Minimally InvasiveSpine Surgery (MIS)

Title

Practice Name

Location

Section 1:Minimally Invasive

Spine Surgery

Minimally Invasive Transforaminal Interbody Fusion

The Dimensions of Back Pain

• More than 65 million Americans annually suffer from lower back pain

• Third most-frequent reason for surgery overall • Approximately 250,000 lumbar spinal fusions

performed• Approximately 400,000 lumbar spinal

decompression procedures performed

Minimally Invasive Surgery: A Breakthrough Innovation

• Potential advantages compared with “open” surgery• May result in

• Smaller incisions and scars• Minimal soft-tissue destruction and scarring• Less surgical blood loss• Shorter hospital stay• Less postoperative pain• Less need for postoperative pain medicine• Faster return to work and daily activities

Minimally Invasive Techniques

Other common minimally invasive surgeries

Gall bladder removal

Appendectomy

Bariatric surgery

Total hip replacement

Section 2:Technique Overview

Minimally Invasive Transforaminal Interbody Fusion

Patient Positioning

• With patient in prone position, incision is made, and sequential dilation begins

Dilator Insertion

• Retractor depth is measured using indices on the side of the dilator

Retractor Insertion

• With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators

Retractor Positioning

• With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure

Retractor Expansion

• Retractor is expanded to visualize anatomy

Spine Visualization

• Curved racks increase visualization distally while limiting the exposure at the skin surface

Telescoping Blade Adjustment

• Telescoping blades are adjusted to prevent muscle creep that can obstruct view

Facetectomy and Annulotomy

• Facetectomy and annulotomy are then performed to gain access to the disc space

• Complete discectomy is performed, and the vertebral body endplates are prepared

Trial Insertion

• Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue

Spacer Insertion

• Spacer is loaded onto inserter and inserted

• If necessary, nerve root or dural retractors can be used

Spacer Positioning

• The inserter is disengaged from spacer and removed

• Spacer is positioned across the midline at roughly 35°, and then autograft is packed around the spacer

Screw and Rod InsertionMark Screw Entry Points

• Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points

Pedicle Preparation

• Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle

Dilator Placement

• Dilators are placed over the guide wire to prepare for appropriately sized tap

• The pedicles are then tapped to prepare for screw placement

Screw Insertion

• Screw and screw-extension assemblies are percutaneously inserted into the pedicles

Patient Positioning

• With patient in prone position, incision is made, and sequential dilation begins

Dilator Insertion

• Retractor depth is measured using indices on the side of the dilator

Retractor Insertion

• With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators

Retractor Positioning

• With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure

Retractor Expansion

• Retractor is expanded to visualize anatomy

Spine Visualization

• Curved racks increase visualization distally while limiting the exposure at the skin surface

Telescoping Blade Adjustment

• Telescoping blades are adjusted to prevent muscle creep that can obstruct view

Facetectomy and Annulotomy

• Facetectomy and annulotomy are then performed to gain access to the disc space

• Complete discectomy is performed, and the vertebral body endplates are prepared

Trial Insertion

• Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue

Spacer Insertion

• Spacer is loaded onto inserter and inserted

• If necessary, nerve root or dural retractors can be used

Spacer Positioning

• The inserter is disengaged from spacer and removed

• Spacer is positioned across the midline at roughly 35°, and then autograft is packed around the spacer

Screw and Rod InsertionMark Screw Entry Points

• Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points

Pedicle Preparation

• Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle

Dilator Placement

• Dilators are placed over the guide wire to prepare for appropriately sized tap

• The pedicles are then tapped to prepare for screw placement

Screw Insertion

• Screw and screw-extension assemblies are percutaneously inserted into the pedicles

Alignment of Screw Extensions

• With screws placed at each level, the openings of screw extensions are aligned

• Holder and assembly are now guided into place

Rod Placement

• Rod is driven downward and pivoted 90° into the bottom slot of the open screw extension

Rod Holder Capturing Rod

• Rod holder handle will then engage the proximal end of the closed screw extension

Rod Holder Capturing Rod

• Set screws are tightened, the rod holder is disengaged, and screw extensions are removed

• Fluoroscopy confirms bilateral constructs

Section 3:Case Studies

Minimally Invasive Transforaminal Interbody Fusion

Case Overview

• 24-year-old woman presented with severe, persistent back pain with both flexion and extension

