Lumbar Spine Current Concepts ANATOMY & BIOMECHANICS: Regiona !

i""erences: Cer#ica : nerve roots exit directly lateral at level of disk, named by the vertebra that it passes above (C5-6 disk C6 nerve), facet surfaces usually flat Lumbar: nerve root exits directly under pedicle fore which it is named, superior to the disk (L -5 disk L nerve), facet surface may be flat or curved $orsa roots: sensor% &entra roots: motor Spon!% t%pes !ype " # dysplastic, con$enital !ype "" # isthmic, lysis or elon$ation of pars via repeated stress !ype """ # de$enerative, loss li$amentous inte$rity of annulus and facets, assoc with normal a$in$ !ype "% # traumatic fx of pars !ype % # patholo$ic, results from bone tumors of pars $isc in'ur%: (rotrusion (annulus still intact, nucleus contained) o radial bul$in$ with intact annulus, locali&ed usually lateral o disk protrusion' intact (LL, diffuse annular bul$e usually posterior and bilateral Herniation o (rolapsed' nucleus has mi$rated throu$h inner layers of annulus, but still contained (a few annular fibers intact ) outer most and (LL still intact) o disk extrusion' ruptured (LL, nucleus has broken outermost layer o disk se*uestration' mi$ration away from disk space, nucleus has broken from disk and is in the spinal or vertebral canal Segmenta instabi it% secon!ar% to $$ or $): lateral flex and ext radio$raphs demonstrate abnormal motion, traction spurs seen +-, mm above the vertebral body ed$e pro-ectin$ hori&ontally, $as in the disk. En! stage $$$: disk space narrowin$, overridin$ and sublux of post -ts (facets) hypertext, leads to no cushionin$, pain with minor provocation, subluxed post -ts repeatedly traumati&ed de$en arthritis Ner#e root impingment: disk protrusion, bony root entrapment, lat stenosis, redundant folds of li$ flav due to loss of elasticity Cau!a e*uina: most often caused by L -5 massive central se*uestration disk A!+esi#e ra!icu itis: nerve roots bounded down by fibrotic tissues, associated with de$en, persistent na$$in$ pain because root is tethered and unable slide

 Mec+anism o" ra!icu ar pain: pain of sciatic non mechanically caused but chemically irritated epineurium secondary to nucleur material destroyin$ root tissue causin$ an inflammatory reaction. Spina cor! in'ur%: Bro,n se*uar!: lateral half of /C in-ury, ispsilat mus and proprio0, pt0vibration, contralat loss of temp, pro$nosis $ood, 12" often penetratin$ trauma Anterior: 12" flexion compression trauma (affects vertebral artery), incomplete motor loss, some sensory loss sparin$ of dorsal column (deep press and proprio), pro$nosis poor if nothin$ returns within , hrs, Centra : 12" 354 yrs (25 in spine) with extension in-ury, 67 3 L7 motor and sensory, sacral sparin$, pro$nosis fair, pro$ressive return of L7 common but hand function is usually poor, amb with spastic $ait. Cord pinched between ant boney spurs and post infolded li$ flav ischemic insult to central cord. (osterior: rare, loss of deep press0pain0proprio with intact motor fxn, pain and temp. amb with slappin$ $ait. Comp ete: 12" burst fx, canal compromise. 8o fxn below level of in-ury. (ro$nosis poor. Bu bus ca#ernosus re" e-: compression of clitoris or $lans penis with sphincter contraction E.AM & ASSESSMENT: Acute: difficulty performin$ 59Ls, hi$h levels of pain C+ronic: 59Ls can be performed, lower levels of pain, difficulties with sports0work0liftin$ Os,estr%' 4: avera$e startin$ score, acute # at least ,4-,5:, hi$her scores indicate hi$her levels of perceived /ear0a#oi!ance Be ie" *uestionnaire' ; items, hi$her numbers indicatin$ $reater level of fear-avoidance beliefs related to work activities, total ,. /core 3< prolon$ed disability, may indicate multidisciplinary approach. /core 3+= reduced likely of success with manipulation. Neuro ogica assessment' components # stren$th of myotomes, dermatome sensation, 9!>s, neural tension si$ns. (ts with nerve root compression # not appropriate for manipulation. (ositive neuro exam more likely to have lon$ term pain and disability. "f no sx distal to knee, no need for neuro assess. S ump an! SLR' relatively sensitive but not specific 1e eg raise or crosse! eg raise' specific but not sensitive

