Disclosure! Torphong(Bunmaprasert,(MD.(

Transcription

1 PRINCIPLE(OF(SURGICAL(TREATMENT( IN(DEGENERATIVE(LUMBAR(DISEASES( รศ.นพ.ต อพงษ บ ญ The$7 th $CMU$Neurosurgery$Forum$$ December$11 มาประเสร ฐ th,$2015! หน วยโรคกระด กส นหล ง ภาคว ชาออร โทป ด กส คณะแพทยศาสตร มหาว ทยาล ยเช ยงใหม Disclosure! Torphong(Bunmaprasert,(MD.( " No((Relationships CHIANG MAI Thailand! Degenerative(Lumbar(Diseases( Osteoarthritis( of(facet(joints! Degenerative( Disc(Diseases! Facet$joints$ Intervertebral$ discs$ Decrease disc volume Decrease disc height ( space ) Laxity of annular ligament Subluxation of disc Osteophyte formation Degeneration of articular cartilage Synovitis Decrease joint space Laxity of joint capsule Subluxation of joint Osteophyte formation Facet joint hypertrophy Degenerative(Lumbar(Diseases! Back$Pain$! Sciatica$! Intermittent$$Neurogenic$ Claudication$! Neurological$Deficit$! Segmental$$$$$$$$$$ Instability$! Imbalance$$ " Coronal( " Sagittal(! Radicular(leg(pain:( compression(of( particular(nerve(roots(! Pain(in(a(specific( dermatomal(pattern( corresponding(to(the( compressed(nerve(root(! May(have(associated( myotomal(weakness,( numbness,(hyporeflexia 1

2 Herniated(Nucleus(Pulposus โรคหมอนรองกระด กส น หล งเคล อน! ปวดเอว ร าวลงสะโพกและ ชาเท า ขย บร างกายจะปวด Nerve(root( Radiculopathy( Motor$disturbance$ Sensory$disturbance$ Hyporeflexia! Lower motor neuron! Spinal(cord( Upper motor neuron! Myelopathy( Sensory$disturbance$ Motor$disturbance$ Bowel$and$bladder$dysfunction$ Hyperreflexia$ Spasticity$ Abnormal$reflexes$:$Clonus,$Babinski,$$ Hoffmann,$Lhermitte,$Inverted$radial$ reflex$(ivr)$ Degenerative(Lumbar(Spinal( Canal(Stenosis((SCS) Thickened$ ligamentum$flavum! โรคข อต อกระด กส นหล ง เส อม (โรคกระด กท บเส น,ห นป น ท บเส นประสาท)( Facet$hypertrophy! Intervertebral$ disc$bulging! Degenerative$Lumbar$Spinal$Canal$Stenosis! Degenerative(Lumbar(Stenosis( without((deformity Degenerative(Spondylolisthesis(L4N5( Spinal(Canal(Stenosis(with(Radiculopathy L4! L5! Common(Orthopaedic(Practice! 2

3 When!degeneration!progress!! Loss(of(disc(height((((( (plus(osteopororsis)( " Sagittal(plane(deformity(! Laxity(of(the(spinal(joints( " Segmental(instability(! Asymmetrical(disc/joint( narrowing(&(deviation(/ Rotation((of(the(column( " Degenerative(scoliosis(! Neurological((deficit Spinal(Imbalance Thoracolumbar+Scoliosis+ with+coronal+imbalance Posi6ve+Sagi9al+Imbalance F,$53$$Chronic$Low$Back$Pain$for$3$months! Occupation:(housekeeper(! Duration:(7(months,(severe(pain(1(mo.(! %(LBP(/(Leg(pain(=(50(/(50(! Low(Back(Pain( " Severe(dullXaching(pain(for(7(months( " Paravertebral(muscle(spasm( " Restriction(of(back(motion(all(direction(! Right(leg(pain( " Intermittent(neurogenic(claudication( " Right(S1(radicular(pain,(burning(sensation( " Minimal(numbness,(no(weakness(! Prior(Rx:(none( Physical$Examination! Severe(pain(with(antalgic(gait(! Marked(paravertebral(muscle( spasm,(tenderness(lsxspine(! Loss(of(lumbar(lordosis(! No(stepping(or(gap(! Limit(AROM/PROM((! Motor:(grade(V(all(! Minimal(diminish(pinprick( sensation(right(s1(dermatome(! DTR(1+(,(SLRT(90/90,(Flip(test(X Treatment$! L5! L5! Plain$XZrays:$AP$,$Lateral$views! Limit(activities(! Weight(reduction(! Back(support(! Physical(therapy(! Back(exercise(! Medications(( "...( "...( "...( 3

