this is doctor corenman and we're going to talk about a transforaminal lumbar
interbody fusion
using minimally
invasive micro surgical technique
stealth and the O Arm
this is a typical picture of a very degenerative L5 S1 disc
the disc has collapsed and you can see black vacuum phenomenon
this is the MRI finding where you can see the lowest disc
is much collapsed compared to the ones above
with bone signal changes indicating stress fracturing
this is a discogram where the two discs above the degenerative disk
obviously normal with a cotton ball appearance and the L5 S1
disc is quite degenerative
this is the technique
of the pedicle screw insertion
we start first
by putting a small frame on the spinous process which you can see protruding out
of
the blue sheets there
we cover it
with a clear sheet in order to protect the
sterility of the field
this device is an O Arm it's an intro operative CT scanner and this device
can lend us images not only front to back and side to side but top to down which
makes surgery
much safer and much easier
for insertion of the screws
we're going to watch how this CT works the light on top comes on
and you'll see this image spin around
and this is the actual CT scan and how long it takes
this CT is one-third the typical exposure
of a standard CT performed in a hospital
here are the tools that we use in order to identify the levels the incisision has alread
been made that device that is protruding out is attached to the spinous process
the device I am and holding identifies the level that we are at
after identify
where the screw is going to be inserted
I use a small burr
to create a starting hole
once that starting holes is created
then i use a tool
called a pedicle finder or pedicle
to find the pedicle
and this is done under direct visualization you'll see here
that this
device that i have has these balls attached
and these balls reflect off of a frame and is very similar to a GPS device
you can actually insert
the device into the pedicle without any problems because you're looking at the
pedicle
both a front and side and a top-down view
you'll see this in a second here
we will switch to the screen and you'll see exactly what i'm staring at so there is
the vertebra
the blue device is the all itself
and you can see that i can easily
find my way down the pedicle
by the feel of the device while i'm actually physically inserting it and by
the visualization that i see both on the front side top and middle views
once this device is in
we have a track the screw is going to follow
we remove the device
and it should be in there pretty rigidly and then we want to tap the hole
just like you would tap a wood screw
and so we take the device out that finds the pedicle and this is the tap that we use
to tap the hole
after we're finished with the tap
we will then insert the screw itself
that's attached to the same type of tracking device
that we used to find the hole in the first place
and we can follow the screw
down into the pedicle
so here the tap is being removed
here the screw is now being inserted into the tapped hole
and then once we visualize its flight planned so-to-speak
the screw is inserted
and it should be inserted with some good force because the pedicle should be a
strong pedicle and hold the screw well
these are the screws that are going to hold a vertebra in place while the
fusion is taking place
once the screw device
is removed
then we insert the other three screws
but here is what i'm visualizing when the screw is being inserted you can
literally watch the screw marching down the pedicle
and avoiding all of the sensitive structures such as the nerves and the
vascular supply
this is one screw insertion and four screws are inserted at this point in
order to be able to complete the surgery
once the screws finished being inserted we can actually save the screw in
position
then we test the screw we run a little bit of electricity through the screw and
by watching this monitor the technician the neural monitoring technician can
determine
whether this screw could be irritating the nerve root or not
and with this device the
O Arm and stealth it is
almost impossible to have a screw
irritating a nerve
this is what the final screw insertion looks like
from the front to back view
you can see that white metal which is attached to the spinous process
that's the registration probe
we will have a side view here also and you can see the screws inserted and where
they exist
in the morphology of the vertebral body or the sacrum and the bottom screws
we complete the rest of the surgery
after we perform a second O Arm scan
to confirm that the screw position
is appropriate
and once these are done then we can review
the CT scan
and here's a good example
of the vertebra
and the screw positioning where you will see the screws
are nicely placed within the pedicle and within the confines of the vertebra
indicating that there is no
screw that's going to irritate a vascular structure or a nerve root
we have post operative films this is a front to back view
of the TLIF the white arrows point
to the solid fusion
between the vertebra
here is the arrow pointing to the solid fusion between
the body of L5 the sacrum
and then this is the CT scan at six months
indicating a rock-solid fusion with the arrow pointing to the solid fusion
we will see this is the front to back view again
of the interbody
with solid bone formation
and this is just at six months it really gets much greater at a year
again the arrows pointing to a solid fusion
and this is
exactly how we insert
pedicle screws using the O Arm thank you