03 14 16 MIS Spine Syllabus
2016-03-14
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3/14/2016 MIS vs Open Surgery for Spinal Deformity: Treatment Algorithm Praveen V. Mummaneni, M.D. Professor Vice-Chairman Dept. of Neurosurgery Co-director: UCSF Spine Center University of California, San Francisco Chair: AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves Todd D. Vogel, MD. UCSF spine fellow Junichi Ohya, MD. International visiting fellow Disclosure • Consultant: – DePuy Spine • Other Financial Support (royalty): – – – – DePuy Spine Thieme Publishing Quality Medical Publishers/Taylor and Francis Springer Publishing • Stock – Spinicity/ISD Burgeoning Adult Deformity Patient Population • Need to Treat More Patients with Adult Spinal Deformity • Need to Avoid Morbidity 1 3/14/2016 Why Would We Want To Do “Less” Surgery for Adult Spinal Deformity? • Complication rates high • Pseudarthrosis rates problematic Mummaneni et al: Neurosurgery 2008 Degen Vs Deformity • In Degenerative 1-2 level spinal disease, MIS approaches decrease hospital stay and EBL – The operations are interchangeable for Most cases • Does this hold true for deformity? – Are the indications for the MIS vs open deformity surgery similar? 2 3/14/2016 J. Cheng and P. Mummaneni: NS Focus 2013 • Compared 50 MIS TLIF with 25 open TLIF • MIS TLIF with fewer complications and lower EBL • MIS TLIF had shorter LOS and saved $4k compared to open TLIF • Long term outcomes similar MIS Deformity • Can decompression be achieved? Yes • Can hardware be placed safely? Yes (even iliac screws) • Can sag balance be restored? Maybe • Will you match LL-PI within 10 degrees? Maybe • Will it take a long time to do? Initially - yes • Can a succesful fusion be established? – This is the Challenge… Anand, et al. NS Focus 2010 Complications 3 3/14/2016 Tormenti, et al. NS Focus 2010 Complications Dakwar and Uribe. NS Focus 2010 • Pitfall: – The authors concentrated on coronal curve and not on sagittal balance Dakwar and Uribe: NS Focus March 2010 • 1/3 of the patients did NOT have sagittal balance restored • Remember: Coronal correction is NOT as important as sagittal correction 4 3/14/2016 Wang & Mummaneni NS Focus March 2010 • 23 patients, retrospective review • High pseudo rate if no interbody fusion is done, can not rely on MIS posterolateral fusion When To Do MIS for Deformity? • Need an algorithm… NS FOCUS May 2014: • Praveen Mummaneni • Chris Shaffrey • Lawrence Lenke • Paul Park • Michael Wang • Frank LaMarca • Justin Smith • Greg Mundis • David Okonkwo • Bertrand Moal • Richard Fessler • Neel Anand • Juan Uribe • Adam Kanter • Behrooz Akbarnia • Kai Ming Fu • MIS ISSG 5 3/14/2016 When To Do MIS for Deformity? • Need an algorithm… NS FOCUS May 2014: • Praveen Mummaneni • Chris Shaffrey • Lawrence Lenke • Paul Park • Michael Wang • Frank LaMarca • Justin Smith • Greg Mundis • David Okonkwo • Bertrand Moal • Richard Fessler • Neel Anand • Juan Uribe • Adam Kanter • Behrooz Akbarnia • Kai Ming Fu • MIS ISSG Class I Treatment • MIS Decompression without fusion or with limited one level fusion 52 year old woman with radicular right leg pain. Minimal back pain. MRI with Right L3-4 lateral recess stenosis from disc bulge (axial shown below). CA 15 PT 3 PI-LL -7 SVA<5 C A B D 6 3/14/2016 Class I Treatment • Decompression alone – Neurogenic claudication secondary