When do we operate the degenerative disease ?
Pain not responding to conservative treatment, lasting more than 3 months
Non improving neurologic deficit
Persistence or deterioration of symptoms of intermitent claudication
Significant restriction of the common daily working and social activities
21. Conservative treatmentConservative treatment
NSAIDSNSAIDS
Injections - Facet’s BlockInjections - Facet’s Block
Epidural - Caudal injectionEpidural - Caudal injection
BraceBrace
Psychological supportPsychological support
Social supportSocial support
Rehabilitation programmRehabilitation programm
22. When do we operate theWhen do we operate the
degenerative disease ?degenerative disease ?
1.1. Pain not responding toPain not responding to
conservative treatment,conservative treatment,
lasting more than 3 monthslasting more than 3 months
2.2. Non improving neurologicNon improving neurologic
deficitdeficit
3.3. Persistence or deteriorationPersistence or deterioration
of symptoms of intermitentof symptoms of intermitent
claudicationclaudication
4.4. Significant restriction of theSignificant restriction of the
common daily working andcommon daily working and
social activitiessocial activities
25. InstabilityInstability
A. Total laminectomyA. Total laminectomy
Vertebral olisthesesVertebral olistheses (65% & 20%)(65% & 20%)
Johnson et al Spine 1992Johnson et al Spine 1992
Re-operationRe-operation : 17%: 17% ptspts
Intensive painIntensive pain : 30% >> 3-6: 30% >> 3-6 yrs popyrs pop
Ketz et al JBJS 1991Ketz et al JBJS 1991
Airaksihen et al Spine 1996Airaksihen et al Spine 1996
Simpson et al JBJS 1993Simpson et al JBJS 1993
Spivak et al JBJS 1998Spivak et al JBJS 1998
ContraindicationContraindication :: multiple levelsmultiple levels
Paine et al Clin Orthop 1976Paine et al Clin Orthop 1976
Sanderson et al JBJS 1993Sanderson et al JBJS 1993
B. FacetectomyB. Facetectomy
26. Post Facetectomies – Laminectomies InstabilityPost Facetectomies – Laminectomies Instability
35. The goals are to:The goals are to:
a)a) Restore the height of theRestore the height of the
intervertebral disc spaceintervertebral disc space
b)b) Restore the width of theRestore the width of the
intervertebral foramenintervertebral foramen
c)c) Achieve the maximumAchieve the maximum
stability and rigiditystability and rigidity
d)d) RelocateRelocate
the subluxatedthe subluxated
jointsjoints
e)e) Restore lumbar lordosisRestore lumbar lordosis
f)f) Restore, close to normalRestore, close to normal
the loads on the anteriorthe loads on the anterior
vertebral columnvertebral column
42. Minimally Invasive LumbarMinimally Invasive Lumbar
FusionFusion
Achieve the sameAchieve the same
goals as open fusiongoals as open fusion
while minimizingwhile minimizing
approach-relatedapproach-related
morbiditymorbidity
(“fusion disease”)(“fusion disease”)
43. SextantSextant
RodRod
InsertionInsertion
SystemSystem
Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle screw fixation of the lumbar spine.
Neurosurg Focus 10(4): 1-8, 2001.
Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results.
Journal of Neurosurgery 97(Spine 1): 7-12, 2002.
44. Clinical ApplicationClinical Application
May be used anytime pedicleMay be used anytime pedicle
fixation is felt to be necessaryfixation is felt to be necessary
and/or desirableand/or desirable
Posterior supplementation for:Posterior supplementation for:
ALIF,ALIF,
minimally invasive PLIF,minimally invasive PLIF,
minimally invasive TLIFminimally invasive TLIF
Supplement to minimallySupplement to minimally
invasive posterolateral fusioninvasive posterolateral fusion
45. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Initial incisionInitial incision
46. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Awl and probe pedicleAwl and probe pedicle
Insert guide wiresInsert guide wires
47. Sextant Rod Insertion ProcedureSextant Rod Insertion Procedure
Rod insertion incision and pathRod insertion incision and path
65. No conclusions areNo conclusions are
possible :possible :
about the relativeabout the relative
effectiveness of anterior,effectiveness of anterior,
posterior, orposterior, or
circumferential fusion.circumferential fusion.
Blumental SL, et al, Spine 1993
Kant AP., et al, Spine 1995
Schorfferman J. et al, Spine 2001
Bono CM et al, Spine 2005
Gibson JN, et al, Updated Cohraming Review, Spine 2005
