The Endoscopic Approach to Lumbar Discectomy, Fusion, and Enhanced Recovery: A Review

Study Design: Review. Objectives: To review the current state of endoscopic spine surgery with regard to discectomy, interbody fusion, and combination with Enhanced Recovery After Surgery programs in order to evaluate its relevance to the future of spine care. Methods: A review of the literature and expert opinion is used to accomplish the objectives. Results: The greatest strength of endoscopic spine surgery lies in its adherence to the basic tenets of minimally invasive surgery and its innate compatibility with Enhanced Recovery After Surgery programs, which aim to improve outcomes and reduce health care costs. The greatest challenge faced is the unique surgical skill set and significant learning curve. Conclusions: Endoscopic spine surgery strives to achieve the core goals of minimally invasive surgery, while reducing cost and enhancing quality. In a healthcare market that is becoming increasingly burdened by cost and regulatory constraints, the utilization of endoscopy may become more widespread in the coming years

Lumbar 3-Lumbar 5 Robotic-Assisted Endoscopic Transforaminal Lumbar Interbody Fusion: 2-Dimensional Operative Video

Minimally invasive spine surgery has the potential to reduce soft tissue destruction, blood loss, postoperative pain, and overall perioperative morbidity while accelerating recovery. Robotic guidance systems are relatively new tools in the minimally invasive surgeon's armamentarium, striving to increase accuracy of instrumentation placement, decrease complications, reduce radiation burden, and enhance surgical ergonomics in order to improve efficiency and maximize patient outcomes. We present the case of a 78-yr-old male with intractable lower back and bilateral lower extremity pain with multilevel degenerative spondylosis. The procedure performed was a L3-5 robotic-assisted endoscopic transforaminal lumbar interbody fusion (TLIF) utilizing the Mazor X robotic guidance system (Medtronic) for both percutaneous pedicle screw placement, as well as trajectory localization for endoscopic discectomy and percutaneous interbody delivery. Previously, clinical and radiographic success has been published regarding the awake, endoscopic TLIF. We document the first use of robotic guidance for disc space localization and its combination with endoscopy to achieve interbody fusion, utilizing an expandable, allograft-filled mesh interbody device. This video demonstrates appropriate patient positioning, work flow for this unique technique, and the benefits of using robotic guidance to plan and execute percutaneous trajectories through Kambin's triangle. This procedure involves the off-label use of recombinant human bone morphogenetic protein-2 (Infuse (TM), Medtronic), OptiMesh (R) graft containment device (Spineology), and liposomal bupivacaine (Exparel (R), Pacira)

Anterior Petrosal [Kawase] Approach to Meckel's Cave Meningioma: 2-Dimensional Operative Video

Abstract Meningiomas arising from Dorello's canal1-3 are a rare disease entity often resulting in an unclear diagnosis even at the time of surgery.4,5 We present a case of a 63-yr-old man who presented with a sixth nerve palsy. He was found to have a lesion in the region of Meckel's cave on neuroimaging studies. Additionally, there were cutaneous and joint complaints that gave rise to a clinical possibility of sarcoidosis. The differential diagnosis also included meningioma or other inflammatory processes. The patient underwent a right-sided middle fossa approach and partial anterior petrosectomy (Kawase approach). Meckel's cave was opened, the tumor resected, and the petrosphenoid ligament (Gruber's) was identified. It was a meningioma. The case presentation, surgical anatomy, technique, and postoperative course and outcome are reviewed. The patient gave verbal consent for participating in the procedure and surgical video

Minimally Invasive Pedicle Subtraction Osteotomy

For patients with significant spinal deformity, the pedicle subtraction osteotomy provides a powerful means for correction, albeit with high morbidity. With the trend toward minimally invasive spine surgery, multiple less invasive techniques have been devised; however, there seems to be an upper limit to the degree of correction possible. The mini-open pedicle subtraction osteotomy addresses these limitations by minimizing the extent of soft tissue destruction needed to perform the osteotomy and by using the rod-cantilever technique to achieve maximum lordosis. Preliminary data are promising, with significant improvements in patient-reported clinical outcome measures as well as coronal and sagittal alignment

