ΕΚΦΥΛΙΣΤΙΚΕΣ ΠΑΘΗΣΕΙΣ (DEGENERATIONS) ΕΠΙΠΛΟΚΕΣ (COMPLICATIONS)

1. LLuummbbaarr IInnssttaabbiilliittyy
CCaauusseess -- DDiiaaggnnoossiiss -- MMaannaaggeemmeenntt
GGeeoorrggee SSaappkkaass
AAsscc.. PPrrooffeessssoorr
11sstt OOrrtthhooppaaeeddiicc DDeeppaarrttmmeenntt
AAtthheennss MMeeddiiccaall SScchhooooll

2. Lumbar Instability
• Clinical
• Radiological

3. Clinical Lumbar Instability
• Not any specific definition
• … the condition that the
patient feels that his back
is unstable
White A. & Panjabi M.
Clinical Biomechanics of the Spine 1980

4. Radiological Instability
• Spondylolysis
• Spondylolisthesis
• Adult Degenerative
Scoliosis
• Post-Laminectomy

5. Lumbar Instability
The main cause
of lumbar instability
in adults is the instability
of the spine that follows
the operative treatment
of lumbar stenosis

6. ETIOLOGY
OF THE
LUMBAR
STENOSIS

7. Lumbar Stenosis
-
Developmental

8. Lumbar
Stenosis
-
Degenerative
Spondylolisthesis

9. Lumbar Stenosis
-
Isthmic Spondylolisthesis

10. Lumbar Stenosis
-
Congenital

11. Lumbar Stenosis
-
Degenerative Adult Scoliosis

12. Etiology of Lumbar Stenosis
AAdduulltt
ssccoolliioossiiss
Congenital
IIsstthhmmiicc
SSppoonnddyylloo
lliisstthheessiiss
DDeevveellooppmmeennttaall
DDeeggeenneerraattiivvee
SSppoonnddyylloolliisstthheessiiss

13. Foramen

14. Interverterbral Disc Space -
Foramen

15. LUMBAR STENOSIS
TREATMENT
• CONSERVATIVE
• OPERATIVE

16. Conservative treatment
• NSAIDS
• Injections - Facet’s Block
• Epidural - Caudal injection
• Brace
• Psychological support
• Social support

17. Operative
treatment

18. Laminectomy without stabilization

19. Laminectomy
associated with
Transpedicular Stabilization

20. Laminectomy associated with PLIF

21. Laminectomy
associated with
PLIF and Transpedicular stabilization

22. Causes of Failure
•Pre-operative
•Intra-operative
•Post-operative

23. Preoperative causes of failure
•Wrong diagnosis
•Pre-existing conditions
associated with
increased operative risk
or
difficulties

24. Wrong diagnosis
• Infection
• Tumor
• Other causes of pain
• Psychological –
social problems

25. Infection Tumor

26. Other causes of pain

27. Psychological – Social
problems

28. Pre-existing conditions associated with
increased operative risk or difficulties
I. Deformities e.g. scoliosis,
spondylolysis,
spondylisthesis
II. Infections or tumors
III. Previous discectomies
IV. Previous laminectomies
V. Previous lumbar fusions
VI. Previous operated spinal
deformities
VII. Pre existing instabilities
VIII.Inadequate investigation
• Clinical
• Radiological

29. Intra-operative causes of failure
• Hemorrhage
• Facets’ – pedicles’
destruction
• Screws misplacement
• Battered nerve roots
• Osteoporosis
• Graft’s quality and
quantity
• Inadequate
decompression

30. Post-operative
causes of failure

31. Early post-operative causes of failure
(0 – 3 wks)
•Haematoma
•Infection
•Implants’
failure

32. Late post-operative causes of failure
(a. 3wks – 3mths)
• Implants‘ failure
– Screws
• loosening
• Broken
• Dislodged
– Rods
• Broken
• Destabilization
• Infection

33. Late post-operative causes of failure
(b. > 3mths)
• Implants failure
• Destabilization
– at the level(s) of the operation
– at the level above -//-
– at the level below -//-
• Pseudarthrosis
• Recurrence of stenosis
• Late infection

34. Consequences

35. Intra-operative
• Removal of the
ligamentous and bony
structures destabilizes
the lumbar spine
• Instability discovered
intra-operatively extends
the operative time.

