Transforaminal Posterior Atraumatic Lumbar Cage System T- Mobile/Synthes International...  For general

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Surgical Technique

Transforaminal Posterior Atraumatic Lumbar Cage System

T-PAL

Image intensifier control

This description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended.

Processing, Reprocessing, Care and MaintenanceFor general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to:http://emea.depuysynthes.com/hcp/reprocessing-care-maintenanceFor general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to: http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

http://emea.depuysynthes.com/hcp/reprocessing-care-maintenancehttp://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

T-PAL Surgical Technique DePuy Synthes 1

Table of Contents

Introduction T-PAL 2

AO Spine Principles 4

Indications and Contraindications 5

Surgical Technique Preoperative Planning and Preparation 6

Patient Positioning 7

Access and Exposure 8 Minimally invasive transforaminal approach 8 Open transforaminal approach 10

Discectomy 11

Disc Space Preparation 12

Trial for Implant Size 13

Implant Preparation 23

PEEK Implant Insertion 26

Titanium Implant Insertion 30

Posterior Support 34

Implant Removal 35

Product Information Implants 37

Instruments 39

Sets 43

Applicator Instructions 45

Function control 48

Filling Material 49

Bibliography 50

2 DePuy Synthes T-PAL Surgical Technique

Rails on top of the implant, designed to guide and turn the cage between the vertebral bodies into the desired position

Three x-ray markers help to visualize the implant under radiographic control

T-PAL. Transforaminal Posterior Atraumatic Lumbar Cage System.

Implant with guiding rails

MaterialAvailable in two materials; PEEK (with Titanium alloy marker pins [TAN]); Titanium alloy (TAN)

Two anterior radiographic marker pinsEnable visualization of the anterior implant positionThe B1.4 pins are located approximately 2 mm from the anterior edge of the implant

One proximal radiographic marker pinEnable visualization of implant tip position while insertion

Connection cylinderPermits the pivoting mechanism in combination with the applicator

Axial windowAccommodates autogenous bone graft or bone graft substitute to allow fusion to occur through the cage

Rails on the surfaceDesigned to guide and turn the cage into the desired position

Pyramidal teethDesigned to provide resistance to implant migration

Self-distracting noseAllows for ease of insertion

Lordotic angle5 to restore the natural spine lordotic curve (except for the 7 mm height)

AP trial marker Lateral trial marker

T-PAL Surgical Technique DePuy Synthes 3

Trial implants can be placed at the same position, where after the implant will be placed

Designed for guided insertion because of the pivoting applicator and the rails on the surface of the implants and trials

Designed for secure insertion because of permanent connection to the implants and trials during insertion process

OR technique based on one key instrument: the applicator

Designed for minimally invasive surgical technique

Guided insertion technique One key instrument for insertion

of implant and trials Applicator is designed to allow

a controlled and guided insertion based on the pivoting option

Security button designed to prevent implant disengagement

Applicator is designed for minimally invasive surgeries

One surgery, oneinstrument

coronalaxial

sagittal

1 DePuy Synthes T-PAL Surgical Technique

The four principles to be considered as the foundation for proper spine patient management underpin the design and delivery of the Curriculum: Stability Alignment Biology Function.1,2

StabilityStabilization to achieve a specifi c therapeutic out-come

BiologyEtiology, pathogenesis, neural protection, and tissue healing

AlignmentBalancing the spine in three dimensions

FunctionPreservations and resto-ration of function to pre-vent disability

AO Spine Principles

Copyright 2012 by AOSpine

1 Aebi et al (1998)2 Aebi et al (2007)

T-PAL Surgical Technique DePuy Synthes 5

Indications and Contraindications

Intended useThe T-PAL implant is intended to replace lumbar inter-vertebral discs and to fuse the adjacent vertebral bodies together at vertebral levels L1S1. The T-PAL implant is designed for atransforaminal approach.

