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5/3/2017 1 What does Minimally Invasive Spine Surgery mean to you and your patients? DR. BRIAN MILLER APEX NEUROSURGERY GOAL IS TO HELP ANSWER THE QUESTION: WHEN TO REFER TO THE NEUROSURGEON AND WHAT IS MINIMALLY INVASIVE SURGERY REALLY ABOUT? Jarvik et al (2001) and McCullough et al (2011): Patients WITHOUT back pain have the following findings on MRI: 83% had severe disc desiccation or degeneration of one or more levels 64% had one of more bulging discs 56% had loss of disc height 6% had disc extrusion MOST LOW BACK PAIN IS NON SPECIFIC (NO RADIOLOGICAL FINDINGS)

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  • 5/3/2017

    1

    What does Minimally Invasive Spine

    Surgery mean to you and your patients?

    DR. BRIAN MILLERAPEX NEUROSURGERY

    GOAL IS TO HELP ANSWER THE QUESTION: WHEN TO REFER TO THE NEUROSURGEON

    AND WHAT IS MINIMALLY INVASIVE SURGERY REALLY ABOUT?

    Jarvik et al (2001) and McCullough et al (2011):

    • Patients WITHOUT back pain have the following findings on MRI:

    83% had severe disc desiccation or degeneration of one or more levels

    64% had one of more bulging discs

    56% had loss of disc height

    6% had disc extrusion

    MOST LOW BACK PAIN IS NON SPECIFIC (NO

    RADIOLOGICAL FINDINGS)

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    MCCULLOUGH (2011) HAS RECOMMENDED THE FOLLOWING

    BE ADDED TO ALL LUMBAR MRI REPORTS:

    Follow up studies showed that among patients whose reports had this disclaimer were significantly less likely to receive narcotic prescriptions for their pain but had no difference in whether they were referred for steroid injections or to a surgeon.

    SEVERE DEGENERATIVE DISC DISEASE

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    DISC SPACE COLLAPSE/DESICCATIO

    N

    DEGENERATIVE DISC DISEASE

    • Rarely caused by major trauma • Everyone has it. (Normal finding on MRI

    over age 60)• When severe, chronic inflammation to the

    disc annulus produces irritation to adjacent nerve root and joints: Normal spine ROM becomes painful (Focally) often with radiculopathy

    FORAMINAL STENOSIS

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    FORAMINAL STENOSIS

    • Usually unilateral in nature from bony overgrowth (Osteophytes, facet hypertrophy) or occasionally soft tissue (ligaments, disc fragment, synovial cyst)

    • Less likely to have focal pain and spasms, more likely to have radiculopathy and weakness of a specific nerve root

    LUMBAR DISC HERNIATION

    CERVICAL DISC HERNIATION

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    DISC EXTRUSION

    DISC HERNIATIONS AND EXTRUSIONS

    • Lots of poorly defined synonyms: Bulging disc, Slipped disc, Herniated disc, Pinched Nerve, Ruptured disc.

    • Extrusions, or free disc fragments, seldom resolve without surgery and can produce severe pain and cauda equina symptoms.

    • ~10% of Disc Herniations will end up having surgery even with maximal conservative treatment

    SPONDYLOLISTHESIS

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    SPONDYLOLISTHESIS

    • Graded from I-IV based on % of overlap of the 2 vertebrae involved.

    • Isthmic: Pars interarticularis fracture (“Scotty dog”), often occult

    • Degenerative: Represents ligamentous laxity, usually present > age 60

    • Pain with position change (sitting to standing), sometimes a “Clunk” is felt, leg spasms and intermittent leg weakness common

    CENTRAL CANAL STENOSIS

    CENTRAL CANAL STENOSIS

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    CENTRAL CANAL STENOSIS

    • Can produce multi-level nerve root or diffuse spinal cord dysfunction symptoms:

    • bowel/bladder/sexual dysfunction• Pain and paresthesias and/or weakness of

    multiple dermatomes• Often Slow and progressive symptoms if from

    facet and ligamentous hypertrophy, tumor versus Fast onset if disc herniation, spondylolisthesis, hematoma, infection

    COMPRESSION FRACTURE

    COMPRESSION FRACTURE

    • Clinically significant when more than 15% compressed

    • Important to also assess for angulation or any retropulsion of fragments (Need axial images to do this)

    • Establish and document precise time frame of symptoms and if history supports pathologic or osteoporotic cause

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    OTHER RADIOGRAPHIC FINDINGS IN PATIENTS

    WITH BACK PAIN

    KYPHOSIS

    SCHMORL’S NODES

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    SCHMORL’S NODE

    FACET HYPERTROPHY/ FACET DISEASE

    FACET HYPERTROPHY

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    REVERSAL OF LORDOSIS

    Algorithm for the management of low back pain in adults.Adapted with permission from Chou R, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society [published correction appears in Ann Intern Med. 2008;148(3):247–248]. Ann Intern Med. 2007;147(7):482.

