Nonfusion

European Continuing Medical Training (Brussels February 16th, 2005)

The «NON-Fusion»

in Lumbar Re-Stabilisation

LEFLOT Jean-Louis M.D.
University Hospital UCL Mont-Godinne
Military Hospital Queen Astrid (Brussels)

jean-louis.leflot@orto.ucl.ac.be

REFUSE TO FUSE ?

Heresy for an
Orthopaedic Surgeon ?


REFUSE TO FUSE ?
Accelerated degeneration
of the adjacent segments

Disorder of the
sagittal balance
NO …

BUT …


Dynamic Instability
M 42 Y
Discectomy L5S1 (6 Y ago)
PLIF + Post. Fusion (5 Y ago)
Material Removal (3 Y ago)

Severe repeating pains (2 Y ago)
- low back pains
- sciatic pains (L4, L5, S1)

« Pain Clinic » proposal … Neuro-Stimulator


Dynamic Instability

Disc degeneration L4L5 (L3L4)
Facet osteoarthritis
Disc protrusion
Spinal and foraminal stenosis

Dynamic Instability


Dynamic Instability

ALIF + Posterior Fusion (1 Y ago)

ALIF
- No intra-canalaire procedures
Spinal fibrosis prevention

- Respect of the posterior stay
Spinous process
Supraspinous ligament


Dynamic Instability

Future of the disc
L3L4 ?


Hypermobility above fusion !
PLIF : HIGH RISK !


Which are the solutions ?

Simple Discectomy ?

YES … BUT !
M 37 Y
Discectomy
L4L5 ,L5S1 (8 Y ago)
Chronic Low Back Pain and
sciatics


The Total Disc Arthroplasty ?


The Total Disc Arthroplasty
Goals of Lumbar TDA ?
! Pain relief

! Improved function

! Restoration of the sagittal balance

! Increased foramenal height

! Avoidance of adjacent level breakdown

! Longevity



The “TDA” maintain or restore segment mobility



• Avoids detrimental
stress being
transmitted to
neighboring
segments
• Counteracts early
degeneration of
these segments


The retro-peritoneal
approach is very
little dilapidating.

- It preserves the
lumbar muscles
- It avoids the
intraspinal fibrosis



« Minimal invasive surgery »
A very good view of the intervertebral space is possible
with a mini-access (5 cm)


DISCECTOMY

MOBILIZATION OF
THE SEGMENT


The « 4 in 1 »
instrumentation
Allows a precise
preparation for a
prosthesis of optimal size

Parallel Distraction
To determine the implant
height


(Small) DISTRESS !

L4L5

If I must go back there ?


There is not another way ?

DIAM
Device Intervertebral for Assisted Motion



M 40 Y

Chronic Low Back Pain and Irritation L4 Left

Intra- and Extraforaminal Disc Herniation



6 months after discectomy and DIAM L4L5
No more leg pain and goed relief of the lumbagos

Normal height of the intervertebral disc


Dynamic Stabilization
With pedicular screws
- GRAF
- DYNESIS

More extensive approach
Loosening
Articular lesions

With interspinous system
-DIAM - ISS
- WALLIS -U

Limited and easy access
No articular lesions

Completely reversible


Dynamic Effects

1. Reduce posterior loading
of the disc

2. Restore the posterior tension
band

3. Restore facets’ congruence

4. Restore foraminal height


BIOMECHANICAL STUDY

Static Tension
Cable will not rip through
silicone. Silicone stronger than
cable.

Static Compression
Silicone does not fail in
compression.

BIOMECHANICAL STUDY

Fatigue Testing
The DIAM device survives at
least 5 million cycles under
physiologic loads without
generating harmful wear
debris.


The « DIAM » : a little genius ?

The « DIAM » device

does not cut any bridge
for a secondary treatment


Surgical Procedure

Prone Position

Physiological Lordosis


Surgical Procedure

Limited and easy access
No articular lesions

Respect of the
supraspinous ligament

(Posterior Stay of the Lumbar Spine)


Surgical Procedure

Restoration of the
tension of the posterior
stay


Surgical Procedure

Distraction and Calibration

Setting in "Physiological"
tension of the Posterior Stay

More close possible of the facet
joints

X-ray Control (No kyfosis)


Surgical Procedure

Associated surgical procedures

Discectomy

Recalibration of the lumbar canal


Surgical Procedure

The « DEVICE »

Synthetic shock absorber

Silicone and Polyethylene


Surgical Procedure

POSITIONING


Surgical Procedure

POSITIONING
positioning of the implant more
close possible of the facet joints


Surgical Procedure

The « non rigid » fixation
Lacing of
the adjacent spinous processes

The "DIAM" offers

a mechanical supplementation by
non-rigid fixation

in moderate lumbar instabilities


INDICATIONS
DISCECTOMY HYPERLORDOSIS

- Massive herniated disc leading - Facet joints overloading
to substantial loss of disc material

- Recurrence of herniated disc

- Herniation of a transitional disc with
sacralization of L5

DEGENERATIVE DISC DISEASE

- Topping off above or below the fused
segment, to support newly created loads.

- Isolated Modic I lesion leading to chronic
low-back pain.


INDICATIONS
DISCECTOMY

Stabilization

in both

extension and flexion

-
L4-5, 0N Preload
10
Intact
8
Sagittal Angular Motion (degrees)

Discectomy without DIAM
6 Discectomy with DIAM

4

2

0

-2

-4

-6

-8
-8 -6 -4 -2 0 2 4 6 8
Extension Flexion
Moment (Nm)


INDICATIONS
Fem. 45 Y
3 Y after fusion L4-S1

Severe Low Back Pain
Improved by articular infiltration

Painless after DIAM


ANATOMICAL LIMITATIONS

L5S1

Isthmic
Spondylolysthesis

Previous laminectomy
with resection of the
laminae and spinous processes


CONCLUSIONS
•Simple and Safe
Good acceptability for surgeons and patients

•Dynamic and restorative
– The “TDA” maintains or restores the segment mobility

– The “DIAM” is a shock absorber allowing optimal
mechanical behavior in compression and flexion.
The “DIAM” restores the normal balance to the spine
providing stability and absorbing loads

•Mini-invasive


CONCLUSIONS

The « TDA » and the « DIAM »
represent a new concept of
« healing of disease » without
definitive irreversible destruction


Nonfusion

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