Post on 24-Mar-2023
Institute of Oncology in MediterraneanI.O.M. M. -- Catania a -- ITALY
rarararaneaneaneaneannnnraInstitutee ooof OncololOutee ooof OI O MI OI OO M
OncoOMMM
oloonco-- CataniaCataaniaaaCCCC aa -- TALYTALYITITIII
ogygyyyy iiiininininnnnnnnnnn M dM dM ddMedMedMedMedititititeiteiterrrrrrrrMMMMMMMogyy innnn editerrMeMM
Haedd DeptMinimal
Haedd DeptDal Invasive Spine ee e Therapy
Luigi gi ManfrèChairpersonnn Spine ee Diagnosticcc &&&&& InterventionalChairperson
EuropeanSpineS e iagnDonn
nn Society of nosticc &&& nterveIniagn
of of Neuroradiologyervegygy-
ntionalenrveyy--yyyy ESNR
Whenn disc c damagedd:: Axiall Rotationn +100% woman, +300% man
The e Discsc:c: AA Mainn Actorr in n determiningg the e Stability
Discc annularr tearss aree responsablee forr increasedd axiall movementt inn comparisonDiscto
cc annulaaiscoo normal
arrulall one
arsstetee when
ree responsararann rotational
ablee forfnsall strenght
ncrr ittt is
reasedd ancss applied
Schmidttt TA,, Spineee 1998
Normall Disc rotationn lesss thann 111°NormaDisc
al Dmacc with
scDisDhhh annularr tears
rotationrotation
esse snn lnnn more
annthtee than
1111nnn 222222°
Pfirrmann CW, Metzdorf A, Zanetti M et-al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine. 2001;26 (17): 1873-8
Magnetic resonance classificHappily Instable
• Shock Absorber• Glue
Creating a miracle:Stability + Mobility
Even if the majority of a healthy adult disc is avascular….it’s ALIVE
THE NORMAL ADULT INTERVERTEBRAL DISC
ty of a healthy adult disc is thy adult disc is avascularavascular….itit ss ALALhe majoritty of a
• Discogenic Pain Syndrome.• Facet Joint Syndrome.• Instability Syndrome.
Specific structural alterations Discogenic Pain SyLOW BACK PAIN
• Intervertebral disc degeneration first appears in the second decade.
• The speed and extent of the degenerative changes appear to be impacted by Genetic Factors as well as specific and continuous Traumatic Events that occur along patient’s life.
This is Normal Anatomy too
Minimalall Invasive Spine e Therapyy Deptpt ––– IOM M M –– Catania, ITALYM
DEGENERATIVE CHANGES
Degenerative changes are very common in the asymptomaticpopulation. Most individuals can anticipate pathological changeson MRI, CT scan or radiographs, even in the absence ofsymptoms.
The incidence of MRI patologycal findings in the normal population
DEGENERATIVE CHANGES should be considered “Normal Anatomy” when no symptoms occurs
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
The ImagingTODAY
What to look for?How to look for?
1. Disc height loss
2. Disc signal changesProgressive loss of hydration best seen on MRI
3. Endplate signal changes
Modic/Ross changes of the endplateWater: low on T1WI, high on T2WI
Fat: high on T1WI, T2WIBone: Low or no signal T1WI, T2WI
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
Disc degeneration is characterized by:
- Progressive fibrous change in the nucleus.
- Loss of distinction from the anulus.
- Loss of organization of the anular lamellae.
- Progressive damage of end plate cartilage
Early signs of age-related alterations could already be observed in the second decade of life
DISC DEGENERATION
ANATOMYTHOMPSON’S GRADING SYSTEM
.
l t d lt ti ld l dl
EM
DisDiDiDisDisDisDisDisDisDisDisDissDDDiDiDDDDDissDisDisDisDDisDisDisisDisDisDDDDisDiDDDDisDissDissDisDisDDDisissDDDDisDiissDDiDisiisssDiiisDDDDisissssissDiDDDDDDisc dc dcc dccccccc dcccccccc degeegegeegeeeeegeeeegeeggegeegegeegeeggegggeeeeegegeegegggggeeeeeeeeeeggegeeeeggeeeegeeeeeeegeeegggenernernernerrrnernernerrrnernnnernenernerneerneeeeeeneernnnnnnnernnenereeneerrrrernnnereeerrrrrnnnererneerrrrnererrnnnnereerereneeeerrneeeerrnnerraatiatiaataaatiatiatatiatatiatiatiatatiatiatiatitiaaaaatatititttitiatiaaatiatttatiaaaatitiaatiiataaattiaattataaaatiaaa on onon ononoonooononnononnonoooonoonononnnoonnonnononoooooonononooooonnnoonnnnonoonnnooononnnnn iiis is iss chahchhhhhchah racracterterizeized bd bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbby:y:yy:yyy:y:y:::y:yy:yyyy::y::y:::y::y::::::::yy
------------------- ProProProProProPrProPPPPProProPPPPProProProooPPProoProPPPrPPrPPPPPPPPPPrrPPPPPrrPrrProPPrPPPPrPrrPPPPPrrorPPPPrPPPPPPPPPPPPPPPPPPPrPPPPPProrrr gregregregregreeessissiississiiissssissiiiiisssiiiiiiis ve veveveveveveeve fibffffibfibffibffibfibfibbbfibbbfffibffiibbbbfibbbbffifibbbbbbfffff bbbfibffffffibbbbbbbfibffffiibbbbbbbibrourrourorrourourouor s cs cs cs cs css cccchanhanhanhanhanhhahhanhhanhanhhhhhhhhahhhhhhhhhhhhahhhhanahhhhhhahaaahhanhha gege gegggegegege iiiiiinininiiiiininiiiniinnnnnn thehethe nnnnnnununnunununnnnnunnuununnuunuuuuunnuuunnuunuclellllclelcleclecleleclecleclecleclclcleccclecleclecleccccleeeeeeeecc ususuususususususussuss..ususs.uusussusususssususssuuusususssssssussusuuss
-------------------- LosLosLosLosLosLosLosLosLLossLLLLosLLossLossLosLosLLLosLossLosLLLossLLLLLLLLooooLooosossLLLLLLLLoLoooooLLoLLLosLLLoooooLLLLLLoLooooLoLLLooooooLLLoooooooLLLLoLLoooo s os os os os s oooooos oooooooos oooooooooooooos f df df df df df df df ddf ddf df dffff ddddddfffff ddddf df df dfff df dff df ddddddddf dfff dfff ddddf df dffff dddf df dfffff ddddf ffffff dddf dddfff dfff df ddffff dddddff df dddfffffff ististististististististisististststisistiiii tisttttsttisiististssssssssiststttsttisistsstsssstttttisssssssstttisissssssttstttistssttttssssisttttissssssttsttttsstincincincincncncincincnincincncincncnciinncnciinncnccncciiinnnnnnincnncccincccncincincncnnnnincciinnnnccccciinnnnnnnnncccinnnnccincnnnnnnccinnnnnccininnnnnncnnn tiotiotiotiotiotioitiotiotiotiotitiotiottititiotittttiiititiotiotitiotiotttiitiooooooooooiotiotttt ooooootiootiooooootiooott oiooooooot oooooottt ooooottiottiiioooooooootit oooioooon fn fn fn fn fn fn fn fn fffn nn fffffffffnnnnnnnnnnnn ffn fn ffffffn fnn fn fn fnnnnn fffn fnnnnnnnn fn ffffn fnnnnnnn ffffn fn fnnnnnnnnnnn ffnnnnnnnnn fffffnnn f ffn rrromrrrromrroromoromromromromooomoorommmmmmmrommmmmromromromromrrrrrrromromromooomommmmmmmmmmrorrrromooromomoommmmmmmmmomrrrrrroooommmmmmrrrroooommmmmomromrrroommmmmmrorrroooooommmmmmmmmmrrrrrrrooommmmmmmmmoooommmmmm ththththththtthtthhhtthttthhhthththtttttththhhhthtthhhhhhttttttthhhthhhhhhhhhthtththththhhhhhhhtthhhhhhthhhhhtthhhtthhhthhhhhhtthhhhhhhhhhhheeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee aaanuanuaanaaanuannnnnnnananuanunnanuaaaanuanaaannnnnnnnanuanuuuunuanuaaaaaannnnanuuanuaaaananaannnnnannnnnuuanuaaaaaaannnuuuaaaannnuuaaaaaannnnnnnnnnnnuuuaaaaaaaaannnnnnnnnullllusususus.....
