Degenerative Disc Degenerative Disc Disease Disease

--360360οο Spinal FixationSpinal Fixation

GEORGE SAPKASASC. PROFESSOR

1st Orthopaedic DepartmentMedical School-Athens University

Attikon Hospital

Metropolitan Hospital

Athens Greece

GEORGE SAPKASASC. PROFESSOR

1st Orthopaedic DepartmentMedical School-Athens University

Attikon Hospital

Metropolitan Hospital

Athens Greece

Interverterbral Interverterbral disc space – foramendisc space – foramen

progressive stenosis and progressive stenosis and neural compressionneural compression

Disc - Facet degeneration - Disc - Facet degeneration - StenosisStenosis

DevelopmenDevelopmental DDDtal DDD

DegenerativeDegenerative

SpondylolisthesisSpondylolisthesis

Degenerative Adult Degenerative Adult ScoliosisScoliosis

Sites of pain origin

Investigations Investigations

Clinical Clinical RadiologiRadiological cal

Clinical Clinical evaluationevaluation

Imaging Imaging studiesstudies

Plain x-raysPlain x-rays Dynamic x-Dynamic x-raysrays

Myelogram Myelogram

CT - scanCT - scan 3D - scan3D - scan

MR-IMR-I

DiscograDiscogramm

Facet’s blockFacet’s block

Psychological investigationPsychological investigation

Pain drawingPain drawingPain drawing

M.M.P.I.M.M.P.I.

OswestryOswestry

Rolland MorrisRolland Morris

SP-36SP-36

Functional – Disability questionnaires

LUMBAR DDD LUMBAR DDD TREATMENT OPTIONSTREATMENT OPTIONS

Conservative treatmentConservative treatment

NSAIDSNSAIDS

Injections - Facet’s Injections - Facet’s BlockBlock

Epidural - Caudal Epidural - Caudal injectioninjection

BraceBrace

Psychological supportPsychological support

Social supportSocial support

Rehabilitation programm Rehabilitation programm

When do we operate the When do we operate the degenerative disease ?degenerative disease ?

1.1. Pain not responding to Pain not responding to conservative treatment, conservative treatment, lasting more than 3 lasting more than 3 monthsmonths

2.2. Non improving Non improving neurologic deficit neurologic deficit

3.3. Persistence or Persistence or deterioration of deterioration of symptoms of intermitent symptoms of intermitent claudicationclaudication

4.4. Significant restriction of Significant restriction of the common daily the common daily working and social working and social activitiesactivities

Operative Operative treatmenttreatment

--Options Options

DecompressioDecompression without n without

spondylodesia spondylodesia

Instability Instability 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% ptsptsIntensive painIntensive pain : 30% >> 3-6 : 30% >> 3-6 yrs popyrs pop

Ketz et al JBJS 1991Ketz et al JBJS 1991 Airaksihen et al Spine 1996 Airaksihen et al Spine 1996 Simpson et al JBJS 1993 Simpson et al JBJS 1993 Spivak et al JBJS 1998 Spivak et al JBJS 1998

ContraindicationContraindication : : multiple levelsmultiple levels Paine et al Clin Orthop 1976Paine et al Clin Orthop 1976 Sanderson et al JBJS 1993 Sanderson et al JBJS 1993

B. Facetectomy B. Facetectomy

Post Facetectomies – Laminectomies Post Facetectomies – Laminectomies InstabilityInstability

Extensive Facetectomies

Post Laminectomy Lumbar Instability

Post Laminectomies - Facetectomies Post Laminectomies - Facetectomies InstabilityInstability

Facetectomies

Lumbar Instability

Spondylodesia with internal Spondylodesia with internal fixationfixation

and postero-lateral graftingand postero-lateral grafting

Laminectomy + spondylodesiaLaminectomy + spondylodesia++

Transpedicular stabilization Transpedicular stabilization with with

semi-rigid rod (PEEK) and semi-rigid rod (PEEK) and postero-lateral graftingpostero-lateral grafting

Lumbar Lumbar Intervertebral Intervertebral

FusionFusion(PLIF – TLIF – X-(PLIF – TLIF – X-

LIF)LIF)

