Disclosure Consultant: DePuy Spine Praveen V. Mummaneni, M.D. - PDF document

11/4/16 MIS Deformity Surgery Update Disclosure • Consultant: DePuy Spine Praveen V. Mummaneni, M.D. • Other Financial Support (royalty): Joan O’Reilly Endowed Professor Vice-Chairman – DePuy Spine Dept. of Neurosurgery Co-director: UCSF Spine Center – Thieme Publishing – Quality Medical Publishers Michael Virk MD, PhD Spine Fellow – Taylor and Francis Publishers • Honoraria: AO Spine University of California, San Francisco • Stock: Spinicity/ISD Why Would We Want To Do “Less” Mummaneni et al: Neurosurgery 2008 Surgery for Adult Spinal Deformity? • Complication rates high • Pseudarthrosis rates problematic 1

11/4/16 Schwab et al: Eur Spine J 2012 Risk Factors for Complication Group vs. Control Group Major Peri-operative Summary of factors differentiating the 2 groups Complications in Adult Spinal No significant impact : Significant impact: Deformity Surgery • Number of stages (p=.011) • Demographics • Surgical approach (p=.011) • Pre-op vitals A Multi-center Review • ASA, respiratory, cardiac, alcohol, and smoking scores of 953 Consecutive • Common Co-morbidities Patients In this sample, MAJOR complications seem more procedure than patient related Conclusion Degen Vs Deformity • Patient related risk factors – Age, sex, BMI, number of co-morbidities, ASA, percentage of revision cases, number of redo • In Degenerative 1-2 level spinal disease, MIS surgeries were not significantly different in patients with and without major complications approaches decrease hospital stay and EBL – May make a difference in minor complications? – The operations are interchangeable for Most cases • Procedure-related risk factors Surgeon – # of stages, surgical approach were significant variables controlled affecting the rate of major complications • Does this hold true for deformity? parameters – Are the indications for the MIS vs open deformity surgery similar? 2

11/4/16 J. Cheng and P. Mummaneni: MIS Deformity NS Focus 2013 • Compared 50 MIS TLIF with 25 open TLIF • Can decompression be achieved? Yes • Can hardware be placed safely? Yes (even iliac • MIS TLIF with fewer complications and screws) lower EBL • Can sag balance be restored? Maybe • MIS TLIF had shorter LOS and saved $4k • Will you match LL-PI within 10 degrees? Maybe compared to open TLIF • Will it take a long time to do? Initially - yes • Long term outcomes similar • Can a succesful fusion be established? – This is the Challenge… Tormenti, et al. NS Focus 2010 Anand, et al. NS Focus 2010 Complications Complications 3

11/4/16 Dakwar and Uribe. NS Focus 2010 Dakwar and Uribe: NS Focus March 2010 • Pitfall: – The authors • 1/3 of the patients did NOT have sagittal concentrated on balance restored coronal curve and not on sagittal balance • Remember: Coronal correction is NOT as important as sagittal correction Wang & Mummaneni NS Focus March 2010 • 23 patients, retrospective review • High pseudo rate if no interbody fusion is done, can not rely on MIS posterolateral fusion 4

11/4/16 When To Do MIS for Deformity? When To Do MIS for Deformity? • Need an algorithm… • Need an algorithm… NS FOCUS May 2014: • Praveen Mummaneni NS FOCUS May 2014: • Chris Shaffrey • Praveen Mummaneni • Lawrence Lenke • Chris Shaffrey • Paul Park • Lawrence Lenke • Paul Park • Michael Wang • Michael Wang • Frank LaMarca • Frank LaMarca • Justin Smith • Justin Smith • Greg Mundis • Greg Mundis • David Okonkwo • David Okonkwo • Bertrand Moal • Bertrand Moal • Richard Fessler • Richard Fessler • Neel Anand • Neel Anand • Juan Uribe • Juan Uribe • Adam Kanter • Adam Kanter • Behrooz Akbarnia • Behrooz Akbarnia • Kai Ming Fu • Kai Ming Fu • MIS ISSG • MIS ISSG 52 year old woman with radicular right leg pain. Minimal back pain. MRI with Right L3-4 lateral recess stenosis from disc bulge (axial shown below). Class I Treatment CA 15 PT 3 PI-LL -7 SVA<5 • MIS Decompression without fusion or with limited C one level fusion A B D 5

11/4/16 Level I Treatment Class 2 “ Medium ” MIS Treatment • Decompression alone • Apex of lumbar curve is – Neurogenic claudication secondary to central stenosis included in instrumented fusion, plus necessary decompression • Requires limited decompression • Minimal or no back pain – back pain associated with – Radiographic findings deformity • Decompression w/ limited instrumented PL Fusion • Radiographic – Stenosis with minimal back pain – LL-PI mismatch 10-30 – Anterior supporting osteophytes degrees – No global imbalance, cobb <20, – No LL-PI Mismatch – May have grade 1,2 spondylolisthesis or lateral listhesis – Caution: Deformity progression and worsening of – PT<25 symptoms – Coronal cobb over 20 degrees Silva FE, Lenke LG: Adult degenerative scoliosis: evaluation and management. Neurosurg Focus 28 (3): E1, 2010 Case Example • 68 F • Morbid obesity – 300 lbs • Multiple prior cervical operations • L4/5 laminectomy in the past • Currently - back and right leg pain • Failed conservative management – PT, ESI – On methadone and oxycodone 6

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11/4/16 • Stage 1; – L2/3, L3/4, L4/5 prepsoas MISLIF – Navigation • Stage 2; – L2-S1 percutaneous pedicle screws – Left iliac bolt – Left L3/4, L4/5, L5/S1 MIS laminoforaminotomies – Intraop CT navigation 8

11/4/16 Case 2 • 62 F • Hx of L5/S1 ALIF/perc PSF 3 years before • Left L5 radiculopathy • L4/5 ESI – complete transient resolution of pain 9

11/4/16 • Stage 1; – L2/3, 3/4, 4/5 MIS transpsoasLIF • Stage 2; – L2-S1 perc screws – CT navigation – Left L4/5 MIS lami/forami 10

11/4/16 Iliac Screws May Be Placed MIS Initial Results • 24 patients underwent percutaneous iliac screw fixation -indications: infection, neoplasm, trauma, deformity • 47 screws placed with fluoroscopic guidance • All screws confirmed with CT – correct placement of all screws. • No hardware complications • One patient died of unrelated medical comorbidities -Wang MY, Williams S, Mummaneni PV, Sherman JD. Minimally invasive percutaneous iliac screws: Initial 24 case experience with CT confirmation 11

11/4/16 There is a limit (ceiling effect) to deformity MIS techniques in selected cases correction using current MIS techniques may diminish complications Conclusion: MIS is NOT Ideal for Class 3 • Avoid 0 – Curves with Cobb >30 – Apical rotation > Grade II – Lateral olisthesis >6mm – Sag imbalance requiring PSO – Thoracic kyphosis • These characteristics predict failure with limited MIS decompression/fusion surgery • Need to do OPEN surgery 12

11/4/16 Conclusions • PI is a fixed parameter • PT may increase to compensate for loss of sagittal balance • Goal LL = PI +/- 10 degrees – Match PI within 10 degrees of the lumbar lordosis Conclusions • Minimally invasive techniques: – Useful for MISDEF Class 1, 2 deformities – Don ’ t forget to restore sagittal balance – Currently, MIS techniques are not ideal for cases requiring 3 column osteotomies for correction of spinal imbalance 13