5 4 16 Lumbar Spine Syllabus

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MIS Spinal Surgery
- Where Are we?
Roger Härtl, MD
Professor of Neurosurgery
Director of Spinal Surgery
Department of Neurosurgery
Weill Cornell Medical College
New York, NY
USA

Four pillars of Minimally Invasive
Spinal Surgery
Access:
Percutaneous
Mini-Open
Navigation:
2D
3D

Microsurgery:
Microscope
Endoscope

Instrumentation:
percutaneous
Mini-open

MIS Spine
• A procedure that by virtue of the
extent and means of surgical
techniques results in …
– less collateral tissue damage,
– measurable decrease in morbidity and
– more rapid functional recovery than
traditional exposures,
– without differentiation in the intended
surgical goal
• McAfee PC, Phillips FM, Andersson G, et al. (2010) Minimally invasive spine
surgery. Spine

1

MIS Spine: Where are we?
• “Targeted MIS” based on clinical
presentation and radiology findings
– Treat pathology
– Minimize overtreatment
– “Surgical Strike” vs. “Carpet Bombing”

• MIS technique principles
– Contralateral decompression
– Minimize iatrogenic instability
– Indirect decompression

• Minimize fusion need
• “Total Navigation”

MIS Principles
• Avoid muscle injury by …
»Muscle splitting self-retaining
retractors
» Limiting the width of the surgical
corridor
» Using known anatomic
neurovascular and muscle planes

• Do not disrupt tendon attachment of
key muscles, particularly at the
spinous process

HAE-DONG JHO, MD, PHD

2

The (cool) tools we use in MIS surgery…
• Tubes
• Microscopes /
Endoscopes
• 3D Navigation
System “GPS of
the Spine”
• Implants

• Sorry…no lasers !

Anterior and Posterior MIS Approaches

Spinal MIS
• Three Principles of Spinal MIS:
1. Contralateral Decompression
2. Minimize Instability
3. Indirect Decompression

3

1. Principle
• Contralateral Decompression:
– You can perform a bilateral
decompression and a contralateral
foraminotomy through a unilateral
minimally invasive approach

Bilateral Decompression via
Unilateral Approach

1997

1997

4

• 1998
“Essentials
of Spinal
Microsurgery” 1998

Foley 1997

5

6

7

8

9

MIS Tubular Laminectomy
(Laminotomy)
• Class III evidence
– Faster recovery
• Mobility
• Return to work

– Improved perioperative clinical outcomes
• EBL, LOS

– Equivalent patient reported long term
outcomes
– Decreased hospital cost/societal cost

10

Contralateral Decompression

81 y/o M with left L4
radiculopathy

L4/5

11

12

13

• Patients presenting with
unilateral radicular pain
• 32 patients / 44 levels
• Mean age: 64
• Median EBL: 10 (0 ; 200)
• Median length of stay: 1 (0 ;
5)
• Mean clinical follow-up:
12.3 +/- 1.7 months

14

Clinical outcome

*

*

* P < 0.05 vs. preoperative value

Next Steps

1. Principle
• Contralateral decompression:
– You can perform a bilateral
decompression and a contralateral
foraminotomy through a unilateral
minimally invasive approach

15

2. Principle
• Minimalize Instability:
– Minimally invasive spinal
decompression can reduce
iatrogenic instability and reduce the
need for instrumentation and fusion

Decompression or Decompression
/ Fusion ?
60 y/o F with stenosis & Grade I Spondylolisthesis

?
Also more recent: Kornblum, et.al.
Spine 2008

16

62 y/o F with stenosis
& Grade I Spondylolisthesis

•
•
•
•

110 patients
Mean F/U > 2 years
54% spondylolisthesis
Reoperation & fusion: 3.5%
VS.
35.7% at 3 years in 58 patients with
spondylolisthesis

Routine Fusion is not indicated in
all patients with LSS and
•
spondylolisthesis
–

Blumenthal et al.

