kostuik revision surgery

8/7/2019 Kostuik Revision Surgery

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CLASSIFICATION-ANALYSIS-

TREATMENT OF FAILURES OF SPINAL

DECOMPRESSION SPINAL FUSION

Chairman & Chief Medical Officer, K2M

Past President SRS and NASS

Past Chief & Chairman Spine Surgery, John Hopkins University

Prof John Kostuik


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CLASSIFICATION-ANALYSIS-

TREATMENT OF FAILURES OF

SPINAL DECOMPRESSION SPINALFUSION

John P. Kostuik, MD ( Emeritus )Johns Hopkins MedicineDepartment of Orthopaedic/ Neurosurgery SurgerySpine SurgeryBaltimore, Maryland

r opae c


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70% of Failed Spinal Surgery

Should Never

Have Had An

Initial Operation


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Causes For Failure

Improper diagnosis

Poor patient selection

Psychosocial factors

Incorrect indications

Poor technique

Complications


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Failures of Decompression


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Immediate Failure (I.F.)

Wrong diagnosis

Discogenic pain (I.D.D.)


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I.F.

Delayed decompression

Technical error

Wrong level

Inadequate decompression

Conjoint nerve root


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Temporary Relief

Early Recurrence Infection

Discitis

Osteomyelitis Epidural Abscess

Meningeal cyst


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Mid-Term Failures

(Weeks-Months)

Recurrent Disc Prolapse

Battered Root Epidural Fibrosis

Arachnoiditis


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Long Term Failures

(Months-Years) Recurrent Stenosis

Disc Space Collapse Lateral Stenosis

Instability after Disc Excision Instability after Decompression


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Post Laminectomy

Kyphosis

Causes

Integrity of facets Ligaments

Age

Osteoporosis


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Bone Complications

After Decompression

Slippage 0-96%

Pars Fracture ~ 3% Facet Fracture 11%


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Failures After

Spinal FusionCauses and surgical treatment results


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Early

Infection

Wrong or insufficient levels

Psychosocial distress Nerve root impingement


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Psychological Tests

High false positive rate


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Patient At Risk

Identification Duration of disability

Perception of injury

Compensability Job satisfaction


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Why Does Intertransverse

Fusion Fail?

Anterior Column Loading


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When Is It Fused?


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Diagnosis of Pseudarthrosis

Suspect Broken instrumentation

Loose instrumentation

Radiographic

Plain x-rays

Flexion extension x-rays

Bone scan

CT

3D CT ( Metal Subtraction)


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Early

Continued pain

Recurrence of deformity =PSEUDARTHROSIS

New deformity

Implant change

Implant pullout

Implant loosening


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Negative Exploration

# Pseudarthrosis


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Type of Pseudarthrosis

Transverse

Plate


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Types of Pseudarthrosis

Transverse

Plate

XXXXXXXXXX Graft

Lamina

Canal


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Proof

Injection

Motion

Secondary Other levels are normal


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Causes of Long-Term Failure

Late pseudarthrosis

Adjacent motion segment degeneration

Spinal stenosis Disc herniation (4%)

Acquired spondylolysis

Sacro iliac instability Donor site pain


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What Predicts A Good Outcome

From Surgery?

Unequivocal symptoms

Unequivocal physical examination Confirmatory imaging studies


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What Can You, Your Patient

Expect? A 4x increase in complications compared to

decompression

A Particular issue in the elderly


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The Surgeon Factor


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Right patient

Right diagnosis

Right surgery (surgeon)

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