Minimally Invasive Spine. Surgery For Your Patients. 1. Lukas P. Zebala, M.D..
Assistant Professor. Orthopaedic and Neurological Spine Surgery. Department of
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Minimally Invasive Spine Surgery For Your Patients Lukas P. Zebala, M.D. Assistant Professor Orthopaedic and Neurological Spine Surgery Department of Orthopaedic Surgery Washington University School of Medicine St. Louis, Missouri
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Agenda • Review of relevant Spinal Anatomy and Pathologies • Overview of MIS Surgical Techniques • Clinical Outcomes • Questions
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Anatomy
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Common Spinal Pathology • Degenerative Disc Disease (DDD) • Occurs naturally as we age • Symptomatic in some patients • Disc Herniation • “slipped” or “ruptured” disc • Protrusion of IVD from inner core 4
Common Spinal Pathology • Spondylolisthesis • Slippage of one vertebra on vertebra below • Degenerative (L4-L5) • Isthmic (L5-S1)
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Common Spinal Pathology • Spinal Stenosis • Spinal canal narrowing that results in pressure on spinal cord, cauda equina or nerves
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Common Spinal Pathology • Facet Joint Osteoarthritis • Degradation of cartillage • Back pain, nerve compression
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Nonoperative Treatment • • • • • • • •
Physical Therapy NSAIDs Steroids Pain Medication Chiropractic care Acupuncture Bracing Behavior Modification 8
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Minimally Invasive Surgical Techniques • MIS can treat disease throughout the spine: • DDD • Disc Herniation • Stenosis • Spondylolisthesis • Scoliosis/Degenerative Deformity • Trauma • Tumor 9
MIS Surgery Goal • The goal of minimally invasive surgery is to accomplish the same clinical outcomes as traditional, open surgery through a less traumatic approach
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MIS Surgical Candidates • Patients with clinical symptoms in accordance with preoperative imaging • Failed course on nonoperative treatment • Any Age • MIS may be of benefit in elderly • Any Activity Level
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MIS Procedures • MIS techniques can be applied to cervical, thoracic, and lumbar procedures • Decompression • Discectomy, foraminotomy, laminectomy • Fusion • Instrumentation, bone grafting 12
Why Choose MIS Surgery • Potential Benefits: • Less invasive surgery • Less soft tissue injury/disruption of normal structures • Shorter hospital stay1 • Less blood loss2 • Earlier ambulation3 • Less post-op medication use4 1,2 Fessler
R, Khoo L. Minimally Invasive Cervical Microendoscopic Foraminotomy: An Initial Clinical Experience. Neurosurgery. 51: 37-45, 2002. 3 Park, Won Ha. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. SPINE 32(5):537-543, 2007. 4 Isaacs. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, 13 2005. 4 Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: 146-154, 2002.
MIS Surgery Risks • Same potential complications as with conventional open spine surgery • Neural injury, infection, nonunion, dural tears • Learning Curve • Initial longer operative times • Technique complications 14
Why MIS Old Approach
New Technology
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MIS Surgery Keys • Image Guidance • Live x-ray or state of the art navigation • Muscle Dilation • Work between natural muscle planes, not cut or strip muscle • Specialized Instruments • Allow for safe techniques through smaller operative windows • Microscope Assistance 16 • Magnification - Safer
MIS Surgery Basics • Soft tissue dilators are used to create a working channel through the musculature
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MIS Surgery Basics • Patient specific tubular retractor is docked onto the area of interest • Working portal
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MIS Discectomy
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MIS Discectomy
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MIS Decompression • Discectomy • Foraminotomy • Laminectomy
• Remove pressure from neural structure
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MIS Posterior Fusion / Instrumentation • Fusion Added: • Instability • DDD • Spondylolisthesis • Scoliosis • Iatrogenic • Posterior 22
MIS Lateral Approach • Spine is approached from the side • Avoid major anterior or posterior structures
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MIS Lateral Fusion / Decompression 1 2 3
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MIS Lateral Fusion / Decompression
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MIS Lateral Fusion / Decompression
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MIS Instrumentation
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Case 1 • 53 yo Female • Back pain and left leg L4/L5 radiculopathy • Failed nonop tx
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Case 1
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Case 1 • Walking POD#1 • Off IV Pain Meds POD#1 • D/C home POD #2
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Case 2 • 63-year-old with 2 year history of low back pain, some leg pain • Loss of disc height • Loss of normal lordosis • Coronal instability
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Case 2
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Case 3 • 30 yo male • High speed MVC • T9 fracture dislocation • Complete SCI • Multiple other injuries 33
Case 3
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Postoperative Protocol • MIS Discectomy/Decompression • Usually home on day of surgery or POD#1 • Activity as tolerated (limit lumbar bending/twisting) • PO pain meds/muscle relaxers • MIS Fusion/Instrumentation • Hospital stay 2-5 days • Activity as tolerated (limit lumbar bending/twisting) • PO pain meds/muscle relaxers 35
Clinical Outcomes MIS Decompression Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: 146-154, 2002. • • •
N = 50 MIS laminotomy vs. open decompression MIS data prospective, open decompression data retrospective.
• Perioperative benefits demonstrated in minimally invasive group • Difference in clinical outcomes did not achieve statistical significance
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Clinical Outcomes MIS TLIF Isaacs. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, 2005.
Perioperative Data
Open
Minimally Invasive
Blood loss
1147 ml
226 ml
Length of hospital stay
5.1 days
3.4 days
Post-op narcotic use (in morphine sulfate equivalent units*)
49.5 units/day
37.5 units/day
Operative time
4.6 hours
5 hours
1 p=.001, 2p=.02, 3 p= .015 *Narcotic usage between patients was normalized to morphine sulfate equivalents.
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Clinical Outcomes MIS TLIF • • •
Scheufler. Percutaneous Transforaminal Lumbar Interbody Fusion for the Treatment of Degenerative Lumbar Instability. Neurosurgery:203-213, 2007. MIS TLIF (n=43) vs. Wiltse (open) approach (n=67). Mid-term functional outcomes at 8 and 16 months after surgery were equivalent for 2 groups Percutaneous group results: • •
Lower intraoperative blood loss Less post-op analgesic use while in hospital
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Clinical Outcomes MIS Lateral Knight, et al. Direct Lateral Lumbar Interbody Fusion for Degenerative Conditions Early Complication Profile. J Spinal Disord Tech. Feb, 2009.
• Major adverse events approximated 8.6% with approachrelated complaints of nerve irritation nearing 3.4%. • Minimally invasive approach minimized blood loss, as compared to historical open cohort
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Thank You!
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