Less Invasive Cervical Decompression via Unilateral Tubular Laminotomy Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E418-E418
Author(s):  
Sertac Kirnaz ◽  
Christoph Wipplinger ◽  
Taylor Wong ◽  
Franziska Anna Schmidt ◽  
Raj Nangunoori ◽  
...  
Keyword(s):  
Computer Navigation ◽  
Cord Compression ◽  
Recurrent Laryngeal Nerve Injury ◽  
Adjacent Segment Degeneration ◽  
Adjacent Segment ◽  
3D Navigation ◽  
3 Dimensional ◽  
Less Invasive ◽  
Patient Consent ◽  
Hospital Stays

Abstract This video demonstrates the step-by-step surgical technique for a less invasive cervical unilateral laminotomy for bilateral decompression (cervical ULBD). This technique allows surgeons to address bilateral cervical pathology while minimizing approach-related complications.1 In the video, we present the case of a 72-yr-old female patient with a past medical history of C3-C4 anterior cervical discectomy and fusion who presented in clinic with persistent posterior spinal cord compression and signal change. The patient had bilateral hand numbness, weakness, poor dexterity, and a positive Hoffman's sign. The patient was treated via a C3-C4 less invasive cervical ULBD using a mobile 3-dimensional (3D) C-arm (Ziehm Vision RFD 3D®, Nürnberg, Germany) combined with 3D computer navigation. Patient consent was obtained prior to performing the procedure. Contrary to anterior techniques, posterior cervical approaches avoid potential dysphasia, recurrent laryngeal nerve injury, and adjacent segment degeneration. Furthermore, the less invasive cervical ULBD results in decreased pain and postoperative narcotic usage, shorter hospital stays and fewer infections compared to open approaches, as well as a lower risk for postlaminectomy kyphosis and deformity, since it requires less muscle disruption and bony removal. Additionally, the use of total 3D navigation facilitates the workflow and minimizes radiation exposure.

Minimally Invasive Laminotomy for Contralateral “Over-the-Top” Foraminal Decompression Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video

2019 ◽  
Vol 19 (3) ◽  
pp. E296-E296
Author(s):  
Sertac Kirnaz ◽  
Christoph Wipplinger ◽  
Franziska Anna Schmidt ◽  
R Nick Hernandez ◽  
Ibrahim Hussain ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Facet Joint ◽  
Computer Navigation ◽  
3D Navigation ◽  
Intraoperative Computed Tomography ◽  
3 Dimensional ◽  
Left Lower Extremity ◽  
Patient Consent ◽  
Foraminal Disc Herniation ◽  
Over The Top

Abstract This video demonstrates the step-by-step surgical technique for the minimally invasive laminotomy for contralateral “over-the-top” foraminal decompression. This technique allows for excellent decompression with clearance of the contralateral recess and foramen. In the video, we present the case of a 51-yr-old female patient with a past medical history of left L5-S1 microdiscectomy who presented in clinic with residual/recurrent foraminal disc herniation at L5-S1 compressing the left L5 nerve root. The patient had left lower extremity pain in the left hip and thigh that radiated down the front and side of the leg, as well as tingling and numbness in the left foot. The patient was treated via a L5-S1 microdiscectomy using a portable intraoperative computed tomography scanner, (Airo®, Brainlab AG, Feldkirchen, Germany), combined with 3-dimensional (3D) computer navigation. Patient consent was obtained prior to performing the procedure. The main advantage of this technique is the direct “over-the-top” trajectory to the foraminal pathology that minimizes the need of facet joint resection. The use of 3D navigation facilitates surgical planning and further minimizes facet joint compromise. Particularly, the inferior facet contralateral to the approach side as well as its outer capsular surroundings can be preserved. Recent biomechanical studies have shown that “over-the-top” decompression produces significantly less instability than a traditional open midline laminectomy.

Minimally Invasive Transforaminal Lumbar Interbody Fusion using 3-Dimensional Total Navigation: 2-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E9-E10
Author(s):  
Sertac Kirnaz ◽  
Rodrigo Navarro-Ramirez ◽  
Christoph Wipplinger ◽  
Franziska Anna Schmidt ◽  
Ibrahim Hussain ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Real Time ◽  
Interbody Fusion ◽  
Intraoperative Imaging ◽  
Computer Navigation ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Radicular Pain ◽  
3D Navigation ◽  
Patient Consent ◽  
K Wires

