Minimally InvasiveSpine Surgery (MIS)
Title
Practice Name
Location
Section 1:Minimally Invasive
Spine Surgery
Minimally Invasive Transforaminal Interbody Fusion
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
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
Minimally Invasive Techniques
Other common minimally invasive surgeries
Gall bladder removal
Appendectomy
Bariatric surgery
Total hip replacement
Section 2:Technique Overview
Minimally Invasive Transforaminal Interbody Fusion
Patient Positioning
• With patient in prone position, incision is made, and sequential dilation begins
Dilator Insertion
• Retractor depth is measured using indices on the side of the dilator
Retractor Insertion
• With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators
Retractor Positioning
• With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure
Retractor Expansion
• Retractor is expanded to visualize anatomy
Spine Visualization
• Curved racks increase visualization distally while limiting the exposure at the skin surface
Telescoping Blade Adjustment
• Telescoping blades are adjusted to prevent muscle creep that can obstruct view
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
Trial Insertion
• Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue
Spacer Insertion
• Spacer is loaded onto inserter and inserted
• If necessary, nerve root or dural retractors can be used
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
Screw and Rod InsertionMark Screw Entry Points
• Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points
Pedicle Preparation
• Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle
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
Screw Insertion
• Screw and screw-extension assemblies are percutaneously inserted into the pedicles
Patient Positioning
• With patient in prone position, incision is made, and sequential dilation begins
Dilator Insertion
• Retractor depth is measured using indices on the side of the dilator
Retractor Insertion
• With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators
Retractor Positioning
• With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure
Retractor Expansion
• Retractor is expanded to visualize anatomy
Spine Visualization
• Curved racks increase visualization distally while limiting the exposure at the skin surface
Telescoping Blade Adjustment
• Telescoping blades are adjusted to prevent muscle creep that can obstruct view
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
Trial Insertion
• Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue
Spacer Insertion
• Spacer is loaded onto inserter and inserted
• If necessary, nerve root or dural retractors can be used
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
Screw and Rod InsertionMark Screw Entry Points
• Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points
Pedicle Preparation
• Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle
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
Screw Insertion
• Screw and screw-extension assemblies are percutaneously inserted into the pedicles
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
Rod Placement
• Rod is driven downward and pivoted 90° into the bottom slot of the open screw extension
Rod Holder Capturing Rod
• Rod holder handle will then engage the proximal end of the closed screw extension
Rod Holder Capturing Rod
• Set screws are tightened, the rod holder is disengaged, and screw extensions are removed
• Fluoroscopy confirms bilateral constructs
Section 3:Case Studies
Minimally Invasive Transforaminal Interbody Fusion
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
Case Comments
• Notice 6 lumbar vertebrae
• Lateral x-ray reveals L6-S1 spondylolysis—also an S1-S2 spondylolysis
• Slight lumbar scoliosis
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Preoperative Planning
• Preoperative planning for percutaneous pedicle screw placement is critical
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
MIS Spine Fusion RequiresAccurate Fluoroscopic Imaging
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
Preparing theDisc Space for Fusion
• Once desired access is achieved, minimally invasive instruments are used to prepare the disc space for spinal fusion
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
Screw Position
• Screws are carefully inserted into the densest part of the vertebral body, the pedicle
• Screw position is confirmed by x-ray images
Rod Insertion
• The appropriate rod length is measured
• The rod is then inserted through the same small incision used to place the screws
Segment Immobilized
• The rod is then locked down into the pedicle screw heads, and screw extensions are disengaged
• The segment is now immobilized securely
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
Section 4:Patient Selection
Minimally Invasive Transforaminal Interbody Fusion
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
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
The VIPER System IndicationsThe VIPER System was cleared under the EXPEDIUM Family for the following
indications:The VIPER System is intended for noncervical pedicle fixation for the followingindications: degenerative disc disease (defined by back pain of discogenic originwith 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 failedprevious fusion in skeletally mature patients. When used in a percutaneous,posterior approach with MIS instrumentation, the VIPER System screwcomponents are intended for noncervical pedicle fixation and nonpediclefixation for the following indications: degenerative disc disease (defined by backpain of discogenic origin with degeneration of the disc confirmed by history andradiographic 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.
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
1. Wilson DH, Harbaugh R. Microsurgical and standard removal of the protruded lumbar disc: a comparative study. Neurosurgery. 1981;8:422-427.
2. 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.
3. 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.
4. 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.