When do we operate the degenerative disease ? Pain not responding to conservative treatment, lasting more than 3 months Non improving neurologic deficit Persistence or deterioration of symptoms of intermitent claudication Significant restriction of the common daily working and social activities

1. Degenerative Disc DiseaseDegenerative Disc Disease
--
360360οο
Spinal FixationSpinal Fixation
GEORGE SAPKAS
ASC. PROFESSOR
1st Orthopaedic Department
Medical School-Athens University
Attikon Hospital
Metropolitan Hospital
Athens Greece

2. InterverterbralInterverterbral
disc space – foramendisc space – foramen
progressive stenosis and neuralprogressive stenosis and neural
compressioncompression

3. Disc - Facet degeneration - StenosisDisc - Facet degeneration - Stenosis

4. DevelopmentalDevelopmental
DDDDDD

5. DegenerativeDegenerative
SpondylolisthesisSpondylolisthesis

6. Degenerative Adult ScoliosisDegenerative Adult Scoliosis

7. Sites of pain origin

8. InvestigationsInvestigations
ClinicalClinical
RadiologicalRadiological

9. Clinical evaluationClinical evaluation

10. Imaging studiesImaging studies

11. Plain x-raysPlain x-rays Dynamic x-raysDynamic x-rays

12. MyelogramMyelogram

13. CT - scanCT - scan 3D - scan3D - scan

14. MR-IMR-I

15. DiscogramDiscogram

16. Facet’s blockFacet’s block

17. Psychological investigationPsychological investigation
Pain drawing
Pain drawing
M.M.P.I.

18. OswestryOswestry
Rolland MorrisRolland Morris
SP-36SP-36
Functional – Disability
questionnaires

19. LUMBAR DDDLUMBAR DDD
TREATMENT OPTIONSTREATMENT OPTIONS

21. Conservative treatmentConservative treatment
NSAIDSNSAIDS
Injections - Facet’s BlockInjections - Facet’s Block
Epidural - Caudal injectionEpidural - Caudal injection
BraceBrace
Psychological supportPsychological support
Social supportSocial support
Rehabilitation programmRehabilitation programm

22. When do we operate theWhen do we operate the
degenerative disease ?degenerative disease ?
1.1. Pain not responding toPain not responding to
conservative treatment,conservative treatment,
lasting more than 3 monthslasting more than 3 months
2.2. Non improving neurologicNon improving neurologic
deficitdeficit
3.3. Persistence or deteriorationPersistence or deterioration
of symptoms of intermitentof symptoms of intermitent
claudicationclaudication
4.4. Significant restriction of theSignificant restriction of the
common daily working andcommon daily working and
social activitiessocial activities

23. OperativeOperative
treatmenttreatment
--
OptionsOptions

24. DecompressionDecompression
withoutwithout
spondylodesiaspondylodesia

25. InstabilityInstability
A. Total laminectomyA. Total laminectomy
Vertebral olisthesesVertebral olistheses (65% & 20%)(65% & 20%)
Johnson et al Spine 1992Johnson et al Spine 1992
Re-operationRe-operation : 17%: 17% ptspts
Intensive painIntensive pain : 30% >> 3-6: 30% >> 3-6 yrs popyrs pop
Ketz et al JBJS 1991Ketz et al JBJS 1991
Airaksihen et al Spine 1996Airaksihen et al Spine 1996
Simpson et al JBJS 1993Simpson et al JBJS 1993
Spivak et al JBJS 1998Spivak et al JBJS 1998
ContraindicationContraindication :: multiple levelsmultiple levels
Paine et al Clin Orthop 1976Paine et al Clin Orthop 1976
Sanderson et al JBJS 1993Sanderson et al JBJS 1993
B. FacetectomyB. Facetectomy

26. Post Facetectomies – Laminectomies InstabilityPost Facetectomies – Laminectomies Instability

27. Extensive
Facetectomies

28. Post Laminectomy Lumbar Instability

29. Post Laminectomies - Facetectomies InstabilityPost Laminectomies - Facetectomies Instability

30. Facetectomies

31. Lumbar Instability

32. Spondylodesia with internal fixationSpondylodesia with internal fixation
and postero-lateral graftingand postero-lateral grafting

33. Laminectomy + spondylodesiaLaminectomy + spondylodesia
++
Transpedicular stabilization withTranspedicular stabilization with
semi-rigid rod (PEEK) andsemi-rigid rod (PEEK) and
postero-lateral graftingpostero-lateral grafting