------ LosLosLosLosLLLosLosLosLosLLLoLosLLoLLooLossssLosssLossLLoLososssssssLLosoossssssosLLLLLLLLoooooossssssLLLLoosssssLLLLoLLLoooosssss os os os os ooooo ooooooooooooooooooooooooooooo oooooooooof of of of of of oof of oooof of offffffff of oooooooof off offffffff of oooooooooffff off of ooooofff off off ooooooooofffff oooooffff of oooooofffffff oooooofffffff ooooooff ooooorgargargargargargargargargaargargargrgaargaaargaaagargargargagargaargargaargargargrrrrrrggggggaggggggargargaaaargarrrrrrrgarggrggggggggggrgrgaaaaaaarrrrgaggggaaarrrgaggggggrgargaargaarrgarggggggarrgrggggggaarrrgargggggagrrrrgggrgggarrgaggggaaaarrrrrrrrrgrgggggggggg nizniznizniznizniznizznizniznizzzzniznniznniziznizzniznniznnnnnnnniiiizzzzzniznizzzznnnnnnnnnnnniziziinizzzzzznizzzznnnnnnniziizzzzzzznizznnnnnnnniziiizzizzzznnnnninizzzizzznnnizzzzznnnnizzzznnnnniizzzznnnnnn zzzzzatiatiatiatiatatitiaatiatitiatiaaatatiaaaaaaaaaatiattatttitiiiaaaaaaaaatttttattiiatitiaaaatiaaaattatttiatiatiaaaaatitatatttiiiaaaaaaaatatttiiiiaaaaaaaattaaatttaaaattttttttiiiaaatiaatttiiiaaataaaaa onononononnonnonononononononnononnnooooooooooonoooonononnnnnnoonooonooooooooononnnnnnnonoooooonoonnnonnooooonnnnnoooonnnnnoooonnoooooonnnnnnoooooonnnnnnnnoonnnnnn ofof of of of of ofofof ofofoooooooooooffffofofffofoooooooofoffffffffffooooofofffffoooooofffffoooooooffofofoooffoooofffooooooooofoffffoff thethethethethethettthehhehthehetthethethetheethetthheeeethettt eeeethettththehhtheeeeeeeeeeeetttthhhehtheeeeeeeeeheettthhhheeeheeeethhehehhheeeeethhhheethhhheeeeetthhhhheeettttthehhtheeeethhehhhee aanuaaanuanuanuaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa llllarararar lllllllllllllameaamaaameameamememeameaaameaaameaamameameameamameaamemeaamemeaaaaaaammaaaamaamaaa llalllallallallallalllllallllllaallaallallaaaallaallaalallaallaallallallaaeeeeeeeeeeee.eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee
- PPProPPPPProProProProProProoPPPPPP ooogregregregreregreeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeessississiississiiississsssissississississississsssssssssssssssssssississississsssssssssssssssssssssissssissssssssisssisssissssssiisiissssssssssssssssssiiisssssssssssiiisssssssssiisssisssssssssssssive ve ve ve ve veve veve vvevevvvvvvvveveeeeeeeeevevevvvvvvvevvvvve eeeeeeeeeevvevevvvvvevvvveeeeveeeevevevvvvvvvvvvveeveeeeeeevvvvvvvveveeeeeeevvveeveeeve vvvvvvevveeeee damdamdamdamdamdamdamddddamdddddamdamdamdamdamdamdamamdaaamdadammaaammmmaadamddddaddamdddadadaaaaaaaammmmmmmmmammdadddddddamaadaaamadammmmmmmmmmmdamdamdamdddddaaamaaaamammmmmmmmmmddaddddamaaaaammmmmdammmmmdddamdddamdaamadaaaammdammmmammddddaaamamammmmmmmmmmdddddddaaaammmmmmageageageageageageageagegeageageageageggeageeageeageggageaaaaaaageagaaaaagegggggggageeeageageeegeageeageageaagaaageaageaaaaggggggeeeeeageeeaaaageaagaggegggegeeegegeeeaageaaaaaagegggaggageeeeeeaageaagaggggageeeeeeeeaaaggggggeeeeeeeaaaaaagggeeeeegegggggg ofofffoffffffofofofofofofofofofofooooooooooofffffofoooooooooffofffffoffooooooooffffffffoofooofooffooooffoooofffoooofffffff eneneneneneneneeeneeenenneneeeeenennnneeenennnneeeeneeneeeennennnennnnnneneeeeneeeeeennnnnennnnneeneeeeeneeeennnennneeeeenneeeennneeennnneeeennnd pd pd pd pd pdddddd pd pd pd pd pd pd pd pd pd pd d pd d pdd pdd pdd pd pdddddddd pd ppppppppppddddddddddd ppd ppppppd pd pppd pddddddddd ppppppppppd ddd ppppppdddddd pddddd pppddddddd dd ppppppl tttl ttl ttlatlattlate ce ccccccccccccccccccccccccccccccccccccccccccccccccccccccartarttaraaartttartartttartrtrtaartartartartartrtaartrttartartartaaaartaartaaartartaararaaraar ilililailailailaillillilailailalallilalaaiilailailalalailaaalailailailalaiilailaaaaailaailaaalaageggggegegeeeeeeegeeeeeeeegeeeeegegeegeeeegegegegeeegggegegegegeeggeggegegeeegegeeegggggeegeeeegegeggeeeeeeeeegeeeeee
MRIPFIRRMANN’S GRADING SYSTEM
Annulus Fibrosus:The integrity of the anulus fibrosus is
critically important for normal disc function.
ATh i t
DISC DEGENERATION
disc function.
