AgnieszkaLakritz
Networker
Pre-op diagnosis:
1. Lumbar DDD with aseptic discitis;
2. Lumbar degenerative spondylolisthesis.
Post-op diagnosis:
same
Procedure done:
1. L5 laminectomy, bilateral S1 laminotomy, open posterior approach;
2. Right L5/S1 posterolateral foraminotomy, with outside-in technique, under direct visualization;
3. L5-S1 posterior spinal fusion with local bone autograft;
4. Open posterior instrumentation of L5, S1 with bilateral pedicle screws;
5. Use of bi-planar navigation for spinal instrumentation;
6. L5/S1 anterior retro-peritoneal interbody fusion, insertion of expandable titanium interbody cage into the prepared L5/S1 disc space, open iliac crest bone grafting, use of DBM allograft and local bone autograft;
7. L5-S1 Smith-Petersen osteotomy for reduction of spondylolisthesis and increase in lumbar lordosis.
Procedure:
INDICATIONS:
This is a 52-year-old Caucasian female who unfortunately developed significant progression of L5/S1 DDD, L5/S1 aseptic discitis, as well as L5/S1 instability/spondylolisthesis. She has failed extensive conservative treatment including ESIs and LMBBs. She is here for the above stated surgery as outpatient.
Patient was seen again at the pre-operative area, we went into details again about the risks and benefits about the above stated surgeries, but are not limited to, tissue or organ injuries including blood vessels, spinal cord/nerves, dura, nerve, infection, anesthesia reactions, increased pain, continuous pain, muscle weakness, need of additional surgery, or even death. The patient understood and consented to proceed the surgery. Informed consent was obtained, surgical site was marked.
DETAILED OPERATION PROCEDURE:
Patient was taken to OR and placed in a prone position on radiolucent Allen table, after induction of general anesthesia. All pressure points were well padded, SCDs were used for DVT prophylaxis. After time-out and peri-operative antibiotics were given, patient's lumbar sacral area was prepped and draped in usual sterile manner.
I first turned our attention to L5 laminectomy, bilateral S1 laminotomy and posterior spinal fusion. I first placed L5, S1 screws through Paramedian incisions, open Wiltse approach and dissection, under biplanar fluoroscopy navigation and monitoring (Nuvasive 7.5mmx45mm for S1, 7.5mmx50mm for L5). Next, I used fluoroscopy to plan the incision and confirm the right level. A 2.5-cm longitudinal incision was made approximal 4 cm off midline to the right side, centered over the L5/S1 disc space on lateral fluoroscopy view. After fascia incision, paramedian approach and dissection was carried under direct visualization for exposure of the L5/S1 interlaminar space. A Mcculloch retractor was placed, and under direct visualization, L5 laminectomy, bilateral S1 laminotomy was done with high-speed drill, 2-mm micro-Kerrison. Contralateral S1 laminotomy (left side) was done with “over-the-top” technique under direct visualization. Next, L5/S1 endplate osteotomy was also done for resection of endplate osteophytes. L5 pars was also drilled and resected for Smith-Petersen osteotomy (posterior column), to fully mobilize the L5-S1 motion segment.
Next, right L5/S1 foraminotomy was done with posterolateral approach, by docking the McCulloch retractor on the right L5 pars. After identifying the right L5/S1 foramen, right L5/S1 posterolateral foraminotomy was done by undercutting the right L5 pars and by undercutting the right S1 superior facet under direct visualization. Next, with osteotome, I did contralateral L5/S1facet decortication for posterior facet fusion with local bone autograft.
Next, I turned my attention to L5-S1 anterior interbody fusion with retro-peritoneal approach with a separate lateral incision approximately 6cm off midline to the right side. Through a postero-lateral, extra-foraminal retro-peritoneal approach, layer by layer dissection was carried to expose the right L5/S1 extra-foraminal space. Next, right S1 superior facet was drilled with high-speed drill under direct visualization, right exiting L5 nerve root, right S1 traversing nerve root, and right S1 pedicle were identified and visualized. Next, while protecting the above exiting and traversing nerve roots, the a small McCulloch retractor blade was advance into the L5/S1 disc space. A thorough L5/S1 discectomy was done with different sized curettes and disc shavers, under direct visualization, care was used not to violate either endplate. Anterior-column osteotomy was done for resection of bridging osteophytes, anterior longitudinal ligament (ALL) was also released (anterior column) under direct visualization and fluoroscopic guidance. Next, after copious irrigation of the disc space, under direct visualization and fluoroscopy monitoring, the above stated titanium expandable interbody cage (Nuvasive MLX) was placed into the prepared L5/S1 disc space, and expanded to final anterior height of 12 mm and large footprint (34mmx24mm) with 12-degree lordosis. The interbody cage was then packed with DBM allograft, local bone autograft, iliac crest bone graft (obtained from right PSIS through an open approach), as well as an extra-small INFUSE sponge. Fluoroscopy confirmed good position of the interbody cage, good restoration of disc height, reduction of spondylolisthesis and increase in lordosis. The incision was irrigated with copious normal saline and closed in layers.
Next, I placed 30 mm in length titanium rods and connected the L5, S1 pedicle screws bilaterally, and before locking the final construct with set screws, compression was done between L5-S1 pedicle screws under direct visualization, to lock in the interbody cage, to increase lumbar lordosis.
