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Microsurgical Monosegmental

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Fusion withInternal Fixator andTransforaminal Interbody Fusion (TLIF)

UweVieweg andStefanKroppenstedt

69.1 Introduction and Core Messages

The methods described here (Method I: ipsilateral transpedicular instrumentation and interbody fusion about a lateral paraspinal approach and contralateral percutaneous transpedicular instrumentation, Method II: instrumentation and interbody fusion about both paraspinal lateral approaches) allow the surgeon to perform less invasive spinal instrumentation with short operating time, less blood loss, and small skin incisions. The technique of transforaminal lumbar interbody fusion involves facetectomy, discectomy, and interbody fusion, carried out with the aid of a highspeed drill burr microsurgical instruments, and an operating microscope or endoscope. Patients benet from reduced trauma, less pain, and shorter hospitalization and recovery times [1–7].

69.2 Indications

• Spondylolisthesis that has not responded, or has responded inadequately, to non-operative treatment of symptoms

• Discogenic low-back pain with or without paresis [1, 2,

4, 6]

69.3 Contraindications

• Severe spinal canal stenosis

• Higher-grade spondylolisthesis (Meyerding grade III–IV) and deformities

• Absent, fractured, or atrophic pedicles and severe osteopenia that limits secure screw purchase

• Signs of current active infection

69.4 Technical Requirements

C-arm uoroscope, microscope or endoscope, supporting pads and cushions to aid positioning, radiolucent surgical table, high-speed burr, and retractor systems (METRx X-TUBE MicroDiscectomy Retraction System (Medtronic), MLD retractor system (Aesculap), ProView Minimal Access Portal System (Blackstone), Luxor (Stryker), MIRA (Synthes)). Internal xator systems (top loading system) with cannulated screws (CD Horizon Sextant I/II and CD Horizon Longitude, Medtronic; S4 internal xator or Enovat, Aesculap). Other systems for minimally invasive screw and rod insertion for posterior stabilization are spirit with cannulated screws Click’X (Synthes), REVOLVE Stabilization System (Globus Medical), SpheRx-DBR system (NuVasive), EXPEDIUM and VIPER (DePuy), Silverbolt (Via 4 Spine).

U. Vieweg (*) Department of Conservative and Surgical Spine Therapy with Interdisciplinary Spinal Deformities Centre and Rummelsberg Sectional Center, Hospital Rummelsberg, Schwarzenbruck, Germany e-mail: uwe.vieweg@sana.de

S. Kroppenstedt Department of Spinal Surgery, Center of Orthopedic Surgery, Sana Hospital Sommerfeld, Kremmen, Germany e-mail: s.kroppenstedt@sana-hu.de

69.5 Planning, Preparation,

andPositioning

The patient is placed in a prone position on a radiolucent table under general anesthesia (see Fig. 69.1) and prepared and draped in the conventional manner. The abdomen is permitted to hang freely. The hips are extended to enhance lumbar lordosis. The skin incision is planned under X-ray control with a C-arm uoroscope using anteroposterior and lateral beam directions. Four needles are placed at the level of the pedicles to ascertain the level (see Fig.69.2). The Ferguson arrangement

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Fig. 69.1 Positioning of the

patient. (With permission from Aesculap AG, Tuttlingen, Germany)

U. Vieweg and S. Kroppenstedt

provides the best image, focusing correctly on the S1 pedicle (see Fig.69.3). Biplanar uoroscopy with two C-arms facilitates safer and easier radiographic assessment (see Fig.69.4). Note: When planning the approach, the spinous processes should appear exactly in the middle between the two pedicles, and the superior end plates should appear exactly parallel when viewed in AP X-rays. Care should be taken to ensure that the superior end plates are also parallel in lateral X-rays.

Fig. 69.2 Planning of the skin incision with C-arm uoroscope

Fig. 69.3 Ferguson arrangement/positioning of the C-arm for the L5/

S1 level

69.6 Surgical Technique

69.6.1 Method I: Ipsilateral Miniopen

andContralateral Percutaneous Instrumentation [1–3]

69.6.1.1 Miniopen Access

• After radiological planning incisions are made in the skin (4–5cm long) and the lateral fascia of or over the pedicle.

