Name: clinical application of microscope-assisted minimally invasive anterior lumbar interbody fusion
Uploaded: 2023-06-16T13:50:00.000+00:00
Duration: 4 min 42 s
Description: Watch this Scientific Journal Video about Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion at JoVE.com

The authors have no acknowledgments.

This study was reviewed and approved by the Hebei Medical University Third Affiliated Hospital ethics committee, and written informed consent was obtained from all the patients. In addition, no images are identifiable to any patients.
1. Preoperative preparation
<ol>
	<li>Select appropriate cases based on the patient history, including symptoms, signs, history of previous lumbar and abdominal surgery, abdominal examination, and imaging, such as lumbar X-ray, computed tomography (CT), and magnetic resonance imaging (MRI).</li>
	<li>Advise the patients to undergo preoperative CT angiography of the abdominal aorta and CT angiography of the inferior vena cava to rule out vascular malformations, as well as fasting and enemas the day before surgery for gastrointestinal preparation.</li>
</ol>
2. Surgical procedures
<ol>
	<li>Figure 1 depicts the surgical procedure for Mini-ALIF. After general anesthesia, place the patient in the supine position with the hands either flat or on the chest to accommodate an intraoperative lateral X-ray. 
	NOTE: If the abdominal wall and psoas major muscles are too tight, padding under the thighs is added, and the patients are maneuvered into the bladder stone position.</li>
	<li>Locate the surgical lumbar segment by abdominal palpation of the iliac crest and the location of the Kirschner needle under X-ray.</li>
	<li>Use a right side incision for the operation of the L5-S1 segment, and use a left approach for the rest of the segments. Use a scalpel to cut the skin and subcutaneous tissue in turn. Make a transverse incision in the lateral rectus abdominis muscle next to the lower abdomen, with a single segment length of ~5 cm. Use oblique or vertical incisions of about 8 cm in double-segment surgery.</li>
	<li>Identify and incise the anterior rectus abdominis sheath with the aid of a microscope (with a working distance of 535 mm). Then, separate the rectus abdominis muscle bluntly to its outer edge, and retract the outer edge of the rectus abdominis toward the midline using a pulling hook to reveal the posterior rectus abdominis sheath.</li>
	<li>Adjust the appropriate distance and magnification from the microscope to the operating area during the operation. Then, separate the anterolateral abdominal wall of the peritoneum with gauze balls under a microscope, and push contralaterally into the retroperitoneal space to reach the anterior aspect of the vertebral space.</li>
	<li>Separate the prevertebral soft tissue bluntly with gauze and vascular forceps. Explore the sacral vascular space microscopically. Use vascular forceps and nerve strippers to separate the iliac arteriovenous vein. Furthermore, ligate the median sacral artery using silk thread depending on its occlusion. 
	NOTE: Take care to avoid having to use electrocoagulation, which can damage the inferior ventral plexus.</li>
	<li>Use the spreader to expose the surgical field in all directions. Fix the pulling hook to the vertebral body using a K-wires positioning tube on either side of the vertical section. Figure 2A shows the pull hook part of the spreader.</li>
	<li>Figure 2B, C shows the second part of the spreader, which is designed as a combination of two draw-off tabs with a puller and a push-rod. Connect the retractor on one side to the straight-grip pull-rod to provide a pulling force on the soft tissue. The other retractor piece has three attachment holes at different depths; have the assistant attach these holes with a T-pusher on the opposite side to assist the surgeon in pushing away the soft tissue.</li>
	<li>Then, use a 3.2 mm diameter positioning tube to secure the spreader to the two adjacent vertebral bodies of the operated segment using K-wires on either side of the retractor.</li>
	<li>Expose the intervertebral space, and incise the disc annulus fibrosus. Remove the diseased disc, and then decompress the spinal canal guided by a microscope.</li>
	<li>Scrape the endplate with an endplate rugine. Select anterior lumbar fusion apparatus of an appropriate size using a trial model. Fill autogenous bone fragments or bone mud and bone particles into the fusion apparatus and implant them into the surgical intervertebral space. Use an appropriate internal fixation according to the bone quality and diagnosis.</li>
</ol>
3. Post-surgery
<ol>
	<li>Use 1 g of cefazolin sodium per 6 h to prevent infection for 24 h after the operation, and restrict the patient from eating until intestinal exsufflation.</li>
	<li>After the patient gets out of bed the next day, advise them to gradually undergo rehabilitation training. Instruct the patient to wear a brace to walk and to use the waistline brace continuously for 3 months.</li>
</ol>

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The authors have no conflicts of interest in this research.

