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3rd Cervical Disc Arthroplasty (CDA)
Practical Course
Speaker:
F Adamo, DVM, DECVN
Instructors:
F Adamo, DVM, DECVN
R Kroll, DACVIM (Neurology)
C Giovannella, DACVIM (Neurology)
Course Objectives
 Mastering the CDA technique
 Avoid common mistakes
 Enable you to perform CDA independently on
your first clinical case
 Additional supervision is available upon request
Morning session:
1st hour:
 History of CDA & description of the instrumentation
 Recent clinical data
 Video of the technique in a clinical case
2nd hour:
 Dr. Kroll lecture
 Frequently Asked Questions
 Practice CDA on canine plastic cervical model
Afternoon session:
 3 hrs Practice CDA on canine cadavers
 1 hrs Discussion & Certification
 Cocktail/Appetizers
Course schedule
Registry Approved Continuing Education (RACE)
 RACE approved for 5 hrs of CE
 To receive the CE- credit hrs at the end of this course you
have to fill out:
 Participation Evaluation form
 14 post-test questions
Padfolio content:
 Schedule
 Printed copy of the CDA surgical technique
 FAQ questions + answers
 Test: 14 questions for RACE
 Evaluation form
 CE credit certificate
 Other information:
- dropbox
- wobblersyndrome.com
CDA course
Hallmarq
Shawn Miller
Perioptix
Urban Skyler
Sontec Instruments
Angus & Dennis
Sponsors
Goals:
Preserve motion after neural
decompression while providing
distraction and stability
Potentials:
May prevent “domino lesions”
Advantages:
Treatment of multiples adjacent
& not adjacent spaces
CDA
Indications:
 Disc Associated Wobbler Syndrome
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
Phase 3. Pilot clinical study in 2 client-owned
dogs mmmmm with DAWS
Titanium alloy
 Results
 Follow up to 3½ years post-op
 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
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
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
To evaluate the immediate postoperative recovery,
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).
Objective
Material & Methods
Implant: similar to that described in the preliminary study, but
with several modifications.
Adamo JAVMA, 239(6), 2011
Adamo Spinal Disc 2nd & 3rd Gen.
 Internal surfaces
 Concavity is titanium
 Convexity is PEEK
 (PolyEther Ether Ketone)
 Thermoplastic polymer
 Decreases friction
 Prevent metallic debris
from a metal to metal joint
 Acts as a ball and socket
Patent: US 8,496,707 B2
 External surface
 Convex
 To resemble natural concavity
of vertebral end plates
 To prevent implant migration
Implant
 External surface
 Concentric grooves
 To provide “grip”
 To allow bone in-growth into the implant
 2nd Generation
 Treated with Dual Acid Etch Bath
 to promotes bone/implant incorporation
 3rd Generation
 Treated with Hydroxyapatite
 to better promotes bone/implant incorporation
Implant
1st generation 2nd generation
- Ball in PEEK
- Thinner size
3rd generation
- Ball in PEEK
- Thinner size
- Hydroxyapatite
Coating
Implant Design Modification
4rd generation
- Ball in PEEK
- Finally thinner size
- Hydroxyapatite
Coating
- Additional wider
& taller sizes
8.5 mm 8.3 mm
Implant Design Modification
 7 different disc sizes
 Set of dedicated tools
+ WL1 & WL2
Threaded pins
• to hold the assembled prosthesis
Dedicated tools
 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
Sizing Probe
• 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
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
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
Caspar Cervical Distractor
• To maintain vertebral distraction during implantation
• To allow visualization through the disc space to the dorsal
longitudinal ligament
Dedicated tools
Disc space prepared for the implant
Vertebral end plate
Dorsal Long. Lig.
