Spine

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Uma abordagem endoscópica para a transecção do nervo do ramo medial pode levar ao alívio da dor causada pela artropatia da articulação facetária. A combinação da visualização 4K com técnicas minimamente invasivas permite que os cirurgiões visualizem e tratem a patologia da coluna vertebral mantendo a precisão cirúrgica e reduzindo as complicações pós-operatórias.1,2
Referências
1. Lewandrowski&nbsp;KU, Ransom NA, Yeung A. Return to work and recovery time analysis after&nbsp;outpatient endoscopic lumbar transforaminal decompression surgery. J Spine Surg. 2020&nbsp;Jan;6(Suppl 1):S100-S115. doi:10.21037/jss.2019.10.01
2. Sivakanthan&nbsp;S, Williams JR,&nbsp;Feroze&nbsp;AH, et al. Endoscopic spine surgery in athletes: case series&nbsp;and review of literature. World&nbsp;Neurosurg. 2021;145:702-707.&nbsp;doi:10.1016/j.wneu.2020.08.211​

This animation demonstrates the steps of medial branch nerve transection (MBT) using the SynergyID™ imaging system and a spine-specific endoscope. It also highlights the unique WishBone™ instrument handle, which is designed for improved ergonomics, and FlexTip electrosurgery probe.

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Medial Branch Nerve Transection With the SynergyID™ System and Spine Endoscopes

The Arthrex medial branch. Transection endoscopic approach utilizes an endoscope for access and direct visualization of the anatomy. Place the patient in the prone position based on the preoperative MRI or CT. Use the c-arm to verify the correct level or levels using both AP and lateral images. Insert the spinal needle. Docking at the junction of the transverse process and facet. Remove the stylet and pass a guidewire through the spinal needle. Remove the spinal needle. Insert a switching stick over the guidewire. Insert the cannula with the opening of the cannula oriented up and medial. Attach the cannula holder securely to the TRIMANO arm adapter. Connect the holder to the cannula to aid in maintaining the trajectory prior to removing the switching stick. Attach a depth stop to the endoscope to maintain the depth within the cannula. Remove the switching stick and insert the endoscope. A series of endoscopic tools, including an electrosurgical probe, graspers, and others, are inserted through the working channel of the endoscope to remove excess tissue and coagulate blood vessels. Arthrex offers a unique WishBone handle design that allows for improved ergonomics and mobility of the instrument by the surgeon. After exposing the mammillary accessory ligament, cut the mal with the punch or hook scissors to expose the nerve. Once the nerve is properly visualized, cut the nerve with a punch or hook. Scissors. Use the electrosurgical probe to treat the excised nerve endings and to breed the surface of the bony anatomy, continuing up towards the facet. Once complete, the scope and cannula are slowly removed. Repeat the process to treat any additional affected levels.

Michael Galizzi, MD (Denver, CO), demonstrates identification and denervation of the medial branch nerve as part of an endoscopic medial branch nerve transection procedure.

