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WHATS HOT WHATS HOT WHATS NOT WHATS NOT

Catherine C. Capps, MDCatherine C. Capps, MD

WellCare WellCare

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WHATS HOT WHATS HOT WHATS NOT WHATS NOT

SPINESPINE

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DEGE N ER ATIV E D ISC D ISE ASE (DDD)DEGE N ER ATIV E D ISC D ISE ASE (DDD)

Studies inconclusive regarding occupationalStudies inconclusive regarding occupationalfactors:factors:

Some found no relationships between occupationSome found no relationships between occupationand DDDand DDDOthers found occupational loading and vehicularOthers found occupational loading and vehicular

vibration is correlated with DDD vibration is correlated with DDDHigher correlation with smoking, body weightHigher correlation with smoking, body weight(increased BMI), and especially heredity.(increased BMI), and especially heredity.

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DDD Cervical SpineDDD Cervical Spine

Conservative Care:Conservative Care:

NSAI sNSAI sSteroidsSteroids

Traction/ Therapy Traction/ Therapy Rest. RestrictionsRest. Restrictions

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DDD Cervical Spine SurgeryDDD Cervical Spine Surgery

Anterior Cervical Decompression Anterior Cervical Decompressionand Fusion ( ACDF )and Fusion ( ACDF ) VS. VS.

Cervical Disc ReplacementCervical Disc Replacement

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ACDF ACDF

The Go ld Standard The Go ld StandardSuccess Rate of Fusion:Success Rate of Fusion:

97% Single Level97% Single Level7575--87% 2 Level87% 2 Level5656--68% 3 Level68% 3 Level

(Higher number reflects plate fixation used )(Higher number reflects plate fixation used )

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ACDF ACDF Whats H ot/ Whats N ot Whats H ot/ Whats N ot

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Whats N ot: Whats N ot:

Metal ImplantsMetal Implants

Risk of increased urine and serum levelsRisk of increased urine and serum levelsof metal ionsof metal ions

Difficulty with subsequent imaging onDifficulty with subsequent imaging onCT, MR ICT, MR I

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Whats H o t: Whats H o t:

Absorbable Implants Absorbable Implants

Hydroxyapatite and calcium phosphateHydroxyapatite and calcium phosphatescrewsscrewsPoly LPoly L--lactic acid mesh plateslactic acid mesh plates

Breakdown after 6 weeksBreakdown after 6 weeks

Fusion 71Fusion 71--77% at 1 year77% at 1 year

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ACDF Pr ob lems: ACDF Pr ob lems:

Acceleration of disc degeneration at Acceleration of disc degeneration atadjacent level in 67% of patients.adjacent level in 67% of patients.

10% require a 210% require a 2ndnd

procedure atprocedure atadjacent level.adjacent level.

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The New Alternative? The New Alternative?

Cervical Disc Replacement:Cervical Disc Replacement:

Medtronics Prestige DiscMedtronics Prestige DiscApproved by the FD A, July 2007 Approved by the FD A, July 2007

Preserve motion and normalPreserve motion and normalkinematics between two vertebraekinematics between two vertebrae

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Cervical D isc R eplacementCervical D isc R eplacement

Complicati ons:Complicati ons:

Spontaneous fusionSpontaneous fusion

Catastrophic failure with implantCatastrophic failure with implantdislocationdislocation

Long term wear debris leading to implantLong term wear debris leading to implant

loosening and failureloosening and failure

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Anterior Displacement Anterior Displacement Airway Obstruction Airway Obstruction

Posterior Displacement into spinal canalPosterior Displacement into spinal canalParalysisParalysis

DeathDeath

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Verdict N ot In Verdict N ot In -- Long TermLong TermR esults Kn o wnR esults Kn o wn

64% good to excellent results at 2 yr64% good to excellent results at 2 yrfollow follow--up in one recent study up in one recent study

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The F uture? The F uture?

ACDF ACDF-- 97% success in single level97% success in single level V s. V s.

