transforaminal-endoscopic-approach-for-combined-far-lateral

Transforaminal Endoscopic Approach for Combined Far Lateral and Paracentral Discectomies at L5-S1 Level

The transforaminal (TF) and interlaminar (IL) approaches compose the two endoscopic approaches to lumbar discectomy. There is a growing tendency to ...

Houston Methodist Neurological Institute

The authors present the first reported use of the lateral retroperitoneal transpsoas approach for interbody arthrodesis in a patient with achondroplastic dwarfism. The inherent anatomical abnormalities of the spine present in achondroplastic dwarfism predispose these patients to an increased incidence of spinal deformity as well as neurogenic claudication and potential radicular symptoms. The risks associated with prolonged general anesthesia and intolerance of significant blood loss in these patients makes them ideal candidates for minimally invasive spinal surgery. The patient in this case was a 51-year-old man with achondroplastic dwarfism who had a history of progressive claudication and radicular pain despite previous extensive lumbar laminectomies. The lateral retroperitoneal transpsoas approach was used for placement of interbody cages at L1/2, L2/3, L3/4, and L4/5, followed by posterior decompression and pedicle screw instrumentation. The patient tolerated the procedure well with no complications. Postoperatively his claudicatory and radicular symptoms resolved and a CT scan revealed solid arthrodesis with no periimplant lucencies.

Lateral retroperitoneal transpsoas interbody fusion in a patient with achondroplastic dwarfism.

Evaluation of lumbar stability is fundamentally dependent on a clear understanding of normal lumbar motion. There are inconsistencies in reported lumbar motion across previously published studies, and it is unclear which provide the most reliable reference data. New technology now allows valid and reliable determination of normal lumbar intervertebral motion (IVM). The object of this study was to provide normative reference data for lumbar IVM and center of rotation (COR) using validated computer-assisted measurement tools.

Sagittal plane lumbar intervertebral motion during seated flexion-extension radiographs of 658 asymptomatic nondegenerated levels.

Image-guided approaches to spinal instrumentation and interbody fusion have been widely popularized in the last decade [1-5]. Navigated pedicle screws are significantly less likely to breach [2, 3, 5, 6]. Navigation otherwise remains a point reference tool because the projection is off-axis to the surgeon's inline loupe or microscope view. The Synaptive robotic brightmatter drive videoexoscope monitor system represents a new paradigm for off-axis high-definition (HD) surgical visualization. It has many advantages over the traditional microscope and loupes, which have already been demonstrated in a cadaveric study [7]. An auxiliary, but powerful capability of this system is projection of a second, modifiable image in a split-screen configuration. We hypothesized that integration of both Medtronic and Synaptive platforms could permit the visualization of reconstructed navigation and surgical field images simultaneously. By utilizing navigated instruments, this configuration has the ability to support live image-guided surgery or real-time navigation (RTN). Medtronic O-arm/Stealth S7 navigation, MetRx, NavLock, and SureTrak spinal systems were implemented on a prone cadaveric specimen with a stream output to the Synaptive Display. Surgical visualization was provided using a Storz Image S1 platform and camera mounted to the Synaptive robotic brightmatter drive. We were able to successfully technically co-adapt both platforms. A minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and an open pedicle subtraction osteotomy (PSO) were performed using a navigated high-speed drill under RTN. Disc Shaver and Trials under RTN were implemented on the MIS TLIF. The synergy of Synaptive HD videoexoscope robotic drive and Medtronic Stealth platforms allow for live image-guided surgery or real-time navigation (RTN). Off-axis projection also allows upright neutral cervical spine operative ergonomics for the surgeons and improved surgical team visualization and education compared to traditional means. This technique has the potential to augment existing minimally invasive and open approaches, but will require long-term outcome measurements for efficacy.

Videoexoscopic real-time intraoperative navigation for spinal neurosurgery: a novel co-adaptation of two existing technology platforms, technical note.

The safe working zone for lateral access to the L4/5 disc space has been said to lie in the anteroposterior (AP) midpoint of the disc space due to the location of the femoral nerve at that level. However, the AP location of the psoas muscle (and thus the lumbosacral plexus within) at L4/5 is variable. A psoas muscle lying excessively anteriorly at the L4/5 disc space may preclude safe access to the L4/5 disc space from a lateral transpsoas approach.

Variation in Psoas Muscle Location Relative to the Safe Working Zone for L4/5 Lateral Transpsoas Interbody Fusion: A Morphometric Analysis.

Standard fluoroscopic navigation and stereotactic computed tomography-guided lumbar pedicle screw instrumentation traditionally relied on the placement of Kirshner wires (K-wires) to ensure accurate screw placement. The use of K-wires, however, is associated with a risk of morbidity due to potential ventral displacement into the retroperitoneum. We report our experience using a computer image-guided, wireless method for pedicle screw placement. We hypothesize that minimally invasive, wireless pedicle screw placement is as accurate and safe as the traditional technique using K-wires while decreasing operative time and avoiding potential complications associated with K-wires.

Minimally Invasive, Stereotactic, Wireless, Percutaneous Pedicle Screw Placement in the Lumbar Spine: Accuracy Rates With 182 Consecutive Screws.

