Name:
10.3171/2022.3.FOCVID2215
Description:
10.3171/2022.3.FOCVID2215
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/561a9472-e3ef-4bc1-85aa-e7e01a150ed2/videoscrubberimages/Scrubber_316.jpg
Duration:
T00H07M39S
Embed URL:
https://stream.cadmore.media/player/561a9472-e3ef-4bc1-85aa-e7e01a150ed2
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/561a9472-e3ef-4bc1-85aa-e7e01a150ed2/22-15.mp4?sv=2019-02-02&sr=c&sig=B0OywdfRH%2B4iIc7sLd5%2BhS6jBXDxCzKkm4cmyHvgUuQ%3D&st=2025-05-11T19%3A42%3A45Z&se=2025-05-11T21%3A47%3A45Z&sp=r
Upload Date:
2022-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER 1: Here we present a navigated mini-open retrodiaphragmatic/ retroperitoneal approach in a patient with symptomatic degenerative scoliosis. The patient is a 58-year-old male with over 20 years of low-back pain presenting with progressive debilitating low-back pain and difficulty ambulating that was refractory to conservative management. He denied any radicular leg pain, numbness, or weakness. He also denied any bowel or bladder incontinence or saddle anesthesia.
SPEAKER 1: On exam, he was full strength in lower extremities. His reflexes were globally diminished. There was no Hoffman's, Babinski, or ankle clonus. Standing full-length x-rays demonstrate a significant levoconvex scoliosis with an L1-5 Cobb angle of 46 degrees. He has both coronal and sagittal imbalance with a 10-cm rightward shift of the C7 plumb line from the central sacral vertical line as well as positive 12- cm sagittal imbalance.
SPEAKER 1: Comparing the standing x-rays to the supine CT scout images reveals a stiff deformity. CT lumbar spine demonstrates collapsed disc space with multiple bridging osteophyte complexes. Lumbar MRI reveals multilevel stenosis, most significant at L4-5, where there is severe central canal stenosis, and L3-4, where there is also severe central canal stenosis, along with multilevel foraminal and lateral recess stenoses.
SPEAKER 1: Our operative plan was for a staged approach, with the first stage involving a left-sided retrodiaphragmatic and retroperitoneal approach for T12-L4 lateral lumbar fusions. This was followed with the second stage, T10-ilium instrumentation infusion, facet osteotomies, and left L4-5 TLIF. The focus of this video will be on the retrodiaphragmatic approach to the T12-L1 disc space as well as highlighting the utility of navigation in performing a lateral osteotomy across a fused portion of the disc space at L1-2.
SPEAKER 1: After general anesthesia, the patient is positioned in lateral decubitus position with the convex side up on the Jackson table. A large gel roll is placed under the torso, and the patient is secured in place with tape. This maneuver elevates the rib cage cranially as well as opens up the disc spaces. Approaching on the concave side poses more of a surgical challenge, since the disc spaces are collapsed and there are numerous bridging osteophytes.
SPEAKER 1: The hips and knees are flexed to prevent strain on the psoas muscle. The patient is prepped and draped in usual sterile fashion. A stab incision overlaying the superior-most portion of the iliac crest was made, and an iliac pin with a stealth reference frame was impacted into the bone. A 3-dimensional image of the spine was obtained.
SPEAKER 2: The navigation system is used to trace out the skin incision, which is centered on the thoracolumbar junction and the 11th rib and measured approximately 2.5 inches. The surgical incision was used for the T12-L1 and L1-2 lateral interbody fusions. Another similar-sized incision was made for the L2-3 and L3-4 lateral interbody fusions, which will not be depicted in this operative video. The skin is incised and electrocautery is used to expose the 11th rib going through the latissimus dorsi and external oblique muscles.
SPEAKER 2: The 11th rib is identified, and the intercostal muscle is dissected off the rib to allow room for insertion of the rib elevator, which will separate the rib from the underlying endothoracic fascia and diaphragm. When dissecting the muscle off the rib caudally, care must be taken not to disrupt the neurovascular bundle that runs inferior to the rib. Once separated, rib cutters are used to cut a portion of the rib approximately 5 cm to allow room for exposure to the thoracolumbar junction.
SPEAKER 2: This piece of bone was saved and used later as local autograft bone. A plane is developed between the intercostal muscle cuff and the diaphragm using blunt dissection.
SPEAKER 3: The intercostal muscle cuff with the neurovascular bundle is lifted, and the diaphragm is exposed underneath. Blunt dissection is continued in the direction of the 12th rib. Diaphragm was dissected dorsally as well as inferiorly. The 12th rib is identified using the navigation pointer. This confirms that our trajectory is correct. The diaphragm is visualized detaching under the 12th rib. Blunt dissection is utilized to free the diaphragm from this rib.
SPEAKER 3: Navigation confirms we are under the 12th rib approaching the vertebral body. A handheld retractor is placed on the diaphragm to elevate it cranially and anteriorly. This allows for an adequate corridor to the T12-L1 disc space. Navigation confirms that we are right over the T12-L1 disc space.
SPEAKER 3: Blunt section is continued to expose the psoas muscle and the underlying disc space. The navigated pointer is anchored into the disc space and confirmed using a navigated system. Sequential dilation through the psoas is utilized, and a tubular retractor is docked on the disc space. EMG is utilized with the navigated pointer as it traverses the psoas and anchors into the disc space.
SPEAKER 3: Of note, the psoas muscle bulk is variable and may be atretic at the T12-L1 disc space. Any remaining psoas muscle fibers are mobilized and displaced using a lateral retractor. A bayoneted knife is used to make an annulotomy into the disc, followed by standard discectomy and endplate preparation. Navigated trials are inserted into the disc space to determine appropriate sizing of the interbody fusion cage.
SPEAKER 3: A biologic to enhance fusion is used in conjunction with the allograft bone. The interbody cage packed with allograft bone is impacted into the disc space utilizing spinal navigation. After placement of the cage, visual inspection is performed to confirm adequate placement of the cage and to achieve hemostasis prior to retract or removal. Since the L1-2 disc space was partially fused, a navigated Cobb was advanced across this fused portion until a complete osteotomy was performed through the lateral osteophyte complex.
SPEAKER 3: Using this approach, the diaphragm does not have to be surgically reapproximated. The surgical incision is closed in layers, making sure to reapproximate both the external oblique and lattisimus dorsi muscles. Skin is closed with skin glue.
SPEAKER 1: In this video, we illustrated a case of symptomatic thoracolumbar scoliosis with both sagittal and coronal imbalance treated with a retrodiaphragmatic/ retroperitoneal approach for lateral interbody fusions and posterior osteotomies, instrumentation, and fusion. We focused on the retrodiaphragmatic approach to the T12-L1 disc space and navigated osteotomy. Utilizing 3D navigation in this case offered several advantages, including planning our incision, assisting in intraoperative localization as we were dissecting the diaphragm off the rib, completing a lateral osteotomy across a fused portion of the disc space, and guiding placement of an interbody cage.
SPEAKER 1: The patient had an uncomplicated hospital course and was discharged on hospital day 5 to home. At the 6-month follow-up visit, he reported significant improvement in his back pain. Postoperative scoliosis x-rays demonstrate significant improvement in alignment with the L1-5 Cobb angle of 46 degrees preoperatively to 8 degrees postoperatively. His coronal offset was markedly improved from 10 cm to half a centimeter.
SPEAKER 1: Also, his sagittal imbalance corrected from 12 cm to 4.5 cm postoperatively.
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