b 756 vertebris gb - marien hospital witten

VERTEBRIS Lumbar-ThoracicFull-endoscopic Spinal Instrumentation

Vertebris

B 756 Vertebris GB 04.11.2008 13:49 Uhr Seite 1

2


VERTEBRIS lumbar-thoracic,full-endoscopic techniquesTable of contents

Vertebris

VERTEBRIS lumbar 4

Introduction 4

The full-endoscopic trans- and extraforaminal technique 6

• Positioning of patient 8

• Determination of lateral access route 8

• Creation of lateral access 9

• Performance of operation 12

• Creation of posterolateral access 13

• Creation of extraforaminal access 14

• Bone resection 15

• Biportal access 16

The full-endoscopic interlaminar technique 17

• Positioning of patient 19

• Determination of access route 19

• Creation of access 20

• Performance of operation 21

• Bone resection 24

VERTEBRIS thoracic 25

Introduction 25

The full-endoscopic transforaminal technique 26

The full-endoscopic interlaminar technique 27

VERTEBRIS basic sets

• VERTEBRIS lumbar trans-/extraforaminal basic set 28

• VERTEBRIS lumbar and thoracic interlaminar basic set 29

• VERTEBRIS thoracic transforaminal basic set 30

• VERTEBRIS instruments 31-39

Literature 40

Notes 41-42

3


VERTEBRIS lumbarIntroduction

Lateral approach for the full-endoscopic trans-foraminal operation

Musculoskeletal pain is one of themost common reasons for visiting thedoctor. Degenerative diseases of thespine form part of daily medical prac-tice and their treatment is complicatedby medical and socioeconomic prob-lems.

Where severe pain or neurologic defi-cits persist and all conservative treat-ment options have been exhausted,surgery may be required. Though con-ventional operations can achieve goodresults, damage may ensue due totraumatization. It is therefore impor-tant that the surgical techniques usedbe optimized on a continuous basis.

The latest research results and techni-cal innovations must be critically re-viewed so that optimal treatment strat-egies can be formulated. The aimshould be to minimize surgically in-duced trauma and negative long-termsequelae, taking existing quality stan-dards into account.

Minimally invasive techniques can re-duce tissue damage and its conse-quences. Endoscopic operations withcontinuous irrigation have advantagesthat have made them the gold stan-dard in a number of areas. Trans-foraminal procedures with posterolat-eral access have been performed inthe lumbar spine for more than 20years now, mostly for intradiscal andintra and extraforaminal procedures.In our Department of Spine Surgeryand Pain Therapy we have thereforebeen developing a lateral transforami-nal and an interlaminar approach forfull-endoscopic access to the spinalcanal since 1998. These approachesbroaden the range of indications andpermit the use in selected indicationsof a visually controlled procedure thatis as effective as conventional surgerywhile benefiting from all the advanta-ges of truly minimally invasive surgery.

Until fairly recently, the endoscopicapproach was subject to technicalproblems in that the intraendoscopicworking channel of the available opti-cal systems was small and the reper-toire of instruments that could be usedwas correspondingly limited. Insur-mountable difficulties could arise inthe resection of hard tissue and interms of limited anatomic access andmobility. Work on the affected tissuewas limited and sometimes had to beperformed without direct visualization.New rod lenses with a 4.1 mm intra-endoscopic working channel and cor-responding new instruments, as wellas shavers and burrs, were thereforedeveloped so that full-endoscopicoperations could be performed undercontinuous and precise visual control.This also permitted adequate bone resection. The range of indications forendoscopic spinal surgery was thus

The latest generation of endoscopes have a large (4.1 mm) working channel

Continuous irrigation provides outstanding intraoperative visualization

broadened to include intervertebraldisc herniations, spinal canal steno-sis, and stabilization techniques.

4


Full-endoscopic surgery has now wona firm place in the surgery of lumbarspine conditions. Provided that the indi-cations for its use are observed, it re-presents a useful and safe addition oralternative to conventional surgery. Full-endoscopic operations can also be per-formed on the cervical and thoracic spi-ne. Recent technical developments andthe use of new access routes have led

to a change that suggests the onset ofa revolution in spinal surgery similar tothat which occurred in orthopedics withthe introduction of arthroscopic proce-dures. Nevertheless, conventional andmaximally invasive operations will con-tinue to play an indispensable role inspinal surgery. Surgeons will need to beable to perform these techniques too inorder to overcome problems and com-plications of full-endoscopic operationssuch as can occur with any invasiveprocedure.

The development of full-endoscopictechniques should not be seen as spel-

Department of Spine Surgery and Pain TherapyHead: Dr. Sebastian Ruetten, M.D.

Center for Orthopaedics and Traumatology St. Anna Hospital, Herne, Germany

Director: Prof. Georgios Godolias, M.D.

at the Department of Radiology and MicrotherapyUniversity of Witten/Herdecke

The development of new instruments broadensthe range of possible procedures

ling the end of existing operative stan-dards; rather, it should be seen as avaluable additional option within thefield of spinal surgery.