 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
 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
 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
 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
C7C6
C5
C7
C6
C5
Pre-op
Post-op
Distraction
Ventro-flexion
Dorsi-flexion
Neutral
Mobility
 Distance between dorsal and ventral
edge of the 2 faces of the implant in
neutral and stressed views
 Present
 Not detectable
 2 years post-op when possible
 As needed, in the event of recurrence of clinical signs
MRI re-evaluation
Results
 Breeds:
 17 Doberman Pinchers (50%)
 3 Dalmatians
 2 Labrador
 2 Bernese Mountain dog
 1 Standard Poodle
 1 Weimeraner
 1 Boxer
 1 Greyhound
 5 Mix
 Sex:
 21 M; 12 F
 Age:
 4 - 13 y; Mean 8.3 y
 27% over 10 y old
 Single level: 19 dogs
 C6-C7 (13 dogs)
 C5-C6 (5 dogs)
 C3–C4 (1 dog)
 Two levels: 10 dogs
 C5-C6 & C6-C7 (8 dogs)
 C4-C5 & C5-C6 (1 dog)
 C3-C4 & C5-C6 (1 dog)
Lesion Localization
 Three levels: 3 dogs
 C3-C4, C5-C6 & C6-C7 (2 dogs)
 C2-C3, C5-C6 & C6-C7 (1 dog)
TOTAL: 50 Spaces treated
C6
C7
C3 C4
C5 C6
C3
C4
C5
C6
Inadequate position
Immediate Post-op Radiographs
 Implant position:
• Optimal (40/48 sites)
• Sub-optimal (7/48 sites)
• Off midline on VD
• Inadequate (1/48 sites)
• Improper technique
 Excessive burring of caudal
endplate
 immediate subsidence
Caudal subsidence
 Distraction:
• Over-distraction (15/50 sites)
• Mostly with 1st generation (thicker)
implant
• Adequate distraction (34/50 sites)
• Mostly with 2nd & 3rd generation
(thinner) implant
• Under-distraction: (1/50 sites)
• Improper technique
 Excessive burring of caudal
endplate – immediate
subsidence
Immediate Post-op Radiographs
 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
 Subsidence
Distraction lost compared to pre-op
 7/50 sites (14%)
 Ventral Osteophytes
 2 sites in one dog
Serial Radiographic Assessment
 Mobility
 Present:
 at 2 wks post-op in 88% in 24 dogs examined
 at 6 mo post-op in 23% in 14 dogs examined
♬ In 7 dogs where dynamic study was
performed immediately after surgery: mobility
although expected was not detectable in 5/10 of
the treated spaces
 No Implant migration
 No Implant infection
Serial Radiographic Assessment
Ventro-flexion
Dorsi--flexion
 6 weeks post-op (1 dog)
 Improper technique C6-C7
 Declined after surgery
 Dorsal compression at C5-C6
due to loss of distraction
 Improved with single dorsal
decompression
 7 mo. post-op (1 dog)
 New osteophytes or
heterotopic ossification
 Clinical status unchanged
Dog 2
C5-C6
C5 C6 C7
T2 sagittal MRI
C5-C6 6 wks post – surg
C5-C6 pre – surgery
MRI Re-assessment: 6 dogs
 20-24 mo. post-op (4 dogs)
 2 dogs: No signs of disc
degeneration or compression at
treated and adjacent sites
 2 dogs: New osteophites or
Heterotopic Ossification.
 1st and 2nd generation implant
C6
C7*
MRI Re-assessment
C3-C4 C5-C6
 In all dogs the implant
didn’t affect the spinal
cord visibility
 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
 25 dogs: 1- 3 days
 2 dogs: 4 - 5 days
 Based on the severity of the neurological
status pre-surgery
Clinical Assessment
Follow-up: Mean 24 mo, (range 2 wks - 42 mo)
 22 dogs still alive
 11 dogs deceased
 8 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
 No Domino lesions during the observation
period
 Better: mild and short duration of signs on presentation
 Worse: chronic non-ambulatory paraparesis + extensor
rigidity of front legs not resolving under general
anesthesia
Clinical Assessment
Patch: 6 y old MN Dalmatian
6 mo ambulatory tetraparesis
worsening 2 mo prior to presentation
Sonny: 8 y old MN Doberman
1y ambulatory tetraparesis, acute tetraplegic
7 months post-op
Complications and
Poor Outcome
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
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
Pre-op
Immediate Post-op
C5 C6 C7
Complications
Nikkie
 2 weeks post-op
 Declined to non-ambulatory tetraparesis
 Intense cervical pain
 Radiography:
 Suspected Axial compression fracture C6
 Ventral implant migration
 Euthanasia - no histopathology
• What went wrong?
