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mINI -open Posterior Decompression & fusion with Percutaneous pedicle screw fixation

mINI -open Posterior Decompression & fusion with Percutaneous pedicle screw fixation. Hyeun Sung Kim, M.D., Ph.D. Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo-city. Introductions. Historical Evolution of Post. Instrumentation. 1’st Evolution.

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mINI -open Posterior Decompression & fusion with Percutaneous pedicle screw fixation

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  1. mINI-open Posterior Decompression & fusion with Percutaneous pedicle screw fixation Hyeun Sung Kim, M.D., Ph.D. Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo-city

  2. Introductions Historical Evolution of Post. Instrumentation 1’st Evolution • 1960s, Dr. Paul R. Harrington; Harrington Rods and Hooks • 1970s, Luque; Luque Rods and Rectangles Luque Rods Harrington Rods & Hook Mokpo Hanook Hospital Hyeun Sung Kim

  3. Introductions Historical Evolution of Post. Instrumentation 1’st Evolution Disadvantages • Instruments failure ---- rod breakage, hook dislocate, wire breakage • Insufficient stability • Insufficient correction • loss of correction • flat-back syndrome Mokpo Hanook Hospital Hyeun Sung Kim

  4. CD CCD Plumo-Winter-Byrd(PWB)System Dynalock Fixation System Fixateur Interne Edwards Modular System TSRH Louis System Isola/VSP System Rogozinski Spinal Rod System Simmons Plating System AMS Reduction Fixation System 4CIS Solar Introductions Historical Evolution of Post. Instrumentation 2’nd Evolution • 1987, Cotrel & Dubousset; Pedicle screw, Rod and Hook TSRH Dynalock fixation system Simmons plating system Rogozinski system AMS reduction system Isola/VSP system Fixateur Interne Louis system Plumo-Winter-Byrd(PWB) system Edwards modular system 4CIS Solar spine system Mokpo Hanook Hospital Hyeun Sung Kim

  5. Introductions Historical Evolution of Post. Instrumentation 2’nd Evolution Disadvantages • large skin incision •extensive muscle dissection • trauma to the lumbar musculoligamentous complex • long operation time •significant blood loss • significant postoperative pain • postoperative paraspinal muscle denervation Mokpo Hanook Hospital Hyeun Sung Kim

  6. Introductions Historical Evolution of Post. Instrumentation 3’rd Evolution Miniopen Decompression & Fusion • 1996, Leu HF & Houser RK; Perc. endoscopic lumbar spine fusion • 1998, Mathews HH; Percutaneous interbody fusions . . . • 2003, Foley KT; Minimally invasive lumbar fusion • 2006, Holly LT; TLIF: indications, technique and complications Mokpo Hanook Hospital Hyeun Sung Kim

  7. Introductions Miniopen Post. Decompression & Fusion Goals To reduce the approach-related morbidity associated with traditional lumbar fusion • minimal skin incision and anatomic dissection • minimal operation time • minimal blood loss & no transfusion • minimal postoperative pain • minimal hospital stay period • better cosmetic benefits Mokpo Hanook Hospital Hyeun Sung Kim

  8. Introductions Miniopen Post. Decompression & Fusion Types •Miniopen-PLIF •TLIF : midline incision : paramedian incision : stripping of m. origin : splitting of m. : interlaminar approach : transforaminal approach Mokpo Hanook Hospital Hyeun Sung Kim

  9. Introductions Miniopen Post. Decompression & Fusion Fixation methods •PPSF(Percutaneous Pedicle Screw Fixation) - using the Rod insertion system (Sextant, Apollon) - using the B-Twin ESS • PFSF (Percutaneous Facet Screw Fixation) Mokpo Hanook Hospital Hyeun Sung Kim

  10. Introductions Miniopen Post. Decompression & Fusion Applications •Spondylolisthesis grade I & II •Spinal stenosis •Instability •Fractures and Dislocations Mokpo Hanook Hospital Hyeun Sung Kim

  11. Purpose To • introduce of surgical technique • assess the safety, efficacy and results Mokpo Hanook Hospital Hyeun Sung Kim

  12. Materials & Methods Materials • From Jan. 2004 to Jul. 2007 • 145 cases : Miniopen-posterior decompression and fusion • Follow-up period : 1 – 4 yrs • Age : 23 – 78 years old (M ; 64) • Sex : 89 (F) / 56 (M) • Level : L4-5 (69 cases) L3-4 (26 cases) L5-S1 (23 cases) Thoracolumbar bursting fracture (13 cases) L3-4-5 (5 cases) L4-5-S1 (4 cases) L2-3 (4 cases) L2-3-4 (1 case) Mokpo Hanook Hospital Hyeun Sung Kim