Robotics in Spine Surgery and Spine Surgery Training

The increasing interest and advancements in robotic spine surgery parallels a growing emphasis on maximizing patient safety and outcomes. In addition, an increasing interest in minimally invasive spine surgery has further fueled robotic development, as robotic guidance systems are aptly suited for these procedures. This review aims to address 3 of the most critical aspects of robotics in spine surgery today: salient details regarding the current and future development of robotic systems and functionalities, the reported accuracy of implant placement over the years, and how the implementation of robotic systems will impact the training of future generations of spine surgeons. As current systems establish themselves as highly accurate tools for implant placement, the development of novel features, including even robotic-assisted decompression, will likely occur. As spine surgery robots evolve and become increasingly adopted, it is likely that resident and fellow education will follow suit, leading to unique opportunities for both established surgeons and trainees

Reduction in complication and revision rates for robotic-guided short-segment lumbar fusion surgery: results of a prospective, multi-center study

Studies evaluating robotic guidance in lumbar fusion are limited primarily to evaluation of screw accuracy and perioperative complications. This is the first study to evaluate granular differences in short and long-term complication and revision rate profiles between robotic (RG) fluoroscopic (FG) guidance for minimally invasive short-segment lumbar fusions. A retrospective analysis of a prospective, multi-center database was performed. Complications were subdivided into surgical (further subcategorized into adjacent segment disease, new-onset back pain, radiculopathy, motor-deficit, hardware failure, pseudoarthrosis), wound, and medical complications. Complication and revision rates were compared between RG and FG groups cumulatively at 30, 90 days, and 1 year. 374 RG and 111 FG procedures were performed. RG was associated with an 86.25, 83.20, and 69.42% cumulative reduction in complication rate at 30, 90 days, and 1 year, respectively, compared to FG (p < 0.001). At all follow-up points, new-onset radiculopathy and medical complications were most prevalent in both groups. The greatest reductions in complication rates were seen for new-onset back pain (88.13%; p = 0.001) and wound complications (95.05%; p < 0.001) at 30 days, new-onset motor deficits (90.11%; p = 0.004) and wound complications (85.16%; p < 0.001) at 90 days, and new-onset motor deficits (85.16%; p = 0.002), wound (85.16%; p < 0.001), and medical complications (75.72%; p < 0.001) at 1 year. RG was associated with a 92.58% (p = 0.002) reduction in revision rate at 90 days and a 66.08% (p = 0.026) reduction at 1 year. RG was associated with significant reductions in postoperative complication rates at all follow-up time points and significant reductions in revision rates at 90 days and 1 year

Fluoroscopy time analysis of a prospective, multi-centre study comparing robotic- and fluoroscopic-guided placement of percutaneous pedicle screw instrumentation for short segment minimally invasive lumbar fusion surgery

Background As minimally invasive spine surgery becomes more widespread, concerns regarding radiation exposure to surgeons and patients alike have become a growing concern. Robotic guidance has been developed as a way to increase the accuracy of instrumentation while decreasing radiation burden. Methods A retrospective analysis of a large, multi-centre, prospective study comparing robotic-guided (RG) to fluoroscopic-guided (FG) (Multi-centre, Partially Randomized, Controlled Trial of MIS Robotic vs. Freehand in Short Adult Degenerative Spinal Fusion Surgeries) was performed to evaluate for differences in radiation exposure between study groups. Results RG was associated with 78.3% (p < 0.001) and 79.8% (p < 0.001) reduction in total and per screw fluoroscopy times, respectively, as compared to FG. RG was also associated with a 50.8% (p < 0.001) reduction in total operative fluoroscopy time. Conclusions RG was associated with significantly lower fluoroscopy times compared to FG. This suggests that utilization of robotic navigation systems may result in decreased operative radiation exposure, which is a growing concern for surgeons performing minimally invasive spine surgery