Abstract This video demonstrates the workflow of a minimally invasive transforaminal interbody fusion (MIS-TLIF) using a portable intraoperative CT (iCT) scanner, (Airo®, Brainlab AG, Feldkirchen, Germany), combined with state-of-the-art total 3D computer navigation. The navigation is used not only for instrumentation but also for intraoperative planning throughout the procedure, inserting the cage, therefore, completely eliminating the need for fluoroscopy. In this video, we present a case of a 72-yr-old female patient with a history of lower back pain, right lower extremity radicular pain and weakness for 2 yr due to L4-L5 spondylolisthesis with instability and severe lumbar spinal stenosis. The patient is treated by a L4-L5 unilateral laminotomy for bilateral decompression (ULBD) and MIS-TLIF. MIS-TLIF using total 3D navigation significantly improves the workflow of the conventional TLIF procedure. The tailored access to the spine is translated into smaller but more efficient surgical corridors. This modification in a “total navigation” modality minimizes the staff radiation exposure to 0 by navigating in real time over iCT obtained images that can be acquired while the surgical staff is protected or outside the OR. Furthermore, this technique makes real-time and virtual intraoperative imaging of screws and their planned trajectory feasible. 3D Navigation eliminates the need for K-Wires, thus decreasing the risk of vascular penetration injury due to K-Wire malpositioning. 3D navigation can also predict the positioning of the interbody cage, thereby, decreasing the risk of malpositioning or subsidence. Patient consent was obtained prior to performing the procedure.

Minimally Invasive Posterior Cervical Foraminotomy Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video

2020 ◽  
Author(s):  
Sertac Kirnaz ◽  
Raj Nangunoori ◽  
Taylor Wong ◽  
Franziska Anna Schmidt ◽  
Roger Härtl
Keyword(s):  
Minimally Invasive ◽  
Neck Pain ◽  
Computer Navigation ◽  
Foraminal Stenosis ◽  
Open Approach ◽  
3D Navigation ◽  
Intraoperative Computed Tomography ◽  
Patient Consent ◽  
Posterior Cervical Foraminotomy ◽  
Cervical Foraminotomy

Abstract Minimally invasive posterior cervical foraminotomy (MPCF) has shown comparable outcomes to those of an open approach, with shorter operation times and length of hospital stays, as well as decreased blood loss and inpatient analgesic use. This surgical technique is mainly used to treat unilateral radiculopathy due to foraminal soft disc fragments or bone spurs. Three-dimensional (3D) navigation-guidance facilitates the surgical workflow, and it is utilized in planning the incision, determining the extent of the medial facetectomy, and confirming sufficient decompression, especially in the lower cervical spine and cervicothoracic junction, where the shoulders make localization with fluoroscopy difficult. In this video, we present the case of a 49-yr-old male patient with mechanical neck pain and C8 radiculopathy due to multilevel cervical spinal stenosis with disc herniations and C7-T1 right-sided foraminal stenosis. There was loss of cervical lordosis at the upper levels. The patient underwent anterior cervical discectomy and fusion (ACDF) at the C4-5, C5-6, and C6-7 levels to treat mechanical neck pain and restore lordosis. In order to avoid an extra-level fusion and preserve motion, we performed a right-sided C7-T1 MPCF using a portable intraoperative computed tomography (iCT) scanner (Airo®; Brainlab AG, Feldkirchen, Germany), combined with 3D computer navigation to address the patient's radicular symptoms. Patient consent was obtained prior to performing the procedure.

Case Example: Adjacent Segment Disease: What Is It, and How Is It Rated?

2011 ◽  
Vol 16 (2) ◽  
pp. 8-9
Author(s):  
Marjorie Eskay-Auerbach
Keyword(s):  
Clinical Symptoms ◽  
Lumbar Fusion ◽  
Adjacent Segment Degeneration ◽  
Adjacent Segment Disease ◽  
Adjacent Segment ◽  
Disc Space Narrowing ◽  
Disc Disease ◽  
Disc Space ◽  
Radiographic Findings ◽  
Asymptomatic Patients

Abstract The incidence of cervical and lumbar fusion surgery has increased in the past twenty years, and during follow-up some of these patients develop changes at the adjacent segment. Recognizing that adjacent segment degeneration and disease may occur in the future does not alter the rating for a cervical or lumbar fusion at the time the patient's condition is determined to be at maximum medical improvement (MMI). The term adjacent segment degeneration refers to the presence of radiographic findings of degenerative disc disease, including disc space narrowing, instability, and so on at the motion segment above or below a cervical or lumbar fusion. Adjacent segment disease refers to the development of new clinical symptoms that correspond to these changes on imaging. The biomechanics of adjacent segment degeneration have been studied, and, although the exact mechanism is uncertain, genetics may play a role. Findings associated with adjacent segment degeneration include degeneration of the facet joints with hypertrophy and thickening of the ligamentum flavum, disc space collapse, and translation—but the clinical significance of these radiographic degenerative changes remains unclear, particularly in light of the known presence of abnormal findings in asymptomatic patients. Evaluators should not rate an individual in anticipation of the development of changes at the level above a fusion, although such a development is a recognized possibility.

