Dr. Steven Yang Adult And Paediatric Spine Surgeon

Dr. Steven YangAdult and Paediatric Spine Surgeon

Disclosures: No shares in surgical implant or pharmaceuticalcompanies. Received no commercial research grants Director of complex spine fellowship in RBWHcofunded Medtronic and Lifehealthcare

OsteoporosisSkeletal disorder characterized by compromised bonestrength predisposing to an increased risk of fracture.NIH Consensus Development Conference, March 27-29, 2000Normal BoneOsteoporotic Bone

OsteoporosisThe bone that is there is normalbone, there simply is not enoughbone there.Normal BoneOsteoporotic Bone

TRENDS IN SPINE SURGERY FORTHE ELDERLY increasing trend toperformsurgery intheelderlyWeinstein, J. N., J. D. Lurie, et al. (2006)."United States' trends and regionalvariations in lumbar spine surgery:1992-2003." Spine (Phila Pa 1976)Deyo, R.31(23):A. and2707-2714.S. K. Mirza (2006). "Trends andvariations in the use of spine surgery." ClinOrthop Relat Res 443: 139-146.

INTERSECTION OF DISEASEspinalosteoporosisdisorders more common in the elderly

PREVALENCE OF OSTEOPOROSIS IN SPINEPATIENTS 1300 cases reviewed overage 50 very common 15% males (46% withosteopenia) vs 50% femaleP revalenc e of os teoporos is in patients requiring s pines urgery: inc idenc e and s ignific anc e of os teoporos is in s pinedis eas e.Chin DK, Park JY, Yoon YS, Kuh SU, Jin BH, Kim KS, ChoYE.Chin, D. K., J. Y. Park, et al. (2007). "Prevalence of osteoporosis inpatients requiring spine surgery: incidence and significance ofosteoporosis in spine disease." Osteoporos Int 18(9): 12191224.

Lumbar Vertebral Strength vs.AgeO.N. Diagnos tics , B erkeley, C A

Paradox of Fixation in theAging Spine Significant age-related compromise of bone quality inthe aging spine More rigid deformity may require greater forces forcorrection and maintenance of correction

Fixation Strategies in the Osteoporotic Spine Hybrid Instrumentation Vertebral Augmentation Dynamic Instrumentation

Hybrid Fixation in the Aging Spine In the aging spine with osteoporosis, there is relativepreservation of cortical bone including laminae Coe J, et al:Influence of bone mineral density on the fixation of thoracolumbarimplants. A comparative study of transpedicular screws, laminar hooks, and spinousprocess wires. Spine 1990

Short-segment pedicle instrumentation. Biomechanicalanalysis of supplemental hook fixation.Chiba M, McLain RF, et al: Spine 1996 Significant improvement of construct rigidity in shortconstructs with protection of screws usingsupralaminar and sublaminar hooks

CHANGING BIOLOGY osteoporosis screw pull out strength fractures “fusion potential” MSCs vascular supply failure to fuse pseudarthrosisCaplan, A. I. (2007), Adult mesenchymal stemcells for tissue engineering versusregenerative medicine. Journal of CellularPhysiology, 213: 341–347.doi: 10.1002/jcp.21200

Frailty Frailty Index has been used to predict morbididty and mortality(Cardiovascular Health Study) Frailty Index: Activity Level Unintentional weight loss Weakness Exhaustion Diminished walking speed

FrailtyFrailty Score:0-1: Non-Frail2-3: Pre-Frail4-5: Frail

Frailty 65 electing to undergo spine surgery HRQOL survey (Godin Shepard Leisure Time Physicalactivity questionnaire) Accelerometer (15 feet) Grip strength meter Exhaustion Weight Loss 10lbs

Frailty n 64 Frail: 12.5% Pre-Frail: 42% Non-Frail: 51.5% 45% of al patients scored in bottom 20th percentile forgrip strength

Frailty Frailty Index may become a useful index to determinerisk of complications and length of recovery

Scoliosis and lumbar kyphosis

Coronal and sagittal deformity

Compensatorymechanism:flexed hips& knees,pelvic tilt,neck hyper extension. Easily fatigue andpainful

Ribcage sits on pelvis-G.I. Dysfunction fromsquashed gut. Can get malnourished

Aging 15 years

Surgical Planning Have a plan. Follow the plan, and you'll be surprised howsuccessful you can be. Most people don't have a plan. That'swhy it's is easy to beat most folks.- Paul "Bear" Bryant You got to be careful if you don't know where you're going,because you might not get there.- Yogi Berra Everyone has a plan until I hit them in the head. Mike Tyson

Surgical Planning By failing to prepare, you are preparing to fail.- Benjamin Franklin Forewarned, forearmed; to be prepared is half the victory.- Miguel de Cervantes Saavedra Those who plan do better than those who do not plan even thouthey rarely stick to their plan.- Winston Churchill

peri-op considerations DEXA for BMD FRAX score Ca2 , 25(OH) Vit D, PTH Bone formation markers:PINP Bone resorption markers:CTX CT FEA start anabolic agentI have an enormous favor to ask you

Defining Adult Spinal DeformityAdult spinal deformity encompasses spinal disordersthat involve a malalignment:GlobalRegionalSegmental level

Defining Adult Spinal DeformityAdult spinal deformity encompasses spinal disordersthat involve a malalignment:GlobalRegionalSegmental level

Defining Adult Spinal DeformityAdult spinal deformity encompasses spinal disordersthat involve a malalignment:GlobalRegionalSegmental level

Adult Scoliosis Adult scoliosis is characterized by:– Adult onset of deformity (de novo)– Adult sequelae of AIS– Degenerative changes within the deformity: StenosisSpondylolisthesisRotatory subluxationLumbar hypolordosisOsteoporosis

Adult ScoliosisAdult Scoliosis is a common cause of spinal deformityPrevalence estimates:Women 50:Elderly women:Volunteers 60:Adult CXR:123412.9%130%2Urrutia, Berven, et al: Spine 2007Robin et al: Spine 1982Schwab et al: Spine 2005Carter and Haynes: Int J Epidem 198768%38.3%4

Impact of Spinal Deformity Spinal deformity in the Adult has asignificant and measurable impacton Health-related Quality of Life Physical Function Pain Self-image Mental Health Quality of Life

Impact of Degenerative Scoliosis4.543.532.521.5Adult ealthBerven, et al. : Spine 2002

International Quality of Life Assessment project 24,936 people from 8 industrialized countries and 3 continents SF-36 scores on patient with: arthritis, COPD, Diabetes, CHF Compared Baseline SF-36 date with patients with ASD Scoliosis 20 degrees PT 20, SVA 5

Conclusions: Adult spinal deformity has a significant andmeasurable impact on health related quality of life The impact of spinal deformity is more significantthan other chronic medical conditions Resources for research and clinical care should beallocated toward management of ASD

Indications for Surgery for AdultDeformity Progression of Deformity Pain unresponsive to non-operative care Functional limitations unresponsive to non-operativecare Neural deterioration Variability: Specific Strategy for Operative Care Patient preference

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Adult Scoliosis Adult Scoliosis is a common cause of spinal deformity . Prevalence estimates: Women 50: 12.9% 1 . Elderly women: 30%2 . Volunteers 60: 68%3 . Adult CXR: 8.3%4 . 1 Urrutia, Berven, et al: Spine 2007 2 Robin et al: Spine 1982 3 Schwab et al: Spine 2005 4 Carter and Haynes: Int J Epidem 1987