退變腰椎管狹窄和腰椎滑脫的治療課件

1、Management of Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar Spine - 2006.退變腰椎管狹窄和腰椎滑脫的治療 Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineHow would you treat this?Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineAlgorithms and ConclusionsS

2、tarted with one QuestionEnded with manyHigh Risk / Low RiskStable / UnstableWhat is a good result ?Adequate vs. inadequate decompressionProtect adjacent Segments? Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar Spine Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar S

3、pineGeneral IntroductionStenosisSpondylolisthesisLiterature ReviewSyracuse StudyAlgorithms and ConclusionsPresentation ContentsDegenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineDisc degenerationLoss of cellsDegeneration of nuclear & annular matrixDiminished H2O bindingDevelopment

4、 of annular fissuresLoss of mechanical competenceEndplate changes Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineDegenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineFacet JointsAnnulus/NucleusSynovial ReactionCartilage DegenerationFacet SyndromeDYSFUNCTIONDis

5、c HerniationCircumferential TearsRadial TearsCapsular LaxitySubluxationDynamic StenosisINSTABILITYDegen SpondylolisthesisInternal DisruptionDisc NarrowingOsteophyte FormationFacet & Lamina HypertrophyFixed StenosisSTABILIZATIONCentral StenosisOsteophyte FormationVertebral Body HypertrophyMulti-level

6、 SpondylosisCombined 3-Joint ComplexYong-Hing & Kirkaldy-Willis, Orth Clin NA 1983Degenerative Spondylolisthesis of the Lumbar SpinePresentation ContentsGeneral IntroductionStenosisSpondylolisthesisLiterature ReviewSyracuse StudyAlgorithms and ConclusionsHenk Verbeist - Neurosurgical department, Uni

7、versity of Utrecht. A radicular syndrome from developmental narrowing of the lumbal vertebral canal. JBJS 1954. Degenerative Spinal Stenosis of the Lumbar SpineDegenerative Spinal Stenosis of the Lumbar SpineStenosis is a disproportion of the spinal canal between the size of the neural elements and

8、the space available.IncidenceThe L4-L5 segment is the most commonly affected, followed by the L3-L4. Occurs at a younger age in men than women.Virtually all individuals in their seventies have at least some degree of spinal stenosis on imaging studies.Only a fraction manifest the true symptoms of ce

9、ntral and/or foramanal stenosis.Degenerative Spinal Stenosis of the Lumbar SpineEtiology ClassificationCongenital DevelopmentalAchondroplasiaAcquiredDegenerative SpondylolisthesisWorse if imposed on a developmental narrowing.Arnoldi (1976)Degenerative Spinal Stenosis of the Lumbar SpineClassificatio

10、nA Central stenosisB Lateral recess stenosisC Foraminal stenosisD Extraforminal stenosisCentral StenosisALateral StenosisB, C and DDegenerative Spinal Stenosis of the Lumbar SpinePathoanatomy Canal Mean ap diam 12 -14mmStenosis 10mm Canal Cross-section area abnormal if 100mm2Stenosis absolute 75mm2r

11、elative 70 - 100 mm2Nerve root tunnel normal 5mm. 3mm or less causes compressionLumbar canal narrowest at the L2-L4 segmentsLumbar canal wider and flatter in the lower segmentsShort pedicles are a factor but not interpedicular distanceDegenerative Spinal Stenosis of the Lumbar SpineCentral StenosisC

12、linical PresentationNeurogenic claudication (from compression on the cauda equina).Increased unsteadiness or loss of balance.Feeling better if they walk stooped forward.Rarely - Urinary Incontinence / Cauda Equina Syndrome.Degenerative Spinal Stenosis of the Lumbar SpineCentral StenosisClinical Pres

13、entationPhysical examination can be unimpressiveAmbulate with a forward-leaning posture and a moderately broad-based gait.Check distal pulses to screen for vascular causes of claudication.Stress Test Walk until symptoms occur.Degenerative Spinal Stenosis of the Lumbar SpineLateral recess, foraminal,

14、 extraforaminalClinical Presentation Radicular signs from narrowing of the lateral recess or the neural foramen.Often, there is a combination of both lateral and central stenosis.Degenerative Spinal Stenosis of the Lumbar SpineDiagnostic StudiesMRICurrently represents the gold standard in the evalua

15、tion of central stenosis. It allows visualization of :DiscNeural elementsLigamentum flavumThecal sacDegenerative Spinal Stenosis of the Lumbar SpineConservative TreatmentRXNSAIDs.Muscle relaxants.Antidepressants for chronic radicular pain.Physical TherapyCan offer symptomatic relief of radicular or

16、low back pain.Not Effective in releiving claudication symptoms.Degenerative Spinal Stenosis of the Lumbar SpineConservative TreatmentEpidural & nerve root block steroid injectionsGood short term relief in patients with foraminal or lateral recess stenosisRelief in central stenosis variable and does

17、not correspond to the severity of the stenosis Degenerative Spinal Stenosis of the Lumbar SpineSurgical Treatment - decompressionIndicationsNeurological ClaudicationIntractable PainFailure of conservative treatmentBowel or bladder dysfunctionElective procedure unless bowel or bladder dysfunctionDege

