Dia 1. Innovations in spinal surgery. Dr. L. Fidlers Dienst Neurochirurgie AZ Groeninge Kortrijk. Dia 2 ANATOMIE. Dia 3 CERVICAAL DORSAAL LUMBAAL

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___________________________________ ___________________________________ ___________________________________ Innovations in spinal surgery Dr. L. Fidlers Dienst Neurochirurgie AZ Groeninge Kortrijk

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ANATOMIE

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___________________________________ CERVICAAL

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DORSAAL

LUMBAAL

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___________________________________ FACETGEWRICHT

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WERVEL LICHAAM

DISCUS PROCESSUS SPINOSUS

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NEUROFORAMEN

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PROCESSUS TRANSVERSUS

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WERVELLICHAAM

SPINALE KANAAL

PEDIKEL

___________________________________ LAMEN

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___________________________________ ___________________________________ FACETGEWRICHT

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___________________________________ ZENUWWORTEL

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___________________________________ Hernia discalis

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___________________________________ ___________________________________ DISCARTHROSE

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___________________________________ D I S C A R T H R O S E

F A C E T A R T H R O S E

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Spondylolisthesis

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S P O N D Y L O L Y S E

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___________________________________ Evolutie

• Decompressieve chirurgie • Fusie: – Posterieur:

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• Schroeven+platen+posterolaterale greffen • PLIF

– Anterieur: • Stand alone ALIF • ALIF+plaat

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• Dynamische stabilisatie – Lig. Van Graff – Discusprothese – Nucleoplastie

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___________________________________ Evolutie

___________________________________ • Minimaal invasieve technieken

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Rationale

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• Discarthrose, facetarthrose: posterieure technieken gouden standaard • Pure rugpijn op discusdegeneratie, jonge patiënten • Mediane HD • Evolutie naar behoud mobiliteit waar mogelijk

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___________________________________ ___________________________________ • Lumbale wervelzuil • Cervicale wervelzuil

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F u s i e p o s t e r i e u r

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___________________________________ ___________________________________ nut cage

___________________________________ pedikelschroef staaf

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___________________________________ ___________________________________ 700114 700125 Verankeringsschroef waarbij de staaf door middel van een afzonderlijke connector wordt gefixeerd, inclusief alle toebehoren voor fixatie en blokkering, connector inbegrepen

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700070 700081 Monoaxiale verankeringsschroef met open schroefkop, waarbij de staaf in de schroefkop wordt gefixeerd, inclusief alle toebehoren voor fixatie en blokkering U 260

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___________________________________ ___________________________________ ___________________________________ ___________________________________ 700092 700103 Polyaxiale verankeringsschroef met open schroefkop, waarbij de staaf in de schroefkop wordt gefixeerd, inclusief alle toebehoren voor fixatie en blokkering

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___________________________________ ___________________________________ ___________________________________ 700055 700066 Twee staven met alle bijkomende elementen voor verankering aan het occiput, inclusief de occiput-schroeven

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___________________________________ ___________________________________ ___________________________________ 700313 700324 Totaal van de elementen van een implantaat, verankerd via 2 haken/schroeven op dezelfde wervel, bedoeld voor de correctie van een spondylolyse

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___________________________________ ___________________________________ ___________________________________ ___________________________________ 700173 700184 Verankeringshaak met open kop, waarbij de staaf in de kop wordt gefixeerd, inclusief alle toebehoren voor fixatie en blokkering

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___________________________________ ___________________________________ 700276 700280 Transversale verbinding tussen staven, voor het geheel van de samenstellende elementen, inclusief alle fixatieelementen

700291 700302 Longitudinale verbinding voor staven, voor het geheel van de samenstellende elementen

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___________________________________ ___________________________________ ___________________________________ 700641 Niet beweegbaar arthrodese-implantaat voor plaatsing in een tussenwervelruimte van de thoraco-lumbale wervelkolom en ontworpen om per twee per niveau geplaatst te worden

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F u s i e a n t e r i e u r

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___________________________________ ___________________________________ ___________________________________ 700615 700626 Niet beweegbaar arthrodese-implantaat voor plaatsing in een tussenwervelruimte van de thoraco-lumbale wervelkolom en ontworpen om als enige per niveau geplaatst te worden

