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Minimally Invasive Spine SurgeryJOHN M SMALL MD

FLORIDA ORTHOPEDIC INSTITUTE

ASSOCIATE PROFESSOR USF DEPARTMENT OF ORTHOPEDIC SURGERY

ORTHOPEDICS FOR THE PRIMARY CARE PRACTITIONER AND REHABILITATIONTHERAPIST

JULY 22, 2018

Trends In Spine Surgery

Motion Preservation

Biologics and Biomaterials

Less / Minimally Invasive

Robotics

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Primary Goals of Spine Surgery

Adequate Decompression

Direct / Indirect

Stabilize Spine

Maintain Spinal Balance

Improve / Speed Recovery

Traditional Surgical Approaches

PLF TLIF ALF Thoracotomy

Back Front Back Side

Surgical Treatment/Approach

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Spine Surgery Procedures: Decompression

Open Laminectomy

Open Fusion

Types of fusion: Posterior / Posterior

lateral fusion (PLF)

Posterior lumbar interbody fusion (PLIF)

Transforaminal lumbar interbody fusion (TLIF)

Anterior lumbar interbody fusion (ALIF)

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Purpose of Fusion

Stabilize/ Correct Deformity

Stop the motion at a painful vertebral segment Decrease pain

Protect the spinal cord/ nerves

Interbody Implants Restore Disc Height- Indirect Decompression

An MIS procedure is one that by virtue of the extent and means of surgical technique results in less collateral tissue damage, resulting in measurable decrease in morbidity and more rapid functional recovery than traditional exposures, without differentiation in the intended surgical goal

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MISS

Conditions Treated Using MIS Procedures Herniated Disc Degenerative Disc

Disease Lumbar spinal stenosis

Spinal deformities scoliosis

Spinal infections

Spinal instability

Vertebral compression fractures

Spinal Tumors

MISS Advantages:

Smaller incisions

few smaller scars instead of one larger scar

Less tissue dissection

Less damage to surrounding muscles

Potential for less blood loss, quicker healing, shorter hospital stay, and less pain

Quicker return to daily activities

Marketing

MISS Disadvantages:

Inadequate treatment/ decompression

Potential for prolonged operative time

Increased radiation exposure

Not appropriate for every case

Less surface area of bone exposed for fusion cases “Spot Welding”

May be difficult to repair a spinal fluid leak if one occurs

Learning curve for surgeons

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“Minimally Invasive Proceedures”

Chronology of Spine Surgery

Modern MISS- started with Kyphoplasty and Tubular Retractor Systems

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Vertebraplasty vsKyphoplasty

MIS Procedures

Micro Endosocopy tubular retractors

Minimal disruption to a patient’s normal anatomy - i.e. Muscles, Ligaments, Bone Structures

Tubular Retactors 14mm, 16mm or

18mm, 22mm and larger tubes are used for the working space.

Expandible

Lengths range from 3cm to 9cm

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Disc Herniation

MIS discectomy

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MISS

Ioflex

Ioflex

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Minimally Invasive Fusion (TLIF)

MIS TLIF

Percutaneous Fixation

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MIS TLIF

MISS- Pedicle Screws Muscle Splitting

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Lateral Access Surgery (XLIF, LLIF, DLIF)

Extreme Lateral Interbody Fusion (XLIF)

JR

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Adult Idiopathic Scoliosis-Case

Intra Op Pictures XLIF

Intra Operative X-rays

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Increased Disc Height

Guide Wires

Multilevel XLIF

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Intra Op Fluoro X-Rays

Post Op Fluoro X-Rays

Robotic Guidance Applications

C1 to Sacrum • Spinal fixation

• Pedicle screws• Transfacet, translaminar-

facet screws• Sacroiliac screws

• Spinal deformities • Scoliosis PSF, osteotomies

• Cement augmentations• Kyphoplasty and vertebroplasty

• Oncological applications• Biopsies, tumor resections

• Revisions

Posterior Surgical Approaches

• Open• MIS• Percutaneous

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CT-based 3D Planning

Software

• CT-based 3D planning

• Guided instrumentation• 1 mm accuracy

Workstation

Guidance Unit

Robotic Guidance

Spine Surgery with Robotic Guidance

Step 1:Preoperative Plan

Step 4:Operate

Step 2:Mount

Step 3:3D Sync

Preoperative blueprint of the ideal surgeryis created in a virtual 3D environment

