Minimally Invasive Options (MIS) for Long

Segment Spinal Deformity

S.P.I.N.E.
June 23-26, 2010
Beirut, Lebanon

Harry Shufflebarger MD
Miami, FL
 Disclosures:

•Consultant DePuy Spine

•Speaker’s Bureau DePuy Spine
•Royalties DePuy Spine

Acknowledgements
•Amer Samdani MD
•Atiq Duranni MD
 MIS in Deformity
Goals of MIS Deformity
Surgery

•Replicate current practice

•Posterior fusion mandatory

•Safe
•Similar outcomes
•Minimal complications
•Don’t repeat errors of
thoracoscopic deformity
surgery
 Background: MIS
 Potential advantages
 Decreased blood loss,
muscle wasting
 Less narcotic, shorter
LOS
 Fewer junctional
problems
 MIS for lumbar surgery well
established
 Park, Spine 2007
 Dhall et al, JNS:Spine
2008
 MIS in Deformity
Areas of Concern

•Derotation
•Releases/osteotomies
•Posterior fusion
•Surgical time
 Categories of MIS

 Pure MIS
 No muscle
stripping

 Hybrid
 Apical levels
muscles stripped

 Ends of a construct
 ? Decrease
junctional
problems
Steps in MIS in Long Segment Spinal Deformity

•Marking skin
•Incision
•Jamshidi placement
•Wire placement
•Facet excision
•Releases
•Decortication
•Grafting
•Screw placement
•Rod placement
•Rod reduction into screw
•Derotation
•Final tightening
Incisions
Fluoro Set-up  AP Image

Endplates
parallel

Spinous
process
equidistant
Pedicle Entry: Mark Jamshidi

Skin 25mm

Pedicle
Position when through the pedicle
on AP fluoroscopy
12

3
9

6
 MIS in Deformity
Potential Areas of Applicability

•Growing rod procedures

•Partially MIS, partially open

•Lenke…HOMSA..hybrid
open muscle sparing
approach

•Totally MIS
•Duranni
•Ashgar & Samdani
 MIS in Deformity
Growing Rod Procedures

•“Classical”
•Requires repeated
•Percutaneous
lengthenings
screws
•Final fusion
•Percutaneous rods
•“Future”
•Sub-fascial
•No final fusion
•Extra-periosteal
•Self-lengthening
•Growth
•External force application
•Phenix M system
 Shilla Growing Rod System
Off-label Product Usage

860

Preop Immediate 3 1/2 yrs postop

Postop

Involves an index surgical procedure that allows continued

spinal growth without repeated lengthenings

Courtesy Dr Richard McCarthy

 Surgical Techniques

 Subperiosteal
exposure of apex
only
3 y/o Pott’s Disease
Paraplegic
Fixed Sliding
Screws Screws
6 mos post-op

Ambulatory
MIS in Long Segment Deformity
Hybrid Technique

Preserve midline
structures
Prevent junctional
problems
 MIS in Deformity
Hybrid Technique

Preserve midline structures

MIS in Deformity
Hybrid Technique Muscle sparing at end
PJK or DJK problem
MIS in Deformity
Hybrid Technique
MIS in Deformity
Hybrid Technique
MIS in Deformity
Hybrid Technique
MIS in Deformity
Hybrid Technique
MIS in Deformity
Hybrid Technique
MIS in Deformity
Hybrid Technique
Steps in MIS in Long Segment Spinal Deformity
Complete
•Marking skin
•Incision
•Jamshidi placement
•Wire placement
•Facet excision
•Releases
•Decortication
•Grafting
•Screw placement
•Rod placement
•Rod reduction into screw
•Derotation
•Final tightening
Pre-op Standing PA & Lateral
 All MIS for Long Deformity

•6 in early 2009
•50 % increase time
•200cc blood loss

2010
•Instruments better
•Retractors better
 MIS for Long Segment Spinal Deformity

•Non-fusion or growing rod techniques

•Ends of long constructs/kyphosis

•Total for long deformity