Surgical Procedures of the Spine

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1 Surgical Procedures of the Spine Jaideep Chunduri, M.D. Orthopaedic Spine Surgeon Beacon Orthopaedics and Sports Medicine Beacon Spine Center Objectives Discuss the 4 most common procedures performed in the spine ACDF (Anterior Cervical Discectomy and Fusion Lumbar Laminectomy Lumbar Microdiscectomy Lumbar Fusion Discuss the following Indications Anatomy/Procedure Spine Consultant Theken Spine Disclosure Development of new products Study of different bone grafts Stryker Spine Education of representatives Teaching courses Aesculap Spine Consulting on changes in instrumentation 1

2 Cervical Spine and Anterior Cervical Fusion Cervical Spine Evaluation Work-up Complaint Physical Exam X-rays MRI Cervical Spine Evaluation Complaint and Physical Exam Neck Pain Arm Pain/Numbness/Tingling (radiculopathy) Myelopathy (cord abnormalities) Balance Unusual sensations Slow wide based gait 2

3 Cervical Spine Evaluation XRAYS Bone structure Alignment Lordosis Instability Cancer/Infection Fracture Cervical Spine Evaluation MRI/CT Myelogram Condition of discs Spinal stenosis/disc herniation Root impingement Myelomalacia Cancer/Infection Cervical Spine Treatment Primary Neck Pain Therapy/Injections Surgery Complete removal of painful disc Motion preservation (TDR) ACDF (gold standard) 3

4 Cervical Spine Treatment Primary Arm Symptoms PT, activity modification, education CESI Conservative care depends on degree of symptoms, degree of nerve compression, and initial response to CESI (studies will usually say 60% successful) Cervical Spine Treatment Primary Arm Symptoms Surgery Removal of disc and removal of herniated fragments and/or stenosis Motion preservation (Total Disc replacement) ACDF (Gold standard) Surgical Indications Persistent pain despite conservative care Progressive weakness Intractable Pain Myelopathy Tumor/Trauma 4

5 Cervical Spine Surgery ACDF Anterior Cervical Discectomy & Fusion Interbody Device (between the bones) Autograft (hip bone) Allograft (cadaver bone) Cage (metal/plastic) Anterior plating-increases increases chance of fusion Single level (+/-) 2 level and up (+) Cervical Spine Surgery ACDF Technique Patient position (neck slight extension) Arms tucked and placed under light traction Left (or right) sided transverse Safe approach to anterior cervical spine Complete removal of disc and decompression Interbody spacer/fusion device Autograft/Allograft/Cage Anterior plating (increases chance of fusion) Cervical collar Post-op op (soft or hard) Cervical Spine Surgery ACDF Approx 1 hour/level Outpatient to 2 day hospital stay 3-66 months to fusion Moderate success in reducing neck pain by >50% Excellent success in reducing arm symptoms by >80% 5

6 Cervical Spine Surgery Surgical Approaches to the Spine by Albert TJ, Balderston RA, Northrup BE, Artist Ashley PM; W.B. Saunders Company, 1997 Cervical Spine Surgery Surgical Approaches to the Spine by Albert TJ, Balderston RA, Northrup BE, Artist Ashley PM; W.B. Saunders Company, 1997 Cervical Spine Surgery Surgical Approaches to the Spine by Albert TJ, Balderston RA, Northrup BE, Artist Ashley PM; W.B. Saunders Company,

7 Cervical Spine Surgery Surgical Approaches to the Spine by Albert TJ, Balderston RA, Northrup BE, Artist Ashley PM; W.B. Saunders Company, 1997 Cervical Spine Surgery Spine Animation Anterior Cervical Discectomy and Fusion 7

8 Cervical Spine Case Studies Cervical Spine Case Studies Cervical Spine Case Studies 8

9 Cervical Spine Case Studies Lumbar Spine Pathologies and Treatments Herniated Nucleus Pulposus The progressive degeneration of a disc, or traumatic event, can lead to a failure of the annulus to adequately contain the nucleus pulposus This is known as herniated nucleus pulposus (HNP) or a herniated disc 9

10 Herniated Nucleus Pulposus Varying degrees Disc bulge Mild symptoms Usually go away with nonoperative treatment Rarely an indication for surgery Extrusion (herniation) Herniated Nucleus Pulposus Diagnosis Magnetic resonance imaging (MRI)/patient exam Nonoperative Care Initial bed rest Nonsteroidal anti- inflammatory (NSAID) medication Physical therapy Exercise/walking Steroid injections Herniated Nucleus Pulposus Surgical care Failure of nonoperative treatment Minimum of 6 weeks in duration Can be months Discectomy Removal of the herniated portion of the disc Usually through a small incision High success rate 10

11 Herniated Nucleus Pulposus Cauda Equina Syndrome Caused by a central disc herniation Symptoms include bilateral leg pain, loss of perianal sensation, paralysis of the bladder, and weakness of the anal sphincter Surgical intervention in these cases is urgent Grouped as spinal stenosis Narrowing of the central part of the spinal canal Spinal Stenosis Spinal Stenosis 11

12 Symptoms Back pain Pain, dysthesias, anesthesias in the buttocks, thighs, and legs Unilateral or bilateral Symptoms occur while walking or standing, and remit when sitting Spinal Stenosis Diagnosis MRI/computerized tomography (CT) scan/ patient examination Nonoperative care Rest NSAID medication Physical therapy Exercise/walking Steroid injections Spinal Stenosis Surgical care Failure of nonoperative treatment Minimum of 3-63 months duration Decompression Bone removal to widen area Laminectomy Foraminotomy High success rate Spinal Stenosis 12