18、nerative Spinal Stenosis of the Lumbar SpineSurgical TreatmentDecompression by unilateral or bilateral LaminotomyLaminectomyLaminoplastyFacetectomyForaminotomyDegenerative Spinal Stenosis of the Lumbar SpineLaminectomyLaminoplastyDegenerative Spinal Stenosis of the Lumbar SpineLaminectomyDegenerativ

19、e Spinal Stenosis of the Lumbar SpineFacetectomyForaminotomyDegenerative Spinal Stenosis of the Lumbar SpineSurgical Treatmentgoal adequate decompression without creating instabilityDegenerative Spinal Stenosis of the Lumbar SpinePosner 1982. Kuniyoshi 1990. Pintar 1992. Graded injury models effect

20、on creating instability of the FSUDorsal ligaments alone no effectUnilateral and bilateral partial facetectomies only flexion instability increasesTotal unilateral or bilateral facetectomies significant rotational and flexion increasesDegenerative Spondylolisthesis of the Lumbar SpineKnown surgical

21、factors in instability of FSU POSTERIOR Most important facets and their capsules and the supraspinatus ligamentLess important interspinous ligaments, lamina and the ligamentum flavum ANTERIOR Most important anterior longitudinal ligament and annulus fibrosusLess important nucleus pulposis Degenerati

22、ve Spondylolisthesis of the Lumbar SpineConclusionConservative treatment is often effectiveNerve root decompression is the most important aspect of surgeryadequate decompression should be done while preserving stabilityDegenerative Spinal Stenosis of the Lumbar SpineGeneral IntroductionStenosisSpond

23、ylolisthesisLiterature ReviewSyracuse StudyAlgorithms and ConclusionsPresentation Contents Degenerative Spondylolisthesis of the Lumbar SpineJurghans 1931MacNab 1950Degenerative Spondylolisthesis of the Lumbar SpineDisc degenerationLoss of cellsDegeneration of nuclear & annular matrixDiminished H2O

24、bindingDevelopment of annular fissuresLoss of mechanical competenceEndplate changesClinical presentationIncidenceAge 60sSymptoms axial back pain, worse with activity and better with unloading the spine Degenerative Spondylolisthesis of the Lumbar SpineDiagnostic studiesX-ray flexion/extension viewsM

25、RI - significance of modic changes? Degenerative Spondylolisthesis of the Lumbar SpineFusion The Gold Standard for instability and deformityTuberculosisScoliosisTraumaDegenerative? Degenerative Spondylolisthesis of the Lumbar SpineSurgical treatmentfusion in situFusion with instrumentationAnterior P

26、osteriorAnterior and posteriorMotion preservation technologiesDegenerative Spondylolisthesis of the Lumbar SpineSurgical treatmentBone GraftLocalIliac Crest Bone GraftBone MarrowAspiration progentior cellsDBMBMP Degenerative Spondylolisthesis of the Lumbar Spine Degenerative Spinal Stenosis and Spon

27、dylolisthesis of the Lumbar SpineDegenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineDegenerative Spinal Stenosis and Spondylolisthesis of the Lumbar Spine Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineMotion Preservation PosteriorPedicle/facet replacementPe

28、dicle Screw devicesDynesysSintecInterspinous spacersX StopDiamWallis Degenerative Spondylolisthesis of the Lumbar SpineThe Dynesys SystemCord, Spacer and Pedicle screw + set screw Degenerative Spondylolisthesis of the Lumbar Spine Degenerative Spondylolisthesis of the Lumbar SpineDegenerative Spinal

29、 Stenosis and Spondylolisthesis of the Lumbar Spine Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar Spine Degenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineGeneral IntroductionStenosisSpondylolisthesisLiterature ReviewSyracuse StudyAlgorithms and ConclusionsPrese

30、ntation ContentsLiterature reviewHerron (89) -decompression no fusionSilver (93) decompression no fusionHerkowitz (91) decompression vrs fusion in situBridwell (93) fusion with instrumentationDegenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineWhat we agree on in generalDecompressi

31、on for StenosisA good operationFusion for symptomatic instabilityA good operationDegenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineWhat we respectfully disagree on:When to fuseWhat to fuseHow to fuse No instrumentationInstrumentationFrontBackFront and backWhen to use motion prese

32、rvationHow to deal with adjacent segmentsDegenerative Spinal Stenosis and Spondylolisthesis of the Lumbar SpineWhy we Debate ?No Level 1 Studies.No Outcome Studies.Algorithms and ConclusionsLevels of Evidence for Primary Research QuestionJBJS ChartLevel IHigh-quality randomized controlled trial with

33、 statistically significant difference.Level IILesser-quality randomized controlled trial (e.g., 80% follow-up, no blinding, or improper randomization).Level IIIRetrospective comparative study.Level IVCase SeriesLevel VExpert opinionAlgorithms and ConclusionsEvidence-Based OrthopaedicsAre trials of t

