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