CLASSIFICATION-ANALYSIS-

TREATMENT OF FAILURES OF SPINAL

DECOMPRESSION SPINAL FUSION

Prof John Kostuik

• Chairman & Chief Medical Officer, K2M
• Past President SRS and NASS
• Past Chief & Chairman Spine Surgery, John Hopkins University
 Orthopaedic

CLASSIFICATION-ANALYSIS-
TREATMENT OF FAILURES OF
SPINAL DECOMPRESSION SPINAL
FUSION
John P. Kostuik, MD ( Emeritus )
Johns Hopkins Medicine
Department of Orthopaedic/ Neurosurgery Surgery
Spine Surgery
Baltimore, Maryland
70% of Failed Spinal Surgery
Should Never
Have Had An
Initial Operation
Causes For Failure
 Improper diagnosis
 Poor patient selection
 Psychosocial factors
 Incorrect indications
 Poor technique
 Complications
Failures of Decompression
Immediate Failure (I.F.)
 Wrong diagnosis
 Discogenic pain (I.D.D.)
I.F.
 Delayed decompression
 Technical error
 Wrong level
 Inadequate decompression
 Conjoint nerve root
Temporary Relief
Early Recurrence
 Infection
 Discitis
 Osteomyelitis
 Epidural Abscess
 Meningeal cyst
 Mid-Term Failures
(Weeks-Months)

 Recurrent Disc Prolapse

 Battered Root
 Epidural Fibrosis
 Arachnoiditis
Long Term Failures
(Months-Years)
 Recurrent Stenosis
 Disc Space Collapse Lateral Stenosis
 Instability after Disc Excision
 Instability after Decompression
Post Laminectomy
Kyphosis

 Causes
 Integrity of facets
 Ligaments
 Age
 Osteoporosis
Bone Complications
After Decompression

 Slippage 0-96%
 Pars Fracture ~ 3%
 Facet Fracture 11%
Failures After
Spinal Fusion
Causes and surgical treatment results
Early
 Infection
 Wrong or insufficient levels
 Psychosocial distress
 Nerve root impingement
Psychological Tests
 High false positive rate
Patient “At Risk”
Identification
 Duration of disability
 Perception of injury
 Compensability
 Job satisfaction
Why Does Intertransverse
Fusion Fail?

Anterior Column Loading

When Is It Fused?
 Diagnosis of Pseudarthrosis
 Suspect
 Broken instrumentation
 Loose instrumentation
 Radiographic
 Plain x-rays
 Flexion extension x-rays
 Bone scan
 CT
 3D CT (± Metal Subtraction)
 Early
 Continued pain
 Recurrence of deformity =PSEUDARTHROSIS
 New deformity
 Implant change
 Implant pullout
 Implant loosening
Negative Exploration
# Pseudarthrosis
Type of Pseudarthrosis
 Transverse
 Plate
Types of Pseudarthrosis
 Transverse
 Plate

XXXXXXXXXX Graft
Lamina
Canal
Proof
 Injection
 Motion
 Secondary
 Other levels are normal
Causes of Long-Term Failure

 Late pseudarthrosis
 Adjacent motion segment degeneration
 Spinal stenosis
 Disc herniation (4%)
 Acquired spondylolysis
 Sacro iliac instability
 Donor site pain
What Predicts A Good Outcome
From Surgery?

 Unequivocal symptoms
 Unequivocal physical examination
 Confirmatory imaging studies
What Can You, Your Patient
Expect?
 A 4x increase in complications compared to
decompression
 A Particular issue in the elderly
The Surgeon Factor
 Right patient
 Right diagnosis
 Right surgery (surgeon)