advances in spine surgery:endoscopic and minimally invasive spine surgery dr sandeep c agrawal ...

DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com1

http://www.drsandeepagrawal.com/spine.php

Dr.Sandeep Agrawal Consultant Orthopedic Surgeon

MS,DNB

Agrasen Hospital Gondia

Maharashtra

India

ADVANCES IN SPINE SURGERYEndoscopic and Minimally Invasive Spine Surgery

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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

http://www.slideshare.net/sandeepcagrawal/understanding-back-pain-basics-of-spine-drsandeep-c-agrawal-agrasen-orthopedic-hospital-gondia-india

DR SANDEEP C AGRAWAL www.drsandeepagrawal.com Gondia Maharashtra www.agrasenortho.com

InterVertebral Disc


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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

http://www.slideshare.net/SANDEEPAGRAWALORTHO/sciatica-low-back-pain-wwwdrsandeepagrawalcom-agrasen-hospital-dr-sandeep-agrawal-gondia-maharashtra-wwwagrasenorthocom-60232530


Degenerative Disc Disease


Provocative Discogram

• 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%.

• 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


IntraDiscal ElectroThermotherapy ( IDET )

For discogenic pain (axial pain)

Thermal energy: 65ºC for 17 minutes •Collagen shrinkage •Destruction of nociceptive fibers

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 (+)

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

Complications

• Discitis • Nerve root injury • Catheter breakage • Cauda equina syndrome

General Concept of IDET

• IDET should be considered as

“Experimental Procedure”

• Maybe useful in highly selected patient

ALIF• Need for an access surgeon (NS) • Nonunion: 2nd procedure for fixation • Great vessels and peritoneal injury • Post-op retrograde ejaculation: 17-25%

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

TLIF• Facetectomy and far-lateral approach • Preserve contralateral side • Minimize approach-related morbidity

– Aggressive retraction of thecal sac – Retraction injury of nerve roots


Traditional Surgery

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


Endoscope Assisted TPS Instrumentation and Fusion

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


Muscle-splitting approach: Interval between multifidus medially and the longissimus laterally

HIVD with Sciatica

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

http://www.slideshare.net/SANDEEPAGRAWALORTHO/radiculopathyspine-low-back-pain-wwwdrsandeepagrawalcom-wwwagrasenorthocom-agrasen-hospital-gondia-vidarbha-dr-sandeep-c-agrawal-gondia-maharashtra

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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:


Radiculogram & Nerve Block

Indications

• Radicular pain resistant to other therapeutic means

• Radicular pain for which operation is contraindicated

Contraindications

• Infection

• Disturbed consciousness

• Bleeding tendency

• Emotional instable

• Lack of understanding of the procedure


Needle Position


L4 Radiculogram


Needle Position


L4, L5 Radiculogram

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

• 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


Percutaneous Endoscope Discectomy

Indication

• Radicular pain

• Positive root tension sign

• Positive imaging study

• Persisted symptom at least 6 weeks of proper conservative treatment

PED Procedures (Marking)

PED Procedures (Discography)

PED Procedures (Local Anes.)

Endoscope-guide Discectomy

PED Procedures (Wound)

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

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)

Patient Selection

Optimal Position

Poor Good

Optimal Instruments

Holmium Laser

RF


MED ( MicroEndoscopic Discectomy )

MED (MicroEndoscopic Discectomy)

–1997 , Smith & Foley • Minimal damage and Direct

visualization by

Muscle-splitting dilators Endoscope and Video monitor

METRx System

Introducer Set

Instruments & Scope

MED ( METRx System )

Scope Images

Disc

Lig. FlavumLower edge of L4


Wound Size ( 2cm)

Potential disadvantages

• Learning curve • Limited visualization • Inadequate exposure • Incomplete decompression • Vessel & nerve damage • Limited ability to treat lateral recess

and foraminal stenosis

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

Kyphoplasty SEE OTHER PPT LINK:

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

Applications• Infection • Biopsy • Debridement • Tumor excision • Disc excision • Corpectomy & Fusion • Deformity correction • Anterior release • Hemivertebtal excision • Internal thoracoplasty • Anterior fusion and instrumentation

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)

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

Other Procedures

• Anterior lumbar scope surgery

– Transperitoneal approach (L4-5, L5-S1)

– Retroperitoneal approach (T12 to S1)

• Anterior thoracolumbar scope surgery

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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.

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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 [email protected] 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 [email protected] or www.agrasenortho.com"or www.drsandeepagrawal.com"

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