17

• 37 studies
• 1156 patients
• In LSS associated with DS:
– MIS laminotomy is associated with
• lower reoperation and fusion rates
• less slip progression and
• greater patient satisfaction than open
surgery

18

MIS = “Minimally
Invasive Spine Surgery”
…or…

“Minimal
Instrumentation
Surgery”

Case Example: Spinal stenosis
and facet joint cyst
• 65 y/o M with
leg pain and
neurogenic
claudication
• Failed PT and
epidural
steroid
injections

19

Safer resection from
contralateral side
No fusion

(J Spinal Disord Tech 2011;00:000–000)

“Tubology” Approach
Pearls
• Foraminal stenosis with radiculopathy
– Contralateral approach

• Central stenosis with neurogenic claudication
–
–
–
–

Right-sided approach for right-handed surgeon
Left-sided approach for left-handed surgeon
1-2 levels: one incision
3-4 levels: “slalom” technique

• Lateral recess stenosis
– approach as above

• Unilateral disc herniation
– ipsilateral approach

• Synovial cyst
– Contralateral approach

Laminectomy adjacent to L4/5 Fusion

MIS laminectomy causes less
L3
instability than open laminectomy
L3

L3/4 MIS
laminectomy

Flexion / Extension

L3/4 Open
Laminectomy
Flexion / Extension

20

MIS decompression
instead of fusion…
1. Lumbar spinal stenosis with
stable spondylolisthesis
2. Unilateral foraminal stenosis
3. Lumbar stenosis adjacent to a
level that requires fusion

MIS = “Minimally
Invasive Spine Surgery”
…or…

“Minimal
Instrumentation
Surgery”

1. Principle
• Contralateral decompression:
– You can perform a bilateral
decompression and a contralateral
foraminotomy through a unilateral
minimally invasive approach

21

2. Principle
• Minimalize Instability:
– Minimally invasive spinal
decompression can reduce
iatrogenic instability and reduce the
need for instrumentation and fusion

3. Principle
• Indirect decompression:
– Minimally invasive spinal surgery
allows indirect decompression of
central and foraminal stenosis in
selected patients

22

Lateral access / Transpsoas
Surgery / ELIF / XLIF

Indirect
Decompression

Indirect Decompression

23

67 y/o Male with right L3/4
radicular pain, minimal back pain

Right L3/L4 Foraminal Stenosis
Right side

3

4

Left side

3
3
4
4

L3/L4

24

Indirect
Decompression

L3 Nerve

15 months postoperative

15 months postoperative
Right side

Left side

3

4

25

Pre vs. 15 months postoperative
L3/L4

• 23 patients with unilateral leg pain
and forminal stenosis
• 1 year follow – up
• Single-level XLIF is an effective
procedure for unilateral foraminal
stenosis & radiculopathy

26

Foraminal Height and
Leg Pain

LIMITATIONs of MIS

27

Intraoperative 3D CT Navigation

28

“TOTAL” Navigation
We eliminate fluoroscopy in 70% of our cases
 Skin incision
 Screw size and planning (no K-wires)
 Screw placement
 Tubular retractor placement
 Decompression
 Cage placement
 Rod measurement
 Final CT check
• Other indications  localization
– Cervical forminotomies
– Spinal tumor
– Thoracic disc herniations

MIS Spine: Where are we?
• “Targeted MIS” based on clinical
presentation and radiology findings
– Treat pathology
– Minimize overtreatment
– “Surgical Strike” vs. “Carpet Bombing”

• MIS technique principles
– Contralateral decompression
– Minimize iatrogenic instability
– Indirect decompression

• Minimize fusion need
• “Total Navigation”

29

MIS course December 2016
Hands-on Symposium
Check “cornellneurosurgery.org” this fall

30

Types of back pain
• Neurogenic claudication
– Lumbar stenosis

• Radicular pain
– Lateral recess
– Disc herniation
– Foraminal stenosis

• Mechanical back pain
– Instability
– Facets
– imbalance

31

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Minimally Invasive
Thoracic Decompressions

Larry T. Khoo, MD
The Spine Clinic of Los Angeles
At Good Sam aritan Hospital
An Affiliate of the University of Southern California

DISCLOSURES OF CONFLICT
Major: Zimmer, Globus, Spineguard, Medacta
Minor: Aesculap, Mallincrodt

Case Presentation
Surgical Technique
 58 yo RH physician

 Sudden onset of thoracic pain
 No history of trauma
 6 wk history of progressive gait sx

 Bladder incontinence
 Rt sided trunk / leg numbness
 3+ DTR, ataxia, dec rectal tone

 8/10 mid thoracic pain

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5/4/2016

Ventrolateral
Approaches
• Advantages
– Ventrolateral exposure of
disc space and ventral
spinal canal
– Midline, densely calcified
discs and intradural
fragments
– Ventral dural repairs and
reconstruction
– Multiple discs