Obesity may be associated with adjacent-segment degeneration after single-level transforaminal lumbar interbody fusion in spinopelvic-mismatched patients with a minimum 2-year follow-up

2021 ◽  
Vol 34 (1) ◽  
pp. 83-88
Author(s):  
Ping-Guo Duan ◽  
Praveen V. Mummaneni ◽  
Minghao Wang ◽  
Andrew K. Chan ◽  
Bo Li ◽  
...  
Keyword(s):  
Interbody Fusion ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Adjacent Segment Degeneration ◽  
Adjacent Segment ◽  
Lumbar Interbody Fusion ◽  
Inclusion Criteria ◽  
Single Level ◽  
Degenerative Lumbar Spondylolisthesis ◽  
Surgery Rates

OBJECTIVEIn this study, the authors’ aim was to investigate whether obesity affects surgery rates for adjacent-segment degeneration (ASD) after transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis.METHODSPatients who underwent single-level TLIF for spondylolisthesis at the University of California, San Francisco, from 2006 to 2016 were retrospectively analyzed. Inclusion criteria were a minimum 2-year follow-up, single-level TLIF, and degenerative lumbar spondylolisthesis. Exclusion criteria were trauma, tumor, infection, multilevel fusions, non-TLIF fusions, or less than a 2-year follow-up. Patient demographic data were collected, and an analysis of spinopelvic parameters was performed. The patients were divided into two groups: mismatched, or pelvic incidence (PI) minus lumbar lordosis (LL) ≥ 10°; and balanced, or PI-LL < 10°. Within the two groups, the patients were further classified by BMI (< 30 and ≥ 30 kg/m2). Patients were then evaluated for surgery for ASD, matched by BMI and PI-LL parameters.RESULTSA total of 190 patients met inclusion criteria (72 males and 118 females, mean age 59.57 ± 12.39 years). The average follow-up was 40.21 ± 20.42 months (range 24–135 months). In total, 24 patients (12.63% of 190) underwent surgery for ASD. Within the entire cohort, 82 patients were in the mismatched group, and 108 patients were in the balanced group. Within the mismatched group, adjacent-segment surgeries occurred at the following rates: BMI < 30 kg/m2, 2.1% (1/48); and BMI ≥ 30 kg/m2, 17.6% (6/34). Significant differences were seen between patients with BMI ≥ 30 and BMI < 30 (p = 0.018). A receiver operating characteristic curve for BMI as a predictor for ASD was established, with an AUC of 0.69 (95% CI 0.49–0.90). The optimal BMI cutoff value determined by the Youden index is 29.95 (sensitivity 0.857; specificity 0.627). However, in the balanced PI-LL group (108/190 patients), there was no difference in surgery rates for ASD among the patients with different BMIs (p > 0.05).CONCLUSIONSIn patients who have a PI-LL mismatch, obesity may be associated with an increased risk of surgery for ASD after TLIF, but in obese patients without PI-LL mismatch, this association was not observed.

scholarly journals TELD with limited foraminoplasty has potential biomechanical advantages over TELD with large annuloplasty: an in-silico study

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Jingchi Li ◽  
Chen Xu ◽  
Xiaoyu Zhang ◽  
Zhipeng Xi ◽  
Mengnan Liu ◽  
...  
Keyword(s):  
Risk Factors ◽  
Postoperative Complications ◽  
Poor Prognosis ◽  
Adjacent Segment Degeneration ◽  
Iatrogenic Injury ◽  
Adjacent Segment ◽  
Fe Model ◽  
High Grade ◽  
Endoscopic Lumbar Discectomy ◽  
Adjacent Segments

