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Innovative Grid Positioning System (GPS) For Endoscopic

Laser Transforaminal Microdecompressive Lumbar Disc

Surgery in the Morbid Obese

John C Chiu, MD, FRCS (US), DSc Chief, Neurospine Surgery California Spine Institute

Thousand Oaks, California, USA President AAMISMS

26th International Congress Laser Medicine & IALMS Course

Laser Florence 2012 Florence, Italy

November 9-10, 2012

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California Spine Institute Medical Center, Inc

Calif. Center for Minimally Invasive Spine Surgery

“Guten Tag!”

“Bonjour”

“Buenos Dias”

“Ciao”

“Konnichi wa”

Kinh Môi

“Greetings from CSI”

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Introduction:

• The morbid obese - more than 100 pounds over ideal body weight, or a BMI of 40 or higher. More than 5 percent of Americans

• Double the incidence (2.41x) of low back pain

• Greater incidence of surgical complications, up to 36% including wound healing, infection, pneumonia, DVT and repeated surgery

• Under anesthesia, have increased risks including difficult airway control and intubation, ventilation/perfusion mismatching, altered pharmacokinetics of anesthetics and drugs

• Risk of developing other co-morbidity diseases, i.e. diabetes, hypertension, cardiovascular disease, stroke, restrictive lung disease, osteoarthritis and others

• Six or more co-morbid conditions in 25 percent

Venus of Willendorf created 24,000–22,000 BC

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Surgical Indications:

• Symptoms - intractable radiculopathy associated with paresthesia, sensory loss, muscle weakness and/or decreased reflexes

• Neurogenic claudication on ambulation • Failed conservative therapy • Positive neurological findings – DTR,

sensation • Positive imaging findings on MRI or CT

scan for disc herniation • Positive provocative discogram • Positive EMG considered helpful • Multiple discs can be treated during one

procedure • Post fusion junctional disc herniation

syndrome (JDHS) 1680 painting of an obese girl by Juan Carreno de Miranda

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Material and Method:

• Since 1995, 203 morbidly obese patients - 330 herniated lumbar discs

• Average age of 42.2 (20 to 67) - symptomatic, single or multiple herniated lumbar discs

• Males: 99 Females: 104

• Each failed at least 12 weeks of conservative care

• Post operative follow up: 7 to 60 mos. (average 46.1 months)

6 2%

9 3% 31

9%

147 45%

137 41%

L-1

L-2

L-3

L-4

L-5

Demographics of 330 Herniated Lumbar Discs

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Surgical Procedure/Technique:

• Local anesthesia and monitored IV conscious sedation

• 2 grams Ancef and 8 mg dexamethasone IV pre-op

• Surface EEG monitoring (BIS) • IOM - EEG, EMG to prevent undue

neural trauma

Pre-op Prep Anesthesia

Positioning and localization – surgical portal of entry

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Surgical Procedure/Technique:

• Endoscopic duck bill tubular retractor, slanted opening

• For navigating into the grid – GPS to avoid neural vascular injury

• To remove difficult deep lesions, even behind the pedicle • Various size of drills and trephines for spinal micro-decompressive laser

discectomy and decompression of osteophytes

• For successful endoscopic MISS

Endoscopic Laser Spinal Instruments

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Surgical Procedure/Technique:

• Duck bill tubular retractor with dilator to enter the GPS for lumbar disc surgery to avoid dura and neuro vascular injury

• Under endoscopy and fluoroscopy, trephine forceps, curette, rasp, knife, discectome, and laser are utilized for micro decompressive discectomy and laser thermodiskoplasty

Close up view

Endoscopic Laser Spinal Instruments

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Surgical Plane/Approach/Technique:

Right posterolateral approach - prone position for endoscopic laser lumbar MISS

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Surgical Plane/Approach/Technique:

Left lateral decubitus position for right posterolateral endoscopic laser lumbar MISS

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GPS (Grid Position System) for Endoscopic Laser MISS Provides safe and precise lumbar spine surgery