700836 700840 Botschroef voor verankering van een cage aan de wervelkolom, inclusief alle toebehoren voor fixatie en blokkering

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___________________________________ ___________________________________ ___________________________________ 700453 700464 Plaat van vaste lengte voor anterieure of antero-laterale fixatie aan de thoracolumbale wervelkolom, te verankeren via schroeven 700490 700501 Enkelvoudige schroef voor verankering aan de thoracolumbale wervelkolom van een anterieure of anterolaterale plaat

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700770 700781 Corporectomiecage, in situ expandeerbaar, voor het geheel van de samenstellende elementen, voor plaatsing in de thoraco-lumbale wervelkolom

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___________________________________ ___________________________________ ___________________________________ 700792 700803 Geheel van cages of wiggen, dat minimaal per 2 stuks gestapeld wordt, ter vorming van een niet beweegbaar corporectomie-implantaat inclusief de fixatie-elementen, voor cervicale plaatsing

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Lumbale wervelzuil • Acute ischiatalgie: microdiscectomie • Discushernia, rugpijn: discectomie minder doeltreffend • Degeneratief discus lijden • PDN • Anterieure discusprothese

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De discusprothese

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___________________________________ WAAROM • Eenvoudige discushernia • Sterk degeneratieve aandoeningen • De schemerzone: – jongere patiënten – rugpijn al dan niet uitstralend zonder echte radiculaire symptomatologie – discusdegeneratie

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___________________________________ WAAROM • Eenvoudige discushernia • Sterk degeneratieve aandoeningen • De schemerzone: – jongere patiënten – rugpijn al dan niet uitstralend zonder echte radiculaire symptomatologie – discusdegeneratie

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___________________________________ WAAROM • Eenvoudige discushernia • Sterk degeneratieve aandoeningen • De schemerzone: – jongere patiënten – rugpijn al dan niet uitstralend zonder echte radiculaire symptomatologie – discusdegeneratie

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___________________________________ Voordelen • Behoud van mobiliteit, balans • Ontlasten bovenliggende niveau • Minder destructieve chirurgie, minder bloedverlies • Vluggere revalidatie • Geen problemen littekenweefsel • Minder pijnlijk • Kortere ziekenhuisopname

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___________________________________ Nadelen • • • •

Kostprijs Lange termijn? Retrograde ejaculatie bloedvaten

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___________________________________ Indicaties

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Mono- of bisegmentaire instabiliteit Post-nucleotomie syndroom Chronische lage rugpijn Segmentaire instabiliteit met degeneratieve discus • Falen van conservatieve therapie

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___________________________________ Contraindicaties

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Uitgesproken degeneratie Vroegere heelkunde Discus hoogte < 5mm BMI > 30

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___________________________________ contraindicaties • • • • • • •

Osteopathie Postinfectieuze toestand Spondylolisthesis Lumbale kanaalstenose Geïsoleerde radiculaire compressie Polysegmentaire instabiliteit leeftijd

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___________________________________ Preoperatieve onderzoeken • • • • • •

Standaard RX LWZ Functionele RX NMR Discografie Botscan Facetblok

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Maverick™ Implant Design

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 Metal on Metal Design

 Posterior Center of Rotation  Semi constraint prosthesis

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 HA Coating Fixation

 Simple Surgical Technique

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Maverick Implant Design Metal on Metal • Cobalt -chromemolybdenum alloy • Less risk with wear debris • No polyethylene • Proven in orthopedics

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Maverick Implant Design Posterior Center of Rotation • Center of rotation is found in the posterior 1/3 • Corresponds to closer to patient anatomy

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Maverick Implant Design Semi Constraint Prosthesis • Less constraints on the posterior facet joints • Allowing physiological lateral bending and flexion/extension

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Maverick Implant Design

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HA Coating • Calcium phosphorus • Provides a geometry which is conductive to bony on growth • Rough surface provides increased friction for a press fit

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Maverick Implant Design Superior Component Eighteen sizes available:

