`
`enaomD3mSLMaEubB.1Fb.3lomr.pac6m.mmmmiSp..SDEv0
`
`m1
`
`.5...W.SC
`
`NE
`
`.VN._Nm.mwMpC
`
`may?01.Em>3mmsmém
`
`._.|—_.___
`
`50mENSA
`
`
`
`
`
`mu...._.._.515.31::a:inJuanEng2551$33:533:33:333*532320:»:[552.0*gang—5U<m5.3"gm—.2mag33.cmcqofimonmachml00525:”._m2..
`
`
`
`
`
`
`
`1
`
`

`

`
`
`
`
`
`
`
`
`t.....I_’_"_‘3.!illfiilfidoO‘s'nliqpeioemideqlieu]puelinedpm“aliqeuiogpewioMBanleuoneNem40uonoanoo31.41mm;patuuusumuuuuaimuuwyurww93+..
`
`
`
`
`
`
`
`
`
`Publisher:
`
`HAN LEY & BELFUS, INC.
`210 South 13th Street
`
`Philadelphia, PA 19107
`(215) 546—4995
`Fax {215) 790-9330
`
`Cl
`
`Prei
`
`Bio:
`Ma;
`
`SPINE: State at the Art Reviews
`
`Volume 6. Number 3
`
`ISSN 088?-9869
`
`ISBN 1-56053-090—1
`
`® 1992 by Hanley & Belfus, inc. under the International Copyright Union. All rights reserved.
`No part of this book may be reproduced, reused, republished, or transmitted in any form or
`by any means without written permission of the publisher.
`
`SPINE: State oi the Art Reviews is published triannually (three times per year) by Hanley 8:
`Belfus. Inc.. 210 South 13th Street, Philadelphia. Pennsylvania 1910?.
`
`POSTMASTER: Send address changes to SPINE: State of the Art Reviews. Hanley & Belfus,
`Inc.. 210 South 13th Street, Philadelphia, PA 1910?.
`
`This issue is Volume 6. Number 3.
`
`2
`
`

`

`[nos
`
`for
`
`(")0a?
`UE,on
`
`
`
`
`
`
`
`______‘rre|_1qopitqogjg'nfiqpeioetomeqnewpusrupeeprint2nqeuioipewtoMEJQH'qungUL“iUuuuuunuum4.wt»,puguu-J“mwunuup“
`
`
`
`
`
`
`
`
`
`HANSJORG F. LEU, MD
`ADAM SCHREIBER, MD
`
`PERCUTANEOUS FUSION
`
`OF THE LUMBAR
`
`SPINE:
`
`A Promising Technique
`
`From the Department of
`Orthopaedic Surgery Balgrist
`Medical School, University
`of Zurich
`
`Zurich, Switzerland
`
`Reprint requests to:
`Adam Schreiber, MD
`Professor and Chairman
`
`Department of Orthopaedic
`Surgery Balgrist
`Medical School, University
`of Zurich
`(DH-3008 Zurich
`Switzerland
`
`EVOLUTION OF THE CONCEPT
`
`Since its clinical introduction in 1979, the
`percutaneous approach to the intervertebral
`space for percutaneous nucleotomy has given
`rise to a stepwise growing concept for the treat-
`ment of different forms of lumbar disc affections.
`
`in 1975, Hijikata2 in Japan had
`Previously,
`described for the first time a minimally invasive
`alternative for the treatment of lumbar disc
`
`herniation and reported his experience in 1978
`at
`the SICOT meeting in Kyoto. Thus,
`the
`method found its way to Zurich, where Sehreiber
`and Suezawa gained the first clinical experience
`showing the practicality of the method.
`The original procedure, performed from
`one side with small calibrated cannulas, had
`some difficulty in achieving sufficient decom-
`pression in the posterior range of the interverte-
`bral discs. Thus, a biportal approach using
`larger—sized 6-mrn cannulas was clinically intro-
`duced in 1980 and 1981. In 1982, after further
`modifications of the instrumentation, for the
`first time the complementary introduction of a
`modified arthroscoPe became possible with
`immediate visual control of the intradiscal ma-
`
`nipulations.‘6 By this useful complement and
`some further instrumental improvements, the
`range of applications of percutaneous nucleot-
`omy with discosmpy became standardized for
`various forms of subligarnentary disc hernia-
`tions.15 For decompressive indications, since
`1989 percutaneous laser nuclear photoablationi
`
`SPINE: State of the Art Reviews—Vol. 6, No. 3, September 1992
`Philadelphia, Hanley & Belfus, inc.
`
`593
`
`3
`
`3
`
`

