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Right common iliac
artery and vein
Procedure 35 | Lumbar Total Disk Arthroplasty 329
Surgical Anatomy
n
During anterior exposure at the L5-S1 level, the disk space is found between
the left and right iliac veins (Figure 35-4).
n
For L3-4 and L4-5 procedures, the vessels should be dissected off the anterior
spine and retracted to the right to expose the spine (Figure 35-5).
Anterior view
Abdominal
aorta
Inferior
vena cava
L4
Left common iliac
artery and vein
Right external iliac
artery and vein
Right internal iliac
artery and vein
FIGURE 35-4
L5
S1
Vena cava
L4
Aorta
Iliolumbar vein
L5
FIGURE 35-5 (Reproduced with permission from Martinez JL, Wang MY.
Anterior lumbar interbody fusion. In: Jandial RJ, McCormick PC, Black
PM, editors. Core Techniques in Operative Neurosurgery. Philadelphia:
Elsevier-Saunders; 2011; Figure 72-5.)
330 Procedure 35 | Lumbar Total Disk Arthroplasty
P O S I TI O N I N G PE A R L S
• Have the surgical disk level at the
“break” in the table to extend the
lumbar spine during the procedure for
better access to disk space.
• Keep the plane of pelvis parallel to the
floor to aid in correct placement of the
implant (use leveler device to verify).
P O S I TI O N I N G PI T FA L L S
• Do not use static bumps or pillows
under the pelvis.
• Lithotomy position is optional (widely
used in Europe; less frequently used in
the United States).
P O RTA L S / E X P O S U R ES
P E A R LS
• Use of intraoperative fluoroscopy to
show angle and level of disk space is
helpful to plan an incision, especially
when using a horizontal incision.
• For larger patients, a vertical incision is
preferred.
• Avoid injury to the inferior epigastric
vessels on the underbelly of the rectus
muscle.
• The ureter should be identified and
retracted along with the peritoneal sac
and never dissected separately.
• For L5-S1 procedures, the middle sacral
artery should be identified and ligated.
• For L3-4 and L4-5 procedures,
segmental vessels may need to be
identified and ligated.
• At L4-5, the ascending lumbar vein may
limit vascular mobilization and require
ligation.
P O RTA L S / E X P O S U R ES
P I T F A L L S
• Horizontal incisions placed improperly
hinder the remainder of the operation.
Positioning
n
The patient is positioned supine on a regular operating table with arms padded
at the elbow and taped across the chest.
Portals/Exposures
n
The anterior approach to the lumbar spine is used through either a transverse
or horizontal incision.
n
The rectus fascia is incised in line with the skin incision, and the midline fascial
raphe of the rectus is identified.
n
The retroperitoneal dissection starts on the medial border of the rectus and
proceeds lateral and posterior to the muscle belly, having less potential chance
of denervation of the rectus.
n
The plane is bluntly dissected superficial to the abdominal contents along the
left abdominal wall outside the peritoneum and taken posteriorly toward the
psoas muscle (Figure 35-6).
n
The entire peritoneal sac (with the ureter) can be bluntly dissected off the
abdominal wall and retracted toward the midline with a handheld retractor.
n
Insertion of a screw or bent needle into the disk space should be done to verify
the level and verify the midline of the disk space with fluoroscopic imaging
(mark the position on the anterior spine with Bovie cautery before removing
marker).
Rectus abdominus
muscle
Peritoneal sac
P O RTA L S / E X P O S U R ES
E Q U I PM E N T
• Use of either handheld retractors or
self-retaining abdominal retractors is
acceptable.
P O RTA L S / E X P O S U R ES
C O N T RO V E R S IE S
• Use of an access surgeon is
recommended.
• The retroperitoneal approach has a
10-fold lower incidence of retrograde
ejaculation in males than the
transperitoneal approach.
Psoas major
muscle
FIGURE 35-6
Procedure 35 | Lumbar Total Disk Arthroplasty 331
S T E P 1 P EA R L S
• A thorough diskectomy in the posterior
corners is crucial for successful
implantation.
• Use a midline marking to create a
symmetric diskectomy.
S T E P 1 P IT FA L L S
• Violation of the end plate should be
avoided during diskectomy.
