why & how minimally invasive lumbar decompression · bilateral lumbar decompression via...

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MINIMALLY INVASIVE LUMBAR DECOMPRESSION WHY & HOW KHALED ALALI, MBBS, FRCSC CONSULTANT NEUROSURGEON ZAYED MILITARY HOSPITAL

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Page 1: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

M I N I M A L LY I N VA S I V E L U M B A R D E C O M P R E S S I O N

W H Y & H O W

K H A L E D A L A L I , M B B S , F R C S C C O N S U LTA N T N E U R O S U R G E O N

Z AY E D M I L I TA R Y H O S P I TA L

Page 2: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

O B J E C T I V E S

• What is Minimally invasive spine surgery?

• advantages and disadvantages of MIS decompression

• Literature review

• How minimally invasive lumber decompression is done?

Page 3: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Tubular lumbar decompression =

Minimally invasive lumbar decompression

Page 4: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

“What is MIS?”

Page 5: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

1 9 6 7 - M I S C R O S C O P I C D I S C E T O M Y ( YA S A R G I L )

2 0 0 1 - S E X TA N T P E R C U TA N O U S

P E D I C L E S C R E W S Y S T E M ( F O L E Y )

2 0 0 3 - T U B U L A R M I C R O S C O P I C

D I S C E C T O M Y ( F O L E Y )

Page 6: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

M I S G A O L S

• Decompression

• Stabilization

• Realignment

S A M E A S O P E N

Page 7: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

W H AT M A K E S M I S A M I S ?

1. muscle splitting

2. retractor (e.g tubular)

3. limited resection (bone, disc)

L E S S C O L L AT E R A L D A M A G E

N O T A B O U T S M A L L I N C I S I O N

Page 8: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

1 . M U S C L E S P L I T T I N G

• minimize muscles damage

• “Save” Multifidus muscle

Page 9: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

M U LT I F I D U S M U S C L E

• strong muscle

• act as a “stabilizer” to the lumbar spine

E V I D E N C E S U G G E S T S T H AT PA R A S P I N A L M U S C L E S A R E S I G N I F I C A N T LY S M A L L E R I N PAT I E N T S W I T H C H R O N I C L B P

F O R T I N M , M A C E D O L G . P H Y S T H E R . 2 0 1 3 J U L ; 9 3 ( 7 ) : 8 7 3 - 8 8

Page 10: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Multifidus muscles

attachment of multifidus muscle

Page 11: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Multifidus muscles

Open decompression: muscle detachment

Page 12: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Multifidus muscles

MIS decompression

Page 13: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Multifidus muscle

MIS decompression

Longissimus muscle

Page 14: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

2 . R E T R A C T O R S

self retaining table mounted

blades / hooks tubular

O P E N D E C O M P R E S S I O N M I S D E C O M P R E S S I O N

Page 15: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

K I M , D . Y. , E T A L . S P I N E 2 0 0 5 . 3 0 ( 1 ) : P. 1 2 3 - 9

“less paraspinal muscles atrophy with MIS ”

O P E N D E C O M P R E S S I O N

M I S D E C O M P R E S S I O N

B R E S N A H A N L E E T A L . J S P I N A L D I S O R D T E C H . 2 0 1 3 O C T 1 3 .

Page 16: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

R E T R A C T O R S

• with open decompression

• increased systemic markers (serum creatinine kinease, Adolase)

• muscle fibrosis and necrosis

K I M , E T A L . S P I N E 2 0 0 6

Page 17: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

3 . M I N I M A L R E S E C T I O N

L A M I N E C T O M Y O P E N D E C O M P R E S S I O N M I S D E C O M P R E S S I O N

Page 18: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

• decompressing the lumbar spine with minimal paraspinal muscle damage

• in case of bilateral decompression, utilizing unilateral approach to decompress both sides

What is MIS lumbar decompression?

S AV I N G M U LT I F I D U S M U S C L E

Page 19: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Bilateral lumbar decompression via unilateral approach - clinical outcome -

• satisfactory surgical outcomes with a minimum 5-year follow-up.

S P I N E V O L U M E 3 6 , N U M B E R 5 , P P 4 1 0 – 4 1 5 2 0 1 1

S U R G I C A L N E U R O L O G Y 6 8 ( 2 0 0 7 ) 4 8 7 – 4 9 2

Page 20: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

• Prospective comparing pre and postop.

• no control

• n = 57 patients

• improved JOA score

S P I N E V O L U M E 3 6 , N U M B E R 5 , P P 4 1 0 – 4 1 5 2 0 1 1

Page 21: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

• more back pain with tubular approach

Eur Spine J (2011) 20:51–57

Page 22: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Bilateral lumbar decompression via unilateral approach - HOW -

Page 23: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

• By studying pre-op MRI

• unilateral, bilateral

• how many levels?

• Central stenosis, lateral recess, foraminal stenosis

1 . W H AT T O D E C O M P R E S S ?

Page 24: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Trajectory of tubular retractor

2 . S K I N I N C I S I O N & T R A J E C T O R Y

Page 25: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

• Mark the skin incision with flour xray

2 . S K I N I N C I S I O N & T R A J E C T O R Y

M E D I A L

Level mark (e.g L4-L5)

medline

incision

L AT E R A L

Page 26: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

• to split the muscle

• to reach contralateral side

2 . S K I N I N C I S I O N & T R A J E C T O R Y

Why paramedic incision?

Page 27: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

2 . S K I N I N C I S I O N & T R A J E C T O R Y

midline incision

Page 28: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

2 . S K I N I N C I S I O N & T R A J E C T O R Y

midline incision

Page 29: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

2 . S K I N I N C I S I O N & T R A J E C T O R Y

Why paramedic incision?

Page 30: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

2 . S K I N I N C I S I O N & T R A J E C T O R Y

Why paramedic incision?

Page 31: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

3 . S E R I A L T U B U L A R D I L AT O R

Page 32: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

4 . P L A C I N G T U B U L A R R E T R A C T O R

Page 33: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

5 . L O C A L I Z I N G W I T H F L U R O

Page 34: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

5 . L O C A L I Z I N G W I T H F L U R O

Page 35: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

5 . L O C A L I Z I N G W I T H F L U R O

X

Page 36: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

6 . S O F T T I S S U E R E M O VA L

Page 37: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

7 . I D E N T I F Y I N G A N AT O M Y

L A M I N A

Medial

Lateral

Rostral Caudal

Page 38: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

7 . I D E N T I F Y I N G A N AT O M Y

Medial

Lateral

Rostral Caudal

Page 39: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

7 . I D E N T I F Y I N G A N AT O M Y

FA C E T

Medial

Lateral

Rostral Caudal

Page 40: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Rostral

Lateral

Caudal

Medial

8 . I P S I L AT E R A L D E C O M P R E S S I O N

dura

nerve root

Page 41: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

Rostral

Lateral

Caudal

Medial

8 . C O N T R A . D E C O M P R E S S I O N

contra.nerve root

Page 42: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

8 . C O N T R A . D E C O M P R E S S I O N

Page 43: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

R E M O VA L O F T U B U L A R R E T R A C T O R

Page 44: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

• Postoperative CT scans show microsurgical bilateral decompression through the right-sided approach.

Page 45: WHY & HOW MINIMALLY INVASIVE LUMBAR DECOMPRESSION · Bilateral lumbar decompression via unilateral approach - clinical outcome - • satisfactory surgical outcomes with a minimum

T H A N K Y O U !