Hyeun Sung Kim (neuros@dreamwiz.com) Conventional Posterior Lumbar Interbody Fusion versus Mini-open Posterior Lumbar Interbody Fusion using the New.

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Hyeun Sung Kim (neuros@dreamwiz.com) Conventional Posterior Lumbar Interbody Fusion versus Mini-open Posterior Lumbar Interbody Fusion using the New Percutaneously Inserted Spinal Transpedicular Screwing System Hyeun Sung Kim(neuros@dreamwiz.com)1 S.K. Park2, H. Joy2, I.H. Park2, J.K. Ryu2 K.H. Park3 C.I. Ju4, S.W. Kim4, S.M. Lee4, H. Shin4 1Hurisarang Hospital, Department of Neurosurgery, Daejeon, Republic of Korea 2Mokpo Hankook Hospital, Department of Neurosurgery, Mokpo, Republic of Korea 3Korea Hospital, Department of Orthopedic Surgery, Jeonju, Republic of Korea 4College of Medicine, Chosun University, Department of Neurosurgery, Kwangju, Korea, Republic of

Hyeun Sung Kim (neuros@dreamwiz.com) Historical Review Disadvantages of posterior fusion large skin incisions extensive muscle dissection trauma to the lumbar musculoligamentous complex long operation time significant blood loss significant postoperative pain postoperative paraspinal muscle denervation Goals of Mini-open Posterior Decompression & Fusion => To reduce the approach-related morbidity associated with traditional lumbar fusion minimal skin incision and anatomic dissection minimal operation time minimal blood loss & minimal transfusion minimal postoperative pain minimal hospital stay period better cosmetic benefits Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Hyeun Sung Kim (neuros@dreamwiz.com) Material and Methods Period : January 2004 to February 2007 Groups Group A (n=86) Microscopic conventional PLIF + open transpedicular screw fixation Group B (n=145) Microscopic Modified mini-open PLIF + percutaneous transpedicular screw fixation Materials Group A Group B Mean Age (years) 56.3 (34 – 73) 59.1 (23 – 78) Number 86 145 Men follow-up period (months) 23.7 (6 – 43) 25.3 (6 - 43) Cases of fusion level 1 level 73 117 2 level 11 22 3 level 4 6 Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Hyeun Sung Kim (neuros@dreamwiz.com) Methods : Device Newly designed percutaneous transpedicular screw fixation system Name Apollon System Manufactured by Solco medical, South Korea Characteristics Detachable screw extender system Easy to rod manipulation Can use thoracolumbar area percutaneously Can use multi-level screwing vertical axis Easier to achieve compression and distraction Threaded screw joint Firm and secure fixation Rimmed screw head Decrease screw head loosening One-touch rod locking system Easy & quick operation Unique alignment guide Poly-axial screw heads Easy to rod insertion Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Methods : Operation Methods Hyeun Sung Kim (neuros@dreamwiz.com) Methods : Operation Methods Spine Classics MLD Total Foraminal Decompression Apollon System Application Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Methods : Operation Methods Hyeun Sung Kim (neuros@dreamwiz.com) Methods : Operation Methods Modified midline total decompressed Mini-open PLIF technique Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Methods : Low Back Outcome Scale Hyeun Sung Kim (neuros@dreamwiz.com) Methods : Low Back Outcome Scale The Low-Back Outcome Scale of Greenough and Fraser Parameter Finding Points Current pain 7 to 10 cm VAS Sex life Severely affected impossible 5 to 6 cm VAS 3 Moderately affected difficult 2 3 to 4 cm VAS 6 Mildly affected 4 O to 2 cm VAS 9 Unaffected employment Unemployed because of back pain Sleeping Part time 1 Full time lighter Full time original Domestic chores odd jobs None Walking A few but not many Most or all but more slowly normally unaffected Sport or active social activities Sitting Some but much less than before Back to previous level resting Resting more than half the day Little rest needed occasional Travelling No need rest Treatment or consultation More than once per month About once per month Rarely Dressing Never Analgesia Several times each day Almost every day Occasionally Total 75 Score Status >= 65 Excellent 50 – 64 good 30 – 49 Fair 0 - 29 poor Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Hyeun