CDR CDR-- 64% success rate in early studies64% success rate in early studies

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Lum bar D isc D iseaseLum bar D isc D isease

Conservative Care:Conservative Care:NSAINSAI

SteroidsSteroidsP TP TExerciseExercise

Weight Loss Weight LossInjectionsInjections

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IDE TIDE T(Intradiscal E lectr othermal Therapy )(Intradiscal E lectr othermal Therapy )

Indications:Indications:Failure post 6 months conservativeFailure post 6 months conservativetherapy therapy Annular tears Annular tearsSmall disc protrusionsSmall disc protrusions

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IDE TIDE T

Small heating coil insertedSmall heating coil insertedpercutaneously percutaneously

Coil heated to denature collagen,Coil heated to denature collagen,

ablate nociceptive fibers and modulateablate nociceptive fibers and modulateinflammatory responseinflammatory response

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IDE TIDE T

Results:Results:Recent prospective randomized trialRecent prospective randomized trial50% of pts had 75% relief 50% of pts had 75% relief

Another recent trial suggests failure Another recent trial suggests failurerate is 50% at 2 yr follow uprate is 50% at 2 yr follow up

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Opti ons in Lum bar F usi ons:Opti ons in Lum bar F usi ons:

Appr oach Appr oach (anterior, posterior,(anterior, posterior,posterolateral, 360posterolateral, 360 ) )

Instrumentati onInstrumentati on (none, pedicle screws(none, pedicle screws with rods or plates, cages, bioabsorbable with rods or plates, cages, bioabsorbablealternatives )alternatives )B one GraftB one Graft (iliac crest, demineralized bone(iliac crest, demineralized bonematrix or bone morphogenic proteinmatrix or bone morphogenic proteinaugmentation, allografts )augmentation, allografts )

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Lum bar F usi onLum bar F usi on

PLI F vs. ALI FPLI F vs. ALI F

Per S wedish spine study group, noPer S wedish spine study group, nosignificant difference overallsignificant difference overall

At 2 yrs, 63% with good or excellent At 2 yrs, 63% with good or excellentresultsresults

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Lum bar F usi on Pr ob lems:Lum bar F usi on Pr ob lems:

Increased risk for adjacent levelIncreased risk for adjacent leveldegenerationdegeneration

Possible need for future additionalPossible need for future additionalproceduresproceduresLimit segmental mobility Limit segmental mobility Successful bone healing does notSuccessful bone healing does notguarantee pain relief guarantee pain relief

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Fusion RateFusion Rate6060--95%95%

Pain Relief Pain Relief 5050--80%80%

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Complicati ons:Complicati ons:

Wound infection Wound infectionPain at ICBG site in pelvisPain at ICBG site in pelvisPseudoarthrosisPseudoarthrosisImplant failureImplant failure

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The New Alternative The New AlternativeLum bar D isc R eplacement (L DR)Lum bar D isc R eplacement (L DR)

Advantages: Advantages:Maintains motion at segmentMaintains motion at segmentDecreases transfer stresses to theDecreases transfer stresses to the

adjacent levelsadjacent levels

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ChariteCharite nonconstrainednonconstrained disc movesdisc movesfreely between end platesfreely between end plates

ProdiscProdisc semiconstrainedsemiconstrained discdiscattached to lower endplate. Discattached to lower endplate. Disc

articulates like ball and socket joint.articulates like ball and socket joint.More intrinsically stable construct.More intrinsically stable construct.