Centra i2ation with repeated movements' stron$ predictor of disco$enic dysfunction, specific and hi$h likelihood ratios

 Strong e#i!ence support use o" tests: centrali&ation, crossed /L>, vibration sensation testin$, superficial pain testin$ (sharp0dull) Mo!erate e#i!ence supporting use o" test: slump, /L>, (5, (("%1s, ?abinski, monofilament, li$ht touch sensation, *uad reflex, 5chilles reflex, myotomal stren$th testin$ /i#e categories o" bac3 pain: o &iscerogenic: internal or$ans, not a$$ravated by activity or rest, kidneys, pelvosacral lesions of the lesser sac, retroperitoneal tumors o &ascu ar: aneurysm, peripheral vasc disease, intermittent claudication associated, sx mimicked by stenosis, a$$ravated by walkin$, abdominal aortic aneurysm not worsened with activity usually inc L?(, stenosis not relieved by standin$ still o Neurogenic: neurofibromas or other nerve tumors, similar sx to disk herniation but have ni$ht pain that is only relieved when $et out of bed (ischemic pain from tumor ,- am secondary to dec blood output but same inc demand by tumor) o (s%c+ogenic: not common, must rule out other causes first o Spon!% ogenic: boney and soft tissue chan$es.

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MANI(4LATION CLASSI/ICATION C(R "or manipu ation' +. @+6 days ,. at least + hypomobile se$ment <. at least + hip "> >21 3<5 de$ . 8o sx distal to knee 5. @+A points on B5?C , most important sx for predictin$ success with manip # duration of sx, lack of sx distal to the knee. 05 factors increase accuracy. Dip ">' pt prone, knee flex A4 de$, inclinometer on lateral calf, meas max passive >21 Choice of techni*ue may not be as important as previously thou$ht' no correlation caviation and tar$eted levels (ost manip' non-E? active >21 ex such as supine pelvic tilts, *uadruped rockin$

 1anip in sidelyin$' manip side up, tar$et force toward hypo se$, top le$ flexed, rotate trunk until motion felt at tar$et se$, (! ant directed force throu$h arm on patientFs pelvis. %ariations # pull arm parallel $ives trunk flex, pull arm perpendicular for ext Chica$o techni*ue # (! stand opposite side to manip, /? pt toward manip side, pt interlock hands behind head, rotate opposite side by thread arm throu$h ptFs arms, (ost0inf thrust on 5/"/ STABILI5ATION CLASSI/ICATION Eithout mm activity, L0/ hi$hly unstable even under low loads 11 endurance, mm balance, and neuro-mm control may be more important than maximal stren$th for outcomes 7rector spinae provide most extensor force for liftin$ >otation re*uires co-contraction of erectors and obli*ues 7rectors and obli*ues do not have direct attachment to L0/ !5 interdi$itates with diaphra$m !5 # feed-forward postural response /u$$ested need for stab' recurrent episodes with minimal perturbation, deformity, short term relief manip, hx trauma, oral contraceptives, improve with brace, step-off, hypermobility, aberrant motions, instability catch, thi$h climbin$ or $owerFs si$n C(R "or stab +. @ 4 y.o. ,. /L> 3A+ de$ (meas with inclinometer placed -ust distal to tib tub) <. G prone instability test . aberrant motions' catch, thi$h climb, painful arc in flex or return from flex mid ran$e Treatment: avoidin$ end-ran$e movements, work for endurance to avoid fati$ue, abdominal bracin$ maneuver. 5b trainin$ may be better in *uadruped b0c more difficult to sub with rectus. Curls with rotation to tar$et obli*ues (with rotation will tar$et mostly rectus). Challen$in$ # han$in$ /L> # very hi$h obli*ue near +44: max. 1ultif se$ stab lift and rotation. 1ultif atrophy in chronic L?(, does not auto recover. Hood startin$ *uadruped, raise opps <4: max voluntary. ?rid$in$. Hreater challen$in$ prone opps, roman chair # 4-64: max but also compressive loads. CL stab for /?, resists compression side plank 5 : max with low compressive loads. S(ECI/IC E.ERCISE CLASSI/ICATION Centralization via Extension bias, Flexion bias, or Lateral Shift Centra i2ation: distal and lateral pain moves more central durin$ direction specific lumbar movement testin$. (erip+era i2ation: sx move from proximal to distal or lateral with direction specific >21.