The Herniated DiscEpiphenomenon of disc degeneration
The Herniated DiscDISC DEGENERATION
The e Painfulul Disc Treatment
Present: Destroy the discChemical
InjectionSteroidOzoneEthanol Gel 2014
PhysicalPhLaserLaserCoblationCoblationAspirationAspirationPercutaneousPercutaneoudiscectomy
1 2
Destroying the discThe Past e e eeeeee eeeeee eeeeee eeeee e eeeeeeeeeeeeeeeeeee eeeeeeeeeeeeeee eee didididddddddididdididddddddididddddddiddddddiddidddidddddddddididdddddddddididididdd sc
micalChem
StS eroidStS eroidOzoneOzO oneOzoneEthaEtha 014
Physical
yyyyChemicalChem
hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPD iPPPPPPPPPP
DDD tt iDeDeDeDeDeDeDeDeDeDeDeDeeeeDeDeDeDeDeDeDeDeDeDeeDeDeDeDeDeDeeDeDeDeDeDeeDeDeDeeeeestststsstsssststsststststststststtststststststssstststssstststststss rororororororoooorrorororoorororooroorororororooororororororooorororroroorooyiyiyyiyyiyyyiyiyiiiyiyiyiyiyiyyiyiyiyiyiyiyiyiyiyiiyiyyiyiyyiyiiy ngnnPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
ngngnnnnnnnnnngnnnnnnnnnnnnngnnngnnnnnnngnnggggggggggggggggggggggggggggggggggggggggggggggggstssststttttrorrorrorrrrooooooooyyiyyyyyiyyyyyinnnngnnnnnnggggggggggggnnngngngnnnnggggggggggggRegeneratinghyyyy hhhhhhtthhroyyyy t
dihhhhhhhhhhh
hhhhthththtttthhhtthhgtttttttttttttttttttttttttttttttttttttttttttttttttttgttttttttt didieeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee didididddiddididddiddiddididididididdididdiddiddidididddd scscscscscscscscscscscscscscscsccscscscscsccscscscscscscscscscscscsscccccccccccccccccccccccccccccceeeeeeee ddddhhhhhhhhhhhhhhhhhhhhhhhhhhheeeeeeeeeeeeeeehhhhhhhhhhhhhhhhheeeeehhthe disc
ChemicalCChemChemTThThThThThTTThThhhhhhhThhhhhhhhheeeeeeeeeeeeeeeThThThThThThThThhhhhhThhhhhhhhhhhhheeeeeeeeeeeeee
micalalamicammiccaeeeeee ttttttttaaaassstststsstaaaaaaaaaaaaaaaaaaaaaaassssssssssssssssaaaaaaaaaaaaaa ttttssststsssstssssssssssssPPPPPPPPPPPPaPPPPPPPPPPPPPPPPPPPPaPPPPPPPPPPPPPPPPPPPrPrrreseseeeeeeeeeeeeeeeeeeeeeee enenTThTTTThTTThThhhhhhThThhhheeeeeeTThThTThThThTTThhThThhhhTThhThTThhheeeeeeeeeesssssssssssssssssssssssssssssssssssseneneneneeeneeeeeeeeeeeeeeeeeeeeeeessssssssssssssssssssssssseneneneneeeneeeeeeeeeeeeeennnnnnttttttttttttttttttttttt:eeeennneeennnnnnnnnnnnnnnnn aaaaaaaaaaaaaPPaPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPttttttttttttttttttttttttttttPaPaPPPaPaPPPPPPPPPPPPPPP::::::::::::::::::P
eeeessssssssssssssssssssssssssssPPPPPPPPPP
stssssststststtstsssssss rorororororrorooooororooooooooooooooorooroyiyyyyiyiyiyiyyyiyiyyiyyiyiyiyyiyiyiyiyiiyiystroyi gttttt
nnnngngnnnnnngnnngngnnnnnnnnnnnnntttttttttttggggggggggggggggggggtttttttttttngggggggggggggggggggggg
treeeeeeeeeeeeeeeeeeeessssssssssssssssssssssssssssssseeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDhtthh
aa eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeDDDDDDDDDDDDDDDDDDDDaaaaaaaaaaaDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDggDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDttttttttttttttttttttttttttttttttt e dddddddididddddddddddddheeeeeeeeee ddddddddddddddddddddddde dththhhhhhhhhhheeeeeeeeeeehehh
The FutureChem
InII j tiInjjjjjjjjjjjjSteroidSteroidInIInInInnInnInnnnnnnnnnnnnnnnnnnnnnnnnnnnjejejejeejeejejejejejejejejejejejejeejejeeejejejejeejejejejjeej ctcctctctctctctcctctctcccctcctcctctcctccccctcctcctcccctioiooioooooioioioioioooioiooioooooooiooioi nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnneeeeeeeeeeeeeeeeeeeeeeeeectctctctctctctctctctcctctctcttctctctctctctctctcctccctcttccttcc ioioioioioioiioioioioioioiooioioioioioiooiooioioiioiooioooiiionnnnnnnnnnnnnnnnnnnnnnnnnnnnnnInInInnnnnInnjejejejejejjejeeeeeeeeeejeeeeeeeejeectctctccctctctctccctctctcttcctctccttctctccttctctctcctcc ioioioioioiooooiooioioioioioiooioiiooioiooionnnnnnnnnnnnnnnnnnnnnnnnnnIntradiscal
calmicmllaa injectionn of:acnnnnnnnnnnnnnnnnnnnnn la njeecin
PRPPRPGFne
anan lPh iPh ih
GGGF
oooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooolllllllllllllooooooooooooooooooooooooollllllllllll GGGGGGeGGGeeeeGGGGGGeGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGeGGeGeGGeGeGGGGeeGeGeGeGGGGeGeGGGeeGGeGGeGeGGeGGeeeGGeGGeGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGStem 202222222222222222222222222222222222
i ll
FeeeeeliieeeeeeeeeeeeeeeeeeelGFmeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee Cells
1 2The Cultural lallal Revolution
2nnnn of Medicine
XXX centuryy Medicine: to cure e sickk people
XXI XI centuryy Medicine: to o o amilioratee healthyy people
Yuvalaal Noahh Harariaari. Homo Deus, s, 2017
27 yo m• Active sport• LBP for years• No sciatica• Chronic pain• He did a lot of Physio
• He came with a 2yo MRI scan
272727272727277777777777777777222772727777777 yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyoooooooooooooooooo••••••••••••••••••••••••••••••••• AAAAAcAcAcAcAcAcAcAcAcAcAcAcAcAccAAAAcAAcAcAcAcAcAAcAAcAcAcAcAcAcctttttttt•••••••• LBLBLBLBLBLBLBLBLBBBLBLBLBLLBLLLLLLBL PPPPP••••••••••••••••• NNNNNNNNNNNNNNNNNNNNNNo o oo o o oo oo oooo oooooooo•••••• CCCCChChChChChChChChChChCChChChCCChCCCCCCC rrrrrrrrrrr••••••• HeHeHeHeHeHeHeHHeHeHHeHeHeHeHeHeHeHeHeHeHeHeHHeHeHeHeHHHHH
•••••••• HeHeHeHeHeHeHeHHHeHeHeHeHeHeHeHHHeHHHHHHHH cacacacacacacacacacacacccacacacaccccac mmmmmmmmmmmmmmmmmmmmeeeeeeeeeeeeeeeeee wwwwwwwwitititthhh h aa 2yoMRMRMRMRMRMRMRMRMRMRMRMRMRMRMRMRMMMRMRMRMMMMMMM IIIIIIIIIIII scssscscscscscscscscscscssscssscssssssssssssss anananananannanananannananannnnnaan
roooooroorororooooonnnnnnnininininiiiniiiiinniniiccccc pcccccc pc pcccccccccc aiinnnnnnnnnnnnnnnnnnnnsio
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmAfterr 222 yearstitttititititiiiiiiiiiiivevevevevevevevevevveveveveveeveveeeeeevev ssssssssss
Aftepppppppoopr 2orrtoo22 earsye
ttppppppppppppveveveveveveveveeeeeeveveeveveve ssssssssssssssssppppopopopopopopopopoppoorrtooBlack disc sears