36. • In case of pre-existed
pathology e.g.
osteoporosis,
tumor,
infection
• The fixation of the
implants is not safe
• The dissemination
(malignant tumor)
is very likely

37. Post-operative
•Immediate
•Early
•Late

38. Immediate / early
post operative
• Unchanged symptoms
• Recurrence of -//-
• Deterioration of -//-

39. Late post-operative
a. Instability

40. b. Recurrence of
stenosis
±
neurologic deficit

41. c. Pain
Post-operative failures due to:
–Buttered nerve roots
–Muscles destruction
–Implants failure
–Instability
cause
a. considerable
back and leg pain
b. disability

42. Neurologic compromise:
•Recurrence of stenosis
•Instability
– May lead to anterioposterior or lateral
subluxation – displacement.
The abnormal spatial relationship is
achieved at the cost of spaces
through which the nerve roots of
the cauda equina travel in their
course from the spinal cord
to and through the neural foramen:
injury to the nerve root(s)
may result.

43. Management

44. Investigations
•Clinical
•Radiological
•Psychological - Social

45. Clinical examination
• Medical evaluation
• Neurological
investigation

46. Radiological investigation
• Plain x-rays
• Dynamic x-rays
• CT- scan
• M.R.I.
• Discograms
• Scanning
• Local injections

47. Conservative treatment
• NSAIDS
• Brace
• Injections – Facets’ Blocks
• Epidural – Caudal injections
• Epidural endoscopy
(pain management)
• Back schools
• Psychological – Social support

48. Local injections
• Epidural
• Caudal
• Facet’s block
Unpredictable results
Temporary improvement
and
Limited satisfaction

49. Operative treatment

50. Intra-operative:
• When the spinal
instability is recognized
intra-operatively
consideration should be
given to perform
spondylodesia
with or without
instrumentation

51. Post Laminectomy Instability

52. Revision surgery
for
post-laminectomy instability

53. Revision surgery
for
post-operative
instability
(above or below
the operated level)

54. Cases

55. 1st case
Degenerative Spondylolisthesis – Lumbar Stenosis

57. Instability at the level above the spondylodesia

58. Extension of the spondylodesia

59. 2nd case
Lumbar Fracture Laminectomy & Plif without
internal fixation

60. Facetectomies - Lumbar Instability

61. Facetectomies

62. Lumbar Instability

63. Lumbar Instability

64. Treatment: Transpedicular Internal Fixation

65. 3rd case
Post Facetectomies – Laminectomies
Instability

66. Extensive Facetectomies

67. Post Laminectomy Lumbar Instability

68. Treatment: Transpedicular Internal Fixation

69. 4th case
Post Laminectomies - Facetectomies
Instability

70. Facetectomies

71. Lumbar Instability

72. Treatment: Transpedicular Stabilization

73. Conclusions

74. I. Careful pre-operative evaluation is
mandatory to realize the underlying
pathology

75. II. The frequency of
instability
complicating lumbar
laminectomy is higher
in patients with:
• pre-existing pars defect
(spondylolysis -
sthesis)
• Spondylolisthesis
• Congenital or
developmental lumbar
stenosis

76. III. Removal of the least
possible of the bone
(facets) and soft
tissues (ligaments &
facets capsule)
is essential in the
prevention of
instability following
lumbar laminectomy

77. IV. Instability complicating
lumbar laminectomy
can be avoided if the
surgeon proceeds in
spondylodesia of the
affected levels with or
without
instrumentation
in case that instability
is encountered
intra-operatively

78. VV.. PPLLIIFF ++ IInntteerrnnaall SSttaabbiilliizzaattiioonn pprroovviiddeess
ssttaabbllee PPoosstt LLaammiinneeccttoommyy ssppiinnaall lleevveellss

79. VVII..SSttaabbiilliittyy ooff tthhee ssppiinnaall lleevveell aabboovvee tthhee
rriiggiidd ttrraannssppeennddiiccuullaarr ssttaabbiilliizzaattiioonn ccaann bbee
pprroovviiddeedd bbyy tthhee iinntteerrssppiinnoouuss iimmppllaannttss

80. VII.The stabilization
of the affected
level is associated
with better results
in the following
conditions:

81. A. Lumbar stenosis associated with
degenerative spondylolisthesis

82. B. Lumbar sstteennoossiiss aassssoocciiaatteedd
wwiitthh aadduulltt ssccoolliioossiiss

83. CC.. RReevviissiioonn ssuurrggeerryy