dlif
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DLIF approach, a new MISS for "de novo"/degenerative scoliosis.Zbiggy Brodzinsky Dubai Bone & Joint CenterDubai Healthcare City Authority, UAE
www.dbaj.ae, www.dhcc.ae
Riyadh, KSA; Jan 20-23, 2012.
Lateral Anatomy and Physiology Review
Anatomy Lateral ApproachObl. Int M Obl. Ext M Transversus M. V. Cave Aorta
Psoas muscle APPROACH
Nerve root
Dorsal M.
Psoas Muscle Attaches to the lateral border of the lumbar spine Wider in lower lumbar spine GreaterMales > Females Tightens with hip extension Muscle fibers run mainly longitudinally
Lateral Dissection to Psoas Direct observation of muscle layers Follow internal abdominal wall Posterior to anterior abdominal wall finger sweep Feel for: 1. Quadratus muscle 2. TP 3. Surface of Psoas
Transpsoas Neuro Considerations Moro T, Kikuchi S, Konno S, Yaginuma H. An Anatomic Study of the Lumbar Plexus with Respect to Retroperitoneal Endoscopic Surgery. Spine 28 (5) 2003. 2003.
Lumbar Plexus Nerves
Cadaver study of relationship between psoas muscle and lumbar plexus and genitofemoral nerve L2/3 and above- all parts of abovelumbar plexus and nerve roots located in dorsal fourth of body and dorsally. L3/4 and L4/5L4/5Lumbar plexus in zone III, IV, & dorsally
Moro et al, Spine V 28 N 5 , pp 423- 428, 2003 423-
Lumbosacral Plexus Benglis DM, Vanni S, Levi AD An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 2009 Feb;10(2):139-44.
Trans-psoas Approach
Deeper
Trans-psoas ApproachL1-2 L2-3 L3-4 L4-5 L5-S1
Sensory Nerve Considerations Genitofemoral NerveNerve(Moro et al) Passes through psoas from cranial third of L3 to caudal L4 Receives contributions from L1 & L2 Pierces Psoas muscle and descends on anterior surface. Divides into femoral and genital branches
DLIF Technique Review
DLIF Technique1. 2. 3. 4. 5. 6. 7. 8. 9. Pre-op planning Needle electrode setup Patient positioning Fluoroscopic localization Dissection to psoas Neuromonitor through psoas Dilation/Retractor placement Fusion preparation Trial/Distract Implant
10. Closure
Pre-op Planning Check for unfavorable anatomy High iliac crest at L4-5 Consider AP and lateral x-ray More problematic in males
Long 11th and 12th ribs Go intercostal or ressect part of ribs
Pre-op Planning Left or right side approach? Go in on side that appears easiest to access on x-rays (e.g., due to crest, ribs, scoliotic collapse, etc.)
Correction can be equally good from either side; consider ease of access Surgeon comfort
Needle Electrode Placement Placed by surgeon or hospital staff Discuss with anesthesiologist regarding use of neuromuscular blockades
Patient Positioning Problematic
Patient Positioning Place hip, not waist, over break Flex top leg Firmly hold patient position (tape) Fluoro under table Bed Selection - Reverse table
Patient Positioning
Patient Positioning Position and fluoro prior to draping: True AP and Lateral Work Perpendicular to floor Need to correct by moving the patient/bed NOT the fluoro In multi-level cases, will need to readjust table for perfect image at each level
Localization Directly over the disc center for single level In between discs for two levels
Dissection to Psoas Approach Path1. Skin, subcutaneous 2. 3 layers of abdominal muscles External oblique Internal oblique TransversalisIncise Bluntly dissect Sweep anterior NIM and dilate
3. Retroperitoneal space 4. Psoas
Dissection to Psoas Direct observation of muscle layers Follow internal abdominal wall Posterior to anterior abdominal wall finger sweep Feel for: 1. Quadratus muscle 2. TP 3. Surface of Psoas1 2 3
Neuromonitor through Psoas Stimulate NIM X-PAK Probe to ensure safety of lumbar plexus Cover tip with finger and guide to psoas Target anterior one-half to one-third
NIM X-PAK Probe
Nerve Proximity Mode Provides audio tone feedback indicating proximity to a nerve root Program automatically changes stimulation intensity while searching for an EMG responseNIM-ECLIPSE Spinal System
Probe Position ConfirmationConfirm position