cc disapppp.PPPPPPPPPPPPPPPPP PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP fffoffffffofooooffoooooof
Bla ppppppppppffofoffofofofoooooooooofofooooofoofofofofofofofofoooooofofofofoofoofofofofoooooooStill rssyeyeeeeeeeeyy arars
k discppssc
rr yyyrrrrrrrrr yyyyyackppppppppppllrrrrrrrrrrrrrrrrrrrrr yyeyeeeeeeyeeeeeearyeyeeeeeeeyeyeeeyyeararyyyyyyyyyyyyyyyyyyyyyyyyyyyyLBP
sssssssssssssssssssssssssssss( iiaaaaaiiaaaaiiaiiiiiiiiiiiiiiiiiiiitil
scscsscscsccccsccsccscscccscciiiiiiiiisssssssccssccccssciiiiiiiiiiiSt(sssscccscsssssssscscscscscscsciaiaaaaaiaiaaiaiaaaaaiaiaiaiaaiaiaiaaaaaiaiaiaiiaaiiaiiaaccccccccccccccccciiiiiiiiiiiiiicccccccccccccccccccccccciiiiiiiiiiiiiiiiiiiibut iiiiicacacacacacacaccaacaaaa
ii
yyyyiiyyyyyyyyyy
aaaaaaaaaaaaaaaaaaaaatititttitititiiitiitl yyyyyyyaaaaaaaatititll yyyyyyyyaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa iiicacacacacacacacacaaaaacaiicacacacacacacacacacacacacacaaaaaaiiiiiiiccccccccccctitittititiititititttiititititititiititititititdifferentntnt pathologygy)
rrrrrrrrdddddddddddrorooooooooooonininnnnininininininiiniinniniinininnnn cccccccccccc pc adddddddddddddddddddddidididdididididididididdiid aaaaaaddddddddddddddddidididididididididdiddiddddddidddd aaaaaaaaaaaaaaDisc y
ainnnnnnnnnnnnnnnnnnnooooooooooooot ot ot ot ot ot ot ooot ot ot ot ot ot ott off PhP ys
ccccc ppcc pccc aaaaaaaaaaaaaaaaaaaaa lolololololololololololoocaaaaaaaaaaaaaaaa herniation
27272727272727277777777777777777 yyyyyyyyyyyyyyyyyyyyyyyyyooooooooooooo mmmmmmmmmmmmmm
Good news: Black Disc could not always last for everBad news: new causes of LBP happens
Take Home Message: 272727272727272727777
DO NOT TRUST ON OLD STUDIES
ss:: llacackk DiDiscscBB cc ooululddcoco dd nononnoott alalwawaysysaa ss aastst ffoolala rr vvererevevBadBBaddBB
lackBs:ddd newnewnewnn
k Discackwsws newnew: n: n
ouldco dscc cww ausesaususeeaauu esescaca
oot alwayad nonsss of LBPofoff LBPBPff LLBBooooo
yss ast fola rwayPPP appensaaappensaapppphahahaBadd newn ws new: n
TTTTTTTakkkkkkke HHHHHHHHHHHHHHHHome MMMMMMMesse MMMMMMMMMM esagew ausesca s of LBPo P appenshaeww
e: T UDDUDUDDUDDUDUDUDUDIEEEIEEIEIEEIEIESSSSSSSSST TRUST ON OLD STUDUDIEIESSNNNNNNNNNOTTOOTOOTOTOTOTOT TTTTTTTTTTT TTOOOOOOOO NNNNNNNNOOOOOOOOO RURUURURURUURUSTSTSTSTSTST OOOOOOOOOOTRURUSTST OOTTTTTTTRRRRRRRTTRR OLOLOLOLOLLOLOLLOLDDDDDD STSSTSTSTSTSSTSSTUUUUUUON OLOLDD STSTUUOOOOOOOOOONNNNNNNNOONNDDDDDDDDDDDDDDD
AAA.GoGoGoGGoGoGGooooGooGGoGooooooooodooooodooooooodooooodooGGGG.GoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGoGGoGoGoGoGoGGoGoGoGooGoGGooGoooGooodododoodododododododododododoododododododoododooodoodoodddoGGGGGGGGGGGGYlmazdddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddenneeeennnnnnnnnnnnnnnnnnnnnnenennnnnnnnnnnnnnnnnnnnnnnnnnnnnnneeeeneeeeneeeneeneennnateeeeeeeeeeeeeeeeeeeeeeeeeeeeeeateeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeaeeeeeeeeeeeeeeeeeeee:wswssswsswwwwwwwwwwww:wwwwwwwww“Physiological movement and a balanced load distribution arenecessary for disc regeneration. We conclude that DSS may decelerate thedegeneration process and appears to facilitate regeneration”. Asian Spine J 2017
HHHHHHHHHHHHomomomomomomomomomoommmomoomooooomommoomommeeeeeeeeeeeeee MeMeMeMeMeMeMMMeMMeMeeMMeMeMeMeMeMMMeMMeeeeMMMeesssssssssssssssssssssssssssssssssssssssagagagagagaagagaggagagagagagagagagaagagggggggagagaagaggggggggggggggggeeeeeeeeeeeeeeeeeeeeee:e::e:e:e::e: OOOOOOOO NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNOOOOOOTOOTOTOOTOOOOTTTTTTTTTOOOOOOOTOOOOOOOTOTTTTTOOTOOOOOOOOOOOOOOOOOOOOOOODDDDDDDDDDDDDDDDHomo e MeessssaageHHomomeee Messssee MM ssageesssaagaggeee::e: OOOOOOOOOOOO NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNOOTOOOTOOTOTOTOTOOTOTOOOTOOOTOTOOOOOOTOOTTTOTTTTOTOOOTOOTOOOOOOOOTOTTOTOOOOTOOOOOOTOOOTTTTTTOOOTOOTTOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNOOTOTOTOOTOTOTOTOTOOTOOOTOOTOOTOTOTOTOTOTOOTOOTOOTTOTTOOOOTOOOTOTOTOOOOTTTOOOOOTOOOTOOTOTOOOOOOOTTTTTTOTOTOTOTOOOTOTOTOOOTOTTTOTOOOOTOOTTTTOOOTTTTOOOOTTTOOOTTOOOOOOOOOOOOOOOOOOOOOO NNNNNNNNNNNNNNNNNNNNNNNNNNNNOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOODDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD
We need more than physical images…we need Chemical Images
In-Vivo MR Spectroscopy (MRS) To identify Painful versus Non-Painful Lumbar Discs
*Freemont, A. J., (2009) Rheumatology; 48:5–10.
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
IIn- iViVivo MMRR SSpectroscopy (((MRMR )S)S)
Voxel Prescription
SagittalCoronal Axial
• Painful (P) discs are distinguished from Non-Painful (NP) discs by hypoxia, inflammation, neovascularization & neoinnervation
• Chemical changes in painful discs = “disc pain biomarkers”
• Not detected by standard MRI or discogram, but detectable and objectively quantifiable via non-invasive MRS
BackgroundIdentify Disc Pain Biomarkers asMR Spectroscopy (MRS) targets
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
Background: Ex Vivo Disc MRS, 11T100% accurate P vs. NP discs (18/18 discs, PG-ProteoGlycan/Lactate ratio)
PG
Lactate
col
Non-Painful Disc
PG
Lactate
Col
Painful Disc
14Keshari, Spine 2008. 33(3): p. 312-317
Courtesy of S. BeckerCourtesy of S. Becker
Lactate=
hypoxia
PGProteoGlycans
=Fiber distruction
Guest which one isThe painful disc…
CourC tesy fffof
Discal Pain
Discal Pain
L5/S1…for sure!L5
L4/L5…minimal, almost normal (?)L4/L5…painful too..
Guest which one isThe painful disc… Courtesy of S. Becker
Antagonist co-contraction (flexors)reduces the risk
ooof
low back injuriesoooos by
increasingss
spinalstabilityKP Granata & co. Spine 2000
Neural Control Unit
BONY COLUMNIntrinsic stability
transducerinfo load – position - motion
MUSCOLAR COLUMNDynamic stability
actuatorsmuscle attivation pattern
Neural Control Unit DisfunctionINSTABILITY
Suboptimalalal Neuromuscolarr ControlpMM
