OPEN OPERATING THEATRE (OOT)

Percutaneous multilevel reconstruction in revision surgery

Nils Hansen-Algenstaedt • Christian Schafer •

Jorg Beyerlein • Lothar Wiesner • Reginald Knight

Published online: 22 May 2012

� Springer-Verlag 2012

Keywords Percutaneous � Minimal-invasive �Spine surgery � Deformity � Infection � Osteomyelitis �Revision surgery � Cross-over decompression

Introduction

Minimal-invasive spine surgery has become a widely

accepted surgical technique not only for decompression

procedures but also for stabilisation of the spinal column.

Percutaneous stabilisation techniques are either used to

achieve fusion, e.g. in degenerative spine surgery when

combined with fusion techniques, or in stabilisation only

procedures in patients suffering from tumor or infection

associated instability. While initial MIS procedures proved

their feasibility, safety and benefit, strategies for revision

surgery are still lacking. Yet with an increasing number of

MIS procedures performed, revision strategies become

more significant. Not only because the natural course

involves additional segments but also because of potential

implant failure and adjacent level disease [1–4].

Case description

The female 82-year-old patient did have extensive MIS

surgery in 2008 with percutaneous stabilisation from Th8–

L1 (Mantis, Stryker) and thoracoscopic body replacement of

Th10 ? 11 (Synex II, Synthes) due to progressive osteo-

myelitis and paravertebral abscess with secondary kyphosis

under conservative therapy for 4 weeks with systemic anti-

biotic therapy. After surgery the patient was treated with

intravenous antibiotics for additional 4 and 6 weeks with

oral antibiotics with a prolonged mobilization and rehabili-

tation because the patient also suffered from coronary heart

disease with compensated left ventricular insufficiency,

compensated chronic renal failure, arteritis temporalis,

cerebral infarct, rheumatoid arthritis, recurrent infection of

the urinary tract, allergic reaction to several antibiotics.

Despite all these limitations and a prolonged rehabilitation

period, the patient recovered completely managing her own

household again. Two years later the patient was again

hospitalized due to a spondylodiscitis at the level of L4/5.

Due to increasing CRP levels (391 mg/l) and progressive

spondylodiscitis and stenosis with neurological impairment,

the patient was again considered for spinal surgery and

transferred to our department.

Surgical procedure

Surgery was planned with extrafocal posterior stabilization

and crossover decompression at L4/5 from the right side,

where clinically neurological deficits were dominant. An

extrafocal stabilisation would begin at S1 and stop at L3.

Because of the existing de novo scoliosis, the instru-

mentation needed to be expanded and combined with the

formerly performed instrumentation.

Electronic supplementary material The online version of thisarticle (doi:10.1007/s00586-012-2361-5) contains supplementarymaterial, which is available to authorized users.

N. Hansen-Algenstaedt (&) � C. Schafer � J. Beyerlein �L. Wiesner

University Medical Center, Hamburg Eppendorf, Hamburg,

Germany

e-mail: nhansen@uke.uni-hamburg.de

R. Knight

Bassett Medical Center, Cooperstown, NY, USA

123

Eur Spine J (2012) 21:1220–1222

DOI 10.1007/s00586-012-2361-5

Posterior procedure

Following disinfection of the skin, sterile draping was per-

formed. Here we demonstrate two different approaches.