13 Laminectomy Spinal Stenosis Laminectomy Spine Animation Spinal Stenosis with Herniated Disc Foraminotomy/Discectomy 13

14 Spine Animation Foraminotomy/Discectomy Spondylolisthesis listhesis Forward displacement Retrolisthesis Backward displacement Lateral listhesis Sideways displacement Instability Segmental Instability Spondylolisthesis A forward translation of 1 vertebral body over the adjacent vertebra Degenerative Adult-onset progressive slip Lytic Develops in children or adolescents, but only 25% experience symptoms Spondylolysis A fracture or defect in the vertebra, usually in the posterior elements most most frequently in the pars interarticularis 14

15 Spondylolisthesis Symptoms Low back pain With or without buttock or thigh pain Pain aggravated by standing or walking Pain relieved by lying down Other possible symptoms Tired legs, dysthesias, anesthesias Partial pain relief by leaning forward or sitting Spondylolisthesis Diagnosis Plain radiographs CT, in some cases with leg symptoms Nonoperative Care Rest NSAID medication Physical therapy CORE Strengthening Steroid injections Spondylolisthesis Surgical care Failure of nonoperative treatment Decompression and fusion Instrumented Posterior approach With interbody fusion 15

16 Degenerative Disease Occurs at all levels of the spine Asymptomatic degeneration in majority of the population Normal Degenerative Degenerative Disease The spinal structures most affected by degenerative disease are Intervertebral discs Articular facet joints These conditions are similar to osteoarthritis and d ti Degenerative Disc Disease Symptoms Low back pain and/or buttocks pain If leg pain also exists, there is likely an additional cause, e.g., HNP, stenosis, etc 16

17 Degenerative Disc Disease Diagnosis Patient examination MRI/X-ray Nonoperative care Rest for acute, low back pain NSAID medication Physical therapy Exercise/walking Low-impact aerobics Trunk strengthening Degenerative Disc Disease Surgical care Failure of nonoperative treatment Minimum of 6 weeks Fusion Removal of disc and replacement with bone graft, or a cage-filled bone graft, or a bone graft substitute Anterior approach Posterior approach Combined approach Arthroplasty Articulating disc replacement Lumbar Fusion Fusion procedure used to treat: Spondylolisthesis Spondylolysis DDD Multiple approaches Posterior, anterior, transforaminal, combined anterior/posterior 17

18 Posterior Lumbar Fusion Posterolateral fusion (PLF) Spondylolisthesis and spondylolysis without disc involvement Usually includes the use of screws/rods for stabilization until the fusion occurs Spine Animation Posterior Spinal Fusion Posterior Lumbar Fusion Posterior lumbar interbody fusion (PLIF) Used with disc involvement Usually includes the use of screws/ rods for stabilization until the fusion occurs Bone graft/cages 18

19 Spine Animation Posterior Lumbar Interbody Fusion (L5-S1) Posterior Lumbar Fusion Transforaminal lumbar interbody fusion (TLIF) Used with disc involvement with or without PLF Usually includes the use of screws/rods for stabilization until the fusion occurs Bone graft/cages Less soft-tissue tissue and bone trauma Spine Animation Transforaminal Lumbar Interbody Fusion 19

20 Anterior Lumbar Fusion Anterior lumbar interbody fusion (ALIF) Used with disc involvement Bone graft/cages/plates Done in conjunction with a vascular surgeon Spine Animation Anterior Lumbar Interbody Fusion (ALIF) Lumbar Arthroplasty Total disc replacement (TDR) DDD Contraindicated for spondylolisthesis and spondylolysis The CHARITÉ Artificial Disc is indicated for spinal arthroplasty in skeletally mature patients with DDD at one level from L4-S1. 20

21 Disc Replacement Disc Replacement-Used in Europe for Many Years Lumbar Disc Replacement with mixed results Cervical Disc Replacement recently approved?? Long Term Results Excellent short term results Insurance companies still consider experimental Spine Animation Disc Arthroplasty (Artificial Disc) What s new? Minimally Invasive Surgery Discectomy/Fusion through small incisions working through a tube or small retractor Less blood loss and muscle stripping This tends to be a marketing term rather than an actual surgical term. There is no definition. 21

22 What s new? Bone Morphogenic Protein (BMP)- prevent need for Iliac Crest Bone Graft Patients often complain of pain ICBG site more than the back FDA is keeping a close eye on this product Stem Cells from Bone Marrow (Symphony) Platelet Rich Gels WHY NEW TECHNOLOGY? Minimal blood loss results in less scarring Less patient morbidity Less muscle stripping Quicker recovery with shorter hospital stay BETTER LONG TERM RESULTS??? Emerging Technologies Nucleus Replacement with Annular Repair Gene Therapy Dynamic Stabilization Laser Surgery-this appears to be a marketing tool used by pain management physicians-there is no literature in the peer reviewed journals to support WILL THESE BE EFFECTIVE??? 22

23 THANK YOU If you have any questions, please contact my office (513) Websites with more information about spinal conditions spinesurgery.com Indications for Surgery Discectomy/Laminectomy Persistent pain despite surgical treatment Radiculopathy/Neurogenic Claudications Progressive Weakness Cauda Equina Syndrome Indications for Surgery Fusion Above conditions with evidence of instability Spondylolisthesis Scoliosis/Lateral Listhesis Need for a wide decompression Repeat surgery (Recurrent disc) Trauma/Tumor Back Pain is a significant component 23

24 500 E. Business Way Cincinnati, OH Harrison Avenue Cincinnati, OH (513) Spine Line (888) Toll Free QUESTIONS??? 24

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