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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6013_Библиотеки_им_академика_М_И_Перельмана.pdf
S T E P 3 C ON T R O V ER S I E S
• Necessity of complete reduction
S T E P 4 P EA R L S
• Fluoroscopic guidance
S T E P 4 I MP L A N T A T I O N /
I N S T RU M E N T A T I O N
• Cruciate reamer (Figure 30-9)
• Titanium mesh cage
Procedure 30 | Surgical Treatment of High-Grade Spondylolisthesis 289
FIGURE 30-7
A
C
FIGURE 30-8, A-C
B
FIGURE 30-9
290 Procedure 30 | Surgical Treatment of High-Grade Spondylolisthesis
L5
L4 screw
Gap closed
S1 screw
FIGURE 30-10
S T E P 5 P EA R L S
• Neuromonitoring during osteotomy
closure
S T E P 5 P IT FA L L S
• Overreduction
S T E P 5
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Transforaminal lumbar interbody fusion
(TLIF) graft in vertebrectomy defect
FIGURE 30-11
Step 5
n
Gaines procedure (L5 vertebrectomy) (Figure 30-10)
n
Posterior closure of resected segment (Figure 30-11)
Procedure 30 | Surgical Treatment of High-Grade Spondylolisthesis 291
P O S T OP E R AT IV E P E A R L S
• Aggressive physical therapy is crucial to
recovery.
P O S T OP E R AT IV E P I T F A L L S
• Patient with significant neurologic
deficit should be immediately taken
back to operating room for reduction
of correction.
P O S T OP E R AT IV E
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Immediate postoperative AP/lateral
plain radiographs
• CT scan if new neurologic deficit
• Standing anteroposterior (AP)/lateral
36-inch scoliosis radiographs before
discharge to assess sagittal balance
P O S T OP E R AT IV E
C O N T RO V E R S IE S
• Mild postoperative weakness may or
may not require return to operating
room.
Postoperative Care and Expected Outcomes
n
Complete blood count (CBC), chemistry panel
n
Pain control (patient-controlled analgesia [PCA])
n
Neurologic monitoring (q 2 hr neurologic checks × 24 hours)
n
Anticoagulation postoperative day (POD) 2
Evidence
Gaines RW. L5 vertebrectomy for the surgical treatment of spondyloptosis: thirty
cases in 25 years. Spine 2005;30(Suppl 6):S66-70.
Hanson DS, Bridwell KH, Rhee JM, et al. Correlation of pelvic incidence with
low- and high-grade isthmic spondylolisthesis. Spine 2002;27:2026-9.
Labelle H, Roussouly P, Berthonnaud E, et al. Spondylolisthesis, pelvic incidence,
and spinopelvic balance: a correlation study. Spine 2004;29:2049-54.
Lehmer SM, Steffee AD, Gaines RW Jr. Treatment of L5-S1 spondyloptosis by
staged L5 resection with reduction and fusion of L4 onto S1 (Gaines procedure).
Spine 1994;19:1916-25.
Ogilvie JW. Complications in spondylolisthesis surgery. Spine 2005;30(Suppl 6):
S97-101.
Sailhan F, Gollogly S, Roussouly P. The radiographic results and neurologic
complications of instrumented reduction and fusion of high-grade
spondylolisthesis without decompression of the neural elements: a retrospective
review of 44 patients. Spine 2006;31:161-9; discussion 170.
Smith JA, Deviren V, Berven S, et al. Clinical outcome of trans-sacral interbody
fusion after partial reduction for high-grade L5-S1 spondylolisthesis. Spine
2001;26:2227-34.
P R O C ED U R E 3 1
Interspinous Process
Motion-Sparing Implant
Christopher F. Wolf, Mark M. Mikhael,
and Arya Nick Shamie
I N D I CAT I O NS P I T F A L L S
• Symptoms unresolved with lumbar
flexion
• Axial back pain as the main complaint
(versus buttock and/or leg pain)
• Osteoporosis with recent history of
fragility fracture (severe osteoporosis)
• Spondylolisthesis greater than 25% on
static or dynamic radiographs
• Significant scoliosis (greater than 25
degrees at the level of stenosis)
• Ankylosis of the involved segment
Indications
n
Lumbar stenosis at one or two levels
• Central stenosis
• Lateral recess stenosis
• Foraminal stenosis
• Facet hypertrophy and cyst formation
n
Patient must report a resolution of symptoms when seated or flexed forward
(i.e., “shopping cart” sign) when upright.
