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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

  1. 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 evolving • MIS has a very limited role in adult deformity surgery • Will MIS eventually have a greater role in adult deformity? 1

  2. 11/13/2015 PSO Can we do this MIS? With this? 2

  3. 11/13/2015 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 operation 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 3

  4. 11/13/2015 Evolution of mini-open vertebrectomy • T6 Metastatic hepatocelluar carcinoma • Cord compression • Gait disturbance • Neurologic deficit Skin incision — make single midline incision or multiple stab incisions? (Fessler) 4

  5. 11/13/2015 Single skin incision Place Jamshidi needles 5

  6. 11/13/2015 Jamshidi’s in Place k-wires in 6

  7. 11/13/2015 Open fascia or skin Tap goes in 7

  8. 11/13/2015 Tap under fluoro Place screw — control k-wire 8

  9. 11/13/2015 Start laminectomy Place temporary rod to prevent translation 9

  10. 11/13/2015 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 osteomy about 3 cm lateral to the costovertebral junction until the rib is mobile 10

  11. 11/13/2015 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 11

  12. 11/13/2015 Place expandable cage Skin closure 12

  13. 11/13/2015 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. 13

  14. 11/13/2015 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 14

  15. 11/13/2015 Open transpedicular corpectomy Implants placed. Laminectomy done 15

  16. 11/13/2015 Contour rods into the shape you want spine to look Cantilever to correct kyphosis 16

  17. 11/13/2015 Post correction Can we do the same thing less invasively? • Mini-open corpectomy with kyphosis correction 17

  18. 11/13/2015 Breast cancer — kyphosis correction via Mini-Open approach Kyphosis intraop picture 18

  19. 11/13/2015 Cage insertion Kyphosis correction 19

  20. 11/13/2015 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 20

  21. 11/13/2015 Preop • Severely limited in ambulation • Chronic narcotic use • Sits in chair all day • 90 degrees kyphosis • 2 compression fractures above & below Standard skin incision 21

  22. 11/13/2015 Preserve fascia Jamshidi needles placed 22

  23. 11/13/2015 Place proximal screws Place distal screws 23

  24. 11/13/2015 Multiple Jamshidis save on fluoro Open fascia over VCR site only 24

  25. 11/13/2015 Begin laminectomy Complete VCR — temporary rod 25

  26. 11/13/2015 Place cage for pivot Thread rod through fascia — cut the fascia distal end 26

  27. 11/13/2015 Correct kyphosis — rod in shape of how you want spine to be Fascial opening 27

  28. 11/13/2015 Drains placed, skin closed • 500cc EBL • No intraop transfusion • Back pain much better • Caveat:s: cement PE, new adjacent fracture at L4 28

  29. 11/13/2015 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 29

  30. 11/13/2015 15 8cm 2cm 60 15 Preop CT: solid fusion T11 to L4 30

  31. 11/13/2015 MRI • No severe stenosis at any level. Treatment plan? 31

  32. 11/13/2015 Can this be done with a mini-open approach? • World Neurosurg. 2014 May-Jun;81(5-6)Mini- open pedicle subtraction osteotomy: surgical technique. • Wang MY1, Madhavan K2. 32

  33. 11/13/2015 ALIF L4-S1 Mini-open L3 PSO T11 to pelvis percutaneous fixation Single skin incision; fascia intact 33

  34. 11/13/2015 Place reference arc for navigation Open skin to desired level 34

  35. 11/13/2015 Navigation arc placed; proximal screws in Navigating Pelvic Fixation 35

  36. 11/13/2015 Placing pelvic fixation Placing iliac screw 36

  37. 11/13/2015 Distal screws in; Screw towers held apart Fascia opened over PSO site only 37

  38. 11/13/2015 Fascia opened Exposing like open PSO 38

  39. 11/13/2015 Assess mobility of spine Mobility of spine 39

  40. 11/13/2015 Cantilever closure Further compression can be applied 40

  41. 11/13/2015 Cantilever 2 rods, compress over domino connector Single skin incision closure 41

  42. 11/13/2015 Same skin incision, but less muscle dissection Correction with Mini-Open PSO Anterior rod cut/screw removed w/PSO 42

  43. 11/13/2015 1 year postop 1 year postop 43

  44. 11/13/2015 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 44

  45. 11/13/2015 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! 45

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