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Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
Minimally Invasive Spine Surgery Overview
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Minimally Invasive Spine Surgery Overview

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  • 1. Minimally Invasive Spine Surgery (MIS) Title Practice Name Location
  • 2. Section 1: Minimally Invasive Spine Surgery Minimally Invasive Transforaminal Interbody Fusion
  • 3. The Dimensions of Back Pain
    • More than 65 million Americans annually suffer from lower back pain
    • Third most-frequent reason for surgery overall
    • Approximately 250,000 lumbar spinal fusions performed
    • Approximately 400,000 lumbar spinal decompression procedures performed
  • 4. Minimally Invasive Surgery: A Breakthrough Innovation
    • Potential advantages compared with “open” surgery
    • May result in
      • Smaller incisions and scars
      • Minimal soft-tissue destruction and scarring
      • Less surgical blood loss
      • Shorter hospital stay
      • Less postoperative pain
      • Less need for postoperative pain medicine
      • Faster return to work and daily activities
  • 5. Minimally Invasive Techniques
    • Other common minimally invasive surgeries
    • Gall bladder removal
    • Appendectomy
    • Bariatric surgery
    • Total hip replacement
  • 6. Section 2: Technique Overview Minimally Invasive Transforaminal Interbody Fusion
  • 7. Patient Positioning
    • With patient in prone position, incision is made, and sequential dilation begins
  • 8. Dilator Insertion
    • Retractor depth is measured using indices on the side of the dilator
  • 9. Retractor Insertion
    • With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators
  • 10. Retractor Positioning
    • With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure
  • 11. Retractor Expansion
    • Retractor is expanded to visualize anatomy
  • 12. Spine Visualization
    • Curved racks increase visualization distally while limiting the exposure at the skin surface
  • 13. Telescoping Blade Adjustment
    • Telescoping blades are adjusted to prevent muscle creep that can obstruct view
  • 14. Facetectomy and Annulotomy
    • Facetectomy and annulotomy are then performed to gain access to the disc space
    • Complete discectomy is performed, and the vertebral body endplates are prepared
  • 15. Trial Insertion
    • Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue
  • 16. Spacer Insertion
    • Spacer is loaded onto inserter and inserted
    • If necessary, nerve root or dural retractors can be used
  • 17. Spacer Positioning
    • The inserter is disengaged from spacer and removed
    • Spacer is positioned across the midline at roughly 35°, and then autograft is packed around the spacer
  • 18. Screw and Rod Insertion Mark Screw Entry Points
    • Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points
  • 19. Pedicle Preparation
    • Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle
  • 20. Dilator Placement
    • Dilators are placed over the guide wire to prepare for appropriately sized tap
    • The pedicles are then tapped to prepare for screw placement
  • 21. Screw Insertion
    • Screw and screw-extension assemblies are percutaneously inserted into the pedicles
  • 22. Patient Positioning
    • With patient in prone position, incision is made, and sequential dilation begins
  • 23. Dilator Insertion
    • Retractor depth is measured using indices on the side of the dilator
  • 24. Retractor Insertion
    • With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators
  • 25. Retractor Positioning
    • With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure
  • 26. Retractor Expansion
    • Retractor is expanded to visualize anatomy
  • 27. Spine Visualization
    • Curved racks increase visualization distally while limiting the exposure at the skin surface
  • 28. Telescoping Blade Adjustment
    • Telescoping blades are adjusted to prevent muscle creep that can obstruct view
  • 29. Facetectomy and Annulotomy
    • Facetectomy and annulotomy are then performed to gain access to the disc space
    • Complete discectomy is performed, and the vertebral body endplates are prepared
  • 30. Trial Insertion
    • Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue
  • 31. Spacer Insertion
    • Spacer is loaded onto inserter and inserted
    • If necessary, nerve root or dural retractors can be used
  • 32. Spacer Positioning
    • The inserter is disengaged from spacer and removed
    • Spacer is positioned across the midline at roughly 35°, and then autograft is packed around the spacer
  • 33. Screw and Rod Insertion Mark Screw Entry Points
    • Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points
  • 34. Pedicle Preparation
    • Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle
  • 35. Dilator Placement
    • Dilators are placed over the guide wire to prepare for appropriately sized tap
    • The pedicles are then tapped to prepare for screw placement
  • 36. Screw Insertion
    • Screw and screw-extension assemblies are percutaneously inserted into the pedicles
  • 37. Alignment of Screw Extensions
    • With screws placed at each level, the openings of screw extensions are aligned
    • Holder and assembly are now guided into place
  • 38. Rod Placement
    • Rod is driven downward and pivoted 90° into the bottom slot of the open screw extension
  • 39. Rod Holder Capturing Rod
