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Minimally Invasive Spine Surgery For Your Patients
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Lukas P. Zebala, M.D. Assistant Professor
Orthopaedic and Neurological Spine Surgery Department of Orthopaedic Surgery
Washington University School of Medicine St. Louis, Missouri
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Agenda
• Review of relevant Spinal Anatomy and Pathologies
• Overview of MIS Surgical Techniques
• Clinical Outcomes • Questions
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Anatomy
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Common Spinal Pathology • Degenerative Disc Disease
(DDD) • Occurs naturally as we age • Symptomatic in some patients
• Disc Herniation
• “slipped” or “ruptured” disc • Protrusion of IVD from inner
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Common Spinal Pathology • Spondylolisthesis
• Slippage of one vertebra on vertebra below • Degenerative (L4-L5) • Isthmic (L5-S1)
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Common Spinal Pathology
• Spinal Stenosis • Spinal canal narrowing that results in
pressure on spinal cord, cauda equina or nerves
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Common Spinal Pathology
• Facet Joint Osteoarthritis • Degradation of cartillage • Back pain, nerve
compression
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Nonoperative Treatment
• Physical Therapy • NSAIDs • Steroids • Pain Medication • Chiropractic care • Acupuncture • Bracing • Behavior Modification
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Minimally Invasive Surgical Techniques
• MIS can treat disease throughout the spine: • DDD • Disc Herniation • Stenosis • Spondylolisthesis • Scoliosis/Degenerative Deformity • Trauma • Tumor 9
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MIS Surgery Goal
• The goal of minimally invasive surgery is to accomplish the same clinical outcomes as traditional, open surgery through a less traumatic approach
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MIS Surgical Candidates
• Patients with clinical symptoms in accordance with preoperative imaging
• Failed course on nonoperative treatment • Any Age
• MIS may be of benefit in elderly • Any Activity Level
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MIS Procedures
• MIS techniques can be applied to cervical, thoracic, and lumbar procedures • Decompression
• Discectomy, foraminotomy, laminectomy
• Fusion • Instrumentation, bone grafting
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Why Choose MIS Surgery • Potential Benefits:
• Less invasive surgery • Less soft tissue injury/disruption of
normal structures • Shorter hospital stay1
• Less blood loss2
• Earlier ambulation3
• Less post-op medication use4
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1,2 Fessler R, Khoo L. Minimally Invasive Cervical Microendoscopic Foraminotomy: An Initial Clinical Experience. Neurosurgery. 51: 37-45, 2002. 3 Park, Won Ha. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. SPINE 32(5):537-543, 2007. 4 Isaacs. Minimally invasive microendoscopy-assisted transforaminal lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, 2005. 4 Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: 146-154, 2002.
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MIS Surgery Risks
• Same potential complications as with conventional open spine surgery • Neural injury, infection, nonunion, dural
tears • Learning Curve
• Initial longer operative times • Technique complications
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Why MIS
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Old Approach New Technology
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MIS Surgery Keys
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• Image Guidance • Live x-ray or state of the art navigation
• Muscle Dilation • Work between natural muscle planes, not
cut or strip muscle • Specialized Instruments
• Allow for safe techniques through smaller operative windows
• Microscope Assistance • Magnification - Safer
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MIS Surgery Basics
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• Soft tissue dilators are used to create a working channel through the musculature
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MIS Surgery Basics
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• Patient specific tubular retractor is docked onto the area of interest • Working portal
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MIS Discectomy
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MIS Discectomy
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MIS Decompression • Discectomy • Foraminotomy • Laminectomy
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• Remove pressure from neural structure
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MIS Posterior Fusion / Instrumentation
• Fusion Added: • Instability
• DDD • Spondylolisthesis • Scoliosis • Iatrogenic
• Posterior
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MIS Lateral Approach
• Spine is approached from the side • Avoid major anterior or posterior
structures
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MIS Lateral Fusion / Decompression
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MIS Lateral Fusion / Decompression
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MIS Lateral Fusion / Decompression
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MIS Instrumentation
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Case 1 • 53 yo Female • Back pain and
left leg L4/L5 radiculopathy
• Failed nonop tx
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Case 1
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Case 1
• Walking POD#1
• Off IV Pain Meds POD#1
• D/C home POD #2
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Case 2
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• 63-year-old with 2 year history of low back pain, some leg pain
• Loss of disc height • Loss of normal lordosis • Coronal instability
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Case 2
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Case 3
• 30 yo male • High speed MVC • T9 fracture
dislocation • Complete SCI • Multiple other
injuries
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Case 3
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Postoperative Protocol • MIS Discectomy/Decompression
• Usually home on day of surgery or POD#1 • Activity as tolerated (limit lumbar
bending/twisting) • PO pain meds/muscle relaxers
• MIS Fusion/Instrumentation • Hospital stay 2-5 days • Activity as tolerated (limit lumbar
bending/twisting) • PO pain meds/muscle relaxers
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Clinical Outcomes MIS Decompression Khoo, Fessler. Microendoscopic Decompressive Laminotomy for the
Treatment of Lumbar Stenosis. Neurosurgery. 51 [Suppl 2]: 146-154, 2002. • N = 50 • MIS laminotomy vs. open decompression • MIS data prospective, open decompression data retrospective. • Perioperative benefits demonstrated in minimally invasive group • Difference in clinical outcomes did not achieve statistical significance
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Clinical Outcomes MIS TLIF Isaacs. Minimally invasive microendoscopy-assisted transforaminal
lumbar interbody fusion. J. Neurosurg: Spine. 3:98-105, 2005.
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Perioperative Data Open Minimally Invasive
Blood loss 1147 ml 226 ml 1
Length of hospital stay 5.1 days 3.4 days 2
Post-op narcotic use (in morphine sulfate equivalent units*) 49.5 units/day 37.5 units/day 3
Operative time 4.6 hours 5 hours 1 p=.001, 2p=.02, 3 p= .015 *Narcotic usage between patients was normalized to morphine sulfate equivalents.
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Clinical Outcomes MIS TLIF Scheufler. Percutaneous Transforaminal Lumbar Interbody Fusion for the
Treatment of Degenerative Lumbar Instability. Neurosurgery:203-213, 2007. • MIS TLIF (n=43) vs. Wiltse (open) approach (n=67).
• Mid-term functional outcomes at 8 and 16 months after surgery were
equivalent for 2 groups • Percutaneous group results:
• Lower intraoperative blood loss • Less post-op analgesic use while in hospital
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Clinical Outcomes MIS Lateral Knight, et al. Direct Lateral Lumbar Interbody Fusion for Degenerative Conditions
Early Complication Profile. J Spinal Disord Tech. Feb, 2009.
• Major adverse events approximated 8.6% with approach-related complaints of nerve irritation nearing 3.4%.
• Minimally invasive approach minimized blood loss, as compared to historical open cohort
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Thank You!
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Questions