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 Assistant Clinical Professor Department of Orthopaedic Surgery 3rd Annual UCSF Techniques in Complex Spine Surgery Nov 8-9, 2013. Las Vegas, NV 2 Overview The Differential Diagnosis • The Differential Diagnosis Same Level Adjacent Level • A Systematic Approach Decompression Infection Stenosis • History CSF leak • Physical Examination Stenosis Fracture • Historical Documentation Instability/Deformity • Imaging Studies • Other investigations Infection Stenosis Fusion • Strategies for Surgical Management Stenosis Fracture Fracture Instability/Deformity • Revision Decompression Symptomatic Hardware • Adjacent Level Fusion Pseudarthrosis • Revision Fusion Instability/Deformity • Deformity Correction 3 4 1
11/8/2013 The Differential Diagnosis The Differential Diagnosis Same Level Adjacent Level Same Level Adjacent Level Decompression Infection Stenosis Decompression Infection Stenosis CSF leak CSF leak Stenosis Stenosis Fracture Fracture Instability/Deformity Instability/Deformity Infection Stenosis Infection Stenosis Fusion Fusion Stenosis Fracture Stenosis Fracture Fracture Instability/Deformity Fracture Instability/Deformity Symptomatic Hardware Symptomatic Hardware Pseudarthrosis Pseudarthrosis Instability/Deformity Instability/Deformity 5 6 The Differential Diagnosis The Differential Diagnosis Same Level Adjacent Level Same Level Adjacent Level Decompression Infection Stenosis Decompression Infection Stenosis CSF leak CSF leak Stenosis Stenosis Fracture Fracture Instability/Deformity Instability/Deformity Infection Stenosis Infection Stenosis Fusion Fusion Stenosis Fracture Stenosis Fracture Fracture Instability/Deformity Fracture Instability/Deformity Symptomatic Hardware Symptomatic Hardware Pseudarthrosis Pseudarthrosis Instability/Deformity Instability/Deformity 7 8 2
11/8/2013 History Taking – Symptoms History Taking – Account of Past Surgical History • Presenting symptoms prior to the • Back pain • L5-S1 Decompression procedure Surgery • Dr. X (1992) • Ind: Leg pain • Leg pain • Outcome: leg pain improved, 1 back pain worse • Treatments (5Ws, 1H) • Cx: none • Neuro deficit • Outcomes (short-term, long-term) • Functional limitations • L5-S1 PSF Surgery • Dr. X (1995) • Complications • Ind: Back pain • Unable to stand straight • Outcome: Initial improvement 2 then worsening back pain • Cx: headaches resolved • Others • infection • L4-S1 Anterior/Posterior • spinal headache Surgery • Dr. Y. (2002) • Ind: Back and leg pain • prominent hardware • Outcome: initial improvement, 3 then progressive stooping • Cx: none 9 10 Physical Examination Historical Documentation • Previous Incisions • Old operative notes • What was done? • Tenderness • Complications • Implants and materials • Neurological • Prior x-rays • Infection • Why was it done? • What improved? • Deformity • What failed? • Alignment • Balance • Joint contractures • General condition Huec et al., Eur Spine J (2011) 20: 699-703. 11 12 3
11/8/2013 Imaging Studies Other Investigations • Standing Plain radiographs • BWK • Flexion/extension views • CBC, ESR, C-reactive protein • Albumin, total lymphocyte count • Standing full-length xrays • EMG/NCS • Cross-sectional imaging • CT/CT-myelogram • Other Imaging: • MRI • SPECT CT • WBC/Gallium scan 13 14 The Differential Diagnosis Preoperative Planning • Infection Same Level Adjacent Level • Two-stage approach – I+D, ?implant removal, IV Abx Decompression Infection Stenosis – Secondary reconstruction CSF leak Stenosis Fracture Instability/Deformity Infection Stenosis Fusion Stenosis Fracture Fracture Instability/Deformity Symptomatic Hardware Pseudarthrosis Instability/Deformity 15 16 4
