2nd - ismiss turkey

Transkript

2nd - ismiss turkey

2nd ISMISS Congress in Turkey on
INTERVENTION IN SPINAL SURGERY
Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional
Contents
Welcome Message by Hansjoerg F. Leu ................................................................ 2
Welcome Message by Tolgay Satana ..................................................................... 3
ISMISS Officers .......................................................................................................4
Organizing Committee ............................................................................................ 5
Faculty .................................................................................................................... 6
Scientific Program ........................................................................................... 7 - 15
Chairpersons ................................................................................................. 16 - 36
Lectures ....................................................................................................... 37 - 103
Poster Presentations .................................................................................. 104 - 111
1
Since its foundation in 1989, the International Society for Minimal Invasive Spinal
Surgery (ISMISS / www.ismiss.com affiliated to SICOT) aims for well controlled
information and methodical instruction in the rapidly evolving field of spinal surgery.
So starting in the US and central Europe in the eighties, since the nineties a rapid
growth was to observe in Korea and Japan, in the young 21th century also in China.
Respectively interested groups of active
spinal surgeons brought up the new techniques and their experiences to periodically
organized meetings under the auspices of ISMISS. The goal remains to allow first
hand information on new techniques, their concepts with well defined indications,
limits and results. As in other fields of surgery, minimal invasive techniques challenge
today former golden standards and sollicitate our critical evaluation and responsibility
for well defined respective clinical practice. So all over the world several courses are
now organized under the auspices of ISMISS under this commitment.
Beside technical and operative aspects also clinical analysis of indications, learningcurves and follow-up criteria deserve our interest in worldwide economically restricted
conditions and an evident need for outcome quality control. So also a need is evident
for ISMISS to define common sense definitions and guidelines, helping so all active
partners in the field of minimal invasive spinal surgery to orient themselves in the
rapid evolution in this field.
So in the nearby 20 years tradition of ISMISS, also this first specific meeting under
the auspices if ISMISS in Turkey shall reflect an up-date on already done proven
steps in this field, the actual state of the art and ongoing innovative developments in
this continuously evolving branch of spinal surgery. We thank Dr. S. Tolgay from
Istanbul and his group for the superb organization of this meeting. It is with great
pleasure that we see the large interest of our colleges in Turkey. We are convinced
that such an exchange between local and international pioneers and experts sharing
the course faculty promise to contribute to a vivid and collegial atmosphere of this
first turkish meeting and making many new friendships and bridges with this amazing
country.
Hansjoerg F. Leu, M.D.
President Elect ISMISS 2008-2011
2
'Primum nil nocere' (Never harm) principle has been the primary principle of medicine
since the Hypocrates era. As surgical treatment methods in general evolve towards
less invasive procedures, former invasive spinal surgery also climbs up rapidly an
analogous ladder of
evolution. Although minimal invasive spinal surgery has become more popular along
with the improving optic systems in the last two decades, it has always prevailed in
throughout the past century.
Beside ISMISS, other spinal societies hosted the early platforms for exchanging
information. owever, their meetings often underperformed innovative expectations.
Sometimes minimal invasive interventions were just lost among glorious implants and
material intensive surgery. That is why various local branches of ISMISS, e.g. Swiss
branch organized 25 annual meetings in Zurich/Switzerland, focussing mainly on
minimal invasive spinal interventions.
Where in conventional spine meetings in the last decade present, minimal invasive
spinal surgery has been included into the programs with individual presentations.
Now for the first time in Turkey, this meeting will be dedicated in its program to the
entire range of today's minimal invasive spinal interventions. Furthermore, our goal is
to allow all physicians interested in minimal invasive surgery to get in contact with
renowned international experts in order to exchange information and share best
practices.
On behalf of International Organizing Committee
Tolgay SATANA, MD
National Representative of ISMISS
3
ISMISS OFFICERS
PRESIDENT
Hj. Leu, M.D., Switzerland
PRESIDENT ELECT
S-H. Lee, M.D., South Korea
VICE PRESIDENT
V. Radchenko, M.D., Ukraine
PAST PRESIDENT
J. Chiu, M.D., United States
SECRETARY
American Branch
European Branch
V. Radchenko, M.D., Ukraine
Asian Branch
S. Nakai, M.D., Japan
TREASURER
European Section
Hj. Leu, M.D., Switzerland
American Section
NATIONAL REPRESENTATIVE
Australia
China
Germany
Italy
Korea
Spain
Turkey
United Kingdom
: G. Speck, M.D.
: Z. Zheng, M.D.
: C. Birkenmaier, M.D.
: A. Fontanella, M.D.
: S-H. Lee, M.D.
: C. Algara Lemagniere, M.D.
: S. Tolgay, M.D.
: L. Wilson, M.D.
Brazil
: Pil-Sun Choi, M.D.
France
: D. Gastambide, M.D.
Hong Kong : K. Fung, M.D.
Japan
: A. Dezawa, M.D.
Russia
: L. Sak, M.D.
Switzerland : M. Rühli, M.D.
Ukraine
: E. Pedachenko, M.D.
United States : J. Chiu, M.D.
SICOT REPRESENTATIVE
M. Hinsenkamp M.D.
4
ORGANIZING COMMITTEE
Honorary Presidents
Parviz Kambin (USA)
Hansjoerg Leu ( Switzerland)
Co-President
Erol Yalnız (Turkey)
Mehmet Zileli (Turkey)
Course Coordinator
Tolgay Şatana (Turkey)
Secretary
Murat Bezer (Turkey)
Oğuz Karaeminoğulları (Turkey)
Alpaslan Şenköylü (Turkey)
Treasurer
Mehmet Altuğ (Turkey)
Murat Ergüven (Turkey)
5
FACULTY
Salahadin Abdi (USA)
Abdul Gaffar Shaikh Ahmed (Bahrain)
Gülseren Akyüz (Turkey)
Vitalli Alexandrovski (Ukraine)
Mehmet Altuğ (Turkey)
Mustafa Anter (Turkey)
Figen Yağmur Aslan (Turkey)
Yair Barzilay (Israel)
Murat Bezer (Turkey)
Christof Birkenmaier (Germany)
Alexander Brekhov (Russia)
Josip Buric (Italy)
John Chiu (USA)
Gun Choi (Korea)
Bayram Çırak (Turkey)
Bambang Darwono (Indonesia)
Jean Destandeu (France)
Akira Dezawa (Japan)
Devanand A. Dominique (USA)
Serdar Erdine (Turkey)
Murat Ergüven (Turkey)
Andrea Fontanella (Italy)
Daniel Gastambide (France)
Lex Giltaij (USA)
Krzok Guntram (Germany)
Nils Haberland (Germany)
Azmi Hamzaoğlu (Turkey)
Mitchell Hardenbrook (USA)
Stefan Hellinger (Germany)
Thomas Hoogland (Germany)
Fujio Ito (Japan)
Sudeep Jain (India)
Chang Il Ju (Korea)
Serdar Kabataş (Turkey)
Parviz Kambin (USA)
Solomon Kamson (USA)
Sri Kantha (USA)
H.Selim Karabekir (Turkey)
Bülent Fahri Kılınçoğlu (Turkey)
Panagiotis Korovessis (Greece)
Banu Kuran (Turkey)
Sang Ho Lee (Korea)
Hansjoerg Leu (Switzerland)
Alexandre Levshin (Ukraine)
Nuket Göçmen Mas (Turkey)
Paolo Menchetti (Italy)
Ahmet Menku (Turkey)
Christian W. Müler (Germany)
Semih Özdemir (Turkey)
Burak Özgür (USA)
Çağatay Öztürk (Turkey)
Chan Wearn Benedict Peng (Singapore)
Andrey Popov (Ukraine)
Konstantin Popsuishapka (Ukraine)
Vladimir A. Radchenko (Ukraine)
Wolfgang Rauschning (Sweden)
Sebastian Ruetten (Germany)
Jan Peter Schilling (Germany)
Jalal Jalal Shokouhi (Iran)
Arsen Shpigelman (Israel)
Artem Skidanov (Ukraine)
Tariq Sinan (Kuwait)
Dilşat Sindel (Turkey)
Alexander Sirenko (Ukraine)
Ufuk Soylu (Turkey)
Kayıhan Şahinoğlu (Turkey)
Tolgay Şatana (Turkey)
Mehmet Şenoğlu (Turkey)
Mehmet Ali Tümöz (Turkey)
Ahmet Usta (Turkey)
Füsun Uysal (Turkey)
İlker Yağcı (Turkey)
Anthony Yeung (USA)
Kemal Yücesoy (Turkey)
Park Kyung-Woo (Korea)
Mehmet Zileli (Turkey)
6
Scientific Programme
7
April 3, 2009
J. Destandau - S. Hellinger
T. Satana
08:30 - 13:00
Live Surgery on " Endoscopic and Cervical Discectomy"
09:00
Posterior Endoscopic Discectomy (Destandau Tecnique)
10:00
Percutaneous Endoscopic Lumbar Discectomy
S. Hellinger
11:00
Percutaneous Endoscopic Lumbar Discectomy
G. Krzok
12:00
Thorasic Discectomy
14:00 - 17.00
Pre-Congress Cadaver Hands-on Workshop on “Foraminal and endoscopic spinal anatomy”
10min
Foraminal and endescopic spinal anatomy
10min
Basic Principles of miss techniques
J. Destandau
J. Chiu
K. Sahinoglu - T. Satana
K. Sahinoglu
T. Satana
Hands on workshop with cadavra:
Percutan endescopic lumbar discectomy - Endoscopic thorasic discectomy - Percutan endescopic cervical
discectomy
April 4, 2009
J. Chiu - S. Hellinger
G. Krzok - S.H.Lee - H. Leu
T. Satana
08.00 - 08:05
Welcome Adress
Mehmet Zileli
08.05 - 08:10
Presidential greeting address of ISMISS
Hansjoerg Leu
Panel 1 - Basic Principles
Hansjoerg Leu
Mahmet Zileli
08:10 - 08:18
History of Minimal Invasive Spinal Surgery
Mehmet Ali Tümöz
08:18 - 08: 26
Definition of MISS procedures and regulations in Turkey
08:26 - 08:34
Outcome measures in low back pain
08:34 - 08:42
Back pain in children and adolescent
08:42 - 08:50
Digital Technology Convergence and Control System: Minimally Invasive Spine Surgeon’s (MISS) Perspective
and Technological Consideration
08:50 - 08:58
Thoracoscopic Management of Spine Tumors
08:58 - 09:06
Biological-functional considerations regarding the treatment of lumbar DDD.
09:06 - 09:14
Intervertebral Foramen from the Anatomic Approach
09:14 - 09:20
Discussion
8
Tolgay Satana
L-1
Fusun Uysal
L-2
John Chiu
L-3
Ahmet Usta
L-4
April 4, 2009
Master lecture
John Chiu
09:20 - 09:35
Full-endoscopic operations of the lumbar, thoracic and cervical spine
09:35 - 09:50
Minimalinvasive Procedures on the cervical spine - From the Nonendoscopic Percutanoues Laserdiscdecompression to the
selective Percutaneous Endoscopic Cervical Decompression and Discectomy
09:50 - 09:55
Discussion
09:55 - 10:15
Coffee Break
Sebastian Ruetten
ML - 1
Stefan Hellinger
ML - 2
Master lecture
Sang Ho Lee
10:15 - 10:30
Complication risks of the foraminal approach to the lumbar spine: It’s corellation with foraminal anatomy,
variations, and anomalous structures in the “hidden” zone”
Antony Yeung
ML - 3
10:30 - 10:45
Endoscopic Surgery of Lumbar Spinal Stenosis. About 145 cases.
Jean Destandeu
ML - 4
10:45 - 10:50
Discussion
Panel 2: Endescopic Spine Techniques
Sang Ho Lee
10:50 - 10:58
Posterior Lateral Thoracic Endoscopic Microdiscectomy
10:58 - 11:06
Endoscopic Approaches to Degenerative Cervical Deseases.
11:06 - 11:14
Transforaminal Endoscopic Microdecompression for Herniated Lumbar Discs and Spinal Stenosis and Tissue
Modulation Technology - Update
11:14 - 11:22
PECD for Noncontained HCD
11:22 - 11:30
Endoscopic lumbar disc surgery : up-date 2009
11:30 - 11:38
The endoscopic resection for Juxta-facet cysts – a new promising technique
11:38 - 11:46
XMR assisted PELD
11:46 - 11:54
Full-endoscopic posterior operation of cervical lateral disc herniations – Prospective, randomized comparison to
anterior cervical decompression and fusion (ACDF)
11:54 - 12:02
Clinical outcomes of percutaneous endoscopic discectomy (peld)
12:02 -12:10
Discussion
12:10 - 13:00
Lunch
12:10 - 13:00
Luncheon Meeting of General Assambly of ISMISS Turkey co joined ISMISS Board.
9
John Chiu
L-5
Jean Destandeu
L-6
John Chiu
L-7
Sang Ho Lee
L-8
Hansjoerg Leu
L-9
Stefan Hellinger
L - 10
Sang Ho Lee
L - 11
Semih Özdemir
L - 12
Fujio ITO
L - 13
April 4, 2009
Stefan Hellinger
Burak Özgür
Program Lectures
13:00 - 13:08
Percutaneous endoscopic discectomy in lumbar disc herniation combined with spinal stenosis having severe unilateral
radiculopathic leg pain caused by dominant root compression : Transforaminal suprapedicular approach
13:08 - 13:16
Comparative study of efficiency of Destandau endoscopic discectomy and open microsurgical discectomy for
lumbar disc herniation.
13:16 - 13:24
Transforaminal endescopic extradiscal vs intradiscal access in lumbar disc herniation
13:24 - 13:32
Minimally invasive approach to lesions located in spinal canal
13:32 - 13:40
Clinical and Radiological outcomes of Minimally Invasive versus open transforaminal lumbar interbody fusion
13:40 - 13:48
Prophylactic of relapses of facet joint syndrome after their’s denervation
13:48 - 13.56
Rigid Interspinous Spacer with Tension Band (ILF)
13:56 - 14:04
Inter-spinous Process Fixation for Degenerative Pathology of the Lumbar Spine
14.04 - 14:12
Analysis of Cervical RF nucleopasty as a minimal invasive procedure with 2-3 years follow-up
14:12 - 14:20
Discussion
Chang Il Ju
L - 14
Guntram Krzok
L - 15
Chan Wearn Benedict Peng
L - 16
Alexander Sirenko
L - 17
Sang Ho Lee
L - 18
Mitchell Hardenbrook
L - 19
Hamit Selim Karabekir
L - 20
Salahadin Abdi
Pier Paolo Menchetti
Master lecture
14:20 - 14:35
Intradiscal Therapies
Serdar Erdine
ML - 5
14:35 - 14.50
Identifying the pain generators in the lumbar spine: Bridging the Gap between Interventional Pain Management
and Traditional Spine Surgery
Antony Yeung
ML - 6
14:50 - 15:05
Endoscopic transforaminal discectomy for recurrent lumbar disc herniation
Thomas Hoogland
ML - 7
15:05 - 15:10
Discussion
15:10 - 15:30
Coffee Break
10
April 4, 2009
MAINHALL
Panel 3 - Intradiscal Therapies and Pain Management
Serdar Erdine
15:30 - 15:38
Cervical Facet Denervation
Serdar Erdine
L - 21
15:38 - 15:46
Paraspinal mapping in lumbar spinal stenosis
İlker Yağcı
L - 22
15:46 - 15.54
Interventional causalgia treatment "image guided"
Jalal Jalal Shokouhi
L - 23
15:54 - 16:02
Advances in the treatment of discogenic back pain
Salahadin Abdi
L - 24
16:02 - 16:10
Is Success Rate of Lumbar Epidural Steroid Injection Predictable?
16:10 - 16:18
Controversies surrounding epidural steroid injections
Salahadin Abdi
L - 25
16:18 - 16:26
Intraoperative alcohol injection for the treatment of a sacral spinal epidural hemangioma. Technical note.
Ahmet Menku
L - 26
16:26 - 16:34
Percutaneous automatic discectomy of cervical and lumbar spine
Konstantin Popsuishapka
L - 27
16:34 - 16: 42
Lumbar and Cervical Facet Joint Denervation with Laser
Sri Kantha
L - 28
16:42 - 16:50
Fluoroscopically guided transforaminal epidural steroid injections for lumbar spinal stenosis and lumbar
discogenic pain
Serdar Kabataş
L - 29
16:50 - 16:55
Discussion
Program Lectures
16:55 - 17:03
Minimal-invasive approach to the surgical treatment of lumbar spinal canal stenosis.
17:03 - 17:11
Minimal Invasive Surgery (Balloon Kyphoplasty plus Short posterior Instrumentation) for Acute Lumbar
Fractures.
17:11 - 17:19
Preliminary report on Percutaneous Transpediculr Screw instrumentation combined with Minimal ALIF approach
17:19 - 17:27
270 degrees fusion with TLIF technique: Tricks to avoid complications
17:27 - 17:35
Panagiotis Korovessis
Josip Buric
L - 30
Two years follow-up results of over 400 lumbar nucleoplasty cases
Kemal Yucesoy
L - 31
17:35 - 17:43
Adult stem cell treatment in spinal cord injury - technique and first clinical results
Nils Haberland
L - 32
17:43 - 17:51
Percutaneous Transsacral Lumbar Interbody Fusion (Axialif)
17:51 - 17:59
Percutaneous Interspinous Spacers in Degenerative Lumbar Spinal Stenosis. Indications and Results at more
than 1 year.
17:59 - 18:07
Diam device for low back pain in degenerative disc disease
Josip Buric
L - 33
11
April 4, 2009
18:07 - 18:15
Hyperosmolar Dextrose Solution Injection on Lumbosacral medial branch and Bilateral Sacroiliac Joint for
Remnant Buttock Pain after Vertebral Augmentation Procedures
18:15 - 18:20
Discussion
Chang Il Ju
L - 34
April 5, 2009
Tolgay Satana
Vladimir Radchenko
Program Lectures
08:00 - 08:08
In-Space (Percutaenous Intarspinous spacer) Treatment of Canal stenosis
Tariq Sinan
L -35
08:08 - 08:16
Endoscopic excision of synovial cyst of facet joint
08:16 - 08:24
Osteoid Osteoma of the Spine: Geiger Guided Resection. 5 cases from our department.
Arsen Shpigelman
L - 36
08:24 - 08:32
Cervical Laminoplasty as a Minimal Invasive Technique in Spondylotic Myelopathy
08:32 - 08:40
Is it really safe to perform Percutaneous Interventions for beginners around Neural Foramens?
08:40 - 08:48
Percutaneous iliosacral screw fixation in Sacral fractures and iliosacral seperation
08:48 - 08:56
Lumbar spine degenerative diseases - treatment using dynamic spinal stabilization systems
08:56 - 09:04
Interspinous fixation with coflex and diam implants in surgical treatment of lumbar spine degenerative disease
09:04 - 09:12
Interspinous Dynamic Spacer (COFLEX) insertion, our experience and surgical technique.
Arsen Shpigelman
L - 37
09:12 - 09:20
“Coflex” experience
Alexandre Levshin
L - 38
09:20 - 09:28
Flexis - System - A interspinous device study of 90 cases
09:28 - 09:36
High anterior cervical approach to the upper cervical spine: A Quantitative Anatomical and Morphometric
Evaluation
Mehmet Senoglu
L - 39
09:36 - 09:44
Syringomyelia: retrospective clinical analysis & review of the surgical treatment options
Bayram Cirak
L - 40
Nuket Gocmen Mas
L - 41
Figen Yağmur Aslan
L - 42
Figen Yağmur Aslan
L - 43
09:44 - 09:52
09:52 - 10:00
10:00 - 10:08
Significans of morphometric evaluation of lumbar vertebral bodies for corpectomy reconstruction: A stereological
study
A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Lumbar Disc
Herniation (Hole Approach) and video presantation
A Novel Technigue Of Microsurgical Approach Through Laminofacet Articular Junction For Foraminal Stenosis
And Spondylolisthesis (Hole Approach) And video presantation
10:08 - 10:15
Discussion
10:15 - 10:35
Coffee Break
12
April 5, 2009
Christof Birkenmaier
Kemal Yucesoy
Master lecture
10:35 - 10:50
The Lumbar Facet Sydrome
Vladimir Radchenko
ML - 8
10:50 - 11:05
Clinical results for lateral lumbar disc herniations with PELD,10-syringe discectomy and retroperitoneoscopy
Akira Dezawa
ML - 9
11:05 - 11:20
Lumbar dynamic segmental restabilization : the DYNESYSR experience 1999-2009
Hansjoerg Leu
ML - 10
11:20 - 11:35
Endoscopic Microdecompressive Cervical Discectomy and Foraminal Decompression over 2000 Patients
John Chiu
ML - 11
11:35 -11:45
Discussion
11:45 - 12:45
Debate Session - Round Table :
Tolgay Satana
Microscopic discectomy versus Percutaneous discectomy
Percutaneous discectomy versus Microscopic discectomy
Sebastian Ruetten, Sang Ho Lee, Antony Yeung, Fahir Özer, Hansjoerg Leu, Thomas Hoogland, Mehmet Zileli,
Stefan Hellinger, Jean Destandeu, John Chiu
12:45 - 13:30
Lunch
Yair Barzilay
Akira Dezawa
Program Lectures
13:30 - 13.38
Kyphoplasty- patient selection, advantages and pitfalls
13:38 - 13:46
Stand-Alone Kyphoplasty of the Thoracolumbar Junction – Potential for Severe Complications
13:46 - 13:54
Vesselplasty using SrHA New cement ( Osteo-G )
13.54 - 14:02
Percutaneous vertebroplasty of osteoporotic fractures of thoracal and lumbar spine with various compositive
materials
14:02 - 14:10
Percutaneous vertebroplasty
14:10 - 14:18
Complications of vertebroplasty
14:18 - 14.26
Design rationale and preliminary clinical results of NuNec, a PEEK-on-PEEK cervical arthroplasty system.
14:26 - 14:34
Long term results of lumbar restabilization using the B-Twin device for lumbar segmental insufficiency. Report
on 350 cases.
14:34 - 14:42
Total disc replacement compared to lumbar fusion. A randomised controlled trial with two-year follow up
14:42 - 14:50
Discussion
13
Christof Birkenmaier
L - 44
Bambang Darwono
L - 45
Andrey Popov
L - 46
Kemal Yucesoy
L - 47
A.R. Giltaij
L - 48
April 5, 2009
MAINHALL
Nils Haberland
Anthony Yeung
Master lectures
14:50 - 15:05
Percutaneous Laser Discectomy. State of the art. Long term results.
ML - 12
15:05 - 15:20
Robotic assisted spine surgery - a breakthrough or a surgical toy?
Yair Barzilay
ML - 13
15:20 - 15:35
Minimally Invasive Lateral Trans-Psoas Approach to Treating Thoracic and Lumbar Spinal Disease
Burak Özgür
ML - 14
15:35 - 15:40
Discussion
15:40 - 16:00
Coffee Break
Figen Yağmur Aslan
Daniel Gastambide
Panel 4- Less Invasiv
16:00 - 16:08
The Clinical Use of Unilateral Minimal Access TLIF surgery
16:08 - 16:16
Aperius™ Interspinous spacer vs open surgery in degenerative lumbar spinal stenosis.Retrospective
multicentric experience.
16:16 - 16:24
Minimally Invasive Trans-Sacral Approach to the Lumbo-Sacral Spine
16:24 - 16:32
Endescopy and percutaneous arthrodesis in relapsed discl hernias
16:32 - 16:40
Influence of facet joints asymmetry on the development of lateral recess stenosis
16:40 - 16:48
16:48 - 16:56
Tubular Microsurgery for Lumbar Discectomies and Laminectomies in Obese Patients: Operative Results and
Outcome
Conventional posterior lumbar interbody fusion Versus Mini-open posterior lumbar interbody fusion Using the
New Percutaneously Inserted Spinal transpedicular screwing System
16:56 - 17:04
Discussion
17:04 - 17:15
Closing Lecture
14
L - 49
Burak Özgür
L - 50
Daniel Gastambide
L - 51
Artem Skidanov
L - 52
Chang Il Ju
L - 53
April 5, 2009
08:30 - 10:30
POSTER DISCUSSION SESSION
Percutaneous vertebroplasty(pvp): an effective and economically viable perspective from a developing country
for vertebral collapse fractures(vcf's) of various etiologies
Screw reinforcing Percutaneous Short Segment Transpedicular Screwing for Unstable Thoracolumbar Burst
Fractures
Sudeep Jain
P-1
Chang Il Ju
P-2
Chang Il Ju
P-3
Far Lateral Extraforaminal Synovial Cyst Not Connecting Facet Joint
Ahmet Menku
P-4
Non-traumatic acute monoplegia associated with intradural cervical disc herniation: a case report
Ahmet Menku
P-5
Nikolaos Syrmos
P-6
Sudeep Jain
P-7
Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis
Fractures of the thoracolumbar spine
Selective nerve root injections in lumbar radiculopathy: A prospective clinical outcome study as a minimally
invasive alternative to surgery. A five year followup
15
Chairpersons
16
Salahadin Abdi, MD, PhD
Salahadin Abdi, MD, PhD, is currently a Professor of Clinical Anesthesiology and
Chief of Pain Medicine at the University of Miami Pain Center. He joined his
current position after serving as the Director of the Massachusetts General
Hospital, Harvard Pain Center. Prior to that he served as the Director of the
Fellowship Program in Pain Medicine at MGH, Harvard.
Dr. Abdi obtained his degrees from the University of Muenster in Germany. He
completed his residencies in Anesthesiology both at the University of Muenster
Medical Center in Germany and at the Massachusetts General Hospital, Harvard
Medical School, Boston, MA. Dr. Abdi also completed his fellowship at the
Shriners Burns Institute and University of Texas Medical Branch in Galveston,
TX.
Dr. Abdi has been an active member in various national and international medical
societies including ASA, APS, ASIPP, IASP, ASRA etc.. He was a Section Editor
for the journal of “Current Opinion in Anaesthesiology - Pain Medicine” and has
been appointed to the editorial board of the journal of minimally invasive surgery
and Pain Physician (official journal of American Society of Interventional Pain
Physicians) where he is currently serving as Associate Editor. Dr. Abdi has
attended several National and International meetings as an invited Speaker.
Furthermore, Dr. Abdi has authored and coauthored over 120 peer-reviewed
articles, book chapters and the popular handbook, “The Massachusetts General
Hospital Handbook of Pain Management”. He is a reviewer for Anesthesiology,
Current Opinion in Anesthesiology, Emerging Drugs, Pain Physician, Clinical
Journal of Pain and Spine to name a few. Dr.Abdi’s current areas of research
interest include: basic science and clinical investigations in the areas of back
pain, neuropathic pain, and cancer pain. Finally, Dr. Abdi has been listed as
“Florida Super Doctors” in 2008 and 2009.
17
Dr. Figen Yağmur Aslan
Education
Publications
Attended
Congresses
Attended
Courses
1985- 1991:Akdeniz University (Antalya, Türkiye);General practitioner \ School of Medicine
1993 - 2001:Akdeniz University (Antalya, Türkiye);Medical Doctor \ School of Medicine,
Specialist Training Programme of Neurosurgery
2001- 2008:: General Hospital
Antalya, Türkiye; Neurosurgeon \ Department of
Neurosurgery
*“Traumatic Cerebrospinal Liquid Rhionere”, Journal of Turkish Neurosurgery, April, 1995.