34. LumbarLumbar
IntervertebralIntervertebral
FusionFusion
(PLIF – TLIF – X-LIF)(PLIF – TLIF – X-LIF)

35. The goals are to:The goals are to:
a)a) Restore the height of theRestore the height of the
intervertebral disc spaceintervertebral disc space
b)b) Restore the width of theRestore the width of the
intervertebral foramenintervertebral foramen
c)c) Achieve the maximumAchieve the maximum
stability and rigiditystability and rigidity
d)d) RelocateRelocate
the subluxatedthe subluxated
jointsjoints
e)e) Restore lumbar lordosisRestore lumbar lordosis
f)f) Restore, close to normalRestore, close to normal
the loads on the anteriorthe loads on the anterior
vertebral columnvertebral column

36. LaminectomyLaminectomy
++
PLIFPLIF

37. Laminectomy- PLIFLaminectomy- PLIF
andand
Transpedicular rigid stabilizationTranspedicular rigid stabilization

38. Laminectomy- PLIFLaminectomy- PLIF
andand
Transpedicular hybrid stabilizationTranspedicular hybrid stabilization
(rigid +dynamic)(rigid +dynamic)
B.T. – O. system
+
Disc – O – Tech
expandable cage

39. Anterior-posterior decompressionAnterior-posterior decompression
and stabilizationand stabilization

40. ImplantsImplants
PYRAMID®
Anterior
Lumbar Plate
PERIMETER™
PEEK
CD HORIZON®
SEXTANT®
Fixation
System

41. Minimally Invasive LumbarMinimally Invasive Lumbar
Fusion & FixationFusion & Fixation

42. Minimally Invasive LumbarMinimally Invasive Lumbar
FusionFusion
Achieve the sameAchieve the same
goals as open fusiongoals as open fusion
while minimizingwhile minimizing
approach-relatedapproach-related
morbiditymorbidity
(“fusion disease”)(“fusion disease”)

43. SextantSextant
RodRod
InsertionInsertion
SystemSystem
Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle screw fixation of the lumbar spine.
Neurosurg Focus 10(4): 1-8, 2001.
Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results.
Journal of Neurosurgery 97(Spine 1): 7-12, 2002.

44. Clinical ApplicationClinical Application
May be used anytime pedicleMay be used anytime pedicle
fixation is felt to be necessaryfixation is felt to be necessary
and/or desirableand/or desirable
Posterior supplementation for:Posterior supplementation for:
ALIF,ALIF,
minimally invasive PLIF,minimally invasive PLIF,
minimally invasive TLIFminimally invasive TLIF
Supplement to minimallySupplement to minimally
invasive posterolateral fusioninvasive posterolateral fusion

45. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Initial incisionInitial incision

46. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Awl and probe pedicleAwl and probe pedicle
Insert guide wiresInsert guide wires

47. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Rod insertion incision and pathRod insertion incision and path

48. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Insert rodInsert rod

49. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Final constructFinal construct

50. METRxMETRx ––
Sextant Percutaneous PLIFSextant Percutaneous PLIF

54. TLIFTLIF
Adult degenerative Kyphosis – ScolioisisAdult degenerative Kyphosis – Scolioisis
(+) Parkinson(+) Parkinson

56. X-LIFX-LIF

61. AxiaLIF
Trans 1
Axial
Lumbar
Interbody
Fusion
Least invasive access
Safe, Reproducible, Pre-Sacral Approach
Soft-tissue sparing
Dynamic decompression via distraction
Immediate rgid segmental stabilization

63. ConclusionsConclusions

64. 360360οο
Spinal fixationSpinal fixation
PLIF+ ALIFPLIF+ ALIF
XLIF +XLIF +
PosteriorPosterior
StabilizationStabilization
PLIF +PLIF +
PosteriorPosterior
StabilizationStabilization
TLIF +TLIF +
PosteriorPosterior
StabilizationStabilization
Trans 1 +Trans 1 +
PosteriorPosterior
StabilizationStabilization

65. No conclusions areNo conclusions are
possible :possible :
about the relativeabout the relative
effectiveness of anterior,effectiveness of anterior,
posterior, orposterior, or
circumferential fusion.circumferential fusion.
Blumental SL, et al, Spine 1993
Kant AP., et al, Spine 1995
Schorfferman J. et al, Spine 2001
Bono CM et al, Spine 2005
Gibson JN, et al, Updated Cohraming Review, Spine 2005

66. University Hospital “ATTIKON”