Several turns surrounding the peritoneum during Mini-ALIF surgical exposure and decompression of the spinal canal are critical steps in the surgery. Injury to the anterior peritoneum when opening the anterior rectus abdominis sheath and separating the transverse abdominal fascia can easily lead to failure with this approach5. In addition, patients with lumbar spine infections and a history of abdominal surgery can develop intraoperative complications such as adhesions of the peritoneum and soft tissues, which are difficult to separate with blunt dissection and can easily cause iliac vein tears12. Past the retroflexion of the peritoneum, the surface and inner edge of the psoas major muscle are traversed by the ureter, genitofemoral nerve, common iliac artery, rectum, and other important tissues. The incidence of venous injury in anterior lumbar surgery, which often occurs in the iliac vein system, has been reported to be 0%-18%, and tearing of the iliac vein due to traction has been reported to be the most common venous complication13,14,15,16. However, abdominal arterial injury is more dangerous than venous injury and can be fatal17,18. When stretching the vascular space to reach the anterior vertebrae, the hypertrophied anterior vertebral fascia in front of the lumbar vertebrae, and the anterior longitudinal ligament with the autonomic nerve, injury to the inferior ventral plexus may occur, which, in turn, can cause postoperative retrograde ejaculation with an incidence anywhere between 0.42% and 27.3%19,20,21.
The use of microscopy allows for easier handling of the retroperitoneal vessels (common iliac vein, segmental vessels, lumbar ascending veins), as well as the prevertebral soft tissues, thus minimizing the risk of tissue damage22. In patients with foraminal stenosis for whom previous indirect decompression alone has not achieved good results, a microscope helps to visualize the stenotic space with enhanced visualization and also provides a coaxial view to the surgical assistant, who may be required to help with blood aspiration, especially when dealing with the intervertebral space. Shin et al. visualized the complete decompression of the dorsal root ganglion at the intervertebral foraminal stenosis caused by lumbar spondylolisthesis combined with posterior bony stenosis with microscopic assistance and were able to achieve good surgical results23.
In auto-static spreaders such as the Synframe, Condor, and Thompson, the main structure is a fixation bracket fixed to the edge of the operating table that holds the pull-hooks in place and draws the surgical channel in all directions11,13,24,25. However, these types of spreaders are not as stable under a microscope and are complex and expensive to install, which greatly increases the time and cost of the procedure. In the absence of a suitable spreader, the field of view is severely obscured; additionally, an inappropriate spreader can also occupy the already inadequate surgical space when using a microscope.
Compared to the traditional ALIF procedure, the new spreader system uses Kirschner wire (K-wire) to fix the retractor piece and retractor to maintain stable spreading and achieve sufficient soft tissue contraction and intervertebral space expansion to reduce complications26. Although the wide and stable field of view under the microscope saves time in the handling of the spinal canal and reduces the risk of nerve damage as well, it takes time to set up the parameters and make adjustments. The average operation time was 143 min, which was not much different from previous studies, but there was some concern that the use of a microscope might prolong the operation and lead to complications such as thrombosis8,10. With the continuing development of microsurgery technology, 3D microscopes without eyepieces have also entered into use in the clinic, and we believe that in the future, it will be possible to perform Mini-ALIF more easily with the aid of 3D microscopes. Indeed, this would further reduce the duration of surgery and the occurrence of complications27,28. Although the microscope can help to separate the tissue, abnormal anatomy of the abdominal vessels, severe peripheral vascular disease, a solitary kidney on the operative side, and severe spondylolisthesis still limit the operation.
The new spreader system provides a method for microscope-assisted Mini-ALIF that facilitates more precise micromanipulation and reduces the surgery time for delicate procedures. Therefore, the spreader system can provide a stable, wide field that addresses the barriers to the use of microscopic techniques and that provides a clear, direct view of the spinal canal and nerves from the microscope, thus allowing for the complete removal of the free nucleus pulposus from inside the spinal canal. Microscope-assisted Mini-ALIF has good clinical efficacy and safety in the treatment of degenerative lumbar diseases10,23.

