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WHATS HOT WHATS HOT WHATS NOT WHATS NOT
Catherine C. Capps, MDCatherine C. Capps, MD
WellCare WellCare
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WHATS HOT WHATS HOT WHATS NOT WHATS NOT
SPINESPINE
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DEGE N ER ATIV E D ISC D ISE ASE (DDD)DEGE N ER ATIV E D ISC D ISE ASE (DDD)
Studies inconclusive regarding occupationalStudies inconclusive regarding occupationalfactors:factors:
Some found no relationships between occupationSome found no relationships between occupationand DDDand DDDOthers found occupational loading and vehicularOthers found occupational loading and vehicular
vibration is correlated with DDD vibration is correlated with DDDHigher correlation with smoking, body weightHigher correlation with smoking, body weight(increased BMI), and especially heredity.(increased BMI), and especially heredity.
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DDD Cervical SpineDDD Cervical Spine
Conservative Care:Conservative Care:
NSAI sNSAI sSteroidsSteroids
Traction/ Therapy Traction/ Therapy Rest. RestrictionsRest. Restrictions
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DDD Cervical Spine SurgeryDDD Cervical Spine Surgery
Anterior Cervical Decompression Anterior Cervical Decompressionand Fusion ( ACDF )and Fusion ( ACDF ) VS. VS.
Cervical Disc ReplacementCervical Disc Replacement
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ACDF ACDF
The Go ld Standard The Go ld StandardSuccess Rate of Fusion:Success Rate of Fusion:
97% Single Level97% Single Level7575--87% 2 Level87% 2 Level5656--68% 3 Level68% 3 Level
(Higher number reflects plate fixation used )(Higher number reflects plate fixation used )
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ACDF ACDF Whats H ot/ Whats N ot Whats H ot/ Whats N ot
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Whats N ot: Whats N ot:
Metal ImplantsMetal Implants
Risk of increased urine and serum levelsRisk of increased urine and serum levelsof metal ionsof metal ions
Difficulty with subsequent imaging onDifficulty with subsequent imaging onCT, MR ICT, MR I
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Whats H o t: Whats H o t:
Absorbable Implants Absorbable Implants
Hydroxyapatite and calcium phosphateHydroxyapatite and calcium phosphatescrewsscrewsPoly LPoly L--lactic acid mesh plateslactic acid mesh plates
Breakdown after 6 weeksBreakdown after 6 weeks
Fusion 71Fusion 71--77% at 1 year77% at 1 year
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ACDF Pr ob lems: ACDF Pr ob lems:
Acceleration of disc degeneration at Acceleration of disc degeneration atadjacent level in 67% of patients.adjacent level in 67% of patients.
10% require a 210% require a 2ndnd
procedure atprocedure atadjacent level.adjacent level.
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The New Alternative? The New Alternative?
Cervical Disc Replacement:Cervical Disc Replacement:
Medtronics Prestige DiscMedtronics Prestige DiscApproved by the FD A, July 2007 Approved by the FD A, July 2007
Preserve motion and normalPreserve motion and normalkinematics between two vertebraekinematics between two vertebrae
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Cervical D isc R eplacementCervical D isc R eplacement
Complicati ons:Complicati ons:
Spontaneous fusionSpontaneous fusion
Catastrophic failure with implantCatastrophic failure with implantdislocationdislocation
Long term wear debris leading to implantLong term wear debris leading to implant
loosening and failureloosening and failure
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Anterior Displacement Anterior Displacement Airway Obstruction Airway Obstruction
Posterior Displacement into spinal canalPosterior Displacement into spinal canalParalysisParalysis
DeathDeath
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Verdict N ot In Verdict N ot In -- Long TermLong TermR esults Kn o wnR esults Kn o wn
64% good to excellent results at 2 yr64% good to excellent results at 2 yrfollow follow--up in one recent study up in one recent study
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The F uture? The F uture?
ACDF ACDF-- 97% success in single level97% success in single level V s. V s.