Herne, July 2007

Dr. Sebastian Ruetten, M.D.Head Department of Spine Surgery andPain Therapy

Vertebris

5


VERTEBRIS lumbarThe full-endoscopic trans- and extraforaminal technique

Percutaneous operations aimed atachieving intradiscal decompression oflumbar intervertebral discs were firstdescribed in the early 1970s. Opticalsystems designed for inspecting the intervertebral space after open operationwere introduced in the early 1980s.Later, a full-endoscopic technique usinga transforaminal approach was develo-ped. In anatomic terms, this means thatthe intervertebral disc is reached via aposterolateral approach through the intervertebral foramen between the exi-ting and traversing nerve roots withoutneed for resection of bony or ligamen-tous structures. The skin entry point foroperative access is determined in centi-meters from the midline. Most suchoperations are performed for the purpo-se of intradiscal or extradiscal forami-nal therapy. Reduction of intradiscal volume and pressure can reduce disc-related compression. Removal of intraand extraforaminal disc material istechnically possible. Sequestered ma-terial lying within the spinal canal cangenerally be resected in retrograde fashion intradiscally via the annular defect. This is done using an "in-out"technique.

Sequestered nuclear material is foundwithin the spinal canal dorsal to the an-nulus in the ventral epidural space me-dial to the medial pedicular line. In many cases it extends to the midline oreven to the contralateral side. Clinicalexperience has shown that the annulardefect is often smaller than the diameterof the sequestered material. In addition,there is generally no longer any directconnection to the intradiscal space. Inthe case of badly degenerated discs orolder disc herniations, the continuity ofthe sequestered material has often beenlost and removal in one piece is gene-rally not possible. These factors often

make it difficult to resect sequesterednuclear material using an intradiscal re-trograde approach. In order to achieveadequate decompression, it is thereforenecessary to access the extradiscalventral epidural space directly undercontinuous visual control.

The most frequent site of lumbar inter-vertebral disc herniations is in the lowersegments. The diameter of the interver-tebral foramen decreases in a cranial tocaudal direction. Additional narrowingmay result from degenerative changes.Particularly at the lower lumbar levels,these anatomic factors often make itdifficult to gain extradiscal access to theventral epidural space under visualcontrol when using the posterolateralapproach. Similarly, lateral placementof the endoscope in order to reach thespinal canal tangentially after accesshas been created is technically difficultdue to the preceding passage throughsoft tissue and the zygapophyseal joint.These problems make it difficult toachieve adequate decompression on areliable basis when using the postero-lateral approach.

For these reasons a lateral transforami-nal approach has been developed in recent years.*

In this technique the skin entry point isdetermined not by measurement in cen-timeters, but on an individual anatomicbasis under radiographic control. Theapproach permits tangential access tothe spinal canal and consequently thedirect visualization of the ventral epidu-ral space with continuous irrigation thatis required in order to achieve adequatedecompression. Used in combinationwith newly developed endoscopes witha large working channel and corre-sponding new instruments, shavers,and burrs, this technique has a broadbut clearly defined range of indications.

As a guideline for decompression of thespinal canal, caudal and cranial mobi-lity should extend to the middle andstart of the pedicle, respectively. Nar-rowed foramina are no longer a limitati-on, since they can be broadened. Thepelvis can prevent the required lateralaccess, therefore in an orthograde later-al radiographic view it should not

The skin entry point for the well-known poste-rolateral approach is measured in centimetersfrom the midline

With the posterolateral approach the workingarea is mostly intradiscal

6


The lateral transforaminal approach providesaccess to the spinal canal in the lower lum-bar segments

The lateral transforaminal approach shiftsthe working area to the spinal canal

In the lower lumbar segments the pelviscan prevent the required lateral transfora-minal access

project beyond the middle of the cranialpedicle. At the highest lumbar levels thelaterality of the approach is limited bythe thoracic and abdominal organs.Because of the greater size of the inter-vertebral foramen cranially and the pos-sibility of bone resection, a larger ra-dius of action is achieved here andconsequently a less lateral access routecan be chosen. In the case of intra andextraforaminal decompression opera-tions there are no restrictions. Here, too,a lateral approach is attempted in orderto permit atraumatic passage below theexiting spinal root. The surgical accesstechnique for intra- or extraforaminaldisc herniations and foraminal stenosismay differ from the conventional techni-que in order to avoid damaging exitingnerve roots that are dislocated or notdefinitely localizable. In such cases theextraforaminal approach is used.

Intradiscal procedures such as thoserequired for fusion or infection often callfor the posterolateral approach. The ap-proach is always determined by the tar-get point, account being taken of indivi-dual pathology and anatomy. Outside

of the established indications for itsuse, the transforaminal approach hasdefinite limitations.

* Ruetten et al. (2005) An extreme lateral ac-cess for the surgery of lumbar disc hernia-tions inside the spinal canal using the full-en-doscopic uniportal transforaminal approach.– Technique and prospective results of 463patients. Spine 30:2570–2578

Ruetten et al. (2007) Use of newly developedinstruments and endoscopes: full-endoscopicresection of lumbar disc herniations via theinterlaminar and lateral transforaminal ap-proach. J Neurosurg Spine 6:521-530

Vertebris

7



1. Positioning of the patient

The patient is positioned prone on a radiolucent table with a pelvic and athoracic roll. Use of a C-arm is requiredduring the operation.

2. Determination of lateral access route

Access is determined on the basis ofanatomic landmarks under orthogradelateral and posteroanterior fluoroscopicguidance, account being taken of thepathology. Depending on the level, thepossibility of injury to abdominal or-gans must be excluded.