How It Works

Pre Op Planning

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Spine Surgery with Robotic Guidance

Step 1:Preoperative plan

Step 4:Operate

Step 2:Mount

Step 3:3D Sync

Rigid attachment to the patient assures maximum surgical accuracy throughout the procedure

How It Works

Step 4:Operate

Step 2:Mount

Step 3:3D Sync

How It Works

Two fluoroscopy images are automatically synchronized with the CT-based surgical blueprint (independent of anatomy)

Step 1:Preoperative plan

Spine Surgery with Robotic Guidance

Spine Surgery with Robotic Guidance

Step 4:Operate

Step 2:Mount

Step 3:3D Sync

Step 1:Preoperative plan

Tools and implants are guided to the planned trajectory with 1 mm accuracy

How It Works

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Other Innovations for MISS

Currently Approved and Distributed Artificial Discs in the United States

Over the last decade 7 arthroplasty devices have gained US (FDA) approval:

(All devices approved for single level arthroplasty) Prestige ST Cervical Disc (Medtronic Sofamor Danek)

Bryan Cervical Disc (Medtronic Sofamor Danek USA Inc.) ProDisc-C Total Disc Replacement Device (Synthes Spine) Secure-C Cervical Artificial Disc (Globus Medical Inc.) PCM Cervical Disc (NuVasive Inc.) Mobi-C Cervical Disc (LDR Spine USA Inc.) – Approval for use at 2

levels Prestige LP Cervical Disc (Medtronic Sofamor Danek) – Approval

for use at 2 levels

Conclusion

MISS here to stay future

Techniques continue to improve

Biologics Image guidance and Robotics appear to

improve accuracy

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Thank You

Rehabilitation After Surgery

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Post op Rehabilitation

Surgical Procedure Performed Magnitude

Complications

“Disabilty” addressed Preop Functional Ability Co morbidities/Other Health or Ortho issues Psycho-Social Issues Expectations Pain Control and ability to manage

RACE BETWEEN FUSION TAKING AND HARDWARE FAILING

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Literature Review 13 articles, 6 high quality “no strong evidence” PT started right after surgery is effective (no

good quality studies) PT 4-6 weeks po strong evidence: intensive exercise program >

mild exercise program on improving functional level and returning to work faster (level 1)

Long term F/U –no diff in results of intense or mild exercise program with overall improvement (level 1)

No “strong evidence” of effectiveness of supervised vs home exercise program or multidisplinary approach

No evidence that pts need to have activities restricted after first time lumbar disc surgery (reherniation)

Spine, 2003

General Guidelines- Post op

Limit sitting to 30 minutes at a time for the first two weeks. Limit riding in a car

avoiding long trips. get out and stretch 5-10 minutes every 30-45 minutes of

riding. DRIVING: Do not drive for 4-6 weeks (?) Keep your spine in neutral position; do not bend or twist. Keep everything in easy reach. Keep lifting to a minimum – no more than 5-10 pounds. (A

gallon of milk weighs 8 pounds.) You may go up and down stairs. Perform exercises two times a day as prescribed by

physical therapist

Sleeping:

Mattress high density foam

rubber or polyfoam, a thick plywood

board, or an innerspring, extra-firm, or firm mattress

Please do not sleep on a waterbed.

Lie on your back, place a pillow under

your knees to slightly flex your knees and hips.

This decreases the tension on your nerve roots.

Lie on your side, place a pillow between your legs.

