September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
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.
Case Presentation
Pt:
M, 63yrs
Presentation:
Ongoing low back pain, bilateral buttock & right
anterior thigh pain.
PMH:
L4/5 & L5/S1 ALIF & percutaneous
stabilisation.
Osteopathic
Evaluation:
Restricted flexion right L3-SIJ.
Restricted extension left L1-SIJ.
TTT given:
Mobilisation of Lsp & hips. Myofascial
treatment to gluteii, LES & LEX musculature.
Pre TTT ODI:
22%
Post TTT ODI: 6%
Case Presentation
Pt:
F, 63yrs
Presentation:
Painful Tsp & Csp with retracted and painful trapezius
muscle post 2nd surgery. Left with exposed spinous
processes over upper Tsp .
PMH:
5yrs previously - T5 discectomy for disc protrusion
with cord compression.
1yr previously - T4-6 posterior fusion with ligation of
T4 nerve root.
Osteopathic
Evaluation:
Restricted flexion and extension C2 – T1. Hypertonic
trapezius, levator scapulae, scalenes and SCM
bilaterally.
TTT given:
Mobilise Csp & Tsp and address soft tissue
component.
Pre TTT NDI:
58%
Post TTT NDI:
32%
Significant reduction in disability, reduction of
medication and increase in daily activity.
Case Presentation
Pt:
F, 15yrs
Presentation:
Pain in right trapezius area.
PMH:
AIS - Instrumented fixation T4-T11.
Chiari malformation type I (decompressed).
Diagnosis:
AIS (posterior correction).
Osteopathic
Evaluation:
Restriction at L3-T4 & C4-T1 right in flexion.
Restricted extension at L5-T4 & C4-T1 left.
TTT given:
Treatment to adjust above levels and to
improve tone in trapezius and periscapular
muscles.
Pre TTT ODI:
15%
Post TTT ODI: 6%