Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6011_Библиотеки_им_академика_М_И_Перельмана.pdf
C H A P T E R 6 0 Minimally Invasive Scoliosis Treatment
405
A
E
F IG UR E 6 0- 9 Case 2: L2-S1 Degenerative Scoliosis. Standing AP (A) and lateral (B) radiographs of 69-year-old woman with back pain, left posterolateral
leg pain, right anterior thigh pain, and neurogenic claudication with walking and prolonged standing. Her walking tolerance was less than 100 feet, limited by
worsening bilateral leg pain, left worse than right. A two-stage procedure was performed. On day 1, DLIF was performed at L2-L3, L3-L4, and L4-L5. She tolerated
the procedure well with 75 ml, of estimated blood loss. Surgical time was 142 minutes. Two days later, she underwent the stage 2 procedure: left L5-S1 MIS TLIF,
mini-open left iliac screw, and percutaneous pedicle screws bilaterally at L2, L3, L4, L5, and S1 (C, D). The rod was passed percutaneously using reduction sleeves (E,
F). Decompression was achieved indirectly via deformity reduction and realignment. No laminectomies, except those at L5-S1 during the MIS TLIF, were performed.
The iliac screw is inserted on the medial aspect of the posterior superior iliac spine about 2 cm distal to the S1 pedicle screw, such that the base of the screw tulips is
aligned to accept a single rod (E to G). Estimated blood loss was 275 ml and total surgery time was 387 minutes. She was ambulatory on postoperative day 1 after
stage 2 and discharged to home on postoperative day 4. She has good resolution of her leg pain and mild to moderate back pain (VAS 4-5).
B
F
C
D
G
406
P A R T V I I Surgical Treatment Modalities: Lumbar Spine
In cases in which there is an oblique takeoff of L5 from the sacrum,
L5-S1 fusion can be achieved using an MIS TLIF (see Figure 60-9). A
novel and promising strategy for L5-S1 fusion is the use of a transsacral fixation device (Figure 60-10). Added construct stability can be achieved with
F IG UR E 6 0- 1 0 Case 3: T10-Pelvis Reconstruction. Standing AP (A) scoliosis films of a 47-year-
old woman with seronegative spondyloarthropathy complaining of worsening back pain and right flank
pain due to impingement of the 12th rib on the iliac crest. Radiographs from 18 months previously
revealed only minimal deformity. Stage 1 DLIF was performed with marked improvement in coronal
alignment (B). Two days later, she underwent posterior reconstruction: L5-S1 transsacral fusion, miniopen bilateral iliac screws, mini-open bilateral T10-L1 pedicle screws, and percutaneous pedicle screws
A
B
bilaterally at L2-L3 with unilateral screws at L4-L5 (C, D). Mini-open exposures for the pedicle screws were
used to expose the facet joints and posterior elements of T10-L1, which were decorticated and bone
grafted. Long contoured rods were passed through proximal stab incisions and advanced through each
of the rod reduction sleeves. The stage 2 procedure was tedious and difficult. Total surgical time was 9
hours, 17 minutes and estimated blood loss was 575 ml. Postoperatively, she was ambulatory on day 2
and discharged home on day 7.
additional pelvic fixation using the L5-S1 surgical corridor to expose the
medial wall of the posterior-superior iliac spine (PSIS) as the entry point
for the pelvic screw. is allows the tulip of the pelvic screw to align with
the S1 screw so that a single rod can be used (see Figures 60-9 and 60-10).
C
D
C H A P T E R 6 0 Minimally Invasive Scoliosis Treatment
407
CONCLUSIONS AND DISCUSSION
The primary indication for surgical treatment is pain. The pain associated
with adult degenerative scoliosis is caused by a combination of early muscle
fatigue due to coronal and sagittal imbalance, spinal stenosis, radiculopathy,
and facet arthropathy. Because most patients with symptomatic degenerative scoliosis are elderly, efforts to minimize the morbidity of surgical intervention is warranted. Minimally invasive techniques strive to decrease blood
loss and associated fluid shifts, systemic stress responses, the need for powerful postoperative narcotic pain medications that can be poorly tolerated in
the elderly patient, and disruption of muscle–tendon complexes that may
provide dynamic stability needed for early ambulation and rehabilitation.
