Minimally Invasive L5 Corpectomy with Navigated Expandable ...

brain

sciences

Technical Note

Minimally Invasive L5 Corpectomy with Navigated Expandable

Vertebral Cage: A Technical Note

Taro Yamauchi 1 , Ashish Jaiswal 1 , Masato Tanaka 1, * , Yoshihiro Fujiwara 1 , Yoshiaki Oda 1 , Shinya Arataki 1

and Haruo Misawa 2

1

2

*









Citation: Yamauchi, T.; Jaiswal, A.;

Tanaka, M.; Fujiwara, Y.; Oda, Y.;

Arataki, S.; Misawa, H. Minimally

Invasive L5 Corpectomy with

Navigated Expandable Vertebral

Department of Orthopaedic Surgery, Okayama Rosai Hospital, Okayama 702-8055, Japan;

ygitaro0307@yahoo.co.jp (T.Y.); drashishjaiswal@ (A.J.); fujiwarayoshihiro2004@yahoo.co.jp (Y.F.);

odaaaaaaamn@yahoo.co.jp (Y.O.); araoyc@ (S.A.)

Department of Orthopaedic Surgery, Okayama University Hospital, Okayama 700-0914, Japan;

misharu@md.okayama-u.ac.jp

Correspondence: tanaka0896@; Tel.: +81-86-262-0131

Abstract: Background: Conventional L5 corpectomy requires a large incision and an extended

period of intraoperative fluoroscopy. We describe herein a new L5 corpectomy technique. Methods:

A 79-year-old woman was referred to our hospital for leg pain and lower back pain due to an L5

vertebral fracture. Her daily life had been affected by severe lower back pain and sciatica for more

than 2 months. We initially performed simple decompression surgery, but this proved effective

for only 10 months. Results: For revision surgery, the patient underwent minimally invasive L5

corpectomy with a navigated expandable cage without fluoroscopy. The second surgery took 215 min,

and estimated blood loss was 750 mL. The revision surgery proved successful, and the patient could

then walk using a cane. In terms of clinical outcomes, the Oswestry Disability Index improved from

66% to 24%, and the visual analog scale score for lower back pain improved from 84 to 31 mm at the

1-year follow-up. Conclusions: Minimally invasive L5 corpectomy with a navigated expandable

vertebral cage is effective for reducing cage misplacement and surgical invasiveness. With this

new technique, surgeons and operating room staff can avoid the risk of adverse events due to

intraoperative radiation exposure.

Cage: A Technical Note. Brain Sci.

2021, 11, 1241.

Keywords: L5 corpectomy; minimally invasive surgery; navigation; single lateral position; C-arm free

10.3390/brainsci11091241

Academic Editor: Christopher Nimsky

1. Introduction

Received: 2 September 2021

Accepted: 17 September 2021

Published: 19 September 2021

Publisher¡¯s Note: MDPI stays neutral

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Copyright: ? 2021 by the authors.

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conditions of the Creative Commons

Attribution (CC BY) license (https://

Thoracolumbar junction shows several features compared with other spine areas. Surgical approaches to pathologies involving the L5 vertebra constitute a significant challenge

due to its anatomical features [1]. The biomechanics of this area are characterized by a high

shearing force and compressive forces [2]. The vascular anatomy of this area is characterized by the locations of the great vessels. As a result, L5 corpectomy has been considered

to have a high complication rate [3]. The problem with major surgeries such as corpectomy

and long posterior corrective fusion in elderly patients is the high rate of complications [4].

Therefore, minimally invasive surgery (MIS) has been receiving increasing attention as a

method of reducing morbidity and perioperative complications for spinal surgery [5]. A

key disadvantage of conventional MIS corpectomy is the misplacement of vertebral cages

and the need for extended use of intraoperative fluoroscopy [6]. Computer-assisted spinal

surgery is the current trend for spinal surgeries, and three-dimensional image guidance

technology is available for spinal MIS [7]. Another concern for MIS surgeons is radiation

exposure when performing MIS under C-arm guidance [4]. Considering the above issues,

we report a new technique for MIS L5 corpectomy with a navigated expandable cage under

navigation guidance.

licenses/by/

4.0/).

