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PRINCIPLE(OF(SURGICAL(TREATMENT(IN(DEGENERATIVE(LUMBAR(DISEASES(

รศ.นพ.ต่อพงษ์ บุญมาประเสริฐ

หน่วยโรคกระดูกสันหลัง ภาควิชาออร์โทปิดิกส์

คณะแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่

The$7th$CMU$Neurosurgery$Forum$$December$11th,$2015!

CHIANG MAI Thailand!

Disclosure !  Torphong(Bunmaprasert,(MD.(

"  No((Relationships

Degenerative(Lumbar(Diseases(

Degenerative(Disc(Diseases !

Osteoarthritis(of(Facet(Joints !

Intervertebral$$discs$

Decrease disc volume Decrease disc height ( space ) Laxity of annular ligament Subluxation of disc Osteophyte formation

Facet$joints$

Degeneration of articular cartilage Synovitis Decrease joint space Laxity of joint capsule Subluxation of joint Osteophyte formation Facet joint hypertrophy

Degenerative(Lumbar(Diseases !  Back$Pain$!  Sciatica$!  Intermittent$$Neurogenic$

Claudication$

!  Neurological$Deficit$

!  Segmental$$$$$$$$$$Instability$

!  Imbalance$$"  Coronal("  Sagittal(

!  Radicular(leg(pain:(compression(of(particular(nerve(roots(

!  Pain(in(a(specific(dermatomal(pattern(corresponding(to(the(compressed(nerve(root(

!  May(have(associated(myotomal(weakness,(numbness,(hyporeflexia

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Herniated(Nucleus(Pulposus โรคหมอนรองกระดูกสัน

หลังเคลื่อน!

ปวดเอว ร้าวลงสะโพกและขา ชาเท้า ขยับร่างกายจะปวดมาก

Nerve(root( Radiculopathy(Motor$disturbance$Sensory$disturbance$Hyporeflexia !

Lower motor neuron!

Spinal(cord( Myelopathy(

•  Sensory$disturbance$

•  Motor$disturbance$

•  Bowel$and$bladder$dysfunction$

•  Hyperreflexia$

•  Spasticity$

•  Abnormal$reflexes$:$Clonus,$Babinski,$$Hoffmann,$Lhermitte,$Inverted$radial$reflex$(IVR)$

Upper motor neuron!

Degenerative(Lumbar(Spinal(Canal(Stenosis((SCS)

Thickened$ligamentum$flavum !

Facet$hypertrophy!

Intervertebral$disc$bulging!

โรคข้อต่อกระดูกสันหลังเสื่อม

(โรคกระดูกทับเส้น,หินปูนทับเส้นประสาท)(

Degenerative$Lumbar$Spinal$Canal$Stenosis !

Degenerative(Lumbar(Stenosis(without((Deformity

Common(Orthopaedic(Practice!

Degenerative(Spondylolisthesis(L4N5(Spinal(Canal(Stenosis(with(Radiculopathy

L4!

L5 !

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When!degeneration!progress!…

!  Loss(of(disc(height((((((plus(Osteopororsis)("  Sagittal(plane(deformity(

!  Laxity(of(the(spinal(joints("  Segmental(instability(

!  Asymmetrical(disc/joint(narrowing(&(Deviation(/Rotation((of(the(column("  Degenerative(scoliosis(

!  Neurological((deficit

Spinal(Imbalance Thoracolumbar+Scoliosis+with+Coronal+Imbalance�

Posi6ve+Sagi9al+Imbalance�

F,$53$$Chronic$Low$Back$Pain$for$3$months !  Occupation:(housekeeper(!  Duration:(7(months,(severe(pain(1(mo.(

!  %(LBP(/(Leg(pain(=(50(/(50(

!  Low(Back(Pain("  Severe(dullXaching(pain(for(7(months("  Paravertebral(muscle(spasm("  Restriction(of(back(motion(all(direction(

!  Right(leg(pain("  Intermittent(neurogenic(claudication("  Right(S1(radicular(pain,(burning(sensation("  Minimal(numbness,(no(weakness(

!  Prior(Rx:(none(

Physical$Examination !  Severe(pain(with(antalgic(gait(!  Marked(paravertebral(muscle(

spasm,(tenderness(LSXspine(!  Loss(of(lumbar(lordosis(!  No(stepping(or(gap(!  Limit(AROM/PROM((!  Motor:(grade(V(all(!  Minimal(diminish(pinprick(

sensation(right(S1(dermatome(!  DTR(1+(,(SLRT(90/90,(Flip(test(X

Plain$XZrays:$AP$,$Lateral$views

L5 !

L5 !

Treatment$!