IndicationsIndications are lumbar and lumbosacral pathologies in which segmental spondylodesis is indicated, for example: Degenerative disc diseases and spinal instabilities Revision procedures for post-discectomy syndrome Pseudarthrosis or failed spondylodesis Degenerative spondylolisthesis Isthmic spondylolisthesis

Contraindications Vertebral body fractures Spinal tumours Major spinal instabilities Primary spinal deformities Osteoporosis

Warning: T-PAL must be applied in combination with posterior fixation.

6 DePuy Synthes T-PAL Surgical Technique

Preparation

Set

01.812.001 Set T-PAL

Optional sets

01.809.011 Dilation Instrument Set

01.615.004 Insight Tubes Setor01.615.002 Insight Retractor Set,

Standard Configuration

01.612.110 Set for MIS Support System

01.605.903 Set for Minimally Invasive Posterior Instruments

Have all necessary imaging studies readily available to plan implant placement and visualize individual patient anatomy.

Have all sets readily available prior to surgery.

Preoperative Planning and Preparation

T-PAL Surgical Technique DePuy Synthes 7

Position the patient

Position the patient in a restored physiological lordosis and decompress the abdomen to reduce venous stasis.

Patient Positioning

8 DePuy Synthes T-PAL Surgical Technique

1. Approach

Optional sets

01.809.011 Dilation Instrument Set

01.615.004 Insight Tubes Setor01.615.002 Insight Retractor Set,

Standard Configuration

01.612.110 MIS Support System Set

Locate the correct operative level with fluoroscopic views. Push the Kirschner wire into the desired facet joint. Separate the posterior soft tissue by inserting the smallest diameter dilator over the Kirschner wire. Repeat with next larger diameter dilator until required dilation is achieved. Use fluoroscopy to determine the location of dilator.

Access and Exposure Minimally invasive transforaminal approach

2a. Retraction with insight tubes

Instrument set

01.615.004 Insight Tubes Set

Optional sets

01.612.110 MIS Support System Set

01.809.011 Dilation Instrument Set

Determine the appropriate tube length from the depth indicators on the dilators.

Slide the tube over the dilators until it contacts the facet joint.

Use the flex arm to stabilize the tube to the OR table. Remove the dilators and the Kirschner wire.

T-PAL Surgical Technique DePuy Synthes 9

2b. Retraction with insight retractor

Instrument set

01.615.002 Insight Retractor Set, Standard Configuration

Optional Sets

01.809.011 Dilation Instrument Set

01.612.110 MIS Support System Set

Determine the appropriate retractor lengths of the cranial/caudal and medial/lateral blades from the depth indicators on the dilators.

Slide the retractor with the cranial/caudal blades over the dilators until the blades contact the facet joints. Distract the blades and introduce the second retractor with the medial/lateral blades.

Use the flex arm to stabilize the retractor to the OR table. Remove the dilators and the Kirschner wire.

3. Cut transforaminal window

Instruments

03.605.508 Osteotome, straight, black

03.605.520 Laminectomy Punch, 40, 4.0 mm, black

Prepare a window for the transforaminal approach using theosteotome to remove the inferior facet of the cranial vertebra and the superior facet of the caudal vertebra.

With the punch, additional bone or osteophytes can be removed.

11 DePuy Synthes T-PAL Surgical Technique

1. Retraction with an open transforaminal approach

Instrument

03.812.040 Lamina Spreader for T-PAL

Make a standard open incision, retract the muscle layer to view the desired segment.

Distract the segment if desired. Position the lamina spreader for T-PAL at the base of the spinous processes. Distract carefully until required distraction is achieved.

Distraction opens the posterior disc space and promotes exposure both for decompression and delivery of the implant.

2. Cut transforaminal window

Instruments

03.605.508 Osteotome, straight, black

03.605.520 Laminectomy Punch, 40, 4.0 mm, black

Prepare a window for the transforaminal approach using theosteotome to remove the inferior facet of the cranial vertebra and the superior facet of the caudal vertebra.

With the laminectomy punch, additional bone or osteophytes can be removed.

Access and Exposure