`

`s94
`
`LEU, SCHREIBER
`
`under discoscopic control has been available, with further reduction in perioperative
`morbidity in the treatment of contained disc herniations. For foraminal and extra-
`foraminal sequestrated herniations, the new technique of percutaneous foraminos—
`copy with an adapted working-scope, under clinical investigation since 1991, seems
`to enlarge further the range of percutaneous treatment of disc herniations.
`Already after only a few years of experience, the percutaneous approach with
`discoscopy has shown its minimal aggressivity against the musculoligamentary
`apparatus in the treatment of disc herniations. So, it is understandable why this
`approach was considered for use also in the treatment of segmental instability.13
`After specific adaption of percutaneous shaver systems for more radical removal
`of disc tissue in 1986, in 1987 the technique of autologous intervertebral bone
`grafting for the treatment of monosegmental lumbar instability showed us the
`applicability of transcannular bone impaction to the intervertebral space. At that
`time, the use of coaxial shavers and curettes did not yet permit the preparation of
`vertebral plates sufficiently to allow solid bony ingrowth. So, in this preliminary
`series of 5 patients, a considerable reabsorption of the autologous “spacer" was
`documented after 1 year with reappearance of clinical symptoms in most cases.
`Specially adapted instruments had to be designed for sufficiently deep preparation
`of the often rather sclerotic adjacent vertebral plates. In addition to the intervertebral
`preparation, the need for sufficient postoperative stabilization also had to be
`considered. To this end, we introduced the percutaneous AO-external pedicular
`fixator10 that we had used since 1985 for special traumatologic purposes. In addition
`to its function for postoperative stabilization of the fused segment, this versatile tool
`also was found to be useful in preoperative selection of an instable lumbar segment.
`Thus, since 1988, a series of over 35 patients has been treated with this technique
`of percutaneous lumbar interbody fusion under discoscopic control.
`
`INDICATIONS FOR PERCUTANEOUS INTERBODY FUSION
`The indications for this percutaneous interbody fusion technique are:
`l. monosegmental instabilities of degenerative origin, in cases with spondy—
`lolysis or after previous back surgery, or
`2. mild, nonerosive forms of (post)-inflammatory segment collapse.
`In any case, free epidural sequesters still remain excluded for this technique. So,
`whenever transligarnentary extrusion of disc tissue is suspected, the preoperative
`screening should include a contrast discomanometric study5 with complementary
`discoscan. Minor foraminal stenosis in the presence of degenerative protrusion in
`degenerative instability is not a basic contraindication. The discogenous thrust in
`this case is reduced by the percutaneous subligamentary discharge, and the
`foramina are somewhat enlarged by the segmental distraction. This release is
`already obtained and clinically checked with the preoperatively applied external
`pedicular external fixation device (see below).8
`The screening of segmental instability for Operative therapy remains one of
`the most challenging tasks besides the selection of the appmpriate surgical
`technique. In addition to the patient’s history and clinical findings, the native
`radiograph showing segmental
`interbody narrowing with increased range of
`motion in the functional radiographs gives the first characteristic patterns. Also in
`these cases, conservative therapies with active lumbar stabilization, eventually
`with complementary elastic lumbar bandage, should be attempted first for at least
`6 to 8 weeks. If there is insufficient effect, a more rigid external fixation with a
`temporary cast brace is applied for at
`least 2 weeks. When stabilization is
`
`4.
`
`
`
`.,_.—.--"~-__..___...—__
`
`PERCU
`
`succes
`
`confir
`additi
`
`When
`relief -
`
`for thi
`exterr
`
`the til
`
`Place
`
`the ex
`
`is in a
`fluorc
`latera
`suital:
`the e'
`follow
`
`Slight
`lordo:
`
`here.
`the so
`
`(AP)
`fluorc
`
`slight
`driller
`
`under
`must
`
`intra;
`resist:
`
`by a
`stepvv
`the ti
`
`be sc:
`This
`
`fluon
`in the
`
`Schai
`distra
`
`mean
`
`distal
`we st
`
`possi‘
`patiei
`In th
`fixatt
`
`is ob!
`
`
`
`
`
`
`
`'Maiiufiuldog‘s'nsqpeioeioidaqlawpuefinedlulu;elqautoipewto£19qu|Bu0ueNBut:0U0!109II00msUJOJlpaidoo89M859dSN:U0IBIJalBul_9_L_I_.L__
`
`
`
`
`
`
`
`
`
`4
`
`

