lumbar stenosis eexot 2016
TRANSCRIPT
Lumbar Stenosis
Degenerative Spondylolisthesis Degenerative Scoliosis
GEORGE SAPKAS
Professor of Orthopaedics Medical School-Athens University
Metropolitan HospitalAthens Greece
Aging of the Disc - Spine
Interverterbral disc space – foramen
progressive stenosis and neural compression
Interverterbral disc space –
foramenprogressive stenosis and
neural compression
Disc - Facet degeneration - Stenosis
Degenerative
Spondylolisthesis
Developmental DDD
Degenerative Adult Scoliosis
Sites of pain origin
Investigations
Clinical Radiological
Degenerative Spondylolisthesis
Degenerative Scoliosis
Clinical evaluation
Degenerative Spondylolisthesis Lumbar Stenosis
Radiographic assessment
Global1. In the coronal plane2. In the sagittal planeRegionalSegmental
This is assessed by the relationship of the C7 plump line to the sacrum in the coronal and sagittal planes
Lumbar Degen. Sp/thesis
TREATMENT
OPTIONS
Conclusions
Four clinically relevant key questions were addressed in this study :
Review articleSurgery for adult spondylolisthesis: a systematic
review of the evidence
Tobias L. Schulte et al, Eur. Spine 2016
A.
Is surgery more successful than conservative treatment
in relation to pain and function in adult patients with isthmic SL?
B. Is surgery more successful than conservative treatment
in relation to pain and function in adult patients with degenerative SL?
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?
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?
Answers
1. In adults with isthmic SL,
surgery appears to be better in relation to pain and function
than conservative treatment (poor evidence).
2. In adults with degenerative SL, surgery appears
to be better in relation to pain and function
than conservative treatment (good evidence).
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).
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)
Adult scoliosis
Primary degenerative scoliosis (‘‘de novo’’ form), mostly located in the thoracolumbar or lumbar spine
Grubb SA, et al (1992)Aebi M. (2005)
1. Body deformity2. Pain 3. Neurological
disorders
Main problems
Coronal –Sagittal imbalance
Automatic fusion
Muscles – LigamentsS-I joints
Neurological disorders
1. Lumbar canal stenosis2. Foraminal stenosis
Operative treatment
Purposes of the operative treatment
I. Prevention of progressionII. Maintenance of lumbar lordosisIII. Restoring global balanceIV. To reduce or to relieve the painV. To anticipate the neurological deficit
Key points
Sagittal imbalance is poorly tolerated in elderly scoliosis patients
Timothy Kuklo, Spine 2006
• A fusion should not be stopped adjacent to a degenerated segment
Timothy Kuklo, Spine 2006
L5
L5 S1
S1
L5
S1
• Inadequate decompression• Post-operative instability • Deterioration of the deformity
Side effects
Decompression
Γ.Π.F 7401-10-07
Decompression and stabilization(short)
Posterior Correction and Stabilization
Transpedicular Screws and TLIF L3-L4 & L4-L5
TLIF
Adult degenerative Kyphosis – Scolioisis(+) Parkinson
Observations
Extensive Operative time
Automatic fusion Multiple osteotomies
for mobilization
Technical issues
Loss of :• Lumbar Lordosis
(flat back) and
• Sagittal balance
Technical issues
• Osteotomies to restore sagittal balance (e.g. S.P. osteotomies)
• Intervetebral cages
Lumbar corrective osteotomies for flat back ± intervertebral spacers
Osteoporosis
Top-off
Extension of spondylodesia
To fuse or not to fuse to the sacrum
The fate of the L5 – S1 disc
sacrumalar
Absolute indication Oblique
take-off at L5 – S1
E. Pant. F. 75
7-4-02
6mts pop
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
Conclusions
Conservative treatment
Deformity Pain Neurological disorders
CorrectionStabilizationDecompression
65
The 3 columns correction and stabilization
Overall gives the best clinical results
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 articleSurgical treatments for degenerative lumbar scoliosis:
a meta analysis
Guohua Wang et al, Eur. Spine 2015
Cont.
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
One study compared the clinical outcome recurrent leg paincomplications 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
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.
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.
Key point for the successful operative treatment of the adult spinal deformity is the restoration of the sagittal balance.