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FUSION is the answer to this

DDD problem

Professor,

Department of Neurosurgery,

Northwestern University,

Feinberg School of Medicine

Interest: MIS, Deformity, Intradural Tumors

Richard G. Fessler, MD, PhD

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RICHARD G. FESSLER, M.D., PH.D.

ProfessorNorthwestern University, Feinberg School of Medicine

Chicago, IL

FUSIONis the answer to this DDD problem

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DISCLOSURE

Medtronic

Consultant

Research

Royalty

DePuy

Consultant

Royalty Stryker

Consultant

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BED REST

Wiesel Spine 5:324-330, 1980

No better than continued ambulation

Deyo et al. N Engl J Med 315:1064-1070, 1993

2 days superior to 4 days

Gilbert et al. BMJ 291:791-794, 1985 0 vs 4 days-pain unchanged but 0 days

returned to work faster

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BED REST

POTENTIAL RISKS

1.0 - 1.5% loss of muscle mass/day

15% loss of aerobic capacity in 10days

bone mineral loss

hypercalcemia and hypercalciuria

thromboembolism

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EXERCISE

Deyo et al. JAMA 250:1057-1062,

1983 Aerobic exercise superior to no

exercise

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TRACTION

NO BENEFIT

Deyo et al. JAMA 250:1057-1060,

1983 Mathews et al. Br J Rheumatol

26:416-423, 1987

Pal et al. Br J Rheumatol 25:181-183, 1986

Quebec Taskforce on SpinalDisorders Spine 12(Suppl):S1-9,

1987

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PHYSICAL THERAPYMODALITIES

There is noevidence which showssufficient benefits to justify cost.

Heat or cold treatments at home areas effective as anything.

Waterworth N Z MED J, 1985

Postacchini NEURO-ORTH, .1988

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ACUPUNCTURE

NO BENEFIT

Minimum 9 studies showing nobenefit

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BACK BRACE

NO BENEFIT

Deyo et al. JAMA 250:1057-1060,1983

Million et al. JBJS 40:449-454, 1981

Quebec Taskforce on SpinalDisorders Spine 12(Suppl):S1-9,1987

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NSAIDS AND NARCOTICS

Significant benefit

Berry et al. Ann Rheum Dis 41:129-132, 1982

Deyo et al. JAMA 250:1057-1060,

1983 Frymoyer et al. JBJS 65:213-218,

1983

Hingorani, Ann Phus Med 8:303-306,

1966

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KUSLICH, SPINE 1998

Prospective evaluation of BAK

cage ALIF

Fusion rate > 90 % at 2 years

Fusion rate > 95 % thereafter

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KUSLICH: NASS, 1999

Long term follow-up

91 % fusion rate

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Anterior thoracolumbar bonedowel fusions

Patient demographics:

Average age 51.9 yrs. (range 28 -77)

Average duration of symptoms: 8.3years

27 patients treated between 1991and 1997

Minimum follow-up: 2 years

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FUSION RATE WITH ALIF

ALLOGRAFT AND PEDICLESCREWS

Fusion Pseudo Equivocal

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VAMVANIJ, SPINE 1998

Compared four different types of

fusion in prospective randomizedclinical trial

PLIF + facet screws

ALIF (allograft) alone

PLIF + pedicle screws

BAK+ facet screws

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VAMVANIJ, SPINE 1998

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WANG, 1996Journal of Spinal Disorders ALIF using autogenous or allograft iliac

crest bone graft Posterior instrumentation using

Diapason or TSRH

95 % fusion rate

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OPEN vs LAP ALIF

Chung et al., Eur.Spine J., 2003

Complications:

1 cage malposition

2 retrograde ejaculation

1 DVT

1 bladder malfunction

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Duggal et al.,

Neurosurgery, 2004

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LAPAROSCOPIC ALIF withrhBMP-2

22 consecutive patients

100 % satisfied with result

100 % improvement in leg pain 100 % significant functional

improvement

100 % fusion rateKleeman et al, 2001

Spine

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OVERALL

Excellent results of ALIF over manyyears of experience

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Endoscopic TLIF andPercutaneous Pedicle ScrewInstrumentation

Khoo,L.T., Palmer,S., Laich,D.T., Fessler,R.G.: MinimallyInvasive Percutaneous Posterior Lumbar Interbody Fusion.Neurosurgery 51(5, Supplement), 166-181, 2002.

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RESULTS

Fusion rate: 98 % VAS

p < .008

*

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RESULTS

Oswestry

*

p < .0001

SF-36

*

P < .01

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LONG TERM OUTCOME

MASTTLIFVAS

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RISK

Open Posterior Fusion

3 % major complication rate 30 % minor complication rate

Cassanelli et al.Spine 32: 230-235, 2007

OBESITY

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OBESITY:OUTCOME FOLLOWING MINIMALLY

INVASIVE FUSION SURGERY

Rosen, D., Ferguson, S., Ogden, A.T., Huo, D., Fessler, R.G.: Obesity andSelf Reported Outcome after Minimally Invasive Lumbar Spinal Fusion

Surgery. Neurosurgery 63:956-960, 2008.

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MINOR COMPLICATIONS

OVERALL 22 %

< 25

25-30

> 30

Major Cx: 0 %

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BMI < 25 BMI 25-30 BMI > 30

Post-opradiculopathy

3 2

Lower extremityweakness 1

Urinary retention 2

Durotomy 1 1

Superficial wound

infection

1

Delirium 3 2

Nausea 1

CHF exacerbation 1

Hypertension 1 1

Hypotension 1 1

Ileus 1

PERCENT OF TOTAL

23 26 14

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BACK PAIN

NO CLEARPATHOLOGY

STENOSISNOSURGERY

1 2 LEVELDDD

MULTILEVELDDD

NOPATHOLOGY

CLEARPATHOLOGY

SEE1-2 LEVEL

NOSURGERY

NOSTENOSIS

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1 2 LEVELDDD

NO STENOSIS STENOSIS

NO

SPONDYLOLISTHESIS SPONDYLOLISTHESIS

CONCORDANT

DISCOGRAM

INSTRUMENTSEE

RADICULOPATHY

NON-CONCORDANT

DISCOGRAM

INSTRUMENT NO SURGERY

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THIS PARTICULAR CASE

Sacralization of L 5

Biomechanics are no longer normal Much higher rate of DDD

Higher rate of spondylolisthesis

Much higher rate of failure oftreatments

Non-surgical treatment

Discectomy alone

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This particular case

ABSOLUTELY requires fusion for

successful long term treatment

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THANK YOU