Failed traditional Spine Surgery

Understanding sciatica and use of endoscopySatishchandra Gore

www.drgore.in

Outcome of discogenic sciatica& Pain generatorsO rig in an d en d p o in t o f s c ia t ica

P o s it iveR e lie f o f p a in

R e sto ra tio n o f fu nc tion

N e ga tiveP a rtia l ad h e re n ceT e the ring o f ro o tP e rsis te n t p a in

D e pe n d s o n t im e fram e an d le ve l o f cyto kin esN u c le ar A b so rp tion

A n n u la r He a lingD e c rea se d P e rira d icu la r In f la m m a tion

Understand sciatica• Cytokine mediated chemical radiculitis : in

early stages only nerve sensitization, similar presentation post op as residual pain or rec. pain. Treatable by sodium channel blockers, anti TNF alpha meds.

• Partial nerve stretch like a SLR is seen in sitting cross legged. Presents as knee pain more often . Should be detected, monitored.

Why ?

• Failure of decompression and stabilisation to relieve pain.– Traditional surgery is IMAGE “guided”– Image symptom paradox 30%– Too invasive to tissues, nerves!!, veins– Missed lateral canal stenosis– Peri radicular fibrosis– Nerve damage extreme: cauda equina– Instability missed or created

Practical definition of fbss• Surgery failed- surgeon responsible-more remedy sought. • The patient makes increasing demands on the surgeon for

pain relief. • The patient grows increasingly angry at the failure and

may become litigious.• Addicting centrally acting meds sought.• Conservation costly-fails-more surgery sought-FAILS

again.• The probability of returning to work and activity

decreases with increasing length of disability.

Where surgery fails?

• Common causes: literature– foraminal stenosis 29%, – painful disc(s) 17%, peri radicular fibrosis.– fusion not solid 15%, – nerve damage 9%, – recurrent disc herniation 6%,– instability 5%, – painful disc plus foraminal stenosis 4%, – painful disc at the level of fusion 3%, – psychological 3%, and others.

Failure due to peri radicular fibrosis

CS showing peri radicular fibrosis

Mobilisatison of exiting L2 root LEFT L23 We are looking at left IV foramen at L23. 9 is head, 3 is leg, 12 is dorsal 6 is ventral in a prone patient. Patient is awake and aware and under local anethesia.

KAMBINS TRIANGLE

Saturday, April 22, 2023 www.drgore.in 19

Saturday, April 22, 2023 www.drgore.in 20

Saturday, April 22, 2023 www.drgore.in 21

Lateral canal stenosis• Visualizing facet and decompressing it laser or

shaver.

Rec disc herniation

ii

iii

Rec herniation in young patient

Recurrent herniation elder pt.

unstable segment with displaced grafts causing pain

CT avi showing grafts displaced

All small things

• 1. Meticulous preservation of the inter/supra spinous ligament. Reattachment.

• 2. No or minimal resection of bone. • 3. Meticulous preservation of the ligamentum

flavum, which should be detached from the laminar extremes, and later closed over the dura as a window following the discectomy.

ii

• 5. The epidural fat must be handled like the precious matter which it is. It offers the dura its freedom to move. Too often it is bruised, or sucked away.

• 6. Only the surgeon should retract the nerve root. • 7. To attempt discectomy without magnification is

not acceptable • 8. The wound, including the disc space, should be

copiously lavaged throughout, but especially before closure.

iii

• 9. An appropriate spinal table• 10. Next to nothing use of diathermy and

absorbable sponges.

• If we follow these guidelines in traditional surgery it will save a lot of complications.