Tumialan Minimally Invasive Spine Surgery

A Primer
1. Auflage 2020
ISBN: 978-1-63853-144-9
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 494 Seiten, ePub

by Luis Manuel Tumialán is the ideal introduction to minimally invasive spine approaches, especially for neurosurgery and orthopedic residents, fellows, and spine surgeons who want to incorporate minimally invasive approaches into their practice. The Primer offers a treasure trove of 3D illustrations and animations that virtually brings the aspiring minimally invasive spine surgeon into the operating room alongside their professor. The text starts with a discussion of open spine surgery versus minimally invasive procedures and the optimal mindset required to convert from one to the other.

The book is divided into lumbar, cervical, and thoracic spine sections, and a fourth section dedicated to the fundamentals of fluoroscopy and radiation exposure. The text begins with an overview, history, and evolution of each procedure, followed by a discussion of the anatomical basis for using a minimally invasive approach. Each anatomical section starts with the least complicated surgeries, thereby laying the foundation for more complex procedures discussed in subsequent chapters. The third section focuses on thoracic decompression, nerve sheath tumors in the lumbar and thoracic spine, and management of metastatic disease and intradural extramedullary lesions.

Key Features

• Single-authored text provides uniform readability and philosophy—cover to cover
• Lumbar approaches include microdiscectomy, laminectomy, transforaminal interbody fusions, and the transpsoas approach
• Cervical procedures encompass posterior foraminotomy, laminectomy, and anterior discectomy
• Superb illustrations, high-fidelity anatomical animations based on computer modeling, and procedural videos enhance understanding of minimally invasive spine principles

This unique, single-author Primer is a must-have resource for early-career spine surgeons who wish to learn minimally invasive principles, as well as veteran surgeons who have a desire to incorporate minimally invasive spine surgery into clinical practice.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Autoren/Hrsg.

Tumialan, Luis Manuel

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Chirurgische Techniken
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Neurochirurgie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Minimalinvasive Chirurgie, Laserchirurgie, Laparoskopie
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Orthopädie- und Unfallchirurgie

Inhaltsverzeichnis

1 A Minimally Invasive Perspective: The Conversion
2 Minimally Invasive Microdiscectomy
3 Minimally Invasive Lumbar Laminectomy
4 Minimally Invasive Transforaminal Lumbar Interbody Fusion
5 Minimally Invasive Far Lateral Microdiscectomy
6 Minimally Invasive Lateral Transpsoas Interbody Lumbar Fusion
7 Minimally Invasive Posterior Cervical Foraminotomy
8 Minimally Invasive Posterior Cervical Laminectomy
9 Anterior Cervical Discectomy with Arthroplasty or Fusion
10 Minimally Invasive Decompressions for Metastatic Spinal Disease
11 Minimally Invasive Resection of Intradural Extramedullary Lesions within the Thoracic Spine
12 Radiation and Minimally Invasive Spine Surgery
13 Minimizing Ionizing Radiation in Minimally Invasive Spine Surgery

Leseproben

1 A Minimally Invasive Perspective: The Conversion

Abstract

A distinct difference exists in the way the mind processes an open exposure as compared to a minimally invasive exposure. In the absence of the midline structures, the basis of orientation is different. The angles converging on the spine on a lateral to medial trajectory alter the appearance of the otherwise familiar surface anatomy. The absence of the recognizable midline structures, along with an unfamiliar perspective of the surface anatomy, has the potential to disorient the mind. This chapter analyzes the difference between these exposures and explores how the mind can become oriented in minimally invasive approaches without the midline structures. Delving into the topics of recall memory and recognition memory of the spinal anatomy furthers our understanding of the basis of orientation and disorientation. Deconstructing the origin of disorientation in minimally invasive approaches becomes the foundation upon which to build a path to a more efficient learning curve for minimally invasive spine surgery. The chapter ends with covering the essential components of minimally invasive spine surgery and reviewing the premise and principles of minimally invasive spine surgery that will be the basis of the subsequent chapters in this Primer.

Keywords: exposure, facet, lamina, learning curve, orientation, recall memory, recognition memory, spinous process, three-dimensional spinal anatomy

The mind once enlightened cannot again become dark.

Thomas Paine

1.1 Introduction

The capacity to reconstruct the spinal anatomy at depth without the midline structures to orient the mind is the very essence of minimally invasive spine surgery. In traditional open approaches, we begin in the midline and work outward. In doing so, we expose the landmarks of the spinous process, lamina, facets and transverse processes in sequential order. These landmarks orient our mind and allow us to move through the procedure confidently and efficiently. Our visualization of these midline landmarks provides us certain knowledge of the anatomy. In minimally invasive approaches, we have neither the midline nor the conventional exposure of these landmarks. Instead, we must rely on visualization of the anatomy in the mind’s eye of what is not seen or even unveiled. The mind must visualize the entire facet, although only a hint of that facet may be exposed. The ability to reconstruct that anatomy with only limited exposure will prevent the mind from becoming disoriented. The capacity to maintain orientation will directly affect the proverbial learning curve in minimally invasive surgery on the spine. Therefore, the concept of what orients our minds in spine surgery is the focus of this chapter.

