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Surgery Discussion 
Seeking the most reliable and safest care.   
 
The most reliable we can find is based upon scientific reviews of the literature for reliable data. Only strong concordant finding predicts a reasonable surgical outcome like those of the AHCPR Guide #14 or the Cochrane Literature review, both of which are based upon a systematic review of the literature seeking reliable data. These reviews reiterate prior retrospective studies in that reasonable result are only predicted by strong concordant findings (Carragee et al, 1997, Schade et al, 1999, Hansson & Hansson, 2000, Carragee et al.,`06). A 2006 study with strong concordant findings of disc herniation causing sciatica by Weinstein et al., confirmed Weber's 1978 trial results with very similar findings in 501 randomized patients in the SPORT trial. Thus, we can say that surgery is a luxury for speeding recovery in patients severely limited with very strong concordant clinical and diagnostic findings. 
 
Certain information needs to be documented: 
1.Sciatica with compromised neurologic structures (concordant obvious nerve root pattern or EMG changes) that might benefit from decompression. 
-  Obvious motor, sensory and reflex findings on physical examination indicating a specific nerve root compromise or electrodiagnostic findings concordant with less obvious physical findings: 
  -  Positive sharp waves / EMG 
      -  Fibrillation potentials / EMG 
      -  H-reflex slowing for S1 nerve root / EMG 
      -  Hints of the above with neuroclaudication of less than 300 meters and significant SEP slowing 
   -  Strong Concordant with Imaging evidence of Spinal Stenosis or Disc Herniation concordant with the neurological compromise.  
                              or  
1. Lost structural integrity (abnormal motion according to the enclosed criteria accorded to trauma at work) that might need a fusion. 
     -  Mobile translation >5 mm. on lateral flexion extension films? 
    -  11 degrees more angular motion at the motion segment to be fused than adjacent segments above L5-S1 where it is 15 degrees? 
                               or  
2. Lost structural integrity (abnormal motion) that might need a fusion (Posner Criteria). 
-  Mobile translation >5 mm. on lateral flexion extension films? 
-  11 degrees more angular motion at the motion segment to be fused than adjacent segments above L5-S1 where it is 15 degrees? 
 
The diagnostic criteria from the AHCPR Guide # 14 and AMA Impairment Guide 4th Ed are intended to find those preoperative findings that best predict a reasonable outcome confirmed by both the Weinstein et al.,`06 SPORT Trial and Carragee et al.,`06, studies. 
 
Should surgery be carried out, do not forget the need for a conditioning plan for regaining comfortable activity tolerance.  Considering the time away from work, time away from normal duties requires a reasonable period to build endurance and stamina conditioning to regain more comfortable activity tolerance that is lost with any episode limited activity. 
 
In summary you need to consider the following information: 
-More probable than the not relationship of the present findings to specific exposures while at work (Causation), 
-Relevant finding as described above 
-The expected return to normal work activity 
-The risks of suggested surgery 
 
For Laminectomy or Laminotomy see Figure 2. -Most common Nerve Root Compromise with Disc Herniation.  For Fusion see Figure - 13.  X-ray Angular Motion of Instability and Figure14- X-ray Translation of Instability according to Posner criteria used by Carragee et al.,`06 "gold standard" article. 
Supportive information is not available for use of IDET as well done Australian double blinded randomized controlled trial by Freeman et al,. 2005 found it ineffective and lesser study found no clinically significant difference Pauza et al., 2004). 
 
Fusion Caveat 
Without evidence of lost structural integrity on motion films, fracture or dislocation, the results of fusion are quite suspect according to the most reliable literature available about lumbar fusion. If there were indications for fusion that I am unable to find in the chart, the patient must be warned about the response to fusion for such cases  The Fritzell et al Volvo award winning study 2001, found a paltry improvement for fusion with a rapid deterioration toward similar complaints from 26% difference at 6 months to only 15% difference at two years reporting pain at 43 on a 100-point visual analog scale below compared to 58/100 points without surgery.  These minor differences were gone at 5 year follow-up. Later they publioshed two year results of over 40% complaints of male sexual alterations with an anterior approach Hägg et al,`05 and mentioned their concerns relative to the total disc replacement that requires an anterior lumbar surgical approach).  
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The non-operative group had markedly less potential placebo effect being offered nothing new and less attention compared to the "latest cure" offered the surgical group. The results were unimpressive as the authors had to include the caveat "There was still a considerable amount of both pain and disability reported 2 years after treatment start even in the surgical group, and it is important to realize that lumbar fusion in this patient category very seldom cures the patient". The "rare cure" caveat includes only 29% of the surgical group reporting being "much better," only 15% more than the 14% than the control group who avoided the significant surgical risks.The limited improvement must be considered relative to a reported 17% surgical complication rate with fusion surgery. Nine percent of the surgery patients had either life threatening complications or complications that require immediate re-operation. This and another of Moller et al.2000, then Ekman et al.,`05 for spondylolisthesis at five years offer no significant difference except the life threatening complications. A second study (Brox et al.,`03, compare fusion for degenerative lumbar disc to a cognitive activation program of one lecture to "not fear using your back" and followup home recommendations 3 times per week for three weeks finding no difference at one year. Fairbank et al.,`05 verified Brox et al.`03 findings with much larger numbers with the 18% surgical complication rate being the only difference at two years between the surgical and activated control group. It is difficult to justify life threatening complications for such meager results as well discussed in Deyo, Nachemson and Mirza '04 NEJM in a polite call for restraint before the Fairbank et al.,'05 and Fritzell complication article by Hägg et al,`05 were available. 
 
