融合還是非融合？脊柱手術(shù)的爭(zhēng)論

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 sta

2、te the spine can maintain its normal sequence and perform normal function,Spine is composed of cervical spine (7 vertebrae), thoracic spine (12 vertebrae), lumbar spine (5 vertebrae) , sacral spine and caudal spine (whi

3、ch 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),Sequential stability,cervi

4、cal 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

5、 cases, the sequence of cervial spine becomes backward,,In any case that spine loses its normal sequence, it is called sequential instability.,Sequential instability,In some cases, cervial spine becomes instability beca

6、use of dislocation,In other cases, spine becomes instability because of compressed fructure,,,Tumar and infection can destory vertebra and consequently result in spinal sequential instability,Sequential instability,,Tum

7、ar 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&q

8、uot;.if "c">3.5 cm, the spine is instability,Dignosis of sequential instability on X-ray image in saggital view,a,b,c,a,b,,α,line "a" is the lower endplate of the upper vertebraline "b"

9、; is the upper endplate of the lower vertebrathe angle formed by "a" and "b" is "α".if "α">11 °, the spine is instability,There are many other manifestations of spinal in

10、stability on X-ray image in coronal 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 i

11、mage,scoliosis,rotation,,,The spinous processes are not along a straight line.,In some cases, sequential stability is normal, but there are some neuro-symptons when patients flex, extend, or rotate their spine. Spinal

12、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 spine.,Neural stabili

13、ty,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

14、 spine flexes, spinal cord is compressed by hyperplastic osteophyte from forward.,When cervical spine extends, spinal cord is compressed by budded ligamentum flavum from backward,,,In some cases, sequential stability an

15、d neural stability is normal.But patients feel back pain, especially when he/she move his/her spine. In those cases, spine can not maintain its normal physiological function because of back pain. This state is called p

16、ainful 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

17、 to deal with instability of spine,Fixation,external fixation,internal fixation,Temporary,What's the permanent method,Fusion,To fuse several segments of spine together to entirety.,How to perform spinal fusion,Bone

18、graft,,Autogenous bone,Allograft bone,Artificial bone(Tissue engineering bone),,Interbody graft,Inter-transverse process graft,Vertebra posterior graft,Vertebra posterior graft,Vertebra posterior,Autogenous bone partica

19、ls,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 pretect spinal cord or nerver root from iatrogeni

20、c 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

21、in which the vertebra plates are widely removed (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

22、to cases in which vertebra anterior are removed or cases in which inter-vertebra discs are removed.,Autogenous bone block graft,Interbody graft,Autogenous bone block graft,,,Advantages: Autogenous bone protects patients

23、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 Artif

24、ical 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

25、or mash,Advantages: fragments gained in the process of exposion can be used, do not need to take bone block from other part of body, and exempt from extra pain and chance of infection. Meanwhile, autogenous bone protects

26、 patients from immunological rejectionDisadvantages: the price of interbody fusion cage is high.,Interbody graft,Interbody fusion cage,Gain bone fragments when expose from posterior or remove vertebra plate.,Pack the

27、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, bec

28、ause several unstable segments 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.

29、As a result, neural stability and painful stabilty can be achieved. Study showed that spinal fusion is able to reduce pain and improve functionin patients with chronic low back pain.,Disadvantages of Fusion,Lower the

30、 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 quality will be lowe

31、red.,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

32、 adjacent segments (upper one and lower one) take place its function, which results load increase of the adjacent segments. Consequently, the adjacent segments degenerated more quickly. This is called ASD (adjacent segme

33、nt degeneration),X-ray: ① intervertebral space narrow ? formation of osteophyte ③ instability,Disadvantages of Fusion,Adjacent segment degeneration,Disadvantages of Fusion,Adjacent segment degeneratio

34、n,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

35、cervical spine, the result 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,Rem

36、ove the herniated discreplace the disc with AID,,Cervical spine can flex and extend normally after surgery,Non-fusion Technique,Artifacial intervertebra disc,Disadvantages: (1) AID cann't provide enough stability

37、 doesn't suit heavy load segments (Lumbar spine)

38、 doesn't suit multi-continuous segments (>3) (2) AID may loosen and shift after years in patients with osteoporosis

39、 (3) AID cann't be removed, thus is different to revise,Non-fusion Technique,Inter-spinous process fixation system,WALLIS System,PE material(polyethylene),elastic belt,Posterior spine column,Non-fusion Technique,

40、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,WALLIS System,Non-fusion Technique,

41、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:

42、 can not provide enough stability, dosen't suit multi-segments elastic belt may loose off can only fix the posterior column of spine,Non-fusion Technique in Surg

43、ery for Scoliosis,Common Surgery for Scoliosis,This girl lose normal spinal sequence, her spine is widely unstable.The physiological functions of lung and heart are harmed.,Non-fusion Technique in Surgery for Scoliosis,

44、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

45、is not the worst disadvantage.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 developme

46、nt.,Non-fusion Technique in Surgery for Scoliosis,Harrington System (dual-rods),Growing rod tech (GR),Non-fusion Technique in Surgery for Scoliosis,Harrington System (single-rods),Growing rod tech (

47、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-fusion Technique i

48、n 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,

49、 fracture of rodKyphosis deformity at junction areaHigh infection rateLoss of distraction,Fusion or Not,Fusion,Non-Fusion,Fusion or Not,There is not a standard for choice correct forever. We choose according to dif

50、ferent situation,Fusion,Main advantage----------------stableFusion technique is mature tech, which has been tested for decades and proved to be effective. Main disadvantage--------------- lowers the motion of spine,N

51、on-fusion,Main advantage----------------reserve moti0nArtificial disc replacement presents better motion than interbody fusion in cervical spine. Main disadvantage--------------- unstable,Choice,Choice depends on whi

52、ch is more important-----------stablilty or motionIn cases the spine is widely unstable, for example, >3 segments are involved, severe degeneration, osteoporosis patient, fusion tech is the prior choice.In cases

53、 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 and non-fusion tech together

54、),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