• Dog’s size too small: 13.2 Kg
• Over-distraction
• Thinner discs sizes currently not available for these dog’s size
• Weak geriatric vertebrae (osteoporosis)!?
• Combination of the above
 Poor patient selection
2 weeks post-op
2 weeks post-op
C5
C6
C7
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 advanced / severe
• Irreversible spinal cord damage
 Poor patient selection
Pierce Simon
Limitations of CDA:
 Dog’s size
 Patient under 23 Kg are not good candidates for
CDA
 Underlying vertebral diseases
 Weaker bone in geriatric dogs
 In humans usually bone density test
Not good candidate for CDA
 Prolonged history of non-ambulatory tetraparesis
 Severe extensor rigidity of front legs not
resolving under general anesthesia
 Overall: too severe / advanced neurological signs
Clinical Relevance
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”
C7
C6
C5
 Spinal cord decompression &
“dynamic stabilization”
 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*
Disadvantages – Limitations
 Concurrent Dorsal spinal compression
 The possible decrease of distraction over
time may exacerbate the dorsal
compression
 If concurrent dorsal compression, it
might be necessary to combine CDA
along with removal of the dorsal
compression at the affected site
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”
 May improve pet-owner willingness to
pursue a surgical option
Conclusions
 CDA is very promising for the treatment
of DAWS.
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
Dr. Zelman column:
number 6 of the most commonly cited
attributes of a “great” surgeon
Current Updates
 HA coating
 Calcium and phosphorous complex
 Promote maturation of collagen fibers surrounding titanium implants and support
osteoconduction
  To improve bone/implant incorporation
 Thinner implants & additional wider and taller sizes
 S1, M1, M2, WT1, WT2, WL1 & WL2
 To avoid over-distraction,
 To increase contact surface implant/vertebral endplate
  to decrease the degree of subsidence
4rd Generation Adamo Spinal Disc™
CDA Surgery kit
Cervical Disc Prostheses –
Sizes Selection – Indication
Disc size selection
 Pre-operative
MRI measurement
 Final assessment during surgery
CDA Surgery video - Clinical case
Inserire video – surgical technique
3rd CDA Course
1. Questions ??
2. Break 10 min.
1. Dr. Kroll Lecture
1. Frequently Asked Questions
Dr. Adamo
2. Practice on spine specimens
Dr. Adamo, Dr. Kroll, Dr. Giovannella
3. Lunch
4. Practice on cadavers
Dr. Robert Kroll
CDA Case
Selection
Cervical Disc Arthroplasty (CDA)k
Frequently Asked Questions & Answers
a. Discectomy with deep cleaning of the end plates from
the annulus
b. Minor burring to accommodate the disc implant
1. Will I be performing a discectomy
or a ventral slot?
Just enough to create space for the disc implant.
a. The small burr is used for the initial burring and to create
enough space to insert the large burr.
b. The large burr is used for the final cleaning of the end-
plate, and to create enough space to accommodate the
disc in the discectomy site
c. Mild exposure of the cancellous bone in the center
area of the caudal vertebral endplate is acceptable and
often needed.
Small burr
Large burr
C5C6
2. How much do I have to burr?
C6 C7
C5
C6
C7
Burring of the caudal vertebral end-plate
C7C6
C7
C6
Parallel to each other but at about a 30-degree angle away from the
midline and away from the side on which the surgeon is standing.
3. Which is the best position to place the
Caspar distractor pins?
Placing the pins too far from the affected disc space may cause
vertebral fracture during distraction.
Place the pins toward the center or caudal third in the cranial vertebral
body, and toward the center or cranial third of the caudal vertebral body
4. How can I prevent vertebral fracture
during Caspar distraction?
X
X
Place the pin toward the center of the vertebral body that will be
receiving the discectomies and the disc implants at both ends
5. In the event that two adjacent sites have to
be treated at the same time, what is the
best pin placement?
Until it becomes difficult to distract any more!
6. How much do I have to distract?
The widest and tallest disc size possible that fits in the
discectomy site.