 $irectiona pre"erence: movements in one direction improve pain and limitation of >21 but does not centrali&e sxI whereas movement opposite cause si$ns and sx to worsen. (ts with L?( and radiation into butt0thi$h0calf who do not exhibit centrali&ation are less likely to have a successful treatment outcome. "nability to centrali&e durin$ eval decreases likelihood of return to work in 6 mo. Centrali&ation positive post-tx and + year pain, disability, work status outcomes. E-amination: repeat movements 5-+4 times or sustain ,4-<4 sec if movement -ud$ed to be status *uo. 1ay also need to chan$e position. E-tension bias: these pts often have si$ns0sx consistent with D8( # standin$ and walkin$ preferred, sittin$ worsens sx, sx extend into buttock or L7 and many have si$ns0sx nerve root compression. o E-ercises: *uadruped $ood to be$in by rock forward without periph, lie prone <4 sec to few min, prop onto elbows +5-<4 sec with ext mm relaxed and pelvic in contact, pro$ress to prone press up +4-,4 times (substantial ext mm activity re*uired), lumbar roll to support lordosis or sittin$ with hi$h strai$ht backrest, may need brace to prevent flexion o )oint mobs: performed in prone (05s, pro$ress to more extension and perform in lower L0/ not upper / e-ion bias: older, stenotic conditions. 8euro$enic claudication # poorly locali&ed pain, paresthesias, crampin$ one or both L7 of neuro ori$in worse with standin$ and walkin$, better with sittin$. /i$ns nerve root compression may be present. o E-ercises: supine # /J!C, 9J!C, post pelvic tilt. Cuadruped # rock back prayer o )oint mobs: prone (05s, spine mob in sidelyin$, hip -oint mob and flexibility into ext o Bo!% ,eig+t supporte! TM training: be$in with sufficient traction force to centrali&e or abolish L7 sx usually ,4- 4: of ?E Latera s+i"t: sx into L7, si$ns of nerve root compression, disc patholo$y, asymmetrical /? >21, $ross limitation of /? opposite direction of lat shift, ext *uite limited and painful until shift corrected. o E-ercises: if able to centrali&e sx in standin$ $ive E? exercise stand in a door frame with forearm to stab trunk then pelvic translocation to frame. 2nce lat shift diminished then pro$ress to ext ex. o "f periph with pelvic translocation' 5utotraction (rone pelvic translocation 6