Anterior lumbar interbody fusion (ALIF), a fusion procedure that takes an abdominal approach to the anterior lumbar spine, was first described by O&#39;Brien in 19831. With the advantages of less bleeding, less muscle and nerve damage, and the ability to restore lumbar lordosis and reduce the impact on adjacent segmental degeneration better than posterior lumbar interbody fusion, ALIF is now widely used to treat lumbar spondylolisthesis, spinal deformities, lumbar spine infections, and degenerative lumbar disc disease2,3. However, the procedure can also lead to complications such as vascular, nerve, and ureteral injuries; early vascular injuries are especially common, occurring in 10.4% of cases4,5,6,7,8,9.
The use of a microscope during the procedure allows for a clearer operative field, resulting in greater safety in terms of reducing tissue damage, as well as smaller surgical incisions8,10. However, minimally invasive anterior lumbar interbody fusion (Mini-ALIF) still requires a high degree of visualization and stability and requires the use of appropriate spreaders. Early framed laparoscopic spreaders, such as the Synframe system&#39;s Activ O spreader or the currently used Miaspas-ALIF spreader (Aesculap), are primarily used for conventional open ALIF surgery11, but their poor microscopic stability, complex installation requirements, and high costs have hampered the use of microscopy in anterior lumbar spine surgery.
In this study, we introduce a new spreader system for microscope-assisted Mini-ALIF that involves opening the operative field and accomplishing nerve decompression under a microscope through a block and retractors fixed to the vertebral body. This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for Mini-ALIF. This system can provide good intraoperative disc exposure, good discrimination of important structures, adequate spreading of the intervertebral space, and the restoration of the necessary intervertebral height, which is very helpful for less experienced surgeons.

<table><tbody><tr><td>Anterior Lumbar Cage Instrument</td><td>LDR Medical</td><td>ROI-A</td><td></td></tr><tr><td>Cefazolin Sodium for Injection</td><td>Brilliant Pharmaceuticals</td><td>Chinese Drug Approval Number H20217016</td><td></td></tr><tr><td>Coagulation Forceps</td><td>Zhenjiang Hengsheng Juen Medical Instrument Co., Ltd.</td><td>BZN-Q-A-S</td><td></td></tr><tr><td>Coated, Braided Silk</td><td>Suzhou Jiasheng Medical Treatment Products Co.,Ltd.</td><td>2-0(4#)</td><td></td></tr><tr><td>Endplate Rugine</td><td>LDR Medical</td><td>IGO16R</td><td></td></tr><tr><td>Microscope</td><td>Carl Zeiss AG</td><td>S88</td><td></td></tr><tr><td>SPSS Statistics for Windows</td><td>IBM Corp</td><td>version 26.0</td><td></td></tr><tr><td>Surgical ablation electrodes</td><td>Jiangsu Yibo Leiming Medical Technology Co., Ltd.</td><td>LM-A5</td><td></td></tr></tbody></table>

clinical application of microscope-assisted minimally invasive anterior lumbar interbody fusion

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for minimally invasive anterior lumbar interbody fusion (Mini-ALIF). This article is a technical description of anterior lumbar spine surgery under a microscope. We retrospectively collected information on patients who underwent microscope-assisted Mini-ALIF surgery at our hospital between July 2020 and August 2022. A repeated-measures ANOVA was used to compare imaging indicators between periods. Forty-two patients were included in the study. The mean volume of intraoperative bleeding was 180 mL, and the mean operative time was 143 min. The mean follow-up time was 18 months. Apart from one case of peritoneal rupture, no other serious complications occurred. The postoperative foramen and disc height were both higher on average than before surgery. The spreader-assisted micro-Mini-ALIF is simple and easy to use. It can provide good intraoperative disc exposure, good discrimination of important structures, adequate spreading of the intervertebral space, and the restoration of the necessary intervertebral height, which is very helpful for less experienced surgeons.