Abstract Background Facetectomy, an important procedure in the in–out and out–in techniques of transforaminal endoscopic lumbar discectomy (TELD), is related to the deterioration of the postoperative biomechanical environment and poor prognosis. Facetectomy may be avoided in TELD with large annuloplasty, but iatrogenic injury of the annulus and a high grade of nucleotomy have been reported as risk factors influencing poor prognosis. These risk factors may be alleviated in TELD with limited foraminoplasty, and the grade of facetectomy in this surgery can be reduced by using an endoscopic dynamic drill. Methods An intact lumbo-sacral finite element (FE) model and the corresponding model with adjacent segment degeneration were constructed and validated to evaluate the risk of biomechanical deterioration and related postoperative complications of TELD with large annuloplasty and TELD with limited foraminoplasty. Changes in various biomechanical indicators were then computed to evaluate the risk of postoperative complications in the surgical segment. Results Compared with the intact FE models, the model of TELD with limited foraminoplasty demonstrated slight biomechanical deterioration, whereas the model of TELD with large annuloplasty revealed obvious biomechanical deterioration. Degenerative changes in adjacent segments magnified, rather than altered, the overall trends of biomechanical change. Conclusions TELD with limited foraminoplasty presents potential biomechanical advantages over TELD with large annuloplasty. Iatrogenic injury of the annulus and a high grade of nucleotomy are risk factors for postoperative biomechanical deterioration and complications of the surgical segment.

scholarly journals Stand-Alone Posterior Expandable Cage Technique for Adjacent Segment Degeneration with Lumbar Spinal Canal Stenosis: A Retrospective Case Series

Medicina ◽  
2021 ◽  
Vol 57 (3) ◽  
pp. 237
Author(s):  
Woo-Jin Choi ◽  
Seung-Kook Kim ◽  
Manhal Alaraj ◽  
Hyeun-Sung Kim ◽  
Su-Chan Lee
Keyword(s):  
Sagittal Balance ◽  
Spinal Canal ◽  
Interbody Fusion ◽  
Adjacent Segment Degeneration ◽  
Spinal Canal Stenosis ◽  
Adjacent Segment ◽  
Lumbar Spinal Canal Stenosis ◽  
Canal Stenosis ◽  
Lumbar Spinal ◽  
Expandable Cages

Background and Objectives: Symptomatic adjacent segment degeneration (ASD) with lumbar spinal canal stenosis (LSCS) is a common complication after spinal intervention, particularly interbody fusion. Stand-alone posterior expandable cages enable interbody fusion with preservation of the previous operation site, and screw-related complications are avoided. Thus, the aim of this study was to investigate the clinicoradiologic outcomes of stand-alone posterior expandable cages for ASD with LSCS. Materials and Methods: Patients with persistent neurologic symptoms and radiologically confirmed ASD with LSCS were evaluated between January 2011 and December 2016. The five-year follow-up data were used to evaluate the long-term outcomes. The radiologic parameters for sagittal balance, pain control (visual analogue scale), disability (Oswestry Disability Index), and early (peri-operative) and late (implant) complications were evaluated. Results: The data of 19 patients with stand-alone posterior expandable cages were evaluated. Local factors, such as intervertebral and foraminal heights, were significantly corrected (p < 0.01 and p < 0.01, respectively), and revision was not reported. The pain level (p < 0.01) and disability rate (p < 0.01) significantly improved, and the early complication rate was low (n = 2, 10.52%). However, lumbar lordosis (p = 0.62) and sagittal balance (p = 0.80) did not significantly improve. Furthermore, the rates of subsidence (n = 4, 21.05%) and retropulsion (n = 3, 15.79%) were high. Conclusions: A stand-alone expandable cage technique should only be considered for older adults and patients with previous extensive fusion. Although this technique is less invasive, improves the local radiologic factors, and yields favorable clinical outcomes with low revision rates, it does not improve the sagittal balance. For more widespread application, the strength of the cage material and high subsidence rates should be improved.

Thrombectomy and Clip Occlusion of a Giant, Stent-Coiled Basilar Bifurcation Aneurysm: 3-Dimensional Operative Video

2021 ◽  
Author(s):  
Fabio A Frisoli ◽  
Joshua S Catapano ◽  
S Harrison Farber ◽  
Jacob F Baranoski ◽  
Rohin Singh ◽  
...  
Keyword(s):  
Circulatory Arrest ◽  
Ventricular Pacing ◽  
Indocyanine Green Videoangiography ◽  
Aneurysm Neck ◽  
3 Dimensional ◽  
Bifurcation Aneurysm ◽  
Patient Consent ◽  
Rapid Ventricular Pacing ◽  
Proximal Occlusion ◽  
Clip Occlusion

Abstract Giant basilar apex aneurysms are associated with significant therapeutic challenges.1–6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7–9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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