TRACTION CLASSI/ICATION: (atients' /x extend into L7, si$ns nerve root compression, inability to establish direction preference or centrali&e sx with any 5>21, ima$in$ positive for disc patholo$y 1echanical' performed in prone, supine with hip and knees flexed for stenotic patients. Hoal to centrali&e sx and pro$ress into ex. "f sx and si$ns of nerve root compression cont to worsen refer out for in-ection, medication or other tx such as sur$ery. o Koun$er pts with D8( # static force with lon$er holds with intermittent trxn o 2lder pts with de$en chan$es # intermittent forces with shorter holds of intermit trxn o 54: ?E recommended' work up to 4-64: ?E or else unlikely therapeutic effect can be obtained $I//ERENTIAL $IA6NOSIS Re! / ags: 1a-or trauma or falls fx (ost menopausal women, bone weakenin$ conditions (steroid use) compression fx 5thletes with persistent L?( hi$h ext sport forces stress fx o /pondy' defect pars, repeated ext0rot # $ymnasts, wei$ht lift, wrestlers, throwin$ athlete track, divers, rowers. 2lder pts with spondy but etiolo$y is de$en in most cases. ?racin$ and activity limitation. /tab ex superior short and lon$ term results. /ur$ical stab only when slippa$e 354: $rade """. 2lder pts sur$ical fusion 8eoplasm' a$e 354, unexplained wt loss, no relief with bed rest, prior hx C5, ni$ht pain, most common metastases brest, lun$ and prostate. 7> sed rate, xray, 1>" $reatest accuracy. 5/' men, fibrosus and ossification li$s and -t caps, DL5 ?,;, @<5 yo, mornin$ stiffness diminish activity, relief with ex, $et 22? at ni$ht to dec pain. (! for flexibility, >21, and trunk stren$th. "nfections' very rare, fever, chills, hx recent infxn ie 6!", "% dru$ use, dental procedure. Cauda e*uina' lar$e, midline D8( or other space-occupyin$ ob-ect sur$ical emer$ency. /addle anesthesia or paresthesia, urinary retention, or loss of sphincter control. TREATMENT 6enera Consi!erations: - sta$e " # reduce pain and disability - sta$e "" # improve complex functional abilities stren$th, flexibility, avoid recurrence (reported 64-=4:) - spec stab can reduce recurrence ) start when less acute - $lut max often weak in pts with L?(, fati$uable brid$in$ and donkey kicks - liftin$ with predominate L0/ flex inc risk of in-ury - inc aerobic fitness dec incidence of L?( and may help avoid recurrence. Low stress aerobic ex effective tx (walkin$ cyclin$). >unnin$ not associated with inc risk L?( but is found to inc compressive loads on L0/

fear avoidance beliefs may be the most important risk factor for recurrence and chronicity research shows that if screen acute pts for B5? and educate early with use of *uotas for pro$ression of activity instead of pain response then disability at 6 mo associated with less lon$ term disability

C+i !ren7a!o escents: L?( btwn A-+; +,-<<:, lifetime <4-5+:. >isk factors' a$e, female, ?1", smokin$, activity level (fre* and type), sports, ti$ht hams or *uads, dec L0/ ext mm stren$th, decd hip -t mobility. >ecurrence appears to be hi$h. (rev hx most predictive risk factor in colle$e athletes, inc likelihood for pain into adulthood Lumbar Post Op Anatom%: Ant co umn: vert body, 5LL, disc, (LL resists ;5-==: of compressive load o &ert bo!%: main E?, flat sup and inf plateaus allow for attenuation applied perpendic, inc si&e cran to caud, 5th lar$est with trape&oidal shape # keystone articulation of axial skeleton, dissipates compression stresses via loadin$ trabeculae axially # desi$ned to absorb compressive and tensile forces, filled with blood which can serve to resist compressive loads. ,0< of all spinal tumors arise from vertebral body and only +0< from post. 5nt pillar most common place for neoplasmI more common mali$nant. +4: of pts with C5 devel mets to spinal columnI L of these compromise spinal column. !0/ more fre* with mets than L/. o Osteopororsis: often ant pillar involvement, common compression fx, max peak bone mass reached mid <4Fs, females lose 4.5: per year, at menopause loss accelerate ,-<: for +4 years. (revent by inc in puberty via lifestyle. "nc risk # body consciousness, inade*uate calcium, smokin$, excessive alcohol b0c inhibit bone mass accumulation. Surgica t- compression "-: %ertebroplasty' re*uires forceable in-ection bone cement into body, free&es deformity without restoration of vert body hei$ht. "f cortical shell not intact cement can leak post into spinal canal or ant into abdom cavity. Jyphoplasty' inflatable balloon tamp placed into vert body and inflated with $oal to restore vert body hei$ht. Creates space so cement can be in-ected under less pressure, dec risk for leak. (ain is often immediately decreased and bone is stable. 1ovement can be started early and $raded exercise can be introduced. >x ex carefully because dec bone density at several se$ments.

