In the Treatment of Lower Back II – Lumbar Stenosis and Disc Herniations Heather Spader, MD, Jonathan Grossberg, MD, Adetokunbo A. Oyelese, MD, PhD  Lo w b a c k p a i n is o n e o f t h e m o s t c o m m o n symptoms benefited more from surgery The diagnosis of lumbar stenosis health problems encountered by the gen- than conservative management (71% is made by a combination of clinical eral population with a lifetime incidence vs. 43%).5 symptoms and radiographic images. The of 70-80%.1 While there are numerous The operative technique for lumbar most common symptoms are back and causes of low , this article will has evolved over the last leg pain, subjective weakness exacerbated deal with two of the most common three decades. In the late 1970s, the by walking, and lower extremity numb- etiologies found in the US population: microscope was first used to assist in the ness. These symptoms are classically lumbar disc disease and lumbar spinal surgery, and technological advantages exacerbated by extension and improved stenosis. today include endoscopic and minimally with flexion. MRI is the imaging study of invasive techniques that offer the poten- choice to document spinal cord compres- Lu m b a r Di s c Di s e a s e tial of less peri-operative pain, smaller sion in lumbar stenosis, while computed While the first anatomical descrip- incisions, and faster recovery and return tomography (CT) helps demonstrate tions of the lumbar disc can be traced to work. bony compression in the disease. Electro- back to Vesalius in the 16th century, physiological studies, such as EMG, can the first lumbar laminectomy was not aid in the diagnosis in more complicated reported until 1829 by AG Smith. It was Non-operative cases. nearly a century later when Mixter and management Non-operative management of Barr first described neural compression stenosis includes physical therapy, oral from a herniated lumbar disc.2 While of stenosis pain medication, and invasive pain man- trauma was thought to be the etiology of includes physical agement, such as steroid injections. lumbar disc disease, it is now known that Operative management of lumbar the majority of lumbar disc disease is the therapy, oral pain spinal stenosis should only be considered result of a normal degenerative cascade in medication, and after patients have failed conservative the annulus itself. therapy. The rationale behind surgical The diagnosis of lumbar disc dis- invasive pain management is to improve the patient’s ease is often a clinical one with the most management, symptoms, and accordingly most of the common symptoms being back pain, procedures involve decompression of radicular pain, numbness, and weak- such as steroid the spinal cord and nerve roots. Op- ness. Imaging studies such as magnetic injections. erative management for lumbar stenosis resonance imaging (MRI) can also help ranges from surgical decompression via with the diagnosis, but only in the correct a laminectomy approach to fusion with clinical scenario, as studies have shown Lu m b a r Sp i n a l St e n o s i s instrumentation for more complex and that the prevalence of degenerative discs Lumbar stenosis is defined as nar- mechanically unstable patients. Our increases with age, and that by age 70, rowing of the central spinal canal, lateral preference is to perform the procedure 80% of lumbar MRIs were abnormal.3 In recesses, or neural foramen which causes through a small incision and with the use addition, electromyography (EMG) can impingement on the neural elements. The of an operative microscope. Studies have help pinpoint the location of a patient’s word stenosis is etymologically derived shown that older patients with increased symptoms. from the Greek term for “choke,” but comorbidities have higher rates of surgi- The majority of cases of pain due while Hippocrates described low back cal complication, and as a result there to lumbar disc disease will resolve over pain and , it was not until 1911 is a trend towards minimally invasive a six week period with a trial of anti- that Bailey and Casamajor postulated that decompression and fusion, which have inflammatory medication and physician chronic compression of the spinal roots the potential advantages of decreased therapy. In more recalcitrant cases, epi- may result from narrowing of the spinal blood loss and shorter operative time.7 Al- dural steroid injections can assist in pain canal or foramina.6 though much advertised, the use of lasers management.4 The incidence of spinal stenosis is in spinal surgery has not been proven safe The indications for operative man- 50/100,000 and it is estimated that 13- or effective, particularly in comparison to agement of herniated lumbar discs 