`

`s
`
`‘4!
`
`.Pl_'"1
`
`l"I"'V'-_-1a.
`
`---..-i."__
`
`PERCUTANEOUS LUMBAR FUSION
`
`595
`
`successful, then a percutaneous external pedicular fixator .is mounted. This has to
`confirm the relevant clinical effects of the monosegmental stabilization with
`additional segmental distraction and, when necessary,
`interbody realignment.
`When under this condition and with functional loading of the patient, quantitative
`relief of symptoms is obtained, the percutaneous interbody fusion is indicated. So,
`for this second step, we preserve the successful interbody position by means of the
`external pedicular fixation during the percutaneous interbody fusion as well as for
`the time of primary postoperative bone healing.
`
`Placement of the External Pedicular Fixator
`In the practical procedure, as the first step of percutaneous interbody fusion,
`the external pedicular fixator is put in place under general anesthesia. The patient
`is in an orthogonal prone position, and the landmarks are inked on the skin under
`fluoroscopic control. As the optimal entry point, a position some 1.5 to 2 cm
`laterally of the pedicle’s dermal epicentrum, visible as the pedicular “eye,” is most
`suitable for sufficient convergence of the Schanz Screws. For optimal selection of
`the entry points in the craniocaudal dimension,
`the fluoroscope is oriented
`following the lordosis of the upper vertebral plate of the respective vertebral body.
`Slight corrections may be calculated following the desired correction of the
`lordosis between the two adjacent vertebrae.
`When this point is defined, a craniocaudal skin incision 1 cm long is 'made
`here. Next, the pedicular trocar with its sleeve-cannula is positioned penetrating
`the soft tissue down to the lateral edge of the pedicular “eye” under antemposterior
`(AP) fluoroscopic control. The craniocaudal orientation is checked as well in
`fluoroscopy. With the trocar, a bone mark is applied and the sleeve—cannula is
`slightly impacted into the bone. Next, the tr'ocar is retracted and the pedicle is
`drilled slowly with a 3.5-mm drill down to the transition into the vertebral body,
`under lateral fluoroscopic projection. In the AP View, at this point, the drill tip
`must not come medially of the medial border of the pedicle’s “eye.” Correct
`intrapedicular positioning of the drill can also be felt by the hands due to the low
`resistance of the intrapedicular spongious bone.
`While the sleeve—cannula is held in place, the drill is retracted and replaced
`by a 5-mm Schanz screw, which is gently screwed in manually (Fig. 1) under
`stepwise lateral fluoroscopic control. With the aimed convergency of 10 to 15° ,
`the tip of the screws should be targeted near the midsagittal plane, so they can
`be screwed down to about S-mm from the anterior wall of the vertebral body.
`This procedure is performed at each of the four pedicular sites. A final axial
`fluoroscopic View is made to check the correct position of every Schanz screw
`in the “eye” of the pedicle (Fig. 2). The external fixator is then mounted on the
`Sehanz screws, allowing the desired correction of lordosis and intervertebral
`distraction.
`
`When necessary, a minor spondylolisthesis can be stepwise reduced by
`means of a complementary adapted spindle device (Fig. 3) that pushes the
`distal vertebra forward in relation to the overlying vertebra. Intraoperatively,
`we strive for optimal interbody distraction and/or realignment, as much as
`possible without excessive reductional stress. With this interbody correction, the
`patient is mobilized the same day without any restriction of physical activity.
`In the following 2 to 3 days, whenever necessary, the effect of the external
`fixator can further be modified until the patient’s most comfortable correction
`is obtained.
`
`5
`
`I
`
`
`
`
`
`
`
`UIUHIUJUUqnewpUI:Ill-“BUPJlL”I5flqautumn“§Ufulfills"|IUUURUNUh"{Uuu'fluvllvvvs."quyup-luvvan-v q
`
`5
`
`