Dock probe into disc space
Remove Inner Stylet
Place Guide wire
Dilators & Retractor Place dilators over wire Assemble retractor with proper size blades Place retractor over last dilator Stimulate pin hole Place pin Prevents migration Keep close to endplate
Retractor and Light Source
Endplate Preparation Incise annulus Discectomy Ronguers, currettes, shavers
Release contralateral annulus Trial Implant
Disc Preparation
Proper Endplate Preparation
Trial and Implant Insertion
Closure
Closure is simple Close fascia of external oblique with 0 Vicryl Close subcutaneous Skin closure with adhesive
Lateral Interbody Fusion (DLIF) in Patients with De-Novo Adult Degenerative Scoliosis
What is Direct Lateral? Variation of retroperitoneal approach that is minimally invasive Muscle-splitting TransPsoas approach Considered closely similar to anterior approach Best suited for L1-L5, can be done in thoracic
Advantages of DLIFCompared to ALIF No need for approach surgeon No retraction of peritoneal contents Easy access to upper lumbar Less risk to vessels & sympathetics Obesity is less of issue No resection of ALL Less blood loss Compared to PLIF/TLIF No bony resection Avoid canal exploration, root manipulation & root adhesion pain Larger graft Obesity is less of issue No disruption of Posterior tension band More stable in torsion* Less blood loss *Voor MJ, Mehta S, Wang M, Zhang YM, Mahan J, Johnson JR. Department of Orthopaedic Surgery, University of Louisville School of Medicine, Kentucky 40292, USA. 1: J Spinal Disord. 1998 Aug;11(4):328-34
Surgical Procedure
Surgical Procedure
Lumbar Plexus Nerves
Moro et al, Spine V 28 N 5 , pp 423- 428, 2003 423-
Surgical ProcedureObl. Int M Obl. Ext M Transversus M. V. Cave Aorta
APPROACH
Surgical Procedure
Surgical Procedure
Distraction
Distraction
DLIF in Deg Scoliosis PLIF/TLIF+post instrumentation has fusion rate & better alignment compared to post instrumentation alone* PLIF is ineffective in restoring sagittal balance*** Anterior placed graft improves lumbar lordosis more than posterior placed graft Restoration of sagittal & global balance improves outcome & loss of lumbar lordosis is associated with pain & Quality of life Anterior grafts are more biomechanically stable than posterior grafts^ Complication rate of open Deg Scoliosis surgery is high (2080%)**Glassman et al: Spine 30, 2005 * Wu et al: J Spinal Disord Tech 21, 2008 ** Cho et al: Spine 32, 2007 ** Bone et al: Spine , 30: 2005 Ploumis et al: Spine 34, 2009 *** Kyu-Jung et al: Eur Spine J, 17: 2008 ^ Voor et al: J Spinal Disord 11, 1998 Daffner et al: Am J Orthop, 2: 2003
DLIF in Deg Scoliosis DLIF is emerging as a viable alternative to Posterior or Posterior/Anterior surgery that is minimally invasive with less complication rate Can be utilized as a primary correcting tool for scoliosis or as a secondary stabilizing tool for scoliotic spine undergoing surgery
Role of DLIF in Scoliosis SurgeryAdvantages* Ant column structural stability disc height & maintains distraction between end plates regional sagittal & coronal balance Indirect neural decompression Good support for hardware end vertebrae fusion rate (osteoporosis Anterior release Unloads facet joints stress on posterior hardware ? Shorter level instrumentation Disadvantages Technically more tricky Rotation Vertebrae Rotation L-S Plexus
? Inferior to osteotomy in Fixed & Rigid Curves. Role may be best for flexible curves and may help in changing PSO to Pont osteotomy
*J Neurosurg Spine 7, 2007
Lateral TransPsoas in Deg ScoliosisCobbAnand et al* Tormenti et al* Dakwar et al* Wang et al* Diaz et al+ Patel et al++
AVT 10 11.5 3.6
Lordosis 1.8 47.3 37.4 34 40.4 45.5 41
VAS 7 8.8 8.1 3 3.5
ODI 55 2.4 53 3.2 49 39 29 19
22 38.5 31.4 18 20.2
7
8 11.7
9.1
++ Superior results to PLIF/TLIF controlled cohort for Cobb angle & AVT Comparable results for VAS to open surgery (Spinal Deformity Study Group) All had blood loss 50-500 ml, less than open surgery (average=2.1 1 Lit**)
+ Diaz et al: Spine 2006 ++ Patel et al: Spine 2009
