Dr Sachin Pathak Associate Spine Surgeon Oyster and Pearl Hospitals, Pune

Gr 1 lumbar spondylolisthesis Traetment plan Degenerative Only decompression will increase more instability Interspinus devices : Traditional fixation fusion with TLIF MISS

How to select case for MISS Mono radiculopathy with predominant back pain due to instability Not useful in multilevel severe lumbar canal stenosis with bilateral stenosis ? Lysis dilema always Full facet sign on MRI

Investigation MRI DYNAMIC X RAY IN LAT VIEW

Total 22 cases of gr 1 listhesis Mean age group 39

Advantages Reduced intraoperative Blood Loss Reduced postoperative drain Less Post operative Back pain Less Pain during Rehabilitation Reduced hospital Stay Less multifidus muscle atrophy Decreased incidence of surgical site infections

Procedure Step 1 Mark pedicles and entry points made using trocars percutaneously. Dilators are inserted and screws and rods inserted bilaterally same procerdure used. The side from where disc is removed a larger incision taken and tubular retractors used to remove disc and insert cage.

Decompression + TLIF by using tubular retractor

Cage insertion

Post op

Under GA prone position Operative time 2hr 30 min initial cases Now 1hr 30 min Avg Blood loss 50 cc anasthesia and analgesia requirement was less during procedure No drain

Mobilised after 48 hrs Pain controlled by dynapar and paracetamol Hospital stay 3 days

Problems I have faced initially Scared for c arm exposure 2 cases I have to open paraspinally as rod introducer broken Screws not like mirror image on xray ? Decompressed completely or not

I m happy about No dural leak in any case no Screw mal position giving rise to neuralgic pain or defecit Mobilization quick Pain over opt site drastically reduced

disadvantages Significant learning curve Pseudarthrosis could be due to the more difficult disc space preparation and grafting using tubular retractors Pedicle screw malposition, cage displacement and iatrogenic foraminal stenosis (14.2%) Increased radiation exposure Duration of surgery greater than conventional open technique (3 Hrs after training nearly 1-1.5hrs reduction in earlier time).

References Mid-term clinical results of minimally invasive decompression and posterolateral fusion with percutaneous pedicle screws versus conventional approach for degenerative spondylolisthesis with spinal stenosis. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. A minimally invasive posterior lumbar interbody fusion using percutaneous long arm pedicle screw system for degenerative lumbar disease. He EX, Cui JH, Yin ZX, Li C, Tang C, He YQ, Liu CW. Slip Reduction Rate between Minimal Invasive and Conventional Unilateral Transforaminal Interbody Fusion in Patients with Low-Grade Isthmic Spondylolisthesis Chang Hyun Oh, Gyu Yeul Ji, Jae Kyun Jeon, Junho Lee,Seung Hwan Yoon, and Dong Keun Hyun Mid-term clinical results of minimally invasive decompression and posterolateral fusion with percutaneous pedicle screws versus conventional approach for degenerative spondylolisthesis with spinal stenosis. Kotani Y, Abumi K, Ito M, Sudo H, Abe Y, Minami A. Comparison of superior-level facet joint violations during open and percutaneous pedicle screw placement. Babu R, Park JG, Mehta AI, Shan T, Grossi PM, Brown CR, Richardson WJ, Isaacs RE, Bagley CA, Kuchibhatla M, Gottfried ON. Clinical study on lumbar spondylolisthesis treated by minimally invasive transforaminal lumbar interbody fusion. Wang J, Zhou Y, Zhang ZF, Li CQ, Ren XJ, Chu TW, Wang WD, Zheng WJ, Pan Y, Huang B. Comparison of instrumented posterolateral fusion versus percutaneous pedicle screw fixation combined with anterior lumbar interbody fusion in elderly patients with L5-S1 isthmic spondylolisthesis and foraminal stenosis. Shim JH, Kim WS, Kim JH, Kim DH, Hwang JH, Park CK. Adjacent segment degeneration after lumbar interbody fusion with percutaneous pedicle screw fixation for adult low- grade isthmic spondylolisthesis: minimum 3 years of follow-up. Bae JS, Lee SH, Kim JS, Jung B, Choi G. Two-level anterior lumbar interbody fusion with percutaneous pedicle screw fixation: a minimum 3-year follow-up study. Lee DY, Lee SH, Maeng DH. Minimally invasive anterior lumbar interbody fusion followed by percutaneous pedicle screw fixation for isthmic spondylolisthesis: minimum 5-year follow-up. Kim JS, Choi WG, Lee SH. Comparison of multifidus muscle atrophy and trunk extension muscle strength: percutaneous versus open pedicle screw fixation. Kim DY, Lee SH, Chung SK, Lee HY. Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. Schwender JD, Holly LT, Rouben DP, Foley KT. Surgeons' Exposure to Radiation in Single- and Multi-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion; A Prospective Study Haruki Funao, Ken Ishii,,* Suketaka Momoshima, Akio Iwanami, Naobumi Hosogane,Kota Watanabe, Masaya Nakamura,Yoshiaki Toyama and Morio Matsumoto

References Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2 Jian Wang, Yue Zhou, Zheng Feng Zhang, Chang Qing Li, Wen Jie Zheng, and Jie Liu A minimally invasive posterior lumbar interbody fusion using percutaneous long arm pedicle screw system for degenerative lumbar disease Er-Xing He,Ji-Hao Cui, Zhi-Xun Yin, Chuang Li, Cheng Tang,Yi-Qian He, and Cheng-Wei Liu Minimally invasive transforaminal lumbar interbody fusion.Results of 23 consecutive cases Amit Jhala, Damandeep Singh, and MS Mistry Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Treatment of Spondylolisthesis and Degenerative Segmental Instability Yung Park, Joong Won Ha, Yun Tae Lee, Hyun Chul Oh, Ju Hyung Yoo, and Hyung Bok Kim Minimal access bilateral transforaminal lumbar interbody fusion for high-grade isthmic spondylolisthesis N. A. Quraishi and Y. Raja Rampersaud Quality-of-Life Outcomes With Minimally Invasive Transforaminal Lumbar Interbody Fusion Based on Long-Term Analysis of 304 Consecutive Patients Mick J. Perez-Cruet, MD, MS, Namath S. Hussain, MD, G. Zachary White, BS, Evan M. Begun, BS, Robert A. Collins, DO, Daniel K. Fahim, MD, Girish K. Hiremath, MD, Fadumo M. Adbi, BS, and Sammy A. Yacob, BS