Patients who received Mini-ALIF for lumbar degenerative disease at Hebei Medical University Third Affiliated Hospital between July 2020 and August 2022 were enrolled retrospectively, and basic information such as age and gender, as well as medical records and imaging information, were recorded. The inclusion criteria were patients receiving Mini-ALIF for lumbar spinal stenosis, discogenic low back pain, and low-grade (I or II) slippage that had failed to respond to strictly conservative treatment for more than 6 months. The exclusion criteria were as follows: 1) a follow-up time of less than 1 year; and 2) incomplete follow-up data.
This study included 42 patients, comprising 18 men and 24 women. The general information regarding enrollment is shown in Table 1. The mean age of the patients was 51.33 years. There were 5 cases of lumbar spondylolisthesis, 9 cases of discogenic back pain, and 28 cases of disc herniation. The number of patients with a history of abdominal surgery was 8. The number of patients who underwent single-segment surgery was 30, and the number who underwent double-segment surgery was 12. Of all these surgeries, 6 were L2-L3, 12 were L3-L4, 19 were L4-L5, and 17 were L5-S1 (a total of 54 segments). The mean surgical bleeding was 180 mL, the mean operative time was 143 min, the mean hospital stay was 7 days, and the mean follow-up period was 18 months. A patient with a history of C-sections had a rupture of the peritoneum during the operation, which was closed with silk sutures. No other severe complications, such as major vascular, nerve, or organ injury, occurred during the perioperative period for any patient.
Table 2 shows the heights of the intervertebral discs and the foramina of the operated segments of the patients before and after surgery. The operation showed a good indirect decompression effect, and the heights of the intervertebral discs and the foramina in each follow-up period were significantly higher than those before the operation (P &#60; 0.05).
Figure 3&#160;shows the changes in the MRI images before and after surgery of a patient with a lumbar disc herniation biased toward the left foramen. A herniated disc at L5-S1 biased toward the left foramen position can be seen in the MRI of the lumbar spine taken 7 days before the surgery (Figure 3A,C), while the disappearance of the herniated disc can be appreciated in the MRI taken 3 days after the surgery (Figure 3B,D).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64955/64955fig01.jpg" /> 
Figure 1: Photographs of the Mini-ALIF surgery. (A) Preoperative body surface marking.(B) Exposure through the retroperitoneal space. (C)&#160;Exposure of the intervertebral space with the aid of the retractor system. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64955/64955fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64955/64955fig02.jpg" /> 
Figure 2: The spreader system. (A) The pulling hook part of the spreader.&#160;(B)&#160;The components of the retractor with the pushers and pullers. (C) The combination of the retractor with the pushers and pullers. The diameter of the positioning tube is 3.2 mm, and the height of the retractor is 135 mm. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64955/64955fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64955/64955fig03.jpg" /> 
Figure 3: Pre- and postoperative imaging changes in a patient with a lumbar disc herniation biased toward the left foramen. (A,C) MRI of the lumbar spine taken 7 days before the surgery showing a large herniated disc at L5-S1 that was biased toward the left foramen position. (B,D) MRI taken 3 days post-operation showing the disappearance of the herniated disc. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/64955/64955fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Characteristics</td>
			<td>Value</td>
		</tr>
		<tr>
			<td>Number of patients</td>
			<td>42</td>
		</tr>
		<tr>
			<td>Age, mean (range)</td>
			<td>51.33 (31&#8211;70)</td>
		</tr>
		<tr>
			<td>BMI (mean)</td>
			<td>26.4</td>
		</tr>
		<tr>
			<td>Sex, male/female</td>
			<td>18/24</td>
		</tr>
		<tr>
			<td>History of abdominal surgery</td>
			<td>8</td>
		</tr>
		<tr>
			<td>Surgical bleeding, mean (mL)</td>
			<td>180</td>
		</tr>
		<tr>
			<td>Operative time, mean (min)</td>
			<td>143</td>
		</tr>
		<tr>
			<td>Hospital stay (day)</td>
			<td>7</td>
		</tr>
		<tr>
			<td>Diagnosis</td>
			<td>Number of patients</td>
		</tr>
		<tr>
			<td>Lumbar spondylolisthesis</td>
			<td>5</td>
		</tr>
		<tr>
			<td>Intervertebral disc herniation</td>
			<td>21</td>
		</tr>
		<tr>
			<td>Lumber formainal stenosis</td>
			<td>7</td>
		</tr>
		<tr>
			<td>Discogenic low back pain</td>
			<td>9</td>
		</tr>
		<tr>
			<td>Surgical segment</td>
			<td>Number of segments</td>
		</tr>
		<tr>
			<td>Single segment</td>
			<td>30</td>
		</tr>
		<tr>
			<td>Double segment</td>
			<td>12</td>
		</tr>
		<tr>
			<td>L2-3</td>
			<td>6</td>
		</tr>
		<tr>
			<td>L3-4</td>
			<td>12</td>
		</tr>
		<tr>
			<td>L4-5</td>
			<td>19</td>
		</tr>
		<tr>
			<td>L5-S1</td>
			<td>17</td>
		</tr>
	</tbody>
</table>
Table 1:&#160;Summary and surgical outcomes of the patients.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Group</td>
			<td>Preoperative</td>
			<td>3 Days Postoperatively</td>
			<td>3 Months Postoperatively</td>
			<td>12 Months Postoperatively</td>
			<td>P</td>
		</tr>
		<tr>
			<td>Intervertebral height&#160;&#160;</td>
			<td>7.05&#160; &#177;0.24a</td>
			<td>10.22 &#177; 0.14b</td>
			<td>9.99 &#177; 0.13c</td>
			<td>9.81 &#177; 0.13d</td>
			<td>&#60;0.01#</td>
		</tr>
		<tr>
			<td>Foraminal height</td>
			<td>17.33 &#177; 0.22a</td>
			<td>21.13 &#177; 0.14b</td>
			<td>20.86 &#177; 0.16c</td>
			<td>20.69 &#177; 0.13d</td>
			<td>&#60;0.01#</td>
		</tr>
	</tbody>
</table>
Table 2: Imaging outcomes. #, repeated-measures ANOVA; at least one identical subscript letter denotes no significant difference from each other.

