El Borno Fusion

8/7/2019 El Borno Fusion

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Keep it Simple:

Percutaneous Facet Fusion

Medical Director: Adventist HinsdaleHospital Pain Center of Excellence; Hinsdale,Illinois.

Founding President: Midwest Academy of

Pain & Spine; Chicago, Illinois. Interests:

M.I.S.S.

Disc Decompression

Spinal Cord Stimulation

Enjoys Backgammon, Chicago Bulls,Classical Music, Traveling, and Painting.

Contact: www.controlchicagopain.com Email: [email protected]

Ahmed Elborno, M.D.
http://www.controlchicagopain.com/http://www.controlchicagopain.com/


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Goals Better understand the facet dowels

role in the treatment of low back pain.

Review of biomechanics and

diagnoses that accompany back pain.

Past and current surgical remediesand products used to treat the

disorder. Better understand the rationale and

basis for facet dowels,its indications .


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The degenerative cascade inlumbosacral stenosis Facet joints: Synoviitis and hypomobility Continuing degeneration Capsular laxity Sublaxation Enlargement of articular processes.

Age related changes: Dysfunction Herniation Instability Lateral nerve entrapment Stenosis Poor quality of life.

Intervertebral disc: Circumferential tears Radial tears Internal disruption Disc resorption osteophyte formation


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Back Pain LBP cost society $50 billion annually.

For most patient has no clear identifiable cause.

1-2% cause like tumor ,trauma,infection can be identified

FACET MEDIATED IS THE MOST READILY AND RELIABLYDIAGNOSED..

80% of people experience at least one episode of low-back pain intheir lifetimes

Recurrence rate of pain 20-40% annually.

2004 more than one million spinal procedures were performed toalleviates or mitigate back pain


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LOW BACK PAIN LBP affect 60 million people represent 20% of US

populations 60% RECOVER IN 6 WEEKS , 80---90% RECOVER WITHIN 6 MONTHS, WITH AND

WITH OUT TREATMENT.

10-12 MILLION PEOPLE SUFFER CHRONIC LBP.

ETIOLOGIES STEM FROM :1. DISC PATHOLOGY.2. FACET PATHOLOGY.3. MUSCLE PATHOLOGY .4. PSYCHOSOCIAL PATHOLOGY.


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Spinal stenosis 1911 bailey described spinal stenosis as a cause of neural

compression

Surgical treatment of spinal stenosis was undertaken as early as1900.

Traditional treatment of spinal stenosis has involved widelaminectomy ,undercutting of the medial facet with foraminotomy.

More limited decompression proceudres include bilateralforaminotomy .

unilateral approach to decompression have been shown to be

effective.

Minimally invasive procedures have now been successfully used.


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Epidemiology of stenosis

8-11% in US

Lumbosacral stenosis is the mostcommon reason for spine surgery in

older people

more than 125.000 laminectomyprocedures performed for LSS in

2003 the rise untill 2010 is reaching up to

40 % increase.


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Causes of neural

compression Disc bulge/herniation Hypertrophied ligamentum flavum Narrowed spinal canal

Narrowed lateral recesses Hypertrophied facets Anterior subluxation of superior vertebral body

over inferior body (degenerative spondylolysis. Symptoms of neural compression are worse with

standing and spinal extension, relieved by sittingand flexion. This is the concept behind distraction devices

like x-stop do away with the spine extension.


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Lumbar stenosis

treatment options Current standard of care : Mild to

moderate:Analgesics/opiates;NSAIDS;S

elf limiting activities;exercise and Wtreduction.;PT;Bracing ;epidural steroids.

More severe:

Decompressive surgery:1. Foraminotomy2. laminotomy3. laminectomy(with and without fusion.


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Facet pain Schwarzer estimates the prevalence of

facetogenic back pain at 15-40% NICOLI BOGDUK ESTIMATION 15% - 52% OF ALL

CHRONIC LOW BACK PAIN (1,500,000-

6,250,000). Facet pain transmitted via impulses from

medial branches of the lumbar dorsal rami Causes of the facet pain may be related to

mechanical stresses in the joints due todegeneration or from inflammation or fromsegmental instability due o incompetentfacets.


