Discecctomy and anterior fusion with cages: advantages and disavantages. A. Zagra

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1 Spinal Surgery Division 1 I. R. S. S. C. Galeazzi Orthpedic Institute Milan Chief : Prof. A. Zagra Discecctomy and anterior fusion with cages: advantages and disavantages A. Zagra

2 CONSERVATIVE TREATMENT PRESENCE OF PERSISTENT PAIN OR NEUROLOGICAL DEFICT APPAREANCE SURGICAL TREATMENT

3 SURGICAL TREATMENT 1952 Bailey and Badgley: I anterior approach 1955 Smith and Robinson: I anterior discectomy without a direct removal of osteophyte and compressive elements, which undergo resorption after fusion Tricortical horseshoe bone graft.

4 SURGICAL TREATMENT

5 DISCECTOMY + INTERBODY FUSION INTERBODY FUSION IS ESSENTIAL TO RESTORE OR PRESERVE NORMAL DISC HEIGHT IN ORDER TO AVOID : - DISCOPATHY - LOCAL KYPHOSIS (INSTABILITY) - CERVICAL AND/OR RADICULAR PAIN

6 G.L. - female - 58 years C6-C7 disc herniation

7 Discectomy without fusion (5 years followup)

8 7 years follow-up local kyphosis and instability

9 SURGICAL TREATMENT 1958 Cloward: Direct removal of compressive elements cylindrical bone graft Complications Higher blood loss Bone graft mobilization Bone graft resorption Bone graft breakdown Nonunion Local kyphosis

10 SURGICAL TREATMENT 1971 Orozco e Houet: introduce an AO smallfragment plate to give additional stability to the fusion Caspar et al. : describe their surgical tecnique (plate) and their synthesis. BICORTICAL SCREW POSSIBILITY OF NEUROLOGICAL INJURY

11 SURGICAL TREATMENT 1986 Morscher et al. : titanium screw locking plate (TSLP) - Monocortical

12 Plate reduces bone graft mobilization risk and giving additional stability to the construct reduces bone graft direct load and its consequent breakdown and resorption risk. Increased complications risk due to possible mobilization or hardware failure. Increased infection risk Tecnically demanding procedure CAGE

13 S.L. - female - 32 years- C5-C6 disc herniation

14 S.L. - female - 32 years- C5-C6 disc herniation

15 Anterior intebody fusion with titanium cage Iliac autologous bone graft

16 Titanim cage: No mobilization or hardware failure Cage subsidence with disc height decrease

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18 ILIAC BONE GRAFT LOCAL PAIN DONOR SITE COMORBIDITY BONE SUBSTITUTE

19 P. I. - female - 52 years- C5-C6 disc herniation

20 Anterior intebody fusion with Peek cage + Beta-tricalcium phosphate (bone substitute osteoconductive, resorbable)

21 Surgical technique Left anterior approach to avoid recurrent laringeal nerve palsy

22 Surgical technique

23 Surgical technique

24 Surgical technique Trasverse skin incision

25 Surgical technique

26 Surgical technique

27 Surgical technique

28 Surgical technique Advantages : Stereoscopic vision with coaxial light and variable magnification Optimal vision for both surgeon Optimal vision of posterior part of the anulus and of the osteophytes Easier hernia and osteophytes removal

29 Surgical technique

30 Surgical technique

31 Surgical technique

32 Surgical technique

33 RADIOGRAPHIC RESULTS PEEK CAGE: No mobilization or hardware failure Optimal anterior fusion with anterior bone bridges formation

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35 CLINICAL RESULTS Good or excellent in all cases Better clinical outcome in the immediate post-operative time whitout autologous bone graft specimen

36 Istituto Ortopedico Galeazzi Anterior intebody fusion ( ) Patients 86 Median age 40 aa (28-71) Sex M 45 F 41 Median follow-up 7,2 aa (5-12) Radiculopathy or mild mielopathy, resistant to at least 3 months conservative treatment

37 SURGICAL TECHNIQUE Discectomy and anterior fusion with plate according to Smith R. technique (group 1): 21 pz Discectomy and anterior fusion with titanium cage and autologous bone graft (group 2): 25 pz Discectomy and anterior fusion with PEEK cage and bone substitute (gruppo 3): 40 pz

38 METHODS Preoperative time and Follow-up Clinical evaluation: Odom s criteria, Neck Disability Index, VAS Radiographic evaluation: MRI and standard and functional X-ray

39 CLINICAL RESULTS Odom s criteria: gr. 1 gr. 2 gr. 3 execellent 89% 95% 92% good 11% 0 % 8 % fair 0 % 0 % 0 % poor 0 % 5 % 0 %

40 CLINICAL RESULTS

41 RADIOGRAPHIC RESULTS group 1 Solid fusion in all patients No mobilization or hardware failure No bone graft resorption

42 C.E. - male 43 aa - C6-C7 disc herniation

43 Discectomy and intebody fusion with locking plate and tricortical iliac bone graft 8 years 8 years

44 RADIOGRAPHIC RESULTS group 2 Solid fusion in all cases No mobilization or hardware failure Cage subsidence with disc height decrease without cervical lordosis loss (7 cases)

45 S.L. - female 32 years - C5-C6 disc herniation

46 S.L. - female 32 years - C5-C6 disc herniation

47 Anterior interbody fusion with titanium cage and iliac bone graft postop. postop.

48 3 months 7 years

49 RADIOGRAPHIC RESULTS group 3 Solid fusion in all cases Absence of disc height decrease or cage subsidence No mobilization or hardware failure Anterior bone bridges formation (30 cases)

50 G.E. - female - 39 years - C6-C7 disc herniation

51 Anterior interbody fusion with Peek cage + Beta-tricalcium phosphate (bone substitute, osteoconductive, resorbable) postop. postop.

52 3 months 5 years

53 CONCLUSIONS Clinical results showed no statistical significative differences among the three group Better clinical outcome in the immediate postoperative time whitout autologous bone graft specimen Better radiographic results in group 3

54 CONCLUSIONS Prefence on the use of pre-filled Peek cages, because: Execution semplicity Low intraoperative risks No need of bone graft specimen Reduction of surgical time and post-operative pain

55 Thank you