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Lumbar Spine

Advice cannot be provided on an individual basis. The Society cannot accept any responsibility for the use of the information provided, the user and their health care professionals must retain responsibility for their health care management.

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Dear Patient

The following information was put together to help in the decision-making process. The graphs show the answers of the members of EuroSpine, the Spine Society of Europe, considered to be the European experts in the field of treatment of spine pathology. This information should help you to learn and understand what most of the experts in the field would do in each specific situation. The information reflects a “common sense” approach to treatment of the members of EuroSpine, yet does not replace a careful evaluation of your individual situation. Therefore, if you find a significant difference between the answers below and you doctor’s opinion, ask your doctor what made him/her reach this decision.

Each specific situation has to be evaluated on an individual basis. EuroSpine and its members cannot be held responsible for any misunderstandings (or misdiagnosis) based on the information provided here, which in no way attempts to replace a targeted evaluation.


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GENERAL INFORMATION FOR THE READER

The graphs in the following text are the result of a questionnaire carried out among the members of EuroSpine, the Spine Society of Europe, which represents experts in different fields of spinal pathology.

Specialist's opinion:
1) Approximately how many patients with degenerative lumbar spine condition do you see per year?
0 - 100

11 votes
101 - 200

21 votes
201 - 400

34 votes
More than 400

70 votes
Total: 136 Specialists answered
2) Your professional background?
Orthopaedic Spine Surgeon

99 votes
Neurosurgeon

31 votes
Neurologist/Pain Specialist

1 votes
Rheumatologist/Physical Medicine

4 votes
Other

0 votes
Total: 135 Specialists answered
3) If you are a spine surgeon, approximately how many patients do you operate per year?
0 - 50

12 votes
51 - 100

21 votes
101 - 200

40 votes
201 - 300

27 votes
More than 300

29 votes
Total: 129 Specialists answered


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THE HEALTHY LUMBAR SPINE

The lumbar spine is the part of the spine located between the pelvis and the thoracic cage. It consists of five lumbar vertebrae. Each vertebra comprises a vertebral body and a vertebral arch that is connected to the corresponding vertebral body by two pedicles. The bony attachments are posterior: the spinous processes (the bone you can feel down the centre of your back), the paired transverse and the articular processes. The transverse processes serve as attachments for muscles, while the articular processes represent the posterior bilateral joints connecting each vertebra to its adjacent vertebrae. This enables motion of the corresponding intervertebral disc on the anterior part of the spine.
Fig 1
Fig 2
The intervertebral discs, joint capsules and ligaments hold the vertebrae together and control the range of segmental motion. The posterior wall of the vertebra, the bony arch and the yellow ligament extending from one arch to the next form a tube (spinal canal) containing the end of the spinal cord and the spinal nerves. Each segment has two lateral openings through which the corresponding nerve roots exit to the periphery.
Fig 3

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PATHOLOGY OF THE LUMBAR SPINE

Degenerative changes of the lumbar spine


General remarks

The main functions of the lumbar spine are to protect the spinal nerves and to facilitate most of the trunk's motion. The five lumbar vertebral bodies maintain distance and transmit loads from the thorax to the pelvis and serve as muscle attachments.

Motion and load create adaptive tissue changes during life. These changes include loss of tissue elasticity, growth of osteophytes and calcification of ligaments. As a result, the structures around the spinal canal increase in volume, thereby reducing the available space for the nerve roots in the canal or the outlets for the roots. This effect is sometimes emphasized by anterior vertebral slippage (degenerative spondylolisthesis) due to insufficiency by wear and tear of the vertebral facets.

The narrowing of the spinal canal is referred to as spinal stenosis.
Fig 4
Fig 5
Fig 6
Fig 7

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DEGENERATIVE DEFORMITY: ROTATIONAL SPONDYLOLISTHESIS

Fig 8

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EPIDEMIOLOGY OF LUMBAR SPINE DEGENERATION

Degenerative change is a physiological response of the body occurring during the life of an adult. Thus, depending on the age and activities of the individual, all of the imaging techniques (radiographs, computer tomography and magnetic resonance imaging) show these changes differently. Many of these changes may be asymptomatic and unknown to the person. The presence of corresponding symptoms (mostly local back pain) is dependent on the extent and localisation of the degeneration and the underlying individual anatomy.

Not all degenerative changes visible on imaging techniques are symptomatic or need treatment.

This sometimes makes it difficult to detect the origin of pain, since the degenerative changes may be spread out (and visible) along the whole lumbar spine, but only one of them might be painful.

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NARROWING OF THE SPINAL CANAL (LUMBAR SPINAL STENOSIS - LSS)

Symptoms of a narrow spinal canal

The predominant symptom of a narrow spinal canal is the so-called neurogenic claudication. This is a painful sensation occurring after a certain walking distance, or during a certain period of standing in an upright position. Typically, the pain disappears in a bending-forward position of the body, e.g. in the sitting position. Even if the most common symptom is leg pain (often in a specific area), other typical symptoms include weakness or unsteadiness in the legs after a certain walking distance. In severe cases, the patient may hardly be able to walk a few metres and is literally immobilized by this condition.