34、herapeutic interventions using tools of outcome as measures of clinical value of that intervention.Algorithms and ConclusionsGibson JN, Waddell G. Surgery for degenerative lumbar spondylosis. Cochrane Database System Review 2005;4CD001352. All studies with inadequate follow-up, poorly reported outco

35、me measures. No evidence to support the different aspects of surgeries proposed. Recommended prospective studies with well defined subgroups.Algorithms and ConclusionsGeneral IntroductionStenosisSpondylolisthesisLiterature ReviewSyracuse StudyAlgorithms and ConclusionsPresentation ContentsSyracuse S

36、tudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisPatients = 50Females = 32Males = 18Average Age = 67.3 YearsRange = 50 to 89 YearsFollow-up = 14.4 Mo.Prior Surgery = 30%Assessment Spinal Stenosis and Degenerative SpondylolisthesisScoliosis = 14% (percent)Range = 14- 35 (degrees)Sagit

37、tal Curve Pre-op = 32.6Range = 4- 68 (degrees)Sagittal Curve Post-op = 28.0Range = 10- 60 (degrees)Sagittal Index Pre-op = 46.5Range = 10- 68 (degrees)Levels of Stenosis = 100Syracuse StudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisLevels of listhesis = 82Average listhesis = 2.6 mm

38、19 Patients1 mm12 Patients2 mm 9 Patients3 mm12 Patients4 mm 4 Patients5 mm 7 Patients6 mm 5 Patients7 mmSyracuse StudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisLevels of listhesis = 82Average listhesis = 2.6 mm 1 Patients8 mm 3 Patients9 mm 4 Patients10 mm 2 Patients12 mm 1 Patie

39、nts14 mm 2 Patients16 mmSyracuse StudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisFlexion Changes87 levels 1 mm11 levels 2 mm11 levels 3 mm 6 levels 4 mm 6 levels 5 mm 3 levels 6 mmSyracuse StudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisListhesis levels:L1-2 10 Pa

40、tientsL2-3 12 PatientsL3-4 23 PatientsL4-5 26 PatientsL5-S1 11 PatientsSyracuse StudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisSurgery - Decompression only14 Levels4 Patients - Fusion insitu16 Levels4 Patients - Posterior fusion inst36 Levels16 Patients - Sintec4 Levels4 Patients

41、- Dynesys51 Levels20 Patients - Posterior & Anterior3 Levels2 PatientsSyracuse StudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisOperated levels4 Levels 4 Patients3 Levels18 Patients2 Levels20 Patients1 Levels14 PatientsSyracuse StudyModified Oswestry Low Back Pain Disability Questio

42、nnaire 1.Pain Intensity6 Answers/Choices for each Category 2. Personal Care (Washing, Dressing, etc) 3. Lifting 4. Walking 5. Sitting 6. StandingSyracuse StudyModified Oswestry Low Back Pain Disability Questionnaire 7. Sleeping6 Answers/Choices for each Category 8. Social Life 9. Traveling10. Employ

43、ment/HomemakingSyracuse StudyGrading Scale for Intervertebral Space DegenerationUniversity of California at Los AngelesGradeDisc-Space NarrowingOsteophytesEnd Plate SclerosisI-II+-III+-IV+Syracuse StudyAssessment Spinal Stenosis and Degenerative SpondylolisthesisArthritis Score = 9.8 Average18 Patie

44、ntsOswestrey Scores:Pre-op = 28Post-op = 17Overall satisfaction with Surgery = 86% Very = 66%Somewhat = 20% Not = 14%Syracuse StudyWhat was wrong with the study? Not prospective No criteria for high risk when it determined surgery performed No objective assesment of pts functional levels Indications

45、 not firmly defined? Radicular, claudication or axial pain? Definition of good result poorly identified No consistent criteria for choosing fusion levels. Syracuse StudyWhat is good about the study?Confirmed most pts do wellIdentified areas that need to be defined in our next prospective studySyracu

46、se StudyGeneral IntroductionStenosisSpondylolisthesisLiterature ReviewSyracuse StudyAlgorithms and ConclusionsPresentation ContentsDiscussionHow would you manage this ?Algorithms and ConclusionsWe know we can make patients different. But can we make them betterIts easier to make a fusion than to mak

47、e a content patient.Algorithms and Conclusions?Algorithms and ConclusionsThe goal of treatment should be:Better Function and/orLessening of painTherefore an improvement in the quality of life.Algorithms and ConclusionsTherefore our measurements of success should, at least in part;Document achieving

48、these goals.Not just:X-ray changes.Re-operation rates.Incidence of complication.Algorithms and ConclusionsProposed AlgorithmsTo arrive at valid conclusionsDefine PatientHigh Risk / Low RiskDefine ProblemRadicularClaudicationInstabilityAlgorithms and ConclusionsProposed AlgorithmsTo arrive at valid c

49、onclusions (Cont)Define TreatmentsDefine ResultsPatient Function and SatisfactionAlgorithms and ConclusionsProposed Algorithms - Define patientHigh risk - morbidity AgeLitigation or Workmans Compensation ClaimSmoking StatusASA ClassDiabetesBody Mass IndexBone DensityAlgorithms and ConclusionsProposed Algorithms Define patient High