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Introduction Modern MIS techniques are evolving MIS has a very - - PDF document

Apr 12, 2023 360 likes •826 views

11/13/2015 Mini-Open Surgery: Can We Achieve the Same Results as Open Surgery with Less Morbidity? Las Vegas, NV November 6, 2015 Dean Chou MD Professor of Neurosurgery The UCSF Spine Center Introduction Modern MIS techniques are

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Mini-Open Surgery: Can We Achieve the Same Results as Open Surgery with Less Morbidity?

Las Vegas, NV November 6, 2015

Dean Chou MD Professor of Neurosurgery The UCSF Spine Center

Introduction

  • Modern MIS techniques are evolving
  • MIS has a very limited role in adult deformity

surgery

  • Will MIS eventually have a greater role in

adult deformity?

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PSO Can we do this MIS? With this?

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VCR

  • Essentially a posterior based corpectomy
  • Use the skills and techniques from posterior

corpectomies

  • Extremely unstable, be careful of both

translation and spinal cord lengthening during

  • peration

Mini-open vertebrectomy

  • Technically challenging
  • Must be familiar with open VCR
  • Must be comfortable with percutaneous

pedicle screws

  • Easiest to start with thoracic kyphosis.
  • Consider kyphotic tumor case to start
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Evolution of mini-open vertebrectomy

  • T6 Metastatic hepatocelluar carcinoma
  • Cord compression
  • Gait disturbance
  • Neurologic deficit

Skin incision—make single midline incision

  • r multiple stab incisions?

(Fessler)

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Single skin incision Place Jamshidi needles

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Jamshidi’s in Place k-wires in

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Open fascia or skin Tap goes in

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Tap under fluoro Place screw—control k-wire

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Start laminectomy

Place temporary rod to prevent translation

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Remove towers after rod in

Trap door osteomy for expandable cage placement Chou et al, J Neurosurg Spine. 2009 Jan;10(1):40-5.

After transpedicular corpectory, a small

  • steomy about 3

cm lateral to the costovertebral junction until the rib is mobile

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Trapdoor osteotomy Chou et al, J Neurosurg Spine. 2009 Jan;10(1):40-5.

  • Expandable Cage

is placed with gentle straight downward pressure against the rib until it is pass the spinal cord, and then the cage is then swing medially

Trap door osteotomy Chou et al, J Neurosurg Spine. 2009 Jan;10(1):40-5.

  • The cage is then

expanded until it is wedged securely

  • The rib is then allowed

to swing back into position

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Place expandable cage Skin closure

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Same skin incision—but is it the same surgery?

Open Mini open

Evolution to mini-open VCR

  • Similar steps to corpectomy
  • Similar principles
  • Consider not using the biggest possible cage.
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  • F. SCHWAB – SPINE MOBILIZATION

ANATOMICAL CONSIDERATIONS

6 Grades of Destabilization:

  • 1. Partial facet joint
  • 2. Complete facet joints
  • 3. Partial body*
  • 4. Partial body and disc*
  • 5. Complete body + discs*
  • 6. >1 body, adjacent*

*posterior vs. anteroposterior

THE TRADITIONAL POSTERIOR APPROACH

Kyphosis correction during posterior based vertebrectomy using cantilever technique

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Open transpedicular corpectomy

Implants placed. Laminectomy done

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Contour rods into the shape you want spine to look

Cantilever to correct kyphosis

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Post correction

Can we do the same thing less invasively?

  • Mini-open corpectomy with kyphosis

correction

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Breast cancer—kyphosis correction via Mini-Open approach

Kyphosis intraop picture

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Cage insertion Kyphosis correction

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Kyphosis correction VCR for severe thoracic kyphosis

  • 80 yo female with 90 degree thoracic kyphosis
  • Failed non-surgical care
  • Wished to proceed with surgery
  • Understood significant risk of surgery
  • Planned mini-open VCR given age
  • Cement augmentation given osteoporosis
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Preop

  • Severely limited in

ambulation

  • Chronic narcotic use
  • Sits in chair all day
  • 90 degrees kyphosis
  • 2 compression fractures

above & below

Standard skin incision

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Preserve fascia Jamshidi needles placed

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Place proximal screws Place distal screws

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Multiple Jamshidis save on fluoro Open fascia over VCR site only

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Begin laminectomy Complete VCR—temporary rod

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Place cage for pivot

Thread rod through fascia—cut the fascia distal end

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Correct kyphosis—rod in shape of how you want spine to be

Fascial opening

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Drains placed, skin closed

  • 500cc EBL
  • No intraop

transfusion

  • Back pain much

better

  • Caveat:s: cement

PE, new adjacent fracture at L4

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Can this be appied to flat back and PSO? Case

  • 52 yo male s/p anterior-only fusion 30 years

ago

  • Now with severe back pain
  • Inability to stand erect
  • No leg pain
  • Neuro intact
  • Healthy
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60 15 8cm 15 2cm

Preop CT: solid fusion T11 to L4

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MRI

  • No severe stenosis at any level.

Treatment plan?

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Can this be done with a mini-open approach?

  • World Neurosurg. 2014 May-Jun;81(5-6)Mini-
  • pen pedicle subtraction osteotomy: surgical

technique.

  • Wang MY1, Madhavan K2.
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ALIF L4-S1 Mini-open L3 PSO T11 to pelvis percutaneous fixation Single skin incision; fascia intact

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Place reference arc for navigation Open skin to desired level

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Navigation arc placed; proximal screws in

Navigating Pelvic Fixation

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Placing pelvic fixation Placing iliac screw

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Distal screws in; Screw towers held apart

Fascia opened over PSO site only

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Fascia opened Exposing like open PSO

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Assess mobility of spine Mobility of spine

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Cantilever closure

Further compression can be applied

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Cantilever 2 rods, compress over domino connector

Single skin incision closure

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Same skin incision, but less muscle dissection Correction with Mini-Open PSO Anterior rod cut/screw removed w/PSO

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1 year postop 1 year postop

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Posterior thoracic corpectomy with cage reconstruction for metastatic spinal tumors: comparing the mini-open approach to the open approach. Lau D, Chou D. J Neurosurg Spine. 2015 Aug;23(2):217-27.

  • 49 patients:

– 21 patient in mini-open and 28 patients in open

  • Well matched cohort. No significant differences in demographics,

comorbidities, preoperative neurological status (ASIA score), tumor type, number of corpectomies performed, and number of levels instrumented.

  • No difference in operative time: open (413.6 minutes) vs. mini-open (452.4

minutes) (p=0.329).

  • Mini-open group had significantly:

– less blood loss (917.7 cc vs. 1697.3 cc, p=0.019) – shorter hospital stay (11.4 days vs. 7.4 days, p=0.001)

  • Mini-open group trended towards:

– lower perioperative complication rate (9.5% vs. 21.4%) (p=0.265) – lower infection rate (9.5% vs. 17.9%) (p=0.409).

  • At follow-up, no differences in: ASIA score (p=0.342), complication rate after

the 30-day postoperative period (p=0.999), and need for surgical revision (p=0.803).

Reference

  • Chou D and Lau D. Mini-Open Pedicle

Subtraction Osteotomy for Flatback Syndrome and Kyphosis. In Press, Neurosurgery

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Conclusions

  • Mini-open surgeries can achieve comparable

results to open surgery

  • Blood loss and length of hospital stay may be

reduced with mini-open surgery

  • Long term studies need to be performed to

evaluate the durability of mini-open procedures compared to open ones

Thank you!