14% of specialist visits for low back pain the well-studied benefits of traditional include: severe, unremitting pain, neu- involve lumbar stenosis. The disease most minimally invasive surgery. Unlike the rologic deficit, and patient preference. often affects the L4-5 and L3-4 levels, and use of laser instruments in ophthalmol- The Main Lumbar Spine Study on is responsible for approximately half of all ogy or dermatology, laser surgery in Sciatica found that patients with severe cases of . the spine still requires an incision and 384 Medicine & Health/Rhode Island endoscopic dilatation, with the sole dif- In conclusion, patients with pain lumbar spine study, Part III. 1-year outcomes of ference being the use of laser instruments from a lumbar disc herniation or neu- surgical and nonsurgical management of . Spine. 1996;21(15):1787–94. to cut away the disc fragment. Incidents rogenic claudication from lumbar spinal 9. Weinstein JN, Lurie JD, Tosteson TD, et of significant arterial bleeding have been stenosis who have not responded to al. Surgical versus nonsurgical treatment for reported, and the procedure is limited conservative, non-surgical intervention lumbar degenerative spondylolisthesis. NEJM. in its ability to remove larger disc frag- may benefit from and often so well with 2007;356 (22):2257–70. ments or visualize and control spinal surgical intervention. However, proper fluid leaks. selection of these patients is crucial in Heather Spader, MD, is a Senior Resi- The Maine Lumbar Spine Study order to avoid poor functional outcomes dent, Department of Neurosurgery, at Rhode prospectively compared operative and which unfortunately are not uncommon Island Hospital and at the Warren Alpert non-operative intervention for stenosis with surgery for patients suffering from Medical School of Brown University. and found that 55% of patients in the lumbar spinal disorders. Jonathan Grossberg, MD, is currently surgical arm had improvement in their Chief Resident in Neurosurgery at Rhode Island Hospital and at the Warren Alpert symptoms at one year compared with Re f e r e n c e s 28% in the non-surgical arm.8 The ran- 1. Andersson GB. Epidemiological features of Medical School of Brown University. domized SPORT trial found that there chronic low-back pain. Lancet. 1999;354: Adetokunbo A. Oyelese, MD, PhD, is 581–5. an Attending Neurosurgeon and the Direc- was no difference in clinical outcomes be- 2. Mixter WJ, Barr JS. Rupture of the interverte- tween surgical and non-surgical patients bral disc with involvement of the spinal canal. tor for Spinal Disorders for the Deparment in its intent-to-treat analysis. The study, N Engl J Med. 1934;211:210–225. of Neurosurgery at Rhode Island Hospital, 3. Powell MC, Wilson M, Szypryt P, et al. Preva- however, was flawed by its high rate of and an Assistant Professor of Neurosurgery lence of lumbar disc degeneration observed by at the Warren Alpert Medical School of cross-over between the arms, and when magnetic resonance in symptomless women. the patients were analyzed in an as-treated Lancet. 1986;13(2):1366–7. Brown University. method, there was a significant advantage 4. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy for surgery at three months, one year, and Disclosure of Financial Interests Assessment Subcommittee of the American Adetokunbo A. Oyelese, MD, PhD, two years.9 College of Physicians; American College of Phy- sicians; American Pain Society Low Back Pain is a teaching consultant (honoraria) for Guidelines Panel. Diagnosis and treatment of Depuy-Synthes Spine. low back pain: a joint clinical practice guideline Neither Heather Spader, MD, Jona- from the American College of Physicians and than Grossberg, MD, nor their spouses/ the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478–91. significant others, have any financial 5. Atlas SJ, Deyo RA, Keller RB, et al. The Maine interests to disclose. lumbar spine study, Part II: 1-year outcomes of surgical and nonsurgical management of o r r e s p o n d e n c e sciatica. Spine. 1996;21(15):1777–86. C 6. Bailey P, Casamajor L. Osteoarthritis of the spine Adetokunbo A. Oyelese, MD, PhD as a cause of compression of the spinal cord and Department of Neurosurgery its roots. J Nerv Ment Dis. 1911;38:588–609. The Warren Alpert Medical School 7. Deyo RA, Cherkin DC, Loeser JD, et al. Morbidity and mortality in association with of Brown University operations on the lumbar spine. The influence 593 Eddy Street, APC-6 of age, diagnosis, and procedure. J Bone Joint Providence, RI 02903 Surg Am. 1992;74(4):536–43. phone: (401) 793-9128 8. Atlas, SJ, Deyo RA, Keller RB, et al. The Maine fax: (401) 444-2661

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