“Post Operative Angiography in intracranialAneurysm”, Journal of Turkish Neurosurgery,
May,2000.
*“A Case Report on Cysthydatic in The Fifth Cervical Vertebrae”, The 14th Scientific
Congress of NeurosurgicalSociety, Antalya, Türkiye, May, 2000.
*“The Effect of Screw Malposition in The Late Period of Stabilization”, The 15th Scientific
CongressofNeurosurgicalSociety,Antalya,Türkiye,May,2001. Acta Neurochir (Wien). 2003
Nov;145(11):949-54;
discussion
954-5.
*“The Treatment of Toracolomber Traumas, The Value of Transpedicular Screw Fixation”,
M.D. Thesis, Akdeniz University, SchoolofMedicine, Department of Neurosurgery, June,
2001.
*Transarticular medial approach with partial facetectomy for lomber disc hernia and
forforaminalstenosis:andspondylolisthesis.
-The 17th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2003. (Disc
Hernia).
-The 18th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2004.
(Foraminalstenosis)
-The 19th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2005. (Disc
hernia,foraminalstenosis).
*Transarticular medial approach with partial facetectomy for lomber disc hernia and for
foraminal foraminal stenosis:and spondylolisthesis, Euro Spine Congress, İstanbul, Türkiye,
April, 2006.
*A Novel
Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Lumbar
Disc Herniation (Hole Approach),The 4th İnternational World Spine Congress, İstanbul,
Türkiye, June, 2007. *A Novel Technique Of Microsurgical Approach Through Laminofacet
Articular Junction For Foraminal Stenosis, And Spondylolisthesis (Hole Approach ) ,The 4th
İnternational World Spine Congress, İstanbul, Türkiye, June, 2007.
*A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For
Foraminal Stenosis, And Spondylolisthesis (Hole Approach ) ,The 10th international Spine
Congress collobration with World Spine Society, Alexandre, Egypt, March, 2008
(İnvitedSpeaker).
*ANovel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For
Lumbar Disc Herniation (Hole Approach) ‘’Video Presentation ‘’ The 1th İnternational
African Neurological Society, Egypt Neurosurgical Society, Egypt Spine Society, Sharm ElShake, Egypt, February, 2009 (İnvitedSpeaker).
*A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For
Foraminal Stenosis, And Spondylolisthesis (Hole Approach ) ‘’Video Presentation’’ ,The 1th
İnternational African Neurological Society, Egypt Neurosurgical Society, Egypt Spine
Society, Sharm El-Shake, Egypt, February,2009, ( İnvited Speaker).
*The9th Scientific Congress of Neurosurgical Society, İzmir, Türkiye, April 9-14, 1995.
*The11th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May 9-11, 1997.
*The12th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May 15-19, 1998.
*The13th Scientific Congress of Neurosurgical Society, İstanbul, Türkiye, May 17-19, 1999.
The*14thScientificCongressofNeurosurgicalSociety,Antalya,Türkiye,May17-21,2000.
*The15thScientificCongressofneurosurgicalSociety,Antalya,Türkiye,May22-26,2001.
*Symposium of Lomber Degenerative Disc Disease, Antalya, Türkiye, October 6-7, 2000.
*The 17th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2003.
*8th Turkish spinal surgery groups meeting,Antalya,Türkiye,November,2008
-Workshop on Spinal Surgery, Ege University, School of Medicine, İzmir, Türkiye,
November
25-26,2000.
-Spinal Surgery ( as a fellow) Ege University, School of Medicine, İzmir, Turkey, at six
18
Yair Barzilay, MD
Date of Birth:
March 20, 1968
Place of Birth:
Jerusalem, Israel
Current Address: 90/5 Hachayil St. Jerusalem, 97891, Israel
Cell phone: + (972) 508-573279
E-mail:
[email protected]
Martial Status:
Married + 3 Children
Current post: Consultant Orthopaedic and Spine surgeon, Spine unit, Department of
Orthopaedic Surgery, Hadassah Hebrew-University Medical Center, Jerusalem,
Israel
Selected Publications
Book Chapters: Y. Barzilay, L. Kaplan, M. Liebergall. Miniature robotic guidance for
spine surgery. In Medical Robots; Vanja Bozociv(ed.) pp 219-232. Advanced Robotic
Systems International & Pro Verlag 2008.
Journal Publications (Peer Reviewed)
Bhatia CK, Barzilay Y, Pollock R, Krishna M. Cement Leakage in percutaneous
vertebroplasty; effect of pre-injection gelfoam embolization – Spine. 31(8):915-919,
April 15, 2006 4;4
Y. Barzilay, M. Liebergall, A. Fridlander, N. Knoller. Miniature robotic guidance for
spine surgery – Introduction of a novel system and analysis of challenges
encountered during the clinical development phase in two spine centers. IJMRCAS
Volume 2, Issue 2, June 2006, Pages: 146-153 3;2
L Kaplan, Y Bronstein, Y Barzilay, A Hasharoni, JA Finkelstein. Canal expansive
laminoplasty in the management of cervical spondylotic myelopathy. IMAJ 2006: 8:
August: 548-552. 0
Aharony S, Milgrom C, Wolf T, Barzilay Y, Applbaum YH, Schindel Y, Finestone A,
Liram N. Magnetic resonance imaging showed no signs of overuse or permanent
injury to the lumbar sacral spine during a Special Forces training course. Spine J.
2008 Jul-Aug;8(4):578-83. Epub 2007 Mar 2. 0
Barzilay Y, Kaplan L, Liebergall M. Robotic assisted spine surgery – a breakthrough
or a surgical toy? Int. J. Med Robot. 2008 Sep;4(3):195-6. 0
Ongoing research projects
* Objective assessment of outcome in various medical conditions using a new
objective tool
* Protection of spinal cord injury in the rabbit model
* Miniature robotics and navigation systems
* New non operative treatment of non specific low back pain
19
Christof Birkvenmaier, MD
Department of Orthopedic Surgery
Grosshadern Medical Center
University of Munich
Marchioninistr. 15
D - 81377 Munich
Ph.: +49-89-7095 0
Fax: +49-89-7095 5814
[email protected]
CLINICAL POSITIONS
2006 – cont.
Faculty,
Dept.
of
Orthopedic
Surgery,
Großhadern
Medical
Center,
University
Head of Spine Team, Head of Osteology Clinics
2004 – 2006
Junior Faculty, Dept. of Orthopedic Surgery, Großhadern Medical Center, University of Munich
2001 - 2004
Resident, Dept. of Orthopedic Surgery, Großhadern Medical Center, University of Munich
1999 - 2001
Resident, Dept. of Orthopedic Surgery, Medical Center rechts der Isar, Technical University Munich
1995 - 1998
Resident, Dept. of Surgery, Medical Center rechts der Isar, Technical University Munich
1993 - 1995
Resident, Dept. of Surgery, University of California, San Francisco, CA, USA
1989 - 1990
House Officer, Departments of Orthopedics and General Surgery, Royal Free Hospital, London, UK
of
Munich
RESEARCH
2006 - ongoing
Study of Epidural Pain Medications in a Fibroblast Cell Culture Modell, B. Braun Foundation research grant
2006 - ongoing
Characterization of Cryolesions Used in Interventional Pain Therapy
2004 - 2006
Randomized Placebo-Controlled Multicenter Trial on the Efficacy of the Racz Epidural Catheter Therapy
2002 - 2006
Prospective Clinical Trial on Percutaneous Cryodenervation of Lumbar Facet Joints
1990 - 1993
Postdoctoral Research Fellowship at the Department of Surgery, University of California, San Francisco, CA, USA.
Deutsche Forschungsgemeinschaft postdoctoral grant.
Topic: ”Immunological Consequences of Trauma”
EDUCATION
1982 - 1989
MD at the University of the Saarland, Homburg, Germany
INTERNATIONAL ELECTIVES
1986, Aug. - Oct. Pediatrics, University Department of Child Health at Mater Children's Hospital, University of Queensland, Brisbane,
Australia
1988, Feb. - May General Surgery and Orthopedics, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
PROFESSIONAL LICENSES
2008, Oktober
Orthopedic Traumatology Board Certfication – M. Board of Bavaria
2004, February
Orthopedic Board Certification - Medical Board of Bavaria
2000, May
Surgical Board Certification - Medical Board of Bavaria
1994, October
California Medical License
1992
German Medical License
1993, June
FLEX (Score 84)
1989, January
FMGEMS
PROFESSIONAL SOCIETIES
AOSPINE
Member since 2005
BVO
Berufsverband der Fachärzte für Orthopädie
DGOOC Deutsche Gesellschaft für Orthopädie & Orthopädische Chirurgie
ISMISS International Society for Minimal Intervention in Spinal Surgery (ass. with SICOT)
FELLOWSHIPS
2009
designated AO Spine Fellow to the Centre For Spinal Studies & Surgery, University Hospital, Queen’s Medical Centre,
Nottingham, UK
AO TRAINING
2004
Interactive Spine Course I, Davos
2003
Advances in Operative Fracture Treatment, Davos
2002
Principles of Operative Fracture Treatment, Davos
TEACHING CREDENTIALS
2005 – 2008
Musculoskeletal Tutor for the revised Medical Curriculum at the University of Munich (MECUM)
2002 – 2004
Tutor of the Musculoskeletal Course, Munich – Harvard International Alliance for Medical Education
LANGUAGE SKILLS
German mother tongue
English excellent (speech & writing)
French good (speech & writing)
Portuguese
good (speech)
Spanish basics (speech)
20
John Chiu, MD
Medical Director, California Center for Minimally Invasive Spinal Surgery and California Spine Institute Medical Center. Dr.
John C. Chiu is a pioneer in the field of endoscopic spinal surgery. He is the President of California Spine Institute Medical
Center and the founding chairman of American Academy of Minimally Invasive Spinal Surgery and Medicine
(AAMISMS)._ With extensive experience in minimally invasive spine surgery (MISS), he is actively involved in MISS
clinical research, development and education. He received a D.Sc. degree in surgical research on Tissue Modulation
Technology and was appointed a Professor of Minimally
Invasive Spinal Surgery in Neurosurgery, and subsequently as the Provost of the American International University and
President, ISMISS/SICOT (International Society of Minimally Invasive Spinal Surgery) in January 2007.
Dr. Chiu is an adjunct Professor in Spine Surgery, Orthopaedic Surgery Dept. Faculty of Medicine, both at Ain Shams
University, Cairo, Egypt, and at Hunan Medical University of TCM, and a Clinical Professor, The First Affiliated Hospital of
Hunan University of TCM, Changsha, Hunan, China.
Dr. Chiu was involved in micro vascular neurosurgery and microspine surgery, before dedicating his practice to the
advancement of minimally invasive spinal surgery and endoscopic spine surgery._ He has been involved in the development
of robotic surgery, telesurgery, OR of the Future, tissue modulation technology including laser thermodiskoplasty, and the
use of radiofrequency and bipolar technology. He is an active advocate of redefining the algorhythm for the treatment of
degenerative spinal disorders and spinal segmental motion preservation with MISS. He has served as a spinal consultant to
eight companies related to MISS products and digital technology. He also served on a spinal advisory committee of one of
the largest health care insurance companies, and as a special advisor / consultant to a State Department of Labor and Work
Force Development. Recently he conducted the first interactive live Webcast on endoscopic MISS, with nearly 1,000 global
participants and viewed by 3,000, and participated in a global tele-video web conference involving 3 continents (UCLA,
USA, North America; Bordeaux, France, Europe; Korea, Asia).
He is the Editor in Chief for “The Internet Journal of Minimally Invasive Spinal Technology” and is a co-editor of the
textbook “Practice of Minimally Invasive Spinal Technique” (2000 and 2005 editions) and on the editorial board of the
journals “Surgical Technology International” and the “Journal of Minimally Invasive Spine Technique,”_Dr. Chiu has
authored numerous articles in peer review journal and 45 textbook chapters and other publications on MISS and related
topics._ He is a recipient of various honors and awards from professional societies, medical universities, and governmental
entities, globally and in the US.
Dr. Chiu has lectured and performed spine surgeries throughout the world. He has held visiting professorships at universities
worldwide and has served as course director for numerous spine surgery seminars and workshops both in the United States
and abroad._ He has written or presented over 800 papers (peer reviewed) at national and international scientific conferences,
including North American Spine Society, American Academy of Neurological Surgeons, Congress of Neurological Surgeons,
World Spine, World Congress of Neurosurgery, AAMISMS, ISMISS/SICOT and other meetings. He also has demonstrated
and performed numerous live endoscopic spine surgeries at major medical centers and university hospitals around the
world._ His patients have included international VIP’s, leading medical professionals (neurosurgeons, spine surgeons, and
others), top government officials, generals and even a head of state.
He has been invited as a lecturer,_visiting professor, chairman of various conferences and keynote speaker on
endoscopic MISS in numerous university medical centers, and in numerous conferences in countries including China, Hong
Kong, India, Iran, Korea, Singapore, Taiwan, England, France, Germany, Greece, Italy, Luxembourg, Spain, Switzerland,
Russia, Ukraine, Israel, Jordan, the Kingdom of Saudi Arabia, Marrakesh, Morocco, United Arab Emirates, Egypt, Brazil,
Colombia, Mexico, Venezuela, Uruguay and others._ Internationally, Dr. Chiu also has served as the honorary President of
the Mexican Minimally Invasive Spine Surgery and Orthopedic and Trauma Society, Cochairman of the 1st Chinese
International Minimally Invasive Spine Surgery Congress, MISS China, 2007 and others. Born in Fukien China, he received
his medical degree from Baylor University College of Medicine and Neurosurgical training at the Mayo School of
Medicine._ Further training and fellowship were undertaken at the State University of New York, University of Zurich and
the University of Lund in Sweden. Dr. Chiu is certified by the American Board of Neurological Surgery. Has served as an
advisor/consultant for American Medical Foundation for Peer Review and Education for major teaching hospitals and
medical staff to establish proper peer review and credentialing process. His outside interests include playing the Chinese
classical musical instrument, Guzheng (Zither) and practice of martial
arts and its philosophy, as a grand master in kung fu, ninjitsu, and jujitsu. He participated in the International Martial Arts
Tournament, St. Petersburg, Russia and is the recipient of the Martial Arts Lifetime Achievement Award, and the Martial
Arts Pioneer Award as well as other awards, and an invited speaker for the Humanitarian Award in Martial Arts, U.S.A.
International Black Belt Hall of Fame.
21
Jean Destandau
Address : 145 Rue de la Pelouse de Douet , 33000 , Bordeaux , France.
Tel. : (33) 0556515160
Fax : (33) 0556986710
e-mail : [email protected]
* Date of Birth : August 23, 1953
* Family Status : married with two children
EDUCATION
* 1970 : Passed Baccalaureat Examination
* 1970-72 : Preparatory classes for competitive examination for Special Engineering University
* 1972-1979 : Medical School of the University of Bordeaux, Bordeaux 2, Rue Leo Saignat, 33000,
Bordeaux.
Passed final examination to become Resident.
* 1979-1983 : Resident with orientation towards neurosurgery and anatomy at Bordeaux University
Hospital, Bordeaux 2, Rue Leo Saignat, 33000, Bordeaux.
* 1981 : Certification in General Anatomy (Medical School of University of Bordeaux - Prof. Videau).`
* 1982 : Certification in Neuro-Anatomy (Medical School of University of Montpellier - Prof. J. Bossy).
* 1982 : Masters in Human Biology and Anatomy, Bordeaux 2.
* 1985 : Diploma in Research in Human Biology and Anatomy (Medical School of University of
Montpellier - Prof. Rabischong).
*1985 : Certification in Neurosurgery
PROFESSIONAL ACTIVITY
- 1980-1983 : University Instructor in Anatomy, Medical School of University of Bordeaux.
- 1983-1987 : Assistant Professor in Anatomy
Neurosurgeon at Bordeaux University Hospital
- 1987-Present : Neurosurgeon in private practice en Bordeaux.
My special interest is the surgery of brain tumors and disc herniations and the reduction of operative
trauma in their treatment.
In this objective, I have developed an endoscopic tehchnique, and its necessary material, for the
surgery of lumbar disc prolapses.
Since 1993, I have operated on over 5000 patients with a rate of cure superior to 90% and a postoperatory period of convalescence greatly inferior to the normal.
By 1998, the success of this treatment aroused a certain interest in the medical community and the
Storz Company undertook the production and the comercialization of the material as well as the
publication and spreading of the technique. As a result, I have been invited to demonstrate this
procedure in many countries including the United States, China, Egypt and Korea.
PROFESSIONAL ASSOCIATIONS
- Member of “la Société Française de Neurochirurgie”.
- Member of “la Société de Neurochirurgie de Langue Francaise”
- Member of “la Société Francophone de Neurochirurgie du Rachis”
- Member of the American Academy of Minimally Invasive Spinal Medecine and Surgery
Extra -curricular activities
- Skiing
- Golf
- Theatre
22
Serdar Erdine, MD, FIPP
Personal
Born in Turkey; 19.10.1954
Personal Address: Department of Algology, Medical Faculty of Istanbul,
34390, Capa Klinikleri, Istanbul, Turkey
Email; [email protected]
Professional
- Graduated from Cerrahpasa Medical Faculty of Istanbul University in 1978
- Completed residency in the Department of Anesthesiology and Reanimation of
Medical
Faculty of Istanbul, Istanbul University in 1982
- Associate Professor in Anesthesiology in 1986
- Professor of Anesthesiology and Algology in 1991
- Professor and Founder and Chairman of Department of Algology since 1990
Scientific
- Member of IASP since 1981
- Founder and President of Turkish Society of Algology
- Founder and Former President of Turkish Society of Regional Anesthesia
- Former Turkish Representative in European Society of Regional Anesthesia
- Former Member of the executive Board of Neuromodulation Society
- Treasurer of EFIC ,1996-1999
- Honorary Secretary of EFIC, 1999-2002
- President Elect of EFIC, 2002-2005
- President of EFIC, 2005-2008
- Founding member of World Institute of Pain-WIP,1994
- General Secretary of WIP,1994-1999
- Vice President of WIP,1999-2002
- President Elect of WIP, 2005-2008
- President of WIP ,2008-2011
- Chair of Board of Examination – WIP,2005-2008
- Member of the WHO Advisory Expert Panel on Drug Dependence.2007-2011
- Member of the editorial Board of European Journal of Pain
- Member of the editorial board of Pain Practice
- Member of the editorial board of Pain Physician
- Editor of Turkish Journal of Pain-cited in index medicus
- Awarded as the Young leader in medicine/Turkish Jaysees,1991
- Invited speaker in 120 lectures on international level
- Invited speaker in 200 lectures on national level
- Author of 25 books in Turkish
- Editor-co editor of 7 books in English
- Author of 200 articles in international or national level mainly on interventional pain
management.
- Organizer of 15 National Congresses on Pain Medicine in Turkey
- Organizer of World Congress of World Society of Pain Clinicians ,Đstanbul,1996
- Organizer of the Annual Congress of European Society of Regional Anesthesia ,
Đstanbul,1999
- Organizer of 3rd World Congress of World Institute of Pain, Đstanbul,2001
- Organizer of the Pain in Europe V, triennial Congress of EFIC, Đstanbul,2006
23
Daniel Gastambide, MD
Born: September 7th, 1942 (France)
Nationality: French
Medical University of Paris: 1960 -1967
Internship Paris: 1969-1973
Residency Paris (Chef de Clinique à la Faculté de Médecine de Paris, Assistant
des Hôpitaux de Paris) : 1973-1975
Medical Doctor : 1974
Orthopedic Surgeon : 1975
Orthopaedic Department Chief :
Nemours 1975-1978
Blois : 1978-1991
Private Practice in Paris since 1992: spine surgery 95%
Founder Member of the International Group for Study of Intervertebral
Approaches (GIEDA INTER RACHIS: Groupe International d’Etude Des Abords
INTERvertébraux du RACHIS) and took part in the organization of its 21 annual
congresses in Europe (Blois 1988, Brussels 1989, Bordeaux 1990, Paris 1991 to
2007, Brussels 2008), and of 4 workshops about endoscopic techniques.
President of this group in 2002
Delegate to the internet site: www.gieda.com, treasurer of the GIEDA since 2007
Multiple presentations about endoscopic techniques for treatment of lumbar and
cervical hernias, and with the use of laser Ho-YAG.
Member of the ISMISS since 1990, delegate for France since 2008
Member of SOFCOT since 1977, SICOT since 1989, IITS since 1993, NASS since
1999, IMLAS since 2004
24
Nils Haberland, MD
Date of birth:
Place of birth:
Nationality:
Marital Status:
School education:
16.10.1957
Luckau
German
Married
1964 – 1972 Elementary School / Upper School
1972 – 1976 Grammar School
Practical training:
01.09.1976 – 27.10.1976 male nurse at a hospital in Neuenhagen near by Berlin
Military service:
1979 – 1979 in the health service
University:
1979 – 1985 Study of human medicine at the Humboldt-University in Berlin, receiving a
university-degree rated “good”
Diploma:
21.05.1985 Receiving a diploma rated “good” at the Humboldt-University in Berlin
Qualification:
01.02.1986 in Berlin
Promotion:
02.02.1987 Promotion rated “cum laude” at the Humboldt-University in Berlin
Vocational experience: 01.02.1986 beginning of occupation as an assistant doctor in the field of Neurosurgery
at the medical academy in Erfurt.
01.01.1990 recognition of specialist in Neurosurgery
01.01.1994 – 14.5.1994 assistant medical director at the neurosurgical hospital in
Erfurt
15.05.1994 – 28.02.2000 assistant medical director at the neurosurgical hospital of the
Friedrich-Schiller-University in Jena
01.03.2000 beginning of occupation as locum of the senior consultant at the Trauma &
Accident Center in Frankfurt
01.09.2004 Chief of Neurosurgical Department, Trauma & Accident Center (BGU
Hospital)Frankfurt am Main
01.10.2007 Chairman of the International Spine Center Cairo and Consultant
Neurosurgeon of the XCell-Center Düsseldorf, Germany
Member of the tumor-center in Erfurt since 1992, member of the German society of neurosurgery since 1996,
member of German society of
spine since 1997
Prof.Dr.Dr.h.c. Nils Haberland
Chairman
International Spine Center Cairo – ISCC
EgyptAir Hospital
www.egyptairhospital.com
[email protected]
Tel.: 0020108745692
Fax: 0020227576895
Consultant Neurosurgeon
XCell-Center
Düsseldorf
GERMANY
www.xcell-center.com
25
Stefan Hellinger, MD
Geb. 16.10.1962
German
Present position:
Klinik
Spec.:
Prof. Address:
Orthopaedic surgeon in privat practice and as consultant in Isar
Spine and jointsurgery, Rheumatology, Pain therapy
Windenmacherstr.2
80333 München
Prof. Qualifications: 1993 MD for medicine Universität Erlangen
Postgrad. Qualifications:
01/1994 Intern at surgical departement
06/1994
Kreiskrankenhaus Auerbach.
07/.1994 Resident surgical department des StädtischenKrankenhaus
Rothenburg o.d.T.
07/1995 Resident in orthopaedic practice
09/1995
in Munich
10/1995Resident in der Orthopädischen Abteilung des
03/2000
Kreiskrankenhaus Rheinfelden
10/1999
certification as orthopaedic surgeon
04/2000Staff surgeon Orthopädischen Abteilung
12/2000
des Dreifaltigkeitshospital Lippstadt
02/2001
Degree for special orthopaedic surgery
01/2001different Fellowships,
06/2001
spine fellow Zurich, Schulthess Clinic Prof. Grob
since07/2001
Orthopaedic and spine surgeon in own practice and as
consultant for the Isar clinic munich
sprec. on spine surgery, development of different minimal
invasive procedures, spinal endoscopy
Director of Institute for clinical research, consulting and expertise
26
Sang Ho Lee, MD, PhD
Chairman, Wooridul Spine Hospital, Seoul, Korea
Education
1968-1975 : Pusan National University College of Medicine, MD
1975-1980 : Intern & Resident, Dept of Neurosurgery, National medical center, Seoul Korea
1980-1981 : Korea, Army Major & Head of Neurosurgery department in 103 field hospital,
1976-1985 : Yonsei University College of Medicine, Master and PhD
1985-1986 : Clinical fellow, UFR Biomedicale Laboratoire D'anatomie, Academie de Paris
Universite Rene Descartes Paris France
Training Experience (Spine Training Courses)
1988 : School of Medicine, University of California, San Francisco, U.S.A.
1989 : School of Medicine, University of Washington, Seattle, U.S.A.
1990 : Uniformed Service, National Institute of Health(NIH)
1992 : Arthroscopic Microdiscectomy, The University of Pennsylvania School of Medicine,
Berwyn, Pennsylvania, U.S.A.
1993 : Laser Medical Institute, Houston, Texas, U.S.A.
1995 : Medical School, University of Zurich, Zurich, Switzerland
1995 : Pitié-Salpêtrière, Universite Pierre et Marie Curie : Paris 6
Current Position
Clinical Professor, Yonsei University College of Medicine, Dept. of Anatomy
Clinical Professor, Dong-A University College of Medicine, Dept. of Neurosurgery
Clinical Professor, Catholic University College of Medicine, Dept. of Neurosurgery
President, World Congress of Minimally Invasive Spinal Surgery & Techniques (WCMMIST)
President-Elect, Intl. Society for Minimal Intervention in Spinal Surgery (ISMISS)
President, International Musculoskeletal Laser-Society (IMLAS)
President, Asian Academy of Minimally Invasive Spinal Surgery (AAMISS)
Honorary President, Korean Musculoskeletal Laser and Radiofrequency Society (KOMULARS)
Executive Chairman, Korean Society for Laser Medicine and Surgery (KSLMS)
President, International Intradiscal Therapy Society (IITS)
Past President, Korean Neurosurgical Society Seoul, Gyunggi, Inchon Branch
International member, American Association of Neurological Surgeons (AANS)
Active member, Congress of Neurological Surgeons (CNS)
Active member, North American Spine Society (NASS)
Chairman, Wooridul Spine Hospital, Korea
President, Wooridul Spine Health, Seoul Korea
27
Hansjoerg Leu, MD, PD
Date of birth
Studies
1979
1993
January 5, 1954, Zurich/Switzerland
Swiss Federal Examination, Medical Degree
Habilitation/Venia Legendi as Private Docent
for Orthop. Surgery, Med. Faculty, Zurich University
Professional Activities
1980/1982
Department for General Surgery and Traumatology,
Aargovian Cantonal Hospital, Aarau/Switzerland.
