Minimally invasive spine surgery Discussion

Minimally invasive spine surgery Discussion

1. Minimally invasive lumbar spine surgery DR. RITESH KARWARIA DEPARTMENT OF NEUROSURGERY SARDAR PATEL MEDICAL COLLEGE, BIKANER

2. Introduction Any procedure that is less invasive than open surgery, used for the same purpose. Coined by John CA Wickham in 1984 . Minimal damage to biological tissues. Accomplish same operative goals as open spinal procedures with less disturbance of normal anatomy .

3. WHAT IS MISS? Minimally invasive spine surgery, also known as MISS, is any minimally invasive procedure that targets conditions specifically within the spine through the use of small incisions as opposed to traditional open-spine surgery which requires large incision .

4. Advantages of MIS Surgery Better cosmetic results from smaller skin incisions Less blood loss from surgery Reduced risk of muscle damage Reduced risk of infection and postoperative pain Faster recovery from surgery and less rehabilitation required Diminished reliance on pain medications after surgery

5. S ome MIS surgeries can be performed as outpalient procedures and utilize only local anesthesia — avoids risks of general anesthesia.

6. Goals of MIS Surgery Goals of MIS surgery include Decompression Fusion and/or instrumentation Realignment. What distinguishes MIS surgery from traditional open surgery is : Avoid muscle crush injury by Self-retaining retractors; Do not disrupt tendon attachment sites of key muscles, particularly the origin of multifidus muscle at the spinous process; Use known anatomic neurovascular and muscle compartment planes , and Minimize collateral soft tissue injury by limiting the width of the surgical corridor.  

7. M uscle group arrangement in lower back-MR cross-sectional image through L4—L5 disc space showing the multifidus (M) iliocostalis(IL ), longissimus ( LO), Q uadratus Lumborum (QL ), intertransverseri (IT ), and psoas muscles

8. Use of MIS Surgery MISS can be used to treat a number of spinal conditions such as degenerative disc disease, disc herniation, fractures , tumors , infections, instability and deformity. It m akes spine surgery possible for patients who were previously considered too high risk for traditional surgery due to previous medical history or the complexity of the condition.

9. Procedures that can be performed via MIS technique Cervical Cervical lamino-foraminotomy Cervical laminoplasty   Dorsal Vertebrectomy Thoracoscopic sympathectorny Posterior Thoracic Fusion

10. Lumbar Discectomy Decompression Lateral foraminotomy Interbody fusion ALIF, PLIF, TLIF, DLIF, OLIF, XLIF Percutaneous pedicle screw fixation Vertebroplasty and balloon kyphoplasty Deformity correction Tumor excision Biopsy

11. Techniques of M inimally I nvasive S pine S urgery Microscopic Techniques Using a Tubular Retractor Serial Tubular Dilators inserted in lumbar region corresponding to diseased part in paraspinal muscles ----> goes through muscle by splitting the muscle rather than cutting. Visualisation Tool: Microscope Less Blood Loss Less Muscle Trauma

12. 2. Endoscopic Techniques Spinal Fusions as well as decompressions can be performed with an endoscopic approach . Advantages over microscope is angled field of view allowing better visualisation A. Full Endoscopic procedure (Trans foraminal) Its a trans muscular approach using endoscope and through ‘single’ incision B. Destandau’s Technique Its an endoscopic approach using the ENDOSPINE C. Biportal Endoscopic Procedure Its a trans muscular approach using endoscope and through two incisions

13. 3. Newer Advances Robotics ( mainly for Pedicle Screw fixation, More precise , least soft tissue abrasion compared to free hand ) Neuro-Navigation guided Spine surgery Augmented Reality assisted Spine surgery

14. Percutaneous Lumbar Discectomy - 1975, Hijikata Indications Failure to respond to non operative measures Correlative pain distribution Positive tension signs Correlative radiological studies With or without neurological deficits Contraindication Cauda Equina Syndrome

15. Small caliber cannula Dorsolateral insertion Positioned in the SAFE zone ( Kambin’s Triangle) Quick look at the canal content Annulotomy Disc extraction -  Can be done for single level discs Visulisation tool : Microscope/ Endoscope / Arthroscope -can be performed with help traditional disc forceps or LASER or Radiofrequency Thermocoagulation

16. Advantages Nerve roots and thecal sac not retracted Peri/epidural scar formation minimal Supportive myeloligamentous structures are not disturbed Post –op stay/cost/morbidity minimized. Disadvantages Learning curve Unable to address migrated disc fragments Unable to address bony or ligamentous pathology

17. Lumbar Microendoscopic Discectomy Developed by Sofamor Danek Same technique as Microscopic Lumbar Discectomy Visulaisation Tool : Endoscope Instead of Microscope Decreased Perioperative blood loss

18. Indications are similar : Spondylolisthesis • Degenerative disc disease • Internal disc derangements • Instability and for reoperations Retroperitoneal approach does not require carbon dioxide insufflation or entrance into the peritoneal cavity and avoids dissection near the large vessels and the hypogastric plexus

19. Endoscopic OR Microscopic Lumbar Surgery ? Endoscopic lumbar surgery can be performed using a single port, two ports or Destandau’s technique while microscopic lumbar surgery through a midline or paraspinal approach. The choice of surgical approach depends on the patient’s condition and the surgeon’s decision. The lumbar posterior approach involves two primary methods using an endoscope : Interlaminar approach used to treat spinal stenosis on both contralateral and ipsilateral sides and, Transforaminal approach used to treat foraminal stenosis.

20. Disadvantages : steep learning curve, limited field of view, and narrow surgical field .

21. Spinal Endoscopy  FDA-approved indications for the use of spinal endoscopy are as follows: documentation of pathological feature documentation of decompression of structures direct nerve inspection inspection of internal fixation and delivery of therapeutic agents

22. Laparoscopic Lumbar S urgery  Can be used for Lumbar Fusion 2 approaches : Intraperitoneal and Retroperitoneal Obenchain , 1991 – Laparoscopic Lumbar Discectomy Mathews, 1991 - Laparoscopic anterior lumbar fusion Dural injury and epidural scarring can be avoided Retroperitoneal approach to the lumbar spine was first described by wahara in 1963

23. Lumbar interbody fusion If the patient’s condition cannot be resolved lumbar posterior decompression surgery, lumbar fusion surgery may be necessary. Sufficient decompression and fusion are possible with conventional posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF).

24. Transforaminal lumbar interbody fusion (TLIF) approach can directly decompress the neural foramen by removing the facet joint through direct approach to unilateral facet joint. A ccess to the disk space is possible through this route, allowing discectomy and interbody cage insertion. A ngle of insertion of the interbody cage is relatively gentle compared to the coronal orientation of human body, this technique allows insertion of a larger cage. TLIF can be performed using a microscope with a tubular retractor or an endoscope. can minimize damage to structures that contribute to posterior stability such as interspinous ligaments, contralateral facet joints, and paravertebral muscles

25. Thank You