Revision Spine Patient Royalties SpineArt Consulting Mazor - - PDF document

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Revision Spine Patient Royalties SpineArt Consulting Mazor - - PDF document

Sep 05, 2022 141 likes •275 views

11/8/2013 Disclosures Surgical Strategies for the Revision Spine Patient Royalties SpineArt Consulting Mazor Robotics, SpineArt, Vertebral Technologies S. Samuel Bederman, MD PhD FRCSC Institutional Research Support Baxano, NuVasive

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11/8/2013 1

Surgical Strategies for the Revision Spine Patient

  • S. Samuel Bederman, MD PhD FRCSC

Assistant Clinical Professor Department of Orthopaedic Surgery 3rd Annual UCSF Techniques in Complex Spine Surgery Nov 8-9, 2013. Las Vegas, NV

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Disclosures Royalties – SpineArt Consulting – Mazor Robotics, SpineArt, Vertebral Technologies Institutional Research Support –Baxano, NuVasive

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Overview

  • The Differential Diagnosis
  • A Systematic Approach
  • History
  • Physical Examination
  • Historical Documentation
  • Imaging Studies
  • Other investigations
  • Strategies for Surgical Management
  • Revision Decompression
  • Adjacent Level Fusion
  • Revision Fusion
  • Deformity Correction

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The Differential Diagnosis Same Level Adjacent Level Decompression

Infection CSF leak Stenosis Fracture Instability/Deformity Stenosis

Fusion

Infection Stenosis Fracture Symptomatic Hardware Pseudarthrosis Instability/Deformity Stenosis Fracture Instability/Deformity

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The Differential Diagnosis Same Level Adjacent Level Decompression

Infection CSF leak Stenosis Fracture Instability/Deformity Stenosis

Fusion

Infection Stenosis Fracture Symptomatic Hardware Pseudarthrosis Instability/Deformity Stenosis Fracture Instability/Deformity

6

The Differential Diagnosis Same Level Adjacent Level Decompression

Infection CSF leak Stenosis Fracture Instability/Deformity Stenosis

Fusion

Infection Stenosis Fracture Symptomatic Hardware Pseudarthrosis Instability/Deformity Stenosis Fracture Instability/Deformity

7

The Differential Diagnosis Same Level Adjacent Level Decompression

Infection CSF leak Stenosis Fracture Instability/Deformity Stenosis

Fusion

Infection Stenosis Fracture Symptomatic Hardware Pseudarthrosis Instability/Deformity Stenosis Fracture Instability/Deformity

8

The Differential Diagnosis Same Level Adjacent Level Decompression

Infection CSF leak Stenosis Fracture Instability/Deformity Stenosis

Fusion

Infection Stenosis Fracture Symptomatic Hardware Pseudarthrosis Instability/Deformity Stenosis Fracture Instability/Deformity

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SLIDE 3

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History Taking – Symptoms

  • Back pain
  • Leg pain
  • Neuro deficit
  • Functional limitations
  • Unable to stand straight
  • Others
  • infection
  • spinal headache
  • prominent hardware

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  • Presenting symptoms prior to the

procedure

  • Treatments (5Ws, 1H)
  • Outcomes (short-term, long-term)
  • Complications

History Taking – Account of Past Surgical History

  • L5-S1 Decompression
  • Dr. X (1992)
  • Ind: Leg pain
  • Outcome: leg pain improved,

back pain worse

  • Cx: none

Surgery 1

  • L5-S1 PSF
  • Dr. X (1995)
  • Ind: Back pain
  • Outcome: Initial improvement

then worsening back pain

  • Cx: headaches resolved

Surgery 2

  • L4-S1 Anterior/Posterior
  • Dr. Y. (2002)
  • Ind: Back and leg pain
  • Outcome: initial improvement,

then progressive stooping

  • Cx: none

Surgery 3

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Physical Examination

  • Previous Incisions
  • Tenderness
  • Neurological
  • Infection
  • Deformity
  • Alignment
  • Balance
  • Joint contractures
  • General condition

Huec et al., Eur Spine J (2011) 20: 699-703.

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Historical Documentation

  • Old operative notes
  • What was done?
  • Complications
  • Implants and materials
  • Prior x-rays
  • Why was it done?
  • What improved?
  • What failed?
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Imaging Studies

  • Standing Plain radiographs
  • Flexion/extension views
  • Standing full-length xrays
  • Cross-sectional imaging
  • CT/CT-myelogram
  • MRI

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Other Investigations

  • BWK
  • CBC, ESR, C-reactive protein
  • Albumin, total lymphocyte count
  • EMG/NCS
  • Other Imaging:
  • SPECT CT
  • WBC/Gallium scan

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The Differential Diagnosis Same Level Adjacent Level Decompression

Infection CSF leak Stenosis Fracture Instability/Deformity Stenosis

Fusion

Infection Stenosis Fracture Symptomatic Hardware Pseudarthrosis Instability/Deformity Stenosis Fracture Instability/Deformity

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  • Infection
  • Two-stage approach

