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

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