Spine Surgery WHO NEEDS IT? M. Gordon Whitbeck Jr., MD April 28, 2018

Common Spine Problems: Low back pain Neck pain Disc herniation Spinal stenosis Spondylolisthesis Scoliosis Fractures

Causes: Genetic factors Environmental factors

Common Symptoms: Neck pain/stiffness Axial Appendicular Neck pain/stiffness Upper or lower back pain/stiffness Radiating leg(sciatica) or arm pain Numbness or tingling Weakness Clumsiness of hands Loss of balance

Common Signs: Deformity Decreased range of motion Axial Appendicular Deformity Decreased range of motion Tenderness to palpation Pain on percussion Decreased sensation Weakness on formal strength testing Atrophy Abnormal tone Abnormal reflexes Unstable gait Tension signs

Diagnosis: History Physical examination Imaging studies Electrodiagnostic studies

Treatment: Observation Physical therapy Chiropractic treatment Nonsurgical Surgical Observation Physical therapy Chiropractic treatment Medication Injections Massage therapy Accupuncture Discectomy Laminectomy Corpectomy Fusion Disc replacement

Natural History: Cervical radiculopathy- 75% will not require surgery Lumbar disc herniation- 85% will not require surgery Cervical myelopathy-15% will not require surgery Lumbar stenosis- 75-85% will not require surgery

MOST SPINE PROBLEMS DO NOT REQUIRE SURGERY

Indications for Surgery: Moderate or severe myelopathy on presentation or progressive myelopathy during observation Severe radiculopathy on presentation or progressive radiculopathy despite nonsurgical treatment treatme Spinal deformity or mechanical instability Axial symptoms that have not responded to prolonged nonsurgical treatment

MOST SURGERY SHOULD BE PERFORMED FOR NEUROLOGIC SYMPTOMS

Who needs decompression? Spinal cord compression with symptoms/signs ? Severe spinal cord compression without symptoms/signs Nerve root compression with profound symptoms/signs Nerve root compression with symptoms/signs not responsive to nonsurgical treatment

Who needs fusion? Neurologic symptoms(usually appendicular) with mechanical instability(spondylolisthesis, scoliosis, fracture) Correction of deformity or stabilization of mechanical instability Axial symptoms(neck or low back pain) related to degenerative disc disease

FUSION FOR AXIAL SYMPTOMS SHOULD BE LEGAL BUT RARE

Results: Results: Surgery for myelopathy generally prevents progression, often results in improvement Surgery for radiculopathy generally results in improvement Axial symptoms respond much less well to surgery(fusion,disc replacement) Response depends on many factors

Managing Expectations: Not all symptoms can be explained Most neck pain and back pain cannot be explained Most common spine problems do not require surgery YOU must be part of the solution even when surgery is needed and ESPECIALLY when it is not

Managing Expectations: Surgery is a treatment not a cure You did not have a normal spine prior to surgery and will not have one after Thoughtful patient selection, meticulous surgical technique, and diligent aftercare will maximize pain relief and recovery of function

COMPREHENSIVE SPINE CARE

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