– I+D, ?implant removal, IV Abx – Secondary reconstruction

Preoperative Planning

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  • Underwent TLIF/PSIF L4-S1 for

back and leg pain within the year with outside surgeon

  • Post-op infection, treated with

removal of posterior instrumentation and ABX

  • Persistent draining sinus and

worsening back pain

  • ESR/CRP elevated despite ongoing

ABX

Case – 58M

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  • Removal of TLIF cage at L4-5
  • Repeat I+D
  • Cultures
  • ABX for 3 months
  • Brace for comfort

Case – 58M

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  • Followed ESR/CRP
  • Remained low on and after

coming off ABX

  • After 3 months off ABX (6

months since TLIF removal) planned reconstruction

  • VCR L4-5
  • T11-P PSIF

Case – 58M

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  • Infection
  • Recurrent/New Stenosis
  • Revision Laminectomy
  • Dural repair/patching

Preoperative Planning

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  • Infection
  • Recurrent/New Stenosis
  • Adjacent segment degeneration
  • r/o superimposed deformity
  • Anterior vs. Posterior vs. Combined

approach

Preoperative Planning

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  • Infection
  • Recurrent/New Stenosis
  • Adjacent segment degeneration
  • Broken/Symptomatic Hardware
  • Posterior Screws
  • Anterior Instrumentation/Cage
  • Hardware removal and reimplantation

– Removal sets, proprietary screw heads, metal cutting burrs

  • Adding on (compatibility)

Preoperative Planning

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  • Infection
  • Recurrent/New Stenosis
  • Adjacent segment degeneration
  • Broken/Symptomatic Hardware
  • Pseudarthrosis
  • Anterior vs. Posterior vs. 360
  • Existing implants
  • Interbody access

– ALIF, XLIF, TLIF, PLIF

  • Fusion mass/landmarks (Guidance)
  • Fusion potential

– patient, fusion bed, graft

Preoperative Planning

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  • Adult Scoliosis Surgery
  • Revised:
  • L3 PSO
  • T10-Pelvis PSF
  • Trans1
  • Progressive Kyphosis
  • Back and leg pain

Case – 63F

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Case – 63F

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  • Revision L3 PSO
  • Bilateral PLIF L5-S1
  • T4-Pelvis PSF

Case – 63F

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Case – 63F

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  • Infection
  • Recurrent/New Stenosis
  • Adjacent segment degeneration
  • Broken/Symptomatic Hardware
  • Pseudarthrosis
  • Deformity
  • Sagittal/Coronal/Combined
  • Focal/Global, Operated/Adjacent
  • Mild/Severe
  • Bone Quality
  • Solid Fusion?

Preoperative Planning

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Retrospective case series (2002-7) 250 patients

  • 126 Primary
  • 126 Primary, 124 Revision, Minimum 2 year follow up
  • Prevalence of overall complications was lower in P than R
  • 45.2% vs 58.2%, p=0.042
  • Higher preop and final clinical outcome for P than R (SRS, ODI),

but not in patients > 60 years

  • Equivalent improvement between P and R over 2 years (SRS, ODI)

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  • Wash U
  • 455 revision patients
  • 21% reoperation rate

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  • Hx of Degen Scoliosis
  • Underwent MIS

Scoliosis correction

  • L1-L5 XLIF
  • Bilateral Wiltse Fusion

L1-S1

  • MIS TLIF @ L5-S1
  • After surgery:
  • Increased back pain
  • Unable to stand

straight

Case – 81F

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Case – 81F

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  • L3 PSO
  • Revision L5-S1 TLIF
  • Dual Iliac screws
  • T10-Pelvis PSF

Case – 81F

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Case – 81F

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  • 2007 presents with

degenerative scoliosis

  • Surgeon A (2007):
  • XLIF L3-5
  • MIS PSF L3-S1
  • Trans1

Case – 78M

Pre-op x-rays (AP and lateral) Pre-op MRI if relevant

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Case – 78M Developed adjacent segment degeneration with coronal and sagittal imbalance Surgeon B (Jan 2011)

  • PSF L2-3

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78M Progressive imbalance Unable to stand up straight Back pain, minimal leg pain

Case – 78M

Pre-op x-rays (AP and lateral) Pre-op MRI if relevant

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Case – 78M

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Case – 78M

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Pre-operative Planning

  • Needs large coronal

and sagittal correction

  • Major osteotomy has

high complications

Surgery

  • Coronal taper T12-L1,

L2-3 (loosen set screw)

  • Hyperlordotic 30°L1-2
  • Then T10-Pelvis PSF
  • T9, T10 kyphoplasties

Case – 78M

Intra-op fluoro or photos, if available

keep to a minimum, fitting on this one slide

  • nly

Coronal Taper Coronal Taper Lordotic 30º

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Patient was walking independently at 6 weeks Patient was discharged to rehab POD #7 3 weeks in rehab then SNF Excellent correction

Case – 78M

Post-op x-rays (AP and lateral)

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Case – 78M

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Summary Comprehensive approach includes:

  • Detailed history

– Current symptoms and prior surgeries

  • Physical Exam

– Assessment of balance – Neuro exam – Prior incisions – Joint contractures – Evidence of infection

  • Advanced imaging and other tests
  • Thorough assessment of pathology at each level and globally
  • Careful preoperative planning to inform most definitive treatment

Thank You!