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Table of Contents    
VIDEO SECTION.OPERATIVE NUANCES: STEP BY STEP
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1196-1199

MITLIF Operative Nuances- Step by Step


Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Date of Submission17-Feb-2021
Date of Decision05-May-2021
Date of Acceptance08-Sep-2021
Date of Web Publication30-Oct-2021

Correspondence Address:
Vamsi K Yerramneni
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329566

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 » Abstract 


Background: MITLIF is popular among minimally invasive lumbar interbody fusion procedures. The common indications of MITLIF are Grade I and selected cases of Grade II spondylolisthesis, Failed Back Surgery Syndrome, spondylodiscitis and deformity correction.
Objective: To describe the technical nuances of MITLIF along with an operative video of a case of L4-L5 Grade I Spondylolisthesis.
Surgical Procedure: Two incisions of 2.5 cm length are made on either side, at the level to be operated and further access is created by muscle splitting. Screws, rods and cage(s) are placed through this corridor under fluoroscopic guidance.
Results: This procedure has the advantages of minimal blood loss, less muscular trauma, retention of intact posterior ligamentous anatomy, shorter hospital stay, lesser CSF leak and infection rates when compared to the open approaches.
Conclusions: MITLIF has emerged as the standard procedure replacing open approaches. Mastery of this approach is strongly recommended to spine surgeons.


Keywords: Minimally Invasive Transforaminal Interbody Fusion (MITLIF), Indications, Technical nuances
Key Message: MITLIF technique has made a relatively recent appearance among spinal surgeries and can be safely performed in failed back surgery cases, spondylodiscitis as well as for deformity correction in addition to spondylolisthesis


How to cite this article:
Yerramneni VK, Kanala RR, Kolpakawar S, Yerragunta T. MITLIF Operative Nuances- Step by Step. Neurol India 2021;69:1196-9

How to cite this URL:
Yerramneni VK, Kanala RR, Kolpakawar S, Yerragunta T. MITLIF Operative Nuances- Step by Step. Neurol India [serial online] 2021 [cited 2021 Dec 7];69:1196-9. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1196/329566




MITLIF has been receiving increasing attention among the posterior approaches for lumbar interbody fusion to treat various degenerative spinal conditions. This is due to its inherent advantages of reduced blood loss, wound infections and CSF leak while ensuring lesser normal damage in comparison to open TLIF.[1],[2],[3] Though open and MITLIF have similar long-term outcomes[4], MITLIF patients have been noted to have lesser adjacent segment degeneration.[5] The current literature[6] on Endoscopic TLIF is limited to case series and technical notes. This operative video of MITLIF and the noted technical nuances will elaborate appropriate surgical anatomy regarding pedicle screw placement and facetectomy for successful execution of the surgical procedure.


 » Objective Top


Description of the technical nuances of MITLIF along with an operative video in a case of L4-L5 grade 1 spondylolisthesis.


 » Case description Top


This 42-year-old female patient with no comorbidities presented with complaints of back pain for 6 months which radiated to the right lower limb and along the lateral aspect of the foot. Complaints were aggravated while climbing up stairs and on standing up from sitting position, and were relieved on lying down. Severity of the complaints have increased over the last 2 months and there was associated paraesthesia in the same dermatomal distribution. The symptoms did not respond to a trial of conservative management. On examination, straight leg raising test (SLRT) was positive on the right side, there was a sensory deficit in L5.

On dynamic X-rays of Lumbosacral spine, a reducible grade-1 L4-L5 listhesis was noted. On supine CT Lumbosacral spine, normal sagittal alignment with bilateral facetal hypertrophy at L4-5 level was noted. Magnetic Resonance Imaging revealed mild disc bulges at L3-4 and L4-5 with foraminal stenoses as L4-5 as well as enlarged facet fluid space at the same level. This last finding is an indicator of dynamic instability. Other presurgical routine workup was unremarkable. DEXA scan was suggestive of normal bone density. With the diagnosis of grade 1 dynamic spondylolisthesis of L4-L5, MITLIF was planned.


 » Brief description of the MITLIF procedure Top


Positioning of the patient, C arm and Incision Marking

Video link: https://youtu.be/vR61103zs24

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Video Timeline for the manuscript

(0.47-0.59 minutes) - Patient is positioned prone with bolsters under the upper chest and the hips. Table alignment is manipulated to minimize the slip in cases of reducible subluxations (0.47-0.59 minutes).