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Facet pain evidence There is often a radiographic eveidence of

osteoarthritic changes in facet joints of patientwith back pain

stimulation of facet joints or the nerve supply tothese joints causes pain similar to that described

in the facet syndrome.

Facet joints in patients undergoing surgery fordegenerative disorders show unusually hi levelsof inflammatory cytokines supporting the idea of

pain being cause by inflammation.

Gordon et al ,neurosurgery focus vol23 dec 2007


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Diagnosis of facet

pain Physical exam ,history: pain that worsens withextension maneuvers and focal tenderness ofparticular joint.

Ct scan is sensitive but not specific . SPECT imaging is specific for hot facet joint McDonald et al have described a method to

marry SPECT (single photon emmission)and CTscanning in identifying abnormal facet joints.inthis study the image quality allowed definitivelocalization of hot lesion in all cases.

McDonald et al neurosurgey focus vol 22 jan 2007


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Current treatment methodsfor facet pain Mainstay treatment for facet-related pain is

intra articular injection and dorsal branchrhizotomies .

Draw back injection provides only short termrelief, necssitating numerous repeatedtreatments,

Rhyzotomy which denervates the facet jointcapsule,carries only moderate efficacy rate

and frequently requires repeated treatments aswell .


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Intrarticular facetinjections THERAPEUTIC :

10% GET PERMANENT. RELIEF

DIAGNOSTIC BLOCKS :

75%-100% TRANSIENT RELIEF FOR 2WEEKsthen PROCEED TO RFA.

RFA WILL GIVE A LONG LASTING RELIEF FOR 6MONTHS TO 12 MONTHS .

IF PAIN RETURN AFTER 6 MONTHS REPEAT RFA

limit two per year.

IF PAIN RETURN BEFORE 6 MONTHS PROCEED TO

FACET FIXATION.


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RFA RED

FLAGS.INDISCRIMINATE USE OF RFA AT MULTIPLE LEVELS denervates the multifidi muscles making the

individual susceptable to vertebral columninstability .

SPONDYLOLISTHESIS.

IATROGENICALLY PRECIPITATING A LUMBAR FUSION.

FAILURE OF RFA MAY REQUIRE A MORE AGGRESSIVESTABILISATION PROCEDURES INCLUDEING :

1. PEDICLE SCREWS FIXATION.2. 360-DGREE FUSION3. VARIATION FUSION OPTIONS


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HIERARCHY OF FACETJOINT MEDIATED CHRONICLOW BACK PAIN

FACET FIXATION .DOWELS.

PEDICLE SCREW.360-DEGREE FUSION.

PHARMACOLOGICALTREATMENT .

NSAIDS.SMR.

PT FLEXION BASED .

CHIROPRACTIC MANAGEMENTOR OSTEOPATHIC MANIPULATION.

HELPFULACUTE :0-6 WEEKS

SUB ACUTE6-12 WEEKS.

LITTLE BENEFITS>12 WEEKS.

INJECTIONTECHNIQUE.

FACET INJECTION .MBB.

RFA.


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WATER ,GAS ,SOLID


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Traditional fusions intreating back pain


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Normal spine

biomechanics Anterior subluxation of one vertebral body onanother is resisted by multiple spinal elements.

Shear forces :

1. Facet joints resist 33%.

2. Intervetebral disc resist 67%

Flexion forces :

1. Supraspinous and interspinous ligamentsresist 19%

2. Facet capsular ligaments 39%

3. Intervertebral disc 29%


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Lumbar arthrodesis 1911 the first lumbar arthrodesis of any kind for

TB .

Later evolved to include the management of spinaldeformity and trauma .

Facet fusions were considered to be an importantelement of spinal fusion, but not initially tried asstand alone procedure.

In scoliosis surgery removing the carilage down tothe cancellous bone in the facet joint was believedto be a critical element in any successful posteriorspinal fusion this was to achieve a solid fusion intreating spinal deformity (scoliosis);but not

operating to treat pain.


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Problems with pediclescrews and rods. Pedicle screw and rod stabilization is

typically used as an adjunct inanterior /post fusions.

Concerns have been arisensurrounding the highly rigid nature ofthese constructs.

Stress shielding of the interbodygraft is believed to be implicated in acertain percentage of psuedo-arthroses.

