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Mini open TLIF
This document describes the mini-open transforaminal lumbar interbody fusion (TLIF) technique. Key points include: 1. Mini-open TLIF provides the benefits of TLIF with less soft tissue disruption through a smaller incision and muscle splitting approach. 2. The technique involves facetectomy, bilateral decompression if needed, interbody cage insertion, and percutaneous pedicle screw fixation through tubular retractors. 3. Advantages over open TLIF include less blood loss, reduced postoperative pain, and shorter hospital stay. However, it requires microsurgical skills and has a steep learning curve.
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Presentation by Mohamed Mohi Eldin, highlighting Mini Open TLIF in neurosurgery.
Introduction of the muscle-splitting Wiltse Approach (1968), decreasing bleeding and enhancing access to lumbar spine.
TLIF provides anterior column support and excellent exposure with minimal nerve root risk.
Standard Open TLIF has negative outcomes due to large incisions, muscle dissection, and long recovery.
MISS aims for efficient target surgery with minimized trauma.
Introduction of Mini-TLIF as a significant technique in minimally invasive surgeries.
Described by Foley et al. (2003), Mini-TLIF reduces soft-tissue injury and is beneficial for revision patients.
Indications include discogenic pain, micro/macrostability issues, and recurrent disc herniation.
Benefits include minimal post-op pain, shorter hospital stays, less damage, and good cosmetic results.
Challenges include technical demands and a steep learning curve affecting operative time.
Key metrics include operative time, bleeding, ambulation start, transfusion rate, and complications.
Technique involves decompression, fixation, and fusion using minimal incision and tubular retractors.
Key details for planning skin incision for Mini-TLIF and its surgical placement.
Guidance for incision under fluoroscopy for lower lumbar fusions at L4-5 and L5-S1.
Emphasis on the correct approach to lumbar fascia and muscle separation to avoid lateral exposure.
Involves freeing attached muscle fibers and preparing for retractor insertion.
Details on using tubular retractors and identifying the pars for facetectomy safely.
Steps for cannulating pedicles and preparing interbody space for TLIF cage insertion.
Process of disc removal and managing nerve roots during cage insertion.
General guidelines for dealing with narrow disc spaces and spondylolisthesis cases.
Care needed during K-wire use post-facetectomy to prevent nerve root damage.
Describes the approach for bilateral decompression using tubular retractors.
Details on skin incisions for multi-level fusion and similarities to single segment fusion.
Discusses cement usage to augment spine stability in osteoporosis cases.
Comparison between minimally invasive and mini-open approaches in terms of decompression.
Challenges of CSF leaks in surgery and strategies for effective management.
Highlights the fusion results post-surgery and improvements in pain and appearance.
Essentials for success in Mini-TLIF include microsurgical skills and proper equipment.
Challenges include equipment needs, radiation exposure, and operative difficulties.
Reiterates the safety, challenges, and learning curve associated with Mini Open TLIF.
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Mini open TLIF
- 1. Mohamed Mohi Eldin Professorof Neurosurgery Cairo University Mini open TLIF
- 2. First described The paraspinalsacrospinalis muscle-splitting approach to the lumbar spine. With decreased bleeding Providing a more direct approach to the transverse processes and pedicles Wiltse Approach (1968)
- 3. TLIF Provides anterior columnsupport for fusion and instrumentation with only one approach via a transforaminal route Offers excellent exposure with minimal risk because of minimal retraction on the nerve roots and dural sac
- 4. Standard Open TLIF adverselyaffect short- and long-term patient outcomes large skin incisions, extensive muscle dissection long operation time, significant blood loss postoperative paraspinal muscle denervation
- 5. Target surgery One ofthe main goals of MISS is to do an efficient “target surgery” with a minimum of iatrogenic trauma
- 6. Mini-TLIF as aGateway Technique
- 7. Mini-TLIF First described byFoley et al. (2003) via local muscle splitting at the area of facetectomy and entry point of pedicle screws insertion significantly diminishes iatrogenic soft-tissue & facet injury.
- 8. Mini-TLIF Because minimal retractionon the nerve roots and dural sac, and lower risk of neurological deficit It also offers advantages in revision patients in whom scar tissue makes open techniques difficult.
- 9. Indications of Miniopen TLIF Discogenic pain due to decreased disc height Micro or macro instability. Recurrent disc herniation.
- 10. Advantages Without compromising theeffectiveness of the conventional fusion Minimal PO pain & hospital stay Unilateral exposure Less soft tissue damage Minimal blood loss Better cosmetic results
- 11. Disadvantages Technically demanding New Old When ? False negative Indifferentresult Positive result Increased operative time, Steep learning curve
- 12. Parameters of learningcurve • Length of operative time • Amount of bleeding Intraoperative Vac drain • Starting day of ambulation • Transfusion incidence • Occurrence of complications
- 13.
