Lumbar spondylolisthesis (MISS TLIF) Case for plenary or small group discussions MISS Curriculum Taskforce Avelino Parajón July 1, 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 performing the procedure Recognize possible complications and how to avoid and manage them

Presentation 66-year-old woman Hypertension Lymphoma (controlled) Lung cancer (controlled) Neurogenic claudication Left leg pain Severe low back pain Rehabilitation, pain unit

Imaging

Imaging

Imaging

Imaging

Previous treatment Physical therapy Pain unit

Diagnosis L4/5 spondylolisthesis and stenosis Neurogenic claudication

Management plan/options Nonoperative treatment Physiotherapy, pain management Surgery Interspinous spacer Laminectomy Open vs MISS tubular: ULBD Endoscopic Decompression and fusion MISS TLIF LLIF OLIF Others?

Treatment MISS TLIF tubular approach (left side TLIF)

Main surgical steps: contralateral screws

Main surgical steps: ipsilateral screws

Main surgical steps: discectomy, decompression, cage

Main surgical steps: discectomy, decompression, cage

Main surgical steps - rod insertion and compression

Main surgical steps – alternative - MISS TLIF with navigation

Outcome Surgery time skin to closure 1.5 to 2 hours Minimal blood loss 2-3 nights at hospital Neuro intact after surgery Postop 2-3 months rigid orthosis Walking improved, pain resolved

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

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 Use navigation Pseudarthrosis Complete discectomy and adequate amount of bone graft in the disc space Consider different options of bone grafts

Take-home messages MISS TLIF via tubular retractor is safe and effective Can address bilateral pathology via unilateral approach Can achieve similar fusion rates to open TLIF 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