L4-S1 navigated transforaminal lumbar interbody fusion and decompression using Medtronic Solera and Artic-L
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Lumbar spinal stenosis is a very common condition affecting up to up to 47% of adults over 60 years old, although only around 9% may be symptomatic. Symptoms often come on with standing or walking and improve with leaning forwards or sitting down. In some instances, patients may also experience a radiculopathy while at rest.
Spinal stenosis can occur at any level of the spine. It is most commonly caused by facet joint hypertrophy, ligamentum flavum hypertrophy, and degenerative broad disc bulges. Since the lumbar spine and cervical spine move more than the thoracic spine, stenotic changes are more common in these mobile sections of the spine. More forces go through the lumbar spine which means stenotic changes are most common in this area.
Spinal stenosis can effect the central canal and lateral recesses but may also cause foraminal stenosis. It can also be associated with spondylolisthesis, retrolisthesis, and lateral listhesis as well as any spinal deformity. There is also a subgroup of patients who have congenital stenosis that predisposes them to becoming symptomatic if they develop degenerative changes later in life.
The condition often presents insidiously with spinal claudication. This manifests itself as paraesthesia or aching, progressing to pain and weakness. Patients typically have spinal claudication effecting both lower limbs but it can present unilaterally. The pain often starts when patients have been standing in one position for more than a few minutes, or if they walk for more than 5-10 minutes. Patients will often complain symptoms are worse if they have to walk slowly around shops. However, leaning forward on a stick, frame, or shopping trolley often alleviate their symptoms since flexion makes the lumbar spinal canal wider. Patients also describe that they need to sit down or lean forwards to allow their symptoms to resolve.
The vast majority of patients can be managed non-operatively and should be encouraged to stay as active as possible, with modification of activities that bring on their symptoms. However, for those who have exhausted non-operative measures, surgery may be beneficial.
Surgical management options available include lumbar decompression or fusion with decompression. In some patients, decompression procedure alone may not achieve satisfactory decompression of the nerves to improve symptoms. In this situation, the surgeon needs to work out if excision of the facet joints will achieve decompression. If the facet joints are excised, instrumentation is required to achieve stability of that spinal segment.
In this procedure, I have used multiaxial screws which can be navigated; for lumbar degenerative work, it is uncommon to require fixed angle screw heads. The interbody cage has been designed to allow control of the cage at all stages during insertion which makes it possible to change the position of the cage, if required. I use a transforaminal interbody (TLIF) cage since this can be positioned anteriorly in the disc space in order to create lordosis across the segment, compared to a posterior interbody (PLIF) cage which are often less lordotic and allow less compression posteriorly.
Author:Mr Stephen Morris FRCS (Tr & Orth).
Institution: The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Question 1 of 18
Spinal stenosis can be caused by which one of the following?CorrectIncorrect
Question 2 of 18
Spinal claudication normally describes which one of the following symptoms?CorrectIncorrect
Question 3 of 18
A lumbar fusion procedure should be considered in which one of the following situations?CorrectIncorrect
Question 4 of 18
Prior to considering a lumbar fusion procedure, which of the following investigations should be obtained?CorrectIncorrect
Question 5 of 18
The surface anatomy for the L4/5 interspinous gap is normally found relative to which anatomical structures?CorrectIncorrect
Question 6 of 18
The exposure required for open posterolateral fusion allows visualisation of which structures?CorrectIncorrect
Question 7 of 18
The navigation reference frame should be positioned in which one of the following ways?CorrectIncorrect
Question 8 of 18
When navigating screws and preparing the pedicle, which one answer describes why it is advantageous to use a drill rather than traditional pedicle finder?CorrectIncorrect
Question 9 of 18
The normal entry point for a lumbar pedicle is which one of the following?CorrectIncorrect
Question 10 of 18
Which one articular process is excised first during an L4/5 instrumented fusion and decompression?CorrectIncorrect
Question 11 of 18
What is the extent of an L4/5 lateral recess decompression?CorrectIncorrect
Question 12 of 18
In order to insert an L4/5 transforaminal lumbar interbody cage via the foramen, which one structure needs to be excised to allow access?CorrectIncorrect
Question 13 of 18
When preparing to insert an L5/S1 transforaminal lumbar interbody cage, which one of the following describes the nerve roots immediately at risk?CorrectIncorrect
Question 14 of 18
Which one of the following answers describes the cage material options available for lumbar interbody fusion?CorrectIncorrect
Question 15 of 18
A transforaminal lumbar interbody cage should ideally lie in which one of the following alignments at the end of the procedure?CorrectIncorrect
Question 16 of 18
Once the rods have been inserted for a transforaminal lumbar interbody fusion, which one manoeuvre can be performed to reduce risk of cage displacement and increase lordosis?CorrectIncorrect
Question 17 of 18
Bone graft placed in the L4/5 posterolateral gutter is laid in which one anatomical location?CorrectIncorrect
Question 18 of 18
Which one of the following answers describes why a post-operative standing plain radiograph should be performed prior to discharge from hospital?CorrectIncorrect