Chairman: Prof.Dr.F.Deucher
1982/1985
Sct. for Orthopaedics, Thurgovian Cant. Hospital,
Frauenfeld/Switzerland. Chief: Dr.U.Romer
1985/1995
Department for Orthopaedic Surgery Balgrist, Medical
School, University of Zurich/Switzerland
Chairman : Prof. Dr. A.Schreiber
1988
Speciality Degree in Orthopaedic Surgery FMH
1989 - 1995
Clinical Lecturer and Senior Clinician, Balgrist Univ.Clinic
since 1993
Private Docent in Orthopaedics with instructional duties
1994-2000
PD-Representative for Orthopaedics, Faculty Group of
Surgical Disciplines, University of Zurich/Switzerland
1992 - 31.3.1995
Senior Surgeon for Spinal Surgery, Balgrist Univ. Clinic Zurich
4.1995 – 10.2004
Consultant Orthop. Surgeon, Neumunster Hospital Zurich
since 10/2004
Consultant Orthopaedic Spine Surgeon, Bethania Clinicum
Bethania Spine Base, Zurich, Switzerland
Grants & merits
1991
1992
2002
ASG-Fellowship of the Austro/Swiss/German Orthopaedic
Societies (ASG-Travelling Studies GB/USA 1992)
Georg-Schmorl Award by the German Society for Spine
Research, Frankfurt/Germany
Doctor honoris causa, Sytenko Institute, Medical Faculty,
University of Charkov, Ukraine
Memberships
numerous memberships in national and international spine Societies
- International Society for Minimal Intervention in Spinal Surgery (ISMISS, since 1990)
President in charge for 2008/2011
Family
married
since
1985
to
Jutta-Maria,
born
Überle,
(Christoph 1986, Martin 1988, Isabelle 1990)
28
3
children
Pier Paolo Menchetti, MD, FRCS
Pier Paolo Maria Menchetti, M.D., FRCS (US)
Born in Neaples (Italy) on 9th April 1968
Residency: Florence (Italy) - 50132, J. Nardi 15
Orthopedic Surgeon
Professor Florence University - Italy
Professor Spine Surgery Unit, La Sapienza University, Rome, Italy
Professor Spine Surgery Unit,Palermo University, Italy
Fellow Royal College of Physicians and Surgeons of United States of America
Fellow American Board Minimally Invasive Spine Medicine and Surgery
Member American Academy Minimally Invasive Spine Medicine and Surgery (AAMISMS)
ISLASS (International Society Laser Assisted Spine Surgery) President
Office:
Florence - Cherubini Clinic
Rome - Rome American Hospital
Milan - Milan City Clinic
29
Burak Özgür, MD.
Director of Minimally Invasive Spine Surgery
Assistant Professor of Neurosurgery
Cedars-Sinai Medical Center
Department of Neuro
surgery
8631 W. Third Street, Suite 800E
Los Angeles, CA. 90048
Office #: (310) 423-7900
FAX #: (310) 423-0810
[email protected]
_____________________________________________________________________________
EMPLOYMENT
Cedars-Sinai Medical Center
Department of Neurosurgery
Attending (Faculty) Neurosurgeon
October 2007- present
University of California, Irvine Medical Center
Department of Neurological Surgery
Assistant Professor of Clinical Neurosurgery
Director of Spinal Neurosurgery
Co-Director of the Multidisciplinary Spine Program
July 2006– October 2007
EDUCATION
University of California, San Diego Me
dical Center
NeurosurgeryChief Resident
June 2005– June 2006
University of California, San Diego Medical Center
Neurosurgery Spine Fellowship
July 2004– December 2004: Neurosurgery Spine (Dr. LF Marshall, Dr. WR Taylor)
January 2005– June 2005: Orth
opedic Spine (Dr. SR Garfin, Dr. C. Kim)
University of California, San Diego Medical Center
General Surgery Internship Neurosurgery
&
Residency
June1999– June 2005
University of Vermont
College of Medicine, Class of 1999
MD degree awarded May 1999
University of California, Irvine
Biological Sciences major
Bachelor of Science degree 1994
30
Vladimir Radchenko
Date of birth 1956, Ukraine
Head od Department of Spine surgery,
Vice-Director of Sytenko Institute of Spine and Joint Pathology,Kharkov,Ukraine
Professor of Orthopaedicsdan
Traumathology,
Professor of Academia of Postgraduate
Education,Kharkov
Merited Statesman of Science and Technique
Presidents Award of Science and Technique
Parlaments Award
Work Experience
Since 1979– General Surgeon in Dneepropetrovsk clinic
1980-1984Department of Orthopaedics and Traumatology, Emergency Hospital
Dneeprodzerginsk
Since 1984- Sytenko Institute of Spine and Joint Pathology
– Department of
Spine Surgery
Spine Society
Ukrainian Society of Orthopaedics and Traumatology (vice
-president)
International Society of Minimal Intervention in Spinal Surgery
ISMISS (vice-president,
European Branch secretary);
Society of Orthopedics and Traumatology
SICOT (since 1994)
AO Spine International
31
Prof.Dr. Kayıhan ŞAHİNOĞLU
32
Tolgay Satana, MD.
He was born in Ankara/Turkey in October 14, 1968. He completed primary,
intermediate and high school education in Ankara. He received MD degree from the
University of Ankara Faculty of Medicine in 1991. Dr. Satana had worked in
Tuzluca/Igdir as a Medical Practitioner from 1991 to 1992 . He completed the
residency in Orthopaedic Surgery and Traumatology at University of Gazi, Faculty of
Medicine Ankara/Turkey in 1997.
He was appointed to Ankara Etimesgut Hospital as an Orthopedic Surgeon in 1997.
Dr Satana completed a military service obligation in Maresal Cakmak Military
Hospital, Erzurum in 1998. After the military service he went to USA and_ attended
postgraduate education as an visitor professor in Pediatric spine surgery in University
of Michigan in 2000. He came back to Turkey at the end of 2000 and be appointed to
Gaziantep Hospital.
He worked as an Orthopaedic surgeon about a year Gaziantep Hospital and resigned
in 2002. He set up the Orthopaedic Clinic and worked in Gaziantep American
Hospital in 2002. In 2003 He appointed to Ankara Research Hospital and Middle East
University Medical Center and worked about five year as an Orthopaedic and trauma
surgeon.
He is minimally invasive spine surgery performer since 2002 and member of IMLAS,_
AAMISS and ISLAS. He observed and be trained by most of MISS surgeon around
world short time period. He is national representative of Ismiss and AAMISS since
2004 and WALA.
Now on He is working _Acibadem Beylikduzu Medical Center Istanbul_ since 2008
as a full-time staff. He is aiming to create miss conducted surgeon society in Turkey
He is married and has a daugther and a son.
33
Anthony Yeung, MD.
Orthopedic and Minimally Invasive Endoscopic Spine Surgeon
Desert Institute for
Spine Care
Phoenix, Arizona
Voluntary Associate Clinical Professor
University of California San Diego School of Medicine
Department of Orthopedi
cs
Dr Yeung is a board certified orthopedic spine surgeon
subspecializ
ing in
endoscopic surgery of the lumbar spine
. He developed theFDA
, allowing for
approvedYeung Endoscopic Spine System (YESS™)
surgical decompression of the disc, spinal canal, and
lumbar foramen
.
Through this development,
offering “no hype, just results,
painful
”
degenerative condtions of the Lumbar spine
are now able to be treated
through Dr Yeung’s
patents, technologic developments, and
innovations.
Dr Yeung is recognized internationally
for hiscontributions to minimally
, receivingbest of meetingawards for
invasive/endoscopic spine surgery
his Podium presentations andosters.
P
He is also a recipient of
honorary
titles fromNational andInternationalOrthopedic andSpine Societiesfor
his innovative work.
He is the co-editor ofthe two volumes ofPractice of Minimally Invasive
Spinal Technique,2000 and 2003, and the author ofover 60 peer
reviewedscientificarticles, publications, and book chapters on
endoscopic spine surgery and related topics. He is a reviewer
for Spine,
Spine Arthroplasty Journal, the Indian Journal of Orthopedics.
Dr Yeung has trainedacademicspine faculty andspine fellows from the
United States,China, and various countries in
North and South America,
Asia, Australia,Europe, and Africa.
Dr Yeung is currently the executive director of the International
served as President and
Intradiscal Therapy Society, having also
Director of Medical Education. Dr Yeung is also a Past
Presidentof the
MaricopaCounty Medical Society
, the Arizona Orthopedic Society, The
Western Orthopedic Society
and Chinese American Medical Society,
Arizona Chapter, as well sa the board of the Arizona Medical
Association. He has served on the Professional Liability Committee of
the American Academy of Orthopedic Surgery
, is past chairmanof the
surgical care committee
.
Locally, Dr Yeung has been honored by the Business Journal as a
“Health Care Hero” and
awarded the Arizona Medical Association’
s
Humanitarian a
nd National leadership Award.
34
Kemal Yucesoy, MD.
Dr.Kemal Yücesoy was born in Ankara, 1963, and received his MD degree from Ege
University Medical Faculty, İzmir.
He trained in Neurosurgery at Dokuz Eylül
University, İzmir and after completion of his residency (1996), he continued his carrier
at the same clinic as a specialist, an assistant professor (1997), and associate
professor (2003).
Dr.Yücesoy especially interested in spine surgery, and he worked with Prof.Sonntag
(BNI, Pheonix, 1999, 2005), and Prof.Crockard (NHNN, London, 2000). He has
authored over 100 scientific papers and book chapters, and presented over 200
papers and lectures at meetings.
He is also educator in Spine Section of Medtronic
and Arthrocare Company.
35
Mehmet Zileli, MD.
Dr.Mehmet Zileli is the Professor of Neurosurgery and Head of the Spine Section of
Neurosurgery Department in Ege University, Izmir, Turkey. He is a faculty member
since 1989.
Between 1987-1988 he has worked as a Research Fellow in the Dept of
Neurosurgery, University of Erlangen-Nürnberg, Germany (Prof.J.Schramm).
He is the founder and first president of the Spine Section of Turkish Neurosurgical
Association, (1995-1999), Ex-Committee Member of the World Spine Society (2003Present), and member of many national (11) and international (13) societies. He is
the program chairman of the World Spine IV Meeting which was held in Istanbul
between July 29 and August 1, 2007. He is the First Vise Chairman of the World
Spine Society. He has served as the President of the Turkish Neurosurgical Society
between 2006-2008.
He has important contributions to education and training in spine surgery in Turkey.
Since 1997 he organizes hands-on practical courses on spine surgery, and has
organized a cadaver course in 2003 and 2005 in colloboration with Cleveland Clinic,
USA and World Spine Society. He is the chief of a spine fellowship program that
served many national and international fellows. He has also been the host of the
“Travelling Fellowship of Spine Society of Europe” in 2002, 2003 and 2004.
He is the author or co-author of 39 international, and 70 national scientific papers,
editor of 4 books, author of 13 international book chapters and 74 national book
chapters. He has presented and given talks in international (154) and national (249)
scientific meetings. He is also reviewer or editorial board member of international (4)
and national (9) scientific journals.
He speaks English and German. He is merried, and father of two children
Address:
Department of Neurosurgery
Ege University Faculty of Medicine
Bornova, Izmir 35100 TURKEY
Phone: +90-232-3903380 / 006
Fax: +90-232-4637751
E-Mail: [email protected]
36
Lectures
37
L-1
MISS Regulations in Turkey
Tolgay SATANA
It would not be wrong to say that the emergence of minimal invasive surgery and its introduction to our country date back to our
master, Hippocrates, who lived in these lands. However, subsequent advancements in this geographic area resulted in the evolution,
development, and appropriation of Hippocrates and his principles throughout western civilization. We generally tend to emulate the rules
and regulations from abroad even when it is not necessary just like we import knowledge when we should develop it ourselves. This time,
we tried to do the opposite by using Asclepius’s healing baton against Poseidon’s wind.
What was the situation in the World? The International Musculoskeletal Laser Society (IMLAS) had published successful studies
on spinal endoscopy, an innovative area of surgery. Şahap Atik, the prominent figure in laser joint surgery in our country, helped us kick off
the MISS journey, starting with use of laser in spinal endoscopy. The introduction of MISS got under way immediately as part of the Osteo
meetings, the studies on Bone and Joint Decay and Osteoporosis of which, was arranged by the Turkish Joint Diseases Foundation, or
TEVAK. In addition to the great success achieved with the Osteo Congress, MISS was now being discussed as a subject matter. It was in
2005 when the Journal of Joint Diseases and Related, in parallel with relocation of the IMLAS meeting to Turkey, was published as a
special report, hence breaking new ground throughout the world and in Turkey.
We succeeded in introducing the Minimal Invasive concept. Now, it was time characteristics. Characterization began to occur in
the minds of fellows who resort to classical surgery techniques as we tried to explain that minimal invasive surgery did not mean
downsizing incisions but rather working in a less traumatic manner. At this stage it was necessary to move from the introduction stage to
the characterization stage. We were supposed to engrave the defined processes into the minds by ensuring they corresponded to the
originals. We started with those dealing with spinal surgery. Azmi Hamzaoğlu, the foremost figure in modern spinal surgery in Turkey,
helped us go through introductory stage very rapidly due to his position as the Chair of the Association. We embarked on our studies,
under Mr. Hamzaoğlu’s leadership. Tolgay Şatana simultaneously performed the first Percutaneous Endoscopic Lumbar Discectomy.
Tolgay Şatana introduced the surgery to the public with the first televised broadcast.
We took part in this time, with IMLAS, the studies of the ISMISS Association, which specializes on the Spine. We presented our
limited experience at the ISMISS meetings and at other local meetings. We were able to practise on only private patients, not even in the
universities and public hospitals despite our readiness to bring the device from outside. An application was submitted to the new chair of
the Spinal Association, Ufuk Aydınlı. In the meantime, we made another application to TTB. Now the characterization stage was completed
too. For the new initiatives were referred to the wise men committee of the bureaucracy.
Our individual application in 2005 was not successful because we were not a legal entity and was thus forgotten. So, we had to
become an association, but it was impossible to achieve that without first forming a society. Patients approached the operation decisions
with doubt. The surgeons practising classical surgery mercilessly used the phrase “charlatan.” A discussion carried out in the e-mail groups
under the leadership of Ufuk Aydınlı gave us the chance to categorize MISS operations. The operations then were explained to a
distinguished group of attendants at the Bursa AO meeting. It bore a result: Drafts, brought up by Neurosurgery and Spinal Association,
were being discussed now. But the split in the Spinal Association’s new governing body interrupted this process.
ISMISS had better come to Turkey and contribute to the formation of a new society. Contacts were made with Spinal
Association, Neurosurgery Association, Physical Treatment and Pain Association. The first ISMISS meeting was held subsequent to
harvesting the necessary support. The world’s leading authorities defined the initiatives at this gathering. Scientific conclusions showed
surgery served the public interest. But the training part of the meeting was obstructed and participant satisfaction waned because the
cadaver course was not conducted. While the persons responsible for this situation were removed a new association was set up, and
formation of a society is still in the works. But the association was comprised of those who did not practice MISS techniques or those who
did so only to a limited extent. Moreover, it maintained the division regarding the management of the Spinal Association. Thus, the ones
blocking the first ISMISS meeting took the lead.
Rather than working for the needs of the country, the newly established association preferred to exchange correspondence with
outside institutions that did not recognize ISMISS’s national representation. The ISMISS meeting was immediately relocated from Ankara
to Istanbul. It won Istanbul University’s backing. Favourable conditions were provided thanks to the cadaver courses. When the only
existing textbook on MISS needed to be translated into Turkish, the members of this group failed to do so and thus the association failed to
serve the public interest. In addition, the year 2008 passed without any regulatory demands and the global crisis had a deep impact on the
second ISMISS meeting. It was apparent that ISMISS had to launch a new cooperation. An offer of combined efforts made at the first
ISMISS get-together was reiterated to the governing body of Turkish Society of Orthopaedics and Traumatology (TOTBID). Nevertheless,
as TOTBID stated it did not recognize ISMISS and so another association was established.
The first thing International Society for Minimal Intervention in Spinal Surgery (ISMISS – Turkish OMID), did was to apply to the
Turkish Medical Association (TTB) with an official statement, which said that the use of MISS was not defined and that this did not serve
the public interest. After classification, OMID informed the other concerned associations and the Ministry of Health.
OMID evaluates the past amendments to the laws related to the individual applications. The Ministry of Health formed the Social
Security Institution (SGK) system by implementing the general health system. This system analyzes classifications that are not compatible
with the TTB’s private practice application manual by referring to the medical practice regulation (SUT).
All the MISS applications can be shown as IDET and Nucleotomy in the SUT and TTB manuals. Endoscopy applications can be
priced by adding 600 units to classical surgery for TTB. This is contrary to MISS’s cost reduction goal. It makes it difficult for the insurance
companies to support the initiative. In fact, MISS is the most low-cost system within the insurance, hospital and doctor triangle. OMID is
working to improve this situation.
38
L-3
Digital Technology Convergence and Control System: Minimally Invasive
Spine Surgeon’s (MISS) Perspective and Technological Consideration
John C. Chiu, M.D., FRCS, D.Sc, Director, Neurospine Surgery
Problems and challenges facing minimally invasive spinal surgery:
Degenerated spinal disc and spinal stenosis are common problems requiring
decompressive spinal surgery. Open spinal discectomy is associated with significant
morbidity, long-term convalescence, prolonged general anesthesia and wide
dissection of tissues that can cause bleeding, scarring and eventual destabilization
of spinal segments. The evolving less traumatic minimally invasive endoscopic
lumbar decompression procedure is free from these potential complications.
Therefore the pursuit of minimally invasive spine surgery (MISS) began. Current and
future trends of spinal surgery are toward minimally or less invasive and biologic
material.
This endoscopic spine surgical procedure, its surgical indications (for treatment of
herniated lumbar discs, post fusion junctional disc herniation, neural compression,
osteophytes, spinal stenosis, vertebral compression fractures, spinal tumor, synovial
cysts and etc.), its operative techniques (both transforaminal endoscopic approach
and interlamina endoscopic assisted approach) including tissue modulation
technology (i.e. laser and radiofrequency surgical application), requires preoperative
planning, intraoperative monitoring, control and image data collection and utilization.
Additional problems and challenges facing MISS include large number of surgical
personal for each case, slow turn over time, preoperative review of numerous
medical records, imaging and X-rays studies, no biometric confirmation of the
surgical patient, many multiple scattered intraoperative data monitors/displays, lack
of adequate bio sensors and warning systems, lack of organized educational and
training displays for MISS etc.
Answer: With increased utilization of complex high tech and digital technologies,
and instruments in the DOR, it requires seamless connectivity and control to perform
the surgical procedures, in a precise and orchestrated manner. The SurgMatix®
prototype, a new integrated DOR, image-data based convergence and control
system has been developed and utilized to facilitate MISS. This system is designed
to promote seamless integration of all aspects related to the surgical procedure and
to reduce surgical time and personal requirement significantly. This ease to use
SurgMatix® system creates an organized control instead of organized chaos is
needed. In addition, it can provide training of other spinal surgeons to perform the
minimally invasive spinal surgery.
Seamless integrated digital OR is needed to provide effective, safer and higher
quality in spinal surgical patient treatment.
39
L-4
INTERVERTEBRAL FORAMEN FROM THE ANATOMIC APPROACH
PROF.DR. AHMET USTA, M.D.
During this small lecture, we will try to understand how the incisura becomes a
foramen, what the relation between the foramen and a spinal nerve. Additionally, the
structures around a foramen.
40
ML - 1
Full-endoscopic operations of the lumbar, thoracic and cervical spine
- State of the art and outlook in disc herniations and stenosis Sebastian Ruetten
The therapy of degenerative diseases of the lumbar spine involves both medical and
socioeconomic problems. A surgical procedure may be necessary if conservative measures
have been exhausted and states of exacerbated pain or neurological deficits persist. Despite
good therapeutic results with conventional operations, there may be consecutive damage
due to traumatization. Thus, it is important to continuously improve these procedures. Taking
existing quality standards into account, the objectives must be to minimize operation-induced
traumatization and negative long-term sequelae. Current research results and technical
innovations must be critically applied in order to guarantee the best-possible treatment
strategies.
Minimal-invasive techniques can reduce tissue damage and its consequences. Endoscopic
operations under continuous fluid flow bring advantages which raise these procedures in
many areas to the standard level.
New optics have been developed with a wide working channel for spinal surgery which
enable sufficient bone resection using burrs under visual control. These days, there are
various full-endoscopic techniques available which can supplement each other: for the
lumbar spine there is the posterolateral to lateral transforaminal as well as the interlaminar
access; for the thoracic spine, the postererolateral transforaminal and the interlaminar
access; for the cervical spine, the anterior transdiscal and the posterior access. There are
specific advantages and disadvantages for all of these techniques. The transforaminal
access can be preferred, since it can be performed atraumatically. Nonetheless, mobility
problems may arise. Here, the interlaminar procedure can expand the spectrum and enable
operation of all disc herniations and lateral spinal stenosis, and in the thoracic spine special
lateral disc herniations. In the cervical spine, the dorsal access enables therapy of all lateral
disc herniations and foraminal stenosis. Unlike the anterior transdiscal procedure, which is
the only treatment available for medial pathologies, the disc is not damaged and mobility is
expanded.
Considering the indication criteria, now the combination of full-endoscopic approaches with
the new developed endoscopes and instruments provides sufficient decompression under
visual control of lumbar, cervical and thoracic disc herniations and spinal stenosis. The
results are equal to that of conventional procedures, but with all the advantages of a truly
minimally-invasive procedure. In addition due to the possibility of resect bone in a sufficient
way the indication is broadened with respect to techniques for spinal canal decompression.
However, total avoidance of known problems in spinal surgery can hardly be imagined. In
addition, open procedures will remain as indispensable in the future as they currently are. At
the moment the full-endoscopic procedures are estimated as a sufficient supplementation
and alternative inside the complete spectrum of spine surgery.
41
ML - 2
Minimalinvasive Procedures on the cervical spine From the Nonendoscopic Percutanoues Laserdiscdecompression to the selective
Percutaneous Endoscopic Cervical Decompression and Discectomy
Dr. Med. Stefan Hellinger
There is a high incidence of cervical discogenic pain symptoms in the population. It is estimated that
one person in five in Germany who visits an orthopedist presents with the symptoms of a cervical disc
syndrome. The treatment of cervical discogenic diseases makes high demands in terms of both
diagnostics and therapy. Diagnostics has been made easier by improved imaging and the
enhancement of neurological measuring methods. Consequently, there is now interdisciplinary
consensus that the principal pathologic causes can be reliably identified.
With the aid of appropriate conservative therapy, approximately 80 percent of all cervical syndromes
can be cured. Only once all the conservative and semi-invasive procedures have been exhausted
should surgery be considered.
The first step in the interventional treatement of cervical syndroms is in our opinion the
nonendoscopic decompression and nucleotomy by Laser introduced 1990 by J. Hellinger. The
technique is simple and will be demonstrated.
As a bridge between open and percutaneous therapy, endoscopy of the cervical spine started to be
used at the beginning of the 1990s, following good experiences on the lumbar spine. The principle of
microsurgery is combined with the minimally invasive principles by bringing the optical level to the
forefront of pathology. Access morbidity has been significantly reduced by the percutaneous access
technique. Furthermore, a large proportion of the intervertebral disc, in particular most of the fibrous
ring, is preserved. The pathology is only removed selectively in the area of the nucleus pulposus and
on the dorsal fibrous ring. This preserves the remaining biomechanical function of the degenerated
intervertebral disc. By means of tried and tested minimally invasive methods under vision, such as the
use of a laser or radiofrequency to ablate and shrink tissue, the risk of complications has been further
reduced, at the same time as enhancing efficiency. Meanwhile segmental fusions if necessary are by
the endoscopic technique performed.
The indications for both procedures are neck pain radiating into the arm (radicular pain), symptoms
of segmental dysesthesia, and motor deficits matching the pathologic segment, conservative therapyresistant vertebrogenic headache with reliable imaging, disc herniation confirmed by MRI or CT, with
associated clinical picture, damage in adjoining segments after preceding fusion, with corresponding
clinical picture, and multisegment disc herniations.
This method cannot be used in cases of serious cervical spinal stenosis, migrated free sequestra,
pronounced spondylosis with large osteophytes, and calcifications of the posterior spinal ligament.
The results of this methods display a success rate of 80% - 95% for good to very good outcomes.
This includes various work techniques of endoscopic cervical decompression, such as laser. Our
experience also confirms this success rate.
The complication rate of percutaneous cervical decompression is extremely small, as is the case
with nonendoscopic percutaneous procedures.
Inadequate decompression when using the nonendoscopic or the endoscopic technique will be
reflected in the incidence of secondary operations.
Summary:
The nonendoscopic percutanoues Leserdiscdecompression and nucleotomy as well as the selective
percutaneous endoscopic decompression and nucleotomy are safe and efficient alternatives to
conventional anterior cervical discectomy, with or without fusion, for the treatment of discogenic
syndromes of the cervical spine. It entails less surgical trauma, and considerably reduces surgeryrelated stress for the patient, while also shortening the period of hospitalization and the operating time.
With the new devices for this procedure we got further possibillities in the current treatement of
cervical disc desease and for develepement of new opportunities.
42
ML - 3
COMPLICATION RISKS OF THE FORAMINAL APPROACH TO THE LUMBAR SPINE: IT’S
CORELLATION WITH FORAMINAL ANATOMY, VARIATIONS, AND ANOMALOUS STRUCTURES IN
THE “HIDDEN” ZONE”
ANTHONY T. YEUNG, M.D.
ARIZONA INSTITUTE FOR MINIMALLY INVASIVE SPINE CARE, PHOENIX, ARIZONA
Purpose: The trans-foraminal approach to the lumbar spine is an excellent minimally invasive portal to the
spine that has gained interest in recent years as an approach for interbody fusion and far lateral disc
herniations. This approach, however, traverses the “hidden zone” of MacNab, and is still unfamiliar territory
for many traditional spine surgeons. With the recent development of endoscopic surgery, pitfalls of the
foraminal approach are important to surgeons in order to avoid adverse clinical outcomes. This is best
learned from the experience of endoscopic spinal surgeons and a through knowledge of the normal, variant,
and patho-anatomy of the foramen.
Method: Complications and adverse side effects encountered in over 3,000 patients and 8,000 lumbar
discs undergoing endoscopic decompression for painful degenerative conditions of the lumbar spine are
retrospectively reviewed. Painful patho-anatomy was confirmed by spinal probing, and recorded in vivo on
analog video and DVD. Discogenic pain reproduction was correlated intra-operatively by evocative
chromodiscography™. Pain reproduction was correlated with abnormal discogram patterns that was
compared with Mri findings. Indigocarmine dye was mixed 1:10 with Isovue 300 to stain the degenerated
nucleus and adjacent structures in the path of the injectate. Extraforaminal, foraminal, and intradiscal normal
and patho-anatomy, included routine visualization of the annulus, the traversing and exiting nerves at each
operative level , and the epidural space.
Findings: The most common endoscopic finding was degenerative nucleus and inflammatory tissue in the
disc and annulus, a common finding in painful disc herniations. Inflammation, granulation tissue, and an
inflammatory membrane denote chronicity. An inflammatory membrane in the annulus was associated with
severe back pain produced by low pressure low volume discography. The pain is not always concordant, but
usually severe, just from distending the disc annulus. Foraminal osteophytes could be seen tethering and
irritating the exiting nerve, producing perineural scar tissue that is difficult to see with open approaches.
“Anomalous” nerves in the “hidden zone” of MacNab identified pain generators in-vivo that have not been
emphasized in the literature. Foraminal branches of either the traversing or exiting nerve (furcal nerves) are
contributed to the symptom complex. Furcal nerves are difficult to differentiate from a conjoined nerve.
