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11/4/16 Disclosures Consultant: Globus, Medtronic, Orthofix Adult - PDF document

Nov 15, 2023 •117 likes •324 views

11/4/16 Disclosures Consultant: Globus, Medtronic, Orthofix Adult Deformity: When to Consider a Royalty: Globus Smaller Procedure Dean Chou, M.D. Professor of Neurosurgery The UCSF Spine Center University of California San Francisco

  1. 11/4/16 Disclosures • Consultant: Globus, Medtronic, Orthofix Adult Deformity: When to Consider a • Royalty: Globus Smaller Procedure Dean Chou, M.D. Professor of Neurosurgery The UCSF Spine Center University of California San Francisco Degenerative problems vs deformity How to determine if it is a degenerative vs problems. deformity? • Manifestations can be same—back pain, leg/buttock pain • Understand pelvic parameters • Pain better sitting vs standing • Understand lumbar parameters • More walking = more pain • Understand sagittal balance • Thorough history • Diagnostic imaging • Diagnostic testing 1

  2. 11/4/16 Why it’s important to understand deformity After an L4-5 fusion even for a one level fusion Can’t stand up. Falling forward. • 80yo female • L4-5 spondylolisthesis • Failed conservative care. • Underwent single level L4-5 fusion Patients clearly needing re-alignment surgery 50 yo female s/p multiple prior surgeries 2

  3. 11/4/16 50 yo female s/p multiple prior surgeries 50 yo female s/p multiple prior surgeries • +SVA • Plan: • PI/LL Mismatch • 1) revision ALIF with more lordosis • Coronal imbalance • 2) Asymmetric PSO with simultaneous coronal and sagittal • Pseudarthrosis plane correction with temporary rod • 3) short segment rod to further induce lordosis • 4) 4-rod construct. After asymmetric PSO and revision ALIF 51 yo with prior fusion 3

  4. 11/4/16 Postop at 2 yrs. Post op What about no severe sagittal or coronal 2 surgeries done, no standing xrays ever taken balance issues? • 80 yo male with left leg pain • Injections—failed • PT—failed • Laminotomies—failed • Repeat laminotomies—failed • On high-dose narcotics for left leg radiculopathy 4

  5. 11/4/16 Left parasagittal MRI Mild scoliosis, but severe pain Pain completely • Pre-psoas approach gone. • Lateral interbody fusion • Percutaneous screws No approach- • No revision laminectomy related symptoms. Home POD #2 5

  6. 11/4/16 Advantages of interbody distraction Principles to keep in mind • Height restoration for severe foraminal up- • 36 inch films in all fusion patients down stenosis • Know lordosis you can get with each tool • Augment fusion rate • Correct coronal plane deformity Which interbody? ALIF VS TLIF • ALIF • TLIF/PLIF • Direct lateral--LIF 6

  7. 11/4/16 ALIF is better than TLI for the foramen and for lordosis • Retrospective x-ray ALIF vs. TLIF review What’s the data show? • ALIF improved foraminal height and segmental lordosis at each level Hsieh PC, J Neurosurg Spine. 2007 Oct;7(4):379-86 TLIF VS ALIF. Wash U Data TLIF VS ALIF. Wash U Data • TLIFs had great blood loss: • ALIFs had more lordosis restoration: • 2011 vs. 1281 mL, P = 0.0002 • 5.6° vs. -1.7°, P<0.0001 at L4-5 • 2.5° vs. -1.4°, P = 0.022 at L5-S1 • Spine (Phila Pa 1976). 2013 Feb 25. [Epub ahead of print] • Transforaminal versus Anterior Lumbar Interbody Fusion in Long Deformity Constructs: a matched cohort analysis. • Spine (Phila Pa 1976). 2013 Feb 25. [Epub ahead of print] • Dorward IG, Lenke LG, Bridwell KH, Oʼleary PT, Stoker GE, Pahys JM, Kang MM, Sides BA, Koester LA. • Transforaminal versus Anterior Lumbar Interbody Fusion in Long Deformity Constructs: a matched cohort analysis. • Dorward IG, Lenke LG, Bridwell KH, Oʼleary PT, Stoker GE, Pahys JM, Kang MM, Sides BA, Koester LA. 7

