Minimally Invasive Spinal Surgery: Principles and Evidence-Based Practice Richard G Fessler, Kai-Uwe Lewandrowski, Michael D Schubert, Jorge Felipe Ramírez León
INDEX
ABCDEFHIKLMNOPRSTVXZ
Note: Page numbers in bold or italic refer to tables or figures respectively.
A
ACDF see Anterior cervical discectomy and fusion (ACDF)
Acetaminophen 248
Acupuncture 248
Adjacent segment disease (ASD) 11, 14, 38
Adult spinal deformity 154–156
AECF see Anterior endoscopic cervical foraminotomy (AECF)
Alexis endoscopic wound retractor 265, 266, 269
ALIF see Anterior lumbar interbody fusion (ALIF)
Annulus fibrosus 99–100
Anterior cervical discectomy and fusion (ACDF) 8, 11, 14, 37, 38
anatomic considerations 39–41
artificial disc replacement and, difference between 38
complications 38–39
posterior MIS foraminotomy vs. 37–46
Anterior endoscopic cervical foraminotomy (AECF) 20
advantages of 20
clinical outcomes 22, 22–23
contraindications to 20
decompressed cervical foramen and nerve root 21
endoscopic equipment 21–22, 22
indications for 20
patient positioning 20, 20
shaver and chisel, use of 21
site of entry of epidural needle 21
surgical technique 20–21, 21
vs. open foraminoplasty 23
Anterior lumbar interbody fusion (ALIF) 171, 175, 197, 205
interbody cages 171
stand-alone, in elderly 175–185 (see also Stand-alone ALIF, in elderly)
Artery of Adamkiewicz 59
Artificial disc replacement (ADR) 37, 38
Axial neck pain 3, 19 see also Cervical thermodiscoplasty (CTDP); Neck pain
Axilliary nerve root compression syndrome 41
B
Back pain 93, 246, 257 see also Low back pain
Bone morphogenetic protein (BMP) 99, 175
C
Calcitonin 246
Cauda equina 101
Cerebrospinal fluid (CSF) leakage 11
oblique paraspinal approach and 75
thoracoscopic discectomy and 56
Cervical facet rhizolysis 360° 4
clinical evidence 7–9
clinical outcomes 7
procedure technique 6–7
Cervical lateral stenosis 19–20 see also Anterior endoscopic cervical foraminotomy (AECF)
Cervical medial branch thermal radiofrequency neurotomy (CMBTRFN) 7
Cervical pain
clinical presentation 3–4
diagnostic tests 4
intervertebral disc and Z-joint degeneration and 3
minimally invasive treatment 4 (see also Thermal therapy, for cervical pain)
non-operative treatment 4
Cervical radiculopathy 25, 37 see also Posterior cervical foraminotomy (PCF)
Cervical spondylotic radiculopathy (CSR) 11
transcorporeal foraminotomy for (see Transcorporeal foraminotomy (TCF))
Cervical thermodiscoplasty (CTDP) 4, 9
clinical outcomes 7
contraindications 5
indications 4–5, 5
surgical technique 5–6, 5–7
C5 nerve palsy 39
Conjoined nerve roots 160
Costotransversectomy 64
CTDP see Cervical thermodiscoplasty (CTDP)
D
Degenerative disc disease (DDD) 3, 81, 271 see also Cervical thermodiscoplasty (CTDP); Thermodiscoplasty (TDP)
Degenerative spondylolisthesis (DS) with spinal stenosis 151–153
Diagnostic block 246
Disc-FX system 5, 7
Discogenic low back pain 87, 87
MRI for 87
treatment of 87
Discogenic test 4
Discography 82–83
Dorsal root ganglion (DRG) 101
Dural tears 56
E
Elderly
severe disc degeneration, minimally invasive treatment for 271–276 (see also Percutaneous cement discoplasty (PCD))
stand-alone ALIF in 175–185
Endoscopic lumbar discectomy, pathoanatomic evidence of 99–108
axial and radicular pain, pathophysiology of 101–102
interlaminar portal 105
lumbar microdiscectomy, surgical anatomy relevant to 104, 105
lumbar spinal motion segment 99–101
open vs. minimally invasive discectomies 106, 106, 107, 107
percutaneous transforaminal portal, anatomic relationship of 103–104, 104
transiliac access channel to L5–S1 disc 105, 106
treatment-based classification of spinal motion-segment degeneration 102, 102, 102, 103
Endoscopic posterior cervical foraminotomy (EPCF) 25, 32–35
anesthesia for 29, 30
benefits of 27–28
equipment 29–30
inverted cone effect 28
neck disability index (NDI), postoperative 32, 33
positioning 30
postoperative care 31–32