Autonomic nerves are also present, confirmed by endoscopic biopsy.
Results: Working near the Dorsal Root Ganglion is a risk by itself, a known risk factor in any foraminal
surgery. Ablation or removal of nerves in the inflammatory membrane results in decreased axial back pain
and sciatica, but may also produce a side effect of dysesthesia of varied severity. Dysesthesia occurs
between 5-15% of the time, depending on the patho genesis of the painful condition. It is usually very mild
and completely self limited and temporary.
Discussion: Dysesthesia responds to Lyrica or Neurontin, foraminal nerve blocks, and lumbar sympathetic
blocks. It can be associated with motor weakness that usually resolves, unless there is significant comorbidity such as peripheral neuropathy, and seizure disorders. Pre-operative Consent should include
usually transient neuropathic pain. Post Operative Neuropathic pain staying the same or worsening may not
be able to be completely eliminated, and is a risk of the endoscopic procedure, even with neuromonitoring
utilizing continuous EMG.
Conclusion: A through discussion of the risks associated with foraminal endoscopic surgery must be
explained to any patient undergoing foraminal endoscopic surgery. It is similar to the risk of trans-canal
surgery. It has unique risks due to variations in foraminalnormal and patho-anatomy. The use of foraminal
epidural injections intra-operatively, post-operatively, and in the management of post-operative dysesthesia
will decrease this adverse side effect of foraminal surgery to approximately 1% of patients with mild
permanent sensory or motor residuals. The overall risks and surgical morbidity are still less than posterior
trans-canal surgery
43
ML - 4
ENDOSCOPIC SURGERY OF LUMBAR SPINAL STENOSIS. ABOUT 145 CASES.
JEAN DESTANDAU
Study Design: Endoscopic technique has been used by the author since 1993 for
lumbar discectomy and since 2001 for spinal stenosis. The technique is discribed
and the results of 145 patients are presented
Material and Methods: The device (Endospine, Karl Storz GmbH, Tuttlingen,
Germany) is composed of three tubes: one for the endoscope, one for suction and
the largest one for classical surgical instruments. Since 2001 this endoscopic
technique has been used in spinal stenosis performing a bilatéral décompression
through a posterior approach from the left side or from the side of prédominant signs.
From February 2001 to September 2007, 145 patients have been operated on with
this technique. In 83% surgery was a single level décompression and in 16% there
was an associated spondylolisthesis. Prolo’s criteria were used.
Results: 104 questionnaires (72%) were returned showing excellent results in 94
cases (90%) and poor in 9 (8,7%). With an average delay of 3 weeks, 94 patients
(90%) returned to a normal life. Four patients (4%) needed a second operation with
an average delay of 5 months. The complications observed were: dural tear in 12
(8,3%); nerve root lesion in 3 (2%); resection of articular process in 7 4,8%); wrong
level décompression in 2 (1,4%); and 1 compressive hematoma. In answer to the
questions on global satisfaction and on the accuracy of the information given before
surgery, 97% responded as satisfied and 95% felt the information given to be
accurate.
Conclusions: This minimally invasive technique is mainly used in single level spinal
stenosis even with associated spondylolisthesis, but can be also used in several
levels décompression. The good results and the fast resumption of normal activities
explain that this endoscopic technique could become the gold standard in spinal
stenosis, pathology that will increase with the lifespan extension
44
L-5
POSTERIOR LATERAL THORACIC ENDOSCOPIC MICRODISCECTOMY
JOHN C. CHIU, M.D., FRCS, D.SC, DIRECTOR, NEUROSPINE SURGERY
CALIFORNIA SPINE INSTITUTE MEDICAL CENTER, THOUSAND OAKS, CA 91360, USA
Purpose: To demonstrate the safety and efficacy of outpatient based endoscopic thoracic
discectomy with laser thermodiskoplasty performed for symptomatic thoracic herniated nucleus
pulposus.
Materials and Methods: Since February 1996, 420 patients’ (525 discs) with symptomatic
thoracic discs without myelopathy, who failed at least 12 weeks of conservative care, were
treated. The technique of percutaneous microdecompressive endoscopic thoracic discectomy
(with laser thermodiskoplasty) by posterolateral approach is described. The thoracic disc levels
were T1 to T12. All patients demonstrated a contained soft thoracic disc herniation on MRI or
CT scans. Intraoperative thoracic discogram and pain provocative tests were positive and
confirmed the disc involved.
Results: Preliminary postoperative follow-up demonstrates 96% of all patients had good to
excellent symptomatic relief. Two patients demonstrated persistent, though reduced thoracic
pain and paresthesia. The average time to return to work was ten days for the non-workers'
compensation patients. Most of the patients received non-ablative lower laser energy
application for thoracic disc shrinkage or tightening.
Conclusion: Percutaneous microdecompressive endoscopic thoracic discectomy with added
application of non-ablative lower Holmium laser energy for disc shrinkage (laser
thermodiskoplasty) appears to be easy, safe and efficacious. This less traumatic, easier
outpatient treatment leads to excellent results, faster recovery, and significant economic savings
45
L-6
ENDOSCOPIC APPROACHES TO DEGENERATIVE CERVICAL DESEASES
JEAN DESTANDAU
The degenerative cervical pathology entails radicular, medullar or radiculo-medullar
compression. Soft cervical hernia occurs on young patients in their forties, whereas
osteophyticcompressions, either radicular or medullar, occur on old and thus more
fragile patients.
ENDOSPINE can be used for three types of operations:
• posterior endoscopic foraminotomy
• anterior endoscopic foraminotomy following Jho’s technique
• anterior endoscopic foraminotomy and partial vertebrectomy also following Jho’s
technique
Posterior endoscopic foraminotomy:
Its main indication is the soft cervical hernia which occurs at C7-T1 or T1-T2 levels,
which are difficult to approach anteriorly. Using a posterior approach, the
ENDOSPINE operating tube is inserted along the spine, positioned on the facets
after fluoroscopic control and we realise a posterior lamino-foraminotomy either with
little Kerrison forceps or with the help of a drill. The relief is immediate, the postoperative course extremely simple, and there are no special precautions to take
during the postoperative period.
Anterior endoscopic foraminotomy following Jho’s technique:
It is indicated for soft and/ or hard foraminal hernia. The technique consists of a
classical antero-lateral approach sliding between the vascular bundle outside and the
visceral bundle inside and exposing the level wanted. We leave the longus colli
aponeurosis intact in order to avoid a sympathetic lesion, but we remove the medial
side of the muscle a little above the disc level. With the ENDOSPINE, we perform a
complete anterior foraminotomy with the use of a drill which exposes the nerve root
from the spinal canal until its passing behind the vertebral artery. Once again, the
relief is immediate and the post-operative course extremely simple without any
particular post-operative precautions.
Anterior endoscopic foraminotomy and partial vertebrectomy following Jho’s
technique:
In case of cervicarthroscopic myelopathy, in elderly patients with pinched or
inexistent disc, the anterior endoscopic foraminotomy with the ENDOSPINE can
easily be extended to the opposite side where the foramen begins and can be done
at several levels if needed.
46
L-7
TRANSFORAMINAL ENDOSCOPIC MICRODECOMPRESSION FOR HERNIATED
LUMBAR DISCS WITH SPINAL STENOSIS AND TISSUE MODULATION TECHNOLOGY
– UPDATE
JOHN C. CHIU, M.D., FRCS, D.SC, DIRECTOR, NEUROSPINE SURGERY
CALIFORNIA SPINE INSTITUTE MEDICAL CENTER, THOUSAND OAKS, CA 91320,
USA
Purpose: To demonstrate effective transforaminal endoscopic microdecompression for
herniated lumbar discs with spinal stenosis, for very large protruded discs, recurrent discs
with scar tissue and bony spurs or spondylitic bars compressing the lumbar nerve root. This
is to be accomplished with endoscopic micro spinal instruments, laser application, and
newly developed endoscopic decompression instruments (including tubular retractors, large
cannulae, more aggressive trephines, curettes, rasps, and ronguers), in addition to laser
thermodiskoplasty for disc shrinkage.
Materials and Methods: Since 1993, 3421 herniated lumbar discs in 2000 patients with
lumbar stenosis. Average age of 44.2 (24 to 92) with symptomatic lumbar single and
multiple herniated intervertebral discs with lumbar stenosis. Males: 1010 - Females: 990.
Each failed at least 12 weeks of conservative care. Post operative follow up 6mos to 72mos
(average 42mos). Progressive series of different diameters endoscopic assisted tubular
retractors, with appropriate sized dilators and more aggressive saw-toothed trephines, and
laser are utilized to perform transforaminal endoscopic microdecompression for herniated
lumbar discs and spinal stenosis, in addition to the posteriorlateral foraminoscope and
endoscopic assisted spinal operating systems. Some tubular retractors have extensions like
a duckbill on one side that can be oriented toward the nerve root to retract and protect it. The
microdecompressive endoscopic assisted discectomy (MEAD) system and/or SMART Endolumbar System are used for dorso-medial spinal decompression/laminotomy and
laminoplasty. Laser application is included for laser thermodiskoplasty.
Results: There was no postoperative mortality, and had morbidity of less than 1%, in 2000
patients. For single level, 94% of patients had good or excellent results, 6% had some
residual symptoms though improved overall, and 3% of patients did not improve significantly.
A newly devised larger and more aggressive decompressive discectomy instrument set,
safely and efficaciously allow wider and more complete removal of large or recurrent disc
protrusions, scar tissue and bony spurs that cause nerve root compression, while protecting
the adjacent nerve root. The MEAD system and or SMART Endo-lumbar System allows a
minimal approach to laminotomy for spinal stenosis decompression and laminoplasty. Laser
thermodiskoplasty reshapes and tightened disc tissue further for decompression.
Conclusion: Transforaminal endoscopic laser microdecompression can effectively
decompress herniated lumbar discs with spinal stenosis, and perform foraminoplasty for
lateral and central spinal stenosis. This minimally invasive endoscopic technique aided by
new instruments and laser application, provides a safe and effective modality to achieve
results in effective decompression of lumbar discs with spinal stenosis, preserves spinal
motion and creates a channel for spinal arthroplasty.
47
L-8
PERCUTANEOUS ENDOSCOPIC CERVICAL DISCECTOMY FOR NONCONTAINED
CERVICAL DISC HERNIATION: MINIMUM 3 YEARS FOLLOW-UP
SANG-HO LEE, MD, PHD, JUNE-HO LEE, MD, SUNG MIN HUR, MD
WOORIDUL SPINE HOSPITAL (WSH), SEOUL, KOREA
Introduction: Although percutaneous endoscopic cervical discectomy (PECD) has
been an effective procedure for soft disc herniation, the conventional technique has the
risk of spinal cord injury because of the relatively blind approach and straight-firing
laser and the difficulty of removal of remnants, especially foraminal fragment. The aim
of this study is to present the surgical technique and clinical outcome of PECD using a
working channel scope (WSH endoscopy set, Storz, Germany) and a side-firing laser
for noncontained cervical disc herniation.
Methods: Between March 2002 and January 2005, 108 of 114 patients underwent
PECD using a WSH endoscopy set were available for follow-up. The inclusion criteria
were cervical radiculopathy due to foraminal, noncontained HCD as demonstrated on
CT/MRI scan not responding to at least 6 weeks of conservative therapy. Under the
conscious sedation, the patient was placed in supine position with neck extension. After
pushing esophagus and trachea to the opposite side, an 18G needle was inserted into
the disc space under C-arm guidance. The tract was dilated using a serial dilators, and
the working channel scope was inserted into disc space. Under the direct visualization,
ruptured disc fragment was removed by a microforceps and vaporized by a side-firing
Ho:YAG laser through the working channel. The clinical outcomes were assessed by
the Visual Analogue Scale (VAS) and the Neck Disability Index (NDI).
Results: The mean follow-up period was 42 (range, 24–68) months. There were 66
males (57.9%) and 48 females (42.1%) with a mean age of 48.3 (range 26–68) years.
The mean VAS score for neck pain dropped from 7.7 to 3.1. The NDI improved from 36
to 4%. There were 6 cases requiring revisional surgery at the affected levels. There
was no associated complication such as infection, hoarseness, esopageal injury or
intraoperative neural injury.
Conclusion: PECD using a WSH working channel scope provided a safer and
effective alternative for the treatment of noncontained cervical disc herniation. The
WSH working channel scope had several advantages, such as a high quality of optics,
a bigger working channel, and a side-firing laser.
48
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ENDOSCOPIC LUMBAR DISC SURGERY : UP-DATE 2009
HANSJOERG LEU, PD DR.MED.
BETHANIA SPINE BASE, ORTHOPAEDIC SPINAL SURGERY, PRIVATKLINIKUM
BETHANIEN
CH-8044 ZÜRICH / SWITZERLAND – [email protected]
Coming up from Japanese Hijikata’s uniportal percutaneous technique of closed
percutaneous nucleotomy introduced in 1979, in 1982 intradiscal biportal endoscopy was
introduced in Zurich for visually controlled intervertebral tissue elaboration. Beside
decompressive indications, in 1987/88, in combination with percutaneous external pedicular
fixation, endoscopy controlled interbody fusion was introduced.
After a first decade in clinical experience with this biportal applications, the idea arised to
combine simultaneous endoscopic control with direct extradiscal tissue elaboration across an
uniportal approach in the later eighties. Experiments with modified urologic workings-scopes
designed for cystoscopic applications demonstrated in 1990, that endoscopic applications are
possible also in non-preformed anatomical spaces when some hyperpressive irrigation was used
for local atraumatic tissue spacing.
After respective technical adaptations we introduced endoscopic coaxial foraminoscopy clinically
for the first time in February 1991 for the treatment of a foraminal sequestrated herniation. A first
publication on the early series was published in 1996*. Since then the technology with improved
endoscopic tools and irrigation systems as well as high-frequency coagulation under irrigation
became almost standardized for this specific range of indication. The posterolateral approach
from 9-12 cm from the midline follows the same criteria as for intradiscal applications, but the
working cannula is directed to the foraminal sequestrum, which is extracted under endoscopic
control then with a special working scope. After a steep learning curve today the optimal
indications and contraindications are clearly defined. Our first clinically controlled series of 200
standardized cases brought successful primary results in 164 cases, including the learning
courve. Here the results trend to "black or white": or the sequester is removed or not. Relatively
freshly sequestrated fragments without local scar-adhesions are easier to remove. Anatomical
limits can occur in L5/S1 when high iliac crests can impair flat approach to medioforaminally
located sequestra. For preop evaluation a 3d-CT offering clear bony analysis of accessible
trajectories can trace the access precisely. Detailed knowledge of foraminal anatomy is
mandatory. Hospital stay could be reduced to 2 to 3 days, out-patient care is possible nowadays
as well. Other pioneering authors as Ruetten in Germany broungt up the interlaminar endoscopic
lumbar decompression, what definitely extende the range of this minimal endoscopic approach
also to more medilateral forms of lumbar disc herniation. So the available complementary
endoscopic techniques today challenge in well trained hands more and more the conventional
golden standards as microdiscectomy.
* Reverence : Leu Hj., Hauser R.: Die perkutan posterolaterale Foraminoskopie : Prinzip,
Technik und Erfahrungen seit 1991. Arthroskopie 9(1996)26-31
49
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The endoscopic resection for Juxta-facet cysts – a new promising technique
Stefan Hellinger, ISAR Clinic Munich
Extradural expensive lesions in the spinal channel can lead to a compression of the nerve
root, the myelon or the cauda equina with related symptoms. Most common are disc
herniations or bony/ligamentous constrictions. Very rare the symptoms are caused by clinical
relevant cysts from the intervertebral joint. The terminus Juxta.facet caysts has been founded
by Kao et al. 1974. This includes the different forms of cysts by the interveertebral joints. We
are finding synovial cysts by degenerative articular joints or ganglions by mucoid
degeneration of the periarticular tissue. Meanwhile synovial cysts are connected to the joint
and have a good response of conservative treatement, the ganglions are without any
connection to the articular space and have a bad tendency for regression. Especially here is
the surgical decompression necessary.
Mostly for the surgical treatement the open microsurgical removal of the cyst and a part of
the intervertebral joint is the standard procedure. Her we are experiencing the same
problems as by microsurgical spine procedures. Especially the potentially induced instability
by a partly resection of the intervertebral joint leads to a recommendation of a concomitant
fusion.
The endoscopic interlaminar accses allows a minimalisation of the approach related
demages.
Beside the disc surgery the endoscopic decompression of facet cysts has shown a good
alternative for surgical treatement of these pathology.
Methods:
The surgical technique is an endoscopic approach to the interlaminar foramen with a 7mm
tube. The flavum and the lamina is partly removed over the cyst in a limited area. After
release of adhesions between the cyst and the neurological structures the cysts is solely
removed by preserving the facet joint.
The Patients had been evaluated preoperativley and 6 weeks postoperatively.
Results:
Until now we treated 3 patients with this techique. The neurological radicular symptoms
recovered in all in all cases. One patient remained local back pain by facett arthrosis and
treated further by rhizotomy. No complications had been exoerienced. The recovery time was
by approximately 2 days.
Conclusion:
The endoscopic technique gives us an new option for the minimal aggressive removal of
clinical relavant cysts by the intervertebral joints. The results are comparable to an open
procedure. Cause of the limited account of cases is a statistical evaluation of the outcome
difficult. The decision of the inervention is by unsuccesful conservativ treatement or by
verification of a ganglion.
For the patient this technique is less harming and gives a fast recovery.
50
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X-MR assisted Percutaneous Endoscopic Lumbar Dicectomy
Sang-Ho Lee, MD, PhD, Gun Choi, MD, PhD, Tae-Joon Ahn, MD
Wooridul Spine Hospital (WSH), Seoul, Korea
Introduction: Although percutaneous endoscopic lumbar discectomy (PELD) for
lumbar disc herniations shows satisfactory outcomes, there have been cases in which
the PELD has failed because of the incomplete removal of disc fragments. The hybrid
magnetic resonance/X-ray suite (X-MR) is a recently introduced imaging solution that
provides intraoperative images. Preoperatively X-MR images were taken without
changing prone position during the procedure to determine a precise skin entry point
and evaluate any change in size or location of herniated disc. Before the finishing the
procedure, X-MR was checked. The purpose of this study is to present our experience
in X-MR assisted PELD during 2 year follow-up.
Methods: A retrospective analysis was performed in 50 patients who underwent X-MR
assisted PELD between Jan. 2006 and Dec. 2006 at our institution are followed
retrospectively. We obtained intraoperative X-MR by placing skin markers on patient’s
back. Postperatively, X-MR was repeated for doubtful remnant fragments. When
remnants were found, procedure was continued until the fragments were removed
completely.
Results: The mean follow-up period was 26 months. Three patients repeated PELD for
remnant disc. Based on the modified Macnab criteria, 93.9 % (out of 50 patients)
showed excellent or good outcomes. The mean visual analogue scale score for leg and
back symptom dropped from 7.7 to 1.7 (p<.05) and 6.8 to 1.8, respectively (p<.05). And
the oswestry disability index decreased from 62.4 to 14.0% (p<0.05). Three patients
underwent repeated PELD for remnant disc by the X-MR. Two patients demonstrated
the progression of disc herniation in preoperative MRI. One patient repeated PELD due
to hematoma. And one patient needed open lumbar discectomy after PELD due to
recurrent disc herniation.
Conclusions: According to progression or migration of herniated fragment since the 1st
preop MRI and duration of conservative treatment more than 6 weeks, the X-MR
assisted PELD facilitates in locating precise skin entry point and confirm complete
removal of disc fragment intraoperatively, thereby increasing the success rate.
51
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Full-endoscopic posterior operation of cervical lateral disc herniations – Prospective,
randomized comparison to anterior cervical decompression and fusion (ACDF)
Semih Oezdemir
Background:
There are various techniques for the operation of cervical disc herniations. The most
common today appears to be ventral decompression and fusion. It brings good results, but
requires more major surgery with loss of segment mobility. Dorsal "keyhole foraminotomy" is
also been used without fusion. This operation is now possible in a full-endoscopic technique.
Objective:
The objective of the prospective randomized study was to compare ventral decompression
and fusion (Group 1) to full-endoscopic dorsal decompression (Group 2) in lateral, soft disc
herniations.
Patients and methods:
70 patients were operated (35 per group). Inclusion criteria were: monosegmental
mediolateral and lateral soft disc herniation, radicular pain. In Group 1, the operation was
performed in known technique using a PEEK cage without plating. In Group 2, the operation
was performed using 5.8-mm endoscopes with a 3.2-mm intraendoscopic working canal
under continuous lavage. The follow-up lasted 24 months. 62 patients (88 %) were followed.
Results:
The mean operation time in Group 1 was 75 minutes., in Group 2 35 minutes There were no
measurable blood loss and serious complications in either group. In Group 1, 2 patients had
transient difficulty swallowing. In Group 2, transient numbness occurred twice. There was no
operation-related neck pain in Group 2 after wound healing. One patient in Group 2 suffered
recurrence. CT-examinations showed resection of less than 1/4 of the facettes in Group 2.
There was no increasing instability or kyphosing in Group 2, in Group 1 no adjacent
instability. 57 patients subjectively attained a satisfactory result. This corresponded to the
significantly constant improvement recorded by the validated measuring instruments. There
were no significant differences between the groups.
Conclusion:
Full-endoscopic dorsal foraminotomy is technically feasible and a potential alternative to
ventral decompression and fusion. It enables a selective procedure with direct visualization,
decompression is rapid, sufficient and the complication rate is low. Traumatization of the
access pathway and the structures of the spinal canal is reduced due to the minimallyinvasive technique. Strict attention must be paid to the indication for lateral and soft disc
herniation. Recurrences cannot be ruled out.
52
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CLINICAL OUTCOMES OF PERCUTANEOUS ENDOSCOPIC DISCECTOMY
(PELD)
Fujio ITO
Objective: Percutaneous Endoscopic Lumbar Discectomy (PELD) is an overnightstay operation that makes a 7 mm incision under local anesthesia. We discuss about
the indications and results of transforaminal (TF) , interlaminar(IL) and extraforaminal
(EF) approach. Materials and methods: The TF approach was used in 241 cases in
L2/3 ~ L5/S1, IL was 129 in only L5/S1 and EF was 52. Total cases were 422
composed of 320 males and 102 females, their average age 45.9. Patients with both
upward and downward migrations of 10 mm or more, instability found, any lateral
recess less than 3 mm, or osseous proliferation of spondylolysis were excluded from
the subjects. Results: JOA (Japanese Orthopaedic Association) scores before
operation and 1 month, 3 months, and 6 months later were 11.0 (N=365), 20.0
(N=290), 22.1 (N=183), and 22.3 (N=113), respectively. The VAS (visual analogue
scales) for buttock and lower limb were 7.1, 2.4, 1.8, and 1.5, respectively. Open
surgery was performed in two cases with canal stenosis. 11remnants and 6
impossible insertion cases were operated on by MED, 12 recurrences and 1 level
mistook case were operated on by the same methods, 2 instabilities were operated
on by fusion. One root damage caused a drop foot, 15 pain residual cases were
under self-control. Conclusion: PELD has indications for a large majority of lumbar
disc herniation not complicated by bone lesions and is a minimally invasive spine
surgery which allows the patient to walk and leave the next morning.
53
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PERCUTANEOUS ENDOSCOPIC DISCECTOMY IN LUMBAR DISC HERNIATION
COMBINED WITH SPINAL STENOSIS HAVING SEVERE UNILATERAL
RADICULOPATHIC LEG PAIN CAUSED BY DOMINANT ROOT COMPRESSION :
TRANSFORAMINAL SUPRAPEDICULAR APPROACH
CHANG IL JU, M.D., HYEUN SUNG KIM, M.D., SEOK WON KIM, M.D., SEUNG
MYUNG LEE, M.D., HO SHIN, M.D.
DEPARTMENT OF NEUROSURGERY, DEPARTMENT OF NEUROSURGERY,
CHOSUN UNIVERSITY,
Objective. Endoscopic discectomy for lumbar disc herniation combined spinal
stenosis have been considered as contraindication. But, we could have obtained
satisfactory results from the cases of lumbar disc herniation combined with spinal
stenosis that have symptoms of severe radiculopathic leg pain with or without back
pain caused by compression traversing nerve root in lateral recess by applying
percutaneous endoscopic discectomy. hence, the outcome is reported here.
Materials and Methods. At our hospital, from October 2006 to December 2007, The
subjects were 26 patients with lumbar disc herniation combined with spinal stenosis.
All patients had severe unilateral leg radiating pain and/or back pain symptoms
caused by dominantly herniated disc compressing the nerve root. Preoperative MR
T2 weighted axial images show spinal stenotic findings that more than 4mm
thickened ligament flavum and evident protruded disc to compress the traversing
nerve root. We had performed percutaneous transforaminal decompressive
discectomy and then decompressed traversing root by suprapedicular approach with
semi-rigid flexible curved probe.
Results. There were 26 patients, 7 male and 19 female patients. One patient was in
her 20's, one patient in their 30's, four patients in their 40's, seven patients were in
their 50's and eight patients were in their 60's, five patients were in their 70's. Mean
follow-up was 6.37 month. The mean visual analogue scale (VAS) of the patients
prior to surgery was 8.08, and the mean postoperative VAS was 2.08. According to
Macnab's criteria, patients who showed excellent result were 6 cases and good result
were 17 cases, fair results were 2 cases, poor result was 1 case and thus satisfactory
results were obtained in 88.46 % cases.
Conclusion. Generally, the lumbar disc herniation combined with spinal stenosis is
known as contraindication of endoscopic discectomy. But, If main symptoms was
caused by herniated disc compression traversing nerve root in the lateral recess,
percutaneous lumbar discectomy could effective methods to decompress the
traversing root by transforaminal suprapedicular approach.
54
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Transforaminal endoscopic extradiscal vs. intradiscal access in lumbar disc
herniation
Guntram Krzok
Orthopaedic Centre Waltershausen
We want to report about our experience after more than 800 transforaminal
endoscopic surgeries in lumbar disc herniation. From 1999 until 2003 we used the
intradiscal access with the YESS-technique in 300 cases with lumbar disc herniation.
This technique was easy and safe, but the indication is limited. The access to level
L5-S1 was nearly impossible in cases with high iliac crest and/or narror foramen. The
removing of sequestered disc material from the spinal canal was mostly impossible.
From 2003 until today we used the extradiscal access with the TESSYS-technique in
more than 500 cases. This technique is useable in nearly all cases of lumbar disc
herniation and allows the direct access to the herniation by stepwise reaming and
enlarging of the foramen. The results can be improved by the combination of
herniotomy and foraminoplasty. Disadvantage of the method is the long learning
curve. Most complications are recuccences (6,5%)and bleedings (1%). Nerve
damages are rare (0,6%)and mostly after trouble with aneathesia.
