Name:
10.3171/2024.1.FOCVID23216
Description:
10.3171/2024.1.FOCVID23216
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/de66377e-a54f-4bfd-910c-92ff23aa3146/videoscrubberimages/Scrubber_330.jpg
Duration:
T00H08M23S
Embed URL:
https://stream.cadmore.media/player/de66377e-a54f-4bfd-910c-92ff23aa3146
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/de66377e-a54f-4bfd-910c-92ff23aa3146/10. 23-216.mp4?sv=2019-02-02&sr=c&sig=wIdw9BHEcBdokKzBz9h7%2BuZuSJwWeJ%2Fbp7vjIIWu1IM%3D&st=2026-05-01T16%3A04%3A07Z&se=2026-05-01T18%3A09%3A07Z&sp=r
Upload Date:
2024-03-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video illustrates a minimally invasive spine surgery technique for addressing L5–S1 listhesis with paracentral disc protrusion. This technique offers the advantage of unilateral biportal endoscopy while mitigating the need for a wet medium. Moreover, it does not necessitate additional instruments beyond those used in standard microscopic minimally invasive transforaminal lumbar interbody fusion.
SPEAKER: The 33-year-old lady presented with severe low backache with left L5 radiculopathy following a recent bike accident. Examination revealed weakness in left extensor hallucis longus and sensory loss along the left L5 dermatome. Standing x-ray lateral view indicated grade 1 L5–S1 anterolisthesis with pars interarticularis fracture. Based on spinopelvic parameters, the patient was classified as type 2 according to the modified Spine Deformity Study Group classification.
SPEAKER: On the MRI, there was a left L5–S1 paracentral disc with foraminal extension and a cranially migrated portion. The patient was diagnosed with L5–S1 grade 1 listhesis with L5–S1 migrated paracentral disc with foraminal extension. She was planned for MIS-TLIF using a 4-mm rigid endoscope followed by percutaneous pedicle screw fixation. The patient was positioned prone under general anesthesia.
SPEAKER: Skin marking were made under fluoroscopic guidance. The midline, a line along the lateral edge of the pedicle, and the upper endplate were marked. A 16-gauge needle was inserted as a guide for docking the Destandau's system, Pointing to the L5–S1 disc space on the contralateral side. A 2-cm longitudinal incision was marked along the pedicle line, starting from the S1 pedicle and extending towards the L5 pedicle for Destandau's system insertion.
SPEAKER: The docking was done, and level was confirmed with C-arm. Initial docking is done at the spinolaminal junction. Lateral exposure of the laminofacet junction is performed by removing the soft tissue and a small amount of muscle with monopolar and bipolar cautery. The facet joint is thus exposed. It is called the "valley between two mountains" view, showing the L5 facet, S1 superior facet, and the intervening joint space.
SPEAKER: The inferior edge of L5 lamina is removed with No. 3 Kerrison punch. The rest of lower lamina is drilled at three strategic points using a 3-mm diamond burr. Firstly, at the lower margin. Secondly, at the junction of pars interarticularis and the inferior facet by working laterally from the first point. This would help resection of the L5 inferior facet. And lastly, at the root of the spinous process to allow over-the-top decompression of the spinal canal and the contralateral nerve root.
SPEAKER: The remaining bone is removed with a Kerrison punch. As the pars interarticularis and inferior facet junction was removed with Kerrison's punch, the whole of inferior facet could be disconnected. The disconnection of L5 inferior facet entails a careful separation from its ligamentous attachment. Utilizing biopsy forceps, it was divided into two halves so as to deliver it through the outer sheath.
SPEAKER: These bony pieces can be used to pack the PEEK cage to improve fusion rates. Now, the physical surface of S1 superior facet is seen. This facet is removed using No. 3 Kerrison punch, working medial to lateral until we reach the S1 pedicle. The surface is smoothened using a burr while avoiding any injury to the pedicle. The ligamentum flavum is then removed in piecemeal. It will expose the underlying epidural fat.
SPEAKER: It should be retained till all the bony work is completed to avoid a dural tear. Removal of the epidural fat exposes the thecal sac. Working laterally to the thecal sac in a craniocaudal direction, the fat and soft tissue are dissected to expose the traversing nerve root.
SPEAKER: The traversing root is gently retracted medially at its shoulder to expose the disc space. The Destandau's retractor is used to keep the nerve root retracted. The engorged epidural veins are coagulated and cut. Using a marking needle, the disc level is confirmed under the C-arm. The lower part of the Kambin's triangle was thus exposed. Using a 15 number blade, the annulus is cut.
SPEAKER: The nucleus pulposus and part of the annulus fibrosus are removed using biopsy forceps. Care is taken to remove all the herniated disc, including the migrated portion. A 1.5-cm horizontal incision was made at the marked level for inserting the L5 percutaneous pedicle screw.
SPEAKER: This incision is deepened to the fascia. The first of the dilators for percutaneous pedicle screw is inserted, and sounding is done with the Destandau's outer sheath to confirm the alignment. The dilator is further navigated into the disc space under endoscopic vision. Triangulation of the instruments is thus achieved.
SPEAKER: Successively, the second dilator is then inserted followed by the third dilator sheath, which is used for screw insertion. It is inserted until its lower margin is just visible by endoscope and left in situ to act as a new port. The endoscope is then inserted in this new port. The inner sheath of the Destandau's system is removed, allowing the outer sheath to serve as a port for the larger instruments to be introduced into the disc space.
SPEAKER: Larger shavers can now be inserted through the Destandau's outer sheath to prepare the disc space like in a tubular discectomy. The endoscope can be freely advanced into the disc space to inspect the status of the endplate preparation. The sizer for the cage was inserted under endoscopic vision, thus preventing nerve injury. Due to the transforaminal corridor, only a slight retraction of the traversing nerve root is required when using a large cage.
SPEAKER: 14 by 28–mm PEEK cage was inserted, and its position was confirmed on C-arm. For adequate visualization of the nerve root on the medial aspect of the cage, a 30-degree endoscope is required at times. The dislodged bone chips from the cage and remaining disc fragments were removed. At the end of the procedure, the L5–S1 left lateral recess and foramina were completely free.
SPEAKER: The spinal canal and the contralateral nerve root were decompressed by the over-the-top technique. The thecal sac and the traversing nerve root can be seen to be well pulsatile and supple, confirming no compression. Afterwards, L5–S1 percutaneous pedicle screw fixation was done. The patient was evaluated 12 hours after surgery. She was now able to walk without pain.
SPEAKER: There was a complete improvement in the left extensor hallucis longus power by the third week of follow-up. Postoperative CT affirmed correction of listhesis with optimal implant position. The total operative time was 4.5 hours with an estimated blood loss of 300 ml. The patient was discharged in five days with significant improvement in the VAS scores. The technique has its own benefits, nuances, and limitations.
SPEAKER: It expands the spectrum of Destandau's system and is a bridge to unilateral bioportal endoscopy, thus increasing the role of endoscopy in minimally invasive spine surgeries. Thank you.
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