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Failed traditional Spine Surgery. Understanding sciatica and use of endoscopy Satishchandra Gore www.drgore.in. Outcome of discogenic sciatica & Pain generators. Understand sciatica.
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Failed traditional Spine Surgery Understanding sciatica and use of endoscopy Satishchandra Gore www.drgore.in
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.
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.
Lateral canal stenosis • Visualizing facet and decompressing it laser or shaver.
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.