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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)
#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 ...
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