Post on 21-Feb-2020
Least Invasive Lumbar Decompression, Interbody Fusion &
Pedicle Screw Implantation (LINDIF)
A Case Series Report
Disclosures
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Least Invasive Lumbar Decompression, Interbody Fusion &
Pedicle Screw Implantation (LINDIF)
A Case Series Report
To our Japanese colleagues who are here and back home:
Kokoro yori okuyami moushiagemasu
(From the heart I give you my condolences)
Least Invasive Lumbar Decompression, Interbody Fusion &
Pedicle Screw Implantation (LINDIF)
A Case Series Report
Said G Osman, M.D.
List of Desirables
Desire to reduce:
* Surgical trauma
* Blood loss and the need for transfusion
* Anesthetic time
* Hospital stay
Post-op pain medicines
Down time to normal activities early
* Risk of complications in the elderly
* Escalating health care cost
* Desire by elderly patients to maintain high level of physical activities
To determine if LINDIF can realize those desirable outcomes
Patient Sample: Case series by one surgeon at two centers
Outcome Measures: Operating time; intra-operative blood loss;
hospital stay; VAS scores for back and leg pain; Roland-Morris
Disability Questionnaire; and post-operative imaging studies.
Materials and Methods
Total # of Patients = 60
Male = 30
Female = 30
Materials and Methods
Deg Disc Disease = 5
Deg. Motion Seg. = 49
Spondylolisthesis = 6
Operative Routine
Prophylactic Antibiotics
* Endotracheal Anesthesia
Foley catheterization
* Neuro-monitor
* DVT prophylaxis
Open frame operating table
* Prone position
* Transparent drapes
Fluoroscopy/Navigation system
Procedure
Percutaneous Pedicle Screw Instrumentation
Interbody fusion
Percutaneous pedicle screw implantation
INTRADISCAL PROCEDURES
Establish Access channel to posterolateraldisc
Osman et al.: Posterolateral Arthroscopic Discectomies of the Thoracic and Lumbar Spine. Clinical Ortho. & Related Research: 304:122-129, 1994.
Osman SG, et al. Endoscopic Transiliac Approach to L5-S1 Disc and Foramen –A Cadaver Study. Spine, Vol 22, #11:1259, 1997.
Osman SG, et al. Transforaminal and Posterior Decompression of Lumbar spine –A comparative study of Stability and IVF Area. Spine: Vol 22, #15: 1690 - 95
ARTHROSCOPIC DISCECTOMY
Postero-lateral approach
ARTHROSCOPIC DISCECTOMY
Foraminal Space Posterolat view of Kambin’sTriangle
ARTHROSCOPIC MICRODISCECTOMY
Mid- Interpedicular placement Lateral placement
Arthroscopic discectomy & end-plate preparation
Endplate PreparationExpandable Reamer System
Endplate Preparation
Expandable Reamer System
Endplate Preparation
Expandable Reamer System
Endplate Preparation
Interbody Grafting
Interbody Graft Material:
Rh-BMP-2
Allograft Bone Chips
Interbody Grafting
Results
Results
# of cases = 60
Mean age= 52. 7 years
Age range = 26 – 85 years.
Age Groups:
20-30y = 3
31-50y = 25
51-70y = 20
71-90y = 120
5
10
15
20
25
Patient #
20-30 y
31-50 y
51-70 y
71-90 y
Duration of illness:
Mean= 5 years
Range = 2m – 32 years
Follow-up:
Mean 12 months
Range 6 – 25 months
Results
Complaints:
Back pain = 60
Leg pain = 60
Fusion Levels
L1-S1 2
L2-3 1
L2-4 3
L2-5 1
L2-S1 1
L3-5 9
L3-S1 6
L4-5 8
* L4-S1 16
* L5-S1 130
2
4
6
8
10
12
14
16
L1-S1
L2-3
L2-4
L2-5
L3-5
L3-S1
L4-5
L4-S1
L5-S1
Fixation Device
Implants used:
* Denali (K2M) 19
SpheRx (Nuv) 6
Pathfinder (AS) 18
Sextant (Sofam) 17
0
5
10
15
20
Denali
SpheRx
Pathfinder
Sextant
Total OR Time
28 patients
Mean = 174 min
Range = 117 – 250.8 min
Total OR Time
1 level (7) = 2.5 hr.
2 levels (13) = 2.8 hrs.
3 levels (5) = 3.3 hrs.
4 levels (2) = 3.05 hrs
5 levels (1) = 4.1 hrs.