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Brace Lessen stress that is

transmitted to the spine Reducing stress

important to increase the probability of your fusion healing.

The brace is to be worn at all times, except lying down or bathing.

Sitting:

straight-back chairs.

lumbar roll rolled-up towel or

a lumbar support. Use corset or

brace. Begin by sitting for

approximately 30 minutes and increase this as your tolerance allows

Light Activity

Walking. begin by walking up to 2 or 3 times daily

Start gradually, perhaps 1/8 to 1/4 mile. Increase your mileage to 1-5 miles 2-3 times a week as endurance improves.

Lifting. Do not lift over 5-10 pounds Lift with your legs Not from your waist Keep the object close to your body

Bending and twisting are dangerous. These activities significantly increase the stress on your back and may cause

damage. Avoid strenuous pushing and/or pulling.

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Phases of physical therapy intervention

Protection phase / Acute stage

Controlled motion phase/ Subacute stage

Return to function phase/ Chronic stage

•To educate the patient•To control pain, edema, spasm•To maintain soft tissue and joint integrity and mobility•To reduce joint swelling if symptoms are present•To maintain integrity and function of associated areas

•To educate the patient•To promote healing of injured tissues•To restore soft tissue, muscle, and/or joint mobility•To develop neuromuscular control, muscle endurance, and strength in involved and related muscles•To maintain integrity and function of associated areas

•To educate the patient•To increase soft tissue, muscle and /or joint mobility•To improve neuromuscular control, muscle endurance, and strength•To improve cardiovascular endurance•To progress functional activities

Protection Phase Protection phase (0-4 wks)

To control pain, edema, spasm Controlling pain is an important

first step in allowing patients to regain their strength

IceTENS

Manual therapy To control pain, edema, spasm Superficial stimulation

Muscle relaxation

Myofascial release

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I Protection Phase

To maintain integrity and function of associated areas and extrimities

Static Isometric

II Controlled Motion Phase

Controlled motion phase( 3-12 weeks)

To promote healing of injured tissues

To restore soft tissue, muscle, and/or joint mobility Myofascial release Direct fascial

technique Deep friction massage

II Controlled motion phase

To restore soft tissue, muscle, and/or joint mobility

To develop neuromuscular control, muscle endurance, and strength involved and

related muscles Dynamic- Trunk

Stabilization

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Dynamic Muscle training

muscle facilitation to gain strength To provide stability

following the surgery. :

Muscles in the incision area

Muscles weakened by nerve problems before the surgery

Small muscles that work around each vertebra and help stabilize the spine. protection

III Return To Normal Activity / Chronic Stage

Chronic Stage 10 wks +

Return to work and normal activities Trunk Stabilzation

Occ Rehab

Chronic Stage:

Things To Avoid

lifting more than 15 pounds,

bending at the waist, such as picking up objects off the floor

stooping, kneeling, crawling and

by bending forward at the waist.

twisting motions. car accidents contact sports Situations that cause a

fall, such as slippery and wet surfaces.

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After 3 mos

natural anxiety about resuming normal duties once the fusion is set (3mos) the more the back is

stressed, the bigger and stronger the fusion becomes Bone responds to stress by growing stronger

Rehabilitation Guidlines

Aquatic exercises

start by walking in the water.

Do short laps in the pool with the water chest high.

Lumbar stabilization exercise in water Fundamental

exercises With kicks

Aerobic exercise in water

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Conclusion

Rehabilitation After Spine Surgery Spine-Complicated

Spine Surgery is a Small Part of the Overall Restoration Process

Team Approach No Such Thing As “Fix Me” Expectations will Determine Outcome

Thank You

Preop Scoliosis Xrays- 75 degrees kyphosis T6-L4

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Surgery

Subtraction Osteotomy L3 TLIF / SPO L4/5 and L5/S1 Posterior Fusion with instrumentation T12-S1 B iliac screws

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Ioflex Foraminotomy