FUSION is the answer to this

DDD problem
• Professor,
Department of Neurosurgery,
Northwestern University,
Feinberg School of Medicine
•Interest:
• MIS, Deformity, Intradural Tumors

Richard G. Fessler, MD, PhD

 FUSION
is the answer to this DDD problem

RICHARD G. FESSLER, M.D., PH.D.

Professor
Northwestern University, Feinberg School of Medicine
Chicago, IL
 DISCLOSURE
• Medtronic
– Consultant
– Research
– Royalty
• DePuy
– Consultant
– Royalty
• Stryker
– Consultant
 BED REST

• Wiesel Spine 5:324-330, 1980

– No better than continued ambulation
• Deyo et al. N Engl J Med 315:1064-
1070, 1993
– 2 days superior to 4 days
• Gilbert et al. BMJ 291:791-794, 1985
– 0 vs 4 days-pain unchanged but 0 days
returned to work faster
 BED REST

• POTENTIAL RISKS

– 1.0 - 1.5% loss of muscle mass/day

– 15% loss of aerobic capacity in 10
days
– bone mineral loss
– hypercalcemia and hypercalciuria
– thromboembolism
 EXERCISE

• Deyo et al. JAMA 250:1057-1062,

1983
– Aerobic exercise superior to no
exercise
 TRACTION

• NO BENEFIT
– Deyo et al. JAMA 250:1057-1060,
1983
– Mathews et al. Br J Rheumatol
26:416-423, 1987
– Pal et al. Br J Rheumatol 25:181-
183, 1986
– Quebec Taskforce on Spinal
Disorders Spine 12(Suppl):S1-9,
1987
PHYSICAL THERAPY
MODALITIES

• HEAT/COLD
• DIATHERMY
• MASSAGE
• ULTRASOUND
• CUTANEOUS LASER
TREATMENT
• ELECTRICAL STIMULATION
 PHYSICAL THERAPY
MODALITIES
•
– There is no evidence which shows
sufficient benefits to justify cost.

– Heat or cold treatments at home are

as effective as anything.

Waterworth N Z MED J, 1985

Postacchini NEURO-ORTH, .1988
 ACUPUNCTURE

• NO BENEFIT
– Minimum 9 studies showing no
benefit
 BACK BRACE

• NO BENEFIT
– Deyo et al. JAMA 250:1057-1060,
1983
– Million et al. JBJS 40:449-454, 1981
– Quebec Taskforce on Spinal
Disorders Spine 12(Suppl):S1-9,
1987
NSAID’S AND NARCOTICS

• Significant benefit
– Berry et al. Ann Rheum Dis 41:129-
132, 1982
– Deyo et al. JAMA 250:1057-1060,
1983
– Frymoyer et al. JBJS 65:213-218,
1983
– Hingorani, Ann Phus Med 8:303-306,
1966
KUSLICH, SPINE 1998

• Prospective evaluation of BAK

cage ALIF
• Fusion rate > 90 % at 2 years
• Fusion rate > 95 % thereafter
KUSLICH: NASS, 1999

• Long term follow-up

• 91 % fusion rate
Anterior thoracolumbar bone
dowel fusions
• Patient demographics:
• Average age 51.9 yrs. (range 28 -
77)
• Average duration of symptoms: 8.3
years
• 27 patients treated between 1991
and 1997
• Minimum follow-up: 2 years
 FUSION RATE WITH ALIF
ALLOGRAFT AND PEDICLE
SCREWS

Fusion Pseudo Equivocal

VAMVANIJ, SPINE 1998

• Compared four different types of

fusion in prospective randomized
clinical trial
– PLIF + facet screws
– ALIF (allograft) alone
– PLIF + pedicle screws
– BAK+ facet screws
VAMVANIJ, SPINE 1998
 WANG, 1996
Journal of Spinal Disorders
• ALIF using autogenous or allograft iliac
crest bone graft
• Posterior instrumentation using
Diapason or TSRH
• 95 % fusion rate
 OPEN vs LAP ALIF

• Complications:
•1 cage malposition Chung et al., Eur.Spine J., 2003
•2 retrograde ejaculation
•1 DVT
•1 bladder malfunction
Duggal et al.,
Neurosurgery, 2004
LAPAROSCOPIC ALIF with
rhBMP-2
• 22 consecutive patients
• 100 % satisfied with result
• 100 % improvement in leg pain
• 100 % significant functional
improvement
• 100 % fusion rate
Kleeman et al, 2001
Spine
 OVERALL

• Excellent results of ALIF over many

years of experience
 Endoscopic TLIF and
Percutaneous Pedicle Screw
Instrumentation

•Khoo,L.T., Palmer,S., Laich,D.T., Fessler,R.G.: Minimally

Invasive Percutaneous Posterior Lumbar Interbody Fusion.
Neurosurgery 51(5, Supplement), 166-181, 2002.
 RESULTS

p < .008

•*

• Fusion rate: 98 % VAS

 RESULTS

p < .0001 P < .01

•*
•*

Oswestry SF-36
LONG TERM OUTCOME

MAST
TLIF
VAS
 RISK

• Open Posterior Fusion

– 3 % major complication rate
– 30 % minor complication rate

Cassanelli et al.
Spine 32: 230-235, 2007
 OBESITY:
OUTCOME FOLLOWING MINIMALLY
INVASIVE FUSION SURGERY

Rosen, D., Ferguson, S., Ogden, A.T., Huo, D., Fessler, R.G.: Obesity and
Self Reported Outcome after Minimally Invasive Lumbar Spinal Fusion
Surgery. Neurosurgery 63:956-960, 2008.
MINOR COMPLICATIONS
OVERALL 22 %

> 30 < 25

25-30
Major Cx: 0 %
 BMI < 25 BMI 25-30 BMI > 30

Post-op 3 2
radiculopathy
Lower extremity 1
weakness
Urinary retention 2
Durotomy 1 1
Superficial wound 1
infection
Delirium 3 2
Nausea 1
CHF exacerbation 1
Hypertension 1 1
Hypotension 1 1
Ileus 1
PERCENT OF TOTAL
23 26 14
 BACK PAIN

MULTILEVEL 1 – 2 LEVEL NO
DDD DDD PATHOLOGY

NO NO
NO CLEAR CLEAR STENOSIS SURGERY
STENOSIS
PATHOLOGY PATHOLOGY

NO SEE
SURGERY 1-2 LEVEL
 1 – 2 LEVEL
DDD

NO STENOSIS STENOSIS

NO
SPONDYLOLISTHESIS
SPONDYLOLISTHESIS

CONCORDANT NON-CONCORDANT
DISCOGRAM DISCOGRAM

SEE
INSTRUMENT NO SURGERY INSTRUMENT
RADICULOPATHY
THIS PARTICULAR CASE

• Sacralization of L 5
– Biomechanics are no longer “normal”
– Much higher rate of DDD
– Higher rate of spondylolisthesis
– Much higher rate of failure of
treatments
• Non-surgical treatment
• Discectomy alone
 This particular case

• ABSOLUTELY requires fusion for

successful long term treatment
THANK YOU