Prone position with pelvic and thoracic roll

Determination of maximum ventrality on the basis of individual anatomic landmarks and markingof the entry line on the skin

Determination of the intervertebral disc level under orthograde posteroanterior fluoroscopic guidance and determination of the skin entry point

8


3. Creation of lateral access

After the skin entry point has been determined and the puncture incisionmade, a spinal cannula is introducedunder fluoroscopic guidance, care be-ing taken not to damage neural struc-tures. Positioning in relation to the spi-nal canal is determined individually inaccordance with the target point. Theguidewire is then introduced and thespinal cannula removed.

Introduced spinal cannula

The spinal cannula touches the dorsal annulus at the medial pedicular line at the beginning of thespinal canal

The spinal cannula is advanced in the dorsal annulus towards the spinal canal

Vertebris

9



Using rotatory movements, the dilatoris passed along the guidewire as far asthe foramen. After removal of the guidewire it is – depending on the pathology – inserted into the spinal canal.

A beveled working sleeve is then inser-ted over the dilator and the dilator is removed. Care must be taken to protectneural structures during all workingsteps. The guidewire is positioned and the spinal

cannula is removed

The dilator is inserted over the guidewireand is in the final position in the spinal canal or dorsal annular defect

10


The working sleeve is positioned via the dilator and the dilator is removed. The beveled opening is situated inside the spinal canal dorsal to the annulus

Vertebris

11



The endoscope is passed through theworking sleeve. The operation is per-formed via the intraendoscopic workingchannel using alternating sets of instru-ments under full visual control and withcontinuous irrigation.

The sealing caps for the optic undworking sleeve should be used only forbrief periods when bleeding obscuresvision, since with long operation timesand unnoticed obstruction to backflowof irrigation fluid there is a theoreticalrisk of volume overload and increasedpressure within the spinal canal and inthe associated and adjacent structures.Experience has shown that, as with allnew techniques, the risk of complica-tions is greatest during the learningperiod.

4. Performance of operation

The lateral approach makes it possible to work in the spinal canal under full visual control

12


Obstruction of lateral access by the pel-vis or the risk of causing injury to ab-dominal or thoracic organs in the crani-al lumbar segments can necessitate amore posterior or even a posterolateralapproach in intradiscal operations. Theskin entry point depends on the indivi-dual pathology and anatomy and canbe either measured in centimeters fromthe midline or determined by appro-priate positioning of the introducedspinal cannula. The subsequent steps,including insertion of the guidewire, thedilator, the sheath, and finally the optic,are the same as in the procedure de-scribed above.

5. Creation of posterolateral access

Vertebris

Measurement of the skin entry point in centimeters from the midline

The maximum laterality of access can bedetermined on the basis of a preoperativeCT scan so as to prevent injury to organs

Operation with posterolateral transforaminalapproach

The introduced spinal cannula at the desiredtarget point can determine the site of thepuncture incision

13


In intra- and extraforaminal interverte-bral disk herniations and in foraminalstenosis, the exiting nerve roots may beat increased risk of injury when the ac-cess instruments are passed throughthe foramen. This may necessitate anextraforaminal approach. The skin entrypoint can be posterolateral to lateral.Instead of being inserted through the foramen into the spinal canal, the spi-

nal cannula is advanced onto the cau-dal pedicle of the segment to be operat-ed on. This is the safest area in termsof the exiting nerve roots and its use re-duces the risk of access-related injury.Subsequently the guidewire, the dilator,and the sheath are likewise advanceduntil they make bony contact with thepedicle. The anatomic structures of thecaudal foramen are then dissected un-der direct vision, the exiting nerve rootis identified, and the operation is per-formed without damaging the nerve root.

6. Creation of extraforaminal access


The caudal pedicle is a safe area in terms ofthe exiting spinal nerve root

Dissection of the anatomic structures of the caudal foramen and the exiting spinal nerve root

Insertion of the spinal cannula as far as the caudal pedicle

14


Vertebris

Resection of bone may be required inorder to increase mobility within the spinal canal or when problems ariseduring access. This can occur, for example, in cases of degenerative orhereditary foraminal stenosis and in recess stenosis operations. The skin entry point can be posterolateral to later-al. After trans- or extraforaminal accesshas been obtained the bony structuresmust be dissected for this purpose. Inmost cases ventral parts of the ascend-ing facet are resected. When parts of thecaudal pedicle are resected it must beremembered that this is a weightbearingstructure. Extensive resection can weak-en the biomechanical structure and result in pedicle fractures.

7. Bone resection

In most cases ventral parts of the ascending facet are resected

Sometimes damaging of the joint in order toreach the medial edge of the ascending facet can not be avoided

15

A range of burrs and bone punches areavailable for bone resection



A biportal approach can be required incertain indications such as spondylo-discitis and insertion of implants andwhen working with special instruments.Access is normally posterolateral usingthe standard technique. The endoscopecan be inserted either unilaterally or inalternating fashion.

8. Biportal access

Biportal transforaminal access

16


Vertebris

Direct access to the epidural space un-der continuous vision is a preconditionfor the performance of satisfactory opera-tions within the spinal canal. When thefull-endoscopic transforaminal techniqueis used, the lateral approach is often re-quired for this purpose. The bony andneural boundaries of the neuroforamenimpose limits to mobility and thus alsoto the indications for operations of thistype. Moreover, in the lower lumbar seg-ments the required lateral access can beblocked by the pelvis. It has been foundthat these limitations make it technicallyimpossible to operate on some patholo-gies using the full-endoscopic transfora-minal approach.