    • Rod holder handle will then engage the proximal end of the closed screw extension
  • 40. Rod Holder Capturing Rod
    • Set screws are tightened, the rod holder is disengaged, and screw extensions are removed
    • Fluoroscopy confirms bilateral constructs
  • 41. Section 3: Case Studies Minimally Invasive Transforaminal Interbody Fusion
  • 42. Case Overview
    • 24-year-old woman presented with severe, persistent back pain with both flexion and extension
    • Right leg pain
    • Pars interarticularis injection improved pain
    Credit: Frank Shen, MD, University of Virginia
  • 43. Case Comments
    • Notice 6 lumbar vertebrae
    • Lateral x-ray reveals L6-S1 spondylolysis—also an S1-S2 spondylolysis
    • Slight lumbar scoliosis
    1 2 3 4 5 6
  • 44. Preoperative Planning
    • Preoperative planning for percutaneous pedicle screw placement is critical
  • 45. Entry Point
    • Entry point for pedicle screws and transforaminal lumbar interbody fusion (TLIF) access are carefully planned using x-ray images
    • MIS PIPELINE™ Expandable Retractor for TLIFs should be placed over the facet complex, spanning pedicle to pedicle
  • 46. MIS Spine Fusion Requires Accurate Fluoroscopic Imaging
  • 47. Retractor Positioning
    • PIPELINE Expandable Retractor is positioned to perform the facetectomy and access the disc space
    • The retractor can then be opened to provide increased visualization
  • 48. Preparing the Disc Space for Fusion
    • Once desired access is achieved, minimally invasive instruments are used to prepare the disc space for spinal fusion
  • 49. Screw Insertion
    • To minimize motion, the vertebral bodies must be secured with a screw and rod construct
    • Screws are then inserted into the pedicle through the existing incision
    • Two separate stab incisions are used contralaterally
  • 50. Screw Position
    • Screws are carefully inserted into the densest part of the vertebral body, the pedicle
    • Screw position is confirmed by x-ray images
  • 51. Rod Insertion
    • The appropriate rod length is measured
    • The rod is then inserted through the same small incision used to place the screws
  • 52. Segment Immobilized
    • The rod is then locked down into the pedicle screw heads, and screw extensions are disengaged
    • The segment is now immobilized securely
  • 53. TLIF/VIPER™
    • This shows a completed right-sided minimally invasive TLIF with decompression of roots
    • The segment was then secured by bilateral percutaneous placement of the VIPER pedicle fixation system
  • 54. Section 4: Patient Selection Minimally Invasive Transforaminal Interbody Fusion
  • 55. Candidate Criteria
    • Not appropriate for everyone
    • Only for patients who have the right indications and have exhausted conservative therapies
      • Bed rest
      • Muscle relaxants
      • Physical therapy
      • Prescription pain relievers
  • 56. Candidate Criteria
    • Commonly used for
      • Decompressions (microdiscectomy and laminectomy)
      • 1- and 2-level lumbar fusions Degenerative Disc Disease: low-grade, spondylolisthesis, recurrent discectomy)
    • Follows a full diagnostic review and primary care physician consultation
  • 57. The VIPER System Indications
    • The VIPER System was cleared under the EXPEDIUM Family for the following indications:
    • The VIPER System is intended for noncervical pedicle fixation for the following
    • indications: degenerative disc disease (defined by back pain of discogenic origin
    • with degeneration of the disc confirmed by history and radiographic studies);
    • spondylolisthesis; trauma (ie, fracture or dislocation); spinal stenosis; curvatures
    • (ie, scoliosis, kyphosis, and/or lordosis); tumor; pseudoarthrosis; and failed
    • previous fusion in skeletally mature patients. When used in a percutaneous,
    • posterior approach with MIS instrumentation, the VIPER System screw
    • components are intended for noncervical pedicle fixation and nonpedicle
    • fixation for the following indications: degenerative disc disease (defined by back
    • pain of discogenic origin with degeneration of the disc confirmed by history and
    • radiographic studies); spondylolisthesis; trauma (ie, fracture or dislocation);
    • spinal stenosis; curvatures (ie, scoliosis, kyphosis, and/or lordosis); tumor;
    • pseudoarthrosis; and failed previous fusion in skeletally mature patients.
  • 58. THANK YOU. QUESTIONS?
    • This information has been supplied for educational purposes courtesy of DePuy Spine, Inc.
    • DEPUY SPINE, DePuy Spine logo, the MIS logo, PIPELINE, VIPER, and PIPELINE Expandable Retractor are trademarks of DePuy Spine, Inc.
    • ©2007 DePuy Spine, Inc. All rights reserved.
    • REFERENCES
    • Wilson DH, Harbaugh R. Microsurgical and standard removal of the protruded lumbar disc: a comparative study. Neurosurgery . 1981;8:422-427.
    • Kambin P. Posterolateral percutaneous lumbar discectomy and decompression: arthroscopic microdiscectomy. In: Kambin P, ed. Arthroscopic microdiscectomy: minimal intervention in spinal surgery. Baltimore, Md: Urban & Schwarzenberg; 1991:67-100.
    • Koebbe CJ, Perez-Cruet MJ. Lumbar microdiscectomy. In: Perez-Cruet MJ, Fessler RG, eds. Outpatient spinal surgery. St. Louis, Mo: Quality Medical Publishing, Inc; 2002:133-157.
    • Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg . 1999;81:958-965.
  • 59.  

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