cervical disc replacement
TRANSCRIPT
Anterior Cervical Disc Replacement
ACDRDr. Fathi Neana, MD
Chief of OrthopaedicsDr. Fakhry & Alrajhy Hospital
Saudi ArabiaDecember, 15 – 2016
Key words
Anterior Cervical Disc Replacement (ACDR)
Anterior Cervical Disc Fusion (ACDF)
Cervical total disc replacement (CTDR)
Lumber total disc replacement (LTDR)
AcclimatizationBiological reaction
SALIX ALBA
Ficus trees
Acclimatization to latent instability
Degenerative changes
Acclimatization to latent
instabilityDegenerative
changes
LIFESTYLE DISEASES
Multi system problemsType II diabetes Arteriosclerosis Heart disease High blood pressure Swimmer's earCancer Stroke Chronic obstructive pulmonary disease CirrhosisNephritis Obesity & Metabolic syndrome
LIFESTYLE DISEASESaccounts for the epidemic proportions
Orthopaedic problemsNeck & low back acheDeg Disc disorders SpondylosisDeg joint diseases - OAMetabolic bone diseasesOsteoporosisOsteomalacia/RicketsFractures Inflammatory joint diseasesAuto immunityMetabolic syndrome – Obesity – DM - Uric a Host A B CSurgical difficultiesComplications
The common risk factors attributing to the orthopedic problemsLack of proper exercises
Improper posturesSedentary lifestyle
Change in work methodsObesity
Lack of Nutritious diet (especially vitamins and minerals)Stress, Stress, Stress!!!
Stress concentration
The DreamThe Science Fiction
العلمي الخيال
How to maintain the intervertebral distance without loosing the mobility
By implanting a mobile, if possible shock-absorbing component with sufficient height to replace the disc
1960 ->> 1980 ->> 1989 –1991 ->> 2000 ->>
Historically, LTDR preceded CTDR.The first LTDR, which had the form of a steel ball, was implanted by Fernstrom, using an anterior approach, in 1960. Initial results seemed encouraging, but proved disappointing in the long-term as the ball subsided into the subchondral bone.In the early 1980s, Schellnack and Buttner implanted the SB Charité® prosthesis, which comprised two chromium-cobalt plates and a mobile polyethylene core. In France, David and Lemaire regularly used the three successive models [1], [2] and [3] of this prosthesis.In 1989, Marnay described the ProDisc-L®, which has plates with a central titanium stem.Since then, many different LTDR designs have come onto the market
In 1962, Fernstrom encountered the same problems in CTDR as in LTDR with his prosthesis.The Prestige® prosthesis was not developed until 1989–1991. It was a metal-metal design, screwed into the vertebral bodies with a stabilization crest.Only in 1995 did Bryan begin to use the CTDR named for him on a regular basis.In Europe, the first implantation in 2000 was followed by numerous multicenter studies, mainly under the supervision of Goffin and Pointillart.A large range of CTDR designs have subsequently been marketed
Five types of Cervical total disc replacement (CTDR)
Anchorage (or contact between the implant and the vertebral plates (Fig. 2)) may be by stem, screw or macro-texture. The surface coating facilitates osseointegration; it may be in hydroxyapatite, tricalcium phosphate, porous titanium or chromium-cobalt.
Stress distribution
Think and ask before taking a decision
Mastering a surgical technique is not an indication to apply it
Unmastering a surgical technique is not a contra indication to offer it
To your patient (referral)
Even mastering a surgical technique is not a contra indication to refer to a
more experienced surgeon
“Spine Arthroplasty”Artificial Disc Replacement
• A new term which is used more and more in international scientific meetings and publications starts to dominate the scenery
• The last three decades have been the most revolutionary in the history of spine treatment
• The 80’s were dominated by the development of modern implants for internal segmental fixation such as pedicle screw systems and others.
• In the 90’s „Mini-open“ as well as „closed“ endoscopic techniques replaced the majority of conventional surgical approaches
“Spine Arthroplasty”Artificial Disc Replacement
• Progress in biological and biochemical research seems to open new perspectives in fusion technology
• We must not forget that bony fusion of a functional spinal unit is non physiological and it is associated with a variety of proven and (yet) unproven undesired effects and sequelae.
