When is Degenerative Disease Really Deformity

Transcription

1 When is Degenerative Disease Really Deformity Cabo State of Spine Surgery Think Tank June 2017 Gurvinder S. Deol, MD Wake Orthopaedics/WakeMed Health and Hospitals Clinical Assistant Professor Department of Orthopaedics UNC School of Medicine

2 Disclosures Consultant Nuvasive, Vertera Royalties Nuvasive, Globus Equity ISD, Vital 5, Vertera, LessRay

3 Spine degeneration Gravity causes age related changes in spino-pelvic alignment Degenerative loss of lordosis moves the spine forwards Compensatory mechanisms such as pelvic retroversion and knee flexion lead to posterior pelvic shift Lafage V et al, ISSG. Defining Spino-Pelvic Alignment Thresholds Should Operative Goals in ASD Surgery account for age? Spine 2016 Lafage V, et al. Standing balance and sagittal plane spinal deformity: analysis of spinopelvic and and gravity line parameters. Spine 2008

4 Spine degeneration These changes occur in an attempt to maintain an erect posture, limit muscle energy expenditure, limit biomechanical loads on intervertebral segments. Failure of this compensation leads to deformity and disability Lafage V et al, ISSG. Defining Spino-Pelvic Alignment Thresholds Should Operative Goals in ASD Surgery account for age? Spine 2016 Legaye J, Duval-Beaupere G. Gravitational forces and sagittal shape of the spine. Clinical estiamtion of their relations. Int Orthop 2008 Mac-Thiong J-M, et al. Can C7 pilumbline and gravity line predict haelth related quality of life in adult scoliosis? Spine 2009

5 Not just the spine Age related changes such as muscle atrophy, neurosensorial and postural control impaired by aging Patients present at various times along this degenerative cascade. Concept of balance is multifactorial Lafage V et al, ISSG. Defining Spino-Pelvic Alignment Thresholds Should Operative Goals in ASD Surgery account for age? Spine 2016

6 What we know 2/3 of lordosis L4-S1 Normal Average Lordosis 61 (Range ) L4/5 Lordosis 16.8 L5/S1 Lordosis Troyanovich SJ, Cailliet R, Janik TJ, et al. Radiographic mensuration characteristics of the sagittal lumbar spine from a normal population with a method to synthesize prior studies of lordosis. J Spinal Disord 1997;10(5):

7 Radiographic parameters are clinically relevant 3 most highly correlated parameters Alignment Objectives 1. PI LL < PT < SVA < 5cm Schwab F, Ungar B, Blondel B, et al. Scoliosis Research Society - Schwab adult spinal deformity classification. A validation study. Spine 2012;37(12):

8 Loss of Global Alignment Loss of lumbar lordosis is especially poorly tolerated and has direct effect on disability Schwab, F., Patel, A., Ungar, B., Farcy, J. P., & Lafage, V. (2010). Adult spinal deformity postoperative standing imbalance: how much can you tolerate? An overview of key parameters in assessing alignment and planning corrective surgery. Spine, 35(25),

9 Alignment vs Balance Preservation/restoration of lumbar lordosis is crucial to the success of any lumbar fusion. Sagittal balance is directly correlated to clinical outcome: avoid sagittal decompensation. If the clinically relevant radiographic parameters are not achieved the patient runs a higher risk of reoperation. Mehta VA, Amin A, Omeis I, et al. Implications of spinopelvic alignment for the spine surgeon. Neurosurgery 2012;70: Rothenfluh DA, Mueller DA, Rothenfluh E, et al. Pelvic incidence-lumbar lordosis mismatch predisposes to adjacent segment disease after lumbar spinal fusion. Eur Spine J 2014

10 Consequences of Postoperative Malalignment The consequences of failure to achieve post-op alignment objectives include: Poor clinical outcome: persistent pain and disability. Failure of fusion/instrumentation: increased stress at caudal and cephalad aspects of the construct. Adjacent level disease: junctional stresses. These negative consequences are applicable for short construct degenerative cases as well as long segment deformity cases. Lazennec, J. Y., Ramare, S., Arafati, N., Laudet, C. G., Gorin, M., Roger, B.,... & Trabelsi, R. (2000). Sagittal alignment in lumbosacral fusion: relations between radiological parameters and pain. European Spine Journal, 9(1),

11 Degen/deformity Lafage et al. ISSG, Spine 2016 Multicenter retrospective analysis of prospectively collected data 773 patients stratified by age Sagittal spino-pelvic alignment varies with age, and operative targets should account for age

12 Conclusion At Minimum: Lumbar radiographs that include the hips!! Able to derive a PI and LL Allows awareness of at risk patients

13 Conclusion ALL degenerative spine disease creates some deformity (focal > regional > global) Life is kyphosing Pay attention to balance Adhere to alignment/fusion goals Plan accordingly Stenosis contributing to imbalance