55
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CLINICAL AND RADIOLOGICAL OUTCOMES OF MINIMALLY INVASIVE VERSUS
OPEN TRANSFORAMINAL LUMBAR INTERBODY FUSION
CWB PENG, WM YUE, SB TAN
Singapore General Hospital, Singapore, Singapore
CLINICAL AND RADIOLOGICAL OUTCOMES OF MINIMALLY INVASIVE VERSUS OPEN
TRANSFORAMINAL LUMBAR INTERBODY FUSION CHAN WB PENG MD (PRESENTING
AUTHOUR), WAI M YUE MD, SEANG B TAN MD Department of Orthopedic Surgery,
Singapore General Hospital, Outram Road, Singapore 169608. Fax: +65 62262684, Tel:
+65 91261586, Email: [email protected] Study Design: Prospective study
Objective: Comparison of clinical and radiological outcomes of minimally invasive (MIS)
versus open transforaminal lumbar interbody fusion (TLIF). Summary of Background
Data: Open TLIF has been performed for many years with good results. MIS TLIF
techniques have recently been introduced with the aim of smaller wounds and faster
recovery. Methods: From 2004 - 2006, 29 MIS TLIF were matched paired with 29 Open
TLIF. Patient demographics and operative data were collected. Clinical assessment in
terms of NASS, SF-36 and VAS scores were performed preoperatively, 6 month and 2
year postoperatively. Fusion rates based on Bridwell grading were assessed at 2 years.
Results: The mean age for MIS and Open procedures were 54.1 and 52.5 years
respectively. There were 24 females and 5 males in both groups. Fluoroscopic time (MIS:
105.5 seconds, Open: 35.2 seconds, p<0.05) and operative time (MIS: 216.4 minutes,
Open: 170.5 minutes, p<0.05) were longer in MIS cases. There was less blood loss in
MIS (150ml) versus Open (681ml) procedures (p<0.05). The total morphine used for
MIS cases (17.4mg) was less compared to Open (35.7mg, p<0.05). MIS (4 days)
patients have shorter hospitalisation compared to Open (6.7 days, p<0.05). Both MIS
and Open groups showed significant improvement in back pain and lower limb symptoms
(NASS and VAS scores, p<0.05) and Quality of Life scores (SF-36, p<0.05) at 6 months
and 2 years but there was no significant difference between the two groups. 80% of MIS
and 86.7% of Open TLIF levels achieved Grade 1 fusion (p>0.05). Conclusion: MIS TLIF
has similar good long term clinical outcomes and high fusion rates of OPEN TLIF with the
additional benefits of less initial postoperative pain, early rehabilitation, shorter
hospitalization and fewer complications. Curriculum Vitae Name: Chan Wearn Benedict
Peng Sex: Male Qualification FRCS (Orthopaedics) (Edinburgh) 2006 MMed
(Orthopaedics) 2002 MB ChB (Honours) 1996 Education University of Leeds Medical
School 1991 - 1996 Hwa Chong Junior College 1989 - 1990 The Chinese High School
1985 - 1988 St. Andrew's Primary School 1979 - 1984 Medical Training Clinical Spine
Fellowship - Hospital for Joint Diseases (New York, USA) 2007 Spine Fellowship
(Observer) - Hospital for Special Surgery (New York, USA) 2007 Advanced Surgical
Trainee (Orthopaedics) 2002-2006 Basic Surgical Trainee - 2000-2002 Awards AO Spine
Traveling Fellowship 2007 SGH Service with A Heart Award 2006 Garland Prize in Clinical
Neurology 1996 Tetley and Lupton Scholarship (University of Leeds) 1991-96 Medical
Insurance Agency Charity Award - for Elective Programme 1995 Lady Moynihan Award for Elective Research 1995 Infirmary Prize - for Best Performance in 2nd MB 1993
Biochemistry Prize - for Best Performance in Biochemistry 1993 Shuttleworth Prize - for
Best Performance in Anatomy 1993 Crabtree Prize - for Outstanding Academic
Performance 1992 Academic Position Clinical Tutor - National University of Singapore
Clinical Supervisor - Singapore General Hospital Orthopaedic Department Professional
Affiliations Member of North American Spine Society Since 2006 Member of AOSpine
Since 2006 Member of Asia-Pacific Orthopaedic Association Since 2006 Member of
Singapore Orthopaedic Association Since 2006 Member of Singapore Medical Association
Since 1997
56
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PROPHYLACTIC OF RELAPSES OF FACET JOINT SYNDROME AFTER THEIR’S
DENERVATION
ALEXANDER SIRENKO
57
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RIGID INTERSPINOUS SPACER WITH TENSION BAND
SANG-HO LEE, MD, PHD, EWY-RYONG CHUNG, MD, PHD, OON KI BAEK,
MD
WOORIDUL SPINE HOSPITAL (WSH), SEOUL, SOUTH KOREA
BACKGROUND CONTEXT: Degenerative lumbar spinal stenosis is a common
condition in elderly patients and many of these patients are candidates for
decompressive surgery. The purpose of study is to evaluate the efficacy of the
interspinous stabilizing device, Locker after microdecompression as an alternative to the
fusion for the treatment of lumbar stenosis with mild degree of instability in the elderly
patients.
METHODS: 51 patients (20 male, 31 female) with the minimum age of 65 years and
symptomatic spinal stenosis who underwent Interspinous Locker Fixation (ILF) after
microdecompression between 2004 and 2007 at our institution are followed
retrospectively. And the mean age of 70.8 years, mean follow-up period was 2 years 4
months.
RESULTS: The mean Visual Analogue Scale (VAS) score for leg and back symptom
dropped from 7.0 to 3.1 and 5.9 to 3.2, respectively (p < 0.05). The Oswestry Disability
Index (ODI) improved from 58.9 to 32.4 (p < 0.05). There was one case requiring
revisional surgery at the affected levels. There was no associated complication such as
infection or intraoperative neural injury. Satisfaction rate was 73.56%.
CONCLUSIONS: This less invasive and bloodless, non-fusion technique in the
management of spinal stenosis has been developed to decrease the morbidity and
mortality associated with large laminectomy with or without lumbar fusion in elderly
patients.
58
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Inter-spinous Process Fixation for Degenerative Pathology of the Lumbar
Spine
Mitchell Hardenbrook
Fusion has been an accepted surgical treatment for degenerative pathology of
the lumbar spine. This has traditionally been enhanced through the use of
pedicle screw and rod instrumentation. Though this instrumentation has
improved the rate of fusion, it has also resulted in numerous adverse outcomes.
Placement of pedicle screw requires a wide surgical exposure with intraoperative
muscle stripping resulting in significant morbidity. Additionally, the pedicle is in
close proximity of the adjacent un-fused facet joint. Placement of pedicle screws
often results in iatrogenic injury of the adjacent facet at the cephalad of the
construct. This fact combined with the rigidity of the screw-rod construct has lead
to accelerated degeneration of the adjacent levels. This has been reported as
high as 30% incident.
This raises a number of questions. First, can alternative fixation be utilized to
avoid the pedicle? This would reduce the need for a wide surgical exposure and
reduce the risk of iatrogenic injury to the adjacent facet. Second, would a less
rigid construct reduce the rate of adjacent segment degeneration while providing
enough stability to enhance surgery?
Inter-spinous process fixation allows for posterior fixation as an adjunct to lumbar
fusion. It has the benefit of providing fixation with only minimal midline muscle
dissection. Biomechanical testing shows inter-spinous fixation to be equal in
stiffness to pedicle screw/rod fixation when paired with anterior interbody fusion
in flexion and extension. However, there is less rigidity in lateral bending and
rotation in the inter-spinous process fixation. Biomechanical testing of the
adjacent level to inter-spinous process more closely matches the intact disc
when compared to the adjacent level of the rod-screw construct. Early
evaluation has demonstrated improved perioperative clinical outcomes.
59
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ANALYSIS OF CERVICAL NUCLEOPLASTY OUTCOMES USING COBLATION
TECHNOLOGY
H.Selim Karabekir,
Kocatepe University School of Medicine,Neurosurgery Department
Background: Nucleoplasty is a minimally invasive procedure for managing chronic
discogenic cervical pain. Although there’s some reports of nucleoplasty outcome
rates, few have dissected the detailed factors affecting those outcomes.
Purpose: To evaluate outcomes of chronic cervical discogenic pains treated with
nucleoplasty and success of it.
Material & Methods: Data were gathered on the basis of records from 08 January
2005 to 08 January 2006. Thirty-six cases treated at a single or double levels with
disc protrusion ≤2 mm, without motor deficities and annular tearing and positive
discogram were studied. Minimum follow-up period was 24 months. All assessments
included visual analog score (VAS) and at 6,12,24 and 36 months post-procedure.
VAS was evaluated by a 10-point numeric rating scale, ranging from no aggravated
pain “0” to the worst aggravated pain “10”.
Results: The improvement of pain with VAS displayed moderate changes at 6, 12,24
and 36 months and patients ability of daily life were good.
Conclusion: Good classified patients with cervical disc degeneration without annular
tearings and motor deficities have a good prognosis managing with minimal invasive
procedure, nucleoplasty.
Key words: Cervical degenerative disc, nucleoplasty, ablation, coagulation,
60
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Intradiscal Therapies
Prof. Serdar Erdine, MD,FIPP
Department of Algology , Medical Faculty of Istanbul, Turkey
The pathological basis for some low back pain may be due to internally
disrupted intervertebral discs and in particular ,sensitized annular
tears.Besides surgical interventions like total disc excision and
artrhrodesis,percutaneous intradiscal therapies may also be considered.
These intradiscal techniques are
1. annuloplasty
a. intradiscal electrothermal therapy (IDET)
b. Radiofrequency posterior annuloplasty (RFA)
c. Biaculoplasty
2. Percutaneous disc decompression
a. Laser discectomy
b. Radiofrequency coblation
c. Mechanical disc decompresson(decompressor)
d. Manual percutaneous lumbar discectomy (PLD)
3. Endoscopic percutaneous discectomy.
Most of these intradiscal therapies are in application more than a decade and
long tem follow ups with each technique are emerging in the literature.
These therapise attempt to reduce pain rather than repair the degenerated
disc.Despite anectodal statements of success,long term results thus far have
found their use to be of little direct benefit.
In this lecture , long term results of these techniques will be presented and
discussed.
Reference;Raj.P; Intervertebral Disc;Anatomy-Physiology- PathophysiologyTreatment. Pain Practice;vol 8,issue 1. 2008,18-44
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Identifying the pain generators in the lumbar spine: Bridging the Gap between
Interventional Pain Management and Traditional Spine Surgery:
Anthony T. Yeung, M.D.,
Introduction:
Interventional pain management physicians attempt to find pain
generators with injection techniques. This usually only provides temporary pain relief,
anticipating that the injection will mitigate the pain. The ability to place a needle in the
vicinity of the pain source, however, and then visualize patho-anatomy with the
endoscope has opened the door for access to the lumbar spine from T-10 to S-1.
Endoscopic Spine Surgery is therefore possible with evolving modalities and techniques
to address the patho-anatomy of pain. While traditional approaches provide standard
proven and optimal access to spinal pathology, there are conditions better suited for the
foraminal endoscopic approach. When a surgeon combines interventional techniques
with endoscopic visualization, additional steps in the treatment algorhythm are available.
Materials and Method: A standardized method for endoscopic foraminal surgery (the
YESS technique) is utilized: 1. A protocol for optimal instrument placement is calculated
by lines drawn on the skin from the C-Arm image. This facilitates needle and cannula
placement for endoscopic surgery. This same trajectory is utilized for diagnostic and
therapeutic injections as a precursor to endoscopic surgical intervention. 2. Injection of
non-ionic radio-opaque contrast will result in a foraminal epiduralgram will produce
foraminal epidural patterns that provide information on foraminal patho-anatomy such as
HNP, and central and lateral spinal stenosis. 3. Evocative chromo-discography. ™ is
performed to confirm discogenic pain and tissue removal is aided by the vital tissue
staining. 5. Endoscopic foraminoplasty can be performed if needed. 6. Diagnostic and
surgical exploration of the epidural space. 7. Probe the hidden zone of MacNab
containing the exiting nerve, DRG, and axilla of the traversing and exiting nerve. 8.
Using the biportal technique for inside-out removal of extruded and sequestered nucleus
pulposus.
Results: The foraminal endoscopic technique will allow surgical access to the lumbar
spine for treatment of a wide spectrum of painful degenerative conditions. There are,
however, conditions where the endoscopic foraminal approach is advantageous over
traditional surgical approaches.
These conditions are 1. Discitis 2. Far lateral
extraforaminal HNP, especially at L5-S1. 3. Upper lumbar HNP 4. Lateral foraminal
stenosis 5. Discogenic pain from annular tears. 6. Visualized endoscopic medial branch
Rhizotomy. Case examples utilizing jpeg and mpeg imaging illustrate the painful
conditions most suitable for foraminal endoscopic surgery.
Conclusion: New surgical skills will become desirable and necessary for the spine
surgeon to incorporate endoscopic spine surgery in their practice. Incorporating
Interventional pain management helps bring additional clinical information that facilitates
patient selection. New spinal procedures such as nucleus replacement, annular repair,
annular reinforcement, and biologics are well suited for the foraminal minimally invasive
approach. Endoscopic foraminal access to the lumbar spine will open the door for true
minimally invasive access to the lumbar spine without affecting and destabilizing the
dorsal muscle column.
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ENDOSCOPIC TRANSFORAMINAL DISCECTOMY FOR RECURRENT LUMBAR
DISC HERNIATION
T. Hoogland; M. Schubert; K. Brekel-Dijkstra; B. Miklitz
ALPHA-KLINIK, Munich, Effnerstr38, 81925 München- Germany
Purpose
Recurrent disc herniation is a significant problem as scar formation and progressive
disc degeneration may lead to increased morbidity with re-operation. The advantage
of the ETD is that there is no need to go through the old scar tissue. The
disadvantage may be a long learning curve for the surgeon. Purpose of this
prospective study was to review complications and results of the Endoscopic
Transforaminal Discectomy (ETD) for recurrent herniated discs.
Material and Methods
262 consecutive patients over a four year period with a MRI proven recurrent discherniation in the lumbar spine with primarily radicular symptoms who did not respond
satisfactory to conservative treatment over were included in this prospective clinical
study. From a lateral approach first the intervertebral foramen was enlarged and a
working cannula was inserted into the spinal canal. The prolapsed or extruded part
was removed under endoscopic view with special forceps’s. With a special reamer
the inferior endplate was perforated, abraded and all loose intradiscal fragments were
removed.
Results
3 months post-operative all patients underwent a clinical evaluation and at two years
post-operative 90.8% returned an extensive questionnaire including VAS Scores,
MacNab Score as well as subjective satisfaction assessment. At two years 85.7% of
the patients rated the result of the surgery as excellent or good. 9.7 % reported a fair
and 4.6 % patients an unsatisfactory result. Patients recorded an average
improvement of their leg pain of 5.9 points and 5.7 points of their back pain on the
VAS scale (1-10). According to Mac Nab criteria 30.7% of the patients felt fully
regenerated, 50 % felt their efficiency to be slightly restricted, 16.8% felt their
efficiency noticeably restricted and 2.5% felt unaltered. All patients had a 3-month
follow-up where possible complications were registered. 3 transient nerve root
irritations and 6 (2.3%) early recurrent herniations (<3 months) were reported. There
was no case of infection or discitis. 11 patients have been re-operated for recurrence,
after 3 months and within 2 years (4.6%).
Conclusion
Endoscopic Transforaminal Discectomy appears to be an effective treatment for
recurrent disc herniation with only few complications and a high patient satisfaction.
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Cervical Facet Denervation
S. Erdine,MD,FIPP
Dept. of Algology,Med Fac of IstanbulTurkey
The
causes of facet pain in the cervical region are; Degenerative
disease,Postural abnormalities and Trauma.If medication or physical therapy
does not sustain pain relif there may be an indication of cervical facet
denervation.
The indications for cervical facet denervation are;Duration (pain) > 3 months,no
causal therapy,transient response to local anesthetic injection and no
neurological deficit.
The
contraindications RF-lesions are central pain syndrome, use of
anticoagulants,or abnormal response to test block. The procedure has to be
performed under fluoroscopy.Recently for cervical region pulsed rf is more
preferred due to less complications.
The complications are;Local pain,dizziness,ataxia,sympathetic block,injury of the
vertebral artery or ventral ramus,local anesthetic injection into the vertebral
artery,convulsion,air injection into the vertebral artery,serious neurological
sequele,excess amount of local anesthetic passing to the epidural and
subarachnoid space and
advancing the needle penetrating to the
epidural,subdural and subarachnoid space. Techniques in cervical region should
be performed by experts and not recommended for beginners.
Reference;
Erdine S. Targets and optimal imaging for cervical spine and head blocks.
Tecniques in Regional Anesthesia and Pain Management 2007; 11(2): 263-72.
64
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PARASPINAL MAPPING IN LUMBAR SPINAL STENOSIS
İLKER YAĞCI, MD, PHYSIATRIST
Lumbar spinal stenosis (LSS) is a clinical syndrome of buttock or lower extremity pain, which may
occur with or without back pain, associated with diminished space available for the neural and
vascular elements in the lumbar spine. LSS is a prevalent condition, with an estimated 13% to 14% of
those patients who seek help from a specialty physician and 3% to 4% who see a general practitioner
for low back pain diagnosed with LSS. LSS is a well known source of significant disability among the
elderly and a common cause for back surgery which is likely to increase in prevalence as society
ages.
The differential diagnosis of spinal stenosis includes numerous disorders ranging from
mechanical back pain to vascular disease to polyneuropathy. The diagnosis is generally based on
clinical findings and supported by radiographic evidence. Magnetic resonance imaging (MRI) is
commonly used to assess lumbar spine. MRI can demonstrate the presence and size of a lesion.
However there is no relationship between the radiologic measurements and symptomatology in LSS.
Additionally, there are many studies addressing high rates of radiologic LSS in asymptomatic persons.
The false positive diagnosis can lead to misdiagnosis and also mistreatments in patient who has a
different condition that mimics LSS. Even in symptomatic LSS defined by AP spinal canal diameter is
not significantly associated with location or severity of clinical symptoms. However the therapeutic
interventions such as selection of roots in transforaminal epidural injections are performed based on
MRI.
The rationale behind performing electrodiagnosis in patients who may have lumbar spinal
stenosis is to evaluate real-time electrophysiological function of nerves and rule out diagnoses with
similar presentations such as peripheral neuropathy and motor neuron disease. Beside differential
diagnosis needle electromyography can demonstrate the nerve root functions. In recent years the
quantification and standardization of paraspinal EMG have been developed which was known as
paraspinal mapping (PSM) technique. It was demonstrated that PSM had higher sensitivity than MRI
in asymptomatic patients. According to our unpublished data the technique is very useful to differ
radiological LSS from the symptomatic patients. The technique can additionally demonstrate the root
functions successfully in symptomatic patients. This feature may guide the treatment approaches but
the prognostic value of PSM is needed to clarify with further investigations.
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INTERVENTIONAL CAUSALGIA TREATMENT "IMAGE GUIDED"
JALAL JALAL SHOKOUHI
JAMEJAM MEDICAL CENTER,IRANIAN SOCIETY OF RADIOLOGY
InterventIonal causalgIa treatment "Image guIded" CausalgIa, complex
regIonal paIn syndrome or reflex sympathetIc dystrophy treated In war
Injured patIents. In 1905 fIrst sympathetIc trunk block made by SelheIm
and followed later wIth blocks by Lawen, KappIs and FInsterer. The
common sympathetIc ganglIon blocks Include: 1. Stellate ganglIon block
for upper extremIty and lower facIal and neck paIn. 2. CelIac ganglIon
block for paIn of the upper abdomen. 3. Lumbar sympathetIc block for
paIn related to the lower extremItIes. 4. Impar ganglIon block for paIn In
the lower pelvIs and perIneal regIons. Lumbar sympathetIc block or
blockage and ethanol sympatectomy may be helpful In cases of lower
extremIty reflex sympathetIc dystrophy or causalgIa of war Injured
patIents. The lumbar sympathetIc plexus extends from L2 down to L5.
The best target Is anterIor of L2 vertebrae. A postero-anterIor approach,
slIghtly off mIdlIne Is made In all patIents. InjectIon of IodIne contrast
medIum (AIr bubble In hypersensItIve patIents) confIrms safety of
InjectIon sIte (to save Aorta, IVC and ureter In the retroperItoneum). All
patIents guIded by X-ray CT Scan. 68 Adult patIents treated by thIs
methods, 18 persons was operated before by surgIcal sympatectomy
methods and vascular surgeons for many tImes but paIn recurred agaIn.
In orthopedIc surgIcal and InterventIonal procedures: LInson,Leffert and
Todd reported use of lIdocaIn and CortIcosteroId wIth 89% paIn
lessenIng In causalgIa and 80% treatment In other dystrophIc varIants.
They used sequentIonal sympathetIc blocks. All our patIents had gunshot
wounds or metallIc fragments from explosIve army materIals. WIth hIgh
velocIty InjurIes spontaneous paIn recovery takes longer tIme (3-9
months for slow velocIty InjurIes). After thIs prIod there Is IndIcatIon for
surgery or InterventIon. We used BupIvIcaIn 0.5% (20 cc) and Ethanol
65% (10-16 cc). PaIn reductIon gaIned In all patIents about 85%. All of
patIents treated by sImple procedure except few patIents wIth
subsequent Ethanol sympatectomy after successful BupIvIcaIn or MarcaIn
sympathetIc block. Speaker: Jalal ShokouhI Jalal-M.D.* FatehI MansourM.D.* AmerI AlIakbar-M.D.* +98-9121137884 +98-21-88317260
[email protected] *IranIan socIety of radIology,Tehran,Iran
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ADVANCES IN THE TREATMENT OF DISCOGENIC BACK PAIN
SALAHADIN ABDI, MD, PHD
Diagnosis and treatment of lumbar discogenic pain due to internal disc disruption (IDD)
remains a challenge. It accounts for 39% of patients with low back pain. The mechanism
of discogenic pain remains unclear and its clinical presentation is atypical. Magnetic
resonance imaging (MRI) can find high-intensity zone as an indirect indication of IDD.
However, relative low sensitivity (26.7% to 59%) and high false positive (24%) and falsenegative (38%) rates reduce the value of MRI in screening for the existence of painful
IDD.
Provocative discography can provide unique information about the pain source and the
morphology of the disc. It may also provide information for selecting appropriate
treatment for the painful annular tear. Adjunctive therapies, including nonsteroidal antiinflammatory drugs, physical therapy, rehabilitation, antidepressants, antiepileptics, and
acupuncture, have been used for low back pain. The value of these treatments for
discogenic pain is yet to be established. Intradiscal steroid injection has not been proved
to provide long-term benefits. Intradiscal electrothermal therapy may offer some pain
relief for a group of well-selected patients. No benefits have been found for the
intradiscal radiofrequency thermocoagulation.
In this presentation, I will discuss about L2 spinal nerve block as this may interfere with
the transition of painful information from the discs to the central nervous system.
Furthermore, I will discuss disc cell transplantation which is in the experimental stage
and has the potential to become a useful option for the prevention and treatment of
discogenic back pain. However, more basic science and clinical studies are needed to
establish its clinical value.
References:
Aprill C et al. Br J Radiol. 1992;65:361–369.
Bogduk N et al. J Anat 132:39-56,1981
Bogduk et al.: Spine J 2002;2:343–350.
Brisby et al.: Orthop Clin North Am 2004;35:85–93.
Cassinelli eta al.: Spine J 2001;1:205–214.
Coppes MH et al. Spine 22:2342-50,1997
Freemont et al.: Lancet 1997;350:178–181.
Groen et al. Am J Anat 188:282-296,1990
Horton WC, Spine 1992;17:S164–S171.
Kitano T et al. Clin Orthop 293, 372-377,1993
Nakamura et al.: J Bone Joint Surg [Br] 1996;78-B:606-612.
Pauza et al.: Spine J 2004;4:27–35.
Schwarzer AC, et al.: Spine 1995;20:1878–1883
Zhou and Abdi, Clin J pain 2006; 22(5):468-81.
Zucherman J, Spine 1988;13:1355–1359.
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CONTROVERSIES SURROUNDING EPIDURAL STEROID INJECTIONS
SALAHADIN ABDI, MD, PHD
EpIdural steroId InjectIon Is a commonly performed procedure In managIng
chronIc back paIn. However, Its effectIveness contInues to be a subject of
controversy. Thus, thIs presentatIon wIll cover the followIng:
I. DIscuss the pathology and pathophysIology of dIsc hernIatIon
II. RevIew the lIterature and present the evIdence of:
- Caudal ESI
- InterlamInar ESI
- TransforamInal ESI
III. DIscuss the controversIes surroundIng ESI
IV. ConclusIons and future dIrectIons
References:
AbdI et al. PaIn PhysIcIan 2007; (10):185-212
Armon et al Neurology 2007; 68(10):723-729
Cannon DT, et al Arch Phys Med Rehab 2000; 81 (S):87-97
Carette et al. NEJM 1997; 336:1634-40.
Devor, M et al; PaIn, 1992, 48:261-268
KawakamI M et al SpIne 19:1780-1794,1994
KIrkaldy-WIllIs WH SpIne 9:49-55,1984
Koes BW et al. PaIn 1995; 63:279-288
Lee HM et al SpIne 23:1191-1196,1998
Nygaard et al. SpIne 1997; 22:2484-8
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INTRAOPERATIVE ALCOHOL INJECTION FOR THE TREATMENT OF A SACRAL
SPINAL EPIDURAL HEMANGIOMA. TECHNICAL NOTE.
AHMET MENKU
Vertebral hemangiomas are not true neoplasms but congenital vascular malformations.
Spinal hemangiomas can also be epidural without vertebral body involvement; these are
extremely rare with few reported cases in the sacral epidural spinal location. Because of
the high vascularization of hemangiomas, preoperative misinterpretation may result in
unexpected intraoperative hemorrhage and incomplete resection, which results in the
persistence of clinical symptoms or recurrence. Reoperation for remnant or recurrent
epidural hemangioma is very difficult because of peridural or periradicular adhesion and
unclear tumor margins; as a result, complete resection cannot be guaranteed in
reoperation. Therefore, proper preoperative planning and complete resection in the first
operation is essential. The authors present a detailed characterization of a sacral spinal
epidural hemangioma in a 38-year-old woman who presented with complaints of gradual
onset of low-back pain that worsened over 1 year. The MR imaging findings indicated a
large L5-S2 epidural spinal mass causing thecal sac compression. The patient underwent
an S1 hemilaminectomy, and a vascular extradural mass was noted on the posterior
aspect of the dura mater. Total resection of the tumor was achieved using intraoperative
alcohal injection and microscopic dissection. The postoperative MR imaging findings and
clinical outcome were excellent. The authors also review treatment modalities and
demonstrate the utility and effectiveness of intraoperative alcohal injection in grosstotal
resection of large difficult spinal epidural hemangiomas.
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PERCUTANEOUS AUTOMATIC DISCECTOMY OF CERVICAL AND LUMBAR SPINE
KONSTANTIN POPSUISHAPKA
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LUMBAR AND CERVICAL FACET JOINT DENERVATION WITH LASER
SRI KANTHA, M.D.
Facet joint arthritis is a common cause of disabling neck and low back pain. Currently the
treatment options include facet joint blocks, radiofrequency and laser facet rhizotomy, and spinal
fusion in severe cases.
The results of facet joint blocks with steroids and local analgesics are temporary. Radiofrequency
rhizotomy of cervical and lumbar facet joints has been implemented over the past 25 years. From
my clinical experience, the results of radiofrequency facet rhizotomy are variable from 9-83%.
