UC UC SF SF Anterior Spine Exposure Expanding Treatment Options - PDF document

UC UC SF SF Anterior Spine Exposure Expanding Treatment Options No Disclosues Charles Eichler , MD UCSF Division of Vascular Surgery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Can we get you here safely? VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 1

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 2

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 3

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Why Go Anterior • Direct access to lowest lumbar disc • Routine cases carry a very low risk spaces L2-S1 of complication • Thorough discectomy • Operative time of one or two level ALIF relatively short • Major deformity correction • Improved fusion rates VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 4

UC UC SF SF ALIF • Effective method to achieve fusion • Allows for correction of deformities • Can be utilized in tumor and infection cases • But • Critical part of the case is exposure VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 5

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Preop evaluation Discuss with exposure surgeon How can we do high risk/complex CT angiogram cases with low complication rates? VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 6

UC UC SF SF Complications Abdominal complications • Vascular • Hernias • Abdominal • Ileus/bowel obstruction • Urologic • Bowel injury RARE!! CTA VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Urologic complications • Ureter • Place ureteral stent if any concern VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 7

UC UC SF SF Vascular Complications • Arterial • Venous Direct venous injury, DVT, PE VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 8

UC UC SF SF Can we safely do the most complicated spine cases with low complication rate?? YES VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Set up Master the simple, straightforward • General anesthesia-complete cases first !! paralysis • Supine-arms abducted • Sat monitor on left great toe VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 9

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF L5-S1 • Left paramedian incision • Work between the left and right iliac vein • Move to midline reflecting rectus muscle laterally • Very easy level • Incise posterior rectus sheath • Minimal risk of complication longitudinally • Identify and mobilized the ureter and protect with fixed table retractor VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 10

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 11

UC UC SF SF L4-L5 • Mobilization is lateral/left of vessels • Requires division of the lowest segmental artery & vein • Must divide ilio-lumbar vein VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 12

UC UC SF SF OLIF 5-1 VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 13

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF How do we do the high risk cases? Do it exactly the same, but with a bit more attention to the anatomy and potential risks VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 14

UC UC SF SF • More iv access • Arterial line • Ureteral catheter • Retrievable ivc filter • Blood products/cell saver VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 15

UC UC SF SF case 57yo m-hx of previous failed multiple procedures at OSH, but never from anterior TLIF and posterior screws in past Can create severe inflammation VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 16

UC UC SF SF • 35yo m –needed L4-S1 ALIF-- noted some venous abnormality on spine MRI • CTA –left sided IVC VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF case • 50 yo 1 month post op from 2L4-S1 ALIF • Cage extrusion VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 17

UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF case • Failed TLIF –two levels-at OSH • Hx of PE VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 18

UC UC SF SF Conclusion • Understand basics and anatomy • Full preop w/u with CTA if any concern • complex cases can be done safely and with low risk VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 19