o $isc: < essential components # annulus, nucleus pulposus, and end plate. 7ndplate separate disc from vert body. (rimary fxn of disc # allow movement to occur btwn vert and simultaneously transfer loads btwn vert. 999 is often assumed to be anatomic source of chronic pain leads to over A4: of spine sur$ery. /econdary problems' herniation, stenosis, facet -t arthrosis, de$en spondy. 5nnulus consists of hi$hly or$ani&ed colla$en in concentric lamellae that completely surrounds 8(. !hick toward center, thinner and finer post. +4: fibers elastic. 2uter +0< innervated (sinuvertbral nerve). 8( is ;4-A4: water, varies with a$e, and hydrophilic proteo$lycans next ma-or component comprises 65: of nucleus dry wei$ht. 8( acts as ball of fluid that allows for deformation but resists compression. 5xial load causes 8( to expand radially to apply a tan$ential force into annular rin$s. 7ndplate is resisted with e*ual and opposite forces. Bxn' maintenance of intradiscal hei$ht, mait of lumb lordosis secondary wed$e shape, absorption of compressive load, distribute load to spine, stores potential ener$y, restricts and allows for movement of se$, provision of afferent neural feedback to C8/ as load transfers or mvmt occurs. 9isc cells depend on diffusion from blood vessels at the disc mar$ins for nutrients and waste removal. 9iffusion may not be mvmt dependent. Loss nutrient supply cell death and matrix de$radation of disc. 1ay be result of inc disc si&e and endplate chan$es. Dealin$ capabilities of disc are limited. 99 # dec 8(, cleft formation, disor$ani&ed annular colla$en, dec amount of colla$en altered stress, altered mechanics, inc aberrant motion, and dec >21. Bra$ments of 8(, its cytokines (!8B, interleukin, interferon) are neurotoxic on neural tissue # hi$h phospholipase en&yme activity, inc macropha$es present. Compression G inflamm around nerve root induces more in-ury than compression alone. 8( can initiate and potentiate inflamm rxn if present in canal nerve roots mechanosensitive epidural steroid in-ection. (ost co umn: &y$ -ts, pars, lamina, /(s, !(s resists +,-,5: compressive load, fxn of boney morpholo$y and posture o /-n: restrictin$ and re$ulatin$ mvmt, E?, boney levers for mm attach, load sharin$, resists shear loads o (ercutaneous pe!ic e scre, "i-ation: less multif atrophy o Laminectomies: decompress central canal o H%pertrop+ic ig " a#: removed sur$ically to decompress canal at spec level, portal entry for microdiskal procedure, epidural in-ections, and various spinal tap procedures. o /ai ure o" pars: fati$ue fx, repeated flex0ext stress. @,5: $rade ", ,5- A: $rade "", 54-; : $rade """, ;5-AA: $rade "%, +44: $rade %. o /acet 'oints: innervated by medial branch of post ramus, spinal unit loaded facets help resist ant shear (which comes from lordosis and facet -oints that resist pelvic inclination) of that se$ment, when facets de$en then disc must attenuate shear dic tiss creep and elon$ation instability. (e!ic es: bony brid$e on ea vert provides interface btwn boney elements of ant and post column

