Download - Failures lumbar instability
Lumbar Instability Lumbar Instability
Causes - Diagnosis - ManagementCauses - Diagnosis - Management
George SapkasGeorge Sapkas
Asc. ProfessorAsc. Professor
11stst Orthopaedic Department Orthopaedic Department
Athens Medical SchoolAthens Medical School
Lumbar Instability
• Clinical
• Radiological
Clinical Lumbar Instability
• Not any specific definition• … the condition that the
patient feels that his back is unstable
White A. & Panjabi M.Clinical Biomechanics of the Spine 1980
Radiological Instability
• Spondylolysis• Spondylolisthesis• Adult Degenerative
Scoliosis• Post-Laminectomy
Lumbar Instability
The main cause of lumbar instability in adults is the instability of the spine that follows the operative treatment of lumbar stenosis
ETIOLOGY OF THE LUMBAR STENOSIS
Lumbar Stenosis-
Developmental
LumbarStenosis
-
DegenerativeSpondylolisthesis
Lumbar Stenosis-
Isthmic Spondylolisthesis
Lumbar Stenosis-
Congenital
Lumbar Stenosis-
Degenerative Adult Scoliosis
Etiology of Lumbar StenosisAdultAdult
scoliosisscoliosis
Congenital
Congenital
DevelopmentalDevelopmental
Isthmic Isthmic SpondyloSpondylolisthesislisthesis
DegenerativeDegenerative
SpondylolisthesisSpondylolisthesis
Foramen
Interverterbral Disc Space - Foramen
LUMBAR STENOSIS TREATMENT
•CONSERVATIVE
•OPERATIVE
Conservative treatment
• NSAIDS• Injections - Facet’s Block• Epidural - Caudal injection• Brace• Psychological support• Social support
Operative treatment
Laminectomy without stabilization
Laminectomy associated with
Transpedicular Stabilization
Laminectomy associated with PLIF
Laminectomy associated with
PLIF and Transpedicular stabilization
Causes of Failure
•Pre-operative •Intra-operative•Post-operative
Preoperative causes of failure
•Wrong diagnosis•Pre-existing conditions associated with increased operative risk or difficulties
Wrong diagnosis
• Infection• Tumor• Other causes of pain• Psychological –
social problems
Infection Tumor
Other causes of pain
Psychological – Social problems
Pre-existing conditions associated with increased operative risk or difficulties
I. Deformities e.g. scoliosis,
spondylolysis, spondylisthesis
II. Infections or tumorsIII. Previous discectomiesIV. Previous laminectomiesV. Previous lumbar fusions VI. Previous operated spinal
deformities VII. Pre existing instabilitiesVIII. Inadequate investigation
• Clinical • Radiological
Intra-operative causes of failure
• Hemorrhage • Facets’ – pedicles’
destruction• Screws misplacement• Battered nerve roots• Osteoporosis• Graft’s quality and
quantity• Inadequate
decompression
Post-operative causes of failure
Early post-operative causes of failure (0 – 3 wks)
•Haematoma•Infection•Implants’
failure
Late post-operative causes of failure(a. 3wks – 3mths)
• Implants‘ failure– Screws
• loosening • Broken • Dislodged
– Rods • Broken
• Destabilization • Infection
Late post-operative causes of failure(b. > 3mths)
• Implants failure• Destabilization
– at the level(s) of the operation– at the level above -//-– at the level below -//-
• Pseudarthrosis • Recurrence of stenosis • Late infection
Consequences
Intra-operative
• Removal of the ligamentous and bony structures destabilizes the lumbar spine
• Instability discovered intra-operatively extends the operative time.
• In case of pre-existed pathology e.g.
osteoporosis,tumor, infection
• The fixation of the implants is not safe
• The dissemination (malignant tumor) is very likely
Post-operative
•Immediate•Early•Late
Immediate / early post operative
• Unchanged symptoms• Recurrence of -//-• Deterioration of -//-
Late post-operative
a. Instability
b. Recurrence of stenosis
± neurologic deficit
c. PainPost-operative failures due to:–Buttered nerve roots–Muscles destruction–Implants failure–Instability
cause a. considerable
back and leg pain b. disability
Neurologic compromise:•Recurrence of stenosis•Instability
– May lead to anterioposterior or lateral subluxation – displacement.
The abnormal spatial relationship is achieved at the cost of spaces through which the nerve roots of the cauda equina travel in their course from the spinal cord to and through the neural foramen:
injury to the nerve root(s) may result.
Management
Investigations
•Clinical •Radiological•Psychological - Social
Clinical examination
• Medical evaluation• Neurological
investigation
Radiological investigation
• Plain x-rays• Dynamic x-rays• CT- scan• M.R.I.• Discograms• Scanning • Local injections
Conservative treatment
• NSAIDS• Brace• Injections – Facets’ Blocks• Epidural – Caudal injections• Epidural endoscopy
(pain management) • Back schools• Psychological – Social support
Local injections
• Epidural• Caudal• Facet’s block
Unpredictable results
Temporary improvement
and
Limited satisfaction
Operative treatment
Intra-operative:
• When the spinal instability is recognized intra-operatively consideration should be given to perform spondylodesia with or without instrumentation
Post Laminectomy Instability
Revision surgery for
post-laminectomy instability
Revision surgery for
post-operative instability
(above or below the operated level)
Cases
1st caseDegenerative Spondylolisthesis – Lumbar Stenosis
Instability at the level above the spondylodesia
Extension of the spondylodesia
2nd caseLumbar Fracture Laminectomy & Plif without
internal fixation
Facetectomies - Lumbar Instability
Facetectomies
Lumbar Instability
Lumbar Instability
Treatment: Transpedicular Internal Fixation
3rd casePost Facetectomies – Laminectomies
Instability
Extensive Facetectomies
Post Laminectomy Lumbar Instability
Treatment: Transpedicular Internal Fixation
4th casePost Laminectomies - Facetectomies
Instability
Facetectomies
Lumbar Instability
Treatment: Transpedicular Stabilization
Conclusions
I. Careful pre-operative evaluation is mandatory to realize the underlying
pathology
II. The frequency of
instability complicating lumbar laminectomy is higher in patients with:
• pre-existing pars defect (spondylolysis - sthesis)
• Spondylolisthesis• Congenital or
developmental lumbar stenosis
III. Removal of the least
possible of the bone (facets) and soft tissues (ligaments & facets capsule) is essential in the prevention of instability following lumbar laminectomy
IV. Instability complicating lumbar laminectomy can be avoided if the surgeon proceeds in spondylodesia of the affected levels with or without instrumentation in case that instability is encountered intra-operatively
V.V. PLIF + Internal Stabilization provides PLIF + Internal Stabilization provides stable Post Laminectomy spinal levelsstable Post Laminectomy spinal levels
VI.VI. Stability of the spinal level above the Stability of the spinal level above the rigid transpendicular stabilization can rigid transpendicular stabilization can be provided by the interspinous be provided by the interspinous implantsimplants
VII.The stabilization of the affected level is associated with better results in the following conditions:
A. Lumbar stenosis associated with degenerative spondylolisthesis
B. Lumbar stenosis associated B. Lumbar stenosis associated with adult scoliosiswith adult scoliosis
C. Revision surgeryC. Revision surgery