Pablo Pazmi ño, MD

Orthopaedic Surgery American Academy of Orthopaedic Surgeons Clinical Faculty Olympia Medical Center Cedars Sinai Medical Center Century City Doctors Hospital Education The University of California, Los Angeles The University of Michigan, Ann Arbor

Education

The University of California, Los Angeles

The University of Michigan, Ann Arbor

Definition Anatomy Imaging Treatment Non Operative Operative History of Arthroplasty Construct Fixation Construct Range of Motion Cases M6 Artificial Disc

Definition

Anatomy

Imaging

Treatment

Non Operative

Operative

History of Arthroplasty

Construct Fixation

Construct Range of Motion

Cases

Hybrid: The combination of an Artificial Disc Replacement and a Fusion Construct in the same Spinal Region Lumbar Cervical

Hybrid:

The combination of an Artificial Disc Replacement and a Fusion Construct in the same Spinal Region

Lumbar

Cervical

Hybrid Cervical Arthroplasty: Indications Patients with Prior Fusions (ACDF) Cases when multilevel arthroplasty are contraindicated (instability, translation, prior trauma)

Hybrid Cervical Arthroplasty:

Indications

Patients with Prior Fusions (ACDF)

Cases when multilevel arthroplasty are contraindicated (instability, translation, prior trauma)

Hybrid Cervical Arthroplasty: 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. 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.

Hybrid Cervical Arthroplasty:

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.

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.

There is a tough ring around the outside called the Annulus Fibrosus , and a thick almost crabmeat like center inside called the Nucleus pulposus.

There is a tough ring around the outside called the Annulus Fibrosus , and a thick almost crabmeat like center inside called the Nucleus pulposus.

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).

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).

Are located posteriorly, these are the joints of the spine and are essential for control of normal motion and based on their orientation Compromised facets will alter the distribution of mechanical forces throughout the spine

Are located posteriorly, these are the joints of the spine and are essential for control of normal motion and based on their orientation

Compromised facets will alter the distribution of mechanical forces throughout the spine

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

Joint Facet Disc Right Nerve Root Left Nerve Root Axial View

The pain is not improving after several days or seems to be getting worse. You are younger than 20 or older than 55 years and are having sciatica for the first time. You presently have cancer or have a history of cancer. You have lost a large amount of weight recently or have unexplained chills and fever with back pain. You continue to have trouble bending forward after more than a week or two. You notice weakness is getting more pronounced over time. You develop any new onset weakness, such as a drop foot. You are dropping items, have noticed a loss of dexterity, difficulty opening jars.

The pain is not improving after several days or seems to be getting worse.

You are younger than 20 or older than 55 years and are having sciatica for the first time.

You presently have cancer or have a history of cancer.

You have lost a large amount of weight recently or have unexplained chills and fever with back pain.

You continue to have trouble bending forward after more than a week or two.

You notice weakness is getting more pronounced over time.

You develop any new onset weakness, such as a drop foot.

You are dropping items, have noticed a loss of dexterity, difficulty opening jars.

The pain is unbearable, despite trying first aid methods , NSAIDs, rest, relaxation, and bedrest. The pain follows a violent injury, such as a fall from a ladder or an automobile crash. The pain is in the back of your chest. You are unable to move or feel your legs or feet. You lose control of your bowels or bladder or have numbness in your genitals. You have a high temperature (over 101°F).

The pain is unbearable, despite trying first aid methods , NSAIDs, rest, relaxation, and bedrest.

The pain follows a violent injury, such as a fall from a ladder or an automobile crash.

The pain is in the back of your chest.

You are unable to move or feel your legs or feet.

You lose control of your bowels or bladder or have numbness in your genitals.

You have a high temperature (over 101°F).

Radiographs CT: Computed Tomography MRI: Magnetic Resonance Imgaing

Radiographs

CT: Computed Tomography

MRI: Magnetic Resonance Imgaing

Radiographs usually reveal findings consistent with degeneration of the lumbar spine, such as Disc space narrowing Endplate sclerosis Formation of osteophytes Facet joint hypertrophy and arthritis Degenerative scoliosis or spondylolisthesis Settling of spinous processes Instability

Radiographs usually reveal findings consistent with degeneration of the lumbar spine, such as

Disc space narrowing

Endplate sclerosis

Formation of osteophytes

Facet joint hypertrophy and arthritis

Degenerative scoliosis or spondylolisthesis

Settling of spinous processes

Instability

CT&MRI 1. Identify location, degree of stenosis (15% trefoil) 2. Absolute stenosis lateral recess diameter <3mm, relative 3-5mm 3. Sagittal absolute <10 , relative <12 Ciric JNeurosurgery ’80:5 Verbeist JBJS B’77:59 4. Cross sectional area <100mm2 absolute stenosis Bolender JBJS ‘85: 67A 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

