Cervical Hybrid Arthroplasty by Pablo Pazmino MD

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This video explains Cervical Arthroplasty in combination with a fusion. When people have more than one cervical disc which has degenerated or which has sustained a traumatic rupture they may need a procedure to address both levels. These herniations may begin to affect the surrounding nerves and/or spinal cord. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Herniations/ Radiculopathy at multiple levels feel free to look us up online www.beverlyspine.com or call toll free 1-8SPINECAL-1

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Cervical Hybrid Arthroplasty by Pablo Pazmino MD

  1. 1. Pablo Pazmi ño, MD
  2. 2. Orthopaedic Surgery American Academy of Orthopaedic Surgeons Clinical Faculty Olympia Medical Center Cedars Sinai Medical Center Century City Doctors Hospital <ul><li>Education </li></ul><ul><ul><li>The University of California, Los Angeles </li></ul></ul><ul><ul><li>The University of Michigan, Ann Arbor </li></ul></ul>
  3. 3. <ul><li>Definition </li></ul><ul><li>Anatomy </li></ul><ul><li>Imaging </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Non Operative </li></ul></ul><ul><ul><li>Operative </li></ul></ul><ul><li>History of Arthroplasty </li></ul><ul><li>Construct Fixation </li></ul><ul><li>Construct Range of Motion </li></ul><ul><li>Cases </li></ul>M6 Artificial Disc
  4. 4. <ul><li>Hybrid: </li></ul><ul><li>The combination of an Artificial Disc Replacement and a Fusion Construct in the same Spinal Region </li></ul><ul><ul><li>Lumbar </li></ul></ul><ul><ul><li>Cervical </li></ul></ul>
  5. 5. <ul><li>Hybrid Cervical Arthroplasty: </li></ul><ul><li>Indications </li></ul><ul><ul><li>Patients with Prior Fusions (ACDF) </li></ul></ul><ul><ul><li>Cases when multilevel arthroplasty are contraindicated (instability, translation, prior trauma) </li></ul></ul><ul><li> </li></ul>
  6. 6. <ul><li>Hybrid Cervical Arthroplasty: </li></ul><ul><li>Many patients who had a prior ACDF have noted resultant neck pain from adjacent level degeneration. After undergoing prior ACDF there is a 3-10% chance of adjacent level breakdown. </li></ul><ul><li>Adding additional fusion constructs to the spine at this point would severely limit cervical motion, in these circumstances Hybrid Cervical Arthroplasty now provides a novel means of maintaining cervical motion. </li></ul><ul><li> </li></ul>
  7. 7. <ul><ul><li>There is a tough ring around the outside called the Annulus Fibrosus , and a thick almost crabmeat like center inside called the Nucleus pulposus. </li></ul></ul>
  8. 8. <ul><ul><li>If the outer edge of the disc ruptures, the center can push through and put pressure on the exiting nerve, leading to the pain of sciatica (referred to as a Herniated nucleus pulposus or disc herniation). </li></ul></ul>
  9. 9. <ul><li>Are located posteriorly, these are the joints of the spine and are essential for control of normal motion and based on their orientation </li></ul><ul><li>Compromised facets will alter the distribution of mechanical forces throughout the spine </li></ul>
  10. 10. Joint Facet Nucleus Pulposus Right Nerve Root Left Nerve Root As you can see here on MRI and CT scans the Facet joints end up looking like the buns of a hamburger. Its just the way the happen to look when they are sliced in this plane. We will show you this on some examples later Annulus Fibrosus Axial View of the Disc and Neural elements
  11. 11. Joint Facet Disc Right Nerve Root Left Nerve Root Axial View
  12. 12. <ul><li>The pain is not improving after several days or seems to be getting worse. </li></ul><ul><li>You are younger than 20 or older than 55 years and are having sciatica for the first time. </li></ul><ul><li>You presently have cancer or have a history of cancer. </li></ul><ul><li>You have lost a large amount of weight recently or have unexplained chills and fever with back pain. </li></ul><ul><li>You continue to have trouble bending forward after more than a week or two. </li></ul><ul><li>You notice weakness is getting more pronounced over time. </li></ul><ul><li>You develop any new onset weakness, such as a drop foot. </li></ul><ul><li>You are dropping items, have noticed a loss of dexterity, difficulty opening jars. </li></ul>
