Minimally Invasive Spine Surgery Techniques, Evidence, and Controversies

AOS_MISS_Book.
indb 2 10/30/12 11:08 AM

Roger Härtl | Andreas Korge
Minimally Invasive Spine Surgery

Techniques, Evidence, and Controversies
AOS_MISS_Book.indb 1 10/30/12 11:08 AM

Roger Härtl | Andreas Korge
Minimally Invasive Spine Surgery

Techniques, Evidence, and Controversies
711 illustrations and images, and 35 cases.

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Foreword
Foreword
John K Webb FRCS incisions, while other chapters describe very innovative ap-
Consultant Spinal Surgeon proaches. It is pleasing to see that the basic AOSpine surgi-
Centre for Spinal Surgery and Research cal principles have been taken into account when formulat-
University Hospital ing the approaches. Even with the drive for all approaches
Nottingham NG7 2UH to be minimal, authors include a realistic valuation that, in
United Kingdom some cases, MISS techniques could be inappropriate.
Co-founder and first President of AOSpine Radiation exposure is a concern and should be closely mon-
itored.
The book is a comprehensive coverage of all techniques in

minimally invasive spine surgery. A word of caution, some
The authors are to be congratulated on producing such a approaches are very complex and the surgeon will have to
comprehensive book on minimally invasive surgical tech- be highly skilled, requiring three-dimensional thinking; such
niques. They stress that access strategies should not com- techniques may be out of reach for lesser mortals. Never-
promise the goal of the surgical procedure, the importance theless, the descriptions, pictures, and diagrams are excel-
of the knowledge of the anatomical planes, and an appre- lent and have made the understanding of the approaches
ciation of the anatomy from the experience of performing very clear.
open procedures. They accept there is a long learning curve
and correctly recommend a strategy of performing more This book is beautifully produced and written to a very high
straightforward cases at the beginning of a surgeon´s intro- standard, a standard one would expect from such eminent
duction to minimally invasive surgery. A concept that many surgeons.
inexperienced surgeons find difficult to acknowledge.
I strongly recommend Minimally Invasive Spine Surgery—
The importance of the four “pillars” of MISS are emphasized: Techniques, Evidence, and Controversies to all current and
microsurgical techniques; access strategies to the spine; im- up-and-coming spine surgeons developing their minimally
aging/navigation techniques; and specialised instruments invasive surgical techniques. I would go so far as to say this
and implants. Some chapters use standard approaches that, is “a must have” book for such surgeons. In fact, it should
with recent technology, have been reduced to very small be on the bookshelf of all spine surgeons.

Dedication
Dedication
To Alasha, Sebastian and Julian.

To Heidrun, Louisa and Daniel.
For all their love, support, understanding and patience,

without which, this book would not have been possible.
VI Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

Acknowledgments
Acknowledgments
We would like to thank the many authors, educators, il- • Marilyn Schreier from Syntax language editing
lustrators, designers, project managers, and technical and • Jecca Reichmuth for scientific illustrations and Roger
administrative contributors that worked tirelessly to bring Kistler for typesetting
this publication to life. • Carl Lau, Cristina Lusti, and Susanne Klein for proof-
reading, and for Susanne's essential administrative work
• Jeff Wang, Khai Lam, and Frank Kandziora, the original (keeping track of our world traveling authors)
members of the expert group team (together with Rog- • Patrick Hiltpold from AO CID for compiling the evidence-
er Härtl and Andreas Korge) for bringing together the based summaries and PICO analyses
ideas for the book • Rosalie Villano from Leica Microsystems, Thomas Kienzle
• Our illustrious team of authors, from all corners of the from Richard Wolf Medical Instruments, and Drew
world, many juggling professorial and academic posi- Messler from Micro Image Technologies for supplying
tions, and or very busy medical and surgical practices photos and images
• Kathrin Lüssi and Patricia Codyre and the entire AO • Thieme publishing
Education team, led by Urs Rüetschi
• Claas Albers from AOTK; and the AOSpine team, led by Roger Härtl
Alain Baumann Andreas Korge
• Amber Parkinson and Michael Gleeson, Project Coor-
dinators
VII

Introduction
Introduction
This is the first edition of “Minimally Invasive Spine Sur- Thoracic Techniques, and Lumbar Sacral Techniques—both
gery—Techniques, Evidence, and Controversies”. The idea posterior and anterior. This comprehensive book not only
for the book came out of our work in the AOSpine Expert provides basic concepts, and the latest clinical and scien-
Group on MISS and Navigation, around 2008, where we tific research, but it is also case-based with clear photographs,
enthusiastically discussed many of the initial hopes and x-rays, MRI, CT scans, and illustrations of anatomy and
controversies that surrounded the evolving field of MISS cases, giving the reader an excellent understanding of the
with our esteemed colleagues Jeff Wang, Khai Lam and decision-making process, as well as the whole surgical pro-
Frank Kandziora. It was clear to all of us that MISS offered cedure from preoperative planning to recovery.
exciting and potentially effective treatment strategies for
many areas in spinal surgery. However, it also seemed to In the end, several conclusions can be drawn:
be heavily dominated by a small number of champion sur- • MISS is here to stay; it is a logical consequence of the
geons and steered by industry, and not necessarily by the evolution of surgery, based on advances in at least four
needs of our patients. As a consequence, we embarked on areas: microsurgery, navigation, new spinal access strat-
an ambitious project to critically explore the possibilities, egies, and spinal instrumentation
the current reality, but also the limitations of MISS. • MISS offers alternative and frequently advantageous
treatment options in all regions of the spine, and for most
The final product has greatly surpassed our initial expecta- pathologies; it expands our technical capabilities as sur-
tions. We proudly present a comprehensive, user-friendly geons and frequently allows the safer and more effective
and didactic overview of the techniques, indications and treatment of patients that were previously not considered
controversies of currently utilized minimally invasive tech- good surgical candidates for a particular operation
niques and spinal navigation in the cervical, thoracic and • More work is needed; especially in the area of spinal
lumbar spine for a wide variety of spinal disorders. We deformity correction. The success of minimally invasive
include critical discussions of the pros and cons of these spine surgery will depend on the integration of scien-
techniques for our patients, and provide an objective, evi- tific progress, technical expertise, and the surgeon’s
dence-based framework of MISS using currently published individual experience and good judgment
literature. We also acknowledge the importance of the sur- • Surgeons have to be willing to learn and evolve; they
geon’s individual experience and wisdom by including sur- have to continue to critically and honestly evaluate the
gical pearls and “tips and tricks” from master surgeons and pros and cons of MISS as well as their own results in
many of the pioneers of MISS. each patient.
The book has been divided into five sections that together We hope that neurological and orthopedic spine surgeons
cover all areas of MISS: In the “Fundamentals” section, we all around the world can benefit from this first edition of
explore the principles of MISS, its historical development “Minimally Invasive Spine Surgery—Techniques, Evidence,
as a consequence of advances made in various subspecialties and Controversies” to improve care of their patients.
within surgery, and how its principles perfectly fit the “AO
philosophy”. The sections following cover technical proce- We are thankful to our colleagues, families and AOSpine
dures and the science behind particular MISS approaches for the unconditional and enthusiastic support they have
based on the anatomic regions: Cervical Techniques, given us throughout the preparation of this book.
VIII Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

Contributors
Contributors
Editors
Roger Härtl, MD Andreas Korge, MD

Leonard and Fleur Harlan Clinical Scholar in Head of Department
Neurological Surgery Spine Center
Associate Professor of Neurological Surgery Schön Klinik München Harlaching
Director of Spinal Surgery Harlachinger Strasse 51
Department of Neurological Surgery 81547 München
Weill Cornell Brain & Spine Center Germany
Starr Building, Room 651
525 East 68th Street
New York, New York 10021
USA
Authors
Beejal Y Amin, MD Ali A Baaj, MD Rahul Basho, MD

Assistant Professor Assistant Professor Clinical Instructor of Spine Surgery
Department of Neurosurgery Director, Spine Surgery Program Department of Orthopaedic Surgery
Loyola University Division of Neurosurgery Riverside County Regional Medical Center
Chicago, IL University of Arizona 26520 Cactus Avenue
USA 1501 Campbell Ave Moreno Valley, CA 92555
Tucson, AZ 85724 USA
Neel Anand, MD USA
Director, Orthopaedic Spine Surgery Minimally Invasive Rudolf W Beisse, Prof Dr
Spine Surgery Gopalakrishnan Balamurali, FRCS Neuro Chief Surgeon
Director, Orthopaedic and Neurosurgery Spine Fel- Consultant Spine and Neurosurgeon Department of Spine Surgery
lowship Department of Orthopaedics, Accident and Spine St Benedict´s Hospital
Spine Center, Cedars-Sinai Medical Center Surgery Bahnhofstrasse 5
444 South San Vicente Boulevard, #800 Ganga Hospital 82327 Tutzing
Los Angeles, CA 90048 Coimbatore, Tamil Nadu Germany
USA India
Oheneba Boachie-Adjei, MD
Vijay Anand, MD FACS Eli M Baron, MD Chief, Scoliosis Service
Clinical Professor of Otolaryngology-Head and Neck Board Certified Neurosurgeon Hospital for Special Surgery
Surgery Spine Surgeon 535 East 70th Street
Weill Cornell Medical College Cedars-Sinai Spine Center New York, NY 10021
New York Presbyterian Hospital 444 South San Vicente Boulevard, Suite 800 Professor of Orthopaedic Surgery
Weill Cornell Medical Center Los Angeles, CA 90048 Weill Medical College of Cornell University
New York, NY USA USA
USA
IX

Contributors
Bronek Boszczyk, PD Dr med Richard G Fessler, MD, PhD Paul F Heini, Prof Dr med
Consultant Spinal Surgeon & Head of Service Professor Spine Service
The Centre for Spinal Studies and Surgery Department of Neurosurgery, Suite 2210 Klinik Sonnenhof
Honorary Clinical Associate Professor Division of 676 North St. Claire Avenue Buchserstrasse 30
Orthopaedic and Accident Surgery Chicago, IL 60611 3006 Bern
Queen’s Medical Centre Campus, Derby Road, West USA Switzerland
Block D Floor
Nottingham University Hospitals NHS Trust Daniel Gelb, MD Paul S Issack, MS, MD, PhD
Nottingham, NG7 2UH Associate Professor and Vice Chairman Chief, Division of Adult Reconstructive Surgery
United Kingdom Department of Orthopaedics New York Downtown Hospital
University of Maryland School of Medicine 170 William Street, 8th Floor
Salvador A Brau, MD, FACS 22 South Greene Street New York, NY 10038
Director – Spine Access Surgery Associates S 11B Clinical Assistant Professor of Orthopaedic Surgery
Visiting Clinical Assistant Professor of Surgery – Keck Baltimore, MD 21201 Weill Medical College of Cornell University
School of Medicine – USC USA USA
Instructor in Surgery – Geffen School of Medicine –
UCLA Alex Gitelman, MD Andrew James, Dr
Los Angeles, CA 90095 ULCA Spine Center Leeds General Infirmary
USA 1250 16th street Leeds Teaching Hospitals NHS Trust
Ste 715 Great George Street
Dean Chou, MD Santa Monica, CA 90404 Leeds
Associate Professor of Neurosurgery USA West Yorkshire
Associate Director of Spine Tumor Surgery LS1 3EX
Department of Neurosurgery Patrick Hahn, Dr med United Kingdom
505 Parnassus Avenue, Box 0112 Center for Spine Surgery and Pain Therapy
San Francisco, CA 94143 Center for Orthopaedics and Traumatology Sheila Kahwaty, Physician Assistant-Certified
USA St Anna Hospital Herne Cedars-Sinai Medical Center
Hospitalstrasse 19 8700 Beverly Boulevard
Michelle J Clarke, MD 44649 Herne Los Angeles, CA 90048
Assistant Professor of Neurosurgery Germany USA
Mayo Clinic School of Medicine
200 First Street SW, Roger Härtl, MD Iain H Kalfas, MD
Rochester, MN 55905 Leonard and Fleur Harlan Clinical Scholar in Department of Neurosurgery
USA Neurological Surgery Cleveland Clinic
Associate Professor of Neurological Surgery 9500 Euclid Avenue
Mark B Dekutoski, MD Director of Spinal Surgery Cleveland, OH 44195
Department of Orthopaedic Surgery Department of Neurological Surgery USA
Associate Professor of Orthopaedics Weill Cornell Brain & Spine Center
Mayo Clinic School of Medicine Starr Building, Room 651 Frank Kandziora, MD, PhD
200 First Street Southwest, 525 East 68th Street Zentrum für Wirbelsäulenchirurgie und Neurotrauma-
Rochester, MN 55905 New York, New York 10021 tologie
USA USA Berufsgenossenschaftliche Unfallklinik
Friedberger Landstraße 430
Eric H Elowitz, MD Franziska C Heider, MD 60389 Frankfurt am Main
Weill Cornell Medical College Spine Center Germany
525 East 68th Street Schön Klinik München Harlaching
Starr 651, Box 99 Harlachinger Strasse 51
New York, NY 10065 81547 München
USA Germany
X Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

Contributors
Rishi Mugesh Kanna, MS, MRCS, FNB Kuansongtham Verapan, MD John McCormick, MD
Associate Consultant Spine Surgeon Director of Bumrungrad Spine Institute, Neurological and Orthopaedic Surgery
Department of Orthopaedics, Accident and Spine Bumrungrad International Hospital, University of Virginia
Surgery Bangkok Charlottesville, Virginia 22908
Ganga Hospital Thailand USA
Coimbatore, Tamil Nadu
India Khai Lam, MD Paul C McCormick, MD, MPH, FAANS
Spinal Unit, Orthopaedic Department Herbert and Linda Gallen Professor of Neurological
Manish K Kasliwal, MBBS, MCh 1st Floor Bermondsey Wing Surgery
Spine Fellow Guy’s Hospital Columbia University College of Physicians and
Department of Neurosurgery & Orthopaedics St Thomas’ Street Surgeons
University of Virginia London, SE1 9RT 710 West 168th Street
Charlottesville, VA 22908 United Kingdom New York, NY 10032
USA USA
Rondall K Lane, MD, MPH
Babak Khamsi, MD Assistant Professor in Residence Christoph Mehren, MD
Spine Fellow UCSF School of Medicine Head of Department
UCLA School of Medicine Department Anesthesia/Perioperative Care Spine Center
UCLA Spine Center 1600 Divisadero Street Schön Klinik München Harlaching
1250 16th Street, Suite 745 San Francisco, CA 94143 Harlachinger Strasse 51
Santa Monica, CA 90404 USA 81547 München
USA Germany
Jeremy Lieberman, MD
Mark Kleinschmidt, Dr med Professor Mark M Mikhael, MD
Spine Service Chief, Division of Spine Anesthesia Spine Surgery – Orthopaedic Surgery
Klinik Sonnenhof Department of Anesthesia & Perioperative Care Illinois Bone and Joint Institute, LLC
Buchserstrasse 30 Box 0648, Room C-450 2401 Ravine Way, Suite 200
3006 Bern 521 Parnassus Avenue Glenview, IL 60025
Switzerland UCSF USA
San Francisco, CA 94143
Martin Komp, Dr med USA Osmar JS Moraes, MD
Center for Spine Surgery and Pain Therapy R. Maestro Cardim 592
Center for Orthopaedics and Traumatology Steven C Ludwig, MD 11 andar
St Anna Hospital Associate Professor and Chief of Spine Surgery Sao Paulo, SP
Hospitalstrasse 19 Director of Spine Surgery Fellowship 02313001
44649 Herne Department of Orthopaedics Brazil
Germany University of Maryland Medical Center
22 South Greene Street Yaron A Moshel, MD, PhD
Andreas Korge, MD Suite 22 SB Assistant Professor
Head of Department Baltimore, MD 21201 Thomas Jefferson University
Spine Center USA Department of Neurological Surgery
Schön Klinik München Harlaching Division of Neuro-Oncology
Harlachinger Strasse 51 H Michael Mayer, MD, PhD 909 Walnut Street, 2nd Floor
81547 München Head of Department Philadelphia, PA 19107
Germany Spine Center USA
Schön Klinik München Harlaching
Harlachinger Strasse 51
81547 München
Germany
XI

Contributors
Praveen V Mummaneni, MD Noel I Perin, MD, FRCS(Ed) Sebastian Ruetten, Priv.-Doz. Dr med habil, MD
Associate Professor and Vice-chairman Professor Neurosurgery Head Department of Spine Surgery and Pain Therapy
Department of Neurosurgery Department of Neurosurgery Center for Orthopaedics and Traumatology
Co-director UCSF Spine Center Suite 8-S St Anna Hospital Herne
University of California, San Francisco NYU Medical Center Hospitalstrasse 19
505 Parnassus Ave, M779 530, 1st Avenue 44649 Herne
San Francisco, CA 94143 New York, NY 10016 Germany
USA USA
Rajiv Saigal, MD, PhD
Eric W Nottmeier, MD Mark Pichelmann, MD PGY-3, Department of Neurological Surgery
Adjunct Associate Professor of Neurosurgery Assistant Professor of Neurosurgery University of California, San Francisco
Mayo Clinic College of Medicine Mayo Clinic School of Medicine 505 Parnassus Avenue, M779
Neurosurgeon, 200 First Street Southwest, San Francisco, CA 94143
St Vincent’s Spine and Brain Institute Rochester, MN 55905 USA
4205 Belfort Road, Suite 1100 USA
Jacksonville, FL 32216 Walter Saringer, Prof Dr med
USA Luiz Pimenta, MD Medizinische Universität Wien
Instituto de Patologia da Coluna Spitalgasse 23
Alfred T Ogden, MD Specialist in minimally invasive spine surgery 1090 Wien
Assistant Professor of Neurological Surgery Rua Vergueiro no 1.421, sala: 305 Austria
The Neurological Institute São Paulo – SP
Columbia University Brazil Philipp Schleicher, Dr
710 West 168th Street Leiter Biomechaniklabor
New York, NY 10032 Shanmuganathan Rajasekaran, Dr, PhD Zentrum für Wirbelsäulenchirurgie und
USA Ganga Hospital Neurotraumatologie
313 Mettupalayam Road Berufsgenossenschaftliche Unfallklinik Frankfurt am
Sylvain Palmer, MD, FACS Coimbatore 641043 Main
Neurological Surgery Medical Associates India Friedberger Landstrasse 430
Orange County Neurosurgical Associates 60389 Frankfurt am Main
26732 Crown Valley Parkway, Suite 561 Marcus Richter, MD Germany
Mission Viejo, CA 92651 Chefarzt des Wirbelsäulenzentrums
USA Facharzt für Orthopädie Meic H Schmidt, MD, FACS
Facharzt für Orthopädie und Unfallchirurgie Ronald I Apfelbaum Endowed Chair in Spine Surgery
Luca Papavero, Prof Dr med St Josefs-Hospital Associate Professor and Chief
Clinic for Spine Surgery, Beethovenstrasse 20 Division of Spine Surgery
Schön Klinik Hamburg-Eilbek, 65189 Wiesbaden Department of Neurosurgery
Dehnhaide 120, Germany Clinical Neurosciences Center
22081 Hamburg Director, Spinal Oncology Service
Germany Daniel Riew, MD Huntsman Cancer Institute
Mildred R Simon distinguished Professor of Orthopaedic University of Utah
Sompoch Paiboonsirijit, MD Surgery 175 N Medical Drive East
Vice Chairman Professor of Neurological Surgery Salt Lake City, UT 84132
Department of Orthopedic Surgery Chief, Cervical Spine Surgery USA
Bumrungrad Spine Institute McDonnell International Scholars Academy Ambassador
Bumrungrad International Hospital, Suite 11, 300 Pavillion
Bangkok One Barnes-Jewish Plaza
Thailand St. Louis, MI 63110
USA
XII Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

Contributors
Theodore H Schwartz, MD, FACS Nicholas Slimack, MD Jeffrey C Wang, MD

Professor of Neurosurgery PGY-6 Resident Professor of Orthopaedics and Neurosurgery
Departments of Neurological Surgery, Neurology Department of Neurological Surgery UCLA School of Medicine
Neuroscience and Otolaryngology Northwestern University UCLA Spine Center
Weill Cornell Medical College Chicago, IL 60611 1250 16th Street, Suite 745
New York Presbyterian Hospital USA Santa Monica, CA 90404
525 East 68th Street, Box #99 USA
New York, NY 10065 Volker Sonntag, MD
USA Vice Chairman, Department of Neurological Surgery Michael Y Wang, MD, FACS
Barrow Neurological Institute Associate Professor
Christopher I Shaffrey, MD, FACS 350 West Thomas Road Departments of Neurological Surgery & Rehabilitation
Harrison Distinguished Professor Phoenix, AZ 85013 Medicine
Neurological and Orthopaedic Surgery USA University of Miami Miller School of Medicine
University of Virginia Lois Pope LIFE Center, 2nd Floor
Charlottesville, VA 22908 John Stark, MD 1095 Northwest 14th Terrace (D4-6)
USA Back Pain Clinic Miami, FL 33136
The Medical Arts Building USA
Ajoy Prasad Shetty, MS DNB Ortho 825 Nicollet Mall, Suite 715
Consultant Spine Surgeon Minneapolis, MN 55402 Jean-Paul Wolinsky, MD
Department of Orthopaedics, Accident and Spine USA Associate Professor of Neurosurgery and Oncology
Surgery Clinical Director of the Johns Hopkins Spine Program
Ganga Hospital Lukasz Terenowski, MD Johns Hopkins Hospital
Coimbatore, Tamil Nadu The Prof Alfred Sokolowsiki Memorial Specialistic 600 North Wolfe Street, Meyer 7.109
India Hospital Baltimore, MD 21287
Department VI of Traumatic and Orthopaedic Surgery USA
Patrick Shih, MD uliza Alfreda Sokołowskiego 11
Department of Neurological Surgery 70-001 Szczecin – Zdunowo James Zucherman, MD
Northwestern University Poland St Mary’s Spine Center
Feinberg School of Medicine One Shrader Street, Suite 450
676 N. St. Clair St., Suite 2210 William D Tobler, MD San Francisco, CA 94117
Chicago, IL 60611 The Christ Hospital USA
USA 2123 Auburn Avenue, Suite 441
Cincinnati, OH 45219
USA
Juan S Uribe, MD
Assistant Professor
Director, Spine Section
Department of Neurological Surgery
University of South Florida
Tampa, FL 33620
USA
XIII

Table of contents
Table of contents
Foreword V
Dedication VI
Acknowledgements VII
Introduction VIII
Contributors IX
Table of contents XIV
Definition of the different classes of evidence table XVI
1 Fundamentals 1 2 Cervical techniques 105
1.1 The definition of minimally invasive spine surgery 3 2.1 Introduction 107
and the rationale for its use
2.2 Posterior foraminotomy 109
1.2 Minimally invasive spine surgery and AOSpine 13
2.3 Anterior foraminotomy: microsurgical and 121
principles
endoscopic procedures
1.3 The four pillars of minimally invasive spine surgery 23
2.4 Posterior C1/2 transarticular screw fixation 135
1.4 Evidence-based medicine and minimally invasive spine 51
2.5 Anterior C1/2 surgery 151
surgery
1.5 Different spinal pathologies and patient selection 57
1.6 Computer-assisted navigation for minimally invasive 67

spine surgery
1.7 Biologics in minimally invasive spine surgery 85
1.8 Anesthetic considerations and minimally invasive 91

spine surgery
XIV Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

Table of contents
3 Thoracic techniques 173 4 Lumbar/sacral techniques 261
3.1 Introduction 175 4.1 Introduction 263
3.2 Extreme lateral mini-thoracotomy approach for 177 4.2 Posterior approaches 267
thoracic spinal pathologies 4.2.1 Bilateral decompression in lumbar spinal stenosis 267
through a microscope-assisted monolateral approach
3.3 Anterior thoracoscopic approaches, including 191
4.2.2 Microsurgical lumbar disc surgery 289
fracture treatment
4.2.3 Endoscopic disc and decompression surgery 315
3.4 Posterior approaches for minimally invasive thoracic 211 4.2.4 Mini-open and percutaneous pedicle 331
decompression and stabilization instrumentation and fusion
4.2.5 Interspinous spacers 355
3.5 Posterior approaches for minimally invasive treatment 223
4.2.6 Fixation of the sacroiliac joint 375
of spinal fractures
4.3 Anterior approaches 393
3.6 Vertebroplasty and percutaneous cement 243
4.3.1 Minimally invasive anterior midline approach to the 393
reinforcement techniques
lumbar spine and lumbosacral junction
4.3.2 Minimally invasive anterolateral retroperitoneal 413
approach to the lumbar spine
4.3.3 The lateral approach to the lumbar spine 431
4.3.4 Deformity correction using minimally invasive spine 445
surgery techniques
4.3.5 Transsacral fixation 467
5 Critical overview and outlook 483
5.1 Minimally invasive spine surgery: a critical overview 485

and outlook
XV

Definition of the different classes of evidence (CoE)
Definition of the different classes of evidence (CoE)
Articles on treatment
Studies of therapy
Level Study design Criteria
I Good quality RCT • Concealment

• Blind or independent assessment for important outcomes
• Co-interventions applied equally
• Follow-up rate of ≥ 85%
• Adequate sample size
II Moderate or poor quality • Violation of any of the criteria for good quality RCT
RCT • Blind or independent assessment in a prospective study, or use of reliable data*
Good quality cohort in a retro study
• Co-interventions applied equally
• Follow-up rate of ≥ 85%
• Adequate sample size
• Control for possible confounding†
III Moderate or poor quality • Violation of any of the criteria for good quality cohort
cohort • Any case-control design
Case control
IV Case series • Any case-series design
Randomized Controlled Trial (RCT)

*
Reliable data are data such as mortality or reoperation.
†
Authors must provide a description of robust baseline characteristics, and control for those that are unequally
distributed between treatment.
(Reproduced with kind permission from the AOSpine Evidence-Based Spine-Care Journal (EBSJ).)
XVI Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

XVII

Author Andreas Korge
XVIII Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

1 Fundamentals
1.1 The definition of minimally invasive spine surgery and the rationale for its use
1 Fundamentals

2 Minimally Invasive Spine Surgery—Techniques, Evidence, and Controversies Roger Härtl, Andreas Korge

1.1 The definition of minimally invasive spine surgery and
the rationale for its use
Andreas Korge
1 Rationale led to a decrease in postoperative pain symptoms with less

pain medication, and to a reduction in overall morbidity
Spine surgery was initially referred to in anecdotal reports with a quicker recovery time and a shorter hospitalization
at the beginning of the 20th century, but later developed period. With so many obvious potential benefits, special
to increasingly cover all the anatomical regions of the ver- emphasis was placed on minimally invasive spine surgery
tebral column. With time, a better understanding of the (MISS) from the early 1990s onwards. While access modi-
pathologies underlying the visible symptoms and improve- fications dominated the results in the literature during the
ments in diagnostic tools and surgical equipment led to a first MISS decade [3, 4], after the year 2000, outcome stud-
dramatic increase in surgical treatment strategies from the ies focused on the question of whether the high expectations
1950s onwards. Macrosurgical exposures were accepted as regarding MISS were justified, and whether they had been
standard practice at the time, since treatment goals focused met [5–9]. Recent studies now increasingly concentrate on
predominantly on target surgery and its practicability. evidence-based outcome evaluation [10–14], and in this
context reference is also made to the individual chapters of
However, macrosurgical exposures are associated with a this book.
large number of side effects including significant muscle
damage and increased bleeding, muscular denervation, re- Modifications in access strategies should not compromise
duced segmental innervation, as well as a decreased or even the goal of the surgical procedure, independent of the type
severely compromised local blood supply with postoperative of pathology involved. Even if this is not always possible in
sequelae such as scar-tissue formation and local pain syn- the beginning when first using a modified surgical technique
dromes. Further postoperative side effects include the need that requires a learning curve, this goal must be strived for.
for prolonged pain medication, a longer immobilization and For example, at the onset, percutaneous pedicle screw place-
recovery period accompanied by an extended period of ment for fusion surgery was limited to mono- and biseg-
physical disability and delayed return to work, and some- mental cases of in situ fusion. Technical advances now en-
times with a limited possibility, or even in some cases no able multisegmental pedicle screw insertion and segmental
possibility, of resuming previous professional activity. reduction to be performed; surgery, for example, is facili-
tated by computer-assisted navigation; and cement aug-
In consequence, the importance of effective approach mo- mentation techniques are available, so that the range of
dalities has become increasingly apparent, and particular indications for treatment by MISS is now nearly the same
focus has been placed on the optimization of access strate- as for open surgery.
gies through minimizing the anatomical working corridor
while simultaneously maintaining the treatment aims of Among the many other examples given in historical reviews
standard open surgery. The measures used to decrease in- [15, 16], typical examples of minimalized treatment strategies
traoperative iatrogenic tissue trauma include reducing ac- are the development of posterior mini-open or percutane-
cess size, making smaller incisions, and using preexisting ous pedicle screw placement techniques in combination
anatomical neurovascular and muscle compartment work- with minimally invasive transforaminal intervertebral
ing planes, with the aim of achieving similar, or if possible, (mini-TLIF) or anterior intervertebral (mini-ALIF) implant
better postoperative results than those obtained via standard placement (Fig 1.1-1) [4, 9,17]. Video-assisted thoracoscopic
open procedures [1, 2]. Less muscle damage as a result of surgery for decompression or fusion procedures has been
muscle-splitting dissection rather than muscle-cutting tech- developed for the treatment of the thoracic spine [18], while
niques, and reduced blood loss due to meticulous hemo- for the cervical spine, even for a single anatomical region
stasis with less postoperative scar-tissue formation, have (ie, the atlantoaxial segment C1/2), four different anterior

minimally invasive techniques are now available (see chap- croscopic or endoscopic conditions. Specific tube or frame-
ter 2.5 Anterior C1/2 surgery). Today, a wide range of like retractor systems have been developed to keep the tiny
minimally invasive surgical procedures can be applied for “keyhole” access route open (Fig 1.1-3). Computer-assisted
the treatment of the entire spine (Table 1.1-1, Table 1.1-2). navigation and intraoperative neuromonitoring have now
become essential tools in facilitating access minimization.
However, the variety and number of minimally invasive
procedures that can currently be performed have only been
made possible by the introduction of numerous technical
innovations within the last decades. These can be summa-
rized as the four “pillars” of MISS (see chapter 1.3 The four
pillars of MISS in this section), namely: microsurgical tech-
niques; access strategies to the spine; imaging/navigation
techniques; and instrumentation and implants. To mention
but a few of these developments, improved visualization
with magnification and illumination of the target area is
ensured by the use of high-end microscopes, endoscopes
or head lamps with adequate xenon light sources (Fig 1.1-2).
Instruments have been further modified, enabling the sur-
geon to operate within a narrow working channel; for ex-
ample, bayonet-shaped instruments and high-speed drills,
etc. ensure a virtually unrestricted visual field under mi- a b
Fig 1.1-1a–b Posterior percutaneous pedicle screw placement at L4/5
after initial anterior cage implantation using a mini-ALIF technique.
a Insertion tubes with adapted screws in place on the right side; on
the left side, completed screw-rod implantation, with only the skin
Cervical spine Foraminotomy incisions visible.
b Intraoperative AP x-ray showing the insertion tubes with screws in
Microfacetectomy place on the right side and completed left-sided instrumentation.
Craniocervical junction decompression
Laminoplasty
Fusion procedures with instrumentation (eg, transpedicular,
translaminar, lateral mass) Cervical spine Uncoforaminotomy
Skip laminectomy Decompression surgery (eg, intervertebral, transnasal,
Thoracic spine Costotransversectomy transoral)
Transpedicular decompression surgery Fusion procedures (eg, cages, plates)
Laminotomy Total disc replacement
Vertebral body augmentation (vertebroplasty/kyphoplasty) Vertebral artery decompression
Fusion procedures (percutaneous pedicle screw placement) Thoracic spine Decompression surgery (eg, disc pathologies, fracture)
Lumbar spine Decompression surgery (disc pathologies, synovial cysts, Fusion procedures (eg, cages, plates)
acquired spinal stenosis) Total disc replacement
Lumbar spine
• Medial and paramedian
• Intraforaminal and extraforaminal Nucleus replacement
Vertebral body augmentation (vertebroplasty/kyphoplasty) Fusion procedures (cages, plates)—mini-ALIF
• Anterior, anterolateral, lateral
Lordoplasty
Spinal canal decompression
Dynamic nonfusion techniques (incl. nucleus replacement)
Anterior extraforaminal decompression
Fusion procedures (eg, percutaneous pedicle screw
placement, translaminar screws, transsacral techniques) Vertebral body augmentation
Intervertebral support (mini-PLIF, TLIF) Tumor marginal resection/curettage
Table 1.1-1 Minimally invasive spine surgery—applications using Table 1.1-2 Minimally invasive spine surgery—applications using
posterior approaches. anterior approaches.

1 Fundamentals
Minimally invasive spine surgery has been defined as: “(a) of the procedure. With careful preparation, both surgeon and
procedure that by virtue of the extent and means of surgical patient should be able to benefit from the potentially positive
techniques results in less collateral tissue damage, resulting aspects of MISS: less tissue trauma, reduced bleeding and
in measurable decrease in morbidity and more rapid func- scar-tissue formation, decreased pain with quicker mobiliza-
tional recovery than traditional exposures, without differen- tion and recovery time, shorter hospital stay, and a more
tiation in the intended surgical goal” [19]. The present author rapid return to daily activities at both a professional and per-
subscribes to this view. In an effective minimally invasive sonal level (Fig 1.1-4). It is most important that these approach
spine operation today, one of the major aspects of preopera- modifications do not influence the treatment strategy at the
tive preparation, which has a significant effect both on the target site itself, which should be independent of the size of
intraoperative procedure and the postoperative results, is the the access pathway, and be adequate and identical for both
meticulous decision-making process and thorough planning macro- and microsurgical approaches.
Medial Medial
Dura
Dura Nerve root L5

Cranial Caudal Cranial Caudal
Synovial cyst
a Lateral b Lateral
Fig 1.1-2a–b Fig 1.1-3 Tube placed over disc space at L4/5
a Microscopic view of the spinal canal at L4/5 with a large synovial cyst compressing left in preparation for interbody work, with
the hidden nerve root L5. K-wires already positioned bilaterally through
b Microscopic view of the spinal canal at L4/5 after removal of the synovial cyst with pedicles L4 and L5 for percutaneous screw
decompressed and now visible nerve L5. placement using a Wiltse type approach.
Quicker return to DLA Smaller incision
Shorter hospital stay Less soft-tissue damage
Quicker recovery Less blood loss
Less postoperative pain Lower complication rate
Less scarring
Fig 1.1-4 Benefits associated
with a MISS strategy
(DLA = daily life activities).

2 Learning curve fect on, eg, intraoperative tissue trauma, blood loss and so
on, and will also include an initially increased complication
As with the use of any new technique, the first attempts at rate [20–22]. The specific learning curve will depend on the
performing minimally invasive surgical approaches will also type of surgery in question and the acquired skills of the
involve learning the procedure itself, how to handle new individual surgeon. Care must be taken when using new
instruments correctly, and specific implants if required. Ac- tools to avoid making any inappropriate surgical gesture,
cepting a relatively steep learning curve and at the onset and caution should be exercised to avoid overestimating
an extended time for surgery must be taken into account. surgical ability. Even for experienced surgeons, a certain
In addition, any learning curve will also have a certain ef- learning curve will always exist (Fig 1.1-5).
2003 2009
20
18
16
14 > 12.5% intl. benchmark
12
Percent
10
8
6 aim < 5%
4
2
0
a b c d e f a b c d e f
a Surgeons Surgeons
Complications (3/05–2/10) Complications (3/05–2/10)

18 18
16 16
14 14
12 12
Percent
Percent
10 10
8 8
6 6
4 4
2 2
0 0
3/05 4/05 1/06 2/06 3/06 4/06 1/07 2/07 3/07 4/07 1/08 2/08 3/08 4/08 1/09 2/09 3/09 4/09 1/10 2/10 3/05 4/05 1/06 2/06 3/06 4/06 1/07 2/07 3/07 4/07 1/08 2/08 3/08 4/08 1/09 2/09 3/09 4/09 1/10 2/10
Quarter Quarter
b c
Fig 1.1-5a–c Examples of learning curves in MISS in relation to complication rates.
a Between-group comparison of MISS surgeons over a 6-year period.
“a” and “b”: surgeons that were experienced in microsurgery of the entire spine, who performed the most difficult procedures;
“c”, “d”, “e”, and “f”: surgeons that were initially less skilled in the new techniques, but who later gained increasing microsurgical experience
(red bars: complication rate [in %]); final team aim: to reduce the complication rate to below 5%.
b Development of complication rates over a 5-year period for MISS procedures performed by an experienced spine surgeon familiar with spine
microsurgery.
c Development of complication rates over a 2-year period for MISS procedures performed by spine surgeons inexperienced in MISS, who
adopted this technique in 2008, showing a significant reduction in complication rates over time.

1 Fundamentals
It is always easier to take a standard, familiar technique size to the well-known macrosurgical length when com-
using a macrosurgical access with a large incision and mod- pared to an endoscopic technique.
ify it to a microsurgical procedure by reducing the length
of the incision than to adopt an entirely different approach Accepting the existence of a learning curve, and adopting
and philosophy. For example, in the case of a mono a strategy like doing more straightforward cases at the on-
segmental thoracic pathology, in traditional open macro- set with meticulous patient selection will help to reduce
surgery, a large thoracotomy is performed, with rib resec- any frustration regarding the new technique, or limit a
tion starting 1–2 disc spaces cranially from the affected tendency to keep within the limits of known standard pro-
target area. However, in minimally invasive open trans- cedures. Also helpful is when the first MISS cases can be
thoracic surgery with a modified access technique, the sur- treated together with an experienced MISS surgeon, as is
geon has to meet the challenge of placing the skin incision possible in, eg, percutaneous pedicle screw placement, with
directly over the pathology, while gradually minimizing each surgeon dealing with his side. Participating in human
the skin incision as much as possible (Fig 1.1-6; and see anatomical specimen workshops on the chosen surgical
chapter 3.2 Extreme lateral mini-thoracotomy approach technique will further optimize the learning curve. In the
for thoracic spinal pathologies). The entire setup required literature, it has been reported that the number of interven-
for MISS will not differ greatly, especially when micro tions required for a surgeon to become familiar with a spe-
surgery is to be performed for other surgical interventions cific MISS procedure ranges between 10 and 20, depending
and the use of a microscope, etc, is part of routine practice. on the type of surgery [23, 24]. However, the author consid-
But if the surgeon switches to video-assisted transthoracic ers that these procedures can only become good routine
surgery for the treatment of the same pathology, this tech- practice with an effective intraoperative workflow after at
nique will include the use of endoscopes with new access least 30 cases in succession have been performed, with a
portals and a different three-dimensional orientation with- subsequent 30 cases per year treated thereafter. If a sufficient
in the thoracic cavity, a new set of instruments, and poten- number of minimally invasive cases are not available for
tially different implants—moreover, with an additionally routine surgery, the author suggests that it might be advis-
stressful and different, new visual working axis (see chap- able to keep to the same familiar and established macro-
ter 3.3 Anterior thoracoscopic approaches, including frac- surgical procedures. In fact, eg, for posterior fusion of the
ture treatment). In the event of an intraoperative compli- lumbar spine, more than 90% of all surgical interventions
cation, it will be easier to deal with the problem when are still currently performed using a macrosurgical or only
using a mini-open technique by just enlarging the incision a limited microsurgical approach (Fig 1.1-7).
Anterior
Cranial
dal
Fig 1.1-6 Marking the incision line for a minimalized

Cau
transthoracic microscopically-assisted approach for the

Poste
rior treatment of a L1 fracture. Red line: theoretical placing and
size of a macrosurgical skin incision, which is usually even
larger; continuous black line: microsurgical incision line; all
four borders of the target vertebral body at L1 have been
marked.

Posterior fusion surgery of the lumbar spine
80 mm 50 mm 35 mm 22 mm 20 mm < 20 mm
Open Controlled open Mini-open Percutaneous tube Advanced retraction Advanced MISS
Current state-of-the-art
Fig 1.1-7 Access progression for posterior fusion surgery of the lumbar spine.
More than 90% of surgeries are currently performed by either open macrosurgical approaches or with an only slightly reduced approach extent
(ie, within the range “Open” to “Mini-open”); MISS includes a variety of approach modifications ranging from “Controlled open” to finger-size incisions.

1 Fundamentals
3 Radiation exposure bar interbody fusion (TLIF) when compared to a certain

amount of radiation exposure (12.4 mRem) without navi-
The minimization of an access route inevitably leads to more gational assistance [30]. Transposition of the study design
limited visualization of the surgical field, or to no visualiza- to an in vivo evaluation demonstrated a statistically sig-
tion whatsoever. The use of x-ray imaging for local orienta- nificant reduction of total image intensification time in the
tion therefore prevails, as visual anatomical landmarks that navigation group of more than 50%. Similar results with a
were once familiar under macrosurgical conditions may be significant reduction in image intensification time (77%
indistinguishable or obscured. Imaging tools are manda- reduction) and radiation dose (60% reduction for the hand
tory at the preoperative stage for meticulous localization, and 32% for the body) were found when an electromag-
and also intraoperatively for verification of the target area. netic navigation system was used for percutaneous pedicle
This is the case for both soft tissue and osseous pathologies. screw placement in comparison to standard image-inten-
Moreover, as regards, eg, vertebral body augmentation (ver- sifier-guided placement [31]. However, it should be noted
tebroplasty, kyphoplasty) and fusion surgery, certain pro- that radiation dose to the individual patient is higher when
cedures require repeated x-ray monitoring of individual CT-based datasets are used.
intraoperative surgical steps like cement distribution, reduc-
tion maneuvers, or pedicle screw placement. As a result, In addition to the beneficial effect of reduced radiation ex-
the radiation dose to the patient, surgeon and support staff posure to the surgeon, computer-assisted or electromag-
may increase, depending on the type of MISS [25–27]. In- netic image-guided navigation as well as computerized
traoperative use of leaded glasses, thyroid shields, and lead isocentric image intensification significantly improve the
aprons help to reduce local radiation exposure. accuracy of percutaneously inserted pedicle screws, thus
decreasing the risk of screw misplacement [31–34]. Despite
Standard image intensification with an image intensifier the increased setup time involved, the overall time for
and/or pre- and intraoperative CT scan is the most fre- navigation-based surgery compared to that for surgery us-
quently used imaging tool. With standard image intensifica- ing standard intraoperative image intensification does not
tion, both patient and surgeon are subjected to radiation differ, as there is no difference in the results regarding blood
exposure in low and limited amounts in the case of a single loss, exposure time or hospital stay between these treatment
procedure [28]. However, repeated radiation exposure due strategies [30, 31].
to image intensifier-assisted surgical interventions that are
continuously performed over time leads to an increased
overall radiation dose to the surgeon, predominantly involv- 4 Cost effectiveness
ing the hand, eye, and other exposed parts of the body.
Careful dose monitoring is therefore mandatory in order to New technologies for both access and target surgery most-
avoid exceeding annual dose limits. ly require a significant initial investment in operating-room
setup (eg, carbon table for isocentric C-arm 3-D image-
Differences in radiation dose have been demonstrated in intensifier navigation, video screens), instruments (eg,
an in vivo study comparing two different microdiscectomy bayonet-shaped instruments, endoscopic equipment), and
procedures [29]. Standard microdiscectomy generally re- implants (eg, cannulated screws for percutaneous pedicle
quires two lateral images, ie, a preoperative view for segment screw placement), and other tools being more or less cost-
localization and an intraoperative view for target area ver- intensive. Adopting these new technologies may involve a
ification. In comparison, MISS lumbar microdiscectomy single investment, or require repetitive investments in sur-
using tubular retractors requires several image-intensifier gical material/setup.
views for level verification, dilator positioning and tube
placement, resulting in a 10- to 20-fold potential increase Once the prerequisites for MISS have been determined,
in the amount of radiation dose. when considering the overall benefit of this new surgical
strategy in terms of direct and indirect costs, the cost-anal-
Computer-assisted navigation with preoperative or intra- ysis and cost-effectiveness aspects must be taken into ac-
operative CT-scan or image intensifier-based datasets helps count [35]. Sources of direct cost include factors such as
to reduce the amount of radiation exposure to the surgeon. those related to time (duration of stay in the emergency
A human anatomical specimen study demonstrated that no room and intensive care unit; time in the operating room,
radiation was detectable when computer-assisted navigation eg, the duration of surgery; length of hospital stay), addi-
with image intensification was used for transforaminal lum- tional investigations (such as laboratory, radiological, or

interdisciplinary investigation, eg, cardiology), other ex- compared to standard open procedures. Further studies with
penses (eg, board, medication, blood units), and profes- longer-term follow-up are necessary to evaluate the effect
sional fees (eg, surgeon, anesthetist), which together con- of MISS on both direct and indirect costs in order to deter-
tribute to the overall cost of MISS. However, over time, mine the possible financial benefit of the latter technique
indirect costs in fact make up approximately 85% of the compared to open spine surgery.
total costs! [36]. Indirect costs among others include post-
operative factors such as patient rehabilitation, delayed The length of hospital stay (LOS) connected with surgical
return to work, loss of productivity, the possible inability interventions is a matter of ongoing debate at scientific
to work, and unplanned early retirement. It should also be meetings, and a subject of controversy in the literature.
noted that the surgeon’s learning curve, at least initially, Length of hospital stay is without any doubt directly re-
may influence the cost-effectiveness of a given procedure. lated to cost-effectiveness. Since, however, the reimburse-
ment systems for identical treatment procedures vary sig-
Several studies have been made comparing the financial nificantly in different countries and healthcare systems,
aspects of MISS strategies with those of open procedures LOS is a parameter of relatively limited value when com-
for different pathologies. In a 2-year cost-utility study comparing the economic impact of different minimally invasive
paring a minimally invasive transmuscular tubular tech- or macrosurgical strategies, in that the predefined minimum
nique versus an open midline retractor-assisted multilevel LOS periods determine hospital reimbursement, and bear-
hemilaminectomy for lumbar stenosis, Parker et al [37] found ing in mind that financial deductions are made if the LOS
that with an identical postoperative health status, both falls below the pre-established lower limits for LOS (as is
techniques were cost-equivalent. As postoperative infec- the case in Germany).
tions are to a large extent responsible for the financial bur-
den involved, and as it is reported that MISS is associated
with a significantly reduced infection rate when compared 5 Summary
to open surgery (0.6% for MISS versus 4% for open surgery,
based on a literature review of 1495 TLIFs), the use of MISS • Minimally invasive spine surgery consists of miniatur-
techniques in terms of direct costs constitutes a possible ized modifications of established access strategies that
economic advantage [38]. In addition, retrospective analy- have been introduced without changing or modifying
sis shows the superior cost-saving aspects of MISS compared the surgical goal
to open procedures for TLIF in terms of direct costs, includ- • Benefits of minimally invasive spine surgery include
ing more rapid patient mobilization and quicker discharge smaller skin incisions and less soft-tissue damage, result-
from hospital, as well as reduced laboratory and medication ing in reduced blood loss and lower complication rates
costs [39, 40]. As far as the economic aspects are concerned, with decreased scar-tissue formation, reduced postop-
little doubt exists that for a monosegmental pathology, the erative pain and need for pain medication, quicker re-
exclusive use of posterior surgery (TLIF) will limit the covery and shorter hospital stay, with more rapid return
cost involved compared to a combined anterior-posterior to work and daily activities
strategy (anterior-posterior interbody fusion) in terms of • A learning curve must be taken into account when de-
reduced time of surgery, shorter stay in the intensive care ciding to use MISS techniques
unit, less blood loss, and shorter period of hospitalization • Radiation dose is increased in specific MISS procedures,
[41]. however, the use of intraoperative navigation reduces
radiation exposure to the surgeon and operating-room
Although the above-mentioned studies show a tendency staff
towards the greater cost-effectiveness of certain MISS pro- • Long-term studies are necessary to determine the ben-
cedures, at the present time insufficient studies are available efits of MISS in terms of cost-effectiveness, which has
to clearly demonstrate the superiority of MISS in this regard already been documented in short-term follow-up.

1 Fundamentals
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11

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1.2 Minimally invasive spine surgery and AOSpine principles
H Michael Mayer
1 Principles of minimally invasive spine surgery 1.2 Access surgery

The spine can be accessed from different directions through
In the history of surgery, reducing iatrogenic tissue trauma different entry points (Table 1.2-2).
to a minimum has always been regarded as one of the basic
principles. Modern surgical techniques and technology have The surgical entry point (skin incision) is usually determined
shifted this goal into a new dimension. In spine surgery, by the topography of the target region and access anatomy.
the last decade of the 20th century was marked by signifi- For MISS, it must be adequately placed and should be as
cant advances in the field of minimally invasive surgical small as possible in size. The cosmetic aspects must be tak-
procedures. These developments continue to follow basic en into consideration (eg, placement, length, and orienta-
principles, and what can almost be qualified as a philosophy tion of skin incision).
regarding minimally invasive surgery.
The surgical route to the target area should be reasonably
1.1 Goals fast, and must follow strict anatomical pathways, such as
The aim of every surgical procedure is to resolve the patient’s preexisting spaces; or, when this is not possible, access sur-
clinical problem by treating the underlying pathology (Table gery should be performed with a minimum of collateral
1.2-1). This pathology can be considered as the target of each damage to the surrounding tissues. If collateral damage
surgical procedure. So one of the goals of minimally invasive cannot be avoided, it should be reparable or at least have
spine surgery (MISS) is to carry out efficient “target surgery” minimal effects on the clinical outcome. Whenever possible,
with a minimum of iatrogenic trauma. To attain this target, muscular and/or ligamentous function should be fully pre-
the surgeon has to create an access to it. So practically speak- served.
ing, either the access part or the target part of the surgical
procedure—or both—can be minimally invasive.
Skin incision Accurate placement

The majority of minimally invasive techniques in spine sur-
gery primarily concern the access, and not what is performed Adequate size
in the target region. Cosmetic aspects

Route to target area Fast
The least traumatic (anatomical pathways!)
Collateral damage Negligible

Access Reparable
Target Target exposure Adequate
Planning Target treatment Efficient
Positioning Unrestricted due to small approach
Skin incision Surgical dissection techniques Negligible
Surgical dissection techniques Not relevant for outcome
Instruments and implants Risk of symptom recurrence, etc
Table 1.2-1 Factors that influence MISS strategy. Table 1.2-2 Access principles in MISS.
13

Author H Michael Mayer
1.3 Target surgery 1.5 Patient positioning

One of the most important considerations in MISS, how- The positioning of the patient can strongly influence the
ever, is to provide adequate exposure of the target area. minimally invasive exposure as well as the target surgery.
The target (eg, disc herniation, disc, spinal nerve, tumor) Preoperative positioning in MISS must enable the surgeon
must be identified and clearly visible. Treatment of the un- to operate without having to adjust the patient’s position
derlying pathology (eg, via discectomy, vertebrectomy, intraoperatively. It should aim at reducing or avoiding col-
neurolysis, tumor removal) should be given full priority, lateral damage, such as pressure sores, and facilitate surgical
and it must be possible to carry this out without any of the dissection. Examples of this are lateral positioning and access
potential compromises that MISS approaches might come to the lumbar levels L2–4 for anterior lumbar interbody fu-
with. Spinal manipulation (eg, reduction maneuvers) should sion (ALIF), which allows easier access to the spine even in
also be possible, as well as the insertion of implants for obese patients; or the knee-chest position in patients un-
spinal stabilization. dergoing lumbar discectomy or decompression procedures,
which allows pressure release within the epidural venous
Retreat from the surgical field should leave no or only mi- system and thus reduces the risk of epidural bleeding.
nor traces, such as hematoma, open annulus fibrosus fol-
lowing discectomy, or scar tissue; and any minor sequelae 1.6 Skin incisions
should not have an effect on the clinical outcome (eg, In MISS, skin incisions should be as small as possible. This
muscle damage). In the case of staged surgical therapy (eg, implies an accurate localization of the incision in terms of
dynamic posterior stabilization) or when there is a risk of the target area to be reached. In the majority of mini-open
pathological recurrence (eg, disc herniations), the postop- techniques, the skin incision is made directly above the tar-
erative sequelae, such as scar tissue, muscle or intervertebral get. In endoscopic techniques, localization of the incision(s)
joint damage should not be such that they negatively affect is determined by the intended working direction as well as
these further therapeutic options. by the angles of view required during the operation.
1.4 Preoperative planning 1.7 Surgical dissection techniques

To achieve all the above-mentioned goals, meticulous pre- Surgical dissection techniques differ according to the type
operative planning is necessary. Positioning of the patient of tissue that is to be treated (eg, nerve versus bone; muscle
on the operating table requires specific modifications. Lo- versus blood vessel). An improved knowledge of the struc-
calization of the entry area under image intensifier control ture and function of these tissues has modified traditional
is mandatory, and surgical preparation techniques must be surgical dissection techniques. In MISS, it has gained even
adapted to the surgery in question. Special instruments, more significance.
light and magnification sources (eg, loupe, surgical micro-
scope, head lamp), as well as retractor devices (eg, frame A muscle or a bone structure should basically be treated
or ring retractors, tubes) are necessary. Positioning of the with the same care as a nerve or a blood vessel. Blunt mus-
equipment and operating room personnel may require cer- cle-splitting techniques are characteristic of MISS. The use
tain modifications. Moreover, the topography and “volu- of high-speed burrs instead of large rongeurs can help to
metry” of the surgical target area must be clearly determined preserve bone structures. The individual mobilization of
before the operation. blood vessels can decrease the vascular complication rate.
The use of hemostatic agents in spinal canal surgery can
This information is usually obtained via different imaging reduce the risk of epidural hematoma. The microsurgical
techniques, such as MRI and CT scan. Preoperative vascu- closure of the annulus fibrosus is aimed at promoting the
lar topography can be determined with the help of color- healing potential of this structure, which is generally re-
coded three-dimensional CT scans, which provide a clear garded as low.
picture of the individual anatomy. The nature and extent
of previous operations in the target—or access—region
should also be taken into account, because they may influ-
ence the access strategy.

1 Fundamentals
1.8 Instruments and implants 2.3 Function

Minimally invasive spine surgery is not possible without Correct spinal function is based on factors, such as stability
the use of optical aids. Light and magnification are needed, and proper alignment. The preservation and restoration of
and are introduced through small skin incisions to illuminate proper function, with the accompanying prevention of dis-
and visualize the surgical target area that may lie deep ability, are therefore major goals of surgical treatment.
within the body. The minimum prerequisites for the surgeon
are head lamps and loupes. The surgical microscope and/ 2.4 Biology
or endoscope are helpful, or even mandatory for certain This AOSpine principle implements knowledge regarding
techniques. Surgical instruments should be bayoneted and/ the etiology and pathogenesis of pathologies and diseases.
or sufficiently long to bridge the distance from the skin to It also emphasizes the importance of neural protection dur-
the target area. The electrocautery instrument tips must be ing or after surgical procedures, as well as aspects of tissue
isolated to prevent thermal damage to the tissues in the healing.
access region.
Each of the AOSpine principles can be applied and adapted
One of the major challenges over the coming years lies in to different groups of pathologies, such as degeneration,
the further development of instruments and implants which trauma, deformity, tumor, and infection, or to metabolic,
will allow for improved intraoperative spinal manipulation inflammatory, or genetic diseases.
(reduction, correction) and fixation. Last but not least, tubes
or frame-type retractor systems are essential for keeping There is no general or natural consistency between the
the surgical corridor open. AOSpine principles and MISS tenets. However, the goal
should be that MISS techniques take into account AOSpine
principles and put them into practice whenever appropriate.
2 The AOSpine principles
AOSpine education has elaborated on four basic principles, 3 AOSpine principles for different pathologies
which can be universally applied to every diagnostic and
treatment strategy for different pathologies. These principles 3.1 Degeneration
are: stability, alignment, function, and biology (Fig 1.2-1). In the treatment of degenerative disorders, the four AOSpine
principles imply the protection of adjacent segments
2.1 Stability (stability), restoration of balance in the case of degenerative
Each type of surgical treatment of the spine aims at the deformities (alignment), assessment of the outcome of in-
restoration and preservation of segmental stability, and the terventions (function) as well as determination of the patho-
achievement of a specific therapeutic outcome. For many genesis of spinal degeneration (biology) (Fig 1.2-2).
years, as far as spine surgery was concerned, stability tend-
ed to be synonymous with the rigid “fixation” of spinal 3.2 Trauma
segments, ie, fusion. This has changed in the last decade In the treatment of traumatic disorders, stability means the
with the introduction of procedures and implants which application of biomechanical principles of internal fixation
enable the surgeon to achieve dynamic, motion-preserving (Fig 1.2-3). Achieving alignment, ie, the reduction and resto-
stability. ration of pretraumatic alignment, is as vital as the protection
of neural elements and the enhancement of bone healing
2.2 Alignment (biology). With regard to function, the preservation of
Alignment implies achieving spinal balance in three dimen- healthy motion segments is of major importance.
sions. For a number of years the importance of alignment,
especially in fusion surgery of the spine, was underesti- 3.3 Deformity
mated. Surgeons who performed surgery on anatomical The goal of achieving stability acquires particular signifi-
deformities were the first to realize the importance of sag- cance, for instance in the case of surgical treatment of junc-
ittal balance. The fusion of spinal segments without fully tional instabilities at the end zones of a deformity (Fig 1.2-4).
taking into account proper alignment limits the ability to In deformity surgery, correct spinal alignment depends
achieve a three-dimensional balance. on proper balancing in all planes, while adequate function
15

implies the preservation of as many mobile segments as often leads to deformities, such as segmental kyphosis, which
possible. An evaluation of the etiology, pathogenesis, and needs to be corrected in order to achieve good clinical
natural history of the spinal deformity in question forms outcomes. Even though, in many tumors, larger surgical
the basis of each therapeutic strategy. approaches that guarantee a maximum resection need to
be applied, MISS approach techniques have become very
3.4 Infection useful in palliative tumor treatment (eg, spinal metastasis).
Achieving stability may also involve performing surgery to The spectrum ranges from simple percutaneous vertebro-
treat any pathological instability due to infection. Restoring plasty procedures, through to percutaneous pedicle screw
balance in the case of a postinfective deformity means stabilization, or thoracoscopic vertebrectomies. These tech-
achieving alignment. The other two principles that can be niques reduce perioperative morbidity and enable a faster
seen in the treatment of spinal infection are the preserva- recovery, and thus have faster functional restoration, which
tion of neurological function (function) and the use of ad- is particularly important for patients with a limited life ex-
equate and appropriate chemotherapy (biology) (Fig 1.2-5). pectancy due to their malignant tumor. MISS techniques
currently do not allow radical tumor resection, however,
3.5 Tumors reduced tissue trauma is important for better wound heal-
The main reasons for applying surgical treatment to spinal ing, especially in patients that are immunosuppressed due
tumors are to decompress neural structures and to remove to chemotherapy and/or irradiation (Fig 1.2-6).
the tumor. The majority of tumors affecting the spinal col-
umn are malignant neoplasms. En-bloc resection of the 3.6 Metabolic, inflammatory, and genetic
tumor and the surrounding healthy structures, which can Assessment of the need for augmentation of an osteopo-
“cure” the patient, is rarely possible. In any type of surgical rotic spine addresses the principle of stability. Alignment
treatment, however, the structural integrity of the spine means the restoration of balance in any type of deformity
and its functional motion segments are affected. So restor- associated with metabolic, inflammatory, or genetic
ing or keeping a sufficient level of stability, using various disorders. Biology implies the use of appropriate medical
implants (pedicle screws, vertebral body relacement etc), therapy, and a good functional outcome can be assessed by
is a paramount goal in tumor surgery. Stability is only use- quality of life, and the satisfactory maintenance thereof
ful if it is achieved in a well aligned spine. Destructing tumors (Fig 1.2-7).

1 Fundamentals
Sagittal
Axial Coronal
Stability Alignment
Stabilization to achieve a specific Balancing the spine in three
therapeutic outcome. dimensions.
Biology Function
Etiology, pathogenesis, neural protection, Preservation and restoration of
and tissue healing. function to prevent disability.
Fig 1.2-1 The four AOSpine principles to be considered as the foundation for proper spinal patient management.
17

Degeneration Stability Alignment
Fig 1.2-2 The AOSpine principles for the Protect adjacent segments Restore balance in degenerative deformity
treatment of degeneration. The goal of fusion for painful segmental degeneration Degenerative scoliosis, kyphosis, and spondylolis-
of the spine is to relieve pain and restore function by thesis often result in spinal imbalance. Particularly
achieving a solid arthrodesis of the selected motion in the elderly, imbalance of the sagittal plane is not
segments. Fusion can be enhanced by the addition of well tolerated. The goal of corrective surgery for
internal fixation. Concerns about the long-term effect degenerative deformity should be to restore alignment
of spinal arthrodesis on the adjacent mobile segments and balance. In the lumbar spine this usually requires
have led to the development of many nonfusion inter- long fusions extending into the thoracic region above
ventions with the aim of achieving pain reduction and and the lumbosacral junction below in order to avoid
functional improvement without sacrificing mobility. decompensation if the fusion is too short.
Biology Function
Understand the pathogenesis of spinal degene- Measure outcomes of interventions

ration Functional outcome tools that measure the benefits
Although spinal degeneration is a natural aging and costs of therapeutic interventions for spinal dege-
process, many patients develop disabilities due to neration are essential to allow surgeons, physicians,
pain, loss of function, or compressive neurological patients, and funding bodies to assess their efficacy.
syndromes. For therapeutic interventions aimed at
relieving pain, restoring function, or decompressing
neural elements the possibility of future progression of
degeneration at treated and untreated levels must also
be considered. Future biological interventions, such as
stem cell implants or biomechanically active implants,
may not be possible if previous surgical interventions
preclude their use when they become available.
Trauma Stability Alignment
Apply biomechanical principles of internal Restore normal alignment

Fig 1.2-3 The AOSpine principles for the fixation Normal spinal alignment balances the head and thorax
treatment of traumatic disorders. The biomechanical principles of internal fixation for over the lower limbs. In the sagittal plane the gravity
trauma include load sharing between implants and line of the center of body mass passes through the
spinal elements. More axial load is supported by the junctional regions of the spine, then through the fe-
vertebral bodies than the posterior elements. Anterior moral heads. In the coronal plane the head is centered
column support is necessary to protect posterior over the sacrum. Correction of malalignment following
implants during bone healing. Posterior constructs are trauma is essential for optimal spinal function.
strengthened by cross-links. Anterior plate systems
act as a tension band in extension and a buttress in
flexion.
Biology Function
Protect the neural elements and enhance bone Preserve motion segments
healing Early mobilization after spinal trauma minimizes the
Protection of the spinal cord and spinal nerves risks of recumbency. Spinal trauma implants must be
following trauma is paramount. Maintenance of able to resist the stresses of spinal loading during bone
adequate oxygenation and perfusion of the cord is healing or be protected by external supports. Long-
essential during initial resuscitation. In the presence of segment constructs resist deformity but sacrifice moti-
neurological deficit, early reduction of displacements on at normal levels. Short-segment fixation is preferred
and decompression of neural structures may improve in the lumbar region to maintain motion segments.
neurological recovery. Bone healing is vital for main-
tenance of spinal alignment, stability, and function.
Augmentation with bone grafts, bone growth factors, or
vertebroplasty may be required.

1 Fundamentals
Deformity Stability Alignment
Stabilize junctional instability Aim for balance in all planes

Fig 1.2-4 The AOSpine principles for the Deformities of the craniocervical or lumbosacral junc- Spinal imbalance in coronal and sagittal plane
treatment of deformity. tion may be unstable. Stabilization of the craniocervical deformities is common. During corrective surgery for
junction often requires occipitocervical fixation, with or scoliosis, kyphosis, and spondylolisthesis the goal is
without decompression of the spinal cord. Lumbosacral often to correct the deformity as much as possible,
spondylolisthesis may be stabilized in situ or reduction but restoration of balance does not necessarily involve
can be performed, either partial or complete. complete correction of all deformities. In some cases it
may be better to partially correct the deformity in order
to maintain balance in all planes.
Biology Function
Evaluate etiology, pathogenesis, natural history Preserve motion segments

The underlying cause and specific pathogenesis of each Long spinal fusions for deformity correction are often
spinal deformity determines the natural history of the necessary and frequently involve extension into the
condition. Surgical interventions with their potential lumbar spine or sacropelvic area, sacrificing motion
risks need to be balanced against the likelihood of segments. Adequate preoperative planning and consi-
improving the natural history, such as avoiding future deration of anterior instrumentation can often preserve
complications of the untreated condition. levels for future mobility.
Infection Stability Alignment
Stabilize pathological instability in spinal infection Restore balance in postinfective deformity

Fig 1.2-5 The AOSpine principles for the Instability of the spine following infection can result The typical deformity following infection of the spine
treatment of bone infection. from the destruction of bone by the infective process is a localized kyphosis due to loss of vertebral body
or following surgical debridement or decompression. integrity. While the local deformity may be significant,
Reconstruction with interbody grafts or cages and rigid overall spinal balance is usually maintained. However,
internal fixation is required. Current evidence suggests realignment of the spine may be required for deformi-
that the addition of internal fixation does not increase ties that threaten to compromise the spinal cord.
the likelihood of recurrence of infection.
Biology Function
Use appropriate chemotherapy Preserve neurological function

Confirmation of the causative organism in spinal The presence of neurological compromise by extension
infection is best obtained by CT biopsy. Appropriate of an abscess into the epidural space or kyphotic
antibacterial or antituberculous chemotherapy is compression requires surgical decompression, with or
the mainstay of treating spinal infection. Duration of without reconstruction and stabilization.
treatment is determined by the nature of the infection
and the condition of the patient.
19

Tumor Stability Alignment
Stabilize pathological instability Restore balance in pathological deformity

Fig 1.2-6 The AOSpine principles for the Spinal instability due to primary or secondary Collapse of the spine due to malignant disease typically
treatment of tumor. malignant disease may arise out of destruction of the results in a spinal deformity which in turn may produce
spine by the tumor or following surgical resection. neurological compression. Restoration of normal align-
Stabilization may require internal fixation, anterior ment, combined with decompression, often requires
column reconstruction, and posterior fusion. Anterior complex reconstructions. The likely prognosis deter-
or posterior or combined approaches may be needed. mines whether realignment should be undertaken.
Long constructs offer greater stability. Vertebral body
reconstruction with biological implants is preferred
if the prognosis is greater than 12 months. Artificial
devices or PMMA may be used in palliative surgery.
Biology Function
Determine likely prognosis and collaborate with Preserve quality of life

oncology colleagues Preserving spinal function and minimizing disability
Management of malignant spinal disease is usually un- must be considered in the context of maintaining
dertaken by collaboration between surgeons, medical quality of life in malignant spinal disease. In all cases,
oncologists, radiation oncologists, and interventional the potential morbidity of surgical intervention must be
radiologists. The choice of optimal treatment depends balanced against the likely prognosis.
on the nature of the tumor and the likely prognosis.
In primary tumors, surgical resection for cure usually
requires clear margins. For metastatic disease, surgical
treatment may be for pain relief, neural decompres-
sion, or debulking—and occasionally for excision of
isolated metastases in suitable tumors.
Metabolic, Stability Alignment
Assess the need for augmentation of the osteo- Restore balance in deformity associated with
Inflammatory, porotic spine
Normal cancellous bone of a vertebral body makes up
metabolic, inflammatory, and genetic disorders
Deformity arising from osteoporotic collapse of the
Genetic about 15% of the volume of the vertebra. Bone density

decreases with age. In the osteoporotic spine, medical
and surgical augmentation may be required to treat
spine or inflammatory conditions such as rheumatoid
arthritis and ankylosing spondylitis can result in loss
of spinal balance. Corrective surgery requires an
Fig 1.2-7 The AOSpine principles for the fragility fractures or prepare the vertebral body for understanding of the specific features of the underlying
treatment of metabolic, inflammatory, and surgical implants. condition to ensure enduring restoration of spinal
genetic disorders. alignment.
Biology Function
Use appropriate medical therapies Maintain quality of life
Calcium content of bone is influenced by age, sex, Patients with osteoporotic spinal fractures or long-
diet, sunlight exposure, hormones, physical activity, standing inflammatory spondyloarthropathies are
and comorbidities. The treatment of osteoporosis is a often elderly and frail. Therapeutic interventions must
major public health issue. The cost of disability related balance the desire for improved function against the
to fractures is reduced by use of appropriate medical possible loss of quality of life due to the development
therapies. of complications.

1 Fundamentals
4 Does minimally invasive spine surgery follow the reduction, correction, and (re)alignment of spinal motion
AOSpine principles? segments are procedures that usually necessitate instru-
mentation and more or less forceful manipulation. Stabili-
Minimally invasive techniques are currently applied to a zation techniques without fusion, percutaneous spinal
wide range of spine surgery procedures (Table 1.2-3 and instrumentation, vertebral body augmentation, and thora-
Table 1.2-4). Surgical invasiveness has been minimized main- coscopic or mini-open access techniques are the cornerstones
ly in the field of surgical access, but also for target surgery of MISS technology, which has taken these demanding
(eg, fragmentectomy instead of discectomy in lumbar disc AOSpine principles into careful consideration and put them
herniations, annular suture postdiscectomy). Despite the into practice (see chapter 4.2.4 Mini-open and percutane-
different techniques, the treatment goals have remained the ous pedicle instrumentation and fusion; chapter 4.3.3 The
same. In the following chapters, excellent examples will be lateral approach to the lumbar spine, and chapter 4.3.4
presented of MISS in different regions of the spine together Deformity correction using minimally invasive spine surgery
with different strategies aimed at achieving the fundamen- techniques).
tal goal, which is to improve the patient’s quality of life.
There is no need to state that preservation or restoration of
The AOSpine principle, biology, applies to all types of sur- function is one of the main goals of MISS. Muscle-sparing
gical procedures and does not need to be adressed specifi- access surgery, disc replacement through mini-open ap-
cally by MISS when it concerns the etiology or pathogen- proaches, dynamic stabilization via percutaneous fracture
esis of spinal disorders. However, as regards the protection treatment to preserve healthy motion segments are some
of neural structures, or the enhancement of bone or tissue of the subjects that will be covered in this book, thereby
healing in general, especially in the chapters on minimally highlighting that MISS tenets are in perfect agreement with
invasive decompression and fusion techniques, there are a AOSpine principles.
number of examples that demonstrate the significant ad-
vantages of minimally invasive surgical techniques com-
pared to the so-called standard techniques.
Cervical spine Foraminotomy
Stability and alignment are probably the most challenging Microfacetectomy
AOSpine principles for implementation in MISS because
Craniocervical junction decompression
Laminoplasty
Fusion procedures with instrumentation (eg, transpedicular,
Cervical spine Uncoforaminotomy translaminar, lateral mass)
Decompression surgery (eg, intervertebral, transnasal, Skip laminectomy

transoral) Thoracic spine Costotransversectomy
Fusion procedures (eg, cages, plates) Transpedicular decompression surgery
Total disc replacement Laminotomy
Vertebral artery decompression Vertebral body augmentation (vertebroplasty/kyphoplasty)
Thoracic spine Decompression surgery (eg, disc pathologies, fracture) Fusion procedures (percutaneous pedicle screw placement)
Fusion procedures (eg, cages, plates) Lumbar spine Decompression surgery (disc pathologies, synovial cysts,
Total disc replacement acquired spinal stenosis)
Lumbar spine
• Medial and paramedian
Nucleus replacement • Intraforaminal and extraforaminal
Fusion procedures (cages, plates)—mini-ALIF Vertebral body augmentation (vertebroplasty/kyphoplasty)
• Anterior, anterolateral, lateral
Lordoplasty
Spinal canal decompression
Dynamic nonfusion techniques (incl. nucleus replacement)
Anterior extraforaminal decompression
Fusion procedures (eg, percutaneous pedicle screw
Vertebral body augmentation placement, translaminar screws, transsacral techniques)
Tumor marginal resection/curettage Intervertebral support (mini-PLIF, TLIF)
Table 1.2-3 Minimally invasive spine surgery—applications using Table 1.2-4 Minimally invasive spine surgery—applications using
anterior approaches. posterior approaches.
21

5 Further reading
Kim DH, Regan JJ, eds (2005) Endoscopic

spine surgery and instrumentation. Stuttgart:
Thieme Verlag.
Mayer HM, ed (2005) Minimally Invasive
Spine Surgery. 2nd ed. Berlin Heidelberg
New York: Springer Verlag.
Ozgur B, Benzel E, Garfin S, eds (2009)
Minimally invasive spine surgery – a practical
guide to anatomy and techniques. Dordrecht
Heidelberg London New York: Springer
Verlag.
Vaccaro AR, Bono CM, eds (2007)
Minimally invasive spine surgery. London:
Taylor and Francis.

1.3 The four pillars of minimally invasive spine surgery
Roger Härtl
1 Introduction In this chapter, an attempt will be made to outline some of

the basic developments that have taken place within these
The first ten years of the 21st century saw the use of mini- fields over recent decades, and which have made MISS pos-
mally invasive surgical procedures become increasingly sible. There are of course many areas that overlap or inter-
widespread. The goal of minimally or less invasive spine sect. Several excellent reviews on these subjects have been
surgery (MISS) is to leave the smallest possible “surgical published, and have been cited herein.
footprint” while still achieving a similar goal to that of open
surgery, but with the same or an even better functional
outcome for the patient. The key principles of MISS relate 2 Spinal microsurgery using the microscope or
to the avoidance of injury to the surrounding tissues. These endoscope
have been recently outlined by Kim [1], and may be sum-
marized as follows: respect for the tendinous attachment 2.1 The microscope
of the major muscles involved (eg, the origin of the mul- The first practical use of the microscope in medicine prob-
tifidus muscle at the spinous process in the lumbar spine); ably dates back to the 17th century when Giuseppe Campani
the utilization of neurovascular and muscle compartment (1635–1735) invented an optical viewing system and re-
anatomical planes for dissection; and the minimization of ported in a letter to the pope in 1686 that he had used it
collateral soft-tissue injury through the use of modern, self- successfully “for the examination of the wound of the leg”
retaining, usually tubular retractors, which limit the width [2]. It was not until the early 20th century that otolaryn-
of the surgical corridor. These principles apply to all stages gologists became the first surgeons to use the microscope.
of the MISS procedure: the planning, the approach or ac- After World War II, ophthalmologists and vascular and
cess, the target surgery including a stabilization procedure plastic surgeons also began to make use of the microscope
if necessary, and finally, closure of the operative field. in the operating room, and added further technical improve-
ments [3]. The introduction of the operating microscope
MISS is not an “invention”; it is based on existing surgical into the field of neurosurgery and subsequently microneu-
principles, and developed out of the advances made in open rosurgery is closely connected with Littmann from the com-
surgical techniques and improvements in tools. There are pany Carl Zeiss in Germany. In 1953, Carl Zeiss introduced
at least four areas of orthopedic and neurological surgery the OPMI-1, the first true surgical microscope with a coaxial
that have been crucial to the development of MISS: light system which allowed for adjustment of magnification
1. Microsurgical techniques have evolved considerably without altering focal length (Fig 1.3-1).
since the 1960s, with the increasingly widespread use
of the microscope and also more recently of the endo- The ear, nose, and throat surgeon House from Los Angeles
scope for intraoperative magnification. introduced the Zeiss microscope into the United States after
2. Percutaneous mini-open and more recent tubular access he had been trained in its use by ear, nose, and throat sur-
strategies have helped to minimize muscle injury. geons in Germany. The neurosurgeon Kurze from the Uni-
3. With fewer landmarks and more limited visualization versity of Southern California was so impressed by the pos-
due to the smaller approach, imaging and navigation sibilities the new technique had to offer that he decided to
techniques have become indispensable for the accurate spend some time in House’s laboratory to gain experience
localization of the target pathology and the proper place- in how it should be used. Kurze eventually performed the
ment of spinal implants. first neurosurgical operation using the operating microscope
4. Finally, the refinement of MISS techniques has neces- in 1957, when he removed a tumor from the seventh nerve
sitated the development of specialized implants and guides in a five-year-old patient [4]. Soon after, in 1958, the neu-
for instrumentation of all the anatomical regions of the rosurgeon Donaghy [4] set up the world's first microsurgery
spine via anterior, posterior, and lateral approaches. research and training laboratory in Burlington, Vermont.
23

Author Roger Härtl
Around the same time, Malis from Mount Sinai Hospital in far greater accuracy during surgical attack and provides the
New York [5] introduced the bipolar coagulation technique means for a more accurate clinical delineation between
into neurosurgery. The microscope rapidly became an in- normal and pathological tissue.”
dispensable tool in microsurgery. One of the landmark pub-
lications was the paper by the vascular surgeons Jacobson Since these early experiences, the microscope has become
and Suarez [6], in which they demonstrated the contribution an integral part of spine surgery. Spine surgery microscopes
of the microscope in improving the outcome of small-ves- have been improved upon: while premium optics, illumina-
sel anastomoses. Jacobson was also the first to develop a tion and focus remain basically unaltered, certain key im-
two-person microscope that allowed a second surgeon to provements have been added (Fig 1.3-2). One of the main
assist during the operative procedure [3]. features of a spine surgery microscope is the depth of field,
which frequently needs to be greater for spine surgery be-
In 1966, a Turkish neurosurgeon named Yasargil, who had cause of the type of instruments used. For example, the
trained in Zurich under Krayenbühl, spent time in Donaghy’s Leica M525 OH4, which was introduced in 2012, integrates
laboratory to learn more about microsurgical techniques. a 400W Xenon bulb for better illumination and greater
Upon his return to Europe, Yasargil and his group made a working distance for tubular spine surgery. Customized
large number of significant technical improvements to the rotatable binoculars help the surgeon achieve a comfortable,
operating microscope. Yasargil is, of course, best known for ergonomic and physically well adapted body position dur-
his pioneering contributions to cranial neurosurgery. How- ing surgery. Current surgical microscopes include the option
ever, he was also one of the first to introduce microsurgical to integrate navigation technology and high-definition
techniques into spine surgery in the late 1960s and early video documentation systems, as well as easy editing and
1970s. He and Caspar from Germany reported separately transfer of videos to hand-held devices. Interactive control
on their 5–7-year experience in lumbar microdiscectomy panels allow touch-screen control of microscope functions.
surgery using the operating microscope, but in the same Customized settings for individual surgeons can be stored
journal and during the same year, in 1977 [7, 8]. Then a year and recalled at the touch of a button to ease workflow. At
later, Williams from Las Vegas [9] published a report on his present, microscopy integrated with three-dimensional
clinical experience using a similar microsurgical approach (3-D) navigation is used primarily for cranial neurosurgery,
for the treatment of lumbar disc herniations. He stated: “The but also shows much promise for use in spinal procedures,
microscope … may revolutionize the quality of patient care especially once intraoperative CT scanners have become
for any practitioner of surgery. The instrument promotes more available (Fig 1.3-3).
Fig 1.3-1 The Zeiss OPMI-1 was introduced Fig 1.3-2 The Leica M525 OH4 provides 36% longer reach, height
in 1953, and was the first true surgical micro- and clearance, allowing surgeons the flexibility required for microscope
scope with a coaxial light system in which the placement. (Image courtesy of Leica Microsystems Inc.)
magnification could be changed without altering
the focal length.

1 Fundamentals
2.2 The endoscope (Fig 1.3-4). Using a number of these advanced techniques,
A cystoscope (“myeloscope”) was used as early as 1938 for in 2009 Ruetten et al [16, 17] reported excellent results on
the evaluation of a disc pathology, nerve roots, and the comparing percutaneous endoscopic surgery of the cervical
cauda equina by Pool at Columbia University [10]. Much and lumbar spine to open microdiscectomy. Percutaneous
later on, in 1977, Apuzzo et al [11] were among the first to endoscopic spine surgery is currently gaining increasing
describe the use of an endoscope for spinal endoscopy. At acceptance among the surgical community, and it will be
this point, it should also be noted that percutaneous spinal interesting to see whether the optical limitations of endo-
discectomies or nucleotomies without direct visualization scopically-assisted surgery and the tools currently available
had been performed since the mid-1970s by Hijikata et al will be as effective as microscope-assisted microsurgery for
[12]. Hausmann and Forst [13] were the first to describe the the treatment of spinal pathologies.
insertion of a rigid arthroscope into the disc space to assist
visualization during lumbar disc surgery. In 1986, Schreiber In 1997, Smith and Foley [18, 19] reported on a microendo-
and Suezawa [14] combined the Hijikata technique with a scopic lumbar discectomy, in which endoscopes were used
percutaneously introduced endoscope for better visualiza- through tubular retractors to perform the discectomy. Ex-
tion. Mayer and Brock [15] had used the endoscopic percu- cellent clinical results using this technique for the treatment
taneous technique for lumbar disc herniations from 1987 of pathologies in the lumbar and cervical spine were sub-
onwards, and in 1993 compared their results to those ob- sequently reported [20–22].
tained with open lumbar microdiscectomy. Percutaneous
endoscopic discectomy was performed using an endoscope However, several questions regarding tubular surgery re-
angled at 70° coupled to a television and video unit, with main, especially regarding the advantages of using the en-
the patient placed under local anesthesia. They found endoscope versus the microscope. In a personal interview with
doscopic discectomy to be an effective procedure for patients Kevin Foley, he stated that “the original tubular retractor
with “contained” and small subligamentous lumbar disc surgeries were performed with small diameter tubes, typi-
herniations. cally 14 mm in diameter. Using an endoscope, rather than
a microscope, allowed the surgeon to visualize off-axis
More recent developments that have significantly contrib- anatomical structures, including anatomy that was adjacent
uted to the advancement of percutaneous spinal endos- to the edge of the tube but not directly beneath the long
copy include the introduction of various angled, high-res- axis of the tube. This remains an advantage over a micro-
olution rod-lens operating endoscopes, variable-sized scope, where an angled lens can be introduced into the
working channels, and highly specialized working instru- surgical space and the surgeon can see ‘around the corner’.
ments such as angled forceps, high-speed drills, and lasers It allows the surgeon to work through a smaller approach
Fig 1.3-3 Photograph of the Brainsuite at BrainLab (Munich, Germany), showing display Fig 1.3-4 Angled high-resolution rod-lens
screens and state-of-the-art imaging equipment (MRI, CT scanner), permitting intelligent preop- operating endoscopes for use in percutaneous
erative planning and intraoperative navigation. spinal endoscopic procedures. The varied-an-
gled Wolf endoscopes, with a large diameter of
4.1 mm and different-sized working channels,
allow the use of highly specialized working in-
struments such as angled forceps, high-speed
drills, and lasers. (Image courtesy of Richard
Wolf Medical Instruments Corporation).
25

Author Roger Härtl
corridor. The disadvantages of the endoscope included: 1) 3 Access strategies to the spine
lack of a 3-D image, 2) diminished image quality as com-
pared to a modern microscope, and 3) ergonomic issues (eg, 3.1 Subperiosteal, intermuscular, and intramuscular
the need to move the endoscope to avoid ‘fencing’, or in- approaches
terference with surgical instruments introduced through Approaches to the spine can be divided into traditional
the tube). Over the early years of surgery through tubular subperiosteal approaches and muscle-sparing intermuscu-
retractors, it became apparent that it was easier for most lar or intramuscular approaches. The subperiosteal midline
surgeons to learn to perform tube surgeries with a micro- approach requires little knowledge of the muscular anato-
scope, rather than an endoscope. When I lectured on this my, and has been successfully used for many years for open
subject, I would teach that it was easier for a surgeon to decompression and fusion surgery in all anatomical regions
learn one new skill, which I termed ‘tubology’ (the skillset of the posterior spine. However, this approach sacrifices
needed to work through a small approach portal), rather large portions of the posterior stabilizing elements includ-
than two new skills (tubology and endoscopy). Interest- ing ligaments, tendons, and bony structures. It may also
ingly, surgeons that were already facile with endoscopy lead to denervation and devascularization of the adjacent
tended to prefer this over the use of the microscope with muscles. A partial exception to this is cervical laminoplas-
tube surgeries. This remains true in much of Japan, for ty, in which an attempt is made to reconstruct the poste-
example.” rior elements. The supraspinous and intraspinous ligament
complex, the multifidus muscles of the lumbar spine, and
Most surgeons in North America currently use the micro- the facet joints significantly contribute to the stability of
scope in preference to the endoscope when performing the spine at their respective levels, and also serve as bridg-
tubular surgery. This is probably due to the fact that the ing structures to the adjacent levels. Disruption of these
majority of surgeons are more familiar with the microscope, structures has been shown in animal and human anatom-
which is commonly used in cranial neurosurgery, and pro- ical specimen studies to cause significant instability, espe-
vides 3-D magnification. cially as regards flexion [34, 35]. In addition, subperiosteal
muscle dissection and the use of self-retaining retractors
Other fields of application for the endoscope have been may result in muscle atrophy [36–38], which in turn can
explored. With the introduction into surgery of video imag- lead to decreased force production capacity [39]. Mayer et
ing and further improvements in endoscopy, “video-assist- al [40] evaluated trunk muscle strength in patients that had
ed thoracoscopic endoscopy” was popularized in the early undergone lumbar surgery and found that in subjects that
1990s by Mack et al [23] and later by others. Video-assisted had undergone fusion procedures, it was significantly
thoracoscopic endoscopy has been used with good clinical weaker than in those that had undergone discectomy.
results for a range of spinal pathologies, using a variety of Muscle denervation due to extensive exposure, especially
procedures including thoracic discectomy, corpectomy for over the facet joint and pars interarticularis, is another
tumor removal and the treatment of trauma, anterior release source of muscle atrophy. All these factors have a significant
for deformity correction, and thoracic sympathectomy [24– impact on patient recovery and on the long-term effect of
28]. However, this technique is associated with a significant surgery both at the index level and as regards adjacent seg-
learning curve and is thus mainly performed in specialized ments [41, 42]. This topic has been recently reviewed by Kim
centers. In 1991, Obenchain [29] was the first to report on et al [1, 43]. Clinical results clearly support these observa-
the use of an endoscope for anterior lumbar discectomy; he tions; in a study comparing trunk muscle strength between
termed this procedure “laparoscopic lumbar discectomy”. patients that underwent open posterior versus percutane-
Although in 1995 larger case series were reported in which ous instrumentation, the latter was found to be associated
patients were treated by laparoscopic lumbar spine surgery with a 50% improvement in lumbar extension strength,
using the endoscope [30, 31], this technique has largely been whereas patients that underwent open surgery displayed
abandoned in favor of the mini-anterior lumbar interbody no significant improvement in this respect [41]. Stevens et
fusion (mini-ALIF) approach due to the complex learning al [42] assessed the appearance of the multifidus muscle via
curve required, the increased risk of complications, and the MRI in patients treated by open versus MISS lumbar inter-
high conversion rate to open surgery. However, computer- body fusion techniques, and found that for the open surgery
assisted endonasal endoscopic resection of odontoid pa- group, marked intermuscular edema was observed on post-
thologies to decompress the cervicomedullary junction has surgical MRI at 6 months postsurgery. In contrast, for pa-
been described as a minimally invasive alternative to “max- tients in the MISS group, normal muscle appearance was
imally invasive” transoral surgery [32, 33]. observed on MRI.

1 Fundamentals
Less invasive access and treatment strategies for the lumbar and Robinson [49], and by Cloward [50] in the same year.
spine have been explored from the very beginning of spine An even less invasive approach was described in 1996 by
surgery, and as previously noted, can be divided into mus- Jho [51] for anterior cervical foraminotomy.
cle-sparing inter- and intramuscular approaches.
In contrast, the intramuscular technique approaches the
Intermuscular approaches make use of anatomically defined spine by splitting the muscles. Most percutaneous endo-
planes between muscle groups to access the spine [44]. In scopic and tubular retractor-assisted approaches are cur-
1953, Watkins [45] was probably the first to describe a para- rently performed via this technique.
spinal approach between the fascial planes of the sacrospi-
nalis and quadratus lumborum muscles to expose the trans- 3.2 Percutaneous intra-/transmuscular approaches
verse processes for posterolateral fusion. Wiltse [46] later For many, the age of MISS began when percutaneous che-
reported on a modified transmuscular approach that differed monucleolysis was introduced in 1963 by Smith [52]. Smith
from Watkins’ exposure in that it involved a longitudinal injected chymopapain percutaneously into the disc of a
separation of the sacrospinalis group between the multifidus sciatic patient to enzymatically dissolve the nucleus pulpo-
and longissimus muscles, and not between the lateral bor- sus. However, this technique subsequently fell out of favor
der of the entire sacrospinalis group and the quadratus because the results did not seem to compare well with those
lumborum (Fig 1.3-5). Wiltse and Spencer [47] later described for open surgery [53].
this approach for the removal of far lateral disc herniations,
the insertion of pedicle screws, and decompression of the Percutaneous nucleotomy without direct visualization was
opposite side from inside the vertebral canal. Excellent then introduced in 1975 by Hijikata et al [12]. Modified
anatomical reviews on this subject have also been published techniques were subsequently described by the orthopedic
[44, 48]. surgeons, Kambin and Gellman [54], who added power shav-
ers and other specialized instruments to the armamentari-
This being said, it is interesting to note that one of the most um of surgical tools. Their approach was based on the idea
popular, least invasive, and most widely used spinal proce- of decompressing the pressurized disc via an annulotomy
dures for anterior cervical discectomy uses an intermuscu- from within, thereby preventing disc herniation, or revers-
lar approach, which was first popularized in 1958 by Smith ing the disc herniation into the spinal canal. This approach
was later termed the “inside-out technique” [55, 56]. In 1986,
Schreiber and Suezawa [14] combined the Hijikata technique
with the use of a percutaneously introduced endoscope for
better visualization. In that same year, Kambin and Samp-
son [57] introduced the endoscopic transforaminal technique
with posterolateral access (Fig 1.3-6). This endoscopic ap-
proach is based on accessing the disc space through Kambin's
triangle in the “safe zone” between the exiting and travers-
ing nerve roots (Fig 1.3-7), an area that is known to surgeons
familiar with the open or MISS transforaminal lumbar in-
4 terbody fusion (TLIF) technique [58]. Due to the limitations
3
2 of this approach in accessing certain parts of the spinal ca-
1 nal, the full-endoscopic lateral trans-/extraforaminal ap-
proach was developed to provide adequate access to most
of the spinal canal under continuous visualization [59]. The
full-endoscopic interlaminar approach was subsequently
Fig 1.3-5 Axial MRI scan showing the added, which permits the treatment of pathologies that are
lumbar cross-sectional anatomy including the outside the range of indications for the transforaminal pro-
intermuscular plane between the multifidus
cedure [60, 61]. Today, the recent technical advances enable
(1: medial) and the longissimus muscles
(2: intermediate), and the plane between the
the full-endoscopic procedure to be performed for the treat-
longissimus (3: intermediate) and iliocostalis ment of most disc pathologies and also for the decompres-
muscles (4: lateral). sion of lumbar spinal stenosis (Fig 1.3-8).
27

Author Roger Härtl
a b
c d
Fig 1.3-6a–d Fig 1.3-7 Endoscopic transforaminal
a–b Endoscopic posterolateral approach. Skin entry point (a). View of the working area technique using a posterolateral approach
provided by this approach, which is mostly suitable for intradiscal pathologies (b). based on accessing the disc space
c–d Endoscopic transforaminal approach. Skin entry point (c). This approach shifts the through Kambin’s triangle in the “safe
working area to the spinal canal (d). zone” (dotted lines) between the exiting
(Images courtesy of Richard Wolf Medical Instruments Corporation.) and traversing nerve roots.
a
Fig 1.3-8a–c
a Range of endoscopic instruments used for complex endoscopic
procedures.
b Burrs and bone punches used for bone resection.
c Postoperative CT scan after interlaminar endoscopic approach for c
laminectomy showing good decompression. Arrows indicate lateral
bone resection down to the floor.
(Images courtesy of Richard Wolf Medical Instruments Corporation.)

1 Fundamentals
Of historical significance was the development of auto- proach in the laboratory since 1994, and the first clinical
mated percutaneous lumbar discectomy in the 1980s. In case was performed in early 1996 (according to a personal
this procedure, an outer cannula was introduced percutane- interview with Kevin Foley). This technique developed out
ously against the disc space and a rotating inner cannula of their experience gained with automated percutaneous
removed disc material under suction aspiration. Initial lumbar discectomy and percutaneous endoscopic transfo-
clinical results were reported in 1987 by Maroon and Onik raminal approaches. Foley and Smith had been frustrated
[62], but the procedure eventually fell out of favor. Simi- by their inability to adequately visualize the relevant anat-
larly, laser discectomy was first reported by Choy et al from omy and the pathology to be treated, by ergonomic issues
Austria [63]. Mayer combined this technique with the en- related to small cannulae and tiny instruments, and by dif-
doscope for better visualization in 1992 [64]. However, both ficulty in adequately decompressing the nerve roots (Kev-
procedures have a very limited indication because they do in Foley, personal interview). Microendoscopic discectomy
not allow direct removal or decompression of pathologies was specifically designed to address these issues, while re-
within the spinal canal. The published literature has never maining a minimally invasive procedure that utilized a
fully supported their use, and laser discectomy is now rare- muscle-sparing, percutaneous approach. The METRx tubu-
ly performed and cannot be recommended for the treatment lar retractor system was introduced in 2003, and allowed
of lumbar disc disease [65]. the use of the microscope during the operative procedure
(Fig 1.3-10b). Excellent clinical results obtained with this
3.3 Tubular intra/transmuscular approaches technique for the treatment of pathologies affecting the
Other approaches have attempted to improve the microd- lumbar and cervical spine were subsequently reported [20–
iscectomy technique by using less invasive retractors. For 22]. In North America, tubular access has gained widespread
example, surgeons have used various types of less invasive popularity, and is currently used to treat pathologies in all
specular retractors for standard microdiscectomy cases fol- regions of the spine via posterior and lateral approaches.
lowing a typical subperiosteal dissection [66] (Fig 1.3-9). In Access via tubular retractors allows complete decompression
1997, Smith and Foley [18, 19] described microendoscopic and instrumentation of the spinal segments, while preserv-
discectomy (MED) for the treatment of lumbar spine pa- ing all the posterior stabilizing elements and protecting the
thologies, an approach that essentially consisted of a mod- muscle tissue and tendon attachments (Fig 1.3-11).
ification of the microtechnique in which an endoscope
through tubular retractors was used to perform the discec- Tubular approaches have been used for the treatment of
tomy (Fig 1.3-10a). These authors had worked on this ap- lumbar and cervical stenoses and disc herniations, lumbar
foraminal narrowing, and synovial cysts. More complex
procedures such as spinal fusion and deformity correction
are also routinely performed through tubular retractors in
conjunction with mini-open or percutaneous instrumenta-
tion techniques. Spine surgery through tubular retractors
offers particular advantages when treating obese and/or
geriatric patients [67–69].
There are several key observations to be made regarding

tubular surgery, the first of them being the ability to achieve
contralateral exposure and decompression of the lumbar
spine via tubular retractors. The anatomical description and
preliminary clinical results on unilateral laminotomy for
contralateral decompression were first reported by Spetzger
et al from Germany in 1997 [70, 71]. This procedure was
subsequently improved upon with the introduction of tu-
bular retractors, and now allows excellent decompression
of the contralateral lateral recess and even lateral disc
herniations and the contralateral foramen (Fig 1.3-11) [72,
73]. Synovial cysts can be resected safely, without compro
mising the facet joint, by approaching them from the
Fig 1.3-9 Caspar Micro Lumbar Retractor. contralateral side, ie, from the “normal” dura and anatomy
29

Author Roger Härtl
a b
Fig 1.3-10a–b
a Illustration of endoscope-assisted disc removal with a pituitary rongeur through a tubular retractor based on Foley and Smith’s initial description
of this technique [18].
b The METRx system of sequential dilators. From left to right, the guide wire and two initial soft-tissue dilators (5.3 mm and 9.4 mm), tubular
retractor sets with respective dilators (14, 16, and 18 mm), and flexible arm assembly with table attachment clamp (Medtronic-Sofamor Danek,
Memphis, USA).
Fig 1.3-11a–b
a Tubular retractor placed in the lumbar spine.
b Decompression of a contralateral pathology. AP intraoperative
x-ray showing a tubular retractor, with the tip of the nerve hook
a at the lateral aspect of the contralateral neural foramen.

1 Fundamentals
(Fig 1.3-12) [74]. Tubular decompression appears to be espe- The first minimally invasive posterior lumbar interbody fu-
cially useful for the treatment of lumbar spinal stenosis but sion was performed in early 2001 by Foley and colleagues
is, however, associated with a significant learning curve [75, (personal interview), and their preliminary clinical results
76]. The clinical results are similar to those reported for open were published in 2002 and 2003 [80, 81]. This was pre-
surgery. However, biomechanical and laboratory results ceded by their description of percutaneous lumbar pedicle
indicate that laminectomy via tubular retractors or bilat- screw insertion using the Sextant system [82, 83]. Although
eral laminotomy cause less destabilization when compared minimally invasive posterior lumbar interbody fusion (PLIF)
to open bilateral laminectomy [77, 78]. Therefore the concept and TLIF surgery have become very popular over the years,
of decompressing patients with spinal stenosis and stable, the question remains whether the results are comparable
grade 1 degenerative spondylolisthesis seems to be a reason- to those obtained for open surgery. A meta-analysis com-
able one, and is currently under investigation. The results paring open to minimally invasive TLIF surgery found the
of a cost-utility study showed that tubular decompression fusion and complication rates to be very similar for both
without fusion for this category of patient is more cost- procedures [84]. On the basis of 16 studies (716 patients),
effective when compared to decompression and fusion [79]. the mean fusion rate for open TLIF was 90.9%, whereas
The possibility of carrying out decompression of spinal struc- for 8 studies (312 patients) the mean fusion rate for mini-
tures without destabilization is considered to be one of the mally invasive TLIF (mTLIF) was 94.8%. The complication
main advantages of tubular surgery. Critics of tubular sur- rates amounted to 12.6% and 7.5% for open and mTLIF
gery point out the learning curve and the possibly increased groups, respectively. Interestingly, the use of recombinant
use of image intensification. bone morphogenetic protein was higher in the mTLIF group
(50% versus 12%).
Thoracic and upper lumbar pathologies requiring decom-

pression and stabilization such as trauma, tumors, or infec-
tion are also targets for less invasive posterior intramuscu-
lar surgery. The feasibility and encouraging clinical results
of an open posterior approach for thoracolumbar corpec-
tomy with the implantation of expandable cages has been
reported [85]. Similar results can also probably be achieved
using less invasive tubular or expandable retractors [86, 87].
Tubular approaches are also routinely utilized for forami-

notomy and laminectomy in the region of the cervical spine,
and were first described by Adamson et al in 2001 [88] and
Fessler and Khoo in 2002 [22] using the endoscope, then in
2007 by Holly et al and also by Hilton using the microscope
through tubular retractors [22, 88–90]. Clinical reports have
shown the results of microendoscopic foraminotomy with
or without discectomy to be similar to those for traditional
open procedures, with the duration of hospital stay and
initial analgesic use favoring the tubular retractor approach,
but no medium- or long-term differences have been ob-
served [91–94].
Fig 1.3-12 Diagram illustrating how spine pathologies can be The lateral approach to the lumbar spine using tubular re-
resected safely and without compromising the facet joint by tractors developed as a combination of traditional ALIF
approaching them through a tubular retractor from the contralateral
procedures, minimally invasive laparoscopic techniques,
side, ie, from the “normal” dura and anatomy.
and MED. In 2006, Ozgur et al [95] reported on a mini-open
technique for the treatment of pathologies affecting the
mid-lumbar spine from a direct lateral transpsoas approach,
utilizing electrophysiological monitoring to avoid nerve dam-
age for the placement of structural interbody fusion cages.
31

Author Roger Härtl
This approach was based on the work of Luiz Pimenta from A presacral approach to the lumbosacral spine without di-
Brazil [96], who in 2001 had presented his preliminary results rect visualization has been developed and refined in recent
with this technique. The above-mentioned authors termed years, and termed “axial lumbar interbody fusion” [99]. This
this approach “extreme lateral interbody fusion”. Their approach was developed in light of the obvious risks and
technique, utilizing triggered electromyographic nerve drawbacks connected with conventional anterior and pos-
monitoring and a table-mounted split-bladed retractor sys- terior lumbosacral fusion surgery, such as injury to the
tem, has become the standard procedure for lateral access lumbar muscles during the surgical approach, nerve root
to the mid-lumbar spine. It has gained increasing popular- injury, risk of vascular or bowel injury, sympathetic dys-
ity over recent years, and provides excellent access not only function, blood loss, and deep vein thromboses. The pos-
to the lumbar spine but also to thoracic pathologies between sibility of reaching the L5/S1 and the L4/5 disc space through
levels T4 to L5. Although the initial results are very prom- a paracoccygeal, transsacral approach avoids many of the
ising, the long-term results and the overall safety profile of aforementioned risks. At the same time, it allows discec-
this technique still need to be evaluated. The transpsoas tomy with interbody fusion to be carried out, and sometimes
approach reintroduced the concept of indirect decompres- also the restoration of disc and foraminal height without
sion of the spinal canal, which had been previously observed annular disruption. However, concerns regarding this ap-
in ALIF surgery [97]. Similar results were reported with proach include rectal perforation, infection at the incision
lateral transpsoas interbody fusion [98], with a significant site and/or along the access tract, connected with the im-
increase in dural sac dimensions, possibly due to stretching plantation of the hardware, or of the disc space and adjacent
and unbuckling of the spinal ligaments, and a decrease in vertebral bodies. Even though some clinical reports have
intervertebral disc bulging (Fig 1.3-13). Hence, one of the shown promising results [100], other studies have found a
most important aspects of the lateral approach currently higher failure rate [101], and the role of the presacral ap-
relates to interbody cage positioning and surgical objectives, proach in MISS has not been clearly defined at this point.
ie, a more posterior placement for indirect decompression
of the central canal and the foramen, or a more anterior Other approaches include “video-assisted thoracoscopic
placement for segmental sagittal correction. surgery” (VATS), which was popularized in the early 1990s
by Mack et al [23] and later by others for various thoracic
spinal pathologies.
In summary, all parts of the spine can now be accessed us-

ing minimally invasive muscle-splitting, intramuscular or
intermuscular approaches, all of which have been examined
in other chapters of this book. The majority of MISS pro-
cedures include percutaneous endoscopic and intramuscu-
lar tubular approaches to the cervical, thoracic, lumbar, and
sacral spine. Many neurosurgeons and orthopedic spine
surgeons currently use tubular or related access strategies.
The main advantages of this type of surgery include the
following:
• Less invasive access resulting in muscle and tendon sparing
a b • Ability to decompress spinal structures without desta-
bilization
Fig 1.3-13a–b Indirect decompression of lumbar spinal stenosis via
the extreme lateral approach. Sagittal lumbar MRI before (a) and after
• Excellent contralateral exposure of the pathology in
(b) implantation of interbody spacer. question
• Indirect decompression with implants, particularly with
lateral approaches
• Reliance on interbody fusion rather than on posterolat-
eral fusion.

1 Fundamentals
4 Imaging, navigation and associated technologies ly breach the pedicle can cause spinal, nerve root, or vas-
cular injury as well as dural tears and cerebrospinal fluid
Imaging in spine surgery is essential for the accurate local- leakage. Intuitively, it makes sense that implants that have
ization of the pathology to be treated, avoidance of wrong- been placed with greater accuracy optimize the long-term
level surgery, and the proper insertion of implants. This is outcome. There is general consensus among surgeons that
even more important in the case of MISS procedures, which imaging techniques are essential for the safe and accurate
lack open visualization based on anatomical reference points placement of spinal instrumentation regardless of the com-
that can be used as a basis for orientation and implant place- plexity of the operation, the anatomical region, the level
ment. Spine surgery inherently involves the potential of of training of the individual surgeon, or the degree of op-
injury to the spinal cord, nerves, and vascular structures. erative comfort required. Traditionally, these imaging tech-
Incorrectly positioned implants and screws that significant- niques have involved the use of x-ray or image intensifica-
Technique Indication Pros Cons
X-ray All spine surgery procedures Inexpensive, universally available, No 3-D information provided; requires
technically easy to use postoperative CT scan to confirm implant
positioning
Image intensification All spinal instrumentation procedures Real-time imaging No 3-D information provided; radiation
exposure to surgeon, staff, and patient;
requires postoperative CT scan to
confirm implant positioning
2-D stereotactic navigation or All spinal instrumentation procedures Can facilitate workflow by eliminating the Significant cost involved; training of staff
“virtual image intensification” Replaces AP/lateral image intensification C-arm(s); less radiation exposure for the and x-ray technician necessary; learning
surgeon, staff, and patient curve required; changes affecting the
anatomy over time are not detected (eg,
stray K-wires or injection of vertebroplas-
ty cement); requires postoperative CT
scan to confirm implant positioning
3-D stereotactic navigation All spinal instrumentation procedures Can facilitate workflow by eliminating the Significant cost involved; training of staff
C-arm(s); less radiation exposure for the and x-ray technician necessary; learning
surgeon and staff; improved accuracy of curve required; changes affecting the
screw placement anatomy over time are not detected (eg,
stray K-wires, vertebroplasty cement).
Use of K-wires requires real-time image
intensification
• with intraoperative image Image intensifier-CT can be brought in Limited image quality, especially in, eg,
intensifier-CT scan as needed, and can also be used for, eg, obese patients, cervicothoracic junction,
image intensification (K-wires), or in- etc; only 3–4 levels can be visualized in
traoperatively to confirm spinal implant one “spin”
positioning
• with intraoperative CT scan Improved image quality; large segments Significant cost involved; physical
of the spine can be visualized; can be integration into the operating room may
used intraoperatively to confirm spinal pose a challenge. Requires special ope-
implant positioning rating room table and other additional
equipment
• with preoperative CT scan Open surgery; can sometimes be used Good image quality; large segments of Difficult to use for MISS; does not
for MISS when matched with intraopera- the spine can be visualized account for positional movement or shif-
tive image intensifier views ting of the spine; requires postoperative
CT scan to confirm implant positioning
Robotic surgery Lumbar/thoracic spinal instrumentation Preoperative planning of instrumenta- Significant cost involved; training of staff
procedures tion size and trajectories, planning of and x-ray technician necessary; learning
osteotomy procedures; no need to use curve required; changes affecting the
cannulated screws or K-wires anatomy over time are not detected;
requires postoperative CT scan to
confirm instrumentation positioning. No
real-time tracking
Table 1.3-1 Summary of the different imaging and navigation techniques in spine surgery.
33

Author Roger Härtl
tion guidance either for active guidance throughout surgery, 4.1 First-generation spinal navigation systems
or as a control at the end of the operative procedure. The first-generation spinal navigation systems included 2-D
navigation that relied on image intensification-based AP
More recently, stereotactic 2-D or 3-D imaging techniques and lateral images to track an instrument’s position in rela-
have been developed and gained general acceptance in neu- tion to the spinal anatomy. However, this “virtual image
rosurgery and in certain orthopedic trauma procedures. In intensification” technology provided only 2-D information
computer-assisted surgery (CAS) a virtual representation (Fig 1.3-14) [105]. The first-generation 3-D navigation systems
of the surgeon’s instruments is shown in relation to the used preoperative CT scans and required matching between
patient’s anatomy, which is displayed on a separate com- the patient’s bone anatomy and the scan through the surgi-
puter screen. Pre- or intraoperative CT scans or image in- cal exposure of anatomical landmarks. Alternatively, intra-
tensifier images are used to generate a “virtual surgical operative AP and lateral image intensification could be used
reality”. This surgical “GPS” requires the attachment of a to match the preoperative CT scan against the patient’s
reference array with reflective beads to the patient’s spinal anatomy in the operating room. The initial clinical reports,
anatomy and to the surgical instrument that is to be tracked. which described spinal instrumentation placement in the
The 2-D information obtained by two infrared cameras track- mid-1990s, showed promising results [106–109]. However,
ing these beads is converted into a 3-D representation based generally speaking, these early navigation systems were
on the different reflective angles. The different types of CAS not well received by the surgical community; they were
have been reviewed in a previous AO publication [102]. considered cumbersome, disruptive to the workflow in the
Tracking using electromagnetic instead of infrared technol- operating room, and seemed to increase operating time.
ogy is under evaluation, and has shown promising results
[103, 104]. The types of spinal imaging and navigation cur- 4.2 Second-generation spinal navigation systems
rently available have been summarized in Table 1.3-1, while The second-generation spinal navigation systems saw the
the potential benefits and possible drawbacks of CAS have light of day in 2002 when Siemens introduced the first por-
been outlined in Table 1.3-2. table cone beam CT scan—the “Iso-C 3-D” image guidance
Possible advantages Possible disadvantages
Improves accuracy of implant The significant learning curve associ-

placement and optimizes size of the ated with these technologies for the
implant used surgeon and the operating room staff
could constitute a drawback
Reduces radiation exposure to the
surgeon and medical team Significant cost involved in acquiring
the basic equipment
Enables less invasive approaches
through smaller access Interruption of surgical “workflow”
Allows preoperative planning of imp- Additional equipment and ‘‘surgical
lant size and trajectories, and planning footprint’’ in the operating room
of osteotomy procedures
Lack of scientific data in support of its
Allows intraoperative verification of clinical benefit
screw placement accuracy (intraope-
rative scanners or image intensifier CT Limited imaging quality and field of
scan only) view with the mobile 3-D imaging
devices currently on the market
Minimizes the risk of wrong-level a b
surgery Potential increase in operating room
time Fig 1.3-14a–b The “virtual fluoroscopy” navigation system used image
Decreases reoperation rate intensification-based AP (a) and lateral (b) images to track an instru-
Potential line-of-sight limitations for
optical systems ment’s position in relation to the spinal anatomy, and provided only 2-D
information [105].
Concerns exist regarding accuracy,
and interference with metallic
instruments using electromagnetic
navigation systems
Table 1.3-2 Possible advantages and disadvantages of CAS.

1 Fundamentals
system—which allowed the reformatting of intraopera- improved screw placement accuracy, and that it was em-
tively acquired 2-D images into a 3-D dataset. This intra- ployed in cases with a higher degree of surgical complexity
operative CT scan could be used for navigation, and also to such as for MISS, cases of deformity, or revision surgery.
confirm the correct placement of instrumentation. Initial Interestingly, it was also observed that CAS was associated
reports confirmed the usefulness of intraoperative 3-D im- with the use of larger pedicle screws and a higher screw-
aging for the placement of spinal instrumentation and for to-pedicle diameter ratio, a finding that can be explained
the verification of correct implant positioning [110]. In 2006, by the possibility afforded by CAS to plan and therefore to
the “O-arm” (Medtronic) was put on the market: it pro- optimize the diameter of the screw used, which is an im-
vided marginally better imaging quality, but a larger field portant factor especially in patients with poor bone quality
of view. The portable isocentric C-arm and portable scanners or deformity (Fig 1.3-15).
offer the advantage that they can also be used as regular
C-arms, however, their imaging quality is inferior to that There is a degree of concern regarding the safety of current
of stationary CT scans. Computed 3-D navigation techniques imaging and navigation techniques for MISS, particularly
in spinal instrumentation can improve the accuracy of screw as regards the issue of radiation exposure and the use of
placement, potentiate the ability to maximize the screw K-wires over which cannulated pedicle screws are intro-
diameter relative to the pedicle, and reduce the risk of induced. The use of K-wires involves a certain risk to the
jury to critical neurovascular structures [103, 111–117]. A patient, as they can break or bend during the surgical
meta-analysis comparing computer-navigated versus non- procedure, and endanger visceral or vascular structures
computer-assisted pedicle screw insertion (4814 navigated (Fig 1.3‑16). In addition, surgical workflow using K-wires is
versus 3725 nonnavigated procedures) showed that there a complicated process, involving the use of multiple instru-
was a significantly lower risk of pedicle perforation for CAS ments that are passed back and forth between the surgeon
pedicle screw insertion compared to nonnavigated insertion, and the scrub nurse. However, when used intelligently,
with an overall pedicle perforation risk of 6% for CAS, and CAS can help to make spine surgery safer for the patient as
15% for nonnavigated insertion [114]. However, this meta- well as for the surgeon and the operating room staff: The
analysis did not reveal a difference in total operative time issue of radiation exposure in second-generation CAS for
or estimated blood loss when comparing the two techniques. MISS has been addressed by Nottmeier et al [119]. In 25
In reviewing his experience, the present author compared MISS cases with 228 screws placed using portable cone-
navigated versus nonnavigated pedicle screw placement in beam CT navigation, no radiation exposure to the surgeon
260 patients and 1434 screws with an evaluation of screw was recorded. This means that K-wires cannot be used [120].
placement accuracy, screw size, and the complexity of However, this problem has been circumvented by the
surgery [118]. It was found that CAS was associated with present author and co-workers, who recently introduced a
a b a b
Fig 1.3-15a–b Axial (a) and sagittal (b) CT reconstruction of the Fig 1.3-16a–b Views showing the inadvertent advancement of a
lumbar region with planned pedicle screw placement. K-wire during minimally invasive lumbar fusion surgery.
a Axial view on CT lumbar imaging showing the tip of a broken
K-wire perforating the anterior cortex of the vertebral body.
b Intraoperative laparoscopic view during the retrieval procedure,
revealing a K-wire tip that has breached the cortex into the
surrounding soft tissue.
35

Author Roger Härtl
navigated guide tube that allows drilling, tapping and the and on a spinous process. The miniature robot is then at-
placement of the final screw without the need for K-wires tached to the clamp and/or frame. On the basis of combined
[121]. This instrument facilitates the workflow in the oper- CT scan and image intensifier data, the robot aligns itself
ating room by reducing the number of instruments that to the desired entry point and trajectory, as dictated by the
need to be navigated, and reduces the potential risks as- surgeon's preoperative plan (Fig 1.3-18). Studies reporting
sociated with current techniques for the insertion of per- procedures using robotic surgery have found high levels of
cutaneous or mini-open pedicle screws by eliminating the accuracy for implant placements. In a retrospective analy-
need for K-wires (Fig 1.3-17). sis of over 3,200 screws instrumented in 14 centers, Devito
et al [125] reported 98% clinically acceptable implant posi-
4.3 Robotic spine surgery tioning and 98.3% accuracy in a subset of 646 implants
Robotic surgery is being used for the placement of pedicle evaluated by postoperative CT scan. Robotic surgery has
screws in the lumbar and thoracic spine [122–124]. For ex- yielded promising results for percutaneous screw placement:
ample, the Renaissance is a semiactive surgical guidance Kantelhardt et al [126] compared conventional screw place-
robot (Mazor Robotics Ltd, Caesarea, Israel) that has been ment to open and percutaneous robotic surgery in 112 pa-
designed to direct surgeons to predetermined locations along tients that underwent pedicle screw implantation, and found
the spine. On a specially designed graphic user interface that the use of robotic guidance significantly increased screw
with specific software, the surgeon uses the preoperative placement accuracy, while cutting x-ray exposure by 50%.
CT scan to plan the trajectory of the screws. Intraoperative Patients also seem to experience a better perioperative course
image intensifier x-rays with targeting devices are then following percutaneous procedures. The downsides of ro-
matched with the CT-based virtual images, as well as the botic surgery include the fact that active tracking is not
surgeon's plan. A clamp is attached to the spinous process, possible, and that implant accuracy can only be checked
or a minimally invasive frame is mounted on the iliac crest after surgery via CT scan.
a b
c d
Fig 1.3-17a–d Views of the navigated guide tube, which eliminates the need for K-wires (a). The
guide is comprised of a metal tube with a 10 mm outer diameter (b). An interface for attachment
to an infrared reference array is positioned on the proximal end. A drill, tap, and then a pedicle
screw without screwhead can be inserted through this guide tube.

1 Fundamentals
The results of this survey send strong messages to the com-

munity of spine surgeons and their industrial partners:
1. In theory, surgeons generally view CAS as being of
value, and almost 80% have a positive opinion of CAS.
2. In practice, current CAS systems do not meet surgeons’
expectations in terms of time-saving, ease of use, and
integration into the surgical workflow.
3. CAS systems have to be affordable and cost-efficient
before they can be used on a more widespread scale.
4. Training has to be more readily available to overcome
the demanding learning curve required for CAS. This
training should not only address individual surgeons,
but ideally should also include the surgical team in or-
der to better integrate CAS into the existing workflow.
5. Conclusive scientific data are needed to more clearly
Fig 1.3-18 This image depicts the minimally invasive mounting plat- determine the precision, radiation exposure levels, and
form for robotic surgery. A minimally invasive frame is mounted to the cost-effectiveness of CAS. This will require the setting
iliac crest and a spinous process. The miniature robot is attached to the
up of well-designed, prospective clinical trials.
frame. On the basis of combined CT scan and image intensifier data, the
robot aligns itself to the desired entry point and trajectory, as dictated by
the surgeon’s preoperative plan. (Image courtesy of Mazor Robotics Ltd, In conclusion, computer-assisted navigation in spine surgery
Caesarea, Israel.) is a rapidly evolving field; and here, the current state of
developments, which are still at an early stage in the evolu-
tion of this technology, has been summarized. More ad-
4.4 Survey on the use of computer-assisted vanced and user-friendly systems that operate, for example,
navigation in spine surgery with true intraoperative CT scanners are becoming available
Computer-assisted surgery in spinal procedures clearly of- and it will be interesting to see how these systems impact
fers advantages over conventional surgery including great- on the use and acceptance of computer-assisted navigation
er screw placement accuracy, reduced radiation exposure, (Fig 1.3-3) [128, 129]. Spine surgeons will increasingly inte-
and better planning of the size and positioning of implants. grate the techniques of microscopic magnification, pre- and
Therefore it is surprising to note that CAS navigation has intraoperative planning, intraoperative real-time imaging,
not been more widely accepted among spine surgeons. In and 3-D navigation. In future, CAS will include more wide-
this regard, the current viewpoint of spine surgeons regard- spread access to better software and imaging technologies,
ing the use of CAS navigation in their everyday practice is and a combination of CAS with different imaging techniques
an important issue, which has not yet been adequately in- and possibly intraoperative functional assessment, such as
vestigated. Therefore AOSpine conducted a survey-based electrophysiological monitoring [130]. It is highly possible
study to assess opinions on CAS navigation in order to de- that the spine surgeons of the future will view CAS as the
termine the current global attitudes of surgeons on the use standard of care as far as imaging techniques are concerned.
of computer-assisted navigation in spine surgery [127]. This
study showed that despite the widespread distribution of
navigation systems in North America and Europe, only 11% 5 Instruments and implants
of surgeons use them on a routine basis. Surgeons dealing
with high-volume procedures, those with a busy MISS The refinement of MISS techniques has necessitated the
practice, and neurosurgeons are more likely to use CAS. development of specialized instruments and implants, and
“Routine users” consider the accuracy, the potential to fa- guides for the instrumentation of all the anatomical regions
cilitate complex surgery, and the reduction in radiation of the spine via anterior, posterior, and lateral approaches.
exposure as being the main advantages. The lack of equip- The availability of new implants and less invasive instru-
ment, inadequate training, and high costs are the main ments, on the other hand, has also stimulated progress in
reasons why "non-users" show a lack of interest in CAS. the field of MISS.
37

Author Roger Härtl
5.1 Tubular retractor systems also used for lateral exposure (Fig 1.3-20). Some retractors
Research has shown that the type of tissue retraction can also incorporate fiber-optic illumination and endoscopic
have a significant impact on the pressure exerted on the options. A black surface coating helps to minimize glare
muscles during surgery, on muscle ischemia, and on post- and reflection during surgery, and a unilateral bevel fre-
operative muscle strength and recovery from spine surgery quently allows better medial visualization and prevents
[131]. The introduction of less invasive retractor systems muscle creep. In the lumbar spine, these retractors can be
has therefore helped to reduce iatrogenic muscle injury easily angled in order to improve access to the contralat-
during surgery. For example, surgeons have used various eral spinal canal (Fig 1.3-11). In the thoracic and cervical
types of specular retractors for standard microdiscectomy spine, however, this should be carried out with extreme
cases following a subperiosteal dissection [66] (Fig 1.3-9). In caution, as the retractor wall may cause compression of
1997, Smith and Foley [18, 19] described a microendoscop- the spinal cord and potentially lead to injury. In obese
ic discectomy procedure in the region of the lumbar spine, patients the standard tubular retractor may sometimes be
a modification of the original approach, in which endo- too short, in which case an expandable retractor for the
scopes were used through tubular retractors to perform lateral transpsoas approach can be utilized (Fig 1.3-20).
the discectomy. The METRx tubular retractor system
(Medtronic, Minneapolis, USA) was introduced in 2003 Some surgeons prefer more versatile retractors that can be
and allowed the use of the microscope (Fig 1.3-10). In North used for “mini-open” surgery. These retractors typically
America, tubular access has gained increasing popularity consist of several components that allow tissue blades to
and is now used to treat pathologies in all regions of the expand, and to expose larger portions of the anatomy (Fig
spine via posterior and lateral approaches. Current retrac- 1.3-21). These instruments may be suitable for mini-open
tor systems are either fixed-diameter or expandable, and tumor resections and the placement of expandable cages
can provide access to all parts of the spine. They are in- via a posterior thoracolumbar approach. Almost every
serted over a set of muscle-splitting atraumatic dilators manufacturing company in the field of spine surgery now
(Fig 1.3-19). The use of a K-wire is not recommended. In has their own retractor system.
the thoracic and lumbar spine these retractor systems are
a b
Fig 1.3-19a–b Fixed diameter retractor systems can provide access to all parts of the spine. They are inserted over a set of muscle-splitting
atraumatic dilators (a), with flex arm (b).

1 Fundamentals
a b
Fig 1.3-20a–b
a The Oracle retractor, part of a modular and comprehensive set of implants and instruments
designed to support a direct lateral approach to the lumbar spine.
b The Oracle retractor and intraoperative patient positioning.
Fig 1.3-21 The more versatile type of retractor, which can

be used for “mini-open” surgery, typically consists of several
components that allow tissue blades to expand and expose
larger portions of the anatomy.
39

Author Roger Härtl
The use of tubular or mini-open retractors made it necessary early years was to develop a technique and instruments
to develop special sets of bayonetted instruments to permit that would allow the minimally invasive placement of rods
clear visualization of the spinal anatomy (Fig 1.3-22a). These or plates under the dorsal muscular fascia to hold the ped-
include Kerrison rongeurs, curettes, pituitary rongeurs, icle screws and achieve a biomechanically stable construct.
Penfield probes, ball-tip probes, nerve hooks, dissectors, In 1995, Mathews and Long [133] reported on the placement
suction, bipolar forceps, to mention but a few. Pneumatic of percutaneous pedicle screws connected to suprafascial,
or electric high-speed drills with a curved drill attachment subcutaneous plates. In 2000, Lowery and Kulkarni [134]
and drill bit can be used to remove bone (Fig 1.3-22b). The used suprafascial pedicle screw instrumentation that was
author prefers to use a 3 mm matchstick drill bit with a later removed in conjunction with mini-open anterior in-
blunt tip that minimizes the risk of dural injury. The inci- terbody fusion, and reported good results in 8 patients.
dence of dural tears and operative time required are clear- However, the longer moment arms associated with supra-
ly dependent on the number of cases performed with this fascial rod placement aroused concerns regarding the over-
technique. The learning curve required is, however, complex all stability of such a construct. Kevin Foley’s Sextant sys-
and should be taken into consideration before counseling tem [82, 83] then became available soon after, in 2001, and
patients about the most suitable approach [75]. marked the beginning of modern minimally invasive tho-
racolumbar instrumentation. This and most later systems
5.2 Minimally invasive posterior thoracolumbar use an approach based on K-wire implantation using Jam-
instrumentation systems shidi needles for screw placement. It was not until the most
Percutaneous or mini-open techniques for the insertion of recent advances in spinal navigation were introduced that
pedicle screws aim at avoiding or minimizing surgical ex- K-wires became unnecessary. The limitations of the Sextant
posure and retractor-related muscle ischemia, and the de- system were mainly related to the arc-type rod insertion
velopment of atrophy and postoperative complications that system that caused problems in patients with deformities,
are connected with conventional open surgery. An external or in cases of multilevel fusion. Follow-up developments
spinal skeletal fixation system was developed in 1977 by improved many of the shortcomings of the initial system.
Magerl in Switzerland [132] and has been used since then Many companies have now developed user-friendly,
for the treatment of patients with spinal fractures and infec- straightforward instrumentation systems and guides for
tion. This probably marked the first “minimally invasive” percutaneous and mini-open pedicle screw placement
use of spinal instrumentation. The challenge during the (Fig 1.3-23 and Fig 1.3-24).
b
Fig 1.3-22a–b Special sets of instruments for
use with tubular retractors.
a Bayonetted Kerrison rongeur used
through a tubular retractor.
b Pneumatic or electric high-speed drill
with a curved drill attachment and drill bit
a used to remove bone.

1 Fundamentals
a b
c d
Fig 1.3-23a–h Outline of steps involved and instruments used in the insertion of
percutaneous and/or mini-open pedicle screws.
a Step 1: Small skin incisions are made just lateral to the lateral border of the facet joint,
based on an intraoperative AP fluoroscopy view.
b–c Step 2: Pedicle preparation is typically performed by placement of a K-wire using either
AP and lateral fluoroscopy or other forms of navigation. As a next step an awl and then a
tap can be used over the K-wire.
d–e Step 3: Cannulated screws with extension sleeves are inserted over the K-wires and a rod
is inserted.
41

Author Roger Härtl
f g
Fig 1.3-23a–h (cont) Outline of steps involved and

instruments used in the insertion of percutaneous and/or
mini-open pedicle screws.
f–g Step 4: Locking caps are then tightened in place
using a counter-torque. Tightening of the locking caps
reduces the rod.
h Multilevel constructs can be preferred using this
h technique.
Fig 1.3-24a–b Views showing multilevel

posterior MISS pedicle screw instrumentation
after previous lateral transpsoas discectomy
and fusion. In this case, the approach involved
a midline skin incision with multiple small
a b fascial incisions (b).

1 Fundamentals
Also of interest is the use of percutaneous fixation in patients The latest generation of top-loading thoracolumbar instru-
with metastatic spine disease following tumor resection, mentation systems offer the following advantages:
and in patients with traumatic fractures [135]. MISS screw • Multilevel fixation from the thoracic spine to the iliac
fixation may offer advantages to these patients, who are crest
more prone to infection, to avoid the wound healing dif- • Allows to reduce deformities (Fig 1.3-25)
ficulties associated with open surgery, or, in the case of • The more lateral entry point between the transverse
tumor patients, after postoperative radiotherapy. process and the facet joint, and the lateral to medial
trajectory increase the pullout strength of the screw
• Lower rod profile is advantageous because the screw
head can frequently be placed closer to the part of anat-
omy to be treated when compared to open systems
• Some manufacturing companies offer perforated pedicle
screws for cement augmentation (Fig 1.3-26).
a b
c d
e f
Fig 1.3-25a–f
a–b Views showing spondylolisthesis and severe stenosis after
previous microdiscectomy at L4/5.
c Intraoperative image demonstrating grade II spondylolisthesis at
L4/5.
d A laminectomy and discectomy were performed through a 22 mm
tubular retractor. An expandable interbody PEEK cage was used to c
reestablish disc height and partially reduce the slip.
e–f Views showing MISS pedicle screw insertion. Placement of the Fig 1.3-26a–c Cannulated and perforated pedicle screw for MISS
rods and locking cap insertion allowed to completely reduce the cement augmentation.
slip.
43

Author Roger Härtl
Challenges and open questions include the following: lolisthesis after previous microdiscectomy at L4/5, a lami-
• Rod insertion in cases of multilevel procedures and de- nectomy and discectomy was performed through a 22 mm
formities tubular retractor (Fig 1.3-25). An expandable interbody poly-
• The choice of skin and fascial incision: multiple small etheretherketone (PEEK) cage was then used to reestablish
skin incisions versus long midline incision or two para- disc height and partially reduce the slip. MISS pedicle screws
median incisions were used to completely reduce the olisthesis and stabilize
• Screw stimulation can be problematic the level. In this case, bone autograft from the facetectomy
• Some authors report a higher incidence of cranial facet was used in conjunction with iliac crest bone core har-
violations with percutaneously placed pedicle screws vested using a minimally invasive access bone-harvesting
[136]. CAS may be helpful in this regard technique (Fig 1.3-27).
• Alignment and connection of lumbar pedicle screws with
iliac instrumentation. Percutaneous S2 alar-iliac fixation 5.3 Other MISS instrumentation and implants
has been described in the literature [137, 138]. It facilitates Interbody devices have been described for use with tubular
rod alignment and may offer a good alternative to tra- retractors. For example, boomerang or banana-shaped in-
ditional iliac screw placement, but more conclusive terbody cages made of various materials can be inserted
clinical data are needed before this technique can be through tubular retractors and are now routinely used for
fully recommended MISS fusion (Fig 1.3-28). Although bone morphogenetic
• Posterolateral fusion is difficult or impossible with per- protein is frequently used for interbody fusion in MISS sur-
cutaneous or mini-open instrumentation. Therefore, the gery [84], the present author prefers bone autograft from
surgeon generally relies on anterior interbody fusion, the facetectomy and/or iliac crest bone core harvested using
apart from certain exceptions such as occasional cases a minimally invasive access bone-harvesting technique
of metastatic cancer or trauma through the same or a separate incision (Fig 1.3-27). The
• The question of implant removal especially after fracture development of expandable cage technology holds great
fixation without fusion is a subject of controversy. The promise for MISS, both for corpectomy, and also for inter-
author prefers to remove instrumentation after the frac- body fusion (Fig 1.3-29). Expandable interbody cages can be
ture has healed. inserted through tubular retractors and minimize the need
for the retraction of neurological structures. Other interbody
The combination of MISS retractors, pedicle screw systems devices that can be considered less or minimally invasive
and interbody technology allows the treatment of patholo- include stand-alone ALIF implants with integrated screw
gies that previously required more invasive surgery. For systems that obviate the need for additional posterior fixa-
example, in the case of a 65-year-old patient with spondy- tion (Fig 1.3-30).
Fig 1.3-27 Two iliac-crest bone

cores harvested using a minimally
invasive access bone-harvesting Fig 1.3-28 MISS interbody fusion. Schematic view of transforaminal
system. posterior atraumatic lumbar cage system for MISS fusion.

