Name: cone beam intraoperative computed tomography-based image guidance for minimally invasive transforaminal interbody fusion
Uploaded: 2019-08-06T14:00:00
Description: Watch this Scientific Journal Video about Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion at JoVE.com

We would like to acknowledge UCSF Medical Center and the Department of Neurosurgery for allowing us to pursue this endeavor.

All procedures and research activities were performed with institutional review board approval (CHR #17-21909).
1. Pre-operative Preparation
<ol>
	<li>Induce general anesthesia in the patient, and position the patient prone on the Jackson table with chest bolster and hip pads.</li>
	<li>Prep and drape the patient&#39;s back in the usual sterile fashion.</li>
</ol>
2. Surgical Procedure
<ol>
	<li>Make a small stab incision using a #15-blade over the PSIS contralatera...

<ol>
	<li>Mobbs, R. J., Phan, K., Malham, G., Seex, K., Rao, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lumbar+interbody+fusion:+techniques,+indications+and+comparison+of+interbody+fusion+options+including+PLIF,+TLIF,+MI-TLIF,+OLIF/ATP,+LLIF+and+ALIF.">Lumbar interbody fusion: techniques, indications and comparison of interbody fusion options including PLIF, TLIF, MI-TLIF, OLIF/ATP, LLIF and ALIF.</a> J Spine Surg. 1 (1), 2-18 (2015).</li><li>Foley, K. T., Holly, L. T., Schwender, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+lumbar+fusion.">Minimally invasive lumbar fusion.</a> Spine (Phila Pa 1976). 28, S26-S35 (2003).</li><li>Foley, K. T., Lefkowitz, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advances+in+minimally+invasive+spine+surgery.">Advances in minimally invasive spine surgery.</a> Clin Neurosurg. 49, 499-517 (2002).</li><li>Schwender, J. D., Holly, L. T., Rouben, D. P., Foley, K. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+transforaminal+lumbar+interbody+fusion+(TLIF):+technical+feasibility+and+initial+results.">Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results.</a> J Spinal Disord Tech. 18 Suppl, S1-S6 (2005).</li><li>Lee, K. H., Yue, W. M., Yeo, W., Soeharno, H., Tan, S. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+and+radiological+outcomes+of+open+versus+minimally+invasive+transforaminal+lumbar+interbody+fusion.">Clinical and radiological outcomes of open versus minimally invasive transforaminal lumbar interbody fusion.</a> Eur Spine J. 21 (11), 2265-2270 (2012).</li><li>Peng, C. W., Yue, W. M., Poh, S. Y., Yeo, W., Tan, S. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+and+radiological+outcomes+of+minimally+invasive+versus+open+transforaminal+lumbar+interbody+fusion.">Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion.</a> Spine (Phila Pa 1976). 34 (13), 1385-1389 (2009).</li><li>Schizas, C., Tzinieris, N., Tsiridis, E., Kosmopoulos, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+versus+open+transforaminal+lumbar+interbody+fusion:+evaluating+initial+experience.">Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience.</a> Int Orthop. 33 (6), 1683-1688 (2009).</li><li>Seng, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Five-year+outcomes+of+minimally+invasive+versus+open+transforaminal+lumbar+interbody+fusion:+a+matched-pair+comparison+study.">Five-year outcomes of minimally invasive versus open transforaminal lumbar interbody fusion: a matched-pair comparison study.</a> Spine (Phila Pa 1976). 38 (23), 2049-2055 (2013).</li><li>Shunwu, F., Xing, Z., Fengdong, Z., Xiangqian, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+transforaminal+lumbar+interbody+fusion+for+the+treatment+of+degenerative+lumbar+diseases.">Minimally invasive transforaminal lumbar interbody fusion for the treatment of degenerative lumbar diseases.</a> Spine (Phila Pa 1976). 35 (17), 1615-1620 (2010).</li><li>Singh, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+perioperative+cost+analysis+comparing+single-level+minimally+invasive+and+open+transforaminal+lumbar+interbody+fusion).">A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion).</a> Spine J. 14 (8), 1694-1701 (2014).</li><li>Wong, A. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+transforaminal+lumbar+interbody+fusion+(MI-TLIF):+surgical+technique,+long-term+4-year+prospective+outcomes,+and+complications+compared+with+an+open+TLIF+cohort.">Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): surgical technique, long-term 4-year prospective outcomes, and complications compared with an open TLIF cohort.</a> Neurosurg Clin N Am. 25 (2), 279-304 (2014).</li><li>Clark, J. C., Jasmer, G., Marciano, F. F., Tumialan, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+transforaminal+lumbar+interbody+fusions+and+fluoroscopy:+a+low-dose+protocol+to+minimize+ionizing+radiation.">Minimally invasive transforaminal lumbar interbody fusions and fluoroscopy: a low-dose protocol to minimize ionizing radiation.</a> Neurosurg Focus. 35 (2), E8 (2013).</li><li>Ringel, F., Villard, J., Ryang, Y. M., Meyer, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Navigation,+robotics,+and+intraoperative+imaging+in+spinal+surgery.">Navigation, robotics, and intraoperative imaging in spinal surgery.</a> Adv Tech Stand Neurosurg. 41, 3-22 (2014).</li><li>Overley, S. C., Cho, S. K., Mehta, A. I., Arnold, P. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Navigation+and+Robotics+in+Spinal+Surgery:+Where+Are+We+Now.">Navigation and Robotics in Spinal Surgery: Where Are We Now.</a> Neurosurgery. 80, S86-S99 (2017).</li><li>Abdullah, K. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radiation+exposure+to+the+spine+surgeon+in+lumbar+and+thoracolumbar+fusions+with+the+use+of+an+intraoperative+computed+tomographic+3-dimensional+imaging+system.">Radiation exposure to the spine surgeon in lumbar and thoracolumbar fusions with the use of an intraoperative computed tomographic 3-dimensional imaging system.</a> Spine (Phila Pa 1976). 37 (17), E1074-E1078 (2012).</li><li>Gelalis, I. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+of+pedicle+screw+placement:+a+systematic+review+of+prospective+in+vivo+studies+comparing+free+hand,+fluoroscopy+guidance+and+navigation+techniques.">Accuracy of pedicle screw placement: a systematic review of prospective in vivo studies comparing free hand, fluoroscopy guidance and navigation techniques.</a> Eur Spine J. 21 (2), 247-255 (2012).</li><li>Nottmeier, E. W., Bowman, C., Nelson, K. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgeon+radiation+exposure+in+cone+beam+computed+tomography-based,+image-guided+spinal+surgery.">Surgeon radiation exposure in cone beam computed tomography-based, image-guided spinal surgery.</a> Int J Med Robot. 8 (2), 196-200 (2012).</li><li>Park, P., Foley, K. T., Cowan, J. A., Marca, F. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+pedicle+screw+fixation+utilizing+O-arm+fluoroscopy+with+computer-assisted+navigation:+Feasibility,+technique,+and+preliminary+results.">Minimally invasive pedicle screw fixation utilizing O-arm fluoroscopy with computer-assisted navigation: Feasibility, technique, and preliminary results.</a> Surg Neurol Int. 1, 44 (2010).</li><li>Van de Kelft, E., Costa, F., Vander Planken, D., Schils, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+multicenter+registry+on+the+accuracy+of+pedicle+screw+placement+in+the+thoracic,+lumbar,+and+sacral+levels+with+the+use+of+the+O-arm+imaging+system+and+StealthStation+Navigation.">A prospective multicenter registry on the accuracy of pedicle screw placement in the thoracic, lumbar, and sacral levels with the use of the O-arm imaging system and StealthStation Navigation.</a> Spine (Phila Pa 1976). 37 (25), E1580-E1587 (2012).</li><li>Kim, T. T., Johnson, J. P., Pashman, R., Drazin, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+Invasive+Spinal+Surgery+with+Intraoperative+Image-Guided+Navigation.">Minimally Invasive Spinal Surgery with Intraoperative Image-Guided Navigation.</a> Biomed Res Int. 2016, 5716235 (2016).</li><li>Kim, M. C., Chung, H. T., Cho, J. L., Kim, D. J., Chung, N. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Subsidence+of+polyetheretherketone+cage+after+minimally+invasive+transforaminal+lumbar+interbody+fusion.">Subsidence of polyetheretherketone cage after minimally invasive transforaminal lumbar interbody fusion.</a> J Spinal Disord Tech. 26 (2), 87-92 (2013).</li><li>Kim, C. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+Invasive+Transforaminal+Lumbar+Interbody+Fusion+Using+Expandable+Technology:+A+Clinical+and+Radiographic+Analysis+of+50+Patients.">Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Expandable Technology: A Clinical and Radiographic Analysis of 50 Patients.</a> World Neurosurg. 90, 228-235 (2016).</li><li>Malham, G. M., Parker, R. M., Blecher, C. M., Seex, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+and+classification+of+subsidence+after+lateral+interbody+fusion+using+serial+computed+tomography.">Assessment and classification of subsidence after lateral interbody fusion using serial computed tomography.</a> J Neurosurg Spine. , 1-9 (2015).</li><li>Safaee, M. M., Oh, T., Pekmezci, M., Clark, A. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radiation+exposure+with+hybrid+image-guidance-based+minimally+invasive+transforaminal+lumbar+interbody+fusion.">Radiation exposure with hybrid image-guidance-based minimally invasive transforaminal lumbar interbody fusion.</a> J Clin Neurosci. , (2017).</li><li>Yu, E., Khan, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+less+invasive+spine+surgery+result+in+increased+radiation+exposure?+A+systematic+review.">Does less invasive spine surgery result in increased radiation exposure? A systematic review.</a> Clin Orthop Relat Res. 472 (6), 1738-1748 (2014).</li><li>Villard, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radiation+exposure+to+the+surgeon+and+the+patient+during+posterior+lumbar+spinal+instrumentation:+a+prospective+randomized+comparison+of+navigated+versus+non-navigated+freehand+techniques.">Radiation exposure to the surgeon and the patient during posterior lumbar spinal instrumentation: a prospective randomized comparison of navigated versus non-navigated freehand techniques.</a> Spine (Phila Pa 1976). 39 (13), 1004-1009 (2014).</li><li>Tabaraee, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+cone+beam-computed+tomography+with+navigation+(O-ARM)+versus+conventional+fluoroscopy+(C-ARM):+a+cadaveric+study+comparing+accuracy,+efficiency,+and+safety+for+spinal+instrumentation.">Intraoperative cone beam-computed tomography with navigation (O-ARM) versus conventional fluoroscopy (C-ARM): a cadaveric study comparing accuracy, efficiency, and safety for spinal instrumentation.</a> Spine (Phila Pa 1976). 38 (22), 1953-1958 (2013).</li><li>Theologis, A. A., Burch, S., Pekmezci, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Placement+of+iliosacral+screws+using+3D+image-guided+(O-Arm)+technology+and+Stealth+Navigation:+comparison+with+traditional+fluoroscopy.">Placement of iliosacral screws using 3D image-guided (O-Arm) technology and Stealth Navigation: comparison with traditional fluoroscopy.</a> Bone Joint J. 98-B. 98-B (5), 696-702 (2016).</li><li>Mendelsohn, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patient+and+surgeon+radiation+exposure+during+spinal+instrumentation+using+intraoperative+computed+tomography-based+navigation.">Patient and surgeon radiation exposure during spinal instrumentation using intraoperative computed tomography-based navigation.</a> Spine J. 16 (3), 343-354 (2016).</li><li>Shin, B. J., Njoku, I. U., Tsiouris, A. J., Hartl, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Navigated+guide+tube+for+the+placement+of+mini-open+pedicle+screws+using+stereotactic+3D+navigation+without+the+use+of+K-wires:+technical+note.">Navigated guide tube for the placement of mini-open pedicle screws using stereotactic 3D navigation without the use of K-wires: technical note.</a> J Neurosurg Spine. 18 (2), 178-183 (2013).</li><li>Lian, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+3D+Airo(R)+Navigation+for+Minimally+Invasive+Transforaminal+Lumbar+Interbody+Fusion.">Total 3D Airo(R) Navigation for Minimally Invasive Transforaminal Lumbar Interbody Fusion.</a> Biomed Res Int. 2016, 5027340 (2016).</li><li>Navarro-Ramirez, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+Navigation+in+Spine+Surgery;+A+Concise+Guide+to+Eliminate+Fluoroscopy+Using+a+Portable+Intraoperative+Computed+Tomography+3-Dimensional+Navigation+System.">Total Navigation in Spine Surgery; A Concise Guide to Eliminate Fluoroscopy Using a Portable Intraoperative Computed Tomography 3-Dimensional Navigation System.</a> World Neurosurg. 100, 325-335 (2017).</li></ol>

