LISS Ricardo Ferreira

LISSLISS ENDOPEDMAXENDOPEDMAX

Adalto Lima

Jose Sergio Franco

Marcus Musafir

Ricardo Ferreira

Rafael Moraes

Ricardo Ferreira

Ricardo

Ferreira

ConceitosMISS / LISS

Minimal Invasive Spine SurgeryLess Invasive Spine Surgery

Objetivo:Mesma Eficiência com Menor Agressão

Questões ???

Por que ?

Para Melhorar algo que já é Bom.

Mas...Você Acredita que isso é Bom ????

Revisão da Literatura

Resultados da Artrodese

• Zdeblick et al. 1993. Spine. 983-91. N=124.

95% fusion rate,

95% good results

• Cloward,1981, N=100, 86% fusion,

98% satisfied

• Hall et al. 1996. Spine. 982-994. N=120. 63% had previous surgery.

73% good results, 91% fusion rate 11% complication rate.

SurgerySurgery StudiesStudies FusionFusion

MeanMean

AIFAIF

PLFPLF

PLIFPLIF

PLF+IFPLF+IF

PLF+PFPLF+PF

PLIF+PFPLIF+PF

1010

1616

88

1010

2222

22

CasesCases

10721072

12641264

13721372

463463

11251125

305305

78.378.3

86.686.6

89.489.4

87.487.4

90.890.8

93.893.8

75.975.9

70.270.2

8282

65.265.2

67.567.5

87.687.6

META-ANALYSIS OF FUSION. ESJ, 1997

BOOS AND WEBB. n= 5601

Good outcome

E quanto a Artroplastia ?

Artroplastia Discal ( TDR ) X ArtrodeseSAS 7 - Berlin 2007

Trabalho Autor n FU Takeaway 5-yr follow up on

ChariteGuyer,R.D

52 5 yrs No significant difference to ALIF with BAK fusion cages

at 5yrs.

2-level

Prodisc

Goldstein, J. 168 > 2yrs Results

comparable to fusion

Disc and Facet Degeneration

after Lumbar Disc (5 yr)

Kube, R.A. 10 5 yrs CT/MRI saw 8/10 facet degeneration at the operative level.

Improvement in

2/10 adjacent discs.

Degeneração de Discos Adjacentes

Adjacent Segment Failure • Leon Wiltse.

1994. In ‘Instrumented Spinal Fusion’.

22.6 yr follow-up of 42 patients with postero-lateral fusion, with a comparison group.

“No difference in rate of degeneration in adjacent segments or of hypermobility.”

– Overall 75% clinical success.

Consenso Atual

• Resultados da Artroplastia Não são melhores do que os da artrodese.

• Exposição à complicações

potencialmente Mais Graves

• Revisão de Artroplastia é possível,

parem de Altíssimo Risco

Então ... Será que TDR está caminho certo ?

Será que ATD esta pronta para o uso ?

E....Como melhorar a Artrodese ???

Menor Lesão de Partes Moles.

INTRAMUSCULAR PRESSURE IS LESS WITH MINIMALLY INVASIVE SPINAL RETRACTORS THAN WITH OPEN RETRACTORS

Kee D. Kim, MD 1; David Spenciner, P.E., Sc.M 2; Marike Zwienenberg-Lee, MD 1 ; James E. Boggan, MD 1

Department of Neurological Surgery University of California Davis 1

RIH OrthopaedicFoundation, Inc.2

Introduction Spinal muscle retraction increases the intramuscular pressure (IMP) and decreases blood flow to the paraspinal muscles that may adversely affect postoperative function.1,2