Examination/Imaging
n
Standing anteroposterior (AP), lateral (neutral, extension [
[
right
]) views (Figure 31-1)
left
] and flexion
FIGURE 31-1
Figures 31-3, 31-5, 31-6, and 31-8 © 2011 Medtronic Spine, LLC. Used with permission.
I N D I CAT I O NS
C O N T RO V E R S IE S
• “Mild to moderate” stenosis indication
for ISP implantation refers to patients’
symptoms (able to walk at least 50
feet), not the MRI findings.
• Although studies show that
claudication in patients with severe
stenosis (on magnetic resonance
imaging [MRI]) can be helped with
ISP implants, some surgeons reserve
this device for mild to moderate
stenosis (on MRI) patients only.
• Three-level implantation of the device is
not currently approved. Some surgeons
have had success with treatment of
three-level stenosis with ISP
implantation.
T R E A T M E N T OP T I O N S
• Nonsurgical management, that is,
physical therapy, epidural steroid
injections, and so forth
• Laminectomy without fusion or with
fusion in setting of spondylolisthesis
• Anterior versus lateral interbody fusion
alone with indirect decompression
• Disk arthroplasty
Procedure 31 | Interspinous Process Motion-Sparing Implant 293
FIGURE 31-2
P O S I TI O N I N G PE A R L S
• Radiolucent table
• Ensure patient positioning with hips
and knees flexed to accentuate lumbar
flexion; this position will splay the
spinous processes, aiding in ease of
insertion of the ISP device.
P O S I TI O N I N G PI T FA L L S
• Inadequate imaging: Use AP and lateral
fluoroscopy to confirm, before incision,
that desired views can be obtained.
P O S I TI O N I N G EQ U I P M EN T
• Bean bag with adequate padding for all
bony prominences
• Secure patient with straps, especially
for procedures done under conscious
sedation/local anesthetic.
FIGURE 31-3
• If patient has grade 2 spondylolisthesis on static or dynamic films, that condition is considered a contraindication to the interspinous process (ISP)
procedure.
n
MRI with axial, sagittal, and coronal imaging to assess disk herniation, canal
stenosis, and Modic changes (Figure 31-2)
Surgical Anatomy
n
Midline skin incision with bilateral fascial incision exposing the inferior and
superior aspects of the spinous processes at the selected interspinous segment
(Figure 31-3)
n
Careful preservation of the supraspinous ligament
n
Avoiding disruption of the facet joint anatomy
294 Procedure 31 | Interspinous Process Motion-Sparing Implant
P O S I TI O N I N G
C O N T RO V E R S IE S
• Appropriate lumbar flexion for lateral
positioning
• Maximum flexion obtained with lateral
decubitus versus prone positioning
P O RTA L S / E X P O S U R ES
P E A R LS
• If operating at the L4-5 level, avoid an
incision directly over the prominent L4
spinous process, and deviate slightly
more caudad to center on the
interspinous space.
• Hypertrophic facet capsules need to
be trimmed to position the implant as
anterior as possible.
P O RTA L S / E X P O S U R ES
P I T F A L L S
• Ensure the patient is adequately
secured to the bed with straps.
• If the facet capsule is hypertrophic, the
implant will be placed too posteriorly,
compromising its efficacy and
increasing the risk of implant
dislodgement.
Positioning
n
Lateral positioning on radiolucent table (Figure 31-4)
n
Prone positioning on a Jackson table with a Wilson frame for maximal flexion
at the index level
Portals/Exposures
n
Make a midline incision.
n
Perform blunt subperiosteal dissection with Cobb elevator, avoiding excessive
muscle injury.
n
Avoid injury to the supraspinous ligament as well as the facet anatomy.
n
Remove excessive spinous process osteophytes with rongeur.
Procedure
Step 1: Positioning
n
The lateral position can be used in combination with conscious sedation and
local anesthetic (see Figure 31-4).
n
General anesthesia and prone positioning is also appropriate if a Wilson frame
is used.
