1. PERCUTANEOUS ENDOSCOPIC INTERSOMATIC TRANSFORAMINAL FUSION WITH 2 CAGES (Pe-TLIF) UNI-/ or BIPORTAL? Daniel Gastambide (Paris) Frédéric Jacquot (Paris)‏ Pierre Finiels (Nîmes)‏ Patrice Moreau (Boursay)

2. Since we began using this technique in 2005, we’ve inserted percutaneous cages for lumbar arthrodesis in “virgin spines” and in previously operated spines. Most of the first patients have been operated on in prone position

3. In the case of treating one disc by using an arthrodesis and one hernia on the level above on the same side in lateral position, we began by carrying out the arthrodesis on only one side. L4L5 L5S1

4. The rationale for percutaneous cage fusion: - obese patient - elderly patients - heavy comorbidity - degenerative scoliosis with spontaneous fusion blocks and dislocations - multiple degenerative disc disease with one elective symptomatic disc Seeing that the results on virgin spines were encouraging, 29 good primary results with a mean follow-up of 2 years on 35 patients, we wanted to simplify the process by making a lateral approach and by using a more simple technique

6. SVI.. 77 year-old man, bilateral cruralgia, persisting discal hernia L2L3 unextractable by a posterieor approach sunk in a post- laminectomy fibrosis for a narrow channel In the case of one patient we put in two cages on the same side on every level, on L2L3 and L3L4 in the middle of the intervertebral space

7. SVI.. 2

8. For one other patient, we put in two cages in L3L4 through the same side. HER.. 47 year-old man, big discal hernia L3L4 + lateral subluxation Open dislocation in a 7°scoliosis, with a right translation of L3 on L4, right gaping of the L3L4 space with an underlying compensation aspect through a left gaping of the L4L5 space. Furthermore, you can note a discrete L4L5 retrolisthesis only in standing position, not visible on the CT scan neither on the MRI

9. Right cage inserted a little too low by the left

10. In the cases of two patients, we made a unilateral approach on L4L5 and put in one cage. GIL…79 year-old lady, couldn’t walk before op; VAS was 9 pre-op and was 5 post- op with 6m follow-up FF

12. PERR.. 61 year-old woman, 98kg, 1.63m, private nurse. Hyperalgic lumbalgia. Lumbar VAS 8 during examination, 10 during crisis. Maximum walking distance 500m because of the lumbalgia; no other source of soothing than resting in a lying position or sitting during painful crisis; took Aceclofenac 100mg*2, Tramadol 100 in the morning, Paracetamol 1000 during painful crisis, with a very limited effect.

13. Intersomatic arthrodesis with Europa cage in L4L5 on November 4 2009 resulting in an insufficient stability : a left cruralgia appeared and a few days later we put in pedicular implants and plates. The CT scan showed a restitution of the intersomatic space of about 4mm, the cage is introduced by the left side and shifted expressly to the right where the osseous tissue of the overlying and underlying vertebral plates is more dense.

14. For two other patients, we put in two cages in L5S1 CHAI… 48 year-old female, auxiliary nurse, L4L5 hernia and degenerative discopathy in L5S1. Transforaminal endoscopic discectomy in L4L5 on the right and and two Europa cages in L5S1

15. The immediate follow-up showed the disappearance of the usual pains and the appearance of new pains: lombalgias and pain when turning over in bed. After 5 months we made another operation: fusion of the instable L4L5 level and osteosynthesis of the painful encaged L5S1

16. CHAR… 70 year- old woman, retired postlady, VAS 7 to 3 f.u.6m High origin of the right L5 root

17. We can’t exactly explain why we can put in two cages for some patients and only one for others, particularly on the L4L5 level Could this be due to the width of the Kambin triangle? Pil Sun Choi A T Yeung

18. L5 L4 S1

20. Or could it be due to the number and the position of anastomosis between the exiting root and the white or grey ramus communicans of the sympathetic system which carries the nociceptive fibers? Patient operated under local anesthesia. Variations of the birth of rami communicantes Ramji DASS, Sympathetic components of the dorsal primary divisions of human spinal nerves, 493-501 Department of Anatomy, New York University College of Medicine. THREE FIGURES. In descriptions of the anatomy of the sympathetic system.

21. Thesis Sylvie Raoul; Pr Robert, Nantes Rami communicantes and sinu vertebral nerves disc medial up Ganglion L3 separated and reclined Radicular anastomosis between L2 and L3

22. If the exiting root is painful while passing the dilators, we take a look at the endoscopic view of it and try to push it away without causing any pain. Then we insert the cage, preceded by the dilators. CRANIAL CAUDAL ILIAC CREST ZYGAPOPHYSAL JOINT PEDICULE ISTHMUS EXITING ROOT L4 foramen lateral medial

23. Conclusions We showed the feasability of putting in two cages for intersomatic arthrodesis with a percutaneous technique by only one side Advantages of this percutaneous technique versus conventional technique: lateral position authorized for all kinds of patients minimal incision no bleeding no fibrosis patient stands up two hours after operation possibility to make a transforaminal endoscopic discectomy at another level very low post-operative morbidity (no thrombo-embolism, no risk of hematoma) Disadvantages steep learning curve sometimes impossibility to enlarge Kambin’s triangle with the dilators difficulty of percutaneous screwed implants and plates on smaller patients if no associated percutaneous plate, brace necessary for 45 days Future We are now studying Tri-dimensional navigation and the possibility of using the C-arm as least as possible, of diminishing individual Xray doses on the patient, on the operation room nurse and on the surgeon.

24. 23th IITS annual meeting 2010 2nd WCMISST biannual meeting conjoined with the 24th IITS meeting Past President WCMISST 2008 President Elect WCMISST 2010 Past President IITS 2009 President Elect IITS 2010