- 14. Procedure include Decompression thru tubularretractor Obliquely inserted TLIF cage fusion Percutaneous pedicle screw fixation
- 15. Planning the skinincision
- 16. Make the skinincision In the parasagittal plane of the pedicles under fluoroscopy. Typically, two fingerbreadths off of the midline . L4-5 fusion (black) L5-S1 fusion (blue) Four pedicles of interest L4-5 Mini-TLIF. Incision size is 3 cm
- 17. Pitfall 1 Lumbar fasciais incised in the plane of the skin incision Pitfall: Do not attempt to find and follow the plane between multifidus and longissimus. This would direct the exposure Too laterally.
- 18. Blunt separation oflongitudinal muscle fibers
- 19. Freeing of theattached muscle fibers
- 20. Prepare for retractor beforeinserting the mini-open retractor system Cut the musculotendinous attachments to the underlying bone
- 21. Retractor blades required Usethe smallest diameter tubular retractor blades required to provide the necessary exposure
- 22. Facetectomy Identify the parsbefore starting the facetectomy (high-speed drill/small osteotome)
- 23. Facetectomy Care should betaken when drilling the pars, as it overlies the exiting nerve root
- 24. Pedicle-to-pedicle exposure Care shouldbe taken when resecting the lateral edge of the lamina from a lateral approach A pedicle-to-pedicle exposure is obtained, exposing the traversing and exiting nerve roots and the disc space
- 25. Pedicle screws First thepedicles are only cannulated; (screw heads might impede access to the disc space)
- 26. Pedicle screws We donot place the pedicle screws until the interbody space is prepared and the TLIF cage is inserted
- 27. Disc Space Preparation Discincised and removed with shavers, rongeurs, and curettes Cartilagenous end plates removed without injuring the bony end plates. Interbody trials serially dilate the disc space.
- 28. Nerve roots Ligamentum flavumis removed piecemeal to expose nerve roots Lordotic cage is then selected with a secure fit, with the autograft packed in it. Nerve roots are visualized during CAGE insertion. Additional autograft is also packed within the disc space
- 29. For narrow discspaces Consider first inserting pedicle screws on the contralateral side and distracting them before inserting the TLIF implant.
- 30. For spondylolisthesis Consider firstinserting pedicle screws on the contralateral side and distracting them before inserting the TLIF implant
- 31. Pitfall 2 If aK-wire is to be used after a facetectomy keep in mind that the nerve roots are exposed and vulnerable. Initial placement of the K-wire should be visually guided
- 32. Spinal canal decompression byangling tubular retractor medially onto hemilamina
- 33. Bilateral decompression achieved byusing 2 sets of expandable tubular retractors in a mini-open fashion If further lordosis is needed: perform (Smith-Peterson osteotomy -SPO)- bilateral laminotomies with complete facetectomies).
- 34. Two levels fusionmini-TLIF The skin incisions extend to cover entry points of uppermost and lowermost pedicle screws indicated by fluoroscopy The lengths of skin incisions are 7 centimeters The fusion procedure is not different to one segment fusion
- 35.
- 36. MI versus mini-openapproach Selection is dependent on the need for unilateral versus bilateral decompression For bilateral decompression = bilateral mini-open approach. For unilateral decompression = minimally invasive technique with percutaneous pedicle screws
- 37. Durotomy - Pitfall3 CSF leaks can be difficult to repair. However, if encountered, close the dural defect primarily by A small needle driver and dural suture. A small piece of dural substitute and fibrin glue (seal) If necessary, a lumbar drain might be placed. One advantage of the smaller opening is decreased space for potential pseudomeningocele formation
- 38.
- 42. Image Documented fusion Absenceof halo around the screws presence of continuous trabecular bone bridge between the upper and lower body on x-ray films
- 43. Fusion 6 month postoperativeCT scan Fusion after 23rd month
- 44. More Results Reduction inintensity of postoperative pain, with much better cosmetic results
- 45. Tubular or speculum like retractor smalllateral skin incisions The Keys of Success Successful Mini-TLIFSuccessful Mini-TLIF The microsurgical skill of the surgeon Microscope, C- arm, and radiolucent table lamina-facet complex, transverse P. clearly identified
- 46. Problems you mayface 1. Radiolucent operative tables 2. Magnification and good illumination 3. A special retractor to work comfortably 4. If the axis line is more than 11 cm (process difficult) 5. Hard ware is expensive in relative to the conventional one 6. Radiation exposure
- 47. Summary and Conclusions Althoughthis technique can be safely applied in patients requiring decompression and fusion It is challenging and requires a steep learning curve to operate in the limited surgical field with microsurgical technique