In order to reduce the incidence of surgi-cally induced traumatization of the struc-tures of the spinal canal, it is expedientto make use of anatomically preformedaccess routes. In addition to the interver-tebral foramen, these include the sacralhiatus and the interlaminar window. Fortechnical reasons, epiduroscopy via thesacral hiatus does not permit resectionof large structures. This leaves open thepossibility of surgical access via the interlaminar window, a long-establishedand commonly used technique in lum-bar spine surgery that was first describedin the early 1920s. Various alternativemethods were developed in later years,e.g. posterolateral biopsy of the spine in

the late 1940s and intradiscal decom-pression by means of chemonucleolysisin the early 1970s. Endoscopic inspec-tion of the intervertebral space after opendecompression was described in theearly 1980s. Full-endoscopic operationswere performed mostly using the transfo-raminal technique with posterolateral ac-cess.

A microsurgical technique performedwith the aid of a microscope was de-veloped in the late 1970s and went on

to become the gold standard for interla-minar decompression of the spinal ca-nal. An endoscopically guided techni-que, or microendoscopic operation, wasdescribed in the late 1990s. This usedan endoscope to provide visualization ofthe exposed surgical site on a monitor.

With the conventional technique, thespinal canal has to be opened in orderto gain access to the epidural space.This generally involves not only incisionof the ligamentum flavum, but alsoresection of bone. The basic require-ment is to achieve adequate accessthat provides visualization of the spinalcanal and permits work with instru-ments. Problems can arise as a resultof traumatization of the access path-way, resection of stabilizing structures,

and – especially in relation to the pos-sible need for revision operations –scarring. The basic role of the micros-cope is to reduce the size of the accessroute and provide optimal conditions oflight and vision. Resection of structuresof the spinal canal is generally unavoi-dable. The microendoscopic techniqueprovides access with less trauma thandoes the microscopic technique. Its ad-vantage lies in the smaller distance between the working area and the vi-sualizing system. Visual conditions andillumination are generally worse. It isnot a full-endoscopic technique in thestrict sense. Nowadays microendosco-pic access is sometimes combined witha microscopic surgical technique. Com-mon to all of these techniques is thefact that the access pathway generallyhas to be bigger than would be neces-sary for the actual work to be performedin the spinal canal.

The full-endoscopic interlaminar ap-proach was therefore developed in re-cent years in order to exploit the knownadvantages of transforaminal operati-ons and arthroscopy.*

* Ruetten et al. (2006) A new full-endoscopictechnique for the interlaminar operation oflumbar disc herniations using 6 mm endos-copes: Prospective 2-year results of 331 pa-tients. Minim Invasive Neurosurgery 49:80-87

Ruetten et al. (2007) Use of newly developedinstruments and endoscopes: full-endoscopicresection of lumbar disc herniations via the interlaminar and lateral transforaminal ap-proach. J Neurosurg Spine 6:521-530

Full-endoscopic interlaminar access

VERTEBRIS lumbarThe full-endoscopic interlaminar technique

17

Use of the endoscope based on the joystickprinciple provides mobility


VERTEBRIS lumbarThe full-endoscopic interlaminar technique

The fact that the lighting and imagingsystem with its 25° angle of vision issituated right in the working area ma-kes it possible to minimize traumatiza-tion not only of the access pathway, butalso of structures of the spinal canal.Continuous irrigation provides excellentvisual conditions. Mobility is achievedby handling of the new endoscope usingthe joystick technique. Neural structuresare protected by use of the beveled oper-ating sheath as a nerve hook. Whenused in conjunction with the newly de-veloped instruments, this is a genuinelyminimally invasive technique.

The main indications are pathologiessituated within the spinal canal. At-tention must be paid to the width of theinterlaminar window, which if too nar-row may prevent free passage of theendoscope. If this occurs the bone canbe resected with a burr until the targetpoint is reached without opening the li-gamentum flavum or damaging thezygapophyseal joints. Bone resectionshould generally be avoided, though incases of spinal canal stenosis it maybe necessitated by the pathology. Theincision in the ligamentum flavum canbe limited to a few millimeters, sincepenetration into the spinal canal is faci-litated by the elasticity of the ligament.Mobility to the contralateral side is simi-lar to that with conventional operations.In order to minimize resection of struc-tures of the spinal canal, craniocaudalaccess via neighboring lumbar seg-ments may be considered. The full-en-doscopic interlaminar technique permitsselective surgery on pathologies situa-ted within the spinal canal with minimal access-induced traumatiza-tion. The transforaminal technique isgenerally more suitable for intradiscaland intra- or extraforaminal work. Thetransforaminal approach is subject to

18

more limitations than the interlaminarapproach, but causes less tissue dam-age. Due to anatomic and pathologicfactors, the ratio of transforaminal to interlaminar procedures in clinical prac-tice is about 40 to 60.

The interlaminar approach provides outstandingvisualization of the structures of the spinal canal


Prone position with pelvic and thoracic roll

1. Positioning

The patient is positioned prone on a radiolucent table with a pelvic and athoracic roll. Use of a C-arm is requiredduring the operation.

