IS THERE A RELATIONSHIP BETWEEN BACK PAIN AND MUSCLE RETRACTION FOLLOWING LUMAR SURGERY?

Abstract

Introduction: Preliminary studies suggest that prolonged retraction of the paraspinal muscle during spinal surgery may produce ischaemic damage. We describe the continuous measurement of intramuscular pressures (IMP) during decompressive lumbar laminectomy and the relationship to back pain and disability.

Methods: In this prospective interventional study, 28 patients undergoing surgery for lumbar canal stenosis were recruited. Back pain and function were assessed using the Visual Analogue Score (VAS), Oswestry Disability Index (ODI) and Short Form 36 (SF36) health survey. During surgery, IMP was continuously recorded from the multifidus muscle using a pressure transducer. The intramuscular perfusion pressure (IPP) was derived as the difference between the patient’s mean arterial pressure (MAP) and IMP (IPP = MAP − IMP). The data was analysed using repeated measures ANOVA (SPSS package).

Results: The mean age was 60.4 ± 3 years and the mean duration of symptoms of 31.0 ± 6 months. The predominant symptoms were neurogenic claudication (14) and/or sciatica (13). Patients underwent 1 (N=3), 2 (N=20) or 3 (N=5) level laminectomies. The muscle retractors used were Norfolk and Norwich (N=16) and McCullock (N=12). The mean duration of deep muscle retraction was 68.5 ± 9 mins (range 19–240). On application of deep muscle retraction, there was a rapid and sustained increase in IMP (F=26.8; p< 0.001; repeated measures ANOVA), and overall the calculated mean IPP approached 0 mmHg or less during this period (F=36.8; p< 0.001). On release of deep muscle retraction there was a rapid decrease in IMP to pre-operative levels. The IPP was greater with Norfolk and Norwich than McCullock retractors (F=12.2; p< 0.001). Compared to pre-operative values, there was a decrease in ODI (F=18.6; p< 0.001) and VAS for back pain (F=9.9; p< 0.001) at discharge, 4–6 weeks and 6 months, post-operatively. Compared to pre-operative values, there was a decrease in SF36 scores at 6 months (F=26.7; p< 0.001). Total duration of muscle retraction over 60 mins was associated with higher VAS scores for back pain at 4–6 weeks and 6 months postoperatively (F=3.7; p< 0.01). There was no relationship between IPP and post-operative ODI or VAS for back pain.

Conclusions: This study demonstrates a simple technique for the continuous monitoring of IMP during spinal surgery, from which the IPP can be derived. Comparison of two muscle retractors has shown that the McCullock retractor generates a higher IMP than Norfolk and Norwich retractor. Decompressive lumbar laminectomy improves the VAS for back pain and ODI and SF36 outcome scores in these patients. The results show that duration of muscle retraction, rather than extent of the pressure generated by the retractor, is related to postoperative back pain.