CT&MRI

1. Identify location, degree of stenosis (15% trefoil)

2. Absolute stenosis lateral recess diameter <3mm, relative 3-5mm

3. Sagittal absolute <10 , relative <12

Ciric JNeurosurgery ’80:5

Verbeist JBJS B’77:59

4. Cross sectional area <100mm2 absolute stenosis

Bolender JBJS ‘85: 67A

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

Joint Facet Disc Right Nerve Root Left Nerve Root Axial View

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

Joint Facet Disc Right Nerve Root Left Nerve Root Axial Scans:

Cervical 7 Spinous Process Nerves 2-3 Disc 3-4 Disc 4-5 Disc 5-6 Disc 6-7 Disc

Early stages intermittent symptoms (neural inflammation) Activity modification Staying in shape physically/aerobically Bedrest 2-3 days: Avoid longterm bedrest Avoid certain activities : bending,twisting, lifting, unnecessary walking…..Usually eases pain PTherapy: stretching and isometrically strengthening atrophied muscles Modalities: heat, U/S, Whirlpool, massage

Early stages intermittent symptoms (neural inflammation)

Activity modification

Staying in shape physically/aerobically

Bedrest 2-3 days: Avoid longterm bedrest

Avoid certain activities : bending,twisting, lifting, unnecessary walking…..Usually eases pain

PTherapy: stretching and isometrically strengthening atrophied muscles

Modalities: heat, U/S, Whirlpool, massage

Avoid Narcotic medications and muscle relaxants (depression/sedation) Anti-inflammatory meds Bracing Epidural steroids and oral steroid ‘dose packs’ relieve pain and inflammation and allow aerobic conditioning and incr fcn Selective Nerve Root Blocks All temporary not a cure for stenosis, and gives indication of severity Chiropractor Accupuncture

Avoid Narcotic medications and muscle relaxants (depression/sedation)

Anti-inflammatory meds

Bracing

Epidural steroids and oral steroid ‘dose packs’ relieve pain and inflammation and allow aerobic conditioning and incr fcn

Selective Nerve Root Blocks

All temporary not a cure for stenosis, and gives indication of severity

Chiropractor

Accupuncture

Surgery should be a last resort, when conservatives measures fail. 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.

Surgery should be a last resort, when conservatives measures fail.

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.

Skeletally mature patients Reconstruction of C3-C7 following a single level discectomy Intractable symptomatic cervical disc disease Neck Pain Arm (Radicular) Pain and/or Functional/Neurological deficit with radiographic findings Herniation Spondylosis Loss of Disc Height

Skeletally mature patients

Reconstruction of C3-C7 following a single level discectomy

Intractable symptomatic cervical disc disease

Neck Pain

Arm (Radicular) Pain and/or

Functional/Neurological deficit with radiographic findings

Herniation

Spondylosis

Loss of Disc Height

Active Systemic Infections or Nearby Infection Osteoporosis as defined by DEXA bone density T score <2.5 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 Allergy or sensitivity to implant materials (Cobalt, Chromium, Molybdenum, Polyethylene, Titanium) Severe Spondylosis Clinically compromised vertebral bodies at the affected level from trauma Cancer Facet Joint Pathology

Active Systemic Infections or Nearby Infection

Osteoporosis as defined by DEXA bone density T score <2.5

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

Allergy or sensitivity to implant materials (Cobalt, Chromium, Molybdenum, Polyethylene, Titanium)

Severe Spondylosis

Clinically compromised vertebral bodies at the affected level from trauma

Cancer

Facet Joint Pathology

Goals: To provide a sufficient implant range of motion While maintaining physiologic range of motion Concepts To limit cantilever stress on adjacent levels above and below levels which would otherwise be fused

Goals:

To provide a sufficient implant range of motion

While maintaining physiologic range of motion

Concepts

To limit cantilever stress on adjacent levels above and below levels which would otherwise be fused

In the 1960s, Sir John Charnley pioneered modern arthroplasty, or joint replacement with the Total Hip Arthroplasty (THA) 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. Sir John Charnley at his lathe working on the first artificial joint

In the 1960s, Sir John Charnley pioneered modern arthroplasty, or joint replacement with the Total Hip Arthroplasty (THA)

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.