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2. Case Presentation

2. Case Presentation

The institutional ethics committee approved this study (approval no. 305). The paThe institutional ethics committee approved this study (approval no. 305). The patient

tient provided written informed consent.

provided written informed consent.

2.1.Patient

PatientHistory

History

2.1.

79-year-old

woman

was

referred

to our

orthopedic

department

the

AA79-year-old

woman

was

referred

to our

orthopedic

department

withwith

painpain

in theinleg

leg

and

lower

back.

Over

the

previous

3

months,

she

had

gradually

become

unable

and lower back. Over the previous 3 months, she had gradually become unable to walk, soto

walk,

she had

visited

anotherand

hospital

andconservative

received conservative

she

hadso

visited

another

hospital

received

treatment.treatment.

Activities Activities

of daily

of

daily

living

were

severely

affected

by

severe

lower

back

pain

and

numbness

and weakliving were severely affected by severe lower back pain and numbness and weakness

of

ness

thefor

left

leg for

more

than 2 months.

the

leftofleg

more

than

2 months.

2.2.Physical

PhysicalExamination

Examination

2.2.

Thepatient

patient

could

walk

or stand

unaided.

No hyporeflexia

thewas

legsdetected

was deThe

could

notnot

walk

or stand

unaided.

No hyporeflexia

of theof

legs

tected

on examination,

she described

severeback

lower

back

pain

with a range

limited

on

examination,

and she and

described

severe lower

pain

with

a limited

ofrange

spinalof

motion.

Numbness

was identified

on both

the at

L5the

and

dermatomes.

Power

in

spinal motion.

Numbness

was identified

onlegs

bothatlegs

L5S1

and

S1 dermatomes.

Power

both

lower

legslegs

waswas

grade

4. No

or bowel

dysfunction

waswas

evident.

in both

lower

grade

4. urinary

No urinary

or bowel

dysfunction

evident.

2.3.

2.3.Preoperative

PreoperativeImaging

Imaging

Radiography

L5 vertebral

vertebralcollapse

collapsewith

withslight

slightinstainRadiographyatatthe

the initial

initial visit

visit demonstrated

demonstrated L5

stability.

Preoperative

computed

tomography

(CT)

showed

a

collapsed

bony

fragment

bility. Preoperative computed tomography (CT) showed a collapsed bony fragment proprotruding

intothe

thespinal

spinalcanal.

canal. Preoperative

Preoperative magnetic

magnetic resonance

truding into

resonance imaging

imaging(MRI)

(MRI)revealed

revealed

severe

spinal

canal

stenosis

at

the

L4¨C5

and

L5¨CS1

levels

(Figure

1A,B).

The

patient

showed

severe spinal canal stenosis at the L4¨C5 and L5¨CS1 levels (Figure 1A,B). The

patient

2 (?1.8 SD).

severe

osteoporosis,

with a bone

mineral

of density

0.856 g/cm

showed

severe osteoporosis,

with

a bonedensity

mineral

of 0.856

g/cm2 (?1.8 SD).

Figure 1. Pre- and postoperative images of the first surgery. (A) Preoperative mid-sagittal reconFigure 1. Pre- and postoperative images of the first surgery. (A) Preoperative mid-sagittal reconstrucstruction CT; (B) Mid-sagittal MRI T2-weighted image; (C) Postoperative radiogram; (D) Postopertion CT; (B) Mid-sagittal MRI T2-weighted image; (C) Postoperative radiogram; (D) Postoperative

ative mid-sagittal reconstruction CT.

mid-sagittal reconstruction CT.

2.4.First

FirstSurgery

Surgeryand

andPostoperative

PostoperativeImages

Images

2.4.

Decompression

surgery

was

initially

performed,

considering

the slight

instability

Decompression

surgery

was

initially

performed,

considering

the slight

instability

and

and

theofage

the patient.

Postoperative

images

indicated

decompression

of spinal

the spithe

age

theofpatient.