Sung Kim (neuros@dreamwiz.com) Results Results Group A(n=86) Group B(n=145) Mean Surgical Time (minutes) 163.7 (120-280) 142.6 (100-240) Blood loss (ml) 753 (350-1200) 438 (160-850) LBOS 56.2 63.8 Skin Incision Length (Cm) : Midline Skin Incision Group A Group B 1 level 6.23 3.71 2 level 11.28 6.27 3 level 15.26 8.35 Complications Group A Group B Dural tear 5 cases(5.8%) 8 cases (5.5%) Deep wound infection 4 cases(4.7%) 4 cases (2.7%) Device failure 5 cases (3.4%) Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Results : Skin Incision Length Hyeun Sung Kim (neuros@dreamwiz.com) Results : Skin Incision Length Conventional Skin Incision 1 level Mini-open Skin Incision 1 level 2 level 3 level Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Discussion : Evolution of Minimal Invasive Lumbar Fusion Hyeun Sung Kim (neuros@dreamwiz.com) Discussion : Evolution of Minimal Invasive Lumbar Fusion Leu HF, Hauser RK. Percutaneous endoscopic lumbar spine fusion. Neurosurg Clin N Am 1996:7;107-17 Foley KT, Smith MM. Microendoscopic dicectomy. Tech Neurosurg 1997:3;301-307 Mathews HH. Percutaneous interbody fusions. Orthop Clin North Am 1998:29:647-53. Foley KT, Gupta SK, Justis JR, Sherman MC. Percutaneous pedicle screw fixation of the lumbar spine. Neurosurg Focus 2001:10;1-9. Foley KT, Gupta SK. Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg 2002:97;7-12. Kim DH, Jaikumar S, Kam AC. Minimally invasive spine instrumentation. Neurosurgery 2002;51:S15-25. Khoo LT, Palmer S, Laich DT, Fessler RG. Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery 2002;51:S166-81. Foley KT, Holly LT, Schwender JD. Minimally Invasive Lumbar Fusion. Spine 2003:28:S26-S35 Lee SH, Choi WG, Lim SR, et al. Minimally invasive anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation for isthmic spondylolisthesis. The Spine Journal 2004:4;644-649 Mummaneni PV, Rodts GE Jr.. The mini-open transforaminal lumbar interbody fusion. Neurosurgery 2005:57;256-61. Schwender JD. Holly LT. Rouben DP. Foley KT. Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF): Technical Feasibility and Initial Results. J Spinal Disord Tech 2005:18;S1-6. Holly LT, Schwender JD, Rouben DP, Foley KT. Minimally invasive transforaminal lumbar interbody fusion: indications, technique, and complications. Neurosurg Focus 2006:20;E6. Deutsch H. Musacchio MJ Jr.. Minimally invasive transforaminal lumbar interbody fusion with unilateral pedicle screw fixation. Neurosurg Focus 2006:20;E10. Anand N, Baron EM, Thaiyananthan G, et al. Minimally invasive multilevel percutaneous correction and fusion for adult lumbar degenerative scoliosis: a technique and feasibility study. J Spinal Disord Tech 2008:21;459-67. Gepstein R, Shabat S, Reichel M, et al. Treatment of postdiscectomy low back pain by percutaneous posterior lumbar interbody fusion versus open posterior lumbar fusion with pedicle screws. The Spine Journal 2008:8;741-46. Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Discussion : Mini-open PLIF Versus TLIF Hyeun Sung Kim (neuros@dreamwiz.com) Discussion : Mini-open PLIF Versus TLIF Mini-open Posterior Lumbar Interbody Fusion(PLIF) The PLIF technique requires significant bilateral retraction on the thecal sac and nerve roots, whereas TLIF provides less extensive neural retraction and injury by accessing the spinal canal and disc via a path that runs through the far-lateral portion of the vertebral foramen. Transforaminal Lumbar Interbody Fusion(TLIF) In Mini-open PLIF and TLIF Not easy to resolve the lateral recess stenosis Not easy to decompress central stenosis Not easy to restore the spinal balance Not easy to operate on multi-level fusion Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Discussion : Modified Mini-open PLIF Hyeun Sung Kim (neuros@dreamwiz.com) Discussion : Modified Mini-open PLIF Modified midline total decompressed Mini-open PLIF the Modified Mini-open PLIF + Newly Designed Pedicle Screwing Minimized the skin incision Minimized the muscle retraction and surround structural damage Maximized the spinal decompression More familiar to spine surgeon More easy to compression and distraction procedure Benefit of a multilevel PLIF Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Discussion : Bone Cement Augmentation for Osteoporosis Hyeun Sung Kim (neuros@dreamwiz.com) Discussion : Bone Cement Augmentation for Osteoporosis Burval DJ, McLain RF, Milks R, Inceoqlu S. Primary pedicle screw augmentation in osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength. Spine 2007:32:1077-83. Frankel BM, Jones T, Wang C. Segmental polymethylmethacrylate-augmented pedicle screw fixation in patients with bone softening caused by osteoporosis and metastatic tumor involvement: a clinical evaluation. Neurosurgery. 