This document summarizes a study on cervical disc arthroplasty using an artificial disc to treat disc-associated wobbler syndrome in 33 dogs. The key findings were:
1) 91% of dogs showed improvement in neurological grade after surgery, with 30 dogs having satisfactory to excellent outcomes.
2) Complications included vertebral fractures during surgery in 2 dogs, immediate subsidence in 1 dog, and subsidence in 7 disc spaces.
3) Poor outcomes occurred in 2 dogs with severe, long-standing neurological signs that did not improve after surgery.
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Cervical Disc Arthroplasty for Disc-Associated Wobbler Syndrome
1. ECVS 24th Symposium July 4th 2015 - Berlin, Germany, Europe
Cervical Arthroplasty:
A Non-Fusion Technique for Disc Associated
Wobbler Syndrome in dogs
Copy of this presentation: Wobblersyndrome.com
under the menu’ tab: “For Veterinarians”
Filippo Adamo, DVM, Dipl. ECVN
East Bay Veterinary Specialists – Walnut Creek, CA
2. ECVS Surgery Symposium
July 2-4, 2015
Disclosure
I designed and developed the medical device included
in this presentation.
Currently involved in the distribution trough Applied
Veterinary Technology, LLC
3. Goals:
Preserve motion after neural
decompression while providing
distraction and stability
Potentials:
May prevent “domino lesions”
Advantages:
Treatment of multiples adjacent &
not adjacent spaces
Cervical Disc Arthroplasty (CDA)
Indications:
Disc Associated Wobbler Syndrome
4. Phase 1.
DESIGN
Madison, WI 2003
Phase 2.
IN VITRO BIOMECHANICAL STUDY
Adamo, Kobayashi et al. Vet Surgery 2007
4 Groups of 6 cervical spines (C5-C6)
a) Arthroplasty,
b) Ventral Slot,
c) Pins+PMMA fixation,
d) and normal spine
The artificial disc was better able
to mimic the behavior of intact
spine compared with ventral slot
and Pin+PMMA groups.
History
5. Phase 3.
Pilot clinical study in 2 client-owned dogs with
DAWS
Titanium alloy
Results
Follow up to 3½ years post-op
Both dogs died for unrelated neurological
diseases
MRI re-check 2 years post-op
No evidence of compression at the treated
and adjacent sites
Conclusions
Cervical arthroplasty was well tolerated
and provided excellent outcome in both
dogs
Warranted further study:
Large number of patients
Longer follow-up
Adamo JAVMA, 239(6), 2011
6. Cervical Disc Arthroplasty using
the Adamo Spinal Disc™ in 33 dogs
affected by Disc Associated
Wobbler Syndrome
at Single and Multiple Levels.
In preparation to be Submitted to JAVMA
7. Study Authors
F Adamo, DECVN
East Bay Vet Specialists – CA
R Da Costa, DACVIM (Neurology)
The Ohio State University – OH
R Kroll, DACVIM (Neurology)
VCA Northwest Vet Specialists – OR
C Giovannella, DACVIM (Neurology)
Gulf Cost Vet Neurology/Neurosurgery – TX
M Podell, DACVIM (Neurology)
Chicago Vet Specialty Group – IL
P Brofman, DACVIM (Neurology)
Veterinary Specialty Care, SC
A Multi-Center Prospective Study
8. To evaluate:
a) the immediate post-operative recovery
b) the short-, intermediate- and long term follow-up
of dogs with one level and multi-level disc-
associated-wobbler-syndrome (DAWS) treated
with cervical disc arthroplasty (CDA).
Objectives
9. Material & Methods
Implant: Similar to that in the pilot study but with several modifications
1st generation
- Ball Titanium
- Dual Ac Etch
2nd generation
- Ball in PEEK
- Thinner size
- Dual Ac. Etch
3rd generation
- Hydroxyapatite Coating
Calcium Phosphate complex
Porosity
Osteoconduction
8.5 mm
10. Spinal Disc 2nd & 3rd Gen.
Internal surfaces
Convexity is PEEK
(PolyEther Ether Ketone)
Thermoplastic polymer
Decreases friction
Prevent metallic debris
from a metal to metal joint
Concavity is titanium
Ball and socket
Patent: US 8,496,707 B2
11. External surface
Convex
To resemble natural
concavity of vertebral end
plates
Spinal Disc 2nd & 3rd Gen.