1 Fundamentals
Other MISS devices and techniques include: In summary, substantial advances in MISS have been made
• Percutaneous facet screw fixation to supplement ante- possible through the development and refinement of spinal
rior interbody fusion instrumentation, implants, and technique guides. The future
• Interspinous distraction devices used for the treatment will likely see the incorporation of biologics and tissue en-
of mild to moderate spinal stenosis. Some devices can gineering techniques into MISS technology. There is a great
also be used for supplemental fixation and stabilization need to further explore and make further advances in the
of the posterior spinous elements field of MISS. The surgeon/manufacturing industry interac-
• A presacral approach and instrumentation system to the tion is crucial, and although current initiatives to regulate
lumbosacral spine without direct visualization has been this relationship are important they should not interfere
developed and refined in recent years, and termed “axial with the creative process that has allowed MISS to mature
lumbar interbody fusion” [99] into a viable and highly successful discipline.
• Intervertebral stapling for spinal deformities
• Odontoid screw fixation systems
• C1/2 transarticular fixation systems
• Vertebral augmentation systems; vertebroplasty/kypho-
plasty.
Fig 1.3-29a–b Expandable interbody cages,

which limit the need for the retraction of
neurological structures, can be inserted through
tubular retractors and used for corpectomies
(a) and also for discectomies and interbody
a b fusion (b).
a b
Fig 1.3-30a–b Stand-alone ALIF device incorporating an anterior fixation plate and a radiolucent interbody spacer. The design
creates a zero profile construct and includes four locking screws that provide anterior fixation and stability.
45

Author Roger Härtl
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49

Author Roger Härtl

1.4 Evidence-based medicine and minimally invasive spine
surgery
Paul C McCormick
1 Introduction or other complications are reduced with MISS. Further,

while some adverse events such as cerebrospinal fluid leak-
Minimally invasive spine surgery (MISS) has been defined age from a dural tear may occur with equal frequency as
as “(a) procedure that by virtue of the extent and means of with traditional open exposures, the smaller dead space
surgical techniques results in less collateral tissue damage, mitigates the potential postoperative implications of this
resulting in measurable decrease in morbidity and more event. Secondly, the more limited incision and muscle split-
rapid functional recovery than traditional exposures, with- ting dissection is considered to reduce postoperative pain,
out differentiation in the intended surgical goal” [1]. If we shorten recovery time, and facilitate a quicker return to
accept this as an operationally adequate definition, then normal activity. It has also been suggested that MISS may
we acknowledge several facts. First, the conditions treated actually be offered to patients that were previously consid-
by MISS are essentially identical to those treated by tradi- ered as being too old or medically infirm to undergo standard
tional open methods. It simply applies different methods. open surgical procedures [3, 4]. Finally, some have claimed
Secondly, surgical indications are also the same, as is the that there are sustained long-term advantages of MISS over
ultimate surgical objective. For example, the surgical objec- open procedures due to the preservation of more of the
tive for a herniated lumbar disc is removal of the herniated bone, joint, and “musculoligamentous” envelope, which
disc fragment, whether performed through a small incision could reduce the incidence of iatrogenic instability or chron-
with a tubular retractor as in an MISS procedure or through ic pain associated with atrophic denervated paraspinal
a small incision with a blade retractor as part of a tradi- muscle retraction injury [3, 5].
tional open microdiscectomy.
It is difficult to objectively assess the evidence cited in sup-
More recent advances in and uses of MISS have been de- port of the superiority of MISS for several reasons. Firstly,
scribed utilizing fundamentally different methods of achiev- as already noted, MISS is merely a tool; the results vary not
ing a common surgical objective. An example of this is the only according to the technique adopted, but also according
use of the extreme lateral transpsoas interbody fusion tech- to who uses it. Secondly, since MISS is just an exposure, in
nique to achieve indirect lumbar decompression of spinal most cases it can be difficult to precisely attribute the ben-
stenosis [2]. These reports are largely anecdotal, and beyond efit of the approach that is distinct from that resulting from
the scope of this chapter; however, they do emphasize that the successful achievement of the operative objective in
MISS is a relatively new and rapidly evolving field with a appropriately selected patients. This is particularly true for
potential that may not as yet have been fully realized. It procedures such as herniated lumbar or cervical disc and
logically follows therefore that MISS is an access, not an spinal stenosis, where the exposure is associated with min-
operation and like other surgical procedures, it is a tool, not imal morbidity and the surgery in question generally pro-
a treatment. Thus, the results may not simply be due to the duces a robust clinical benefit.
MISS exposures, but also be related to the skill and judg-
ment of the surgeon, the conditions and circumstances Ideally, to accurately identify and quantify the benefit of
under which MISS is employed, and how thorough, ac- MISS one would need to perform a randomized clinical
curate, and valid the assessments which have been report- trial (RCT). Patients randomized to either standard open
ed actually are. surgery or MISS treatment groups would have to be com-
parable in every respect except for surgical exposure. Thus,
The current purported benefits of MISS generally fit into any difference in outcome would presumably be due to the
one of three categories. First, it is claimed that perioperative difference in exposure. The surgeon would have to be
morbidity such as infection, the need for blood transfusion, equally proficient in both exposure techniques, and the
51

Author Paul C McCormick
patient would have to be blinded as to which exposure he/ Numerous studies have evaluated the comparative benefits
she was to receive in order to eliminate bias. Unfortunate- of MISS and standard open microsurgical lumbar discec-
ly, RCTs are expensive, time-consuming, and often cannot tomy [6–8]. In one recent study from the Netherlands [6], a
be generalized to real-world practice because of the strict prospective randomized trial comparing MISS tubular dis-
study inclusion criteria, limited patient participation, and cectomy to conventional microdiscectomy used standardized
ideal study circumstances. Indeed, patients and surgeons patient functional outcome scales for pain and perceived
alike often have strong preferences and convictions that recovery as primary endpoints at 8 and 52 weeks following
can limit their respective participation in these trials. surgery. Small but statistically significant improvements in
visual analog scale (VAS) back and leg pain scores were
Nevertheless, some RCTs do exist that directly compare noted in patients treated with standard microsurgery. Func-
MISS to standard exposures for certain diagnoses. Short of tional outcomes, as measured by the Roland disability scale,
prospective comparative experimental trials, however, were also slightly better with the standard microdiscectomy.
evidence in support of the benefits of MISS has been lim- None of these differences exceeded the minimally important
ited to anecdotal case reports, uncontrolled case series, and clinical difference. No significant differences were found in
a few comparative observational studies. However, the perioperative morbidity or complications. The author not-
latter studies are significantly flawed by the choice of the ed a similar rate of recovery after both MISS and open mi-
comparative group. In many studies, for example, a retro- crodiscectomy, and concluded that “overall differences
spective review of prospectively collected data from a con- favored the conventional microdiscectomy approach.”
temporary MISS cohort is compared to same-site historic
controls or previously published series. Such “straw man” In a German study [7], 60 patients with lumbar disc her-
comparisons to historic controls and prior publications are niation were randomized to either open microdiscectomy
deeply biased, and nearly always favor the most recent treat- or MISS. Small non-significant differences were noted that
ment group. Other studies have used selective literature favored MISS discectomy for operating room time, blood
review for comparisons, which is equally problematic. How- loss, skin incision length, and complications. At a mean
ever, evidence from peer-reviewed literature is important— follow-up of 16 months, however, there were no differ-
but must be critically assessed by the practitioner. In the ences in clinical outcomes as measured by the VAS pain,
end, the surgeon has to rely on his/her own experience and Oswestry Disability Index (ODI), or SF-36 scales. In an-
careful observations to reach conclusions regarding the po- other randomized prospective trial comparing MISS tubu-
tential benefit of MISS in his/her own practice. lar discectomy to open loupe discectomy in 40 patients, no
significant difference in outcome was measured at 24 months
on either the VAS pain scale or the ODI [8].
2 Lumbar disc herniation
Based on these well-designed studies it seems clear that,
Lumbar disc herniation is one of the most common condi- for unilateral single-level lumbar disc herniation, MISS does
tions treated by spinal surgeons (see also chapters 4.2.2 not appear to present any significant advantage over stan-
Microsurgical lumbar disc surgery and 4.2.3 Endoscopic dard microdiscectomy. Such results are not surprising in
disc and decompression surgery). Properly performed in light of the limited disruption and soft tissue dissection ob-
appropriately selected patients, lumbar discectomy is one served with the standard open microsurgical technique.
of the most effective procedures for the relief of persistent,
severe, or progressive radiculopathy. It was one of the first
procedures for which MISS techniques were applied to spi- 3 Lumbar laminectomy
nal surgery. Both MISS and microsurgical techniques are
now routinely employed in clinical practice and during Lumbar laminectomy for the decompression of spinal ste-
resident training. Most surgeons tend to perform one or the nosis is the most common spinal operation performed in
other procedure for this condition rather than both, although the US Medicare population. Like lumbar discectomy, lam-
in the authors’ experience, the MISS exposure seems to be inectomy for properly selected patients with neurogenic
preferred by residents in training. Each technique produc- claudication or radiculopathy due to spinal stenosis pro-
es excellent results, with sustained clinical benefits and duces excellent long-term outcomes with minimal risk and
minimal risks or perioperative morbidity. complications (see chapter 4.2.1 Bilateral decompression
in lumbar spinal stenosis through a microscope-assisted
monolateral approach). Unlike lumbar disc herniation,

1 Fundamentals
1.4 Evidence-based medicine and minimally invasive spine surgery
however, no rigorous prospective trials exist that validly study [3] reported zero mortality and stated that their com-
compare standard laminectomy to MISS decompression. plication rate of 38% compared favorably with those in
Most studies present their data as an uncontrolled case se- previously published studies on open decompression for
ries, with few references to alternative approaches. This stenosis. Based on this observation, the same authors
makes it difficult to rigorously assess the claims of MISS claimed that “patients not considered eligible for lumbar
superiority over the current gold standard of lumbar lami- spine surgery may be given access to this treatment.” How-
nectomy. The studies that do provide comparisons utilize ever, there are two problems surrounding this claim. First-
cohorts from previously published studies or historical co- ly, mortality is an extremely rare occurrence following
horts, but these comparisons are notoriously biased, usu- decompression for segmental spinal stenosis, and this applies
ally in favor of the contemporary treatment. One such report to open approaches as well. Secondly, a closer review of
presented a series of 50 elderly patients (> 75 years) that the cited historical literature reveals that the cases reported
underwent lumbar decompression for stenosis with a MISS in these studies were much more complex, with a higher
technique [3]. The study consisted of a retrospective review number of multilevel procedures and fusions. Indeed, de-
of a prospectively maintained database of patients treated spite these differences, if one carefully reviews these stud-
over a 3-year period (2002–2005). Validated outcomes as- ies it is clear that the incidence and severity of complications
sessment with VAS, ODI, and SF-36 was performed. The are comparable to the present series.
mean follow-up was only 7 months. Comparison of out-
comes was made to the previously published literature. Thus, as in the case of lumbar disc herniation, there does
Evaluation of the treatment group revealed that, for the not appear to be clear evidence in support of a relative
most part, it represented a population that had undergone advantage of MISS over standard decompression for lumbar
low-complexity surgical treatment. Single-level decompres- stenosis. Irrespective of the technique utilized for decom-
sion, for example, was performed in > 70% of patients. pression, whether standard open surgery or MISS, the pa-
Symptoms were unilateral in > 50% of patients, and over tients recover very well with minimal morbidity and excel-
one-third of patients had only unilateral decompression lent sustained clinical outcomes.
performed. No patients underwent spinal fusion or had
undergone previous surgery. Postoperative outcomes were
improved, but the degree of improvement was only modest. 4 Lumbar fusion
Indeed, subgroup analysis revealed no significant improve-
ment in patients aged < 80 years with multilevel decompres- The use of MISS exposures for performing lumbar fusion
sion, or with minimally invasive foraminotomy. with or without concomitant decompression is being in-
creasingly adopted. The techniques and strategies vary con-
In the absence of a direct comparison group, it is difficult siderably, although single-level transforaminal lumbar
to know whether better results might have been achieved interbody fusion (TLIF) is by far the most common MISS
by the authors of the above-mentioned report had they fusion procedure (see chapter 4.2.4 Mini-open and
used a standard open decompression. Interestingly, they percutaneous pedicle instrumentation and fusion and
noted only a 2% reoperative rate, which they underlined chapter 4.3.3 The lateral approach to the lumbar spine).
was less than half of the 5% reoperative rate reported by Even here, however, a variety of techniques are utilized.
Jansson et al [9] in a large series of patients treated with In most cases, a unilateral laminectomy and facetectomy is
open decompression for spinal stenosis. The authors [3] performed with thorough discectomy. Interbody fusion is
concluded that “minimally invasive techniques may reduce usually performed with a spacer device. Bone morphoge-
the likelihood of (instability) by maintaining the anatomic netic protein (BMP), local autograft, and/or allograft may
integrity of more of the posterior spinal elements than open be placed in and/or around the device within the disc space.
surgery.” On closer scrutiny of Jansson et al’s study, how- Pedicle screw fixation is performed either percutaneously
ever, one can see that the 5% reoperative rate was at or through an expandable tubular retractor. Onlay trans-
2 years postsurgery, while at 1 year this rate was only 2%. verse process fusion is usually not performed. This technique
This compares favorably to the 2% reoperative rate follow- is now widespread, and seems to produce comparable out-
ing MISS decompression at a mean follow-up of only comes to more standard open surgical procedures. An initial
7 months. Further, the patient population in Jansson et al’s concern was related to the adequacy of the fusion surface,
study consisted of more complex cases, with many of the since only a single interbody spacer was placed with lim-
patients having multilevel stenosis and 11% being treated ited transverse process augmentation. This concern was
with concomitant fusion. Finally, the authors of the MISS exemplified by earlier-reported cases of pseudarthrosis and
53

preliminary published series, which provided inadequate 6 Intradural surgery

follow-up with respect to time of follow-up and radiograph-
ic assessment [10]. More recent series seem to reflect a rel- Most of the evidence regarding MISS procedures for intra-
atively high fusion rate, although valid comparisons of MISS dural pathologies is anecdotal, but does establish the feasi-
results on fusion with those for more standard open pro- bility of these procedures for selected intradural pathologies
cedures are lacking [11, 12]. [5, 20, 21]. It is also likely these techniques will be increas-
ingly used for intradural pathologies. In this context, it
There are numerous studies comparing outcomes between should be noted that the purported benefit of MISS is re-
MISS TLIF and open or mini-open TLIF [12–14]. Most of lated to the reduction in morbidity of the surgical exposure.
them are limited by study design, particularly by the use of For intradural pathologies, however, nearly all the morbid-
non-concurrent control groups. In the majority of cases, ity is related to the intradural portion of the procedure, not
operating room time is longer with MISS techniques, but to the exposure. One concern is that the limited intradural
estimated blood loss is less and hospital stay is shorter. This exposures achieved with MISS techniques might compro-
latter variable, however, is often under the control of, or mise the safe achievement of the operative objective, or
influenced by the surgeon. Postoperative pain is reported may even reduce the quality of resection. Small MISS ex-
to be less with MISS in most series, although valid methods posures, for example, often require piecemeal tumor resec-
of assessment are inconsistent. There does not appear to be tion; but such piecemeal resection for benign myxopapillary
any significant difference in long-term outcomes between cauda equina ependymomas can result in a higher rate of
patients treated by either open or MISS techniques. One recurrence and cerebrospinal fluid dissemination than en
recent study reported a dramatic reduction in perioperative bloc resection.
morbidity for fusion in elderly patients using a MISS tech-
nique, but such extraordinary results will need to be repro-
duced to determine whether they are generalizable [4]. 7 Infection
Postoperative wound infection is one of the most troubling

5 Complex procedures adverse events following spine surgery. For patients with
conditions such as herniated disc or spinal stenosis, infec-
An evolving use of MISS techniques shows a tendency to- tions can seriously complicate an otherwise straightforward
wards more complex spinal procedures such as multilevel procedure for a benign condition. In these patients, there
fusion, scoliosis, fracture repair and stabilization, and cor- is little margin or room for complications. Increased pain
pectomy [15–21]. The MISS exposures are often performed and wound drainage occasionally accompanied by an abscess
in conjunction with other procedural components. In these or more rarely discitis will usually require wound debride-
multi-component surgical procedures, it can be difficult to ment and several weeks of intravenous antibiotics. The
quantify the benefit directly attributable to the MISS com- stakes are higher for more complicated procedures, par-
ponent. ticularly those requiring instrumentation since removal of
hardware and future revision surgery may be necessary.
For example, a MISS transpsoas extreme lateral interbody Therefore, any procedure or technique that can reduce the
fusion may be performed to augment a concomitant pos- incidence of infection would be of considerable value.
terior segmental instrumented fusion. In such cases, the
avoidance of an open retroperitoneal exposure is clearly of Due to the smaller incision and tight-fitting tubular retrac-
value. While there may arguably not be much difference tors, one might postulate that this could result in less con-
between a single-level extreme lateral interbody fusion tamination of the surgical field during MISS procedures,
(XLIF) and a mini-open anterior interbody fusion, the ben- with a subsequently lower postoperative infection rate.
efit of the MISS approach seems more apparent with mul- While there is no definitive evidence in support of this, it
tilevel procedures [17, 18]. More recent anterior MISS ex- has nevertheless been clinically observed by a large number
posures of the thoracic and lumbar spine allow for more of surgeons. In a multicenter retrospective, noncomparative
complex procedures such as corpectomy and stabilization cohort study of surgical site infection following MISS, a
[19, 20]. Reports published on these procedures clearly es- review of 1,338 procedures performed by three surgeons
tablish proof of concept, although the distinctions between at four centers over 8 years showed an infection rate of
the larger MISS incisions and the dissections in small stan- 0.22% (n = 3) [22]. The authors compared their results to
dard open or mini-open exposures are less apparent. 13 previously published series of open spine surgery cases,

1 Fundamentals
1.4 Evidence-based medicine and minimally invasive spine surgery
which reported infection rates ranging from 0.15 to 7.2%. plex spinal procedures. The difference, however, is prob-
They concluded that MISS was associated with as much as ably much less than the 10-fold reduction claimed by O’Toole
a 10-fold reduction in postoperative infection. Beyond the et al [22] when the differences in the complexity of the
limitations inherent in any comparison with a noncom- procedures performed are taken into account.
parative cohort study, however, additional limitations be-
come apparent that undermine their conclusion, particu-
larly with respect to the differences in the patient populations 8 Conclusion
and types of surgical procedure compared. For example,
most of the procedures performed in the MISS study popu- Robust clinical evidence establishing the benefits of MISS
lation were single-level lumbar decompressions. Only 20% procedures over established open techniques is limited.
of patients underwent spinal fusion and, of these, 80% were There does not appear to be any comparative benefit for
single-level fusions. relatively simple single-level discectomy or laminectomy.
Claims of reduced hospital length of stay and blood loss for
When comparing infection rates for similar types of opera- these procedures when performed by MISS are of little sig-
tion, a different picture emerges. In one of the control stud- nificance when the differences are in the range of a few
ies of 663 nonfusion open spine surgery operations, an hours or less than 100 ml, respectively. A meaningful re-
infection rate of only 0.15% was reported [23]. This result duction in postoperative pain has not been validly quanti-
is very similar to the 0.1% infection rate for similar patients fied for these patients, and both types of procedure result
in the MISS cohort. The 10-fold difference noted between in excellent long-term outcomes with minimal morbidity.
the 0.22% infection rate in the MISS study patients and the The comparative benefit of MISS for more complex proce-
2% rate in a large open-surgery study of 2,316 patients is dures, especially when there is considerable morbidity as-
confounded by the fact that nearly 73% of patients in the sociated with the exposure, seems more plausible but must
open series underwent spinal fusion (versus just 20% in be mitigated by potential concerns related to the satisfac-
the MISS study), with only 34% undergoing one-level fu- tory achievement of the surgical objective, and to the ben-
sion (versus 80% in the MISS series) [24]. Twenty-five per- efits which may be temporary and/or not of substantial
cent of the open surgery patients had four or more levels clinical significance.
fused. Thus, the complexity of the procedures was substan-
tially greater in the open surgery group. It appears likely, Minimally invasive spine surgery is a rapidly evolving dis-
therefore, that while infection rates are very similar between cipline, however, and it seems likely that with future ad-
MISS and open procedures for single-level decompressions, vances in the field, its comparative benefits may be more
a somewhat lower rate of infection may exist for more com- fully realized for many spinal procedures.
55

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ability of the extreme lateral interbody Minimal access versus open (2010) A prospective, nonrandomized,
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35 Suppl 26:S331–S337. Spine; 35(26): 2273–2281. treatment of adult degenerative
3. Rosen DS, O'Toole JE, Eichholz KM, 12. Karikari IO, Isaacs RE (2010) scoliosis: perioperative outcomes and
et al (2007) Minimally invasive Minimally invasive transforaminal complications. Spine; 35 Suppl
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1.5 Different spinal pathologies and patient selection
Nicholas P Slimack, Patrick Shih, Richard G Fessler
1 Introduction In this chapter, the range of pathologies that are amenable

to MISS techniques will be reviewed, with a focus on prop-
Minimally invasive spine surgery (MISS) was developed er patient selection and contraindications for treatment.
with the intention of decreasing the incidence of surgical The future of MISS and how it can be applied to conditions
approach-related morbidity and ultimately to improve pa- other than the currently treated spectrum of spinal pathol-
tient outcomes. The philosophy behind MISS stems from ogies will also be discussed.
the concept that “less is more.” The basic tenet of MISS lies
in its ability to offer less tissue disruption and thereby pre-
serve local anatomy. Limiting approach-related morbidity 2 Cervical spine
has long been thought to translate into improved postop-
erative outcomes [1–3]. The surgical goals are the same in 2.1 Cervical disc pathologies
MISS as in open surgery, with the anatomical and clinical Cervical spondylosis affects approximately 13% of men in
result being identical. their 30s, and increases to nearly 100% by 70 years of age.
The prevalence is 5% for women in their 40s and about
For MISS to adhere to the principle of “surgical minimal- 96% for women over 70 years of age [5]. Degenerative cer-
ism,” several goals must be achieved despite smaller incisions vical spine disease is a unique pathology in that it lends
and less anatomical exposure. First, in comparison to an itself to surgical procedures that utilize anterior or poste-
open procedure, a MISS procedure should result in less rior approaches. In the late 1950s, several authors described
blood loss, reduced postoperative pain and medication us- the anterior technique for the surgical management of cer-
age, as well as shorter stays in hospital. Operative procedures vical disc disease [6–8]. Since that time, anterior approach-
should be comparable to the traditional open techniques es have become a popular choice for the treatment of lat-
that have long been used and refined over the years. The eral cervical disc herniations and foraminal stenosis. The
minimally invasive techniques must also involve a learning anterior approach offers several advantages including re-
curve that allows surgeons to master the skills. It must be duced muscle trauma, as it utilizes an approach through
possible to perform surgery within a reasonable operative natural tissue planes. This translates into less postoperative
time window. Complication rates should not exceed those pain and potentially shorter hospital stays. However, there
of traditional open surgery. Lastly, the minimally invasive are several disadvantages to the anterior approach, includ-
concept should be applicable to many different clinical sce- ing the risk of esophageal injury, vascular injury, recurrent
narios. laryngeal nerve paralysis, dysphagia, and adjacent segment
disease [9].
Over the past two decades, MISS has gained increasing
popularity. In 1991, Obenchain [4] first reported a case of In 1944, Spurling and Scoville [10] published their findings
laparoscopic lumbar discectomy. Prior to that case report, on the safety and efficacy of posterior cervical foraminot-
many attempts had been made to access different parts of omy for lateral disc herniation and foraminal stenosis. In
the spinal column with less invasive instruments. A variety carefully selected patients with isolated cervical radicu-
of anatomical approaches has since been described to access lopathy, posterior laminoforaminotomy resulted in im-
the entire spinal column. Furthermore, the range of pa- proved symptoms in 93–97% of patients [11, 12]. Tradition-
thologies treatable with MISS has broadened. Today, sur- ally, the posterior approaches required extensive
geons use the MISS concept to routinely approach degen- subperiosteal stripping of the paraspinal musculature. This
erative spine conditions and treat infectious diseases and resulted in significant postoperative pain, muscle spasm,
oncological processes within the bone anatomy as well as and dysfunction that could be severely disabling in 18–60%
the neural elements of the spine. As more surgeons become of patients [13–15]. These undesired consequences largely
comfortable with MISS tools, the indications will expand. caused surgeons to avoid this approach when an anterior
trajectory could be as efficacious.
57

Authors Nicholas P Slimack, Patrick Shih, Richard G Fessler
Herkowitz et al [16] prospectively compared anterior versus 2.2 Cervical stenosis

posterior approaches for cervical disc disease and found that Most patients who are candidates for open noninstrument-
good to excellent results were achieved in 90% of anteri- ed, posterior cervical decompression are also candidates for
orly operated patients and in 75% of posteriorly operated minimally invasive posterior cervical decompression. Pos-
patients. However, 90% of the posterior group experienced terior cervical decompression for cervical stenosis achieves
relief of radicular symptoms. In 2000, Wirth et al [17] ran- neurological improvement in 62.5–83% of myelopathic
domized 72 patients to either posterior foraminotomy or patients undergoing either laminectomy or laminoplasty
anterior discectomy with or without fusion. They reported [13, 24–26].
that nearly 100% of patients experienced relief of symptoms,
with no statistically significant differences in outcomes. It Cervical microendoscopic decompression for stenosis
therefore seems that the primary difference between the (CMEDS) is a suitable procedure for patients who present
anterior and posterior approaches lies in the degree of post- with signs and symptoms of cervical myelopathy. However,
operative discomfort experienced by the patients. How- use of the operating microscope can achieve similar results.
ever, the anterior approach typically requires fusion or disc Contraindications to CMEDS are similar to those for tradi-
arthroplasty with its associated downsides. tional cervical laminectomy. Patients with significant mobil-
ity or fixed kyphotic deformity may be best treated with an
As previously stated, the main principle of MISS is to reduce anterior approach or a combined anterior and posterior
approach-related morbidity. In 1997, Foley and Smith [18] trajectory. Patients with slight loss of normal cervical lor-
introduced the microendoscopic technique for the treatment dosis or mild kyphosis may be treated endoscopically in the
of lumbar disc disease. This muscle-splitting technique uses presence of dorsal compression. Ideal candidates have pos-
a tubular retractor system that reduces paraspinal muscle terior compression resulting from buckling of the ligamen-
denervation. Muscle and ligamentous attachments to the tum flavum. The CMEDS procedure preserves the midline
spine are preserved, translating into less postoperative pain dorsal tension band, contralateral muscular attachments,
and maintaining long-term stability. The microendoscopic and contralateral facet complex. This serves to minimize
technique achieves decompression via a keyhole type of disruption of the overall ligamentous integrity. Cervical
osteotomy at the junction of the facet and lamina. Similar MEDS can be used to treat as many as three levels through
results can be achieved with the use of the operating mi- a single incision. While at the time of publication there is
croscope. As long as less than 50% of the facets are removed, no published data to support the theory, the risk of spinal
there is little compromise of the biomechanical strength of cord injury is probably less than with the traditional open
the cervical spine. Human anatomical specimen studies procedure given that there is much less manipulation of
demonstrated that the average vertical and transverse di- the dorsal elements.
ameters of laminotomy and nerve root decompression were
equivalent compared with open techniques [19, 20]. In clin- A minimally invasive approach can also be used in cases
ical reports, the results of microendoscopic foraminotomy where instrumentation and fusion are performed. A midline
with or without discectomy have been equivalent to those incision is preferred in this instance for the transmuscular
of traditional open procedures [14, 21]. The authors have approach. The same incision could be used for both sides.
recently reported on clinical outcomes after cervical micro- After exposure of the facet joint, a hand drill is used to cre-
endoscopic foraminotomy and discectomy (CMEF/D). They ate a pilot hole. The starting point is 1 mm medial to the
validated outcome instruments in a prospective cohort of midpoint of the lateral mass, and the trajectory will be 25˚
30 patients. In these patients, a significant decrease from lateral and parallel to the facet joint. Appropriately dimen-
2.0 to 0.6 for headache, 5.0 to 2.1 for neck pain, and 4.8 to sioned screws are inserted after tapping, and a rod is fixed
1.9 for arm pain was observed in mean visual analog scores. with set screws. Image intensification guidance is preferred.
Short Form-36 scores were also statistically significantly
decreased [22]. Furthermore, CMEF/D performed with the 2.3 Atlantoaxial pathologies
patient in the sitting position has been shown to result in C1/2 fusion is commonly performed in the surgical manage-
decreased operative times, less blood loss, and shorter hos- ment of conditions including neoplastic, inflammatory,
pitalization times [23] (see also chapter 2.2 Posterior congenital, infectious, degenerative, and traumatic disor-
foraminotomy). The evidence available in the published ders. Achieving successful fusion can be a challenging un-
literature suggests that CMEF/D is a safe, effective, and dertaking, given the amount of rotator motion at the C1/2
minimally invasive procedure that may provide a better joint. Historically, wiring and cable techniques were utilized.
option for selected patients. Recently, more biomechanically stable fixation devices, such

1 Fundamentals
as screws and rods, have gained popularity. Conventional benefits of a thoracotomy-based approach are that it provides
C1/2 fusion requires extensive muscle stripping and retrac- a direct view of the anterior thoracic spine. Disadvantages
tion, which affects the degree of postoperative pain, amount include approach-related morbidity and potential complica-
of intraoperative blood loss, and the risk of impaired mus- tions, such as pulmonary contusion, atelectasis, pleural ef-
cle function. The MISS techniques employ an expandable fusion, hemothorax, and chylothorax [30]. Additionally,
tubular retractor system (eg, the Quadrant system, Medtron- there can be significant postoperative pain as a result of rib
ic, Memphis, TN) which decreases the aforementioned risks. resection and retraction. These morbidities can occur in up
In order to preserve the midline ligamentous attachments, to 11.5% of patients and can prolong hospitalization [31].
bilateral incisions are used. With the aid of intraoperative Thoracoscopy has subsequently gained increasing popular-
image intensification, C1 lateral mass and C2 pars/pedicle ity, since it does not require extensive opening of the pleu-
screws can be inserted in the standard fashion. This tech- ral cavity. However, there is a steep learning curve and
nique can also be utilized with intraoperative CT-scan thoracoscopy can still carry some of the same risks as an
navigation. Bone graft is laid along the rods bilaterally as open procedure (see chapter 3.3 Anterior thoracoscopic
well as at the C1/2 joint space. This procedure is ideal for approaches, including fracture treatment). Therefore, the
patients that have relatively normal C1/2 anatomy, includ- posterolateral techniques are often preferred by the surgeon.
ing the vertebral arteries. An open procedure is probably Utilizing minimal access surgery principles, Kim et al [32]
best suited to patients who have had prior surgery in the described an approach for thoracic corpectomy in human
C1/2 region. It is also imperative that the surgeon has suf- anatomical specimens and four clinical cases. Sequential
ficient knowledge of the atlantoaxial spinal anatomy and muscle dilators (METRx Microdiscectomy System, Medtron-
is comfortable when performing an open procedure. Ad- ic Sofamor Danek, Memphis, TN) were utilized, followed
ditionally, the surgeon should have experience in perform- by a Quadrant (Medtronic Sofamor Danek, Mephis TN)
ing minimally invasive fusion and decompression procedures retractor inserted over the largest dilator and fixed to the
in other regions of the spine. Minimally invasive approach- flexible table-mounted arm assembly. These authors con-
es to C1 and C2 will be discussed further in chapters 2.4 cluded that the corpectomy and complete spinal canal de-
Posterior C1/2 transarticular screw fixation and 2.5 Anterior compression can be performed safely without the need for
C1/2 surgery. aggressive muscle stripping that is performed in a standard
open case. Furthermore, successful instrumentation and
fusion can be combined with minimally invasive corpec-
3 Thoracic spine tomy (Fig 1.5-1). There is ample evidence that a minimal
access fusion technique can be successfully employed in
3.1 Thoracic disc pathologies cases of trauma, infection, deformity, or neoplasm [33]. More
Thoracic disc herniations present a unique challenge for
the spine surgeon in terms of patient selection, surgical
approach, and potential complications. Disc herniations in
this location are relatively rare, with a reported incidence
of 1 in 1,000 to 1 in 1,000,000 annually [27, 28]. A large
number of posterior surgical techniques have been described,
including laminectomy, costotransversectomy, transfacet
pedicle-sparing discectomy, transpedicular discectomy, and
lateral extracavitary trajectories. Thoracic microendoscop-
ic discectomy has been developed with the aim of avoiding
the potential complications of the aforementioned tech-
niques [29]. Again, use of the operating microscope can
allow similar visualization with comparable outcomes.
3.2 Thoracic vertebral body pathologies

Thoracic corpectomy is often indicated for the treatment of
traumatic fractures, neoplasms, and infections. The ante-
rior portion of the thoracic spine can be exposed through a b
a variety of techniques, including a posterolateral, antero- Fig 1.5-1a–b Example of a T10 minimally invasive corpectomy per-
lateral retropleural, or an anterior transthoracic view. The formed through an expandable tubular retractor.
59

minimally invasive approaches to thoracic spine pathology injury to the paraspinal musculature and limiting the re-
will be covered in section 3 Thoracic techniques. moval of stabilizing dorsal structures. This technique may
be particularly useful in the elderly and obese, or those
patients with significant comorbidities [48, 49] (see chapters
4 Lumbar spine 4.2.1 Bilateral decompression in lumbar spinal stenosis
through a microscope-assisted monolateral approach and
4.1 Lumbar disc pathologies 4.2.2 Microsurgical lumbar disc surgery).
Microscopic lumbar disc resection through a tubular retrac-
tor was first reported by Faubert and Caspar in 1991 [34]. 4.3 Lumbar spinal instability
In 1997, Foley and Smith [18] reported their experience Lumbar spine fusions have been performed for approxi-
with more advanced endoscopic technology and a tubular mately 100 years as a treatment modality for several lumbar
retractor system. Microsurgical endoscopic discectomy spine diseases including spondylosis, trauma, infection,
(MED) of the lumbar spine combines the standard lumbar neoplasm, and spinal instability. The traditional operation
microsurgical techniques with endoscopy to address com- has consisted of posterolateral fusion with autologous bone
monly encountered disc herniations, free fragment hernia- graft. Internal fixation with instrumentation and interbody
tion, and lateral recess stenosis. This technique can be per- grafts were conceived with the aim of improving fusion
formed with the same results as those using the operating rates as well as achieving rapid stabilization of the spine.
microscope, as it allows smaller incisions, and results in less Over time, different surgical approaches and techniques
tissue trauma compared to an open procedure. Other pa- have been developed to achieve solid fusion. In standard
thologies that can be addressed with this MED technique open surgical procedures, long incisions, extensive muscle
include extreme lateral disc herniations, synovial cysts [35], dissection, and prolonged retraction can have adverse con-
and recurrent disc herniations [36] (see also chapters 4.2.2 sequences that affect patient outcomes. Therefore, efforts
Microsurgical lumbar disc surgery and 4.2.3 Endoscopic have been made to develop minimally invasive techniques
disc and decompression surgery). and instruments. Minimally invasive techniques for lumbar
spine fusion include: minimally invasive transforaminal
4.2 Lumbar stenosis lumbar interbody fusion (TLIF), minimally invasive ante-
Lumbar stenosis is one of the most common conditions rior lumbar interbody fusion (ALIF), extreme or direct lat-
encountered by the practicing spine surgeon [37]. Entrap- eral interbody fusion (XLIF, or DLIF), transsacral approach
ment of the cauda equina within the spinal canal can cause for lumbar fusion (AxiaLIF), percutaneous pedicle screws,
a myriad of symptoms that are quite debilitating. When and minimally invasive translaminar facet screw fixation.
conservative management fails to provide symptom relief, These techniques have gained popularity over the last two
surgical intervention is indicated [38–41]. The aim of the decades. Recent publications have focused on their benefits
operation is to completely decompress the nerve roots from including less tissue damage, preservation of the anatomy,
the surrounding damaged structures such as disc herniation, decreased postoperative scarring, potentially shorter hos-
enlarged facets, or hypertrophied ligamentum flavum. The pital stay, earlier patient recovery, equal clinical outcomes,
traditional surgical approach to treating the problem of and better cosmesis compared to traditional open surgery.
lumbar stenosis involves a midline incision, lateral retrac- These procedures are covered in greater detail in section 4
tion of the erector spinae musculature, subperiosteal expo- Lumbar/sacral techniques.
sure of the laminae and facets, and complete removal of
the dorsal elements [42]. However, such an extensive lam- Over the last decade, TLIF has become a popular technique
inectomy can lead to significant operative blood loss, post- for achieving decompression and circumferential fusion of
operative pain and delayed spinal instability [41, 43–47]. the lumbar spine. This procedure reduces the risks associ-
ated with neural element retraction and avoids the com-
Microendoscopic decompression is a safe and effective treat- plications of an anterior access approach. This approach can
ment option for lumbar stenosis. Early clinical results are be performed through a small paramedian incision, avoid-
comparable to those reported for all surgical procedures ing the surgical trauma to paraspinal muscles induced by a
used in the treatment of this common condition. Although standard open technique. As with other MISS techniques,
surgical times may initially be longer because of the learn- it is designed to lessen operative morbidity, which translates
ing curve associated with endoscopic techniques, MED can into less blood loss, earlier ambulation, and decreased hos-
result in less blood loss and a quicker postoperative recov- pitalization times. However, there is a learning curve that
ery. It may also provide long-term benefits by reducing the surgeon must overcome, and some authors have rec-

1 Fundamentals
ognized the longer initial operative times [50]. The indica- • Does MISS widen the range of patients that can be op-
tions include spondylolisthesis, degenerative disc disease erated on now compared to before? Have patients who
with back pain, treatment of pseudarthrosis, and selected were previously denied surgery now become surgical
cases of deformity. candidates? For example, elderly patients with severe
degenerative scoliosis?
Percutaneous lumbar pedicle screws may be used alone or • Surgeons that have mastered MISS skills have found
to confer additional stability for other primary procedures that the range of patients offered surgical interven-
such as the DLIF or TLIF [51]. Indications include degen- tion has broadened. Because of the potentially low-
erative disc disease, spondylolisthesis, spinal trauma [52, er blood loss, shorter operative time, and earlier
53], and deformity correction [54]. mobilization secondary to decreased postoperative
pain, certain categories of patient, such as the el-
Transfacet screws were first described by King [55], then derly, can now be considered for surgical intervention
Magerl [56] modified the technique to a translaminar facet much more than they were in the past.
approach. This technique could be used by itself or in as-
sociation with other lumbar fusion techniques, with the
aim of increasing stability and fusion rate. Minimally inva- 5 Surgeon's learning curve
sive translaminar facet screw fixation is performed percu-
taneously, or with a small open midline exposure of the 5.1 Minimally invasive techniques and patient
posterior spine to allow for additional posterior fusion. Suit- anatomy
able candidates for this approach include those patients Minimally invasive spine surgery depends significantly on
considered for a fusion procedure. However, this technique the surgeon’s skill and knowledge of the surgical anatomy.
can prove difficult in cases of previous extensive laminec- In contrast to traditional open approaches, where the sur-
tomy, and in cases of severe deformities where the anatomy rounding anatomy is well visualized, MISS procedures pro-
is dramatically altered. vide extremely limited exposure. Often, key surgical land-
marks do not even lie within the operative field and
4.4 Patient selection therefore the surgeon can easily be misguided. Minimally
• Age group: invasive surgical techniques require the surgeon to have a
• Between 18 to 85 years old clear understanding of the individual patient’s anatomy
• Obesity: and pathological area of interest. Furthermore, MISS neces-
• The longest tube measures 10 cm, and therefore suit- sitates that the operator has a clear mental image of the
able candidates for a MISS lumbar procedure should three-dimensional characteristics of each anatomical region.
have no more than 10 cm of tissue between the dor- The correct insertion of instrumentation is highly dependent
sal lumbar surface and the lamina. This can be eval- on this mental picture of the anatomy. Taking all these
uated on the preoperative axial MRI aspects into account allows for the safe and timely comple-
• Revision surgery, failed fusion: is it better to perform tion of the surgical procedure.
open surgery?
• MISS techniques are now routinely and safely em- 5.2 Minimally invasive surgical equipment and
ployed in cases of revision surgery, including revision instruments
fusion and instrumentation. Cases where fusion Minimally invasive surgery also requires more equipment,
needs to be extended are also amenable to MISS such as table attachments and the tubular retractors them-
• Comorbidities: selves. In the case of endoscopic procedures, the operator
• Generally, there are no comorbidities that preclude navigates the surgical field from a screen, which can be
the adoption of a MISS approach. A less invasive quite disorienting early in the course of a surgeon’s MISS
surgical procedure is often more desirable because experience. Proper handling and knowledge of the tools is
of the potential benefits of less blood loss, shorter a prerequisite to performing MISS procedures. A surgeon
operative time, and quicker return to activity should have a thorough understanding of the equipment
• Underlying pathologies, eg, cancer: and the different ways in which it can be manipulated to
• As will be discussed in topic 7 Future applications in achieve adequate exposure. The tubular retractor system
this chapter, MISS techniques can be employed in is placed using a series of dilators, usually starting with a
cases of neoplasm that involve virtually any element guidewire. The K-wire is initially inserted blindly through
of the spinal column, as well as for infection a skin incision using image intensification as a guide. It is
61

advanced or “docked” on the anatomical region of interest 6 Limitations of minimally invasive surgery
and followed by progressively larger dilators until the final
tube is inserted. Because of the risk of possible dural or Minimally invasive techniques have evolved to replace many
nerve injury, some surgeons prefer to use a small-diameter open surgical procedures performed on the spine. How-
blunt dilator instead of the K-wire. It is imperative that the ever, certain limitations still exist. Foremost, a solid under-
surgeon acquires a feel for the dilator insertion, as this se- standing of open surgery anatomy is a prerequisite before
ries of steps will ultimately provide the surgical corridor. performing any minimally invasive procedure. Thus, sur-
geons that lack thorough knowledge of the human anato-
Surgical instruments are often longer than those used for my should familiarize themselves with this through open
open approaches, and bayoneted, which can initially feel surgical cases before attempting minimally invasive ap-
uncomfortable to the inexperienced MISS surgeon. In the proaches.
absence of direct visualization of the anatomical region, a
thorough understanding of intraoperative image intensifi- The lateral transpsoas procedure has become increasingly
cation is of paramount importance. Interpretation of the popular as an alternative to posterior interbody fusion. The
intraoperative x-ray is often the only feedback from which ideal patient has a thin body habitus and a corridor void of
the surgeon has to make operative decisions. Because of ribs and the iliac crest for interspace access. However, there
the learning curve associated with MISS, this can often lead are still some relative contraindications to this procedure.
to increased radiation exposure and overall operative ex- Fractional curves of the lumbar spine may be difficult to
pense early in the course of a surgeon’s MISS practice. There treat with a lateral interbody technique, if the iliac crest
are multiple components of MISS to be mastered, and it is prevents direct access to the disc space. At times, the iliac
therefore highly recommended that a surgeon starts with crest rides too high for proper access at L4/5, and this is true
a relatively simple MISS procedure, such as discectomy, in almost all cases at L5/S1. Thus, if there is a substantial
before attempting more complex endeavors. Several articles fractional curve at these levels, an alternative approach
in the literature address the learning curve of spine surgery should be considered, such as an ALIF or a TLIF. If the
[57, 58]. In a 2005 publication, Nowitzke [59] noted that it preoperative plain x-ray reveals the iliac crest at a height
takes about 30 cases to become proficient. In another pub- halfway or more up the L4 vertebral body, the lateral trajec-
lication, McLoughlin and Fourney [60] found that for a tory will prove to be difficult. Furthermore, the location of
single surgeon 15 cases were needed to achieve a desired the aorta, vena cava, and iliac vessels should be examined
comfort level. In a recent study, Neal and Rosner [57] eval- on the preoperative images. In some cases, it will be clear
uated residents’ learning curves for minimal access TLIF that surgical corridor will be hindered by their presence.
using operative time as a primary outcome. They conclud- Furthermore, a thorough review of the axial MRI should
ed that the learning curve plateaus at approximately 15 be made at each level of consideration. In rare instances,
cases. the psoas muscle will lie anterior to its normal position. The
lumbar plexus, therefore, can also rest more anteriorly than
5.3 Intraoperative complications usual. This can place the plexus in a situation where it
Minimally invasive surgery can prove to be more difficult overlies the disc space of interest.
when intraoperative complications arise. These scenarios
are more likely to present themselves in cases where a Previous abdominal surgery can indicate potential difficul-
larger anatomical region is being targeted, during revision ties to be encountered with a direct lateral technique. Scar-
surgery, and in the event of inadvertent dural laceration ring of the peritoneum to the retroperitoneal cavity can
with subsequent cerebrospinal fluid leakage. This highlights present a dangerous situation when blindly traversing this
the importance of building up MISS experience by begin- corridor. Even though obese patients can be treated with
ning with less technically demanding procedures. Revision minimally invasive techniques, tubular retractors may be
surgery often calls for a wider exposure, which MISS tech- limited by the length of the tube. Patients with more than
niques do not always allow. As the surgeon gains more 10 cm of tissue separating the lamina and skin surface as
experience with the smaller and more straightforward measured via the MRI for posterior approach surgeries
cases such as discectomy and decompression, proper han- should be carefully evaluated for MISS candidacy (Fig 1.5-2).
dling of abnormal anatomy and undesired complications So, at times, an open surgical alternative may be necessary,
become less daunting challenges. or the surgeon may consider using a longer expandable
tubular retractor from a lateral transpsoas set (see topic 5
Instruments and implants, chapter 1.3 The four pillars of
minimally invasive spine surgery).

1 Fundamentals
Regarding the TLIF procedure, there are few absolute con- 7 Future applications
traindications. However, individual patient factors can in-
fluence the surgeon’s decision to employ an open versus a Advances in the field of MISS have allowed surgeons to
minimally invasive technique. Pelvic incidence is also an treat a wide spectrum of deformity-related pathologies of
important measure of the angle needed to approach the L5/ the spine. As spine surgeons become more experienced with
S1 disc space for discectomy and TLIF. High pelvic incidence the techniques and technology of MISS, the range of indi-
can be associated with difficulties in angling a tube needed cations for this treatment approach continues to expand.
to be parallel to the L5/S1 endplate. Furthermore, a patient’s In fact, the benefit that MISS techniques offer may be far
specific anatomy may be unfavorable for adequate angula- greater in cases of trauma, oncology, and deformity opera-
tion of tubular systems. If a patient carries too much dorsal tions [60]. Because these cases often require a great deal of
tissue, access to the lower lumbar region disc spaces may tissue dissection, muscle retraction, and blood loss, the MISS
be compromised, as during manipulation the surgical in- techniques can help to decrease these approach-related
struments can bump against the skin of the dorsal thorax. morbidities.
Unfortunately, this scenario is difficult to assess prior to
placing the patient prone on the operating table. If it is Until recently, scoliosis surgery was performed via an open
anticipated that this scenario may arise, the patient should corrective stabilization procedure. In recent years, surgeons
be informed preoperatively of the potential need for an who are comfortable with MISS approaches have begun to
open procedure (see chapter 4.2.4 Mini-open and address spinal deformity adopting MISS principles [61]. How-
percutaneous pedicle instrumentation and fusion). ever, there are some contraindications to solely using MISS
for scoliosis. The first is the presence of a structural main
thoracic curve. Minimally invasive approaches should be
used primarily for structural curves of the lumbar spine or
Lenke 5 curves. Furthermore, curves associated with posi-
tive sagittal balance in which there are kyphosis-related
symptoms should rather be considered for open surgery.
There are limitations to the use of MISS for the treatment
of thoracic deformities and fixed deformities of the spine.
The feasibility of posterior approach osteotomies for treat-
ing kyphosis may vary according to the individual patient,
and may not be realistic for fixed iatrogenic deformities,
where they are most often applied.
Even though MISS pedicle subtraction osteotomies have

been carried out on human anatomical specimens, they
have not been widely used in clinical practice [62]. The au-
Fig 1.5-2 Example of an obese patient with more than 10 cm of tissue thors anticipate the future application of pedicle subtraction
between the skin and the spinal lamina. The surgeon must ensure that osteotomies for fixed sagittal imbalance. Furthermore, they
the retractors and instruments are suitable. It may be necessary to use
consider that minimally invasive techniques will be applied
an expandable tubular retractor from a lateral transpsoas instrument set,
since the latter frequently includes blade lengths up to and over 15 cm.
to pediatric deformity correction.
Minimally invasive surgical techniques can also be utilized

when addressing neoplasms of the spinal column. A mini-
mal access surgical approach is of particular interest when
patients harbor benign tumors, or have tumors but an oth-
erwise long life expectancy. Minimally invasive surgical
procedures can be applied to oncological spine surgery, and
a variety of surgical approaches have been developed [63,
64]. Whether the pathology lies in the bony elements, the
epidural space, or even in the intradural compartment,
minimally invasive systems can be utilized (Fig 1.5-3).
63

Although there is still a relative absence of MISS techniques 8 Conclusions

for posterior subaxial cervical spine instrumentation, the
authors anticipate that future advancements will be made Less invasive surgical techniques have evolved as rapidly
in this area of spine surgery. Minimally invasive surgical as technological advances have been made. Minimally in-
approaches may provide a long-term benefit for spinal vasive spine surgery offers several advantages compared
trauma with vertebral body disruption; and as they involve with traditional open approaches and, with time and expe-
internal bracing without disruption to the posterior liga- rience, can be applied to a wide array of spinal pathologies.
ments, this is advantageous for preventing posttraumatic Patients often recover faster and experience less approach-
kyphosis. Vascular lesions such as type I dural AVF have related morbidity. However, there are limitations and risks
been traditionally treated with open surgery to disconnect that may not permit a MISS technique to be employed in
the fistula, or with endovascular embolization. Tubular re- certain situations. It is critical that the surgeon understands
traction can provide another avenue for treating these vas- the limitations of MISS procedures, and that there is a
cular abnormalities by providing direct access to the fistula backup plan. In addition to a careful evaluation of the pa-
which lies along the nerve root underneath the pedicle [65]. tient’s history and physical examination, a thorough pre-
Minimal access techniques have even been applied to con- operative discussion with the patient should include the
ditions such as tethered cord and syringomyelia [66, 67]. potential drawbacks of MISS. Sound surgical judgment and
proper patient selection remain the cornerstones to a suc-
cessful outcome.
a b
Fig 1.5-3a–b Preoperative images of a lumbar schwannoma

completely resected via a minimally invasive approach.

1 Fundamentals
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fusion for the treatment of degenerative 59. Nowitzke AM (2005) Assessment of
lumbar diseases. Spine; the learning curve for lumbar
35(17):1615–1620. microendoscopic discectomy.
Neurosurgery; 56(4):755–762; discussion
755–762.

1.6 Computer-assisted navigation for minimally invasive
spine surgery
Eric Nottmeier
1 Introduction clude multilevel registration of the spine with the patient

in the surgical prone position. Additionally, since no points
Image-guided spinal surgery involves the tracking of surgi- need to be matched on the patient’s spinal anatomy, regis-
cal instruments in three-dimensional (3-D) space, which tration can easily ensue in patients with previous laminec-
allows the surgeon to navigate the patient’s spinal anatomy tomy, as well as in patients undergoing minimally invasive
using a preoperative or intraoperative CT scan. The tracking surgery in which the spine is not fully exposed. Another
is accomplished using infrared technology via reference ar- advantage of cbCT technology is the ability to check instru-
rays that are located on the surgical instruments and also mentation placement prior to leaving the operating room.
attached to the patient’s spine. Accurate instrumentation
placement and decreased surgeon radiation exposure have Traditional techniques of pedicle screw placement in mini-
been reported with the use of image guidance in spinal mally invasive fusion procedures have employed the use of
surgical procedures [1–6]. A key component to image-guid- biplanar or multiplanar image intensification, which results
ed spinal surgery is registration of the patient’s spinal anat- in radiation exposure to the surgeon and operating room
omy, as the navigation system needs to localize the patient’s staff [7]. Additionally, placing spinal instrumentation using
spine in 3-D space. Initial techniques of spinal registration active image intensification can be cumbersome to the sur-
included point- and surface-matching techniques that in- geon in addition to the inconvenience of having to wear a
volved meticulous dissection of the spinal bone anatomy. protective lead apron, not to mention the ergonomics as-
After the bone anatomy had been exposed, the surgeon sociated with maneuvering around an image intensifier
then had to match points on the dissected anatomy to points during instrumentation placement. Advantages of image
chosen on a preoperative 3-D reconstructed CT scan. To guidance in minimally invasive fusion procedures include
most surgeons, this process was quite tedious and time con- the ability to accurately place pedicle screws while minimiz-
suming, as only one vertebral level at a time could be reg- ing radiation exposure [8–10]. Also, once the intraoperative
istered, and adequate navigational accuracy was not always cbCT scan has been acquired, the cbCT device is moved out
obtained when relying on this approach. Additionally, point- of the surgical field and does not serve as an impediment to
and surface-matching was difficult to accomplish in patients the surgeon during instrumentation placement.
who had undergone a previous laminectomy, and even more
difficult to carry out in patients undergoing minimally in-
vasive procedures. Accordingly, the majority of surgeons
who initially tried this technology quickly abandoned it.
The advent of intraoperative cone-beam computed tomog-

raphy (cbCT) has constituted a major breakthrough in
image-guided surgery. A reference array located on the cbCT
device allows the device to be tracked during image acqui-
sition throughout surgery. By recognizing the reference
array on the cbCT device and the reference array attached
to the patient’s spinal anatomy, the navigation platform is
able to accurately register the patient’s spinal anatomy with- a b
out the need for matching points. This intraoperative cbCT Fig 1.6-1a–b View of an image-guided screwdriver being tracked
scan can then be used for spinal navigation using tracked by the image-guidance system, allowing the surgeon to navigate the
instruments (Fig 1.6-1). Advantages of cbCT registration inpatient’s spinal anatomy using an intraoperative cbCT scan.
67

Author Eric Nottmeier
During the registration process, the patient (and not the traditional techniques of percutaneous pedicle screw place-
cbCT device) is draped to allow for the cbCT device to be ment this will involve a change of sequence, as some of
brought in for the registration process, following which, it them will perform the interbody portion of the procedure
is then removed (Fig 1.6-2). Draping of the cbCT device can first and reserve pedicle screw placement for last.
be cumbersome, and is not possible with some models. For
registration to take place, a reference array needs to be With any minimally invasive spinal fusion procedure, the
placed on the patient. In minimally invasive spinal proce- vertebral level(s) to be fused need to be localized by x-ray
dures, this array is typically placed via a percutaneous or prior to the skin incision. Performing the cbCT registration
mini-open approach onto the iliac crest or spinous process as the initial step also allows for localization, which maxi-
(Fig 1.6-3). To help maintain adequate line-of-sight between mizes efficiency as the cbCT device is brought into the ster-
the camera and the tracked instruments, the camera should ile field only once to accomplish these two tasks. The total
be positioned so that the reference array is located between time required to register the patient, including placement
the camera and the area where the instruments are to be of the reference array and draping, is typically less than
used. Accordingly, if the reference array is placed on the 10 minutes [11].
iliac crest, then the camera is positioned at the foot of the
bed. If the reference array is placed on the spinous process For minimally invasive transforaminal lumbar interbody
above the vertebral levels to be fused, then the camera fusion (TLIF) procedures in which 3-D image guidance is
should be placed at the head of the bed. Care should be utilized, the options that exist for placement of pedicle
taken not to touch or bump this reference array after reg- screws include:
istration has taken place, as this could result in naviga- • Percutaneous placement of pedicle screws using cannu-
tional inaccuracy. Navigation is most accurate immediate- lated screws and K-wires
ly after the registration process has taken place and before • Percutaneous placement of pedicle screws without the
the interbody or decompression tasks of the procedure are use of cannulated screws and K-wires
performed. To maximize navigational accuracy and effi- • Placement of pedicle screws through mini-open retractors
ciency, pedicle screw placement should constitute the ini- • A combination of the above.
tial step of the procedure. For surgeons who are used to
Fig 1.6-2 Intraoperative photograph showing the draping method Fig 1.6-3 Intraoperative photograph showing the location of the
when performing cbCT registration in the operating room. Two sterile percutaneous reference array on the iliac crest in a minimally invasive
half-drapes are used and are clamped in sterile fashion above the fusion case.
patient by the surgeon. The nurse then clamps the drapes in nonster-
ile fashion beneath the patient. The result is a boundary drape that
protects the sterile field.

1 Fundamentals
1.6 Computer-assisted navigation for minimally invasive spine surgery
2 Percutaneous placement of pedicle screws using 3 Percutaneous placement of pedicle screws

cannulated screws and K-wires without the use of cannulated screws and K-wires
With this method of percutaneous pedicle screw placement, Percutaneous placement of pedicle screws can be performed
image guidance is used for the placement of K-wires, which using image guidance without the use of K-wires [8]. In this
in turn guide the placement of cannulated pedicle screws. method, an image-guided probe is placed on the surface of
Introduction of the K-wire is performed using image-guid- the skin to determine the optimal point where the stab
ed instruments, which allow accurate insertion of the K-wire incision is to be made. This point will allow an adequate
into the pedicle (Fig 1.6-4). After this has been accomplished, trajectory to the pedicles as determined by 3-D image guid-
the pedicle can be tapped with a cannulated, image-guided ance (Fig 1.6-6). After this point has been located, a small
tap placed over the K-wire. The cannulated screw is then incision is made and an image-guided awl is directed down
placed over the K-wire into the pedicle, and the K-wire is onto the pedicle-screw entry point. The image-guided sys-
subsequently removed. Advantages of this technique include tem’s intraoperative planning function then places a vir-
the ability to find the pedicle entry point easily and repeat- tual plan on the tip of the instrument to enable the surgeon
edly via the K-wire during the tapping and screw placement to determine the proper trajectory, width, and length of the
steps. A disadvantage is that unintended advancement of screw. After this has been performed, the virtual plan can
the K-wire can occur as the cannulated instruments are be locked into place and the awl is then tamped down ac-
placed over it (Fig 1.6-5). Live image intensification allows cording to the planned trajectory. After the awl has been
for real-time visualization of the K-wire for the detection removed, the entry point to the pedicle can easily be found
of any unintended advancement, but this introduces ra- by subsequent instruments as it is at the base of the virtual
diation exposure and added operating room time, if em- plan shown on the image-guided system and these instru-
ployed. ments should fall into the hole already created by the awl.
The hole is then tapped and the screw placed using image
guidance (Fig 1.6-7).
Fig 1.6-4 View from the applica- Fig 1.6-5 Axial CT scan revealing a b c
tion window of an image-guided unintended advancement of a
system showing the insertion of K-wire through the anterior aspect Fig 1.6-6a–c Screenshots from the image-guided system showing the
an image-guided instrument into of the vertebral body. image-guided probe being used to locate the optimal point for the skin
the pedicle to facilitate placement incision, which allows for adequate trajectory to the L5 pedicle (a), disc
of a K-wire. space (b), and S1 pedicle (c).
69

dilators to be tracked, which helps guide optimal placement

of the expandable retractor. Once the retractor is docked,
it can be expanded to expose the pedicle entry points. Using
image-guided instruments, the pedicle screws can be in-
serted into the pedicles. In some cases, the polyaxial heads
of the pedicle screws may impede interbody cage placement.
If this occurs, then one of the screws can be removed prior
to performing the interbody portion of the procedure, and
then replaced afterwards into the pedicle hole. However,
it should be noted that once the interbody portion of the
procedure has been performed, navigation will no longer
be as accurate due to the distraction of the disc space, so
replacement of the screws should only be performed using
a b direct visualization. If it is anticipated that one or both screw
heads could impede the interbody portion of the procedure,
the pedicles can be tapped using image guidance, and the
screws can then be placed into the pedicles using direct
visualization after the interbody portion of the procedure
has been performed.
A variety of combinations of the above methods can be

employed for image-guided placement of pedicle screws in
minimally invasive TLIF procedures. For example, the screws
can be placed percutaneously on the contralateral side of
Fig 1.6-7a–c Intraoperative the TLIF with the ipsilateral screws placed through the ex-
photograph and screenshots
pandable retractor. Alternatively, percutaneous screws can
from the image-guided system
showing percutaneous placement
be placed bilaterally, with the interbody portion of the pro-
of tracked instruments on an intra cedure being performed through a nonexpandable tubular
c operative plan. retractor. A bilateral mini-open approach for placement of
pedicle screws can also be employed.
After placement of the pedicle screws and the interbody

4 Placement of pedicle screws through mini-open cage, a second cbCT scan can be performed to confirm ad-
retractors equate placement of all instrumentation prior to wound
closure.
The mini-open TLIF includes the use of expandable retrac-
tors that allow exposure of the facet targeted for facetec- Two-dimensional image guidance can be used for placement
tomy, as well as the pedicle-screw entry points (Fig 1.6-8). of percutaneous pedicle screws, but this technique can be
With this technique, the pedicle screws can be placed di- more challenging, as static 2-D image intensification is used
rectly into the pedicle using both direct visualization and for navigation and provides no advantage over standard
image guidance, a procedure that is similar to open tech- image intensification for visualization of the patient’s anat-
niques of image-guided pedicle-screw placement. The fac- omy. Additionally, without the ability to navigate from a
et is localized with image guidance using the image-guided cbCT scan, the exact tip location of the navigated instrument
probe on the skin surface. The optimal location of the inci- cannot be fully determined in three dimensions, which can
sion for the expandable retractor should allow for docking result in inaccurate screw placement. Studies are lacking
of the retractor on the facet joint at an angle that would be that describe the placement of percutaneous pedicle screws
optimal for both interbody cage and pedicle screw place- using 2-D image guidance, and surgeons should use caution
ment. Some image-guided systems allow for the retractor if implementing this technique.

1 Fundamentals
5 Evidence-based results
A systematic review of the literature has yielded 19 stud-

ies—17 cohort studies and two randomized controlled trial
studies published between 2000 and 2011 (see topic 10
Evidence-based summaries in this chapter) [12]. The total
number of screws included was 8,539 (4,814 navigated and
3,725 nonnavigated). The relative risk for pedicle-screw
perforation was determined to be 0.39% (P < 0.001), there-
by favoring navigation. The overall pedicle screw perforation
risk for navigation was 6%, while the overall pedicle screw
perforation risk was 15% for conventional insertion. No
related neurological complications were reported with
navigated insertion (4,814 screws in total), and three neu-
rological complications in the nonnavigated group (3,725
screws in total). Furthermore, the meta-analysis did not
reveal a significant difference in total operative time and
estimated blood loss when comparing the two modalities.
In summary, there is a significantly lower risk of pedicle
perforation for navigated screw insertion compared to non-
navigated insertion for all spinal regions.
Fig 1.6-8 Intraoperative photograph showing the use of an

expandable retractor through which an interbody cage and
pedicle screws can be placed.
71

6 Tips and tricks
Iain H Kalfas, Cleveland, USA in the surgical field. Ideally these points the traditional anatomical landmarks in
• As with any other surgical technology, should all be at the same level being navi- the surgical field. Navigation can then be
successful application is dependent on gated. They need to be spread out over used to confirm the surgeon’s accuracy or
surgeons recognizing the strengths and the area of interest (ie, the pedicles). They to make the necessary adjustment. The
limitations of the device, adhering to the should not all be in the same line or the intention of this approach is to reduce
appropriate method for its use and, most same plane as this will affect accuracy. the potential for the surgeon to be too
importantly, acknowledging that it is not • For lumbar navigation, placement of the reliant on the technology, and to serve
a replacement for sound intraoperative reference frame onto a pin placed percu- as an added check for accuracy.
judgment and surgical technique but taneously into the iliac crest keeps it out
rather a tool used to facilitate improv- of the surgical field and helps maintain Roger Härtl, New York, USA
ing surgical techniques and outcomes. a line of sight with the camera. • Use of a custom-made navigated drill
• For surgeons beginning to use image- • Performing the navigation prior to any guide allows placement of the drill, tap,
guided navigation, it is advisable to select required decompression allows for screw and screw (detached from the screw
relatively straightforward procedures for placement without the difficulty of epi- head) without the use of K-wires (Fig
the initial cases. dural bleeding. 1.6-9). This increases safety, minimizes
• During these initial cases, image-inten- • The most important principle of image- the need to switch between navigated
sifier back-up can be helpful as the sur- guided navigation is for the surgeon to instruments, and streamlines the process
geon’s navigation techniques improve, recognize that the technology is not of navigation.
and trust in the technology and its ac- designed to replace intraoperative judg- • The key to navigation is to develop a well-
curacy is developed. ment or understanding of the surgical trained, efficient team that facilitates the
• When paired-point registration is used anatomy and technique. For every case navigation process in the operating room.
with preoperative CT-based navigation, a in which navigation is used, the sur- The x-ray technicians, nurses, and residents
minimum of 3–4 registration points need geon should first select the appropriate should be taught and trained to streamline
to be selected in the image data set and screw entry point and trajectory using navigation in the operating room.
Fig 1.6-9 View of a navigated drill guide allowing

the insertion of the drill, tap, and screws without
K-wires and without the need to switch between
navigated instruments.

1 Fundamentals
7 Conclusion
Image guidance can be used safely and efficiently in mini-

mally invasive spine surgery. A thorough understanding of
this technology is essential for its successful implementation
in these procedures. As a surgeon’s experience with this
technology matures, he/she will notice that the use of im-
age guidance can result in minimally invasive spinal pro-
cedures being accomplished more easily and efficiently as
compared with more traditional techniques.
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image guidance: experience in a large placement with fluoroscopy vs sextant percutaneous pedicle screw
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et al (2007) A comparison of two 7. Bindal RK, Glaze S, Ognoskie M, et al Timing of vertebral registration in
techniques in image-guided thoracic (2008) Surgeon and patient radiation three-dimensional, fluoroscopy-based,
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retrospective study of 37 patients and transforaminal lumbar interbody Disord Tech; 22(5):358–360.
277 pedicle screws. J Neurosurg Spine; fusion. J Neurosurg Spine; 9(6):570–573. 12. Shin BJ, James AR, Njoku IU, et al
7(4):393–398. 8. Nottmeier EW, Fenton D (2010) (2012) Pedicle screw navigation: a
4. Laine T, Lund T, Ylikoski M, et al Three-dimensional image-guided systematic review and meta-analysis of
(2000) Accuracy of pedicle screw placement of percutaneous pedicle perforation risk for computer-navigated
insertion with and without computer screws without the use of biplanar versus freehand insertion. J Neurosurg
assistance: a randomised controlled fluoroscopy or Kirschner wires: Spine; 17(2):113–122.
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73

9 Further reading
Arand M, Hartwig E, Hebold D, et al Lee GY, Massicotte EM, Rampersaud YR Sakai Y, Matsuyama Y, Nakamura H, et
(2001) [Precision analysis of navigation- (2007) Clinical accuracy of cervicothoracic al (2008) Segmental pedicle screwing for
assisted implanted thoracic and lumbar pedicle screw placement: a comparison of idiopathic scoliosis using computer-assisted
pedicled screws. A prospective clinical the "open" lamino-foraminotomy and surgery. J Spinal Disord Tech; 21(3):181–186.
study.] Unfallchirurg; 104(11):1076–1081. computer-assisted techniques. J Spinal Schnake KJ, König B, Berth U, et al
German. Disord Tech; 20(1):25–32. (2004) [Accuracy of CT-based navigation of
Han W, Gao ZL, Wang JC, et al (2010) Liu YJ, Tian W, Liu B, et al (2005) pedicle screws in the thoracic spine
Pedicle screw placement in the thoracic [Accuracy of CT-based navigation of compared with conventional technique.]
spine: a comparison study of computer- pedicle screws implantation in the cervical Unfallchirurg; 107(2):104–112. German.
assisted navigation and conventional spine compared with X-ray fluoroscopy Seller K, Wild A, Urselmann L, et al
techniques. Orthopedics; 33(8). technique.] Zhonghua Wai Ke Za Zhi; (2005) [Prospective screw misplacement
Ishikawa Y, Kanemura T, Yoshida G, et al 43(20):1328–1330. Chinese. analysis after conventional and navigated
(2010) Clinical accuracy of three- Merloz P, Troccaz J, Vouaillat H, et al pedicle screw implantation.] Biomed Tech
dimensional fluoroscopy-based computer- (2007) Fluoroscopy-based navigation (Berl); 50(9):287–292. German.
assisted cervical pedicle screw placement: a system in spine surgery. Proc Inst Mech Eng; Tian W, Liu YJ, Liu B, et al (2006) [Clinical
retrospective comparative study of H 221(7):813–820. contrast of cervical pedicle screw fixation
conventional versus computer-assisted Nakashima H, Sato K, Ando T, et al assisted by C-arm fluoroscopy or 3D
cervical pedicle screw placement. (2009) Comparison of the percutaneous navigation system.] Zhonghua Wai Ke Za
J Neurosurg Spine; 13(5):606–611. screw placement precision of isocentric Zhi; 44(20):1399–1402. Chinese.
Ito H, Neo M, Yoshida M, et al (2007) C-arm 3-dimensional fluoroscopy- Tormenti MJ, Kostov DB, Gardner PA, et
Efficacy of computer-assisted pedicle screw navigated pedicle screw implantation and al (2010) Intraoperative computed
insertion for cervical instability in RA conventional fluoroscopy method with tomography image-guided navigation for
patients. Rheumatol Int; 27(6):567–574. minimally invasive surgery. J Spinal Disord posterior thoracolumbar spinal
Kotani Y, Abumi K, Ito M, et al (2003) Tech; 22(7):468–472. instrumentation in spinal deformity
Improved accuracy of computer-assisted Rajasekaran S, Vidyadhara S, Ramesh P, surgery. Neurosurg Focus; 28(3):E11.
cervical pedicle screw insertion. J et al (2007) Randomized clinical study to Yu X, Xu L, Bi LY (2008) [Spinal navigation
Neurosurg; 99 Suppl 3:257–263. compare the accuracy of navigated and with intra-operative 3D-imaging modality
Kotani Y, Abumi K, Ito M, et al (2007) non-navigated thoracic pedicle screws in in lumbar pedicle screw fixation.] Zhonghua
Accuracy analysis of pedicle screw deformity correction surgeries. Spine; Yi Xue Za Zhi; 88(27):1905–1908. Chinese.
placement in posterior scoliosis surgery: 32(2):E56–E64.
comparison between conventional Richter M, Cakir B, Schmidt R (2005)
fluoroscopic and computer-assisted Cervical pedicle screws: conventional
technique. Spine; 32(14):1543–1550. versus computer-assisted placement of
cannulated screws.
Spine; 30(20):2280–2287.

1 Fundamentals
10 Evidence-based summaries
Laine T, Lund T, Ylikoski M, et al (2000) Accuracy of Han W, Gao ZL, Wang JC, et al (2010) Pedicle screw
pedicle screw insertion with and without computer placement in the thoracic spine: a comparison study of
assistance: a randomised controlled clinical study in 100 computer-assisted navigation and conventional
consecutive patients. Eur Spine J; 9(3):235–240. techniques. Orthopedics; 33(8).
Study type Study design Class of evidence Study type Study design Class of evidence
Therapy Randomized controlled trial I Therapy Comparative study II
Purpose Purpose
To assess the accuracy of computer-assisted pedicle screw To evaluate the technique of computer-assisted pedicle
insertion versus conventional screw placement under screw installation and its clinical benefit as compared with
clinical conditions. conventional pedicle screw installation.
P Patient Patients scheduled for posterior thoracolumbar or lumbosa- P Patient Patients undergoing trauma, spinal stenosis, segmental
cral pedicle screw instrumentation (N = 91) instability, metastasis, or spondylolisthesis surgeries using
posterior pedicle screw instrumentation of the thoracic
I Intervention Conventional pedicle screw placement (n = 50, n = 277
spine (N = 42)
screws)
I Intervention Thoracic screw insertion under 3-D computer-assisted
C Comparison Computer-assisted screw application using an optoelectro-
navigation (n = 22 patients, n = 92 screws)
nic navigation system (n = 41, n = 219 screws)
C Comparison Thoracic screw insertion under conventional image intensi-
O Outcome Operating time, blood loss, time taken for screw insertion,
fier control (n = 20 patients, n = 84 screws)
screw positions assessed using a CT-imaging protocol,
pedicle perforation rate O Outcome Accuracy of screw placement, screw insertion time by
postoperative thin-cut CT scans, cortical perforations, screw
insertion time
Authors’ conclusion
Pedicle screws were inserted more accurately with image-
guided computer navigation than with conventional Authors’ conclusion
methods. Three-dimensional computer-assisted navigation pedicle
screw placement can increase accuracy, reduce surgical
time, and be performed safely and effectively at all levels
of the thoracic spine, particularly in the upper thoracic
spine.
75

Rajasekaran S, Vidyadhara S, Ramesh P, et al (2007) Ishikawa Y, Kanemura T, Yoshida G, et al (2010)

Randomized clinical study to compare the accuracy of Clinical accuracy of three-dimensional fluoroscopy-based
navigated and non-navigated thoracic pedicle screws in computer-assisted cervical pedicle screw placement: a
deformity correction surgeries. Spine; 32(2):E56–E64. retrospective comparative study of conventional versus
computer-assisted cervical pedicle screw placement. J
Study type Study design Class of evidence Neurosurg Spine; 13(5):606–611.
Therapy Randomized controlled trial I–II
Study type Study design Class of evidence
Purpose Therapy Retrospective comparative study III
To compare the accuracy of nonnavigation and Iso-C-
based navigation in pedicle screw fixation in thoracic spine Purpose
deformities. To evaluate the feasibility and accuracy of cervical pedi-
cle screw (CPS) placement using 3-D image intensifier-
P Patient Thoracic spine deformities (N = 33) including scoliosis based navigation (3-D FN).
(n = 27) and kyphosis (n = 6)
I Intervention Pedicle screw fixation with screw insertion under Iso-C- P Patient Patients undergoing posterior stabilization of the cervical
based navigation (n = 17) spine (N = 62)
C Comparison Pedicle screw fixation with screw insertion under image I Intervention CPS placement using 3-D FN (n = 32 patients, n = 150
intensifier control (n = 16) screws)
O Outcome Pedicle breaches, penetration of cortex, screw insertion time C Comparison CPS placement using conventional techniques (CVTs) with
a lateral image intensifier view (n = 30 patients, n = 126
screws)
O Outcome Prevalence of perforations, malpositioning
Iso-C navigation increases accuracy, and reduces surgical
time and radiation in thoracic deformity correction sur-
geries.
Three-dimensional image intensifier-based navigation can
improve the accuracy of CPS insertion; however, severe
CPS malpositioning that causes injury to the vertebral
Arand M, Hartwig E, Hebold D, et al (2001) [Precision
artery or neurological complications can occur even with
analysis of navigation-assisted implanted thoracic and
3-D FN. Advanced techniques for the insertion of CPSs
lumbar pedicled screws. A prospective clinical study.]
and the use of modified insertion devices can reduce the
Unfallchirurg; 104(11):1076–1081. German.
risk of a malpositioned CPS and provide increased safety.
Therapy Cohort III
Purpose
To study the accuracy of pedicle screw placement of con-
secutive computer-aided and conventional techniques.
P Patient Patients scheduled for thoracolumbar pedicle screw

instrumentation
I Intervention CT-controlled patients (n = 72 screws)
C Comparison Conventional technique (n = 86 screws)
O Outcome Operation time, complications, misplacement of screws
The application of the computer-assisted freehand navi-
gation can improve results concerning the precision of
spinal screw placement. However, in using the spinal
navigator there is a learning curve for the clinical inau-
guration of the system and the implant system must be
suitable for computer-assisted application.

1 Fundamentals
Ito H, Neo M, Yoshida M, et al (2007) Efficacy of Kotani Y, Abumi K, Ito M, et al (2003) Improved
computer-assisted pedicle screw insertion for cervical accuracy of computer-assisted cervical pedicle screw
instability in RA patients. Rheumatol Int; 27(6):567–574. insertion. J Neurosurg; 99 Suppl 3:257–263.
Therapy Cohort III Therapy Cohort III
Purpose Purpose
To evaluate the efficacy of computer-assisted cervical To introduce a unique computer-assisted cervical pedicle
pedicle screw insertion compared with those inserted screw (CPS) insertion technique used in conjunction with
without the help of the system on the cervix of rheuma- specially modified original pedicle screw insertion instru-
toid arthritis patients. ments.
P Patient Rheumatoid arthritis patients (N = 10; N = 52 screws) P Patient Cervical disorders (spondylotic myelopathy with segmental
instability or kyphosis, metastatic spinal tumor, rheumatoid
I Intervention Cervical pedicle screws insertion with a computer-assisted spine, and postlaminectomy kyphosis) (N = 17)
system (n = 5 patients, n = 25 screws)
I Intervention Cervical pedicle screw fixation using a computer-assisted
C Comparison Cervical pedicle screws insertion with a conventional system surgical navigation system (n = 17, n = 78 screws)
(n = 5 patients, n = 27 screws)
C Comparison Conventionally treated patients using manual insertion
O Outcome Accuracy of the screw insertions evaluated by a CT-based techniques (historical group of patients n = 180)
method, efficacy of the computer-assisted system, operati-
on time, blood loss O Outcome Accuracy of screw placement, rate of pedicle-wall perforati-
on, surgery-related outcome, complication rate
The screws in rheumatoid arthritis patients tended to be Authors’ conclusion
more deviated than those in nonrheumatoid arthritis pa- In contrast to the previously reported computer-assisted
tients. Even if the use of a computer-assisted system re- technique, the authors' CPS insertion technique provides
quires more time or causes some blood loss during the real-time 3-D instrument/screw tip information. This
operation, the importance of the accurate surgical tech- serves as a powerful tool for safe and accurate pedicle
nique cannot be overstated, especially in the fragile vas- screw placement in the cervical spine.
cular abnormality-plagued rheumatoid arthritis spine.
The authors strongly support the use of computer-assist-
ed pedicle screw insertion in rheumatoid arthritis patients.
77

Kotani Y, Abumi K, Ito M, et al (2007) Accuracy Lee GY, Massicotte EM, Rampersaud YR (2007)
analysis of pedicle screw placement in posterior scoliosis Clinical accuracy of cervicothoracic pedicle screw
surgery: comparison between conventional fluoroscopic placement: a comparison of the "open" lamino-
and computer-assisted technique. Spine; 32(14):1543– foraminotomy and computer-assisted techniques. J
1550. Spinal Disord Tech; 20(1):25–32.
Purpose Purpose
To compare the pedicle screw placement accuracy in pos- To compare the “open” laminoforaminotomy with com-
terior scoliosis surgery between conventional image-in- puter-assisted techniques of cervicothoracic pedicle screw
tensifier and computer-assisted surgical techniques. placement.
P Patient Scoliosis (N = 45) P Patient Posterior spinal procedures (N = 60)

I Intervention Posterior surgery with navigation (n = 20) I Intervention Closed 2-D or 3-D computer-assisted technique (n = 28)
C Comparison Posterior surgery with manual control (n = 25) C Comparison Open laminectomy or laminoforaminotomy techniques
(n = 32)
O Outcome Vertebral rotation, pedicle axes, screw insertion angle error,
perforations O Outcome Pedicle breaches, pedicle screw accuracy, need for screw
revision
The use of a surgical navigation system successfully re- Authors’ conclusion
duced the perforation rate and insertion angle errors, Computer-assisted surgery allows for more accurate place-
demonstrating the clear advantage in safe and accurate ment of pedicle screws at the CTJ. Although a higher
pedicle screw placement of scoliosis surgery. proportion of major pedicular breaches occurred in the
“open lamina/laminoforaminotomy” group, no screws
required revision in either group.

1 Fundamentals
Liu YJ, Tian W, Liu B, et al (2005) [Accuracy of CT- Merloz P, Troccaz J, Vouaillat H, et al (2007)
based navigation of pedicle screws implantation in the Fluoroscopy-based navigation system in spine surgery.
cervical spine compared with X-ray fluoroscopy Proc Inst Mech Eng; H 221(7):813–820.
technique.] Zhonghua Wai Ke Za Zhi; 43(20):1328–1330.
Chinese. Study type Study design Class of evidence
Therapy Cohort III
Therapy Cohort III Purpose
To describe a computer-assisted surgical navigation system
Purpose based on image-intensifier image calibration and 3-D op-
To evaluate the feasibility and accuracy of cervical spine tical localizers in order to reduce radiation exposure while
pedicle screw fixation assisted by x-ray image intensifica- increasing accuracy and reliability of the surgical proce-
tion and CT-based navigation system. dure for pedicle screw insertion.
P Patient (N = 304) P Patient Patients who suffered thoracolumbar disorders (N=52 ) re-
ceiving instrumentation using transpedicular screw fixation
I Intervention Cervical pedicle screws placement assisted by x-ray image
intensification (n = 145) I Intervention Navigated surgical procedure (virtual image intensification)
(n = 26 patients, n = 140 screws)
C Comparison Cervical pedicle screws placement assisted by a CT-based
navigation system (n = 159) C Comparison Conventional surgical procedure (n = 26 patients, n = 138
screws)
O Outcome Screw positions evaluated by postoperative CT scans or
C-arm x-ray 3-D reconstruction; mean time for registration, O Outcome Evaluation of screw placement using x-rays, CT scans
surface matching and screw-marker insertion; mean positi- Cortex penetration, radiation running time, operative time
on deviation; complications
Authors’ conclusion The image-intensifier-based (2-D) navigation system for
CT-based navigation system can significantly increase the pedicle screw insertion is a safe and reliable procedure
accuracy of cervical pedicle screw implantation. for surgery in the lower thoracic and lumbar spine.
79

Nakashima H, Sato K, Ando T, et al (2009) Richter M, Cakir B, Schmidt R (2005) Cervical pedicle
Comparison of the percutaneous screw placement screws: conventional versus computer-assisted placement
precision of isocentric C-arm 3-dimensional fluoroscopy- of cannulated screws. Spine; 30(20):2280–2287.
navigated pedicle screw implantation and conventional
fluoroscopy method with minimally invasive surgery. Study type Study design Class of evidence
J Spinal Disord Tech; 22(7):468–472. Therapy Cohort III
Study type Study design Class of evidence Purpose

Therapy Retrospective cohort study III To evaluate whether cervical pedicle screws can be placed
safely in a conventional technique when using cannu-
Purpose lated screws and separate stab incisions. Also, to evaluate
To evaluate the accuracy of clinical percutaneous pedicle if accuracy and safety of pedicle screw placement can be
screw placement using Iso-C 3-D image-intensifier navi- improved using a computer-assisted surgery (CAS) system
gation. (VectorVision; BrainLAB AG, Germany).
P Patient Patients with degenerative spondylolisthesis with lumbar P Patient Patients with posterior cervical or cervicothoracic instru-
spinal canal stenosis undergoing percutaneous pedicle mentations using pedicle screws (N=52) due to spondylotic
screw placement (N = 67 patients, N = 300 pedicle screws ) myelopathy, fractures, metastases, implant failures, cor-
rections of kyphotic deformities, rheumatoid or iatrogenic
I Intervention Insertion of pedicle screws under Iso-C 3-D image-intensi-
instabilities.
fier navigation (n = 150 pedicle screws )
I Intervention Pedicle screws implanted using the conventional technique
C Comparison Insertion of pedicle screws with conventional image intensi-
with the image intensifier in the lateral view (n = 20 pati-
fication (n = 150 pedicle screws )
ents, 93 pedicle screws)
O Outcome Blood loss, image intensification time, accuracy of pedicle
C Comparison Pedicle screws implanted using additionally a CAS system
screw placement by CT, screw malpositioning
(n = 32 patients, 167 screws)
O Outcome Blood loss, operating time, postoperativex-ray control of pe-
Authors’ conclusion dicle screw placement, complications (pedicle perforations,
The difference in frequency of screw misplacement be- displacements)
tween the procedure using Iso-C 3-D image-intensifier-
based image-guidance assistance and that using image Authors’ conclusion
intensification was statistically significant. This study Transpedicular screws in the cervical spine and cervico-
demonstrates the feasibility of placing percutaneous pos- thoracic junction can be applied safely and with high
terior lumbar pedicle screws with the assistance of Iso-C accuracy using a conventional technique. Cannulated
3-D navigation. screws and the use of separate stab incisions from C3–6
with a trocar system allow for reduced screw misplace-
ment rates. The CAS system leads to significantly reduced
screw misplacement rates. Therefore, because of the po-
tential risk of injury to the vertebral artery and neural
elements, the use of a CAS system seems to be beneficial,
especially for pedicle instrumentation C3–6.

1 Fundamentals
Sakai Y, Matsuyama Y, Nakamura H, et al (2008) Schnake KJ, König B, Berth U, et al (2004) [Accuracy
Segmental pedicle screwing for idiopathic scoliosis using of CT-based navigation of pedicle screws in the thoracic
computer-assisted surgery. J Spinal Disord Tech; spine compared with conventional technique.]
21(3):181–186. Unfallchirurg; 107(2):104–112. German.
Purpose Purpose
To evaluate the accuracy of computer-assisted surgery To evaluate the accuracy of CT-based computer-assisted
for idiopathic scoliosis. pedicle screw insertion in the thoracic spine in patients
with fractures, metastases, and spondylodiscitis compared
P Patient Idiopathic scoliosis (N = 40) to a conventional technique.
I Intervention Pedicle screw placement using CT-based navigation
(n = 20) P Patient Patients with fractures, metastases, and spondylodiscitis
(N = 85)
C Comparison Pedicle screw placement without guidance (n = 20)
I Intervention Pedicle screws placed using a CT-based optoelectronic
O Outcome Accuracy of placement, pedicle perforation
navigation system assisted by an image intensifier (n = 211)
C Comparison Pedicle screws placed with a conventional technique
(n = 113)
In the navigation group, a tendency to lateral perforation
O Outcome Screw positions evaluated with postoperative CT scans
at the concave side and medial perforation at the convex
side was noted, like in the control group. Use of the nav-
igation system significantly reduced the screw misplace- Authors’ conclusion
ment rate for rotated vertebrae as compared with the In the computer-assisted group, significantly more screws
control group. were found completely within their pedicles compared
with correctly placed screws in the conventional group.
Despite use of the navigation system, 1.9% of the com-
puter-assisted screws perforated the pedicle wall by more
than 4 mm. The additional use of the image intensifier
helped to identify the correct vertebral body and avoided
cranial or caudal pedicle wall perforations.
81

Seller K, Wild A, Urselmann L, et al (2005) Tian W, Liu YJ, Liu B, et al (2006) [Clinical contrast of
[Prospective screw misplacement analysis after cervical pedicle screw fixation assisted by C-arm
conventional and navigated pedicle screw implantation.] fluoroscopy or 3D navigation system.] Zhonghua Wai Ke
Biomed Tech (Berl); 50(9):287–292. German. Za Zhi; 44(20):1399–1402. Chinese.
Purpose Purpose
The aim of this prospective study is to: To evaluate the feasibility and accuracy of cervical (C2–7)
1. Evaluate the accuracy of pedicle screw placement using pedicle screw fixation assisted by C-arm image intensifi-
computer-assisted orthopedic surgery (CAOS) in com- cation or 3-D navigation system (CT-based navigation
parison to conventionally image-intensifier-controlled system or Iso-C 3-D navigation system).
pedicle screw instrumentation.
2. Compare results with data from the literature. P Patient (N = 332)
3. Report the authors’ experiences with this technique. I Intervention Cervical pedicle screws inserted with C-arm image intensifi-
cation (n = 145)
P Patient Patients planned for spine surgery (N = 16) C Comparison Cervical pedicle screws inserted with 3-D navigation system
(n = 187)
I Intervention Pedicle screw placement with computer-aided surgery
(n = 36) O Outcome Postoperative CT or Iso-C 3-D scan
Investigation of the process of navigation (n = 25)
C Comparison Pedicle screw placement with image-intensifier control
(n = 24)
Outcome Intraindividual comparison, evaluation of pedicle screw
O
placement (with postoperative CT scan or MRI) A 3-D navigation system can increase accuracy of cervical
pedicle screw fixation.
Computer-assisted surgery reduces significantly the mis-
placement rate of pedicle screws, and for experienced Tormenti MJ, Kostov DB, Gardner PA, et al (2010)
spine surgeons remains an important support in the op- Intraoperative computed tomography image-guided
erative treatment of complex spinal deformities for the navigation for posterior thoracolumbar spinal
future. In additional, it can be expected that computer instrumentation in spinal deformity surgery. Neurosurg
navigation will also spread out in the field of minimally Focus; 28(3):E11.
invasive spine surgery, eg, kyphoplasty. Besides the im-
proved medical-technical knowledge, the use of this tech- Study type Study design Class of evidence
nique supports an improved 3-D orientation in the edu- Therapy Cohort III
cation of spine surgeons.
Purpose
To report the prospective evaluation of the accuracy of
posterior thoracolumbar spinal instrumentation using a
new intraoperative CT operative suite with an integrated
image-guidance system.
P Patient Thoracolumbar spinal deformity (N = 26)

I Intervention Posterior thoracolumbar instrumentation using intraopera-
tive CT-based image guidance (n = 12)
C Comparison Instrumentation using image intensification and postopera-
tive CT scanning (n = 14)
O Outcome Accuracy of thoracolumbar pedicle screw placement
Intraoperative CT-based image guidance for placement
of thoracolumbar instrumentation has an accuracy that
exceeds reported rates with other image-guidance systems.

1 Fundamentals
Yu X, Xu L, Bi LY (2008) [Spinal navigation with

intra-operative 3D-imaging modality in lumbar pedicle
screw fixation.] Zhonghua Yi Xue Za Zhi; 88(27):1905–
1908. Chinese.

Therapy Cohort III
Purpose
To evaluate the efficacy and safety of spinal navigation
with intraoperative 3-D imaging modality in lumbar
pedicle screw fixation.
P Patient Patients with lumbar degenerative disorders or fracture

(N = 401)
I Intervention Pedicle screw fixation by spinal navigation with intraopera-
tive 3-D imaging system
C Comparison Pedicle screw fixation by traditional method
O Outcome Position of pedicle screw assessed by intraoperative 3-D
imaging system, rate of pedicle screw position, mean time
of pedicle screw implantation, operating time, blood loss,
and postoperative complication
With spinal navigation combined with the intraoperative
3-D imaging modality, implantation of lumbar pedicle
screws is simplified, more accurate, safer, and can be per-
formed with a shorter operating time.
83


1.7 Biologics in minimally invasive spine surgery
Alex Gitelman, Rahul Basho, Jeffrey Wang
1 Introduction 2.1 Autografts

Autografts have long been considered the gold standard, as
Arthrodesis procedures include a significant proportion of they combine all of the afore-mentioned properties. How-
spine surgery that is carried out for the treatment of degen- ever, the limited supply of autografts as well as the morbid-
erative disease, trauma, and deformity. However, achieving ity associated with their harvesting has led to the develop-
solid fusion is often made more difficult by a number of ment of a large number of bone graft substitutes and
factors, such as smoking, or a range of medical comorbidi- extenders, which may have one or more of the properties
ties including diabetes, osteoporosis, hormonal imbalance, just-described [6].
nutritional deficiency, or metabolic abnormalities, among
others [1, 2]. The advances made in stable internal fixation 2.2 Allografts
over the past decades have significantly increased the rates Allografts obtained from human anatomical specimens pro-
of successful fusion, but a relatively high percentage of pa- vide an osteoconductive scaffold, and are weakly osteoin-
tients go on to develop pseudarthrosis [3–5]. While the out- ductive. They do not have any osteogenic potential, as all
come may still be successful for many of these patients, the the bone cells are destroyed during processing in order to
problems associated with symptomatic pseudarthrosis and decrease the risk of transmission of infection and antigenic-
instability require further surgical treatment, and thus sig- ity. However, a minimal risk of infection due to viral trans-
nificant medical expenditure. mission still exists, eg, hepatitis, cytomegalovirus, and hu-
man immunodeficiency virus infection. Allografts may also
The past decade has seen a marked increase in minimally undergo further processing such as demineralization and
invasive procedures, including spine fusion techniques. the production of demineralized bone matrix (DBM) which
While the outcomes of minimally invasive spine surgery lacks the structural support of strut allografts, but still has
are generally considered to be similar to those of tradi- osteoconductive and osteoinductive properties.
tional open techniques they do have certain limitations,
including decreased visualization and exposure. Thus, the Several prospective studies have compared the respective
area of decorticated bone available for fusion as well as the efficacy of structural allografts and autografts for spinal fu-
amount of local autograft is often less than in open proce- sion surgery. Bishop et al [7] conducted a prospective com-
dures, thereby resulting in potentially lower fusion rates. parative study of tricortical iliac crest allografts and auto-
As a result, bone graft substitutes and extenders have been grafts in 132 patients that underwent uninstrumented
increasingly used to help achieve spinal fusion, and increase anterior cervical discectomy and fusion procedures. These
fusion rates. authors found that the results for the autograft group were
better with respect to the maintenance of cervical interspace
height, interspace angulation, and fusion success rates as
2 Types of bone graft and bone graft substitutes determined by x-ray and clinical examination. On the oth-
er hand, Savolainen et al [8] found no significant difference
Bone grafts and bone graft substitutes are generally classi- between 250 patients who underwent uninstrumented
fied into one or more of the following categories: struc- anterior cervical discectomy and fusion (ACDF) procedures
tural, osteoconductive, osteoinductive, and osteogenic. with either tricortical iliac crest autograft or allograft. More-
Structural grafts such as tricortical iliac crest grafts or fem- over, Samartzis et al [9] did not find any advantage of using
oral ring allografts provide mechanical support to the con- allografts over autografts in instrumented ACDF surgery
struct; osteoconductive grafts provide a scaffold for bone with respect to nonunion rates.
formation; osteoinductive grafts induce osteoblastic differ-
entiation of the progenitor cells; and osteogenic grafts di- An et al [10] compared the efficiency of autografts versus
rectly contribute to cell growth and bone formation. allografts in adult posterolateral lumbar spine fusion, and
85

Authors Alex Gitelman, Rahul Basho, Jeffrey Wang
found that the use of autografts resulted in a significantly parative study demonstrated that the use of allograft com-
greater bone density of the fusion mass, followed in decreas- bined with DBM composite for anterior cervical fusion
ing order of efficiency by a mixture of autograft and allograft, resulted in higher rates of graft collapse and pseudarthrosis
frozen allograft, and freeze-dried allograft. Jorgenson et al when compared with autograft [18]. Currently available
[11] conducted a prospective study comparing autograft and evidence appears to support the use of DBM for anterior
allograft use in the same patient; the former was found to lumbar interbody fusion when used in conjunction with
be superior to the latter. Interestingly, however, similar internal fixation; however, the evidence is weaker for an-
pseudarthrosis rates, maintenance of curve progression, and terior cervical fusion, for which better results appear to be
assessment of bone graft mass were found for autografts obtained with structural grafts [18].
and allografts when these were used in pediatric patients
with idiopathic scoliosis [12, 13]. 2.4 Ceramics
Ceramics constitute an attractive type of bone graft ex-
2.3 Demineralized bone matrix tender and bone substitute for several reasons. They can
Demineralized bone matrix is a bone graft substitute with be manufactured in large quantities and in a variety of
primarily osteoconductive and certain osteoinductive prop- shapes and sizes, do not carry the risk of disease transmis-
erties. It is formed by acid extraction of allograft bone, re- sion, are biodegradable, and are easy to sterilize. On the
sulting in the loss of the mineralized bone component while other hand, they only provide an osteoconductive scaffold,
retaining the type 1 collagen framework and many growth have little shear strength, and are brittle. As such, they
factors. The osteoinductive quality of DBM differs according cannot be used as structural grafts without the protection
to the product due to the variability in content of bone of rigid instrumentation. Commercially available forms of
morphogenetic proteins (BMPs) [6, 14]. This bone graft sub- ceramics include calcium carbonate and beta-tricalcium
stitute is currently available in a wide range of forms, in- phosphate.
cluding putty, injectable gel, and flex strips.
The osteoconductive scaffold in ceramics consists of a porous
There is strong evidence in the literature in support of the matrix, which allows for bone and blood vessel ingrowth.
use of DBM both as a bone graft substitute and as an ex- The optimal pore size has been determined as being between
tender in lumbar fusion surgery. In a prospective compar- 150 and 500 micrometers [19, 20]. The hydroxyapatite (HA)
ative study conducted on the efficacy of autograft on the coating available on some ceramics theoretically leads to
one hand and a smaller amount of autograft combined with faster bone ingrowth. Thalgott et al [21] reported a 100%
DBM on the other, in 120 patients that underwent instru- fusion rate for an HA-coated coral graft used in combination
mented posterolateral lumbar spine fusion surgery [15], the with rigid plating at 2-year follow-up in 22 patients who
authors found nearly identical fusion mass and graft min- underwent ACDF.
eralization for both techniques. This demonstrated that
when autograft is combined with DBM, a smaller amount The results on the use of ceramics for posterior lumbar in-
of the former needs to be used. Vaccaro et al [16] also found tertransverse fusion, even with rigid instrumentation, do
that DBM provided similar results to autograft in posterior not appear to be as positive. Korovessis et al [22] conducted
spinal fusion surgery. a prospective randomized study comparing coralline HA
mixed with bone marrow versus iliac crest autograft, and
The evidence in favor of the use of DBM in anterior lumbar found that HA was not appropriate for intertransverse fu-
and cervical surgery is not quite as strong as it is for poste- sion due to the small area of bleeding bone surfaces. How-
rior surgery. The currently available DBM products lack the ever, the authors did note that the use of HA over decorti-
structural stability needed for anterior cervical and lumbar cated laminae with a large bleeding bone surface was
interbody fusion procedures, and have to be used in con- followed by solid fusion within the expected time period.
junction with a structural spacer [6]. Thalgott et al [17] On the other hand, Chen et al [23] carried out a prospective
evaluated fusion rates and clinical outcomes in 50 patients study comparing calcium sulfate combined with local au-
who underwent anterior lumbar interbody fusion (ALIF) tograft on one side of a short-segment lumbar fusion and
with the use of titanium mesh cages, coralline hydroxy- iliac crest autograft on the other, and found similar fusion
apatite, and DBM as part of a circumferential fusion. The rates between the two sides. Thus, the best use for ceramics
authors noted good radiological and clinical results, with at the present time appears to be over large decorticated
96% fusion rates observed. However, a prospective com- areas of bone combined with local autograft.

1 Fundamentals
2.5 Bone morphogenetic proteins mented posterolateral fusions. These authors found that
Bone morphogenetic proteins were first identified by Urist both groups scored significantly better at 2 years on the
in 1965 [24]. Initially, their widespread use was not possible Short Form 36 and Oswestry Disability indices; however,
as BMPs represented only 0.1% of DBM, and their extrac- the BMP group achieved a higher fusion rate, with a short-
tion was extremely expensive. However, with advances in er operative time and less blood loss than the iliac crest
molecular engineering, nonimmunogenic strains of recom- group. Vaccaro et al [33] investigated the rates of fusion,
binant BMP have become available. Two currently available clinical success, and complications in a prospective random-
rhBMPs for surgical use in humans are rhBMP-2 and rh- ized study comparing rhBMP-7 and iliac crest autograft in
BMP-7. These proteins are water-soluble, and are rapidly a patient group that underwent single-level lumbar lami-
diffused from the surgical site, if used alone. Thus the clin- nectomy and posterolateral uninstrumented fusion for de-
ical use of BMPs requires a carrier matrix in order to prevent generative spondylolisthesis. They found that the rates of
their rapid dissolution, and permit their consistent release radiographically determined fusion, clinical improvement,
over time. and overall success in the rhBMP-7 group were at least
comparable to those in the autograft group at 4-year follow-
A large number of animal studies have been performed to up. No adverse effects directly related to the use of BMP,
assess the effectiveness of BMPs in producing bone and such as local or systemic toxicity or ectopic bone formation,
achieving fusion [25–29]. Good results have been obtained were noted in this study.
using rhBMP-2 and rhBMP-7 in primate, sheep, rat, and
rabbit models using a variety of carrier matrices, and both However, some studies have reported complications associ-
anterior and posterior intertransverse fusion techniques. ated with the use of BMP. Pradhan et al [34] noted aggres-
Fusion rates were found to be as good or better than those sive early resorption of the bone graft on x-rays and CT
in autograft controls. scans in patients who underwent ALIF with femoral ring
allograft and rhBMP-2. This phenomenon resulted in graft
The results of several prospective randomized human stud- fracture and bone graft disintegration in some patients. Le-
ies support the use of BMPs. Boden et al [30] compared the wandrowski et al [35] reported similar complications in a
fusion rates in 11 patients who underwent ALIF with cage series of 5 patients that underwent transforaminal lumbar
insertion and rhBMP-2 on a collagen sponge carrier, and interbody fusion (TLIF) with cage placement and rhBMP-2.
iliac crest autograft in 3 patients. They found that all patients All patients had good initial clinical results, but began to
treated with BMP achieved solid fusion, and that the clin- experience increasing low back and radicular pain at 1 to
ical results were better in the BMP group than in the auto- 3 months postsurgery; CT scans demonstrated the develop-
graft group at 3 months, but similar at 6 months. Slosar et ment of vertebral osteolysis. However, all bone defects
al [31] conducted a larger study comparing the use of fem- eventually filled in, and the symptoms resolved after
oral ring allograft alone and allograft combined with rh- 3 months of further nonoperative care. Given these find-
BMP-2 for ALIF with posterior pedicle screw instrumenta- ings, caution is needed when using BMPs, and when con-
tion. They found significantly better fusion rates in the fronted with worsening clinical results following initial
rhBMP-2 group, with successful fusion at 12 months for all improvement, the possible development of osteolysis should
103 levels treated in 45 patients; this group was also noted be investigated.
to have better clinical outcomes. The use of rhBMP-2 and
rhBMP-7 has also been approved by the US Food and Drug The use of BMP in treating the cervical spine has also been
Administration for anterior lumbar fusion surgery. reported to improve fusion rates, while also involving the
risk of complications. Baskin et al [36] conducted a prospec-
In addition, there is convincing evidence in support of the tive randomized study comparing the efficacy of using
use of BMP in posterior lumbar fusion surgery. Boden et al fibular allograft with either rhBMP-2 or cancellous iliac
[32] carried out a prospective randomized pilot study exam- crest autograft in patients that underwent anterior cervical
ining the use of rhBMP-2 in posterolateral fusion. They fusion surgery. These authors reported a 100% fusion rate
found a 100% fusion rate in the group treated with BMP in all patients at 6 months postoperatively, with no device-
and HA/tricalcium phosphate, regardless of whether instru- related adverse effects; however, they noted that the BMP
mentation had been used; this was superior to the results group had higher neck and arm disability scores at 2 years
with autograft and instrumentation. Dimar et al [12] com- postoperatively. A large number of studies have also found
pared the use of rhBMP-2 with compression-resistant ma- complications related to the use of BMP in anterior neck
trix and autogenous iliac crest graft in single-level instru- surgery. Vaidya et al [37] reported that the use of rhBMP-2
87

in patients who underwent anterior cervical fusion result- [55–57].Several methods for increasing the concentrations
ed in a higher rate of dysphagia, as well as increased post- of these growth factors from the patient’s blood into an
operative swelling anterior to the vertebral body for up to autologous growth factor (AGF) concentrate have been
6 weeks postsurgery, as determined on lateral cervical x- developed, and considerable interest has been shown in
rays. These effects appeared to be dose-related, and second- the potential of these concentrates to improve fusion rates.
ary to increased inflammation. Due to the concern over Lowery et al [58] provided early encouraging evidence that
these adverse effects, in June 2008 the US Food and Drug AGF may increase lumbar fusion rates when used in con-
Administration issued a public health warning regarding junction with autografts. Hee et al [59] conducted a prospec-
possible life-threatening complications associated with tive study on 23 patients undergoing TLIF with the use of
rhBMP when used for cervical spine fusion. AGF. At a minimum 2-year follow-up, they found that
while AGF use did not result in increased fusion rates, it
Significant concerns regarding the use of BMP have been could promote earlier fusion. Feiz-Erfan et al [60] carried
raised [38–49]. Multiple articles and editorials in the June out a double-blind, randomized study to evaluate the use
2011 issue of Spine Journal focused on discussion of pos- of platelet concentrate gel in anterior cervical discectomy
sible problems with the research studies of BMP, as well as and fusion, and found that its use promoted early fusion
possible complications that may have been underreported. in patients with degenerative disc disease, although
These concerns have not been resolved [38–49]. As such, early fusion was not observed in patients with soft disc
great care should be taken when considering the use of herniations.
BMP in spine surgery and the ongoing literature should be
carefully studied. However, other recent evidence suggests that AGF may not
be effective in improving fusion rates. Carreon et al [61]
2.6 Mesenchymal stem cells retrospectively compared a group of patients who underwent
Mesenchymal stem cells (MSCs) have the capacity to dif- posterolateral lumbar fusion with autogenous iliac crest
ferentiate into multiple cell lines, including osteoprogenitor graft with and without AGF, and found no significant dif-
cells. Animal studies provided initial evidence that MSCs ference in fusion rates between the two groups. Interest-
are able to promote lumbar spine fusion [50–52]. While MSCs ingly, one study even found decreased fusion rates for pos-
are present at many sites in the body, bone marrow has terior lumbar intertransverse fusion surgery when using
been identified as a particularly good source of these cells. AGF in combination with autograft as opposed to autograft
Gan et al [53] investigated the use of MSCs obtained from alone [62]. At the present time, there is no strong evidence
bone marrow aspirate from iliac crests combined with tri- to support the routine use of platelet concentrates in spine
calcium phosphate in posterior spinal fusion, achieving a fusion surgery.
fusion rate of 95% at 34.5 months with this technique.
Neen et al [54] compared autograft with bone marrow as-
pirate on a collagen/HA matrix in anterior and posterolat- 3 Conclusion
eral spine fusion. They noted that while bone marrow as-
pirate was inferior to autograft for anterior interbody fusion, Minimally invasive spine surgery presents a unique series
the two techniques were equivalent when the posterolat- of challenges and specificities, in which orthobiologics will
eral approach was used. While sufficient class of evidence play an increasingly important role. Shorter incisions and
level I is lacking regarding the efficacy of MSCs and bone smaller areas of available decorticated bone require the ap-
marrow aspirate in achieving successful spine fusion, it appropriate selection of bone graft substitute or extender in
pears that this technique may lead to increased fusion rates order to optimize the conditions for successful fusion. This
without the morbidity associated with autograft harvesting issue is further complicated by the mutual desire of both
or the high cost of BMPs. surgeon and patient to avoid the morbidity associated with
autologous bone graft harvesting, but also by the need to
2.7 Autologous platelet concentrates balance the cost of the bone graft extender against each
The release of growth factors such as platelet-derived growth patient’s unique set of risk factors for pseudarthrosis. While
factors (PDGFs) and transforming growth factor-beta (TGF- there is reliable evidence in support of currently available
beta) at an injury zone has been the subject of significant bone graft options for specific scenarios, further research is
research over the past two decades. These factors are known necessary to more accurately identify the specific applica-
to promote the differentiation and proliferation of mesen- tions of each bone graft extender to minimally invasive
chymal stem cells and enhance bone and tendon healing surgery.

1 Fundamentals
4 References
1. Boden SD, Sumner DR (1995) Biologic 13. Aurori BF, Weierman RJ, Lowell HA, 25. Blattert TR, Delling G, Dalal PS, et al
factors affecting spinal fusion and bone et al (1985) Pseudarthrosis after spinal (2002)Successful transpedicular
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28(17):1968–1970.

1.8 Anesthetic considerations and minimally invasive spine
surgery
Rondall K Lane, Jeremy Lieberman
1 Introduction Additionally, to minimize bleeding risks, nonsteroidal an-

tiinflammatory drugs (NSAIDs) are often stopped in advance
Advances in endoscopy, microsurgical procedures, video- of surgery, leading to increased preoperative discomfort.
assisted thoracic surgical techniques, and anesthesia, have Regardless of the preoperative regimen, spinal procedures
allowed for the development and increasingly widespread can leave patients with significant additional pain. Hence,
use of minimally invasive spine surgery (MISS). While of- although finding ways to improve pain control can be dif-
ten associated with shorter hospital stays, less postoperative ficult, this issue is of paramount importance in terms of
pain, and reduced nausea and vomiting, MISS still carries achieving patient satisfaction and optimal outcomes.
the risk of morbidity including postoperative pneumonia,
myocardial infarction, congestive heart failure, and stroke. 2.1 Types of pain
Additionally, spine patients are often of advanced age and/ To lessen the amount of postoperative pain, a differentiation
or present with serious medical comorbidities, such as obe- must be made between the various types of pain, and the
sity or rheumatoid arthritis, which warrant specific consid- medications best suited for each specific type.
eration from the anesthesiologist and surgeon [1–3]. When
developing an anesthetic plan, care must be taken to prop- Pain is often thought of as being nociceptive or nonnocicep-
erly assess a patient’s comorbid conditions, and to correct- tive in nature. Nociceptive pain develops after stimulation
ly determine the surgical techniques to be utilized. By do- of receptors that respond to cold, heat, stretch, vibration,
ing so, optimal patient outcomes will be facilitated. and damaged tissue. It can be somatic or visceral in nature.
This type of pain is usually responsive to treatment with
A recent review article has pointed out the importance of opioids, NSAIDs, acetaminophen, or a combination of these
communication between the anesthesiologist and spine medications.
surgeon in developing a protocol with the best short- and
long-term outcomes for the benefit of the patient [4]. This Nonnociceptive pain does not involve specific receptors,
chapter focuses on the anesthetic management of patients but occurs after stimulation of the peripheral and central
undergoing MISS, with specific emphasis on preoperative nervous system with resultant cell dysfunction. Nonnoci-
assessment, postoperative pain management, control of ceptive pain, which can be secondary to nerve damage or
postoperative nausea and vomiting, and some important an overactive sympathetic nervous system, is often only
considerations associated with specific procedures. minimally responsive to opioids, NSAIDs and acetamino-
phen. This type of pain often requires treatment with agents
such as antidepressants, anticonvulsants, antiarrhythmics,
2 Pre-, intra-, and postoperative pain management and N- methyl-D-aspartic acid (NMDA) receptor antagonists
strategies [7].
Pain is a significant source of patient stress and anxiety, 2.2 Preoperative pain management strategies
with many patients fearing postoperative pain more than Efficient planning for postoperative pain relief should start
the surgical procedure itself. In addition to provoking anx- before surgery. Detailed information on the patient’s
iety, poorly controlled pain may have a negative impact on medications, including adjuncts such as anxiolytics, anti-
the cardiovascular and immune systems as well as on post- depressants and anticonvulsants, should be obtained. Close
operative recovery [5, 6]. Furthermore, as many spine surgery communication between the anesthesiologist, patient and
patients suffer from chronic pain necessitating ongoing surgeon is essential to alleviate patient fears and to develop
treatment with narcotics, this may lead to opioid tolerance. a specific perioperative pain management plan. Clear
91

Authors Rondall K Lane, Jeremy Lieberman
instructions should be given as to which analgesics should 2.4 Postoperative pain management strategies
be withheld and which should be taken. If NSAIDs are to Postoperatively, it should be noted that the patient’s pre-
be withheld, a plan should be put in place for the treatment operative dose regimen is a baseline that will often need to
of discomfort in the days leading up to surgery. This may be continued with supplementation [18]. In addition to a
include the use of acetaminophen, opioids or a combination multimodal analgesic approach, the use of regional tech-
of the two. niques, such as a lumbar epidural in appropriate settings,
should be strongly considered. Postoperatively, if patient
Preoperatively, a plan for preemptive analgesia can also be controlled analgesia is planned, dosing for a patient using
developed and shared with the patient to help alleviate chronic opiates needs to be higher than for opioid-naive
anxiety. Preemptive analgesia is a method of reducing post- patients [19]. Combinations of opioid and nonopioid medi-
operative pain by administering analgesics prior to painful cations can have synergistic effects, potentially lowering
surgical stimuli, such as incision [8]. While controversial, the side effects caused by one particular agent. Addition-
preemptive analgesia is considered more effective at reduc- ally, continuing infusions of ketamine or lidocaine into the
ing pain than only providing analgesia after a stimulus [9]. postoperative period can have beneficial effects on nar-
For laminectomy, preemptive analgesia with soft-tissue cotic consumption [20]. It is important to pay careful atten-
infiltration of local anesthetic prior to incision has demon- tion to the patient’s preoperative opioid regimen in order
strated successful results as well as after exposure, with to avoid underdosing, which could lead to withdrawal
anesthetic placed near the nerve root [10, 11]. For discec- symptoms. Patches and continuous intravenous infusions
tomy, preemptive analgesia with a single caudal epidural of opioids are best reserved for chronic pain patients, and
injection of a local anesthetic and a NSAID was found to be are not advised in the acute pain setting because of their
superior to placebo in reducing postoperative pain [12]. Ket- delayed onset of action and increased risk of side effects as
amine, an NMDA receptor antagonist, administered prior the pain resolves.
to surgical incision, has been reported to aid in postopera-
tive pain relief following surgical procedures in which the
abdominal cavity is entered (eg, anterior lumbar interbody 3 Anesthetic management in centers for ambulatory
fusion) [13]. The preoperative administration of gabapentin surgery
or pregabalin has also shown good results in early studies
when continued into the postoperative period [4]. Non- 3.1 Postoperative nausea and vomiting (PONV)
steroidal anti-inflammatory drugs may also be considered The anesthetic management of patients in centers for am-
as part of a multimodal preemptive analgesic strategy [14]. bulatory surgery differs from that in nonambulatory settings.
Although concern over increased nonunion rates has lim- Anesthetic methods focus on using short-acting anesthetic
ited NSAID use in some centers, short-term exposure to agents that allow for early hospital discharge. However,
normal doses of NSAIDs does not appear to alter nonunion challenges persist for those caring for ambulatory surgery
rates and may be beneficial with regards to postoperative patients. Major concerns facing these care providers include
pain reduction [15]. preventing PONV, adequately treating pain, and avoiding
delays in recovery and discharge.
2.3 Intraoperative pain management strategies
In addition to preemptive analgesia, the choice of intraop- Postoperative nausea and vomiting is one of the most com-
erative anesthetic agents can have a significant impact on mon complaints amongst ambulatory surgery patients, with
reducing postoperative discomfort. Intraoperative lidocaine an incidence ranging from 30% to 80% in high-risk popu-
and ketamine are effective in reducing postoperative nar- lations [21]. Postoperative nausea and vomiting has been
cotic consumption and improving pain scores when given reported to occur less often in the ambulatory compared to
as continuous infusions [16, 17]. This holds particularly true the inpatient setting. However, this may be due to the un-
for ketamine use in opioid-dependent patients scheduled derreporting of PONV, as ambulatory patients spend less
for major lumbar spine surgery. In this clinical scenario, time in the medical setting where PONV would be more
ketamine given intraoperatively with 15 mg of ketorolac easily detected. Additionally, this could explain why post-
in nonfusion surgery reduced postoperative morphine con- discharge nausea and vomiting (PDNV) often goes unde-
sumption and improved pain scores, with benefit noted for tected by the surgical team despite a reported incidence of
up to 42 days after the surgical procedure [17]. up to 50% [22]. The key to preventing PONV is to identify

1 Fundamentals
1.8 Anesthetic considerations and minimally invasive spine surgery
risk factors that allow for appropriate adjustment in anes- needed, especially in high-risk patients. Commonly used
thetic and antiemetic selection (Fig 1.8-1). Patient risk factors agents include the 5-HT receptor antagonists, antihista-
that predict PONV with accuracy include: a history of pre- mines, dopamine antagonists, NK1 receptor antagonists,
vious PONV, a history of motion sickness, being female, anticholinergics, cannabinoids, benzodiazepines, and ste-
and being a nonsmoker. Anesthetics that can promote nau- roids. 5-HT receptor antagonists can be effective if admin-
sea and vomiting include perioperative opioids, nitrous istered at the beginning or at the end of surgery. Addition-
oxide, and volatile anesthetics. Lastly, when the operative ally, continuing 5-HT receptor antagonist administration
time extends beyond 30 minutes, the length of surgery can after ambulatory surgery has been shown to significantly
play a role in the development of PONV [23, 24]. reduce the incidence of PONV [25]. The intravenous admin-
istration of a steroid together with a 5-HT receptor antago-
Unfortunately, no single agent can completely prevent or nist may be more protective against PONV than either agent
treat PONV. Hence, several classes of anti-emetics may be given alone [26].
Risk factors
Cost-effectiveness
Adult risk factors
• History of PONV or motion sickness
• Female
• Nonsmoker
• Perioperative opioid use
• Duration and type of surgery Baseline risk reduction
Pediatric risk factors • Avoid volatile anesthetics
• Personal or family history of PONV Patient risk • Avoid nitrous oxide
• Age ≥ 3 years • Avoid high-dose neostigmine
• Strabismus surgery • Minimize perioperative opioids/use
• Sugery > 30 minutes non-opioid adjuncts for pain
Low risk Moderate risk High risk

(20–40%, 0–1 factor present) (40–80%, 2–3 factors present) (> 80%, ≥ 4 factors present)
Wait and see • Choose 1 or 2 available intervention Choose 2 or more available intervention
for adults
5-HT3 receptor antagonist recommended • Choose 2 or more interventions for Consider multimodal approach:
for rescue, if needed children • Adequate hydration
• Combination therapy
• Total intravenous anesthesia with
propofol
• Local anesthetics
Possible interventions • Anxiolytics
• 5-HT3 receptor antagonist • Nonpharmacological techniques
• Acupuncture
• Dexamethasone
• Droperidol or haloperidol
• NK1 receptor antagonist
• Promethazine, prochlorperazine,
doxylamine or perphenazine
• Propofol anesthesia
• Regional anesthesia
Fig 1.8-1 Important patient and anesthetic risk factors for postoperative nausea and vomiting.
(This figure was published in Anesthesiology Clinics, 28(2), Le TP and Gan TJ, Update on the management
of postoperative nausea and vomiting and postdischarge nausea and vomiting in ambulatory surgery,
pages 225–249, Copyright Elsevier 2010.)
93

An anticholinergic agent administered via a transdermal and pruritis. However, using nonopioid agents alone is of-
patch can also be effective in reducing the incidence of ten associated with insufficient pain control.
PONV [27]. Propofol given at induction and/or when used
for the maintenance of anesthesia reduces PONV during Some of the most important strategies for postoperative
the first 24 hours after surgery. In high-risk patients, pro- pain control rely on intraoperative agents such as ketamine
pofol is a sensible alternative to maintenance with volatile and lidocaine, as mentioned above. Low-dose intravenous
anesthetics. lidocaine in the ambulatory setting has been shown to re-
duce pain scores as well as pre-discharge opioid use, while
Acupuncture may also help reduce PONV. In a recent Co- not having any significant effect on time to discharge [33].
chrane Review, the use of acupuncture point pericardium Agents commonly used for mild pain or as an adjunct for
6 (P6) has been reported to result in less PONV. P6 is lo- the relief of moderate to severe pain include nonopioid
cated between the tendons of the palmaris longus and analgesics, such as NSAIDs and acetaminophen. Oral opioids
flexor carpi radialis muscles. In over 40 trials, the application are often used either alone, or combined with acetamino-
of pressure at this point has shown effectiveness in prevent- phen or NSAIDs. It is important to pay careful attention not
ing PONV, with the additional benefit of having few side to exceed the maximum recommended dose of acetamino-
effects [28]. phen, as accidental overdose is certainly possible. Although
NSAIDs carry the risk of platelet dysfunction and impaired
Despite preventive treatment with a variety of agents, many coagulation and hence should be used with caution, they
patients will still develop PONV. In such situations, switch- are effective in the treatment of mild postoperative pain or
ing to a class of medication other than those administered as an adjunct to opioids for moderate to severe pain.
for prophylaxis should be considered. In addition, other
causes of PONV should also be evaluated and treated, such In a prospective, randomized double-blind trial of ketorolac
as pain, anxiety, opioid use, dysphagia, gastrointestinal ob- administration after lumbar decompression surgery, this
struction, and swallowing blood as a result of trauma dur- drug appeared to be safe and effective. Patients reported
ing endotracheal intubation, or nasal airway trauma. better pain scores and required less morphine postopera-
tively [34].
In addition to antiemetics, PONV can be lessened by avoid-
ing the dehydration associated with fasting. Some studies Opioids are most often administered for moderate to severe
have advocated allowance of oral intake of clear fluids up pain. Some opioids can cause histamine release, leading to
to 2–3 hours prior to surgery [29], even in the case of obese pruritis, bronchospasm, and hypotension, limiting their ef-
patients, where the intake of clear liquids has been shown fectiveness in postoperative pain control. All opioids have
to increase gastrointestinal motility and not adversely affect side effects including urinary retention and respiratory de-
gastric volume [29]. If dehydration is present, the use of a pression. Hence, patients should not be discharged after am-
liberal infusion of crystalloids to reverse the volume deficit bulatory surgery until these side effects have resolved and
has been shown to improve patient outcomes with regard appropriate discharge criteria have been met [35] (see World
to PONV [30, 31]. Health Organization surgical safety checklist Table 1.8-1).
4 Postoperative pain control 5 Complications associated with MISS: concern for

the anesthesiologist and surgeon
Like PONV, poorly treated postoperative pain can lead to
prolonged recovery times after ambulatory surgery, delayed Given the similarities between MISS and traditional ap-
discharge, as well as having a negative impact on resuming proaches regarding positioning, operative site, and patient
the activities of daily living. Poor postoperative pain control population, it would be unwise to assume that complications
is one of the most common reasons for unplanned hospital could not occur in patients undergoing MISS. Preventing
admission after ambulatory surgery [32]. Treatment of post- the potential complications associated with spine surgery
operative pain may be most effective when it consists of is of paramount importance, as patients are often already
using more than one class of agent. Reliance upon opioids incapacitated by chronic back pain and/or neurological
alone will often lead to the development of clinically sig- deficits, and would therefore tolerate further handicap
nificant side effects such as PONV, constipation, drowsiness, poorly.

1 Fundamentals
Surgical Safety Checklist
Before induction of anaesthesia Before skin incision Before patient leaves operating room
(with at least nurse and anaesthetist) (with nurse, anaesthetist and surgeon) (with nurse, anaesthetist and surgeon)
Has the patient confirmed his/her  Confirm all team members have Nurse Verbally Confirms:
identity, site, procedure, and consent? introduced themselves by name  The name of the procedure
 Yes and role.  Completion of instrument, sponge
and needle counts
 Specimen labelling (read specimen
Is the site marked?  Confirm the patient’s name, labels aloud, including patient
 Yes procedure, and where the incision name)
 Not applicable will be made.  Whether there are any equipment
problems to be addressed
Is the anaesthesia machine and Has antibiotic prophylaxis been given
medication check complete? within the last 60 minutes? To Surgeon, Anaesthetist and Nurse:
 Yes  No  What are the key concerns for
 Yes recovery and management of this
Is the pulse oximeter on the patient and patient?
functioning? Anticipated Critical Events
 Yes
To Surgeon:
Does the patient have a:  What are the critical or non-routine
steps?
Known allergy?  How long will the case take?
 No  What is the anticipated blood loss?
 Yes
To Anaesthetist:
Difficult airway or aspiration risk?  Are there any patient-specific
 No concerns?
 Yes, and equipment/assistance
available To Nursing Team:
 Has sterility (including indicator
Risk of > 500ml blood loss (7ml/kg in results) been confirmed?
children)?  Are there equipment issues or any
 No concerns?
 Yes, and two IVs/central access and
fluids planned
Is essential imaging displayed?
 Yes
 Not applicable
Table 1.8-1 Surgical Safety Checklist. (As published by the World Health Organization.)
95

5.1 Postoperative vision loss (POVL) rence might be helpful. Direct pressure on the globe must
Postoperative impairment of or complete loss of vision be avoided during surgery in the prone position. Patients
(POVL) is a distressing problem that reverses any benefit with severe anemia should, where possible, not be consid-
gained from an elective surgical procedure. Fortunately, ered for surgery. For those patients who proceed to surgery,
such complications are rare, with an incidence of 0.94% the hematocrit should be kept around 30. Mean arterial
for all postoperative visual disturbances and 0.006% for pressure should be maintained close to preoperative levels.
ischemic optic neuropathy (ION) [36]. Despite these low The staging of long procedures should be considered, espe-
percentages, clinicians should be aware of potential risk cially in cases with significant blood loss when patients are
factors for POVL and of the possible interventions to at risk, or in those who already have significant visual def-
minimize its occurrence, and have prepared a plan to deal icits in one or both eyes. Elevating the head 5° and avoidance
effectively with these complications, if this is possible. of excessive crystalloid administration should be considered.
A recent systematic literature review associated postopera-
Postoperative vision loss is not limited to spine surgery in tive ischemic neuropathy with prone position surgery of
the prone position: in anterior fusion surgery, cervical more than 5 hours surgical duration and blood loss of more
laminectomy, and cervical fusion surgery, cases of POVL than 1000 cc [38]. The authors pointed out that efforts should
have also been reported. Two of the more devastating types be made to minimize venous outflow resistance in the head
of loss of vision include ION and central retinal artery oc- and neck area. For this reason, some surgeons have been
clusion (CRAO) [37]. using head clamp fixation or traction in cranial tongs rath-
er than other forms of head support for prone surgery.
Possible mechanisms for the development of ION include
variations in optic nerve vascular anatomy, associated with
a loss of autoregulation and heightened sensitivity to hy- 6 Considerations regarding specific procedures
potension. Potential risk factors for ION include hypoten-
sion, anemia, significant blood loss with large volume re- 6.1 Vertebroplasty, kyphoplasty, lordoplasty
suscitation, impaired venous drainage from the head, For these procedures, anesthetic options include local an-
prolonged surgery in the prone position, vascular disease, esthesia with sedation (monitored anesthetic care) or gen-
diabetes, smoking, embolic material (air, bone, thrombi), eral anesthesia. Spinal anesthesia has been described for
and the use of vasopressors. After surgery, patients may these procedures, but is rarely used. Monitored anesthetic
awaken with ION or develop visual deficits several days care is less invasive and may be preferred over general an-
later, with an abrupt decline in sight that progresses over esthesia in patients with multiple comorbidities. It enables
several days. Ischemic optic neuropathy is usually bilateral, a shorter postanesthetic care-unit stay, possibly facilitating
whereas central retinal artery occlusion is often unilateral same-day discharge. However, general anesthesia with en-
and presents upon awakening after surgery. dotracheal intubation provides superior airway control and
allows for better respiratory support. Monitored anesthetic
Globe compression is most often associated with CRAO. care may suffice for simple vertebroplasty, limited to 1 or 2
Like ION, CRAO is usually not reversible. Cortical blindness levels. Kyphoplasty is more painful, especially as the ver-
may also present upon awakening; it is associated with in- tebral body is expanded prior to cementing. Patients under
traoperative hypotension or emboli, such as those that can sedation may not tolerate prolonged surgery in the prone
occur during pedicle screw placement. position. If general anesthesia is used, endotracheal intuba-
tion is indicated. If the patient has remained immobile for
If a patient develops POVL, immediate ophthalmological a prolonged period or any neurological deficit is present,
consultation is warranted to exclude potential reversible succinylcholine is not recommended for muscle relaxation
causes of vision loss, such as acute angle-closure glaucoma, for intubation. Invasive monitoring is typically not required
direct globe injury, or retinal detachment. If the etiology for these procedures, as bleeding and intraoperative fluid
cannot be determined after direct fundoscopic examination, shifts are not significant issues. Underlying cardiac or pul-
CT scan or MRI of the head aids in determining whether monary conditions may warrant placement of an arterial
the newly acquired visual deficits are due to occipital infarc- line for blood pressure and blood gas monitoring. Neuro-
tion or to pituitary apoplexy. physiological monitoring, using electromyography, somato-
sensory or motor evoked potentials, is not routinely used.
While the evidence in support of any one technique for the If the surgeon elects to monitor with electromyography or
prevention of POVL is lacking, steps to minimize its occur- motor evoked potentials, the anesthesiologist needs to avoid

1 Fundamentals
neuromuscular blockade. Generally, evoked potential mon- The low central venous pressure associated with venous
itoring mandates the use of an anesthetic that minimally pooling may promote venous air embolism (VAE), another
depresses the responses, ie, with reduced levels of volatile potential complication associated with the sitting position.
agents, or a total intravenous anesthetic technique. While VAE is not unique to the sitting position, it is one of
the most apprehended complications, as the head elevation
When surgery is performed in the prone position, appropri- above the heart in the sitting position facilitates the entrance
ate padding is necessary, especially in osteoporotic patients of air into open veins. The incidence of VAE has been re-
who are at increased risk for positioning injuries, such as ported as varying from 25% to 76%, depending on the
rib fractures. Extremely kyphotic patients may be difficult methods used to detect venous air emboli [42]. Venous air
to position on a bed. The prone position usually does not embolism can be fatal because of the risk of subsequent
compromise ventilation or oxygenation. If the arms are right heart failure as the acute obstruction of the right ven-
tucked at the patient’s side, it is important to ensure that tricular outflow does not allow time for the right heart to
the intravenous lines work. The face must be placed in a compensate. Hence, a vicious cycle of hypoxia, hypotension,
proper foam headrest, with care taken to avoid pressure on ischemia, and heart failure may develop, leading to cardio-
the eyes. pulmonary collapse and possible death. Venous air embolism
can cause paradoxical air emboli (PAE) through a patent
Serious intraoperative complications are rare. Acute neu- foramen ovale (PFO). PAE occur when right atrial pressure
rological injury may occur if the cement extravagates from is greater than left atrial pressure. Once air enters the left
the vertebral body. Pulmonary emboli are a known com- heart, it can become embolic, causing end-organ damage,
plication of orthopedic procedures. Pulmonary emboli occur such as cerebral, coronary, and peripheral artery ischemia.
less frequently in spine surgery than in other types of or-
thopedic surgery, with a reported incidence of approxi- Previously, it was thought positive end-expiratory pressure
mately 0–13% [39]. Care providers for spine patients should (PEEP) could prevent PAE by adjusting PEEP to recreate
be prepared to resuscitate a patient that experiences a pul- the central venous hemodynamics of the prone position
monary embolism. Appropriate intravenous access and [43]. However, controversy exists with regards to PEEP, and
emergency drugs should be readily available [40]. certain authors do not recommend the use of this technique.
Adding PEEP may cause PAE by increasing right atrial pres-
6.2 Minimally invasive cervical surgery sure; decreasing previously set PEEP can facilitate PAE by
Minimally invasive cervical foraminotomy is used for de- increasing venous return and subsequently right atrial pres-
compressing cervical nerve roots and provides the same sure [44, 45]. On the other hand, other authors have not
benefits of less invasive surgery as discussed above (see also found the use or release of PEEP to support the development
chapter 2.2 Posterior foraminotomy). Surgeons use an en- of PAE [44]. Treatment of VAE includes flooding the surgi-
doscope or a microscope for visualization in this procedure. cal field with sterile saline, sealing off any venous opening,
Cervical foraminotomy can be performed in the sitting as placing the patient in the Trendelenburg position (head
well as in the prone position. For the surgeon, the sitting downwards) with left lateral decubitus positioning (on their
position offers several advantages. For the anesthesiologist, left side), and aspirating the right atrium through an ap-
however, the sitting position involves several physiological propriately placed central venous catheter. Additional treat-
changes that could result in devastating complications, if ments include compression of bilateral jugular veins to
not well managed. Venous pooling, with up to 1500 ml of increase cerebral venous pressure.
blood sequestered in the lower extremities, can lead to sig-
nificant systemic hypotension. The cardiovascular depres- Postoperatively, procedures that involve the cervical spine
sant effects of many anesthetic agents can also exacerbate can be complicated by Horner’s syndrome as a result of
hypotension in this position. In patients with chronic hy- injury to the sympathetic chain, pneumothorax secondary
pertension, cerebral autoregulation has been shifted to ac- to air entrainment from the surgical wound site, bleeding
commodate the higher systemic pressures. Thus, a decrease into the neck from the surgical wound, or vertebral artery
in blood pressure can be even more significant, leading to injury (especially when the operative site includes the C6/7
the development of cerebral ischemia. However, wrapping vertebral levels). Elevations in peak airway pressure, tachy-
the lower extremities prior to placing the patient in the cardia and/or hypotension may be signs of pneumothorax.
sitting position can attenuate hypotension [41]. If suspected, pneumothorax can be detected by observing
diminished breathing sounds on the affected side, and sub-
sequently confirmed by chest x-ray. Treatment includes
97

rapid needle decompression, or the placement of a chest cardiopulmonary compromise, including bradycardia, asys-
tube on the affected side. If a vertebral artery injury occurs, tole, and respiratory acidosis secondary to the development
an immediate evaluation for dissection or pseudoaneurysm of hypercapnea. Subcutaneous emphysema, pneumome-
should be made. Neck swelling from a hematoma can cause diastinum, tension pneumothorax, pneumopericardium and
acute loss of airway patency, and should be treated by open- other complications have been described as being associ-
ing the neck wound immediately and removing clots prior ated with this technique. If complications such as hypoten-
to attempting endotracheal intubation. Other complications sion or respiratory acidosis occur, the prompt release of
that can occur in the sitting position include macroglossia abdominal pressure, and returning the patient to the supine
from extreme flexion of the head after placement of the position usually improves the cardiopulmonary derange-
chin on the chest. Flexion of the head may result in obstruc- ment [47]. Improving cardiovascular preload with an intra-
tion of venous drainage, leading to macroglossia, as well as venous fluid bolus and treatment with an anticholinergic
swelling of other pharyngeal structures, such as the soft agent may allow for subsequent abdominal insufflation [48].
palate and posterior pharyngeal wall [46]. Other complications may require prolonged resuscitation
and transferring the patient to the intensive care unit for
6.3 Lumbar microdiscectomy further care.
Lumbar microdiscectomy is usually performed for herni-
ated lumbar disc, and is more effective for treating radicu- 6.5 Thoracoscopy for spine surgery
lar pain of the lower extremities than for back pain. During Video-assisted thoracoscopic surgery (VATS) has been uti-
this procedure, either a portion of disc material or bone is lized for many years for the treatment of lung pathologies.
removed to alleviate nerve entrapment and provide space Because of the benefits of VATS over traditional thoracic
for the nerve root to heal. Lumbar microdiscectomy can be surgery, there has been increasing interest in its use among
performed under general anesthesia, spinal anesthesia, or spine surgeons (see chapter 3.3 Anterior thoracoscopic
epidural anesthesia. If performed under spinal anesthesia, approaches) [49]. Some of the reported benefits of VATS in
there is a small risk of postdural puncture headache, and spine surgery include the avoidance of thoracic rib-splitting,
the benefits of monitoring motor and sensory function could thereby subsequently ensuring greater preservation of the
be delayed until the effect of the local anesthetic has re- patient's functional residual capacity, reduced damage to
solved. Hemodynamic changes and arterial hypotension the muscles and other tissues of the chest wall and those
during surgery or in the early postoperative period should tissues next to the surgical field, less blood loss, fewer re-
raise the suspicion of an accidental injury to the great ves- spiratory problems, and decreased postoperative pain. These
sels. This can be the result of direct injury to the blood benefits have led to fewer postoperative pulmonary com-
vessels during the removal of disc material. This complica- plications, faster recovery times, and reduced hospital stays.
tion can be fatal, and requires immediate diagnosis and In healthy patients, VATS is indicated in the surgical treat-
open surgical or endovascular treatment. ment of many disease states including scoliosis and tumor
resection, and also in decompression surgery for fracture
6.4 Laparoscopy for anterior spinal fusion and and nerve roots; and in corrective surgery for thoracic de-
discectomy formities.
Laparoscopy for anterior spinal fusion and discectomy re-
quires general anesthesia and was previously considered as The anesthesiologist and surgeon should be familiar with
having many advantages over other techniques. However, using double-lumen tubes or bronchial blockers to achieve
it has fallen out of favor because of a significantly higher one-lung ventilation. Malpositioning of the endotracheal
surgical complication rate when compared to other mini- tube during one-lung ventilation is not uncommon, and
open anterior procedures, and shall not be further discussed can lead to cardiopulmonary collapse (Fig 1.8-2). Total in-
in this book. A brief discussion is given here, so that the travenous anesthesia may be required, as volatile agents
reader can become aware of the potential pitfalls associ- may blunt the normal pulmonary vasoconstrictive response
ated with this technique. to hypoxia, potentially worsening gas exchange. Hypoxia
can be treated with PEEP to the nonoperative (ventilated)
Laparoscopic surgery has several potential complications lung and if needed, constant positive airway pressure (CPAP)
related to the physiological changes induced by the insuf- to the operative (non-ventilated) lung. Occasionally, an
flation of CO2, steep Trendelenburg and reverse Trendelen- inhaled pulmonary artery dilator, such as nitric oxide, can
burg positioning. Steep Trendelenburg positioning risks improve gas exchange in the short term, since it will only
brachial plexus injury. Abdominal insufflation may cause dilate vessels in ventilated parts of the lung. For refractory

1 Fundamentals
AL BL CL DL
a b c d
AR BR CR DR
e f g h
Fig 1.8-2a–h Tube misplacement during one-lung ventilation may lead to hypoxemia. The correct position (AL) and possible misplacements
(BL–DL) of the left-sided double-lumen tube are shown. In the lower four figures, correct position (AR) and possible misplacements (BR–DR) of
the right sided double-lumen tubes are shown.
(As published in Karzai W, Schwarzkopf K (2009) Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology;
110(6):1402–1411. Reproduced with permission from Wolters Kluwer Health.)
99

cases of hypoxia, intermittent reinflation of the deflated hesion between the visceral and parietal layers of the pleu-
lung and an evaluation for the development of air-trapping ra is created to therapeutically obliterate the pleural cavity
(auto-PEEP) may be warranted. Surgical compression of [52]. Even in patients with lung disease, VATS can be a
the non-ventilated lung and a pulmonary artery clamp are better choice than thoracotomy. However, other conditions
additional possible treatments (Fig 1.8-3) [50]. Pulmonary that may make VATS less appealing include mediastinal
complications can range from mild to severe, with up to mass, severe coagulopathy, bullous lung disease, previ-
64% of patients showing the development of abnormalities ously failed VATS attempt or thoracotomy, or prior pneu-
on chest x-ray [51]. These include pleural effusion, atelec- monectomy. In patients with a scarred chest, visualization
tasis, partial or complete lobar collapse, hypoxemia, and of the surgical site may be impaired with accompanying
pneumonia. difficulty in manipulating the instruments, making VATS
more problematical to perform. Lastly, patients that are
There are a few contraindications to performing VATS, with hemodynamically unstable are not recommended as suit-
the two most frequently cited being an inability to tolerate able candidates for VATS.
one-lung ventilation, and pleurodesis, where a fibrous ad-
Hypoxemia during OLV: SpO2 < 90%
Increase FiO2 to 100%
Life threatening Non-life threatening (SpO2 > 90%)

(SpO2 < 90%) Continue OLV
and/or occurrence
of arrhythmia
and/or ST changes
Improve oxygenation
Stop surgery Treatable cause Optimize ventilation Optimize perfusion
Resume bipulmonary ventilation Fiberoptic bronchoscopy Nonventilated lung Decrease shunt

• DLT position • Manual re-expansion • IV almitrine
• Secretions/blood (O2 100%) • Surgical lung compression
• CPAP (O2 100%) • Pulmonary artery clamp
Hemodynamic
• Low blood pressure Ventilated lung Improve ventilated lung
• Too deep level of anesthesia • PEEP perfusion
• Blood loss • Recruitment maneuver • Pressure-controlled ventilation
• Right ventricular dysfunction • iPEEP evaluation • Inhaled nitric oxide, PGI2
Fig 1.8-3 Algorithm recommended to be performed in case of hypoxemia during one-lung ventilation (OLV).
CPAP: continuous positive airway pressure; DLT: double-lumen tube; FIO2: inspired fraction of oxygen; PEEP:
positive end-expiratory pressure; PGI2: prostacyclin; ST: ST segment.
(As published in Rozé H, Lafargue M, Ouattara A (2011) Case Scenario: Management of Intraoperative Hypox-
emia during One-lung Ventilation. Anesthesiology; 114(1):167–174. Reproduced with permission from Wolters
Kluwer Health.)

1 Fundamentals
6.6 Use of K-wires 7 Conclusion

Whenever K-wires are used, the possibility exists of inad-
vertent vascular injury caused by migration or malposition- Minimally invasive spine surgery offers several advantages
ing of the K-wire (see chapters 3.4 Posterior approaches for over traditional surgery with regards to perioperative man-
minimally invasive thoracic decompression and stabilization, agement. However, careful planning with regard to patient
and 3.5 Posterior approaches for minimally invasive comorbidities, pain management, and the unique charac-
treatment of spinal fractures). This may result in acute or teristics of each procedure is needed to ensure optimal out-
delayed onset of arterial hypotension and requires immedi- comes from an anesthetic standpoint.
ate diagnosis, adequate fluid resuscitation, and possible open
surgical or endovascular repair.
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1 Fundamentals
103


2 Cervical techniques
2
2.1 Introduction
Cervical techniques
105


2.1 Introduction
Andreas Korge
With its increased availability and more widespread use of tional motion-preserving or fusion procedures. In all
endoscopes and microscopes, over recent decades, anterior instances, appropriate patient selection as well as meticulous
cervical spine surgery can now be viewed as a good ex- preoperative analysis of the localization of the pathology is
ample of minimally invasive spine surgery (MISS). How- necessary to achieve an optimal outcome.
ever, posterior cervical spine surgery still remains a fre-
quently macrosurgical procedure, especially in regard to Atlantoaxial instabilities refer to specific chronic or acute
fusion techniques, even though there is active interest in pathologies that often require rigid segmental fixation with
making these procedures less invasive by using, eg, advanced or without extension to the occipitocervical or subaxial
navigational techniques and minimally invasive access strat- region. From a biomechanical point of view, posterior fu-
egies [1, 2]. Posterior approach-related morbidity is mainly sion procedures with transarticular C1/2 screws and ad-
related to increased muscle trauma, impaired three-dimen- ditional three-point fixation provide the most satisfactory
sional orientation, and the risk of postoperative sequelae, segmental stability. A percutaneous C1/2 screw placement
such as failed wound healing and infection, which have in technique, in combination with a small midline incision
turn resulted in the development of tissue-preserving, for segmental fixation, is presented in chapter 2.4 Posterior
modified access strategies. C1/2 transarticular screw fixation. The additional use
of computer-assisted navigation further reduces the
Four descriptive chapters are included in this cervical tech- extent of the approach, and decreases the risk of screw
niques section. Two of them examine surgical approaches misplacement.
using the posterior access corridor, whereas the other two
chapters are focused on anterior exposure and target tech- From an anatomical and technical point of view, anterior
niques. All these techniques require a learning curve and C1/2 surgery includes the use of highly challenging tech-
the routine use of microscopes and/or endoscopes. An ad- niques. Four fascinating approach strategies have been ex-
ditional description of cervical MISS procedures, including amined including, the endonasal, transoral, and retropha-
multilevel decompression and tumor resection, can also be ryngeal approaches, which provide access to the anterior
found in chapter 1.5 Different spinal pathologies and patient occipitocervical and atlantoaxial regions, and enable the
selection. satisfactory treatment of anterior pathologies. Stereotactic
computer-assisted navigation is helpful in all approaches.
The treatment of pathologies affecting a nerve root in the Thorough knowledge of the anterior occipitocervical anat-
far lateral spinal canal or in the intraforaminal corridor with omy, sufficient training and competency in three-dimen-
dominant radicular symptoms but with negligible neck pain, sional orientation, and extensive experience in microscop-
can be carried out through either an anterior or posterior ically or endoscopically-assisted surgery are mandatory
approach, with microscope- or endoscope-assisted neuro- when using these techniques. Some of the techniques de-
foraminal enlargement and concomitant nerve root decom- scribed also enable the surgeon to perform simultaneous
pression. Both techniques can be applied without addi- instrumentation.
107

References
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(2011) Percutaneous instrumentation Computer-assisted posterior
of the cervical and cervico-thoracic instrumentation of the cervical and
spine using pedicle screws: preliminary cervico-thoracic spine. Eur Spine J;
clinical results and analysis of accuracy. 13(1):50–59.
Eur Spine J; 20(6):977–985.

2.2 Posterior foraminotomy
Andrew James, Roger Härtl, Osmar Moraes
1 Historical perspective 3 Patient selection
Anterior cervical decompression and fusion (ACDF) has The primary aim of MIS-PF is the foraminal decompression
remained the standard surgical procedure for the manage- of a cervical nerve. Therefore, the best outcome is achieved
ment of cervical disc herniations since its description by for lateral or intraforaminal monosegmental and monolat-
Smith and Robinson in 1958 [1]. This surgical approach was eral radicular pathologies. However, bi- and multisegmen-
popularized by Cloward for discectomy [2]. The anterior tal as well as bilateral pathologies can also be treated by this
approach facilitates wide access to the spinal cord and bi- approach.
lateral nerve roots through the extensive removal of disc
material, which is then replaced by an artificial disc or a 3.1 Indications
fusion device with graft material. • Cervical radiculopathy refractory to nonoperative man-
agement
In 1951, Frykholm [3] described the surgical anatomy of the • Single-level disease with a lateral osteophyte or lateral
cervical spine, with particular emphasis on the correspond- soft disc herniation causing radiculopathy
ing nerve roots, and provided a detailed account of the • Multilevel disease with radicular pain syndromes
dorsal foraminotomy approach. This technique avoids the • Bilateral radiculopathy
risk of certain previously reported complications associated • Calcified disc herniation.
with an anterior approach, such as vascular injury, esoph-
ageal injury, dysphagia, dyspnea, injury to the recurrent 3.2 Contraindications
laryngeal nerve, and adjacent segment disease following • Presence of symptomatic myelopathy in addition to ra-
fusion. With the posterior approach, the preservation of diculopathy
mobility associated with minimal osseous resection is coun- • Central disc herniation
terbalanced against the risk of postoperative neck pain or • Preexisting instability of the cervical spine possibly re-
spasm. This risk is a consequence of the surgical access requiring additional stabilization (relative contraindication)
quired for the foraminotomy, however, the use of a mini- • Presence of a kyphotic deformity at the approach level
mally invasive surgical approach may reduce the incidence (relative contraindication)
of postoperative events. • Patients with significant mechanical neck pain could
experience exacerbation of their symptoms with the
posterior approach, and it may be preferable for them
2 Terminology to be treated by anterior stabilization.
This chapter focuses on the minimally invasive surgical ap-

proach for posterior foraminotomy (MIS-PF), which typi- 4 Pros and cons of posterior foraminotomy
cally includes surgery performed via microscopic or micro-
endoscopic magnification using tubular retractor systems. The major advantage of a posterior foraminotomy is that it
This approach was first described by Adamson et al [4] in affords minimally invasive segmental exposure of the target
2001 and Fessler and Khoo [5] in 2002 using the endoscope, region and the corresponding pathology without the need
and by Holly et al [6] and Hilton [7] in 2007 using the mi- for additional stabilization (ie, fusion procedures, arthro-
croscope through tubular retractors. Mention should also plasty, etc).
be made of alternative approaches, such as microendo-
scopic foraminotomy, lateral foraminotomy, and transcor-
poreal foraminotomy, but these will not be discussed in
further detail in this chapter.
109

Authors Andrew James, Roger Härtl, Osmar Moraes
4.1 Pros a Mayfield skull clamp or in a horseshoe headrest. Soft

• Minimal tissue dissection and reduced morbidity padding of the shoulders, lateral chest, and iliac crest/pelvis
• Direct visualization of the foramen, allowing accurate is performed. Thoracic and abdominal compression should
assessment of the decompression be avoided. Slight flexion of the neck facilitates the skin
• Maintained motion segment incision and surgical access; extreme flexion, however, has
• Comparable outcomes to those for open surgery, with to be avoided in order to prevent possible anterior compres-
clinical improvement in 90% of cases [8] sion myelopathy from bony spurs, etc. Mild traction of the
• Shorter inpatient stay, with increased cost-effectiveness arms using tapes could assist in the pre- and intraoperative
[5] x-ray identification of the target area, especially when ex-
• More rapid functional recovery and return to work [9] posing the lower cervical spine or cervicothoracic junction.
• Can be carried out the level adjacent to a fusion or disc Intraoperative imaging for determination of the correct
arthroplasty (see topic 11 Case example in this chapter). target segment and operative magnification for intrafo-
raminal surgery must be ensured. Care should be taken that
4.2 Cons the anesthesiologist has free access to the endotracheal tube
• Not indicated for central disc herniation and to all the relevant equipment.
• Does not address problems of instability or deformity
• Bilateral surgery and multilevel surgery can both be
performed, but these are more complex procedures 6 Surgical technique
• Delayed postoperative instability may develop, requiring
further surgery. The correct level is determined with a preoperative lateral
x-ray to minimize extraneous soft tissue involvement. For
minimally invasive surgery with conventional retractors, a
5 Preoperative planning and positioning midline incision is made with dissection extended to expose
the lateral lamina and medial aspect of the facet joint in
Preoperative imaging studies comprising MRI and/or CT addition to the lateral mass cranially and caudally. For sur-
scans must be undertaken to determine both the localiza- gery involving tubular retractors, a paramedian incision is
tion and suitability of a posterior foraminotomy. Addition- made on the side intended for treatment (Fig 2.2-1). Guide
ally, information should also be obtained on the anatomical wires should not be used, due to the risk of accidental in-
relationship or any abnormalities of the vertebral artery, jury to the spinal cord, nerves, or vascular structures. In-
the calcification of disc herniations, and the degree of fac- stead, the fascia is opened sharply and a blunt dilator is
etal hypertrophy contributing to the foraminal narrowing. advanced under image intensifier guidance towards the
It is essential for these findings to be in agreement with the lateral mass at the indicated level. Sequential dilators and
clinical examination, and electromyogram (EMG) if appro- a final tubular retractor are inserted and fixed in position.
priate. Plain x-ray studies, in addition to lateral flexion and The authors tend to make a more generous incision and
extension lateral views, permit an accurate assessment of fascial opening when compared, for example, to the open-
instability both at the initial stage and at follow-up. ing made in the lumbar spine, in order to facilitate dissection
through the tense fascia and muscle down to the lamina.
Shaving of the surgical area is recommended. Further spe-
cific patient preparation is not required.
The positioning of the patient depends on the preference

Cranial
of the surgeon and anesthetist, and may either be sitting or
prone. Preference is given to general endotracheal anes-
thesia, in order to secure the airway. The sitting position
can improve visualization by minimizing blood loss from
Left Right
the epidural venous plexus and facilitating blood drainage
from the surgical field, but involves the increased risk of
venous air embolism [10, 11]. However, the prone position
is more anatomically familiar and may be preferred, in which Caudal
case the head should be elevated at a 30° angle to reduce
central venous pressure. The head can be held securely in Fig 2.2-1 Surgical approach for tubular retractor.

Magnification with either a microscope or a surgical loupe The pedicle above and below should be palpable with a
is required. Partial removal of the hemilamina and medial nerve hook (Fig 2.2-4). If the indication for surgery is a soft
aspect of the facet is facilitated by a high-speed burr. With disc herniation, it is now necessary to find the disc and
care taken to preserve the lateral half of the joint, the bone perform a partial discectomy. The nerve must be retracted
should be thinned down to its inner plate and then removed cranially (Fig 2.2-4)—both the motor and sensory portions
with a 1 mm Kerrison punch, or “flicked off” with a 3-O that might be present in separate dural sheaths—with care
curette [12] (Fig 2.2-2). Anatomical studies have shown that not to mobilize the cord itself. Identification of the ruptured
a 50% facetectomy exposes approximately 3–5 mm of the annulus fibrosus with the detection of extruded fragments
nerve root without compromising stability, while the re- may be possible, otherwise, a micro-blade may be used to
moval of 70% of the facet joint exposes up to 10 mm of incise the posterior longitudinal ligament, following which
nerve root, but is also associated with a higher risk of me- the disc material is removed with a micro-pituitary rongeur.
chanical failure [13–16]. Sometimes an extruded disc fragment can also be found
cranial to the nerve root.
The pedicle above and below should be palpable with a
nerve hook. The nerve should be exposed with care as it Hemostasis is ensured with the use of bipolar diathermy as
remains compressed in the foraminal canal. The ligamentum required, and an antibiotic wash is undertaken prior to re-
flavum should be opened, medial to the decompression at moval of the retractors. The muscle is carefully inspected
its laminar portion, and careful use of bipolar diathermy at and bleeding is controlled with bipolar coagulation. The
this stage will minimize bleeding from the venous plexus. fascia is then closed in a watertight fashion, and the skin is
This procedure may be undertaken with a nerve hook, or closed up in the usual manner.
by incision under direct visualization (Fig 2.2-3). Use of the
diathermy device with the tips enclosing the ligamentum The use of computer-assisted surgical navigation in MIS-PF
flavum and venous plexus protect the nerve root at this has not been reported to date; image intensification and
point, and following cauterization, sharp dissection can be direct visual observation are the standard means of visual-
performed to reveal the lateral dura and nerve root. izing the surgical field. Instrumentation is not required for
this type of surgery, unless there is significant destabilization
of the joint with more than 70% facetectomy [15, 16].
Cranial
Left Right
Cranial
Caudal
Fig 2.2-2 Removal of the thinned-out hemilamina utilizing a

Kerrison punch. Left Right
Cranial
Caudal
Fig 2.2-4 Cranial retraction of the nerve root. The pedicle above
Left Right
and below should be palpable with a nerve hook. The position of the
pedicles is indicated.
Caudal
Fig 2.2-3 The ligamentum flavum may be divided over a nerve

hook under direct visualization.
111

7 Postoperative care was a retrospective study and no later outcomes were re-
ported [23]. A retrospective review of 38 cases in which
Most patients can be discharged and sent home within 24 patients underwent either ACDF or MIS-PF for unilateral
hours, with the expectation of surgical-site pain and mus- cervical radiculopathy showed an overall cost benefit for
cle spasms during the immediate postoperative period. posterior surgery, shorter length of hospital stay, earlier
Wound inspection is performed at dressing changes, with return to work—with no differences in blood loss or surgery
care being taken to exclude the presence of infection. Stan- times [9]. A retrospective study from Germany [22] compar-
dard antiinflammatory medication and analgesics are rou- ing anterior discectomy with polymethylmethacrylate
tinely prescribed, but if required, muscle relaxants or opioid (PMMA) interbody stabilization to posterior cervical fo-
treatment for pain control may be administered. Rapid raminotomy in a total of 292 patients concluded that the
mobilization is encouraged, and physical therapy may be overall clinical success rate based on the Odom scale was
initiated once the wound has healed in cases where more higher in the anterior surgery group, but that the complica-
extensive surgical intervention is required. The use of a soft tion rates were also higher (96.6% versus 85.0% and 6.5%
collar is optional and depends on the surgeon’s preference, versus 1.8%, respectively).
but is not part of the present authors’ routine. No further
follow-up imaging is generally required. Return to work is Recent studies [8, 24, 25] have reported little difference be-
as individually tolerated, but is usually rapid. tween MIS-PF and open posterior surgery in terms of dura-
tion of hospitalization, outcome, or complications. Kim and
Kim’s study [18] is the only reported randomized clinical
8 Evidence-based results trial comparing open to MIS-PF. In 41 patients randomized
to either an open or tubular retractor approach, the only
There is no high-grade evidence reported in the literature significant differences in outcomes were related to incision
on MIS-PF. The majority of studies include retrospective length, duration of hospital stay, and initial analgesic use,
case series, or compare anterior to posterior procedures which favored the tubular retractor approach, but no me-
rather than minimally invasive to open procedures. Gener- dium- or long-term differences were observed, although
ally, these studies note a resolution of symptoms in around this may have been due to the low power of this study. The
90% of cases, with a low rate of neurological injury, further largest study included a 5-year follow-up [26], and reported
disc degeneration, or instability [7, 17–19]. A systematic re- on 162 patients that underwent MIS-PF. In these patients,
view sponsored by the American Association of Neurolog- the Neck Disability Index improved in 93% of cases, and
ical Surgeons/Congress of Neurological Surgeons [20], which 95% of patients experienced improvement in their radicu-
included data up to 2007, concluded that only Class III lopathy. Three percent of patients underwent additional
evidence was available in support of posterior laminofo- cervical spine surgery, with one patient requiring posterior
raminotomy for the treatment of cervical radiculopathy stabilization. The authors found that age > 60 years, previ-
resulting from soft lateral cervical disc displacement or cer- ous posterior surgery, and < 10° of lordosis preoperatively
vical spondylosis with resulting narrowing of the lateral were predictive of delayed sagittal misalignment, and close
recess. The most relevant papers included a review carried follow-up of these at-risk patients was recommended. These
out in 1983 of 846 posterior foraminotomy cases in which findings reflect the previous results of a long-term study
92% of patients rated their outcome as good or excellent investigating same-segment and adjacent-segment disease
[21], and a 2006 study of 292 posterior foraminotomy pa- after posterior cervical foraminotomy [27], in which a 6.7%
tients with a mean 6-year follow-up, and good or excellent rate of symptomatic adjacent-segment disease and a 5.0%
outcomes in 85% of cases [22]. rate of same-segment disease at 10 years was reported. Treat-
ment of multilevel disease has also been reported, with no
As far as ACDF versus MIS-PF is concerned, a recent study perioperative complications encountered. During the 2-year
on early in-hospital outcomes found improved clinical out- follow-up period, the complete resolution of symptoms was
come for the ACDF procedure versus MIS-PF, however, this achieved in 90% of patients [6].

9 Complications and avoidance Careful use of bipolar diathermy, both to minimize excessive
bleeding from the venous plexus and to avoid neural injury,
The complications associated with MIS-PF are primarily is an important consideration. The high-speed burr may cause
related to surgical error. One of the major challenges can local thermal injury, and careful irrigation must be ensured,
be the accurate localization of the correct surgical level in particularly when the patient is in the sitting position.
the lower cervical spine. The sitting position may offer ad-
vantages in this respect. However, taping the patient’s shoul- Air embolism constitutes a serious complication in the sitting
ders and the use of intraoperative image intensification can position, therefore, vigilant intraoperative monitoring and
facilitate localization of the correct level with the patient careful surgical techniques are essential in this regard. In-
in the prone position. traoperative Doppler cardiac monitoring may be considered.
Injury to the nerve root can occur as a result of it being Postoperative instability is limited by rigorous preoperative
mistaken for a disc (especially in cases of duplicated nerve patient selection, avoidance of bilateral surgery and careful
roots), or due to the insertion of surgical instruments that preservation of the lateral aspect of the facet joint. Patients
compress the nerve within the stenotic foramen. To avoid with a straight or kyphotic spine may be better treated via
these risks, utmost care must be taken to fully visualize an anterior approach and/or fusion. The authors aim to
the nerve and decompress it, with an accompanying aware- resect up to 50% of the joint, as resection greater than this
ness that the nerve may be divided into separate branch- may lead to fracture and instability [15, 16].
es, which could inadvertently be mistaken for disc mate-
rial. Vertebral artery injury may manifest as significant intraop-
erative hemorrhaging, either as a consequence of a dissec-
Patients with calcified discs or disc/osteophytes may not be tion that has been extended too far laterally or due to an
ideal candidates for this approach as extensive retraction abnormal or aneurysmal artery. Films should be carefully
of the neural elements is required to remove the osteophytes. reviewed at the preoperative stage in order to detect any
Simple decompression without an attempt of removing the anatomical abnormalities of the vertebral artery.
osteophyte may be preferable.
New onset symptoms or recurrence of radiculopathy should
Incidental durotomy can generally be managed by tampon- be worked up aggressively, as they may be indicative of
ade with dural sealant materials, but persistent leakage may nerve injury or the presence of a postoperative epidural
require a lumbar drain, when required, in conjunction with abscess. Chronic regional pain syndrome associated with
a direct repair. MIS-PF has recently been reported [28].
113

10 Tips and tricks
Volker Sonntag, Phoenix, USA the dural sac. Occasionally, depending of electrical stimulation and performing
• Even if more than 50% of the facet is re- on the site of the abnormality, the nerve the operation under magnification will
moved, it is unlikely that instability will root has to be retracted caudally. help the surgeon to differentiate disc ma-
develop because the midline structures • If the operation is performed to treat a terial from the nerve root.
and the opposite facets are intact. hard-disc herniation, the surgeon must • Use of the posterior approach avoids
• It often is necessary to remove part of judge whether only a decompression is complications associated with anterior
the pedicle to decompress the nerve root. indicated, or whether removal of the surgery, such as dysphagia and dyspho-
This can be done under magnification bone spurs should also be considered. If nia.
by drilling into the pedicle with a high- the latter is pursued, it should be done • This operation can be performed with the
speed diamond drill and then cracking under magnification using the diamond- patient in the sitting or prone position.
the inferior wall of the pedicle with a drill bit. The sitting position reduces bleeding,
microcurette. • Intraoperative imaging should be per- but increases the risk of air embolism.
• After a soft-disc herniation has been re- formed as close as possible to the inter- Conversely, the prone position reduces
moved, extensive venous bleeding can space. The surgeon should not be misled the risk of air embolism but increases the
occur. Such bleeding is normal and can by the oblique facets or abnormal osteo- chances of bleeding.
usually be contained by the use of he- phytes. • This operation can be performed with the
mostatic agents. • After posterior foraminotomy and discec- surgical microscope or loupe magnifica-
• To expose the interspace, it is preferable tomy, an external orthosis is unnecessary. tion. This author prefers the microscope
to retract the root rostral and remove • The posterior-motor portion can have its because the assistant has a clearer view,
the disc or drill down the osteophyte in own dural sheath and be mistaken for and the magnification and lighting are
the axilla between the nerve root and herniated disc material. The application better.

11 Case example 12 Key learning points
A 42-year-old man presented with neck pain and right C6 • Single-level radiculopathy associated with soft lateral
and C7 radiculopathy with biceps and triceps weakness. No disc herniation is most appropriately treated via poste-
other symptoms were present, and the patient was unre- rior cervical foraminotomy. Osteophytes can be removed
sponsive to nonsurgical treatment. Preoperative MRI showed in this manner, but care must be taken to avoid irritation
a broad disc herniation at C5/6, causing spinal cord com- of the nerve root during surgery (Fig 2.2-8)
pression; in addition, a lateral disc herniation at C6/7 was • Patients should be carefully selected. Mechanical neck
apparent on the right side, with an osteophyte arising from pain, deformity, central disc herniation, and symptom-
the uncovertebral joint (Fig 2.2-5). The surgical technique atic myelopathy are contraindications for this type of
consisted of an anterior discectomy at C5/6 with a cervical surgery, and may respond better to anterior decompres-
disc arthroplasty, followed by minimally invasive C6/7 sion with or without stabilization
posterior foraminotomy. The surgical procedure was un- • Postoperative instability is an uncommon occurrence in
eventful, and postoperatively the patient experienced excel- appropriately selected patients, and most surgeons rec-
lent symptomatic relief from the radiculopathy (Fig 2.2-6, ommend removing less than 50% of the facet joint.
Fig 2.2‑7).
a b
Fig 2.2-5a–b
a Preoperative axial T2 MRI at C6/7 showing right foraminal narrowing. Fig 2.2-7 CT scan reconstruction
b MRI of the level C5/6 showing large disc herniation with spinal demonstrating right-sided C6/7
cord compression. foraminotomy.
Fig 2.2-8 Foraminal compression due to

lateral osteophyte causing monoradiculopathy.
a b This nerve can be decompressed via a poste-
rior cervical foraminotomy. Care must be taken
Fig 2.2-6a–b Preoperative (a) and postoperative (b) lateral x-rays.
to mechanically minimize irritation of the nerve
Foraminotomy was performed at C6/7 below the cervical disc
during microsurgery.
arthroplasty at C5/6.
115

13 References
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intervertebral disc and interbody prospective study with technique for cervical radiculopathy:
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approach for removal of ruptured 12. Vaccaro A, Albert T (2003) Spine al (2006) Posterior foraminotomy or
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15(6):602–617. York: Thieme, 4–10. methacrylate interbody stabilization for
3. Frykholm R (1951) Lower cervical 13. Kumaresan S, Yoganadan N, Pintar cervical soft disc disease: results in 292
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4 Adamson TE (2001) Microendoscopic 10(1):40–46. 23. Schebesch KM, Albert R, Schödel P,
posterior cervical laminoforaminotomy 14. Raynor RB, Carter FW (1991) Cervical et al (2011) A single neurosurgical
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Kim KT, Kim YB (2009) Comparison between open Korinth MC, Krüger A, Oertel MF, et al (2006)
procedure and tubular retractor assisted procedure for Posterior foraminotomy or anterior discectomy with
cervical radiculopathy: results of a randomized controlled polymethyl methacrylate interbody stabilization for
study. J Korean Med Sci; 24(4):649–653. cervical soft disc disease: results in 292 patients with
monoradiculopathy. Spine; 31(11):1207–1214; discussion
Study type Study design Class of evidence 15–16.
Therapy Randomized controlled trial II
Purpose Therapy Cohort III
To compare the clinical parameters and surgical outcomes
of open foraminotomy/discectomy and tubular-retractor Purpose
assisted foraminotomy/discectomy in the treatment of To evaluate the long-term outcome after two different
cervical radiculopathy. surgical procedures in the treatment of cervical radicu-
lopathy, compare them with each other and with previ-
P Patient Cervical radiculopathy (N = 41) ous data from other surgical techniques, and outline the
I Intervention Tubular-retractor assisted foraminotomy/discectomy (group indications, advantages, and disadvantages of each pro-
2, n = 22) cedure.
C Comparison Open foraminotomy/discectomy (group 1, n = 19)
O Outcome Clinical parameters, surgical outcomes P Patient Cervical radiculopathy (N = 292)
I Intervention Ventral microdiscectomy and PMMA stabilization (n = 124)
Authors’ conclusion (group A)
Tubular-retractor assisted foraminotomy/discectomy is C Comparison Posterior foraminotomy (n = 168) (group B)
as clinically effective as the open foraminotomy/discec- O Outcome Success rate, complications
tomy.
A higher success rate appears to result after anterior mi-
crodiscectomy with PMMA interbody stabilization for
treatment of degenerative cervical monoradiculopathy
than after posterior foraminotomy. Although statisti-
cally significant differences in clinical data were found in
both groups, both approaches seem to have equivalent
value in individual indications.
117

Schebesch KM, Albert R, Schödel P, et al (2011) A Tumialán LM, Ponton RP, Gluf WM (2010)
single neurosurgical center's experience of the resolution Management of unilateral cervical radiculopathy in the
of cervical radiculopathy after dorsal foraminotomy and military: the cost effectiveness of posterior cervical
ventral discectomy. J Clin Neurosci; 18(8):1090–1092. foraminotomy compared with anterior cervical
discectomy and fusion. Neurosurg Focus; 28(5):E17.
Therapy Retrospective cohort study III Study type Study design Class of evidence
Therapy Retrospective cohort study III
Purpose
To evaluate the neurological outcomes after surgical treat- Purpose
ment with dorsal foraminotomy and sequestrectomy To identify the difference in time to return to active duty
(Frykholm's method), or ventral discectomy and inter- between a posterior cervical foraminotomy (PCF) and
vertebral cage (modified Cloward's method). anterior cervical discectomy and fusion (ACDF) in military
personnel and to examine the cost effectiveness and
P Patient Cervical radiculopathy (N = 100) clinical outcomes in those patients.
I Intervention Ventral discectomy and intervertebral cage (Cloward group,
n = 49) P Patient Unilateral cervical radiculopathy (N = 38)
C Comparison Dorsal foraminotomy and sequestrectomy (Frykholm I Intervention PCF (n = 19)
group, n = 51)
C Comparison ACDF (n = 19)
O Outcome Neurological outcomes
O Outcome Time to return to active duty, cost effectiveness, clinical
outcomes
Complete removal of the affected cervical disc via a ven- Authors’ conclusion
tral approach and segmental fusion results in a superior In the management of unilateral posterior cervical ra-
neurological performance in the short-term compared to diculopathy for military active-duty personnel, PCF offers
a dorsal foraminotomy and nerve root decompression by a benefit relative to ACDF in immediate short-term direct
sequestrectomy. and long-term indirect costs. The indirect cost of time
away from duty was the more significant contributor to
difference in cost effectiveness.

Winder MJ, Thomas KC (2011) Minimally invasive

versus open approach for cervical laminoforaminotomy.
Can J Neurol Sci; 38(2):262–267.