The use of minimally invasive techniques relies heavily on interbody
fusion. This is the most permissive fusion environment and requires no disruption of muscle tendon complexes. This is in contrast to posterolateral
fusions, which require detachment of the paraspinal muscle tendon attachment sites from the lateral aspect of the superior articular process and transverse processes. The use of interbody fusion techniques facilitates improved
deformity correction by allowing an anterior release and correction of asymmetric disc height loss.
The application of MIS techniques for the treatment of scoliosis remains
in evolution. The techniques remain challenging. The learning curve is
exceedingly long, and only limited instrumentation is currently available.
Reliance on intraoperative imaging leads to high radiation exposures for the
surgical team. Future efforts must focus on improved instrumentation for
rapid and accurate multilevel pedicle screw insertion. This technology must
be combined with a corresponding rod insertion system that accommodates
various degrees of spinal curvature as well as the sudden lordosis that occurs
at the lumbosacral junction. A key aspect of this issue is the need to place
the screws in line with each other such that they do not pull out during rod
reduction.
References
1. A. Ploumis, E.E. Transfledt, F. Denis, Degenerative lumbar scoliosis associated with spinal
stenosis, Spine J. 7 (2007) 428–436.
2. K.J. Cho, S.I. Suk, S.R. Park, J.H. Kim, S.S. Kim, W.K. Choi, K.Y. Lee, S.R. Lee, Complica-
tions in posterior fusion and instrumentation for degenerative lumbar scoliosis, Spine (Phila
Pa 1976) 32 (2007) 2232–2237.
3. N. Bogduk, J.E. Macintosh, M.J. Pearcy, A universal model of the lumbar back muscles in the
upright position, Spine (Phila Pa 1976) 17 (1992) 897–913.
4. S.R. Ward, C.W. Kim, C.M. Eng, L.J. Gottschalk, A. Tomiya, S.R. Garfin, R.L. Lieber,
Architectural analysis and intraoperative measurements demonstrate the unique design of
the multifidus muscle for lumbar spine stability, J. Bone Joint Surg. Am. 91 (2009) 176–185.
5. A.T. Yeung, C.A. Yeung, In-vivo endoscopic visualization of patho-anatomy in painful
degenerative conditions of the lumbar spine, Surg. Technol. Int. 15 (2006) 243–256.
6. B.M. Ozgur, H.E. Aryan, L. Pimenta, W.R. Taylor, Extreme lateral interbody fusion (XLIF):
a novel surgical technique for anterior lumbar interbody fusion, Spine J. 6 (2006) 435–443.
7. R.Q. Knight, P. Schwaegler, D. Hanscom, J. Roh, Direct lateral lumbar interbody fusion for
degenerative conditions: early complication profile, J. Spinal Disord. Tech. 22 (2009) 34–37.
8. J.D. Schwender, L.T. Holly, D.P. Rouben, K.T. Foley, Minimally invasive transforaminal lum-
bar interbody fusion (TLIF): technical feasibility and initial results, J. Spinal Disord. Tech.
18 (Suppl.) (2005) S1–S6.
9. D.J. Burval, R.F. McLain, R. Milks, S. Inceoglu, Primary pedicle screw augmentation in
osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength, Spine
(Phila Pa 1976) 32 (2007) 1077–1083.
10. M.Y. Wang, S.C. Ludwig, D.G. Anderson, P.V. Mummaneni, Percutaneous iliac screw placement: description of a new minimally invasive technique, Neurosurg. Focus 25 (2008) E17.
Lateral XLIF Fusion Techniques
Luiz Pimenta, Etevaldo Coutinho, Jose Carlos Sauri Barraza, and Leonardo Oliveira
61
k e y p o i n t s
Appropriate patient positioning
Retroperitoneal access
Transpsoas access
Disc space preparation
Implant insertion
INTRODUCTION
Demands of mobility and quality of life have increased in the elderly segment of society over the past decades. A rising number of elderly patients
suffering from adult degenerative scoliosis may be eligible for surgical treat-
1
ment.