Neura consi!erations 8 in!ications "or spina surger%: A

"ndications' - (ain relief - >esolution of neural compromise - (revention of future dama$e to neuro tiss - "ntervention for rapidly chan$in$ or deterioratin$ neuro si$ns # , stron$est (ossible causes' - Dypertroph li$ flav - 2ssified (LL - (rolapsed disc - ?reakdown of disc, &y$ -t cartila$e, support li$s 8erve root irritation # result of disc lesion, inflamm condition, reco$ni&ed by sx rather than si$n. - 7xtremity pain 3 spine pain - Cuality # more disconcertin$ than other patterns of L7 - Clear demarcation of pain often below the knee - 9ermatomal distribution of pain in L7 more pain in proximal aspect, more paresthesia in distal portion - 8eural tension testin$ reproduces radicular0extremity pain - Hentle spinal motions excessive pain irradiation - Treatment: $entle specific passive -oint mob complex, interventions to dec inflamm stimulation 8erve root compression # more clinical si$ns than sx - 1m wastin$ - 1m weakness - /ensory impairment - 5ltered *uality of reflexes - Treatment: ex to maintain flex if stenosis, decompression of intervert foramen, traction, spinal unloadin$ techni*ues. /ur$ery may not reverse a motor or reflex dependin$ on de$ of axonal dama$e. Hoal # resolve le$ pain and prevent further dama$e, reduce disability, teach pt to self mana$e spineI L?( may be present post op. m$mt # active exercise and modification of activities. Spina "usion: - /pinal canal' central re$ion and lateral recess (starts at most medial aspect of "% foramen). Central ant border # "%, disc, vert body, (LL. (ost border # lamina, li$ flav. Lat border # "% foramen. - "% foramen' sup and inf border # pedicles. 5nt border # postinf upper vert body, disc, postsup lower vert body. (ost # pars, superior facet, li$ flav. - Loss disc hei$ht secondary de$en superior artic process of inf vert to sublux ant and superior diminishin$ "% forament - 9ynamic stenosis secondary to subtle de$en chan$es (translation of vert) may not be appreciated on static ima$in$, makin$ foraminal stenosis difficult to dia$nose (oster atera intertrans#erse "usion 9(L/:: bone placed to -oin decorticated !(s. ?one $raft harvested from iliac crest laid alon$ post surface &y$ -ts and pars. 5pply bone

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morpho$enic protein to enhance fusion rate and minimi&e need for extensive $raft harvest. Common to add pedicle screws and direct decompression of neural tissues. o 9rawback # vert bodies not directly stabili&ed continued strain on disc, dama$e to paraspinals musculature. (e!ic e scre, "i-ation: screws places hori&ontally throu$h pedicles and vert body of each vert, vertically placed rods are coupled to screw in order to fixate ad-acent se$ments /acet "usion: facets fused not usually without interbody fusion Interbo!% "usion: desi$ned to stab ant column directly o Anterior: approach does not dama$e mm but risk for dama$e to abdom aorta, vena cava and sympathetic plexus. L -5 problematic b0c vena cava bifurcates. o (osterior: oldest, wide laminectomy, discectomy, then insertion of a lar$e spacer with auto$enous bone $raft into space btwn vert bodies to restore disc hei$ht and stab se$ by boney fusion. (edicle screw fixation added to $ain immediate se$ment ri$idity while bone fusion occurs. o Trans"oramina umbar interbo!% "usion: unilateral facetectomy, most of lamina of post arch left intact, discectomy performed, spacer for disc hei$ht and bone $raft used to fill void disc space.

(ost0op protoco : - Dip motion @ 5 de$ - <-6 mo before stren$th, hip mobility, and spine mobility - /!1 to paraspinals okay - 5fter bone healin$' dynamic erector spin and multif resistance ex pro$ram - 5nt approach' may result in disruption of abdom mechanism, 5LL, and possibly medial aspect of psoas. - 8umber of levels fused does not appear to affect outcome - ?ack cafM support $roup leads to better outcomes - (ost approach' inf facet (medially placed) removed to access disc space vulnerable to excessive rotatry motion - 5nterior fusion less resistant to ext than post in early sta$es, possibly due to compromised of 5LL Lumbar Laminectom%: - /pinal stenosis most common indication for sur$ery in pts 365 y.o. - Laminectom% 8 removal of lamina of post arch, medially placed facet for decompress of lateral recess, and possibly foraminotomy. "f includes facet, loadin$ capacity of &y$ -t in rotation decreased - Intent 8 decompress central and0or lateral canal - Centra !ecompression 8 via bilateral laminect and removal /( but lateral may still be compromised - Latera !ecompression 8 removeal of inf facet partially or totally in addition to the lamina