Therapy Retrospective cohort study III
Purpose
To determine any appreciable differences between the use
of microscopic tubular assisted posterior foraminotomies
(MTPF) compared with traditional open foraminotomies
and to compare results of MTPF with the reported results
of microendoscopic posterior foraminotomies.
P Patient Cervical radiculopathy (N = 107)

I Intervention MTPF (n = 42)
C Comparison Traditional open laminoforaminotomy (n = 65)
O Outcome Clinical parameters, surgical outcomes
The results suggest that MTPF is comparable to endo-
scopic posterior foraminotomy and enables shorter hos-
pital stays, while minimizing analgesic requirements, with
similar complication rates when compared to open pro-
cedures performed.
119


2.3 Anterior foraminotomy: microsurgical and endoscopic
procedures
Luca Papavero, Walter Saringer
1 Historical perspective variation of this procedure called the “upper vertebral trans-
corporeal approach”: the entry point corresponded to the
The average annual age-adjusted incidence rate of cervical inferolateral part of the upper vertebra, superior to the an-
radiculopathy caused by a soft-disc fragment or, more fre- terior surface of the tip of the uncinate process. The advan-
quently, by a posterolateral spondylotic spur is approxi- tage was a shorter distance to the target area due to the
mately 85 cases per 100,000 population, but with a peak of cephalad inclination of the cervical disc on the sagittal plane.
203 cases for the 50 to 54-year-old age group [1]. It is there- In the same year, in a study involving 34 patients, one of
fore not surprising that a common clinical disorder has led the authors of this chapter reported on a modification of
to various surgical treatment options. Jho et al’s [5] technique: a thin lateral shell of the uncinate
process was left as a protective shield for the vertebral artery
At the end of the 20th century, anterior techniques, such and to serve as a landmark to avoid entering the transverse
as discectomy with or without fusion, and posterior fo- foramen while drilling. The vertebral artery was not exposed,
raminotomy were the most popular treatment modalities. and the disc was left alone [6].
Spontaneous kyphotic fusion, pseudarthrosis, graft harvest-
ing morbidity, and accelerated adjacent segment degen- In 2007, Choi et al [7] treated 20 patients via a medialized,
eration were the main shortcomings of anterior procedures. upper vertebral transcorporeal approach. The drill entry
Persistent neck pain following the paramedian subperios- point was placed 4–6 mm above the lower border of the
teal approach, occasional segment instability, and the lim- upper vertebra (approximately mid-body level) at the lev-
itations of an indirect decompression were reported after el of the medial border of the longus colli muscle. The drill-
posterior approaches. However, the overall success rate of ing direction was from medial to lateral and from a super-
80–90% was convincing [2]. ficial level down to the inferolateral vertebral endplate. The
medial wall of the transverse foramen was not opened, and
Anterior cervical foraminotomy (ACFor) was conceived as the vertebral artery was not exposed. The longus colli mus-
a nonfusion, minimally invasive, and cost-effective proce- cle was minimally retracted.
dure to decompress the root anteriorly, where the problem
is usually located. Jho [3] termed this concept “functional Since the first ACFor procedures, concurrent anterior tech-
spine surgery”. niques have also evolved. The introduction of cages (avoid-
ance of graft harvesting morbidity, good biomechanical
In 1989, in a study that included 63 patients, Snyder and performance) and disc prostheses (motion preservation,
Bernhardt [4] reported on their experience with “fraction- hypothetical reduction of adjacent segment disease) has
al interspace decompression”, a technique that combined increased the appeal of established techniques, which re-
resection of the uncinate process with the lateral third of quire a relatively short learning curve while obtaining good
the disc. clinical results. Furthermore, the transmuscular approach
via a tubular retractor to the lamino-facet junction has sig-
In 1996, Jho [3] presented his results on the transuncal ap- nificantly reduced the incidence of postsurgical neck pain.
proach, whereby, in order to maintain the disc integrity, a The selective removal of an axillary disc fragment or the
lateromedial approach from the medial margin of the ver- trimming of a spondyloarthrotic facet usually provides an
tebral artery was used, which preserved the medial wall of excellent outcome.
the uncinate process. However, the exposure of the verte-
bral artery limited the acceptance of this technique by the Anterior cervical foraminotomy is a cost-effective option
surgical community. In 2002, Jho et al [5] reported on a among the different surgical procedures for the treatment
121

Authors Luca Papavero, Walter Saringer
of cervical disc disease. Although the probability of it be- is especially the case for ACFor. Patients with all of the fol-
coming the gold standard is fairly low, the positive aspects lowing indications may be considered as candidates for
and weaknesses of this nevertheless effective technique will ACFor:
now be examined. • Unilateral (mono- or bisegmental) radiculopathy not
responding to conservative treatment over a period of
more than 6 weeks, if neurological deficits are apparent
2 Terminology • Absence of cervical myelopathy or predominant neck
pain
Anterior cervical foraminotomy performed with the aid of • Imaging (AP, oblique, and lateral extension/flexion plain
a microscope or an endoscope can be defined as the mono- films; MRI and thin-slice CT scan of the involved level)
or multisegmental unilateral resection of an offending lesion, showing an intraforaminal soft or calcified disc fragment;
either a posterolateral spondylotic spur or a disc fragment in the fifth decade (peak incidence), foraminally locat-
compressing the nerve root anteriorly between its origin in ed spondylotic spurs impinging on the nerve root
the spinal cord and its passage behind the vertebral artery, • Unusual indication but with increasing incidence: per-
in such a way as to ensure that the integrity, ie, form and sistent spondylotic narrowing of the root canal follow-
function, of the intervertebral disc is maintained. ing anterior cervical fusion with insufficient foraminal
decompression.
Due to the small diameter of the approach tunnel (approx-
imately 7 × 5 mm), the direction of the surgical corridor has However, patients should not be considered with the ap-
to take into account the location of the offending lesion. pearance of any of the following contraindications:
Furthermore, over the years, the original approach, eg, as • Cervical myelopathy, predominant neck pain, or bilat-
described by Snyder and Bernhardt [4], has been miniatur- eral syndromes
ized and modified to reduce the inherent risks, such as lesion • Significant spinal canal stenosis (median soft or hard disc)
of the vertebral artery, Horner´s syndrome, damage to the • Alignment abnormalities or segmental instability
disc, and incomplete decompression. Anterior cervical fo- • Narrowing of the root canal due to dorsal spondyloar-
raminotomy includes a variety of approaches, which un- throtic changes of the facet or focal hypertrophy of the
derlines the fact that ACFor is not a “one fits all” procedure: yellow ligament (Ligamentum flavum).
• Transuncal approach:
Drilling starts from the medial border of the exposed
vertebral artery up to the medial wall of the uncinate 4 Pros and cons
process, leaving a thin shell to protect the disc
• Upper vertebral-transcorporeal approach: Anterior cervical foraminotomy is a procedure that still lacks
The entry point is located in the most inferolateral part general acceptance. The literature on the subject compris-
of the upper vertebra. Exposure of the vertebral artery es small retrospective case series graded as class of evidence
is not imperative level IV [5]. Nevertheless, the surgeon that adopts this spe-
• Lower vertebral-transcorporeal approach: cific technique for selected patients with relevant indications
The bone opening is initiated at the base of the uncinate for surgery will obtain satisfying clinical results. The argu-
process of the inferior vertebra. This approach is used ments in favor of or against the use of this minimally inva-
cranially to the level C4/5 because the drilling direction sive procedure have been summarized below.
is not obstructed by the mandible
• Medialized upper vertebral-transcorporeal approach: 4.1 Pros
The mainly intracorporeal surgical tunnel does not en- • Direct resection of the offending lesion compared to
danger the vertebral artery and the sympathetic nerve posterior foraminotomy
chain, and should not damage the medial wall of the • Preservation of the motion segment by maintaining the
transverse foramen or the disc. integrity (form and function) of the intervertebral disc
at the affected level
• Use of the microscope or of the endoscope provides bet-
3 Patient selection ter visualization and illumination
• Shorter operative time compared to anterior cervical
The statement that 90% of a successful outcome is based discectomy and fusion due to avoidance of the fusion
on indications for surgery and 10% on surgical technique procedure

2.3 Anterior foraminotomy: microsurgical and endoscopic procedures
• Reduced operative trauma compared to anterior cervi- 5 Preoperative planning and positioning
cal discectomy and fusion, shorter hospital stay, and
earlier return to work Once the clinical indication for ACFor has been established,
• Avoidance of implant-related complications the imaging required includes AP, lateral, and oblique x-
• Avoidance of fusion-related complications including rays, and MRI of the cervical spine. In the event of insuf-
graft-related and graft-site complications, and adjacent ficient visualization of the foraminal anatomy, which may
level disease. occur when MRI is used in the case of spondylotic disease,
a thin-slice CT scan and high-resolution CT scan is essential
4.2 Cons for an accurate diagnosis (Fig 2.3-1 and Fig 2.3-2). In addition,
• Mandatory preoperative CT scan and/or MRI evaluation CT scans are utilized for preoperative measurement of the
of the vertebral artery depth and direction of the drill-hole trajectory. As patients
• Steep learning curve, especially as regards use of the usually present with radiculopathy and distinct motor weak-
endoscope ness, electroneurographic investigations are not routinely
• Specific microsurgical skills and miniaturized instru- performed.
ments are essential
• Contralateral side cannot be addressed The patient is positioned supine with the head optionally
• Risk of iatrogenic vertebral artery lesion. turned slightly to the contralateral side. The cervical spine
a b
Fig 2.3-1a–b a
a Axial CT scan: intraforaminal disc fragment at C6/7.
b Axial MRI: the disc herniation can be seen encroaching on the C7
nerve root.
b e
Fig 2.3-2a–e
a Bone spur (white arrow) and resultant narrowing
of the root canal in comparison to the cephalad
neuroforamens.
b Sagittal MRI: the “black” neuroforamen.
c Axial MRI: right-sided narrowing of the C6 root canal.
d–e Axial CT scans: note the asymmetry of the root
canals.
123

is gently extended in a lordotic position by placing a gel 6.2 Skin to prevertebral space
cushion under the neck. A cervical traction device or cau- The surgical approach closely resembles that of conven-
dal fixation of the arms is not used. The approach is made tional anterior cervical discectomy and fusion (ACDF) and
at the side on which the radiculopathy is present. is performed macroscopically [6, 8]. A 3 cm transverse skin
incision is made at the intended site, two-thirds medial and
General anesthesia is performed. A central venous line is one-third lateral to the medial border of the sternocleido-
not necessary. Arterial blood pressure monitoring as well mastoid muscle (Fig 2.3-3). The platysma is incised along the
as the use of a urinary catheter are recommended, irrespec- line of the skin incision. A sharp and blunt dissection leads
tive of the expected duration of surgery. The average blood to the superficial fascia at the medial border of the sterno-
loss is minimal, therefore neither blood transfusions nor cleidomastoid muscle, keeping the visceral structures medi-
autologous blood donations are necessary. ally and the neurovascular bundle laterally. The preverte-
bral fascia is opened and the anterior aspect of the vertebral
bodies, the intervertebral disc, and the medial portion of
6 Surgical techniques: microsurgical and endoscopic the longus colli muscle of the target level, are exposed. The
procedures correct level is confirmed by lateral image intensification.
6.1 Localization Approximately 5 mm caudally and cranially to the margin

The vertebral level and site of the skin incision is confirmed of the intervertebral disc space, the medial portion of the
preoperatively by image intensification. Localization is per- ipsilateral longus colli muscle is incised transversally up to
formed by positioning a spinal needle lateral to the neck. 10 to 14 mm. The incised portion is retracted laterally by
The anterior neck is then prepared and draped using an the blade of a retractor, which is anchored medially by an
aseptic technique. The transverse skin incision is made pre- adjustable bone screw (Medicon, Tuttlingen, Germany) (Fig
cisely over the segment of interest. If two adjacent levels 2.3-4). The lateral border of the uncinate process is deliber-
have to be approached, projected skin incisions of the cra- ately exposed. At C7, care must be taken not to imperil the
nial and caudal level are marked under lateral image inten- vertebral artery, where it runs between the transverse pro-
sifier guidance. Then a transverse skin incision is made cess and the longus colli muscle. The vertebral artery is not
slightly inferior to the midline between the two marked exposed intentionally.
sites. If two nonneighboring levels have to be treated, two
separate approaches with separate skin incisions are recom-
mended.
a b
Fig 2.3-3 The skin incision is placed two-thirds medially of the medial Fig 2.3-4a–b
border of the sternocleidomastoid muscle; the black line indicates the a Retractor with a lateral PEEK valve.
medial border of the longus colli muscle, the blue line indicates the tip b Medial telescopic anchoring screw.
of the uncinate process, and the red line shows the skin incision.

6.3 Microsurgical anterior foraminotomy Then a 2 mm ball-shaped diamond burr is used. Remnants
At this stage, the use of the microscope is recommended. of the bony endplate are removed with the drill, leaving
The operative field is limited cranially, caudally, and later- the cartilaginous endplate untouched. The thinned poste-
ally by the longus colli muscle. The laterally reflected por- rior cortical layer and the posterior part of the lateral wall
tion of the longus colli muscle serves as an additional proof the uncinate process are then removed by careful drilling
tective layer for the vertebral artery. The exposed field under continuous rinsing. This procedure enables bone spurs
includes the lateral third of the intervertebral disc, lateral of the posterolateral endplate and the uncinate process to
portion of the caudal vertebral body with the uncinate probe removed, and the underlying nerve root decompressed.
cess, and the lateral portion of the cranial vertebral body. A thin piece of cortical bone from the lateral wall of the
A long-handled high-speed drill with a 1.8 mm matchstick- uncinate process is left, to serve as a landmark, and is a
style cutting burr is used to initiate the resection of the protective layer for the underlying vertebral artery (Fig 2.3‑6).
uncinate process. A triangular-shaped hole of 6–8 mm in At this stage, the periosteum covers the nerve root, disc
transverse diameter and 9–11 mm in height is drilled. The fragments, and the lateral portion of the posterior longitu-
drilling is advanced to the posterior cortical layer (Fig 2.3-5). dinal ligament.
VA
UP
b
3 mm
LCM
a c
a
Fig 2.3-5a–c
a Surgical target area delineated by the blue rectangle.
b Prior to drilling, the yellow asterisk indicates the tip of the
uncinate process.
c After drilling off the superficial part of the uncinate process.
The asterisk indicates the tip of the uncinate process.
b c
Fig 2.3-6a–c
a Drilling off the medial part of the uncinate process (UP) leaving a
thin protective bony shell around the vertebral artery (VA). LCM:
longus colli muscle.
b Intraoperative view.
c Postoperative CT scan.
125

The periosteum and the cartilaginous and degenerative fi- the nerve root. The lateral margin of the posterior longitu-
brous tissue between the tip of the uncinate process and dinal ligament is elevated with a microhook and, selec-
the lower endplate of the cranial vertebral body are removed tively, if there is a hidden epidural disc fragment under the
using a 1 and 2 mm thin footplate Kerrison rongeur ligament, resected with a 2 mm thin footplate Kerrison
(Fig 2.3‑7). Final osseous decompression of the nerve root, rongeur. The disc fragment is then mobilized and extracted.
caused by bone spurs or posterolateral osteophytes at the The disc within the intervertebral space remains untouched,
lower endplate of the cranial vertebral body, is accomplished and thus preserved. The removal of disc fragment(s) and
with a 2 mm thin footplate Kerrison rongeur. In the case the resection of the lateral portion of the posterior longitu-
of spondylotic foraminal stenosis, the operation is accom- dinal ligament may be complicated by epidural bleeding
plished at this stage. A posterolateral disc herniation requires from the anterior internal venous plexus and the venous
the removal of the fragment(s). It may be visible in front plexus encasing the root. This bleeding can be stopped by
of the underlying nerve root. The fragment(s) can safely be cauterization, or by rinsing with hydrogen peroxide solu-
mobilized with a microhook (Fig 2.3-7) and removed with tion. The nerve root can now be clearly visualized from its
a micropunch. origin to its entry into the intervertebral foramen, which
may be safely approached without removing the fragment
The lateral portion of the posterior longitudinal ligament of the lateral wall of the uncinate process by passing a mi-
covers the lateral margin of the thecal sac and the origin of crohook inferiorly and superiorly to the nerve root (Fig 2.3‑8).
NR
* *
DF
PLL
Fig 2.3-7a–b
a Bony decompression of the axilla of the nerve
root (NR); PLL: posterior longitudinal ligament;
DF: disc fragment; asterisk: tip of the uncinate
process.
b Hooking of the disc fragment, with asterisk
a b marking tip of the uncinate process.
Thecal sac Shoulder
Fig 2.3-8a–b
7–8 mm * a Following left-sided ACFor, the shoulder and the axilla of
the C6 nerve root are shown. Note that a thin bony shell of
UP * the uncinate process (asterisk) has been left to protect the
m m
venous plexus of the vertebral artery.

12
–
b This patient developed cervical spondylotic myelopathy

10
13 years after ACFor. Anterior cervical fusion at C5–C7 was

Axilla therefore performed. No stenosis of the root canal following
a b ACFor was noted.

6.4 Closure fixed to a pneumatic holding arm (Unitrac, Aesculap, Tut-

At the end of the procedure, the bone surface is sealed with tlingen, Germany). After coarse adjustment of the endo-
bone wax if significant blood loss is observed. To prevent scope, further fine three-dimensional corrections of the tip
any potential compression of the nerve root or the spinal are possible via the steering device. The precise maneuver-
cord, hemostatic agents (eg, Gelfoam, Surgicel) are avoiding in sub-millimeter steps is facilitated by three adjustment
ed. Finally the retractor is removed, the platysma is closed screws on the steering device.
with interrupted absorbable stitches, then a subcuticular
skin closure is made. Wound drainage is usually not neces- 6.6 Skin to prevertebral space
sary. The surgical approach is performed macroscopically. A trans-
verse 2-cm long skin incision is made at the intended site,
6.5 Endoscopic technique two-thirds medial and one-third lateral to the medial bor-
Two types of endoscope can be used: the MED system der of the sternocleidomastoid muscle. Using the MED sys-
(Medtronic, MN, USA), or an endoscope with a steering tem, first a K-wire is placed through the incision as far as
device (NeuroPilot, Aesculap, Tuttlingen, Germany). The the target uncinate process. Then the sequential dilators
MED system includes a rigid 25° angled lens endoscope are introduced along the K-wire with slightly rotating move-
(shaft length 100 mm, outer diameter 3 mm), mounted on ments. A constant pressure on the first dilator ensures that
a tubular retractor by means of a ring attachment with an the system does not migrate while the dilators are being
integrated cleaning device. Two sizes of retractor are avail- inserted. Finally, the tubular retractor is introduced over
able, enabling a 16 mm or 18 mm surgical corridor. The the last dilator and is anchored to the retractor arm. The
retractor is anchored to the retractor arm. The endoscope dilators are then removed. The tube is adjusted parallel to
does not have a built-in working channel. The surgical in- the longitudinal axis of the uncinate process. The procedure
struments are inserted coaxially to the endoscope through is performed under image intensifier guidance (Fig 2.3-9).
the tubular retractor. A camera head, an integrated video When the Aesculap system is used, a standard cervical re-
system that combines camera and xenon light source, and tractor with slim blades is chosen.
video peripherals, such as a 19 inch monitor, a video re-
corder, and a video printer are assembled and connected to 6.7 Endoscopic anterior foraminotomy and/or
the endoscope. removal of the herniated disc
Surgery is continued under endoscopic visual control in a
The Aesculap system includes two endoscopes (0° or 30° similar manner to the microsurgical procedure (Fig 2.3-10).
angled lens endoscope, shaft length 181 mm, shaft diam- The operation can be performed at two adjacent ipsilateral
eter 2.7 mm) mounted on a steering device, which can be levels via the same skin incision.
Fig 2.3-9a–b Lateral (a) and

AP (b) views of the MED working Fig 2.3-10 Endoscopic view of
tube centered on the C6/7 unci- the decompressed nerve root
a nate process. (NR) arising from the thecal sac
(T) with the sucker (S) positioned
on the right.
127

7 Postoperative care (20.6%) were left with residual numbness, largely in the
distal portion of the corresponding dermatome.
Patient mobilization is allowed 6 hours postoperatively.
Patients are advised to minimize physical activity and to In one patient, x-ray follow-up data three months postop-
avoid excessive neck movement for 14 days. However, it is eratively showed evidence of delayed instability and sig-
not necessary to wear a collar. nificant loss of disc height at the operated level. In this case,
an anterior cervical discectomy and fusion of the affected
Patients can be discharged on the first postoperative day, level was performed.
or the surgical procedure can even be performed on an
outpatient basis. In Austria, for example, patients are dis- The overall subjective patient satisfaction rate amounted
charged eight days following surgery for health insurance to 95.6%. Seventy-nine patients (90.8%) returned to work
purposes, and are encouraged to return to full activity six or to the preoperative physical activity they had practiced
weeks postoperatively. within 6 weeks postoperatively.
8 Evidence-based results 9 Complications
In 2009, a systematic review was published with the objec- Traditionally, the complications associated with ACFor may
tive of using evidence-based medicine to identify the indica- be divided as follows:
tions for, and utility of using ACFor among other anterior 1. Access surgery-associated complications:
cervical decompression techniques [9]. Seven retrospective • Soft-tissue and visceral injuries
studies (class of evidence level III), including 467 patients 2. Target surgery-associated complications:
in all, were analyzed. Good or better outcomes (Odom's • Spinal cord or nerve root injuries
criteria) were observed in 85–90% of patients. However, • Vascular injuries (involving the vertebral artery or
one class of evidence level III study reported revision surgery perivertebral venous plexus)
in 30% of cases [10]. • Insufficient decompression
In the series reported by one of the present authors [6], 9.1 Access surgery-associated complications
anterior cervical foraminotomy was equally successful us- In a series of 87 patients [6] that underwent microsurgical
ing either the microsurgical or the endoscopic technique. or endoscopic ACFor, the following access surgery-associ-
Success was measured by the reduction of the preoperative ated complications were reported:
and postoperative neck disability index values, the visual • Poor wound healing was observed in three patients, and
analog scale (VAS) concerning radicular pain, patient sat- in all three cases this minor complication resolved with
isfaction, and the absence of analgesic medication. no untoward effects
• Transient recurrent laryngeal nerve palsy was observed
The postoperative neck disability index score improved by in five patients, mostly after a left-sided C6/7 approach.
44.7%, from a mean preoperative score of 28.4 to 14.7
after surgery (P > .05). The preoperative VAS score was Recommendations: The tendency to keep the skin incision
6.75, and decreased to 0.25 postoperatively: an improve- as short as possible for cosmetic reasons may sometime
ment of 96.3% was observed (P > .05). The VAS-based hamper wound healing. Furthermore, diabetes mellitus,
outcomes for relief from radicular pain were excellent in nicotine abuse, and skin diseases may play a role in poor
91% and good in the remaining 9% of patients. Fair or poor wound healing.
results were not observed in this series.
The prolonged retraction of anatomical structures that are
In 51 out of the 65 patients that presented with weakness, not sufficiently mobile is probably the most common cause
the motor deficit did not immediately improve after surgery, of hoarseness, dysphagia and recurrent laryngeal nerve
but complete recovery following physiotherapy was ob- palsy (especially following a left-sided C6/7 approach). The
served in 37 patients. Fourteen patients (16.6%) retained use of a retractor (Fig 2.3-4) that is anchored to the midline
persistent but slight motor weakness (class of evidence instead of underneath the contralateral longus colli
level IV). Of the 73 patients that presented with numbness, muscle, may reduce retraction pressure on the esophageal
55 later regained normal sensation. Eighteen patients wall. Furthermore, the reduction of the cuff pressure to

20–25 mm Hg is helpful in decreasing the incidence of post- Recommendations: If postsurgical persistent radicular pain
operative sore throat and hoarseness. does not improve within 48 hours following steroid thera-
py, the possible presence of a remaining disc fragment, or
9.2 Target surgery-associated complications insufficient bony decompression should be investigated.
In the above-mentioned series, the following target surgery- Revision surgery should be undertaken on the basis of MRI/
associated complications occurred: CT findings. In some cases, enlarged anterior cervical de-
• One patient presented with recurrent radicular pain 2 compression and fusion may be necessary.
days after surgery and underwent revision surgery
• In the first endoscopic series, in one case, severe arte- Thinning of the lateral wall of the uncinate process (using
rial bleeding occurred while drilling part of the lateral a burr coated with diamond dust) may be “complicated” by
wall of the uncinate process. This hemorrhage could be vigorous venous bleeding. Usually the combined use of col-
controlled with a collagen fleece coated with fibrin com- lagen fleece and bone wax stops the hemorrhage. Rela-
ponents, eg, TachocombTM. A postoperatively performed tively rare arterial bleeding equally requires a collagen
angiography revealed no evidence of injury to the ver- tampon as first maneuver. Vascular clips are the second
tebral artery. option.
10 Tips and tricks
Daniel Riew, St Louis, USA • Use new ultrasonic bone dissectors

avoided for at least the first 3 months
1. The surgeon should check the preopera- to remove bone without damaging following the original surgery, or un-
tive MRI and CT scan for: soft tissues. In future these may be til the neck structures feel as soft as
• The dominant vertebral artery.
proven to be a superior alternative the opposite side, and the trachea can
• The presence of abnormal vertebral
to steel burrs. easily be mobilized to the opposite
artery course. 3. Excellent technique is required to de- side.
If the MRI and CT scan are unclear, it is compress the foramen in a patient that • Tubular surgery through the scar is

recommended that the surgeon obtain has had previous arthroplasty or anterior not recommended.
an MR angiogram or a CT angiogram. fusion with inadequate foraminal decom- • With a previous fusion, one can start

An alternative operation should be con- pression. These are revision cases so there at the lateral aspect of the disc space,
sidered if the patient has a dominant or are additional concerns: instead of above or below the disc.
unilateral vertebral artery on the side • Recurrent laryngeal nerve function
Remove bone and the residual disc,
of decompression. must be evaluated with an ear, nose, as well as the entire uncus, leaving
2. To protect the vertebral artery it is recom- and throat assessment. If the patient the fusion bone graft intact.
mended to: is injured on the side of the original
• Place a Penfield retractor #2 or #4
operation, revision surgery must be
immediately lateral to the uncinate performed on the same side. If intact,
process. revision surgery may be approached
• The Penfield retractor protects
from the opposite side.
the vertebral artery from the • If operating on the same side as the

burr original operation, surgery should be
129

11 Case examples 11.2 Case 2

A 75-year-old man complained of severe left-sided radicu-
11.1 Case 1 lar pain at C8. Furthermore, the onset of atrophy was ob-
A 57-year-old man had suffered from neck and radicular served, affecting the interosseous muscles digitorum IV and
pain on the right side for 1 week. Clinical evaluation of the V. Eighty percent hypesthesia of the left hypothenar was
patient revealed the following: also noted. The symptoms had developed over 10 weeks.
• Lower cervical syndrome on the right side
• Radicular pain at C7 on the right side A CT scan was performed because of the patient’s cardiac
• Hypesthesia in the forearm and hand according to the pacemaker: severe left-sided bony narrowing of the root
C7 distribution canal C7/T1 explained the clinical findings. The spinal canal
• Palsy of the right triceps muscle (class of evidence level III). was not clearly apparent (Fig 2.3-12a).
The MRI revealed a large paramedian/intraforaminal disc Microsurgical ACFor C7/T1 was performed (Fig 2.3-12b). The
herniation (Fig 2.3-11a). Because of the classical radicular radicular symptoms and findings disappeared after 6 weeks.
symptoms, an ACFor was planned. A persisting mild local neck pain due to postsurgical insta-
bility at the cervicothoracic junction (Fig 2.3-12c–d) was suc-
The patient underwent ACFor at C6/7, and following re- cessfully treated with infiltrations of the facet joints at C7/
moval of a soft-disc fragment (Fig 2.3-11b) recovered com- T1. Segmental fixation was unnecessary.
pletely within 6 weeks of surgery (Fig 2.3-11c–d).
a b c d
Fig 2.3-11a–d
a Preoperative axial MRI.
b Preoperative sagittal MRI revealing a posterolateral disc fragment at C6/7 encroaching on the right C7 nerve root.
c Postoperative axial MRI showing decompression of the right C7 nerve root. Arrows indicate the canal drilled through the
C7 vertebral body.
d Postoperative sagittal MRI showing decompression of the right C7 nerve root.

a b
Fig 2.3-12a–d
a Severe bony narrowing of the left side of the root canal at C7/T1.
b Adequate decompression was performed via ACFor. c d
c–d Complete resection of the uncinate process eventually led to
segmental instability, which was not treated surgically.
12 Key learning points • There is a steep learning curve, especially with the en-
doscope
• Appropriate patient selection is essential in obtaining a • The different approach techniques vary slightly. Dissec-
successful outcome regarding ACFor: the best indications tion of the vertebral artery is usually avoided
are monosegmental intraforaminal root compression • Anterior cervical foraminotomy should be considered
due to a soft-disc fragment, or a spondylotic spur whenever an implant-free technique is desired for an-
• Solid microsurgical experience with ACDF is required terior cervical intraforaminal root compression. Alterna-
before undertaking the ACFor approach. The endoscop- tive options, such as ACDF or posterior foraminotomy
ic technique should have been previously practiced ex- are not precluded by previous ACFor.
tensively at the lumbar level
13 References
1. Radhakrishnan K, Litchy W, O'Fallon 4. Snyder GM, Bernhardt M (1989) 7. Choi G, Lee SH, Bhanot A, et al
M, et al (1994) Epidemiology of Anterior cervical fractional interspace (2007) Modified transcorporeal
cervical radiculopathy. A population- decompression for treatment of cervical anterior cervical microforaminotomy
based study from Rochester, radiculopathy. A review of the first 66 for cervical radiculopathy: a technical
Minnesota, 1976 through 1990. Brain; cases. Clin Orthop Relat Res; 246:92–99. note and early results. Eur Spine J;
117(2):325–335. 5. Jho HD, Kim WK, Kim MH (2002) 16(9):1387–1393.
2. Henderson et al (1983) Posterior- Anterior microforaminotomy for 8. Cloward RB (1958) The anterior
lateral foraminotomy as an exclusive treatment of cervical radiculopathy: approach for removal of ruptured
operative technique for cervical part 1-disc-preserving “functional cervical discs. J Neurosurg;
radiculopathy: A review of 846 cervical disc surgery”. Neurosurgery; 15(6):602–614.
consecutively operated cases. 51(5):S46–53. 9. Matz PG, Holly LT, Groff MW, et al
Neurosurgery, 13 (5):540–550 6. Saringer W, Nöbauer I, Reddy M, et (2009) Indications for anterior cervical
3. Jho HD (1996) Microsurgical anterior al (2002) Microsurgical anterior decompression for the treatment of
cervical foraminotomy for cervical foraminotomy cervical degenerative radiculopathy.
radiculopathy: a new approach to (uncoforaminotomy) for unilateral Neurosurg Spine; 11(2):174–182.
cervical disc herniation. J Neurosurg; radiculopathy: clinical results of a new 10. Hacker RJ, Miller CG (2003) Failed
84(2):155–160. technique. Acta Neurochir; anterior cervical foraminotomy.
144(7):685–694. J Neurosurg; 98(2):126–130.
131

Matz PG, Holly LT, Groff MW, et al (2009) Indications Hacker RJ, Miller CG (2003) Failed anterior cervical
for anterior cervical decompression for the treatment of foraminotomy. J Neurosurg; 98(2 Suppl):126–130.
cervical degenerative radiculopathy. J Neurosurg Spine;
11:174–182. Study type Study design Class of evidence
Therapy Case series IV
Therapy Meta-analysis I–II Purpose
To examine cases of failure of anterior cervical forami-
Purpose notomy to determine the efficacy of the approach.
To identify the indications and utility of anterior cervical
nerve root decompression. P Patient Unilateral cervical radiculopathy due to degenerative
cervical disc disease (N = 23)
P Patient Cervical radiculopathy I Intervention Anterior cervical foraminotomy
I Intervention Anterior cervical discectomy (ACD), anterior cervical C Comparison No comparison group
foraminotomy
O Outcome Number of procedures, procedure type, interval between
C Comparison Anterior cervical discectomy with fusion (ACDF) index procedure and reoperation
O Outcome Clinical and functional results
Authors’ conclusion The reoperation rate is considerably higher than in most
Anterior cervical discectomy, ACDF, and anterior cervical series of anterior cervical surgery for radiculopathy. The
foraminotomy may improve cervical radicular symptoms. presumed benefit of anterior cervical foraminotomy is
preservation of the disc interspace, however, in this study,
a significant number of patients failed to experience a
Choi G, Lee SH, Bhanot A, et al (2007) Modified satisfying outcome. Currently the authors do not recom-
transcorporeal anterior cervical microforaminotomy for mend anterior cervical foraminotomy as a stand-alone
cervical radiculopathy: a technical note and early results. procedure.
Eur Spine J; 16(9):1387–1393.

Purpose
To evaluate early results of a functional disc surgery in
which decompression for the cervical radiculopathy is
done by drilling a hole in the upper vertebral body and
most of the disc tissue is preserved.
P Patient Cervical radiculopathy (N = 20)

I Intervention Modified transcorporeal anterior cervical microforamino-
tomy
C Comparison No comparison group
O Outcome Relief of symptoms, complications
Modified transcorporeal anterior cervical microforami-
notomy is an effective treatment for cervical radiculopa-
thy. It avoids unnecessary violation of the disc space and
much of the bony stabilizers of the cervical spine. Short-
term results are encouraging.

Jho HD, Kim WK, Kim MH (2002) Anterior Saringer W, Nöbauer I, Reddy M, et al (2002)
microforaminotomy for treatment of cervical Microsurgical anterior cervical foraminotomy
radiculopathy: part 1—disc-preserving "functional (uncoforaminotomy) for unilateral radiculopathy:
cervical disc surgery". Neurosurg; 51(5 Suppl):46–53. clinical results of a new technique. Acta Neurochir;
144(7):685–694.
Therapy Case series IV Study type Study design Class of evidence
Purpose
To report the surgical results of anterior cervical micro- Purpose
foraminotomy. To report the clinical application of a new microsurgical
technique.
P Patient Cervical radiculopathy (N = 104, n = 45 men, median age
46 years) P Patient Unilateral cervical radiculopathy (N = 34, n = 16 men, mean
I Intervention Anterior cervical microforaminotomy age 43.8 years)
C Comparison No comparison group I Intervention Anterior cervical foraminotomy (uncoforaminotomy)
O Outcome Surgical results, decompression, functional outcomes, C Comparison No comparison group

complications O Outcome Pain relief, motor weakness, sensory deficit, complications
Authors’ conclusion Authors’ conclusion

Anterior microforaminotomy provided good or excellent The results indicate that this new microsurgical technique
outcomes, with minimal morbidities for 98% of 104 pa- is an attractive treatment option for adequate anterior
tients with cervical discogenic radiculopathy. The func- decompression of the cervical nerve root via a minimized
tional anatomical features were well preserved for 99% approach. It was associated with excellent clinical outcome
of the patients. and a less painful postoperative course, allowing patients
an almost immediate return to unrestricted full activity.
133

Snyder GM, Bernhardt M (1989) Anterior cervical Jho HD (1996) Microsurgical anterior cervical
fractional interspace decompression for treatment of foraminotomy for radiculopathy: a new approach to
cervical radiculopathy. A review of the first 66 cases. Clin cervical disc herniation. J Neurosurg; 84(2):155–160.
Orthop Relat Res; (246):92–99.
Study type Study design Class of evidence Therapy Case report NA
Purpose
Purpose To describe a new microsurgical technique to accomplish
To report the results of the first 66 operations and describe direct nerve root decompression via an anterior approach
the surgical technique of anterior cervical fractional in- while preserving the functioning motion segment.
terspace decompression (ACFID).
P Patient Cervical radiculopathy (N =1, woman, age 44 years)
P Patient Cervical radiculopathy (N = 63 patients and 66 operations, I Intervention Microsurgical anterior foraminotomy
n = 33 men, only 55 patients were followed up)
I Intervention ACFID
O Outcome Range of motion, muscle strength, pain, x-rays
O Outcome Pain relief, work status, limitations of daily activities, Authors’ conclusion
complications The new technique accomplishes a direct resection of the
compressive lesion, that is, the soft disc fragment, the
spondylotic spur, or both.
ACFID is indicated for radiculopathy due to both soft and
hard discs and can be particularly valuable in treating
patients with disc herniation adjacent to a previous fusion
or radiculopathy with multiple-level myelographic filling
defects.

2.4 Posterior C1/2 transarticular screw fixation
Markus Richter
1 Historical perspective Anatomical and radiological studies of the atlantoaxial re-

gion have nevertheless suggested that in up to 20% of
A variety of techniques for atlantoaxial fixation using an- cases the safe placement of transarticular screws is not pos-
terior, bilateral, and posterior approaches have been de- sible, mostly because of a high-riding transverse foramen
scribed in the literature [1–8]. In recent years, several reports [16]. Alternative techniques such as a combination of C1
have been published on posterior wiring techniques and lateral mass screws with C2 pedicle screws [5] or C2 trans-
their subsequent modifications [9–15]. The differences be- laminar screws [6] have been described. The biomechanical
tween these wiring techniques mainly involve the number stability of these screw fixation techniques is nearly com-
of sublaminar wires used, wire placement, graft position, parable to that using transarticular screws in combination
and the shape of the bone graft; however, all of them are with an atlas claw [1, 7] but the C1 lateral mass screw can
associated with potential risks due to the use of wires. Fur- irritate the dorsal root ganglion at C2, and blood loss can
thermore, as the primary stability of wiring techniques tends be significant due to the proximity of the epidural venous
to be poor, a relatively long period of postoperative im- plexus and the C1/2 facet joint. Nevertheless, in situations
mobilization is necessary, and the rates of nonunion as well where a C1/2 transarticular screw cannot be safely placed,
as the loss of reduction are high [1]. Other techniques have these alternative techniques are extremely helpful.
been developed in an attempt to avoid these risks by using
clamp or claw constructs [2]. Although these methods do
not involve the same risks as those associated with wiring, 2 Terminology
the biomechanical stability is still not adequate. In 1987,
Magerl and Seemann [3] introduced a new technique using Minimally invasive atlantoaxial fixation with posterior C1/2
posterior transarticular screws through the C1/2 joint. Sev- transarticular screws constitutes a modification of well es-
eral studies subsequently showed that the biomechanical tablished, standard techniques and screw trajectories. Re-
stability provided by this technique was superior to that of duced morbidity is achieved by percutaneous computer-
various wire fixation methods [1]. However, although bio- assisted screw placement, which ensures a significantly
mechanical stability is high for axial rotation and lateral reduced incision length and less muscle trauma associated
bending, flexion/extension is not stabilized adequately. with this approach. Using an atlas claw in the case of fusion
Therefore, in the case of atlantoaxial fusion, the transar- further reduces operative time, donor-site problems and
ticular screws should be combined with posterior inter- potential complications, as neither sublaminar wiring nor
laminar stabilization to provide three-point fixation. structural bone grafts are needed [8]. The use of computer-
assisted surgery (CAS) for the placement of the transar-
The standard procedure for additional posterior interlaminar ticular screws allows for further reduction in size of the
stabilization is the Gallie technique, which combines cortical approach, and reduces the rate of screw misplacement
bone graft and sublaminar wiring. The clinical results using [17].
this combined three-point fixation are excellent, and increased
fusion rates have been reported [4]. However, the disadvan-
tage of this procedure is the need for a cortical bone graft, 3 Patient selection
and the risks associated with sublaminar wiring. This led to
the introduction of C1 arch clamps fixed to the transarticular In general, this technique can be used for all patients re
screws (atlas claw); and as a result of this new technology, quiring C1/2 stabilization: either for level C1/2 only, or in
to a decrease in the morbidity and risks involved: operative combination with fixation to the occiput or subaxial spine.
time, blood loss, and donor-site morbidity have been reduced, Indications for surgery include instabilities, degenerative
and even biomechanical stability has improved [1]. changes, or tumor involvement.
135

Author Markus Richter
3.1 Indications for posterior C1/2 transarticular 4.1 Pros

screw fixation • Small skin incision
The following more detailed indications should also be • Reduced muscle trauma
taken into consideration: • Reduced intraoperative and postoperative blood loss
• Rheumatoid instability at C1/2 (anteroposterior or/and • Shorter operative time
lateral instability) • Faster convalescence
• Rheumatoid instability at C0–2 with concomitant basi- • Absence of donor-site morbidity when the atlas claw
lar impression (fixation to the occiput in combination technique is used for three-point fixation
with C1/2 transarticular screws) • Provides the highest biomechanical stability of all C1/2
• Unstable os odontoideum/nonunion fixation techniques.
• Odontoid fracture (Anderson type II or III) in specific
cases, ie, poor bone quality, extensive comminution, 4.2 Cons
associated C1/2 intraarticular fracture, associated Jef- • Limited visualization of the target area
ferson fracture, marked kyphosis of the high thoracic • Learning curve.
region (anterior approach not possible), or unsuitable
fracture line for anterior odontoid screw fixation
• Unstable Jefferson fracture 5 Preoperative planning and patient positioning
• Unstable rotatory dislocation at C1/2 or recurrent rota-
tory dislocation at C1/2 following conservative therapy Clinical assessment including the determination of neuro-
with closed reduction and immobilization logical status should be carried out.
• Atlantooccipital dislocation
• Tumor involvement at C1/2 (metastasis or primary bone The following imaging studies are required:
tumor) with pathological fracture or imminent patho- • X-ray in AP and lateral projection, and transoral AP view
logical fracture, as well as compression of the myelon • Functional lateral x-ray in extension/flexion
• Congenital atlantoaxial instabilities • Functional AP x-ray with side-bending if lateral instabil-
• Osteoarthritis of the C1/2 facet joints. ity is suspected
• CT scan of occiput—C3 with multiplanar reconstruction
3.2 Contraindications for posterior C1/2 • MRI if compression of the myelon is suspected, or in the
transarticular screw fixation case of tumors.
The following contraindications should be taken into con-
sideration: Preoperative planning for screw placement is made on the
• Remote infections in the area of the surgical approach basis of the CT scan and multiplanar reconstruction in the
• Poor health, contraindicative to the use of general an- C1/2 transarticular screw axis, with determination of the
esthesia course of the vertebral artery and assessment of the angu-
• Variations in the course of the vertebral artery at C2 lation and length of the screws.
which render impossible the placement of C1/2 trans-
articular screws (”high-riding transverse foramen”). To On the day of surgery, the surgical area is shaved before
detect variations in the course of the vertebral artery, a the patient is taken to the operating room.
preoperative CT scan with multiplanar reconstruction
is mandatory. General endotracheal anesthesia with muscle relaxation is
mandatory. The patient is placed in a supine position, the
pin sites are disinfected and the Mayfield clamp is fixed to
4 Pros and cons of posterior C1/2 transarticular the occiput using the standard technique for positioning.
screw fixation The patient’s head may also be positioned in a mold with-
out sharp clamp fixation; but this option is not recommend-
After taking into consideration the above-described indica- ed, as the possibilities of reduction and fixation are limited
tions and contraindications, the majority of patients can be by the head mold. The patient is then turned so that he/she
treated by a minimally invasive technique when C1/2 fix- is lying in the prone position on a gel-filled mattress; the
ation is required. There are of course arguments for and thorax and pelvis are supported with foam pillows. The
against the use of the minimally invasive method, which arms are fixed at the side of the body with adhesive tapes,
have been summarized here. and their correct positioning is ensured by a pulley system
with 2.5 kg traction on each side (Fig 2.4-1).

If necessary, closed reduction can be performed under lat- 6 Surgical technique

eral x-ray control. The cervical spine should be in flexion
and the head inclined, if reduction can be maintained. The 6.1 Access
image intensifier should be permanently positioned in lat- After the patient has been prepared and draped, with the
eral view, and preoperatively, a straight metal instrument image intensifier in lateral view a midline incision is made
should be used to determine whether the planned screw from the posterior arch of C1 to the spinous process of C2.
trajectory is possible under x-ray control. Intraoperatively, The length of the incision depends on the patient’s weight—
AP views should also be obtained at least once. Therefore on average, the incision length is 4 cm. After subcutaneous
it is important at the preoperative stage that the surgeon preparation, a fascial incision is made in the midline, fol-
determines whether the AP view is possible; at this point, lowed by subperiosteal exposure of the posterior arch of C1
the image intensifier positioning for this AP view should be and the spinous process as well as the posterior arch of C2.
marked on the floor, so that it can easily be found again It is important to stay exactly in the midline in order to
during the operative procedure if the patient is draped. Care minimize blood loss and limit muscle trauma. The prepara-
should be taken to avoid the image intensifier inadver- tory steps can be performed using an electrocautery knife;
tently coming into contact with the Mayfield clamp during the use of an ultrasonic Harmonic scalpel helps to limit
the switch in positioning between the AP and lateral view. further blood loss and tissue trauma.
It is advantageous to perform the operation with two image
intensifiers, and thus obtain a biplanar x-ray view without 6.2 Microsurgical technique
having to reposition the single image intensifier (Fig 2.4-2). The method described for C1/2 fixation is a microsurgical
Antibiotic prophylaxis is administered once, 20–30 minutes procedure, with the advantage of reduced approach morbid-
prior to making the skin incision. ity as a result of the shorter incision length, percutaneous-
Fig 2.4-1 Patient placed in the prone position on a gel-filled mattress, Fig 2.4-2 Positioning of the two image intensifiers to provide a bipla-
with the thorax and pelvis supported by foam pillows. The arms are nar x-ray view, which avoids repositioning maneuvers. When only one
fixed at the sides of the body with adhesive tapes and their correct image intensifier is used, it is placed in the lateral position.
positioning is ensured by a pulley system with 2.5 kg traction on either
side.
137

assisted screw placement, and three-point fixation with an After exposure of the surgical field, the insertion point for
atlas claw. As the atlas-claw provides excellent three-point the trocar system is determined by holding the trocar lat-
fixation without sublaminar wiring and harvested cortical eral to the neck, and determining the correct screw direction
bone, the morbidity is reduced. Due to the small size of the via lateral x-ray view. A stab incision is then made, and the
approach, a head lamp is useful to ensure adequate illumina- trocar system is introduced percutaneously up to the screw
tion of the operative site. insertion point. If a closed reduction is not possible or is
insufficient, in most cases open reduction can be performed
6.3 Instrumentation by manipulating the C2 arch with a clamp. For most types
Before examining the various surgical steps involved, the of instability with anterior dislocation of C1 over C2, C2
trajectory and insertion point of the transarticular screws can be pushed anteriorly with the aid of a clamp to complete
should be described (Fig 2.4-3). The entry point for the C1/2 the reduction. In the case of posterior dislocation of C1 over
transarticular screw lies in a straight sagittal line in the C2, C2 can be pulled back with the clamp. After adequate
center of the isthmus (connection between the cranial and reduction has been carried out the trocar system is placed
caudal joint facet) at the inferior border of the caudal facet at the screw insertion point, and the correct positioning is
of C2, 2 mm cranial and lateral to the medial border. The checked by lateral x-ray. Then the K-wire or drill is placed
medial border of the isthmic part of C2 can be determined on the first side under lateral x-ray control. Care should be
via a dissector in the spinal canal lateral to the dura or taken to prevent the tip of the K-wire from penetrating the
through an AP x-ray view. The trajectory is aimed towards anterior cortical border. Following this, the procedure is
the cranial part of the anterior tubercle of C1; the exact repeated on the other side. After the bilateral placement of
screw direction should be planned preoperatively using CT the K-wires or drills, the correct positioning is checked by
scan with multiplanar reconstruction. biplanar x-ray. When this has been determined, self-drilling
screws are inserted over the K-wires through the cannular
For minimally invasive instrumentation, a cannular system system with the aid of a screwdriver, then the K-wires are
for percutaneous-assisted screw placement is needed. Oth- removed. If noncannulated screws are used, the drill is re-
erwise, because of the recommended screw angulation, the moved on one side before placing the first screw through
approach would not be 4 cm, but 20 cm for open screw the trocar system. Then the other screw is placed, again
placement. Several cannulated systems are available: either following K-wire removal. With noncannulated screws, the
with cannulated screws which are placed over the K-wires, surgeon must ensure that there is no movement between
or noncannulated screws which are placed after preparing C1 and C2 after drill removal, especially in the case of high-
the screw hole with a drill. grade instabilities. After placement of both screws, x-rays
in AP and lateral projection must be taken to document the
correct screw position.
a b c
Fig 2.4-3a–c C1/2 transarticular screw positioning according to the Magerl classification;
the entry point and screw trajectory are shown in 3-D orientation.

For three-point fixation using the minimally invasive tech- 6.4 Navigation
nique, atlas claws which are fixed to the posterior arch of C1/2 transarticular screws can be placed with sufficient ac-
C1 are connected to the C1/2 transarticular screws (Fig 2.4‑4). curacy using the above-described minimally invasive tech-
For the fusion procedure the posterior arches of C1 and C2 nique. Nevertheless, potential risks still remain regarding
are decorticated, and bone substitute is placed in an onlay iatrogenic damage to the vertebral artery or the spinal cord
technique. Cancellous bone from the posterior iliac crest due to screw misplacement. Furthermore, the C1 lateral
can also be used, but with this method the risk of morbid- mass should be correctly fixed to ensure sufficient biome-
ity is increased. chanical stability.
If the implant system in question does not include the pos- In 1993, following reports of misplacement rates amount-
sibility of atlas claw fixation, a Gallie procedure should be ing to between 5% and 40% using conventional techniques,
performed with sublaminar wires at C1 and a cortical bone CAS using navigation systems was first introduced for the
graft harvested from the posterior iliac crest. Three-point insertion of pedicle screws in the lumbar spine. In vitro
fixation is strongly recommended because if this technique studies showed that misplacement rates for lumbar pedicle
is not performed the risk of nonunion as well as implant screws could be significantly reduced using CAS systems,
failure is increased considerably. and in vivo studies subsequently confirmed these results.
As in vitro as well as in vivo studies have shown that cervi-
Wound closure is carried out over a subfascial drain. Skin cal pedicle screws and C1/2 transarticular screws can be
closure should be performed with interrupted sutures. The safely placed using CAS [5, 18, 19], this system will be brief-
cannulas are removed after closure of the midline incision, ly described below, although computer-assisted navigation
following which the stab incisions are closed with subcu- is not mandatory for the placement of C1/2 transarticular
taneous suture and skin suture. screws.
After turning the patient back to the supine position, the The CAS system is positioned on the right side, in front of
Mayfield clamp is removed, and sterile draping of the pin the patient’s head once the posterior aspect of the spine has
sites should be performed. been approached. The monitor with touchscreen is posi-
tioned in such a way that the surgeon has a good view of
the operative field and can easily reach the draped touch-
screen. To ensure a good line of sight, the camera is posi-
tioned on the left side of the patient’s head for C1/2 trans
articular screw placement. The surgeon also stands on the
left side of the patient for this operative procedure.
After the posterior approach has been performed, the refer-

ence clamp is fixed to the spinous process of C2 (Fig 2.4-5).
Next, vertebral registration takes place using a surface-
matching algorithm, where a predicted accuracy < 1.0 mm
is acceptable. If the predicted accuracy is > 1.0 mm, the
registration procedure should be repeated until an accu-
racy of < 1.0 mm is achieved. After vertebral registration,
the virtual reality provided by the CAS system has to be
checked to see whether it corresponds to the surgical real-
ity. The pointer is used to indicate points on the posterior
surface of the vertebra which are easy to find and clearly
identifiable, then the pointer position displayed on the CAS
Fig 2.4-4 Completed instrumentation with C1/2 transarticular
screws and atlas claws for three-point fixation.
system screen is compared with the elements on the op-
erative site. If this verification is found to be accurate,
navigated instrumentation can begin. However, if any inac-
curacy is found, the whole registration procedure must be
repeated.
139

The navigation system can be used to find the ideal position When K-wires are used, the CAS system can only visualize
for the stab incision for percutaneous-assisted screw place- the trajectory of the K-wire but not the K-wire itself due
ment. Therefore, the pointer with an offset of 8–10 cm is to the bending of the latter. Therefore, an image intensi-
used to identify the optimal position for the stab incision fier in lateral projection should be used to check the position
(Fig 2.4-6). Once the stab incision has been made, the cali- of the K-wire. Because only one surgical object at a time
brated trocar system is introduced. can be navigated, the instruments can only be navigated in
C2 when using the CAS system; and therefore the image
intensifier is also needed to check the K-wire/drill position
in C1 (Fig 2.4-7).
Fig 2.4-5 Intraoperative setup for computer-assisted screw placement. Fig 2.4-6 Intraoperative screenshot of the navigation system, while
After the posterior approach has been completed, the reference clamp the correct position of the stab incision for the percutaneous screw
is fixed to the spinous process of C2, and the navigation system is placement is determined using the pointer with offset setting.
placed at the patient’s head.
Fig 2.4-7 Intraoperative screenshot of the navigation system showing

the various steps in the percutaneous placement of one K-wire using
the precalibrated and preoperatively checked trocar system.

7 Postoperative care The placement of a transarticular screw in a patient with a

“high-riding transverse foramen” can result in injury to the
Due to the excellent biomechanical stability afforded by the vertebral artery. It is therefore of utmost importance to iden-
C1/2 transarticular screws in combination with three-point tify these anatomical abnormalities at the preoperative stage:
fixation, no postoperative collar is needed. However, if a preoperative CT scan of the craniocervical junction with
three-point fixation is not performed, postoperative im- multiplanar reconstruction in the proposed screw axis is
mobilization with a cervical collar is required for 6 weeks. mandatory. The course of the vertebral artery can usually
The drain can be removed 2 days postoperatively and the be identified, as the vertebral groove is clearly apparent on
skin sutures are removed 14 days after surgery. X-ray con- the CT scan (Fig 2.4-8). If there are any doubts regarding the
trols are recommended before discharge from hospital, and course of the vertebral artery, an angio-CT scan or angio-
again 3 and 12 months after surgery. MRI should be performed. In patients with a vertebral artery
abnormality where transarticular screws cannot be placed
safely either on one or both sides (Fig 2.4-8), alternative sta-
8 Evidence-based results bilization methods should be used. If C2 pedicle screw inser-
tion is possible, this screw can be combined with a C1 lat-
Posterior C1/2 transarticular screw fixation provides im- eral mass screw [5]. In certain cases of severe vertebral artery
mediate atlantoaxial stabilization, with excellent long-term abnormality, the placement of a C2 pedicle screw is also not
fusion rates being documented [2–4, 8]. Reported complica- possible, and under these circumstances a translaminar screw
tions associated with this procedure include vertebral artery should be used. This screw crosses the posterior lamina to
injury, dural tears, hypoglossal nerve paresis, suboccipital the opposite side, and can be placed in all cases [8].
numbness due to C2 root injury, wound infection, and screw
misplacement [2–4, 8, 16, 17, 20–22]. Injury to the vertebral In a patient with suitable anatomy as determined by pre-
artery, which has been reported in approximately 2–4% of operative CT scan, the misplacement of a C1/2 transarticu-
cases, may lead to the development of arteriovenous fis- lar screw can also cause injury to the vertebral artery, es-
tula, or to occlusion, narrowing, or dissection of the verte- pecially if the screw angle is too acute in relation to the
bral artery; injured tissue may remain asymptomatic, or endplate of C2. In the case of an injury to the vertebral
could result in transient ischemic attacks, stroke, or even artery on one side, the screw on that side should neverthe-
death [17, 21, 22]. The best strategy for reducing the risk of less be inserted to stop the bleeding. Repair of the vertebral
vertebral artery injury is to ensure thorough preoperative artery in this location is not possible. If the vertebral artery
planning including CT scan, and the exclusion of patients has been injured on the side of the first screw, a type of
with vertebral artery abnormalities which make them un- screw should be chosen for the other side which makes
suitable candidates for the placement of transarticular screws injury to the vertebral artery on the other side impossible.
on one or both sides [16]. The risk of vertebral artery injury The safest type of screw that can be used in this situation
due to screw misplacement can be further limited by com- is a translaminar crossing screw, as described above.
puter-assisted navigation for the screw placement procedure
[17, 18]. In a case series of 21 patients, 42 transarticular screws
were placed using the above system, without any injury to
the vertebral artery being observed. Postoperative x-ray
control showed the correct placement of all the screws [8].
9 Complications and avoidance
The main complications involved in posterior instrumenta-

tion with C1/2 transarticular screws are related to the mis-
placement of one or both screws, or to the placement of a b
screws in a patient whose anatomy is unsuitable for C1/2 Fig 2.4-8a–b Preoperative CT scans showing reconstruction in the
transarticular screws. In the latter case, the most frequent- screw axis.
a Vertebral artery abnormality known as a “high-riding transverse
ly encountered reason is the abnormal course of the verte-
foramen”.
bral artery in C2, otherwise known as the “high-riding b Virtual image showing how faulty C1/2 transarticular screw
transverse foramen”. placement could cause injury to the vertebral artery.
141

The misplacement of a transarticular screw can also result To identify a wrong entry point or incorrect screw trajec-
in impaired biomechanical stability if the C1 lateral mass is tory, AP and lateral x-ray control should be performed as
not properly fixed with this screw. This tends to occur if the early as possible after placement of either K-wires or drills.
screw angle is too acute; more rarely, the reason is that the If wrong placement is evident, the drill or K-wire position
screw has been placed too laterally or too medially. can be changed before screw insertion.
Correct patient positioning is an extremely important factor Another approach-related complication is that of injury to
in preventing screw misplacement. In older patients with the vertebral artery during dissection of the posterior arch
high thoracic kyphosis, positioning can be especially difficult. of C1. To avoid any possible damage, dissection should not
It is helpful to check positioning via a lateral image intensi- be carried out more than 16 mm lateral to the midline on
fier view, with a straight instrument held laterally to the both sides.
patient to determine whether the optimal screw angulation
is possible. If it is not possible, the positioning of the patient Other possible complications include those typically associ-
should be changed until the required screw angulation can ated with spine stabilization, such as wound healing prob-
be achieved. Normally a higher foam pillow placed under lems or infection. However, with the minimally invasive
the patient’s chest allows for a more pronounced inclination approach, these complications occur less frequently com-
of the cervical spine. pared to traditional approaches. In the case of wound heal-
ing complications, early revision with debridement and
However, if patient positioning is correct and not the reason possibly vacuum suction may help to avoid deep infection.
for screw misplacement, other possible reasons include In the event of deep infection at the implant site, early
wrong entry point or incorrect screw trajectory. To avoid revision is also beneficial. Implant removal is not necessary,
screw misplacement, a thorough knowledge of the three- but the use of local antibiotics, such as septopal chains, is
dimensional anatomy of C1/2 is essential. recommended.
10 Tips and tricks
Volker Sonntag, Phoenix, USA • If the first transarticular screw injures the • An Allis clamp on the spinous process of
• Unlike the Goel/Harms technique, where vertebral artery, that screw should be left C2 can be used to provide direct upward
transarticular screws are placed between in place but a second screw should not traction of C2, in order to align C1 and
C1 and C2, with the C1/2 transarticular be inserted on the opposite side, possibly C2.
screw fixation technique C1 and C2 have with the exception of a laminar screw. • Good clinical results can be achieved even
to be reduced either before surgery or • If the vertebral artery is injured intra- if only one screw can be placed when
intraoperatively [3]. operatively, angiography should be complemented by a midline bone graft
• Most surgeons would place these C1 performed to rule out the presence of a with wire [25].
screws 10–25° medially, but detailed CT fistula or a pseudoaneurysm, which could • Bicortical purchase of the transarticular
scan analysis will determine the medial be treated by endovascular techniques. screw is desirable, but not necessary.
orientation of the C1 lateral mass [23]. • The most common reason for failed fixa- • Transarticular screws that are too long
• Crossing C2 translaminar screws is not tion of the C1 lateral mass when using a could injure the hypoglossal nerve, in-
always possible, eg, when the lamina has transarticular technique is that the screw ternal carotid artery, or both.
been damaged or if it is too thin to ac- has been placed inferiorly to the lateral • If C1/2 wiring cannot be achieved be-
commodate screws. mass. cause the C1/2 lamina is absent or frac-
• For the transarticular techniques, if the • The configuration of the anterior arch tured, the C1/2 facet should be decorti-
length of the screw is not measured, it of C1 can vary; consequently, the length cated, followed by the placement of bone
should be recalled that the appropriate of the transarticular screw needs to be chips.
length for an adult patient is about 40 tailored accordingly [23].
mm [24].

11 Case examples Diagnostic infiltration of the C1/2 joint under local anes-
thesia resulted in complete but temporary pain relief. As
11.1 Case 1 conservative treatment failed to provide long-term pain
An 85-year-old woman presented with progressive cervical relief. and after obtaining the patient’s informed consent,
pain radiating to the mandibular region on the right side, it was decided to carry out open reduction followed by pos-
accompanied by increasing pain on head rotation. The AP terior C1/2 instrumented fusion with C1/2 transarticular
x-ray showed subluxation at C1/2 with C1/2 rheumatoid screws placed via a computer-assisted technique, combined
arthritis on the right side and malrotation of C1 versus with atlas claw fixation and bone substitute to achieve fu-
C2 (Fig 2.4-9a). The CT scan confirmed significant C1/2 sion (Fig 2.4-9c–g). Postoperatively, the pain was reported
rheumatoid arthritis on the right side with joint subluxation as being significantly reduced.
and complete destruction of the joint space (Fig 2.4-9b).
a b c
d e
Fig 2.4-9a–g Case 1: an 85-year-old woman presented with progressive
cervical pain radiating to the mandibular region on the right side, accompa-
nied by increasing pain on head rotation.
a AP x-ray of the cervical spine.
b Preoperative CT scan with frontal plane reconstruction showing
subluxation and facet joint destruction.
c Intraoperative lateral x-ray view showing placement of the second K-wire.
d Navigation screen showing the various steps involved in determining
the correct position of the stab incision and trocar placement.
e Navigation screen showing the various steps involved in planning
screw and K-wire placement.
f g
f Intraoperative AP x-ray for determining the correct placement of both
K-wires.
g Postoperative x-ray, lateral view.
143

11.2 Case 2 12 Key learning points

A 69-year-old woman presented with progressive C1/2 AP
instability due to rheumatoid arthritis. The AP x-ray in in- • Posterior C1/2 transarticular screws in combination with
clination showed a pathologically increased atlantodental posterior three-point fixation allows for stable C1/2
distance at C1/2 of 12 mm (Fig 2.4-10a). The CT scan con- fixation and optimal biomechanical stability compared
firmed AP instability even in a neutral position, and ac- to all other techniques
companying spinal canal stenosis (Fig 2.4-10b). Due to the • The use of atlas claws fixed to the C1/2 transarticular
progressive instability which had been documented by x-ray screws for three-point fixation reduces the overall risk
over a 2-year period and the persistence of neck pain, after and morbidity, as C1 sublaminar wires and cortical bone
obtaining the patient’s informed consent, open reduction grafts are not needed
was carried out followed by posterior C1/2 instrumented • Percutaneous-assisted screw placement in combination
fusion performed with C1/2 transarticular screws, placed with a small midline incision reduces approach-related
via a percutaneous-assisted technique, combined with morbidity and facilitates correct screw placement
atlas claw fixation and bone substitute to achieve fusion • Computer-assisted navigation is not mandatory for screw
(Fig 2.4‑10c–d). placement, but helps to reduce the risk of screw mis-
placement.
a b
c d
Fig 2.4-10a–d A 69-year-old woman presented with progressive C1/2
AP instability due to rheumatoid arthritis.
a Lateral x-ray of the cervical spine in functional inclination, showing
AP instability with a pathological anterior atlantodental distance of
12 mm.
b Preoperative CT reconstruction in sagittal plane showing AP instability.
c Postoperative lateral x-ray control.
d Postoperative AP x-ray control.

13 References
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(2002) Posterior atlantoaxial fixation: Techniques of subaxial posterior al (1995) Computer-assisted pedicle
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27(16):1724–1732. 11. Coe JD, Warden KE, Sutterlin CE 3rd, 20. Stillerman CB, Wilson JA (1993)
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Surg Br; 66(3):422–425. in a human cadaveric model. Spine; technical description and report of 22
3. Magerl F, Seemann PS (1987) Stable 14(10):1122–1231. cases. Neurosurgery; 32(6):948–954;
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Weidner A (eds), Cervical Spine Vol. 1. arthrodesis. Indications, technic and Vertebral artery injury in C1-2
Vienna New York: Springer-Verlag, results. Clin Orthop Relat Res; transarticular screw fixation: results of
322–327. 65:118–129. a survey of the AANS/CNS section on
4. Grob D, Jeanneret B, Aebi M, et al 13. Grob D, Dvorak J, Gschwend N, et al disorders of the spine and peripheral
(1991) Atlanto-axial fusion with (1990) Posterior occipito-cervical nerves. American Association of
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Joint Surg Br; 73(6):972–976. Orthop Trauma Surg; 110(1):38–44. Neurological Surgeons. J Neurosurg;
5. Goel A, Laheri V (1994) Plate and 14. Hamblen DL (1967) Occipito-cervical 88(4):634–640.
screw fixation for atlanto-axial fusion. Indications, technique and 22. Prabhu VC, France JC, Voelker JL, et
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129(1–2):47–53. 49(1):33–45. pseudoaneurysm complicating
6. Wright NM (2004) Posterior C2 15. Lipscomb PR (1957) Cervico-occipital posterior C1-2 transarticular screw
fixation using bilateral, crossing C2 fusion for congenital and post- fixation: case report. Surg Neurol;
laminar screws: case series and traumatic anomalies of the atlas 55(1):29–33; discussion 33–34.
technical note. J Spinal Disord Tech; and axis. J Bone Joint Surg; 23. Wait SD, Ponce FA, Colle KO, et al
17(2):158–162. 39-A(6):1289–1301. (2009) Importance of the C1 anterior
7. Melcher RP, Puttlitz CM, Kleinstueck 16. Paramore CG, Dickman CA, Sonntag tubercle depth and lateral mass
FS et al (2002) Biomechanical testing VK (1996) The anatomical suitability of geometry when placing C1 lateral mass
of posterior atlantoaxial fixation the C1-C2 complex for transarticular screws. Neurosurgery; 65(5):952–956;
techniques. Spine; 27(22): 2435–2440. screw fixation. J Neurosurg; discussion 956–957.
8. Richter M (2003) Posterior 85(2):221–224. 24. Dickman CA, Sonntag VK (1998)
instrumentation of the cervical spine 17. Weidner A, Wähler M, Chiu ST, et al Posterior C1-C2 transarticular screw
for instability. Using the “neon (2000) Modification of C1-C2 fixation for atlantoaxial arthrodesis.
occipito-cervical system”. Part 1: transarticular screw fixation by Neurosurgery; 43(2):275–280; discussion
Atlanto-axial instrumentation. Operat image-guided surgery. Spine; 280–281.
Orthop Traumatol; 15: 70–89. 25(20):2668–2674. 25. Song GS, Theodore N, Dickman CA,
9. Zygmunt SC, Ljunggren B, Alund M, 18. Richter M, Mattes T, Cakir B (2004) et al (1997) Unilateral posterior
et al (1988) Realignment and surgical Computer-assisted posterior atlantoaxial transarticular screw
fixation of atlanto-axial and subaxial instrumentation of the cervical and fixation. J Neurosurg; 87(6):851–855.
dislocations in rheumatoid arthritis cervico-thoracic spine. Eur Spine J;
(RA) patients. Acta Neurochir Suppl 13(1):50–59.
(Wien) 43:79–84.
145

Melcher RP, Puttlitz CM, Kleinstueck FS, et al (2002) Richter M, Schmidt R, Claes L, et al (2002) Posterior
Biomechanical testing of posterior atlantoaxial fixation atlantoaxial fixation: biomechanical in vitro comparison
techniques. Spine; 27(22):2435–2440. of six different techniques. Spine; 27(16):1724–1732.
Biomechanical test In vitro comparison N/A Biomechanical test In vitro comparison N/A
Purpose Purpose
To investigate and compare the acute stability afforded To evaluate the immediate three-dimensional stability of
by a novel rod-based construct that uses direct polyaxial a new atlas claw combined with transarticular screws and
screw fixation to C1 and C2 with contemporary transar- alternative techniques for transarticular screw fixation
ticular screw-wire techniques. in comparison with established techniques.
P Patient Fresh-frozen human anatomical cervical spine specimens P Patient Human anatomical cervical specimen (N = 6)
with occiput (C0–4) (N = 10)
I Intervention Transarticular screws and a new atlas claw (n = 1)
I Intervention Polyaxial screw-rod construct (n = 5)
C Comparison Gallie fixation (n = 1), transarticular screws and Gallie
C Comparison Bilateral C1–2 transarticular screws with Gallie wiring (n = 5) fixation (n = 1), transarticular screws (n = 1), isthmic screws
in the axis and the atlas claws (n = 1), and lateral mass
O Outcome Range of motion under moment loading
screws in the atlas and isthmic screws in the axis connected
with rods (n = 1)
O Outcome Stability after nondestructive loading with pure moments
The results clearly indicate the screw-rod system's equiv-
alence in reducing relative atlantoaxial motion in a se- Authors’ conclusion
verely destabilized upper cervical spine, as compared with Biomechanically, the three-point fixation with transar-
the transarticular screw-wiring construct. These findings ticular screws and the atlas claw provides a rigid internal
mirror the previously reported clinical results attained fixation that is not dependent on bone graft and sub-
using this new screw-rod construct. Thus, the decision to laminar wiring. In cases wherein transarticular screws
use either screw construct should be based on safety con- are not feasible, the isthmic screws and claw or the lat-
siderations rather than acute stability. eral mass screws and isthmic screws are biomechanical
alternatives with less immediate stability.

Weidner A, Wähler M, Chiu ST, et al (2000) Grob D, Jeanneret B, Aebi M, et al (1991) Atlanto-
Modification of C1/2 transarticular screw fixation by axial fusion with transarticular screw fixation. J Bone
image-guided surgery. Spine; 25(20):2668–2674. Joint Surg Br; 73(6):972–976.
Therapy Prospective cohort study with II–III Therapy Case series IV
historical control group
Purpose
Purpose
To evaluate the results and complications of transarticu-
To evaluate the potential benefits and disadvantages of
lar screw fixation with posterior atlantoaxial fusion.
image-guided surgery for C1/2 screw placement.
P Patient Various indications for posterior fusion of the upper cervi-
P Patient Rheumatoid arthritis, os odontoideum, pseudarthrosis, and cal spine (N = 161, n = 100 men, mean age 49.7 years)
arthrosis (N = 115)
I Intervention Transarticular screw fixation with posterior atlantoaxial
I Intervention Image-guided surgery for C1/2 transarticular screw fixation fusion
(n = 37, mean age 51.7 years)
C Comparison Intraoperative image intensifier guidance for C1/2 transarti-
cular screw fixation (n = 78, mean 56.6 years) O Outcome Pain, functional outcome, complications
O Outcome Screw position, surgical time, complications, atlantodental
interval Authors’ conclusion
Transarticular screw fixation of the atlantoaxial joints,
Authors’ conclusion with posterior bone grafting, provides good fixation and
Image-guided surgery is an effective tool for the achieve- has proved successful even in cases in which the laminae
ment of correct screw placement in C1/2 transarticular are deficient. In a large series of operations performed by
screw fixation procedures. The procedure remains tech- several surgeons, the vertebral artery and the spinal cord
nically demanding. were never injured.
147

Paramore CG, Dickman CA, Sonntag VK (1996) The Harms J, Melcher RP (2001) Posterior C1/2 fusion with
anatomical suitability of the C1/2 complex for polyaxial screw and rod fixation. Spine; 26(22):2467–
transarticular screw fixation. J Neurosurg; 85(2):221–224. 2471.
Therapy Case series IV Therapy Case series IV
Purpose Purpose
To review CT scans and to evaluate the suitability of each To describe the technique and the initial clinical and x-ray
patient for transarticular screw fixation of the atlanto- results for posterior C1/2 fixation with a new implant
axial joint. system.
P Patient Cervical trauma (N = 94, n = 71 men, mean age 35.7 years, P Patient Dens fractures, symptomatic os odontoideum, rheumatoid
range 6–94 years) arthritis, rotatory subluxation, osteoarthritis C1/2, congeni-
tal malformation (N = 37, n = 27 available for reassessment,
I Intervention 1 mm fine-slice C1/2 CT scans
average age 49 years, range 2–90 years)
C Comparison No comparison group Intervention Posterior C1/2 fusion with polyaxial screw and rod fixation
I
O Outcome Screw trajectory reconstruction, suitability of C1/2 joint to Comparison No comparison group
C
receive a transarticular screw
O Outcome Complications, screw placement, reduction
On the basis of these data, it is postulated that approxi- Authors’ conclusion
mately 20% of the patients may not be suitable for pos- Fixation of the atlantoaxial complex using polyaxial-head
terior C1/2 transarticular screw fixation on at least one screws and rods seems to be a reliable technique and
side. should be considered an efficient alternative to the previ-
ously reported techniques.

Wright NM (2004) Posterior C2 fixation using bilateral, Richter M (2003) Posterior instrumentation of the
crossing C2 laminar screws: case series and technical cervical spine for instability. Using the “neon occipito-
note. J Spinal Disord Tech; 17(2):158–162. cervical system”. Part 1: Atlanto-axial instrumentation.
Operat Orthop Traumatol; 15:70–89.
Purpose
To describe the novel use of bilateral, crossing C2 laminar Purpose
screws to effect C2 fixation and to review the results in To achieve an atlantooccipital arthrodesis through pos-
a series of 10 patients. terior instrumentation of the cervical spine.
P Patient Cervical disorders (trauma, neoplasm, pseudarthrosis, and P Patient Rheumatoid instability, dens fractures, unstable dens
degenerative disease) (N = 10, average age 49.5 years) pseudarthroses, rupture of alar ligament, reoccurring
rotational dislocation, neoplastic instability, or congenital
I Intervention C2 rigid screw fixation using bilateral, crossing C2 laminar
malformation (N = 24)
screws
I Intervention Dorsal instrumentation and atlantoaxial fusion using the
neon system
O Outcome Complications, reduction, hardware position Comparison No comparison group
C
O Outcome Complications, fusion
The author believes that C2 fixation utilizing bilateral, Authors’ conclusion
crossing C2 laminar screws represents an advantage to In all patients where a bone consolidation was seen, no
prior reported techniques of C2 fixation due to the elim- implant failure occurred, and neither removal of implant
ination of the risk to the vertebral artery during C2 screw nor revision surgery was necessary.
placement. This technique is simpler, is not limited by
the position of the vertebral artery in the body of C2, and
may be applicable to a wider number of patients.
149

Richter M, Mattes T, Cakir B (2004) Computer-assisted Wright NM, Lauryssen C (1998) Vertebral artery injury
posterior instrumentation of the cervical and cervico- in C1/2 transarticular screw fixation: results of a survey
thoracic spine. Eur Spine J; 13(1):50–59. of the AANS/CNS section on disorders of the spine and
peripheral nerves. American Association of Neurological
Study type Study design Class of evidence Surgeons/Congress of Neurological Surgeons.
Therapy Case series IV J Neurosurg; 88(4):634–640.
Purpose Study type Study design Class of evidence

To evaluate whether C1/2 transarticular screws and trans- Therapy Case series IV
pedicular screws can be applied safely and with high ac-
curacy in the cervical spine and the cervicothoracic junc- Purpose
tion using a CAS system. To quantitate the risk of vertebral artery (VA) injury dur-
ing C1–2 transarticular screw placement.
P Patient Various diseases requiring posterior instrumentation of the
spine (N = 19) (N = 64 screws) P Patient Any patient treated with transarticular screws (N = 1318)
I Intervention Posterior instrumentation of the occipitocervical, cervical, (N = 2492 screws)
and cervicothoracic spine using CAS system I Intervention C1/2 transarticular screw fixation
C Comparison No comparison group C Comparison No comparison group
O Outcome Screw position, complications, surgery time, blood loss, O Outcome VA injury, complications
screw revision

C1/2 transarticular screws, as well as transpedicular screws Including both known and suspected cases, the risk of
in the cervical spine and the cervicothoracic junction, can VA injury was 4.1% per patient or 2.2% per screw in-
be applied safely and with high accuracy using a CAS serted. The risk of neurological deficit from VA injury was
system. Computer-assisted instrumentation is recom- 0.2% per patient or 0.1% per screw, and the mortality
mended especially for pedicle screws at C3–6. rate was 0.1%. The risk of subsequent neurological defi-
cit from iatrogenic VA injury is small.

2.5 Anterior C1/2 surgery
Yaron A Moshel, Vijay K Anand, Theodore H Schwartz
1 Historical perspective 1.3 Endoscopic endonasal approach

The endoscopic endonasal approach (EEA) to the ventral
A variety of surgical approaches to the craniovertebral junc- CVJ offers an alternative to the traditional transoral, retro-
tion (CVJ) outlined below have evolved over the years and pharyngeal upper cervical, and lateral skull-base approach-
continue to develop with the introduction of new tech- es to the CVJ. With the introduction of endoscopic technol-
nologies. Anterior approaches to the CVJ have recently ogy, the field of endoscopic endonasal skull-base surgery
undergone significant evolution with the introduction of has rapidly developed over the past several years. The EEA
less invasive open microsurgical techniques using the op- allows for improved exposure of the clivus without the need
erating microscope and minimally invasive endoscopic for a hard- or soft-palate incision and is minimally disrup-
technology [1–4]. tive to the oropharynx, leading to more rapid extubation,
feeding, and mobilization [6].
1.1 Transoral approach
Kanavel [5] first described a transoral approach to the CVJ The EEA can be utilized to address pathologies along the
for removing a bullet that was lodged between the foramen entire rostrocaudal extent of the clivus and ventral foramen
magnum and C1. The transoral (transpharyngeal) approach magnum, and upper cervical spine [1–3]. Pathologies such
has been most commonly used to resect the dens in the as degenerative basilar invagination, odontoid fractures,
treatment of basilar invagination secondary to rheumatoid RA with pannus or craniocervical settling, metastatic lesions,
arthritis (RA), congenital abnormalities of the skull base, chordomas and chondrosarcomas can be addressed with
axis, and extradural tumors [6, 7]. Most neurosurgeons are this approach [8]. The dura can also be opened to remove
familiar with this approach; it is technically straightforward intradural lesions, such as foramen magnum and clival me-
with a short operative time, and has been refined over the ningiomas, epidermoid tumors, and neurenteric cysts. With
years by a number of surgeons [6, 7]. new multilayered closure techniques that also incorporate
a vascularized mucosal flap, the cerebrospinal fluid (CSF)
The transoral approach can be performed with a palatal leakage rate for intradural lesions has been reduced to
incision and can be extended to include splitting of the soft < 5% [9].
and hard palate to expose C1 and the anterior margin of
the foramen magnum and odontoid process. The exposure 1.4 Endoscopic transcervical approach
afforded by the transoral approach can be further extended Another endoscopically-assisted approach to the ventral
rostrally with an open-door maxillotomy, which provides craniocervical junction is the endoscopic transcervical odon-
additional access to the sphenoid and clivus, or caudally via toidectomy (ETO). This approach provides access to the
a median transmandibular and transglottic approach, which base of C2 through a standard cervical (Cloward) approach.
provides exposure down to C3 and C4. A beveled tubular retractor is used which provides protec-
tion for the surrounding tissues and vascular structures,
1.2 Retropharyngeal upper cervical approach and a working corridor that places minimal retraction on
The retropharyngeal upper cervical approach is an alternative adjacent structures. Combined with an endoscope, this ap-
to the transoral and endonasal approaches to the ventral proach allows excellent visualization of the ventral cranio-
CVJ. It can provide exposure of the anterior aspect of the cervical junction through a sterile corridor that avoids tra-
foramen magnum and C1–4 without traversing the nonster- versing the oral or nasopharyngeal cavities. This technique
ile mucosal surfaces of the oropharynx. Although most sur- can provide exposure from the distal clivus through the
geons are not familiar with this approach, it can be performed entire cervical spine. Pathologies, such as degenerative
once the fascial anatomy and course of the traversing nerves basilar invagination, odontoid fractures, RA with pannus
are understood. It is a rostral modification of the otherwise or craniocervical settling, and some tumors have been
well-known anterior cervical approach to the spine. treated with this technique [4].
151

Authors Yaron A Moshel, Vijay K Anand, Theodore H Schwartz
1.5 Lateral skull-base approaches of approach with limited inferior visibility when using
The transcondylar and transatlas approaches to the CVJ the operating microscope and the transoral approach
were introduced for resection of the odontoid as an alterna- • Pathologies that extend more than 1.5–2 cm lateral to
tive to the transoral approach. By approaching the CVJ the midline may be difficult to access
through a lateral route they enable operative decompression • The transoral approach may limit access to the rostral
of the CVJ in a sterile field and allow for simultaneous aspect of the clivus and CVJ.
unilateral occipitocervical fusion. As this chapter focuses
on the anterior corridors to C1/2, the transcondylar and 3.2 Retropharyngeal upper cervical approach
transatlas approaches to the CVJ are beyond its scope—but
are nevertheless mentioned for completeness. 3.2.1 Indications
• Degenerative basilar invagination, odontoid fractures
with irreducible subluxation and ventral spinal cord
2 Terminology compression, RA with pannus or craniocervical settling,
and anterior foramen magnum lesions.
Minimally invasive endoscopically-assisted surgery refers
to the use of an endoscope to improve the visualization of 3.2.2 Contraindications
deep-lying anatomy. Endoscope-assisted transoral surgery • Pathologies with significant extension rostral to the pha-
was initially developed as an alternative to standard micro- ryngeal tubercle—which is the superior limit of the ex-
surgical techniques for transoral approaches to the ante- posure and is situated at the ventral surface of the clivus
rior CVJ. Visualization with endoscopically-assisted surgery • Prior anterior cervical surgery with recurrent laryngeal
can provide superior results compared to microsurgery. In nerve injury.
particular, the endoscope permits improved visualization
down a narrow corridor, allowing the higher resolution of 3.3 Endoscopic endonasal approach
anatomical details, and clearer demarcation of pathological
tissue from the surrounding structures. Moreover, the use 3.3.1 Indications
of angled endoscopes enables the surgeon to look around • The EEA can be utilized to address pathologies along
corners. The EEA avoids the use of retractors and moves the entire rostrocaudal extent of the clivus, ventral fo-
the lens and light source to the target in order to achieve ramen magnum, and upper cervical spine down to the
better visualization. body of C2 [1–3]
• Degenerative basilar invagination, odontoid fractures
with irreducible subluxation and ventral spinal cord
3 Patient selection compression, RA with pannus or craniocervical settling,
metastatic lesions, chordomas, and chondrosarcomas [8]
3.1 Transoral approach • The dura can also be opened to remove intradural le-
sions, such as foramen magnum and clival meningiomas,
3.1.1 Indications epidermoid tumors, and neurenteric cysts medial to the
• Degenerative basilar invagination, odontoid fractures cranial nerves and the carotid arteries
with irreducible subluxation and ventral spinal cord • Pathologies involving the anterior aspect of the foramen
compression, RA with pannus or craniocervical settling, magnum can also be removed
metastatic lesions, chordomas, chondrosarcomas, and • Preoperative imaging must be scrutinized to identify the
anterior foramen magnum lesions [8] possible presence of intradural tumor extension, so that
• When exposure is necessary of pathologies extending the harvesting of appropriate grafts for successful closure
from the inferior clivus, anterior aspect of the foramen following tumor removal, such as fat, fascia lata, or a
magnum down to the inferior aspect of C2. vascularized nasoseptal flap is performed during the
surgical approach.
3.1.2 Contraindications
• Limited ability to open the patient’s mouth secondary 3.3.2 Contraindications
to temporomandibular joint pathology • The EEA is ideal for CVJ lesions that are medial to the
• The presence of oral mucosal or dental infections pterygoid plate, eustachian tube, and paraclival carotid
• Patients with a fixed flexion deformity of the cervical artery. Although more lateral access is possible with an
spine can present a technically difficult surgical angle endonasal, transmaxillary transpterygoid approach di-

rected superiorly to the pterygopalatine fossa, petrous 3.4 Endoscopic transcervical approach
apex and Meckel’s cave [10] or inferiorly via a transmax-
illary approach to the infratemporal fossa, hypoglossal 3.4.1 Indications
canal and medial occipital condyle [3, 10, 11], these ap- • Degenerative basilar invagination, odontoid fractures
proaches are more demanding and should be considered with irreducible subluxation and ventral spinal cord
together with other lateral skull-base approaches decompression, RA with pannus or craniocervical settling,
pending on the lateral extent of the lesion and anterior foramen magnum lesions
• Medially coursing carotid arteries (“kissing” carotids) • Pathologies extending from the distal clivus along the
are a contraindication for using the EEA to access pa- entire cervical spine.
thologies in the rostral aspect of the clivus and CVJ
• The most caudal exposure that is possible is limited by 3.4.2 Contraindications
the extent to which the nasal bones and cartilaginous • Barrel-chested, severely kyphotic, or obese patients
soft tissue around the nose can be elevated to increase • Highly vascular tumors, are a relative contraindication
the downward-angled line-of-view. The line created by given the long working channel and the limitations of
connecting the inferior edge of the nasal bone to the current endoscopic instruments for hemostasis using
posterior edge of the hard palate on a midsagittal CT electrocautery.
scan represents the most caudal dissection that is pos-
sible with straight endoscopic instruments (Fig 2.5-1).
The most-inferior limit of dissection is generally 0.9 cm 4 Pros and cons of the transoral, endoscopic
above the base of the C2 vertebral body, and even low- endonasal, retropharyngeal upper cervical, and
er in patients with basilar invagination. endoscopic transcervical approaches to the CVJ
4.1 Transoral approach to the CVJ
4.1.1 Pros
• The anatomy visible through this exposure is easily iden-
tifiable to most surgeons
• The transoral approach provides a wide corridor of expo-
sure that is easily performed with a standard operating
microscope
• The approach provides a direct anterior exposure for
pathologies that are located anterior to the cranial nerves
• It provides good access to the inferior third of the clivus.
The upper clivus can be exposed with incorporation of
the extended approaches, and can be performed with
the operating microscope.
4.1.2 Cons
Fig 2.5-1 Mid-sagittal contrast-enhanced CT scan demonstrating the
sphenoid sinus, clivus, CVJ, and relationship to the nasal bones and
• The operative corridor can lead into a deep working
hard palate. The dotted line represents the maximal angle of exposure space, and the superior aspect of the exposure can be
that can be achieved with the use of a 0° endoscope. Compared to difficult to reach
the dotted line, the real-time intraoperative exposure is further slightly • The exposure is limited superiorly by the pterygoid plates
limited by the soft tissues of the nose. However, these limitations can
and laterally by the hypoglossal canals, eustachian tubes,
be overcome with angled endoscopes.
and vertebral and carotid arteries
• As the operative corridor traverses the nonsterile oral
mucosa, the risk exists of contamination of the intradu-
ral space
• There is a risk of postoperative velopharyngeal insuf-
ficiency. This occurs especially in the case of intradural
pathologies due to the need for more extensive bone
removal, which increases the likelihood of posterior
153

pharyngeal wall injury and damage to the soft palate. a hard- or soft-palate incision. Incisions of the soft pal-
Postoperative velopharyngeal insufficiency needs to be ate increase the risk of postoperative velopharyngeal
distinguished from dysphagia and dysphonia secondary insufficiency and may require a tracheostomy.
to lower cranial nerve injury
• Inability to stabilize the spine during the same operative 4.3.2 Cons
procedure, requiring a second-stage posterior stabiliza- • Mastering the EEA requires an experienced neurosurgery
tion procedure and otolaryngology team familiar with this technology
• Longer recovery period and possible need for a feeding and instrumentation, who are comfortable when oper-
tube and tracheotomy. ating with a two-dimensional screen compared to the
operating microscope
4.2 Retropharyngeal upper cervical approach to the • Postoperative nasal crusting can be a recurrent problem,
CVJ requiring particular attention on the part of the otorhi-
nolaryngologist
4.2.1 Pros • Until recently, closure of the dura for cases with intra-
• The retropharyngeal upper cervical approach allows dural extension of pathology presented a challenge.
operative exposure from the basiocciput of the clivus to However, with the introduction of the gasket seal and
the foramen magnum down through C1–4 vascularized nasoseptal flaps, postoperative CSF leakage
• The approach provides a broader exposure than the has been minimized
transoral or EEA approaches • Endoscopic microsurgical equipment for delicate intra-
• The upper cervical incision heals better than the transoral dural dissection is still under continuous refinement,
or EEA incisions and is a sterile, noncontaminated ex- and is not currently equivalent to the state-of-the-art
posure microscopic equipment used for open surgery.
• The approach can be utilized to address most CVJ pa-
thologies 4.4 Endoscopic transcervical approach to the CVJ
• It provides exposure that would enable arthrodesis of
the ventral cervical spine. 4.4.1 Pros
• The ETO approach allows operative exposure from the
4.2.2 Cons basiocciput of the clivus to the foramen magnum down
• The retropharyngeal upper cervical approach is techni- through C7
cally more difficult than the transoral approach due to • The anterior cervical approach to the spine is very fa-
the difficulty in maintaining midline orientation miliar to spinal surgeons
• Transient hypoglossal dysfunction is common postop- • The ETO approach provides a broader exposure than
eratively the transoral or EEA approaches. The ventral C1 arch
• Retraction of the pharynx can lead to dysphagia, pos- can remain intact (except in cases of cranial settling),
sibly requiring a temporary percutaneous gastrostomy and thus the carotid arteries and sympathetic chain are
after surgery protected as they enter the skull base
• The superior laryngeal nerve is at risk of injury, which • Medially coursing carotid arteries (“kissing carotids”)
could result in postoperative hoarseness and increase are not a contraindication for the ETO to access pa-
the risk of pulmonary aspiration. thologies in the rostral aspect of the CVJ, as the access
is behind the ventral C1 arch and the carotid arteries
4.3 Endoscopic endonasal approach to the CVJ are not in the operative field
• The clivus is not resected to obtain access to very high-
4.3.1 Pros lying odontoid lesions except in cases of cranial settling
• The nasopharyngeal incision, as opposed to an oropha- with platybasia
ryngeal mucosal incision, permits earlier extubation and • The cervical incision heals better than the transoral and
is also less likely to become contaminated by food, sa- EEA incisions and is a sterile, non-contaminated expo-
liva, and oral flora. This enables earlier food intake by sure.
the patient after surgery, with little risk of infection or
postoperative swallowing dysfunction 4.4.2 Cons
• The EEA can provide complete exposure of the rostral • Mastering the ETO requires an experienced neurosur-
CVJ, as high as the dorsum sella, without the need for geon familiar with the specific technology and instru-

mentation, and comfortable when operating with a palate; however, the transoral and transcervical approach-
two-dimensional screen compared to the operating mi- es provide progressively more caudal access. The line cre-
croscope ated by connecting the inferior edge of the nasal bone to
• There is a steep learning curve for understanding and the posterior edge of the hard palate on a midsagittal CT
mastering the technique of odontoid resection. scan represents the most caudal dissection that is possible
with straight endoscopic instruments (Fig 2.5-1). The infe-
rior-most limit of dissection is generally 0.9 cm above the
5 Preoperative planning and patient positioning base of the C2 vertebral body and even lower in patients
with basilar invagination. Patients with a high-positioned
When evaluating a patient for a surgical approach to a le- odontoid and platybasia often require removal of the an-
sion in the CVJ, it is important to determine whether a terior margin of the foramen magnum and lower clivus to
suitable operative corridor is possible considering the indi- expose the upper part of the odontoid. This can often be
vidual patient’s anatomy. For lesions in the clivus, such as performed endonasally without disruption of the anterior
chordomas or clival meningiomas, the most important con- rim of the atlas or the alar and transverse ligaments as the
sideration is the relationship between the carotid arteries superior to inferior angle is advantageous [2]. In contrast,
and the tumor. Midline and paramedian tumor extension with a transoral exposure, the body of C2 and the anterior
can be addressed utilizing an endonasal, transmaxillary ring of C1 are exposed first, and it can be difficult to remove
transpterygoid approach directed superiorly to the ptery- the odontoid without disruption of the C1 anterior arch.
gopalatine fossa, petrous apex, and Meckel’s cave [10]. In-
feriorly the transmaxillary approach can provide access to The presence of any preoperative lower cranial nerve dys-
the infratemporal fossa, hypoglossal canal, and medial oc- function must be evaluated prior to surgery, especially be-
cipital condyle [3, 10, 11]. Although these paramedian en- fore a transoral and transcervical approach where there is
donasal approaches enable surgical access lateral to the risk of velopharyngeal insufficiency and lower cranial nerve
carotid arteries, the risks of this maneuver must be clearly damage. Lesions which lie high behind the clivus can be
identified before surgery and should be considered togeth- approached through the ETO without resection of the clivus
er with other lateral skull-base approaches, depending on or anterior arch of C1 (except in cases of cranial settling
the lateral extent of the lesion. Large lesions in particular with platybasia). The trajectory of the resection of the odon-
(> 4 cm in diameter) that are both medial and lateral to the toid through the ETO allows resection of the odontoid, no
lower cranial nerves may be best addressed in stages, re- matter how high within the skull base the odontoid has
moving the midline tumor endonasally and the lateral tu- migrated. In addition, the access posterior to the ventral
mor transcranially [8, 12]. arch of C1 provides a natural barrier to accidental injury to
the carotids, sympathetic chain, hypoglossal nerves, and
The need for exposure along the rostrocaudal axis must also oropharynx.
be evaluated for all approaches to the CVJ. Rostral lesions
of the clivus are best addressed endonasally, and may require
extradural elevation of the sellar dura and a sphenoidotomy; 6 Surgical technique
and further rostral exposure may require pituitary trans-
position with extracapsular mobilization of the pituitary Surgery for all approaches is often performed with somato-
gland to access tumor extension in the retrosellar space, sensory- and motor-evoked potential monitoring and awake
interpeduncular cistern, and along the posterior clinoids fiberoptic nasotracheal intubation. The use of image inten-
and dorsum sella [1]. The preoperative imaging must also sification is advisable. Stereotactic navigation can be used
be scrutinized to identify the possible presence of intradu- in all these approaches. The reference array is typically at-
ral tumor extension so that the harvesting of appropriate tached to the Mayfield headclamp, just as in cranial surgery
grafts for successful closure following tumor removal, such [13]. Instrumentation is rarely inserted via an anterior ap-
as fat, fascia lata, or a vascularized nasoseptal flap is per- proach and stabilization is usually added via a separate
formed during the exposure. posterior approach. For transoral or transcervical approach-
es, it may be advantageous to perform a posterior stabiliza-
In addressing lesions along the caudal aspect of the CVJ, tion procedure after the anterior decompression since the
such as upper cervical spine tumors or RA with pannus patient’s neck frequently needs to be extended to improve
surrounding the odontoid process, the endonasal exposure access. For endonasal surgery this is not necessary, and the
is limited superiorly by the nasal bones and cartilaginous posterior instrumentation procedure is usually performed
soft tissues of the nose and inferiorly by the hard and soft first.
155

6.1 Transoral approach to the CVJ In cases where the dura has been opened, the dural edges
Antibiotics are administered during the induction of anes- are closed with sutures, if possible, then covered with Sur-
thesia and continued for 2 days postoperatively. Bacterio- gicel and fibrin glue. An inlay of synthetic collagen matrix
logical samples of the nasal and oropharyngeal cavity are dural substitute (eg, Duramatrix or Duragen) is placed and
taken prior to surgery so that appropriate antibiotics can be anchored in position, then an onlay fascia lata graft is placed
given if an infection ensues. Patients that present with over the dural defect and held in place using fibrin glue.
lower cranial nerve dysfunction or who need to have ex- The clival defect is then filled with abdominal fat graft,
tended transoral procedures (eg, mandibulotomy or maxil- after which the pharyngeal wall is sutured using interrupt-
lotomy) may require a preoperative tracheotomy and per- ed vicryl sutures in two layers.
cutaneous gastrostomy. A lumbar drain is placed in patients
where intradural dissection is anticipated. 6.2 Retropharyngeal upper cervical approach to the
CVJ
The patient is positioned supine on the operating table, The patient is positioned with the head placed in slight
head placed in three-point fixation and the operating table extension on a horseshoe headrest, and rotated contralat-
turned towards the surgeon, avoiding any head rotation. eral to the approach. A transverse incision is placed a fin-
The oropharyngeal cavity is prepared with chlorhexidine gerbreadth below and parallel to the mandible extending
and the posterior pharynx is injected with a 1% lidocaine/ from the mandibular angle to the midline (Fig 2.5-3a). The
epinephrine solution. It is important to check that the re- fascial planes are widely dissected and undermined to
tractor system is placed correctly and that undue pressure achieve maximal exposure and minimize traction on neu-
to the soft tissues is avoided, and also that the patient’s rovascular structures (Fig 2.5-3b). The subcutaneous tissues
tongue is not pressed onto the teeth. Careful placement of are undermined from the platysma using sharp and blunt
the retractor system can help avoid postoperative swelling. dissection. The platysma is then elevated medially and un-
The soft palate may be elevated with a curved retractor dermined from the underlying fascia and incised horizon-
blade or by placing a balloon catheter through the nasal tally along the lines of the skin incision. The underlying
cavity, which can be used to retract and elevate the soft facial artery and submandibular gland are dissected and
palate and avoid a palatal incision. retracted laterally. The digastric tendon is then identified
under the submandibular gland and dissected free from its
The mucosa is vertically incised over the anterior tuber- fascial attachments to the hyoid bone and retracted towards
cule of C1 and retracted with a pharyngeal retractor system the mandible (Fig 2.5-3c). The underlying hypoglossal nerve
(Fig 2.5-2a). The underlying longus colli muscles are elevat- is also carefully dissected from its fascia and retracted later-
ed from the foramen magnum, atlas, and axis using mono- ally. The hyoid bone is then identified and the carotid sheath
polar cautery exposing the anterior bone surfaces. Ana- and the surrounding fascia is widely dissected and retract-
tomical landmarks are identified including the C1/2 ed laterally. The pharyngeal muscles are then retracted
interspace, anterior ring of the atlas, inferior edge of the medially and the prevertebral fascia is incised bringing the
clivus and the odontoid process. When the anatomy is de- anterior surfaces of C2 and C3 into view. Midline orienta-
formed, the image guidance system and image intensification is gained by palpating the C1 tubercle and with the
tion can be of great help in locating the vertebral arteries longus colli muscles which are next elevated and retracted
and bone landmarks. The apical and alar ligaments are laterally. With adequate retraction and wide fascial dissec-
sharply divided, and the appropriate bone decompression tion, the foramen magnum and C1 can be exposed (Fig
is performed with an air- or electric-powered side-cutting 2.5-3d). The remainder of the bone removal and microdis-
drill bit, with care being taken to avoid a durotomy (Fig section is similar to that for the transoral and endoscopic
2.5-2b–d). A diamond drill may be used when there is con- approaches.
cern regarding the risk of a dural tear, and after the bone
has been thinned, the remaining bone is removed using 6.3 Endoscopic endonasal approach to the CVJ
pituitary and Kerrison rongeurs. Rheumatoid pseudotumors Preoperative antibiotics, glucocorticoids, and antihistamines
are removed with great care to avoid a durotomy and sub- are administered. Prior to the operation, a lumbar puncture
sequent CSF fluid leakage. In some cases, the anterior aspect is performed, and 0.2 ml of 10% fluorescein is injected in
of the foramen magnum needs to be removed to obtain 10 ml of CSF to help visualize CSF leaks. A lumbar drain is
sufficient access. placed prior to surgery in cases where a large skull-base

a b
c d
Fig 2.5-2a–d Transoral approach to the craniovertebral junction.

a A vertical incision is made in the median raphe of the oropharynx, exposing the anterior
arch of C1 and the body of C2.
b The inferior portion of the C1 arch is drilled off to expose the base of the odontoid.
c The dens is drilled down, starting at its base.
d The dens is carefully removed to complete the decompression, with care being taken to
avoid any injury to the dura.
157

dural defect is anticipated. Topical 4% cocaine is used over neuronavigation with MRI and/or CT scan is used for all
the nasal mucosa for vasoconstriction, then a mixture of procedures. The patient’s head is fixed in a slightly flexed
lidocaine 1% and epinephrine (1:100,000) is injected. The position to improve the view towards the clivus and the
patient’s head is placed in three-point fixation, slightly el- axial cervical spine. The lateral thigh is prepared for au-
evated and slightly turned to the right, and intraoperative tologous fat and fascia lata grafts.
a b
c d
Fig 2.5-3a–d Transcervical retropharyngeal approach to the craniovertebral junction.

a The patient is positioned with the head in slight extension and rotated contralateral to the approach.
The incision is placed 2 cm below the lower margin of the mandible.
b Extensively undermining the subcutaneous layer from the platysma enables a wide exposure.
The platysma is opened from the midline parallel to the skin incision.
c The platysma is retracted and the submandibular gland, facial artery, and digastric tendon are retracted
superiorly, exposing the hypoglossal nerve which is dissected and also retracted superiorly.
d The hyoid bone is exposed and the lateral wall of the superior pharyngeal constrictor is identified and
retracted to expose the retropharyngeal space and longus colli muscles.

6.3.1 Endoscopic endonasal access be controlled with hemostatic agents (Fig 2.5-4b). The amount
Under 0° endoscopic view, the inferior, middle, and supe- of drilling required depends on the aeration of the sinus,
rior turbinates as well as the sphenoid ostia are identified and the location of the carotid arteries is verified using a
bilaterally. The middle and superior turbinates are most Doppler ultrasound probe. The inferior intercavernous sinus
often retracted laterally; however, rarely in some patients is cauterized and transected. The dura is then opened in the
the right middle turbinate is removed to optimize the ex- midline to expose the basilar tip, superior cerebellar and
posure and allow the easy passage of instruments and the posterior cerebral arteries, and third cranial nerve. The sixth
endoscope. cranial nerve runs along the lateral edge of the exposure as
it enters Dorello’s canal.
The use of a pedicled nasoseptal vascular flap of the naso-
septal mucoperiosteum based on the nasoseptal artery has 6.3.3 Inferior clivus
become an important adjunct in the multilayered endo- The approach to the inferior two-thirds of the clivus is also
scopic reconstruction of large skull-base defects [9]. The combined with a transsphenoidal exposure to facilitate in-
nasoseptal flap is generally harvested at the beginning of strument placement. The basipharyngeal fascia and prever-
the operation, before tumor removal, and before the pos- tebral musculature are dissected free from the clivus and
terior septectomy is performed. The vascular supply of the cauterized, and cut laterally to create a U-shaped flap, which
nasoseptal flap is derived from the posterior septal artery, is reflected inferiorly. The lateral margins of the nasopha-
a terminal branch of the internal maxillary artery [9]. The ryngeal flap are demarcated by the vidian nerves superi-
flap is raised by placing two parallel incisions within the orly and the eustachian tubes laterally, which mark the
septal mucosa, one along the nasal floor and the other just location of the carotid arteries (Fig 2.5-4c–d). The clivus is
inferior to the most superior aspect of the septum. These drilled back until flush with the dura. Extensive venous
incisions are joined anteriorly to create the flap, and pos- bleeding from the basilar plexus can be controlled with
teriorly are extended over the rostrum of the sphenoid su- careful cautery, hemostatic agents, and gentle pressure. The
periorly and to the choana inferiorly. The flap is elevated use of cautery along the dural incision should only be per-
anterior to posterior and lateral with a dissector, and held formed after the position of the abducens nerves is deter-
out of the way of the surgeon during the operation. For mined. Opening the dura, when necessary, will expose the
CVJ approaches, the flap can be stored either in the sphenoid basilar trunk, anteroinferior cerebellar and vertebral arter-
sinus or maxillary sinus so as not to interfere with the sur- ies, and ventral pons. The dura is opened with an “I” -shaped
gical corridor. incision to avoid damaging the near midline abducens nerve.
The average distance between the abducens nerves at the
The endonasal approach to lesions of the clivus can require dural emergence is 19.8 mm.
a sphenoidotomy depending on the rostrocaudal extent of
the pathology. For lesions of the upper third of the clivus 6.3.4 Odontoid, C1 and C2 approach
located behind the posterior wall of the sphenoid sinus, a The transodontoid approach is a continuation of the infe-
bilateral transsphenoidal opening and removal of the pos- rior extent of the transclival approach. It is usually not
terior third of the septum is performed (Fig 2.5-4a). necessary to perform a sphenoidotomy at this level unless
there is a significant degree of basilar invagination requir-
The lateral margins of the floor of the sphenoid sinus are ing removal of the inferior aspects of the clivus. However,
marked by the course of the vidian nerve, which runs pos- bimanual dissection is achieved by removing the inferior
teriorly along the floor into the vertical segment of the part of the vomer. The approach courses parallel to the hard
carotid artery. The sella can also be opened to mobilize the palate, and an angled endoscope can be helpful in obtaining
pituitary gland laterally or rostrally, in order to drill down an inferiorly directed view. The mucosal flap is reflected
the posterior wall of the sella which forms the upper extent starting at the base of the sphenoid sinus and limited later-
of the clivus and extends up behind the pituitary gland. ally by the eustachian tubes, which will expose the lower
With this maneuver, the posterior clinoid processes and the third of the clivus (Fig 2.5-5a, Fig 2.5-6a–c). The bone at the
dorsum sella can be thinned with a microdrill and removed base of the clivus is removed between both occipital con-
with a Kerrison rongeur. dyles. Below this, the atlantooccipital membrane, longus
capitis, and longus colli muscles as well as the anterior as-
6.3.2 Upper clivus pects of C1 and C2 are exposed. The anterior arch of C1 can
The bone of the upper clivus can be opened from carotid to be removed if necessary to expose the odontoid which is
carotid artery with a microdrill, and the venous plexus can then removed with a microdrill (Fig 2.5-5b, Fig 2.5-6d). Once
159

CL
AP
TL
D
ET ET
C1
C2
a b
CP CP
DM
c d
Fig 2.5-4a–d Endoscopic endonasal approach to the CVJ.
a Using a flat angle, limited by the position of the nasal cartilage and the hard palate, exposure of the clivus, foramen magnum,
C1 and C2, and medial occipital condyle can be achieved. The use of angled endoscopes and inferior retraction of the soft
palate can also help improve the exposure of the C2 vertebral body.
b After inferior reflection of the pharyngeal mucosa the clivus (CL), foramen magnum, anterior arch of C1, and the odontoid
process (D) can be visualized with the transverse (TL) and apical (AP) ligaments. The lateral limits of the exposure are the
eustachian tubes (ET) and the associated carotid arteries, unless a transpterygoid approach is performed.
c After removal of C1 and C2, the ventral dura mater (DM) of the CVJ and the underlying rostral spinal cord and pontomedullary
junction can be visualized.
d The position of the paraclival carotid protuberance (CP) adjacent to the eustachian tubes can be verified with intraoperative
neuronavigation and a Doppler probe.

CLIVUS
C1
FLAP
Fig 2.5-5a–d Intraoperative views of an EEA
a b for odontoidectomy.
a Intraoperative endoscopic views of the CVJ
SS demonstrating the clivus and the inferiorly
reflected nasopharyngeal mucosal flap.
b Further dissection inferior to the clivus
reveals the anterior arch of C1.
c After removal of the anterior arch of C1, an
os odontoideum (OS) can be visualized.
ET d A nonmagnified view demonstrates the
ET sphenoid sinus (SS), the lateral limits of
OS
the exposure determined by the eusta-
chian tubes (ET), and the epidural space
after removal of C1 and the odontoid
c d process.
a b c
d e f
Fig 2.5-6a–f Intraoperative endoscopic views of the EEA to the CVJ.
a Endoscopic view after exposure of the sphenoid sinus (SS) with identification of the eustachian tubes (ET) and the nasopharyngeal mucosa (NP).
b–c The nasopharyngeal mucosa is incised in a U-shaped flap with the lateral limits demarcated by the opening of the eustachian tubes (ET).
d After inferior reflection of the mucosal flap, the clivus (CL) and anterior arch of C1 are identified.
e After removing the anterior arch of C1 and the surrounding ligamentous attachments at the top, the odontoid process (O) is identified.
f Further drilling of the arch of C1 reveals the body of the dens (D) at the bottom of the exposure.
161

the central portion of the dens has been removed, the lat- then to ensure a watertight closure at the end of the case.
eral aspects can be mobilized medially with a small curette. First, any dead space left behind after the tumor resection
The use of an intraoperative CT scan is useful to ensure is filled with autologous fat graft. Then a “gasket-seal” clo-
complete removal of the dens. Retrodental inflammatory sure is performed which consists of a fascia lata onlay placed
pannus can be resected with an ultrasonic aspirator until over a rigid buttress of either vomer bone or a high-densi-
the dura is visualized (Fig 2.5-4c–d, Fig 2.5-6e–f). Stereotactic ty polyethylene implant (eg, Medpore, Stryker, Newman,
navigation is also extremely useful for these maneuvers. CA) that is cut to the exact size of the defect and countersunk
into the skull-base defect (Fig 2.5-7a–c). Small areas of defect
6.3.5 Transpterygoid approach between the vomeric bone or the Medpore plate are filled
Tumors with a significant component extending lateral to in with autologous fat graft. Finally, a vascularized naso-
the paraclival carotid artery and that are to be exposed septal flap is placed directly over the gasket-seal construct
through an endonasal as opposed to a lateral skull-base followed by a final layer of dural sealant material (eg, Du-
corridor require a transpterygoid approach to identify the raseal, Confluent Surgical, Waltham, MA) to hold everything
vidian nerve and the paraclival carotid at the level of fora- in place and ensure a watertight closure [9] (Fig 2.5-7d). No
men lacerum. This necessitates a maxillary antrostomy and sealant material is applied between the flap and the gasket-
posterior maxillary wall resection to gain access to the seal construct since it would prevent fibrosis and vascular-
pterygopalatine fossa. The transmaxillary, transpterygoid ization of the flap to the skull base. It is critical to ensure
approach can be used to reach a variety of targets in the that the nasoseptal flap is positioned over the entire defect,
paramedian skull base including the pterygopalatine fossa, that it is not doubled over on itself, and that the mucosal
infratemporal fossa, petrous apex, and Meckel’s cave. The surface is facing the nasal cavity. If fascia lata is used, it is
approach is begun with an uncinectomy and opening of the critical that the nasoseptal flap lies beyond the edges of the
maxillary ostium followed by elevation of the posterior fascia lata so that the flap is in contact with the sphenoid
maxillary sinus mucosa off the orbital process of the palatine bone to fully cover the defect. For odontoid resection,
bone and posterior wall of the maxillary sinus. The sphe- merely replacing the fascial flap is adequate.
nopalatine artery is identified and ligated at the crista eth-
moidalis. The orbital process of the palatine bone and pos- The nasal cavity is then filled with a hemostatic agent (eg,
teromedial wall of the maxillary sinus are removed to expose Floseal, Baxter, Deerfield, IL). A small piece of Telfa is fi-
the pterygopalatine fossa. The anterior genu between the nally placed in each nostril overnight to absorb any drain-
petrous carotid and the paraclival carotid at the foramen age and is removed after 1–2 days. If a lumbar drain is placed,
lacerum is then identified by following the vidian nerve in it is typically drained at ~5 ml/hr for 1–2 days and then
the pterygoid canal and by drilling the medial pterygoid clamped and removed in the evening, so that after its re-
plate and the sphenoid floor. moval the patient can lie flat during the night to decrease
the risk of spinal headache. Patients are placed on low-dose
The exposure lateral to the carotid in the middle third of heparin to prevent deep venous thrombosis.
the clivus can then be extended superiorly to the petrous
apex and Meckel’s cave, or inferiorly to the parapharyngeal 6.4 Endoscopic transcervical approach to the CVJ
carotid artery and occipital condyle, jugular foramen, and The patient is positioned supine on a radiolucent operating
hypoglossal canal. The eustachian tube is the anatomical table. The head is placed in a halo ring and immobilized in
landmark to gain control of the parapharyngeal carotid ar- a neutral position via a Mayfield halo adapter. If frameless
tery during exposure of the occipital condyle, jugular fora- stereotaxis is to be used during the operation, the reference
men, and hypoglossal canal. Entry into Meckel’s cave re- array is connected to the halo ring. Intraoperative isocentric
quires removal of the pterygoid process along the vidian image intensifier images are acquired and registered onto
nerve and identification of the infraorbital nerve up to the the frameless stereotactic system. The neck is cleaned, pre-
foramen rotundum. The so-called “quadrangular space”, pared, and draped in a standard fashion. Perioperative an-
which is bounded medially by the vertical carotid and later- tibiotics are administered. The approach can be made from
ally by the maxillary nerve, can be drilled open to expose either side of the spine, whichever is preferred by the sur-
Meckel’s cave. geon. A transverse incision is made starting at the midline,
and heading laterally for 3.5 cm at approximately the C4/5
6.3.6 Multilayered closure level. Using the standard Cloward technique, the ventral
The use of intrathecal fluorescein helps to ensure adequate spine is approached. Using Kittner dissectors, the dissection
closure at each stage, first to identify small CSF leaks and along the spine is carried out rostrally until the anterior

Duraseal
Overlying fascia lata
a b
c d
Fig 2.5-7a–d
a A coronal view of the suprasellar contents and closure of the skull-base defect with a gasket
seal alone. The countersunk rigid buttress is cut to a size slightly larger than the skull-base
defect and countersunk with overlying fascia lata for a watertight seal. A final layer of
Duraseal is applied to hold the construct in position to ensure a watertight closure.
b Illustration of a gasket-seal closure similar to c.
c Intraoperative view of a gasket-seal reconstruction of the skull base. Note the large margin
of overhanging fascia lata (black arrow) and the countersunk bone.
d Intraoperative view shows a rotated nasoseptal flap (black arrow) secured in place over a
gasket-seal closure. The edges of the nasoseptal flap are secured in place with dural sealant
material to hold the flap in position over the gasket-seal closure.
163

tubercle of C1 is palpated. A beveled (30° bevel) tubular and tracing the edges of the odontoid to identify where the
retractor (22 mm diameter) is inserted (Fig 2.5-8a). The su- odontoid meets the body of C2. Resection of the odontoid
perior aspect of the retractor is docked on the C1 tubercle; then proceeds by first drilling into the base of C2, then fol-
the inferior aspect usually lies over the C3 vertebral body. lowing the ventral aspect of C2, behind the arch of C1, in
For comfort, a right-handed surgeon will usually stand on a rostral direction until the tip of the odontoid is encoun-
the right side of the patient, and a left-handed surgeon will tered. The resection is then continued in a “top-down”
stand on the left. The video screens for the navigation sys- fashion (Fig 2.5-8b). After the bone resection is complete,
tem and endoscope are positioned facing the surgeon on the posterior longitudinal ligament, transverse ligament,
the opposite side of the operating table. A 30° endoscope and nuchal ligament can be resected, exposing the under-
is used for visualization, and can be held either by an as- lying dura. The retractor is then removed and the platysma
sistant or an endoscope holder. An endoscope with a cam- and skin closure are completed. The halo ring is then at-
era angled at 90° is preferable so that it does not interfere tached to the halo vest, and the patient is repositioned in
with the surgeon's hands. The surgeon then identifies the the prone position for the posterior instrumentation and
midline by determining the lateral aspects of the odontoid, fusion.
Surgical approach
of tubular retractor
Anterior arch of C1
Basilar artery (partial resection) Beveled tubular retractor (~30°)
Neuroendoscope
Clivus
Suction
Irrigation catheter
Burr
Pons
Foramen magnum
Invagination of dens
C2
into medulla C3
C1 C4
C5
Fig 2.5-8a–b Endoscopic C1 C2 C3 C4 Vertebral artery Cervical dura mater

transcervical odontoidectomy.

7 Postoperative care dysfunction, and pharyngeal wall trauma after the trans-
cervical and transoral approaches are significant. All patients
Postoperative management after surgical approaches to the should be carefully evaluated to ensure that the swallowing
craniovertebral junction focuses on the issue of cervical mechanism is intact prior to being cleared for an oral food
spine stability, considerations regarding fusion, swallowing, intake. Some patients may require a tracheotomy for man-
and the risks of possible velopharyngeal dysfunction, CSF agement of airway secretions and a gastrostomy tube for
leakage, and meningitis. feeding. These complications occur most frequently if there
is trauma to the soft palate, especially after an extended
The new multilayered closure techniques used after endo- transoral procedure.
scopic intradural surgery have dramatically reduced the in-
cidence of postoperative CSF leakage after EEA to the CVJ.
The use of synthetic grafts, allografts, autografts, and/or 8 Evidence-based results
vascularized mucosal flaps together with dural sealants and
structural support have been instrumental in preventing There are no class I evidence-based studies that compare
postoperative CSF leaks. The potential for CSF leakage after the EEA, transoral, or retropharyngeal upper cervical ap-
transoral surgery has also been reduced with the combination proaches to the CVJ. With EEA for clival chordomas, the
of lumbar drainage, inlay and onlay dural grafts, placement reported CSF leakage rates range from zero to 33% [7, 11].
of fat in the epidural space, and suturing of the pharyngeal However, with the evolution of newer multilayered closure
mucosa. Intraoperative lumbar puncture and injection of techniques including a structural gasket seal and a vascular-
fluorescein to help visualize the location or the presence of ized mucosal flap these have been essentially eliminated.
a leak also greatly facilitates a watertight dural closure. With Other potential complications include sixth nerve palsy,
the EEA, postoperative lumbar drainage is used only when carotid injury, and postoperative hematoma formation. The
a persistent CSF leak is identified at the end of surgery. In rates of gross total resection range from 33% in the early
other cases, if there is concern regarding recurrent CSF leak- experience to 60–71% in the more recent reports [2, 8, 12].
age, poor closure with a large defect, or a patient with a large With EEA odontoidectomy, no significant rate of CSF leak-
body habitus, a postoperative drain may be placed to facilitate age has been reported, and most patients are extubated
postoperative management and to ensure a good closure. on the day of surgery, with only 6% of patients requiring
postoperative tracheotomy for postoperative pharyngeal
Since the introduction of minimally invasive EEA, the in- dysfunction [2, 8, 12].
cidence of postoperative velopharyngeal dysfunction has
been essentially eliminated. By approaching the operative
site at the CVJ through the nose and avoiding damage to 9 Complications and avoidance
the soft palate most patients can be extubated on the day
of surgery and are able to safely tolerate an oral diet the As regards complications and their avoidance, the authors
next day. The risks of postoperative swallowing dysfunction refer the reader to the individual strategies described in
due to lower cranial nerve dysfunction, velopharyngeal topic 6 Surgical technique, in this chapter.
165

10 Tips and tricks
Jean-Paul Wolinsky, Baltimore, USA and meningitis is higher). The lateral extent 10.2 Sterile surgical corridors
Many different surgical corridors are avail- of the exposure is limited by the location • Retropharyngeal upper cervical ap-
able to approach ventral pathologies of the of the carotid arteries and eustachian tubes. proach: exposure of the anterior fora-
C1/2 region. When considering an approach, men magnum through to C4. Hypoglossal
it is paramount to understand the pathology • Transoral approach: exposure from the nerve is at risk through this exposure.
to be treated, the lateral extent of the pathol- distal clivus through C2. Patients with • Endoscopic transcervical odontoidectomy
ogy, the relationship of the carotid arteries limited jaw opening may not be suitable approach: exposure of the distal clivus
to the lesion and the surgical corridor, how candidates for this approach. through to C7. This is an unsuitable cor-
much exposure is really needed to visual- • Transoral transmaxillary approach: ridor for obese or barrel-chested patients.
ize the region safely, how much exposure is extends rostral exposure to the clivus Given the working channel, vascular le-
needed for surgical resection if a lesion is vas- •
Transoral transmandibular approach: sions can be difficult to control with this
cular, and the kind of postoperative therapy extends rostral exposure to the cli- approach.
the patient may require. The body habitus vus and caudal exposure through to • Lateral skull-base approaches: eg, the
of the patient is also an important factor. the cervical spine. Can be performed far lateral transcondylar approach, with
Considerations for approaches for anterior transglossally or circumglossally. exposure of the clivus through C2. This
pathologies at C1/2 are shown in Fig 2.5-9. Gives excellent exposure. Requires is the workhorse exposure for intradural
tracheotomy and gastrostomy pathologies. Excellent vascular control
10.1 Nonsterile surgical corridors • Endoscopic endonasal approach: expo- can be achieved.
The following surgical corridors transgress sure from the frontal skull base through
the oral or nasopharyngeal cavity (contami- 0.9 cm above the base of C2. “Kissing”
nated field-pathologies that may require vio- carotid arteries are a contraindication for
lation of the dura should be approached with surgery.
caution, as the risk of persistent CSF leakage
a Endoscopic endonasal
b Transoral
Fig 2.5-9a–c Summary of endoscopic approaches.

a Endonasal approach.
b Transoral approach.
c Endoscopic transcervical c Transcervical approach.

11 Case examples
11.1 Case 1 11.3 Case 3

This patient presented with compression of the upper spinal This patient presented with myelopathy due to severe bas-
cord secondary to os odontoideum and atlantoaxial instabil- ilar invagination (Fig 2.5-12).
ity (Fig 2.5-10).
11.4 Case 4
11.2 Case 2 This patient presented with progressive myelopathy due
This patient presented with compression of the upper cer- to compression at multiple levels of the cervical spine
vical spinal cord and brainstem secondary to basilar in- (Fig 2.5‑13).
vagination and cranial settling (Fig 2.5-11).
a b c d
Fig 2.5-10a–d
a–b Preoperative sagittal CT scan (a) and MRI (b) demonstrating severe cord compression.
c–d Postoperative lateral x-ray demonstrating the occipitocervical fusion (c) which was followed by endonasal
endoscopic removal of the odontoideum and anterior arch of C1 depicted on the CT scan (d).
Fig 2.5-11a–b Pre- and postoperative sagittal

CT scans.
a Preoperative sagittal CT scan demonstrat-
ing the previous occipitocervical fusion
with basilar invagination and severe brain-
stem and upper cervical cord compres-
sion.
b Postoperative CT scan demonstrating
decompression of the CVJ with removal
of the anterior arch of C1 and odontoid
process up to the body of C2 using an
a b endonasal endoscopic approach.
167

a b a b
Fig 2.5-12a–b Fig 2.5-13a–b
a Preoperative CT scan demonstrating severe basilar invagination a Preoperative MRI showing C2 pannus and C6 stenosis.
with brainstem compression. b Postoperative CT scan showing resection of C2 and pannus via
b Postoperative CT scan after endoscopic transcervical odontoid- endoscopic transcervical odontoidectomy and C6 corpectomy
ectomy, demonstrating resection of C2, and decompression of with C5–7 anterior reconstruction, all performed through the
basilar invagination. same incision.
12 Key learning points • The retropharyngeal approach allows simultaneous in-

strumentation for spinal stabilization
• Endoscopic endonasal approaches to the CVJ have de- • The transoral and retropharyngeal approaches provide
creased the rate of postoperative velopharyngeal insuf- access to the lower CVJ and to the subaxial spine includ-
ficiency and allow faster postoperative patient mobiliza- ing C3/4
tion • The endoscopic transcervical odontoidectomy approach
• Endoscopic endonasal approaches to the CVJ can provide provides access to the distal clivus through the entire
access to the entire skull base from the upper clivus to cervical spine
the body of C2, with the nasopalatine line demarcating • The retropharyngeal and ETO approaches do not traverse
the anatomical limits of the exposure the oral cavity, and are therefore noncontaminated pro-
cedures.

13 References
1. de Divitiis O, Conti A, Angileri FF, et 6. Crockard HA, Pozo JL, Ransford AO, 11. Hofstetter CP, Singh A, Anand VK, et
al (2004) Endoscopic transoral– et al (1986) Transoral decompression al (2010) The endoscopic, endonasal,
transclival approach to the brainstem and posterior fusion for rheumatoid transmaxillary transpterygoid approach
and surrounding cisternal space: atlanto-axial subluxation. J Bone Joint to the pterygopalatine fossa,
anatomic study. Neurosurgery; Surg Br; 68(3):350–356. infratemporal fossa, petrous apex, and
54(1):125–30; discussion 30. 7. Menezes AH, VanGilder JC (1988) the Meckel cave. J Neurosurg;
2. Kassam AB, Snyderman C, Gardner P, Transoral–transpharyngeal approach to 113(5):967–974.
et al (2005) The expanded endonasal the anterior craniocervical junction. 12. Stippler M, Gardner PA, Snyderman
approach: a fully endoscopic transnasal Ten-year experience with 72 patients. CH, et al (2009) Endoscopic endonasal
approach and resection of the odontoid J Neurosurg; 69(6):895–903. approach for clival chordomas.
process: technical case report. 8. Fraser JF, Nyquist GG, Moore N, et al Neurosurgery; 64(2):268–77; discussion
Neurosurgery; 57(1):E213; discussion E. (2010) Endoscopic endonasal 77–78.
3. Schwartz TH, Fraser JF, Brown S, et al transclival resection of chordomas: 13. Laufer I, Greenfield JP, Anand VK, et
(2008) Endoscopic cranial base surgery: operative technique, clinical outcome, al (2008) Endonasal endoscopic
classification of operative approaches. and review of the literature. resection of the odontoid process in a
Neurosurgery; 62(5):991–1002; J Neurosurg; 112(5): 1061–1069. nonachondroplastic dwarf with
discussion 1002–1005. 9. Hadad G, Bassagasteguy L, Carrau juvenile rheumatoid arthritis:
4 Wolinsky JP, Sciubba DM, Suk I, et al RL, et al (2006) A novel reconstructive feasibility of the approach and utility of
(2007) Endoscopic image-guided technique after endoscopic expanded the intraoperative Iso-C three-
odontoidectomy for decompression of endonasal approaches: vascular pedicle dimensional navigation. Case report.
basilar invagination via a standard nasoseptal flap. Laryngoscope; J Neurosurg Spine; 8(4):376–380.
anterior cervical approach. Technical 116(10):1882–1886.
note. J Neurosurg Spine; 6(2):184–191. 10. Kassam AB, Vescan AD, Carrau RL, et
5 Kanavel AB (1919) Bullet locked al (2008) Expanded endonasal
between atlas and the base of the skull: approach: vidian canal as a landmark
technique for removal through the to the petrous internal carotid artery.
mouth. Surg Clin; 1:361–366. J Neurosurg; 108(1):177–183.
169

14 Evidence-based summary
Nayak JV, Gardner PA, Vescan AD, et al (2008)

Experience with the expanded endonasal approach for
resection of the odontoid process in rheumatoid disease.
Am J Rhinol; 21(5):601–606.

Purpose
To asses preoperative characteristics, postoperative com-
plications, and outcomes in patients with rheumatoid
pannus undergoing transnasal endoscopic resection of
the odontoid.
P Patient Patients with rheumatoid arthritis and pannus formation

(N = 9, mean age 76 years)
I Intervention Endoscopic transnasal resection of the odontoid process
O Outcome Functional status, complications
The early series of patients with rheumatoid pannus shows
the feasibility of a fully endoscopic, completely transna-
sal approach for the resection of the odontoid process.
The potential advantages include improved visualization,
limited morbidity, decreased pain, and faster recovery
than traditional approaches.

171

Author Roger Härtl

3 Thoracic techniques
3.1 Introduction
3
Thoracic techniques
173

Author Roger Härtl

3.1 Introduction
Roger Härtl
The thoracic spine is a region with a very particular anat- associated with improved outcome and survival in cancer
omy: the curvature of the spine is kyphotic; compared to patients was an important factor that led to renewed inter-
the cervical and lumbar spine, the posterior muscular cov- est in posterior approaches for minimally invasive thoracic
erage is less developed; mechanical stability is conferred by decompression and stabilization. Many elderly patients with
the thoracic rib cage, and the thoracic cavity allows access metastatic cancer and infections of the thoracic and upper
to the anterior portions of the spine. These anatomical fea- lumbar spine were considered too ill to undergo transtho-
tures have been determining factors in the development of racic surgery. For many of these patients, posterior ap-
specific and less invasive access strategies to the thoracic proaches can often achieve the same goal as anterior, trans-
spine, which are covered in the following chapters. thoracic surgery, ie, vertebral body resection with anterior
spinal column reconstruction. Variants of this technique
The extreme lateral minithoracotomy approach for the treat- include transpedicular corpectomy, costotransversectomy,
ment of thoracic spinal pathologies developed from Mayer’s and the lateral extracavitary approach. Combined with tu-
[1] and Kossman et al’s [2] work on less invasive transtho- bular retractor systems and percutaneous or mini-open
racic approaches. This approach has since become used on pedicle screw placement, the posterior thoracic approach
a more widespread scale and rendered more practicable becomes less or minimally invasive. However, the limita-
through a modification of the lateral transpsoas procedure tions and possible complications associated with this ap-
for lumbar fusion based on Ozgur et al’s [3] work during the proach have to be clearly understood, and in this respect
first decade of this century. The main advantage of this ap- Saigal's and Chou’s chapter 3.4 Posterior approaches for
proach is that it allows most surgeons to apply skills they minimally invasive thoracic decompression and stabilization
are familiar with, rather than having to confront the chal- provides an excellent summary of the different techniques
lenging learning curve required to master endoscopic trans- currently utilized together with the indications, contrain-
thoracic techniques. The extreme lateral minithoracotomy dications, and the advantages and drawbacks involved.
technique can thus be viewed as a less invasive, mini-open
compromise between traditional open thoracotomies and Less invasive pedicle screw fixation in the thoracic spine is
endoscopic approaches. relevant for all posterior thoracic fixation procedures. This
and more has been discussed in Dekutoski et al’s scholarly
Since the 1990s, anterior thoracoscopic approaches have review in chapter 3.5 Posterior approaches for minimally
provided a minimally invasive access strategy that presents invasive treatment of spinal fractures. An external spinal
unique opportunities to surgeons who are prepared to mas- skeletal fixation system was developed by Magerl [7] in
ter the complex learning curve required. Rosenthal et al [4] Switzerland, and has been in clinical use since 1977 for the
from Germany first developed thoracoscopic procedures for treatment of patients with spinal fractures and infection.
the treatment of spinal pathologies. Independently, Mack This was probably the first “minimally invasive” utilization
et al [5], Dickman et al [6], and others established thoraco- of spinal instrumentation. The challenge was, and still is,
scopic techniques in spine surgery in the USA. As Heider to develop a technique and instruments that allow the
and Beisse’s chapter 3.3 Anterior thoracoscopic approaches, minimally invasive placement of rods to connect the ped-
including fracture treatment illustrates, in dedicated and icle screws, in order to achieve a biomechanically stable
experienced hands, this approach provides an elegant way construct. This has been elegantly solved for short-segment
to treat a wide variety of spinal pathologies including trau- fixation with many of the modern instrumentation systems.
ma, tumor, infection, and deformities from levels T3 down However, rod placement for multilevel fixation remains a
to L2. challenging issue, as pointed out by Ludwig and Wang in
their “Tips and tricks” in the same chapter. Percutaneous
The realization in the 1990s and early 2000s that the ag- screw fixation offers advantages for patients prone to infec-
gressive surgical treatment of spinal metastatic lesions was tion and wound healing difficulties when operated on by
175

Author Roger Härtl
open surgery. The approach in trauma patients to “fuse future include, among others, the transoral treatment of
short and rod long” by using mini-open or percutaneous metastatic C2 lesions [10], the treatment of metastatic tho-
bridge fixation across injured motion segments and staged racic lesions combining vertebral augmentation with radio-
hardware removal is a fascinating concept. However, it is surgery [11], and the development of bioactive cement [9].
unclear whether the removal of hardware is really neces-
sary in these patients; future studies will hopefully resolve Different forms of navigation are integral to the application
this and other controversial issues. of MISS in the thoracic spine, and have been examined in
the various chapters. The future will undoubtedly see in-
Vertebral augmentation procedures have provided a major traoperative CT scanners, integration of imaging modalities,
example of minimally invasive spine surgery since their and improved software that will facilitate the integration
first use for treating vertebral hemangiomas by Galibert et of 3-D navigation into the surgical workflow.
al in 1987 [8]. As Heini’s chapter 3.6 Vertebroplasty and
percutaneous cement reinforcement techniques nicely The success of minimally invasive spine surgery depends,
describes, the technique has been much refined over the among other factors, on the integration of state-of-the-art
years and is currently used not only to treat isolated tho- scientific knowledge, technical expertise, and the surgeon’s
racic and lumbar pathologies but also to augment spinal individual experience. The following chapters cover techni-
instrumentation, leading to greatly improved screw/bone cal procedures and developments, and the scientific know-
interface biomechanics [9]. As such, it has become an im- how behind particular surgical approaches. In an attempt
portant adjunct to minimally invasive surgery and frequent- to underline the importance of the surgeon’s individual
ly enables the treatment of elderly patients with poor bone experience and “wisdom”, in each chapter there is a short
quality and more complex pathologies, such as degenerative section entitled “Tips and tricks”, which includes invaluable
scoliosis. Other more recent indications that are not further comments and advice given by some of the masters in the
discussed here but may become increasingly relevant in the field.
References
1. Mayer HM (1997) A new microsurgical 5. Mack MJ, Regan JJ, Bobechko WP, et 9. Choma TJ, Frevert WF, Carson WL, et
technique for minimally invasive al (1993) Application of thoracoscopy al (2011) Biomechanical analysis of
anterior lumbar interbody fusion. Spine; for diseases of spine. Ann Thorac Surg; pedicle screws in osteoporotic bone
22(6):691–699; discussion 700. 56(3):736–738. with bioactive cement augmentation
2. Kossmann T, Jacobi D, Trentz O 6. Dickman CA, Rosenthal DJ, Perin NI using simulated in vivo
(2001) The use of a retractor system (1999) Thoracoscopic spine surgery. 1st ed. multicomponent loading. Spine;
(SynFrame) for open, minimal invasive New York: Thieme Medical Publishers. 36(6):454–462.
reconstruction of the anterior column 7. Magerl FP (1984) Stabilization of the 10. Dorman JK (2010) Vertebroplasty of
of the thoracic and lumbar spine. Eur lower thoracic and lumbar spine with the C2 vertebral body and dens using
Spine J; 10(5):396–402. external skeletal fixation. Clin Orthop an anterior cervical approach: technical
3. Ozgur BM, Aryan HE, Pimenta L, et al Relat Res; 189:125–141. case report. Neurosurgery;
(2006) Extreme lateral interbody fusion 8. Galibert P, Deramond H, Rosat P, et 67(4):E1143–E1146.
(XLIF): a novel surgical technique for al (1987) [Preliminary note on the 11. Papanastassiou ID, Aghayev K, Saleh
anterior lumbar interbody fusion. Spine treatment of vertebral angioma by E, et al (2012) The actual management
J; 6(4):435–443. percutaneous acrylic vertebroplasty.] of tumor and vertebral compression
4. Rosenthal D, Rosenthal R, de Simone Neurochirurgie; 33(2):166–168. French. fractures. J Neurosurg Sci; 56(2):77–86.
A (1994) Removal of a protruded disc
using microsurgical endoscopy. A new
technique. Spine; 19(9):1087–1091.

3.2 Extreme lateral mini-thoracotomy approach for thoracic
spinal pathologies
Roger Härtl
1 Historical perspective to prefer open surgery for, eg, large thoracic disc herniations
[10]. In this context, Mayer was the first to publish a study
Until the 1950s, most thoracic spinal pathologies, including on less invasive retroperitoneal and transperitoneal ap-
thoracic disc herniations, were approached posteriorly proaches using a self-holding spreader frame [11], and sub-
through laminectomy [1]. Today, posterior and posterolat- sequently described a microsurgical anterior approach to
eral approaches, such as costotransversectomy and trans- the thoracic spine and thoracolumbar junction through a
pedicular techniques, have become part of the spine sur- small lateral incision using a specially designed soft-tissue
geon’s armamentarium for selected pathologies. Early on, spreader [12, 13]. Kossmann et al [14] reported on the suc-
however, it was already recognized that purely posterior cessful use of an operating table-mounted retractor system
procedures for the treatment of primarily anterior and mid- via a mini-thoracotomy approach in 65 patients with tho-
line pathologies were frequently associated with poor results. racolumbar pathologies.
This led surgeons to explore the feasibility of a more direct,
anterior or anterolateral surgical corridor. Hodgson [2] and In 2006, Ozgur et al [15] reported their results in 13 patients
Hodgson et al [3] were among the first to report encourag- treated via an extreme lateral translumbar approach for
ing outcomes with surgical debridement via thoracotomy interbody fusion using tubular retractors. This technique
for the treatment of Pott's disease. Many authors have sub- was largely based on Pimenta’s [16] work, which was first
sequently described variations of anterior thoracic approach- presented in 2001. Since then, the extreme lateral approach
es for certain pathologies depending on the spinal levels for interbody fusion has gained widespread popularity as a
involved. Cauchoix and Binet [4], for example, described less invasive option for fusion between L1 and L5.
the use of median sternotomy for pathologies located be-
tween levels C7 and T4, while Heitmiller [5] reported on a The extreme lateral minithoracotomy (ELMT) approach
thoracolumbar approach for pathologies between T10 and using tubular retractors for the treatment of thoracic spine
L2. These studies contributed towards establishing the four pathologies was subsequently developed as an extension
categories that now constitute the standard anterior ap- of the above technique, using the same surgical principle;
proaches to the thoracic spine, namely: anterior cervical it allows surgery to be carried out between T4/5 down to
approach or median sternotomy for C7–T3; right thora- L4/5 using microscopic or loupe magnification [17–19]. Since
cotomy for T2–6; left thoracotomy for T6–11; and a left its introduction, the ELMT approach has been described for
thoracolumbar approach for T10–L2. a number of thoracic spine pathologies, including thoracic
disc herniations, traumatic fractures, infection, tumors, and
Early on, the morbidity associated with open anterior sur- deformity correction [17–24].
gery led to increasing interest on the part of surgeons in
developing alternative, less invasive approaches. In 1994,
Rosenthal et al [6] described a video-assisted thoracoscopic 2 Terminology
(VATS) approach for thoracic disc herniations. The pre-
liminary results of endoscopically-assisted spine surgery The ELMT approach represents a modification of the extreme
demonstrated the benefits of this approach, including re- lateral translumbar approach for interbody fusion and in-
duced surgical trauma, less blood loss, less pain at the op- strumentation. As it has subsequently been promoted by
erative site, as well as improved postoperative respiratory certain commercial manufacturers, it is also known as
function [7–9]. This technique is still commonly used for “XLIF”, “DLIF”, or “Oracle” surgery. The general principle,
sympathectomies, but the challenging learning curve and however, remains the same for all these techniques: direct
long operating time associated with more complex endo- lateral access through a small incision using tubular soft-
scopic surgery have led even experts in the field of VATS tissue retractors.
177

Author Roger Härtl
3 Patient selection retractor placement. Once the retractor is in place, it

provides direct visualization of the surgical anatomy
3.1 Indications for the ELMT approach through a limited but adequate corridor without the
Indications for the ELMT approach do not differ from those need for full thoracotomy and without the drawback of
for open surgery, and include pathologies located in the relying on 2-D monitors
anterior and median portion of the spinal column, or the • ELMT can be performed using single-lumen ventilation,
anterior portion of the spinal canal between T4 and L1/2. and deflation of the lung is usually not necessary
This technique has been successfully used for the following • Most procedures are performed under the operating
indications, among others: microscope, which provides excellent visualization of
• Degenerative pathologies the pathology and nervous structures in question.
• Traumatic injuries
• Infectious or neoplastic processes. 4.2 Cons
• The use of the operating microscope usually requires
The ELMT approach may be used as a stand-alone procedure, previous microsurgical training. The surgeon should be
or combined with posterior stabilization. familiar with approaches using tubular retractors for
lumbar spine pathologies before performing this tech-
3.2 Contraindications for the ELMT approach nique in the thoracic cavity
The following relative contraindications should be taken • Multilevel surgery is usually performed through one
into consideration: skin incision, but it may require multiple approaches
• Previous surgery in the same area through separate intercostal spaces
• Risk of injury to the thoracic cavity and lung tissues; a • The insertion of multilevel plates or other larger instru-
history of pneumonia or emphysema may have caused mentation may prove difficult intraoperatively, and
damage and scarring, and constitute a potential risk dur- should be carefully planned preoperatively, with ap-
ing exposure. Compromised pulmonary function due propriate instrumentation selected beforehand
to restrictive airway disease, among others, or as a result • Although ELMT provides excellent visualization of the
of heavy smoking, should also be carefully evaluated target anatomy, the view of the surrounding structures
• Pathologies located in the posterior portion of the spinal is limited
canal, or spinal stenosis, cannot be addressed via the • There is a risk of inadvertent tissue injury: the retraction
extreme lateral approach of lung tissue has to be performed carefully, as sometimes
• Patient body mass (eg, obesity or body habitus) may there is a tendency for lung tissue to creep into the
constitute a drawback. If an ELMT approach is decided operative field, which increases the risk of pulmonary
upon, the surgeon should ensure that the retractor blades injury. (However, this risk can usually be avoided by
and instruments used are of sufficient length. using plastic shims or surgical sponges that help seal the
“gaps” between the retractor blades)
• Careful preoperative planning and emphasis on correct
4 Pros and cons of the ELMT approach for thoracic patient positioning is required for accurate intraopera-
spinal pathologies tive localization using image intensification
• Body mass should be taken into consideration if the
4.1 Pros patient is large or obese, and the surgeon should ensure
The main advantages of the ELMT approach include reduced that the retractor blades and instruments used are of
access size, avoidance of lung deflation, and enhanced 3-D sufficient length.
visualization provided by the microscope.
• The small size of the opening is associated with reduced
trauma to the thoracic cavity and reduced risk of a post- 5 Preoperative planning and positioning
thoracotomy pain syndrome
• Less risk of injury to the intercostal nerve and neuro- 5.1 Preoperative planning
vascular bundle; it is also frequently possible to avoid Preoperative planning and correct positioning are crucial
resection of the rib, or limit resection to only a small for the successful outcome of the procedure, and should be
portion of the rib taken very seriously. Preoperative imaging studies should
• Compared to VATS, the opening is less extensive yet it at the very least include a CT scan and/or MRI depending
allows direct visualization of the pleura and lung during on the underlying pathology. The CT scan and plain films

3.2 Extreme lateral mini-thoracotomy approach for thoracic spinal pathologies
are used for the accurate localization of the pathology in to be treated should also be clearly identified and visualized.
question and should include the thoracolumbar junction This will ensure the accurate placement of the incision, and
down to L2. The exact location of the pathology and the avoid unnecessary extension of the surgical approach be-
incision can then be determined by counting up from the yond one or two intercostal spaces. The operating table
lowest rib. The entry site (right or left) is determined by the should be adjusted for each level in order to optimize the
anatomy of the large vessels, the pathology to be treated, anatomical orientation.
and the position of the scapula and the liver. Between T4–
6/7, the left side is relatively less accessible due to the loca- With the aid of AP and lateral image intensification, the
tion of the great vessels and the aortic arch. For pathologies vertebral body above and below the pathology and the skin
above T4/5, the scapula frequently limits an ELMT approach, incision are marked (Fig 3.2-1d, Fig 3.2-2). During this pro-
and alternative surgical approaches should be considered, cedure, the surgeon is usually positioned behind the patient’s
ie, anterocervical, transsternal, posterior, or posterolateral. spine, and facing the x-ray screen (Fig 3.2-1a). The C-arm
For pathologies below T6/7 and down to the thoracolumbar and the microscope are brought into the operating field
junction, the left side is usually preferred because the aor- from opposite the surgeon’s position.
ta can be easily identified, retraction of the liver is avoided,
and the insertion of the diaphragm is usually lower. How-
ever, approaches from the right side are also possible, and 6 Surgical technique
the final decision should be made based on the exact loca-
tion and extension of the pathology, eg, a large, right-sided 6.1 Access
calcified disc herniation with significant spinal cord com- A skin incision is made along a line exactly over the target
pression is usually approached from the right side. In the disc space, as identified on lateral x-rays, and a combination
presence of a deformity, an approach performed from the of blunt and sharp dissection is used to gain access to the
convex side of the spine is usually preferred. intercostal space (Fig 3.2-1d). Depending on the specific
anatomy and the need for exposure, the rib may either be
Preoperative embolization should be considered when vas- preserved, in which case the retractor is inserted between
cular tumors are present. Intraoperative neurophysiological the ribs; or a portion of the rib can be resected in order to
monitoring and cell-saving procedures are carried out for increase the exposure for multilevel procedures or corpec-
most surgical interventions. The use of double-lumen in- tomies. If part of the rib is removed, the edges should be
tubation may be useful, especially during the first cases to smoothed down, and bone wax can be applied to the cut
allow for the deflation of one lung in order to improve vi- surface. Then, using blunt-finger dissection, the parietal
sualization. However, surgeons frequently find that this is pleura is identified and incised. The lung and diaphragm
not necessary, and that the lung can be kept out of the can then be palpated, and adequate mobility of the lung
surgical field using the tubular retractor. A typical operating and absence of any adhesions confirmed. The next step
room setup for a left-sided approach is shown in Fig 3.2-1a. involves the placement, with one hand, of the first blunt
dilator (Fig 3.2-3) along the chest wall down to the spinal
5.2 Positioning column, while using the index and ring finger of the other
The patient is positioned on a radiolucent table in a true hand the surgeon retracts the lung anteriorly. A K-wire
90° lateral decubitus position with or without the aid of a should not be used when performing thoracic spine surgery,
bean bag (Fig 3.2-1b–c). An adjustable table, as used in the since it could result in serious injury to the lung and vas-
extreme lateral approach for the lumbar spine, is usually cular structures. The position of the dilator over the desired
not necessary unless a coronal deformity is present, or the level is then confirmed with AP image intensification
surgeon wishes to adjust the table in order to open up the (Fig 3.2‑4), and the subsequent dilators are placed. The depth
intercostal space and allow improved access with the retrac- of the thoracic exposure is determined using the markers
tor. The patient is then secured to the operating table with on the dilators, after which the tubular retractor is assem-
surgical tape. Image intensification is used to achieve true bled. In contrast to lumbar procedures, in thoracic tech-
AP and lateral orientation of the surgical levels, with the niques, the retractor is inserted with the handles and the
spinous processes situated exactly in the midline between middle blade opposite the surgeon, with the lung retracted
the pedicles. The endplates above and below the pathology away from the operative field (Fig 3.2-5).
179

Author Roger Härtl
Anesthetist’s cart
Anesthetist
Microscope Table-mounted retractor
C-arm
Surgeon
Assistant
C-arm screen
Mayo stand
Tech
b
NV unit Bovie Back table
a
c d
Fig 3.2-1a–d
a Typical operating room setup for a left-sided approach. The surgeon typically approaches the spine from posterior. The C-arm is moved
caudally during the procedure in order to allow the surgeon and the microscope to move into the operating field.
b The patient is positioned on a radiolucent table in true 90° lateral decubitus position without beanbag and with the knees flexed.
c The use of an adjustable table as used in the extreme lateral approach for the lumbar spine is usually not necessary, unless a coronal
deformity is present or the surgeon wishes to adjust the table in order to open up the intercostal space to allow improved access.
d The target level is identified on AP and lateral image intensifier levels and its projection in marked on the skin. For the incision, we use the
projection of the traget disc space on the skin, obtained from a lateral image. K-wires are only used to localize the affected level and plan
the skin incision.

Fig 3.2-2 Patient placed in lateral position

with the T8 and T9 vertebral bodies marked in
the AP and lateral projections.
a b
Fig 3.2-3a–d Placement of the first dilator

through the mini-thoracotomy incision.
a Illustration of the initial digital approach.
b Introduction of the first dilator and
targeting of the disc. The dilator tip is
directed along the thoracic wall to
prevent injury to the lung or vascular
structures.
c The first dilator is docked at the level of
the pathology. Image intensification is
used to confirm the correct placement.
c d d Sequential dilators are placed.
181

Author Roger Härtl
6.2 Microsurgical technique

Once the retractor has been placed, the microscope is
brought in, the operative level is identified and confirmed
by image intensification, and the exposure optimized
(Fig 3.2‑6a–c). When opening the retractor blades, lung tis-
sue may creep into the operative field. Some manufacturers
have developed plastic shims and “fan-type” retractors that
can be inserted between the retractor blades, and which
help to keep the lung tissue out of the way. Surgical gauze
sponges equipped with long sutures are routinely used to
move the lung out of the operative field. The sutures are
Fig 3.2-4 X-ray confirmation of the correct secured to the surgical drapes outside the chest cavity, and
placement of the dilators. Note that pedicles, allow reliable retrieval of the sponge upon completion of
spinous processes, and endplates are visualized
the surgical procedure. Bayoneted microinstruments, which
in a true AP.
were originally developed for tubular microsurgery of the
lumbar spine, are routinely used. The microsurgical proce-
dure generally does not differ from that performed in open
surgery, and depends on the underlying pathology. Seg-
Anterior mental vessels are carefully dissected under the microscope,
and bi- and monopolar electrocoagulation is used to co-
agulate and separate the vessels.
Cranial Caudal
6.3 Navigation
Intraoperative image intensification is used throughout the
procedure, and is also essential at the preoperative stage
for the localization and accurate planning of the incision
Posterior
and access using the tubular retractor. Preoperatively, some
Fig 3.2-5 Placement of the tubular expandable retractor. This surgeons utilize small metallic markers that are placed in
middle blade retracts the lung away from the operative field. the rib head under CT guidance. Image intensification is
used to achieve true AP and lateral orientation, with ade-
quate positioning and rotation of the patient through ad-
justment of the operating table. Although 3-D stereotactic
navigation has been used in open transthoracic surgery, its
Access can be extended down to the T12–L1 disc space via application to ELMT requires further investigation.
the mini-thoracotomy approach. This may require incision
of the diaphragm at its point of insertion in the spinal col- 6.4 Instrumentation
umn. This should be carried out very carefully in order to Instrumentation of the thoracic spine using the ELMT ap-
avoid injury to the retroperitoneal structures. If the thora- proach is possible, but requires careful preoperative planning
columbar junction is approached from the lumbar side, eg, and the selection of implants suitable for insertion though
as part of a lumbar interbody fusion procedure via an ex- a small opening. Several manufacturers have developed
treme lateral lumbar approach, the dilator will typically appropriate implants for single and multilevel instrumenta-
pass through the costodiaphragmatic recess, through the tion. For single-level discectomy in the mid-thoracic spine
diaphragm and into the retroperitoneal space. down to approximately T10, instrumentation is not usu-
ally required.
Once the procedure has been completed, the retractor is
collapsed and carefully removed under direct visualization
of the lung surface as well as the segmental vessels in order 7 Postoperative care
to ensure hemostasis. A chest tube should be inserted for
one to two days postoperatively. Some surgeons prefer a A chest tube is typically placed at the end of the operative
temporary catheter introduced for aspiration of residual air procedure. However, in one subset of patients it was re-
from the cavity while the lung is being re-inflated. ported that chest tube placement could be avoided if they

Cranial
Caudal
Posterior
a b
Anterior
Caudal Cranial
Fig 3.2-6a–c
a View of the retractor attached to a bed-mounted holder and the
microscope in place.
b Operative setup with the retractor attached to the operating room table.
c The microscopic view permits accurate identification of the operative
Posterior
field. In this image the rib head has been removed and the thoracic disc is
c identified.
were treated via a retropleural approach, or after a Val- effective, with results comparable to those for open or en-
salva maneuver for thoracic cavity air expulsion [25]. As a doscopically assisted surgery, but without the steep learn-
general rule, patients are extubated in the operating room, ing curve associated with the latter and with the advantage
and stay in the intensive care unit overnight. If a chest tube of providing direct 3-D visualization of the pathology in
has been inserted, this is usually removed on the first post- question while still remaining a minimally invasive proce-
operative day. Patients are mobilized the day after surgery. dure. One small study compared a minithoracotomy ap-
Bracing is generally not required, unless there is concern proach to thoracoscopy for the treatment of medially lo-
about preexisting poor bone quality, or in the case of mul- cated thoracic disc herniations in 28 patients [26]. No
tilevel procedures. statistically significant differences were found between the
two procedures, but the authors concluded that the mini-
thoracotomy might be superior to the endoscopic approach
8 Evidence-based results because it was not associated with such a difficult learning
curve, and took advantage of the surgeon’s previous expe-
Kossmann et al [14] reported on the successful use of a table- rience with standard operating techniques.
mounted retractor system (eg, SynFrame) introduced via
a mini-thoracotomy incision in 65 patients with a thoraco- So far, only a limited number of studies in the literature
lumbar pathology between T6 and L5, mostly involving have reported significant outcome data regarding ELMT or
fracture. These authors found this technique to be safe and related minithoracotomy approaches to the thoracic spine
183

Author Roger Härtl
using tubular retractors. Smith [18] described a series of 19 9 Complications and avoidance
patients with traumatic fractures, tumors, or infection that
underwent an ELMT approach involving corpectomy with The possible complications are similar to the risks encoun-
instrumentation. No serious intra- or postoperative com- tered with regular open thoracotomies. When using the
plications were observed, but it should also be noted that retractor blades, the surgeon should be aware of the risks
the follow-up time was very limited. The successful treat- involving the direct retraction of lung tissue and the lung’s
ment of thoracic spinal tumors, including meningiomas, proximity to the surgical field. The thoracic duct, segmen-
neurofibromas, and other lesions, was described by Uribe tal vessels, and the large vessels are also at risk. Due to the
et al [22] in 21 patients, the majority of whom underwent limited exposure, brisk bleeding from the segmental vessels
corpectomy. Eighteen of these patients also underwent ad- is sometimes more difficult to control. The author recom-
ditional instrumentation with either pedicle screws or an- mends clipping or carefully coagulating segmental vessels
terolateral plating. The treatment of traumatic fractures at a distance from the aorta. The surgeon should be prepared
using the ELMT approach was described by Smith et al in to convert the minithoracotomy into an open procedure if
52 patients [23]. necessary. During the learning curve required for this tech-
nique, it is particularly advisable to have a thoracic surgeon
The largest series of patients treated by tubular ELMT in- at hand to assist in access and closure if necessary. For sur-
cluded 60 subjects from five institutions treated for thoracic geons that are experienced in open thoracic surgery and
disc herniations [20]. The authors concluded that the mini- microsurgical techniques, however, the learning curve for
mally invasive lateral approach was a safe and reproducible ELMT does not present a major challenge.
technique: excellent or good outcomes were achieved in 80%
of cases, while only 15% of patients experienced a fair or
unchanged outcome, and 5% a poor outcome. Symptom
resolution was achieved at similar percentages to those re-
ported in the literature for the most effective techniques,
with, in most cases, fewer complications.
10 Tips and tricks
Juan S Uribe, Tampa, USA • The average incision should measure 3–5 • In cases involving corpectomy, it is critical
• A thorough understanding of the region- cm, 90° off-midline (ie, directly lateral), to electrocoagulate the segmental vessels
al anatomy is critical in avoiding poten- either between or over the rib, and in prior to osteotomy.
tial neurovascular and visceral injuries. line with the angle of the rib, which can • Discectomy is performed using standard
• The side of the approach should be cho- be partially resected (5–6 cm) depending techniques, with rib head, index-level
sen according to the vertebral level and on surgeon preference or in the case of pedicle resection, and wedge osteotomy
the location of the pathology: corpectomy, where a wider exposure is carried out on the posterior aspect of the
• T2–6: right-sided approach
required. vertebral bodies, as necessary.
• T6–L2: left-sided approach
• The approach can be performed retro- • A chest tube is usually not necessary as
• The ipsilateral lung can remain inflated pleurally (extracavitary approach) or long as the visceral pleura remains in-
(dual-lumen tube intubation is not nec- transpleurally (transthoracic approach) tact. The comment author places a uni-
essary). [25]. directional drain (eg, Hemovac) into the
• It is important to place the patient in a • The approach is made using blunt ante- surgical bed, and a Valsalva maneuver is
true 90° lateral decubitus position. rior digital deflection of the diaphragm/ performed to expel excess air before con-
• Real-time neuromonitoring is recom- pleura (retropleural approach) or lung necting the drain to a sealed container.
mended using somatosensory and motor- (transpleural approach), prior to using • The wound is closed in standard fashion
evoked potentials. the sequential dilators and docking the (the resected rib can be used as auto-
expandable tubular retractor. graft, or reconstructed using standard
techniques) including all the muscle and
fascial layers.

