WHATS HOT WHATS NOT

1
WHATS HOTWHATS NOT

• Catherine C. Capps, MD
• WellCare

2
WHATS HOTWHATS NOT

• SPINE

3
DEGENERATIVE DISC DISEASE (DDD)

• Studies inconclusive regarding occupational
  factors
• Some found no relationships between occupation
  and DDD
• Others found occupational loading and vehicular
  vibration is correlated with DDD
• Higher correlation with smoking, body weight
  (increased BMI), and especially heredity.

4
DDD Cervical Spine

• Conservative Care
• NSAIs
• Steroids
• Traction/ Therapy
• Rest. Restrictions

5
DDD Cervical Spine Surgery

• Anterior Cervical Decompression and Fusion (ACDF)
• VS.
• Cervical Disc Replacement

6
ACDFThe Gold Standard

• Success Rate of Fusion
• 97 Single Level
• 75-87 2 Level
• 56-68 3 Level
• (Higher number reflects plate fixation used)

7
ACDFWhats Hot/ Whats Not
8
Whats Not

• Metal Implants
• Risk of increased urine and serum levels of metal
  ions
• Difficulty with subsequent imaging on CT, MRI

9
Whats Hot

• Absorbable Implants
• Hydroxyapatite and calcium phosphate screws
• Poly L-lactic acid mesh plates
• Breakdown after 6 weeks
• Fusion 71-77 at 1 year

10
ACDF Problems

• Acceleration of disc degeneration at adjacent
  level in 67 of patients.
• 10 require a 2nd procedure at adjacent level.

11
The New Alternative?

• Cervical Disc Replacement
• Medtronics Prestige Disc
• Approved by the FDA, July 2007
• Preserve motion and normal kinematics between two
  vertebrae

12
Cervical Disc Replacement Complications

• Spontaneous fusion
• Catastrophic failure with implant dislocation
• Long term wear debris leading to implant
  loosening and failure

13
(No Transcript)
14

• Anterior Displacement
• Airway Obstruction
• Posterior Displacement into spinal canal
• Paralysis
• Death

15
Verdict Not In - Long Term Results Known

• 64 good to excellent results at 2 yr follow-up
  in one recent study

16
The Future?

• ACDF- 97 success in single level
• Vs.
• CDR- 64 success rate in early studies

17
Lumbar Disc Disease

• Conservative Care
• NSAI
• Steroids
• PT
• Exercise
• Weight Loss
• Injections

18
IDET(Intradiscal Electrothermal Therapy)

• Indications
• Failure post 6 months conservative therapy
• Annular tears
• Small disc protrusions

19
IDET

• Small heating coil inserted percutaneously
• Coil heated to denature collagen, ablate
  nociceptive fibers and modulate inflammatory
  response

20
IDET

• Results
• Recent prospective randomized trial 50 of pts
  had 75 relief
• Another recent trial suggests failure rate is 50
  at 2 yr follow up

21
Options in Lumbar Fusions

• Approach (anterior, posterior, posterolateral,
  360)
• Instrumentation (none, pedicle screws with rods
  or plates, cages, bioabsorbable alternatives)
• Bone Graft (iliac crest, demineralized bone
  matrix or bone morphogenic protein augmentation,
  allografts)

22
Lumbar Fusion

• PLIF vs. ALIF
• Per Swedish spine study group, no significant
  difference overall
• At 2 yrs, 63 with good or excellent results

23
Lumbar Fusion Problems

• Increased risk for adjacent level degeneration
• Possible need for future additional procedures
• Limit segmental mobility
• Successful bone healing does not guarantee pain
  relief

24

• Fusion Rate
• 60-95
• Pain Relief
• 50-80

25

• Complications
• Wound infection
• Pain at ICBG site in pelvis
• Pseudoarthrosis
• Implant failure

26
The New AlternativeLumbar Disc Replacement (LDR)

• Advantages
• Maintains motion at segment
• Decreases transfer stresses to the adjacent levels

27
LDRTypes Available in USA

• Depuy Charite Artificial disc for single
  level disc disease at L4-5.
• Synthes Prodisc for single level L3-S1
• (Or for multi-level usage off label)
• Both have 2 metal endplates with polyethylene
  center component

28

• Charite nonconstrained disc moves freely
  between end plates
• Prodisc semiconstrained disc attached to
  lower endplate. Disc articulates like ball and
  socket joint. More intrinsically stable construct.

29

• Contraindications
• Osteoporosis
• Abnormal curvature of spine (scoliosis, for
  example)
• Instability (spondylolisthesis)
• Facet disease of significance

30
Surgical Approach

• Anterior need to work behind the abdominal
  contents, to move and protect the major blood
  vessels to legs

31
(No Transcript)
32
Complications of ADR

• Damage to organs, ureters, vessels
• Retrograde ejaculation in 2-5 of male patients
  (semen released into bladder. Sperm banking
  suggested pre-op in those men desirous of
  children).
• Migration of implants
• Vertebral fracture
• Subsidence into bone (limits movement)
• Implant failure/ breakage
• Wear debris/ loosening

33

• Some reports say the abnormal motion of the
  artificial disc leads to accelerated posterior
  facet degeneration too soon to say.
• No definitive data to suggest disc replacement is
  superior to fusion.