procedure 31, 31
study outcomes 32, 33
surgical technique 28–31
visual analog scale score, postoperative 32, 33
Endoscopic transforaminal thoracic discectomy (ETTD) 59, 113–115, 114–117
advantages of 65, 65
anatomic considerations 59, 60
anesthesia for 61
clinical evidence 62–64, 64
clinical experience 62
clinical presentation 59–60
contraindications 60–61
costotransversectomy and transpedicular thoracic discectomy and, comparison of 64–65
differential diagnosis 60
disadvantages of 65, 65
entry point for 61, 62
equipment 61, 61
incision to suture 61, 63
indications 60
informed consent 62
intraoperative views 63
patient positioning 61, 61
postoperative care 62
preoperative evaluation 60, 60
surgical technique 61–62
Endplate junction failure (EPJF) 125
EPCF see Endoscopic posterior cervical foraminotomy (EPCF)
Epiduroscopic laser neural decompression (ELND) 263
Epiduroscopy 257
ETTD see Endoscopic transforaminal thoracic discectomy (ETTD)
F
Facet augmentation procedures (FAPs) 249, 254 see also Lumbar facet joint pain
Facet joints see Zygapophysial joints (Z-joints)
Facet syndrome, lumbar rhizotomy vs. fusion for 93–97 see also Z-joint pain
Fatigue fractures 238
Foraminal stenosis, radiologic classification of 215, 216, 225
Foraminoplasty 160, 167, 216
instruments 217
H
Holmium: yttrium-aluminium-garnet (Ho:YAG) laser 257, 257
Hydroxyapatite 175
I
Iceberg lesion 257
Implant removal 237–243 see also Spinal hardware removal
Interbody cages 169, 169
anterior lumbar interbody fusion 171
clinical outcomes with 171, 173
geometry 169, 169–171, 172
lateral lumbar interbody fusion 170–171
materials for construction of 169
posterior lumbar interbody fusion 170
subsidence 171
transforaminal lumbar interbody fusion 170
Interlaminar approach, endoscopic 117, 120
Interspinous microscopic tubular decompression
advantages 134
case illustration 134, 136
clinical evidence 136–138
clinical results 134–135
complications 135–136
indications for 132
for lumbar spinal stenosis 131–139
surgical technique 132–134, 133–135
Interspinous process distraction systems
clinical evidence 143–147, 144, 146
devices and indications 142–143
ISP spacer, use of 141–142
for lumbar spinal stenosis 141–147
surgical technique 143
Interspinous process (ISP) spacers 141
Interspinous spacers 249
Intervertebral disc, pathoanatomy of 99–100
Intra-articular blocks 248
Intradiscal electrothermal therapy (IDET) 4, 81, 89
Intramedullary tumors, minimally invasive resection of 235
Investigational device exemption (IDE) 149
K
Kambin's triangle 104, 159, 159, 198, 198, 206
anatomic variations 160
Kili cage 181
Kim's low back pain scale 181
L
Laminoforaminotomy 11
Laparoscopic anterior lumbar interbody fusion (LALIF) 267
Laser-assisted spinal endoscopy (LASE) 87, 87
Lateral extracavitary approach (LECA) 77
Lateral lumbar interbody fusion (LLIF) 197–198, 205–206
interbody cages for 170–171
Lateral stenosis 19
Ligamentum flavum (LF) 100
hypertrophy of 131
LLIF see Lateral lumbar interbody fusion (LLIF)
Low back pain 87, 99, 189, 189, 246
discogenic 87
treatment costs for 189
Z joint and 93
Lumbar arthrodesis, complications with fusion procedures for 205–206
Lumbar discectomy 149–150
Lumbar disc herniation 111, 121–122, 257 see also Trans-sacral epiduroscopic laser decompression (SELD)
clinical presentation 113
endoscopic interlaminar approach 117, 120
endoscopic transforaminal discectomy 113–115, 114–117
endoscopic transiliac approach 115–117, 117, 118
merits of minimally invasive surgery 121
morphology 111, 111
nonoperative treatment 113
open vs. minimally invasive surgery evidence 118–120, 121
radiculopathy from, pathophysiology of 111
socioeconomic impact 120–121
surgical treatment 112, 113
topography 113, 113
treatment-based classification of 111, 111–113, 112
Lumbar disc pain 81
Lumbar facet arthropathy (facet syndrome) 252, 252 see also Lumbar facet joint pain
Lumbar facet joint degeneration 93