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Hours
1 level
2 levels
3 levels
4 levels
5 levels
Estimated Blood Loss
Mean 57.6 cc
Range 30 – 100 cc
Blood Loss vs # of Fused segments
1 Level (20) 47.8 cc
2 levels (31) 64.4 cc
3 levels (7) 61.4 cc
4 levels (1) 75.0 cc
5 levels (2) 62.5 cc
0
10
20
30
40
50
60
70
80
1 Level
2 Levels
3 Levels
4 Levels
5 Levels
Length of Hospital Stay
Mean : 2.6 days
Range : 1-12 days
Hospital Stay vs # Fused Seg
1 level (20) 1.7 days
2 levels(21) 3.0 days
3 levels (8) 3.6 days
4 levels (1) 4.0 days
* 5 levels (12) 12.0 days
0
2
4
6
8
10
12
Days
1 level
2 levels
3 levels
4 levels
5 levels
Back Pain
Pre-op on VAS:
Mean : 7.5
Range: 0 – 10
At Last Follow-up:
Mean : 2
Range: 0 - 8
0
1
2
3
4
5
6
7
8
Back Pain
Pre-op
Follow-up
Leg Pain
Pre-op on VAS:
Mean: 7.0
Range: 0 – 10
At Follow-up:
Mean : 1.7
Range: 0 - 5
0
1
2
3
4
5
6
7
Leg Pain
Pre-op
Follow-up
Prior Back Surgery
Decompressions = 10
One Level = 5
Two Levels = 5
Prior Back Surgery
Back Pain /Leg Pain
All :
Preop: 7.5/7.0
Postop: 2.0/1.7
Failed Back:
Preop: 7.0/8.0
Postop: 0.8/0.6
0
1
2
3
4
5
6
7
8
ALL FailedBack
Preop BP
Postop BP
Preop LP
Postop LP
Prior Back Surgery
Hospital stay
All : 2.0 days
Failed Bk: 1.8 days
1.7
1.75
1.8
1.85
1.9
1.95
2
Hosp. Days
ALL
Failed Bk
Post-op Images
45 sets reviewed
28 solid fusion
15 stable constructs
2 cases of osteolysis
around pedicle screws
0
5
10
15
20
25
30
FUSED
STABLE
LOOSE HW
HW BREAK
Post-operative Imaging Studies
3 months post-op 6 months post-op
Complications:
1 medial penetration of S1 pedicle with irritation of S1 nerve root - revised
1 case of painful loose pedicle screws – Removal.
Comparative Data
OR TIME(min)
EBL(ml)
LOS(Days)
COMPLICATIONRATES (%)
LINDIF 174* 57.6 2.6 1.8
X-LIF+/- Post. ins
165 119 3.4 13.3
MIS TLIF 230.2 264.7 5.6 5.6
OPEN PLIF/ TLIF
213.9 693 8.1 4.9
CONCLUSION
LINDIF minimizes surgical trauma:
Avoids violation of natural cavities –
spinal, peritoneal, thoracic
Avoids excision of the facet joint
Avoids the Psoas Space
Avoids retroperitoneal space
Reduced Surgery time
Reduced Blood loss
Short Hospital stay
Minimal rate of complications
Good symptomatic relief
Walking 3 hrs post-op
CONCLUSION
VERY WELL TOLERATED BY ELDERLY PATIENTS
LEAST STRESSFUL FOR THE SURGICAL TEAM
CONCLUSION
Randomized Controlled Trial (RCT) is needed to determine:
Accuracy of above findings
Cost-Effectiveness Analysis
Reduction in rehab duration
Earlier return to prior occupation/recreation
Complication compared with open & other MIS procedures.
Bibliography
Osman et al.: Posterolateral Arthroscopic Discectomies of the Thoracic and Lumbar Spine. Clinical Ortho. & Related Research: 304:122-129, 1994.
Osman SG, et al. . Endoscopic Transiliac Approach to L5-S1 Disc and Foramen –A Cadaver Study. Spine: 22, #11:1259, 1997.
Kambin P. Arthroscopic Microdiscectomy. Arthroscopy 1992; 8:287-295.
Deluzio et al. Value and cost in less invasive spinal fusion surgery: lessons learned from a community hospital. SAS J 2010; 4:37-40.
Knight RQ et al. Direct lateral lumbar interbody fusion for degenerative condition: early complication profile. J Spinal Disord Tech 2009; 22:34-7.
Oliviera L. et al. The use rh-BMP2 in stand alone extreme lateral interbody fusion (X-LIF): clinical and radiological results after 24 months follow-up. World Spinal Column J 2010; 1:19-25.
Ozgur BW et al. Two year clinical and radiographic success of minimally invasive lateral transpsoas approach for the treatment of degenerative lumbar conditions. SAS J 2010. 4:41-6.
Rogers WB et al. Minimally invasive treatment (XLIF) of adjacent segment disease after prior lumbar fusions. Internet J Minimally Invasive Spinal Technol, 2010.; 3.
Anand N et al. Mid-term and long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis. Neurosurg Focus 2010; 28:E6
Dakwar E et al. Early outcomes and safely of minimally invasive, lateral retroperitoneal transpsoas approach for the adult degenerative scoliosis. Neurosurg Focus 2010; 28:E8
Villavicencio AT et al. Minimally invasive versus open transforaminal lumbar interbody fusion. SurgNeurol. Int 2010; 1:12.
Wang et al. Comparison of one level minimally invasive and open transforaminal lumbar interbodyfusion in degenerative and spondylolisthesis grade 1 and 2. Euro Spine J 2010; 19:1780-4
Schizas et al. Minimally invasive versus open transforaminal lumbar interbody fusion; evaluating initial experience. Int Ortho 2009; 33:1693-8
Thanks