Degenerative L4-5 SPONDYLOLISTHESIS with Stenosis: Laminectomy and Postero-Lateral Fusion. Rick C. Sasso MD

Transcription

1 Degenerative L4-5 SPONDYLOLISTHESIS with Stenosis: Laminectomy and Postero-Lateral Fusion Rick C. Sasso MD Professor Chief of Surgery Clinical Orthopaedic Surgery University School of Medicine Disclosure: Research support-medtronic, Stryker, AO, Cerapedics, Smith & Nephew, Lilly Royalties-Medtronic, Saunders Elsevier

2 Degenerative Spondylolisthesis Non-op L5 nerve decompression Lam + Fusion Interlaminar approaches MIS TLIF LLIF Indirect Decomp

3

4 Decompression only: L5 radic. in elderly with stable 4-5 Mardjetko 1994 Epstein JOSDT 1998 Kristof J Neurosurg 2002 Jang JOSDT 2012 Musluman J Neurosurg 2012

5

6

7 Prospective, randomized operative vs non-op 2 and 4 yr. F/U functional outcomes better OP Weinstein NEJM 2007 Weinstein JBJS 2009 No difference in surgical techniques at 4 yrs interbody fusion does not enhance laminectomy and posterolateral fusion with pedicle screw instrumentation Abdu 2009

8 Reduction of the spondylolisthesis does not improve clinical outcome. No correlation between slip reduction in low-grade spondylolisthesis or change in neuroforaminal morphology and clinical outcome. Hagenmaier, BMC Musculoskelet Disord 2013

9 Transforaminal lumbar interbody fusion and posterior lumbar interbody fusion utilizing BMP- 2 in treatment of degenerative spondylolisthesis: neither safe nor cost effective Surg Neurol Int Mar 22;4(Suppl 2):S doi: / Print 2013 Moatz B 1, Tortolani PJ the addition of interbody fusion along with BMP does not lead to significantly better clinical outcomes and increases costs when compared with more routine posterolateral fusion techniques. To date, there is insufficient evidence to support the use of interbody fusion devices along with BMP to treat routine cases of focal stenosis accompanied by DS, which are routinely adequately treated utilizing posterolateral fusion techniques.

10 Does TLIF improve outcomes in DS? Nope No difference in clinical results with addition of IB fusion

11

12 FACT!!!!! Complications of MIS TLIF Bilateral neurological deficits following unilateral minimally invasive TLIF: A review of four patients Fessler et al., Surg Neurol Int, 2014 Neurologic impairment from ectopic bone in the lumbar canal: a potential complication of off-label PLIF/TLIF use of bone morphogenetic protein-2 (BMP-2) Wong et al., J., 2008 Post op Radiculitis Anand et al., JSDT 2006

13 Minimally invasive lateral retroperitoneal Transpsoas interbody fusion for L4-5 spondylolisthesis: clinical outcomes Ahmadian J Neurosurg 2013

14 Extreme lateral interbody fusion relieves symptoms of spinal stenosis and lowgrade spondylolisthesis by indirect decompression in complex patients Pereira J Clin Neurosci 2017 Retrospective study Small number of patients Several Plexopathies did not hinder long-term recovery

15 Relevant Anatomy Iliac Veins Iliac Arteries Psoas Approach Lumbar Plexus

16 Working Zone Regev (, 2009) 100 lumbar MRIs from spine pts studied safe zone is smaller at L4/L5 Right vessels Nerve roots Complications of LLIF

17 Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Lykissas J 2014 Anterior thigh/groin pain 38.5% Sensory deficit 38% Motor deficit 23.9% BMP associated with persistent motor deficits Level treated risk factor for lumbosacral plexus injury

18 Patient chart review; 3.2yr period, 59 pts. 62.7% had thigh symptoms post-op New thigh symptoms 1 st f/u 3m post-op Burning, aching, stabbing or other pain 39% 15.5% Numbness 42.4% 24.1% Paresthesias 11.9% 5.6% Weakness 23.7% 11.3% Resolution of half at 3 months and more than 90% by 1 year

19 Extreme lateral lumbar interbody fusion: Do the cons outweigh the pros? Epstein Surg Neurol Int 2016 XLIF higher neuro deficits plexus injuries 13% permanent sensory deficit 63% motor deficit 33% anterior thigh pain 25% Major vascular injuries-life ending Bowel perforations No superiority-potential inferiority question whether XLIF should remain

20