Spine conditionsnew treatments. Ben Okafor FRCS FRCS.orth Consultant Orthopaedic Surgeon

Transcription

1 Spine conditionsnew treatments Ben Okafor FRCS FRCS.orth Consultant Orthopaedic Surgeon

2 Certainties of life Death Taxes Back pain

3 New Advances Minimal access surgery Indirect Lumbar decompression Dynamic Spine Stabilisation Kyphoplasty Disc replacement Fusion techniques Pain management

4 BUT BASIC PRINCIPLE UNCHANGED

5 Low back pain prevalence Croft et al BMJ % LBP stopped consulting at 3 months 50% Radicular pain improve by 6 weeks Deyo, Spine % relapsed at 12 months

6 Rx of Simple Low Back Pain Educational advice Symptom control Rapid return to usual activities (incl. work) Consider referral to -physiotherapists -osteopaths -chiropractors Address any psycho-social risk factors. Assess response to treatment

7 BACK PAIN poor responders Stress Obesity Smoker/alcoholism Depression Passivity Social/financial pressures Yellow flags

8 THERAPEUTIC EXERCISES Flexion exercises increase canal foramen;flexibility Extension eg Mckenzie Aerobic eg walking, cycle, swimming Core stability

9 simple low back pain Traumatic Referred pain Degenerative Inflammatory Infective Neoplastic Metabolic etc Causes

10 Referral guidelines Cauda equina - immediately Serious spinal pathology Progressive neurological deficit Nerve root pain that is not resolving after 6 weeks Recalcitrant/Recurrent back pain

11 Red flags Spine fracture Cancer or Infection Cauda equina syndrome

12 Red flags for cauda equina syn. Perianal/perineal sensory loss (Saddle anaes.) Bladder dysfunction (e.g. urine retention, increased frequency, overflow incontinence) Faecal incontinence Neurological deficit in the lower extremities Unexpected laxity of the anal sphincter

13 RED FLAG FOR SERIOUS PATHOLOGY Children, Elderly, Infirm, Inactive Violet trauma Non-mechanical: constant, progressive Thoracic pain; Night pain Weight loss; Unwell Cancer history Widespread neurology

14 OSTEOPOROTIC FRACTURES

15 OSTEOPOROTIC FRACTURES BACK PAIN PROGESSIVE DEFORMITY IMMOBILTY DISABILITY MEDICAL THERAPY BRACING?? KYPHOPLASTY

16 Indications Balloon Kyphoplasty is designed for patients with Vertebral Compression Fractures caused by: Primary Osteoporosis Secondary Osteoporosis Multiple Myeloma Bone Metastasis

17 Balloon Kyphoplasty Procedure

18 Step 1 Insertion of two balloons into the fractured vertebral body.

19 Step 2 Inflation of the balloons to create a cavity and perform fracture reduction.

20 Step 3 Filling the cavity, created by the balloons, with bone cement to obtain fracture fixation.

21 Step 4 The fracture is stabilised which facilitates patient mobility and gives fast pain relief.

22 Fast pain relief Stabilisation/correction deformity

23 Less back pain related health care visits Significant reduction in the number of back pain related health care visits when comparing the Balloon Kyphoplasty group with the control group. Kapserk C. et al; Treatment of Painful vertebral fractures by Kyphoplasty in patients with primary osteoporosis: a prospective nonrandomized controlled study, J Bone Miner Res 15: Grafe et al; Reduction of pain and fracture incidence after Kyphoplasty: 1-year outcomes of a prospective controlled trial with primary osteoporosis, Osteoporosis Int (2005) 16:

24 Less usage of narcotic pain medication The proportion of patients requiring narcotic medication significantly decreased after Balloon Kyphoplasty treatment (p<0.001). Ledlie J.T.; Kyphoplasty Treatment of Vertebral Fractures: 2-Year Outcomes show Sustained Benefits

25 Fast and sustained pain relief Complete pain relief is reported by 68% of the patients after one week and by 86% by 3-6 months post-operatively. This result is maintained for 2 years (90%). Ledlie J.T.; Kyphoplasty Treatment of Vertebral Fractures: 2-Year Outcomes show Sustained Benefits

26 Kyphoplasty- complication 1-5% Infection Cement leakage Radiculopathy Pulmonary emblosim Paralysis (rare) Refracture

27 Leakage rate vs other technique Balloon Kyphoplasty makes it possible to limit the risks for serious adverse events. Rod S Taylor, Rebecca J Taylor, Peter Fritzell, Balloon Kyphoplasty in the Management of Vertebral Compression Fractures: An Updated Systematic Review and Meta-analysis, report August 2006

28 How serious can leakages be Results of a large systematic review. More than 3650 treated levels were studied and analysed. Rod S Taylor, Rebecca J Taylor, Peter Fritzell, Balloon Kyphoplasty in the Management of Vertebral Compression Fractures: An Updated Systematic Review and Meta-analysis, report August 2006

