Rome Rehabilitation 2011Rome Rehabilitation 2011XX XX CongressoCongresso Nazionale S.I.C.D. Nazionale S.I.C.D.
LA VIA ENDOSCOPICA LA VIA ENDOSCOPICA INTRAFORAMINALE INTRAFORAMINALE
NEL TRATTAMENTO DELLE ERNIE NEL TRATTAMENTO DELLE ERNIE DISCALI LOMBARIDISCALI LOMBARI
RelatoreRelatore: Luigi D’Orazio: Luigi D’OrazioMedicina del doloreMedicina del doloreA.O. San Camillo-ForlaniniA.O. San Camillo-Forlanini
TheThe TESSYS-Concept TESSYS-Concept
Operation of lumbar disc Operation of lumbar disc herniations via herniations via
lateral, transforaminal,lateral, transforaminal,endoscopic Approachendoscopic Approach
The TESSYS-ConceptThe TESSYS-ConceptIndicationsIndications
Radiologic confirmation of Radiologic confirmation of lumbar herniated discs lumbar herniated discs using MRI- or CT withusing MRI- or CT with
clinical signs of nerve root clinical signs of nerve root compressioncompression
ForaminalForaminal Approach: Lumbar Spine Approach: Lumbar SpineAdjunctAdjunct to Traditional Surgery to Traditional Surgery
•Preferred for foraminal and Preferred for foraminal and extraforaminal HNPextraforaminal HNP•Allow access to these pain Allow access to these pain generators:generators:•DiscDisc•Exiting nerveExiting nerve•Traversing nerveTraversing nerve•Epidural spaceEpidural space•Superior facetSuperior facet•Axilla containing the DRGAxilla containing the DRG•Foraminal osteophytesForaminal osteophytes
Visualizes the Visualizes the “Hi“Hidden dden ZoneZone”” Foraminal of MacNab Foraminal of MacNab
Hidden Zone
The TESSYS-ConceptThe TESSYS-Concept• Transforaminal puncture of Transforaminal puncture of
the disc space at the medial the disc space at the medial pedicular planepedicular plane
• Entry point at the skin about Entry point at the skin about
8 to 18 cm from the midline 8 to 18 cm from the midline
The TESSYS-ConceptThe TESSYS-Concept
The direction of the trajectory The direction of the trajectory depends on the specific depends on the specific localization of the disc localization of the disc
herniationherniation
The TESSYS-ConceptThe TESSYS-ConceptDiscography orDiscography or
chromography chromography
and insertion of and insertion of
the guide wirethe guide wire
The TESSYS-ConceptThe TESSYS-Concept• Stab incision at the entryStab incision at the entry
point on the skin andpoint on the skin and• insertion of the guiding rodinsertion of the guiding rod
(angled or straight) into the(angled or straight) into theneuroforamenneuroforamen
The TESSYS-ConceptThe TESSYS-ConceptIf necessary If necessary enlargementenlargement of the of the
neuroforamen using guiding tubes and neuroforamen using guiding tubes and crown reamerscrown reamers (5, 6.5, 7.5 mm (5, 6.5, 7.5 mm Ø)Ø) to to remove parts of the facet jointremove parts of the facet joint
The TESSYS-ConceptThe TESSYS-Concept
Advancement of Advancement of fenestratedfenestrated working tubeworking tube (outer diameter (outer diameter7.5 mm) over the red guiding7.5 mm) over the red guidingtube tube andand insertion of the insertion of the foraminoscopeforaminoscope
The TESSYS-ConceptThe TESSYS-Concept
• Viewing angle 30°Viewing angle 30°• Outer diameter: 6,3 mmOuter diameter: 6,3 mm• Working channel: 3,7 mmWorking channel: 3,7 mm• Length: 174 oder 208 mmLength: 174 oder 208 mm
The TESSYS-ConceptThe TESSYS-Concept
• Removal of disc material Removal of disc material using forcepsusing forceps
• Application of the Application of the radiofrequency probe radiofrequency probe to arrest bleedingto arrest bleeding
TheThe TESSYS-Concept TESSYS-Concept
NeuroforamenNeuroforamen
PediclePedicle
Facet jointsFacet joints
Spinous processSpinous process
Spinal canalSpinal canal
Disc spaceDisc space
Thecal sac and nerve Thecal sac and nerve rootsroots
Anatomic considerationsAnatomic considerations
TheThe TESSYS-Concept TESSYS-ConceptAnatomic considerations
TheThe TESSYS-Concept TESSYS-ConceptRadiologic landmarksRadiologic landmarks
The TESSYS-ConceptThe TESSYS-ConceptPatient positioningPatient positioning
In prone or lateral position In prone or lateral position
