posterior spinal fusion - ahn.org · normal function of the spine conduit for spinal cord and...
TRANSCRIPT
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Posterior Spinal Fusion
Robert Liss MD Orthopaedic Institute
Allegheny Health Network
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Posterior Spinal Fusion
Definition Evolution Indications Techniques Complications/results Cases
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Normal Function of the Spine
Conduit for spinal cord and nerves Support the body weight and external load
– Stability Allow efficient motion of the body for
various activities – Flexibility – BALANCE in sagittal and coronal plane
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Spinal Disorders
Trauma
Tumor
Infection & Inflammatory Disease
Deformity
Degenerative
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Treatment of Spinal Disorders
Conservative Treatment – Degenerative disease – Stable fracture – Mild deformity
Surgical Treatment – Failed conservative treatment – Unstable fracture (dislocation) – Progressive deformity – Neurologic deficit
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Spinal Fusion
Restore stability Elimination of movement across a motion
segment by bone union
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Spinal instability
A state in which normal loads result in (painful) abnormal motion or deformity with the potential for damage to neurologic structures
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Clues to instability
>4mm translation on flexion/extension views
Excess angular motion Spondylolisthesis or retrolisthesis Traction spurs Abnormal flexion rhythm Radiographic progression of deformity
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Natural spine fusions
Congenital failure of segmentation Spontaneous ankylosis
– Post traumatic – Inflammatory, AS – Post infectious – Degenerative (DISH)
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DISH
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Post infection
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Ankylosing spondylitis
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Ankylosing spondylitis
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Posterior Spinal Fusion Posterior incision Joins together one or more vertebrae to
reduce pain and impart stability Requires bone graft or substitute Various techniques
– Posterolateral or intertransverse – Posterior interbody – Transforaminal interbody
+/- instrumentation Open or MIS
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Spinal fusion: History
Fred Albee 1911 bone grafting from tibia Russell Hibbs 1911 feathered lamina,
overlapping bone, later added iliac bone
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Posterior spinal instrumentation: History
Hadra 1891 wiring spinous processes Harrington-rod/hook 1960’s Cotrel-Dubousset segmental fixation Luque- sublaminar wires Roy-Camille 1970 pedicle screws Steffee 1980’s plate-screw Rod-screw constructs
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Harrington
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Flat back
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Luque
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Cotrel Dubousset Instrumentation
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Spinal Instrumentation
Adjunct to fusion May correct deformity Increases the chance of successful fusion
for multilevel procedures Anchor point: pedicle screw, laminar hook,
wire Rod or plate connecting points of fixation
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Spinal instrumentation today
Segmental fixation multiple pedicle screws Pelvic Dual contoured rods +/- interbody fusion/implant MIS option Image or robotic guidance
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Bone graft
Ideal graft provides both: – Osteoinduction- biological stimulus to bone
formation – Osteoconduction- scaffolding for bone
formation – Osteogenesis-cells forming bone
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Properties of Graft Materials Graft Osteogenic Osteo- Osteo- Materials Potential induction conduction Autogenous bone + + + Bone marrow cells + ? Allograft Bone ? + DBM + + BMPs + ? Ceramics + DBM = Demineralized bone matrix; BMP = Bone morphogenetic proteins
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Posterior approach fusion options
Posterolateral—graft over transverse processes and lateral to facets
Posterior—graft over laminae Facet—graft in facet joints Interbody—graft in disc space, can be
accessed directly posterior or transforaminal
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Posterior spine fusion
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Facet fusion
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Posterior approach interbody fusion
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interbody fusion
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Non fusion options
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Robotic guidance
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Jackson Spinal Surgery Table
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Posterior spinal fusion: Complications
acute – infection – neurologic – Dural injury – Medical complication – Dvt
chronic – adjacent segment
problems – Nonunion – imbalance
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JAMA. 2010;303(13):1259-1265. doi:10.1001/jama.2010.338
Complications: fusion
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Complications: PLIF
S. Okuda, et. al, J. Neurosurg:Spine/Volume 4/April, 2006
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Infection: incidence by technique
PLF vs PLIF 0.3 vs 1.37% – Ahn, DK et AL., J Spinal Disord Tech. 2012
Dec;25(8):E230-4 MIS vs open 0.24 vs 1.1%
– Gerard, E et al., SMISS 2011
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Neurologic complications: instrumentation injury
Pedicle screw – Use landmarks for starting point – Laminotomy to palpate pedicle – Probe, sound, tap, sound – EMG stimulation – Fluoroscopy – Image guidance – WOF pedicle fracture
Postop deficits: CT and remove errant hardware
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Figure 11a. Medial deviation of a pedicle screw.
Young P M et al. Radiographics 2007;27:775-789
©2007 by Radiological Society of North America
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Figure 11b. Medial deviation of a pedicle screw.
Young P M et al. Radiographics 2007;27:775-789
©2007 by Radiological Society of North America
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Neurologic: Instrumentation injury
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Complications: late
Recurrent herniation Arachnoiditis Adjacent segment degeneration Pseudarthrosis Instability
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Figure 21a. Symptomatic disk herniation at a level adjacent to instrumentation.
Young P M et al. Radiographics 2007;27:775-789
©2007 by Radiological Society of North America
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Young P M et al. Radiographics 2007;27:775-789
©2007 by Radiological Society of North America
Adjacent segment degeneration
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Case 1
49 y female with RA on steroids, methotrexate and Humira
Prior ACDF C5-6, TKR Unable to walk or stand > 20 minutes due to
back and bilateral leg pain PT, NSAIDs and LESI ineffective
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Degenerative spondylolisthesis, stenosis
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Degenerative Spondylolisthesis, stenosis
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Cervical stenosis, spondylolisthesis C7-T1
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Cervical stenosis
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Case 2, Trauma
24-year-old male with unfortunate dismount from trampoline
severe back pain neurologically intact
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24 y m L 4 burst fracture
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L4 burst
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L4 burst
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L4 burst
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L4 burst
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Case 3, Trauma
67-year-old male fell while constructing his tree stand
presented with upper back pain and no motor or sensory function below nipples.
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T4 burst
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T4 burst
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T4 burst
pre post
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Case 4 Isthmic Spondylolisthesis
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Isthmic Spondylolisthesis
6y po
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Case 5
26 year old female with 2 prior L5-S1 discectomies, chronic LBP
Back and bilateral leg pain No weakness in legs Perineal numbness Unable to void
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Recurrent HNP
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Recurrent HNP
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Spinal Fusion: Guiding principles
Primum non nocere “The goal of the OR should be to have a good
office” Fulfill your patient’s expectations
– Create realistic expectations – Don’t try to solve psychosocial problems with an
operation – Address the offending pathology at surgery
No role for exploratory surgery
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Goals of Spinal Surgery
Relieve pain by eliminating the source of problems (decompression)
Stabilize the spinal segments after decompression when necessary – pay attention to sagittal and coronal alignment – Prevent the progression of deformity of the spine
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Call in by AM. Fused by PM. Same-day fixes are available now.
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Thank You!