Subarticular

Extraforaminal

Foraminal 1 disc

2

3 pedicle

B C D A

• Lumbar spine has neuro foramen and intra-lamina foramen openings restricting portal of entry

• Critical structures within the foramen – DRG, neural structure

• GPS provides a precise and safe path to reach the lesion and to avoid trauma to the nerve vessels, DRG, dura and even the spinal cord

• The grid – the GPS System – Zones (in A,B,C, D and 1,2,3) provides an accurate navigation map for MISS

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Endoscopic Laser MISS Technique: With GPS

• Obese patient had left posterolateral endoscopic laser lumbar discectomy with GPS system

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GPS (Grid Position System) for Endoscopic Laser MISS

Fluoroscopic/imaging and endoscopy to provide safe and precise lumbar MISS discectomy and foraminoplasty

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Surgical Procedure/Technique:

Endoscopic Surgical Approach

Flexible cutter grasper forceps Endoscopic bone ronguer

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Surgical Procedure/Technique:

Microdiscectomy with micro forceps Side firing laser probe for LTD

Endoscopic MISS and Laser Thermodiskoplasty • Mechanical microdiscectomy • Laser thermodiskoplasty (LTD) for disc shrinkage and tightening • Disc fragment removal

Disc fragment removal

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Surgical Procedure/Technique:

• Absorbed by water • A pear shaped

cavitation bubble formed by vaporization of water molecules, undergoes expansion and collapse - resulting in acoustic and shock wave emission

• Simultaneously a vapor channel is formed that effectively conducts laser energy to the target “MOSES EFFECT”

Holmium YAG laser with photo thermal effect and mechanism:

MOSES EFFECT

Parting the water (Red Sea)

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Surgical Procedure/Technique:

• Spinal discectome for rapid disc removal

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Surgical Procedure/Technique:

• SMART Endolumbar System dilatation technology, is designed

• It is an effective, safe, and easier MISS for treatment of herniated discs, intraspinal lesions, and spinal stenosis

• It preserves spinal segmental motion

• An excellent access for spinal arthroplasty and even fixation

Para-medium SMART Endolumbar Laser Spine System

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Surgical Instruments and Equipment:

Tissue Modulation Technology laser, radio frequency and cryogenic technology requiring

monitoring/display for control

Holmium YAG laser generator Radiofrequency generator

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Post Operative Care:

• Ambulatory within one hour and discharged subsequently

• May shower the following day

• Ice pack is helpful • Mild analgesics and

muscle relaxant are required at times

• Progressive spine exercise second post operative day on

• Postoperatively on average, resumed usual activity in a few days and in 2-5 weeks resumed full active lives, providing no heavy work

Spinal motion measurement (spine mouse)

Advanced exercise

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Case Illustration I:

• Morbidly Obese – 36 year old male,

450 lbs, one hour after his successful endo L4 & L5 micro laser discectomy with GPS

– He was turned down for open lumbar disc surgery due to morbid obesity

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Case Illustration II:

• Morbidly Obese – 48 year old male,

450 lbs, one hour after his successful endo L4 & L5 laser micro discectomy with GPS

– He was turned down for open lumbar disc surgery due to morbid obesity

Multiple level herniated lumbar discs - “not a candidate for open spine surgery”

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Surgical Outcome:

• For 203 patients, average follow-up 46.1 months (7-60months)

• Overall result: 183 (90%) patients with good to excellent results, fair results 13 (6.4%) patients (single level)

• Various evaluations of response to treatment: modified Mac Nab criteria, Oswestry disability score/index (ODI), visual analogue pain scale (VAS), patient satisfaction scoring, pain diagram and/or patient target achievement score (PTA) for assessment were utilized

• Average satisfaction score – 189 (93.1% ) patients

• 14 (6.9%) patients had mild residual pain and paresthesia, although overall their pain lessened

• Complication rate: less than 1% • No cardio pulmonary or vascular complications

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Discussion:

• Through a very small incision • Less tissue trauma – tissue sparing approach • MISS has fewer complications (less than 1%) • Often local anesthesia with IV sedation • Early ambulation and post – op exercise • Ideal for high risk anesthetic patients including

morbidly obese, emphysematous, and cardiac conditions

• IOM - Intra-operative neurophysiological/EMG monitoring, and direct visualized endoscopy provides a safer surgery

• Preserves spinal motion

The advantages of Minimally Invasive Spinal Surgery (MISS) for the Morbid Obese are numerous:

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Conclusion:

• MISS techniques with GPS and laser thermodiskoplasty to treat morbidly obese and high-risk patients is an effective, safe, and less traumatic spine surgery

• Avoids the more dangerous alternative of open spinal surgery

• This less traumatic outpatient procedure avoids and reduces the risk and complications of open spine surgery

• It is a smart way to perform spinal surgery for the morbid obese

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References:

1. Chiu J, Maziad, A., Innovative Grid Positioning System (GPS) Guidance for Minimally Invasive Spinal Surgery, In, Szabo Z, Coburg AJ, Reich H, Yamamotto M, Brem, H., Harwin, S., eds. Surgical Technology International XX, UMP, San Francisco, CA 2010 p.363-372

2. Chiu J. Endoscopic lumbar foraminoplasty. In: Kim D, Fessler R, Regan J (eds), Endoscopic spine surgery and instrumentation. New York: Thieme Medical Publisher; Chapter 19, pp 212–29, 2004.

3. Kambin P, Casey K, O’Brien E, et al. Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg 1996;84:462–7.

4. Chiu J, Maziad A. Rappard G, et al Evolving minimally invasive spine surgery: a surgeon’s perspective on technological convergence and digital OR control system. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds), Surgical technology international, XIX ed. San Francisco: Universal Medical Press; pp 211–22, 2009.

5. Chiu JC. A surgeon’s perspective on digital technological convergence and control system for minimally invasive spine surgery, abstract published in Computer Assisted Radiology and Surgery, Proceedings of the 24th International Congress and Exhibition, Geneva, Switzerland, Volume 5, Supplement 1: S5-S10, DOI 10.1007/211548-0101-0431-x - Springer Verlag, Heidlberg, Germany, June 2010.

6. Clifford T, Chiu JC, Rogers G. Neurophysiological monitoring of peripheral nerve function during endoscopic laser discectomy. J Minim Invasive Spinal Tech 2001;1:54–7.

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References:

7. Chiu J. Posterolateral endoscopic thoracic discectomy. In: Kim D, Fessler R, Regan J (eds), Endoscopic spine surgery and instrumentation. New York: Thieme Medical Publisher; Chapter 11, pp 125–36, 2004.

8. Chiu J, Clifford T, Princenthal R. Junctional disc herniation in post spinal fusion treated with endoscopic spine surgery. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds), Surgical technology international, XIV ed. San Francisco: Universal Medical Press; pp 305–15, 2005.

9. Knight M, Goswami A. Endoscopic laser foraminoplasty. In: Savitz MH, Chiu JC, Yeung AD (eds), The practice of minimally invasive spinal technique. Richmond, VA: AAMISMS Education, LLC; pp 337–40, 2000.

10. Chiu J. Endoscopic assisted lumbar microdecompressive spinal surgery with a new smart endoscopic system. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds), Surgical Technology International, XV ed. San Francisco: Universal Medical Press; pp 265–75, 2006.

11. Chiu J. Endoscopic assisted lumbar microdecompressive spinal surgery with a new smart endoscopic system. In: Szabo Z, Coburg AJ, Savalgi R, et al. (eds), Surgical Technology International, XV ed. San Francisco: Universal Medical Press; pp 265–75, 2006.

12. Chiu JC, Clifford T. Multiple herniated discs at single and multiple spinal segments treated with endoscopic microdecompressive surgery. J Minim Invasive Spinal Tech 2001;1:15–9

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Hope you enjoyed this presentation!

“Danke schön”

“Merci” “Gracias”

“Cám ón”

“Arigato”

“Thank you”

John C. Chiu, M.D., FRSC (US), D.Sc.

California Spine Institute

Thank you for your kind attention!