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Advances in spine surgery:
Endoscopic and minimally invasive spine surgery dr sandeep c agrawal www.drsandeepagrawal.com gondia maharashtra www.agrasenortho.com

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There are many different types of conditions that cause back pain. Like most medical conditions, back pain is treatable through several methodologies. Determining what condition you have is the key to determining the right treatment option for you. Back pain comes in many forms, lower back pain, middle back pain, and upper back pain are just a few of the symptoms associated with spinalconditions. You may also have pain or tingling in your extremities that may be indications of spinal conditions. Feel free to browse through our articles about conditions. Contact your doctor to set up an appointment to start your road to recovery.

Every person is different, so symptoms of conditions may present
differently for different people. Symptoms also vary depending on the
condition, its severity, location, and other factors.

Published in: Health & Medicine

Advances in spine surgery:
Endoscopic and minimally invasive spine surgery dr sandeep c agrawal www.drsandeepagrawal.com gondia maharashtra www.agrasenortho.com

  1. 1.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com 1 http://www.drsandeepagrawal.com/spine.php Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India ADVANCES IN SPINE SURGERY
 Endoscopic and Minimally Invasive Spine Surgery
  2. 2. 2 Understanding Back Pain Basics of Spine: " " http://www.slideshare.net/ sandeepcagrawal/understanding-back- pain-basics-of-spine-drsandeep-c- agrawal-agrasen-orthopedic-hospital- gondia-india
  3. 3.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com InterVertebral Disc
  4. 4.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com 4 Herniated disk in the lower back: " http://www.slideshare.net/SANDEEPAGRAWALORTHO/ herniated-disk-in-the-lower-back-agrasen-hospital-dr-sandeep- agrawal-gondia-vidarbha-maharashtra-india- wwwdrsandeepagrawalcom-wwwagrasenorthocom " " Sciatica low back pain : " http://www.slideshare.net/SANDEEPAGRAWALORTHO/ sciatica-low-back-pain-wwwdrsandeepagrawalcom-agrasen- hospital-dr-sandeep-agrawal-gondia-maharashtra- wwwagrasenorthocom-60232530 For Details click below links
  5. 5.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Degenerative Disc Disease
  6. 6.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Provocative Discogram
  7. 7. • Provocative discography (+) is the definite diagnosis of DDD • 90% patients will go on to complete pain relief within 2 to 6 weeks • NSAID and antispasmolytic medicine are effective in the management of acute back pain, but is unclear in chronic pain • Intradiskal electrothermotherapy (IDET) has been proposed as an option of the treatment • Lumbar fusion the surgical procedure of choice for the treatment of discogenic back pain with poor response to conservative treatment • Disc excision or decompression procedure are another recommended procedures in treating DDD • Successful fusion is obtained in 60% to 90% of patients who undergo posterior procedure, but clinical outcomes are satisfactory in only 40% to 70%.
  8. 8. • Posterior procedures – PLIF – TLIF • ALIF can remove pain fibers and receptors from the annulus fibrosus and nucleus pulposus, eliminate motion across disc, restore disc height and indirectly decompress neuroforamen, avoid posterior muscle disruption – Open – Laparoscopic ALIF
  9. 9.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com IntraDiscal ElectroThermotherapy ( IDET )
 For discogenic pain (axial pain)
  10. 10. Thermal energy: 65ºC for 17 minutes •Collagen shrinkage •Destruction of nociceptive fibers
  11. 11. Indications (Saal & Saal) • Axial pain > 6 months • Non-operative care at least 3 months • No psychosocial problems • SLRT (-) • Disc height: > 50% preserved • MRI: no compressive lession • Provocative discogram (+)
  12. 12.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  13. 13. Results of IDET! highly varied • 70% satisfied result Saal JA. Spine. 2000 • 50% were dissatisfied Davis TT. Spine. 2004 • Not effective Spruit M. Eur Spine J. 2002 • Potentially beneficial in carefully selected patients Biyani A. Spine. 2003 • Worthwhile in a small proportion of strictly defined patients Pauza KJ. Spine J. 2004
  14. 14. Complications • Discitis • Nerve root injury • Catheter breakage • Cauda equina syndrome
  15. 15. General Concept of IDET • IDET should be considered as “Experimental Procedure” • Maybe useful in highly selected patient
  16. 16. ALIF • Need for an access surgeon (NS) • Nonunion: 2nd procedure for fixation • Great vessels and peritoneal injury • Post-op retrograde ejaculation: 17-25%
  17. 17. PLIF • Advantages – Single approach – Prevent ALIF drawback • Drawbacks – Wide laminectomy – Aggressive retraction of thecal sac – Nerve root injury & dural fibrosis – Not good for upper lumbar spine
  18. 18. TLIF • Facetectomy and far-lateral approach • Preserve contralateral side • Minimize approach-related morbidity – Aggressive retraction of thecal sac – Retraction injury of nerve roots
  19. 19.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Traditional Surgery
  20. 20. Minimal Invasive Surgery • Less wound size • Less trauma ( physically and psychologically ) • Less surgical & anesthesia risk • Same-Day surgery or Less hospitalization • Early rehab & recovery • Less cost
  21. 21.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Endoscope Assisted TPS Instrumentation and Fusion
  22. 22. Challenges for Posterior Endoscopic Spinal Surgery • No physiologic potential space or tissue plane • Need to create a working space • Need to place hardware through small cannula
  23. 23.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  24. 24.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  25. 25.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Muscle-splitting approach: Interval between multifidus medially and the longissimus laterally
  26. 26.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  27. 27.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  28. 28.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  29. 29. HIVD with Sciatica
  30. 30. 1.Exploring sciatica & back pain : " http://www.slideshare.net/sandeepcagrawal/exploring-sciatica-back-pain-wwwdrsandeepagrawalcom- wwwagrasenorthocom-agrasen-hospital-gondia-vidarbha-dr-sandeep-c-agrawal-gondia-maharashtra " 2. PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc
 
