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

Minimally Invasive Spine Surgery For Your PatientsAgendaAnatomyCommon Spinal PathologyCommon Spinal PathologyCommon Spinal PathologyCommon Spinal PathologyNonoperative TreatmentMinimally Invasive Surgical TechniquesMIS Surgery GoalMIS Surgical CandidatesMIS ProceduresWhy Choose MIS SurgeryMIS Surgery RisksWhy MISMIS Surgery KeysMIS Surgery BasicsMIS Surgery BasicsMIS DiscectomyMIS DiscectomyMIS DecompressionMIS Posterior Fusion / InstrumentationMIS Lateral ApproachMIS Lateral Fusion / DecompressionMIS Lateral Fusion / DecompressionMIS Lateral Fusion / DecompressionMIS InstrumentationCase 1Case 1Case 1Case 2Case 2Case 3Case 3Postoperative ProtocolClinical OutcomesClinical OutcomesClinical OutcomesClinical OutcomesThank You!