Endoscopic placement of pedicle screws is done with less retraction than an open procedure and may thus cause less ischemic damage.The exact effect of retraction on the muscle has not been demonstrated previously. We have designed a cadaver study in which IMP measurements using a minimally invasive retractor and an open retractor are compared.Methods Two unembalmed cadavers were used to compare FlexPosure, a flexible minimally invasive retractor (Endius, Plainville, MA) and Versa-Trac open lumbar retractor (V. Mueller, McGaw Park, IL). An ultra-miniature pressure transducer catheter (Millar Instruments, Houston TX) was used to measure pressure at specific locations next to the incision during retraction. A 3.5 cm paramedian incision for L4-5 posterolateral fusion was made after a serial dilation and FlexPosure was deployed. The needle pressure transducer was inserted into the paraspinal musculature and IMP was measured at three sites: 1.5 cm cephalad and caudad to the incision and 2.5 cm lateral to the incision. These steps were repeated on the contralateral side. Midline incision followed by open retraction with Versa-Trac retractor necessary for same posterolateral fusion was performed. The IMP measurements were again recorded at three different sites: 2.5cm lateral to cephalad, caudad and center of the incision. For the second cadaver, the same sequence of measurements was performed but only one side. Maximum IMP was measured three times at each site. A Mann-Whitney Rank Sum Test was used to analyze the data.

Results The mean IMP measured with the minimally invasive retractor was 10.7 +/- 6.3 mm Hg (n=27) and the mean IMP with the open retractor was 34.9 +/- 18.8 mm Hg (n=18) (P<0.001). The maximum pressure was maintained throughout the time that the open retractor was applied. The maximum pressure with the minimally invasive retractor, in contrast, was noted only briefly with the initial expansion. Planning of IMP

measurement sites No of measures (n)

Mean IMP

(mm Hg)

Openprocedure

18 34.9Endoscopic

procedure27 10.7

Discussion and conclusions This study shows that the peak IMP during spine surgery with a minimally invasive retractor is significantly less than with the open retractor. This may in part explain the diminished post-operative pain and more rapid recovery of endoscopically treated patients. It encourages the use of the endoscopic technique in eligible patients.References1 Taylor H. et al. The impact of self-retaining retractors on the paraspinal muscles during posterior spinal surgery. Spine 27: 2758-2762, 2002

2 Datta G. et al. Back pain and disability after lumbar laminectomy: Is there a relationship to muscle retraction? Neurosurgery 54: 413-419, 2004

Endoscopic retraction

Open retraction

Acknowledgements: This study was funded by Endius,Inc., Plainville MA.

Positioning of the fiberoptic probe

Sistema P2S ( GM Reis )• Parafusos Pediculares Poli-Axiais Canulados com Cabeça Longa

• Formas de Utilização : – Como Sistema Minimamente Invasivo (MISS)

• Vantagem = Menor Agressão

– Como Sistema “ Tradicional ”• Maior Precisão

Indicações

• Como Sistema “LISS”– DDD– Instabilidades

• Espondilolistese• Fraturas

– Adjuvante ao ALIF– Adjuvante PLIF

• Como Sistema “Tradicional”– Pedículos Difíceis

• Escolioses• Grandes Espondilolistes• Má Formações

Técnica Cirúrgica

#1 Posicionamento do paciente

# 2 Localizar Pedículos

Acesso aos Pedículos

# 3 Puncionar Pedículos ( Fio Guia 2 mm)

#4 PUNÇÃO C/ CANULA 3.5mm

#5 TROCA POR FIO 1.0 mm

#6 Dilatação de Partes Moles

#7 Escolha e Colocação dos Parafusos

# 8 Acessos e Colocação das Hastes

# 9 Distração e Bloqueio

#10 Enxertia e Quebra dos Cabeças

FINAL

CasoDDD

Caso DDD

CasoEscoliose 50/60

CasoEscoliose

Caso Escoliose 85

Caso Escoliose

CasoListesis

+ PPLIF

Complicações

Mensagem Final

... Algo Minimamente invasivo também pode ser Maximamente Lesivo ...

OBRIGADO

RICARDO FERREIRA

ricardoferreira@vertebralis.com.br

www.lombar.com.br