Step 2: Incision
n
Make a midline skin incision with bilateral fascial incision exposing the inferior
and superior aspects of the spinous processes at the selected interspinous
segment (Figure 31-5).
P O RTA L S / E X P O S U R ES
E Q U I PM E N T
• Cobb elevator
• Large right-angled Gelpi retractor
S T E P 1 P EA R L S
• In patients with high anesthetic risk,
the lateral position can be used in
combination with conscious sedation
and ample local anesthetic, avoiding
general anesthesia.
S T E P 2 P EA R L S
• If operating at the L4-5 level, avoid an
incision directly over the prominent L4
spinous process, and deviate slightly
more caudad to center on the
interspinous space.
S T E P 2 P IT FA L L S
• An incision too cephalad, making
implant insertion more difficult
FIGURE 31-4
FIGURE 31-5
Procedure 31 | Interspinous Process Motion-Sparing Implant 295
S T E P 3 P EA R L S
• All implants have specific dilators for
their respective system. It is important
to become familiar with them before
the procedure.
S T E P 3 P IT FA L L S
• Ensure, radiographically, the correct
level, as well as that the dilators and
sizers for the interspace are positioned
sufficiently anteriorly, just posterior to
the spinolaminar junction.
• Avoid overdilating, because this may
lead to fracture of the spinous
processes or rupture of the
interspinous/supraspinous ligaments.
S T E P 4 P EA R L S
• When sizing, the interspace tension in
the supraspinous ligament should be
developed until the sizing device has
two-finger resistance; oversizing the
implant should be avoided.
Step 3: Preparing Interspace
n
Develop the interspinous space with the small and large dilators, and confirm
the position on a radiograph (Figure 31-6).
n
Gradually increase the space by dilation using the sizer until it is noted, clinically,
that the interspinous ligament is taut (sometimes a “vacuum disk” is noted
radiographically at the posterior aspect of the disk space, confirming a disk
space distraction) (Figure 31-7).
Step 4: Implantation
n
Select the appropriate implant size based on the sizing trials.
n
Each implant has unique fixation methods that should be clearly understood by
the surgeon before the procedure (Figure 31-8).
S T E P 4 P IT FA L L S
• Do not overstuff the interspace with
too large an implant, because this
may stress the spinous processes and
result in a delayed fracture caused by
superphysiologic forces on the spinous
processes.
FIGURE 31-7 FIGURE 31-8
FIGURE 31-6
296 Procedure 31 | Interspinous Process Motion-Sparing Implant
P O S T OP E R AT IV E P E A R L S
• Most patients state that their
preoperative claudication pain is
relieved immediately after surgery.
• Inadequate preoperative symptom relief
should be evaluated with further
imaging and may potentially require
additional therapy, including physical
therapy and at-time epidural steroid
injections.
• If patient continues complaining of
axial low back pain, they should be
reminded that the surgery was to
address their buttock and leg pain;
once the leg and buttock pain is
relieved, the patient may start
complaining of the remaining low back
pain.
P O S T OP E R AT IV E P I T F A L L S
• Although rare, any neurologic change
occurring abruptly postoperatively
should signal immediate evaluation by
the surgeon, because dislodgement,
fracture, disk herniation, and infection
are a concern.
Postoperative Care and Expected Outcomes
n
The patient can mobilize postoperatively with adequate analgesia.
n
A 2-week follow-up should be done for wound evaluation as well as standing
AP and lateral radiographs to ensure maintained implant positioning.
Evidence
Christie S, Song J, Fessler R. Dynamic interspinous process technology. Spine
2005;30(Suppl 16):S73-8.
This article is an overview of interspinous technology.
Kabir SM, Gupta SR, Casey AT. Lumbar interspinous spacers: a systematic review of
clinical and biomechanical evidence. Spine 2010;35:E1499-506.
This is a review of the biomechanical and clinical evidence related to
interspinous spacer technology.
Kim D, Albert T. Interspinous process spacers. J Am Acad Orthop Surg 2007;15:
200-7.
This article is an overview of interspinous technology.
Siddiqui M, Nicol M, Karadimas E, et al. The positional magnetic resonance
imaging changes in the lumbar spine following insertion of a novel interspinous
process distraction device. Spine 2005;30:2677-82.
