1. Department of Neurosurgery, Mokpo Hankook Hospital, Mokpo-city

2. 1’st Evolution Introductions Historical Evolution of Post. Instrumentation 1970s, Luque; Luque Rods and Rectangles 1960s, Dr. Paul R. Harrington; Harrington Rods and Hooks Harrington Rods & Hook Luque Rods Mokpo Hanook Hospital Hyeun Sung Kim

3. 1’st Evolution Introductions Historical Evolution of Post. Instrumentation Disadvantages Instruments failure ---- rod breakage, hook dislocate, wire breakage Insufficient stability Insufficient correction loss of correction flat-back syndrome Mokpo Hanook Hospital Hyeun Sung Kim

4. 2’nd Evolution Introductions Historical Evolution of Post. Instrumentation 1987, Cotrel & Dubousset; Pedicle screw, Rod and Hook TSRH Dynalock fixation system Simmons plating system Rogozinski system AMS reduction system Isola/VSP system Fixateur Interne Louis system Plumo-Winter-Byrd(PWB) system Edwards modular system 4CIS Solar spine system CD CCD TSRH Dynalock Fixation SystemSimmons Plating System Rogozinski Spinal Rod System AMS Reduction Fixation System Isola/VSP System Fixateur InterneLouis System Plumo-Winter-Byrd(PWB)System Edwards Modular System 4CIS Solar Mokpo Hanook Hospital Hyeun Sung Kim

5. 2’nd Evolution Introductions Historical Evolution of Post. Instrumentation Disadvantages large skin incision extensive muscle dissection trauma to the lumbar musculoligamentous complex long operation time significant blood loss significant postoperative pain postoperative paraspinal muscle denervation Mokpo Hanook Hospital Hyeun Sung Kim

6. 3’rd Evolution Introductions Historical Evolution of Post. Instrumentation Miniopen Decompression & Fusion 1996, Leu HF & Houser RK; Perc. endoscopic lumbar spine fusion 1998, Mathews HH; Percutaneous interbody fusions. 2003, Foley KT; Minimally invasive lumbar fusion 2006, Holly LT; TLIF: indications, technique and complications Mokpo Hanook Hospital Hyeun Sung Kim

7. Goals Introductions Miniopen Post. Decompression & Fusion minimal skin incision and anatomic dissection minimal operation time minimal blood loss & no transfusion minimal postoperative pain minimal hospital stay period better cosmetic benefits Mokpo Hanook Hospital Hyeun Sung Kim To reduce the approach-related morbidity associated with traditional lumbar fusion

8. Types Introductions Miniopen Post. Decompression & Fusion Miniopen-PLIF TLIF : midline incision : paramedian incision : stripping of m. origin : splitting of m. : interlaminar approach : transforaminal approach Mokpo Hanook Hospital Hyeun Sung Kim

9. Fixation methods Introductions Miniopen Post. Decompression & Fusion PPSF (Percutaneous Pedicle Screw Fixation) - using the Rod insertion system (Sextant, Apollon) - using the B-Twin ESS PFSF (Percutaneous Facet Screw Fixation) Mokpo Hanook Hospital Hyeun Sung Kim

10. Applications Introductions Miniopen Post. Decompression & Fusion Spondylolisthesis grade I & II Spinal stenosis Instability Fractures and Dislocations Mokpo Hanook Hospital Hyeun Sung Kim

11. Purpose To introduce of surgical technique assess the safety, efficacy and results Mokpo Hanook Hospital Hyeun Sung Kim

12. From Jan. 2004 to Jul. 2007 145 cases : Miniopen-posterior decompression and fusion Follow-up period : 1 – 4 yrs Age : 23 – 78 years old (M ; 64) Sex : 89 (F) / 56 (M) Level : L4-5 (69 cases) L3-4 (26 cases) L5-S1 (23 cases) Thoracolumbar bursting fracture (13 cases) L3-4-5 (5 cases) L4-5-S1 (4 cases) L2-3 (4 cases) L2-3-4 (1 case) Materials & Methods Materials Mokpo Hanook Hospital Hyeun Sung Kim

13. 1. Skin incision Materials & Methods Surgical Techniques Mokpo Hanook Hospital Hyeun Sung Kim - midline in 3-6 cm