2. Determination of access route

Access is determined on the basis ofanatomic landmarks under posteroan-terior fluoroscopic guidance, accountbeing taken of the pathology. The skinincision should be made as far medial-ly in the interlaminar window as possi-ble in order to permit insertion in a lateral direction below the obliquely ori-ented zygapophyseal joints.

The skin entry point should be as medial aspossible

Marking of skin entry point

Entry below the zygapophyseal joints shouldbe made possible

Puncture incision

Vertebris

19


VERTEBRIS lumbalThe full-endoscopic interlaminar technique

After the skin entry point has been determined and the puncture incisionmade, the dilator is inserted as far asthe ligamentum flavum under postero-anterior fluoroscopic guidance. Thesubsequent procedure is performed un-der lateral fluoroscopic guidance. Theworking sleeve with a beveled openingis advanced towards the ligament viathe dilator and the dilator is removed.

3. Creation of access

Insertion firstly of the dilator and then of the sheath to the ligamentum flavum under fluoroscopicguidance

20


The endoscope is passed through theworking sleeve. The operation is performed via the intraendoscopic workingchannel using alternating sets of instru-ments under full visual control and withcontinuous irrigation. Once the liga-mentum flavum has been opened, thespinal canal can be entered. Mobility isachieved by handling the endoscopeusing the joystick technique. The oper-ating sheath with its beveled openingserves as a second instrument and canbe rotated so as to protect the neuralstructures.

4. Performance of operation

The operating sheath with its beveled openingcan be rotated so as to serve as a second instrument

Vertebris

21



Use of the endoscope based on the joystick principle provides mobility

Opening of the ligamentum flavum View of L5-S1 axilla

The sealing caps for the optic undworking sleeve should be used only forbrief periods when bleeding obscuresvision, since with long operation timesand unnoticed obstruction to backflowof irrigation fluid there is a theoreticalrisk of volume overload and increasedpressure within the spinal canal and inthe associated and adjacent structures.In order to reduce the risk of neurologic

damage particularly in the cranial seg-ments, prolonged and continuous ex-cessive medial retraction of the neuralstructures with the working sleeve mustbe avoided or else retraction must beperformed on an intermittent basis.Experience has shown that, as with allnew techniques, the risk of complica-tions is greatest during the learningperiod.

22


Bone can be resected as necessary using theavailable instruments and burrs

The interlaminar approach makes it possible towork in the spinal canal under visual control

Vertebris

23



Lateral bone resection is performed on the floorof the spinal canal in the working area

5. Bone resection

Resection of bone may be required inorder to increase mobility within thespinal canal or when problems ariseduring access. This can occur, for ex-ample, in cases of sequestered discherniations or small interlaminar wind-ow and in recess stenosis operations.After access has been obtained, the bo-ny structures are dissected. It may beuseful to start decompression at thecaudal end of the descending facet.Depending on the pathology, medialparts of the descending or ascendingfacet or of the caudal and cranial lami-na are then resected.

It may be useful to start decompression atthe caudal end of the descending facet

The extent of bone resection depends on the pathology

A range of burrs and bone punches that canbe introduced through the intraendoscopicworking channel are available for bone resection

24


Vertebris

Depending on the individual pathologyand anatomy, transforaminal and inter-laminar procedures can also be per-formed in the thoracic spine. The princi-pal indication is thoracic intervertebraldisc herniations without major spinalcord compression that remains sympto-matic despite conservative therapy.Only laterally situated pathologies aregenerally amenable to operation, sincemanipulation of the spinal cord must beavoided because of the risk of injuryand because lateral transforaminal ac-cess is prevented by the thoracic or-gans. When a transforaminal procedure

is planned, a preoperative CT scanshould always be performed in order todetermine the exact skin entry point andthe possibility of free access to the in-tervertebral disc. Interlaminar accessnormally requires resection of bone,since the size of the interlaminar win-dow is generally insufficient, especiallylateral to the spinal cord. Operationsusing either access route can be per-formed anywhere from the cervicothora-cic to the thoracolumbar junction andare performed in the same way as in

the lumbar spine. Compared to thelumbar spine, the thoracic spine is sub-ject to a greater risk of injury to neuraland surrounding structures and hencealso to technical limitations in terms of access and surgical procedure. Incases that are borderline in terms ofanatomy, pathology, or clinical featu-res, a conventional operation may bethe only suitable option.

Thoracic disc herniation

VERTEBRIS thoracicIntroduction

25


VERTEBRIS thoracic

1. The full-endoscopic transforaminal technique

Access is determined with the aid of apreoperative CT scan. Structures to bespared are laterally the lung, mediallythe spinal cord, and ventrally the ves-sels. Access may be prevented by ana-tomic or degenerative bone structuressuch as ribs, transverse processes, orosteophytes. In general a decidedly posterior approach is required.

In order not to cause injury, the spinalcannula should be inserted parallel tothe intervertebral space under postero-anterior fluoroscopic guidance; it shouldlie strictly caudally in the foramen andon making contact with the disc shouldbe situated exactly between the medialand the lateral pedicular line in the fora-men. For added safety the spinal can-nula can first be advanced onto the bony structures of the intervertebral jointand then directed ventrally along thebone. After the dilator, the operatingsleeve, and the optic have been intro-duced, particular attention should bepaid during the operation to the medial-ly situated spinal cord.

26


Vertebris

2. The full-endoscopic interlaminar technique

The skin entry point is situated over theintervertebral joint/disc on the medialpedicular line, as in cervical foramino-tomy. From this point the spinal canalcan be reached without manipulation ofthe spinal cord.