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Inten!e! post op outcome: minimi&e claudication and mechanical compromise of cauda e*uine if they coexistI many have low $rade back pain but C2B is improved secondary to dec L7 pain. R- e-ercise: if no fusion must accommodate for loss of post pillar (lamina and facet) by avoidin$ extension and rotation. Control over torsional stresses. "f facet removed, rotary stress often source of low back pain. A$Ls t+at inc compressi#e oa!ing 8 rollin$ in bed, twistin$ in standin$, reachin$ overhead and D??. $)$ o" +ips: common comorbidity, dec hip >21 hypertext L/ especially with pushoff, worse downhill. (T inter#ention: hip 50(>21, hip rotation and extension emphasi&ed, encoura$e flex bias but avoid end-ran$e flex secondary to ant shear btwn facets, flex via hip extensors, spinal ext stren$thenin$ in controlled ran$es.

I$ET: - >isk factor for failure # obesity - In!icate!: chronic internal disc disruption that do not involve serious 999, nerve compression, se$ instab. - Intention: to address axial disco$enic pain. - Con"irmation: provocative disco$raphy to confirm disco$enic pain and location. (t awake, catheter into disc, load contrast dye, internal disc pressure inc, and determine if reproduce sx. 8on-path disc # no pain - (roce!ure: place cath into disc, thermal coil circumfrentially on outer annulus, $uided by fluoroscopy, slowly heated to A4 de$ Celsius for +5-,4 min - T+eoretica mec+anism o" t-: nerve denervation, colla$en deformation and contraction. /hrink wrap effect # seal off leaky disc, cauteri&e nociceptors, stiffen and stab se$ment. !hou$ht not to cause dama$e to endplate but case studies report bone necrosis esp if disc se$ with endplate compromise (relative contraindication). - (ost op re+ab: limit compressive loadin$, lumbar brace +-< mo, pain initially will inc, spinal precaution for 6 mo # no liftin$, prolon$ed sittin$ for ,- weeks and discoura$e up to 6 mo, avoidance of early mornin$ flexion activity since disc pressure hi$hest in mornin$, stand0walk encoura$e prior to sit, at 6-+, weeks $entle stab ex can be initiated but no flex0rot0compressive forces, return to sport0work considered after 6 months. Micro!iscectom%: - In!ications: (ro$ressive pattern weakness, loss of bowel and bladder control, and foot drop. (ain not helped by in-ection, medication, traction, anti-inflamm. Common in youn$er pts b0c hi$her hydration levels which may cause more forceful extrusion and herniation of 8(. /ince hi$her hydration disc space maintained and se$ stable. - Dow lon$ ptFs fxn and overall stren$th have been affected often predicts how *uickly pt will return to normal and how *uick0a$$ressive rehab can be. (less betterN) - (ost op re+ab: fxnl mvmt with neutral spine, bed mobility, amb, transfers. 5mb may be$in same day as sur$ery. Limit excessive compressive, sheerin$, and rotational forces. 11 dama$e should not be expected. - (ost op treatment: 6sually be$ins -6 weeks post op. >ecent studies su$$est initiation of early a$$ressive ex can positively affect pain, disability, and spinal fxn vs.

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conservative stren$thenin$. /tren$then back flex and extensor with emph on ext. Bull return to normal activity expected. Contrain!ications: few, no evidence su$$ests limitin$ ptFs activity after first time sur$ery.

In#ertebra !isc art+rop ast%: - In!icate!: chronic, severe, disablin$ disco$enic L?( isolated to + or , levels. 1ust fail a minimum of 6 mo non-op therapy. /pine should have $ood stability and free of si$nificant facet arthrosis. 2ften pts youn$er ,4- 4 y.o. "ntractable pain secondary to 999. 8ot typical if nerve root si$ns and sx predominate. - Contrain!ications: si$nificant psychosocial issues, obesity 3, /9 above normal ?1", osteoporosis, infection. - (rost+esis s%stem: , metal alloy endplates anchored to vert body via pe$s. (olyethylene slidin$ core to mimic physio motion. 2nly approved for L -5 and L5-/+. - (ost op: 6-= weeks activity restrictions minimal. Lon$-term biocompatibility unknown. 1obility $radually achieved within first < months. >eturn to normal activities faster than fusion.

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