* Neurosurg Focus 28 (3), 2010** Cho et al: Spine 32, 2007
Case RoBack & Leg Pain
Case Ro: Back & Leg Pain
Case Ro: Back & Leg Pain
L4-L5
Case Ro: Back & Leg Pain
32 9
Case RoBack & Leg Pain
Case DG: Back & Leg Pain
Case DGBack & Leg Pain
Case DG: Back & Leg Pain
Case DGBack & Leg Pain
30 45
Case DGBack & Leg Pain
Case JBBack Pain
1 yr
Case JB: Back Pain
Case JB: Back Pain
25
10
Case JBBack Pain
40 25
Case LWBack Pain
Case LW: Back Pain
Case LW: Back Pain
Case LW: Back Pain
Case LW: Back Pain
Case LWBack Pain
0 16
Case LWBack Pain
50 55
Case Bo: Back & Leg Pain
Case Bo: Back & Leg Pain
Case BoBack & Leg Pain
32
10
Case BoBack & Leg Pain
19
39
Case HaBack Pain
Case Ha: Back Pain
Case Ha: Back Pain
3 10
Case Ha: Back Pain
41 24
Case Jo: Back Pain
Case Jo: Back Pain
10
3
Case No
Lateral Options for Deformitys management
Adult Degenerative Deformity Always involves the Lumbar spine Painful Patients: Elderly Co-morbidities Fusion harder to achieve vs pediatric
Must have Solid fusion Good sagittal balance Decompression
Fusion options Posterior anterior
Challenging questions regarding MIS osteotomy X How to achievesagittal balance How to achieve fusion Decompression: direct vs indirectInterbody reconstruction Posterior interbody laminectomy facetectomy
X
X
Spinal reduction Foraminal distraction
Why inter-body fusion? Better Mechanics Better Biology Better physiology May be The best option to Address the pain generators
MECHANICS
Why Interbody Biology: under compression. Better pysoelectric charges Better Physiology: The only compartment in the spine void of functional muscles
Potentially Eliminates Pain generators
Promising techniquesMIS Lateral/Anterolateral Techniques Straight lateral surgery (XLIF, DLIF, Lat concord etc) Indicated for lateral pathology Lateral decubitus position Incision at lateral border of erector spinae Dilates through iliopsoas Finger assisted
Risks Lumbar plexus (in psoas) Requires monitoring
WHY LATERAL!! Viscera are out of the way No need for vascular mobilization Preserves the ALL: Containment Anterior tension band Protects against over-distraction
Can be done with the posterior work simultaneously without repositioning No iatrogenic stenosis Less risk for retrograde ejaculation No traumatic sympathectomy
Traditional Anterior Approach
Anatomy
Analysis of Vascular Anatomy
High Lateral Configuration
Analysis of Vascular Anatomy
Very Low Medial Configuration
Anatomy Psoas gets wider in lower lumbar spine (males>females) Lumbar plexus posterior 2/5 of psoas
LLIFAnterior Posterior
Favorable Anatomy
Unfavorable Anatomy
AnteroAntero-lateral interbody fusion L1-2, L2-3, L3-4, L4-5 Split fibers of oblique and transversus muscles Retract anterior 20% psoas be Very careful of the misleading Quadratus Lumborum muscle
Concave vs convex side
Concave side
Concave approach:
54 yo, multiple spinal surgeries severe pain
Before and after
Before and after
72 YO lady. Severe back and leg pain. Failed conservative Rx.
MRI
conservative Lost 90 pounds 8 ESIs Yoga Psychiatric eval. Not better
BEFORE AND AFTER
BEFORE AND AFTER
58 yo male. Still disease. Severe back and hip/thigh pain
Sagittal balance
Axial cut at L3-4
Failed conservative RxCONSERVATIVE RX PT TIME PAIN MEDS OPTIONS: Don nothing Laminectomy Laminectomy fusion Approach: Posterior Anterior posterior
Fusion levels:
T11-L4
Before and after
Before and after
preop
Full Spine Films
Post op
55 yo, 325 lbs
MRI
Intraoperative pictures
Post op
Conclusion. MIS is very promising: Approach Anterior vs posterior Concave vs convex
Indirect decompression
More studies need to be done
Conclusion Fusion surgery is quite Morbid. MIS is very promising option and might be the best option We have to rethink anterior fusion Go concave
Be careful, bad stuff can happen through small holes
IT WILL THROW YOU UP IN THE AIR
Conclusion Role of DLIF in Degenerative Scoliosis Surgery is still being defined but is emerging as a viable option either alone or in combination with other techniques
Thank you/Shokran!