Dissecting the ALPHABET SOUP of Spine Surgery Eric Sundberg, M.D. Coastal Orthopedic Spine Surgery ----------------------------------------------------------------- Coastal Orthopedics Sports Medicine | Pain Management

Disclosures None

Posterolateral Fusion

Interbody Fusion

Minimally Invasive Spine Surgery (MISS) PAIN DYSFUCTION Much of the morbidity of spinal procedures is related to accessing the spine Muscle retraction Denervation Devascularization Facet denervation In the past 2-3 decades, we have witnessed the emergence of minimally invasive techniques in most surgical specialties, however the role of MIS in spine surgery remains controversial. So Why MISS? Much of the morbidity of spinal procedures are related to accessing the spine. Open spinal decompression and fixation requires extensive soft tissue and muscle dissection. This dissection can lead to denervation of the facet capsule and weakening of other supportive structures. This can result in pain, dysfunction and less than optimal functional outcome Mayer et al. Spine 1989 McNab et al. Spine 1977 Sihvonen et al. Spine 1993 PAIN DYSFUCTION

Potential advantages of MISS Smaller incisions & scars Minimal soft-tissue destruction & scarring Less surgical blood loss Shorter hospital stay Less postoperative pain Less need for postop pain meds Faster return to work and daily activities Potential advantages compared with “open” surgery, MIS may result in

Fringe/voodoo procedures (“lasers”, scopes…) Definition of MISS What MISS is not: Fringe/voodoo procedures (“lasers”, scopes…) About small incisions PR hype What defines MIS surgery?

Requires a different set of skills than open surgery What MISS is: Well-established procedures with proven outcomes without sacrificing the surgical goals Unfortunately questionable procedures marketed as MIS have tainted the field Requires a different set of skills than open surgery Performing well-established procedures with proven outcomes using less invasive approaches without sacrificing the surgical goals Shorter OR times (no opening/closing), Less blood loss, Shorter LOS, Less post-op pain, Faster recovery

Anatomy

Anatomy MU: multifidus QL: quadratus lumborum IL: iliocostalis One of the main goals of minimally invasive spine surgery is to reduce trauma to the two posterior paraspinal muscle groups— the deep paramedian muscle group, including the multifidus, interspinales, intertransversarii, and short rotators, and the more superficial and lateral erector spinae muscles including the longissimus and iliocostalis. These muscles run along the thoracolumbar spine and attach caudally. The multifidus muscle in particular is important for dynamic stability of the spine MU: multifidus IL: iliocostalis LO: longissimus QL: quadratus lumborum IT: intertransversarii PS: psoas

Anatomy One of the main goals of minimally invasive spine surgery is to reduce trauma to the two posterior paraspinal muscle groups— the deep paramedian muscle group, including the multifidus, interspinales, intertransversarii, and short rotators, and the more superficial and lateral erector spinae muscles including the longissimus and iliocostalis. These muscles run along the thoracolumbar spine and attach caudally. The multifidus muscle in particular is important for dynamic stability of the spine

Various Approaches to the Lumbar Spine

Lumbar Fusion Acronyms ALIF - Anterior Lumbar Interbody Fusion PLIF - Posterior Lumbar Interbody Fusion MLIF - Midline Lumbar Interbody Fusion TLIF - Transforaminal Lumbar Interbody Fusion XLIF - eXtreme Lateral Interbody Fusion DLIF - Direct Lateral Interbody Fusion OLIF - Oblique Lumbar Interbody Fusion Minimally Invasive Options for all approaches

ALIF

ALIF

ALIF

PLIF

PLIF

TLIF

TLIF Tubular Retractor Arts M et al. JAMA 2009 This technique involves progressive dilation of the soft tissues, as opposed to cutting directly through the muscles. By using tubes to keep the muscles out of the way, you can work through the incision without having to expose the area widely. You can use a microscope or loupes to focus down the tube to assist with performing the surgery through a tube. Once the procedure is complete, the tubular retractor can be removed, allowing the dilated tissues to come back together. Guide pen insertion under fluoroscopy  Dilator Insertion  Retractor depth is measured using indices on the side of the dilator Retractor Insertion  With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure TLIF Tubular Retractor Arts M et al. JAMA 2009

With the use of a high speed burr, a laminectomy is performed on the cephalad vertebrae. The burr is then used to pass through the pars interarticularis laterally and the inferior articular process of the cephalad vertebrae is then removed bilaterally. The removed bone is saved for the graft. The ligamentum flavum is removed using a Kerrison rongeur to expose the nerve roots bilaterally. The venous complex overlying the disc space is coagulated via electrocautery and an annulotomy is performed. A subtotal discectomy is achieved via disc shavers, pituitary rongeurs, and curved curettes. The disc space is adequately prepared and a trial interbody device is placed to restore appropriate lumbar lordosis. The trial is removed and bone graft saved from the earlier procedure is packed into the disc space with a goal being 20-30cc of bone graft per level of fusion. Once half the graft is placed, an articulating interbody spacer is placed such that the position of the cage is in the anterior third of the disc space allowing for restoration of segmental lordosis through compression of the posterior pedicle screws. MIS TLIF

XLIF

OLIF

Postoperative Rehabilitation The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review. Madera et al (J Neurosurg Spine 2017) “although caregivers from multiple disciplines agree that the majority of their patients will benefit from this effort, the supporting data remains sparse” Rehabiltation Following Lumbar Fusion Surgery: A Systematic Review and Meta-Analysis. Greenwood et al (Spine 2016) “a small number of low-quality studies suggest that ‘complex rehabilitation’ reduces short and long-term disability and fear avoidance behavior following LFS.” Physiotherapeutic interventions before and after surgery for degenerative lumbar conditions: a systematic review. Gilmore et al (Physiotherapy 2015) “very-low-quality evidence suggests that physiotherapy may improve pain and function following lumbar surgery”

Postoperative Protocol Variations Exist Based on the Patient/Surgeon Days 1-3 -walk on POD 0 -concentrate on short walks and mobilization -goal home with minimal dependance Week 1 -walking/mobilization, progression toward independence -hamstring and quadricep stretching (nerve glide, supine and seated hamstring stretching, prone knee flexion) Weeks 1-6 -static stabilization therapy (pelvic tilt, bridge, prone hip extension) -balance therapy

Postoperative Protocol Weeks 6-12 -Dynamic Exercises (abdominal strengthening, curls, bands, exercise ball Weeks 9-12 -Low impact aerobic exercise (swimming, brisk walking, exercise bike) Months 3-6 -Return to low impact sporting activities (swimming and biking) Months 6-12 -Return to sport (tennis, golf, running)

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