Minimal Access Surgical Technique Transforaminal Lumbar Posterior Interbody

Minimal Access Surgical Technique Transforaminal Lumbar Posterior Interbody Fusion “MAST-TLIF” Patient Education Edition David P. Rouben, M. D. River City Orthopaedic Surgeons, PSC Louisville, KY

REALITY CHECK 8 out of 10 adults have back pain 85% suffer recurrences Back

Back Disorders: A Widespread Problem Key Points $80 billion in lost work & productivity u 175 million working days are lost annually due to chronic back pain u Significant improvement in outcomes in past decade u Choose Fusion 12 Million Impaired by Back Pain 45 Million with Back Pain Copyright 2003 Medtronic Sofamor Danek

Spine Anatomy Cervical = C 1 -C 7 Dura Dorsal/Thoracic = T 1 -T

Functions of the Spine Arc of motion in six Spatial Planes Flexion and Extension

Vertebral Structures (Axial View) Body Pedicle Transverse Process Vertebral Canal Lamina Spinous Process Articular

Structural Spinal Segment (Sagittal view) Vertebrae body above Disc Vertebral body below Copyright 2003

Intervertebral Disc Fibrocartilaginous joint of the motion segment Makes up ¼ the length of the spinal column Present at levels Cervical 2 to Lumbar 5 Allows compressive, tensile, and rotational motion Largest avascular structures in the body Copyright 2003 Medtronic Sofamor Danek

Intervertebral Disc Annulus Fibrosus l Outer portion of the disc l Made up of lamellae l Layers of collagen fibers l l Arranged obliquely 30° Reversed contiguous layers Great tensile strength Copyright 2003 Medtronic Sofamor Danek Annulus Fibrosus Lamellae

Intervertebral Disc Nucleus Pulposus l l Inner structure Gelatinous High water content Resists axial

Intervertebral Disc Largest structure without a true blood supply Blood supply by diffusion through end plates Even partial damage to the blood supply leads to dessication (so called degeneration) of the disc Copyright 2003 Medtronic Sofamor Danek

Spinal Ligaments Protect the Spinal Segment from excessive excursion Copyright 2003 Medtronic Sofamor Danek

Ligaments Posterior longitudinal ligament Anterior longitudinal ligament Ligamentum flavum Copyright 2003 Medtronic Sofamor Danek

The Most Common Spinal Disorders Producing Pain Acute strains and sprains -Muscle, ligament, joint capsule Spinal Segment Osteoarthritis – Facet Joint Disc strain-Annular Tear -progressing to Disc Protrusion-Extrusion-Sequestration Copyright 2003 Medtronic Sofamor Danek

Acute Strains and Sprains Cause Improper lifting, twisting, falls or other injuries Pathology Tearing, Stretching, and/or Separation of muscles or ligaments with commensurate Bleeding Treatment l l If minor injury, no more than two days of rest If severe injury, Progress to Physical therapy Copyright 2003 Medtronic Sofamor Danek

Disc Strain Pathology Annulus disruption/Chemical “itis” Pain will be often severe to the back and buttock as well as to the leg Treatment Restricted Activities for no more than 48 hours Anti-inflammatories, Muscle relaxants, analgesics Exercises- Physical Therapy Time and Patience-Usually Self-Limiting Copyright 2003 Medtronic Sofamor Danek

Annular Disruption/Tears “Disc Bulge” Copyright 2003 Medtronic Sofamor Danek

Disc Protrusion (Progressive Disc Strain) Annulus Tear becomes a Symmetric or Asymmetric Protrusion Copyright

Disc Extrusion Protrusions can Progress to become Disc Extrusions- nucleus comes through the annulus

Disc Sequestration Disc Extrusions can Progress to become Disc Sequestrationsnucleus material breaks free of

Lumbar Spinal Stenosis Cause A “Segment” Problem (vertebrae/Disc/vertebrae) Narrowing of the Central or Lateral canal or Foramina with neural root compression (squeezing the nerve) Pathology (what it is!) Thickening of the Ligamentum Flavum + Discal Compression+ Facet Arthropathy+ Intervertebral Collasp Treatment l l Anti-inflammatory medications, steroid injections, physical therapy Surgery may be necessary due to pain, lifestyle compromise, motor loss Copyright 2003 Medtronic Sofamor Danek

Spinal Stenosis Copyright 2003 Medtronic Sofamor Danek

SURGICAL OPTIONS Copyright 2003 Medtronic Sofamor Danek

Common Lumbar Surgical Options Decompressive Laminectomy/Laminotomy- remove bone and ligament or Add a Discectomy-remove disc material also Fusion-permanent bone connection l. Anterior-ALIF-exposure through front l. Posterior (Back side only)-Transverse Process/Facet- bone only l 360 Degree (both front and back sides)-TLIF-both disc space and bone l Minimally Invasive ( MAST) l OPEN access (traditional exposure) Copyright 2003 Medtronic Sofamor Danek

Laminotomy/ Laminectomy (bone and ligament removal) Copyright 2003 Medtronic Sofamor Danek

Anterior Lumbar Interbody Fusion (ALIF) The ALIF operation is performed with the patient lying on his or her back. Incision The surgeon makes an incision in the patient's abdomen to access the spine. To have a clear view of the spine, the surgeon then retracts the abdominal and vascular structures. Disc Removal Once the spine is in view, the surgeon removes a portion of the degenerated disc from the affected disc space. Copyright 2003 Medtronic Sofamor Danek

