5 4 16 Lumbar Spine Syllabus

2016-05-04

: Pdf 5 4 16 Lumbar Spine Syllabus 5_4_16_Lumbar_Spine_Syllabus 5 2016 pdf

Open the PDF directly: View PDF .
Page Count: 55

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

Navigation:

Access:

Percutaneous

Mini-Open

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

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

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

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

•1998

“Essentials of Spinal

Microsurgery” 1998

Foley 1997

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

Contralateral Decompression

81 y/o M with left L4

radiculopathy

L4/5

•Patients presenting with

unilateral radicular pain

•32 patients / 44 levels

•Mean age: 64

•Median EBL: 10 (0 ; 200)

•Median length of stay: 1 (0 ;

•Mean clinical follow-up:

12.3 +/- 1.7 months

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

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

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

–Blumenthal et al.

Routine Fusion is not indicated in

all patients with LSS and

spondylolisthesis

•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

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

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

Safer resection from

contralateral side

No fusion

“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

L3/4 MIS

laminectomy

Flexion / Extension

L3/4 Open

Laminectomy

Flexion / Extension

Laminectomy adjacent to L4/5 Fusion

MIS laminectomy causes less

instability than open laminectomy

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

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

Lateral access / Transpsoas

Surgery / ELIF / XLIF

Indirect

Decompression

Indirect Decompression

67 y/o Male with right L3/4

radicular pain, minimal back pain

Right L3/L4 Foraminal Stenosis

Right side Left side

L3/L4

Indirect

Decompression L3 Nerve

15 months postoperative

Right side

Left side

L3/L4

Pre vs. 15 months postoperative

•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

Foraminal Height and

Leg Pain

LIMITATIONs of MIS

Intraoperative 3D CT Navigation

“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”

MIS course December 2016

Hands-on Symposium

Check “cornellneurosurgery.org”this fall

Types of back pain

•Neurogenic claudication

–Lumbar stenosis

•Radicular pain

–Lateral recess

–Disc herniation

–Foraminal stenosis

•Mechanical back pain

–Instability

–Facets

–imbalance

5/4/2016

Larry T. Khoo, MD

The Spine Clinic of Los Angeles

At Good Samaritan Hospital

An Affiliate of the University of Southern California

Minimally Invasive

Thoracic Decompressions

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

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

•Provides good angle

of decompression

•Decreased Neural

Retraction

•Combine with

minimally invasive

technologies and

principles

Minimally Invasive Extracavitary Thoracic

Discectomy and Fusion (MI-ECTDF)

5/4/2016

Oblique docking of the

portal on lateral facet

Drilling of Lateral Facet Complex

Skeletonize the superior aspect

of the pedicle & transverse process

5/4/2016

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

5/4/2016

Journal of Neurosurgery Spine: Jan 2011

J Neurosurg: Spine / Month Day, 2010

DOI: 10.3171/2010.10.SPINE09456

THORACIC -

31 -

Clinical article

LARRY T. KHOO, M.D.,1 ZAC HARY A. SMITH, M.D.,1 FARBOD ASGARZADIE, M.D.,1

YORGIOS BARLAS, M.D.,2 SEAN S. ARMIN, M.D.,3 VARTAN TASHJIAN, M.D.,1

AND BARON ZARATE, M.D.4

1Department 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

Object. -

Methods. -

Results.

Conclusions. -

(DOI: 10.3171/2010.10.SPINE09456)

KEY WORDS

Abbreviations used in this paper:

MS# 09'456 author proof

Disclosure

Not for ReprintNot for Reprint

Not for Reprint

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 (52.5y, 5 men, 6 women)

13 –Min Invasive EC-TDF (51.8 y, 4 men, 9 women)

Distribution of

Pathological

Herniated Discs

11 single, 2 two levels –MI-ECTDF

10 single , 1 two levels –OPEN

Very similar co-morbidity index

T11/12

T10/11

T9/10

T8/9

T7/8

T6/7

T5/6

T4/5

T3/4

T2/3

5/4/2016

Operative data

OR Time

(hrs)

EBL (dl)

Stay (days)

Fusion

2.92

2.95

5.80

91%

1.55

0.33

3.00

93%

Summary

MI-ECTDF

Open

Complications

CSF leaks

Radicular Numbness

Trunk wall weakness

Trunk wall hyperesth

Wound Infection

MI-ECTDF Open

1 3

Peri-operative Course

( 4.2x risk ratio, p<.01)

Chest Tube Drainage

Early Wound Infection

Pts in ICU postop

Transfusion

Pneumonia

Urinary Tract Infect

DVT

Cardiac Events

Hematoma

Prolonged Ileus

MI-ECTDF Open

011 (1.5d)

07 (1.25d)

5/4/2016

100

Morphine

equivalents

1 2 3 4 5 6 7

MI-ECTDF

Open

Results –Pain Outcomes

20%

40%

60%

80%

100%

MI-ECTDF Open

60%

91%

27%

Postop overall

VAS decrease

6wk

3mo

6mo

1yr

Neurological Outcomes (p<.05)

Frankel A C E

0 0

Pre-MIS

Postop

Frankel A C E

0 0

Pre-Open Postop

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)

5/4/2016

MIS Posterior

Thoracic

Extracavitary

Corpectomies

J Neurosurgery Spine: December 2011 (accepted

pending)

5/4/2016

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

5/4/2016

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.

5/4/2016

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

28o

•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

THE FAR LATERAL POSTERIOR

EXTRACAVITARY APPROACH

CORRIDOR

5/4/2016

Larry T. Khoo, MD

THANK YOU

The Spine Clinic of Los Angeles

At Good Samaritan Hospital

An Affiliate of the University of Southern California

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.

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

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.

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

5/3/2016

Disadvantages: Posterior

vs. Anterior

Post-op incisional neck pain

Unable to address central disc/osteophyte

–Pre-op MRI or CT-myelogram to exclude

Need for neural retraction

–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: 2016-

2028.

5/3/2016

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

Introducer Set

Flexible Arm

Assembly

Dilators

GuideWire

.062 x 12”

9.4 mm

5.3 mm

Minimally Invasive

Microdiscectomy Surgical Technique

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

5/3/2016

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:

results of a new technique in 100 cases, J Neurosurg (Spine 1) 95:51–57, 2001

Tubular Retractor: Minimally Invasive

Posterior Cervical Discectomy Results

Adamson TE, J Neurosurg (Spine) 95:51-57, 2001

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

Tubular Retractor: Minimally Invasive

Posterior Cervical Discectomy Results

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

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

5 4 16 Lumbar Spine Syllabus

Navigation menu

Versions of this User Manual:

Views

Navigation