• Right leg pain• Pars interarticularis

injection improved pain

Credit: Frank Shen, MD,University of Virginia

Case Comments

• Notice 6 lumbar vertebrae

• Lateral x-ray reveals L6-S1 spondylolysis—also an S1-S2 spondylolysis

• Slight lumbar scoliosis

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Preoperative Planning

• Preoperative planning for percutaneous pedicle screw placement is critical

Entry Point

• Entry point for pedicle screws and transforaminal lumbar interbody fusion (TLIF) access are carefully planned using x-ray images

• MIS PIPELINE™ Expandable Retractor for TLIFs should be placed over the facet complex, spanning pedicle to pedicle

MIS Spine Fusion RequiresAccurate Fluoroscopic Imaging

Retractor Positioning

• PIPELINE Expandable Retractor is positioned to perform the facetectomy and access the disc space

• The retractor can then be opened to provide increased visualization

Preparing theDisc Space for Fusion

• Once desired access is achieved, minimally invasive instruments are used to prepare the disc space for spinal fusion

Screw Insertion

• To minimize motion, the vertebral bodies must be secured with a screw and rod construct

• Screws are then inserted into the pedicle through the existing incision

• Two separate stab incisions are used contralaterally

Screw Position

• Screws are carefully inserted into the densest part of the vertebral body, the pedicle

• Screw position is confirmed by x-ray images

Rod Insertion

• The appropriate rod length is measured

• The rod is then inserted through the same small incision used to place the screws

Segment Immobilized

• The rod is then locked down into the pedicle screw heads, and screw extensions are disengaged

• The segment is now immobilized securely

TLIF/VIPER™

• This shows a completed right-sided minimally invasive TLIF with decompression of roots

• The segment was then secured by bilateral percutaneous placement of the VIPER pedicle fixation system

Section 4:Patient Selection

Minimally Invasive Transforaminal Interbody Fusion

Candidate Criteria

• Not appropriate for everyone• Only for patients who have the right

indications and have exhausted conservative therapies• Bed rest• Muscle relaxants• Physical therapy• Prescription pain relievers

Candidate Criteria

• Commonly used for• Decompressions (microdiscectomy and

laminectomy)• 1- and 2-level lumbar fusions

Degenerative Disc Disease: low-grade, spondylolisthesis, recurrent discectomy)

• Follows a full diagnostic review and primary care physician consultation

The VIPER System IndicationsThe VIPER System was cleared under the EXPEDIUM Family for the following

indications:The VIPER System is intended for noncervical pedicle fixation for the followingindications: degenerative disc disease (defined by back pain of discogenic originwith degeneration of the disc confirmed by history and radiographic studies);spondylolisthesis; trauma (ie, fracture or dislocation); spinal stenosis; curvatures(ie, scoliosis, kyphosis, and/or lordosis); tumor; pseudoarthrosis; and failedprevious fusion in skeletally mature patients. When used in a percutaneous,posterior approach with MIS instrumentation, the VIPER System screwcomponents are intended for noncervical pedicle fixation and nonpediclefixation for the following indications: degenerative disc disease (defined by backpain of discogenic origin with degeneration of the disc confirmed by history andradiographic studies); spondylolisthesis; trauma (ie, fracture or dislocation);spinal stenosis; curvatures (ie, scoliosis, kyphosis, and/or lordosis); tumor;pseudoarthrosis; and failed previous fusion in skeletally mature patients.

THANK YOU. QUESTIONS?

This information has been supplied for educational purposes courtesy of DePuy Spine, Inc.

DEPUY SPINE, DePuy Spine logo, the MIS logo, PIPELINE, VIPER, and PIPELINE Expandable Retractor are trademarks of DePuy Spine, Inc.

©2007 DePuy Spine, Inc. All rights reserved.

REFERENCES

1. Wilson DH, Harbaugh R. Microsurgical and standard removal of the protruded lumbar disc: a comparative study. Neurosurgery. 1981;8:422-427.

2. Kambin P. Posterolateral percutaneous lumbar discectomy and decompression: arthroscopic microdiscectomy. In: Kambin P, ed. Arthroscopic microdiscectomy: minimal intervention in spinal surgery. Baltimore, Md: Urban & Schwarzenberg; 1991:67-100.

3. Koebbe CJ, Perez-Cruet MJ. Lumbar microdiscectomy. In: Perez-Cruet MJ, Fessler RG, eds. Outpatient spinal surgery. St. Louis, Mo: Quality Medical Publishing, Inc; 2002:133-157.

4. Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg. 1999;81:958-965.