5/18/2018

1

Anders J. Cohen, DOChief- Neurosurgery & SpineThe Brooklyn Hospital Center

Trans1 – Surgeon Advisory Panel

Evolution from Postero-lateral gutter to Interbody

InterbodyApproaches have blossomed

ALIF, DLIF, ELIF, GLIF, ILIF, LLIF, OLIF, PLIF, TLIF, XLIF, AxiaLIF, etc.

5/18/2018

2

Poor Fusion Results Posterolateral

Wolff’s Law Interbody Cage

Approach & Development –Reduce & Balance

Additional Decompression –Indirect

360 Fusion PLIF ALIF TLIF

Newer generations Less invasive /

disruptive Skew good / bad

ratio Improve Pt outcomes

Short Term Better Long Term

Results

The Least Invasive Approach to the Lumbosacral Region

Access Pre-Sacral Fusion Discectomy Osteogenic Material Distraction and Stabilization

5/18/2018

3

Pre-sacral space between parietal and visceral fascia

Potential for deviation into visceral structures reduced by advancing trocar along the sacrum

Average sagittal diameter of presacralspace measured 1.2 cm

Typical excellent trajectory Infrequent and unsuitable trajectory

5/18/2018

4

EARLY Bleeding Infection Bowel Injury Nerve Injury

LATE Subsidence Lucency Pseudoarthrosis Fusion mass / rate

11

AxiaLIF ® Clinical StudiesComplication Rates / Length of Stay / Surgical Time

Complication Rate(%)

Procedure Time(hours)

Length of Stay(days)

3%

3%

Author / Facility Pts

Avg F/U

months

Avg. Blood Loss

Fusion Rate

ODI Pre

ODI Post

VAS Preop

VAS Post 1yr

VAS Leg Pre

VAS Leg Post TIME Comp.Rate

LOS (days)

Pimenta (1) 26 24 47.1cc 93% 43 19 80 29 122 3% 1.4

TBI (2) 20 5 38cc 85% 43 26 73 26 (5mo) 5.32 1.85 80 0% 1.2

UCSF/UCSD (3) 35 14.5 30cc 91% 42 22 75 31 42 3% 1.0

UCLA (4) 28 12 Minimal 90% 48 22 82 12 8.2 1.2 45 0% 1.0

Mayfield Clinic (5) 26 24 88cc 88% 49 33 67 41 216 0% 2.6

12

0.0

0.2

0.4

0.6

0.8

1.0

Q105 Q2 Q3 Q4 Q106 Q2 Q3 Q4 Q107 Q2 Q3 Q4

0

500

1,000

1,500

2,000

Changes with Complications

Inci

den

ce R

ate

(%

)

Num

ber of P

rocedures

Num

ber of P

rocedures

Recommendation to include coccyx in pre-op imaging

Q106

Soft Tissue model Q206

Blunt Finger Dissection Q306

Finger sweep technique added to surgical

techniqueQ306

Fixation wire became available

Q206

Exchange cannulaQ406

Fixation wire added to surgical technique

Q107

5/18/2018

5

13

Pre-op Workup

Indications for fusion

Contraindication

• Previous bowel surgery, IBD, Pelvic disease

Age appropriate

Failure of conservative therapy

Images: MRI & Flexion/Extension films

• Standard field of view for lumbar MR increased to include coccyx

Review for trajectory & anatomy

Overnight bowel prep

Unique Anatomy Transition Segment Natures 1st Adjacent

Level Synd Unique

Biomechanics

Anterior InterbodyConstruct & Biologics

Posterior Demands› Stand alone› Pedicle Screw› Facet Screw› Combo› Intraspinous

5/18/2018

6

• “Load Bearing”

• Surface Area

• Location

• Conduit to Fusion

• Still highly debatable

• Better Anterior Technique

• Bigger Grafts

• Load Sharing

• Accessing Strongest Bone

• Long Construct

• “Too Strong?”

• Stress Shield

5/18/2018

7

• Facet screws

• Intraspinous Devices

• Load Sharing?

• Shear Resistance

5/18/2018

8

6 Month Postop

70 Male Unable to Ambulate Multiple Co

morbidities Anticoagulation

5/18/2018

9

4 month

ScrewLucency

TLIF 2005

5/18/2018

10

Standard F/U

VAS = 3 (pre op 9)

7 m

onth

Face

t Fus

ion?

40 female

VAS = 9

5/18/2018

11

6 month

12 month VAS=1

5/18/2018

12

5/18/2018

13

Legitimate Technology Significantly Less Disruptive of Healthy, Supportive

Structures Complication rate in line with alternative approaches New Considerations of Biomechanics Must Continue to Assess Complimentary Posterior

Support (Inverse of Post-Lat Shortcomings) Patient Selection / Indications Surgeon MUST be Critical Thinker & Independent

Analyst Surgeons Must Confer & Share Experiences – The

good, Bad & Ugly…