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TIME FOR SURGERY: The pendulum has swung too far – Stop Wasting time, This Is What I Do

TIME FOR SURGERY: The pendulum has swung too far – Stop Wasting time, This Is What I Do. Scott D. Boden, MD Professor and Chair, Department of Orthopaedics Emory University School of Medicine Atlanta, Georgia. Guiding Concepts. KEY QUESTIONS. WHO? WHY? WHEN? WHAT? WOW?.

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TIME FOR SURGERY: The pendulum has swung too far – Stop Wasting time, This Is What I Do

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  1. TIME FOR SURGERY: The pendulum has swung too far – Stop Wasting time, This Is What I Do Scott D. Boden, MD Professor and Chair, Department of Orthopaedics Emory University School of Medicine Atlanta, Georgia

  2. Guiding Concepts

  3. KEY QUESTIONS • WHO? • WHY? • WHEN? • WHAT? • WOW?

  4. Patient Selection

  5. Nerve Root Tension Signs 1880 SLR95% 1881 Lasegue71% 1888 Bowstring69% 1901 Crossed SLR21%

  6. MRI JARGON • HNP - herniated discwprotrusionwherniation wsequestration • Bulging discwrarely clinically relevant • Degenerative discwvery common wdoesnot change management of acute LBP or leg pain

  7. Abnormal Findings In ASx Myelogram 24% CT Scan 36% MRI Scan 33%

  8. WHY?: Indications for Surgery Bowel / BladderDysfunction 1-2%

  9. Indications for Surgery Progressive Motor Weakness 3%

  10. Indications for Surgery Recurrent Episodes of Sciatica < 5%

  11. Indications for Surgery Intractable Leg >90%

  12. WHEN?: Natural History - Hakelius % IMPROVED 4 Weeks75% 6 Weeks80% 12 Weeks90% 24 Weeks93%

  13. 86% 86% Natural History -Bush Better Without Surgery • N = 165 • Used epidural and nerve root blocks

  14. Natural History -- Saal 90% Better Without Surgery • N = 64 • 87% with motor weakness • Bedrest, NSAIDs, active exercise

  15. Natural History -- Saal 92% Return to Work No Comp 3.2 months Yes Comp 9.0 months

  16. Natural History - Radiographic DISC 20%  by 0 - 50% 35%  by 50 - 75% 45%  by 75 - 100% 80%   50%

  17. Literature Summary > 90% NO SURGERY!

  18. Literature Summary WAITING 3 MONTHS OK

  19. THE PROSPECTIVE TRIALS

  20. 14 Day Hospital Bedrest, Analgesia, Exercise 126 Randomized Study Weber 280 Sciatica 87 36 Surgery No Surgery

  21. Weber 126 Randomized 60 66 Surgery 6 Wk Physio Rx 59 (55) 17 Surgery 1 49 Conservative

  22. Weber 1 Year Surgery Patients More Satisfied

  23. Weber 4 + 10 Years • Motor, sensory, reflex • Back pain • Leg pain No difference

  24. Weber -- Considerable Back Pain 12% 12% 9% 10% 8% 4 Yr F/U 10 Yr F/U 6% 4% 0% 0% 2% 0% Surgery Conservative

  25. No Pain Some Pain Weber -- Leg Pain (10 Years) 100% 90% 98% 98% 80% 70% 60% 50% 40% 30% 20% 10% 2% 2% 0% Surgery Conservative

  26. Cochrane Meta-Analysis of MINI vs MICRO Discectomy (Rasouli et al., 2014) • 11 RCTs, 1172 pts • MINI – inferior leg pain relief • MINI – higher recurrent HNP • MINI – slightly lower infection

  27. Conclusions: Surgically treated patients with a herniated lumbar disc had more complete relief of leg pain and improved function and satisfaction compared with non-surgically treated patients over 10 years. Nevertheless, improvement in the patient’s predominant symptom and work and disability outcomes were similar regardless of treatment received. For patients in whom elective discectomy is a treatment option, an individualized treatment plan requires patients and their physicians to integrate clinical findings with patient preferences based on their symptoms and goals.

  28. Conclusions: In a combined as-treated analysis at 4 years, patients who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status.

  29. Philosophical Question To cut... or Not to cut?

  30. 1934 - 2018 After 84 Years of Human Experimentation What have we learned?

  31. SCIATICA IMPROVES QUICKER WITH SURGERY

  32. LAW OF SURGICAL SUCCESS: “Selection is 9/10 of the law”

  33. Indications for Surgery • Bowel / Bladder • Progressive motor • Recurrent episodes • Intractable leg pain

  34. THANK YOU!

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