Minimally Invasive Spine Surgery For Your Patients

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1 Minimally Invasive Spine Surgery For Your Patients Lukas P. Zebala, M.D. Assistant Professor Orthopaedic and Neurological Spine Surgery Department of Orthopaedic Surgery Washington University School of Medicine St. Louis, Missouri 1

2 Agenda Review of relevant Spinal Anatomy and Pathologies Overview of MIS Surgical Techniques Clinical Outcomes Questions 2

3 Anatomy 3

4 Common Spinal Pathology Degenerative Disc Disease (DDD) Occurs naturally as we age Symptomatic in some patients Disc Herniation slipped or ruptured disc Protrusion of IVD from inner core 4

5 Common Spinal Pathology Spondylolisthesis Slippage of one vertebra on vertebra below Degenerative (L4-L5) Isthmic (L5-S1) 5

6 Common Spinal Pathology Spinal Stenosis Spinal canal narrowing that results in pressure on spinal cord, cauda equina or nerves 6

7 Common Spinal Pathology Facet Joint Osteoarthritis Degradation of cartillage Back pain, nerve compression 7

8 Nonoperative Treatment Physical Therapy NSAIDs Steroids Pain Medication Chiropractic care Acupuncture Bracing Behavior Modification 8 8

9 Minimally Invasive Surgical Techniques MIS can treat disease throughout the spine: DDD Disc Herniation Stenosis Spondylolisthesis Scoliosis/Degenerative Deformity Trauma Tumor 9

10 MIS Surgery Goal The goal of minimally invasive surgery is to accomplish the same clinical outcomes as traditional, open surgery through a less traumatic approach 10

11 MIS Surgical Candidates Patients with clinical symptoms in accordance with preoperative imaging Failed course on nonoperative treatment Any Age MIS may be of benefit in elderly Any Activity Level 11

12 MIS Procedures MIS techniques can be applied to cervical, thoracic, and lumbar procedures Decompression Discectomy, foraminotomy, laminectomy Fusion Instrumentation, bone grafting 12

13 Why Choose MIS Surgery Potential Benefits: Less invasive surgery Less soft tissue injury/disruption of normal structures Shorter hospital stay 1 Less blood loss 2 Earlier ambulation 3 Less post-op medication use 4 1,2 Fessler R, Khoo L. Minimally Invasive Cervical Microendoscopic Foraminotomy: An Initial Clinical Experience. Neurosurgery. 51: 37-45, Park, Won Ha. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. SPINE 32(5): , Isaacs. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: , 2002.

14 MIS Surgery Risks Same potential complications as with conventional open spine surgery Neural injury, infection, nonunion, dural tears Learning Curve Initial longer operative times Technique complications 14

15 Why MIS Old Approach New Technology 15

16 MIS Surgery Keys Image Guidance Live x-ray or state of the art navigation Muscle Dilation Work between natural muscle planes, not cut or strip muscle Specialized Instruments Allow for safe techniques through smaller operative windows Microscope Assistance 16 Magnification - Safer

17 MIS Surgery Basics Soft tissue dilators are used to create a working channel through the musculature 17

18 MIS Surgery Basics Patient specific tubular retractor is docked onto the area of interest Working portal 18

19 MIS Discectomy 19

20 MIS Discectomy 20

21 MIS Decompression Discectomy Foraminotomy Laminectomy Remove pressure from neural structure 21

22 MIS Posterior Fusion / Instrumentation Fusion Added: Instability DDD Spondylolisthesis Scoliosis Iatrogenic Posterior 22

23 MIS Lateral Approach Spine is approached from the side Avoid major anterior or posterior structures 23

24 MIS Lateral Fusion / Decompression

25 MIS Lateral Fusion / Decompression 25

26 MIS Lateral Fusion / Decompression 26

27 MIS Instrumentation 27

28 Case 1 53 yo Female Back pain and left leg L4/L5 radiculopathy Failed nonop tx 28

29 Case 1 29

30 Case 1 Walking POD#1 Off IV Pain Meds POD#1 D/C home POD #2 30

31 Case 2 63-year-old with 2 year history of low back pain, some leg pain Loss of disc height Loss of normal lordosis Coronal instability 31

32 Case 2 32

33 Case 3 30 yo male High speed MVC T9 fracture dislocation Complete SCI Multiple other injuries 33

34 Case 3 34

35 Postoperative Protocol MIS Discectomy/Decompression Usually home on day of surgery or POD#1 Activity as tolerated (limit lumbar bending/twisting) PO pain meds/muscle relaxers MIS Fusion/Instrumentation Hospital stay 2-5 days Activity as tolerated (limit lumbar bending/twisting) PO pain meds/muscle relaxers 35

36 Clinical Outcomes MIS Decompression Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: , N = 50 MIS laminotomy vs. open decompression MIS data prospective, open decompression data retrospective. Perioperative benefits demonstrated in minimally invasive group Difference in clinical outcomes did not achieve statistical significance 36

37 Clinical Outcomes MIS TLIF Isaacs. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, Perioperative Data Open Minimally Invasive Blood loss 1147 ml 226 ml 1 Length of hospital stay 5.1 days 3.4 days 2 Post-op narcotic use (in morphine sulfate equivalent units*) 49.5 units/day 37.5 units/day 3 Operative time 4.6 hours 5 hours 1 p=.001, 2 p=.02, 3 p=.015 *Narcotic usage between patients was normalized to morphine sulfate equivalents. 37

38 Clinical Outcomes MIS TLIF Scheufler. Percutaneous Transforaminal Lumbar Interbody Fusion for the Treatment of Degenerative Lumbar Instability. Neurosurgery: , MIS TLIF (n=43) vs. Wiltse (open) approach (n=67). Mid-term functional outcomes at 8 and 16 months after surgery were equivalent for 2 groups Percutaneous group results: Lower intraoperative blood loss Less post-op analgesic use while in hospital 38

39 Clinical Outcomes MIS Lateral Knight, et al. Direct Lateral Lumbar Interbody Fusion for Degenerative Conditions Early Complication Profile. J Spinal Disord Tech. Feb, Major adverse events approximated 8.6% with approachrelated complaints of nerve irritation nearing 3.4%. Minimally invasive approach minimized blood loss, as compared to historical open cohort 39

40 Thank You! Questions 40 40

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