14. 2. Dissection Materials & Methods Surgical Techniques Mokpo Hanook Hospital Hyeun Sung Kim - stripping of origo-insertion of muscle - extend to facet joint

15. 3. Decompression (interlaminar approach) Materials & Methods Surgical Techniques Mokpo Hanook Hospital Hyeun Sung Kim - supra & interspinous lig., below half of spinous process & lamina

16. 4. Disc preparation for fusion Materials & Methods Surgical Techniques Mokpo Hanook Hospital Hyeun Sung Kim unilateral or bilateral

17. 5. Insertion of bone chips & cages Materials & Methods Surgical Techniques Mokpo Hanook Hospital Hyeun Sung Kim - anterior & both lateral area in disc space

18. 6. Percutaneous pedicle screw fixation Materials & Methods Surgical Techniques Mokpo Hanook Hospital Hyeun Sung Kim - using with Apollon rod insertion system

20. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 1 : L4 Degnerative Spondylolisthesis grade I (M/65) Preoperative X-ray Preoperative MRI Postoperative 1 st day Postoperative 1yrs

21. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 2 : L4 Isthmic Spondylolisthesis Grade II without Osteoporosis(F/51) Preoperative X-ray, MRI Postoperative X-ray : 6months later Postoperative CT : 6months later

22. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 3 : L4 Isthmic Spondylolisthesis Grade II with Osteoprosis (F/63) Preoperative X-ray, MRI Postoperative X-ray : 6 months later Postoperative CT : 6 months later

23. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 4 : Unilateral Foraminal Stenosis with Instability : L4-5 (F/56) Preoperative X-ray, MRI Postoperative CT

24. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 5 : Bilateral Foraminal Stenosis with Instability : L3-4-5 (F/60) Preoperative X-ray Preoperative MRI : Rt. : Lt. Postopertative X-ray Postopertative CT

25. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 6 : T10 Bursting fracture (F/23) : Percutaneous Screw Fixation Preoperative X-ray, CT, MRI Postoperative X-ray, CT, MRI : 6 months later Postoperative Skin Scar

26. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 7 : T12 Bursting fracture with Osteoporosis (F/58) Postoperative X-ray, CT : 6 months later

27. Cases Mokpo Hanook Hospital Hyeun Sung Kim Case 8 : T12 Pyogenic spondylitis(69/M) Preoperative X-ray, MRI PostoperativeX-ray

28. Mean op time Pre & Post-op blood loss Risk of blood transfusion Post-op back pain (total narcotics use) Duration of hospital stay Post-op surgical scar Clinical outcomes (by McNab’s criteria) Radiological results Complications Results Assessments for Results Mokpo Hanook Hospital Hyeun Sung Kim

29. Compare Miniopen-PLIF with Conventional PLIF Results Clinical Results Miniopen-PLIF Conven- PLIF Mean op time 135 mins (100-185) 150 mins(120-215) Pre & Post-op blood loss 240 ml(160-390) 420 ml(300-580) Risk of blood transfusion No 2 - 4 pints Post-op back pain 4 days 7days (total narcotics use) Duration of hospital stay 7 days (5-14) 12 days (7-21) Post-op surgical scar Satisfactory Unsatisfatory Clinical outcomes 95 % 93 % (Excellent & Good) (by McNab’s criteria) Mokpo Hanook Hospital Hyeun Sung Kim

30. Results Radiological Results At last follow-up, all patients had solid fusions. The period for fusion was not different between Mini-open PLIF and Conventional PLIF. Mokpo Hanook Hospital Hyeun Sung Kim

31. Results Complications 2 cases of screw malposition (at the early learning period) Mokpo Hanook Hospital Hyeun Sung Kim

32. is safe and efficacious method has more advantages than the conventional PLIF 1. minimizing destruction to adjacent tissue 2. decreased blood loss & risk of transfusion 3. decreased postoperative pain 4. decreased total narcotics use 5. decreased medical morbidity 6. shorter hospital stay period 7. better cosmetic Conclusions Miniopen-PLIF with PSF Mokpo Hanook Hospital Hyeun Sung Kim