to central stenosis • Requires limited decompression • Minimal or no back pain – Radiographic findings • Decompression w/ limited instrumented PL Fusion – – – – Stenosis with minimal back pain Anterior supporting osteophytes No global imbalance, cobb <20, No LL-PI Mismatch – Caution: Deformity progression and worsening of symptoms Class 2 “Medium” MIS Treatment • Apex of lumbar curve is included in instrumented fusion, plus necessary decompression – back pain associated with deformity • Radiographic – LL-PI mismatch 10-30 degrees – May have grade 1,2 spondylolisthesis or lateral listhesis – PT<25 – Coronal cobb over 20 degrees Silva FE, Lenke LG: Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 28 (3): E1, 2010 Case Example • 67 year old woman with low back pain and bilateral sciatica and anterior thigh pain – Failed multiple steroid injections – On oral narcotics 7 3/14/2016 36-Inch X-rays revealed L2-3 lateral listhesis SVA: 4.3cm Lumbar lordosis: 27° Dynamic X-rays MRI L3/4 L4/5 What Levels to Treat? 8 3/14/2016 • 1st stage surgery: – Lateral interbody fusion at L2-3, L3-4, L4-5 • 2nd stage surgery: – Posterior MIS L2-S1 pedicle screw fixation and right iliac screw fixation – TLIF at L5-S1 9 3/14/2016 C D A B 10 3/14/2016 Iliac Screws May Be Placed MIS Initial Results • 24 patients underwent percutaneous iliac screw fixation -indications: infection, neoplasm, trauma, deformity • 47 screws placed with fluoroscopic guidance • All screws confirmed with CT – correct placement of all screws. • No hardware complications • One patient died of unrelated medical comorbidities -Wang MY, Williams S, Mummaneni PV, Sherman JD. Minimally invasive percutaneous iliac screws: Initial 24 case experience with CT confirmation MIS techniques in selected cases may diminish complications 11 3/14/2016 There is a limit (ceiling effect) to deformity correction using current MIS techniques Conclusion: MIS is NOT Ideal for Class 3 • Avoid – – – – – 0 Curves with Cobb >30 Apical rotation > Grade II Lateral olisthesis >6mm Sag imbalance requiring PSO Thoracic kyphosis • These characteristics predict failure with limited MIS decompression/fusion surgery • Need to do OPEN surgery Conclusions • PI is a fixed parameter • PT may increase to compensate for loss of sagittal balance • Goal LL = PI +/- 10 degrees – Match PI within 10 degrees of the lumbar lordosis 12 3/14/2016 Conclusions • Minimally invasive techniques: – Useful for MISDEF Class 1, 2 deformities – Don’t forget to restore sagittal balance – Currently, MIS techniques are not ideal for cases requiring 3 column osteotomies for correction of spinal imbalance 13 3/7/2016 MIS Deformity Management using the Lateral Approach Luiz Pimenta, MD PhD 1Instituto de Patologia de Coluna - São Paulo – Brazil 2UCSD, San Diego, CA – USA 2016 ADULT DEFORMITY Surgical Principles • Decompress neural structures • Promote fusion • Preserve/ correct alignment – CORONAL/ SAGITTAL Method and approach selection • • • • • Previous surgery? Free levels Focal deformity? More correction in lower levels Risks – – – – – Bleedind Surgery duration ICU Neurological risks PJK REDUCE REDUCE REDUCE 1 3/7/2016 Method and approach selection LLIF ACR Posterior LLIF Osteotomies LLIF + SPO PSO, SPO, VCR ASD TLIF/PLIF ALIF MIS ALIF HYBRID ACR OPEN ALIGNED COMPENSATED DECOMPENSATED The majority of the cases are “ALIGNED to