After the dilator, the operating sleeve,and the optic have been introduced, thesize of the interlaminar window is gen-erally found to be insufficient to permitentry into the spinal canal without boneresection. A small amount of burring istherefore performed on the medial side

of the joint facets and if necessary onthe cranial and the caudal laminae. Thelateral part of the spinal canal must be

accessible as far as the intervertebraldisc without need to displace the spinalcord medially. There is no limit tocraniocaudal extension.

27


28

VERTEBRIS

Article Types pcs.

Basic set, VERTEBRIS lumbar trans-, extraforaminal Set-Nr. 892101111devised by Dr. Ruetten

Panoview Plus discoscope, 25°, WL 207 mm, Ø 6.9 x 5.6 mm, working channel Ø 4.1 mm 89210.1254 1

Conical adapter 8791.751 1

Membrane attachment 8792.451 1

Spinal cannula set, 10 pieces, sterile, WL 150 mm, Ø 1.25 mm 4792.803 1

Dilator, Ø. 6.9 mm 89220.1508 1

Working sleeve with bevel, Ø 8.0 mm, WL 185 mm 89220.1078 1

Extension sleeve, Ø 8.0 mm 89220.1408 1

Working sleeve attachment, Ø 8.0 mm 89200.1008 1

Micro-punch, Ø 2.5 mm, WL 360 mm 8792.671 1

Micro-rongeur with long jaws, Ø 2.5 mm, WL 360 mm 89240.1125 1

Nucleus grasping forceps, Ø 3.0 mm, WL 360 mm 89230.1003 1


Tube shaft punch, Ø 4.0 mm, WL 360 mm 89240.1904 1

Atraumatic dissector, Ø 2.5 mm, WL 350 mm 8792.591 1


X-Tractor 89230.0000 1

Mallet 8866.956 1

Power control generator 2303.001 1

Power stick M4 handle 8564.121 1

Resector, Ø 4.0 mm, WL 350 mm 89970.1004 1

Oval burr, laterally hooded, Ø 4.0 mm, WL 350 mm 89970.1504 1

Oval burr, frontally hooded, Ø 4.0 mm; WL 350 mm 89970.1514 1

"Surgitron" radiofrequency unit 2343.001/ .002 1

Trigger Flex handpiece, complete 8792.691 1

Trigger Flex bipolar electrodes 4792.6912 1


Vertebris

29

VERTEBRIS

Article Types pcs.

Basic set, VERTEBRIS lumbar and thoracic interlaminar Set-Nr. 892102222devised by Dr. Ruetten


Conical adapter 8791.751 1


Dilator, Ø 6.9 mm 89220.1508 1














Oval burr, frontally hooded, Ø 4.0 mm, WL 350 mm 89970.1514 1





30

VERTEBRIS

Article Types pcs.

Basic set, VERTEBRIS thoracic transforaminal Set-Nr. 892103333devised by Dr. Ruetten


Conical adaptor 8791.751 1


Spinal cannula set, 10 pieces, sterile, WL 150 mm, Ø 1.25 mm 4792.803 1

Dilator, Ø 5.9 mm 8792.764 1


Extension sleeve, Ø 7.0 mm 89220.1407 1








X-Tractor 89230.0000 1

Mallet 8866.956 1





Oval burr, frontally hooded, Ø 3.0 mm, WL 350 mm 89970.1513 1





VERTEBRIS

31

Article Types

Endoscopes, working channel 4.1 mm

Article Types

Endoscope accessories/attachments

Article Types


Panoview Plus discoscope, 20°, Ø 5.8 x 5.1 mm, WL 205 mm 8792.411

Panoview Plus discoscope, 20°, Ø 5.8 x 5.1 mm, MRI-compatible, WL 205 mm 8767.412





Sealing cap attachment, incl. 10 rubber caps 8792.452

Sealing caps Ø up to 2.4 mm, pack of 10 89.00

Sealing membrane 15 479.006

Membrane attachment 8792.451

Tap attachment 8791.951

Conical adapter 8791.751

O-rings for sealing between fluid adaptor and endoscope, pack of 10 9500.113

Plug-on eyepiece funnel for connecting C-mount objectives to endoscope optics with plug-on connection 8885.901

Drip rejector, pack of 20 89200.1000

Preparation basket for mechanical preparation and sterilization for discoscopes 89210.xxxx 38044.411

Preparation basket for mechanical preparation and sterilization for discoscopes 8792.411, 8767.412 38044.111

