interspinous fusion devices. midterm results
TRANSCRIPT
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Interspinous Fusion Devices.
Midterm results.
ROME SPINE 2012, 7th International Meeting
Rome, 6-7 December 2012
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•Posterior distraction and decompression •Secure Fixation and Stabilization •Integrated Bone Graft Enclosure for Minimally Invasive Fusion •Option for Minimal invasive 360° Fusion
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Several IFD on the market ASPEN (LANX) ILIF (Nuvasive) CD HORIZON SPIRE (Medtronic)
PrimaLOK (Osteomed)
AXLE (Axis Spine) ROMEO®2 PAD (Spineart)
Allo-Span (SpineFrontier)
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- IFD stand alone: using bone from the decompression and the device
for the instrumentation, biomechanical tests showed ROM restriction
with a stabilizing result (Karahalios D.G. et al, J Neurosurg. Spine, 2010)
- Posterolateral fusion + IFD: significantly increasing fusion rate with
adjunctive instrumentation (Kornblum M.B. et al, Spine, 2004)
- ALIF (Anterior Lumbar Interbody Fusion)+ IFD: equivalent
biomechanical results to ALIF + bilateral pedicle screws (Wang J.C. et al, J.
Neurosurg., 2007)
- TLIF (Transforaminal Lumbar Interbody Fusion) with unilateral
pedicle screws + IFD: equivalent biomechanical stability to TLIF +
bilateral pedicle screws (Deutsche H, Neurosurg Focus, 2006)
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- TLIF (Transforaminal Lumbar Interbody Fusion) + IFD: similar ROM
respect to TLIF with unilateral pedicle screws + interspinous fusion
device, but lateral bending and axial rotation increased (Deutsche H,
Neurosurg Focus, 2006)
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Mild DLSS + NIC
Chronic Low Back Pain, DDD (Pfirrmann IV)
Spondylolisthesis grade 1 (stable on dynamic X-Ray)
Iatrogenic Instability
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Wang J.C. et al.: Comparison of CD HORIZON SPIRE spinous process
plate stabilization and pedicle screw fixation after anterior lumbar interbody
fusion. J Neurosurg Spine, 2006
32 patients
21 cases ALIF + IFD
11 cases ALIF + pedicle screws
Mean f.u.: 11 months (9-20)
IFD (CD HORIZON SPIRE):
Less blood loss
Shorter hospitalization
No failure hardware
No pseudoarthrosis increase
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Hardenbrook M.A.: Posterior fixation using an interspinous device for
the treatment of degenerative spine disease. Orthopaedics Today, 2010
Biomechanical and clinical studies show Aspen device for
decompression and fusion as a construct stability system comparable
to pedicle screws, but with fewer risks
Wokshoor A.: Aspen MIS system fusion rate. Presented at Western Neurosurgical
Society Annual Meeting (september 2012)
85 patients submitted to lumbar fusion with Aspen device
Mean f.u.: 24 months (18-30)
Posterior fusion detected on CT Scan of more than 85%
VAS preop 6.5
VAS postop 2.9
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Epstein N.E. : A review of interspinous fusion devices: High complication, reoperation rates, and costs with poor outcomes. Surg Neurol Int, 2012
Review literature studies over an average postop 23 – 42.9 months
4 Biomechanical studies (Sobottke R. et al: Spine J., 2009; Bowers C. et al: Neurosurg. Focus,
2010; Nandakumar A. et al: Spine J., 2010; Hartmann F. et al: Arch. Orthop. Trauma Surg., 2011)
- Reduction in flexion/extension, ROM increasing in lateral bending and axial rotation
- Radiographic improvement in foraminal area, at 1 – 2 yrs return to initial values
Complications rate:
- 11% devices related complication: device dislocation and spinous process fracture
(Barbagallo G.M. et al: Neurodurgery, 2009)
- 23% spinous process fracture at an average of 42.9 postop months (Bowers C. et al: Neurosurg. Focus, 2010)
- 22% spinous process fracture at CT Scan, asymptomatic in 50% (Kim D.H. et al: Spine 2010)
Reoperation rate:
58% in spondylolisthesis grade 1 (Weerhoof O.J., Eur. Spine J., 2008)
4.6% persisting pain (Kutcha J. et al: Eur. Spine J., 2009)
6% persisting pain at 3 months due to spinous process fracture (Kim D.H. et al: Spine 2010)
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Epstein N.E. : A review of interspinous fusion devices: High
complication, reoperation rates, and costs with poor outcomes. Surg Neurol
Int, 2012
Recurrent pain more than 50% (Brusee P. et al: Eur. Spine J., 2008; Weerhoof O.J., Eur.
