Transcript MIS - About Back & Neck Pain

Minimally Invasive
Spine 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
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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 Insertion
Mark 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 screwextension 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 Insertion
Mark 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 screwextension 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
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• Notice 6 lumbar
vertebrae
• Lateral x-ray reveals
L6-S1 spondylolysis—
also an S1-S2
spondylolysis
• Slight lumbar scoliosis
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 Requires
Accurate 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 the
Disc 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
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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 Indications
The VIPER System was cleared under the EXPEDIUM Family for the following
indications:
The VIPER System is intended for noncervical pedicle fixation for the following
indications: degenerative disc disease (defined by back pain of discogenic origin
with 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 failed
previous fusion in skeletally mature patients. When used in a percutaneous,
posterior approach with MIS instrumentation, the VIPER System screw
components are intended for noncervical pedicle fixation and nonpedicle
fixation for the following indications: degenerative disc disease (defined by back
pain of discogenic origin with 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 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.