Surgical Treatment of Low Back Pain & Sciatics LEFLOT Jean-Louis Lieutenant Colonel Orthopaedic Surgeon Military Hospital Queen Astrid Brussels 29 May 2008

LEFLOT Jean-Louis

Lieutenant Colonel

Orthopaedic Surgeon

Disc Herniation

Disc Hernia

Disc Hernia

Facet joints « Overloading »

Failure of the conservative treatment Medical treatment Physiotherapy Infiltrations « Pain Clinic »

Medical treatment

Physiotherapy

Infiltrations « Pain Clinic »

DISCECTOMY

DISCECTOMY Fibrosis

DISCECTOMY Thinning of the disc Recurrence of disc herniation Foramenal stenosis Facet joints « overloading »

Recurrence of disc herniation

Foramenal stenosis

Facet joints « overloading »

DIAM

DIAM Man 42Y Chronic Low Back Pain and Irritation L4 Left Intra- and Extraforamenal Disc Herniation

D evice I ntervertebral for A ssisted M otion 6 months after discectomy and DIAM L4L5 No more leg pain and good relief of the lumbagos Normal height of the intervertebral disc

DIAM INDICATIONS DISCECTOMY Massive herniated disc leading to substantial loss of disc material Recurrence of herniated disc Herniation of a transitional disc with sacralization of L5 DEGENERATIVE DISC DISEASE Topping off above or below the fused segment, to support newly created loads. Isolated Modic I lesion leading to chronic low-back pain. HYPERLORDOSIS - Facet joints overloading

DISCECTOMY

Massive herniated disc leading

to substantial loss of disc material

Recurrence of herniated disc

Herniation of a transitional disc with

sacralization of L5

DEGENERATIVE DISC DISEASE

Topping off above or below the fused

segment, to support newly created loads.

Isolated Modic I lesion leading to chronic

low-back pain.

Disc Arthroplasty Man 39Y ( Infantery )‏ Chronic Low Back Pain and Sciatic L5 right Disc Hernia L4L5 right Discopathy from levels L3L4, L4L5, L5S1 Severe L4L5 and L5S1

Disc Arthroplasty ALIF L5S1 + TDA L4L5 Only 1 approach (RetroPeritoneal Anterior) ! Control after 6 months No more lumbago & sciatic

The Total Disc Arthroplasty Goals of Lumbar TDA ?

The Total Disc Arthroplasty The “TDA” maintain or restore segment mobility

The Total Disc Arthroplasty Avoids detrimental stress being transmitted to neighboring segments Counteracts early degeneration of these segments

Avoids detrimental stress being transmitted to neighboring segments

Counteracts early degeneration of these segments

The Total Disc Arthroplasty The retro-peritoneal approach is very little dilapidating. It preserves the lumbar muscles It avoids the intraspinal fibrosis

The Total Disc Arthroplasty « Minimal invasive surgery » A very good view of the intervertebral space is possible with a mini-access (5 cm)‏

« Minimal invasive surgery »

A very good view of the intervertebral space is possible with a mini-access (5 cm)‏

The Total Disc Arthroplasty ?

Refuse to fuse ?

Refuse to fuse ?

NO … BUT … Accelerated degeneration of the adjacent segments Disorder of the sagittal balance ?

NO …

BUT …

Dynamic Instability Disc degeneration L4L5 (L3L4)‏ Facet osteoarthritis Disc protrusion Spinal and foramenal stenosis Dynamic Instability

Hypermobility above fusion ! HIGH RISK after PLIF !

ALIF is beter than PLIF Man 32 Y (Infantery)

ALIF is beter than PLIF ALIF restore : Disc Space & Lumbar Lordosis Foramenal Height Facet Decompression Combined Anterior & Posterior Fusion permits : Circonferential Fusion No intra-canalaire intrusion No risk of peri-neural fibrosis N.B. We can perform a DIAM stabilization above the fusion to avoid the hypermobility

ALIF

ALIF

ALIF

ALIF

ALIF

Conclusion Disc Hernia Disc Height Foramenal Height Fibrosis Sagital Balance

Disc Hernia

Disc Height

Foramenal Height

Fibrosis

Sagital Balance