LISS

1. FIXAÇÃO MENOS INVASIVA
Ricardo Ferreira
Rafael Moraes

5. LISS
ENDOPEDMAX
ic rdoF
a erera
ri
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Adalto Lima Rafael Moraes
Jose Sergio Franco Ricardo Ferreira
Marcus Musafir
Ricardo Ferreira

6. Conceito
MISS / LISS
Minimal Invasive Spine Surgery
Less Invasive Spine Surgery

7. Conceitos
MISS / LISS
Minimal Invasive Spine Surgery
Less Invasive Spine Surgery

8. Objetivo:
Mesma Eficiência com Menor Agressão

9. Questões ???

10. Por que ?

11. Para Melhorar algo que já é Bom.

12. Mas...Você Acredita que isso é Bom ????

13. Revisão da Literatura

14. 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.

15. 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

16. E quanto a Artroplastia ?

17. 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.

19. 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.

20. 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

21. Então ... Será que TDR está caminho certo ?

22. Será que ATD esta pronta para o uso ?

23. Artroplastia Discal:
Tendência ou Influência Comercial ?

24. E....Como melhorar a Artrodese ???

25. Menor Lesão de Partes Moles.

26. 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.

27. High Tech te assusta ?

28. Novidade ou Evolução Natural ?
“

29. 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

30. Indicações
• Como Sistema “LISS” • Como Sistema “Tradicional”
– DDD – Pedículos Difíceis
– Instabilidades • Escolioses
• Espondilolistese • Grandes Espondilolistes
• Fraturas • Má Formações
– Adjuvante ao ALIF
– Adjuvante PLIF

31. OBJETIVO

32. Técnica Cirúrgica

33. #1 Posicionamento do paciente

34. # 2 Localizar Pedículos

35. Acesso aos Pedículos

36. # 3 Puncionar Pedículos ( Fio Guia 2 mm)

38. #1 LOCALIZAR PEDíCULOS

39. #2 PUNÇÃO C/ FIOS GUIA 2.0 mm

40. #4 PUNÇÃO C/ CANULA 3.5mm

41. #5 TROCA POR FIO 1.0 mm

42. #6 Dilatação de Partes Moles

43. OPÇÕES
WILTSE SEXTANTE

44. #7 Escolha e Colocação dos Parafusos

45. PASSAGEM DA HASTE

46. # 8 Acessos e Colocação das Hastes

47. # 9 Distração e Bloqueio

48. #10 Enxertia e Quebra dos Cabeças

49. FINAL

50. PO DIFERENCIADO # D1PO

51. Caso
DDD

52. Caso
DDD

53. Caso
Escoliose 50/60

54. Caso
Escoliose

55. Caso
Escoliose 85

56. Caso Escoliose

58. Caso
Listesis

59. + PPLIF

60. Nova Opção “ LISS”

61. Complicações

62. Mensagem Final

63. ... Algo Minimamente invasivo também
pode ser Maximamente Lesivo ...

64. OBRIGADO
RICARDO FERREIRA
ricardoferreira@vertebralis.com.br
www.lombar.com.br