ppMM Punjabibibi,ii,i JJJ Electromyoyoyo. and d d Kineseses., 2003
ororrrrrrrrrrrrrrrssssssssssss))))))))))))))))))))))ororororrrorrrrrrrrrrsssssssss))))))))))))))))))))))))))ofofofofoffffffofffffffffffffffffffffofofoffoffofffffff offfofofofffffffff
bybybybybyybyybbbbbbyyyybybyyybybybybybybbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb
AAAAAAAAAnAnAnAnAnAAAnAnAAAnAnAnAAAAnAAA tatatatatataaaaatataaaaaaaaaaaagogogogoggggogogogoggogggggggooogooggg nininininininininniininininininnininininininiinin sssssssssssststtstststststtt cccccccccooooooooooooccccccc ------AnAnAnAnAnAnAnAAAnAAA tatatatatataaaaaaatataaaaaaagogogoggggggogogogogoogogogogogoggggogogogogogoggg nininnnnnnnnnnninininninininniiiisssssssssstsstststtstcocccccococococooocococc ntntntntntntntttntrararrarararararactctctcttctcctioioioioiiioioiioiiioiioiooioioiioi nnnnnnnnnnnnn
tttttttnnnnnnnnn
--oooooooo---cccccccoooooooccccccnnnnnn ((((((((((((((((( xxxxxxxxxxxxxoooooooxxxxxxxxxxxxxxxxxxxexeexexexexexeflflflflflflflflflflf eeeeefffffffffntntntntnntntnnttrararararararrararacccccccccocococococococcoocc ntntnntnn rarararrraractccctctctc iiiiooooooo
rrrrreeeeeeeeeeerrerrrrrr dududududududududuududucececececececececececeeoooooooonnnnnooooooooonnnnnnnnnnnnnnnnnnccctcttcttctioioioioioooooooiioooctctctctctcctioiiioioioooooooooo
sssssssssss hhhhhhhhhhhhhhhhhheeeeeeeeeeeeeeeeeetthtthththththtthththththhtththhhhthhhheeeeeeeeexexeeexeflflflflflllfleeeflflflflleennnnnnnnnnnnnnnnnn (((((((((((((((flflfflflflflfflfflflflflflfffffffff
eeeeeeeeeeeeeeeeeee kkkkkkkkkkkkskskskskskskskksiiiiiiiiiisssssssssririririririririrrrrexexexexxxexxxxexxxexxxxxxxxxxxxxxxxoooooooxxxexexexxxxxxxexxeexexexexeexexkkkkkkkkkkkkkkkkkkkkkkkk ooooooooooooorerrerrrrererereeeereeeeererererrr dddddddddddrrrrrrrrreeeeeeeeerererrrrerreeedudududdududuuducccccccc
lolololololololololololololoooooooooooooooolooooowwwwwwwwwwwwwwwwwwwwwwwweeeeeeeeeeeeeeeeeeessssssssssssssdudududuuduududuud cccccccccccdudududuuudud ccccccc
wwwwwwwwwwwwwwwwwwwwwwwww bababaababababaaabaaaaaaaaaaaaaaaaaaaaaaaaaacccccccccccccccbbbbbbbbbbssssskskskskskssssksksksskkssssskkskskkskksksksksssksssskssskssskririririiiririririririiiiiiissssssiriririirrissrriririrri kkkkkkkkkkkkkkkkkkkkkkkkkkkkkhhhhhhhhhhhhhheeeeeeeeeeehhhhhhhhhhhheeeeeeetthththththththhthhhhttthtthtththhhhthhheeeeeeeeeeeeeee e ee ee eeeeeeeeeeeeeeeeeeeeeeririririririririririinnnnnnnnnnnnnnnnnnjujujujujujujujjujujuujujujujujujujujujjjujj rrrrrrriiiiiiiiiiiieeeeeeeeeeeeeeeeeeeeeeeiiiiiiiiiiiiiiiiiinnnnnnnnnnnnnnnnnnnnnnnnnnjjjjjjjjjjjj
ooooooooooooooooooooooosssssssssssssssslollolollooloooooooooooooololoooolol wlllololooooooooololooooooololowwwwwwwwwwwwwwwwwwwwwwwwwww bbabaaaaaabbaaaababaaabaabb cccbabababaaaaaaaaaaaaaaacbbbbbbbbbbbbbbbbbbbbbbbbbb
iii iiiiiiiiiaaaaaaaaaaaaaaaaajujujujujujujujuujuririririrririririeeeeeeeeeeeeeeejujuuuuuuriririrriririijujuujujujuuuuurrrrriiiiieeeeeeeeeeeeessssssssssssssssssssssnnnnnnnnnnjjjjjjjjjjjjjjnnnnnnnjjjjjjjjjininininninnininiii jjjjjjiiiiiiiiiiinnnnnnnnnjjjppppppppppppppininininnnininninnnaaaaaaaalaaaaaaaaaaapppppppppppininininininiiininininnaaaaaaalalaaaaaaaaaaaaaaaaaallspsppspspspspspsspspspspsaaaaaaaaaaaaaaaaaaaaaa
llllll
electrically stimulation of the outer annulus activate multifidus at multiple levelsA Indahl, Spine 1995
cocccococcoccoococcccooooooccccococooooccccooocccooccooonnnnncoccccoccoooooc nnrrrererererererrererererererreeeeedddddddddddddddd
iiiiiiiiiiiinininiiiinininininiiiiiiininiiiininnnninininiinncccccccccccccccrrrrrrrrcrcrrrrcrrrrrcrrrrrcrrrrrrcrcrrrrcreeeeaeeeeaeaeeeeeeeeeeeeeaaeaeeeeaeeeeaeeinininininnnni crcrrcrrrrrrrrrrcrcrrcrrrreeeeeeeeaeeaaeaeeeeeaeeeaeeaaeeeeaeeeeinininiininnniinncccccccrcrrcrrrrrrrrrrrrrrrrrrrrreeeeeeeeeeaaeeeeeeaeeeeaeeaaststttstabababababstststtstababbbbbbabbbbbabbbbiiiiiiilllliiiiiliilllsttts abaabbbttababab
ckkkkkkkkkcckkckkckkkkkkkkckkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkkk iiiiiiiiiickckkkkkkkkkkkkkkkkkkkkcckkkkkckkkkkkkckkkkkkkkkkkkkkkkkkkkkkk kkkkkk iiiiiiiiiiii
llllllllllllllllllliiiiiiiillliiiiiililliiiiiiiliiiiiillllillliiilllllllllliilliliiililiiiliiiiliiiiiiiiiiilliiliiiiiiiiiiiiiillllaaaaaaaaaaaaaaaaaaaaassisisisisisisisiisisisisisissiiisiiiiiiisiiisisssiiisiiiiisiississsss nnnnnnnnnnnnnaaaaaaaaaaaaaaaaa ngngngngngngngngngngngngggggggggggggggggggggggggggg sssssssssssssssssssssssssssaaaaaaaaaaaaaaaaaaaaaaaaassssssssisisissssssiissssiississsissss ngngnngngngggaaaaaaaaaaaaaaasssssssssssiisssssssiiss nnnnaaaaaaaaa ngnnngngnggggggggggttttyyyyyllliiiitiiiiiiittiittttttyyyyyyyyytttyyyyyylliiiiiitttiittiitttiiiiiiiiilllllllllliiitititiititiiitiiiiiitiiiitiiiiiiiititiiitiiiiiiiitttlliiiiiiiitittttt
eee 2002000020 002222coco SpinSpSaKPKKPKKPKKPKPKPKKPKPKPKPKPKPPPPPPPPPPPPPPPPPP GGGGrGraraGraGGraraGGrraaGGGGGGGGGGGGG aanatnananatnatnatatnatannatnnatataaaaaaaaaaaaaaaaaa &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& cc eeeeeeeeeeeeeeeeeeeeeeeee 20020000000000000000000000000000000000002222222222222222KKKPKPKKPKKKPKPPPPPPPPP G aG aG aG aaaaaaG aaG aaaanatnatnannnnatnatnatnanatnaattnanatnatnata aaaaaraGraaaGrarrrararaaannatnatnanatatnnnataaaaGGGGGGGGGGGGGGGGGGGG aaaaaaaaaaaaaaaa &&&&&&&&&&&&&&&&&&&&&&&&& cccooooooooooooooooooocooooooooooo.. SpiSpiSpiSpiSpiSpiSpiSpipSpiSpiSpipipipipippppp nnnnnnnnnnnnSpSpSSSpSpSSSpppSSSSSSSKPKPKPKPKPKKKKKPKKKKKKPPPPPPPPPPPP GGraGraGGrGGrGraaGGGGGGGGGGGGG aaaanatnatnatnatttnataaanataaaannataann aaaaaaaaaaaaaa &&&&&&&&&&&&&&&&&& cccelectrically stimulation of the facet or interspinous ligament activate eee locallyyyyyyyyyyyyyyyyyyyy multifidus
MUSCLES COUNTS: LOOK AT THEMSteps
MUSCLEs Theory
CLEryry:
S COUNTS:ESLE:: Disfunction
TS:nn,
OOK AT TL:, Instability
T Ttyty,
EMHT, StabilizationSt
KirkaldyStydy-
epss TheTteStyy-Willis WH,
eorryhe,, Farfan
Dy::n HF.
sfunctioDisD. Instability
on,,,tioyy of the
nstabnIne lumbar
bilittyabr spine.
