Spine motion preservation

1. Dr. Bahaa Ali Kornah Prof.. Of Orthopedic Al-Azhar University Cairo - Egypt

2. Dr. Bahaa Ali Kornah Prof.. Of Orthopedic Al-Azhar University Cairo - Egypt bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

3.  Introduction  Methods  Total disc replacement  Nucleus replacement  Interspinous spacer devices  Pedicle screw based stabilization devices  Total facet replacement system  Autologus disc chondrocyte transplantation bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

4. EACH VERTEBRA HAS THREE FUNCTIONAL COMPONENTS: bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

5. The verbral body • Weight bearing • Compression side The neural arch • neural elements protection • tension band side Body process es • Site of muscle and ligamentous attachment • increase the efficiency of muscle action bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

6. functional spinal unit A functional spinal unit (FSU) (or motion segment) is the smallest physiological motion unit of the spine to exhibit biomechanical characteristics similar to those of the entire spine. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

7. functional spinal unit -2 adjacent vertebrae. -Intervertebral disc. -The connecting ligaments. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

8. Biomechanics of spinal motion bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

9.  Movements of the lumbar spine  Stability of the lumbar spine  Forces acting on the lumbar spine bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

10. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

16.  Treatment for Axial Backache Secondary to Degenerative Disc Disease (DDD) (Fritzell et al. 2002, 2001 Volvo Award) FUSION bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

17.  Spinal fusion is the gold standard treatment of patients with disabling low back pain due to degenerative disc disease not responding to conservative therapy. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

18.  The Rational for Fusion in DDD The relief of backache through acceleration of the lumbar degenerative cascade to its end stage Ideally,  allowing adequate room for the neural elements and  preserving the normal sagittal alignment bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

20.  Problems regarding fusion surgery for axial backache Symptomatic accelerated degeneration of the adjacent segments above or below the fused levels for the young patient and even the elder bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

21. Fusion procedures have -ve side effects ➢Abnormal segmental sagittal alignment+ Adjacent segment degeneration ➢Increase intradiscal pressure ➢Hyper mobility above and below fused segment ➢ Superior segment facet joint violation, ➢Adjacent segment spondylarthrosis with consecutive spinal canal stenosis ➢persisting pain from harvesting of the Autologus bone graft Causing bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

22. development of new clinical symptoms that correspond to radiographic changes adjacent to the level of a previous spinal fusion. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

25.  Problems regarding fusion surgery for axial backache: The most critical one The persistent dissociation between radiographic success of fusion and clinical outcome (pain and return): 95% radiographic fusion vs. 60 to 80% of clinical success Prime motivator to look for alternative means bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

26. FUSION IS GOOD, BUT MOTION IS BETTER. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

27. NONFUSION SURGERY = MOTION PRESERVATION SURGERY = FUNCTIONAL SURGERY bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

28.  This new category of Thoracolumbar spinal surgery focuses on the concept of  Maintaining or  Restoring Intervertebral motion in a controlled fashion, whether by restricting the extremes of spinal movement or by dampening the kinetic energy involved in motion.  The goal of these surgeries is to mimic the behavior of the healthy spinal column. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

29. 1. Total disc replacement (TDR) 2. Nucleus replacement 3. -Interspinous spacer devices 4. Pedicle screw based stabilization devices 5. Total facet replacement system 6. Autologus disc chondrocyte transplantation bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

30. Most of these Devices are under trial and several controlled prospective studies are ongoing to assess the effectiveness of these devices. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

31. Surgical modalities preserving spinal motion include, - Total disc replacement -Nucleus replacement -Interspinous spacer devices -Pedicle screw based stabilization devices -Total facet replacement system -Autologus disc chondrocyte transplantation bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

33.  Two of the most important fundamental objectives of replacement arthroplasty 1. Pain relief 2. Restoration of the joint function bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

34.  Ideal Design for Total Disc Prosthesis 1) providing proper ROM (quantity) 2) providing proper patterns of motion (quality) 3) providing proper stiffness in motion 4) postoperative stability, immediately and long term 5) providing shock absorption property bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

35. Total Disc Prosthesis  Prosthesis for motion: Unconstrained; semi-constrained  Prosthesis for motion & shock absorption: Fluid-filled cavity; springs; fiber-reinforced composite; and elsatomeric polymer (AcroFlex Disc) bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

36. Selection criteria DDD resulting in pain arising from the disc that has not been adequately relieved with non-operative care. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

