushing and generalized erythema in patients whereas patients with sedentary occupations responded better after epidural steroid injection. The most serious complication to intensive back exercises. reported was bacterial meningitis. The total complication rate Numerous treatment methods have been advanced for the in most series is about 5%, and the complications are almost treatment of back pain. Some patients respond to the use of always transient. transcutaneous electrical nerve stimulation (TENS). Others do This procedure is contraindicated in the presence of well with traction varying from skin traction in bed with 5 to 8 infection, neurological disease (such as multiple sclerosis), pounds to body inversion with forces of over 100 pounds. Back hemorrhagic or bleeding diathesis, cauda equina syndrome, and braces or corsets may be helpful to other patients. Ultrasound and a rapidly progressive neural deficit. Rapid injections of large diathermy are other treatments used in back pain. The scientific volumes or the use of large doses of steroid also can increase efficacy of many of these treatments has not been proved. In the complication rate. The exact effects of intrathecal injection addition, all therapy for disc disease is only symptomatic. of steroids are not known. This technique must be used only in EPIDURAL STEROIDS the low lumbar region. We prefer to abort the procedure if a bloody tap is obtained or if CSF is encountered. ◆ EPIDURAL STEROIDS We prefer to do the procedure in a room equipped for The epidural injection of a combination of a long-acting steroid resuscitation and with the capability to monitor the patient. This with an epidural anesthetic is an excellent method of procedure lends itself well to outpatient use, but the patient symptomatic treatment of back and leg pain from discogenic must be prepared to spend several hours to recover from the disease and other sources. Most studies show a 60% to 85% block. Methylprednisolone (Depo-Medrol) is the usual steroid short-term success rate that falls to a 30% to 40% long-term injected. The dosage may vary from 80 to 120 mg. The (6-month) good result rate. The local effect of the steroids has anesthetics used may include lidocaine, bupivacaine, or been shown to last at least 3 weeks at a therapeutic level. In a procaine. Our current protocol is to inject the patient three well-controlled study Berman et al. found that the best results times. These injections are made at 7- to 10-day intervals. This were obtained in patients with subacute or chronic leg pain with ensures at least one good epidural injection and decreases the no prior surgery. They also found that the worst results were in volume of material injected at each procedure.

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requirements, not only because of gender and occupation TECHNIQUE 39-20 (Brown) variations in response to physiotherapy and intensive back The equipment needed includes material for an appropriate exercises, but also because no therapy appeared to have the skin preparation, sterile rubber gloves, a 31⁄2-inch, 20-gauge same or better results. Physical examination should reveal or 22-gauge disposable spinal needle (45-degree blunt- or signs of sciatic irritation and possibly objective evidence of curve-tipped epidural needles are preferred), several dispos- localizing neurological impairment. CT, lumbar MRI, or able syringes, bacteriostatic lidocaine, and methylpredniso- myelography should confirm the level of involvement consis- lone acetate, 40 mg/ml. The injection may be done with the tent with the patient’s examination. patient in the sitting or lateral decubitus position. Anesthe- Surgical disc removal is mandatory and urgent only in cauda tize the skin near the midline. Advance the needle until the equina syndrome with significant neurological deficit, espe- resistance of the ligamentum flavum is encountered. Then cially bowel or bladder disturbance. All other disc excisions attach a syringe and slowly advance the needle while should be considered elective. This should allow a thorough applying light pressure on the syringe. When the epidural evaluation to confirm the diagnosis, level of involvement, and space is encountered, the resistance is suddenly lost and the the physical and psychological status of patient. Frequently, if epidural space will accommodate the air. Remove the there is a rush to the operating room to relieve pain without syringe and inspect the needle opening for blood or spinal proper investigation, both the patient and physician later regret fluid. If there is no flow out of the needle, then inject 3 ml the decision. of 1% lidocaine or other appropriate anesthetic. This may Regardless of the method chosen to treat a disc rupture be preceded or followed by the chosen dosage of surgically, the patient should be aware that the procedure is methylprednisolone. predominantly for the symptomatic relief of leg pain. Patients Several variations also can be used. Some physicians use with predominant back pain may not be relieved of their major a sterile balloon to indicate the proper space. Others use the complaint—back pain. Spangfort, in reviewing 2504 lumbar ‘‘disappearing drop’’ technique, which involves placing a disc excisions, found that about 30% of the patients complained drop of sterile saline over the hub of the needle. When the of back pain after disc surgery. Failure to relieve sciatica was epidural space is entered, the drop disappears. Caudal proportional to the degree of herniation. The best results of injection also is used, but this may require larger volumes to 99.5% complete or partial pain relief were obtained when the wash the steroid up to the involved level. This method is disc was free in the canal or sequestered. Incomplete herniation safer but less reliable than an injection at L4-5. or extrusion of disc material into the canal resulted in complete relief for 82% of patients. Excision of the bulging or protruding OPERATIVE TREATMENT disc that had not ruptured through the annulus resulted in OPERATIVE TREATMENT complete relief in 63%, and removal of the normal or minimally bulging disc resulted in complete relief in 38%, If nonoperative treatment for lumbar disc disease fails, the next which is near the stated level for the placebo response. consideration is operative treatment. Before this step is taken, Likewise, the incidence of persistent back pain after surgery the surgeon must be sure of the diagnosis. The patient must be was inversely proportional to the degree of herniation. In certain that the degree of pain and impairment warrants such a patients with complete extrusions the incidence was about 25%, step. Both the surgeon and the patient must realize that disc but with minimal bulges or negative explorations the incidence surgery is not a cure but may provide symptomatic relief. It rose to over 55% (Figs. 39-38 and 39-39). neither stops the pathological processes that allowed the herniation to occur nor restores the back to a normal state. The General Principles for Open Disc Surgery patient must still practice good posture and body mechanics Most disc surgery is performed with the patient under after surgery. Activities involving repetitive bending, twisting, general endotracheal anesthesia, although local anesthesia has and lifting with the spine in flexion may have to be curtailed or been used with minimal complications. Patient positioning eliminated. If prolonged relief is to be expected, then some varies with the operative technique and surgeon. To position the permanent modification in the patient’s lifestyle may be patient in a modified kneeling position, a specialized frame or necessary. custom frame modified from the design of Hastings is popular. The key to good results in disc surgery is appropriate patient Positioning the patient in this manner allows the abdomen to selection. The optimal patient is one with predominant, if not hang free, minimizing epidural venous dilation and bleeding only, unilateral leg pain extending below the knee that has been (Fig. 39-40). A head lamp allows the surgeon to direct light into present for at least 6 weeks. The pain should have been the lateral recesses where a large proportion of the surgery may decreased by rest, antiinflammatory medication, or even be required. The addition of loupe magnification also greatly epidural steroids but should have returned to the initial levels improves the identification and exposure of various structures. after a minimum of 6 to 8 weeks of conservative care. Some Some surgeons also use the operative microscope to further managed care plans now insist on a trial of physiotherapy. The improve visibility. The primary benefit of the operating work of Hansen et al. is indicative of the problems with such microscope compared with loupes is the view afforded the

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Fig. 39-38 Percentage relief of sciatica with type of disc herniation. (From Spangfort E: Acta Orthop Scand Suppl 142:1, 1972.)

Fig. 39-39 Types of disc herniation. A, Normal bulge. B, Pro- Fig. 39-40 Kneeling position for lumbar disc excision allows trusion. C, Extrusion. D, Sequestration. abdomen to be completely free of external pressure.

assistant. Roentgenographic confirmation of the proper level is research has gone into techniques to prevent epidural fibrosis. necessary. Care should be taken to protect neural structures. Hoyland et al. noted dense fibrous connective tissue about Epidural bleeding should be controlled with bipolar electrocau- previously operated nerve roots. They also found fibrillar tery. Any sponge, pack, or cottonoid patty placed in the wound foreign material within the scar in 55% of patients. This finding should extend to the outside. Pituitary rongeurs should be should remind the surgeon to minimize the use of cotton marked at a point equal to the maximal allowable disc depth to patties. The placement of autogenous fat appears to be a prevent accidental biopsy of viscera or aorta. Considerable reasonable although not foolproof or complication-free tech-

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C A B

F E

Fig. 39-41 Technique of lumbar disc excision. A, With lamina and ligamentum flavum exposed, use curet to remove the ligamentum flavum from inferior surface of lamina. Kerrison rongeur is used to remove bone. B, Elevate ligamentum flavum at upper corner and carefully dissect it back to expose dura and epidural fat below. Patties should be used to protect dura during this procedure. C, Expose dura and root. Remove additional bone if there is any question about adequacy of exposure. D, Retract nerve root and dural sac to expose disc. Inspect capsule for rent and extruded nuclear material. If obvious ligamentous defect is not visible, then carefully incise capsule of disc. If disc material does not bulge out, press on disc to try to dislodge herniated fragment. E, Carefully remove disc fragments. It is safest to avoid opening pituitary rongeur until it is inserted into disc space. F, After removing disc, carefully explore foramen, subligamentous region, and beneath dura for additional fragments of disc. Obtain meticulous hemostasis using bipolar cauterization.

nique of minimizing postoperative epidural fibrosis. Commer- cially available products may reduce scar volume, but clinical from the spinous processes and laminae of these vertebrae benefit remains uncertain. on the side of the lesion. Retract the muscles either with a self-retaining retractor or with the help of an assistant and expose one interspace at a time. Verify the location with a ◆ Ruptured Lumbar Disc Excision (Open Technique) roentgenogram so that no mistake is made regarding the interspaces explored. Secure hemostasis with electrocautery, TECHNIQUE 39-21 bone wax, and packs. Leave a portion of each pack After thoroughly preparing the back, identify the spinous completely outside the wound for ready identification. processes of L3, L4, L5, and S1 by palpation. Make a Denude the laminae and ligamentum flavum with a curet midline incision 5 to 8 cm long, centered over the interspace (Fig. 39-41). Commonly the lumbosacral interspace is large where the disc herniation is located. Incise the supraspinous enough to permit exposure and removal of a herniated ligament; then, by subperiosteal dissection, strip the muscles nucleus pulposus without removal of any bone. If not,

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remove a small part of the inferior margin of the fifth lumbar proper level and review preoperative imaging studies to lamina. Exposure of the disc at higher levels usually confirm proper sidedness. requires removal of a portion of the inferior lamina. Thin the If the herniated fragment is especially large, it is much ligamentum flavum using a pituitary rongeur to remove the better to sacrifice a portion of the facet to obtain a more superficial layer. Detach the ligamentum from its cephalad lateral exposure than to risk injury to the root or cauda or caudad laminar attachment using a small curet. Use care equina by excessive medial retraction. With such a lateral to keep the cutting edges of the curet directed posteriorly to exposure the nerve root usually can be elevated, and the minimize the chance of dural laceration. Using an angled herniated fragment can be teased from beneath the nerve Kerrison rongeur, preferably one with a thin foot plate and root and cauda equina, even when the fragment is large appropriate width, remove the detached ligamentum later- enough to block the entire canal. If the fragment is very ally and preserve the more medial ligamentum. Keep the large as with cauda equina lesions typically, a bilateral Kerrison rongeur oriented parallel to the direction of the laminectomy is preferred to allow safer removal. If the disc nerve root to minimize the risk of root injury, and the root cannot be teased from under the root, make a cruciate will be more posterior than is normal due to the dis- incision in the disc laterally. Gently remove disc fragments placement caused by the herniated disc fragment. An until the bulge has been decompressed to allow gentle alternative technique that can be used with good lighting and retraction of the root over the defect. magnified visual aid is to divide the ligamentum parallel If the herniation is upward or downward, further removal with its fibers using a no. 11 blade knife. Once the full of bone from the lamina and facet edges may be required. thickness of the ligamentum has been divided, bluntly The herniated nucleus pulposus may be covered by a layer extend the division across the interspace with a Penfield 4 of posterior longitudinal ligament or may have ruptured dissector and remove the lateral portion of the ligamentum. through this structure. In the latter event, carefully lift the The lateral shelving portion of the ligamentum should be loose fragments out by suction, blunt hook, or pituitary excised, often with a portion of the medial inferior facet to forceps. If the ligament is intact, incise it in a cruciate gain access to the lateral aspect of the nerve root. Next, fashion and remove the loose fragments. The tear or hole in retract the dura medially and identify the nerve root. If the the annulus should then be identifiable in most instances. root is compressed by a large extruded fragment, it The cavity of the disc can be entered through this hole, or commonly will be displaced posteriorly. Retract the nerve occasionally the hole may need to be enlarged to allow root, once identified, medially so that the underlying insertion of the pituitary forceps. Remember that the extruded fragment or bulging posterior longitudinal liga- anterior part of the annulus is adjacent to the aorta, vena ment can be seen. Occasionally the nerve root adheres to the cava, or iliac arteries and veins and that one of these fragment or to the underlying ligamentous structures and structures can be injured if one proceeds too deeply. requires blunt dissection from these structures. If the Remove other loose fragments of nucleus pulposus with the position of the root is not known for certain, remove the pituitary forceps and remove additional nuclear material lamina posterior to the root and medial to the pedicle until along with the central portion of the cartilaginous plates, the root is clearly identified. Bipolar cautery on a low setting both above and below as necessary. can be used to coagulate the epidural veins and maintain When placing instruments into the disc space do not hemostasis. Gelfoam and small cottonoids also are useful. penetrate beyond a depth of 15 mm to avoid injury to the Take care to minimize packing about the nerve root. Retract anterior viscera. Then carry out a complete search for the root or dura, identify any bleeding vein, and cauterize it additional fragments of nucleus pulposus, both inside and with a bipolar cautery. Earlier insertion of cotton patties may outside the disc space. Additional fragments commonly well displace fragments from view. The underlying disc migrate medially beneath the posterior longitudinal liga- should be clearly visible at this time. ment but outside the annulus and can easily be missed. Then Gently retract the nerve with a Love root retractor or a remove all cotton pledgets and control residual bleeding blunt dissector, thus exposing the herniated fragment or with Gelfoam and bipolar cautery. Forcefully irrigate any posterior longitudinal ligament and annulus. If an extruded loose fragments from the disc space using a syringe with a fragment is not seen, carefully palpate the posterior spinal needle placed into the disc space under direct vision longitudinal ligament and seek a defect or hole in the until no fragments are returned with the irrigating solution. ligamentous structures. A microblunt hook can be used for Close the wound routinely with absorbable sutures in the this. If no obvious abnormality is detected, follow the root supraspinous ligament and subcutaneous tissue. Various around the pedicle or even outside the canal in search of absorbable sutures are most commonly used in routine skin fragments that may have migrated far laterally. Additional closure. Staples are avoided for patient comfort. searching in the root axilla helps ensure that fragments that have migrated inferiorly are not missed. If the expected pathology is not found, obtain another roentgenogram with AFTERTREATMENT. Neurological function is closely mon- a blunt dissector at the level of the disc to be certain of the itored after surgery. The patient is allowed to turn in bed at will and to select a position of comfort such as a semi-Fowler Copyright 2003. Elsevier Science (USA). All Rights Reserved.