The prevalence of adult scoliosis rises with age: from 4% before age
45 years, to 6% at age 59 years, to 15% in patients older than 60 years.
Adult scoliosis is defined as acquired deformity in the skeletally mature
patient with a Cobb angle of at least 10 degrees in the coronal plane due to
asymmetric disc and facet joint degeneration. It is associated not only with
severe back and/or leg pain but also with complicated surgical outcomes.
All nonoperative treatments should be exhausted before considering
surgical treatment. Usually, the surgical procedure is focused on two aims.
The first aim is to decompress the comprised neural elements in cases of
symptomatic spinal stenosis, and the second is to balance and stabilize the
spine in the coronal and sagittal planes when there is imbalance.
a wide variety of approaches—anterior, posterior, or a combination—are
available to achieve fusion, but all include significant operative morbidity.
Newer implants have improved cosmesis and correction, obtaining better
results; however, the elderly patient is not a candidate for this kind of surgery
because of the higher risk of complications and generally poorer bone quality in this population.
The eXtreme Lateral Interbody Fusion (XLIF) approach may offer various clinical advantages over more traditional techniques for treating adult
degenerative scoliosis.
a horizontal position through bilateral annular release, placement of a large
implant across the disc space spanning the ring apophysis, and the effects
of ligamentotaxis. The XLIF technique restores disc and foraminal heights,
indirectly decompressing the neural elements, and promotes stabilization
through an anterior intervertebral fusion stopping progression of the curve.
6
7
This less invasive procedure realigns the endplates to
2
4
Today
9
INDICATIONS AND CONTRAINDICATIONS
The indications for the XLIF approach in the treatment of adult scoliosis do
not differ from those for traditional techniques, except that the L5-S1 level
cannot be accessed laterally.
408
CLINICAL STUDY
In a larger patient series, 23 patients have 3-year follow-up (FU). Mean age
is 66 years (range, 39 to 88). Three to seven levels were treated between T10
to L5. Three of these needed lateral plate fixation (Figure 61-1).
The procedures were performed without major complication in an average of 121 minutes and with <50 ml blood loss. Mean hospital stay was
40 hours. After 3-year FU, one patient (4%) presented with pseudarthrosis
according to Food and Drug Administration (FDA) fusion criteria.
patients (12%) had subsidence at 6-month FU, but all were asymptomatic.
Visual Analogue Scale (VAS) pain scores improved from an average of 8.1
preoperatively to 3.3 at 3-year FU.Oswestry scores improved from an average 47.8 preoperatively to 22.8 at 3-year FU. Coronal and sagittal alignments improved from average Cobb angles of 16 degrees preoperatively to
7.4 degrees at 3-year FU, and average lordosis angles of 37.8 degrees preoperatively to 48 degrees at 3-year FU. The mean preoperative Cobb angle
was not high because in our earliest series we were not treating large curves.
Currently, using the XLIF approach we can treat curves up to 90 degrees,
with very good clinical results (Figure 61-2).
PREOPERATIVE ASSESSMENT AND PLANNING
Operative Technique
Patient Positioning
For the XLIF approach, the patient is placed and taped in a true 90degree lateral decubitus position (Figure 62-3A), being preferable to
approach from the concavity side. The table and/or patient should be
5
laterally flexed to increase the distance between the iliac crest and the rib
cage.
Incision and Retroperitoneal Access
The midposition of the disc of interest is identified using a Kirschner wire
(K-wire) and fluoroscopy (Figure 61-3B). A small incision is created for
insertion of the atraumatic tissue dilators and an expandable retractor
(MaXcess, NuVasive, Inc., San Diego, Calif.), which will be the working
portal. An incision posterior to this lateral marking is first made to introduce a finger into the retroperitoneal space to sweep open the space and
ensure that all lateral attachments of the peritoneum are released to provide
safe lateral entry (Figure 61-3C).