Diagnostics of LSS

The most important clue to diagnosis is the patient’s history, as the physical examination may not reveal conclusive findings. Imaging confirms the suspected narrowing and defines the extent of the stenosis. Magnetic resonance and sometimes computer tomography (also combined with myelography) are the most commonly used techniques.

Treatment

Treatment of symptomatic LSS can be non-operative or surgical.
Non-operative: Although the narrowness in the spinal canal has its mechanical factor, some tissue swelling and oedema are often involved in (part of) the origin of symptoms. Medical treatment may positively influence these non-mechanical factors and lead to a reduction of pain.

Specialist's opinion:
4) Should LSS be treated operatively or non-operatively? (Select the answer that comes closest to your practice)
Symptomatic LSS is always (>90%) a domain of non-operative treatment

2 votes
Non-operative treatment should be carried out at least three months before surgical treatment is discussed.

17 votes
Only if non-operative treatment is unsuccessful should surgery be indicated

86 votes
Symptomatic LSS should always (>90%) be approached surgically

15 votes
Other

7 votes
Total: 129 Specialists answered
5) If conservative treatment is chosen, please indicate the frequency
NSAIDs

97 %
Systemic steroids

23 %
Epidural steroids

59 %
Calcitonin

13 %
Pain medication

92 %
Antidepressants

45 %
Vitamins/roborant

21 %
Physical exercises

100 %
Total: 123 Specialists answered

LSS is primarily a mechanical problem. If not solved otherwise, surgery has to be performed. The goal of intervention is to decompress the spinal canal and to relieve pressure on neural structures, thus diminishing (or eliminating) the severity of symptoms.


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SURGERY IN SPINAL STENOSIS

Specialist's opinion:
6) When do you operate on a patient with symptomatic LSS?
The decision for surgery is made at the time of diagnosis

3 votes
Only after unsuccessful non-operative treatment

31 votes
Timing is mainly determined by the severity of symptoms

76 votes
Only in the presence of permanent neurological symptoms

2 votes
Other

7 votes
Total: 120 Specialists answered

Decompression of the nerve roots in the spinal canal can be performed by different techniques. Indirect decompression is applied if part of the stenosis is caused by infolding ligaments. By posterior distraction, the ligaments can be stretched and the volume of the spinal and nerve root canal increased. This technique avoids manipulation in the direct vicinity of neural structures and represents a minor procedure.
Fig 9


Laminectomy is the most invasive procedure. All posterior elements covering the nerve roots are removed and the neural structures are thus efficiently decompressed. This method might involve some problems with the stability of the spine and necessitate an additional fusion in certain cases.
Fig 10
Selective (undercutting) laminotomy decompresses the neural structures by removing the thickened ligaments, thinning the laminae and reducing the volume of the facets. This technique does not usually interfere with the stability of the spine. The technique is less invasive, but the operative area might be less accessible.
Fig 11
Newer, less invasive methods decompress the spinal canal by percutaneous methods. By inserting instruments into the spinal canal, decompression is performed using different techniques such as with razors or lasers.

Specialist's opinion:
7) What is the most frequently used technique for decompression in LSS in your clinic?
Indirect decompression/interspinous distraction

4 votes
Fusion without decompression

2 votes
Laminectomy

31 votes
Laminotomy

57 votes
Percutaneous methods

2 votes
Other

20 votes
Total: 118 Specialists answered

Simultaneous fusion combined with decompression is occasionally discussed as a possible treatment. Fusion (immobilization) of the spine (or part of it) might be helpful in reducing back pain and eliminating instability or deformity, but it calls for longer surgical procedures. (See also “Fusion of the lumbar spine”)
Specialist's opinion:
8) When do you perform fusion simultaneously with decompressive procedures?
Always

5 votes
Never

1 votes
Only for patients with instability/deformity

82 votes
For patients with dominant back pain

19 votes
Other

11 votes
Total: 118 Specialists answered


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LOW BACK PAIN - SURGERY

Low back pain (LBP) is an unspecific description of pain located in the lumbar spine or pelvic region. The pain does not typically radiate down the legs or at least follow the typical pattern of the anatomic distribution of the nerves. (See “Lumbar nerve root pain”).

The list of treatment modalities is endless and includes surgery, which reflects the fact that none of these procedures are the ideal solution for the problem of low back pain.

With regard to surgery, the literature is controversial. Some papers deny the existence of an objective anatomical origin of LBP and reject surgery – regardless of the procedure chosen – as a possible treatment. Others support surgery if the diagnostic procedure leads to an identifiable anatomic source (facet/disc) of pain. Newer surgical techniques promise to improve the results by preserving segmental motion of the lumbar spine.

