Minimally Invasive Spine Surgery

Transcription

1 Minimally Invasive Spine Surgery Kasra Ahmadinia MD Spine Center at Eastern Oklahoma Orthopedics Center

2 Why Minimally Invasive Surgery (MIS)? MIS Goal: Minimize the surgical assault, post-operative pain, morbidity and expedite recovery, while not compromising the surgical goals

3 Open Spinal Surgery Much of the morbidity of traditional spinal procedures is related to accessing the spine Delicate work on the spinal structures Extensive muscle dissection and retraction with large open incision damages the muscle s blood and nerve supply and causes acute pain and chronic dysfunction

4 Why MIS? Open posterior spine surgery consequences Muscle retraction duration corresponded with MRI muscle damage and post-op low back pain Gejo R Spine 1999 Intra-operative muscle retraction may cause muscle pressure to point of ischemia (permanent damage) Styf JR Spine 1998

5 MIS: RULES Should not compromise established principles to perform surgery through a small incision Should not let thrust towards minimallyinvasive procedures, generate fringe technologies Unless procedure can be done in an efficient, cost-effective fashion, with documented outcome advantages it becomes questionable

6 Why MIS? Patients Smaller incisions Less need for blood transfusions Less post-operative use of narcotics Shorter length of hospital stay More rapid resumption of activities and employment Payers Less expensive (days in hospital strongest driver of costs) Lower risk of infection (often leads to multiple additional surgeries and prolonged treatment)

7 MIS surgical skills Different surgical skills Visualize only a small area of anatomy, not entire spine higher level of anatomic appreciation Complications more difficult to treat deal with Rely heavily on radiographs Convert 1-D fluoro image into 3-D anatomic appreciation Rely on tactile feedback

8 MIS Evolution Minimally invasive spine since 90 s Early experience, MIS was limited by technology Over past decades enabling technologies have been developed allowing for safe and reproducible minimally invasive spine surgery Microscopes and endoscopes Specially designed retractor systems Real time imaging Real time nerve monitoring Specialized tools and implants

9 Minimally invasive spinal surgery Goal is to perform established surgeries that are validated as effective in a less invasive fashion Avoid minimally-invasive, minimally effective procedures Spinal Procedures (MIS or Open) Decompress nerves (bone spurs/ discs) Restore spinal alignment with deformity (scoliosis) Prevent abnormal motion with fusion

10 Minimally Invasive Nerve Decompression muscle-sparring using tubular retractors

11 Minimally Invasive Decompression muscle-sparring using tubular retractors MIS discectomy or laminectomy Usually + 1 hr No blood loss Home 2 hrs after surgery

12 Pre-op Decompressiom Post-op

13 SPORT STUDY Largest NIH sponsored study on Spine Surgery Rush participated Surgical versus nonoperative treatment for lumbar disc herniation and spinal stenosis: four-year results. Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J. In the 4-year combined as-treated analysis, those receiving surgery demonstrated significantly greater improvement in all the primary outcome measures (95% CI): BP (45.6 vs. 30.7; 15.0; 11.8 to 18.1), PF (44.6 vs. 29.7; 14.9;12.0 to 17.8) and ODI (-38.1 vs ; -13.2; to -10.9).

14 Minimally Invasive Posterior Lumbar Fusion (TLIF) Pedicle screws-rod and cage in the disc space through 1.5 inch incision Length of stay 1-2 days Lower hospital costs in both WC and noncomp patients with MIS vs open TLIF (Singh K, Phillips FM. Spine 2012)

15 Disc Preparation

16 Implant Insertion

17 Why MIS TLIF? Patients recover faster Rapid, reproducible (2hrs every time) improves my OR efficiency Pt size doesn t matter, musculature not an issue Step-by-step procedure No wound opening and closing Faster discharge, less rounding 80% pts discharged POD 1 Less expensive for hospital Lesser use of resources (OR time, LOS, blood transfusions etc,,,,) Singh, Phillips Spine 2012 BUT, DIFFICULT INITIAL LEARNING CURVE!!!!!!!

18 extreme Lateral Interbody Fusion (XLIF) Surgical Goals Minimally-invasive, retroperitoneal trans-psoas lateral interbody fusion Provide indirect neural decompression Restore proper coronal and sagittal alignment Promote fusion Minimize soft tissue disruption

19 Surgical Benefits Conventional surgery through small incisions Minimal soft tissue/muscle damage Reduced post-operative morbidity Outpatient or 23 hr procedure Adequate exposure Safe and reproducible Meet or exceed traditional results

20 Localization

21 Direct Lateral Access

22 Position Confirmation

23 Trans-psoas dissection requires real time neuro-monitoring

24 Dilators

25 Distraction and Sizing

26 Implant Insertion

27 Result

28 68 yo male with scoliosis L2-5 XLIF, Percutaneous screws 3.5 hrs; EBL < 50cc

29 Where is MIS? Minimally-invasive spine surgery is safe and reliable but requires advanced training Data confirming benefits over open surgery is compelling ( I don t believe in it ) Can now do majority of cases with minimally invasive techniques ( I do minimally invasive, but you re not the right patient ) Can customize operation to patients pathology and expectations

30 Questions?