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 52/74 Pg: 2006 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 2007 position. Pain should be controlled with oral medication. evacuation of the vacuum pack. Alternatively, the Andrew’s Muscle relaxants are used postoperatively as well. Bladder type frame previously described can be used. The microscope stimulants can be used to assist voiding. The patient is allowed can be used from skin incision to closure. However, the initial to stand with assistance on the evening after surgery to go to the dissection can be done under direct vision. A lateral bathroom. Discharge is permitted when the patient is able to roentgenogram is taken to confirm the level. walk and void. Currently most patients are discharged within 24 hours after surgery. Isometric abdominal and lower TECHNIQUE 39-22 (Williams, Modified) extremity exercises are started. The patient is instructed to Make the incision from the spinous process of the upper minimize sitting and riding in a vehicle. Increased walking on vertebra to the spinous process of the lower vertebra at the a daily basis is recommended. Lifting, bending, and stooping involved level. This usually results in a 1-inch (2.5-cm) skin are prohibited for the first several weeks. As the patient’s incision (Fig. 39-42). Maintain meticulous hemostasis with strength increases, gentle isotonic leg exercises are started. electrocautery as the dissection is carried to the fascia. Between the fourth and sixth postoperative week, back Incise the fascia at the midline using electrocautery. Then school instruction is resumed or started, provided that pain is insert a periosteal elevator in the midline incision. Using minimal. Lifting, bending, and stooping are gradually restarted gentle lateral movements separate the deep fascia and after the sixth week. Increased sitting is allowed as pain muscle subperiosteally from the spinous processes and permits, but long trips are to be avoided for at least 4 to 6 lamina. Obtain a lateral roentgenogram with a metal clamp weeks. Lower extremity strength is increased from the eighth to attached to the spinous process to verify the level. Now, twelfth postoperative weeks. Patients with jobs requiring much using a Cobb elevator gently sweep the remaining muscular walking without lifting are allowed to return to work within 2 attachments off in a lateral direction exposing the interlami- to 3 weeks. Patients with jobs requiring prolonged sitting nar space and the edge of each lamina. Meticulously usually are allowed to return to work within 4 to 6 weeks cauterize all bleeding points. Insert the microlumbar provided minimal lifting is required. Patients with jobs retractor into the wound and adjust the microscope. Identify requiring heavy labor or long periods of driving are not allowed the ligamentum flavum and lamina. Use a pituitary rongeur to return to work until 6 to 8 weeks and then to a modified duty. to remove the superficial leaf of the ligamentum. Using a no. Some patients with jobs requiring exceptionally heavy manual 15 blade with the microscope, carefully incise the thinned labor may have to permanently modify their occupation or seek ligamentum flavum superficially. Then use a Penfield no. 4 a lighter occupation. Keeping the patient out of work beyond dissector to perforate the ligamentum. Minimal force should 3 months rarely improves recovery or pain relief. be used in this maneuver to prevent penetration of the dura. Once the ligamentum is open, use a 45-degree Kerrison rongeur to remove the ligamentum flavum laterally. The ◆ Microlumbar Disc Excision lamina, facet, and facet capsule should remain intact. Microlumbar disc excision has replaced the standard open However, one must remove the ligamentum flavum and laminectomy as the procedure of choice for herniated lumbar bone from the lamina as needed to clearly identify the nerve disc. This procedure can be done on an outpatient basis and root. Once identified, carefully mobilize the root medially; allows better lighting, magnification, and angle of view with a this may require some bony removal. Gently dissect the much smaller exposure. Because of the limited dissection nerve free from the disc fragment to avoid excessive traction required there is less postoperative pain and a shorter hospital on the root. Bipolar cautery for hemostasis is very helpful. stay. Zahrawi reported 103 outpatient microdiscectomies, Once mobilized, retract the root medially. Maintain the noting 88% excellent and good results in the 83 who responded. orientation of the Kerrison parallel to that of the nerve root Newman reported 75 conventional laminectomies done on an at all times. Once identified, the nerve root can be gently outpatient basis and noted 2 complications unrelated to the mobilized and retracted medially. Then make an extradural procedure or the outpatient setting. Kelly et al. noted less exploration using a 90-degree hook. In large herniations the pulmonary morbidity and temperature elevation in patients nerve root appears as a large, white, glistening structure and after microlumbar discectomy. Numerous other investigators can easily be mistaken for a ruptured disc. Follow the root such as Silvers, Zahrawi, Lowell et al., and Moore et al. to the pedicle if necessary to be certain of its location. The reported excellent results with low morbidity and early return small opening and magnification can make the edge of the to activity using microlumbar disc excision. Williams, the dural sac appear as the nerve root. When using bipolar originator of the term, questioned its current usage, since the cautery make sure only one side is in contact with the nerve concept of the technique has changed over the years. root to avoid thermal injury to the nerve. Also, when using Microlumbar discectomy requires an operating microscope a Kerrison rongeur for bone or ligamentum removal, orient with a 400-mm lens, special retractors, a variety of small- it parallel to the course of the nerve root as much as possible angled Kerrison rongeurs of appropriate length, micro instru- to minimize the risk of nerve root or dural injury. Epidural ments, and preferably a combination suction–nerve root fat is not removed in this procedure. Insert the suction–nerve retractor. The procedure is performed with the patient prone. A root retractor, with its tip turned medially under the nerve vacuum pack is molded around the patient, and an inflatable root, and hold the manifold between the thumb and index pillow is positioned under the abdomen and is removed after Copyright 2003. Elsevier Science (USA). All Rights Reserved. continued

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Penfield no. 4 Ligamentum dissector L3 Spinous flavum process L4

A L5 B Lamina Spinous process Ilium Lamina

Facet joint capsule

Sacrum

Nerve root Penfield no. 4 dissector Micro 45-degree angle Suction (into opening in HNP) Ligamentum Kerrison rongeur retractor Spinous flavum process

Lamina C Lamina D Lamina Lamina

Facet

Spinous process Disc forceps

Suction retractor

Fig. 39-42 Microlumbar disc excision. A, Position of Nerve Nerves E skin incision for microlumbar disc excision. B, Entrance root of epidural space by penetration of ligamentum ﬂavum. C, Removal of ligamentum ﬂavum with Kerrison rongeur. D, Dilation of annular defect before removal of disc fragment. E, Decompression of disc hernia by repeated small evacuations with discectomy forceps. (Redrawn from Cauthen JC: Lumbar spine surgery, Baltimore, 1983, Williams & Wilkins.) Disc Vertebra

finger. With the nerve root retracted, the disc will now be insert the instrument into the disc space beyond the angle of visible as a white, fibrous, avascular structure. Small tears the jaws, which usually is about 15 mm, to minimize the risk may be visible in the annulus under the magnification. Now of anterior perforation and vascular injury. Remove the enlarge the annular tear with a Penfield no. 4 dissector and exposed disc material. Do not curet the disc space. Inspect remove the disc material with the microdisc forceps. Do not the root and adjacent dura for disc fragments. Irrigate the

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disc space using a lock syringe and 18-gauge spinal needle inserted into the disc space. Obtain meticulous hemostasis. If the expected pathology is not found, review preoperative imaging studies for level and sidedness. Also obtain a repeat L4 L4 root roentgenogram with a metallic marker at the disc level to verify the level. Be aware of bony anomalies that may alter L4-L5 disc the numbering of the vertebrae on imaging studies. Close the fascia and the skin in the usual fashion, using absorbable L5 sutures.

AFTERTREATMENT. Postoperative care is similar to that after standard open disc surgery. Typically this procedure is done on an outpatient basis. Injecting the paraspinal muscles on the involved side with Bupivacaine 0.5% with epinephrine at the beginning of the procedure and additional Bupivacaine Fig. 39-43 Lateral approach for discectomy. L4 foraminotomy allows exposure of root. (Redrawn from Donaldson WF et al: Spine at the conclusion aids patient mobilization immediately 18:1264, 1993; original by P Gretsky.) postoperatively.

Endoscopic Techniques Endoscopic techniques have been developed over the past several years with the purported advantage of shortened A disc that is far lateral may require exposure outside the hospital stay and faster return to activity. These techniques spinal canal. This area is approached by removing the generally are variations of the microdiscectomy technique intertransverse ligament between the superior and inferior using an endoscope rather than the microscope and different transverse processes lateral to the spinal canal. The disc hernia types of retractors. Thus far the purported advantages have not usually is anterior to the nerve root that is found in a mass of been demonstrated. This remains another alternative technique. fat below the ligament. A microsurgical approach or a per- Each system is somewhat unique, and the reader is referred to cutaneous approach are good methods for dealing with this the technique guide of the various manufacturers for details. problem. Maroon et al. also recommended discography to The basic principles remain the same as with microdiscectomy. confirm the lesion before surgery. Epstein noted little difference between lateral intertransverse exposure, facetectomy, and a Additional Exposure Techniques more extensive hemilaminectomy with medial facetectomy. A large disc herniation or other pathological condition such Donaldson et al. recommended the lateral approach after first as lateral recess stenosis or foraminal stenosis may require a finding the root medially and dissecting laterally down to a greater exposure of the nerve root. Usually the additional probe on top of the root (Fig. 39-43), and Strum et al. pathological condition can be identified before surgery. If the recommended an anterolateral approach. extent of the lesion is known before surgery, the proper approach can be planned. Additional exposure includes Lumbar Root Anomalies hemilaminectomy, total laminectomy, and facetectomy. Hemi- Lumbar nerve root anomalies (Figs. 39-44 to 39-47) are laminectomy usually is required when identifying the root is more common than may be expected, and they rarely are a problem. This may occur with a conjoined root. Total correctly identified with myelography. Kadish and Simmons laminectomy usually is reserved for patients with spinal identified lumbar nerve root anomalies in 14% of 100 cadaver stenoses that are central in nature, which occurs typically in examinations. They noted nerve root anomalies in only 4% of cauda equina syndrome. Facetectomy usually is reserved for 100 consecutive metrizamide myelograms. They identified four foraminal stenosis or severe lateral recess stenosis. If more than types of anomalies. Type I is an intradural anastomosis between one facet is removed, then a fusion should be considered in rootlets at different levels. Type II is an anomalous origin of the addition. This is especially true in the removal of both facets nerve roots. They separated this type into four subtypes: and the disc at the same interspace in a young, active person (1) cranial origin, (2) caudal origin, (3) combination of cranial with a normal disc height at that level. and caudal origin, and (4) conjoined nerve roots. Type III is an On rare occasions disc herniation has been reported to be extradural anastomosis between roots. Type IV is the extradural intradural. An extremely large disc that cannot be dissected division of the nerve root. The surgeon must be aware of the from the dura or the persistence of an intradural mass after possibility of anomalous roots hindering the disc excision. This dissection of the disc should alert one to this potential problem. may require a wider exposure. Sectioning of these roots results Excision of an intradural disc requires a transdural approach, in irreversible neurological damage. Traction on anomalous which increases the risk of complications from CSF leak and nerve roots has been suggested as a cause of sciatic symptoms intradural scarring. without disc herniation. Copyright 2003. Elsevier Science (USA). All Rights Reserved.

