research work done on spine patients having incapacitating pain due to lumber spine instability including micro instability and macroinstability.

1. Operative
Management of
Incapacitating
lumber
Instability: A
short term
outcome of 25
cases
DR.ABU BAKAR SIDDIQUE
ASSOCIATE PROF.
MS,WOC-SICOT(INT) FELLOW
SPINE MICROSURGERY FELLOW
FELLOW SPINE DEFORMITY
CORRECTION(GANGA HOSPITAL)
BSSCON 2019

2. LUMBER INSTABILITY
• Lumber instability is
an important cause of
mechanical LBP &
can be associated
with substantial
disability.
Low back gluteal thigh
muscle pain.
BSSCON 2019

3. POORLY RECOGNIZED
The condition is poorly recognized
and diagnosed, hence the
diagnosis is often presumptive &
treatment options are empirical.
BSSCON 2019

4. Instability Vs Spondylolysthesis.
• Generally the ward
“Spinal instability” is
loosely use to indicate
spondylolysis and
spondylolysthesis but
the real clinical
scenario of spinal
instability is not
properly express and
explains by the ward
spondylolysis or
spondylolysthesis.
BSSCON 2019

5. Instability vs Spondylolysthesis
• The terminology Instability is
clinically based.
Spondylolysthesis are mostly
radiological diagnosis,
sometime it is overwhelmed –
sometime it is inadequate .
BSSCON 2019

6. Microinstability vs
macroinstability
• Microinstability is
exclusively a clinical
condition, no proven
radiological signs are there,
where as macroinstabilities
are well evident in imaging
though the facilities for true
dynamic view radiograph
and of MRI is questionable.
BSSCON 2019

7. Clinical Vs Radiological
instability
• So clinical instability
and radiological
instability is not
equivocal, here is the
dilemma.
• Spine surgeons are
facing the problems in
everyday practice
• Question is how to
deal with it?
BSSCON 2019

8. Panjabi et al 1992
3 systems 3 zones
BSSCON 2019

9. Panjabi et al: Def of SI
• Instabily not simply the hypermobility
of spine rather “a significant decrease
in the capacity of the stabilizing
system of the spine to maintain the
intervertebral neutral zones within the
physiological limits so that there is no
neurological dysfunction, no major
deformity, and no incapacitating pain”.
-Panjabi et al
BSSCON 2019

10. Gap zone
• In this study we have tried to
reduce the “Gap zone” between
the clinical and radiological
instability by a new proposal.
BSSCON 2019

11. For this
• We typified the clinicoradiological
instability into a clinical type
according to our set criteria.
BSSCON 2019

12. Objective of the study
• To evaluate the outcome of
instrumentation and fusion for the
management of incapacitating spinal
instability of selective type.
BSSCON 2019

13. Inclusion criteria
Incapacitating spinal
instability associated
with
-Spondylolysis.
-Isthmic, degenerative
and post operative
spondylolysthesis,
following disc and
decompression
surgeries.
BSSCON 2019

14. Exclusion criteria
• Dysplastic spondylolysthesis
• Spondylolysis or spondylolysthesis does
not fullfil our set criteria.
• Compression fracture, tubercular
spondylitis and tumor.
BSSCON 2019

15. Clinical variables
• Disabling low back, gluteal thigh pain.(n=22).
• Muscle spasm and rigidity of back and gluteal
region (n=25).
• Restricted and painful flexion, extension,
rotational and bending movement of back
(n=25).
• Sense of giving way back, wake up pain and
fatigue back pain (n=18)
• Palpable step (n=13
BSSCON 2019

16. Radiological signs of instability
A.Vertebral body angel in
ant.post motion >11 is
diagnostic
B.VB translation->2.5 mm
is pathognomic.
C.Loss of parallelism
D.Loss of sup .facet
contact<50% is
significant.
E.Interspinous widening.
F.Spinous rotaton
G.Open posterior joint in
bending view
BSSCON 2019

17. Faruk 45.post op degenerative
lysthesis L4/L5
BSSCON 2019

18. Radiological evaluation
• Facet arthropathy.
• Interspinous widening.
• Static and dynamic
translation(Antero
posterior and lateral)
of vertebral body.
• Facet joint contact.
• Horizontal expansion
of vertebral body.
BSSCON 2019

19. Faruk:45
Loss of parallalism After 4 months

20. NAZIR 34,SPONDYLOLYSIS L5,PLF
PRE OP ODI=75
BSSCON 2019

21. AFTER 3 WEEK
OF SURGERY
JUST BEFORE SURGERY
ODI -35BSSCON 2019

22. After 16 month
BSSCON 2019

23. Samsunnahar 55
Deg .lysthesis with incapacitatin
After
18
month
s
BSSCON 2019

24. ASAD
44
BSSCON 2019

25. Methodology
Prospective observational study
• A total 25 patients are selected for this
study.
• Study period: May 2016 to May 2019
• Study place : Private Hospitals in Dhaka
are of same standard.
• Average age: 48 years, Ranging from 34
to 67 years.
BSSCON 2019