4 L4Z5! L5ZS1! L5! MRI$LSZspine WHEN(CONSERVATIVE( TREATMENT(FAILED,( PATIENTS(MAY(NEED( Surgical$treatment$$ of$chronic$low$back$pain Indications$for$surgery$ 1. Cauda(equina(compression(syndrome( 2. Severe,(progressive(neurological(deficit( 3. Failure(of(nonoperative(treatment( 4. Intolerable(pain! Principles(of(Spinal(Surgery( for(low(back(pain! Decompression$เม อม การกดท บ ระบบประสาท$! Fusion$เม อม หล กฐานว าเก ด ภาวะไม ม นคงของกระด กส นหล ง$ " Bone(graft(&(substitutions( " Instrumentation((! Deformity$correction$เม อเก ดความ ผ ดร ป$! Motion$preservation$เม อต องการ Lumbar(Spinal(Stenosis! Intermittent(Neurogenic(Claudication(is( relieved(by(bending(over,(sitting,(or(leaning( forward(while(walking Interspinous$Process$Spacers(! indirectly(decompress(the(neural(elements(! unload(the(spinal(structures(! decrease(segmental(instability( 4

5 Interspinous$Process$ Spacers( Indication:(symptomatic( neurogenic(claudication( with(radiographic( evidence(of(spinal( stenosis(and( claudication(relief(with( sitting(and(flexion Interspinous$Process$Spacers( Contraindications( ((((X(isthmic(spondylolisthesis( ((((X(highXgrade(degenerative(( ((((((spondylolisthesis( ((((X(scoliosis(greater(than(25 ( ((((X(bony(ankylosis( ((((X(cauda(equina(syndrome( ((((X(severe(osteoporosis การผ าต ดขยายโพรงกระด ก ส นหล ง (Laminectomy)! เป นการผ าต เพ อเอาส งท ไขส นหล งและ ประสาทออกไป เช น หมอนรอง กระด กงอก ห เอ นกระด กท หล งผ าต ดอา ปวดร าวลงขา แ อาการอ อนแรง Decompressive$Techniques( (! Laminectomy$! Medial$facetectomies$! Foraminotomies$! Laminotomy$! Discectomy$! Minimally$invasive$surgery$ Gold+standard+Rx! Relieves( Leg(pain(symptoms( Create(stability( Correct(deformity( Back(pain(may(! Laminectomy+ Typical(Midline(Decompression( of(lumbar(spinal(canal(stenosis! Iatrogenic(instability((excessive(removal(of(discs,(facet(joints,( stabilizing(ligaments,(pars(interarticularis)(! 4X31%(recurrent(stenosis(or(spondylolisthesis(after( facetxsparing(laminectomy( 5

6 Medial+facetectomy+ Foraminotomy+ Laminotomy+ Positioning1Lumbar(Laminectomy( Prone(position( Flexed(hips(&(knees( Abdomen(free( Padding(! Lumbar(HNP(L4N5( severe!lbp!&!sciatica Lumbar(( Discectomy! Reduces(intraop.(Bleeding( Maintain(lumbar(lordosis! Decompression!procedure! Central(canal(decompression! เม อม Compression$ ต อ neural$elements$ แก ไขด วย Decompression! 6

7 Central(canal(decompression! Lateral!canal!decompression! Minimally+invasive+surgery+(MIS)+ Minimally+invasive+surgery+(MIS)+ Open+Laminectomy! MinimallyGInvasive+Lumbar+ Microdecompression+! (X(Less(softXtissue(dissection(( (X(Greater(preservation(of( ((( (((stabilizing(structures( (X(Minimization(of(epidural(((( (((((((((((((scar(formation(and((( ((postoperative(low(back(pain ( Minimally+invasive+surgery+(MIS)+! Suboptimal(visualization(of(pathology(! More(technicallyXdemand(! Lengthen(surgical(times,(higher(costs Operating$ Microscope Open+Sx! MIS! 7