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Fig. 39-44 Type I nerve root anomaly: intradural anastomosis. (From Kadish LJ, Simmons EH: J Bone Joint Surg 66B:411, 1984.) CD

Results of Open (Micro or Standard) Surgery for Disc Herniation Numerous retrospective and some prospective reviews of open disc surgery are available. The results of these series vary greatly with respect to patient selection, treatment method, evaluation method, length of follow-up, and conclusions. Good Fig. 39-45 Type II: anomalous origin of nerve roots. A, Cranial results range from 46% to 97%. Complications range from origin. B, Caudal origin. C, Closely adjacent nerve roots. D, Con- joined nerve roots. (From Kadish LJ, Simmons EH: J Bone Joint none to over 10%. The reoperation rate ranges from 4% to over Surg 66B:411, 1984.) 20%. The detailed studies of Spangfort, Weir, and Rish are suggested for more detailed analysis. A comparison between techniques also reveals similar reports. Several points do stand out in the analysis of the results of lumbar disc surgery. Patient selection appears to be extremely important. Several studies noted that a low educational level is significantly related to poor results of surgery. The works of Wiltse and Rocchio, and Gentry indicate that valid results of the MMPI (hysteria and hypochondriasis T scores) are very good indicators of surgical outcome regardless of the degree of the pathological condition. The extremely detailed work of Weir suggests that the duration of the current episode, the age of the patient, the presence or absence of predominant back pain, the number of previous hospitalizations, and the presence or absence of compensation for a work injury are factors affecting final outcome. Spangfort’s work also indicates that the softer the findings for disc herniation clinically and at the time of Fig. 39-46 Type III nerve root anomaly: extradural anastomosis. surgery, the lower the chance for a good result. (From Kadish LJ, Simmons EH: J Bone Joint Surg 66B:411, 1984.)

Complications of Open Disc Excision The complications associated with standard disc excision developed in ﬁve patients. Laceration of the aorta or iliac artery and microlumbar disc excision are similar. Spangfort’s series also has been described as a rare complication of this operation. (Table 39-9) of 2503 open disc excisions lists a postoperative Rish, in a more recent report with a 5-year follow-up, noted a mortality of 0.1%, a thromboembolism rate of 1.0%, a total complication rate of 4% in a series of 205 patients. The postoperative infection rate of 3.2%, and a deep disc space major complication in his series involved a worsening infection rate of 1.1%. Postoperative cauda equina lesions neuropathy postoperatively. There was one disc space infection

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a free fat graft or fascial graft can be sutured to the dura. Fibrin glue applied to the repair also is helpful but will not seal a significant leak. 3. All repairs should be tested by using the reverse Trendelenburg position and Valsalva maneuvers. 4. Paraspinous muscles and overlying fascia should be closed in two layers with nonabsorbable suture used in a watertight fashion. Drains should not be used. 5. Bed rest in the supine position should be maintained for 4 to 7 days after the repair of lumbar dural defects. A lumbar drain should be placed if the integrity of the closure is questionable. The development of headaches on standing and a stormy Fig. 39-47 Type IV nerve root anomaly: extradural division. postoperative period should alert one to the possibility of an (From Kadish LJ, Simmons EH: J Bone Joint Surg 66B:411, 1984.) undetected CSF leak. This can be confirmed by MRI studies. The presence of glucose in drainage fluid is not a reliable diagnostic test. On rare occasions a pseudomeningocele has been implicated as a cause of persistent pain from pressure on Table 39-9 Complications of Lumbar Disc a nerve root by the cystic mass. Surgery

Complication Incidence (%) ◆ Dural Repair Augmented with Fibrin Glue 1. Cauda equina syndrome 0.2 Dural repair can be augmented with fibrin glue. Pressure testing 2. Thrombophlebitis 1.0 of a dural repair without fibrin glue reveals that the dura is able 3. Pulmonary embolism 0.4 to withstand 10 mm of pressure on day 1 and 28 mm on day 7. 4. Wound infection 2.2 5. Pyogenic spondylitis 0.07 With fibrin glue the dura is able to withstand 28 mm on day 1 6. Postoperative discitis 2.0 (1122 patients) and 31 mm on day 7. Fibrin glue also can be used in areas of 7. Dural tears 1.6 troublesome bleeding or difficult access for closure such as the 8. Nerve root injury 0.5 ventral aspect of the dura. 9. Cerebrospinal fluid fistula * 10. Laceration of abdominal vessels * TECHNIQUE 39-23 11. Injury to abdominal viscera * Mix 20,000 U of topical thrombin and 10 ml of 10 calcium chloride. Draw the mixture up into a syringe. In another Modified from Spangfort EV: Acta Orthop Scand Suppl 142:65, 1972. *Rare occurrence (numbers 10 and 11 not identified in Spangfort’s study but syringe, draw5Uofcryoprecipitate and inject equal reported elsewhere). quantities of each onto the dural repair or tear. Allow the glue to set to the consistency of ‘‘Jello’’ (Box 39-10). Commercially available kits also are available. and one wound infection. Dural tears with CSF leaks, pseudomeningocele formation, CSF fistula formation, and Free Fat Grafting meningitis also are possible but are more likely after re- Fat grafting for the prevention of postoperative epidural operation. The complications of microlumbar disc excision scarring has been suggested by Kiviluoto; Jacobs, McClain, appear to be lower than with standard laminectomy. Alexander and Neff; and Bryant, Bremer, and Nguyen. The study by reviewed patients who had sustained incidental durotomy at the Jacobs et al. indicated that free fat grafts were superior to time of disc surgery and found no perioperative morbidity or Gelfoam in the prevention of postoperative scarring. The compromise of results if the dura was repaired. They noted a current rationale for free fat grafting appears to be the pos- 4% incidence of this complication in 450 discectomies. sibility of making any reoperation easier. Unfortunately, the The presence of a dural tear or leak results in the potentially benefit of reduced scarring and its relationship to the prevention serious problems of pseudomeningocele, CSF leak, and of postoperative pain have not been established, neither has the meningitis. Eismont, Wiesel, and Rothman suggested five basic increased ease of reoperation in patients in whom fat grafting principles in the repair of these leaks (Fig. 39-48): was performed. Caution should be taken in applying a fat graft 1. The operative field must be unobstructed, dry, and well to a large laminar defect because this has been reported to result exposed. in an acute cauda equina syndrome in the early postoperative 2. Dural suture of a 4-0 or 6-0 gauge with a tapered or period. We currently reserve the use of a fat graft (or fascial reverse cutting needle is used in either a simple or grafts) for dural repairs and small laminar defects where the running locking stitch. If the leak is large or inaccessible, graft is supported by the bone. A study by Jensen et al. found

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Fig. 39-48 A, Illustration of dural repair using running-locking dural suture on taper or reverse-cutting, A one-half-circle needle. A smaller- C sized suture should be used. Use of suction with sucker and small cotton pledgets is essential to protect nerve roots while operative ﬁeld is kept dry of CSF. B, Single dural stitches can be used to achieve closure, each suture end being left long. Second needle then is attached to free suture end, and ends of suture are passed through piece of muscle or fat, which is tied down over repaired tear to help to achieve watertight closure. Whenever dural material is inadequate to allow closure without placing excessive pressure on underlying neural tissues, free graft of fascia or fascia lata, or freeze-dried dural graft, should be secured to margins of dural tear using simple sutures of appropriate size. C, For small dural defects in relatively inaccessible areas, transdural approach can be B used to pull small piece of muscle or fat into defect from inside out, thereby sealing CSF leak. Cen- tral durotomy should be large enough to expose defect from dural sac. Durotomy is then closed in standard watertight fashion. (From Eismont FJ, Wiesel SW, Roth- man RH: J Bone Joint Surg 63A: 1132, 1981.)

BOX 39-10 • Fibrin Glue the patient is thin, a separate incision over the buttock may be required to get sufficient fat to fill the defect. INGREDIENTS CHEMONUCLEOLYSIS Two vials of topical thrombin, 10,000 U each 10 ml of calcium chloride CHEMONUCLEOLYSIS 5 U of cryoprecipitate Two 5-ml syringes Chemonucleolysis has been used in the United States for more Two 22-gauge spinal needles than 30 years. The enzyme was released for general use by the Food and Drug Administration (FDA) in December of 1982. INSTRUCTIONS Before its release in the United States it was used extensively Do not use saline that comes with thrombin Mix thrombin and calcium chloride in Europe and Canada. A wealth of experimental and clinical Draw mixture into syringe information exists concerning the technique and the enzyme. Draw cryoprecipitate into second syringe Specific guidelines have been suggested by the FDA regarding Apply equal amounts to area of need the use of the enzyme in the United States. The initial Allow to set to a ‘‘Jello’’ consistency enthusiasm for the use of chymopapain has all but vanished in the United States; however, the use of this enzyme is still popular in Europe and elsewhere, with therapeutic results that fat grafts decreased the dural scarring but not radicular scar similar to surgery. formation. The clinical outcome was not improved. Because of the disclosure of neurological sequelae and other The technique of free fat grafting is straightforward. At the complications, the original guidelines issued in January of 1983 end of the procedure, just before closing, take a large piece of were radically changed. Those interested in performing the subcutaneous fat and insert it over the laminectomy defect. If technique should contact the pharmaceutical companies that Copyright 2003. Elsevier Science (USA). All Rights Reserved.

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Table 39-10 Results and Complications of Chemonucleolysis and Open Disc Excision

Results (percent)

No. Partial/ Persistent Technique Year Performed Excellent Good None Worse Complications Reoperation Back Pain

Open Disc Semmes 1955 1440 53.6 43.3 1.7 1.4 NA 6.3 Spangfort 1972 2503 76.9 17.0 5.0 0.5 8.0 31.5 Weir 1979 100 73.0 22.0 3.0 1.0 NA NA Rish 1984 57 74.0 17.0 9.0 4.0 18.0 Chemonucleolysis Illinois trial 1982 273 90.0 10.0 1.1 Javid 1983 40 82.0 18.0 Nordby 1983 641 55.0 25.0 20.0 NA NA

produce the drug for information regarding training and phy. Patients with moderate lateral recess or foraminal stenosis certification in the technique. Treating physicians also are may worsen after the procedure because of collapse of the disc encouraged to frequently check the package insert accompa- space and narrowing of the foraminal opening. Large disc nying the drug and the information bulletins sent out by the herniations may not shrink sufficiently to result in relief of FDA and the pharmaceutical companies regarding any new symptoms, and sequestered discs may be untouched by the changes in the protocol or use of the enzyme. Careful patient enzyme. Smith et al. reported cauda equina syndromes in three selection and proficiency in performing this procedure are patients after chymopapain was injected after a myelogram mandatory. revealed a complete block. The indications for the use of chemonucleolysis are the Chymopapain injection is specifically contraindicated in same as for open surgery for disc herniation. Fraser reported the patients with a known sensitivity to papaya, papaya derivatives, results of 60 patients treated for lumbar disc herniation in a or food containing papaya, such as meat tenderizers. Other 2-year double-blind study of chemonucleolysis. At 2 years 77% contraindications include severe spondylolisthesis, severe, of the patients treated with chymopapain were improved, progressive neurological deficit or paralysis, and evidence of whereas only 47% of the saline injection group were improved. spinal cord tumor or a cauda equina lesion. The enzyme cannot At 2 years from injection 57% of the chymopapain group were be injected in a patient who has been previously injected, pain-free compared with 23% of the placebo group. Numerous regardless of the level injected. Use of chymopapain is limited other studies of the efficacy of the drug place the good or to the lumbar intervertebral discs. Relative contraindications excellent results between 40% and 89%, which is comparable include allergy to iodine or iodine contrast material, use of the to the clinical reports for open surgery (Table 39-10). enzyme in a previously operated disc, patients with elevated Tregonning et al. reviewed 145 patients who had received allergy studies such as radioallergosorbent (RAST), Chymo- chymopapain injection and 91 patients who had laminectomy at Fast, and skin testing with the drug, and patients with a severe 10-year follow-up and concluded that the surgically treated allergic history, especially with a previous anaphylactic attack. group had slightly better results than the chymopapain group. Spinal Instability from Degenerative Javid compared 100 patients who had laminectomy with 100 patients who had chemonucleolysis and reported that patients Disc Disease who had received chymopapain had better results with respect Spinal Instability from Degenerative to 6-month overall improvement, short-term improvement in Disc Disease numbness and motor strength, and longer improvement in sensory status. Also, chymopapain was significantly less Farfan defined spinal instability (caused by degenerative disc expensive than laminectomy. Nordby and Wright reviewed 45 disease) as a clinically symptomatic condition without new clinical studies of chymopapain and laminectomy. They injury, in which a physiological load induces abnormally large concluded that chemonucleolysis was somewhat less effective deformations at the intervertebral joint. Biomechanical studies than open disc excision, but it did avoid the trauma of surgery have revealed abnormal motion at vertebral segments with and postoperative fibrosis. degenerative discs and the transmission of the load to the facet As with open disc surgery, this technique is not applicable in joints. Numerous attempts at roentgenographic definition of all lumbar disc herniations. The use of the drug is limited to the spinal instability with disc disease have resulted in more lumbar spine. The patient optimally has predominantly controversy than agreement as to a standard method of unilateral leg pain and localized neurological findings con- measurement. The method described by Knutsson is simple and sistent with confirmatory testing with MRI, CT, or myelogra- relatively efficient in determining anteroposterior motion. The Copyright 2003. Elsevier Science (USA). All Rights Reserved.