!  Limit(activities(!  Weight(reduction(!  Back(support(!  Physical(therapy(!  Back(exercise(!  Medications((

"  ………………………....("  ………………………....("  ………………………....(

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MRI$LSZspine

L5 !

L4Z5 !

L5ZS1!

WHEN(CONSERVATIVE(TREATMENT(FAILED,(PATIENTS(MAY(NEED(…

Surgical$treatment$$of$Chronic$Low$Back$Pain Indications$for$surgery$1.  Cauda(equina(compression(syndrome(2.  Severe,(progressive(neurological(deficit(3.  Failure(of(nonoperative(treatment(4.  Intolerable(pain !

Principles(of(Spinal(Surgery(for(Low(Back(pain ! Decompression$เมื่อมีการกดทับระบบประสาท$

!  Fusion$เมื่อมีหลักฐานว่าเกิดภาวะไม่มั่นคงของกระดูกสันหลัง$"  Bone(graft(&(substitutions("  Instrumentation((

! Deformity$correction$เมื่อเกิดความผิดรูป$

! Motion$preservation$เมื่อต้องการคงการเคลื่อนไหว$"  NonXfusion(technology

Interspinous$Process$Spacers(!  indirectly(decompress(the(neural(elements(!  unload(the(spinal(structures(!  decrease(segmental(instability(

Surgical(Treatment Lumbar(Spinal(Stenosis !  Intermittent(Neurogenic(Claudication(is(relieved(by(bending(over,(sitting,(or(leaning(forward(while(walking

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Surgical(Treatment

Interspinous$Process$Spacers(•  Indication:(symptomatic(

neurogenic(claudication(with(radiographic(evidence(of(spinal(stenosis(and(claudication(relief(with(sitting(and(flexion

Surgical(Treatment

Interspinous$Process$Spacers(• Contraindications(((((X(isthmic(spondylolisthesis(((((X(highXgrade(degenerative((((((((spondylolisthesis(((((X(scoliosis(greater(than(25°(((((X(bony(ankylosis(((((X(cauda(equina(syndrome(((((X(severe(osteoporosis

การผ่าตัดขยายโพรงกระดูกสันหลัง (Laminectomy)!เป็นการผ่าตัด

เพื่อเอาสิ่งที่กดทับ ไขสันหลังและราก ประสาทออกไป เช่น หมอนรองกระดูก กระดูกงอก หินปูน เอ็นกระดูกที่หนาตัว หลังผ่าตัดอาการชา ปวดร้าวลงขา และ อาการอ่อนแรงจะดีขึ้น

Decompressive$Techniques((!  Laminectomy$

!  Medial$facetectomies$

!  Foraminotomies$

!  Laminotomy$

!  Discectomy$

!  Minimally$invasive$surgery$

Surgical(Treatment

Gold+standard+Rx!

Relieves(•  Leg(pain(symptoms(•  Create(stability(•  Correct(deformity(•  Back(pain(may( !

!  Iatrogenic(instability((excessive(removal(of(discs,(facet(joints,(stabilizing(ligaments,(pars(interarticularis)(

!  4X31%(recurrent(stenosis(or(spondylolisthesis(after(facetXsparing(laminectomy(

Surgical(Treatment Laminectomy+

Typical(Midline(Decompression((of(Lumbar(Spinal(Canal(Stenosis

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Surgical(Treatment Foraminotomy+Medial+facetectomy+ Laminotomy+

Surgical(Treatment

Positioning1Lumbar(Laminectomy(

Prone(position(Flexed(hips(&(knees(Abdomen(free(Padding( !

Reduces(intraop.(Bleeding(Maintain(lumbar(lordosis !

Lumbar(HNP(L4N5((severe!LBP!&!sciatica

Lumbar((Discectomy !

Decompression!procedure!

เมื่อมี Compression$ต่อ neural$elements$แก้ไขด้วย Decompression!

Central(canal(decompression !

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Central(canal(decompression !Lateral!canal!decompression!

Surgical(Treatment Minimally+invasive+surgery+(MIS)+

Open+Laminectomy! MinimallyGInvasive+Lumbar+Microdecompression+ !

(X(Less(softXtissue(dissection(((X(Greater(preservation(of( ((((((stabilizing(structures((X(Minimization(of(epidural((((

(((((((((((((scar(formation(and(((((postoperative(low(back(pain

(

Surgical(Treatment

Minimally+invasive+surgery+(MIS)+

!  Suboptimal(visualization(of(pathology(!  More(technicallyXdemand(!  Lengthen(surgical(times,(higher(costs

Surgical(Treatment Minimally+invasive+surgery+(MIS)+

Open+Sx ! MIS !