37. Exclusion criteria include -spondylolisthesis -Osteoporosis - vertebral body fracture - allergy to the materials in the device -spinal tumor -spinal infection -morbid obesity -significant changes of the facet joints - pregnancy or child-bearing period -chronic steroid use - autoimmune problems. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

38. „Constrained“ vs. „Unconstrained“ „unconstrained“replicating the anatomical (healthy) situation. The prosthesis allows only limited axial rotation. Constrained Semi- constrained Unconstrained The prosthesis allows full axial rotation. No translation due to ball and socket joint. Translation possible. No restriction in axial rotation. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

39.  Total Disc Prosthesis for Motion Clinical data: Successful pain relief, functional recovery and shorter recovery period comparable to that of spinal fusion  Griffith, et al 1994  Cinotti, et al 1996  Guyer, et al 2003 bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

42.  The SB Charite´ III—Disc (Depuy Spine; Raynham, MA, USA)  This artificial disc is the most widely used implant currently available in the world  The device has a bi-convex ultrahigh molecular weight polyethylene (UHMWPE) spacer that acts as a mobile core.  The two end-plates are cobalt chrome molybdenum alloy (Co-Cr Mo alloy). There are ventral and dorsal teeth on the device and the latest version of the device has titanium as well as hydroxyapatite coating. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

44.  The ProDisc (Synthes Inc., Paoli, PA)  It is constructed of superior and inferior titanium endplates with a polyethylene articulating bearing. The endplates have a plasmapore titanium coating.  The prosthesis was manufactured in two sizes, three heights and two lordosis angles to reconstruct the individual patient anatomybahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

47. The Maverick Disc (Medtronic, Minneapolis, MN, USA) This Design includes the use of a highly polished Co-Cr-Mo ball-and- socket (metal-on-metal design). The center of rotation is fixed and located in the posterior third of the disc space. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

50. The Flexicore Disc (Stryker, Kalamazoo, MA, USA) FlexiCore is also a Co-Cr-Mo highly polished ball-and-socket metal-on-metal prosthesis. The endplates are dome shaped and thus adapt to the concavity of the vertebral endplates. The surfaces of the endplates are titanium plasma-sprayed to promote bone on-growth fixation. There are fixation spikes on both upper and lower base plates.bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

52. The Mobidisc (LDR medical; Troyes, France) This disc consists of three pieces, two flat metal endplates with porous coated surfaces and a keel to provide immediate and long-term stability bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

54. Activ L (Aesculap AG Tuttlingen, Germany) This implant has a sliding nucleus, which is anchored in the lower endplate. The endplates are available with spikes and/or keels to allow for different types of primary fixation. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

56. Kineflex (Spinal Motion, South Africa) This is another metal-on-metal semi-constrained disc bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

57.  Total Disc Prosthesis for motion & shock absorption Lack of shock absorption can produce abnormal stress concentration on surrounding structures within the segment and at the adjacent segment. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

58.  Total Disc Prosthesis for motion & shock absorption Fluid-filled cavity: with metal or polymer encasement Springs: with hinge joint or polymer bag Fiber-reinforced composite structure Elastomeric polymer disc prosthesis: silicone, rubber and polyurethane sandwitched between metal end plates bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

59. Known Complications for Total Disc Prosthesis (Charite III)  Subsidence (3-9%)  Dislocation (2-9%) A large portion of the unsatisfactory results were attributed to the surgical learning curve and improper patient selection.bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

60.  surgical modalities preserving spinal motion include, 1. -Total disc replacement 2. -Nucleus replacement 3. -Interspinous spacer devices 4. -Pedicle screw based stabilization devices 5. -Total facet replacement system 6. -Autologus disc chondrocyte transplantation bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

62.  Some designs include hydro gels developed by Bao et al and Ray. The Ray device is a pair of interdiscal, double- woven prosthetic nuclei inserted from a posterior approach .  The devices will swell after insertion because of hydroscopic gel (hyaluronic acid) held within a semipermeable membrane lying inside each woven jacket. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

63. Disc Prosthesis • Bulky • Complicated design • Hard to mimic all functions • Fixed to vertebra • More invasive and only for anterior approach • More difficult to implant and revise – more risk • Should be only for late stage DDD Nucleus Prosthesis • Small dimension • Simple design • Easy to mimic all functions • Not fixed to vertebra • Less invasive and can be used for all approaches • Easy implantation, revision – less risk • Early to Moderate DDD Nucleus Vs Total Disc bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

65. Prosthetic disc nucleus pellet and encasing polyethylene jacket. Shown is a wedge-shaped anterior component designed to fit the anterior portion of the vacated disc nucleus. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