Sy,,. Clin
tabiliztSn Orthop
zationizpp 1982; 1100-0-23
Age predominance of instability > 46 y.oADisc degeneration & Muscolar atrophy
BAD MUSCLES – BAD BONE-JOINTS
Stability: disc degeneration but muscolar protection
GOOD MUSCLES – BAD BONE-JOINTS
INSTABILITY: THE E AGEE-E-DISTRIBUTION
DEMONSTRATING MUSCOLAR COLUMN ROLEATINGT
G MUSTINGT T Iguchi
SCOLAR COMUShihi, Spine 2003
20 4545-55-5525252 -5--40
Angulation > 100°
Translation > 3mm
NNormalal position slip > 3mm
Hypermobilee segmentss withoutt disc c degenerationypermobilee segmentssWEAK MUSCLES
ntssS S –
without discd c dewws–– GOOD BONE
deEE-
enerationgeegdeEEE--JOINTS
HYPERMOBILITY Y IS NOTT INSTABILITY
edemarupture
diffuse atrophy
diffuse atrophydiffusno deeper
se atrophyffusr paraspinal
yphyal muscles
focal atrophy
Imagingg the e Muscles
30000.0 0000 spinee fusionn // yearr inn USA30+
003000+ 76
0.00076%
00000%%% in
spsn 5
nee usiofupinp55 years++++ 7777777676%%%%%%%%
32000nnnnnn 5555555 yeyeearyy%% iniin
00 lumbarssarsarsar
rr fusion/yearr inn EuropeMccc Cormickkk PCCC.CC. Clinnn Neurosurggg 2015
Neuroimagingg ofof thee Instabilityty...Flying
g gg without
ggttt the
ye parachute?
The diagnosis of degenerativeThe diaginstability
iagyy is
osisgnogssss still
sisllll “an
of degenonn unproved
nerativgendd label
veativelel forinstabi
backilityyabi
kk pains stils ll anan uy isss
nn patients”ppNachemsonn eteet al
pala .
appl. Lippincott,,t, 1999
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
MIMIKINGG “Pseudoo-o-DINAMIC”” Imaging of the Spine
R. . Cartolariri et al. Riv. R..Ita
CartolarCa ri. Caaa Neuroradiol
et al.eri elll 2001
Blankenbakerr DG et al. BlankeAJR
enbaknkeR R 2006
TORSOR
Rotational Instability Axial Instability
After loadfffffffffffffffff
Axial-loading
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
AAAAAAAAAAAAAAAAAAAAAAxAxAxAxAxAxAxAxAxAxAxAxAxAxxAxxAxAxxxiiiiiiaaiaiiaiiiiiiaiiiaaaaaaaaaalllllllllllllllllllllll--- ooooooooooaaadadadadadadadadddddddaadadaddaddadaddadaaddiniiiniiiiiniiinininnoooooaaaaadadaadooooooooooooooooooooooooooooooooooooooooooooooooololololooooololoololoollloooooolo
ffffffffffffffteteteteteteteteteteeeeeteteteeteteeteeer r rrrrrrrr lolololololololololololollolololololololllooolloadadadadadaaddadadadadadadadadadaddaaddddddddddddddddddddddddd
nnnnnnnnnnggggggggggggggg
before load after load
++++ anterolisthesisbulging gg ligggigig.gg. flavum
We need dd Physiological alal Examination Of Of the Spiney
Courtesyy of A. A. Splendiani
neutral Seated-flexion
UPP-P-RIGHT MRI SCANNER
Occult Foraminal Stenosis
Pre-load
After-load
Cadaver studies before and after axial load (1996) Radiol Med. 2014 Mar;119(3):164-74., Occult neural foraminal stenosis caused by
association between disc degeneration and facet joint osteoarthritis: demonstration withdedicated upright MRI system., Splendiani A et al
Pre-load After-load
Courtesyy of A. A. Splendiani
Dynamic MR
Supine Upright
Physiologic disc thickness: 13mm in supine / 11.2mm upright
Significative differences among sex - disc thickness is << in females
U. Tarantino; E. Fanucci; R. Iundusi; et al. Lumbar spine MRI in upright position for diagnosing acute and chronic low back pain - J Orthopaed Traumatol (2013) 14:15–22
Dynamic MRI Changes: Physiological
Male, 30 yrs, back painIncrease of disc protrusion in extension
Flexion Extension
Dynamic MRI Changes: Pathological
Courtesy of M. Muto
Male, 56 yrs, back pain.anulus lesion and hypermobility in extension
Seated - flexion Seated - extension
F. Alyas, D. Connell, A. Saifuddin.Upright positional MRI of the lumbarspine. Clinical Radiology (2008) 63,1035e1048
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
Proposed risk factors for osteoarthritis of the facet joints include anatomical abnormalities such as an increased facet angle and tropism (congenital predisposition)
Anatomy of the Facet Joints & InstabilityThe Most common cause of LBP
After load
MICROINSTABILITYPainful Facet Joint Syndrome (FJS)
Small Things cause Great Pain…
Be gentle….
Y
Instrumentation &“solution”?
Anatomy: relevant nerves
L4
DORSAL RAMUS OF SPINAL NERVE
MEDIAL BRANCH
INFERIOR ARTICOLAR BRANCH
LATERAL BRANCH
L5
L3
SUPERIOR ARTICOLAR BRANCH
Each facet joint receives dual innervation from medial branches arising from posterior primary rami at the same level and one level above the z-joint
DORSSPINA
AR BRANCH
Stepp n. 11: RFRF-F-ablationporpp nn. 1 R: R: RFF blationabapporoor Crioablationoor CrioablationC
Fasterer:r: ---80080°0°C in 33-3-4secFasteerr:Powerful
8ululu :
inCC 330088080:: freezing
secs3 44gg in 90 secPowerfu
Painlessfrefuul: f
ssss: no zingeeze
ooo needn 90 secngg in
ddd for Lidocaine e duringg the procedure PainlesEfficacy
ssscycyy:
noo nns: yy:: Pain
eedd or Lidofoenenn reduction
ocainee urinduLidonn in 30days (
ngurin((not
he procehgg thotoot 90days
oces s as
reduss with RF F ablationon)
155-5-21% FAILUREEE…
MUSCLESDILATORS
CT-GuidedTFF SCREW
Step. 2
MUSCLESDILATORS
CTCT-TT GGuidid dedTFF SCREWMUSCLESMUSCLES
Step. 2
Large Gantry diameterCT scan duringthe procedure
Combined vision
X-ray + CT
Precise Position
Proving Mechanical Efficacy of MicroFixation with FU MRIMicroFixation with FU MRI
Hypermobility = InstabilityModic I: painful edemaainful edemaModic I: paainfu
6 months FU: STABILITYModic II: painless fatty degeneration
Facet Joint SyndromeFacet Joint SyndromeThe Occult Syndromes
Dynamic MRI & Dynamic MRI & Functional Data
Upright
Dynamic MR & Starting InstabilityIncreasing intrarticular fluid
in Supine position
Supine
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
Dynamic MR, patient standing seated or upright with trunk extension, improves the synovial cyst detection
F. Alyasa, D. Connella, A. Saifuddina. Upright positional MRI of the lumbar spine. Clinical Radiology (2008) 63, 1035-1048.Niggemann P1, Kuchta J, Hoeffer J, Grosskurth D, Beyer HK, Delank KS. Juxtafacet cysts of the lumbar spine: a positional MRI study. Skeletal Radiol. 2012 Mar;41(3):313-20.
Facetsdegeneration Intrarticular fluid
Dynamic MR and synovial cyst
+
Synovial cyst
Radicularpain
y y y
Flexion
Extension
Minimalal Invasive Spine e Therapyy Deptpt ––– IOM M –– Catania, ITALYM
The Pedicle: When the Scotty Dog is beheaded…
The Painful Spondylolysis Treat IN TIME (before Spondylolisthesis comes)
Treatinggg Spondylolysis
Minimalal Invasive e painful Spondylolysiss treatment
The Buck’s technique
The Yellow Ligaments: enfolding the dural sac & nervesg g
LF
ISL
SSL
Dural sacdiameter
N.V. 13,1 mm(13,2 ± 1,9 mm)
Interspinousdistance
N.V. 14,6 mm(15 ± 2,9 mm)
Gradingg the Gradinggbulging
he g hthgg of bulgingg of o
ligaments
Stenosis: a dynamic concept…
Old Style Myelograms EXTENSIONEnlarge ligaments
Reduce Spinal Canal
FLEXIONFlat ligaments
Increase Spinal Canal
Minimalalal Invasive Spine e e Therapyyyy Deptppt ––– IOM M –– Catania, ITALYMM
It’s a Mechanical problemm………let’ss go to o BiomechanicsInterspinous Spacersrs: how do they work
EBMEVIDENCEBASED MEDICINE
IBMINTELLIGENCE BASED MEDICINE
PATIENT SELECTIONBe a Physician before beeing a NRadiologistClinical symptoms count!