Postoperative

images

indicated

goodgood

decompression

of the

nal canal

(Figure

1C,D).

She received

moderate

could

300

canal

(Figure

1C,D).

She received

moderate

painpain

reliefrelief

and and

could

walkwalk

moremore

thanthan

300 m

m

after

surgery.

after surgery.

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2.5.

2.5.Second

SecondSurgery

Surgeryand

andPostoperative

PostoperativeImages

Images

symptoms

had

again

worsened,

andand

sheshe

revisited

our our

hospital.

Follow2.5. After

Second

Surgery

and

Postoperative

Images

After9 9months,

months,

symptoms

had

again

worsened,

revisited

hospital.

Folup

images

showed

that

the

L5

vertebra

had

refractured,

increasing

lumbar

instability

at

low-up

images

showed

that

the

L5

vertebra

had

refractured,

increasing

lumbar

instability

After 9 months, symptoms had again worsened, and she revisited our hospital. Folthis

level.

CT

demonstrated

a

pincer-type

fracture

and

MRI

indicated

dural

compression

at

this level.

CTshowed

demonstrated

fracture

and MRI

indicated

duralinstability

compreslow-up

images

that the aL5pincer-type

vertebra had

refractured,

increasing

lumbar

(Figure

2A,B).

Fusion

MR-CT

images

revealed

an an

abnormal

ofofthe

left

common

sion

(Figure

Fusion

MR-CT

images

revealed

abnormal

course

the

leftcomprescommon

at this

level. 2A,B).

CT

demonstrated

a pincer-type

fracture

and

MRIcourse

indicated

dural

iliac

ofofthe

severity

ofofabnormal

symptoms,

we

to

perform

iliac

artery(Figure

(Figure

2C,D).As

Asaaresult

result

the

severity

symptoms,

wedecided

decided

tocommon

perform

sionartery

(Figure

2A,B).2C,D).

Fusion

MR-CT

images

revealed

an

course

of the left

L5

MIS

corpectomy

with

a

navigated

expandable

cage,

using

a

posterior

percutaneous

L5

MIS

corpectomy

with

a

navigated

expandable

cage,

using

a

posterior

percutaneous

iliac artery (Figure 2C,D). As a result of the severity of symptoms, we decided to perform

pedicle

for

fixation

of L3

L3totothe

thepelvis.

pelvis.

The

second

surgery

215 min,

pedicle

screw

for the

thewith

fixation

of

The

second

surgery

tooktook

215 min,

with

L5 MISscrew

corpectomy

a navigated

expandable

cage,

using

a posterior

percutaneous

with

an

estimated

blood

loss

of

750

milliliters.

No

intraor

postoperative

complications

an

estimated

blood

loss

of

750

milliliters.

No

intraor

postoperative

complications

were

pedicle screw for the fixation of L3 to the pelvis. The second surgery took 215 min, with

were

encountered.

Postoperative

images

showed

good

spinal

decompression

and

encountered.

Postoperative

images

showed

spinal

canal canal

decompression

and were

restoan estimated

blood

loss of 750

milliliters.

Nogood

intraor postoperative

complications

restoration

of

spinal

alignment

(Figure

3A,B).

Postoperative

CT

showed

satisfactory

cage

ration

of spinal

alignment (Figure

Postoperative

showed

satisfactoryand

cagerestoposiencountered.

Postoperative

images3A,B).

showed

good spinalCT

canal

decompression

position

3C,D).

tion

(Figure

3C,D).

ration

of(Figure

spinal

alignment (Figure 3A,B). Postoperative CT showed satisfactory cage position (Figure 3C,D).

Figure 2. Images at the 9-month follow-up. (A) Mid-sagittal reconstruction CT; (B) Mid-sagittal T2Figure 2. Images at the 9-month follow-up. (A) Mid-sagittal reconstruction CT; (B) Mid-sagittal

weighted

image; at

(C)the

Anteroposterior

3D vascular

image; (D)reconstruction

Lateral 3D vascular

Figure 2. Images

9-month follow-up.