 The increased area of contact between the implant and the vertebral
end-plate, may decrease the degree of subsidence.
 It is best to select the disc that fits firmly in the disc space but that
doesn’t cause excessive vertebral distraction; too much distraction
may increase subsidence.
7. Which disc size is best to use?
• Before closure, bone wax can be packed on the ventral
edges of each vertebra facing the external surface of the
implant.
8. How can I prevent ventral bridging
spondylosis and tissue ingrowth between
the two articulating faces of the implant?
 A lateral, VD, and dynamic views in dorsi-flexion and ventro-
flexion
 This to have a baseline to assess distraction and mobility on the
following serial post-operative radiographs
9. Which views should be included in the
immediate post-operative radiographs?
NEUTRAL
VENTRO-FLEXION V-D
DORSI-FLEXION
2 weeks, 3, 6, 12 and 24 month follow-up
10. To evaluate distraction and mobility when is
recommended to perform serial post-op
radiographs?
NEUTRAL
VENTRO-FLEXION
DORSI-FLEXION
V-D
9 mo. Post-op:
- Maintained Mobility,
- Maintained Distraction,
- No Subsidence
Fracture of the vertebral body
• Weak bone in old dogs
• Excessive distraction (disc too thick)
• Using this implant in dogs < 23kg
Less likely to affect the outcome:
 Osteophytes and Heterotopic Ossifications
 Vertebral ankylosis
 Spondylarthrosis
 Loss of distraction and/or mobility
 Minor Subsidence
11. Which one is the most serious complication
of CDA that may affect the clinical outcome?
2 weeks post-op
2 weeks post-op
C5
C6
C7
 Not less than 23 kg
12. What is the recommended minimum patient
weight for the application of this prosthesis?
 Leash walk until 3 month
radiographic re-check
 Full activity after 6 months
radiographic re-check
3 mo. post-op
6 mo. post-op
13. For how long is activity restriction
recommended?
Questions
CDA Practice on spine specimens
Objective: Familiarization with the technique and instruments
(discs not treated with HA)
Wet-lab – CDA- guidelines
 Implants used in this lab are not HA coated
 10 cadavers
 5 surgery stations x 2 times
 3 participants in 3 stations
 2 participants in 2 stations
 Each participant will practice 2 CDA surgeries
 The instructor will first show CDA at C3-4
 Your disc spaces to practice are C4-5; C5-6 & C6-7
 Name yourself #1, #2 and #3
 On the first set cadavers: #1  C4-5; #2  C5-6; #3  C6-7
 On the second set of cadavers #1  C6-7; #2  C4-5; #3
 C5-6
 Post-op Radiographs Discussion:
 Remember on the 2nd cadaver: your dog number and the disc space
where you placed the implant
Questions?
Thanks for your attention
Wet-lab session – CDA
Post - Surgery - Radiographs
Discussion
How to place the order
Allison Hsia: Events Assistant AVT
How to place the order
 Special offer for attending the Course:
 Total value of surgery kit: $ 15,260
 Discount for attending the course: - $ 1,200
 2 additional discs sizes of $1,500 value: Complimentary
 Additional 10% discount for placing the
order within 30 days: - $ 1,406
---------------------------------------------------------------------
 New Total $ 12,654
Cost of Shipment not included
 Opportunity to promote and differentiate your practice
with an innovative surgical technique
 Average surgery cost (surg. + anesthesia):$ 3,500
 Mark up implant (x1.5 or x2): $ 1,000 - 1,500
 Total cost of surgery: $ 4,500 -
5,000
 Number of surgeries to recup. the investment: 3
Cost Analysis
How to place the order
 For Full discount: place order within 30 days from
today.
 Payment options:
 Payment in full today and take the surgery kit home
 Deposit $500 minimum and remaining balance before shipment
 Guarantees one of the limited available surgery kits
 To assemble a new surgery kit it may take up to 3 month from the
order.
 Order can also be placed by contacting:
 Preeti Zalavadia, pzal@appliedvt.com - Administrative Assistant
of AVT.
Certificates
Participants of the very 1st CDA Course – 2013
Thank you for your participation and attention!