Depth 25mm (S) 27mm (M) 30mm (L) Height 10mm 12mm 14mm

Lordosis 6°, 9° or 12°

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Width 32mm (S) 35mm (M) 39mm (L) Inferior Component Six sizes available:

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___________________________________ • Opname van een drietal dagen • Dag van operatie reeds mobilisatie, geen Redon, geen corset • Zo snel mogelijk beginnen wandelen • 1ste maand op eigen tempo • Daarna start rugschool • 2 à 3 maanden wob

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___________________________________ Eerste maand • • • • • •

Veel wandelen Niet autorijden Niet lang zitten, lang stilstaan Geen rotatiebewegingen Niet tillen Na enkele weken fietsen/zwemmen

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4-in-1 Instrument 1. Templating Distraction

2. Parallel

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Midline & Depth Positioning of the 4-in-1 on the endplates

In-situ parallel distraction on the posterior and anterior endplates

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4-in-1 Instrument 3. Center Keel Cutting Cutting

4. Corner

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Midline cutting for ideal implant keel placement

Bi-lateral cutting of the bonny endplates

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Implant Final Position

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Implant Final Position

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Besluit Goede indicatie+goede chrirurgie=goed resultaat  Toekomst: 

Nucleusprothese Prothese facetgewrichten  Stamcellen  Dynamische posterieure fixatie  

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___________________________________ De cervicale wervelzuil

___________________________________ • cervicale prothese

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Why?? • Preservation of motion • Adjacent level disease –

J.Spinal disorders 1995 J. Goffin et alt Long term results after ant. cerv. fusion and osteosynthetic stabilization for fractures and or dislocations of the cerv. Spine

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5-9 Y follow up in 25pt. 60 % late degeneration of adjacent level, without subjective nor clinical repercussions –

J. Bone Joint Surg Am. 1999 Hilibrand et alt. Radiculopathy and myelopathy at segments adjacent to the site of a previous ant. cerv. arthrodesis

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374 pt, 409 fusions 21 Y follow-up

Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis. Greatest riskfactors: C5-C6 and C6-C7 and preexisting degeneration. 2/3 needed a new operation. –

J Spinal Disord 2001 Feb Zaveri GR, Ford M. Cervical spondylosis: the role of anterior instrumentation after decompression and fusion. 3,4 Y, 47 pt Accelerated degenerative changes at levels adjacent to the fusion were seen in 17% of patients

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___________________________________ Indications • Single level • Degenerative disc • Radiculopathy or myelopathy

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– Herniated disk – Osteophytosis

• Mobile segment

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___________________________________ titanium

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siliconemembrane

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___________________________________ Conclusions • Not better nor worse than traditional procedures on short term • Safe and easy to use • Indications: carefull with facetjoint problems • Discogenic pain • Best: simple herniated disc • Need for prospective studies • Cost

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Minimally Invasive Technique – Evolution Dr. L. Fidlers dep of neurosurger y AZ Groeninge

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___________________________________ History of spinal surgery • Victor Horsley: removal of thoracic spinal cord tumor • 1920s: Walter Dandy: herniated disk • 1940s Dh LS en CS: widely discribed and discussed in litterature • 1960s ant. approach CS • 1970s operating microscope • 1960s Collis: keyhole surgery for HD • Developement of better endoscopes, high resolution videoscopy, perioperative imaging, microscope

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___________________________________ Minimal invasive spine surgery • Skin incision and exposure required • Concepts of spin. surgery haven’t changed with exposure reduction • Other facets of miss: – Percutaneous procedures: vertebroplasty, kyphoplasty – Regrowth cartilage, lig,..?

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Act: miss = less tissue trauma Future: regenerative technique High quality perioperative imaging Neuronavigation and robotics

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___________________________________ Cervical Spine • Endoscopic assisted transoral surgery – Fang and Ong 1962: transoral decompression – Frempong-Boadu endoscopic assisted transoral surgery

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• Cervical Microdiscetomy – Post approach in selected cases: lat. DH, for.stenosis,… – MED: less trauma, less pain

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___________________________________ Thoracic Spine • Thoracoscopic Spine Surgery – 1910 Jacobaeus first thoracoscopic procedure – 1990 video imaging – modern era of thoracoscopy : HD, biopsy – Ant. IF, scoliosis, corpectomies, vertebral instrumentation for tumors and fractures