(A) Mid-sagittal

CT; (B)image.

Mid-sagittal T2T2-weighted image; (C) Anteroposterior 3D vascular image; (D) Lateral 3D vascular image.

weighted image; (C) Anteroposterior 3D vascular image; (D) Lateral 3D vascular image.

Figure 3. Postoperative images of second surgery. (A) Posteroanterior radiogram; (B) Lateral radiFigure 3.

Postoperative

images ofreconstruction

second surgery.

Posteroanterior

radiogram;

radiogram:

(C) Mid-sagittal

CT;(A)

(D)

Coronal

reconstruction

CT.(B) Lateral

Figure

3.neutral;

Postoperative

images of second surgery.

(A)

Posteroanterior

radiogram;

(B) Lateral

ogram: neutral; (C) Mid-sagittal reconstruction CT; (D) Coronal reconstruction CT.

radiogram: neutral; (C) Mid-sagittal reconstruction CT; (D) Coronal reconstruction CT.

Brain Sci. 2021, 11, 1241

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2.6.

2.6.Follow-Up

Follow-UpResults

Results

After

ofof

almost

normal

activity.

Muscle

weakness

After4 months,

4 months,the

thepatient

patientwas

wascapable

capable

almost

normal

activity.

Muscle

weakness

had

inin

both

legs

(power

grade

5/5).

CT

demonstrated

aa

hadresolved

resolved

both

legs

(power

grade

5/5).AtAtthe

the1-year

1-yearfollow-up,

follow-up,

CT

demonstrated

slight

toto

the

pelvis

and

maintenance

good

slightL4L4fracture,

fracture,but

butsolid

solidbony

bonyfusion

fusionfrom

fromL3L3

the

pelvis

and

maintenanceofof

good

alignment

were

also

seen

(Figure

4).4).Clinical

alignment

were

also

seen

(Figure

Clinicaloutcomes

outcomeshad

hadimproved

improvedatatthe

the1-year

1-yearfollowfollowup.

The

Oswestry

Disability

Index

improved

from

66%

to

24%,

and

lower

back

pain,

asas

up. The Oswestry Disability Index improved from 66% to 24%, and lower back

pain,

assessed

using

a

visual

analog

scale,

improved

from

84

to

31

mm.

assessed using a visual analog scale, improved from 84 to 31 mm.

Figure 4. CT at final follow-up at one year. (A) Anteroposterior 3D CT; (B) Posteroanterior 3D CT;

Figure 4. CT at final follow-up at one year. (A) Anteroposterior 3D CT; (B) Posteroanterior 3D CT;

(C) Lateral 3D CT.

(C) Lateral 3D CT.

3. Operative Procedure

3. Operative Procedure

3.1. Mini-Extraperitoneal Approach

3.1. Mini-Extraperitoneal Approach

The patient is placed in the right lateral decubitus position on an adjustable hinged

The patient is placed in the right lateral decubitus position on an adjustable hinged

operating carbon table. The percutaneous reference frame for navigation is fixed at the left

operating carbon table. The percutaneous reference frame for navigation is fixed at the

sacroiliac

joint

(Figure

5). 5).

Then,

the O-arm

is positioned,

and three-dimensional

reconleft

sacroiliac

joint

(Figure

Then,

the O-arm

is positioned,

and three-dimensional

structed

images

are

obtained

and

transmitted

to

the

StealthStation

surgical

navigation

reconstructed images are obtained and transmitted to the StealthStation surgical navigation

systemSpine

Spine77RR.. Navigated

Navigated spinal

oblique

5 cm

skin

system

spinalinstruments

instrumentsare

areregistered,

registered,and

anda left

a left

oblique

5 cm

incision

is made

along

the best

point,

which

is marked

with awith

navigation

pointer

(Figure

skin

incision

is made

along

the best

point,

which

is marked

a navigation

pointer

6A,B).

The

tip

of

the

left

iliac

wing

should

be

removed

for

a

vertical

approach

to

thetoL5

(Figure 6A,B). The tip of the left iliac wing should be removed for a vertical approach

vertebra.