Transpsoas Access
With the retroperitoneal space identified, the finger is brought up under the
lateral skin marking and an incision is made at this direct lateral location
for the introduction of an initial dilator (Figure 61-3D). The finger in the
retroperitoneal space is used to escort the dilator safely from the direct lateral incision to the psoas muscle. The dilator is then placed over the surface
7
Three
Preoperative
A
1 week
C H A P T E R 6 1 Lateral XLIF Fusion Techniques
409
B
C
F IG U RE 61 - 1 Patient example. A, A 62-year-old woman wit h degenerative scoliosis, back and right leg
pain, neurogenic claudication, and unable to walk more th an 100 m. B, One week after surgery, we can see
improvement of the coro nal balance using XLIF. C, Seven lev el surgery a chieved with two small i ncisions.
of the psoas muscle, exactly over the disc space to be treated, confirmed
by fluoroscopy. The fibers of the psoas muscle are then gently separated
with the dilators until the disc is reached (Figure 61-3E). The NeuroVision electromyographic (EMG) monitoring system (NuVasive, Inc.)
assesses the proximity of the lumbar nerve roots to the advancing dilator
(Figure 61-3G). An expandable retractor (MaXcess) is advanced over the
last dilator (Figure 61-3F and H).
Under direct illuminated vision, a thorough diskectomy is performed
using standard instruments (Figure 61-3I). The posterior and anterior
annulus are left intact. The annulotomy window is centered in the anterior
lateral half of the disc space. Disc removal and release of the contralateral
T10-11 to L4-5
annulus using a Cobb elevator (Figure 61-3J) provides the opportunity to
place a long implant (Figure 61-3K) that will rest on both lateral margins
of the apophyseal ring, maximizing endplate support, restoring height, and
correcting imbalance alignment. Hemostasis is confirmed and no drains are
required (Figure 61-3L).
POSTOPERATIVE CARE
Patients should be encouraged to walk the same day to aid their recovery
and muscle function. Postoperative pain tends to be minimal, and may be
discharged after only an overnight hospital stay.
410
P A R T V I I Surgical Treatment Modalities: Lumbar Spine
Preoperative
75°
F IG U RE 6 1- 2 Patient example: An 83-year-old woman with degenerative scoliosis, pain in back and both legs,
neurogenic claudication, unable to walk, huge pain even in bed. One week after surgery the subject was walking. The
anteroposterior x-ray shows improvement in the correction of coronal alignment.
40°
1 week
COMPLICATIONS AND AVOIDANCE
In some series of adult deformity surgery, the complication rate is high,
with elevated morbidity and mortality in some cases.
our results demonstrate a lower level of complications due to the minimally invasive nature of the procedure. We observed minor complications in the immediate postoperative period, such as tenderness with
hip flexion on the operative side and less commonly, sensory disturbance
in the operative side leg. Painful dysesthesias and motor disturbance
are rare, but possible. In these cases, a CT scan is recommended to rule
out a psoas hematoma. If a hematoma is found, draining it improves
symptoms.
In the long-term FU, subsidence was observed in some cases, already
described in the results (Figure 61-4).
8
In comparison,
CONCLUSION
The treatment for adult scoliosis differs from that for adolescent idiopathic
9
scoliosis.
and stop curve progression through fusion.
The most important issues are reduction of back and leg pain,
10
The complication rate has been
lower than traditional surgical methods of treatment. Subsidence is the most
common complication in the XLIF stand-alone technique but our experience has shown no clinical compromise in the final result. We have been
successfully performing fusion using stand-alone cages through a lateral
minimal invasive approach, decreasing pain, decompressing indirectly neurological structures, restoring disc height and stopping the curve progression.
This paper shows that with this less invasive procedure, good final
results are obtained with low morbidity.
References
1. F. Schwab, A. Dubey, L. Gamez, et al., Adult scoliosis: prevalence, SF-36, and nutritional
parameters in an elderly volunteer population, Spine 30 (2005) 1082–1085.
2. Y. Floman, Degenerative scoliosis: indications for surgery and results, Journal of Bone and
Joint Surgery-British Volume, 88-B (Suppl.) 4–5.