Thoracotomy - Disadvantages
 Approach morbidity of 14% in large

multicenter study (Spine 1995),
n=770
 Post thoracotomy syndrome

 Abdominal relaxation
 Poor cosmesis & rib defomity

 High overall morbidity (24%):
 wound infection, radiculopathy, aortic laceration,

Horner’ s syndrome, pleural effusion,
pneumothorax, hemothorax, chylothorax, brachial
plexus injury, lung herniation, renal failure, sepsis,
pneumocephalus and chronic pain

Minimally Invasive Extracavitary Thoracic
Discectomy and Fusion (MI-ECTDF)
• Provides good angle
of decompression
• Decreased Neural
Retraction
• Combine with
minimally invasive
technologies and
principles

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Oblique docking of the
portal on lateral facet

Drilling of Lateral Facet Complex

Skeletonize the superior aspect
of the pedicle & transverse process

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Discectomy with
minimal retraction of
the spinal cord

Insertion of Soft PLIF material, followed
by interbody cage (to prevent pain and
recurrence)

Postop Course
 OR time 2 hours

 EBL 25cc
 Full motor recovery
 Residual mild rt numbness

 Bladder issues resolved
 24 month followup
 No further back pain

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5/4/2016

MS# 09' 456 author proof
Disclosure

Not for Reprint

DOI: 10.3171/2010.10.SPINE09456

Journal of Neurosurgery Spine: Jan 2011

Clinical article
LARRY T. K HOO, M.D.,1 ZACHARY A. SMITH, M.D.,1 FARBOD ASGARZADIE, M.D.,1
YORGIOS BARLAS, M.D., 2 SEAN S. A RMIN, M.D., 3 VARTAN TASHJIAN, M.D.,1
AND BARON ZARATE, M.D. 4
Department of Neurological Surgery, University of California, Los Angeles, California; 2Department of
Neurological Surgery, General Hospital of Nikea, Athens, Greece; 3Department of Neurosurgery, Loma Linda
University, Loma Linda, California; and 4Department of Spinal Surgery, Institucion Nacional de
Rehabilitation, Mexico City, Mexico
1

Object.
Methods.
-

Results.

Conclusions.
(DOI: 10.3171/2010.10.SPINE09456)

KEY WORDS

T

HORACIC
4

-

31

29

-

Abbreviations used in this paper:

-

Not for Reprint

J Neurosurg: Spine / Month Day, 2010

1

Patients & Methods

 Prospective, non-randomized study

 Class II / III study,Single surgical group
 All with cord compression / myelopathy
 Mean duration sx- 4.2 months
 Total of 24 patients, 1 year f/u
 Two arms:

11 – Open mini-thoracotomy
13 – Min Invasive EC-TDF

T2/3

(51.8 y, 4 men, 9 women)

1

Distribution of
Pathological
Herniated Discs

T3/4
T4/5
T5/6

1

T6/7
T7/8

(52.5y, 5 men, 6 women)

11

4

T8/9

2

T10/11
T11/12

5

22

T9/10

1

3

2

11 single, 2 two levels – MI-ECTDF
10 single , 1 two levels – OPEN
 Very similar co-morbidity index

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5/4/2016

Operative data

Fusion

93%
91%
3.00

Stay (days)

EBL (dl)

OR Time
(hrs)

5.80
0.33

MI-ECTDF

2.95

Open

1.55
2.92
Summary

Complications
MI-ECTDF





CSF leaks
Radicular Numbness
Trunk wall weakness
Trunk wall hyperesth

 Wound Infection

Open

1
1
1
1

3
9
6
4

1

3

Peri-operative Course
( 4.2x risk ratio, p<.01)

MI-ECTDF











Chest Tube Drainage
Early Wound Infection
Pts in ICU postop
Transfusion
Pneumonia
Urinary Tract Infect
DVT
Cardiac Events
Hematoma
Prolonged Ileus