The goals are to:The goals are to:a)a) Restore the height of the Restore the height of the

intervertebral disc spaceintervertebral disc spaceb)b) Restore the width of the Restore the width of the

intervertebral foramenintervertebral foramenc)c) Achieve the maximum Achieve the maximum

stability and rigiditystability and rigidityd)d) Relocate Relocate

the subluxated the subluxated jointsjoints

e)e) Restore lumbar lordosisRestore lumbar lordosisf)f) Restore, close to normal Restore, close to normal

the loads on the anterior the loads on the anterior vertebral columnvertebral column

Laminectomy Laminectomy

+ + PLIFPLIF

Laminectomy- PLIF Laminectomy- PLIF and and

Transpedicular rigid Transpedicular rigid stabilizationstabilization

Laminectomy- PLIF Laminectomy- PLIF and and

Transpedicular hybrid Transpedicular hybrid stabilization stabilization

(rigid +dynamic)(rigid +dynamic)

B.T. – O. system +

Disc – O – Techexpandable cage

B.T. – O. system +

Disc – O – Techexpandable cage

Anterior-posterior Anterior-posterior decompression decompression and stabilizationand stabilization

Implants Implants

PYRAMID® Anterior Lumbar Plate

PERIMETER™ PEEK

CD HORIZON® SEXTANT® Fixation System

Minimally Invasive Minimally Invasive Lumbar Fusion & Lumbar Fusion &

FixationFixation

Minimally Invasive Minimally Invasive Lumbar FusionLumbar Fusion

Achieve the Achieve the same goals as same goals as open fusion open fusion while minimizing while minimizing approach-related approach-related morbidity morbidity (“fusion (“fusion disease”)disease”)

Sextant Sextant Rod Rod

InsertioInsertion n

SystemSystemFoley 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.

Clinical ApplicationClinical ApplicationMay be used anytime May be used anytime pedicle fixation is felt to be pedicle fixation is felt to be necessary and/or desirablenecessary and/or desirablePosterior supplementation Posterior supplementation for:for:

ALIF, ALIF, minimally invasive PLIF, minimally invasive PLIF, minimally invasive TLIFminimally invasive TLIF

Supplement to minimally Supplement to minimally invasive posterolateral invasive posterolateral fusionfusion

Sextant Rod Insertion Sextant Rod Insertion ProcedureProcedure

Initial incisionInitial incision

Sextant Rod Insertion Sextant Rod Insertion ProcedureProcedure

Awl and probe pedicleAwl and probe pedicle

Insert guide wiresInsert guide wires

Sextant Rod Insertion Sextant Rod Insertion ProcedureProcedure

Rod insertion incision and pathRod insertion incision and path

Sextant Rod Insertion Sextant Rod Insertion ProcedureProcedure

Insert rodInsert rod

Sextant Rod Insertion Sextant Rod Insertion ProcedureProcedure

Final Final constructconstruct

METRxMETRx – – Sextant Percutaneous Sextant Percutaneous

PLIFPLIF

TLIFTLIF

Adult degenerative Kyphosis – ScolioisisAdult degenerative Kyphosis – Scolioisis(+) Parkinson(+) Parkinson

X-LIFX-LIF

AxiaLIF Trans 1Axial Lumbar Interbody Fusion

Least invasive access

Safe, Reproducible, Pre-Sacral Approach

Soft-tissue sparingDynamic decompression via

distraction

Immediate rgid segmental stabilization

ConclusionsConclusions

360360οο Spinal Spinal fixationfixation

PLIF+ ALIFPLIF+ ALIF

XLIF + XLIF + Posterior Posterior StabilizatiStabilizati

onon

PLIF + PLIF + Posterior Posterior

StabilizationStabilization

TLIF + TLIF + Posterior Posterior StabilizatiStabilizati

onon

Trans 1 + Trans 1 + Posterior Posterior StabilizatiStabilizati

onon

No conclusions No conclusions are possible :are possible :

about the relative about the relative effectiveness of effectiveness of anterior, posterior, anterior, posterior, or circumferential or circumferential fusion. fusion.

Blumental SL, et al, Spine 1993Kant AP., et al, Spine 1995Schorfferman J. et al, Spine 2001Bono CM et al, Spine 2005Gibson JN, et al, Updated Cohraming Review, Spine 2005

University Hospital “ATTIKON”