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A LUMBAR VERTEBRAL INTERBODY FUSION B LUMBAR VERTEBRAL INTERBODY FUSION Anterior lumbar intervertebral fusion (ALIF) and posterior lumbar intervertebral fusion (PLIF) have been suggested as definitive procedures for lumbar disc disease. Biomechanically the lumbar interbody fusion offers the greatest stability. It also eliminates the disc segment as a further source of pain. The primary problems are the more involved and potentially dangerous dissection, the risk of graft extrusion, and pseudarthrosis. Most series of these fusions include a significant number of salvage procedures and complex pathological conditions, thus making direct comparison with primary disc surgery difficult. The routine use of such procedures for simple lumbar disc herniation with sciatica is not justified. Most often, different types of grafts are taken from the iliac Fig. 39-49 Loss of motion segment integrity. A, Translation. crest; however, hollow, perforated cylinders filled with B, Angular motion. (From American Medical Association: autologous bone are now available for use in posterior and Guide to the evaluation of permanent impairment, ed 4, Chicago, anterior lumbar intervertebral fusion. These cylinders are not 1993, AMA.) indicated for spondylolisthesis greater than grade 1, osteopenia, malignancy, or gross obesity. Kuslich and Dowdle reported 98% fusion at one level anteriorly and 89% fusion at two levels with a slightly better functional improvement than the fusion fourth edition of the American Medical Association Guide to rates using this device. This device also can be introduced by the Evaluation of Permanent Impairment defined instability as a percutaneous, laparoscopic anterior approach. The laparo- an anterior slip of 5 mm or more in the thoracic or lumbar spine scopic approach requires a team consisting of a laparoscopic (Fig. 39-49, A) or a difference in the angular motion of two general surgeon, spine surgeon, anesthesiologist, camera adjacent motion segments more than 11 degrees from T1 to L5 operator, scrub nurse, circulating nurse, and a radiology and motion greater than 15 degrees at L5-1 compared with L4-5 technician. It is strongly advised that the team attend a course (Fig. 39-49, B). There is little controversy as to the surgical on this technique or observe several cases before attempting treatment of lumbar spinal instability and spinal fusion of the such a procedure. unstable segments. The type of fusion performed and the indications for fusion are areas of controversy. The major problem in spinal instability is the correlation of ◆ Anterior Lumbar Interbody Fusion the patient’s symptoms of giving way, catching, and predominant back pain to the roentgenographic identification of TECHNIQUE 39-24 instability. Other factors such as concomitant spinal stenosis, Place the patient supine on a radiolucent operating table. disc herniation, and psychological problems only complicate Support the lumbar spine with a rolled sheet or inflatable any evaluation of spinal instability. Currently the decision for bag. Prepare and drape the patient’s abdomen from upper surgery for clinically significant lumbar spine instability caused chest to groin, leaving the iliac crests exposed for obtaining by degenerative disc disease should be made on an individual bone grafts. Expose the lumbar spine through a transab- patient basis with all the factors and risks weighed carefully. dominal or retroperitoneal approach as desired. Mobilize the DISC EXCISION AND FUSION great vessels over the segment to be excised. Ligate the DISC EXCISION AND FUSION median artery and vein at the bifurcation of the aorta to prevent tearing this structure when exposing the disc at L4-5 The necessity of lumbar fusion at the same time as disc excision or L5-S1. was first suggested by Mixter and Barr. In the first 20 years after Identify and inspect all major structures before and after their discovery the combination of disc excision and lumbar disc excision and fusion. Use anteroposterior fluoroscopy to fusion was common. More recent data comparing disc excision confirm the proper disc level. Then incise the anterior alone with the combination of disc excision and fusion by longitudinal ligament superiorly or inferiorly over the edge Frymoyer et al. and others indicate that there is little if any of the vertebral body. Elevate the ligament as a flap if advantage to the addition of a spinal fusion to the treatment of possible. Next remove the annular and nuclear material of simple disc herniation. These studies do indicate that spinal the disc. The use of magnification can be beneficial as the fusion increases the complication rate and lengthens recovery. dissection nears the posterior longitudinal ligament. Re- The indications for lumbar fusion should be independent of the move all nuclear material from the disc space. indications for disc excision for sciatica.

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Fig. 39-50 Anterior lumbar intervertebral fusion (ALIF) can be performed using tricortical iliac crest graft (A) or ﬁbular grafts (B). (A from Ruge D, Wiltse LL: Spinal disorders: diagnosis and treatment, Philadelphia, 1977, Lea & Febiger; B from Wiltse LL: Instr Course Lect 28:207, 1979.)

AFTERTREATMENT. The patient is allowed to sit as soon as Techniques for fusion vary. Some prefer to use dowel possible. Extension of the lumbar spine is prohibited for at least grafts to fill the space. Others prefer to use tricortical iliac 6 weeks. Bracing or casting is left to the discretion of the grafts (Fig. 39-50). Obtain the grafts from the iliac crest as surgeon after considering the stability of the grafts and described for anterior cervical fusions (Chapter 36). Prepare reliability of the patient. the graft area for the desired grafting technique. We prefer tricortical grafts for this fusion. Good results using fibular grafts and banked bone also have been reported. Prepare the ◆ Posterior Lumbar Interbody Fusion vertebrae by curetting the endplates to cancellous bone posteriorly. Then carefully make a slot in the vertebra to TECHNIQUE 39-25 (Cloward) accommodate the grafts; use an osteotome slightly larger Position the patient in the prone or kneeling position as than the width of the disc space for this purpose and direct desired. Expose the spine through a midline incision the cut toward the inferior vertebral body. Try to leave the centered over the level of the pathological condition. Strip upper and lower lips of the vertebral bodies intact. Remove the muscle subperiosteally from the lamina bilaterally. Insert enough tricortical iliac bone to allow insertion of at least the laminar spreader between the spinous processes at the three individual grafts. Fashion the grafts to fit snugly in the level of pathological findings. Open and remove the space with a laminar spreader in place. Insert the grafts so ligamentum flavum from the midline laterally. Enlarge that the cancellous portions face the decorticated endplates. the opening laterally by removing the lower one third of the The grafts should be 3 to 4 mm shorter than the inferior facet and the medial two thirds of the superior facet anteroposterior diameter of the vertebral body. Impact the (Fig. 39-51, A). The upper lamina also can be thinned by grafts and seat them behind the anterior rim of the vertebral undercutting to increase the anteroposterior diameter of the bodies. Usually three such grafts can be inserted. Add canal. Retract the lower nerve root and dura to the midline additional cancellous chips around the grafts. Suture the and protect it with the self-retaining nerve root retractor. anterior longitudinal ligament. Close the retroperitoneum Cauterize the epidural vessels with bipolar cautery. Cut out and abdomen in the usual manner. the disc and vessels over the annulus laterally. Remove as

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Fig. 39-51 Posterior lumbar interbody fusion technique. A, Bilat- eral laminotomy with preservation of facets. Control of epidural A B hemorrhage. Dipolar or insulated coagulation forceps are used on left side. On right side, epidural hemorrhage is controlled by impacted surgical tampons. Impacted surgical tampons also push nerve root medially and expose disc space without need for nerve root retractor. B, After intervertebral rims are removed, cleavage of disc attachment to cortical plate is identi- ﬁed. Curved, up-bite curet is used to remove concave centrum of lower cartilaginous plate. Then detached large chunks of disc material are removed with rongeur. C C, Medial graft advancement with single chisel. (From Cauthen JC: Lumbar spine surgery, Baltimore, 1983, Williams & Wilkins.)

reasons for the failures have been advanced. The best results much disc material as possible (Fig. 39-51, B). Remove a from repeat surgery for disc problems appear to be related to thin layer of the endplates posteriorly. Repeat this process the discovery of a new problem or identification of a previously on the opposite side. Remove the remaining anterior edges undiagnosed or untreated problem. Waddell et al. suggested of the endplates to the anterior longitudinal ligament. This that the best results from repeat surgery occur when the patient must be done under direct vision to avoid injury to the great had experienced 6 months or more of complete pain relief after vessels. Prepare a surface of bleeding cancellous bone on the first procedure, when leg pain exceeded back pain, and both vertebral bodies. Obtain tricortical iliac crest grafts as when a definite recurrent disc could be identified. They previously noted from the posterior iliac crest. (Cloward identified adverse factors such as scarring, previous infection, used frozen human cadaver bone grafts.) Shape the grafts to repair of pseudarthrosis, and adverse psychological factors. be slightly shorter and the same height or slightly higher Similar factors were identified by Lehmann and LaRocca and than the disc shape. Tamp the first graft in place and lever it Finnegan et al. Satisfactory results from reoperation have been medially to allow insertion of the remaining grafts. Repeat reported to be from 31% to 80%. Patients should expect the procedure on the opposite side (Fig. 39-51, C). Remove improvement in the severity of symptoms rather than complete the laminar spreader and check the graft for stability. relief of pain. As the frequency of repeat back surgeries Close the wound in the usual fashion. increases, the chance of a satisfactory result drops precipi- tously. Spengler et al. and Long et al. observed that the major cause of failure is improper patient selection. AFTERTREATMENT. Aftertreatment is the same as for The recurrence or intensification of pain after disc surgery lumbar discectomy (p. ••••). Early walking is encouraged. should be treated with the usual conservative methods initially. Failed Spine Surgery If these methods fail to relieve the pain, the patient should be completely reevaluated. Frequently a repeat history and Failed Spine Surgery physical examination will give some indication of the problem. Additional testing should include psychological testing, my- One of the greatest problems in orthopaedic surgery and elography, MRI to check for tumors or a higher disc herniation, neurosurgery is the treatment of failed spine surgery. Numerous and reformatted CT scans to check for areas of foraminal Copyright 2003. Elsevier Science (USA). All Rights Reserved.