Watch this Scientific Journal Video about Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion at JoVE.com

Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

The technique described in this article is well-suited to the Mini-ALIF procedure, allows for excellent exposure and decompression, and facilitates microscope-assisted manipulation.

This study aims to investigate the technical aspects of microscope-assisted anterior decompression fusion and to introduce a spreader system suitable for ...

clinical-application-microscope-assisted-minimally-invasive-anterior

Universidad San Sebastian

Research

JoVE Journal

Medicine

483 Views.  Hebei Medical University Third Affiliated Hospital. The technique described in this article is well-suited to the Mini-ALIF procedure, allows for excellent exposure and decompression, and facilitates microscope-assisted manipulation.

Video: Clinical Application of Microscope-Assisted Minimally Invasive Anterior Lumbar Interbody Fusion

Minimally Invasive Establishment of Murine Orthotopic Bladder Xenografts

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable cell lines are inoculated either by intravesical instillation (model of nonmuscle invasive growth) or intramural injection into the bladder wall (model of invasive growth). Both procedures are complex and highly time-consuming. Additionally, the superficial model has its shortcomings due to the lack of cell lines that are tumorigenic following instillation. Intramural injection, on the other hand, is marred by the invasiveness of the procedure and the associated morbidity for the host mouse.
With these shortcomings in mind, we modified previous methods to develop a minimally invasive approach for creating orthotopic bladder cancer xenografts. Using ultrasound guidance we have successfully performed percutaneous inoculation of the bladder cancer cell lines UM-UC1, UM-UC3 and UM-UC13 into 50 athymic nude. We have been able to demonstrate that this approach is time efficient, precise and safe. With this technique, initially a space is created under the bladder mucosa with PBS, and tumor cells are then injected into this space in a second step. Tumor growth is monitored at regular intervals with bioluminescence imaging and ultrasound. The average tumor volumes increased steadily in in all but one of our 50 mice over the study period.
In our institution, this novel approach, which allows bladder cancer xenograft inoculation in a minimally-invasive, rapid and highly precise way, has replaced the traditional model.