(1.01-1.06 minutes) - C arm is used to confirm the level in both lateral and AP views. Care must be taken to avoid misjudging the surgical level particularly in cases of sacralisation of L5 or lumbarisation of the S1 vertebra. C arm positioning is vital. In the AP view, the spinous process must be visible in the midline, the endplates of the vertebrae must be parallel and entire pedicle boundaries must be clearly visible. In the lateral view, the endplates should be parallel and any rotation must be avoided.

(1.15-1.30 minutes) - In cases of mild scoliosis of the spine, the C arm position needs to be adjusted for each vertebral level. In each case, the disc space and lateral pedicle line are marked on AP and confirmed on lateral view X rays on the C arm [Figure 1]B. Paramedian incisions of 2.5 to 3cm length are made on either side, about 3 to 3.5 cm lateral to the midline and half a centimetre lateral to the lateral margin of the pedicle.
Figure 1: (a) Position of patient; (b) Images from C arm showing True AP view; (c) Image showing bilateral 2.5-cm-long skin incision and 3 cm from the midline; (d) Initial direction of Jamshidi needle; (e) Jamshidi needle at the pedicle–body junction, after this Jamshidi needle; (f) Final guidewire placement in AP view; (g) Distal ends of guidewires anchored to the surgical drape

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The centre point of the incision should correspond to a transverse line drawn across the disc space.

Incision

Skin is incised and the incision is extended deeper into the facia. The fascial incision is extended both cranially and caudally beyond the skin incision by about 5mm to achieve easy manoeuvrability of instruments.

(1.38-2.00 minutes) - Pedicle tapping

Muscle is split from the cranial pedicle entry point to the caudal pedicle entry point using blunt dissection with a finger. The transverse process and superior facet junction is palpated and Jamshidi needles are parked lateral to the lateral border of the pedicles at the junction of their upper 1/3 and lower 2/3 as visualised on AP view of C-arm. Subsequently, tapping is done. The general rule to be followed while tapping is that advancement of approximately 20-25mm of needle tip on lateral x-ray translates to reaching the pedicle-body junction. At this point, the needle tip should be at the centre of the pedicle on AP view.

(2.14-2.34 minutes) - Beyond the pedicle-body junction, a more medially directed trajectory is adopted with supero-inferior angulation guided by lateral view X rays. Guide wires are now inserted via the Jamshidi needles in all pedicles and their distal ends are bent and anchored to the surgical drapes.

Steps, thus far are illustrated in [Figure 1].

(4.47-4.59 minutes) - Facetectomy and Decompression

Serial dilators are positioned over the facets at the pathological level under C arm guidance and finally the tubular retractor system (MARS 3V, GLOBUS medical, Philadelphia, USA) is inserted and fixed in place.

(5.05-5.30 minutes) - Under microscopic vision, facets are visualized after clearing the overlying muscle using monopolar cautery. Facetal bone is excised using a chisel and hammer. For excision of the inferior/medial facet, two cuts, one at the lamino-facetal junction and one at the pars, are required followed by ligamentous disconnection using Kerrison rongeurs.

(5.35-5.44 minutes) - Superior 1/3rd of lateral/superior facet is also excised for complete visualization of the Kambin's triangle.

(6.23-7.12 minutes) - Disc Space Preparation and Cage insertion

The disc space is accessed in between the exiting and the traversing nerve root. Annulus is cut with a no. 15 knife. Disc curette, disc punch/forceps, disc shaver and box curette (REVOLVE system, GLOBUS medical, Philadelphia, USA) are used for completing the discectomy and preparing the end plates.

