Elsevier

World Neurosurgery

Volume 115, July 2018, Pages 29-34
World Neurosurgery

Technical Note
Intraoperative Computed Tomography Navigational Assistance for Transforaminal Endoscopic Decompression of Heterotopic Foraminal Bone Formation After Oblique Lumbar Interbody Fusion

https://doi.org/10.1016/j.wneu.2018.03.188Get rights and content

Highlights

  • Foraminal compromise is a possible complication of OLIF.

  • We describe a new technique for treating heterotopic foraminal bone formation.

  • CT-guided endoscopic decompression is presented for transforaminal decompression.

Transforaminal endoscopic spine surgery is an emerging technique in spine surgery, but it offers 2 distinct challenges to spine surgeons looking to adopt it: 1) targeting spine pathology and 2) understanding the endoscopic anatomy visualized through the endoscope. Intraoperative computed tomography (CT)-guided navigation is also an emerging technique in spine surgery that is becoming widely adopted for its benefits in assisting surgeons in localizing pathology and guided spine instrumentation placement. In this technical note, we describe a technique that uses intraoperative CT-guided navigation concomitantly with a transforaminal endoscopic approach to decompress a L4-L5 foraminal heterotopic bone formation after an oblique lumbar interbody fusion. The addition of intraoperative CT-guided navigation proved beneficial in targeting the pathology during the procedure and ensuring that the pathology was resolved by offering postoperative CT visualization of the decompressed neural foramen.

Introduction

Transforaminal endoscopic lumbar discectomy is a minimally invasive spinal surgery procedure that was introduced by Kambin and Gellman in 1973.1 Advances in endoscopic visualization and instrumentation have led to an increased popularity of the technique; however, like other minimally invasive spine procedures, whether they are needle based (vertebroplasty, kyphoplasty, injections, and rhizotomy) or performed through a tubular retractor system (minimally invasive discectomies, interbody fusions, and screw placement), endoscopic spine surgery presents challenges to surgeons who are considering adopting the technique in terms of novel targeting and visualization. We describe a novel technique for incorporating intraoperative computed tomography (CT)-guided navigation with a tranforaminal endoscopic surgical technique to decompress a heterotopic bone formation after an oblique lumbar interbody fusion.

Section snippets

Case Presentation

Patient is a 49 year old male who had a Lumbar 4-5 oblique lumbar interbody fusion (OLIF) 2 years prior for a left paracentral disc herniation and positive discogram (allograft and bone morphogenic protein were used). The patient's preoperative right lumbar radicular symptoms resolved immediately after surgery. He had 3 months of right L4 radicular-type radicular symptoms that resolved and were thought to be due to the right side OLIF approach. Thirteen months after his surgery, he returned

CT Navigation

The patient was positioned prone on a Jackson table and Wilson frame. The patient was prepared and draped with a clear adhesive endoscopic draping system. The navigation tracking device (BrainLab, Munich, Germany) was placed over the skin at L5-S1 and affixed with an antimicrobial adhesive drape—the fiducials were then affixed (Figure 2). The first CT scan was obtained to allow autoregistration for spinal navigation and 3-dimensional reconstruction of the lower lumbar spine. To maintain

Discussion

Minimally invasive spine surgery and needle-based interventional spine procedures typically depend on fluoroscopy for localization and guidance in instrumentation placement.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Fluoroscopy is a key tool in transforaminal endoscopic spine surgery procedures to establish safe and effective access to the neural foramen: access to medial to the pedicle endangers traversing root and thecal sac, access to superior or too lateral endangers the

References (23)

  • R. Kruger et al.

    Radiation dose reduction to medical staff during vertebroplasty: a review of techniques and methods to mitigate occupational dose

    Spine (Phila Pa 1976)

    (2003)
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      Notwithstanding the proven benefits, several studies regarding complications associated with the use of rhBMP-2 have been so far published. Increased rates of infection, postoperative seromas and hematomas, delayed wound healing, dysphagia and neck swelling, retrograde ejaculation, symptomatic radiculitis, vertebral osteolysis, cage subsidence, as well as heterotopic bone formation have all been reported following the use of rhBMP-2 in spine surgery.11-18 We report a case of symptomatic heterotopic bone formation following lumbar spinal revision surgery and posterolateral fusion with rhBMP-2, successfully treated using a minimally invasive tubular approach and provide documentation of the technical aspect of the procedure.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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