fessler fusion
TRANSCRIPT
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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