11 Case examples tomy and partial corpectomy with spondylodesis using a 6

mm polyetheretherketone implant filled with silicated cal-
11.1 Case 1 cium phosphate and anterior instrumentation using a tita-
A 37-year-old man presented with midthoracic back pain nium plate were performed (Fig 3.2-8). Intraoperative blood
and mild myelopathy. An MRI and CT scan revealed a large loss amounted to 100 cc, and the patient was discharged on
calcified central T8/9 disc herniation with spinal cord com- postoperative day 3. Postoperative imaging studies revealed
pression (Fig 3.2-7). A right-sided ELMT approach was cho- excellent decompression and the good placement of instru-
sen in order to avoid the aorta on the left. A T8/T9 discec- mentation (Fig 3.2-9, Fig 3.2-10).
a b
a b c d
Fig 3.2-7a–b Fig 3.2-8a–e Intraoperative view
a Preoperative view: sagittal T2-weighted MRI showing a large of the same case.
central disc herniation at T8/9 with spinal cord compression. a Spinal cord compressed by
b Preoperative view: axial T2-weighted MRI showing a large central the large disc herniation.
disc herniation at T8/9. b Removal of the herniated
disc.
c Decompression after disc
removal.
e
d Placement of a poly-
etheretherketone interbody
spacer.
e Placement of a titanium
plate.
a b
Fig 3.2-9 Intraoperative image following Fig 3.2-10a–b Postoperative CT scan showing instrumentation and
decompression and instrumentation. the significant amount of bone removal required for an adequate and
safe discectomy.
185

Author Roger Härtl
11.2 Case 2 scan demonstrated bilateral pleural effusions, parenchymal

A 19-year-old man was originally admitted to another hos- opacities consistent with hemorrhage, and atelectasis. Be-
pital with an American Spinal Injury Association B incom- cause of persistent spinal cord compression (Fig 3.2-12), a
plete spinal cord injury caused by a motor vehicle accident. right-sided ELMT approach was performed consisting of T5
A CT scan demonstrated a severe burst fracture at T5 and corpectomy with decompression of the spinal cord, place-
milder fracture at T6, with cord compression and transloca- ment of an expandable cage, and additional stabilization
tion of the T4 and T5 vertebral bodies (Fig 3.2-11). The patient using a lateral plate (Fig 3.2.-13). Both lungs were venti-
first underwent an emergency procedure consisting of tho- lated during the procedure, and intraoperative blood loss
racic laminectomy and stabilization, and was then trans- amounted to 400 cc. The patient remained intubated for
ferred to the author's institution for further management. several days after surgery, and subsequently made a good
According to the surgeon that originally dealt with the case, recovery. Six months after surgery the patient was ambula-
there was concern regarding the stability of the posterior tory, able to walk with the aid of a cane, and experienced
pedicle screw instrumentation, because the screws used minimal pain. Postoperative imaging studies demonstrated
were very short. The patient was intubated and a chest CT stable instrumentation (Fig 3.2-14).
Fig 3.2-11 Sagittal CT scan of Fig 3.2-12 Sagittal MRI showing Fig 3.2-13 Postoperative sagittal
the thoracic spine after posterior residual spinal cord compression. CT scan showing decompression
decompression and stabilization and insertion of an expandable
for a T5/T6 fracture. cage with placement of bone
screws at T4 and T6.
Fig 3.2-14a–b Postoperative

a b plain AP (a) and lateral (b) x-rays.

12 Key learning points and that postoperative morbidity may be reduced when
compared to open surgery
• Anterior approaches for the treatment of thoracic spinal • Extreme lateral approaches allow access to the spine
pathologies can be performed safely and effectively us- from T5 all the way down to L5
ing minimally invasive surgery • Compared to VATS procedures, the ELMT access has a
• Class III evidence indicates that minimally invasive pro- much less demanding learning curve while still offering
cedures for thoracic spine surgery are safe and effective, all the advantages of minimally invasive surgery.
13 References
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187

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Bartels, RH, Peul WC (2007) Mini-thoracotomy or Kossmann T, Jacobi D, Trentz O (2001) The use of a
thoracoscopic treatment for medially located thoracic retractor system (SynFrame) for open, minimal invasive
herniated disc? Spine; 32(20):E581–E584. reconstruction of the anterior column of the thoracic and
lumbar spine. Eur Spine J; 10(5):396–402.
Therapy Retrospective cohort study III Study type Study design Class of evidence
Purpose
To compare the minithoracotomy to thoracoscopy for the Purpose
treatment of calcified thoracic herniated disc. To describe a new method in which the anterior column
of the thoracic and lumbar spine was reconstructed
P Patient Calcified thoracic herniated disc (N = 28) through an open, but minimally invasive approach with
I Intervention Minithoracotomy (n = 21) the use of the new retractor system, SynFrame.
C Comparison Thoracoscopy (n = 7)
P Patient Traumatic injuries, metastasis, or pseudarthrosis of the
O Outcome Pain, surgical success thoracic/lumbar spine (N = 65, n = 37 males, mean age 42
years)
Authors’ conclusion I Intervention Open, minimally invasive reconstruction of the anterior
The minithoracotomy has some theoretical advantages column of the thoracic and lumbar spine
over a thoracoscopy and is also a minimally invasive ap- C Comparison No comparison group
proach. O Outcome Surgery time, blood loss, complications
The results indicate that this technology for minimally
invasive access to the spine is safe and easy to use. This
makes the method not only an alternative to thoraco-
scopic or laparoscopic procedures, but it also overcomes
the disadvantages of endoscopic spine surgery.

Uribe JS, Smith WD, Pimenta L, et al (2012) Minimally Smith WD, Dakwar E, Le TV, et al (2010) Minimally
invasive lateral approach for symptomatic thoracic disc invasive surgery for traumatic spinal pathologies: a
herniation: initial multicenter clinical experience. mini-open, lateral approach in the thoracic and lumbar
J Neurosurg Spine; 16(3):264–279. spine. Spine; 35 Suppl 26:S338–S346.
Purpose Purpose
To examine the safety and early results of a minimally To examine patient outcomes using a mini-open, lateral
invasive lateral approach for symptomatic thoracic herni- approach for the treatment of traumatic thoracic and
ated intervertebral discs. lumbar fractures.
P Patient Symptomatic thoracic herniated intervertebral discs with or P Patient Traumatic thoracic or lumbar fractures (N = 52)
without calcification (N = 60, n = 32 males, mean age 57.9
years, N = 75 symptomatic thoracic herniated discs) I Intervention Mini-open lateral corpectomy
I Intervention Minimally invasive lateral approach C Comparison No comparison group
C Comparison No comparison group O Outcome Neurological status, complications, operative time, estima-
ted blood loss, length of hospital stay
O Outcome Operating time, estimated blood loss, length of hospital
stay, complications, pain Authors’ conclusion
The mini-open lateral approach for thoracic and lumbar
Authors’ conclusion corpectomy was shown to be safe and effective in this
The authors’ early experience with a large multicenter series while avoiding many of the associated morbidities
series suggested that the minimally invasive lateral ap- of thoracotomies for anterior column reconstruction and
proach is a safe, reproducible, and efficacious procedure open posterior approaches.
for achieving adequate decompression in thoracic disc
herniations in a less invasive manner than conventional
surgical techniques and without the use of endoscopes.
Symptom resolution was achieved at similar rates using
this approach as compared with the most efficacious tech-
niques in the literature, and with fewer complications in
most circumstances.
189

Author Roger Härtl

3.3 Anterior thoracoscopic approaches, including fracture
treatment
Franziska Heider, Rudolf Beisse
1 Historical perspective 2 Terminology
Endoscopy has a rich history, and from slow beginnings has By definition, “thoracoscopy” means the performance of
undergone a remarkable evolution. The origin of the word surgery through small skin incisions (“keyhole surgery”)
is derived from the ancient Greek, meaning visualization with the aid of a 30° endoscope for magnification of the
(scopien) from inside (endo) [1]. surgical field. The thoracoscopic anterior technique allows
a minimally invasive anterior approach to the thoracic spine,
At the beginning of the 20th century, three techniques were as well as to the thoracolumbar junction (T3–L2).
developed: ventroscopy (intrapelvic endoscopy), laparos-
copy (intraabdominal endoscopy), and thoracoscopy (in-
trathoracic endoscopy) [1]. Jacobeus, a professor of internal 3 Patient selection for anterior thoracoscopic
medicine in Stockholm, Sweden, was the first to perform approaches, including fracture treatment
laparoscopic and thoracoscopic procedures in human beings
[1–3]. In so doing, he introduced the technique of thoracos- As regards patient selection, in general there are no limita-
copy into medical practice for the diagnosis and treatment tions regarding age, pathology, or spinal level.
of pulmonary tuberculosis [1–3]. At that time, the main
indication for thoracoscopy was for the lysis of tuberculous 3.1 Indications
pleural adhesions (intrapleural pneumolysis) [1]. However, Overall, the range of indications for the techniques described
after the development of antibiotic agents for the treatment here can be defined as follows:
of tuberculosis, intrapleural pneumolysis was no longer used • Anterior reconstruction of fractures of the thoracic spine,
and the interest in thoracoscopy waned. From the 1950s as well as of the thoracolumbar junction (T3–L2) includ-
until the 1980s, thoracoscopy was almost entirely replaced ing fractures classified as type A1.2, A1.3, A2, A3, B,
by open surgical procedures [1]. Its renaissance in the 1990s and C according to the Müller AO Classification [10],
was the direct result of the explosive development of en- with significant curvature displacement of 20° or more
doscopic techniques in other surgical specialties [1]. in the sagittal or frontal plane. In type B and C fractures,
posterior instrumentation is mandatory; in other types,
Since the early 1990s, thoracoscopic procedures have been it is optional
used on an increasingly widespread scale. In Germany at • Discoligamentous segmental instability
the beginning of the 1990s, Rosenthal and colleagues [4] • Posttraumatic deformity of healed fractures with or
developed thoracoscopic approaches for the treatment of without instability
spinal pathologies. Independently of this German group, • Degenerative deformities
Mack et al [5] and Regan et al [6] established the technique • Anterior interbody fusion in cases of long posterior in-
of thoracoscopy in the United States. Comprehensive treat- strumentation (eg, scoliosis correction)
ment for spinal trauma including thoracoscopic anterior • Inflammatory states
decompression, vertebral body replacement, and anterior • Presence of tumors
instrumentation was further developed by the present au- • Thoracic disc herniation
thors’ group in the mid-1990s [7–9]. Since that time, tho- • Posttraumatic, degenerative, or tumor-associated nar-
racoscopy has emerged as a safe surgical technique with a rowing of the spinal canal
wide field of applications. • Revision surgery (ie, implant removal, infection, implant
failure, and loosening)
191

Authors Franziska Heider, Rudolf Beisse
• Preparation and release of the anterior column in cases • Treatment of oligo- and multisegmental pathologies
of primary tumors or metastases without additional surgical approaches
• Sympathectomy for hyperhidrosis [1]. • Reduced blood loss
• Less postoperative pain
3.2 Contraindications • Low peri- and postoperative morbidity due to less wound
The thoracoscopic approach is contraindicated in the fol- pain, early extubation, fast postoperative mobilization
lowing situations: and rapid rehabilitation.
• Significant previous cardiopulmonary disease with lim-
ited cardiopulmonary function and associated contra- 4.2 Cons
indications for single-lung ventilation • Increased amount of anesthetic monitoring and prepa-
• Major contraindications for general anesthesia and sur- ration due to single lung ventilation (double-lumen tube)
gery • Technically demanding procedure
• Acute posttraumatic lung failure • Thoracoscopic training required, with a steep learning
• Significant hemostatic disturbances. curve for the surgeon and operative assistant
• The two-dimensional (2-D) nature of the image has its
limitations, and makes it difficult for the surgeon to
4 Pros and cons of anterior thoracoscopic correctly assess the working angle and the penetration
approaches depths of the instruments and screws from an orthograde
view.
The main advantage of the thoracoscopic approach is that
it provides a direct view of the anterior surface of the tho-
racic spine, the thoracolumbar junction, and the spinal cord, 5 Preoperative planning and positioning
thereby requiring only small incisions in the intercostal
spaces. The cosmetic aspects, although of prime importance The preoperative evaluation and planning procedures are
to the patients, are only one of its obvious advantages. In of particular importance in guaranteeing successful surgery.
comparison to an open procedure like thoracotomy, tho- Preoperative imaging provides vital information on the
racoscopic surgery benefits the patient in several other ways, anatomical as well as the pathoanatomical structure and
which include less disruption of the normal anatomy, less positioning of the spine, including malpositioning in all
postoperative scar tissue, decreased postoperative pain, a three dimensions—sagittal, frontal, and horizontal—and
shorter period of hospitalization due to more rapid recovery the topographical anatomy of the target area.
and mobilization, reduced disability, and less expense.
Preoperative imaging studies include mandatory standard
The thoracoscopic technique, however, requires in-depth x-rays: AP and lateral views in a standing position; and
anatomical knowledge as well as a learning curve that ne- functional x-rays with the patient in a lateral position (flex-
cessitates significant adaptation on the part of the surgeon. ion-extension views) to assess the curvature of the spine
and configuration of the vertebral bodies. Flexion-extension
In the following, the specific advantages of thoracoscopic views reveal the existence of possible translational segmen-
procedures as well as the reasons for limiting the use of this tal slipping, fractures, as well as vertical instability. Under-
technique have been presented. standably, in highly unstable fractures dynamic x-rays
should be avoided.
4.1 Pros
• Minimally invasive intercostal surgical approach with- Magnetic resonance imaging is also obligatory for the pre-
out the necessity for rib resection or the use of rib retrac- operative planning stage. It is the diagnostic tool of choice
tors, with improved postoperative cosmetic results for evaluating the paraspinal soft tissues, the neural struc-
• Reduced soft-tissue trauma tures including the situation within the spinal canal, as well
• Excellent intraoperative view of the target area through as the localization and course of the greater vessels in rela-
the use of a high-resolution 30° endoscope coupled to tion to the spine. T1- and T2-weighted sagittal and T2-
state-of-the-art video-imaging equipment weighted axial images are most frequently used in this
• Efficient and safe anterior decompression of the spinal regard. The additional contribution of sagittal short-time-
canal, as well as anterior stabilization of the spine inversion-recovery (STIR) sequences is required in fracture
cases to evaluate the maturity of the fracture (bone edema).

3.3 Anterior thoracoscopic approaches, including fracture treatment
Especially in fracture cases, CT scans are also recommend- central venous catheter, as well as an arterial line ensures
ed and represent the diagnostic tool of choice for evaluating continuous intraoperative anesthetic monitoring. The use
the type of fracture according to the Müller AO Classifica- of a urinary catheter is mandatory. If there are no contra-
tion [10], as well as, eg, the bone structure in cases of post- indications, cell-saving procedures are routinely required.
traumatic deformity. Furthermore, a sufficient supply of blood for transfusion
purposes is obligatory for all thoracoscopic procedures. Usu-
In elderly patients who are to undergo fusion procedures, ally, perioperative antibiotic prophylaxis starts 20 minutes
a bone densitometry measurement is recommended. In prior to the skin incision. Routinely, 24-hour antibiotic
cases of osteoporosis, cement augmentation and stabiliza- protection is recommended. In order to minimize periop-
tion has shown very good results (quod vide following the erative complications, the authors refer to the World Health
case reports). Organization Surgical Safety Checklist for all surgical in-
terventions.
Specific preoperative preparation of the patient is required
the day before surgery. The patient is placed in a stable lateral position on the right
or left side and secured with a four-point support at the
A pulmonary function test and breathing test are com- symphysis, sacrum, and scapula, as well as with an arm rest
monly performed preoperatively to assess the patient’s vi- (Fig 3.3-1) [11]. The upper arm is abducted and elevated to
tal parameters. Routine bowel evacuation is usually carried avoid interfering with the placement of the endoscope. To
out to decrease intra-abdominal pressure and tension on minimize the risk of brachial plexus irritation, the arm
the diaphragm. Prior to surgery, shaving of the surgical area should be placed in such a way that this avoids hyperabduc-
is performed if necessary. tion and hyperextension.
General anesthesia with single-lung ventilation and com- The decision regarding which side to choose for access in
plete relaxation is required for the operation. Intubation each individual case is based on the anatomical course of
with single-lung ventilation facilitates intrathoracic prepa- the aorta and vena cava, as well as on the preoperative CT
ration. The exact positioning of the double-lumen tube is scans and MRI. The authors recommend looking at the
controlled by auscultation, as well as by bronchoscopy. A greater vessels, and then choosing the side for access.
L2 T12
Portal
b c Vertebral body
Fig 3.3-1a–c Correct patient positioning.
193

Opinions in the literature on portal placement are divided, Before the surgical procedure begins, the position and free
and should be viewed as depending on the surgical school tilt of the C-arm must be checked. Incorrect positioning of
and specialist field from which the authors originate [7]. the patient, as well as that of the C-arm, could result in
Thus, in the American school, as advocated by Dickman et malpositioning of, eg, the K-wires or screws with the sub-
al [1], Rosenthal et al [4], and Regan et al [6], the neurosur- sequent risk of damage to the aorta, vena cava, lung, or
geon and orthopedic surgeon usually stand in front of the other paraspinal soft tissues.
patient, facing and working in a diagonal dorsal direction
towards the spinal canal [7]. By contrast, surgeons special- As already described above, the correct placement of the
izing in orthopedics and trauma are accustomed to open portals is of particular importance. Almost every portal
spine surgery, and stand behind the patient in order to placement is permitted, but it depends on the aims of the
operate on the spine from the side. surgery in question, as well as on the pathology/target area.
Independently of these divergent opinions and approaches, As a first step, preoperative localization of the target area
experience shows that the correct placement of portals is is determined under image intensification in both AP and
of fundamental importance for the entire course of the op- lateral views. The target area is projected onto the skin
eration. level under image intensification, and the borders of the
target area (disc, vertebra) are marked on the skin (Fig 3.3-
The arrangement of the equipment and positioning of the 3). The correct projection of the vertebrae is of prime im-
surgeon that the authors normally use for endoscopic access portance. The endplates, the anterior, and the posterior
is described in the following. margins of the vertebrae should be displayed in the central
beam, in sharp focus and with no double contour. This
The monitors are placed at the lower end of the operating marking is used as reference for the subsequent placement
table, as well as opposite the surgeon in order to provide of the portals.
an unimpeded view for the surgeon, the assistant, and the
cameraman (Fig 3.3-2). The surgeon and the cameraman The working portal is centered over the target area (10 mm).
stand behind the patient. The C-arm is situated between The optical channel is placed between two and three inter-
the surgeon and the cameraman. The assistant, the “sur- costal spaces cranial to the target area in the spinal axis. For
geon’s monitor”, as well as the C-arm monitor are placed targets at the middle and upper thoracic spine, the optical
on the opposite side. channel is placed caudal to the target area. The approaches
1
3
4
2
2
1
3
a b
Fig 3.3-2a–b Operating room setup showing installation of the equip-
ment and positioning of the operative team.
1 Surgeon
2 Assistant
3 Cameraman
4 Nurse

for suction/irrigation and for the retractor are placed ap- 6 Surgical technique
proximately 5–10 cm anterior to the working and optical
channels (Fig 3.3-4). The correct placement of these portals 6.1 General principles of thoracoscopy
is of utmost importance to ensure the correct working di- The sequence of preparative and surgical steps in thoracos-
rection and avoid loss of orientation. copy is no different from that followed in open surgery.
Operative maneuvers that would not be used during open
surgery should never be performed thoracoscopically [1].
First, the anatomical structures should be clearly identified
[1]. Dissection and working with sharp instruments should
never be performed blindly; all maneuvers must be clearly
visualized [1].
Although the sequence closely resembles that used during

open procedures, thoracoscopic surgery requires new skills,
psychomotor strategies, and altered perceptions in the ap-
plication of anatomical knowledge [1].
6.2 Thoracoscopic equipment and instruments

The key to any endoscopic approach lies in image recording
Fig 3.3-3 Preoperative localization of the target area. and transmission. Therefore, state-of-the-art high-definition
video-imaging techniques have also revolutionized the en-
doscopic technique, which now provides views comparable
to those that the microscope is able to provide.
Illumination of the thoracic cavity is effected by a high-

intensity xenon light source. For image transmission, a 30°
endoscope is used, which enables an undisturbed working
A C D field, as well as variable adjustment of the angle of vision
B (Fig 3.3-5). The intraoperative site is transmitted onto one
large flat screen (the “surgeon’s monitor”), as well as onto
three other flat screens, which form part of an endoscopic
tower equipped with a digital image recorder (Storz, Tut-
tlingen, Germany), a xenon light source (Storz, Tuttlingen,
Germany), and a pumping system for suction and irrigation
(Fig 3.3-6). Air insufflation is not necessary.
Fig 3.3-4 Diaphragmatic anatomy at the thoracolumbar junction and Fig 3.3-5 View of a 30°endoscope.
position of the portals.
A: Working portal
B: Fan-shaped retractor
C: Suction/irrigation
D: Optical portal
195

6.3 Use of instruments

To prevent uncontrolled movements of the instruments
and the risk of damage to the paraspinal soft tissues, the
so-called three-point anchoring of tools is recommended
4 (Fig 3.3-7). All thoracoscopic instruments are held with both
hands. One hand is used for stabilizing the instrument, while
1
the other is used for guiding it, thereby avoiding uncon-
trolled movements. Inaccurate or faulty handling of the
2 instruments risks injury to the aorta, vena cava, and other
paraspinal tissues.
3
Due to the 2-D nature of the image, it is difficult to cor-
rectly assess the penetration depths of the instruments.
Therefore, as previously noted, a depth scale should be in-
a cluded on both sides of the instrument to ensure that the
exact depth is indicated during surgery (Fig 3.3-8).
6.4 Access
Routinely, the surgical procedure begins with the most cra-
nial approach (optical channel). Small Langenbeck hooks
are inserted through a 1.5 cm skin incision above the in-
tercostal space. The muscles of the thoracic wall are traversed
using a blunt, muscle-splitting technique and the intercos-
tal space is then opened by blunt dissection. The pleura is
exposed, following which an opening into the thoracic cav-
b ity is created, the trocar is inserted, then the 30° endoscope
is inserted at a flat angle in the direction of the second
Fig 3.3-6a–b Endoscopic tower.
a 1: xenon light source, 2: digital image
trocar. Perforation of the thoracic wall to insert the second,
recorder, 3: pumping system for suction third, and fourth trocars is performed under visual control
and irrigation, 4: flat-screen monitors. through the endoscope. The surgical procedure begins and
b Close-up of the xenon light source. ends with a thorough inspection of the thoracic cavity.
First, the target area should be exposed. The anterior cir-

For the thoracoscopic approach, four reusable 11 mm di- cumference of the motion segment, as well as the course
ameter, flexible threaded trocars are employed. Flexible of the spine and the aorta are palpated and identified with
trocars are used in order to reduce pressure on the inter- a blunt probe (Fig 3.3-9).
costal nerve as much as possible, as well as on the vascular
bundle. Light reflection and its interference with the regu- 6.5 Splitting of the diaphragm and working with
lation of light intensity can be avoided by using black trocars landmarks
and instruments with matt surfaces [7]. To perform thora- For treatment below the 12th thoracic vertebra, it is usu-
coscopic surgery, the following instruments are necessary: ally necessary to open the diaphragm. The dome-like dia-
a standard surgical set for skin incision and preparation of phragm is firmly connected at its margins to the sternum,
the thoracic wall/intercostal space, osteotomes, dissection ribs and spine, and arches up into the thoracic cavity [7, 8,
hooks, hook probes, sharp and blunt rongeurs, Kerrison 12]. Topographically, the attachment sites of the diaphragm
rongeurs, curettes, reamers, mono- and bipolar probes, awls; to the spine are at the level of the first lumbar vertebra. The
a screwdriver, a fan-shaped retractor or a clip applicator. lowest point of the thoracic cavity projects with the phren-
Various manufacturers now also offer sets of instruments icocostal sinus at the level of the baseplate of the second
for soft-tissue and bone preparation. It is important to make lumbar vertebra. This configuration makes it possible to
sure that there is a depth scale on both sides of each instru- place a trocar intrathoracically in the phrenicocostal sinus
ment, and that it has been ergonomically designed for good [7, 8].
control and handling.

a b c
Fig 3.3-7a–c Three-point anchoring technique showing the surgeon using two hands to control the instruments.
a c
b d
Fig 3.3-8a–d
a–b Osteotomes/chisel
c Punch
d Bone currette
1 Fig 3.3-9a–b
a Anatomical view of the left
1
2 middle thorax. 1: aorta, 2:
hemiazygos vein, 3: splanchnic
3 2 nerve, 4: spine, 5: segmental
vessel, 6: disc space.
4
5 b Anatomical view of the region
3
of the thoracolumbar junction.
6 1: aorta, 2: attachment of
4 the diaphragm, 3: segmental
5 vessel, 4: splanchnic nerve, 5:
a b lung.
197

The line of dissection for the diaphragm is marked with space, the first K-wire is inserted under image intensifica-
monopolar cauterization or an ultrasonic knife. To prevent tion into the caudal vertebra. Under endoscopic conditions,
a postoperative diaphragmatic hernia, the authors recom- it has proved valuable to work with landmarks such as the
mend an incision that runs parallel to the diaphragmatic above-mentioned K-wires very early in the course of the
attachment. The diaphragm is then incised using monopo- surgical procedure, since they greatly facilitate orientation
lar cauterization as well as endoscissors (Fig 3.3-10). A 1 cm at the operating site.
rim is left on the spine to facilitate closure of the diaphragm
at the end of the procedure. The incision must be 4–5 cm The K-wires are inserted under image intensification into
long to access the baseplate of the second lumbar vertebra. the neighboring vertebrae of the target area. The optimal
Access to the first lumbar vertebra can be obtained with a position of the K-wire is between the middle to the dorsal
shorter incision of 2–3 cm. third of the vertebra, adjacent to the disc space (Fig 3.3-12).
Retroperitoneal fatty tissue is then exposed and mobilized The position of the K-wires is similar to that for, eg, the
from the anterior surface of the psoas insertions. The psoas posterior osteotomy, as is the position of the screws for the
muscle is mobilized very carefully from the vertebral bod- anterior stabilization plate (eg, MACS-II Plate System,
ies from anterior to posterior in order not to damage the Modular-Anterior-Construct-System, Aesculap). The loca-
segmental blood vessels hidden underneath (Fig 3.3-11). tion of the anterior border of the vertebra and the spinal
After opening the diaphragm to access the retroperitoneal canal can be calculated from the position of the K-wires.
1 1
2
2
Fig 3.3-10 Splitting of the diaphragm I. 1: lung, Fig 3.3-11 Splitting of the diaphragm II (the
2: attachment of the diaphragm, 3: spine. muscle layers of the diaphragm are visible). 1: lung,
2: attachment of the diaphragm, 3: spine.
a b
Fig 3.3-12a–b Working with landmarks. K-wires are inserted in T12 and T11, in addition
there is the fan-shaped retractor at the attachment of the diaphragm as well as a suction
irrigation device.

The surgeon has to make sure that the tip of the K-wire should be two clips towards the aorta. After clipping and
does not perforate the diaphragm or the thoracic wall. To dissection, the clipped vessels are prepared carefully ven-
avoid perforation, the tip of the K-wire can be secured with trally and dorsally from the side of the vertebra.
a drainage tube (Fig 3.3-13). Thorough knowledge of the
local anatomy is required for safe practice. With this infor- 6.7 Closure of the diaphragm and inflation of the
mation at his/her disposal, the surgeon can create a so-called lung
“safety working area” (Fig 3.3-14). After defining the safety Each incision in the attachment of the diaphragm that is
working area, the next steps can be carried out, eg, corpec- longer than 2 cm has to be sutured endoscopically to avoid
tomy or anterior stabilization. a hernia. The gap in the diaphragm is closed up with sutur-
ing under endoscopy. After irrigating the thoracic cavity
6.6 Preparation of the segmental vessels and removal of blood clots, the chest tube is inserted with
One of the most important steps during vertebral body re- its end placed in the costodiaphragmatic recess. The chest
placement, anterior decompression, and anterior stabiliza- tube should be inserted carefully to avoid perforation or
tion is the preparation of the segmental vessels. Insufficient injury to the diaphragm and abdominal organs. The instru-
preparation of the segmental vessels can result in acciden- ments and portals are then removed, and the lung is rein-
tal injury, bleeding, and loss of visual control of the target flated under image intensification control in order to prevent
area. atelectasis and the development of effusions. After adapta-
tion suturing of the muscles and subcutaneous tissue, the
The segmental vessels of the target vertebra are mobilized, skin is closed with resorbable intracutaneous running su-
closed with vascular clips, and dissected (Fig 3.3-15). There tures.
1
2
3
Safety working area
Fig 3.3-13 Protection of the tip of the K-wire Fig 3.3-14 Safety working area.
(2) with a drainage tube (1); 3: the psoas
muscle.
4
1
2
a b
Fig 3.3-15a–b Preparation of the segmental vessels. 1: segmental artery, 2: segmental vein,
3: pleura (anterior), 4: clipped segmental vessels.
199

7 Postoperative care reduce the initially longer operating times required by en-
doscopic procedures to nearly the same level as those for
The patient is generally extubated immediately after surgery. conventional open approaches.
In exceptional cases (eg, patients with chronic obstructive
pulmonary disease, cardiovascular disease, elderly subjects) In a study of 186 thoracoscopic procedures carried out be-
artificial ventilation may be necessary. The chest tube can tween May 1996 and June 1999, Beisse et al [8, 9, 13] re-
usually be removed on the first postoperative day. After ported a significant reduction in postoperative pain and a
removal of the chest tube, in normal cases patient mobiliza- prompt return to functional mobility of the patient. In the
tion and ventilation training can be started on the first post- endoscopic group, the duration of administration of anal-
operative day. After mobilization, physiotherapy is initi- gesics was decreased by 31% and the overall dosage of an-
ated and intensified from the second postoperative week algesics administered was reduced by 41%. Furthermore,
onwards. the authors found that the duration of surgery became
shorter over time.
Sterile adhesive plaster is placed over the operated area for
72 hours. For wound healing, no further wound covering The thoracolumbar junction of the spine, which represents
is necessary. the border region between the thoracic and abdominal
cavities, was long considered to be difficult to access endo-
According to the indication, temporary bracing may be ap- scopically [7]. The lower limit of what was regarded as being
plied for the following 12 weeks. thoracoscopically accessible was generally claimed to be the
first lumbar vertebra [1]. However, with the partial detach-
X-ray examination of the lungs is performed directly after ment of the diaphragm as described above, and based on
surgery, following removal of the chest tube, and on the the findings first reported in 1998 [8], it is now also possible
next day to check ventilation status to exclude the presence to reach the region of the second lumbar vertebra near the
of pneumothorax, pleural effusion, or atelectasis. Further baseplate under thoracoscopic conditions. This ensures that
controls depend on the ventilation capacity of the patient. the first lumbar vertebra, which is the most frequently af-
Standard x-rays of the target area in both AP and lateral fected by injuries, can also be treated endoscopically using
views are carried out on the second day after surgery with the bisegmental technique. As shown in a collective study
further routine follow-up at 3, 6, and 12 months postop- on 220 patients in 2004 [12], the above-described approach
eratively. In fracture cases, as well as in cases of complex to the thoracolumbar junction has a low complication rate.
reconstruction surgery, the authors recommend a postop- Crucial for the successful implementation of this technique
erative CT scan 6 months after surgery. is an incision parallel to the attachment of the diaphragm
onto the spine and ribs [7].
Thromboembolic prophylaxis with fractionated heparin is
performed until the patient has regained full mobilization. In 2002, Han et al [14] reported on their experience with
Prolonged antibiotic therapy is not recommended. In nor- 241 thoracoscopic procedures that were performed between
mal cases, postoperative intravenous antibiotics are given January 1994 and January 2000 (thoracic sympathectomy,
for 24 hours only. discectomy, neurogenic tumor resection, corpectomy, spi-
nal reconstruction, anterior release, and biopsy). In sum-
Food intake commences 12 hours postoperatively according mary, these authors showed that thoracoscopic spine surgery
to bowel function. is an effective technique that provides full and direct access
to the anterior circumference of the spine, with a morbid-
ity rate that appears to be lower than that associated with
8 Evidence-based results open procedures [14]. Thoracoscopic surgery improves pa-
tient comfort and cosmetic results, and shortens recovery
Over the past 10 years, endoscopically assisted surgery of time [14].
the spine has developed from being an alternative technique
to becoming the standard spinal surgery procedure with a As with Han et al's [14] study, a review of thoracoscopic
wide range of indications. The subsequent development of spine surgeries in Switzerland showed the advantages of
specific instruments and implants, as well as the standard- the thoracoscopic technique: better cosmetic results, short-
ization of the operating procedures has meant that an in- er stay in intensive care and other hospital units, earlier
creasing number of even complex surgical procedures can recovery and return to work, and less expense [15].
be carried out endoscopically. It has become possible to

Another study published in 2011 by Wait et al [16] showed Intraoperative vascular injury represents the most life-threat-
the effectiveness of the thoracoscopic procedure. The clin- ening complication and requires immediate intraoperative
ical results on 121 patients that underwent thoracoscopic intervention. In the case of damage to the segmental vessels,
resection of symptomatic herniated thoracic discs clearly coagulation and clipping are recommended. In addition, the
demonstrated that the thoracoscopic procedure is a safe, application of a powerful hemostatic agent (eg, FloSeal, He-
effective, and minimally invasive method. The patients that mostatic Matrix, Baxter International Inc., Deerfield IL, and
underwent thoracoscopic resection had less approach-re- Surgiflow Hemostatic Matrix, Ethicon 360, Menlo Park, CA)
lated morbidity than an unmatched cohort that underwent with subsequent compression can be helpful.
resection with thoracotomy [16]. The complication rate was
acceptable, and most patients showed improvement or Injury or lacerations to the aorta, vena cava, or to the azy-
procedure-associated symptoms that resolved with minimal gos or the hemiazygos vein should be treated by immediate
morbidity [16]. transfer to an open approach (thoracotomy) to obtain a
better overview for control of the bleeding complication
In summary, the thoracoscopic procedure results in sig- (suture of the damaged vessels).
nificant benefits for the patients. These include decreased
pain, less disruption of the normal anatomy, shorter dura- To minimize the intraoperative risk of injury to the greater
tion of hospitalization, less disability, and less expense. vessels, lung, diaphragm, and neural structures, the authors
recommend thorough preoperative planning, correct posi-
tioning of the patient and equipment, as well as exact place-
9 Complications and avoidance ment of the portals. Additionally, the three-point anchoring
technique for the tools is recommended, to avoid the risk
It should, nevertheless, be noted that when using the tho- of uncontrolled movements when using the surgical instru-
racoscopic technique, the following potential intraoperative ments. For optimal intraoperative orientation, working with
as well as postoperative complications can occur. landmarks and creating the so-called “safety working area”
is mandatory.
9.1 Potential intraoperative complications
• Risk of injury to the aorta and vena cava To avoid the risk of surgery being performed at the wrong
• Accidental injury to the heart, lung, diaphragm, tho- level, verification of the target area by image intensification
racic duct, or the abdominal organs (especially the liver, is necessary.
ureter, and spleen)
• Risk of damage to the spinal nerve roots and sympa- Injury to the ureter is an infrequent occurrence, and requires
thetic nerve trunk (deafferentation syndrome), with immediate repair by suturing.
ensuing neurological deficit
• Irritation of the subcostal nerves 9.2 Potential postoperative complications
• Intercostal neuralgia due to irritation of the intercostal • Intrathoracic hemorrhage
nerves • Wound infection (superficial as well as deep-seated)
• Spinal cord injury or ischemia • Recurrent pleural effusions
• Dural tear • Residual pneumothorax
• Opening of the peritoneum • Subcutaneous emphysema
• Accidental injury, bleeding, and loss of visual control • Pneumonia
due to insufficient preparation, and damage to the seg- • Lung atelectasis
mental vessels • Chylothorax
• Incorrect positioning of the patient, as well as incorrect • Intrathoracic adhesions
positioning of the C-arm can result in misplacement of • Implant failure
K-wires, screws, plates, etc • Port and diaphragmatic hernia with the risk of incar-
• Inaccurate and inadequate handling of the surgical in- ceration of abdominal contents
struments • Paresis of the diaphragm.
• Possibility of conversion to a standard thoracotomy
• Surgery at the wrong level.
201

The authors have carried out a survey on 196 thoraco- cant postoperative neurological deficits or life-threatening
scopic operations from 2008 until the present day, and so complications were observed, which have been reported to
far have found that there is no necessity for transfer to an amount to around 0.5% in open procedures [17]. The over-
open approach. No vascular complications were reported. all rate of complications in the 196 patients was 4.9%.
During this time period, the authors found one case of loos-
ening and failure of an extendable cage that required revi- With the extension of the thoracoscopic technique and the
sion surgery. Complications due to the thoracoscopic ap- development of specific instruments and implants, the com-
proach, such as encapsulated pleural effusion, plication rate associated with the minimally invasive endo-
pneumothorax, and neuralgia of the intercostal nerve oc- scopic procedure is of the same scale as that for open pro-
curred in 3.4% of cases as compared to 14% in the multi- cedures, but with clear advantages in terms of reduced
center study of Faciszewski et al [17]. Moreover, no signifi- access morbidity.
10 Tips and tricks
Meic Schmidt, Salt Lake City, USA • For endoscopic spinal canal decompres- • One important step in the preoperative
• Locating the correct level is important sions, in particular for the thoracic spinal planning with thoracic discs is to have all
and can be difficult in pathologies like cord and thoracic disc herniations that patients undergoing an anterior thora-
thoracic disc herniations since they are are central and calcified, intraoperative coscopic approach marked by the inter-
not visible on standard image intensifica- neuromonitoring should be considered. ventional radiologist. With the assistance
tion. Placement of a preoperative marker • If an intraoperative cerebrospinal fluid of CT guidance, a small metallic marker
can be useful to avoid performing surgery (CSF) leak is encountered, the applica- is placed in the rib head. This saves sig-
at the wrong level. tion of fibrin glue and collagen matrix in nificant time in the operating room and
• For the thoracoscopic resection of vascu- conjunction with a lumbar drain should allows for definitive identification.
lar metastases (eg, renal cell carcinoma, be considered. Direct intraoperative clo- • Appropriate placement of the portals is
thyroid carcinoma), preoperative embo- sure with sutures can be difficult. The critical. When working with a thoracic
lization should be considered. chest tube should be used with great cau- surgeon, the operating neurosurgeon/
• If a trochar site (portal) is not ideally tion in the setting of a CSF leak. orthopedic surgeon should decide on
placed, one should not hesitate to move the location of the portals. The working
it to a new site. The increase in incisional Noel Perin, New York, USA portal should be in line with the target.
morbidity is minimal compared with the • The indications for anterior thoracoscopic During placement of the initial endoscop-
potential complications arising from poor approaches to the spine have increased ic portal, the anesthesiologist is asked to
visualization and "fencing" interference since its introduction in the early 1990s. hold the breathing to prevent injury to
with the surgical tools as a result of a Though the techniques are generally ap- the lung and mediastinal structures. Once
poor trochar site. plicable to most patients, there are some the endoscopic portal is established, the
• For most thoracoscopic procedures, three relative contraindications: remaining portals are placed with con-
surgeons (one main operator and two • Prior history of empyema and exces-
tinuous endoscopic visualization.
assistants) are ideal, however, if only two sive adhesions, and patients that can- • Use of the ultrasonic Harmonic scalpel,
surgeons are available, a table-mounted not tolerate single-lung ventilation which cuts as well as coagulates small
retractor system can be used to replace • In young children it is difficult to vessels, has the advantage of not produc-
one of the assistants. place double-lumen endotracheal ing any charring as with Bovie coagu-
• To prevent clouding of the endoscope tubes lation. This enables visualization of the
lens, a defogging agent and irrigation • The author has found morbidly obese
anatomy during the approach, especially
with warm saline should be used. patients difficult. Excessive chest- with sympathectomy and thoracic discec-
• Placing K-wires and/or the instrumenta- wall thickness requires longer por- tomy.
tion first greatly enhances the surgeon's tals and limits manipulation of the
orientation in a 2-D surgical field. instruments.

• A telescoping hand piece on the drill sutured over the repair. Post-op chest • In the case of large calcified thoracic discs
prevents soft tissue getting caught dur- tube to water seal and place a lumbar with severe spinal cord compression, a
ing bone drilling. This author prefers a drain for 4–5 days. In these patients, the tubular retractor-guided discectomy us-
coarse-diamond drill bit that cuts as well spinal drain is first clamped, the surgeon ing the operating microscope affords 3-D
as packs the bone dust and reduces bone must check for increase in the chest tube visualization (see chapter 3.2 Extreme
bleeding. drainage, and if there is no increase, the lateral mini-thoracotomy approach for
• Dural tears and CSF leakage: small tears chest tube is first removed, and then a thoracic spinal pathologies). The tubu-
in the dura are treated with, eg, Duraseal day later the spinal drain is removed. lar retractor is placed with thoracoscopic
or Tisseel with a piece of fat harvested • With regard to bone for interbody grafting guidance using two 5 mm portals.
from the subcutaneous fat at one of the after thoracic disc herniations: the head
portal sites. Postoperatively, the chest and neck of the rib that were removed
tube is on water-seal drainage only. With for access to the canal can be fashioned
larger tears in the dura, suture the tear and used for interbody graft.
with 5-0 Tevdek, with a piece of muscle
11 Case examples of thoracoscopic vertebral body The x-ray findings showed an unstable fracture of the 12th
replacement thoracic vertebra (chance fracture type C2.3 according to
the Müller AO Classification [10]), as well as a dislocated
11.1 Case 1: Fracture fracture of the ventral part of the first lumbar vertebra with
The preferred technique for reconstruction of the load- resulting pathological kyphosis of the thoracolumbar junc-
bearing anterior spine in the case of fracture involves resection (Cobb 27°) (Fig 3.3-16).
tion of the injured intervertebral discs and burst sections
of the fractured vertebra as a partial corpectomy, preserving Based on the clinical and x-ray findings, a combined dor-
the anterior longitudinal ligament and a small rim of the soventral fusion procedure was carried out from T12 to L2.
vertebral body [7]. Vertebral body replacement is carried First, dorsal stabilization and repositioning from T12 to L2
out with an autologous bone graft from the iliac crest or an was carried out (the authors used a pedicle screw system
extendable titanium cage filled with and surrounded by from USS Fracture System, Synthes), followed by a thora-
spongiosa or bone morphogenetic protein. coscopic hemicorpectomy of the first lumbar vertebra and
vertebral body replacement using a titanium cage (eg, Syn-
A 22-year-old man, who had fallen from fifth-floor scaf- mesh-Cage, Synthes), filled with Induct OS/bone morpho-
folding, received conservative treatment for 1 month with- genetic protein and autologous spongiosa. In addition, an-
out significant improvement being observed. Progressive terior stabilization was performed with a MACS-II plate
back pain in the region of the thoracolumbar junction (vi- (Aesculap) from T12 to L1. Postoperative x-ray control
sual analog scale score 8–9/10) was experienced on stand- demonstrated a nearly complete reconstruction of the tho-
ing and walking, with additional mild pain radiating into racolumbar junction (Fig 3.3-17). The postoperative course
the right anterior thigh. Neurological examination did not was uneventful and without any pathological findings. A
reveal any pathological changes. Neither motor or sensory CT scan follow-up, carried out 1 year after surgery, showed
deficit nor bladder dysfunction was found. complete healing, with bony fusion of the fractures
(Fig 3.3‑18). Removal of the posterior internal fixation was
Clinical findings determined pain associated with the tho- performed in July 2011 (Fig 3.3-19).
racolumbar osseous and paravertebral muscular structures;
and pain on extension, with an overall limited range of
spinal motion. However, the straight leg-raising test was
negative, and no motor or sensory deficit was found.
203

a b c d e
Fig 3.3-16a–c
a–b Preoperative x-rays in AP (a) and lateral (b) projection.
c–d CT scans in AP (c) and lateral (d) projection.
e–f MRI in sagittal (e) and axial (f) view.
a b
Fig 3.3-17a–b Postoperative x-rays in AP (a) and lateral ( b) projection
demonstrating correction and repositioning of the fractures.
a b
Fig 3.3-19a–b Postoperative x-rays in AP (a) and
lateral (b) projection after removal of posterior internal
fixation 1 year after initial surgery.
a b
Fig 3.3-18a–b CT scan in AP (a) and lateral (b) projection 1 year after
stabilization surgery demonstrating solid fusion at T12/L1.

11.2 Case 2: Kyphosis lumbar junction (Fig 3.3-20). Based on the clinical and x-ray
A 77-year-old woman presented with immobilizing low findings, reconstruction surgery for the fracture and the
back pain which had been present for 3 weeks subsequent kyphosis was carried out via a combined dorsoventral fusion
to a domestic injury (visual analog scale score 9/10). No procedure from T11 to L3 (dorsal navigated stabilization
motor or sensory deficit and no bladder dysfunction were from T11 to L3 with cement augmentation of the screws,
noted. The patient’s case history included a diagnosis of anterior thoracoscopic hemicorpectomy of L1 with subse-
osteoporosis (T-score –3.7). quent vertebral body replacement of L1 with an expandable
titanium cage (eg, Hydrolift, Aesculap). The postoperative
Clinical findings showed pressure pain in the region of the x-ray controls showed good reconstruction of the fractured
thoracolumbar junction. The range of motion was extreme- vertebra, as well as a nearly complete correction of the
ly restricted. Bilateral standard x-rays, MRI and CT scans kyphosis (postoperative Cobb 14°) (Fig 3.3-21). The patient’s
revealed an osteoporotic burst fracture of the first lumbar postoperative condition was most satisfactory, with rapid
vertebra (type A3.1 according to the Müller AO Classifica- mobilization and rehabilitation.
tion [10]) with a resulting kyphosis of 38° of the thoraco-
a b c d
Fig 3.3-20a–d
a Preoperative x-ray in AP projection.
b Preoperative x-ray in lateral projection.
c Sagittal CT scan.
d Axial CT scan.
a b
Fig 3.3-21a–b Postoperative x-rays in AP (a) and lateral (b)
projection.
205

12 Key learning points control, and move long tools precisely, and to ensure
that uncontrolled movements of the surgical instruments
• In thoracoscopic surgery, the surgical technique presents with the accompanying risk of injury to the paraspinal
a challenge compared to open procedures. The surgeon soft tissues are avoided
operates while simultaneously watching a monitor, and • As regards potential complications, there is risk of in-
does not look down at the operative site. Therefore, the jury to the paraspinal soft tissues as well as the neural
motor skills as well as the visual and sensimotor feedback structures. In the event of emergency, open exposure
loops have to be readjusted accordingly. Thoracoscopic can be rapidly performed
surgery involves the use of new skills, eg, endoscopic • Thoracoscopic approaches with thorough preparation,
navigation and triangulation, determination of the tra- small skin incisions, and blunt muscle dissection reduce
jectory, angulation and depth, so that the surgeon has tissue trauma, blood loss, decrease the rate of approach-
full orientation during surgery (Fig 3.3-22) [1] related complications, and provide good clinical results.
• Thoracoscopic surgery requires a steep learning curve • Due to the remarkably reduced intraoperative morbid-
for the surgeon, the assistant, and the whole team (in- ity, postoperative recovery is facilitated, with earlier
cluding the anesthesiologist and the nurses). Addition- mobilization, reduced pain medication, faster rehabili-
al laboratory or human anatomical specimen training tation, and less time spent in hospital
is recommended. This surgical procedure is less practical • After a steep learning curve, thoracoscopy can be used
for surgeons that do not perform it frequently as a safe surgical technique with a wide field of applica-
• The three-point-angle technique is useful to stabilize, tions.
Fig 3.3-22 Surgical technique: operating

while looking at a monitor.

13 References
1. Dickman CA, Rosenthal DJ, Perin NI 8. Beisse R, Potulski M, Temme C, et al 13. Beisse R, Potulski M, Bühren V (1999)
(1999) Thoracoscopic Spine Surgery. 1st (1998) [Endoscopically controlled Thorakoskopisch gesteuerte ventrale
ed. New York: Thieme-Verlag. division of the diaphragm. A minimally Plattenspondylodese bei Frakturen der
2. Jacobeus HC (1910) Possibility of the invasive approach to ventral Brust- und Lendenwirbelsäule. Operat
use of the cystoscope for investigation management of thoracolumbar Orthop Traumatol; 11(1):54–69.
of serious cavities. Munch Med fractures of the spine.] Unfallchirurg; 14. Han PP, Kenny K, Dickman CA (2002)
Wochenschr; 57:2090–2092. 101(8):619–627. German. Thoracoscopic approaches to the
3. Jacobeus HC (1921) The practical 9. Beisse R, Potulski M, Ufer B, et al thoracic spine: experience with 241
importance of thoracoscopy on surgery (1999) [Thoracoscopically assisted surgical procedures. Neurosurgery; 51
of the chest. Surg Gynecol Obstet; treatment of fractures of the thoracic Suppl 5:S88–S95.
32:493–500. and lumbar spine—surgical technique 15. Büff, HU (1997) [Thoracoscopic
4. Rosenthal D, Rosenthal R, de Simone and preliminary results in 100 operations of the spine.] Ther Umsch.;
A (1994) Removal of a protruded disc patients.] Arthroskopie; 12(2):92–97. 54(9): 529–532. German.
using microsurgery endoscopy. A new German. 16. Wait SD, Fox DJ, Kenny KJ, et al
technique. Spine; 19(9):1087–1091. 10. Magerl F, Aebi S, Gertzbein SD, et al (2012) Thoracoscopic resection of
5. Mack MJ, Regan JJ, Bobechko WP, et (1994) A comprehensive classification symptomatic herniated thoracic discs:
al (1993) Application of thoracoscopy of thoracic and lumbar injuries. Eur clinical results in 121 patients. Spine;
for diseases of spine. Ann Thorac Surg; Spine J; 3(4):184–201. 37(1):35–40.
56:736–738. 11. Beisse R, Perez-Cruet MJ (2011) 17. Faciszewski T, Winter RB, Lonstein
6. Regan JJ, Mack MJ, Picetti GD III Thoracoscopic Setup and Approaches to JE, et al (1995) The surgical and
(1995) A technical report on video- the Thoracic and Upper Lumbar Spine. medical perioperative complications of
assisted thoracoscopy in thoracic spinal Perez-Cruet MJ, Beisse R, Pimenta L, Kim anterior spinal fusion surgery in the
surgery. Preliminary description. Spine; DH (eds), Minimally Invasive Spine thoracic and lumbar spine in adults. A
20(7):831–837. Fusion—Techniques and Operative review of 1223 procedures. Spine;
7. Beisse R (2010) Endoscopic surgery on Nuances. St Louis: QMP, 581–594. 20(14):1592–1599.
the thoracolumbar junction of the 12. Kim DH, Jahng TA, Balabhadra RS, et
spine. Eur Spine J; 19 Suppl 1:S52–S65. al (2004) Thoracoscopic
transdiaphragmatic approach to
thoracolumbar junction fractures. Spine
J; 4(3):317–328.
207

Beisse R, Potulski M, Bühren V (1999) Beisse R, Potulski M, Ufer B, et al (1999)

Thorakoskopisch gesteuerte ventrale Plattenspondylodese [Thoracoscopically assisted treatment of fractures of the
bei Frakturen der Brust- und Lendenwirbelsäule. Operat thoracic and lumbar spine—surgical technique and
Orthop Traumatol; 11(1): 54–69. preliminary results in 100 patients.] Arthroskopie;
12(2):92–97.
Therapy Retrospective case series IV
Purpose
Reposition of thoracic and lumbar spine fractures and Purpose
endoscopic intervertebral fusion of the affected segments To report the feasibility and effectiveness of the thoraco-
with autologous bone graft and plate osteosynthesis. scopic transdiaphragmatic approach (TTA) in the manage-
ment of thoracolumbar junction fractures.
P Patient (N=100) (N = 103 unstable fractures)
I Intervention Endoscopic intervertebral fusion P Patient Patients undergoing surgery by the TTA (N = 212)
Patients aged 16–75 years
I Intervention Spinal decompression, reconstruction, and instrumentation
O Outcome Surgery time, pain medication, complications by the TTA
Anterior instrumentation alone, or combined anterior and
posterior instrumentation
Authors’ conclusion Z-Plate, or MACS-TL system
The experiences so far show the advantages of the mini-
mally invasive procedure during the postoperative phase,
O Outcome Neurological outcomes (neurological status assessed by
leading to a decrease of postoperative pain and quick Frankel neurological performance scale), surgical durations,
recovery of function and mobility of the patient. fusion rates (assessed by plain x-rays), complications
The thoracoscopic transdiaphragmatic approach provides
excellent access to the entire thoracolumbar junction,
permitting satisfactory spinal decompression, reconstruc-
tion, and instrumentation. Diaphragmatic opening and
repair can be accomplished safely and effectively without
special endoscopic instrumentation. It also precludes the
need for retroperitoneoscopic or open thoracoabdominal
approaches and thus avoids the associated significant
morbidity.

Han PP, Kenny K, Dickman CA (2002) Thoracoscopic Wait SD, Fox DJ, Kenny KJ, et al (2012) Thoracoscopic
approaches to the thoracic spine: experience with 241 resection of symptomatic herniated thoracic discs: clinical
surgical procedures. Neurosurgery; 51 Suppl 5:S88–S95. results in 121 patients. Spine; 37(1):35–40.
Therapy Retrospective IV Therapy Retrospective review of a pro- IV
spectively maintained surgical
Purpose database
To evaluate the efficacy, surgical results, and complica- Purpose
tions of the thoracoscopic procedures. Report the indications for surgical procedures performed,
and outcomes of the largest series of thoracoscopically
P Patient Patients undergoing thoracoscopic procedures (N = 241) treated herniated thoracic discs (HTDs).
(Thoracic sympathectomies (N = 164), discectomies (N =
60), neurogenic tumor resections (N = 5), corpectomies
and spinal reconstructions (N = 8), anterior releases (N = To compare approach-related complications to an un-
2), and biopsies (N = 2)) matched cohort undergoing thoracotomy for HTD.
I Intervention Thoracoscopic surgical techniques to perform sympathec-
tomy, discectomy, corpectomy, paraspinal tumor resection, P Patient Patients (N = 121) undergoing thoracoscopic-assisted
biopsy, anterior release, and spinal instrumentation operations for symptomatic HTDs (N = 139)
Comparison No comparison group Indications for thoracoscopic resection included: small sym-
C
ptomatic disc, anterior location, nonmorbidly obese patient,
O Outcome Relief of palmar or of axillary hyperhidrosis, morbidity rate, favorable chest anatomy, and T4–11 location
quality of life, efficacy, complications
I Intervention Triportal method of thoracoscopic discectomy
Authors’ conclusion C Comparison Excision using thoracotomy (unmatched cohort)
Thoracoscopic spinal surgery is an effective technique O Outcome Hospital stay, resolution of myelopathy, radiculopathy, and
back pain, patient satisfaction, complication rate, morbidity
that provides full, direct access to the ventral thoracic
spine. Its morbidity rate appears to be lower than that
associated with open thoracotomy. It improves patient
Thoracoscopically assisted microsurgical resection is a safe,
comfort and cosmetic results and shortens recovery. This
effective, and minimally invasive method of treating symp-
technique has become the authors' surgical approach of
tomatic HTDs in appropriately selected patients. The
choice for removing benign intrathoracic paraspinal neu-
symptoms of most patients improve or resolve with min-
rogenic tumors and central herniated thoracic discs, and
imal morbidity.
for performing biopsies and thoracic sympathectomies.
The senior author still prefers open surgical approaches
for most thoracic corpectomies and spinal reconstruction
procedures.
209

Faciszewski T, Winter RB, Lonstein JE, et al (1995)

The surgical and medical perioperative complications of
anterior spinal fusion surgery in the thoracic and lumbar
spine in adults. A review of 1223 procedures. Spine;
20(14):1592–1599.

Purpose
To document the incidence and specific types of perspec-
tive complications related to anterior spinal fusions.
P Patient Patients undergoing anterior spinal fusions between levels

T1 and S1 (N = 1223)
I Intervention Thoracic and lumbar anterior spinal fusion
O Outcome Perioperative complications, complication risk, complication
rate, comorbidity
Anterior spinal fusion surgery is a safe procedure and can
be used with confidence when the nature of a patient's
spinal disorder dictates its use. Complications are often
approach-specific.

3.4 Posterior approaches for minimally invasive thoracic
decompression and stabilization
Rajiv Saigal, Dean Chou
1 Historical perspective lateral extracavitary approach removes a significant portion

of the rib, with a very lateral approach to the ventral spine.
Thoracic corpectomy is a useful tool for treating neoplastic As the costotransversectomy and lateral extracavitary ap-
and infectious processes of the spine. Because it is a desta- proaches necessitate pleural dissection, the authors prefer
bilizing procedure, thoracic corpectomy generally requires to use the transpedicular approach. A trap-door rib-head
reconstruction surgery. Although anterior approaches have osteotomy allows sufficient lateral exposure to facilitate
historically been performed, posterior approaches can also anterior column reconstruction [2].
be performed with relative ease, access to multiple levels
of the spine, and comparable or lower morbidity [1]. Recent Minimally invasive and mini-open posterior corpectomies
techniques have been developed to facilitate expandable utilize a direct midline approach and provide circumferen-
cage placement from a posterior approach, and yet avoid tial decompression. The degree of rib-head preservation
the morbidity of rib-head removal and the potential com- depends on the specific technique used, as described below.
plication of postoperative pleural effusion [2, 3]. Minimally The direct midline approach facilitates the surgical proce-
invasive surgical (MIS) approaches for posterior thoracic dure, as it allows for 360° decompression of the spinal cord
corpectomy and reconstruction, however, are relatively new with a single approach [7].
and not yet in widespread use.
Minimally invasive posterolateral corpectomy first devel- 2 Terminology

oped from anatomical studies with modified paramedian
approaches. Musacchio et al [4] performed a feasibility study This mini-open technique first began as a strictly minimal-
in an anatomical model, and found that by using a dual- ly invasive approach. A tubular retractor was placed midline
tube technique they could achieve good decompression in and true percutaneous screws were placed above and below
the thoracic spine. Patient studies were first described by the corpectomy site. However, the authors found two draw-
Deutsch et al [5], who demonstrated the resection of sig- backs to this method; and as they refined their surgical
nificant vertebral body tumors in eight patients using a approach, it gradually developed into a mini-open tech-
unilateral MIS approach; however, this study only described nique.
resection without spinal reconstruction. Kim et al [6] later
reported on their technique of unilateral corpectomy with First, the tubular retractor limited the transpedicular place-
percutaneous screws and cage reconstruction in four pa- ment of the cage, even though it allowed for a good cor-
tients. This unilateral approach included rib-head removal. pectomy. Because the retractor is placed midline, this does
not facilitate cage placement from a posterolateral approach.
Posterior corpectomies have been performed for some time,
and provide an alternative to anterior approaches. They can Second, the skin incision encompasses all levels of instru-
often achieve the same goal as the latter: anterior vertebral mentation, but the fascia opening is only over the corpec-
body resection with anterior spinal column reconstruction. tomy site. The percutaneous screws are placed in the stan-
Variants of this technique include transpedicular corpec- dard manner through the fascia. The authors found that a
tomy, costotransversectomy, and the lateral extracavitary single, long skin incision was cosmetically more appealing
approach. The definition of these approaches is based on than multiple small stab incisions.
the anatomical aspects in question: transpedicular corpec-
tomy is performed through the pedicle, costotransversec- There are three variants of posterior corpectomy: the trans-
tomy is performed with distal rib-head removal, and the pedicular, the costotransversectomy, and the extracavitary
211

Authors Rajiv Saigal, Dean Chou
approach. Each of these differs with regard to the degree of 3.2 Contraindications for posterior approaches for
rib-head removal. In transpedicular corpectomy, as its name minimally invasive thoracic decompression and
implies, corpectomy is performed entirely through the stabilization
pedicle; no rib is removed during this procedure. In costo- The following contraindications should be taken into con-
transversectomy, the rib head is removed; while in the ex- sideration:
tracavitary approach, a significant amount of rib is removed • Poor surgical candidates due to medical comorbidities
extrapleurally in order to approach the spine. Of these mini- • Limited life expectancy (less than 3 months)
open approaches, the authors find that transpedicular cor- • Poor functional performance score
pectomy offers three advantages: • Severe osteoporosis
1. It allows a direct midline approach, which gives the • Previous laminectomy that may preclude the use of per-
surgeon access to both sides of the spinal cord and ver- cutaneous pedicle screws due to the risk of placing Jam-
tebral body. shidi needles into a laminectomy defect.
2. It provides the surgeon with familiar anatomical land-
marks, enabling him/her to operate through a less in-
vasive approach. 4 Pros and cons of posterior approaches for
3. It preserves the rib head and avoids pleural dissection, minimally invasive thoracic decompression and
which should in theory decrease the risk of pleural ef- stabilization
fusion.
As with any minimally invasive procedure, pros and cons
should be weighed in deciding the best approach for the
3 Patient selection patient.
Suitable candidates for posterior minimally invasive tho- 4.1 Pros

racic decompression and stabilization are patients who need • Smaller fascial opening
a thoracic corpectomy for the treatment of various pathol- • Less blood loss probable
ogies. Thorough evaluation of the patient’s neurological • Avoids anterior approach
status and appropriate imaging are critical in deciding • Less stripping of spinous process muscles
whether surgery is indicated. For instance, any patient with • Better preserved vascular supply to the area because of
cord compression and neurological deficit secondary to less muscle stripping, which may decrease wound com-
neoplastic or infectious processes requiring corpectomy plications.
would be a good candidate for this procedure. This approach
has also recently been described for trauma patients [8]. 4.2 Cons
• Potentially longer operative time
In addition, if no neurological compromise is noted, patients • Requires familiarity with percutaneous pedicle screw
with osteomyelitis that is refractory to medical treatment techniques
would also be good candidates. Neoplastic processes requir- • Requires familiarity with open transpedicular corpec-
ing piecemeal corpectomy can also be treated via mini-open tomy
transpedicular corpectomy (en bloc resections are current- • Steep learning curve.
ly not feasible with this approach).
3.1 Indications for posterior approaches for 5 Preoperative planning and positioning
minimally invasive thoracic decompression and
stabilization A combination of MRI, CT scan, and plain x-rays is useful
The following indications should be taken into consideration: in preoperative planning. MRI allows high-resolution view-
• Neoplastic processes of the vertebral body ing of the affected areas. The degree of spinal cord compres-
• Osteomyelitis resistant to nonsurgical management sion can be assessed on the basis of preservation of the
• Trauma, in very selected cases surrounding cerebrospinal fluid and intrinsic cord signal
• Ventral epidural abscess causing cord compression abnormalities suggestive of myelomalacia. In cases of infec-
• Intractable pain; motor or sensory deficits due to any of tion, the involvement of perivertebral soft tissues can be
the above assessed. Care must be taken when evaluating the MRI
• Inability to tolerate an anterior thoracoabdominal approach. findings in osteomyelitic cases because the T2 signal can be

3.4 Posterior approaches for minimally invasive thoracic decompression and stabilization
exaggerated, signifying the presence of significant edema, pression. In addition, neuromonitoring can alert the surgeon
and not necessarily active infection. to minor but potentially significant spinal column transla-
tion during the corpectomy procedure. As the corpectomy
A CT scan is the best means of assessing bone quality, and is being performed, the spinal column becomes unstable
is a critical tool for use in the above-mentioned cases for and can translate, causing shear forces, kinking, or stretch-
numerous reasons. Firstly, it is important to determine the ing of the spinal canal. To prevent this complication, a tem-
extent of bony destruction resulting from the pathological porary rod should be used to stabilize the spine. Neuro-
process. Secondly, CT evaluation above and below the monitoring will help identify whether or not translation is
pathological level can provide information on bone quality taking place, and can alert the surgeon to address this prob-
(whether osteoporotic or not), pedicle size (for the place- lem intraoperatively.
ment of percutaneous pedicle screws), and any destruction
of the adjacent levels by the pathological process.
6 Surgical technique
Plain x-ray is also critical for preoperative planning. Taken
with the patient in the sitting or standing position, it allows 6.1 Access
for the evaluation of alignment, as kyphosis may be second- After the patient has been prepared and draped in a sterile
ary to bone destruction. This assessment of preoperative fashion, image intensification is used to localize the correct
kyphosis allows for the planning of sagittal correction in- vertebral level. A midline skin incision spanning the levels
traoperatively. The preoperative x-ray is also used as a base- to be instrumented is made, and the fascia is preserved. The
line to follow the patient postoperatively, since most clini- authors then begin placement of the pedicle screws above
cal follow-up is performed on the basis of plain x-rays. and below the level of interest. Pedicle screw placement is
Finally, plain x-ray also provides information on the distal accomplished through small individual fascial incisions. For
and proximal ends of the construct. For instance, if the the corpectomy, a midline fascial opening is made with
planned distal level is at the apex of a sharp, angular ky- Bovie electrocautery over the vertebral body to be removed
phosis, extension of the distal level can be considered. using standard cerebellar retractors.
A standard preoperative assessment is important, including 6.2 Navigation

information on medical comorbidities, operative risk, an- The authors use standard AP and lateral image intensifica-
esthetic risk, any laboratory abnormalities, and medications tion to guide screw placement. However, if available, three-
currently being taken. Despite the mini-open nature of this or two-dimensional (3-D, 2-D) intraoperative navigation
operation and depending on the pathology, especially in for such procedures can prove to be useful. As well as guid-
the case of vascular tumors, hundreds, if not thousands, of ing pedicle screw placement, 3-D navigation intraopera-
cubic centimeters of blood loss can still occur. Thus, standard tively allows the exact location of the disc spaces, the end-
anesthetic preparation must be ensured, as for an open plates, and the depth of the corpectomy to be determined
thoracic corpectomy. without radiation exposure. It can also help limit the dosage
of radiation to the operating room personnel by decreasing
The patient is positioned prone on a standard radiolucent the image intensification time. It is an adjunct tool that can
operating table (eg, an OSI Jackson table). The authors do be most useful if the hospital has such equipment available.
not use any frame that will flex the patient’s hips, so as not
to fuse the patient in a flat-back position. The legs are always 6.3 Implants and instrumentation
fully extended. The arms are placed forward on armrests in
the “Superman” position if the pathology is mid-thoracic 6.3.1 Pedicle screw insertion
(usually T7) or lower. If the pathology is higher (T6 or Different methods utilized for pedicle screw insertion are
above), the authors tend to tuck the arms by the patient’s referred to in chapter 4.2.4 Mini-open and percutaneous
sides with a sheet to avoid having them in the way when pedicle instrumentation and fusion. In the authors’ practice,
performing the surgical procedure. The iliac crest is prepped. once the vertebral level has been confirmed, Jamshidi nee-
The authors use neuromonitoring with motor-evoked po- dles are guided in through the fascia under AP image in-
tentials (MEPs) and somatosensory-evoked potentials tensification. The needles are docked on the lateral aspect
(SSEPs) to provide immediate feedback on the patient’s of the pedicles on the AP view. A lateral view is then obtained
neurological status. Neuromonitoring helps to ensure ad- to confirm that the trajectory passes through the pedicles.
equate perfusion pressure in cases of significant cord com- The Jamshidi needles are then gently advanced under AP
213

image intensification until they are firmly embedded in the Because transpedicular corpectomy is a destabilizing pro-
bone, usually 3 mm. At this point, the needles are marked cedure, it is preferable to instrument at least two levels
about 20 mm away from the edge of the skin to gauge the above the corpectomy site. In patients with osteoporosis or
depth. The needles are then advanced approximately half- severe kyphosis, the surgeon may consider extending the
way (10 mm) under AP image intensification. Care should instrumentation to three or more levels above and below
be taken that the needles do not violate either medially the pathology.
(towards the cord) or inferiorly (towards the nerve root).
After the needles have advanced halfway under AP image 6.3.2 Corpectomy
intensification, a lateral view is taken to ensure a good tra- After the screws have been inserted, a midline fascial open-
jectory and to evaluate progress in the lateral plane. At this ing is made with Bovie electrocautery over the vertebral
point, it should be noted that the authors do not advance body to be removed. This fascial opening extends from the
the Jamshidi needles in through the pedicles under lateral bottom to the top of the lamina of the vertebral body in
image intensification because of the high risk of medial or question. Either an expandable tubular retractor or a sim-
inferior perforation, which could cause damage to the spi- ple cerebellar retractor can be placed. In the authors' ex-
nal cord or exiting nerve root. perience either works well for the corpectomy, but it is
easier to place the cage with the cerebellar retractor. The
The authors then continue to advance the needles under lamina is exposed with Bovie electrocautery all the way to
AP image intensification until the 20 mm marks that were the rib laterally. A laminectomy is performed in the standard
made on the needle are all the way under the skin. Lateral fashion. The bone is removed all the way to the rib so that
image intensification is then used to ensure that the needles both transverse processes are completely removed. The ribs
are ventral to the posterior cortex of the vertebral body. If are exposed.
still within the pedicle, the needles are further advanced
under AP image intensification until past the posterior cor- The pedicles are then removed with a rongeur or drill. The
tex of the vertebral body. This is confirmed under lateral disc spaces above and below are identified under image
image intensification. intensification or via navigation, and then incised with ei-
ther a 15-blade knife or Bovie electrocautery set on ex-
K-wires are then passed through the Jamshidi needles with tremely low cautery to prevent inadvertent drilling into the
the blunt end inserted into the vertebral body. Because the normal adjacent levels. The disc spaces are defined, but
K-wires can easily pierce the anterior cortex of the vertebral otherwise left intact. To help ascertain the true orientation
body and injure the viscera or large vessels ventrally, it is of the endplates, AP image intensification can be obtained
recommended to always insert the blunt tip of the K-wire to directly visualize the endplates. The disc spaces will then
into the vertebral body. The K-wires are advanced three- protect the normal adjacent levels from the drill and prevent
quarters of the way into the vertebral body, after which the inadvertent damage to the adjacent vertebral body. The
Jamshidi needles can be removed. vertebral body is then removed with either a drill or a ron-
geur, depending on the firmness of the bone. This is removed
The size of the fascial opening depends on the dimensions all the way to the disc spaces above and below, and later-
of the instrumentation that is used. Either a 10-blade knife ally all the way to the costovertebral junction. The costo-
or Bovie electrocautery are recommended to gently open the vertebral junction should be clearly defined and dissected,
fascia to accommodate the cannulated pedicle screw. A can- but extreme care must be taken to avoid disruption of the
nulated tap is then used under lateral image intensification. segmental vessels. If the segmental vessels are violated,
Tapping past the K-wire may dislodge and loosen it; thus bleeding can be stopped by applying a combination of throm-
extreme care must be taken during this step to prevent ven- bin and an absorbable gelatin sponge or other hemostatic
tral migration of the K-wire into the viscera and great vessels. agent (eg, Gelfoam) with gentle pressure. The vertebrec-
After tapping, the tap is removed; and again, extreme care tomy is completed with the drill or rongeur as far as the
should be taken not to loosen the K-wire during this step. anterior longitudinal ligament. A side-cutting matchstick-
type burr may be used to advance the drill safely ventrally;
The cannulated pedicle screw is then inserted over the K- a round-cutting burr is not recommended, since there is a
wire. Once the pedicle screw has obtained good purchase high risk of injury to the dura or the thoracic vessels. At
in the vertebral body the K-wire is withdrawn, and the this point, the posterior vertebral body is dissected away
screw is placed in an optimal position under lateral image from the dura with a 90° angled dissection instrument
intensification. This step is repeated for all pedicle screws. (angled Woodson instrument or similar). There may be ad-

hesions of the posterior longitudinal ligament to the dura; After adequate space has been made for the cage, a trial
these can be identified with a blunt nerve hook, stretched sizer is inserted. Many different cages will have trial foot-
laterally away from the dura, and cut sharply with a 15-blade prints that can be used to assess the diameter of the cage.
knife. At least one of the nerve roots is ligated to accom- The largest diameter footprint should be used as long as it
modate the cage. The authors prefer to use a medium sur- can be safely placed past the spinal cord. After an appropri-
gical clip and then cut sharply with a 15-blade knife. Pre- ately sized cage has been selected, it is inserted into the
ganglionic nerve ligation is carried out to avoid the risk of defect and expanded. Positioning is checked under image
neuroma formation. If multiple nerve roots are to be li- intensification. Graft material may be placed within or
gated, postganglionic ligation to preserve the blood supply around the cage, depending on personal preference.
may be considered.
If kyphosis is present, this may be corrected after the cage
Once the dura is free from the posterior longitudinal liga- has been put in place. A new rod is fashioned based on the
ment, the ligament is then cut with a 15-blade knife at the desired correction. The cephalad portion of this rod is then
level of the disc spaces, and the dura is protected with the inserted and locked into the cephalad screws. A rod holder
angled Woodson instrument. The discs are then dissected is then used at the caudal end of the rod. The temporary
using a combination of up-going curettes, a dissector, and rod on the contralateral rod is then removed, and the cau-
a small cervical Cobb elevator. The discs and the posterior dal rod is cantilevered into the inferior screw heads, fol-
longitudinal ligament are then removed. The endplates are lowing which the rod is locked into the inferior screw heads
prepared using up-going curettes. after the kyphosis has been corrected. Care must be taken
during this maneuver to prevent screw pullout in osteopo-
Before the corpectomy is completed, a temporary rod is rotic patients, or in spines with long-standing kyphosis that
inserted to prevent translation, stretching, or kinking of the have become rigid.
spinal cord, which could cause the loss of MEPs during the
operation and result in spinal cord damage and neurologi- The contralateral permanent rod is then placed in position.
cal deficit. To facilitate working with the temporary rod in Because of the destabilizing nature of the transpedicular
place, the rod should sometimes be changed from one side corpectomy, the authors use at least one cross-linker, pref-
to the other until the corpectomy is completed. erably two, before closure. The wound is closed in the stan-
dard fashion after multiple large drains have been left in
The transpedicular corpectomy is extremely destabilizing; the epidural space.
extreme caution should be used when considering perform-
ing this procedure on severely osteoporotic patients. In In summary, the disc spaces above and below the vertebral
summary, the same principles as open surgery should apply: body have to be carefully defined with low-setting electro-
good hemostasis, meticulous dissection, complete cord de- cautery to prevent inadvertent drilling into the normal ad-
compression, biomechanical stability, and good endplate jacent levels. To help ascertain the true orientation of the
preparation for arthrodesis. endplates, AP image intensification, or 3-D navigation can
be used to directly visualize the endplates. A temporary rod
6.3.3 Cage insertion should be prepared as a precautionary measure in case the
To facilitate cage insertion and positioning, after the cor- spine begins to translate in order to stabilize it. The authors
pectomy is completed, the vertebral body wall on the side prefer a standard single skin incision and multiple stab in-
of cage insertion must be completely removed all the way cisions through the fascia for cosmetic reasons. However,
to the ventral aspect of the spine. To place the cage, the separate skin incisions may also be performed, but with
authors prefer a trap-door rib-head osteotomy [2]. This al- multiple parallel skin incisions care must be taken to prevent
lows preservation of the rib head, avoids pleural dissection, skin necrosis. Postoperative drains should be left in the
yet "swings" the rib head out of the way to facilitate cage epidural space to prevent epidural hematomas. The authors
placement. Another option is to remove the rib head en- recommend at least two to three large bore drains, as for
tirely, a modification of the costotransversectomy technique open surgery. Drains are not left over the sites of the ped-
[9]. icle screws, but hemostasis at these sites is obtained with
Gelfoam/thrombin slurry, electrocautery, and compression.
215

7 Postoperative care transpedicular vertebrectomy followed by reconstruction

with polymethylmethacrylate (PMMA) and Steinmann pins
Postoperatively, patients are usually placed under observa- led to 90% good or better functional status 1 month post-
tion at least overnight in an intensive care unit or a step- operatively [14].
down unit. This allows for regular 1–2-hour neurological
checks, close monitoring of hemodynamic status, and drain- Although thoracotomy is associated with relatively high
age output. The greatest risk during the initial postoperative morbidity, Wiggins et al [15] found no statistical difference
period is the development of epidural hematoma, thereby between anterior approaches involving thoracotomy for
causing spinal cord compression. Pain management is usu- vertebral metastasis and costotransversectomy. Thirty-nine
ally via a patient-controlled analgesic device during the percent (7/18) of patients in the thoracotomy group and
initial postoperative period, with a gradual transition to- 38% (11/29) of patients in the costotransversectomy group
wards oral analgesics. Patients are mobilized immediately suffered from postoperative complications [15]. These data
with physical therapy. Postoperative x-rays are obtained to suggest that posterior approaches are as effective as ante-
ensure good implant placement, alignment of the thoracic rior approaches, and that minimally invasive routes might
spine, and to check for the possible presence of pneumo- offer room for further improvement. In the authors' study
thorax or pleural effusion. The authors do not brace their of 80 patients who underwent thoracolumbar corpectomy,
patients after this procedure. Usually, deep venous throm- the transpedicular approach was found to result in lower
bosis prophylaxis is started with heparin 5,000 units SQ morbidity than the anterior-posterior approaches, and in
TID on postoperative day 2, rather than using low-molec- comparable morbidity to the anterior-only approach. In
ular-weight heparin. addition, it was also found that patients who underwent
the transpedicular approach showed better neurological
improvement than those who underwent anterior corpec-
8 Evidence-based results tomy alone [1]. A recent multicenter study on 67 patients
who underwent open single-stage posterior corpectomy and
Given that minimally invasive posterior thoracic decom- cage placement with pedicle screw fixation for various pa-
pression techniques are relatively new, there is a paucity thologies reported good neurological outcomes and sus-
of high-grade clinical evidence in the literature. The exist- tained postoperative correction of sagittal deformity [16].
ing data range from the anatomical specimen technique
studies to retrospective case series. Ogden et al [10] described
a human anatomical specimen study in which varying tu- 9 Complications and avoidance
bular retractor distances off midline were used, and found
that 6 cm provided the optimal combination of corpectomy One area of difficulty is how to address the rib head after
extent and ventral decompression without requiring sub- corpectomy has been performed. There are many possible
stantial rib resection. alternatives available [2, 3, 5]. To avoid dissection or viola-
tion of the pleura, a trap-door rib-head osteotomy combined
Several authors have published reports on their techniques with disarticulation of the rib head allows the latter to be
of minimally invasive transpedicular corpectomy [4–6, 11]. preserved [2, 5]. A standard costotransversectomy approach
Unfortunately, these are mainly technical notes, and no can be performed, but this involves pleural dissection. Be-
statistical comparisons with open techniques have been cause of the significant amounts of seromatous fluid and
made. blood that drain postoperatively, pleural dissection can lead
to pleural effusion if any small rents occur. Even with small
There are a number of published case series in the literature, rents, pneumothorax is a rare occurrence.
but few include statistical comparisons with alternative
surgical approaches. Furthermore, none of them concern For the placement of percutaneous screws it is critical that
minimally invasive or mini-open cases. In a series of 21 no laminectomy defects are present, so that the Jamshidi
consecutive patients with vertebral body tumors, Shen et needles do not inadvertently pierce the dura. After screw
al [12] demonstrated the feasibility of extracavitary expand- placement it is also critical to prepare temporary rods as a
able cage reconstruction. Similarly, Snell et al [13] showed precautionary measure in order to avoid translation. During
the feasibility of a posterior midline single-stage vertebrec- the corpectomy, as the spine becomes destabilized, it can
tomy and reconstruction in 11 fracture and four tumor translate and cause neurological compromise (with subse-
patients. In an earlier large series of 140 patients, single-stage quent changes in MEPs and SSEPs). Thus it is sometimes

vital to stop the translation immediately, and place a uni- For most single-level corpectomies, the authors instrument
lateral temporary rod. Therefore, the temporary rod should two levels above and two levels below the level of interest.
be placed well ahead of time. For two-level corpectomies, the same number of levels can
be instrumented above and below if the bone quality is good
To prevent cerebrospinal fluid leakage from dissection of and kyphosis correction can be performed with this con-
the posterior longitudinal ligament, dissection with a nerve struct. In patients with poor bone quality, significant ky-
hook is recommended, and any adhesions should be sharp- phosis, or a three-level corpectomy, the authors instrument
ly cut. It is critical to ensure that there is no movement of three levels above and three below the levels of interest.
the dura when pushing downwards on the posterior lon- PMMA reinforcement of the screws can also be performed
gitudinal ligament. The authors also use Weck clips to ligate in cases of very poor bone quality. It is important to note
the nerve roots, as this technique is easier to use than tying that this procedure is extremely destabilizing, and that ap-
off the nerve roots with suture. propriate stabilization with good anterior column support
must be achieved.
10 Tips and tricks
Alfred Ogden, New York, USA • For thoracic pedicles, it is recommended • Never tap past the end of the K-wire in
• The thoracic corpectomy described in this to carefully measure pedicle size for screw any procedure. It is recommended to
chapter is really a hybrid procedure that selection and tailor the angle of the bed stop tapping once the fat part of the tap
utilizes an open or mini-open corpec- and/or image intensifier for each level to reaches the isthmus of the pedicle.
tomy in conjunction with percutaneous ensure an in-line trajectory. The initial • A down curette and a mallet may be used
pedicle screws. Other minimally invasive cannulation must be performed under to remove the ventral cortex of the ver-
approaches involve a single lateral inci- AP imaging, with precise utilization of tebral body. This decompression can be
sion through which corpectomy, cage the “bulls-eye” technique (see topic 12 verified with a dental mirror.
placement, and vertebral body screw Summary of different methods for pedicle • Tap stimulation is an option up to T6.
insertion are performed [6, 10]. This is a screw insertion in chapter 4.2.4 Mini-
different procedure from that described, open and percutaneous pedicle instru- Roger Härtl, New York, USA
and more closely approximates a lateral mentation and fusion for a more detailed • In patients with limited life expectancy
extracavitary or retropleural approach. description). due to metastatic disease, or patients for
• The surgeon should keep in mind that • Blunt K-wires are safer to use in osteopo- whom surgery times need to be mini-
with the corpectomy as presented in this rotic patients, but pointed K-wires may mized due to medical reasons, this com-
chapter there is no arthrodesis at either be necessary for dense bone, which can ment author performs total or partial
end of the construct. One could argue bend or deflect blunt K-wires from their transpedicular corpectomies with PMMA
that this is immaterial in the metastatic desired trajectory. augmentation. These patients can be con-
population, or less relevant in the mid- • It is important to periodically check that sidered for postoperative adjuvant radia-
thoracic spine as opposed to a level at or the K-wire is not being advanced un- tion therapy or radiosurgery [17].
near the cervicothoracic or thoracolum- intentionally during tapping or screw • With a longer midline skin incision, an
bar junction. placement. This usually occurs when epifascial drain should be placed. With
• The author prefers to perform initial gross soft tissue gets trapped in the cannula multiple small incisions there is a higher
discectomy prior to the corpectomy to or because the K-wire is inadvertently risk of skin necrosis.
better define the limits of the vertebral bent. Use of tissue dilators and a can-
body. nulated awl prior to tapping will reduce
• When performing a multilevel MISS pro- the likelihood of the former. The latter
cedure, particularly a thoracic one, this is usually the result of not verifying, vi-
comment author agrees that a midline sually and by x-ray, if the tap is in the
skin incision is preferable. It is cosmeti- self-same trajectory as the K-wire.
cally more appealing and allows for open
revision surgery if required.
217

11 Case example served (Fig 3.4-3). The pedicles were cannulated with Jam-
shidi needles guided under image intensification. K-wires
A 60-year-old woman with a history of breast cancer pre- were then inserted (Fig 3.4-4). Percutaneous screws were
sented with difficulty ambulating. Neurological examination placed through the fascia (Fig 3.4-5). The fascia was then
demonstrated 4/5 strength and sensory loss below T4. MRI opened with electrocautery over the intended corpectomy
demonstrated T4 cord compression secondary to a probable level (Fig 3.4-6). The laminectomy and corpectomy were
metastatic tumor (Fig 3.4-1). Urgent surgical intervention performed (Fig 3.4-7). An appropriately sized cage was in-
was planned. serted (Fig 3.4-8). After cage placement had been confirmed
under image intensification, the rods were placed, tightened,
The patient was brought to the operating room and placed and the cross-connectors positioned. Large drains were left
on a standard OSI Jackson table (Fig 3.4-2). A preoperative in the epidural space (Fig 3.4-9).
x-ray was taken, and the skin opened. The fascia was pre-
Fig 3.4-1 MRI demonstrating T4 cord com- Fig 3.4-2 The patient is positioned on a radiolucent OSI Jackson table.
pression secondary to a probable metastatic
tumor.
Fig 3.4-3 After x-ray confirmation of the correct level, the skin is Fig 3.4-4 The pedicles are cannulated with Jamshidi needles guided
opened. The fascia is preserved. under image intensification. K-wires are then inserted.

Fig 3.4-5 Percutaneous screws are placed through the fascia under Fig 3.4-6 The fascia is opened with Bovie electrocautery over the
image intensification. intended corpectomy level.
Fig 3.4-7 The laminectomy and transpedicular corpectomy are per- Fig 3.4-8 An appropriately sized cage is inserted.
formed.
Fig 3.4-9 A cross-connector can be placed at the level of the

corpectomy and drains are inserted.
219

12 Key learning points • Transpedicular corpectomy allows access to the ante-

rior spine from a posterior approach
• The same principles as for open surgery should apply to • Percutaneous screw placement allows for stabilization
posterior approaches for minimally invasive thoracic of the mini-open transpedicular corpectomy
decompression and stabilization: good hemostasis, me- • The mini-open transpedicular corpectomy has a much
ticulous dissection, complete cord decompression, bio- smaller fascial opening despite its comparable skin inci-
mechanical stability, and good endplate preparation for sion size. The authors have found that a single, long skin
arthrodesis incision achieves better cosmetic and wound healing
results.
13 References
1. Lu DC, Lau D, Lee JG, et al (2010) The 8. Maciejczak A, Barnas P, Dudziak P, et al 14. Wang JC, Boland P, Mitra N, et al (2004)
transpedicular approach compared (2007) Posterior keyhole corpectomy Single-stage posterolateral
with the anterior approach: an analysis with percutaneous pedicle screw transpedicular approach for resection
of 80 thoracolumbar corpectomies. stabilization in the surgical of epidural metastatic spine tumors
J Neurosurg Spine; 12(6):583–591. management of lumbar burst fractures. involving the vertebral body with
2. Chou D, Wang VY (2009) Trap-door Neurosurgery; 60(4 Suppl 2):232–241; circumferential reconstruction: results
rib-head osteotomies for posterior discussion 241–242. in 140 patients. Invited submission
placement of expandable cages after 9. Chou D, Lu D, Chi J, et al (2008) from the Joint Section Meeting on
transpedicular corpectomy: an Rib-head osteotomies for posterior Disorders of the Spine and Peripheral
alternative to lateral extracavitary and placement of expandable cages in the Nerves, March 2004. J Neurosurg Spine;
costotransversectomy approaches. treatment of metastatic thoracic spine 1(3):287–298.
J Neurosurg Spine; 10(1):40–45. tumors. J Clin Neurosci; 15(9):1043– 15. Wiggins GC, Mirza S, Bellabarba C, et al
3. Chou D, Wang VY, Gupta N (2009) 1047. (2001) Perioperative complications with
Transpedicular corpectomy with 10. Ogden AT, Eichholz K, O'Toole J, et al costotransversectomy and anterior
posterior expandable cage placement (2009) Cadaveric evaluation of approaches to thoracic and
for L1 burst fracture. J Clin Neurosci; minimally invasive posterolateral thoracolumbar tumors. Neurosurg Focus;
16(8):1069–1072. thoracic corpectomy: a comparison of 3 11(6):e4.
4. Musacchio M, Patel N, Bagan B, et al approaches. J Spinal Disord Tech; 16. Hofstetter CC, Chou D, Newman B, et al
(2007) Minimally invasive 22(7):524–529. (2011) Posterior approach for
thoracolumbar costotransversectomy 11. Hunt T, Shen FH, Arlet V (2006) thoracolumbar corpectomies with
and corpectomy via a dual-tube Expandable cage placement via a expandable cage placement and
technique: evaluation in a cadaver posterolateral approach in lumbar spine circumferential arthrodesis: a
model. Surg Technol Int; 16:221–225. reconstructions. Technical note. multicenter case series of 67 patients.
5. Deutsch H, Boco T, Lobel J (2008) J Neurosurg Spine; 5(3):271–274. J Neurosurg Spine; 14(3):388–397.
Minimally invasive transpedicular 12. Shen FH, Marks I, Shaffrey C, et al 17. Eleraky M, Papanastassiou I, Tran ND,
vertebrectomy for metastatic disease to (2008) The use of an expandable cage et al (2011) Comparison of
the thoracic spine. J Spinal Disord Tech; for corpectomy reconstruction of polymethylmethacrylate versus
21(2):101–105. vertebral body tumors through a expandable cage in anterior vertebral
6. Kim DH, O'Toole JE, Ogden AT, et al posterior extracavitary approach: a column reconstruction after posterior
(2009) Minimally invasive multicenter consecutive case series of extracavitary corpectomy in lumbar
posterolateral thoracic corpectomy: prospectively followed patients. Spine J; and thoraco-lumbar metastatic spine
cadaveric feasibility study and report of 8(2):329–339. tumors. Eur Spine J; 20(8):1363–1370.
four clinical cases. Neurosurgery; 13. Snell BE, Nasr FF, Wolfla CE (2006)
64(4):746–752; discussion 752–743. Single-stage thoracolumbar
7. Chou D, Lu DC (2011) Mini-open vertebrectomy with circumferential
transpedicular corpectomies with reconstruction and arthrodesis: surgical
expandable cage reconstruction. technique and results in 15 patients.
J Neurosurg Spine; 14(1):71–77. Neurosurgery; 58(4 Suppl 2):ONS-263–
ONS-268; discussion ONS-269.

14 Evidence-based summary
(2010) The transpedicular

Lu DC, Lau D, Lee JG, et al
approach compared with the anterior approach: an
analysis of 80 thoracolumbar corpectomies. J Neurosurg
Spine; 12:583–591.

Therapy Cohort III
Purpose
To analyze whether there was a difference in outcomes
by comparing transpedicular corpectomies to standard
anterior thoracolumbar corpectomies.
P Patient Patients undergoing thoracolumbar corpectomies (N = 80)

I Intervention Transpedicular corpectomies (n = 34)
C Comparison Anterior thoracolumbar (n = 46)
O Outcome Clinic visits, x-rays, telephone interviews, neurological
outcome, complications, operative times, revision surgery
rates, estimated blood loss
The transpedicular corpectomy appears to have a com-
parable morbidity rate to anterior-only corpectomies, but
its morbidity rate is lower than that of anterior-posterior
corpectomies.
221


3.5 Posterior approaches for minimally invasive treatment
of spinal fractures
Mark B Dekutoski, Mark Pichelmann, Michelle Clarke
1 Historical perspective open screw placement, stripping of the facet capsules, and
removal of screws from a midline approach caused signifi-
Less invasive posterior approaches for the management of cant iatrogenic damage to the open instrumented but non-
spinal fractures originated in the late 1950s, when Har- fused segments.
rington first applied a midline hook-rod distraction system
for the treatment of unstable thoracolumbar fractures. Contemporary MISS posterior fracture techniques have been
Early cases involved limited midline exposure, facet pre significantly improved by access to high-resolution image
servation, with fractures that were instrumented for reduc- intensification and further developments in pedicle screw-
tion but not fused [1]. These historic key features still apply based instrumentation systems. These technologies allow
in contemporary surgical philosophy: soft-tissue and liga- for greater accuracy in screw and rod placement, less soft-
ment preservation, maintenance of the articular facet cap- tissue stripping, and less muscle denervation and retraction.
sule, and selective instrumentation and fusion of the injured
or pathological motion segment. Posterior MISS systems have evolved around two distinct
tissue-handling techniques: the muscle-splitting and muscle-
Jacobs [2] is widely credited with popularizing the tissue- dilating approaches. The traditional muscle-splitting tech-
and motion-preserving techniques that have been coined nique, often called the '’Wiltse approach'’, is a historical
“rod long—fuse short” procedures. In his historic articles, mainstay. It involves anatomical dissection, with denervation
he emphasized the principles of tissue management and of the posterior rami where they enter the paraspinal mus-
restoration of motion to instrumented and nonfused seg- cle above and below the facet; retractors placed within the
ments that we now associate with minimally invasive spine split tissue require direct tension on the muscle tissue for
surgery (MISS) techniques. The other innovative observa- the retention of exposure [5]. However, retraction within
tion made in the late 1970s was the role of the disrupted the muscle-splitting window creates direct pressure on the
endplate and posterior ligamentous structures in the devel- muscle, with the risk of subsequent pressure-induced mus-
opment of postoperative kyphosis. This led to the develop- cle necrosis and postoperative atrophy/fibrosis [6].
ment of the Magerl/AO classification [3], which first high-
lighted the critical role of the posterior ligamentous complex The other technique, the muscle-dilating approach, uses
(PLC) in the management of thoracolumbar trauma. tubular dilators to create and maintain the surgical window.
Pressure studies have demonstrated a reduction of pressure
Percutaneous pedicle screw placement was first performed within the tissue surrounding the retractor when using
by Magerl in 1977 [4], and popularized by the fixateur in- tubular-based muscle-dilating MISS surgical procedures.
terne, later extensively used for thoracolumbar fractures.
This implant was the focus of one of Magerl’s original Food MISS techniques for the treatment of thoracolumbar frac-
and Drug Administration (FDA) Investigational Device Ex- ture patients have been reported in several small series with
emption studies on pedicle screw fixation. During the ear- a limited follow-up. The presence of comorbidities, con-
ly 1980s, the fixateur interne was also used percutane- comitant injuries, and the desire for earlier fracture fixation
ously to reduce fractures, high-grade spondylolisthesis, and have driven these attempts to reduce the morbidity associ-
to treat infections. While most procedures were carried out ated with spinal fracture treatment [7–9].
by open surgery, in a number of cases pedicle screws were
also placed via mini-open techniques. With the advent of The widespread adoption of MISS for fracture management
open segmental fixation, however, selective fusion prac- remains difficult due to the limited familiarity on the part
tices fell out of favor since the extensile approach using of surgeons with the techniques involved, an unclear defi-
223

Authors Mark B Dekutoski, Mark Pichelmann, Michelle Clarke
nition regarding the latter, an imprecise definition of the 2.6 Constrained rod passage
specific indications for surgery, and the lack of specialized This term refers to the passage of a subfascial rod via a link-
trauma centers. In North America, the rod long—fuse short age system that guides the rod in a fixed sequence through
technique, or the instrumentation of segments that are not screw holders.
fused, were reclassified as “Off-Label” by the FDA in Octo-
ber 2008. Although the FDA does not direct medical care 2.7 Open rod passage
policy, due to this reclassification, many health insurance This term refers to the passage of a rod/longitudinal device
organizations categorize the medical care received as ex- via an open muscle-splitting approach which, by nature of
perimental, and therefore reject payment claims. Decision- the latter, is a transfascial technique.
making regarding individual treatment plans should be based
on the best possible outcome, and what is in the patient’s 2.8 Unconstrained rod passage
best interest given the available resources and experience This term refers to the passage of a subfascial rod through
of patient care. screw holders via a holder that allows for the rod to be
advanced through the tissues and screw holders.
2 Terminology 2.9 Posterior ligamentous complex

The posterior ligamentous complex includes the interspinous
2.1 Minimally invasive spine surgery (MISS) ligament, supraspinous ligament, ligamentum flavum, and
Minimally invasive spine surgery involves the use of surgi- facet capsules.
cal techniques that are associated with soft-tissue and liga-
ment preservation, maintenance of the articular facet cap-
sule, and selective fusion of the injured or pathological 3 Patient selection
motion segment.
The selection of any surgical technique depends on the as-
2.2 Tissue preservation techniques sessment/diagnosis of the pathology in question, patient
These techniques refer to surgical exposure procedures that comorbidities, appropriate indication(s), relevant technical
preserve the soft tissues by limiting dissection and tissue principles, the surgeon's technical skill or experience, and
denervation, and avoid the risk of tissue-pressure necrosis. the care team's experience. Decisions regarding the man-
agement of thoracolumbar injuries should be based on a
2.3 Muscle-dilating techniques thorough knowledge of the patient’s neurological status,
These surgical techniques utilize dilators and tubes or fixed and full characterization of the ligamentous and osseous
blade retractors that preserve muscle innervation and do injury. The use of the Magerl classification [3] is invaluable
not depend on ongoing retractor tension on soft tissues for in defining the spectrum of anterior, posterior column/PLC,
stability and intraoperative visualization. rotational, and combined deficiencies. A treatment algorithm
based on the “thoracolumbar injury classification and sever-
2.4 Muscle-splitting techniques ity score” (TLICS), which takes into consideration neuro-
These techniques utilize surgical planes created by dividing logical status, mechanism, morphology, and integrity of the
the muscle parallel to the muscle fiber bundles to effect posterior ligaments, expands on the principles of the Mag-
denervation of the intraoperatively exposed tissues by tran- erl classification and can assist in determining the indications
section of the dorsal rami. In this exposure, retractors are for intervention [3, 10].
placed under tension against the muscles to maintain posi-
tion and enable access. The application of the stabilization principles of buttress,
neutralization, and tension band fixation to the pathome-
2.5 Rod long—fuse short technique chanics of the injury allows for proactive planning of the
This technique involves the use of bridge fixation across surgical intervention. In order to better understand the
injured motion segments, isolated fusion of pathological criteria determining patient selection, it may be helpful to
segments, and staged hardware removal to restore motion discuss these three mechanical principles of stabilization
to segments that have been temporarily instrumented but involved in the pathomechanics of different thoracolumbar
not fused. injuries Magerl type A, type B, and type C (Fig 3.5-1).

3.5 Posterior approaches for minimally invasive treatment of spinal fractures
a b c
A1 A2 A3
d e f
B1 B2 B3
g h i
C1 C2 C3
Fig 3.5-1a–i Magerl AO Fracture Classification.
a–c Type A injuries.
d–f Type B injuries.
g–i Type C injuries.
225

3.1 Type of spinal injury 3.1.2 Flexion or bending injuries and combined axial
bending and loading injuries (Magerl type B) (Fig
3.1.1 Axial loading injuries (Magerl type A) (Fig 3.5-1a–c) 3.5-1d–f)
Axial loading injuries (Magerl A1, A2, A3) include supe- Flexion or bending injuries (Magerl B1, B2, B3) represent
rior endplate injuries, pincer fractures, and stable burst a subset of thoracolumbar injuries with instability ranging
fractures. These main axial loading injuries are generally from moderate to severe (B3). The most stable of these
more stable, since they have an intact PLC and can be treat- injuries is the osseous Chance injury (B2), which can be
ed by various nonoperative and operative means, with ex- treated with a specific posterior tension band construct (Fig
cellent outcomes [3]. For specific patient indications and 3.5-3). Fusion is carried out when the bone surfaces are
goals, surgical intervention may be determined on the ba- limited, or when treatment has been delayed. Flexion dis-
sis of, eg, pain control, correction or prevention of kypho- traction injuries with PLC disruption are generally prone
sis, prevention of neurological deterioration, or comorbid- to progressive kyphosis and non-healing of the PLC. This
ity-driven mobilization without orthosis. Within the is the injury pattern affecting the disco-ligamentous complex
category of Magerl A injuries, pincer fractures (A2) and that Jacobs [2] recognized as being prone to failure. Magerl
those with sagittal splits (A1 or A3) may be prone to sagit- B1 ligamentous injuries are treated with reduction and
tal collapse or kyphosis, coronal translation and/or non- neutralization if the facets are disrupted, or by a compres-
union (A2). These generally stable axial loading injuries sion/tension band instrumentation technique when the
may be selectively treated by MISS percutaneous fixation facets are intact. Fusion is necessary, as the ligamentous
techniques that involve bridging the injured motion seg- injury will not heal with sufficient strength to prevent ky-
ment with or without posterior facet fusion, followed by phosis and late instability (Fig 3.5-4).
staged hardware removal after the bone has healed. Patients
with significant kyphosis, significant anterior disc or end- Combined axial loading and bending injuries (Magerl
plate injury, or neurological injury that needs indirect de- A3+B1, A3+B2) have been well described within the spec-
compression, are usually treated by fusing several motion trum of unstable “burst” injuries. This injury pattern displays
segments (Fig 3.5‑2). axial loading and flexion deficiency, and benefits from sur-
a b a b
Fig 3.5-2a–b Fig 3.5-3a–b
a Sagittal lumbar CT scan of a “stable burst” or Magerl A3 injury in a Sagittal CT scan of a bony Chance fracture or Magerl B2 injury in a
a polytrauma patient with pelvic and extremity injuries for whom young patient with intraabdominal injuries requiring laparotomy.
mobilization in a thoracolumbar sacral orthosis was not possible. b Intraoperative image intensifier view showing fracture reduc-
b Lateral x-ray taken 12 weeks postoperatively demonstrating a tion and steerable transfascial muscle-splitting rod passage with
bridging, neutralizing construct with early fracture consolidation implants placed in a tension band construct.
and maintenance of sagittal alignment. An inferior vena cava filter
was placed due to the polytraumatized state for pulmonary
embolism (PE) prophylaxis.

gical stabilization to provide enhanced mobility, prevent segments. Extension injuries are common in cases of an-
neurological deterioration, improve return to normal func- kylosing spondylitis, diffuse idiopathic skeletal hyperosto-
tion, and reduce the risk of late deformity and associated sis (DISH), and high-energy-ejected motor vehicle accident
pain. The definition of stable versus unstable burst fractures patients. These B3 injuries are grossly unstable (Fig 3.5-5).
is subject to controversy in the surgical literature, which in The use of MISS techniques for treating this injury pattern
turn renders outcome assessment problematic for this patient involves posterior neutralization of multiple segments
population [9]. Application of MISS techniques involves proximal and distal to the injury. Due to the gross instabil-
neutralization often across several segments above and be- ity involved, certain patients may require a staged anterior
low the area of injury, with selective fusion of the injured surgery in addition to the posterior instrumentation using
PLC. Staged hardware removal restores motion to nonfused a buttress technique (Fig 3.5-6).
a b a b
Fig 3.5-4a–b Fig 3.5-5a–b
a Sagittal CT reconstruction demonstrating a kyphotic Chance a Sagittal CT reconstruction showing an extension distraction or
fracture, flexion distraction or Magerl B1 injury with displaced Magerl B3 injury with diastasis of the anterior column in a patient
posterior elements in a patient that presented more than 1 week with DISH.
postinjury. b Postoperative lateral x-ray showing bridging fixation three to four
b Six-week postoperative x-ray demonstrating the application of levels above and below the injury, which was applied as a neu-
a posterior tension band construct and partial reduction of the tralization construct. In this ankylosed patient, it can be seen that
kyphosis. Posterior facet fusion was conducted over the disrupted the fixation endpoints are transitioned from bilateral to unilateral
posterior ligamentous complex. pedicle fixation points to reduce junctional stress on the implant–
bone interface.
Fig 3.5-6a–c
a Sagittal CT scan reconstruction of an unstable burst or
Magerl A3+B1 injury in a patient that presented with groin
hypesthesia and reduced sphincter tone. Imaging shows
retropulsion of the “delta” fragment attached to the poste-
rior annulus.
b Magnetic resonance imaging with FS-T2-weighted signal
intensity demonstrating the axial loading injury with conus
effacement and disruption of the ligamentum flavum or
“black stripe”. Posterior soft-tissue edema is also present.
c Postoperative lateral x-ray showing anterior buttress fixation
provided by the cage and plate and the posterior tension
band created by the posterior percutaneous construct.
Bone grafting material is visible anterior to the cage in the
a b c region of the anterior longitudinal ligament.
227

3.1.3 Rotational injuries (Magerl type C) (Fig 3.5-1g-i) 3.2 Indications

Rotational injuries (Magerl C1, C2, C3) are grossly unstable • (Highly) unstable fractures with/without malposition
high-energy injuries that are commonly associated with of the spine
neurological deficits. These are generally polytrauma pa- • Open injuries
tients often with brain injury, and pulmonary and/or vis- • Injuries with primary complete/incomplete paraplegia
ceral injuries that require interdisciplinary management. (quicker posttraumatic rehabilitation!)
When these patients are able to undergo a specific surgical • Injuries with secondary onset or progression of neuro-
procedure, MISS techniques that include bridge fixation logical symptoms in case of narrowing of the spinal canal
across multiple segments can be performed with limited • Progressive secondary posttraumatic segmental malpo-
blood loss. The benefit lies in the possibility to mobilize sition (eg, kyphosis)
these patients and thereby improve pulmonary management • Chronic instability (non-union)
and reduce the risk of systemic inflammatory response syn- • Impossibility of non-surgical treatment (eg, impossibil-
drome (SIRS) [9]. This early “salvage fixation” is based on ity to wear an orthosis).
the treatment of long-bone trauma, whereby early stabili-
zation reduces the risk of SIRS. In general, fusion and de- 3.3 Contraindications
finitive reconstruction can be delayed for weeks to months, • Maior contraindications for general anesthesia and
until the patient’s nutritional, pulmonary, and infection surgery
status have stabilized (Fig 3.5-7). • Severe comorbidities.
Summarizing, it seems obvious that indications and con-

traindications are in a great extent dependent on the frac- 4 Pros and cons
ture type as mentioned above. However some overall indi-
cations and contraindications for spinal fracture treatment The main advantages of minimally invasive procedures are
can be summarized: the reduced tissue trauma and preservation of muscles, with
the consequence of less intraoperative bleeding, a shorter
time for surgery, and in many cases, a quicker postoperative
mobilization and earlier onset of the rehabilitation phase.
However, cons should also be taken into consideration.
4.1 Pros
The advantages of minimally invasive posterior approach-
es for the management of spinal fractures include the fol-
lowing:
• Limited fusion of motion segments
• Reduced surgical invasiveness
• Less blood loss
• Early patient mobilization
• Improved recovery
• Quicker rehabilitation.
a b c
4.2 Cons
Fig 3.5-7a–c
a Sagittal CT reconstruction of a high-energy polytraumatized motor
The disadvantages associated with the minimally invasive
vehicle accident patient showing injuries over four consecutive treatment of spinal fractures include the following:
upper thoracic vertebrae in a patient that also sustained a sternal • Two procedures involved: placement of implants and
fracture. staged removal
b Coronal CT reconstruction showing an oblique fracture pattern
• Radiation exposure to patient and medical staff during
consistent with a rotational injury.
c Eight-week postoperative AP x-ray showing bridging instrumenta-
pedicle screw placement under image intensification.
tion placed in a neutralization pattern.

5 Preoperative planning and positioning 6 Surgical technique
Thorough patient evaluation, careful neurological assess- For posterior thoracolumbar percutaneous instrumentation
ment, and adequate preoperative imaging including CT scan using the muscle-dilating or muscle-splitting approach, the
or MRI are necessary for identifying the injury pattern and patient must be intubated and placed in a prone or lateral
planning the surgical procedure, as outlined previously (see position on a radiolucent table with image intensification
topic 3 Patient selection). Preoperative planning should access in AP and lateral planes. The prone position is rou-
include a comprehensive assessment of the trauma patient, tinely used, as patient movement, instrument trajectory,
education, medical history, and the patient’s informed con- and image intensifier visualization can impede instrumen-
sent. When possible, as a preventive measure, it is advanta- tation in the lateral position. The lateral position might
geous to wash or sponge-bath the patient with a chlorhex- serve as an alternative, eg, if longer positioning in a prone
idine solution, which has been shown to reduce the incidence position is less favorable in case of concomitant thoracic
of postoperative wound infection. To provide optimal care injuries.
to the trauma patient, a multidisciplinary team should pri-
oritize hemodynamic resuscitation or stabilization, and the 6.1 Access
improvement of nutritional status and pulmonary function. Two distinct subcutaneous skin techniques can be used in
The timing of surgery depends on the assessment of trauma MISS thoracolumbar fracture management:
and critical care systems. While as a rule acute intervention • The traditional paraspinal incision in line with the ped-
is considered to optimize outcome, it depends on the co- icle trajectory (Fig 3.5-8)
morbidities present and on resuscitation. Interdisciplinary • A midline incision and dissection lateral to the screw
trauma care systems and direct communication between entry zone via a subcutaneous or interfascial plane
care providers can optimize patient outcome due to shared (Fig 3.5-9).
expertise and integrated care.
In polytrauma patients with skin ecchymosis, paraspinal
Defining a surgical plan and communicating it to the entire incisions result in less dead space and potential for infection.
surgical team has been shown to improve procedural effi- As these incisions are made over the muscle, should any
ciency, and to reduce the number of sentinel events. infection develop, there are fewer potential problems to be
Fig 3.5-8 View of two screw extenders traversing a single paraspinal Fig 3.5-9 Intraoperative view of a midline wound demonstrating an
wound. interfascial plane that has been established and sutured to the dermis.
A transmuscular muscle-dilating approach has been used to place
wires in a cephalo-caudad direction, while the screw towers have been
inserted in a caudo-cephalad direction to assist image access, implant
and wire management.
229

encountered with a midline incision, which is the preferred Once the trocar has been placed and confirmed via imaging,
surgical approach for most trauma patients. The midline the cannula is removed and a blunt threaded guidewire is
incision is also preferred from a cosmetic standpoint, and passed within the bony corridor. Typically the authors place
is typically closed over flat channel drains to reduce hema- the wire under proprioception, thus confirming the osseous
toma formation. endpoints. As bilateral and consecutive wires are placed,
the authors ensure that the wire length is similar, thereby
6.2 Microsurgical techniques avoiding retroperitoneal passage of the wires. Some surgeons
have used split flexible wires to avoid retroperitoneal place-
6.2.1 Muscle-dilating subfascial approach ment, however, these thin wires are prone to breaking off,
For implant techniques that allow a muscle-dilating ap- and subsequently being reported as retained foreign objects.
proach for pedicle screw and subfascial rod placement, the
overall volume of tissue dissected will be significantly re- In order to facilitate insertion and handling, the wires are
duced. Pedicle screw placement using this technique in- generally placed in a cephalo-caudal direction and angled
volves several steps. First, the localization of the planned but not bent in a cephalad direction. Once the wires have
screw trajectory can be determined with the aid of spinal been placed, the blood is wiped off, the dilators are passed,
needles. A lidocaine with epinephrine 1/100,000 injection the tap is used to a minimum depth of 25 mm, and then
can be given to ensure additional hemostasis, and a longi- the screw-tower assemblies are placed over the guidewire.
tudinal incision made that encompasses adjacent screw Care during wire management is necessary for dilator place-
trajectories. As the screw towers are generally around 15 ment, tapping, and screw-tower insertion, in order to stay
to 18 mm in diameter, a single incision 30 mm in length collinear with the wire and to avoid advancing the wire
will typically allow for the passage of the screw-tower as- into the retroperitoneum, or pulling it free. Generally, main-
sembly and for manipulation during rod passage. Once the taining a hold on the wire for dilator, tap, and screw tower
dermis has been incised, the Pedicle Access Kit (PAK) nee- placement is all that is necessary.
dles can be passed using a muscle-dilating approach up to
the pedicle screw entry zone, and the latter confirmed un- Once the screws have been placed, the screw tower assem-
der image intensification (Fig 3.5-10a). Advancing the needle blies are positioned to form a slight, continuous arc (Fig
without applying leverage is the key to reducing soft-tissue 3.5-10b). The rod is placed in the holder and contoured to
disruption. PAK needle trocar tips can be used; bevel tips, match the intended reduced position of the spine. The rod
however, will allow for steerage of the PAK needle within length is estimated via placement of the rod along the skin
the bone, and more refined purchase on the lateral side of edge and measurement at the cephalad and caudad screw
the facet and transverse process of the thoracic elements. towers (Fig. 3.5-10c). A 6 mm rod entry incision is placed 3
Once the needle position at the lateral edge of the pedicle to 4 cm away from the proximal tower, following which a
has been confirmed on AP view, the PAK needle can be transfascial corridor to the latter is created with a hemostat.
advanced into the pedicle via an oblique passage through A contoured rod on the holder is then introduced through
the pedicle to the medial edge of the pedicle shadow as the stab incision and passed through the trans- and subfas-
visualized on AP image intensification. Although oblique cial corridor into the proximal tower. The instruments for
barrel views of the pedicles can be utilized and are recom- the subfascial rod technique have a screw holder that allows
mended in the case of narrow pedicles, if a true AP view is for the passage of a 5.5 mm rod into an 8 × 20 mm window
used, only a single image intensifier shot is necessary to above the screw yoke, then, using the screw holder, the rod
confirm the location of the PAK needle for two sets of bi- is inserted into the screw yoke.
lateral pedicles, thereby reducing the total image intensifi-
cation exposure time. Once the needle has been localized For each of the subsequent screw-tower assemblies, the rod
toward the medial wall of the pedicle, a lateral image in- is steered into the tower and engagement is confirmed either
tensifier view can confirm the appropriate depth within the by twisting the screw-tower assembly or using a depth gauge
pedicle. The trocar tips will direct in a straight line, while to confirm that the rod is within the tower. Once the distal
the bevel tips can be rotated to redirect their trajectory as tower is engaged, AP and lateral image intensification are
they are passed down through the body of the pedicle. Usu- used to confirm rod placement through the tower and the
ally, the AP and lateral views of the needle at the base of length of the rod proximally and distally. The screw tower
the pedicle body junction are kept as reference for the con- assemblies are used to introduce the rods into the screw
firmation of implant placement. yokes in a sequential manner, thereby reducing the risk of
spinal fracture (Fig 3.5-10d).

Several techniques have been used for reducing spinal frac- Total image intensifier exposure times for placement of the
tures. Careful assessment of the injury is first required, and typical 8-screw construct and 2 rods amount to under 0.5
monitoring either via laminotomy or image intensification minutes. Experience with pedicle cannulation, avoidance
is often necessary to avoid folding of the ligamentum flavum of real-time imaging, cutting down on the use of image
or fractured posterior elements. The authors typically use intensifier shots, limiting lateral views, or the use of dual
a tube-based MISS approach to debride a disrupted PLC at image intensifiers, have allowed for instrumentation with
the level of the injury, reduce the spine and then achieve as little as 2 to 3 seconds per screw.
facet fusion through this portal. In addition to applying
pressure to the patient’s chest wall and pelvis, screw drivers 6.2.2 Muscle-splitting semi-open approach
can be placed within the screw tower assemblies that do For implant techniques that are not designed for subfascial
not yet have a rod inserted. If translation is present, the rod placement and reduction, screw insertion is conducted
curved rod tip can be used to engage and translate the spi- through a Wiltse-type muscle-splitting approach. The main
nal motion segments. This segmental translation maneuver distinction between semi-open versus subfascial techniques
requires rod exchange after temporary reduction. Under- is the need for bilateral splitting of the dorsal fascia over
contoured rods can be used to reduce a kyphosis and/or the entire length of the construct, since in mini-open or
restore lordosis. Once the rods have been inserted and set muscle-splitting techniques the rod has to be passed from
screws placed, the screw-tower–rod assemblies can be dis- above the paraspinal fascia to below it, then advanced down
tracted, compressed or derotated, depending on the poly- into the screws. Although this semi-open technique is clos-
axial head design. er to open surgery, it requires the use of retractors that
a b c
Fig 3.5-10a–d
a Intraoperative AP image intensifier view demonstrating PAK needle
placement at the 3 versus 9 o’clock position, at the lateral midpoint
of the pedicle.
b Intraoperative view showing alignment of the screw towers in the
sagittal plane via adjustment of screw height.
c Intraoperative view showing estimation of rod length via placement
along the skin edge and measurement at the cephalad and caudad
screw towers.
d Intraoperative view showing rod insertion proximal to the first screw
tower and placement of the depth gauge in the rod tower to confirm
d rod passage.
231

compress the paraspinal muscle, and involves significantly 6.4 Instrumentation

greater muscle denervation, with the resulting risk of tissue
necrosis. 6.4.1 Muscle-dilating subfascial approach
Several instrumentation systems enable pedicle screw and
For the semi-open muscle-splitting approach, the skin inci- rod placement to be carried out via a muscle-dilating ap-
sion is located over the pedicles and dissection is carried proach with placement of a subfascial rod. One of the ear-
out through the paraspinal muscles, the plane between the ly products to be marketed, ie, the Medtronic Sextant, used
longissimus and multifidus muscles over the entire length linkage to proximal and distal screws and then, by mating
of the wound, or the segments wherein the pedicle screws the towers, a curved rod was passed through the fascia in
are to be placed. Various authors have recommended sep- a constrained orientation through the screw holders and
arate versus joined incisions with splitting of the thoraco- into the screw yokes.
lumbar fascia over the length of the construct to avoid the
development of pressure necrosis of the fascia and muscle More recent generations of rod holders and screw-tower
during the reduction and insertion procedure. designs allow for the placement of a subfascial steerable rod
that is positioned through the fascia and directed via rota-
Through the paraspinal split, the pedicle entry zones are tion and translation into the screw towers that are designed
approximated in a semi-open manner or using image in- to allow the insertion of the rod into the screw yokes. The
tensifier guidance as described above. The screws can be Medtronic Longitude system is an example of this technical
placed over wires or under direct visualization using the development. This type of insertion allows for the mainte-
established landmarks. Once the screws have been tapped nance of a percutaneous muscle-dilating approach, and
and placed, the rod is directed through the paraspinal wound therefore optimizes paraspinal viability.
into the screw heads. Vigilance is required in noting and
avoiding any paraspinal muscle and fascial entrapment and 6.4.2 Muscle-splitting semi-open approach
crush as the rod is inserted in a semi-open manner. Muscle Semi-open muscle splitting and transfascial insertion of
and fascial entrapment would lead to a visible tenting of pedicle screw implants and rods was first described by Mag-
the interval skin and subcutaneous tissues when the rod is erl in 1980 [4] with the insertion of the fixateur interne.
inserted. This muscle-splitting approach is characteristic of the Wil-
tse technique, and requires fascial division for access and
6.3 Navigation rod passage. This implant insertion concept has been further
Intraoperative imaging is necessary for safe pedicle screw developed in systems such as Synthes Matrix, DePuy Viper,
placement, as the surgeon does not have visual access to and K2M Serengeti.
the anatomical landmarks when using a percutaneous tech-
nique. As an alternative, many surgeons have used intra-
operative fluoroscopic image intensification, or CT-based 7 Postoperative care
image acquisition and navigation can be used. When image-
based navigation systems are used, however, the limitations Stabilization of fracture patients should be ensured to allow
of navigating across the unstable fracture need to be rec- for early mobilization and initiation of postoperative reha-
ognized and incorporated into the operative plan. bilitation. However, in some cases, the resumption of full
activity may be limited by neurological deficits and comor-
An example of surgical strategy across the unstable segment bidities. Early ambulation, core stabilization, and aerobic
with the use of CT-based navigation is as follows: the fidu- exercise are essential in restoring general health, well-being,
cial marker is first placed distal to the injury and the pedi- and socioeconomic functioning. Patients are routinely man-
cles are instrumented, followed by placement of the fiducial aged in the immediate postoperative period with same-day
marker proximal to the injury, reacquisition of data, and progression to sitting and standing, and early initiation of
the use of CT-guided navigation to perform proximal fixa- physical therapy including training stairs and lifting mechan-
tion. By following this sequence, the relationship between ics prior to discharge. The authors check wound healing and
the fiducial marker and the motion segments is maintained, initiate a formal core strengthening and progressive aerobic
and it stays that way even if the patient’s spine becomes exercise program that encourage full resumption of activ-
displaced and rotation takes place at the level of the injury. ity by the sixth postoperative week, with lifting limited to

15–20 kg until bone union has been established after about outcomes, and subsequent loss of reduction were similar
3 to 4 months. Most patients resume non labor-intensive to those published in the literature for more conventional
employment within 3 to 6 weeks, and progress to full activ- surgery [14–16].
ity without limitations around 3 months post-surgery.
In a comparative, prospective study, Grass et al [17] compared
The authors have followed up these patients with the goal percutaneous versus open instrumentation for fractures of
of their achieving full resumption of socioeconomic activ- the thoracolumbar region. Time for surgery itself and for
ity, with bony union confirmed via CT scan between 6 and intraoperative imaging as well as the accuracy of pedicle
9 months postoperatively. For patients with implants that screw positions didn’t show any statistical difference. How-
span unfused motion segments, hardware removal is typi- ever, intraoperative blood loss was remarkably lower in the
cally scheduled within a convenient time frame for return- group with percutaneous screw placement (P < 0.005).
ing to studies or employment; that is, within 9–12 month Postoperative needle electromyography documented normal
postinjury. Patients are hospitalized for hardware removal, physiological activity and muscle potentials in the percu-
and are generally discharged the next day. taneous group, whereas the open procedure induced per-
manent and significant damage to the extensor muscles.
Hardware removal involves using the prior skin incision
and following the muscle-dilating scar tissue down to the 8.2 Muscle-splitting semi-open approach
screw head. The set screws are then removed, and the rod In a feasibility study involving 104 patients with an instabil-
is backed out through the proximal or distal incision. Fol- ity due to degenerative bone disorders or trauma, Ringel et
lowing rod removal, the screwdrivers are inserted into the al [11] used fixateur interne-type instrumentation with a
screw heads and the screws are removed. Fascial openings muscle-splitting approach, and reported a 10% revision rate.
are sewn up with a single absorbable suture and the skin is Using postoperative CT scans, 87% of screw positions were
closed up in a subcuticular manner. The authors instruct rated good and 10% of screw positions were rated accept-
patients to keep wounds dry for 10–14 days and to apply a able. With 3% of all 488 screws being rated unacceptable,
vitamin E ointment and sunblock to reduce scarring. altogether 11 surgical revisions were performed (9 for mis-
placed screws and 2 for loosening of anchor bolts). No stan-
dardized outcome assessment was included.
Poelstra et al [9] have published several studies on a limited
MISS posterior procedures were directly adapted from semi- series involving the paraspinal semi-open instrumentation
open procedures until the early/mid 2000s, when muscle- of polytrauma patients thatwere acutely instrumented in a
dilating instrumentation became available. However, so far “damage control” manner. Their 2008 feasibility report [9]
the results in the literature are limited. documents the potential for improving outcomes in a high-
ly challenging patient population.
8.1 Muscle-dilating subfascial approach
A number of studies have been published on the treatment
of Chance fractures by percutaneous muscle-dilating tech- 9 Complications and avoidance
niques, including a series by Wild et al [8], as well as case
reports by Beringer et al [12] and Foley et al [13]. There are a number of potential problems to avoid, ranging
from soft-tissue management issues to instrumentation
The studies by Wang et al [7] and Wild et al [8] are limited challenges.
by the lack of patient-reported outcome measures, and by
insufficient information regarding patient selection. In Wang 9.1 Soft-tissue management
et al’s study [7], Magerl type A fractures were treated with Soft-tissue management is an essential aspect of all surgical
the constrained rod passage and percutaneous technique interventions, but with more limited dermal windows, skin
using Medtronic Sextant instrumentation. tension management is also necessary. As mentioned ear-
lier, carefully avoiding tenting the fascia with rod insertion,
More recent retrospective case series using MISS instru- and excessive paraspinal muscle tissue crush become more
mentation for the treatment of thoracolumbar trauma re- of an issue when rod insertion passes through the fascia
ported that the results for initial fracture reduction, clinical between the screws.
233

9.2 Instrumentation-associated complications tical value of using human anatomical specimens is sub-
Rod manipulation and the accompanying risk of screw- stantial.
tower dislodgement can be a concern for the novice team,
and may be resolved by proactive management of the screw Placing pedicle implants parallel to the endplate and with
trajectory parallel to the endplates, and by alternating the slightly greater axial angulation within the pedicle allows
orientation of the screw-head tilt medially and laterally for greater flexibility in rod placement, and reduces the risk
through the lordotic segments of the instrumentation. of cannulation of the facet joint and inadvertent transdural
trocar or implant placement.
Bearing in mind the adage “Luck favors the prepared mind”,
it is advisable for screw and rod insertion to be practiced on 9.3 Wound-healing complications
spine models and human anatomical specimens prior to Wound-healing complications have rarely been reported,
attempting clinical implantation. Most commercial suppli- but as the paraspinal wounds are lateral to the midline,
ers fund surgical education activities, and although their tissue coverage is usually not challenging.
promotional influence may have a certain effect, the prac-
10 Tips and tricks
Kelley Banagan and Steven C Ludwig, spine, and translating the spine anteriorly Michael Wang, Miami, USA
Baltimore, USA are options. Technical tips [18]:
• The operating room setup for MISS is • Once properly positioned, the screws • If only one image intensifier is available,
identical to that for conventional open should be advanced until they meet slight primarily utilizing AP images is a safe and
procedures: the patient is positioned resistance against the lateral border of effective technique. With this approach,
prone on a radiolucent table, the abdo- the facet joint; evaluating the tops of the image used must have the spinous
men is free of compression, and all bony the screw extensions and the cannulae process centered between the pedicles,
and vital structures are well padded. should reveal a smooth transition. and the upper vertebral endplate should
• The ability to use and interpret image in- • Passage of the rod is performed in a cra- be perfectly aligned to appear as a sin-
tensifier views is of utmost importance in nio-caudal direction secondary to the gle line. Using this image, the Jamshidi
MISS; a true AP view should be obtained morphology of the thoracic and lumbar needle should be inserted 2 cm into the
for each vertebral level to be addressed. lamina, providing a protective shingling bone without passing the medial wall of
• To obtain a true AP view, the center of effect over the spinal canal and neural the pedicle (as seen on x-ray). This will
the x-ray beam must be parallel to the su- elements; the bend in the rod should be ensure that no medial pedicle violation
perior endplate of the vertebra, produc- used to facilitate passage. takes place. Placing the Jamshidi needle
ing a single superior endplate shadow; • If screw extensions can be turned 360°, parallel to the endplate on this view will
the pedicle shadows should be slightly the rod has been passed outside the screw ensure good lateral alignment. This mini-
inferior to the endplate shadow, and the extension; by simultaneously pushing the mizes the need for lateral images.
spinous process should be equidistant be- rod holder and rotating and derotating • Difficulty in positioning the Jamshidi
tween the pedicles. the screw extensions, this can be avoided; needle in the ideal location may be due
• True AP targeting is the comment au- the surgeon can also place a screwdriver to sclerotic bone or uneven bone topogra-
thors’ preferred method for MISS pedicle or other device into the screw extensions phy. If several attempts have failed, then
instrumentation; however, this tech- to feel the rod as it is passed through. using a burr to create a hole or depression
nique is contraindicated if proper imag- • It is important to remember that although at the ideal starting site is safe if carried
ing of the vertebra cannot be obtained. MISS offers considerable benefits, the out under AP image intensification.
• Minimally invasive fixation of the upper disadvantages involved and the steep • Exchange of the Jamshidi needles for a
thoracic spine can be difficult secondary learning curve are important consider- Kirschner wire should place the wire tip
to thoracic kyphosis; to aid in image in- ations, and might preclude the use of 1/2 to 2/3 of the way into the vertebral
tensification, placing the patient’s head MISS techniques in certain patients. bodies. This is deep enough to avoid ac-
in a skeletal headrest, flexing the cervical

cidental wire removal, but superficial will compress and necrose the underly- to narcotics to control pain secondary to
enough to prevent entry into the ab- ing muscle when it is tightened down spasm.
dominal cavity. against the screw heads. It is helpful to • The timing of and necessity for late hard-
• Great care should be taken to minimize make the incision for the most cranial or ware removal is somewhat controversial.
over bending or kinking of the wires as caudal screw slightly longer and deeper Contemporary instrumentation differs
this may lead to breakage or fracture to assist with the proper seating of the from earlier techniques in that the rods
inside the body. “heel” of the rod (where the rod connects are placed below the fascia. Thus, most
• Rod passage in long-construct surgeries is to its holder). surgeons will have to wait longer or until
made easier if there is some curvature in solid fusion is established before remov-
the rod, at least at its tip. This curvature Postoperative management tips: ing the instrumentation (6–18 months
will help to guide the rod between screw • Patients undergoing muscle-preserving after surgery). Other surgeons will defer
head or attachment towers. It can be very MISS can be susceptible to significant this procedure indefinitely until evidence
difficult to pass a straight rod. muscle spasm as the tissues are not de- of pain, or when loosening occurs (see
• Care should be taken to ensure that rod vitalized. Muscle relaxants such as benzo- topic 11.3 Case example 3).
passage is subfascial. A superficial rod diazepines may be used as a supplement
11 Case examples and forearm, ankle and pelvic fractures. The patient under-
went hemodynamic stabilization followed by interdisciplin-
11.1 Case 1 ary evaluation and management. Neurological assessment
A 20-year-old unrestrained female passenger was ejected was limited to the purposeless movement of the four ex-
from a vehicle during a rollover motor vehicle accident tremities. The trauma team collectively considered that
(Fig 3.5-11). The patient was intubated on the spot for airway prioritization of thoracic fracture stabilization would allow
and respiratory compromise. Subsequent trauma evaluation for enhanced mobilization, and improved pulmonary and
identified facial fractures, traumatic brain injury, flail chest, systemic trauma response.
a b c d
Fig 3.5-11a–d
a Sagittal CT reconstruction showing the anterior and posterior injuries characteristic of a fracture dislocation
or Magerl C2 rotational and bending injury.
b Axial CT scan showing the oblique fracture pattern extending through the vertebral body, pedicle and
costovertebral complex, consistent with a rotational, flexion injury pattern.
c Intraoperative image intensifier view demonstrating the reduction achieved with a neutralization construct.
d Sagittal CT reconstruction at 6-months follow-up showing maintenance of the sagittal plane, facet fusion mass
and consolidation of the anterior spinal column injury.
235

The patient underwent surgery, with tracheostomy and Within 1 week postinjury, further CT scans were performed
thoracic stabilization. Spine stabilization was performed in that showed the extension pattern of the injury, while MRI
90 minutes from incision to closure. revealed a fracture characteristic of DISH (diffuse idiopath-
ic skeletal hyperostosis) at the junction between the verte-
The patient's pulmonary and systemic trauma response bral body and the endplate, and a small hematoma.
improved, with intubation being required for 1 week. The
patient then underwent facial and orthopedic reconstruc- As the injury in question was very unstable, a thorough
tion surgery, after which she was transferred to the reha- evaluation was performed, and surgeons engaged in a pro-
bilitation unit during the 4-week postinjury period. cess of informed patient consent, explaining the natural
history of DISH to the patient and comparing open versus
In the course of the patient's clinical follow-up, imaging percutaneous approaches for the treatment thereof. As it
demonstrated fracture consolidation with bridged segments. was a bone injury, the patient was informed that stabiliza-
Implants were removed 1 year postinjury. tion would be required for fracture healing.
The patient was placed in a prone position and remained

11.2 Case 2 fully conscious under local anesthesia, in order to avoid
A 70-year-old man fell onto the ice, an accident associated fracture displacement, while in situ instrumentation was
with immediate loss of urinary continence and lower extrem- performed considering the patient´s native kyphotic lumbar
ity weakness (Fig 3.5-12). The patient was examined at an posture.
outside facility by x-ray and axial CT scan, then was dis-
charged and sent to a nursing home. Although urinary con- Following surgery, as assessment of the patient’s neuro-
tinence and strength improved, the outside facility request- logical function was satisfactory, he was allowed to return
ed further evaluation for intractable back pain and spasm. home.
a b c d
Fig 3.5-12a–d
a Axial CT scan of the lumbar vertebra of an elderly patient with DISH, demonstrating an oblique fracture.
b Sagittal MRI T1-weighted image showing an anterior distraction injury extending through the osseous and disc endplate junctions,
with a hematoma anterior to the posterior longitudinal ligament.
c Intraoperative photo of the positioning of the dual image intensifiers used for guiding the placement of guide wires and for
confirmation of insertion.
d Postoperative lateral standing x-ray showing application of a neutralization construct to the patient’s flat-back posture, with bone
union to be confirmed by subsequent follow-up. In this case, the hardware will not be removed, as all the instrumented segments
are ankylosed.

11.3 Case 3 12 Key learning points

A 64-year-old woman developed severe back pain after a
fall. The patient suffered from an L2 burst fracture (Fig 3.5- • Minimally invasive percutaneous posterior fixation tech-
13) with height loss and spinal canal violation (D–F). She niques for spinal fracture treatment using pedicle screws
underwent percutaneous pedicle screw fixation using an vary in the degree of soft-tissue disruption involved.
AP-based image intensifier-guided MISS technique from Muscle-dilating subfascial techniques result in less tissue
T12 to L4 (Fig 3.5-14). The hardware was removed 1 year damage than muscle-splitting approaches
later after the fracture had fully healed. • Bridge fixation of motion segments and fusion of the
injured motion segments can potentially improve patient
outcome by reducing the number of fused motion seg-
ments
• Minimally invasive spine surgery techniques that spare
segmental innervation and ligamentous structures allow
instrumented and unfused segments to be restored to
motion and function.
a b b
Fig 3.5-13a–c Fig 3.5-14a–c

a Sagittal MRI T2-weighted a Intraoperative AP image in-
image showing an L2 burst tensifier view demonstrating
fracture with impaction of two transpedicular K-wires
the endplates. in the cranial vertebral body
b Corresponding sagittal CT and two transpedicular Jam-
scan showing the destroyed shidi needles in the adjacent
vertebral body L2 with frag- caudal vertebral body.
ment disclocation into the b Postoperative AP standing
spinal canal. x-ray showing the posterior
c Axial CT scan of L2 showing instrumentation T12-L4.
the dislocated fragment c Postoperative lateral
with narrowing of the spinal standing x-ray showing the
c canal. c posterior instrumentation
T12-L4 with restoration of
the sagittal profile.
237

13 References
1. Rampersaud YR, Anand N, Dekutoski 8. Wild MH, Glees M, Plieschnegger C, et 14. Pelegri C, Benchikh El Fegoun A, et al
MB (2006) Use of minimally invasive al (2007) Five-year follow-up (2008) [Percutaneous osteosynthesis of
surgical technique in the management examination after purely minimally lumbar and thoracolumbar spine
of thoracolumbar trauma: current invasive posterior stabilization of fractures without neurological deficit:
concepts. Spine; 31 Suppl 11:S96–S102; thoracolumbar fractures: a comparison surgical technique and preliminary
discussion S104. of minimally invasive percutaneously results]. Rev Chir Orthop Repar Appar
2. Jacobs RR, Asher MA, Snider RK (1980) and conventionally open treated Mot; 94(5):456–463. French.
Thoracolumbar spinal injuries. A patients. Arch Orthop Trauma Surg; 15. Palmisani M, Gasbarrini A, Brodano GB,
comparative study of recumbent and 127(5):335–343. et al (2009) Minimally invasive
operative treatment in 100 patients. 9. Poelstra K, Gelb D, Kane B, et al (2008) percutaneous fixation in the treatment
Spine; 5(5):463–477. The feasibility of damage control spine of thoracic and lumbar spine fractures.
3. Magerl F, Aebi M, Gertzbein SD, et al surgery minimally invasive spinal Eur Spine J; 18 Suppl 1:71–74.
(1994) A comprehensive classification stabilization (MISS) in the acute setting 16. Ni WF, Huang YX, Chi YL, et al (2010)
of thoracic and lumbar injuries. Eur for complex thoracolumbar fractures. Percutaneous pedicle screw fixation for
Spine J; 3(4):184–201. Spine J; 8(5):S89. neurological intact thoracolumbar
4. Magerl F (1980) [Injuries of the 10. Whang PG, Vaccaro AR, Poelstra KA, et burst fractures. J Spinal Disord Tech;
thoracic and lumbar spine.] Langenbecks al (2007) The influence of fracture 23(8):530–537.
Arch Chir; 352(1):428–433. German. mechanism and morphology on the 17. Grass R, Biewener A, Dickopf A, et al
5. Kim DY, Lee SH, Chung SK, et al (2005) reliability and validity of two novel (2006) Percutaneous dorsal versus open
Comparison of multifidus muscle thoracolumbar injury classification instrumentation for fractures of the
atrophy and trunk extension muscle systems. Spine; 32(7):791–795. thoracolumbar border. A comparative,
strength: percutaneous versus open 11. Ringel F, Stoffel M, Stüer C, et al prospective study. Unfallchirurg;
pedicle screw fixation. Spine; (2006) Minimally invasive 109(4):297–305.
30(1):123–129. transmuscular pedicle screw fixation of 18. Wang MY, Anderson DG, Poelstra KA, et
6. Bresnahan L, Fessler RG, Natarajan RN the thoracic and lumbar spine. al (2008) Minimally invasive posterior
(2010) Evaluation of change in muscle Neurosurgery; 59 (4 Suppl 2): ONS361– fixation. Neurosurgery; 63 Suppl
activity as a result of posterior lumbar ONS366. 3:197–203.
spine surgery using a dynamic 12. Beringer W, Potts E, Khairi S, et al
modeling system. Spine; 35(16):E761– (2007) Percutaneous pedicle screw
E767. instrumentation for temporary internal
7. Wang HW, Li CQ, Zhou Y, et al (2010) bracing of nondisplaced bony Chance
Percutaneous pedicle screw fixation fractures. J Spinal Disord Tech;
through the pedicle of fractured 20(3):242–247.
vertebra in the treatment of Type A 13. Foley KT, Holly LT, Schwender JD (2003)
thoracolumbar fractures using Sextant Minimally invasive lumbar fusion.
system: an analysis of 38 cases. Chin J Spine; 28 Suppl 15:S26–S35.
Traumatol; 13(3):137–145.

Wild MH, Glees M, Plieschnegger C, et al (2007) Five-year (2010) Percutaneous pedicle

Ni WF, Huang YX, Chi YL, et al
follow-up examination after purely minimally invasive screw fixation for neurological intact thoracolumbar
posterior stabilization of thoracolumbar fractures: a burst fractures. J Spinal Disord Tech; 23(8):530–537.
comparison of minimally invasive percutaneously and
conventionally open treated patients. Arch Orthop Study type Study design Class of evidence
Trauma Surg; 127(5):335–343. Therapy Case series IV
Study type Study design Class of evidence Purpose

Therapy Cohort III To evaluate the efficacy and safety of percutaneous ped-
icle screw fixation (PPSF) for thoracolumbar type A3
Purpose fractures with a specially designed surgical instrument
To compare the clinical and radiological results of mini- system.
mally invasive versus conventionally open posterior sur-
gery and to measure the loss of correction after purely P Patient Single thoracolumbar type A3 fracture and load-sharing
score of ≤ 6 (N = 36)
posterior stabilization.
I Intervention Percutaneous short-segment pedicle screw fixation
P Patient Thoracolumbar vertebral body fractures (N = 21) C Comparison No comparison group
I Intervention Minimally invasive posterior stabilization (n = 10) O Outcome Radiological parameters (eg, kyphotic angle, vertebral
height loss), functional outcome (Prolo questionnaire),
C Comparison Open posterior surgery (n = 11)
surgery time, intraoperative blood loss
O Outcome Blood loss, x-ray time, Hannover spine score, SF-36, biseg-
mental wedge, vertebral body angle
Authors’ conclusion The clinical results suggest that PPSF can be an alternative
The minimally invasive posterior stabilization leads to for management of thoracolumbar type A3 fractures that
reduced blood loss in comparison to the conventional have no neurological deficits. With a specially designed
open method, and can be carried out without any special percutaneous instrument and pedicle screw system, the
effort. However, it is limited to type A fractures without procedure has been proved as relatively safe and a mini-
any neurological symptoms. mally invasive approach for the management of thora-
columbar burst fracture without neurological deficit.
239

Palmisani M, Gasbarrini A, Brodano GB, et al (2009) Pelegri C, Benchikh El, Fegoun A, et al (2008) [Percutaneous
Minimally invasive percutaneous fixation in the osteosynthesis of lumbar and thoracolumbar spine
treatment of thoracic and lumbar spine fractures. Eur fractures without neurological deficit: surgical technique
Spine J; 18 Suppl 1:71–74. and preliminary results]. Rev Chir Orthop Repar Appar
Mot; 94(5):456–463. French.
Purpose
To study the results of surgical treatment of thoracolum- Purpose
bar and lumbar spine fractures by percutaneous trans- To study the technique of percutaneous osteosynthesis
pedicular fixation and stabilization with minimally inva- of lumbar and thoracolumbar spine fractures without
sive technique. neurological deficit and to report preliminary results.
P Patient Fractures of the thoracolumbar and lumbar spine (N = 51, P Patient Lumbar or thoracolumbar spine fractures (N = 15, 47%
n = 34 males, mean age 45 years, N = 64 fractures) male, mean age 36 years, age range 16–58 years)
I Intervention Percutaneous transpedicular fixation and stabilization with I Intervention Percutaneous osteosynthesis
minimally invasive technique
O Outcome Mean operative time, mean hospital stay, VAS scores,
O Outcome Surgery time, pain, complications, x-ray and subjective Oswestry Disability Index scores, return to work, patient
evaluation satisfaction, x-ray parameters, complications

Minimally invasive percutaneous fixation in the treatment Percutaneous osteosynthesis of lumbar and thoracolum-
of thoracolumbar and lumbar spine fractures represents bar spine fractures is an attractive therapeutic option.
a good alternative to conservative treatment.

Rampersaud YR, Anand N, Dekutoski MB (2006) Use of

minimally invasive surgical techniques in the
management of thoracolumbar trauma: current concepts.
Spine; 31 Suppl 11:S96–S102.

Therapy Expert opinion and N/A
literature review
Purpose
To provide an overview of the current concepts of mini-
mally invasive spine surgical (MISS) techniques for the
management of thoracolumbar (TL) spinal trauma.
P Patient Not applicable

I Intervention Anterior endoscopic decompression and stabilization
Posterior percutaneous tension band restoration or
augmentation
Percutaneous vertebral-body balloon-assisted endplate
reduction and augmentation
Temporary percutaneous posterior fixation
C Comparison Conventional techniques
O Outcome Blood loss, perioperative pain, reduced time to mobiliza-
tion, and hospital stay, Prolo score, revision surgery, adverse
events
The application of MISS techniques to spinal trauma is
theoretically sound. However, the indications and tech-
nology are evolving. Insufficient clinical data exist with
which to draw any conclusions as to whether these tech-
niques are associated with superior or inferior outcomes
compared with conventional techniques. Although very
limited information is available, the results of current
MISS techniques for the management of TL trauma are
encouraging.
241


3.6 Vertebroplasty and percutaneous cement reinforcement
techniques
Paul Heini, Mark Kleinschmidt
1 Historical perspective restored and maintained by inserting and afterwards ex-

panding a vertebral body stent (VBS). In vesselplasty, cement
More than 20 years have passed since the first report by is injected directly into a permeable balloon to decrease the
Galibert et al [1] on the injection of acrylic cement for treat- risk of cement leakage. From a clinical point of view, there
ing vertebral hemangioma. This technique, known as ver- is no difference in outcome for kyphoplasty or vertebro-
tebroplasty, was successfully extended to the treatment of plasty. However, a higher incidence of leakage has been
metastatic lesions [2] and is increasingly used for osteopo- reported for vertebroplasty in comparison to kyphoplasty
rotic vertebral fractures [3]. Nowadays, it has become the [7]. This is mainly due to the different technique of cement
gold standard for addressing painful vertebral compression delivery. Meanwhile, it is generally accepted that viscosity
fractures [4, 5]. is the key to safety, and therefore, high-viscosity cement is
also used for vertebroplasty [9].
The technique's refinements entail using a balloon to create
a cavity in the vertebral body, thereby simplifying the ap-
plication of cement [6]. The restoration of vertebral body 3 Patient selection / indications / imaging
height, on which emphasis was initially placed, has not
fulfilled the original expectations [7]. Vertebral body compression fractures increasingly occur
with advancing age. However, the majority of fractures are
The widespread use of cement reinforcement has been chal- not brought to clinical attention and show a self-limiting
lenged by two randomized controlled trials (RCTs) compar- pain course.
ing vertebroplasty with a sham procedure. Both types of
intervention were found to provide similar pain relief [8]. Patients with acute back pain (thoracic, lower back) and a
However, these findings have been criticized regarding the risk profile (eg, patients over 65 years old; a history of previ-
external validity of the presented data. Moreover, the most ous fracture; renal disease; steroid medication; body mass
recent RCT comparing vertebroplasty with conservative index [BMI] below 20) should undergo an imaging investi-
treatment reveals the clear advantage of the former [4]. gation. The preferred examination strategy remains standing
x-rays of the region of interest in two planes. Comparing
these to previous x-rays can often disclose a new fracture;
2 Terminology such a fracture can be followed up easily through two con-
secutive controls, which are usually performed within 2 weeks
Vertebroplasty and other percutaneous cementing tech- of the index image (Fig 3.6-1). If there is any uncertainty, MRI
niques, such as kyphoplasty, stentoplasty, and vesselplasty allows the identification of a fresh fracture by the signal
aim to reinforce fragile osteoporotic vertebrae, ie, vertebral change in the STIR sequence (Fig 3.6-2, Fig 3.6-8). Furthermore,
body compression fractures (VCFs). Characteristic of all these a CT scan can be helpful in assessing an atypical fracture
techniques is the injection of acrylic cement (polymethyl- pattern and is sometimes used if patients are not suitable for
methacrylate [PMMA]) into the vertebral body. While in MRI examination. A bone scan can be used as a screening
vertebroplasty a filling cannula is inserted and the cement tool if the diagnosis remains unclear. Flexion–extension views
is directly injected into the vertebral body, in kyphoplasty are not helpful in this regard, but the comparison of a stand-
a balloon is first inserted, inflated, then deflated and re- ing film and any supine view can assist in identifying re-
moved, thereby creating a cavity aimed at decreasing the sidual mobility in the fractured vertebra. A cross-table view
risk of cement leakage. In stentoplasty, which presents a with a hypomochlion might be useful if the situation remains
further development in percutaneous techniques, height is unclear and the patient is able to tolerate this.
243

Authors Paul Heini, Mark Kleinschmidt
T1 T2
a b a b
Fig 3.6-1a–b X-rays showing progressive collapse of a fractured Fig 3.6-2a–c Different MRI
STIR
vertebra at L1 within 1 week. In this situation, cement reinforcement sequences showing the stron-
can stabilize the vertebral body and provide pain relief, and also prevent gest signal change in the STIR
further loss of posture. sequence, clearly disclosing a
fresh fracture. Only L2 shows an
increased signal.
Patient with back pain (red flag)
X-ray assessment (standing) (MR/CT scan if unclear situation) c
Patient with severe pain / Patient with moderate pain /

hospital admission outpatient
Follow-up x-ray
Stable
Progressive collapse
situation
Follow-up x-ray
Consider vertebroplasty Conservative treatment
Fig 3.6-3 Algorithm for patient assessment and indications for cement
reinforcement surgery.