This article reports the MRI changes before and after interspinous process
implantation.
Weiner BK. Interspinous process decompression system device affords superior
outcomes and equal safety to non-operative therapy. Spine 2005;30:2846-7.
The article highlights the clinical advantages of the interspinous spacer over
nonoperative therapy.
Zucherman JF, Hsu KY, Hartjen CA, et al. A multicenter, prospective, randomized
trial evaluating the X STOP interspinous process decompression system for the
treatment of neurogenic intermittent claudication: two-year follow up results.
Spine 2005;30:1351-58.
This a Level I research paper evaluating the 2-year results of interspinous
process spacer implantation for neurogenic intermittent claudication.
P R O C ED U R E 3 2
Anterior Lumbar
Interbody Fusion
Michael D. Daubs
I N D I CAT I O NS P I T F A L L S
• Prior anterior lumbar surgery
• Prior anterior abdominal surgery
(retroperitoneal)
• Peripheral vascular disease/vessel
calcification
• Osteopenia
• Morbid obesity
I N D I CAT I O NS
C O N T RO V E R S IE S
• Males have a 2% to 5% risk for
retrograde ejaculation with the anterior
lumbar approach.
Indications
n
Lumbar degenerative disk disease
n
Anterior column support in long fusion constructs
n
Restoring lumbar lordosis
n
Pseudarthrosis following posterior lumbar fusion
n
Lumbar fusions at high risk for nonunion
n
Tumor and trauma
Examination/Imaging
n
Use magnetic resonance imaging to assess degree of disk degeneration (Figure
32-1).
n
Obtain a standing lateral radiograph of the lumbar spine to assess whether the
sacral slope and L5-S1 disk are at an angle that can be accessed through the
anterior approach (Figure 32-2). If the sacral slope is severe (L5-S1 spondylolisthesis), access to the disk can be very difficult.
FIGURE 32-1
FIGURE 32-2
298 Procedure 32 | Anterior Lumbar Interbody Fusion
Inferior vena cava
Median sacral
vessels
L5, S1 disc
FIGURE 32-3
Aorta
Superior hypogastric
plexus
Iliac arteries
Left common
iliac vein
T R E A T M E N T OP T I O N S
• Posterior intertransverse fusion
• Posterior lumbar interbody fusion
• Transforaminal lumbar interbody fusion
• Direct lateral transpsoas lumbar
interbody fusion
P O S I TI O N I N G PE A R L S
• A bolster can be used in the lumbar
region to accentuate lordosis as
needed.
P O S I TI O N I N G PI T FA L L S
• If using fluoroscopy, obtain images
preoperatively to ensure that all views
are obtainable without obstruction from
the table or the patient’s extremities.
P O S I TI O N I N G EQ U I P M EN T
• An operating room table that can
rotate side to side can be helpful for
visualization during the approach.
Surgical Anatomy
n
Aorta, vena cava, iliac veins and arteries (Figures 32-3 and 32-4)
n
Ureter
n
Sympathetic nerves
n
Hypogastric plexus
Positioning
n
The patient is positioned supine on a radiolucent operating room table.
n
The patient’s arms are positioned at the sides in an abducted position on rests
to allow lateral imaging (Figure 32-5).
Portals/Exposures
n
A lateral fluoroscopic image is used to mark the level of incision.
n
A radiopaque rod or pin is used to mark the angle of the disk and the corre-
sponding trajectory to the abdominal wall. The incision site is adjusted to give
optimum access to the disk to be operated upon.
n
A transverse or longitudinal incision is made a few centimeters lateral to midline
at the corresponding disk level, in line with the angle of the disk space. Figure
32-6, (
line A
) shows the more vertical approach to L4-5 and a higher incision
level, and Figure 32-6, (
levels are being addressed, the incision should be between the levels, or a
longitudinal incision can be used.
n
The anterior rectus sheath is incised transversely, while avoiding the underlying
rectus muscle.
n
The transversalis fascia is gently incised with a no. 15 scalpel, and the interval
between the peritoneum and fascia is developed.
n
The retroperitoneal cavity is dissected bluntly toward the midline (left to right),
and the peritoneal contents are retracted to expose the anterior spine.
line B
) displays the trajectory to the L5-S1 disk. If both