2007:61:531-7. Kim HS, Park IH, Ryu JK, Kim SW, Shin H. Bone Cement Augmentation of Pedicular Screwing in severe Osteoporotic Spondylolisthetic Patients. J Korean Neurosurg Soc 2007:42;6-10. Tan JS, Balley CS, Dvorak MF, et al. Cement augmentation of vertebral screws enhances the interface strength between interbody device and vertebral body. Spine 2007:32;E317-24. Chang MC, Liu CL, Chen TH. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine 2008:33;334-341. Kim HS, Park SK, Joy H, Ryu JK, Kim SW, Ju CI. Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis. J Korean Neurosurg Soc 2008:44;8-14 Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Cases : One Level – Non-osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : One Level – Non-osteoporotic 70/F : Isthmic Spondylolisthesis L5 on S1 6Months F/U 51/F : Isthmic Spondylolisthesis L4 on L5 1yrs F/U 58/F : Spinal stenosis L4 on L5 6Months F/U Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Cases : One Level - Osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : One Level - Osteoporotic 62/F :Degenerative Spondylolisthesis L4 on L5, L2 osteoporotic VCFs 6Months F/U 59/F : Isthmic Spondylolisthesis L4 on L5 1yrs F/U 65/M : Isthmic Spondylolisthesis L4 on L5 1yrs F/U Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Cases : Two Level – Non-osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : Two Level – Non-osteoporotic 60 /M : Spinal stenosis and instability L3-4-5 1yrs F/U 60/F : both foraminal stenosis L4-5-S1 6Months F/U 56/F : Isthmic Spondylolisthesis L4 on L5 on S1 1yrs F/U Hyeun Sung Kim (neuros@dreamwiz.com)

Cases : Two Level –Osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : Two Level –Osteoporotic 78/F : degenerative Spondylolisthesis L3 on L4 on L5, osteoporotic VCFs L4 6Months F/U 71/F : spinal stenosis L4-5-S1 1 yrs F/U Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Cases : Three Level – Non-osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : Three Level – Non-osteoporotic 53/F : Degenerative Spondylolisthesis L3 on L4 on L5, Foraminal stenosis L5-S1 Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Cases : Three Level – Non-osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : Three Level – Non-osteoporotic 60/F : Spinal stenosis L3-4-5-S1 1yrs F/U 68/F : spinal stenosis L3-4-5-S1 6Months F/U 51/F : Spinal stenosis and instability L3-4-5-S1 6Months F/U Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Cases : Three Level – Non-osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : Three Level – Non-osteoporotic 67/F : Spinal stenosis L3-4-5-S1 and instability, Spondylitis 6Months F/U 68/M : Spinal stenosis and Instability L3-4-5-S1, HNP L5-S1 6Months F/U Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Cases : Three Level – Osteoporotic Hyeun Sung Kim (neuros@dreamwiz.com) Cases : Three Level – Osteoporotic 59/M : Spinal stenosis and instability L2-3-4-5 9Months F/U Metal failure 51/F : Spinal stenosis L4-5-S1 and Iatrogenic intraoperative joint damage L3-4 6Months F/U Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)

Hyeun Sung Kim (neuros@dreamwiz.com) Conclusion A vertical axis and detachable screw extender system makes it easier to perform rod manipulation as well as compression and distraction. As compared with conventional PLIF, it can decrease the length of the midline skin incision. It is therefore useful in reducing operative time and intra-operative blood loss, thus minimizing the postoperative occurrence of back pain and complications. Accordingly, a prompt recovery and a good clinical outcome can be expected. Hyeun Sung Kim (neuros@dreamwiz.com, www.ilovespine.com)