3.6 Vertebroplasty and percutaneous cement reinforcement techniques
The indications for a percutaneous cement injection pro- 4.1 Pros

cedure are based on clinical and imaging findings, and in- • Immediate pain relief after cement injection
clude the following: • The procedure can be performed under local anesthesia
• Painful fracture of a vertebral body, refractory to con- with standby control
servative treatment (avoid morphine as first-line treat- • Repeated injections are possible (when new fractures
ment for pain control in the elderly) occur)
• Vertebral body compression fractures (VCFs), which • Multiple injections (into more than one vertebra) in one
require hospitalization due to pain session are possible
• Progressive loss of vertebral height during the follow-up • PMMA is inert and mechanically stable
period • Vertebroplasty is an inexpensive, cost-effective procedure.
• Multiple vertebral fractures within a short time period
• Vertebral compression fractures associated with meta- 4.2 Cons
static lesions and myeloma • Increased risk of adjacent fractures
• Internal fixation for improved implant anchorage. • Cement leakage is an inherent procedural risk
• PMMA is not bioactive
An algorithm for patient selection/treatment indications is • Height restoration is not possible with vertebroplasty.
presented in Fig 3.6-3.
There are obvious contraindications for this treatment strat- 5 Preoperative planning and patient positioning
egy. Firstly, fractures needing open surgical stabilization
are not suitable for this minimally invasive approach. When the indication for a vertebroplasty procedure has
been established, the surgeon should assess the preoperative
Patients with any of the following should not be treated x-rays for anatomical singularities. The pedicle size can be
with this technique: indicative of the choice of approach; if a reduction procedure
• Pain unrelated to the fracture with a stentoplasty is planned, the exact placement of the
• Infection stent is crucial and needs to be planned preoperatively via
• Neurological compromise with cord or nerve compression CT scan or MRI (Fig 3.6-4, Fig 3.6-7).
• Fatigue fracture in ankylosed spines
• General contraindications for surgery (eg, clotting dis- Preoperative patient assessment includes the determination
orders, cardiac disease) of normal coagulation status and sufficient respiratory and
• Limited visibility during surgery/technical problems. cardiac function. Generally, if patients can tolerate the prone
position they can be treated by the cement injection tech-
nique. If local anesthesia is used, patients must be placed
4 Pros and cons of vertebroplasty and percutaneous in the most comfortable prone position. The authors prefer
cement reinforcement techniques to use a beanbag that can be adjusted individually. Free
access for the C-arm in both planes is mandatory (Fig 3.6-5).
Osteoporosis is a systemic disease involving the whole skel- An intravenous line should be established and ECG, oxygen
eton. Injecting PMMA only addresses a local problem. There- saturation, and blood pressure monitoring ensured. Mild
fore, it remains mandatory that patients with osteoporotic sedation is initiated by an anesthesiologist standing by. For
fractures be assessed in terms of their bone metabolism and sedation and analgesia propofol (Disoprivan) and fentanyl
treated accordingly. are used, and adapted to the patient's individual needs and
tolerance. Depending on the local facilities and the patient's
The injection of PMMA may increase fracture risk to the individual situation, it is preferable that the procedure be
adjacent vertebrae. However, the natural history alone performed under general anesthesia. This allows for better
shows an increased fracture risk of up to 20% 1 year after patient monitoring on the one hand, but is more compli-
the index fracture. There are advantages and disadvan- cated and expensive on the other. For more complex pro-
tages to percutaneous vertebral cement reinforcement tech- cedures such as stentoplasty or the treatment of multiple
niques, which are summarized as follows: levels, general anesthesia is nevertheless advantageous. It
also allows the patient to be positioned in hyperextension
during surgery.
245

Fig 3.6-4 Placement of guidewire/cannula based on anatomical

landmarks. The medial border of the pedicle and the posterior wall define
the safe corner (red line/red angle). Depending on the final positioning,
the angle of approach differs and the skin incision is made according the
trajectory planned for the cannula. The dotted red arrow indicates to the
bilateral approach, while the black arrow indicates the monolateral and
more convergent approach.
c d
Fig 3.6-5a–d For a surgical procedure under local/standby anesthesia, the patient
is placed in a prone position on a beanbag that can be adjusted to individual needs.
Free access for the C-arm in the AP and lateral projection in the area of interest is
mandatory. A high-quality C-arm is essential. The area to be treated is examined
before draping, and the levels to be treated are indicated preoperatively. It is also
possible to install two C-arms to monitor both planes simultaneously. Otherwise,
it is necessary to switch from lateral to AP monitoring during the cement-filling
b procedure.

6 Surgical technique under AP image intensification until its tip reaches the
medial border of the pedicle (Fig 3.6-4)
The surgical steps for vertebroplasty are as follows: • If more than one approach is necessary, this step is re-
• Cannula placement peated
• Preparation of the cement • The position in the lateral projection is checked, and it
• Cement injection/cannula removal. is ensured that the K-wire is at the level of the poste-
rior wall
6.1 Access, cannula placement • The position of the guidewire is readjusted, if necessary.
Placement of the filling cannula or working portal can be • The filling cannula or working portal is introduced. The
either trans- or parapedicular, depending on the patient's tip of the filling cannula should reach the anterior half
specific anatomical characteristics and the chosen sequence of the vertebral body (Fig 3.6-6)
for the approach. Generally, the approach at the thoracic • A biopsy is taken if needed
and upper lumbar spine is performed monolaterally—unless • A blunt trocar is used to clear the cannula.
the fracture pattern is special (for instance, a comminuted
endplate presents a higher risk of cement leakage)—or un-
less a kyphoplasty or stentoplasty procedure is planned (Fig
3.6-6). The angulation to approach the center of the verte-
bral body (VB) is increased (Fig 3.6-4). In the lower lumbar
spine, the approach is usually transpedicular and carried
out bilaterally, in order to achieve sufficient filling and sup-
port for the VB.
Any percutaneous procedure depends on image-guided

navigation. The standard modus operandi is the C-arm.
High-quality equipment is desirable, and a combination of
two C-arms can ease and speed up the procedure, although
this is not mandatory (Fig 3.6-5). Also, CT guidance is used,
or the intervention is performed, in the angiography suite.
For cement injection, real-time monitoring is crucial. For a b
cannula placement, computer-guided navigation is de-
scribed.
The procedural steps are as follows:

• After patient positioning, the site to be treated is exam-
ined with the C-arm, ensuring that the anatomical land-
marks are clearly visible in both planes (Fig 3.6-4)
• The levels and points of entry are indicated
• Disinfection and surgical draping are performed
• The C-arm is introduced in strict AP projection, the beam
adjusted parallel to the endplates, identify the pedicle c d
• Local anesthesia is injected into the skin in the projec- Fig 3.6-6a–d Cement injection under continuous lateral C-arm moni-
tion of the pedicle and around the periosteum of the toring. The appearance of the cement at the tip of the cannula must be
observed very carefully. If the cement disperses in any direction away
transverse process/facets (about 5 cc)
from the tip, this indicates direct connections to vascular channels in the
• A stab incision is made according the planned trajectory bone. Then 45 to 180 seconds should elapse before applying another
• Stepwise placement of a 2 mm guide wire then follows: small amount of cement. The cement should be injected in a stepwise
when the guide wire tip touches the bony surface, the fashion, and build up gradually. After the first 2 cc have been injected,
starting point is usually lateral to the outlines of the checking via AP C-arm monitoring should be performed. Following this,
cement injection can be continued with the C-arm in the lateral projec-
pedicle, thus achieving sufficient convergence. If a mono-
tion. Once resistance to the injection becomes apparent, the trocar
lateral approach is chosen (according the preoperative can be used to push in the remaining cement. This ensures controlled
planning), the starting point is located up to 1.5 cm application of the cement. At any sign of leakage, the injection must be
lateral of the pedicle eye. The guidewire is advanced stopped immediately.
247

6.2 Cement preparation a significant height loss (Fig 3.6-7, Fig 3.6-8). The surgical
There are several cement formulas on the market that are technique follows the principles described beforehand. Pre-
specially designed for vertebroplasty. They have an increased operative planning for correct stent placement is important.
radiopacity and longer working time at the optimal viscos- Then the stents are expanded and height is restored. After-
ity level. Some of these cements are ready for immediate wards, the cementing is performed in exactly the same man-
use, others require several minutes before they can be inner as in a vertebroplasty procedure, taking the same pre-
jected. It is important to be aware of the temperature sen- cautions. To obtain sufficient support, determining the
sitivity of the setting time. High viscosity is a crucial factor appropriate amount of cement is crucial. The cement should
for controlling cement leakage. infiltrate the surrounding bone (Fig 3.6-7, Fig 3.6-8).
6.3 Cement injection

Low-viscosity cement should not be injected. Another con-
sideration is that many injection tools on the market are
not well designed, and should not be used as they do not
allow the injection of high-viscosity cement. The use of
small syringes (1 cc, 3 cc) or the plunger technique, which
is applied in kyphoplasty, allows direct feedback during
cement injection and provides the best way of injecting
high-viscosity cement.
• Prepare the cement and inject it once it has reached the a b

desired viscosity
• Carry out cement injection under continuous lateral
C-arm control with intermittent AP checks (Fig 3.6-6)
• Stop injecting whenever any cement leakage is ob-
served—depending on the type of cement used, injection c
can be resumed after 45 to 180 seconds (check the clock)
• Complete the filling procedure until the vertebral body
is supported from the upper to the lower endplate re-
spectively to the stable area of the VB
• Wait until the cement has set, then remove cannula and d e
close the stab incision
• Parallel injection of up to three levels/cannulas can be
performed if the surgeon is experienced. Ensure that
there is sufficient cement available when treating the
lumbar spine
• The maximum amount of cement that can be injected
safely in one session is about 25 cc [10]
• Any manipulation or injection in the VB displaces fat
into the venous system, regardless of which technique
f g
is used.
Fig 3.6-7a–g
a–b Preoperative CT scan for the planning of stent placement in a
6.4 Height restoration by stentoplasty
78-year-old man that presented with a 4-week history of severe
Vertebral body compression fractures usually increase the back pain.
kyphotic deformity, thereby altering the spinal balance with c–e Intraoperative view before and after stent expansion with
an increasing load on the anterior column and higher strain subsequent height restoration.
on the back muscles. In severely deformed vertebral bodies f–g Standing postoperative view showing maintained alignment, with
prophylactic cement injection of the adjacent levels. The fact that
that still show a potential for height restoration (see topic
the patient had a history of steroid medication and a smoking-
3 in this chapter) the use of a vertebral body stent is recom- associated obstructive pulmonary disorder represents a high risk
mended. Adopting this approach should be considered if for adjacent fractures. Therefore the prophylactic injection of the
the kyphosis is more than 15° or the vertebral body shows adjacent levels appears justified.

a b c d
Fig 3.6-8a–f
a Supine view showing a mild compression fracture at L1 and T12 in
a 77-year-old man (asterix).
b MRI showing a signal change at L1, indicating a fresh lesion,
whereas the signal at T12 is regular.
c Preoperative standing view showing an important height loss and
displacement of the anterior wall (arrows).
d Expanded titanium vertebral body stent.
e–f Complete height gain of the fractured vertebra can be seen follow-
ing stentoplasty.
e f
249

6.5 Cement reinforcement for enhanced implant are inserted before the cement has set. This technique allows
anchorage / Avoidance of fractures adjacent to a the use of any standard stabilization system. The procedure
stabilization is somewhat complex and time-consuming, but reliable.
The problems related to osteoporosis and internal fixation Alternatively, perforated screws allow direct cement injec-
are increasing, as well as the numbers of patients with VCFs tion through the screw, thus improving stability (Fig 3.6-9).
and concomitant neurological involvement, or patients with The amount of cement required for improving stability is
spinal instabilities and spinal stenosis. In these cases, ad- between 1 and 4 cc per screw. Certain cements are available
ditional stabilization is necessary but fixation failure remains with a very long duration of effectiveness that allow safe
a major issue. Furthermore, vertebral fractures adjacent to cement injection through four screws in one run. The same
the stabilization are a common problem. principles and precautions apply as for any other cement
injection technique. Today, the clear indication for addi-
The application of PMMA to increase spinal stability has tional cement reinforcement remains an open question. If
been used for a long time. Vertebroplasty offers the option maximizing the implant dimensions (diameter, length) ap-
of using the same fixation principles as those for normal pears insufficient, the surgeon should consider enhancing
bone. To increase the stability of the screws, a vertebro- the fixation stability using cement.
plasty procedure is performed in which the pedicle screws
a b c
Fig 3.6-9a–e Screw reinforcement techniques. A vertebroplasty procedure

directly followed by screw insertion allow the adoption of standard techniques for
implants, as in healthy bone. Perforated screws permit direct cement injection. For
any of these techniques the principle of vertebroplasty applies and needs careful
d e C-arm monitoring.

To decrease the incidence of VCFs subsequent to fixation, of the adjacent levels. Adjacent level injections can be per-
prophylactic reinforcement of the vertebrae next to the formed during the main intervention, if the patient can
fixation level can be carried out. The risk of a fatigue frac- tolerate the additional cement. In this case, the main pro-
ture following stabilization increases with the number of cedure is carried out and the percutaneous injection is per-
levels fixed. Therefore, special attention is required for deal- formed under the same anesthesia. Alternatively, the patient
ing with scoliosis correction in the elderly. Common failures can be treated secondarily under local anesthesia during
include fractures of the adjacent vertebrae and failure of the early postoperative phase, after 1–3 weeks. Adjacent
the last instrumented vertebrae. Failure may occur despite fractures are usually observed very early on, within the first
cemented screw fixation and the prophylactic augmentation 4 weeks (Fig 3.6-10).
b d
Fig 3.6-10a–e Failure pattern

in the adjacent vertebrae. In long
constructs, an adjacent fracture
can occur despite the “good”
hold of implants. Even with the
prophylactic cementing of adjacent
levels, the bone can give way and
a c e the disc space collapse.
251

6.6 Anterior column support by PMMA injection 7 Postoperative care

A further aspect to be considered in the context of verte-
broplasty is the issue of anterior column support in deficient After a percutaneous cementing procedure (vertebroplasty,
spines, ie, spines with severe osteoporotic fractures or tu- kyphoplasty, stentoplasty) the patient is placed supine for
mors. Once posterior fixation has been completed, it may 1 hour to apply compression to the back muscles. During
be found that stabilization/support of the anterior column the operation, a painful hematoma may develop shortly
is necessary. Instead of carrying out another intervention after the injection. After the surgical procedure, the patient
to reinforce the anterior column an additional cementing can be mobilized as much and as early as tolerated wheth-
procedure can be performed, in which high-viscosity cement er they undergo a general or local anesthesia. Sutures are
is used to fill the void/defect. As the segment is stabilized removed after 1 week. The patient should avoid forced for-
and intended to fuse, the cement is also applied into the ward bending during the early postoperative phase; other-
disc space without hesitation. Usually very high amounts wise, there are no restrictions except for heavy lifting. No
of cement are required to achieve sufficient stability. This brace is applied. Patients should be instructed about the risk
is a technically demanding intervention, in which the sur- of further fractures, and reexamined whenever new pain
geon should use biplanar imaging. Filling should be aggres- occurs. The osteopath or family doctor should provide sys-
sive, in order to prevent the risk of the cement plug loosen- tematic treatment for the osteoporosis according to the
ing, with accompanying instability that could provoke established guidelines.
further erosion and failure to the construct (Fig 3.6-11).
b d f
a c e g
Fig 3.6-11a–g L3 fracture in a 72-year-old woman. Obvious instability can be seen on comparing standing
and supine views (arrows). After decompression and stabilization, an increased defect of the anterior column
became apparent. Percutaneous cement injection (about 20 cc of cement) was performed under biplanar
C-arm monitoring. The filling pattern corresponds to the preoperative CT scan.

8 Evidence-based results nula placement appears to be a safe procedure. Using a guide-

wire allows for easy navigation and change of orientation and
As mentioned at the onset, vertebroplasty has gained wide- is additionally helpful if large-diameter cannulas are used.
spread acceptance for treating VCFs and metastatic lesions.
Numerous case series have been published, which report The foremost problem and major risk is that regarding ce-
favorable outcomes in about 80–90% of patients, with sig- ment leakage. Although most cement leaks are clinically
nificant pain reduction immediately after the intervention not relevant, cement embolism with a lethal outcome as
and a good mid-term outcome [5]. Two RCTs comparing well as cement leakage into the canal with subsequent spi-
vertebroplasty against a sham procedure, however, have nal cord compression and paraplegia have been reported
questioned the efficacy of this intervention [8]. In these [13]. Avoiding this complication primarily means being aware
trials, the patients showed a modest but similar improve- of the potential risks and understanding the basic principles
ment, regardless of whether a facet-joint infiltration or a of injection biomechanics and rheology. The most important
real cement injection had been used. Although the pre- factor in leakage is cement viscosity. Only high-viscosity
sented results were based on sound statistical analysis, the cement should be used for the procedure. Therefore, ce-
findings are disputable as their external validity has not menting systems with long delivery tubes are not appropri-
been established: patients with older fractures had been ate. Only large cannulas (8-, 10-gauge) should be used. The
chosen, and the technical aspects were ignored [11]. On the safest and simplest means of cement injection is to use small
other hand, a recent RCT (VERTOS II) comparing vertebro- syringes or a plunger system that also allow the injection
plasty against conservative treatment shows that the former of very pasty cements. Cement behavior and duration of
procedure is advantageous and also demonstrates its cost- working time are important aspects. If any leakage is ob-
effectiveness [4]. Finally, a survey assessing the 4-year sur- served, the injection must be stopped immediately. After
vival probability in a US Medicare population including waiting 1–3 minutes (depending on individual cement char-
more than 800,000 patients with a diagnosis of VCF shows acteristics) the injection can be continued. The cement sets
a strong and highly statistical difference in favor of verte- faster at body temperature, which can help in occluding
broplasty and kyphoplasty [12]. local openings, and then the filling can be completed as
desired. Sometimes the above steps, ie, trying then waiting,
need to be repeated. If the leakage cannot be controlled,
9 Complications and avoidance the injection must be stopped.
The risks and complications related to any cement reinforce- The risk of adjacent fractures presents a further problem.
ment procedure can be seen in the surgical steps involved. In severely osteoporotic patients, injecting the adjacent
Misplacement of the cannulas can injure a nerve root or even levels in a prophylactic manner seems justified [14]. Based
the spinal cord. Vascular injury may also occur, with ante- on the individual risk profile and the patient's specific an-
rior perforation of the vertebrae. However, if the surgical atomical characteristics, the surgeon should consider the
principles and the anatomical landmarks are respected, can- injection of cement at multiple levels.
10 Tips and tricks
Bronek Boszczyk, Nottingham, UK ance of bone marrow displacement into • Typically individual stages are 4–6 weeks
• Increasing prevalence of adult defor- the bloodstream (excessive amounts can apart, but can be shorter if well tolerated.
mity, corrective implant constructs uti- cause acute pulmonary hypertension and As stated by the authors this is possible
lizing PMMA to supplement purchase in the worst case heart failure). with any pedicle screw system, whereby
in osteopenic or osteoporotic bone are • In a staged procedure, PMMA-augmented the use of “anterior” spinal screws with a
becoming more common. screws can be placed in one or two sepa- deeper thread probably provide the high-
• These frequently complex reconstructive rate procedures with a final subsequent est resistance to pullout if required.
procedures occasionally benefit from a procedure to complete the construct with
staged procedure due to the limited toler- rod insertion and the frequently neces-
sary osteotomies.
253

11 Case examples formed, with complete height gain of the fractured vertebra
(Fig 3.6-8d–f). This case illustrates the utility of MRI assess-
11.1 Case 1 ment when multiple fractures are present, and of compar-
Fig 3.6-8shows a straightforward case example: a 77-year- ing standing and supine images to determine the stability.
old man fell from a ladder, and was admitted to the hospi-
tal. The supine films showed a mild compression fracture 11.2 Case 2
at L1 and T12 (Fig 3.6-8a; asterix). MRI showed a signal An 81-year-old woman presented with a 1-year history of
change at L1 that indicated a fresh lesion, whereas the sig- mild spinal claudication, and now with acute immobilizing
nal at T12 was regular (Fig 3.6-8b). The decision regarding back pain and increased leg pain when standing (Fig 3.6-12).
whether to perform conservative or surgical treatment was MRI showed a fresh mild compression fracture at L2. A
based on a standing film taken on the day of admission. The vertebroplasty procedure was performed to stabilize the
film showed an important height loss with displacement of vertebral body. The aim of treatment was primarily pain
the anterior wall (Fig 3.6-8c; arrows). Therefore, a percuta- control and the prevention of further collapse to avoid the
neous height restoration procedure (stentoplasty) was per- progression of stenosis.
a b c d
Fig 3.6-12a–d
a–b Preoperative MRI showing a fresh mild compression fracture at L2 in an 81-year-old woman.
c–d A vertebroplasty procedure was performed to stabilize the vertebral body.

12 Key learning points • Subacute fractures with positive MR scan and especial-
ly with persisting mobility in the fracture show a favor-
• VCFs are the hallmark of osteoporosis, the incidence of able response to treatment by vertebroplasty
which increases exponentially with advancing age • The inherent risk in any percutaneous cement injection
• Cement reinforcement appears to be an efficient means procedure is that of cement leakage. Cement viscosity
of stabilizing painful fragility fractures caused by osteo- is the determining factor in this risk
porosis or metastatic lesions • Patients with osteoporotic VCFs should undergo osteo-
• Indications for treatment should focus on patients with logical work-up and receive osteoporosis treatment.
acute fractures with progressive collapse and/or patients
who are bedridden due to a fracture
13 References
1. Galibert P, Deramond H, Rosat P, et 6. Berlemann U, Franz T, Orler R, et al 11. Boszczyk B (2010) Volume matters: a
al (1987) [Preliminary note on the (2004) Kyphoplasty for treatment of review of procedural details of two
treatment of vertebral angioma by osteoporotic vertebral fractures: a randomised controlled vertebroplasty
percutaneous acrylic vertebroplasty.] prospective non-randomized study. Eur trials of 2009. Eur Spine J; 19(11):1837–
Neurochirurgie; 33(2):166–168. German. Spine J; 13(6):496–501. 1840.
2. Heini PF, Pfäffli S (2009) [Cement 7. Hulme PA, Krebs J, Ferguson SJ, et al 12. Edidin AA, Ong KL, Lau E, et al (2011)
injection for spinal metastases (2006) Vertebroplasty and kyphoplasty: Mortality risk for operated and
(vertebroplasty and kyphoplasty).] a systematic review of 69 clinical nonoperated vertebral fracture patients
Orthopade; 38(4):335–336, 338–342. studies. Spine; 31(17):1983–2001. in the Medicare population. J Bone
German. 8. Kallmes DF, Comstock BA, Heagerty Miner Res; 26(7):1617–1626.
3. Jensen ME, Evans AJ, Mathis JM, et al PJ, et al (2009) A randomized trial of 13. Baumann C, Fuchs H, Kiwit J, et al
(1997) Percutaneous vertebroplasty for osteoporotic spinal (2007) Complications in percutaneous
polymethylmethacrylate vertebroplasty fractures. N Engl J Med; 361(6):569–579. vertebroplasty associated with
in the treatment of osteoporotic 9. Baroud G, Crookshank M, Bohner M puncture or cement leakage. Cardiovasc
vertebral body compression fractures: (2006) High-viscosity cement Intervent Radiol; 30(2):161–168.
technical aspects. Am J significantly enhances uniformity of 14. Diel P, Merky D, Röder C, et al (2009)
Neuroradiol;18(10):1897–1904. cement filling in vertebroplasty: an Safety and efficacy of vertebroplasty:
4. Klazen CA, Lohle PN, de Vries J, et al experimental model and study on early results of a prospective one-year
(2010) Vertebroplasty versus cement leakage. Spine; 31(22):2562– case series of osteoporosis patients in
conservative treatment in acute 2568. an academic high-volume center. Ind J
osteoporotic vertebral compression 10. Diel P, Freiburghaus L, Röder C, et al Orthop; 43(3):228–233.
fractures (VERTOS II): an open-label (2011) Safety, effectiveness and
randomised trial. Lancet; predictors for early reoperation in
376(9746):1085-1092. therapeutic and prophylactic
5. Muijs SP, Nieuwenhuijse MJ, Van vertebroplasty: short-term results of a
Erkel AR, et al (2009) Percutaneous prospective case series of patients with
vertebroplasty for the treatment of osteoporotic vertebral fractures. Eur
osteoporotic vertebral compression Spine J; 21 Suppl 6:S792–S799.
fractures: evaluation after 36 months.
J Bone Joint Surg Br; 91(3):379–384.
255

Baroud G, Crookshank M, Bohner M (2006) High- Kallmes DF, Comstock BA, Heagerty PJ et al (2009) A
viscosity cement significantly enhances uniformity of randomized trial of vertebroplasty for osteoporotic spinal
cement filling in vertebroplasty: an experimental model fractures. N Engl J Med; 361(6):569–579.
and study on cement leakage. Spine; 31(22):2562–2568.
Study type Study design Class of evidence Therapy Randomized controlled trial I–II
Laboratory testing Experimental study N/A
Purpose
Purpose To compare the outcomes of patients with one to three
To examine the working hypothesis that high-viscosity painful osteoporotic vertebral compression fractures ran-
cements will spread uniformly, thus significantly reduc- domized to undergo either vertebroplasty or a simulated
ing the risk of leakage. procedure without cement.
P Patient N/A (experimental model of the leakage phenomenon of P Patient Painful osteoporotic vertebral compression fractures
vertebroplasty) (N = 131)
I Intervention Injection of cement of varying viscosities I Intervention Vertebroplasty (n = 68)
C Comparison No comparison group C Comparison Simulated procedure without cement
(control group; n = 63)
O Outcome Filling pattern, cement mass that has leaked, time at which
leakage occurred, injection pressure O Outcome Modified Roland-Morris Disability Questionnaire (RDQ),
patients' ratings of average pain intensity, adverse events
High-viscosity cement seems to stabilize cement flow. Authors’ conclusion
However, the forces required for the delivery of high- Improvements in pain and pain-related disability associ-
viscosity cement may approach or exceed the human ated with osteoporotic compression fractures in patients
physical limit of injection forces and may not be manu- treated with vertebroplasty were similar to the improve-
ally injectable with a standard syringe or cannula. ments in a control group.

Klazen CA, Lohle PN, de Vries J et al (2010) Diel P, Freiburghaus L, Röder C, et al (2011) Safety,
Vertebroplasty versus conservative treatment in acute effectiveness and predictors for early reoperation in
osteoporotic vertebral compression fractures (Vertos II): therapeutic and prophylactic vertebroplasty: short-term
an open-label randomized trial. Lancet; 376(9746):1085– results of a prospective case series of patients with
1092. osteoporotic vertebral fractures. Eur Spine J; [Epub ahead
of print].
Therapy Randomized controlled trial I–II Study type Study design Class of evidence
Purpose
To clarify whether vertebroplasty has additional value Purpose
compared with conservative treatment in patients with To assess the safety and efficacy of vertebroplasty in al-
acute osteoporotic vertebral compression fractures. leviating pain, improving quality of life, and restoring
alignment.
P Patient Patients with osteoporotic vertebral compression fractures
(N = 202) P Patient Patients with osteoporotic vertebral fractures (N = 233)
I Intervention Percutaneous vertebroplasty (n = 101) I Intervention Vertebroplasty (n = 249 interventions)
C Comparison Conservative treatment (n = 101) C Comparison No comparison group
O Outcome Pain measures by VAS score O Outcome Demographics, treatment and x-ray details, pain alleviation
(VAS), QoL Improvement (NASS and EQ-5D), com-
Authors’ conclusion plications, and predictors for new fractures requiring
reoperation
In a subgroup of patients with acute osteoporotic vertebral
compression fractures and persistent pain, percutaneous
vertebroplasty is effective and safe. Pain relief after ver- Authors’ conclusion
tebroplasty is immediate, is sustained for at least one year, If routinely used, vertebroplasty is a safe and efficacious
and is significantly greater than that achieved with con- treatment option for osteoporotic vertebral fractures with
servative treatment, at an acceptable cost. regard to pain relief and improvement in the quality of
life. Even segmental realignment can be partially achieved
with proper patient positioning.
257

Edidin AA, Ong KL, Lau E, et al (2011) Mortality risk

for operated and nonoperated vertebral fracture patients
in the Medicare population. J Bone Miner Res;
26(7):1617–1626.

Purpose
To evaluate the mortality risk for patients with vertebral
compression fractures (VCFs) undergoing nonoperative
(conservative) and operative (kyphoplasty or vertebro-
plasty) treatment.
P Patient VCF (N = 858,978)

I Intervention Operative treatment (n = 182,946: n = 119,253 kyphoplasty,
n = 63,693 vertebroplasty)
C Comparison Nonoperative treatment (n = 676,032)
O Outcome Mortality rate
The authors observed improved survivorship for patients
after treatment of VCF in the operated group compared
to the nonoperated group, and also detected a signifi-
cantly improved survival rate for patients treated with
kyphoplasty compared with vertebroplasty.

259

Author Roger Härtl

4 Lumbar/sacral techniques
4.1 Introduction
4
Lumbar/sacral techniques
261

Author Roger Härtl

4.1 Introduction
Roger Härtl
For many, the age of minimally invasive spine surgery stenosis with up to grade I spondylolisthesis, while minimiz-
(MISS) began with the introduction by Smith of percutane- ing the risk of iatrogenic destabilization.
ous lumbar chemonucleolysis in 1964 [1]. Just over ten
years later, in 1975, percutaneous nucleotomy without Open, minimally invasive and percutaneous approaches for
direct visualization was first reported by Hijikata and col- lumbar discectomies have been covered in the two follow-
leagues [2]. Then in the 1980s the next major development ing chapters. In chapter 4.2.2 Microsurgical lumbar disc
of historical significance was automated percutaneous lum- surgery, Rajasekaran et al provide an encyclopedic overview
bar discectomy. In 1986, Schreiber and Suezawa combined of the current microsurgical techniques for lumbar discec-
the Hijikata technique with a percutaneously introduced tomies. They conclude that the key to success lies in careful
endoscope for better visualization [3]. Mayer brought this patient selection, meticulous preoperative and intraopera-
technique to Europe, and he and Brock were the first to tive localization of the pathology, as well as complete but
directly compare endoscopic percutaneous approaches for conservative disc removal. Following this, in chapter 4.2.3
lumbar disc herniations with open lumbar microdiscectomies Endoscopic disc and decompression surgery, Ruetten and
[4]. Others attempted to improve the microdiscectomy tech- co-workers then describe the development of endoscopi-
nique by using less invasive retractors, an example of this cally assisted disc and decompression surgery and emphasize
being Caspar and Faubert, who used less invasive specular not only the challenges, such as the demanding learning
retractors for percutaneous discectomies in 1991 [5]. Inde- curve required, but also the various advantages that this
pendently of this, and as they had experienced the limita- type of surgery can provide for decompression in patients
tions of automated percutaneous lumbar discectomy, Smith with leg symptoms like radicular pain or neurogenic clau-
and Foley in 1997 introduced the technique of microendo- dication.
scopic discectomy for treatment of the lumbar spine, in
which endoscopes were used through posteriorly placed Further developments in lumbar/sacral techniques were
tubular retractors to perform the discectomy [6, 7]. Several reported by Foley and colleagues in 2001 and 2002, who
years later, in 2003, the METRx tubular retractor system described their preliminary clinical results on lumbar ped-
was introduced and allowed the use of the microscope in icle screw insertion using the Sextant system [8, 9]. They
MISS. In North America, tubular access has gained wide- were the first to perform minimally invasive posterior lum-
spread popularity and is currently used to treat pathologies bar interbody fusion in early 2001, and their first clinical
in all regions of the spine via posterior and lateral approach- results were published in 2002 and 2003 [10, 11].
es.
In chapter 4.2.4, Lam and Terenowski describe the current
Based on these and other technical advances, a wide variety posterior techniques for mini-open and percutaneous ped-
of strategies have been developed that allow the elegant icle instrumentation and fusion. They point out that regard-
and effective treatment of lumbar spinal pathologies via less of the specific instrumentation system or approach used,
anterior, lateral, and posterior approaches, most of which meticulous attention to biomechanical principles in com-
are covered in the following chapters. bination with careful preparation of the interbody and/or
the posterolateral fusion bed are prerequisites for satisfac-
In Chapter 4.2.1 Bilateral decompression in lumbar spinal tory clinical and radiological outcomes.
stenosis through a microscope-assisted monolateral ap-
proach, Korge examines the state-of-the-art unilateral ap- In chapter 4.2.5 Interspinous spacers, Mayer provides a
proach for bilateral decompression in patients with lumbar comprehensive and balanced overview of these devices,
spinal stenosis. This approach is gaining increasing accep- which have gained popularity since the early 2000s. He
tance as surgeons become more familiar with the advan- differentiates between extension stoppers, dynamic stabiliz-
tages it offers: excellent clinical results in patients with ers without tension banding, and dynamic stabilizers with
263

Author Roger Härtl
tension banding, each with specific indications for use (and combination with posterior fixation, especially in patients
contraindications). The surgery involved in implanting these requiring multilevel surgery. The current state of knowledge
devices is generally safe and well tolerated, but their ben- regarding the indications, long-term results and complica-
eficial effect is frequently only short-term, and little is known tion profile, especially as it relates to other anterior ap-
about the long-term benefits. proaches, is still poor and further investigation is needed.
In chapter 4.3.4 Deformity correction using minimally in-
The sacroiliac (SI) joint can be affected by a wide range of vasive spine surgery techniques, Anand et al explore the
disorders including loosening of SI ligaments during preg- possibilities of combined lateral transpsoas surgery, trans-
nancy, arthritic conditions in rheumatoid diseases such as sacral fixation, and posterior MISS pedicle screw instru-
ankylosing spondylitis or Crohn’s disease, posttraumatic mentation in correcting thoracolumbar deformities. Al-
arthritis, or chronic pyogenic sacroiliitis. The SI joint can though their results and those of other authors are
also undergo degeneration following spinal fusion proce- encouraging, they still lag behind those achieved with open
dures, mainly after fusion of L5 to the sacrum. Current surgery, as Manish and Shaffrey point out in the “Tips and
treatment relies mainly on injection therapy and denerva- tricks” comments in this chapter. The future will see the
tion procedures with unsatisfactory or only temporary pain further adaptation and integration of open corrective surgi-
relief. Surgical techniques involving percutaneous stabiliza- cal procedures, such as osteotomies, into MISS surgery.
tion of the joint via lag screws under CT scan or image in- These new procedures are now just starting to be used, and
tensifier guidance have been in use from the beginning of will without doubt improve the ability of MISS surgery to
the 1990s. In chapter 4.2.6 Fixation of the sacroiliac joint, even tackle cases of severe deformity.
Schleicher and Kandziora describe the latest advances in
minimally invasive SI joint screw fixation as effective and Finally, in chapter 4.3.5 Transsacral fixation, Elowitz out-
safe treatment options for the treatment of traumatic or lines the technique, indications, and limitations of the trans-
chronic SI lesions using navigation in carefully selected sacral approach for L5–S1 fusion and instrumentation. This
patients. approach was developed in light of the obvious drawbacks
of conventional anterior and posterior lumbosacral fusion
The remainder of section 4, Lumbar/sacral techniques, then surgery such as the risk of injury to the lumbar muscles
focuses on anterior and lateral approaches to the lumbar during the surgical approach, nerve root damage, risk of
spine. Korge and colleagues present a detailed account of vascular and bowel injury, sympathetic dysfunction, blood
the anterior midline and the anterolateral retroperitoneal loss, and deep vein thrombosis. The possibility to reach the
approach to L2–S1 and L2–5 and the lumbosacral junction L5–S1 and even the L4/5 disc space through a paracoccygeal,
in chapters 4.3.1 and 4.3.2. These approaches fully spare transsacral approach avoids many of the aforementioned
the posterior lumbar musculature and are therefore quint- risks. At the same time, it allows discectomy with interbody
essentially “minimally invasive”. fusion to be performed, and sometimes also the restoration
of disc and foraminal height without annular disruption.
The lateral approach to the lumbar spine using tubular re- Although this is certainly an innovative technique, surgeons
tractors developed as an outgrowth of traditional anterior should be aware of what can be realistically expected. Even
lumbar interbody fusion, minimally invasive laparoscopic though some clinical reports are promising [14], others have
techniques, and tubular surgery. In 2006, Ozgur et al [12] reported a higher failure rate than with other approaches
reported on a mini-open technique to the midlumbar spine [15]; moreover, the specific role of the presacral approach
via a direct lateral transpsoas approach utilizing electro- within MISS has not been clearly defined at this point. The
physiological monitoring to avoid the risk of nerve damage potential limitations of this approach have to be weighed
during the placement of structural interbody fusion cages. very carefully against other MISS techniques for L5–S1 fu-
This was based on the work of Pimenta from Brazil, who sion, such as anterior lumbar interbody fusion or transfo-
had reported on his initial experience with this technique raminal lumbar interbody fusion.
in 2001 [13]. As Gelb points out in chapter 4.3.3 The lat-
eral approach to the lumbar spine, the lateral transpsoas Different forms of navigation that are integral to the ap-
approach has gained popularity over the past years but re- plication of MISS in the lumbar spine are discussed in these
quires splitting of the psoas muscle and is therefore associ- chapters. The future will see intraoperative CT scanners,
ated with the risk of nerve and muscle irritation. However, the integration of imaging modalities, and better software
it offers the possibility of deformity correction and indirect that will facilitate the integration of three-dimensional
decompression, either as a stand-alone procedure or in navigation into the surgical workflow.

4 Lumbar/sacral techniques
4.1 Introduction
The success of MISS depends on a combination of factors In an attempt to pay tribute to the importance of an indi-
including the integration of scientific advances in the field, vidual surgeon’s experience, each chapter includes a short
technical know-how, and the surgeon’s individual experi- section with “Tips and tricks” provided by some of the mas-
ence. These chapters cover the technical aspects and the ters in the field.
science behind particular surgical approaches.
References
1. Smith L (1964) Enzyme dissolution of 6. Foley KT, Smith MM (1997) 12. Ozgur, BM, Aryan HE, Pimenta L, et
the nucleus pulposus in humans. Microendoscopic discectomy. Tech al (2006) Extreme lateral interbody
JAMA; 187:137–140. Neurosurg; 3(4):301–307. fusion (XLIF): a novel surgical
2. Hijikata S, Yamagishi M, Nakayama 7. Smith MW, Foley KT (1998) MED: The technique for anterior lumbar
T, et al (1975) Percutaneous first 100 cases. Annual Meeting of the interbody fusion. Spine J; 6(4):435–443.
nucleotomy: a new treatment method Congress of Neurological Surgeons, October 13. Pimenta L (2001) Lateral endoscopic
for lumbar disc herniation. J Toden 1998. Seattle, USA. transpsoas retroperitoneal approach for
Hosp; 5:39–44. 8. Foley KT, Gupta SK, Justis JR, et al lumbar spine surgery. VIII Brazilian
3. Schreiber A, Suezawa Y (1986) (2001) Percutaneous pedicle screw Spine Society Meeting, May 2001. Belo
Transdiscoscopic percutaneous fixation of the lumbar spine. Neurosurg Horizonte, Brazil.
nucleotomy in disk herniation. Orthop Focus; 10(4):1–8. 14. Gerszten PC, Tobler WD, Nasca RJ
Rev; 15(1):35–38. 9. Foley KT, Gupta SK (2002) (2011) Retrospective analysis of L5-S1
4. Mayer HM, Brock M (1993) Percutaneous pedicle screw fixation of axial lumbar interbody fusion
Percutaneous endoscopic discectomy: the lumbar spine: preliminary clinical (AxiaLIF): a comparison with and
surgical technique and preliminary results. J Neurosurg; 97 Suppl 1:7–12. without the use of recombinant human
results compared to microsurgical 10. Foley KT, Lefkowitz MA (2002) bone morphogenetic protein-2. Spine J;
discectomy. J Neurosurg; 78(2):216–225. Advances in minimally invasive spine 11(11):1027–1032.
5. Faubert C, Caspar W (1991) Lumbar surgery. Clin Neurosurg; 49:499–517. 15. Hofstetter CP, James AR, Härtl R
percutaneous discectomy. Initial 11. Foley KT, Holly LT, Schwender JD (2011) Revision strategies for AxiaLIF.
experience in 28 cases. Neuroradiology; (2003) Minimally invasive lumbar Neurosurg Focus; 31(4):E17.
33(5):407–410. fusion. Spine; 28 Suppl 15:S26–S35.
265

Author Roger Härtl

4.2.1 Bilateral decompression in lumbar spinal stenosis
through a microscope-assisted monolateral approach
Andreas Korge
1 Historical perspective case series, each including more than 450 patients treated
by laminectomy for lumbar spinal stenosis, a very success-
Lumbar spinal stenosis is a pathology that is characterized ful outcome was obtained in 85% of cases, with excellent
by the narrowing of the central spinal canal and nerve root or good postoperative results and a high patient satisfaction
canals, and which involves a triad of symptoms: hypertro- rate [11, 12]. Several modifications of the laminectomy tech-
phy of the ligamentum flavum; hypertrophy of degener- nique were introduced after 1980 [13–15], however, in par-
ated facet joints; and an anterior, space-occupying, bulging allel to studies on the use of this technique and its modifi-
intervertebral disc. cations, reports also appeared in the literature
demonstrating the risk of postoperative translational insta-
More than 200 years ago, Portal [1] described a narrowed bility [16, 17]. Consequently, especially after the adoption
spinal canal both with and without neurological deficit. of microscope-assisted techniques in neurosurgery in
More than 100 years later, Sumita [2] reported on the nar- 1977/1978, more sophisticated procedures for decompres-
rowing of the spinal canal in achondroplastic individuals sion using bilateral approaches with mono- to multiseg-
while Dejerine [3] described the symptoms of spinal clau- mental laminotomy of the index segments were used on
dication. In 1911, Bailey and Casamajor [4] published a an increasingly widespread scale [18, 19]. Young et al [20]
study on the implication of vertebral osteoarthritis in the and McCulloch [21] then modified the microscope-assisted
compression of neural intraspinal structures. In the same techniques by limiting the approach to only one side and
year, independently of each other, Goldthwait [5] and Mid- performing an ipsilateral and contralateral “over-the-top”
dleton and Teacher [6] provided the first descriptions of a bilateral decompression of both the spinal canal and nerve
herniated nucleus pulposus. Then in 1934, following an root canals with subarticular fenestration, partial removal
increasingly large number of publications, Mixter and Barr of the facet joints, undercutting of the remaining joint, and
[7] presented the first case series of surgically-treated disc fenestration of the ligamentum flavum through a mono-
herniations. They demonstrated the association between lateral approach. Spetzger et al [22] provided sufficient
sciatica and lumbar disc herniation, and, consequently, anatomical considerations for using this technique. Re-
lumbar disc herniation was seen as the major cause of the cently, a similar approach has been described using tubular
narrowing of the spinal canal for more than a decade. It retractors [23, 24].
was not until 1954 that Henk Verbiest [8] made a break-
through by introducing the concept of developmental ste- This chapter examines the microscope-assisted minimally
nosis and the pathological narrowing of the lumbar verte- invasive bilateral decompression of the central and lateral
bral canal. Subsequent definitions of lumbar spinal stenosis aspects of the spinal canal for the treatment of lumbar spi-
were largely based on Verbiest´s original findings. nal stenosis using a monolateral approach and avoiding
destructive laminectomy.
Some anecdotal reports on laminectomy had already ap-
peared in the 19th century (in 1814, Clyne reported on
spinal abscess drainage; in 1829, Alban Gilpin Smith de- 2 Terminology
scribed treatment for secondary worsening of a fracture
that had failed to respond to primary treatment [9]), while With the assistance of a surgical microscope, bilateral mi-
larger series using this same technique [10] were already crosurgical decompression of the central and lateral spinal
being reported by the early 20th century. Much later on, canal via a monolateral approach using an “over-the-top”
Verbiest [8] established laminectomy as the gold standard technique with inner osteoclastic laminoplasty for the en-
and treatment of choice for lumbar spinal stenosis. In large largement of the central and lateral spinal canal represents
267

a modification of established, traditional approach and de- 3.2 Contraindications for surgery
compression techniques such as laminectomy aimed at The following contraindications for exclusive microsurgical
treating a narrow lumbar spinal canal. This technique can over-the-top decompression without additional segmental
be adopted for mono-, bi-, or multisegmental and mono- or instrumentation should be taken into consideration, par-
bilateral surgery. Using the monolateral approach, the con- ticularly in the case of concomitant degenerative scoliosis
tralateral paravertebral muscles remain untouched and the [25]:
contralateral facet remains mostly intact, resulting in com- • Dominating back pain
plete protection of the contralateral paravertebral compart- • Significant vertical instability
ment. This technique can be used for decompression pro- • Significant translational instability with concomitant
cedures alone, or in combination with fusion surgery. The dynamic canal narrowing
term “tubular laminectomy” has been adopted to refer to • Segmental stable translational displacements > Meyerding I°
surgery in which tubular retractors are used [23, 24]. • Lateral olisthesis > 6 mm
• Scoliosis > 30 °
• Patients that have undergone previous extensive intra-
3 Patient selection spinal decompression procedures
• Contraindications for general anesthesia and surgery
In general, the above-mentioned decompression procedure • Congenital central spinal stenosis.
can be applied to all patients suffering from acquired lum-
bar central and/or lateral spinal stenosis, independent of
the number of affected segments or the extent of narrowing. 4 Pros and cons of bilateral decompression in
In the case of exclusive or dominating leg symptoms, with lumbar spinal stenosis through a microscope-
or without intermittent claudication, the decompression assisted monolateral approach
procedure can be performed with no additional surgical
steps. If the degree of back pain is similar to the leg pain, The main advantage of this decompression technique lies
or if it is the dominating symptom, and in the case of severe in the bilateral enlargement of both the entire spinal canal
translational rigid or functional displacement and/or major and the lateral recess ipsi- and contralaterally. In addition,
curvature in the frontal plane, additional stabilizing or re- decompression of the contralateral neuroforamen can be
constructive techniques—such as pedicle-based screw-rod achieved via a unilateral approach, thus preserving the
instrumentation—should be considered. complete contralateral paravertebral compartment includ-
ing the paravertebral muscles, their innervation and vas-
3.1 Indications for surgery cular support.
The following clinical symptoms should be taken into ac-
count as indications for surgery: A significant number of intra- and postoperative benefits
• Monolateral or bilateral leg pain with sensation of heavy is obtained, including reduced blood loss, less postoperative
legs. Pain in the buttocks or thighs scar-tissue formation, as well as quicker patient recovery
• Nonspecific weakness of the lower limbs. Sensory dis- and mobilization. The most relevant advantage could well
turbances and paresthesia. Reduced or absent reflex pat- be the preservation of the ligamentous and bone anatomy,
tern. Usually no distinct radicular symptoms which ensures preserved stability and less need for instru-
• Progressive neurological deficits mentation and fusion surgery down the line [26, 27]. The
• Neurogenic gait disturbances (“intermittent spinal clau- technique itself, however, requires experience in micro-
dication”) with reduced walking distance scope-assisted surgery and a practical and in-depth knowl-
• Reduced ability to remain standing edge of the intraspinal anatomy. The specific benefits of the
• Less pain experienced on bending forward and flexing procedure as well as the limitations of this technique are
the spine (eg, moving a shopping trolley) noted in the following:
• Increased pain when standing, walking, and upon hy-
perextension of the back 4.1 Pros
• Reduction of lumbar lordosis with flat-back syndrome • Small skin incision with improved postoperative cosmesis
• Low back pain • Unilateral approach with bilateral decompression
• Bladder dysfunction, ie, cauda equina syndrome. • Reduced damage to ipsilateral paravertebral muscles and
ipsilateral facet joint

4 Lumbar/sacral techniques | 4.2 Posterior approaches
4.2.1 Bilateral decompression in lumbar spinal stenosis through a microscope-assisted monolateral approach
• Preservation of contralateral paravertebral muscles, vertical and translational segmental instabilities. Antero-
ligaments, and other extravertebral soft tissue posterior x-rays show the spinal configuration in the fron-
• Preservation of the contralateral facet joint tal plane, and provide information on spinal curvature and
• Preservation of the supraspinous and interspinous liga- the size of the interlaminar window for entry towards the
ments maintaining the posterior tension band complex spinal canal. Only in rare selected cases are functional x-
• Maintenance of segmental stability without creating seg- rays in frontal projection with left and right lateral bending
mental hypermobility or instability, therefore with a performed for the analysis of frontal tilt hypermobility or
possibly reduced need for fusion postoperatively instability. Oblique x-rays are not recommended as they
• Good overview of the neural structures within the cen- involve an unnecessary dose of radiation, without provid-
tral spinal canal as well as the nerve root canal bilater- ing any additional information.
ally (lateral recess), with visual control of the dura and
nerve roots MRI represents the radiological diagnostic tool of choice for
• Meticulous and effective intraspinal hemostasis possible evaluating the situation within the central spinal and nerve
• Reduced soft-tissue trauma root canals. It provides the most comprehensive information
• Reduced blood loss about soft-tissue structures that may limit the size of the
• Reduced scar-tissue formation spinal canal such as bulging yellow ligaments, discogenic
• Quick patient mobilization and rehabilitation pathologies, and canal-narrowing synovial cysts. In ex-
• Less postoperative pain. tremely stenotic segments, remaining fatty tissue, mostly
located in the dorsal parts of the canal, can be detected and
4.2 Cons used to guide the surgeon towards a safety zone when en-
• Limited visualization outside the target area with the tering the spinal canal. Contrast medium can be used to
risk of inadvertent destruction of anatomical structures differentiate between remaining scar-tissue formation fol-
or damage to concealed or not clearly visible neurologi- lowing prior surgery and primary pathologies. T1- and T2-
cal structures, possibly resulting in neurological deficits weighted sagittal and T2-weighted axial images are most
• Technically demanding procedure, especially as regards frequently used in this regard (Fig 4.2.1-1). The additional
contralateral decompression—insufficient decompression value of frontal images is largely underestimated. Taking
could lead to unsatisfactory results the nerve root sedimentation sign into account, as a new
• Far lateral (“far out”) stenosis [28] is not possible (ipsilat- radiological sign, could gain increasing significance in the
erally) or difficult (contralaterally) to address surgically future [29]. Evaluation of the neuroforamina is best carried
• Longer operative time for multisegmental cases when out by analyzing T1-weighted sagittal images. Functional
compared to a laminectomy procedure upright MRI, which is not widely available at present, may
• Microsurgical training required, with a “learning curve” replace x-ray with contrast medium for the detection of a
for surgery performed through a narrow working channel dynamic stenosis of the lumbar spinal canal.
• Not possible without the use of a microscope or at least
head lamps and loops. With the widespread availability of MRI and in comparison
to the latter, the CT scan has lost much of its importance in
the diagnosis of lumbar spinal stenosis due to its poor reso-
5 Preoperative planning and positioning lution of soft-tissue structures and its radiation emissions.
If the use of MRI is contraindicated (eg, in the case of patients
5.1 Planning procedures with a pacemaker, or metal implants in the index segment),
Meticulous preoperative planning is mandatory for an opti- CT represents the diagnostic tool of choice (eg, Postmyelo-
mal surgical outcome and in order to avoid incomplete/faulty CT) and is best used in combination with x-ray and contrast
intraoperative management of the pathology in question. medium, which can provide additional information regard-
The more that minimization is used, the more accurate the ing a dynamic stenosis in lateral flexion/extension views
preoperative evaluation and planning procedure should be. (Fig 4.2.1-2a–b). The narrowing of the central spinal canal
and compression of nerve roots in the lateral recess can be
Imaging studies should include standard x-rays in both an- detected in this way (Fig 4.2.1-2c–d). However, only limited
teroposterior (AP) and lateral view, and also functional x- diagnostic information regarding the neuroforamina can
rays in lateral projection in order to detect any possible be obtained due to anatomical constraints.
269

a b
Fig 4.2.1-1a–b
a Preoperative T2-weighted MRI in sagittal projection showing a monosegmental narrow
central spinal canal as well as curling nerve roots below the stenotic level at L4/5
b Preoperative T2-weighted MRI in axial projection showing a narrow central spinal canal, and
lateral recess bilaterally in the same segment.
a b c d
Fig 4.2.1-2a–d
a X-ray with contrast medium (myelography) showing reduced narrowing of the spinal canal at L2/3 and L4/5 in flexion.
b X-ray with contrast medium (myelography) showing increased narrowing of both stenotic segments in extension, thus demonstrating the
dynamic character of the stenosis
c Post-myelographic CT scan axial view of a separate case showing a stenosis at L2/3.
d Post-myelographic CT scan; sagittal view of same case as Fig 4.2.1-2c.

5.2 Patient preparation and positioning Careful padding of the anatomical weight-bearing areas
No specific patient preparation is required the day before (knee and tibia, chest, elbows, head) should be performed
surgery. Prior to surgery, shaving of the surgical area is using soft cushion pads. Arms are placed in a 90°/90° posi-
performed, if necessary. tion for shoulder and elbow to avoid hyperabduction so as
to minimize the risk of brachial plexus irritation. In young-
General anesthesia with the patient’s body in complete re- er patients, the head is placed in slight rotation, but this
laxation is required for the operation. Venous and arterial should be no more than 60–70°. However, in elderly patients
lines are placed. Anesthetic intraoperative monitoring has with limited flexibility of the cervical spine, a prone head
to be adapted to the possible comorbidities of these mostly position with a gel pad under the forehead is more appro-
elderly patients. A urinary catheter is not necessary for priate. On the side opposite the surgeon, a separate lateral
mono- and bisegmental cases, however, for multilevel support is placed at trochanter level to maintain the patient
cases, its use is strongly recommended. Cell-saving proce- in position when tilting for the over-the-top procedure
dures as well as blood transfusion are not routinely required. (Fig 4.2.1-3b). After final positioning, the operating table can
Single-shot antibiotics 20 minutes prior to the skin incision be adjusted at the level of the lumbar spine in order to
should be given with a second shot after 2 hours for longer compensate for lumbar lordosis and provide an open inter-
operative procedures. As a routine procedure for all surgi- laminar access corridor.
cal interventions, the present author utilizes a surgical “time
out” safety checklist in order to minimize perioperative Preoperative localization of the index segment is performed
complications. using sterile needle placement under lateral image intensi-
fier control to identify the trajectory to the disc space
The patient is placed in a prone knee-chest position with (Fig 4.2.1-4). Needle placement is usually performed contra-
hips and knees flexed at 90° with the abdomen hanging laterally to the approach side in order to avoid hematoma
free without any compression (Fig 4.2.1-3a). Hyperflexion formation at the access corridor. The needle trajectory must
of the hip and knee joint should be avoided to prevent be parallel to the disc space and endplates of the index
restriction of venous blood flow from the legs with the ac- level, and in order to avoid wrong-level surgery, the surgeon
companying major risk of deep venous thrombosis. A sup- must ensure that it does not follow an oblique approach
port bracket is placed on the buttocks. In the case of diffi- corridor (Fig 4.2.1-5). In the case of bi- or multilevel surgery,
culty in correctly obtaining this positioning (eg, restricted separate needle placement for each segment is helpful; at
knee/hip flexion, abdominal aortic aneurysm), prone po- least the most cranial and caudal segment should be iden-
sitioning using a Wilson frame is a possible alternative. tified clearly. The skin incision line is marked slightly para-
a b
Fig 4.2.1-3a–b
a Left-sided view of patient placed in the knee-chest position.
b Contralateral view of same patient with additional lateral support against the trochanteric region in preparation for the over-the-top procedure.
271

median to the midline, exceeding the index level marking retractors are available (Fig. 4.2.1-7). Blunt preparation
by about 15–20 mm in the craniocaudal direction (Fig 4.2.1- after skin incision using tubular retractors is also an alter-
4a). Separate incision lines should be marked in the case of native. The interlaminar window is cleaned completely of
spared segments (eg, L2/3 and L4/5) or in the event of soft tissue.
opposite approach sides.
Using a high-speed drill with cylindrical, conical, or Rosen
The approach side has to be chosen preoperatively. In most burrs, modified osteoclastic hemilaminotomy of the supe-
cases surgery is performed from the side where the leg symp- rior hemilamina is carried out until the insertion zone of
toms are more dominant. In the absence of unilateral dom- the yellow ligament at the hemilamina is reached and epi-
inance of pain syndromes, the surgeon may then choose dural fat or the dura becomes visible (Fig 4.2.1-8). At this
whichever approach side is considered best. However, in stage, a switch to diamond burrs is strongly recommended
the case of a deformity in the frontal plane, an approach in order to avoid damage to the dura. In addition, the an-
via the convex side is mostly chosen due to the fact that the terior part of the spinous process could be thinned until
corresponding segment(s) is/are rotated towards the con- epidural fat becomes visible. The exposure of the inter-
vexity, and also because the over-the-top procedure would laminar window is completed by removal of the superior
be difficult if not impossible from the concave side. In mul- part of the caudal hemilamina. In the case of a hypertrophic
tilevel procedures, decompression can be performed either facet joint, the inferior facet has to be thinned medially by
from one side or from alternate sides with one midline in- sparing osteoclastic facetotomy.
cision or separate incisions for each segment (Fig 4.2.1-6).
As a first step, decompression of the ipsilateral central spi-
nal canal is performed (Fig 4.2.1-9). Using dissectors, explo-
6 Surgical technique ration hooks and Smith-Kerrison-like rongeurs, the yellow
ligament is mobilized and removed entirely. Upward-cutting
In routine practice, for both mono- and bisegmental de- rongeurs are more practical than 90°-angled rongeurs as
compression procedures, surgery begins with the micro- they permit better visibility during handling. In the case of
scope already in place. After the skin incision and sharp adhesions, mobilization of the dura and removal of the ad-
dissection of subcutaneous tissue have been carried out, a hesions medially to laterally is possible. Residual compres-
semicircular fasciotomy is followed by blunt subperiosteal sion of the dura by the adjacent hemilaminae can be resolved
mobilization of the paraspinal muscles laterally towards by superior and inferior sublaminar undercutting. Syno-
the facet joint. Adjacent superior and inferior hemilaminae vial cysts in the central spinal canal can be removed during
are exposed. An articulated or solid-frame speculum retrac- this step under direct visual control to ensure that the dura
tor is placed. For monosegmental decompression, mini- is not violated.
Cranial
Needle
contralateral
Ski
n i ine
nci
l
sio
vel
n
c le
Mi
Dis
dli
ne
a Caudal b a b
Fig 4.2.1-4a–b Fig 4.2.1-5a–b
a Preoperative localization of the index segment with correct needle a Incorrect needle placement for cranial corridor marking,
placement and marked skin incision line. demonstrating the risk of wrong-level surgery.
b Lateral x-ray control demonstrating correct needle placement b Incorrect needle placement for caudal corridor marking,
demonstrating the risk of wrong-level surgery.

Fig 4.2.1-6a–b Different approach possibilities for bi- and multiseg-

mental decompression surgery with different skin incisions. Continuous
black line: midline skin incision; broken black line: two segments per side;
red line: separate cutaneous and/or separate subcutaneous/subfascial
approach.
a Single skin incision.
a b b Separate subcutaneous/subfascial approaches.
Medial
Caudal
Cranial CHL
ILW
a b c Lateral
Fig 4.2.1-7a–c
a Mini-retractor used for monosegmental decompression.
b Mini-retractor in place in a three-segmental ipsilateral approach with a separate incision for each segment.
c Mini-retractor with microscopic view of the target interlaminar window.
ILW: interlaminar window; CHL: cranial hemilamina.
Medial Medial
Caudal
1 Caudal
YL Cranial D YL
CHL d
IF
IF
a
Fig 4.2.1-8 Enlarged interlaminar window Fig 4.2.1-9a–b
with the yellow ligament still in place. a Removal of the yellow ligament. YL: yellow
1: the initial opening of the spinal canal; ligament; D: dura; IF: inferior facet.
YL: yellow ligament; CHL: cranial hemilamina; b Schematic drawing of the ipsilateral b
IF: inferior facet. target area.
273

The ipsilateral lateral recess, consisting of parts of the su- from the surgeon with the microscope aligned to deliver a
perior facet, the joint capsule and remaining yellow ligament sufficiently oblique corridor (Fig 4.2.1-12). The anterior part
and covering the exiting nerve root, can now be approached. of the interspinous ligament and the base of the spinous
The lateral border of the dura and the exiting nerve root process are removed. Then the contralateral yellow ligament
are mobilized with a dissector. Remaining yellow ligament is stripped off entirely with rongeurs under direct visual
and compressive parts of the joint capsule are removed by control of the thecal sac (Fig 4.2.1-13). Adhesions can easily
small-caliber rongeurs (Fig 4.2.1-10). Using small diamond be mobilized by dissectors. In the case of osseous compres-
burrs, the medial part of the superior facet is thinned out. sion of the dura, the medial part of the facet is thinned with
Subarticular undercutting decompression enlarges the cor- a diamond drill. If necessary and for safety reasons, the dura
ridor for the exiting nerve root. In the event of substantial can be gently retracted medially with a nerve hook. Supe-
pedicular compression of the nerve root, additional partial rior and inferior hemilaminae are then undercut by rongeurs
resection of the medial pedicle is required. Osteoclastic for further enlargement of the canal and better visualization
hemilaminotomy of the inferior lamina might also be nec- of the neural structures. Contralateral lateral recess decom-
essary. Starting with the nerve root decompression at the pression includes partial removal of the joint capsule and
shoulder reduces the risk of nerve root damage. At the end enlarged osteoclastic thinning of the medial parts of the
of lateral recess decompression, sufficient posterior and superior facet. Exposure and decompression of the exiting
lateral nerve root decompression as far as to the foramen nerve root is completed by subarticular undercutting until
can be visualized under microscopic control (Fig 4.2.1-11). the nerve root passes the contralateral inferior pedicle
(Fig 4.2.1-14). A comparison of pre- and postoperative im-
For decompression of the contralateral central canal and ages demonstrates the effectiveness of the decompression
lateral recess, the table is tilted approximately 20° away (Fig 4.2.1-15).
Medial
Medial
P Caudal
Caudal
r
to
YL contralateral ec
ss
Di
D
D
IF
Lateral
Fig 4.2.1-10 Decompression of the ipsilater-

Fig 4.2.1-13 Over-the-top decompression
al lateral recess with rongeur targeting towards
with the dura (D) and dissector visible be-
the lateral recess, away from the dura.
neath the contralateral yellow ligament (YL).
IF: inferior facet; D: dura; P: punch.
Medial
Medial
Caudal
Caudal
Fig 4.2.1-12 The tilted table with lateral
support for an optimal oblique view and CLR
D working corridor for the contralateral N
over-the-top decompression procedure.
D
N nh
Lateral
Fig 4.2.1-11 Ipsilateral complete decompres- Fig 4.2.1-14 Decompressed contralateral

sion with relieved nerve root. central canal and lateral recess with the exiting
D: dura; N: nerve root. nerve root visible. D: dura; N: exiting nerve
root; nh: nerve hook; CLR: contralateral lateral
recess.

essary afterwards. After initial patient mobilization, there

are no restrictions concerning different mobility patterns
such as sitting, standing, or walking. A brace is not rou-
tinely used. However, depending on the patients´ com-
plaints, the number of decompression levels (over 2 levels),
and if translational immobile displacements or degenerative
deformities are present, temporary soft bracing is reasonable
for 4 weeks. Thromboembolic prophylaxis with fraction-
ated heparin is performed until full mobilization. Prolonged
a b antibiotic therapy is not recommended.
Fig 4.2.1-15a–b
a Preoperative axial MRI showing index segment at L3/4 with
severe central canal stenosis and bilateral recess stenosis.
b Postoperative axial MRI showing index segment at L3/4 and
demonstrating the effective bilateral enlargement of the spinal
canal and lateral recess. With the technique of bilateral decompression using a mono-
lateral approach, 1914 patients were operated on at the
author's spine center between June 1998 and June 2008.
An initial series consisted of 275 patients (52% men, 48%
women; mean age 69 years, range 34–89 years) with symp-
At this point, a final check for complete decompression of tomatic central lumbar spinal canal stenosis and bilateral
the neural structures (dura, nerve roots) and meticulous lateral recess stenosis, who underwent decompression with-
epidural hemostasis including the possible use of adequate out additional instrumented fusion procedures. This series
hemostatic agents should be performed. In the case of bone was analyzed retrospectively at a mean follow-up of 24
bleeding, bone wax or high-speed drilling without irrigation months; monolateral isolated lateral recess stenosis was
helps to close the bony surface. The use of a subfascial drain excluded from this analysis [30]. Nonsurgical treatment over
(without suction) is rarely indicated. After closure of the a long preoperative period had proved unsuccessful in all
fascia and adaptation sutures of the subcutaneous tissue, patients. Intermittent neurogenic claudication (91.6%) and
the skin is closed by resorbable intracutaneous running su- leg pain with unspecific sciatica (73%) were the dominant
ture. symptoms, with 52% of patients experiencing additional
subordinate back pain. In 54.5% of cases, accompanying
Since in routine practice decompression surgery is a proce- mono- or polyradicular symptoms, including pain and vary-
dure that does not require instrumentation, navigational ing degrees of sensorimotor deficit, were found depending
techniques are normally not necessary as a standard add-on. on which nerve roots had been compromised. Only 75 pa-
Additional instrumentation may be necessary for certain tients (27.3%) presented with sciatica alone. Preopera-
indications. Different types of instrumentation include in- tively the average walking distance amounted to 250 meters,
terspinous spacers (see chapter 4.2.5 Interspinous spacers) with a few patients being unable to walk at all. Preoperative
and pedicle-based fusion procedures (see chapter 4.2.4 average standing time was 10 minutes.
Mini-open and percutaneous pedicle instrumentation and
fusion). Ninety-nine percent of the patients required elective surgery.
However, due to the intensity of the pain syndromes and
the presence of neurological symptoms, 52% underwent
7 Postoperative care surgery within 1–2 weeks of the first contact. One percent
of all patients were operated on without delay, due to
Independently of the number of levels that have been de- chronic cauda equina syndrome with bladder and/or bow-
compressed, the patient can be mobilized within hours fol- el dysfunction. In total, 568 segments were decompressed
lowing surgery. If additional instrumentation procedures with the majority being at L4/5 (252/275) and L3/4
have been performed or in the case of elderly patients, mo- (178/275). There were more cases of bisegmental decom-
bilization is delayed until the day after surgery. Drain re- pression (44%) compared to monosegmental (29%) and
moval is carried out within 24–48 hours of surgery. Sterile trisegmental (22%) procedures. The mean time of surgery
adhesive plaster is placed for 48 hours. If wound healing amounted to 37 minutes per segment, and mean blood loss
progresses satisfactorily, no further wound covering is nec- to 57 ml per segment. Twenty-four months after surgery,
275

leg pain had significantly decreased in 71% of patients, but improvement was found over the follow-up period for post-
this symptom remained unchanged in 29% of cases. No operative leg and back pain, predominantly at 1-year follow-
increase in unspecific sciatica or radicular symptoms was up, with some deterioration in the improvement of pain
found. Back pain decreased in 40% of patients, remained level at 5-year follow-up. Improvement measured by the
unchanged in 57.5%, and increased in 2.5% of cases. Pain- ODI was also found to be statistically significant at the 1-year
free standing time improved from 10 minutes preopera- and 5-year intervals. As regards general health, the SF-36
tively to 82 minutes postoperatively, and pain-free walking documented improvement for both follow-up intervals,
distance from 250 meters preoperatively to approximately mainly at the 1-year interval. However, for the assessment
5000 meters postoperatively. When questioned about gen- of social functioning, only at the 1-year interval was sig-
eral satisfaction, 74% of the patients reported a better post- nificant improvement found. In this study, the indication
operative overall quality of life, 14% reported an unchanged group included patients that had undergone bilateral (83%)
situation, and 12% felt dissatisfied. and monolateral (17%) surgical procedures, and thus dif-
fered from the study groups mentioned earlier.
The perioperative surgery-related complication rate amount-
ed to 10% overall. The majority of complications involved In a prospective study with a mean follow-up of 5.4 years,
dural tears (5%) requiring immediate intraoperative ac- Cavusoglu et al [33] compared two treatment groups (n = 50
tivities or early revision, followed by hematomas (3.8%). patients per group) that underwent decompression surgery
In one case, an unplanned segment was decompressed. for lumbar spinal stenosis—ie, unilateral laminectomy ver-
sus unilateral laminotomy—in both instances, for bilateral
Similar results were published by Costa et al in 2007 [31] decompression. No difference in outcome was found in fa-
using an identical over-the-top decompression technique vor of either technique. Considerable enlargement of the
for the treatment of degenerative lumbar spinal stenosis. spinal canal was noted postoperatively in all cases, as docu-
In a retrospective study with a mean follow-up of 30.3 mented by comparison between pre-and postoperative MRI
months, the postoperative outcome of 374 patients was (unilateral laminectomy, 4.0–6.1-fold, unilateral laminot-
analyzed. Outcome measurements included the visual an- omy, 3.3–5.9-fold enlargement). Both groups showed sta-
alog scale (VAS) and the Prolo Economic and Functional tistically significant improvement in the ODI scores at early
Scale. Five hundred and twenty levels were decompressed (1-year) as well as late (5-year) follow-up intervals, where-
with a predominance of segments at L4/5 and L3/4. Mono- as for the evaluation of general health the SF-36 showed a
segmental pathologies dominated in 76.2 % of cases. The remarkable improvement at late (5-year) follow-up evalu-
mean time of surgery was 75 minutes (without differentiat- ation, which was, however, without statistical significance.
ing between the number of levels included) and the esti-
mated blood loss was 60 ml. Clinical and functional im- Several studies have been published on the use of tubular
provement was reported in 87.9% of cases. In patients with retractors for a unilateral “over the top” approach. Parikh
preoperative radiculopathy, 40% demonstrated some post- et al [24] reported results comparable to those in the pub-
operative sensorimotor deficit. Three out of 374 (0.8%) lished literature using open surgery in patients that under-
patients developed a mild segmental instability, however, went one- and two-level tubular laminectomy for lumbar
without the need for surgical intervention. For the eco- spinal stenosis. A significant learning curve was required.
nomic and functional assessments, subjective postoperative Rahman et al [34] compared 38 patients that underwent
evaluation demonstrated a statistically highly significant minimally invasive tubular decompression for stenosis to
benefit with a mean decrease in VAS from 8.9 preopera- 88 patients undergoing standard open decompression. The
tively to 4.2 postoperatively and a mean increase in the minimally invasive lumbar laminectomy patients experi-
Prolo score of 3 (± 2). enced shorter operating times, less blood loss, shorter length
of hospital stay, and fewer complications. Celik et al [35]
In a prospective study, Anjarwalla et al [32] analyzed the compared open total laminectomy to bilateral microdecom-
5-year outcome of patients that had undergone decompres- pressive laminotomy in 34 and 37 patients respectively,
sion surgery for lumbar spinal stenosis. The long-term out- each group with a mean follow-up of 5 years. The clinical
come evaluation, made on the basis of general health ques- outcome was comparable in both groups, but the complica-
tionnaires, included the VAS, the Oswestry Disability Index tion rates and postoperative instability rates were signifi-
(ODI) and the Short Form 36 (SF-36). Statistically significant cantly higher in the total laminectomy group.

9 Complications and avoidance As regards decompression surgery for lumbar spinal steno-
sis, to date no evidence-based studies are available on the
The overall complication rates, when using microscope- relationship between the degree of postoperative asymp-
assisted decompression techniques for the treatment of tomatic or symptomatic epidural scar-tissue formation and
acquired lumbar spinal stenosis, have been reported as be- the specific decompression technique used. However, since
ing between 7% and 17% [36, 37]. As regards complication the amount of bleeding and subsequent scar-tissue forma-
rates for minimally invasive decompression procedures there tion is directly related to the extent of the exposure chosen,
is a tendency toward fewer new neurological deficits, as microsurgical approaches as presented in this chapter may
well as fewer overall complications [36]. No difference is help to reduce postoperative symptomatic epidural scar tis-
found when comparing the described method with other sue formation.
microsurgical bilateral techniques.
Wrong-level decompression is a rare occurrence (1/275 in
Incidental dural tears with subsequent cerebrospinal fluid the author’s series ie, 0.4% [30], up to 3.3% in the literature
leakage represent the major complication associated with de- [43]). For the most part, meticulous preoperative planning
compression surgery, amounting to 8–13% for primary surgery including x-ray-controlled needle placement for level lo-
[38, 39]. Especially in the elderly population, the dura becomes calization and intraoperative x-ray verification of the target
thinner and frequently more adherent to the surrounding segment before perforation of the yellow ligament should
structures, with the inherent risk of increased vulnerability. help to avoid this complication.
Immediate repair of a dural tear by suturing, surface sealing
with fibrin glue, or the application of a tamponading fleece Incomplete decompression might affect both the ipsilat-
(eg, TachoSil, Nycomed Pharma GmbH, Konstanz/Germany) eral and contralateral cranial and caudal areas. Care must
helps to avoid the development of a pseudomeningocele or in particular be taken when decompressing the ipsi- as well
persisting cerebrospinal fluid (CSF) fistulas. as the contralateral cranial area, since remaining parts of
the tip of the superior facet might continue to impinge on
Nerve root injury is a less frequent occurrence, with a re- the exiting nerve root. With proper over-the-top decom-
ported rate of 1–2% [40, 41]. The over-the-top decompression pression, recurrence of an acquired lumbar spinal stenosis
procedure for the reduction of contralateral spinal canal is extremely rare. In most cases, “recurrent” stenotic seg-
narrowing might in particular lead to a possible temporary ments are a result of insufficient primary decompression.
compression of the cauda equina if the entrance corridor In the present author’s series, no patient had to be oper-
of the decompression route is too narrow due to insufficient ated on within a follow-up period of 8 years due to recurrent
undercutting of the lamina. On analyzing the present au- stenosis. Reoperation rates amounting to 11–13% have been
thor’s own data pool, no direct nerve root injury could be reported, but without precise details regarding the indica-
found. However, one transient hemicaudal syndrome was tion [44, 45].
observed.
As with all advanced surgical techniques, microsurgical
The postoperative development of epidural hematoma fol- over-the-top decompression includes a steep learning curve.
lowing decompression surgery is a relatively frequent oc- Initially, the time of surgery per segment might be increased
currence with a reported 58% incidence thereof, most when switching from macrosurgical laminectomy tech-
cases being asymptomatic and usually extending to adjacent niques to microsurgical procedures performed through a
levels in 28% of patients [42]. Meticulous intraoperative small working channel [24]. Previous intraoperative routine
hemostasis using bipolar coagulation or hemostatic (eg, use of a microscope, however, will shorten the learning
Surgicel, Ethicon GmbH, Somerville, USA) or sealing agents curve. The surgeon should be familiar with the microanat-
(FloSeal, Baxter GmbH, Deerfield, USA) helps to reduce the omy of the lumbar spine. The over-the-top decompression
risk of epidural hematoma. In the case of increasing dull procedure, contralaterally within the canal itself, cranially
leg pain or increasing radicular pain during the postopera- and caudally, as well as in the lateral recess, presents a
tive course, MRI examination is recommended to exclude particular challenge both as regards anatomical orientation
the presence of a possible compression that may require and the manual skill required.
surgical revision.
277

Segmental instability is a potential risk following decompres- over 30° are considered risk factors that could result in in-
sion surgery. Extensive decompression procedures such as creased instability and are therefore viewed as contraindica-
laminectomy may worsen existing instability, or lead to the tions for decompression procedures without additional sta-
development of previously nonexistent instability. On the bilization [25]. Instability does not usually depend on the
contrary, microsurgical interventions such as the decompres- number of levels that are decompressed [46], however, an
sion technique presented herein, which preserves the entire accompanying symptomatic large disc herniation treated by
contralateral paravertebral musculature including the ner- sequestrectomy or even discectomy could result in segmen-
vous structures and vascular supply, will generally not trig- tal instability. When fusion is also performed, however, com-
ger or accelerate segmental instability [33]. Already existing bined decompression and fusion surgery imply an increased
large hypermobile translational instabilities or stable displace- risk of complications, as a statistically higher postoperative
ments exceeding slips greater than grade I or frontal tilts of neurological complication rate has been reported [36].
10 Tips and tricks—with special emphasis on tubular decompression surgery
Sylvain Palmer, Mission Viejo, USA It is also helpful to remember that in a degen- nerve root. Palpation of the disc space and
erated spine the inferior edge of the lamina removal of any offending protrusion com-
10.1 Patient selection has often migrated caudally with disc-space pletes this evaluation.
Patients with lumbar central spinal steno- collapse; therefore, the surgeon should target
sis, lateral recess stenosis, foraminal stenosis the lower edge of the disc space. It is better to The primary aim in decompressive surgery
herniated or bulging discs, synovial cysts, err on being too low than too high, so that at for spinal stenosis is to achieve a satisfac-
and other intraspinal pathologies are suitable least the inferior edge of the lamina is visible tory decompression. However, this is often
candidates for tubular decompression surgery at the end of the tube. Ideally, it should be compromised by an attempt to limit any po-
[23]. Tubular decompression further limits possible to see the inferior edge of the lamina tential postoperative instability. Achieving an
approach-related morbidity, as it involves a in the middle of the tube. adequate decompression may require partial
muscle-splitting ligament-sparing technique. removal of the pars on the ipsilateral side.
After exposure of the inferior edge of the This is particularly the case at or above L3/4,
Patients with grade I spondylolisthesis are superior lamina, initial dissection is carried where the facets tend to become progressively
suitable candidates for decompression sur- out with a straight curette to separate the more vertical. If the pars interarticularis is
gery without stabilization [47]. However, ligamentum flavum. The ligamentum is usu- compromised during the surgical procedure
patients with overt instability with motion ally quite thick and drilling can be safely per- the loose inferior articular process should be
≥ 4 mm on flexion-extension, with signifi- formed with a 3 mm diamond drill until only removed, as if it is left this could result in
cant scoliosis or lateral listhesis, should be a thin layer of bone remains to be removed postoperative pain. It is not necessary to per-
considered for stabilization surgery. with a Kerrison rongeur. On the contralateral form fusion at this time. The patient should
side once the ligamentum flavum has been re- nevertheless be informed of the situation,
10.2 Operative procedures moved, the medial aspect of the contralateral and appropriately monitored for the potential
The treatment approach is normally from facet can be seen. It is important to remove need for stabilization. In the present author’s
the most symptomatic side unless a specific as much of the facet complex as necessary to experience, the incidence of postoperative
intraspinal pathology dictates otherwise. This fully decompress the opposite lateral recess. instability is less than 5% for all patients, and
would be the case for synovial cysts or disc no significant difference has been noted in
herniations contralateral to the most symp- Often the most stenotic portion, the waist of patients in whom a pars interarticularis has
tomatic side. the stenosis, is located at the superior border been sacrificed.
of the lower lamina. It is important to fully
Image intensification is highly recommended remove this inferior attachment of the liga-
for localization, as there a greater risk of in- mentum flavum and to visualize or palpate
advertently straying from the intended level the nerve root along the lower pedicle. This
with minimally invasive techniques. ensures the complete decompression of the

10.2.1 Foraminal stenosis 10.2.3 Bilateral disc herniations be better performed using a tubular approach,
The exposure of an ipsilateral foraminal pa- It is possible to use a unilateral tubular ap- which limits the need to deal with soft-tissue
thology is often incomplete if the pars interar- proach for treating bilateral disc herniations. scar formation. Upon reexploration, the bone
ticularis is not sacrificed. The contralateral fo- After decompressing the opposite lateral re- anatomy provides the necessary landmarks
ramen is actually more easily decompressed, cess, the dura can be retracted medially and to finding one’s way during surgery.
and this has led some surgeons to recommend any disc pathology on the contralateral side
contralateral exposure for the treatment of can be removed. However, this can be chal- Roger Härtl, New York, USA
pure foraminal stenosis. lenging in the case of bilateral free disc frag- • This comment author routinely treats
ments, where a bilateral tubular approach lumbar spinal stenosis patients with up
10.2.2 Far-lateral foraminal stenosis using two separate incisions, one on each to grade 1 spondylolisthesis and no other
Far-lateral foraminal stenosis with or with- side, may be preferable. signs of instability and 1–2 level disease
out a disc herniation is best treated via a far by tubular decompression without sta-
lateral approach, which is greatly facilitated Dural tears are easily dealt with through the bilization [24].
by the use of the tubular MISS technique. tube. Primary repair, when possible, is pre- • Using a 3 mm matchstick fluted burr, the
The junction of the pars and the transverse ferred. Tissue adhesive and flat bed rest over- risk of dural injury is minimal. CSF leak-
process is targeted, starting about 3 cm from night in the hospital or at home with limited age is managed with fibrin glue or other
the midline and aiming halfway between activity for a few days is usually adequate. If synthetic polyethylene sealant materi-
the disc space and the superior pedicle. The a positional HA occurs postoperatively with als and postoperative bed rest for 8–12
pedicle, transverse process, and facet can be or without a recognized intraoperative dural hours.
felt with the initial dilator. Sometimes AP as tear, bed rest and a blood patch can be used • Synovial cysts can be treated effectively
well as lateral image intensification is neces- to treat the CSF leak. Reexploration with in- through tubular retractors [48]. A contra-
sary to confirm localization. Initial resection traoperative repair is rarely necessary. lateral approach using a tubular retractor
is performed at the mamillary body of the system provides excellent visualization of
transverse process, exposing the pedicle and Persisting or recurrent symptoms can occur the facet cyst, allowing safe cyst resection
the superior nerve root. Then dissection can postoperatively. Except for symptomatic in- and nerve root decompression without
be safely carried out to decompress the nerve stability, these can all be handled with repeat compromising the facet joint [49].
root as necessary. tubular exploration. Reexploration can often • Ambulatory outpatient surgery is an option.
11 Case example pain. The straight leg raising test was negative, and no mo-
tor or sensory deficit was present.
A 72-year-old man presented with long-lasting, nonsig-
nificant back pain (VAS 2/10), but had experienced increas- Bilateral standard x-rays showed a multisegmental degen-
ing and clearly dominating bilateral unspecific pseudora- eration of the entire lumbar spine with some segmental
dicular leg pain (VAS 8/10) when standing and walking for rotation, a monosegmental frontal tilt which was predom-
14 months. Progressive intermittent claudication had de- inantly left-convex at L1/2 and right-convex at L4/5 and a
veloped with reduction of walking distance due to the leg translational shift at L4/5, which appeared stable in dy-
pain. He had suffered from additional pain radiating into namic lateral x-rays (Fig 4.2.1-16). Preoperative MRI and CT
the right anterior thigh 9 months later. Mild unspecific tin- scan showed a right mediolateral disc herniation at level
gling in the left leg was observed without, however, motor L1/2 and a central canal stenosis at L4/5 in combination
dysfunction of the lower extremity. Nearly no pain was with a bilateral recess stenosis (Fig 4.2.1-17).
present when resting or lying down. Nonsurgical treatment
had failed to provide long-lasting benefit. No sensorimotor Selective infiltrations on an inpatient basis resulted in re-
deficit was reported. petitive, but not continuous pain relief to a selective nerve
root block at L2 on the right, as well as temporary effective
Clinical findings revealed pain-free lumbar osseous and pain relief after epidural injection at L4/5. A negligible ef-
paravertebral muscular structures with a painful extension fect without significant influence on the dominating pain
but an overall unlimited range of motion of the lumbar pattern was found for facet joint infiltrations as well as for
spine. The right sacroiliac joint showed significant pressure iliosacral joint injections.
279

Simultaneous sequestrectomy was subsequently performed Postoperative MRI and CT scan demonstrated good decom-
at L1/2 from the right side due to the position of the disc pression at both levels and preserved facet joints (Fig 4.2.1‑18).
herniation, and bilateral decompression of the spinal canal
and lateral recess at level L4/5 in an over-the-top technique
from the right side due to the rotated position of the lumbar
spine.
a b c d
Fig 4.2.1-16a–d
a Preoperative x-ray in AP projection demonstrating a monosegmental frontal tilt predominantly
left-convex at L1/2 and right-convex at L4/5.
b Preoperative x-ray in lateral projection demonstrating a spondylolisthesis at L4/5.
c Preoperative view, lateral in flexion demonstrating no segmental instability.
d Preoperative view, lateral in extension. The dynamic functional x-rays demonstrate a stable segmental
displacement L4/5 Meyerding I°.
a b c d
Fig 4.2.1-17a–d
a Preoperative axial MRI of the index segment at L1/2 showing a right mediolateral disc herniation.
b Preoperative axial CT scan of the index segment at L1/2 with identical finding as in the corresponding
MRI.
c Preoperative axial MRI of the index segment at L 4/5 demonstrating a central canal stenosis in
combination with a bilateral recess stenosis.
d Preoperative axial CT scan of the index segment at L4/5 with identical finding as in the corresponding MRI.

Fig 4.2.1-18a–c Postoperative

axial MRI and CT scan of the index
segment at L1/2 (a, b) and L4/5
(c) demonstrating good decom-
pression at both levels and
a b c preserved facet joints.
12 Key learning points • In multisegmental cases including more than three seg-
ments, the duration of surgery could be prolonged
• Bilateral microsurgical decompression of acquired de- • All the advantages of microscope-assisted surgery includ-
generative lumbar spinal canal stenosis and lateral recess ing improved control over the neural structures and
stenosis using a monolateral approach enables sufficient meticulous epidural and paravertebral hemostasis are
enlargement of the spinal canal and provides complete available
relief to all intraspinal neural structures • Outcome studies show good clinical results with an ac-
• Due to the minimized approach, which ensures that the ceptably low complication rate. Limited standing time
contralateral paravertebral region remains untouched and walking distance as major preoperative symptoms
and the posterior tension band system is protected, this improve significantly in the postoperative course, with
technique can be performed in cases of translational dis- a substantial reduction in leg pain and, less frequently,
placement of up to I° (according to the Meyerding clas- with decreased back pain
sification), and even in cases of severe degenerative ro- • Contralateral decompression is a technically demanding
tational deformity procedure with the risk that insufficient visualization of
• With negligible low back pain, additional instrumentation neural structures may result in damage, and the risk of
and fusion can be avoided using this microscope-assisted accompanying neurological deficits. In addition, insuf-
over-the-top-procedure, since segmental stability is main- ficient contralateral decompression may lead to unsat-
tained and the risk of postoperative iatrogenic instability is isfactory results
minimized • The described technique requires a certain amount of
• Due to reduced tissue trauma, intra- and postoperative microsurgical experience, and necessitates a steep learn-
morbidity is minimized with a reduction of both intra- ing curve since the working channel is narrow
operative blood loss and operative time, resulting in ear- • As acquired lumbar spinal canal and lateral recess ste-
lier patient mobilization and quicker rehabilitation when nosis is only part of a complex degenerative procedure
compared to treatment by open laminectomy. This is involving the lumbar spine, a pain-free postoperative
especially important for elderly patients and those with course tends to be rather rare, and therefore patients
severe comorbidities should be made aware of this.
281

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al (2003) A ligamentum flavum- Clinical outcomes of microendoscopic Bilateral decompressive surgery in
preserving approach to the lumbar decompressive laminotomy for lumbar spinal stenosis associated with
spinal canal. Spine; 28(19):E385–390. degenerative lumbar spinal stenosis. spondylolisthesis: unilateral approach
41. Fourney DR, Dettori J, Norvell DC, et Eur Spine J; 18(5):672–678. and use of a tubular retractor system.
al (2010) Does minimal access tubular 44. Jansson KA, Németh G, Granath F, et Neurosurg Focus; 13(1):E4.
assisted spine surgery increase or al (2005) Spinal stenosis re-operation 48. Sandhu F, Santiago P, Fessler R, et al
decrease complications in spinal rate in Sweden is 11% at 10 years – a (2004) Minimally invasive treatment of
decompression or fusion? Spine; national analysis of 9664 operations. lumbar synovial cysts. Neurosurgery;
35(9S):S57–65. Eur Spine J; 14(7):659–663. 54(1):107–112.
42. Sokolowski MJ, Garvey TA, Perl J, et 45. Weinstein JN, Tosteson TD, Lurie JD, 49. James A, Laufer I, Parikh K, et al
al (2008) Prospective study of et al (2010) Surgical versus (2012) Lumbar juxtafacet cyst
postoperative lumbar epidural nonoperative treatment for lumbar resection: the facet sparing
hematoma—incidence and risk factors. spinal stenosis: four-year results of the contralateral minimally invasive
Spine; 33(1):108–113. Spine Patient Outcomes Research Trial. surgical approach. J Spinal Disord Tech;
Spine; 35(14):1329–1338. 25(2):E13–E17.
46. Park DK, An HS, Lurie JD, et al (2010)
Does multilevel lumbar stenosis lead to
poorer outcomes? Spine; 35(4):439–
446.
Celik SE, Celik S, Göksu K, et al (2010) Weinstein JN, Tosteson TD, Lurie JD, et al (2010)
Microdecompressive laminotomy with a 5-year follow- Surgical versus nonoperative treatment for lumbar spinal
up period for severe lumbar spinal stenosis. J Spinal stenosis. Four-year results of the spine patient outcomes
Disord Tech; 23(4):229–235. research trial. Spine; 35(14):1329–1338.
Therapy Prospective comparative study II Therapy Randomized cohort and a II–III
concurrent observational
Purpose cohort
This prospective case control study sought to evaluate
Purpose
bilateral microdecompressive laminotomy (MDL) for
To compare 4 year outcomes of surgery to nonoperative
treatment of severe lumbar spinal stenosis.
care for spinal stenosis.
P Patient Severe lumbar spinal stenosis (N = 71)
P Patient Patients suffering from lumbar spinal stenosis (N = 654: 289
I Intervention Total laminectomy (n = 34) patients randomized cohort + 365 patients observational
cohort)
C Comparison Bilateral bilateral microdecompressive laminotomy (MDL)
(n = 37) I Intervention Standard posterior decompressive laminectomy
O Outcome Degree of postoperative back and leg pain (VAS), ODI low C Comparison Standard nonoperative treatment
back pain questionnaire, ODI, walking distance without
pain, perioperative complications, postoperative instability, O Outcome SF-36 bodily pain (BP) and physical function scales,
radiographic analyses modified ODI (AAOS/Modems version), stenosis and low
back pain, satisfaction with symptoms, self-rated progress,
complications
Compared with classic approaches, bilateral MDL provides Authors’ conclusion
adequate and safe decompression in lumbar spinal ste- Patients with symptomatic spinal stenosis treated surgi-
nosis. It significantly reduces clinical symptoms and dis- cally compared to those treated nonoperatively maintain
ability. However, total laminectomy shows higher peri- substantially greater improvement in pain and function,
operative complications and postoperative instability. To satisfaction, and self-rated progress through 4 years.
the best of our knowledge, this is the first study to define
a bilateral MDL approach to treat the stenotic lumbar
spine without a herniated disc.
283

Cavusoglu H, Kaya RA, Türkmenogly ON, et al (2007) Anjarwalla NK, Brown LC, McGregor AH (2007) The
Midterm outcome after unilateral approach for bilateral outcome of spinal decompression surgery 5 years on. Eur
decompression of lumbar spinal stenosis: 5-year Spine J; 16(11):1842–1847.
prospective study. Eur Spine J; 16(12):2133–2142.
Study type Study design Class of evidence Therapy Case series IV
Therapy Randomized controlled trial II
Purpose
Purpose To ascertain the long term outcome with respect to pain
To evaluate the results and effectiveness of bilateral de- and function.
compression via a unilateral approach in the treatment
of degenerative lumbar spinal stenosis. P Patient Degenerative lumbar spinal stenosis (DLSS) (N = 77)
I Intervention Posterior decompression surgery through a midline
P Patient Degenerative lumbar spinal stenosis (N = 269 levels in 100 approach
patients)
I Intervention Unilateral laminectomy (Group 1)
O Outcome Back and leg pain (VAS), physical and social function
C Comparison Laminectomy (Group 2) (Oswestry Disability Index, SF-36)
O Outcome Spinal canal size, ODI, SF-36
Authors’ conclusion This study showed that physical function assessed by Os-
For degenerative lumbar spinal stenosis unilateral ap- westry Disability Index and back and leg pain were sig-
proaches allowed sufficient and safe decompression of nificantly improved after surgery but that these improve-
the neural structures and adequate preservation of ver- ments had deteriorated slightly by 5 years. In particular,
tebral stability, resulted in a highly significant reduction early improvements in social functioning observed at 1
of symptoms and disability, and improved health-related year were not sustained.
quality of life.
Costa F, Sassi M, Cardia A, et al (2007) Degenerative

Fu KMG, Smith JS, Polly DW, et al (2010) Morbidity lumbar spinal stenosis: analysis of results in a series of
and mortality in the surgical treatment of 10329 adults 374 patients treated with unilateral laminotomy for
with degenerative lumbar stenosis. J Neurosurg Spine; bilateral microdecompression. J Neurosurg Spine;
12(5):443–446. 7(6):579–586.
Therapy Cohort III Therapy Case series IV
Purpose Purpose
To assess the incidences of morbidity and mortality in the To present a minimally invasive surgical technique per-
operative treatment of degenerative lumbar stenosis. formed using a unilateral approach for lumbar decom-
pression.
P Patient Degenerative lumbar stenosis (N = 10,329, average age
63 years) P Patient Degenerative lumbar spinal stenosis (DLSS) (N = 374)
I Intervention Decompression and fusion procedure (n = 3720) I Intervention Unilateral microdecompression
C Comparison Decompression procedure alone (n = 6609) C Comparison No comparison group
O Outcome Morbidity and mortality O Outcome Clinical Outcome (Prolo Scale), Pain (VAS), radiographs
This analysis of the SRS morbidity and mortality database Authors’ conclusion
provide surgeons with useful information for preoperative Evaluation of the results indicates that unilateral micro-
counseling of patients contemplating surgical intervention decompression of the lumbar spine offers a significant
for symptomatic degenerative lumbar stenosis. improvement for patients with DLSS, with a lower rate
of complications.

Jansson KA, Németh G, Granath F, et al (2005) Spinal Mayer HM, List J, Korge A, et al (2003) [Microsurgery
stenosis re-operation rate in Sweden is 11% at 10 of acquired degenerative lumbar spinal stenosis. Bilateral
years—A national analysis of 9664 operations. Eur Spine over-the-top decompression through unilateral
J; 14(7):659–663. approach]. Orthopäde; 32(10):889–895. German.
Therapy Case-series IV Therapy Case-series IV
Purpose Purpose
To report the 10-year lumbar spinal stenosis re-operation To describe a microsurgical technique that can achieve a
rate based on comprehensive national data from Sweden bilateral decompression of the central and lateral lumbar
during the years 1987–1999. spinal canal through a unilateral surgical approach.
P Patient Patients operated on for spinal stenosis (N = 9664) P Patient Degenerative lumbar spinal stenosis (DLSS)
(N = 275, n = 143 males, average age 69 years)
I Intervention Lumbar spinal stenosis (laminectomy or decompression
with additional fusion ) I Intervention Bilateral decompression of the central and lateral spinal
canal
O Outcome Length of stay, rate of reoperation, risk or reoperation
O Outcome Standing time, walking distance, pain, complications
One out of ten spinal stenosis patients will be reoperated Authors’ conclusion
after 10 years. The reoperation rate lowered over time DLSS can be treated at a high age with low risk. Micro-
and was almost one-third lower at the end of the study. surgical mono- or multisegmental decompression of the
Adding a fusion may lower the re-operation risk, an ob- central and lateral lumbar spinal canal through a unilat-
servation that can only be evaluated in randomized trial. eral surgical approach leads to good results in terms of
standing time and walking distance.
Pao JL, Chen WH, Chen PQ (2009) Clinical outcomes of

microendoscopic decompressive laminotomy for
degenerative lumbar spinal stenosis. Eur Spine J;
18(5):672–678.

Therapy Case-series IV
Purpose
To investigate the effectiveness of microendoscopic de-
compressive laminotomy by evaluating the clinical out-
comes with patient-oriented scoring systems.
P Patient Moderate to severe stenosis with persistent neurological

symptoms and failure of conservative treatment (N = 53,
32% male, mean age 62 years)
I Intervention Microendoscopic decompressive laminotomy (MEDL )
O Outcome Patient satisfaction, ODI, Japanese Orthopaedic Association
(JOA) score, complications
MEDL appears to be a safe and very effective minimally
invasive technique for degenerative LSS.
285

Parikh K, Tomasino A, Knopman J, et al (2008) Podichetty VK, Spears J, Isaacs RE, et al (2006)
Operative results and learning curve: microscope-assisted Complications associated with minimally invasive
tubular microsurgery for 1- and 2-level discectomies and decompression for lumbar spinal stenosis. J Spinal Disord
laminectomies; Neurosurg Focus; 25(2):1–6. Tech; 19(3):161-166.
Therapy Case-series IV Therapy Case-series IV
Purpose Purpose
To present the clinical results and the learning curve as- To evaluate the risks associated with performing a mini-
sociated with the use of tubular retractors for 1- and mally invasive decompression for spinal stenosis in a large
2-level lumbar microscope-assisted discectomies and group of patients.
laminectomies.
P Patient Lumbar spinal stenosis (N = 379 spinal levels in 220 pati-
P Patient Patients suffering from degenerative lumbar spinal disease ents, average age 74 years, age range 49–98 years) with a
(decompression of a facet joint cyst, herniated lumbar disc grade 1 degenerative spondylolisthesis (n = 69 patients)
or degenerative spinal stenosis) (N = 230), mean age 54 I Intervention Microscopic or microendoscopic minimally invasive decom-
years pression surgery
I Intervention 1- or 2-level LMD or laminectomy performed using tubular C Comparison No comparison group
retractors and an operating microscope (microscope-
assisted tubular microsurgery ) O Outcome Operative blood loss, length of hospital stay, readmissions,
narcotic pain medication use, durotomy, complications
O Outcome Operative results (length of stay, blood loss, operative
times, surgical complications), clinical outcomes, VAS, ODI,
Macnab outcome scale Minimally invasive decompression strategies for spinal
stenosis seem consistently to result in short hospital
Authors’ conclusion lengths of stay, minimal requirements for narcotic pain
The use of tubular retractors for microsurgical decompres- medications, and a low rate of readmission and complica-
sion of degenerative spinal disease is a safe and effective tions.
treatment modality. As surgeons become more comfort-
able with the procedure, its applications can be expand-
ed to include, for example, spinal instrumentation and
deformity correction.

Sokolowski MJ, Garvey TA, Perl J, et al (2008)

Prospective Study of Postoperative Lumbar Epidural
Hematoma – Incidence and Risk Factors. Spine;
33(1):108–113.

Therapy Case-series IV
Purpose
To determine the incidence, volume, and extent of post-
operative epidural hematoma resulting in thecal sac com-
pression, and to identify risk factors correlated with mea-
sured hematoma volumes.
P Patient Patients with spinal and/or foraminal stenosis, isthmic or

degenerative spondylolisthesis, and recurrent disc hernia-
tion (N = 50)
I Intervention Lumbar decompression surgery with or without fusion
laminectomy, laminotomy, posterolateral fusion, posterior,
and/or anterior interbody fusion of one or multiple levels
O Outcome Collection of pre- and intraoperative risk factors , preope-
rative thecal sac (cross-sectional area) CSA, relative thecal
sac compression due to hematoma, hematoma volumes,
incidence and sites of hematoma, postoperative MRIs,
blood loss, operative time
Lumbar decompression surgery results in a 58% incidence
of asymptomatic compressive postoperative epidural he-
matoma. Adjacent level compression by hematoma occurs
in 28% of patients. Advanced age, multilevel procedures,
and international normalized ratio are independently as-
sociated with postoperative hematoma volume.
287


4.2.2 Microsurgical lumbar disc surgery
Shanmuganathan Rajasekaran, Gopalakrishnan Balamurali, Rishi Mugesh Kanna, Ajoy Prasad Shetty
1 Historical perspective 2 Terminology
In the early 20th century, surgery for lumbar disc prolapse, Minimally invasive techniques require accurate preopera-
as described by Mixter and Barr [1], involved an extensive tive identification of the location, nature, and size of the
exposure of at least two segments bilaterally and a lami- prolapsed disc. It is important that precise and universally
nectomy due to the lack of safe, simple, and accurate imag- accepted terminology be used for the description and doc-
ing. This procedure was termed the standard discectomy umentation of the prolapsed disc.
(SD). The ability for accurate preoperative localization of
the disc prolapse due to improved imaging facilities and an 2.1 Location and extent of the disc prolapse
increasing awareness of the stabilizing role of the paraspinal Several terms are used to describe the extent of disc prolapse
muscles and posterior vertebral elements led surgeons to as seen under MRI. Herniation is defined as a localized dis-
develop less invasive techniques. placement of disc material beyond the limits of the inter-
vertebral disc space. Disc herniation may take the form of
The 1970s witnessed the development of many less invasive protrusions or extrusions, depending on the shape of the
approaches. Of these, the microsurgical lumbar discectomy displaced material. A disc is said to be extruded if any dis-
(MLD) technique, which allowed for magnified visualiza- tance between the edges of the disc material beyond the
tion of the precise pathology through a small incision, less disc space is greater than that between the edges of the base
traumatic tissue dissection of the muscles, easier identifica- measured in the same plane. If the disc material is displaced
tion of deep-seated structures, gentle manipulation of neu- away from the site of extrusion, regardless of the presence
ral structures, and a direct view of the disc space, was ad- or absence of continuity, it is called a migrated disc. If there
opted on a widespread scale [2]. Improved patient outcomes is lack of continuity with the disc of origin, it is termed a
have been reported for lumbar discectomy performed via sequestrated disc or free fragment.
the MLD technique, making it the gold standard procedure
for lumbar disc surgery [3]. The location of the prolapsed disc is defined in both the
axial and sagittal planes. In the axial plane, the location of
In the late 1990s, various other minimally invasive, percu- the disc can be in the central, paramedian, or lateral recess,
taneous discectomy techniques using endoscopes, high- or in the foraminal, extraforaminal, or far lateral regions
definition cameras, and tubular working channels were (Fig 4.2.2-1). Wiltse proposed a classification to describe the
developed. Although these newer techniques were designed location of the migrated disc in the sagittal plane using
to specifically improve patient outcomes, there is little proof pedicles as a reference [8] (Fig 4.2.2-2).
in the literature in support of their superiority over the
MLD procedure. There is also sufficient evidence in the Based on the location of the herniated disc in the sagittal
literature demonstrating that MLD is superior to other in- MRIs, McCulloch made a “three-story house” analogy to
vasive methods of discectomy such as chemonucleolysis, accurately localize the disc fragment [9] (Fig 4.2.2-3):
percutaneous discectomy, thermocoagulation, and ar- • The first story is located opposite the intervertebral disc
throscopic discectomy [4–7]. • The second story includes the lower half of the vertebral
body with the neural foramen at its posterior aspect. A
herniated disc, which has migrated cephalad, is present
in the second story of the proximal vertebra
• The third story corresponds to the upper half of the
vertebral body near the pedicle. A caudally migrated
disc is located in the third storey of the inferior vertebra,
and is also called the “basement disc”.
289

Authors Shanmuganathan Rajasekaran, Gopalakrishnan Balamurali, Rishi Mugesh Kanna, Ajoy Prasad Shetty
a b Supra pedicle
Pedicle
Infra pedicle
Disc
c d
Fig 4.4.2-1a–d Axial views showing different types of lumbar Fig 4.2.2-2 Wiltse’s classification of the various levels of disc hernia-
disc prolapse. tion. Coronal section of a lumbar motion segment showing the different
a Median (posterocentral) type of lumbar disc prolapse. levels at which the disc can herniate in the sagittal plane. The migrated
b Median and paramedian type of lumbar disc prolapse. disc can be located at the disc level, infrapedicle level, pedicle level, or
c Posterolateral type of lumbar disc prolapse. suprapedicle level.
d Far lateral lumbar disc prolapse.
a b c d
Fig 4.2.2-3a–d McCulloch’s three-story concept indicating the location of the migrated disc.
a McCulloch’s three-story concept indicating the different levels at which the prolapsed disc can be identified via
sagittal MRI: the exact preoperative localization helps in planning surgery.
b–d Sagittal MRI showing different types of migration of herniated disc. The extruded fragment may have migrated
inferiorly (story 3), at the level of the disc (story 1), or may have migrated superiorly (story 2).

Recently Mysliwiec et al [10] proposed a new classification were the most common, lesions 2-B were more commonly
system for lumbar disc herniation that incorporates both symptomatic, and 3-A lesions were often seen in cauda
the location and size of the disc (Fig 4.2.2-4). They have equina syndrome. This system seems to be a simple and
graded the size of the disc herniation as 1, 2, and 3, and the reliable method for objectively measuring the herniated
location as A, B, and C. It was observed that lesions 2-AB lumbar disc (Fig 4.2.2-5).
Fig 4.2.2-4a–b Axial sections of a lumbar vertebra showing different

1 C C grades and zones of disc prolapse.
B B
2 A A a Disc herniation graded according to size: grade 1 lesions have
3 little effect, while grade 3 lesions have the most effect on nerve
root compression.
b Three different zones for the location of the prolapsed disc. Disc
prolapses have more significant impact on the nerve roots in the
a b narrower zones B and C.
Fig 4.2.2-5a–b Diagram showing the size and location of the

prolapsed disc.
a 2-B lesions are generally symptomatic, while 3-A lesions are often
observed in cauda equina syndrome.
b 2-C lesions are the largest foraminal lesions; 2-AB lesions are
a quite common, occurring along the line between zones A and B.
291

2.2 Terminology for various discectomy techniques • Successful results of discectomy are more commonly
It is also important to differentiate between the terms mi- seen in patients with persistent radicular pain that has
crosurgical lumbar discectomy (MLD), microendoscopic not responded to a 6-week trial of conservative care, a
discectomy (MED), microsurgical tubular discectomy (MTD), positive straight-leg raise test on the same side, positive
and percutaneous endoscopic discectomy (PED). Microsur- cross-straight-leg raise test, and positive MRI that cor-
gical lumbar discectomy refers to the removal of prolapsed relates anatomically. If at least three of these factors are
parts of lumbar intervertebral discs through a small poste- present, surgery has a 90% success rate [13]. On the
rior surgical incision with the aid of a surgical microscope other hand, factors such as sick-leave stress, depression,
and microsurgical instruments. The entry into the spinal poor psychological profile, level of education, work/dis-
canal using this technique can be through the interlaminar, ability claims, and compensation play a significant neg-
translaminar, or the far lateral approaches depending on ative role on the outcome.
the location of the prolapsed disc fragment. The same sur- • When discectomy is indicated, MLD can be used suc-
gery can be performed using a tubular retractor with a cessfully in all types of herniation, irrespective of their
muscle-splitting technique, ie, MTD. Both MED and MTD location, such as posterocentral, posterolateral, intrafo-
use a percutaneous approach through a series of dilators raminal, and extraforaminal, and for subligamentous,
and tubes with a muscle-splitting technique to gain access cephalad, and caudad extrusions.
to the interlaminar space. Percutaneous lumbar discectomy
is a technique where an endoscope is inserted percutane- 3.3 Timing of surgery
ously into the disc space through a posterolateral or trans- All patients must have an adequate period of conservative
foraminal approach for the removal of disc fragments. treatment of at least 3–6 weeks before surgery is advocated.
Relief of radicular pain is the primary surgical indication in
most patients. While urgent intervention is required for
3 Patient selection severe and progressive neurological deficits, there is con-
siderable controversy regarding the relative urgency of
3.1 Patient selection for disc surgery surgery in the face of chronic and static neurological deficits.
“Surgical success in disc surgeries depends approximately However, an absolute surgical indication is the development
10% on technique and 90% on proper patient selection” of cauda equina compression syndrome matched by relevant
[11]. MRI findings. Patients with normal neurological findings
but without pain relief even after an adequate trial of con-
It is important to note that minimally invasive surgery does servative therapy may also be considered for surgical inter-
not change the indications or timing for discectomy. At least
90% of patients with first-time acute disc herniation improve
with conservative treatment. In the absence of an acute,
severe, and progressive neurological deficit, most patients
with lumbar disc herniations and radiculopathy can be suc- Classical symptoms
cessfully treated nonoperatively. In patients with symptoms of nerve root
compression
of more than 6 weeks’ duration, surgery has been demon- Ideal patient
strated to provide a better prognosis with less residual sci- for disc surgery
atica and recurrence [12].
3.2 Indications
An ideal candidate for lumbar microdiscectomy is a patient
that fulfills the triad of classical clinical symptoms(Fig 4.2.2- Comparable Demonstrable signs
6): MRI findings of nerve root tension
• Leg pain more than back pain
• Disc prolapse documented by MRI
• MRI findings for level and side matching the clinical
symptoms
• An MRI finding of a disc prolapse alone is an inadequate Fig 4.2.2-6 Patients with all three features, ie, typical signs and
indication for surgery, as incidental herniated discs are symptoms of nerve root compression with an evident disc prolapse
present in one-third of asymptomatic individuals [13] at the relevant level, are ideal candidates for disc surgery.

vention. Relative indications for surgery include patients ness, simulation and distraction tests, overreaction, and
that express preference for early surgery for reasons of in- nonanatomical regional disturbances) are not suitable
tolerance to pain, or need for early return to work. candidates for any disc surgery [14].
3.4 Contraindications
While there are no absolute contraindications, there are a 4 Pros and cons for microsurgical lumbar disc
few situations where MLD is relatively contraindicated surgery
mainly due to the need for a wide decompression (Table
4.2.2-1). The microsurgical approach (MLD, MTD) to the lumbar disc
• The presence of cauda equina syndrome, or severe neu- has several advantages over standard discectomy and oth-
rological deficits due to a massive central sequestrated er less invasive techniques of discectomy. However, there
disc usually require a wide decompression. A microsur- are also a few inherent disadvantages of microsurgical lum-
gical approach through a fenestration for a huge disc bar discectomy. The advantages and disadvantages of mi-
prolapse in the presence of severe neurological deficits crosurgical discectomy in comparison to other techniques
would entail further damage to the neural structures, are summarized in Table 4.2.2-2.
and hence a wide decompression is advised
• Similarly, a large central disc with significant compres- 4.1 Advantages of the microsurgical approach (MLD,
sion on both sides would necessitate a central fenestra- MTD)
tion and bilateral neural canal decompression • The operating microscope enables magnification and
• Disc herniation in the presence of severe central canal illumination of the surgical field. Hence with a small
stenosis may also entail a wide decompression in the skin incision and minimal damage to the paravertebral
form of a laminectomy. A minimally invasive unilat- muscles, the interlaminar space is clearly exposed
eral fenestration and microdiscectomy in these condi- • The preservation of muscle insertions and the segmen-
tions is difficult, and risks worsening of neurological tal innervation of the paravertebral muscles due to lim-
deficits ited retraction also help in quicker rehabilitation
• Patients in whom the triad of clinical symptoms, clinical • The use of the microscope obviates the need for lami-
signs, and MRI findings do not correlate and who have nectomy and avoids damage to the facet joint, thereby
nonorganic findings evidenced by the presence of at retaining spinal stability
least three of the five Waddell’s signs (superficial tender- • In selected cases at L5/S1 levels, the ligamentum flavum
can be raised as a flap and preserved, thereby reducing
the incidence of postoperative adhesions. The epidural
fat and epidural venous plexus can be preserved
Classical indications Contraindications Relative contraindi- • Exploration of the target disc with limited manipulation
cations
of the nerve root helps to prevent perineural adhesion
Acute progressive neuro- Symptoms not corre- Large disc-causing cauda formation
logical deficits lating with the imaging equina syndrome and a
studies disc prolapse with severe
• Due to the possibility of identification and coagulation
spinal canal stenosis. of epidural veins, better hemostasis and reduced blood
These require extensive loss are achieved
decompression.
• The clear surgical field facilitates gentle handling of neu-
Cauda equina syndrome Primary low back pain ral structures
symptoms in a setting
of minimal pathology • With experience, the operating time can be reduced and
causing the radicular pain the complications are fewer.
Failed conservative ma- Significant nonorganic
nagement for a minimum symptoms and signs After discectomy, suturing the rent in the annulus fibrosus
of 6 weeks (Waddell’s signs [14]) and/or the ligamentum flavum is also possible with micro-
Patient preference—in- discectomy. The former can potentially reduce recurrent
tolerance to radicular disc herniations [15]. Due to less tissue trauma, it can also
pain or inability to invest
time in nonsurgical be performed as an outpatient procedure in selected patients.
management In special situations like recurrent disc herniations, safe
Table 4.2.2-1 Indications and contraindications for micro-lumbar dissection of epidural adhesions, and/or scar tissue is made
discectomy. possible by microdiscectomy. This reduces the risk of ac-
cidental dural tears.
293

Standard discectomy Microsurgical tubular Microsurgical discecto- Microendoscopic Percutaneous endosco-

discectomy (MTD) my (MLD) discectomy (MED) pic discectomy (PED)
Procedural factors
Retractor Tubular retractor Eg, Caspar Tubular retractor None
Surgical instruments Bayonetted microinstru- Microsurgical instruments Endoscope Endoscope
ments
Navigation Preoperative x-ray/image Preoperative x-ray/image Preoperative x-ray/image Preoperative x-ray/image Preoperative x-ray/image
intensification intensification intensification intensification intensification
Surgical exposure 1. Wide exposure 1. Small skin incision 1. Small skin incision 1. Small skin incision 1. Percutaneous stab
2. Good visualization of 2. Surrounding struc- 2. Surrounding struc- 2. Surrounding struc- incision
surrounding structures tures protected by tures protected by tures protected by 2. Structures traversed
retractors retractors tubes by endoscope
Paraspinal muscles Injured during surgical Potentially less damage to • Minimal damage to Potentially less damage to • Least muscle damage
exposure muscles due to muscle- paravertebral muscles muscles due to muscle- • Segmental muscle of
splitting technique • Preservation of splitting technique erector spine is not
muscle insertions and violated
segmental innervation
Bony window Laminotomy needed Obviates need for Laminotomy, potential Facet joints are protected
laminectomy and avoids damage to medial facet
damage to facet joint joints
Magnification and — +++ ++++ ++ ++
illumination of the (microscope) (microscope) (endoscope)
surgical field
Ligamentum flavum Not possible Possible Ligamentum flavum can Very difficult to raise Flavum not violated at all
flap be raised as a flap and a flap
preserved
Hemostasis • Hemostasis is very • Hemostasis around • Better hemostasis due • Hemostasis around • Laser discectomy
difficult the tube is difficult to to identification, co- the tube is difficult to causes very less
• Blood loss is more access and control agulation of epidural access and control bleeding
• Blood loss is less veins • Blood loss is less • Blood loss is least
• Blood loss is less
Annulus repair Very difficult Possible Possible Not possible Not possible
Surgical technique Easy to perform Significant learning curve Significant learning curve Significant learning curve Significant learning curve
Wound infection Less chance Minimal Potential risks ++ Minimal Less chances
Surgical limitations — Tubular retractor may — Tubular retractor may • Difficult to treat cen-
need to be angled to need to be angled to tral disc herniations,
optimize visualization optimize visualization those associated with
foraminal stenosis
• Movement of the
instruments is limited
inside the foramen
• If the disc has
migrated cranially or
caudally, the transfora-
minal approach is not
possible
• At L5–S1 it is
impossible to gain
adequate access and
at the upper levels,
the procedure is quite
demanding
Table 4.2.2-2 Comparison between the different techniques of discectomy.

The “+” symbol indicates the strength of association of a particular feature with the type of surgery. The more "+" symbols, the stronger the association.

Standard discectomy Microsurgical tubular Microsurgical discecto- Microendoscopic Percutaneous endosco-

discectomy (MTD) my (MLD) discectomy (MED) pic discectomy (PED)
Patient factors
Surgical Incision • Long incision • Good cosmesis • Good cosmesis • Good cosmesis • Excellent cosmesis
• Painful (++++) (2.5 cm long scar) (2.5 cm long scar) (2.5 cm long scar) • Stab wound incisions
• Less painful (++) • Less painful (++) • Less painful (++) much less painful
• Advantageous in • Advantageous in
obese patients (good obese patients (good
retraction with mini- retraction with mini-
mal skin incision) mal skin incision)
Hospitalization Longer hospitalization and • Earlier return to work Shorter hospitalization • Earlier return to work • Least period of inacti-
delayed rehabilitation • Day care procedure in period, quicker rehabilita- • Day care procedure in vity
most cases tion, earlier return to work most cases • Outpatient procedure
in most cases
Anesthesia Always under general Usually under general Usually under general Usually under general Carried out under local
anesthetic anesthetic, but can also anesthetic anesthetic, but can also anesthetic
be performed under local be performed under local
anesthetic anesthetic
Surgeon factors
Teaching aid Not possible for two Optimal teaching aid to Optimal teaching aid to Only the surgeon can Only the surgeon can
people to visualize simul- assistants assistants see, feel, and do at the see, feel, and do at the
taneously same time same time
Handling of instru- Direct visualization of Needs hand-eye coordina- Needs hand-eye coordina- Needs hand-eye coordina- Needs hand eye-coordi-
ments field and instruments tion with microscope tion with microscope tion with monitor nation with monitor
Surgery in recurrent Difficult surgery in recur- In surgery for recurrent In surgery for recurrent Difficult surgery in recur- The posterolateral
discs rent discs disc herniations, safe disc herniations, safe rent discs approach does not cause
dissection of epidural dissection of epidural fibrosis along the simply
adhesions and/or scar adhesions and/or scar muscle-dilating approach.
tissue is possible tissue is possible Recurrent surgeries are
easier and safe to do
Visualization of field Unmagnified 3-D view 3-D view through 3-D view through 2-D view but angled Only 2-D view possible
microscope microscope endoscope can also
see medially displaced
fragments
Table 4.2.2-2 (cont) Comparison between the different techniques of discectomy.

The “+” symbol indicates the strength of association of a particular feature with the type of surgery. The more "+" symbols, the stronger the association.
295

The use of the operating microscope enables the assistant 5 Preoperative planning and positioning
to watch simultaneously, assist, and learn the procedure in
a proactive manner. Optimal teaching to assistants due to Detailed preoperative discussion with the patient about the
an unobstructed view of the surgical field is thus possible. goals of surgery, its limitations, and the possible complica-
The use of tubular retractors has been found to be advanta- tions is mandatory prior to obtaining written informed con-
geous in obese patients when compared to open procedures, sent. The discussion should include details regarding the
as the length of the incision, blood loss, operative times, potential risk of injury to neurological structures and pa-
and length of stay are less with the use of tubes [16]. Tubu- ralysis, vessel and visceral injury, accidental dural opening
lar retractors also seem to be associated with a decreased (ADO), wound-related complications, discitis, failure to
infection rate when compared to open surgery [17]. improve symptoms, postoperative intraspinal and perira-
dicular scar-tissue formation, and recurrence of disc pro-
4.2 Disadvantages of the microsurgical approach lapse. Postoperative course, wound care, physical therapy,
• The main disadvantage of a microsurgical approach is and follow-up should also be explained.
the limited visualization of anatomical structures beyond
the field of microsurgical vision. Thus there exists the All patients require AP and lateral x-rays of the lumbosacral
possibility of damaging structures outside the surgeon’s spine. In patients that complain of significant low back pain,
visual field, and hence it is vital to protect important flexion and extension x-rays are taken to identify instabil-
neighboring anatomical structures ity. The sagittal curvature of the lumbar spine, the height
• The microsurgical technique requires good hand-eye of the disc, presence of osteophytes and posterior vertebral
coordination, and hence has a steep learning curve [18] lipping, the degree of degenerative changes, and disc calci-
• A longer period of supervised training is necessary for fication are evaluated in the lateral x-rays. The size and
beginner surgeons before they start performing micro- shape of the interlaminar window is estimated in the AP
surgical procedures view, as it helps to assess the need for laminotomy (Fig 4.2.2‑7).
• Since surgery is performed through a mini-incision, small The presence of a pars defect and facetal laxity augurs the
changes in the angle of dissection can lead to wrong- need for a spinal stabilization.
level surgery
• Since the microscope is handled frequently by the surgeon The MRI is the gold standard investigation for evaluating a
and the assistant during surgery, there is an ongoing risk disc prolapse. If there are any contraindications for an MRI,
of surgical wound contamination. a CT myelogram is performed. Presence of lumbosacral
Fig 4.2.2-7a–b
a The lamina of the superior vertebra
overlaps the intervertebral disc space to
a varying extent. At the L3/4 and L4/5
levels, a laminotomy needs to be carried
out to access the disc space. At the L5/
S1 level, the interlaminar space is wide,
without any lamina overhang.
b AP x-ray of the lumbar spine demonstrat-
S
ing the progressive decrease in size of the
interlaminar space (indicated by dotted
L5 lines) when advancing in the cephalad di-
L3 L4 rection from L5/S1. Also, the interlaminar
angle (indicated by a solid line) is wide
and obtuse at L5/S1 and progressively
becomes more acute at the upper lumbar
levels. This morphological feature of L5/
a b S1 enables adequate access to the disc
space without the need for a laminotomy.

transitional vertebrae can potentially lead to wrong-level 5.1 Positioning

surgical exploration. In such cases, the lateral x-ray or the The optimal position for MLD should widen the interlami-
lateral image intensifier image should be compared with nar space to allow easy surgical access to the disc. This is
the MRI sagittal views and the correct level identified maximally achieved by obtaining a kyphotic curvature of
(Fig 4.2.2-8). The MRI also provides information regarding the lumbar spine through a knee-chest position with an
the foramen, lateral recess, and spinal canal, if they need Andrews’s table or Wilson frame. However, the authors
to be addressed during the procedure. Caution should be prefer the use of a Relton-Hall frame for reasons of less time
taken when there is congenital absence of posterior bony consumption, ease of positioning, and better patient comfort
elements or if there is a conjoined nerve root. If the nature (Fig 4.2.2-9). Obese patients, those with hip or knee stiffness,
of symptoms has changed recently, or if more than 6 months or a prosthesis could also be positioned easily on a Relton-
have elapsed since the MRI examination, a fresh MRI should Hall frame avoiding a knee-chest position. The abdomen
be obtained. Patients with a previous history of surgery should be left free to avoid pressure on the inferior vena
should have a gadolinium-enhanced scan to differentiate cava, which would increase epidural venous bleeding dur-
scar tissue from recurrent disc material. Detailed examina- ing the procedure. The hip and knee joints are flexed to just
tion of the disc location is necessary for planning the op- more than 70° in order to ensure venous drainage from the
erative strategy, as described previously. lower extremities, and thus reduce the risk of deep venous
thrombosis. The eyes, chin, forehead, breasts, anterior su-
Patients should have a complete medical workup, and their perior iliac spine, anterior thighs, knee joints, and the pa-
fitness for a general anesthesia should be assessed. Micro- tella must be well-padded to prevent pressure sores. In men,
surgical lumbar disc surgery is performed under general the testicles must be free of any compression. The arms are
anesthesia in a prone position, as described below. abducted at the shoulder joint and the forearm is flexed to
about 90° and well-padded to protect the radial and ulnar
nerves. The neck must be placed in a neutral position while
turning the patient to the prone position. This is especially
important in elderly patients that have coexisting degen-
erative changes in the cervical spine, where hyperextension
and extreme neck rotation can lead to severe cervical spinal
cord compromise.
a b c d
Fig 4.2.2-8a–d Procedure for avoiding the risk of wrong-level surgery: the presence of a lumbosacral
transitional vertebra could potentially confuse the surgeon.
a–b Comparison between the lateral x-ray and the MRI sagittal view enables the correct level to be identified.
c–d The sagittal MRI view is placed horizontally, and compared with the disc space orientation on the lateral
C-arm image. This ensures the exact identification of the correct level.
297

After the patient has been positioned prone, the spine is 5.2 Localization of the level of surgery
aligned parallel to the floor by adjusting the table. Before The authors recommend the use of an image intensifier for
marking the surgical incision, a first-generation cephalo- localization of the surgical level before the skin incision is
sporin such as 1 g of injectable Cefazolin or 1.5 g of injectable made. Because of the small size of the incision, meticulous
Cefuroxime is administered as an intravenous bolus dose. attention should be paid to confirming the appropriate sur-
When administered at this stage, the drug reaches appropri- gical level.
ate peak serum levels at the time of surgical incision.
Imaging, preferably by a C-arm, is performed at three stag-
es during the surgical procedure to avoid wrong-level surgery
(Fig 4.2.2-10).
a b
Fig 4.2.2-9a–b
a The patient is placed prone on a Relton-Hall frame. Note that the abdomen is hanging
free without any pressure, and the superficial bony points have been adequately padded.
b Lateral image intensification of the lumbosacral spine with the level-marking needle
inserted into the subcutaneous space (red arrow). The table is tilted appropriately to
ensure that the surface of the low back region is parallel to the floor and the needle
is inserted perpendicular to the skin surface, directed towards the disc space to be
treated.
a b c
Fig 4.2.2-10a–c Lateral image intensifier views indicating the three different stages of surgery
where localization of the correct level is essential in order to avoid wrong-level surgery.
a For accurate localization of the disc space, the first image is taken with the needle pointing to
the disc space, as shown by the arrow.
b The second lateral image intensifier view is taken after exposing the interlaminar space with
an instrument placed under the lamina of L5 (arrow).
c The final image is taken after discectomy with a probe placed inside the disc space. This
image ensures that the procedure has been performed at the correct level.

1. After positioning the patient, the first localization step 5.3 Surgical microscope and microsurgical
is performed to mark the appropriate incision. A hypo- instruments
dermic needle is used to locate and mark the skin inci- In planning this procedure, the microscope for spine surgery
sion exactly over the disc space to be operated. should include the following features:
2. A wrong level can potentially be approached following • Motorized adjustment of the focus and zoom (with
a mini-incision if the wrong trajectory is taken to perform separate control for the surgeon and the assistant)
the dissection (Fig 4.2.2-11). This is avoided by the second • Symmetrical stereo bridge that provides similar images
localization step which is made after exposing the in- in both eye pieces. These features enable the surgeon
terlaminar space with a probe placed under the supe- and the assistant to stand on opposite sides of the surgi-
rior lamina. Confirmation of the correct level before cal field and independently control the microscope with
performing a laminotomy or flavotomy is mandatory in active participation during surgery
MLD. • Binocular adjustable tubes with rotatable adapters
3. The final image is optional, and can be taken at the end • An optical system with a focal length of 400 mm. This
of the surgical procedure with an instrument at the disc ensures a good working space for the use of long-handled
level, to confirm the exact level that has been operated instruments over the surgical field.
on. This is particularly necessary in patients for whom
the intraoperative findings do not match the preopera- Apart from this, the other desirable features of an operating
tive images. The final image can also be of medico-legal microscope include:
value when symptom recurrence is attributed to surgery • Easy options for adjusting the interpupillary distance
at the wrong level. • Homogeneous and coaxial illumination system
• Highly modular, easily maneuverable suspension system
• Touch screen with display
• Quick autofocus system
• Foot control panel to adjust the focus and zoom
• Video attachments for teaching and recording purposes.
Specialized microsurgery retractors are essential to provide

adequate tissue retraction and working space for handling
neurostructures and performing discectomy. Different types
of tissue retraction system are available, such as the Caspar,
Williams, and McCulloch systems. The authors prefer the
use of a McCulloch retractor for its modularity, versatility,
and ease of application (Fig 4.2.2-12). The surgeon would
Fig 4.2.2-12 A Mc-

Culloch retractor used
Fig 4.2.2-11 Even when using the same skin incision, a small change for MLD. The McCull-
in the direction of dissection and the angle of the microscope, can eas- och retractor is fitted
ily direct the surgeon to the wrong adjacent level. The circle indicates with a medial hook
the surgical incision and the two arrows indicate that with the same for placement on the
incision, it is possible to access both L4/5 and L5/S1 levels with a slight interspinous ligament
change in the angle of dissection. Hence, extreme care should be taken and a lateral retractor
when placing the incision during dissection, and in the positioning of blade for retracting the
the microscope. paraspinal muscles.
299

also need a set of Kerrison rongeurs of various sizes with proximally or distally, the incision is placed appropriately.
standard and thin foot plates, disc forceps with straight and Once the needle position has been confirmed, a 2 to 2.5 cm
angled tips, nerve-root probes, and root retractors. A high- longitudinal line is drawn to mark the incision on the mid-
speed burr system and a fine-tipped bipolar cautery are also line (Fig 4.2.2-13).
required in cases where there is a need for bone removal
and to obtain hemostasis. Bayonet-shaped and angulated 6.1.2 Deep dissection
instruments and tools are essential to keep the surgeon´s The skin and the subcutaneous tissue are cut along the line
field of vision as free as possible. of the planned incision. The subcutaneous fat is separated
with a monopolar diathermy using an insulated tip to avoid
5.3.1 Loupe-assisted microdiscectomy contact with the skin. Skin and subcutaneous bleeders are
Some surgeons prefer the use of head lamps and optical meticulously cauterized to prevent blood from constantly
loupes instead of an operating microscope, with equivalent tricking into the wound. The thoracolumbar fascia is then
clinical results. However, this procedure has the disadvan- incised longitudinally between the spinous processes with
tages of inadequate visualization of the operating field by a monopolar cautery in the midline. Alternatively, this can
the assistant, poor facility for training the assistant, and the be performed a few millimeters from the midline to provide
constraints of fixed focal length and working distance. a fascial cuff to safeguard the interspinous and the supra-
spinous ligaments. The medial part of the fascia is then
gently lifted with a forceps, and the paraspinal muscles are
6 Surgical technique elevated from the spinous process and the lamina with the
help of Cobb elevators or by finger dissection. As the para-
6.1 Microsurgical lumbar discectomy spinal muscles are swept laterally, they are retracted away
from the field using a McCulloch retractor blade. The authors
6.1.1 Skin incision use a broad McCulloch retractor blade laterally, and a hook
The skin is prepared with an aqueous solution of Betadine is placed on the interspinous ligaments to expose the inter-
and a hypodermic needle is passed perpendicular to the laminar space (Fig 4.2.2-14). The hook retractor on the me-
skin at the presumed level of the disc space, as described dial side must be one size smaller than the lateral retractor
earlier. Multiple needles can be used to avoid multiple ex- blade to avoid penetration into the canal and damage to
posures. It is advisable to insert the needle on the contra- the dura. Once the retractor blades are open, the origin of
lateral side of the discectomy, as this avoids hematoma short rotators from the inferior margin of the lamina can
formation on the surgical side or the direct introduction of be divided sharply with monopolar diathermy. Once the
infection into the wound. Once the needle position has interlaminar space is visualized and the edges of the supe-
been established as satisfactory on a lateral image intensi- rior and inferior laminae are seen, a probe is placed under
fier view, the skin incision is marked between the upper the superior lamina and a lateral image intensifier image is
and the lower spinous processes. If the disc has migrated taken to confirm the appropriate level.
RB La
LF
Ce Lm Ca
RH
Me
Fig 4.2.2-13 The first step in the microdiscectomy procedure. A small Fig 4.2.2-14 Step two in the microdiscectomy procedure. The L4/5
skin incision (3 cm) is placed about 5 mm from the midline centered interlaminar space has been exposed unilaterally with the McCulloch
over the disc space. The position of the incision needs to be adjusted retractor in place. The upper and lower lamina are visualized with the
according to the level of the disc prolapse, and according to whether the intervening ligamentum flavum.
disc has migrated superiorly or inferiorly. Ce: cephalad; Ca: caudad; Me: medial; La: lateral; Lm: lamina;
LF: ligamentum flavum; RH: retractor hook; RB: retractor blade.

The operating microscope can now be brought into the field. 6.1.4.1 Midline entry
Adequate working space should be available between the The authors prefer to incise the ligamentum flavum longi-
surgical field and the microscope. The operating microscope tudinally close to the midline using a No15 blade knife along
should have a focal length of 400 mm to ensure a good the direction of the fibers. As the superficial layers are cut,
working space between the lens and the surgical wound. a tissue forceps is used to hold the cut fibers taut while the
This allows the surgeon to safely use long surgical instru- deeper layers are cut. The knife is moved in a caudal to
ments without touching the lens, thereby reducing the risk cranial direction with the blade facing upwards to avoid
of wound infection. accidental entry into the spinal canal. As the deepest layers
of the ligamentum flavum are cut, epidural fat bulges into
6.1.3 Interlaminar space at different vertebral levels the wound, confirming entry into the canal. The dissector
At the L5/S1 disc space, the ligamentum flavum usually is then passed between the epidural fat overlying the dural
overlies the thecal sac at the level of the disc space and there sac and the undersurface of the ligamentum flavum to re-
is no need to remove any lamina. However, when moving lease any adhesions. Once the flavum has been incised, a
in a cephalad direction, the disc space is located more prox- 3 mm Kerrison rongeur is used to complete the flavectomy.
imally in relation to the interlaminar space, and exposure
of the disc space may require removal of the edge of the 6.1.4.2 Lateral entry
lamina (Fig 4.2.2-7). The ligamentum flavum can be kept Another zone of entry into the spinal canal is the inferior
intact to protect the dura during the laminotomy. Sometimes lateral corner (4 o’clock) of the interlaminar space, near
bone from the medial aspect of the facet may need to be the inferior facet. Entry at this level leads the surgeon be-
removed to achieve adequate lateral exposure. Herniated tween the layers of the ligamentum flavum. The neural
fragments can migrate, either cranially or caudally, neces- structures are deep-seated and medially situated at this
sitating enlargement of the bony window. While removing point, and hence it is safe to start the flavectomy with a 2
part of the superior lamina, care should be taken not to mm Kerrison rongeur. As the outer layers of the flavum are
resect the isthmus or the pars interarticularis, which might resected, a blunt microdissector probe (eg, Watson Cheyne)
result in segmental instability. The facet joint must also be is used to enter the inner layers. The probe is moved cra-
protected. niocaudally in a gentle manner, dissecting through the fla-
vum. The hook side of the probe is then passed under the
6.1.4 Entry into the spinal canal flavum to release any adhesions between the flavum and
Different methods have been described to enter the spinal the thecal sac. A 3 mm Kerrison rongeur is used to complete
canal by dividing the ligamentum flavum (Fig 4.2.2-15). the flavectomy. This kind of preparation minimizes the risk
of perforating the dura. Care should be taken when remov-
ing the ligamentum flavum from the lateral aspect as it
continues with the medial facet-joint capsule. But in cases
La with a huge extruded fragment, the traversing nerve root
is pushed posteriorly towards the flavum near the lateral
recess. In such instances, removal of the medial edge of the
Lm ligamentum flavum with the Kerrison rongeur can catch
LF
Ce Ca the nerve root. The authors consider that this complication
can be avoided when the ligamentum flavum is opened
near the midline.
Me
The epidural fat can then be teased out of the way with a
Fig 4.2.2-15 Step three in the microdiscectomy procedure. The dif- dissector, and any epidural vein cauterized with bipolar
ferent techniques of opening the ligamentum flavum (LF) are shown. coagulation and cut sharply with microscissors. Excessive
An incision (dashed line) can be placed near the midline, then the
removal of the epidural fat should be avoided to prevent
flavotomy is completed. Alternatively, the flavum can be opened at the
inferolateral margin near the facet joint.
adhesions and scarring.
Lm: lamina; Me: medial; La: lateral; Ce: cephalad; Ca: caudad.
301

6.1.5 Ligamentum flavum flap sequestrated free disc fragment can be gently mobilized
At the L5/S1 level, the interlaminar space is usually suffi- with the help of the probe and removed. At this stage, if
ciently wide, thus facilitating the preservation of the liga- an overhang of the lamina, ligamentum flavum, or the
mentum flavum as a flap. This flap is raised by detaching superior articular facet is found to obstruct the view or
the flavum on three sides (superior, inferior, and medial or access, these can be undercut with the Kerrison rongeur.
lateral) and leaving the fourth side attached, either medi- At the L5/S1 level, a layer of epidural fat covers the nerve
ally or laterally (Fig 4.2.2-16). At the end of surgery, the flap root. Care should be taken to avoid unnecessary coagula-
can be placed back over the thecal sac, thus preventing the tion of these structures. Since the dorsal root ganglion is
formation of adhesions. usually situated within the neural canal at this level, exces-
sive coagulation can lead to severe postoperative neuritic
6.1.6 Identification of neural elements pain.
The epidural space is explored to identify the neural struc-
tures. The medial border of the dural sac, the shoulder of Once the lateral edge of the nerve root is clearly visible, the
the nerve root, and the lateral margin of the nerve root are nerve root retractor or the nerve root probe is passed later-
identified. Nerve root anomalies are rarely observed, and ally just beneath its shoulder and retracted slowly. As the
more than one nerve root may be encountered in the lat- nerve root is retracted, the disc bulge, covered by epidural
eral recess (Fig 4.2.2-17). After identifying the lateral border veins, becomes evident. The veins are either gently dis-
of the nerve root, the surgeon should ensure by gentle sected off or cauterized by bipolar cautery and cut with
probing that no anomalous nerve roots are situated further micro-scissors (Fig 4.2.2-18). If there is any undue difficulty
laterally. The lateral gutter is probed from cephalad to cau- in retracting the nerve root, the possibility of disc herniation
dally to avoid entering the axilla of the nerve root. Any at the level of the axilla should be considered.
S1 L5
LF L5 S1
Ce Ca
Lm
Th
Fig 4.2.2-16 Step four in the microdiscectomy procedure. Ligamentum Fig 4.2.2-17 T1 axial MRI view showing nerve root anomaly at the
flavum flap: the ligamentum flavum has been raised as a laterally-based L5/S1 level. The L5/S1 nerve root has a common origin, with the
flap, and is held with a forceps by the assistant. bifurcation occurring distally. Both the nerve roots are shown in the
Lm: lamina; La: lateral; Ce: cephalad; Ca: caudad; Th: thecal sac; LF: same axial image.
ligamentum flavum.
La
Ce Ca
Fig 4.2.2-18 Step five in the microdiscectomy procedure. Nerve root
retraction and exposure of disc bulge. The thecal sac and the nerve root
(white arrow) have been retracted with a nerve root retractor, exposing
the disc bulge (blue arrow).
Du La: lateral; Me: medial; Du: nerve root retractor; Ce: cephalad;
Me Ca: caudad.

6.1.7 Disc excision can result in increased postoperative pain and also a high-
er incidence of discitis. If a large extruded fragment is pres-
6.1.7.1 Annular incision ent, care must be taken to remove it in one piece by ap-
If there are no free disc fragments, the surgeon can proceed plying gentle but constant pressure to the base rather than
with exposing the disc bulge. The posterior longitudinal the tip, and going over the fragment until the last loose
ligament is stretched over the annulus. A cruciate incision piece is removed. During the procedure, it is important
(Fig 4.2.2-19) is placed with the blade always facing away to intermittently release the tension on the nerve root
from the thecal sac to avoid accidental neurological injury. retraction.
As the annulus is incised, the disc material under pressure
usually protrudes through the opening (Fig 4.2.2-20). Before 6.1.8 Nerve root decompression
using the disc forceps to remove the disc material, it is Disc surgery is essentially nerve-root decompression surgery,
useful to use a probe or a McDonalds retractor to gently and so the endpoint of MLD is to achieve an adequately
push the disc from outside, just medial to the cruciate inci- decompressed root. This should be confirmed by determin-
sion. This will increase the pressure on the disc and push ing the free mobility of the nerve root and probing the nerve
out more material, and thus facilitate the discectomy. When root canal. A final check is made before closure for any free
using the disc forceps, it is important to keep the teeth of fragments at the disc level medially, at the pedicle levels
the forceps closed before entering the disc space. The au- cephalad and caudally. The exiting nerve root running un-
thors recommend the use of William’s disc rongeurs, as der the pedicle should also be probed and decompressed
they have teeth that can grip the fragments better. The with a 2 or 3 mm Kerrison rongeur, if necessary. The pres-
teeth are opened as wide as possible inside the disc space ent authors do not routinely repair the annular opening,
to grab the free disc fragments and grip them very tightly place a fat graft, or use steroids over the nerve root
before gently pulling them out. Large disc fragments must (Fig 4.2.2‑21). When there is a large sequestrated fragment
not be forcibly pulled out, as this may result in inadvertent with an opening in the annulus, they do not routinely ex-
neural injury. The authors do not recommend the use of tend this opening, if removal of the sequestrated fragment
curettes in the disc space or scraping the end plates, as this ensures that the nerve root is free.
LF
Th
La
Th
Nerve root
Du
probe
Fig 4.2.2-19 Step six in the microdiscectomy procedure. Annular Fig 4.2.2-20 Step seven in the microdiscectomy procedure. Disc
cruciform incision. After retracting the thecal sac (Th) and the traversing prolapse: as the annulus fibrosus is incised, the prolapsed disc (arrow)
nerve root with a nerve root retractor, the annulus fibrosus is incised protrudes out under pressure.
with a No 11 blade knife in a cruciform manner (red cross) to perform La: lamina; Du: nerve root retractor; Th: thecal sac; LF: ligamentum
the discectomy. flavum.
La
Ce Ca
Fig 4.2.2-21 Photograph taken postdiscectomy. The disc

space (blue arrow) is visible after performing the discectomy.
Du
La: lateral; Me: medial; Du: nerve root retractor;
Me Ce: cephalad; Ca: caudad; white arrow: nerve root.
303

6.1.9 Hemostasis and wound closure 6.2 Far lateral discectomy

After discectomy, good hemostasis is achieved by bipolar The term “far lateral” refers to the prolapse of a lumbar disc
cauterization. Unidentifiable bleeding should be managed in the extraforaminal zone, and which compresses the ex-
with cottonoids or Surgicel for a few minutes, but these iting nerve root. About 6–10% of all lumbar disc prolapses
must be removed before closing the wound. In most cases, fall under the far lateral category. When approaching
the bleeding invariably stops with time. If a ligamentum through an interlaminar window, the full exposure of the
flavum flap has been raised, this can be placed back over exiting nerve root and the prolapsed disc requires total re-
the thecal sac (Fig 4.2.2-22). The thoracolumbar fascia is closed section of the facet joint. As this would affect the stability
with continuous absorbable No1 Vicryl and the subcutane- of the motion segment, it has led to the development of an
ous layer is closed with resorbable undyed sutures. The skin intertransverse approach to expose the nerve root by a
is closed with a monofilament resorbable subcutaneous muscle splitting, paramedian approach (Fig 4.2.2-23).
suture.
6.2.1 Technique of far lateral discectomy
6.1.10 Microsurgical lumbar discectomy in recurrent disc The patient is positioned prone over the Relton-Hall frame
prolapse or padded bolsters as for a standard microdiscectomy. The
In the case of microdiscectomy for a recurrent disc prolapse, pedicles and the transverse processes of the corresponding
the superior lamina is partially removed to reach the prox- vertebrae are marked on the side of the disc prolapse. About
imal attachment of the ligamentum flavum and entry into two finger breadths lateral to the midline, a 4 cm long vertical
the spinal canal is made superiorly and then laterally. This incision is placed between the two facet joints (Fig 4.2.2-24a).
reduces the risk of accidental dural opening and nerve root The deep fascia is incised in line, and the plane between the
injury. Unlike a primary microdiscectomy, the midline is multifidius and longissimus muscles is developed to reach
accessed last of all, where epidural scarring and adhesions the intertransverse region (Fig 4.2.2-24b). The muscle fibers
could be present. Recurrent disc herniations can also be are swept off the intertransverse membrane with a Cobb’s
approached using MTD [19]. elevator (Fig 4.2.2-24c). Use of an operating microscope from
La
Flap
Ce
Ca
Fig 4.2.2-22 After discectomy, the flap has

been placed back. The white line indicates the
superior and inferior lamina margin.
La: lateral; Ce: cephalad; Ca: caudad.
a b
Fig 4.2.2-23a–b L5 Longissimus
a Far lateral disc prolapse compressing the exiting nerve root. and Iliocostal
b The Wiltse’s paraspinal approach to a far lateral disc Multifidus
herniation. Through a paramedian incision, the plane between Psoas major
the multifidus muscle and the longissimus and iliocostalis
muscles is developed to reach the intertransverse region.

this stage enhances visibility and improves the surgical out- 6.3 Microdiscectomy through tubular retractors
come. The medial branch of the posterior ramus of the spinal Microdiscectomy can be also performed through tubular re-
nerve can be identified near the facet joint. This can be traced tractors, ie, by the MTD procedure. Here image intensification
across the intertransverse membrane to reach the nerve root. is used more frequently, and the operating theater personnel
Alternatively, the intertransverse membrane can be incised should wear lead aprons throughout the procedure.
to expose the nerve root as it traverses through the psoas
muscle fibers. The disc is found lying just medial to the exit- The tubular retracting system consists of multiple dilators,
ing nerve root (Fig 4.2.2-24d). Care should be taken not to use working port retractor, clamp, and a snake holder (Fig 4.2.2‑25).
cautery close to the nerve root or retract the nerve root ex- The light cable is attached to the retractor and secured with
cessively. The prolapsed disc is removed with disc forceps. a clamp that is attached to the contralateral side of the op-
After discectomy, the muscles are allowed to fall back and erating table. Suction tubing is then connected to the aspi-
the deep fascia is closed. The postoperative rehabilitation ration port. The surgeon stands on the side of the pathology
protocol is similar to that for a standard lumbar microdiscec- that is to be treated, with the assistant. The scrub staff is also
tomy. Some surgeons prefer MTD or MED for the treatment positioned on the same side. The image intensifier and mon-
of far lateral disc herniations [20, 21]. itor are positioned at the foot end of the patient and the
microscope is brought from behind the surgeon.
L4 facet joint L5 facet joint
Longissimus
IT membrane
Multifidus
a b c
Medial
Disc
Fig 4.2.2-24a–d Steps in far lateral discectomy.
a The skin incision (dashed line) has been marked about 3 cm from the
Nerve root midline (dotted line) between the superior and inferior facet joint.
b The plane between the longissimus and multifidius muscles has been
developed to reach the intertransverse region.
c The intertransverse membrane (IT) has been exposed between the two
Lateral spinous processes.
d The intertransverse membrane has been excised, and the nerve root with
d the disc prolapse can be seen.
Fig 4.2.2-25a–c
a–b Several dilators of increasing
diameter are used to split
through the lumbodorsal
fascia to reach the interlami-
nar space.
c After dilation through the
fascia and muscle, the
retractor system is attached
to the snake retractor tube,
which in turn is fixed to the
a b c operating table.
305

A small incision is made 1.5 cm from the midline over the weeks to check their wound and general physical ability.
disc space of interest. A blunt dilator that is provided with Most patients return to work at any time between 3–6 weeks
the retractor system is passed perpendicularly over the in- postsurgery depending on the intensity of their work. The
cision until a bony surface is encountered. A K-wire should authors generally recommend a period of reduced activity
be avoided during this step, due to risk of dural and nerve for up to 2 months in the case of heavy manual labor. Iso-
injury. The intention is to touch the facet complex over the metric exercises can be started 2 weeks postsurgery.
disc space laterally and not to advance medially to avoid
entry into the interlaminar space. A lateral image intensi-
fier view is taken to confirm that the dilator is sitting on 8 Evidence-based results
the facet complex. Once the position is satisfactory, the skin
incision is extended to about 2 cm, and then the dilators As with any other new surgical intervention, spine micro-
are passed with a twisting motion to avoid undue pressure surgery was initially viewed with much skepticism. Subse-
and plunging. This splits the thoracolumbar fascia and the quent to Yasargil’s [22] and Caspar et al’s [23] initial series
muscles. Image intensification is used to confirm that the in which they carried out microdiscectomy with good clin-
dilators are positioned directly on the bone, with no inter- ical results, in 1978 Williams [24] introduced the idea of a
vening soft tissue. The working diameter can be dilated smaller incision, the use of special retractors, and selective
from 16 up to 22 mm. Once the working channel has been sequestrectomy instead of total discectomy. His clinical out-
secured with the snake retractors, the whole working chan- comes also showed good results. In the ensuing years, sev-
nel is then directed medially, pointing to the lamina and eral authors presented their retrospective analysis of mi-
spinous process. The microscope is brought inside the field, crodiscectomy results, with clinical success rates in these
and the soft tissues bulging through the tubular retractor series varying from 76% to 100% [25–28]. Comparative
are cleared to identify the bony landmarks. The edges of analyses of microsurgical discectomy and macrodiscectomy
the lamina are identified and the interlaminar space is de- showed that the major advantages of microsurgical tech-
fined. A burr or a Kerrison rongeur can then be used to niques were shorter operating time with increasing experi-
partially remove the hemilamina in the form of a hemi- ence, less blood loss, shorter hospital stay, and earlier return
laminotomy and the medial facet. From here onwards, the to work (Table 4.2.2-3). Recent studies have demonstrated
steps are very similar to those for the MLD technique de- better outcomes in terms of shorter operating time, fewer
scribed earlier. Alternatively, an endoscope with camera intraoperative complications, and a reduced rate of reher-
attachments can be used to perform the discectomy (MED). niation in patients that underwent a sequestrectomy only
The advantage of the endoscope is the use of the 30° angu- as compared to those that underwent a sequestrectomy and
lation to deal with any disc fragment lying medially beneath disc exploration as well. In the series of Barth et al [29], the
the thecal sac. After the discectomy has been performed, reherniation rates were similar at 2 years in both groups,
the whole working assembly is removed and the skin is but during the 2-year observation period the patients in the
closed up in standard fashion. microdiscectomy group showed declining clinical results
(analgesic use, improvement of neurological deficits, per-
formance) in a questionnaire-based self-rated assessment.
7 Postoperative care
Initial criticisms had been made about prolonged operating
Postoperative pain is managed with oral analgesia. Very times and higher incidence of wrong-level surgeries associ-
occasionally, morphine administered as patient-controlled ated with microsurgical procedures. Although the actual
anesthesia pump is used for microdiscectomy. Patient mo- time spent using the microscope is less, the time it takes to
bilization is allowed 3–4 hours after surgery depending on drape and position the microscope in the surgical field does
individual pain tolerance and level of consciousness. Early require an experienced team. However, with careful preop-
mobilization reduces the need for deep venous thrombosis erative surgical planning and experience, the time involved
prophylaxis. When this procedure is performed as a day in performing surgery and the incidence of wrong-level ex-
case, patients can go home at any time after 4 hours when plorations can actually be reduced [30]. The contention that
they are fully conscious and their pain is tolerable. Clear microdiscectomy is associated with fragments that have been
oral and written instructions are given to avoid strenuous overlooked and thus achieved poorer outcomes, has also
activity including twisting, lifting weights of more than 10 been disproved [31]. With microsurgical techniques, the rate
kg, or forced bending for 1–2 weeks to avoid early recur- of severe intraoperative complications is actually decreased
rence. A doctor or a nurse again reviews the patients at 3–6 as compared to standard techniques.

