Table Of ContentH.M.Mayer(Ed.)MinimallyInvasiveSpineSurgery
SecondEdition
H.M. Mayer (Ed.)
Minimally Invasive
Spine Surgery
A Surgical Manual
SecondEdition
With492Figuresin851Partsand36Tables
H.MichaelMayer,M.D.Ph.D.
HeadandMedicalDirector,AssociateProfessor
SpineCenterMunich,OrthozentrumMünchen,OrthopädischeKlinik
HarlachingerStrasse51
81547Munich,Germany
ISBN3-540-21347-3 Springer-VerlagBerlinHeidelbergNewYork
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Preface to the Second Edition
Fiveyearshavepassedsincethefirsteditionofthisbook.Minimallyinvasivesurgi-
caltechniqueshavebecomeasignificantpartofthedailyroutineinspinesurgery.
Someofthetechniqueswhichhavebeendescribedinthefirsteditionhavebecome
standardinspinecentresallaroundtheworld,othershavebeenstrugglingtostand
thetestoftime.
Threeimportanttrendscouldbeobservedinthepastfiveyears:
1.Microsurgical and endoscopic surgical techniques have been improved. The
applicationspectrumhasbeenenlargedandtheresultsarenowmorereliableand
predictable.
2.So-called“semi-invasive”techniques,mainlyforthetreatmentoflowbackpain,
have become more popular although evidence-based data concerning efficacy
andsuccessarestilllacking.
3.Spine arthroplasty is the term for a significant change of paradigms in spinal
surgery.Minimallyinvasivepartialortotaldiscreplacementinthedegenerated
cervical and lumbar spine, “dynamic” fixation, or disc-unloading techniques
withinnovativeimplantsarebeingtestedinvariousclinicalstudiesallaroundthe
world. Autologous percutaneous disc chondrocyte transplantation is the first
clinicalattempttoachieveabiologicalregenerationofthedegenerateddisc.
Thisnew,revisedandextendededitionof MinimallyInvasiveSpineSurgerycon-
tainsallcurrentapplicationsofminimallyinvasivetechniquesforspinesurgery.A
totalof 70authorsandco-authorshavecoveredallaspectsofminimallyinvasive
spinesurgeryin51chapters,whichhasmorethandoubledthevolumeofthefirst
edition.
Againwemustpointoutthatthebookconcentratesonsurgicaltechniquesand
thatitwasouraimtoprovidethereaderwiththeinformationnecessarytoperform
thesetypesofsurgery.However,someofthetechniquesdescribedarestillpartofan
ongoingprocessofdevelopmentand,althoughwehavetriedtogivethereadera
mainlyunbiasedandneutraldescriptionofthetechniques,weareawareofthefact
thatthiscouldnotberealizedforallchapters.
I thank all my colleagues for againspendingtheir time to produce high-quality
chapters,tosharetheirtremendousexperiencewithusandtoprovideuswiththe
newestinformation.
Isincerelyhopethatoureffortswillbehonouredbyanumberofreadersandthat
againwecanallcontributetothedevelopmentofminimallyinvasivetechniquesin
spinesurgery.
Munich,Summer2005 H.MichaelMayer
Foreword to the First Edition
Thisbookcontainsawealthofinformationonaspectsofminimallyinvasivespinal
surgery.Forasurgeonofmyvintage,nearingtheendofacareerspanningthepast
fortyyears,Iamreassuredbytheenthusiasm,dedicationandseriousnessofpurpose
ofthisnewgenerationofsurgeonsandscientistswhoseworkisoutlinedinthebook.
In 1957 Walter Blount deliveredhis Presidential Address entitled: “Don’t Throw
AwaytheCane”totheAmericanAcademyofOrthopaedicSurgeons.Thegistofthis
monumentaladdresswasthat,ashipsurgerywasevolving,thelessonsofconverva-
tisminmanagementofhipdisordersshouldnotbeforgotten.Whilepreparingthis
ForewordIwasremindedofitsmainmessagebecauseitremainspertinenttopre-
senttrendsinthepracticeofspinalsurgery.
