Rome Rehabilitation 2011 Rome Rehabilitation 2011 XX Congresso Nazionale S.I.C.D. LA VIA ENDOSCOPICA INTRAFORAMINALE NEL TRATTAMENTO DELLE ERNIE DISCALI.

Rome Rehabilitation 2011Rome Rehabilitation 2011XX XX CongressoCongresso Nazionale S.I.C.D. Nazionale S.I.C.D.

LA VIA ENDOSCOPICA LA VIA ENDOSCOPICA INTRAFORAMINALE INTRAFORAMINALE

NEL TRATTAMENTO DELLE ERNIE NEL TRATTAMENTO DELLE ERNIE DISCALI LOMBARIDISCALI LOMBARI

RelatoreRelatore: Luigi D’Orazio: Luigi D’OrazioMedicina del doloreMedicina del doloreA.O. San Camillo-ForlaniniA.O. San Camillo-Forlanini

TheThe TESSYS-Concept TESSYS-Concept

Operation of lumbar disc Operation of lumbar disc herniations via herniations via

lateral, transforaminal,lateral, transforaminal,endoscopic Approachendoscopic Approach

The TESSYS-ConceptThe TESSYS-ConceptIndicationsIndications

Radiologic confirmation of Radiologic confirmation of lumbar herniated discs lumbar herniated discs using MRI- or CT withusing MRI- or CT with

clinical signs of nerve root clinical signs of nerve root compressioncompression

ForaminalForaminal Approach: Lumbar Spine Approach: Lumbar SpineAdjunctAdjunct to Traditional Surgery to Traditional Surgery

•Preferred for foraminal and Preferred for foraminal and extraforaminal HNPextraforaminal HNP•Allow access to these pain Allow access to these pain generators:generators:•DiscDisc•Exiting nerveExiting nerve•Traversing nerveTraversing nerve•Epidural spaceEpidural space•Superior facetSuperior facet•Axilla containing the DRGAxilla containing the DRG•Foraminal osteophytesForaminal osteophytes

Visualizes the Visualizes the “Hi“Hidden dden ZoneZone”” Foraminal of MacNab Foraminal of MacNab

Hidden Zone

The TESSYS-ConceptThe TESSYS-Concept• Transforaminal puncture of Transforaminal puncture of

the disc space at the medial the disc space at the medial pedicular planepedicular plane

• Entry point at the skin about Entry point at the skin about

8 to 18 cm from the midline 8 to 18 cm from the midline

The TESSYS-ConceptThe TESSYS-Concept

The direction of the trajectory The direction of the trajectory depends on the specific depends on the specific localization of the disc localization of the disc

herniationherniation

The TESSYS-ConceptThe TESSYS-ConceptDiscography orDiscography or

chromography chromography

and insertion of and insertion of

the guide wirethe guide wire

The TESSYS-ConceptThe TESSYS-Concept• Stab incision at the entryStab incision at the entry

point on the skin andpoint on the skin and• insertion of the guiding rodinsertion of the guiding rod

(angled or straight) into the(angled or straight) into theneuroforamenneuroforamen

The TESSYS-ConceptThe TESSYS-ConceptIf necessary If necessary enlargementenlargement of the of the

neuroforamen using guiding tubes and neuroforamen using guiding tubes and crown reamerscrown reamers (5, 6.5, 7.5 mm (5, 6.5, 7.5 mm Ø)Ø) to to remove parts of the facet jointremove parts of the facet joint

The TESSYS-ConceptThe TESSYS-Concept

Advancement of Advancement of fenestratedfenestrated working tubeworking tube (outer diameter (outer diameter7.5 mm) over the red guiding7.5 mm) over the red guidingtube tube andand insertion of the insertion of the foraminoscopeforaminoscope

The TESSYS-ConceptThe TESSYS-Concept

• Viewing angle 30°Viewing angle 30°• Outer diameter: 6,3 mmOuter diameter: 6,3 mm• Working channel: 3,7 mmWorking channel: 3,7 mm• Length: 174 oder 208 mmLength: 174 oder 208 mm

The TESSYS-ConceptThe TESSYS-Concept

• Removal of disc material Removal of disc material using forcepsusing forceps

• Application of the Application of the radiofrequency probe radiofrequency probe to arrest bleedingto arrest bleeding