(7.14-7.30 minutes) - Bone graft obtained from the excised facets is packed in the ventral portion of the disc space following which a cage filled with bone chips is inserted under C-arm guidance

(7.50-8.12 minutes) - Screw placement and wound closure

Screws are inserted over the guide wires and subsequently rods are inserted in to screw heads. Compression is done to snugly hold the Interbody cage in situ. These steps are illustrated in [Figure 2] and [Figure 3].
Figure 2: (a) Tubular retractor system placement; (b) Spine model showing cuts for facetectomy; (c) Intraoperative C arm image one side screw placement and insertion of Trailer; (d) image showing final cage placement; (e) AP view of C arm showing final implants and cage position; (f) Skin incision after closure

Click here to view
Figure 3: (a) Lateral Roentgenogram showing L4-L5 Grade 1 listhesis, (b) CT LS spine sagittal section, (c) CT Axial section of L4-L5 disc level, (d) Sagittal MRI of lumbosacral spine, (e) Axial MRI image of L4-L5 level showing bilateral foraminal stenosis, (f) Postoperative X ray LS spine AP view showing implants in situ

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Technique pertaining to Spondylodiscitis

In Spondylodiscitis cases, if the involved vertebrae have healthy pedicles and only partial destruction of the body, screws are placed in the pathological vertebrae. Otherwise, the adjacent healthy vertebrae are chosen for placement of screws. Facetectomy in lumbar spine and transpedicular approach in thoracic spine are taken to access the disc space. Complete debridement of necrotic disc material is done and tissue is sent for histopathological examination, culture and GeneXpert for tuberculosis (TB). In cases of suspected and proven TB, antituberculosis treatment (ATT) is started immediately and the drugs are continued for 18 months[7].

Pearls and pitfalls

  1. Bone densitometry to be done in patients over 40 years of age, especially in females, to rule out osteoporosis.
  2. While positioning the patient, adjustment of the table is required to achieve reduction of slip when deemed reducible on dynamic X rays.
  3. True AP and Lateral C-arm views should be ensured for proper placement of screws.
  4. Simultaneous placement of pedicle screws on both sides is a must to reduce radiation exposure and operative time.
  5. Bicortical purchase of screws is necessary in high grade listhesis especially in L5-S1 listhesis
  6. Facetectomy is undertaken on the symptomatic side. Bilateral facetectomy is indicated in high grade listhesis and bilateral foraminal stenosis
  7. Care is taken during endplate preparation to avoid cortical bone damage aided by usage of large size shavers.
  8. Contralateral placement of screws and distraction increases available space, thereby facilitating discectomy and placement of a large sized cage.
  9. It is better to avoid operating high grade listhesis at the beginning of one's learning curve.



 » Conclusion Top


MITLIF has ensured its place in the armamentarium of today's spinal surgeon. Attention to the technical notes described above will aid smoothen and shorten the learning curve for this procedure.



 
 » References Top

1.
Fan S, Hu Z, Zhao F, Zhao X, Huang Y, Fang X. Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach. European spine journal 2010; 19:316–324.  Back to cited text no. 1
    
2.
Goldstein CL, Macwan K, Sundararajan K, Rampersaud YR. Comparative outcomes of minimally invasive surgery for posterior lumbar fusion: a systematic review. Clin Orthop Relat Res 2014; 472:1727–37.  Back to cited text no. 2
    
3.
Tian NF, Wu YS, Zhang XL, Xu HZ, Chi YL, Mao FM. Minimally invasive versus open transforaminal lumbar interbody fusion: a meta-analysis based on the current evidence. European Spine Journal 2013;22:1741–1749.  Back to cited text no. 3
    
4.
Mummaneni PV, Bisson EF, Kerezoudis P, Glassman S, Foley K, Slotkin JR, et al. Minimally invasive versus open fusion for Grade I degenerative lumbar spondylolisthesis: analysis of the Quality Outcomes Database. Neurosurg Focus 2017;43  Back to cited text no. 4
    
5.
Guang-Xun LI, Chun-Kun P, Jung-Woo HU, Jin-Sung KI. Time Course Observation of Outcomes between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Posterior Lumbar Interbody Fusion. Neurologia medico-chirurgica 2019;59:222.  Back to cited text no. 5
    
6.
Wu J, Liu H, Ao S, Zheng W, Li C, Li H, et al. Percutaneous endoscopic lumbar interbody fusion: technical note and preliminary clinical experience with 2-year follow-up. BioMed research international 2018;2018.  Back to cited text no. 6
    
7.
Yeraagunta T, Yerramneni VK, Kanala RR, Gaikwad G, Kumar HP, Phutane AS. Minimally invasive spinal fusion and decompression for thoracolumbar spondylodiscitis. Journal of Craniovertebral Junction and Spine 2020;11:17.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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