COMPENSATED”… 2 3/7/2016 Not only SVA but also PI-LL Disability is underappreciated in compensated cases Compensated SVA x PI-LL Both groups experienced similar improvements with sagittal correction Decompensated x SVA x PI-LL Examples 3 3/7/2016 Examples MIS ALIF LLIF MIS post X HYBRID ALIF LLIF Limited open posterior X OPEN Open posterior osteot/fixation Summary MIS; HYB; OPEN • Complications MIS < HYB < OPEN • Surgery duration OPEN = MIS < HYB • EBL MIS < HYB < OPEN • Power of correction OPEN > HYB > MIS 4 3/7/2016 PLF/ TLIF/ PLIF and Alignment PLF alone average PLIF/TLIF alone reported pre- to postop lordosis change per level treated was -10.7° to 0° in lordosis (1) average reported preto post-op lordosis change per level treated was -5.6° to 0°in lordosis (2) PLIF/TLIF plus SPO average reported pre- to post-op lordosis change per level treated was 15° to 20°lordosis per level (3) 1. Hsieh, P. C., Koski, T. R., O'Shaughnessy, B. A., Sugrue, P., Salehi, S., Ondra, S., & Liu, J. C. (2007). Anterio r lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance. 2. Kepler, C. K., Rihn, J. A., Radcliff, K. E., Patel, A. A., Anderson, D. G., Vaccaro, A. R., ... & Albert, T. J. (2012). Restoration of lordosis and disk height after single‐level transforaminal lumbar interbody fusion. Orthopaedic surgery, 4(1), 15-20. 3. Jagannathan, J., Sansur, C. A., Oskouian Jr, R. J., Fu, K. M ., & Shaffrey, C. I. (2009). Radiographic restoration of lumbar alignment after transforaminal lumbar interbody fusion. Neurosurgery, 64(5), 955-964. 3-column osteotomy 423 consecutive patients (8 Surgical centers) •Major Intraop complications – 7% – spinal cord deficit (2.6%) •Major Periop complications – 39% – Unplanned reop (19.4%) •Major overall complications – 42% Higher risk of complications average % of total blood volume lost - 55% !!! Major blood loss (over 4 L) – 25% 3-column osteotomy – Minimize colateral damage Hu et al • ultrasonic bone ressectors Safe and effective Decrease the risk of soft tissue injury Decrease blood loss 5 3/7/2016 “Standard” Lateral LIF Good for coronal realignment Poor for sagittal correction Posterior Osteotomies (SPO) Pedicle subtraction osteotomy (PSO) Vertebral column resection (VCR) Anterior Column Realignment (ACR) NEW OPTIONS FOR MIS powerful correction Posterior shortening x Anterior elongation LLIF and Alignment LLIF average reported pre- to postop lordosis change per level treated was 1.2° to 3.6° in lordosis LLIF with SPO average reported preto post-op lordosis change per level treated 27.6° in lordosis LLIF ACR average reported pre- to post-op lordosis change per level treated was 10° to 30° in lordosis Rodgers, W. B., Gerber, E. J., & Patterson, J. R. (2010). Fusion after minimally disruptive anterior lumbar interbody fusion: analysis of extreme lateral interbody fusion by computed tomography. SAS Journal, 4(2), 63-66 6 3/7/2016 Anterior Column Realignment (ACR) by the lateral approach • Segmentar Sagittal Correction → Regional/ Global changes – Lateral/ Anterior access – ALL ressection – Hyperlordotic cages Anatomical Considerations - ALL 20/30° Planning for a lateral ACR • CLINICAL ANALYSIS – Hip flexion contractures – Neuromuscular conditions – Dynamic flexibilty supine vs. Prone vs. standing – Neurologic impairment (UMN) •RADIOGRAPHIC ANALYSIS – – – – – 36” XRAYS, CT, and MRI Sagittal parameters