0
0
0
0
0
1
1
1
0
0

Open
11 (1.5d)
2
7 (1.25d)
4
3
4
3
2
1
2

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5/4/2016

Results –Pain Outcomes

Morphine
equivalents

100
80
60
40
20
0

99
54
41

17

1

2

3

4

5

6

7

Postop overall
VAS decrease
6wk
3mo
6mo
1yr

100%
91%
80%
60%

MI-ECTDF
Open

60%

40%

27%

20%
5%

0%

MI-ECTDF

Open

Neurological
Outcomes
(p<.05)
11
12
10
8
6

2

0

Pre-MIS
Postop

4
5

4

2

1

0

3

0

0
8

Frankel A

C

E

7
6
5

2
1
0 0

5

3

4
3

8

3

Pre-Open Postop

1

0
Frankel A

2

0
C

E

Conclusions
At 1 year followup, Mi-ECTDF has
become the standard approach in our
armamentarium for paracentral and soft
midline thoracic herniated discs causing
spinal cord compression and myelopathy
for the following reasons:
– Improved operative time + blood loss (p<.01)

– Improved perioperative complications (p<.01)
– Improved 6 wk, 3, 6 mo pain scores (p<.01)
– Equivalent neurological outcomes

(p<.01)

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5/4/2016

MIS Posterior
Thoracic
Extracavitary
Corpectomies

J Neurosurgery Spine: December 2011 (accepted
pending)

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83 yo frail Asian Male
4 month h/o upper back pain
10 day history of Acute BLE

paraplegia in legs 1/5 strength,
loss of bowel bladder control,
T9 sensory level with
numbness below-

BONE SCAN T4/5 LESION
TB PPD / PCR: + TB

T4/5 Pathological Fracture-Dislocation
3 Col Injury-CT, kyphotic angulation

42o

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T2,3 to T6,7 MIS mini-open pedicle screws; Placed
5.5mm x 35mm screws in right T2,3 and T6,7
pedicles. Then nitinol wires only after prepared
pedicles on left T2,3,6,7 pedicles.

Placed expandable type mini-open
multiblade retractor for MIS approach to left
sided T4 and T5.

10

5/4/2016

42
to
28o

Neuro unchanged 1/5 BLE strength. Surgery length 4 hrs 30
minutes, ebl 450cc. No csf leak. Chest tube placed. POD #4
LLE 4-/5, RLE 2/5 proximally and 3/5 distally

THE FAR LATERAL POSTERIOR
EXTRACAVITARY APPROACH
CORRIDOR
• Provides good angle of
decompression
• Decreased Neural
Retraction
• Key is actual an OBLIQUE
approach to the anterior
spine
• Combine with minimally
invasive technologies and
principles

11

5/4/2016

THANK YOU

Larry T. Khoo, MD
The Spine Clinic of Los Angeles
At Good Sam aritan Hospital
An Affiliate of the University of Southern California

12

5/3/2016

Indications and Techniques for
Minimally Invasive Cervical
Laminoforaminotomy using a
Tubular Retractor
Kevin T. Foley, M.D.
Professor of Neurosurgery, Orthopaedic Surgery, & Biomedical
Engineering
Semmes-Murphey Clinic & University of Tennessee Health
Science Center, Memphis

Disclosures
Consultant to Medtronic
 Royalties from Medtronic
 BOD member and stockholder for
BioD, Discgenics, & TrueVision
 Ownership (stock) in Medtronic,
NuVasive, and SpineWave


History
Historically, surgery for cervical
radiculopathy was posterior.




Stookey B. Compression of the spinal cord due to ventral
extradural cervical chordomas: diagnosis and surgical treatment.
Arch Neurol Psychiat 1928; 20: 279-291
Semmes RE. Diagnosis of ruptured intervertebral disk without
contrast myelography and comment on recent experience with
modified hemilaminectomy for their removal. Yale J Biol & Med
1939; 11: 433-435.

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5/3/2016

Posterior Cervical Discectomy
Indications
Cervical radiculopathy recalcitrant to
nonoperative management
 Disc herniation, osteophyte, or
foraminal stenosis producing nerve
root compression that correlates with
the patient’s clinical presentation
 No evidence of instability


Posterior Cervical
Foraminotomy

PCF

2

5/3/2016

Posterior Cervical Discectomy
Contra-indications
Central compressive lesion (disc
and/or osteophyte)
 Ventral spinal cord compression
 Cervical spine instability
 Significant mechanical neck pain


Advantages: Posterior vs.
Anterior


Maintain functional motion segment
– Minimize adjacent level disc degeneration

Excellent visualization of nerve root
 Avoid certain anterior complications


– Recurrent laryngeal nerve injury, Horner’s

syndrome, esophageal injury, carotid injury,
graft-related complications


Avoid post-op neck immobilization

3

5/3/2016

Disadvantages: Posterior
vs. Anterior


Post-op incisional neck pain
Unable to address central disc/osteophyte



Need for neural retraction



– Pre-op MRI or CT-myelogram to exclude
– Can minimize

Positioning a bit more cumbersome
 Risk of instability?
 Risk of recurrence?


