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Minimal invasive techniques in lumbar degenerative diseases
Minimally invasive techniques (MIT) are increasingly used to treat lumbar disc disease. They offer advantages over open surgery such as smaller incisions, less tissue damage, shorter recovery times, and lower risks. MITs include discography, epidural injections, facet/nerve blocks, nucleoplasty, kyphoplasty, tumor debulking, and interspinous spacers. They aim to diagnose and treat back pain conditions under local anesthesia or mild sedation using fluoroscopy guidance. MITs are generally low risk and allow many patients to be treated as outpatients or with only overnight hospitalization.
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Minimal invasive techniques in lumbar degenerative diseases
- 1. Minimally Invasive Techniques(MIT) in Management of Lumbar Disc Disease (New Trends in Spine Interventions) Mohamed Mohi Eldin Prof. of Neurosurgery, Faculty of Medicine, Cairo University
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- 6. Causes of Lowback Pain • Muscle Spasm • Disc herniation (bulge, protrusion, extrusion) • Annulus Fissures • Facet disease • Spinal Canal stenosis • Saco-iliac disease • Spondylolisthesis • V.C.F. (Osteoprosis, Tumours) • Biopyschosocial model
- 7. Back pain • Treatingback pain is a big problem. • 80% of all people will experience back pain in their life • Traditionally people fear back pain (? Paralysis ) • No proper consensus on best treatment.
- 8. History taking isthe most important part of Diagnosing the condition Changing the look to MRI ( how many MRIs formerly seen as –ve ?) Discogenic Pain Facetogenic Pain Foraminal Pain
- 9. Conservative treatment still first-line(8-10 Ws) Injections Nucleoplasty Endoscopic Approaches Percutaneous Techniques Microsurgical Techniques Open Surgery M O R E I N V A S I V E More Improvements Less Invasiveness
- 10. Definition of MIT •Treatment that requires no or minimal dissection or cutting. • Under Local anaesthesia, mild sedation or epidural. • Day case or one day hospitalisation. • Quick recovery and results. • Side effects are minimal or none. • Usually under fluoroscopy.
- 11. Role of MinimallyInvasive Interventions Many Minimally-Invasive Methods : 1. Discography 2. Epidural Injection 3. Facet / median nerve block and Ablation. 4. Selective Nerve root block 5. Sacro-iliac joint injection 6. Nucleoplasty 7. Vertebroplasty and Kyphoplasty 8. Cavity assisted Tumour Debulking 9. Percutaneous Intraspinous spacer 10. Percutaneous Spinal Fixation
- 12. General Contra-Indications toMIT • Conditions that require surgery • Progressive or Neurological Deficit • Evidence of Infection • Coagulopathy • Other disease causing the pain • Pregnancy.
- 13. Discography • Assessing discmorphology + pain response • More sensitive than MRI in detecting Fissure as a cause of LBP • 5 grades. Modified Dallas Classification
- 14. Facet joint &Median branch block • Diagnostic and Therapeutic • Intra or Extra- articular
- 15. Selective Nerve rootBlock • Injecting into the nerve root sleeve • SNRB has both diagnostic and therapeutic value
- 16. Epidural Injection • Betteroutcome with acute pain conditions than chronic pain. • Steroids inhibit the inflammatory process in the Epidural space arising from release of inflammatory mediators secondary to any pain generator.
- 17. Indications Interlaminar Epidural • Spinalcanal compromise • Disc Degeneration or herniation Transforaminal Epidural • Spinal root compression. • Spinal root Inflammation.
- 19. Sacroiliac Joint Injection •Another cause of LBP • Degenerative or Inflammatory • Difficult to diagnose Clinically • S-I joint injection is the best diagnostic tool • Plain x-ray is enough. • Intra-articular or Extra-articular injection. • Image Guidance is essential for accurate needle placement
- 20. NucleoplastyNucleoplasty (Percutaneous disc decompression)(Percutaneousdisc decompression) • Under mild sedation and LocalUnder mild sedation and Local • Day case.Day case. • Lasts 20-30 minutes.Lasts 20-30 minutes. • 17 Gauge needle17 Gauge needle • Ablation of Nucleous withAblation of Nucleous with coblation wand through thecoblation wand through the needleneedle
- 21. Indications: Radicular/Axial Symptoms: • Legpain or back pain • MRI evidence of contained posterior lateral focal disc protrusion • Failed conservative therapy or selective nerve root block (if this is done) • Mild or no Neurological deficit.
