PERCUTANEOUS ENDOSCOPIC

INTERSOMATIC

TRANSFORAMINAL FUSION

WITH 2 CAGES

 (Pe-TLIF)

UNI-/ or BIPORTAL?

Daniel Gastambide (Paris)Frédéric Jacquot (Paris)

Pierre Finiels (Nîmes)Patrice Moreau (Boursay)

Since we began using this technique in 2005, we’ve inserted percutaneous cages for lumbar arthrodesis in “virgin spines” and in previously operated spines.

Most of the first patients have been operated on in prone position

In the case of treating one disc by using an arthrodesis and one hernia on the level above on the same side in lateral position, we began by carrying out the arthrodesis on only one side.

L4L5L5S1

The rationale for percutaneous cage fusion:- obese patient- elderly patients- heavy comorbidity- degenerative scoliosis with spontaneous fusion blocks and dislocations- multiple degenerative disc disease with one elective symptomatic disc

Seeing that the results on virgin spines were encouraging, 29 good primary results with a mean follow-up of 2 years on 35 patients, we wanted to simplify the process by making a lateral approach and by using a more simple technique

SVI.. 77 year-old man, bilateral cruralgia, persisting discal hernia L2L3 unextractable by a posterieor approach sunk in a post-laminectomy fibrosis for a narrow channel

In the case of one patient we put in two cages on the same side on every level, on L2L3 and L3L4 in the middle of the intervertebral space

SVI.. 2

For one other patient, we put in two cages in L3L4 through the same side.

HER.. 47 year-old man, big discal hernia L3L4 + lateral subluxationOpen dislocation in a 7°scoliosis, with a right translation of L3 on L4, right gaping of the L3L4 space with an underlying compensation aspect through a left gaping of the L4L5 space. Furthermore, you can note a discrete L4L5 retrolisthesis only in standing position, not visible on the CT scan neither on the MRI

Right cage inserted a little too low by the left

In the cases of two patients, we made a unilateral approach on L4L5 and put in one cage. GIL…79 year-old lady, couldn’t walk before op; VAS was 9 pre-op and was 5 post-op with 6m follow-up

FF

PERR.. 61 year-old woman, 98kg, 1.63m, private nurse. Hyperalgic lumbalgia. Lumbar VAS 8 during examination, 10 during crisis.Maximum walking distance 500m because of the lumbalgia; no other source of soothing than resting in a lying position or sitting during painful crisis; took Aceclofenac 100mg*2, Tramadol 100 in the morning, Paracetamol 1000 during painful crisis, with a very limited effect.

Intersomatic arthrodesis with Europa cage in L4L5 on November 4 2009 resulting in an insufficient stability : a left cruralgia appeared and a few days later we put in pedicular implants and plates. The CT scan showed a restitution of the intersomatic space of about 4mm, the cage is introduced by the left side and shifted expressly to the right where the osseous tissue of the overlying and underlying vertebral plates is more dense.

For two other patients, we put in two cages in L5S1

CHAI… 48 year-old female, auxiliary nurse, L4L5 hernia and degenerative discopathy in L5S1.Transforaminal endoscopic discectomy in L4L5 on the right and and two Europa cages in L5S1

The immediate follow-up showed the disappearance of the usual pains and the appearance of new pains: lombalgias and pain when turning over in bed.After 5 months we made another operation: fusion of the instable L4L5 level and osteosynthesis of the painful encaged L5S1

CHAR… 70 year-old woman, retired postlady, VAS 7 to 3 f.u.6m

High origin of the right L5 root

We can’t exactly explain why we can put in two cages for some patients and only one for others, particularly on the L4L5 levelCould this be due to the width of the Kambin triangle?

Pil Sun Choi A T Yeung

L5

L4

S1

Or could it be due to the number and the position of anastomosis between the exiting root and the white or grey ramus communicans of the sympathetic system which carries the nociceptive fibers? Patient operated under local anesthesia.

Variations of the birth of rami communicantes

Ramji DASS, Sympathetic components of the dorsal primary divisions of human spinal nerves, 493-501 Department of Anatomy, New York University College of Medicine. THREE FIGURES. In descriptions of the anatomy of the sympathetic system .

Thesis Sylvie Raoul; Pr Robert, Nantes

Rami communicantes and sinu vertebral nerves

disc

medial

upGanglion L3 separated and reclined

Radicular anastomosis between L2 and L3

If the exiting root is painful while passing the dilators, we take a look at the endoscopic view of it and try to push it away without causing any pain. Then we insert the cage, preceded by the dilators.

CRANIAL

CAUDAL

ILIAC CREST

ZYGAPOPHYSAL JOINT

PEDICULEISTHMUS

EXITING ROOT L4

foramen

lateral

medial

ConclusionsWe showed the feasability of putting in two cages for intersomatic arthrodesis with a percutaneous technique by only one side

Advantages of this percutaneous technique versus conventional technique:•lateral position authorized for all kinds of patients•minimal incision•no bleeding•no fibrosis•patient stands up two hours after operation•possibility to make a transforaminal endoscopic discectomy at another level•very low post-operative morbidity (no thrombo-embolism, no risk of hematoma)

Disadvantages•steep learning curve•sometimes impossibility to enlarge Kambin’s triangle with the dilators•difficulty of percutaneous screwed implants and plates on smaller patients•if no associated percutaneous plate, brace necessary for 45 days

FutureWe are now studying Tri-dimensional navigation and the possibility of using the C-arm as least as possible, of diminishing individual Xray doses on the patient, on the operation room nurse and on the surgeon.

23th IITS annual meeting 2010

2nd WCMISST biannual meetingconjoined with

the 24th IITS meeting

Past President WCMISST 2008

President Elect WCMISST 2010

Past President IITS 2009

President Elect IITS 2010