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Contraindicati ons:Contraindicati ons:

OsteoporosisOsteoporosis

Abnormal curvature of spine Abnormal curvature of spine(scoliosis, for example )(scoliosis, for example )Instability (spondylolisthesis )Instability (spondylolisthesis )Facet disease of significanceFacet disease of significance

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Surgical Approach:Surgical Approach: Anterior Anterior need to work behindneed to work behindthe abdominal contents, to movethe abdominal contents, to moveand protect the major bloodand protect the major blood

vessels to legs vessels to legs

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DDDDDD -- The F uture The F uture

Intradiscal Gene Therapy Intradiscal Gene Therapy

V iral transfer of growth factor genes V iral transfer of growth factor genesto increase the production of to increase the production of

proteoglycan in vivo and in vitroproteoglycan in vivo and in vitro

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Intradiscal Gene TherapyIntradiscal Gene Therapy

Safe at correct dose and delivered intoSafe at correct dose and delivered intodiscdisc

Toxic at higher dose or when misdirected Toxic at higher dose or when misdirectedinto epidural or intradural spaceinto epidural or intradural spaceRabbits with misdirected injectionRabbits with misdirected injectionsuffered lower extremity paralysis andsuffered lower extremity paralysis andsensory loss; 2 found dead.sensory loss; 2 found dead.

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Oste o porotic Verte b ralOste o porotic Verte b ralCompressi on F racturesCompressi on F ractures

10 million in USA have osteoporosis.10 million in USA have osteoporosis. Approx 1.5 million osteoporosis Approx 1.5 million osteoporosisrelated fractures in the US in 2001;related fractures in the US in 2001;700,000 in spine.700,000 in spine.

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Oste o porosis R isk F act ors:Oste o porosis R isk F act ors:

FemaleFemaleCaucasian/ AsianCaucasian/ Asian

Small FrameSmall FrameAge AgeEstrogenEstrogen

Deficiency Deficiency Amenorrhea Amenorrhea

Inactivity Inactivity Smoking Smoking

Alcohol Intake Alcohol IntakeMedsMeds

CorticosteroidsCorticosteroids

Excess thyroid hormoneExcess thyroid hormone Anticonvulsants Anticonvulsants Antacids containing Antacids containing

aluminumaluminum

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Occupati onal Significance:Occupati onal Significance:

Fracture may occur with very minorFracture may occur with very minorinjury (even just sitting down firmly orinjury (even just sitting down firmly or

hard on a chair ).hard on a chair ).

Dx: XR, CT, MR I Dx: XR, CT, MR I (helps determine chronicity )(helps determine chronicity )

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Treatment Treatment

ConservativeConservativeBedrest* / Activity RestrictionBedrest* / Activity RestrictionPain MedicationPain MedicationBracing Bracing

*Beware in elderly *Beware in elderly

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Whats H ot, Whats Whats H ot, Whats

N ot In UpperN ot In UpperEx tremity InjuriesEx tremity Injuries

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Cumulative TraumaCumulative Trauma

D isordersD isorders(CTD s )(CTD s )

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CumulativeCumulative Trauma Trauma D isordersD isorders

Repetative Biomechanical StressRepetative Biomechanical StressOver TimeOver TimeE rgonomicsE rgonomics Focus on PreventionFocus on PreventionMultifactorialMultifactorial

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CT DCT D

Controversal TermControversal TermImplies a level of presumed knowledgeImplies a level of presumed knowledgeregarding etiology which does notregarding etiology which does notnecessarily existnecessarily exist

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Further epidemiologic studiesFurther epidemiologic studies warranted to estimate relative warranted to estimate relativecausationcausation

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Wrist Wrist

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Carpal Tunnel Syndr omeCarpal Tunnel Syndr omeSX and Signs:SX and Signs:

Paresthesias: 1Paresthesias: 1 4 Digits4 Digits Tinels Tinels

PhalensPhalensMedian N erve Compression TestMedian Nerve Compression TestRole of Radiographic StudiesRole of Radiographic Studies

Role of N C V / EMGRole of N C V / EMG

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Carpal Tunnel Syndr omeCarpal Tunnel Syndr ome Treatment: Treatment:

ConservativeConservativeBlah, Blah, BlahBlah, Blah, Blah

SurgicalSurgicalOpen ReleaseOpen ReleaseEndoscopic ReleaseEndoscopic Release Associated Procedures Associated Procedures