 " http://www.slideshare.net/sandeepcagrawal/prolapse-disc-slip-disc-herniation-intervertebral-disc- agrasen-hospital-gondia-vidarbha-dr-sandeep-c-agrawal-wwwdrsandeepagrawalcom- wwwagrasenorthocom " 3. Discogenic low back pain Treatment: " http://www.slideshare.net/sandeepcagrawal/discogenic-low-back-pain-treatment-agrasen-hospital- gondia-vidarbha-dr-sandeep-c-agrawal-wwwdrsandeepagrawalcom-wwwagrasenorthocom 4. Radiculopathy(spine) Low back pain : " http://www.slideshare.net/SANDEEPAGRAWALORTHO/radiculopathyspine-low-back-pain- wwwdrsandeepagrawalcom-wwwagrasenorthocom-agrasen-hospital-gondia-vidarbha-dr-sandeep-c- agrawal-gondia-maharashtra For Details: Click below links
  31. 31. 31 Back pain and spine injections http://www.slideshare.net/SANDEEPAGRAWALORTHO/back- pain-and-spine-injections-wwwdrsandeepagrawalcom- wwwagrasenorthocom-agrasen-hospital-gondia-vidarbha-dr- sandeep-c-agrawal-gondia-60235593 For Details click below:
  32. 32.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Radiculogram & Nerve Block
  33. 33. Indications • Radicular pain resistant to other therapeutic means • Radicular pain for which operation is contraindicated
  34. 34. Contraindications • Infection • Disturbed consciousness • Bleeding tendency • Emotional instable • Lack of understanding of the procedure
  35. 35.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Needle Position
  36. 36.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com L4 Radiculogram
  37. 37.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Needle Position
  38. 38.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com L4, L5 Radiculogram
  39. 39. Results • 47% improved, 28% unchanged, 16% worse Tong HC. Spine J. 2003 • 84% success rate Vad VB. Spine. 2002 • 75.4% had a successful long-term outcome Lutz GE. Arch Phys Med Rehabil. 1998
  40. 40. • Persistent intractable pain> 6 weeks ! surgery • Disc herniation into stenotic cannal, patients can not comply with dictates of conservative regimen, numbers of csiatica episodes are also surgical indications • Absolute surgical indications are bladder and bowel involvement and progressive neurologic deficit • The laminotomy and diskectomy is the gold standard for surgical treatmentof posterolateral HIVD • Wiltse paraspinal approach is for extraforaminal HIVD • Endoscopic discectomy – PED – MED Surgical Treatment
  41. 41.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Percutaneous Endoscope Discectomy
  42. 42. Indication • Radicular pain • Positive root tension sign • Positive imaging study • Persisted symptom at least 6 weeks of proper conservative treatment
  43. 43.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  44. 44. PED Procedures (Marking)
  45. 45. PED Procedures (Discography)
  46. 46. PED Procedures (Local Anes.)
  47. 47. Endoscope-guide Discectomy
  48. 48. Endoscope-guide Discectomy
  49. 49. PED Procedures (Wound)
  50. 50. Results • Kambin: 88.2% Clin Orthop 1998! • Hermantin: 97% J Bone Joint Surg [Am] 1999! • Yeung AT: 81.4% Spine 2002! • Mayer HM: 3/20 re-op J Neurosurg 1993! • Kleinpeter G: 5 / 8 < 1 M shift to open ! Surg Neurol 1995
  51. 51. PELD Indications for good result • Soft disc content (CT) • Contained or not sequestrated (MRI) • Without spinal stenosis • Without instability • Young age (<40 Y/O) • Shorter S/S duration (3-6Ms)
  52. 52. Patient Selection
  53. 53. Patient Selection
  54. 54. Optimal Position Poor Good
  55. 55. Optimal Instruments Holmium Laser RF
  56. 56.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com MED
 ( MicroEndoscopic Discectomy )
  57. 57. MED