To borrow from nautical analogy, we should consider how, when learning to sail the ocean, we would be ill-advised to lose sight of the shore. The shoreline orients the mind of the sailor to the cardinal directions of north, south, east and west. Becoming familiar with a vessel by doing nothing more than sailing up and down the coastline provides the sailor with a foundation to venture farther and farther out to the sea. Eventually, the sailor no longer requires a view of the shoreline to remain oriented. With an understanding of the position of the sun, the stars, a sextant and even the use of computer-assisted navigation, the sailor can safely bring the ship back into a safe harbor.

In traditional midline open spine surgery, the midline structures are the shoreline that forms the basis of orientation for the surgeon. Recognizing it as such helps the surgeon to understand how the absence of the midline in minimally invasive approaches is the root cause of disorientation, the same way the loss of the shoreline is potentially disorienting for the novice sailor. The reader must always keep this key principle in mind. The limited exposure of a transverse process or the inferior aspect of a facet can become indistinguishable when viewed through a 16-mm-diameter aperture ( ? Fig. 1.1).

Fig. 1.1 A juxtaposition of two exposures. Two minimally invasive exposures seen through a 16-mm minimal access port. At first glance, both exposures look very similar. However, each represents a completely different part of the lateral spinal anatomy, as shown by the fully dissected exposure on the right. In the absence of the midline elements, orientation with limited exposure can be quite challenging. In the end, one exposure appears ideally suited for a transforaminal approach, whereas the other exposure is too lateral to access the foramen. The length of the access port and the starting distance from the midline collectively orient the mind by incorporating the trajectory of convergence.

The mind must replace those visual reference points with its own reconstruction of the anatomy. The angle of convergence of a minimal access port onto the spine or its rostrocaudal trajectory further affects that reconstruction. Although such factors are not relevant in an open procedure, they can change the entire landscape in a minimally invasive procedure. On the one hand, the traditional midline exposures offer the visual cues of spinous processes, lamina and facets ( ? Fig. 1.2). These reference points allow you to keep your bearings during an operation. On the other hand, a minimally invasive approach does not unveil any of these midline bony landmarks. Instead, only limited portions of these landmarks in isolation are available to orient the mind. In the end, minimally invasive approaches require more from your mind than the open equivalent.

Fig. 1.2 Traditional midline open exposure for a lumbar laminectomy. Illustration demonstrates the midline elements, which remain in the surgeon’s field of view. The midline keeps the mind oriented throughout the procedure. The absence of these midline elements in minimally invasive exposures can make bony prominences resemble one another, as shown in ? Fig. 1.1.

What you accomplish with a midline exposure is a complete unveiling of the spinal anatomy at depth. As a result, there is no need for the mind to reconstruct any component of that anatomy or to speculate on whether a bony prominence is a facet or a transverse process, as demonstrated in ? Fig. 1.1. Whether or not you realize it, your eye is constantly scanning these visual cues in an open exposure to keep your mind oriented. In a midline open approach, you never lose sight of the shore.

A minimally invasive exposure is completely different. It forces your mind to become oriented and to stay oriented without the midline and with less visualization of the spinal anatomy. Although it is a highly efficient exposure with regard to the surgical target relative to the surgical exposure, there is no midline and very little anatomy to scan as a reference point. Your mind is left to reconstruct the anatomy around the limited exposure offered by the diameter of the minimal access port. Open approaches teach us the anatomy, but reconstruction of the anatomy is unnecessary by the nature of the exposure. We can see everything. Therefore, the capacity to accurately and efficiently reconstruct this anatomy is an acquired skill unique to minimally invasive spine procedures. To confidently and expediently move through a procedure, the minimally invasive surgeon must learn how to connect the lines of the anatomy from what is seen to what is unseen. The mind must also incorporate the trigonometry of convergence and the effect it has on the exposure at depth.? Fig. 1.3 illustrates this point by demonstrating how the degree of convergence can result in two different exposures despite the same incision. You will find that as the length of the minimal access port increases, the effect of convergence plays an increasingly detrimental role in envisioning the ideal position of the exposure.

Fig. 1.3 The effect of convergence. (a) Illustration of a lumbar segment in the axial plane demonstrates two exposures (medial, turquoise dashed line; lateral, ruby dashed line) through the same access port (16 mm in diameter and 7 cm in length). The mind must consider several factors to reconstruct the spinal anatomy at depth. The location of the incision off the midline, the degree of convergence of the access port, and the rostrocaudal trajectory collectively affect the exposed anatomy at depth. (b) Posterior view of the spine of the previous axial image again demonstrates that both incisions can be placed 2 cm off the midline. A different exposure of the anatomy at depth may be the result, depending on the degree of convergence. The large dark ring represents the proximal aspect of the port at the level of the skin, and the smaller colored rings represent the access port at the level of the spine. The degree of convergence is the difference in these two exposures, which otherwise are identical with regard to the location of the incision and the length of the minimal access port. The medial exposure (turquoise ring) is ideal for a microdiscectomy, whereas the more lateral exposure (ruby ring) is too lateral and suboptimal for the procedure.

You must not think that the reconstruction of the spinal anatomy at...