surgical treatment in degenerative lumbar diseases · • partial(facetectomy!...
TRANSCRIPT
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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 !