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• Post./posterolat. Endoscopic diskectomy

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___________________________________ Lumbar spine • • • • • • • • •

Chemonucleolysis Percutaneous diskectomy Percutaneous laser diskectomy Arthroscopic Microdiskectomy Percutaneous intradiscal radio-frequency thermocoagulation Spinal endoscopy Lumbar microendoscopic diskectomy Endoscopic pedicle screw fixation Laparascopic lumbar spine surgery

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___________________________________ MAST • • • •

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Minimal Access Spinal Technologies

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___________________________________ MAST QUADRANT™ METRx®

X-Tube™

___________________________________ 1996

‘97

‘98

‘99

‘00

‘01

‘02

‘03

‘04

‘05

2009

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Cervical Foraminotomy

XTube-TLIF

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Lateral fusions

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___________________________________ ___________________________________ MetrX MED

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___________________________________ Micro-Endoscopic System

Dia 85 MetrX MED

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Description

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METRx MED

•Endoscopic •Muscle dilatators •2-D Vision •See outside of “keyhole” •FDA approved for Lumbar spine •Straight instruments

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Description

Dia 87 Instrument Set 90 Kerrisons Upbiting Pituitaries

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40 Kerrisons

 Comprehensive Set of Microsurgical Instruments  Black, Glare Resistant, Ceramic coated instruments

Curved Scissors

Wide Nerve Root Retractor

Penfield # 2 

Straight & Upbiting Micropituitary

Suction Retractor

Nerve Root Retractor

Pituitary with tooth

Nerve Hook

Ball Probes

Sheathed Knife

Dissectos

Bipolar Forceps

Reverse Angle Curettes

Angled Bipolar Forceps

Angled Curettes

Pituitaries

Downbiting Pituitary

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___________________________________ Description

Introducer Set

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Flexible Arm Assembly

16.8 mm Dilator 14.5 mm Dilator

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12.8 mm Dilator 9.4mm Dilator 5.3 mm Dilator Guide Wire .062 x 12” 16 mm Tubular Retractor

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18 mm Tubular Retractor

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Video Equipment

Description

Monitor, 13”or 19”

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Video Integrator System

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VHS or SVHS Recorder

Color Video Printer

Video Cart

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Autoclavable Camera Head

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Dia 90 Diagram illustrates left sided disc herniation

___________________________________ Room Set Up  Operative Corridor (tubular retractor) is positioned between the surgeon and video tower

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Patient Positioning  Prone with abdomen free (Wilson Frame or Andrews table)

 Spine Flexed

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___________________________________ Technique

Guide Wire Placement  Spinal needle is placed into paraspinous musculature 1.5cm off of midline at the appropriate level confirmed using lateral fluoroscopy  The spinal needle is removed and a vertical incision is made at the puncture site

 The guide wire is placed through the incision and directed toward the inferior aspect of superior lamina under lateral fluoroscopy

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___________________________________ Technique

Initial Dilator Insertion  Insert initial cannulated soft tissue dilator over the guide wire  Once the fascia is penetrated remove guide wire and advance the dilator down to the inferior edge of superior lamina  Confirm placement of initial dilator using lateral lateral flouroscopy

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 Use the initial dilator to palpate the lamina in both the coronal and sagital planes  The tip of the dilator is used to sweep the paraspinal musculature off the laminar edge  This maneuver affirms coronal placement and expedites soft tissue removal

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___________________________________ Technique

Sequential Dilator Insertion  The second, third and fourth dilators are placed over the initial dilator down to the lamina

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Tubular Retractor Insertion  The Flexible Arm is attached to the Tubular Retractor and the ipsilateral bed rail  The Tubular Retractor is placed over the sequential dilators, docking on the lamina  It is important to always apply downward pressure while adjusting flexible arm

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___________________________________ Technique

___________________________________ ___________________________________ Tubular Retractor Insertion (cont.)  Sequential dilators are removed establishing an operative corridor to the lamina and interlaminar space Fluoroscopy is used to confirm appropriate positioning

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___________________________________ Endoscope Insertion

Technique

 Insert the endoscope into the Tubular Retractor

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 The endoscope can be place anywhere within the 360 periphery of the retractor  Initial placement of the endoscope should be in its most retracted position in order to avoid contact with soft tissue.