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 62/74 Pg: 2016 Team: CHAPTER 39 ◆ Lower Back Pain and Disorders of Intervertebral Discs 2017 stenosis or for lateral herniation. The use of the differential Elsberg CA: Experiences in spinal surgery: observations upon 60 spinal, root blocks, facet blocks, and discograms also can help laminectomies for spinal disease, Surg Gynecol Obstet 16:117, 1913. Forst JJ: Contribution a l’etude clinique de la sciatique, thesis, Lyon, identify the source of pain. The presence of abnormal France, 1881. psychological test results or an abnormal differential spinal Goldthwait JE: The lumbosacral articulations: an explanation of many should serve as a modifier to any suggested treatment indicated cases of ‘‘lumbago,’’ ‘‘sciatica,’’ and paraplegia, Bost Med Surg J 164:365, 1911. by the other testing. Satisfactory nonoperative treatment of this Hall GW: Neurologic signs and their discoverers, JAMA 95:703, 1930. problem should be attempted before additional surgery is Kepes ER, Duncalf D: Treatment of backache with spinal injections of local performed, provided that this surgery is elective. A distinct, anesthetics, spinal and systemic steroids: a review, Pain 22:33, 1985. Kirkaldy-Willis WH, Hill RJ: A more precise diagnosis for low-back pain, surgically correctable, anatomical problem should be identified Spine 4:102, 1979. before surgery is contemplated. The surgery should be tailored Kocher T: Die Verlitzungen der Wirbelsaule Zurleich Als Beitrag zur specifically to the anatomical problem(s) identified. Physiologic des Menschichen Ruchenmarks, Mitt Grenzgeb Med Chir 1:415, 1896. REPEAT LUMBAR DISC SURGERY Lase`gue C: Considerations sur la sciatique, Arch Gen Med 2:558, 1864. Love JG: Removal of intervertebral discs without laminectomy, Proc Staff ◆ Meet Mayo Clin 14:800, 1939. REPEAT LUMBAR DISC SURGERY Middleton GS, Teacher JH: Extruded disc at T12-L1 level: microscopic The technique of repeat lumbar disc surgery at the same level exam showed it to be nucleus pulposus, Glasgow Med J 76:1, 1911. and side as the previous procedure is nearly the same as for Middleton GS, Teacher JH: Injury of the spinal cord due to rupture of an initial surgery. The procedure is longer and involves more intervertebral disc during muscular effort, Glasgow Med J 76:1, 1911. Mixter WJ, Barr JS: Rupture of the intervertebral disc with involvement of meticulous dissection. the spinal canal, N Engl J Med 211:210, 1934. Murphy PL, Volinn E: Is occupational low back pain on the rise? Spine TECHNIQUE 39-26 24:691, 1999. Oppenheim H, Krause F: Ueber Einklemmung bzw. Strangulation der Approach the spine using the method described previously. Cauda equina, Deutsche Med Wochenschr 35:697, 1909. Identify normal tissue first. Use a curet to carefully remove Robinson JS: Sciatica and the lumbar disk syndrome: a historic perspective, scar from the edges of the lamina. Then remove additional South Med J 76:232, 1983. Semmes RE: Diagnosis of ruptured intervertebral discs without contrast bone as necessary to expose normal dura. Identify the myelography and comment upon recent experience with modified pedicles superiorly and inferiorly if there is any question of hemilaminectomy for their removal, YaleJBiolMed11:433, 1939. position and status of the root. Carry the dissection from the Shulman M, Joseph NJ, Haller CA: Effect of epidural and subarachnoid injections of a 10% butamben suspension, Reg Anesth 15:142, 1990. pedicles to identify each root. This will allow the Sjo¨qvist O: The mechanism of origin of Lase`gue’s sign, Acta Psych Neurol development of a normal plane between the dura and scar. 46(suppl):290, 1947. Maintain meticulous hemostasis with bipolar cautery. Then Smith L, Garvin PJ, Gesler RM, et al: Enzyme dissolution of the nucleus pulposus, Nature 198:1131, 1963. remove disc material as indicated by the preoperative Sugar O: Charles Lase`gue and his ‘‘Considerations on Sciatica,’’ JAMA evaluation. Meticulously check the roots, dura, and posterior 253:1767, 1985. longitudinal ligament after removal of the offending disc Virchow R: Untersuchunger uber die Enwickelung die Schadeigrunder, Berlin, 1857, G Reimer. herniation. Spinal fusion is not performed unless an unstable Waddell G: Low back pain: a twentieth-century health care enigma, Spine spine is created by the dissection or was identified 21:2820, 1996. preoperatively as a correctable and symptomatic problem. Wiltse LL: History of lumbar spine surgery. In White AA, ed: Lumbar spine surgery: techniques and complications, St Louis, 1987, Mosby. EPIDEMIOLOGY AFTERTREATMENT. Aftertreatment is the same as for disc Andersson GBJ: Epidemiologic aspects of low-back pain in industry, Spine 6:53, 1981. excision (p. ••••). Andersson GBJ, Svensson HO, Oden A: The intensity of work recovery in low back pain, Spine 8:880, 1983. Biering-Sorensen F, Hilden J: Reproducibility of the history of low-back References trouble, Spine 9:280, 1984. Buckle PW, Kember PA, Wood AD, Wood SN: Factors influencing HISTORY occupational back pain in Bedfordshire, Spine 5:254, 1980. Alajouanine TH: From the presidential address for Professor Jean Cauchoix Carey TS, Evans A, Haler N, et al: Care-seeking among individuals with before the annual meeting of the International Society for the Study of chronic low back pain, Spine 20:312, 1995. the Lumbar Spine, San Francisco, June 1978. Damkot DK, Pope MH, Lord J, Frymoyer JW: The relationship between Aurelianus C: Acute diseases and chronic diseases, Chicago, 1950, work history, work environment, and low-back pain in men, Spine 9:395, University of Chicago Press. 1984. Barr JS, Hampton AO, Mixter WJ: Pain low in the back and ‘‘sciatica’’ due Deyo RA, Bass JE: Lifestyle and low-back pain: the influence of smoking to lesions of the intervertebral discs, JAMA 109:1265, 1937. and obesity, Spine 14:501, 1989. Catchlove RF, Braha R: The use of cervical epidural nerve blocks in the Dillane JB, Fry J, Kalton G: Acute back syndrome: a study from general management of chronic head and neck pain, Can Anaesth Soc J 31:188, practice, Br Med J 2:82, 1966. 1984. Frymoyer JW, Cats-Baril WL: An overview of the incidences and costs of Cotugnio D: Treatise on the nervous sciatica or nervous hip gout, London, low back pain, Orthop Clin North Am 22:263, 1991. 1775, J Wilkie. Frymoyer JW, Newberg A, Pope MT, et al: Spine radiographs in patients Dandy WE: Loose cartilage from the intervertebral disc simulating tumor with low-back pain: an epidemiological study in men, J Bone Joint Surg of the spinal cord, Orthop Surg 19:1660, 1929. 66A:1048, 1984. de Se`ze S: Sciatique ‘‘banale’’ et disques lombo-sacre´s, Presse Med Frymoyer JW, Pope MT, Clements JH, et al: Risk factors in low-back pain: 51-52:570, 1940. an epidemiological survey, J Bone Joint Surg 65A:213, 1983. de Se`ze S: Histoire de la sciatique, Rev Neurol 138:1019, 1982. Grabias S: Current concepts review: the treatment of spinal stenosis, J Bone Dyck P: Lumbar nerve root: the enigmatic eponyms, Spine 9:3, 1984. Joint Surg 62A:308, 1980.

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Gyntelberg F: One-year incidence of low back pain among male residents Bose K, Balasubramaniam P: Nerve root canals of the lumbar spine, Spine of Copenhagen aged 40-59, Dan Med Bull 21:30, 1974. 9:16, 1984. Harreby M, Nygaard B, Jessen T, et al: Risk factors for low back pain in Botsford DJ, Esses SI, Ogilvie-Harris DJ: In vivo diurnal variation in a cohort of 1389 Danish school children: an epidemiologic study, Eur intervertebral disc volume and morphology, Spine 15:935, 1994. Spine J 8:444, 1999. Crock HV: Normal and pathological anatomy of the lumbar spinal nerve Hult L: The Munkfors investigation, Acta Orthop Scand Suppl 16:1, 1954. root canals, J Bone Joint Surg 63B:487, 1981. Jackson RP, Simmons EH, Stripinis D: Incidence and severity of back pain de Peretti F, Hovorka I, Ganansia P, et al: The vertebral foramen: a report in adult idiopathic scoliosis, Spine 8:749, 1983. concerning its contents, Surg Radiol Anat 15:287, 1993. Johnsson K, Willner S, Pettersson H: Analysis of operated cases with Hasue M, Kikuchi S, Sakuyama Y, Ito T: Anatomical study of the lumbar renal stenosis, Acta Orthop Scand 52:427, 1981. interrelation between lumbosacral nerve roots and their surrounding Kelsey JL, White AA III: Epidemiology and impact of low-back pain, Spine tissues, Spine 8:50, 1983. 5:133, 1980. Inoue H: Three-dimensional architecture of lumbar intervertebral discs, Knutsson F: The instability associated with disk degeneration in the lumbar Spine 6:139, 1981. spine, Acta Radiol 25:593, 1944. Jayson MIV: Compression stresses in the posterior elements and pathologic Kostuik JP, Bentivoglio J: The incidence of low-back pain in adult consequences, Spine 8:338, 1983. scoliosis, Spine 6:268, 1981. Kikuchi S, Hasue M, Nishiyama K, Ito T: Anatomical and clinical studies Manning DP, Shannon HS: Slipping accidents causing low-back pain in a of radicular symptoms, Spine 9:23, 1982. gearbox factory, Spine 6:70, 1981. King AG: Functional anatomy of the lumbar spine, Orthopedics 6:1588, Middleton GS, Teacher JH: Injury of the spinal cord due to rupture of an 1983. intervertebral disc during muscular effort, Glasgow Med J 76:1, 1911. Kirkaldy-Willis WH: The relationship of structural pathology to the nerve Mooney V, Robertson J: The facet syndrome, Clin Orthop 115:149, 1976. root, Spine 9:49, 1984. Nachemson AL: Prevention of chronic back pain: the orthopaedic challenge Knutsson F: The instability associated with disc degeneration in the lumbar for the 80s, Bull Hosp Jt Dis 44:1, 1984. spine, Acta Radiol 25:593, 1944. Riihimaki H, Tola S, Videman T, Hanninen K: Low-back pain and Mayoux-Benhamou MA, Revel M, Aaron C, et al: A morphometric study occupation: a cross-sectional questionnaire study of men in machine of the lumbar foramen: influence of flexion-extension movements and of operating, dynamic physical work and sedentary work, Spine 14:204, isolated disc collapse, Surg Radiol Anat 11:97, 1989. 1989. Miller JAA, Haderspeck KA, Schultz AB: Posterior element loads in Ryden LA, Molgaard CA, Bobbitt S, Conway J: Occupational low-back lumbar motion segments, Spine 8:331, 1983. injury in a hospital employee population and epidemiologic analysis of Neumann P, Keller T, Ekstrom L, et al: Structural properties of the anterior multiple risk factors of a high-risk occupational group, Spine 14:315, longitudinal ligament: correlation with lumbar bone mineral content, 1989. Spine 18:637, 1993. Sandover J: Dynamic loading as a possible source of low-back disorders, Paajanen H, Lehto I, Alanen A, et al: Diurnal fluid changes of lumbar discs Spine 8:652, 1983. measured indirectly by magnetic resonance imaging, J Orthop Res Snook SH: The costs of back pain in industry, Spine: State of the Art 12:509, 1994. Reviews 2:11, 1987. Pazzaglia UE, Salisbury JR, Byers PD: Development and involution of the Snook SH, Webster BS: The cost of disability, Clin Orthop 221:77, 1987. notochord in the human spine, J R Soc Med 82:413, 1989. Svensson HO, Andersson GBJ: Low back pain in 40- to 47-year-old men: Pedersen H, Blunck CFJ, Gardner E: The anatomy of lumbosacral posterior work history and work environment factors, Spine 8:272, 1983. rami and meningeal branches of spinal nerves (sinu-vertebral nerves), Svensson HO, Andersson GBJ: The relationship of low-back pain, work J Bone Joint Surg 38A:2377, 1956. history, work environment and stress: a retrospective cross-sectional Postacchini F, Urso S, Ferro L: Lumbosacral nerve-root anomalies, J Bone study of 38- to 64-year-old women, Spine 14:517, 1989. Joint Surg 64A:721, 1982. Svensson HO, Vedin A, Wilhelmsson C, Andersson GBJ: Low-back pain in Rhalmi S, Yahia LH, Newman N, Isler M: Immunohistochemical study of relation to other diseases and cardiovascular risk factors, Spine 8:277, nerves in lumbar spine ligaments, Spine 18:264, 1993. 1983. Rudert M, Tillman B: Lymph and blood supply of the human intervertebral Troup JDG, Martin JW, Lloyd DC: Back pain in industry: a prospective disc: cadaver study of correlations to discitis, Acta Orthop Scand 64:37, survey, Spine 6:61, 1981. 1993. van-Doorn JW: Low back disability among self-employed dentists, Rydevik B, Brown MD, Lundborg G: Pathoanatomy and pathophysiology veterinarians, physicians, and physical therapists in The Netherlands: a of nerve root compression, Spine 9:7, 1984. retrospective study over a 13-year period (N 1,119) and an early Spencer DL, Irwin GS, Miller JAA: Anatomy and significance of fixation intervention program with 1-year follow-up (N 134), Acta Orthop Scand of the lumbosacral nerve roots in sciatica, Spine 8:672, 1983. Suppl 263:1, 1995. Wall EJ, Cohen MS, Abitbol J, Garfin SR: Organization of intrathecal nerve Waddell G, Main CJ, Morris EW, et al: Chronic low-back pain, roots at the level of the conus medullaris, J Bone Joint Surg 72A:1495, psychological distress, and illness behavior, Spine 9:209, 1984. 1990. Webster BS, Snook SH: The cost of compensable low back pain, J Occup Wilder DG, Pope MH, Frymoyer JW: The functional topography of the Med 32:13, 1990. sacroiliac joint, Spine 5:575, 1980. Webster BS, Snook SH: The cost of 1989 workers’ compensation low back Young A, Getty J, Jackson A, et al: Variations in the pattern of muscle pain claims, Spine 19:1111, 1994. innervation by the L5 and S1 nerve roots, Spine 8:616, 1983. Weisz GM: Lumbar spinal canal stenosis in Paget’s disease, Spine 8:192, Ziv I, Maroudas C, Robin G, Maroudas A: Human facet cartilage: swelling 1983. and some physiochemical characteristics as a function of age. II. Age White AWM: Low back pain in men receiving workmen’s compensation: changes in some biophysical parameters of human facet joint cartilage, a follow-up study, Can Med Assoc J 101:61, 1969. Spine 18:136, 1993. Wilder DG, Woodworth BB, Frymoyer JW, Pope MH: Vibration and the human spine, Spine 7:243, 1982. NATURAL HISTORY OF DISC DISEASE Biering-Sørensen F, Hilden J: Reproducibility of the history of low-back GENERAL DISC AND SPINE ANATOMY trouble, Spine 9:280, 1984. Adams MA, Hutton WC: The mechanical function of the lumbar Gibson MJ, Szypryt EP, Buckley JH, et al: Magnetic resonance imaging of apophyseal joints, Spine 8:327, 1983. adolescent disc herniation, J Bone Joint Surg 69B:699, 1987. Bogduk N: The clinical anatomy of the cervical dorsal rami, Spine 7:319, Goldthwait E: Low-back lesions, J Bone Joint Surg 19:810, 1937. 1982. Hakelius A: Prognosis in sciatica: a clinical follow-up of surgical and Bogduk N: The innervation of the lumbar spine, Spine 8:286, 1983. nonsurgical treatment, Acta Orthop Scand 129(suppl):1, 1970. Bogduk N, Engel R: The menisci of the lumbar zygapophyseal joints: a Jackson RP, Simmons EH, Stripinis D: Incidence and severity of back pain review of their anatomy and clinical significance, Spine 9:454, 1984. in adult idiopathic scoliosis, Spine 8:749, 1983. Bogduk N, Macintosh JE: The applied anatomy of the thoracolumbar Jayson MIV: Compression stresses in the posterior elements and pathologic fascia, Spine 9:164, 1984. consequences, Spine 8:338, 1983.

