1. Neurosurgical Updates 2016 Brain & Spine Symposium:
Presented by:
Mary L. Dombovy, MD, MHSA
Paul K. Maurer, MD
Anthony L. Petraglia, MD
Patrick J. Reid, MD
Matthew L. Dashnaw, MD, Pharm D
M. Gordon Whitbeck, Jr., MD

2. Putting Your Back Front and Center
Lumbar Disc Disease
Putting Your Back Front and Center
Presented by
Anthony L. Petraglia, MD
Neurosurgeon
Executive Director, Concussion Program
Rochester Regional Health

3. Lumbar Disc Disease Low Back Pain: major public health concern
60 – 90% of adults experience back pain at some point in their life.
 incidence age y.o.
90% resolve in months
7% become chronic
Most patients with LBP improve on their own in time (even without treatment).
LBP is extremely common; a majority of individuals will experience at least one episode of it in their life
Second leading cause of physician visit behind common cold

4. Discogenic LBP v. ???
Evaluation of patients with LBP should be geared towards identification of those patients with a potentially serious underlying etiology.
Cancer
Infection – osteo, abscess
Fracture
Cauda Equina Syndrome
Previous hx of cancer, unexplained weight loss
Immunosuppression, hx of steroid use, hx of IV drug abuse, hx of skin/other infection(s)
Hx of recent falls or trauma (including surgery)
Bladder dysfunction (usually urinary retention or overflow incontinence) or fecal incontinence, “saddle anesthesia”, leg weakness
Pain that doesn’t improve with rest; failure to improve after 4 weeks conservative management

5. Degenerative Disc Disease (DDD)
DDD sort of a “wastebasket term”
While the changes are indeed “degenerative,” this happens as we age
Is not necessarily indicative of any significant underlying pathology or condition
Overwhelming majority of individuals > 60 will show some type of degenerative change(s) on lumbar imaging
Back pain is strongly associated with degeneration of the intervertebral disc
DJD is often used to describe age-related changes on MRI, etc.

6. Hydrostatic, load bearing structure between the vertebral bodies
Nucleus pulposus + annulus fibrosus
No blood supply
Annulus Fibrosis -- Type 1 collagen fibers (wrap) and Nucleus pulposus Type 2 collagen and hydrophilic proteoglycan (hydrated mostly made up of water)

7. Disc Degeneration loss of disc height loss of water content
fibrosis and end plate sclerosis

8. Also mechanical stressors affect nutrient supply

10. Herniated Nucleus Pulposus
Classic presentation is radiculopathy
The disc herniation impinges upon a nerve root, causing characteristic pain.
Aggravating and alleviating factors
May be assoc. with numbness/tingling
Also as a part of this --- patients can develop disc herniation
Pain may be worsened by sitting, straining, coughing or sneezing, and may be relieved upon standing or flexing the knee and thigh. There may also be associated numbness and weakness of the affected leg.

11. Clinical Story Is Everything
Evaluation
Motor/Dermatomal patterns
L3-4 (5%)
L4-5 (40-45%)
L5-S1 (45-50%)
Root usually compressed L4 L5 S1
Weakness
Quadriceps, ant tib
(knee extension, dorsiflexion)
EHL
(big toe extension)
Gastrocnemius, soleus
(plantar flexion)
Sensory loss
Medial foot, medial calf
Big toe, dorsum of foot
Lateral foot, bottom foot
Reflex diminished
Patellar
---
Achilles

13. Role of Imaging
An integral part of the evaluation of the patient with signs and symptoms of spine disorder
The studies (MRI,CT etc) VERIFY the plan, should not drive it
Abnormalities in more than 30% of asymptomatic volunteers
Boden SD et al: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: A prospective investigation. J Bone Joint Surg Am 1990;72:
Morbidity ?? Costs ??
Findings do not always = symptoms
Findings do not always = surgery
Will find most recommendations are to not obtain imaging prior to 4-6 weeks - unless red flag of some sort

16. Bulge v. Protrusion v. Extrusion
Bulge – generalized disc displacement involving circumference --- is not considered a disc herniation; can be symmetrical or assym
Intravertebral disc herniation aka Schmorls node
Annular tear

17. Lumbar HNP
90% of herniated discs are paracentral (slightly off to one side)
affect the nerve root that corresponds to the lower vertebral level.
Example: a typical L4-5 disc herniation would cause symptoms referrable to the L5 nerve root.
As many as 10% of herniated discs, however, are “far lateral” and impinge upon the nerve root that corresponds to the upper vertebral level.
A far lateral disc hernation at L4/5, then, would be expected to cause symptoms relative to the L4 root.

18. Woman with
Anterolateral thigh,
medial calf pain;
Dorsiflexion weak

20. Conservative Treatment
Pharmacologic
NSAIDs
Muscle Relaxants
Opiates/Non-Opiate Pain Rx
Neuromodulators
Steroid taper
Topical Analgesic
Non-Pharmacologic
Heat/Ice
Physical Therapy
Chiropractic Therapy
Acupuncture
Massage Therapy
Epidural Injections
- The overwhelming majority of people with a herniated disc will get better
TOPICAL: gels creams lotions, lidocaine patches, salonpas, biofreeze
Neuromodulators: gabapentin, lyrica, TCAs, cymbalta
Patient Education!!!

22. Surgery In the carefully chosen patient …
“Surgery provides faster pain relief and perceived recovery in patients with herniated disc.”
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. Jama. 2006;296:2451–9.
Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. Jama. 2006;296:2441–50.
Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine. 1983;8:131–40.
Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1- year outcomes of surgical and nonsurgical management of sciatica. Spine ;21:1777–86.
Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007;356:2245– 56.
Several randomized trials and large prospective cohorts have demonstrated that ….

23. Surgery
Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patient Outcomes Research Trial (SPORT) Spine 2014 Jan 1; 39(1): 3–16.
“ In patients with a herniated disc confirmed by imaging and leg symptoms persisting for at least 6 weeks, surgery was superior to non-operative treatment in relieving symptoms and improving function.
In the as-treated analysis, the treatment effect for surgery was seen as early as 6 weeks, appeared to reach a maximum by 6 months and persisted over 8 years; it is notable that the non-operative group also improved significantly and this improvement persisted with little to no degradation of outcomes in either group (operative and non-operative) between 4 and 8 years.”
Long term analysis holds up

24. Laminectomy

25. Goals of Surgery Free up nerve from compression
Allow nerve chance to heal
Early mobilization

26. Personal Philosophy Patient Centered Approach
Informed and shared decision-making
Complete evaluation
Thorough explanation of symptoms
Discussion of non-operative and operative tx options
Develop personal relationship with good communication and empathy
committed to listening to and guiding the patient, with respect and compassion. Only Through this process, we empower our patients to make the best decision for their treatment.