Operating$Microscope

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MicroscopicNAssisted((Spinal(Surgery

!  Illumination(((แสงสว่าง)(! Magnification((กำลังขยาย)(!  Academic(training(!  Recording(&(

Presentation(

Microscopic(Lumbar(Discectomy

Microscopic(Lumbar(Tubular(Discectomy

!  Foley&&&Smith&1999&!  Series+of+concentric+dilators+and+thinGwalled+tubular+retractors+of+variable+lengths+

!  Typically+18G22+mm.+!  Visualiza6on+

"  Naked+eyes+"  Endoscope++(MED)+"  Opera6ng+Microscope+

การผ่าตัดกระดูกสันหลังผ่านเครื่องมือ!ที่มีลักษณะคล้ายท่อ (tube surgery)!

Imaging(Studies

Plain X-rays (ภาพเอกซเรย์) MRI (คลื่นแม่เหล็กไฟฟ้า)

L4

L5

AP$Fluoroscopy$until$the$parallelism$$of$the$L4$inferior$endplate$&$the$L5$superior$endplate$was$seen

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Lateral(Fluoroscopy(Check Preoperative!Planning!for!Microscopic!Decompression!!

Lt!S1!Nerve!Root

Measure!for!Reduction!of!Radiation!Exposure

Palpate$Anatomy$with$Initial$Dilator$$

“Tubular$Retractor”$Sequential(Muscle(Dilatation(

Application$of$$Tubular$Retractor

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caudad

cephalad

L5!L4!

Placement$of$Tubular$Retractor$

Remove$the$inferior$edge$$of$the$superior$lamina$(L4)

Midline(

Remove$the$medial$edge$$of$the$superior$articular$process$of$L5$

Remove$Ligamentum$Flavum

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Identify$L5$nerve$root Retract$L5$nerve$root$&$coagulate$the$vessels

Microscopic(Lumbar(Discectomy Check$the$adequacy$of$$nerve$root$decompression$

caudad

cephalad Microscopic$Lumbar$Decompression$of$$Degenerative$$Spinal$Canal$Stenosis

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MIS$$Lumbar$Decompression$of$Degen.$Lumbar$SCS$with$Radiculopathy

MIS$$Lumbar$Decompression$of$Degen.$Lumbar$SCS$with$Radiculopathy

•  Laminotomy(L4XL5(at((the(symptomatic(side(•  Detach(the(lig.(flavum(•  Partial(facetectomy!

Thickening(of((Ligamentum(Flavum

Superior(articular(facet(of(L5(“True(Culprit”

CHIANG MAI

((((((a)(Neutral ((((((((((b)(Flexion( (((((((((c)(Extension

Degenerative(Spinal(Instability •  >3(mm(of(translation(of(one(

vertebral(body(on(another(or(•  more(than(10°(of(motion !

Static(Dynamic(!

การผ่าตัดเชื่อมข้อต่อกระดูกสันหลัง !

(Spinal Fusion)!

เป็นการผ่าตัดเพื่อให้ข้อต่อกระดูกสันหลังที่เคลื่อนและไม่มั่นคง ให้อยู่นิ่ง เพื่อจะไม่เคลื่อนกดทับระบบประสาท ซึ่งเป็นสาเหตุของอาการปวดเอว อ่อนแรงกล้ามเนื้อ ชา นิยมทำการปลูกกระดูก โดยใช้กระดูกผู้ป่วยเองหรืออาจใช้วัสดุทดแทน ใช้เวลา3-6 เดือน ข้อต่อนั้นจะอยู่นิ่งไม่ก่อให้เกิดปัญหาใดๆ

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Posterolateral((fusion((PLF)(

Posterolateral(Fusion(L3N4(L4N5

Lumbar(Interbody(Fusion

!  Anterior+Lumbar+Interbody+Fusion+(ALIF)+!  Posterior+Lumbar+Interbody+Fusion+(PLIF)+!  Transforaminal+Lumbar+Interbody+Fusion+(TLIF)+

!  Lateral+Lumbar+Interbody+Fusion+(LLIF)+!  Transsacral+Lumbar+Interbody+Fusion+(AXIALIF)+

Anterior$Lumbar$Interbody$Fusion$

(ALIF)(

Anterior(Retroperitoneal(Approach( Anterior(Lumbar(Discectomy((

Anterior$Lumbar$Interbody$Fusion$(ALIF)(

ALIF$with$Anterior$Instrumentation$

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Anterior$Lumbar$Interbody$Fusion$(ALIF)(