Khoueir P, neurosurgery focus vol.22 Jan 2007


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Problems with pediclescrews and rods. No difference in clinical outcome when

comparing spinal fusions fordegenerative spondylolysis either with

or without spinal instrumentation.Fischgrund JS,et al. spine 22(24) 2807-12 Dec 1997 Meta-analysis suggested that fusion with

pedicle srews produced a higher fusion rate(90%) than fusion without instrumentation

although the difference was not statisticallysignificant and produced no difference inclinical outcomes (86% vs.90%)

Mardjetko SM,et al spine 20 (supp1)S2256-65,1994


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Argument applies to useof facet dowels Perioperative morbidity of patients

undergoing lumbar fusion usingtranslaminar facet screw fixation was

with decreased perioperativemorbidity compared to pedicle screwfixation.Tuli SK et al. orthopedics, 2005, August;28( 8) 773-8.

50% ASD in the presence of pedicle screwswhen both the cranial and caudal segments areevaluated..

Park JY, et al, KNS soc 2009 ,Feb 45(2):81-4

ranspe cu ar screws


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ranspe cu ar screwsand higher incidence of

ASD Adjacent segment disease is higherin patients with transpedicularinstrumentation (12-18%) compared

with patients fused with other formsof instrumentations or with noinstrumentations (5%).

Study from the university of michigan neurosurgical

department.


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Potential risk factors forsymptomatic ASD Type of instrumentation used .

Fusion length.

Facet injury and pre-existingdegenerative disease.

Biomechanical changes consist of :

1. Increased intradiscal pressure.

2. Increased facet loading

3. Increased mobility at the facet jointsAll Have been implicated in causing ASD

P t ti ll difi bl


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Potentially modifiablerisks factors for the

development of ASD Fusion with out instrumentation

Protecting facet joint of adjacentsegment during placement of pediclescrews

Fusion length

Saggittal balance .

Park P ,et al. spine 2004 Sep 1:29 (17)1938-44.


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Dynamic InterspinousSpacers (PDS)

The concept is maintain and restore intervertebralmotion in a controlled fashion by:

1. restricting the extremes of spinal movement or by

2. damping the kinetic energy involved in motion . Treat facet pain in two ways :

1. Unloading the facet joint ,

2. allow for repair and restoration of the joint.

Total facet replacement devices allow for completeremoval of the facet ,as a pain generator ,as well aspreserving the remaining functional segment unit. Of the

spine.

n ca ons or


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n ca ons ordevices

Controlled motion in theiatrogenically destabilized spine

Increased anterior load sharing to

augment interbody fusion

Protection and Restoration ofDegenerated Facet Joints and

Intervertebral Discs Prevention of Fusion Related

Sequelae


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Classification of PDSdevices Interspinous spacer devices Indication: neurogenic claudication

Examples: Wallis, X-STOP, DIAM, coflex, EstenSure, CoRoent

Pedicle screw/rod-based devices Indication: unload discs and facets, promote fusion, prevent

adjacent-segment disease

Examples: Graf ligament, Dynesys, AccuFlex rod, MedtronicPEEK rod, Scient'X Isobar

Total facet replacement systems Indications: Replacement for facet disease as part of a

functional spine unit reconstruction, to control motion iniatrogenically destabilized spine

Examples: TFAS, TOPS, Stabilimax NZ


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Biomechanics of facetfusions Facet fusion alone relieves or reduce

back pain is based on the conceptthat the facet ,synovium-lined joint

,causes back pain through facetarthrosis and nerve root pressure.

Facet blocks and facet rhizotomy

have been better at short term thanlong term.

That imply the need for more durablesolution which may be facet fusion.


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Bone plugs (dowels)

1993 STEIN won a young invistigatoraward when he demonstrated incanines that drilling and surgical

insertion of bone plugs into the facetjoints was feesible with promissingresults.

These plugs were placedpercutaneously with X-R guidance.

Stein M,et al journal of vascular and interventional radiology;jvir.4(1)69-74.1993.

I t t d f t


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Instrumented facetfusion The safety and efficacy of stand-

alone facet fusions has been studiedand results have been positive.

A two-year neurosurgical study of 99patients, with Grade I or IIdegenerative spondylolisthesis and

stenosis that underwent lumbar andlumbosacral isolated facet fusion.

They reported no technique-relatedcomplications.