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Kelsey JL, Githens PB, White AA III, et al: An epidemiologic study of Boden SD, McCowin PR, Davis DO, et al: Abnormal magnetic-resonance lifting and twisting on the job and risk for acute prolapsed lumbar scans of the cervical spine in asymptomatic subjects, J Bone Joint Surg intervertebral disc, J Orthop Res 2:61, 1984. 72A:1178, 1990. Kirkaldy-Willis WH, Hill RJ: A more precise diagnosis for low-back pain, Boos N, Rieder R, Schade V, et al: The diagnostic accuracy of magnetic Spine 4:102, 1979. resonance imaging, work perception, and psychosocial factors in Matsui H, Kanamori M, Ishihara H, et al: Familial predisposition for identifying symptomatic disc herniations, Spine 20:2613, 1995. lumbar degenerative disc disease, Spine 23:1029, 1998. Brem SS, Hafler DA, Van Uitert RL, et al: Spinal subarachnoid hematoma: Miller JAA, Schmatz C, Schultz AB: Lumbar disc degeneration: correlation a hazard of lumbar puncture resulting in reversible paraplegia, N Engl with age, sex and spine level in 600 autopsy specimens, Spine 13:2173, J Med 304:1020, 1981. 1988. Charles MF, Byrd SE, Cohn ML, Huntington CT: Metrizamide com- Pope MH, Bevins T, Wilder DG, Frymoyer JW: The relationship between puter tomography of the postoperative lumbar spine, Orthop Rev 11:49, anthropometric, postural, muscular, and mobility characteristics of males 1982. age 18-55, Spine 10:644, 1985. Coin CG: Cervical disk degeneration and herniation: diagnosis by Roland M, Morris R: A study of the natural history of back pain. I. computerized tomography, South Med J 77:979, 1984. Development of a reliable and sensitive measure of disability in low- Collier BD, Johnson RP, Carrera GF, et al: Painful spondylolysis or back pain, Spine 8:141, 1983. spondylolisthesis studied by radiography and single-photon emission Rydevik B, Brown MD, Lundborg G: Pathoanatomy and pathophysiology computed tomography, Radiology 154:207, 1985. of nerve root compression, Spine 9:7, 1984. Deburge A, Benoist M, Boyer D: The diagnosis of disc sequestration, Spine Saal JA: Natural history and nonoperative treatment of lumbar disc 9:496, 1984. herniation, Spine 21:2S:1996. Delamarter RB, Bohlman HH, Dodge LD, Biro C: Experimental lumbar Sandover J: Dynamic loading as a possible source of low-back disorders, spinal stenosis: analysis of the cortical evoked potentials, microvascu- Spine 8:652, 1983. lature, and histopathology, J Bone Joint Surg 72A:110, 1990. Takata K, Inoue S, Takahashi K, Ohtsuka Y: Swelling of the cauda equina Delamarter RB, Leventhal MR, Bohlman HH: Diagnosis of recurrent in patients who have herniation of a lumbar disc: a possible pathogenesis lumbar disc herniation vs postoperative scar by gadolinium-DTPA- of sciatica, J Bone Joint Surg 70A:3361, 1988. enhanced magnetic resonance imaging (unpublished data). Urban JPG, McMullin JF: Swelling pressure of the lumbar intervertebral Dvonch V, Scarff T, Bunch WH, et al: Dermatomal somatosensory discs: influence of age, spinal level, composition, and degeneration, evoked potentials: their use in lumbar radiculopathy, Spine 9:291, Spine 13:2179, 1988. 1984. Urovitz EP, Fornasier VL: Autoimmunity in degenerative disk disease: a Edelstein WA, Schenck JF, Hart HR, et al: Surface coil magnetic resonance histopathologic study Clin Orthop 142:215, 1979. imaging, JAMA 253:828, 1985. Varlotta GP, Brown MD, Kelsey JL, Golden AL: Familial predisposition for Eisen A, Hoirch M: The electrodiagnostic evaluation of spinal root lesions, herniation of a lumbar disc in patients who are less than twenty-one years Spine 8:98, 1983. old, J Bone Joint Surg 73A:124, 1991. Eldevik OP: Side effects and complications of myelography with water- Weber H: Lumbar disc herniation: a controlled, prospective study with ten soluble contrast agents, J Oslo City Hosp 32:121, 1982. years of observation, Spine 8:131, 1983. Esses SI, Moro JK: The value of facet joint blocks in patient selection for Yasuma T, Koh S, Okamura T, Yamauchi Y: Histological changes in aging lumbar fusion, Spine 18:185, 1993. lumbar intervertebral discs, J Bone Joint Surg 72A:220, 1990. Fager CA: Evaluation of cervical spine surgery by postoperative myelography, Neurosurgery 12:416, 1983. DIAGNOSTIC STUDIES Firooznia H, Benjamin V, Kricheff II, et al: CT of lumbar spine disc Abel MS, Smith GR, Allen TNK: Refinements of the anteroposterior herniation: correlation with surgical findings, Am J Roentgenol 142:587, angled caudad view of the lumbar spine, Skeletal Radiol 7:113, 1984. 1981. Fitzgerald RH, Reines HD, Wise J: Diagnostic radiation exposure in trauma Abraham SR, Tedeschi AA, Partain CL, Blumenkopf B: Differential patients, South Med J 76:1511, 1983. diagnosis of severe back pain using MRI, South Med J 81:487, 1988. Ford LT, Goodman FG: X-ray studies of the lumbosacral spine, South Med Alemohammad S, Bouzarth WF: Intracranial subdural hematoma following J 10:1123, 1966. lumbar myelography: case report, J Neurosurg 52:256, 1980. Frymoyer JW, Newberg A, Pope MH, et al: Spine radiographs in patients Amundsen P: Cervical myelography with Amipaque: seven years’ with low-back pain: an epidemiological study in men, J Bone Joint Surg experience, Radiology 21:282, 1981. 66A:1048, 1984. Angiari P, Crisi G, Merli GA: Aphasia and right hemiplegia after cervical Fullenlove TM, Williams AJ: Comparative roentgen findings in symptom- myelography with metrizamide: a case report, Neuroradiology 26:61, atic and asymptomatic backs, Radiology 63:572, 1957. 1984. Gibson MJ, Buckley J, Mulholland RC, Worthington BS: The changes in Asztely M, Kadziolka R, Nachemson A: A comparison of sonography the intervertebral disc after chemonucleolysis demonstrated by magnetic and myelography in clinically suspected spinal stenosis, Spine 8:885, resonance imaging, J Bone Joint Surg 68B:719, 1986. 1983. Gibson MJ, Szypryt EP, Buckley JH, et al: Magnetic resonance imaging of Barrow DL, Wood JH, Hoffman JC Jr: Clinical indications for computer- adolescent disc herniation, J Bone Joint Surg 69B:699, 1987. assisted myelography, Neurosurgery 12:47, 1983. Glasauer FE, Alker G: Metrizamide enhanced computed tomography: an Beattie PF, Meyers SP, Stratford P, et al: Associations between patient adjunct to myelography in lumbar disc herniation, Comput Radiol 7:305, report of symptoms and anatomical impairment visible on lumbar 1983. magnetic resonance imaging, Spine 25:819, 2000. Greenberg RP, Ducker TB: Evoked potentials in the clinical neurosciences, Bell GR, Rothman RH, Booth RE, et al: A study of computer-assisted J Neurosurg 56:1, 1982. tomography. II. Comparison of metrizamide myelography and computed Gulati AN, Guadognoli DA, Quigley JM: Relationship of side effects to tomography in the diagnosis of herniated lumbar disc and spinal stenosis, patient position during and after metrizamide lumbar myelography, Spine 9:552, 1984. Radiology 141:113, 1981. Birney TJ, White JJ, Berens D, Kuhn G: Comparison of MRI and Haldeman S: The electrodiagnosis evaluation of nerve root function, Spine discography in the diagnosis of lumbar degenerative disc disease, 9:42, 1984. J Spinal Disord 5:417, 1992. Harrington H, Tyler HR, Welch K: Surgical treatment of post-lumbar Blade´ J, Gaston F, Montserrat E, et al: Spinal subarachnoid hematoma after puncture dural CSF leak causing chronic headache: case report, lumbar puncture causing reversible paraplegia in acute leukemia: case J Neurosurg 57:703, 1982. report, J Neurosurg 58:438, 1983. Haughton VM, Eldevik OP, Magnaes B, Amundsen P: A prospective Bobest M, Furo´ I, Tompa K, et al: 1H nuclear magnetic resonance study of comparison of computed tomography and myelography in the diagnosis intervertebral discs: a preliminary report, Spine 11:709, 1986. of herniated lumbar disks, Radiology 142:103, 1982. Boden SD, Davis DO, Dina TS, et al: Abnormal magnetic-resonance scans Hayes MA, Howard TC, Gruel CR, Kopta JA: Roentgenographic of the lumbar spine in asymptomatic subjects: a prospective investiga- evaluation of lumbar spine flexion-extension in asymptomatic individu- tion, J Bone Joint Surg 72A:403, 1990. als, Spine 14:327, 1989.