`

`l-lm'l—w-q...
`nu-uu'1'"u-
`
`
`
`
`
`
`
`
`
`IMBINDIJAUOQ8nflqDQIUBJUJU3L]ABUJ[JUU.NJBUfull.“L'-AL]UUlUlpUW*Umust.”|IUUUHUNall"anuuuuvnuuan”wua,Pull-amul-um
`
`
`
`
`
`
`
`
`
`596
`
`LEU, SCHREIBER
`
`Pram
`
`
`
`FIGURE I.
`collar rim.
`
`Screwing in of the first Schanz screw. The screw passes the guide sleeve with
`
`Percutaneous lnterhody Fusion under DiscoscOpy
`Clinical success for 24 hours under probatory percutaneous pedicular fixation
`with functional activity confirms the indication for the second operative step, the
`percutaneous interbody fusion.
`The percutaneous approach to the intervertebral space follows the guidelines
`for percutaneous nucleotomy under discoscopy. The procedure is performed now
`routinely under general anesthesia without initial muscular relaxation. In this way,
`if the level of anesthesia is kept superficial in the first stage, during the introduction
`of the cannulas, a direct feedback from the patient in case of mechanical stress of
`the nerve root is still possible. For fusion, 7-mm cannulas, larger than the types used
`for decompressive percutaneous nucleotomy, permit the necessary approach to the
`intervertebrai space. When these working cannulas are put in the desired position,
`the level of anesthesia and muscular relaxation can be modified as necessary.
`The entry points for the biportal percutaneous approach are selected some 8.5
`to 10.5 cm laterally to the midline. Over a central guide needle, four cannulas of
`increasing diameter are stepwise overslipped, one upon the other. The largest
`working cannula is positioned in the periphery of the posterolateral intervertebral
`space, penetrating the anulus fibrosus for about 1 cm to ensure its stability.
`Across the working cannulas, introduced from both sides, the remaining disc
`tissue is removed under discoscopic control. In addition to adapted rongeurs,
`
`6
`
`HGi
`cont:
`screw
`
`pedit
`
`suct:
`reac
`
`appl
`disc
`rater
`
`peril
`cape
`elab-
`
`adja
`preli
`tilag
`
`abra
`
`scler
`to t]
`mea.
`
`heat
`60 t(
`V6111
`
`imp:
`
`accc
`CF31]
`
`inter
`
`6
`
`

`

`‘BER
`
`PERCUTANEOUS LUMBAR FUSION
`
`597
`
`l-I—v-l—r—"ld.
`
`
`nvuv—vl-“u‘—
`
`FIGURE 2. Axial fluoroscopic
`control. The position of a Sehanz
`screw L4 just in the “eye“ of the
`
`pedicle is confirmed.
`
`suction punches are also helpful. When a sufficient centrodiscal excavation is
`reached, the subannular disc tissue in the periphery is denaturated with laser
`applications. For this purpose we use, due to its minimal energy transmission in
`disc tissue, the Holmium—YAG laser (2100 nm) with 18 to 22 W in adapted pulse
`rates under discoscopic control. With this procedure, we can further shrink the
`peripheral disc tissue and, at the same time, denaturate its natural osteoinhibitive
`capacity. The laser energy is not applied to the vertebral plates, which are
`elaborated in the following steps with special mechanical instruments,
`The most important step of this procedure remains the preparation of the
`adjacent vertebral plates under discoscopic control. As we established with our
`preliminary experience in 1986 and 1987, without deep opening of the corticocar—
`tilaginous transition, solid interbody fusion cannot be achieved.6
`To obtain solid interbody fusion with autologous bone chips, the best possible
`abrasion of the cortico—spongious transition of the vertebral plates is mandatory.
`These plates should be ground cranially and caudally into the often reactive
`sclerotic vertebral bone; thus, considerable forces have to be transmitted laterally
`to the axis of the cannula. This can be achieved under discoscopy (Fig. 4) by
`means of an excentrically active milling cutter (Fig. 5) with a rotating abrasive
`head that reaches about 5-mm depth to each side of the cannula, covering
`60 to 70% of the vertebral surface. With such exposure of the bleeding spongious
`vertebral bone, optimal conditions for bony ingrowth of the subsequently
`impacted autologous bone grafts can be achieved.
`As soon as the desired deep spongious preparation of the vertebral body is
`accomplished and documented by fluoroscopy (Fig. 6) both caudally and
`cranially, fresh autologous bone chips, harvested directly from the iliac crest, are
`immediately impacted through the cannulas from both sides. The best homogenous
`interbody filling is obtained by means of adapted impactors and by a slight tilting
`
`7
`
`
`
`m,
`
`he
`
`“BL“P“““3”WW5M4UUIUWUWJV"JUN!IIUWHHN“H!wWHWIIWmuWW:rvww-... on
`
`res
`)w
`1 ,
`on
`of
`:red
`3 he
`.11,
`
`in
`
`
`
`
`
`'MB‘ U}G_IQDUAUUQ3'“nopBKJBFJJ'.03'91$919.,
`
`7
`
`

