1. Lumbar Problems and their Surgical Results
Mats Agren, M.D.

2. Lumbar Diagnosis Lumbar Disk Herniation (DH)
Lumbar Spinal Stenosis (SS)
Lumbar Degenerative Spondylolisthesis (DS)

3. Lumbar Diagnosis Lumbar Degenerative Disk Disease (DDD)
Lumbar Degenerative Scoliosis (DSc)

4. Lumbar Diagnosis Rules Symptomatic not radiographic Bad enough?
Going on long enough?
Predicable enough?
Limiting enough?
Progressive enough?

5. DDD Natural History Genetic, not activity Small effect of smoking
Twin studies
Small effect of smoking
Increased load in adolescents
MRI + >30% in asymptomatic
10%/decade

6. DDD Diagnosis difficult Exam Radiographic vs clinical Focal pain
Sitting intolerant
Better staying active
Focal MRI

7. DDD Treatment Conservative Surgical Aggressive PT/Exercise program
Emotional/Psychological care
Rare Injection
Surgical
>6 month agressive care
Fusion vs Disk replacement

8. DSc Natural History ~70% elderly ~70% Left curve
~55% Spondylolisthesis
~40% Lateral Lishthesis
>80% present with radicular pain

9. DSc Conservative care Surgery PT: Aerobic and core
Tricyclics for night
? Gabapentin
Brace: symptoms not curve
Surgery
Rare for curve
Common for radicular pain

10. DH Disc Bulge Disk Protrusion Disk Extrusion Disk Sequestration
“normal” degeneration
Disk Protrusion
Large base
Disk Extrusion
Small waist
Disk Sequestration
“free fragment”

11. DH Chemical Inflammation Mechanical Compression Pain
+/- Neurological findings
Less neurological tension
Mechanical Compression
Neurological Tension

12. DH Presentation Leg pain> back pain Dermatomal symptoms
+/- Valsalva
SLR
Ipsilateral sensitive, not specific
Contralateral specific, not sensitive
Femoral Stretch Test(anterior thigh pain)
L4 and above

13. DH Cauda Equina Conus Medullaris Rare Saddle Anesthesia
Overflow Incontinence

14. DH Conservative Care 90% improve in 6 weeks
Does not alter natural history
Symptomatic relief
NSAID
? Steroids
? Narcotics
ESI
Avoid 50% of surgery

15. DH Surgical Care Discectomy Micro vs regular >75% success
Age Dependent
Expectations
% leg pain
Neurologic Tension Signs

16. SS Symptoms Neurogenic Claudication Pain- >90% Numbness ~60%
Standing
Walking
Extending
Better Flexing
Pain- >90%
Numbness ~60%
Weakness <50%

17. SS Natural History 9% of population 6th decade >90% at L4-L5
Radiographic severity poor clinical correlation
20% in asymptomatic

18. SS
Natural History (>4 years)
70% unchanged
15% worse
15% improved

19. SS
Work Up
MRI
CT/CT Myelogram
+/- Xrays (Standing)

20. SS Central Lateral Only fair interobserver correlation
Lateral recess
Foraminal
Extra Foraminal
Usually DH
Only fair interobserver correlation
Surgical/Injection planning

21. SS Conservative Care PT: <60% improved in 6 weeks NSAIDS
Older Population
? Narcotics
ESI: <60% improved
? Number of shots
? Osteoporosis
Diagnostic Test

22. SS Surgical Care Laminectomy Laminotomy >70% Improved
Gold Standard
Instability
Laminotomy
Less destruction
>70% Improved
4% Instability

23. DS Common Usually L4-L5 More common in Women Most present with SS
Back pain if instability
Treat symptoms

24. DS Work Up Follow the symptoms Xrays with Dynamic views
MRI/CT/CT Myelogram

25. DS Most Grade 1 or 2 Uncommon to progress Unstable or not? Young
Tall disk
Unstable or not?

26. DS Conservative care PT: Core and Aerobic program ESI (SS)
Facet Injections (back pain)
Diagnostic

27. DS Surgical Care Decompression Fusion 80% if stable
If Unstable- Intrumentation +/- Interbody
High fusion rate
If Stable- ? In Situ
High Psudoarthrosis rate, good outcomes
Lower cost
Lower complication rates

28. DS SPORT >80 Satisfaction ODI Cost Decreased 23 points with surgery
Decreased 9 points with conservative care
Cost
QALY similar to THA/TKA

29. Questions?
Mats Agren, M.D.