Antifogging agent 102.02

Cleaning brush 6.03


Article Types

Vertebris


32

VERTEBRIS

Article Types

Working sleeves, Ø 7.0 mm

Article Types

Spinal cannula set

Spinal cannula set, Ø 1.25 mm, pack of 10, sterile, WL 250 mm 4792.802

Spinal cannula set, Ø 1.25 mm, pack of 10, sterile, WL 150 mm 4792.803

Dilator, Ø 5.9 mm, 1-channel for working sleeves Ø 7.0 mm 8792.763



Working sleeve with 30° bevel, WL 120 mm 89220.3007

Working sleeve for foraminoplasty, WL 145 mm 89220.1017

Working sleeve without window, WL 145 mm 89220.1057

Working sleeves, basic set, WL 165 mm 89220.1907

Working sleeve with long elevator lip, WL 165 mm 89220.1117

Working sleeve with long window, WL 165 mm 89220.1087


Working sleeve with distally closed window, WL 165 mm 89220.1137

Working sleeve with dual window, WL 185 mm 89220.1027

Working sleeve with elevator lip, WL 185 mm 89220.1157




Working sleeve with bevel, WL 185 mm 89220.1147

Extension sleeve WL 155 mm 89220.1407

Dilators

Article Types


VERTEBRIS

33

Article Types

Trephines

Article Types

Working sleeves, Ø 8.0 mm



Working sleeve, basic set, WL 165 mm 89220.1908


Working sleeve with dual window, WL 185 mm 89220.1028

Working sleeve with elevator lip, WL 185 mm 89220.1088




Extension sleeve, WL 155 mm 89220.1408

Fluid adaptor, Ø 7.0 mm 89220.1307

Fluid adaptor, Ø 8.0 mm 89220.1308

Working sleeve attachment, Ø 7.0 mm 89200.1007

Working sleeve attachment, Ø 8.0 mm 89200.1008

Sealing caps, pack of 10 89.03

Trephine, WL 195 mm, Ø 5.9 mm, cutting window Ø 3.0 mm 8792.503



Fluid adaptors

Article Types

Vertebris


Irrigation pump system

34

VERTEBRIS

Article Types

Article Types

Burrs / rotation knives

Article Types

Accessories

Small spongiosa funnel, for working sleeve Ø 7.0 mm 89220.1517

Large spongiosa funnel, for working sleeve Ø 7.0 mm 89220.1527

Spongiosa ram, for working sleeve Ø 7.0 mm 89220.1507

Power control 2303.001

Power stick M4 8564.121

Oval burr, Ø 2.5 mm, WL 350 mm, laterally hooded 8792.312

Resector, Ø 2.5 mm, WL 350 mm, laterally hooded 8792.313

Nucleus resector, Ø 3.0 mm, WL 350 mm, laterally hooded 89970.1003


Oval burr, Ø 3.0 mm, WL 350 mm, laterally and frontally hooded 89970.1513

Nucleus resector, Ø 4.0 mm, WL 350 mm, laterally hooded 89970.1004


Oval burr, Ø 4.0 mm, WL 350 mm, laterally and frontally hooded 89970.1514



Fluid control 2203.001

Tube system, disposable, with puncture needle, pack of 10 4170.223

Tube system, disposable, with Safe Lock, pack of 10 4170.224

Shaver system

Article Types


VERTEBRIS

35

Article Types

HF instruments, bipolar

Article Types

HF electrodes, bipolar, Ø 2.0 mm, WL 400 mm

Article Types

HF electrodes, monopolar, WL 400 mm

Article Types

HF / RF generators

Surgitron radiofrequency unit, 4 MHz 2343.001/ .002

Bipolar generator 2352.001/ .002

Trigger Flex handpiece, complete 8792.691

Trigger Flex bipolar electrodes, pack of 6 4792.6912

Bipolar micro grasping forceps, Ø 2.6 mm, WL 390 mm 89930.1010

Bipolar inner part, pack of 3 89930.1001

Tube shaft 89930.1002

Handle 89930.1000

Ring electrode 8765.613

Button electrode 8765.621

Stepped ball electrode 8765.612

Connecting piece 8765.554

Button electrode, Ø 1.6 mm 823.05



RF accessories/electrodes

Article Types

Vertebris


36

VERTEBRIS

Article Types+

Forceps / punches, Ø 3.0 mm

Article Types


Double-spoon forceps, WL 360 mm 8793.561

Grasping forceps, WL 360 mm 8793.621

Micro-punch, WL 360 mm 8793.661

Micro-rongeur, WL 290 mm 89240.2025

Micro-rongeur, double-action, WL 290 mm 89240.2125


Micro-bone punch, WL 290 mm 89240.2325




Micro-rongeur, extended jaws, WL 360 mm 89240.1125

Nucleus grasping forceps, WL 360 mm 89230.1125




Tube shaft punch, WL 290 mm 89240.3903





Spreader, WL 360 mm 89230.1803

Scissors, WL 360 mm 89240.1703



Article Types


VERTEBRIS

37

Article Types

Assorted forceps / punches / scissors for use through the working sleeve

Article Types










Micro-rongeur, curved, WL 360 mm 89240.1624

Tube shaft punch, curved, WL 360 mm 89240.1904

Micro-rongeur, curved, WL 360 mm 89240.1044

Micro-punch, Ø 2.5 mm, curved, WL 360 mm (fits in 4 mm working channel) 89240.1034