`

`598
`
`LEU, SCHREIBER
`
`PERC
`
`
`
`FIGURE 3. The percutaneous pedieular fixator is mounted. For supplemental interver-
`tebral realignment, an adapted spindle device is hooked up bilaterally at the plate of the
`lower segment. By pushing forward on this vertebra, the upper vertebra is relatively
`retracted and the olisthesis can stepwise be reduced.
`
`motion of the cannulas during the stepwise impaction. Temporary additional
`distraction with the external fixator optimizes maximal filling of the intervertebral
`space. When the impaction is completed, the intervertebral space is preloaded with
`the external fixation device until slight bending of the Schanz screws is visible (,1;
`40—50 kp) in the fluoroscopic control.
`A possible concern of this impaction procedure could be a retrograde migra-
`tion of the bone chips through the annular defect when the cannulas are removed.
`To prevent this, we believe that the design of the cannulas used is most important.
`In contrast to other authors,3 who use a coronary trephine for percutaneous
`nucleotomy, the tip of our cannulas are designed with a prismatic grind that, when
`stepwise overslipped by each cannula of the next caliber, smoothly penetrates the
`annulus fibros us without a cutting effect. Thus, the crossed annular fibers are only
`temporarily stretched, and after the procedure they can realign themselves. So, a
`kind of “inborn” containment for the autologous bone graft is maintained that
`prevents accidental backfall of bony fragments outside the annulus into the
`extraforaminal area with possible mechanical irritation of the root.“s'2
`Regarding the quality of the impacted bone, optimal vitality of the grafts
`with maximal osteoinductive capacity is absolutely essential for future ingrowth
`and consolidation of the interbody fusion. In comparison to conventional surgery
`
`FIG!
`salin:
`lowel
`
`with
`mecl
`
`idem
`
`
`
`FIG!
`work
`
`apprt
`
`
`
`--—':*1r*—
`
`nu."
`
`
`
`
`
`'MB'IJLIDIJAUUOMs“M}pBIUBJUJUHqABUJpUUflue”Hull“'25nuuulullpuyujUHJUJq!I’BUVHGNcu."inuvnuvlluuwe."was,In...
`
`
`
`
`
`
`
`8
`
`

`

`E
`
`on m 70
`
`PERCUTANEOUS LU MBAB. FUSION
`
`599
`
`
`
`IBJQH[BUOHBNout10UOHOBIIOO9|.“UJUJJ.p8]UUUHEMHutuan.”uuIUEJWUWem;
`
`
`
`
`
`
`
`FIGURE 4. Discoscopic control of the eccentrically abrasive milling cutter under
`saline irrigation. The denticulated cutter head that erodes the vertebral plate is seen in the
`lower right.
`
`«a Yep
`l0
`the
`g my
`
`the
`with massive interbody grafting from posterior or anterior approaches,
`mechanical properties of impacted autologous bone material physically cannot be
`identical. So one would expect somewhat more interbody narrowing during bony
`
`5 E
`
`Jral
`
`8 1&5
`énvth
`gery
`on
`
`,2
`
`FIGURE 5. Overview of the application of the motor-driven milling cutter across the
`working cannula. The external fixator does not interfere with the posterolateral percutaneous
`approach.
`
`:
`
`9
`
`9
`
`

`

`600
`
`LEU, SCHREIBER
`
`
`
`Fluoroscopic check of the deep erosion of the vertebral plate. The head of the
`FIGURE 6.
`milling cutter reaches the level of spongious bone.
`
`In our eXperience, by
`ingrowth until solid interbody consolidation occurs.
`applying maximal segmental distraction with the external fixator right before the
`impaction of the grafts,
`the density of the intervertebrally contained graft
`conglomerate reaches satisfactory values so that some loss of gained distraction in
`the first postoperative year usually does not exceed 30 to 40% of the initial value.
`In none of our 29 cases Operated on in the first 3 years have clinical symptoms
`reappeared due to recurrent narrowing of the foraminas. Thus, we believe that the
`radiologically slight narrowing seen is a normal phenomenon without direct
`clinical impact in this minimally invasive technique.
`
`POSTOPERATIVE REHABILITATION
`The postoperative management starts with the patient’s mobilization right in
`the evening of the day of the interbody intervention. The functional activities are
`increased, while an isometric physiotherapeutic program is foregone during the
`first postoperative week. With ongoing wound healing at the two cannular entry
`points and the S—cm skin incision at the iliac crest, the sutures are removed and a
`protective fenestrated brace is applied. The aim of this brace is not as an
`additional external stabilization beside the percutaneous pedicular fixation, but
`rather a kind of shield for the external pedicular fixation device. With this brace,
`the patient is discharged and can move around without hooking up, even sleeping
`in his or her standard bed at home. The periodic disinfection of the pin tracts can
`be performed by the family doctor. Routinely, antibiotic prophylaxis with
`trimethoprim—sulfamethoxazole is given in the first 6 weeks.
`This postoperative procedure is conducted in our practice with a 10- to 12-
`day hospital stay. Depending on different facilities for outpatient management,
`most of this management could be adapted also toward an outpatient basis.
`
`10
`
`PERCL'
`
`time t
`
`contrt
`are re
`
`When
`
`duces
`
`slight
`
`remot
`
`a pro;
`
`CLIl‘
`
`done
`
`donel
`level
`
`indica
`
`posto;
`tebral
`betwe
`
`of the
`with c
`In an:
`
`be re]
`banks
`cient
`
`early
`
`prima
`A rel:
`in 7 c.-
`
`FIGU
`montl
`remaii
`while
`functi:
`the ht
`
`poster
`nght l:
`
`
`
`‘-'-‘1|||--iv-n"II'7"-u--u-
`
`
`
`
`
`'"UUHI‘UUI"VVU'UJH9&1I'HIII-l-IFuv"FUD-Irial“!H"‘1VUEU:FV"’vrH“!.anHvIPi
`
`10
`
`