  13. 13. <ul><li>The pain is unbearable, despite trying first aid methods , NSAIDs, rest, relaxation, and bedrest. </li></ul><ul><li>The pain follows a violent injury, such as a fall from a ladder or an automobile crash. </li></ul><ul><li>The pain is in the back of your chest. </li></ul><ul><li>You are unable to move or feel your legs or feet. </li></ul><ul><li>You lose control of your bowels or bladder or have numbness in your genitals. </li></ul><ul><li>You have a high temperature (over 101°F). </li></ul>
  14. 14. <ul><li>Radiographs </li></ul><ul><li>CT: Computed Tomography </li></ul><ul><li>MRI: Magnetic Resonance Imgaing </li></ul>
  15. 15. <ul><li>Radiographs usually reveal findings consistent with degeneration of the lumbar spine, such as </li></ul><ul><li>Disc space narrowing </li></ul><ul><li>Endplate sclerosis </li></ul><ul><li>Formation of osteophytes </li></ul><ul><li>Facet joint hypertrophy and arthritis </li></ul><ul><li>Degenerative scoliosis or spondylolisthesis </li></ul><ul><li>Settling of spinous processes </li></ul><ul><li>Instability </li></ul>
  16. 16. <ul><li>CT&MRI </li></ul><ul><li>1. Identify location, degree of stenosis (15% trefoil) </li></ul><ul><li>2. Absolute stenosis lateral recess diameter <3mm, relative 3-5mm </li></ul><ul><li>3. Sagittal absolute <10 , relative <12 </li></ul><ul><li>Ciric JNeurosurgery ’80:5 </li></ul><ul><li>Verbeist JBJS B’77:59 </li></ul><ul><li>4. Cross sectional area <100mm2 absolute stenosis </li></ul><ul><ul><li>Bolender JBJS ‘85: 67A </li></ul></ul><ul><ul><li>5. The critical height of the intervertebral foramen is believed to be 15 mm and posterior disc height of 3 mm. N Root compression 80% when below </li></ul></ul>
  17. 17. Joint Facet Disc Right Nerve Root Left Nerve Root Axial View
  18. 18. Joint Facet Disc Right Nerve Root Left Nerve Root Next I will show you some MRIs You will see this is a patient with a left sided herniation pinching off her exiting left nerve root
  19. 19. Joint Facet Disc Right Nerve Root Left Nerve Root Axial Scans:
  20. 20. Cervical 7 Spinous Process Nerves 2-3 Disc 3-4 Disc 4-5 Disc 5-6 Disc 6-7 Disc
  21. 21. <ul><li>Early stages intermittent symptoms (neural inflammation) </li></ul><ul><li>Activity modification </li></ul><ul><li>Staying in shape physically/aerobically </li></ul><ul><li>Bedrest 2-3 days: Avoid longterm bedrest </li></ul><ul><li>Avoid certain activities : bending,twisting, lifting, unnecessary walking…..Usually eases pain </li></ul><ul><li>PTherapy: stretching and isometrically strengthening atrophied muscles </li></ul><ul><li>Modalities: heat, U/S, Whirlpool, massage </li></ul>
  22. 22. <ul><li>Avoid Narcotic medications and muscle relaxants (depression/sedation) </li></ul><ul><li>Anti-inflammatory meds </li></ul><ul><li>Bracing </li></ul><ul><li>Epidural steroids and oral steroid ‘dose packs’ relieve pain and inflammation and allow aerobic conditioning and incr fcn </li></ul><ul><li>Selective Nerve Root Blocks </li></ul><ul><li>All temporary not a cure for stenosis, and gives indication of severity </li></ul><ul><li>Chiropractor </li></ul><ul><li>Accupuncture </li></ul>
  23. 23. <ul><li>Surgery should be a last resort, when conservatives measures fail. </li></ul><ul><li>In some cases surgery needs to be done sooner than later, or even urgently, depending on the physical exam, history, neural deficits, and size of the herniation. </li></ul>
  24. 24. <ul><li>Skeletally mature patients </li></ul><ul><li>Reconstruction of C3-C7 following a single level discectomy </li></ul><ul><li>Intractable symptomatic cervical disc disease </li></ul><ul><li>Neck Pain </li></ul><ul><li>Arm (Radicular) Pain and/or </li></ul><ul><li>Functional/Neurological deficit with radiographic findings </li></ul><ul><li>Herniation </li></ul><ul><li>Spondylosis </li></ul><ul><li>Loss of Disc Height </li></ul>