8 MicroscopicNAssisted(( Spinal(Surgery Microscopic(Lumbar(Discectomy! Illumination(( (แสงสว าง)(! Magnification( (กำล งขยาย)(! Academic(training(! Recording(&( Presentation( Microscopic(Lumbar(Tubular(Discectomy! Foley&&&Smith&1999&! Series+of+concentric+ dilators+and+thingwalled+ tubular+retractors+of+ variable+lengths+! Typically+18G22+mm.+! Visualiza6on+ " Naked+eyes+ " Endoscope++(MED)+ " Opera6ng+Microscope+ การผ าต ดกระด กส นหล งผ านเคร องม อ! ท ม ล กษณะคล ายท อ (tube surgery)! Imaging(Studies AP$Fluoroscopy$ until$the$parallelism$$ of$the$l4$inferior$endplate$ &$the$l5$superior$endplate$ was$seen Plain X-rays (ภาพเอกซเรย ) MRI (คล นแม เหล ก ไฟฟ า) L4 L5 8

9 Lateral(Fluoroscopy(Check Preoperative!Planning!for! Microscopic!Decompression! Lt!S1!Nerve!Root Measure!for!Reduction!of! Radiation!Exposure Palpate$Anatomy$with$Initial$Dilator$$ Tubular$Retractor $ Sequential(Muscle(Dilatation( Application$of$$Tubular$Retractor 9

10 Placement$of$Tubular$Retractor$ caudad L4! L5! cephalad Remove$the$inferior$edge$$ of$the$superior$lamina$(l4) Midline( Remove$the$medial$edge$$ of$the$superior$articular$process$of$l5$ Remove$Ligamentum$Flavum 10

11 Identify$L5$nerve$root Retract$L5$nerve$root$ &$coagulate$the$vessels Microscopic(Lumbar(Discectomy Check$the$adequacy$of$$ nerve$root$decompression$ cephalad Microscopic$Lumbar$Decompression$ of$$degenerative$$spinal$canal$stenosis caudad 11

12 MIS$$Lumbar$Decompression$ of$degen.$lumbar$scs$with$radiculopathy MIS$$Lumbar$Decompression$ of$degen.$lumbar$scs$with$radiculopathy Thickening(of(( Ligamentum(Flavum Superior(articular(facet( of(l5( True(Culprit Laminotomy(L4XL5(at(( the(symptomatic(side( Detach(the(lig.(flavum( Partial(facetectomy! CHIANG MAI Degenerative(Spinal(Instability Static( Dynamic(! >3(mm(of(translation(of(one( vertebral(body(on(another(or( more(than(10 (of(motion! การผ าต ดเช อมข อต อ กระด กส นหล ง! (Spinal Fusion)! ((((((a)(neutral ((((((((((b)(flexion( (((((((((c)(extension เป นการผ าต ดเพ อให ข อต อ กระด กส นหล งท เคล อนและ ไม ม นคง ให อย น ง เพ อจะ ไม เคล อนกดท บระบบประสาท ซ งเป นสาเหต ของอาการปวดเอว อ อนแรงกล ามเน อ ชา น ยม 12

13 Posterolateral(( fusion((plf)( Posterolateral(Fusion(L3N4(L4N5 Lumbar(Interbody(Fusion! Anterior+Lumbar+Interbody+Fusion+(ALIF)+! Posterior+Lumbar+Interbody+Fusion+(PLIF)+! Transforaminal+Lumbar+Interbody+Fusion+ (TLIF)+! Lateral+Lumbar+Interbody+Fusion+(LLIF)+! Transsacral+Lumbar+Interbody+Fusion+ (AXIALIF)+ Anterior$Lumbar$ Interbody$Fusion$ (ALIF)( Anterior(Retroperitoneal(Approach( Anterior(Lumbar(Discectomy(( Anterior$Lumbar$Interbody$Fusion$ (ALIF)( ALIF$ with$anterior$instrumentation$ 13

