indications for surgery in adult spondylolisthesis
TRANSCRIPT
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Dr. Kshitij Chaudhary, MS, DNBConsultant Spine Surgeon
Sir HN Reliance Foundation HospitalMumbai
@kcspine
I N D I C AT I O N S F O R S U R G E R YH O W T O C H O O S E T H E R I G H T PAT I E N T ?
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A N O N .
"If operating on the wrong leg is a medical error, what do we call operating on a someone who doesn't
need it.”
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@kcspine
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@kcspine
Asymptomatic Subjects
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@kcspine
No correlation with symptoms
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- I M M A N U E L K A N T ( 1 8 0 0 )
“Physicians think that they do a lot for a patient when they give his disease a name”
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@kcspine
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Fail-safe system
1. Is pain a diagnostic trap? Non-spondylogenic ?2. If spondylogenic - Any red flags?3. Is pain mechanical? If so, which syndrome? 4. Is pain a true physical disability? Yellow Flags?5. After history, PE, imaging and tests – what is
structural lesion? 6. Does clinical picture fit with structural lesion?
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@kcspine
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Is the back pain from the spine ?
Viscerogenic
Vascular
Psychogenic
1
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ViscerogenicKidney, Retroperitoneal tumor, pelvic viscera
@kcspine
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VascularAortic aneurysm, Peripheral Vascular d/s
@kcspine
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@kcspine
Spondylogenic back painis the most common
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Are there any red flags?
Degeneration
Inflammatory
Tumor
Infections
Trauma
Osteoporosis
2 @kcspine
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Which mechanical pain syndrome?
Axial Back Pain
Referred Leg Pain
Neurogenic Leg Pain
3 @kcspine
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Leg pain - Referred@kcspine
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@kcspine
Leg pain
Radicular Claudicatory
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Back pain or leg pain predominant ?
Pearson, A., Blood, E., Lurie, J., Abdu, W., Sengupta, D., Frymoyer, J. F., & Weinstein, J. (2011). Predominant Leg Pain Is Associated With Better Surgical Outcomes in Degenerative Spondylolisthesis and Spinal Stenosis. Spine, 36(3), 219–229.
90%
10%
50%
50% 90%
10%
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Vascular claudications
Pain relief on STANDING !
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D/D Leg pain
Hip joint, Knee OA
Pelvis / SI
PVD / Varicose veins
Muscle pulls (Hamstrings)
Neuropathy (Diabetes)
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Is pain a true physical disability?4
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@kcspine
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Listen to the patient !
80% History
10% Physical examination
5% Imaging, Labs etc
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What is structural lesion? 56 Does it explain the clinical picture?
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Is there a nonoperative option?7
Paracetamol / NSIADSPregabalin
Physical therapyManipulation
TENSBrace
Traction
No studies: Workgroup Consensus Statement - NASS
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Is there a nonoperative option?7
Epidural steroid injections
Small or no benefit
Chou R et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015.Friedly JL, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med 2014;371:11-21.
Controversial
@kcspine
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Epidural steroid injection
Diagnostic Value ?
@kcspine
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Co-morbidities
AgeObesitySmokingDiabetes
OsteoporosisCardiac etc.
de Kleuver et.al. (2012). Optimizing Outcomes in the Management of Degenerative Spondylolisthesis. Spine Deformity, 1–9.
8 @kcspine
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@kcspine
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@kcspine
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What is the functional limitation?
Dissatisfied with their symptoms
Pearson et.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21), 1799–1811.
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Oswestry Disability Index
• 0 to 20: Minimal disability• 21-40: Moderate Disability• 41-60: Severe Disability• 61-80: Crippling disability• 81-100: Bed-bound or exaggeration
Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine 2000 Nov 15;25(22):2940-52
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Patient expectations
“Patient expectation can be a self fulfilling prophecy”
Pearson et.al. (2013). Who Should Undergo Surgery for Degenerative Spondylolisthesis? Treatment Effect Predictors in SPORT. Spine, 38(21), 1799–1811.
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@kcspine
DECISION > INCISION
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@kcspine
www.orthotimes.com
@kcspine