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M I N I M A L LY I N VA S I V E L U M B A R D E C O M P R E S S I O N
W H Y & H O W
K H A L E D A L A L I , M B B S , F R C S C C O N S U LTA N T N E U R O S U R G E O N
Z AY E D M I L I TA R Y H O S P I TA L
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O B J E C T I V E S
• What is Minimally invasive spine surgery?
• advantages and disadvantages of MIS decompression
• Literature review
• How minimally invasive lumber decompression is done?
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Tubular lumbar decompression =
Minimally invasive lumbar decompression
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“What is MIS?”
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1 9 6 7 - M I S C R O S C O P I C D I S C E T O M Y ( YA S A R G I L )
2 0 0 1 - S E X TA N T P E R C U TA N O U S
P E D I C L E S C R E W S Y S T E M ( F O L E Y )
2 0 0 3 - T U B U L A R M I C R O S C O P I C
D I S C E C T O M Y ( F O L E Y )
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M I S G A O L S
• Decompression
• Stabilization
• Realignment
S A M E A S O P E N
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W H AT M A K E S M I S A M I S ?
1. muscle splitting
2. retractor (e.g tubular)
3. limited resection (bone, disc)
L E S S C O L L AT E R A L D A M A G E
N O T A B O U T S M A L L I N C I S I O N
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1 . M U S C L E S P L I T T I N G
• minimize muscles damage
• “Save” Multifidus muscle
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M U LT I F I D U S M U S C L E
• strong muscle
• act as a “stabilizer” to the lumbar spine
E V I D E N C E S U G G E S T S T H AT PA R A S P I N A L M U S C L E S A R E S I G N I F I C A N T LY S M A L L E R I N PAT I E N T S W I T H C H R O N I C L B P
F O R T I N M , M A C E D O L G . P H Y S T H E R . 2 0 1 3 J U L ; 9 3 ( 7 ) : 8 7 3 - 8 8
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Multifidus muscles
attachment of multifidus muscle
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Multifidus muscles
Open decompression: muscle detachment
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Multifidus muscles
MIS decompression
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Multifidus muscle
MIS decompression
Longissimus muscle
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2 . R E T R A C T O R S
self retaining table mounted
blades / hooks tubular
O P E N D E C O M P R E S S I O N M I S D E C O M P R E S S I O N
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K I M , D . Y. , E T A L . S P I N E 2 0 0 5 . 3 0 ( 1 ) : P. 1 2 3 - 9
“less paraspinal muscles atrophy with MIS ”
O P E N D E C O M P R E S S I O N
M I S D E C O M P R E S S I O N
B R E S N A H A N L E E T A L . J S P I N A L D I S O R D T E C H . 2 0 1 3 O C T 1 3 .
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R E T R A C T O R S
• with open decompression
• increased systemic markers (serum creatinine kinease, Adolase)
• muscle fibrosis and necrosis
K I M , E T A L . S P I N E 2 0 0 6
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3 . M I N I M A L R E S E C T I O N
L A M I N E C T O M Y O P E N D E C O M P R E S S I O N M I S D E C O M P R E S S I O N
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• decompressing the lumbar spine with minimal paraspinal muscle damage
• in case of bilateral decompression, utilizing unilateral approach to decompress both sides
What is MIS lumbar decompression?
S AV I N G M U LT I F I D U S M U S C L E
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Bilateral lumbar decompression via unilateral approach - clinical outcome -
• satisfactory surgical outcomes with a minimum 5-year follow-up.
S P I N E V O L U M E 3 6 , N U M B E R 5 , P P 4 1 0 – 4 1 5 2 0 1 1
S U R G I C A L N E U R O L O G Y 6 8 ( 2 0 0 7 ) 4 8 7 – 4 9 2
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• Prospective comparing pre and postop.
• no control
• n = 57 patients
• improved JOA score
S P I N E V O L U M E 3 6 , N U M B E R 5 , P P 4 1 0 – 4 1 5 2 0 1 1
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• more back pain with tubular approach
Eur Spine J (2011) 20:51–57
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Bilateral lumbar decompression via unilateral approach - HOW -
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• By studying pre-op MRI
• unilateral, bilateral
• how many levels?
• Central stenosis, lateral recess, foraminal stenosis
1 . W H AT T O D E C O M P R E S S ?
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Trajectory of tubular retractor
2 . S K I N I N C I S I O N & T R A J E C T O R Y
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• Mark the skin incision with flour xray
2 . S K I N I N C I S I O N & T R A J E C T O R Y
M E D I A L
Level mark (e.g L4-L5)
medline
incision
L AT E R A L
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• to split the muscle
• to reach contralateral side
2 . S K I N I N C I S I O N & T R A J E C T O R Y
Why paramedic incision?
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2 . S K I N I N C I S I O N & T R A J E C T O R Y
midline incision
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2 . S K I N I N C I S I O N & T R A J E C T O R Y
midline incision
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2 . S K I N I N C I S I O N & T R A J E C T O R Y
Why paramedic incision?
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2 . S K I N I N C I S I O N & T R A J E C T O R Y
Why paramedic incision?
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3 . S E R I A L T U B U L A R D I L AT O R
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4 . P L A C I N G T U B U L A R R E T R A C T O R
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5 . L O C A L I Z I N G W I T H F L U R O
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5 . L O C A L I Z I N G W I T H F L U R O
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5 . L O C A L I Z I N G W I T H F L U R O
X
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6 . S O F T T I S S U E R E M O VA L
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7 . I D E N T I F Y I N G A N AT O M Y
L A M I N A
Medial
Lateral
Rostral Caudal
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7 . I D E N T I F Y I N G A N AT O M Y
Medial
Lateral
Rostral Caudal
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7 . I D E N T I F Y I N G A N AT O M Y
FA C E T
Medial
Lateral
Rostral Caudal
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Rostral
Lateral
Caudal
Medial
8 . I P S I L AT E R A L D E C O M P R E S S I O N
dura
nerve root
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Rostral
Lateral
Caudal
Medial
8 . C O N T R A . D E C O M P R E S S I O N
contra.nerve root
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8 . C O N T R A . D E C O M P R E S S I O N
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R E M O VA L O F T U B U L A R R E T R A C T O R
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• Postoperative CT scans show microsurgical bilateral decompression through the right-sided approach.
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T H A N K Y O U !