The established technique to inoculate primary invasive orthotopic bladder cancer xenografts requires laparotomy and mobilization of the bladder. This procedure inflicts significant morbidity on the mice, is technically challenging and time-consuming. We therefore developed a high-precision, percutaneous approach utilizing ultrasound guidance.

Orthotopic bladder cancer xenografts are the gold standard to study molecular cellular manipulations and new therapeutic agents&#160;in vivo. Suitable ...

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients &#8804;55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged &#8804;55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Minimally invasive thumb-sized pterional craniotomy for aneurysm clipping has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve ...

Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. Minimally invasive surgery (MIS) approaches have been applied to this technique with an associated decrease in estimated blood loss (EBL), length of hospital stay, and infection rates, while preserving outcomes with traditional open surgery. Previous MIS TLIF techniques involve significant fluoroscopy that subjects the patient, surgeon, and operating room staff to non-trivial levels of radiation exposure, particularly for complex multi-level procedures. We present a technique that utilizes an intraoperative computed tomography (CT) scan to aid in placement of pedicle screws, followed by traditional fluoroscopy for confirmation of cage placement. Patients are positioned in the standard fashion and a reference arc is placed in the posterior superior iliac spine (PSIS) followed by intraoperative CT scan. This allows for image-guidance-based placement of pedicle screws through a one-inch skin incision on each side. Unlike traditional MIS-TLIF that requires significant fluoroscopic imaging during this stage, the operation can now be performed without any additional radiation exposure to the patient or operating room staff. After completion of the facetectomy and discectomy, final TLIF cage placement is confirmed with fluoroscopy. This technique has the potential to decrease operative time and minimize total radiation exposure.

The purpose of this article is to provide image-guidance for minimally invasive transforaminal interbody fusion.

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. ...

Three-dimensional Navigation-guided, Prone, Single-position, Lateral Lumbar Interbody Fusion Technique

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large implant size and optimal implant position. However, current methods for lateral interbody cage placement require either a two-staged procedure or a single lateral decubitus position that precludes surgeons from having either full access to the posterior spine for direct decompression or comfortable pedicle screw placement.
Herein is one institution's experience with 10 cases of a prone single-position approach for simultaneous access to the anterior and posterior lumbar spine. This allows both lateral lumbar interbody cage placement, direct posterior decompression, and pedicle screw placement, all in one position. Three-dimensional (3D) navigation is utilized for increased precision in both approaching the lateral spine and interbody cage placement. The traditional blind psoas muscle tubular dilation was also modified. Tubular retractors and lateral vertebral body retractor pins were used to minimize the risks to the lumbar plexus.

The single-position, prone, lateral approach allows for both lateral lumbar interbody placement and direct posterior decompression with pedicle screw placement in one position.

Lateral interbody fusion provides a significant biomechanical advantage over the traditional transforaminal lumbar interbody fusion due to the large ...

Neuroscience

C-arm-Free Simultaneous OLIF51 and Percutaneous Pedicle Screw Fixation in a Single Lateral Position

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 level (OLIF51) is technically difficult because of the anatomical structures. We present a novel simultaneous technique of OLIF51 with percutaneous pedicle screw fixation without fluoroscopy. The patient is placed in a right lateral decubitus position. A percutaneous reference pin is inserted into the right sacroiliac joint. An O-arm scan is performed, and 3D reconstructed images are transmitted to the spinal navigation system. A 4 cm oblique skin incision is made under navigation guidance along the pelvis. The internal/external and transverse abdominal muscles are divided along the muscle fibers, protecting the iliohypogastric and ilioinguinal nerves. Using a retroperitoneal approach, the left common iliac vessels are identified. Special muscle retractors with illumination are used to expose the L5-S1 intervertebral disc. After disc preparation with navigated instruments, the disc space is distracted with navigated trials. Autogenous bone and demineralized bone material are then inserted into the cage hole. The OLIF51 cage is inserted into the disc space with the help of a mallet. Simultaneously, percutaneous pedicle screws are inserted by another surgeon without changing the lateral decubitus position of the patient.
In conclusion, C-arm-free OLIF51 and simultaneous percutaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This novel technique reduces surgical time and radiation hazards.