The Discover ™ features a unique Fixed core ball-and-socket design:

The Discover ™ features a unique Fixed core ball-and-socket design:

The Prestige ™ features a unique ball and trough design with a posterior center of rotation, which allows for translation. Cervical motions are coupled. Flexion/Extension and Anterior/Posterior translation. Prestige design to achieve this coupled motion with the ball and trough articulation

The Prestige ™ features a unique ball and trough design with a posterior center of rotation, which allows for translation.

Cervical motions are coupled. Flexion/Extension and Anterior/Posterior translation. Prestige design to achieve this coupled motion with the ball and trough articulation

The Prodisc ™ features a unique core ball-and-socket design: Shown to maintain a mean ROM 9.4 degrees in flexion/extension at 2 years. Translation is limited to rotation of the superior endplate around the ball in the inferior endplate The instantaneous center of rotation is fixed during motion.

The Prodisc ™ features a unique core ball-and-socket design:

Shown to maintain a mean ROM 9.4 degrees in flexion/extension at 2 years.

Translation is limited to rotation of the superior endplate around the ball in the inferior endplate

The instantaneous center of rotation is fixed during motion.

The M6™ features a unique viscoelastomeric core Nucleus • Viscoelastic polymer designed to simulate native nucleus • Allows physiologic axial compression • Retained between endplates & fiber annulus matrix • Designed to enable physiologic Center Of Rotation 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

The M6™ features a unique viscoelastomeric core

Nucleus

• Viscoelastic polymer designed to simulate native nucleus • Allows physiologic axial compression • Retained between endplates & fiber annulus matrix • Designed to enable physiologic Center Of Rotation

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)

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. Because of this secure implant fixation is paramount to implant longevity.

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.

Because of this secure implant fixation is paramount to implant longevity.

In order to provide secure implant fixation , the implant should offer both immediate and long term fixation.. Initial immediate strategies for fixation . Keel Spike Screws As well as Long term Implant fixation properties

In order to provide secure implant fixation , the implant should offer both immediate and long term fixation..

Initial immediate strategies for fixation .

Keel

Spike

Screws

As well as Long term Implant fixation properties

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.

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.

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.

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

Using our knowledge from Total hip arthroplasty we know that bone will actually grow into the metal endplates when coated with Hydroxapatite 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.

Using our knowledge from Total hip arthroplasty we know that bone will actually grow into the metal endplates when coated with Hydroxapatite

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.

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.

Flexion / Extension Literature: Panjabi, White (1990) Prestige +/- 10 Degrees Prodisc +/- 20 Degrees M6 6 Degrees 20 ° Unlimited

Lateral Bending Literature: Panjabi, White (1990) Prestige +/- 10 degrees Prodisc +/- 20 degrees M6 6 degrees 15 ° Discover 42 °

Axial Rotation Literature: Panjabi, White (1990) 14 ° Unlimited

Posterior bullet Radius C L Lordosis L ordotic endplates Disc Height Heights: 5, 6, 7, 8, 9mm

Posterior bullet

L ordotic endplates

Heights: 5, 6, 7, 8, 9mm

Angled Flanges to fit anterior vertebrae Radius C L Lordosis L ordotic endplates Disc Height Heights: 6, 7 mm

Angled Flanges to fit anterior vertebrae

L ordotic endplates

Heights: 6, 7 mm

Zero Profile Implant Radius C L Lordosis L ordotic endplates Disc Height Heights: 5, 6, 7mm

Zero Profile Implant

L ordotic endplates

Heights: 5, 6, 7mm

Zero Profile Implant C L Lordosis Disc Height Heights: 3 Heights: 6mm, 7mm & 8mm 2 Footprints: Medium & Large

Endplate footprints Trapezoidal in shape Dovetail holding feature

Endplate footprints

Trapezoidal in shape

Dovetail holding feature

Endplate footprints Trapezoidal in shape

Endplate footprints

Trapezoidal in shape

All our procedures are performed in a minimally invasive manner. All discectomies are performed as a microdiscectomy as opposed to the traditional open discectomy. All patients receive a plastics closure and are followed closely afterwards

All our procedures are performed in a minimally invasive manner.

All discectomies are performed as a microdiscectomy as opposed to the traditional open discectomy.

All patients receive a plastics closure and are followed closely afterwards

Teamwork: All Procedures performed with both an Orthopaedic Spine Surgeon and a Neurological Surgeon

Thank you for your time. 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 1-8SPINECAL-1 www.beverlyspine.com

Thank you for your time.

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

1-8SPINECAL-1

www.beverlyspine.com