Minimally Invasive Procedures in Spine Surgery

Fahir Özer

Minimally Invasive Procedures in Spine Surgery

ISBN: 978-605-5004-08-8

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Contents

Intro

1. History of Minimally Invasive Spine Surgery

2. Spinal Anatomy

3a. Anterior Microendoscopic Discectomy and Fusion for the Cervical Spine

3b. Posterior Cervical Microendoscopic Discectomy and Laminoforaminotomy

3c. Microendoscopic Minimally Invasive Posterior Cervical Instrumentation and Fusion Techniques

3d. Anterior Cervical Microforaminotomy

3e. Anterior Cervical Microdiscectomy and Fusion

4a. How to Improve Surgical Skills in Endoscopic Surgery

4b. Endoscopic Thoracal Procedures (VATS)

4c. Thoracoscopic Discectomy

4d. Thoracoscopic Management of Spine Tumors

4e. Thoracoscopic Management of Spinal Trauma

4f. Simultaneous Thoracoscopic Release and Posterior Instrumentation in Adolescent Idiopathic Scoliosis

4g. Thoracoscopic Sympathectomy

5a. Microlumbar Discectomy

5b. Transforaminal Endoscopic Discectomy

5c. Posterolateral Selective Endoscopic Discectomy the Yess Technique

5d. Microendoscopic Discectomy using Metrx System

5e. Percutaneous Transpedicular Screw Insertion Technique (Sextant)

5f. Translaminar Facet Screw Fixation

5g. Anterior Microendoscopic Discectomy and Fusion

5h. Minimally-Invasive Lumbosacral Axial Instrumentation Technique

5i. Posterior Percutaneous Transpedicular Lumbar Dynamic Stabilization

5j. Lumbar Interspinous Devices

5k. Minimal Invasive Methods For Anterior Approach To Lower Lumbar Vertebrae

5l. Laparoscopic Anterior Lumbar Fusion

5m. The Surgical Risks and Efficacy of Foraminal Endoscopic Spine Surgery: As Defined by Visualization of Painful Patho-Anatomy

5n. Micro Lumbar Decompression for Lumbar Spinal Stenosis

6a. Percutaneous Vertebroplasty

6b. Percutaneous Kyphoplasty

6c. Percutaneous Laser Disc Decompression

6d. Epiduroscopy

7a. Ct Based Image Guidance in Spine Surgery

7b. Lumbar Disc Replacement

7c. Spinal Stereotactic Body Radiotherapy

7d. Neurostimulation For Pain Secondary To Spine Problems

7e. Stereotactically-Guided Spinal Radiosurgery

Intro

Minimally Invasive

Procedures

in Spine Surgery

Editors:

Larry T. Khoo, Ali Fahir Özer

Co Editors:

Murat Coşar, Farbod Asgarzadie, Zachary A. Smith

ISBN: 978-605-5004-08-8

INTERTIP

2016

Turkey

To Our Family...

AUTHORS (in alphabetical order)

Abitbol, Jean-Jacques

Department of Orthopaedic Surgery,  University of California at Los Angeles,  Los Angeles, CA, USA

Aras, Adem Bozkurt

Çanakkale 18 March University, Faculty of  Medicine, Department of Neurosurgery  Çanakkale - Turkey

Altaş, Murat

Department of Neurosurgery, Faculty of Medicine,  Mustafa Kemal University,  Hatay - Turkey

Asgarzadie, Farbod

Department of Neurosurgery, Loma Linda  University Medical Center,  Loma Linda, CA-USA

Aslan, Adem

Department of Neurosurgery, Afyon Kocatepe  University, Faculty of Medicine,  Afyonkarahisar - Turkey

Aslantaş, Ali

Department of Neurosurgery, Eskisehir Osmangazi  University, Faculty of Medicine,  Eskişehir - Turkey

Aydın, Ahmet Levent

Department of Neurosurgery, SB 75 th Years  State Hospital,  İstanbul - Turkey

Bari, Ausaf

Resident Neurosurgeon, UCLA Department of  Neurosurgery,  Los Angeles, CA

Barolat, Giancarlo

Barolat Neuroscience  Presbyterian/ St Lukes Medical Center  1721East 19th Ave, Suit 434  Denver, Colorado

Carıllı, Şenol

Department of General Surgery, VKV American  Hospital,  İstanbul - Turkey

Ceylan, Davut

Sakarya University, Faculty of Medicine, Department  of Neurosurgery  Sakarya - Turkey

Coşar, Murat

Çanakkale 18 March University, Faculty of  Medicine, Department of Neurosurgery  Çanakkale - Turkey

De Salles, Antonio A.F.