Lasers have been used in disc decompression since 1991 with excellent results. This has
prompted us to use laser on intractable cervical and lumbar facet joint arthritis pain and facet joint
mediated pain post discectomy.
Laser is widely employed in various surgical specialties for its precision in thermocoagulation.
Laser has the advantage that a relatively larger area in the vicinity of the probe undergoes
thermocoagulation in contrast to a radiofrequency probe.
We have used this procedure on patients with intractable facet joint mediated pain since 1993.
Many of our patients had multiple open spinal surgeries and also endoscopic discectomies. Their
radiculopathy had improved, but these patients continued to experience paraspinal neck and back
pain, and referred pain including headaches, suprascapular discomfort, and pain radiating to the
posterior thigh. Some patients who had failed or experienced short lasting relief following
radiofrequency denervation, underwent laser facet
joint denervation, with complete and long lasting relief.
Percutaneous laser facet joint denervation is a technique which can be used in intractable pain
secondary to cervical and lumbar facet joint arthritis, and post-discectomies. This is a minimally
invasive procedure with good to excellent success rate.
Cervical and lumbar facet joint denervation by laser-assisted technique is performed using a
cannula to approach the facet joints. A HO:YAG laser straight firing probe is inserted through the
cannula and laser heat is applied at 10 Hz, 5 watts to selectively denervate the facet joint. Every
effort is made to denervate the joint yet preserve the capsule of the joint. From my personal
experience, the results of laser denervation are more rewarding than radiofrequency lesioning for
denervation of cervical and lumbar facet joints causing mechanical neck and low back pain.
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FLUOROSCOPICALLY GUIDED TRANSFORAMINAL EPIDURAL STEROID
INJECTIONS FOR LUMBAR SPINAL STENOSIS AND LUMBAR DISCOGENIC PAIN
SERDAR KABATAS
Introduction: Epidural steroid injections (ESIs) have been used in the treatment of
chronic low back pain (CLBP) with success. We therefore analysed the efficacy of
fluoroscopically guided transforaminal ESI in patients with lomber spinal stenosis (LSS)
and lumbar discogenic pain (LDP) with radiculopathy.
Methods: We retrospectively analyzed the prospectively collected data of all patients
with a diagnosis of CLBP performed fluoroscopically guided transforaminal ESI between
February 2008 and December 2008. Twenty-nine patients with neuroradiological
evidence of disc pathology with radiculopathy and LSS were included. All patients
received at least one fluoroscopically guided transforaminal epidural injection with 80 mg
methylprednisolone acetate and 2 cc of bupivacaine HCl 0.5%. Collected follow-up
information included Visual Numeric Pain Scale (VNPS) and North American Spine
Society (NASS) patient satisfaction scores.
Results: Ages of patients ranged from 34 to 83 years old (mean,56.1±1.2 years old).
Among them, 22 are women (75.86%), and 7 are men (24.14%). 68.96 % of patients
were determined to have a successful outcome and 31.04% were deemed failures,
respectively. Successes were found to differ significantly from failures in pre-injection
pain scores and patient satisfaction (p<0.05).
Conclusion: Fluoroscopically guided transforaminal ESIs have reliable results to
perform in patients with LSS and LDP with radiculopathy.
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PRELIMINARY REPORT ON PERCUTANEOUS TRANSPEDICULR SCREW
INSTRUMENTATION COMBINED WITH MINIMAL ALIF APPROACH
JOSIP BURIC*, DOMENICO BOMBARDIERI*, LUCA CORÒ°
Objective: This study was performed to compare the minimally invasive circumferential
fusion to standard open circumferential fusion for low back pain in lumbar degenerative
disc disease. Background: Standard open circumferential fusion is associated with better
clinical and radiological results than PLIF or TLIF fusion procedures but has a higher
degree of intraoperative and post-operative complications. Minimally invasive ALIF
combined with percutaneous trenaspedicular screw instrumentation has the potential of
reducing the disadvantages of the procedure.
Methods: Eighteen patients affected by low back and leg pain due to degenerative disc
disease from L3 to S1 levels were submitted to the operation during 2007 year using this
minimally invasive approach. Posterior part of the procedure was performed using the
percutaneous transpedicular screws (Pathfinder, Abbott Spine) while the ALIF was
performed in a minimally invasive retroperitoneal way implanting anterior full-body cage
(Perimeter, Medtronic).
Results: All of 18 patients improved upon surgery. The mean improvement was of 5,7
points on VAS scale and 7 points on the Roland Morris Disability Quetionnaire. The mean
operating time for the posterior part of the procedure (skin to skin) was as follows: 50
minutes for one level and 80 minutes for two levels. The mean operating time for the
anterior approach was 90 minutes for one level and 110 minutes for two levels. The total
amount of time for both approaches, including the turn-up time for patient repositioning
ranged from 160 minutes for one level till 300 minutes for double level. No major
complications due to vascular rupture or peritoneal damage were encountered. As well, a
nerve root damage was ever found. The mean blood loss per surgery was approximately
250 milliliters and in no patient blood transfusion was indicated. Surgical wound drainage
was never used. All the patients were raised from the bed between 12 to 18 hours after
the surgery. The longets hospital stay was 6 days. As compared to standard
circumferential fusion, the reported post-operative pain was 3-fold less and the use of
post-operative opioids and pain killers was 60% less. No wound or systemic infection was
ever encountered. There were no complicatioins observed due to pulmonary embolism.
Conclusion: Minimally invasive ALIF combined with posterior percutaneous
transpedicular screw instrumentation seems an equally usefull system as compared to
standard open circumferential fusion with the advantage of less blood loss, fewer
complication rate, shorter operation time and shorter hospital stay. Longer follow-up is
mandatory to verify clinical and radiological results.
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TWO YEARS FOLLOW-UP RESULTS OF OVER 400 LUMBAR NUCLEOPLASTY
CASES
KEMAL YÜCESOY, MD
Objective: To evaluate long term follow-up period results of lumbar disc nucleoplasty
for the treatment of degenerative disc disease.
Methods: We presented four hundred and two cases. All patients were evaluated
with visual analogue scores and Oswestry back pain questionnaire results.
Preoperative, early postoperative, first, third, and sixth month, one, and two year
follow-up results were discussed.
Results: 494 levels were treated by percutaneous disc nucleoplasty using coblation
technique in four hundred and thirty six cases. 327 of these patients were female,
and mean age was found 42.7 (14-64 years old). One level coblation was performed
in 378 cases, and two level in fifty-eight (L5-S1 level in eighty-six, L4-5 level in three
hundred and thirty-eight, L3-4 level in sixty-two, L2-3 level in five, L1-2 level in two,
and T12-L1 level in one) without any complications. 34 of these cases dismissed
during one and two years control follow-up examination, and we presented as late
results of 402 cases. Mean visual analogue score was detected preoperatively,
postoperatively, at one, three and sixth month, one, and two year follow-up controls
and, 8.30, 1.02, 2.37, 1.55, 1.36, 1.48, and 1.64 was found, respectively. Also
Oswestry back pain questionnaire scores were detected as 53.69, 16.18, 12.19,
7.18, 4.52, 6.38, and 8.04 at the same examinations. During the follow-up period
second disc nucleoplasty was performed at same level in thirteen cases, and open
surgery was performed in twenty-two.
Conclusion: We can conclude that successful results are directly related to patient
selection, physical examination and changing of life style.
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ADULT STEM CELL TREATMENT IN SPINAL CORD INJURY – TECHNIQUE
INDICATION AND FIRST CLINICAL RESULTS
NILS HABERLAND,
The adult stem cell therapy is nowadays established in the treatment of blood cancer
and heart attack. New is the application of adult stem cells for neurological diseases
and in brain and spinal cord injury. The aim of the study was to achieve first results in
cases of spinal cord injury for the evaluation of the efficiency of the adult stem cell
therapy.
Method: We used bone marrow material from the iliac crest for the isolation and
separation of the adult stem cells (CD34+). The reinjection of the stem cells we
perform via lumbar puncture. We treated 100 patients with incomplete and complete
spinal cord injury and evaluated 40 patients with a minimal follow up time of 3
months.
Result: In 57.5% of the examined patients we saw an improvement of the
neurological deficit. A deterioration of the neurological symptoms was not found and
we observed not a specific complication regarding the adult stem cells.
Conclusion: The first clinical results of the adult stem cell treatment are
encouragering in cases of spinal cord injury. In our study the treatment was effective
and safe. Prospective randomised studies are necessary for a scientific evaluation of
this kind of stem cell treatment.
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DIAM DEVICE FOR LOW BACK PAIN IN DEGENERATIVE DISC DISEASE
J BURIC; M PULIDORI
Objective: To evaluate the usefulness of the DIAM device in patients affected by low
back pain due to degenerative disc disease. Background: Recently a number of
interspinous devices for dynamic interspinous distraction-stabilization have entered the
clinical practice in Europe. All of these devices have a common property of acting on the
posterior part of the functional spinal unit by distracting the spinous processes and
avoiding extension of the treated segment. Consequently, these systems seem to
improve the cross-sectional area of the thecal sac and enlarge the diameter of the
intervertebral foramina. What was found as a collateral observatin after implantation of
these devices was that those patients affected by low back pain, improved significantly in
their pain level. Methods and
Materials: Fifty-two consecutive patients were included in the study. There were 29
females and 23 males, aged between 29 and 77 years (mean 49.4 ± s.d.12.4). The preoperative symptom duration ranged from 6 to 84 months (mean 31.8 ± s.d.20.2, median
24 months).The following diagnositic measures were prformed in each patients: MRI,
dynamic x-rays and provocative discography positive for pain reproduction. The patients
were followed for pain by VAS and for functional status by self-reported Roland-Morris
Disability Questionnaire. The minimum follow-up was 24 months (24 to 36). The
intermediate follow-up at six, twelve and eighteen months was tested for, too.
Results: To determine the number of improved patients we have arbitrarly selected a
cut-off criteria based on a 30³% of improvement as calculated on the Roland Morris
Disability Questionnaire scale comparing the 24 months values to the baseline values.
Fourthy-six patients (88%) were considered as success and 2 (4%) were considered as
failure. No long-term complications were observed.
Conclusions: This preliminary report indicates that the DIAM device colud possibly be
usefull in the treatment of LBP due to DDD. Further research with RCT is necessary to
confirm these preliminary results. Keywords – low back pain, degenerative disc disease,
interspinous spacers, spine instrumentation
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HYPEROSMOLAR DEXTROSE SOLUTION INJECTION ON LUMBOSACRAL
MEDIAL BRANCH AND BILATERAL SACROILIAC JOINT FOR REMNANT
BUTTOCK PAIN AFTER VERTEBRAL AUGMENTATION PROCEDURES
CHANG IL JU, M.D.
Background: Osteoporotic vertebral compression fractures (VCFs) in the elderly
patient can cause significant pain and lead to restrict their daily life activities.
Augmentation procedures (Vertebroplasty(VP) and kyphoplasty(KP)) have reported
as a standard treatment of VCFs in cases of not responding to conservative
treatment. However, the patients who have remnant pain after augmentation
procedures are challenges to doctors and require the definite treatment. We have
tried to inject hyperosmolar dextrose solution into the lumbosacral medial branch and
bilateral sacroiliac joint for remnants buttock pain and report our results.
Methods: Thirty six patients with remnant pain after augmentation procedures of 321
patients were surveyed. We judged the remnant pain when patients complained the
pain after postoperative 2 days. The patients were performed bilateral lumbosacral
(L4, L5, S1) medial branch injection and bilateral sacroiliac joint injection using
hyperosmolar dextrose solution. Injection was given after 3-5 days VP and KP
procedures. All remnant pain patients were evaluated at interval of 1-2 weeks and
added injection if they had pain.
Results: Total number of injection was 2.31. Pain intensity using VAS (visual analog
scale) was decreased, from 8.78 before augmentation procedures to 4.33 after
augmentation procedures to 2.67 after the first injection procedure and 1.97 after the
second injection procedure. Successful outcome was determined if pain reduction
exceeded 50% relief than post-augmented buttock pain state. 5 of the 36 patients
(13.9%) did not respond favorably to injection (pain reduction less than 50%), and 31
patients (86.1%) showed successful responses.
Conclusions: The hyperosmolar dextrose solution injection into the lumbosacral
medial branch and bilateral sacroiliac joint to the patient who has a remnant pain
after augmentation procedures in the patients with VCFs is the one of the methods
that decreases the symptoms.
77
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IN-SPACE (PERCUTAENOUS INTARSPINOUS SPACER) TREATMENT OF
CANAL STENOSIS.
T. SINAN, A. OBAID
Intraspinous spacers have become an accepted minimally invasive method for
treating Dynamic spinal canal stenosis. We present our experience using the INSPACE (Percutaenous Intraspinous spacer) in treating Dynamic canal stenosis in
Kuwait. Material and method: Prospective study of 30 patients presenting with
neurological claudication with dynamic canal stenosis on MRI. All patients were aged
50 +. IN-SPACE was used in these entire patients under fluoroscopy. Follow up was
made at 1 week, 1 month, 3 month and some patients 6 months. VAS score was
compared before and after procedure. Complications rate and patient satisfaction
were noted. Results: > 70 % patients had significant improvement with no
complications. We also describe the procedure.
78
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OSTEOID OSTEOMA OF THE SPINE: GEIGER GUIDED RESECTION.
ARSEN SHPIGELMAN, MD
Background:
It is often difficult to accurately localize the Nidus of Osteoid Osteoma ( OO )
during the operation.
There has been a tendency to extensively excise the lesion with surrounding
sclerotic bone to avoid recurrence due to presence of residual Nidus.
We describe method of Geiger guided Resection of Osteoid Osteoma of the
spine in 5 cases from our department.
Method:
We localized intraoperatively the Nidus with preoperatively injected technetium
labeled methylene diphosphonate and a sterile wrapped Geiger counter.
The radioactive agent was injected 12 hours before operation.
The tissue around the Nidus reduce radioactivity 12 hours after injection of
radioactive Technetium.
Results:
5 cases of Block Resection of Osteoid Osteoma from the pedicle and facet area
were proceeding.
Technetium labeled methylene diphosphonate was injected 12 hours
preoperative.
We localized the Nidus of OO with Geiger counter intraoperative.
Pain relive after operation in all cases.
Clear Bone scan – without uptake – in the operative region half year after
operation.
Without local recurrence of the disease.
Conclusion:
We describe the simple and clear method to identify of Osteoid Osteoma of the
Spine:
* Before operation.
* Intraoperative.
We recommended to inject a radioactive agent 12 hours before operation for
reduce of false negative identification of the tissue around the Nidus.
We recommended to use of this method for identify and resection of Osteoid
Osteoma from the pedicles of the vertebras.
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INTERSPINOUS DYNAMIC SPACER (COFLEX) INSERTION,
OUR EXPERIENCE AND SURGICAL TECHNIQUE.
A.P.SHPIGELMAN, M.D., K.ASLAN, M.D., D.ANGEL, M.D.
“BNAI ZION” MEDICAL CENTER, HAIFA, ISRAEL.
Background:
-More than 60% of the population suffer from low back pain at some time in their lives.
-Low back pain is the primary cause of disability in individuals younger than 50 years.
Subsequent interspinous process devices have been designed for longer-term
implantation for managing various conditions, including spinal stenosis, disk herniation,
segmental instability, and degenerative disk disease.
Method:
-We localized the surgical level with intraoperative X-Ray.
-Limited incision approach was performed: 3 cm’ to one level disease and up to 5 cm’ to
two level pathology.
-Semilunate incision of the fascia was opened to the side of the foramenal stenosis or
disc herniation.
-Full removal of the Interspinous Ligament.
-Spreading of the vertebras with laminar spreader.
-Insertion of the Interspinous Spacer and fixation of the Spacer to the spinous
processes.
Results:
-Radicular and Low Back Pain relief immediately after the surgery.
-Minimal postoperative wound pain due to Less Invasive Surgery.
-Early patient’s mobilization after the surgery.
-On the postoperative and follow-up examinations and imaging – preserve of the
Intervertebral Disc Space and Foramenal Diameter, natural motions in the segment.
Conclusion:
-We describe the simple and clear technique of Back Pain Treatment.
-Motion Preservation by Dynamic Interspinous Spacer insertion.
-Limited Incision Procedure was performed to insertion of the Spacer.
80
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“COFLEX” EXPERIENCE
ALEXANDRE LEVSHIN
81
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HIGH ANTERIOR CERVICAL APPROACH TO THE UPPER CERVICAL SPINE: A
QUANTITATIVE ANATOMICAL AND MORPHOMETRIC EVALUATION
MEHMET SENOGLU 1, DAVUT OZBAG 2, YAKUP GUMUSALAN 2
Abstract Object Knowledge of the quantitative anatomy of the C2 spine is essential to
safely perform anterior plate-screw fixation of the C2 spine. Injury to the spinal cord
during drill or screw placement is the most feared complication of this procedure.
Therefore, proper screw length is the most important issue for safety of vertebral
body screw placement. Obviously, understanding the safety distance between the
entry point of screw insertion and the posterior cortex of the vertebral body is
essential. In this study, we analyze the anatomy of the C2 body relevant to C2
anterior plate-screw fixation. Materials and Methods Eighty-six dried C2 spines were
evaluated directly for this study. Measurements were made on the C2 body width and
midsagittal anteroposterior (AP) depth as well as AP parasagittal depth 5 mm lateral
to the midline on the inferior endplates, in addition to on the middle body.
Measurements also were made on AP parasagittal vertebral depth with both medial
and lateral inclination of 10 degrees, with respect to the parasagittal plane of the
vertebral body. Results The ideal maximum screw length and trajectory was found to
be AP medial parasagittal depth of inferior surface of the C2 body [Right: 13.7±1.4
mm (11.0-17.9), Left: 13.6±1.5 mm (10.7-17.8)]. Conclusions We report the
measurements of the vertebral body of the C2. We think these measurements
provide guidelines for conducting operations on the anterior C2 spine, and enhance
the confidence interval of the surgeon. Key Words: anterior plate, screw, corpus, C2,
axis.
82
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SYRINGOMYELIA: RETROSPECTIVE CLINICAL ANALYSIS & REVIEW OF THE
SURGICAL TREATMENT OPTIONS
BAYRAM CIRAK, ACAR F, COSKUN E, SITTI I.
DEPARTMENT OF NEUROSURGERY, PAMUKKALE UNIVERSITY, MEDICAL
SCHOOL
SYRINGOMYELIA: RETROSPECTIVE CLINICAL ANALYSIS & REVIEW OF THE
SURGICAL TREATMENT OPTIONS Sitti I, Cirak B, Acar F, Coskun E Syringomyelia
is a progressive and degenerative disease characterized by longitudinal cystic
cavities all along the spinal cord. Cervical spinal cord being the most commonly
affected part. Magnetic Resonance İmaging study is the gold standart for the
diagnosis. Although diagnosis is easy there is a controversy about the treatment.
There are different types of surgical treatment some of which are, simple drainage by
either percutaneous or open surgical route, posterior fossa and foramen magnum
decompression and dural decompression in case of tonsillar herniation and
syringomyelia, cysto-pleural (or cysto peritoneal, or cystosubarachnod) shunting. In
these study, we retrospectively analysed the surgical treatment results of patients
admitted to our clinic with the diagnosis of syringomyelia. All the cases have been
evaluated with respect to type of surgical treatment. In between 2005 and 2008 19
patients have been admitted and operated on with the diagnosis of syringomyelia.
Mean age was 33 (r:3-64), male / female ratio was 8/11, All the patients were
diagnosed with the evaluation of MRI. 19 patients have undergone 28 operations.
Mean follow up was 13 months. Neurological condition and status of all the patients
were evaluated before and after the surgery and during follow up.
83
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SIGNIFICANS OF MORPHOMETRIC AND VOLUMETRIC EVALUATION OF LUMBAR
VERTEBRAL BODIES FOR CORPECTOMY RECONSTRUCTIONS: A STEREOLOGICAL
STUDY
NUKET MAS MD PHD ASSIST PROF., SELIM KARABEKIR MD ASSIST PROF., TOLGA
ERTEKIN PHD,
METE EDIZER MD PHD ASSIST PROF., YAZICI CANAN PHD ASSIST PROF.
Objectives
The use of technologies for the treatment of degenerative spinal diseases has undergone
rapid clinical and scientific development. It has been extensively studied in combination with
various techniques for spinal stabilization from both anterior and posterior approach. Anterior
access to the L1-L5 disc space can be technically challenging, frequently requiring the use of
an approach surgeon for adequate exposure. For a successful surgery and a suitable
instrumental design via screw, adequate morphometric knowledge about body of lumbar
vertebra and standardized volumetric data is also required. There are some reports about the
relationships between the surgical manifestations and the vertebral body morphology in
patients with degenerative spinal disease, traumatic and non-traumatic fractures and
vertebral malignities. Delineating the normal lumbar vertebra volume and its neurosurgical
importance interested in both the anatomists and the spinal surgeons. In the present study,
we aimed to evaluate the lumbal vertebra using a stereological technique. determine the
morphometric mesurements of the bodies depending on gender.
Materials and methods
Randomly selected individuals (11 males, 10 females) aged between 25– 85 years who have
normal lumbar MR and CT were enclosed in the study. Volumetric lumbal vertebras were
evaluated via stereological method on the magnetic resonance (MR) images of healthy
subjects. We evaluated volumetric measurements of the body of lumbar vertebrae using a
CT scan and MR via stereological technique. The shape and volumetry of the L1-L5
vertebra, vertebral body length, vertebral body width, and also height were analyzed selected
axial and sagittal slices that passed through the upper part of the body of all lumbar
vertebras and another one that passed through the lower part of them with comparing each
other. The data set were analyzed by two factor repeated measure analysis.
Results
The lumbal vertebra volumes were evaluated comparing with each other according to
gender.. Body of vertebra measurements were evaluated.
Conclusions
The stereological evaluation of lumbar vertebral analysis in humans correlate with gender
is of importance for both clinicians and anatomists. The stereological volume analysis
technique is simple, reliable, unbiased and inexpensive. Further studies are needed with
larger samples in order to support the data.
Keywords
Lumbar vertebra, body, morphometry, volumetry, stereology, magnetic resonance
imaging,computed tomography
84
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A NOVEL TECHNIQUE OF MICROSURGICAL APPROACH THROUGH
LAMINOFACET ARTICULAR JUNCTION FOR LUMBAR DISC HERNIATION
(HOLE APPROACH) AND VIDEO PRESENTATION
FIGEN YAGMUR ASLAN
Objects: Hole approach has not been described in lumbar disc herniation,
previously. We aim to give details and results of a new operation technique, used in
516 patients with different localization and types of disc herniation.
Methods: Between March 2001 to 2007, 516 patients with lumbar disc herniation
underwent Hole approach. In this procedure, in order to expose facets of the inferior
articular edge superior and inferior facets were removed minimally by high-speed
drill. The facet capsule left intact and opened a hole (as large as a thumb nail) in the
junction between the facets and the lamina. After the root was found, the disc was
removed, yellow ligament opened minimally. Also the residue disc may be taken out
from contralateral side by using this technique. Same side and controlateral side disc
may be cleaned at the one side operation in this technique. Patients data included;
leg and back pain, return time to daily activity, Oswestry pain score, and final
outcome. Patients were evaluated with post operative spiral CT and three
dimensional reconstruction CT to show the amount of bone removing.
Results: Following the operation no one had leg or back pain. All patients were able
to mobilize at ½ to 4 hours, returned to daily activities at 5 to 7 days postoperatively.
When compared with preoperative Oswestry pain score (46 ± 3,3), postoperative
score (3,1 ± 0,9) was significantly decreased (p<0,001).
Conclusion: The goal of this approach were to protect to the facet articular joint, to
used procedure in every type and size of disc herniation, to open the yellow ligament
minimally, and return the daily activity and work early. Hole approach is a very safe
and effective by means of treatment for back pain and sciatica pain caused by same
side and controlateral side disc herniation.
85
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A NOVEL TECHNIGUE OF MICROSURGICAL APPROACH TROUGH
LAMINOFACET ARTICULAR JUNCTION FOR FORAMINAL STENOSIS AND
SPONDYLOLISTHESIS (HOLE APROAACH) AND VIDEO PRESENTATION
FIGEN YAGMUR ASLAN
Objectives: Hole approach on the foraminal stenosis and spondylolisthesis has not
been described previously. In this study, we aim to give details and results of a new
operation
technique, used in 136 patients with foraminal stenosis and
spondylolisthesis.
Patients and Methods: Between March 2001 and 2007, 93 patients with foraminal
stenosis and 43 patients with spondylolisthesis, who had conservative treatment
before, were operated with hole approach. During operation a hole 0,5-1 cm was
opened articular joint edge and conjunction between facet and lamina. At this
approach minimaly inferomedial edge of the superior facet and superomedial edge of
the inferior facet were drilled away by Anspach. Facet capsule leave intact. By
guidance of the disc space, the portions and osteofit anteriorly, and medial face of
the facet posteriorly were cleaned. Inferior and superior root conjunctions were
exposed and interapophyseal space was released. Any instrumentation system and
fusion were not used. Patients data included; leg pain, paresthesia, and weakness,
return time to daily activity and Oswestry pain score and final outcome. Patients were
evaluated with post operative spiral CT and three dimensional reconstruction CT to
show the amount of bone removing.
Results: All patients were mobilized within 4-6 hr, discharged within 24-48 hr, sat
down within 8-12 days, returned to daily activities and works within 15-25 days.
Postoperative Oswestry pain score (3,4±1,7) was significantly decreased when
compared with the preoperative pain scores (38,8±5,01) in the patients with foraminal
stenosis (p<0.001).
Conclusion: Hole approacch may be considered as a safe and effective a new
procedure for the patients with foraminal stenosis and spondylolisthesis. This
approach will be use multilevel segment and any instrumentatition system were not
used .
86
ML - 8
THE LUMBAR FACET SYNDROME
RADCHENKO V., M.D.
SYTENKO INSTITUTE OF SPINE AND JOINT PATHOLOGY 61024, KHARKOV,
UKRAINE
Introduction. The lumbar facet syndrome is encountered most frequently, it follows
that possible ways of its treatment are particularly important.
Purpose Estimation of possibilities of diagnostics and treatment of patients with a
lumbar facet syndrome
Materials and methods We used morphological material of 56 facet joints of the
lumbar spine taken in the course of the operation of the posterior lumbar interbody
fusion on levels L4-5 and L5-S1 for various structural and functional disorders of the
lumbar spine; 52 arthrograms of the facet joints.
Results of intraarticular blocades (518 patients), data about 428 patients having
lumbar facet syndrome which underwent mini-invasive surgical treatment including
denervation and percutaneous arthrodesis.
201 patients were treated by way of denervation through electrocoagulation (1-st
group) and 211 by way of cryodestruction (2-nd group).
Percuteneous arthrodesis was performed in 16 patients. The results were
evaluated by Oswestry scale.
Results Morphological investigation demonstrated the whole range of changes
characteristic for the sinovial joints.
By data of the articular arthrography the picture peculiar to instability, severe
arthrosis was determined. In 3 cases diverticuli of the upper turn of the facet joint
markedly influencing the formation of clinical symptoms were identified.
