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Rome Rehabilitation 2011 XX Congresso Nazionale S.I.C.D.

Rome Rehabilitation 2011 XX Congresso Nazionale S.I.C.D. LA VIA ENDOSCOPICA INTRAFORAMINALE NEL TRATTAMENTO DELLE ERNIE DISCALI LOMBARI. Relatore : Luigi D’Orazio Medicina del dolore A.O. San Camillo-Forlanini. The TESSYS-Concept. Operation of lumbar disc herniations via

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Rome Rehabilitation 2011 XX Congresso Nazionale S.I.C.D.

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  1. Rome Rehabilitation 2011 XX Congresso Nazionale S.I.C.D. LA VIA ENDOSCOPICA INTRAFORAMINALE NEL TRATTAMENTO DELLE ERNIE DISCALI LOMBARI Relatore: Luigi D’Orazio Medicina del dolore A.O. San Camillo-Forlanini

  2. The TESSYS-Concept Operation of lumbar disc herniations via lateral, transforaminal, endoscopic Approach

  3. The TESSYS-Concept Indications Radiologic confirmation of lumbar herniated discs using MRI- or CT with clinical signs of nerve root compression

  4. Foraminal Approach: Lumbar Spine Hidden Zone Adjunct to Traditional Surgery • Preferred for foraminal and extraforaminal HNP • Allow access to these pain generators: • Disc • Exiting nerve • Traversing nerve • Epidural space • Superior facet • Axilla containing the DRG • Foraminal osteophytes Visualizes the “Hidden Zone” Foraminal of MacNab

  5. The TESSYS-Concept • Transforaminal puncture of the disc space at the medial pedicular plane • Entry point at the skin about 8 to 18 cm from the midline

  6. The TESSYS-Concept The direction of the trajectory depends on the specific localization of the disc herniation

  7. The TESSYS-Concept Discography or chromography and insertion of the guide wire

  8. The TESSYS-Concept • Stab incision at the entry point on the skin and • insertion of the guiding rod (angled or straight) into the neuroforamen

  9. The TESSYS-Concept If necessary enlargement of the neuroforamen using guiding tubes and crown reamers(5, 6.5, 7.5 mm Ø) to remove parts of the facet joint

  10. The TESSYS-Concept Advancement of fenestrated working tube (outer diameter 7.5 mm) over the red guiding tube and insertion of the foraminoscope

  11. The TESSYS-Concept • Viewing angle 30° • Outer diameter: 6,3 mm • Working channel: 3,7 mm • Length: 174 oder 208 mm

  12. The TESSYS-Concept • Removal of disc material using forceps • Application of the radiofrequency probe to arrest bleeding

  13. The TESSYS-Concept Anatomic considerations Neuroforamen Pedicle Facet joints Spinous process Spinal canal Disc space Thecal sac and nerve roots

  14. The TESSYS-Concept Anatomic considerations

  15. The TESSYS-Concept Radiologic landmarks

  16. The TESSYS-Concept Patient positioning In prone or lateral position in analgo-sedation or general anesthesia

  17. The TESSYS-Concept Requirement in the OR Radiolucent table and C-arc in ap and lateral view Optimal arrangement of monitors and instruments

  18. Amount of removed disc material

  19. Wound closure in subcutaneous fashion

  20. The TESSYS-Concept Limitations Massive deformity Spondylolisthesis Dorsal stenosis of the spinal canal Steep iliac crest for herniation at level L5/S1

  21. The TESSYS-Concept Limitations Massive deformity Spondylolisthesis Dorsal stenosis of the spinal canal Steep iliac crest for herniation at level L5/S1

  22. The TESSYS-Concept Limitations Massive deformity Spondylolisthesis Dorsal stenosis of the spinal canal Steep iliac crest for herniation at level L5/S1

  23. The TESSYS-Concept Limitations Massive deformity Spondylolisthesis Dorsal stenosisofthe spinal canal Steepiliaccrestfor herniationatlevel L5/S1

  24. The TESSYS-Concept VANTAGGI 1)Non problemi di sanguinamento 2) Ridotte complicanze( danno nervoso,trombosi,infezioni) 3) Possibile in paz. obesi< BMI 30-40 4) Riabilitazione più rapida 5) Nessuna formazione di aderenze post-operatorie 6) Anestesia locale e sedazione 7) Non crea instabilità 8) Consente di eseguire la foraminotomia 9(Day- Surgery) 10)E' una piattaforma per futuri trattamenti chirurgici discali

  25. Incidence of Complications 3.5% Yeung AT, Tsou PM :Spine Vol 27 April 2002 Gradual decrease with avoidance experience • Dysesthesias 5%-15% (Most common, usuallytemporary, notcompletelyavoidable!) • DRG, Circulatorychanges, furcalnerves, anomalousnerves • Persistentsensory deficit 1% • Persistentmotorweakness 2% • Discitis .03% • Duraltear 1% • Thrombophlebitis .5% • Bowelinjury 1/3,000 (.003%) • Vascularinjury 0% Duraltears do notneedrepair Due to no Surgicalapproach dissection

  26. CASISTICA The TESSYS-Concept L4-L5 10 F 7 M 3 L5-S1 5 F 2 M 3 Tot 15 Lateralità Dx 8 Sn 6 Mediana 1

  27. COMPLICANZE The TESSYS-Concept • Disestesie temporanee 1 (regredite con terapia medica) • Irritazione temporanea del nervo 1 • Interventi interrotti 1 (per anomalia del nervo • Interventi convertiti con altro approccio 1 ( approccio mediano per via endoscopica L5- S1)

  28. The TESSYS-Concept Conclusion • minimal invasivity • good clinical results • low complication rate • Due to: the Tessys-method represents an : attractiveandefficienttreatmentmodalityfor median toextraforaminalpositionedlumbardisc herniationsevenatthelevel L5/S1 andreducestheindicationfor „open“ discsurgery

  29. GRAZIE

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