Percutaneous screw and rod placement Case for plenary or small group discussions MISS Curriculum Taskforce Néstor Taboada July 2019 2019 and 2020

Learning objectives Describe the indications and how to select the correct patient Discuss the decision making process for the specific procedure Outline important aspects of step by step of performing the procedure Recognize possible complications and how to avoid and manage them

Presentation 70-year-old woman Neurogenic claudication Left leg radicular pain Severe low back pain

Imaging

Narrow multifactor channel L4/5 observed Imaging Narrow multifactor channel L4/5 observed

Previous treatment Physical therapy Pain unit No improvement of pain Deterioration of Oswestry score

Diagnosis L4/5 spondylolisthesis and stenosis Neurogenic claudication

Management options Nonoperative treatment Physical therapy, pain management Surgery Interspinous spacer Laminectomy Open vs MIS tubular: ULBD Endoscopic Decompression and fusion MIS TLIF LLIF OLIF Others?

Treatment performed Percutaneous screws and rods

Procedure Percutaneous screws in right position. Check the position of screws and rods in AP and Lateral views. Step by step of key wire and them screws. Check the position of TLIF in AP and Lateral

Outcome Surgery time skin to closure 1.5 to 2 hours Minimal blood loss 1 night stay in hospital Neuro intact after surgery Postoperative 2-3 months soft orthosis Walking improved, radicular and low back pain resolved

Patient selection Patient complaints and patient imaging Stability Canal stenosis Foraminal stenosis (unilateral and/or bilateral) Previous surgery Comorbidities Bone quality

Potential complications and prevention Dural tear and CSF leak Use ball tip nerve hook for dural sac dissection Protect dural sac during cage insertion Neural injury - very rare Avoid traction on nerve Protect nerve root during cage insertion Check the trajectory of the screws in AP and lateral images Use navigation Pseudarthrosis Complete discectomy and adequate amount of bone graft in the disc space Consider different options of bone grafts Compression in the screws over the rods

Take-home messages MIS percutaneous screws is a safe procedure Is necessary check the step by step in the placement of the screws and rods (AP and Lateral x-ray or navigation) Can address bilateral pathology via unilateral approach Can achieve similar fusion rates to open procedures Adherence to strict MIS techniques minimizes complications such as CSF leak, neural/vascular injury, infection, etc Navigation is an excellent tool to prevent malposition of implants and reduce radiation exposure to the surgical team