Capps 9.18.07 W Extra

WHAT’S HOT
WHAT’S NOT
Catherine C. Capps, MD
WellCare
WHAT’S HOT
WHAT’S NOT
SPINE
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.
DDD Cervical Spine
 Conservative Care:
 NSAI’s
 Steroids
 Traction/ Therapy
 Rest. Restrictions
DDD Cervical Spine Surgery
Anterior Cervical Decompression

and Fusion (ACDF)
VS.
Cervical Disc Replacement
ACDF
“The Gold Standard”
 Success Rate of Fusion:
 97% SingleLevel
 75-87% 2 Level
 56-68% 3 Level
(Higher number reflects plate fixation used)

ACDF
What’s Hot/ What’s Not
What’s Not:
 Metal Implants
 Risk of increased urine and serum

levels of metal ions
 Difficulty with subsequent imaging on

CT, MRI
What’s Hot:
 Absorbable Implants
 Hydroxyapatite and calcium phosphate

screws
 Poly L-lactic acid mesh plates
 Breakdown after 6 weeks
 Fusion 71-77% at 1 year

ACDF Problems:
 Acceleration of disc degeneration at

adjacent level in 67% of patients.
 10% require a 2nd procedure at

adjacent level.
The New Alternative?
Cervical Disc Replacement:
 Medtronics “Prestige” Disc

 Approved by the FDA, July 2007
 Preserve motion and normal

kinematics between two vertebrae
Cervical Disc Replacement
Complications:
 Spontaneous fusion
 Catastrophic failure with implant dislocation
 Long term wear debris leading to implant

loosening and failure
 Anterior Displacement
 Airway Obstruction
 Posterior Displacement into spinal

canal
 Paralysis
 Death
Verdict Not In - Long Term
Results Known
 64% good to excellent results at 2

yr follow-up in one recent study
The Future?
ACDF- 97% success in single level

Vs.
CDR- 64% success rate in early
studies
Lumbar Disc Disease
 Conservative Care:
 NSAI
 Steroids
 PT
 Exercise
 Weight Loss
 Injections
IDET
(Intradiscal Electrothermal
Therapy)
Indications:
 Failure post 6 months conservative
therapy
 Annular tears
 Small disc protrusions

IDET
 Small heating coil inserted
percutaneously
 Coil heated to denature collagen,

ablate nociceptive fibers and
modulate inflammatory response
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
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)
Lumbar Fusion
PLIF vs. ALIF
 Per Swedish spine study group, no

significant difference overall
 At 2 yrs, 63% with good or excellent

results
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
Fusion Rate
60-95%
Pain Relief
50-80%
Complications:
 Wound infection
 Pain at ICBG site in pelvis
 Pseudoarthrosis
 Implant failure
The New Alternative
Lumbar Disc Replacement (LDR)
 Advantages:
 Maintains motion at segment
 Decreases transfer stresses to the

adjacent levels
LDR
Types 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
 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.
 Contraindications:
 Osteoporosis
 Abnormal curvature of spine

(scoliosis, for example)
 Instability (spondylolisthesis)
 Facet disease of significance

Surgical Approach:
Anterior – need to work behind

the abdominal contents, to move
and protect the major blood
vessels to legs
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
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.
DDD- The Future
Intradiscal Gene Therapy
Viral transfer of growth factor genes

to increase the production of
proteoglycan in vivo and in vitro
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.
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.
Osteoporosis Risk Factors:
 Female  Inactivity
 Caucasian/ Asian  Smoking
 Small Frame
 Alcohol Intake
 Meds
 Age
 Corticosteroids
 Estrogen  Excess thyroid hormone
Deficiency  Anticonvulsants
 Amenorrhea  Antacids containing
aluminum
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)
Treatment
 Conservative
 Bedrest* / Activity Restriction
 Pain Medication
 Bracing
*Beware in elderly
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
Complications
 Cement emboli or  Rib fractures
extravasation  Reaction to cement
 Fat emboli/  Nerve root
Pulmonary emboli compression/ injury
 Cerebral emboli  Spinal cord
 Pedicle fracture compression/ injury
 Infection
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
What’s Hot, What’s
Not In Upper
Extremity Injuries
Cumulative Trauma
Disorders
(CTD’s)
Cumulative Trauma Disorders
 Repetative Biomechanical Stress
 Over Time
 Ergonomics – Focus on Prevention
 Multifactorial
CTD
 Controversal Term
 Implies a level of presumed

knowledge regarding etiology which
does not necessarily exist
 Further epidemiologic studies
warranted to estimate relative
causation
Wrist
Carpal Tunnel Syndrome
 Most common peripheral
 Compression Neuropathy
 Etiology
 Anatomy
 Physiology
 Position and use of wrist