• The retractor system (METRx, Medtronic) is delivered via the dilatation tubes at approximately the angle at which the pedicle screws are to be inserted.

• The expansion and position of the retractor system are conrmed by imaging.

• A Jamshidi needle is inserted. After locating the entry point on the pedicle, the Jamshidi needle needs to be aligned with the pedicle trajectory. The needle is driven in as far as the anterior edge of the vertebral body. It should not extend beyond the medial edge of the pedicle (see Figs.69.5 and 69.6a, b). If necessary, the needle must be reinserted and realigned. The position is xed by slightly pushing the Jamshidi needle into the cortex.

• The pedicle is prepared with the appropriate tap. The tap must correspond to the screw type and diameter.

• The Kirschner wire is replaced with a marker pin or about 3cm of wire (see Fig.69.8b).

• The second pedicle is prepared as described above.

• The microscope is swung into place.

• Transforaminal access to the disk is typically performed on the most symptomatic side. The facet is resected with

69 Microsurgical Monosegmental Fusion withInternal Fixator andTransforaminal Interbody Fusion (TLIF)

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Fig. 69.4 Using two C-arm

uoroscopes for percutaneous instrumentation

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Fig. 69.5 Positioning the Jamshidi needle

Fig. 69.6 AP (a) and lateral (b) X-ray views of the ideal positioning of

the cannula in the pedicle

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Fig. 69.7 Insertion of the K-wire

U. Vieweg and S. Kroppenstedt

a high-speed reamer. Note: Bone removal should begin caudally between the two pedicles, directly over the disk space.

• A diamond reamer is then used. This is subsequently replaced with a punch. The nerve roots leaving the vertebra are viewed microscopically.

• The end plate is prepared for interbody fusion.

• Once the disk space has been meticulously prepared, cancellous bone is inserted into the disk space using angled and straight forceps (or a funnel). A cage or spacer is then inserted with autologous bone or bone substitute.

• The marker pin is removed, and the pedicle screws are screwed in. The rod is inserted either using the conventional technique or with a rod inserter (below).

69.6.1.2 Percutaneous Instrumentation

oftheContralateral Side

• Skin incisions 1–2cm long are made, as planned, slightly lateral to the pedicle. Incisions are also made in the fascia to make tissue dilatation easier.

• Using C-arm uoroscopy, the pedicle is accessed with a Jamshidi needle. The correct entry point should be identied in both AP and lateral X-ray views (see Fig.69.5).

• After placing the Jamshidi needle at the intersection of the facet and the transverse process, the needle may be driven partially through the pedicle using a hammer. When the Jamshidi needle reaches the medial wall on the AP view, its position needs to be veried in the lateral

Fig. 69.8 (a, b) Insertion of the dilatation sheath

view to ensure that the needle is in the bony canal of the pedicle (see Fig.69.6a, b).

• The handle and inner trocar are removed from the Jamshidi needle, and a K-wire is inserted. The position of the K-wire is veried with uoroscopy to ensure that it extends through 2/3 of the vertebral body (see Fig.69.7). Note: During advancement of the K-wire, its progress must be checked using continuous radiological monitoring.

• An incision is made in the skin and fascia around the K-wire. The incision is dilated with dilatation tubes (see Fig.69.8a, b).

69 Microsurgical Monosegmental Fusion withInternal Fixator andTransforaminal Interbody Fusion (TLIF)

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Fig. 69.9 Screwing in the pedicle screws

• The pedicle is prepared by placing an awl over the K-wire or, if the bone is too hard, a tap may be used to prepare the pedicle screw canal. The K-wire must be held in position when removing the awl or tap. Note: The axis of the tap must be kept constant to avoid bending the wire. The K-wire must not advance during tapping and must not become displaced when instruments are removed.

• Using the additional extender, the pedicle screws are driven over the K-wire into the prepared pedicle. Fluoroscopy must be used to monitor screw insertion and placement (Fig.69.9). Once the screw reaches the posterior aspect of the vertebral body, the wire can be removed.

• Note: The screw assembly must not be inserted too far. The K-wire must not be allowed to advance.

• The second screw is inserted in the same way. Note: After inserting additional bone screws, the heads of the bone screws should be at the same height.

• The extenders are connected.

• The rod inserter is attached.