34
DDD- The Future

• Intradiscal Gene Therapy
• Viral transfer of growth factor genes to
  increase the production of proteoglycan in vivo
  and in vitro

35
Intradiscal Gene Therapy

• Safe at correct dose and delivered into disc
• Toxic at higher dose or when misdirected into
  epidural or intradural space
• Rabbits with misdirected injection suffered lower
  extremity paralysis and sensory loss 2 found
  dead.

36
Osteoporotic Vertebral Compression Fractures

• 10 million in USA have osteoporosis. Approx 1.5
  million osteoporosis related fractures in the US
  in 2001 700,000 in spine.

37
Osteoporosis Risk Factors

• Female
• Caucasian/ Asian
• Small Frame
• Age
• Estrogen Deficiency
• Amenorrhea

• Inactivity
• Smoking
• Alcohol Intake
• Meds
• Corticosteroids
• Excess thyroid hormone
• Anticonvulsants
• Antacids containing aluminum

38
Occupational Significance

• Fracture may occur with very minor injury (even
  just sitting down firmly or hard on a chair).
• Dx XR, CT, MRI
• (helps determine chronicity)

39
Treatment

• Conservative
• Bedrest / Activity Restriction
• Pain Medication
• Bracing
• Beware in elderly

40
Treatment

• Surgery
• Vertebroplasty
• Kyphoplasty
• Inject PMMA (bone cement) via cannula
• Reduce kyphosis, stabilize fracture
• 67-100 if pts with good to excellent pain relief
  shortly post procedure

41
Complications

• Cement emboli or extravasation
• Fat emboli/ Pulmonary emboli
• Cerebral emboli
• Pedicle fracture
• Infection

• Rib fractures
• Reaction to cement
• Nerve root compression/ injury
• Spinal cord compression/ injury

42
The Future?

• Prophylactic Reinforcement in the high
• fracture risk patient.
• Best choice
• Early intervention
• Calcium and Vitamin D
• No smoking, limit alcohol intake
• Weight bearing exercise
• Medical treatment

43
Whats Hot, Whats Not In Upper Extremity Injuries
44
Cumulative Trauma Disorders

• (CTDs)

45
Cumulative Trauma Disorders

• Repetative Biomechanical Stress
• Over Time
• Ergonomics Focus on Prevention
• Multifactorial

46
CTD

• Controversal Term
• Implies a level of presumed knowledge regarding
  etiology which does not necessarily exist

47

• Further epidemiologic studies warranted to
  estimate relative causation

48
Wrist
49
(No Transcript)
50
(No Transcript)
51
Carpal Tunnel Syndrome

• Most common peripheral
• Compression Neuropathy
• Etiology
• Anatomy
• Physiology
• Position and use of wrist

52
(No Transcript)
53
Carpal Tunnel SyndromeSX and Signs

• Paresthesias 1 4 Digits
• Tinels
• Phalens
• Median Nerve Compression Test
• Role of Radiographic Studies
• Role of NCV / EMG

54
Carpal Tunnel SyndromeTreatment

• Conservative
• Blah, Blah, Blah
• Surgical
• Open Release
• Endoscopic Release
• Associated Procedures

55
Wrist Tendonitis

• Extensors De Quervains Disease
• Sheath of EPB, AbPL
• Most Common Tendonitis of Wrist
• Etio Direct Trauma or Overuse

56
De Quervains

• Sx Signs
• Finklesteins
• Treatmant
• Conservative vs. Surgical

57
Intersection Syndrome

• Second compartment involved
• Friction of AbPL ECR tendons leads to
  inflammation
• Etio Direct trauma, overuse
• Treatment Conservative vs. Surgical

58
Extensor Carpi Ulnaris Problems

• 6th Compartment
• Can develop subluxation
• In acute cases, splint 6 weeks
• In chronic subluxation, reconstruct sling

59
Wrist Tendonitis - Flexors

• Tenosynovitis
• FCR
• FCU
• Wrist Flexors
• Digits Trigger Fingers

60

• Etiology
• Look for Systemic Factors
• Overuse
• Treatment
• Conservative vs Surgical

61
Elbow
62
(No Transcript)
63
(No Transcript)
64
Lateral Epicondylitis

• Most Common Tendonitis at Elbow
• Disruption at ECRB Aponeurosis
• Repetative Microtrauma, Overload Injury, or
  Direct Trauma

65
Lateral Epicondylitis

• SX and Signs Cozens
• XR Poss Calcification
• Treatment
• Conservative
• Whats Beneficial?
• Surgical
• Release or Repair?
• Failure of Surgery
• Misdiagnosis?

66
Cubital Tunnel Syndrome

• Second Most Common Peripheral Nerve Compression
  Syndrome
• Concurrent Systemic Factor

67
Cubital Tunnel Syndrome

• Other Etiologic Considerations
• Trauma / Direct Blow / FX
• Protracted Elbow Flexion
• Vibrating Tool Use
• Repetative Elbow Flexion / Extension, Push /
  Pull
• Resting Elbow on Hard Surface
• Anatomic Considerations

68
Cubital Tunnel SyndromeSx and Signs

• Pain Medial Elbow
• Dysthesias /Parethesis - ring little finger
• Sensory Motor Findings
• Tinels, Bent Elbow, Sublex
• NCV, EMG
• XR

69
Cubital Tunnel Syndrome Treatment

• Conservative
• NSAI
• Injections
• Night splints
• Padded chair/table top or elbow pads
• Vary degree of elbow flexion/ Extension

• Surgery
• Release in Situ
• Transposition