66.  Nucleus Prosthesis bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

67. PDN-SOLO device in dehydrated and hydrated states. The PDN-SOLO device is designed to swell both in height and in width within the disc space. The porous polyethylene weave allows fluid to pass into the hydrophilic core, which causes the device to expand vertically and horizontally. This process maximizes the device’s footprint on the vertebral endplates. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

68. Nuclear replacements may be placed  At the time of discectomy for sciatica, or  Poster laterally as a treatment for painful early stage disc degeneration. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

69.  Advantages  Small annular incision  Implant conformity  Challenges  Potentially leakable  Implant property consistency  DASCOR –Disc Dynamics  In situ cured PU with PU balloon  Preclinical study  CE marked  Early clinical bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

70.  Advantages  Same as preformed hydrogel  Ability to implant through small annular incision  Challenges  Same as preformed hydrogel  Leakage through annular defect during injection  Nucore by Spine Wave  Silk protein  Early OUS clinical bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

71. surgical modalities preserving spinal motion include, 1. -Total disc replacement 2. -Nucleus replacement 3. -Interspinous spacer devices 4. -Pedicle screw based stabilization devices 5. -Total facet replacement system 6. -Autologus disc chondrocyte transplantation bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

73.  :  Interspinous Spacer Devices  By keeping the spine in a rather flexed position, the interspinous devices 1. increase the total canal and foraminal size, 2. decompressing the quada equina bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

75. Selection criteria -Lumbar spinal stenosis at one or two levels -Degenerative disc disease at a segment adjacent to fusion bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

77. The Coflex, ExtendSure, and CoRoent Devices: It is a U-shaped metallic device that is inserted between the spinous processes. As with other interspinous devices, this one is designed to increase the cross-sectional diameter of the stenotic canal in patients suffering from neurogenic claudication. ExtendSure and CoRoent are other interspinous dynamic stabilization devices that were recently launched, in 2005 and 2006, respectively. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

79.  Lumbar spinal stenosis failed to respond to conservative treatment(one or two levels between L1 andL4)  Degenerative disc disease with arthritic facet joint and chronic low back pain  Voluminous herniated disc  Degenerative spondylolithesis grade1 bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

80.  Severe osteoporosis  Previous surgery that altered the morphology of the spine  L5-S1 as the spinous process of S1 is deficient  Spine deformity(Scoliosis or kyphosis) bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

82. The Wallis System: In 1986 the first interspinous device. The device's original design was a block (titanium or Peek) that was inserted between adjacent processes and held in place with a flat Dacron cord or ribbon wrapped around the spinous process above and below the block. T bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

85.  The X STOP Device:  This device is an oval titanium metal spacer . This implant is designed to fit between two adjacent lumbar spinous processes. The X STOP device is placed between the spinous processes while the patient is in a slight flexion position. The supraspinous ligament is carefully protected. Although the implant is not rigidly attached to the osseous anatomy, it is restricted from migrating posteriorly by the supraspinous ligament, anteriorly by the lamina, cranially and caudally by the spinous processes, and laterally by the device's wings on each side. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

88.  The DIAM System:  The DIAM Spinal Stabilization System is a soft interspinous spacer .  The core is made of silicone, which is covered by a polyethylene coating.  The surgical technique consists of identifying the interspinous space, removing the remnants of the interspinous ligament down to the ligamentum flavum, and using a distracter of the spinous processes to facilitate the insertion of the device. It is secured in place with two laces, one around the spinous process above, and another around the one below. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

92.  Pedicle Screw/Rod-Based Stabilization Devices ((Posterior dynamic stabilization))  By unloading the pressure on the degenerated discs and facets, pedicle- based dynamic devices have the potential to reduce pain associated with these anatomical structures. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

93. Motion Preservation Therapy in the Spine Posterior dynamic stabization 1. Interspinous distraction devices 2. Interspinous ligament device 3. Pedicle based ligament devices 4. Pedicle based dynamic metallic device • bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

94.  Interspinous distraction devices ▪ Wallis, X-stop, Diam, Coflex ▪ Interspinous ligament device ▪ Loop system ▪ Pedicle based ligament devices ▪ Graf, Dynesys, FASS ▪ Pedicle based dynamic metallic device ▪ PDS (Synthes), Protex (Globus), DSS (Abbott Spine), M- Brace (AST), NFlex (N Spine) ▪ Artificial facet devices ▪ TOPS (Impliant), TFAS (Archus), ACADIA bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

95.  For relief of chronic back pain in DDD  For stabilization as well as motion preservation with/without decompression surgery bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