`

`' J
`Ee: m as
`
`PERCUTANEDUS LUMBAR FUSION
`
`601
`
`
`
` .9th‘|lauoueNouttouonoanoooutwonpardonsemafiedStu]nowomanan;
`
`
`
`
`
`BUIOI
`
`_.RgEr"9+on
`
`finedpJILllEliq
`
`.ht in
`B m m"l('D
`
`a; the
`:
`qteur as83“:
`
`('D
`_,
`.05 an
`
`a race,
`Swing
`a: s can
`
`Ciwith
`31‘3
`O J 12-
`lid
`inent,
`
`finalwill
`
`After 6 weeks, the patient comes in for a radiographic check, and at the same
`time the brace is readapted.
`After 12 weeks, this second brace is removed. After another radiographic
`control, the posterior segmental plates and intersegmental axial screw connections
`are removed, and the patient is mobilized including stair-training for 24 hours.
`When this so-called “dynamization” (Fig. 7) of the external fixation device pro-
`duces no negative clinical impact, the Schanz screws are screwed out under just
`slightoral medication.
`During the following weeks, a light flexible corset is given for smooth lumbar
`remobilization in association with an active muscular stabilizating program. Thus,
`a progressive reintegration into a normal way of life is soon achieved.
`
`CLINICAL EXPERIENCES
`Between October 1988 and July 1990, percutaneous interbody fusion was
`done on 20 patients, of whom 10 were female and 10 male- The operations were
`done between the first lumbar vertebra and sacrum; 12 cases were operated on the
`level L4/5. The mean age of patients at the intervention was 46 years. The
`indications included monosegmental
`instability, being degenerative in 8 cases,
`postoperative in 7 cases, spondylolysis in 3 cases, and postinflammatory interver-
`tebral collapse in 2 cases. This reported series of 20 cases has been followed
`between 16 to 3? months after percutaneous interbody fusion.
`.
`In three patients of this cohort, we noticed an almost quantitative reabsorption
`of the interbody grafts, so that all of them later had a conventional reintervention
`with conventional posterolateral interbody fusion with internal pedicular fixation.
`In another patient, the graft became integrated only caudally, so that he could not
`be removed from his lumbar brace. The reasons for this failure were the use of
`banked bone material for the percutaneous intervertebral impaction and insuffi—
`cient preparation of the vertebral plates due to some technical problems in the
`early series.
`A radiologic interbody consolidation (Fig. 8) was obtained in 16 cases. The
`primary gain of segmental distraction was maintained at 75 to 100% in 10 cases.
`A relative loss of the initially achieved distraction of up to 40 to 60% was noticed
`in 7 cases. Nevertheless, in all consolidated fusions, there was no direct correlation
`
`FIGURE 7. Pin site at 3
`months. The Schanz screws
`remain in situ for 24 hours
`
`right beneath the “bikini level. "
`
`while the patient undergoes a
`functional load program. Note
`the healed scar at the right
`posterior iliac crest,
`located
`
`11
`
`11
`
`

