Degenerative Disc Degenerative Disc Disease CascadeDisease Cascade

--Treatment options Treatment options available to treat available to treat

different stages of DDD different stages of DDD in lumbar spinein lumbar spine

George SapkasGeorge SapkasAsc. ProfessorAsc. Professor

--Medical School Medical School

Athens UniversityAthens University

Interverterbral Interverterbral disc space – foramendisc space – foramen

progressive stenosis and progressive stenosis and neural compressionneural compression

Disc - facet degeneration - Disc - facet degeneration - stenosisstenosis

DevelopmenDevelopmental DDDtal DDD

DegenerativeDegenerative

SpondylolisthesisSpondylolisthesis

Degenerative Adult Degenerative Adult ScoliosisScoliosis

Sites of pain origin

Investigations Investigations

Clinical Clinical RadiologiRadiological cal

Clinical Clinical evaluationevaluation

Imaging Imaging studiesstudies

Plain x-raysPlain x-rays Dynamic x-Dynamic x-raysrays

Myelogram Myelogram

CT - scanCT - scan 3D - scan3D - scan

MR-IMR-I

DiscograDiscogramm

Facet’s blockFacet’s block

Psychological investigationPsychological investigation

Pain drawingPain drawingPain drawing

M.M.P.I.M.M.P.I.

OswestryOswestry

Rolland MorrisRolland Morris

SP-36SP-36

Functional – Disability questionnaires

LUMBAR DDD LUMBAR DDD TREATMENTTREATMENT

CONSERVATIVECONSERVATIVE

OPERATIVEOPERATIVE

Conservative treatmentConservative treatment

NSAIDSNSAIDS

Injections - Facet’s Injections - Facet’s BlockBlock

Epidural - Caudal Epidural - Caudal injectioninjection

BraceBrace

Psychological supportPsychological support

Social supportSocial support

Rehabilitation programm Rehabilitation programm

When do we operate the When do we operate the degenerative disease ?degenerative disease ?

1.1. Pain not responding to Pain not responding to conservative treatment, conservative treatment, lasting more than 3 lasting more than 3 monthsmonths

2.2. Non improving Non improving neurologic deficit neurologic deficit

3.3. Persistence or Persistence or deterioration of deterioration of symptoms of intermitent symptoms of intermitent claudicationclaudication

4.4. Significant restriction of Significant restriction of the common daily the common daily working and social working and social activitiesactivities

Operative Operative treatmenttreatment

--Options Options

Disc Disc degenerationdegeneration

Gold standardGold standard

Microdiscectomy Microdiscectomy

Flexible Flexible or or

Dynamic Dynamic spondylodesia spondylodesia

± ± microdiscectommicrodiscectom

yy

??

Graf Dynesys

Isolock Twinflex Agile Agile (Medotronic)(Medotronic)

Interspinous Interspinous spacersspacers

± ± microdiscectommicrodiscectom

yy

Lindsey DP et al. Spine 2003Lindsey DP et al. Spine 2003Zucherman J, et al. Spine 2005Zucherman J, et al. Spine 2005Richards JC, et al. Spine 2005 Richards JC, et al. Spine 2005

Vertebral disc degenerationModic I changesNarrow spinal canal anticipated without laminectomyPrevent degeneration of the adjacent intervertebral disc and facet

Indications: Indications:

3 ½ p.op

Pre-op6 mts pop

The interspinous spacer reduces the intradiscal pressure and assists in the re-hydration of the disc

Swanson K, et al. Spine 2003

Interspinous spacer

Degenerated discs Degenerated discs

Lumbar Lumbar Intervertebral Intervertebral

FusionFusion(PLIF – TLIF – X-(PLIF – TLIF – X-

LIF)LIF)

The goals are to:The goals are to:a)a) Restore the height of the Restore the height of the

intervertebral disc spaceintervertebral disc spaceb)b) Restore the width of the Restore the width of the

intervertebral foramenintervertebral foramenc)c) Achieve the maximum Achieve the maximum

stability and rigiditystability and rigidityd)d) Relocate Relocate

the subluxated the subluxated jointsjoints

e)e) Restore lumbar lordosisRestore lumbar lordosisf)f) Restore, close to normal Restore, close to normal

the loads on the anterior the loads on the anterior vertebral columnvertebral column

Degenerative Degenerative Disc Disease Disc Disease

Spinal Spinal stenosisstenosis

DecompressioDecompression without n without

spondylodesia spondylodesia

Instability Instability A. Total laminectomyA. Total laminectomy

Vertebral olisthesesVertebral olistheses (65% & 20%) (65% & 20%) Johnson et al Spine 1992Johnson et al Spine 1992

Re-operationRe-operation : 17% : 17% ptsptsIntensive painIntensive pain : 30% >> 3-6 : 30% >> 3-6 yrs popyrs pop

Ketz et al JBJS 1991Ketz et al JBJS 1991 Airaksihen et al Spine 1996 Airaksihen et al Spine 1996 Simpson et al JBJS 1993 Simpson et al JBJS 1993 Spivak et al JBJS 1998 Spivak et al JBJS 1998

ContraindicationContraindication : : multiple levelsmultiple levels Paine et al Clin Orthop 1976Paine et al Clin Orthop 1976 Sanderson et al JBJS 1993 Sanderson et al JBJS 1993

B. Facetectomy B. Facetectomy

Laminectomy Laminectomy

+ + PLIFPLIF

Spondylodesia with internal Spondylodesia with internal fixationfixation

Laminectomy- PLIF Laminectomy- PLIF and and

Transpedicular stabilizationTranspedicular stabilization

Anterior-posterior Anterior-posterior decompression decompression and stabilizationand stabilization

Implants Implants

PYRAMID® Anterior Lumbar Plate

PERIMETER™ PEEK

CD HORIZON® SEXTANT® Fixation System