Specialist's opinion:
9) I perform surgery for LBP
No

21 votes
Yes

95 votes
I am not a surgeon, but sometimes refer patients for surgery

2 votes
I am not a surgeon and do not refer patients for surgery

0 votes
Total: 118 Specialists answered


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DIAGNOSTIC PROCEDURES

One of the problems with surgery for LBP is accurately identifying the source (disc, facets, ligaments, etc.) of pain. Several diagnostic procedures are regarded as suitable for this purpose. Not all of these diagnostic tests are adequately validated and their significance remains somewhat controversial.

Specialist's opinion:
10) How often do you use the following diagnostic procedures for patients with LBP?
Clinical examination

100 %
Imaging (radiographs, MRI, CT, others)

95 %
Facet infiltration

46 %
Discography

30 %
Nerve root infiltration

34 %
Epidural infiltration

33 %
Total: 120 Specialists answered

Surgery in Spinal Stenosis

Specialist's opinion:
11) Under which circumstances would you recommend surgery to LBP patients? (Multiple answers possible)
Ineffective non-operative treatment for at least three months

73 votes
Source of pain identified (with invasive diagnostic procedures)

69 votes
Multilevel pain (>3 levels)

8 votes
Paucilevel (<3 segments)

33 votes
Only in the presence of vertebral slipping

25 votes
Only in the presence of degenerative deformity

19 votes
If the MRI shows a “black disc” corresponding to the level of subjective pain (no discography)

22 votes
Other

21 votes
Total: 120 Specialists answered
12) If you do not recommend surgery for LBP, what alternatives would you suggest?
Pain medication

95 %
Psychotropic medication

40 %
Physical exercises

100 %
Manual therapy/chiropractic

52 %
“Alternative” medicine (acupuncture/acupressure, atlas therapy etc.)

31 %
Psychological exercises (e.g. yoga or similar techniques)

37 %
Psychiatric exploration

34 %
Total: 116 Specialists answered

If the painful anatomical structure is identified, it seems logical to approach this structure to eliminate pain. Different surgical options are available.

Specialist's opinion:
13) What surgical option would you recommend for patients with discogenic LBP (positive discography, negative control-discography)?
Disc replacement by prosthesis

23 votes
Fusion

53 votes
Posterior motion-preserving instrumentation

12 votes
IDET

3 votes
Other

21 votes
Total: 115 Specialists answered
14) What surgical option would you suggest for LBP originating from facets (positive facet infiltration)?
Fusion

49 votes
Percutaneous treatment (ramus posterior)

37 votes
Disc prosthesis

1 votes
Posterior motion-preserving instrumentation

8 votes
Other

14 votes
Total: 114 Specialists answered


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FUSION OF THE LUMBAR SPINE

The traditional method to approach various pathologies of the spine is fusion of one or more segments depending on the individual situation. This technique of immobilizing motion segments was adopted from other areas of orthopaedic surgery, such as that of the hip and knee, where the painful joint was immobilized if the problem could not otherwise be solved. Increased understanding and improved technology allowed the joint to be replaced in spite of fusing it. This type of surgery has developed into a standard procedure for most joints in the body.

Fusion is still the most frequently used technique in the spine. The complexity of the anatomy and proximity to neural structures makes it more difficult to replace parts of the spine and preserve motion. These techniques do exist today, but widespread conclusive clinical data and results are not yet available. (See also chapter “Motion preserving procedures”)

Fusion of the spine can be performed in various ways. However, the principle always remains the same: to achieve solid bony union between the fused vertebrae. The fusion mass to enhance bony union is generally the autologous bone of the patient, specially prepared allogenic bone or bone substitutes. To enhance solid union, metallic implants are generally used anteriorly, posteriorly or combined.
Fig 13
Fig 14
Specialist's opinion:
15) Which fusion technique (1–2 segments) do you prefer for 1–2 segments of the lumbar spine?
Patient’s own bone (pelvis/fibula)

58 votes
Allogenic bone

20 votes
Bone substitute

17 votes
Morphogenetic proteins

4 votes
Other

11 votes
Total: 112 Specialists answered
16) Do you use metallic implants to enhance fusion (1–2 segments)?
Yes

98 votes
No

9 votes
Comment below

4 votes
Total: 112 Specialists answered
17) What instrumentation do you prefer for the lumbar spine without marked deformity (1–2 segments)?
Stand-alone posterior instrumentation (pedicle screws/translaminar)

40 votes
Stand-alone anterior instrumentation (interbody cages, screws, plates)

6 votes
Combined anterior (cages) and posterior instrumentation (combined approach or PLIF/TLIF)

58 votes
Other

7 votes
Total: 112 Specialists answered
18) Possible complications connected to one or more of the aforementioned procedures are:
Nerve root injury/neurological deficit

48 votes
Cerebro-spinal fluid leakage

18 votes
Wound healing/infection

22 votes
Recurrence/incomplete decompression of stenosis (narrowing of the spinal canal)

16 votes
Total: 112 Specialists answered

© The above text, figures and data are property of EUROSPINE®, the Spine Society of Europe and may not be reproduced or used in any other way.

EUROSPINE, April 2007
© EUROSPINE, the Spine Society of Europe - website by bestview gmbh page last updated on 23.06.2015