Name:
10.3171/2025.4.FOCVID2516
Description:
10.3171/2025.4.FOCVID2516
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/11c09903-2851-48d4-9397-9a018001bafc/videoscrubberimages/Scrubber_422.jpg
Duration:
T00H10M41S
Embed URL:
https://stream.cadmore.media/player/11c09903-2851-48d4-9397-9a018001bafc
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/11c09903-2851-48d4-9397-9a018001bafc/13. 25-16.mp4?sv=2019-02-02&sr=c&sig=OysA7UkXmtDRLqh3yrguzSQR8BaT5cY6mRK9pcFpG%2Bo%3D&st=2025-11-27T04%3A53%3A13Z&se=2025-11-27T06%3A58%3A13Z&sp=r
Upload Date:
2025-06-02T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: The aim of this video is to describe the surgical technique of robotic and navigated minimally invasive TLIF for the treatment of spondylolisthesis. In this video, we will present the clinical case of a 70-year-old woman affected by low back pain and bilateral leg pain for over 5 years, which was unresponsive to conservative treatments. X-rays shows L4-L5 spondylolisthesis, which is unstable at dynamic X-ray evaluation.
SPEAKER: MRI shows spinal stenosis at L4-L5 with bilateral facet hypertrophy. The surgical procedure is aided by a robotic arm, which is solidly fixed to the operative table. The end effector is then attached to the robotic arm. The patient is secured in a prone position on a carbon fiber floating top, radiolucent table, and Wilson frame. The neuromonitoring that will aid in the surgical procedure is set up. The sterile field is then prepped in a way so that the cone beam CT can freely scan the patient. This procedure is done by wrapping the floating table and leaving a free passage underneath. The robotic arm is sterile prepped, and the navigation instruments are calibrated.
SPEAKER: Prior to image acquisition, a reference frame is rigidly attached to the PSIS to permit the navigation station to correlate the 3D image to the patient's position in space. The intraoperative cone beam CT scan is brought into position after 2D AP and lateral X-ray are obtained. The field of view is defined and the CT scan is performed.
SPEAKER: Following imaging acquisition, preoperative planning is performed. Each level of interest is automatically segmented and labeled. Pedicle screws are automatically positioned by the software. Instrumentation planning can be manually adjusted. Individual screws are positioned along the desired trajectories by visualizing the screw placement in all three dimensions and optimizing the trajectory accordingly in all anatomical planes.
SPEAKER: Screw length and diameter may also be adjusted. The robotic arm is moved into the operative field to guide percutaneous screw positioning. The end effector automatically adjusts according to the preplanned screw trajectory. Minimal skin and fascia incisions are performed. The trocar is advanced to reach the cortical bone, and soft tissues are dilated.
SPEAKER: Attention must be paid to avoid skiving. The drill guide is then inserted and fixed to the cortical bone, locking the system. A depth gauge set on 30 millimeters of length is used to avoid overdrilling. A drill bit of 2.6 millimeters is used to drill the pedicle.
SPEAKER: Drilling is performed under neuromonitoring guidance as an additional intraoperative safety check. A K-wire is then inserted deep into the spongious bone, filling the typical loss of resistance as a tactile feedback. The trocar removed and the robotic arm moved to the next screw.
SPEAKER: The placement of K-wires can also be performed through the so-called "navigated drill guide technique." The drill guide is aligned with the preplanned trajectory and held in place. The pedicle is then drilled under neuromonitoring.
SPEAKER: A K-wire is then inserted deep into the spongious bone, filling the typical loss of resistance as a tactile feedback. After insertion of all the K-wires, they are hold in place to allow decompression, interbody cage implantation, and final screw insertion. Intraoperative cone beam CT images performed in prone position are fused with the preoperative MRI performed in supine position.
SPEAKER: This allows navigation of soft tissue such as disk sequestrum in the spinal canal, ligamentous flavum helping the surgeon in targeted decompression. The navigated probe is used to establish the proper skin incision. A median incision centered on the L4-L5 disk space is made and monoliteral access to the laminae is performed. A minimal detachment and lateral retraction of the paraspinal muscles are performed to expose the posterior elements of the spine.
SPEAKER: Navigation is used to visualize the correct facet joint to be removed to access the disk space. The superior facet joint is partially removed using a spinal chisel. A partial hemilaminectomy is performed using the high-speed burr first, and later with Kerrison rongeurs to create a window access to the disk.
SPEAKER: Inferior facet joint is carefully removed. The ligamentum flavum is removed to expose neurological structures. The disk space is then identified.
SPEAKER: Dural sac, superior and inferior nerve roots are visualized and retracted. The disk space is accessed by a wide disk incision and removal of the annulus. Discectomy is performed using disk forceps with different shape and size.
SPEAKER: The height of the disk space is assessed under distraction to decide the proper interbody cage size. The intervertebral disk space is thoroughly prepared, ensuring all disk material is removed, and the endplates are carefully decorticated to promote fusion. The trail of the cage is inserted into the disk space to assess the appropriate height, width, depth, and stability to prevent cage migration and subsidence.
SPEAKER: Morselized bone autograft obtained from the lamina in the articular process previously removed is inserted in the interbody space. The interbody cage, filled with local morselized bone autograft, is easily calibrated in size and shape using the navigation software.
SPEAKER: The interbody cage is carefully placed into the disk space under careful retraction of superior nerve root cranially and dural sac with inferior nerve root medially. Navigation of the cage allows real-time visualization of the device in the disk space, indicating the exact depth and orientation toward the final position.
SPEAKER: Following removal of the detractor, pedicle screws are implanted under neuromonitoring using the K-wires. A final bone beam CT scan is performed to check implants placement, listhesis reduction, and segmental lordosis. In postoperative 3D CT images, hardware positioning is evaluated and any deviations from the preoperative planning are assessed.
SPEAKER: The rods are inserted percutaneously through the small distal incision, enlarging it if necessary. Screws are secured with lordotic bars in proper compression and then when closure is performed. Postoperative AP and lateral X-ray show correct implant placement, sagittal alignment, and correction of spondylolisthesis. The patient had a clear improvement in preoperative symptoms, including reduced pain and better neurological function.
SPEAKER:
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