SX and Signs:
 Paresthesias: 1 – 4 Digits
 Tinels
 Phalens
 Median Nerve Compression Test
 Role of Radiographic Studies
 Role of NCV / EMG
Treatment:
 Conservative
 Blah, Blah, Blah
 Surgical
 Open Release
 Endoscopic Release
 Associated Procedures
Wrist Tendonitis
 Extensors De Quervain’s Disease:
 Sheath of EPB, AbPL
 Most Common Tendonitis of Wrist
 Etio Direct Trauma or Overuse

De Quervain’s
 Sx & Signs
 Finklesteins
 Treatmant
 Conservative vs. Surgical

Intersection Syndrome
 Second compartment involved
 Friction of AbPL & ECR tendons leads to

inflammation
 Etio: Direct trauma, overuse
 Treatment: Conservative vs. Surgical

Extensor Carpi Ulnaris Problems
 6th Compartment
 Can develop subluxation
 In acute cases, splint 6 weeks

In chronic subluxation, reconstruct sling
Wrist Tendonitis - Flexors
 “Tenosynovitis”
 FCR
 FCU
 Wrist Flexors
 Digits “Trigger Fingers”

 Etiology
 Look for Systemic Factors
 Overuse
 Treatment
 Conservative vs Surgical
Elbow
Lateral Epicondylitis
 Most Common Tendonitis at Elbow
 Disruption at ECRB Aponeurosis
 Repetative Microtrauma, “Overload

Injury”, or Direct Trauma
Lateral Epicondylitis
 SX and Signs: Cozen’s
 XR: Poss Calcification
 Treatment
 Conservative
 What’s Beneficial?
 Surgical
 Release or Repair?
 Failure of Surgery
 Misdiagnosis?
Cubital Tunnel Syndrome
 Second Most Common Peripheral Nerve
Compression Syndrome
 Concurrent Systemic Factor

 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
Sx and Signs
 Pain Medial Elbow
 Dysthesias /Parethesis - ring & little finger
 Sensory & Motor Findings
 Tinels, Bent Elbow, Sublex
 NCV, EMG
 XR
Treatment
 Conservative  Surgery
 NSAI  Release in Situ
 Injections  Transposition
 Night splints
 Padded chair/table
top or elbow pads
 Vary degree of
elbow flexion/
Extension

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WHAT’S HOT

 Studies inconclusive regarding occupational

Anterior Cervical Decompression

(Higher number reflects plate fixation used)

 Risk of increased urine and serum

 Difficulty with subsequent imaging on

 Hydroxyapatite and calcium phosphate

 Breakdown after 6 weeks

 Fusion 71-77% at 1 year

 Acceleration of disc degeneration at

 10% require a 2nd procedure at

 Medtronics “Prestige” Disc

 Preserve motion and normal

 Catastrophic failure with implant dislocation

 Long term wear debris leading to implant

 Posterior Displacement into spinal

 64% good to excellent results at 2

ACDF- 97% success in single level

 Small disc protrusions

 Coil heated to denature collagen,

 Another recent trial suggests failure

 Per Swedish spine study group, no

 At 2 yrs, 63% with good or excellent

 Successful bone healing does not

 Pain at ICBG site in pelvis

 Decreases transfer stresses to the

 Synthes – “Prodisc” for single level L3-S1

 Both have 2 metal endplates with polyethylene

 Prodisc – semiconstrained – disc

 Abnormal curvature of spine

 Facet disease of significance

Anterior – need to work behind

No definitive data to suggest disc

Viral transfer of growth factor genes

 10 million in USA have osteoporosis.

Dx: XR, CT, MRI

Reduce kyphosis, stabilize fracture

67-100% if pts with good to excellent

 Ergonomics – Focus on Prevention

 Implies a level of presumed

 Position and use of wrist

 Sheath of EPB, AbPL

 Most Common Tendonitis of Wrist

 Etio Direct Trauma or Overuse

 Conservative vs. Surgical

 Friction of AbPL & ECR tendons leads to

 Etio: Direct trauma, overuse

 Treatment: Conservative vs. Surgical

 Can develop subluxation

 In acute cases, splint 6 weeks

 Digits “Trigger Fingers”

 Disruption at ECRB Aponeurosis

 Repetative Microtrauma, “Overload

 Concurrent Systemic Factor

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