A minimally invasive approach to the L2-S1 disc spaces through a single, left-sided, retroperitoneal oblique corridor has been previously described. However, the size of this corridor varies, limiting access to the disc space in certain patients. Here, the authors retrospectively reviewed lumbar spine magnetic resonance imaging (MRI) in 300 patients to better define the size and variability of the retroperitoneal oblique corridor.

Variability in the size of the retroperitoneal oblique corridor: A magnetic resonance imaging-based analysis.

Meningiomas of the spinal canal comprise up to 40% of all spinal tumors. The standard management of these tumors is gross total resection. The outcome and extent of resection depends on location, size, patient's neurologic status, and experience of the surgeon. Heavily calcified spinal meningiomas often pose a challenge for achieving gross total resection without cord injury.

Resection of Spinal Meningioma Using Ultrasonic BoneScalpel Microshaver: Cases, Technique, and Review of the Literature.

Patient-specific instrumentation is an emerging technology with the promise of a better fit to patient anatomy. With the advent of deformity correction planning software, prefabricated rods can mitigate the need to bend rods in the operating room. Prefabricated rods allow the surgeon to provide a deformity correction closely in line with the surgical plan.

Utility of Patient-Specific Rod Instrumentation in Deformity Correction: Single Institution Experience.

Lateral lumbar interbody fusion (LLIF), first described in the literature in 2006 by Ozgur ., involves direct access to the lateral disc space via a retroperitoneal trans-psoas tubular approach. Neuromonitoring is vital during this approach since the surgical corridor traverses the psoas muscle where the lumbar plexus lies, risking injury to the lumbosacral plexus that could result in sensory or motor deficits. The risk of neurologic injury is especially higher at L4-5 due to the anatomy of the plexus at this level. Here we report our single-center clinical experience with L4-5 LLIF.

Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series.

Several studies have demonstrated the utility of intraoperative neuromonitoring (IOM) including somatosensory evoked potentials (SSEPs), motor-evoked potentials (MEPs), and electromyography (EMG), in decreasing the risk of neurologic injury in spinal deformity procedures. However, there is limited evidence supporting the routine use of IOM in elective posterolateral lumbar fusion (PLF).

The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample.

Response to the Letter: Utility of Patient-Specific Rod Instrumentation in Deformity Correction: Single Institution Experience.

Lumbar drain placement is a common neurosurgical procedure, with several surgical and medical indications extending even beyond the specialty. One complication of placement is a fractured catheter fragment. In some circumstances, catheter retrieval is necessary which is classically performed through an open approach. Here, we present the only reported case of a retained lumbar drain catheter which was retrieved using a transforaminal endoscopic approach to the lumbar spine.

Article	Year
Lateral retroperitoneal transpsoas interbody fusion in a patient with achondroplastic dwarfism. Journal of neurosurgery. Spine\| PubMed ID: 25415482	2015
Sagittal plane lumbar intervertebral motion during seated flexion-extension radiographs of 658 asymptomatic nondegenerated levels. Journal of neurosurgery. Spine\| PubMed ID: 26296193	2015
Videoexoscopic real-time intraoperative navigation for spinal neurosurgery: a novel co-adaptation of two existing technology platforms, technical note. Journal of robotic surgery\| PubMed ID: 28656505	2018
Variation in Psoas Muscle Location Relative to the Safe Working Zone for L4/5 Lateral Transpsoas Interbody Fusion: A Morphometric Analysis. World neurosurgery\| PubMed ID: 28797977	2017
Minimally Invasive, Stereotactic, Wireless, Percutaneous Pedicle Screw Placement in the Lumbar Spine: Accuracy Rates With 182 Consecutive Screws. International journal of spine surgery\| PubMed ID: 30619667	2018
Variability in the size of the retroperitoneal oblique corridor: A magnetic resonance imaging-based analysis. Surgical neurology international\| PubMed ID: 32363049	2020
Resection of Spinal Meningioma Using Ultrasonic BoneScalpel Microshaver: Cases, Technique, and Review of the Literature. Operative neurosurgery (Hagerstown, Md.)\| PubMed ID: 32726428	2020
Utility of Patient-Specific Rod Instrumentation in Deformity Correction: Single Institution Experience. Spine surgery and related research\| PubMed ID: 32864493	2020
Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series. Journal of spine surgery (Hong Kong)\| PubMed ID: 33102893	2020
The utility of intraoperative neuromonitoring on simple posterior lumbar fusions-analysis of the National Inpatient Sample. Journal of spine surgery (Hong Kong)\| PubMed ID: 34296025	2021
Response to the Letter: Utility of Patient-Specific Rod Instrumentation in Deformity Correction: Single Institution Experience. Spine surgery and related research\| PubMed ID: 34966876	2021
Fractured Lumbar Drain Catheter Retrieval Using an Endoscopic Transforaminal Approach to the Lumbar Spine. Operative neurosurgery (Hagerstown, Md.)\| PubMed ID: 36227253	2022

Paul Holman

Biography

JoVE Journal Publications

Other Publications