Professor of Neurosurgery, Head of Stereotactic  Radiosurgery  UCLA Department of Neurosurgery  Ronald Reagan-UCLA Medical Center  Los Angeles, CA

Eser, Olcay

Department of Neurosurgery, Balıkesir University,  Faculty of Medicine,  Balıkesir - Turkey

Geisler, Fred H.

Illinois Neuro-Spine Center,  Aurora, Illinois, USA.

Gülmen, Vehbi

Specialist, SB Karşıyaka State Hospital, Department  of Neurosurgery  İzmir - Turkey

Güven, Mustafa

Çanakkale 18 March University, Faculty of  Medicine, Department of Neurosurgery  Çanakkale - Turkey

İplikçioglu, A. Celal

Department of Neurosurgery, Bayındır Hospital,  İstanbul - Turkey

İnan, Kaan Bilal

Department of Neurosurgery, Haydarpaşa  Gulhane Military Medical Academy  İstanbul, Turkey

Kaner, Tuncay

SB Pendik State Hospital, Department of Neurosurgery  İstanbul-Turkey

Khoo, Larry T.

UCLA, David Geffen Medical School, Department  of Neurosurgery  Los Angelos, CA-USA

Kıbıcı, Kenan

Department of Neurosurgery, Kasimpasa Military  Hospital,  İstanbul - Turkey

Koç, R. Kemal

Department of Neurosurgery, Erciyes University,  Faculty of Medicine,  Kayseri - Turkey

Köse, Kamil Çağrı

Department of Orthopedics, Sakarya University,  Faculty of Medicine,  Sakarya - Turkey

Lieberman, Isador H.

Cleveland Clinic Spine Institute, Minimally Invasive  Surgery Center, Cleveland Clinic Foundation,  Cleveland, Ohio, USA

Naderi, Sait

Department of Neurosurgery, SB Umraniye  Education Hospital, Faculty of Medicine  Istanbul - Turkey

Öktenoğlu Tunç

Department of Neurosurgery, VKV American  Hospital, Istanbul - Turkey

Özen, Oğuz Aslan

Namik Kemal University, Faculty of Medicine,  Department of Anatomy  Afyonkarahisar - Turkey

Özer, A. Fahir

Department of Neurosurgery, VKV American  Hospital,  İstanbul - Turkey

Pimenta, Luiz

Department of Minimal Invasive and Reconstructive  Spine Surgery, Santa Rita Hospital,  São Paulo, Brazil.

Regan, John J.

Orthopedic Surgeon,  West Coast Spine Institute, Beverly Hills, CA, USA

Sasani Mehdi

Department of Neurosurgery, VKV American  Hospital,  Istanbul - Turkey

Sedrac, Marc

Attending Physician, Torrance Memorial Hospital,  Director of Minimally Invasive Neurosurgery;  Los Angeles,CA

Selch, Michael

Attending Physician, Department of Radiation  Oncology,  Ronald Reagan-UCLA Medical Center.  Los Angeles,CA

Selek, Uğur

M.D. Anderson Cancer Center  Huston-Texas - USA

Songur, Ahmet

Department of Anatomy Afyon Kocatepe University,  Faculty of Medicine,  Afyonkarahisar - Turkey

Smith, Zachary A.

Los Angeles Spine Clinic,  The Good Samaritan Hospital  Los Angeles, CA

Yeung, Christopher A.

Arizona Institute for Minimally Invasive Spine  Care, Phoenix, AZ

Yeung, Antohny T.

Arizona Institute for Minimally Invasive Spine  Care, Phoenix, AZ

Zheng, Yinggang

Desert Institute for Spine Care  Phoenix, Arizona, USA

Zileli, Mehmet

Ege University, Faculty of Medicine, Department  of Neurosurgery  İzmir - Turkey

PREFACE 

Minimally invasive techniques in spine surgery are gaining great popularity between spine surgeons. It is quite evident that the current trend is to switch most of the conventional open surgeries to minimally invasive techniques. In the near future we can estimate they will be our standard in most cases.

