1. Percutaneous screw and rod placement
Case for plenary or small group discussions
MISS Curriculum Taskforce
Néstor Taboada
July 2019
2019 and 2020

2. Learning objectives
Describe the indications and how to select the correct patient
Discuss the decision making process for the specific procedure
Outline important aspects of step by step of performing the procedure
Recognize possible complications and how to avoid and manage them

3. Presentation 70-year-old woman Neurogenic claudication
Left leg radicular pain
Severe low back pain

4. Imaging

5. Narrow multifactor channel L4/5 observed
Imaging
Narrow multifactor channel L4/5 observed

6. Previous treatment Physical therapy Pain unit No improvement of pain
Deterioration of Oswestry score

7. Diagnosis
L4/5 spondylolisthesis and stenosis
Neurogenic claudication

8. Management options Nonoperative treatment
Physical therapy, pain management
Surgery
Interspinous spacer
Laminectomy
Open vs MIS tubular: ULBD
Endoscopic
Decompression and fusion
MIS TLIF
LLIF
OLIF
Others?

9. Treatment performed
Percutaneous screws and rods

10. Procedure Percutaneous screws in right position.
Check the position of screws and rods in AP and Lateral views.
Step by step of key wire and them screws.
Check the position of TLIF in AP and Lateral

11. Outcome Surgery time skin to closure 1.5 to 2 hours Minimal blood loss
1 night stay in hospital
Neuro intact after surgery
Postoperative 2-3 months soft orthosis
Walking improved, radicular and low back pain resolved

12. Patient selection Patient complaints and patient imaging Stability
Canal stenosis
Foraminal stenosis (unilateral and/or bilateral)
Previous surgery
Comorbidities
Bone quality

13. Potential complications and prevention
Dural tear and CSF leak
Use ball tip nerve hook for dural sac dissection
Protect dural sac during cage insertion
Neural injury - very rare
Avoid traction on nerve
Protect nerve root during cage insertion
Check the trajectory of the screws in AP and lateral images
Use navigation
Pseudarthrosis
Complete discectomy and adequate amount of bone graft in the disc space
Consider different options of bone grafts
Compression in the screws over the rods

14. Take-home messages MIS percutaneous screws is a safe procedure
Is necessary check the step by step in the placement of the screws and rods (AP and Lateral x-ray or navigation)
Can address bilateral pathology via unilateral approach
Can achieve similar fusion rates to open procedures
Adherence to strict MIS techniques minimizes complications such as CSF leak, neural/vascular injury, infection, etc
Navigation is an excellent tool to prevent malposition of implants and reduce radiation exposure to the surgical team