Advances In Minamilly Invasive Spine Surgery: Minimally invasive - - PowerPoint PPT Presentation

Advances In Minamilly Invasive Spine Surgery: Minimally invasive spinal posterior decompression surgery using endoscope for cervical disorders

Akihito Minamide, MD, PhD*; Andrew K. Simpson, MD, MHS** Munehito Yoshida, MD, PhD*; Hiroshi Yamada, MD, PhD* *Department of Orthopaedic Surgery, Wakayama Medical University, Wakayama, Japan ** Texas Back Institute, Dallas, TX, USA

Orthopaedic Summit 2017: Evolving Techniques in the Spine Session Las Vegas, NV, USA, December 6-9, 2017

Spine Session

Advances In Minamilly Invasive Spine Surgery

Akihito Minamide, MD

(n) Nothing

Orthopaedic Summit 2017: Evolving Techniques

Authors’ disclosure statement: The authors report no actual or potential conflict of interest in relation to this article.

和歌山県立医科大学

WAKAYAMA MEDICAL UNIVERSITY

Microendoscopic Spinal Surgery

1996 MED Foley KT Smith MM 1999 METRx-MED System development 3CCD camera 2005 Optical tools

Hi-Vision camera Special Instruments

Kerrison's rongeurs

Drill SONOPET

Curved Kerrison's rongeurs

has developed with

Ultrasonic Knife “SNOPET”

Midas Legend system

Curved high-speed drill

disposable endoscope 1CCD camera 3mm endoscope 3CCD camera 4mm endoscope Hi-vision camera Contribution to the development of microendoscopic spinal surgery

Progress of Video Image

和歌山県立医科大学

WAKAYAMA MEDICAL UNIVERSITY

1996- 1999- 2005-

Perspective of viewing modality

Microscope- assisted

Co nve ntio na l

• OPE

N

• Mic ro sc o pe

Endoscope-assisted

E ndo sc o pe

The endoscopic surgery allows us to clearly visualize the ipsilateral and contralateral recesses and more effectively perform the decompression. positioned

• utside the skin

places the perspective inside the tube

Indications of Microendoscopic Spinal Decompression Surgery

 Lumbar disc herniation  Lumbar spinal stenosis

degenerative spondylolisthesis degenerative scoliosis

 Lumbar isthmic spondylolisthesis  Thoracic myelopathy

spondylosis, OYL

 Cervical myelopathy or radiculopathy

spondylosis, disc herniation, CYL

etc.

和歌山県立医科大学

WAKAYAMA MEDICAL UNIVERSITY

Application of Microendoscopic Laminotomy for Cervical Myelopathy

和歌山県立医科大学

WAKAYAMA MEDICAL UNIVERSITY

Cervical Microendoscopic Laminotomy (CMEL)

The patient is turned to the prone position, and is fixed in a Mayfield head holder. The neck position is a neutral or slightly flexion.

The tubular retractor is put on the lamina and facet joint. Inter-lamina space

Cervical Microendoscopic Laminotomy (CMEL)

Developing to the bilateral decompression surgery by the unilateral approach Minamide A. Eur Spine J 19:487-493,2010.

Pathomechanism of CSM

Otani K, et al. Spine 34(3): 268-273, 2009.

Pincer mechanism

 Compression of the spinal cord is observed in the

articular segment.

 A bulging disc compresses the spinal cord anteriorly.  The hypertrophied ligamentum flavum compresses the

spinal cord posteriorly.

和歌山県立医科大学

WAKAYAMA MEDICAL UNIVERSITY

Cervical Spondylotic Myelopathy (CSM)

 A segmental partial laminectomy for CSM:

Showed the same clinical outcomes in comparison with comventional expansive laminoplasty.

(Otani K, et al. Spine, 2009)

Posterior segmental articular decompression

和歌山県立医科大学

WAKAYAMA MEDICAL UNIVERSITY

Surgical Methods

 Posterior shift of spinal cord with conventional LAP:

OPLL

 Segmental articular decompression: CSM

Surgical methods include …….

• Segmental Partial Laminectomy (Ohtani K. Spine 2009)
• Skip Laminectomy (Shiraishi T. Spine 2003)
• Microendoscopic Laminotomy (CMEL)

CMEL

Case: 74 y.o Female

Clumsiness, numbness in her hands, and spastic gait Pre-Op. JOA = 12/17 CMEL surgery：C3/4,4/5, 5/6

Before surgery

2 years after surgery JOA = 14/17

CT scan

The laminotomy are done at each level by the unilateral approach.

Clinical outcomes of CMEL surgery for CSM patients …….

Questions:

1. How is the difference in clinical outcomes between CMEL and conventional expansive laminoplasty? 2. Also, is there a difference in the long-term clinical

• utcomes between two groups?

3. Is it possible for CMEL to respond to cases of spinal cord compression due to anterior factors?

和歌山県立医科大学

WAKAYAMA MEDICAL UNIVERSITY

Question 1  To investigate the long-term clinical and radiological results of CMEL surgery (articular segmental decompression using endoscopy) for CSM patients and to compare outcomes to conventional expansive laminoplasty (ELAP).

Minamide A, et al. Spine 40, 1807-1815, 2015. Minamdie A, et al. J Neurosurg Spine 27(2), 2017.

Study Design

Retrospective case-controlled study using propensity score matching:

This retrospective case–control study of the clinical outcomes of CMEL and ELAP for the treatment of CSM used the propensity score matching method.

