Anatomic MIS Treatment-based classification of spinal

Anatomic MIS Treatment-based classification of spinal

motion-segment disease and application in Endoscopically-

assisted lamino-foraminoplasty

Said G Osman, M.D., F.A.A.O.S., F.R.C.S.Ed.(ortho)

Frederick, Maryland USA

BACKGROUND

1. Lack of a universal comprehensive treatment-based classification

• When a vehicle breaks down the necessary part is ordered using a catalogue number (universal code) for that part. When the part is fixed, the vehicle, almost invariably is cured!

BACKGROUND

1. Lack of a universal comprehensive treatment-based classification

• The diagnosis of back problem is much more complicated than that of vehicular breakdown! But it is desirable to have “ Universal Codes” which can guide treatment options!

BACKGROUND

Why is universal comprehensive treatment-based classification desirable?

1. Multiple anatomic structures contributing to pain at each spine level,

2. Advanced imaging technology identifies each pathologic entity

3. Medical professionals across the globe will be able to accurately developments

4. It makes comparison of outcome studies of different treatment options more accurate and relevant

BACKGROUND

Recent opinions about how to treat this case:

o Classify the disease, Facet block, discography, then decide based on patient-specific data

o Facet block L5-S1

o Discography then endoscopy

o Radiofrequency anuloplasty + caudal block.

o mechanical percutaneous annuloplasty

o AxiaLIF as ALIF through paracoccygeal approach

o More data and axial views, good discography and treatment with STALIF L5/S1 or ADR L5/S

o Artificial disc replacement if not, comfortable posture & walking traction( vertetrack)& standing extension excersise trial to rebalancing between psoas & extensors 1st. Then consider annuloplasty.

BACKGROUND

o Why so many opinions?

Based on the clinical information and MRI findings:

1. Each doctor probably had arrived at a differentdiagnosis; or

2. Some may have arrived at same diagnosis butrecommended different options.

Differences of opinion aremeaningful if we agree onthe diagnosis (or if we have a Universal code tolabel the disease!)

BACKGROUND

2. Emergence of sophisticated diagnostic tools:

oMRI scan:

oDisc

oAlignment

oFacet joint

oLigamentum

oCanal dimensions

oCT scan

oWithout contrast

oCT-mylelogram

o3D images

BACKGROUND

4. Emergence of multiple treatment modalities:

oDiscectomy:

oOpen interlaminar

oTubular interlaminar

oEndoscopic interlaminar:

oUniportal

oBiportal, unilateral vs bilateral

oEndoscopic transforaminal

oUniportal

oBiportal

oEndoscopic trans-iliac

oFusions:

oOpen: Posterolateral, PIF, TLIF, ALIF

oMIS: PLIF, TLIF, LLIF, OLIF,

oEndoscopically assisted: KLIF, ETIF, Trans-osseous interbody fusion

oDisc arthroplasty

oPosterior dynamic stabilization

PURPOSE

To develop a comprehensive treatment-based

classification of spinal motion-segment disease

METHODS

o Review of literature

o Grading of the pathology of intervertebral disc, facet joint, ligamentum flavum, and spinal column alignment

o Development of a matrix with all the SMS components

o Computation of all possible combinations of SMS grading

o Retrospective study of the prevalence of the combination in clinical situation.

METHODS

o Grading of the pathology of intervertebral

disc, facet joint, ligamentum flavum, and

spinal column alignment

A = Alignment D = Disc F = Facet L = Ligamentum Flavum (LF)

A0 = NormalA1= RetrolisthesisA2 = Grade I spondyA3 = Grade 2SpondyA4= Grade III & IVspondy w/o synovialcyst formation

D0 = Normal discD1 = Global bulging discD2 = ContainedherniationD3 = Free frag herniationD4 = Disc osteophytesposterior

F0 = Normal facetF1 = IAP hypertrophyF2 = SAP hypertrophyF3 = IAP & SAP hypertrophyF4 = IAP & SAP hypertrophy & synovial cyst.

Key:IAP = Inferior Articular ProcessSAP = Superior Articular Process

L0 = NormalL1= Minimal hypertrophy ofLFL2= Moderate hypertrophyof the LFL3= Severe hypertrophy ofthe LFL4 = Calciified/ossified

RESULTS

: a: normal alignment (A0); b – retrolisthesis (A1); c – grade 1 spondylolisthesis (A2); d

– grade II spondylolisthesis (A3); e – grade III & IV spondylolisthesis (A4)

RESULTS

: a – normal disc (D0); b – global bulge (D1); c – intra-annular disc herniation (D2);

d – extra-annular disc herniation (D3); and e – posterior disc osteophytes (A4).

RESULTS

a – normal facet (F0); b – inferior articular process hypertrophy (F1); c- superior

articular process hypertrophy (F2); d - inferior and superior process hypertrophy

(F3); e – facet hypertrophy and synovial cyst formation (F4)

RESULTS

normal LF (L0); b – mildly hypertrophied LF (L1); c – moderately hypertrophied (L2); d

– severely hypertrophied LF (L3); d - calcified LF (L4)

METHODS Development of a matrix with all the SMS components

D0

(normal disc)

D1

(global bulge)

D2

(Intra-annular

herniation)

D3

(Extra-annular

herniation)

D4

(Disc

osteophytes)

F0

(Normal facet = normal foraminal height & AP

diameter)

D0A0L0F0 DI A0L1F0 D2A0L2FO D3A0L3F0 D4A0L4F0

A0

(Normal alignment)

F1

(IAP hypertrophy = ↓ lat recess AP diameter)

D0L0A0F1 D1L1A1F1 D2A1L2F1 D3A1L3F1 D4A1L4F1

A1

(Retrolisthesis = ↓ disc height, global bulge )

F2

(SAP hypertrophy = ↓ foraminal height & AP

diameter)

D0A2L0F2 D1A2L1F2 D2A2L2F2 D3A2L3F2 D4A2L4F2

A2

(Grade I listhesis = Mild to moderate central and

foraminal stenosis)

F3

(S&IAP hypertrophy = ↓ Foraminal height &

foraminal/lat recess AP diameter)


A3

(Grade II listhesis = moderate to severe central & foraminal

stenosis)

F4

(S&IAP hyper + cyst =↓ foraminal, height &

foraminal/lat recess ±central AP diameter)


A4

(Grade III&IV listhesis = extreme central and foraminal stenosis)

L0

(normal LF)L1

(mild LF hypertrophy)

L2

(moderate LF hypertrophy)

L3

(severe LF hypertrophy)

L4

(Calcified, hypertrophied LT

RESULTS 494 Possible Combinations

BASIC DISC CODE STANDARDIZED DISC CODE BASIC ALIGNMENT CODE STANDARDIZING ALIGN CODE BASIC LIG CODE STANDARD LIG CODE BASIC FACET CODE STANDARD FACET CONE

D0A0L0F0 D001 D0A0L0F0 A001 D0A0L0F0 L001 D0A0L0F0 F001

D0A0L1F0 D002 D1A0L1F0 A002 DIA0L0F0 L002 D0A1L0F0 F002

D0A0L2FO D003 D2A0L2FO A003 D2A0L0FO L003 D0A2L0F0 F003



D0A0L0F1 D006 D0A0L0F1 A006 D0A0L0F1 L006 DI A0L1F0 F006




















D1A0L0F0 D026 DI A1L1F0 A026 D0A0L1F0 L026 D0A0L0F1 F026

D1A0L1F0 D027 D2A1L2F0 A027 DI A0L1F0 L027 D0L0A1F1 F027




D1L0A0F1 D031 D1A1L1F1 A031 D0L1A0F1 L031 DI A0L1F1 F031

D1L1A1F1 D032 D2A1L2F1 A032 D1L1A1F1 L032 D1L1A1F1 F032




















D2A0L1F0 D052 D1A2L1F0 A052 D1A0L2F0 L052 D0L0A1F2 F052

D2A0L2F0 D053 D2A2L2FO A053 D2A0L2F0 L053 D0A2L0F2 F053



D2L0A0F1 D056 D0A2L0F1 A056 D0A0L2F1 L056 DI A0L1F2 F056

D2L1A1F1 D057 D1A2L1F1 A057 D1A1L2F1 L057 D1A1L1F2 F057




















D3A0L1F0 D077 DI A3L1F0 A077 D1A0L3F0 L077 D0L0A1F3 F077

D3A0L2F0 D078 D2A3L2FO A078 D2A0L3FO L078 D0A2L0F3 F078



D3L0A0F1 D081 D0L0A3F1 A081 D0L3A0F1 L081 DI A0L1F3 F081

D3A1L1F1 D082 D1A3L1F1 A082 D1A1L3F1 L082 D1L1A1F3 F082




















D4 A0L2F0 D102 D1A4L1F0 A102 D1A0L4F0 L102 D0L0A1F4 F102

D4A0L3FO D103 D2A4L2F0 A103 D2A0L4FO L103 D0A2L0F4 F103























RESULTS

o Review of MRI Films:

o 204 Spinal motion-segments

o 57 patients

o Male = 30, Female = 27

o Age range; 16 to 87 years (Mean = 47.3 yrs)

RESULTS

Review of MRI Films:

CODE % Pathologic

D0A0L0F0 33.3 Normal disc, normal alignment, normal ligamentum flavum, normal facet joint

D1A0L0F0 8.8 Degenerative global bulging disc, normal alignment, normal LF, and normal facet joint

D2A0L0F2 6.9 Intra-annular disc herniation, normal alignment, normal LF, and hypertrophy of superior articular

process

D1A0L1F3 6.4 Global bulging disc, normal alignment, mild hypertrophY LF, hypertrophic superior & inferior

articular processes

D1A0L1F0 3.9 Global disc bulge, normal alignment, mild hypertrophy of LF, normal facet joint

D2A0L1F0 2.5 Intra-articular disc herniation, normal alignment, mild hypertrophy of LF,

D3A0L0F0 2.5 Extra-annular disc herniation, normal alignment, normal LF, normal facet joint

D1A0L0F3 2 Global disc bulge, normal alignment, normal LF, Superior and inferior articular processes

D1A1L0F0 2 Global disc bulge, retrolisthesis, normal LF, normal facet joint.

D2A0L0F3 2 Intra-discal herniation, normal alignment, normal LF, Superior and inferior articular processes

D2A0L1F3 2 Intra-annular herniation, normal alignment, mild LF hypertrophy, superior and inferior process

hypertrophy

D1A1L1F1 3 Global disc bulge, retrolisthesis, mile LF hypertrophy, superior and inferior process hypertrophy

D1A2L1F3 3 Global disc bulge, grade I spondylolisthesis, mild LF hypertrophy, superior and inferior process

hypertrophy

Clinical Application of the Classification System.

o Case # 1:

o 57 year old male with 3 year old low back pain and increasing

radicular pain and weakness in the left lower extremity. Back pain

was 3/10, leg pain 7/10,

o SLR = 20 degrees on left, Tibialis Anterior strength = 2/5, EHL = 2/5,

and EHL = 3/5. Leg pain and weakness got worse over 6 weeks

pre-operatively.

o MRI showed D3A0L1F3 at L4-5. Patient had endoscopic

interlaminar discectomy, and laminoplasty/foraminoplasty using

Endo-Flex system.


Case # 1: Pre-op MRI study:

o D1A0L2F3

Foraminotomy vs laminectomy and partial facetectomy.

(Transforaminal and Posterior Decompression of the Lumbar Spine – A Comparative Study of Stability and Intervertebral Foraminal Area. Spine, 22 #15:1690-1697.)

Endoscopic Foraminoplasty:

o 1. 45.5% increase in the intervertebralforaminal area

o 2. There was no flexibility change

o 3. Minimal anatomic damage to the spine.

Laminectomy and medial-third facetectomy:

o 1. 34.2% increase in the intervertebralforaminal area

o 2. Significant increase in extension andaxial rotation flexibility

o 3. Structural compromise – posteriorligaments, spinous process, laminae andfacets

Endoscopic Lamino-foraminoplasty and Discectomy

IO-Flex system - Amendia


IO-Flex system - Amendia


• D1A0L3F3


o Ipsilateral Interlaminar Approach:

o Debulk ligamentum flavum and stay extra-canal

o Debride/burr IAP to enter lateral recess

o Perform discectomy – if necessary


o Ipsilateral Interlaminar Approach:

o Discectomy


o Passage of Endo-Flex wire medio-laterally


o Endo-Flex lamino-foraminoplasty


o Contra-lateral Endo-Flex lamino-foraminoplasty


o Bilateral Endo-Flex lamino-foraminoplasty + Transforaminal discectomy


Case # 1: Intra-perative.

o Placement of

ipsilateral Endo-flex

wire and lamino-

foraminoplasty with

microblade.



o Placement of

contralateral Endo-

flex wire and lamino-

foraminoplasty with

microblade.



o Application of the Endoflex for

endoscopic lamino-

foraminoplasty.


CONCLUSION

• Comprehensive treatment-based SMS Classification is feasible

• Many combinations have no clinical relevance

• 33.3% of the studied cohort are normal SMS

• The most prevalent diseased SMS is degenerated and globally bulging disc without facet, alignment or LF abnormality

• Treatment-based classification is clinically applicable and reproducible.

• The Treatment-based classification can be used to compare outcomes of different treatment options

• The large clinically relevant combinations will need software development for quick reference and choice of treatment options

Documents

Anatomic MIS Treatment-based classification of spinal