Both will end with the same result in terms of skin incision

and rod insertion. Surgery was started with exposing the

formerly implanted screws and rods using the same skin

incisions. After incision of the fascia and a blunt muscle split

the implants are exposed using a Cobb and rongeurs. The

blades are inserted into the screws from medial to lateral, first

blade will be hold aside using Langenbeck retractors

allowing seeing the lateral blade insertion slot. Once the

blades are both inserted the construct will be stabilized with

the ring coming with the system. All other procedures can be

now done reverse to the insertion process. The sequence of

inserting the blades into the formerly placed screws first was

chosen to enable a better harmonic line up of the new inserted

screws. For extrafocal instrumentation we started with S1. A

spinal needle was used to identify the pedicle entry point,

where correct positioning was checked using lateral and AP

fluoroscopic control. A transverse skin incision of approxi-

mately 1.5 cm was followed by a longitudinal incision of the

fascia. Blunt digital muscle dissection was performed and the

anatomical structures of the facet joint and the transverse

process were palpated. A Jamshidi needle was placed at the

pedicle entry point, where the correct positioning and ori-

entation parallel to the endplate were double-checked fluo-

roscopically. The Jamshidi needle was then pushed forward

until it reached the base of the pedicle at which point further

fluoroscopic control and documentation of the correct posi-

tioning was performed. A K-wire was inserted through the

cannula of the Jamshidi needle, and the latter was subse-

quently removed. The K-wire was used as a guide for tapping

and screw insertion (Mantis/Stryker). Following placement

of all new pedicle screws, the segment L4/5 was fluoro-

scopically marked using a spinal needle. A paramedian skin

incision of approximately 2.5 cm was done on the right side

to perform a microscopic decompression of the right side and

cross-over of the left side using a caspar distractor. There-

after dural sack and nerve root were mobilized, the disc

exposed, incised and partially removed. This procedure can

also be used in degenerative cases as PLIF procedure. After

decompression, the old rod was removed and heads of the

screws were mobilized to gain back their polyaxiality. After

removal of the rod, the old screws were checked for loos-

ening to evaluate whether or not screws needed to be

replaced. In this case none of the screws were exchanged.

Rod contouring shafts were then inserted in order to mirror

the inside pedicle screw situation to the outside; the shafts

can be used for adjusting the depth of screw insertion and rod

contouring. Typically the adjustment of the screws into a

harmonic line could be done through the rod contouring

shafts. After appropriate bending of the rod this is inserted in

a cephalic to caudal direction. The insertion and initial

reduction were facilitated by the use of a persuader, if

required. Following final tightening of the pedicle screw

blockers to fix the rod in place, the retractor ring and blades

were sequentially removed. Drains were inserted, and a

stepwise closure with fascia reconstruction, subcutaneous

and skin closure were performed.

Anterior procedure

The patient was positioned on her back, after marking

disinfection of the skin and sterile taping a left paramedian

retroperitoneal mini-ALIF procedure was performed

described more detailed elsewhere.

Postoperative information

Even with this percutaneous procedure the patient had a

cardio-pulmonal decompensation 2 days after surgery

requiring ICU treatment for 2 more days. The patient was

mobilized 1 day after surgery having a primarily stable

fixation identical to open procedures. Thrombosis prophy-

laxis was identical to that in open procedures. After surgery

patient was treated with intravenous antibiotics for addi-

tional 4 weeks. She was mobilized with external help and

sent to neurological rehabilitation, receiving oral antibiot-

ics for 6 weeks. Postoperative CT scan and plain X-ray

demonstrate correct implant positioning. The patient was

sent to rehabilitation program.

Discussion and conclusion

This is an ideal case to demonstrate the benefits of MISS. A

complex procedure in an old and very sick patient, who

would have had significantly higher risks during and after

open surgery. It also underlines the importance that a MISS

system can be revised using the same technique and the

formerly performed stabilization can be included into the

concept. Revision surgery also allows to asses the benefits

for the soft tissue of the formerly performed surgery. Here

we could see an intact musculature with some fibrous tissue

only covering the implant itself.

Conflict of interest None.

References

1. Lee SH, Kang BU et al (2006) Revision surgery of the lumbar

spine: anterior lumbar interbody fusion followed by percutaneous

pedicle screw fixation. J Neurosurg Spine 5(3):228–233

Eur Spine J (2012) 21:1220–1222 1221

123

2. Mobbs RJ, Sivabalan P, Li J (2011) Technique, challenges and

indications for percutaneous pedicle screw fixation. J Clin Neu-

rosci 18(6):741–749

3. Selznick LA, Shamji MF, Isaacs RE (2009) Minimally invasive

interbody fusion for revision lumbar surgery: technical feasibility

and safety. J Spinal Disord Tech 22(3):207–213

4. Wang J, Zhou Y et al (2011) Minimally invasive or open

transforaminal lumbar interbody fusion as revision surgery for

patients previously treated by open discectomy and decompression

of the lumbar spine. Eur Spine J 20(4):623–628

1222 Eur Spine J (2012) 21:1220–1222

123