Conséquences défavorables sur l’équilibre sagittal du rachis du système de neutralisation dynamique

Abstract

Purpose of the study The dynamic neutralization system (Dynesis™) has been proposed for the treatment of symptomatic lumbar discopathy. This system preserves the mobility of the instrumented vertebral segment and restores discal height by posterior distraction on pedicular screws, stabilization being ensured by compression on a spacer. The potential kyphosing effect of this system and the impact on sagittal morphology of the spine were analyzed. Material and methods Twenty-six patients were studied. Lateral x-rays of the lumbar spine in the upright position were obtained before and after the surgical procedure and at mean 9.5 ± 3.3 months follow- up.Comparisons were made between the pre- and postoperative presentation with measurement of the pelvic and spinal sagittal parameters described by Duval-Beaupère: inclination of the pelvic segement on the sacrum, lordosis, and disc wedge angles at each level (particularly the instrumented levels). Sagittal morphology was assessed pre- and postoperatively. Results Mean kyphosing effect was 6 ± 1.4°, induced by the posterior distraction system. This accentuated the initial lumbar hypolordosis related to the degenerative disease. Comparison of the pre- and postoperative films revealed four types of sagittal reaction of the lumbopelvic segment: no modification (type A), significant loss of lordosis without change at the pelvis level (type B) or with compensatory pelvic retroversion (type C), accentuation of the lordosis with pelvic anteversion (type D). Conclusion The dynamic neutralization system (Dynesis™) can stabilize degenerative discopathy and protect the adjacent levels. Posterior distraction perturbs the initial hypokyphosis and can lead to pelvic compensation to achieve better dynamic balance. This loss of lordosis is however a cause of excessive mechanical stress on the lumbar structures and can lead to long-term degradation. Future developments of this dynamic system should take into account the essential factor of sagittal balance.