`

`
`
`602
`
`LEU, SCHREIBER
`
`FIGURE 8. A, Preoperative
`view in a case of degenerative
`instability with slight pseudo-
`spondylolisthesis L4/S in a 46-
`year—old woman. B, Early post-
`operative view after percutane-
`ous interbody fusion. Note the
`remodeling of the alignment and
`lordosis. C, Follow-up at I year
`after the percutaneous interbody
`fusion. A solid interbody bone
`bridge is established. The patient
`is painfree under full socioeco-
`
`nomic reintegration.
`
`between functional tolerance of the lumbar spine and the finally maintained
`percentage of segmental distraction.
`Despite radiologic consolidation, six of the patients nevertheless had to
`reduce their professional activity. In two cases, a temporary pin tract irritation was
`successfully managed with intensified local care and a short period of therapeutic
`antibiotics. In younger and more active patients, we noticed some temporary
`muscular contractions in the area of the Schanz screws after some stressing
`physical activities between the 6th and 12th weeks postoperatively, probably due
`to the local muscular transfixation. In the first weeks after the removal of the
`
`12
`
`PERC
`
`Scha
`area
`
`punc
`
`in th
`
`tion,
`and
`their
`
`arou
`
`to it
`
`epidl
`proc
`trans
`
`pediu
`conv
`
`of th
`
`imag
`limit
`
`fusic
`cont
`
`COI
`
`Witt
`
`for t
`
`graft
`C011
`
`redu
`
`step!
`preo
`duril
`coul:
`
`rend
`most
`
`last
`
`.selec
`man
`
`at It:
`the 1
`mor:
`
`bene
`
`RE]
`I. A
`2.1-
`3.14
`
`-'l‘
`
`I':'_1_——-
`---'i'"-v-
`
`
`
`
`
`'MBIlllDHMOO'S'nM1[131091010at]new[JUBNJBUWM8MIWPWUWJUMUN!IIUWHUNmuwWuWIIW"‘1'w"!'“I‘m‘'“"‘
`
`
`
`
`
`12
`
`

`

`PERCUTANEOUS LUMBAR FUSION
`
`-
`
`603
`
`Schanz screws, some patients reported short moments of “puncturing" pain in the
`area of the former pin tracts, which may be explained by remobilization of
`punctual adhesion of the fascia] layer at the posterior pin tracts.
`The external pedicular fixation was accepted by the patients and functioned
`in their social surroundings generally without problems. Here, we have to men-
`tion, that in Switzerland we can rely on an efficient public transportation network,
`and so patients do not necessarily have to use their own automobile to care for
`their needs.
`this minimally invasive technique achieved
`Recounting our experience,
`around 80% clinically and radiologically successful results in this first series. Due
`to its extracanalicular posterolateral approach,
`the sometimes cumbersome
`epidural scar problems could be avoided successfully. In no case did the operative
`procedures require any blood transfusion, which favors economy and avoids
`transfusion-related contaminations.” The operating time,
`including external
`pedicular fixation and interbody fusion, of around 3 hours is comparable to
`conventional open surgery with internal pedicular fixation. Finally, after removal
`of the Schanz screws, no metallic implant remains in situ, so therefore any modern
`imaging technique such as CT or MRI can be performed without technical
`limitations. In addition to this, a follow—up radiograph showing single-segment
`fusion without any implant and the aspect of minimal low-back discomfort may
`contribute to the patients’ feeling of optimally regained musculoskcletal integrity.
`
`CONCLUSIONS
`Like every new technique, percutaneous interbody fusiori remains in evolution.
`With the aim to reduce further the operative invasiveness, possible new choices
`for the interbody graft are being investigated. Our first experience with composite
`grafts of porous apatites with autologous bone marrow seems rather promising.
`Complementary use of bone-inducing proteins under preclinical evaluation could
`reduce the necessary time for postoperative external pedicular fixation.
`In our experience, the temporary external fixation with its unique virtue of
`stepwise intervertebral corrections under clinical feedback is most helpfulin the
`preoperative patient selection and intraoperative temporary distraction. However,
`during the postoperative bone-healing period, a subcutaneous epifascial surrogate
`could also be mechanically sufficient. Thus, our preliminary experience could
`render this minimally invasive fusion technique more attractive for patients in
`most automobile-oriented societies abroad.
`.
`If we look back at the amazing evolution of percutaneous spine surgery in the
`last decade, this new minimally invasive approach with endoscopic control and
`selective percutaneous access to the structural pathology reflects the tendency in
`many fields of modern surgery.'9 Many of the new techniques already replace or
`at least complement conventional surgical technologies. Therefore, in addition to
`the need for specific technical instructions, the main challenge becomes more and
`more the selection‘hl‘l of the most minimal possible technique for an optimal
`benefit to the patient in his or her society.
`
`REFERENCES
`l. Alexander-Williams .I: A requiem for vagotomy. BMJ 302: 547, 199].
`2 HijikataS: Percutane Nucleotomie—neue Behandlung der Discushernie. J Toden Hosp5:5—13,1975
`3. Kambin P: Posterolateral percutaneous lumbar discectomy and decompression: Arthroscopic
`microdiscectomy. In Kamhin P (ed): Arthroscopic Microdiscectomy. Baltimore, Urban &
`Schwarzenherg, 1990, pp 67—101.
`
`13
`
`I—l—
`
`UH“*5."(Jm'u
`
`
`
`
`
`
`
`
`
`_:MElILIDUAUOO8“All]peloelmaQqflewput?I‘UEUinq].EfiqBugatpawJ0NHan|HUUHHNHI.“[UUUHUUHUUBl.“LUUJ}putuuuDD!!!uuuuup.“uvIVP‘WUWuuLL
`
`
`
`
`
`
`
`
`
`—"——"-——-———_—fl
`
`(H“J
`
`13
`
`

