Perhaps the greatest challenge in spine surgery today is the intelligent management of patients with advanced multi-level degenerative disorders producing neurologic impairment (as opposed to just back pain). As our population becomes more geriatric pre-existing congenital genomic problems and acquired insult and injury become of greater clinical significance over time.
The surgical management of this group of patients has been poor as reflected by outcome and patient satisfaction data. An important reason for this is that little real understanding exists among those who treat these conditions regarding the actual underlying pathology. In addition to this the mind set of many of the involved physicians really hasn’t progressed much beyond their understanding of “disc herniation.”
Surgical procedures, such as multi-level pedicle screw fixation, are frequently employed when simpler, safer and more meaningful treatments exist for the patient. While some of this may be due to the surgeon’s lack of familiarity, or prior training with these advanced technologies a great deal of treatment seems to be predicated on the surgeon’s personal financial interest as opposed to the best interest of their patients. Professional surgeon certification programs are only now in their infancy. It remains important for patients to select their surgeons as carefully as they select their automobiles.
As the 20th century drew to a close it became increasingly more evident that well-placed posterior titanium cages were a most effective alternative to pedicle screw fixation. The problem with their use was that few spine surgeons had the training to safely employ these devices or understood how to avoid the potential pitfalls involved in their use. It then became evident to some experienced spine surgeons that the bony incorporation of a single cage, if optimally placed, was just as effective as two cages as shown above. Because cages also represent rigid instrumented stabilizations they are clearly optimal for segmental stabilization but were also capable of placing stress on adjacent spine segments (particularly when these were degenerated). The combination of single titanium cage placement with a flexible non-instrumented stabilization has added a new dimension to the surgical management of degenerative spinal disorders.
In the case shown above the patient experienced severe nerve compression at the L4-5 level where the degenerative spondylolisthesis was associated with central and lateral spinal stenosis. Severe lateral spinal stenosis was also present at L5-S1. As shown to the right, a single Ray titanium cage was placed to stabilize L4-5 after multi-level decompression. A bilateral autogenous bone flexible stabilization was then created from L3 to the sacrum utilizing in-situ bone.
Demonstrated above is the use of a single titanium cage as both a stabilizer and a spacer. The collapse of the interspace is shown to the left (red dot).
This 67 year old patient was incapacitated by a lumbar claudication syndrome due to multi-level advanced degeneration and instability with severe central, spinal recess and lateral spinal stenosis further complicated by a large synovial chondroma producing cauda equina compression.
In addition to adequate decompression single cages were placed at two levels in association with a flexible bilateral autogenous bone stabilization (see green dots on post-operative axial CT scan).
The multilevel degenerative changes shown above are typical for geriatric genomic cases where the pathology is extensive. There is a two level degenerative spondylolisthesis of a high degree with associated multi-level severe stenosis. Two single Ray cages with a L2-S1 flexible autogenous bone stabilization were used to treat the patient.
To be able to convert patients like these to normal function with freedom of pain is the primary goal of treatment. By utilizing meaningful decompression, and combinations of less invasive and cost-effective modalities consistently good outcomes for patients, with high patient satisfaction are possible. Additionally it is important to not create additional problems for the patient down the road.