This textbook Minimally Invasive Procedures in Spine Surgery is a great contribution to spine surgery literature. The sections contain not only advanced techniques of the minimally invasive spine surgery, but also related anatomy, some injection techniques and even radiosurgery of the spine. The authors are from Turkish spine surgeons and also well- known international names. I congratulate Dr.Larry T. Khoo and Dr. Ali Fahir Özer for editing this book that will be a very comprehensive guide for beginners and advanced spine surgeons. 

Mehmet Zileli, 

M.D.Professor of Neurosurgery

Past President of the Turkish Neurosurgical Society

Past President of the World Spinal Column Society

Honorary President of the Middle East Spine Society 

1. History of Minimally Invasive Spine Surgery

1. Introduction

The history of spine surgery goes back at least 5000 years. The first evidence of spinal surgery was found in Egyptian mummies from 3000 BC and elucidated 15 centuries later in the Edwin Smith papyrus in 1550 BC (1,2). Most spine surgeons believe that Hippocrates is the father of spine surgery because of his extensive writings and the treatment principles he proposed. For example the first traction procedure was proposed by Hippocrates in 390 BC (3). In the 7th century, the first operative treatment of spinal surgery was performed by Paulus of Aegina (4). In the 14th century, Serafettin Sabuncuoglu elucidated the treatment of spinal fracture dislocations in his surgical atlas (5).

Before the relatively recent evolution of technological advancements such as high speed drills microscopic surgical techniques and spinal instrumentation, spinal surgery consisted mainly of spinal decompressions, different fusion procedures and external corrective orthoses with staged operations. These early surgical maneuvers were often very lengthy, highly morbid and caused prolonged disability and negative psychological sequelae. The development of rigid and semi-rigid internal metallic fixation allowed the spine surgeons to rapidly stabilize the pathological spine in the early 1980s. Nowadays, it has become a worldwide standard of care. However, the placement of spinal implants often require long and extensive surgical exposures which strip away the overlying soft-tissues, there by oftentimes causing denervation and regional ischemia in the adjacent soft tissues. These iatrogenic injuries can cause significant postoperative pain and disability.

With the advent of modern surgical Technologies such as digital fluoroscopy, image guidance, highresolution endoscopy, and minimally invasive surgical tools, less invasive approaches have become more popular. The majority of these minimally invasive techniques use a small corridor focusing on the area of anatomy, thereby minimizing the resultant injury to the dorsal neural, muscular and ligamentous soft tissues. Minimally invasive techniques have been successfully applied to the cervical spine, thoracic spine and the lumbar region since the 1990’s (6,7,8,9,10,11).

2. Cervical Spine

2.a. Anterior Procedures

Percutaneously establishing a safe corridor to the anterior cervical spine can be difficult and can carry the risk of potential injury to the carotid artery, jugular vein, esophagus, trachea, thyroid and laryngeal nerves. Minimally invasive tubular approaches to the anterior cervical spine are therefore less commonly reported compared to minimally invasive posterior cervical spine techniques. The first anterior cervical cord decompression was described by Key in 1838 (12). More than a century later in 1968, Verbeist reported the anterior cervical foraminotomy (13) and it was popularized by Cloward, Smith and Robinson for the treatment of cervical spondylotic radiculopathy and disc diseases of the cervical spine (14,15,16). In 1975, Lankinson and Wilson (17) reported the use of the microscope for anterior cervical discectomy. In the early 1980s, the concept of internal fixation to aid in cervical fusion was introduced (18). In 1989, Snyder and Berhardt (19) developed the anterior cervical foraminotomy in an effort to avoid adjacentsegment disease after fusion procedures. Joe popularized percutaneous anterior cervical techniques in the early 1990s (²⁰,²¹).

Since then anterior cervical microforaminotomy and endoscopic-assisted anterior cervical discectomy and fusion have become popular minimally invasive anterior cervical spine procedures.