!  Contraindica*ons,# Male+with+increased+risk+of+infer6lity+

# Arthrodesis>2+levels+# HighGgrade+spondylolisthesis++++++++++&+spondylolysis+in+children+

# Elderly+pa6ents+with+osteoporosis+

Posterior$Lumbar$$Interbody$Fusion$(PLIF)$

!  Performing+followed+decompressive+laminecGtomy+at+the+level+of+spinal+stenosis+or+spondylolisthesis+

!  Assess+to+the+disc+space+++++++is+obtained+through+the+interlaminar+window+by+retrac6on+of+the+thecal+sac+and+traversing+nerve+root+

Lumbar$Spine$Instrumentation$$

!  Wires,!  Hooks,!  Screws+“Pedicle+screws”+

•  Segmental+fixa6on+•  Increased+torsional+rigidity+++of+the+constructs+

•  Improve+fusion+rate+•  Maintain+lumbar+lordosis+•  Decreased+numbers+of+mo6on+segment+fused+

Posterior!Lumbar!Instrumentation!Pedicle!Screw!Fixation!System!

Identify$Entry$Point!

Probing$for$$The$Lumbar$Pedicles !

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Insertion$of$$the$Lumbar$$Pedicle$Screws !

Cephalad$ Caudad$

Insertion$of$$the$Lumbar$$Pedicle$Screws !

Posterior$Lumbar$$Interbody$Fusion$(PLIF)(

Transforaminal$Lumbar$Interbody$Fusion$(TLIF)$

Transforaminal$Lumbar$Interbody$Fusion$(TLIF)(

TLIF$in$Spondylolisthesis$

Traversing Nerve Root

Exiting Nerve Root

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MinimallyNInvasive((Lumbar(Interbody(Fusion

การผ่าตัดเชื่อมข้อต่อกระดูกสันหลัง โดยใช้เทคนิคเนื้อเยื่อบาดเจ็บน้อย

MIS((TLIF((Transforaminal((Lumbar((Interbody((Fusion)

Percutaneous$Screw$Fixation

MIS$$TLIF((Transforaminal(Lumbar(

Interbody(Fusion)

Lateral$Interbody$Fusion$(LLIF)

!  MinimallyXinvasive(retroperitoneal(approach(to(the(interbody(space(through(the(psoas(muscle(

!  Transpsoas(approach(ideally(located(within(the(anterior(½(of(the(psoas(

!  EMG(monitoring(needed(!  Disc(space(is(prepared,(

interbody(device(is(placed(

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การใช้โลหะดามกระดูกสันหลัง !

(Spinal Instrumentation)!

เป็นส่วนหนึ่งของการผ่าตัดเชื่อมข้อต่อกระดูกสันหลัง เพื่อแก้ไขความผิดรูป

เร่งให้การเชื่อมติดเร็วขึ้น หลังผ่าตัดสามารถลุกเดินและกลับไปทำงานได้เร็ว

แต่ข้อเสียคือราคาแพงและใช้เวลาผ่าตัดนานขึ้น

Spondylolisthesis(Reduction

การใช้โลหะดามกระดูกสันหลัง แก้ไขความผิดรูป!(Spinal Deformity Correction)!

Degenerative(Scoliosis(Surgery !

Degenerative(Lumbar(Scoliosis !  Limited(decompression(!  Decompression(+(ShortXsegment(Fusion(!  Decompression(+(Deformity(Correction(+(LongXsegment(Fusion(

!  Spinal(Osteotomies

Principles(of(Surgical(Treatment(Degen.(Scoliosis !  Radiculopathy$

"  Nerve(root(decompression("  Therapeutic(diagnosis(

!  Spinal$instability$"  Fusion(("  +/X(Instrumentation(

!  Significant$Imbalance$"  Deformity(correction("  Flexible(vs(Rigid

Degenerative(TLNscoliosis(ShortNsegment(Fusion

Absence,of,,Global,Imbalance�

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Concave(Rod(Application(Distraction(+(Derotation(

Correction(Maneuvers(

!  Apical$vertebral$derotation$(AVD)$"  Vertebral(column(

manipulators((VCM)(

!  In$situ$bending(("  Lordotic(/(Kyphotic(benders(

!  Cantilever$maneuver$

((

!  Compression–Distraction$maneuver$

Posterior(Lumbar(Interbody(Fusion((PLIF)(

Transforaminal(Lumbar(Interbody(Fusion((TLIF)(

Second(Rod(Application

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CONCLUSION

!  Low$Back$Pain$(LBP)$"  Most(Common(Ortho.(Problems(

!  Conservative$Treatment$"  Mainstay((

!  Surgical$Treatment$$"  Decompression$

"  Fusion$!  with(instrumentation(!  without(instrumentation(

"  Deformity$correction$

"  Motion$preservation$

THANK YOU FOR YOUR ATTENTION

T.$Bunmaprasert !