C-arm-free oblique lumbar interbody fusion at the L5-S1 level (OLIF51) and simultaneous pedicle screw fixation are performed in a lateral position under navigation guidance. This technique does not expose the surgeon or operating staff to radiation hazards.

Oblique lumbar interbody fusion (OLIF) is an established technique for the indirect decompression of lumbar canal stenosis. However, OLIF at the L5-S1 ...

Full Endoscopic Interlaminar Approach for Paracentral L5-S1 Disc Herniation

The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other conventional discectomy methods, including less traumatization of the soft tissues, fewer complication rates (dural injury, bleeding), rapid rehabilitation, quick return to daily life activities, and preferable cosmetic results. FEILA is a surgery with a relatively steep learning adaptation. Endoscopic surgery is a closed tubular approach, and all surgical maneuvers are performed within a uniportal single working channel. Also, the technique has not yet been standardized and well-documented. Therefore, the early learning stages of this technique may not be easy for most surgeons. Despite these, FEILA is easy, and the operation length is comparable to and even shorter than other techniques of lumbar discectomy. FEILA for lumbar discectomy could be considered a safe and effective alternative procedure for paracentral L5-S1 disc herniation. Here, we describe the technique of FEILA, including every cutoff step required to reach technical proficiency for surgeons who want to start applying this approach.

Here, we present a protocol to describe the full endoscopic interlaminar approach (FEILA) technique, including every cutoff step required to reach technical proficiency. FEILA is a surgery with a relatively steep learning adaptation. Despite this, any surgeon capable of microdiscectomy can perform FEILA with enough practice and suitable patient selection.

The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other ...

Application of Stand-Alone Oblique Lateral Interbody Fusion in L4-5 Lumbar Diseases

Lumbar spine diseases often cause lower back pain, lower extremity pain, numbness, and paresthesia. In severe cases, intermittent claudication may occur, affecting the quality of life of patients. Surgery is often required when conservative treatment fails, or when patients' symptoms become unbearable. Surgical treatments include laminectomy and discectomy, as well as interbody fusion. The main purpose of laminectomy and discectomy is to relieve nerve compression; however, recurrence is common due to spinal instability. Interbody fusion improves stability while relieving nerve compression and significantly reduces the risk of recurrence compared to non-fusion surgery. Nonetheless, conventionally posterior intervertebral fusion requires separation of the muscles to expose the operated segment, which causes more trauma to the patient. In contrast, the oblique lateral interbody fusion (OLIF) technique achieves spinal fusion with minimal trauma to the patients and shortens the recovery time. This article introduces procedures of stand-alone OLIF surgery performed in the lumbar spine, providing a reference for other spine surgeons.

This study describes the application of oblique lateral interbody fusion in lumbar spinal surgeries.

Lumbar spine diseases often cause lower back pain, lower extremity pain, numbness, and paresthesia. In severe cases, intermittent claudication may occur, ...

Oblique Lumbar Interbody Fusion at L5-S1 Segment Through an Approach Between the Psoas Muscle and the Great Vessels