Concentric grooves + Central notch
To provide “grip” & to prevent implant migration
14. Thick end
Parallel channels to hold
the assembled prosthesis
during implantation
Thin end
Slotted to remove the pins
after implantation
Barrel Holder – Double function
Dedicated tools
15. Sizing Probes
• Resemble at each end the shape of either
mthe S, M, or W disc size
•To probe/test the disc space during
nburring, before final disc implantation
Dedicated tools
16. Small burr
• To clean end-plates and begin
creating concavity
Large burr
• matches the external disc
convexity
• To facilitate implant
accommodation by the disc
space
Large burrSmall burr
Two dedicated burrs
Dedicated tools
17. 20 degree angle attachment for the Surgairtome
To facilitate working at an angle parallel to the disc
space during burring
Particularly useful at C6-C7 (and C7-T1 !!)
Dedicated tools
18. Caspar Cervical Distractor
• To maintain vertebral distraction during implantation
• To allow visualization through the disc space to the dorsal
longitudinal ligament
Dedicated tools
21. Sample population:
First 33 clients-owned dogs w/ over 2
mo. history of DAWS
Diagnosed by MRI or CT myelo
Weight over 23 kg, but one (12.2 Kg)
Neurologically and
radiologically evaluated
Prior to surgery
Shortly after surgery
within 24 hrs
At 2 wks & 3, 6, 12 & 24 mo. after
surgery
Including Criteria
22. Total = 50 disc sites treated
Single, two and three level lesions
Neurological Assessment
Grade 0 to 6
De Decker, et al. JAVMA 2012; 240:848–857
C3
C4
C5
C6
Material and Methods
0: No apparent neurological deficits
1: Cervical hyperesthesia w/o deficits
2:: Hind limb ataxia w/o visible paresis
3: Hind limb ataxia with paresis &
no appreciable forelimb ataxia
4:: Ambulatory tetraparesis: broad-
based ataxia hind limbs & choppy
gait forelimbs (“two engine gait”)
5:: Non-ambulatory tetraparesis: able
to stand/walk few steps before collapse
6: Tetraplegia
23. Optimal
Implant well centered in
the disc space on lateral
& VD views
Sub-optimal
Off midline on VD
Inadequate
Not seated in center of
the disc space on lateral
view
Inadequate position
Implant Position
24. Relative Distraction ratio (RDR):
Ratio between post-op and pre-op
width at the treated space
Adequate / Ideal*
RDR > 1.7 and < 2
* Equivalent to a
distraction of 2-3 mm
Under distraction
RDR < 1.7
Over-distraction
RDR > 2
Distraction
C7C6
C5
C7
C6
C5
Pre-op
Post-op
32. Distraction:
Minor Subsidence: Distraction lost
compared to immediate post-op, but maintained
when compared to pre-op
All sites
More pronounced with 1st generation (thicker)
implant
Less pronounced with 2nd and 3rd generation
(thinner) implant
Severe Subsidence
Distraction lost compared to pre-op
7/50 sites (14%)
Serial Radiographic Assessment
33. Mobility
Decreased or not detectable over time in the
majority of patients.
Maintained at 2 wks post-op in 88% of 24 dogs examined
Maintained at 6 mo post-op in 23% of 14 dogs examined
Maintained at 9 mo post op in one dog
Maintained at 3 years post-op in one dog
♬ In 7 dogs where dynamic study was performed
immediately after surgery: mobility although
expected was not detectable in 5 out of 10 treated
spaces
in 3 dogs was later detectable on the serial
follow-ups.
No Implant migration
No Implant infection
Serial Radiographic Assessment
Ventro-flexion
Dorsi-flexion
34. 3 dogs: 7-24 mo post-op
Osteophites or Heterotopic Ossification.
Didn’t affect the clinical status
1st and 2nd generation implant
3 dogs: 24-36 mo post-op
No signs of disc degeneration or
compression at treated and adjacent sites
1 dog: 6 wks post-op
Spinal compression secondary to
immediate subsidence
Improper technique
Improved with single dorsal
decompression
MRI Re-assessment: 7 dogs
C3-C4 C5-C6
C5 C6 C7
C5-C6 6 wks post – op
C6 C7*
In all dogs the implant didn’t affect the spinal cord visibility
35. Post-op recovery time
Immediate in all dogs
Neurological status unchanged compared
to pre-op status in all dogs
Post-op hospitalization time *
5 dogs: Discharged same day
26 dogs: 1- 3 days
2 dogs: 4 - 5 days
Based on the severity of the neurological
status pre-surgery
Clinical Assessment
36. Follow-up: Mean 24 mo, (range 2 wks - 42 mo)
21 dogs still alive
12 dogs deceased
9 for non-neurological diseases
3 euthanasia: insufficient improvement or complications
Patient Outcome
91% have shown improvement of at least 1+
neurological grade
Satisfactory to Excellent: 30 dogs
Unsatisfactory: 1 dog
Poor: 2 dogs
Better Outcome: mild and short duration of signs on
presentation
Worse Outcome: chronic non-ambulatory tetraparesis +
extensor rigidity of front legs not resolving under general
anesthesia
No Domino lesions during the observation period
37. Patch: 6 y old MN Dalmatian
6 mo ambulatory tetraparesis
worsening 2 mo prior to presentation
39. Complications
Vertebral fissure fracture during distraction: 2 dogs
Improper Caspar pins placement
+/- excessive distraction with Caspar Distractor
Did not affect the outcome
Immediate subsidence: 1 dog
Improper technique: over-burring.