Instability After Posterior Cervical
Discectomy/Foraminotomy
Rare
 Chen BH et al. Comparison of biomechanical
response to surgical procedures used for
cervical radiculopathy: Posterior keyhole
foraminotomy vs. anterior foraminotomy and
discectomy vs. anterior discectomy with fusion.
J Spinal Disorders 2001; 14(1): 17-20


– “minor” increase in motion over normal spine

Recurrent HNP After Posterior
Cervical Discectomy/Foraminotomy



Rare
1/2032 patients in Collias’ and Roberts’
series (.05%)
– Collias JC, Roberts MP. Posterior surgical

approaches for cervical disk herniation and
spondylotic myelopathy. In:Schmidek HH, ed.
Operative Neurosurgical Techniques:
Indications, Methods, and Results,
Philadelphia: W.B. Saunders, 2000: 20162028.

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Results


Murphey F, Simmons J, Brunson B.
Ruptured cervical discs: 1939 to 1972.
Clin Neurosurg 1973; 20: 9-17.
– Hemilaminectomy & discectomy, prone
– 648 patients,96% good/excellent results
– 1% recurrence rate



“The results of this operation are better
than those of any other operation in
neurosurgery”

Minimally Invasive
Posterior Cervical
Discectomy/Foraminotomy
Extension of the “classical” open technique
 Operation is identical except for approach
 Minimally invasive approach via tubular
retractor minimizes post-op pain
 Can be routinely performed on an
outpatient basis


Minimally Invasive
Microdiscectomy Surgical Technique
Dilators

Introducer Set
Flexible Arm
Assembly

9.4 mm
5.3 mm
GuideWire
.062 x 12”

5

5/3/2016

Minimally Invasive Posterior
Cervical Discectomy


Prone or sitting position
– Reverse Trendelenberg if prone

Fluoroscopic localization—use AP if
shoulders block lateral view
 Incision 1.5 cm lateral to midline
 NO K-WIRE! Perforate fascia with sharp
iris scissors, spread fascia bluntly with
Metzenbaum’s
 14mm or 16mm diameter tube


6

5/3/2016

7

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8

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9

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Tubular Retractor: Minimally Invasive
Posterior Cervical Discectomy Results










100 consecutive patients with cervical
radiculopathy
Decompression via tubular retractor (MED)
D/C 3 hours post-surgery
Mean F/U 14.8 months
91 excellent, 6 good, 2 fair, 1 poor (re-op at 18
months)
Return to work and/or full baseline activity 1 day
to 4 weeks (mean 1.9 weeks) post-op

Adamson TE: Microendoscopic posterior cervical laminoforaminotomy for unilateral radiculopathy:
TE,
J Neurosurg
(Spine)
95:51-57,
2001
results of a newAdamson
technique in 100
cases,
J Neurosurg (Spine
1) 95:51–57,
2001

Tubular Retractor: Minimally Invasive
Posterior Cervical Discectomy Results











222 consecutive patients with cervical
radiculopathy, mean F/U 26 months
Decompression via tubular retractor, prone position
Mean surgery time 63 minutes, mean EBL 71 cc
188 excellent, 22 good, 9 fair, 3 poor (all re-op with
ACDF)
LOS data for 191 patients - same day (167) or
overnight (24)
Complications: 1 infection, 2 dural tears
(Duragen/Tisseel)

Adamson TE: Microendoscopic posterior cervical laminoforaminotomy for unilateral radiculopathy:
results of a new technique in 100 cases, J Neurosurg (Spine 1) 95:51–57, 2001

Hilton DL, Spine Journal 7:154-158, 2007

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5/3/2016

Conclusions
Minimally invasive posterior cervical
discectomy/foraminotomy using a
tubular retractor is a safe and effective
procedure
 Minimally invasive approach allows for
routine outpatient surgery and quicker
RTW/activity than the conventional
open procedure


12



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