Low Back Pain: Current Surgical Approaches - PubMed (original) (raw)

Review

Low Back Pain: Current Surgical Approaches

Santosh Baliga et al. Asian Spine J. 2015 Aug.

Abstract

Low back pain (LBP) is a worldwide phenomenon. The UK studies place LBP as the largest single cause of absence from work; up to 80% of the population will experience LBP at least once in their lifetime. Most individuals do not seek medical care and are not disabled by their pain once it is managed by nonoperative measures. However, around 10% of patients go on to develop chronic pain. This review outlines the basics of the traditional approach to spinal surgery for chronic LBP secondary to osteoarthritis of the lumbar spine as well as explains the novel concepts and terminology of back pain surgery. Traditionally, the stepwise approach to surgery starts with local anaesthetic and steroid injection followed by spinal fusion. Fusion aims to alleviate pain by preventing movement between affected spinal segments; this commonly involves open surgery, which requires large soft tissue dissection and there is a possibility of blood loss and prolonged recovery time. Established minimally invasive spine surgery techniques (MISS) aim to reduce all of these complications and they include laparoscopic anterior lumbar interbody fusion and MISS posterior instrumentation with pedicle screws and rods. Newer MISS techniques include extreme lateral interbody fusion and axial interbody fusion. The main problem of fusion is the disruption of the biomechanics of the rest of the spine; leading to adjacent level disease. Theoretically, this can be prevented by performing motion-preserving surgeries such as total disc replacement, facet arthroplasty, and non fusion stabilisation. We outline the basic concepts of the procedures mentioned above as well as explore some of the novel surgical therapies available for chronic LBP.

Keywords: Intervertebral disc degeneration; Low back pain; Minimally invasive surgical procedures; Pedicle screws, Zygapophyseal joints; Spinal fusion.

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Conflict of interest statement

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1

Fig. 1. In the normal spine, the discs have high water content (left). As the disc degenerates, it dehydrates, losing height or collapse (right). This puts pressure on the facet joints and may result in arthritis of these joints. Both diagrams show a spinal segment; two adjacent vertebrae with a pair of facet joints and the intervertebral disc.

Fig. 2

Fig. 2. The classic versus new treatment ladder of back pain. Reprinted from Bertagnoli [21] with permission from North American Spine Society.

Fig. 3

Fig. 3. A picture of interspinous spacer (SMS Q Spine) implanted between the spinous process of two lumbar vertebrae.

Fig. 4

Fig. 4. Radiographs of an L5-S1 total disc replacement and a photograph of the prosthesis. Reprinted image of the Freedom Lumbar Disc with permission from AxioMed Spine Co., Cleveland, OH, USA.

Fig. 5

Fig. 5. Schematic diagram of the total facet arthroplasty system. Reprinted with permission from Globus Medical Inc., Phoenixville, PA, USA.

Fig. 6

Fig. 6. Approaches to lumbar spine can be broadly divided into anterior (red arrow) and posterior (blue arrow). Axial magnetic resonance imaging also demonstrating extreme lateral access (black arrow) and transforaminal (green arrow) approaches.

Fig. 7

Fig. 7. Pedicle screws are inserted posteriorly through the pedicles into the vertebral body. Rods are used to stabilise the two vertebrae by linking them to the pedicle screws. If indicated, several levels can be fused at the same time.

Fig. 8

Fig. 8. Schematic drawing showing the extreme lateral interbody fusion procedure; the retractor is inserted into the retroperitoneal space, penetrating the psoas muscle, and positioned directly on the lateral intervertebral disc space.

Fig. 9

Fig. 9. Radiograph showing interbody fusion after the extreme lateral interbody fusion procedure supplemented by posterior instrumentation, which can also be achieved by minimally invasive spine surgery; useful in correcting the spinal deformity.

Fig. 10

Fig. 10. The axial interbody fusion rod is implanted into the L5-S1 disc space, making it a stable construct containing bone graft. Reprinted with permission from Surgi-C Ltd., Birmingham, UK.

Fig. 11

Fig. 11. (A) Computer tomography image of the axial interbody fusion with the formation of a bridging callus between the sacrum and the L5 vertebra. (B) Schematic showing AxiaLIF Rod inserted between S1 and L5 vertebrae. Reprinted from Tobler et al. [62] with permission of Wolters Kluwer Health Inc.

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