reoperations after minimally invasive lumbar spine surgery

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RE-OPERATIONS AFTER MINIMALLY INVASIVE LUMBAR SPINE SURGERY BECAUSE OF RECURRENT DISC HERNIATION: PROSPECTIVE STUDY 914 patients (group 1) with 1012 levels of lumbar disc herniation underwent microdiskectomy 1063 patients (group 2) with 2588 levels of degenerative lumbar spinal stenosis *patients underwent one or multilevel bilateral decompression via unilateral approach *228 patients underwent concomitant diskectomies at the index level Totally 1240 levels microdiskectomy were done Mean follow-up time was 14 years,

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  • 1. REOPERATIONS AFTER MINIMALLY INVASIVE LLUUMMBBAARR SSPPIINNEESSUURRGGEERRYY BBEECCAAUUSSEE OOFF RREECCUURRRREENNTT DDIISSCC HHEERRNNIIAATTIIOONN::PPRROOSSPPEECCTTIIVVEE SSTTUUDDYYMEMORIAL L HOSPITALNEUROSURGERY CLINICSTANBUL, TURKEYYunus AYDIN, MDHalit AVUOLU, MDOkan KAHYAOLU, MD

2. SIMPLY THE BEST!!~No instability in patients with degenerative lumbar disc disease andspinal stenosis before operation. Surgeons create it.~Adjacent segment disease eliminated by avoiding fusion~No more fusion, no more metal~Discharge same day or 1 day after surgery 3. OOuurr aarrttiicclleeVolume 57 (Issue1): pages 5-13, 2002Citation (n=50) 4. OOuurr aarrttiicclleeCitation (n=59) 5. OOuurr aarrttiiccllee 6. Topic: 27 Spinal degenerative diseasesTitle: LONGTERM OUTCOME AFTER UNILATERAL APPROACH FOR BILATERALDECOMPRESSION OF LUMBAR SPINAL STENOSIS: 9-YEAR PROSPECTIVESTUDYAuthor(s): Y. Aydn, H. avuolu, A.M. Mslman, A. Yilmaz, O. Kahyaolu, Y. ahinInstitute(s): Neurosurgery Clinic, ili Etfal Education and Research Hospital, Istanbul, TurkeyText:Introduction: The aim of our study is to evaluate the results and effectiveness ofbilateral decompression via a unilateral approach in the treatment of degenerativelumbar spinal stenosis.Methods: We have conducted a prospective study to compare the midterm outcomeof unilateral laminotomy with unilateral laminectomy. 100 patients with 269 levels oflumbar stenosis without instability were randomized to two treatment groups: unilaterallaminectomy (Group 1), and laminotomy (Group 2). Clinical outcomes were assessedwith the Oswestry Disability Index (ODI) and Short Form-36 Health Survey (SF-36).Spinal canal size wasmeasured pre- and postoperatively.Results: The spinal canal was increased to 4-6.1-fold (mean 5.1 SD0.8-fold) thepreoperative size in Group 1, and 3.3-5.9-fold (mean 4.7 SD 1.1-fold) the preoperativesize in Group 2. If theanteroposterior diameter of the spinal canal (APD) was normal,laminotomies provided adequate decompression. If the APD was reduced,laminectomies provided more adequate decompression. If the transverse diameter andAPD were normal, removing the hypertrophic ligamentum flavum alone providedadequate decompression. The mean follow-up time was 9 years (range 7-10 years).The ODI scores decreased significantly in both early and late follow-up evaluations andthe SF-36 scores demonstrated significant improvement in late follow-up results in ourseries. Analysis of clinical outcome showed no statistical differences between twogroups.Conclusions: For degenerative lumbar spinal stenosis unilateral approaches allowedsufficient and safe decompression of the neural structures and adequate preservationof vertebral stability, resulted in a highly significant reduction of symptoms anddisability, and improved health-related quality of life.Author Keywords: Laminectomy, Laminotomy, Lumbar spinal stenosis, Unilateral approach, Vertebralstability.Presentation Type: Oral Presentation 7. OOuurr aarrttiicclleeCitation (n=14) 8. OUR BIOMECHANICAL STUDY 9. MATERIAL & METHOD~914 patients (group 1) with 1012 levels of lumbar disc herniationunderwent microdiskectomy~1063 patients (group 2) with 2588 levels of degenerative lumbar spinalstenosis*patients underwent one or multilevel bilateral decompression viaunilateral approach*228 patients underwent concomitant diskectomies at the index level~Totally 1240 levels microdiskectomy were done~Mean follow-up time was 14 years, 10. (1) lumbar disc herniation with neurological deficits(2) symptoms of neurogenic claudication referable to the lumbar spine(3) radiological/neuroimaging evidence of lumbar disc herniation and/ordegenerative lumbar stenosis(4) failure of conservative measures(5) the absence of associated pathology such as instability, inflammation ormalignancyINDICATIONS 11. SURGICAL PROCEDURE(disc herniation)Lumbar microdiskectomy technique with preserving lliiggaammeennttuumm ffllaavvuumm A 2 cm skin incision (for 1 level disc herniation) A modified mini Taylor retractor The ligamentum flavum was released and preserved as a 3-sided flap Bipolar coagulation is avoided as much as possible !.. The disk content was totally removed and ligamentum flavum and apediculated fat graft was used to cover the root at the end.~ re-opening is easier when the ligament protected 12. SURGICAL PROCEDURE(disc herniation + stenosis)BBiillaatteerraall ddeeccoommpprreessssiioonn vviiaa aa uunniillaatteerraall aapppprrooaacchh aanndd mmiiccrrooddiisskkeeccttoommyy A 24 cm skin incision (for 25 level stenosis) A linear median fascial incision (on the patients most symptomatic side) A modified mini Taylor retractor Ipsilateral decompression is made (with pneumatic kerrison rongeurs and ahigh-speed burr), The microscope is angulated medially and, the patient tilted contralaterally, toafford visualization across the midline beneath the deepest portion of theinterspinous ligament. Resection of portions or all of the interspinous ligaments, and supraspinousligaments is not performed. 13. SURGICAL PROCEDURE(disc herniation + stenosis)BBiillaatteerraall ddeeccoommpprreessssiioonn vviiaa aa uunniillaatteerraall aapppprrooaacchh aanndd mmiiccrrooddiisskkeeccttoommyy The contralateral portion of ligamentum then is resected sequentially fromcephalad to caudal with curved curettes and Kerrison rongeurs. The microscope then is angulated into the contralateral subarticular zone and, Soft tissue and bony stenosing pathology is excised using high-speed drill andpneumatic kerrison rongeurs. This is done sequentially until nerve root at the operative level is seen exitingfreely into the foramen. If necessary, disk material is removed (ipsi- or contralaterally). To reduce postoperative granulation, the decompressed nerve roots areprotected with small blocks of fat resected from subfascial tissue. 14. Intraoperative views;1, 2 - Contralateral diskectomy3 - View of after contralateraldiskectomy.4,5,6 - Bilaterally decompresseddural sac.7 - View of contralateral nerveroot after the contralateraldecompression (white arrow) 15. 35 (3.8%) patients with 46 (4.5%) levels disc herniation were underwent reoperation.