Pelvic parameters Mobile interbody disc Hyper-extension view to evaluate disk space motion 7 3/7/2016 Dynamic X-Rays Dorsal Decubitus + Bolster 37° Courtesy: Dr Akbarnia CT/ MRI Free levels Can give a clue about flexibility orthostatic supine LLIF= 25 ACR= 9 ACR correction (per level): Lordosis 12° SVA 3.1cm ACR equivalent to SPO Selection bias... 8 3/7/2016 Lessons learned: limited posterior osteotomies (Pontè) can give superior correction Hyperlordotic ALIF ALIF and Alignment ALIF Alone average reported pre- to post-op lordosis change per level treated was 5.6° in lordosis ALIF + SPO average reported pre- to post-op lordosis change per level treated was 15° to 20° in lordosis ALIF ACR average reported pre- to post-op lordosis change per level treated was 10° to 30° in lordosis Lu, Y., Falcone, M. M., Wang, M. Y., & Wu, S. (2014). Multilevel TLIF for Spinal Deformity. In Minimally Invasive Spinal Deformity Surgery (pp. 173-183). Springer Vienna. Dorward, I. G., Lenke, L. G., Bridwell, K. H., O'Leary, P. T., Stoker, G. E., Pahys, J. M., ... & Koester, L. A. (2013). Transforaminal versus anterior lumbar interbody fusion in long deformity constructs: a matched cohort analysis.Spine, 38(12), E755-E762. 9 3/7/2016 Case example – 1-level HL ALIF PI-LL = 30° PI-LL = 6° Importance of PLANNING Pre-Op Surgical Plan Post-Op Result Summary Anterior colunm reconstruction • Proper indication and planning • Adequate exposure • Safety (protection of neurovascular & monitoring) • Complete release (ALL & annulus; any posterior?) • Proper cage position & size • Cage fixation & screw • Good stabilization & fusion technique • Achievement of Goal 10 3/7/2016 www.patologiadacoluna.com.br 11 3/8/2016 MIS Applications for Pediatric Deformity Firoz Miyanji MD, FRCSC VuMedi Seminar 2016 12 yo How can we achieve the correction through MIS? Lenke 1B Deformity Correction • Remains a delicate balance between construct and application of forces and surgical technique of mobilizing the spine • With changes in available instrumentation, techniques for deformity correction have also evolved • A number of traditional techniques exist for open procedures not all of which are available for MIS 1 3/8/2016 Correction Maneuvers… Translation…Uniplanar Coronal Plane Maneuver Compression/Distraction…U niplanar Coronal Plane Maneuver (affects sagittal plane) 2 3/8/2016 Rod Rotation…Biplanar Rod Rotation…Biplanar Coronal Plane Maneuver Rod Rotation…Biplanar 3 3/8/2016 Rod Rotation…Biplanar Sagittal Plane Maneuver In Situ Contouring Coronal/Sagittal Plane Maneuver Direct Vertebral Apical Derotation (DVAD) Axial Plane Maneuver 4 3/8/2016 Direct Vertebral Apical Derotation (DVAD) Differential Rod Contouring : “Newtonian Principle” Axial Plane Maneuver Intra-operative Halo-Femoral Traction • Increasingly popular in open deformity procedures for large, stiff curves • Advantage in MIS – powerful indirect deformity correction away from operative field 5 3/8/2016 Intra-operative Halo-Femoral Traction Deformity Correction - MIS • Correction maneuvers rely heavily on: • Rod derotation • Differential Rod Contouring • DVAD • Compression/Distraction fairly limited due to exposure and size of available instruments Steps – MIS Deformity • Exposure • Grafting – fusion • Screw placement • Deformity Correction 6 3/8/2016 Fluoroscopy: Midline Skin Incisions Planned Paramedian