3. M. Aebi, The adult scoliosis, Eur. Spine J. 14 (2005) 925–948.
4. A. Ploumis, E.E. Transfledt, F. Denis, Degenerative lumbar scoliosis associated with spinal
stenosis, Spine J. 7 (4) (2007 Jul-Aug) 428–436.
5. M.C. Gupta, Degenerative scoliosis options for surgical management, Orthop. Clin. N. Am.
34 (2003) 269–279.
6. C.B. Tribus, Degenerative lumbar scoliosis: evaluation and management, J. Am. Acad.
Orthop. Surg. 11 (2003) 174–183.
7. B.M. Ozgur, H.E. Aryan, L. Pimenta, W.R. Taylor, Extreme Lateral Interbody Fusion
(XLIF): a novel surgical technique for anterior lumbar interbody fusion, The Spine Journal 6
(2006) 435–443.
8. D.S. Bradford, B.K. Tay, S.S. Hu, Adult scoliosis: surgical indications, operative management, complications, and outcomes, Spine 24 (1999) 2617–2629.
9. H.R. Weiss, Adolescent idiopathic scoliosis (AIS)—an indication for surgery? A systematic
review of the literature, Disabil. Rehabil. 30 (10) (2008) 799–807.
10. S.D. Daffner, A. Vaccaro, Adult degenerative lumbar scoliosis, Am. J. Orthop. 2 (2003)
77–82.
C H A P T E R 6 1 Lateral XLIF Fusion Techniques
A B C
411
D E F
G H I
J K L
F IG UR E 6 1 - 3 XLIF surgical technique. A, Patient positioning. B, Index level identification. C, Retroperitoneal access. D, E, Transpsoas access. F, Maxcess
insertion. G, NeuroVision Electromyographic System. H, Maxcess fixation. I, Diskectomy. J, Endplate preparation. K, Implant insertion. L, Surgical wound.
412
P A R T V I I Surgical Treatment Modalities: Lumbar Spine
Preoperative
12 month follow
up
F IG UR E 6 1- 4 Patient example: An 84-year-old woman with degenera-
tive scoliosis. Twelve months after surgery, clear evidence of fusion is seen on
CT scan, despite subsidence (red circle). Clinical improvement after surgery was
maintained.
Pelvic Fixation of the Aging Spine
Joseph M. Morreale, Ravi Ramachandran, Jonathan N. Grauer, and Peter G. Whang
62
k e y p o i n t s
Incorporation of the iliac crest into lumbosacral fusions may serve to decrease
the rate of pseudarthrosis.
Instrumentation that extends beyond the lumbosacral pivot point augments
the stiffness of the construct.
e bony fixation and pullout strength of implants progressively increase as
they are placed more laterally into the pelvis (i.e., the iliac wings).
Multiple screw anchors may be needed to obtain solid iliac fixation in
patients with severe osteoporosis.
Fully threaded screws may prevent loosening or failure by maximizing
cortical purchase.
INTRODUCTION
Iliolumbar fixation is an important adjunctive technique that may be beneficial for the operative management of multiple conditions affecting the aging
spine, including untreated idiopathic or degenerative scoliosis, sagittal plane
deformities such as kyphosis or flat-back syndrome, high-grade spondylolisthesis, sacral fractures, tumors or infections requiring sacrectomy, and stenotic
lesions distal to a multilevel lumbar arthrodesis. It has been well established
that the biomechanical and biological conditions unique to this region make
it more difficult to achieve a successful fusion. Therefore, the incorporation of
Case Studies
instrumentation into the pelvis is extremely valuable in many situations,
because it helps to restore spinal balance and confers greater stability to the
lumbosacral junction. The increasing rigidity of these constructs may also
serve to enhance bone formation in complex reconstructive cases that may
otherwise be prone to the development of a nonunion.
Reliable fixation to the pelvis was first achieved in the 1970s with Luque
instrumentation which utilized a bar with a curved distal end that could be
advanced into the iliac crest. A decade later, the Galveston method was introduced, which provided even greater fixation because it allowed for the application of contoured rods, which were inserted though the posterior superior
iliac spine, in between the inner and outer tables of the pelvis, toward the
sciatic notch. Nevertheless, these early systems were still found to give rise
to an relatively high incidence of pseudarthrosis, ranging from 6% to 41%.
