Minimally Invasive Spine Surgery Overview

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Minimally Invasive Spine Surgery Overview

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

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