The results of the intraarticular blocades in the intraarticular group were good - 65%,
satisfactory - 33%, unsatisfactory - 2% . In the paraarticular group they were good 58%, sutisfactory – 35%, unsatisfactory - 7%.
In the course of comparative analysis of the results in first and second group facet
denervation we could find significant difference in favour of cryodestruction.
Among the patients with the percutaneous arthrodesis performad 15 patients had
good result and in 1 patient the condition was not changed.
Conclusion Variable changes of the facet joints of the lumbar spine play a significant
role in the formation of pain syndrome and their diagnostics and treatment demand a
special consideration.
Application of active tactics in the treatment of the lumbar facet syndrome makes it
possible to achieve good results.
87
ML - 9
CLINICAL RESULTS FOR LATERAL LUMBAR DISC HERNIATIONS WITH PELD,
10-SYRINGE DISCECTOMY AND RETROPERITONEOSCOPY
AKIRA DEZAWA
Purpose
The object of this study was to introduce the transforaminal Percutaneous Endoscopic
Lumbar Discectomy (PELD) and retroperitoneal laparoscopic (retroperitoneoscopic)
lateral approach. Techniques and to assess the safety and efficacy of treating patients
with far-lateral and foraminal disc herniations via a percutaneous transforaminal
endoscopic approach.
The incidence of a lumbar disc herniation lateral to the facet has been reported to be
between 0.7 and 11.7% over all sites of a lumbar disc herniation.
Methods
From May 1997 to December 2007 we operated 39cases of PED (20cases) and 10syringe discectomy (16) and retroperitoneal laparoscopic lateral approach (3) for far
lateral and foraminal lumbar disc herniations. A retrospective analysis was performed of
39consecutive patients who underwent surgery via this approach. All procedures were
performed after induction of a local anesthetic on an outpatient basis. Surgical
indication was intractable leg pain regardless of symptom period, which was resistant
to conservative treatment including selective root block.
Results
Outcome was measured with Macnab criteria and by determining a patient's return-toprevious work. The median follow-up period was 15months (range 10-33 months).
Excellent or good outcome was obtained in 31 (79.5%) of 39 patients. Of the 39patients
playing sports and working before the onset of symptoms, 32 (82.1%) returned to
previous work and sports. One patient (2.5%) experienced poor outcomes and
subsequently underwent open procedures at the same level. There were no
complications.
Conclusions
RLLA 10-syringe discectomy provide adequate exposure necessary for extraforaminal
exploration, discectomy and nerve root decompression. PELD is sufficient for minimally
invasive treatment of extreme lateral lumbar herniation.
88
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LUMBAR DYNAMIC SEGMENTAL RESTABILIZATION : THE DYNESYS® EXPERIENCE
1999-2009
LEU HJ., PD DR.MED., PRESIDENT ISMISS 2008-2011
BETHANIA SPINE BASE, ORTHOPAEDIC SPINAL SURGERY, KLINIKUM BETHANIEN
CH-8044 ZÜRICH / SWITZERLAND – [email protected]
In modern western societies, degenerative disc disease is an increasing therapeutic and
economic problem in modern societies and afflicts over 80% op population at least once in
lifetime. The reasons ground in changed live stile with more sitting working position, long
sitting schooling periods in decisive adolescent skeletal maturation phase of life. Beside
changes in physical behavior also some nutritional aspects in post-agricultural societies may
play a relevant role. While in an early stage lumbar disc failures as protrusion and herniation
prevales, in a later stage segmental instability deserves our diagnostic and therapeutic
interest.
Segmental instability has become a controversially defined and treated vertebral pathology
with considerable impact also on tt costs. From asymptomatic hypermobility up to instability
covers a larger field of different combined pathologies that need well differentiated
treatments. In cases without neurologic implication a physical therapy with isometric
circumferential stabilization remains the golden standard. Where this fails, treatment options
are to consider following the structures to treat. For diagnostics, beside clinical examination
various imaging techniques help to determine the concerned level. First is conventional
functional x-ray, the classic lumbar functional myelography and where available dynamic
MR-imaging. This newest technique nevertheless has its methodical limits in symptomatic
patients due to up to unbearable pain with motion-artefacts during still relatively long
exposure time.
In cases with isolated mono- or bisegmental instability of the ventral pillar including alsp
posterior facet disease, interbody restabilization with fusion or total disc replacement (TDR)
are available; in cases with isolated inborn defects of the posterior facet pillar - such as
spondylolysis – an interbody fusion (PLIF) remains the golden standard. TDR is fine in cases
with untreatable dysfunction of the disc with intact mid/posterior pillar structures. Due to
persisting facet problems where preoperatively present and potential problems due to its
anterior operative approach (e.g. lesions of the plexus hyposgastricus with potential sexual
dysfunctions), its indication remains narrow and its outcome controversial. Where instability
is due to spondylolysis, local isthmic repair hardly brings reproducible results in larger series.
In degenerative facet disease without pseudolisthesis less then grade II, a dynamic
restabilization with pedicular anchorage (e.g. DYNESYS® developed by Dubois in France
1994)) is our treatment of choice since its clinical introduction in 1999. In mayor
pseudolisthesis segmental instrumented fusion remains the tt of choice. Interspinal implants
can be a favorable option in an elderly patient without considerable all-day demands and
restricted systemic options for mayor surgery. In an younger active patient, beside lost of
correction due to spinal process arrosion and other risks as their limited lateral bending
stability can maintain facet irritation symptoms. As degenerative instability is often combined
with soft (ligamentary) stenosis, combined treatment is mandatory and deserves our
individual evaluation for specific operative adaptations.
Since 1999 to 2007 over 572 cases with lumbar posterior facet disease and lumbar soft
stenosis were treated with a combination of interlaminar decompression in combination with
a pedicular based posterior bilateral dynamic stabilization device. A selscted group of 224
cases with over 5 year decourse and some specific problems as screw-loosening,
spontaneous interfacet fusion and seldom reported late infection of its textile cable
components are presented. The clinical overall outcome reached a score of 7.6 while a
control group of 100 cases with conventional fusion reached 6.8 in the Balgrist-score. As the
indications of Dynesys involve less advanced pathologies, the slightly better score is not
significant. The same is to consider for the slightly lower rate of adjacent level degeneration
over 5 years. The main advantages remain its less invasive operative procedure and the
easier muscular rehabilitation.
89
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ENDOSCOPIC MICRODECOMPRESSIVE CERVICAL DISCECTOMY AND FORAMINAL
DECOMPRESSION OVER 2000 PATIENTS
CHIU, JOHN C., M.D., FRCS, D.SC, DIRECTOR, NEUROSPINE SURGERY
CALIFORNIA SPINE INSTITUTE MEDICAL CENTER, THOUSAND OAKS, CA 91320,
USA
Purpose: To demonstrate outpatient endoscopic microdecompressive cervical discectomy
and foraminal decompression, with mechanical decompression and lower level non-ablative
Holmium laser for disc shrinking and tightening effect (laser thermodiskoplasty), performed
for treatment of symptomatic herniated cervical disc to be efficacious and safe, and
preserves spinal motion.
Materials and Methods: Since 1995, 2100 patients (3875 Discs), who failed at least 12
weeks of conservative care were treated. Levels were C2 to C7, inclusive. All patients
demonstrated unilateral radicular pain of a specific dermatome, single level or multiple
levels, confirmed with EMG/NCV. MRI or CT scans demonstrated the herniated cervical
disc. Anterior endoscopic microdecompressive cervical discectomy and foraminal
decompression technique is described. Non-ablative lower Holmium laser energy was added
for disc shrinkage.
Results: Average time to return to work was ten to fourteen days. At an average follow-up of
48 months. For single level, 94% had good to excellent symptomatic relief and spinal motion
preservation. There were no intraoperative complications. Postoperatively, one patient with
transient Horner’s syndrome and one transient hoarseness voice were noted. 6% of patients
had persistent neck and upper extremity pain associated with parasthesia, after surgery.
Conclusion: This endoscopic microdecompressive cervical discectomy and foraminal
decompression with mechanical decompression and lower level non-ablative Holmium laser
for disc shrinking and tightening effect (laser thermodiskoplasty), has proven to be safe, less
traumatic, easier, and efficacious with significant economic savings. It preserves spinal
motion and provides a channel for spinal arthroplasty. It is an effective alternative or
replacement for conventional open cervical spinal surgery for discectomy, and can
decompress stenosis, in degenerative spine disease.
90
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STAND-ALONE KYPHOPLASTY OF THE THORACOLUMBAR JUNCTION – POTENTIAL
FOR SEVERE COMPLICATIONS
C. BIRKENMAIER1, T. SEIDL2, B. WEGENER1, V. JANSSON1 AND H. TROUILLIER2
Introduction:
Kyphoplasty is a popular therapy for osteoporotic vertebral fractures (OVF), based on an easyto-learn technique and few perioperative complications. Good reimbursement and intense
advertisement by the industry also play a role. The technique is not exclusively being performed
by surgeons with experience in the treatment of traumatic spinal fractures. The PMMA-bonecement that is employed for the procedure is much stiffer than osteoporotic cancellous bone, it
does not biologically integrate into bone and there is no secondary stabilization around the
tamp.
Methods:
Analysis of 9 cases referred to our departments from 2006 through 2008. All patients had
received kyphoplasty of the thoracolumbar junction or the thoracic spine at other institutions and
were subsequently referred to our departments. After initial improvement, all patients
experienced renewed pain and immobilization within weeks, several patients suffered
neurological deficits. Presented is an analysis of the radiographic features of these fractures,
their biomechanics, how these relate to the AO fracture classification and what the implications
for the primary stability of these fractures are.
Results:
In all 9 cases, gross instability was found around the cement tamp, in several cases with
advanced destruction of neighboring vertebrae and in several cases with subtotal spinal canal
occlusion. 1 case had an infected bone tamp in addition. Analysis of the preoperative imaging
studies gave evidence to unstable burst fractures, pedicle root discontinuity or disc-withendplate avulsion. The low contrast of severely osteoporotic vertebrae in CT combined with
thick slices and incomplete multiplanar reconstructions may have been contributing to
misjudging these fractures. 8 patients required multisegment posterior instrumentation, some
with vertebral body replacement for anterior support. 1 patient died from complications of
immobilization prior to the scheduled stabilization.
Discussion and Conclusion:
Performing kyphoplasty in unstable OVF may cause complications that far exceed the original
problem. Correct fracture analysis is of paramount importance and a high-resolution, thin-slice
CT scan with multiplanar reconstructions is required. Fractures of the thoracolumbar junction
are demanding to treat and stand-alone kyphoplasty in this region carries significant risks. If,
based on thorough fracture analysis, kyphoplasty cannot with certainty achieve adequate
primary stability, additional pedicle screw stabilization should be used. Because of the
osteoporosis, pedicle screw augmentation with PMMA may be needed in order to avoid screw
cut-out. Alternatively, conservative treatment with a custom cast brace may be considered.
91
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VESSELPLASTY USING SRHA NEW CEMENT (OSTEO-G®).
A PRELIMINARY REPORT.
DARWONO A. BAMBANG, M.D.
DEPARTMENT OF ORTHOPAEDIC SURGERY, GADING PLUIT HOSPITAL,
JAKARTA, INDONESIA.
Object. Vesselplasty system, was percutaneous Osteoplasty technique
(moulding the bone) to treat the symptomatic vertebral compression fractures
(VCFs), by injection of bone filler materials (BFMs) : polymethyl metacrylate
(PMMA), other kinds of bone cement, or different kind of osteoinductive /
osteoconductive materials. Since 2004 over two hundreds vesselplasty were
done using a mixture of PMMA 70% + Ca sulfate 30% + radioopaque dye in
viscous condition. The point of this mixture is to reduce the heat, extend the
setting time longer, and the visibility of cement during the procedure through Carm imaging. The viscous condition is used as a hydrostatic pressure to restore
the vertebral body’s height while injecting inside the vessel container. In certain
condition the vesselplasty was performed in bilateral or unilateral through transpedicle or extra-pedicle routes, and through a proper procedure this system is
able to prevent risk of leakage of BFMs. A New SrHA cement (Osteo-G®) from
A-Spine Holding Co was used as BFMs in vesselplasty. The purpose of this
study was to review the advantage of SrHA cement compare to the previous
mixture of PMMA and Ca sulfate cement.
Methods. A non randomized prospective study of vesselplasty using new
SrHA cement was done either bilateral, unilateral, through trans- or extra-pedicle
routes. The heat, viscosity, setting time of the cement, the short term, mid- and
long term result inside the vertebra of the patients were evaluated by X-ray and
Ct-scan.
Results. 8 cases of VCFs that have been treated using vesselplasty and
new SrHA cement. Two cases dropped and only 6 cases can be evaluated and
reported.
Conclusions. The results of Vesselplasty technique are excellent. This
technique allows the stabilization and restoration of vertebral body height of
VCFs, with the advantage in controlling the volume of the injected BFMs , the
pressure inside BFC, also preventing the leakage of BFMs, and left as an
implant body expander. The preliminary results of new SrHA cement show that
the heat, viscosity, and setting time of the cement are ideal for vesselplasty, but
to evaluate the result inside the vertebra in short-, mid- and long term need
longer follow up and bigger number of samples.
Key Words :
92
L - 46
PERCUTANEOUS VERTEBROPLASTY OF OSTEOPOROTIC FRACTURES OF
THORACAL AND LUMBAR SPINE WITH VARIOUS COMPOSITIVE MATERIALS
ANDREY POPOV
93
L - 47
COMPLICATIONS OF VERTEBROPLASTY
KEMAL YUCESOY
Objective: The aim of this study is to
vertebroplasty in pathological fractures.
evaluate the complications of percutaneous
Introduction: Complications related with vertebroplasty have become the subject of clinical
studies with the increasing number of procedures. There can be puncture associated
complications such as wrong needle path leading to fracture of the pedicle or mechanical
irritation of the nerve root, pneumotorax , thecal injury and epidural bleeding. Cement
leakage can also be an important complication during the procedure. Since
polymethymethacrylate is injected as liquid, microfractures at the margins of the vertebral
bodies or filling of intraosseous veins can lead to extravasation.
Methods: Vertebroplasty technique was applied on 101 patients and 122 levels with the
diagnosis of vertebral fractures. Procedure was undertaken under local anesthesia with the
aim of a x-arm device. Complications of the surgical procedure along with the clinical and
radiological properties of the cases were evaluated. Etiological factors were secondary to
trauma in 41 cases, osteoporotic compression fracture in 39, compression secondary to
metastatic tumor in 16 cases, hemangioma in 3 cases and solitary plasmasytoma in 2 cases.
79 cases were treated at one level and 22 cases at 2 levels.( 1 case of T3, 1 case of T4, 3
cases of T7, 2 cases of T8, 2 cases of T9, 5 cases of T10, 6 cases of T11, 32 cases of T12,
36 cases of L1, 15 cases of L2, 7 cases of L3 , 7 cases of L4 and 5 cases of L5). All patients
were evaluated with visual analogue scores and Oswestry back pain questionnaire results.
Results: The major problem experienced in our series was complications related with
cement leakage. Minor leakage was detected in 25 cases; leakage into intervertebral disc
space (14 cases), vascular leakage (3 cases), extravasation beneath ALL (8 cases). Major
leakage was detected in 3 cases as leakage into the neural canal. We applied open surgery
in all of these 3 cases. First case was belongs to our late (three hour later) procedures
because of slowly progressive neurological deficit and, insufficient viewing on C-arm. She
was treated with hemilaminectomy to decompress the neural structures but resulted in
paraplegia. Others were operated on with a very quick manner with total laminectomy and
removal of the extravasated PMMA and were all deficit-free (Figure 1). Long-term follow-up
of our cases revealed that 5 cases were re-operated because of adjacent segment fractures.
Four of these cases suffered from leakage into the intervertebral disc space in the first
procedure. We experienced no complications related with the puncture of the needle, nor
allergic reactions in our series.
Conclusion: In general, PVP is quick, safe and easy but complications can be severe and
should not be underestimated. Excellent fluoroscopy technique is mandatory to optimize the
anatomic orientation and awareness of cement leakage or puncture associated situations. All
PVP procedures must be done in operating room in order to access to the neural canal with
open surgery in cases of major complications. Sedation can also be superior to general
anesthesia as patients can be aware of symptoms such as radicular pain or paresthesis and
can warn the clinicians for the possibility of complication.
94
L - 48
DESIGN RATIONALE AND PRELIMINARY CLINICAL RESULTS OF NUNEC, A
PEEK-ON-PEEK CERVICAL ARTHROPLASTY SYSTEM.
A.R. GILTAIJ
Introduction
Fusion has been the gold standard as the surgical treatment for DDD, but disc
arthroplasty is gaining more popularity based on motion-preserving characteristics and
theoretically, preventing accelerated disc degeneration at adjacent levels.
NuNec is a novel cervical device developed to maintain motion, while not interfering
with MRI/ CT and incorporating a fixation system that does not require overdistraction or
keel cutting of bone.
Design
Similar to most cervical disc arthroplasty devices, NuNec has an inner ball/socket
articulation. The device is manufactured from PEEK-OPTIMA with hydroxyapatitecoated outer surfaces and is fixated by a unique CAM interference screw locking
mechanism. Fixation strength was tested with bench-top pullout testing and bony
ingrowth was examined in a pilot study with an in-vivo caprine model. Wear testing of
the device was conducted following ASTM/ISO recommendations.
Most cervical arthroplasty devices are of metal-on-metal or metal-on-UHMWPE,
resulting in strong MRI/CT artifacts prohibiting accurate future diagnosis on the index
level. NuNec is made from radiolucent PEEK and will not interfere with MRI and CT.
For fixation of the endplates to the adjacent vertebrae, most devices use keels, flangescrews or spikes. Keel designs have the potential risk of spinal cord injury during keel
cutting and splitting of the vertebral body, especially for multi-level disc arthroplasty.
Spikes need overdistraction for implantation of the device. Also most devices have
roughened, plasma-sprayed metallic surfaces to enhance by bone ingrowth. The CAM
design of NuNec offers implantation with zero profile and fixation by rotating
interference CAM’s into the endplates.
Bench-top pullout testing has shown this CAM design has a fixation force higher than
most keel and flange-screw designs. The hydroxyapatite coating does not affect the
chemical and mechanical properties of the device; 3-month results from an in-vivo
caprine model have shown excellent bony apposition to the coating/PEEK with no
adverse histological response. Wear testing shows a wear rate comparable to other
devices.
Conclusion
NuNec is the first articulating radiolucent cervical arthroplasty device in combination
with a unique, instinctive mechanical fixation with a hydroxyapatite coating. These
design benefits have been demonstrated through preclinical testing and have allowed
for advancement to the clinical stage.
95
ML - 12
PERCUTANEOUS LASER DISCECTOMY. STATE OF THE ART. LONG TERM
RESULTS.
PIER PAOLO MENCHETTI
96
ML - 13
MINIATURE ROBOTIC SPINE SURGERY – A SURGICAL TOY OR A BREAK-THROUGH?
Y. BARZILAY, M. LIEBERGALL, L. KAPLAN
SPINE UNIT, DEPARTMENT OF ORTHOPEDIC SURGERY, HADASSAH HEBREWUNIVERSITY MEDICAL CENTER, JERUSALEM, ISRAEL
Instrumentation has become an integral part in traumatic, infected, neoplastic and
degenerative spinal conditions. Misplacement of implants may result in immediate
catastrophic events, or may lead to inferior mechanical properties of the construct and may
lead to late sequel such as adjacent level degeneration.
Many efforts have been made to increase the safety of instrumentation. Factors affecting
misplacement include: surgical experience, the area of the spine operated on, factors
affecting anatomy (deformity, severe degeneration, previous surgery, etc.).
Fluoroscopy guided implantation increases the accuracy, however, lumbar pedicle screw
misplacement may reach 30%, thoracic misplacement may reach 50% and cervical screws
misplacement may reach 70%. The rate of clinical consequences, although much lower,
harbors medical, legal and financial issues.
The need for navigated systems in the aid of spinal instrumentation is quite intuitive, however
until efficacy and cost-effectiveness are proven their routine use is not expected. Computer
assisted navigation systems have been introduced in the 1990's, however none gained
enough popularity, and most are sitting in the corridors of the operating theaters serving as
"white elephants". The reasons for failure may include high cost, cumbersome procedures,
the need for extra-staff and the need for a direct line of sight.
Miniature robotic spine surgery is a new concept for aiming instrumentation in various spinal
procedures. The basic steps in its use include:
1. A high resolution CT scan
2. Pre-operative planning based on 3-plane 2-D reconstructions of the CT imported to
the software
3. Connection of one of the three robotic platforms to the patient
4. Acquisition of 2-plane fluoroscopy images with a target connected to the robotic
platform
5. Connection of the robot to the platform and execution of the surgical plan.
Studies performed on cadavers have demonstrated its accuracy and reliability, together with a
short learning curve and a significant reduction in the need for image control and the
exposure of the OR staff to irradiation. Robotic guidance has been used in several centers
around the world in the introduction of pedicle screws, translaminar screws, vertebral
augmentation needles and biopsy needles. It was also used in deformity surgery and to locate
and excise small lesion such as osteoid osteoma.
Between 9/2006 and 1/2009 robotic guidance was used in 65 patients in our institution. Mean
patient's age was 61.7 (14-84), 39 were fames and 29 were males. In 51 patients pedicle
screws were inserted with robotic guidance, while 11 patients underwent vertebral body
augmentation with cement or core needle biopsy and 1 patient underwent excision of an
osteoid osteoma. Mean surgical time was 196 minutes (47-435), off which 34 minutes (14-95)
were needed for robotic guidance. 245 trajectories were planned (1 to 8, mean 3.8 per case).
Misplaced entry points and trajectories were recorded in slightly over 4% (10 trajectories),
however, these were detected before the vertebra was instrumented and therefore no harm
was done to the patient. Two critical steps prevent better results at the moment – errors of
planning and technical errors causing an unstable connection between the robot's platform
and the patient's body. Omitting all cases were technical errors were encountered
(Malfunction of the system or mounting the platform in an unstable manner) – the system was
found to have an accuracy of 97%.
97
ML - 14
MINIMALLY INVASIVE LATERAL TRANS-PSOAS APPROACH TO
TREATING THORACIC AND LUMBAR SPINAL DISEASE
BURAK M. OZGUR MD.
Purpose: The purpose of this study is to demonstrate the versatility and
effectiveness of the minimally invasive lateral trans-psoas approach (XLIF).
Introduction: This approach can be used in accessing the lumbar spine above
L5 and the lower thoracic spine. We have used it repeatedly, safely, and
effectively for common single level degenerative disc disease as well as multilevel adult degenerative scoliosis. It affords minimally side-effects and lend itself
to much of the spine disease population. Patients tend to recovery very quickly
and soft tissue is preserved especially in comparison to traditional open spine
surgery.
Methods: We aim to demonstrate five key representative cases in which we
have used technique to access the spine from the lower thoracic spine to L5. A
retrospective data and imaging analysis has been performed.
Results: Our results confirm the safe and effective use of the XLIF procedure in
accessing the spine from the thoracic spine down to L5. Complications are rare.
The results are reproducible.
Conclusions: The minimally invasive lateral trans-psoas approach to the spine
is a safe and effective technique used more and more by the spine surgeon. The
advantages of minimally invasive surgery are appreciated and the outcomes are
thusfar at least equivalent to traditional spine surgery.
98
L - 49
PERCUTANEOUS LASER DISCECTOMY. STATE OF THE ART. LONG TERM
RESULTS.
PIER PAOLO MENCHETTI
99
L - 50
MINIMALLY INVASIVE TRANS-SACRAL APPROACH TO THE LUMBOSACRAL SPINE
BURAK M. OZGUR MD.
Purpose: The purpose of this study is to demonstrate the versatility and
effectiveness of the minimally invasive trans-sacral approach to the lumbo-sacral
spine (AxiaLIF).
Introduction: This approach can be used in accessing the L5-S1 lumbar spine
and in select cases may afford access to L4-S1. We have used it repeatedly,
safely, and effectively for single level degenerative disc disease as well as 2-level
disease in some patients with appropriate anatomy. It affords minimally sideeffects. Patients tend to recovery very quickly and soft tissue is preserved
especially in comparison to traditional open spine surgery.
Methods: We aim to demonstrate five key representative cases in which we
have used technique to access the L5-S1 or L4-S1 spine levels. A retrospective
data and imaging analysis has been performed.
Results: Our results confirm the safe and effective use of the AxiaLIF procedure
in accessing the lumbo-sacral spine. Complications are rare. The results are
reproducible.
Conclusions: The minimally invasive trans-sacral approach to the spine is a
safe and effective technique used more and more by the spine surgeon. The
advantages of minimally invasive surgery are appreciated and the outcomes are
thusfar at least equivalent to traditional spine surgery.
100
L - 51
ENDOSCOPY AND PERCUTANEOUS ARTHRODESIS IN RELAPSED DISCAL HERNIAS
DANIEL GASTAMBIDE (PARIS), PIERRE FINIELS (NIMES), PATRICE MOREAU
(BOURSAY)
Relapsed lombosciaticas provoked by recurrence of a discal hernia previously operated on
are the most worrying for the patient and the surgeon together. The rate is from 5 to 16% and
is increasing with the follow-up of the observed series. The aim of this study is to show the
updated indications of secondary surgery, by endoscopic transforaminal discectomy (ETD),
by percutaneous intersomatic arthrodesis by percutaneous cages (Europa) under local
anesthesia and sedation, and by open posterolateral arthrodesis (PLIF).
The story of several series amongst our patients is complex: 52 suffered from relapsed
lumbosciatica due to discal hernia at the same level. The following graphic shows the
different kinds of last operations according to the first operations:
Last OP type according to 1st OP type of same level
FIRST
OP
last OP
21 open
surgery
14 ETD
19 ETD
9 ETD
8 open
surgery
2 ETD
then
ETD
3 RF or
laser
1 CNL
5 Europa
5 Europa
6 Europa
1
1
4 PLIF
1
3 ETD
1
Two other patients suffered from a relapsed hernia at another level, 8 patients suffered from
a new hernia on a hinge disc after arthrodesis due to relapsed discal hernia, and 7
recurrences of discal hernia were associated with a central stenosis. In all cases, there is
often an associated foraminal stenosis or a flare of the end plates of Modic type, which can
be symptomatic or predominant
Our indications are:
-if the disc is little degenerated (less than one third of loss of intersomatic height): ETD ,
rarely conventional open surgery;
-if the disc is degenerated, as it is most often the case:
− if there is an associated foraminal stenosis, or if there is a Modic 1 and/or 2, and
without important radicular adhesions, indication of percutaneous arthrodesis by
Europa cages;
− if a surgical exposure with exploration is necessary, PLIF, keeping in mind that our
previous series of terminal PLIF has only 62,8% of good results after two years on 36
personal cases operated on between 1999 and 2003.
Since endoscopical surgery appeared and since we begun the percutaneous intersomatic
arthrodesis that we call Europa, therapeutical indications for treatment of recurrence of discal
hernia have become more various, more targeted, and less invasive.
FBSS prevention is passing by early mini-invasive surgery, particularly by percutaneous
intersomatic arthrodesis. Further studies are necessary to confirm these recent indications of
mini-invasive surgery.