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3nd CDA Lecture - Dr Adamo - May 7, 2015 - Oquendo Center

  • 1. 3rd Cervical Disc Arthroplasty (CDA) Practical Course Speaker: F Adamo, DVM, DECVN Instructors: F Adamo, DVM, DECVN R Kroll, DACVIM (Neurology) C Giovannella, DACVIM (Neurology)
  • 2. Course Objectives  Mastering the CDA technique  Avoid common mistakes  Enable you to perform CDA independently on your first clinical case  Additional supervision is available upon request
  • 3. Morning session: 1st hour:  History of CDA & description of the instrumentation  Recent clinical data  Video of the technique in a clinical case 2nd hour:  Dr. Kroll lecture  Frequently Asked Questions  Practice CDA on canine plastic cervical model Afternoon session:  3 hrs Practice CDA on canine cadavers  1 hrs Discussion & Certification  Cocktail/Appetizers Course schedule
  • 4. Registry Approved Continuing Education (RACE)  RACE approved for 5 hrs of CE  To receive the CE- credit hrs at the end of this course you have to fill out:  Participation Evaluation form  14 post-test questions
  • 5. Padfolio content:  Schedule  Printed copy of the CDA surgical technique  FAQ questions + answers  Test: 14 questions for RACE  Evaluation form  CE credit certificate  Other information: - dropbox - wobblersyndrome.com CDA course
  • 6. Hallmarq Shawn Miller Perioptix Urban Skyler Sontec Instruments Angus & Dennis Sponsors
  • 7. Goals: Preserve motion after neural decompression while providing distraction and stability Potentials: May prevent “domino lesions” Advantages: Treatment of multiples adjacent & not adjacent spaces CDA Indications:  Disc Associated Wobbler Syndrome
  • 8. 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
  • 9. Phase 3. Pilot clinical study in 2 client-owned dogs mmmmm with DAWS Titanium alloy  Results  Follow up to 3½ years post-op  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
  • 10. 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
  • 11. 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
  • 12. To evaluate the immediate postoperative recovery, 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). Objective
  • 13. Material & Methods Implant: similar to that described in the preliminary study, but with several modifications. Adamo JAVMA, 239(6), 2011 Adamo Spinal Disc 2nd & 3rd Gen.  Internal surfaces  Concavity is titanium  Convexity is PEEK  (PolyEther Ether Ketone)  Thermoplastic polymer  Decreases friction  Prevent metallic debris from a metal to metal joint  Acts as a ball and socket Patent: US 8,496,707 B2
  • 14.  External surface  Convex  To resemble natural concavity of vertebral end plates  To prevent implant migration Implant
  • 15.  External surface  Concentric grooves  To provide “grip”  To allow bone in-growth into the implant  2nd Generation  Treated with Dual Acid Etch Bath  to promotes bone/implant incorporation  3rd Generation  Treated with Hydroxyapatite  to better promotes bone/implant incorporation Implant
  • 16. 1st generation 2nd generation - Ball in PEEK - Thinner size 3rd generation - Ball in PEEK - Thinner size - Hydroxyapatite Coating Implant Design Modification 4rd generation - Ball in PEEK - Finally thinner size - Hydroxyapatite Coating - Additional wider & taller sizes 8.5 mm 8.3 mm
  • 17. Implant Design Modification  7 different disc sizes  Set of dedicated tools + WL1 & WL2
  • 18. Threaded pins • to hold the assembled prosthesis Dedicated tools
  • 19.  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
  • 20. Sizing Probe • 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
  • 21. 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
  • 22. 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
  • 23. Caspar Cervical Distractor • To maintain vertebral distraction during implantation • To allow visualization through the disc space to the dorsal longitudinal ligament Dedicated tools
  • 24. Disc space prepared for the implant Vertebral end plate Dorsal Long. Lig.