• A trocar is used to prepare the way through the fascia and muscle (see Fig.69.10a). The trocar is inserted through a small skin incision and pushed through the muscle, checking its position on the image converter, until it reaches the rst screw.

Fig. 69.10 Swinging items into place: trocar (a), rod (b), and nal

position (c)

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Fig. 69.11 Fixing the setscrews

• A rod-measuring instrument is used to determine the correct rod length.

• Using the rod inserter, the rod is then pushed into the heads of the polyaxial screws (see Fig.69.10b, c). Note: The AP view must also be used to check whether the rod has been inserted into both the screw heads.

• The rod is then xed with setscrews (see Fig. 69.11). Note: Fixation must start with the deepest screw. The rmness of the connection must be checked by pulling on the inserter.

69.6.2 Method II: Less Invasive 360° Fusion

About Two Lateral Paraspinal Approaches

• A 4–5-cm skin incision is made approximately 3cm from the midline, and the fascia is incised and divided (see Figs.69.12a and 69.21).

• Using the ngers, the muscles are bluntly dissected, and an MLD retractor (Aesculap) is introduced (see

U. Vieweg and S. Kroppenstedt

Fig. 69.12b, c). Upon insertion, the retractor exposes portions of the lamina, facet joints, and transverse process.

• Conventional screw technique with uncannulated screws.

• Under X-ray control and using a Steinmann nail, the pedicles are drilled open and polyaxial screws (S4 internal system, Aesculap) are then placed transpedicularly (see Fig.69.13).

• Cannulated screw technique.

• After the screw entry point has been determined, the pedicle is accessed. The guiding instrument is inserted at the junction between the facet and the transverse process. The trocar is then removed, leaving the targeting device in the pedicle. The K-wire is inserted to guide the screws. Note: Care must always be taken to ensure that the K-wire is not inserted too far.

• The working area must be dilated with the metal dilatation sheath so that the implant screws can be positioned. The dilatation sheath is guided in via the K-wire targeting device.

• The pedicle is prepared by placing an awl over the K-wire or, if the bone is too hard, a tap may be used to prepare the pedicle screw canal.

• Using the additional extender, the pedicle screws are driven over the K-wire into the prepared pedicle.

• The disk space is distracted with angulated distraction forceps.

• After pedicle screw insertion, the superior and inferior articular processes are resected with a high-speed drill and Kerrison punch. In cases of unilateral nerve root compression, the facet joint is resected on that side only.

• The intervertebral disk is exposed and is subtotally resected using angled rongeurs, shavers, and curettes (see Figs.69.14a, b and 69.15).

• After scraping off the end plates, bone or bone substitute is packed into the anterior part of the disk space. Insertion of a trial to measure the height of the implant (see Fig.69.16).

• A curved PEEK cage specially designed for the TLIF technique is packed with bone or bone substitute and inserted into the disk space (see Fig.69.17a–d).

• The tulips heads of the bone screws are aligned using a screw head adjuster to facilitate rod insertion.

• The appropriate rod is loaded into a xed rod holder.

• A rod is inserted into the heads of the polyaxial screws and xed with setscrews. The precontoured bullet-nosed rod is inserted.

• The polyaxial head is given 42° angulation to provide optimal and easy rod placement. To reposition the vertebra in cases with spondylolisthesis, the setscrew of the higher pedicle is xed rst. Only then is the setscrew of the lower pedicle xed. Note: Rod position and advancement must be veried using uoroscopy until fully seated (see Fig.69.18a).

69 Microsurgical Monosegmental Fusion withInternal Fixator andTransforaminal Interbody Fusion (TLIF)

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Fig. 69.12 Skin incision about 3cm from the midline (a), separation of muscle fascia, and preparation of muscle using the ngers (b), demonstra-

tion of the lateral paraspinal approach on an MRI scan (c)

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U. Vieweg and S. Kroppenstedt

Fig. 69.13 Insertion of MLD retractor and transpedicular positioning of pedicle screws (a), intraoperative situation (b)

Fig. 69.14 (a) Discectomy

and debridement of the intervertebral surfaces of the (b) vertebral body as far as the contralateral side using angled instruments. (With permission from Aesculap AG, Tuttlingen, Germany)