2.b. Posterior Procedures

The posterior cervical approach for cervical disc disease was first introduced by Elsberg in 1913 (22). Over the last 4 decades the posterior cervical lamino-foraminotomy has been well documented (23,24,25). Scoville and Whitcomb (26) popularized the concept of posterior cervical disc surgery in 1966. The posterior approach via a key hole osteotomy foraminotomy provided a better exposure to decompress the nerve roots and to remove lateral osteophytes and discs compared to the anterior cervical approaches. Murphy et al. (25) reported their open lamino-foraminotomy series of 648 cases with 80% reduction of preoperative symptoms.

However, this open procedure can cause significant muscular injury, atrophy, pain and spasm during the recovery period. After the advent of micro endoscopic foraminotomy (MEF) for posterior cervical foraminotomy by Roh et al. (27) in cadavers, the wide incision and paraspinous muscular dissection for the approach was. Adamson (6) and Khoo (28) described their experience with MEF in over 125 patients demonstrating less overall postoperative narcotic use, less postoperative pain compared to open posterior cervical spine procedures without compromising extent of nerve root decompression. Additionally, percutaneous posterior cervical instrumentation, laminectomy and laminoplasty have also been performed using minimally invasive techniques. Although these experiences are preliminary, the presented reports and technical notes are without any significant complications (29,30,31,32,33).

3. Thoracic Spine

In 1779, Pott (³⁴) performed the first thoracic spine approach to drain a tuberculosis abscess. Additionally, Key (12) reported the first case of thoracic disc disease in 1838. The lateral extracavitary approach was described by Menard in 1894 (35). Additionally, the first known thoracic laminectomy and discectomy was performed by Adsen in 1922 (36). Transsternal, transthoracic and transpedicular approaches were described in the last four decades (18).

The first thoracoscopic procedure was performedby Jacobaeus, an internal medicine professor, in 1990 (38). After the introduction of video imaging to standard endoscopy, Mack et al. (39) in the United States and Rosenthal et al. (40) in Europe first reported the technique of video assisted thorascopic surgery (VATS) in 1993. Initially, thoracoscopic procedures were performed for disc herniations, pathologies of vertebral body, tumor biopsies and drainage of abscesses. As the learning curve developed, it was performed for scoliosis, tumors, fractures, fusions and instrumentations, symphatectomy, osteotomies, corpectomies, and bone grafting (1). VATS allows visualization of the operation by the operating team with small incisions and minimum amount of rib resection.

In 1997, Joe (37) reported the first endoscopic transpedicular thoracic discectomy for disc herniations. A 0- and 70 degree 4 mm endoscope was used with a small incision and minimal tissue dissection for this technique. Additionally, the first laser thermodiskoplasty was performed with a 4 mm 0- degree endoscope by Chiu and Clifford (41).

4. Lumbar Spine

Traumatic lumbar disc rupture was first described by Virchow in 1857 (42), but it wasn’t until 50 years later that the first lumbar laminectomy and discectomy was performed by Oppenheim and Krause (43). In 1938, Love (44) reported the first minimal invasive interlaminar technique for lumbar disc surgery. Yaşargil (45) and Caspar (46) were the first to popularize the use of the operating microscope for the treatment of lumbar disc disease.

4.a. Percutaneous Procedures

The first injection of chymopapain was performed by Smith et al. (47) into a herniated nucleus pulposus for the treatment of sciatica. Injection of chymopapain causes chemonucleolysis and polymerization of the nucleus pulposus (1). Today, there is no consensus in the spine surgery community regarding the use of chymopapain.

Hijikata et al. (48) in 1975 reported the first percutaneous nucleotomy for posterolateral lumbar disc herniations using arthroscopic techniques. In 1985, Onik et al. (49) described the automated percutaneous lumbar discectomy using a 2 mm blunt-tipped suction cutting probe. Additionally, percutaneous laser discectomy was introduced by Choy et al. (50) in the late 1980s.

The first percutaneous vertebroplasty procedure was developed in 1984 by Galibert and Deramond with polymethylmethacrylate (PMMA) injection to the vertebral body through the pedicles (51). In 2001, kyphoplasty was developed to restore the height of the vertebrae via using an inflatable bone tamp before injecting PMMA (52).

In late 1990s, Saal and Saal (53) reported intradiscal electrothermal therapy to treat discogenic back pain. Nowadays, stereotactic and magnetic resonance guided microdiscectomies are also reported (18).

