This is doctor corenman and we’re going to talk about a transforaminal lumbar interbody fusion using minimally invasive micro surgical technique stealth and the O Arm this is a typical picture of a very degenerative L5 S1 disc the disc has collapsed and you can see black vacuum phenomenon this is the MRI finding where you can see the lowest disc is much collapsed compared to the ones above with bone signal changes indicating stress fracturing this is a discogram where the two discs above the degenerative disk obviously normal with a cotton ball appearance and the L5 S1.
Disc is quite degenerative this is the technique of the pedicle screw insertion we start first by putting a small frame on the spinous process which you can see protruding out of the blue sheets there we cover it with a clear sheet in order to protect the sterility of the field this device is an O Arm it’s an intro operative CT scanner and this device can lend us images not only front to back and side to side but top to down which makes surgery much safer and much easier.
For insertion of the screws we’re going to watch how this CT works the light on top comes on and you’ll see this image spin around and this is the actual CT scan and how long it takes this CT is onethird the typical exposure of a standard CT performed in a hospital here are the tools that we use in order to identify the levels the incisision has alread been made that device that is protruding out is attached to the spinous process the device I am and holding identifies the level that we are at.
L5 S1 Fusion TLIF Back Surgery Tutorial O Arm CT Vail Colorado
After identify where the screw is going to be inserted I use a small burr to create a starting hole once that starting holes is created then i use a tool called a pedicle finder or pedicle to find the pedicle and this is done under direct visualization you’ll see here that this device that i have has these balls attached and these balls reflect off of a frame and is very similar to a GPS device you can actually insert the device into the pedicle without any problems because you’re looking at the.
Pedicle both a front and side and a topdown view you’ll see this in a second here we will switch to the screen and you’ll see exactly what i’m staring at so there is the vertebra the blue device is the all itself and you can see that i can easily find my way down the pedicle by the feel of the device while i’m actually physically inserting it and by the visualization that i see both on the front side top and middle views once this device is in we have a track the screw is going to follow.
We remove the device and it should be in there pretty rigidly and then we want to tap the hole just like you would tap a wood screw and so we take the device out that finds the pedicle and this is the tap that we use to tap the hole after we’re finished with the tap we will then insert the screw itself that’s attached to the same type of tracking device that we used to find the hole in the first place and we can follow the screw down into the pedicle.
So here the tap is being removed here the screw is now being inserted into the tapped hole and then once we visualize its flight planned sotospeak the screw is inserted and it should be inserted with some good force because the pedicle should be a strong pedicle and hold the screw well these are the screws that are going to hold a vertebra in place while the fusion is taking place once the screw device is removed then we insert the other three screws but here is what i’m visualizing when the screw is being inserted you can.
Literally watch the screw marching down the pedicle and avoiding all of the sensitive structures such as the nerves and the vascular supply this is one screw insertion and four screws are inserted at this point in order to be able to complete the surgery once the screws finished being inserted we can actually save the screw in position then we test the screw we run a little bit of electricity through the screw and by watching this monitor the technician the neural monitoring technician can determine whether this screw could be irritating the nerve root or not.
And with this device the O Arm and stealth it is almost impossible to have a screw irritating a nerve this is what the final screw insertion looks like from the front to back view you can see that white metal which is attached to the spinous process that’s the registration probe we will have a side view here also and you can see the screws inserted and where they exist in the morphology of the vertebral body or the sacrum and the bottom screws we complete the rest of the surgery.
After we perform a second O Arm scan to confirm that the screw position is appropriate and once these are done then we can review the CT scan and here’s a good example of the vertebra and the screw positioning where you will see the screws are nicely placed within the pedicle and within the confines of the vertebra indicating that there is no screw that’s going to irritate a vascular structure or a nerve root we have post operative films this is a front to back view of the TLIF the white arrows point.
To the solid fusion between the vertebra here is the arrow pointing to the solid fusion between the body of L5 the sacrum and then this is the CT scan at six months indicating a rocksolid fusion with the arrow pointing to the solid fusion we will see this is the front to back view again of the interbody with solid bone formation and this is just at six months it really gets much greater at a year again the arrows pointing to a solid fusion and this is exactly how we insert.