Lumbar facet joint pain 246
clinical evidence 252–254
clinical experience 249, 252
complications 252
conservative treatment 248
diagnosis 246–247
facet augmentation devices 249
facet denervation procedures 249
imaging and grading systems 247, 247
injury mechanisms 246
intra-articular injections 248
medial branch blocks 248–249
outcome 252
pain referral patterns 247
prevalence 246
Revel's criteria 246
treatment 247–249
Lumbar facet syndrome 246 see also Lumbar facet joint pain
Lumbar interbody fusion techniques 197, 206–207
anterior lumbar interbody fusion 197
clinical evidence for minimal access for 209–210
lateral lumbar interbody fusion 197–198
oblique lateral lumbar interbody fusion 198–200 (see also Oblique lateral lumbar interbody fusion (OLLIF))
outpatient minimally invasive surgery 201–202
posterior lumbar interbody fusion 197
transforaminal interbody lumbar fusion 197
Lumbar medial branch neurotomy 4 see also Cervical thermodiscoplasty (CTDP)
Lumbar spinal motion segment, pathoanatomy of 99
facet joint 100
intervertebral disc 99–100
intervertebral foramen 100–101
ligamentum flavum 100
neural structures 101
spinal canal 100, 101
Lumbar spinal stenosis (LSS) 131–132, 151
interspinous microscopic tubular decompression for 131–139
interspinous process distraction systems for 141–147
pathogenesis of 131
structural findings in 131
Luschka joints 19
M
Medial branch blocks (MBB) 248–249
Medial branch neurolysis 3
Metastatic epidural spinal cord compression (MESCC), 233
Metastatic spine disease, minimally invasive surgery in 233–234
Microendoscopic discectomy (MED) 137–138
Migrated lumbar disc herniation 257
Minimally invasive spine surgery (MISS) 149 see also specific techniques
for adult spinal deformity 154–156
benefits of 149
for lumbar degenerative disorders 149–156
lumbar discectomy 149–150
lumbar interbody fusion 153, 153–154
minimally invasive decompression vs. laminectomy 151–153
primary goals of 149
rationale behind 149
Minimally invasive ventral decompression, by oblique paraspinal approach 73–77
Mini-open anterior lumbar interbody fusion surgery 265–269
clinical evidence 266–269
clinical results 266
indications 265, 265
technique 265–266, 266
transumbilical retroperitoneal approach, use of 265–269
MISS see Minimally invasive spine surgery (MISS)
Muscle-preserving interlaminar decompression (MILD) 132
Musculoskeletal system, effect of aging on 19
N
Neck disability index 22
Neck pain 3
cause of 3
intervertebral disc and Z-joint degeneration 3 (see also Cervical pain)
prevalence of 3
Neoinnervation 81
Neuroforamen 19, 220
Neurogenesis, in posterior rim of annulus 81, 81
Non-steroidal anti-inflammatory drugs (NSAIDs) 248
O
Oblique lateral lumbar interbody fusion (OLLIF) 198–200, 207, 211
economic advantages of 200–201
Kambin's triangle 198, 198
minimally invasive 198, 198
outcome data 209
outpatient, clinical outcomes 199–200
procedural steps 199, 199, 207, 207–209, 207–209, 208
target planning 198–199
technical advances of 207
Oblique paraspinal approach, for thoracic spine 73–77 see also Ventral decompression via oblique paraspinal approach
OLLIF see Oblique lateral lumbar interbody fusion (OLLIF)
Oswestry disability index (ODI) 63, 163, 260
P
Patients’ Global Impression of Change (PGIC) scale 8
PCD see Percutaneous cement discoplasty (PCD)
PCF see Posterior cervical foraminotomy (PCF)
Pedicle-based devices (PBD) 249
Pedicle screw loosening 238, 242
Pendulum concept, degenerative disc disorders and 175–176, 176, 177
PercuDyn system 249, 250–251, 254
Percutaneous cement discoplasty (PCD) 271–276
clinical evidence 274–276
clinical outcomes 274
patients and complications 273–274
rationale and indication 272, 273
surgical technique 272–273
for vertical instability 271, 271–272, 272
Percutaneous discectomy lumbar laser (PDL) 81, 82
Percutaneous endoscopic intra-annular subligamentous herniotomy 123–128
