Surgical Technique Ronnie I Mimran MD Danville CA

Surgical Technique Ronnie I. Mimran, MD Danville, CA PMD 009794 -2. 0

DLIF Vs. Oblique Lateral Technique Standard Oblique 1. Pre-op planning (X-Rays) 1. Pre-op planning (Axial MRI) 2. Needle electrode setup 3. Patient positioning 4. Fluoroscopic localization 5. Incision at Midbody 5. Incision 5 cm Anterior to Mid-Body 6. Dissection to psoas 7. Neuromonitor (through psoas) 7. Neuromonitor (Anterior to Psoas) 8. Dilation/Retractor placement 9. Fusion preparation (Laterally) 9. Fusion preparation (Orthogonally) 10. Trial/Distract – Implant (Orthogonally) 11. Closure 3 | MDT Confidential PMD 009794 -2. 0

Pre-op Planning Standard • Check for unfavorable anatomy (X-Rays) – High iliac crest at L 4 -5 – Long 11 th and 12 th ribs Oblique • Check for unfavorable anatomy (Axial MRI) – Kidneys – Irregular Vasculature 4 | MDT Confidential PMD 009794 -2. 0

Pre-op Planning Standard Vena Cava Oblique Vena Cava Aorta Psoas Standard Zone Right Aorta e. A u bliq O Psoas Left s s cce Psoas Right Left 5 | MDT Confidential PMD 009794 -2. 0

DLIF Vs. Oblique Positioning Standard Oblique • Put In Lateral Position with Right or Left Side Up • Axillary Roll and Pillows Between Arms and Legs • Break Bed at Patient’s Crest • Flex Both Hips and Knees • Surgeon Works at Anterior or Posterior Side of Patient • Put In Lateral Position ALWAYS Left Side Up • Axillary Roll and Pillows Between Arms and Legs • Do not have to break Patient on Bed • Patient Legs Can be Extended • Surgeon Works at Anterior Side of Patient 6 | MDT Confidential PMD 009794 -2. 0

Standard Oblique 7 | MDT Confidential PMD 009794 -2. 0

Tape Circumferential Around Bed Oblique C-Arm is Posterior Surgeons Stand Anterior Standard C-Arm is Anterior or Posterior Surgeons Stands Anterior or Posterior 8 | MDT Confidential PMD 009794 -2. 0

Patient Marking Incision 5 cm off of MAL Standard Oblique 9 | MDT Confidential PMD 009794 -2. 0

Skin Marking Standard Ant Oblique Post Ant Post 10 | MDT Confidential PMD 009794 -2. 0

Dissection down to the disc space – use finger to protect peritoneal membrane 15 | MDT Confidential PMD 009794 -2. 0

NIM® Probe Standard Oblique 16 | MDT Confidential PMD 009794 -2. 0

Dilation Oblique Standard 17 | MDT Confidential PMD 009794 -2. 0

Retractor Placement Standard Oblique 18 | MDT Confidential PMD 009794 -2. 0

Working Position Standard Oblique C-Arm Stationery C-Arm Moves Head Position Shoulder Hands Bending Erect 19 | MDT Confidential PMD 009794 -2. 0

SIGNATURE MOVE 20 | MDT Confidential PMD 009794 -2. 0

Orthogonal Maneuver Proper Placement of Retractor Allows for rotation of: - Disc Prep Instruments (still able to get to contralateral side of disc space - Trials - Implant 21 | MDT Confidential PMD 009794 -2. 0

OM – Disc Prep 22 | MDT Confidential PMD 009794 -2. 0

OM – Disc Prep 23 | MDT Confidential PMD 009794 -2. 0

OM – Disc Prep 24 | MDT Confidential PMD 009794 -2. 0

Distraction 25 | MDT Confidential PMD 009794 -2. 0

Distraction 26 | MDT Confidential PMD 009794 -2. 0

Distraction 27 | MDT Confidential PMD 009794 -2. 0

CLYDESDALE ® Spinal System Indications The CLYDESDALE® Spinal System is designed to be used with autogenous bone graft to facilitate interbody fusion and is intended for use with supplemental fixation systems cleared for use in the lumbar spine. The CLYDESDALE® Spinal System is used for patients diagnosed with degenerative disc disease (DDD) at one or two contiguous levels from L 2 to S 1. These DDD patients may also have up to Grade 1 Spondylolisthesis or retrolisthesis at the involved levels. DDD is defined as discogenic back pain with degeneration of the disc confirmed by history and radiographic studies. These patients should be skeletally mature and have had six months of non-operative treatment. These implants may be implanted via a minimally invasive lateral approach. 28 | MDT Confidential PMD 009794 -2. 0

The surgical technique shown is for illustrative purposes only. The technique(s) actually employed in each case will always depend upon the medical judgment of the surgeon exercised before and during surgery as to the best mode of treatment for each patient. Please see the package insert for the complete list of indications, warnings, precautions, and other important medical information. 29 | MDT Confidential PMD 009794 -2. 0