A carregar...
Publicação
Endoscopic spine surgery : transforaminal access to the lower lumbar spine
| Nome: | Descrição: | Tamanho: | Formato: | |
|---|---|---|---|---|
| 30.21 MB | Adobe PDF |
Autores
Orientador(es)
Resumo(s)
Unlike other vertebrates, human beings have the unique ability to maintain an upright position
and bipedal locomotion, which is only possible due to the morphology of the human spine.
However, this comes at a cost. With increased strain and stress in the lumbopelvic transition, there
is a higher susceptibility to degenerative disc disease in the lower lumbar spine. Despite self adaptative and compensatory mechanisms, some pathologies may still need surgical treatment
whenever adequate conservative measures have failed or are unsuitable.
Spine surgery has always been challenging due to the spine's neurological and biomechanical
complexity. In order to reduce tissue trauma, decrease complication rates, and improve functional
recovery, minimally invasive surgical techniques have been developed throughout the years.
However, advances in endoscopic spine surgery (ESS) further minimized tissue aggression, making
its way into a new era in spine surgery. The benefits of ESS are well established, namely in the
treatment of disc herniations and decompression surgeries. Furthermore, it has also shown
promising results in lumbar interbody fusion surgeries. The most common approach in lumbar
endoscopic assisted fusions is through the foramen, using an intraforaminal access. However, the
lower lumbar spine, and particularly L5S1, poses several challenges to this technique due to the
potential conflict with the iliac crest, the disc slope, the dorsal root ganglion, or the facet joint's
morphology, remaining an open field for research.
This thesis focuses on assessing the lumbopelvic morphology in different populations and
investigates an innovative surgical technique to overcome the anatomical challenges for an
endoscopic assisted intraforaminal lumbar interbody fusion (iLIF). Specifically, this research focuses
on: 1) Detailing characteristics of lumbopelvic morphology; 2) Developing an anatomic-based transforaminal surgical approach to L5S1 iLIF to overcome the iliac crest limitation; 3) Analyzing
treatment outcomes and complications of L5S1 transiliac iLIF.
In PART I, we discuss the relevant topics to understand the scope of our thesis. Chapter 1 is
dedicated to spine development and morphology. Chapter 2 focuses on bipedalism, sagittal
balance, and intervertebral disc degeneration. Finally, Chapter 3 provides a historical perspective
on minimally invasive spine surgery, particularly endoscopic spine surgery.
In PART II, we develop the rationale and aims of this thesis.
In PART III, we present the original research performed. In Chapter 1, we present a systematic
review and meta-analysis on endoscopic assisted lumbar interbody fusion, providing a state-of-the art overview and underlining the gaps in knowledge regarding the approach to the lower lumbar
spine (Paper I). Chapter 2 focuses on lumbopelvic anatomic and morphological correlations for a
transforaminal endoscopic approach to the L5S1 disc space in asymptomatic and symptomatic (low
back pain) individuals (Paper II). In line with the results presented in the previous chapters,
in Chapter 3, we describe a transiliac approach for iLIF in L5S1. The results of a cadaver study are
presented, reporting the feasibility and potential risks of the technique. Furthermore, we compare
cage positioning after a suprailiac and transiliac endoscopic intraforaminal approach to L5S1 (Paper
III). Finally, Chapter 4 describes the initial clinical experience with the transiliac iLIF technique,
reporting preliminary outcomes and complications (Paper IV).
We provide an overview of our work in PART IV, discussing the results, summarizing our
conclusions, and looking into future prospects within this field.
In short, our thesis suggests the following:
First, iLIF for treating lumbar degenerative diseases has significantly less intraoperative blood
loss and reduced length of hospital stay than minimally invasive transforaminal lumbar
interbody fusion (MI-TLIF).
Second, iLIF provides significant clinical improvement and high fusion rates at 12 months or
later, without significant difference in complication rates compared to MI-TLIF.
Third, a deep understanding of the patient's anatomy will increase surgical procedures' safety,
accuracy, and effectiveness. Our results comprehensively characterize lumbosacral
morphology for L5S1 transforaminal access, setting preliminary reference values for access
and working angles, its correlation to the iliac crest, and reference values for skin incision
planning.
Forth, as traditionally measured, the projection of the highest point of the iliac crest does
not correspond to the potential point of conflict with the transforaminal access to L5S1.
Only in a small percentage of cases will the iliac crest eventually prevent this approach.
Fith, in the subset of patients in which the iliac crest prevents transforaminal endoscopic
access to L5S1, the transiliac iLIF is a feasible surgical technique. It allows us to overcome
the limitations imposed by the iliac crest and, at the same time, preserve the major anatomic
structures at risk. Also, the cage can be placed more centrally without compromising its
anterior position in the lateral plane.
Sixth, the first patients who underwent transiliac L5S1 iLIF reported good clinical outcomes
and high fusion rates at 12 months. However, dysesthesia of the ipsilateral lower limb is a
significant concern when programming this type of surgery. Therefore, special care must
always be taken to prevent L5 doral root ganglion (DRG) injury by performing a wide facet
removal and decompression. Previous experience in lumbar transforaminal ESS is
mandatory.
As we look to the future, the field of ESS will most surely continue to evolve, striving to achieve
the best possible clinical outcomes to tackle the complexity of spine pathology. The path to
predictive medicine will be established with the growing range of analytic parameters available,
combined with the advancements in artificial intelligence, including machine learning and deep
learning. More precise pre-operative planning and progressive incorporation of not only navigation
and robotics but also augmented reality during surgical procedures will probably lead to improved
patient outcomes and more personalized approaches in spine care.
Descrição
Palavras-chave
endoscopic spine surgery lumbar interbody fusion iliac crest L5S1 dorsal root ganglion transiliac transforaminal endoscopic approach pre-operative planning reference value