1. Minimally Invasive Spine Surgery (MIS)
Title
Practice Name
Location

2. Section 1: Minimally Invasive Spine Surgery
Minimally Invasive Transforaminal Interbody Fusion

3. The Dimensions of Back Pain
More than 65 million Americans annually suffer from lower back pain
Third most-frequent reason for surgery overall
Approximately 250,000 lumbar spinal fusions performed
Approximately 400,000 lumbar spinal decompression procedures performed

4. Minimally Invasive Surgery: A Breakthrough Innovation
Potential advantages compared with “open” surgery
May result in
Smaller incisions and scars
Minimal soft-tissue destruction and scarring
Less surgical blood loss
Shorter hospital stay
Less postoperative pain
Less need for postoperative pain medicine
Faster return to work and daily activities

5. Minimally Invasive Techniques
Other common minimally invasive surgeries
Gall bladder removal
Appendectomy
Bariatric surgery
Total hip replacement

6. Section 2: Technique Overview
Minimally Invasive Transforaminal Interbody Fusion

7. Patient Positioning
With patient in prone position, incision is made, and sequential dilation begins

8. Dilator Insertion
Retractor depth is measured using indices on the side of the dilator

9. Retractor Insertion
With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators

10. Retractor Positioning
With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure

11. Retractor Expansion
Retractor is expanded to visualize anatomy

12. Spine Visualization
Curved racks increase visualization distally while limiting the exposure at the skin surface

13. Telescoping Blade Adjustment
Telescoping blades are adjusted to prevent muscle creep that can obstruct view

14. Facetectomy and Annulotomy
Facetectomy and annulotomy are then performed to gain access to the disc space
Complete discectomy is performed, and the vertebral body endplates are prepared

15. Trial Insertion
Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue

16. Spacer Insertion Spacer is loaded onto inserter and inserted
If necessary, nerve root or dural retractors can be used

17. Spacer Positioning The inserter is disengaged from spacer and removed
Spacer is positioned across the midline at roughly 35°, and then autograft is packed around the spacer

18. Screw and Rod Insertion Mark Screw Entry Points
Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points

19. Pedicle Preparation
Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle

20. Dilator Placement
Dilators are placed over the guide wire to prepare for appropriately sized tap
The pedicles are then tapped to prepare for screw placement

21. Screw Insertion
Screw and screw-extension assemblies are percutaneously inserted into the pedicles

22. Patient Positioning
With patient in prone position, incision is made, and sequential dilation begins

23. Dilator Insertion
Retractor depth is measured using indices on the side of the dilator

24. Retractor Insertion
With retractor set to proper depth, the cannulator introducer handle is used to insert retractor over the dilators

25. Retractor Positioning
With retractor in place, the rigid arm is connected in order to maintain positioning throughout the procedure

26. Retractor Expansion
Retractor is expanded to visualize anatomy

27. Spine Visualization
Curved racks increase visualization distally while limiting the exposure at the skin surface

28. Telescoping Blade Adjustment
Telescoping blades are adjusted to prevent muscle creep that can obstruct view

29. Facetectomy and Annulotomy
Facetectomy and annulotomy are then performed to gain access to the disc space
Complete discectomy is performed, and the vertebral body endplates are prepared

30. Trial Insertion
Spacer trial is carefully inserted, taking care not to impinge on any nerve tissue

31. Spacer Insertion Spacer is loaded onto inserter and inserted
If necessary, nerve root or dural retractors can be used

32. Spacer Positioning The inserter is disengaged from spacer and removed
Spacer is positioned across the midline at roughly 35°, and then autograft is packed around the spacer

33. Screw and Rod Insertion Mark Screw Entry Points
Anteroposterior (AP) and lateral fluoroscopy are used to target and mark the correct pedicle entry points

34. Pedicle Preparation
Fluoroscopy guides the Jamshidi needle, and then the guide wire, into pedicle

35. Dilator Placement
Dilators are placed over the guide wire to prepare for appropriately sized tap
The pedicles are then tapped to prepare for screw placement

36. Screw Insertion
Screw and screw-extension assemblies are percutaneously inserted into the pedicles

37. Alignment of Screw Extensions
With screws placed at each level, the openings of screw extensions are aligned
Holder and assembly are now guided into place

38. Rod Placement
Rod is driven downward and pivoted 90° into the bottom slot of the open screw extension

39. Rod Holder Capturing Rod
Rod holder handle will then engage the proximal end of the closed screw extension

40. Rod Holder Capturing Rod
Set screws are tightened, the rod holder is disengaged, and screw extensions are removed
Fluoroscopy confirms bilateral constructs

41. Minimally Invasive Transforaminal Interbody Fusion
Section 3: Case Studies
Minimally Invasive Transforaminal Interbody Fusion