CDR CDR-- 64% success rate in early studies64% success rate in early studies
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Lum bar D isc D iseaseLum bar D isc D isease
Conservative Care:Conservative Care:NSAINSAI
SteroidsSteroidsP TP TExerciseExercise
Weight Loss Weight LossInjectionsInjections
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IDE TIDE T(Intradiscal E lectr othermal Therapy )(Intradiscal E lectr othermal Therapy )
Indications:Indications:Failure post 6 months conservativeFailure post 6 months conservativetherapy therapy Annular tears Annular tearsSmall disc protrusionsSmall disc protrusions
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IDE TIDE T
Small heating coil insertedSmall heating coil insertedpercutaneously percutaneously
Coil heated to denature collagen,Coil heated to denature collagen,
ablate nociceptive fibers and modulateablate nociceptive fibers and modulateinflammatory responseinflammatory response
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IDE TIDE T
Results:Results:Recent prospective randomized trialRecent prospective randomized trial50% of pts had 75% relief 50% of pts had 75% relief
Another recent trial suggests failure Another recent trial suggests failurerate is 50% at 2 yr follow uprate is 50% at 2 yr follow up
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Opti ons in Lum bar F usi ons:Opti ons in Lum bar F usi ons:
Appr oach Appr oach (anterior, posterior,(anterior, posterior,posterolateral, 360posterolateral, 360 ) )
Instrumentati onInstrumentati on (none, pedicle screws(none, pedicle screws with rods or plates, cages, bioabsorbable with rods or plates, cages, bioabsorbablealternatives )alternatives )B one GraftB one Graft (iliac crest, demineralized bone(iliac crest, demineralized bonematrix or bone morphogenic proteinmatrix or bone morphogenic proteinaugmentation, allografts )augmentation, allografts )
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Lum bar F usi onLum bar F usi on
PLI F vs. ALI FPLI F vs. ALI F
Per S wedish spine study group, noPer S wedish spine study group, nosignificant difference overallsignificant difference overall
At 2 yrs, 63% with good or excellent At 2 yrs, 63% with good or excellentresultsresults
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Lum bar F usi on Pr ob lems:Lum bar F usi on Pr ob lems:
Increased risk for adjacent levelIncreased risk for adjacent leveldegenerationdegeneration
Possible need for future additionalPossible need for future additionalproceduresproceduresLimit segmental mobility Limit segmental mobility Successful bone healing does notSuccessful bone healing does notguarantee pain relief guarantee pain relief
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Fusion RateFusion Rate6060--95%95%
Pain Relief Pain Relief 5050--80%80%
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Complicati ons:Complicati ons:
Wound infection Wound infectionPain at ICBG site in pelvisPain at ICBG site in pelvisPseudoarthrosisPseudoarthrosisImplant failureImplant failure
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The New Alternative The New AlternativeLum bar D isc R eplacement (L DR)Lum bar D isc R eplacement (L DR)
Advantages: Advantages:Maintains motion at segmentMaintains motion at segmentDecreases transfer stresses to theDecreases transfer stresses to the
adjacent levelsadjacent levels
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ChariteCharite nonconstrainednonconstrained disc movesdisc movesfreely between end platesfreely between end plates
ProdiscProdisc semiconstrainedsemiconstrained discdiscattached to lower endplate. Discattached to lower endplate. Disc
articulates like ball and socket joint.articulates like ball and socket joint.More intrinsically stable construct.More intrinsically stable construct.
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Contraindicati ons:Contraindicati ons:
OsteoporosisOsteoporosis
Abnormal curvature of spine Abnormal curvature of spine(scoliosis, for example )(scoliosis, for example )Instability (spondylolisthesis )Instability (spondylolisthesis )Facet disease of significanceFacet disease of significance
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Surgical Approach:Surgical Approach: Anterior Anterior need to work behindneed to work behindthe abdominal contents, to movethe abdominal contents, to moveand protect the major bloodand protect the major blood
vessels to legs vessels to legs
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DDDDDD -- The F uture The F uture
Intradiscal Gene Therapy Intradiscal Gene Therapy
V iral transfer of growth factor genes V iral transfer of growth factor genesto increase the production of to increase the production of
proteoglycan in vivo and in vitroproteoglycan in vivo and in vitro
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Intradiscal Gene TherapyIntradiscal Gene Therapy
Safe at correct dose and delivered intoSafe at correct dose and delivered intodiscdisc
Toxic at higher dose or when misdirected Toxic at higher dose or when misdirectedinto epidural or intradural spaceinto epidural or intradural spaceRabbits with misdirected injectionRabbits with misdirected injectionsuffered lower extremity paralysis andsuffered lower extremity paralysis andsensory loss; 2 found dead.sensory loss; 2 found dead.
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Oste o porotic Verte b ralOste o porotic Verte b ralCompressi on F racturesCompressi on F ractures
10 million in USA have osteoporosis.10 million in USA have osteoporosis. Approx 1.5 million osteoporosis Approx 1.5 million osteoporosisrelated fractures in the US in 2001;related fractures in the US in 2001;700,000 in spine.700,000 in spine.
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Oste o porosis R isk F act ors:Oste o porosis R isk F act ors:
FemaleFemaleCaucasian/ AsianCaucasian/ Asian
Small FrameSmall FrameAge AgeEstrogenEstrogen
Deficiency Deficiency Amenorrhea Amenorrhea
Inactivity Inactivity Smoking Smoking
Alcohol Intake Alcohol IntakeMedsMeds
CorticosteroidsCorticosteroids
Excess thyroid hormoneExcess thyroid hormone Anticonvulsants Anticonvulsants Antacids containing Antacids containing
aluminumaluminum
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Occupati onal Significance:Occupati onal Significance:
Fracture may occur with very minorFracture may occur with very minorinjury (even just sitting down firmly orinjury (even just sitting down firmly or
hard on a chair ).hard on a chair ).
Dx: XR, CT, MR I Dx: XR, CT, MR I (helps determine chronicity )(helps determine chronicity )
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Treatment Treatment
ConservativeConservativeBedrest* / Activity RestrictionBedrest* / Activity RestrictionPain MedicationPain MedicationBracing Bracing
*Beware in elderly *Beware in elderly
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Whats H ot, Whats Whats H ot, Whats
N ot In UpperN ot In UpperEx tremity InjuriesEx tremity Injuries
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Cumulative TraumaCumulative Trauma
D isordersD isorders(CTD s )(CTD s )
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CumulativeCumulative Trauma Trauma D isordersD isorders
Repetative Biomechanical StressRepetative Biomechanical StressOver TimeOver TimeE rgonomicsE rgonomics Focus on PreventionFocus on PreventionMultifactorialMultifactorial
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CT DCT D
Controversal TermControversal TermImplies a level of presumed knowledgeImplies a level of presumed knowledgeregarding etiology which does notregarding etiology which does notnecessarily existnecessarily exist
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Further epidemiologic studiesFurther epidemiologic studies warranted to estimate relative warranted to estimate relativecausationcausation
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Wrist Wrist
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Carpal Tunnel Syndr omeCarpal Tunnel Syndr omeSX and Signs:SX and Signs:
Paresthesias: 1Paresthesias: 1 4 Digits4 Digits Tinels Tinels
PhalensPhalensMedian N erve Compression TestMedian Nerve Compression TestRole of Radiographic StudiesRole of Radiographic Studies
Role of N C V / EMGRole of N C V / EMG
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Carpal Tunnel Syndr omeCarpal Tunnel Syndr ome Treatment: Treatment:
ConservativeConservativeBlah, Blah, BlahBlah, Blah, Blah
SurgicalSurgicalOpen ReleaseOpen ReleaseEndoscopic ReleaseEndoscopic Release Associated Procedures Associated Procedures
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Wrist Tend onitis Wrist Tend onitis
Extensors De Quervain s Disease:Extensors De Quervain s Disease:
Sheath of
EPB,
Ab
PL
Sheath of
EPB,
Ab
PL
Most Common Tendonitis of WristMost Common Tendonitis of Wrist
E tio Direct Trauma or OveruseE tio Direct Trauma or Overuse
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D e QuervainsD e Quervains
Sx & SignsSx & Signs
FinklesteinsFinklesteins
Treatmant Treatmant
Conservative vs. SurgicalConservative vs. Surgical
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Ex tens or Carpi Ulnaris Pr ob lemsEx tens or Carpi Ulnaris Pr ob lems
66thth CompartmentCompartment
Can develop subluxationCan develop subluxation
In acute cases, splint 6 weeksIn acute cases, splint 6 weeks
In chronic subluxation, reconstruct sling In chronic subluxation, reconstruct sling
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Wrist Tend onitis Wrist Tend onitis -- F lexo rsF lexo rs
TenosynovitisTenosynovitisFCR FCR
FCUFCU Wrist Flexors Wrist FlexorsDigits Trigger FingersDigits Trigger Fingers
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E tiology E tiology Look for Systemic FactorsLook for Systemic FactorsOveruseOveruse
Treatment Treatment
Conservative vs SurgicalConservative vs Surgical
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E lbo w E lbo w
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Lateral E pic ondylitisLateral E pic ondylitis
Most Common Tendonitis at E lbow Most Common Tendonitis at E lbow
Disruption at ECRB AponeurosisDisruption at ECRB Aponeurosis
Repetative Microtrauma, Overload Injury,Repetative Microtrauma, Overload Injury,or Direct Traumaor Direct Trauma
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Lateral E pic ondylitisLateral E pic ondylitis
SX and Signs: CozensSX and Signs: CozensXR: Poss CalcificationXR: Poss Calcification
Treatment TreatmentConservativeConservative
Whats Beneficial? Whats Beneficial?
SurgicalSurgical
Release or Repair?Release or Repair?Failure of Surgery Failure of Surgery
Misdiagnosis?Misdiagnosis?
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Cu b ital Tunnel Syndr omeCu b ital Tunnel Syndr ome
Second Most Common Peripheral NerveSecond Most Common Peripheral NerveCompression SyndromeCompression Syndrome
Concurrent Systemic FactorConcurrent Systemic Factor
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Cu b ital Tunnel Syndr omeCu b ital Tunnel Syndr ome
Other E tiologic ConsiderationsOther E tiologic Considerations
Trauma / Direct Blow / FX Trauma / Direct Blow / FX
Protracted E lbow FlexionProtracted E lbow Flexion V ibrating Tool Use V ibrating Tool UseRepetative E lbow Flexion / Extension, Push / PullRepetative E lbow Flexion / Extension, Push / PullResting E lbow on Hard SurfaceResting E lbow on Hard Surface Anatomic Considerations Anatomic Considerations
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Cu b ital Tunnel Syndr omeCu b ital Tunnel Syndr omeSx and SignsSx and Signs
Pain Medial E lbow Pain Medial E lbow Dysthesias / ParethesisDysthesias / Parethesis -- ring & little fingerring & little finger
Sensory & Motor FindingsSensory & Motor Findings Tinels, Bent E lbow, Sublex Tinels, Bent E lbow, SublexNC V , EMGNC V , EMG
XR XR
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Cu b ital Tunnel Syndr ome TreatmentCu b ital Tunnel Syndr ome Treatment
ConservativeConservativeNSAINSAIInjectionsInjectionsN ight splintsN ight splintsPadded chair/tablePadded chair/tabletop or elbow padstop or elbow pads V ary degree of elbow V ary degree of elbow flexion/ Extensionflexion/ Extension
Surgery Surgery Release in SituRelease in Situ
Transposition Transposition