1. Dott. Nicola Zullo
UF Neurochirurgia Clinica Eporediese Policlinico di Monza
SS Neurochirurgia Ospedale U. Parini di Aosta
Responsabile: dott. C. Musso
2. • Central nucleus poloposus: proteoglycan + water
• Peripheral anulus fibrosus: concentric rings of
collagenous lamellae intermingled with fibrous fibers
• Avascular and aneural structure
• Nutrients mainly diffuse through vertebral endplate
3. • Losening of water content in the central NP,
progressive increase in fibrous fibers
• Cracking of the peripheral anulus fibrosus (anular
tears), Nitrogen incoming, nucleus polposus
expansion
• Areas of air density within the disc: due to nitrogen
incoming, are signs of advanced degeneration
• Possible outward extension of the nucleus polposus
through anular tears: disc disruption
• Height reduction
• Nerve and vascular ingrowth: discogenic back pain
• Discal degeneration leads to osseus degeneration
4. Progressive disc degeneration: loss of
disc height and inflammatory mediators
formation
Endplates closer to one another
Endplates fissuring and disruption
Formation of fibrovascular granulation
tissue, vascular density and sensory
nerve fibers increase
Facet joint hypertrophy and cartilage loss
Abnormal movement of the spinal
funcional unit
Osteophytes formation with central canal
and neuroforamina narrowing
Ligamentum flavum hypertrophy
5.
6. • Modic1: hyperintense in T2, hypointense in T1 w. Images; water content increase,
inflammatory response
• Modic 2: hyperintense in T1 and T2 w. Images; conversion of BM to adipose tissue due to
BM ischemia
• Modic 3: hypointense in T1 and T2 w. Images; subcondral bone sclerosis
7. • 21 patients treated with Xlif in one year
• Diagnosis: 19 DDD and 2 degenerative scoliosis
• Pre-operative clinical evaluation, ODI, VAS back and VAS leg administration
• Follow up criteria: diagnosis of DDD, clinical evaluation at 1 month post-op,
ODI, VAS back and VAS leg at three and six month post-op., X-ray films in a-p
and l-l at three month post-op.
• 15 patients matched the FU criteria and were enrolled in the study (8 males, 7
females).
11. • Ipsilateral transitorial muscular strength reduction: 6
• No major nerve injury, no wound infection, no spondylitis
• Numbness of the ipsilateral lower limb: 7 cases
• Numbness of controlateral lower limb: 2 cases
• Transitorial ipsilateral lower limb vasodilatation
• Implant disruption: 4 cases (3 8mm cages, 1 10 mm cage)
• Subsidence: 3 cases (1 patient worsened, two improved)
Remember the trajectory
during the cotrolateral
anulus fibrosus realease
manoeuvre
12. • Overall complication rate: form 2 to 30,4%
• Minor complications: about 20%
• Major complications: about 8.6%
• Most frequent complications: thigh symptoms from 0.7 to
60.1%
13. • DDD with disc bulging causing lumbar pain and/or raduclopaty
• After microsurgical erniectomy for recurrent disc erniation
• Alternative to PLIF:: prevention of muscular injury and denervation
• Alternative to TLIF: ligament sparing
• Alternative to ALIF: large surface and bone graft volume, with ALL
integrity, reduced risk of vascular injury
• Spondylolistesis less than grade 2.
Minimal access surgery: decrease blood loss, shorter operative
time, reduce post-op. pian, shorter recovery, rapid mobiization. low major
complication rate