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___________________________________ Focus and Image Orientation

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Technique

 The endoscope is focused by adjusting the black focus ring on the METRx Endoscope  Endoscopic orientation is such that medial anatomy is on top of the video monitor and lateral on the bottom

___________________________________ When the endoscope is first inserted, the video image will not likely correspond to the underlying anatomy

To achieve proper orientation rotate the gold orientation ring so that the indicator is in the same place on the video monitor as the endoscope is in the Tubular Retractor

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Proper image orientation occurs when medial anatomy is on the top of the video monitor and lateral anatomy is on the bottom

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___________________________________ Technique

Dia 97 Soft Tissue Removal  Soft tissue over the lamina and interlaminar space is removed with a pituitary rongeur  It is essential to remove all soft tissue exposed in the operative corridor in order to maximize the working space within the Tubular Retractor

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 The laminar edge is identified and the ligamentum flavum is detached from the undersurface of the lamina with a curved curette

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Technique

Laminotomy  A hemilaminotomy / medial facetotomy is performed with a Kerrison punch or high speed drill.  Effective utilization of lateral fluoroscopy will help tailor the Medial necessary dissection to access specific pathology

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 If the pathology is beyond the confines of the Tubular Retractor, the retractor can be move or angled over the pathology by a process known as wanding. Wanding allows the surgeon to place the objects of interest in the center of the operative corridor

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Technique

Dia 99 Ligamentum Removal

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 The ligamentum flavum is opened with an angled curette. The curette is placed under the remaining superior lamina where the ligament is thin  The ligament is penetrated with a curette utilizing a twisting motion.  It is pealed back caudally and dorsally, then resected with a Kerrison punch

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___________________________________ Technique

Nerve Root Identification

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 The dura and traversing nerve root are identified  The nerve root is retracted medially utilizing a Penfield dissector, Love style or suction retractor  The volar epidural space can be explored and epidural veins can be cauterized

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Technique

Dia 101

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Discectomy

 An annulotomy can be performed with the Sheathed Annulotomy Knife while protecting the nerve root with the retractor

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Technique

Dia 102 Closure

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Dia 103

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___________________________________ ___________________________________ MetrX MD

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Dia 105 METRx MD

•For use with your own Microscope •Muscle dilatators •3-D vision •Keyhole •Class 1 device (Lumbar, Thoracic & Cervical use) •Bayoneted instruments

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Microscope Surgical Technique

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Technique

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Description

Dia 107 Instrument Set

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Bayonetted Kerrisons Various Pituitaries

 Comprehensive Set of Bayoneted Microsurgical instruments

Assorted Curettes Assorted Probes

Curved Scissors

Wide Nerve Root Retractor

Straight & Upbit.

Suction Retractor

Black, Glare Resistant, Micropituitary Ceramic coated instruments Pituitary with tooth

Nerve Root Retractor

Downbiting Pituitary

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Ball Probes

Nerve Hook Sheathed Knife

Pituitaries

Penfield # 2 

Bipolar Forceps

Dissector

Reverse Angle Curettes

Angled Bipolar Forceps

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Angled Curettes

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Dia 108 All Instruments are Bayonneted for optimal microscope vision « hands apart »

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=> No Endoscope BUT a set of Tubular retractors :

Instrument Set

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___________________________________ Description

Dia 109

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Introducer Set Flexible Arm Assembly

___________________________________ 9.4mm Guide Wire . 062 x 12”

5.3 mm

___________________________________ Dilators

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Dia 110 • • • •

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14, 16 and 18mm tubes Color coded Varying length 3cm to 9cm Tube length determined by graduations on dilators

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___________________________________ Micro Discectomy

Technique

Room Set Up Diagram illustrates left sided disc herniation

Patient Positioning  Prone with abdomen free (Wilson Frame or Andrews table)  Spine Flexed  Depending on surgeon preference, microscope can be placed on either side of patient.