~ Mean recurrence time was 45 months (range 1 84 months),~ 6 patients with different level,29 (% 3,1) patients with same level recurrence,~ 4 patients with 2 times recurrence,~ 2 patients with 3 times recurrence,~ 1 patient with 4 times recurrence~ 5 of them underwent bilateral decompression via unilateral approach andmicrodiskectomy,~ recurrence were seen at 3 patients but reoperation were not required.Mean age were 39.4 yearsRESULT(disc herniation) 16. 13 (1.2%) patients with 14 (0.5%) levels disc herniation were underwent reoperation.~ Mean recurrence time was 19 months (range 1 54 months),~ 4 patients with different level,9 (% 0,8) patients with same level recurrence,~ 1 patient with 2 times recurrence (one same, one different level)~ recurrence were seen at 1 patients but reoperation were not required.Mean age were 61,8 yearsRESULT(disc herniation + stenosis) 17. RESULT(Oswestry Disability Index) The ODI scores decreased significantly in both early and late follow-upevaluations. (Newman-Keuls multiple comparison test, p < 0.0001)Disc herniation(Group1)Disc herniation and Stenosis(Group 2)Preop. 29.62 8.19 32.14 9.27Early postop. 12.22 6.46 13.22 9.88Late postop. 12.40 6.30 12.02 9.27Quality of life 18. RESULT(Short Form 36)The scores demonstrated a marked andsignificant improvement(except in the areas of emotional role)Quality of lifeGroupDisc herniation(Group1)Disc herniation andStenosis (Group 2)PPhysical FunctionPreop 56.12 11.43 55.16 9.03 0.642Early 71.62 8.81 71.80 7.71 0.811Late 70.56 9.90 72.78 10.8 0.776Physical RolePreop 27.50 11.57 28.50 11.08 0.66Early 44.80 9.57 45.20 10.38 0.841Late 47.62 11.32 46.20 9.70 0.502Body PainPreop 43.24 11.77 42.60 10.31 0.773Early 61.78 11.92 62.64 9.52 0.7Late 68.32 9.92 69.64 10.52 0.459General HealthPreop 53.62 10.54 52.66 9.03 0.202Early 60.62 11.28 59.66 10.52 0.202Late 63.12 9.61 60.96 13.98 0.122Vitality/EnergyPreop 41.84 11.57 42.12 13.90 0.326Early 60.12 10.57 59.38 10.11 0.33Late 61.62 10.65 62.66 11.67 0.202Social FunctionPreop 41.88 11.35 42.96 10.16 0.235Early 49.63 10.54 49.67 9.03 0.202Late 50.27 9.65 50.31 11.24 0.202Emotional RolePreop 61.28 10.23 62.14 11.58 0.459Early 63.54 9.54 63.24 9.85 0.459Late 62.74 12.54 61.95 10.35 0.788Mental HealthPreop 60.98 11.58 61.84 10.35 0.459Early 71.38 12.65 72.24 9.52 0.459Late 71.27 9.68 70.49 12.8 0.776 19. CONCLUSIONAs expected, in the elderly group were less likely torecurrence.For this group less mobile and/or fixed spine advantages,disadvantages of fragility should be.~ osteophytes with thickening of the ligaments result in decreasedmobility of the spine as aging occurs, with natural fusion occurringbetween vertebral bodies by the osteophytes.~ the addition of instrumentation to this natural process does notgive any added advantage. 20. CONCLUSIONFor degenerative compressive lumbar spinal lesionsminimally invasive spine surgery with low recurrencerate allowed sufficient and safe decompression of the neuralstructures, allowed adequate preservation of vertebral stability, resulted in a highly significant reduction of symptomsand disability, improved health-related quality of life. 21. CCaassee SSaammpplleess 22. BURAYA VDEO LNK YAPILACAK 23. PPrree--oopp PPoosstt--oopp 77tthh mmoonntthhssRREECCUURRRREENNTT DDIISSCC HHEERRNNIIAATTIIOONN11 lleevveell sstteennoossiiss 24. 22 lleevveellss sstteennoossiissPPrree--ooppPPoosstt--oopp 66tthh mmoonntthhssFFAARR LLAATTEERRAALL HHNNPP 25. PPrree--oopp PPoosstt--ooppPPoosstt--oopp 66tthh mmoonntthhssDDiiffffeerreenntt lleevveell RREECCUURRRREENNCCEE33 lleevveellss sstteennoossiiss 26. 11 lleevveell sstteennoossiissPPrree--oopp PPoosstt--oopp 27. 11 lleevveell sstteennoossiissPPrree--o

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