S T E P 2 P EA R L S
• It is important to fully restore the disk
height to recreate a mobile segment
and avoid expulsion of the implant
because of tight soft tissues.
S T E P 2 P IT FA L L S
• When using the disk space distractors,
they must be inserted to the posterior
aspect of the disk space to use solid
peripheral bone; otherwise, an end
plate fracture can occur.
• Use of curettes during release of
the PLL should be visualized under
fluoroscopic imaging to minimize risk.
Procedure
Step 1: Diskectomy
n
Perform a complete diskectomy (leaving only the lateral annulus and posterior
longitudinal ligament), with removal of cartilaginous end plate from both superior and inferior vertebral bodies (Figure 35-7).
Step 2: Remobilization
n
Release of the posterior longitudinal ligament (PLL) off of the posterior vertebral
bodies should be completed using a small curved curette (Figure 35-8).
n
Specialized distractors and paddles are inserted into the disk space to help with
remobilization (Figure 35-9).
FIGURE 35-7
FIGURE 35-8 FIGURE 35-9
332 Procedure 35 | Lumbar Total Disk Arthroplasty
S T E P 3 P EA R L S
• Depending on intended implant, know
all available sizes.
• If the trial is translated off-center,
further diskectomy or annulotomy may
be required to “balance” the disk
space, thereby allowing the trial to
center.
S T E P 3 P IT FA L L S
• Improper position of trial can lead to
poorly placed implant and eventual
failure of the arthroplasty.
Step 3: Trial Insertion
n
Based on midline marking, insert appropriately sized trial into disk space under
lateral fluoroscopy and visualize on anteroposterior (AP) fluoroscopy for verification (Figure 35-10).
n
Start with a 10-mm trial, and increase in size depending on the resistance felt
and amount of disk height restoration on the lateral fluoroscopic images.
Step 4: Keel Preparation
n
For keeled total disk arthroplasty devices, the keels should be cut under lateral
fluoroscopy to visualize depth (Figure 35-11).
FIGURE 35-10
FIGURE 35-11
Procedure 35 | Lumbar Total Disk Arthroplasty 333
S T E P 5 P EA R L S
• Double check assembly of the device
on the instrumentation before insertion.
• If the device is difficult to insert, extend
the lumbar spine by using the table
controls (restore to neutral before final
positioning of device).
S T E P 5 P IT FA L L S
• For keeled devices, if the trial was not
placed posterior enough in the disk
space, the implant will also not be
posterior enough.
P O S T OP E R AT IV E P E A R L S
• Physical therapy can commence after
wound healing; patients must avoid
extension exercises for 6 weeks.
• Return to activities without restriction
is at 3 months. Low-impact sports are
then acceptable (i.e., golf, tennis,
skiing, basketball).
Step 5: Device Insertion
n
The arthroplasty device should be inserted as far posterior as possible within
the disk space (Figure 35-12).
n
Lateral fluoroscopic images should be used frequently to verify the angle at
which the device is being inserted and the depth.
n
A final AP image should be taken to verify that the device is positioned in the
midline (Figure 35-13).
Postoperative Care and Expected Outcomes
n
Patient should be admitted for inpatient observation.
n
Start with clear liquid diet, and advance as tolerated.
n
Ambulation should commence on the day of surgery.
n
A corset brace should be used for comfort until the wound has healed.
FIGURE 35-12 FIGURE 35-13
334 Procedure 35 | Lumbar Total Disk Arthroplasty
Evidence
Bertagnoli R, Yue JJ, Shah RV, et al. The treatment of disabling single-level lumbar
diskogenic low back pain with total disc arthroplasty utilizing the ProDisc
prosthesis: a prospective study with 2-year minimum follow-up. Spine
2005;30:2230-6.
This is a prospective study with 2-year follow-up presenting the results of total
disk replacement (TDR) in 118 patients with diskogenic low back pain. A
single-level TDR was performed at L3-S1, with outcome measurements taken at
3, 6, 12, and 24 months after surgery. The authors found that improvements
in the Visual Analogue Scale, the Oswestry Disability Index, and patient
satisfaction occurred at 3 months and were maintained at 24 months, all with
statistical significance. At the index level, disk height increased from 4 to
13 mm, and segmental motion increased from 3 to 7 degrees, both with
statistical significance as well. They concluded that TDR is a successful
alternative to fusion, with consistent results at 2-years follow-up. Although this
is a prospective case series, it legitimizes TDR as a treatment option for
disabling low back pain resulting from diskogenic syndrome.
