Lumbar degenerative spinemodalities

Transcription

1 Lumbar degenerative spinemodalities of treatment Prof. dr Mirza Bišćević Spine department, Orthopedics

2 What should we accept as normal siutuation? - morphologic abnormalities in the lumbar spine are common in asymptomatic individuals, but severe (Modic) changes and severe facet arthrosis are rare in healthy individuals less than 50 years of age, Pain we should NOT ACCEPT as a normal situation! What hurts, what is source of pain? Three pain sidromes.

3 Diskogenic pain syndrome: - mostly L5/S1 is involved combined with or without L4/5, or L4/5 alone, then suspicious for L/S transitional anomaly, - discograms: functional pain evaluation with memory pain provocation or not; concomitant facet joint pathology. Facet syndrome: - pain provocation on repetitive backward bending, on repetitive side rotation, and hyperextension in the prone position.

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6 Instability syndrome: - abnormal spinal rhythm (when straightening from a forward bent position, hurts in standing position, relife in laying; hand-on-thigh support.

7 Instability syndrome: no pain in laying position, omnly in standing; simple fixation solve the problem.

8 Solutions are simple when pathology is located in 1-2 disk spaces. Options for disc space surgeries: - disectomy - TLIF - PLIF - ALIF - XLIF - Axialif - Pedicle fixation alone with PLF - Disc prosthesis

9 SP, PLIF, TLIF, ALIF, AxiLIF, disk prosthesis

10 If pathology is located on 3 or more levels, it can be: stenosis and degenerative spine deformity. Spinal deformity in adults is consequence of: - prior idiopathic scoliosis, de novo degenerative scoliosis, paralytic curves, posttraumatic deformities, iatrogenic deformities, or curves related to severe osteoporosis.

11 In clinical terms it is combination of syndromes: diskogenic, faset and instability syndrome. In pathology/radiology terms it is combination of: disk and faset arthrosis, flavum hypertrophy, extensor muscle atrophy, stenosis (foraminal and central), and nonphysiological curves (scoliosis, hypolordosis/ kyphosis), with anterior sagittal imbalance.

12 Surgical goal - decompression of stenotic segments, - decompression of impinged roots, - stabilization of the deformity, - solid arthrodesis, - moderate correction of the deformity to reach a balanced spine in coronal and frontal plane, - functional restoration. Bradford DS,et al. COOR 1988 Boachie-Adjei & Gupta OKU,2002 Aebi ESJ, 2005

13 DS surgical triggers are: - not correction of curve, but reliving a patient of neurogenic claudications, back and leg pains, - level of pain which patient is not tolerating any more, motor weakness (similar surgical indications to other degenerative pathology of lumbar spine disectomies, lystesis, stenosis...), - appearance is not an issue in DS patents.

14 Preoperatively what to do? - clinical assessment: subjective complaints: % lower back pain vs. radiculopathy, in standing and laing position, neurological exam (deficit, claudications), imbalance (coronal/sagittal), DEXA, scan, patient s and pt s family expectations (high rate of complications), - X-ray assessment: flex-extension, side-bending, supine, push-prone, traction images; define flexible vs. stiff vs. fused curves.

15 Intraoperatively, to think about: - do the minimum that needs to be done, - consider a team approach and osteotomies, - iliac fixation recommend for any PSF L2 (or longer)- sacrum may be overkill for some pts., but highly protective for all others!, - proximal junctional kyphosis PJK (positive sagittal imbalance immediately cephalad to the proximal instrumented levels), and discarthrosis of free levels (iatrogenic vs. natural degenerative process), - distal junctional problems (sacral fractures and distal loss of fixation, lystesis).

16 Postoperatively, what we can expect 1.? - 4% mortality, - 17% new neurologic deficits, - 23% major medical complications, - 35% re-operation (~50% wound infections). - Howe (2011) adults with long fusions (mean age 64) 16

17 Postoperatively, what we can expect 2.? - postop. Cobb ~17, - ODI, SF 36 PCS improved, - VAS improved at 2 year f/up, - back pain 3,7 (7,8vs.4,1) and leg pain 3,9 (7,0vs.3,1), - no correlation between: number of levels fused, preop. SF-36 scores, BMI, ASA grade, surgical approach, coronal and sagittal Cobb correction, 13% of patients required revision, adjacent DDD 11%, non-union 2%, and removal of instrumentation 1%. Park (2013) Adult lumbar deg. scoliosis 40, retrospective review of 105 pts. (decompression and fusion)

18 Postoperatively, what we can expect 3.? - overall complication rate 37% (17/46 pts.), - major complication rate 20% (9/46), - reoperation 33% (15/46), - 3 pts. within 1st month postop., - 12 pts. after one year postop. (1 prominent implants, 2 progressions of scoliosis and 9 pseudoarthroses) overall rate 19,5%. Daubs, Lenke (2007) Adult spinal def. Surgery, Complications and outcomes in patients over 60y., 46 consecutive pts. who underwent fusion 5 levels.

19 How far to go with surgery? Is less better surgery?

20 Failure of Fusion/Stabilization in Reconstructive Surgery Distinguish between functional failure in terms of outcome and pain on one hand and the biological, mechanical or technical failure of the fusion in form of a non-union or malunion, secondary adjacent segment problems etc. on the other hand. Focus on the analysis of the problem behind a surgically failed fusion/stabilization.

21 Clinical analysis of the failure is differentiation between three major problems: - failure due to wrong indication, - failure due to wrong biology, - failure due to wrong biomechanics.

22 Some of conclusions: - a complex interaction between structural deformity, compensatory mechanism, and biology of the patient, - harmony among the spinopelvic parameters is of primary importance, but some pts. have a high potential of compensation, - sagittal spinal and global balance was strongly related to the ODI in adult scoliosis; coronal spinal and global balance did not influence the ODI,

23 - short fusion is sufficient for patients with small Cobb angle and good spinal balance, - for patients with severe Cobb angle and rotatory subluxation, long fusion should be carried out to minimize adjacent segment disease, - for patients who have severe sagittal imbalance, spinal osteotomy is an alternative technique to be considered.

24 Patient 1. Female 67 years old with degenerative lumbal scoliosis of 50 and kyphosis. Tractional X ray reduces Cobb angle on 30.

25 Reduction of Cobb angle for about 2/3, and restauration of lumbal lordosis, but, more important is spine stability and balance.

26 Patient y. old female with spondiloptosis reduced on the 2 nd degree od lystesis.

27 Patient 3. Male 54 years old with L4-L5 central and foraminal stenosis.

28 Patient 4. Leg pain/claudication is typically caused by compression of roots in concave side of apexes; SNRB of L3, L4 root on concave side of the main curve, and L5, S1 root on concave side of lower fractional cruve.

29 Patient 5. Bilateral S1 SNRB for axial back pain related to the diskarthrosis L5-S1.

30 Patient 6. Previous back surgery and bilateral THR, clinical finding is intractable left buttock pain (hip spine syndrome); SNRB of left L5 root, to exclude symptoms caused by its compression.

31 Patient 7. Left L5 SNRB controls symptoms after this failed back surgery.

32 Patient 8. Angular kyphosis, apex at Th 12 vertebra, untreated osteoporotic fracture, myelopathy.

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34 Patient 9. Failed backsurgery

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36 1 year after root block, no surgery Patient y. old female with severe radiculpathy and some back pain

37 I, još nešto! Nastoj raditi one operacije koje se mogu popraviti (back up plan), a popravka im nije potrebna. Koliko je važno znati operisati, isto toliko je važno znati šta operisati. ;-)