29 PAIN SOURCE?

30 SACROILIAC PAIN FOCAL PAIN STRESS TEST 25% BACK PAIN

31 PYRIFORMIS SYNDROME TWISTING INJURY MUSCLE SPASM + SCIATIC NERVE COMPRESSION TENDERNESS SCIATIC NOTCH

32 NON-AXIAL PAIN QUATRATUS LUMBORUM LATERAL MUSCLE PAIN

33 FACET ARTHROPATHY FOCAL TENDERNESS PAIN ON EXTENSION FACET BLOCK

34 Facet degeneration Facet arthropathy Normal facet

35

36 DISC PATHOLOGY

37 DISC PATHOLOGY BACK PAIN BACK SPASM BACK GIVING WAY/INSTABILITY BACK STIFFNESS SCIATICA REFERED LEG PAIN NEUROLOGICAL SYMPTOMS/SIGNS

38 STERIOD INJECTION epidural root transforaminal facet PRONE POSITION PREFERABLE SEDATION TO REDUCE ANXIETY (XRAY ) KENOLOG 40mg-80mg Can be repeated Effect within 6 weeks

39 DISCOGRAM?DOUBT?YELLOW FLAGS SURGICAL PLANNING

40 Extruded disc herniation

41 Central disc herniation

42 Sequestrated disc herniation

43 Bulging/protruding disc herniation

44 Far lateral disc prolapse

45 Far lateral disc

46 Disc herniationsurgical indications Impairment of bowel/bladder function Gross motor weakness Evidence of increasing impairment of nerve conduction Severe sciatic pain despite 4-6 week treatment Recurrent sciatic pain

47 Discectomy Micro Mini laminectomy

48 % relief of sciatica with type of disc herniation age at operation (years) bulging protruded extruded % relief

49 Surgery on herniated disc results % relief pain Best results within 3 months Poorer results after 6 months ( nerve degeneration) Earlier return to work than conservative treatment Avoid neuropathic pain Improve neurology 5 % recurrence

50 ALGORITHM SCIATICA/NEUROLOGY decompression indirect Direct/Laminectomy Foraminotomy discectomy micro

51 Distraction devices X-STOP DIAM

52 80 year old LBP Leg pain Weakness COAD Mx?- Dx? Ix? Rx?

53 X STOP

54 X STOP indirect lumbar decompression Distracts and opens intervertebral foramen Distracts facet joint Relief of leg pain Foraminal and lateral stenosis Aged 65 plus Multiple co-morbidities

55

56 Back pain/disc tear/degeneration Moderate Dynamic stabilisation Disc replacement?? Fusion?? Thermal therapy????? Severe Fusion Disc replacement?

57 Recalcitrant back pain 40 year old healthcare assistant Recurrent LBP Giving way/spasms Numerous sick leave? Yellow flag? Waddell s? Mx?- Dx? Ix? Rx?

58 Recalcitrant discogenic Back pain Failed conservative Rx Options? Wallis ligament dynamic stabilisation Fusion Dynesis dynamic stabilisation Disc replacement

59 Surgical options-criteria Degree of disc degeneration/collapse Facet joint degeneration Degree of instability Need to decompress? Age Co-morbidities

60 WALLIS LIGAMENT

61 WALLIS LIGAMENT Recalcitrant back pain and leg pain Disc degeneration (at least 50 % height) Minimal facet joint disease Dynamic stabilisation Short surgery; quicker recovery Preserves fusion option

62

63

64

65 Wallis ligament indications Voluminous herniated disc in young adults Recurrent herniated disc Degenerative disc disease at a segment adjacent to fusion degenerative lesions Lumbar canal stenosis Contraindications advanced degenerative lesions Non-specific low back pain Spondylolisthesis L5-S1 Litigation Patent psychological disorders

66 SOFT DYNAMIC STABILISATION

67 DYNESIS dynamic stabilisation Back pain +- leg pain Disc tear/degeneration (at least 50% disc height preserved) Minimal facet foint disease Minimal spondylolisthesis Preserves fusion option Reported 70-80% satisfaction at 2 year

68

69 FUSION? INSTABILITY ADJUNCT TO DECOMPRESSION BONE DESTRUCTIVE LESIONS RECALCITRANT DISCOGENIC PAIN

70 ISTHMIC SPONDYLOLISTHESIS

71 SPINE FUSION

72 DISC REPLACEMENT Motion preservation??? Good early results Sympathetic/vascular/sexual dysfunction complication Long term results no better than fusion?

73 INTRADISCAL THERAPY/ IDET/COBLATION Heat annular defect Disorganise and shrink protein Destroy nociceptive fibres GOOD SHORT TERM RESULTS BETTER FOR LEG PAIN BETTER FOR SMALL DISC PROLAPSE POOR MEDIUM/LONG TERM RESULTS

74 Spine surgery results? RIGHT TIME RIGHT PATIENT RIGHT DIAGNOSIS RIGHT OPERATION RIGHT REHABILITATION