POSSIBILITIES OF SURGICAL MANAGEMENT OF DEGENERATIVE DISORDERS OF THORACIC AND LUMBAR SPINE Chaloupka R., Ryba, L. Faculty of Medicine, MU Brno Head: Prof. MUDr. Martin Repko, Ph.D. Czech Republic Degenerative disorders of discs (osteochondrosis) > stadium of dysfunction 15 - 35 yrs > stadium of instabili lity 35 - 55 vrs - hernia b yrs > stadium of stabilisation from 55 yrs University Hospital Brno, Orthopaec^ Back pain scles SfiHE lories, joints, Jjgamsni3y rnu Mechano-Chemoreceptors Dorsal root qanqlion - neurooeDtids Lig longit post - the most sensitive of a lumbar spine ligaments Radicular pain Due to compression Chemical irritation Irritation of dorsal root ganglion - DRG - electrical impulses - neuropeptids synthesis - VIP (vasoactive intestinal peptid, substance P) Levels of evaluation • anamnesis, • subjective - VAS score 0-10 • objective, • imaging methods, X-ray, MRI • laboratory, • internal exam • neurological exam - level of lesion, EMG Pain • Acute - chronic (>3 months) • Nociceptive - injury, degen arthritis, inflammation • Neuropatic - damage of neural system (brain, spinal cord, nerve roots, perif nerves) • Mixed - low back pain with nerve compression • Damage: functional - structural - mixed • Simulation - dissimulation Risk factors of pain • Older age • Bad physical and psychic condition • psychic stress • genetic disposition • obesity • hypokinesis • abuse of alcohol and smoking • Sedentary work • Heavy physical work Etiology due to damage tissue • discogenic, • vertebrogenic, • myogenic, • neurogenic, B Neuropathic • vascular - vasogenic • viscerogenic - from internal organs, • psychogenic, Evaluation • Structural Psychological • X-ray, standing, will • functional • MRI cooperation • Functional Social • Neurological - EMG Method of Wiltse a Winter Dupuis et al Instability: flexion/extension translational > 8% rotatory > 11 Wood et a Loui Wood et a I Schizas et al. Spine 2010, 35, 21, 1919-1924 Classification of lumbar spinal stenosis Surgery: C, D Jllllli^ lllllll^^ Conservative tx and tx after surgery • Regime measures - changing of positions, ergonomy • Limitation of stress - no carrying and lifting of loads/weights • physiotherapy - isometry + strengthening of muscles, correct posture, respiratory physiotherapy, .. - effect after 3 months • Exercises daily, permanently • Temporary use of orthoses Indication of surgical tx Depletion of conservative tx of • - deformities (spondylolisthesis) • - spinal stenosis • - instabilities • - worsening of neural deficit (herniae, stenosis) • - clear origine of pain • - corresponding clinical + radiological finding Correlation Subjective difficulties Clinical finding Neurological examination aging rnstnoc Psychological condition Possibilitis of surgical tx • Decompression • Decompression + dynamic stabilisation • Dynamic stabilisation - posterior - (anterior) • Posterolat fusion + transped instrumentation • 360° fusion + transpedicular fixation with deformities correction - special cages for PLIF, TLIF, (ELIF, ALIF) • (Anterion - ALIF - special cages) ALIF - anterior lumbar interbody fusion, special cages Mobile disc prosthesis - endoprosthesis, limited use 360° fusion - Posterolateral fusion- bone grafts, transpedicular fixation + PLIF TLIF Posterior lumbar... transforaminal lumbar interbody fusion - special cages M 73 yrs, gait disturbance, Lumbar Spinal Stenosis T10-11 - 360° fusion, TLIF M70 yrs, pain, gait disturbance, radicular SI pain - 360° fusion + TLIF L2-5 F 70 yrs, neurogenic claudications, radiculopathy L4, slip L4, L5 - sagittal imbalance, L2-S1 360° fusion with cages Conclusion - surgical tx After depletion of conservative tx: • - deformities (spondylolisthesis) • - stenosis • - instability • - worsening of neural deficit (herniae, stenoses) • - clear origine of pain • - corresponding clinical + radiological finding