Over the years, the oblique lateral interbody fusion (OLIF) technique has gained significant recognition for treating various spinal conditions in lumbar segments L2-L5. However, the adoption of OLIF for the L5-S1 segment has not been widely embraced by the spinal surgery community, given that significant concerns remain regarding the applicability of OLIF for lumbosacral fusion. In this study, a cohort of 20 patients underwent interbody fusion at the L5-S1 level using the OLIF technique through a single retroperitoneal oblique approach positioned between the Psoas muscle and the great vessels. The procedure involved discectomy and endplate preparation accomplished through a surgical window created on the anterolateral side of the L5-S1 disc. For secure interbody fusion cage placement, a supplementary cage insertion approach was employed. All patients were followed up for a minimum of 12 months. The mean preoperative visual analog scale (VAS) score for lower back pain was 6.3 &#177; 1.5 and experienced a significant reduction to 1.2 &#177; 0.8 at 12 months. The VAS score for lower limb pain significantly decreased from 5.6 &#177; 1.4 preoperatively to 0.8 &#177; 0.3 at 12 months after the surgery. Furthermore, the preoperative Oswestry disability index (ODI) improved from 82.4% &#177; 16.2% to 8.1% &#177; 2.0% at 12 months. Radiographic evaluations after surgery confirmed improved lumbosacral junction reconstruction for all patients. At the final follow-up, successful bony fusion was observed in all cases. Based on these findings, the OLIF technique for L5-S1 fusion represents an attainable approach for lumbosacral reconstruction. The procedure&#39;s success hinges on a comprehensive preoperative plan and precise intraoperative techniques.

The protocol presents an OLIF L5-S1 technique that offers a more feasible approach for lumbosacral fusion sharing a common surgical plane with OLIF L2-5. This facilitates reproducible multi-level interbody fusions extending from L2 to S1 through a retroperitoneal oblique corridor between the Psoas muscle and the great vessels.

Over the years, the oblique lateral interbody fusion (OLIF) technique has gained significant recognition for treating various spinal conditions in lumbar ...

Technique of Sagittal Adjusting Screw System for Thoracolumbar Burst Fractures

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the indication for surgical treatment of neurologically intact TL fractures remains under debate, studies have demonstrated that posttraumatic malalignment may lead to a deterioration in the patient&#39;s quality of life. For burst fractures with malalignment or fragments in the spinal canal, a reduction technique using ligamentotaxis is commonly used to improve long-term outcomes.
The sagittal adjusting screw (SAS) system is a monoaxial screw system with a fixed head and concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. SAS also has a percutaneous option and has been used for TL spine fractures. Notably, the SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction. The SAS has certain advantages over the conventional Schanz screw system or normal mono-/multiaxial pedicle screws for TL spine fracture treatment. In addition, specialized trauma reduction devices are available for the SAS system. In this video protocol, we discuss the indication for the SAS system in TL burst fracture and describe a technique of TL burst fracture reduction and fixation using the SAS system. Additionally, we describe our recent case series with radiological evaluation, including regional kyphotic angle and percent loss of anterior vertebral body height, to evaluate the newly introduced trauma reduction device.

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the ...

Surgical Approach and Complications of Stand-alone Lateral Trans-Psoas Interbody Fusion

Interbody fusion of the lumbar spine is a standard procedure for symptomatic degenerative lumbar spine disease if conservative treatment fails. Surgical decompression and fusion of the segment can be achieved using several different techniques. Over the last decades, minimally invasive techniques, such as lateral interbody fusion (LLIF), have been developed to reduce tissue damage and complications and allow quicker patient recovery. With growing popularity, indications for LLIF have expanded to treat spinal deformities and foraminal/central stenosis. Mechanically, it allows for an unsurpassed fixation through the left-to-right apophyseal ring placement of the cage. LLIF utilizes a minimally disruptive retroperitoneal corridor and includes both trans-psoas and pre-psoas approaches. For the pre-psoas approach, the risk of damage from manipulation of the intramuscular lumbar plexus is reduced compared to a trans-psoas approach. However, increased risks of major vascular, ureteral, bowel injury and sympathetic plexus damage are reported.
This article aims to provide a detailed and comprehensive guide on stand-alone lateral trans-psoas interbody fusion, including its indications, surgical procedure, potential complications, and outcomes based on a decade of experience from a single center.

Interbody fusion of the lumbar spine can be achieved surgically using different techniques. Minimally invasive techniques, including lateral interbody fusion, have been developed within recent decades to reduce rates of complications and allow for quicker patient recovery. We provide insight into stand-alone lateral trans-psoas interbody fusion, highlighting potential complications and pitfalls.

Interbody fusion of the lumbar spine is a standard procedure for symptomatic degenerative lumbar spine disease if conservative treatment fails. Surgical ...