14 Anterior$Lumbar$Interbody$Fusion$ (ALIF)(! Contraindica*ons, # Male+with+increased+ risk+of+infer6lity+ # Arthrodesis>2+levels+ # HighGgrade+ spondylolisthesis &+spondylolysis+in+ children+ # Elderly+pa6ents+with+ osteoporosis+ Posterior$Lumbar$$ Interbody$Fusion$(PLIF)$! Performing+followed+ decompressive+laminecg tomy+at+the+level+of+spinal+ stenosis+or+spondylolisthesis+! Assess+to+the+disc+space is+obtained+through+the+ interlaminar+window+by+ retrac6on+of+the+thecal+sac+ and+traversing+nerve+root+ Lumbar$Spine$Instrumentation$$! Wires,! Hooks,! Screws+ Pedicle+screws + Segmental+fixa6on+ Increased+torsional+rigidity+++ of+the+constructs+ Improve+fusion+rate+ Maintain+lumbar+lordosis+ Decreased+numbers+of+ mo6on+segment+fused+ Posterior!Lumbar!Instrumentation! Pedicle!Screw!Fixation!System! Probing$for$$ The$Lumbar$Pedicles! Identify$Entry$Point! 14

15 Insertion$of$$ the$lumbar$$ Pedicle$Screws! Insertion$of$$ the$lumbar$$ Pedicle$Screws! Cephalad$ Caudad$ Posterior$Lumbar$$ Interbody$Fusion$(PLIF)( Transforaminal$Lumbar$Interbody$ Fusion$(TLIF)$ Transforaminal$Lumbar$Interbody$ Fusion$(TLIF)( TLIF$in$Spondylolisthesis$ Traversing Nerve Root Exiting Nerve Root 15

16 MinimallyNInvasive(( Lumbar(Interbody(Fusion MIS((TLIF( (Transforaminal((Lumbar((Interbody((Fusion) อมข อต อกระด กส นหล ง โดยใช เทคน คเน อเย Percutaneous$Screw$Fixation MIS$$TLIF( (Transforaminal(Lumbar( Interbody(Fusion) Lateral$Interbody$Fusion$(LLIF)! MinimallyXinvasive( retroperitoneal(approach( to(the(interbody(space( through(the(psoas(muscle(! Transpsoas(approach( ideally(located(within(the( anterior(½(of(the(psoas(! EMG(monitoring(needed(! Disc(space(is(prepared,( interbody(device(is(placed( 16

17 การใช โลหะดามกระด กส น หล ง! (Spinal Instrumentation)! Spondylolisthesis(Reduction เป นส วนหน งของการผ าต ดเช อมข อต อกระด ก ส นหล ง เพ อแก ไขความผ ดร ป เร งให การเช อมต ดเร วข น หล งผ าต ดสามารถ ล กเด นและกล บไปทำงานได เร ว การใช โลหะดามกระด กส นหล ง แก ไขความผ ดร ป! (Spinal Deformity Correction)! Degenerative(Lumbar(Scoliosis! Limited(decompression(! Decompression(+(ShortXsegment(Fusion(! Decompression(+(Deformity(Correction(+( LongXsegment(Fusion(! Spinal(Osteotomies Degenerative(Scoliosis(Surgery! Principles(of(( Degen.(Scoliosis! Radiculopathy$ " Nerve(root(decompression( " Therapeutic(diagnosis(! Spinal$instability$ " Fusion(( " +/X(Instrumentation(! Significant$ Imbalance$ " Deformity(correction( " Flexible(vs(Rigid Degenerative(TLNscoliosis( ShortNsegment(Fusion Absence,of,, Global,Imbalance 17

18 Concave(Rod(Application( Distraction(+(Derotation( Correction(Maneuvers(! Apical$vertebral$ derotation$(avd)$ " Vertebral(column( manipulators((vcm)(! In$situ$bending(( " Lordotic(/(Kyphotic(benders(! Cantilever$maneuver$ ((! Compression Distraction$ maneuver$ Posterior(Lumbar(Interbody( Fusion((PLIF)( Transforaminal(Lumbar( Interbody(Fusion((TLIF)( Second(Rod(Application 18

19 CONCLUSION! Low$Back$Pain$(LBP)$ " Most(Common(Ortho.(Problems(! Conservative$Treatment$ " Mainstay((! Surgical$Treatment$$ " Decompression$ " Fusion$! with(instrumentation(! without(instrumentation( " Deformity$correction$ " Motion$preservation$ THANK YOU FOR YOUR ATTENTION T.$Bunmaprasert! 19