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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom - PowerPoint PPT Presentation

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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom Osteopathic Management of Patients with Instrumented Spinal Fusions. Instrumented Spinal Fusion.

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September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom

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September 5th – 8th 2013

Nottingham Conference Centre, United Kingdom

Osteopathic Management of Patients with Instrumented Spinal Fusions

Instrumented Spinal Fusion

  • Spinal fusion is a process using bone graft to cause two opposing bony surfaces to grow together – Arthrodesis.

  • Instrumentation utilises surgical procedures to implant devices that maintain spinal stability while facilitating the process of fusion.

The Purpose of Instrumentation

  • Procedures are used to:

    • Restore stability of the spine.

    • Correct deformity, e.g. Scoliosis.

    • Bridge space by the removal of a spinal element, e.g. intervertebral disc.

  • Instrumentation immobilises the involved spinal levels.

    Patients often actually feel they are more mobile following the procedure as their pain has been reduced or eliminated.

Importance of Bony Fusion

  • Instrumentation placed without fusion can result in hardware failure.

  • All metal fatigues with repetitive stress.

  • Continual stress on an implant, unsecured by a solid bone growth, can lead to screw pullout, or even fracture of the metal → complete breakdown of the construct.

  • Consequently a solid bony fusion is crucial to the proper healing of a spinal fusion.

Bony Fusion

  • Full bony fusion takes 6 months.

  • Instrumentation is only designed to be functional for 9 months, after that it is ‘just there’.

  • Factors such as osteoporosis and smoking are known to impair bone healing and reduce the success of fusion.

  • These patients are more likely to have a pseudofusion, which can result in continued pain at the surgical site and hardware failure.

Osteopathic Considerations

  • Presence of localised scar tissue.

  • New junctions will establish above and below the fusion.

    Important not to stress these new junctional areas when articulating – never rotate specifically at those levels.

    Risk of pseudoarthrosis, particularly proximal to fusion, if over rotate or thrust too hard at that level.

  • Soft tissue structures that should mobilise fused areas no longer contract/relax as the spine does not now move.

  • With an upper Lsp fusion, often get a pseudo SIJ problem.

Treatment Strategy

  • Examine as normal – including fused areas.

  • Key is to optimise spinal function throughout the rest of the spine.

  • Reduce tension in soft tissues, increase elasticity and break the pain/contracture cycle.

  • Initiate tissue lengthening using long levers to break down adhesions.

  • In Lsp fusions, supporting structures become very tight - particular areas to stretch and mobilise include iliocostalis, QL, gluteii, iliopsoas, iliacus, T/L & 12th rib, thorax & pelvis.

  • Focal manipulation can be utilised when better tissue health is established.

Sacral Fusion

  • Spinal & pelvic mechanics change, and SIJ function alters.

  • Unilateral SIJ fusion  contralateral SIJ becomes hypermobile.

  • Bilateral SIJ fusion  early degeneration & hypermobility at L/S.

  • Often have a flat back, fixed flexed posture – movement comes from hips.

  • T/L & hips are inter-related through structures such as QL, psoas, thoraco-lumbar fascia.

  • Patients tend to have reduced hip extension & they extend from T/L.

  • Encourage extension throughout – hips, Tsp, shoulder girdles, etc.

  • Give consideration to occupation – e.g. desk job – fixed pelvis  increased mobility at junctional areas, especially T/L.

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