Endoscopic Approach to Medial Branch Nerve Transection

This is Doctor Michael Gleeson from the Steadman Clinic in Vail, Colorado. And this is my draping technique for the endoscopic surgical medial branch transection. To start the draping, we take a three quarter sheet and drape the cranial aspect of the patient. From the caudal aspect of the patient, mindful of the location of the Sis. I then take folded towels and place them in the field, going as wide as possible to make sure we have enough room to perform any surgical intervention. I then take the I band. And go from a caudal to cranial direction to seal off the sterile operative space. I feel the midline here. And make sure we have enough space on either side. Using a drape with pockets on the side to catch any excess overflow of fluid, extravasation is recommended. You can also use a shower curtain or hip fracture drape if your institution has one, which has the I band built into it. For added control in the depth stop to the patient, I make a small stopper about a thumb's width wide. I then longitudinally bisect it with scissors. I then place that over the endoscope and slide that all the way down here. And then take a small steri strip and or tegaderm. We remove the piece of tegaderm and wrap around. To secure it in place prior to initiating the procedure. This helps to migration of the endoscope down into the wound. And I found this is the appropriate depth about one finger breadth of your thumb wide in order to optimize the visualization. Typically I have my fluoro x ray as well as the 4K monitor stacked on top at the foot of the bed to assist in visualization and ergonomics for this procedure. Once prepped and draped, I place my knife here on the border of the pedicle and advance it to the lateral border of the pedicle. I then make a horizontal incision wide as necessary for the surgical endoscope going through the fascia. I then take the switching stick or dilator and press through the fascia, going down to the transverse process until I feel a solid stop. I then take a test shot to verify that I am at the junction of the facet and transverse process. I then feel the drop off onto the transverse process Thus. And then I feel the cranial and caudal extent of the transverse process and help dilate through to get down to the transverse process joint where the medial branch will be located. I then take the endoscopic cannula and place that over the dilator, and go down to the facet transverse process junction, trying to be right near where the medial branch should be located anatomically. I then save that x ray for documentation purposes. Once held in place. I remove the inner dilator and ask C-arm to back out. I then continue to have firm pressure down on the endoscopic cannula and bring in the surgical endoscope. I then have my assistant turn the water on, which is a gravity assisted water flow. I typically use the open blue cap to assist in the instrumentation coming in and out of the surgical endoscope, and I modulate how much water pressure and flow I have on the left side of the scope in order to assist with visualization. I then bring in the RF probe in order to debride the overlying tissue to get down to the transverse process facet junction. I then feel for a positive stop on that facet ball transverse process junction. There's typically some overlying tissue that needs to be resected. I like using COAG first to get any sort of vessels to prevent bleeding and loss of visualization during the procedure. Always feeling for a positive firm stop. Once I have adequately coagulated the visual visualized blood vessels, I then take the pituitary and to breed a small amount of tissue left over to allow me to get down to the transverse process facet joint. Always making sure that I have a positive stop. I continue to use the RF probe to assist in debriding the tissue to get down to the facet joint transverse process junction again, always making sure that I have positive stops before ablating. During this process you may encounter other deeper blood vessels which need to be coagulated. Identification of these will be necessary to prevent any clouding or bleeding within the surgical endoscope. Once down and bone is identified, I began to slowly debride the rest of the remaining tissue to try and identify the anatomic structures, including the medial branch, which on this frame should be located to the left side of the arthroscopic picture. I then, with my foot off the pedal, feel that cranial portion of the transverse process. And feel for that neuro foramen where the medial branch will be coming from. I then also feel the caudal side to make sure that I have the entire resection window in place. We can see this tubular structure here actually coming out of the neuro foramen, which should be part of the medial branch complex. I then take the endoscopic scissors and come around both sides and transect the medial branch with the scissors. I then take the radiofrequency probe and complete the procedure by thoroughly debriding the facet wall. And transverse process area to make sure that no neural tissue remains behind. Once the entire facet wall, medial branch, and neural tissue is thoroughly debrided, you should have what looks like denuded bone in your surgical field. And again, with your foot off the pedal, you feel into the foramen to make sure that there's nothing there. And you move to the back of the transverse process to make sure that you have completely denuded the lateral facet wall. The transverse process to the level of the mammillary body. Now that we have completed the left side medial branch transection, I typically go to the other side of the table and switch with my assistant to perform the right side of this L4 medial branch transection. Again, I take the knife and go from the lateral border of the pedicle and make a horizontal incision wide enough for the surgical endoscope. I then cut the fascia as well. With that, under Fluoroscopic guidance, I take the dilator and feel for that transverse process. And again you do not proceed unless you have a nice solid positive end point that is confirmed on fluoroscopy. I then feel the cranial and caudal aspect of the transverse process and feel for that lateral facet wall. Once I have a positive stop, I then bring in the endoscopic cannula. Place that over the dilator again feeling for that positive stop that we are on the transverse process. I then ask for a fluoro shot to confirm we're in the correct location, and then c-arm is removed. Holding downward pressure onto the transverse process, I then remove the dilator and insert the surgical endoscope. Again, typically soft tissue is present. I then use the RF probe. And place that down the surgical endoscope. I then coagulate any tissue that I feel could be bleeding and cause a decrease in visualization during the procedure. Once I have coagulated that tissue, I then take the pituitary and place that down the surgical endoscope and remove any overlying tissue that impedes the visualization of the transverse process facet joint junction. I then continue the procedure with the RF probe again, making sure I have a positive stop and end point, and I am maintaining the correct trajectory with my foot off the pedal. I then probe the cranial and caudal areas to make sure that I know where the beginning and end of the transverse process is. I then identify the small band of tissue and fibers coming out of the neural foramen right here as the medial branch. I then take my endoscopic scissors, place it through the endoscope, and transect the medial branch. I then proceed to remove any excess neural tissue that is on the transverse process and facet joint area. We complete the procedure by removing any remaining neural tissue, taking care to treat the lateral aspect of the facet wall, as well as the transverse process from the cranial and caudal aspects. Always remove your foot off the foot pedal when you are attempting to enter the neuro foramen, to make sure that there is no neural tissue, and you have no chance of turning on the RF probe inadvertently in the neuro foramen. Once we have completed the treatment of the bilateral L4 medial branches, they have been transected and the above picture is identified. We then proceed to the next level depending on the number of levels to be treated. This process is repeated in a similar fashion for the adjacent cranial or caudal treatment levels.

