Lumbar spondylolisthesis MISS TLIF Case for plenary or

Lumbar spondylolisthesis (MISS TLIF) Case for plenary or small group discussions Presenter’s name Presenter’s title Author: Avelino Parajón, AOSpine MISS Taskforce Version: Jan 2020

Learning objectives • • Describe the indications and how to select the correct patient Discuss the decision making process for the specific procedure Outline important aspects of performing the procedure Recognize possible complications and how to avoid and manage them Author: Avelino Parajón, AOSpine MISS Taskforce

Presentation • • 66 -year-old woman Hypertension Lymphoma (controlled) Lung cancer (controlled) Neurogenic claudication Left leg pain Severe low back pain Rehabilitation, pain unit Author: Avelino Parajón, AOSpine MISS Taskforce

Imaging Author: Avelino Parajón, AOSpine MISS Taskforce

Previous treatment • • Physical therapy Pain unit Author: Avelino Parajón, AOSpine MISS Taskforce

Diagnosis • • L 4/5 spondylolisthesis and stenosis Neurogenic claudication Author: Avelino Parajón, AOSpine MISS Taskforce

Management plan/options • • • Nonoperative treatment Physiotherapy, pain management Surgery Interspinous spacer Laminectomy • Open vs MISS tubular: ULBD • Endoscopic Decompression and fusion • MISS TLIF • LLIF • Others? Author: Avelino Parajón, AOSpine MISS Taskforce

Treatment • MISS TLIF tubular approach (left side TLIF) Author: Avelino Parajón, AOSpine MISS Taskforce

Main surgical steps: contralateral screws Author: Avelino Parajón, AOSpine MISS Taskforce

Main surgical steps: ipsilateral screws Author: Avelino Parajón, AOSpine MISS Taskforce

Main surgical steps: discectomy, decompression, cage Author: Avelino Parajón, AOSpine MISS Taskforce

Main surgical steps - rod insertion and compression Author: Avelino Parajón, AOSpine MISS Taskforce

Main surgical steps – alternative - MISS TLIF with navigation Author: Avelino Parajón, AOSpine MISS Taskforce

Outcome • • • Surgery time skin to closure 1. 5 to 2 hours Minimal blood loss 2 -3 nights at hospital Neuro intact after surgery Postop 2 -3 months rigid orthosis Walking improved, pain resolved Author: Avelino Parajón, AOSpine MISS Taskforce

Patient selection • • • Patient complaints an patient imaging Stability Canal stenosis Foraminal stenosis (unilateral and/or bilateral) Previous surgery Comorbidities Author: Avelino Parajón, AOSpine MISS Taskforce

Potential complications and prevention • • • Dural tear and CSF leak Use ball tip nerve hook for dural sac dissection Protect dural sac during cage insertion Neural injury - very rare Avoid traction on nerve Protect nerve root during cage insertion Use navigation Pseudarthrosis Complete discectomy and adequate amount of bone graft in the disc space Consider different options of bone grafts Author: Avelino Parajón, AOSpine MISS Taskforce

Take-home messages • • • MISS TLIF via tubular retractor is safe and effective Can address bilateral pathology via unilateral approach Can achieve similar fusion rates to open TLIF Adherence to strict MIS techniques minimizes complications such as CSF leak, neural/vascular injury, infection, etc Navigation is an excellent tool to prevent malposition of implants and reduce radiation exposure to the surgical team Author: Avelino Parajón, AOSpine MISS Taskforce