Treatment of spinal stenosis in the elderly with a minimally invasive approach of ipsilateral ULBD unilateral laminectomy bilateral decompression with BMP bone morphogenic protein in the posterior lateral space.

1. Ipsilateral non-instrumented fusion using BMP with ULBD for instability and stenosis
Spine conference
Upper Chesapeake medical Center
February 3rd, 2017

4. 6/10/16

7. L1L2

8. L2L3

9. L3L4

10. L4L5

11. L5S1

12. ?

14. 7/30/17

17. Optimal anatomy: canal should be the same L1S1

18. L5S1

19. L4L5

20. L3L4

21. L2L3

22. L1L2

23. T12L1

24. T11T12

25. xter and Barr JBJS 1934
s the first description of
rniated discs causing
atica with surgery as a
ccessful treatment

26. Henk Verbiest
1909-1997
Dutch neurosurgeon
introduced the concept
of a developmental
spinal stenosis 1940
due to a small AP
diameter spinal canal

31. Kleeman, T.J., Hiscoe, A.C., Berg, E.E.: “Patient Outcomes Following
Minimally Destabilizing
Lumbar Stenosis Decompression: The ‘Port Hole’ Technique”, Spine,
April 2000.

34. • J Neurosurg Spine. 2014 Aug;21(2):179-86. doi: 10.3171/2014.4.SPINE13420. Epub 2014 May
30.
• Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between
minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy:
clinical article.
• Mobbs RJ1, Li J, Sivabalan P, Raley D, Rao PJ.
79 patients prospective 1:1 ULBD v. open laminectomy, oswestry disability and
Patient satisfaction were similar, ULBD had shorter stay 55 h v 100 h, shorter time
To mobilize 15h v 33 h and more people not requiring opiates 51% v 15%

36. Toyoda et al. Clinical Outcome of Microsurgical Bilateral Decompression via Unilateral Approach for Lumbar
Canal Stenosis. Spine 2011; 36:410-415
Poletti CE. Central Lumbar Stenosis caused by ligamentum flavum unilateral laminectomy for bilateral
ligamentectomy. Neurosurgery 1995; 37: 343-347

37. Slide a
Ligamentum
flavum

38. 144 single level, korea, Trefoil canal stenosis patients were more difficult to
decompression due to angle of approach and patients had worse outcomes

41. Neurosurgery. 2006 Dec;59(6):1264-9; discussion 1269-70.
Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral
laminotomy for bilateral decompression.
Oertel MF1, Ryang YM, Korinth MC, Gilsbach JM, Rohde V.
• 133 patients mean fu 5.6 years up to 10 years
• Reoperation 11%, 2 instability, 7 restenosis
• 85% excellent to fair long term results
Dr M F Oertel Department of Neurosurgery, University Hospital, School of
Medicine, Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany

42. ULBD pitfalls complications
• Restenosis( contralateral side)
• Dural tear
• Nerve injury
• Instability
• Persistent pain from facet
• Pars fracture
• Inadequate decompression

46. 1.5 mg/cc
ACS: absorbably collagen sponge

47. Bone Graft
• Iliac crest
• Local
• Allograft: structural, morselized
• BMP
• DBM
• Ceramic: tricalcium phosphate and corraline hydroxyapatitie

48. ILIAC CREST

49. CANCELLOUS ALLOGRAFT

51. Marshall Urist
made the key
discovery that
demineralized,
lyophilized segments
of bone induced new
bone formation
when implanted in
muscle pouches in
rabbits
^ Urist, Marshall R. (1965). "Bone: formation by
autoinduction". Science 12:150 (698): 893–
899. doi:10.1126/science.150.3698.893. PMID 5319
761

52. INFUSE rhBMP-2
• FDA approval 7/2/02
for the treatment of
L4S1 ALIF for DDD
after 6 month of
nonop treatment can
include grade 1
spondylolisthesis
• 85% current use is off
label
• Approved for revision
PLF
nonunions/smokers

53. INFUSE rh_BMP-2
• FDA approved
4/30/04 for acute
open tibial
fractures treated
with IM nailing
within 14 days of
injury
J Bone Joint Surg Am. 2002 Dec;84-A(12):2123-34.
Recombinant human bone morphogenetic protein-2 for
treatment of open tibial fractures: a prospective,
controlled, randomized study of four hundred and fifty
patients