In recent years, as an alternative to microdiscectomy, the results of microdiscectomy using tubular retractors to con-
minimally invasive technique of transmuscular microsurgi- ventional microdiscectomy, the results were contradictory.
cal tubular discectomy (MTD) has been introduced. It is The results at 1 year showed superior outcomes following
based on the rationale that with the use of muscle-splitting conventional microdiscectomy compared to tubular discec-
tubular retractors there is less tissue damage, which should tomy. Moreover, tubular discectomy resulted in less favor-
result in a faster recovery rate with similar long-term out- able results for patient self-reported leg pain, back pain,
comes. However, in a randomized controlled trial involving and recovery [7].
328 patients reported by Arts et al [7], who compared the
Procedure Standard discectomy versus micro- Standard discectomy versus micro- Microsurgical tubular discectomy
surgical discectomy (MLD) (a) surgical discectomy (MLD) (b) (MTD) versus microdiscectomy (c)
Study design Prospective randomized Prospective, nonrandomized Multicenter prospective randomized
Parameters Standard MLD Standard MLD MTD MLD (loupe

magnification)
Patients per group 62 57 225 36 167 161
Surgical duration (minutes) 40±12 45±8 (S) NS 47 ± 22 36 ±16 (S)
Blood loss 39±11 g 25±9 g (S) Significantly less in microdiscectomy 150 ± 90ml 135 ± 85 ml (NS)
Hospital stay (days) 8.3±0.8 8.5±2.3 (S) 5.9 ± 3 6.0± 2.8 (NS) 3.3± 1.2 3.3 ± 1.1 (NS)
Analgesic need NS Not assessed Not assessed
Muscle damage/need for analgesics NS Not assessed Not assessed
Postoperative back pain Significantly more in standard VAS 4.4 ± 2.7 4.5 ± 2.9 (NS) Significantly less pain in MLD
discectomy
Leg pain improvement Significantly better in microdiscectomy VAS 7.6 ± 1.7 6.9 ± 2.5 (NS) Significantly more improvement in MLD
Complications NIL 2 recurrences 2.8% 2.2% (NS) 20 13 (NS)
Short-term results Not assessed No significant difference No significant difference
Long-term results 77% good 77% good Leg pain significantly better 69% 79% (S)
Table 4.2.2-3 Evidence-based results of three prospective trials comparing standard discectomy,
microdiscectomy, and microendoscopic discectomy techniques.
S: statistically significant, NS: not statistically significant, VAS: visual analog scale.
a) atayama Y, Matsuyama Y, Yoshihara H (2006) Comparison of surgical outcomes

K
between macrodiscectomy and microdiscectomy for lumbar disc herniation: a
prospective randomized study with surgery performed by the same spine surgeon.
J Spinal Disord Tech; 19(5):344–347.
b) Porchet F, Bartanusz V, Kleinstueck FS (2009) Microdiscectomy compared with
standard discectomy: an old problem revisited with new outcome measures within the
framework of a spine surgical registry. Eur Spine J; 18 Suppl 3:S360–S366.
c) Arts MP, Brand R, Akker ME, et al (2009) Tubular diskectomyvs conventional
microdiskectomy for sciatica: a randomized controlled trial. JAMA; 302(2):149–158.
307

9 Complications and avoidance avoid bleeding is to position the patient in such a way that
he/she has a pressure-free abdomen. Unnecessary fiddling
The complication rate for microsurgical discectomy ranges and wandering away from the disc space, especially around
from 1.5 to 15.8% [7, 17, 18, 22, 32]. The complications may the posterior aspect of the vertebral body, can cause stretch-
be intraoperative, occur during the immediate postoperative ing and bleeding of the epidural veins. During discectomy,
period, or in the late postoperative period after discharge. the teeth of the rongeurs should be kept closed before en-
Although most complications are only minor, they can still tering the disc space to avoid catching any epidural vein.
have an influence on patient recovery and the long-term
outcome. Epidural veins are encountered near the lateral recess and
medially behind the thecal sac. Epidural veins near the lat-
9.1 Intraoperative complications eral recess are seen crossing over the disc space, and should
Most intraoperative complications can be avoided by paying be cauterized with bipolar cauterization. If the bleeding
careful attention to detail, including an awareness of any vessel cannot be identified, firm packing with a small cot-
anatomical variations in the lumbar spine, and radiological tonoid or a Surgicel will control the bleeding. The use of
knowledge regarding the location of the disc and its con- Gelfoam or thrombotic agents (eg, Floseal) should be avoid-
nection with the symptoms in question. The availability of ed, as they can swell up and cause neurological deficits.
appropriate instrumentation and the good working condi- Bleeding from the medial epidural veins is problematic and
tion of the microscope and image intensifier should be risky, if an attempt is made to arrest it by cauterization or
checked at the preoperative stage to avoid subsequent frus- packing. It is advised that the surgeon proceeds with the
tration or delays. discectomy, the bleeding then usually stops when the nerve
root retraction is released.
9.1.1 Positioning
When placing a patient in the knee-chest position, care 9.1.4 Accidental dural opening
must be taken to avoid pressure on superficial bony regions The incidence of ADO in a lumbar discectomy varies from
and nerves. The arms, elbows, knees, and ankles must be 1–2% [32]. Cerebrospinal fluid (CSF) leakage following a
well padded to prevent neural compression of peripheral microdiscectomy is an infrequent occurrence in experienced
nerves. The anesthetist should take care to adequately pad hands. Dural tears are more likely to occur in revision sur-
the patient’s face, and avoid hyperextension of the neck gery, in the case of elderly patients, and when the surgeon
especially in the elderly who may suffer from coexistent is less experienced. CSF leakage can lead to pseudomenin-
cervical degeneration. gocele formation, and this should be prevented by the im-
mediate recognition and repair of a dural tear whenever
9.1.2 Wrong-level surgery possible. The majority of dural tears are evident at the time
Wrong-level surgery is a potentially dangerous complication of surgery. Although the overall outcome of the patient
for both patient and surgeon, but is nevertheless avoidable. would not be adversely affected by this complication, it
In a group of less experienced surgeons, the risk was found could cause meningitis, delay in wound healing, wound
to be 3.3% as compared to a risk of 1.2% (P < .01) for very infection, headache as a result of CSF depletion, or delayed
experienced surgeons [32]. For the patient, wrong-level sur- pseudomeningocele formation. ADO can occur at the time
gery can result in the persistence of symptoms, need for of entry into the ligamentum flavum, when it is very thin
revision surgery, and the risk of degeneration of a healthy or adherent. It can also happen when the disc is very large,
disc at the operated level. For the surgeon, this is a potential with the ligamentum flavum thinned out, and the dura in
scenario for litigation and stress. The only way to avoid this close proximity to the flavum. Accidental dural opening
is by strict adherence to the step-by-step radiological local- commonly occurs in the midline, but in microdiscectomy
ization of the target level during the operative procedure, it can occur on the lateral side of the thecal sac, which makes
as outlined previously. The side where the pathology is pres- repair difficult.
ent should also be clearly marked before the patient is
brought into the operating theater, and both the level and The management of dural tears is controversial. When the
the side must be reconfirmed during the time-out procedure. dural breach is small or has not been visualized properly,
it can be managed conservatively by a watertight wound
9.1.3 Epidural bleeding and hematoma closure alone. If it is of reasonable size, primary suturing is
Epidural venous bleeding can obscure visibility during sur- advised. Sometimes Hydrogel sealants are used, but care
gery, and lead to potential complications. The first step to must be taken to use them in moderate amounts to prevent

the risk of cauda equina compression caused by the swell- abdominal distention, discomfort, and signs of peritonitis
ing of the material. or hemodynamic instability, this should be investigated via
ultrasound or CT scan for vessel or visceral injury. This
9.1.5 Retained pathology complication can be prevented by the careful use of disc
Retained disc fragments have been documented in 0.2% of rongeurs. No force should be applied when inserting the
cases [32]. When intraoperatively the surgeon does not find rongeur into the disc space, or when performing discectomy.
what he expected from the preoperative imaging, then a The safest distance for inserting the instrument should be
second look at the whole situation, including the level of less than 25 mm.
surgery, should be considered. When large disc fragments
are present, sufficient time must be taken to account for 9.2 Immediate postoperative complications
these fragments, and the surgeon should have a low thresh-
old to extend the bony decompression. Removal of a large 9.2.1 Wound infection
disc fragment does not mean that all the fragments have The rate of superficial infection following lumbar disc sur-
been removed. The neural canal should be probed ade- gery is between 2–3% [32]. It can occur as early as 48 hours
quately for free disc fragments, thus ensuring complete nerve postsurgery, but is mostly seen after the patient has been
root decompression. Not addressing the lateral recess and discharged, during the first week at home. The most im-
foraminal stenosis is one of the common causes for failure portant step in preventing infections is the administration
to improve symptoms. of a single dose of intravenous antibiotic 30 minutes before
the skin incision. Superficial infections usually resolve with
9.1.6 Nerve root injury oral antibiotics. Deep infections require a thorough debride-
The incidence of nerve root injury after a microdiscectomy ment.
has been estimated at 0.5% [32]. Poor visibility, excessive
nerve root retraction, perineural adhesions, and congenital 9.2.2 Persistent leg pain and neurological deficits
nerve root abnormalities are the most common causes of A common complication after a microdiscectomy is persis-
damage to the nerve roots. Accidental puncture of the dura tent or residual leg pain. Possible causes are residual, missed
and/or neural structures using a K-wire during the initial or displaced fragments of nucleus pulposus, intraoperative
dilation process for MED or MTD can also occur. Therefore, nerve root injury, foreign body retention (cottonoids, Gel-
the use of a K-wire is not recommended; instead, the first foam, Surgicel, etc), or early recurrent herniation. On rare
blunt dilator should be used. It is essential to clearly define occasions, an epidural hematoma or dural or hemostatic
the lateral edge of the root, the shoulder and the dural sac sealants can swell up and cause severe neural compression
border before attempting entry into the disc space. Nerve resulting in a cauda equina syndrome. Suspicion regarding
root injury can occur in a setting where the disc is found to the development of any of these complications requires an
be herniated through the axilla, preventing medial retrac- early MRI within 72 hours and if the diagnosis is confirmed,
tion of the root. The surgeon must recognize this, and the immediate surgery to decompress the cauda equina is nec-
axilla of the nerve root must first be decompressed, then essary.
the root retracted medially to enter the disc space. Intermit-
tent release of the nerve root retraction during the procedure 9.2.3 Thromboembolic symptoms
avoids prolonged neural compression. All patients should be assessed for the risk of deep venous
thrombosis, and a prophylactic compression stocking should
9.1.7 Anterior vessel and visceral injuries be worn unless contraindicated. The knee-chest position
These are potentially lethal complications if not recognized can cause increased venous pooling in the lower limbs. In
early on. If the discectomy rongeur penetrates the anterior the literature, the rate of embolic complications has been
annulus and anterior longitudinal ligament, it can injure reported as ranging from 0.1 to 1% [32]. Early mobilization
the major blood vessels and viscera. The most common le- prevents this complication from developing, but in patients
sion is an isolated injury of the left common iliac artery at that are not mobile, antithrombotic stockings must be used.
the L4/5 disc level. The overall complication rate for ante-
rior vessel injury is 0.045%. It is important to recognize 9.3 Delayed complications
this serious complication, which can present as a hemody-
namic instability and hypotension. If a vascular injury is 9.3.1 Postoperative discitis
diagnosed, emergency laparotomy must be performed im- This is a rare but serious and painful complication. Septic
mediately. When the patient wakes up from anesthesia with discitis presents with fever, leucocytosis, raised C-reactive
309

protein (CRP) levels, and positive cultures. Under normal higher risk of neural injury and CSF leakage, together with
conditions, CRP levels increase after surgery, attaining peak a reduced success rate. Recurrence after primary lumbar
levels on postoperative day 3–5 and return to normal with- discectomy has been shown to occur in between 1.7 and
in10 days. Persistently high CRP levels even after the 5th 13% of patients [22]. Some of the nonmodifiable patient
postoperative day should raise the suspicion of possible risk factors identified were young age, male sex, smoking,
wound infection. In the literature, the risk is reported as history of trauma, prolonged hospitalizations, diabetes, and
being between 0.1–0.9% [33–35]. It has been claimed that low body mass index. Various correlations have been made
microdisc surgery is associated with a higher infection rate with the amount of disc material to be removed, annulus
than standard disc surgery because of manipulations with opening versus repair, large annular defect versus smaller
the microscope over the open surgical wound. However, opening, sequestrectomy or annular opening, and early or
recent publications have shown that the deep-wound infec- late mobilization. There is some skepticism about the argu-
tion rate in microdisc surgery is less frequent [36, 37]. Again, ment put forward on the risk of recurrence being higher
the use of single-dose antibiotics will reduce the risk of this with MLD compared to SD where more disc fragments are
complication. Aseptic discitis is due to chemical irritation removed aggressively. This is not well supported, with vary-
and inflammation by inflammatory mediators released from ing views on the subject being expressed in the literature
the disc and loose cartilaginous end plates, and this condi- [38, 39]. Comparing microdiscectomy with an annular inci-
tion usually resolves spontaneously. sion or just performing a sequestrectomy showed no sig-
nificant difference in recurrence rates. When there is a
9.3.2 Recurrent disc herniation free-lying fragment, limited discectomy or sequestrectomy
Recurrent disc disease can present a challenge both as re- without an annular opening is associated with good results
gards diagnosis and treatment. Revision surgery carries a in the authors' experience.
10 Tips and tricks
Richard Fessler, Chicago, USA • Regardless of the technique used, near- • The comment author finds it helpful to
The present chapter authors have provided ly all disc herniations can be removed check that the epidural space between
an excellent and detailed description of all through the “lateral” or “shoulder” ap- the disc and the dura has been correctly
aspects of the surgical treatment of lumbar proach, with the “axillary” approach entered by running a right-angled spat-
disc herniation, but it may nevertheless be rarely being required. The approach can ula or hook between them throughout
useful to reiterate certain points, which are be significantly facilitated by drilling 2 the exposed space. If the spatula moves
covered below: mm off the medial facet, and retracting freely, this indicates that the surgeon has
• Although for small operations, such as the nerve root slightly medially if neces- safely entered the right space. If not, this
lumbar discectomy, there is a minimal sary. should be checked again to ensure that he
difference in long-term outcome be- • Another technique that is helpful in es- has successfully passed under the nerve
tween microdiscectomy and MED, avail- tablishing the plane between the liga- root.
able evidence supports the short-term mentum flavum and the dura is to use • Dural violation and subsequent CSF
benefits of the latter technique, such as an up-angled curette, which is first slid leakage can generally be avoided by
reduced blood loss, shorter hospital stay, under the cephalad lamina. Because the making sure that the Kerrison punch is
and lower infection rates. insertion of the ligamentum flavum is only closed when the instrument is per-
• Without entering into a general com- located on the anterocaudal aspect of the pendicular to the dura, never when it is
parison between microdiscectomy ver- lamina, this is usually dissected through parallel or angled.
sus standard MED, the use of the MED the ligament and establishes the plane. • In the comment author’s experience,
technique for far lateral disc herniation is Rotating the curette caudally then defines with adequate cephalocaudal and lateral
greatly superior to the former procedure, the plane, following which the curette exposure, laminectomy is not required
resulting in much less muscle dissection can be used to pull the ligament safely for the safe removal of large disc hernia-
and reduced blood loss, better visualiza- away from the dura. tions causing cauda equine syndrome.
tion, decreased postoperative pain, and a
much more rapid discharge from hospital.

11 Case example 12 Key learning points
A 42-year-old man presented with exacerbation of left- • The use of microsurgical techniques does not change
sided sciatica and low back pain which had been experienced the indications for disc surgery. Appropriate patient se-
for about 6 weeks. The MRI showed an L5/S1 disc prolapse, lection is the key to a successful outcome in microsurgi-
causing impingement of the left S1 nerve root. On clinical cal lumbar discectomy
examination, although the patient was of normal build, a • Detailed preoperative radiological evaluation of the lo-
left-sided list was apparent in the standing position. The calization and extent of the prolapsed disc is essential
straight leg-raising test was painful at 40° on the left side, before surgical intervention
and a crossed leg-raising test was also positive. On neuro- • Accurate localization of the operative level at three dif-
logical examination, weakness of the ankle plantar flexors ferent stages of surgery is important to avoid wrong-
(Medical Research Council grade IV) and hypoesthesia over level surgery
the S1 dermatome were observed. The plantar stretch reflex • The magnification and illumination provided by the
was depressed on the left side. X-rays of the lumbosacral microscope should be effectively used by the surgeon
spine were normal, but MRI showed a left-side extruded to ensure deft and gentle handling of the neural struc-
disc prolapse at the L5/S1 level with inferior migration caus- tures, avoiding adhesions and scar tissue formation
ing significant compression over the left S1 nerve root (Fig • Removal of the disc material should be adequate and
4.2.2-26). Since the patient’s symptoms had worsened dur- conservative
ing previous conservative treatment and a good clinical- • Exclusive sequestrectomy does not provide less favorable
radiological correlation was possible, the patient underwent results when compared to discectomy.
microdiscectomy. Intraoperatively, a left-sided approach to
the L5/S1 interlaminar space was made, and the ligamentum
flavum was raised as a flap. A large sequestrated fragment
was removed, relieving the nerve root of compression. Post-
operatively the patient showed good resolution of symptoms,
and follow-up at 8 months showed complete resolution of
pain and normal strength in the ankle.
LF
La
Th
Du
a b c
Fig 4.2.2-26a–d
a–b T2 sagittal and axial MRI showing a large inferiorly migrated disc impinging on the left
L5 nerve root.
c Intraoperative photograph taken through the microscope showing the large disc fragment
protruding laterally into the epidural space.
La: lateral; Th: thecal sac; Du: nerve root retractor; LF: ligamentum flavum.
d d This large disc fragment was removed as a single piece.
311

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Arts MP, Brand R, Akker ME, et al (2009) Tubular Katayama Y, Matsuyama Y, Yoshihara H, et al (2006)
discectomy vs conventional microdiskectomy for sciatica: Comparison of surgical outcomes between
a randomized controlled trial. JAMA; 302(2):149–158. macrodiscectomy and microdiscectomy for lumbar disc
herniation: a prospective randomized study with surgery
Study type Study design Class of evidence performed by the same spine surgeon. J Spinal Disord
Therapy Randomized controlled trial I–II Tech; 19(5):344–347.
Purpose Study type Study design Class of evidence

To determine outcomes and time-to-recovery in patients Therapy Randomized controlled II
treated with tubular discectomy compared with conven- trial
tional microdiscectomy.
Purpose
Patient Lumbar disc herniation with sciatica (N = 328, age range
To compare surgical outcomes between macrodiscectomy
P
18–70 years) and microdiscectomy for lumbar disc herniation.
I Intervention Tubular discectomy (n = 167)
P Patient Lumbar disc herniation (N = 119)
C Comparison Conventional microdiscectomy (n = 161)
I Intervention Microdiscectomy (n = 57, 58% male, mean age 41 years,
O Outcome Roland-Morris Disability Questionnaire, VAS for leg pain and age range 18–65 years)
back pain, self-report of recovery
C Comparison Macrodiscectomy (n = 62, 69% male, mean age 34 years,
age range 14–62 years)
Authors’ conclusion Outcome Operative time, amount of bleeding, length of hospital stay,
O
Use of tubular discectomy compared with conventional amount of analgesic agent used after surgery, Japanese Or-
microdiscectomy did not result in a statistically significant thopaedic Association score, VAS for lumbago and sciatica,
complications, further surgery
improvement in the Roland-Morris Disability Question-
naire score. Tubular discectomy resulted in less favorable
results for patients' self-reported leg pain, back pain, and
For herniotomy for lumbar disc herniation, both macro-
recovery.
discectomy and microdiscectomy are appropriate, as long
as surgeons have mastered the procedures.
313

Porchet F, Bartanusz V, Kleinstueck FS, et al (2009)

Microdiscectomy compared with standard discectomy: an
old problem revisited with new outcome measures
within the framework of a spine surgical registry. Eur
Spine J; 18 Suppl 3:S360–S366.

Therapy Cohort III
Purpose
To compare the relative merits of microdiscectomy and
standard discectomy.
P Patient Degenerative lumbar disease

I Intervention Microdiscectomy (n = 225)
C Comparison Standard discectomy (n = 36)
O Outcome Blood loss, length of hospital stay, surgical complications,
Core Outcome Measures Index (leg/buttock pain, back pain,
back-related function, symptom-specific well-being, general
quality-of-life, social and work disability), overall satisfac-
tion, global outcome, perceived complications
No clinically relevant difference was detected in outcome
after lumbar disc excision dependent on the use of the
microscope.

4.2.3 Endoscopic disc and decompression surgery
Sebastian Ruetten, Martin Komp, Patrick Hahn
1 Historical perspective posterolateral access (Fig 4.2.3-1) [11], which has now become
the most widespread procedure to be used for endoscopic
Over the past 90 years, lumbar spine surgery has evolved surgery on patients with lumbar disc disease. Since the be-
considerably, and modifications have been developed from ginning of the 1990s, a number of reports have appeared
the originally described techniques. The focus has frequent- in the literature on endoscopically assisted surgical proce-
ly been on reducing invasiveness and improving visualiza- dures, including visualization of the open surgery site using
tion during the surgical procedure. The microscope-assist- an endoscope and a monitor [12, 13].
ed technique, which was introduced approximately 30 years
ago, is the current standard for decompression surgery The above-mentioned endoscopic posterolateral transfo-
[1, 2]. raminal approach allows the intervertebral space to be ac-
cessed within the intervertebral foramen between the exit-
Gaining access to the spinal canal via an interlaminar ap- ing and traversing spinal nerves, and enables the direct
proach with complete or partial laminectomy was first re- removal of intraforaminal and extraforaminal sequestrated
ported at the beginning of the 20th century [3, 4]. The pos- disc portions. The removal of prolapsed disc material with-
terolateral approach for vertebral biopsies was described at in the spinal canal under retrograde resection, ie, intradis-
the end of the 1940s [5]. Percutaneous surgery has been cally through the annular defect, has been described and
performed since the beginning of the 1970s [6, 7]. A micro- designated as the “in-out technique” [14, 15]. However,
surgical approach using the microscope was also developed technical constraints are frequently encountered, due to
in the 1970s, and today has achieved the status of gold specific anatomical characteristics and the pathology in-
standard for interlaminar decompression in the region of volved. Direct access to the extradiscal anterior epidural
the spinal canal [8, 9]. Endoscopy has been used since the space under continuous visualization is therefore necessary
beginning of the 1980s [10], initially to inspect the interver- for adequate decompression. This is prevented if the pos-
tebral space following open surgery. This subsequently de- terolateral approach is used, particularly in the caudal seg-
veloped into the endoscopic transforaminal technique with ments with small intervertebral foramina.
a b
Fig 4.2.3-1a–b Transforaminal surgery using the posterolateral approach.
315

Authors Sebastian Ruetten, Martin Komp, Patrick Hahn
Because of these problems, the full-endoscopic lateral trans-/ 2 Terminology

extraforaminal approach was developed to provide adequate
access to the spinal canal under continuous visualization Full-endoscopic lumbar surgery can be defined as an op-
(Fig 4.2.3-2). The use of irrigation fluid provides excellent erative technique for the treatment of the lumbar spinal
visualization conditions. The procedure is carried out under canal and neighboring structures under continuous visual
image intensification/x-ray control, which obviates having control and irrigation, via a minimally invasive approach.
to carry out metric measurements to define an entry point It is not an endoscopically-assisted procedure performed
through the skin [16, 17]. However, when using the lateral through a tubular retractor, but a uniportal technique using
transforaminal approach with possible bone resection, there an endoscope with intraendoscopic working channels. In
are not only clearly defined indications but also constraints addition to reduced invasiveness, it combines the advan-
related to mobility, and to obstruction of the approach by tages of arthroscopic procedures, such as improved visibil-
the pelvis or organ systems. ity and illumination. Two different approaches are adopted,
the full-endoscopic interlaminar and the full-endoscopic
The limitations of the transforaminal approach motivated trans-/extraforaminal approach.
the development of the full-endoscopic interlaminar ap-
proach, which also permits surgery for pathologies outside
the range of indications for the transforaminal procedure 3 Patient selection
(Fig 4.2.3-3) [17, 18].
3.1 General indications
Today, a combination of the new surgical approaches and The indications for surgery are based on radicular symptoms,
technological advances permits the first full-endoscopic neurogenic claudication, and existing neurological deficits.
procedure under visualization that is equivalent to standard In general, isolated back pain cannot be improved by de-
open surgery, taking into consideration the indication cri- compression surgery. Existing secondary pathologies, such
teria. The transforaminal approach is subject to more limi- as instability, may have to be treated at the same time using
tations than the interlaminar procedure, but provides the other procedures. The current indications are as follows:
best preservation of tissue. The anatomical and pathologi- • Sequestered or nonsequestered lumbar disc herniations,
cal considerations mean that the ratio of performed trans- independent of localization
foraminal to interlaminar procedures is about 30:70. • Recurrent disc herniations following conventional or
full-endoscopic surgery.
Fig 4.2.3-2 Full-endoscopic transforaminal surgery using the lateral Fig 4.2.3-3 Full-endoscopic interlaminar surgery.
approach.

• Lateral bony and ligamentous spinal canal stenosis specific technical possibilities of each surgical procedure,
• Central bony and ligamentous spinal stenosis and the inclusion criteria
• Cysts of the zygapophyseal joint • If the patient suffers from cauda equina syndrome, con-
• Implant delivery into the intervertebral space for very ventional open surgery should be considered.
specific indications, eg, nucleus replacement, distractable
cages
• Intervertebral debridement and draining in specific 4 Pros and cons of endoscopic disc and
cases, eg, of spondylodiscitis or epidural abscess. decompression surgery
3.2 Indications for the transforaminal approach Conventional open procedures are indispensable today, and
All intraforaminal and extraforaminal disc herniations or will remain so in the future. The possible complications and
cysts of the zygapophyseal joints are considered as indica- consequential damage associated with such procedures are
tions for the transforaminal approach. well known. New techniques must offer the means to attain
the surgical goal, with at least the same effectiveness as
In disc herniations within the spinal canal or lateral spinal established procedures and with the same or less risks to
canal stenosis, the following inclusion criteria need to be the patient.
taken into account due to the limited mobility of the surgeon
in the spinal canal associated with the transforaminal ap- 4.1 Pros
proach: Full-endoscopic operations, true minimally invasive pro-
• Localization of the sequestered disc material between cedures, offer numerous advantages which have been list-
the lower border of the cranial pedicle to the central ed below. These largely correspond to the advantages of
portion of the caudal pedicle microscope-assisted surgery, as evidenced in the endoscop-
• The craniocaudal extension of the lateral spinal canal ically treated case examples given in this chapter, over con-
stenosis should be between maximally from the upper ventional open surgery. Full-endoscopic operations can
border of the caudal pedicle to the lower border of the therefore be viewed as the next step in the development of
cranial pedicle. surgical techniques. The advantages of endoscopic disc and
• In the orthograde lateral x-ray path, pelvic overlay of decompression surgery include:
the level in question should extend maximally to the • Excellent visualization, good illumination, and extend-
middle of the cranial pedicle. ed field of vision for surgeons with 25˚ endoscopes
• Cost-effective procedure with short operating time,
When using the standard lateral approach, the access path- rapid rehabilitation, high rate of return to earlier levels
way should not be obstructed by abdominal structures. This of activity, and reduced cost of postoperative care
is particularly important for the levels cranial to L4/5. If the • Less invasive procedure, with resulting benefits for the
preoperative MRI findings are not entirely clear, an ab- surrounding tissue, stabilizing structures of the spinal
dominal CT scan should be obtained for evaluation and canal, and epidural space
preoperative planning. • Revision surgery is facilitated
• Lower complication rates, eg, reduced dural injury,
3.3 Indications for the interlaminar approach bleeding, infection, etc
• All disc herniations or cysts of the zygapophyseal joint • The monitor can be used as a training tool for assistants
located within the spinal canal that do not meet the • High level of patient acceptance.
inclusion criteria for the transforaminal approach, and
technically cannot be operated on via this approach 4.2 Cons
• All lateral spinal canal stenosis cases that do not meet The disadvantages of endoscopic disc and decompression
the inclusion criteria for the transforaminal approach, surgery are as follows:
and technically cannot be operated on via this approach • Limited mobility of the surgeon in the spinal canal with
• Central spinal canal stenosis. the transforaminal approach
• Limited possibility to extend surgery in the event of
3.4 Contraindications for all full endoscopic unforeseen complications
approaches • Full-endoscopic suturing of the dura technically not
• All factors that are generally taken as contraindications possible
for decompression surgery, also taking into account the • Difficult learning curve.
317

5 Preoperative planning quent correction of anesthetic-related problems may be

difficult. Therefore, the risk: benefit ratio suggests that the
5.1 Examinations performance of this procedure under local anesthesia should
As with all microsurgical techniques, the intraoperative be reserved for rare exceptions only.
procedure must be planned preoperatively on the basis of
imaging findings. The goal is to carry out the resection of 5.4 Positioning
spinal canal structures as sparingly as possible, depending Endoscopic disc and decompression surgery is performed
on the pathology in question. On the diagnostic side and with the patient in the prone position on an x-ray-perme-
depending on the findings, the entire instrumental and able table, under orthograde two-dimensional x-ray control.
clinical spectrum must be taken into account, as in conven- The patient should be placed on a hip and thorax roll to
tional procedures. Conventional two-dimensional x-rays relieve the abdominal and thoracic organs. The operating
of the lumbar spine and MRI with sagittal and transverse table should be lordotically or kyphotically adjustable in-
reconstruction are mandatory. When using the lateral trans- traoperatively at lumbar level depending on the anatomy
foraminal approach, the access pathway should not be ob- and pathology in question.
structed by abdominal structures. This is especially the case
in the levels cranial to L4/5. If the findings are not entirely 5.5 Technical equipment
clear, an abdominal CT scan should be obtained for evalu- An x-ray-permeable, adjustable operating table and C-arm
ation and preoperative planning. Other examinations spe- are necessary. For endoscopic surgery under fluid flow, in
cifically for full-endoscopic operations are not necessary. addition to the surgical instruments and endoscopes, gen-
eral equipment is needed such as a monitor, camera unit,
5.2 Preparation light source, documentation system, fluid pump, shaver
Patients must be fully informed about their pathology, its system, and radiofrequency generator. Equipment available
possible long-term course and consequences. Despite the either for arthroscopy or endoscopy can be used. Depend-
minimal invasiveness and associated advantages of this sur- ing on the indication, the rod-lens endoscope should have
gical procedure, all known side effects, complications, and an outer diameter of 6.9 or 9.9 mm and include an in-
therapeutic options must also be explained, as for conven- traendoscopic, eccentric working channel with diameter of
tional procedures. As regards the full-endoscopic procedure, 4.1 or 6.5 mm. The angle of vision is 25°. The working
it is important to emphasize that even with minimally in- sheaths have a beveled opening, which enable the creation
vasive interventions, scarring cannot be completely avoid- of visual and working fields in an area without a clear ana-
ed. The patient should also be informed that should unfore- tomically preformed cavity (Fig 4.2.3-4 and Fig 4.2.3-5).
seen complications arise, a switch to an open procedure
may be required during the operation, or subsequently in
an additional procedure.
The preoperative preparation of the patient is the same as

for microsurgical techniques. Additional preparation spe-
cifically for full-endoscopic operations is not necessary. For
every procedure, a single-shot antibiotic is administered
prior to surgery for infection prophylaxis.
5.3 Anesthesia
Full-endoscopic operations can usually be performed under
general, or in certain cases local anesthesia. When local
anesthesia is used, it is necessary to anesthetize the access
route and the neural structures. Due to the risk of inflam-
matory reaction, epidural anesthesia alone is not usually
sufficient, and therefore the intrathecal administration of
local anesthetic must be ensured. In addition, systemic se-
dation is necessary for patient immobilization. Positioning Fig 4.2.3-4 Surgical setup with C-arm, monitors, arthroscopy tower,
involves the careful control of vital parameters, as subse- and typical patient positioning.

An atraumatic spinal needle is inserted through the skin

incision orthograde to the disc space in the target area.
After a target wire has been introduced and the cannula
removed, the cannulated dilator is inserted. The target wire
is then removed, and the surgical sheath with beveled open-
ing is pushed through the dilator. From this point on, de-
compression is performed under visualization and contin-
uous irrigation with isotonic saline free from any special
additives. Any further entry into the epidural space that
Fig 4.2.3-5 Various endoscopes with intraendoscopic working channel. may be required is made under visual control (Fig 4.2.3-6b,
Fig 4.2.3-7, Fig 4.2.3-8).
If the bony diameter of the foramen does not permit ade-

quate passage, the foramen is widened with a burr and
6 Surgical technique special instruments. If the position of the exiting nerve is
not clear, eg, in the intraforaminal or extraforaminal her-
6.1 Trans/extraforaminal approach niation or foraminal stenosis, an extraforaminal access is
First, the skin incision should be localized. The goal is to created on the caudal pedicle as a safe zone, and further
reach the spinal canal as tangentially as possible. At levels dissection toward the pathology is carried out under visual
L4/5 and L3/4, in the lateral x-ray path, the posterior line control (Fig 4.2.3-9 and Fig 4.2.3-10). Full-endoscopic access
of the descending facet usually serves as the boundary which is provided in the same way, even if previous operations
should not be crossed in the anterior direction (Fig 4.2.3-6a). have been performed in the operative area.
To avoid injury to the abdominal organs, the abdominal CT
scan images through the corresponding disc should be re- The specific decompression procedure depends on the find-
viewed preoperatively, especially at the cranial levels when ings in each case. After the operation has been completed,
the findings are equivocal. Depending on the scan, an in- the instrument set is removed and the stab incision closed.
dividual, less lateral approach should be selected. Drainage is not necessary.
a b
Fig 4.2.3-6a–b Lumbar Spine.
a Lateral x-ray path of the lumbar spine with marked ascending (yellow) and descending (green) facet
and posterior line of the descending facets (red).
b Positioning of the spinal cannulas in the transforaminal approach.
319

Fig 4.2.3-7 Transforaminal work in the spinal canal. Fig 4.2.3-8 Intraoperative view after
decompression of the intervertebral disc and
traversing spinal nerve using the transforaminal
approach.
Fig 4.2.3-9 Approach to the caudal pedicle Fig 4.2.3-10 Intraoperative view of extrafo-
using an extraforaminal technique. raminal spinal disc herniation and exiting spinal
nerve using the transforaminal approach.

6.2 Interlaminar approach The surgical sheath with a beveled opening is inserted via
The skin incision is made as medially as possible in relation the dilator in the direction of the ligament. The subsequent
to the interlaminar window. The craniocaudal localization procedure is then performed under continuous visualization
depends on the pathological findings. and irrigation with isotonic saline solution free from any
special additives.
The dilator is inserted bluntly at the lateral edge of the
ligamentum flavum or on the descending facet of the zyg- To reach the spinal canal, the ligamentum flavum is incised
apophyseal joint under AP x-ray control. From this point laterally to approximately 3–5 mm. The subsequent proce-
on, the operation is performed under lateral x-ray control. dure is made possible by the elasticity of the ligament. By
rotating, the surgical sheath with a beveled opening can be
used as a second instrument and serves, eg, as a nerve hook
in shifting the neural structures in the medial direction. If
the bony diameter of the interlaminar window does not
permit passage in the case of large sequestered herniations
or a spinal canal stenosis, the window can be enlarged
using a burr and instruments (Fig 4.2.3-11, Fig 4.2.3-12,
Fig 4.2.3‑13). When operating on central spinal stenosis, a
single-sided approach with bilateral “over-the-top” decom-
pression is performed. During preliminary surgery in the
operative area, the medial edge of the descending facets is
identified and dissected anteriorly, directly along the bone
until the medial edge of the ascending facet can be localized.
A blunt insertion to the base of the spinal canal is carried
out here close to the bone.
The way the decompression is performed depends on the

findings in each case. After the operation has been com-
pleted, the instrument set is removed, and the stab incision
Fig 4.2.3-11 Interlaminar work in the spinal canal. closed. Drainage is not necessary.
3 2
Fig 4.2.3-12 Intraoperative view after decom- Fig 4.2.3-13 Intraoperative view of articular
pression of the ligamentum flavum (thin arrows), facet and the ligamentum flavum after bone
traversing nerve route (long bold arrow), dura of resection using the interlaminar approach.
the cauda equina (1), annulus (2) and defect of
the annulus (3) in the axilla.
321

7 Postoperative care be used in cases that, for technical reasons, are inoperable
using the transforaminal approach. The full-endoscopic
The length of hospital stay depends on the surgery in ques- techniques that have been developed can now achieve re-
tion. Pure discectomies or simple decompressions are fol- sults where the clinical outcomes equal those of conven-
lowed by brief hospitalization or, if patient care at home is tional microsurgical procedures. At the same time, signifi-
adequate, on an outpatient basis. Mobilization is immediate, cant advantages are evidenced that remain consistent over
ie, as soon as possible following recovery from anesthesia. subsequent follow-up periods of examination [20].
No medication is required for pain following the operation.
Apart from patients with neurological deficits, no reha- Despite the marked developments over the past 10 years,
bilitative measures are necessary. Isometric and coordina- there are clear limits to full-endoscopic techniques. Open
tion exercises can be performed without supervision once and maximally invasive procedures are necessary today,
they have been learned. A passive lumbar brace is prescribed and will remain so in the future. Surgeons must be able to
during the day for about 6 weeks. The level of exercise can perform such operations, not simply to offer patients the
be increased depending on the pathology and the patient’s most appropriate surgical procedure for their particular
subjective sense of well-being. Return to work and sports pathology, but also to deal safely with any problems and
activity are possible under the same conditions once the complications that might emerge during full-endoscopic
wound has healed. Limitations are imposed only to the interventions, as in any other invasive procedures. The de-
extent that there should be no signs of increased pain dur- velopment of full-endoscopic techniques should not be
ing any activity. After more complex operations, the post- regarded as a replacement for existing standard surgery,
surgical treatment regimen is usually more restrictive, and but as a complementary procedure and an alternative with-
depends on the individual and the intervention carried out. in the overall concept of spine surgery.
8.1 Disc herniation

8 Evidence-based results The following significant results were found in Ruetten et
al’s [20] prospective randomized study comparing full-endo-
The objective in the development of surgical treatment for scopic versus microsurgical techniques: One hundred and
radicular compression syndromes caused by spinal disc her- seventy-eight patients were included in follow-up after 2
niations or spinal canal stenoses is to provide adequate de- years. The mean operating time for the full-endoscopy group
compression under optimal visualization conditions with was 22 minutes, and therefore significantly shorter than for
minimal surgery-induced trauma and resulting negative the microsurgery group at 43 minutes. Access-related bone
consequences. As a minimum criterion, when new tech- resection was required in 91% of patients in the microsurgery
niques are introduced the same clinical results as those group and in 13% in the full-endoscopy group (P < .001).
achieved by standard procedures must be attained [19]. At No serious complications were observed in either group, but
the same time, further advantages in surgical technique overall the complication rate was significantly higher in the
and/or clinical variables should be the goal. microsurgery group (transient dysesthesia, postoperative
bleeding, delayed wound healing, soft-tissue infection, tran-
The development of new rod-lens endoscopes with large sient urinary retention). Recurrence was observed in 5.7%
intraendoscopic working channels and appropriate instru- of patients in the microsurgery group and in 6.6% in the
ment sets has provided the technical platform for full-en- full-endoscopy group (no significant difference between the
doscopic surgery for all types of lumbar spinal disc hernia- groups). After 2 years, a constant and significant improve-
tions within and outside the spinal canal, and for spinal ment was observed in leg pain, and in daily activities in both
stenoses. To fully ensure complete decompression, it is es- groups. However, ten patients in the microsurgery group
sential that operations on spinal disc herniations and spinal suffered from progressive back pain, a significantly higher
canal stenosis are carried out using a full-endoscopic tech- number than the two patients in the full-endoscopy group.
nique under continuous visualization. The development of Eighty-eight percent of patients in the microsurgery group
the lateral transforaminal approach optimizes and facilitates and 97% in the full-endoscopy group reported subjective
access to the spinal canal, and working under continuous satisfaction, and stated that they would be prepared to un-
visualization. This eliminates the problems associated with dergo the operation again. Postoperative pain, the need for
the posterolateral approach. However, the lateral approach pain medication, and work disability were significantly re-
also has clear inclusion and exclusion criteria, and hence duced in the full-endoscopy group. Overall, 11% of patients
certain limitations. Today, the interlaminar approach can from both groups underwent revision surgery.

The possible negative consequences of conventional opera- Recurrence was observed in 4.8% of patients in the micro-
tions on the lumbar spine are widely known, and have been surgery group and in 6.7% in the full-endoscopy group,
documented in an extensive body of literature [21, 22]. A with no significant between-group differences being ob-
comparison of the literature and underlying studies reveals served in this regard. After 2 years, a constant and significant
that the full-endoscopic procedure results in reduced operat- improvement in leg pain, and in daily activities was observed
ing times, tissue trauma, and complications. This corresponds in both groups. Four patients in the microsurgery group
to the published reports on the benefits of a minimally in- suffered from progressive back pain, a significantly higher
vasive intervertebral and epidural approach. The current state number than in the full-endoscopy group with one patient
of knowledge indicates that instabilities can be avoided as a experiencing back pain. Eighty-six percent of the micro-
result of the possibility to reduce or eliminate bone and lig- surgery group and 95% of the full-endoscopy group re-
ament resection, combined with atraumatic curettage of the ported subjective satisfaction, and stated that they would
intervertebral space [23, 24]. The full-endoscopic technique be prepared to undergo the operation again. Postoperative
minimizes the annulus defect, and this appears to exert a pain, the need for pain medication, and work disability were
protective influence. Postsurgery rehabilitation measures are significantly reduced in the full-endoscopy group. Overall,
not necessary, and a comparatively high recovery of the per- ten patients from both groups underwent revision surgery
formance level required for work and sports activities is without any significant differences being observed in results
achieved. There is no evidence of increased morbidity result- between groups.
ing from accompanying factors. Based on a comparison of
the literature and within studies, the recurrence rate dem- Recurrent spinal disc herniation following discectomy can
onstrates no significant difference from that associated with never be completely excluded. The rate of relapse is re-
the conventional approach. Revision surgery can also be ported in the literature as ranging between 5% and over
carried out using the same technique. The type of spinal disc 20%, depending on the type of fragment and annular defect.
herniation and annulus defect appears to exert a greater When operating on recurring spinal disc herniation follow-
influence on the rate of recurrence than the extent of curet- ing a previous operation, the risk of dural and nerve injury
tage of the intervertebral space. No relevant disadvantages is increased if there is existing epidural scarring. Extensive
connected with the adoption of the full-endoscopic technique dissection generally needs to be carried out in the operative
for the treatment of spinal disc herniations have been iden- area to reduce such injury, and the resulting increase in
tified, overall. At the same time, there is clear evidence of trauma has to be taken into account. As a result, sequelae,
advantages in operating technique and reduced trauma re- such as segmental instability following surgery, progressive
garding the access route to the structures of the spinal canal degeneration, increased epidural scarring or arachnoiditis
[20]. The transforaminal approach has been found to induce may occur. This may result in clinical symptoms and create
reduced trauma on account of reduced bone and ligament difficulties for further revision surgery. The scar tissue left
resection. It is therefore considered to be the approach of between the dura and paravertebral musculature may cause
choice. However, as the anatomical and pathological prereq- so-called “tethering” of the cauda equina. The increased
uisites impose significant restrictions, the interlaminar ap- resection of stabilizing structures is conducive to instabil-
proach has a wider field of application. ity following surgery. The trauma caused by the access
pathway in the innervation area of the dorsal branch of the
8.2 Recurrent disc herniation spinal nerve may exert a negative effect on the stabilizing
The following significant results were found in Ruetten et and coordinating system. Therefore, the aim is to use tech-
al’s [25] prospective randomized study, which compared the niques designed to preserve tissue when carrying out revi-
full-endoscopic versus the microsurgical technique: Eighty- sion, as in the case of primary surgery. When using the
seven patients were included in follow-up after 2 years. The full-endoscopic procedure, the parameters that determine
mean operating time for the full-endoscopy group was 24 the results and benefits are comparable to those for pri-
minutes, and was therefore significantly shorter than for mary spinal disc herniation as regards reduced operative
the microsurgery group at 58 minutes. Access-related bone times, tissue trauma, and complications. No relevant dis-
resection was required in 94% of patients in the microsur- advantages have been identified in comparison with the
gery group compared to only 6% in the full-endoscopy conventional microscopically-assisted technique. The same
group (P < .001). Overall, the complication rate was sig- inclusion and exclusion criteria are applicable. The trans-
nificantly increased in the microsurgery group (21% versus foraminal access is particularly effective because it com-
6%) (dural injury, transient dysesthesia, delayed wound pletely circumvents the existing epidural scarring caused
healing, soft-tissue infection, transient urinary retention). by the previous operation.
323

8.3 Spinal canal stenosis inal approach, on account of anatomical and pathological
The following significant results were found in Ruetten et limitations. This approach is therefore limited to a small
al’s [26] prospective randomized study which compared full- number of individual cases.
endoscopic versus microsurgical techniques: One hundred
and sixty-one patients were included in the follow-up after
2 years. The mean operating time in the full-endoscopy 9 Complications and avoidance
group was 34 minutes, which was therefore significantly
shorter than in the microsurgery group at 48 minutes. Apart The possible complications connected with microsurgical
from transient dysesthesia and transient urinary retention, procedures are now widely known, and there is a large body
the complication rate was significantly higher in the micro- of literature on the subject [27, 28]. A minimally invasive
surgery group (dural injury, epidural hematoma, delayed procedure can reduce the complication rate, although sta-
wound healing, soft-tissue infection). After 2 years, a con- tistically speaking this cannot be completely avoided. In
stant and significant improvement was observed in leg pain, principle, all the complications that could arise in the course
and in daily activities in both groups. In general, a slight of conventional operative procedures may also occur.
deterioration was observed during the follow-up period
between the first and second year, but this was not signifi- As far as full-endoscopic procedures are concerned, it is
cant. Six patients in the microsurgery group suffered from important to emphasize that a one-sided or two-sided switch
progressive back pain, a significantly higher number than to an open procedure may become necessary in the event
in the full-endoscopy group, with only one patient experi- of complications. In particular, endoscopic suture of a dural
encing back pain. Eighty-six percent of the microsurgery injury is technically not possible. Theoretically, if operating
group and 92% of the full endoscopy group reported sub- times are extended and blockage of the outflow of irrigation
jective satisfaction, and stated that they would be prepared fluid is overlooked, the consequences of increased pressure
to undergo the operation again. Postoperative pain and pain within the spinal canal and the attached and neighboring
medication were significantly reduced in the full endos- structures cannot be completely ruled out. Surgery should
copy group. Overall, five patients from both groups under- therefore be performed leaving the system open, such that
went revision surgery due to persistent leg pain or recurrent outflow of irrigation fluid is possible.
back pain, without any significant differences being observed
in results between groups. In the interlaminar approach, long-lasting and uninter-
rupted excessive retraction of the neural structures with
The same problems arise in surgery for spinal canal steno- the working sheath in the medial direction must be avoid-
sis, such as discectomy. Resection of joints and soft-tissue ed, or carried out only intermittently to avoid the risk of
structures in the lateral and anterior region is generally neurological damage. In the transforaminal approach, the
more extensive because of the pathology involved. There- risk of injury to the exiting nerves cannot be completely
fore, any instability that may be induced as a result of sur- eliminated. The highest risk occurs when performing the
gery always needs to be taken into account. Extensive de- approach itself. If the risk is to be avoided, it is necessary
compressions, or additional instabilities and deformities may to remain strictly within the caudal aspect of the foramen.
require additional fusion. Attempts to reduce trauma are Alternatively, if the foramen is narrowed, an extraforami-
made through the use of various tissue-conserving tech- nal approach should be performed, if necessary.
niques. A key prerequisite in using full-endoscopic tech-
niques has been the development of appropriate abraders When the lateral access is used, it is important to ensure
that permit bone resection under visualization. This provides that abdominal organs do not block the access pathway. It
the technical capability for the adequate decompression of is particularly important to take this into account at the
spinal canal stenosis. When using the full-endoscopic ap- levels cranial to L4/5. If the findings are not entirely clear,
proach, the parameters that determine the results and ben- a single abdominal CT scan should be made through the
efits are comparable to those for primary spinal disc her- disc for purposes of evaluation, preoperative planning and
niation or recurrent spinal disc herniation in terms of measurement of the approach.
complications, tissue trauma, and reduced operating times.
Also in this case, no relevant disadvantages have been iden- Important factors regarding successful outcome include the
tified in comparison with the conventional microscopical- correct indication for the procedure itself, and determining
ly-assisted technique. However, only a small number of the proper approach. Since this relates to a decompression
these stenoses meet the inclusion criteria for a transforam- procedure, indications are leg symptoms like radicular pain,

neurological deficits, or neurogenic claudication. Back pain ing practice on human anatomical specimens may be in-
is normally the result of secondary phenomena such as structive. Strict adherence to the indication criteria for the
instability, disc degeneration, arthrosis of the zygapophy- appropriate full-endoscopic approach is necessary. In the
seal joints, or scoliosis. Isolated back pain cannot usually first instance, operations should be carried out on “simple”
be improved by decompression surgery. cases where no difficulties are to be expected as regards
the anatomical aspects. The possibility of an intraoperative
The authors’ experience has demonstrated that especially switch to a standard procedure is helpful if problems are
during the learning curve there is an increased risk of com- encountered. Nonetheless, it is important to recall that
plications as with any new technique. Prior observation difficulties can never be ruled out during the learning
of and participation in procedures and workshops involv- phase.
10 Tips and tricks
Verapan Kuansongtham and Sompoch 10.2 Full-endoscopic interlaminar ap- 10.3 Decompression in recess stenosis
Paiboonsirijit, Bangkok, Thailand proach for disc herniation • For spinal stenosis, bone resection is
• Identify the lateral margin of the tra- necessary and previous experience in
10.1 Full-endoscopic trans-/extraforam- versing nerve and the lateral dural sac endoscope and instrument handling is
inal approach for disc herniation to confirm the lateral recess. In the case mandatory.
• Select pure disc herniation with associ- of a small interlaminar window or hy- • To ensure sufficient decompression, de-
ated leg symptoms. For surgeons new to pertrophic facet joint, bone resection is compress cranially as far as the tip of the
this approach, avoid migrated disc and necessary to avoid damage to the neural ascending facet and caudally to half of
spinal stenosis. structures. For surgeons new to this ap- the pedicle.
• For the transforaminal approach, identify proach, choose L5/S1. • Choose the entry point where more bone
the exiting nerve root based on the MRI • Avoid retracting the dural sac for too long can be resected cranially rather than cau-
scan and make sure there is sufficient a time period, or too forcefully medially dally. The ligamentum flavum inserts un-
space to insert the dilator without risking and release retraction intermittently to der the upper lamina, which allows safer
injury to the root; if this is not the case, reduce the risk of neural damage. bone resection than at the lower lamina.
the extraforaminal approach should be • In the case of a migrated disc, begin the
considered. incision on the opposite side (cranially
• Avoid damage to the exiting nerve root or caudally) for more mobility and to
by keeping all instruments precisely at reduce bone resection.
the disc level, ensuring that they do not • As in conventional surgery, recurrence is
slip cranially. more dependent on the annulus defect
• This approach is required for intra-/ than on other factors. For a covered de-
extraforaminal herniation, however, fect at the edge, or a small defect at disc
proficiency in instrument handling is level, pure sequestrectomy is sufficient.
necessary. For larger defects, intradiscal removal
will reduce recurrence.
325

11 Case examples 11.2 Case 2: Lumbar central spinal stenosis

A 62-year-old patient presented with leg pain similar to
11.1 Case 1: Lumbar disc herniation that observed for neurogenic claudication, which he had
A 33-year-old patient presented with intermittent back pain experienced for the past 8 months when exercising. The
that had been experienced for many years. The patient had pain had increased over the past 10 weeks, with concomi-
suffered from 13 days of severe sciatica on the left side, and tant reduction in walking time to 10 minutes (longer than
for 3 days had experienced progressive weakness in flexion this was too painful). For 2 weeks, he had also experienced
of the foot with a significantly restricted walking capacity. weakness in raising the foot on the left side. The patient
Neurological examination revealed an S1 syndrome with had previously participated in an intensive conservative
corresponding neurological deficits, while MRI revealed an therapy program for 4 months. The neurological examina-
L5/S1 spinal disc hernia sequestrated caudally. A decision tion revealed an L5 syndrome on the left with correspond-
was taken in consultation with the patient to perform de- ing neurological deficits in addition to neurogenic claudica-
compression surgery on account of progressive, advanced, tion. The MRI revealed a central spinal canal stenosis at
partial paralysis. The indications for a full-endoscopic in- L4/5 without significant instability. A decision was taken
terlaminar approach were the localization within the spinal in consultation with the patient to perform surgery on ac-
canal at L5/S1 and sequestration caudally (Fig 4.2.3-14, Fig count of the progressive symptoms that had been resistant
4.2.3-15, Fig 4.2.3-16). to conservative therapy, and due to the onset of partial
paralysis. The indications for bilateral decompression using
a full-endoscopic interlaminar technique with a unilateral
approach were based on the absence of back pain, and symp-
toms on both sides (Fig 4.2.3-17, Fig 4.2.3-18, Fig 4.2.3-19).
Fig 4.2.3-18 CT scan after inter-

laminar bilateral decompression
using the unilateral approach.
Fig 4.2.3-14 Caudally seques- Fig 4.2.3-15 AP x-ray image

trated spinal disc herniation on for assessing the interlaminar
preoperative MRI. window.
Fig 4.2.3-17 Central spinal ca-

nal stenosis on preoperative MRI.
Fig 4.2.3-16 MRI after inter- Fig 4.2.3-19 CT reconstruction

laminar decompression. after decompression.

12 Other areas of application stricted, and adequate bone resection is limited. Greater
mobility is provided posteriorly as well as the possibility
Depending on the pathology and individual patient anato- of carrying out all surgical procedures under direct vision.
my, the transforaminal and interlaminar approaches may The spinal disc is retained. Surgery is primarily focused on
also be used in the region of the thoracic spine. The main lateral pathologies due to the risk of damage to the spinal
indication is constituted by thoracic spinal disc herniation cord during manipulation, as evidenced from standard
without significant spinal cord compression, with persisting posterior foraminotomy. Other indications may be poste-
symptoms despite conservative therapy. Generally, only rior pathologies like facet cyst, epidural abscess, or spinal
pathologies in a lateral position are operable since manipu- stenosis.
lation of the spinal cord must be avoided due to the risk of
lesion, and a lateral transforaminal approach is precluded
by the organs located in the thorax. Technical implementa- 13 Key learning points
tion of both ports is equivalent to the lumbar procedure,
and is possible from the cervicothoracic to the thoracolum- • Full-endoscopic surgery is primarily decompression sur-
bar junction. Other indications may include posterior pa- gery, and is therefore mainly indicated for the treatment
thologies, such as facet cyst, epidural abscess, or spinal of leg symptoms, eg, radicular pain or neurogenic clau-
stenosis. Contrary to the lumbar spine, in the case of the dication
thoracic spine there is a higher overall risk of injury to the • On the basis of evidence-based medicine criteria, full-
neural and the surrounding structures, both in the imple- endoscopic surgery offers improved visualization and
mentation of the ports and during the surgical procedure. illumination
In borderline cases, as far as anatomy, pathology, and symp- • Full-endoscopic surgery is advantageous for both the
toms are concerned, conventional open surgery may be the patient and surgeon
only appropriate option. • Cost benefits to full-endoscopic surgery
• The different surgical approaches have very specific in-
The anterior transdiscal and the new posterior forami- dications and contraindications depending on the un-
notomy techniques can be used in the region of the cervi- derlying pathology and need to be carefully selected
cal spine. Only relatively small endoscopes with more • Alternatively, surgery can be performed on all patholo-
restricted visualization possibilities and a small intraendo- gies within the spinal canal using the interlaminar ap-
scopic working channel can be used for the anterior trans- proach. The trans-/extraforaminal approach is manda-
discal procedure. Some specific surgical procedures have tory for intra-/extraforaminal pathologies
to be carried out in the absence of direct visualization un- • Full-endoscopic surgery may have a demanding learn-
der x-ray control, mobility in the spinal canal may be re- ing curve.
327

14 References
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1: S24–S29.

Ruetten S, Komp M, Merk H, et al (2008) Full- Ruetten S, Komp M, Merk H, et al (2009) Recurrent
endoscopic interlaminar and transforaminal lumbar lumbar disk herniation following conventional
discectomy versus conventional microsurgical technique: discectomy: a prospective, randomized study comparing
a prospective, randomized, controlled study. Spine; full-endoscopic interlaminar and transforaminal versus
33(9):931–939. microsurgical revision. J Spinal Disord Tech; 22(2):122–
129.
Therapy Randomized controlled trial I–II Study type Study design Class of evidence
Purpose
To compare results of lumbar discectomies in full-endo- Purpose
scopic interlaminar and transforaminal technique with To compare results of lumbar revision discectomies in
the conventional microsurgical technique. full-endoscopic interlaminar and transforaminal tech-
nique with the conventional microsurgical technique.
P Patient Degenerative lumbar spine with herniation (N = 178)
I Intervention Lumbar discectomies with full-endoscopic interlaminar and P Patient Recurrent lumbar disc herniation (N = 87)
transforaminal technique I Intervention Full-endoscopic interlaminar and transforaminal discectomy
C Comparison Lumbar discectomies with the conventional microsurgical C Comparison Conventional microsurgical discectomy
technique
O Outcome VAS, German version of the North American Spine Society
O Outcome Visual analog score (VAS), German version of the North Instrument, Oswestry Low Back Pain Disability Questi-
American Spine Society Instrument, Oswestry Low Back Pain onnaire
Disability Questionnaire
Authors’ conclusion The clinical results of the full-endoscopic technique are
The clinical results of the full-endoscopic technique are equal to those of the microsurgical technique. There are
equal to those of the microsurgical technique. At the same also advantages in the operation technique and reduced
time, there are advantages in the operation technique traumatization of the full-endoscopic technique.
and reduced traumatization.
329

Ruetten S, Komp M, Merk H, et al (2009) Surgical

treatment for lumbar lateral recess stenosis with the
full-endoscopic interlaminar approach versus
conventional microsurgical technique: A prospective,
randomized, controlled study. J Neurosurg Spine;
10(5):476–485.

Purpose
To compare the surgical results for the full endoscopic
technique via the interlaminar approach with those of
the conventional microsurgical technique in patients with
degenerative lateral recess stenosis.
P Patient Lumbar degenerative lateral recess stenosis (N = 161)

I Intervention Full-endoscopic decompression via interlaminar approach
C Comparison Conventional microsurgical decompression
O Outcome VAS for pain, German version of the North American Spine
Society instrument, Oswestry Low Back Pain Disability
Questionnaire, complication rate
The clinical results of the full-endoscopic interlaminar
technique are equal to those of the microsurgical tech-
nique. At the same time, there are advantages in the op-
eration technique, such as reduced traumatization.

4.2.4 Mini-open and percutaneous pedicle instrumentation
and fusion
Khai Lam, Lukasz Terenowski
1 Historical perspective within the subcutaneous superficial plane. The risk of infec-
tion was thereby reduced, but as it was an inherently me-
Posterior instrumentation and fusion techniques performed chanically weak construct, this technique led to high non-
via a standard open approach with a midline lumbar inci- union rates. It was also uncomfortable for patients, and
sion and subperiosteal muscle dissection are associated with ultimately did not gain widespread approval.
the risk of iatrogenic soft-tissue and muscle injury. Many
recently published studies have confirmed approach-relat- Foley [6, 7] presented a system for placing percutaneous
ed changes affecting the paraspinal muscles and their effect screws and rods in the submuscular plane, which was made
on clinical outcomes [1–3]. Kawaguchi et al [2] highlighted possible by using screw extension sleeves and a unique rod
the impact of protracted retraction times and increased pres- insertion device.
sure on the paraspinal muscles. Intraoperative multifidus
muscle biopsy specimens showed histopathological lesions, In the treatment of degenerative disc disease, Cloward [8,
the development of which was dependent on retraction 9] was the first to consider that posterolateral fusion (PLF)
time and the pressure induced by self-retaining retractors alone was insufficient, and that it was associated with an
during posterior lumbar surgery. Gejo et al [1] evaluated unacceptably high nonunion rate and symptom recurrence.
the influence of posterior surgery muscle damage on clini- He therefore proposed interbody fusion using structural
cal outcome. These authors found significant positive cor- bone autograft, a procedure that is commonly referred to
relations between retraction time and the severity of mus- as posterior lumbar interbody fusion (PLIF). There are sev-
cle injury, decreased muscle strength, and magnitude of eral clinical advantages of PLIF over instrumented PLF. These
persistent low back pain three and six months after surgery. include higher fusion rates, more complete decompression
Using CT scans, Sihvonen et al [3] examined a large patient of the spinal canal and nerve roots, improved biomechan-
population with a long-term follow up after previous lum- ical properties of the construct, and restoration of interver-
bar spine surgery. They concluded that patients with the tebral height in the case of segmental lordosis. Despite all
worst clinical outcomes were those for whom electromyo- these advantages, PLIF remains a technically demanding
graphic (EMG) studies and paraspinal muscle biopsies re- procedure that necessitates the removal of the posterior
spectively revealed poor performance tests and local dener- stabilizing ligamentous structures and frequent retraction
vation atrophy. As a consequence, surgeons have of the neural elements.
endeavored to develop alternative techniques to reduce
muscle damage to the paraspinal musculature and to im- The transforaminal lumbar interbody fusion (TLIF) is a dif-
prove the patients’ clinical outcomes. ferent concept, designed to achieve the same goal, ie, a
circumferential lumbar fusion through a single posterolat-
Magerl [4] pioneered minimally invasive instrumentation eral incision that is performed in a less traumatic manner.
of the spine, and in 1982 used percutaneous pedicle screw First described by Harms and Jeszenszky in 1998 as an open
insertion into the spine. In trauma settings, he combined procedure [10], TLIF approaches the spine more laterally
pedicle screws with external fixation in the lower thoracic and thereby preserves more of the posterior ligamentous
and lumbar spine. However, this technique was associated and bony complex, and certainly requires less retraction of
with high infection rates and was poorly tolerated by the the nerve root and thecal sac. In modern-day surgery, it
patients. has now become a well-established technique associated
with good clinical outcomes, high fusion rates and a low
A subsequent modification of this procedure was introduced incidence of complications, and has more recently been
by Mathews and Long [5] in 1995. They inserted pedicle applied in minimally invasive spine surgery (MISS) [11, 12].
screws with longitudinal connectors beneath the skin, but
331

Authors Khai Lam, Lukasz Terenowski
In 1994, Foley and Smith [13] introduced a unique tubular The mini-open (nonvisual) or percutaneous approaches,
retractor system which was initially designed for microdis- the latter more precisely referred to as a transmuscular ap-
cectomy, and that is composed of a series of sequential di- proach, utilize sequential tubular dilators followed by ex-
lators to help split the muscle working corridor in an atrau- tension screw sleeves and rod insertion devices to assist in
matic fashion, to allow surgical access. In 2003, adaptation the insertion of the pedicle screws and rods (Fig 4.2.4-1).
of this non-expandable tubular retractor system and sub- These pedicle screw fixation nonfusion techniques are per-
sequent expandable tubes have led to the concept of mini- formed indirectly, ie, without direct visualization of the
mally invasive TLIF (misTLIF) [14]. target area, and are entirely dependent on image intensifi-
cation, or computer-assisted 3-D navigation (see chapter
Over the last decade, there has been a significant evolution 1.6 Computer-assisted navigation for minimally invasive
and expansion in performing these original techniques of spine surgery). Therefore, these techniques offer a truly
PLIF or TLIF in a minimally invasive fashion [15–18]. Today, minimally invasive approach that causes the least access-
less traumatic instrumentation techniques have now become and retraction-related damage to the surrounding soft tis-
established as reliable, and are regularly performed as a sues. However, to perform either a PLIF or TLIF, interbody
method of choice by many spine surgeons, practicing MISS, fusion has to be achieved via a separate working port or
in treating a wide spectrum of spinal disorders. tube. Other alternative interbody fusion approaches include
the extralateral interbody fusion (XLIF, or translumbar dis-
In the following chapter, the terminology connected with cectomy and fusion; see chapter 4.3.3 The lateral approach
minimally invasive strategies will be discussed together with to the lumbar spine) or anterior interbody fusion technique
detailed surgical techniques for performing mini-open vi- (ALIF; see chapter 4.3.1 Minimally invasive anterior midline
sual and nonvisual misTLIF.
2 Terminology
Posterior approaches to the spine can be classified by their

degree of invasiveness, ie, i) open; ii) mini-open (visual or
nonvisual); or iii) transmuscular, more widely known as
the “percutaneous” approach.
A midline standard open exposure offers reasonable access

with good visualization of the target structures and sur- a b
rounding anatomy. This approach allows for the direct vi-
sual placement of pedicle screws, interbody cages, and bone
graft. It is performed, however, to the detriment of certain
key factors: operative time, blood loss, and damage to the
paraspinal soft tissues, which results in scarring and subse-
quent reduction in postoperative muscle function, are all
increased. There are also potentially negative consequenc-
es on the short- and long-term clinical outcomes.
Mini-open or minimal access “visual” techniques utilize c d

soft-tissue dilators and expandable tubular retractors. This
Fig 4.2.4-1a–d
internervous muscle splitting or Wiltse approach [19] sig- a AP image intensification of L5/S1 showing that the tip of the Jam-
nificantly reduces posterior soft-tissue and muscle trauma, shidi needles have not breached the medial pedicle wall. Note
and at the same time allows for direct visualization of up the divergent position of the needles.
to two spinal motion segments. Furthermore, the approach b–c Lateral image intensifcation confirming that the needles have
been advanced into the posterior vertebral body before a guide
enables direct visual placement of pedicle screws, interbody
wire is threaded, followed by tapping of the pedicle.
cages and bone graft. d Lateral image intensification showing that an appropriate length
precountoured rod has been secured in position into the polyaxial
heads of the pedicle screws.

4 Lumbar/Sacral techniques | 4.2 Posterior approaches
4.2.4 Mini-open and percutaneous pedicle instrumentation and fusion
approach to the lumbar spine and lumbosacral junction). • Interbody disc space collapse with exit foraminal nerve
Subsequent supplementary posterior segmental fixation root compression secondary to:
helps secure the facets in extension, and thus restores the • DDD
integrity of the posterior tension band in order to minimize • Lateral recess stenosis
interbody graft loading, and therefore improves the outcome • Lytic or degenerative spondylolisthesis
of an interbody fusion. • Postdiscectomy or laminectomy syndrome
• Treatment of pseudarthrosis where interbody fusion is
required.
3 Patient selection
3.2 Contraindications for misTLIF
Posterior mini-open and transmuscular pedicle screw in- • Treatment of sagittal and coronal deformities of the lum-
strumentation and fusion techniques can be used for treat- bar spine
ing a large number of different spinal pathologies, eg, de- • Degenerative kyphosis/scoliosis
generative disorders, trauma, tumors, infections and certain • Postlaminectomy kyphosis
select cases of spinal deformity [20]. The main goal is to • Multilevel disease (> 2)
minimize collateral damage to the posterior soft tissues. • Deep-seated pelvis with high iliac wing—iliac crest os-
However, it has to be kept in mind that patient selection, teotomy feasible to help gain surgical access
indications and subsequent surgical techniques remain the • Morbid obesity.
same, irrespective of the choice made between a standard
open or minimally invasive approach. For the most part,
degenerative disc disease (DDD) resulting in discogenic low 4 Pros and cons
back pain, lumbar spinal lateral recess stenosis, and degen-
erative spondylolisthesis leading to segmental instability The main advantage of MISS over the open procedures is
are the main indications for the application of these ap- its distinct preservation of the posterior soft tissues and
proaches. paraspinal muscles. However, presently there are no level
1 randomized control trials investigating the differences in
In the degenerative setting, misTLIF has been established outcome between misTLIF and open TLIF. In the literature,
as a safe and reliable technique for performing single- or the remaining differences between these two procedures
double-level surgery [21], and in some cases revision surgery are predominantly observed in their immediate intraop-
[22]. Therefore, circumferential lumbar fusion through a erative and short-term clinical outcome results [23, 24].
single-stage posterior mini-open approach is readily achiev- Conversely, the long-term clinical outcomes appear com-
able in this way. In some patients, the disc space is much parable [23].
too collapsed to accommodate an interbody cage; thus in
these cases, the mini-open PLF will suffice. 4.1 Advantages
Intraoperative advantages:
3.1 Primary indications for misTLIF • Reduced approach-related soft-tissue and paraspinal
• Primary DDD causing discogenic low back pain with or muscle injury
without disc herniation • Reduced blood loss
• Segmental instability causing low back pain with or • Reduced length of surgery
without nerve root compression • Reduced intraoperative complications, ie, dural tear,
• Lytic or degenerative instability neural and vascular injuries, implant malpositioning.
• Lytic or degenerative grade I or II spondylolisthesis
• Traumatic instability Immediate and short-term advantages:
• Postoperative or iatrogenic instability following ex- • Reduced postoperative pain and analgesic intake
cessive facetectomy or removal of the pars interar- • Reduced total blood loss (and drain blood loss), obviat-
ticularis ing the need for blood transfusion
• Unilateral facet-joint dysplasia or tropism • Allows for early mobilization and reduced need for re-
• Previous surgery causing low back pain with or without habilitation
nerve root compression • Reduced length of hospital stay, possibly performed as
• Post-discetomy syndrome day surgery
• Post-laminectomy syndrome • Reduced early complications, eg, wound infection.
333

Long-term advantages: Standing AP and lateral plain x-rays of the whole spine as
• Decreased local denervation and atrophy of paraspinal well as the pelvis and femoral heads, and also flexion/ex-
muscles tension dynamic x-rays are extremely useful. They provide
• Increased fusion rate (a large number of studies suggest basic information about important parameters concerning
that this may be related to the more frequent use of the spine, such as sagittal and coronal spinal balance, ver-
bone morphogenetic proteins (BMPs) and therefore this tebral anomalies, segmentation anomalies, segmental and
requires re-evaluation) global lordosis, intervertebral disc-space height loss and
• Satisfying cosmetic effect foraminal height loss. MRI provides accurate views of the
• Early return to work and sports activity soft tissues and is a useful means of determining the loca-
• Reduced adjacent-level DDD due to preservation of soft tion and extent of disc herniation, or stenotic elements that
tissue and posterior elements. impinge on the neural structures. It is also essential in plan-
ning the exact level of the spinal decompression, implant
4.2 Disadvantages size, length and position in relation to the surrounding
Intraoperative disadvantages: anatomy. Furthermore, it is useful in cases of revision sur-
• Training and certification required gery in determining the exact location and extent of scar-
• Limited to one or two levels; in addition, limited mul- tissue formation. In contrast, CT scans give clearer definition
tisegmental surgery is unachievable of the bony elements of the spine, and can provide addi-
• Limited visualization of the target area anatomy tional information about pars defects, bony stenotic ele-
• Steep learning curve compared to open surgery ments, osteophytes, the 3-D characteristics of deformities,
• Increased x-ray exposure time, however, this can be and previous fusion procedures. Exact pedicle screw mea-
minimized with the use of computer-assisted navigation surements, ie, diameter, length, and orientation may be
• Reconstructive surgery of long kyphotic and scoliotic evaluated on CT scans as well as on MRI using calibrated
deformities unachievable tools that are integrated into interactive software radiology
• Morbid obesity makes surgery impossible. modules.
Short- and long-term disadvantages: Because of the limited access and intraoperative views, it
• More extensive soft-tissue dissection when considering is crucial to adjust the patient’s preoperative on-table posi-
proximal or distal extension of fusion. tion accordingly, and to accurately determine the surgical
corridor. Additional factors, such as the optimal placement
of image intensification equipment, navigation devices,
5 Preoperative planning and positioning television monitors, and microscope, should also be taken
into full consideration because these utilities will ultimate-
The significance of preoperative planning remains extremely deplete the surgeon’s essential operational space around
ly high, and is strongly correlated with clinical outcomes the operating table. Spending invaluable time on these
in MISS. A limited working corridor permits only a partial considerations at the preoperative stage translates into time
view of the potentially complex target pathology. Because saved during the operative procedure.
only a limited number of anatomical landmarks are exposed,
accurate preoperative CT scans and MRI are essential ad- The patient may be positioned prone on a Montreal mattress
juncts in ensuring the accurate positioning of the implants. and radiolucent frame table. Both arms are abducted at 90°
This accuracy may be noticeably improved with the use of and secured with arm pads in a symmetrical manner. In the
intraoperative 3-D computer-assisted navigation. event of the patient presenting with hyperlordosis, this
causes closing of the posterior intervertebral disc spaces and
Preoperative planning starts with proper patient selection. makes the procedure more challenging. Furthermore, fusion
Information obtained from the patient’s history, physical in this position may overload the facet joints. On the other
examination, clinical diagnostic testing and imaging studies hand, fusion in a kyphotic position, especially when per-
(eg, MRI, CT scan, static and dynamic x-rays) should be forming a bisegmental fusion, results in an unacceptable
sufficient to determine the appropriate level or levels re- flat-back surgery syndrome. Placing both the hips and knees
quiring surgery. If any doubts remain, then electromyog- in a semiflexed position helps eliminate a flat-back posture.
raphy, nerve conduction studies (NCS), discography, or For a more convenient working corridor, the present authors
selective facet joint and nerve root injections may be useful prefer to keep the desired intervertebral disc space almost
preoperative adjuncts to help establish a final diagnosis. perpendicular to the floor, which is especially invaluable

at the L5/S1 level. General anesthesia is routinely performed, sected at the level of the corresponding facet joint complex,
and a single dose of preoperative antibiotic prophylaxis is if surgery involves a monosegmental fusion, or at the mid-
administered approximately 30 minutes before the skin dle of the pedicle if a bisegmental fusion is planned. When
incision. A standard mandatory pre incision surgical check- using expandable soft-tissue retractors, a 3–4 cm cranio-
list is routinely made in order to minimize any surgery- caudal vertical incision will suffice for single-level, and
related complications. should be extended to 5–6 cm for double-level surgery.
The senior author’s preference is to start with the less symp-

6 Surgical technique tomatic or asymptomatic side first. After the skin incision,
the subcutaneous and fat-tissue layers are incised from the
6.1 Mini-open misTLIF or PLF underlying fascia inferiorly until the iliac crest is digitally
The senior author prefers a mini-open visual technique for palpable. This optional subfascial incision is made to harvest
performing a misTLIF. This ensures direct visualization and iliac crest autograft bone to help enhance the bone fusion.
decompression of the target pathology, with reduced image Bone wax is used to stop the bone from bleeding, a drain is
intensification time, the possibility to perform a full decor- securely positioned, and the fascia is approximated with a
tication of the bony elements, and the subsequent execution running suture. Using the same skin incision, a second me-
of a posterolateral fusion. In this regard, this technique dially orientated subfascial incision is performed for tubular
allows for an absolute 360° motion segment fusion. retractor placement. A medially orientated blunt digital dis-
section between the multifidus and longissimus muscles is
After aseptic preparation and draping of the patient, the made according to the Wiltse internervous muscle-splitting
skin incision is planned using AP image intensification and approach [19]. The soft tissues between the palpable trans-
marking of the skin. For each specific motion segment, the verse processes are gently swept aside in a cephalocaudal
amount of lordosis of the gantry must be adjusted so that manner. Then sequential soft-tissue dilatators are docked
the endplates are seen in parallel. The midline spinous pro- accurately over the desired facet-joint complex, which is
cesses and lateral border of the pedicles are used as ana- confirmed under AP and/or lateral image intensifier control
tomical guidelines (Fig 4.2.4-2). The skin incision should be (Fig 4.2.4-3). Appropriate-length tubular retractors are firm-
positioned approximately 1.0–1.5 cm lateral to the outer ly inserted and medially angulated for optimal trajectory.
pedicular line or 4.0–4.5 cm lateral to the midline and bi- The dilators are removed and the working port is securely
TLIF
4.0–4.5 cm
Pedicle screw
3.0–3.5 cm
PLIF
2.0–2.5 cm
Discectomy
1.0–1.5 cm
a b
Fig 4.2.4-2a–b Fig 4.2.4-3 AP image intensifica-
a AP intraoperative image intensification used in tion confirming that the tubular
helping plan the incision. The midline spinous retractor is accurately docked
processes and lateral border of the pedicles serve over the desired L4/5 facet-joint
as anatomical guidelines. A 3–4 cm vertical inci- complex.
sion should be positioned adjacent to the facet-
joint complex, represented by the knife blade in
the case of a monosegmental L4/5 TLIF.
b Representation of the variation in transverse plane
distances from the vertical midline of the spine
depending on the planned surgical procedure.
335

fastened to the table frame and adjusted with a flexible located at the mamillary process, which corresponds to the
clamp. The retractor is gently expanded as required in a midpoint junction where the transverse process meets the
cephalo-caudal direction to fully visualize the target seg- superior articular process of the facet joint. The appropriate
ment, which is confirmed by image intensification before length, diameter and trajectory of the pedicle screws that
proceeding further (Fig 4.2.4-4). Appropriate length medio- have been preplanned on preoperative CT scans or MRI are
lateral distraction blades are adjusted to provide maximal inserted and confirmed under AP and lateral image inten-
visualization of the surgical working area. The remaining sification, or using computer-assisted 3-D navigation. An
soft tissues are removed using electrocautery and pituitary appropriate length rod is inserted and tightened temporar-
rongeurs down to, but not beyond, the intertransverse mem- ily in a semidistracted position in order to help open up the
brane. The facet joint and transverse process are identified interbody disc space. Iliac crest bone autograft bulked with
and decorticated using a high-speed drill. The pedicles are a bone extender, eg, demineralized bone matrix (DBX) or
opened under direct visualization by gently introducing a tricalcium phosphate (TCP) granules, is carefully placed over
pedicle awl and finder, then palpated with a pedicle feeler the decorticated transverse processes, pars interarticularis,
and tapped (Fig 4.2.4-5). The exact pedicle entry point is and facet joint. It is generally considered best to avoid using
Fig 4.2.4–4a–b
a AP image intensification showing that the
retractor has been expanded appropriately
in a cephalo-caudal direction to visual-
ize the target L4/5 segment. A pituitary
rongeur has been used to confirm the
position of the superior transverse process.
b A spine model showing mini-open direct
visualization of the posterolateral L4/5
facet-joint complex and transverse pro-
a b cesses.
a b c
Fig 4.2.4-5a–e The pedicle entry points are

directly visualized and entered using a pedicle
awl and finder. The integrity of the pedicle must
be confirmed both clinically by palpating with a
pedicle feeler, and radiologically by using intra-
d e operative AP and lateral image intensification.

BMPs because of their highly angiogenic characteristics, The other decompression technique comprises the "In-Out"
which may result in undesirable but temporary postopera- or intracanal technique. This technique is especially useful
tive inflammatory radiculitis. when, on the basis of the clinical symptoms and subsequent
preoperative planning, bilateral spinal canal and nerve root
The exact same steps are repeated on the contralateral, decompression is desired, which can be readily performed
symptomatic side, except for harvesting of the iliac bone via an ipsilateral approach in order to reach the contralat-
autograft. The pedicle entry points are plugged with bone eral pathology (see chapter 4.2.1 Bilateral decompression
wax to prevent blood from continually oozing into the work- in lumbar spinal stenosis through a microscope-assisted
ing field. Then the retractor blades are angled medially and monolateral approach). In this case, a thorough complete
the working zone over the facet joint is cleared out of its facetectomy and removal of the ligamentum flavum from
remaining soft tissue. Using a combination of bayoneted its laminar attachment is performed. For improved visual
Kerrison rongeurs, osteotomes, and a long-tipped high- access, the patient is tilted away on the table frame and the
speed drill, a unilateral subtotal facetectomy is performed retractor is angled more acutely in a medial direction. The
under direct visualization using a head light source, surgi- base of the spinous process and inferior aspect of the con-
cal loupes, or microscopic assistance. tralateral lamina are undercut using a Kerrison rongeur
and/or high-speed drill. When the dura is gently retracted,
The senior author considers that two different modified this maneuver permits direct visualization and decompres-
techniques are available to perform a comprehensive de- sion, ie, flavectomy and facet undercutting of the contra-
compression of the spinal canal and nerve roots according lateral stenosis to reach the nerve root that is trapped be-
to the patient’s clinical symptoms and preoperative plan. neath the lateral recess. The ligamentum flavum may be
The first technique comprises the “Out-In”, or extracanal temporarily used to prevent iatrogenic neural damage when
technique, which is the true TLIF technique that is princi- performing a posteriorly directed channel of decompression
pally indicated in situations with a paracentral, lateral or towards the lateral recess, and subsequently removed to-
extra-lateral disc herniation or foraminal osteophytic pa- wards the end of the decompression. Following a satisfac-
thology associated with segmental DDD or instability. A tory adequate decompression, a subtotal discectomy is per-
unilateral, subtotal facetectomy is performed with preserva- formed as described above.
tion of the ligamentum flavum in most cases. The triangu-
lar “working space” is made up of the exiting nerve root Using a combination of enlarging trial implants and fixed
laterally, the dura alongside the traversing nerve root me- distraction of the contralateral screw-rod construct, the
dially, and the superior border of the inferior pedicle. The intervertebral disc space is comfortably enlarged to its nat-
exiting nerve root is identified and protected with a Neuro ural size, which helps restore the normal physiological lor-
Patty. Bleeding from the epidural veins is cautiously cauter- dosis and neuroforaminal diameter. The appropriate size
ized with a bipolar forceps, thus exposing the intervertebral of the implant is confirmed by lateral image intensification
disc that is visualized at its posteromedial aspect, ie, the (Fig 4.2.4-6) before placement of the cage, which is tightly
axilla of the exiting nerve root. pre-packed with bone autograft (from the iliac crest and/
or decompressed local bone) and extended with DBX. Un-
While protecting the neural structures, a scalpel blade is der image intensification, the curved interbody cage is care-
used to carefully incise the annulus fibrosus and as much fully rotated into a position that is close to the anterior
of the disc material that can be removed down to the bleed- margin of the vertebral endplates to help achieve lordosis
ing endplates. The bony endplates are prepared methodi- restoration and uniform apophyseal loading, and to prevent
cally using a variety of bayoneted cartilage shavers, curettes, cage migration (Fig 4.2.4-7). The interbody disc space
and rasps. During this process, sequential distraction of the posterior to the cage is filled tightly with bone autograft
contralateral screw-rod construct is applied to help achieve and DBX.
an adequately wide opening of the interbody space. In or-
der to improve trial and final cage access into the interver- Afterwards, the transverse processes and surrounding bone
tebral space, the posterior marginal endplates and osteo- are decorticated with a high-speed drill. Final pedicle screw/
phytes are removed using a combination of osteotomes, rod instrumentation is secured in position, and the remain-
Kerrison rongeurs, or a high-speed drill. Then the disc space ing bone graft and DBX is placed in the posterolateral gut-
and lateral recess is carefully examined using a neurologi- ter for the fusion. Uniform bilateral compression of the
cal hook to remove any residual disc material or bony end- pre-contoured lordotic rod must be gently applied to the
plates. interbody cage to prevent unwanted intracanal implant and
337

bone-graft migration. Finally, an angled nerve hook is used approximated with running sutures (Fig 4.2.4-9). A drain is
to confirm that both the traversing and exiting nerve roots generally not required due to the limited empty surgical
are free of any soft tissue or bony compression. Once the dead space that has been created. Evidently, when the disc
final AP and lateral image intensification has confirmed the space is far too collapsed, a PLF rather than a TLIF will suf-
correct positioning of all the implants (Fig 4.2.4-8), the fice, provided that the affected nerve roots have been ad-
wounds are irrigated with saline, and the soft-tissue layers equately decompressed.
a b
Fig 4.2.4-6 Lateral image intensifi- Fig 4.2.4-7a–b
cation showing that an appropriately a A definitive-size cage has been tightly packed with a mixture of bone autograft
sized trial implant has been used for and DBX.
a L4/5 misTLIF. b Under lateral image intensification, the interbody cage has been rotated into a
position that is satisfactorily close to the anterior margin of the apophyseal end-
plates.
a b
Fig 4.2.4-8a–b Final AP (a) and lateral (b) intensification images confirming Fig 4.2.4-9 Immediate postoperative closed
the correct positioning of all implants, in this case showing a 2-level L4–S1 wounds, in this case showing 4 cm long
misTLIF. wounds after performing mini-open L4/5
misTLIF.

6.2 Mini-open nonvisual and transmuscular misTLIF the attached extension sleeves is inserted (Fig 4.2.4-1c), then
Alternatives to the mini-open visual misTLIF described above a rod is introduced using a rod insertion device (Fig 4.2.4-1d)
are the somewhat less invasive mini-open nonvisual and trans- and distracted as required to help open up the intervertebral
muscular misTLIF. The subtle variation in these techniques space opening, and temporarily tightened.
depends on the type of pedicle screw system that is employed,
and therefore dictates whether the respective incision needs A nonexpandable tubular working port is inserted using
to be created via a single 2–3 cm long incision or multiple 1.5 sequential dilators and docked over the facet complex using
cm stab incisions. Both these techniques of screw fixation are maneuvers that are very similar to the technique described
perceived as being the least invasive, but their major short- above. Both the “In-Out” and “Out-In” techniques of de-
coming is that they are both performed entirely “blind”, and compression are possible. Once the tubular port is perfect-
are thus wholly dependent on image intensification or com- ly positioned and securely tightened to a flexible table clamp,
puter-assisted 3-D navigation. Additionally, they are consid- routine preparation of the disc space and decompression
ered to be fixation nonfusion techniques; it is therefore man- remains almost identical to that described above. At this
datory to achieve interbody fusion using a different point, contralateral distraction of the screw-rod construct
nonexpandable port or an alternative access for the fusion, is performed to improve access to the intervertebral disc
eg, a tubular port for PLIF, TLIF, ALIF, or XLIF. In these cases, space. Unfortunately, a direct view into the disc space is
a 270° intervertebral interbody fusion can be achieved. limited and frequent suboptimal contralateral disc space
clearance remains a technical drawback. Endplate prepara-
In the case of a misTLIF, there are no specific differences in tion and cage insertion remains indistinguishable from the
skin incision planning, approach and fixation between these mini-open visual technique. Once the appropriately sized
two techniques. Firstly, the pedicle screws are inserted be- cage prepacked with a mixture of local autograft bone and
fore performing the interbody fusion. For a one-level fusion, DBX or BMP has been inserted, the pedicle screw-rod con-
and under direct AP image intensifier control or 3-D navi- struct is compressed uniformly on both sides. A drain is not
gation, two separate 1.5 cm stab incisions (or one single 3 routinely placed in this technique, and the soft tissues are
cm incision) are planned approximately 3–3.5 cm lateral to approximated in layers using running sutures.
the midline of the spinous processes at the level of the cor-
responding pedicle (Fig 4.2.4-2). Once the skin and fascia
have been incised in a Wiltse-type approach, a beveled 7 Postoperative care
Jamshidi needle is placed onto the transverse process by
manual palpation and then gently maneuvered medially • Thromboembolic prophylaxis with fractionated heparin
until it meets the superior articular process. The entry point until full mobilization is possible (usually 2 to 3 days)
for the pedicle screw is approximately at the 9.00 o’clock • Two postoperative doses of antibiotic prophylaxis
position on the left side (Fig 4.2.4-1a) and at 3.00 o’clock on • Mobilization on the first postoperative day with the aid
the right side on the AP view. The image intensifier gantry of a physiotherapist
may be tilted approximately 10° laterally to develop an • No additional immobilization or brace is required
“en-face” visualization of the pedicle. As for the mini-open • Optional wound drain removed on the first or second
visual TLIF, for each specific motion segment the amount postoperative day
of gantry lordosis must be adjusted so that the endplates • Wound dressings changed as required
are seen to be “in parallel”. • Check standing AP and lateral x-rays once the patient
is independently mobile
Then the beveled Jamshidi needle is introduced medially • The patient is discharged on 2nd or 3rd postoperative
through the pedicle until it reaches the posterior vertebral day or when independently mobile
body wall without touching or breaching the medial pedicle • The patient is advised to limit lumbar spinal movements
wall (Fig 4.2.4-1a–b). Afterwards the projection is altered to for the first 3 months of surgery
the lateral view and the needle is gently advanced by an- • Gentle outpatient core stability exercises for up to 6
other 1 cm. Moving the image intensifier projection between weeks, with no restrictions thereafter depending on pa-
AP and lateral views will help to ensure the correct placement tient capability
of the Jamshidi needle; rotating the bevel will also help guide • Routine clinical assessment (Oswestry Disability Index
the needle tip to the desired position. Then a threaded guide- [ODI] and visual pain analog scale [VAS]); and check
wire is inserted into the posterior vertebral body. After tap- plain x-rays at 3, 6, 12, and 24 months after surgery
ping for an appropriate length, the cannulated screw with • Optional CT scan 3–6 months after surgery.
339

8 Evidence-based results operative back VAS was 22% in the misTLIF versus 43%
in the open group. However, the mean x-ray exposure time
Minimally invasive instrumentation and fusion techniques was higher in the misTLIF at 73 s compared to 39 s in the
have gained increasing popularity in the last decade. Nev- open group. The authors reported a higher incidence of
ertheless, prospective randomized controlled trials compar- dural tears and superficial wound infections in the open
ing minimally invasive versus open techniques are so far TLIF group. No significant differences were reported in the
lacking in the published literature. Most papers report ret- operating times, or long-term clinical (Oswestry Disability
rospective case series, ie, class of evidence level III studies. Index (ODI) and VAS scores) and radiological outcomes.
For the most part, these limited studies report a trend to-
wards reduced operative blood loss, shorter operating times
and hospital stays in favor of misTLIF, but the results re- 9 Complications and avoidance / salvage
garding long-term clinical and radiological outcomes be- procedures, learning curve
tween the two techniques appear to be equivocal.
Much of the literature has reported reduced complication
In a quantitative meta-analysis on published studies (up to rates among the minimally invasively treated population
March 2008), Wu et al [24] reported two main clinical out- groups. In Wu et al’s meta-analysis of published studies [24],
comes, ie, fusion rates and complication rates for both open general complication rates were 12.6% for the open and
TLIF and misTLIF in the treatment of symptomatic degen- 7.5% for the misTLIF groups.
erative lumbar disease. A total number of 1028 patients
with a mean age of 49.7 years (range 38–64.9) and a mean Complications can be divided into those occurring during
follow-up 26.6 months (range 6–46) were included in their the intraoperative period, in the early postoperative period
statistical analysis. Spinal fusion, as defined by CT evidence and those occurring later on. Dural tears with cerebrospinal
of trabecular bone bridging or lack of motion on lateral fluid (CSF) leakage and radiculopathy were the most com-
flexion/extension x-rays, was observed in 90.9% of the monly reported intraoperative complications in both groups.
open TLIF versus 94.8% of patients in the misTLIF groups. However, because of a more lateral and physiological ap-
However, the use of BMP was significantly higher in the proach, neural element injuries are less likely to occur in
misTLIF group (50% versus 12%). Complication rates were the minimally invasive group. To prevent these complica-
reduced in the misTLIF (7.5%) compared to the open TLIF tions, good visualization through accurately positioned
(12.6%) groups. working surgical corridors is essential. Additionally, vigilant
protection of the neural elements has to be ensured at all
Dhall et al [23] published a well-designed case series with a times with the use of small cottonoid Neuro Patties. These
long-term follow-up, comparing misTLIF versus open TLIF, serve to protect the dura and exiting nerve root, which are
performed via a standard midline lumbar incision and sub- continually retracted during the discectomy, endplate prep-
periosteal muscle dissection. Significant trends toward re- aration, and cage insertion maneuvers.
ducing estimated blood loss, operating times, and hospital
stays were observed in the minimally invasive group. The Open conversion in the case of dural injury with CSF leak-
mean estimated blood loss was 194 ml versus 505 ml, mean age is contraindicated, and can be justified only in the event
length of stay was 3 days versus 5.5 days, and mean operat- of severe damage. The buildup of lower volumes of CSF
ing time was 199 minutes versus 237 minutes in favor of within the restricted free dead space coupled with the high-
the minimally invasive group. No statistically significant er pressures generated by the surrounding intact muscles
difference was observed in patient clinical outcomes mea- remain favorable factors for the sealing any incidental du-
sured by the modified Prolo scale. rotomies. The interrupted dura only rarely requires suture
and repair. Additionally, a small piece of Duragen and fibrin
Wang et al [22] compared the outcomes of misTLIF against glue may be used to stop the CSF leak. In the case of con-
open TLIF performed following previous open discectomy tinuous leakage, tension sutures and a gravity drain may
or decompression procedures. Statistically significant dif- be employed.
ferences were observed in intraoperative and total blood
loss, second day postoperative pain, and x-ray exposure Also, pedicle screw and interbody spacer malpositioning
times. The mean intraoperative and total blood loss was are frequently reported problems. Preoperative planning
291 ml and 316 ml respectively in the misTLIF and 652 ml remains essential in avoiding these surgeon-related com-
and 799 ml in the open group. The mean second day post- plications. Intraoperative biplanar image intensification is

effective in confirming correct hardware positioning, but Implant failure may be secondary to poorly positioned im-
as an alternative, computer-assisted 3-D navigation may be plants and interbody cages, resulting in a deficient biome-
used to improve accuracy. Specific nerve-root EMG moni- chanical setting or nonunion as a consequence of a poorly
toring can also be useful in detecting a breach of the me- executed fusion. To this end, an accurately sized interbody
dial pedicle wall caused by the screw. spacer and correct placement within the anterior apophy-
seal rim plays an important role in both instances, restoring
Early postoperative complications, such as hematoma, su- the physiological lordosis and conferring uniform load-
perficial and deep wound infections, or general health com- bearing onto the interbody bone graft. A sturdy posterior
plications (eg, postoperative stroke, pulmonary embolism, tension band is dependent on the appropriate screw diam-
or chest infection), subsequent to a direct reduction in op- eter, length, and position, as well as on the bone quality.
erating time and blood loss combined with early mobiliza- All these factors may be predetermined on CT or bone den-
tion, may be reduced in minimally invasive cases but this sity scans, or MRI prior to the operation. Both sagittally
can only be determined through prospective multicenter divergent and coronally convergent pedicle screws provide
studies. improved biomechanical strength to the construct.
Pseudarthrosis and implant failures are considered late post- The learning curve in performing a misTLIF is rather steep,
operative complications. According to Wu et al [24], fusion but can be mastered without difficulty through proper train-
rates amounted to 90.9% and 94.8% for open and misTLIF ing and certification followed by an approved training pro-
respectively; the use of BMP in the misTLIF groups may gram. In order to achieve a sound fusion, meticulous at-
explain the improved fusion rate. Complete intervertebral tention to the correct biomechanical principles of the
disc removal and careful endplate preparation is crucial in instrumented construct, in combination with careful prep-
achieving high-quality interbody fusion. The utilization of aration of the interbody disc space and/or the posterolat-
iliac crest, versus local decompression autograft bone, ver- eral gutters, will undeniably result in highly satisfactory
sus DBX and BMP, are subject to continuing controversy. patient clinical and radiological outcomes.
The senior author’s preference is to use a combination of
DBX mixed with iliac crest bone autograft because of the
latter’s excellent osteoinductive and osteoconductive prop-
erties. Achieving a sound posterolateral and interbody fusion
will prevent the development of pseudarthrosis, and sub-
sequent implant failure.
341

10 Tips and tricks
Praveen V Mummaneni and Beejal Y Amin, move the intervening pelvic bone prior bilaterally and to restore lordosis. This
San Fransisco, USA to placement of tubular retractor. avoids the need to distract the pedicle
• The operating table can be placed in a • The surgeon should look for the Wiltse screws, which may loosen if the patient
reverse Trendelenburg position for better intermuscular plane after making the is osteopenic.
access and visualization of the L4/5 and skin and fascial incisions. • Iliac crest autograft and local bone au-
L5/S1 disc spaces. The reverse Trendelen- • Take the time to identify initial land- tograft should be packed anterior to and
burg position will orient the disc spaces marks with image intensification before within the interbody cage to achieve fu-
of L4–S1 perpendicular to the floor and bone decompression or instrumentation. sion.
facilitate visualization and instrumenta- Due to limited visualization provided • Compressing the pedicle screws bilater-
tion. by tubular retractors, the lamina may ally without performing bilateral forami-
• After preparation and draping, a super- be mistaken for the transverse process, notomies may cause iatrogenic foraminal
ficial percutaneous needle (one to two leading to attempted placement of the stenosis.
inches off midline) is placed along the pedicle screw at the lamina/spinous pro- • We prefer to carry out the TLIF proce-
lateral margin of the pedicles on the AP cess junction instead of at the transverse dure with the patient on a Wilson frame/
image intensifier view. On the lateral im- process/facet junction. Image intensifica- OSI Jackson table. Initially, the frame is
age intensifier view, this needle should tion helps minimize such errors. cranked to the kyphotic (up) position to
be in line with the target disc space. This • The pedicle entry points are prepared make decompression and graft insertion
helps the surgeon plan the ideal location with drill and gearshift. Pedicle mark- easier. Prior to securing the rod, the frame
for the mini-open skin incision. ers are placed prior to performing a fac- is returned to a lordotic (down) position.
• For obese patients (BMI over 35), the ini- etectomy for a TLIF. The pedicle markers • We use EMG screw stimulation to check
tial incision should be made more lateral serve as an orienting guide to help the for pedicle breaches with mini-open
to allow for adequate lateral-to-medial surgeon avoid excess facet removal with TLIFs.
pedicle trajectory. resultant pedicle violation. • For percutaneous pedicle screws, stim-
• AP image intensification is used to check • Time must be taken to fully remove the ulus-evoked EMG testing to detect
for a narrow posterior pelvic inlet, which disc material and care taken not to vio- breached pedicles is less reliable. Typi-
may obstruct proper screw trajectory at late the bone endplates during interbody cally a sheathed tap is stimulated to assess
S1. preparation in order to avoid cage subsid- EMG with percutaneous screws.
• If the inlet is too narrow the iliac crest ence. • References used for this tips and tricks:
bone graft may be harvested through • Trials may be used to dilate the inter- [12, 17, 23, 25].
the Wiltse-approach skin incision to re- body space to restore foraminal height

11 Case example Preoperative x-rays (Fig 4.2.4-10a–b) showed an incidental

L4 and S1–5 spina bifida occulta. The MRI showed a L4/5
A 28-year-old woman presented with an insidious-onset Pfirrmann grade III degenerate disc with a diffuse left-sid-
6-month history of acute to chronic left-sided low back pain ed disc bulge with early degenerative listhesis (Fig 4.2.4-11)
with mild L5 sciatica. Her preoperative ODI score was 44%, as well as partial tethering of the filum with a lipoma, but
and the VAS low back pain equaled her leg pain at 60%. apart from this finding, the patient was clinically asymp-
The patient underwent physiotherapy and foraminal epi- tomatic. The CT 3-D reconstruction showed a dysplastic
dural injections without satisfactory symptom relief. left-sided L4/5 facet joint (Fig 4.2.4-10c).
Clinically, reduced lumbar movements were observed sec- She underwent a straightforward left-sided mini-open vi-
ondary to low back pain and mild left L5 nerve tension signs sual L4/5 misTLIF with decompression of the left L5 nerve
beyond 50° of straight leg raising, but no abnormal neuro- root. At six months postsurgery, the CT scan and x-ray
logical findings were observed during the examination. findings confirmed a solid 360° fusion (Fig 4.2.4-12). The
patient’s ODI score at that time was 8%, VAS back pain was
10%, with 0% pain in her left leg.
c
Fig 4.2.4-10a–c
a–b Standing AP and lateral x-rays
showing incidental L4 and
S1–5 spina bifida occulta and
mild L4/5 degenerative spon-
dylolisthesis.
c The 3-D CT reconstruction
additionally showed the
dysplastic left-sided L4/5 facet
a b joint.
Fig 4.2.4-11a–b T2W sagittal and axial cuts

showing mild L4/5 degenerative listhesis and a
a b diffuse left-sided disc bulge.
343

c d
Fig 4.2.4-12a–d Six-month postoperative 3-D CT reconstruction show-

a b ing mature L4/5 posterolateral and interbody fusion.
12 Summary of different methods for pedicle screw • Over the last decade, there has been significant develop-
insertion ment and expansion of surgical techniques, instrumen-
tation and implants that assist in performing a PLIF or
• Straight AP/lateral TLIF in a minimally invasive fashion
• Bull’s-eye: The pedicles are cannulated using the “bull’s- • Atraumatic instrumentation techniques have now be-
eye” technique. An AP x-ray is taken directly in line come established as reliable, and are regularly performed
with the pedicle to be cannulated. The tip of a large-bore as the method of choice for many spine surgeons, regu-
bone biopsy is applied to the facet over the anatomical larly practicing MISS for the treatment of a wide range
center of the pedicle, then rotated in line with the ped- of spinal disorders
icle such that the shaft of the needle, the stylet cap, and • Patient selection, indications, and subsequent surgical
the pedicle are seen as concentric rings on the AP image, techniques remain identical irrespective of the choice
hence the “bull’s-eye”. The stylet of the needle is re- between an open or minimally invasive approach
moved and the K-wire is advanced into the pedicle, • MisTLIF can be performed via a direct mini-open vi-
verifying the cortical integrity of the cannulation by AP sual or indirect mini-open nonvisual approach, depend-
and lateral image intensification as the wire is advanced. ing on the type of pedicle instrumentation system utilized
The pedicle is tapped over the K-wire and a cannulated • In the case of a mini-open nonvisual misTLIF, interbody
screw is placed. The tap may be stimulated to verify fusion is mandatory and can be achieved using a differ-
cortical integrity ent portal system or surgical approach
• Navigation: 2-D and 3-D. • The learning curve in performing a misTLIF is steep, but
can be mastered without difficulty through proper train-
ing and certification followed by an approved training
13 Key learning points program
• To achieve a sound fusion, meticulous attention to the
• Posterior instrumentation and fusion techniques per- correct biomechanical principles of the instrumented
formed via a standard open approach with a midline construct in combination with careful preparation of
lumbar incision and subperiosteal muscle dissection are the interbody disc space and/or the posterolateral gutters
associated with iatrogenic soft-tissue and muscle injury will undeniably result in highly satisfactory patient
clinical and radiological outcomes.

14 References
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6. Foley KT, Gupta SK, Justis JR, et al (2002) Minimally invasive 24. Wu RH, Fraser JF, Härtl R (2010)
(2001) Percutaneous pedicle screw percutaneous posterior lumbar Minimal access versus open
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Focus; 10(4):E10. Suppl 5:S166–181. fusion: meta-analysis of fusion rates.
7. Foley KT, Gupta SK (2002) 17. Mummaneni PV, Rodts GE Jr (2005) Spine; 35(26):2273–2281.
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9. Cloward RB (1953) The treatment of Suppl 2:203–213.
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345

Park Y, Ha JW (2007) Comparison of one-level posterior Fan S, Hu Z, Zhao F, et al (2010) Multifidus muscle
lumbar interbody fusion performed with a minimally changes and clinical effects of one-level posterior lumbar
invasive approach or a traditional open approach. Spine; interbody fusion (PLIF): minimally invasive procedure
32(5):537–543. versus conventional open approach. Eur Spine J;
19(2):316–324.
Therapy Cohort I–II Study type Study design Class of evidence
Therapy Prospective comparative study II
Purpose
To determine the statistical difference between the min- Purpose
imally invasive and traditional open approach for one- To determine whether a minimally invasive approach for
level instrumented posterior lumbar interbody fusion by one-level instrumented posterior lumbar interbody fusion
comparing the perioperative data, clinical outcome, and reduced undesirable changes in the multifidus muscle,
x-ray result. compared to a conventional open approach.
P Patient Degenerative lumbar disc (N = 61) To investigate associations between muscle injury during
I Intervention One-level PLIF procedure performed with minimally surgery (creatinine kinase levels), clinical outcome and
invasive approach (n = 32) changes in the multifidus at follow-up.
C Comparison One-level PLIF procedure with traditional open approach
(n = 29) P Patient Patients with segmental instability at the level of spinal
O Outcome Clinical and x-ray results, surgical time, estimated blood stenosis, huge lumbar disc herniation, or low-grade
loss, transfusion needs, VAS, time needed before ambulati- spondylolisthesis confirmed by anteroposterior, lateral,
on, length of hospital stay, complications oblique, and flexion-extension plain x-rays, CT scans, and
MRIs (N = 59)
Authors’ conclusion I Intervention Minimally invasive procedure (PLIF) (n = 28)
The minimally invasive approach results in less blood C Comparison Conventional open approach (n = 31)
loss, less need for transfusion, less postoperative back Outcome Changes in multifidus muscle (assessed by MRI), muscle
O
pain, quicker recovery, and shorter hospital stay. injury, clinical outcomes, VAS and ODI scores
The minimally invasive approach caused less change in
multifidus muscle, less postoperative back pain and func-
tional disability than a conventional open approach.
Muscle damage during surgery was significantly corre-
lated with long-term multifidus muscle atrophy and
fatty infiltration. Furthermore these degenerative chang-
es of multifidus were also significantly correlated with
long-term clinical outcome.

Peng CW, Yue WM, Poh SY, et al (2009) Clinical and Shunwu F, Xing Z, Fengdong Z, et al (2010) Minimally
radiological outcomes of minimally invasive versus open invasive transforaminal lumbar interbody fusion for the
transforaminal lumbar interbody fusion. Spine; treatment of degenerative lumbar diseases. Spine;
34(13):1385–1389. 35(17):1615–1620.
Therapy Prospective comparative study II Therapy Prospective cohort study II
Purpose Purpose
Comparison of clinical and x-ray outcomes of minimally To determine whether minimally invasive TLIF using the
invasive versus open transforaminal lumbar interbody tubular retractor system reduces the approach-related
fusion (TLIF). morbidity inherent in conventional open surgery.
P Patient Patients with (i) grade 1 or 2 spondylolisthesis and (ii) P Patient Patients with degenerative lumbar diseases undergoing
degenerate discs presenting with mechanical low back pain 1-level TLIF (N = 62)
and radicular symptoms undergoing TLIF (N = 58)
I Intervention Minimally invasive TLIF using the tubular retractor system
I Intervention Minimally invasive TLIF (n = 29) (n = 32)
C Comparison Open TLIF (n = 29) C Comparison Traditional open procedure (n = 30)
O Outcome Clinical outcomes (North American Spine Society, ODI, O Outcome Operative time, blood loss, complications, hospital stay, re-
short form-36, VAS), radiological outcomes, fusion rate covery time, clinical outcomes (ODI, VAS, soft-tissue injury
(Bridwell grading), blood loss, pain medication (by measuring serum creatine kinase)), x-ray images
Minimally invasive TLIF as a management of one-level
Minimally invasive TLIF has similar good long-term clin-
degenerative lumbar diseases is superior to the tradition-
ical outcomes and high fusion rates as open TLIF with the
al open procedure in terms of postoperative back pain,
additional benefits of less initial postoperative pain, ear-
total blood loss, need for transfusion, time to ambulation,
ly rehabilitation, shorter hospitalization, and fewer com-
length of hospital stay, soft-tissue injury, and functional
plications.
recovery. However, this procedure has a longer operative
time and requires close attention to the risk of technical
complications. Longer-term studies involving a larger
sample are needed to validate the long-term efficacy of
minimally invasive TLIF.
347

Wang J, Zhou Y, Zhang ZF, et al (2010) Comparison of Wang J, Zhou Y, Zhang ZF, et al (2011) Minimally
one-level minimally invasive and open transforaminal invasive or open transforaminal lumbar interbody fusion
lumbar interbody fusion in degenerative and isthmic as revision surgery of patients previously treated by open
spondylolisthesis grades 1 and 2. Eur Spine J; discectomy and decompression of the lumbar spine. Eur
19(10):1780–1784. Spine J; 20(4):623–628.
Therapy Prospective comparative study II Therapy Prospective cohort study II
Purpose Purpose
To compare clinical and radiological results of minimally To evaluate the clinical and x-ray results of minimally
invasive (MiTLIF) with open (OTLIF) in degenerative and invasive TLIF as an alternative new technique in the re-
isthmic spondylolisthesis grades 1 and 2. vision surgery for patients previously treated by open
procedure
P Patient Patients with degenerative (N = 46) and isthmic lower
grade (N = 39) spondylolisthesis (N = 85) P Patient Patients with previous discectomy (N = 13), hemilaminec-
I Intervention One-level minimally invasive transforaminal lumbar inter- tomy (N = 16), laminectomy (N = 12), and facetectomy
body fusion (TLIF) (n = 42) (N = 11)
C Comparison Open TLIF (n = 43) I Intervention Monosegmental and bisegmental minimally invasive trans-
foraminal lumbar interbody fusion (MITLIF) (n = 25)
O Outcome Clinical outcome (VAS, ODI), x-ray results, operative time,
blood loss, transfusion needs, x-ray exposure time, posto- C Comparison OTLIF (n = 27)
perative back pain, length of hospital stay, complications O Outcome Clinical (VAS and ODI) outcome and x-ray results, operative
time, blood loss, radiation exposure time, postoperative
Authors’ conclusion back pain, complications
Minimally invasive TLIF has similar surgical efficacy when
compared with the traditional open TLIF in treating one- Authors’ conclusion
level lower-grade degenerative or isthmic spondylolis- Minimally invasive TLIF is a safe and effective procedure
thesis. The minimally invasive technique offers several for treatment of selected revision patients previously
potential advantages including smaller incisions, less tis- treated by open surgery with some potential advantages.
sue trauma and quicker recovery. However, this technique However, this technique needs longer x-ray exposure
needs longer x-ray exposure time. time.

Adogwa O, Parker SL, Bydon A, et al (2011) Bagan B, Patel N, Deutsch H, et al (2008)

Comparative effectiveness of minimally invasive versus Perioperative complications of minimally invasive
open transforaminal lumbar interbody fusion: 2-year surgery (MIS): comparison of MIS and open interbody
assessment of narcotic use, return to work, disability, and fusion techniques. Surg Technol Int; 17:281–286.
quality of life. J Spinal Disord Tech; 24 (8):479–484.
Study type Study design Class of evidence Therapy Retrospective comparative case III
Therapy Retrospective cohort comparison III series
Purpose
Purpose
To assess the perioperative complication rate with mini-
To assess two earlier unstudied endpoints (duration of
mally invasive single- and two-level interbody fusions
narcotic use and return to work) and long-term pain,
and compare this incidence with a contemporaneous co-
disability, and quality of life (QOL) for MIS-TLIF versus
hort of open single- and two-level open interbody fusions
open TLIF.
P Patient Patients undergoing TLIF and PLIF for degenerative
P Patient Patients undergoing MIS-TLIF or open-TLIF for grade I pathologies
degenerative spondylolisthesis-associated back and leg
pain (N = 30) I Intervention Sofamor-Danek X-Tube and Stryker Luxor minimally invasive
systems (n = 28)
I Intervention MIS-TLIF (n = 15)
C Comparison Open interbody fusion (single- and two-level) (n = 19)
C Comparison Open TLIF (n = 15)
O Outcome Adverse events, complications, risk of perioperative
O Outcome Length of hospitalization, narcotic use, long-term pain complications
(assessed by VAS), low back disability (ODI), quality of life
(EuroQol-5D), occupational disability return to work
Authors’ conclusion Perioperative complications are not more common in
Both MIS-TLIF and open TLIF provide long-term improve- well-selected MIS patients. Allowing for proper patient
ment in pain, disability, and EuroQol-5D in patients with selection, MIS techniques have a favorable complication
back and leg pain from grade I degenerative spondylolis- profile.
thesis. However, MIS-TLIF may allow for shortened hos-
pital stays, reduced postoperative narcotic use, and ac-
celerated return to work, reducing both direct medical
costs and indirect costs of lost work productivity associ-
ated with TLIF procedures.
349

Dhall SS, Wang MY, Mummaneni PV (2008) Clinical McGirt MJ, Parker SL, Lerner J, et al (2011)
and radiographic comparison of mini-open Comparative analysis of perioperative surgical site
transforaminal lumbar interbody fusion with open infection after minimally invasive versus open posterior/
transforaminal lumbar interbody fusion in 42 patients transforaminal lumbar interbody fusion: analysis of
with long-term follow-up. J Neurosurg Spine; 9(6):560– hospital billing and discharge data from 5170 patients. J
565. Neurosurg Spine; 14(6):771–778.
Therapy Cohort III Therapy Retrospective comparative study III
Purpose Purpose
To compare outcomes after mini-open TLIF with open To determine the incidence of perioperative surgical site
TLIF. infection (SSI) in patients undergoing minimally invasive
(MI) techniques versus open posterior (P/TLIF) and the
P Patient Degenerative disc disease or spondylolisthesis (N = 42, direct hospital cost associated with the diagnosis and man-
mean age 53 years)
agement of SSI after P/TLIF as reported in a large admin-
I Intervention Mini-open TLIF (n = 21) istrative database.
O Outcome Blood loss, length of hospital stay, fusion rate, modified P Patient Patients undergoing one- or two-level MI or open P/TLIF for
Prolo scale (mPS), complications lumbar spondylotic disease, disc degeneration, or spondy-
lolisthesis (N = 5170)
Authors’ conclusion I Intervention Minimally invasive
Mini-open TLIF is a viable alternative to traditional open C Comparison Open P/TLIF
TLIF with significantly reduced estimated blood loss and Outcome Charlson Comorbidity Index, surgical site infection,
O
length of hospital stay. infection-related costs cost savings
In this multihospital study, the MI technique was associ-
ated with a decreased incidence of perioperative SSI and
a direct cost savings of $38,400 per 100 P/TLIF procedure
when used in two-level fusion. There was no significant
difference in the incidence of SSIs between the open and
MI cohorts for one-level fusion procedures. The results
of this study provide further evidence of the reduced pa-
tient morbidity and health care costs associated with MI
P/TLIF.

Ntoukas V, Müller A (2010) Minimally invasive Parker SL, Adogwa O, Witham TF, et al (2011)
approach versus traditional open approach for one level Post-operative infection after minimally invasive versus
posterior lumbar interbody fusion. Minim Invasive open transforaminal lumbar interbody fusion (TLIF):
Neurosurg; 53(1):21–24. literature review and cost analysis. Minim Invasive
Neurosurg; 54(1):33–37.
Therapy Retrospective comparative study III Study type Study design Class of evidence
Therapy Literature review and cost III
Purpose analysis
To demonstrate the efficacy of the minimally invasive
Purpose
lumbar posterior lumbar interbody fusion (PLIF) ap-
To determine the incidence of surgical site infection (SSI)
proach, comparing it to the traditional approach.
in patients undergoing minimally invasive (MIS) versus
Patient Patients treated for one level, degenerative lumbar instabi-
open TLIF reported in the literature.
P
lity (N = 40)
I Intervention Minimally invasive PLIF using the "SpiRIT"-system (n = 20) To determine the direct hospital cost associated with the
treatment of SSI following TLIF at the authors' institution.
C Comparison PLIF through a traditional open approach (n = 20)
O Outcome Stabilized segments, number of implanted pedicle screws, P Patient Patients undergoing MIS or open TLIF for the treatment of
blood loss, surgical, and radiation time, recovery time, grade I–II spondylolisthesis or degenerative disc disease
hospital stay. complications, radiographic images, clinical
outcomes (VAS, ODI) I Intervention Minimally invasive TLIF (n = 362)
Authors’ conclusion O Outcome Surgical site infection and hospital costs
This study confirmed the results of previous studies, which
advocated the advantages of less blood loss, less postop-
erative pain, quicker recovery and shorter duration of
Postoperative wound infections following TLIF are cost-
hospitalization. However, in the long run, one year after
ly complications. MIS versus open TLIF is associated with
surgery, both groups showed no significant difference
a decreased reported incidence of SSI in the literature
with regards to clinical and radiographic outcome. There-
and may be a valuable tool in reducing hospital costs as-
fore long-term controlled studies are necessary to validate
sociated with spine care.
the role of the minimally invasive PLIF in degenerative
lumbar instability.
351

Schizas C, Tzinieris N, Tsiridis E, et al (2009) Villavicencio AT, Burneikiene S, Roeca CM, et al

Minimally invasive versus open transforaminal lumbar (2010) Minimally invasive versus open transforaminal
interbody fusion: evaluating initial experience. Int lumbar interbody fusion. Surg Neurol Int; 1:12–20.
Orthop; 33(6):1683–1688.
Study type Study design Class of evidence Therapy Retrospective case-control III
Therapy Cohort III study
Purpose
Purpose
To directly compare safety and effectiveness for mini-
To compare minimally invasive TLIF with open midline
mally invasive and open approaches for TLIF.
transforaminal lumbar interbody fusion.
P Patient Patients treated for painful degenerative disc disease
P Patient Isthmic spondylolisthesis or degenerative disc disease with or without disc herniation, spondylolisthesis, and/or
(N = 36) stenosis at one or two spinal levels (N = 139)
I Intervention Minimally invasive TLIF (MITLIF) (n = 18) I Intervention Minimally invasive TLIF (n = 76)
C Comparison Open midline TLIF (n =18) C Comparison Open TLIF (n = 63)
O Outcome Clinical outcomes, VAS, ODI, length of surgery, blood loss, O Outcome Clinical outcomes (VAS, patient satisfaction, and MacNab's
length of hospital stay, fusion, complications criteria), operative data (operative time, estimated blood
loss), length of hospital stay, rate of neurological deficit,
complications
The MITLIF approach had a steeper learning effect as
compared to the open TLIF approach but does not appear
Minimally invasive TLIF technique may provide equiva-
to be linked with increased morbidity. Even though there
lent long-term clinical outcomes compared to an open
was a significant difference in blood loss and shorter length
TLIF approach in selective patient populations. The po-
of hospital stay in the MITLIF group, the authors found
tential benefit of minimized tissue disruption, reduced
no difference in analgesia consumption or pain perception
blood loss, and length of hospitalization must be weighed
during the early postoperative period. The occurrence of
against the increased rate of neural injury-related com-
pseudarthrosis in the MITLIF group is of concern and
plications associated with a technique learning curve.
suggests that extra care should be taken while preparing
and grafting the disc space, especially with isthmic spon-
dylolisthesis patients. Larger prospective randomized tri-
als, including patients operated on after the learning curve
has stabilized, would be needed to confirm the findings.

Wang MY, Cummock MD, Yu Y, et al (2010) An Wu RH, Fraser JF, Härtl R (2010) Minimal access versus
analysis of the differences in the acute hospitalization open transforaminal lumbar interbody fusion: meta-
charges following minimally invasive versus open analysis of fusion rates. Spine; 35(26):2273–2281.
posterior lumbar interbody fusion. J Neurosurg Spine,
12(6):694–699. Study type Study design Class of evidence
Therapy Meta-analysis III
Therapy Retrospective comparative study III Purpose
To establish benchmark fusion rates for open TLIF and
Purpose minimally invasive TLIF (mTLIF) based on published stud-
To assess differences in clinical results and costs following ies. A secondary goal was to review complication rates
minimally invasive versus open posterior lumbar inter- for both approaches.
body fusion.
P Patient Patients diagnosed with degenerative spinal disease (N =
P Patient Patients with spondylolisthesis, spinal stenosis, and dege- 1028)
nerative disc disease (N = 74) I Intervention Minimally invasive TLIF
I Intervention Minimally invasive PLIF C Comparison Open TLIF
C Comparison Open PLIF O Outcome Fusion rates, complications
O Outcome Costs, length of stay, rehabilitation
Authors’ conclusion Fusion rates for both open and mTLIF are relatively high
While hospital setting, treatment population, patient se- and in similar ranges. Complication rates are also similar,
lection, and physician expectation play major roles in with a trend toward mTLIF having a lower rate. This
determining hospital charges and length of stay, this pilot analysis provides clear benchmarks for fusion rates in
study at an academic teaching hospital shows trends for open and mTLIF procedures for spine surgeons.
quicker discharge, reduced hospital charges, and lower
transfer rates to inpatient rehabilitation with minimally
invasive PLIF. However, larger multicenter studies are
necessary to validate these findings and their relevance
across diverse US practice environments.
353


4.2.5 Interspinous spacers
H Michael Mayer
1 Historical perspective fixed with straps around the spinous processes to augment
segmental fusion. In 2005, the same principle was also dis-
In 2003, Lindsey et al and Swanson et al [1, 2] first described cussed in two other papers, which described a soft interspi-
the biomechanical effects of an interspinous spacer on the nous spacer for the “dynamic” fixation of lumbar motion
instrumented and adjacent segments of the lumbar spine. segments [12, 13].
This report was part of an ongoing study with a new implant
type called X-Stop. In the following years, a series of stud-
ies was published that reported on the clinical as well as 2 Terminology
the biomechanical effects of interspinous distraction [3–8].
The increase in size and area of the spinal canal as well as In recent years, a number of interspinous implants have
of the subarticular zones and the foramen was viewed as been tested or are still under investigation in clinical ap-
the main biomechanical effect of such interspinous spacers. plication studies. They all have the same above-described
The above-mentioned authors conclusively demonstrated biomechanical effects in common, but are used for different
in clinical studies that their indirect “decompression” effect purposes (eg, dynamic stabilization, rigid stabilization to
on neural structures made interspinous spacers an innova- augment fusion, indirect decompression of the spinal canal).
tive treatment alternative for degenerative lumbar spinal However, since the rationale for utilizing such implants
stenosis. The secondary effect to be identified in biome- depends on the specific biomechanical and clinical goal (eg,
chanical studies was an unloading effect on the facet joints, indirect decompression, fusion, treatment of neurogenic
as well as on the posterior part of the intervertebral disc. It claudication, relief of low back pain), a clear consensus
thus appeared that interspinous spacers could have a po- regarding the indications and contraindications is still lack-
tentially positive influence on low back pain, due to the ing. To simplify this, categorization into three main groups
shift in pathological load-bearing on these anatomical struc- of interspinous implants may be useful.
tures. Although a significant number of patients reported
an improvement of low back pain after device implantation, 2.1 Group I implants: “extension stoppers”’
this was in fact not the main focus of the studies, but was Group I implants consist of non-stabilizing devices that are
rather seen as a positive “side effect” by the authors [3, 9, used for the primary treatment of dynamic spinal stenosis
10]. with or without low back pain (“extension stoppers”) (Fig
4.2.5-1). These types of implant are currently either in rou-
As early as 2002, Sénégas [11] reported on a new surgical tine clinical use or are under investigation in clinical stud-
technique using a rigid interspinous implant, which was ies. Their purpose is to achieve interspinous segmental
Fig 4.2.5-1a–c ‘‘Extensions stop-

pers’’: non-stabilizing, ‘‘free-floating’’
interspinous implants.
a InSpace interspinous implant.
a b c b–c X-Stop interspinous implant.
355

distraction and to limit extension; their use is mainly indi- 2.3 Group III implants: “dynamic and rigid”
cated for the primary treatment of dynamic degenerative stabilization
lumbar spinal stenosis, and as a substitute for open decom- Group III implants consist of interspinous spacers which
pression. The main therapeutic goal is to increase the size provide more “dynamic and rigid stabilization” with poste-
of the spinal canal and foramen, as well as to unload the rior tension banding, and which are used either to avoid,
facet joints and the intervertebral disc [14, 15]. or to promote fusion (Fig 4.2.5-3). The aim of using this group
of interspinous implants is to achieve interspinous stabiliza-
2.2 Group II implants: “dynamic stabilizers” tion either in order to avoid, or to augment fusion. Where-
Group II implants consist of dynamic (U- or W-shaped) as the above-described “extension stoppers” do not provide
interspinous spacers, which provide an elastic limitation of “stabilization”, these implants can block or elastically lim-
extension (Fig 4.2.5-2). These dynamic extension stoppers it extension, and are also able to limit flexion or rotational
usually act like a spring, in such a way that extension leads movements [16–19]. They are thus mainly indicated for use
to an elastic compression of the metal implant. They are as an adjunct to open decompression procedures in patients
mainly used as an adjunct to open decompression in treat- with spinal stenosis, or as an alternative to other types of
ing cases of spinal stenosis, in order to avoid fusion proce- lumbar fusion in cases of low back pain. The indications
dures. They thus unload the facet joints and “keep the spi- therefore do not overlap those for the majority of extension
nal canal open”. Group II implants can also be used stoppers, possibly with the exception of the Coflex device.
following discectomy in order to “protect” the disc from
excessive load. They thus represent an alternative treatment All these devices have in common a less invasive implanta-
concept for low back pain, ie, dynamic stabilization to reduce tion technique that is associated with a lower complication
the load on the facet joints and/or the disc space, and/or to rate compared to alternative procedures such as open de-
keep the spinal canal “open” by interspinous distraction compression or pedicle-screw instrumented fusion. This
following decompression procedures. makes them attractive for use, especially in an elderly patient
population.
a b c d
Fig 4.2.5-2a–d ‘‘Interspinous dynamic stabilizers’’: interspinous implants with flat or anatomically-adapted surface to match
the anatomy of the spinous processes.
a–b Coflex interspinous implant.
c–d Stenofix interspinous implant.

Fig 4.2.5-3a–c “Interspinous elastic or rigid stabilizers” with

posterior tension banding. Wings and/or bands fixed around the
spinous processes provide some rotational stability, and may limit
flexion.
a DIAM interspinous implant.
b Wallis interspinous implant.
c c InSwing interspinous implant.
3 Patient selection 3.2 “Dynamic stabilizers” without tension banding
3.1 “Extension stoppers” 3.2.1 Indications

• Spinal stenosis with mild/moderate symptomatic facet
3.1.1 Indications joint osteoarthritis (low back pain)
• Central, lateral, and foraminal dynamic lumbar spinal • Revision surgery following discectomy
stenosis • As an adjunct to discectomy for large disc herniations.
• Discogenic and arthrogenic (facet osteoarthritis) low
back pain 3.2.2 Contraindications
• Symptomatic, segmental hyperlordosis • Degenerative instabilities
• Disc degeneration with dynamic (reducible) retrolisthe- • Advanced facet joint osteoarthritis
sis • Loss of segmental mobility
• Interspinous pain (“kissing spines”). • Deformities
• Spondylolysis
3.1.2 Contraindications • Tumors
• Osteoporosis • Infection.
• Conus/cauda syndrome
• Structural spinal stenosis
• Spondylolisthesis (> Grade I; degenerative and/or isth-
mic)
• Deformities
• Previous posterior surgery involving index segment.
357

3.3 “Dynamic and rigid stabilizers” with posterior 4.1.2.2 Cons

tension banding (eg, DIAM, InSwing, Wallis) • Therapeutic effect is probably only temporary, due to
subsidence and progressive degeneration of the segment
3.3.1 Indications • Influence on sagittal balance, especially in the case of
• Facet joint pain two-level implantations is unclear
• Postdiscectomy pain • More invasive compared to a percutaneous approach.
• Spinal and foraminal stenosis with low back pain
• Recurrent disc herniations 4.2 “Dynamic stabilizers” without tension banding
• Degenerative disc disease.
4.2.1 Pros
3.3.2 Contraindications • Less invasive surgical approach compared to fusion
• Spondylolysis • Dynamic limitation of range of motion without fusion
• Lamina defects (eg, following hemilaminectomy) • Unloading of facet joints and intervertebral disc
• Translational instability • Indirect enlargement of foraminal area.
• Spondylolisthesis (> Grade I)
• Malformations 4.2.2 Cons
• Ankylosis of the index segment • No relevant stability on rotation and side-bending
• Deformities, tumors, infection. • Implantation is only possible at L5/S1 if there is a spinous
process at S1 (rare)
• Multisegmental implantation is more invasive.
4 Pros and cons of interspinous spacers
4.3 “Dynamic and rigid stabilizers” with posterior
4.1 “Extension stoppers” tension banding (eg, DIAM, InSwing, Wallis)
4.1.1 Percutaneous surgical technique 4.3.1 Pros

• Less invasive surgical approach compared to fusion
4.1.1.1 Pros • Dynamic or rigid limitation of range of motion without
• Small skin incision fusion
• Atraumatic blunt penetration of the paravertebral mus- • Unloading of facet joints and intervertebral disc
cles • Indirect enlargement of foraminal area
• No violation of the dorsolumbar fascia • Preservation of supraspinous ligament together with
• Supraspinous ligament is left intact proprioceptors (eg, with DIAM, InSwing)
• Interspinous ligament only dilated • Radiolucency
• No bone resection necessary. • No violation of adjacent segment structures.
4.1.1.2 Cons 4.3.2 Cons

• Only possible for L2–5 • No relevant stability in rotation and side-bending
• Not to be combined with open decompression • Implantation is only possible at L5/S1 if there is a spinous
• Limited application in previously operated segment process at S1 (rare)
• Radiation exposure. • Multisegmental implantation is more invasive and some-
times not possible.
4.1.2 “Open” interspinous approach
4.1.2.1 Pros 5 Preoperative planning

• Small approach
• Short operating time compared to fusion Preoperative planning mainly consists of plain x-rays in AP
• Outpatient procedure (can be performed under local and lateral projection as well as functional x-rays in exten-
anesthesia) sion and flexion in lateral projection in order to exclude
• Reduced blood loss the presence of translational instability. MRI is mandatory
• Low complication rates. for providing information on the disc space and the degree
of disc degeneration as well as on the type and degree of

narrowing within the spinal canal. Axial T2- and sagittal moval of the distractors, the implant can be introduced
T1- and T2-weighted images are necessary for baseline in- through an application sleeve and the implant wings de-
formation. ployed under AP image-intensifier control. Once the wings
are completely deployed, the implant is uncoupled from
the implant holder, which, together with the application
6 Surgical technique sleeve, is then removed “en bloc”, leaving the implant cor-
rectly in place.
6.1 Extension stoppers
6.1.1 Percutaneous surgical technique This approach is used for two different categories of implant
The surgical procedure can be performed under either local (“nonfixed” free-floating spacers and dynamic/rigid inter-
or general anesthesia. The patient is placed in a prone posi- spinous stabilizers). For the implantation of the “nonfixed”
tion on a flat soft-frame on an adjustable operating table or free-floating spacer category such as X-Stop, the patient is
on a Wilson frame. Passive distraction of the interspinous placed in a prone, a knee-chest, or a lateral (“embryo”)
space is achieved by tilting the footend of the surgical table position (Fig 4.2.5-6). The dorsolumbar fascia is split on both
and adjusting it until maximum “opening” of the interspi- sides of the spinous processes, following which the para-
nous space is attained (Fig 4.2.5-4). The implant (eg, InSpace) vertebral muscles are retracted and the interspinous liga-
is placed through a lateral percutaneous approach (Fig 4.2.5- ment is pierced (Fig 4.2.5-7). The spinous processes are then
5). Piercing of the interspinous ligament is performed with actively distracted with a distraction forceps and the implant
a K-wire, and enlargement of the interspinous space is is introduced from one side. The wing on the contralateral
achieved with blunt distractors of increasing size. After re- side is then attached (Fig 4.2.5-8).
Fig 4.2.5-4 Positioning of the patient for percutaneous interspinous spacer implantation.
The lower end of the table should be tilted down.
359

c d
Fig 4.2.5-5a–d Percutaneous implantation of an interspinous spacer (InSpace).

a Prone positioning, lateral transcutaneous-transmuscular approach.
b Application tool with undeployed implant.
c Implant with deployed wings.
d Final position of the interspinous implant.

Fig 4.2.5-6a–c
a Patient in prone position.
b Patient in knee-chest position.
c Patient in lateral ‘‘embyro’’ position.
c
Screwdriver
Fig 4.2.5-7 Splitting of para- Fig 4.2.5-8 Implantation of the

vertebral fascia and piercing of spacer and fixation of the contra-
interspinous ligament. lateral wing.
361

6.2 “Dynamic stabilizers” without tension banding the spinous processes (and subsequently reattached with
The patient positioning is the same as for open decompres- transsosseous sutures after the implantation procedure).
sion (knee-chest or prone position). After segmental de- The size of the implant is determined with the aid of
compression, the surfaces of the spinous processes are templates, following which it is inserted between the spinous
“shaped” to achieve an anatomically adapted fit for the processes as far anteriorly as possible, leaving a 2–3 mm
implant (Fig 4.2.5-9). The interspinous ligament is complete- space between the dura and the bottom of the “U” (Fig 4.2.5-
ly resected, and the supraspinous ligament is detached from 10).
Fig 4.2.5-9 Shaping of the sur-

faces of the spinous processes.
Gauge
Implant
a b c
Fig 4.2.5-10a–d Implantation of

a U-shaped interspinous spacer.
a–c Coflex implant.
d d Stenofix implant.

6.3 “Dynamic and rigid stabilizers” with posterior In the case of a rigid implant (eg, Wallis or InSwing), there
tension banding (eg, DIAM, InSwing, Wallis) are two possible approaches depending on the device used:
The implantation can be performed with or without resec- either the supraspinous ligament is detached from the spi-
tion of the supraspinous ligament. The interspinous ligament nous processes (eg, with the Wallis implant) and the inter-
is resected, and the implant size is determined with the aid spinous ligament is resected; or (eg, with the InSwing im-
of templates after interspinous distraction with a distraction plant), the supraspinous ligaments can be preserved. The
forceps (Fig 4.2.5-11). In the case of an elastic implant size of the interspinous spacer is determined with the aid
(eg, DIAM), the implant is “folded” with a special implant of templates after the surfaces of the spinous processes have
holder and inserted into the interspinous space. The liga- been trimmed. The concave surface of the superior spinous
ments are passed around the spinous processes and fixed process is flattened, as is the junctional zone between the
(Fig 4.2.5‑12). spinous process and the laminae. The spacer is inserted
Fig 4.2.5-11a–b Distraction of

the interspinous space and size
determination.
a Size determination with trial
implant.
b Distraction with distraction
forceps.
a b
Fig 4.2.5-12a–b
a Implantation of an elastic inter-
spinous device (DIAM).
b Fixation of bands around the
a b spinous processes.
363

either from the posterior (eg, Wallis) or from one side, and 8 Evidence-based results
the bands are passed around the superior and inferior spi-
nous process, then fixed. Depending on the implant type, 8.1 “Extension stoppers”
different fixation techniques are used which have in com-
mon that the tightness of the band can be adjusted to achieve 8.1.1 Percutaneous surgical technique
good compression (Fig 4.2.5-13). The first operation of its kind to be carried out was performed
on March 15, 2006. Preliminary results in 41 patients
showed a good reduction of pain level as well as a lower
score on the Oswestry Disability Index (ODI) for low back
pain patients as well as for patients with dynamic degen-
erative lumbar spinal stenosis [20, 21].
Performing the implantation procedure with InSpace is sig-

nificantly less invasive than for the other “extension stop-
pers” currently on the market. The average intraoperative
blood loss is < 5 cc, and surgical time for a single level is
usually less than 15 minutes in uncomplicated cases. No
clinically relevant intraoperative complications have been
Fig 4.2.5-13 Tightening
reported. Other advantages of this lateral approach are the
the bands around the spinous short learning curve and the nonsignificant blood loss. Sur-
processes. gery can be performed as an outpatient procedure. In gen-
eral, postoperative MRI shows no evidence of muscular
damage or hematoma. The technical limitations involve
implantation at L5/S1, or in the case of a high iliac crest
7 Postoperative care due to the angle of approach required to access the inter-
spinous space. There are still few clinical data available.
7.1 Percutaneous technique and “open” approach
7.1.1 Percutaneous surgical technique Some randomized controlled trials have demonstrated that
• Immediate immobilization without restriction. the results using this approach for the treatment of dy-
namic spinal stenosis are superior to those for conservative
7.1.2 “Open” interspinous approach treatment [1, 5, 13]. Whereas in initial reports the efficacy
• Same-day mobilization of the “open” interspinous technique was also documented
• No brace necessary for the treatment of degenerative spondylolisthesis not
• Return to normal activities after wound healing (2 weeks). greater than grade I, recent data has been unable to confirm
this [22–25]. And although the “open” implantation of in-
7.2 “Dynamic stabilizers” without tension banding terspinous spacers of the “X-Stop" type is claimed to be
• Same-day mobilization “minimally invasive”, the procedure occasionally requires
• Wound drainage for 24 hours a larger skin incision and a wider bilateral muscular dissec-
• Soft brace for 4–6 weeks tion compared to modern microsurgical “direct” decompres-
• Return to work according to postoperative course (usu- sion techniques [26, 27]. Moreover, due to the iatrogenic
ally between 2–6 weeks postoperatively). alteration of the dorsolumbar fascia and the paraspinal
muscles, it cannot be considered a treatment option for
7.3 “Dynamic and rigid stabilizers” with posterior discogenic or arthrogenic low back pain. Lastly, it should
tension banding (eg, DIAM, InSwing, Wallis) also be noted that bisegmental or multilevel implantations
• Same-day mobilization require more extensive surgical approaches.
• Soft brace for 4–6 weeks
• Avoidance of heavy lifting for 6 weeks 8.2 “Dynamic stabilizers” without tension banding
• Return to work according to postoperative course (usu- Preliminary results have been presented by Adelt et al [28].
ally between 2–6 weeks postoperatively). In a series of more than 200 patients with spinal stenosis,
this type of implant was used as an adjunct to open decom-

pression. After an average follow-up of 2 years, subjective patients with herniated discs, foraminal or central spinal
satisfaction was described by more than 90% of the patients. canal stenosis. The median follow-up was 18.1 months, and
Out of a total of 429 patients, a 75% improvement in low significant pain relief was observed in 83.8% of patients.
back pain, an 85% improvement in leg pain, and an 87%
improvement in intermittent neurogenic claudication was Kim et al [31] used this implant in patients suffering from
found 1 year postoperatively. Ninety-three percent of the disc herniations. They compared the results of simple mi-
patient population answered “yes” to the question of wheth- crodiscectomy with the same procedure followed by the
er they would be prepared to undergo this type of operation implantation of DIAM in patients suffering from radicular
again if they were in the same situation. The complication as well as low back pain.
rate in this series amounted to 6%. Satisfactory results were
also recently reported by Brussee et al [23] in a series of 65 After a mean postoperative follow-up of 12 months, sig-
patients treated for degenerative lumbar spinal stenosis who nificantly reduced pain was noted in both treatment groups;
were very or moderately satisfied in 74.2% of cases. How- no differences were found regarding disc space height or
ever, when all the items on the Zurich Claudication Ques- VAS values between the nonDIAM and the DIAM group.
tionnaire were assessed, an overall good result could only
be achieved in 30.6% of patients [29]. In this prospective In 2007, Sénégas et al [18] first reported on the long-term
study, the Coflex device was used in 18 patients with seg- survival of the Wallis implant in a series of 241 patients that
mental lumbar instability, and the results compared to those had been treated between 1987 and 1995. The survival
for 24 patients in whom a posterior lumbar interbody fusion results for this implant were 75.9% for “any subsequent
(PLIF) procedure had been performed [29]. After 1 year lumbar operation” and 81.3% for “implant removal”, with
follow-up, both groups showed significant improvement the overall reoperation rate amounting to 21.1%.
on the visual analog scale (VAS), however, the range of
motion in the segment above the index level increased sig- In 2007, Floman et al [19] reported on a series of 37 patients
nificantly following the fusion procedure compared to the that underwent lumbar discectomy followed by fixation
dynamic stabilization achieved with a Coflex implant. The with the Wallis implant. The follow-up period was 16
authors therefore concluded that the Coflex implant can months. The indications for surgery included patients with
provide a good alternative to fusion, causing less stress in low back pain and those with large disc herniations. The
the adjacent level. aim of surgery was to “protect” the segment from collapse
and thus prevent recurrent disc herniations and/or the de-
The U-shaped type of metal implant seems to be a good velopment of low back pain postdiscectomy.
alternative to segmental fusion following open decompres-
sion in patients with lumbar spinal stenosis and low back A significant improvement was observed in the ODI values
pain. Considering the fact that the patient population is as well as in the VAS for back and leg pain. However, recur-
elderly and that a number of comorbidities are usually pres- rent herniations were observed in 13% of patients. The
ent, the low complication rates following implantation of authors therefore concluded that, although the implant had
the Coflex device compared to fusion procedures as well as a positive effect on VAS and ODI values, it was probably
the high subjective satisfaction rates seem to justify its ap- not capable of reducing the incidence of recurrent disc her-
plication. However, evidence-based data are also lacking. niations.
This implant is currently under assessment in a US Food
and Drug Administration Investigational Device Exemption Soft interspinous distraction with tension banding probably
trial. leads to dynamic neutralization of the motion segment.
Although this technique seems to be less aggressive com-
8.3 “Dynamic and rigid stabilizers” with posterior pared to lumbar fusion procedures, reliable clinical data are
tension banding (eg, DIAM, InSwing, Wallis) lacking and the evidence is still insufficient.
The first results on the use of DIAM were reported by
Mariottini et al [12], who found statisfactory outcomes in The Wallis implant is probably the sturdiest interspinous
97% out of a total population of 43 patients. In an Italian implant with the greatest capability to “stabilize” the seg-
multicenter trial, high rates of satisfaction as well as low ment. However, it is that which requires the most aggressive
complication rates were found by Guizzardi et al in 2005 surgical approach and, with the exception of x-ray exposure,
[13]. Good results with the DIAM implant have also been is therefore not significantly less invasive than PLIF tech-
reported by Taylor et al [30] in a multicenter series of 104 niques. Its protective effect on the disc has not yet been
365

established with any certainty, and whether it might con- Among the rare complications that have been described for
stitute an alternative to other less invasive interspinous the various procedures, those listed below are noteworthy,
spacers or to fusion procedures remains to be determined. and have been classified according to their clinical signifi-
cance.
9 Complications and avoidance 9.1 Clinically significant complications

• Implant subsidence affecting the spinous processes with
Interspinous spacers of the different kinds described in this loss of distraction
chapter are used to avoid more invasive types of surgical • Spinous process fatigue fractures (especially in osteo-
procedure. In addition to their being less invasive, the oth- porotic patients)
er main advantage lies in the significantly lower rate of • Implant dislocation/extrusion (usually technical errors)
complications. This is the case for the “extension stoppers” • Migration of implant into the spinal canal.
such as the use of InSpace or X-Stop compared to open
decompression procedures, and it is also true for the dy- 9.2 Complications of no clinical significance/
namic and rigid interspinous stabilization devices compared incidental findings
to pedicle-screw augmented fusion procedures. • Bone remodelling at interface between implant and spi-
nous process
The implant-related complication rates for all devices • Peri-implant ossifications
amounts to less than 5%. • Bent or broken wing (InSpace; Coflex).
10 Tips and tricks
James Zucherman, San Francisco, USA • Lytic spondylolisthesis will render

– Both positions are effective
• Indications (relevant to X-Stop and sim- treatment of the index segment and – Lying on one side ideal for local

ilar stand-alone interspinous devices): the cephalad segment ineffective, or anesthesia
correct patient selection is an essential less effective – Ensures maximum flexion

factor. •
Degenerative spondylolisthesis on – Safest position

• Clinical aspects: the device is designed for lateral flexion with over 30% slip • Prone position:
the treatment of neurogenic intermittent will have a reduced success rate • Better for obese patients

claudication; its use should be restricted • Presence of facet cysts does not re-
• Maximum flexion position must be

to this clinical indication: duce the success rate obtained on operating table
• The patient should be able to sit for
• Effective for the treatment of central,
• Small cervical-type lamina spreader

50 minutes at a time with little or no subarticular, and foraminal stenosis can help open interspinous space
pain • Bone mineral density (BMD): the hip and during implant insertion
• The patient should be able to walk
spine score should be assessed and the • The tip of the implant can be inserted

at least 30 meters lowest score taken into consideration: between tips of the distractor blades
• Success rate diminishes in patients
• BMD < 3.5: the patient is probably
and inserted simultaneously as the
over the age of 70 (probably true for not a suitable candidate distractor is removed
most surgery) • BMD < 2.7 and > 3.5: polymethyl-
• Anatomical aspects:
• Radiographic aspects: methacrylate injection in the spinous • Anticipate problems during insertion

• Coronal segmental list at the level of
processes or a different decompres- – Feel and visualize the shape and

the treated segment does not com- sion technique should be considered size of each interspinous space
promise the results; however, scoli- • Technical aspects (relevant for all inter- –
Pay attention to osteophytes
otic curves extending over multiple spinous spacers): and angle of the interspace in
segments and with over 25° curva- • Prone position versus patient lying
the coronal and sagittal plane
ture will have a reduced success rate on one side • Advance anterior portion of the load-
bearing element of the implant into the

junction between the spinous process • Verify effect on lateral x-ray with distrac- • Make sure the mobile load-bearing ele-
and lamina, if possible. tor when selecting size. ment is locked by the main body inserter
• Implant size should usually be 2–4 mm • Do not overload the bone; take bone and cannot rotate.
less than distractor measurement. density and size of spinous process into
• Use the trials. account in the distraction force applied.
11 Case examples
subarachnoid space (Fig 4.2.5-15). Based on these findings,
11.1 Case 1 a diagnosis was made of degenerative, dynamic spinal ste-
A 74-year-old woman presented with neurogenic claudica- nosis at L3/4.
tion with the ability to walk for a distance of 100 m, fol-
lowing which she experienced heaviness and tingling in Treatment consisted of the percutaneous implantation of
both legs. No radicular symptoms, but occasionally low back an InSpace interspinous spacer at L3/4 (Fig 4.2.4-16).
pain centred over L3/4 was observed. Immediate relief of
symptoms were reported upon flexion of the lumbar spine. After surgery, the patient was allowed bed rest for 4 hours,
The patient remained symptom-free at rest. then mobilized on the same day. On the first postoperative
day, walking distance amounted to 3000 meters (around
Standard x-rays showed a physiological total lumbar lor- the hospital), with nonsignificant wound pain. The patient
dosis with preserved disc height, in particular at L3/4, and was discharged from the hospital on the second postopera-
also the presence of “kissing spines” at L3/4 (Fig 4.2.5-14). tive day. Persisting good results were observed at 2 years
MRI revealed a spinal stenosis at level L3/4 with a reduced follow-up.
a b a b
Fig 4.2.5-14a–b Fig 4.2.5-15a–b
a Standard preoperative x-ray in AP projection. a Axial MRI T2-weighted image showing a normal spinal canal at
b Standard preoperative x-ray in lateral projection showing a ‘‘kissing level L2/3.
spine’’ at L3/4 (arrow). b Axial T2-weighted image showing spinal canal narrowing at level
L3/4 with significant lumbar spinal canal stenosis.
367

vious cardiac bypass surgery, and carotid artery surgery with

a stent) which necessitated two separate surgical procedures.
Clinical findings showed predominantly left-sided sciatica,

no clear radicular distribution, reduced patellar reflexes,
no presence of motor deficit, but with pressure pain at the
iliosacral joint and lower lumbar spine. There were no signs
of significant peripheral vascular disease in the lower ex-
tremity. Facet joint infiltrations at L2/3 provided 50% tem-
a b porary relief from back pain.
Fig 4.2.5-16a–b
a Preoperative standard x-ray of segment L3/4 in lateral projection. X-ray investigation showed a left-convex lumbar degen-
b Postoperative standard x-ray of segment L3/4 in lateral projection;
erative scoliosis with a monosegmental tilt and disc space
note the enlargement of the posterior intervertebral disc space
(compare the preoperative findings with the postoperative results
narrowing at L2/3 (Fig 4.2.5-17), while MRI revealed spinal
within the black circles). canal stenosis at L2/3, L3/4, and L4/5, and osteochondrosis
at L2/3 (Fig 4.2.5-18).
Surgical intervention included microsurgical bilateral “over-

11.2 Case 2 the-top” decompression at level L2/3, L3/4, and L4/5
An 85-year-old man presented with a considerable degree through a left unilateral approach with the implantation of
of leg pain (subjective classification rated at 75%) and with a Coflex interspinous spacer at L2/3 (10 mm implant height)
less intense back pain (subjective classification rated at 25%) (Fig 4.2.5-19).
and clearly dominating and debilitating symptoms of spinal
claudication. The patient was almost completely immobilized No intra- or postoperative general or specific complications
due to the pain, and walking distance was reduced to < 10 were observed. The patient was mobilized on the first post-
meters. Unspecific low back pain had been experienced for operative day, and fitted with a flexible lumbar orthosis for
several decades. 4 weeks. Significant improvement of walking ability with-
in the first postoperative days and remarkable reduction of
The patient suffered from multiple comorbidities (compen- low back pain of more than 50% were noted. The patient
sated renal insufficiency, coronary heart disease, angina was discharged from hospital on the fourth postoperative
pectoris, high blood pressure, diabetes mellitus type II, pre- day (prolonged stay due to the monitoring of comorbidities).
Fig 4.2.5-17a–b
a Standard preoperative x-ray in AP projection showing a degenerative
left convex lumbar scoliotic deformity.
b Standard preoperative x-ray in lateral projection of a degenerative
left convex lumbar scoliotic deformity, clearly showing a frontal tilt
a b and disc space narrowing at L2/3.

c d e
Fig 4.2.5-18a–e Sagittal (a–b) and axial (c–e) MRI images showing spinal canal
stenosis at L2/3, L3/4, and L4/5 with a segmental osteochondrosis and Modic type
I changes at L2/3.
a b
Fig 4.2.5-19a–c
a Standard postoperative x-ray in AP projection showing the Coflex
interspinous implant at L2/3.
b Standard postoperative x-ray in lateral projection showing the
Coflex interspinous device at L2/3.
a b c Postoperative color-coded sagittal CT scan.
12 Summary and key learning points with extension stoppers, the most likely candidates are
mainly older patients with dynamic or early-stage lumbar
Interspinous distraction or fixation is in the process of be- spinal stenosis, who would otherwise have to be treated by
coming a new trend in spinal surgery, and there are a num- more invasive procedures such as open decompression.
ber of other interspinous spacers with stabilizing effects Patients can potentially benefit and at least derive temporary
currently under clinical trials throughout the world, all of relief from minimally invasive interspinous distraction with
which follow the same general clinical and biomechanical implant types such as InSpace or X-Stop, etc. The other
principles. group of potential candidates could be younger patients
with discogenic and/or arthrogenic low back pain due to
As with all new trends in medicine, we are currently con- degenerative disc disease and/or facet joint osteoarthritis
fronted with a situation in which an increasing number of who, in the event of failed or unsuccessful conservative
implants and procedures are being introduced, but there is treatment, would otherwise be candidates for either spinal
a lack of empirical as well as evidence-based data for most fusion or total disc replacement.
of them. The mode of action and the rationale behind the
clinical application of these interspinous spacers seems to The third group of patients that might derive advantage
be clear. The results of biomechanical studies support the from stabilizing interspinous devices are those needing open
expected or established clinical effects. There appears to be decompression or discectomy, for whom the present author
a patient population which could be potentially suitable would also advise an additional fusion procedure for seg-
candidates for these new surgical procedures. For treatment mental instability and low back pain. These patients may
369

benefit from implants such as Coflex, DIAM, Wallis, or However, it seems that there will be a certain place in
InSwing. The major advantages, which emerge from the clinical routine for at least some of the techniques pre-
short-term results, seem to be the low complication rates sented.
and the reduced invasiveness compared to fusion proce-
dures. In a clinical setting, this lowers the “application The key learning points may be briefly summarized as fol-
threshold”, especially as regards patients with severe co- lows:
morbidities, older age, or other contraindications for fusion • Three different groups of interspinous devices are avail-
procedures. able:
• Group I: Extension stoppers
However, it should be borne in mind that all these inter- • Group II: Dynamic stabilizers without tension band-
spinous implants will most probably constitute temporary ing as an adjunct to decompression
surgical solutions with only a short- to mid-term clinical • Group III: Dynamic or rigid stabilization devices with
effect; thus, the level of invasiveness, as well as the impor- posterior tension banding
tance of not “burning down bridges”, are major consider- • Implantation techniques are minimally invasive, and
ations given that further surgical procedures may well be- are easy to perform
come necessary. • Low complication rate
• Interspinous spacers probably have only a temporary
The above-mentioned aspects are addressed in most of the clinical effect
current clinical trials. The usefulness, clinical efficacy, and • Heterogeneous pattern of indications and contraindica-
average duration thereof remain to be determined for the tions
majority of implants. This is also the case regarding the • Limited information on mid-term results. Long-term
clearer determination of indications and contraindications. results are lacking (see point 4).
13 References
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al (2003) The effects of an interspinous AD, et al (2005) The effect of an supplementation by non-rigid fixation
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3. Zucherman JF, Hsu KY, Hartjen CA, et 2962. pathology. Acta Neurochir; Suppl
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et al (2005) The treatment mechanism decompression: application of the et al (2006) Interspinous process
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lumbar neurogenic intermittent degenerative spondylolisthesis. J for lumbar spinal stenosis. a 4-year
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lumbar spine following insertion of a STOP interspinous device was spinous process injection of PMMA to
novel interspinous process distraction implanted. J Neurosurg Spine; 5(6):500– augment the strength of an inter-
device. Spine; 30(23):2677–2682. 507. spinous process device such as the X
STOP. Spine; 33(4):452–456.