Iliac screws improve on these initial approaches by taking advantage of
innovations in implant design and modularity. These constructs are not only
more rigid; their pull-out strength has been shown to be three times greater
than that of a standard Galveston rod.
properties, it is anticipated that the use of iliac screws may reduce the risk of
pseudarthrosis compared to other types of lumbosacral constructs. However,
the proper placement of this instrumentation requires an intricate knowledge
of pelvic anatomy in order to avoid cortical breaches through the ileum or
penetration into the acetabulum.
into account the position of the screws for the purpose of contouring the rod
and ensure adequate soft tissue coverage to ensure the heads will not be too
prominent, which could contribute to patient discomfort.
2
Given their superior biomechanical
3
Furthermore, the surgeon must also take
4
1
CLINICAL CASE #1—DEGENERATIVE SCOLIOSIS
A 69-year-old woman presents with complaints of severe axial low back
pain that radiates into her anterior thighs in conjunction with a curvature of her thoracolumbar spine. e patient had previously been treated
in a Milwaukee brace for a diagnosis of adolescent idiopathic scoliosis
until skeletal maturity but had never undergone a previous spinal procedure. She feels as if her symptoms and her deformity have been
worsening despite multiple conservative treatments, including physical therapy, pain medications, and a series of spinal injections. Her past
medical history is notable for osteoporosis and a 30 pack-year history of
smoking.
Physical examination findings include obvious thoracic and lumbar
prominences upon forward flexion with some tenderness to palpation at
the apices of the curves. However, her shoulders and pelvis are essentially
level. She exhibits normal motor and sensory function with no long tract
signs. She also has no tension signs in her lower extremities.
Posteroanterior and lateral scoliosis x-rays display a right thoracic curve
from T5 to T11 and a left lumbar curve from T11 to L4, measuring 58
degrees and 67 degrees, respectively (Figure 62-1). However, her overall
coronal and sagittal alignment appears to be reasonably balanced. ese
films demonstrate clear progression compared to previous radiographs
acquired several years ago. Aside from her deformity, an MRI study of her
entire spine reveals no intraspinal abnormalities or significant compression
of the neural elements.
CLINICAL CASE #2—PATHOLOGIC FRACTURE
A 59-year-old man who initially presented with a 1-month history of axial low
back pain with occasional lower extremity symptoms consistent with neurogenic
claudication. e patient has a known diagnosis of colorectal cancer that was
treated with multiple abdominal operations and chemotherapy. e patient is
currently requiring high-dose narcotics for his pain, which is increasing in severity.
His past medical history is otherwise unremarkable except for mild hypertension.
A physical examination of the patient reveals limited range of motion
of the lumbar spine with diffuse tenderness to palpation. He has no apparent neurologic deficits with normal reflexes as well as negative straight legraising tests in both lower extremities.
Imaging studies include plain films of the lumbar spine, which demonstrate L3 and L4 vertebral body fractures (Figure 62-2). ese fractures
were confirmed to be burst-type injuries on a subsequent CT scan with
obvious height loss, focal kyphosis, and retropulsion of fragments with
approximately 25% canal compromise. An MRI study displays a large soft
tissue mass extending into the epidural space at these levels, which results
in significant spinal stenosis with near-obliteration of the thecal sac.
413
414
P A R T V I I Surgical Treatment Modalities: Lumbar Spine
F IG UR E 6 2- 1 Posteroanterior scoliosis x-ray reveals thoracic and lumbar curves measuring 58 degrees and
67 degrees, respectively.
A B C
D E
F IG UR E 6 2- 2 Sagittal (A) and axial (B, C) CT images of the lumbar spine demonstrate burst-type fractures of the L3 and L4 vertebrae with obvious height
loss, focal kyphosis, and retropulsion of fragments into the spinal canal. Sagittal (D) and axial (E) views from T2-weighted MRI study confirm the presence of a large
anterior epidural mass resulting in significant spinal stenosis and compression of the thecal sac.