Degenerative Spondylolisthesis Degenerative Scoliosis

1. Lumbar Stenosis
Degenerative Spondylolisthesis
Degenerative Scoliosis
GEORGE SAPKAS
Professor of Orthopaedics
Medical School-Athens University
Metropolitan Hospital
Athens Greece

2. Aging of the Disc - Spine
Interverterbral
disc space – foramen
progressive stenosis and neural
compression

3. Interverterbral
disc space –
foramen
progressive
stenosis and
neural
compression

4. Disc - Facet degeneration -
Stenosis

5. Degenerative
Spondylolisthesis

6. Developmental
DDD

7. Degenerative Adult Scoliosis

8. Sites of pain origin

9. Investigations
Clinical
Radiological
Degenerative
Spondylolisthesis
Degenerative
Scoliosis

10. Clinical evaluation
Degenerative Spondylolisthesis Lumbar Stenosis

11. Radiographic
assessment
Global
1. In the coronal plane
2. In the sagittal plane
Regional
Segmental

12. This is assessed by the relationship of
the C7 plump line to the sacrum in the
coronal and sagittal planes

13. Lumbar Degen. Sp/thesis
TREATMENT
OPTIONS

17. Conclusions

18. Four clinically relevant key questions were
addressed in this study :
Review article
Surgery for adult spondylolisthesis: a systematic
review of the evidence
Tobias L. Schulte et al, Eur. Spine 2016

19. A.
 Is surgery more successful
 than conservative treatment
in relation
to pain and function
in adult patients
with isthmic SL?

20. B.
 Is surgery more successful
 than conservative treatment
in relation
to pain and function
in adult patients
with degenerative SL?

21. C.
 Is instrumented fusion
with decompression
more successful
in relation
to pain and function
 than decompression alone
in adult patients with
degenerative SL
and spinal canal stenosis?

22. D.
 Is instrumented fusion with reduction
more successful
in relation to pain and function
 than instrumented fusion
without reduction
in adult patients with isthmic
or degenerative SL?

23. Answers

24. 1. In adults with isthmic SL,
 surgery appears to be
better in relation to
pain and function
 than conservative treatment
(poor evidence).

25. 2. In adults with degenerative SL,
 surgery appears
to be better in relation
to pain and function
 than conservative treatment
(good evidence).

26. 3. In adults with degenerative SL and
spinal stenosis,
 instrumented fusion
with decompression appears
to be more successful
in relation to
pain and function
 than decompression alone
(poor evidence).

27. 4. In adults with isthmic
or degenerative SL,
 reduction and
instrumented fusion
does not appear
to be more successful in relation
to pain and function
 than instrumented fusion
without reduction
(moderate evidence)

28. Adult scoliosis

29. Primary
degenerative
scoliosis
(‘‘de novo’’
form), mostly
located in the
thoracolumbar
or lumbar spine
Grubb SA, et al (1992)
Aebi M. (2005)

30. 1. Body deformity
2. Pain
3. Neurological
disorders
Main problems

31. Coronal –Sagittal imbalance

32. Automatic
fusion
Muscles – Ligaments
S-I joints

33. Neurological disorders
1. Lumbar canal stenosis
2. Foraminal stenosis

34. Operative treatment

35. Purposes of the operative treatment
I. Prevention of progression
II. Maintenance of lumbar lordosis
III. Restoring global balance
IV. To reduce or to relieve the pain
V. To anticipate the neurological deficit

36. Key points
Sagittal imbalance
is poorly tolerated
in elderly scoliosis
patients
Timothy Kuklo, Spine 2006

37. • A fusion should not
be stopped adjacent
to a degenerated
segment
Timothy Kuklo, Spine 2006
L5
L5
S1
S1
L5
S1

38. • Inadequate decompression
• Post-operative instability
• Deterioration of the deformity
Side effects
Decompression

39. Γ.Π.
F 74
01-10-07
Decompression and stabilization
(short)

40. Posterior Correction and Stabilization
Transpedicular Screws and TLIF L3-L4 & L4-L5

41. TLIF
Adult degenerative Kyphosis – Scolioisis
(+) Parkinson

43. Observations

44. Extensive
Operative time

45. Automatic fusion
Multiple osteotomies
for mobilization
Technical issues

46. Loss of :
• Lumbar Lordosis
(flat back)
and
• Sagittal balance
Technical issues
• Osteotomies to restore
sagittal balance
(e.g. S.P. osteotomies)
• Intervetebral cages

47. Lumbar corrective osteotomies
for flat back ± intervertebral spacers

48. Osteoporosis
Top-off

49. Extension of
spondylodesia
To fuse or not to fuse
to the sacrum
The fate of the
L5 – S1 disc
sacrumalar

50. Absolute
indication
 Oblique
take-off
at L5 – S1
E. Pant.
F. 75
7-4-02
6mts
pop

51. Implants failure ~ 4%
Pseudarthrosis ~ 7% - 15%
Loss of correction
Complications related
to implants and fusion
K.St.
F. 67
8 yrs
pop
16-02-07
K.St.
F. 67
8 yrs pop
16-02-07

52. Conclusions

53. Conservative treatment

54. Deformity
Pain
Neurological
disorders
Correction
Stabilization
Decompression
65

55. The 3 columns correction and
stabilization
Overall gives the best clinical results

56. This meta-analysis made
 no recommendation for which specific type of
surgery is the best
and
 which surgical technique should be selected
for different patients
because
 the circumstances surrounding each patient
are highly complex.
Review article
Surgical treatments for degenerative lumbar scoliosis:
a meta analysis
Guohua Wang et al, Eur. Spine 2015
Cont.

57. This meta analysis included a study that
found no significant differences in
 Roland–Morris score, Oswestry score,
and
 patients’ satisfaction between patients who
 underwent isolated decompression,
 short fusion,
and
 long fusion surgery
Cont.
Transfeldt EE, et al, Spine 1976

58. One study compared
 the clinical outcome
 recurrent leg pain
 complications between isolated
decompression and decompression plus
limited fusion
revealed that
 recurrent leg pain occurred significantly more
often in patients within 6 months
 post isolated decompression.
Cont.
Daubs MD,, et al, Evid Based Spine Care J. 2012

59. Despite a high rate of complications, this
review demonstrates that surgery
 is an effective and reasonable treatment
intervention for severe DLS
and
 ultimately improves spine function and
deformity.
Cont.

60. This review also suggests
 that large scale,
 high quality studies
 with long term follow-up
are needed
to provide more reliable
evidence for future evaluation.

61. Key point
for the successful
operative treatment
of the adult
spinal deformity
is the restoration
of the
sagittal balance.