  13. Materials & Methods Surgical Techniques 1. Skin incision - midline in 3-6 cm Mokpo Hanook Hospital Hyeun Sung Kim

  14. Materials & Methods Surgical Techniques 2. Dissection - stripping of origo-insertion of muscle - extend to facet joint Mokpo Hanook Hospital Hyeun Sung Kim

  15. Materials & Methods Surgical Techniques 3. Decompression (interlaminar approach) - supra & interspinous lig., below half of spinous process & lamina Mokpo Hanook Hospital Hyeun Sung Kim

  16. Materials & Methods Surgical Techniques 4. Disc preparation for fusion unilateral or bilateral Mokpo Hanook Hospital Hyeun Sung Kim

  17. Materials & Methods Surgical Techniques 5. Insertion of bone chips & cages - anterior & both lateral area in disc space Mokpo Hanook Hospital Hyeun Sung Kim

  18. Materials & Methods Surgical Techniques 6. Percutaneous pedicle screw fixation - using with Apollon rod insertion system Mokpo Hanook Hospital Hyeun Sung Kim

  19. Cases Case 1 : L4 Degnerative Spondylolisthesis grade I (M/65) Preoperative X-ray Preoperative MRI Postoperative 1yrs Postoperative 1st day Mokpo Hanook Hospital Hyeun Sung Kim

  20. Cases Case 2 : L4 Isthmic Spondylolisthesis Grade II without Osteoporosis(F/51) Preoperative X-ray, MRI Postoperative CT : 6months later Postoperative X-ray : 6months later Mokpo Hanook Hospital Hyeun Sung Kim

  21. Cases Case 3 : L4 Isthmic Spondylolisthesis Grade II with Osteoprosis (F/63) Preoperative X-ray, MRI Postoperative CT : 6 months later Postoperative X-ray : 6 months later Mokpo Hanook Hospital Hyeun Sung Kim

  22. Cases Case 4 : Unilateral Foraminal Stenosis with Instability : L4-5 (F/56) Preoperative X-ray, MRI Postoperative CT Mokpo Hanook Hospital Hyeun Sung Kim

  23. Cases Case 5 : Bilateral Foraminal Stenosis with Instability : L3-4-5 (F/60) Preoperative X-ray Preoperative MRI : Rt. : Lt. Postopertative X-ray Postopertative CT Mokpo Hanook Hospital Hyeun Sung Kim

  24. Cases Case 6 : T10 Bursting fracture (F/23) : Percutaneous Screw Fixation Preoperative X-ray, CT, MRI PostoperativeX-ray, CT, MRI : 6 months later Postoperative Skin Scar Mokpo Hanook Hospital Hyeun Sung Kim

  25. Cases Case 7 : T12 Bursting fracture with Osteoporosis (F/58) Postoperative X-ray, CT : 6 months later Mokpo Hanook Hospital Hyeun Sung Kim

  26. Cases Case 8 : T12 Pyogenic spondylitis(69/M) Preoperative X-ray, MRI PostoperativeX-ray Mokpo Hanook Hospital Hyeun Sung Kim

  27. Results Assessments for Results • Mean op time • Pre & Post-op blood loss • Risk of blood transfusion • Post-op back pain (total narcotics use) • Duration of hospital stay • Post-op surgical scar • Clinical outcomes (by McNab’s criteria) • Radiological results • Complications Mokpo Hanook Hospital Hyeun Sung Kim

  28. Results Clinical Results Compare Miniopen-PLIF with Conventional PLIF Miniopen-PLIFConven- PLIF • Mean op time 135 mins (100-185) 150 mins(120-215) • Pre & Post-op blood loss 240 ml(160-390) 420 ml(300-580) • Risk of blood transfusion No 2 - 4 pints • Post-op back pain 4 days 7days (total narcotics use) • Duration of hospital stay 7 days (5-14) 12 days (7-21) • Post-op surgical scar Satisfactory Unsatisfatory • Clinical outcomes 95 % 93 % (Excellent & Good) (by McNab’s criteria) Mokpo Hanook Hospital Hyeun Sung Kim

  29. Results Radiological Results • At last follow-up, all patients had solid fusions. •The period for fusionwas not different between Mini-open PLIF and Conventional PLIF. Mokpo Hanook Hospital Hyeun Sung Kim

  30. Results Complications • 2 cases of screw malposition (at the early learning period) Mokpo Hanook Hospital Hyeun Sung Kim

  31. Conclusions Miniopen-PLIF with PSF •is safe and efficacious method • has more advantages than the conventional PLIF1. minimizing destruction to adjacent tissue 2. decreased blood loss & risk of transfusion 3. decreased postoperative pain 4. decreased total narcotics use 5. decreased medical morbidity 6. shorter hospital stay period 7. better cosmetic Mokpo Hanook Hospital Hyeun Sung Kim

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