Name:
10.3171/2025.4.FOCVID2520
Description:
10.3171/2025.4.FOCVID2520
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/859796b6-41a1-4e8c-b572-adee434fcb73/videoscrubberimages/Scrubber_302.jpg
Duration:
T00H08M10S
Embed URL:
https://stream.cadmore.media/player/859796b6-41a1-4e8c-b572-adee434fcb73
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/859796b6-41a1-4e8c-b572-adee434fcb73/10. 25-20.mp4?sv=2019-02-02&sr=c&sig=WzzehQO1ptP6hP%2BHaijNzwUCtIhbrUyoxt4%2BClyr%2Fl8%3D&st=2026-02-25T00%3A04%3A15Z&se=2026-02-25T02%3A09%3A15Z&sp=r
Upload Date:
2025-05-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: The authors present robot-assisted minimally invasive transforaminal lumbar interbody fusion with contralateral facet decortication, a novel technique for posterolateral fusion. 58-year-old female with five-month history of low-back pain radiating bilaterally to the posterior lateral hips and feet with numbness and tingling. Pain worsened with ambulation and improved with sitting. She had intermittent urinary hesitancy but no bowel incontinence.
SPEAKER: Conservative measures was minimally effective, and an epidural provided only transient relief. Ambulation was significantly limited at the time of her presentation. Past medical history is significant for hypothyroidism, hyperlipidemia, and osteopenia. Past surgical history included a C3 through C6 ACDF for degenerative cervical myelopathy.
SPEAKER: The physical exam showed an antalgic gait, and further gait analysis was limited by pain. Patient had full strength bilaterally in her upper and lower extremities. However, she had hyperreflexia on her Achilles and patellar tendons, and a positive FABER test bilaterally. She also had a positive straight leg test on her right. Lateral X-ray in neutral and standing position demonstrated a 1.5-centimeter grade 2 anterolisthesis at L4 and L5, along with a stable grade 1 retrolisthesis at L1 to L2.
SPEAKER: Flexion/extension views in exhibit B reveal no significant motion instability. T2-weighted sagittal MRI on the left shows multilevel degenerative spondylosis that is most significant at L5 through S1. At L4 through L5, we again see the grade 2 anterolisthesis, but now reveal severe canal stenosis causing cauda equina compression and L5 nerve root impingement on the subarticular recesses.
SPEAKER: Additionally, moderate foraminal stenosis is seen at L4 through L5 and L5 through S1, especially on the left. In summary, we have an older female presenting with bilateral radiculopathy secondary to spondylolisthesis and L4 and L5 stenosis. Despite conservative measures, she continued to have debilitating leg and back pain, and ultimately consented to an MIS-TLIF.
SPEAKER: The operative plan for this patient included a minimally invasive right L4 through L5 TLIF with an expandable cage, a posterolateral arthrodesis at L4 and L5 with allograft, bilateral L4 laminotomy and left medial facetectomy, and ultimately a robot-assisted pedicle screw placement at L4 and L5. This preoperative thin-section CT without contrast was obtained to accurately register the patient's anatomy with intraoperative fluoroscopy for accurate robotic navigation.
SPEAKER: After induction of general anesthesia, the patient was placed in prone position on a Jackson table, with all the pressure points carefully padded. An iliac pin was then placed on the left PSIS for robotic registration. AP and oblique fluoroscopy images were obtained to register the patient's anatomy with her preoperative CT scan. The robot was then connected to the iliac pin, and accuracy of robotic navigation was verified.
SPEAKER: Using the preplanned trajectories on the robotic navigation system, the left L4 and L5 pedicles were cannulated percutaneously and screws were placed. The robot was used to guide a navigated cannula down to the left L4 and L5 facet joint. A specialized facet decortication tool with a 1.5-millimeter safety margin was used to carefully decorticate the joint without encroaching on the canal or the foramen. Allograft was packed through the cannula into the decorticated joint space to establish a posterolateral fusion bed.
SPEAKER: On the right side, L4 and L5 pedicle screw trajectories were mapped and cannulated under robotic navigations, and K-wires were placed in anticipation of later screw insertion. A 20-millimeter tubular retractor was docked on the right L4–5 facet and confirmed with navigation.
SPEAKER: Once the tubular retractor was docked on the facet, a thin layer of muscles were dissected to reveal the superior and inferior articular processes. A right-sided facetectomy and laminotomy was performed to decompress the exiting nerve root. Contralateral laminotomy was achieved by angling the tube across midline and removing the ligamentum flavum to decompress the thecal sac adequately.
SPEAKER: A standard annulotomy and discectomy was performed at L4 and L5, followed by a thorough disk space preparation with shavers and rounders. Autograft and allograft were packed into the interspace, and a 9-millimeter TLIF cage was inserted and expanded under fluoroscopy. Additional graft was post-packed around the cage to promote fusion.
SPEAKER: Right L4 and L5 screws were then placed over the existing K-wires. Rods were subsequently inserted, and the screws were used to gently reduce the L4–5 spondylolisthesis. Fluoroscopy images confirmed the restoration of lumbar lordosis and correction of spondylolisthesis. Patient successfully recovered from anesthesia and subsequently transferred to the floor. She reported improvement in her preoperative symptoms and was discharged in postoperative day one.
SPEAKER: In her 1 week follow-up, she reported pain-free ambulation and was contemplating returning to virtual work. In postoperative week 6, she had minimal foot tingling and was back to full activity with lifting restrictions. Week 6 postoperative imaging showed stable hardware with no complications and an improvement in her spondylolisthesis when compared to her preoperative imaging. The facet decortication tool allows contralateral facet decortication and graft placement using a minimally invasive approach.
SPEAKER: This enables a posterolateral arthrodesis to supplement the MIS-TLIF. By matching the trajectory angle of the inferior screw so that it is parallel to the pedicle screw, the same incision can be used for the decortication tool. If the facet joint is large, plan multiple trajectories to decorticate the entire joint surface. This enlarges the fusion surface area. In traditional MIS-TLIF, the primary fusion mass comes from the interbody space.
SPEAKER: By adding facet decortication on the contralateral side, you gain an additional posterolateral fusion bed. This is particularly valuable in patients with osteopenia or spondylolisthesis. This technique is also very versatile because it can be used whenever percutaneous screws are placed using the robot to ensure a posterolateral arthrodesis. By integrating robotic navigation, we demonstrate the ability for robot-guided osseous drilling that could lead to further advances in semi-automated robotic surgery.
SPEAKER:
Form Title Download
Form Title Bookmark
Form Title Share
Form Title Cite