Ninety-day complication, revision, and readmission rates for current-generation robot-assisted thoracolumbar spinal fusion surgery: results of a multicenter case series

OBJECTIVE Robotics is a major area for research and development in spine surgery. The high accuracy of robot -assisted placement of thoracolumbar pedicle screws is documented in the literature. The authors present the largest case series to date evaluating 90-day complication, revision, and readmission rates for robot-assisted spine surgery using the current generation of robotic guidance systems. METHODS An analysis of a retrospective, multicenter database of open and minimally invasive thoracolumbar instrumented fusion surgeries using the Mazor X or Mazor X Stealth Edition robotic guidance systems was performed. Patients 18 years of age or older and undergoing primary or revision surgery for degenerative spinal conditions were included. Descriptive statistics were used to calculate rates of malpositioned screws requiring revision, as well as overall complication, revision, and readmission rates within 90 days. RESULTS In total, 799 surgical cases (Mazor X: 48.81%; Mazor X Stealth Edition: 51.19%) were evaluated, involving robot-assisted placement of 4838 pedicle screws. The overall intraoperative complication rate was 3.13%. No intraoperative implant-related complications were encountered. Postoperatively, 129 patients suffered a total of 146 complications by 90 days, representing an incidence of 16.1%. The rate of an unrecognized malpositioned screw resulting in a new postoperative radiculopathy requiring revision surgery was 0.63% (5 cases). Medical and pain-related complications unrelated to hardware placement accounted for the bulk of postoperative complications within 90 days. The overall surgical revision rate at 90 days was 6.63% with 7 implant-related revisions, representing an implant-related revision rate of 0.88%. The 90-day readmission rate was 7.13% with 2 implant-related readmissions, representing an implant-related readmission rate of 0.25% of cases. CONCLUSIONS The results of this multicenter case series and literature review suggest current-generation robotic guidance systems are associated with low rates of intraoperative and postoperative implant-related complications, revisions, and readmissions at 90 days. Future outcomes-based studies are necessary to evaluate complication, revision, and readmission rates compared to conventional surgery

Essential Step-by-Step Techniques for Minimally Invasive Spinal Surgery

The ultimate resource for learning and mastering minimally invasive spine surgery techniques An estimated 1.5 million instrumented spinal procedures are performed every year in the US. The majority of decompressions and about 50% of fusion procedures can be performed completely or partially using minimally invasive spine surgery (MISS) techniques. The full potential of MISS techniques has yet to be realized. Essential Step-by-Step Techniques for Minimally Invasive Spinal Surgery by internationally renowned MISS neurosurgeon Roger Härtl, spine-neurosurgeon Rodrigo Navarro-Ramirez, and an impressive group of global multidisciplinary contributors is the most comprehensive and detailed textbook written to date on this topic. The foundation of the book is built on six interacting principles critical to surgical success, and MISS in particular: Target, Technology, Technique, Teaching and Training, Testing, and Talent. The text starts with an opening chapter on the definition of MISS and introduction of these principles. Fifty-six subsequent chapters provide a comprehensive discussion on how to utilize an MISS approach for a full spectrum of spinal pathologies using nuanced variations specific to the operating surgeon. To ensure readers are well versed in all aspects of MISS, these chapters include painstaking details on indications, contraindications, pathoanatomy, operating room set-up, step-by-step techniques, and postoperative management. Key Highlights Contributions from master spine surgeons across the world provide a balanced global perspective on mastering and incorporating diverse techniques into practice Invaluable clinical pearls including tips/tricks and complication avoidance High-quality images, figures, anatomic drawings, and imaging studies illustrate relevant anatomic approaches and corridors and delineate why anatomic masteryis critical to MISS Twenty-five videos enhance the ability to learn and implement MISS approaches This is a must-have resource for practicing spine surgeons interested in MISS who wish to learn the latest techniques from master surgeons and achieve optimal patient outcomes. The text and videos also provide a robust training tool for senior-level orthopaedic and neurosurgery residents and spine fellows