 A one-to-one matching analysis was performed between patients

who underwent ELAP and CMEL on the basis of the estimated propensity scores of each patient.

 Patients were matched according to calculated propensity scores in

a logistic regression model adjusted for age, sex, and preoperative severity of disorder (JOA score).

 A nearest-neighbor matching procedure was used, with the

restriction that the propensities matched had to be within 0.05 units

• f each other.

Kumano Shrine Nachi Shrine

Results

World Heritage in Wakayama

Characteristics of each group on matching by the calculated propensity score

ELAP CMEL P value Patients 71 pts 71 pts Sex M 47, F 24 M 47, F 24 Age 63.8±11.7 62.8±13.7 0.645 Preoperative JOA 10.1±2.4 10.2±2.6 0.96 Surgical levels 2.0 ± 0.8 3.9 ± 0.3 <0.0001

Clinical outcomes on each surgical procedure at the 2-year follow-up

ELAP CMEL P value JOA 13.9±2.1 14.1±1.9 0.485 JOA recovery rate 56.3±22.2 62.8±13.7 0.349 VAS for axial symptoms 42.8±32.4 24.5±25.6* 0.001 Satisfaction for surgery 7.8±2.1 8.5±1.8* 0.036

Influence of surgical techniques on soft tissues

Finger Surgery

The microendoscopic surgery is much more different in the involvement to soft tissues than the conventional approach.

1 or 2 level(s) CMEL 4 levels CMEL ELAP

Subaxial cervical lordosis between C2 and C7 angle on lateral radiograph

CMEL ELAP P value Pre-operation 12.7 ± 15.1 O 10.0 ± 8.3 O 0.45 5-year follow-up 14.9 ± 15.8 O 7.9 ± 9.5 O *0.042

Differences between pre- and 5 years

2.6 ± 7.7 O

• 1.2 ± 5.0 O

*0.031

There were significant differences in the lordotic differences pre- and postoperatively between two groups (p<0.05). CMEL surgery maintained postoperative cervical lordosis.

Summary (1)

 This 5-year follow-up data demonstrates that after undergoing CMEL surgery, patients have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis.  CMEL for CSM is indicated for posterior decompression

• f the articular segment along with a pincer mechanism.

 This minimally invasive technique may have potential advantages compared with conventional ELAP, and may provide an alternative surgical option.

Is it possible for CMEL to respond to cases of spinal cord compression due to anterior factors?

 To investigate the regression of cervical disc in patients, who underwent CMEL surgery, on pre- and post-operative MRI.  Based on this result, to reconsider about the indication of CMEL.

Question 2

Cervical myelopathy with CDH

 Neck pain  Numbness in both hand  Clumsiness in finger motions  Spastic gait  Urinary disturbance  JOA score: 13/17

50 y.o. Woman

What is your surgical strategy ?

Cervical myelopathy with CDH

 Neck pain  Numbness in both hand  Clumsiness in finger motions  Spastic gait  Urinary disturbance  JOA score: 13/17

50 y.o. Woman

What is your surgical strategy ?

• 1. ACDF
• 2. Posterior decompression
• laminoplasty
• laminectomy and fusion

Cervical myelopathy with CDH

 Neck pain  Numbness in both hand  Clumsiness in finger motions  Spastic gait  Urinary disturbance  JOA score: 13/17

50 y.o. Woman

What is your surgical strategy ?

• 1. ACDF
• 2. Posterior decompression
• laminoplasty
• laminectomy and fusion

We pla ne d po ste rio r de c o mpre ssio n b y CME L surg e ry.

Cervical myelopathy with CDH

 Neck pain  Numbness in both hand  Clumsiness in finger motions  Spastic gait  Urinary disturbance  JOA score: 13/17

50 y.o. Woman

What is your surgical strategy ?

• 1. ACDF
• 2. Posterior decompression
• laminoplasty
• laminectomy and fusion

We pla ne d po ste rio r de c o mpre ssio n b y CME L surg e ry.

6 months after CMEL surgery

JOA score = 16/17

Regression of disc herniation!!

Cervical Disc Herniation

 Anterior cervical discectomy and fusion (ACDF)

Smith GW et al. JBJS (Am ), 1958 Cloward RB J Neurosurg Spine, 2007  Regression of soft disc herniation after cervical

laminoplasty

Iwasaki M, et al. Spine 21(1):32-38, 1996. Yoshida M, et al. Spine, 23(2): 2391-7, 1998.

• Laminoplasty provide equal neurologic improvement

as ACDF.

• Changes of dural pulsation after cervical laminoplasty

may play a role in regression of CDH.

Postoperative regression of anterior region

 68 patients underwent CMEL surgery.

Spondylotic bulged disc Soft disc herniation Bony spur

0/11pts (0%) 30/46pts (65.2%) 10/11pts (90.9%)

Types of anterior factors

Summary (2)

 Disc herniation (soft disc) and spondylotic bulged disc were regressed in 91% and 65% respectively following CMEL surgery.  CMEL surgery for cervical myelopathy can also be applied to cases of anterior factors due to disc herniation

• r spondylotic bulged disc.

.

Thank you for your kind attention.

Minimally Invasive Posterior Cervical Decompression

Advantage

 Minimally invasive surgery  Preservation of neck motion  Avoid

• spinal fusion
• anterior approach related complications

Puvanesarajah V, et al. Spine 2017. Tasiou A, et al. J Spine Surg 2017.

ASD (adjacent segment disease) dysphagia soft tissue swelling hematoma esophageal perforation laryngeal nerve palsy infection etc.

T he re a re