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Facet fusion

The overall 2-year success rate of fusion was96%: 99% in the single level fusions and 88%in two-level fusions.

Degenerative spondylolysis had the highestsuccess rate at 100%,

the success rate in patients with concurrentstenosis experienced the lowest success rate:80%.

They concluded, "Instrumented facet fusionalone is a simple, safe, and effective surgicaloption for the treatment of patients with single-level disorders, especially patients withdegenerative spondylolysis. (2)

Park,youn-kwan,et al neurosurgery july 2002-vol.3,no 1 2009


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Translaminar facet screw(magerls)fixation Translaminar facet screw fixation (TLFS)

achieves stabilization by screws inserted at thebase of the spinous process, through theopposite lamina, traversing the facet joint, and

ending in the base of the transverse process. Supplemental translaminar facet screw fixation

has been used to enhance stability of motionsegments treated with an anterior threaded

cage, particularly during conditions of lowcompressive preloads, the very condition inwhich the cage alone is least effective inproviding stability.

Phillips FM,etal spine 2004AUG15 1731-6

Translaminar facetal screw


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Translaminar facetal screw(Magerl's) fixation

This argument also applies to


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This argument also applies tofacet dowel.

In an excellent review article,Rajasekaran discusses thebiomechanics, surgical technique and

outcomes of TLFS, noting its lowercost, low morbidity, shorter operative

times, and the fact that it does not

interfere with adjacent facetjoints. Rajassekaran S ,neurology india vol53 no ,2005 520-24


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TRANSFACET BONE BLOCKFOR LUMBOSACRAL FUSION

EARL D.McBRIDE J BONE JOINT SURGAM.1949,31:385-399.

135 CASES IN WHICH FUSION WAS

ACHIEVED BY THIS METHOD . NO DEATH OR SERIOUS

COMPLICATIONS.

the facet fusion as an importantcomponent in achieving fusion in thoracolumbar scoliosis, 266 patients review

Moe JBJS 40529-551,1958


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History of Facet Stabilization


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Southern med JI vol70 no


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Southern med JI,vol70,no2,feb 1977 In 1962, Harrington began using a "dowel" facet fusion

technique (31) In a series of 51 spinal fusions forscoliosis using hook and rod instrumentation and acylindrical inlay facet fusion,

the authors found that no additional posterior bone

grafting was needed to achieve a successful fusion.

Technique: A distraction device was placed to separatethe joint. "The facet joints...were removed with acylindrical plug cutter and the cylindrical grafts wereimpacted. The distraction apparatus was removed. The

cylindrical grafts were taken from spinous processes oriliac area.

Without using supplemental iliac graft, there was lessbleeding and shorter operative time. Overallpseudoarthrosis rate was 6%.


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S bili i


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Stabilizationmis vs open surgery.

Percutaneous spinal stabilizationminimizes muscle trauma.

Open surgery contributes to morbidity

through muscle denervation, retractionnecrosis,

blood loss and inflammation,

extended recovery periods,

and compartment syndrome.


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MIS VS OPEN SURGERY

effects of open surgery may accelerate theprocess of adjacent segment disease.

MIS reduce the need for large incisions andmuscle stripping.

Dilating the muscle , allowing the instrumentsand implants to be placed through a closedtube, avoiding denervation and generation of asystemic inflammatory response.


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flouroscopy

Fluoroscopy has beenshown to be a valuable

tool in accurate andsafe placement of

percutaneous implants.


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FACET FIXATION FIRST


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FACET FIXATION FIRSTGENERATION

CD RAY MD.1988

EXPANDED ON THE CONCEPT .

BILATERAL FACET FIXATION.

SERIES OF 50 PATIENTS WHO

UNDERWENT EITHER UNILATERALOR BILATERAL FACET FIXATIONWITH BONY DOWELS.


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THIRD GENERATION

FUSIO (FRONTIERDEVICES,INC.PEHLAM AL.)


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FOURTH GENERATION

OSTEOLOCK BACFAST BYBACTERIN.


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FIFTH GENERATION


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INDICATION FOR FACET


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INDICATION FOR FACETFIXATION PATIENTS WITH FACET MEDIATED CHRONIC LOWBACK

PAIN,UNRESPONSIVE TO CONSERVATIVE CARE .