case presentation 124, 126, 127
clinical evidence 126–128
demographic data, and clinical and radiologic findings 124, 125
for large centrally herniated disc 123
surgical technique 123–124, 124
Percutaneous endoscopic laser annuloplasty (PELA) 87–90
clinical evidence 88–90
clinical results 88
contraindications 88
indications 88
surgical technique 88, 88, 89
Percutaneous endoscopic lumbar discectomy (PELD) 257
and annuloplasty 89, 125
Percutaneous endoscopic thoracic discectomy (PETD) 77
Percutaneous lumbar laser discectomy (PLDD) 89
Percutaneous transforaminal portal 103–104, 104
Percutaneous vertebral augmentation (PVA) 234
Physician extenders, role of, study on 213–220
clinical evidence 219
patient inclusion criteria 214
patient management model, in nurse-led spine specialty clinic 213, 213
postoperative rehabilitation and utilization 216–217
preoperative work up and clinical follow-up 215
results of study 218–219
statistical methods 217–218
surgical techniques and 215–216
Polycarbonate–urethane stabilizer (PCU) 249
Polyetheretherketone (PEEK) cages 169, 170, 276
Polymethylmethacrylate (PMMA) 271
Post-discectomy syndrome 123
Posterior cervical foraminotomy (PCF) 25, 37, 38
after prior ACDF 43
anatomic considerations 25, 25–27, 26, 26, 27, 39–41
anterior cervical discectomy and fusion vs. 37–46
approaches for, comparison of 30
clinical evidence 32–34
complications 38–39
contraindications to 27, 28
endoscopic 25 (see also Endoscopic posterior cervical foraminotomy (EPCF))
inclusion and exclusion criteria 28
indications for 27, 28
landmarks 26
open and endoscopic procedure, comparison between 25, 29
postoperative care 31–32, 32
socioeconomic benefits 34
symptoms and work-up 27
Posterior dynamic stabilization (PDS) devices 249
Posterior longitudinal ligament (PLL) 12, 14, 74, 124
Posterior lumbar interbody fusion (PLIF) 197, 205
interbody cages 170
Postlaminectomy syndrome 108
R
Racial and ethnic disparities, impact of, on spinal surgery outcomes 223–230 see also Spinal surgery for lumbar stenosis in minorities, case study on
Radiofrequency denervation, for lumbar facet pain 249
Recombinant bone morphogenic protein-2 (rh-BMP-2) 175
Roland–Morris Disability Questionnaire (RMDQ) 263
S
Screw loosening 238, 238
SELD see Trans-sacral epiduroscopic laser decompression (SELD)
Shoulder-abduction relief sign 27
Shoulder cervical nerve root compression syndrome 41
Single-incision laparoscopic surgery (SILS) 265
Sixth lumbar vertebra 159
Sodium channel block 248
Spinal cord ischemia 56
Spinal hardware removal 237–243
clinical evidence 240–241
FDA implant regulations 237–238
and pain relief 237, 240
preoperative anesthetic injection 239–240
protocol for 240
screw loosening 238, 238
soft tissue hardware irritation 239
stress shielding and pseudoarthrosis 238–239
Spinal motion-segment, treatment-based classification for 102, 102, 102, 103
Spinal nerve 206
Spinal surgery for lumbar stenosis in minorities, case study on 223–230
clinical evidence 227–229
language barrier outcome measures 224
materials and methods 223, 223–224, 224
postoperative rehabilitation and utilization 225
preoperative work up and clinical follow-up 224–225
radiologic classification of foraminal stenosis 225
results 225–226, 226
statistical methods 225
surgical technique 225
Spinal tumors, MISS for 233–235
intradural tumors/lesions 234–235
spinal malignancies/extradural tumors 233–234
vertebral augmentation 234
Spurling sign 27
Stand-alone ALIF, in elderly 175–185
access-related complications 183
advantages of 175
biomechanical considerations 176–177
clinical evidence 183–185
clinical experience 180–183, 181–184
Hohman retractors, use of 178
pendulum concept 175–176, 176, 177
postoperative rehabilitation 180
retroperitoneal approach 178, 178
subsidence and vertebral body fracture 180, 182
supplemental fixation, use of 176–177
surgical approach and patient positioning, choice of 178, 178–179, 179