Blumenthal S, McAfee PC, Guyer RD, et al. A prospective, randomized, multicenter
Food and Drug Administration Investigational Device Exemptions study of
lumbar total disc replacement with the CHARITE Artificial Disc versus lumbar
fusion: part I: evaluation of clinical outcomes. Spine 2005;30:1565-75.
This is a Level I study comparing total disk replacement (TDR) with anterior
lumbar interbody at a single level from L4-S1. A total of 304 patients were
randomized. Both groups showed significant improvement following surgery.
Patients in the TDR group were found to have lower levels of disability at every
time interval from 6 weeks to 24 months. At the 24-month follow-up period,
a greater percentage of patients in the TDR group were satisfied with their
treatment compared with the fusion group (P < .05). The complication rates
were similar between the groups, and the hospital stay was significantly shorter
for TDR than for fusion patients. Reoperation was higher in the fusion group
(9.1% versus 5.4%).
Brau SA, Delamarter RB, Schiffman ML, et al. Vascular injury during anterior
lumbar surgery. Spine J 2004;4:409-12.
This publication is a retrospective case series of 1315 consecutive patients who
underwent anterior approach to the lumbar spine. A significant vascular
complication rate of 1.9% was reported. Six patients had left iliac artery
thrombosis, and 19 patients had major venous injuries. The study concluded
that anterior lumbar surgery is safe, although special attention should be given
during mobilization of the vessels to avoid serious complications.
David T. Long-term results of one-level lumbar arthroplasty: minimum 10-year
follow-up of the CHARITE Artificial Disc in 106 patients. Spine 2007;32:661-6.
This was a Level III study with long-term follow-up of total disk arthroplasty
patients. Eighty percent of patients reported excellent or good clinical success
after Charité total disk replacement (TDR) at a mean of 13.2-years follow-up.
Ninety percent of the prostheses were still mobile. The reoperation rate for
TDR patients was 7.5% and the adjacent level degeneration rate was found
to be 2.8%. Almost 90% of the patients returned to work after TDR. The
complications rate was 4.6%, with a 2.8% rate of subsidence and less than a
2% rate of core subluxation.
Guyer RD, McAfee PC, Banco RJ, et al. Prospective, randomized, multicenter Food
and Drug Administration Investigational Device Exemption study of lumbar
total disc replacement with the CHARITE Artificial Disc versus lumbar fusion:
five-year follow-up. Spine J 2009;9:374-86.
This represents a Level I study comparing total disk replacement (TDR) and
fusion at the 5-year follow-up time point. Five-year follow-up was completed
by 133 randomized patients. Overall success was defined as improvement of at
least 15 points on the Oswestry Disability Index (ODI) versus baseline, no device
failure, absence of major complications, and maintenance or improvement of
neurologic status. The overall success was 57.8% in the TDR group versus 51.2%
in the fusion group. Changes from baseline for ODI, Visual Analogue Scale pain
scores, and SF-36 Health Survey Scores were similar for both groups. In patient
satisfaction surveys, 78% of TDR patients were satisfied versus 72% of fusion
patients. Higher rates of employment were noted in the TDR group. Long-term
disability was higher in the fusion group by nearly threefold (P = .0441).
Additional index-level surgery was also higher for the fusion group.
Radiographic data were similar to that reported in the 2-year follow-up study
(see Blumenthal et al, 2005, this section).
Procedure 35 | Lumbar Total Disk Arthroplasty 335
Guyer RD, Tromanhauser SG, Regan JJ. An economic model of one-level lumbar
arthroplasty versus fusion. Spine J 2007;7:558-62.
