1. Lumbar spondylolisthesis (MISS TLIF)
Case for plenary or small group discussions
MISS Curriculum Taskforce
Avelino Parajón
July 1, 2019
2019 and 2020

2. 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

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

4. Imaging

5. Imaging

6. Imaging

7. Imaging

8. Previous treatment
Physical therapy
Pain unit

9. Diagnosis
L4/5 spondylolisthesis and stenosis
Neurogenic claudication

10. 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?

11. Treatment
MISS TLIF tubular approach (left side TLIF)

12. Main surgical steps: contralateral screws

13. Main surgical steps: ipsilateral screws

14. Main surgical steps: discectomy, decompression, cage

15. Main surgical steps: discectomy, decompression, cage

16. Main surgical steps - rod insertion and compression

17. Main surgical steps – alternative - MISS TLIF with navigation

18. 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

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

20. 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

21. 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