Surgical revision with dorsal laminectomy
Regained improvement
Subsidence: 7/50 disc spaces
Too thick and too narrow discs
Except for 1 dog, did not affect the outcome
Improper technique
40. Complications
Vertebral Axial Compression fracture: 1 dog
Nikkie
Sheltie Mix, F, 12.4 y old,
29 lb = 12.2 kg
History: 4 years ambulatory ataxia,
6 month prior to referral non ambulatory tetraparesis with
extensor rigidity all 4 legs, not resolving under anesthesia
Overdistraction
RDR 3.2 (normal > 1.7 and < 2)
2 weeks post-op: Declined to non-ambulatory
tetraparesis; Intense cervical pain; Suspected
Axial compression fracture C6 + Ventral implant
migration Euthanasia - no histopathology
2 weeks post-op
Pre-op
Immediate Post-op
C5 C6 C7
• What went wrong?
• Dog’s size too small: 12.2 Kg
• Over-distraction
Poor patient selection
41. Poor Outcome
2 dogs
Chow Mix, F, 13.5 y old
Doby, M, 12 y old
History
8-14 months progressive non ambulatory tetraparesis
Severe extensor rigidity all 4 legs, not resolving under anesthesia
Outcome:
Dog 1 (Chow): Euthanized 8 mo. after surgery d/t insufficient
improvement
Dog 2 (Doby): Neuro score improved only from 6 to 5
• What went wrong?
• Neurological signs too severe
• Irreversible spinal cord damage
Poor patient selection
Pierce Simon
42. Advantages of CDA
Less invasive than traditional surgeries
Rapid post-surgical recovery
Can be performed on a out-patient basis
Treatment of multiple lesions at adjacent or non-adjacent sites
Prophylactically for “Incipient lesions”
May prevent “Domino lesions”
Spinal cord decompression & “dynamic stabilization”
C7
C6
C5
43. Immediate relief of radicular pain
and vascular compression at the
intervertebral foramina
Enable MRI re-assessment
for complications
for long term re-assessment of
domino lesions
Other Benefits
C6 C7*
44. Disadvantages – Limitations
Concurrent Dorsal spinal compression
The possible decrease of distraction may
exacerbate the dorsal compression
It might be necessary to combine CDA with
dorsal decompression at the affected site
Not good candidate for CDA
< 23 Kg
Too advanced neurological status
Severe front legs extensor rigidity not
resolving under general anesthesia
45. Conclusions
CDA using this prosthesis appears to be safe
and effective
Suitable for medium and large breed dogs
Rapid post-surgical recovery
Ideal for treating multiple levels
Not technically difficult and easy to master
May prevent “Domino Lesions”
Case selection, Early Intervention and Correct
execution of the surgical technique may be critical factors
for the outcome
“Case selection is King,
…. technique is the Prince”
number 6 of the most commonly cited attributes of a “great”
surgeon!
Dr. Zelman column
46. Currently in use
4th Generation Spinal Disc™
Thinner implants: 8.3mm
To avoid over-distraction
To allow implant positioning along the
natural angle of disc space
Additional wider & taller sizes
S1, M1, M2, WT1, WT2, + WL1 & WL2
To increase contact surface
implant/vertebral endplate To decrease
subsidence
47. Two External Layers of Coating:
Commercial Pure Titanium (CPTi):
To create sponge porosity
HA
To promote bone/implant
incorporation
CPTi + HA
Future Directions
5th Generation Spinal Disc™
48. 3 mo. post-op
4th practical CDA Course
November 5, 2015
Las Vegas, Oquendo Center
Program: Wobblersyndrome.com
Event Coordinator:
Nancy Kroll: nkroll@appliedvt.com
49. Questions
Contact:
Filippo Adamo, DVM, DECVN
East Bay Veterinary Specialists
Walnut Creek – California
Phone: 925.937.5000
flppadamo@yahoo.com
Wobblersyndrome.com