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Hemminghytt S, Daniels DL, Williams AL, Haughton VM: Intraspinal Rockey PH, Tompkins RK, Wood RW, Wolcott BW: The usefulness of synovial cysts: natural history and diagnosis by CT, Radiology 145:375, x-ray examinations in the evaluation of patients with back pain, J Fam 1982. Pract 7:455, 1978. Herkowitz HN, Romeyn RL, Rothman RH: The indications for metriza- Scavone JG, Latshaw RF, Rohrer GV: Use of lumbar spine films: statis- mide myelography: relationship with complications after myelography, tical evaluation of a university teaching hospital, JAMA 246:1105, J Bone Joint Surg 65A:1144, 1983. 1981. Herkowitz HN, Wiesel SW, Booth RE Jr, Rothman RH: Metrizamide Schelkun SR, Wagner KF, Blanks JA, Reinert CM: Bacterial meningitis myelography and epidural venography: their role in the diagnosis of following Pantopaque myelography: a case report and literature review, lumbar disc herniation and spinal stenosis, Spine 7:55, 1982. Orthopedics 8:74, 1985. Hirschy JC, Leue WM, Berninger WH, et al: CT of the lumbosacral spine: Schutte HE, Park WM: The diagnostic value of bone scintigraphy in importance of tomographic planes parallel to vertebral endplate, Am patients with low back pain, Skeletal Radiol 10:1, 1983. J Roentgenol 136:47, 1981. Schwarzer AC, Aprill CN, Derby R, et al: The relative contributions of the Holt EP Jr: The question of lumbar discography, J Bone Joint Surg disc and zygapophyseal joint in chronic low back pain, Spine 19:801, 50A:720, 1968. 1994. Howie DW, Chatterton BE, Hone MR: Failure of ultrasound in the Shima F, Mihara K, Hachisuga S: Angioma in the paraspinal muscles investigation of sciatica, J Bone Joint Surg 65B:144, 1983. complicated by spinal epidural hematoma: case report, J Neurosurg Hudgins WR: Computer-aided diagnosis of lumbar disc herniation, Spine 57:274, 1982. 8:604, 1983. Siddiqi TS, Buchheit WA: Herniated nerve root as a complication of spinal James AE Jr, Partain CL, Patton JA, et al: Current status of magnetic tap: case report, J Neurosurg 56:565, 1982. resonance imaging, South Med J 78:580, 1985. Siqueira EB, Kranzler LI, Schaffer L: Intraoperative myelography: Jepson K, Nada A, Rymaszewski L: The role of radiculography in the technical note, J Neurosurg 58:786, 1983. management of lesions of the lumbar disc, J Bone Joint Surg 64B:405, Smith GR: Nerve root cut-off on metrizamide-enhanced computerized 1982. tomography, South Med J 79:553, 1986. Johansen JP, Fossgreen J, Hansen HH: Bone scanning in lumbar disc Smith SE, Darden BV, Rhyne AL, Wood KE: Outcome of unoperated herniation, Acta Orthop Scand 51:617, 1980. discogram-positive low back pain, Spine 20:1997, 1995. Kambin P, Nixon JE, Chait A, Schaffer JL: Annular protrusion: Steiner RE: Nuclear magnetic resonance: its clinical application, J Bone pathophysiology and roentgenographic appearance, Spine 13:671, 1988. Joint Surg 65B:533, 1983. Kapoor W, Hemmer K, Herbert D, Karpf M: Abdominal computed Stokes IAF, Wilder DG, Frymoyer JW, Pope MH: Assessment of patients tomography: comparison of the usefulness of goal-directed vs non-goal- with low-back pain by biplanar radiographic measurement of interver- directed studies, Arch Intern Med 143:249, 1983. tebral motion, Spine 6:233, 1981. Kelsey JL, Githens PB, Walter SD, et al: An epidemiological study of Szypryt EP, Twining P, Wilde GP, et al: Diagnosis of lumbar disc acute prolapsed cervical intervertebral disc, J Bone Joint Surg 66A:907, protrusion, J Bone Joint Surg 70B:717, 1988. 1984. Tchang SPK, Howie JL, Kirkaldy-Willis WH, et al: Computed tomography Kieffer SA, Cacyorin ED, Sherry RG: The radiological diagnosis of versus myelography in diagnosis of lumbar disc herniation, J Can Assoc herniated lumbar intervertebral disk: a current controversy, JAMA Radiol 33:15, 1982. 251:1192, 1984. Teplick JG, Haskin ME: Intravenous contrast-enhanced CT of the Kikuchi S, Macnab I, Moreau P: Localisation of the level of symptomatic postoperative lumbar spine: improved identification of recurrent disk cervical disc degeneration, J Bone Joint Surg 63B:272, 1981. herniation, scar, arachnoiditis, and diskitis, Am J Roentgenol 143:845, Killebrew K, Whaley RA, Hayward JN, Scatliff JH: Complications of 1984. metrizamide myelography, Arch Neurol 40:78, 1983. 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Macnab I, Cuthbert H, Godfrey CM: The incidence of denervation of the Whelan MA, Hilal SK, Gold RP, et al: Computed tomography of the sacrospinales muscles following spinal surgery, Spine 2:294, 1977. sacrum. II. Pathology, Am J Roentgenol 139:1191, 1982. Macnab I, St Louis EL, Grabias SL, Jacob R: Selective ascending Wiesel S, Tsourmas N, Feffer HL, et al: A study of computer-assisted lumbosacral venography in the assessment of lumbar disc herniation, tomography. I. The incidence of positive CAT scans in an asymptomatic J Bone Joint Surg 58A:1093, 1976. group of patients, Spine 9:549, 1984. Macon JB, Poletti CE: Conducted somatosensory evoked potentials during Wilberger JE Jr, Pang D: Syndrome of the incidental herniated lumbar disc, spinal surgery. I. Control conduction velocity measurements, J Neuro- J Neurosurg 59:137, 1983. surg 57:349, 1982. 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Bigos SJ, Battie´ MC, Spengler DM, et al: A prospective study of work Wiltse LL, Rocchio P: Preoperative psychological tests as predictors of perceptions and psychosocial factors affecting the report of back injury, success of chemonucleolysis in the treatment of the low-back syndrome, Spine 16:1, 1991. J Bone Joint Surg 57A:478, 1975. Carron H, DeGood DE, Tait R: A comparison of low back pain patients in the United States and New Zealand: psychosocial and economic factors CERVICAL DISC DISEASE affecting severity of disability, Pain 21:77, 1985. Aldrich F: Posterolateral microdiscectomy for cervical monoradiculopathy Chapman SL, Pemberton JS: Prediction of treatment outcome from caused by posterolateral soft cervical disc sequestration, J Neurosurg clinically derived MMPI clusters in rehabilitation for chronic low back 72:370, 1990. pain, Clin J Pain 10:267, 1994. 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Kramer J: Pressure dependent fluid shift in the intervertebral disc, Orthop THORACIC DISC DISEASE Clin North Am 8:211, 1977. Antoni N: Fall av kronisk rotkompression med ovanlig orsak, hernia nuclei Lindsey RW, Newhouse KE, Leach J, Murphy MJ: Nonunion following pulposi disci intervertebralis, Sv Lakartidn 28:436, 1931. two-level anterior cervical discectomy and fusion, Clin Orthop 223:155, Bohlman HH, Zdeblick TA: Anterior excision of herniated thoracic discs, 1987. J Bone Joint Surg 70A:1038, 1988. Lunsford LD, Bissonette DJ, Jannetta PJ, et al: Anterior surgery for cervical de Looze MP, Toussaint HM, van Dieen JH, Kemper HC: Joint moments disc disease. I. Treatment of lateral cervical disc herniation in 253 cases, and muscle activity in the lower extremities and lower back in lifting and J Neurosurg 53:1, 1980. lowering tasks, J Biomech 26:1067, 1993. 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Berman AT, Garbarino JL, Fisher ST, Bosacco SJ: The effects of epidural Kosteljanetz M, Bang F, Schmidt-Olsen S: The clinical significance of injection of local anesthetics and corticosteroids on patients with straight-leg raising (Lase`gue’s sign) in the diagnosis of prolapsed lumbar lumbosciatic pain, Clin Orthop 188:144, 1984. disc: interobserver variation and correlation with surgical findings, Spine Bernard TN, Kirkaldy-Willis WH: Recognizing specific characteristics of 13:393, 1988. nonspecific low back pain, Clin Orthop 217:266, 1987. Kostuik JP, Bentivoglio J: The incidence of low-back pain in adult Berwick DM, Budman S, Feldstein M: No clinical effects of back schools scoliosis, Spine 6:268, 1981. in an HMO: a randomized prospective trial, Spine 14:338, 1989. 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Tay EC, Chacha PB: Midline prolapse of a lumbar intervertebral disc with Hansen FR, Bendix T, Skov P, et al: Intensive, dynamic back-muscle compression of the cauda equina, J Bone Joint Surg 61B:43, 1979. exercises, conventional physiotherapy, or placebo-control treatment Tonelli L, Falasca A, Argentieri C, et al: Influence of psychic distress on of low-back pain: a randomized, observer-blind trial, Spine 18:98: short-term outcome of lumbar disc surgery, J Neurosurg Sci 27:237, 1993. 1983. Hazard RG, Fenwick JW, Kalisch SM, et al: Functional restoration with Troup JDG: Straight leg raising (SLR) and the qualifying tests for increased behavioral support: a one-year prospective study of patients with chronic root tension: their predictive value after back and sciatic pain, Spine low-back pain, Spine 14:157, 1989. 6:526, 1981. 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Ward NG: Tricyclic antidepressants for chronic low-back pain: mecha- Epstein JA, Carras R, Ferrar J, et al: Conjoined lumbosacral nerve roots, nisms of action and predictors of response, Spine 11:661, 1986. J Neurosurg 55:585, 1981. Weber H: Lumbar disc herniation: a controlled, prospective study with ten Epstein NE: Different surgical approaches to far lateral lumbar disc years of observation, Spine 8:131, 1983. herniations, J Spinal Disord 8:383, 1995. Weise MD, Garfin SR, Gelberman RH, et al: Lower-extremity sensibility Epstein NE: Evaluation of varied surgical approaches used in the testing in patients with herniated lumbar intervertebral discs, J Bone management of 170 far-lateral lumbar disc herniations: indications and Joint Surg 67A:1219, 1985. results, J Neurosurg 83:648, 1995. Weitz EM: The lateral bending sign, Spine 6:388, 1981. 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Bradford DS, Garcia A: Lumbar intervertebral disk herniations in children Jane JA, Haworth CS, Broaddus WC, et al: A neurosurgical approach to and adolescents, Orthop Clin North Am 2:583, 1971. far-lateral disc herniation, J Neurosurg 72:143, 1990. Bryant MS, Bremer AM, Nguyen TQ: Autogeneic fat transplants in the Jensen TT, Asmussen K, Berg-Hansen E-M, et al: First-time operation for epidural space in routine lumbar spine surgery, Neurosurgery 13:367, lumbar disc herniation with or without free fat transplantation, Spine 1983. 21:1072, 1996. Capanna AH, Williams RW, Austin DC, et al: Lumbar discectomy— Kadish L, Simmons EH: Anomalies of the lumbosacral nerve roots and percentage of disc removal and detection of anterior annulus perforation, anatomical investigation and myelographic study, J Bone Joint Surg Spine 6:610, 1981. 66B:411, 1984. Carruthers CC, Kousaie KN: Surgical treatment after chemonucleolysis Kahanovitz N, Viola K, Muculloch J: Limited surgical discectomy and failure, Clin Orthop 165:172, 1982. microdiscectomy: a clinical comparison, Spine 14:79, 1989. Castellvi AE, Goldstein LA, Chan DPK: Lumbosacral transitional Kambin P: Lumbar discectomy, surgical technique. Paper presented at the vertebrae and their relationship with lumbar extradural defects, Spine American Academy of Orthopaedic Surgeons Course, St Louis, May 9:493, 1984. 1996. Cauthen C: Lumbar spine surgery, Baltimore, 1983, Williams & Wilkins. Kataoka O, Nishibayashi Y, Sho T: Intradural lumbar disc herniation: Chow SP, Leong JCY, Yau AC: Anterior spinal fusion for deranged lumbar report of three cases with a review of the literature, Spine 14:529, intervertebral disc: a review of 97 cases, Spine 5:452, 1980. 1989. 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Lowell TD, Errico TJ, Fehlings MG, et al: Microdiskectomy for lumbar Waddell G, Main CJ, Morris EW, et al: Chronic low-back pain, psychologic disk herniation: a review of 100 cases, Orthopedics 18:985, 1995. distress, and illness behavior, Spine 9:209, 1984. Macnab I: Management of low back pain. In Ahstrom JP Jr, ed: Current Waddell G, Reilly S, Torsney B, et al: Assessment of the outcome of low practice in orthopaedic surgery, St Louis, 1973, Mosby. back surgery, J Bone Joint Surg 70B:723, 1988. Macnab I, Cuthbert H, Godfrey CM: The incidence of denervation of the Wayne SJ: A modification of the tuck position for lumbar spine surgery: a sacrospinales muscles following spinal surgery, Spine 2:294, 1977. 15-year follow-up study, Clin Orthop 184:212, 1984. Macon JB, Poletti CE: Conducted somatosensory evoked potentials during Weber H: Lumbar disc herniation: a controlled, prospective study with ten spinal surgery. I. Control, conduction velocity measurements, J Neuro- years of observation, Spine 8:131, 1983. surg 57:349, 1982. Weinstein J, Spratt KF, Lehmann T, et al: Lumbar disc herniation: a Macon JB, Poletti CE, Sweet WH, et al: Conducted somatosensory evoked comparison of the results of chemonucleolysis and open discectomy after potentials during spinal surgery. II. Clinical applications, J Neurosurg ten years, J Bone Joint Surg 68A:43, 1986. 57:354, 1982. Weinstein JN, Scafuri RL, McNeill TW: The Rush-Presbyterian–St. Luke’s Maroon JC, Kopitnik TA, Schulhoff LA, et al: Diagnosis and microsurgical lumbar spine analysis form: a prospective study of patients with ‘‘spinal approach to far-lateral disc herniation in the lumbar spine, J Neurosurg stenosis,’’ Spine 8:891, 1983. 72:378, 1990. Weir BKA: Prospective study of 100 lumbosacral discectomies, J Neuro- Moore AJ, Chilton JD, Uttley D: Long-term results of microlumbar surg 50:283, 1979. discectomy, Br J Neurosurg 8:319, 1994. 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Pa´sztor E, Szarvas I: Herniation of the upper lumbar discs, Neurosurg Rev Zahrawi F: Microlumbar discectomy: is it safe as an outpatient procedure? 4:151, 1981. Spine 19:1070, 1994. Pau A, Viale ES, Turtas S, Zirattu G: Redundant nerve roots of the cauda Zamani MH, MacEwen GD: Herniation of the lumbar disc in children and equina, Ital J Orthop Traumatol 4:95, 1984. adolescents, J Pediatr Orthop 2:528, 1982. Posner I, White AA III, Edwards WT, Hayes WC: A biomechanical analysis of the clinical stability of the lumbar and lumbosacral spine, Spine 7:374, CHEMONUCLEOLYSIS 1982. Abdel-Salam A, Eyres KS, Cleary J: A new paradiscal injection technique Postacchini F, Urso S, Ferro L: Lumbosacral nerve-root anomalies, J Bone for the relief of back spasm after chemonucleolysis, Br J Rheumatol Joint Surg 64A:721, 1982. 31:491, 1992. Rechtine GR, Reinert CM, Bohlman HH: The use of epidural morphine to Agre K, Wilson RR, Brim M, McDermott DJ: Chymodiactin postmarketing decrease postoperative pain in patients undergoing lumbar laminectomy, surveillance: demographic and adverse experience data in 29,075 J Bone Joint Surg 66A:1, 1984. patients, Spine 9:479, 1984. Rish BL: A critique of the surgical management of lumbar disc disease in Alexander AH: Debate: resolved—chemonucleolysis is the best treatment a private neurosurgical practice, Spine 9:500, 1984. of the recalcitrant acute herniated nucleus pulposus: what’s new and Ruggieri F, Specchia L, Sabalat S, et al: Lumbar disc herniation: diagnosis, what’s true in the Napa Valley. Paper presented March 14, 1985. surgical treatment, and recurrence: a review of 872 operated cases, Ital Apfelbach HW: Technique for chemonucleolysis, Orthopedics 6:1613, J Orthop Traumatol 14:15, 1988. 1983. 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Castro WH, Halm H, Jerosch J, et al: Long-term changes in the mag- Suguro T, Oegema TR, Bradford DS: Ultrastructural study of the short-term netic resonance image after chemonucleolysis, Eur Spine J 3:222, effects of chymopapain on the intervertebral disc, J Orthop Res 4:281, 1994. 1986. Crawshaw C, Frazer AM, Merriam WF, et al: A comparison of surgery and Tregonning GD, Transfeldt EE, McCulloch JA, et al: Chymopapain versus chemonucleolysis in the treatment of sciatica: a prospective randomized conventional surgery for lumbar disc herniation: 10-year results of trial, Spine 9:195, 1984. treatment, J Bone Joint Surg 73B:481, 1991. Dolan P, Adams MA, Hutton WC: The short-term effects of chymopapain Tsay YG, Jones R, Calenoff E, et al: A preoperative chymopapain on intervertebral discs, J Bone Joint Surg 69B:422, 1987. sensitivity test for chemonucleolysis candidates, Spine 9:764, 1984. 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Hijikata S: Percutaneous nucleotomy: a new concept of technique and 12 Leavitt F, Garron DC, Whisler WW, D’Angelo CM: A comparison of years’ experience, Clin Orthop 238:9, 1989. patients treated by chymopapain and laminectomy for low back pain Kahanovitz N, Viola K, Goldstein T, Dawson E: A multicenter analysis of using a multidimensional pain scale, Clin Orthop 146:136, 1980. percutaneous diskectomy, Spine 15:713, 1990. Maciunas RJ, Onofrio BM: The long-term results of chymopapain: ten-year Kahanovitz N, Viola K, McCullough J: Limited surgical diskectomy and follow-up of 268 patients after chemonucleolysis, Clin Orthop 206:37, microdiskectomy: a clinical comparison, Spine 14:79, 1989. 1986. Kambin P, Brager MD: Percutaneous posterolateral discectomy: anatomy McCulloch JA: Chemonucleolysis: experience with 2000 cases, Clin and mechanism, Clin Orthop 223:145, 1987. Orthop 146:128, 1980. Kambin P, Gellman H: Percutaneous lateral discectomy of the spine, Clin McCulloch JA, Ferguson JM: Outpatient chemonucleolysis, Spine 6:606, Orthop 174:127, 1983. 1981. Kambin P, Schaffer JL: Percutaneous lumbar discectomy: review of 100 Moneret-Vautrin DA, Feldmann L, Kanny G, et al: Incidence and risk patients and current practice, Clin Orthop 238:24, 1989. factors for latent sensitization to chymopapain: predictive skin-prick Maroon JC, Onik G, Sternau L: Percutaneous automated discectomy: a new tests in 700 candidates for chemonucleolysis, Clin Exp Allergy 24:471, approach to lumbar surgery, Clin Orthop 238:64, 1989. 1994. Monteiro A, Lefevre R, Pieters G, Wilment E: Lateral decompression of a Nachemson AL, Rydevik B: Chemonucleolysis for sciatica: a critical pathological disc in the treatment of lumbar pain and sciatica, Clin review, Acta Orthop Scand 59:56, 1988. Orthop 238:56, 1989. Naylor A, Earland C, Robinson J: The effect of diagnostic radiopaque fluids Morris J: Percutaneous discectomy, Orthopedics 11:1483, 1988. used in discography on chymopapain activity, Spine 8:875, 1983. Onik G, Helms CA, Ginsburg L: Percutaneous lumbar discectomy using a Nordby EJ, Wright PH: Efficacy of chymopapain in chemonucleolysis: a new aspiration probe, Am J Radiol 144:1137, 1985. review, Spine 19:2578, 1994. Onik G, Maroon J, Davis GW: Automated percutaneous discectomy at the Nordby EJ, Wright PH, Schofield SR: Safety of chemonucleolysis: adverse L5-S1 level: use of a curved cannula, Clin Orthop 238:71, 1989. effects reported in the United States, 1982-1991, Clin Orthop 293:122, Schreiber A, Suezawa Y, Leu H: Does percutaneous nucleotomy with 1993. discoscopy replace conventional discectomy? Eight years of experience Oegema TR Jr, Swedenberg S, Johnson SL, et al: Residual chymopapain and results in treatment of herniated lumbar disc, Clin Orthop 238:35, activity after chemonucleolysis in normal intervertebral discs in dogs, 1989. J Bone Joint Surg 74A:831, 1992. Schweigel J: Automated percutaneous discectomy: comparison with Parkinson D: Late results of treatment of intervertebral disc disease with chymopapain. In Automated percutaneous discectomy, San Francisco, chymopapain, J Neurosurg 59:990, 1983. 1988, University of California Press. Shields CB, Reiss SJ, Garretson HD: Chemonucleolysis with chymopa- Shepperd JAN, James SE, Leach AB: Percutaneous disc surgery, Clin pain: results in 150 patients, J Neurosurg 67:187, 1987. Orthop 238:43, 1989. Simmons JW, Stavinoha WB, Knodel LC: Update and review of Stern MB: Early experience with percutaneous lateral discectomy, Clin chemonucleolysis, Clin Orthop 183:51, 1984. Orthop 238:50, 1989. Smith S, Leibrock LG, Gelber BR, Pierson EW: Acute herniated nucleus Wilson D, Harbaugh R: Microsurgical and standard removal of protruded pulposus with cauda equina compression syndrome following chemo- lumbar disc: a comparative study, Neurosurgery 8:422, 1986. nucleolysis: report of three cases, J Neurosurg 66:614, 1987. Strum PF, Armstrong GW, O’Neil DJ, Belanger JM: Far lateral lumbar disc COMPLICATIONS OF LUMBAR SPINE SURGERY herniation treated with an anterolateral retroperitoneal approach: report Benoist M, Ficat C, Baraf P, Cauchoix J: Postoperative lumbar epiduro- of two cases, Spine 17:363, 1992. arachnoiditis: diagnostic and therapeutic aspects, Spine 5:432, 1980.