101
L - 52
INFLUENCE OF THE FACET JOINTS ASYMMETRY ON THE DEVELOPMENT OF
LATERAL RECESS STENOSIS
ARTEM SKIDANOV, VLADYMYR RADCHENKO
SYTENKO INSTITUTE OF SPINE AND JOINT PATHOLOGY, KHARKOV, UKRAINE
Purpose of study. To improve the diagnostics of the vertebral canal lateral arthritic stenosis
with the patients suffering from degenerative diseases of the lumbar spine on the ground of
the vertebral canal structure peculiarities study, back supporting complex study and disease
development mechanisms study.
Methods used: As the material for the clinical research we used the examination data of 110
patients suffering from the lumbar spine degenerative diseases. All the patients have been
clinically examined, including neurological examination, Oswestry disability index study;
roentgenometrical study of regular and functional spondylograms; rentgenocontrast ways of
study, spiral computer and magnetic resonance imaging tomography of the lower lumber
spine. In addition, 92 tomograms of the lower lumbar spine of the patients under the age of
20 have been analyzed. Biomechanical study of the lumbar spine has been carried out with
the help of mathematical modeling using finite element method. Classical methods of
statistical data manipulation has been used for analysis.
Summary of findings
In this thesis the authors reveal clinical, roentgenological, computer-tomographic, magnetic
resonance tomographic symptoms that accompany lateral recess stenosis. Special features
of the structure of the lumbar spine vertebral canal predisposing to the development of lateral
recess stenosis have been ascertained and innate character of these special features has
been proved. The methodology of determination of vertebrae articular processes spatial
orientation has been developed, the character of the arc-shaped process joints asymmetry
bringing on the development of lateral degenerative stenosis has been revealed.
Mechanisms of the development of this disease have been studied with the help of
mathematical modeling using the finite element method.
Relationship between findings and existing knowledge:
Both the innate character of the lumbar spine trefoil form and a possibility of the nervous
roots arthritic compression in the lateral section of the vertebral canal have been known for a
long time. Our research established the possible variants of the vertebral canal trefoil form
and specific peculiarities of facet joints constitution leading to the development of the lateral
recess stenosis.
Overall significance of findings:
The received data not only allowed to improve the diagnostics of the lateral recess lumbar
stenosis but also gave rise to the further study of other degenerative spine diseases
development mechanisms, and besides, figure prominently in the designing of facet joints
implants.
The key words:
Lateral recess stenosis, vertebral canal, degenerative diseases, lumbar spine.
102
L - 53
CONVENTIONAL POSTERIOR LUMBAR INTERBODY FUSION VERSUS MINI-OPEN
POSTERIOR LUMBAR INTERBODY FUSION USING THE NEW PERCUTANEOUSLY
INSERTED SPINAL TRANSPEDICULAR SCREWING SYSTEM
CHANG IL JU, M.D., HYEUN SUNG KIM, M.D., SEOK WON KIM, M.D., SEUNG MYUNG
LEE, M.D., HO SHIN, M.D.
DEPARTMENT OF NEUROSURGERY, CHOSUN UNIVERSITY, GWANGJU, KOREA
Objectives: Between the group where the conventional posterior lumbar interbody fusion
(PLIF) was performed using microscope and the open transpedicular screw fixation system
and that where mini-open PLIF was performed using the newly-designed percutaneous
transpedicular screw fixation system characterized by vertical axis and detachable screw
extender system, the surgical outcome was compared. Thus, attempts were made to analyze
the usefulness of vertical axis and detachable screw extender system.
Methods: During a period ranging from January 2004 to February 2007, the surgical
outcome was compared between the group where the conventional posterior lumbar
interbody fusion (PLIF) was performed using microscope and the open transpedicular screw
fixation system and that where mini-open PLIF was performed using the newly-designed
percutaneous transpedicular screw fixation system (Apollon system, Solco medical, South
Korea) characterized by vertical axis and detachable screw extender system. The number of
cases in which the conventional PLIF was performed was 86 (Group A) and that of those in
which the mini-open PLIF was performed was 145 (Group B). In the Group A, mean followup period was 23.7 months (6 months to 43months) and mean age was 56.3 (34 to 73)
years. In regard to the level, one level was seen in 73 cases, two levels were seen in 11
cases and three levels were seen in 4 cases. In the Group B, mean follow-up period was
25.3 months (6 months to 43months) and mean age was 59.1 (23 to 78) years. In regard to
the level, one level was seen in 117 cases, two levels were seen in 22 cases and three levels
were seen in 6 cases. Clinical outcome was assessed using last clinical follow up Low Back
Outcome Score (LBOS). We also compared the operation time, intra-operative bleeding loss,
postoperative surgical scar and complications. Results: In the Group A, mean surgical time
was 163.7 minutes (120-280 minutes), bleeding loss was 753 ml (350-1200ml) and average
LBOS was 56.2. The levels of postoperative surgical scar were as follows: one level: 6.23
Cm, two levels: 11.28Cm and three levels: 15.26Cm. Complications include five cases
(5.8%) of dural tear, four cases (4.7%) of deep wound infection and four cases (4.7%) of
device failure and fusion failure. In the Group B, mean surgical time was 142.6 minutes (100240minutes), bleeding loss was 438 ml (160-850ml) and average LBOS was 63.8. The levels
of postoperative surgical scar were as follows: one level: 3.71 Cm, two levels: 6.27 Cm and
three levels: 8.35Cm. Complications include eight cases (5.5%) of dural tear, four cases
(2.7%) of deep wound infection and five cases (3.4%) of device failure and fusion failure.
Conclusions: Vertical Axis and detachable Screw Extender System makes it easier to
perform rod manipulation as well as compression and distraction. As compared with
conventional PLIF, it can diminish midline skin incision. It is therefore useful in reducing
operation time and intra-operative bleeding loss, thus minimizing the postoperative
occurrence of back pain and complication. Accordingly, a prompt recovery and a good
clinical outcome can be expected.
103
Poster Presentations
104
P-1
PERCUTANEOUS VERTEBROPLASTY(PVP): AN EFFECTIVE AND ECONOMICALLY VIABLE PERSPECTIVE FROM A
DEVELOPING COUNTRY FOR VERTEBRAL COLLAPSE FRACTURES(VCF'S) OF VARIOUS ETIOLOGIES
DR. SUDEEP JAIN: REGISTRAR/SENIOR RESIDENT, DEPARTMENT OF ORTHOPAEDICS; ALL INDIA INSTITUTE OF
MEDICAL SCIENCES(AIIMS), NEW DELHI(INDIA)
ALL INDIA INSTITUTE OF MEDICAL SCIENCES(AIIMS) & VARDHMAN MAHAVIR MEDICAL COLLEGE(VMMC) & ASSOC.
SAFDARJUNG HOSPITAL(SJH)
INTRODUCTION: Approximately ⅓rd of patients who have clinical vertebral fractures develop chronic pain that does not
respond to conservative therapy. One thoracic VCF is associated with a 9% reduction in forced vital capacity. PVP provides pain
relief and minimally invasive mechanical stabilization within a vertebral body to prevent further vertebral body collapse. It is
hypothesized that the exothermic reaction of cement polymerization may destroy the nociceptive receptors in the vertebra. In
addition by affording strength to the VB, the biomechanics of axial loading is altered and this also contributes to the pain relief.
Fractures of thoracolumbar junction (T11-L1), burst fractures, wedge anterior compression fractures with >30° of sagittal
angulation, vacuum shadow in fractured body (ischemic necrosis of bone) and patients with progressive radiographic collapse
are less likely to benefit from conservative treatment. Although the French developed PVP 20 years ago, it is only now
beginning to gain widespread acceptance. Hence, a prospective clinico-radiological outcome study was conducted to better
define the various indications, contra-indications, technique, complications, clinical outcomes and role of adjunctive imaging in
PVP in a developing country set-up.
AIMS & OBJECTIVES: To evaluate prospectively the effects of PVP on mobility, analgesic use, pain, kyphosis and other
patient/ fracture variables in patients with painful VCFs. To formulate guidelines for PVP in a developing country set up. To
discuss the role of adjunctive imaging and vertebrography in PVP.
MATERIALS AND METHODS: From may 2005 to October 2006, a total of 84 patients with 135 vertebral pathologies due to
various etiologies satisfying the following inclusion/ exclusion criteria were taken up for PVP. The decision to perform PVP was
based on clinical and imaging evaluation.
INCLUSION CRITERIA: Acute and sub-acute painful osteoporotic VCFs, Painful vertebrae due to osteolytic metastasis, Painful
vertebrae due to multiple myeloma, Painful vertebrae due to Kummell's disease (vertebral osteonecrosis), Painful vertebral
hemangioma and other benign lesions, Severe resistant back pain with vertebral osteoporosis, Selected post-traumatic VCFs
(>3 wks old) in non-osteoporotic patients.
EXCLUSION CRITERIA: active systemic/localized (spine) infection, cardiopulmonary compromise, bleeding disorders/ anticoagulant therapy, improvement on medical t/t, High energy injury, severe VB collapse (vertebra plana), neurological
compromise, osteoblastic metastasis, posterior VB wall deficiency, very old fractures, pre-existing epidural extension of
metastatic tumour, unstable fractures with posterior element involvement especially with facet joint disruption. Cord compression
on MRI in the absence of neurological findings was considered a relative contraindication.
RESULTS: Multiple vertebral involvement was quite common in our series and was seen in 45/84 cases (53.6%). A kyphotic
deformity of ≥30° (Cobb's angle) was present in 30/84 patients (35.7%). Venography was performed in only 6 cases towards the
initial part of the study. The distribution of iodinated contrast did not accurately predict the eventual distribution of cement and
only increased the operative and fluoroscopic times. The average amount of cement injected per level was 4.4ml. There was a
decrease in mean pain score of 5.47, mean analgesic score of 2.11 & mean disability score of 8.86 immediately following the
procedure. A mean improvement of 0.05 in the VB compression ratio and 5.28° in the Cobb's angle was obtained immediately
post-procedure. Their mean pain, analgesic and disability scores at 2 yr follow-up were 0.6, 0.4 and 4.4 respectively while their
mean VB compression ratio and kyphotic angle were 0.7 and 17.4° respectively. The changes in mean pain scores, analgesic
scores, disability scores, VB compression ratios and kyphotic angles both immediately post-procedure (p<0.001) and at 2 yrs
following the procedure (p<0.001) were highly significant. The scores improved significantly immediate post-procedure and kept
improving till 2 yrs. Asymptomatic cement extravasation was seen in 39/84 patients (46.4%) at 60/135 augmented levels
(44.4%).
DISCUSSION: In our own series, we noted an improvement in disability scores by a mean of 8.9 immediately after the
procedure (p<0.001) and remained so at 2 yrs(p<0.001). The distribution of cases is skewed in favour of osteoporosis (50%)
with much less proportion of osteoporotic + traumatic (25%) & traumatic VCFs (25%). PVP is a safe & effective alternative for
the treatment of many types of painful vertebral lesions, including OVCFs, hemangiomas, or malignancy-induced pathologic
vertebral fractures. Medical therapy often is limited to pain control, which may not be effective, and immobilization, which can
result in dangerous deconditioning of an elderly patient. Because surgery is contraindicated frequently in persons who have
OVCFs because of the high incidence of instrumentation failure, and because patients who have widespread metastatic disease
often are not surgical candidates, PVP may be the only practical option available. Regardless of etiology, PVP is a safe,
inexpensive, and highly efficacious procedure in appropriately selected patients; however, because of the potential for
devastating complications, all efforts must be made to optimize patient safety.
CONCLUSIONS: There was a highly significant improvement in mean pain, analgesic & disability scores and mean kyphotic
angles & VB compression ratios immediate post-procedure which was sustained at 2 years follow-up (p value < 0.01). Minor
instances of cement leak were seen in a few patients without any major clinical significance. There were no new adjacent level
VB fractures seen after the 135 vertebroplasty procedures in 84 patients till the last mean follow-up of 2 years. KEY WORDS:
vertebral body(vb), vertebral collapse fractures(vcf's), percutaneous vertebroplasty(pvp), polymethyl methacrylate.
105
P-2
SCREW REINFORCING PERCUTANEOUS SHORT SEGMENT
TRANSPEDICULAR SCREWING FOR UNSTABLE THORACOLUMBAR BURST
FRACTURES
DEPARTMENT OF NEUROSURGERY, CHOSUN UNIVERSITY, GWANGJU,
KOREA
Objective: The purpose of this study was to determine the efficacy of bone cement
or hydroxyapatite reinforcing percutaneous short segment transpedicular screwing
following postural reduction and present a technique for thoracolumbar burst
fractures without fusion.
Methods: Retrospectively, eleven consecutive patients (average age, 50.73 ± 24.6
years) who sustained thoracolumbar (T10-L3) burst fractures were included. All
patients had unstable burst fractures with canal compromise, but their motor power
was intact. All patients underwent bone cement or hydroxyapatite reinforcing short
segment transpedicular screwing with a percutaneous screwing system (Apolon
System, Solco Medical, South Korea) following postural reduction using a soft roll at
the involved vertebra in cases of severely collapsed vertebrae of more than one-half
their original height. The surgical procedure included postural reduction for 2 days
and bone cement (with osteoporosis) or hydroxyapatite (without osteoporosis)
reinforcing screw fixations at one level above, adjacent above and below level
including fractured level itself. Imaging and clinical findings, including the level of the
involved vertebra, vertebral height restoration, local kyphosis, clinical outcome, and
complications were analyzed.
Results: The mean follow-up period was 10.64 months. The operative time and
blood loss averaged 76minutes and 50.9 mL, respectively. The mean pain score
(visual analogue scale) prior to surgery was 8.09, which decreased to 2.36 at the last
follow-up. The kyphotic angle improved significantly from 20.8° ± 8.2° before surgery
to 5.7° ± 2.3° at the last follow up. The fraction of the height of the vertebra increased
from 43.45% ± 8.05% to 80.73% ± 5.25% in the anterior portion of the vertebra.
There was no evidence of neurologic deterioration in any case. Bone cement leakage
was observed in two cases without clinical sequelae; no other complications were
observed. There were no signs of hardware pull-out or aggravation of kyphotic
deformities and vertebral height correction.
Conclusion: In the management of unstable thoracolumbar burst fractures, if
patients are neurologically intact, bone cement or hydroxyatpatite reinforcing
percutaneous short segment pedicle screwing following postural reduction can be
used to reduce the total levels of pedicle screwing and to correct kyphotic
deformities, as well as to reduce the complication rate as occurs in open surgery.
106
P-3
BONE CEMENT AUGMENTATION OF SHORT SEGMENT FIXATION FOR
UNSTABLE BURST FRACTURE IN SEVERE OSTEOPOROSIS
DEPARTMENT OF NEUROSURGERY, CHOSUN UNIVERSITY, GWANGJU,
KOREA
Objective: The purpose of this study was to determine the efficacy of short segment
fixation following postural reduction for the re-expansion and stabilization of unstable
burst fractures in patients with osteoporosis.
Methods: Twenty patients underwent short segment fixation following postural
reduction using a soft roll at the involved vertebra in cases of severely collapsed
vertebrae of more than half their original height. All patients had unstable burst
fracture with canal compromise, but their motor power was intact. The surgical
procedure included postural reduction for 2 days and bone cement-augmented
pedicle screw fixations at one level above, one level below and the fractured level
itself. Imaging and clinical findings, including the level of the vertebra involved,
vertebral height restoration, injected cement volume, local kyphosis, clinical outcome
and complications were analyzed.
Results: The mean follow-up period was 15 months. The mean pain score (visual
analogue scale) prior to surgery was 8.1, which decreased to 2.8 at 7 days after
surgery. The kyphotic angle improved significantly from 21.6±5.8° before surgery to
5.2±3.7° after surgery. The fraction of the height of the vertebra increased from 35%
and 40% to 70% in the anterior and middle portion. There were no signs of hardware
pull-out, cement leakage into the spinal canal or aggravation of kyphotic deformities.
Conclusion: In the management of unstable burst fracture in patients with severe
osteoporosis, short segment pedicle screw fixation with bone cement augmentation
following postural reduction can be used to reduce the total levels of pedicle screw
fixation and to correct kyphotic deformities.
107
P-4
FAR LATERAL EXTRAFORAMINAL SYNOVIAL CYST NOT CONNECTING
FACET JOINT
AHMET MENKU*, KAGAN KAMASAK**, CUNEYT GOCMEZ***, YURDAER
DOGU***
ERCIYES UNIVERSITY*, DEPARTMENT OF NEUROSURGERY,
KAYSERI/TURKEY BATMAN STATE HOSPITAL **, DEPARTMENT OF
NEUROSURGERY, BATMAN,/TURKEY TEKDEN HOSPITAL *** , DEPARTMENT
OF NEUROSURGERY, KAYSERI/TURKEY
Synovial cysts of the spine may occur anywhere in the cervical, thoracic, and lumbar
spine predominantly at L4-L5 level. Almost all symptomatic synovial cysts originate
from the facet joint and usually present as intraspinal extradural masses, which
compress nerve root and dural sac from posterolaterally. The authors report a case
of lumbar radiculopathy caused by a synovial cyst located in the L5-S1 far lateral
extraforaminal area. The patient underwent decompression of the L5 nerve root via
transmuscular micro endoscopic surgery. No connection to the facet joint was
observed radiographically or at operation. Postoperative recovery was uneventful,
and the patient was totally pain free with no motor deficit. The clinical and
radiographic features of the unusual case are discussed and a comprehensive review
of the existing literature is presented. An extraforaminal synovial cyst is a highly
unusual finding. To our knowledge, only 8 cases of symptomatic extraspinal synovial
cysts have been described in the literature. However, in our case, the cyst developed
in the far lateral extraforaminal region at the L5-S1 level of the spine and no
connection to the facet joint was observed.
108
P-5
NON-TRAUMATIC ACUTE MONOPLEGIA ASSOCIATED WITH INTRADURAL
CERVICAL DISC HERNIATION: A CASE REPORT
AHMET MENKU*, KAGAN KAMASAK**, CUNEYT GOCMEZ***, YURDAER
DOGU***
ERCIYES UNIVERSITY*, DEPARTMENT OF NEUROSURGERY,
KAYSERI/TURKEY BATMAN STATE HOSPITAL **, DEPARTMENT OF
NEUROSURGERY, BATMAN,/TURKEY TEKDEN HOSPITAL *** , DEPARTMENT
OF NEUROSURGERY, KAYSERI/TURKEY
Intradural disc herniation is rare, especially in the cervical spine. Most cervical
intradural disc herniations occur at C5–C6 or C6–C7 levels and affect patients who
are 40–50 years of age. As serious symptoms can progress rapidly, immediate
surgical treatment is often a necessity We present a unique case of intradural
cervical disc herniation causing only monoplegia and pain in the left lower extermity.
To our knowledge, this is the first case described in the literature. Magnetic
resonance imaging of the thoracic and lumbar spine was normal. However, the
cervical spine revealed a disc herniation at C6–C7 with a more left-sided appearance
and signal intensity was observed in the spinal cord. Microdiscectomy and anterior
cervical fusion with peec cage containing otogreft was performed. After surgery, the
patient was free of complaints, with her motor function immediately improving in a
several weeks with rehabilitation. Our experience of this case suggests that in the
diagnosis of patients with monoplegia and pain in the lower extremitiy, spinal cord
compression should be explored by imaging studies not only in the thoracic and
lumbar spine, but also in the cervical spine, especially at the C6–C7 level, even if the
symptoms and abnormal neurological findings are absent in the upper extremities.
109
P-6
FRACTURES OF THE THORACOLUMBAR SPINE
NIKOLAOS SYRMOS, VASILIOS VALADAKIS, KOSTANTINOS GRIGORIOU,,
DIMITRIOS ARVANITAKIS
NEUROSURGICAL DEPARTMENT-VENIZELEION GENERAL HOSPITALHERAKLION,GREECE
INTRODUCTION Thoracolumbar fracture can be a disabling condition that requires
thorough evaluation and treatment. Although most thoracolumbar spine injuries are
benign myofascial strains that respond well to nonsurgical management, the spectrum of
injuries is broad and includes fractures and bony instability, ligamentous instability, and
neurologic compromise. Evaluation of thoracolumbar injuries requires a rapid and
focused evaluation at the time of injury to rule out catastrophic and neurologically
threatening injuries; a detailed history and physical examination carried out at a later
point in time should be paired with appropriate imaging studies.. Spinal trauma is
classified according to the mechanism of injury and the presence or absence of stability.
A variety of imaging modalities, including radiography, conventional tomography,
computed tomography, and magnetic resonance imaging are available for assessment of
the injured spine. Acute treatment may be required and initiated at the time of injury;
further treatment should be carried out once the nature and extent of the injury is fully
understood. Nonoperative treatment is successful in most of the injuries. Operative
treatment is applied in selected cases of structural instability or neurologic compromise
MATERIAL-METHODS At our department during the period 2003-2007 years 46
patients were observed with thoracolumbar spine fractures, from were 23 - 50% - were
falls, 15-32, 6% - were car accidents and the rest 8-17, 4% - were other types of
injuries. 40 cases - 86,9% - were multiple traumas. Average age of patients All patients
underwent the following examinations: 1.¬was 39 (16-66).
RESULTS Instability fractures was mentioned in 20 cases¬x-ray, 2. C.T-scan, 3. M.R.I.
- 43% - Neurological disorders in 10 - 21,7% - 28 patients - 60,8% - underwent
conservative treatment. 18 patients - 39,2% - were operated-posterior
In case
of¬approach-deccomression-transpendicle
screw
fixation
of
segments.
Good¬Neurological disorders the operation was done in the first 12 hours. ¬outcome
was seen in 40 cases - 87% - with regress of neurology symptoms, Minimal rest
neurological deficit in 4 cases and poor results in 2 patients
110
P-7
SELECTIVE NERVE ROOT INJECTIONS IN LUMBAR RADICULOPATHY: A PROSPECTIVE CLINICAL OUTCOME STUDY
AS A MINIMALLY INVASIVE ALTERNATIVE TO SURGERY. A FIVE YEAR FOLLOWUP.
DR. SUDEEP JAIN{Senior Resident/Registrar, Department of Orthopaedics; All India Institute of Medical
Sciences(AIIMS), New Delhi(India)}.
DR. SUDEEP JAIN{Senior Resident/Registrar, Department of Orthopaedics; All India Institute of Medical
Sciences(AIIMS), New Delhi(India)}.
TYPE OF STUDY: A prospective clinical outcome study.
AIM OF STUDY: To establish selective nerve root injections in lumbar radiculopathy as an effective, minimally invasive
alternative in patients either unwilling or unfit for surgery.
INTRODUCTION: Treatment of lumbar radiculopathy ranges from bed rest to decompression. Many unsatisfactory results of
different surgical interventions has led to reappraisal of some more conservative treatment options. Low back and sciatic pain
are most likely due to a combination of mechanical compression and inflammatory changes. An autoimmune or chemical basis
for lumbar radiculopathy was postulated in 1977. Recent evidence supports a neurochemical basis for pain generation. Based
on these findings, epidural instillation of steroids was implicated as a treatment modality for low back and radicular pain. Studies
done by using MRI done at serial intervals revealed that herniated nucleous pulposus size decreased in 66-88% patients on
conservative management and this correlated with clinical outcomes. In these injections, epidural space is entered dorsally
which is distant from perceived source of pain and inflammation which lies anteriorly thus large volumes must be injected which
can dilute their potency. Extensive degenerative changes and altered anatomy and scarring of previous surgery also hamper
this blind translaminar technique. Thus an alternative method for delivery was first described by Macnab and later by Krempen
and Smith called selective nerve root injections in which under fluoroscopic guidance a needle is placed next to the affected
nerve root ensuring a precise and concentrated delivery of drug. Success of injection depends on precise delivery of high
concentration of drug directly to interface between herniated nucleus pulposus and ventral dura and nerve root sleeve which
can only be done reliably by a fluoroscopically guided transforaminal approach with pre-injection contrast documenting flow to
the target tissue.
METHODS: A five year prospective clinical outcome study conducted on patients with lumbar radicular pain with disc herniation,
secondary foraminal stenosis confirmed by an MRI and patients with failed previous surgery demonstrating persistent
symptoms. All these patients had failed atleast 6 weeks of conservative management and were ideal candidates for surgery but
had either refused or were unfit. In all 150 patients were injected with Bupivacaine and Betamethasone, 220 nerve roots were
injected and 300 injections were given with a minimum followup of 5 years. We used 1 ml of betamethasone(4mg/ml) with 1 ml
of 0.25% bupivacaine. All injections were performed fluoroscopically and needle placement confirmed by injecting omnipaque240.
RESULTS: Of 150 patients, 80 had single level involvement and 70 had multilevel disease. 10 patients had B/L radiculopathy,
rest had almost equal distribution among rt and lt lower limbs. All pts had LBP with radicular pain. Duration of LBP ranged from
3 months to 3 yrs while that of radicular pain ranged from 1-6 months. 35 patients had history of similar episodes in the past.
80% had list and 2/3rd had marked paraspinal spasm. 140 had localized tenderness. SLR restricted in all pts. While sciatic
stretch test was positive in all but 5 pts.. 30 had positive cross SLR. Post injection, SLR improved in 140 out of 150, list
persisted in only 25 pts while nerve tension test continued to be positive in only 15 pts. Preinjection 140 pts were severely
disabled with an oswestry score between 40-60 while 10 pts were crippled with scores more then 60. Following injection, 120
out of 150 were left with only a minimum disability whereas 30 did not show much improvement. On an average, oswestry
scores improved by 34% from an average of 54.1% in preinjection to 20.03% in postinjection pts. 100 pts improved with a single
injection while a second injection had to be repeated after 2 wks in 10 pts. 5 pts required 3 injections for complete relief. 5 pts
were improved after 2 injections but had a recurrence after 3 months for which they required a third injection. Thus out of 150
pts who were ideal candidates for surgery, 115 were able to avoid a surgery after a minimum followup period of 5 yrs.
DISCUSSION: Perfect approach to management of degenerative disc disease has been controversial. When sciatic symptoms
persist, it is thought that local inflammatory changes may be contributory factor. Some recent studies show that after 4 yrs,
results of conservative management are same as that of surgery. Many studies have now proven the biochemical nature of
radicular pain. This has led to popularity of epidural steroid injections as it is thought that pain is produced only in presence of
inflammation. Blind nature of translaminar epidural steroid placement led to inconsistent results. These shortcomings led to
appraisal of fluoroscopically guided transforaminal injections with reported success rates from 60-80%. In our study, 80%
operative candidates were able to avoid surgery which is comparable to other studies using similar techniques. Like other
studies, results were better in pts with symptom duration less then 3 months. This can be explained by development of
irreversible neurophysiologic changes due to chronic inflammation. We also found that patients who had concomitant secondary
foraminal stenosis responded less favourably compared to pts who had just prolapse disc as cause of their symptoms.
CONCLUSION: It can be concluded that selective, fluoroscopically guided lumbar nerve root injections are current, state of the
art form of local anaesthetic and steroid delivery to exact trigger site of pain with minimal complication. They may be diagnostic
as well as therapeutic and may obviate need for a lumbar surgery. KEY
WORDS: lumbar radiculopathy, fluoroscopically guided, transforaminal, selective nerve root injection, bupivacaine,
betamethasone.
111

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