- 22. Contra-Indications • Disc height< 50% • Severe disc degeneration • Severe spinal stenosis • Progressive or severe Neurological Deficit • Disc occupying one-third or more of spinal canal • Non-contained disc. • Evidence of Infection or Coagulopathy • Age < 18 and > 65
- 23. Nucleoplasty (Experience) - IntroducedOct. 2005 - Chronic LBP, - Failed conservative therapy (8 – 12 weeks) - Contained disc protrusion - Lumbar discs (1-3 levels)
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- 33. Case 3 95% improvement.Walk next day. No leak95% improvement. Walk next day. No leak
- 34. Cavity Spine Wand •Has a bouquet of active electrodes at the tip – This is where the plasma is formed – The device ablates in a “forward motion” • Has an ‘S’ shaped tip to maneuver off-axis Active Electrodes Insulator Return Electrode
- 35. Cavity Tumor Procedure 1-Tumorin vertebral body 2- Insert Access Cannula
- 36. Cavity Tumor Procedure 3-Deploy cavity spinewand 4- Debulk Tissue to Create Void 5- Augment with Cement
- 39. Interspinous process-based DynamicStabilization Distraction (IPD) devices Indications 1. Stenosis: • Central, lateral and foraminal lumbar spinal stenosis with leg, buttock or groin pain, which can be relieved during flexion 1. Low Back Bain: • Facet syndrome due to facet osteoarthritis • Degenerative spondylolisthesis up to Grade I with hyperlordotic curve • DDD with retrolisthetis • Interspinous pain arising from (“Kissing Spines”)
- 40. In Lumbar CanalStenosis • Implants are placed between adjacent spinous processes • to act as physical blocks to extension (and thus lumbar canal narrowing) on standing or walking, relieving pressure on the nerves. • Play a role between medical symptom control and the more invasive procedure of laminectomy.
- 41. Principle of action •Flexion decreases the amount of stenosis by distracting the soft tissues – ligamentum flavum, – posterior annulus and – facet capsule • Therefore increasing the area of the spinal canal. • A correctly placed spacer mimics flexion at the implanted spinal segment. • This usually relieves the neurogenic claudication which improves a patient’s function.
- 42. The targets ofinterspinous spacers are the joints at the dorsal part of the column not the disc, which is located far away ventrally
- 43. Some Available Spacers Posteriorapproach Percutaneous, lateral approah X’Stop Diam Coflex Wallis
- 44. In-Space Percutaneous Interspinous Spacer(Synthes Spine) UndeployedUndeployed DeployedDeployed
- 45. The Diam System (MedtronicSofamor Danek, Memphis,Tennessee) • a deformable damper • made of silicone, • with a polyester jacket • designed with oversized wings, which contribute to the stability and performance of the implant • does not burn any bridges for potential surgeries in the future
- 46. The Coflex TitaniumSystem (Paradigm Spine, LLC, New York) • Functionally dynamic – Compressible in extension, allowing flexion – Increased rotational stability – Center of rotation close to spinal canal • Protection of posterior elements – Stress reduction on facet joints – Maintenance of foraminal height • Ease of use – Less invasive, tissue-sparing procedure – Easy and precise application
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- 51. Case 5454years:Spinal stenosis L4-L5years:Spinalstenosis L4-L5 VAS Back 5, VAS Leg 8, 50m, ODI 25/50VAS Back 5, VAS Leg 8, 50m, ODI 25/50
- 52. 3m FU: VASBack 3, Leg 3 ODI 15, Free Walking
- 53. Spinal stenosis /63 yearsSpinal stenosis / 63 years Case exampleCase example
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- 55. DDD with segmentalhyperlordosis / 41 yearsDDD with segmental hyperlordosis / 41 years Case exampleCase example
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- 57. Case example Soft disc/ 41 yearsSoft disc / 41 years
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- 59. Retrolisthesis / 53yearsRetrolisthesis / 53 years Case examplesCase examples
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- 61. Minimal Invasive SpinalSurgery • Allows for minimally invasive visualization • A series of soft-tissue dilators create a small tunnel through the muscles of the back • A tube is inserted to the level of the spinal column • Surgery can be guided by a video camera with magnifying lens and fiber- optic light source
- 62. Mini-TLIF (Transforaminal Lumbar InterbodyFusion) • Used in decompression procedures • Versatile instruments allow a surgeon to approach the spine using an open, mini-open or minimally invasive technique
- 63. PLIF Posterior Lumbar InterbodyFusion • DISC SPACE DISTRACTION
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- 67. Minimal Invasive SpinalSurgery Open • 6-8 inch incision • Tissues are separated and held apart during surgery • Hospital stay could be days Minimally Invasive • 1 inch incision • Tissues are left intact and split along natural divisions • Outpatient surgery for some
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