New advances in spine surgery

Dr Attila Szabo Orthopaedic Surgeon Special Interest in Spinal Disorders

MEDICLINIC CAPE TOWN

http://www.spinesurgerycapetown.co.za

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Disease of mankind• Effects most of people

• 3 groups

• Lower back > neck

Back pain

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Complex anatomy & function

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Acute back or neck pain

• Most common

• Axial spinal pain

• No nerve root symptoms

• Muscle strain

• Segmental sprain (facet joint , disc)

• Pinched nerve – local irritation

Prevention

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Acute back or neck pain

90% settles within 6

weeks

Non surgical

treatment1. Medication

oNSAIDs oAnalgaesicsoMuscle relaxantsoSometimes as inpatient

2. PhysiotherapyoExercise programoAcupuncture, TENS

3. Modification of activities

oRest / bed-rest / tractionoEarly mobilization

InvestigationsX-raysCT / MRI scanBlood tests

Presentation out of ordinary•Age - < 20 yrs or > 60 yrs•Red flags – trauma, tumour, infection•Radicular symptoms, neurology (incontinence, weakness, absent reflex)•Ongoing / chronic pain – no response to conservative Rx

Spinal pathology

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Common spinal pathology

Cervical and Lumbar

Disc Disc

ProlapseProlapse

Spinal StenosisStenosis

DegenerativeDegenerative

Disc DiseaseDisc Disease

Neural compressionNeural compression

• Protection of neural elements

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Common spinal pathology

Spinal InstabilityInstability

• Supporting structure for the skeleton

FracturesFractures

• trauma

• pathological

DegenerativeDegenerative (spondylolisthesis)

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Non surgical treatmentNon surgical treatment

No or mild neurology,

instability

Restore functionRestore function1. Medication

oNSAIDs oAnalgaesicsoMuscle relaxantsoSometimes as inpatient

2. PhysiotherapyoAcupunctureoExercise program

3. Modification of activitiesoRest / bed-rest / tractionoEarly mobilization

4. Caudal epidural Caudal epidural cortisonecortisone

oGood results

Surgical treatment options

Neural compression•Disc Herniation •Spinal Stenosis•Degenerative Disc Disease

DecompressionDecompression•creating more space and freeing the nerves and spinal cordDiscectomyDiscectomy•removing herniated disc

Techniques

Laminectomy

Laminotomy

Foraminotomy or a Combination of the above procedures

Spinal instability •Fractures•Tumours

•Post surgery

Spinal fusionSpinal fusion•one or more of the vertebrae of the spine are united together (“fused”)

Bone graft only or with

Instrumentation

Posterior or Anterior or a Combination of the

above techniques

Spine Surgery - New AdvancesNew Advances

Minimally invasive spinal surgeryMinimally invasive spinal surgery

•RhizotomyRhizotomy

•Kyphoplasty or vertebroplastyKyphoplasty or vertebroplasty

Cervical disc replacementCervical disc replacement

Minimal Access Lumbar Surgery Minimal Access Lumbar Surgery

•Discectomy, decompressionDiscectomy, decompression

•Interbody fusionInterbody fusion

• TLIF, DLIFTLIF, DLIF

•Pedicle screw instrumentationPedicle screw instrumentation

New AdvancesNew AdvancesRadio-frequency rhizotomyRadio-frequency rhizotomy

• Minimally invasive surgical technique • Limited application

New AdvancesNew AdvancesBalloon kyphoplastyBalloon kyphoplasty•minimally invasive surgical technique •treat vertebral compression fractures •caused by osteoporosis, spinal injury

New AdvancesNew AdvancesAnterior cervical fusion vsAnterior cervical fusion vs..Cervical disc replacementCervical disc replacement

Cervical disc prolapse or degenerative Dx•intractable neck and/or arm pain •herniated disc or bony spurs (osteophytes)

Neck trauma – fractures / dislocations

• Preservation of motion

• Protection of the neighbouring levels from accelerated wear and tear

• Younger patients

Anterior Cervical Decompression Anterior Cervical Decompression and and

Fusion Cervical disc replacementCervical disc replacement

• Classic operation -great results

• Iliac graft – morbidity

• Adjacent segment Dx

New AdvancesNew AdvancesAnterior cervical fusion vsAnterior cervical fusion vs..Cervical disc replacementCervical disc replacement

New AdvancesNew AdvancesMinimal Access Spinal Techniques Minimal Access Spinal Techniques

(MAST)(MAST)Conventional spinal surgery•Larger skin incision

•Muscle stripping / cutting

•Damage to structures

•More post-op pain, longer stay

Minimally invasive spinal surgery Minimally invasive spinal surgery •Small incision

•Tubular device provide the working channel

•Muscle splitting / spreading – less damage

•Less post-op pain, shorter hospital stay

•Quicker functional recovery

MAST-ering technique – expertise, learning curve

Special equipment Selected cases

New New AdvancesAdvancesMinimally invasive lumbar discectomyMinimally invasive lumbar discectomy

Conventional discectomy

•Remove herniated disc

•Laminectomy or laminotomy

Micro discectomyMicro discectomy

New AdvancesNew AdvancesSpinal fusionSpinal fusion

Conventional fusion Combined fusion techniquesCombined fusion techniques

• two or more of the vertebrae of the spine joined together (“fused”) so that motion no longer occurs between them

•Lumbar Interbody fusionLumbar Interbody fusion• PLIF - posterior• TLIF - transforaminal• DLIF – direct lateral

• Postero – lateralPostero – lateral fusionfusion

• Pedicle screw Pedicle screw instrumentationinstrumentation

• Anterior interbodyAnterior interbody fusionfusion

New AdvancesNew AdvancesMinimal access lumbar fusionMinimal access lumbar fusion

New AdvancesNew AdvancesMinimal access lumbar fusionMinimal access lumbar fusion

DLIF – direct lateral interbody fusionDLIF – direct lateral interbody fusion

Right patient selection

Successful surgerySuccessful surgery

Successful surgerySuccessful surgery

Clinical findings•Acute leg pain•S1 nerve root (EHL, TA reflex)

Investigations

Failure of conservative Rx

Right surgery•discectomy

Successful surgerySuccessful surgery

Clinical findings•Leg and back pain•Spinal claudication

Investigations

Failure of conservative Rx

Right surgery

Decompression + fusion Limited decompression

Second opinion

Thank you