Fritzell's 2004 ISSLS meeting in Porto Portugal report the minor differences at 2 year gone at 5 year follow-up similar to Brox et al.,`03 report at 1 year and Fairbank et al.,`05 at 2 years indicating the only true differences are the added complication risks from lumbar fusion surgery.  
 
In these and multiple other prospective studies, a solid fusion or lack thereof, did not seem to influence whether a patient had a good or a bad result. Such findings continue to question the whole premise of fusion as dealing with the true source of symptoms.   
 
I am unable to find reliable literature to justify instrumentation for fusion with these findings. Information now available from at least 8 randomized trials indicates that hardware only adds complications as screw placement is technically demanding proper screw placement as seen below without compromising the nerve root foramen or anterior vessels. 
    
 
Predicting Reasonable Results from Elective Fusion - Only through Posner Criteria 
We now have indications for lumbar fusion that predict a reasonable result. Carragee et al.,`06 seeking a gold standard of fusion indications, compared fusion results after "ideal discography" to those based upon "ideal instability". Ideal discography criteria included isolated >15mmHg opening pressure and stringent concordant pain criteria.  Ideal instability criteria were Posner's >4 mm translation or >11 angular motion). Excellent surgical fusion results (no daily analgesia and return to usual work) using "Posner criteria" indications was 72% compared to 26.6% for "ideal discography" indications. Minimally acceptable results (no narcotics and return to some work) were 91% for Posner criteria and 43% for discography. A 57% poor results (requiring narcotics and unable to work) from fusion seems unacceptable relative to the surgical complication risks. Thus, we now have the Posner criteria for instability that predict reasonable surgical results.  
 Carragee et al.`03 assessed the minimally acceptable expectations of patients awaiting spinal fusion for presumed diskogenic pain. He found that greater than 90% of the patients wanted at least, 1. return to some gainful employment, 2. narcotic discontinuation, and 3. high physical functioning level.  According to the available literature, such results are uncommon after disk surgery in patients with persistent disabling back pain without Posner Criteria indications (Fritzell`01, Brox`03, Fairbank`05, Pauza`04, Freeman`05, Carragee`06). 
 
Total Disk Replacement (TDR) has been touted as the procedure to overcome the shortcomings of fusion by maintaining the motion. The components are technology are similar to the components for other joint replacements. Components are similar enough that, the FDA (Federal Drug Administration) only requires TDR only to have outcomes to the dismal outcomes of spine fusion to be approved. Two studies, Delamarter et al.,`03 and McAfee et al.,`03 have now been published that provide sufficient evidence that total disc replacement provides no worse results than the more contemporary fusion that it will even more expensively replace. Thus total disc replacement now has FDA approval but not the endorsement of Medicare.   
                                   
 
Considering the Anterior Lumbar Surgical approach, the most reliable information we have about the required the anterior lumbar approach for total disc replacement comes from the 2 year follow up by Hägg et al.,`05 with an addendum to the original 2 year data by Fritzell et al., first published in 2001. Their prospective trial had 25 men with anterior approach for fusion as required for total disk replacement.  Half of the men had either penile numbness or abnormal ejaculation at five years with over 40% of the men had penile numbness and over 40% had ejaculation abnormalities with 50% having one or both. Complications were slightly less in women. Considering the prior problems with clinician reporting of complications such as in dysphonia and dysphagia in the cervical spine, we need high level studies of the total disc procedure under rigid research criteria before we are able to simply dismiss the Hägg et al.,`05 follow up data due to small numbers.  
Concerning anterior Lumbar surgical approach, it is difficult to disagree with those who recommended that until further studies are done, the patient consent form for Total Disk Replacement should include the warning in large letters about ejaculation abnormalities and genital numbness to serve as a "caveat emptor" until we better understand how to avoid such issues expensive procedure with additional risks and can only matches the paltry results of more standard fusion. Medicare in USA seems to concur. 
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Note the anterior lumbar fusion approach required for Total Disk Replacement and anterior lumbar inter-body fusion relative to the large abdominal vessels and nerves to the genitals that can effect ejaculation and sensation. These important structures should not be left out to simplify diagrams of the procedure as in the right diagram. 
 
 
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