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Endoscopic trans-iliac approach to L5-S1 disc and foramen - a report on clinical experience.

Osman SG, Sherlekar S, Malik A, Winters C, Grewal PK, Narayanan M, Gemechu N - Int J Spine Surg (2014)

Bottom Line: The ODI dropped by more than 50%.Endoscopic trans-iliac approach to the L5-S1 disc and foramen is feasible and safe.Decompression can be performed safely via trans-iliac access with minimal blood loss, and in a short operative time.

View Article: PubMed Central - PubMed

Affiliation: American Spine, Germantown, MD.

ABSTRACT

Background: The lumbosacral junction is a difficult area for spine surgery because of the complex anatomy. In the era of minimally invasive spine surgery, the presence of the iliac wing has, at the level of lumbosacral junction, created a major obstacle in the paths of two of the major approaches, namely, the direct lateral and percutaneous posterolateral endoscopic approaches. A trans-iliac cadaver study published by the senior author and co-workers in 1997, suggested the possibility of an alternative approach to the lumbosacral junction.

Purpose: To determine the feasibility of percutaneous, endoscopic trans-iliac approach to the L5-S1 disc and foramen.

Study design: Prospective case series study.

Materials and methods: 15 consecutive patients undergoing the transiliac approach to L5-S1 disc and foramen were included in the study. Pre- and postoperative visual analogue scale (VAS); Oswestry Disability Index (ODI); and intra-operative blood loss and operative time, were obtained for the study. Preoperative MRI or CT scan was used to determine the need for trans-iliac access. The procedure was performed with the patient in prone position and under monitored sedation for decompression. Endotracheal anesthesia was used for fusion cases. The transiliac access was established with a cannulated drill or core drill through the iliac wing. Once the trans-iliac window had been created, the rest of the procedure proceeded as for percutaneous endoscopic transforaminal decompression and fusion.

Results: 15 patients (9 male and 6 female) participated in the study. The VAS for back and leg pain significantly improved in all patients. The ODI dropped by more than 50%. There was minimal blood loss, and transient post-operative dysesthesia in 2 cases which resolved after 3 weeks.

Conclusion: Endoscopic trans-iliac approach to the L5-S1 disc and foramen is feasible and safe. Decompression can be performed safely via trans-iliac access with minimal blood loss, and in a short operative time.

No MeSH data available.


Related in: MedlinePlus

a) Trans-iliac window is 4.16 cm anterolateral to the posterosuperior iliac spine; b) trans-iliac track is posterior to the sacral ala, and cephalad to the S1 pedicle; c) trans-iliac track does not violate the retroperitoneal space, and is safe distance from the lumbosacral trunk; d) the superior gluteal neurovascular bundle is 4.8 cm caudal to the trans-iliac window; e) trans-iliac access portal and its anatomic relationships.
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Figure 0001: a) Trans-iliac window is 4.16 cm anterolateral to the posterosuperior iliac spine; b) trans-iliac track is posterior to the sacral ala, and cephalad to the S1 pedicle; c) trans-iliac track does not violate the retroperitoneal space, and is safe distance from the lumbosacral trunk; d) the superior gluteal neurovascular bundle is 4.8 cm caudal to the trans-iliac window; e) trans-iliac access portal and its anatomic relationships.

Mentions: The senior author and his co-workers performed a cadaver study to determine the feasibility of the trans-iliac approach, in late 1990s and this work was published in 1997.17 The background to that study was the inaccessibility of the L5-S1 disc and foramen for trans-foraminal endoscopic instrumentation in situations where the disc is seated deep in the pelvis. The cadaver study revealed that the trans-iliac access channel traversed gluteus maximus and gluteus medius in four out of five specimens. The superior gluteal neurovascular bundle was about 4.8 centimeters caudal to the transiliac window. There were no injuries to the sacro-iliac joints, ilio-lumbar ligaments or facet joints (Figure 1).