  25. 25. <ul><li>Active Systemic Infections or Nearby Infection </li></ul><ul><li>Osteoporosis as defined by DEXA bone density T score <2.5 </li></ul><ul><li>Marked cervical instability on neutral resting lateral or flexion/extension radiographs. Translation>3 mm and/or 11 degrees of rotational difference to either adjacent level </li></ul><ul><li>Allergy or sensitivity to implant materials (Cobalt, Chromium, Molybdenum, Polyethylene, Titanium) </li></ul><ul><li>Severe Spondylosis </li></ul><ul><li>Clinically compromised vertebral bodies at the affected level from trauma </li></ul><ul><li>Cancer </li></ul><ul><li>Facet Joint Pathology </li></ul>
  26. 26. <ul><li>Goals: </li></ul><ul><ul><li>To provide a sufficient implant range of motion </li></ul></ul><ul><ul><li>While maintaining physiologic range of motion </li></ul></ul><ul><li>Concepts </li></ul><ul><li>To limit cantilever stress on adjacent levels above and below levels which would otherwise be fused </li></ul>
  27. 27. <ul><li>In the 1960s, Sir John Charnley pioneered modern arthroplasty, or joint replacement with the Total Hip Arthroplasty (THA) </li></ul><ul><li>Over the next two decades he refined all aspects of the procedure, working with the firm Chas F. Thackray Limited, now a subsidiary of DePuy Orthopaedics. </li></ul>Sir John Charnley at his lathe working on the first artificial joint
  28. 28. <ul><li>The Discover ™ features a unique Fixed core ball-and-socket design: </li></ul>
  29. 29. <ul><li>The Prestige ™ features a unique ball and trough design with a posterior center of rotation, which allows for translation. </li></ul><ul><li>Cervical motions are coupled. Flexion/Extension and Anterior/Posterior translation. Prestige design to achieve this coupled motion with the ball and trough articulation </li></ul>
  30. 30. <ul><li>The Prodisc ™ features a unique core ball-and-socket design: </li></ul><ul><li>Shown to maintain a mean ROM 9.4 degrees in flexion/extension at 2 years. </li></ul><ul><li>Translation is limited to rotation of the superior endplate around the ball in the inferior endplate </li></ul><ul><li>The instantaneous center of rotation is fixed during motion. </li></ul>
  31. 31. <ul><li>The M6™ features a unique viscoelastomeric core </li></ul><ul><li>Nucleus </li></ul><ul><li>• Viscoelastic polymer designed to simulate native nucleus • Allows physiologic axial compression • Retained between endplates & fiber annulus matrix • Designed to enable physiologic Center Of Rotation </li></ul>Annulus • Ultra High Molecular Polyethylene (UHWMPE) fiber material • Intended to simulate native annulus & its performance • Designed to provide controlled physiologic motion in all planes and axes • Robust fiber matrix with multiple layers similar to native annulus
  32. 32. Sheath • Designed to minimize tissue in-growth & debris migration • Allows for full range of motion Fixation • Titanium endplates with tri-keel design • Titanium Plasma Spray (TPS) coated endplate • Low profile keel height (2mm)
  33. 33. <ul><li>Cervical disc replacements should be expected to withstand the repetitive stress and strain of weight bearing and motion that occurs in the cervical spine over a life span of approximately 30 to 40 years. </li></ul><ul><li>Because of this secure implant fixation is paramount to implant longevity. </li></ul>
  34. 34. <ul><li>In order to provide secure implant fixation , the implant should offer both immediate and long term fixation.. </li></ul><ul><li>Initial immediate strategies for fixation . </li></ul><ul><ul><li>Keel </li></ul></ul><ul><ul><li>Spike </li></ul></ul><ul><ul><li>Screws </li></ul></ul><ul><li>As well as Long term Implant fixation properties </li></ul>
  35. 35. Discover ADR Immediate and initial fixation is provided through 6 Lateral Teeth which notch into the subchondral bone of the vertebral bodies above and below the implant itself.