#6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 73/74 Pg: 2027 Team: 2028 PART XII ◆ The Spine

Bryant MS, Bremer AM, Nguyen TQ: Autogeneic fat transplants in the Shaw ED, Scarborough JT, Beals RK: Bowel injury as a complication of epidural space in routine lumbar spine surgery, Neurosurgery 13:367, lumbar discectomy: a case report and review of the literature, J Bone 1983. Joint Surg 63A:478, 1981. Caplan LR, Norohna AB, Amico LL: Syringomyelia and arachnoiditis, Zide BM, Wisoff JH, Epstein FJ: Closure of extensive and complicated J Neurol Neurosurg Psychiatr 53:106, 1990. laminectomy wounds: operative technique, J Neurosurg 67:59, 1987. Choudhury AR, Taylor JC: Cauda equina syndrome in lumbar disc disease, Acta Orthop Scand 51:493, 1980. FAILED SPINE SURGERY Di Lauro L, Poli R, Bortoluzzi M, Marini G: Paresthesias after lumbar disc Blaauw G, Braakman R, Gelpke GJ, Singh R: Changes in radicular function removal and their relationship to epidural hematoma, J Neurosurg following low-back surgery, J Neurosurg 69:649, 1988. 57:135, 1982. Cauthen C: Lumbar spine surgery, Baltimore, 1983, Williams & Wilkins. Eismont FJ, Wiesel SW, Rothman RH: The treatment of dural tears Ebeling U, Kalbarcyk H, Reulen HJ: Microsurgical reoperation following associated with spinal surgery, J Bone Joint Surg 63A:1132, 1981. lumbar disc surgery: timing, surgical findings, and outcome in 92 Floman Y, Wiesel SW, Rothman RH: Cauda equina syndrome presenting as patients, J Neurosurg 70:397, 1989. a herniated lumbar disc, Clin Orthop 147:234, 1980. Finnegan WJ, Fenlin JM, Marval JP, et al: Results of surgical intervention Javid MJ, Nordby EJ, Ford LT, et al: Safety and efficacy of chymopapain in the symptomatic multiply operated back patient, J Bone Joint Surg (Chymodiactin) in herniated nucleus pulposus with sciatica: results of a 61A:1077, 1979. randomized, double-blind study, JAMA 249:2489, 1983. Frymoyer JW, Hanaley EN, Howe J: A comparison of radiographic findings Jones AA, Stambough JL, Balderson RA, et al: Long-term results of lumbar in fusion and nonfusion patients ten or more years following lumbar disc spine surgery complicated by unintended incidental durotomy, Spine surgery, Spine 5:435, 1979. 14:443, 1989. Lehmann TR, LaRocca AS: Repeat lumbar surgery: a review of patients May ARL, Brewster DC, Darling RC, et al: Arteriovenous fistula following with failure from previous lumbar surgery treated by spinal cord lumbar disc surgery, Br J Surg 68:41, 1981. exploration and lumbar spinal fusion, Spine 6:615, 1981. Mayer PJ, Jacobsen FS: Cauda equina syndrome after surgical treatment of Long DM, Filtzer DL, BenDebba M, Hendler NH: Clinical features of the lumbar spinal stenosis with application of free autogenous fat graft: a failed-back syndrome, J Neurosurg 69:61, 1988. report of two cases, J Bone Joint Surg 71A:1090, 1989. Nakano N, Tomita T: Results of surgical treatment of low back pain: a McLaren AC, Bailey SI: Cauda equina syndrome: a complication of lumbar comparative study of the anterior and posterior approach, Int Orthop discectomy, Clin Orthop 204:143, 1986. 4:101, 1980. Nielsen B, deNully M, Schmidt K, Hansen RI: A urodynamic study of Quimjian JD, Matrka PJ: Decompression laminectomy and lateral spinal cauda equina syndrome due to lumbar disc herniation, Urol Int 35:167, fusion in patients with previously failed lumbar spine surgery, 1980. Orthopedics 2:563, 1988. Puranen J, Makela J, Lahde S: Postoperative intervertebral discitis, Acta Spengler DM, Freeman C, Westbrook R, Miller JW: Low-back pain Orthop Scand 55:461, 1984. following multiple lumbar spine procedures: failure of initial selection? Salander JM, Youkey JR, Rich NM, et al: Vascular injury related to lumbar Spine 5:356, 1980. disc surgery, J Trauma 24:628, 1984. Tria AJ, Williams JM, Harwood D, Zawadsky JP: Laminectomy with and without spinal fusion, Clin Orthop 224:134, 1987.

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