Fascial Incisions - 1 Fingerbreadth from Midline Blunt muscle splitting approach in line with fibres Traditional Wiltse •Multifidus medial and Longissimus lateral 7 3/8/2016 MIS: Multifidus retracted more medial to expose facet joint…important for “release” and “fusion” Exposure of Facet Joints Principle of Wide Facetectomy • Similar to open technique as posterior release to mobilize column • Cannulated bone pegs allow for bilateral facetectomies prior to rod passage and application of correction maneuvers • Ponte releases can be considered through apical area by doing a hybrid procedure 8 3/8/2016 Facetectomy followed by Decortication Decortication using highspeed burr TP Facetectomy Superior facet Facetectomy Pedicle cannulation using ‘free-hand’ technique Guide wires inserted to keep cannulated pedicles localized 9 3/8/2016 Meticulous decortication and bone grafting prior to screw insertion Bone grafting prior to screw insertion • Bone Peg option prior to guide wire insertion • Allows for less cluttering of operative field • Enables bilateral facetectomies prior to rod insertion 10 3/8/2016 After grafting, pedicle screws are placed – concave side initially Concave Rod Passed First - Distal to Proximal Rod Rotation 11 3/8/2016 Rod Rotation Differential Rod Contouring : “Newtonian Principle” 12 3/8/2016 Pre-op 2.5 Years Post-op 13 3/8/2016 Pre-op 2.5 Years Post-op Other Lenke Type Curves? Lenke 2’s 14 3/8/2016 Lenk 2 – Structural PTC Right and Left Bend Films High Left shoulder 15 3/8/2016 2 Years Post-op 2 Years Post-op 2 Years Post-op 16 3/8/2016 2 Years Post-op “Long, Swooping” Lenke 1 (Lenke ‘1AR’) • Longer fusion to L2/L3 despite being “Lenke 1” curves… “Long, Swooping” Lenke 1 (Lenke ‘1AR’ – Miyanji et al. Spine 2008) 17 3/8/2016 Perceived Limitations • Fusion • Application of correction maneuvers • Rod Passage Perceived Limitations – 1 year post-op CT • Fusion – facet/lamina fusion • Model for pseud risk different than adults • Aggressive decortication and allograft bone. • Primary Goal: • To compare curve correction between MIS and open techniques • Secondary Goal: • To identify potential differences in peri-operative variables between the two groups 18 3/8/2016 Results MIS OPEN 2:14 1(8); 2(5); 3(2); 4(1) SD 1.2 4 0.5 8 SD 4 5 Demographics Gender M:F Lenke Class (n) Age (yrs) BMI Risser Pre Op Major Cobb Primary Outcome Post-Op Major Cobb Post-Op Thoracic Kyphosis (T5-T12) Percent Curve Correction Secondary Variables OR Time (min) EBL (ml) LOS (days) Mean 16.8 21 4.5 56 Mean SD 1.2 3 0.5 5 SD 1:15 1(9); 2(2); 3(3); 4(1); 6(1) Mean 16.4 22 4.5 56 Mean 20 21 8 9 18 17 95% CI Lower -2.4 -1.7 95% CI Upper 7.2 9.4 63% 13 68% 8 -0.12 0.04 Mean SD Mean SD 444 277 4.63 89 105 .96 350 388 6.19 76 158 1.68 95% CI Lower 34.8 -207.8 -2.6 95% CI Upper 154.0 -14.1 -0.6 Conclusions Perceived Limitations • Prospective and long-term studies are critical to evaluate possible limitations and to demonstrate the true clinical benefits of minimally invasive surgery in the setting of deformity 19 3/8/2016 Results Patient Demographics Gender M:F Lenke Class (n) Mean Age (yrs) Mean Weight (kg) Mean Preop Major Cobb (°) Mean Preop Lat (T5-T12) No. of Fusion Levels MIS (n=23) PSIF (n=23) 3:20 4:19 1: 20 2: 2 4: 1 16.8±0.40 (14-20) 59.1±1.74 (43-72) 56.7±1.62 (45-77) 20.5±2.08 (-2-39) 10.2 1: 12 2: 8 3:3 16.4±0.28 (13-19) 