Be a NRadiologist before beeing a Surgeon
Hi-Res CT – Full spine MRI
NO “SPACE FOR SPACER” IF:Ligament calcificationDegenerative arthropathyOther neurodisease (Parkinson, Altzh)
Multilevel SCS-Hyperkyphosis !!!
LumbarStenosis
Meningioma
CervicalMielopathy
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEBBBBBBBBCCCCCCCCCC
CCCCCCCCCCCCCCC
IIIIIIIIIIEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBEEEEEEEEEEEEEEEEEEEEEEEEEEENNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCEEEEEEEEEEEEEEEEEEEEEEEEEEENNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCDDDDDD DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD DDDDDDDDDDDDDDDDDDDDDDDDDDCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEBBBBBBBBBBBB SSSSSSSSSSSSSSEEEEEEEEEEEEEEEEEEEEEEEEVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVIIIIIIIIIIIIIIIIDDDDDDDDDDDDDDDDDDDDDDDDDDDDDEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVIIIIDDDDDDDDDDDDDDDDDDDDDDDDDDDEEEEEEEEEEEEEEEEEEEEE
SSSSSSSSSSSSSSSBBBBBBBBBBBBBBBBBBBBBBBBAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSEEEEEEEEEEEEEEEEEEEDDDDDDDDDDDDDDDDDDDDDDDBBBBBBBBBBBBBBBBBBBBBBBBAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSEEEEEEEEEEEEEEEEDDDDDDDDDDDDDDDDDDMMMMMMMMMM CCCCCCCCCCCCCCCCCCMMMMMMMMMMMMMMMMMMMMMMMMMEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEDDDDDDDDDDDDDDDDDDDDDDDDDDDDDIIIIIIIIIIIIIIIIIIIIIICCCCCCCCCCCCCCCCCCCCCCCCCCMMMMMMMMMMMMMMMMMMEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEDDDDDDDDDDDDDDDDDDDDDDDIIIIIIIIIIIIIIIIIIIIIICCCCCCCCCCCCCCCCCCCCCC
LLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS
MMMMMMMMMMMMMMMMMMMMMMMMM
CCCCCCeCeCeCeCeCCeeeeCeCeeeeeCCeCeCeCCeCeCCeCeeCeCeeeeCeeCCeCCeCCeeeCeeC rEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBMiMiMiMiMMiMiMiMMiMiMMiMiMiMMMMMMiMiMiMiMiMMMiMiMMMMiMMiMiMMiMiMiMMMiMiM eeeeeeeeeGGGGGGGGGGGGGGGGNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCCNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCNNNCCCCCCCCCCCC
MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMEEEEEEEEEEEENNNNNNNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEvvvicicccccccccccciciciciciccicicccalalallalalalalalalllalllalaallallllllllMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMopopopopopopopopopopopopopopopopoppopopopppoo atatatatatatatataatatatatatttthyhyhyhyhhyhyhyhyhyyyyyyyhyhhyyyhyyyhyyhyhyhhyyhEEEENNNNNNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCCCCCCCEENNNNNNNNNNNNNNNNNNCCCCCCCCCCCCCCCCCCEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEiiiii iiiieeeeeeeeeeeeeeeee inininnininininininiinininininininningngngngnngngngngngngngngngngngnngngnnnnnnnggioioiioioiooooooooioiooooiooooioiioooiooooioomamamamammamammmmamamamamamamamammmmm
mmbmbmbmbmbmbmbmbmbmbmbmbmbmbmbmmmbmmmbmbmbmmmbmmm aararararararararararararaaaraaaenenenenenenenenenenennnnnenenennnnnnennnenenennnosososososososososososososososososossoooosssssisisisisisisisisisssssississisisisiisisssis
B
C
D
Schizas classification of LSCS
Sturesson B et al. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine 2000Sturesson B et al A radiostereometric analysis of the movements ofB
SACROt lt
O-A di t mlt
O-ILIAC JOINT: a tri-planar shock absorber
Finite ElementsSIJ POWER
The largest (17.5cmm2m2)
The strongest hT(Raise up 4800NNN)
Small rotation (<4°)Small translation movement (1.6mm app.)
SACROILIAC JOINT INSTABILITY C JOINT I(SIJI)
Frequentnt &..FrequeFrequently
nnt &..&ueyy unknownwnw …
SIJ J Instability55-5-25525%
SIJJ %% of ALL
tabilnstInL L Low
itybilww Back k k Painn!!!
Polly, Sembrano Spine 2008Cohen, SA Anesthesia and analgesia 2005
• Afterr DeliveryAftPost
teAftss -
er DeDteAftstst-Partum
eliveryelimm syndrome
• Afterr PIF F Posteriorr Fusion75
A75755%
er PIFPAfteA%%%% patients
ostePoFFsss have
eriorsteee SIJI775%
afteratientspa%%% p
ererr PIF in 5 avee SSss hah
5 55 yearsHA Young , Spine 2008Ivanov Spine 2009
INNERVATION: a a NightmareINNEA
ERVATIONNEAAnterior
: aa ightmareNPosterior
LAAntLL2
tertnt22 to
riorero ooo S
rorSS2
Po L
osPoLL4
steos44 to
erioeo ooo S
orrioSS4
PPoPPoCCCo
Symptoms No use…
Physicalal MMManouvreses.Physicaysicaalal MMMMMM nouvnanansuggestive
vrevrees.nouvnouvonlygggggggggggggggggeeeeseseseseeeeeeeeeeeeeeeee tiveggessssesssssesssseeseeesti eveveevessssssssstiiiititititttitititttttititit vvvvssssssssssssss eeeeeeeee ynnnnnnnnnnlyynlyyonononooooononooooooonnnonooooooooooooooooo
Lidocaine e Blockk TEST
SPECT T -- CT
5-7 14G needles, Generally bilateral5 7 14G needles Generally bilaateral
Option. n. 11::: destroyy the e nerves
7 1
OptiCT
4
OptiTT-
dl
onn. 1io
4G
OptiTT--guided
G
estroyde:: ddddd Radio
royioio-oyoo--/
ll bil t l
hee ervesne
ll
hth
l
tyy--// Crioablation
ProblemsFAILURE 5-21%
So many needles/cannulas
Option. 2: CTCT-T-TT guidedd Endoscopicc RadioablationOption. 2: CCTT uidedgug d EndoE oscopicc RadioablationRoscopicc R
The Final Option: SIJ JJ FIXATION
SIJ Sagittal global displacementssimulations at 1000 N
uninstrumented one screw
80% sacral nutation mov. reduced
