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Degenerative Disc Disease - 360 Spinal Fixation

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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

Published in: Health & Medicine
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Degenerative Disc Disease - 360 Spinal Fixation

  1. 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. 2. InterverterbralInterverterbral disc space – foramendisc space – foramen progressive stenosis and neuralprogressive stenosis and neural compressioncompression
  3. 3. Disc - Facet degeneration - StenosisDisc - Facet degeneration - Stenosis
  4. 4. DevelopmentalDevelopmental DDDDDD
  5. 5. DegenerativeDegenerative SpondylolisthesisSpondylolisthesis
  6. 6. Degenerative Adult ScoliosisDegenerative Adult Scoliosis
  7. 7. Sites of pain origin
  8. 8. InvestigationsInvestigations ClinicalClinical RadiologicalRadiological
  9. 9. Clinical evaluationClinical evaluation
  10. 10. Imaging studiesImaging studies
  11. 11. Plain x-raysPlain x-rays Dynamic x-raysDynamic x-rays
  12. 12. MyelogramMyelogram
  13. 13. CT - scanCT - scan 3D - scan3D - scan
  14. 14. MR-IMR-I
  15. 15. DiscogramDiscogram
  16. 16. Facet’s blockFacet’s block
  17. 17. Psychological investigationPsychological investigation Pain drawing Pain drawing M.M.P.I.
  18. 18. OswestryOswestry Rolland MorrisRolland Morris SP-36SP-36 Functional – Disability questionnaires
  19. 19. LUMBAR DDDLUMBAR DDD TREATMENT OPTIONSTREATMENT OPTIONS
  20. 20. 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
  21. 21. 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
  22. 22. OperativeOperative treatmenttreatment -- OptionsOptions
  23. 23. DecompressionDecompression withoutwithout spondylodesiaspondylodesia
  24. 24. 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
  25. 25. Post Facetectomies – Laminectomies InstabilityPost Facetectomies – Laminectomies Instability
  26. 26. Extensive Facetectomies
  27. 27. Post Laminectomy Lumbar Instability
  28. 28. Post Laminectomies - Facetectomies InstabilityPost Laminectomies - Facetectomies Instability
  29. 29. Facetectomies
  30. 30. Lumbar Instability
  31. 31. Spondylodesia with internal fixationSpondylodesia with internal fixation and postero-lateral graftingand postero-lateral grafting
  32. 32. Laminectomy + spondylodesiaLaminectomy + spondylodesia ++ Transpedicular stabilization withTranspedicular stabilization with semi-rigid rod (PEEK) andsemi-rigid rod (PEEK) and postero-lateral graftingpostero-lateral grafting
  33. 33. LumbarLumbar IntervertebralIntervertebral FusionFusion (PLIF – TLIF – X-LIF)(PLIF – TLIF – X-LIF)
  34. 34. 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
  35. 35. LaminectomyLaminectomy ++ PLIFPLIF
  36. 36. Laminectomy- PLIFLaminectomy- PLIF andand Transpedicular rigid stabilizationTranspedicular rigid stabilization
  37. 37. Laminectomy- PLIFLaminectomy- PLIF andand Transpedicular hybrid stabilizationTranspedicular hybrid stabilization (rigid +dynamic)(rigid +dynamic) B.T. – O. system + Disc – O – Tech expandable cage
  38. 38. Anterior-posterior decompressionAnterior-posterior decompression and stabilizationand stabilization
  39. 39. ImplantsImplants PYRAMID® Anterior Lumbar Plate PERIMETER™ PEEK CD HORIZON® SEXTANT® Fixation System
  40. 40. Minimally Invasive LumbarMinimally Invasive Lumbar Fusion & FixationFusion & Fixation
  41. 41. 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”)
  42. 42. 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.
  43. 43. 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
  44. 44. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure Initial incisionInitial incision
  45. 45. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure Awl and probe pedicleAwl and probe pedicle Insert guide wiresInsert guide wires
  46. 46. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure Rod insertion incision and pathRod insertion incision and path
  47. 47. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure Insert rodInsert rod
  48. 48. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure Final constructFinal construct
  49. 49. METRxMETRx –– Sextant Percutaneous PLIFSextant Percutaneous PLIF
  50. 50. TLIFTLIF Adult degenerative Kyphosis – ScolioisisAdult degenerative Kyphosis – Scolioisis (+) Parkinson(+) Parkinson
  51. 51. X-LIFX-LIF
  52. 52. 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
  53. 53. ConclusionsConclusions
  54. 54. 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
  55. 55. 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
  56. 56. University Hospital “ATTIKON”

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