Ipsilateral non-instrumented fusion using BMP with ULBD for instability and stenosis

Spine conferenceUpper Chesapeake medical Center

February 3rd, 2017

6/10/16

L1L2

L2L3

L3L4

L4L5

L5S1

?

7/30/17

Optimal anatomy: canal should be the same L1S1

L5S1

L4L5

L3L4

L2L3

L1L2

T12L1

T11T12

Mixter and Barr JBJS 1934 was the first description of herniated discs causing sciatica with surgery as a successful treatment

Henk Verbiest1909-1997Dutch neurosurgeon introduced the concept of a developmental spinal stenosis 1940 due to a small AP diameter spinal canal

Kleeman, T.J., Hiscoe, A.C., Berg, E.E.: “Patient Outcomes Following Minimally DestabilizingLumbar Stenosis Decompression: The ‘Port Hole’ Technique”, Spine, April 2000.

• J Neurosurg Spine. 2014 Aug;21(2):179-86. doi: 10.3171/2014.4.SPINE13420. Epub 2014 May 30.

• Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article.

• Mobbs RJ1, Li J, Sivabalan P, Raley D, Rao PJ.

79 patients prospective 1:1 ULBD v. open laminectomy, oswestry disability andPatient satisfaction were similar, ULBD had shorter stay 55 h v 100 h, shorter timeTo mobilize 15h v 33 h and more people not requiring opiates 51% v 15%

Toyoda et al. Clinical Outcome of Microsurgical Bilateral Decompression via Unilateral Approach for Lumbar Canal Stenosis. Spine 2011; 36:410-415 Poletti CE. Central Lumbar Stenosis caused by ligamentum flavum unilateral laminectomy for bilateral ligamentectomy. Neurosurgery 1995; 37: 343-347

Slide a Ligamentumflavum

144 single level, korea, Trefoil canal stenosis patients were more difficult to decompression due to angle of approach and patients had worse outcomes

Neurosurgery. 2006 Dec;59(6):1264-9; discussion 1269-70.Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminotomy for bilateral decompression.Oertel MF1, Ryang YM, Korinth MC, Gilsbach JM, Rohde V.

• 133 patients mean fu 5.6 years up to 10 years• Reoperation 11%, 2 instability, 7 restenosis• 85% excellent to fair long term results

Dr M F Oertel Department of Neurosurgery, University Hospital, School of Medicine, Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany

ULBD pitfalls complications• Restenosis( contralateral side)• Dural tear• Nerve injury• Instability• Persistent pain from facet• Pars fracture• Inadequate decompression

1.5 mg/ccACS: absorbably collagen sponge

Bone Graft• Iliac crest• Local• Allograft: structural, morselized• BMP• DBM• Ceramic: tricalcium phosphate and corraline hydroxyapatitie

ILIAC CREST

CANCELLOUS ALLOGRAFT

Marshall Urist made the key discovery that demineralized,

lyophilized segments of bone

induced new bone formation when implanted

in muscle pouches in

rabbits

^ Urist, Marshall R. (1965). "Bone: formation by autoinduction". Science 12:150 (698): 893–899. doi:

10.1126/science.150.3698.893. PMID 5319761

INFUSE rhBMP-2• FDA approval 7/2/02 for

the treatment of L4S1 ALIF for DDD after 6 month of nonop treatment can include grade 1 spondylolisthesis• 85% current use is off

label• Approved for revision

PLF nonunions/smokers

INFUSE rh_BMP-2• FDA approved

4/30/04 for acute open tibial fractures treated with IM nailing within 14 days of injury

J Bone Joint Surg Am. 2002 Dec;84-A(12):2123-34.Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients

COST: $5k case

45 woman infection one year out

Adjacent level inadvertent fusion of facet

ALIF

Retrograde ejaculation ALIF• The underlying mechanism of the dysfunction is the inability of the internal vesical sphincter to contract during ejaculation, resulting in retrograde flow of semen to the urinary bladder.[13] As the muscle is innervated by the superior hypogastric plexus, i.e., a thin, retroperitoneal plexus of nerves overlying the lumbosacral junction, damage to the plexus during (or after) ALIF can denervate the bladder neck sphincterRetrograde Ejaculation after ALIF with rh-BMP

• 7% versus 0.5%

• Retrograde ejaculation after anterior lumbar interbody fusion using rhBMP-2: a cohort controlled study

• Eugene J. Carragee, MD The Spine Journal 2011

Soft Tissue swelling s/p acdf with fibular allograft

Adverse swelling associated with use of rh-BMP-2in anterior cervical discectomy and fusion: a case studyBrian Perri, DO*, Martin Cooper, MD, Carl Lauryssen, MD, Neel Anand, MDThe Spine Journal 2007

ORTHOPEDIC AND DENTAL INDUSTRY NEWS      COMPLETE ARCHIVE »

FDA Issues Warning Regarding Off-Label Use of rhBMPBY LAUREN UZDIENSKI, JULY 7, 2008Last week the FDA released a public health notification regarding the off-label use of of rhBMP (InFuse, OP-1) in the cervical spine. The agency says that over the past four years there have been at least 38 reports of complications associated with using BMP in unapproved cervical fusion cases, ranging from difficulty swallowing, breathing or speaking to severe dysphagia.Most reported complications occurred between two and 14 days following surgery. Treatments included respiratory support with intubation, anti-inflammatory medication, tracheotomy and most commonly second surgeries to drain the surgical site. The seriousness of the complications was correlated with the anatomical proximity of the cervical spine to airway structures. The FDA adds, "The mechanism of action is unknown, and characteristics of patients at increased risk have not been identified."

POSTOPERATIVE SEROMA

• Postoperative Cervical Myelopathy and Cord Compression Associated with the Use of rh-BMP-2 in Posterior Cervical Decompression, Instrumentation, and Arthrodesis: A report of two cases; Anderson DW, Burton DC, Jackson RS; Spine (Jan 2011)

774 man with postoperative seroma POD #8 I&D bedside

66 YEAR OLD WOMAN S/P L4L5 PSF ADMITTED FOR LBP POD #18

Psoas calcification

• Brower RS, Vickrov NM. A case of psoas ossification from the use of BMP-2 for posterolateral fusion at L4-L5. Spine 2008;33:E653-55.

• Rob D Dickerman, Ashley S Reynolds, Matthew Bennett in Spine (2009)

77 year old woman with cc: LBP B buttock pain PMH: type 2 DM, HTN,

L3L4

LEFT PSOAS

COMPLAINTS OF LEFT GROIN AND THIGH PAIN PROMPTED CT OF THE ABDOMEN AND HIP POD #32 WHICH REVEALED CALCIFICATIONS AND SWELLING OF THE LEFT PSOAS MUSCLE

MRI 9/24/09 which was 7 weeks postop revealed evolving calcification of the psoas c/w myositis ossificans

Ectopic bone formation

60 WOMAN CC: L SCIATICA S/P L3L5 POSTERIOR DECOMPRESSION WITH L4L5 INSTRUMENT FUSION ON 9/29/08 INTIALLY DID WELL BUT HAD RECURRENT SCIATICA IN MARCH 2011. REPEAT MRI SCAN REVEILED A L L5S1 LATERAL RECESS COMPRESSIVE PROCESS FROM THE L L5S1 FACET/DISC SPACE,BUT ALSO OVERGROWTH OF THE L4L5 FACET FUSION PROCESS WHERE BMP WAS PLACED

osteolysis

radiculitis

Contraindicated in cancer patients

BMP dosage• Acdf: 0.2-0.6 mg/level: low complication rate with

better fusion rates than control• PLF: 8.5-12 mg bmp/level• TFLIP: <4.2 mg/level, min improvement in fusion

rate• ALIF:<4.2mg/level

thanks