Finite Element Analysis of Sacroiliac Joint Fixation under Compression Loads Claire Bruna-Rosso et al. IJSS AUG.2016l OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOThTTTTTTThTTThTTTTTTTTThThThThTTTThThTThTThTTThTTThThhThTTTThThTTTThThTTTTTThTThTTThhThTTTTThTThThTTThTTThhThThhThhThTTTThTThTThThThThThThhhThTTThThTTTTTThThhThhhhhTTThThTTTTTTTTThhhThThTTTTTTTTTTTTTThhhhhTTTTTTTTTTThThThhThTTTTTTTTTThhThThTTTTTTTTTTThhhThTTTTTTTTTTTThhhThTTThThTTTTTTThhhhTThTThTTTTTTTThhTTTTTTTTTTTThhhTThTTTTTTTTThThTTTTTTTThTTTTTTThhTTTTTTTThhhhTThTTTTTTTTTThhTTTTTTTThhTTTTTThhhTTTTTTTTTTTTTTTThhhhhTTTTTTTThhTTTTTTTTThTTTTThTThhhTThhhThhheeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee iiiiiiiiiiinannannnnnanananannnanannnnnnnnaannnannnnnnnnnnnnanaaaaaananannnnnnaaaaaannnnaaaannnnnaaaannnaanaaaaanannaaaaannnaaaaaaaaaaaFFFFFFFFiFFFFFFFFFFFFFFFFFFFFFFFFFFFiiFFFFFiFFFFFFFFiFFFFFFFiFFFFFFFFiiFFFF aaaaaaaalllllllllltetteeeeeeeFinFiFinFFF nnnnnnnFFFFFF itititteeeeeeeeeeeeeee iiiiiiiiiiiinnnnnnnnnnnnnniiiiiiiiiinnnnnnFFFFFFFFiFiFFFFFFFFiFFFFFFFFiFFFiFFFFFFFFiFFFFFFFFFFFFFFiFFFFFFFFiiFFFFFFFFFFFFFFFFFFFFFFFFiFiFFFFFFFiFFFFFFFiFFFiFFFFFFiFFFFFFFFFiFFFFFFFFiiFFFFFFFFFF meeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeemmmmmmmmmmmmmmmmmmmmmll OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOEEEEEEEEEEEEEaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaElellellleaaaaalllllllllllllll ossissssssississssssssissssssssssssssssssssssssssssssssssssssssssssssssssssssssll OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOmmmmmmmmmmmmmmmmmmmmmppreprppprrrrrreeeeeppppppprerrprrrreeeepppppprrrrrrrrreeepppppprrrrprrpreppprprrprepprepreprepComComCoComCCCCComCooCoooCCComCooCoCoComCooCoCCComCCoComCooCCCCCComomoooommmmmmComCCCoooooommCoCCComComCoCoCoomooComommeeeeeeeeeeeeeeeeeee eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee iiinaaaaanananaaaaaanaaaaaanaanaaanaaaaannnnnanaaanaaaannannnnnnannnnaannnannnnnaaaaannnnnnaaaaaaaannnnnnnaaaaaannnnnaaaaaaaannnnnnnaaaaaaaiinannanaannnnaannnnnnaaaannnnnaaaaaaaannnnnnaaaaannnnaaaaaaanaaaaFFFFFFFFiFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFiFFFFFFiFFFFFFiFFFFFFFFFFFFFFFFFFFFFFFFFFFi eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeessssssssssaaaaalllllllllllllaaaalllllll XAXXXXAXXXXAXXXAXAXXXAAAXXXXAXAAXAAAAXAXAXXAXAXXXXXXAXXAAXXXAXXXXXXXAAXAAXXAXAXXAAAAAXXXXAXAAAXAAXAXXXXXXXXXXXXXXAXXXAXXXXAXAXXXAAAAXAAAAAAXXXAAAAAAAAAXXXAAAAXAAAAXAAAAAAATITTTTTTTIITITTTITITTTTTTTTTIITTTTTT ONONOOOOOONOONOOOONOONOOOOOONOOOOOOONOONOOOOOOONOOOOONOOONOOONONOOOOOONNNOOOOOOOONOOONOOOOONOOOOOOONNOOOOOONOOONOOOOOOOONONNOOOOOOOOOOONNNNNOOOOONNONOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOONOONNOOOOOOOOcroiliacXAXXXXXAXXXXXXXXXXAXAAAXAAXAAAAXAXXXXAAAXAAAAAXXXXAXAAAAXAAAXXXXXXXXXXAAAAAAAXXAXAXXXXXXAAAAAXXXXXXXXXXXXAAAAAXXXXXXXAAAAAAAXXXAXXXXXXXAAAATITTTTTTTTTTTITTTTTTTITTITTTITTTTTTTITITTTTTITTTTXAXXXXAXXXXXXAAAAAAAXAXXAAAAXAAXAAXXXXXAAAAXAAXXXAAAAAXXXXXXAAAAAXXXXXAAAAAAXAATITTTTTTTTTTTITTTTTITTITTITTTTTTITTTTTTITT Joint tttttttttttttttttttttttttttttttONONOOOOOONONONNNONNNNNNNNONNNONOOOONONONNNNNNONOOOOOONNNNNONNOOOOOOOONONONNNNONONONNNNNNNONOOONOOOOONNNNONONNNNNNNNOONOOOOOOONNNONONNNNNOOOONONNNNNNNNOOOONNNNNOOOOOOOONNNNONNNNNNNNONNNONNONONNNONOOOONNNNONOOOOOONNNNNOONONNNONOOONOOOONNNONONNNNNOOOOOOOONONONOOONNNOOOOOOOO xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxatiattiattitiaaaaaaatiatttttatiatiatiaataaatiaatiattatatiiaatataatitttatatiiataaatattatttiatiataaatittttiaaaaaaatttiaataaaattttiaaatttttiiaaattttt onoooooooonnnnnnnnnooonooooonnononononoonoonnnooonooooononnnnoonooooonnnnnnnonnoooooonnnnnnnnnnoooooonnnnnnnoononoooonnnoononnooFixFFFixiiFFFFFFFFFFixixFFFFFFFFFixiFixFFFFiFFFFFFiixxFFFFiiixFFFFFiiFFFFFFi u
aaaaaaaaaaaaaaaaaaa-RosRos-RosRosRRosR-RRRRRRosRo-RosoooooooossssRosRossRos-RRos--RosRRRosRosRRRRRRoooRosoRosssRossssss-RosRRRRRRRRoooos-RossssRR-RRosRR-Rosoooooossss--Ros--RoRRRRRRRRooooosssos-Ros---Ros-RRRRRosRosR-RoRRoooosssss--Ros-RRosRRRRooooooossssRosRosRosRosRosRosRosRossRRosRosRoRo sossssso ooosossssooossssoosssooossosossssssoossooso sXAXXXAAAAAXAAAAAAAAXXXAXXXAAAAAAAAAAAXXXXXXXAXXAAAXAAAAAAAXAAXAXAXXXXXXAAAAAAAAAAXXXXXAAAAAAAXAAAAAXXAXXXXAXXAAAAAAAAAAAXXXXXXXAAAAAAAAAAAATITTTTTTTTTTITTTTTTITTTTTTTIITTTTTITTTITTTTTTTTTTTTTTTITTTIXAXXAAAAXAAAAAAXAAAAAXXAAAXAAXXXAXAAAAXXAAAATITIITTTTTTTTTTITITI SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS AUG.AUAUGAAAUGAUAUGAUGAAAUUGUUAUUUGAUGAUGAUAUGAUGGAAUAAAAAUGAUUAUGGGGGGGGGAUGAAUGAAAAAAUAUAUUUAUUUUGAUGGGGGGAUGAAUAUGAUGAUUGUGUGUUAUGAUGUGGAAUGAAAAAUUUAUAUGAUGGAUGGAAAUGAAUUUGUGUGAUGGGGGGAAAAAUUUUGGGGGGAAAUUAUAUGAUGAUGAAAAUUUGGAUGAAUAUGAAAUUUUUGGAUGAAUGAAUGAAUUGUUUUGAUAAUAAAAAUG.UGUUUUGAUGAUG.AUAUG.AUAUGAUG.AUG.AUGAUGAUG.AUGUGG 2022222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222222et aet aet aet aaeet aaet aaeet aet aaee aaeet aeet aet aetttet aaaaat aet aeeet aeeet aet aeett aaaaaet aaaet aeeeetteeet aeeet aaeeeeeeet ae aaaaaet aaaet aeet aet aeet aaaaaaaeeet aeet aaaaaaaet aet ae aet aaeeet atet aet aet aal. Illl Ill Illllllllllllll.l.l.ll.. l. llll. l. l JSSJJSSJSSJJJJJJJJSJSJSSSSJJJSJJJSSSSJJJSJJJSSSSJJJJJSJJSJJJSSSSSSSSJJJJSJSSSSJJSJSJJSSSSSSJSSJJSSSSSSSJJSJSSSJJJJSSSSSSSSSSSSJJSJSJSSSSSSSSSSJSJJSSSSSSSSSJSJSSSSJSSSSJJSJSSJSJJSJSJSSSONONOOOOOOOOOOOOOONNNNNONOONOOOOONOOONNNNNOOOOOOONOOOONONNNNNNNOOOOOOONONOONNNNNOOOOOONNNNOOOOOOONONNNNNOOOOONNNNNNN ONONNNNOONNOONNNOOONONNOONNOOONNNNOOOOOOONNNN