 (MicroEndoscopic Discectomy) –1997 , Smith & Foley •Minimal damage and Direct visualization by 
 Muscle-splitting dilators Endoscope and Video monitor
  58. 58. METRx System
  59. 59. Introducer Set
  60. 60. Instruments & Scope
  61. 61.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  62. 62. MED ( METRx System )
  63. 63. Scope Images Disc Lig. Flavum Lower edge of L4
  64. 64.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  65. 65.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com Wound Size ( 2cm)
  66. 66. Potential disadvantages • Learning curve • Limited visualization • Inadequate exposure • Incomplete decompression • Vessel & nerve damage • Limited ability to treat lateral recess and foraminal stenosis
  67. 67. Vertebral Compression Fracture • DETAILED PPT LINK: Percutaneous Vertebroplasty( SUTURELESS SURGERY ) and Osteoporotic Spinal Compression Fracture Treatment: " http://www.slideshare.net/sandeepcagrawal/ osteoporotic-compression-fracture-and- percutaneous-vertrebroplasty-drsandeep-c- agrawal-agrasen-hospital-gondia-maharashtra- india
  68. 68. Kyphoplasty SEE OTHER PPT LINK:
  69. 69. VATS • Same indications and goals as open • Advantages and disadvantages: as minimally invasive surgery • 6th intercostal space at midaxillary line • No need of CO2 insufflation • Technical demanding & learning curve
  70. 70. Applications • Infection • Biopsy • Debridement • Tumor excision • Disc excision • Corpectomy & Fusion • Deformity correction • Anterior release • Hemivertebtal excision • Internal thoracoplasty • Anterior fusion and instrumentation
  71. 71. Contraindications • Inability to tolerate one-lung ventilation • Severe or acute respiratory insufficiency • High airway pressure with positive pressure ventilation • Pleural symphysis • Bullous lung pathology • Empyema (relative) • Previous thoracotomy (relative) • Previous tube thoracotomy (relative) • Narrow A-P chest diameter (relative)
  72. 72. Complications • Same as open approach • Spinal cord injury or ischemia • Dural laceration • Intercostal neuralgia (21% patients) • Incomplete anterior release • Lung, diaphragm heart, thoracic duct, azygos vein, esophagus, sympathetic chain, segmental artery and splanchnic nerves injury by instruments
  73. 73. VATS
  74. 74.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  75. 75.  DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra  www.agrasenortho.com
  76. 76. Other Procedures • Anterior lumbar scope surgery – Transperitoneal approach (L4-5, L5-S1) – Retroperitoneal approach (T12 to S1) • Anterior thoracolumbar scope surgery
  77. 77. 78 Humor And Laughter Are Important! " Humor in our daily lives is an essential ingredient! of happiness. So, learn to look on the funny! side of things. Even serious situations. Have you had a good laugh today? ! If you haven't, then please do - don't! let the day go to waste! Laughter! melts the distances between people.
  78. 78. 79 This presentation is for  doctors and students in general." . Graphics,Images and jpeg files are taken from Google and yahoo  Image  to heighten the specific points in this presentation. " • If there is any objection/or copyright violation, please inform drsandeep123@gmail.com for prompt deletion. " • It is intended for use only by the doctors of orthopaedic surgery." . Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. " • Every body is allowed to copy or download and use the material best suited to him. " There is no financial involvement."  • For any correction or suggestion please contact drsandeep123@gmail.com or www.agrasenortho.com" or www.drsandeepagrawal.com"

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