Spine J., 2008; Kutcha J. et al: Eur. Spine J., 2009; Bowers C. et al: Neurosurg. Focus, 2010)
High Cost expensive
Criticism:
Epstein ‘s review included studies fucused only on
X-STOP
Aspen
Diagnosis: DLSS/NIC
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Kim H.J. et al.: Posterior Interspinous Fusion Device for One-Level Fusion
in Degenerative Lumbar Spine Disease : Comparison with Pedicle Screw
Fixation. J. Korean Neurosurg, 2012
76 patients
40 PLIF + IFD (CD HORIZON SPIRE, Medtronic)
- 26 spinal stenosis
- 12 spondylolisthesis grade 1
- 2 disc herniation with severe disc height loss
36 PLIF + pedicle screw
X-Ray dynamic evaluation at 1, 6, 12 months postop
CT Scan at 6 months
Bone fusion: trabecular bone on the sagittal view CT or an angle change of less
than 2 degrees in dynamic X-Ray (Zdeblick T.A., Spine 1993)
Mean f.u.: 14 months (12 – 22)
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Results
VAS preop: 7.1
VAS postop: 1.3
No difference in VAS improvement (better VAS improvement in IFD group immediate postop)
No difference in ODI improvement
Statistically significant ROM increase in pedicle screw group at upper adjacent segment (adjacent segment degeneration ?)
No difference bone fusion (≥ 90%)
Complications:
1 (2.5%) spinous process fracture (IFD)
2 (5%) hardware retropulsion (IFD)
3 (8%) deep infection (pedicle screws)
2 (5.5%) CSF leakage (pedicle screws)
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52 patients (17 male, 35 female)
Perioperative data and complications are
reported for all patients at 12 months
Clinical outcomes available for 43 patients
12 months radiographic data available for 38
patients
Patient Demographics
Age 69 (range 39 – 82)
Body Mass Index 27
Comorbidities
Diabetes 14%
Osteoporosis 5%
Smokers 10%
Prior lumbar Sx (treatment, or an adjacent level)
16%
Levels treated
• L1-2 (n=2, 3.8%)
• L3-4 (n=2, 3.8%)
• L4-5 (n=48, 92.3%)
The primary diagnosis for surgery was
stenosis: secondary diagnosis included
• 47% Spondylolisthesis grade 1 (X Ray stable)
• 35% Degenerative disc disease
• 15% Herniated nucleus pulpous
• 3% Degenerative scoliosis
Operative Data
Procedure time 69 (SD 30) minutes
Blood loss 93% <100 cc
Hospitalization 1.7 (SD 1.1) days
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Summary of Clinical Outcomes
n Pre-op
Mean (SD)
12-month
Mean (SD) % ∆ p
VASLEG 10 7.5 (3.4) 4.7 ( 4.4) 37% 0.191
VASBACK 8 7.1 (3.6) 2.9 ( 3.1) 59% 0.037
VASOVERALL 22 5.9 (1.8) 3.3 ( 2.6) 44% 0.001
ODI 37 43.2 (18.1) 23.0 (21.4) 47% <0.001
Complications
2 (3.8%) early wound complications occurring in the first 2 weeks postoperatively
• 1 infection requiring irrigation and debridement,
• 1 wound drainage responding to oral antibiotics
3 (5.7%) supplemental interventions of the surgical site
• 2 RF treatment for persistent pain
• 1 expanded decompression to treat recurrent stenosis
3 (5.7%) non-surgical site complications
• 1 vertebroplasty at a non-adjacent lumbar level after a traumatic incident 12 mo post-op
• 1 incident of cardiac arrest 2 weeks after surgery
• 1 incident of mild congestive heart failure 3 weeks after surgery
Minimal Clinical Important Difference
• ODI, MCID (score improvement >10 points) was
achieved in 75% of patients
• VAS, MCID (score improvement >2 points in any
VAS score) was achieved in 69.0% of patients
• 80% of patients achieved MCID improvements
with respect to either VAS or ODI outcomes
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Radiographic Review
There were no reports
• Graft fracture
• Plate fracture
• Spinous process fracture
• Plate migration
Graft migration was observed in 2/38 (5.3%)
Graft subsidence was documented in 2/38 (5.3%) levels
All patients with flexion/extension films (n=30) were stable in flexion/extension
Radiological observation of new bone growth
.
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Esses S.I.: Spine, 1993
- Screw misplacement: 5.2%
- Pedicle fracture and CSF leak: 4.2%
- Transient neuropraxia: 2.4%
- Permanent nerve root injury: 2.3%screw breakage: 2.9%
Lonstein J.E. et al: JBJS, 1999
- Screw misplacement: 5.2%
- Screw breakage: 2.2%
- Late-onset disconfort or pain due to pseudoarthrosis: 23%
- root irritation: 1%
- Pedicle fracture: 0.4%
- Dural tear: 0.4%
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Amiot L.P.: Spine 2000
- Screw misplacement: 15%
Jutte P.: Eur. Spine J., 2002
- Deep infection: 4.7%
- Screw misplacement: 6.5%
- Screw breakage: 12.4%
Shizas C.: Eur. Spine J., 2007
- Pedicle perforation in percutaneous procedure, after CT Scan: 23%
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62 yrs old female, 2 operations: 3 yrs f.u. FAILED BACK SURGERY
1) L4-L5, L5-S1 posterior instrumentation
2) ALIF
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In WELL SELECTED CASES, IFD could be considered as a viable
alternative to traditional posterior instrumented decompression and
fusion in mild DLSS and instability, also in aging population with
increased comorbidities
DO NOT PRECLUDED INCREASING SURGICAL STEPS (i.e.
PEDICLE SCREWS)
Improvements in clinic outcomes and minimal complications provide
confidence in the procedure’s success
Our experience: no significant fusion rate (X Ray, CT Scan), even
in case MICD (VAS, ODI)
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