11/8/2013 Case – 58M Case – 58M • Underwent TLIF/PSIF L4-S1 for • Removal of TLIF cage at L4-5 back and leg pain within the year • Repeat I+D with outside surgeon • Cultures • Post-op infection, treated with removal of posterior • ABX for 3 months instrumentation and ABX • Brace for comfort • Persistent draining sinus and worsening back pain • ESR/CRP elevated despite ongoing ABX 17 18 Case – 58M Preoperative Planning • Followed ESR/CRP • Infection • Remained low on and after • Recurrent/New Stenosis coming off ABX • Revision Laminectomy • After 3 months off ABX (6 • Dural repair/patching months since TLIF removal) planned reconstruction • VCR L4-5 • T11-P PSIF 19 20 5
11/8/2013 Preoperative Planning Preoperative Planning • Infection • Infection • Recurrent/New Stenosis • Recurrent/New Stenosis • Adjacent segment degeneration • Adjacent segment degeneration • r/o superimposed deformity • Anterior vs. Posterior vs. Combined • Broken/Symptomatic Hardware • Posterior Screws approach • Anterior Instrumentation/Cage • Hardware removal and reimplantation – Removal sets, proprietary screw heads, metal cutting burrs • Adding on (compatibility) 21 22 Preoperative Planning Case – 63F • Infection • Adult Scoliosis Surgery • Recurrent/New Stenosis • Revised: • L3 PSO • Adjacent segment degeneration • T10-Pelvis PSF • Trans1 • Broken/Symptomatic Hardware • Progressive Kyphosis • Pseudarthrosis • Anterior vs. Posterior vs. 360 • Back and leg pain • Existing implants • Interbody access – ALIF, XLIF, TLIF, PLIF • Fusion mass/landmarks (Guidance) • Fusion potential – patient, fusion bed, graft 23 24 6
11/8/2013 Case – 63F Case – 63F • Revision L3 PSO • Bilateral PLIF L5-S1 • T4-Pelvis PSF 25 26 Case – 63F Preoperative Planning • 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? 27 28 7
11/8/2013 Retrospective case series (2002-7) 250 patients • Wash U • 126 Primary • 455 revision patients • 126 Primary, 124 Revision, Minimum 2 year follow up • 21% reoperation rate • 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) 29 30 Case – 81F • 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 31 32 8
11/8/2013 Case – 81F Case – 81F • L3 PSO • Revision L5-S1 TLIF • Dual Iliac screws • T10-Pelvis PSF 33 34 Case – 81F 35 36 9
11/8/2013 Case – 78M Case – 78M Developed adjacent segment • 2007 presents with degeneration with coronal and degenerative scoliosis Pre-op x-rays (AP and lateral) sagittal imbalance • Surgeon A (2007): Pre-op MRI if relevant Surgeon B (Jan 2011) • XLIF L3-5 • PSF L2-3 • MIS PSF L3-S1 • Trans1 37 38 Case – 78M Case – 78M 78M Pre-op x-rays (AP and lateral) Progressive imbalance Unable to stand up straight Pre-op MRI if relevant Back pain, minimal leg pain 39 40 10
11/8/2013 Case – 78M Case – 78M Pre-operative Planning Intra-op fluoro or photos, if available • Needs large coronal Coronal keep to a minimum, fitting on this one slide Taper and sagittal correction only • Major osteotomy has Lordotic high complications 30º Coronal Surgery • Coronal taper T12-L1, Taper L2-3 (loosen set screw) • Hyperlordotic 30 ° L1-2 • Then T10-Pelvis PSF • T9, T10 kyphoplasties 41 42 Case – 78M Case – 78M Patient was walking independently at 6 weeks Post-op x-rays (AP and lateral) Patient was discharged to rehab POD #7 3 weeks in rehab then SNF Excellent correction 43 44 11
11/8/2013 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 45 46 Thank You! 12
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