Rome Rehabilitation 2011
XX Congresso Nazionale S.I.C.D.
LA VIA ENDOSCOPICA
INTRAFORAMINALE
NEL TRATTAMENTO DELLE ERNIE
DISCALI LOMBARI
Relatore: Luigi D’Orazio
Medicina del dolore
A.O. San Camillo-Forlanini
The TESSYS-Concept
Operation of lumbar disc
herniations via
lateral, transforaminal,
endoscopic Approach
The TESSYS-Concept
Indications
Radiologic confirmation of
lumbar herniated discs
using MRI- or CT with
clinical signs of nerve root
compression
Foraminal Approach: Lumbar Spine
Adjunct to Traditional Surgery
Hidden Zone
•Preferred for foraminal and
extraforaminal HNP
•Allow access to these pain
generators:
•Disc
•Exiting nerve
•Traversing nerve
•Epidural space
•Superior facet
•Axilla containing the DRG
•Foraminal osteophytes
Visualizes the “Hidden
Zone” Foraminal of MacNab
The TESSYS-Concept
• Transforaminal puncture of
the disc space at the medial
pedicular plane
• Entry point at the skin about
8 to 18 cm from the midline
The TESSYSConcept
The direction of the trajectory
depends on the specific
localization of the disc
herniation
The TESSYS-Concept
Discography or
chromography
and insertion of
the guide wire
The TESSYS-Concept
• Stab incision at the entry
point on the skin and
• insertion of the guiding rod
(angled or straight) into the
neuroforamen
The TESSYS-Concept
If necessary enlargement of the
neuroforamen using guiding tubes and
crown reamers (5, 6.5, 7.5 mm Ø) to
remove parts of the facet joint
The TESSYS-Concept
Advancement of fenestrated
working tube (outer diameter
7.5 mm) over the red guiding
tube and insertion of the
foraminoscope
The TESSYS-Concept
•
•
•
•
Viewing angle 30°
Outer diameter: 6,3 mm
Working channel: 3,7 mm
Length: 174 oder 208 mm
The TESSYS-Concept
• Removal of disc material
using forceps
• Application of the
radiofrequency probe
to arrest bleeding
The TESSYS-Concept
Anatomic considerations
Neuroforamen
Pedicle
Facet joints
Spinous process
Spinal canal
Disc space
Thecal sac and nerve
roots
The TESSYS-Concept
Anatomic considerations
The TESSYS-Concept
Radiologic landmarks
The TESSYS-Concept
Patient positioning
In prone or lateral position
in analgo-sedation or general
anesthesia
The TESSYS-Concept
Requirement in the OR
Radiolucent table and C-arc in ap and lateral view
Optimal arrangement of monitors and instruments
Amount of removed disc material
Wound closure in subcutaneous fashion
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1
The TESSYS-Concept
Limitations
Massive deformity
Spondylolisthesis
Dorsal stenosis of the
spinal canal
Steep iliac crest for
herniation at level L5/S1
The TESSYS-Concept
VANTAGGI
1)Non problemi di sanguinamento
2) Ridotte complicanze( danno nervoso,trombosi,infezioni)
3) Possibile in paz. obesi< BMI 30-40
4) Riabilitazione più rapida
5) Nessuna formazione di aderenze post-operatorie
6) Anestesia locale e sedazione
7) Non crea instabilità
8) Consente di eseguire la foraminotomia
9(Day- Surgery)
10)E' una piattaforma per futuri trattamenti chirurgici
discali
Incidence of Complications 3.5% Yeung
AT, Tsou PM :Spine Vol 27 April 2002
Gradual decrease with avoidance experience
•Dysesthesias 5%-15%
(Most common, usually
temporary, not
completely avoidable!)
•DRG, Circulatory
changes, furcal nerves,
anomalous nerves
•Persistent sensory deficit
1%
•Persistent motor
weakness 2%
•Discitis .03%
•Dural tear 1%
Dural tears do not
need repair
Due to no Surgical
approach
dissection
•Bowel injury 1/3,000 (.003%)
•Thrombophlebitis .5%
•Vascular injury 0%
The TESSYS-Concept
CASISTICA
L4-L5
10
F 7
M 3
L5-S1
5
F 2
M 3
Tot 15
Lateralità
Dx
8
Sn
6
Mediana 1
The TESSYS-Concept
COMPLICANZE




Disestesie temporanee 1
(regredite con terapia medica)
Irritazione temporanea del nervo 1
Interventi interrotti 1
(per anomalia del nervo
Interventi convertiti con altro approccio 1
( approccio mediano per via endoscopica
L5- S1)
The TESSYS-Concept
Conclusion
Due to:
 minimal invasivity
 good clinical results
 low complication rate
the Tessys-method represents an :
attractive and efficient treatment modality for
median to extraforaminal positioned lumbar disc
herniations even at the level L5/S1 and reduces the
indication for „open“ disc surgery
GRAZIE