1、Fusion or Not? A Controversy in Spinal Surgry,Dr. Chan QiDepartment of Orthopaedics, Affiliatted Hospital of Jiangsu University,Purposes of Spinal Surgery,Stability of the Spine,In which state the spine can maintain its normal sequence and perform normal function,Spine is composed of cervical spine
2、(7 vertebrae), thoracic spine (12 vertebrae), lumbar spine (5 vertebrae) , sacral spine and caudal spine (which are non-functional). Normally, there are 3 physiological spine curvatures of spine: the cervial curvature (forward), the thoracic curvature (backward), and the lumbar curvature (forward),S
3、equential stability,cervical spine,thoracic spine,lumbar spine,In any case that spine loses its normal sequence, it is called sequential instability.,Sequential instability,Cervical spine loses its forward curvatureand becomes straight.,In some cases, the sequence of cervial spine becomes backward,I
4、n any case that spine loses its normal sequence, it is called sequential instability.,Sequential instability,In some cases, cervial spine becomes instability because of dislocation,In other cases, spine becomes instability because of compressed fructure,Tumar and infection can destory vertebra and c
5、onsequently result in spinal sequential instability,Sequential instability,Tumar of spine,Infection of tuberculosis,line a is the back edge of the upper vertebraline b is the back edge of the lower vertebrathe distance between a and b is c.if c3.5 cm, the spine is instability,Dignosis of sequential
6、instability on X-ray image in saggital view,a,b,c,a,b,line a is the lower endplate of the upper vertebraline b is the upper endplate of the lower vertebrathe angle formed by a and b is .if 11 , the spine is instability,There are many other manifestations of spinal instability on X-ray image in coron
7、al view, such as scoliosis and rotation of spine. These manifestations in coronal view are often accompanied with imagings in saggital view.,Dignosis of sequential instability on X-ray image,scoliosis,rotation,The spinous processes are not along a straight line.,In some cases, sequential stability i
8、s normal, but there are some neuro-symptons when patients flex, extend, or rotate their spine. Spinal cord or nerve root are compressed by movement of spine.In other words, spine fails to allow spinal cord and nerve root to perform their normal function. This situation is called neural stability of
9、spine.,Neural stability,Neural instability,Disc Herniation,spinal cord and nerve root is not compressed when spine is in normal position,When patient flex her spine, nerve root is compressed by herniated disc,Neural instability,When cervical spine flexes, spinal cord is compressed by hyperplastic os
10、teophyte from forward.,When cervical spine extends, spinal cord is compressed by budded ligamentum flavum from backward,In some cases, sequential stability and neural stability is normal.But patients feel back pain, especially when he/she move his/her spine. In those cases, spine can not maintain it
11、s normal physiological function because of back pain. This state is called painful instability.,Painful stability,Painful instability of spine is caused by accumulative strain, and results in dysfunction of soft tissue of the back. including muscles, ligaments, and tendons.,Painful stability,How to
12、deal with instability of spine,Fixation,external fixation,internal fixation,Temporary,Whats the permanent method,Fusion,To fuse several segments of spine together to entirety.,How to perform spinal fusion,Bone graft,Autogenous bone,Allograft bone,Artificial bone(Tissue engineering bone),Interbody gr
13、aft,Inter-transverse process graft,Vertebra posterior graft,Vertebra posterior graft,Vertebra posterior,Autogenous bone particals,Mainly used to stable the posterior column of spine;Apply to cases in which vertebra plates are integrated (Lamino-plasty)Don not need to open canalis spinalis, thus pret
14、ect spinal cord or nerver root from iatrogenic injury;Exposion and operation is easy;,Inter-transverse process graft,Expose transverse process,Graft autogenous bone stickstransverse process,Used to stable the posterior of spinal column;Apply to cases in which the vertebra plates are widely removed (
15、Lamino-ectomy),Interbody graft,Used to stable the anterior of spinal column;Expose from anterior;If expose from posterior, canalis spinalis must be opened;Apply to cases in which vertebra anterior are removed or cases in which inter-vertebra discs are removed.,Autogenous bone block graft,Interbody g
16、raft,Autogenous bone block graft,Advantages: Autogenous bone protects patients from immunological rejection.Disadvantages: Surgeon must take a whole bone block from other part of the patient, such as ilium or fibular, thus increase pain, chance of infection.,Interbody graft,Allograft bone or Artific
17、al bone,Advantages: Do not need to take autogenous bone from self, and exempt from extra pain and chance of infection.Disadvantages: increase the risks of immunological rejection,Interbody graft,Interbody fusion cage or mash,Advantages: fragments gained in the process of exposion can be used, do not
18、 need to take bone block from other part of body, and exempt from extra pain and chance of infection. Meanwhile, autogenous bone protects patients from immunological rejectionDisadvantages: the price of interbody fusion cage is high.,Interbody graft,Interbody fusion cage,Gain bone fragments when exp
19、ose from posterior or remove vertebra plate.,Pack the cage with bonefragments.,Fuse the vertebrae withcage.,Interbody graft,Interbody fusion mushin cervical spine,Interbody fusion cagein lumbar spine,Advantages of Fusion,Spine obtains reliable sequential stability, because several unstable segments