PATIENTS THAT HAVE UNDERGONE A FACET BLOCK,WITH 75-100 %SUBJECTIVE PAIN RELIEF,LASTING AT LEAST 2 WEEKS BEFORE THEPAIN RETURNS.

PATIENTS THAT HAVE UNDERGONE RFA OF THE MB WITH FAIR TOGOOD RESULTS AND THE PAIN HAS RETURNED IN LESS THAN 6MONTHS.

PATIENT WITH SPINAL STENOSIS WHO UNDERGONE DECOMPRESSIVELAMINECTOMY AND FORAMINOTOMY,WHICH HAVE EITHER SPINAL

STABILITY OR GRADE 1 SPONDYLOLISTHESIS.

IN THE COURSE OF AN OPEN PROCEDURE IF THE MEDIAL 1/3 OF THEFACET HAS BEEN BREACHED

INDICATION OF FACET JOINT


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INDICATION OF FACET JOINTFIXATION

IF THE ANTERIOR LUMBAR INTERBODY FUSION HAS BEENPERFORMED AND THE SURGEON DESIRES POSTERIORFIXATION WITH OUT PEDICLE SCREWS

STABILISATION OF THE LUMBAR SPINE FOLLOWINGDECOMPRESSIVE PROCEDURES OR WHERE MINORINSTABILITY EXISTS OR PRESENTS POST OPERATIVELY.

IN THE PRESENCE OF MINOR INSTABILITY (GRADE I, 1-2 MM

LISTHESIS)

POSTERIOR SUPPLEMENTAL FIXATIONTO INTERBODYFUSION.

AS AN ADJUNCT TO MOTION LIMITING DEVICES .


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Potential Complications


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pFOR NONE INSTRUMENTAL FACETFUSION

Dowel Pull-Out

Pseudoarthrosis

Infection (AllograftManufacturing Process)


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BIOMECHANICAL TESTING OF SPINAL


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BIOMECHANICAL TESTING OF SPINALSEGMENT IMPLANTED WITH TRUFUSEDOWELS

TOV VESTAGAARDEN MS,SUNILSAIGAL,DAVID PETERSEN ,.MD

AXIAL COMPRESSION,AXIALROTATION,FLEXION,EXTENSION,AND LATERALBENDING,RESPECTIVLY .

MINSURG CORPORATION 2008 .


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Overview Biomechanics compare favorably withpedicle screw systems and outperform

facet screws


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BIOMECHANICS OF BONE


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BIOMECHANICS OF BONEFUSION

BONE FUSION :

IN SITU

ONLAY.

AND INTERBODY FUSION.(BEARAXIAL LOAD).


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INSITU

WHEN FUSIONS ARE USED WHENNATIVE BONE IS ALLOWED TO COMEIN CONTACT WITH OTHER NATIVE

BONE THAT WAS PREVIOUSLYPREVENTED FROM DOING SOBECAUSE OF INTERVENING SOFTTISSUE .eg (denuding of facet carilage

performed in conjunction with placinglateral mass plate system).


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Onlay fusion

Decorticated graft bed and the subsequentapplication of cortical and cancellousautograft.

eg,. Facet joint fusion with intrafacetal dowel.


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Interbody implants

Provide the spine with the ability to bear an axialload,.

They function optimally when placed along theneural axis and thus produce little if any significant

bending movement.

They may be comprised of bone ,nonbonematerials such as acrylic,or combination ofboth.such as interbody cages.

All three methods may be used alone or incombination with other implants that can beapplied through anterior or posterior applications.


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Overview

What is FACET FUSION

It is a specially

engineered dowelmade from allograft or

absorbable synthetic

material.

Inserted into the planeof the facet joints C2-

S1, it stops motion and

stabilizes the

vertebrae, allowing

fusion to occur.

Overview


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Overview

Why facet fusion?

It works with human biology

to achieve natural fusion.

It is less invasive, lessdestructive, less expensiveand will not preclude otheroptions in the event that it is

not successful.

Represents a surgicalalternative earlier in thecontinuum of care.