There are several critical steps to the procedure described. The first critical step is the process of registration. The reference arc must be placed in solid bone and should be oriented appropriately to avoid interfering with the S1 pedicle screw placement if needed. The second critical step is maintaining accuracy of the navigation after an intraoperative CT scan is performed, which can be done by identifying normal anatomic structures and confirming the correct positioning. The accuracy should be periodically verified...

The TLIF is one of several options available when considering interbody fusion for degenerative disc disease and spondylolisthesis. The TLIF technique was initially developed in response to complications associated with the more traditional posterior lumbar interbody fusion (PLIF) approach. More specifically, the TLIF minimized retraction of neural elements, thereby reducing the risk of nerve root injury as well as the risk of dural tears, which can lead to persistent cerebrospinal fluid leak. As a unilateral approach, the TLIF technique also affords better preservation of the normal anatomy of the posterior elements1. The TLIF can be performed either open (O-TLIF) or minimally invasive (MIS-TLIF), and MIS-TLIF has proven to be a versatile and popular treatment for lumbar degenerative disease and spondylolisthesis2,3,4. Compared to the O-TLIF, the MIS-TLIF has been associated with decreased blood loss, shorter hospital stay, and less narcotic use; patient-reported and radiographic outcome measures are also similar between open and MIS approaches, thus suggesting the MIS-TLIF is an equally effective but potentially less morbid procedure5,6,7,8,9,10,11.
However, a frequent limitation of the traditional MIS technique is the heavy reliance on fluoroscopy which exposes the patient, surgeon, and operating room staff to non-trivial radiation doses and fluoroscopy time ranging from 46-147 s12. More recently, however, the use of intraoperative CT-guided navigation has been studied, with several different systems available and described in the literature including the O-arm/STEALTH, Airo Mobile, and Stryker Spinal Navigation Systems.13,14 This type of navigated technique has been shown to result in accurate pedicle screw placement while also minimizing the radiation risk to the surgeon15,16,17,18,19. In this article, we present a novel technique for MIS-TLIF that utilizes image-guidance-based pedicle screw placement followed by cage and rod placement with traditional fluoroscopy. This strategy has the potential to increase the speed and accuracy of the pedicle screw placement while minimizing the radiation exposure to both the patient and operating room staff.

<table border="0" cellpadding="0" cellspacing="0" style="width:899px;" width="899">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">O-arm intraoperative CT</td>
			<td style="width:288px;">Medtronic, Minneapolis, MN</td>
			<td style="width:136px;"></td>
			<td style="width:191px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Stealth Navigation System</td>
			<td style="width:288px;">Medtronic, Minneapolis, MN</td>
			<td style="width:136px;"></td>
			<td style="width:191px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Jamshidi Needles</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td>for bone marrow biopsy</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">Cefazolin&#160;</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td>antibiotic.</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Vicryl Sutures</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Steri-Strips</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td>for skin closure</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">telfa dressing</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">tegaderm</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td>for dressing</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Jackson table</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">15-blade</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">High-speed bone drill</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Tubular dilator</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">K-wires</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Reduction towers</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">TLIF retractor</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">2 or 3 mm Kerrison rongeur</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Woodson elevator</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Disc shaver and distractor</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Fluoroscopy</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Allograft cellular bone matrix</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Interbody cage</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Rod</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Soft lumbar brace</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:284px;">X-ray</td>
			<td style="width:288px;"></td>
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			<td></td>
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		<tr height="21">
			<td height="21" style="height:21px;width:284px;">Patient-controlled analgesia pump</td>
			<td style="width:288px;"></td>
			<td style="width:136px;"></td>
			<td></td>
		</tr>
	</tbody>
</table>

cone beam intraoperative computed tomography-based image guidance for minimally invasive transforaminal interbody fusion

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. Minimally invasive surgery (MIS) approaches have been applied to this technique with an associated decrease in estimated blood loss (EBL), length of hospital stay, and infection rates, while preserving outcomes with traditional open surgery. Previous MIS TLIF techniques involve significant fluoroscopy that subjects the patient, surgeon, and operating room staff to non-trivial levels of radiation exposure, particularly for complex multi-level procedures. We present a technique that utilizes an intraoperative computed tomography (CT) scan to aid in placement of pedicle screws, followed by traditional fluoroscopy for confirmation of cage placement. Patients are positioned in the standard fashion and a reference arc is placed in the posterior superior iliac spine (PSIS) followed by intraoperative CT scan. This allows for image-guidance-based placement of pedicle screws through a one-inch skin incision on each side. Unlike traditional MIS-TLIF that requires significant fluoroscopic imaging during this stage, the operation can now be performed without any additional radiation exposure to the patient or operating room staff. After completion of the facetectomy and discectomy, final TLIF cage placement is confirmed with fluoroscopy. This technique has the potential to decrease operative time and minimize total radiation exposure.

Fifty patients underwent surgery with this technique under a single surgeon (AC). The average age was 53 years (range 29-84 years) with 30 women and 20 men. Patients presented with the following pathology: spinal stenosis (n=45), spondylolisthesis (n=29), facet cysts (n=5), degenerative scoliosis (n=3), and cauda equina syndrome (n=1). Symptoms were back and leg pain in 42 cases, back pain alone in 2 cases, and lower extremity radiculopathy in 6 cases. In 10 cases, patients had undergone ...

Watch this Scientific Journal Video about Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion at JoVE.com

Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion

The purpose of this article is to provide image-guidance for minimally invasive transforaminal interbody fusion.

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. ...

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