16. Schmoelz W, Huber JF, Nydegger T, et 22. Lauryssen C (2007) Appropriate 27. McCulloch A (1998) Microsurgery for
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Spinal Disord Tech; 16(4):418–423. Neurosurg Focus; 22(1):E5. Lippincott-Raven Publishers, 453–486.
17. Phillips FM, Voronov LI, Gaitanis IN, 23. Brussee P, Hauth J, Donk RD, et al 28. Adelt D, Samani J, Kim WK, et al
et al (2006) Biomechanics of posterior (2008) Self-rated evaluation of outcome (2007) Coflex interspinous
dynamic stabilizing device (DIAM) of the implantation of interspinous stabilization: clinical and radiographic
after facetectomy and discectomy. The process distraction (X-Stop) for results from an international
Spine Journal; 6(6):714–722. neurogenic claudication. Eur Spine J; multicenter retrospective study.
18. Sénégas J, Vital JM, Pointillard V, et 17(2):200–203. Paradigm Spine J; 1:1–4.
al (2007) Long-term actuarial 24. Kong DS, Kim ES, Eoh W (2007) 29. Kong DS, Kim ES, Eoh W (2007)
survivorship analysis of an interspinous One-year outcome evaluation after One-year outcome evaluation after
stabilization system. Eur Spine J; interspinous implantation for interspinous implantation for
16(8):1279–1287. degenerative spinal stenosis with degenerative spinal stenosis with
19. Floman Y, Millgram MA, Smorgick Y, segmental instability. J Korean Med Sci; segmental instability. J Korean Med Sci;
et al (2007) Failure of the Wallis 22(2):330–335. 22(2):330–335.
interspinous implant to lower the 25. Verhoof OJ, Bron JL, Wapstra FH, 30. Taylor J, Pupin P, Delajoux S, et al
incidence of recurrent lumbar disc et al (2008) High failure rate of the (2007) Device for intervertebral
herniations in patients undergoing interspinous distraction device (X-Stop) assisted motion: technique and initial
primary disc excision. J Spinal Disord for the treatment of lumbar spinal results. Neurosurg Focus; 22(1):E6.
Tech; 20(5):337–341. stenosis caused by degenerative 31. Kim KA, McDonald M, Pik JH, et al
20. Mayer HM, Mehren C, Skidmore G, et spondylolisthesis. Eur Spine J; (2007) Dynamic intraspinous spacer
al (2009) A new percutaneous lateral 17(2):188–192. technology for posterior stabilization:
approach for the insertion of an 26. Mayer HM (2005) Microsurgical case-control study on the safety,
interspinous spacer. Annual Meeting of decompression for acquired central and sagittal angulation, and pain outcome
the American Academy of Neurological lateral spinal canal stenosis. Mayer HM at 1-year follow-up evaluation.
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USA. 2nd ed. Berlin Heidelberg New York:
21. Mayer HM, Mehren C, Siepe C, et al Springer Verlag, 397–408.
(2009) A new interspinous spacer for
minimally invasive treatment of
dynamic lumbar spinal stenosis and
low back pain. Annual Meeting of the
American Academy of Neurological
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USA.
371

Lindsey DP, Swanson KE, Fuchs P, et al (2003) The Schmoelz W, Huber JF, Nydegger T, et al (2003)
effects of an interspinous implant on the kinematics of Dynamic stabilization of the lumbar spine and its effects
the instrumented and adjacent levels in the lumbar on adjacent segments: an in vitro experiment. J Spinal
spine. Spine; 28(19);2192–2197. Disord Tech; 16(4):418–423.
Therapy Human anatomical specimen Not applicable Therapy Human anatomical specimen Not applicable
study study
Purpose Purpose
To understand the kinematics of the instrumented and To investigate the DYNESYS, a dynamic nonfusion system,
adjacent levels due to the insertion of this interspinous which is designed to stabilize the bridged segments while
implant. maintaining the disc and the facet joints.
T Test Healthy lumbar spines from human anatomical specimens T Test Lumbar (L2–5) human anatomical specimen spines (N = 6)
material (L2–5) (N = 7) material
I Intervention Interspinous spacer (X Stop, SFMT) placed at the L3/4 level I Intervention Fixation with the DYNESYS, a dynamic nonfusion system
C Comparison Without implant C Comparison Fixation with the internal fixator
O Outcome Flexion-extension, lateral bending, and axial rotation tests O Outcome Measurement of intersegmental motions, range of motion,
Images to determine the kinematics of each motion and neutral zone
segment
The DYNESYS is capable of stabilizing an unstable segment
The implant does not significantly alter the kinematics of
sufficiently but allows more motion in the segment than
the motion segments adjacent to the instrumented level.
the internal fixator. The adjacent segment does not seem
to be influenced by the stiffness of the fixation procedure
under the described loading conditions.
The DYNESYS provides substantial stability in case of de-

generative spinal pathologies and can therefore be con-
sidered as an alternative method to fusion surgery in these
indications while the motion segment is preserved.

Wiseman CM, Lindsey DP, Fredrick AD, et al (2005) Zucherman JF, Hsu KY, Hartjen CA, et al (2005) A
The effect of an interspinous process implant on facet multicenter, prospective, randomized trial evaluating the
loading during extension. Spine; 30(8):903–907. X STOP interspinous process decompression system for
the treatment of neurogenic intermittent claudication:
Study type Study design Class of evidence two-year follow-up results. Spine; 30(12):1351–1358.
Therapy Human anatomical specimen Not applicable
study Study type Study design Class of evidence
Therapy Randomized controlled trial I
Purpose
The study was undertaken to quantify the influence of Purpose
an interspinous implant on facet loading at the implant- To determine the safety and efficacy of the X-Stop inter-
ed and adjacent levels during extension. spinous implant.
P Patient Neurogenic intermittent claudication patients (N=191)

T Test Human anatomical specimen spines (L2–5) (N=7)
material I Intervention Interspinous process decompression system (X-Stop)
I Intervention Interspinous process implant (X-Stop) placed between the C Comparison Nonoperative treatment
L3/4 spinous processes
O Outcome Zurich claudication questionnaire, a patient-completed, va-
C Comparison Without implant lidated instrument for neurogenic intermittent claudication;
x-ray examination; satisfaction
O Outcome Measurement of facet loading parameters of lumbar human
anatomical specimen spines measured during extension;
peak pressure, average pressure, contact area, and force Authors’ conclusion
The X-Stop provides a conservative yet effective treatment
for patients suffering from lumbar spinal stenosis. In the
Interspinous process decompression will unlikely cause
continuum of treatment options, the X-Stop offers an
adjacent level facet pain or accelerated facet-joint degen-
attractive alternative to both conservative care and de-
eration. Furthermore, pain induced from pressure origi-
compressive surgery.
nating in the facets and/or posterior annulus of the lum-
bar spine may be relieved by interspinous process
decompression. Clinical results from patients with a com-
Siddiqui M, Karadimas E, Nicol M, et al (2006)
ponent of low back pain suggest that this is a valid con-
Influence of X-Stop on neural foramina and spinal canal
clusion.
area in spinal stenosis. Spine; 31(25):2958–2962.

Purpose
To quantify the effect of the implant in vivo on the lum-
bar spine at the instrumented levels in various postures.
P Patient Lumbar spinal stenosis (N = 26)

I Intervention One or two level X-Stop procedure
O Outcome Neural foramen and canal area
The X-Stop device improves the degree of central and
foraminal stenosis in vivo.
373

Adelt D, Samani J, Kim WK, et al (2007) Coflex

interspinous stabilization: clinical and radiographic
results from an international multicenter retrospective
study. Paradigm Spine J; 1:1–4.

Purpose
To determine the safety and efficacy of the Coflex inter-
spinous implant in patients between 40–80 years old with
the primary diagnosis of spinal stenosis (1 or 2 levels),
neurogenic claudication, and low back pain.
P Patient Spinal stenosis (1 or 2 levels), neurogenic claudication, and

low back pain (N=209)
I Intervention Coflex interspinous implant
C Comparison VAS pain scale
O Outcome Objective examination: neurogenic claudication, radiculopa-
thy, and back pain
X-ray data: spinal segment motion (index and adjacent le-
vels), implant position and migration, and bone remodeling
at the bone-implant interface
Patient satisfaction
The Coflex interspinous stabilization after microsurgical
decompression for spinal stenosis demonstrates excellent
short-term and long-term results for safety as well as for
efficacy (ie improvement in back pain, neurogenic clau-
dication, and patient satisfaction).

4.2.6 Fixation of the sacroiliac joint
Philipp Schleicher, Frank Kandziora
1 Historical perspective for arthritic conditions, which is undertaken in order to

determine the benefit of a definitive arthrodesis. In all sta-
Techniques for fusion of the sacroiliac (SI) joint were first bilization procedures, care is taken to minimize damage to
introduced in the third decade of the 20th century [1–5]. the joint surfaces and ligaments in order to preserve optimal
These procedures involved an open, posterior approach to physiological function after joint healing and in most cases
the SI joint and promotion of bony fusion by debridement implant removal.
of joint surfaces and/or press-fit implantation of a cortico-
cancellous bone block between the posterior iliac crest and Sacroiliac joint arthrodesis aims at achieving bony fusion of
the sacrum. Open repositioning and lag screw osteosynthe- the SI joint, and may be performed by removing cartilage and
sis of an unstable SI dislocation was first described by Lehm- inserting bone graft or bone substitute to promote osseous
ann in 1934 [6]. bridging. In contrast to temporary SI joint stabilization, ar-
throdesis involves decortication of the joint structures and at
As regards minimally invasive spinal surgery (MISS), per- least partial removal of the cartilage. Further, it regularly
cutaneous stabilization of the SI joint via lag screws under requires additional stability to facilitate SI joint fusion.
CT control or image intensifier guidance was developed
from the beginning of the 1990s [7–9]. Following the intro-
duction and increasingly more widespread use of comput- 3 Patient selection
er-assisted navigation, percutaneous lag screw stabilization
of the SI joint has also been performed using this system. Since the main aim of SI joint stabilization and arthrodesis
One of the earliest descriptions of this technique was made is to achieve mechanical stability—either temporary or per-
by Barrick et al in 1998 [10]. manent—the indications for surgery include either gross
instability, or pain due to any kind of microinstability as
can be observed in inflammatory joint conditions, where
2 Terminology even physiological micromotions can cause severe pain.
The term “sacroiliac joint disease”, often abbreviated as SJD, Gross instability, which mainly occurs in cases of acute trau-
refers to all chronic pain conditions in the area of the SI matic instability, is usually easily identified on standard
joint. Sacroiliac joint disease has a wide variety of etiologies. pelvic x-rays (standard AP, inlet, outlet views) or at least
These include loosening of the SI ligaments during preg- on CT scans, which comprise part of the standard diagnos-
nancy and postpartum, arthritic conditions in rheumatoid tic procedures for pelvic injury. A thorough classification
diseases such as ankylosing spondylitis (Bechterew’s disease) of the type of injury is essential to determine the most ap-
or Crohn’s disease, posttraumatic arthritis and chronic pyo- propriate surgical treatment.
genic sacroiliitis [11–13]. The SI joint can also be affected
after spinal fusion procedures, mainly after fusion of L5 to Fixation of the posterior pelvic ring is generally required
the sacrum [14]. for the correction of any form of vertical instability affect-
ing the posterior pelvic ring (type C injuries according to
A differentiation should be made between SI joint stabiliza- the AO Müller Classification), since the common techniques
tion and SI joint arthrodesis or fusion. of anterior stabilization (external supraacetabular fixator,
symphysis plating) are not designed to withstand the high
Sacroiliac joint stabilization is performed as a temporary shear forces along the sagittal plane that occur in this type
measure. It is often carried out in cases of traumatic insta- of instability. However, type B injuries usually do not require
bility until healing has occurred or as probative stabilization posterior stabilization.
375

Authors Philipp Schleicher, Frank Kandziora
The choice of which minimally invasive stabilization meth- In summary, patients with the following indications may
od to adopt depends on a further analysis of the type of be considered for SI joint fixation:
injury. The classical and most frequently used minimally • Temporary SI joint fixation:
invasive SI stabilization procedure, percutaneous lag screw • Unstable type C pelvic injuries without the need for
fixation of the SI joint, is intended for the treatment of pure open decompression of neurovascular structures
ligamentous SI joint dislocations or transiliosacral fracture • Chronic SI joint pain due to posttraumatic, inflam-
dislocations (AO 62-C1.2, -C2.2, -C3.1, -C3.2). matory, or arthritic conditions: viewed as a further
step in the diagnostic process (Fig 4.2.6-1)
The treatment of vertical sacral fractures (AO 62-C1.3, -C2.3, • Permanent SI joint arthrodesis:
-C3.2, -C3.3) is controversial. Some authors have reported • Chronic SI joint pain due to posttraumatic, inflam-
on the treatment of vertical sacral fractures with percutane- matory, or arthritic conditions, with diagnosis estab-
ous screws [15–17]. In a retrospective case control study of lished by at least two repeated SI joint blocks
62 patients treated with percutaneous screws, Griffin et al • Lack of significant benefit derived from a 6-month
[16] noted 13% fixation failure in vertical sacral fractures physical therapy rehabilitation program
compared to a 0% failure rate in transiliosacral fractures. • Pain and associated discomfort could be significant-
Ebraheimand [8] reported a 100% healing rate for poste- ly reduced by prior temporary SI joint fixation.
rior fractures, in a series of 19 patients. If screw-based os-
teosynthesis is performed, the screws should be fully thread- There are few contraindications for minimally invasive
ed for efficient use in this type of injury, to prevent the fixation of the SI joint if the surgeon follows the previ-
compression of comminuted fractures. ously mentioned guidelines. General contraindications for
surgery, for instance bleeding disorders or poor general state
Minimally invasive treatment of SI joint injuries may neces- of health, are of course to be taken into full account. Oth-
sitate a closed reduction. This is generally most effective er contraindications are:
during the first 5 days after trauma. Afterwards, performing • Comminuted sacral fractures with the risk of neurovas-
a closed reduction becomes significantly more difficult [18, cular compression
19]. • Grossly displaced fractures, which are over 5 days old
• Poor bone stock due to osteoporosis
In cases of chronic instability, which include postpartum • Septic arthritis which requires thorough debridement,
SJD, sacroiliitis in Bechterew’s or Crohn’s disease, or post- rinsing and possibly drainage of the SI joint.
traumatic arthritis, it is crucial to identify the SI joint as the
major pain generator. Imaging studies, such as x-ray, CT
scan, and MRI, can reveal certain indicative signs, but since 4 Pros and cons of fixation of the sacroiliac joint
there is a high rate of false-positive and false-negative results
connected with imaging, the indication for SI joint stabili- The advantages of minimally invasive SI joint fixation and
zation and fusion relies mainly on a thorough clinical ex- fusion are mainly based on minimization of complications
amination and a reproducible positive reaction on an SI associated with the approach strategy. They include the
joint block under local anesthetic. It must be emphasized following:
that the diagnostic SI joint block should be performed at
least twice as a confirmatory measure, since Maigne and 4.1 Pros
Planchon [14] and Maigne et al [20] showed a 20% false- • Reduced soft-tissue trauma
positive rate in single, nonrepeated diagnostic blocks. With • Less bleeding
two positive SI joint-block results, the final diagnostic step • Decreased wound healing morbidity.
before undertaking definitive SI fusion surgery will be a
probative SI joint fixation (Fig 4.2.6-1) that follows the sur- These aspects are especially important for arthrodesis pro-
gical procedures described later in topic 6 Surgical technique. cedures, which in open procedures are usually associated
with extensive stripping of the soft tissues in the region of
For the treatment of pyogenic sacroiliitis, a rare condition the posterior sacrum and pelvis, and which may even have
that requires a thorough debridement of the joint, a mini- to be combined with an additional anterior approach for
mally invasive procedure has also been described [21]. some techniques.

The disadvantages include the following: for SI stabilization procedures. One of the drawbacks of this
approach is that it offers less possibility to reduce SI fractures,
4.2 Cons and thus limits this technique to certain fracture types, which
• Risk of screw misplacement in addition have to be operated on within 5–7 days.
• Inability to access the whole SI joint for debridement in
the event of septic conditions
• The possibilities for bone graft harvesting are limited, 5 Preoperative planning
so the use of bone substitutes might become necessary
• The placement of a bone graft to promote bony fusion Preoperative imaging studies include an AP view, inlet/
is technically more demanding in minimally invasive outlet views and a lateral view of the pelvis. A CT scan is
procedures also necessary to exclude the presence of any abnormalities
• Compromised possibility to reduce SI fractures. and obtain specific anatomical information. Prior to the
surgical procedure, the definitive diagnosis should be fully
The disadvantages when using a computer-assisted naviga- established (see also Fig 4.2.6-1).
tion system include the financial and logistic efforts involved
in the investment and use of such equipment, which can At the preoperative stage, the risks involved in the surgical
be considered as a conditio sine qua non for the safe ap- procedure must be explained to the patient before he/she
plication of percutaneous SI fusion techniques as well as gives his/her informed consent. The possible general
SI joint pain
Standard treatment
Manual therapy, exercise therapy, fango, massage
Successful
Pain killers, specific medication
Local injections (local anesthesia and/or corticosteroids)
Not successful
Diagnostic block Not successful
No surgery
Successful
2nd diagnostic block

Not successful
(confirmation block)
Successful
Probative SI joint fixation Not successful
Successful
SI joint arthrodesis Fig 4.2.6-1 Diagnostic algorithm for the

treatment of patients with chronic SI joint
pain.
377

complications that could arise, eg, the risks of a spinal nerve For moderately unstable lesions (certain traumatic and most
lesion or injury to the superior gluteal artery, which can chronic lesions), the prone position may be of advantage,
lead to gluteal muscle necrosis or to the development of as it facilitates the handling of surgical instruments
aneurysms, must also be outlined. Further, the hypogastric (Fig 4.2.6‑2, Fig 4.2.6-3). The entry point for the SI lag screw
plexus is at risk if cortical perforation during the insertion is located in the posterior third of the gluteal region.
of anterior SI joint screws occurs, with the associated risk
of sexual dysfunction. A radiolucent table is essential. Prior to surgery, it is neces-
sary to check whether an inlet and outlet view via image
Preoperative bowel preparation can help to optimize intra- intensification is possible. If using a 3-D image intensifier,
operative visualization, because bowel gases may occasion- care has to be taken to ensure the collision-free rotation of
ally obscure important image intensifier landmarks. This the C-arm around the operating table, with the focus of
option might be of advantage especially in obese patients, surgery (ie, the SI joint) in the center of the image intensi-
where imaging is invariably poor (see also Fig 4.2.6-2). fier beam and with no metallic devices (armrests, etc) ob-
structing the beam.
All patients should be operated under general anesthesia.
During draping, the far posterior entry point for the percu-
In the operating room, the patient can be positioned in a taneous screw has to be taken into account. The patient’s
supine or prone position. For highly unstable (traumatic) ipsilateral leg should be accessible for reductional maneuvers
lesions, most surgeons prefer the supine position because by the surgeon’s assistant in the case of highly unstable
it facilitates traction and rotation of the leg for reduction lesions. If a 3-D image intensifier is used, the draping should
[8]. If operating with the patient in the supine position, he/ allow for the creation of a “sterile tunnel” beneath the table
she should be positioned towards the ipsilateral edge of the (Fig 4.2.6-2).
operating table, to provide unimpeded access to the pos-
terolateral part of the buttock.
Head Cranial Caudal
Feet
Fig 4.2.6-2 Intraoperative view showing patient position- Fig 4.2.6-3 The patient is positioned prone. Posterior
ing for sacroiliac arthrodesis. The patient is lying in the view, showing a Schanz screw, which will receive the refer-
prone position; a “sterile tunnel” has been created for the ence base, being drilled percutaneously into the posterior
3-D image intensifier C-arm. superior iliac crest. Laterocaudally of the entry point, the
scar left by the probatory SI screw stabilization procedure
is visible.

6 Surgical technique 3-D image intensification or intraoperative CT scan) is rec-

ommended instead of the standard preoperative CT-based
6.1 Percutaneous screw stabilization using image system, because the preoperative acquisition technique
intensifier control usually requires some bony surface to be exposed during
After correct patient positioning and draping, the entry point the operation for the registration procedure. This is not
is located under image intensifier control in the AP, inlet, necessary with an intraoperative 3-D image intensifier-based
outlet, and lateral projections. The entry point is usually in navigation technique.
the posterior gluteal region, about 15 mm anterior of the
linea glutea and at the level of the posterior superior iliac The surgical technique with 3-D image intensifier-based
spine in the craniocaudal direction. A skin incision of ap- navigation differs slightly from the previously mentioned
proximately 2 cm is made somewhat posterior to the exten- image intensifier-guided percutaneous technique: when
sion of the axis of the femur at the level of the posterior draping the patient, a “sterile tunnel” should be created
superior iliac spine [17]. The soft tissues are spread apart beneath the operating table, where the C-arm can rotate
with a blunt instrument. Usually, the correct entry point unhindered during image acquisition for navigational pur-
can easily be palpated. It is located in a groove, where the poses (Fig 4.2.6-2).
outer surface of the iliac wing changes direction. A soft
tissue protector is introduced and a guidewire is placed into The procedure starts with mounting the reference base (Fig
the sacrum under repeated image intensifier control in the 4.2.6-3). This step depends on the type of navigation system
inlet and outlet projection. The trajectory is usually direct- used. When mounting the reference base, the authors rec-
ed anteriorly 15–20°, perpendicular to the surface of the ommend the posterior iliac crest, when operating with the
ilium. The anatomical target area for the guidewire and the patient in a prone position, or the anterior iliac crest when
screw is S1. Three cortices (outer and inner ilium, outer operating in a supine position (Fig 4.2.6-3, Fig 4.2.6-4). If an
sacrum) must be penetrated. The tip of the guidewire may external fixator is already present, the fixator pins can be
finally reach the midline; a position in the contralateral used for reference base mounting as well, but preopera-
sacral ala will potentially provide better bone purchase for tively, they should be checked manually for possible loos-
the screw, but will also make surgery on the contralateral ening. When mounting the reference base, the C-arm tra-
side more difficult. jectory during registration and the position of the surgeon
and his instruments during navigation have to be taken
After the correct position of the guidewire is checked via into account. The reference base must be visible at all times
AP, inlet, outlet, and lateral views, the drilling and insertion during registration and surgery, and care should be taken
of a cannulated cancellous bone screw follows. The screw that the C-arm does not collide with it during registration.
length depends on the desired trajectory, screw location It has to be taken into consideration that repeated image-
(S1 or S2) and on the patient’s anatomy, and measures intensifier control might become necessary when using a
between 70 and 110 mm in most cases. Screw diameter navigation system to avoid the risk of accidental instrument
should be as large as possible: the author recommends a bending or dislocation of the reference base.
screw diameter of 6.0 or 8.0 mm. In ligamentous injuries,
simple fractures and in chronic SJD, partially threaded
screws with a 32-mm-long screw thread are recommended
to achieve a lag screw effect. In complex fractures, fully Cranial
threaded screws must be used to prevent unintended com-
pression.
Titanium screws enhance postoperative visualization of

screw placement via CT scans [22].
6.2 Percutaneous screw stabilization using

computer-assisted navigation systems
When computer-assisted navigation based on 3-D datasets
is available it should be used, because it reduces screw mis-
placements significantly [23]. When possible, a navigation Fig 4.2.6-4 Mounting of the reference base at the
system with intraoperative image acquisition (usually via posterior iliac crest.
379

6.3 Fusion techniques is identical to the previously described image intensifier-

After conservative treatment approaches have failed, ar- based preoperative preparation, with the prone position
throdesis of the SI joint is a possible treatment for any of being recommended. After mounting the reference base on
the aforementioned chronic conditions. As in other arthrod- the posterior iliac crest, 3-D images are acquired and the
esis procedures, the aim is to create a bony bridge between dataset is registered to match the anatomy.
the two articulating bones. The success of this procedure is
based on three requirements: Using a navigated drill guide, the SI joint cartilage is de-
1. Induction of bone growth and bony bridging. brided by drilling percutaneously in a windshield-wiper-like
2. Removal of opposing tissue, eg, cartilage. manner (Fig 4.2.6-5). Because of the highly variable anatomy
3. Stability. of the SI joint, this step is very difficult to perform without
the aid of a navigation system. The joint can be accessed
For open arthrodesis, a large number of surgical techniques for debridement via the same incision that is used for mount-
have been described, most of them based on the Smith- ing of the reference base (Fig 4.2.6-6).
Petersen technique first reported in 1926 [4]. This includes
exposure and osteotomy of the posterior iliac crest, creating The correct screw entry point is defined via image intensifica-
a wedge-shaped bone graft, which is impacted between the tion, the target area being S2. After the previously performed
sacrum and the ilium. probatory SI screw fixation of the S1 vertebra, an additional
SI screw is inserted via navigated guidewire into the S2 ver-
Although there has been a significant trend towards mini- tebra to create additional stability. Then another guide wire
mally invasive surgical approaches in the past decades, only is placed under navigation control into the sacral ala crossing
a few reports describing techniques for minimally invasive the SI joint, forming a triangle-like configuration with the
SI arthrodesis have been published. two already inserted screws. Using a large-diameter cannu-
lated drill (at least 8–10 mm) the joint is opened and traversed.
One technique was described by Khurana et al [11], who This should be done either under navigation or image inten-
used 10 mm hollow screws filled with demineralized bone sifier guidance, to ensure the correct drill depth and position.
matrix (DBM). They performed no additional removal of With the guide wire left in place, a cannulated allograft or
cartilaginous tissue. Out of 15 patients that underwent sur- autograft bone cylinder is then introduced into the SI joint
gery, 13 good or excellent results were reported. via the third guidewire, which serves as a kind of “railway”
for the bone graft (Fig 4.2.6-7).
Wise and Dall [24] reported on a technique in which two
threaded spine fusion cages filled with recombinant human The correct positioning of the graft is determined via an
bone morphogenetic protein type 2 (rhBMP-2) were intro- intraoperative 3-D scan. The surgical procedure is com-
duced into the joint space parallel to the joint surfaces. The pleted by removal of the guidewire and the reference base,
rhBMP-2 is a tissue hormone that acts as a bone growth- followed by skin closure. Drainage is usually not needed.
inducing factor. Its standard use is for promoting bone fu- A postoperative 3-D scan or CT scan is recommended to
sion in the treatment of complex long-bone pseudarthroses document screw and graft position. Fig 4.2.6-8 shows the
as well as spinal fusions. In a case series of 13 patients, these postoperative situation following wound closure.
authors reported a fusion rate of 89% and a visual analog
scale (VAS) back pain reduction of 4.9 points on a 10-point 6.4 Alternative technique: minimally invasive
scale. posterior plate stabilization
Dolati et al [26] have developed an alternative technique of
Gebhard et al [25] presented a case report on navigated SI minimally invasive SI joint fixation using a sliding plate
arthrodesis, in which a bone cylinder was cut out of the instead of screws, applied via a posterior approach. With
ilium and inserted medially into the SI joint space. How- the patient in the prone position, two 4 cm longitudinal
ever, no information is available on the follow-up results skin incisions are made to reveal the posterior superior il-
using this technique. iac crest. After removal of a small bone block from the pos-
terior iliac crest, a 4.5 mm pelvic reconstruction plate is
At the author’s institution, this procedure has been con- bent to fit to the anatomy of the posterior aspect of the
tinuously improved. After successful probatory SI joint sacrum and the iliac crest, and introduced with a sliding
stabilization, a fusion procedure is performed using 3-D technique beneath the skin. An additional bone graft is not
image intensifier-based navigation. Positioning and draping included.

Fig 4.2.6-5 Posterior debridement of the SI joint with a Fig 4.2.6-6 The same incision as that made for the refer-
navigated drill sleeve operating in a windshield-wiper-like ence base can be used for the debridement of the SI joint.
manner. The drill sleeve is shown in green, and the drill in
red. The upper two quadrants show the perpendicular cuts
along the instrument axis; the lower left shows a coronary
view. The lower right quadrant displays four transverse cuts
along the instrument axis at a distance of 0, 5, 10 and 15
mm from the tip of the tool. The metal artifacts result from
the reference base and the previously performed probatory
stabilization.
Fig 4.2.6-7 A cannulated allograft is slid via the guidewire Fig 4.2.6-8 Postoperative view of healed
into the predrilled large-diameter hole to bridge the SI joint. skin incisions following SI joint arthrodesis.
381

7 Postoperative care In general, conservative therapy is found to be effective,

but there are certain cases that do not respond to it.
Patient mobilization is allowed from the first postoperative
day onwards. Due to the minimally invasive nature of this Although the complication rate for a purely MISS approach
procedure, there is no need for prolonged antibiotic pro- might be lower than the 13.7% reported for open and MISS
phylaxis. procedures combined, the authors recommend that this
procedure must be considered as the final option, only after
In unstable traumatic lesions treated with percutaneous the failure of a seriously conducted rehabilitation program.
screw fixation, partial weight-bearing of 15 kg is recom-
mended for the first 6–8 weeks. Full weight-bearing may 8.2 Open versus minimally invasive surgery
be allowed after 6–8 weeks. With SI fusion procedures, No comparative randomized controlled trials have so far
mobilization starts with partial weight bearing of 15 kg for been carried out on open surgical SI joint fusion versus a
6 weeks followed by continuously increased weight bearing, minimally invasive approach, and further studies need to
until full weight bearing in the 12th postoperative week. be carried out in this regard.
Postoperative imaging includes AP, inlet and outlet views, Although open arthrodesis is often considered to be associ-
as well as a lateral view of the pelvis. In arthrodesis tech- ated with a high rate of wound complications, there are few
niques, a postoperative CT scan is recommended to docu- reports of such complications in the literature. In case series,
ment the correct positioning of the bone graft, which nor- the wound infection rate has been reported as being between
mally cannot be adequately visualized on conventional x-ray 4–10% for open procedures [28, 29]. In percutaneous screw
images. The necessity of implant removal in temporary SI placement, the infection rate has been reported as being
joint stabilization remains controversial. In percutaneous between 0–11%. The pooled infection rate based on the
screw fixation without fusion, the joint bridging screw may number of SI joints treated by MISS in the studies in ques-
be removed after 6–12 months. However, a CT scan to tion amounted to 0.7% (3 cases of screw-associated infec-
evaluate the consolidation of bony bridging might be nection out of 418 screws placed) [8, 24, 26, 30–32].
essary before implant removal.
Reports on the fusion rate, another criterion that could be
used to differentiate between the results of open versus
8 Evidence-based results MISS procedures, are surprisingly scarce. Regarding the
published results, fusion rates are estimated at around 90%,
8.1 Surgery versus conservative treatment for both open and MISS fusion (not stabilization) procedures.
No randomized controlled trials have so far been carried
out comparing surgical SI joint fusion to conservative treat- Concerning the use of a computer-based navigation system,
ment. in a randomized study on 24 patients that received 48 SI
screws for arthrodesis, Schep et al [12] showed that a 2-D
A thorough review comparing surgical SI joint fusion (either navigation system was able to reduce radiation exposure
by open or minimally invasive surgery) to percutaneous and procedure time with no difference in complication rates
denervation showed a low level of evidence-based results compared to conventional percutaneous SI screw placement.
for both types of treatment, with no comparative, prospec- Again using a 2-D image intensifier navigation system, Grüt-
tive, or retrospective study meeting the inclusion criteria zner et al [32] found no incidence of infection or screw
[27]. Investigation of pooled results on 95 cases of fusion misplacement in a case series of 7 patients. These results
and 68 cases of denervation showed a higher complication are in disagreement with laboratory findings, which showed
rate (13.7% versus 7.3%; n=163) for surgical treatment, a screw misplacement rate of 20% using conventional im-
with infections occurring only in the surgical population age intensification or a 2-D navigation system compared to
(5.3% versus 0.0%; n=57). The overall satisfaction rate was 0% using a 3-D navigation system [23]. In another experi-
higher in the denervation group (89%; n=9) than in the mental laboratory study, Citak et al [33], found a higher S2
surgical group (57.6%; n=59), but this result should be screw misplacement rate of 10% when using 2-D navigation
interpreted with caution due to the small sample size of the compared to 0% in 3-D image intensifier navigation.
former group. Mean pain improvement ranged from 3.5 to
4.9 points on a 10-point VAS, with no differences observed In a retrospective study on a trauma population that received
between surgical treatment and denervation. conventional image intensifier-guided percutaneous SI

screw stabilization, Tonetti et al [34] reported a 25% screw limited reliability of neuromonitoring, the author recom-
misplacement rate and 7% iatrogenic neurological damage. mends that the use of intraoperative imaging is preferable
to the latter. Since cases of screw misplacement with ensu-
Although there is some discrepancy in the screw misplace- ing neurological impairment have been reported even after
ment results, the potential advantages of a navigation sys- thorough compliance with the imaging techniques the au-
tem are convincing, and therefore its use is recommended thors advocate the use of intraoperative navigation when-
whenever possible. ever possible [38, 39]. In laboratory investigations, the use
of a 3-D navigation system was found to reduce the mis-
placement rate from 20% to 0% [23, 40]. This system is
9 Complications and avoidance particularly effective for instrumentation of the S2 vertebra.
In percutaneous SI screw placement, approach-related com- In percutaneous posterior plating, complications result
plications are very infrequent. The major complications mainly from subcutaneous irritation caused by implants
result from failed reduction or screw misplacement, associ- [26], which have been reported as necessitating implant re-
ated with the percutaneous nature of the intervention and moval after bony healing in 29% of cases [41]. Neurovas-
the large amount of soft-tissue coverage of the pelvic ring. cular complications were not observed.
Reports on neurovascular complications after SI joint screw
placement are rare. Theoretically at risk are the lumbosacral For minimally invasive arthrodesis of the SI joint in the
plexus, the presacral sympathetic trunk, the iliac vessels, treatment of chronic conditions, only some case reports and
and the presacral venous plexus. Injuries to the superior one cohort study including 13 patients are available [11, 21,
gluteal artery, however, have also been reported on occa- 25, 30]. None of the authors reported any neurovascular
sion. complications or wound infections associated with the pro-
posed techniques.
Pattee et al [35] reported on an S1 root impingement after
placement of five iliosacral screws in a patient for the treat- The complications theoretically involved may be similar to
ment of chronic SJD. Weil et al [36] reported an L5 root those for SI joint stabilization in the case of acute trau-
irritation after percutaneous placement of an SI screw, which matic lesions, but should occur much less frequently; be-
was remedied by screw removal via an anterior approach. cause in arthrodesis there is no need for reduction, the
Routt et al [9] described a case of transient L5 neurapraxia anatomy is more or less physiological and surgery is per-
in a series of 177 patients (244 screws in all) treated with formed with the patient in the prone position, which fa-
percutaneous SI screw placement (0.4%). Gardner et al [37] cilitates determination of the correct entry point. Further,
noted an absence of neurological complications in 86 pa- bowel preparation is possible and in many cases there is no
tients that received 106 screws without neuromonitoring instrumentation of the anterior pelvis, which could addi-
(0%). Due to the low rate of neurological damage and the tionally compromise intraoperative imaging.
383

10 Tips and tricks—with special emphasis on distraction-interference arthrodesis
John Stark, Minneapolis, USA 4. The preferred arthrodesis method protects access within a relatively avascular, an-
the integrity of the soft-tissue and bone eural plane.
10.1 Clinical decision making treatment, follows anatomical landmarks, 2. The recess anatomy is analogous to the
1. Especially because of the potential for respects biomechanical loading, restores lumbar spine, with recognizable elements
diagnostic ambiguity, the surgeon’s deci- deformity, preserves bone, and provides of vestigial structure, including transverse
sion to treat any of the component or- for revision. processes, intertransverse space (the re-
thopedic structures within the hip-spine 5. Methods of fusing the SI joint may be cess), foramina, and facets. The recess
axis requires a full understanding of any either lateral (compression or neutral- presents a void, which can be grafted to
coexisting disease and any treatment ef- ization) or posterior-medial (distraction- accomplish fusion between the ilium and
fects on the other structures. interference). Distraction-interference sacrum.
2. Application of surgical principles must uses the principles of ligamentotaxis, 3. The anterior column represents the forces
respect the oblique orientation of the reduction, and intercalary interposition. which converge on the axial spine from
forces, which are not oriented directly 6. Instrumentation is undertaken after the hip, and the alignment of the guide-
to gravity as they would be in the limb. satisfactory extraarticular arthrodesis of wire and implant follows landmarks
This may require creative combinations the recess, which provides for neovas- which represent these forces.
of neutralization, compression, and dis- cularization, inductive, and conductive 4. The bone and structure of the recess are
traction. mechanisms. receptive and can be prepared to receive
3. Imaging considerations are generally an implant that slightly separates the sur-
correlated, but the decision is clinical, 10.2 Distraction-interference arthrod- faces (Fig 4.2.6-9).
dictated by disabling symptoms, and a esis: considerations 5. The healing situation requires correction
failure of all other compensating and 1. Viewing from the contralateral side, the of any metabolic, endocrine, and nutri-
palliative methods. approach to the SI joint recess provides tional impairment to patient healing.
b
a
Fig 4.2.6-9a–d Views of the threaded interference implant

a Schematic drawing with the implant in place. Nerves and vessels are visible
immediately anterior and medial to the SI joint.
b Axial view, tipped into the plane of the anterior column, demonstrates the
implant and the relationships to the foramen and neural canal.
c–d Sagittal (c) and coronal/frontal (d) images demonstrate solid fusion. c d

11 Case example As the temporary SI joint stabilization resulted in complete

pain relief, definitive arthrodesis was scheduled 4 months
A 32-year-old man, suffering from ileitis terminalis (Crohn’s later.
disease) presented with moderate buttock pain, with slight
emphasis on the left side but with no radiating pain. No This procedure was also performed via a minimally invasive
sensorimotor deficit was found. Clinical tests were positive computer-navigated technique, with the implantation of
for degenerative changes of the SI joint. Imaging studies another SI screw into S2. Additionally, an allograft was
including x-ray and CT scans revealed arthritic changes placed within the joint space. It was ensured that neither
(subchondral sclerosis, osteophytes, and intraarticular gas) screw passed the midline, to allow for an additional fusion
in both SI joints, which were slightly more severe on the procedure on the contralateral side.
left side (Fig 4.2.6-10, Fig 4.2.6-11, Fig 4.2.6-12).
Postoperative x-ray and CT scans showed intraarticular
Diagnostic injection into the SI joint resulted in temporary bridging of the bone graft and correct placement (Fig 4.2.6‑14,
pain relief, which was confirmed by repeated injections. This Fig 4.2.6-15). At 6 weeks follow-up, the patient reported
positive result identified the SI joint as pain generator, so being completely pain free.
probatory SI joint fixation using a navigated percutaneous
screw procedure was performed, to be followed by a definitive
arthrodesis in the event of a positive result (Fig 4.2.6-13).
Fig 4.2.6-10 Scout image in AP projection of Fig 4.2.6-11 Preoperative CT scan. Both SI Fig 4.2.6-12 Preoperative CT scan in coro-
the pelvis of a 32-year-old man suffering from joints show signs of arthritic degeneration and nary projection. Subchondral sclerosis and
buttock pain on the left side. Note the bowel the presence of gas (indicative of microinsta- bone cysts are indicative of arthritis of the SI
gas artifacts, which make visualization of the SI bility) on the left side. joint.
joint difficult.
Fig 4.2.6-13 X-ray after probatory SI joint

fixation with a single percutaneous lag screw
at S1.
385

a b c
Fig 4.2.6-14a–c
a Postoperative x-ray, AP projection. This is a standard projection: the correct positioning of
the SI screws cannot be confirmed in this projection.
b Postoperative x-ray, inlet projection. Note the two SI screws, which do not traverse the
anterior border of the sacrum.
c Postoperative x-ray, outlet projection. Note the two SI screws, which are placed between
the neuroforamina of S1 and S2.
Fig 4.2.6-15 Postoperative CT scan. Two SI

screws stabilize the joint. The joint space is
partially filled with bone graft material, which
was inserted in between the two screws (ar-
row).
12 Key learning points • SI joint screw placement should be performed with a

navigation system using a 3-D dataset (CT scan- or im-
• Minimally invasive (percutaneous) SI joint screw fixa- age-intensifier-based), if available
tion is an effective and safe treatment option for trau- • Intraoperative 3-D imaging is a major advantage in
matic or chronic SI lesions minimally invasive SI joint screw fixation
• Minimally invasive SI joint screw fixation is suitable for • For chronic conditions, confirmation by repeated injec-
the treatment of specific traumatic lesions of the SI joint tions of the SI joint as pain generator is essential
within 5 days of trauma • SI arthrodesis can be carried out via a percutaneous
approach, but further investigation is necessary on the
mid- and long-term results of this approach.

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14 Further reading
Stark JG, Fuentes JA, Fuentes TI,

Idemmili C (2011) The history of sacroiliac
joint arthrodesis: a critical review and
introduction of a new technique. Current
Orthopaedic Practice; 22(6):545–557.

Schep NW, Haverlag R, van Vugt AB (2004) Computer- Gardner MJ, Farrell ED, Nork SE, et al (2009)
assisted versus conventional surgery for insertion of 96 Percutaneous placement of iliosacral screws without
cannulated iliosacral screws in patients with postpartum electrodiagnostic monitoring. J Trauma; 66(5):1411–
pelvic pain. J Trauma; 57(6):1299–1302. 1415.
Therapy Prospective cohort study II Therapy Case series IV
Purpose Purpose
To assess the value of image intensification-based com- To evaluate the neurological complications after percu-
puter-assisted surgery (CAS) for the insertion of iliosacral taneous iliosacral screw placement without neurodiag-
screws. nostic monitoring.
P Patient Patients with postpartum pelvic pain syndrome (N = 24, P Patient Patients with pelvic ring disruptions (N = 68 with n = 106
mean age 36 years) screws placed)
I Intervention Operative treatment with image-intensification-based CAS I Intervention Percutaneous stabilization of pelvic ring injuries without
(n = 12, n = 48 screws) neurodiagnostic monitoring
C Comparison Conventional operative treatment (n = 12, n = 48 screws) C Comparison No comparison group
O Outcome Image intensification, guide wire insertion, operating times, O Outcome Neurological examination, screw placement
complication rate
Using a standardized technique, appropriate and reliable
The image intensification time is reduced by two and a
image intensification landmarks are available in the vast
half times using CAS. Guide wire insertion time was
majority of percutaneous iliosacral screw fixation proce-
similar in both groups. The reduction in operative time
dures. Iliosacral screw placement without neurodiagnos-
using CAS was due to the fact that patients were oper-
tic monitoring has a low rate of neurological complica-
ated in the supine position during the whole procedure.
tions.
This study shows that CAS is a safe technique for insertion
of iliosacral screws.
389

Routt ML Jr, Simonian PT, Agnew SG, et al (1996) Maigne JY, Planchon CA (2005) Sacroiliac joint pain
Radiographic recognition of the sacral alar slope for after lumbar fusion. A study with anesthetic blocks. Eur
optimal placement of iliosacral screws: a cadaveric and Spine J; 14(7):654–658.
clinical study. J Orthop Trauma; 10(3):171–177.
Purpose
Purpose To evaluate the frequency of sacroiliac syndrome in a
To report on the early complications related to the per- series of lumbar fusion patients with persistent postsurgi-
cutaneous placement of iliosacral screws for the operative cal low back pain, with the use of anesthetic blocks under
treatment of displaced posterior pelvic ring disruptions. image intensification.
P Patient Patients with unstable pelvic ring fractures (N = 177, n = 102 P Patient Patients with persistent low back pain after a lumbar fusion
males, mean age 32 years) (N = 40)
I Intervention Operative treatment of unstable pelvic ring fractures using I Intervention Sacroiliac anesthetic block under image intensifier control
244 percutaneous iliosacral screws
O Outcome Pain measured with VAS, sacroiliac pain provocation test
O Outcome Complications, fracture or dislocation reduction, implant
safety
The study confirms that the sacroiliac joint can play a
significant role in pain persisting after lumbar fusion. Its
Iliosacral screw fixation of the posterior pelvis is difficult.
role should be particularly evoked when the postoperative
The surgeon must understand the variability of sacral
pain distribution differs from the preoperative pattern,
anatomy. Quality triplanar image intensification of the
and when postfusion low back pain appears after a pain-
accurately reduced posterior pelvic ring should allow for
free interval of at least 3 months after surgery.
safe iliosacral screw insertions. Anticipated noncompliant
patients or those with craniocerebral trauma may need
supplementary posterior pelvic fixation. Low rates of in-
fection, blood loss, and nonunion can be expected.

Maigne JY, Aivaliklis A, Pfefer F (1996) Results of Buchowski JM, Kebaish KM, Sinkov V, et al (2005)
sacroiliac joint double block and value of sacroiliac pain Functional and radiographic outcome of sacroiliac
provocation tests in 54 patients with low back pain. arthrodesis for the disorders of the sacroiliac joint. Spine
Spine; 21(16):1889–1892. J; 5(5):520–528; discussion 529.
Purpose Purpose
To determine the prevalence of sacroiliac pain in a se- To describe the outcome of sacroiliac joint arthrodesis for
lected population of patients suffering from low back pain sacroiliac joint disorders, with the hypothesis that sacro-
and to assess certain pain provocation tests. iliac arthrodesis leads to improved postoperative function.
P Patient Patients with unilateral low back pain, pain mapping P Patient Patients with sacroiliac joint disorders (N = 20, n = 3 males,
compatible with a sacroiliac origin, tenderness over the mean age 45.1 years)
sacroiliac joint, and no obvious source of pain in the lumbar
I Intervention Sacroiliac joint arthrodesis
spine (N = 54)
Intervention Double anesthetic block performed under image intensifier C Comparison No comparison group
I
guidance O Outcome General health and function (Short Form-12, American
C Comparison No comparison group Academy of Orthopaedic Surgeons), clinical evaluation, and
x-ray assessment
O Outcome Pain measured with VAS, sacroiliac pain provocation tests
For carefully selected patients, sacroiliac arthrodesis ap-
The present study suggests that the sacroiliac joint is an
pears to be a safe, well-tolerated, and successful procedure,
uncommon but real source of low back pain. The accu-
leading to significant improvement in functional outcome
racy of some of the presumed “sacroiliac pain provocations
and a high fusion rate.
tests” is questioned.
Waisbrod H, Krainick JU, Gerbershagen HU (1987)

Sacroiliac joint arthrodesis for chronic lower back pain.
Arch Orthop Trauma Surg; 106(4):238–240.

Purpose
To report on the experience of sacroiliac joint arthrodesis
in cases of overt osteoarthritis.
P Patient Patients with degenerative disease of the sacroiliac joint in

the late phase of overt osteoarthritis (N = 21, n = 3 males,
average age 42 years)
I Intervention Sacroiliac joint arthrodesis
O Outcome Pain reduction, use of analgesics, resumption of preopera-
tive occupation
In carefully and well-selected cases 70% satisfactory re-
sults can be expected.
391

Tonetti J, Cazal C, Eid A, et al (2004) [Neurological

damage in pelvic injuries: a continuous prospective series
of 50 pelvic injuries treated with an iliosacral lag screw].
Rev Chir Orthop Reparatrice Appar Mot; 90(2):122–131.
French.

Purpose
To analyze lesions to the lumbosacral plexus related to
pelvic injury and its treatment.
P Patient Patients with posterior osteoligamentary lesions of the

pelvic girdle (N = 48 with 50 lesions)
I Intervention Image-intensifier-guided percutaneous lag screw fixation
O Outcome Screw placement, neurological data, functional score
(Majeed score), VAS, use of analgesic drugs
About 52% of posterior osteoligamentary injuries are as-
sociated with neurological symptoms. After recovery,
permanent deficit persists in 21.7% of patients. The most
common sequelae are hallux extensor and gluteus me-
dius palsy due to stretching of the lumbosacral trunk.

4.3.1 Minimally invasive anterior midline approach to the
lumbar spine and lumbosacral junction
Andreas Korge, H Michael Mayer
1 Historical perspective to approach the lumbosacral junction, whereas retroperi-

toneal routes were more often used for exposing the mid
Standard macrosurgical anterior approaches to the lumbar and lower lumbar spine from L2–5. Due to the potential
spine and lumbosacral junction are long-established tech- problems and complications inherent in intraperitoneal
niques, and were first described in 1932 [1]. They are rou- surgery, there is a tendency to prefer the retroperitoneal
tinely used as exposure routes for anterior fusion procedures access route to the lumbosacral junction. Therefore, when-
[2, 3]. A macrosurgical anterior approach, whether retro- ever possible, the minimally invasive retroperitoneal ap-
peritoneal or transperitoneal, may be used to expose the proach is currently recommended to ensure the preservation
target area of the lumbar fusion region regardless of the of the intraperitoneal anatomical structures and avoid in-
fusion procedure chosen. Modern motion-preserving tech- traperitoneal scar-tissue formation and the development of
niques, such as lumbar total disc replacement for the treat- adhesions. As a consequence, the transperitoneal access
ment of pathologies in the mid and lower lumbar spine, route is proposed as second choice, as a salvage route for
also rely on macrosurgical approaches that differ according revision surgery, or under special circumstances.
to the type of implant.
This chapter describes the minimally invasive retroperito-
Depending on the access route chosen, macrosurgical an- neal and transperitoneal anterior midline approaches to the
terior approaches are associated with the risk of significant mid and lower lumbar spine as well as to the lumbosacral
tissue trauma—intraperitoneally, retroperitoneally, and junction.
prevertebrally—with resulting scar-tissue formation, and
therefore may be subject to a substantial spectrum of com-
plications [2, 4–7]. Large scars leading to poor cosmesis ad- 2 Terminology
ditionally make macrosurgical approaches less attractive.
However, these potential disadvantages should be weighed Minimally invasive anterior lumbar spine surgery constitutes
against acceptable postoperative morbidity rates and good a modification of established macrosurgical approach tech-
clinical results [8, 9]. niques. The minimized anterior midline access has adapted
open approach modalities, and combined them with the
To reduce intraoperative and postoperative morbidity and benefits and techniques specific to microsurgery. It was
complication rates, Mayer developed and popularized two initially used for fusion procedures of the lumbar spine, and
tissue-conserving microsurgical approaches to the lumbar was therefore abbreviated to ‘‘minimally invasive anterior
spine and lumbosacral junction using a retroperitoneal or lumbar interbody fusion’’ (mini-ALIF), but can be used for
transperitoneal corridor [10-12]. The intraoperative use of many other types of lumbar anterior spine surgery, such as
a microscope was recommended as part of a comprehensive total disc replacement.
surgical strategy of minimal invasiveness, which includes
modifications that are based on the minimization of more
traditional and well-established macrosurgical access tech- 3 Patient selection
niques.
The minimally invasive anterior midline approach is used
In principle, for both macro- and microsurgical access pro- for all anterior intervertebral pathologies at the L5/S1 lum-
cedures, a retroperitoneal or transperitoneal approach may bosacral junction and at more cranial lumbar segments for
be used for exposure of the anterior lumbar spine. Initially, anterior lumbar total disc replacement, especially when
the transperitoneal approach was more frequently chosen using keel implants requiring anterior midline insertion.
393

Authors Andreas Korge, H Michael Mayer
For patients undergoing fusion procedures, the authors usu- that previous intraabdominal or retroperitoneal surgery may
ally recommend additional posterior open or percutaneous counterindicate the use of this technique.
pedicle screw fixation for 360° support, an exception to this
being anterior instrumentation procedures if stand-alone 4.1 Pros
devices with locking screws penetrating the adjacent ver- The advantages of using a minimally invasive anterior mid-
tebral bodies are used. line approach are as follows:
• Small skin incision with improved postoperative cos-
3.1 Indications for anterior midline approach to the mesis
lumbar spine and lumbosacral junction • A retroperitoneal approach significantly reduces the risk
The following indications for minimally invasive anterior of intraabdominal tissue damage and scar-tissue forma-
lumbar spine surgery should be taken into consideration: tion, unless opening of the peritoneum occurs acciden-
• Degenerative disc disease (DDD) with or without disc tally
herniation • Decreased iatrogenic trauma involving the access route
• Degenerative or isthmic spondylolysis • Reduced intraoperative blood loss
• Degenerative monosegmental deformities • Shorter operative time
• DDD with sagittal or frontal instabilities • Reduced (low) intraoperative complication rate, no ad-
• Failed back surgery syndrome (post-discectomy, non- ditional approach-related complications
union, failed total disc replacement) • In the event of intraoperative complications, the ap-
• Spondylitis, spondylodiscitis proach can be rapidly enlarged
• Spinal stenosis with segmental instability. • Intervertebral implant application for up to two levels
• Unlimited choice of intervertebral segment support
3.2 Contraindications for anterior midline approach • Reduced intra- and postoperative morbidity
to the lumbar spine and lumbosacral junction • Faster postoperative mobilization
The following contraindications should be taken into con- • Shorter postoperative convalescence
sideration: • Certain aspects are already familiar: modification of a
• Previous abdominal and/or gynecological surgery (rel- well-known macrosurgical approach
ative contraindication) • Short learning curve
• Critical aortal bifurcation/venous confluence directly in • Only one assistant required
front of the index segment (relative contraindication) • No laparoscopic surgeon required
• Presence of infection with large prevertebral develop- • No laboratory training necessary.
ment of granulation tissue and psoas abscess formation
• Morbid obesity 4.2 Cons
• Diseases of the gastrointestinal tract (relative contrain- • Limited visualization outside the target area
dication). • Microsurgical training is necessary, with acceptance of
a learning curve
• Following previous abdominal surgery, use of the “min-
4 Pros and cons of the anterior midline approach to imally invasive” approach may be severely limited
the lumbar spine and lumbosacral junction • Potential risk of indirect tissue trauma to adjacent struc-
tures
Most patients can be treated by a minimally invasive ap- • Limited at maximum to bisegmental procedures
proach in situations where anterior lumbar spine surgery • Limited to the L2–S1 region
is required. There are of course arguments in favor of or • Patient-specific vascular anatomy (see contraindications)
limiting the degree of minimization involved. The major could limit a mini-approach; therefore accurate preop-
advantages of this approach include reduced soft-tissue erative examination and diagnosis via angio-CT scan is
trauma, decreased complication rates, shorter operative strongly recommended
time, less blood loss, quicker rehabilitation, and therefore • Reconstruction of sagittal (kyphotic) and scoliotic de-
a more rapid postoperative improvement in the patient's formities is not possible
quality of life. The main disadvantages include the limited • Reconstruction of multisegmental deformities is not pos-
extent of the exposure, and thus the limited number of sible
segments that can be treated, which precludes multiseg- • Patients with morbid obesity cannot be treated by these
mental application; the anatomical constraints; and the fact approach techniques.

4 Lumbar/sacral techniques | 4.3 Anterior approaches
4.3.1 Minimally invasive anterior midline approach to the lumbar spine and lumbosacral junction
5 Preoperative planning MRI provides detailed information about the pre- and para-
vertebral soft tissue and allows the prevertebral vessels
The more a surgical approach is minimized, the more care- (aorta, inferior vena cava, common iliac vessels, ascending
ful the preoperative planning should be in order to optimize lumbar vein) to be accurately localized. Intraspinal pathol-
the intraoperative conditions. This applies both to case se- ogies, eg, disc herniation, as well as intervertebral details
lection—whether the patient is a suitable candidate for an become clearly visible. The position and size of the psoas
anterior mini-approach or not—and to the preoperative muscle, which acts as a bilateral landmark, can be deter-
imaging studies. mined. In the case of previous surgery, gadolinium-en-
hanced films can show the extent and location of scar-tissue
Preoperative imaging supplies vital information on the formation.
anatomical or pathoanatomical posture of the spine, includ-
ing the presence of abnormalities in all three dimensions— Especially at L4/5, color-coded 3-D angio-CT scan [13] pro-
sagittal, frontal, and horizontal—and the topographical vides invaluable information about the vascular anatomy—
anatomy of the circumference of the index segment. eg, venous confluence, arterial bifurcation—and thus assists
the surgeon in deciding whether to carry out a minimally
Standard x-rays of the lumbar spine in sagittal and AP pro- invasive or a standard macrosurgical open procedure (Fig
jection provide information about the curvature of the spine 4.3.1-1). In addition, CT scan supplies comprehensive infor-
and the configuration of the vertebral bodies, as well as the mation for evaluating the success or failure of a previous
height of the intervertebral disc space. The presence of lat- fusion procedure in terms of verified osseous integration.
eral or frontal osseous spurs can be determined or exclud-
ed. Congenital anomalies, such as lumbarization or sacral- Gastrointestinal preparation is initiated the day before sur-
ization at the lumbosacral junction (with the corresponding gery, with routine large bowel preparation to empty the
topographical reference to the prevertebral vascular anat- colon. Prior to surgery, shaving of the surgical area is per-
omy) are visualized. For mid and upper lumbar spine ap- formed.
proaches, AP views provide information on the thoracic
cage, while flexion-extension views demonstrate the pos- After the patient has been brought to the operating room,
sible presence and extent of any translational segmental he/she is put under general anesthesia and complete relax-
slipping or vertical instability. ation is initiated. Immediately before surgery, a stomach
probe and urinary tract catheter are placed, followed by
venous and arterial lines. Intraoperative antibiotic prophy-
laxis is started 20–30 minutes prior to skin incision, and
routinely extended for 24 hours. As a standard procedure
for all surgical interventions, the authors use an adapted
surgical safety checklist to minimize the risk of intraopera-
tive complications [14].
The patient is placed in a supine “da Vinci” position with

maximum abduction of the legs and arms (Fig 4.3.1-2). For
total disc replacement, the lumbar spine should be in a
neutral position, whereas for fusion procedures the lumbar
spine should be in hyperextension. This patient positioning
offers the surgeon an optimal forward-working direction
and straight visual axis towards the corresponding disc space
and the pathology to be treated, ie, at the lumbar spine or
Fig 4.3.1-1 Color-coded 3-D lumbosacral junction. Another alternative is that the sur-
angio-CT scan showing L3–S1 with geon stands laterally to the patient, who lies in a supine
arterial bifurcation in the midline in
position with straight closed legs, but this is optional. Es-
front of the disc space at L4/5, ve-
nous confluence, paramedian right
pecially for surgery at level L4/5, continuous oxygen satu-
in front of the vertebral body L5. ration is measured on the left big toe for monitoring ischemic
phases during mobilization and retraction of the arterial
vessels.
395

The minimization of an approach implies reducing the A 4–5 cm skin incision in the midline is marked over the
amount of approach-related landmarks. Therefore, accurate index level, taking into account the corridor line (Fig 4.3.1-
preoperative localization of the index segment is crucial, 5). Vertical or horizontal incision lines can be used, although
and is determined under lateral image intensifier control the horizontal line provides better cosmetic results. In very
by applying pressure to the abdomen with a forceps and a obese patients, the skin incision line is moved slightly para-
swab, and in this manner marking out the working corridor median right (right-sided retroperitoneal approach) or left
line from the skin to the target area (Fig 4.3.1-3). Alterna- (left-sided retroperitoneal approach). At level L4/5 and
tively, using lateral projection, two lines can be marked on higher, the skin incision line is moved slightly left, lateral
the lateral abdomen: one line—the “disc line”—is made to the umbilicus. In the case of two-level stabilization, an
parallel to the corresponding disc space, whereas the second oblique incision line is chosen.
line—the “front line”—connects the edges of the adjacent
vertebral bodies close to the disc space. The intersection of
these two lines indicates the “corridor line” towards the
midline of the abdomen (Fig 4.3.1-4).
a b
Fig 4.3.1-2a–b The “da Vinci” position for anterior lumbar midline approaches: the patient is
placed in a supine position with maximum abduction of the legs and arms.
d
f
a b b
Fig 4.3.1-3a–b Index level identification. Fig 4.3.1-4a–b Index level identification us-
a Index level identification using lateral image intensifier and a blunt metal-tip marker. ing indicator lines: “disc line”, “front line”, and
b Corresponding lateral x-ray. “corridor line”.
a Colored indicator lines: yellow: disc line;
red: front line.
b Skin markings: d: disc line; f: front line;
c: corridor line.

anterolateral circumference of the disc space at L5/S1. As

the arterial vessel wall is more stable in comparison to a
L2/3 venous vessel, more tissue resistance will be encountered
L3/4 as the surgeon advances. However, should vascular damage
occur, it is easier to close the arterial vessel. Another ad-
L4/5
vantage of choosing a retroperitoneal approach from the
L5/S1
right side is that there is a reduced risk of injury to the
superior hypogastric plexus. Lastly, an initial approach from
the right side for L5/S1 surgery maintains the anatomy
intact on the left side, and therefore facilitates any left-
sided intervention in the event of adjacent segment disease
at L4/5.
However, in the case of previous open abdominal surgery

Fig 4.3.1-5 Skin incision lines: red line, horizontal or vertical, L5/S1; on the patient’s right side, such as appendectomy, a left-
blue line, horizontal, L4/5; black line, horizontal, L2/3 and L3/4. sided access is recommended. In addition, the left-sided
approach might be preferable if the left common iliac vein
is large or traverses the disc space at L5/S1 more medially—
in the event of vessel laceration, it provides a better access
for tissue repair.
6 Surgical technique
At level L4/5 and more cranially up to L2/3, the authors
The anterior lumbar spine and lumbosacral junction can be routinely recommend an approach from the patient’s left
approached using a minimally invasive access technique side, mainly because of the prevertebral retroperitoneal
either by a retroperitoneal or transperitoneal route. When- vascular anatomy.
ever possible, the authors recommend a retroperitoneal
access as the approach of choice in order to avoid intraab- To approach L5/S1, a 4–5 cm skin incision is made in the
dominal scar-tissue formation and pain-triggering bowel midline over the disc space according to the preoperatively
adherences. If revision surgery from the anterior is required, determined localization (Fig 4.3.1-6). In obese patients, asym-
eg, in the case of nonunion, or in the event of dislocated metrical transposition of the skin incision slightly to the
implants necessitating implant replacement, the transperi- chosen side (right or left) is helpful. For cosmetic reasons,
toneal access may serve as salvage route as it gives a better a horizontal incision is preferred, however, a vertical inci-
overview. In addition, the transperitoneal route is helpful sion is also possible. The subcutaneous tissue is then sepa-
when operating on very obese or extremely slim patients. rated by blunt dissection, or by monopolar electrocauteriza-
tion. Using self-retaining retractors, the rectus fascial sheet
To ensure sufficient illumination of the approach and target is next exposed and split craniocaudally in the midline along
area, the access procedure can be performed macroscopi-
cally with the help of halogen headlamps or with the aid
of a microscope. Self-retaining retractor systems with inte-
grated halogen light sources may also be used.
Both retroperitoneal and transperitoneal approaches to the

lumbar spine and lumbosacral junction will be described
below.
6.1 Retroperitoneal approach

At level L5/S1, the prevertebral space can be approached
via a retroperitoneal route from the patient´s left or right
side. However, an approach from the patient´s right side is
generally recommended, as the right common iliac artery
serves as a medial landmark when advancing towards the Fig 4.3.1-6 Horizontal skin incision, 4–5 cm long.
397

the linea alba. The peritoneum is exposed (Fig 4.3.1-7), and The target area is adequately exposed. Target surgery in-
bluntly mobilized from the inner abdominal wall in a me- cludes opening of the disc space, removal of disc material,
dial direction. Care is taken to leave the epigastric vessels endplate processing, with removal of the cartilaginous parts,
intact. Following further mobilization of the peritoneal sac and supply of the disc space according to the preoperative
medially, the psoas muscle is then identified as the lateral planning and surgical aim (eg, total disc replacement, cage
landmark. In the case of severe fascial tension, the transverse insertion) (Fig 4.3.1-10, Fig 4.3.1-11). When using a mini-
fascia is incised at the arcuate line as much as is considered mally invasive anterior approach towards the lumbosacral
necessary to mobilize the abdominal contents. The right junction as well as the lumbar spine, there are no restrictions
common iliac artery and the peritoneum-adherent right regarding the use of rigid or dynamic implants. If comput-
ureter are localized. Medial to the iliac artery, the perito- er-assisted navigation is required, eg, for optimal placement
neal sac together with the ureter is mobilized bluntly towards of an intervertebral disc prosthesis, it can be performed at
the opposite (left) side using swabs and Langenbeck retrac- this point. Retreat from the surgical field includes reposi-
tors. Simultaneously, the retroperitoneal prevertebral fat tioning of the peritoneum and ureter, followed by closure
tissue with the hidden superior hypogastric plexus is moved of the rectus fascial sheet with continuous suture. The sub-
by blunt mobilization over the midline, and the anterolat- cutaneous tissue is closed with single stitches, and after
eral circumference of L5/S1 is exposed bilaterally over a disinfection, intracutaneous absorbable continuous sutures
distance of 4 cm (Fig 4.3.1-8). Use of bipolar electrocauteri- then complete the surgical procedure.
zation is reduced to a minimum in order to protect the
superior hypogastric plexus. The medial sacral vessels are Alternatively, the left-sided approach at L5/S1 can be cho-
closed by vessel clips or ligature and completely dissected. sen due to the reasons mentioned above. The route from
If the exposure is not sufficient, blunt mobilization of the the skin to the psoas muscle is identical to that used in the
left common iliac vein towards the left side might be re- right-sided approach. After exposing the psoas muscle as
quired. The imaginary midline is marked using a K-wire, a the primary retroperitoneal landmark, the left common
dissector, or a 3.5 mm screw (20 mm long) to ensure under iliac vein is then identified as the next lateral landmark. In
x-ray control that the approach level is correct, and to de- the case of a large vein covering the disc space, access to
termine the midline (Fig 4.3.1-9). A self-retaining retractor the target area can be difficult. The peritoneal sac is mobi-
(eg, Synframe) is positioned with the lateral retraction valves lized towards the patient´s right side, following which the
placed in contact with the disc space underneath the iliac anterolateral left circumference of the disc space at L5/S1
vessels bilaterally. is exposed. In a procedure identical to that used for the right
a b
Fig 4.3.1-7 Exposed peritone- Fig 4.3.1-8 Exposure of 4 cm of Fig 4.3.1-9a–b Intraoperative midline marking using a dissector with
um after dissection of the subcu- the anterolateral circumference of translucent self-retaining retractor valves already in place and radiologi-
taneous tissue and rectus fascia the disc space at L5/S1. cal verification of correct level at L5/S1.
vertically along the linea alba. a View of intraoperative site.
b X-ray control.

followed by a lateral longitudinal incision of the posterior

rectus sheath. The peritoneum and the ureter are mobilized
medially, and the psoas muscle, which serves as a lateral
landmark, is exposed. Medial of the psoas muscle, the com-
mon iliac artery and vein are identified. Exposure of the
lateral border of the iliac vein helps to identify the branch-
es of the ascending lumbar and iliolumbar veins. These veins,
which vary in number and size, are ligated and dissected to
avoid tear-out from the common iliac vein. Initial medial-
ization of the common iliac vein is then possible. At this
point, the access route is modified slightly by mobilizing
the rectus muscle with the aid a retractor laterally while
using the already prepared route. The anterolateral left cir-
cumference of the disc space at L4/5 is exposed. The common
Fig 4.3.1-10 Empty disc space
prepared for intervertebral cage
iliac vein and artery are mobilized with swabs as medially
implantation. as necessary. In the case of implants, which can be placed
through an oblique disc corridor, eg, oblique lumbar total
disc replacement, the vascular structures do not have to be
mobilized over the midline. If anterior midline implantation
is required, the vessels have to be mobilized towards the
contralateral right side. Vessel preparation at L4/5 in par-
ticular requires meticulous preoperative planning and care-
ful intraoperative tissue mobilization. In this respect, color-
coded CT scan is extremely helpful in determining the pre-
vertebral access route.
In the majority of cases, both venous and arterial vessels

are mobilized over the midline towards the contralateral
a b prevertebral space. Since this mobilization will cause tension
Fig 4.3.1-11a–b Titanium cage with autogenic bone graft implanted stress to the left common iliac artery with a resulting reduc-
intervertebrally at L5/S1. tion in, or arrest of blood flow and oxygenation to the left
a Intraoperative site.
leg, continuous oxygen saturation is measured on the left
b Lateral x-ray control.
big toe. The authors recommend using retractor-based re-
traction of the vessels instead of pin-based retraction because
side, the superior hypogastric plexus is mobilized bluntly the latter might create dead space intervals with hemostasis
together with the retroperitoneal fat tissue to the patient´s between the pins, and an increased risk of thrombosis.
right side. The medial sacral vessels again are closed with
vessel clips or ligature, and dissected. Subsequent target In the case of high venous confluence and arterial bifurca-
surgery involves the same steps as those described for the tion, a midline approach similar to that described for L5/S1
right-sided approach. can be used. Median sacral vessels should be identified,
ligated, and dissected. Only in this rather rare anatomical
The retroperitoneal approach to L4/5 is the most difficult case can the previously described identification and ligation
of all, due to the prevertebral vascular anatomy (venous of the ascending lumbar vein be disregarded due to the fact
confluence, arterial bifurcation) directly in front of the an- that no traction is transferred to this vessel.
terior disc space. Generally, the access route includes the
left retroperitoneal compartment. The skin incision is placed As a third access alternative and depending on the vascular
slightly paramedian left. Oblique or transverse dissection anatomy, it may be possible to mobilize the left common
of the rectus fascia enables better mobilization of the rectus iliac vein and the inferior vena cava towards the patient´s
muscle. The rectus muscle is mobilized medially, and the right side and at the same time stay between both common
posterior rectus fascia and the arcuate line are exposed, iliac arteries.
399

After dealing with the challenging vascular aspects, the an- 6.2 Transperitoneal approach
terolateral circumference of the disc is exposed by about 2 The transperitoneal access constitutes a second-choice ap-
cm on each side, thereby guaranteeing a lateral extension proach. The authors recommend this approach in extreme-
and working corridor of about 4 cm. Self-retaining retrac- ly slim patients (especially for L2/3) and in very obese sub-
tor frames help to optimize the overview of the prevertebral jects. It is also used in cases of known retroperitoneal
space and to safely keep the vessels out of the way. Once fibrosis. Lastly, the transperitoneal approach serves as a
the target area is exposed, treatment and stabilization of salvage corridor for revision surgery if previous surgery has
the corresponding index disc space can be performed as been carried out via a retroperitoneal approach. If a large
described for level L5/S1. exposure is required, eg, if major vascular challenges are
expected (removal of a total disc prosthesis at L4/5), the
In the rare cases of anterior midline approaches to levels authors prefer a transperitoneal approach. In the case of
L2/3 and L3/4, the left-sided approach is slightly modified. previous large abdominal exposure, which might preclude
The skin incision is placed a little more paramedian in com- or contraindicate the use of minimally invasive approach-
parison with the L4/5 approach, and is usually made at or es, macroinvasive open transperitoneal exposure may be
above the umbilicus level. The skin incision is generally required.
performed horizontally, however, a paramedian vertical
incision can also be made if the skin incision is exactly at The skin incision, traversal of subcutaneous tissue, and ex-
umbilicus level. After opening the anterior rectus fascia, posure of the linea alba are as described in topic 6.1 Retro-
the authors again recommend first advancing towards the peritoneal approach. The visceral peritoneum is opened to
psoas muscle with initial medialization of the rectus muscle a length similar to the skin incision. The peritoneum is
and lateral incision of the posterior rectus fascia and the opened and held back with four sutures placed at the cra-
arcuate line. Following these preliminary procedures, the nial and caudal edges. The small bowel and the mesente-
main access route is then medial of the rectus muscle, tak- rium in the abdominal cavity are mobilized gently towards
ing into account the above-mentioned lateral and medial the upper right quadrant craniolaterally using Langenbeck
landmarks, and with the peritoneum mobilized contralater- retractors and small abdominal towels. In an analogous
ally over the midline. Again, there are two alternatives for technique, the sigmoid colon is mobilized towards the up-
vessel mobilization in order to approach the lumbar spine: per left quadrant. Self-retaining retractor frames are placed.
if the vena cava is placed anterolaterally on the right, the The parietal peritoneum is dissected in a right convex curve
aorta and vena cava can be simultaneously mobilized to- craniocaudally along an imaginary midline, and the retro-
wards the patient´s right side. During this preparative pro- peritoneal space is entered. At L5/S1, retroperitoneal prep-
cedure, the left segmental veins and arteries should be li- aration starts medially from the right common iliac artery
gated and dissected to avoid laceration or tear-out from the with blunt dissection of the retroperitoneal fat tissue towards
major vessels. In the case of a right-sided vena cava and a the left side. As mentioned earlier, care must be taken not
left-positioned aorta, an intervascular approach can be per- to injure the superior hypogastric plexus, and no bipolar
formed in which the aorta is mobilized towards the left side electrocauterization should be performed. Exposure of the
and the vena cava towards the right side. As a result, when anterolateral circumference of the index disc space is carried
using this intervascular access route, the left segmental veins out in the same way as described for the retroperitoneal
and the right segmental arteries require ligation and dis- approach.
section. At level L2/3, careful preparation and mobilization
are necessary to avoid undue tension, or rupture of the Retreat from the surgical field first includes closure of the
renal vessels. parietal peritoneum with continuous suture and the repo-
sitioning of the abdominal contents followed by closure of
Retreat from the surgical field includes the repositioning of the visceral peritoneum with continuous suture. The final
the peritoneum, followed by closure of the rectus sheath steps are performed in the same way as described above.
with continuous suture. The subcutaneous tissue is then
closed, and finally the skin is closed up with resorbable
intracutaneous suture.

7 Postoperative care degenerative spondylolisthesis with different grades of ver-

tebral slip, and cases of infection. Dynamic segmental sta-
Independently of the type of intervertebral support chosen, bilization with total disc replacement was performed in 251
as a general rule no drain is placed in the prevertebral ret- cases; rigid stabilization was carried out in 203 cases, includ-
roperitoneal space in front of the anterior lumbar or lum- ing an intervertebral support with titanium or PEEK cages
bosacral spine. However, if a prevertebral drain is placed, in combination with autogenic bone graft, bone morpho-
it is removed on day 1 or 2 postsurgery, depending on the genetic protein, or other synthetic bone substitutes. Aver-
amount of secretion still present. Whenever possible, the age blood loss amounted to less than 100 cc. Approach-
authors avoid using the anterior iliac crest for bone graft related vascular lacerations, mainly involving the left
harvesting, but if this is considered necessary, the wound common iliac vein, occurred in 0.5% of cases. Two patients
drain placed following harvesting is removed on the second with total disc replacement at L5/S1 showed postoperative
postoperative day. Sterile adhesive plaster is placed for 48 symptoms of retrograde ejaculation (one persisting and one
hours, and no further wound covering is necessary. temporary). No damage to structures of the gastrointestinal
or urogenital tract occurred. No postoperative deep or su-
Thromboembolic prophylaxis with fractionated heparin is perficial infection was observed in this series.
performed until full mobilization. Postoperative intravenous
antibiotics are given for 24 hours (eg, Cefuroxim). Between April 1998 and January 2000, an earlier series of
patients with the inclusion criterion of degenerative disc
Mobilization is first allowed for younger patients 8 hours disease (134 patients in all: 84 female, 50 male; mean age
postoperatively for both nonfusion and fusion indications. 56.2 years; age range: 20.4–87.2 years) were treated by
All other patients are mobilized immediately on the first posterior instrumentation with a macrosurgically applied
postoperative day. Following initial mobilization, there are pedicle-based screw-rod construct and anterior stabilization
no restrictions regarding different mobility patterns such with exclusively autogenic, solid tricortical bone graft har-
as sitting, standing, or walking. These procedural guidelines vested from the anterior iliac crest [16]. Approach-related
apply equally to patients with an intervertebral rigid or a complications amounted to 7/134, representing a complica-
dynamic support. tion rate of just 5.2%. Complications in this series included
irritation of the genitofemoral nerve (three cases) and
In patients with total disc replacement, no external support sexual dysfunction (one occurrence). No vascular complica-
is provided. Patients that have undergone mono- or biseg- tions or cases of infection were observed. A relatively sig-
mental fusion procedures will be supplied with an external nificant proportion of patients (n = 31/134), however, com-
stabilizing orthosis, eg, a Boston brace. The use of a brace plained of nonapproach-related temporary or persisting
is recommended for 10–12 weeks postoperatively. problems associated with the bone-graft harvesting area at
the iliac crest, including local pain, meralgia paresthetica,
Food intake is permitted 24 hours postoperatively depend- and numbness; and as three fractures of the anterior upper
ing on bowel function. iliac spine occurred, this led to the complete avoidance of
this alternative for segmental anterior intervertebral sup-
Standard x-rays in two planes are performed on day 2 post- port.
surgery, with further routine follow-ups at 3, 6, and 12
months. Siepe et al [17] reported on 99 patients treated by a mini-
mally invasive midline anterior approach for mono- or
bisegmental total lumbar disc replacement at levels L4/5,
8 Evidence-based results L5/S1 and L4/5–S1. They found access-related complications
in 2/99 cases, amounting to a complication rate of 2%. The
At the authors' institution between February 2002 and De- two cases of complications included one patient with sym-
cember 2007, a total of 454 patients (248 female, 206 male; pathectomy-related dysesthesia and one subject with tem-
mean age 47.3 years; age range: 15.4–80 years) were oper- porary sexual dysfunction and retrograde ejaculation. No
ated on at the lumbosacral junction using a minimally in- vascular or gastrointestinal complications and no cases of
vasive anterior approach [15]. The range of indications in- infection were reported.
cluded a variety of pathologies, ie, monosegmental
degenerative disc disease with segmental osteochondrosis, Mayer [11], who introduced and first popularized the min-
spinal stenosis with concomitant instability, isthmic and imally invasive anterior retroperitoneal and transperito-
401

neal approaches, did not observe any complications in a L4/5 as well as for higher levels, as a routine procedure the
series of 29 patients treated by a transperitoneal approach authors recommend a preoperative color-coded 3-D angio-
to L5–S1. CT scan in order to facilitate the critical intraoperative ma-
neuvers. At L5/S1, axial MRI provides sufficient information
Brau [4] performed a midline approach to L2–5 in a group about the vascular anatomy in most cases; in the event of
of 444 patients. The average duration of access surgery to- doubtful vessel location, performing a 3-D angio-CT scan
wards an index segment in the above-mentioned region is also recommended (Fig 4.3.1-12). In the case of damage to
amounted to 22.7 minutes. Six months after surgery, ap- the epigastric vessels, the authors advocate the use of liga-
proach-related complications were evaluated. The overall ture and electrocauterization. Segmental vessels can be
complication rate amounted to 3.8%, including six cases of closed with endoclips. Small venous lesions of the common
arterial thrombosis and seven cases of deep vein thrombo- iliac vein can be treated by application of a powerful he-
sis. Six cases of laceration to the left common iliac vein mostatic agent (eg, FloSeal, Baxter) with subsequent com-
occurred. The overall vascular complication rate amounted pression and the use of an additional hemostyptic agent
to 4.2%; vascular damage due to approach-related proce- (eg, TachoComb fleece, Nycomed Pharma). Lacerations of
dures alone amounted to 1.4%. One case of retrograde the inferior vena cava and the aorta and iliac arteries should
ejaculation was reported. In addition, three wound infec- be treated by immediate vascular suture (eg, Prolene 6.0
tions, four cases of postoperative ileus, and two cases of suture). Enlargement of the approach is strongly recom-
abdominal hernia were documented. mended in the event of severe bleeding to obtain a better
overview for dealing with the complication. In the case of
To the authors' knowledge no comparative studies are yet a large postoperative prevertebral hematoma, it is essential
available on minimally invasive anterior retroperitoneal or to remove the hematoma and carry out a meticulous search
transperitoneal approaches versus open “standard” macro- to determine the source of bleeding.
surgical procedures.
Arterial and deep vein thrombosis at the target area occur
in up to 3% of cases in anterior lumbar spine surgery. To
9 Complications and avoidance/salvage procedure, limit this complication, especially for surgery at L4/5 and
learning curve higher, the authors recommend placing an oxygen measur-
ing device on the left big toe for the continuous monitoring
Approach-related complications connected with macrosur- of blood oxygenation. If continuous arterial undersupply
gical approaches have been reported to result in a compli- to the left limb and persisting ischemia is demonstrated,
cation rate of 11.5% [5]. The pattern ranges from abdominal retractor pressure on the vessels should be intermittently
herniation as the most frequently reported event to vascu- relieved after 30 minutes. To prevent dead-space volume
lar and neurological problems, such as sexual dysfunction
and genitofemoral nerve irritation.
Intraoperatively, vascular complications represent the most

life-threatening events, and require immediate intraopera-
tive intervention. For traditional macrosurgical approach-
es, the vascular complication rate reported for venous lac-
eration ranges between 7.7% and 18.4% [18, 19], while for
arterial laceration it amounts to 2.3% [19]. However, with
a minimized approach using a mini-open access route, the
prevertebral arterial vascular complication rate drops to less
than 1% [4, 15, 20]. This reduced vascular complication rate
may partly be due to meticulous preoperative planning and
individualized intraoperative surgical management of the
vascular structures. When performing an anterior midline
approach at L4/5, it is important to first identify, isolate,
Fig 4.3.1-12 Color-coded 3-D angio-CT
and ligate the ascending lumbar vein with endoclips and/ scan of L3–S1, showing the arterial course
or by ligature before advancing towards the anterior lumbar and kinking of the left common iliac artery
spine. When using a midline approach, especially for level directly in front of the disc space at L5/ S1.

within the vessels, the authors recommend the use of re- approach. Permanent high muscle tension causes unreason-
tractors and the avoidance of retracting fixation pins, such able stress to the surgeon during the approach as well as
as Steinman pins. target area procedures, resulting in accelerated physical
fatigue.
Optimal positioning is mandatory to obtain satisfactory re-
sults when minimized approaches are used for target area Perforation of the sigmoid colon or small bowel requires
exposure. Placement of the patient in a supine “da Vinci” immediate suturing. Using a retroperitoneal access route
position with abducted hips and with a straight (for total helps to avoid intraperitoneal lesions and subsequent post-
lumbar disc replacement) or hyperextended (for fusion operative adhesions. Retraction of the abdominal contents
procedures) lumbar spine enables the surgeon to work in is very difficult if the bowels are not empty. Therefore, care
a straightforward manner as far as the target area, along an must be taken to ensure full bowel evacuation before sur-
optimized corridor. It should, however, be recalled that the gery. In the event of postoperative bowel occlusion with
greater the angle between the surgeon's visual axis and the ileus symptoms, surgical exploration might be required ac-
corresponding disc space to be treated, the more difficult it cording to the severity of the symptoms.
is to have an unimpeded, straightforward working corridor.
Preoperatively, the patient’s bilateral hip abduction should Lacerations of the ureter or bladder are a rare occurrence,
be examined to ensure proper positioning. In the case of and require immediate repair with suturing. If adequate
limited hip abduction, the surgeon should consider stand- surgical training has not been provided, transfer to a spe-
ing in a lateral position during the operative procedure. cialized center is recommended.
Before starting surgery, accurate localization of the target Neurological complications could involve irritation or dam-
area on the skin is essential; as the approach is minimally age to the superior hypogastric plexus as well as to the
invasive, the overview both as regards the access route and genitofemoral nerve [21]. To prevent irritation to the plex-
target area is limited in comparison to macrosurgery. Inac- us, the authors therefore recommend blunt dissection at
curate preoperative localization can easily lead to disorien- the lumbosacral junction prevertebrally from the patient´s
tation and thus to a faulty approach that results in wrong right side towards the left side with small swabs, and if
target locations either too cranially or too caudally. The necessary, only limited use of bipolar electrocauterization.
small size of the approach then makes correction of the As regards the risk of genitofemoral nerve damage, which
access route difficult. In the case of a misleading access tends to occur more frequently in lateral retroperitoneal
route, enlargement of the approach is recommended. approaches, care must be taken during preparation and re-
tractor placement around the psoas muscle at L4/5 and
After exposing the target area, verification of the index higher to avoid this injury and associated problems, such
segment under image intensifier control is required. De- as postoperative paresthesia, pain, and other symptoms in
pending on the segmental support chosen, lateral x-rays or the groin and medial thigh. Irritation of the sympathetic
if needs be additional AP x-rays should be made. Marking nerve chain might occur from uncontrolled tissue dissection
of the disc space can be carried out with a K-wire, a dissec- towards the lateral left circumference of the disc space.
tor, or a 3.5 mm screw (20 mm long). The advantage of
using a screw is that no tools project from the abdomen, Finally, as is always the case when using new techniques
and the peritoneal sac can be replaced smoothly in its orig- for the first time, a learning curve must be accepted. How-
inal position with the screw head exactly marking the in- ever, since minimally invasive approaches are modifications
terface between the anterior annulus and the retroperito- of well-established macrosurgical approaches, there are no
neal prevertebral space. additional medicolegal issues involved compared with con-
ventional approaches. A further advantage is that laparo-
It is important to ensure that the patient's abdominal mus- scopic equipment is not necessary, and no laparoscopic or
cles are sufficiently relaxed when practicing a minimized vascular surgeon has to be present during surgery.
403

10 Tips and tricks
Salvador Brau, Los Angeles, USA as possible towards the femoral canal iliofemoral thrombosis in 25% of cases
1. Place a pulse oxymeter on the left first or when exposing L4/5. This artery (usu- [22–24].
second toe and measure baseline satura- ally) has no branches. This allows for the 7. It is important to identify the superior
tion. If the saturation level drops, allow artery to be mobilized far to the right hypogastric plexus. These nerve fibers
30–45 minutes before releasing the re- without stretching it. The artery toler- run along and are adherent to the peri-
tractors, then redeploy the retractors for ates compression well, but stretching may toneum, so when the peritoneal sac is
another 30 minutes. If saturation does cause intimal disruption, which leads to elevated away from the promontory and
not return to baseline value after the a thrombogenic state [22–24]. the middle sacral vessels are clearly ex-
lumbar procedure, the diagnosis of left 5. To reduce venous injury, always iden- posed, these fibers will accompany the
iliac artery thrombosis is highly prob- tify the iliolumbar vein and transect it peritoneum and can then be protected
able, and further vascular evaluation and if necessary. This vein is single in 75% from injury [22–24].
treatment needs to be carried out in the of cases; there are two veins in 22% of 8. An antiadhesion barrier should be de-
operating room at that time [22–24]. cases, three veins in 3% of cases, and ployed after all artificial disc replace-
2. Mobilize the rectus muscle widely for it is absent in 6% of cases. It is always ments, anterior tension bands, and all
5–6 cm both caudally and cranially for situated below the L4/5 disc space, and is fusions at L4/5 or above to help reduce
easier access to the retroperitoneal space most commonly located 1.5 cm distal to the challenge of subsequent revision sur-
[22–24]. it. It varies in size from 2 to 13 mm, but gery [22–24].
3. Elevate the ureter together with the peri- averages 5.75 mm in diameter [22–24]. 9. If fluid collection develops postopera-
toneum away from the psoas and prom- 6. If a venous laceration occurs, an attempt tively in the retroperitoneum, the fluid
ontory. Separating the ureter from the should be made to control this with he- should be aspirated and analyzed for pos-
peritoneum will devascularize it [22–24]. mostatic agents. Suturing should not be sible creatinine content. The presence
4. To avoid left iliac artery thrombosis, carried out unless absolutely necessary. of creatinine is indicative of an urinoma
bluntly dissect this artery as far distally Suturing the common iliac vein leads to [22–24].
11 Case example tal instability (Fig 4.3.1-13). MRI displayed a narrow disc
space with Pfirrmann grade 4 intervertebral changes, and
A 40-year-old man had undergone microscope-assisted disc gadolinium-enhanced images showed some scar-tissue for-
surgery at L5/S1 three times between 2005 and 2006 at mation in the spinal canal (Fig 4.3.1-14). No Modic changes
different care facilities. Postoperatively, clearly reduced leg were seen at the vertebral bodies L5 and S1.
pain was observed. However, the patient developed increas-
ing and dominating low back pain with persisting but less Extensive selective infiltrations were carried out under in-
intense leg pain with unspecific radiation to the right leg. patient conditions. No pain relief was obtained either fol-
lowing facet-joint injections or iliosacral joint injections,
Clinical findings showed an inconspicuous scar. Extension although short-term relief was observed following the epi-
was pain-free, while flexion was slightly painful at the end dural injection.
of the range of motion. The straight leg-raising test was
negative, and no existing sensorimotor deficit was found. In view of the above findings, an anterior surgical procedure
The patient experienced no pressure pain at the lower lum- was therefore indicated, consisting of total lumbar disc re-
bar spine, and no specific signs or symptoms were found in placement with implantation of an artificial disc prosthesis
both iliosacral joints. (ProDisc II). Using a minimally invasive anterior midline
approach via a retroperitoneal route, the disc prosthesis
Standard x-rays showed a decrease in disc height at L5/S1, was implanted at L5/S1 (Fig 4.3.1-15, Fig 4.3.1-16).
while flexion/extension x-rays did not reveal any segmen-

a b c d
Fig 4.3.1-13a–d Preoperative standard x-rays.
a AP view showing a normal vertical profile without pathological curves.
b Lateral view showing a decrease in disc height at L5/S1.
c–d Lateral flexion/extension view in which no segmental instability is apparent.
a b
Fig 4.3.1-14a–b
a Preoperative lateral MRI showing a degeneration and disc height
decrease L5/S1.
b Preoperative axial MRI with gadolinium enhancement showing
only mild scar-tissue formation.
a b
Fig 4.3.1-16a–b Implantation of artificial disc prosthesis (ProDisc II)
at L5/S1.
a AP standard x-ray showing artificial disc prosthesis centered in the
midline.
L5 b Lateral x-ray showing an enlarged intervertebral height and the
implant in correct place.
S1
Fig 4.3.1-15 View showing intraopera-

tive placement of artificial disc at L5/S1
(ProDisc II).
405

12 Key learning points • The surgeon should be highly experienced in macrosur-

gical approaches before switching to minimally invasive
• Anterior macrosurgical retroperitoneal and transperi- techniques
toneal approaches to the lumbar spine and lumbosacral • There is a potential risk of indirect trauma to the struc-
junction are well established techniques, however, they tures around the target area, however, in the case of
are associated with a number of approach-related com- emergency, open exposure can be rapidly performed
plications • A learning curve is required, and must be respected,
• Minimally invasive anterior midline approaches with a however, in the authors' experience, no additional hu-
4–5 cm skin incision, blunt muscle dissection that pre- man anatomical specimen training is necessary. Micro-
serves the abdominal muscles, and blunt tissue dissection surgical training is essential and helpful
reduce tissue trauma, blood loss, and operating time, • Minimally invasive anterior approaches can be per-
decrease approach-related complications and provide formed with only one assistant present
good clinical results • The fact that minimally invasive anterior lumbar ap-
• Due to reduced intraoperative morbidity, postoperative proaches are modifications of standard macrosurgical
recovery is facilitated with earlier mobilization, less pain access strategies should not influence the type of seg-
medication, and quicker rehabilitation mental stabilization chosen
• The retroperitoneal approach is advocated as the ap- • The two approaches presented are applicable to the lum-
proach of choice. Transperitoneal approaches can be bar and lumbosacral region from L2 to S1. However,
performed in specific indications, and may also serve as they are limited to mono- and bisegmental pathologies.
salvage routes for revision surgery or for the treatment Multisegmental pathologies cannot be addressed using
of patients with a challenging vascular anatomy microsurgical techniques. L4/5 is the most ambitious
level, and surgery at this level should not be attempted
during the learning phase of these techniques.
13 References
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Study type Study design Class of evidence Therapy Prospective cohort study II
Therapy Prospective cohort study II
Purpose
Purpose To assess the influence of the disc level and number of
To determine the incidence of retrograde ejaculation in discs replaced following total lumbar disc replacement
male patients treated for single-level degenerative lumbar (TDR) on postoperative outcome (midterm clinical re-
disc disease at L4/5 or L5/S1 with stand-alone anterior sults).
interbody fusion using tapered, threaded titanium fusion
cages. P Patient Patients with lumbar DDD without accompanying patholo-
gies (N = 99)
P Patient Male patients with symptomatic DDD (N = 146) I Intervention Monosegmental TDR with ProDisc-II performed at L4/5
I Intervention Open surgical exposure of the lumbosacral junction and C Comparison Monosegmental TDR with ProDisc-II performed at L5/S1
single-level interbody fusion at either L4/5 or L5/S1, using a and bisegmental TDR at L4/5 and L5/S1
retroperitoneal approach Outcome Visual Analog Scale (VAS), Oswestry Disability Index (ODI),
O
C Comparison Open surgical exposure of the lumbosacral junction and patient satisfaction rate, clinical parameters, complications,
single-level interbody fusion at either L4/5 or L5/S1, using a return to work, postTDR-pain patterns analyzed with image-
transperitoneal approach intensifier-guided spine infiltrations
O Outcome Adverse events, incidence of retrograde ejaculation
The level and the number of lumbar disc replacements
significantly influence the postoperative outcome. Satis-
A transperitoneal approach to the lumbar spine at L4/5
factory outcome was achieved for monosegmental L4/5
and L5/S1 has a 10-times greater chance of causing ret-
and L5/S1 disc replacement procedures with best results
rograde ejaculation in men than a retroperitoneal ap-
achieved following TDR at L4/5. For bisegmental TDR,
proach.
complication rates are significantly higher and inferior
postoperative results are to be expected.
407

Ikard RW (2006) Methods and complications of anterior Brau SA (2002) Mini-open approach to the spine for
exposure of the thoracic and lumbar spine. Arch Surg; anterior lumbar interbody fusion: description of the
141:1025–1034. procedure, results and complications. Spine; 2:216–223.
Therapy Systematic review III–IV Therapy Case series IV
Purpose Purpose
To review the methods and complications of exposing the To describe a mini-open approach to the lumbar spine
anterior aspects of the thoracic and lumbosacral spine. and discuss the results and the complications seen.
P Patient Patients undergoing anterior spinal exposure of the thoracic P Patient Patients undergoing ALIF with a mini-open approach (N =
and lumbar spine 684 patients)
I Intervention Anterior exposure of the thoracic and lumbar spine I Intervention ALIF with a threaded device
Thoracic, open; thoracolumbar, open; thoracic, endoscopic;
lumbosacral, open; lumbar, endoscopic C Comparison No control group
C Comparison No control group O Outcome Time of exposure, incision size, complications
O Outcome Complications, mortality, and morbidity

A well-planned, small incision that preserves the muscu-
lature can be performed quickly and safely to allow the
The exposure portions of anterior spine operations result
spine surgeon adequate access to the anterior lumbar
in numerous complications. There are fewer reported
spine.
complications with endoscopic exposures of the anterior
spine than with open exposures, although endoscopic
exposures have been used for less complicated cases. In
Faciszewski T, Winter RB, Lonstein JE, et al (1995)
comparable cases, neither exposure nor results of endo-
The surgical and medical perioperative complications of
scopic operations have proven better than operations
anterior spinal fusion surgery in the thoracic and lumbar
performed through minilaparotomy incisions. Periop-
spine in adults. Spine; 14:1592–1599.
erative cooperation between exposure and spine surgeons
is necessary to enhance results in anterior spine opera- Study type Study design Class of evidence
tions. Therapy Case series IV
Purpose
To document the incidence and specific types of perspec-
tive complications related to thoracic and lumbar ante-
rior spinal fusions.
P Patient Patients undergoing anterior spinal fusion between levels

T1 and S1 (N = 1152 patients with 1223 procedures, average
age 42 years)
I Intervention Anterior spinal fusion only, combined anterior and posterior
fusion
C Comparison No control group
O Outcome Complications and risk factors for complications
be used with confidence when the nature of a patient’s
spinal disorder dictates its use. Complications are often
approach-specific.

Fantini GA, Pappou IP, Girardi FP, et al (2007) Major Greenough CG, Taylor LJ, Fraser RD (1994) Anterior
vascular injury during anterior lumbar spinal surgery: lumbar fusion: results, assessment techniques and
incidence, risk factors, and management. Spine; 32:2751– prognostic factors. Eur Spine J; 3:225–302.
2758.
Purpose
Purpose To evaluate results, assessment techniques, and prognos-
To examine the incidence of major vascular injury during tic factors of anterior lumbar fusion.
anterior lumbar spine surgery, attempt to identify pre-
disposing risk factors, and to discuss management tech- P Patient Patients with intractable back pain (discogenic or mecha-
nical back pain, previous failed surgery, motion segment
niques. instability, spondylolysis or spondylolisthesis) (N = 151,
median age 41 years)
P Patient Patients undergoing anterior lumbar spine surgery (N =
I Intervention ALIF
338) with 345 operations, mean age 56 years)
Intervention Anterior lumbar spine surgery, ALIF C Comparison No control group
I
Comparison No control group O Outcome Radiology, clinical and neurological examination, VAS,
C
return to work, low back pain outcome score, ODI, satisf-
O Outcome Incidence of major vascular complications, predisposing action rating, psychometric instruments: Modified Somatic
risk factors Perception Questionnaire, Zung Depression Scale

Current or previous osteomyelitis or discogenic infection, Anterior interbody lumbar spinal fusion has a place in
previous anterior spine surgery, spondylolisthesis, osteo- the severely disabled patient with back pain, but these
phyte formation, transitional lumbosacral vertebra and patients require very careful assessment. Compensation
anterior migration of interbody device point to an in- status and psychological disturbance at presentation were
creased risk of vascular injury during anterior lumbar significant prognostic factors. Psychological disturbance
spine surgery. at review had a profound effect on the outcome and on
patient satisfaction ratings.
409

Mayer HM (1997) A new microsurgical technique for Mayer HM, Wiechert K (2002) Microsurgical anterior
minimally invasive anterior lumbar interbody fusion. approaches to the lumbar spine for interbody fusion and
Spine; 22:691–699. total disc replacement. Neurosurgery; 51:159–165.
Purpose Purpose
To investigate the feasibility of performing an ALIF To describe the results of microsurgical ALIF.
through a 4 cm skin incision and a standardized muscle-
splitting approach. P Patient Microsurgical ALIF: patients with spondylolisthesis, spinal
instability, spinal stenosis, failed back surgery, fracture,
spondylitis, and pseudarthrosis (N = 171)
P Patient Patients with degenerative or postoperative lesions associ- Total disc replacement: patients with discogenic low back
ated with low back pain (Patients with disabling segmental pain caused by degenerative disc disease (N = 26)
instability due to DDD, degenerative spondylolisthesis
Grades I or II, isthmic spondylolisthesis Grades I or II, or I Intervention Mini-ALIF by:
“failed back surgery syndrome”; N = 25, average age 48 • a microsurgical retroperitoneal approach to levels L2–5 or
years) • a microsurgical transperitoneal approach through a
“minilaparotomy” to L5/S1
I Intervention Minimally invasive ALIF by two new approaches:
• microsurgical retroperitoneal approach to levels L2/3, C Comparison No control group
L3/4
O Outcome Radiological evaluation, operative time, blood loss,
• L4/5 and microsurgical transperitoneal approach through
complications, morbidity, pseudarthrosis rates, Economic
a “minilaparotomy” to L5/S1
Functional Rating score, total disc replacement: VAS, ODI
O Outcome Intraoperative data such as blood loss, operating time, Authors’ conclusion
intraoperative and postoperative complications, morbidity, Microsurgical anterior approaches to the lumbar spine
preliminary fusion results
provide a reasonable surgical alternative to convention-
al approaches for anterior interbody fusion and total disc
replacement.
The microsurgical approaches described in this article are
applicable to the L2/3, L3/4, L4/5, and L5/S1 levels. They
are associated with only negligible surgical trauma, no
intraoperative complications, low intraoperative blood
loss, and with decreased incisional discomfort, postop-
erative morbidity, and recovery time. The approaches are
not restricted to the type of fusion (iliac crest autograft)
presented in this series, and can be used for a variety of
degenerative or postoperative lesions and, if desired, com-
bined with posterior instrumentation.

Westfall SH, Berooz AA, Merenda JT, et al (1987)

Exposure of the anterior spine. Technique, complications,
and results in 85 patients. Am J Surg; 54:700–704.

Purpose
To describe the application of the anterior approach to
the spinal column to virtually any pathological process
involving the vertebral bodies.
P Patient Patients who underwent anterior spinal fusion alone or in

conjunction with posterior spinal fusion for correction of
structural scoliosis, kyphosis, trauma, infections, or tumors
(N = 85)
I Intervention Thoracoabdominal approach, thoracotomy, lumbar
approach, interbody fusion, strut graft
O Outcome Complications, morbidity, mortality
This study emphasizes the aspects of preoperative, op-
erative, and postoperative care that minimize operative
morbidity and mortality while enabling satisfactory cor-
rection and fusion of the spine.
411


4.3.2 Minimally invasive anterolateral retroperitoneal
approach to the lumbar spine
Andreas Korge, Christoph Mehren
1 Historical perspective access route. The major indications are mono- or bisegmen-
tal pathologies that require fusion procedures or the inser-
Descriptions of anterior approaches to the lumbar spine tion of intervertebral nucleus implants for motion preserva-
date back to the early 20th century [1–3]. Transperitoneal tion.
approaches were used at the onset, and it was not until
1944 that the first account of a lateral approach was given
by Iwahara [4]. Hodgson and Stock [5] further developed 3 Patient selection
the latter, and established the retroperitoneal technique as
the standard approach to the lumbar spine. The following This approach technique can be used for mono- and biseg-
decades witnessed the introduction of various mechanical mental pathologies of the anterior lumbar spine from L2 to
implants for spinal stabilization after intervertebral discec- L5 requiring anterior stabilization. If fusion procedures are
tomy or following vertebrectomy [6, 7]. As approach-relat- planned both intervertebral implant placement as well as
ed complications became an increasingly important issue, segment-bridging monovertebral corpectomy are possible
a new discussion on approach modalities emerged [8], as a with this approach, which may also be used for additional
result of which a laparoscopic approach was developed for intraspinal intervention such as fragment removal and ca-
fusion procedures in the lower lumbar spine and lumbosa- nal clearance (eg, tumor, infection, fracture). Multilevel
cral junction [9, 10]. However, reports on technical problems pathologies including 3 or more levels require an enlarged
and a significant complication rate [11] limited the wide- “non-mini” skin incision of 6 cm or more, and more exten-
spread use of this procedure. sive tissue preparation. With only a few exceptions, addi-
tional posterior instrumentation is routinely recommended
Following on from the standard retroperitoneal approach- for fusion procedures.
es described by Iwahara [4] and Hodgson and Stock [5], and
avoiding the risks associated with laparoscopic techniques, 3.1 Indications
in 1997 Mayer [12] introduced a new microsurgical antero- Indications for surgery first include the patient´s medical
lateral retroperitoneal technique for anterior lumbar fusion history, clinical and x-ray findings, and the failure of previ-
surgery that combines the advantages of less invasiveness ous conservative treatment. After these aspects have been
and makes use of important anatomical landmarks. This considered, the following indications are taken into account:
anterolateral access technique has been described below. • Degenerative disc disease (DDD) with or without disc
herniation
• Degenerative vertical and translational instabilities in-
2 Terminology cluding short-range frontal tilts
• Isthmic spondylolisthesis
This minimally invasive anterolateral approach for the treat- • Spondylodiscitis and spondylitis
ment of the anterior lumbar spine uses a retroperitoneal • Nonunion following earlier fusion procedures (eg, pos-
route, and constitutes a modification of traditional approach terolateral, posterior lumbar interbody fusion, transfo-
techniques aimed at a target region from L2 to L5. It has raminal lumbar interbody fusion)
the advantage of being a tissue-preserving procedure, with • Tumors
a mini-incision of only 4–5 cm for surgery on up to 2 levels, • Fractures
but requires specific positioning that differs from that used • Failed back surgery syndromes (postdiscectomy, insta-
in techniques with a midline or strictly lateral transpsoatic bility following decompression procedures).
413

Authors Andreas Korge, Christoph Mehren
3.2 Relative contraindications 4.1 Pros

No absolute contraindications exist for using a minimized • Modification of a well-established surgical approach,
anterior approach. However, the following relative contra- with no completely new surgical technique involved
indications should be taken into consideration, and may • Small skin incision, with improved postoperative cosmesis
require a macrosurgical approach: • Preservation of abdominal-wall muscle innervation due
• Previous abdominal surgery in the left retroperitoneal to blunt dissection in the direction of the muscle fibers
region with significant scar tissue formation • Easy access to disc levels L2–5, with minimal risk of
• Distinct vascular abnormalities with extreme lateral damaging neural structures (lumbar plexus, genito-
course of the left common iliac vein obstructing access femoral nerve)
to the anterolateral circumference of L4/5 at disc level • No neuromonitoring necessary
(Fig 4.3.2-1) • In very obese patients, the peritoneal sac, including the
• Large paravertebral and/or intrapsoatic mono- or bilat- contents, falls away from the access route thus facilitat-
eral abscess formation in cases of infection. ing the preparation procedure
• Low blood loss
• Short operating time
• Low complication rate
• In the event of a complication, approach enlargement
L4 is quick and easy
• Early and almost painless patient mobilization due to
minimal iatrogenic trauma
• Short and rapid learning curve
• Approach strategy independent of the type of implant
L5 chosen
• No laboratory training necessary
• No access surgeon necessary
• Only one assistant necessary.
4.2 Cons
• Limited visualization outside the target area, with the
potential risk of inadvertent damage to or destruction
Fig 4.3.2-1 Color-coded CT scan showing of adjacent anatomical structures
a large vena cava and left common iliac vein • Access limited to segments L2–5
crossing the disc at L4/5, and also a large
• No bisegmental access possible to L4–S1 including the
lumbar ascending vein (arrows).
lumbosacral junction
• Access to disc space at L4/5 is difficult in the case of a
high iliac crest
4 Pros and cons of a minimally invasive • Reduction possibility is limited, and in the case of large
anterolateral retroperitoneal approach to the deformities is not practicable
lumbar spine • With a 4 cm incision, no more than 2 segments can be
treated
The main advantage of this access technique is that it rep- • Anterior stand-alone support with only intervertebral
resents a minimized version of a widely accepted, standard cage implantation is not recommended, and additional
macrosurgical approach including all the benefits of mini- posterior instrumentation is advisable.
mally invasive surgery, such as reduced tissue trauma, blood
loss, and scar-tissue formation. In many cases the macro-
surgical approach will remain the access technique of choice. 5 Preoperative planning and positioning
However, for the indications mentioned above, large expo-
sures can be avoided; the target area can be addressed Preoperative imaging studies include standard x-rays in AP
through a minimized, tissue-protecting, direct access route and lateral projection with the patient in a standing posi-
with an almost exclusively blunt dissection technique taking tion. Specific attention should be focused on the left iliac
into account established anatomical landmarks and limits. crest in the case of an L4/5 target segment to determine

4.3.2 Minimally invasive anterolateral retroperitoneal approach to the lumbar spine
whether a minimized access to that level is possible. A high- gadolinium-enhanced MRI will reveal the amount and lo-
riding iliac crest might require a larger access and more cation of scar tissue formation.
extensive tissue preparation. The AP view provides addi-
tional information on the distance between the rib cage and CT scan is helpful in the case of uncertainty regarding the
the iliac crest, which is an important consideration when prevertebral vessels, and since 2000 color-coded 3-D angio-
accessing L2/3. Flexion-extension films help to exclude the CT scan has been used as a powerful tool in this respect
presence of translational or vertical instabilities. With in- (Fig 4.3.2-2).
stabilities requiring a reduction, initial posterior reconstruc-
tion and instrumentation is recommended. Lateral bending There is no difference between minimally invasive ante-
x-rays in AP projection help to detect any segmental flex- rior and anterolateral approaches as regards preoperative
ibility in frontal plane tilts. patient preparation or subsequent anesthetic workup, in-
cluding general anesthesia. The present authors therefore
Magnetic resonance imaging provides the necessary infor- refer readers to the corresponding passage in chapter 4.3.1
mation on the pre- and paravertebral anatomy, in particu- Minimally invasive anterior midline approach to the lum-
lar as regards the vascular course and the level of arterial bar spine and lumbosacral junction.
bifurcation and venous confluence, and also the left iliac
vessels including the common iliac artery and vein. In many The patient is placed in a right lateral decubitus position on
cases an ascending lumbar vein can be identified, thus pre- an adjustable operating table. The arms are placed in a
paring the surgeon for possible intraoperative challenges 90°/90° position, and the legs are padded and attached with
[13]. The ureter adhering to the peritoneum and the left straps. The target segment should be located directly above
kidney falling away from its usual position due to the effect the tilting point of the table. Gentle tilting will open the
of gravity during the intraoperative procedure are usually distance between left costal arch and the iliac crest, thus
of no concern when sufficient caution is exercised. How- enlarging the access corridor. Depending on the segment
ever, the size, position, and course of the left psoas muscle to be approached, the table then is tilted backwards in the
and their relationship to the anterolateral lumbar spine are axial plane (20° for L4/5, 30° for L3/4, 40° for L2/3) [12].
important factors, and these aspects should be assessed pre- This step is based on the converging anatomical course of
operatively. Of course, the location of intraspinal patholo- the anterior longitudinal ligament, which serves as an an-
gies such as bone fragments, sequestered disc fragments, or terior landmark intraoperatively. Positioning is completed
intraspinal epidural abscess formation, should be detected by tilting the whole operating table to the adjusted angle,
by means of MRI or CT scan. In the case of previous surgery, in order to position the target segment with perfectly paral-
a b
Fig 4.3.2-2a–b Preoperative imaging (CT scan and MRI) demonstrating anatomical variation.
a Color-coded CT scan showing a prevertebral vascular variation at L4/5 with a large left venous
connection between the inferior vena cava and left external iliac vein.
b Corresponding axial MRI at L4/5 does not show the prevertebral vascular variation in such detail
compared to the color-coded CT scan.
415

lel endplates in an AP projection (Fig 4.3.2-3). Especially in The authors do not use and do not consider neurophysio-
obese patients, this position provides a practicable access logical monitoring necessary for this approach since it does
route, since the bowels and adipose tissue are displaced due not produce relevant information. The presented technique
to the effect of gravity. uses an access route that elegantly stays exclusively outside
and in front of the psoas muscle avoiding any transpsoatic
Localization of the target segment, using image intensifica- corridor. Thus, neural injuries affecting nerve roots or the
tion in strictly vertical projection, is ensured by identifying lumbar plexus due to direct or indirect compression, stretch-
a disc line (parallel to the disc space) and a vertebral body ing, transection, or postoperative hematoma are avoided.
line (from central point to central point) (Fig 4.3.2-4). Both Postoperative analysis of 754 cases using the presented ap-
lines are drawn onto the skin, thereby defining a crossing proach (see topic 8 Evidence-based results in this chapter)
point. A 4 cm skin-incision line traversing this crossing point documented a neurological complication in only two cases,
is marked in an oblique direction, following the imaginary namely, in the form of an irritation of the lateral cutaneous
course of the external oblique abdominal muscle fibers nerve of the thigh, which is probably due to a preparation
(Fig 4.3.2-5). In very obese patients, the skin incision might failure (retractor hook within the groove between the pso-
be enlarged up to 6 cm. as and quadratus lumborum muscles).
Fig 4.3.2-3a–b Patient po-

sitioning in a right decubitus
position with the table ad-
justed at the target level and
tilted backwards according to
the level to be approached.
a Frontal view.
a b b Caudal view.
Anterior
line
l body
Vertebra
Disc lin
Disc lin
Caudal Inc line Cranial

e
ody
isi al b
on
Ver tebr
lin
e
Fig 4.3.2-5 Skin marking of

Fig 4.3.2-4 Image intensification of segment
the incision line over segment
localization at L4/5. Orange: disc line; red:
Posterior
L4/5; skin incision length is
vertebral body line. Crossing point is the center
4 cm.
of the disc space at L4/5.

6 Surgical technique abdominal muscle), as they should be preserved, their func-

tion being to innervate the rectus abdominis muscle. After
The skin incision is made obliquely, anterocaudally to dor- dissecting the transverse abdominal muscle, the retroperi-
socranially, and directly above the disc space of the target toneal adipose tissue becomes visible. Keeping as laterally
segment in the direction of the fibers of the external oblique as possible when dissecting the transverse abdominal mus-
abdominal muscle, followed by the sharp dissection of sub- cle helps to avoid any accidental opening of the peritoneum.
cutaneous tissue. Then in sequence, the fascia of all three
muscles of the anterolateral abdominal wall (the external The peritoneal sac with the attached ureter is then mobilized
oblique abdominal muscle, the internal abdominal muscle, dorsally to ventrally using Langenbeck retractors and pea-
and the transverse abdominal muscle) is opened with blunt nut swabs. The greater psoas muscle is then exposed as the
dissection of the corresponding muscle, always in the direc- first landmark. Particular attention must be paid to the
tion of the muscle fibers (Fig 4.3.2-6). Special attention must genitofemoral nerve at level L3/4 and higher, since it cross-
be paid to the intercostal nerves D10–12, as well as to the es the muscle and emerges in the above-mentioned area,
iliohypogastric and ilioinguinal nerves, which might cross running along the muscle itself (Fig 4.3.2-7). The lateral bor-
the access route (in most cases above L4/5 in the layer der of the anterior longitudinal ligament is identified as the
between the internal abdominal muscle and the transverse medial landmark.
External oblique Internal oblique

abdominal muscle abdominal muscle
a b
Transverse abdominal muscle Peritoneum
Psoas muscle
Genitofemoral nerve
Fig 4.3.2-7 Anatomical view at L3/4 showing the

anterolateral course of the greater psoas muscle and
the genitofemoral nerve emerging from the muscle.
c d
Fig 4.3.2-6a–d Transmuscular corridor through the anterolateral

abdominal wall muscles performed by blunt dissection in the direction
of the muscle fibers traversing in sequence the external oblique
abdominal muscle, the internal oblique abdominal muscle, and the
transverse abdominal muscle, finally reaching the retroperitoneal cavity.
417

Depending on the target segment and on the individual proach towards the pedicle area, the lumbar plexus is not
anatomy, different vascular structures, such as the left com- exposed to risk, even at L4/5 during exposure of the target
mon iliac artery and vein and a lumbar ascending vein, can area [14]. If the sympathetic nerve chain is within the surgi-
be identified (Fig 4.3.2-8). Vessels are mobilized by blunt cal area, mobilization can be attempted. However, in some
dissection if the required anterolateral circumference of the cases, the sympathetic nerve chain lies directly against the
disc space is initially too small. Preparation and ligation of lumbar spine and has to be cauterized and dissected. At the
the segmental vessels is not necessary in routine practice, preoperative stage, it is therefore mandatory that the patient
and is only required in the case of vertebrectomy (eg, for be informed of a possible temporary postoperative tem-
fractures, tumors). The psoas muscle serves as a lateral land- perature difference between the left and right legs, which
mark. Additional enlargement of the anterolateral circum- in most cases resolves after 6–9 months.
ference of the target disc space can be achieved by blunt
mobilization and detachment of the anteromedial insertion With a distance of 10 mm between the lateral rim of the
of the psoas muscle fibers with mild retraction in a lateral anterior longitudinal ligament serving as medial landmark
direction. However, no muscle splitting or dissection of the and the medial aspect of the psoas muscle as lateral land-
psoas muscle is required, and no neuromonitoring is neces- mark, the target area is then exposed (Fig 4.3.2-9), and self-
sary. Using this technique and avoiding too lateral an ap- retaining retractor frames can be adjusted. Before complete
Common iliac artery
Common iliac vein Anterior longitudinal

ligament
Ascending lumbar vein
L5 L4
Psoas major muscle
Fig 4.3.2-8a–b View showing the prevertebral

retroperitoneal vascular anatomy (common iliac artery
a b and vein, ascending lumbar vein).
Left common iliac vein

Anterior longitudinal ligament
Segmental vessels
L4/5 disc
Ascending lumbar vein
Psoas major muscle

Fig 4.3.2-9 View following final anterolateral
segment preparation. Anterior landmark: anterior
longitudinal ligament; posterior landmark: retracted
psoas muscle, with the disc space between the two
landmarks surrounded by vessels.

opening of the intervertebral disc space, the adjacent end- stage is highly recommended in order to avoid accidental
plates are identified and the disc space is marked with a anterior dural tears. After the graft bed has been prepared,
dissector after a mini-incision for x-ray determination of it is then possible to envisage the implantation of various
the target disc. types of interbody support (eg, autogeneic or allogeneic
graft material, cages, osteoconductive/osteoinductive bone
The next surgical steps focus on the target surgery. In the substitutes including bone morphogenetic protein, etc
case of intervertebral nucleus replacement a small opening (Fig 4.3.2-11). After implantation of an interbody support,
in the annulus is created, followed by limited nucleus re- the disc space is covered with a hemostatic agent. If an ad-
moval and the subsequent implantation of an artificial ditional stabilizing plate has been planned, the implant can
nucleus prosthesis and closure of the annulus opening. be inserted at this stage.
More frequently, interbody devices are implanted to pro- Retreat from the surgical field includes the control of bleed-
mote segmental stability and support the fusion process. ing around the target area. In routine practice, a drain is
Therefore, the disc space is opened in box-shaped manner, not necessary. After determining the integrity of the para-
and the disc is removed subtotally. Cranial and caudal end- vertebral and retroperitoneal structures, the peritoneal sac
plates are curetted for complete cartilage removal; gentle is then replaced in its origin position. The three fasciae of
opening of the endplates is then performed with punctual the anterolateral abdominal wall muscles are each closed
bleeding, thus creating a perfect graft bed for accelerated separately with continuous suture. Closure of the subcu-
bone ingrowth (Fig 4.3.2-10). If intraspinal surgical interven- taneous tissue is then carried out with single stitches,
tion is required (eg, removal of disc fragments at disc level, and, after disinfection, intracutaneous absorbable continu-
epidural abscess, intraspinal fracture fragment), these steps ous suture and a sterile dressing complete the surgical
can also be integrated. Use of a surgical microscope at this intervention.
Anterior
Caudal Cranial
Chisel for endplate

Graft bed preparation
a b
Fig 4.3.2-10 Intraoperative microscopic view Fig 4.3.2-11a–b
of prepared graft bed. a Intraoperative in situ microscopic view of an intervertebral mesh-like titanium
cage filled with autogeneic bone graft at level L4/5.
b Corresponding postoperative lateral x-ray.
419

7 Postoperative care ed to 12% “fair” and 88% “poor” ratings, whereas postop-
eratively the scores amounted to 20% “excellent”, 30%
No drain is necessary following meticulous final prevertebral “good”, 30% “fair” and 19% “poor”. Understandably, it was
hemostasis. Younger patients are mobilized 8 hours post- not possible to carry out a comparison between approach-
operatively for both fusion and nonfusion indications. All surgery-related versus target-surgery-related outcome
other patients are mobilized the day after surgery. There analysis.
are no restrictions regarding sitting, walking or standing.
A stabilizing Boston-type brace is worn for 10–12 weeks The same author later reported on a larger group of patients
only after fusion surgery, whereas nonfusion patients do (n = 120) treated by this anterolateral approach [17]. Seg-
not require any external support. mental support was performed in all cases with an autolo-
gous bone graft. In an overall assessment of mono- (n =
Perioperative antibiotics are routinely prolonged for a pe- 104) and bisegmental (n = 16) cases, operative time amount-
riod of 24 hours postsurgery (eg, cefuroxime). Thrombo- ed to 102.2 min on average (50–192 min) and blood loss
embolic prophylaxis with fractionated heparin is performed for approach and target surgery combined to 67 ml. Outcome
until full mobilization. assessment was again measured using the Prolo score, and
showed significant functional improvement; whereas pre-
Eating may be started on the first postoperative day depend- operatively 100% “bad” scores were observed, postopera-
ing on bowel function. tively 62% “excellent” or “good” scores were recorded.
Patient satisfaction was evaluated at 73% of individuals
Radiological follow-up includes standing x-rays in two pro- recorded as being satisfied or very satisfied.
jections on day 2 postsurgery, followed by routine x-ray
controls after 3, 6, and 12 months. This anterolateral retroperitoneal technique has been imple-
mented together with Mayer at the present author’s spine
center, with 754 cases (544 mono-, 210 bisegmental) oper-
8 Evidence-based results ated on between April 1998 and December 2010. Patients
presenting with indications such as degenerative conditions,
Contrary to posterior fusion surgery of the lumbar spine tumors, infections, fractures, failed back surgery, etc were
where open, mini-open and percutaneous techniques can all considered for treatment. The overall complication rate
be compared relatively easily, only limited data are available amounted to 9.8%, while the intraoperative complication
on anterior access-focused strategies, and the benefits of rate was only 0.5% (n=4/754). Three vascular complications
using minimally invasive techniques in this regard. For the involved laceration of the left iliac common vein, which
most part, studies tend to focus on the target surgery itself was treated by suturing and/or the application of a hemo-
or associated complications, and fail to take into account static agent containing thrombin (eg, Floseal or TachoSil);
the influence of approach parameters on the immediate while a fracture case, which necessitated fragment remov-
postoperative outcome. In addition, in anterior surgery of al and in which the dura had been lacerated, the dura was
the lumbar spine, it is much more difficult to analyze the closed, and surface sealing carried out with fibrin glue and
parameters that are exclusively related to the approach (eg, the application of a tamponading fleece. No abdominal or
tissue injury markers) [15]. So far, no class I or II compara- urogenital complications occurred intraoperatively. Post-
tive study has been made on macrosurgical versus micro- operatively, a complication rate of 9.3% was observed. The
surgical techniques using a retroperitoneal approach to the infection rate amounted to 2.1% (10 superficial wound
lumbar spine. Most of the results reported involve class healing problems and 6 deep-seated infections), and the
IV-type retrospective study cohorts. rate of hematoma formation to 2.8% (10 involving the tar-
get area, 12 superficial). Other complications included car-
In a study on an initial series of 54 patients (43 single- diovascular disorders (10/754), urinary tract infection
level, 11 double-level) that underwent a retroperitoneal (7/754), pneumonia (6/754), nerve irritation (2 cases of
approach to L2–5, Mayer [16] reported the following results. irritation affecting the cutaneous lateral femoral nerve).
The mean operating time amounted to 115 minutes, and Revision surgery was required in only two cases, ie, one
the mean intraoperative blood loss to 59.6 ml. No approach- abscess drainage and one implant replacement after implant
related complications were reported. Clinical outcome was dislocation, together representing a revision rate of just
assessed using the Prolo Economic Functional Rating (EFR) 0.3%. A meticulous analysis by an independent investigator
score; preoperatively the scores for clinical outcome amount- is now underway, and these recent results will be reported

in the near future. However, despite the high number of 9 Complications and avoidance
cases treated, the drawback of this analysis lies in its retro-
spective character. Following on from experience in macrosurgical anterolat-
eral approaches, the logical development in measures aimed
Based on the technique described by Mayer [12], Lin et al at reducing access-related complications is the gradual re-
[18] modified the access procedure by extending the ana- duction in the length of the incision. The minimization of
tomical target area for this minimally invasive fusion tech- the approach, however, includes reduced visual control of
nique up to level T12, and terming it “mini-open anterior the surgical anatomy and thus an increased risk of injury.
spine surgery” (MOASS). Modifications were in particular In this regard, the present author recommends at the very
introduced for exposing T12 to L2 through various subcos- minimum a head lamp for better illumination of the access
tal or intercostal approaches. Sixty-one patients with dif- corridor, and for problematic cases, especially when con-
ferent indications for surgery (eg, fracture, failed back sur- fronted with challenging vascular situations, the use of a
gery, infection, among others), operated on using an microscope.
anterior stand-alone strategy including intervertebral cage
positioning and lateral screw-rod fixation without addi- The acceptance of a learning curve is a sine qua non for
tional posterior instrumentation, were retrospectively ensuring the success of this minimally invasive approach
analyzed using the Oswestry Disability Index for subjective technique, even for surgeons with extensive experience in
evaluation. With most patients (91.8%) reporting that they traditional macrosurgical techniques. However, the sur-
felt satisfied after the surgical intervention, a remarkable geon’s familiarity with macrosurgical approaches is of in-
improvement in quality of life was achieved. As regards valuable assistance in the event of complications, since a
approach-related complications, temporary irritation of the mini-approach can be rapidly converted to a large exposure
sympathetic nerve chain was reported as being the most of the target area.
frequent (13%), followed by only one other complication
(sagging abdomen: 1 case). The technique itself was judged Minimization of the approach corridor requires accurate
as being “feasible, effective, and safe”. preoperative positioning and localization of the target area.
Imprecise preoperative planning could lead to significant
An increasing number of papers are appearing in the lit- intraoperative difficulty in localizing the disc space and de-
erature, not only on the anterolateral retroperitoneal access termining the orientation of the endplates. The orientation
technique presented in this chapter, but also on the lateral and the projection by the image intensifier is only correct
transpsoas approach to the lumbar spine. The latter tech- when the endplates are visualized in parallel, and if the
nique shall not be examined in this chapter, but for further posterior wall of the vertebral body does not show “double
information readers are referred to chapter 4.3.3 The lat- lines”.
eral approach to the lumbar spine.
The disc spaces at L4/5 and L2/3 might be concealed by the
Numerous studies have reported on the intraoperative com- iliac crest or the lower costal arch. Tilting the table more
plications associated with anterior spinal fusion procedures posteriorly will shift the skin incision more anteriorly, thus
[8, 19, 20]. The pattern of complications clearly differs ac- ensuring that the corresponding disc levels are approach-
cording to the specific approach and the type of surgery in able. Additional adjustment of the table at the level of the
question (eg, endoscopic versus mini-invasive versus mac- pelvis enlarges the distance between the left iliac crest and
ro-invasive procedures; primary surgery versus revision the lower costal arch. In most cases, this guarantees a direct
surgery). A midline approach to the lumbar spine at L2–5 approach to the disc space.
presents an increased risk of vascular damage compared to
an extreme lateral transpsoas approach [19]. So far, no study Intraoperative mobilization of the psoas muscle laterally
has yet focused specifically on the differences in the rate could result in transient postoperative pain upon flexing
and type of complications for macrosurgical versus micro- the left hip. At the preoperative stage during positioning,
surgical retroperitoneal surgery of the anterior lumbar spine. mild flexion of the left hip and knee joint ensures that the
However, there does seem to be a trend towards a reduced psoas muscle is relaxed and reduces any tension, subse-
complication rate for minimally invasive techniques [19]. quently with less need for muscle mobilization.
421

A nerve-related motor deficit affecting the hip flexors is the most threatening intraoperative complication. Therefore
extremely rare when using this approach. In contrast to preoperatively, attention should be focused on determining
extreme lateral transpsoatic approaches, irritation or dam- the specific course of the aorta and inferior vena cava, as
age to the lumbar plexus as well as to the genitofemoral well as that of the left-sided common iliac vessels. The ex-
nerve is infrequently observed, and when it occurs is prob- istence of a lumbar ascending vein should be clearly estab-
ably due to inadequate preparation and poorly controlled lished. In the case of uncertainty, color-coded 3-D angio-CT
retraction of the psoas muscle. scan will help provide additional information on the pre-
vertebral vascular anatomy [22]. Segmental vessels are usu-
An accidental opening of the peritoneum should be closed ally not prepared for monosegmental supports. In the event
with resorbable continuous suturing (eg, 2.0 Vicryl). With of laceration, vessel closure with endoclips is recommend-
an anterolateral approach, laceration of the colon (descend- ed. In the case of damage to the ascending lumbar vein,
ing/sigmoid colon) is an extremely rare occurrence, how- clipping and suturing should be performed. If a large as-
ever, in the event of laceration, immediate suturing is nec- cending lumbar vein crosses the disc space at L4/5 and suf-
essary. ficient mobilization is impossible, the author recommends
ligation in advance. As described in chapter 4.3.1 Mini-
In the event of an injury to the ureter, immediate suturing mally invasive anterior midline approach to the lumbar
and splinting is recommended, followed by specific uro- spine and lumbosacral junction, small lesions of the common
logical postoperative management. iliac vein can be treated with a hemostatic agent containing
thrombin (eg, Floseal or TachoSil), whereas larger lesions
Vascular complications amount to between 0.08% and 3.5% and lacerations of the aorta, inferior cava vein and left iliac
[8, 20], but in revision surgery for implant removal the rate artery require immediate closure with a vascular suture
rapidly increases to as much as 57% [21], and represents (eg, Prolene 6.0 suture).
10 Tips and tricks
H Michael Mayer, Munich, Germany the disc space at L4/5 in the anterior Intraoperative procedures
third, it might be advisable to open • The iliocostal nerves should be carefully
Preoperative planning the psoas muscle sheath anteromedi- surveyed upon blunt dissection of the
• X-rays: ally, and advance between the mus- internal oblique muscle.
• For L4/5 approaches, the level of the
cle sheath, using it as safety layer, • The retroperitoneal space should be en-
iliac crest should be checked via stan- and the muscle itself; then traverse tered as far laterally as possible to avoid
dard x-rays to determine whether an the sheath again, directly over the peritoneal injury.
approach parallel to the endplates disc space • The genitofemoral and ilioinguinal
is possible. If not, a larger incision • The patient should be informed before- nerves running along the psoas muscle
or a retroperitoneal midline mini- hand about temporary postoperative should be carefully surveyed. Retractor
approach might be an alternative temperature differences in the leg due blade pressure or direct injury may result
• MRI: to dissection of the sympathetic nerve in groin pain and dysesthesia in the groin,
• The diameter of the psoas muscle can
trunk (see below). scrotum and outer labia as well as in a
be assessed via MRI to see whether • A ureteral stent is mandatory in revision motor deficit of the cremaster muscle.
an anterolateral approach anterior surgery. • If the sympathetic nerve trunk cannot be
to the psoas muscle is possible mobilized, it should be cut through and
• 3-D angiogram: Positioning the nerve endings cauterized. Forceful
•
This imaging technique provides • Slightly tilting the foot end of the table manipulation or pressure may lead to
information on the localization and helps to stretch the psoas muscle fibers, sympathetic dystrophy in the left leg.
course of the left common iliac vein thereby facilitating blunt dissection. • During refixation of the muscle layers,
and ascending lumbar vein (which • The operating table should be adjusted carefully check the intercostal nerve to
might consist of up to five branches). until the endplates are in parallel projec- prevent fixation or compression due to
With a common iliac vein crossing tion in the preoperative x-rays. the suture.

11 Case examples Standard x-rays demonstrated endplate irregularities at L4/5

with lateral and anterior spondylophyte formation. How-
11.1 Case 1 ever, the disc space was nearly normal and without signs
A 61-year-old man had experienced persisting low back of segmental collapse (Fig 4.3.2-12a–b). Flexion/extension
pain radiating into the groin, buttocks and legs for one year. films did not detect the presence of any translational insta-
The pain in the back, and the pain radiating into the legs bility. Magnetic resonance imaging revealed possible signs
were of equivalent intensity. Increased pain was experienced of spondylodiscitis at L4/5 (contrast enhancement showed
on walking, accompanied by the development of numbness disc and vertebral bodies at L4/5 with perivertebral inflamed
in the left thigh down to the knees. Walking distance was tissue) but without epidural or paravertebral abscess forma-
limited to 10 meters due to progressive buttock and groin tion (Fig 4.3.2-12c–d). Due to the elevated infection param-
pain. The patient’s medical history showed an absence of eters (C-reactive protein, white blood cells, erythrocyte
fever or shivering. Conservative treatment, including ex- sedimentation rate), a diagnosis of spondylodiscitis at L4/5
ercises, acupuncture, nonsteroidal antiinflammatory drugs was made, and surgical treatment was decided upon. Surgery
and other medication had failed to provide satisfactory re- was initiated with posterior percutaneous in situ instru-
sults (Fig 4.3.2-12). mentation using a screw-rod system, with bone harvesting
from the posterior iliac crest carried out through a mini-
Clinical findings show tenderness on tapping, and when incision, followed by an anterior procedure via a minimal-
pressure was exerted on the lower lumbar spine. The right ly invasive left-sided anterolateral approach with disc re-
iliosacral joint was also painful on pressure. Significant moval and local debridement at L4/5 and cage insertion
limitation of flexion and extension was observed, due to with autogenous bone graft (Fig 4.3.2-12e–f). Mobilization
local pain in the lower lumbar spine. The straight leg raising started the day after surgery, and a Boston brace-type sup-
test was negative; sensorimotor function was normal, with port was worn for 12 weeks. Antibiotics (ie, cefuroxime,
a normal reflex pattern in both legs. clindamycin) were administered intravenously for 2 weeks,
and taken orally for an additional 4 weeks. Infection pa-
rameters returned to normal values within 4 weeks post-
surgery.
a b c d e f
Fig 4.3.2-12a–f Pre- and postoperative imaging.
a–b Preoperative standard AP (a) and lateral (b) x-rays showing endplate irregularities with lateral or anterior spondylophyte formation.
c–d Preoperative axial MRI (c) (T1-weighted image with gadolinium contrast medium), and sagittal MRI (d) (T2-weighted image with gadolinium
contrast medium) showing contrast enhancement in the disc at L4/5 as well as in the adjacent vertebral bodies, with perivertebral inflamed
tissue.
e–f Postoperative standard AP (e) and lateral (f) x-rays showing monosegmental posterior percutaneous instrumentation and anterior cage placement.
423

11.2 Case 2 Standard x-rays showed a substantial increase in spondy-

A 67-year-old woman had experienced significant left- lolisthesis at L4/5 with translational displacement (Fig 4.3.2-
sided unspecific leg pain for 4 years, with the gradual de- 13a–b). Magnetic resonance imaging and CT scan revealed
velopment of intense low back pain. She was unable to exacerbating factors such as absolute spinal stenosis at L4/5,
move around without the aid of a walking stick, and felt accompanied by an intradiscal vacuum phenomenon at L4/5,
pain upon walking any distance. However, when sitting or and a destroyed facet joint bilaterally (Fig 4.3.2-13c–d).
lying, the patient was relatively pain-free. No sensorimotor
deficit was reported (Fig 4.3.2-13). As all conservative treatment attempts had proven ineffec-
tive, surgery was therefore indicated. Posterior reduction
Clinical examination showed tenderness on tapping in the and instrumentation as well as microscope-assisted decom-
region of the lower lumbar spine preoperatively, no pres- pression at L4/5 was performed, followed by anterior disc
sure pain affecting the iliosacral joints, and no sensorimo- space clearance, cage insertion and autogeneic bone graft-
tor deficit in either leg. ing (from the facet joints at L4/5) in combination with
beta-tricalcium phosphate, all carried out under the same
Semi-invasive nonsurgical treatment with image-guided general anesthesia using a minimally invasive anterolat-
selective infiltrations, in particular L4/5 facet blocks and eral approach (Fig 4.3.2-13e–f). Postoperative antibiotics were
epidural injection at L4/5, had provided only short-term administered for 24 hours, and the patient was mobilized
relief of low back pain. the day after surgery, with a brace to be worn for the 12
following weeks. The patient subsequently progressed very
well, with negligible back and leg pain being reported.
a b c d
Fig 4.3.2-13a–f Pre- and postoperative standard x-rays and preoperative MRIs.
a Preoperative standard AP x-ray.
b Preoperative standard lateral x-ray showing spondylolisthesis at L4/5 with
translational displacement.
c Preoperative axial T2-weighted MRI showing severe lumbar spinal stenosis at
L4/5.
d Preoperative sagittal T2-weighted MRI showing posterior instrumentation and
anterior intervertebral cage placement.
e Postoperative standard AP x-ray showing posterior instrumentation and anterior
intervertebral cage placement.
f Postoperative standard lateral x-ray showing surgical reconstruction of the
anatomical profile at L4/5 through posterior instrumented reduction and anterior
e f intervertebral cage stabilization with use of autogeneic bone graft.

12 Key learning points • The exposed target area is limited to either monoseg-
mental or bisegmental anterior intervertebral segment
• A minimally invasive retroperitoneal approach to the stabilization, or to a vertebrectomy of a single vertebral
anterior lumbar spine from L2 to L5 using a 4–5 cm skin body when one skin incision is used. Larger exposures
incision, first reported by Mayer in 1997, has been de- including more segments would need enlarged access
scribed. It represents a tissue-preserving modification corridors or require an additional mini-incision
of the well-known macrosurgical anterolateral retro- • In contrast to other techniques such as the extreme lat-
peritoneal access technique described by Hodgson and eral transpsoas approach, no muscle dissection or mus-
Stock [5] cle transition is necessary, thereby minimizing the risk
• As this technique is a modification of an established of neural damage to the genitofemoral nerve or lumbar
approach, the learning curve is very short plexus
• This approach makes use of known anatomical land- • The range of possible complications is manageable. If a
marks—anteriorly, the anterior longitudinal ligament; complication is encountered, rapid enlargement of the
and posteriorly, the psoas muscle—and ensures sufficient exposure is possible, as performed for macrosurgical ap-
target exposure proaches
• This approach applies only to segments L2–5. The low-
er costal arch prevents a more cranial application, while
the iliac crest limits its application to L5/S1.
13 References
1. Burns BH (1933) An operation for 9. Mathews HH, Evans MT, Molligan HJ, 16. Mayer HM, Wiechert K (1998) Ventral
spondylolisthesis. Lancet; 1:1233–1239. et al (1995) Laparoscopic discectomy fusion operations in the lumbar spine.
2. Capener N (1932) Spondylolisthesis. Br with anterior lumbar interbody fusion. Microsurgical techniques. Orthopäde;
J Surg; 19:374–386. Spine; 20(16):1797–1802. 27:466–476.
3. Müller W (1906) Transperitoneale 10. Southerland SR, Remedios AM, 17. Mayer HM (2000) The ALIF concept.
Freilegung der Wirbelsäule bei McKerrell JG, et al (1995) Eur Spine J; 9 Suppl 1:S35–S43.
tuberkulöser Spondylitis. Dtsch Z Chir; Laparoscopic approaches to the lumbar 18. Lin RM, Huang KY, Lai KA (2008)
85:128–139. vertebrae. An anatomic study using a Mini-open anterior spine surgery for
4. Iwahara T (1944) A new method of porcine model. Spine; 20(14):1620– anterior lumbar diseases. Eur Spine J;
vertebral body fusion. Surgery (Japan); 1623. 17:691–697.
8:271–287. 11. McAfee PC, Regan JR, Zdeblick T, et 19. Rodgers WB, Gerber EJ, Patterson J
5. Hodgson AR, Stock FE (1956) Anterior al (1995) The incidence of (2010) Intraoperative and early
spinal fusion. A preliminary complications in endoscopic anterior postoperative complications in extreme
communication on the radical thoracolumbar spinal reconstructive lateral interbody fusion: an analysis of
treatment of Pott's disease and Pott's surgery. A prospective multicenter 600 cases. Spine; 36(1):26–33.
paraplegia. Br J Surg; 44:266–275. study comprising the first 100 20. Sasso RC, Best NM, Mummanemi PV,
6. Crock HV (1983) Anterior lumbar consecutive cases. Spine; 20(14):2034– et al (2005) Analysis of operative
interbody fusion: indications for its use 2035. complications in a series of 471 anterior
and notes on surgical technique. Clin 12. Mayer HM (1997) A new microsurgical lumbar interbody fusion procedures.
Orthop Rel Res; 165:157–163. technique for minimally invasive Spine; 30(6):670–674.
7. Harmon PH (1963) Anterior excision anterior lumbar interbody fusion. Spine; 21. Nguyen HV, Akbarnia BA, van Dam
and vertebral body fusion operation for 22(6):691–699; discussion 700. BE, et al (2006) Anterior exposure of
intervertebral disk syndromes of the 13. Jasani V, Jaffray D (2002) The anatomy the spine for removal of lumbar
lower lumbar spine: three- to five-year of the iliolumbar vein. A cadaver study. interbody devices and implants. Spine;
results in 244 cases. Clin Orthop Rel Res; J Bone Joint Surg Br; 84(7):1046–1049. 31(21):2449–2453.
26:107–127. 14. Moro T, Kikuchi SI, Konno SI, et al 22. Datta JC, Janssen ME, Beckham R, et
8. Faciszewski T, Winter RB, Lonstein (2003) An anatomic study of the al (2007) The use of computed
JE, et al (1995) The surgical and lumbar plexus with respect to tomography angiography to define the
medical perioperative complications of retroperitoneal endoscopic surgery. prevertebral vascular anatomy prior to
anterior spinal fusion surgery in the Spine; 28(5):423–428; discussion anterior lumbar procedures. Spine;
thoracic and lumbar spine in adults. 427–428. 32:113–119.
Spine; 20(14):1592–1599. 15. Kim TK, Lee SH, Suk KS, et al (2006)
The quantitative analysis of tissue
injury markers after mini-open lumbar
fusion. Spine; 31(6):712–716.
425

Moro T, Kikuchi SI, Konno SI, et al (2003) An Datta JC, Janssen ME, Beckham R, et al (2007) The
anatomic study of the lumbar plexus with respect to use of computed tomography angiography to define the
retroperitoneal endoscopic surgery. Spine; 28 (5):423– prevertebral vascular anatomy prior to anterior lumbar
428; discussion 427–428. procedures. Spine; 32:113–119.
Therapy Human anatomical specimen Not applicable Therapy Prospective cohort IV
study
Purpose
Purpose
To determine the efficacy of a single-slice CT angiogram
To clarify the safety zone to prevent nerve injuries with
to define the prevertebral anatomy in patients undergo-
respect to retroperitoneal endoscopic surgery.
ing an anterior lumbar spine procedure.
T Test material Lumbar spines of human anatomical specimens
(N = 30) P Patient Patients requiring anterior lumbar surgery, either a disc
replacement or arthrodesis; patients undergoing a minimal
O Outcome Computer analyses of anatomy incision approach for anterior lumbar surgery (N = 76)
I Intervention Mini-open anterior lumbar surgery
Authors’ conclusion C Comparison No comparison group
The safety zone, excluding the genitofemoral nerve, is at Outcome Presurgery CT angiography, complications, complication
O
L4/5 and above. The muscle should be split more anteri- rate
orly than the dorsal fourth of the lumbar vertebral body
from the cranial third of the L3 vertebral body and above Authors’ conclusion
to prevent nerve injuries. CT angiography correlated with intraoperative vascular
anatomy in all cases. Preoperative CT angiography before
When the psoas major muscle is split at the L3 or L4 anterior approaches was determined to be effective in
vertebral body, there is a risk of injury to the genito- evaluating the prevertebral vascular anatomy.
femoral nerve.

Faciszewski T, Winter RB, Lonstein JE, et al (1995) Lin RM, Huang KY, Lai KA (2008) Mini-open anterior
The surgical and medical perioperative complications of spine surgery for anterior lumbar diseases. Eur Spine J;
anterior spinal fusion surgery in the thoracic and lumbar 17:691–697.
spine in adults. Spine; 20(14):1592–1599.
Purpose
Purpose To introduce the modified MOASS and to evaluate the
To document the incidence and specific types of perspec- feasibility, effectiveness, and safety in the treatment of
tive complications related to anterior spinal fusions. various anterior lumbar diseases with this technique.
P Patient Patients undergoing thoracic and lumbar anterior spinal P Patient Patients with various anterior lumbar diseases (vertebral
fusions (N = 1223) fracture, failed back surgery, segmental instability or
spondylolisthesis, infection, herniated disc, undetermined
I Intervention Thoracic and lumbar anterior spinal fusions
lesion for biopsy, hemivertebra) (N = 61)
C Comparison No comparison group Intervention Modified MOASS
I
O Outcome Perioperative complications, complication risk, complica- Comparison No comparison group
C
tion rate
O Outcome Operation time, blood loss, length of hospital stay, bone fu-
sion, Oswestry Disability Index, grade of fusion (evaluated
Authors’ conclusion by plain film and dynamic x-ray), complications
be used with confidence when the nature of a patient's Authors’ conclusion
spinal disorder dictates its use. Complications are often Mini-open anterior spine surgery is feasible, effective,
approach-specific. and safe for patients with various anterior lumbar dis-
eases.
427

McAfee PC, Regan JR, Zdeblick T, et al (1995) The Mayer HM (1997) A new microsurgical technique for
incidence of complications in endoscopic anterior minimally invasive anterior lumbar interbody fusion.
thoracolumbar spinal reconstructive surgery. A Spine; 22 (6):691–699; discussion 700.
prospective multicenter study comprising the first 100
consecutive cases. Spine; 20(14):2034–2035. Study type Study design Class of evidence
Therapy Prospective case series and IV
Study type Study design Class of evidence technical report
Therapy Prospective case series IV Purpose
To investigate the feasibility of performing an anterior
Purpose
lumbar interbody fusion through a 4 cm skin incision and
To evaluate the early perioperative complications in 100
a standardized muscle-splitting approach.
endoscopic spinal procedures, 78 video-assisted thoracic
surgical procedures, and 22 laparoscopic lumbar instru- Patient Patients with disabling segmental instability due to degene-
P
mentation and fusion procedures. rative disc disease, degenerative spondylolisthesis Grades I
or II, isthmic spondylolisthesis Grades I or II, or “failed back
P Patient Patients undergoing anterior decompression or fusion of surgery syndrome” (N = 25)
the thoracolumbar spine (N = 100) I Intervention Standardized, microsurgical retroperitoneal approach to
I Intervention Video-assisted thoracic surgical procedures levels L2/3, L3/4, and L4/5 and a microsurgical transperito-
Anterior laparoscopic lumbar instrumentation and fusion neal approach through a “minilaparotomy” to L5/S1
C Comparison No comparison group C Comparison No comparison group
O Outcome Mean operative time , mean length of hospital stay, O Outcome Intraoperative data (blood loss, operating time), intra- and
complications postoperative complications, preliminary fusion results,
morbidity
The endoscopic spinal approaches proved to be safe op-
The microsurgical approaches described in this article are
erative procedures in 100 consecutive cases. There were
atraumatic techniques to reach the lumbar spinal levels
no permanent iatrogenic neurological injuries and no deep
L2/3, L3/4, L4/5, and L5/S1. They represent microsurgi-
spinal infections.
cal modifications of the surgical approaches well known
to the spine surgeon. They can be learned in a step-by-step
fashion, starting with a conventional skin incision and,
once the surgeon is familiar with the instruments, mov-
ing on to the microsurgical technique. The approaches
are not restricted to the type of fusion (iliac crest autograft)
presented in this series.

Nguyen HV, Akbarnia BA, van Dam BE, et al (2006) Rodgers WB, Gerber EJ, Patterson J (2010)
Anterior exposure of the spine for removal of lumbar Intraoperative and early postoperative complications in
interbody devices and implants. Spine; 31(21):2449– extreme lateral interbody fusion: an analysis of 600
2453. cases. Spine; 36(1):26–33.
Purpose Purpose
To report on patients having undergone revision lumbar To delineate and describe complications in a large, pro-
surgery anteriorly to remove interbody devices placed spective series of minimally invasive lateral lumbar fusion
anteriorly or posteriorly and to determine the incidence procedures (XLIF).
of associated complications.
P Patient Patients with a lumbar degenerative spinal condition, after
P Patient Degenerative disc with interbody devices placed (N = 14, exhaustion of a full course of conservative care for whom
50% male, mean age 43 years) fusion was indicated (N=600)
I Intervention Anterior approach for revision and interbody device I Intervention XLIF
removal C Comparison With data from the literature:
C Comparison No comparison group • Other minimally invasive (mini-anterior lumbar interbody
fusion and minimally invasive surgical transforaminal
O Outcome Complications, mortality lumbar interbody fusion)
• More traditional fusion approaches (posterior intertrans-
Authors’ conclusion verse fusion, anterior lumbar interbody fusion, posterior
lumbar interbody fusion, transforaminal lumbar interbody
Anterior removal of lumbar interbody devices placed an-
fusion)
teriorly or posteriorly has a high incidence of complication.
O Outcome Operative and early postoperative complications
Hemoglobin change
Hospital stay
Pain score
Patient satisfaction
Compared with traditional open approaches, the mini-
mally invasive lateral approach to fusion by using the
XLIF technique resulted in a lower incidence of infection,
visceral and neurological injury, and transfusion as well
as markedly shorter hospitalization. Complications in
minimally invasive spine surgical XLIF compare favorably
with those from other minimally invasive spine surgery
fusion procedures; duration of hospitalization is shorter
than with any previously reported technique. Complica-
tions are statistically more common if the L4/5 level is
treated operatively. Postoperative neural deficits were
extremely rare (< 0.7%), transient, and may be prevent-
ed by the preoperative administration of dexamethasone
(10 mg IV) before skin incision.
429

Sasso RC, Best NM, Mummanemi PV, et al (2005)

Analysis of operative complications in a series of 471
anterior lumbar interbody fusion procedures. Spine;
30(6):670–674.

Purpose
To compare the intraoperative and perioperative compli-
cations associated with the placement of threaded and
nonthreaded devices used in anterior lumbar interbody
fusions (ALIFs).
P Patient Patients suffering from lumbar DDD treated with ALIF

(N = 471)
I Intervention ALIF with threaded device (eg, cage or bone dowel)
C Comparison ALIF with nonthreaded device (eg, femoral ring)
O Outcome Acute intraoperative, postoperative, and overall compli-
cations
Association of complications with specific operative levels
Placement of threaded devices, such as cages or bone
dowels, was associated with a higher acute complication
rate than was the placement of nonthreaded devices dur-
ing anterior lumbar interbody fusion. There were sig-
nificantly more intraoperative complications when the
fusion was done at the L4/5 level as compared with the
L5/S1 level. The most common complication was intra-
operative vascular injuries.

