6/1/2013 SURGICAL INDICATIONS INDICATIONS FOR COMBINED ASF/PSF - - PowerPoint PPT Presentation

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6/1/2013 SURGICAL INDICATIONS INDICATIONS FOR COMBINED ASF/PSF - - PowerPoint PPT Presentation

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6/1/2013 SURGICAL INDICATIONS INDICATIONS FOR COMBINED ASF/PSF Neurologic compression SPINAL SURGERY Spinal instability Severe or progressive deformity UCSF Spine Course Pain attributable to spinal cause

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SLIDE 1

6/1/2013 1 INDICATIONS FOR COMBINED ASF/PSF SPINAL SURGERY

UCSF Spine Course Serena S. Hu, MD David S. Bradford Endowed Chair of Orthopedic Surgery Department of Orthopedic Surgery University of California, San Francisco

  • Neurologic compression
  • Spinal instability
  • Severe or progressive

deformity

  • Pain attributable to spinal

cause

  • Spondylolisthesis
  • Deformity
  • Truncal imbalance
  • ?degenerative conditions

SURGICAL INDICATIONS

  • Decompress neural

elements

  • Stabilize spine
  • Correct and stabilize

deformity

  • Achieve truncal balance
  • May require spinal fusion

GOALS OF SURGERY

  • Stabilizing the spine by removing

motion

  • Bone bridges motion segments
  • Healing rate improved by
  • Improved rigidity of construct
  • Instrumentation: screws, hooks,

wires, rods

  • Growth factors
  • Circumferential fusion

SPINAL FUSION

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SLIDE 2

6/1/2013 2

INDICATIONS FOR COMBINED SURGERY

  • High risk of

pseudoarthrosis

  • Prior pseudoarthrosis

INDICATIONS FOR COMBINED SURGERY

  • High risk of

pseudoarthrosis

  • Prior pseudoarthrosis
  • Deficient bone stock

INDICATIONS FOR COMBINED SURGERY

  • High risk of

pseudoarthrosis

  • Prior pseudoarthrosis
  • Deficient bone stock
  • Long fusion to sacrum
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SLIDE 3

6/1/2013 3

INDICATIONS FOR COMBINED SURGERY

  • High risk of

pseudoarthrosis

  • Prior pseudoarthrosis
  • Deficient bone stock
  • Long fusion to sacrum
  • Improve curve

correction

  • Sagittal balance

INDICATIONS FOR COMBINED SURGERY

  • High risk of

pseudoarthrosis

  • Prior pseudoarthrosis
  • Deficient bone stock
  • Long fusion to sacrum
  • Improve curve correction
  • Sagittal balance
  • Coronal balance:

shoulders, trunk

INDICATIONS FOR COMBINED SURGERY

  • High risk of pseudoarthrosis
  • Prior pseudoarthrosis
  • Deficient bone stock
  • Long fusion to sacrum
  • Improve curve correction
  • Sagittal balance
  • Coronal balance:

shoulders, trunk

  • Clinical deformity (don’t

forget thoracoplasties)

ACHIEVING CIRCUMFERENTIAL FUSION

  • Open anterior approach
  • Lateral approach
  • Posteriorly based approach
  • PLIF
  • TLIF
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SLIDE 4

6/1/2013 4

ANTERIOR APPROACH

  • Advantages
  • Most complete removal of disc
  • Least risk to neural elements
  • Most correction of sagittal

deformity

  • Disadvantages
  • Most invasive
  • Abdominal muscle weakness
  • Risk of DVT
  • May need vascular surgeon for

approach

LATERAL APPROACHES

  • Advantages
  • Less invasive
  • ?less pain
  • Technique allows horizontalization
  • f disc space
  • Disadvantages
  • More nerve retraction (esp L4-5)
  • Cannot access L5-S1
  • May still have muscle weakness
  • More xray exposure

POSTERIOR BASED APPROACH: TLIF, PLIF

  • Advantages:
  • Same incision as posterior
  • Can decompress directly
  • Disadvantages
  • Nerve retraction
  • Least disc resection
  • Least lordosis restoration

WHEN TO STAGE?

  • Surgery too long (>12

hours)

  • Patient unable to tolerate
  • Coagulopathy
  • Pulmonary
  • Cardiac
  • Surgeon unable to tolerate
  • ?decreased efficiency
  • ?technical fatigue
  • Less experienced staff
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SLIDE 5

6/1/2013 5

IMPROVE DEFORMITY CORRECTION

60 yo WF, healthy progressive and increasingly painful curve Has lived with deformity all of adult life, but now that she has opportunity to correct, she wants maximal deformity correction

  • After first stage ALIF

L4-5 and L5-S1

  • XLIF L1-2, L2-3, L3-4
  • Traditionally, this might

have included a TL anterior approach

  • Nutritional depletion
  • Pulmonary compromise
  • Development of

complications: may delay, preclude 2nd stage

  • Longer hospital stay
  • Increased costs

RISKS OF STAGED SURGERY

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SLIDE 6

6/1/2013 6

  • Nutritional

supplementation: staged spinal surgery

  • TPN
  • Decreased nutritional

depletion (prealbumin)

  • Higher rate of

pneumonias, infectious complications in malnourished patients

NUTRITIONAL DEPLETION PULMONARY COMPLICATIONS

  • Preexisting disease
  • Thoracotomy
  • High EBL
  • Fluid shifts
  • Transfusion-related ARDS

DECISION MAKING

  • Risk-benefit ratio

ALTERNATIVES

  • Potential role for widely

staged surgery?

  • Lumbar fusion
  • Delayed thoracic fusion
  • Posterior first: repair

pseudo or Thomasen

  • Delayed ASF
  • ?older patients
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SLIDE 7

6/1/2013 7

SUMMARY

  • Indications for combined surgery
  • Increase fusion rate
  • Improve deformity correction

and balance

  • Options for circumferential fusion
  • ASF
  • Lateral fusion
  • Posterior interbody
  • Selection based on indications for

surgery and risk benefit ratio

THANK YOU FOR MORE INFORMATION WWW.ISSLS.ORG