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Overview

Where facet fusion Fits In the Marketplace

Broad, well-researched pending

patent

Unique approach, modern

technique

Does not try to overcome

biology with metal constructs

Does not compete with motion

limiters or rod and screw based

devices

Overview


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OverviewWhere facet fusion Fits In the Marketplace

Treats minor instability,

mechanical back pain and

degenerative joint disease

Burns no bridges

Minimally invasive, less

destructive

True percutaneous option

that can be performed

stand alone in about 20

minutes - outpatient


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Overview


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Overview Most often used to prevent

or treat minor instability inlaminectomy

/decompression cases 6-

8 minutes added table time

Supplements anterior

interbody fusion with

posterior support

intraoperatively or

postoperatively

Treats or prevents

adjacent segment

deterioration


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Overview

Surgical Science Behind facet fusionWolffs Law

Bone is deposited and resorbed inaccordance with the stresses placed

upon it.

New bone will begin growing wherethere are stimulating stresses.

Micro-motion is needed to allow bone

fusion to occur. The facet fusion cortical allograft dowel

was developed to lock the facet(s) in

place while allowing micro-motion.

O i


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Overview

Surgical Science Behind facet fusion

Factors Promoting Fusion

Allograft is partially replacedover time with living tissue byCreeping Substitution.

A growing body of evidenceindicates that initial primaryhealing occurs around the dowelwithin weeks, then into the dowelwithin months.

O i


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Overview

Primary cause of failure isdowel pullout

Reported in about 5% ofcases

Suspected in about 10% ormore

>50% of pullout casesremain asymptomatic


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Overview


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Overview

Instrumentation

Open Minimally Invasive

Percutaneous


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Overview


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Overview

Facet fusion Open/MI Instrumentation

Drill Guide - The Guide iscentered over the facet jointin a superior to inferiormanner.

The Guides superior and

inferior larger teeth are

placed into the joint todistract the joint slightlyand stabilize the Guide.This allows for facet jointreaming in the plane of the

facet joint.

Overview


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Overview


Reamer A compactiondrilling process that packssubchondral bone against

the tunnel walls. A drill stopis on the Reamer and Guideto prevent drilling too deep.

O i


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Overview


Inserter Assembly Inserted intothe Drill Guide after reaming. TheTruFUSE dowel is picked fromthe graft holder.

The graft is impacted at the sameangle that the facet joint wasdrilled until it is fully seated.

Overview


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Overview


Graft Holder - Used tohold the dowels largeside up to be pickedup by the InserterAssembly.

Overview


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Overview

Facet fusion Minimally Invasive Instrumentation

Dilator Tubes - Used

minimallyinvasively tovisualize the facetjoint.

Dilator Tube 1

Dilator Tube 2

Overview


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OverviewFacet fusion Percutaneous Instrumentation

Dilator - Slides over theguide wire ensuring proper

orientation of the Guideinto the facet joint.

Spatula Used to locatethe facet joint and ensureproper Guide orientation.

Overview


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Overview

Facet fusion Instrumentation Demonstration

Open

MinimallyInvasive

Percutaneous


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Open Surgical Procedures


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Open Surgical Procedures

Augmentation Alternatives

Anterior InterbodySupplementation (ALIF, XLIF)

Adjacent level to Posterior toprevent adjacent level disease

Laminectomy Decompression

ALIF XLIF


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Patient Selection


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Patient Selection

Specific Contraindications

Grossly Unstable Spine

PARS Defect - Floating lamina

Severe Osteoporosis

Trauma, Fracture

Vertebral Dislocation

Active or Latent Infection

Steroid Use Abnormal White Count >15

Increased Body Temperature

Positive Urine Culture

Synovial Cysts

Severe Osteoporosis

Vertebral Dislocation

Outcome Expectations


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Post Surgical Rehabilitation Aftercare RTNA Post-Op Expectations Lumbar Corsets Physical Therapy Indications


4-6 weeks post-op - initialhealing of cancellous bone

growth with allograft providingsupport

3 months - cancellous fusion

1 year complete fusion withallograft

Benefits


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Benefits

Patient Advantages Minimized tissue and nerve

damage

Dramatic and instant reduction inpain

Substantially reduced hospitalstays

Much faster healing

Much faster recovery

Less rehabilitation required

Recognized by all insurers

Reduced time in hospital Return to normal activity faster

Benefits


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Benefits

Physician Advantages

Rapid training

Less time in the OR

Less physically demandingcases

Less hospital rounding timeLess follow-up visits


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Documents

El Borno Fusion