Lumbar Stenosis

Degenerative Spondylolisthesis Degenerative Scoliosis

GEORGE SAPKAS

Professor of Orthopaedics Medical School-Athens University

Metropolitan HospitalAthens Greece

Aging of the Disc - Spine

Interverterbral disc space – foramen

progressive stenosis and neural compression

Interverterbral disc space –

foramenprogressive stenosis and

neural compression

Disc - Facet degeneration - Stenosis

Degenerative

Spondylolisthesis

Developmental DDD

Degenerative Adult Scoliosis

Sites of pain origin

Investigations

Clinical Radiological

Degenerative Spondylolisthesis

Degenerative Scoliosis

Clinical evaluation

Degenerative Spondylolisthesis Lumbar Stenosis

Radiographic assessment

Global1. In the coronal plane2. In the sagittal planeRegionalSegmental

This is assessed by the relationship of the C7 plump line to the sacrum in the coronal and sagittal planes

Lumbar Degen. Sp/thesis

TREATMENT

OPTIONS

Conclusions

Four clinically relevant key questions were addressed in this study :

Review articleSurgery for adult spondylolisthesis: a systematic

review of the evidence

Tobias L. Schulte et al, Eur. Spine 2016

A.

Is surgery more successful than conservative treatment

in relation to pain and function in adult patients with isthmic SL?

B. Is surgery more successful than conservative treatment

in relation to pain and function in adult patients with degenerative SL?

C.

Is instrumented fusion with decompression more successful in relation to pain and function

than decompression alone in adult patients with degenerative SL and spinal canal stenosis?

D. Is instrumented fusion with reduction

more successful in relation to pain and function

than instrumented fusion without reduction in adult patients with isthmic or degenerative SL?

Answers

1. In adults with isthmic SL,

surgery appears to be better in relation to pain and function

than conservative treatment (poor evidence).

2. In adults with degenerative SL, surgery appears

to be better in relation to pain and function

than conservative treatment (good evidence).

3. In adults with degenerative SL and

spinal stenosis, instrumented fusion

with decompression appears to be more successful in relation to pain and function

than decompression alone (poor evidence).

4. In adults with isthmic or degenerative SL,

reduction and instrumented fusion does not appear to be more successful in relation to pain and function

than instrumented fusion without reduction (moderate evidence)

Adult scoliosis

Primary degenerative scoliosis (‘‘de novo’’ form), mostly located in the thoracolumbar or lumbar spine

Grubb SA, et al (1992)Aebi M. (2005)

1. Body deformity2. Pain 3. Neurological

disorders

Main problems

Coronal –Sagittal imbalance

Automatic fusion

Muscles – LigamentsS-I joints

Neurological disorders

1. Lumbar canal stenosis2. Foraminal stenosis

Operative treatment

Purposes of the operative treatment

I. Prevention of progressionII. Maintenance of lumbar lordosisIII. Restoring global balanceIV. To reduce or to relieve the painV. To anticipate the neurological deficit

Key points

Sagittal imbalance is poorly tolerated in elderly scoliosis patients

Timothy Kuklo, Spine 2006

• A fusion should not be stopped adjacent to a degenerated segment

Timothy Kuklo, Spine 2006

L5

L5 S1

S1

L5

S1

• Inadequate decompression• Post-operative instability • Deterioration of the deformity

Side effects

Decompression

Γ.Π.F 7401-10-07

Decompression and stabilization(short)

Posterior Correction and Stabilization

Transpedicular Screws and TLIF L3-L4 & L4-L5

TLIF

Adult degenerative Kyphosis – Scolioisis(+) Parkinson

Observations

Extensive Operative time

Automatic fusion Multiple osteotomies

for mobilization

Technical issues

Loss of :• Lumbar Lordosis

(flat back) and

• Sagittal balance

Technical issues

• Osteotomies to restore sagittal balance (e.g. S.P. osteotomies)

• Intervetebral cages

Lumbar corrective osteotomies for flat back ± intervertebral spacers

Osteoporosis

Top-off

Extension of spondylodesia

To fuse or not to fuse to the sacrum

The fate of the L5 – S1 disc

sacrumalar

Absolute indication Oblique

take-off at L5 – S1

E. Pant. F. 75

7-4-02

6mts pop

Implants failure ~ 4%

Pseudarthrosis ~ 7% - 15%

Loss of correction

Complications related to implants and fusion

K.St.

F. 67

8 yrs pop

16-02-07

K.St.

F. 67

8 yrs pop

16-02-07

Conclusions

Conservative treatment

Deformity Pain Neurological disorders

CorrectionStabilizationDecompression

65

The 3 columns correction and stabilization

Overall gives the best clinical results

This meta-analysis made no recommendation for which specific type of

surgery is the best and

which surgical technique should be selected for different patients

because the circumstances surrounding each patient

are highly complex.

Review articleSurgical treatments for degenerative lumbar scoliosis:

a meta analysis

Guohua Wang et al, Eur. Spine 2015

Cont.

This meta analysis included a study that found no significant differences in Roland–Morris score, Oswestry score,

and patients’ satisfaction between patients who

underwent isolated decompression, short fusion,

and long fusion surgery

Cont.

Transfeldt EE, et al, Spine 1976

One study compared the clinical outcome recurrent leg paincomplications between isolated

decompression and decompression plus limited fusion

revealed that recurrent leg pain occurred significantly more

often in patients within 6 months post isolated decompression.

Cont.

Daubs MD,, et al, Evid Based Spine Care J. 2012

Despite a high rate of complications, this review demonstrates that surgery is an effective and reasonable treatment

intervention for severe DLS and

ultimately improves spine function and deformity.

Cont.

This review also suggests that large scale, high quality studies with long term follow-up

are needed to provide more reliable evidence for future evaluation.

Key point for the successful operative treatment of the adult spinal deformity is the restoration of the sagittal balance.