Endoscopic trans-iliac approach to L5-S1 disc and foramen - a report on clinical experience.

Osman SG, Sherlekar S, Malik A, Winters C, Grewal PK, Narayanan M, Gemechu N - Int J Spine Surg (2014)

a) Trans-iliac window is 4.16 cm anterolateral to the posterosuperior iliac spine; b) trans-iliac track is posterior to the sacral ala, and cephalad to the S1 pedicle; c) trans-iliac track does not violate the retroperitoneal space, and is safe distance from the lumbosacral trunk; d) the superior gluteal neurovascular bundle is 4.8 cm caudal to the trans-iliac window; e) trans-iliac access portal and its anatomic relationships.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4325494&req=5

Figure 0001: a) Trans-iliac window is 4.16 cm anterolateral to the posterosuperior iliac spine; b) trans-iliac track is posterior to the sacral ala, and cephalad to the S1 pedicle; c) trans-iliac track does not violate the retroperitoneal space, and is safe distance from the lumbosacral trunk; d) the superior gluteal neurovascular bundle is 4.8 cm caudal to the trans-iliac window; e) trans-iliac access portal and its anatomic relationships.
Mentions: The senior author and his co-workers performed a cadaver study to determine the feasibility of the trans-iliac approach, in late 1990s and this work was published in 1997.17 The background to that study was the inaccessibility of the L5-S1 disc and foramen for trans-foraminal endoscopic instrumentation in situations where the disc is seated deep in the pelvis. The cadaver study revealed that the trans-iliac access channel traversed gluteus maximus and gluteus medius in four out of five specimens. The superior gluteal neurovascular bundle was about 4.8 centimeters caudal to the transiliac window. There were no injuries to the sacro-iliac joints, ilio-lumbar ligaments or facet joints (Figure 1).

Bottom Line: The ODI dropped by more than 50%.Endoscopic trans-iliac approach to the L5-S1 disc and foramen is feasible and safe.Decompression can be performed safely via trans-iliac access with minimal blood loss, and in a short operative time.

View Article: PubMed Central - PubMed

Affiliation: American Spine, Germantown, MD.

ABSTRACT

Background: The lumbosacral junction is a difficult area for spine surgery because of the complex anatomy. In the era of minimally invasive spine surgery, the presence of the iliac wing has, at the level of lumbosacral junction, created a major obstacle in the paths of two of the major approaches, namely, the direct lateral and percutaneous posterolateral endoscopic approaches. A trans-iliac cadaver study published by the senior author and co-workers in 1997, suggested the possibility of an alternative approach to the lumbosacral junction.

Purpose: To determine the feasibility of percutaneous, endoscopic trans-iliac approach to the L5-S1 disc and foramen.

Study design: Prospective case series study.

Materials and methods: 15 consecutive patients undergoing the transiliac approach to L5-S1 disc and foramen were included in the study. Pre- and postoperative visual analogue scale (VAS); Oswestry Disability Index (ODI); and intra-operative blood loss and operative time, were obtained for the study. Preoperative MRI or CT scan was used to determine the need for trans-iliac access. The procedure was performed with the patient in prone position and under monitored sedation for decompression. Endotracheal anesthesia was used for fusion cases. The transiliac access was established with a cannulated drill or core drill through the iliac wing. Once the trans-iliac window had been created, the rest of the procedure proceeded as for percutaneous endoscopic transforaminal decompression and fusion.

Results: 15 patients (9 male and 6 female) participated in the study. The VAS for back and leg pain significantly improved in all patients. The ODI dropped by more than 50%. There was minimal blood loss, and transient post-operative dysesthesia in 2 cases which resolved after 3 weeks.

Conclusion: Endoscopic trans-iliac approach to the L5-S1 disc and foramen is feasible and safe. Decompression can be performed safely via trans-iliac access with minimal blood loss, and in a short operative time.

No MeSH data available.


Related in: MedlinePlus