1. 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

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

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

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

5. Make sure to address the chief complaint!

6. 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

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

8. 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

9. 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

10. 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

11. Infection
< 1% incidence for decompression, % 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

12. 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

13. 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

14. 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!

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