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Lateral Options for Deformities Management
• Assistant Professor, Department of Orthopedics, Boston University• Chief of Spine, Boston University• Founding President, Society for Progress & Innovations for the Near East• Interest:
• MIS, Deformity, Tumors• Designs: Viper, Lateral Cougar cage• Medical education exchange: national and international
• Enjoys Tennis, Ski, Travel, Social Networking• Contact: www.neareastspine.org
Tony Tannoury, MD
Lateral Options for
Deformity’s management
Tony Y Tannoury, MDAssistant professor,
Department of Orthopedics
Boston University
[email protected] www.neareastspine.org
Which patient is most likely to have
chronic pain?
Adult Degenerative Deformity
Always involves the Lumbar spine
Painful
Patients:
Elderly
Co-morbidities
Fusion harder to achieve vs pediatric
Must have
Solid fusion
Good sagittal balance
Decompression
Fusion options
Posterior
anterior
Challenging questions regarding
MIS How to achieve sagittal
balance
How to achieve fusion
Decompression: direct vs
indirect
osteotomy
Interbody reconstruction
Posterior
interbody
laminectomyfacetectomy
Spinal reductionForaminal distraction
X
X
X
LET ME MAKE MY CASE
Why inter-body fusion?
Better Mechanics
Better Biology
Better physiology
May be The best option to Address the pain
generators
MECHANICS
Why Interbody
Biology: under
compression.
Better pysoelectric
charges
Better Physiology:
The only compartment in
the spine void of
functional muscles
Potentially Eliminates
Pain generators
Promising techniquesMIS Lateral/Anterolateral Techniques
Straight lateral surgery (XLIF, DLIF, Lat concord etc…)
Indicated for lateral pathology
Lateral decubitus position
Incision at lateral border
of erector spinae
Dilates through iliopsoas “Finger assisted”
Risks Lumbar plexus (in psoas)
Requires monitoring
WHY LATERAL!!
Viscera are out of the way
No need for vascular mobilization
Preserves the ALL:
Containment
Anterior tension band
Protects against over-distraction
Can be done with the posterior work simultaneously without repositioning
No iatrogenic stenosis
Less risk for retrograde ejaculation
No traumatic sympathectomy
Traditional Anterior Approach
Anatomy
Analysis of Vascular Anatomy
High Lateral
Configuration
Analysis of Vascular Anatomy
Very Low Medial
Configuration
Psoas gets wider in lower lumbar spine (males>females)
Lumbar plexus posterior 2/5 of psoas
Anatomy
LLIF
Anterior Posterior
Favorable Anatomy
Unfavorable Anatomy
Antero-lateral interbody fusion
L1-2, L2-3, L3-4, L4-5
Split fibers of oblique and
transversus muscles
Retract anterior 20%
psoas
be Very careful of the
misleading Quadratus
Lumborum muscle
approach
2 inch incision
Head ofpatient
abdomen
legs
External oblique fascia and muscle
split
Internal oblique and transversus
fascia split
discectomy
Cage and buttress screw
Skin closure
2 level A/P fusion
Concave vs convex side
Concave side
Concave approach:
54 yo, multiple spinal surgeries
severe pain
Before and after
Before and after
72 YO lady. Severe back and leg
pain. Failed conservative Rx.
MRI
conservative
Lost 90 pounds
8 ESIs
Yoga
Psychiatric eval.
Not better
BEFORE AND AFTER
BEFORE AND AFTER
58 y0 male. Still disease. Severe back
and hip/thigh pain
Sagittal balance
Axial cut at L3-4
Failed conservative Rx
CONSERVATIVE RX
PT
TIME
PAIN MEDS
OPTIONS:
Don nothing
Laminectomy
Laminectomy fusion
Approach:
Posterior
Anterior posterior
Fusion levels:
T11-L4
Before and after
Before and after
12 months postop
Both are happy:his pain is gone & I feel good/look tall
preop
Full Spine Films
Post op
55 yo, 325 lbs
MRI
Intraoperative pictures
Post op
Conclusion.
MIS is very promising:
Approach
Anterior vs posterior
Concave vs convex
Indirect decompression
More studies need to be done
Conclusion
Fusion surgery is quite Morbid.
MIS is very promising option and might be the
best option
We have to rethink anterior fusion
Go concave
Be careful,
bad stuff can happen through small
holes
IT WILL THROW YOU UP IN THE AIR