26. Surgical Procedure
• Single handed
surgery done by
author following
standard protocol
• Prone position over
special spine
frame/traditional sand
bags with well padded
support.
• Posterior midline
incision
BSSCON 2019

27. Per operatives
• Focused on aetiopathology.
• If main pathology involving disc degeneration
PLIF was chosen.(n= 14 )
• If main pathology involving facet joints and disc
height is ok, degeneration is minimum PLF as
chosen.(n= 7)
• In isolated spondylolysis we have done
Instrumentation only (n=4).
•
BSSCON 2019

28. Socio demographic variable
Age
• Total population : 25
Male:16
Female:09
Sex
• Ranging from 36 to64 years
average age: 48 years
Occupation
Manual labour-03
Underground heavy worker-01
Farmar-07
Businessman-06
Football player -01
House wife-05
Teacher-02
BSSCON 2019

29. Results
• Average duration of surgery
was 3.25 hours,17 patients
required three units of fresh
human blood in peri
operative period, ODI score
were recorded for every
patients. Pre operatively
Vertebral body slippage
ware not measure.
BSSCON 2019

30. Results
• Excellent: 68% (n=17)
ODI-72/18,VAS-10/1.5,returned to works
by 6 to 12 weeks. happy and satisfied.
• Good: 24% (n=6)
ODI-68/24,VAS-10/3,returned works after
4 to 6 months, used to take analgesic
sometimes.
Poor: 8%(n=2).ODI-84/41,VAS-10/5,bed
ridden preopratively can walk and can
performs house hold works with difficulty
BSSCON 2019

31. Limitations
• Short follow up time
• Small sample size
• Populations are of heterogeneous group.
BSSCON 2019

32. Take home message
• Before decision making for surgery
thorough clinical and radiological
evaluation to be done.
• Signs of instabilities should be recorded .
True dynamic view X-Ray to be done in
every spine cases requires surgery to
exclude occult spondylolysis.
Aetiopathology base surgical planning
may be good option for a spine surgeon
BSSCON 2019

33. THANK
MY
MENTOR
BSSCON 2019

36. Set modalities of Surgery
Spondylolysis and isthmic
spondylolysthesis.
-Spinal instrumentation:
- instrumented fusion: Interbody type or
posterior gutter type.

37. Degenerative spondylolysthesis
• Decompression and instrumented fusion.
• Decompression done by laminectomy and
Posterior lumber interbody fusion done in
8 cases and posterior lumber fusion done
in 5 cases

38. Patient profile of post operative
spinal instability patients,(n=5)
no Previous
surgery
Previous
diagnosis
New
diagnosis
New surgery
done
3 Fenestration
and
discectomy
plid Post operative
degenerative
spondylolysth
esis
PLIF
1 Fenestration
and
discectomy
plid Isthmic
lysthesis
PLIF
1 Recurrent
disc
laminectomy Degenerative
spondylolysth
esis
PLIF

39. Clinical instability

40. Set criteria
• LBGT pain.
• Radiological
instability.
• Radiculopathy and
claudication pain.

41. • Painful translation of vertebra associated
with static and/or dynamic low back
gluteal thigh pain with radiculopathy and/or
claudication pain.

42. Macroinstability
• So in large scale we can say our concern
is regarding macroinstability not regarding
microinstability.

43. • Macroinstability does,t associated with
incapacitating pain and disability

44. • But in macro instability spine's inherent
elastic deferments is painful and
compensated by muscle spasm or other
protective & compensated mechanisms
are failed leading incapacitating LBP.

45. Variable
Age
Sex
Occupation
Duration of
suffering
Pre operative
ODI
Post operative
ODI score

46. Clinical features
Variable Fixation
(n=4)
PLF
(n= 7)
PLIF
(n= 14)
Preoperative
ODI
68 (average) 75 79

47. CT

48. • Though a large number cases of
spondylolysis & spondylolysthesis
remain painless and are found to be
functionally almost normal still there
are significant number of patients
with spinal instability are suffering
from incapacitating low back gluteal
thigh pain with radiculopathy and
neurogenic claudication.

54. pic

55. PANJABIS THEORY

56. Stability Vs Instability
• When this stabilization system
failed to compensate the
pathology, instability is evident.
• Kirkaldy Willis conceptualized
the three stages of
degeneration process
-Dysfunction
-Instability
-Restabilization

57. Other signs
A.Facet
arthropathy
B.Facet
degeration.
C.Facet oedema

59. FARUK

61. pic