96. Indications  Controlled Motion in the Iatrogenically Destabilized Spine  Protection of Degenerated Facet Joints and Intervertebral Discs  In Combination With Anterior Motion Preservation for 360° Circumferential Motion Segment Reconstruction bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

98. The Graf System: The Graf system is the only pedicle-based device with polyester bands instead of rods. It is composed of 5- to 7-mm titanium pedicle screws and looped 8-mm braided polyester bands. After the spine is exposed and pedicle screws inserted, the bands are connected under applied compressive force between the pedicle screws as a ligamentoplasty. The tension and compression force used is determined by the length of the bands. The product was conceived to immobilize the lumbar spine in lordosis; alter the load bearing on the annulus and endplate; compress the posterior annulus, splint the motion segment, allowing healing of damaged tissue to occur; and relax over time, allowing some return to movement. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

101. The Dynesys System: The Dynesys Spine System , like standard frame devices, is fixed in place by using standard pedicle screws made of a titanium alloy . The whole system is stabilized by polyester cords that connect the screw heads through a hollow spacer and hold the screws in place. The stabilizing cords resist flexion movements, and the spacers resist compressive forces. The Dynesys devices restabilize and realign the segments in physiological position and neutralize the excessive forces. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

106. The AccuFlex, PEEK, and Isobar Rods: Other semi rigid rods being used in the US include the AccuFlex , PEEK rod, and Isobar rods . bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

107. the Isobar semi rigid rod system. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

108. SoftFlex™ system consists of 6-mm diameter titanium rods, with spiral cuts, which makes it flexible. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

109. Photograph of a spine model showing the proper placement of the AccuFlex construct at the L5– S1 position. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

112. surgical modalities preserving spinal motion include, 1. -Total disc replacement 2. -Nucleus replacement 3. -Interspinous spacer devices 4. -Pedicle screw based stabilization devices 5. -Total facet replacement system 6. -Autologus disc chondrocyte transplantationbahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

114. Artificial facet device: ACADIA bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

115. Artificial facet device: bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

116.  Total Facet Replacement Systems  Total facet replacement is an emerging new technology designed to completely restore facet joints functionally. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

117. Indications  Moderate to severe lumbar spinal stenosis, with or without spondylolisthesis (up to grade 1) and with or without facet hypertrophy. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

118. TOTAL FACET REPLACEMENT SYSTEMS Anatomic Facet Replacement System (AFRS) The implant is made from a super-alloy with highly polished articulating surfaces. The backing of the implant that interfaces with the bone is coated with material to promote bony in-growth. The implant is secured to the bone with conventional pedicle screws. Separate implants are used for both the top and bottom facets. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

125. Surrounding Boot Avoids impingement of soft tissues Pedicle Screw Based Design Standard surgical approach bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

126. Total Posterior System, the TOPS Implant: composed of a titanium construct with an interlocking PCU articulating core. The design allows relative movement between the titanium plates to enable axial rotation, lateral bending, extension, and flexion. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

128. AUTOLOGUS DISC CHONDROCYTE TRANSPLANTATION Disc material removed during open microdiscectomy was placed into sterile buffered saline. Cells were transported immediately to the culturing facility. Transplantation was scheduled approximately 3 months following initial surgery. Cells were not transplanted until intradiscal pressure could be assured through a pressure volume test. A pressure of 300mmHg was kept over 2 minutes to demonstrate complete healing of the annulus. Central positioning in the center of the nucleus was ascertained using fluoroscopy prior to transplanting cells. Patients remained strictly supine for 12 hours following transplantation, after which they were mobilized and an orthosis was provided for 3 weeks. bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

129. SUMMARY bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

130. Advantages:  Elimination of the need for bone graft  Reduction in surgical morbidity  RCT of TDR vs. 360º fusion (Zigler et al. 2003)  Elimination of pseudoarthrosis  One of the most significant advantages Reduction of adjacent level degeneration  The most significant potential advantage motion preservation bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

131. Potential Disadvantages: “New technology brings the possibility of new modes of failure” Mechanical failure, dissociation, migration Subsidence Same level degeneration bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

132. Thank You bahaa Ali kornah-Al.Azhar Un.-Cairo- EGYPT

Spine motion preservation

Esté a ler uma amostra.

Confira estes a seguir

Spine motion preservation

Mais Conteúdo rRelacionado

Diapositivos para si (20)

Semelhante a Spine motion preservation (20)

Mais de Bahaa Kornah (9)

Mais recentes (20)