A cost-minimization model comparing costs of total disk replacement (TDR) to
three spinal fusion procedures: anterior lumbar interbody fusion (ALIF) with
iliac crest bone graft (ICBG), ALIF with INFUSE Bone Graft and LT-Cages, and
instrumented posterior lumbar interbody fusion (IPLIF) with ICBG. The hospital
perspective compares direct medical costs during the index hospitalization. The
payer perspective considers direct medical costs of the index hospitalization and
those incurred in the following 2-year period. Compared with TDR, hospital
costs are 12.0% higher for ALIF with ICBG, 36.5% higher for ALIF with INFUSE,
and 36.5% higher for IPLIF. For payers, compared with TDR, ALIF with ICBG has
4.4% lower cost, whereas ALIF with INFUSE and IPLIF have costs of 16.1% and
27.1% higher, respectively. The study concluded that the overall economic effect
of one-level TDR procedures (for payers and hospitals) is at worst equivalent to
fusion.
Lemaire JP, Carrier H, Sariali el-H, et al. Clinical and radiological outcomes with
the Charité Artificial Disc: a 10-year minimum follow-up. J Spinal Disord Tech
2005;18:353-9.
This is a long-term series with a minimum follow-up of 10 years. A total of 107
patients underwent lumbar total disk replacement (TDR): 54 one-level and 45
two-level procedures, and 1 three-level procedure. Clinically, 62% had an
excellent outcome, 28% had a good outcome, and 10% had a poor outcome.
Greater than 90% of eligible patients returned to work. Motion measurements
showed 10.3 degrees of flexion/extension for all levels. No subluxation of the
implants was noted, and no cases of arthrodesis occurred. Five patients required
a secondary posterior arthrodesis because of poor clinical outcomes, not
because of catastrophic device failure.
Zigler J, Delamarter R, Spivak JM, et al. Results of the prospective, randomized,
multicenter Food and Drug Administration Investigational Device Exemption
study of the ProDisc-L total disc replacement versus circumferential fusion for
the treatment of 1-level degenerative disc disease. Spine 2007;32:1155-62.
This is another Level I study comparing total disk replacement (TDR) to
circumferential spinal fusion for the treatment of diskogenic pain at a
single level between L3 and S1. The study involved 286 patients. No major
complications occurred in the investigational group. At 2-years follow-up,
77.2% of investigational and 64.8% of control patients met the Oswestry
Disability Index improvement criteria of at least 15%. Overall neurologic success
in the investigational group was superior to the control group. Visual Analogue
Scale improvement was superior at 24 months in the investigational group
versus the control group (P = .015). Radiographic range of motion averaged 7.7
degrees in the TDR patients and was of normal values in more that 90% of
these. TDR not only showed non-inferiority to fusion, it showed superiority on
several clinical parameters.
P R O C ED U R E 3 6
Kyphoplasty
Issada Thongtrangan and Isador H. Lieberman
I N D I CAT I O NS P I T F A L L S
• Local active osteomyelitis
• Systemic pathology
• Coagulopathy
• Cardiopulmonary pathology
• Burst fracture configuration
• Vertebral bodies with deficient posterior
cortices
• Fractured pedicles
• Patients with neurologic signs and
symptoms
• Acute traumatic nonosteoporotic fracture
• Allergy to contrast medium
I N D I CAT I O NS
C O N T RO V E R S IE S
• Timing of intervention (acute versus
6 weeks)
• Choice of bone void filler material
(polymethylmethacrylate [PMMA] versus
synthetic)
• Treat biomechanics or treat pain
Indications
n
Progressive, painful osteoporotic vertebral wedge compression fractures in the
absence of neurologic signs
n
Osteolytic vertebral compression fractures (multiple myeloma)
n
Painful spinal metastases (breast, lung, prostate, gastrointestinal) resulting from
collapse, tumor necrosis, or postradiation
n
Sagittal spinal malalignment resulting from osteoporotic or osteolytic collapse
Examination/Imaging
n
Pain to palpation/percussion over presumed fracture site, normal neurologic
n
Plain radiographs, including 36-inch cassette scoliosis films (anteroposterior and
lateral)
n
Magnetic resonance imaging (T1-weighted, T2-weighted, short time inversion
recovery, T1-weighted gadolinium); acute compression MRI showing hypointensity on T1-weighted (Figure 36-1, A) and hyperintensity on T2-weighted (Figure
36-1, B) images
A
FIGURE 36-1, A-B
B
T R E A T M E N T OP T I O N S
• Bed rest
• Brace
• Narcotic analgesics
• Vertebroplasty
• Open surgical procedure
P O RTA L S / E X P O S U R ES
P E A R LS
• Obtain true lateral and anteroposterior
views.