  8. 11/4/16 TLIF VS ALIF • At the L5-S1 level, radiographic results indicated that ALIF was superior to TLIF in its capacity to restore disc height, lumbar lordosis, What’s the data show for lateral sacral slope (decreasing pelvic tilt) surgery? • J Neurosurg Spine. 2010 Feb;12(2):171-7. doi: 10.3171/2009.9.SPINE09272. • Which lumbar interbody fusion technique is better in terms of level for the treatment of unstable isthmic spondylolisthesis? • Kim JS, Lee KY, Lee SH, Lee HY. Lordosis per level is about 3 degrees What about the coronal & sagittal plane? • 43 consecutive patients at HSS 8 patients with degenerative scoliosis (36 patients total) • 1-year f/u for DDD, spondy, or scoliosis • Pre- and postoperative regional lumbar coronal Cobb angles were 21.4° • 25 patients with scoliosis and 9.7°, respectively (p = 0.0004). • scoliosis angle correction was 10.4 degrees (P=0.001, • In the sagital plane, the mean segmental Cobb angle measured -5.3° 43%) preoperatively and -8.2° postoperatively (p < 0.0001). • mean correction of 3.7 degrees (P≤0.001) at each • The mean pre- and postoperative regional lumbar lordoses were 42.1° instrumented disc level in coronal plane and 46.2°, respectively (p > 0.05). • 2.8 degrees (P≤0.001) of lordosis at each level • Lateral interbody fusion does not improve regional lumbar lordosis or global sagittal alignment, despite great coronal correction. • Sharma AK,Lateral lumbar interbody fusion: clinical and radiographic outcomes at 1 year: a preliminary report. J Spinal Disord Tech. 2011 Jun;24(4):242-50. • Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. • Acosta F, J Neurosurg Spine. 2011 Jul;15(1):92-6. Epub 2011 Apr 8. 8

  9. 11/4/16 Remember your tools—even useful in a single level Smith-Petersen Osteotomy fusion • Ponte osteotomies • Cantilever • Lordose your rod • Compression without foraminal compromise Single-level posterior osteotomy 9

  10. 11/4/16 Degenerative stenosis & back pain Degenerative case—avoiding flatback Treatment? L2 to • Laminectomy alone ilium. • Laminectomy fusion L2-5 • Laminectomy fusion L2 to ilium Posterior • Laminectomy fusion T10 to ilium Induce • Laminectomy fusion T2 to ilium lordosis 10

  11. 11/4/16 One level fusion--revisted • 63 yo female with leg pain • Patient ambulates cautiously, with a modified gait, in a flexed forward posture. • s/p L4-5 fusion in 1974 at an OSH, who presents to the UCSF Spine Center with complaints of leg pain • The patient has AP and lateral standing scoliosis x-rays which demonstrate that the patient has a pelvic incidence of 50°, and lumbar lordosis of 20°, a pelvic tilt of 46°, and positive sagittal balance of 11 cm. 11

  12. 11/4/16 Further questioning • She has no back pain • She can stand “fairly straight” • Clinical examination shows knees and hips are straight 12

  13. 11/4/16 Treatment? Treatment plan • Pt does not want multi-level fusion • Key points are: • Fully release segment to correct the slip angle, aka lordosis • Do not fuse in the kyphotic position—flat back • Even though it ’s one segment, get as much as you can • Adding on top of prior fusion with kyphosis may tip patient over edge Single-level lateral fusion with Ponte/Smith Petersen Osteotomy. 13

  14. 11/4/16 Is it possible just to address Pt ODI down, “I can stand up straight”. the fractional curve only? The majority of disability is nerve compression in most patients Does everybody need T10 to the pelvis? The fractional curve Side bending films • 64 yo female • s/p 2 decompressions • Left leg pain • Scoliosis diagnosed as adolescent • Back pain manageable 14

  15. 11/4/16 MRI Left leg/buttock pain (L4-5) Failed 2 laminectomies Candidate for fractional curve treatment only • Does not want entire scoliosis addressed • More leg pain than back pain • Pt aware back pain may still be there 15

  16. 11/4/16 Does the cobb angle always need to be included in instrumentation? • L4-S1 ALIF to induce • 60 year old nurse lordosis • Severe back pain and unilateral leg pain • L4-S1 lami/fusion • Leg pain completely gone 16

  17. 11/4/16 Limited decompression with TLIF • L3-4 and L4-5. • Pt understood that entire scoliosis not addressed MIS applications in deformity surgery 17

  18. 11/4/16 79 yo female with left leg pain Fractional curve and MIS L4-S1 ALIF with MIS screws 18

  19. 11/4/16 69 yo with leaning to right, right leg pain, forward lean L3-S1 ALIF L3-pelvis MIS fixation Conclusions • Even a single level fusion can have profound effects on the patient • Keep deformity principles in mind when counseling patients—not L3 to necessarily change the surgery • Deformity techniques can be useful in limited, 1-2 level surgeries Pelvis • Although some patients need large, reconstructive procedures, the many degenerative spine patients are helped with nerve decompression • In patients without sagittal or coronal issues, limited fusion over compressed nerve levels is an option, especially in elder patients. 19

  20. 11/4/16 • Thank you. 20

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