Transforaminal Lumbar Inter-Body Fusion “TLIF” Distraction Disk Removal Decortication Copyright 2003 Medtronic Sofamor Danek

TLIF FINAL CONSTRUCT Compression as final step Reconstructing normal alignment Copyright 2003 Medtronic Sofamor

MAST-TLIF Minimal Access Spinal Technology Transforaminal Lumbar Interbody Fusion Copyright 2003 Medtronic Sofamor Danek

MAST TLIF: Procedural Benefits Minimal Soft Tissue Dissection/ Retraction No Muscle Stripping Preservation of Posterior Elements Reduce Neural/Dural Retraction Ease of Revision “ 360 Degree” Fusion l Facet/ Transverse Process Copyright 2003 Medtronic Sofamor Danek

MAST TLIF ECONOMIC BENEFITS Hospital Stay Reduced Less Pain Fewer Medicines/Supplies l No Post op Transfusions l Reduced Rehabilitation Off Work Time Reduced l Reduced Drain on Societal Financial Resources Copyright 2003 Medtronic Sofamor Danek

MAST TLIF INDICATIONS Same as Open Technique l l HNP (Large Volume Extrusion) Intervertebral Collapse-Degenerative Instability l l l Traumatic Instability Recurrent Disc Surgery (Failed Disc) Grade I or II Spondylolisthesis Spinal Stenosis-Central or Lateral l Foraminal Stenosis One level/Bilateral Two level/Unilateral Discogenic Back Pain Copyright 2003 Medtronic Sofamor Danek

MAST TLIF: A System Assimilation SEXTANT™ Rod Insertion System l l CD-Horizon M-8 cannulated multi axial screws Pre-cut, pre-curved rods METRx™ System-Tube Access System l 26 mm cannula, 22 mm cannula, or X-Tube “DR SET #366”™ Instrument Set l Specially Modified Pyrametrix Advanced TLIF instruments Copyright 2003 Medtronic Sofamor Danek

SEXTANT: ROD INSERTION SYSTEM Copyright 2003 Medtronic Sofamor Danek

CD HORIZON® M-8 SEXTANT ROD/SCREW CONSTRUCT Copyright 2003 Medtronic Sofamor Danek

MAST™ TLIF DISC IMPLANT OPTION BOOMERANG + BMP + BONE CAPSTONE™ + BMP +

Identify Pedicle Location At Skin Level - Aim Pins or Medtronic PAK at Center of Each Pedicle Canal With C -Arm Via Oblique Angle - Mark Skin with Ink - Connect the Dots (Must be Straight Line) Copyright 2003 Medtronic Sofamor Danek

Use Multiple Angles of C-Arm X -ray Copyright 2003 Medtronic Sofamor Danek

Guide-Wire Insertion MAST™ TLIF: PERCUTANEOUS GUIDEWIRE INSERTION Copyright 2003 Medtronic Sofamor Danek

Pedicle Preparation Insert Tissue Dilators Over SEXTANT™ Guide Wire Then Tap using 5. 5

Technique The Rod Inserter is attached to the Screw Extenders The Rod Trocar is attached to the Inserter The thumb screw on the inserter is backed out until the black line appears. The thumb screw is depressed as the trocar is placed in the inserter. Tighten the thumb screw gently. Copyright 2003 Medtronic Sofamor Danek

Technique The Rod Trocar helps to make a path through the muscle and fascia

Technique While the Inserter is in the patient, the appropriate rod length can be

Technique The Rod is attached to the Rod Inserter and passed through the two

MAST™ TLIF: PERCUTANEOUS FIRST DILATOR INSERTION Copyright 2003 Medtronic Sofamor Danek

MAST™ TLIF SEQUENTIAL DILATION 26 mm TUBULAR RETRACTOR INSERTION Dock on Facet Copyright 2003

MAST™ TLIF BONY EXPOSUREinvolves LAMINOTOMY FORAMINOTOMY FACECTOMY Using the MAST TLIF Set #366 Incorporates

MAST™ TLIF DISC REMOVAL involves using the MAST TLIF Set #366 Incorporates technology developed

Distract Disc Space: Hold with Rod/Screws Already Inserted On the Other Side

MAST™ TLIF RESTORATION OF DISC SPACE HEIGHT Scissor Jack Distractor or Bullet Intra-Discal Distractors

Distract Disc Space/ Channel Cut Copyright 2003 Medtronic Sofamor Danek

Bone Morphogenic Protein (BMP) and Patient Bone put into Implant of Preference Copyright

Stabilize & Compress Construct Compressor Handles can be used to Distract Disc Space Initially

Final Construct Copyright 2003 Medtronic Sofamor Danek

Wound Closure Skin Glue Dry Telfa Dressing Water Occlusive Dressing OK TO SHOWER Copyright

MAST TLIF 6 WEEKS POST-OP All patients: l Driving l Sitting l Household chores

MAST TLIF REHAB PROTOCOL Rick Farley, P. T. STONESTREET PHYSICAL THERAPY Remember, All Activity Pre and Post Operatively should be Performed to Patient’s Tolerance Level. Sixteen Week Regimented Program begins on Post Op Day #7 Most Patients return to Work within 12 Weeks Copyright 2003 Medtronic Sofamor Danek

THE TRUE UNKNOWN What is the natural course of Disc Degeneration in Humans? No one really knows! Does Adjacent Level Degeneration caused by fusions really Exist? No one really knows this either! Copyright 2003 Medtronic Sofamor Danek