4.3.3 The lateral approach to the lumbar spine
Daniel E Gelb
1 Historical perspective peripheral rim of the apophysis, the strongest part of the
endplate. Interbody cage placement can be performed
The evolution of adult spine surgery over the last several through a minimally invasive approach without mobiliza-
decades has witnessed an increasing reliance on lumbar tion of the great vessels. A thorough discectomy and release
fusion to treat various forms of spinal pathology. Surgical can be carried out to correct deformity. In conjunction with
techniques have developed in response to the need for a posterior instrumentation (which may also be placed via
reliable method of obtaining a solid arthrodesis. Posterior MIS), deformity correction can thus be maintained.
(interlaminar) and posterior lateral (intertransverse process)
fusion is a surgically challenging issue. Even with posterior The restoration of anatomical alignment combined with
instrumentation, pseudarthrosis rates in adult fusion pa- rigid stable internal fixation, and respect for and preserva-
tients are relatively high. Although pedicle screws are an tion of the blood supply to the surrounding soft tissues, are
effective tool in the correction of spinal deformity, this the hallmarks of the traditional AO technique. The lateral
technique has its limitations in maintaining deformity cor- approach to the lumbar spine embodies these tenets.
rection in cases of adult degenerative deformity. Posterior
arthrodesis with or without posterior instrumentation often The lateral approach to the lumbar spine developed as an
results in significant loss of correction, or in pseudarthrosis. offshoot of traditional open anterior lumbar interbody fu-
sion and minimally invasive laparoscopic techniques. Tra-
Lumbar interbody fusion has been successfully used to com- ditional open anterior lumbar interbody fusion limits the
pensate for some of the shortcomings of other surgical ap- ability to place an interbody device within the AP dimension
proaches to adult degenerative spinal pathologies including of the interspace. Minimally invasive techniques were de-
deformity correction. Unfortunately, traditional techniques veloped to reduce the need for extensive surgical dissection.
have certain significant limitations. The risk of iatrogenic However, although transperitoneal laparoscopic techniques
nerve root damage or epidural bleeding, and the limited allow for the placement of interbody devices without major
ability to place a large interbody structural support device surgical dissection, the approach to the disc space is still
have all been reported as drawbacks to the posterior lumbar from the front and the great vessels remain at risk. The
interbody fusion and transforaminal lumbar interbody fu- ability to control bleeding from the great vessels is limited,
sion techniques. Traditional anterior interbody fusion re- and significant hemorrhage can occur. Dissatisfaction with
quires an extensive surgical approach with high potential laparoscopic techniques thus led to the development of
morbidity. Significant bleeding from the great vessels, dam- mini-open surgical approaches [1]. Retroperitoneal mini-
age to the viscera, and postoperative hernia are among some open approaches were first developed to access the L4 and
of the potential complications associated with the anterior L5 disc spaces, and proved superior to laparoscopic tech-
exposure. niques [2].
An improved understanding of the role of spinal deformity The correct placement of a large interbody device with sub-
and its effect on the proper functioning of the spine has led stantial endplate contact and coverage is a theoretically
to a fuller awareness of the role of chronic deformity in the desirable but technically difficult undertaking. The greatest
development of back pain. Despite adequate decompression transverse diameter of the vertebral endplate is in the cor-
of the neural elements and even with a solid arthrodesis, onal plane. However, the trajectory for the insertion of such
spinal imbalance can result in persistent symptoms. a device necessitates a direct lateral approach. McAfee et al
[3] described the lateral laparoscopic approach to the spine
The lateral interbody fusion technique was developed in for BAK cage placement, with mobilization of the psoas
response to these challenges. It allows for the placement of muscle posteriorly. Subsequently, Bergey et al [4] reported
a large interbody structural support device, resting on the good results in a series of 21 patients that underwent a
431

Author Daniel E Gelb
lateral laparoscopic approach through the psoas muscle. Almost any pathology that requires anterior interbody fu-
This technique was utilized as early as 1996. Transversely sion at the midlumbar level can be addressed using the
oriented BAK cages were placed and supplemented with lateral approach. Degenerative pathologies are the most
pedicle screws. No vascular injuries were observed, although common indications for this technique, and include the
27% of patients complained of persistent groin or thigh following:
pain. • Painful disc degeneration requiring fusion
• Degenerative scoliosis
In 2003, Bertagnoli and Vazquez [5] reported on a transpsoas • Multiple levels can be addressed consecutively, as
lateral approach for the insertion of a prosthetic disc nu- needed. Thorough discectomy and release permit
cleus replacement device. Blunt dissection through the substantial deformity correction. The long transverse
psoas muscle was used to expose the lateral annulus of the diameter of the implant helps to level the disc space
disc. Eight patients underwent the procedure, with no sig- in the coronal plane
nificant surgical complications being reported. • Low-grade spondylolisthesis
• However, there has to be sufficient apposition be-
In 2006, Ozgur et al [6] reported on a mini-open technique tween adjacent vertebral bodies to support an im-
to the midlumbar spine from a direct lateral transpsoas ap- plant. Moreover, a significant amount of vertebral
proach utilizing electrophysiological monitoring to avoid body remodeling may render stable implant place-
nerve damage for the placement of structural interbody ment impossible
fusion cages. Their approach, which they termed “extreme • Symptomatic adjacent segment degeneration following
lateral interbody fusion”, was largely based on Pimenta’s previous posterior fusion
work [7], an account of which had first been published in • Foraminal stenosis secondary to disc space collapse, caus-
abstract form in 2001. Their technique, utilizing triggered ing radicular pain
electromyographic (EMG) nerve monitoring and a table- • Central or lateral recess stenosis
mounted split-blade retractor system, has become the stan- • Restoration of disc height may improve stenosis by
dard method for lateral access to the midlumbar spine. stretching and tensioning the posterior longitudinal
ligament and ligamentum flavum. However, the de-
gree of severity of stenosis that can be effectively
2 Terminology treated in this manner without formal posterior de-
compression remains unclear
In their 2006 report, as mentioned above, Ozgur et al [6] • Infectious discitis requiring debridement
coined the term “extreme lateral interbody fusion (XLIF)” • Epidural abscess may not be adequately addressed
to distinguish this approach from traditional open anterior by this technique.
interbody fusion. The term XLIF was trademarked by Nu-
vasive in 2005. With minor modifications, this technology It is not generally advisable to perform more aggressive
has been promoted by other commercial entities and is also procedures such as corpectomies using this technique. The
known as “direct lumbar interbody fusion (DLIF)” (Medtron- segmental vessels are not ligated during this approach and
ic) or “Oracle” (Synthes). All of these products share the the great vessels are not mobilized. There is a risk of sig-
common characteristics of direct lateral access through a nificant bleeding with more aggressive surgical procedures.
small incision using a table-mounted soft tissue retractor Relative contraindications include the following:
to place a long structural interbody device. This approach • Significant vertebral endplate irregularities
will be referred to as “transpsoas discectomy and fusion”. • High-grade spondylolisthesis
• Fracture/dislocation
• Significant vertebral body destruction or structural com-
3 Patient selection promise that render stable implant placement impos-
sible
The lateral approach can theoretically be performed at al- • Advanced vertebral osteomyelitis
most any level of the spine except L5/S1, where the iliac • Vertebral destruction secondary to metastatic disease
wing obstructs lateral access to the disc space. However, • High degree of instability
this approach is most commonly used for the midlumbar • A direct lateral approach can potentially be utilized
spine, ie, L2–4. Above this level, the ribs render access to in conjunction with posterior segmental instrumen-
the lateral spine more difficult. tation in certain situations.

The ultimate success of the reconstruction depends on there 5 Preoperative planning and positioning
being sufficient mechanical stability to maintain correction
and allow for eventual arthrodesis. Stand-alone implants Proper patient positioning is fundamental to a successful
may not have adequate stability, especially in cases of doc- procedure. Placement of the interbody device through a
umented preoperative instability such as spondylolisthesis. minimally invasive approach requires x-ray guidance to
Likewise, osteoporosis or violation of the vertebral endplate ensure that it has been placed safely and accurately. The
during disc-space preparation can lead to subsidence of the window for safe placement is fairly small, and narrows the
implant and loss of correction [8]. Although somewhat con- further the surgeon progresses distally. Regev et al [9] found
troversial, it is the author’s opinion that this technique that the safe corridor behind the great vessels and in front
should never be performed as a stand-alone procedure. of the exiting nerve roots, as measured on MRI, varied from
Either supplementary anterior or posterior instrumentation 48% of the vertebral body diameter (L2/3) down to as little
should be utilized to increase the stability of the reconstruc- as 13.1% (L4/5). The patient must be positioned appropri-
tion. Anterior instrumentation has been developed that can ately to ensure the best possible x-ray views, and the pro-
be implanted through the same surgical exposure. The au- cedure should not commence until the surgeon is able to
thor’s preferred method is to use posterior pedicle screw obtain adequate imaging. The patient is placed in the lat-
instrumentation, placed through a percutaneous technique, eral decubitus position. The spine may be approached from
in order to secure the reconstruction. Screws placed under either the right or the left side depending upon any scolio-
image intensifier control can be inserted while the patient sis that might be present (see below). Care should be taken
is still in the lateral position, but repositioning the patient that all bony prominences are adequately padded and that
into the more familiar prone position for screw insertion is the brachial plexus, ulnar nerve and peroneal nerve of the
recommended, and takes a minimal amount of time. In underside lower extremity are adequately protected. An
either case, the complete reconstruction is performed under axillary roll is placed beneath the chest and the head is
a single anesthetic and staged surgery is not necessary. supported in such a way that the neck is maintained in a
neutral position. The patient must be secured to the operat-
ing table in a manner that prevents movement during the
4 Pros and cons of the lateral approach to the surgical procedure, so that the orientation remains the same
lumbar spine for the surgeon. Large amounts of wide cloth tape are uti-
lized to secure the patient in position on the table (Fig 4.3.3‑1).
4.1 Pros
• Large surface available for fusion Any type of radiolucent operating table can be used. In
• Optimal implant size and position order to facilitate the exposure, the patient’s body is max-
• Adequate disc annulus release for deformity correction imally flexed laterally. This draws the lower ribs away from
• Great vessel mobilization not required the rim of the pelvis. It is easier to achieve this position on
• Does not require “access” surgeon a table that can be mechanically flexed. Otherwise, a radio-
• Low incidence of postoperative hernia lucent inflatable pillow should be placed under the patient’s
• Can be performed in obese patients. flank to achieve lateral flexion. A large inflatable IV pressure
bag serves the purpose well. In either case, it is important
4.2 Cons to ensure that the base of the table does not interfere with
• Limited visualization beyond the disc space the positioning of the image intensifier, and that good lat-
• Limited access for anterior instrumentation eral images of the spine can be obtained. Sometimes the
• Cannot address vertebral body-associated pathologies patient needs to be placed at the end of the operating table
• Risk of lumbosacral plexus injury with psoas dissection away from the pedestal in order to avoid interference with
• Inability to address pathologies below the iliac crest (L5/ the image intensifier. The patient should be secured to the
S1, L4/5 occasionally). table before his/her body is flexed laterally. This measure
will facilitate maximal lateral flexion, and prevent the pa-
tient from slipping on the table as it moves. Once the patient
has been securely positioned, image intensifier-based views
of the spine are obtained. It is important to obtain images
in true lateral and AP projections. The vertebral endplates
at the level to be treated should appear linear rather than
oval-shaped. The pedicles should be superimposed in the
433

a b
Fig 4.3.3-1a–b Patient positioning for the lateral approach.
The patient is secured to the table with a large quantity of wide tape, following which a radiolucent bolster is placed below the flank to maximally
stretch the lateral abdominal wall.
The operating table is positioned (Trendelenburg/reverse Trendelenburg) and rotated so that the disc space to be approached is perpendicular to
the floor, such that it appears completely neutral with no rotation on anterior-posterior and lateral images.
lateral projection. The spinous processes should be in the 6 Surgical technique

midline, and each pedicle equally spaced in the AP view. It
may be necessary to rotate the table from side to side, or 6.1 Access
into a Trendelenburg or reverse-Trendelenburg position in The surgical approach requires a retroperitoneal dissection
order to obtain these views. In general, it is preferable to down to the psoas muscle. The disc space to be treated is
adjust the position of the table rather than that of the image localized under image intensification. A small incision is
intensifier, leaving the latter in a neutral position (vertical made directly over the lateral aspect of the disc. For single-
or horizontal to the floor). Altering the position of the table level fusions, a transverse incision ensures the most cos-
rather than that of the image intensifier ensures the main- metic scar. When treating multiple levels, an oblique or
tenance of appropriate orientation during the surgical pro- even longitudinal incision can be utilized. The muscular
cedure. During multilevel procedures, the position of the layers of the body wall are split either sharply or by blunt
table will need to be readjusted for each operative level to dissection and the retroperitoneal space is entered. An ini-
ensure adequate visualization of each disc space to be treat- tial posterior paramedian incision just lateral to the tip of
ed. The procedure is performed under general anesthesia, the transverse process of the inferior vertebra can be utilized
and no special bowel preparation is needed. Muscle relax- to help locate the retroperitoneal space [6]. If a finger is
ants are avoided so that continuous EMG monitoring can inserted through this incision, it can provide the surgeon
be employed throughout. The flank is prepared and draped with guidance down through the lateral incision to avoid
in routine fashion. inadvertent violation of the peritoneal cavity. Once the
retroperitoneal space has been entered through the lateral
The surgeon and assistant stand by the patient’s back. The incision, blunt finger dissection is used down to the psoas
image intensifier is positioned on the opposite side. Con- muscle itself. A table-mounted, split-blade retractor is used
tinuous EMG monitoring is performed of the muscles of the to maintain the exposure during disc-space preparation and
ipsilateral lower extremity. cage insertion. Various manufacturers offer their own vari-
ations of this retractor type.

6.2 Microsurgical technique in order to potentially detect any traversing nerve roots and
Dissection through the psoas muscle must be performed protect them accordingly. Dissection through the muscle
with care taken to avoid damage to the nerves of the lum- proceeds as anteriorly as is feasible. The nerve roots are
bosacral plexus. Human anatomical specimen dissections more likely to be found in the posterior aspect of the mus-
have demonstrated that the nerve roots traveling to the leg cle [11] (Fig 4.3.3-2). The bulk of the muscle increases more
can be found throughout the substance of the psoas muscle. distally, and it becomes increasingly difficult to retract the
Even in the anterior half of the muscle belly, it is possible majority of the muscle posteriorly when performing the
to expose the nerve roots to risk during the procedure [10]. procedure at L4. Some authors prefer to start with the dis-
In addition to the nerves of the lumbosacral plexus, the section more anteriorly, and sweep the psoas muscle back.
genitofemoral nerve as well as the sympathetic nerve chain However, too anterior a dissection may put the great vessels
can be found in the operative field. Several options exist at at risk. Once the lateral aspect of the annulus has been
this point. Electrophysiological monitoring may be used in visualized, a guide wire is inserted into the disc space. Fol-
order to alert the surgeon to the presence of a nerve root lowing x-ray confirmation of this step, the retractor is then
within the field. Both spontaneous and triggered EMG replaced deep into the psoas muscle, directly onto the lateral
cordings of the lower extremity muscles can be helpful in annulus. Blunt dilators are used to maintain the opening
this regard. Spontaneous EMG activity can occur with me- in the psoas muscle as the retractor is lowered into place.
chanical stimulation of the nerve root. Triggered EMG has
been utilized to try to localize the nerve roots in the psoas The stimulating probe or guide wire should be placed in the
muscle. No data exist, however, regarding the safety thresh- center of the disc space in the lateral projection, and the
olds for triggered responses. guide wire should be positioned parallel to the disc space
in the AP projection. This ensures that the retractor will be
Using a stimulating electrode under image intensifier guid- placed in an appropriate position. If the retractor is placed
ance, the surgeon places the probe onto the lateral aspect obliquely to the disc space, it may be difficult to insert the
of the disc space and then inserts a series of graduated dila- interbody device without damage to the vertebral endplates;
tors to bluntly dissect the psoas muscle. An alternative strat- if this were to occur, it could result in later subsidence. The
egy is to place a retractor above the psoas muscle, and then interbody device needs to rest on the intact endplates in
gently dissect through the muscle under direct visualization order to maintain the correction of scoliosis and lordosis.
It is acceptable for the guide wire to be slightly anterior to
the mid-aspect of the disc space on the lateral view. How-
ever, if guidewire placement is too anterior, it can result in
damage to the anterior longitudinal ligament or even to the
great vessels during preparation of the disc space and place-
ment of the interbody device. Damage to the anterior lon-
Ilioinguinal nerve gitudinal ligament can lead to displacement of the interbody
Iliohypogastric nerve cage anteriorly.
L5 Genitofemoral
A table-mounted, split-blade retractor is used to maintain
L4
L3 the exposure during disc-space preparation and cage inser-
tion. In addition to anchoring the retractor to the table, it
L2
L1 is advantageous to attach the retractor to the spine itself in
some manner. This prevents movement of the retractor
during the next step of the procedure. Some retractors pro-
vide for a shim on one of the blades, which projects di-
rectly into the disc space. Others allow for the blades to be
Femoral nerve Obturator nerve Lateral femoral
fixed to the bone of the vertebral body with pins or screws.
cutaneous nerve
Either alternative is acceptable. A flexible fiber optic light
Fig 4.3.3-2 Position of the lumbar nerve roots within the psoas source can be useful. Alternatively, an operating microscope
muscle. can provide magnification and illumination into the deep-
er parts of the wound. This can be helpful in identifying
nerve roots, and has also been proven advantageous for
teaching purposes.
435

6.3 Navigation 7 Postoperative care

Intraoperative image intensification is used for this proce-
dure, as described above, and is essential for positioning, Postoperatively, the patient may be mobilized as soon as
accurate planning of the incision and access with the split- he/she is sufficiently comfortable, usually on postoperative
blade retractor. Image intensification is used to achieve true day 1. Postoperative bracing is not required, especially if
AP and lateral orientation, with adequate positioning and supplemental fixation has been utilized. Since this approach
rotation of the patient using the operating table. Three- can be rapidly performed, if further surgery is needed it can
dimensional stereotactic navigation has been employed by generally be carried out under the same anesthetic, and the
some surgeons (personal communication), but its use needs author has not found it necessary to stage the procedure.
to be further explored. Routine hospital discharge can be anticipated one or two
days postsurgery for most procedures. However, posterior
6.4 Implants and instrumentation treatment involving open surgery, if necessary in conjunc-
Once the exposure has been obtained, a thorough discec- tion with the lateral approach, will dictate the length of
tomy is performed under image intensifier control. A gen- stay. In general, patients are rapidly able to return to normal
erous lateral annulectomy is created, following which the activity, but specific restrictions may be imposed at the dis-
disc space is completely evacuated with a combination of cretion of the surgeon to allow for fusion healing to take
curettes and rongeurs. Specific disc preparation instruments place.
are available. Graduated disc spreaders help to restore disc
height. Reamers can efficiently evacuate disc tissue. It is
important to work completely across the disc space and 8 Evidence-based results
even through the annulus on the opposite side to ensure
that sufficient release is obtained to correct any existing Published reports on the use of this lateral approach to the
scoliosis. Care should be taken to maintain the vertebral lumbar spine have demonstrated its efficacy in terms of the
endplates in order to prevent possible subsidence of the technical ability to place cages. However, some initial stud-
graft later on. The size of the disc space is determined, and ies have reported complications associated with the proce-
the appropriate implant chosen. The implant should fill the dure [8, 12]. The largest prospective series to date included
disc space completely from side to side. Implant size and 107 patients that underwent a transpsoas approach for de-
geometry vary according to the manufacturer. Most implants generative scoliosis [13]. This approach has also been suc-
are made out of plastic, but allografts can also be used. The cessful in a series of patients over 70 years of age [14]. How-
implant can be filled with the surgeon’s choice of material ever, no large series are yet available on outcomes
to help promote fusion. The insertion of a lateral plate and following this technique compared to other, more tradi-
screws for single-level instrumentation is also possible tional approaches. The specific advantages and disadvan-
through the same incision. Various plates have been devel- tages of the lateral approach compared to other interbody
oped for this purpose (for example, the anterior tension techniques have not yet been fully established.
plate Fig 4.3.3-3).
9 Complications and avoidance
The importance of secure patient positioning and adequate

x-ray imaging cannot be overemphasized. The exposure is
small, and provides the surgeon with a limited view of the
spine. It is relatively easy to become disoriented and stray
outside the safe bounds of the surgical field. The segmental
arteries lie at the mid-portion of the vertebral bodies. The
exposure should stay close to the vertebral endplates to
avoid inadvertent damage to and bleeding from these arter-
ies. Likewise, dissection that is too anterior can result in
damage to the inferior longitudinal ligament (compromis-
ing the stability of the implant) or even to the great vessels.
Fig 4.3.3-3 Anterior tension plate.

The other major drawback of this procedure is the risk of cle or protect the nerve behind a smooth retractor blade
postoperative ipsilateral groin and thigh pain as the result during disc space preparation. Up to 8% of patients may
of damage to the lumbosacral plexus of the nerves as they experience persistent thigh pain and weakness following
traverse from the neural foramen to the pelvis. Moro et al surgery, but in most cases this will resolve within a few
[15] performed a human anatomical study in an attempt to weeks [12]. Youssef et al [16] noted only one case of psoas
determine the safety zone for traversing the psoas muscle. weakness out of 84 patients that underwent transpsoas dis-
These authors found that the lumbosacral nerve roots were cectomy and fusion at two different institutions. As previ-
at risk progressively more anteriorly as they advanced dis- ously noted, the largest prospective series to date involved
tally from L2 to L4. Occasionally, even quadriceps weakness 107 patients that underwent the transpsoas approach for
can occur. A certain amount of pain in the groin is probably degenerative scoliosis [13]. An average of 4.4 levels were
related to the dissection of the psoas muscle. It is also pos- treated per patient, with significant transient motor weak-
sible to cause injury to the lumbosacral nerve roots during ness observed in 6.5% of cases. In another study [17], out of
the dissection procedure. Neurophysiological monitoring of 59 patients that underwent transpsoas surgery, 62.7% de-
the quadriceps muscles with both free-running and triggered veloped thigh symptoms postoperatively, and weakness was
EMG responses is recommended in this regard. Dissection noted in 23.7% of cases. At 3 months postsurgery, weakness
through the psoas muscle under direct visualization is also was still reported in 11.3% of patients. In conclusion, patients
possible. If a nerve root is encountered during dissection, should be advised at a preoperative stage that the surgical
the surgeon can choose a different plane through the mus- procedure involves the risk of transient motor weakness.
10 Tips and tricks
Luiz Pimenta, São Paolo, Brazil • It is possible to access the L4/5 disc space • Interbody cage positioning can be chosen
• Lateral interbody fusion generates disc if the surgeon respects two major points: according to surgical objectives: a little
height gain, and through ligamentotaxis electrophysiological monitoring and pa- more posterior for powerful indirect de-
is able to provide indirect decompres- tient positioning. compression or a little more anterior for
sion. However, hypertrophic/blocked • Additionally, hip flexion will result in segmental sagittal correction.
facets and/or small pedicles may be a relaxation of the psoas muscle and pro- • The lateral access has been recently
contraindication. vide less tension on the lumbar plexus, shown to allow the safe performance of
• Accurate patient positioning is one of the thus less risk of nerve damage. vertebral corpectomies after trauma.
key points of the procedure. An articu- • Avoid moving the retractor around too • Stand-alone procedures without addi-
lated table must be available to perform much inside the psoas muscle. If a good tional posterior instrumentation can be
proper lateral flexion, moving the iliac retractor position cannot be achieved, it performed as a simple and effective op-
crest away from the surgical route. is better to remove the retractor, reposition in patients with good quality bone
• To achieve the maximum result and en- tion and redilate. without any sign of instability at the in-
sure risk avoidance, it is imperative to • Although the procedure has a relatively dex spine level.
respect nerve monitoring and the surgi- small working portal, excellent 3-D vi-
cal learning curve. sualization can be achieved with fiber
optic illumination.
437

11 Case examples noninsulin-dependent diabetes, and high cholesterol levels.

Fig 4.3.3-4 shows AP and lateral views displaying degenerative
11.1 Case 1: degenerative scoliosis scoliosis, but with preserved lumbar lordosis. The disc heights
A 69-year-old woman suffered from 15 months of severe at L3/4 and L4/5 were well preserved. The patient underwent
low back pain radiating into her left groin. The pain started two-level anterior fusion L1–3 through a left-sided lateral
without a history of previous trauma, and primarily affected approach followed by posterior percutaneous instrumenta-
the buttock and groin. The patient had been treated by phys- tion. Fig 4.3.3-5 shows the postoperative result, with correc-
ical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), tion of the scoliosis and restoration of disc-space height. The
and multiple injections without relief of symptoms. Medical patient’s preoperative symptoms were no longer apparent,
history was positive for myocardial infarction, hypertension, and pain relief was observed.
a b a b
Fig 4.3.3-4a–b AP (a) and lateral (b) views displaying degenerative Fig 4.3.3-5a–b Postoperative AP (a) and lateral (b) views showing
scoliosis but with preserved lordosis. correction of scoliosis and restoration of disc height.

11.2 Case 2: adjacent segment degeneration with stage revision surgery would have required an extensive
instability approach to remove the old pedicle screws and extend the
A 62-year-old woman presented with 1 year of persistent instrumentation proximally. Scarring from previous surgery
back and right leg pain. She had undergone an L5/S1 pos- would have made dissection difficult with considerable blood
terior interbody fusion 11 years previously with good results loss. Instead, the patient underwent an L4/5 fusion through
until recently. Pain had progressively increased, to become a left lateral approach with cage placement in conjunction
sharp and burning. The pain radiated in the L5 region and with an anterior plate to reduce and stabilize the spondy-
was associated with numbness and a subjective sense of lolisthesis (Fig 4.3.3-7). Despite the fact that no formal de-
weakness. The patient had received physical therapy, chi- compression was performed, the patient’s preoperative leg
ropractic, and NSAIDs, without beneficial results. X-ray pain was completely relieved. However, some left thigh
examination demonstrated spondylolisthesis at L4/5 above pain and weakness was experienced postoperatively, which
previous well-placed instrumentation (Fig 4.3.3-6). Second- resolved within 3 months of surgery.
a b a b
Fig 4.3.3-6a–b Preoperative AP (a) and lateral (b) x-ray views Fig 4.3.3-7a–b Postoperative AP (a) and lateral (b) views showing
showing spondylolisthesis at L4/5 above previous well-placed L4/5 fusion via cage placement in conjunction with an anterior plate to
instrumentation. reduce and stabilize the spondylolisthesis.
439

12 Key learning points • Careful annular release and maintenance of endplate

integrity are necessary to avoid cage subsidence
• Preoperative patient positioning and x-ray assessment • Supplemental fixation is recommended to secure cage
in the operating room are crucial to the success of the placement. Either anterior or posterior instrumentation
procedure can be utilized
• Direct visualization of the spine is limited. Liberal use • Postoperative thigh pain and weakness are the most
of intraoperative image intensification is mandatory common complications encountered, but usually resolve
• Dissection through the psoas muscle should be performed within a few weeks. Patients should be advised preop-
as anteriorly as possible, under direct visualization and/ eratively regarding this.
or with intraoperative neuromonitoring to prevent dam-
age to the lumbosacral plexus
13 References
1. Brau SA (2002) Mini-open approach to 7. Pimenta L (2001) Lateral endoscopic 13. Isaacs RE, Hyde J, Goodrich JA, et al
the spine for anterior lumbar interbody transpsoas retroperitoneal approach for (2010) A prospective, nonrandomized,
fusion: description of the procedure, lumbar spine surgery. VIII Brazilian multicenter evaluation of extreme
results and complications. Spine J; Society Congress on Spine Pathology, May lateral interbody fusion for the
2(3):216–223. 2001. Belo Horizonte, Brazil. treatment of adult degenerative
2. Zdeblick TA, David SM (2000) A 8. Sharma AK, Kepler CK, Girardi FP, et scoliosis: perioperative outcomes and
prospective comparison of surgical al (2011) Lateral lumbar interbody complications. Spine; 35 Suppl
approach for anterior L4–L5 fusion: fusion: clinical and radiographic 26:S322–S330.
laparoscopic versus mini anterior outcomes at 1 year: a preliminary 14. Karikari IO, Grossi PM, Nimjee SM, et
lumbar interbody fusion. Spine; report. J Spinal Disord Tech; 24(4):242– al (2011) Minimally invasive lumbar
25(20):2682–2687. 250. interbody fusion in patients older than
3. McAfee PC, Regan JJ, Geis WP, et al 9. Regev GJ, Chen L, Dhawan M, et al 70 years of age: analysis of peri- and
(1998) Minimally invasive anterior (2009) Morphometric analysis of the postoperative complications.
retroperitoneal approach to the lumbar ventral nerve roots and retroperitoneal Neurosurgery; 68(4):897–902.
spine: emphasis on the lateral BAK. vessels with respect to the minimally 15. Moro T, Kikuchi S, Konno S, et al
Spine; 23(13):1476–1484. invasive lateral approach in normal and (2003) An anatomic study of the
4. Bergey DL, Villavicencio AT, deformed spines. Spine; 34(12):1330– lumbar plexus with respect to
Goldstein T, et al (2004) Endoscopic 1335. retroperitoneal endoscopic surgery.
lateral transpsoal approach to the 10. Banagan K, Gelb D, Poelstra K, et al Spine; 28(5):423–428; discussion
lumbar spine. Spine; 29(15):1681–1688. (2011) Anatomic mapping of lumbar 427–428.
5. Bertagnoli R, Vazquez RJ (2003) The nerve roots during a direct lateral 16. Youssef JA, McAfee PC, Patty CA, et
anterolateral transpsoatic approach transpsoas approach to the spine: a al (2010) Minimally invasive surgery:
(ALPA): a new technique for cadaveric study. Spine; 36(11):E687– lateral approach interbody fusion:
implanting prosthetic disc-nucleus E691. results and review. Spine; 35 Suppl
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404. al (2010) Defining the safe working 17. Cummock MD, Vanni S, Levi AD, et al
6. Ozgur BM, Aryan HE, Pimenta L, et al zones using the minimally invasive (2011) An analysis of postoperative
(2006) Extreme lateral interbody fusion lateral retroperitoneal transpsoas thigh symptoms after minimally
(XLIF): a novel surgical technique for approach: an anatomical study. invasive transpsoas lumbar interbody
anterior lumbar interbody fusion. Spine J Neurosurg Spine; 13(2):260–266. fusion. J Neurosurg Spine; 15(1):11–18.
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Cummock MD, Vanni S, Levi AD, et al (2011) An Knight RQ, Schwaegler P, Hanscom D, et al (2009)
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Therapy Case series IV Therapy Case series with historical IV
control group
Purpose
To better understand the relationship between the min- Purpose
imally invasive transpsoas fusion procedure and postop- To assess patient demographics and adverse events re-
erative thigh symptoms. Specifically, to analyze the lated to direct lateral lumbar approach during hospital
prevalence and survival of postoperative thigh pain, stay or within 6 weeks of discharge.
numbness, paresthesias, and weakness when stratified
by lumbar site and number of levels fused. P Patient Patients with degenerative conditions (N = 58, 43 women,
mean age 61 years)
P Patient Patients with lumbar spine pathologies (spondylotic disease, I Intervention Lateral lumbar interbody fusion (n = 58)
degenerative scoliosis, spondylolisthesis, pseudarthrosis,
C Comparison Open posterior spinal fusion (historical control group)
degenerative disc disease, compression fracture, and remo-
val of cage instrumentation from previous interbody fusion O Outcome Adverse events, estimated blood loss, operative time
procedures) (N = 59)
I Intervention Minimally invasive transpsoas lumbar interbody fusion Authors’ conclusion
C Comparison No comparison group Major adverse events approximated 8.6% with approach-
Outcome Pain chart, numbness, paresthesias, and weakness of
related complaints of nerve irritation nearing 3.4%. Mild
O
iliopsoas and quadriceps muscles. complications occurred in 13.7% of patients. Meralgia
paresthetica was a primary approach-related complaint.
Authors’ conclusion Most complaints significantly reduced by the first post-
Transpsoas interbody fusion is associated with high rates operative visit. One patient (1.7%) had symptoms lasting
of immediate postoperative thigh symptoms. While larg- over a year that did not adversely affect function. Sig-
er, prospective studies are necessary to validate these nificant findings related to exposure, that is, 1- versus
findings, the authors found that half of the patients had 2-level cases. Overall morbidity reduction noted by esti-
symptom resolution at approximately 3 months postop- mated blood loss is considerably less when compared with
eratively and more than 90% by 1 year. the historical cohort. Direct lateral lumbar interbody fu-
sion has proven to be of value.
441

Isaacs RE, Hyde J, Goodrich JA, et al (2010) A Karikari IO, Grossi PM, Nimjee SM, et al (2011)
prospective, nonrandomized, multicenter evaluation of Minimally invasive lumbar interbody fusion in patients
extreme lateral interbody fusion for the treatment of older than 70 years of age: analysis of peri- and
adult degenerative scoliosis: perioperative outcomes and postoperative complications. Neurosurgery; 68(4):897–
complications. Spine; 35 Suppl 26:S322–S330. 902; discussion 902.
Purpose Purpose
To compile perioperative measures to identify the short- To identify and describe perioperative and postoperative
term results and complications of the procedure. complications in patients 70 years and older who have
undergone minimally invasive lumbar interbody spinal
P Patient Patients with degenerative scoliosis (N = 107, mean age 68 fusion.
years, range 45–87)
I Intervention Extreme lateral interbody fusion (XLIF) with or without P Patient 66 Patients ≥ 70 years (mean age 74.9 years, range 70–86)
supplemental posterior fusion undergoing lumbar interbody fusion procedures (N = 68
Comparison No control group cases)
C
I Intervention Extreme lateral interbody fusion (n = 41) and minimally
O Outcome Surgical procedural details, operative time, estimated blood
invasive transforaminal lumbar interbody fusion (n = 27)
loss, surgical and postoperative complications, length of
hospital stay, and neurological status C Comparison No control group
O Outcome Perioperative and postoperative complications, procedures,
Authors’ conclusion and patient demographics
The morbidity in adult scoliosis surgery is minimized with
less invasive techniques. The rate of major complications Authors’ conclusion
in this study (12.1%) compares favorably to that report- Minimally invasive interbody fusions can be performed
ed from other studies of degenerative deformity surgery. in the elderly (ages 70 years and older) with an overall
low rate of major complications. Graft subsidence in this
population when not supplemented with posterior in-
strumentation is a concern. Age should not be a deterrent
to performing complex minimally invasive interbody fu-
sions in the elderly.

Sharma AK, Kepler CK, Girardi FP, et al (2011) Lateral Youssef JA, McAfee PC, Patty CA, et al (2010)
lumbar interbody fusion: clinical and radiographic Minimally invasive surgery: lateral approach interbody
outcomes at 1 year: a preliminary report. J Spinal Disord fusion: results and review. Spine; 35 Suppl 26:S302–S311.
Tech; 24(4):242–250.
Study type Study design Class of evidence Therapy Case series with historical IV
Therapy Case series IV control
Purpose
Purpose
To analyze the outcomes from historical literature and
To assess the x-ray change in the coronal and sagittal
from a retrospectively compiled database of patients hav-
plane alignment of the lumbar spine after the lateral lum-
ing undergone anterior interbody fusions performed
bar interbody fusion (LLIF) approach using XLIF cages
through a lateral approach.
and additionally, to describe x-ray and clinical outcomes,
and complications associated with the approach. Patient Patients treated with anterior lumbar interbody fusion using
P
a minimally invasive lateral retroperitoneal approach (N
P Patient Patients with lumbar degenerative disc disease, spondylolis- = 84)
thesis, or de novo scoliosis (N = 43)
I Intervention Extreme lateral interbody fusion (XLIF)
I Intervention LLIF procedure
C Comparison 14 peer-reviewed articles reporting outcomes and complica-
C Comparison No control group tions after XLIF
O Outcome X-ray measurements, complications, patient outcome O Outcome Operating room time, estimated blood loss, length of
hospital stay, complications, and fusion rate
The LLIF approach is effective in correcting the coronal Authors’ conclusion
plane deformity and in gaining lordosis at individual in- Current data corroborates and contributes to the existing
strumented levels. Implant insertion will parallelize ad- body of literature describing XLIF outcomes. Procedures
jacent endplates to correct the lumbar scoliotic curves. are generally performed with short operating room times,
Complications are mostly approach-related and transient. minimal estimated blood loss, and few complications.
Patients recover quickly, requiring minimal hospital stay,
although transient hip/thigh pain and/or weakness is
common. Long-term outcomes are generally favorable,
with maintained improvements in patient-reported pain
and function scores as well as x-ray parameters, including
high rates of fusion.
443


4.3.4 Deformity correction using minimally invasive spine
surgery techniques
Neel Anand, Eli M Baron, Sheila Kahwaty
1 Historical perspective a retroperitoneal dissection. This technique involves a true

anterior approach to the lumbar spine, and provides an
Adult deformity remains a challenging field for spine sur- alternative to laparoscopic transperitoneal ALIF and open
geons. Given the age and often associated medical comor- approaches. At 2-years follow-up a 92% fusion rate, with
bidities in persons undergoing surgery, treatment can be 78% of patients reporting significant pain relief of more
particularly challenging [1]. Historically, surgical complica- than 50%, was reported. They noted a conversion rate of
tions have been reported in the range of 20–80% in patients 16.8% in a total of 202 patients.
undergoing open treatment for lumbar degenerative sco-
liosis [2–4]. Additionally, medical complications occurring Mayer [17] described a novel approach to the lumbar spine
in such patients undergoing adult deformity surgery have where an approach anterior of the psoas muscle was per-
been reported in as many as 70% of cases [5]. Further, aver- formed to access lumbar discs and perform fusion from
age blood loss for open adult deformity fusion and correc- L1–5. A large quadrilateral retraction frame was used, with
tion surgery has been reported at 1.5 liters, ranging from 60% of patients describing their results as excellent.
360–7,000 ml [6, 7].
McAfee et al [18] first described a minimally invasive lat-
Given these statistics, a less invasive approach to defor- eral endoscopic retroperitoneal approach to the lumbar spine
mity surgery is desirable. For this strategy to be accepted, for discectomy and fusion. These authors used either a bal-
it must result in similar clinical and x-ray outcomes with loon to develop the retroperitoneal space, or CO2 insuffla-
fewer complications, if possible [8]. Minimally invasive spine tion. Bergey et al [19] later reviewed their experience with
surgery (MISS) is theoretically associated with less tissue this approach. It was developed to reduce the risk of vas-
damage and blood loss, thus resulting in lower morbidity cular injury and retrograde ejaculation associated with an-
than traditional open spinal surgery [9–11]. The authors terior approaches for insertion of the BAK cage. While
have used a combination of three minimally invasive tech- technically feasible, this technique required both image
niques in the setting of deformity to achieve deformity cor- intensification and specialized endoscopic equipment to
rection and fusion. These include transpsoas discectomy perform discectomy and fusion. Additionally, the endo-
and fusion, transsacral discectomy and fusion, and percu- scopic equipment had similar learning curves to laparos-
taneous screw and rod placement. copy. It was rather cumbersome compared to that used for
the more modern technique of transpsoas discectomy and
Transpsoas discectomy and fusion builds upon the earlier fusion as described by Ozgur [20], a variant of which is de-
experiences where minimally invasive approaches were at- scribed here in section 6 Surgical techniques.
tempted for anterior lumbar interbody fusion (ALIF). Dur-
ing the 1990s, laparoscopic ALIFs were performed. While The transsacral approach was described by Cragg et al [21]
technically feasible, it was questioned whether any sig- where the anatomical corridor was successfully used for
nificant benefit was achieved by these minimally invasive lumbosacral biopsy in three patients. This was further de-
techniques [12–14]. Additionally, several authors suggested veloped into a minimally invasive technique where discec-
that laparoscopic ALIF was associated with a significantly tomy and fusion could be readily performed [22]. Consider-
higher complication rate than open or mini-open ALIF [15]. able experience exists using transvertebral strut grafting in
the setting of high-grade spondylolisthesis [23–25], which
Thalgott et al [16] described a gasless endoscopic approach also influenced the development of a minimally invasive
to the lumbar spine, where a balloon was used to perform transsacral approach.
445

Authors Neel Anand, Eli M Baron, Sheila Kahwaty
Percutaneous pedicle screw instrumentation was first used 3.2 Contraindications

in the trauma setting with external fixators [26–28]. Although • Patients with kyphotic deformities are generally treated
percutaneous pedicle screw placement had been used in a using traditional open methods in order to facilitate the
limited fashion by others, Foley and Gupta [29] described a performance of osteotomies
device allowing the straightforward placement of a rod us- • It is not recommended to use this surgical approach for
ing geometric principles and a rod insertion device that treating patients with higher-grade lytic spondylolisthesis
linked to the screw insertion sleeves. Minimally invasive • The presence of osteoporosis should be ruled out; in gen-
pedicle screw insertion for the correction of multilevel de- eral, a T-score of > -2 is used as an inclusion criterion.
formity was described by Anand et al [8, 9], where the free-
hand passage of a rod was performed in up to eight segments
in the setting of scoliosis. 4 Pros and cons of deformity correction using
minimally invasive spine surgery techniques
2 Terminology 4.1 Pros

• Reduced tissue trauma, and subsequently less blood loss
In 2006, Ozgur et al [20] reported their results in 13 patients and need for hospital intensive care stays commonly
using an extreme lateral transpsoas approach for interbody seen after deformity correction
fusion, and tubular retractors. They termed this approach • Soft-tissue structures are better preserved, with theo-
“extreme lateral interbody fusion”. With minor modifica- retically less pain and improved postoperative func-
tions, this technology has been promoted by commercial tional outcomes than with open approaches
entities and is also known as the “XLIF”, “DLIF”, or “Oracle” • Iliac fixation is not routinely used, as the authors have
approach. The general principle, however, is similar for all found the transsacral discectomy and fusion technique
these techniques: direct lateral access through a small inci- to provide very rigid lumbosacral fixation (see also
sion using tubular soft-tissue retractors to perform a trans- chapter 4.3.5 Transsacral fixation). If using iliac fixation
psoas translumbar discectomy and fusion. This approach on revision cases, the authors use the S2 alar-iliac tech-
will subsequently be referred to as “transpsoas discectomy nique, which can be performed in a minimally invasive
and fusion”. fashion [31].
The transsacral approach for lumbar fusion utilizes the pre- 4.2 Cons
sacral space, which is generally filled with fat and connec- • Kyphotic deformities may be more readily corrected with
tive tissue. In the literature, it has also been termed “axial traditional approaches
lumbar interbody fusion” (AxiaLIF) [30]. • High-grade spondylolisthesis and retroperitoneal scar-
ring or rectal region scarring may contraindicate such
an anterior approach
3 Patient selection • Increased radiation exposure, particularly for the sur-
geon. However, as neuronavigation techniques improve
3.1 Indications and become more widespread, this may become less of
• Patients with deformity, who have exhausted nonop- a concern in the future.
erative treatment of their back pain and radiculopathy,
are candidates for minimally invasive deformity correc-
tion 5 Preoperative planning
• They have already been treated by physical therapy,
injections, and, in many cases, alternative medicine mo- For all patients that are to undergo minimally invasive de-
dalities, such as acupuncture and chiropractic care formity correction, 36” anteroposterior (AP) and lateral
• Most patients to be treated by this approach have lum- standing x-rays are obtained. In cases of large idiopathic
bar degenerative scoliosis, but adult idiopathic scoliosis curves, lateral bending films are also taken. MRI and CT
can also be treated in this way scans are also obtained. In cases of suspected osteoporosis,
• Patients with up to grade I spondylolisthesis. the use of dual-energy x-ray absorptiometry is a consider-
ation. The authors prefer to include patients with bone
density T-values > -2.

4.3.4 Deformity correction using minimally invasive spine surgery techniques
In all cases where a transsacral approach is planned, pre- spine). Typically, this approach is applied to the inferior
operative MRI of the pelvis (or sacrum) is obtained to rule thoracic and lumbar disc spaces, excluding L5/S1. Patients
out the presence of midline vascular structures that would are often excluded from this procedure due to adhesion
prohibit the procedure. Contraindications to the transsacral formation if they have previously undergone massive ab-
approach include high-grade spondylolisthesis, previous dominal surgery.
surgery in this region, a history of prior colostomies, or
pathologies in the region of the rectum, such as fistulas. If 6.1.1 Positioning
any of these exist or a severe compressive pathology such For the procedure, the authors prefer to position the patient
as a large disc herniation is present, then minimally invasive on a Skytron operating table in the right lateral recumbent
transforaminal lumbar interbody fusion (TLIF) could be position, exposing the patient’s left side. The surgeon tries
considered. Contraindications for the transpsoas approach to keep the left side facing upwards, as this minimizes the
include high-grade spondylolisthesis, a very low seated L4–5 risk to the venous structures, especially in the case of de-
disc, or prior retroperitoneal surgery [20]. If the L4–5 seg- formity as venous damage could be catastrophic. A key
ment appears inaccessible via the transpsoas route, perform- factor in patient positioning is to keep the spine as orthog-
ing a two-level transsacral fusion should be considered. onal to the ground as possible. A kidney rest is elevated just
above the level of the iliac crest. This maximizes the distance
between the rib cage rostrally and the iliac crest caudally.
6 Surgical technique Additionally, an axillary roll is placed in position and the
left arm is secured on an airplaned arm rest. Rolled towels
The basic techniques used for minimally invasive defor-
mity correction and fusion have been described elsewhere
[9]. All patients undergoing deformity corrective surgery
have exhausted conservative measures prior to considering
surgical correction of the deformity (Fig 4.3.4-1). The authors
use a combination of three techniques in their surgical can-
didates: the lateral transpsoas approach to the thoracolum-
bar spine with radical discectomy and fusion; the transsacral
approach to L5–S1 and occasionally L4–5; and multilevel
percutaneous pedicle screw fixation. In order to perform
these techniques, excellent x-ray visualization and a thor-
ough anatomical knowledge of spinal structures are manda-
tory in the operating room.
In terms of which segments to include in the construct, all

levels in the Cobb angle are included. The authors end at
the first parallel disc that appears reasonably well preserved
on MRI, even if it is L1 or T12. This differs from the dictum
used in open surgery of ending at T10 when crossing the
thoracolumbar junction [32]. In terms of deciding to stop at
L5 versus the sacrum, the authors follow the criteria de-
scribed by Bridwell [33]. Factors to consider are the antici-
pated neutral, stable, and horizontal vertebrae, the health
of the discs above and below the anticipated fusion site, and
the anticipated end vertebra relative to the sagittal plane.
In the adult patient with lumbar degenerative scoliosis, the
point of distal termination is usually L5 or S1.
a b
6.1 Transpsoas discectomy and fusion
Fig 4.3.4-1a–b AP and lateral 36” standing x-rays of a 65-year-old
The transpsoas approach for radical discectomy and lumbar woman with severe back pain and leg pain in whom conservative
interbody fusion has been described elsewhere [10, 20, 34] measures failed, showing a 35° degenerative curve from T12 to L5 with
(see also chapter 4.3.3 The lateral approach to the lumbar an apex to the left at L2/3.
447

attached with tape are used as bolsters on either side of the transpsoas procedure. Additionally somatosensory evoked
patient’s torso, then strapping tape is used to secure the potential monitoring is routinely performed.
patient to the table. Towels may be placed under the strap-
ping tape in order to avoid irritation to the skin. The top 6.1.2 Procedure
hip is flexed in order to achieve laxity of the psoas muscle. A scalpel is used to incise the skin. Subcutaneous bleeders
A pillow is placed under the bottom leg and between the are gently cauterized using Bovie electrocautery. The sur-
legs in order to pad the fibula and prevent peroneal nerve geon's gloved finger descends through the most caudal
palsy. Strapping tape is used on the top leg in a cruciate level to enter the retroperitoneal space. The finger enters
manner to secure the patient in the operative position posteriorly on the inside of the iliac crest and sweeps along
(Fig 4.3.4-2). the inside, persuading the peritoneum and its contents an-
teriorly. The finger is then extended cephalically to palpate
After positioning the patient, a C-arm is brought in and, the transverse process and the undersurface of the 12th rib,
using lateral image intensification, incisions are planned confirming clearance of the retroperitoneal space.
(centered over the relevant disc spaces). For the initial sur-
gical procedures, a posterior incision is planned, through Then, under lateral image intensifier guidance, a PAK nee-
which the retroperitoneum would be accessed with the dle is brought down to the level of the psoas muscle. The
surgeon’s gloved finger in order to escort percutaneous ac- PAK needle is controlled with the right hand, while the
cess kit (PAK) needles down to the level of the psoas. Now- needle tip is escorted by the surgeon’s left hand, in order
adays, however, it is recommended to use only one incision to avoid visceral or vascular injury. Neuromonitoring is
at each target level to access and develop the retroperito- continuously used during the passage of the needle through
neal space. Under image intensification, the authors target the psoas into the disc space. The authors use continuous
the junction between the anterior and middle third of the real-time EMG monitoring. If any signal is noted, they
disc space on the skin, and mark the skin at all relevant stimulate at 6 mA to obtain a triggered EMG response. If
levels. After localizing this junction, oblique incisions run- positive, the direction of the needle is redirected appropri-
ning with the grain of the external abdominal oblique ately. A Kocher clamp is used to hold the PAK needle in
muscle are planned and marked. One incision is sufficient place while imaging in order to avoid radiation to the op-
for two disc space levels. The patient is then prepared and erator's hand. Once the position has been confirmed and
draped in the usual manner. The L4–5 level incision is used neuromonitoring is safe, the PAK needle is docked into the
to develop the retroperitoneal space as described below. disc and a guide wire is placed through the PAK needle into
the disc space (Fig 4.3.4-3).
In terms of anesthesia for this technique, the authors avoid
paralytics as triggered and free running electromyography Under AP image intensification, serial dilators are placed
(EMG) are used to monitor neural irritation during the over the guide wire and advanced to the disc space. Through-
Fig 4.3.4-2 Positioning for the DLIF procedure. Note the elevated Fig 4.3.4-3 Lateral image intensifier view showing targeting of the
kidney rest, the taping and the position of the left arm. L2/3 disc space with a PAK needle. Note that the junction between the
anterior and middle third of the disc is targeted. Direct lateral interbody
fusion has already been performed at L4/5 and L3/4.

out this process, each dilator is monitored with free-running the risk of entering the thoracic cavity. However, at T12/L1
and triggered EMG. The length of the tubular retractor is and above, the thoracic cavity is usually accessed between
determined from the last dilator and a corresponding retrac- the ribs. While passing the PAK needle into the thoracic
tor is then placed in position. The authors prefer to use the cavity and docking the needle into the disc space, the authors
Quadrant retractor (Medtronic Sofamor Danek, Memphis, ask the anesthesiologist to hold expiration to prevent inad-
TN). A pin is used to secure the retractor to an underlying vertent injury to the lung. Serial dilators and the Quadrant
vertebral body. The pin is placed along the retractor blade retractor are then positioned as described above. Once the
closest to an endplate. An articulating arm is then used to retractor is in place, the procedure is the same as for the
attach the retractor to the table. In this manner, the retrac- lumbar spine regarding discectomy and interbody fusion.
tor is well secured to both the table and the spine.
Upon closure, the tip of a 16 French red rubber catheter is
A light source is introduced and attached to the retractor, inserted through one of the caudal incisions communicat-
following which a blunt monitoring probe is once again ing with the thoracic cavity and situated in the posterior
used to monitor the area visible through the tube. Once it thoracic cavity. The thoracic incisions are all closed in a
has been confirmed that there are no neural elements in watertight fashion. The incision through which the cath-
the plane of the discectomy, a radical discectomy then en- eter exits is closed last with a purse-string stitch around the
sues. Should a neural element be encountered with signal catheter. The anesthesiologist is asked to have the patient
changes on the free-running EMG, this level is typically perform a Valsalva maneuver. At the same time, the cath-
aborted. This is occasionally the case at L4/5. The radical eter is connected to suction and then pulled out while the
discectomy first entails using a 15-blade to incise the disc. purse-string suture is closed in a watertight fashion. The
A series of Cobb elevators are used to release the disc space, authors have not had to use chest tubes when they have
while preserving the anterior longitudinal ligament. A Cobb carried out this procedure. Postoperative chest x-rays have
elevator is taken across the disc space to the contralateral shown patients to have less than 10% pneumothorax or
side (described as “coast-to-coast”) and rotated in order to mild pleural effusions, both of which can be observed and
achieve release. This is especially necessary for deformity followed with serial chest x-rays.
correction. Subsequently, after meticulously preparing the
endplates with rasps and radically excising the disc, serial The authors typically perform the second stage of surgery
interbody spacer trials are evaluated for length and height 2–3 days after the initial surgery. This allows the patient to
under AP image intensification. Once an adequate size has recover and get out of bed prior to undergoing the second
been determined, a polyether ether ketone (PEEK) spacer stage of the correction. Additionally, in the case of preexist-
is packed with recombinant bone morphogenetic protein ing foraminal stenosis, the authors assess whether a decom-
(rhBMP-2/ACS) (Infuse, Medtronic Sofamor Danek, Mem- pression is necessary or not during the second stage. If the
phis, TN) and Grafton Putty demineralized bone matrix patient experiences no radicular pain after the first stage,
(DBM) (Osteotech, Eatontown, NJ). In terms of rhBMP-2/ then in general the authors will not perform a decompression
ACS dosing, the authors use 2–4 mg in each PEEK cage [8]. during the second stage. If a decompression is performed,
In terms of spacer size and profile, the lordotic spacers are
used at every level. As far as size is concerned, the trial must
fit quite snugly and also restore disc height. Care should be
taken to make sure the trial goes in fairly easily and fits
tightly; too large a trial or spacer may damage the endplates.
The prepared spacer is then placed along the anterior corti-
cal apophyseal ring under image intensification (Fig 4.3.4-4).
The space is then packed with additional Grafton Putty.
While removing the retractor, the authors encourage direct
visualization of the tissues to ensure the absence of injury.
In this procedure, the authors proceed caudally to rostrally a b

in order to achieve optimal deformity correction. When
Fig 4.3.4-4a–b AP and lateral image intensifier views showing the
proceeding to more rostral levels in the thoracolumbar area, Medtronic Quadrant retractor in place with completed DLIF at L2/3.
the surgeon pushes the diaphragm upwards when advanc- Note that after the AP view, the lateral view was obtained prior to re-
ing a PAK needle into the disc space in order to minimize moval of the graft inserter to ensure appropriate graft placement.
449

it is carried out under the operating microscope using MISS of the sacrum up to the L5/S1 disc space. A radical discec-
access techniques. tomy is then performed at L5/S1 using a series of Nitinol
brushes, cutters, and rasps. The disc space is then grafted
6.2 Transsacral discectomy and interbody fusion with local bone autograft, bone morphogenetic protein and
For the second stage of surgery, the authors typically per- Grafton Putty DBM. The authors use 2.1 mg of rhBMP-2
form a transsacral fusion prior to inserting pedicle screws per disc space fused in this way. A twist drill is then used
unless there is a preexisting lumbosacral junction obliq- to drill into the L5 vertebral body and the guide wire is used
uity (see also chapter 4.3.5 Transsacral fixation). If an obliq- to measure the appropriate length of a Trans1 axial 3-D
uity is present, the authors correct it with pedicle screws screw. Subsequently, the working cannula is exchanged for
prior to the transsacral fusion. Transsacral discectomy and a larger working cannula and a screw is inserted through
fusion (Trans1, Wilmington, USA) is used for percutaneous the sacrum, across the L5/S1 disc space, and into the L5
interbody transsacral fusion at L5/S1, but also possibly at vertebral body (Fig 4.3.4-5). A plug is then placed at the end
L4/5 should the L4/5 disc space not be accessible through of the screw and the working cannula is removed. Should
the transpsoas approach. This technique has been described any of the working cannulas become dislodged during the
by Marotta et al [22]. It is imperative to check the sacrum procedure at any stage, it is extremely important to start all
and pelvis by MRI before surgery in order to rule out any over again from the beginning with a blunt probe. In this
presacral adhesions or aberrant blood vessels at the midline way, the risk of inadvertent bowel injury is minimized.
at the level of S1/2. If any contraindications to transsacral
fusion exist (see above) or if a severe compressive pathol- A similar technique is used for the placement of a Trans1
ogy such as a large disc herniation is present, then mini- axial 3-D 2L screw across the L4/5 and L5/S1 disc spaces.
mally invasive TLIF may be preferable to this technique. In this case, a second stage of drilling and grafting is required
across the L4/5 disc space, followed by the insertion of two
6.2.1 Positioning screws that join together.
For this procedure, the patient is positioned prone on a
Jackson table with extra padding to elevate the buttocks
and legs. The legs must be slightly parted in order to obtain
the appropriate trajectory for the transsacral discectomy
and fusion technique. The rectal area is prepared and iso-
lated from the field. The skin of the thoracolumbosacral
coccygeal spine is prepared and draped in the usual manner.
During this part of the procedure, and during screw and
rod insertion, the authors typically monitor somatosensory
evoked potentials. For more significant curves motor evoked
potentials will also be monitored.
6.2.2 Procedure
A 1-inch (2.5 cm) incision is planned in the midline over
the sacrococcygeal junction. The skin is then incised. A
blunt probe is introduced via the paracoccygeal notch and a b
is used in a controlled manner with the operator using both Fig 4.3.4-5a–b Final AP and lateral image intensifier views showing
hands to pierce through the fascia. Under biplanar image posttranssacral discectomy and fusion status at L5/S1. In this patient,
percutaneous pedicle screws and rods were placed prior to performing
intensification, the blunt probe is advanced along the ven-
L5/S1 interbody fusion.
tral surface of the sacrum. Utmost care is taken not to enter
the ventral sacral neural foramina. The blunt probe is then
rested at the S1/2 junction to allow for the correct trajec-
tory across the L5/S1 disc space, and the L4/5 disc space if
necessary. A sharp guide wire is introduced through the
probe into the sacrum and advanced into the bone with a
slap hammer. Subsequently, a working cannula is placed
over the dilators and docked in the sacrum. The wire is then
removed, and a twist drill is used to drill a core of bone out

6.3 Percutaneous pedicle screw and rod insertion The percutaneous pedicle screw extenders are then aligned
Percutaneous pedicle screw insertion is also described in and a flexible rod is used to measure the length of rod
chapter 3.4 Posterior approaches for minimally invasive required. An appropriately-sized rod is then contoured.
thoracic decompression and stabilization, and chapter 4.2.4 The natural lumbar lordosis and also an appropriate ky-
Mini-open and percutaneous pedicle instrumentation and phosis at the thoracolumbar junction are approximated as
fusion. necessary. The rod is then passed freehand through a stab
incision just rostral to the most proximal pedicle screw
6.3.1 Positioning (Fig 4.3.4-6). Sometimes the rod will need to be further
The patient is positioned prone on an OSI Jackson table for contoured, as experience will dictate when the initial bend
this part of the procedure (or left in the same position as is insufficient. Once it has passed through all of the extend-
when he/she underwent transsacral interbody fusion). ers and placement has been confirmed via x-ray, the rod
is reduced with the extenders. Screw caps are placed
6.3.2 Procedure into the extenders and locked into position caudally to
For the posterior spinal fusion, the authors use Medtronic CD rostrally, following which the extenders are removed
Horizon Longitude pedicle screws and rods (Medtronic Sofamor (Fig 4.3.4‑7). When necessary, compression can be performed
Danek, Memphis, TN). Linear incisions are planned on the using a manufacturer-supplied compression device prior
skin by localizing the lateral border of the pedicles via AP im- to locking all the screws in place. Additionally, distraction
age intensification, as visualized when a scalpel is rested on can be performed if necessary. A vertebral column ma-
the skin. The 2-o’clock and 10-o’clock positions of the pedicles
are used to target the pedicle on the right and left side respec-
tively. For L4/5 and L5/S1, the authors prefer to use one inci-
sion. For the most rostral pedicle, they localize slightly lower
in order to avoid impingement on the supra-adjacent facet.
Under AP image intensification, a Jamshidi needle is ad-

vanced into each pedicle. Great care is taken to not violate
the medial border of the pedicle. The Jamshidi needle is
advanced through the pedicle to a depth of 20 mm under
x-ray confirmation. Lateral image intensification confirms
the appropriate trajectory and depth. A guide wire is then a b
advanced through the needle, into the vertebral body under
Fig 4.3.4-6a–b
lateral image intensifier verification. Subsequently, the a Lateral image intensification demonstrating cannulated pedicle
Jamshidi needle is removed. Serial dilators are used, fol- screws placed ipsilaterally with guide wires on the contralateral
lowed by a cannulated tap, then by a cannulated pedicle side. It is easier to verify initial rod placement via lateral image
screw with extender. This technique is repeated bilaterally intensification when screws are first placed unilaterally.
b A rod is then placed percutaneously and reduced into position.
at each operative segment.
In general, during primary deformity surgery the authors

do not use supplemental pelvic fixation as the Trans1 axial
3-D screw provides for strong interbody fixation and the
S1 sacral screws are typically 7.5-mm tricortical screws, as
per Lehman et al [35]. A pelvic inlet x-ray view assists the
placement of these screws and verifies that the screw taps
are indeed into the promontory bilaterally. Nevertheless,
in revision surgery supplemental pelvic fixation can be used.
In order to place these screws in a minimally invasive man-
ner, the S2 alar-iliac pelvic screw may be used [36], where a b
the starting point is below the S1 dorsal sacral foramen. The
Fig 4.3.4-7a–b
authors currently perform this screw insertion in a mini- a After the contralateral pedicle screws have been inserted,
open fashion—a gearshift is used to cannulate through the a second rod is contoured and passed into position.
sacrum into the ilium using a pelvic inlet view. b The rod is locked into place and the extenders are removed.
451

nipulator has also been devised for derotation maneuvers. 8 Evidence-based results
(When carrying out these techniques, especially for ado-
lescent idiopathic scoliosis, the authors will perform a The authors have reported on mid- to long-term clinical,
derotation maneuver as needed.) x-ray, and functional outcomes of this approach in adult
patients that underwent minimally invasive deformity cor-
Afterwards, the facet joints can be fused. Whenever using rection for scoliosis [8]. Twenty-eight consecutive patients
a transsacral technique, the lumbosacral facets can be fused that underwent this procedure for three or more levels and
by simply joining the pedicle screw incisions and using a more than 15° scoliosis with a minimum of 1 year follow-up
speculum to reach the facets. A Bovie is used to expose the were studied. The mean follow-up was 22 months. The
facets. A high-speed burr is then used to decorticate the mean age of patients in this study was 67.7 years. The mean
facets, followed by packing with Grafton Putty DBM, local estimated blood loss for the transpsoas procedure was 241
bone autograft, and rhBMP-2 ACS. Fusion of the facets at ml (range: 20–2,000 ml). The mean estimated blood loss
the rostral end of the construct, for example at T10/11 or for second-stage procedures, including transsacral interbody
T11/12, is recommended in case of interbody fusion due to fusion when performed and percutaneous screw fixation
variations in patient anatomy. The authors used approxi- and deformity correction, was 231 ml (range: 50–400 ml).
mately 1.62 mg of rhBMP-2 per facet-pars complex fused The mean operating time was 232 minutes for first-stage
with this technique [8]. procedures and 248 minutes for second-stage procedures.
The mean length of hospital stay was 10 days (range: 3–20
The authors have used neuronavigation on occasion with days). The preoperative mean caudal angle was 22° (range:
the O-arm for pedicle screw placement. This allows for re- 15–62°), which corrected to a mean of 7° postoperatively
duced operator radiation when compared to image inten- (range: 0–22°) (Fig 4.3.4-8). All patients maintained the cor-
sification. As more instruments and theoretically, guide rection of deformity, with solid arthrodesis as determined
wires, become navigable, this technology may be used on on plain x-rays during their follow-up evaluations. Solid
a more widespread scale. It could be extremely useful in arthrodesis was also confirmed in 21 patients via CT scan
cases where there are pedicles on the concavity of a curve, (Fig 4.3.4-9).
especially in cases of idiopathic scoliosis that do not read-
ily lend themselves to cannulation. In such situations skip- In terms of clinical outcomes, the mean preoperative vi-
ping pedicles can work with good results. Nevertheless, sual analog score was 7.05. Postoperatively, it was 3.03.
intraoperative navigation may allow for the cannulation of Preoperatively, the mean Oswestry Disability Index (ODI)
pedicles that normally would have been skipped. was 39.13; postoperatively, it was 7. The mean preoperative
SF-36 health survey was 55.73; postoperatively, it was 61.5.
In terms of complications, two patients developed quadriceps
7 Postoperative care palsy, but recovered within 6 months. One patient sustained
a retrocapsular renal hematoma, which was identified and
Patients are mobilized to walking within 1 day postopera- evacuated during the surgical approach; while another pa-
tively. The Foley catheter can be removed early on, to aid tient had an unrelated cerebellar hemorrhage, which re-
patient mobilization. Pain control is achieved using a com- quired craniotomy. These numbers compare quite favorably
bination of long-acting and immediate-release narcotics. to the results reported in the study by Glassman et al [37],
AP and lateral lumbar x-rays are also performed in the im- in which they assessed patients that underwent traditional
mediate postoperative period. Postoperative intravenous posterolateral instrumented lumbar spinal fusion. In their
antibiotics are continued for the first 24 hours, but not series, 17 patients with degenerative scoliosis were noted
beyond that point. Patients can be discharged within 24–48 to have an improvement in the ODI score of 21.2 at 1 year
hours of surgery, however, typically, since the surgeries are and an improvement in the SF-36 physical component of
usually staged with two days in between, patients are in 6.8. In the authors' study, the mean ODI improvement was
the hospital 6 to 7 days. In addition to pain-control medica- 32.13 points at 1 year, and the mean SF-36 improvement
tions, patients are encouraged to use a stool softener. Ex- was 5.77. Both of these results are consistent with achiev-
ercise in the form of significant walking is also encouraged ing a minimal but clinically important difference for outcome
during the postoperative period, although patients are measures, where an improvement of 10 points for the ODI
counseled to avoid heavy lifting or strenuous activity with- and 5.42 points for the SF-36 physical component score are
in the first 6 weeks of surgery. Bracing is not required. considered as clinically significant differences [38, 39].

8.1 Evidence in the literature supporting minimally

invasive spinal deformity correction
Similar outcomes were reported in 2010 by Wang and Mum-
maneni [40], who reviewed the transpsoas approach for
deformity correction, followed by minimally invasive ped-
icle screw fixation at L5/S1, and minimally invasive trans-
foraminal interbody fusion. In their series, the mean total
blood loss was 477 ml. The mean operative time was 401
minutes. They reported a 9% complication rate in terms of
return to the operating room, and a 30.4% complication
rate in terms of thigh numbness, dysesthesia, pain, or weak-
ness. At a mean follow-up of 13.4 months, the mean pre-
operative Cobb angle of 31.4° was reduced to a mean Cobb
angle of 11.5° postoperatively. These authors concluded
that this was a promising method for the reduction of sur-
gical morbidity in the correction of spinal deformity.
Dakwar et al [41] reported outcomes on 25 patients that

underwent lateral retroperitoneal discectomy and fusion
for adult degenerative deformity. Two patients had no in-
strumentation, seven patients had pedicle screws, 15 patients
had lateral plates, and one patient had a combination of
pedicle screws and lateral plates placed. Thus this series
represents a combination of MIS and open surgical tech-
niques. The mean patient age was 62.5 years; the mean
a b follow-up was 11 months (range: 3–20 months). A mean
Fig 4.3.4-8a–b Postoperative 36” AP (a) and lateral (b) standing films improvement of 5.7 points in the visual analog scale scores
of the same patient showing correction of the previous 35° curve to 15° and 23.7% in the ODI was observed. The mean blood loss
after deformity correction and fusion from T12 to S1. Note the excellent
was 53 cc per segment fused. Complications reported in-
sagittal and coronal balance achieved with a combination of minimally
invasive techniques.
cluded transient postoperative anterior thigh numbness
ipsilateral to the side of the approach (12%), rhabdomy-
olysis requiring temporary hemodialysis in one patient,
asymptomatic subsidence in another patient, and one case
of asymptomatic hardware failure.
Tormenti et al [42] also reported outcomes in eight patients

that underwent combined MIS with open posterior pedicle
screw placement and poster spinal fusion. They noted a
median preoperative coronal Cobb angle of 38.5° which
was reduced to 10° postoperatively. They reported that six
out of eight patients suffered from postoperative thigh dys-
esthesia and two patients had motor radiculopathies. They
also noted a single case of intraoperative bowel injury.
The authors’ figures compare favorably with those on pa-

a b tients that underwent more traditional open procedures for
deformity. Cho et al [43] reviewed their experience with 47
Fig 4.3.4-9a–b Coronal (a) and sagittal (b) reconstructions showing
solid arthrodesis through the L5/S1 transsacral fusion at 1 year postop-
patients that underwent posterior lumbar interbody fusion
eratively. with instrumentation for lumbar degenerative scoliosis.
Overall, their complication rate amounted to 68% with 30%
of patients experiencing early perioperative complications
453

and 38% having late complications. These authors con- including free-run and triggered EMG throughout the pro-
cluded that abundant blood loss was a significant risk factor cedure.
for early postoperative complications. Their mean blood loss
was 2.1 liters, with an average hospital stay of 20 days. In order to minimize the risk of vascular and viscus injury,
Similarly, Wu et al [44] reported on 29 consecutive patients strongly escorting the PAK needle down to the level of the
with degenerative scoliosis that underwent a posterior lum- psoas musculature with the surgeon’s opposite hand is
bar interbody fusion (PLIF) procedure. They noted a mean strongly recommended. In this manner, an organ or vessel
blood loss of 1.7 liters plus/minus 129 ml, with an average can be moved out of the way. Great care should be taken
hospital stay of 11.7 +/- 8.3 days. In an analysis of cold data, to avoid tissue creep into the retractor by appropriately
Bono and Lee [45] reviewed 78 articles on spinal fusion for dilating the musculature and docking the tube retractor.
lumbar degenerative disc disorders. They reported overall The anterior longitudinal ligament should be preserved. In
good to excellent outcomes in 82% of patients that under- this way, the surgeon avoids entering the abdomen ante-
went surgery for lumbar degenerative scoliosis. Nevertheless, riorly. Strict fluoroscopic control should be maintained,
the pooled complication rate amounted to 55%. Clearly, especially when releasing the contralateral annulus, but
based on these figures, the early results seen with mini- also when using discectomy and endplate instruments in
mally invasive deformity correction are quite favorable when the disc space. As regards positioning, the patient’s left side
compared to open surgery. facing upwards is recommended to minimize the risk of
catastrophic venous injury. Strict attention must also be
paid to the positioning of the spine, ensuring that it is as
9 Complications and avoidance close to 90° as possible to the ground.
Of note, the authors observed a major complication rate of Regarding the transsacral approach, the authors have en-
14% in their study, including two patients with quadriceps countered only minimal complications using this corridor
palsy, one patient with a retrocapsular renal hematoma, to date. A preoperative MRI examination should be per-
and one patient with a cerebellar hemorrhage. Sixty percent formed to rule out the possibility of aberrant midline vas-
of patients experienced thigh dysesthesia, which was tran- culature. In case the working channel at any point becomes
sient and related to the transpsoas approach. displaced, the procedure should be restarted with the blunt
probe from the very beginning. Given the relative proxim-
At the authors' institution, vascular and viscus complica- ity of the incision to the rectum, a meticulous preparation
tions experienced via the transpsoas approach included a is recommended, with a lap sponge soaked in Betadine in-
single case of ureteral and iliac vein injury. Tormenti et al serted into the proximal rectum and with the rectum iso-
[42] reported a case of bowel injury. lated by adhesive-containing drapes prior to preparing the
surgical site for the procedure. Additionally, a three-layer
Given the anatomical location of the genitofemoral nerve closure of the skin with cyanoacrylate glue in addition to
and the distribution of the lumbar plexus within the psoas Steri strips is recommended.
musculature, it is not surprising to observe paresthesia af-
ter the transpsoas approach. Nevertheless, the authors have For the placement of percutaneous pedicle screws, close
not found this to be a sustained problem after this procedure; monitoring of the guide wires is mandatory to avoid inad-
it typically resolves within 3 months. As in the study of vertent vascular or viscus injury resulting from guide wire
Moro et al [46], the authors prefer to target the junction of advancement. During freehand rod placement, any leverage
the anterior and middle third of the disc space to minimize on the proximal screws should be avoided as this may result
the risk of motor injury, and they use neuromonitoring in screw pullout.

10 Tips and tricks
Juan S Uribe and Ali A Baaj, Tampa, USA potential morbidity (operating room 9. Electrophysiological directional EMG
10.1 MIS deformity correction time, blood loss, lumbar plexus inju- monitoring is critical for positioning the
• For optimal clinical outcomes, a com- ry, psoas injury, damage to peritoneal dilators/retractor anterior to the main
prehensive treatment strategy (includ- and retroperitoneal structures) components of the lumbar plexus and
ing levels of fixation, biological choice, • Comprehensive soft-tissue release on
sufficiently posterior to the genitofemo-
fixation material) should be individually the contracted side ral nerve and vascular structures.
tailored on the basis of the realignment • Allows improved deformity correc-
10. Ensure minimal manipulation of the
needs. tion tube/retractor.
• Tailoring patient-specific treatment in- •
Restores foraminal height/indirect 11. Use the widest graft possible to avoid
volves the crucial pelvic incidence–lum- decompression subsidence.
bar lordosis (PI–LL) relationship. • Decreases number of fascial/skin inci-
12. Do not over-distract the implant to fa-
• Realignment objectives in the sagittal sions cilitate coronal deformity correction and
plane are the following: • Easier approach to L4/5
avoid subsidence.
• Sagittal vertical axis (SVA) < 50 mm • Break-table to facilitate correction
13. Use lordotic cages (if indirect decompres-
• Pelvic tilt (PT) < 20
3. Preoperative x-ray considerations that sion is the main goal, a posteriorly placed
• Spinopelvic harmony LL = Pl ± 9.
influence the side of the approach (CT standard cage may be preferable).
• MISS deformity realignment objectives scan/MRI/36’’ standing x-rays, scoliosis 14. Consider anterior longitudinal ligament
are obtained by performing spinal fixa- series) include the following: resections in cases with suboptimal sagit-
tion through a combined anterior-pos- • Location of vascular structures (iliac
tal balance.
terior MISS technique (mini-open ALIF, arteries/veins, in particular)
mini-open TLIF, lateral MISS). • Iliac crest height in relation to L4/5
10.3 Transsacral approach
• Direct decompression (open or MISS) disc space 1. Preoperative x-ray evaluation should
should be considered in cases with sig- • Osteophytes
include MRI and x-rays of the pelvis to
nificant central canal and foraminal ste- • Axial rotation
assess presacral structures and spino-
nosis and/or advanced facet hypertro- • SVA, PT, PI, sacral slope, LL
pelvic parameters (angle of approach
phy and associated clinical neurological 4. The patient is positioned in a true 90° feasibility).
claudication or radiculopathy. lateral decubitus position. 2. Assess whether there is adequate sagittal
• Since interbody fusion is obtained with- 5. The operating room table is adjusted at balance (SVA < 50 mm).
out posterolateral exposure or exten- each level to compensate for coronal/ 3. Not recommended in cases with forami-
sive paraspinal muscle dissection, and axial and sagittal deformity. nal stenosis or significant central canal
as the entry point of the percutaneous 6. It should be kept in mind that adjust- stenosis.
pedicle screws is lateral (transverse ing the operating room table to com- 4. Does not provide coronal deformity cor-
process/facet junction) as compared to pensate for the rotational component rection.
open techniques, there is a potentially dictates anterior skin incisions, with the
decreased risk of adjacent segment and potential risk of injury to peritoneal and 10.4 TLIF
hardware failure. vascular structures. 1. Provides direct foraminal and canal de-
7. Muscle-fiber splitting along the abdomi- compression in cases with significant
10.2 Minimally invasive lateral retroperi- nal wall, rather than transecting muscle, foraminal and central canal stenosis.
toneal transpsoas approach avoids injury to the iliohypogastric, il- 2. Recommended in cases with significant
1. Thorough knowledge of the regional ioinguinal and subcostal nerves, which radicular symptoms, particularly at the
anatomy is critical in avoiding potential run within the abdominal wall muscle L5/S1 level.
neurovascular and visceral injuries. layers. 3. Bilateral mini-open transfacet approach
2. The usual approach is from a concavity 8. Gentle blunt digital dissection of the provides facet release and basis for sagit-
(advantages): retroperitoneal space avoids injury to tal balance correction.
• Iliac crest inferior, which provides
free-running nerves at the retroperito- 4. May not be as effective in providing cor-
easier access to L4/5 level and avoids neum outside the psoas. onal and sagittal correction as compared
a bilateral approach and associated to the ALIF or MISS lateral approach.
455

10.5 Mini-open ALIF reported as being more common occur- sion and interbody fusion can represent
1. Provides adequate indirect decompres- rences with certain minimally invasive challenges for MISS techniques.
sion. approaches. • Indirect decompression through trans-
2. Not recommended in cases with signifi- • Complications from transpsoas ap- psoas lateral interbody fusion has been
cant foraminal and central stenosis. proaches include temporary or perma- demonstrated to increase both disc space
3. Effective in providing lordosis and sagit- nent thigh weakness, dysesthesias in the and foraminal height. The literature is,
tal balance. L2, L3, L4 or femoral nerve distributions, however, inconclusive as to whether
4. Best published fusion rates at the L5/S1 or injury to the bowel or other abdomi- indirect decompression can lead to a
level. nal contents [42]. similar improvement in neurological
• Complications can occur that are specific symptoms in patients with preexisting
10.6 Iliac fixation to the MISS procedure in question. Axi- central canal or foraminal stenosis as
1. Recommended as a supplement to S1 aLIF used for transsacral L5/S1 or L4–S1 that observed following standard poste-
pedicle screws in long constructs that interbody fusion has been found to be rior decompression. Particularly in cases
include the thoracolumbar junction, or in associated with rectal perforation in up of severe stenosis with significant neu-
cases of severe sagittal/coronal imbalance to 3% of cases. Bowel perforation and rological symptoms, a certain amount
or advanced L5/S1 spondylolisthesis. other retroperitoneal structural injuries of concern exists when using an indi-
2. S2 alar percutaneous iliac-pelvic screws following a lateral transpsoas approach rect decompression-only approach that
provide easier in-line rod connection as have also been reported. Especially at preoperative symptoms could persist, in
compared with iliac bolts. the L4/5 and L5/S1 levels, minimally spite of excellent deformity correction.
3. S2 alar-iliac pelvic screws avoid poten- invasive TLIF may constitute a safer and • The currently available minimally in-
tial skin complications related to super- an equally or more effective option. vasive techniques do not allow the per-
ficial hardware as compared with iliac • Coexisting sagittal imbalance is common formance of advanced osteotomies (eg,
bolts. in patients with adult deformity. Despite pedicle subtraction osteotomy (PSO),
4. 3-D CT-guided navigation is a useful tool improvements in minimally invasive vertebral column resection (VCR)) for
in assisting screw insertion. techniques, substantial sagittal imbal- the correction of severe spinal defor-
ance is difficult to correct using current mities. In particular, the correction of
Manish K Kasliwal, John McCormick, and MISS techniques. Although transpsoas focal fixed kyphosis and severe coronal
Christopher I Shaffrey, Charlottesville, USA lateral interbody fusion, with associated deformities cannot be addressed using
• Minimally invasive deformity correction posterior segmental instrumentation, current MISS techniques.
using MISS techniques can theoretically can correct cases of minor imbalance • Standing AP and lateral 36" x-rays in-
reduce tissue trauma and blood loss and (< 8 cm), significant sagittal imbalance cluding the hips and knees in full ex-
appears to be a promising option for se- requiring major realignment is usually tension are needed to adequately assess
lected adults with degenerative/de novo best treated with an open procedure in- the deformity, with the additional use of
scoliosis. However, early reports demon- cluding spinal osteotomy such as pedicle both supine neutral and supine benders
strated inferior results when compared subtraction osteotomy. when deemed necessary to characterize
with open techniques in cases of stiff • Transpsoas lateral interbody fusion has the relative flexibility of each aspect of
coronal curves with associated sagittal been shown to result in excellent cor- the deformity in the coronal and sagit-
imbalance [41, 42]. rection of coronal deformity. However, tal planes, and to determine the extent
• A minimally invasive technique does clinical outcomes have not always been of correction and type of osteotomy
not necessarily mean that it is totally optimal as regards sagittal plane correc- required to achieve acceptable spinal
innocuous and free of complications. tion. Thus when using MISS approaches, alignment. Assessment of sagittal and
Although skin and muscle damage is attention to detail is important in order coronal alignment, measurement of
less, visualization of important anatomi- to optimize sagittal realignment, so that pelvic parameters (PI, PT, relation be-
cal structures is also frequently reduced. results become comparable to those ob- tween LL and PI), should be performed
Because of this more limited exposure, tained with open approaches. on the basis of standing x-rays. The pres-
MISS-associated complications can be • Patients with adult degenerative defor- ent comment authors aim at restoring
more challenging to avoid or correct, mity have frequently undergone previ- these parameters to within a certain
especially for the inexperienced sur- ous spinal surgical procedures. As a re- range (SVA < 5 cm, PT < 25° and LL
geon. Complications including dural sult, revision surgery including removal proportional to PI), thereby optimizing
tear, retroperitoneal structural injury, of previously placed implants, extension postoperative clinical outcomes. A com-
and lumbar plexus injury have all been of instrumentation, revision decompres- parison of standing and supine x-rays

can provide invaluable information on most always have to be instrumented adequate decompression of the nerve
curve flexibility, both in the coronal and and fused. However, in certain cases root, correction, and stabilization of lat-
sagittal planes, and can improve surgical with a lower degree of scoliosis, good eral listhesis, greater curve correction
planning. sagittal alignment, and maintained lum- along the convexity, and additional seg-
• Staged surgical procedures, particularly bar lordosis with isolated radicular pain mental release achieved through associ-
as regards transpsoas lateral interbody or neurogenic claudication, decompres- ated discectomy and osteophyte resec-
fusion, may be considered in cases of sion alone or decompression and focal tion. If a TLIF is performed by removing
moderate sagittal imbalance. Standing fusion performed by a MISS approach both facet joints, it greatly increases the
x-rays can be obtained after the first can be envisaged. flexibility of the deformed spine and per-
surgical procedure to assess sagittal • The present comment authors almost mits better deformity correction with
alignment and its impact on pelvic pa- invariably supplement fusions above L2 less force applied to the implants.
rameters. Following this assessment, it to the sacrum with pelvic fixation, and • The overall radiation exposure and im-
is then possible to determine whether strongly advocate this technique even plant costs associated with MISS surgery
more aggressive posterior realignment when performing MISS procedures. Al- remain areas of concern, and need to
procedures are required, either through though they prefer to use iliac screws, a be carefully evaluated and compared to
an MISS or open technique. sacral alar iliac technique may be pref- similar risk and cost considerations asso-
• Care should be taken to fully extend erable when performing MISS proce- ciated with traditional open approaches.
the hips when positioning during the dures compared to traditional iliac screw • The goals of surgery with either an open
instrumentation phase of prone surgical placement as its entry point aligns well or MISS approach remain the same, ie,
procedures to allow the lumbar spine to with the S1 screws and may be easier obtaining normal lumbar lordosis, a
achieve maximal lordosis. to incorporate in the construct. good match between LL and PI, and a
• One of the concerns regarding MISS • In patients with good sagittal alignment restoration of a low pelvic tilt with a low
techniques is the failure to achieve ade- where the correction of coronal plane complication rate. In cases where pain,
quate preparation of the fusion bed, par- deformity is the major focus of surgery, length of hospital stay, postoperative re-
ticularly in posterior-only procedures. the use of a unilateral TLIF along the covery period, and complications can be
The facet joints need to be thoroughly convexity of the curve with placement reduced while there is a strong likeli-
decorticated to facilitate achievement of of an interbody cage can provide positive hood of obtaining the aforementioned
fusion at levels where interbody fusion results. When the correction of a mild surgical goals, MISS techniques should
has not been performed. sagittal deformity, coexisting spondy- be considered. If these goals cannot be
• When treating a thoracolumbar curve, lolisthesis or lateral listhesis is also an realistically achieved, then a mixed or
the vertebral bodies included in the issue, bilateral facetectomy can be per- open procedure should be performed.
Cobb measurement of both the major formed during the TLIF. This procedure
and lumbosacral fractional curves al- helps to restore foraminal height, with
457

11 Case examples bar radicular symptoms. Poststage 1, 36” deformity films

were obtained (Fig 4.3.4-13). However, in spite of the dis-
11.1 Case 1 cectomy and interbody fusion, the patient's deformity was
A 69-year-old woman presented with more than 2 years of still not adequately corrected in terms of vertebral body
severe back pain, with pain radiating to her thighs bilaterally. translation.
Despite conservative measures including physical therapy,
facet blocks, and epidural steroids, the symptoms persisted. Stage two involved the use of percutaneous pedicle screws
and rods (Fig 4.3.4-14). Compression was performed along
Work-up revealed the patient to have a 24° degenerative the left side from L3–5. Final image intensifier control dem-
curve from roughly L1–5 with an apex to the left and lat- onstrated excellent results, with correction of the apical
eral listhesis at L2/3 (Fig 4.3.4-10). MRI showed the patient translation (Fig 4.3.4-15). This case demonstrates the impor-
to have foraminal stenosis at numerous segments from L1 tance of using the rods with the extenders to correct the
through L5. Her L5/S1 disc appeared to be within normal deformity, as treatment by discectomy and interbody fusion
limits (Fig 4.3.4-11). alone does not correct translational deformity.
The patient subsequently underwent a two-stage MISS de- Postoperatively the patient recovered well, with low-dose
formity correction. In the first stage, she underwent L1–5 narcotics for pain control and with no complications ob-
transpsoas discectomy and fusion (Fig 4.3.4-12). After stage served, and left the hospital 3 days after the second stage
one, she was allowed to ambulate and no longer had lum- of deformity correction.
a b
Fig 4.3.4-10a–b AP (a) and lateral (b) lumbar films demonstrating Fig 4.3.4-11 T2 sagittal MRI Fig 4.3.4-12 AP image intensi-
a 24° lumbar degenerative curve extending roughly from L1–5. The demonstrating a healthy-appear- fier view showing a DLIF graft be-
patient has a smaller curve apex to the right in the thoracic spine. ing disc at L5/S1. Given the fact ing inserted at L1/2. The DLIF is
that this disc is not within the performed sequentially, caudally
degenerative deformity and that it to rostrally. Also note the retractor
is normal, the decision was made docked with a retention pin.
to stop at L4/5.

a b
Fig 4.3.4-13a–b 36” deformity films demonstrating the presence of Fig 4.3.4-14 AP image intensi-
L2/3 lateral listhesis with the degenerative curve still remaining despite fier view demonstrating Jam-
discectomy and interbody fusion. shidi needles used to cannulate
pedicles in preparation for the
insertion of percutaneous pedicle
screws.
a b
Fig 4.3.4-15 a–b AP (a) and lateral (b) image intensifier views dem-
onstrating excellent MIS correction of the deformity. Note the consider-
able correction of the apical translation at L2/3, achieved via the rod
insertion through the extenders, which was not achieved by DLIF alone.
459

11.2 Case 2 normal midline sacral anatomy at S1/2, indicating the ab-
A 67-year-old woman presented with a history of severe sence of aberrant midline vasculature (Fig 4.3.4-19)
back and right lower limb pain. Despite physical therapy
and treatment by injections, the symptoms were not ade- Stage two involved the placement of percutaneous pedicle
quately controlled. Thirty-six-inch standing films revealed screws and rods, including tricortical S1 screws (Fig 4.3.4-20).
a 47° levoscoliotic curve extending from T12 to L5 and a
degenerated L5/S1 disc (Fig 4.3.4-16). In addition to the lat- Stage three involved a transsacral discectomy and fusion
ter, MRI also showed numerous segments with foraminal (Fig 4.3.4-21).
stenosis (Fig 4.3.4-17).
The patient subsequently recovered well. Nine months post-
The patient subsequently underwent a three-stage MISS operatively she was pain free, with an excellent correction
deformity correction and fusion. Stage one (Fig 4.3.4-18) of her deformity and maintenance of sagittal and coronal
involved DLIF at T12–L5. MRI of the sacrum demonstrated balance (Fig 4.3.4-22).
Fig 4.3.4-17 T2-weighted axial

MRI showing foraminal stenosis
secondary to superior articular
facet hypertrophy.
Fig 4.3.4-18 Lateral image

intensifier view taken after
completion of DLIF at L2/3, L3/4,
and L4/5.
a b
Fig 4.3.4-16 Long cassette AP (a) and lateral (b) films demonstrating Fig 4.3.4-19 Axial T2-weighted
a 47° convex degenerative scoliotic curve to the left, extending from T12 view at the level of S1/2 demon-
to L5. strating the absence of midline
vasculature. This imaging study
should be performed prior to
performing transsacral interbody
fusion.

a b a b
Fig 4.3.4-20a–b Percutaneous pedicle screw and rod insertion. Fig 4.3.4-21a–b AP (a) and lateral (b) image intensifier views show-
a Pelvic inlet view demonstrating the insertion of percutaneous ing posttranssacral discectomy and interbody fusion status.
tricortical sacral pedicle screws.
b After the rod has been contoured, it is passed freehand through
the extenders.
a b
Fig 4.3.4-22a–b AP (a) and lateral (b) 36” films taken 9 months post-
operatively demonstrating excellent deformity correction via MISS.
461

12 Key learning points cutaneous pedicle screws, in particular for the placement
of Jamshidi needles, with minimal radiation exposure
• Currently, minimally invasive surgical techniques are to the surgeon. Nevertheless, when advancing guide
not yet adequate for the correction of fixed kyphosis; wires, tapping, and for the placement of screws, the
these should be performed in a traditional open manner, authors still prefer spot checks using image intensifica-
as pedicle subtraction osteotomies, Ponte osteotomies, tion
or Smith-Petersen osteotomies are more readily per- • The authors consider that in the future, all these instru-
formed in this way ments will probably become navigable, with an accom-
• For the treatment of scoliosis, however, including ado- panying reduction in exposure to radiation; it should
lescent idiopathic scoliosis, subsets can be readily cor- be noted that navigable instruments are already being
rected through transpsoas discectomy, release of defor- developed for the transpsoas discectomy and interbody
mity, interbody fusion, and posterior instrumentation fusion approach, and this appears to be the direction of
• For most adolescents, anterior transpsoas release and future deformity correction
fusion is not needed. Secondary percutaneous fixation • MISS deformity correction is a promising alternative to
and derotation maneuvers can effectively achieve excel- open surgery; it is associated with similar operating times,
lent correction. The authors have also found second- but with reduced blood loss, fewer complications, and
stage surgery necessary for treating true idiopathic sco- shorter hospital stays
liosis as compared to simple degenerative scoliosis, as • The use of biologics has certainly made spinal fusion
stand-alone transpsoas discectomy and interbody fusion more readily achievable and has increased fusion rates.
for deformity does not appear to satisfactorily correct The authors consider that as these techniques are further
rotation and also has a higher pseudarthrosis rate refined and biological options expand and become more
• A potential limitation of MISS deformity correction is readily available, operating times may be shortened,
high operator radiation exposure. The authors have re- outcomes improved, and theoretically, that complica-
cently been using the O-arm for the placement of per- tions will be reduced.
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21:459–467.
Therapy Cohort III
Purpose
Purpose To assess the operative outcomes of adult patients with
To assess the feasibility of minimally invasive spine surgery scoliosis, who were treated surgically with minimally in-
techniques in the correction of lumbar degenerative de- vasive correction and fusion.
formity.
P Patient Scoliosis (N = 28, mean age 68 years)
P Patient Lumbar degenerative scoliosis (N = 12, 58% male, mean I Intervention Minimally invasive correction and fusion via anterior
age 73 years, age range 50–85 years) procedures, including transpsoas discectomy and interbody
I Intervention Circumferential fusion by posterior procedures fusions
C Comparison Circumferential fusion by anterior procedures C Comparison Minimally invasive correction and fusion via posterior pro-
cedures, including L5/S1 transsacral interbody fusion, L4/5
O Outcome Blood loss, surgical time, Cobb angles, visual analog scale and L5/S1 transsacral interbody fusion, and percutaneous
(VAS) scores, treatment intensity scores screw fixation
O Outcome Blood loss, operating time, length of hospital stay, Cobb
Authors’ conclusion angle, VAS, ODI, SF-36, complications
A combination of three MISS techniques allows for cor-
rection of lumbar degenerative scoliosis. Multisegment Authors’ conclusion
correction can be performed with less blood loss and mor- Minimally invasive surgical correction of adult scoliosis
bidity than for open correction. results in mid- to long-term outcomes similar to tradi-
tional surgical approaches.

Wang MY, Mummaneni PV (2010) Minimally invasive Dakwar E, Cardona RF, Smith DA, et al (2010) Early
surgery for thoracolumbar spinal deformity: initial outcomes and safety of the minimally invasive, lateral
clinical experience with clinical and radiographic retroperitoneal transpsoas approach for adult
outcomes. Neurosurg Focus; 28:E9. degenerative scoliosis. Neurosurg Focus; 28:E8.
Therapy Case series IV Therapy Cohort III
Purpose Purpose
To assess minimally invasive surgery for adult degenera- To evaluate an alternative surgical approach to degen-
tive scoliosis in an effort to reduce the high complication erative thoracolumbar deformity in adults.
rates associated with adult deformity surgery.
P Patient Degenerative thoracolumbar deformity (N = 25)
P Patient Adult degenerative scoliosis (N = 23) I Intervention Minimally invasive lateral retroperitoneal transpsoas
I Intervention Lateral interbody fusion followed by posterior percutaneous approach
screw fixation and minimally invasive surgical transforami- C Comparison No comparison group
nal lumbar interbody fusion as necessary
O Outcome ODI, VAS, complications
O Outcome Cobb angle, operative time, blood loss, VAS score, compli- Authors’ conclusion
cations
The minimally invasive lateral retroperitoneal transpsoas
approach for placement of a large interbody graft for an-
terior column support, restoration of disc height, arthrod-
The minimally invasive surgical treatment of adult de-
esis, and realignment is a feasible alternative.
formities is a promising method for reducing surgical
morbidity.
465


4.3.5 Transsacral fixation
Eric H Elowitz
1 Historical perspective vasculature running over the sacrum [6]. Since transsacral
fixation utilizes an anterior and percutaneous approach,
Lumbar fusion has become a common procedure for treat- the spinal supporting structures, such as the facets and disc
ing a large number of spinal pathologies including lumbar annulus, are left intact. As with other minimally invasive
instability, symptomatic disc degeneration, and spinal ste- techniques, one of the theoretical advantages of the presa-
nosis with spondylolisthesis. In recent years, multiple ap- cral approach is a quicker recovery time for the patients.
proaches have been described to facilitate lumbar fusion.
Many of the procedures performed have required extensive
open surgery, either anterior or posterior, sometimes with 2 Terminology
the assistance of an access surgeon. For anterior lumbar
interbody fusion (ALIF), an access surgeon is used for mo- The transsacral approach for lumbar fusion utilizes the pre-
bilization of the surrounding vasculature and retroperito- sacral space, which is generally filled with fat and connec-
neal contents. While this technique has been shown to be tive tissue. In the literature, this approach has also been
an effective means of promoting fusion, the complication termed axial lumbar interbody fusion (AxiaLIF) [3].
rates have included retrograde ejaculation of approximate-
ly 1% and vascular injury [1]. Posterior lumbar approaches
have also been developed including both open and, more 3 Patient selection
recently, minimally invasive procedures. The more tradi-
tional posterior procedures include the open placement of Transsacral fixation of the lumbar spine is used primarily
pedicle screws with either an intertransverse process fusion for pathologies at the L5/S1 level. This approach can also
and/or an interbody graft. This open surgery requires con- be used for two-level fusion incorporating L4/5 [9]. The
siderable muscle retraction, which has been shown to cause indications for transsacral fixation are the same as those for
fibrosis as well as weakening of the paraspinal musculature any other type of lumbar fusion. Due to the presacral ap-
[2]. proach to the spine, several other unique factors have to
be taken into account, particularly the sacral anatomy. Ap-
Recent advances in minimally invasive techniques are aimed propriate trajectories to the lumbosacral area are essential,
at reducing the morbidity associated with traditional open and therefore preoperative analysis of the specific sacral
surgery. Tubular retractor systems for interbody fusion, structure, especially as it relates to the disc spaces, is critical.
coupled with the placement of percutaneous pedicle screws, Also, a detailed patient history regarding any prior bowel
have gained increasing popularity. However, this procedure or rectal pathology is required.
has the disadvantage of requiring removal of a facet joint,
and there is often a recovery period relating to direct mus- Another consideration in patient selection is the degree of
cular trauma for the patients. deformity correction needed. Restoration of lordosis is dif-
ficult to achieve with the transsacral approach, and may be
The presacral approach to the lumbosacral spine has been best accomplished by placement of an interbody cage using
developed and refined over recent years [3–8]. Initial reports either an anterior or posterior approach. Some patients may
on this procedure emphasized the percutaneous aspect of present with significant radiculopathy related to disc space
the segmental fusion at L5/S1, which has since also been collapse and foraminal narrowing. While some degree of
extended to L4/5 [9]. The major advantage of this procedure disc height restoration can sometimes be achieved by trans-
lies in the avoidance of paraspinal muscular dissection. In sacral fixation, it can be quite variable. If the patient’s main
addition, there is no requirement for removal of the spinal complaints relate to foraminal narrowing at L5/S1, a direct
facet or lamina. This approach takes advantage of the nat- decompression may be required either in lieu of, or follow-
ural presacral tissue plane and the lateral position of the ing a transsacral fusion.
467

Author Eric H Elowitz
3.1 Indications 4.1 Pros

Indications for transsacral fixation are similar to those for • Percutaneous technique
other methods of lumbar fusion: • Sparing of paraspinal musculature
• Degenerative disc disease • No removal of bone or facet
• Spondylolisthesis • Immediate stabilization of the L5/S1 disc space
• Multiple recurrent disc herniations • Quick patient recovery times
• Prior failed fusion • No access surgeon required
• Spinal stenosis with instability • The disc annulus is left intact
• Foraminal stenosis with collapsed disc. • Direct disc space distraction in some cases.
3.2 Contraindications 4.2 Cons

• Prior perirectal abscess or inflammation • Risk of bowel injury
• History of diverticulitis or diverticulosis • No direct neural decompression
• History of prior perineal or pelvic radiation • Limited ability to restore lordosis
• Prior colon or rectal surgery • Requires correct sacral anatomy and trajectory to L5/
• Unusual sacral anatomy S1
• Complex trajectory to the disc space via the transsacral • Limitations for use in patients with prior bowel surgery
approach. or infection, diverticulitis or diverticulosis, or pelvic ra-
diation therapy.
4 Pros and cons of transsacral fixation

5 Preoperative planning and patient positioning
Transsacral fixation should be considered as one possible
method for lumbosacral fusion in addition to other standard A major consideration in selecting patients for the trans-
open and minimally invasive approaches. Not all patients sacral approach is the sacral anatomy and its relation to the
undergoing L5/S1 fusion would be appropriate candidates lower lumbar disc spaces. Preoperative planning of the tra-
for transsacral fixation; a complex trajectory to the lumbo- jectory is of major importance (Fig 4.3.5-1). Preoperative
sacral region, or a prior bowel pathology would constitute imaging of the entire sacrum down to the coccyx is neces-
exclusion criteria. The major advantages of the presacral
approach include the percutaneous nature of the procedure
and the sparing of spinal support structures, such as the
musculature and facet. As is the case with all approaches,
there are also certain disadvantages. There is a limited abil-
ity to restore lumbar lordosis; in patients requiring correc-
tion of a sagittal imbalance, other approaches, such as an-
terior lumbar interbody fusion (ALIF), may be more
appropriate. Although the transsacral approach can some-
times achieve disc height restoration and indirect foraminal
decompression, in patients whose main symptoms include
radiculopathy due to foraminal narrowing, a direct decom-
pression should also be considered. One concern with the
transsacral approach is the limited nature of the discectomy
and endplate preparation that can be performed with a per-
cutaneous technique, with a possibly deleterious effect on
fusion potential. Also there is the risk of bowel or vascular
injury. Another consideration with transsacral fixation is
the need for additional posterior supplementation, includ-
ing the use of pedicle screws or percutaneous facet screws.
Fig 4.3.5-1 Lateral x-ray with the arrow indi-
cating the proper trajectory for the transsacral
approach to L5/S1.

sary. Routine lumbar MRI generally does not show the In patients undergoing the transsacral approach, bowel
entire sacrum and, in the majority of cases, new imaging is preparation is carried out one day before surgery. This
required. Plain x-rays are useful in this regard. MRI is also bowel preparation is similar to that used for colon surgery
used to assess the fat pad in the presacral space (Fig 4.3.5-2). or colonoscopy. Many patients undergoing lumbar surgery
Based on variations in sacral anatomy, there are patients are on chronic opioids and may have some degree of bow-
for whom the transsacral approach would not be advisable. el impaction. The author prefers to use Golytely (Braintree
Patients with a very arched sacrum and coccyx often have Laboratories Inc, Braintree, USA) on the preoperative day.
a hyperlordotic L5/S1, making the trajectory unsuitable for
this approach. Alternatively, patients with a very flat sacrum At surgery, the patient is positioned prone on the OSI Jack-
may also be unsuitable candidates (Fig 4.3.5-3). son table. It is necessary to flex the hip, at least to some
degree, to facilitate the dissection along the anterior sacrum.
Special attention must be paid to patients being considered Either a small roll can be placed under the hips, or the hips
for a two-level transsacral approach. Many patients that can be flexed by using a sling attachment to the OSI Jackson
would be ideal candidates for a single-level L5/S1 trans- table (Fig 4.3.5-5). As the procedure is percutaneous, image
sacral fusion would not be considered appropriate for a intensification in both the AP and lateral planes is critical.
two-level fusion. In patients for whom a two-level trans- Using two image intensifier units to obtain biplanar imag-
sacral approach is planned (Fig 4.3.5-4), extra attention must ing can be most helpful in this regard. Using one image
be paid to the trajectory visualized on preoperative imaging. intensifier unit to move back and forth from the AP to the
Fig 4.3.5-2 Sagittal MRI showing suitable Fig 4.3.5-3 Lateral x-ray revealing Fig 4.3.5-4 Two-level transsacral
presacral fat pad for the transsacral approach. a flat sacrum, which would provide fusion with supplemental pedicle
a poor trajectory for the transsacral screws.
approach.
Fig 4.3.5-5 Patient positioned

on an OSI Jackson table with sling.
469

lateral planes is also possible, although this can be more 6 Surgical techniques
time-consuming. Even before draping, the trajectory is again
mapped out to the lumbosacral disc levels. A Foley catheter 6.1 The transsacral approach
is inserted, which can be removed immediately at the end The incision for the transsacral approach is made just lat-
of the procedure. Routine first-generation cephalosporin eral to the coccyx, approximately 2 cm to the left or right
antibiotics, such as cefazolin, are administered and a single of the paracoccygeal notch. A direct midline incision is to
dose of metronidazole, eg, Flagyl, is also added for gram- be avoided because of potential concerns about wound heal-
negative prophylaxis. Once proper positioning has been ing. It is necessary to penetrate the underlying fascia. This
obtained and pressure points appropriately padded, the im- can be done either with a blunt finger dissection or with a
age intensifier is then brought in and the trajectory is re- clamp. Lateral image intensification is necessary to ensure
checked. After this has been determined as adequate, initial proximity to the bone of the sacrum in order to avoid rec-
preparation is performed in the gluteal crease and perianal tal injury. Once the fascia has been penetrated, the presacral
region. This area is then dried, drapes are placed over the space is then accessed. A probe is introduced and advanced
anus, and the paracoccygeal and lumbar region are prepped slowly along the anterior sacrum. AP image intensification
and draped in the usual fashion. It is left to the surgeon's is helpful in maintaining the midline approach. If at any
preference whether to use supplementary fixation, such as time it is felt that the probe cannot be advanced further, an
unilateral or bilateral pedicle screws or transfacet screws AP view should be obtained as it is possible that the probe
(Fig 4.3.5-6). The incisions for the other screws can be prepped could enter a lateral sacral foramen. On lateral imaging, the
and draped at the same time as the transsacral approach. probe is slowly passed and the presacral plane dissected
until the desired anterior point for the correct trajectory
into the L5/S1 disc space is achieved. Generally, this dock-
ing occurs at the S1/2 level (Fig 4.3.5-7). Alternatively, a
finger sweep can also be performed, which will bluntly dis-
sect the tissue away from the face of the sacrum. The probe
can be passed after this point.
a b a b
Fig 4.3.5-6a–b “Hybrid construct” following L5/S1 transsacral fusion Fig 4.3.5-7a–b Intraoperative docking of probe at the S1/2 level for
using pedicle screws and contralateral facet screws. the transsacral approach.
a Lateral view. a Lateral view.
b AP view. b AP view.

Using a firm K-wire, the sacrum is then entered and passed A 7.5 mm drill is then passed through the working channel
into the L5/S1 disc space. A series of dilators are impacted into the L5 body to approximately two-thirds of the way to
into the sacrum until the 10 mm working channel is placed. the L4/5 disc space. The drill is turned in counterclockwise
The working channel must be secured entirely within the direction in order to avoid extracting bone-graft material.
sacrum to avoid a soft-tissue injury as well as to prevent The initial working channel is removed over a K-wire, and
the channel from becoming dislodged. Through this work- an exchange cannula is inserted. It is important that the
ing channel, a 9 mm drill is then passed into the L5/S1 disc, exchange cannula lies flush against the sacrum to avoid
but not into the L5 body. Once this drill has been removed, soft-tissue injury. The exchange cannula can be fixed to the
bone material can be harvested and saved for the autograft. sacrum using a small wire, but having an assistant manu-
Discectomy and endplate preparation are then performed. ally hold the cannula against the sacrum is also very help-
A series of nitinol loop cutters are used (Fig 4.3.5-8). These ful. The fusion rod is passed through the exchange can-
can be either straight or slightly down-angled to better pre- nula and over the guide wire into the L5 and S1 bodies
pare the S1 endplate. In patients with a very collapsed L5/ under direct image intensifier guidance. The degree of dis-
S1 disc, a straight cutter can be used. This disc is then extraction and height restoration can also be determined based
tracted with a series of wire brushes. on the rod placement. The variable pitch of the rod results
in stabilization and, generally, at least in some degree of
The disc space is filled with the harvested autograft as well height restoration via distraction.
as additional bone extending material or biologics. Although
there is no general consensus regarding the type of graft Closure of the paracoccygeal incision is then performed.
material recommended, recombinant human bone mor- Deep dermal sutures of #2-0 Vicryl are placed. A running
phogenetic protein-2 (rhBMP-2, eg, InFuse, Medtronic, subcuticular suture of #4-0 Vicryl is also used. A glue-type
Memphis, USA; or InductOs in Europe) has been reported sealant is then placed over the incision.
to result in satisfactory fusion rates [7]. These materials are
impacted using a series of inserters, which can be directed Posterior supplementation has been shown to reinforce the
in any direction. Image intensification can be very helpful strength of the construct [10], and is almost always per-
in determining the direction of impaction of graft material. formed. The options available include unilateral or bilat-
In patients that have undergone prior discectomy, or who eral pedicle screw placement and facet screws. If a direct
are known to have an incompetent disc annulus, care must neural decompression is necessary, such as in the case of
be taken to avoid impaction in the posterior direction in foraminal narrowing or disc herniation, this can be per-
order to prevent the direct extrusion of graft material into formed via tubular retractors. In patients with a known
the spinal canal. Frequently on lateral image intensification, isthmic spondylolisthesis and pars lysis, bilateral pedicle
distraction is observed simply as a result of the impaction screw fixation is required.
of graft material.
6.2 Two-level transsacral fusion
A transsacral approach can also be used for a two-level fu-
sion incorporating both L4/5 and L5/S1 (Fig 4.3.5-9). Patient
selection is most critical in this type of surgery. Careful
preoperative planning of the trajectory is required. Some
patients that would be appropriate candidates for a single-
level fusion would not meet the trajectory requirements
for the two-level fusion. For this reason, patients with sig-
nificant lumbar lordosis may be poor candidates for the
two-level transsacral approach. Conversely, patients with
loss of lordosis, or “flat-backs”, may also be poor candidates
for the transsacral approach as it is difficult to restore prop-
er sagittal alignment with this technique. Patients requiring
an L4/5 and L5/S1 fusion but who are not suitable candidates
for the two-level transsacral approach may require a sepa-
rate approach for L4/5, such as a lateral interbody approach
Fig 4.3.5-8 Nitinol loop cutter (Fig 4.3.5-10). Luther et al [8] have described the use of 3D
used for percutaneous discectomy. navigation, which may assist in determining the trajectory
for optimal screw placement.
471

In patients undergoing two-level transsacral fusion, poste- Inc, Wilmington, USA), that is better able to distract both
rior supplementation is necessary. Strong consideration the L4/5 and L5/S1 levels compared to previous versions.
must be given to using bilateral segmental pedicle screws, In time, more advanced technology for the transsacral ap-
L4 to S1, to aid in immediate stabilization and to facilitate proach may be developed to enable disc-height restoration
ultimate fusion. New instrumentation for two-level trans- to be consistently achieved.
sacral fusion has been introduced, ie, AxiaLIF 2-L (Trans1
7 Postoperative care
Patients are mobilized to walking within hours of this sur-

gery. The Foley catheter can be removed in the operating
room to aid early patient mobilization. Pain control is
achieved using a combination of long-acting and immediate-
release narcotics. AP and lateral lumbar x-rays are also
performed in the immediate postoperative period. Postop-
erative intravenous antibiotics are continued for the first
24 hours, but not beyond that point. Patients can be dis-
charged within 24 hours of surgery. In addition to pain
medication, patients are encouraged to use a stool softener.
Significant walking is also encouraged during the postop-
erative period, although the patients are counseled to avoid
a b heavy lifting or strenuous activity within the first 6 weeks
after surgery. Bracing is not required.
Fig 4.3.5-9a–b CT scans of the patient 12 months after the two-level
transsacral approach showing fusion at L4/5 and L5/S1.
a Sagittal view.
b Coronal view. 8 Evidence-based results
The transsacral approach has been proposed as a new, min-

imally invasive access to the lumbosacral spine. Preclinical
studies have been performed focusing on the anatomy and
feasibility of this approach. Human anatomical specimen
dissections and animal models have indicated the potential
safety of the presacral approach and the paucity of critical
structures in the presacral space.
In 2004, Cragg et al [4] described a human study utilizing

the transsacral procedure for the biopsy of the L5/S1 disc
to determine the feasibility and safety of this access. This
was performed safely in three patients without any com-
Fig 4.3.5-10 Lateral intraoperative image
intensification following L4/5 anterior fusion,
plications being observed. In 2006, Marotta et al [5] published
L5/S1 transsacral fusion, and pedicle screw a technical paper, including two case examples, and con-
placement. cluded that the transsacral approach was reproducible.
Aryan et al [3] reported on a case series of 35 patients with
an average follow-up of 17.5 months. In this study, local
bone autograft and BMP were utilized as the fusion mate-
rial. Radiographic evidence of a stable interbody cage and
fusion was found in 91% of the patients. Bohinski et al [7],
in a series of 50 patients, reported a fusion rate of 88% and
developing bone in 10% of patients at 1 year; one major
operative complication occurred of bowel perforation in a
patient with a prior perirectal abscess. Luther et al [8] used

intraoperative 3-D navigation to determine the proper tra- While rectal injury is a potential complication associated
jectory for the transsacral approach and screw placement; with this approach, appropriate patient selection and care-
this navigational tool may be especially useful for two- ful surgical technique can greatly minimize the risk of
level fusion. bowel injury. A case series in the literature has demon-
strated a rate of bowel injury up to 2% [7]. Initial penetra-
Clearly, more and longer-term follow-up studies are re- tion of the fascia adjacent to the coccyx must be performed
quired to evaluate the safety and efficacy of the transsacral under image intensifier guidance in close proximity to the
approach. While early studies have been encouraging, sacrum to enter the safe presacral plane. Many surgeons
larger series will be necessary to evaluate the ultimate fu- advocate the use of a blunt finger dissection technique. If
sion rate when using this procedure. concern for colonic violation should arise in the operating
room, consultation with a colorectal surgeon is necessary.
The patient can undergo contrast-medium administration
9 Complications and avoidance for bowel examination using intraoperative image intensi-
fication. Endoscopy may also be performed in this particu-
As in many operations, appropriate patient selection for the lar situation. Management should be determined by both
transsacral approach is critical to its safety and positive out- the spinal surgeon and colorectal surgeon. Options include
come. Accurate patient history regarding prior bowel pa- intravenous antibiotic administration, primary repair of the
thologies, as well as careful x-ray evaluation of the presacral laceration or possibly a temporary diverting colostomy. As
fat pad and the proper trajectory to L5/S1 are required for the patient would have already undergone bowel prepara-
good results. MRI scanning to include the sacrum is advo- tion, many colorectal surgeons could manage a small per-
cated to rule out a vascular anomaly [7]. While sexual dys- foration expectantly without the need for a colostomy. All
function relating to injury to the inferior hypogastric plex- patients should be advised to contact their surgeon in the
us is a risk of anterior lumbar interbody fusion [1], this case of abdominal pain or postoperative fever; fever 3–5
complication has not been shown to be a factor with the days following surgery could be a potential sign of perirec-
transsacral approach. tal abscess and should be evaluated appropriately.
10 Tips and tricks
Paul S Issack and Oheneba Boachie-Adjei, with a pillow elevating the pelvis. This 10.3 Exposure
New York, USA improves the trajectory from the tip of • At the right side of the coccyx, a 3 cm
the coccyx to L5, and L4 if a two-level transverse incision is made and carried
10.1 Preoperative planning AxiaLIF is to be performed. through the subcutaneous tissue with
• All patients should have preoperative • Obtaining good AP and lateral visualiza- cautery. The author has found decreased
MRI demonstrating a clear fat plane tion via biplanar image intensification is wound complications with a transverse
devoid of vascular structures separat- essential prior to preparation and draping. incision compared to a longitudinal inci-
ing the visceral peritoneum and rectum • When the AxiaLIF is performed in con- sion.
from the anterior sacral wall. If extensive junction with additional posterior spinal
vasculature is observed in this plane, or procedures, the posterior wound is closed 10.4 Preparation of osseous channel and
if patients have undergone prior retro- and dressed, the patient is repositioned, disc spaces
peritoneal surgery with scarring in this and the distal sacrococcygeal region is • Once docked at the S1/2 level, the inner
area, this procedure is contraindicated as prepared again and draped. The authors blunt stylet is exchanged for a guide pin.
it cannot be safely performed percutane- suggest that this two-step preparation The guide pin is introduced into the S1
ously. and draping be performed to minimize vertebral body, across the L5/S1 disc space
the risk of infection and allow for optimal and 1–2 mm into the L5 vertebral body
10.2 Patient positioning and operative patient positioning in lumbosacral lordo- under direct visualization. A trajectory
setup sis for accurate targeting of the implant that is too anterior may result in frac-
• The patient is positioned prone on an OSI into the L5 vertebral body (and into L4 ture of the anterior sacral cortex when
Jackson frame with the hips flexed and if it is necessary to fuse L4/5). instruments or the implant are inserted. A
473

trajectory that is too posterior may result William Tobler, Cincinnati, USA image intensifier guidance, advancing the
in a fracture of the posterior vertebral • It is recommended to inform and edu- probe into the prelumbar space above the
cortex, potentially resulting in injury to cate a colorectal surgeon in the spine sur- L5/S1 disc into the great vessels could be
the neural elements (Fig 4.3.5-11). geon's institution about this procedure catastrophic.
• A series of dilators is then passed over prior to performing it. • Complete discectomy, preparing the end-
the guide pin to dilate the sacral osseous • Standing plain x-rays from the mid-lum- plates thoroughly with looped and flat
path. During these passages, it is critical bar to the tip of the coccyx must be evalu- cutters, is required. The tactile feedback
to make sure under image intensifica- ated for trajectory planning. This must of the cutters against bony endplate is
tion that the guide pin does not advance be specified in the x-ray order. Standing important. Circumferential preparation
beyond the anterior vertebral cortex. rather than supine films demonstrate the is possible in most cases. The surgeon
• Endplates should be prepared using ra- patient's natural lordosis for a baseline must carefully evaluate the size of the
dial up-cutting and down-cutting tools, study. Trajectory planning for 1 or 2 level disc space and the location within the
with care taken to avoid endplate viola- procedures should be templated on this disc space. In some cases, a long cutter
tion. Cutting instruments should not be film. cannot be used because it could project
turned 360°, as they may enter the spinal • An MRI of the sacrum is necessary. It too far posteriorly and enter the canal. At
canal. discloses any vascular anomaly of the iliac L4/5 the cutter could project anteriorly to
• After discectomy, the disc space is bone- vessels that would be a contraindication the spine and lacerate the great vessels.
grafted with local bone and/or allograft. to the procedure. Commonly seen small, In some cases even a small cutter cannot
Again, care should be taken to avoid transverse, sub-periosteal veins are not be used because of the same limitations.
directing any bone graft posteriorly to- problematic. The surgeon must carefully evaluate the
wards the spinal canal. • Superior fixation is ideal for the presacral anatomy in each case.
device in spondylolisthesis as long as in- • The discectomy is complete only when
10.5 Implant insertion traoperative reduction can be achieved no more disc material is removed by the
• When choosing the size of the implant, for a proper trajectory. This may require brushes. This may require multiple cycles
and especially when performing two- osteotomies, placement of pedicle screws, of using multiple cutters and multiple
level fusion, it is important to carry out and reduction prior to the placement of brushes, until all accessible disc material
templating in situ using the dilator trial the presacral rod. A mobile/reducible is removed. Commonly the disc space
as well as operative templates. The L4/5 grade III spondylolisthesis is not a con- is irrigated with a pressurized irrigation
rod is chosen on the basis of length and traindication under these circumstances. system. Meticulous disc preparation is
thread pitch differential to allow for L4/5 • Obesity in patients is not usually a prob- the most important aspect of obtaining
distraction. lem. The trajectory distance from the tip a successful arthrodesis.
• The inferior portion of the S1 anchor of the coccyx to the L5/S1 disc is not • Thorough, tight packing of the disc space
should be proud on the anterior sacrum affected by any degree of obesity. Many is an important principle of achieving
by one or two threads to avoid a sacral patients too obese for an ALIF, and on successful arthrodesis in any approach.
stress fracture. whom a posterior approach is too dif- An annular defect, however, could allow
ficult, can be treated successfully. extrusion of graft material into the spinal
Juan S Uribe and Ali A Baaj, Tampa, USA • Severe osteoporosis may be a contrain- canal if the disc is vigorously packed in
• Preoperative x-ray evaluation should dication. Soft bone and endplates may the direction of the defect. Obtaining a
include MRI and x-rays of the pelvis to prevent successful completion of the history of prior discectomy, and whether
assess presacral structures and spino- procedure. left or right, will help the surgeon modify
pelvic parameters (angle of approach • Patient positioning on the operating table this portion of the procedure.
feasibility). to induce maximal lordosis is important. • It is important to choose the length of
• Consideration should be given as to The surgeon can alter lordosis by varying the axial rod carefully. Placing the distal
whether there is adequate sagittal bal- positioning techniques. tip of the rod too close to the endplate at
ance (sagittal vertical axis < 50 mm). • Injecting air into the rectum prior to the the disc level above risks damage to the
• Not recommended in cases of foraminal incision allows the surgeon to visualize normal endplate at the adjacent disc level
stenosis or significant central canal ste- the location of the rectum. especially if any subsidence occurs. It is
nosis. • Blunt-finger dissection opens the presa- important that the proximal tip, in its fi-
• Does not provide coronal deformity cor- cral space, which is especially helpful in nal position, protrudes a few threads into
rection. patients with little or no presacral fat pad. the presacral space. This provides another
• Never advance a probe or pin without point of cortical fixation on the anterior

sacrum. It also plugs the exposed, drilled- image intensification should identify a • A colorectal surgeon can repair a lacer-
out sacral channel preventing any de- laceration. Another option is to inject sa- ation without consequence. Failure to
layed oozing of exposed medullary sacral line into the rectum, then aspirate. Iden- recognize a rectal perforation/laceration
bone into the presacral space. tifying any blood-tinged fluid indicates leads to infection and colostomy. Since
• Injecting 200 cc of half-strength gastro- a possible laceration. An intraoperative introducing the preventive measures dis-
grafin into the rectum at the end of the consultation with a colorectal surgeon cussed, the incidence of infection and
procedure and viewing AP and lateral should be obtained. colostomy has declined significantly.
Fig 4.3.5-11a–b Sagittal and axial MRI cut

demonstrating posteriorly placed implant with
a b violation of the posterior vertebral cortex of L5.
11 Case example erative disc disease, with marked loss of disc height and
Modic endplate changes (Fig 4.3.5-12). The patient underwent
A 42-year-old man presented with increasing low back pain a L5/S1 fusion via a transsacral approach with placement
and only occasional radicular pain. Conservative treatment of an interbody rod (Trans1 Inc, Wilmington, USA) and
had failed, including physical therapy, medications, facet percutaneous facet screws (Fig 4.3.5-13). He was discharged
blocks, and trigger-point injections. His lumbar plain x-rays within 24 hours and has experienced marked improvement
and MRI were consistent with a diagnosis of severe degen- in his back symptoms.
a b a b
Fig 4.3.5-12a–b Preoperative views showing marked L5/S1 degenerative Fig 4.3.5-13a–b Postoperative x-rays following transsacral
changes. fusion and facet screw placement.
a Sagittal MRI. a Lateral view.
b Lateral x-ray. b AP view.
475

12 Key learning points all patients would be good candidates for single-level
fusion; even fewer patients would be appropriate for a
• The transsacral approach is a percutaneous method for two-level transsacral approach
fusion of the L5/S1, and possibly L4/5 disc spaces. The • Detailed case history must be obtained regarding prior
presacral space is utilized as an entry corridor, and has bowel pathologies, such as perirectal abscess, diverticu-
a paucity of vital structures litis, diverticulosis, and pelvic radiation therapy
• The transsacral approach avoids lumbar muscular dis- • Posterior supplementary instrumentation is usually re-
section and maintains the bony elements. Unlike many quired. In cases of isthmic spondylolisthesis with pars
other techniques, the disc annulus is kept intact lysis, bilateral pedicle fixation is recommended
• Preoperative x-ray and MRI evaluation is critical. Imag- • If concern arises regarding possible rectal injury, either
ing studies should include the tip of the coccyx to plan intraoperatively or postoperatively, consultation with
the appropriate trajectory to the lumbosacral region. Not a colorectal surgeon is necessary.
13 References
1. Sasso R, Burkus K, LeHuec J, et al 5. Marotta N, Cosar M, Pimenta L, et al 8. Luther N, Tomasino A, Parikh K, et al

(2003) Retrograde ejaculation after (2006) A novel minimally invasive (2009) Neuronavigation in the
anterior lumbar interbody fusion: presacral approach and minimally invasive presacral approach
transperitoneal versus retroperitoneal instrumentation technique for anterior for lumbosacral fusion. Minim Invasive
exposure. Spine; 28(10):1023–1026. L5–S1 intervertebral discectomy and Neurosurg; 52(4):196–200.
2. Mayer TG, Vanharanta H, Gatchel RJ, fusion: technical description and case 9. Erkan S, Wu C, Mehbod AA, et al
et al (1989) Comparison of CT scan presentations. Neurosurg Focus; (2009) Biomechanical evaluation of a
muscle measurements and isokinetic 20(1):1–8. new AxiaLIF technique for two-level
trunk strength in postoperative 6. Yuan PS, Day TF, Albert TJ, et al lumbar fusion. Eur Spine J;
patients. Spine; 14(1):33–36. (2006) Anatomy of the percutaneous 18(6):807–814.
3. Aryan HE, Newman CB, Gold JJ, et al presacral space for a novel fusion 10. Akesen B, Wu C, Mehbod AA, et al
(2008) Percutaneous axial lumbar technique. J Spinal Disord Tech; (2008) Biomechanical evaluation of
interbody fusion (AxiaLIF) of the 19(4):237–241. paracoccygeal transsacral fixation.
L5–S1 segment: initial clinical and 7. Bohinski RJ, Jain VV, Tobler WD J Spinal Disord Tech; 21(1):39–44.
radiographic experience. Minim Invas (2010) Presacral retroperitoneal
Neurosurg; 51(4):225–230. approach to axial lumbar interbody
4. Cragg A, Carl A, Casteneda F, et al fusion: a new, minimally invasive
(2004) New percutaneous access technique at L5–S1: clinical outcomes,
method for minimally invasive anterior complications, and fusion rates in 50
lumbosacral surgery. J Spinal Disord patients at 1-year follow-up. SAS J;
Tech; 17(1):21–28. 4(2):54–62.

Gerszten PC, Tobler WD, Nasca RJ (2011) Aryan HE, Newman CB, Gold JJ, et al (2008)
Retrospective analysis of L5-S1 axial lumbar interbody Percutaneous axial lumbar interbody fusion (AxiaLIF) of
fusion (AxiaLIF): a comparison with and without the use the L5/S1 segment: initial clinical and radiographic
of recombinant human bone morphogenetic protein-2. experience. Minim Invasive Neurosurg; 51(4):225–230.
Spine J; 11(11):1027–1032.
Therapy Retrospective cohort study III Purpose
To review experience with a minimally invasive technique
Purpose
for L5/S1 interbody fusion that exploits the presacral space
To assess fusion rates and clinical outcomes of patients
and its relative dearth of critical structures.
undergoing presacral AxiaLIF at L5/S1 with posterior
instrumentation, with or without the use of rhBMP-2. Patient Back pain secondary to lumbar degenerative disc disease,
P
degenerative lumbar scoliosis, or lytic spondylolisthesis (N =
P Patient Persistent low back pain with or without radicular compo- 35, 43% male, mean age 54 years)
nent (degenerative disc disease, spondylolisthesis, spinal
I Intervention Percutaneous paracoccygeal axial image intensifier-guided
stenosis, revision surgery) (N = 99)
interbody fusion (AxiaLIF) with cage, local bone autograft,
I Intervention Single-level L5/S1 fusion using an AxiaLIF rod with rhBMP-2 and rhBMP
(n = 45, mean age 43 years)
C Comparison Single-level L5/S1 fusion using an AxiaLIF rod without
rhBMP-2 (n = 54, mean age 43 years) O Outcome Stability of cage placement
O Outcome Fusion rate, pain measured with visual analog scale (VAS),
blood loss, length of hospital stay, Oswestry Disability Index Authors’ conclusion
(ODI) in intervention group and Odom's outcome criteria The percutaneous paracoccygeal approach to the L5/S1
in comparison group, complications
interspace provides a minimally invasive corridor through
which discectomy and interbody fusion can safely be per-
formed.
In this case-matched study, clinical outcomes were sim-
ilar for patients that underwent an AxiaLIF L5/S1 inter-
body fusion with or without rhBMP-2. The data strongly
suggest that there is a high confidence for no effect on
fusion rate by using rhBMP-2.
477

Bohinski RJ, Jain VV, Tobler WD (2010) Presacral Gerszten PC, Tobler W, Raley TJ, et al (2012) Axial
retroperitoneal approach to axial lumbar interbody presacral lumbar interbody fusion and percutaneous
fusion: a new, minimally invasive technique at L5/S1: posterior fixation for stabilization of lumbosacral isthmic
clinical outcomes, complications, and fusion rates in 50 spondylolisthesis. J Spinal Disord Tech; 25(2):E36–40.
patients at 1-year follow-up. SAS J; 4(2):54–62.
Purpose
Purpose To describe a minimally invasive surgical technique for
To describe clinical and x-ray outcomes at 1-year follow- treatment of lumbosacral spondylolisthesis.
up for 50 consecutive patients that underwent the pre-
sacral ALIF. P Patient Symptomatic L5/S1 level isthmic spondylolisthesis (N = 26)
I Intervention Axial presacral lumbar interbody fusion and percutaneous
P Patient Patients suffering from mechanical back pain and radicu- posterior fixation
lopathy (disc degeneration, discectomy, spondylolisthesis)
(N = 50)
O Outcome VAS for pain severity, Odom's criteria, x-ray fusion, length of
I Intervention Presacral ALIF procedure for interbody fusion at L5/S1
hospital stay, blood loss, complications
O Outcome VAS, ODI scores, complications, fusion based on CT scans Authors’ conclusion
The minimally invasive presacral axial interbody fusion
and posterior instrumentation technique is a safe and
Our initial 50 patients, that underwent presacral ALIF
effective treatment for low-grade isthmic spondylolisthe-
showed clinical improvement and fusion rates compa-
sis.
rable with other interbody fusion techniques; its safety
was reflected by low complication rates. Its efficacy in
future patients will continue to be monitored, and will
be reported in a 2-year follow-up study of fusion.

Gundanna MI, Miller LE, Block JE (2011) Marotta N, Cosar M, Pimenta L, et al (2006) A novel
Complications with axial presacral lumbar interbody minimally invasive presacral approach and
fusion: a five-year postmarket surveillance experience. instrumentation technique for anterior L5/S1
SAS J; 5(3):90–94. intervertebral discectomy and fusion: technical
description and case presentations. Neurosurg Focus;
Study type Study design Class of evidence 20(1):E9.
Therapy Technical note with case series IV
Purpose
To evaluate complications associated with axial interbody Purpose
lumbar fusion procedures using the AxiaLIF system in The purpose of this technical note is to demonstrate a
the postmarketing period. novel surgical approach, technique, and instrumentation
system for the treatment of L5/S1 instability in degen-
P Patient Any patient undergoing axial interbody lumbar fusion with erative disc disease and spondylolisthesis.
the AxiaLIF system (N = 9152)
I Intervention Axial interbody lumbar fusion with the AxiaLIF system (n = P Patient (N =2)
8034 single-level L5/S1 fusion, n = 1118 two-level L4–S1
fusion) I Intervention AxiaLIF (TranS1) transsacral system. Via a novel presacral
approach corridor, a truly percutaneous L5/S1 discectomy,
C Comparison No comparison group interbody distraction, and fixation are achieved, and retro-
Outcome Complications (bowel injury, superficial wound and peritoneal viscera and dorsal neural elements are avoided.
O
systemic infections, transient intraoperative hypotension, Percutaneous pedicle screw fixation is then used to provide
migration, subsidence, presacral hematoma, sacral fracture, additional stabilization at the treated level
vascular injury, nerve injury, and ureter injury) C Comparison No comparison group
O Outcome Intraoperative electromyographic and somatosensory-
evoked potential neurophysiological monitoring, duration
The five-year postmarketing surveillance experience with of surgery, blood loss, duration of hospital stay, x-ray films,
the AxiaLIF system suggests that axial interbody lumbar pain
fusion via the presacral approach is associated with a low
incidence of complications. The overall complication rates Authors’ conclusion
observed in the current evaluation compare favorably to This novel technique of interbody distraction and fusion
those reported in trials of open and minimally invasive via a truly percutaneous approach corridor allows for
lumbar fusion surgery. circumferential treatment of the lower lumbar segments
with minimal risk to the anterior organs and dorsal neu-
ral elements.
479

Tobler WD, Gerszten PC, Bradley WD, et al (2011) Tobler WD, Ferrara LA (2011) The presacral
Minimally invasive axial presacral L5/S1 interbody retroperitoneal approach for axial lumbar interbody
fusion: two-year clinical and radiographic outcomes. fusion: a prospective study of clinical outcomes,
Spine; 36(20):E1296–1301. complications and fusion rates at a follow-up of two
years in 26 patients. J Bone Joint Surg Br; 93(7):955–960.
Purpose
To evaluate and report the 2-year clinical and x-ray out- Purpose
comes associated with a L5/S1 interbody fusion procedure To evaluate the safety and effectiveness of presacral ALIF
that employs an axial presacral surgical approach. over a 2-year period.
P Patient Refractory axial low back pain (degenerative disc disease, P Patient Degenerative disc disease, spondylolisthesis (N = 26, n =
spondylolisthesis, revision surgery, herniated nucleus 15 men)
pulposus, spinal stenosis) (N = 156, mean age 43.6 years)
I Intervention Presacral ALIF at L5/S1 with an AxiaLIF implant
I Intervention L5/S1 interbody fusion via the presacral approach with the
AxiaLIF system C Comparison No comparison group
C Comparison No comparison group O Outcome Clinical outcomes (ODI, VAS for low back pain), surgery
time, blood loss, fusion rates, complications
O Outcome Back pain, functional impairment measured with ODI,
fusion status, complications
Authors’ conclusion Findings from this clinical series of patients treated with
Findings from this clinical series of patients treated with a presacral interbody fusion procedure, stabilized with
a presacral interbody fusion procedure, stabilized with the AxiaLIF rod, reflect favorable and durable outcomes
the AxiaLIF rod, reflect favorable and durable outcomes through 2 years of follow-up.
through 2 years of follow-up.

481

Authors Mark M Mikhael, Babak Khamsi, Jeffrey C Wang

5 Critical overview and outlook
5.1 Minimally invasive spine surgery: a critical overview and outlook
5 Critical overview and

outlook
483


5.1 Minimally invasive spine surgery: a critical overview and
outlook
Mark M Mikhael, Babak Khamsi, Jeffrey C Wang
1 Introduction window possible. The incision is therefore generally reduced

in size, and in addition to a minimized approach, develop-
The initial interest in minimally invasive spine surgery ments in lighting and magnification techniques have proved
(MISS) dates back several decades, and the primary goal to be advantageous when combined with microsurgical
since the onset has been to develop novel techniques with techniques. The adaptation and integration of the operating
similar or better clinical outcomes than those obtained with microscope into spine surgery dates back to the late 1960s,
conventional open spine surgery. Research in the field of when it was first utilized in MISS to perform lumbar de-
MISS aims at minimizing iatrogenic soft-tissue exposure compression [1]. Since that time, the operating microscope
associated with traditional open procedures, theoretically has been used in a wide range of minimally invasive spine
resulting in less damage to nervous and vascular structures procedures, as is regularly outlined in the “Preoperative
in the region of the paraspinal muscles, decreased blood planning” topic throughout this text, because, when com-
loss, reduced postoperative pain, smaller incisions, less scar- bined with superior lighting, it ensures improved magnifi-
ring, shorter length of hospital stay, and faster recovery cation possibilities, in addition to providing both the surgeon
times. Although strongly supported throughout this text, and his/her assistant with a three-dimensional view of the
further longitudinal and comparative studies are still need- operative site. This surgical tool has facilitated the perfor-
ed in order to fully endorse the assumption that MISS pro- mance of the most delicate operative tasks within extreme-
vides better long-term outcomes than those observed after ly restricted spaces, and allowed the use of very fine sutures
traditional open surgery. and microscopic instruments. Although there have been
few major advances in the field in recent years, the role of
The current tools and procedures utilized in MISS have the operating microscope in present-day MISS is already
been adapted from those already in use in a number of well established [2, 3].
other surgical fields. Although state-of-the-art imaging
techniques, limited exposures, and specialized instruments 2.2 Minimized access
are important and of undoubted assistance in MISS, the To achieve the goal of adequate visualization with minimal
main consideration is to ensure that the proposed goals of soft-tissue injury, several developments have been intro-
the surgical procedure can actually be achieved. duced to facilitate minimized access, ranging from fiber-
optic endoscopes and video systems to fixed or expandable
Current advances in MISS can be divided into four main tubular retractor systems used in combination with percu-
aspects: microsurgical techniques; minimized access; spe- taneous techniques. Thoracoscopic and laparoscopic tech-
cialized instrumentation; and imaging and navigation sys- niques have been adapted from other open surgical proce-
tems (see chapter 1.3 The four pillars of minimally invasive dures and now play a significant role in MISS. These
spine surgery). microsurgical approaches have allowed access to the spinal
cord, spinal nerves, disc spaces, vertebral bodies, paraver-
tebral soft tissues, and sympathetic chain [4]. Certain pro-
2 The four pillars of MISS cedures include microdecompression of the thoracic and
lumbar spine, reconstruction and instrumentation follow-
2.1 Microsurgical techniques ing trauma, anterior lumbar interbody fusion, and the treat-
The goal of all MISS techniques is to successfully perform ment of idiopathic scoliosis and kyphotic deformities. While
the necessary procedure with a minimum of injury to the some studies suggest that their minimally invasive nature
soft tissues; thus, the basic tenet underlying this type of is beneficial to the patient, with decreased operative time,
surgery is to achieve the aim of using the smallest approach less blood loss, lower morbidity, improved cosmesis, and
485

reduced length of hospitalization [4, 5], other reports have rods are then passed under the skin and connected to the
indicated that these procedures do not present a definitive screws using swinging jigs that guide the rod into the lock-
advantage over mini-open exposures [6]. For instance, trans- ing heads of the pedicle screws. These techniques are per-
sacral (AxiaLif) fusion surgery and the overall safety of formed through small percutaneous incisions. Other systems
lateral transpsoas approaches for lumbar fusion surgery still have also been designed whereby instrumentation is placed
need to be evaluated. Further studies are therefore neces- under direct visualization in combination with special MISS
sary, either in the form of prospective trials or on the basis retractors in order to perform minimized access fusion.
of surgical registries, in order to collect more data and hope-
fully provide definitive conclusions regarding the advan- Minimized access interbody fusion has also been made pos-
tages of MISS. sible by developing transforaminal, straight lateral, and
axial interbody fusion systems, which have facilitated the
Tubular retractor systems have been developed to facilitate performance of anteroposterior spinal fusion through either
minimized access, their mode of action being through se- percutaneous or minimally invasive incisions. While some
rial dilation. These retractors are used via a transmuscular of the more recent technologies and techniques still lack
approach; the tubes are gradually enlarged or expanded to long-term clinical and backup data, the interest in and use
create a wider viewing area. For optimal visualization of all of these systems is increasing. The interaction between sur-
the pertinent anatomical landmarks, the retractors may geons and their industrial partners has been, and will con-
often need to be directed at various angles during the sur- tinue to remain, crucial in order to further extend the pos-
gical procedure, eg, to visualize contiguous lumbar levels. sibilities of MISS.
Given the restricted working area, specially adapted instru-
ments have to be used in conjunction with tubular retrac- 2.4 Imaging and navigation systems
tor systems. Because of the complexity of the spinal anatomy and the
extremely low margin for error permitted in spine surgery,
Endoscopic techniques and the use of robotics are also be- image guidance systems are regarded as ideal tools for MISS,
ing investigated for use in spine surgery. One of the major and are strongly supported by the authors of this text. The
advantages of endoscopic surgery includes the enhanced theoretical benefits include increased accuracy and safety
visualization through small percutaneous portals. Robotic of MISS procedures provided by the more limited surgical
technology has been used in other surgical specialties to exposure, and also the reduced exposure of both the patient
improve precision and to ensure control over the insertion and surgeon to ionizing radiation. The surgeon is also able
of instrumentation through minimized access portals. to place instrumentation either through small corridors
between critical anatomical structures, or his/her task can
2.3 Specialized instrumentation be facilitated during revision surgery in cases where the
Because of the limited access available to the surgeon, spe- normal anatomy may have been distorted. Several studies
cially adapted instruments have been developed for use have attempted to systematically compare MISS techniques
with minimally invasive techniques, and these have been with traditional procedures [7–9].
outlined in the “Instrumentation” sections of several chap-
ters in this text. For example, the instruments utilized with Computer-assisted navigation systems involve real-time
tubular retractor systems need to be bayoneted and longer, tracking of sensors on virtual surgical instruments to help
so that they can be used through narrow channels. As well identify landmarks related to previously acquired imaging
as specifically designed instrumentation, state-of-the-art studies. This technology has been adopted in all areas of
techniques of soft-tissue ablation, such as electrocautery, orthopedics, particularly as regards joint arthroplasty, and
have been developed to help accomplish the goals of surgery spine surgery. It allows the surgeon to accurately place
while maintaining minimized access. Such developments pedicle screws via a percutaneous technique with the use
have facilitated discectomy and decompression. In addition, of image intensification and previously programmed CT
fusion with instrumentation has been achieved as a result scan, with the aid of a computer, which helps position “vir-
of further advances in this field. tual” instruments relative to image intensification or CT
scan on a computer monitor. In this manner, the surgeon
Percutaneous instrumentation systems play a major role in is able to position instruments in multiple planes without
MISS. Relatively recent developments in cannulated screw excessive use of intraoperative image intensification (see
systems have facilitated the accurate placement of pedicle the “Planning procedures” and Surgical techniques” topics
screws, passed over guide wires, down to the pedicles. The in many of the chapters).

Intraoperative CT scan is yet another technological advance pable of modulating cell growth, differentiation, and extra-
in the field of imaging that may change the landscape of cellular matrix (ECM) accumulation have all shown prom-
both traditional open surgery and MISS. It allows the sur- ise in the treatment of degenerative disk disease [22].
geon to obtain circumferential data that would not otherwise
be obtainable with intraoperative image intensification or A group of patients that may particularly benefit from MISS
x-ray. These data can be processed to construct axial imag- are those with metastatic spine tumors. These patients have
ing, or used in conjunction with a navigation system to been traditionally treated with major, highly invasive sur-
ensure the proper placement of instrumentation during gical interventions such as laminectomy, corpectomy and
surgery. However, the role of intraoperative CT scan in fusion. However, unfortunately, these patients are often
spine surgery has not yet been fully established, and still debilitated and at a high risk for surgical morbidity and with
requires further investigation to determine the benefits, limited life expectancies from their underlying disease. For
safety, and efficacy compared with more traditional imag- this reason, less invasive treatment options such as radio-
ing modalities. therapy and percutaneous cement augmentation are being
utilized more with promising results [23–24].
3 Outlook MISS is being more frequently utilized for the cervical spine
as well. In 2000, Burk et al first demonstrated that cervical
Although less invasive surgical treatment of spinal pathol- microendoscopic foraminotomy/discectomy achieved equiv-
ogy was already described in the 1970s [10], minimally in- alent bony resection and nerve root decompression com-
vasive techniques did not gain popularity until recent de- pared with traditional open techniques in a cadaveric mod-
cades, with MISS still being considered “new” requiring el [25]. This was followed by another cadaveric study
better and more prospective studies to evaluate its efficacy. performed by Wang [26] showing that laminoplasty can be
Currently, full endoscopic techniques have been described successfully performed using minimally invasive techniques.
for a variety of procedures such as disk herniations and In recent years, these techniques are being used more fre-
spinal stenosis [11], lumbar discectomy [12], lumbar lateral quently with early results comparable to open techniques
recess stenosis [13], anterior cervical decompression [14] and [27]. Less invasive instrumentation of the cervical spine re-
posterior cervical decompression [15] with results compa- mains a challenge. Interesting results using trans-facet screws
rable to more traditional open techniques. and robotic surgery have recently been reported and may
offer a promising avenue for future developments [28, 29].
Further, robotic technology already in use in other surgical
specialties is being investigated for use in spine surgery to MISS has gained momentum in recent years, since it is a
improve precision and to ensure control over the insertion rapidly evolving field with new techniques and more refined
of instrumentation through minimized access portals. For instruments continually being incorporated. Surgeons in
example, the da Vinci surgical system (Intuitive Surgical, conjunction with their industrial partners continue to de-
Sunnyvale, USA) has already been established in urology, velop easier-to-use systems, and the educational updating
gynecology, and otolaryngology [16–18]. This system com- of surgeons worldwide has been facilitated with the latest
bines all the pillars discussed above by allowing the surgeon web-based technology. With the increasing popularity of
to remotely control three or four robotic arms while being mobile internet access devices, the surgeon’s educational
seated at a console, viewing a high definition, 3-D image landscape has changed. The widespread availability through
inside the patient’s body. It has been used for the resection mobile technology of educational materials and online
of spinal tumors [19] and recently this system was used for courses has made these tools easily accessible throughout
the first time to perform an anterior lumbar interbody fu- the globe. Advances in means of communication and meth-
sion (ALIF) in a 52-year-old woman with degenerative disc ods of instruction have constituted a major factor in the
disease and low back pain [20]. In addition, robotic surgery rapid development and distribution of MISS techniques.
has been used successfully for implantation of percutaneous
screw systems in the lumbar and thoracic spine [21]. The increasing complexity of new minimally invasive tech-
niques implies a significant learning curve for the surgeon.
The advancement in biologics and their potential use in Specialized education through courses and human ana-
spinal pathology, may decrease the need for more invasive tomical specimen training are helpful in gaining experience,
surgical approaches currently widely used. Proteins such first of all in simple cases, then subsequently progressing
as growth factors and other biological agents that are ca- towards the more complex. An experienced surgeon needs
487

to ensure that the proposed goals of the surgical procedure rate, and a lower number of residual events [33]. A different
can actually be achieved, and be prepared to switch to a retrospective, multi-institutional database review demon-
more traditional approach if any major difficulty is encoun- strated that MISS lumbar interbody fusion results in a sta-
tered. Although the latest minimally invasive techniques tistically significant reduction in hospital LOS and a reduc-
can be extremely effective, the individual surgeon must tion in total hospital costs with two-level surgery after
have the necessary experience and technical skills. adjusting for significant covariates. In this study the major-
ity of cost savings from MISS were due to more rapid mo-
However, minimally invasive techniques in spine surgery bilization and discharge, as well as a reduction in outliers
still require rigorous assessment, and further comparison with extended hospitalizations [34].
of scientific data on these new techniques versus tradi-
tional surgical procedures. Some reports have already sug- Enthusiasm over recent developments and techniques in
gested that the minimized access used in MISS may either the field of MISS should be both welcomed and viewed with
result in incomplete treatment, or provide no clear advan- caution. As with all new developments, the various ad-
tage over more traditional techniques [30–32]. More pro- vances in the field must be subjected to careful scrutiny in
spective studies are required to accurately determine the order to ensure patient safety and the efficacy of the prog-
specific role, risks, benefits, learning curve, and ultimate ress made. It is also important to consider those aspects that
patient outcomes for MISS when compared with more tra- might make this technology more viable in the future. Ac-
ditional approaches. quired skills in this area will help the surgeon to better adapt
to further progress in the field, as outcome data confirm
Lastly, it is important to consider the effect of minimally the benefits of MISS. As this technology becomes more
invasive spinal surgery on overall healthcare cost. There widely accepted, it is likely that surgical tools, such as nav-
have been a number of studies comparing the cost of MISS igation and imaging systems combined with specific surgi-
to open surgery. One study looking at patient outcomes cal sets and instrumentation, may develop further. Lessons
and cost of surgically treated patients at a community hos- learned from previous initiatives have demonstrated that
pital for degenerative conditions of the lumbar spine, with any innovative technology is accompanied by new problems,
either a MISS or open approach for two-level instrument- confrontations, or controversial issues. Despite the high
ed lumbar fusion, found that utilizing minimally invasive technological level of current imaging, the limited exposure
techniques results in decreased hospital costs in the early and the specialized instruments available, it is imperative
perioperative period in addition to benefits of significantly for the surgeon to ensure that the proposed goals of the
less blood loss, shorter hospital stays, lower complication surgical procedure can be safely achieved.

4 References
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489


Minimally Invasive Spine Surgery Techniques, Evidence, and Controversies

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Minimally Invasive Spine Surgery Techniques, Evidence, and Controversies

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AOS_MISS_Book.

indb 2 10/30/12 11:08 AM

Minimally Invasive Spine Surgery

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Minimally Invasive Spine Surgery

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Hazards Legal restrictions

Check hazards and legal restrictions on www.aofoundation.org/legal

Copyright © 2012 by AOSpine, Switzerland, Clavadelerstrasse 8, CH-7270 Davos Platz

ISBN: 978-3-13-172381-9 123456

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The book is a comprehensive coverage of all techniques in

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To Alasha, Sebastian and Julian.

For all their love, support, understanding and patience,

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AOS_MISS_Book.indb 7 10/30/12 11:08 AM

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Roger Härtl, MD Andreas Korge, MD

Beejal Y Amin, MD Ali A Baaj, MD Rahul Basho, MD

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Theodore H Schwartz, MD, FACS Nicholas Slimack, MD Jeffrey C Wang, MD

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Table of contents XIV

Definition of the different classes of evidence table XVI

1 Fundamentals 1 2 Cervical techniques 105

1.5 Different spinal pathologies and patient selection 57

1.6 Computer-assisted navigation for minimally invasive  67

1.7 Biologics in minimally invasive spine surgery 85

1.8 Anesthetic considerations and minimally invasive  91

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3 Thoracic techniques 173 4 Lumbar/sacral techniques 261

3.1 Introduction 175 4.1 Introduction 263

5 Critical overview and outlook 483

5.1 Minimally invasive spine surgery: a critical overview  485

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Definition of the different classes of evidence (CoE)

Level Study design Criteria

I Good quality RCT • Concealment

Randomized Controlled Trial (RCT)

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1 Rationale led to a decrease in postoperative pain symptoms with less

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Transpedicular decompression surgery Fusion procedures (eg, cages, plates)

Laminotomy Total disc replacement

Vertebral body augmentation (vertebroplasty/kyphoplasty) Vertebral artery decompression

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Dura Nerve root L5

Quicker return to DLA Smaller incision

Shorter hospital stay Less soft-tissue damage

Quicker recovery Less blood loss

Less postoperative pain Lower complication rate

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Complications (3/05–2/10) Complications (3/05–2/10)

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Fig 1.1-6 Marking the incision line for a minimalized

ISBN: 978-3-13-172381-9 123456

Table of contents XIV

Definition of the different classes of evidence table XVI

1 Fundamentals 1 2 Cervical techniques 105

1.5 Different spinal pathologies and patient selection 57

1.6 Computer-assisted navigation for minimally invasive 67

1.7 Biologics in minimally invasive spine surgery 85

1.8 Anesthetic considerations and minimally invasive 91

3 Thoracic techniques 173 4 Lumbar/sacral techniques 261

3.1 Introduction 175 4.1 Introduction 263

5 Critical overview and outlook 483

5.1 Minimally invasive spine surgery: a critical overview 485

I Good quality RCT • Concealment