56. COST: $5k case

57. 45 woman infection one year out

58. Adjacent level
inadvertent fusion of
facet

59. ALIF

60. Retrograde ejaculation ALIF• The underlying mechanism of the dysfunction is the
inability of the internal vesical sphincter to contract
during ejaculation, resulting in retrograde flow of semen
to the urinary bladder.[13] As the muscle is innervated by
the superior hypogastric plexus, i.e., a thin,
retroperitoneal plexus of nerves overlying the
lumbosacral junction, damage to the plexus during (or
after) ALIF can denervate the bladder neck
sphincterRetrograde Ejaculation after ALIF with rh-BMP
• 7% versus 0.5%
• Retrograde ejaculation after anterior lumbar interbody
fusion using rhBMP-2: a cohort controlled study
• Eugene J. Carragee, MD The Spine Journal 2011

61. Soft Tissue swelling s/p acdf with fibular allograft

62. Adverse swelling associated with use of rh-BMP-2
in anterior cervical discectomy and fusion: a case study
Brian Perri, DO*, Martin Cooper, MD, Carl Lauryssen, MD, Neel Anand, MD
The Spine Journal 2007

63. ORTHOPEDIC AND DENTAL INDUSTRY
NEWS COMPLETE ARCHIVE »
FDA Issues Warning Regarding Off-Label
Use of rhBMPBY LAUREN UZDIENSKI,
JULY 7, 2008
Last week the FDA released a public
health notification regarding the off-
label use of of rhBMP (InFuse, OP-1)
in the cervical spine. The agency says
that over the past four years there
have been at least 38 reports of
complications associated with using
BMP in unapproved cervical fusion
cases, ranging from difficulty
swallowing, breathing or speaking to
severe dysphagia.
Most reported complications occurred
between two and 14 days following
surgery. Treatments included
respiratory support with intubation,
anti-inflammatory medication,
tracheotomy and most commonly
second surgeries to drain the surgical
site. The seriousness of the
complications was correlated with the
anatomical proximity of the cervical
spine to airway structures. The FDA
adds, "The mechanism of action is
unknown, and characteristics of
patients at increased risk have not
been identified."

64. POSTOPERATIVE SEROMA
• Postoperative Cervical Myelopathy and Cord
Compression Associated with the Use of rh-BMP-2 in
Posterior Cervical Decompression, Instrumentation,
and Arthrodesis: A report of two cases; Anderson
DW, Burton DC, Jackson RS; Spine (Jan 2011)

65. 774 man with postoperative
seroma POD #8 I&D bedside

66. 66 YEAR OLD
WOMAN S/P L4L5
PSF ADMITTED FOR
LBP POD #18

68. Psoas calcification
• Brower RS, Vickrov NM. A case of psoas ossification from the use of BMP-2 for
posterolateral fusion at L4-L5. Spine 2008;33:E653-55.
• Rob D Dickerman, Ashley S Reynolds, Matthew Bennett in Spine (2009)

69. 77 year old woman with cc: LBP B buttock pain PMH: type 2 DM, HTN,

70. L3L4

71. LEFT PSOAS

73. COMPLAINTS OF LEFT GROIN AND THIGH PAIN PROMPTED CT OF THE
ABDOMEN AND HIP POD #32 WHICH REVEALED CALCIFICATIONS AND
SWELLING OF THE LEFT PSOAS MUSCLE

74. MRI 9/24/09 which was 7 weeks postop revealed evolving calcification
of the psoas c/w myositis ossificans

75. Ectopic bone formation
60 WOMAN CC: L SCIATICA S/P L3L5 POSTERIOR DECOMPRESSION WITH L4L5
INSTRUMENT FUSION ON 9/29/08 INTIALLY DID WELL BUT HAD RECURRENT SCIATICA
IN MARCH 2011. REPEAT MRI SCAN REVEILED A L L5S1 LATERAL RECESS COMPRESSIVE
PROCESS FROM THE L L5S1 FACET/DISC SPACE,BUT ALSO OVERGROWTH OF THE L4L5
FACET FUSION PROCESS WHERE BMP WAS PLACED

77. osteolysis

78. radiculitis

79. Contraindicated in cancer patients

80. BMP dosage
• Acdf: 0.2-0.6 mg/level: low complication rate with
better fusion rates than control
• PLF: 8.5-12 mg bmp/level
• TFLIP: <4.2 mg/level, min improvement in fusion
rate
• ALIF:<4.2mg/level

81. thanks