    KEY: Clinical findings correlated with radiographic findings

    Review old imaging reports for mention of same findings from when patient was asymptomatic.

    Progression of symptoms and radiographic findings in tandem

    Any progressive neurological deficit even in the absence of convincing imaging findings.

    Pain control or symptom control failure after conservative management, PT referrals or Pain management

    SO WHO DO I REFER TO A SURGEON?

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    Lumbar stenosis: Neurogenic Claudication

    Cervical Stenosis: Any signs of myelopathy

    Formaminal Stenosis: Drop foot, Dropping objects from hands

    Spondylolisthesis: Severe back pain, sensory loss

    Compression fracture: any detectable pinprick level or band of anesthesia

    SO WHO DO I REFER TO A SURGEON?

    OPEN VS MINIMALLY INVASIVE SURGERY

    • All Spinal surgical procedures break down into 3 broad categories:• Decompression, Fusion or Arthoplasty• Minimally Invasive Spine Surgery (MIS) changes

    the road, not the destination, of these procedures

    • Improvement in: Post-op Pain, Blood Loss, Hospital Days, and Return to Work associated with MIS procedures

    MIS BENEFITS

    • Better outcomes when treating pain as asurgical indication because of less muscle and soft

    tissue destruction and atrophy• Improved cosmesis (Surgical scar and swelling

    significantly reduced) and wound healing time• Reduced post-op Infections (1.5-4% vs 5-6%)• Less rehab and Post-op PT indicated• Global cost-saving for patient and facility (after

    initial investment)

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    MIS LAMINECTOMY TRADITIONAL

    SURGICAL SCAR COMPARISON

    • Steep learning curve with MIS surgery

    • Many older surgeons reluctant to change practice style and

    undergo more training• High initial cost: imaging, retractors, OR suite re-design

    • Long term outcomes are statistically

    equivalent (Fusion rates, satisfaction, re-

    operation rate)• Radiation exposure is

    significantly higher for surgeon over

    course of a career

    WHY DOESN’T EVERY SPINE SURGEON OFFER MIS SURGERY?

    Tradi t iona l Open Fusion MIS Fusion

    MIS VS OPEN

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    • Image Guidance or assisted surgery

    • Advanced knowledge of anatomic planes for surgical planning to

    maximize results• Use of specialized tools,

    training and products to achieve conventional

    spine surgery outcomes

    • “Laser Surgery”• Called a “Treatment” or

    “Procedure”• Is a label that can be

    used by any spine surgeon

    • The best approach for all conditions

    • Used by most Spine Surgeons (Only 10% in US are trained in MIS)

    MIS IS:MIS IS NOT

    WHAT MIS SURGERY IS AND ISN’T

    OR With Imaging Guidance for MIS Spine Surgery

    TREATMENT OF RADICULOPATHY

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    LAMINECTOMY AND FORAMINOTOMY

    TREATMENT OF CENTRAL STENOSIS

    LAMINECTOMY

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    LUMBAR DISC HERNIATION OR EXTRUSION

    DISC HERNIATION OR EXTRUSION

    DISCECTOMY

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    CERVICAL DISCECTOMY

    ACDF INTERBODY PEEK CAGE

    ACDF INSTRUMENTATION

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    CERVICAL ARTHOPLASTY

    CURRENT ARTHOPLASTYDEVICES

    SPONDYLOLISTHESIS

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    SEGMENTAL INSTRUMENTATION AND FUSION

    VERTEBRAL COMPRESSION FRACTURE

    VERTEBROPLASTY/KYPHOPLASTY

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    MINIMALLY INVASIVE DESCRIBES SOFT-TISSUE ROUTES

    MINIMALLY INVASIVE IS NOT NON-INVASIVE

    TAKE HOME POINTS

    • Patients who require spine surgery have more treatment options when evaluated by a Minimally Invasive Spine trained surgeon

    • They are statistically more likely to recover quicker, with less post-op pain and blood loss, less narcotic usage, and less surgical morbidities with MIS surgery.

    • Outcomes are equivalent at >1 year regardless of surgical approach used