  • 25.  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
  • 26.  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
  • 27.  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
  • 28.  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 C7C6 C5 C7 C6 C5 Pre-op Post-op Distraction
  • 29. Ventro-flexion Dorsi-flexion Neutral Mobility  Distance between dorsal and ventral edge of the 2 faces of the implant in neutral and stressed views  Present  Not detectable
  • 30.  2 years post-op when possible  As needed, in the event of recurrence of clinical signs MRI re-evaluation
  • 32.  Breeds:  17 Doberman Pinchers (50%)  3 Dalmatians  2 Labrador  2 Bernese Mountain dog  1 Standard Poodle  1 Weimeraner  1 Boxer  1 Greyhound  5 Mix  Sex:  21 M; 12 F  Age:  4 - 13 y; Mean 8.3 y  27% over 10 y old
  • 33.  Single level: 19 dogs  C6-C7 (13 dogs)  C5-C6 (5 dogs)  C3–C4 (1 dog)  Two levels: 10 dogs  C5-C6 & C6-C7 (8 dogs)  C4-C5 & C5-C6 (1 dog)  C3-C4 & C5-C6 (1 dog) Lesion Localization  Three levels: 3 dogs  C3-C4, C5-C6 & C6-C7 (2 dogs)  C2-C3, C5-C6 & C6-C7 (1 dog) TOTAL: 50 Spaces treated C6 C7 C3 C4 C5 C6 C3 C4 C5 C6
  • 34. Inadequate position Immediate Post-op Radiographs  Implant position: • Optimal (40/48 sites) • Sub-optimal (7/48 sites) • Off midline on VD • Inadequate (1/48 sites) • Improper technique  Excessive burring of caudal endplate  immediate subsidence
  • 35. Caudal subsidence  Distraction: • Over-distraction (15/50 sites) • Mostly with 1st generation (thicker) implant • Adequate distraction (34/50 sites) • Mostly with 2nd & 3rd generation (thinner) implant • Under-distraction: (1/50 sites) • Improper technique  Excessive burring of caudal endplate – immediate subsidence Immediate Post-op Radiographs
  • 36.  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  Subsidence Distraction lost compared to pre-op  7/50 sites (14%)  Ventral Osteophytes  2 sites in one dog Serial Radiographic Assessment
  • 37.  Mobility  Present:  at 2 wks post-op in 88% in 24 dogs examined  at 6 mo post-op in 23% in 14 dogs examined ♬ In 7 dogs where dynamic study was performed immediately after surgery: mobility although expected was not detectable in 5/10 of the treated spaces  No Implant migration  No Implant infection Serial Radiographic Assessment Ventro-flexion Dorsi--flexion
  • 38.  6 weeks post-op (1 dog)  Improper technique C6-C7  Declined after surgery  Dorsal compression at C5-C6 due to loss of distraction  Improved with single dorsal decompression  7 mo. post-op (1 dog)  New osteophytes or heterotopic ossification  Clinical status unchanged Dog 2 C5-C6 C5 C6 C7 T2 sagittal MRI C5-C6 6 wks post – surg C5-C6 pre – surgery MRI Re-assessment: 6 dogs
  • 39.  20-24 mo. post-op (4 dogs)  2 dogs: No signs of disc degeneration or compression at treated and adjacent sites  2 dogs: New osteophites or Heterotopic Ossification.  1st and 2nd generation implant C6 C7* MRI Re-assessment C3-C4 C5-C6  In all dogs the implant didn’t affect the spinal cord visibility
  • 40.  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  25 dogs: 1- 3 days  2 dogs: 4 - 5 days  Based on the severity of the neurological status pre-surgery Clinical Assessment
  • 41. Follow-up: Mean 24 mo, (range 2 wks - 42 mo)  22 dogs still alive  11 dogs deceased  8 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  No Domino lesions during the observation period  Better: mild and short duration of signs on presentation  Worse: chronic non-ambulatory paraparesis + extensor rigidity of front legs not resolving under general anesthesia Clinical Assessment
  • 42. Patch: 6 y old MN Dalmatian 6 mo ambulatory tetraparesis worsening 2 mo prior to presentation
  • 43. Sonny: 8 y old MN Doberman 1y ambulatory tetraparesis, acute tetraplegic 7 months post-op
  • 45. 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
  • 46. 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 Pre-op Immediate Post-op C5 C6 C7
  • 47. Complications Nikkie  2 weeks post-op  Declined to non-ambulatory tetraparesis  Intense cervical pain  Radiography:  Suspected Axial compression fracture C6  Ventral implant migration  Euthanasia - no histopathology • What went wrong? • Dog’s size too small: 13.2 Kg • Over-distraction • Thinner discs sizes currently not available for these dog’s size • Weak geriatric vertebrae (osteoporosis)!? • Combination of the above  Poor patient selection 2 weeks post-op 2 weeks post-op C5 C6 C7
