Neurosurgical Updates 2016 Brain & Spine Symposium: Presented by: Mary L. Dombovy, MD, MHSA Paul K. Maurer, MD Anthony L. Petraglia, MD Patrick J. Reid, MD Matthew L. Dashnaw, MD, Pharm D M. Gordon Whitbeck, Jr., MD

Revision Spinal Surgery Who Needs It? Presented by M. Gordon Whitbeck, Jr., MD Orthopaedic Spine Surgeon Rochester Regional Health

Multiple Indications Recurrent/residual neural compression Instability following decompression Adjacent segment disease Pseudarthrosis Hardware malposition/migration/failure Infection Sagittal imbalance

Diagnosis History Objective findings on PE EDX abnormalities Imaging that correlates with all of the above (XR, MRI, myeloCT, nuclear medicine)

Make sure to address the chief complaint!

Recurrent Disc Herniation 15-20 % incidence Greatest risk with large annular defect Delay early advanced imaging(3-6 mo.) in absence of progressive deficits Aggressive conservative Rx Re-exploration associated with results comparable to primary surgery

Instability After Decompression De novo spondylolisthesis, progressive spondylolisthesis, progressive scoliosis Aggressive conservative Rx Fusion with or without revision decompression with less predictable results

Adjacent Segment Disease Incidence as high as 30% Stenosis, spondylolisthesis, scoliosis, kyphosis above or below fusion Risk increased after fusion of 3 or more motion segments Aggressive conservative Rx Decompression with fusion with less predictable results

Pseudarthrosis True incidence poorly defined Risk depends on numerous patient and surgeon factors Smoking a well documented risk Aggressive conservative Rx Stable-no surgery Unstable-circumferential surgery with less predictable results than primary fusion

Implant Complications True incidence poorly defined Malposition, migration, failure Risk related to surgical technique, bone mass, pseudarthrosis development Revision with or without extension of fusion to adjacent levels

Infection < 1% incidence for decompression, 2-10% incidence for instrumented fusion Risk multifactorial High index of suspicion within 3 mo. postop Aggressive surgical Rx of wound issues, especially in presence of implants Retain well fixed implants

Sagittal Imbalance True incidence poorly defined Most commonly positive sagittal balance -can’t straighten up Generally a judgment/surgical technique issue Aggressive conservative Rx Revision with osteotomy and extension of fusion

Avoiding Revisions Assess and optimize medical condition Assess bone mass in at-risk patients Insist on preop smoking cessation for fusions Adhere to accepted evidence-based indications for primary surgery Adhere to evidence-based biological and biomechanical surgical principles

Conclusions More lumbar surgery means more revision lumbar surgery Results of revision lumbar surgery are less predictable than for primary surgery Avoid the need for revision lumbar surgery - control what you can during primary surgery!

Conclusions Evaluate revision surgical candidate carefully and establish reasonable treatment goals Manage patient expectations Avoid revision of the revision – DO YOUR BEST WORK!