56.4±1.57 (44.6-76.2) 58.1±1.57 (46-71) 22.6±3.38 (-4-54) 12.2 Peri-op Outcomes 20 3/8/2016 Operative Time 600 OR Time (min) 500 P= 0.000 400 300 200 100 0 -100 MIS OPEN -200 Number of Days Length of Hospital Stay (LOS) 9 8 7 6 5 4 3 2 1 0 -1 -2 P= 0.000 MIS OPEN Estimated Blood Loss (EBL) 700 600 P= 0.000 500 ml 400 300 200 100 0 -100 MIS OPEN -200 21 ml 3/8/2016 100 90 80 70 60 50 40 30 20 10 0 Mean Volume of Cell Saver Transfused 69.0 P= 0.005 0 MIS OPEN 2-yr Follow-up Mean Post-op Major Cobb at 2 years Major Cobb (degrees) 70 60 P= 0.017 50 40 30 58.1% 68% Pre-op Post-op 20 10 0 MIS OPEN 22 3/8/2016 Complications 6 21.7% Pseudarthrosis 5 Hardware Failure Infection 4 P= 0.08 3 2 4.3% 1 0 MIS OPEN 2 year SRS-22 Outcomes Scores 5 P= 0.715 ml 4 3 2 1 MIS OPEN Conclusions Mean 5.2° difference – Clinical significance? 23 3/8/2016 Summary • Steps: • • • • Exposure Grafting Screw Placement Deformity Correction • Fusion level selection should follow “traditional rules” • Consider HFT for ‘stiff’ curves • Start with flexible Lenke 1A/B curves Summary • MIS very feasible in deformity • Correction is NOT significantly compromised • Advantages include blood loss, transfusion rates, and LOS • At 2 years SRS functional outcome scores equivalent to open techniques Thank You 24 3/14/2016 EMERGING TRENDS IN MIS DEFORMITY SURGERY Richard G. Fessler, MD, PhD Professor Department of Neurosurgery Rush University Medical Center CATEGORIES • DEVICES – Hyperlordotic cages – Patient specific pre-contoured rods – “Growing” rods for MIS • BIOLOGICS – Non-BMP fusion augmentation • TECHNIQUE – Expandable disc space distractors – Sectioning the ALL – Technique for bending rods into lordosis • PLANNING – Computer programs for optimal correction 2 DEVICES • HYPERLORDOTIC CAGES 1 3/14/2016 Recent modifications • 65 yo male with 20 years of worsening back pain s/p L2-4 laminectomy 6 years ago • Unable to stand or walk for more than a few minutes; failed PT, injections, chiro, meds Courtesy of John O’Toole T2 sagittal 2 3/14/2016 • Stage 1: – L5S1 ALIF with 15 degree cage – R L2-5 LLIF (10 and 20 degree cages at L23, 45) • L3-4 ALL release with 30 degree cage • Stage 2: – L3-4 MIS posterior osteotomies – L2-S1 percutaneous screws w/ navigation 3 3/14/2016 Pre to postop PRO scores • Has severe knee arthritis affecting VAS leg and ODI DEVICES • PATIENT SPECIFIC PRECONTOURED RODS DEVICES • GROWING RODS FOR MIS 4 3/14/2016 BIOLOGICS • NON-BMP BONE GROWTH AUTMENTATION – Protein – Calciumphosphosilicate P-15 PROTEIN TECHNIQUE: EXPANDABLE DISTRACTORS and CAGES LORDOTIC MIS 5 3/14/2016 TECHNIQUE: CUTTING ALL TECHNIQUE FOR BENDING RODS Haque, R., Fessler, R.G.: “Push-Through” Rod Passage Technique for the Improvement of Lumbar Lordosis and Sagittal Balance in Minimally Invasive Adult Degenerative Scoliosis Surgery. Journal of Spinal Disorders and Techniques, 2014. 6 3/14/2016 PUSH THROUGH AND BEND INTO LORDOSIS EMERGING TRENDS: WHERE ARE WE GOING? 7 3/14/2016 16 Y/O FEMALE 56º 58.6º Coronal balance: 28 mm; Sagittal balance: -113 mm; PI=39.4; PT=0; SS=29; LL=43 POST MIS CORRECTION 24.2º 0º Coronal balance: 26mm; Sagittal balance: 0 mm PI=52.3; PT=24.4; SS=26.1 LL=30.9 PLANNING • SURGIMAP EOS 8 3/14/2016 PLANNING GOAL: EMERGING TRENDS • All deformity correction performed through MIS technique! THANK YOU 9
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