• At the beginning of this century, the progress in implant technology open a new dimension for spinal reconstructive non-fusion surgery.
A variety of new implants are used today for
nucleus pulposus total disc replacement
dynamic posterior reconstruction systemsposterior shock absorbers
injectable intradiscal materials
New dimensions forspinal reconstructive non-fusion surgery
is an alternative to cervical fusion in people with
Neck painRadiculopathy
Myelopathy
Cervical disc replacement
Presentation
Compression of nerve and/or spinal cord most commonly due to:– Cervical spondylosis– Disk herniation– Combination
Patho anatomy
Non Operative Treatment
• Life style• Immobilization Short term use for 1-2
weeks may relieve neck spasms.
• Traction• Medication NSAIDs, Opioids, Oral
Corticosteroids• Physical Therapy• Chiropractor / Manipulation• Epidurals
Surgical Treatment
Indications• Failure of 6-12 wks of
conservative care• Neurologic deficit
(weakness or numbness)• Imaging consistent with
clinical signs and symptoms
Anterior Cervical Discectomy and Fusion (ACDF)
• “Gold standard” for cervical radiculopathy
• Predictable results with 80-90% satisfactory results
• Issues include: Adjacent segment disease,
pseudarthrosis
ACDF (Fusion)
ACDF: Outcomes
• 122 pts with cervical radiculopathy• Non instrumented ACDF with ICBG• F/U 2-15 yrs.• 83% with mild or no neck pain at f/u. 108 pts. with no functional impairment• 24 cases pseudoarthrosis: 11% 1 one level, 27% in two level and three level. P < .01. Pseudos only
developed at one level.• Pseudos did not preclude satisfactory outcomes• Only four pseudoarthroses required further surgery
1993
Adjacent Segment Disease
Hilibrand A et al.:Radiculopathy and Myelopathy at Segments Adjacent to the Site of a Previous Anterior Cervical Arthrodesis, JBJS 1999 April; Vol. 81-A,
No. 4, 519-528.
374 pts(409 procedures) retrospectively reviewed over 20 yrs. 338 ACDFs and 71 ACCFs with strut grafts 2.9% per year incidence of adjacent segment disease(ASD) 25% ASD at 10 years using K-M survivorship curve C5-6 and C6-7 highest risk 12% ASD in multilevel sx. vs. 18% ASD in single level sx. 27/55 pts went on to sx. for ASD
Anterior Cervical Discectomy and Fusion ACDF
• Overall Still Very Good / Excellent results• However:
– Fails to restore normal biomechanics / kinematics of the cervical spine
– Increases adjacent segment loads
• So still there is a need of another option?
Cervical Disc Replacement
• Motion preserving surgery• Treat painful / pathologic process while
restoring/maintaining motion• Decreased stress in adjacent levels• May prevent problems of adjacent
segment disease, secondary surgery, pseudoarthrosis
Cervical Disc Replacement
Cervical Arthroplasty Arthroplasty versus allograft fusion
Mummaneni P et al.: Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: A
randomized control trial, J Neurosurg Spine, 2007 Mar, 6(3);198-203.
