1. Physician determines eligibility
Eligibility Criteria
Physician determines eligibility
Copyright  1999, Trustees of Dartmouth College

2. Eligibility Criteria
Copyright  1999, Trustees of Dartmouth College

3. Eligibility Criteria
Diagnosis of Intervertebral Disc Herniation, Spinal Stenosis, or Isolated Spinal Stenosis with L4 -5 Degenerative Spondylolisthesis
A Confirmatory Imaging Study (MRI)
No Exclusion Criteria
Copyright  1999, Trustees of Dartmouth College

4. Intervertebral Disc Herniation
Radicular Pain
AND
Nerve Root Tension Sign
(SLR, Femoral Stretch) OR
Corresponding Neurologic Deficit
(Sensory, Motor, or Reflex )
Copyright  1999, Trustees of Dartmouth College

5. Intervertebral Disc Herniation
Confirmatory Imaging Study
a protrusion, extrusion, or sequestered fragment of the intervertebral disc at the level and side corresponding with the patient’s radicular symptoms or signs
Copyright  1999, Trustees of Dartmouth College

6. an associated neurologic deficit
Spinal Stenosis
Pseudoclaudication
Pain in buttock, thigh, or leg with ambulation that resolves with rest
Strong distal pulses or other testing to rule out true vascular claudication OR
Radicular pain with
an associated neurologic deficit
Copyright  1999, Trustees of Dartmouth College

7. Spinal Stenosis Confirmatory Imaging Study No instability
narrowing of the central spinal canal, lateral recesses, or neural foramina due to encroachment on the neural structures by the surrounding bone and soft tissue
No instability
defined as a change of greater than 10o of angulation of adjacent segments by Cobb measurement or a change of more than 4 mm of AP or PA translation
Copyright  1999, Trustees of Dartmouth College

8. Degenerative Spondylolisthesis
Syndrome of Spinal Stenosis
Pseudoclaudication OR
Radicular pain with an associated neurologic deficit
Copyright  1999, Trustees of Dartmouth College

9. Degenerative Spondylolisthesis
Confirmatory Imaging Study
isolated spinal stenosis at the L4-5 level with a degenerative forward slippage of the L4 vertebral body relative to the L5 vertebral body in the sagittal plane. Displacement is usually less than or equal to 25% of the vertebral body
No instability
defined as a change of greater than 10o of angulation of adjacent segments by Cobb measurement or a change of more than 4 mm of AP or PA translation
Copyright  1999, Trustees of Dartmouth College

10. Exclusion Criteria Insufficient Trial of Non-surgical Therapy
6 weeks for IDH, 12 weeks for SpS and DS
Cauda Equina Syndrome or progressive neurologic deficit
Patient not a surgical candidate
e.g. overall health makes surgery too dangerous
Active malignancy
Possible pregnancy
Copyright  1999, Trustees of Dartmouth College

11. Exclusion Criteria
fracture, infection, or significant deformity (greater than 15o of lumbar scoliosis) of the spine
age less than 18
prior lumbar spine surgery
patient currently enrolled in any experimental “spine-related” study
unavailability for follow-up or inability to complete data surveys
Copyright  1999, Trustees of Dartmouth College