Low back pain is one of the commonest disorders
of mankind. While majority of the patients get relieved
with simple rest, medication, spinal exercises and physio
& occupational therapy, few require surgical management.
Patients who require surgical management invariably have
significant problem in spine (vertebral body) and the disc
(cushion between the vertebral bodies).
Spine is an important structure of human
body. Most of body weight is transferred through the lower
lumbar spine to the legs. Hence wear and tear due to aging
and improper use of our back causes severe degeneration
in the lumbar spine and the disc. Degenerative disc disorder,
spondylosis, facet dystrophy, facet hypertrophy are some
of the diseases causing back pain.
Spondylolysis (Defect in a part of spine)
and spondylolysthesis (slippage of one vertebral body over
the other) are other causes of low back pain. Some of the
disorders treated (managed) surgically are detailed below
with clinical history of the patients. All these patients
required surgery following failure of adequate conservative
management.
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Case report
1: SPONDYLOSIS
Diagnosis: Lumbar spondylosis / Degenerative
disc disorder / Lumbar canal stenosis
Treatment: Spinal Decompression, Instrumentation and Bony
fusion.
A forty five year old lady had chronic back pain for more
than four years. She underwent medical management and physiotherapy
on and off with temporary relief of back pain. However she
started developing aching thigh and leg pains along with
severe back pain, which restricted her mobility significantly
for the past twenty days.
Investigations showed significant lumbar
spine diseases – lumbar spondylosis, degenerative
disc bulge, facet dystrophy and secondary canal stenosis
at lumbar 4 and 5 vertebral level.
X-ray
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MRI
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Degenerative lumbar spine produce back
pain and lumbar canal (which contains the nerves and blood
vessels) stenosis produces thigh and leg pain due to venous
stasis in the spine causing congestion of the nerve roots.
A definitive surgical management provided
good relief of patients’ symptomatology. Spinal decompression
(subspinous laminectomy) released venous stasis and neural
compression, spinal instrumentation (Pedicle screw –
rod fixation) provided support to the degenerative spinal
level and posterior lumbar inter body fusion (PLIF), posterolateral
inter transverse fusion with autologous (patients own iliac
crest) bone graft provided good fusion at the L4 L5 segment.
Post-operatively patient was provided
with a brace and gentle mobilization. The patient is symptom
free in first two weeks time and started walking comfortably.
Post operative x-rays 3 months after surgery
showing good fusion and stable instrumentation.
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Case report 2: SPONDYLOLYSIS
Diagnosis: Spondylolysis – Defect
in the pars
Treatment: Spinal stabilization & grafting
Pars is a bony structure in the spine which
connects the vertebral body and the posterior spinal structures
like lamina & spinous process. Occasionally this structure
may be thin or may not have formed. A thin pars may get
fractured following trivial injury. This will cause severe
back pain, which may get well with bed rest.
Healing of the pars defect invariably
relieves back pain. In cases of failure of fusion with conservative
management fails. Spinal stabilization will provide optimal
enviroment for the pars to fuse. One such case is illustrated
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Fig
1 shows pars defect |
Fig
2 Operative picture demonstrating pars defect |
Fig
3 spinal stabilization & fusion
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Case
report 3: SPONDYLOLYSTHESIS
Diagnosis: Spondylolysthesis (Slippage
of one vertebral body over another vertebral body)
Treatment: Slippage reduction, spinal instrumentation and
fusion.
Spondylolysthesis may be due to congenital
degeneration or traumatic cause. Since the spinal alignment
is lost, patient develops severe back pain due to excessive
strain over the slipped vertebra. The slippage of vertebra
can also cause nerve root compression due to lumbar canal
stenosis. Hence a patient may develop postural deformity
along with back & leg pain. the ideology of the treatment
is achieve a good fusion of the slipped vertebral bodies
after reducing the slip to the maximum. This can be achieved
by spinal instrumentation and bone grafting. While achieving
reduction of the slipped vertebra the neural decompression
is achieved as well. In few cases nerve root decompression
and spinal canal expansion need to be achieved by laminectomy.
Some case examples are given below.
Technique Posterolateral
fusion and long level instrumentation
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Disc is a cushion like
structure that lie between the end surface of bones
that from the spine. The disc allows movement of the
spine & acts like a shock absorber. The nerves run
close to the disc in the spinal canal. When a disc is
damaged, the soft center may slip out (prolapse) and
press on a nerve(Fig .1.)
In
majority of the cases conservative (physiotherapy
and bed rest) and medical line of treatment will
reduce the pain. However some of the patients may
not recover completely. Hence may require surgery.
Surgery is carried out to relieve persisting pain
and to arrest further neurological deficit. Advanced
spinal surgical procedure like micro lumbar discectomy
and micro endoscopic discectomy are offered to the
patient. Both these techniques are keyhole procedures
performed through a small incision on the back