Findings:
significant L5/S1 DDD with instability
1. Lumbar DDD with aseptic discitis;
2. Lumbar degenerative spondylolisthesis.
Post-op diagnosis:
same
Procedure done:
1. L5 laminectomy, bilateral S1 laminotomy, open posterior approach;
2. Right L5/S1 posterolateral foraminotomy, with outside-in technique, under direct visualization;
3. L5-S1 posterior spinal fusion with local bone autograft;
4. Open posterior instrumentation of L5, S1 with bilateral pedicle screws;
5. Use of bi-planar navigation for spinal instrumentation;
6. L5/S1 anterior retro-peritoneal interbody fusion, insertion of expandable titanium interbody cage into the prepared L5/S1 disc space, open iliac crest bone grafting, use of DBM allograft and local bone autograft;
7. L5-S1 Smith-Petersen osteotomy for reduction of spondylolisthesis and increase in lumbar lordosis.
Procedure:
INDICATIONS:
This is a 52-year-old Caucasian female who unfortunately developed significant progression of L5/S1 DDD, L5/S1 aseptic discitis, as well as L5/S1 instability/spondylolisthesis. She has failed extensive conservative treatment including ESIs and LMBBs. She is here for the above stated surgery as outpatient.
Patient was seen again at the pre-operative area, we went into details again about the risks and benefits about the above stated surgeries, but are not limited to, tissue or organ injuries including blood vessels, spinal cord/nerves, dura, nerve, infection, anesthesia reactions, increased pain, continuous pain, muscle weakness, need of additional surgery, or even death. The patient understood and consented to proceed the surgery. Informed consent was obtained, surgical site was marked.
DETAILED OPERATION PROCEDURE:
Patient was taken to OR and placed in a prone position on radiolucent Allen table, after induction of general anesthesia. All pressure points were well padded, SCDs were used for DVT prophylaxis. After time-out and peri-operative antibiotics were given, patient's lumbar sacral area was prepped and draped in usual sterile manner.
I first turned our attention to L5 laminectomy, bilateral S1 laminotomy and posterior spinal fusion. I first placed L5, S1 screws through Paramedian incisions, open Wiltse approach and dissection, under biplanar fluoroscopy navigation and monitoring (Nuvasive 7.5mmx45mm for S1, 7.5mmx50mm for L5). Next, I used fluoroscopy to plan the incision and confirm the right level. A 2.5-cm longitudinal incision was made approximal 4 cm off midline to the right side, centered over the L5/S1 disc space on lateral fluoroscopy view. After fascia incision, paramedian approach and dissection was carried under direct visualization for exposure of the L5/S1 interlaminar space. A Mcculloch retractor was placed, and under direct visualization, L5 laminectomy, bilateral S1 laminotomy was done with high-speed drill, 2-mm micro-Kerrison. Contralateral S1 laminotomy (left side) was done with “over-the-top” technique under direct visualization. Next, L5/S1 endplate osteotomy was also done for resection of endplate osteophytes. L5 pars was also drilled and resected for Smith-Petersen osteotomy (posterior column), to fully mobilize the L5-S1 motion segment.
Next, right L5/S1 foraminotomy was done with posterolateral approach, by docking the McCulloch retractor on the right L5 pars. After identifying the right L5/S1 foramen, right L5/S1 posterolateral foraminotomy was done by undercutting the right L5 pars and by undercutting the right S1 superior facet under direct visualization. Next, with osteotome, I did contralateral L5/S1facet decortication for posterior facet fusion with local bone autograft.
Next, I turned my attention to L5-S1 anterior interbody fusion with retro-peritoneal approach with a separate lateral incision approximately 6cm off midline to the right side. Through a postero-lateral, extra-foraminal retro-peritoneal approach, layer by layer dissection was carried to expose the right L5/S1 extra-foraminal space. Next, right S1 superior facet was drilled with high-speed drill under direct visualization, right exiting L5 nerve root, right S1 traversing nerve root, and right S1 pedicle were identified and visualized. Next, while protecting the above exiting and traversing nerve roots, the a small McCulloch retractor blade was advance into the L5/S1 disc space. A thorough L5/S1 discectomy was done with different sized curettes and disc shavers, under direct visualization, care was used not to violate either endplate. Anterior-column osteotomy was done for resection of bridging osteophytes, anterior longitudinal ligament (ALL) was also released (anterior column) under direct visualization and fluoroscopic guidance. Next, after copious irrigation of the disc space, under direct visualization and fluoroscopy monitoring, the above stated titanium expandable interbody cage (Nuvasive MLX) was placed into the prepared L5/S1 disc space, and expanded to final anterior height of 12 mm and large footprint (34mmx24mm) with 12-degree lordosis. The interbody cage was then packed with DBM allograft, local bone autograft, iliac crest bone graft (obtained from right PSIS through an open approach), as well as an extra-small INFUSE sponge. Fluoroscopy confirmed good position of the interbody cage, good restoration of disc height, reduction of spondylolisthesis and increase in lordosis. The incision was irrigated with copious normal saline and closed in layers.
Next, I placed 30 mm in length titanium rods and connected the L5, S1 pedicle screws bilaterally, and before locking the final construct with set screws, compression was done between L5-S1 pedicle screws under direct visualization, to lock in the interbody cage, to increase lumbar lordosis.
Findings:
significant L5/S1 DDD with instability