Michael A. Gallizzi, MD (Vail, CO), demonstrates how to use the tactile feel of a positive stop to identify the transverse process facet joint junction to establish the start point for the approach for an endoscopic medial branch nerve transection.

SpeedPearl: Endoscopic Medial Branch Transection—Positive Stop

Michael A. Gallizzi, MD (Vail, CO), demonstrates how to optimize hemostasis for better visualization of the pathology by using the flexible tip of a radiofrequency probe to coagulate bleeding vessels during medial branch transection procedures.

SpeedPearl: Endoscopic Medial Branch Transection—Coagulation for Bleeding

Michael Gallizzi, MD (Denver, CO), shares pearls for identifying, transecting, and denervating the medial branch nerve during an endoscopic approach to medial branch transection (MBT).

SpeedPearl: Endoscopic Medial Branch Transection—Nerve Identification

As a privately held company for more than 40 years dedicated to its mission of Helping Surgeons Treat Their Patients Better®, Arthrex has pioneered arthroscopic surgery technology with more than 20,000 revolutionary arthroscopic and orthobiologics products that allow surgeons to treat joint pathology in the least invasive way possible—as an outpatient procedure.
Arthrex helped evolve diagnostic arthroscopy to arthroscopic resection, then repair, and finally arthroscopic and MIS reconstructions with orthobiologic augmentation. We helped restore—not replace—joints and ligaments. We frequently use autografts and allografts instead of metal to anatomically reconstruct cartilage, bone, and soft tissues. We create less-invasive surgical options and orthobiologics to preserve anatomy without more invasive hardware and end-stage procedures.
Fast forward to 2023, when Arthrex is applying its accumulated experience and expertise to revolutionize endoscopic and orthobiologics procedures for the spine. Arthrex visualization options deliver endoscopic image quality never before seen by spine surgeons, opening the door to less-invasive endoscopic treatments supported by advanced instrumentation and unparalleled surgical skills training, all aimed at someday replacing open surgery and microscope use for many spine procedures.
Learn these endoscopic procedures and how to incorporate innovative orthobiologics solutions into spine procedures through an endoscopic spine-specific course—taught by experienced clinical specialists and incorporating hands-on cadaveric surgical skills programs—at Arthrex global headquarters in Naples, FL, or in one of our many labs located across the US and around the world.

Transecção do ramo medial

Transecção do ramo medial