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Wrist Tend onitis Wrist Tend onitis

Extensors De Quervain s Disease:Extensors De Quervain s Disease:

Sheath of

EPB,

Ab

PL

Sheath of

EPB,

Ab

PL

Most Common Tendonitis of WristMost Common Tendonitis of Wrist

E tio Direct Trauma or OveruseE tio Direct Trauma or Overuse

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D e QuervainsD e Quervains

Sx & SignsSx & Signs

FinklesteinsFinklesteins

Treatmant Treatmant

Conservative vs. SurgicalConservative vs. Surgical

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Ex tens or Carpi Ulnaris Pr ob lemsEx tens or Carpi Ulnaris Pr ob lems

66thth CompartmentCompartment

Can develop subluxationCan develop subluxation

In acute cases, splint 6 weeksIn acute cases, splint 6 weeks

In chronic subluxation, reconstruct sling In chronic subluxation, reconstruct sling

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Wrist Tend onitis Wrist Tend onitis -- F lexo rsF lexo rs

TenosynovitisTenosynovitisFCR FCR

FCUFCU Wrist Flexors Wrist FlexorsDigits Trigger FingersDigits Trigger Fingers

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E tiology E tiology Look for Systemic FactorsLook for Systemic FactorsOveruseOveruse

Treatment Treatment

Conservative vs SurgicalConservative vs Surgical

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E lbo w E lbo w

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Lateral E pic ondylitisLateral E pic ondylitis

Most Common Tendonitis at E lbow Most Common Tendonitis at E lbow

Disruption at ECRB AponeurosisDisruption at ECRB Aponeurosis

Repetative Microtrauma, Overload Injury,Repetative Microtrauma, Overload Injury,or Direct Traumaor Direct Trauma

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Lateral E pic ondylitisLateral E pic ondylitis

SX and Signs: CozensSX and Signs: CozensXR: Poss CalcificationXR: Poss Calcification

Treatment TreatmentConservativeConservative

Whats Beneficial? Whats Beneficial?

SurgicalSurgical

Release or Repair?Release or Repair?Failure of Surgery Failure of Surgery

Misdiagnosis?Misdiagnosis?

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Cu b ital Tunnel Syndr omeCu b ital Tunnel Syndr ome

Second Most Common Peripheral NerveSecond Most Common Peripheral NerveCompression SyndromeCompression Syndrome

Concurrent Systemic FactorConcurrent Systemic Factor

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Cu b ital Tunnel Syndr omeCu b ital Tunnel Syndr ome

Other E tiologic ConsiderationsOther E tiologic Considerations

Trauma / Direct Blow / FX Trauma / Direct Blow / FX

Protracted E lbow FlexionProtracted E lbow Flexion V ibrating Tool Use V ibrating Tool UseRepetative E lbow Flexion / Extension, Push / PullRepetative E lbow Flexion / Extension, Push / PullResting E lbow on Hard SurfaceResting E lbow on Hard Surface Anatomic Considerations Anatomic Considerations

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Cu b ital Tunnel Syndr omeCu b ital Tunnel Syndr omeSx and SignsSx and Signs

Pain Medial E lbow Pain Medial E lbow Dysthesias / ParethesisDysthesias / Parethesis -- ring & little fingerring & little finger

Sensory & Motor FindingsSensory & Motor Findings Tinels, Bent E lbow, Sublex Tinels, Bent E lbow, SublexNC V , EMGNC V , EMG

XR XR

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Cu b ital Tunnel Syndr ome TreatmentCu b ital Tunnel Syndr ome Treatment

ConservativeConservativeNSAINSAIInjectionsInjectionsN ight splintsN ight splintsPadded chair/tablePadded chair/tabletop or elbow padstop or elbow pads V ary degree of elbow V ary degree of elbow flexion/ Extensionflexion/ Extension

Surgery Surgery Release in SituRelease in Situ

Transposition Transposition