  36. 36. Prodisc ADR Immediate and initial fixation is provided through a keel which notch into the subchondral bone of the vertebral bodies above and below the implant itself.
  37. 37. M6 ADR Immediate and initial fixation is provided through a keel which notch into the subchondral bone of the vertebral bodies above and below the implant itself.
  38. 38. Prestige ADR Immediate and initial fixation is provided through interbody screw fixation which secure into the subchondral bone of the vertebral bodies above and below the implant itself. Angled screws to resist pullout
  39. 39. <ul><li>Using our knowledge from Total hip arthroplasty we know that bone will actually grow into the metal endplates when coated with Hydroxapatite </li></ul>Microscopic view of bony ingrowth onto hydroxyapatite which provides for long term fixation A human long bone cell growing on the surface of a hydroxyapatite ceramic foam. The presence of microporosity allows the cell processes to attach more readily.
  40. 40. <ul><li>Roughened surface finishes composed of titanium have resulted in improved initial implant fixation and are believed to support improved bone ingrowth onto the surface of joint arthroplasty at the host–prosthesis interface. </li></ul>
  41. 41. Flexion / Extension Literature: Panjabi, White (1990) Prestige +/- 10 Degrees Prodisc +/- 20 Degrees M6 6 Degrees 20 ° Unlimited
  42. 42. Lateral Bending Literature: Panjabi, White (1990) Prestige +/- 10 degrees Prodisc +/- 20 degrees M6 6 degrees 15 ° Discover 42 °
  43. 43. Axial Rotation Literature: Panjabi, White (1990) 14 ° Unlimited
  44. 44. <ul><li>Posterior bullet </li></ul>Radius C L Lordosis <ul><li>L ordotic endplates </li></ul>Disc Height <ul><li>Heights: 5, 6, 7, 8, 9mm </li></ul>
  45. 45. <ul><li>Angled Flanges to fit anterior vertebrae </li></ul>Radius C L Lordosis <ul><li>L ordotic endplates </li></ul>Disc Height <ul><li>Heights: 6, 7 mm </li></ul>
  46. 46. <ul><li>Zero Profile Implant </li></ul>Radius C L Lordosis <ul><li>L ordotic endplates </li></ul>Disc Height <ul><li>Heights: 5, 6, 7mm </li></ul>
  47. 47. Zero Profile Implant C L Lordosis Disc Height Heights: 3 Heights: 6mm, 7mm & 8mm 2 Footprints: Medium & Large
  48. 48. <ul><li>Endplate footprints </li></ul><ul><ul><li>Trapezoidal in shape </li></ul></ul><ul><ul><li>Dovetail holding feature </li></ul></ul>
  49. 49. <ul><li>Endplate footprints </li></ul><ul><ul><li>Trapezoidal in shape </li></ul></ul>
  50. 50. <ul><li>All our procedures are performed in a minimally invasive manner. </li></ul><ul><li>All discectomies are performed as a microdiscectomy as opposed to the traditional open discectomy. </li></ul><ul><li>All patients receive a plastics closure and are followed closely afterwards </li></ul>
  51. 51. Teamwork: All Procedures performed with both an Orthopaedic Spine Surgeon and a Neurological Surgeon
  52. 52. <ul><li>Thank you for your time. </li></ul><ul><li>If you know someone who could benefit from a consultation for Cervical Artificial Disc Replacement please refer them to our online website or call toll free to schedule an appointment </li></ul><ul><li>1-8SPINECAL-1 </li></ul><ul><li>www.beverlyspine.com </li></ul>

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