4.b. Endoscopic Procedures

Forst and Hausman (54) reported the first insertion of a modified rigid arthroscope into the center of the intervertebral disc space for visualization purposes in 1983. In 1988, Kambin (55) went on to apply this discoscopic view of a herniated disc fragment from within the disc. Additionally, in 1996, Kambin (56) went on to describe and document a safe posterolateral triangular working zone known subsequently as Kambin’s triangle. In 1997, Foleyand Smith introduced and illustrated the MicroEndoscopic Discectomy (MED) system to decompress a symptomatic lumbar nerve root (57). The MED system allowed surgeons to address not only contained lumbar disc herniations, but also sequestered disc fragments and bony lateral recess stenosis.

As experience and efficacy with tubular-type endoscopic approaches grew, these techniques were beginning to be applied to a broader range of pathologies. Khoo et al. (16) have previously reported a prospective, nonrandomized comparison of patients undergoing either open hemilaminotomyversus minimally-invasive microendoscopicdecompressive hemilaminotomy (MEDL) for the treatment of lumbar stenosis. Since then, advancement in the wide angled endoscopes and wider working channels have allowed for multiple types of mechanical instruments, drills and lasers to be applied as well.

4.c. Lumbar Arthrodesis Procedures

The first posterior lumbar interbody fusion (PLIF) was introduced by Cloward in 1953 for degenerative disc disease and spondylolisthesis (58). Since the advent of minimally invasive teqhniques, tubular approaches have also been applied to lumbar interbody fusions. Near total facetectomies and foraminotomies were performed to create a pedicle-to-pedicle exposure to allow for interbody fusion and grafting while ensuring the safety of the neural elements without overly aggressive retraction by extending the decompression through the access portal. After decompression, all phases of the interbody process including distraction, scraping, end plate preparation and placement of the allograft interbody spacers can be accomplished through the tubular access portal under close inspection of the neural elements (14).

In 1995, Matthews and Long (59) introduced the first percutaneous lumbar instrumentation using pedicle screws connected by subcutaneous plates placed above the dorsolumbar fascia. In 2000, Lowery et al. (60) subsequently described a similar procedure utilizing a rod as the joining member. However, these early attempts at spinal fixation necessitated subsequent hardware removal in some cases due to patient discomfort and nonunion (14). In 2002, Foley (61) introduced the Sextant (Medtronic Sofamor Danek, Memphis, TN) system for the purpose of achieving a percutaneous pedicle screw rod fixation. Since the Sextant, several other minimally-invasive lumbar fixation systems have been developed including the ATAVI (Endius; Plainville, MA), Aperture (Depuy Spine; Raynham, MA), and Pathfinder (Spinal Concepts; Austin, TX) systems (14). Multilevel instrumentation, compression, distraction and reductionof spondylolisthesis are possible with severalof these newer systems thus allowing for fixation of the most common lumbar pathologies via a truly percutaneous technique through only two small incisions (14).

Anterior lumbar interbody fusion (ALIF) was introduced as an alternative to PLIF in 1965 (63). In recent years, more minimally invasive ALIF procedures were reported (62), McAfee et al. (64) reported the first endoscopic retroperitoneal approach to the lumbar spine in 1997. The first laparoscopic approach to the lumbar spine was introduced by Obenchain in 1991 (65) and this paved the way for other laporoscopic lumbar spine procedures (66,67).

5. Conclusion

In the 5000? year-old history of spine surgery, the last 4 decades have seen a tremendous amount of development. With the advance of surgical, microspcopic and endoscopic tools, MIS surgery has made significant progress in the last ten years. We believe MIS surgery will continue to make strides in all subdisciplines of spinal surgery. Advances in MIS surgery have led to greatly improved outcomes, while reducing complication rates, shortening hospital stays, and lowering costs. Appropriate patient selection and strict adherence to indications will help to result in optimal outcomes and patient satisfaction.

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2. Spinal Anatomy

Oğuz Aslan Özen MD. PhD., Ahmet Songur MD. PhD.