in analgo-sedation or generalin analgo-sedation or general
anesthesiaanesthesia
The TESSYS-ConceptThe TESSYS-ConceptRequirement in the ORRequirement in the OR
Radiolucent table and C-arc in ap and lateral viewRadiolucent table and C-arc in ap and lateral view
Optimal arrangement of monitors and instrumentsOptimal arrangement of monitors and instruments
Amount of removed disc materialAmount of removed disc material
Wound closure in subcutaneous Wound closure in subcutaneous fashionfashion
The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations
Massive deformityMassive deformity
SpondylolisthesisSpondylolisthesis
Dorsal stenosis of the Dorsal stenosis of the
spinal canalspinal canal
Steep iliac crest for Steep iliac crest for
herniation at level L5/S1herniation at level L5/S1
The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations
Massive deformityMassive deformity
SpondylolisthesisSpondylolisthesis
Dorsal stenosis of the Dorsal stenosis of the
spinal canalspinal canal
Steep iliac crest for Steep iliac crest for
herniation at level L5/S1herniation at level L5/S1
The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations
Massive deformityMassive deformity
SpondylolisthesisSpondylolisthesis
Dorsal stenosis of the Dorsal stenosis of the spinal canalspinal canal
Steep iliac crest for Steep iliac crest for
herniation at level L5/S1herniation at level L5/S1
The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations
Massive deformityMassive deformity
SpondylolisthesisSpondylolisthesis
Dorsal stenosis of the Dorsal stenosis of the
spinal canalspinal canal
Steep iliac crest for Steep iliac crest for herniation at level L5/S1herniation at level L5/S1
1)Non problemi di sanguinamento2) Ridotte complicanze( danno
nervoso,trombosi,infezioni)3) Possibile in paz. obesi< BMI 30-40 4) Riabilitazione più rapida 5) Nessuna formazione di aderenze post-operatorie 6) Anestesia locale e sedazione 7) Non crea instabilità 8) Consente di eseguire la foraminotomia9(Day- Surgery)10)E' una piattaforma per futuri trattamenti chirurgici
discali
VANTAGGIThe TESSYS-ConceptThe TESSYS-Concept
Incidence of Complications 3.5% Incidence of Complications 3.5% Yeung AT, Tsou PM :Spine Vol 27 April Yeung AT, Tsou PM :Spine Vol 27 April
20022002Gradual decrease with avoidance Gradual decrease with avoidance experience experience •Dysesthesias 5%-15% Dysesthesias 5%-15%
(Most common, usually (Most common, usually
temporary, not temporary, not
completely avoidable!)completely avoidable!)
•DRG, Circulatory DRG, Circulatory
changes, furcal nerves, changes, furcal nerves,
anomalous nervesanomalous nerves
•Persistent sensory Persistent sensory
deficit 1%deficit 1%
•Persistent motor Persistent motor
weakness 2%weakness 2%
Dural tears do not Dural tears do not need repairneed repair
Due to no Surgical Due to no Surgical approach approach dissectiondissection
•Discitis .03%Discitis .03%
•Dural tear 1%Dural tear 1%
•Thrombophlebitis .5%Thrombophlebitis .5%
•Bowel injury 1/3,000 (.003%)Bowel injury 1/3,000 (.003%)
•Vascular injury 0%Vascular injury 0%
CASISTICA
L4-L5 10 F 7 M 3
L5-S1 5 F 2 M 3
Tot 15 Lateralità Dx 8 Sn 6 Mediana 1
The TESSYS-ConceptThe TESSYS-Concept
COMPLICANZE Disestesie temporanee 1
(regredite con terapia medica) Irritazione temporanea del nervo 1 Interventi interrotti 1
(per anomalia del nervo Interventi convertiti con altro approccio 1
( approccio mediano per via endoscopica L5- S1)
The TESSYS-ConceptThe TESSYS-Concept
Due toDue to::
Conclusion minimal invasivity minimal invasivity
good clinical results good clinical results
low complication ratelow complication rate
the the Tessys-methodTessys-method represents an : represents an :
attractive and efficient treatment modality forattractive and efficient treatment modality for
median to extraforaminal positioned lumbar discmedian to extraforaminal positioned lumbar disc
herniations even at the level L5/S1 and reduces the herniations even at the level L5/S1 and reduces the
indication for „open“ disc surgeryindication for „open“ disc surgery
The TESSYS-ConceptThe TESSYS-Concept
GRAZIE