  • 48. 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 advanced / severe • Irreversible spinal cord damage  Poor patient selection Pierce Simon
  • 49. Limitations of CDA:  Dog’s size  Patient under 23 Kg are not good candidates for CDA  Underlying vertebral diseases  Weaker bone in geriatric dogs  In humans usually bone density test Not good candidate for CDA  Prolonged history of non-ambulatory tetraparesis  Severe extensor rigidity of front legs not resolving under general anesthesia  Overall: too severe / advanced neurological signs Clinical Relevance
  • 50. 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” C7 C6 C5
  • 51.  Spinal cord decompression & “dynamic stabilization”  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*
  • 52. Disadvantages – Limitations  Concurrent Dorsal spinal compression  The possible decrease of distraction over time may exacerbate the dorsal compression  If concurrent dorsal compression, it might be necessary to combine CDA along with removal of the dorsal compression at the affected site
  • 53. 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”  May improve pet-owner willingness to pursue a surgical option
  • 54. Conclusions  CDA is very promising for the treatment of DAWS. 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 Dr. Zelman column: number 6 of the most commonly cited attributes of a “great” surgeon
  • 56.  HA coating  Calcium and phosphorous complex  Promote maturation of collagen fibers surrounding titanium implants and support osteoconduction   To improve bone/implant incorporation  Thinner implants & additional wider and taller sizes  S1, M1, M2, WT1, WT2, WL1 & WL2  To avoid over-distraction,  To increase contact surface implant/vertebral endplate   to decrease the degree of subsidence 4rd Generation Adamo Spinal Disc™
  • 58. Cervical Disc Prostheses – Sizes Selection – Indication
  • 59. Disc size selection  Pre-operative MRI measurement  Final assessment during surgery
  • 60. CDA Surgery video - Clinical case Inserire video – surgical technique
  • 61. 3rd CDA Course 1. Questions ?? 2. Break 10 min. 1. Dr. Kroll Lecture 1. Frequently Asked Questions Dr. Adamo 2. Practice on spine specimens Dr. Adamo, Dr. Kroll, Dr. Giovannella 3. Lunch 4. Practice on cadavers
  • 62. Dr. Robert Kroll CDA Case Selection
  • 63. Cervical Disc Arthroplasty (CDA)k Frequently Asked Questions & Answers
  • 64. a. Discectomy with deep cleaning of the end plates from the annulus b. Minor burring to accommodate the disc implant 1. Will I be performing a discectomy or a ventral slot?
  • 65. Just enough to create space for the disc implant. a. The small burr is used for the initial burring and to create enough space to insert the large burr. b. The large burr is used for the final cleaning of the end- plate, and to create enough space to accommodate the disc in the discectomy site c. Mild exposure of the cancellous bone in the center area of the caudal vertebral endplate is acceptable and often needed. Small burr Large burr C5C6 2. How much do I have to burr?
  • 66. C6 C7 C5 C6 C7 Burring of the caudal vertebral end-plate C7C6 C7 C6
  • 67. Parallel to each other but at about a 30-degree angle away from the midline and away from the side on which the surgeon is standing. 3. Which is the best position to place the Caspar distractor pins?
  • 68. Placing the pins too far from the affected disc space may cause vertebral fracture during distraction. Place the pins toward the center or caudal third in the cranial vertebral body, and toward the center or cranial third of the caudal vertebral body 4. How can I prevent vertebral fracture during Caspar distraction? X X
  • 69. Place the pin toward the center of the vertebral body that will be receiving the discectomies and the disc implants at both ends 5. In the event that two adjacent sites have to be treated at the same time, what is the best pin placement?
  • 70. Until it becomes difficult to distract any more! 6. How much do I have to distract?
