anders j. cohen, do chief- neurosurgery & spine the ...€¦ · anders j. cohen, do chief-...
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Anders J. Cohen, DOChief- Neurosurgery & SpineThe Brooklyn Hospital Center
Trans1 – Surgeon Advisory Panel
Evolution from Postero-lateral gutter to Interbody
InterbodyApproaches have blossomed
ALIF, DLIF, ELIF, GLIF, ILIF, LLIF, OLIF, PLIF, TLIF, XLIF, AxiaLIF, etc.
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Poor Fusion Results Posterolateral
Wolff’s Law Interbody Cage
Approach & Development –Reduce & Balance
Additional Decompression –Indirect
360 Fusion PLIF ALIF TLIF
Newer generations Less invasive /
disruptive Skew good / bad
ratio Improve Pt outcomes
Short Term Better Long Term
Results
The Least Invasive Approach to the Lumbosacral Region
Access Pre-Sacral Fusion Discectomy Osteogenic Material Distraction and Stabilization
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Pre-sacral space between parietal and visceral fascia
Potential for deviation into visceral structures reduced by advancing trocar along the sacrum
Average sagittal diameter of presacralspace measured 1.2 cm
Typical excellent trajectory Infrequent and unsuitable trajectory
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EARLY Bleeding Infection Bowel Injury Nerve Injury
LATE Subsidence Lucency Pseudoarthrosis Fusion mass / rate
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AxiaLIF ® Clinical StudiesComplication Rates / Length of Stay / Surgical Time
Complication Rate(%)
Procedure Time(hours)
Length of Stay(days)
3%
3%
Author / Facility Pts
Avg F/U
months
Avg. Blood Loss
Fusion Rate
ODI Pre
ODI Post
VAS Preop
VAS Post 1yr
VAS Leg Pre
VAS Leg Post TIME Comp.Rate
LOS (days)
Pimenta (1) 26 24 47.1cc 93% 43 19 80 29 122 3% 1.4
TBI (2) 20 5 38cc 85% 43 26 73 26 (5mo) 5.32 1.85 80 0% 1.2
UCSF/UCSD (3) 35 14.5 30cc 91% 42 22 75 31 42 3% 1.0
UCLA (4) 28 12 Minimal 90% 48 22 82 12 8.2 1.2 45 0% 1.0
Mayfield Clinic (5) 26 24 88cc 88% 49 33 67 41 216 0% 2.6
12
0.0
0.2
0.4
0.6
0.8
1.0
Q105 Q2 Q3 Q4 Q106 Q2 Q3 Q4 Q107 Q2 Q3 Q4
0
500
1,000
1,500
2,000
Changes with Complications
Inci
den
ce R
ate
(%
)
Num
ber of P
rocedures
Num
ber of P
rocedures
Recommendation to include coccyx in pre-op imaging
Q106
Soft Tissue model Q206
Blunt Finger Dissection Q306
Finger sweep technique added to surgical
techniqueQ306
Fixation wire became available
Q206
Exchange cannulaQ406
Fixation wire added to surgical technique
Q107
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Pre-op Workup
Indications for fusion
Contraindication
• Previous bowel surgery, IBD, Pelvic disease
Age appropriate
Failure of conservative therapy
Images: MRI & Flexion/Extension films
• Standard field of view for lumbar MR increased to include coccyx
Review for trajectory & anatomy
Overnight bowel prep
Unique Anatomy Transition Segment Natures 1st Adjacent
Level Synd Unique
Biomechanics
Anterior InterbodyConstruct & Biologics
Posterior Demands› Stand alone› Pedicle Screw› Facet Screw› Combo› Intraspinous
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• “Load Bearing”
• Surface Area
• Location
• Conduit to Fusion
• Still highly debatable
• Better Anterior Technique
• Bigger Grafts
• Load Sharing
• Accessing Strongest Bone
• Long Construct
• “Too Strong?”
• Stress Shield
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• Facet screws
• Intraspinous Devices
• Load Sharing?
• Shear Resistance
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6 Month Postop
70 Male Unable to Ambulate Multiple Co
morbidities Anticoagulation
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4 month
ScrewLucency
TLIF 2005
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Standard F/U
VAS = 3 (pre op 9)
7 m
onth
Face
t Fus
ion?
40 female
VAS = 9
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6 month
12 month VAS=1
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Legitimate Technology Significantly Less Disruptive of Healthy, Supportive
Structures Complication rate in line with alternative approaches New Considerations of Biomechanics Must Continue to Assess Complimentary Posterior
Support (Inverse of Post-Lat Shortcomings) Patient Selection / Indications Surgeon MUST be Critical Thinker & Independent
Analyst Surgeons Must Confer & Share Experiences – The
good, Bad & Ugly…