HISTORY OF SPINAL

INSTRUMENTATION
Mohamad Hidayat
Andhika Yudistira
 SPINAL DISORDERS

Trauma
 Fractures, Whiplash injury, etc.

Tumor
Infection & Inflammatory Disease
Deformity
 Scoliosis, spondylolisthesis, degenerative lumbar kyphosis, etc.

Cervical & Low-back Pain

 Degenerative disease, such as disc herniation, stenosis,
spondylolisthesis, etc.
TREATMENT OF SPINAL DISORDERS
Conservative Treatment
 Degenerative disease
 Stable fracture
 Mild deformity

Surgical Treatment
 Failed conservative treatment
 Unstable fracture (dislocation)
 Progressive deformity
 CRANE ANALOG IN
SPINE BIOMECHANICS
 GOALS OF SPINAL INSTRUMENTATION
 To support the spine when its structural integrity is severely
compromised (iatrogenic, traumatic, infectious, or tumorous, etc).
CORRECTION  SPINAL STABILITY
 To prevent progression or to maintain the achieved profile after
correction of spinal deformities (scoliosis, kyphosis,
spondylolisthesis).
MAINTAIN STABILITY AFTER CORRECTION
 To alleviate or eliminate pain originating from various anatomical
structures by achiving fusion or stiffening spine segments and thereby
diminishing movement.
ENHANCE SPINAL FUSION
THE EMERGE OF SPINAL FUSION &
INTRUMENTATION
 Fred Albee and Russell Hibbs
published the first spinal fusion in
1911, for progressive deformities from
tuberculosis.
 In 1914, Hibbs described operative
fusion and cast correction for the
treatment of Idiopathic Scoliosis.
 Spinal fusion has now been extended
to treat various spinal conditions
including scoliosis, kyphosis,
fracture/dislocations, spondylolisthesis,
and intervertebral disc disease.
TYPES OF FUSION
 FACTORS FOR CONSIDERATION
IN SPINE FUSION
Biologic Factors
 Local Factors:
 Soft tissue bed, Graft recipient site preparation, Radiation, Tumor and
bone disease, Growth factors, Electrical or ultrasonic stimulation
 Systematic Factors:
 Osteoporosis, Hormones, Nutrition, Drugs, Smoking

Graft Factors
 Material, Mechanical strength, Size, Location

Biomechanical Factors
 Stability, Loading
SPINAL INSTRUMENTATION TYPES

Implantation Method:
 Wiring, Hooks, Screws

Vertebra  Rods vs. Plates

Spinal Level:
Graft
 Cervical, Thoracolumbar

Vertebra Position:
 Anterior vs. Posterior
Pedicle screw instrumentation Instrumentation
CERVICAL SPINE INSTRUMENTATION
THORACOLUMBAR SPINE INSTRUMENTATION
POSTERIOR SPINAL INSTRUMENTATION

 Paul Harrington
 Eduardo Luque
 Hartshill
 Roy Camille
 Magerl
 Moss Miami
 Isola
 Subroto Sapardan
 Steffee
 Etc.
 PAUL HARRINGTON – 1950S

Hook & Rod system

 Consisted of a rod and a hook
at either end of the spine.
 Performing distraction
mechanism across the rod, as
well as compression hooks and
rods, to partially reduce spinal
deformities.
 However, Harrington system
did not address normal spinal
alignment, particularly sagittal
plane.
 PAUL HARRINGTON - 1973
• In 1973, Dr. Harrington published an 11 year follow-up of 578 patients who were
treated with spinal instrumentation.

• The average correction of the scoliosis curve in the frontal plane was 54%. He
published a 4% rate of pseudarthrosis or non-union which was a significant
improvement when compared with previous fusions performed without instrumentation.

• These techniques were not without significant complications which included fracture
or failure of the instrumentation as well as degeneration or instability affecting
portions of the spine above or below the instrumentation

• The distraction forces of the Harrington instrumentation tended to decrease the amount
of lumbar lordosis (swayback) which led some patients to develop a “flat-back
syndrome”

• Hook dislodgement and rod breakage also proved to be troublesome complications.

 EDWARDO LUQUE - 1973
 Known as the first
Segmental Spinal
instrumentation/fixation.
 Using two rod system in
posterior spine, and attached to
spinal bones with wires
(sublaminar wires) at each level
of spine.
 Purpose : to increase number of
fixation points and to obviate the
need for a postoperative cast /
brace.

Hybrid system : Paul Harrington (Texas) + Edwardo Luque (Mexico), referred to as

the TEX-MEX surgery. Using rod and sublaminar wires.
HARTSCHILL RECTANGLE

 Luque sublaminar wire

modification
 Although the corrective power of sublaminar wires was
well-appreciated, many surgeons had reservations in using
them.
 Reports of neurologic injury resulting either from direct
trauma or from epidural hematoma.
 In addition, revision surgery to alter sublaminar wiring is
problematic.
 Drummond et al.developed a method for segmental
fixation using a button-wire implant passed through the
base of the spinous process.
 This technique does not provide as strong fixation as do
sublaminar wires.
 It avoids, however, passing anything into the spinal canal
and thus reduces the risk of direct neurologic injury.
 Some pundits referred to the procedure as the “chicken-
Luque” procedure.
POSTERIOR LUMBAR INSTRUMENTATION
MAGERL’S SCREW