The advanced techniques described in Dr. Mayer’s book must not be attempted
withoutintensivestudyofanatomyandathoroughunderstandingofspinalpathol-
ogy.Throughoutthetextindividualauthorsusetheterm“learningcurve”,aterm
whichcanspelldisasterforthepatientwhomaybeonthe“curve”.Spinalsurgeryis
potentially dangerous. Mastery of it is best gained by personal tuition under the
guidanceofabusyexperiencedsurgeon.Thetrendtowardslearningsurgicaltech-
niquesinworkshopsettingsorinshortcoursesorganisedbymanufacturersofsur-
gicalequipment,usingplasticmodelsorcadaversisnotentirelygoodfortraineesor
forsurgeonsaimingtoexpandtheirpracticesintominimalinvasivesurgeryofthe
spine,asitmayleadtothetriumphoftechnologyoverreason.Byfocussingonhow
tousethewiderangeofequipmentrequiredtoperformtheseoperations,biological
factorswhichmayadverselyaffecttheiruseshouldnotbeneglected.Forexample
evenintheoutstandingchapter“MicrosurgeryoftheCervicalSpine”theStatement
ismadethat:“Retracterbladesmaystickaftermanyhoursofsurgery:theyshould
beremovedunderirrigationandindividually”.Oneofthemostimportantleasons
tohaveemergedinrecentyearsinspinalsurgeryhasbeenthatretractorsshouldbe
releasedatregularintervalsthroughoutanoperationtopreventirreversibledamage
tothebloodsupplyofthemusclesatthesiteofsurgery.
AtthebeginningofthisnewmillenniumDr.MichaelMayerhasshowngreatforesight
inassemblingsuchanarrayofinternationalexpertstopresentaclearpictureofwhat
hasbeenachievedintheleastdecadeofthe20thCenturyandaviewofwhatliesahead
assurgeonsstrivetoharnesstherapidlychangingtechnologiesinthefieldsofimag-
ing,optics,endoscopyandinstrumentdesignfortheirwideruseinminimalinvasive
spinalsurgery.Thisbookshouldbecomethevademecumforspinalsurgeonsinthis
decade.Thewiderangeofinformationinitcoverstechnicaldetails,logisticalfactsand
manyinformativeandbalancedviewsonaspectsofthesenewtechniques.Theseau-
thors form a worthy cohort of surgeons and scientists from differing backgrounds
withcommonaims.Theyarevoyagersheadingintopreviouslyunchartedwaters.
“Butfarforwardvoyagers”.
T.S.Elliot,FourQuarters,p40.TheFolioSocietyLondon,MCMI.XVIII
February2000 HenryVernonCrock
DirectoroftheSpinalDisordersUnit
TheCromwellHospitalLondon
Preface to the First Edition
“Thereisnodarkness–thereisjustabsenceoflight.”
“Minimallyinvasivesurgery”hasbeenthekeyphrasedominatingclinicalandsci-
entificeffortsinallsurgicalspecialtiesoverthelastdecade.Therehasneverbeena
comparableperiodinsurgerywhere,withinashortspanoftime,surgicaltechnolo-
gyhasundergonesuchwidespreadandfundamentalchanges.Thesedevelopments
areduetothesynergismproducedbyaparallel“explosion”ofknowledgeandtech-
nologicalabilitiesinmodernradiologicalimagingtechniques,inadvancedsurgical
instrumentationandimplanttechnology,aswellasinintraoperativevisualization
usingmoderndigitalandconventionalopticalsystems.Althoughthereiscontro-
versyregardingthesemanticcorrectnessoftheterm“minimallyinvasivesurgery”
(becauseinthemajorityofthetechniquesonlythesurgicalapproachis“minimally
invasive”),itisstillsynonymousofallsurgicaltechniqueswhichare“less”or,bet-
ter,“suitably”invasivecomparedtoconventionalsurgicalapproaches.
Spinalsurgeryisprobablythesubspecialtywhichhasundergonethemostrevolu-
tionarychangestriggeredbylessinvasiveprocedures.Itallstartedwiththeinaugu-
rationofmicrosurgicalandendoscopicproceduresforthetreatmentoflumbardisc
herniationsinthemid-1970s.Todaywearewitnessingavarietyofmicrosurgicaland
endoscopictechniques,aswellasprocedures,whichrequirenodirectvisualcontrol.
Mostofthesetechniquesareusedinclinicalstudiesbutarestilllackingbasicsci-
entificevidence,sometechniqueshavealreadyreplacedstandardtechniques,while
othershavebeengenerallyacceptedatleastasalternativestoconventionalsurgical
procedures.Themajorityofthesetechniquesarehighlysophisticatedandrequire
specialsurgicaltrainingorevenlaboratorytraining,whichposesproblemsinpar-
ticularforthesurgeonnotspecializedinspinesurgery.Scientificmeetingsaredom-
inatedworldwidebythepresentationofminimallyinvasivespinesurgery;however,
itisdifficultforthesurgeontokeepabreastoftherapiddevelopmentsandtobeable
todecidewhichtechniqueheshouldadoptforhisdailywork.
Itwasourintentiontopresentanoverviewofthemostimportantandrelevantmi-
crosurgicalandendoscopictechniqueswhichhavebeeninauguratedoverthelast
twodecades.Thisbookisneitheratextbooknorasurgicalatlas.Itwasouraimto
providethereaderwithclearinformationregardingterminology,history,indica-
tions,surgicalprinciples,aswellasacriticalevaluationofthespecifictechnique.It
doesnotattempttopassfinaljudgementonthevalueandnecessityofthevarious
procedures;however,itmayenablethereadertomakeher/hisownassessmentof
thevalueandacceptabilityofeachtechnique.