The

retroperitoneal

space

is

separated

by

blunt

finger

dissection,

and

the

the L5 vertebra. The retroperitoneal space is separated by blunt finger dissection, andpsoas

the

major

muscle,

vessels,

andand

L5 L5

vertebra

areare

exposed.

After

psoas

major

muscle,

vessels,

vertebra

exposed.

Afterthe

thefirst

firstnavigated

navigatedprobe

probe is

psoas major

major muscle,

muscle, sequential

sequentialdilation

dilationisisused

useduntil

until2222mm

mmis is

issafely

safely positioned

positioned on

on the

the psoas

reached.The

Thespecial

specialself-retaining

self-retainingretractor

retractorisisplaced

placedininthe

thecorrect

correctposition.

position.IfIfnecessary,

necessary,

reached.

L3¨C4oblique

obliquelumbar

lumbarinterbody

interbodyfusion

fusioncage

cagecan

canbebeinserted

insertedtotoenhance

enhancecranial

cranialscrew

screw

ananL3¨C4

anchors

(Figure

6C,D).

anchors (Figure 6C,D).

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Figure 5. Position of the reference frame.

Figure 5. Position of the reference frame.

Figure 5. Position of the reference frame.

Figure 6. Navigated pointer and OLIF cage. (A,B) Skin incision with a navigated pointer; (C,D)

Figure 6. Navigated pointer and OLIF cage. (A,B) Skin incision with a navigated pointer; (C,D)

Navigated OLIF cage.

Figure 6.OLIF

Navigated

Navigated

cage. pointer and OLIF cage. (A,B) Skin incision with a navigated pointer; (C,D

Navigated

OLIFwith

cage.

3.2.Corpectomy

Corpectomy

Navigation

3.2.

with Navigation

First,the

theleft

leftureter

ureterand

andleft

leftcommon

commoniliac

iliacvessels

vesselsare

areidentified.

identified.The

Themost

mostimportant

important

3.2.First,

Corpectomy

with Navigation

point

the

ascending

lumbar

vein,

iliolumbar

should

be identified,

ligated,

point

is is

the

ascending

lumbar

vein,

andand

thethe

iliolumbar

veinvein

should

be identified,

ligated,

or

First,

and

common

areand

identified.

The

most

importa

or clipped,

and left

then

cut. discs

The

discs

of

L4¨C5

andiliac

L5¨CS1

are exposed,

and thorough

discecclipped,

and the

then

cut.ureter

The

ofleft

L4¨C5

and L5¨CS1

arevessels

exposed,

thorough

discectomy

theusing

ascending

vein,

and the

iliolumbar

vein

should

be

identified,

tomy

isisperformed

usinglumbar

Kerrison

rongeurs,

pituitary

forceps,

navigated

shavers,

a navi- ligate

ispoint

performed

Kerrison

rongeurs,

pituitary

forceps,

navigated

shavers,

a navigated

gated

Cobb

elevator,

and

navigated

ring

curettes.

The

navigated

osteotome

is

used

or

clipped,

and

then

cut.

The

discs

of

L4¨C5

and

L5¨CS1

are

exposed,

and

thorough

Cobb elevator, and navigated ring curettes. The navigated osteotome is used to removeto

there- disce

move

the

L5

vertebra

(Figure

7A,D).

In

the

same

single

position,

percutaneous

pedicle

L5

vertebra

(Figure 7A,D).

InKerrison

the same rongeurs,

single position,

percutaneous

screws

are a nav

tomy

is performed

using

pituitary

forceps, pedicle

navigated

shavers,

screwsCobb

are inserted

simultaneously

during

neuromonitoring

(Figure 7B,C).

inserted

simultaneously

during

neuromonitoring

(FigureThe

7B,C).

gated

elevator,

and navigated

ring

curettes.

navigated

osteotome is used to r

move the L5 vertebra (Figure 7A,D). In the same single position, percutaneous pedic

screws are inserted simultaneously during neuromonitoring (Figure 7B,C).

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