`

`4. Kramer J: Perkutane Diskotomie, Chemonukleolyse oder ofl‘ene Operation an_der Iumbalen
`Bandscheibe? Med Orthop Tech 109:82—38, 1989.
`5.
`Lavignolle B, Castagnera L, Senegas J: Pression intradiscale et discolyse enzymatique. Rev Med
`OrthOp 15:46, 1989.
`leu HJ: Von der perkutanen Nukleotomie mit Diskoskopie zur perkutanen Spondylodese: Ein
`neues Konzept zeichnet sich ab. Z Orthop 128:266—275, 1990.
`. Leu HJ, Schreiber A: Laser nuclear photoablation. In Kambin P (ed): Arthroscopic Microdiscec—
`tomy. Baltimore, Urban & Schwarzenberg, 1990, p 141.
`Leu HJ, Schreiber A: Perkutane bandscheibenchirurgie mil diskoskopie: Erfahrungen seit I979—
`neue perspektiven.
`In Springorum HW, Katthagen B (eds): Aktuelle Schwerpunkte der
`Orthopfidio, Band 3. Stuttgart, Thieme, 1992, pp 17—26.
`Ligoury C, Vitale GC: Biliary perestroika. Am J Surg 160:23?—233, 1990.
`Magerl F: Der wirbel-fixateur externe. In Weber BG, Magerl F (eds): Fixateur Externe. Berlin,
`Springer, 1935, pp 289-366.
`Patsiaouras T, Bulstrode C, Cook P, Wilson D: Percutaneous nucleotomy: An anatomical study
`of the risks of root injury. Spine 16:39—42, 1991.
`Schaffer JL, Kambin P: Percutaneous posterolateral lumbar discectomy and decompression with
`a 6.9-millimeter cannula: Analysis of operative failures and complications. J Bone Joint Surg
`73A2882—83l, 1991.
`Schreiber A, Leu HJ: Restabilisation intervertébrale et arthrodése intersomatique 'percutanée:
`Possibilités aujourd‘hui. Rachis I:173—l?9, 1989.
`Schreiber A, Suezawa Y, Lou Hi: Does percutaneous nucleotomv with discoscopy replace
`conventional discotorny? Clin Orthop 238:35—42, 1989.
`Schreiber A, Leu HJ: Biportal percutaneous lumbar nucleotomy: Development, technique and
`evolution. In Kambin P (ed): Arthroscopic Microdiscectomy. Baltimore, Urban & Schwarzen-
`berg, 1990, pp 101—107.
`Suezawa Y, Jacob HAC, Brandenberg JE, Blasbalg DT: Diskoskopie—ein weiterer Schritt zur
`Diagnostik und Behandlung der lumbalen Diskuslétsion. [n Hackcnbroch MH (ed): Biomechanik
`der Wirhelsa'ule. Stuttgart, Thieme, 1983, pp 130—135.
`Ward JW, Holmberg SD, Allen JR, et at: Transmission of human immunodeficiency virus (HIV)
`by blood transfusions screened as negative for HIV antibody. N Engl J Med 318:427—478, 1988.
`
`11.
`
`12.
`
`13.
`
`14.
`
`15.
`
`16.
`
`I7.
`
`604
`
`-
`
`LEU, SCHREIBER
`
`__'W"__""_'
`
`6.
`
`D]
`
`Hon:
`in
`Or
`and 1
`
`Roy:
`
`Ham
`Lonc
`Dire:
`
`Cron
`Lonc
`
`Repr
`Mr. I-
`Cron
`Cron
`Lonc
`UK
`
`14
`
`‘
`
`SPIP
`
`
`
`
`
`'MEIiuounooo's'nnqpeioeiomsonewpuenueuWM3nqaugogpew,u~5qu1|uuuHuNUL“wuugwunwm1,ww,paw."w...w-..-,..,..,..,...,-._"'."'
`
`
`
`
`
`
`
`14
`
`