Minimally Invasive Spine Surgery For Your Patients

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Lukas P. Zebala, M.D. Assistant Professor

Orthopaedic and Neurological Spine Surgery Department of Orthopaedic Surgery

Washington University School of Medicine St. Louis, Missouri

Agenda

• Review of relevant Spinal Anatomy and Pathologies

• Overview of MIS Surgical Techniques

• Clinical Outcomes • Questions

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Anatomy

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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

Common Spinal Pathology • Spondylolisthesis

• Slippage of one vertebra on vertebra below • Degenerative (L4-L5) • Isthmic (L5-S1)

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Common Spinal Pathology

• Spinal Stenosis • Spinal canal narrowing that results in

pressure on spinal cord, cauda equina or nerves

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Common Spinal Pathology

• Facet Joint Osteoarthritis • Degradation of cartillage • Back pain, nerve

compression

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Nonoperative Treatment

• Physical Therapy • NSAIDs • Steroids • Pain Medication • Chiropractic care • Acupuncture • Bracing • Behavior Modification

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Minimally Invasive Surgical Techniques

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

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

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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

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MIS Procedures

• MIS techniques can be applied to cervical, thoracic, and lumbar procedures • Decompression

• Discectomy, foraminotomy, laminectomy

• Fusion • Instrumentation, bone grafting

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Why Choose MIS Surgery • Potential Benefits:

• Less invasive surgery • Less soft tissue injury/disruption of

normal structures • Shorter hospital stay1

• Less blood loss2

• Earlier ambulation3

• Less post-op medication use4

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1,2 Fessler R, Khoo L. Minimally Invasive Cervical Microendoscopic Foraminotomy: An Initial Clinical Experience. Neurosurgery. 51: 37-45, 2002. 3 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):537-543, 2007. 4 Isaacs. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, 2005. 4 Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: 146-154, 2002.

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

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Why MIS

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Old Approach New Technology

MIS Surgery Keys

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• 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 • Magnification - Safer

MIS Surgery Basics

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• Soft tissue dilators are used to create a working channel through the musculature

MIS Surgery Basics

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• Patient specific tubular retractor is docked onto the area of interest • Working portal

MIS Discectomy

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MIS Discectomy

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MIS Decompression • Discectomy • Foraminotomy • Laminectomy

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• Remove pressure from neural structure

MIS Posterior Fusion / Instrumentation

• Fusion Added: • Instability

• DDD • Spondylolisthesis • Scoliosis • Iatrogenic

• Posterior

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MIS Lateral Approach

• Spine is approached from the side • Avoid major anterior or posterior

structures

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MIS Lateral Fusion / Decompression

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1 3 2

MIS Lateral Fusion / Decompression

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MIS Lateral Fusion / Decompression

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MIS Instrumentation

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Case 1 • 53 yo Female • Back pain and

left leg L4/L5 radiculopathy

• Failed nonop tx

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Case 1

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Case 1

• Walking POD#1

• Off IV Pain Meds POD#1

• D/C home POD #2

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Case 2

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• 63-year-old with 2 year history of low back pain, some leg pain

• Loss of disc height • Loss of normal lordosis • Coronal instability

Case 2

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Case 3

• 30 yo male • High speed MVC • T9 fracture

dislocation • Complete SCI • Multiple other

injuries

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Case 3

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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

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Clinical Outcomes MIS Decompression Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the

Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: 146-154, 2002. • 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

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Clinical Outcomes MIS TLIF Isaacs. Minimally invasive microendoscopy-assisted transforaminal

lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, 2005.

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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, 2p=.02, 3 p= .015 *Narcotic usage between patients was normalized to morphine sulfate equivalents.

Clinical Outcomes MIS TLIF Scheufler. Percutaneous Transforaminal Lumbar Interbody Fusion for the

Treatment of Degenerative Lumbar Instability. Neurosurgery:203-213, 2007. • 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

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Clinical Outcomes MIS Lateral Knight, et al. Direct Lateral Lumbar Interbody Fusion for Degenerative Conditions

Early Complication Profile. J Spinal Disord Tech. Feb, 2009.

• Major adverse events approximated 8.6% with approach-related complaints of nerve irritation nearing 3.4%.

• Minimally invasive approach minimized blood loss, as compared to historical open cohort

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Thank You!

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Questions