surgical technique 179–180, 180
transperitoneal approach 178, 178
Sternocleidomastoid (SCM) muscle 11
Stress shielding 238–239
Substance P 3, 246
T
TCF see Transcorporeal foraminotomy (TCF)
TDH see Thoracic disc herniation (TDH)
TDP see Thermodiscoplasty (TDP)
Thermal therapy, for cervical pain 4 see also Cervical facet rhizolysis 360°; Cervical thermodiscoplasty (CTDP)
cervical thermodiscoplasty 4
360° rhizolisis 4
Thermodiscoplasty (TDP) 3, 4, 81
biologic effects of 82
cervical 4
clinical evidence 85
clinical experience 83–84
contraindications 82
Dallas Discogram Description 82–83
for degenerative disc disease 81–82
discography for 82–83
indications 82
lumbar 4
mechanical discectomy with punch forceps 84
patient position and site approach 83, 83
with radiofrequency 84
surgical technique 83, 83, 84
Thoracic disc herniation (TDH) 51, 59, 67, 73
anterior/anterolateral approach 51, 52, 68–69
clinical presentation 67
endoscopic posterolateral transpedicular discectomy 69–70, 70
epidemiology 67
giant TDH, excision of 51
minimally invasive extracavitary vs. open approach for 70–71
multiple levels 51
nonsurgical treatment 51
posterior/posterolateral approach 51, 52, 69
radiologic evaluation 67, 68
retropleural technique 69
surgical treatment 51, 59, 59, 67–70 (see also Endoscopic transforaminal thoracic discectomy (ETTD); Thoracoscopic discectomy)
Thoracic microendoscopic discectomy (TMED) 69
Thoracic spine 59
Thoracolumbar orthosis (TLSO) 180
Thoracoscopic discectomy 51
anatomic landmark marking and portal placement 53
case presentation 56–57, 57
and cerebrospinal fluid leakage 56
clinical evidence 56
complication rate 55–56
considerations for 51–52
contraindications to 51
and dural tears 56
fluoroscopic guidance 53
ideal patient for 51
indications 51
patient positioning 53
preoperative CT scan 52
and spinal cord ischemia 56
technique 52–55, 53–56
wrong level surgery 56
TLIF see Transforaminal lumbar interbody fusion (TLIF)
Torque removal wrench 238, 238, 240
Transcorporeal foraminotomy (TCF) 11
case presentation 15, 17, 18
and cerebrospinal fluid leakage 13
clinical evidence on 15
complications 13–14
contraindications 11
and direct cord injury 13
foraminal osteophytes and 11
indications 11
kyphotic progression of cervical curvature 14
limitation of 15
multiple and extreme disc levels and 11, 14, 15
practical considerations during 15
recurrent herniation and 13–14
and spontaneous fusion 14
structural integrity, preservation of 15
surgical technique 12, 11–13, 13, 14
vertebral body and 15, 16
Transforaminal endoscopic lumbar decompression and foraminoplasty (TELDF), cost-effectiveness of 189–193, 193
clinical evidence 192–193
outcome measures 190
patient population 190
results 190–192, 190–192
study design 190
Transforaminal lumbar interbody fusion (TLIF) 153, 153–154, 159, 197, 205, 210–211
anatomic considerations 159, 159–160, 160, 206, 206
clinical experience 163–164
clinical outcomes 165, 165
complications 165–166
contraindications 163, 165
decompressive laminectomy 161
disc space management 161–162
economic advantages of 200–201
facet-pedicular screws 162, 164
foraminoplasty 160, 167
indications 162–163, 165
interbody fusion cage 162, 162, 170
minimally invasive 159–166
open vs. endoscopically-assisted 161, 162–163, 165, 166, 166–167
patient and outcome analysis 164–165
pedicle screw placement 162
preoperative planning 161
surgical technique 160–161
Transiliac approach, endoscopic 115–117, 117, 118
indications 116
preoperative planning 117
surgical anatomy 115–116, 117, 118
surgical technique 117, 117, 118
Transpedicular approach 64
Trans-sacral epiduroscopic laser decompression (SELD) 257–264
advantages 257, 263–264
case series study 259–261
clinical evidence 262–263
complications 261–262
contraindications 259
indications 257
surgical technique 257–259, 257–262
Tropism 246
Tumor necrosis factor (TNF) 111
V
Vacuum sign 271, 271, 272