20、are fused to a whole, risk factors which results in constructive instability are eliminated. As a whole, there are no movement among fused segments, thus, dynamic instability is reversed. As a result, neural stability and painful stabilty can be achieved. Study showed that spinal fusion is able to r
21、educe pain and improve functionin patients with chronic low back pain.,Disadvantages of Fusion,Lower the spinal mobility,Normal spinal mobility,Spinal mobility are dispersed to each motion unit.Because fused motion unit can not move anymore, lumbar spinal mobility will be lowered. Consequently, life
22、 quality will be lowered.,Disadvantages of Fusion,Lower the spinal mobility,Single segment fusion,Multi-segments fusion,Atlas-axis (C1-2) fusion,Disadvantages of Fusion,Adjacent segment degeneration,Because fused segment lose its motion, the adjacent segments (upper one and lower one) take place its
23、 function, which results load increase of the adjacent segments. Consequently, the adjacent segments degenerated more quickly. This is called ASD (adjacent segment degeneration),X-ray: intervertebral space narrow formation of osteophyte instability,Disadvantages of Fusion,Adjacent segment degenerati
24、on,Disadvantages of Fusion,Adjacent segment degeneration,ASD? maybe just natural history,The patient has the susceptible factors, the intervertebra disc is easy to degenerat, no matter it is fused or not.I compared ASD rate of fusion group with that ot non-fusion group in cervical spine, the result
25、is the ASD rate in these two groups has no statistically significant difference.,4 years,Without fusion,ASD ?,Non-fusion Technique,Artifacial intervertebra disc,Reserve the spinal mobility,Remove the herniated discreplace the disc with AID,Cervical spine can flex and extend normally after surgery,No
26、n-fusion Technique,Artifacial intervertebra disc,Disadvantages: (1) AID cannt provide enough stability doesnt suit heavy load segments (Lumbar spine) doesnt suit multi-continuous segments (3) (2) AID may loosen and shift after years in patients with osteoporosis (3) AID cannt be removed, thus is dif
27、ferent to revise,Non-fusion Technique,Inter-spinous process fixation system,WALLIS System,PE material(polyethylene),elastic belt,Posterior spine column,Non-fusion Technique,Inter-spinous process fixation system,WALLIS System,Non-fusion Technique,Inter-spinous process fixation system,WALLIS System,No
28、n-fusion Technique,Inter-spinous process fixation system,WALLIS System,Non-fusion Technique,Inter-spinous process fixation system,WALLIS System,Non-fusion Technique,Inter-spinous process fixation system,Advantages: because the belt is elastic, motion of spine is reserved Disadvantages: can not provi
29、de enough stability, dosent suit multi-segments elastic belt may loose off can only fix the posterior column of spine,Non-fusion Technique in Surgery for Scoliosis,Common Surgery for Scoliosis,This girl lose normal spinal sequence, her spine is widely unstable.The physiological functions of lung and
30、 heart are harmed.,Non-fusion Technique in Surgery for Scoliosis,Common Surgery for Scoliosis,The common surgery is orthopaedy, fusion and fixation in long segmengts.,Non-fusion Technique in Surgery for Scoliosis,Long segmengts fusion results in lost of motion of spine.However, it is not the worst d
31、isadvantage.Scoliosis is commonly seen in teenages who is pysiological developping.Their organs and pysiological functions are not developped yet.Long fusion hinders the spine from further development.,Non-fusion Technique in Surgery for Scoliosis,Harrington System (dual-rods),Growing rod tech (GR),
32、Non-fusion Technique in Surgery for Scoliosis,Harrington System (single-rods),Growing rod tech (GR),Non-fusion Technique in Surgery for Scoliosis,Harrington System,Growing rod tech (GR),pedical screw,plate hook,Non-fusion,Change a longer stick every half year to adapt to the growth of spine,Non-fusi
33、on Technique in Surgery for Scoliosis,Harrington System,Growing rod tech (GR)Disadvantages,Patients accept too many surgeries - enormous pain, sky high costInternal-fixation failure: withdraw of screw, disconnect of hook, fracture of rodKyphosis deformity at junction areaHigh infection rateLoss of d
34、istraction,Fusion or Not,Fusion,Non-Fusion,Fusion or Not,There is not a standard for choice correct forever. We choose according to different situation,Fusion,Main advantage-stableFusion technique is mature tech, which has been tested for decades and proved to be effective. Main disadvantage- lowers
35、 the motion of spine,Non-fusion,Main advantage-reserve moti0nArtificial disc replacement presents better motion than interbody fusion in cervical spine. Main disadvantage- unstable,Choice,Choice depends on which is more important-stablilty or motionIn cases the spine is widely unstable, for example,
36、 3 segments are involved, severe degeneration, osteoporosis patient, fusion tech is the prior choice.In cases the motion of spine is more significant, for example, C1-2 is involved, young patient, special job, non-fusion tech is firstly choosed.Some patients choose hybrid tech (combine fusion tech a
37、nd non-fusion tech together),Choice,Some patients choose hybrid tech (combine fusion tech and non-fusion tech together),Interbody fusion,Artifical cervical disc,Stability is acceptable, and part of motion is reservedThis technique is not mature and lack of long-termfollow-up results.,Conclusion,Make your own choice according to conditions.,