• 541 pts: 276 arthroplasty and 265 ACDF• 2 yr f/u• Higher neurologic success, lower revision sx, and earlier
return to work in arthroplasty group• 7 degrees of maintained motion
Cervical Arthroplasty Artificial Disc Versus Fusion
Sasso R et a., Artificial Disc Versus Fusion: A Prospective, Randomized Study With 2-Year Follow-up on 99 Patients,
Spine: Volume 32(26)15 December 2007pp 2933-2940
99 pts 1:1 Arthroplasty: ACDF 2 yr f/u Statistically significant better NDI, Arm pain, VAS, and SF-36
scores in Arthroplasty group 4 reoperations in the ACDF group vs. 2 reoperations in the
Arthroplasty group. 7.9 degrees of retained motion
Cervical Arthroplasty Artificial Disc Versus Fusion
• Kesman et al. Evid Based Spine Care J 2012– Prospective RCT; 22 pts in each arm ACDA/ACDF with 7 yr f/u– NDI improved in Prodisc-C more than ACDF (54.2 to 14.1 v 53.6
to 26.9)– ROM maintained in Prodisc group– 7 reoperations in ACDF gp. (3 same level; 4 adjacent level); No
reoperations for ACDA• Zigler et al. Spine 2013
– 103 ProDisc; 106 ACDF with 5 yr f/u– Both gps showed significant improvement in all outcomes– Reoperation rate greater for ACDF – 11.3% v 2.9%
SUMMARY
Artificial Cervical Disc (ACDR)Indications
The candidate must meet defined criteriaBy Jeffrey A. Goldstein, MD, FACS
(ACDR) Similar to those of cervical discectomy and fusion (ACDF).
Age between 18 and 60 years
Symptomatic cervical disc Causing arm pain, weakness or numbness, and/or neck pain.
These symptoms may be due to Herniated nucleus pulposus, Spondylosis (presence of osteophytes) , loss of disk height compressing adjacent nerves or the spinal cord.
This condition most commonly occurs at cervical spine levels C4-C5, C5-C6, or C6-C7.(C3 –C7 )
Cervical disc replacement (ACDR)Indications
The candidate must meet defined criteria
Significant neck pain and/or pain and neurological symptoms that radiates into the arm
Progressive symptoms or signs of nerνe root/spinal cord compressionNeck Disability Index [13] score greater than or equal to 15/50 (30%)
At least 4 to 6 weeks of nonsurgical treatment, usually consisting of at least anti-inflammatory medications, physical therapy, or epidural injections
No prior neck surgery (typically)
Suitable general health for safe anesthesia (Host A B C) Psychosocially, mentally, and physically able to comply with the postoperative protocol
Signed informed consents
Only one, or possibly two, levels of the neck affected
Cervical disc replacement (ACDR)Contra indications
Active infection - systemic or local
Allergy to the implant material Known allergy to cobalt, chromium, molybdenum, titanium, or polyethylene
Facet joint arthritis Radiographic confιrmation of severe facet joint! disease or degeneration
Severe spondylosis at the level to be treated as characterized by : a. bridging osteophytes
b.loss of disk height greater than 50 % c. absence of motion < 20)
Clinical or X-ray evidence of instabilityMarked cerνical instability on resting lateral or flexion/extension radiographs
a. translation greater than 3 mm and/or b. greater than 11 ο of angular motion
Cervical disc replacement (ACDR)Contra indications
Systemic or local Neck or arm pain of unknown etiology
Prior surgery at the level to be treatedfused level adjacent to the level to be treated
Compromised vertebral bodies at the affected level due to current orΓ past trauma, e.g., radiographic appearance of fracture callus, malunion, or nonunion
Osteoporosis: DEXA Τ score less than ΟΓ equal to -2.5Paget's disease. Osteomalacia, or any other metabolic bone disease
Severe diabetes mellitus requiring insulinPregnant or possible pregnancy ίη next 3 years
Concurrent drugs that affect healing (e.g..steroids)
Rheumatoid arthritis ΟΓ other autoimmune disease
Systemic disease. e.g.. AIDS. ΗIV. hepatitis
Active malignancy
Higher neurologic success
Earlier return to work
Degrees of maintained motion
Adjacent Segment Degeneration 5 yrs
Statistically significant better scores(NDI, Arm pain, VAS, and SF-36 scores)
lower revision rateReoperation rate for ACDF – 11.3% vs 2.9% ACDR
Arthroplasty (ACDR) vs fusion (ACDF)Studies in favour of (ACDR)
• Is the implantation procedure less invasive than
interbody fusion with a cage?
• Can segmental mobility be achieved and/or maintained?
• Can the physiological curvature be restored and retained?
• What will be the rate of spontaneous fusions?
• How does the implant behave iη the long term?
Cervical disc replacement (ACDR)Questions need an answer
