New advances in spine surgery

1. New advances in spine
surgery
Dr Attila Szabo
Orthopaedic Surgeon
Special Interest in Spinal Disorders
MEDICLINIC CAPE TOWN
http://www.spinesurgerycapetown.co.za

2. 2
Disease of mankind
• Effects most of people
• 3 groups
• Lower back > neck
Back pain

3. 3
Complex anatomy & function

4. 4
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

5. Preventio
n
5
Acute back or neck pain
90% settles within 6
weeks
Non surgical treatment
1. Medication
oNSAIDs
oAnalgaesics
oMuscle relaxants
oSometimes as inpatient
2. Physiotherapy
oExercise program
oAcupuncture, TENS
3. Modification of
activities
oRest / bed-rest / traction
oEarly mobilization

6. Investigations
X-rays
CT / MRI scan
Blood 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

7. 7
Common spinal pathology
Cervical and Lumbar
DiscDisc
ProlapseProlapse
Spinal StenosisStenosis
DegenerativeDegenerative
Disc DiseaseDisc Disease
Neural compressionNeural compression
• Protection of neural elements

8. 8
Common spinal pathology
Spinal InstabilityInstability
• Supporting structure for the skeleton
FracturesFractures
• trauma
• pathological
DegenerativeDegenerative
(spondylolisthesis)

9. 9
Non surgical treatmentNon surgical treatment
No or mild neurology,
instability
Restore functionRestore function
1. Medication
oNSAIDs
oAnalgaesics
oMuscle relaxants
oSometimes as inpatient
2. Physiotherapy
oAcupuncture
oExercise program
3. Modification of activities
oRest / bed-rest / traction
oEarly mobilization
4. Caudal epidural cortisoneCaudal epidural cortisone
oGood results

10. Surgical treatment options
Neural compression
•Disc Herniation
•Spinal Stenosis
•Degenerative Disc Disease
DecompressionDecompression
•creating more space and freeing
the nerves and spinal cord
DiscectomyDiscectomy
•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

11. 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 SurgeryMinimal Access Lumbar Surgery
•Discectomy, decompressionDiscectomy, decompression
•Interbody fusionInterbody fusion
• TLIF, DLIFTLIF, DLIF
•Pedicle screw instrumentationPedicle screw instrumentation

12. New AdvancesNew Advances
Radio-frequency rhizotomyRadio-frequency rhizotomy
• Minimally invasive surgical technique • Limited application

13. New AdvancesNew Advances
Balloon kyphoplastyBalloon kyphoplasty
•minimally invasive surgical technique
•treat vertebral compression fractures
•caused by osteoporosis, spinal injury

14. 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 DecompressionAnterior Cervical Decompression andand
Fusion Cervical disc replacementCervical disc replacement
• Classic
operation
-great results
• Iliac graft –
morbidity
• Adjacent segment Dx

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

16. New AdvancesNew Advances
Minimal Access Spinal TechniquesMinimal 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 surgeryMinimally 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

17. NewNew
AdvancesAdvances
Minimally invasive lumbar discectomyMinimally invasive lumbar discectomy
Conventional discectomy
•Remove herniated disc
•Laminectomy or laminotomy
Micro discectomyMicro discectomy

18. New AdvancesNew Advances
Spinal 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 screwPedicle screw
instrumentationinstrumentation
• Anterior interbodyAnterior interbody
fusionfusion

19. New AdvancesNew Advances
Minimal access lumbar fusionMinimal access lumbar fusion

20. New AdvancesNew Advances
Minimal access lumbar fusionMinimal access lumbar fusion
DLIF – direct lateral interbody fusionDLIF – direct lateral interbody fusion

21. Right patient selection
Successful surgerySuccessful surgery

22. Successful surgerySuccessful surgery
Clinical findings
•Acute leg pain
•S1 nerve root
(EHL, TA reflex)
Investigations
Failure of
conservative Rx
Right surgery
•discectomy

23. Successful surgerySuccessful surgery
Clinical findings
•Leg and back pain
•Spinal claudication
Investigations
Failure of
conservative Rx
Right surgery
Decompression + fusion Limited decompression

24. Second opinion

25. Thank you