Mini open TLIF
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This document describes the mini-open transforaminal lumbar interbody fusion (TLIF) technique. Key points include: 1. Mini-open TLIF provides the benefits of TLIF with less soft tissue disruption through a smaller incision and muscle splitting approach. 2. The technique involves facetectomy, bilateral decompression if needed, interbody cage insertion, and percutaneous pedicle screw fixation through tubular retractors. 3. Advantages over open TLIF include less blood loss, reduced postoperative pain, and shorter hospital stay. However, it requires microsurgical skills and has a steep learning curve.
Mini open TLIF
- 1. Mohamed Mohi Eldin Professor of Neurosurgery Cairo University Mini open TLIF
- 2. First described The paraspinal sacrospinalis muscle-splitting approach to the lumbar spine. With decreased bleeding Providing a more direct approach to the transverse processes and pedicles Wiltse Approach (1968)
- 3. TLIF Provides anterior column support for fusion and instrumentation with only one approach via a transforaminal route Offers excellent exposure with minimal risk because of minimal retraction on the nerve roots and dural sac
- 4. Standard Open TLIF adversely affect short- and long-term patient outcomes large skin incisions, extensive muscle dissection long operation time, significant blood loss postoperative paraspinal muscle denervation
- 5. Target surgery One of the main goals of MISS is to do an efficient “target surgery” with a minimum of iatrogenic trauma
- 6. Mini-TLIF as a Gateway Technique
- 7. Mini-TLIF First described by Foley et al. (2003) via local muscle splitting at the area of facetectomy and entry point of pedicle screws insertion significantly diminishes iatrogenic soft-tissue & facet injury.
- 8. Mini-TLIF Because minimal retraction on the nerve roots and dural sac, and lower risk of neurological deficit It also offers advantages in revision patients in whom scar tissue makes open techniques difficult.
- 9. Indications of Mini open TLIF Discogenic pain due to decreased disc height Micro or macro instability. Recurrent disc herniation.
- 10. Advantages Without compromising the effectiveness of the conventional fusion Minimal PO pain & hospital stay Unilateral exposure Less soft tissue damage Minimal blood loss Better cosmetic results
- 11. Disadvantages Technically demanding New Old When ? False negative Indifferent result Positive result Increased operative time, Steep learning curve
- 12. Parameters of learning curve • Length of operative time • Amount of bleeding Intraoperative Vac drain • Starting day of ambulation • Transfusion incidence • Occurrence of complications
- 13. Technique Decompression + Fixation + Fusion
- 14. Procedure include Decompression thru tubular retractor Obliquely inserted TLIF cage fusion Percutaneous pedicle screw fixation
- 15. Planning the skin incision
- 16. Make the skin incision In the parasagittal plane of the pedicles under fluoroscopy. Typically, two fingerbreadths off of the midline . L4-5 fusion (black) L5-S1 fusion (blue) Four pedicles of interest L4-5 Mini-TLIF. Incision size is 3 cm
- 17. Pitfall 1 Lumbar fascia is incised in the plane of the skin incision Pitfall: Do not attempt to find and follow the plane between multifidus and longissimus. This would direct the exposure Too laterally.
- 18. Blunt separation of longitudinal muscle fibers
- 19. Freeing of the attached muscle fibers
- 20. Prepare for retractor before inserting the mini-open retractor system Cut the musculotendinous attachments to the underlying bone
- 21. Retractor blades required Use the smallest diameter tubular retractor blades required to provide the necessary exposure
- 22. Facetectomy Identify the pars before starting the facetectomy (high-speed drill/small osteotome)
- 23. Facetectomy Care should be taken when drilling the pars, as it overlies the exiting nerve root
- 24. Pedicle-to-pedicle exposure Care should be taken when resecting the lateral edge of the lamina from a lateral approach A pedicle-to-pedicle exposure is obtained, exposing the traversing and exiting nerve roots and the disc space
- 25. Pedicle screws First the pedicles are only cannulated; (screw heads might impede access to the disc space)
- 26. Pedicle screws We do not place the pedicle screws until the interbody space is prepared and the TLIF cage is inserted
- 27. Disc Space Preparation Disc incised and removed with shavers, rongeurs, and curettes Cartilagenous end plates removed without injuring the bony end plates. Interbody trials serially dilate the disc space.
- 28. Nerve roots Ligamentum flavum is removed piecemeal to expose nerve roots Lordotic cage is then selected with a secure fit, with the autograft packed in it. Nerve roots are visualized during CAGE insertion. Additional autograft is also packed within the disc space
- 29. For narrow disc spaces Consider first inserting pedicle screws on the contralateral side and distracting them before inserting the TLIF implant.
- 30. For spondylolisthesis Consider first inserting pedicle screws on the contralateral side and distracting them before inserting the TLIF implant
- 31. Pitfall 2 If a K-wire is to be used after a facetectomy keep in mind that the nerve roots are exposed and vulnerable. Initial placement of the K-wire should be visually guided
- 32. Spinal canal decompression by angling tubular retractor medially onto hemilamina
- 33. Bilateral decompression achieved by using 2 sets of expandable tubular retractors in a mini-open fashion If further lordosis is needed: perform (Smith-Peterson osteotomy -SPO)- bilateral laminotomies with complete facetectomies).
- 34. Two levels fusion mini-TLIF The skin incisions extend to cover entry points of uppermost and lowermost pedicle screws indicated by fluoroscopy The lengths of skin incisions are 7 centimeters The fusion procedure is not different to one segment fusion
- 36. MI versus mini-open approach Selection is dependent on the need for unilateral versus bilateral decompression For bilateral decompression = bilateral mini-open approach. For unilateral decompression = minimally invasive technique with percutaneous pedicle screws
- 37. Durotomy - Pitfall 3 CSF leaks can be difficult to repair. However, if encountered, close the dural defect primarily by A small needle driver and dural suture. A small piece of dural substitute and fibrin glue (seal) If necessary, a lumbar drain might be placed. One advantage of the smaller opening is decreased space for potential pseudomeningocele formation
- 38. RESULTS
- 42. Image Documented fusion Absence of halo around the screws presence of continuous trabecular bone bridge between the upper and lower body on x-ray films
- 43. Fusion 6 month postoperative CT scan Fusion after 23rd month
- 44. More Results Reduction in intensity of postoperative pain, with much better cosmetic results
- 45. Tubular or speculum like retractor small lateral skin incisions The Keys of Success Successful Mini-TLIFSuccessful Mini-TLIF The microsurgical skill of the surgeon Microscope, C- arm, and radiolucent table lamina-facet complex, transverse P. clearly identified
- 46. Problems you may face 1. Radiolucent operative tables 2. Magnification and good illumination 3. A special retractor to work comfortably 4. If the axis line is more than 11 cm (process difficult) 5. Hard ware is expensive in relative to the conventional one 6. Radiation exposure
- 47. Summary and Conclusions Although this technique can be safely applied in patients requiring decompression and fusion It is challenging and requires a steep learning curve to operate in the limited surgical field with microsurgical technique