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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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