Ventral decompression via oblique paraspinal approach 73, 73–77
complications 75
contraindications to 74
indications 73
minimally invasive vs. open decompression 75–76
technique 73–74, 74, 75
Vertical instability 271, 271–272, 272
Visual analog scale (VAS) 4, 22, 63, 163, 240, 260
X
X-STOP interspinous spacer 142, 142
Z
Z-joint pain
clinical evidence 96–97
clinical experience 95–96
diagnosis 93–94
360° facet rhizotomy 94, 94–95, 95
fusion techniques 96
prevalence of 93
thermodiscoplasty and 360° facet rhizotomy 96
treatment 94
Zygapophyseal joint osteoarthritis (ZJO) 3 see also Cervical facet rhizolysis 360°
Zygapophysial joints (Z-joints) 93, 245
function and biomechanics 245–246
innervation of 245
lumbar 245–246
pain (see Z-joint pain)
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MINIMALLY INVASIVE SPINAL SURGERY: Principles and Evidence-Based Practice
MINIMALLY INVASIVE SPINAL SURGERY: Principles and Evidence-Based Practice
Kai-Uwe Lewandrowski MD Orthopaedic Surgeon Center for Advanced Spine Care of Southern Arizona Tucson, Arizona USA Michael D Schubert MD Orthopaedic Surgeon International Spine Center Munich Germany Jorge Felipe Ramírez León MD Minimally Invasive Spine Surgeon Spine Surgery Department Reina Sofia Clinic Sanitas University Bogotá Colombia Richard G Fessler MD Professor of Neurological Surgery Rush University Medical School Chicago, Illinois USA
© 2018 JP Medical Ltd.
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Preface
Spinal fusion used to be associated with a long list of negative results: long incisions and significant blood loss; prolonged hospitalization and recovery; persistent pain, reduced mobility and limited return to function. Recently, newer and less traumatizing techniques have found their way into mainstream spinal surgery. These are increasingly accepted as alternatives to traditional open procedures, and have led many spine surgeons to rethink their traditional approaches to common clinical problems.
Examples of these new approaches include the use of advanced endoscopic techniques to debride spinal infections, to perform spinal fusion surgery, and to remove a herniated disc for the treatment of spinal stenosis. Other advances include the application of percutaneous pedicle screws instead of open screw placement, and minimally invasive decompressions via small, percutaneously-placed tubes instead of open, wide laminectomies through large incisions. Minimally invasive techniques are now aided by computerized navigation systems and advances in osteobiologics, obviating the need for autologous bone graft harvest and thereby enhancing the benefits of surgery.
Minimally Invasive Spinal Surgery: Principles and Evidence-Based Practice discusses the effectiveness of these pioneering new techniques and systems, thereby helping to establish new standards of care that clinicians can deploy in everyday practice.
We have taken a multidisciplinary approach by representing aspects ranging from anatomy, biomechanics and biologics to surgical technique and research into clinical outcomes. The book focuses on the application of specific, state-of-the art technologies as well as on the use of biomaterials in reconstructive procedures of the spine. Individual chapters describe not just the clinical indications and surgical techniques associated with each procedure, but also evaluate clinical outcomes and standards in analytical methodology and quality control. Each author has given specific clinical examples to impart the applied nature of this emerging field.
We believe that Minimally Invasive Spinal Surgery: Principles and Evidence-Based Practice will convey the intensity of this fast-moving field, while at the same time discussing and grading the available clinical evidence.
Kai-Uwe Lewandrowski
Michael D Schubert
Jorge Felipe Ramírez León
Richard G Fessler
February 2018
Contributors