• Frequently check the anteroposterior
(AP) and lateral fluoroscopy images to
make sure of the entry point and
trajectory.
Procedure 36 | Kyphoplasty 337
n
Computed tomography scan
n
Bone scan
n
White blood cell count, sedimentation rate, C-reactive protein, platelet count,
international normalized ratio, prothrombin time/partial thromboplastin time
Surgical Anatomy
n
Pedicle shape is cylindrical, which tapers in the middle, and nerve root lies just
inferomedial to the pedicle (Figure 36-2: pedicle morphology)
n
Define the pedicular rings (waist of the pedicle) to define the starting point.
n
Define the spinous process to gauge vertebral body rotation.
n
Define end plates to plan the trajectory anterior to posterior and superior to
inferior.
n
Define cortical margins to avoid anterior margin of the spinal canal, the great
vessels, and the lungs.
Positioning
n
Use general or local anesthesia.
n
The patient is prone on a Jackson table or other radiolucent table with appropri-
ate padding for spine surgery.
n
Biplanar fluoroscopy and operating room setup is shown in Figure 36-3.
Nerve
Medial
FIGURE 36-2
Lateral
FIGURE 36-3
338 Procedure 36 | Kyphoplasty
P O RTA L S / E X P O S U R ES
P I T F A L L S
• Accurate definition of radiographic
landmarks
• Parallel superior and inferior vertebral
body end plates in both anteroposterior
and lateral views
• The spinous processes should be
equidistant between vertebral body
pedicles.
• On lateral fluoroscopic images, the
pedicles should be superimposed
(Figure 36-4, A and B: true fluoroscopic
images in AP and lateral plane).
P O RTA L S / E X P O S U R ES
E Q U I PM E N T
• Biplanar fluoroscopy
• The approach to the vertebral body is
percutaneous via the transpedicular or
extrapedicular approach with a Jamshidi
needle.
Pedicles
in upper
half of
vertebral
body
Spinous process
A
Pedicles
superimposed
Endplates
parallel
equidistant
Endplates
parallel
S T E P 1 P IT FA L L S
• Avoid angling the Jamshidi needle too
medially or too laterally. There is a risk
of injury to the spinal cord if the medial
cortex of the pedicle is violated and a
risk of injury to the lung if the lateral
cortex of the pedicle is violated.
• Avoid penetration of the anterior cortex
of the vertebral body and injury to the
great vessels.
• Use frequent pulsed fluoroscopic
images in both the AP and lateral
planes to monitor the advancement
of all tools.
S T E P 1
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Local anesthetic
• Jamshidi needle
• Mallet
• Guidewire
• Blunt dissector
• Working cannula
B
FIGURE 36-4, A-B
Procedure
Step 1
n
Using biplanar fluoroscopy, identify the entry point and the skin incision.
n
After injecting local anesthetic, a 3-mm paramedian skin incision is created over
the entry site to the fractured bone.
n
Use a Jamshidi needle to locate the entry point to the pedicle and to feel the
bony landmarks.
n
The Jamshidi needle is advanced through the bone of the pedicle using a tapping
mallet.
n
The Jamshidi needle should be positioned at the junction of the pedicle and the
vertebral body.
n
After removing the trocar, place a guidewire in the hollow core of the needle.
n
Advance the guidewire until it is slightly posterior to the anterior cortex of the
vertebral body.
n
Remove the Jamshidi needle.
n
A cannulated blunt dissector is passed over the guidewire into the vertebral
body.
n
The working cannula is passed over the blunt dissector, and becomes seated
just anterior to the posterior cortex (Figure 36-5).
n
Remove the blunt dissector.
n
A drill or solid stylet is used to create a channel in the vertebral body to accom-
modate the inflatable bone tamp. A vertebral body biopsy with the appropriate
trephine may be obtained at this time.
n
The procedure is repeated on the contralateral side.