TheThe TESSYS-Concept TESSYS-Concept

NeuroforamenNeuroforamen

PediclePedicle

Facet jointsFacet joints

Spinous processSpinous process

Spinal canalSpinal canal

Disc spaceDisc space

Thecal sac and nerve Thecal sac and nerve rootsroots

Anatomic considerationsAnatomic considerations

TheThe TESSYS-Concept TESSYS-ConceptAnatomic considerations

TheThe TESSYS-Concept TESSYS-ConceptRadiologic landmarksRadiologic landmarks

The TESSYS-ConceptThe TESSYS-ConceptPatient positioningPatient positioning

In prone or lateral position In prone or lateral position

in analgo-sedation or generalin analgo-sedation or general

anesthesiaanesthesia

The TESSYS-ConceptThe TESSYS-ConceptRequirement in the ORRequirement in the OR

Radiolucent table and C-arc in ap and lateral viewRadiolucent table and C-arc in ap and lateral view

Optimal arrangement of monitors and instrumentsOptimal arrangement of monitors and instruments

Amount of removed disc materialAmount of removed disc material

Wound closure in subcutaneous Wound closure in subcutaneous fashionfashion

The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations

Massive deformityMassive deformity

SpondylolisthesisSpondylolisthesis

Dorsal stenosis of the Dorsal stenosis of the

spinal canalspinal canal

Steep iliac crest for Steep iliac crest for

herniation at level L5/S1herniation at level L5/S1

The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations

Massive deformityMassive deformity

SpondylolisthesisSpondylolisthesis

Dorsal stenosis of the Dorsal stenosis of the

spinal canalspinal canal

Steep iliac crest for Steep iliac crest for

herniation at level L5/S1herniation at level L5/S1

The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations

Massive deformityMassive deformity

SpondylolisthesisSpondylolisthesis

Dorsal stenosis of the Dorsal stenosis of the spinal canalspinal canal

Steep iliac crest for Steep iliac crest for

herniation at level L5/S1herniation at level L5/S1

The TESSYS-ConceptThe TESSYS-ConceptLimitationsLimitations

Massive deformityMassive deformity

SpondylolisthesisSpondylolisthesis

Dorsal stenosis of the Dorsal stenosis of the

spinal canalspinal canal

Steep iliac crest for Steep iliac crest for herniation at level L5/S1herniation at level L5/S1

1)Non problemi di sanguinamento2) Ridotte complicanze( danno

nervoso,trombosi,infezioni)3) Possibile in paz. obesi< BMI 30-40 4) Riabilitazione più rapida 5) Nessuna formazione di aderenze post-operatorie 6) Anestesia locale e sedazione 7) Non crea instabilità 8) Consente di eseguire la foraminotomia9(Day- Surgery)10)E' una piattaforma per futuri trattamenti chirurgici

discali

VANTAGGIThe TESSYS-ConceptThe TESSYS-Concept

Incidence of Complications 3.5% Incidence of Complications 3.5% Yeung AT, Tsou PM :Spine Vol 27 April Yeung AT, Tsou PM :Spine Vol 27 April

20022002Gradual decrease with avoidance Gradual decrease with avoidance experience experience •Dysesthesias 5%-15% Dysesthesias 5%-15%

(Most common, usually (Most common, usually

temporary, not temporary, not

completely avoidable!)completely avoidable!)

•DRG, Circulatory DRG, Circulatory

changes, furcal nerves, changes, furcal nerves,

anomalous nervesanomalous nerves

•Persistent sensory Persistent sensory

deficit 1%deficit 1%

•Persistent motor Persistent motor

weakness 2%weakness 2%

Dural tears do not Dural tears do not need repairneed repair

Due to no Surgical Due to no Surgical approach approach dissectiondissection

•Discitis .03%Discitis .03%

•Dural tear 1%Dural tear 1%

•Thrombophlebitis .5%Thrombophlebitis .5%

•Bowel injury 1/3,000 (.003%)Bowel injury 1/3,000 (.003%)

•Vascular injury 0%Vascular injury 0%

CASISTICA

L4-L5 10 F 7 M 3

L5-S1 5 F 2 M 3

Tot 15 Lateralità Dx 8 Sn 6 Mediana 1

The TESSYS-ConceptThe TESSYS-Concept

COMPLICANZE Disestesie temporanee 1

(regredite con terapia medica) Irritazione temporanea del nervo 1 Interventi interrotti 1

(per anomalia del nervo Interventi convertiti con altro approccio 1

( approccio mediano per via endoscopica L5- S1)

The TESSYS-ConceptThe TESSYS-Concept

Due toDue to::

Conclusion minimal invasivity minimal invasivity

good clinical results good clinical results

low complication ratelow complication rate

the the Tessys-methodTessys-method represents an : represents an :

attractive and efficient treatment modality forattractive and efficient treatment modality for

median to extraforaminal positioned lumbar discmedian to extraforaminal positioned lumbar disc

herniations even at the level L5/S1 and reduces the herniations even at the level L5/S1 and reduces the

indication for „open“ disc surgeryindication for „open“ disc surgery

The TESSYS-ConceptThe TESSYS-Concept

GRAZIE