Minimally Invasive Spine Surgery MISS

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Minimally Invasive Spine Surgery (MISS)

• Post Operative Care

H. Dennis Mollman, M.D.,PhD. Division Chair
Neurosurgery SIU
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Why all the Interest In MISS

• Patient Outcomes
• Costs
• Length of Stay
• Length of Recovery
• Decreased rehabilitation services
• Less Invasive for elderly patient

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Surgical Techniques

• O-Arm
• Image Guidance

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Intra-operative ImagingO-Arm

• In order to perform minimally invasive procedures
  visualization of the surgical site through some
  sort of portal is required.
• In the abdomen and chest endoscopes can be used
  due to the large open areas.
• In the spine radiographic imaging is the portal
  for visualization.

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O-Arm Three Diminsional Imagaing
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Images
AP and Lateral Fluoroscopy
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Image Guidance
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Marriage of Imaging and Image Guidance
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Intra-operativeReal Time Guidance
Without continued radiation exposure
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Post Operative Cares

• Standard Post Operative Evaluation
• Wound
• Neurological Function
• Pain Management

• Activities
• Early ambulation day of surgery
• PT/OT POD 1
• Anticipate Discharge POD 1-3

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Wounds

• Typically paramedian 3cm may be multiple and
  bilateral
• Dressings changed daily
• Shower day 3
• Bracing when up greater than 15 minutes
• does not need to be worn in bed
• Rare to see CSF leaks with these techniques

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Neurological Assessment

• Focused to anatomic level of surgery the
  surgeon will be interested in deficits
  corresponding to the surgical level
• Cervical upper spinal cord and cervical roots
• Thoracic- mid spinal cord
• Lumbar- lumbar roots, cauda equina

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Common Findings and Complaints

• Increased or persistent numbness in an
  extremity
• Persistent pain in an extremity
• Persistent or more pronounced weakness in an
  extremity
• Episodic back pain related to spasms can be
• 10/10

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Post Op Complications

• Hematoma formation resulting in compression
  of adjacent structures
• nerve root, spinal cord, cauda equina, muscle,
  airway
• Undetected neural injury during the procedure
• Infection usually detected 24-72 hours post op
• Instrumentation failure, movement
• Post Op hemorrhage locally or into surrounding
  structures

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Hematoma
Anterior Cervical
Difficulty swallowing, painful Hoarse, nasal
voice Anxious Airway occlusion
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Hematoma
Anterior Cervical
Spinal cord compression quadraparesis Incontinen
ce Sensory Loss below neck Often severe neck pain
and spasm
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HematomaThoracic

• Spinal Cord Compression
• Paraparesis
• Sensory loss below level of compression
• Bowl/bladder dysfunction
• Severe back pain

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HematomaLumbar

• Neurological Symptoms vary with Level
• L1 cauda equina, bowel and bladder dysfunction
• paraparesis, saddle anesthesia
• L2 same as L1, may present with hip flexor
  
• weakness
• L3 proximal leg weakness, upper thigh numbness
• L4 knee flexion weakness, numbness lateral calf
• L5 dorsiflexion weakness, numbness top of foot
• S1- plantar flexion weakness, numbness bottom of
  foot

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Typical Post Op Course

• Day of Surgery out of bed, may ambulate
• Day 1 PT/OT start ambulation in hall
• Day 2 many patients are discharged
• Day 3 either planning discharge or looking at
  interim care facility

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Pain Management

• With MISS rare use of PCA or epidural analgesia
• IV MS first day, to PO narcotics day 1 or 2
• If pain management difficult PCA for 1- 2 days
• Open procedures continuous epidural analgesia
• days 1 and 2. Allows patient to be
  comfortable and participate in PT

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Bracing

• Lumbar LS corset to be worn when up more than
  15 minutes unless otherwise specified
• Cervical rare use of brace unless large
  posterior fusion, comfort only for ACD
• Thoracic varies. Procedures done for cancer
  often require extensive bracing.

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Length of Stay

• The driving force is patient outcome.
• There is solid evidence showing the rate of
  poorer outcomes and of medically related
  complications is directly proportional to the
  length of stay.
• The LOC is directly related to how quickly the
  patient is ambulated.
• The time of initial ambulation post op is related
  to the amount of IV analgesia used post op
• Thus the drive to minimize narcotic use (keeping
  the patient comfortable) and to early ambulation.

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Thank You for Your Attention
Check the website for more information
www.siumed.edu/surgery/neurosurgery