Thebookconcentratesonsurgicaltechniqueandprovidesthereaderwiththerele-
vantinformationnecessarytobepreparedfortheuseofthedifferentprocedures.
Iwouldliketoexpressmydeepestthankstoallcolleagueswhohavecontributedto
thisbookandwhohaveprovideduswithatremendousamountofnewinformation.
Itismysincerehopethatthisbookwillcontributetothefurtherunderstandingand
acceptanceofminimallyinvasivephilosophiesintheemergingfieldofspinalsurgery.
Munich,February2000 H.MichaelMayer
Contents
General
1 MinimallyInvasiveSpineSurgery
H.M.Mayer........................................................ 3
2 TechnologicalAdvancesofSurgicalMicroscopesforSpineSurgery
W.Rulffes ......................................................... 8
3 SpinalMicrosurgery:AShortIntroduction
H.M.Mayer....................................................... 12
4 MicrosurgicalInstruments
A.Korge.......................................................... 16
5 OperatingRoomSetupandHandlingofSurgicalMicroscopes
K.Wiechert....................................................... 23
6 Computer-assistedMinimallyInvasiveSpineSurgery–StateoftheArt
F.Langlotz,L.P.Nolte .............................................. 26
Cervical Spine
Odontoid
7 TechniqueofTransoralOdontoidectomy
P.J.Apostolides,A.G.Vishteh,R.M.Galler,V.K.H.Sonntag ............... 35
8 MicrosurgicalTreatmentofOdontoidFractures
P.KlimoJr,G.Rao,R.I.Apfelbaum ................................... 42
DiscSurgery/Decompression
9 MicrosurgeryoftheCervicalSpine:TheAnteriorApproach
L.Papavero ....................................................... 54
10 AnteriorCervicalForaminotomy(MicrosurgicalandEndoscopic)
W.F.Saringer...................................................... 82
11 FunctionalSegmentalReconstructionwiththeBryanCervical
DiscProsthesis
J.Goffin .......................................................... 92
12 MicrosurgicalTotalCervicalDiscReplacement
H.M.Mayer...................................................... 100
13 MicrosurgicalPosteriorApproachestotheCervicalSpine
P.H.Young,J.P.Young,J.C.Young ................................... 107
14 MicrosurgicalC1–1Stabilization
D.Fassett,R.I.Apfelbaum.......................................... 118
XII Contents
Thoracic/ThoracolumbarSpine
GeneralTechniques
15 MicrosurgicalAnteriorApproachtoT5–10(Mini-TTA)
H.M.Mayer...................................................... 129
16 MicrosurgicalAnteriorApproachtotheThoracolumbarJunction
H.M.Mayer...................................................... 138
17 AnatomicPrinciplesofThoracoscopicSpineSurgery
U.Liljenqvist .................................................... 144
18 PrinciplesofEndoscopicTechniquestotheThoracicandLumbarSpine 149
G.M.McCullen,A.A.Criscitiello,H.A.Yuan........................... 149
19 BiomechanicalRequirementsinMinimallyInvasiveSpinalFracture
Treatment
M.Schultheiss,E.Hartwig,L.Claes,L.Kinzl,H.-J.Wilke ............... 156
Deformities
20 ThoracoscopicApproachesinSpinalDeformitiesandTrauma
M.Dufoo-Olvera ................................................. 164
21 ThoracoscopicTechniquesinSpinalDeformities
D.Sucato ........................................................ 176
22 Mini-openEndoscopicExcisionofHemivertebrae
R.Stücker ....................................................... 197
Fractures
23 ThoracoscopicallyAssistedAnteriorApproachtoThoracolumbarFractures
R.Beisse ........................................................ 203
24 AMinimallyInvasiveOpenApproachforReconstructionoftheAnterior
ColumnoftheThoracicandLumbarSpine
B.Knowles,I.Freedman,G.Malham,T.Kossmann .................... 215
25 PercutaneousVertebroplastyinOsteoporoticVertebralFractures
G.M.Hess,H.M.Mayer ............................................ 222
26 MicrosurgicalOpenVertebroplastyandKyphoplasty
B.M.Boszczyk,M.Bierschneider,B.Robert,H.Jaksche................. 230
27 PercutaneousKyphoplastyinTraumaticFractures
G.Maestretti,P.Otten ............................................. 239
LumbarSpine
LowBackPain
28 InterventionalandSemi-invasiveProceduresforLowBackPain
andDiscHerniation
M.K.Schäufele ................................................... 249
Disc
29 IntradiscalElectrothermalTherapy
J.Saal ........................................................... 260
30 MicrotherapyinLowBackPain
A.T.Yeung,C.A.Yeung ............................................ 267