1. The Vertebral Column as a Whole

The vertebral column is situated in the median line, at the posterior part of the trunk. It (backbone) consists of a series of 26 individual irregular bones called vertebrae, separated by fibrocartilaginous intervertebral discs and are secured to each other by interlocking processes and binding ligaments. There are 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, and 4-5 fused coccygeal vertebrae (1-8). The vertebrae in the upper three regions of the column are known as true or movable vertebrae. Vertebrae enclose and protect the spinal cord, support the head and upper extremities while permitting freedom of movement, articulate with the rib cage, and provide for the attachment of various muscles and visceral organs (5,9,10). The fibrocartilaginous intervertebral discs lend flexibility to the vertebral column and absorb vertical shock. This structural arrangement permits limited movement between adjacent vertebrae but extensive movement for the vertebral column. The lateral opening windows between the vertebrae are called intervertebral foramina that allow passage of spinal nerves (10,11).

The vertebral column contains several important anatomical curves. Viewed laterally, the cervical, thoracic, lumbar curves are designated by the type of vertebrae they include (Figure 1). The cervical curve begins from apex of the odontoid process, continues to the middle of the second thoracic vertebra. The thoracic curve begins from middle of the 2nd vertebra and continues to the middle of the 12th thoracic vertebra. The lumbar curve begins at the middle of the last thoracic vertebra, ends at the sacrovertebral angle. The pelvic curve (sacral curve) is formed by the shape of the sacrum and coccyx. The curves play an important functional role in increasing the strength and maintaining the balance of the upperpart of the body. These spinal curves also makepossible a bipedal stance. The four vertebral curves are not present in an infant. First, the cervical curve begins to develop at about 3-4 months. The lumbar curve develops as a child begins to walk. The vertebral canal follows the different curves of the column (3,5,6,10-12).

Figure 1:  Vertebral Column (lateral view).

2. General Characteristics of Vertebrae

The vertebrae are similar in their general characteristics from one region to another. A typical vertebra consists of two essential parts, an anterior segment, drumshaped body, and a posterior part, the vertebral or neural arch. These form the vertebral foramen, through which the spinal cord passes. The vertebral arch consists of two supporting pedicles and two arched laminae. Seven processes arise from the vertebral arch of a typical vertebrae: one spinous process, two transverse processes, andfour articular processes (4,8,10) (Figure 2).

Figure 2:  Thoracic vertebra (superior view).

Between the pedicles of adjacent vertebrae are the intervertebral foramina, one on either side, for the transmission of the spinal nerves and vessels (4,8,10).

The body (corpus vertebræ) is the largest part of a vertebra. Its upper and lower surfaces attach to the intervertebral fibrocartilages. The pedicles (radices arci vertebræ) are two short, thick processes, which project backward, one on either side, from the upper part of the body. The laminae are two broad plates directed backward and medially away from the pedicles. Their upper borders and the lower parts of their anterior surfaces are rough for the attachment of the ligamenta flava. The spinous process (processus spinosus) protrudes backward and downward from the vertebral arch. The transverseprocesses (processus transversi) extend laterally fromeach side of a vertebra at the point where the lamina joins the pedicle. The spinous process and transverse processes serve for the attachment of muscles and ligaments. The two superior and two inferior articular processes limit twisting and rotational movement of the vertebral column (4,5,8,10,12).

3. Regional Characteristics of Vertebrae

3.a. Cervical Vertebrae (Vertebrae Cervicales)

The bone tissue of cervical vertebrae is more dense than that found in the other vertebral regions, and the cervical vertebrae are the smallest of the true vertebrae. The seven cervical vertebrae support the head. Cervical vertebrae are distinguished from those of the thoracic or lumbar regions by the presence of a transverse foramen (foramen transversarium) in each transverse process. The vertebral arteries, veins and a plexus of sympathetic nerves pass through this opening in the upper six vertebrae. Cervical vertebrae (C2-C6) generally have a short and bifid, the two divisions being often of unequal size, spinous process. The bifid spinous processes increase the surface area for attachment of the nuchal ligament (ligamentum nuchæ). The first cervical vertebra (atlas) has no spinous process, is ring-like in nature, and consists of an anterior and a posterior arch. The spinous process of 7th cervical vertebra (vertebra prominens) is not bifid and is more prominent than those of the other cervical vertebrae. The atlas has no body, but it does have a rudimentary spinous process called the posterior tubercule. The tiny sizeof this process prevents any interference with movementsbetween atlas and skull. It also has cupped superior articular surfaces that articulate with the oval condyles of the occipital bone, and are importantly adapted to the nodding movements of the head. The second cervical