  • 71. The widest and tallest disc size possible that fits in the discectomy site.  The increased area of contact between the implant and the vertebral end-plate, may decrease the degree of subsidence.  It is best to select the disc that fits firmly in the disc space but that doesn’t cause excessive vertebral distraction; too much distraction may increase subsidence. 7. Which disc size is best to use?
  • 72. • Before closure, bone wax can be packed on the ventral edges of each vertebra facing the external surface of the implant. 8. How can I prevent ventral bridging spondylosis and tissue ingrowth between the two articulating faces of the implant?
  • 73.  A lateral, VD, and dynamic views in dorsi-flexion and ventro- flexion  This to have a baseline to assess distraction and mobility on the following serial post-operative radiographs 9. Which views should be included in the immediate post-operative radiographs? NEUTRAL VENTRO-FLEXION V-D DORSI-FLEXION
  • 74. 2 weeks, 3, 6, 12 and 24 month follow-up 10. To evaluate distraction and mobility when is recommended to perform serial post-op radiographs? NEUTRAL VENTRO-FLEXION DORSI-FLEXION V-D 9 mo. Post-op: - Maintained Mobility, - Maintained Distraction, - No Subsidence
  • 75. Fracture of the vertebral body • Weak bone in old dogs • Excessive distraction (disc too thick) • Using this implant in dogs < 23kg Less likely to affect the outcome:  Osteophytes and Heterotopic Ossifications  Vertebral ankylosis  Spondylarthrosis  Loss of distraction and/or mobility  Minor Subsidence 11. Which one is the most serious complication of CDA that may affect the clinical outcome? 2 weeks post-op 2 weeks post-op C5 C6 C7
  • 76.  Not less than 23 kg 12. What is the recommended minimum patient weight for the application of this prosthesis?
  • 77.  Leash walk until 3 month radiographic re-check  Full activity after 6 months radiographic re-check 3 mo. post-op 6 mo. post-op 13. For how long is activity restriction recommended?
  • 79. CDA Practice on spine specimens Objective: Familiarization with the technique and instruments (discs not treated with HA)
  • 80. Wet-lab – CDA- guidelines  Implants used in this lab are not HA coated  10 cadavers  5 surgery stations x 2 times  3 participants in 3 stations  2 participants in 2 stations  Each participant will practice 2 CDA surgeries  The instructor will first show CDA at C3-4  Your disc spaces to practice are C4-5; C5-6 & C6-7  Name yourself #1, #2 and #3  On the first set cadavers: #1  C4-5; #2  C5-6; #3  C6-7  On the second set of cadavers #1  C6-7; #2  C4-5; #3  C5-6  Post-op Radiographs Discussion:  Remember on the 2nd cadaver: your dog number and the disc space where you placed the implant
  • 82. Thanks for your attention Wet-lab session – CDA
  • 83. Post - Surgery - Radiographs Discussion
  • 84. How to place the order Allison Hsia: Events Assistant AVT
  • 85. How to place the order  Special offer for attending the Course:  Total value of surgery kit: $ 15,260  Discount for attending the course: - $ 1,200  2 additional discs sizes of $1,500 value: Complimentary  Additional 10% discount for placing the order within 30 days: - $ 1,406 ---------------------------------------------------------------------  New Total $ 12,654 Cost of Shipment not included
  • 86.  Opportunity to promote and differentiate your practice with an innovative surgical technique  Average surgery cost (surg. + anesthesia):$ 3,500  Mark up implant (x1.5 or x2): $ 1,000 - 1,500  Total cost of surgery: $ 4,500 - 5,000  Number of surgeries to recup. the investment: 3 Cost Analysis
  • 87. How to place the order  For Full discount: place order within 30 days from today.  Payment options:  Payment in full today and take the surgery kit home  Deposit $500 minimum and remaining balance before shipment  Guarantees one of the limited available surgery kits  To assemble a new surgery kit it may take up to 3 month from the order.  Order can also be placed by contacting:  Preeti Zalavadia, pzal@appliedvt.com - Administrative Assistant of AVT.
  • 88. Certificates Participants of the very 1st CDA Course – 2013
  • 89. Thank you for your participation and attention!