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”
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