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___________________________________ Micro Discectomy

Technique

Guide Wire Placement  Spinal needle is placed into paraspinous musculature 1.5cm off of midline at the appropriate level confirmed using lateral fluoroscopy  The spinal needle is removed and a vertical incision is made at the puncture site

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 The guide wire is placed through the incision and directed toward the inferior aspect of superior lamina under lateral fluoroscopy

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___________________________________ Technique

Initial Dilator Insertion  Insert initial cannulated soft tissue dilator over the guide wire  Once the fascia is penetrated remove guide wire and advance the dilator down to the inferior edge of superior lamina  Confirm placement of initial dilator using lateral fluoroscopy

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Use the initial dilator to palpate the lamina inboth the coronal and sagital planes The tip of the dilator is used to sweep the paraspinal musculature off the laminar edge This maneuver affirms coronal placement and expedites soft tissue removal

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Technique

Dia 114 Sequential Dilator Insertion  The second, third and fourth dilators are placed placed over the initial dilator down to the lamina  Use depth markings on dilator to determine the correct tubular retractor length

Tubular Retractor Insertion  The Flexible Arm is attached to the Tubular Retractor and the ipsilateral bed rail  The Tubular Retractor is placed over the sequential dilators, docking on the lamina  It is important to always apply downward pressure while adjusting flexible arm

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Dia 115

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Technique

Sequential Dilator Insertion

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Insertion of the appropriate diameter last Dilator (Here 14 mm diam.)

Mark on dilator at skin level prescribes choice of tubular retractor length ; Then the T.R. Is attached to the flexible arm.

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Technique

Dia 116 Tubular Retractor Insertion cont.  Sequential dilators are removed establishing an operative corridor to the lamina and interlaminar space  Fluoroscopy is used to confirm appropriate positioning  To wand the tube: Insert last dilator into tube to use as leverage.

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Dia 117 Technique

Microscope -> Microscope Focal Length : 300 - 400 mm

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-> Light Source Diaphragma for precise illumination of the Tubular Retractor inner diameter.

-> Spine Microscope allow fr both surgeon and assistant to work in front of each other. -> according to Tubular Retractor length, variable angulation of the sight is possible.

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-> Partnership with Carl Zeiss Microscopes for compatibility.

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___________________________________ Technique

Further technique is similar to the MED-technique (see MED-presentation)

Difference : you’re looking through your microscope instead of at a videomonitor as in the MED-technique.

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___________________________________ Summary

Pro MD-system : -All advantages of MED -No extra capital equipment needed (own microscope) -Useable in cervical & thoracic spine -New developments : even bigger tubes and possibility to place a PLIF through same tube !!!

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___________________________________ MAST-Quadrant

___________________________________ • Access • Fusion • Fixation

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___________________________________ MAST-quadrant

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___________________________________ ACCESS

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___________________________________ Fusion

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___________________________________ Fixation

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___________________________________ • MAST-quadrant TLIF

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___________________________________ Kyphoplastie • Indeukingsfractuur wervel – Osteoporose – Trauma – Multiple myeloma

• Percutaan • Reductie • stabilisatie

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___________________________________ • Percutaan plaatsen van de naalden

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___________________________________ • Reductie van de fractuur

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___________________________________ • stabilisatie

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___________________________________ Verpleegkundige aspecten • Mobilisatie zo snel mogelijk – HD: dag van de ingreep – Discusprothese: dag van de ingreep – Fusie: volgende dag

• • • • • • • •

Vooroverbuigen, torsie: niet gedurende een maand Geen buiklig Zitten beperken: 15’ in ziekenhuis, 45’ thuis, op stoel Geen auto 1 maand Fietsen na een drietal weken Rugschool na een maand Eerste maand geen kiné Geen wondzorg

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___________________________________ Additional developments • • • •

Image guidance systems Vertebroplasty Kyphoplasty Endoscopic application of biological agents

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___________________________________ Image guidance

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___________________________________ Minimaal invasieve laterale fusie • • • • • •

Laterale benadering Praktisch geen weefselschade Retroperitoneaal Door m. psoas Cave plexus lumbalis L1-L5

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___________________________________ ___________________________________ ___________________________________ That’s all folks!

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