Published on July 21, 2009
FIXAÇÃO MENOS INVASIVA Ricardo Ferreira Rafael Moraes
LISS ENDOPEDMAX ic rdoF a erera ri R Adalto Lima Rafael Moraes Jose Sergio Franco Ricardo Ferreira Marcus Musafir Ricardo Ferreira
Conceito MISS / LISS Minimal Invasive Spine Surgery Less Invasive Spine Surgery
Conceitos MISS / LISS Minimal Invasive Spine Surgery Less Invasive Spine Surgery
Objetivo: Mesma Eficiência com Menor Agressão
Por que ?
Para Melhorar algo que já é Bom.
Mas...Você Acredita que isso é Bom ????
Revisão da Literatura
Resultados da Artrodese • Zdeblick et al. 1993. Spine. 983-91. N=124. 95% fusion rate, 95% good results • Cloward,1981, N=100, 86% fusion, 98% satisfied • Hall et al. 1996. Spine. 982-994. N=120. 63% had previous surgery. 73% good results, 91% fusion rate 11% complication rate.
META-ANALYSIS OF FUSION. ESJ, 1997 BOOS AND WEBB. n= 5601 Surgery Studies Cases Fusion Good Mean outcome AIF 10 1072 78.3 75.9 PLF 16 1264 86.6 70.2 PLIF 8 1372 89.4 82 PLF+IF 10 463 87.4 65.2 PLF+PF 22 1125 90.8 67.5 PLIF+PF 2 305 93.8 87.6
E quanto a Artroplastia ?
Artroplastia Discal ( TDR ) X Artrodese SAS 7 - Berlin 2007 Trabalho Autor n FU Takeaway 5-yr follow up on 52 5 yrs No significant Guyer,R.D Charite difference to ALIF with BAK fusion cages at 5yrs. 2-level Goldstein, J. 168 > 2yrs Results comparable Prodisc to fusion Disc and Facet Kube, R.A. 10 5 yrs CT/MRI saw 8/10 facet degeneration at Degeneration the operative level. after Lumbar Disc Improvement in (5 yr) 2/10 adjacent discs.
Degeneração de Discos Adjacentes Adjacent Segment Failure • Leon Wiltse. 1994. In ‘Instrumented Spinal Fusion’. 22.6 yr follow-up of 42 patients with postero-lateral fusion, with a comparison group. “No difference in rate of degeneration in adjacent segments or of hypermobility.” – Overall 75% clinical success.
Consenso Atual • Resultados da Artroplastia N ão são melhores do que os da artrodese. • Exposição à complicações potencialmente Mais Graves • Revisão de Artroplastia é possível, parem de Altíssimo Risco
Então ... Será que TDR está caminho certo ?
Será que ATD esta pronta para o uso ?
Artroplastia Discal: Tendência ou Influência Comercial ?
E....Como melhorar a Artrodese ???
Menor Lesão de Partes Moles.
INTRAMUSCULAR PRESSURE IS LESS WITH MINIMALLY INVASIVE SPINAL RETRACTORS THAN WITH OPEN RETRACTORS Kee D. Kim, MD 1; David Spenciner, P.E., Sc.M 2; Marike Zwienenberg-Lee, MD 1 ; James E. Boggan, MD 1 Department of Neurological Surgery Introduction University of California Davis 1 Results The mean IMP measured with the Spinal muscle retraction increases the RIH OrthopaedicFoundation, Inc.2 minimally invasive retractor was 10.7 +/- intramuscular pressure (IMP) and decreases blood flow to the paraspinal muscles that may 6.3 mm Hg (n=27) and the mean IMP with adversely affect postoperative function.1,2 the open retractor was 34.9 +/- 18.8 mm Endoscopic placement of pedicle screws is Hg (n=18) (P<0.001). done with less retraction than an open The maximum pressure was maintained procedure and may thus cause less ischemic throughout the time that the open retractor damage. was applied. The maximum pressure with The exact effect of retraction on the muscle the minimally invasive retractor, in has not been demonstrated previously. contrast, was noted only briefly with the Positioning of the initial expansion. We have designed a cadaver study in which Planning of IMP IMP measurements using a minimally measurement sites fiberoptic probe No of Mean IMP invasive retractor and an open retractor are Methods compared. measures (n) (mm Hg) Two unembalmed cadavers were used to compare FlexPosure, a flexible minimally invasive retractor Open (Endius, Plainville, MA) and Versa-Trac open lumbar retractor (V. Mueller, McGaw Park, IL). An ultra- miniature pressure transducer catheter (Millar procedure 18 34.9 Instruments, Houston TX) was used to measure pressure at specific locations next to the incision during retraction. A 3.5 cm paramedian incision for L4-5 Endoscopic retraction Endoscopic procedure 27 10.7 posterolateral fusion was made after a serial dilation and FlexPosure was deployed. The needle pressure Discussion and conclusions transducer was inserted into the paraspinal This study shows that the peak IMP during musculature and IMP was measured at three sites: spine surgery with a minimally invasive retractor 1.5 cm cephalad and caudad to the incision and 2.5 is significantly less than with the open retractor. cm lateral to the incision. These steps were This may in part explain the diminished post- repeated on the contralateral side. operative pain and more rapid recovery of Midline incision followed by open retraction with endoscopically treated patients. It encourages Versa-Trac retractor necessary for same the use of the endoscopic technique in eligible posterolateral fusion was performed. The IMP patients. measurements were again recorded at three References 1 Taylor H. et al. The impact of self-retaining retractors on the different sites: 2.5cm lateral to cephalad, caudad and center of the incision. For the second cadaver, Open retraction paraspinal muscles during posterior spinal surgery. Spine 27: 2758-2762, 2002 the same sequence of measurements was 2 Datta G. et al. Back pain and disability after lumbar performed but only one side. Maximum IMP was laminectomy: Is there a relationship to muscle retraction? measured three timesThis study was funded by Endius,Inc., Plainville MA. Acknowledgements: at each site. A Mann-Whitney Neurosurgery 54: 413-419, 2004 Rank Sum Test was used to analyze the data.
High Tech te assusta ?
Novidade ou Evolução Natural ? “
Sistema P2S ( GM Reis ) • Parafusos Pediculares Poli-Axiais Canulados com Cabeça Longa • Formas de Utilização : – Como Sistema Minimamente Invasivo (MISS) • Vantagem = Menor Agressão – Como Sistema “ Tradicional ” • Maior Precisão
Indicações • Como Sistema “LISS” • Como Sistema “Tradicional” – DDD – Pedículos Difíceis – Instabilidades • Escolioses • Espondilolistese • Grandes Espondilolistes • Fraturas • Má Formações – Adjuvante ao ALIF – Adjuvante PLIF
#1 Posicionamento do paciente
# 2 Localizar Pedículos
Acesso aos Pedículos
# 3 Puncionar Pedículos ( Fio Guia 2 mm)
#1 LOCALIZAR PEDíCULOS
#2 PUNÇÃO C/ FIOS GUIA 2.0 mm
#4 PUNÇÃO C/ CANULA 3.5mm
#5 TROCA POR FIO 1.0 mm
#6 Dilatação de Partes Moles
OPÇÕES WILTSE SEXTANTE
#7 Escolha e Colocação dos Parafusos
PASSAGEM DA HASTE
# 8 Acessos e Colocação das Hastes
# 9 Distração e Bloqueio
#10 Enxertia e Quebra dos Cabeças
PO DIFERENCIADO # D1PO
Caso Escoliose 50/60
Caso Escoliose 85
Nova Opção “ LISS”
... Algo Minimamente invasivo também pode ser Maximamente Lesivo ...
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