Post on 24-Jan-2017
Spinal Unit , Tripode , Bordeaux , FRANCE
SAGITTAL BALANCE &SURGICAL SPINAL DISORDERS
J. M. VITAL
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DURING
LUMBAR
VERTEBRA »
SPINE
« PELVIC
PELVIC INCIDENCE
M:52°
DUVAL-BEAUPERE
DYNAMIC STATIC
PELVIC VERSION
Mean : 12°
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Mean : 11°
SAGITTAL LIST
IN T9QuickTime™ et un
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FEMORO TIBIAL ANGLE
O
Normal: 0°
ITOI
C7 PLUMBLINE
EAC-FH DISTANCE
« CRANIAL VERTEBRA »
3 SAGITTAL POSITIONS
B
FULL SPINE
FULL LIMBS
« NATURAL POSITION »
« CORRECTED POSITION »
PREOP POSTOP
Peng L, Cooke MS. Fifteen-year reproducibility of natural head posture: A longitudinal study. Am J Orthod Dentofacial Orthop
1999;116:82-5.
Solow B, Tallgren A. Natural head position in standing subjects. Acta Odontol Scand 1971;29:591-607.
Gravity plateformGravity plateform
STEREORADIOGRAPHYSTEREORADIOGRAPHY
External Auditive Duct projection /
Femoral Head centers
CHARPAK
BALANCE
IDEAL OR ECONOMIC
BALANCECOMPENSATED
by
Pelvic Retroversion
+Knees Flexion
ANTERIOR IMBALANCE
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GAIT ANALYSIS
SPINE 2001
+ 6 MONTHS�
2. SPINAL DISORDERS
DEGENERATIVE KYPHOSIS
SPONDYLOLISTHESIS
OSTEOTOMIES in P.O. FLAT BACK
2.1.DEGENERATIVE KYPHOSIS
25 CASES
P.I.:56°
P.V.:29°
T.K.:38°
L.L. :36°
15°
12°
10°
PROFESSIONNAL FACTORS:12/25
TAKEMITSU,1988
HADAR (1989)
FAT DEGENERATION
HADAR 2
HADAR 3
THORACOLUMBAR A
ISOCINETISM 60°/sec.
TRUNK EXT.
TRUNK FLEX
PSOAS/GLUTEUS MAX.
QUADRICEPS/ISCHIO-TIBIALIS
SERIES(10
CASES)
NORMAL SUBJECTSMean age : 30 Y.O.
Ratio Spine Flexors Spine Extensors
63 % 149 % S
Ratio Psoas Gluteus maximus
110 % 63 % S
Ratio Ischio-jambiers Quadriceps
56 % 71 % NS
149% 63%
11O% 6O%
56% 71%
ARTHROGENIC KYPHOSIS : 10 CASES
2.2.SPONDYLOLISTHESIS
• DYSPLASTIC or CONGENITAL SPL• ISTHMIC LYTIC SPL• DEGENERATIVE SPL• TRAUMATIC SPL• TUMORAL SPL• IATROGENIC SPL
SPONDYLOLISTHESIS CLASSIFICATION(MARCHETTI , 1997)
INCIDENCE
(MANGIONE,ROUSSOULY)
PELVIC SHAPE
PELVIC POSITION
- PELVIC VERSION
- LOMBOSACRAL KYPHOSIS
LOMBOSACRAL ANGLE(BRADFORD,DUBOUSSET)
More than 90°
PELVIC TILTINCREASING
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TRUNK POSITION
- T9 SAGITTAL LIST
- THORACIC KYPHOSIS
- LUMBAR LORDOSIS
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SURGICAL TREATMENT of SEVERE DYSPLASTIC SPL
FIRST : ANTERIOR ARTHRODESIS
SECOND : POSTERIEUR ARTHRODESIS
LOMBOSACRAL ANGLE
2. HOW TO PREVENT ?
SAGITTAL IMBALANCE
INTRAOPERATIVE POSITION
MUSCULAR LESIONS
INSTRUMENTATION
POSTERIOR SURGERY
P.O. FLAT BACK
I.O. POSITION
standing seated
POSITION STANDING / SEATED / 4 PADS / G. P.
41°
48°
2°
5°
4 pads G.P.
36°
32°
0°
6°
GENU PECTORAL SEATED 4 PADS STANDING
MUSCULAR LESIONS�
2. TREATMENT
SAGITTAL IMBALANCE
LUMBAR POSTERIOR ( PETERSEN)
LUMBAR PEDICLE SUBSTRACTION
PELVIC
LUMBAR MULTILEVEL POSTERIOR
(CLOSE WEDGING , EGG SHELL)
2.3. SPINAL OSTEOTOMIESin POSTOPERATIVE FLAT BACK
LENKE , J.B.J.S. , 2004
MULTILEVEL POST. O.+/-DISCAL RELEASE+/- CAGES
TRANSPEDICULAR O. (TPO)
VERTEBRAL RESECTION
PREOPERATIVE CALCULATION
in the LUMBAR OSTEOTOMIES
40° 45°
MAXIMUM ANGLE
LUMBAR PEDICLE SUBSTRACTION
TRACINGS ( MANGIONE )
L3L4
LEVEL ( VAN ROYEN )
ANGLE
L3
T9
VP
1212°°
Vertical after osteotomy
SPINEVIEW
L3
T9
PV=12PV=12°°
1111°°
SL=11SL=11°°
Theoric sagittal list
T9
: osteotomy angle
L3
PV=12PV=12°°
SL=11SL=11°°
Theoric sagittal list to 11°
TECHNIQUE
L3 L3L3
IMPLANTS
TRANSPEDICULAR EVIDEMENT
EGG SHELL
INSTRUMENTAL CLOSURE
REDUCTION by the
MOVEMENTS of the O. TABLE
L3:42°
L4:26°
CASE 1
CASE 2
60°
TRANSPEDICULAR OSTEOTOMY RISKS
• NEUROLOGIC DEFICIT (radicular , transitory))
• BLEEDING
• CSF LEAKAGE
• PSEUDARTHROSIS
• SEPSIS
L3 OSTEOTOMY
SCOLIOSIS WORSENING
8°à10°
TRANSPEDICULAR OSTEO. MULTILEVEL O.
ANTERIOR RELEASE
4 LEVELS POST. OST.
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PRE OPERATIVE WALKING
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POSTOPERATIVE WALKING
T.L.I.F.
PELVIC OSTEOTOMY
WILSON 1969
SEGAL 1971
30°
ANTERIOR & POSTERIOR MULTIOPERATED P.
LEFT OSTEOTOMY
GRAFT
PREOP
CONCLUSIONS (1)
to EVALUATE SAGITTAL BALANCEyou must consider
SHAPE & POSITION of PELVIS
POSITION of HIPS and KNEES +++
ARTHROGENIC KYPHOSIS
there is ASSOCIATION with
OSTEOARTICULARMUSCULAR LESIONS
CONCLUSIONS (2)
CONCLUSIONS (3)
SPONDYLOLISTHESIS
ISTHMIC LYSIS is correlated with HIGH INCIDENCE
LUMBOSACRAL KYPHOSIS (L.S.K.) is more PEJORATIVE than SLIPPAGE
SURGICAL CORRECTION of the L.S.K. can correct the GLOBAL IMBALANCE
CONCLUSIONS (4)
OSTEOTOMIES
TRANSPEDICULAR O. is a good procedure to correct fixed imbalance cases
PREOPERATIVE CALCULATION is mandatory
PELVIC OSTEOTOMY is the last possibility