Intradiscal grasping forceps, articulating, WL 210 mm 8792.623

Intradiscal punch, WL 210 mm 8792.663

Intradiscal rongeur, conical jaw, WL 210 mm 89240.1052

Punch, Ø 2.7 mm, WL 210 mm 8792.661

Scissors, Ø 2.7 mm, WL 240 mm 8792.641

Grasping forceps, Ø 3.4 mm, WL 240 mm 8792.621

Punch, Ø 3.4 mm, WL 240 mm 8792.662

Suction punch, Ø 4.5 mm, WL 240 mm 8792.681

Rongeur, Ø 4.5 x 4.2 mm, WL 210 mm 8791.601

Rongeur, Ø 4.5 x 4.2 mm, WL 210 mm 8791.691

Forceps / punches, Ø 5.2 mm for use through the working sleeve

Article Types

Vertebris


38

VERTEBRIS

Article Types

Hand-held / accessory instruments, atraumatic

Article Types

Hand-held / accessory instruments, sharp-edged

Annulotome, Ø 2.5 mm, WL 290 mm 89260.2125

Bone dissector, Ø 2.5 mm, WL 290 mm 89260.2225

Rasp, Ø 2.5 mm, WL 290 mm 89260.2325

Trocar, Ø 2.5 mm, WL 290 mm 89260.2425

Spoon, Ø 2.5 mm, WL 290 mm 89260.2525

Curette, Ø 2.5 mm, WL 290 mm 89260.2625

Rasp, Ø 2.5 mm, WL 350 mm 8792.541

Trocar, Ø 2.5 mm, WL 350 mm 8792.551

Spoon, Ø 2.5 mm, WL 350 mm 8792.562

Annulotome, Ø 2.5 mm, WL 350 mm 8792.581

Curette, Ø 2.5 mm, WL 350 mm 8792.571

End-cut burr, Ø 3.0 mm, WL 350 mm 89260.1113

End-cut burr, Ø 4.0 mm, WL 350 mm 89260.1114

Elevator, Ø 2.5 mm, WL 290 mm 89250.2025

Hook probe, Ø 2.5 mm, WL 290 mm 89250.2125

Probe, Ø 2.5 mm, WL 290 mm 89250.2225

Dissector, Ø 2.5 mm, WL 350 mm 8792.591




VERTEBRIS

39

Article Types

Accessories

Positioning probe 8791.701

Instrument grasping forceps 8793.856

"X-Tractor" withdrawal instruments, complete set 89230.0000

"X-Tractor" clamping device, small 89230.0003

"X-Tractor" clamping device, large 89230.0004

"X-Tractor" handle 89230.0008

Mallet 8866.956

Flushing valve, foot-operated 89870.0000

Suction connector 89270.1000

Sucker, Ø 2.5 mm, WL 290 mm 89270.2025

Sucker, Ø 4.0 mm, WL 340 mm 89270.1004

Suction and irrigation accessoriesArtikel TypenArticle Types

Vertebris


40

Literature

RUETTEN S, KOMP M, MERK H, GODO-LIAS GUse of newly developed instrumentsand endoscopes: full-endoscopic resec-tion of lumbar disc herniations via theinterlaminar and lateral transforaminalapproach.J Neurosurg Spine 2007; 6:521-530

RUETTEN S, KOMP M, GODOLIAS GLumbar discectomy with the full-endos-copic interlaminar approach using newdeveloped optical systems and instru-ments.WSJ 2006;3:148-156

RUETTEN S, KOMP M, GODOLIAS GNew developed devices for the full-en-doscopic lateral transforaminal operati-on of lumbar disc herniations.WSJ 2006;3:157-165

RUETTEN S, KOMP M, GODOLIAS GA new full-endoscopic technique for theinterlaminar operation of lumbar discherniations using 6 mm endoscopes:Prospective 2-year results of 331 pa-tients.Minim Invasive Neurosurg 2006, 49:80-87

RUETTEN S, KOMP M, GODOLIAS GAn extreme lateral access for the surge-ry of lumbar disc herniations inside thespinal canal using the full-endoscopicuniportal transforaminal approach. –Technique and prospective results of463 patients.Spine 2005, 30, 2570-2578

RUETTEN S, KOMP M, GODOLIAS GFull-endoscopic interlaminar operationof lumbar disc herniations using newendoscopes and instruments.Orthopaedische Praxis 2005, 10,527532

RUETTEN SThe full-endoscopic interlaminar ap-proach for lumbar disc herniations. In:Mayer HM (ed) Minimally InvasiveSpine Surgery. Springer, BerlinHeidelberg New York, 2005, pp346355

YEUNG ATMinimally invasive disc surgery with theYeung Endoscopic Spine System(YESS). Surg Technol Int 8:267-277,2000

YEUNG ATThe evolution of percutaneous spinalendoscopy and discectomy: state of theart. Mt Sinai J Med 67:327-332, 2000

YEUNG AT, TSOU PMPosterolateral endoscopic excision forlumbar disc herniation: surgical techni-que, outcome and complications in307 consecutive cases. Spine 27:722-731, 2002

YEUNG AT, YEUNG CAAdvances in endoscopic disc and spinesurgery: foraminal approach. SurgTechnol Int 11:255-263, 2003


Notes

41


42

Notes


43


M E D I C A L

V E T E R I N A R Y

I N D U S T R I A L

Subj

ect t

o ch

ange

with

out n

otic

e.B

756.

XI.0

8.G

Bw

ww

.stu

etzl

epar

tner

.de

sp i r i t o f exce l lence

Prin

ted

on p

aper

bas

ed o

n ce

llulo

se w

hich

has

bee

n bl

each

ed w

ithou

t the

use

of c

hlor

ine.

RICHARD WOLF GmbH · 75434 Knittlingen · PF 1164 · Telephone +49 70 43 35-0 · Telefax +49 70 43 35-300 · GERMANY · [email protected] · www.richard-wolf.com

AUSTRIA · BELGIUM / NETHERLANDS · FRANCE · GERMANY · INDIA · U.A.E. · UK · USA


b 756 vertebris gb - marien hospital witten

Documents