Percutaneous Transforaminal Interbody Fusion Research Articles

490 Beyond Placement of Pedicle Screws - New Applications for Robotics in Spine Surgery: A Multi-Surgeon, Single-Institution Experience

INTRODUCTION: Interest in robotic-assisted spine surgery has grown as surgeon comfort and technology have evolved to maximize the benefits of time-saving and precision. However, the Food and Drug Administration (FDA) has currently only approved robotics to assist in determining the ideal trajectory for pedicle screw placement after extensive research supporting its efficacy and efficiency. To be considered a durable and effective option, robotics need to expand beyond the indication of just placing pedicle screws. METHODS: We will explore accessing Kambin’s Triangle in percutaneous transforaminal interbody fusion (percLIF), iliac fixation in metastatic cancer, and sacroiliac (SI) fusions. Each of these topics will be covered in-depth with associated background information and subsequent discussion. RESULTS: Without the need for laminectomies or facetectomies, minimal tissue disruption was attained by using RA instrumentation finely tuned to each patient’s unique spinal landscape for percLIF. In the cases of iliac fixation, the use of S2AI screws was precluded by the extensive damage to the sacrum. Therefore, a modified iliac screw entry point was utilized with an entry point slightly more medial than the traditional method, with a pre-planned trajectory of the screws using robot assistance. For SI joint fusion, we review our group at Duke University's published case series displaying the “off-label” use of the robot, which is the first reported case series of its kind in the literature. CONCLUSIONS: We show that with a proper understanding of its limitations, robots can help surgeons perform difficult surgeries in a safe manner.

Beyond Placement of Pedicle Screws - New Applications for Robotics in Spine Surgery: A Multi-Surgeon, Single-Institution Experience.

Interest in robotic-assisted spine surgery has grown as surgeon comfort and technology has evolved to maximize benefits of time saving and precision. However, the Food and Drug Administration (FDA) has currently only approved robotics to assist in determining the ideal trajectory for pedicle screw placement after extensive research supporting its efficacy and efficiency. To be considered a durable and effective option, robotics need to expand beyond the indication of just placing pedicle screws. This article aims to illustrate a multi-surgeon, single-institution experience with unique applications of robotic technologies in spine surgery. We will explore accessing Kambin’s Triangle in percutaneous transforaminal interbody fusion (percLIF), iliac fixation in metastatic cancer, and sacroiliac (SI) fusions. Each of these topics will be covered in depth with associated background information and subsequent discussion. We show that with proper understanding of its limitations, robots can help surgeons perform difficult surgeries in a safe manner.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P129. True percutaneous transforaminal lumbar interbody fusion (pTLIF) with an expandable interbody cage using the endoscopic posterolateral approach: a long-term follow-up report of 50 cases

BACKGROUND CONTEXT Interbody fusion by open discectomy is the usual treatment for degenerative disc disease but requires a relatively long recovery period. The transforaminal posterolateral approach is a well-known standard in endoscopic spine surgery that allows direct access to the disk with progressive tissue dilation, avoiding tissue and bone dissection. PURPOSE The aim of this study was to assess the efficacy and safety of percutaneous transforaminal interbody fusion (pTLIF) for lumbar spinal fusion. pTLIF consists of percutaneous insertion of an expandable implant with the endoscopic posterolateral approach through an endoscopic cannula with progressive tissue dilatation. The anterior cage placement is complemented with a percutaneous posterior fixation. STUDY DESIGN/SETTING Prospective, nonrandomized, single-arm, single-center, single surgeon sequential case series study. PATIENT SAMPLE Between 2009 and 2017, the pTLIF procedure was performed in one center for 50 patients with an expandable interbody cage. OUTCOME MEASURES Patient outcome was scored pre- and post-operatively with visual analogic scale (VAS), Oswestry disability index (ODI) and modified Macnab criteria. Scores were performed preoperatively and at 1 month, 3 months, 6 months, 1 year and at least 2yearspost-operatively. A CT scan was performed immediately after surgery. Conventional X-ray controls were performed at 1 month and 1 year post-operatively. METHODS Indication for surgery was degenerative disc disease of the lumbar spine with or without spondylolisthesis up to grade 2, and for revision surgery. Percutaneous transforaminal interbody fusion was performed by inserting an expandable implant with the endoscopic posterolateral approach through an endoscopic cannula with progressive tissue dilatation. Percutaneous posterior fixation comprised transpedicular screws and rods, interspinous spacer and transfacet screws depending on each case. Significance between pre- and postoperative scores was analyzed with Student's paired t-test. RESULTS The mean follow-up period was 33.1 (SD 20.4) months. The outcome was excellent in 28 (56%), good in 17 (34%), fair in 3 (6%) and poor in 2 (4%) cases according to Macnab criteria. The latter two cases were lost before 6 months of follow-up and consequently classified as poor. Significant differences (p CONCLUSIONS The pTLIF technique shows 90% of Excellent and Good postoperative results and no major complications for a long-term mean follow-up of 33 months, proving the efficacy and safety of the pTLIF procedure for primary and revision surgery cases. Percutaneous transforaminal interbody fusion allows bypassing posterior scar tissue from previous operations in revision surgery cases hereby reducing the risk of dural tear and nerve injury. Postoperative median time until walking (6 hours) and until hospital discharge was faster compared to standard open TLIF (25hours vs. 5 days), probably due to the less invasive handling of the soft and bony tissues with the endoscopic posterolateral approach. The pTLIF technique has disruptive potential as it opens the way to ambulatory fusion surgery in an outpatient clinical setting.