Jean-Louis.Leflot@mil.be

Surgical Treatmentof Low Back Pain &

SciaticsLEFLOT Jean-Louis

Lieutenant ColonelOrthopaedic Surgeon

Military Hospital Queen Astrid BrusselsBelgian Back Society

10-11 december 2010

Disc Herniation

Disc Herniation

Disc Herniation

Facet joints « Overloading »

Failure of the conservative treatment

• Medical treatment• Physiotherapy• Infiltration « Pain Clinic »

DISCECTOMY

DISCECTOMYFibrosis

DISCECTOMYThinning of the disc

• Recurrence of disc herniation• Foramenal stenosis• Facet joints « overloading »

DIAM

DIAM

Man 42Y

Chronic Low Back Pain and Irritation L4 Left

Intra- and Extraforamenal Disc Herniation

Device Intervertebral for Assisted Motion

6 months after discectomy and DIAM L4L5

No more leg pain and good relief of the lumbagosNormal height of the intervertebral disc

DIAM ou INTRASPINEINDICATIONS

DISCECTOMY

- Massive herniated disc leadingto substantial loss of disc material

- Recurrence of herniated disc

- Herniation of a transitional disc withsacralization of L5

DEGENERATIVE DISC DISEASE

- Topping off above or below the fusedsegment, to support newly created loads.

- Isolated Modic I lesion leading to chroniclow-back pain.

HYPERLORDOSIS

- Facet joints overloading

Disc Arthroplasty

Man 39Y (Infantery)‏

Chronic Low Back Pain and Sciatic L5 right

Disc Hernia L4L5 rightDiscopathy from levels L3L4, L4L5, L5S1

Severe L4L5 and L5S1

Disc Arthroplasty

ALIF L5S1 + TDA L4L5Only 1 approach (RetroPeritoneal) !

Control after 6 monthsNo more lumbago & sciatic

Disc Arthroplasty

Goals of Lumbar TDA ?

• Pain relief• Improved function• Restoration of the sagittal balance• Increased foramenal height• Avoidance of adjacent level breakdown• Longevity

Disc Arthroplasty

The retroperitonealapproach is very

little dilapidating

•It preserves the lumbar muscles

•It avoids the intraspinal fibrosis

Disc ArthroplastyRetroperitoneal Approach

Disc Arthroplasty

« Minimal invasive surgery »

A very good view of the intervertebral space ispossible with a mini-access (5 cm) ‏

Disc Arthroplasty

NO …

BUT …

Accelerated degenerationof the adjacent segments

Disorder of thesagittal balance ?

Dynamic Instability

Disc degeneration L4L5 (L3L4)‏

Facet osteoarthritis

Disc protrusion

Spinal and foramenal stenosis

DynamicInstability

HIGH RISK after PLIF !

Hypermobility above fusion !

ALIF is beter than PLIF

Man 32 Y(Infantery)

ALIF is beter than PLIF

ALIFrestore :

• Disc Space & Lumbar Lordosis• Foramenal Height• Facet Decompression

Combined Anterior & Posterior Fusionpermits :

• Circonferential Fusion• No intra-canalaire intrusion• No risk of peri-neural fibrosis

N.B. We can perform a DIAM stabilization above thefusion to avoid the hypermobility

ALIF

AXIALIF

AXIALIF

AXIALIFIndications- Discopathy L5S1

without hernia

- Spondylolisthesis L5S1grade 1

+ Posterior fixation

Jean-Louis.Leflot@mil.be

Conclusion

• Disc Hernia• Disc Height• Foramenal Height• Fibrosis• Sagitall Balance