Translaminar / Transarticular Screws in Lumbar Spine

 ROY CAMILLE – 1963 &
1970
 In 1963, Raymond managed a 17-old
girl who had severe dislocation of
the fourth and fifth lumbar vertebrae
and cauda equina syndrome as the
result of a traffic accident.
 She had had a laminectomy
previously at another hospital,
performed by the neurosurgical "The reduction was easy, but I had no
team more spinous processes, I had no
more laminae, and the wires and Wilson
plates we had at this time were not helpful.
So I had to do something, I tried to
stabilize the spine with two Scherman
plates, implanting screws where I could. I
was an anatomist and I knew about the
pedicle; I understood immediately that a
good location to have an implant fixed
to the spine was the pedicle. That is how
I started with this surgery the first time."
PEDICLE AS A SITE FOR SEGMENTAL SPINE
FIXATION
 Pedicle screws presented many advantages when compared with other
tools for spinal fixation.
 Pedicle screws are biomechanically superior as a point of fixation
compared with hook- or wire-rod constructs and can be placed into
the sacrum, an area to which fixation is otherwise difficult.
 In addition, they can be placed even after a laminectomy has been
performed and can be positioned without entering the spinal canal.
 This advantage allowed for the massive proliferation of spinal
instrumentation into the area of degenerative spinal disorders.
COTREL-DUBOUSSET SYSTEM – 1980S
 The CD instrumentation system
allowed for multiple fixation
points along the spine using a
variety of hook (laminar/pedicle)
and rod combinations.
 This instrumentation system
allowed for correction of the
spine in the coronal, sagittal, and
axial planes (rotation) during
spinal reconstructions.
 Gradually develop using
sublaminar wire (hybrid)
DEVELOPMENT OF CD SYSTEM
 Texas Scottish Rite Hospital
(TSRH) System.
 It was similar to the CD system
in its use of multiple hooks and
cross links
 The following decade saw the
introduction of numerous, similar
dual-rod systems like Moss-Miami
and Isola.
 The last decade has seen the
introduction of numerous
systems that operate with the
same design principles, with a
shift toward the use of polyaxial
screws that make coupling of the
fixation points to the rods easier.
 Today’s systems often have a wide
range of screw choices, such as
Monoaxial Screws, Polyaxial
Screws, Reduction Screws, etc.
 MOSS MIAMI & ISOLA

MOSS MIAMI ISOLA

ANTERIOR SPINAL INSTRUMENTATION

Allen Dwyer
Zielke
Kaneda
Kostuik
Z plate
Etc.
ALLEN DWYER - 1964
 Dwyer insert a specially
designed screw and staple unit
into each vertebral body at the
apex of spinal curvature.
 A flexible, braided titanium-wire
cable then was passed through
holes in the heads of the
screws.
 The compression was held by
crimping the screw heads into
the cable.
KLAUS ZIELKE - 1975
 The Zielke system, developed in 1975, was the next step in the
development of ventral instrumentation.
 The Zielke device connected transvertebral screws with a threaded rod
and nuts and was more rigid than the Dwyer cables.
 This added both strength and the capacity for incremental correction
and derotation, permitting a more powerful correction.
 The Zielke system produced a lower pseudarthrosis rate and
somewhat lower recurrence of the flat back syndrome.
 In spite of these benefits, the system had many shortcomings. The
pseudarthrosis rate remained high when the system was used as a
stand-alone device but was lowered with supplementation of dorsal
fixation.
 This system also suffered from the tendency to shorten the ventral
columns and to produce kyphosis.
ZIELKE SYSTEM + HARRINGTON
POSTERIOR ROD
KANEDA ANTERIOR SPINAL SYSTEM
 Initiated and developed by
Kiyoshi Kaneda from Hokkaido
University, Sapporo, Japan.
 It was frist used for anterior
stabilization after anterior
decompression in
thoracolumbar burst fractures
with neurologic deficits
 Consisted two pieces of
vertebral plates with
tetraspikes, two rigid rods, four
screws, and eight nuts.
THORACOLUMBAR SPINE INSTRUMENTATION

Z-plate (Danek) Kaneda (AcroMed)

SPINAL SURGERY & INSTRUMENTATION IN
INDONESIA

SOELARTO REKSOPRODJO SUBROTO SAPARDAN

PEDICLE SCREW – SUBLAMINAR WIRE
(PSSW)
SUBROTO SAPARDAN
UI SYSTEM 1998 – SUBROTO SAPARDAN
SPINAL INSTRUMENTATION TO THIS DATE

Non-Fusion Technique :
Growing Rods

Posterior Lumbar
Interbody Fusion
MOTION-PRESERVATION TECNIQUE
TDR & DPS

Motion preserving : Non-Fusion Stabilization Device :

Disc arthroplasty Dynamic Posterior Stabilization
 SUMMARY
 Treatment of spinal deformity has improved due the development of
advanced surgical techniques and improved spinal instrumentation.
 These advances allow surgeons to help their patients maximize their
quality of life while striving to minimize the potential for complications.
 Advances in the past few decades have improved correction of spinal
deformity, decreased the morbidity of surgical procedures, and allowed
for earlier return to activity after surgery.
 Current research focuses on improving and developing motion
preserving surgical techniques and less invasive surgical options.