Dr. Pablo Pazmiño discusses the normal spine structure and the effects of arthritis on spinal health, emphasizing the importance of a foundational understanding of MRI imaging in spinal surgery. He outlines the process of minimally invasive lumbar decompression surgery, detailing the techniques used to avoid destabilizing the spine, including hemilaminotomy and careful decompression. The presentation concludes with an invitation for referrals for consultations related to lumbar decompression.

1. Pablo Pazmiño, MD

2. Orthopaedic Surgery American Academy of Orthopaedic Surgeons Clinical Faculty Olympia Medical Center Cedars Sinai Medical Center Century City Doctors Hospital Education The University of California, Los Angeles The University of Michigan, Ann Arbor

3. Here is the normal spine of an 18 year old cadaver male. Notice the nice ample, round space available for the spinal cord and neural elements

4. With time the space begins to narrow slowly as Arthritis develops

5. More and More Bony overgrowth occurs

6. With time the space begins to narrow to an almost Triangular space and can compress the neural elements within

7. There can be side to side differences meaning the left side may be tighter than the right and vice versa

8. With my background as a Third grade teacher I always make it a point to build a foundation concept before moving on to more complex ideas. I would like to take a moment to build some foundations before continuing to discuss MRIs.

9. Here is what I mean by a foundation concept. You will see side view images and top down images throughout this presentation and on your MRIs. This can be hard to grasp unless we stop and point a few things out initially The Sagittal view is also called the lateral view and this is pictured here it displays the spine as viewed from the SIDE.

10. Here is what I mean by a foundation concept. You will see side view images and top down images throughout this presentation and on your MRIs. This can be hard to grasp unless we stop and point a few things out initially The Axial view is a top down view of the spine. This image repsents a slice obtained as if an Axe were to chop you, therefore the name Axial view.

11. Next we will review some basic anatomy Some images will be in the Sagittal plane

12. Others will be in the Axial Plane

13. Joint Facet Nucleus Pulposus Right Nerve Root Left Nerve Root As you can see here on MRI and CT scans the Facet joints end up looking like the buns of a hamburger. Its just the way the happen to look when they are sliced in this plane. We will show you this on some examples later Annulus Fibrosus Axial View of the Disc and Neural elements

16. The degree and location of stenosis can produce the different clinical presentations. Centrally Lateral recess: Subarticular(anterior SAF) Entrance Zone C. Foraminal : Between pedicles Midzone D. Extraforaminal: Lateral to pedicle Exit Zone

17. Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. The degree and location of stenosis produce the different clinical presentations. Centrally The Central Area under the Laminae

18. Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. The degree and location of stenosis produce the different clinical presentations. Centrally Lateral recess: Subarticular(anterior SAF) Entrance Zone C

19. Structural Relationship between neural elements, discs, facets, hypertrophic ligaments, and bony elements. The degree and location of stenosis produce the different clinical presentations. Centrally Lateral recess: Subarticular(anterior SAF) Entrance Zone C . Foraminal : Between pedicles Midzone D

20. The degree and location of stenosis produce the different clinical presentations. Centrally Lateral recess: Subarticular(anterior SAF) Entrance Zone C. Foraminal : Between pedicles Midzone D . Extraforaminal: Lateral to pedicle. The Exit Zone

21. On this diagram The number 2 is the nerve exiting the spine through a hole called the Foramen From here the nerve will provide sensation and strength to the legs

22. If the Nerve is compressed within the spine or foramen the nerve can refer pain to buttock, thigh, leg, calf or foot. Where does your pain refer to???

24. Patients are usually an older age group >40 years of age History of recurring or persistent back pain Occasional buttocks pain and referred pain radiating down the legs Weakness Trouble walking long distances

25. To remove this pressure from the neural elements you may need to decompress the area highlighted here on the right

26. Traditional Surgery was a WIDE LAMINECTOMY. However history has shown that this may risk destabilizing the spine

27. With the traditional Laminectomy the entire lamina and the Spinous process of each spinal segment was removed. This was shown to cause an unstable spine in some cases

28. With this in mind: A limited approach was proposed as a microsurgical decompression

29. With proper training your surgeon can perform a thorough decompression of all needed areas while decreasing the likelihood of spinal instability

30. Dr Pazmino positions all his patients personally, and carefully with the assistance of the Operative team

31. The entire procedure is performed using special Spinal microsurgical instrumentation

32. An Incision is made on your lower back The muscles on your back are not cut instead with this approach they are simply moved out of the way. This is why patients feel pain after surgery, because we hold these muscles out of the way to do surgery and you wake up you will have a muscle sprain

33. At this point the incision is so small we need to use a surgical microscope to allow for the best visualization. There are two eyepieces for the microscope and you will have two Spinal surgeons there for your surgery. Dr Pazmino and Dr Lauryssen.

34. Once we have exposure we remove the thickened ligamentum flavum. This is also known as the yellow ligament. It has two layers and must be removed to begin any spinal surgery

35. Feet Patient’s Head

36. Dr Pazmino prefers to maintain the lamina’s integrity. In order to do this he performs a hemilaminotomy on the side that needs to be decompressed. This can be performed bilaterally as well

37. Dr Pazmino prefers to maintain the lamina’s integrity. In order to do this he performs a hemilaminotomy on the side that needs to be decompressed. This can be performed bilaterally as well

40. Next Dr Pazmino removes all the arthritic, extra, overgrown bone. We are trying to reapproximate the image on the left to the normal spine on the right

41. Dr Pazmino carefully removes all the arthritic, extra, overgrown bone, here is an intraoperative view

42. The wound is next thoroughly washed with an antibiotic solution and closed with Absorbable sutures Final closure is performed using Dermabond. Dr Pazmino’s brother is a plastic surgeon. www.miamiaesthetic.com. This allows patients to shower the same day of surgery with NO DRESSING !!!!

43. Team approach All procedures are done by two Spinal Surgeons

44. All our procedures are performed in a minimally invasive manner. All patients receive a plastics closure and are followed closely afterwards

45. Thank you for your time. If you know someone who could benefit from a consultation for a Lumbar Minimally Invasive Decompression please refer them to our online website or call toll free to schedule an appointment 1-8SPINECAL-1 www.beverlyspine.com www.santamonicaspine.com