Cervical Osteotomies: Choosing the Right Surgical Approach

Transcription

1 Cervical Osteotomies: Choosing the Right Surgical Approach Todd J. Albert, MD Surgeon-in-Chief and Medical Director Korein-Wilson Professor Hospital for Special Surgery Chairman, Department of Orthopaedic Surgery Weill Cornell Medical College NY, NY

2 Todd J Albert, MD: Disclosures Industry (c,e) DePuy, Biomet; (d) Vertech, In Vivo Therapeutics, Paradigm Spine, Biomerix, Breakaway Imaging, Crosstree, Invuity, Pioneer, Gentis, ASIP, PMIG; (e) Facetlink a)research or institutional support received; b) Miscellaneous non-income support (e.g., equipment or services), commercially derived honoraria, or other non-research related funding (e.g., paid travel); c) Royalties; d) Stock or stock options held; e) Employee or Consultant; n) Nothing of value received External Advisory Role SIC HSS; MAB United Healthcare; CSRS Past President; SRS President Elect; IMAST Past Chair;

3 Sagittal alignment: what did we learn on global alignment? Patient specific Lordosis should match Pelvic Incidence (PI-LL) Age specific alignment targets Simple rule LL = PI 3

4 Sagittal alignment: what did we learn on global alignment? Patient specific Lordosis should match Pelvic Incidence (PI- LL) Age specific alignment targets Normative studies: Fon, Stagnara, Benhardt, Roussouly, Jackson, Gelb, Vialle, Thoracic kyphosis Lumbar Lordosis Harmony of the curves Chain of correlation pelvis, lordosis, kyphosis Theoretical LL tll = ½ (PI +TK) + 10 LL ~ PI TK ~ 2/3 LL 4

5 What is considered a Cervical Deformity? Probably No May Be Probably Yes Global, Regional, and focal considerations

6 The GOLD standard #1 C2-C7 Cervical Lordosis: 6

7 Cervical alignment: beyond these 6 vertebrae Horizontal gaze measurements: CBVA and surrogates: McGregor slope Slope of line of sight 5 up 18 down Range of CBVA associated to low disability 7

8 Normal Cervical Regional Alignment 100 Asymptomatic Volunteers Hardacker Spine 1997 Cervical plumb lines from the odontoid to C7 for all 100 volunteers were distributed in a narrow range (16.8 ± 11.2 mm)

9 70% comes from Terminal Segments Jackson SRS 1994 Normal 75% L5-S1 disc 41% of total lumbar lordosis L4-5 disc 27% C1-C2 75% 68% Courtesy of C. Ames

10 Regional

11 Regional

12 Global Alignment PI 55 LL 102 Max Kyphosis 90 (C6-T11) C CBVA 0 C2-7 SVA 3cm SVA -9cm PT -7

13 How about Cervical Deformity? Algorithm Fixed (Not Passively Correctable) Not Ankylosed Anterior Release/Grafting +/- Posterior Fusion Fused Anterior Anterior Osteotomy/ Grafting/ Posterior Instrumentatio n Cervical Deformity Ankylosed Osteotomy Fused Posterior Posterior Osteotomy, Anterior Release and Interbody, Posterior Instrumentati on Flexible (Passively Correctable) ACDF or Corpectomy Posterior Decompression and Fusion Circumferentially Fused Cervicothoracic Junction Pedicle Subtraction Osteotomy Combined AP Approach (increased biomechanical stability, increased fusion rate)

14 Assessment of Deformity Flexible vs. Rigid CT Scan Supine Images Clinical Deformity is Just as Important!

15 Rigid vs. Non-Rigid Deformity Osteotomy Type Approach History of Prior Operations

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17 Partial Facet Joint Resection with anterior discectomy

18 Complete Facet Joint/Ponte Osteotomy C.Ames

19 Partial or Complete Corpectomy

20 Complete Uncovertebral joint resection to transverse foramen KDR

21 Opening Wedge Osteotomy complete posterior element resection w/ osteoclasis & open wedge creation Simmons Osteotomy C.Ames

22 Pedicle Subtraction Osteotomy

23 Vertebral Column Resection

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25 Osteotomy Technique Anterior Osteotomy (Grade 4) Posterior Osteotomy Posterior Column (Grade 2) Three-Column (Grade 6)

26 Osteotomy Technique Anterior Osteotomy (Grade 4) Posterior Osteotomy Posterior Column (Grade 2) Three-Column (Grade 6)

27 Anterior Osteotomy 62F progressive loss of ambulatory capacity, balance, coordination, bladder incontinence Exam: myelopathy

28 FLEXION EXTENSION

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31 Fused uncinates

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37 Case Courtesy of K. Daniel Riew MD

38 Anterior Osteotomy

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41 Osteotomy Technique Anterior Osteotomy (Grade 4) Posterior Osteotomy Posterior Column (Grade 2) Three-Column (Grade 6)

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45 Bivector Traction Extension Flexion

46 Bivector Traction Extension Flexion

47 Bivector Traction Extension Flexion

48 Flexion Extension

49 Flexion Extension

50 Complete SAP Resection

51 Flexion Extension

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53 61 patients 3 approaches to deformity correction SPO PSO Anterior (Riew) Osteotomy

54 Comparison of Correction Various Angular Corrections with Osteotomy Types

55 Comparison of Correction Anterior Only Moderate Angular Correction

56 Comparison of Correction Posterior More Translational Correction

57 Comparison of Correction Combined MOST Overall Correction (for Translation and Angulation)

58 PSO has Greatest Angular Correction Why? Combined Approach packs the Anterior Column Limits Posterior Corrective ability!

59 Highest EBL

60 Outcomes NDI scores better, but failed to reach MCID! Pre-op NDI 26 Post-op NDI 19 P-value 0.63 NDI may not adequately address Cervical Deformity patients

61 Summary Cervical Deformity cases are Challenging but Rewarding Management of Patient expectations are paramount Riew Osteotomy with Posterior Instrumentation may be better approach to minimize Blood loss while maximizing correction

62 THANK YOU! 62

63 Thank You