42. Case Overview
24-year-old woman presented with severe, persistent back pain with both flexion and extension
Right leg pain
Pars interarticularis injection improved pain
Credit: Frank Shen, MD,
University of Virginia

43. Case Comments Notice 6 lumbar vertebrae1 2 3 4 5 6
Notice 6 lumbar vertebrae
Lateral x-ray reveals L6-S1 spondylolysis—also an S1-S2 spondylolysis
Slight lumbar scoliosis

44. Preoperative Planning
Preoperative planning for percutaneous pedicle screw placement is critical

45. Entry Point
Entry point for pedicle screws and transforaminal lumbar interbody fusion (TLIF) access are carefully planned using x-ray images
MIS PIPELINE™ Expandable Retractor for TLIFs should be placed over the facet complex, spanning pedicle to pedicle

46. MIS Spine Fusion Requires Accurate Fluoroscopic Imaging

47. Retractor Positioning
PIPELINE Expandable Retractor is positioned to perform the facetectomy and access the disc space
The retractor can then be opened to provide increased visualization

48. Preparing the Disc Space for Fusion
Once desired access is achieved, minimally invasive instruments are used to prepare the disc space for spinal fusion

49. Screw Insertion
To minimize motion, the vertebral bodies must be secured with a screw and rod construct
Screws are then inserted into the pedicle through the existing incision
Two separate stab incisions are used contralaterally

50. Screw Position
Screws are carefully inserted into the densest part of the vertebral body, the pedicle
Screw position is confirmed by x-ray images

51. Rod Insertion The appropriate rod length is measured
The rod is then inserted through the same small incision used to place the screws

52. Segment Immobilized
The rod is then locked down into the pedicle screw heads, and screw extensions are disengaged
The segment is now immobilized securely

53. TLIF/VIPER™
This shows a completed right-sided minimally invasive TLIF with decompression of roots
The segment was then secured by bilateral percutaneous placement of the VIPER pedicle fixation system

54. Section 4: Patient Selection
Minimally Invasive Transforaminal Interbody Fusion

55. Candidate Criteria Not appropriate for everyone
Only for patients who have the right indications and have exhausted conservative therapies
Bed rest
Muscle relaxants
Physical therapy
Prescription pain relievers

56. Candidate Criteria Commonly used for
Decompressions (microdiscectomy and laminectomy)
1- and 2-level lumbar fusions Degenerative Disc Disease: low-grade, spondylolisthesis, recurrent discectomy)
Follows a full diagnostic review and primary care physician consultation

57. The VIPER System Indications
The VIPER System was cleared under the EXPEDIUM Family for the following indications:
The VIPER System is intended for noncervical pedicle fixation for the following
indications: degenerative disc disease (defined by back pain of discogenic origin
with degeneration of the disc confirmed by history and radiographic studies);
spondylolisthesis; trauma (ie, fracture or dislocation); spinal stenosis; curvatures
(ie, scoliosis, kyphosis, and/or lordosis); tumor; pseudoarthrosis; and failed
previous fusion in skeletally mature patients. When used in a percutaneous,
posterior approach with MIS instrumentation, the VIPER System screw
components are intended for noncervical pedicle fixation and nonpedicle
fixation for the following indications: degenerative disc disease (defined by back
pain of discogenic origin with degeneration of the disc confirmed by history and
radiographic studies); spondylolisthesis; trauma (ie, fracture or dislocation);
spinal stenosis; curvatures (ie, scoliosis, kyphosis, and/or lordosis); tumor;
pseudoarthrosis; and failed previous fusion in skeletally mature patients.

58. THANK YOU. QUESTIONS?
This information has been supplied for educational purposes courtesy of DePuy Spine, Inc.
DEPUY SPINE, DePuy Spine logo, the MIS logo, PIPELINE, VIPER, and PIPELINE Expandable Retractor are trademarks of DePuy Spine, Inc.
©2007 DePuy Spine, Inc. All rights reserved.
REFERENCES
Wilson DH, Harbaugh R. Microsurgical and standard removal of the protruded lumbar disc: a comparative study. Neurosurgery. 1981;8:
Kambin P. Posterolateral percutaneous lumbar discectomy and decompression: arthroscopic microdiscectomy. In: Kambin P, ed. Arthroscopic microdiscectomy: minimal intervention in spinal surgery. Baltimore, Md: Urban & Schwarzenberg; 1991:
Koebbe CJ, Perez-Cruet MJ. Lumbar microdiscectomy. In: Perez-Cruet MJ, Fessler RG, eds. Outpatient spinal surgery. St. Louis, Mo: Quality Medical Publishing, Inc; 2002:
Hermantin FU, Peters T, Quartararo L, Kambin P. A prospective, randomized study comparing the results of open discectomy with those of video-assisted arthroscopic microdiscectomy. J Bone Joint Surg. 1999;81: