DLIF approach, a new MISS for "de novo"/degenerative scoliosis.

Zbiggy Brodzinsky Dubai Bone & Joint Center

Dubai Healthcare City Authority, UAE

www.dbaj.ae, www.dhcc.ae

Riyadh, KSA; Jan 20-23, 2012.

Lateral Anatomy and Physiology Review

Anatomy Lateral Approach

Obl. Int M Obl. Ext M Transversus M. V. Cave Aorta

Psoas muscle APPROACH

Nerve root

Dorsal M.

Psoas Muscle
Attaches to the lateral border of the lumbar spine Wider in lower lumbar spine GreaterMales > Females Tightens with hip extension Muscle fibers run mainly longitudinally

Lateral Dissection to Psoas

Direct observation of muscle layers Follow internal abdominal wall Posterior to anterior abdominal wall finger sweep Feel for: 1. Quadratus muscle 2. TP 3. Surface of Psoas

Transpsoas Neuro Considerations

Moro T, Kikuchi S, Konno S, Yaginuma H. An Anatomic Study of the Lumbar Plexus with Respect to Retroperitoneal Endoscopic Surgery. Spine 28 (5) 2003. 2003.

Lumbar Plexus Nerves

Cadaver study of relationship between psoas muscle and lumbar plexus and genitofemoral nerve L2/3 and above- all parts of abovelumbar plexus and nerve roots located in dorsal fourth of body and dorsally. L3/4 and L4/5L4/5Lumbar plexus in zone III, IV, & dorsally

Moro et al, Spine V 28 N 5 , pp 423- 428, 2003 423-

Lumbosacral Plexus
Benglis DM, Vanni S, Levi AD An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine.
J Neurosurg Spine. 2009 Feb;10(2):139-44.

Trans-psoas Approach

Deeper

Trans-psoas Approach
L1-2 L2-3 L3-4 L4-5 L5-S1

Sensory Nerve Considerations

Genitofemoral NerveNerve(Moro et al)
Passes through psoas from cranial third of L3 to caudal L4 Receives contributions from L1 & L2 Pierces Psoas muscle and descends on anterior surface. Divides into femoral and genital branches

DLIF Technique Review

DLIF Technique
1. 2. 3. 4. 5. 6. 7. 8. 9. Pre-op planning Needle electrode setup Patient positioning Fluoroscopic localization Dissection to psoas Neuromonitor through psoas Dilation/Retractor placement Fusion preparation Trial/Distract Implant

10. Closure

Pre-op Planning
Check for unfavorable anatomy
High iliac crest at L4-5
Consider AP and lateral x-ray More problematic in males

Long 11th and 12th ribs

Go intercostal or ressect part of ribs

Pre-op Planning
Left or right side approach?
Go in on side that appears easiest to access on x-rays (e.g., due to crest, ribs, scoliotic collapse, etc.)

Correction can be equally good from either side; consider ease of access
Surgeon comfort

Needle Electrode Placement

Placed by surgeon or hospital staff Discuss with anesthesiologist regarding use of neuromuscular blockades

Patient Positioning Problematic

Patient Positioning
Place hip, not waist, over break Flex top leg Firmly hold patient position (tape) Fluoro under table Bed Selection - Reverse table

Patient Positioning

Patient Positioning
Position and fluoro prior to draping: True AP and Lateral Work Perpendicular to floor Need to correct by moving the patient/bed NOT the fluoro In multi-level cases, will need to readjust table for perfect image at each level

Localization
Directly over the disc center for single level In between discs for two levels

Dissection to Psoas Approach Path

1. Skin, subcutaneous 2. 3 layers of abdominal muscles
External oblique Internal oblique Transversalis
Incise Bluntly dissect Sweep anterior NIM and dilate

3. Retroperitoneal space 4. Psoas

Dissection to Psoas
Direct observation of muscle layers Follow internal abdominal wall Posterior to anterior abdominal wall finger sweep Feel for: 1. Quadratus muscle 2. TP 3. Surface of Psoas
1 2 3

Neuromonitor through Psoas

Stimulate NIM X-PAK Probe to ensure safety of lumbar plexus Cover tip with finger and guide to psoas Target anterior one-half to one-third

NIM X-PAK Probe

Nerve Proximity Mode

Provides audio tone feedback indicating proximity to a nerve root Program automatically changes stimulation intensity while searching for an EMG response
NIM-ECLIPSE Spinal System

Probe Position Confirmation

Confirm position

Dock probe into disc space

Remove Inner Stylet

Place Guide wire

Dilators & Retractor

Place dilators over wire Assemble retractor with proper size blades Place retractor over last dilator Stimulate pin hole Place pin
Prevents migration Keep close to endplate

Retractor and Light Source

Endplate Preparation
Incise annulus Discectomy
Ronguers, currettes, shavers

Release contralateral annulus Trial Implant

Disc Preparation

Proper Endplate Preparation

Trial and Implant Insertion

Closure

Closure is simple Close fascia of external oblique with 0 Vicryl Close subcutaneous Skin closure with adhesive

Lateral Interbody Fusion (DLIF) in Patients with De-Novo Adult Degenerative Scoliosis

What is Direct Lateral?

Variation of retroperitoneal approach that is minimally invasive Muscle-splitting TransPsoas approach Considered closely similar to anterior approach Best suited for L1-L5, can be done in thoracic

Advantages of DLIF
Compared to ALIF No need for approach surgeon No retraction of peritoneal contents Easy access to upper lumbar Less risk to vessels & sympathetics Obesity is less of issue No resection of ALL Less blood loss Compared to PLIF/TLIF No bony resection Avoid canal exploration, root manipulation & root adhesion pain Larger graft Obesity is less of issue No disruption of Posterior tension band More stable in torsion* Less blood loss
*Voor MJ, Mehta S, Wang M, Zhang YM, Mahan J, Johnson JR. Department of Orthopaedic Surgery, University of Louisville School of Medicine, Kentucky 40292, USA. 1: J Spinal Disord. 1998 Aug;11(4):328-34

Surgical Procedure

Surgical Procedure

Lumbar Plexus Nerves

Moro et al, Spine V 28 N 5 , pp 423- 428, 2003 423-

Surgical Procedure
Obl. Int M Obl. Ext M Transversus M. V. Cave Aorta

APPROACH

Surgical Procedure

Surgical Procedure

Distraction

Distraction

DLIF in Deg Scoliosis

PLIF/TLIF+post instrumentation has fusion rate & better alignment compared to post instrumentation alone* PLIF is ineffective in restoring sagittal balance*** Anterior placed graft improves lumbar lordosis more than posterior placed graft Restoration of sagittal & global balance improves outcome & loss of lumbar lordosis is associated with pain & Quality of life Anterior grafts are more biomechanically stable than posterior grafts^ Complication rate of open Deg Scoliosis surgery is high (2080%)**
Glassman et al: Spine 30, 2005 * Wu et al: J Spinal Disord Tech 21, 2008 ** Cho et al: Spine 32, 2007 ** Bone et al: Spine , 30: 2005 Ploumis et al: Spine 34, 2009 *** Kyu-Jung et al: Eur Spine J, 17: 2008 ^ Voor et al: J Spinal Disord 11, 1998 Daffner et al: Am J Orthop, 2: 2003

DLIF in Deg Scoliosis

DLIF is emerging as a viable alternative to Posterior or Posterior/Anterior surgery that is minimally invasive with less complication rate Can be utilized as a primary correcting tool for scoliosis or as a secondary stabilizing tool for scoliotic spine undergoing surgery

Role of DLIF in Scoliosis Surgery

Advantages* Ant column structural stability disc height & maintains distraction between end plates regional sagittal & coronal balance Indirect neural decompression Good support for hardware end vertebrae fusion rate (osteoporosis Anterior release Unloads facet joints stress on posterior hardware ? Shorter level instrumentation Disadvantages Technically more tricky
Rotation Vertebrae Rotation L-S Plexus

? Inferior to osteotomy in Fixed & Rigid Curves. Role may be best for flexible curves and may help in changing PSO to Pont osteotomy

*J Neurosurg Spine 7, 2007

Lateral TransPsoas in Deg Scoliosis

Cobb
Anand et al* Tormenti et al* Dakwar et al* Wang et al* Diaz et al+ Patel et al++

AVT 10 11.5 3.6

Lordosis 1.8 47.3 37.4 34 40.4 45.5 41

VAS 7 8.8 8.1 3 3.5

ODI 55 2.4 53 3.2 49 39 29 19

22 38.5 31.4 18 20.2

8 11.7

9.1

++ Superior results to PLIF/TLIF controlled cohort for Cobb angle & AVT Comparable results for VAS to open surgery (Spinal Deformity Study Group) All had blood loss 50-500 ml, less than open surgery (average=2.1 1 Lit**)

+ Diaz et al: Spine 2006 ++ Patel et al: Spine 2009

* Neurosurg Focus 28 (3), 2010

** Cho et al: Spine 32, 2007

Case Ro
Back & Leg Pain

Case Ro: Back & Leg Pain

Case Ro: Back & Leg Pain

L4-L5

Case Ro: Back & Leg Pain

32 9

Case Ro
Back & Leg Pain

Case DG: Back & Leg Pain

Case DG
Back & Leg Pain

Case DG: Back & Leg Pain

Case DG
Back & Leg Pain

30 45

Case DG
Back & Leg Pain

Case JB
Back Pain

1 yr

Case JB: Back Pain

Case JB: Back Pain

25

10

Case JB
Back Pain

40 25

Case LW
Back Pain

Case LW: Back Pain

Case LW: Back Pain

Case LW: Back Pain

Case LW: Back Pain

Case LW
Back Pain

0 16

Case LW
Back Pain

50 55

Case Bo: Back & Leg Pain

Case Bo: Back & Leg Pain

Case Bo
Back & Leg Pain

32

10

Case Bo
Back & Leg Pain

19

39

Case Ha
Back Pain

Case Ha: Back Pain

Case Ha: Back Pain

3 10

Case Ha: Back Pain

41 24

Case Jo: Back Pain

Case Jo: Back Pain

10

Case No

Lateral Options for Deformitys management

Adult Degenerative Deformity

Always involves the Lumbar spine Painful Patients:
Elderly Co-morbidities Fusion harder to achieve vs pediatric

Must have
Solid fusion Good sagittal balance Decompression

Fusion options
Posterior anterior

Challenging questions regarding MIS osteotomy X How to achieve

sagittal balance How to achieve fusion Decompression: direct vs indirect
Interbody reconstruction Posterior interbody laminectomy facetectomy

Spinal reduction Foraminal distraction

Why inter-body fusion?

Better Mechanics Better Biology Better physiology May be The best option to Address the pain generators

MECHANICS

Why Interbody
Biology: under compression. Better pysoelectric charges Better Physiology:
The only compartment in the spine void of functional muscles

Potentially Eliminates Pain generators

Promising techniques
MIS Lateral/Anterolateral Techniques Straight lateral surgery (XLIF, DLIF, Lat concord etc)
Indicated for lateral pathology Lateral decubitus position Incision at lateral border of erector spinae Dilates through iliopsoas
Finger assisted

Risks
Lumbar plexus (in psoas) Requires monitoring

WHY LATERAL!!
Viscera are out of the way No need for vascular mobilization Preserves the ALL:
Containment Anterior tension band Protects against over-distraction

Can be done with the posterior work simultaneously without repositioning No iatrogenic stenosis Less risk for retrograde ejaculation No traumatic sympathectomy

Traditional Anterior Approach

Anatomy

Analysis of Vascular Anatomy

High Lateral Configuration

Analysis of Vascular Anatomy

Very Low Medial Configuration

Anatomy
Psoas gets wider in lower lumbar spine (males>females) Lumbar plexus posterior 2/5 of psoas

LLIF
Anterior Posterior

Favorable Anatomy

Unfavorable Anatomy

AnteroAntero-lateral interbody fusion

L1-2, L2-3, L3-4, L4-5 Split fibers of oblique and transversus muscles Retract anterior 20% psoas be Very careful of the misleading Quadratus Lumborum muscle

Concave vs convex side

Concave side

Concave approach:

54 yo, multiple spinal surgeries severe pain

Before and after

Before and after

72 YO lady. Severe back and leg pain. Failed conservative Rx.

MRI

conservative
Lost 90 pounds 8 ESIs Yoga Psychiatric eval. Not better

BEFORE AND AFTER

BEFORE AND AFTER

58 yo male. Still disease. Severe back and hip/thigh pain

Sagittal balance

Axial cut at L3-4

Failed conservative Rx
CONSERVATIVE RX PT TIME PAIN MEDS OPTIONS: Don nothing Laminectomy Laminectomy fusion Approach:
Posterior Anterior posterior

Fusion levels:

T11-L4

Before and after

Before and after

preop

Full Spine Films

Post op

55 yo, 325 lbs

MRI

Intraoperative pictures

Post op

Conclusion.
MIS is very promising:
Approach
Anterior vs posterior Concave vs convex

Indirect decompression

More studies need to be done

Conclusion
Fusion surgery is quite Morbid. MIS is very promising option and might be the best option We have to rethink anterior fusion Go concave

Be careful, bad stuff can happen through small holes

IT WILL THROW YOU UP IN THE AIR

Conclusion
Role of DLIF in Degenerative Scoliosis Surgery is still being defined but is emerging as a viable option either alone or in combination with other techniques

Thank you/Shokran!