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Jitpakdee K, Sommer F, Gouveia E, Mykolajtchuk C, Boadi B, Berger J, Hussain I, Härtl R. Expandable cages that expand both height and lordosis provide improved immediate effect on sagittal alignment and short-term clinical outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). JOURNAL OF SPINE SURGERY (HONG KONG) 2024; 10:55-67. [PMID: 38567017 PMCID: PMC10982918 DOI: 10.21037/jss-23-106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/07/2024] [Indexed: 04/04/2024]
Abstract
Background Failure to restore lordotic alignment is not an uncommon problem following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), even with expandable cages that increase disc height. This study aims to investigate the effect of the expandable cage that is specifically designed to expand both height and lordosis. We evaluated the outcomes of MIS TLIF in restoring immediate postoperative sagittal alignment by comparing two different types of expandable cages. One cage is designed to solely increase disc height (Group H), while the other can expand both height and lordosis (Group HL). Methods Patients undergoing MIS TLIF using expandable cages were retrospectively reviewed, including 40 cases in Group H and 109 cases in Group HL. Visual analog scores of back and leg pain, and Oswestry disability index were collected. Disc height, disc angle, and sagittal alignment were measured. Complications were recorded, including early subsidence which was evaluated with computed tomography. Results Clinical and radiographic outcomes significantly improved in both groups postoperatively. Group HL showed superior improvement in segmental lordosis (4.4°±3.5° vs. 2.1°±4.8°, P=0.01) and disc angle (6.3°±3.8 vs. 2.2°±4.3°, P<0.001) compared to Group H. Overall incidence of early subsidence was 23.3%, predominantly observed during initial cases as part of the learning curve, but decreased to 18% after completion of the first 20 cases. Conclusions Expandable cages with a design specifically aimed at increasing lordotic angle can provide favorable outcomes and effectively improve immediate sagittal alignment following MIS TLIF, compared to conventional cages that only increase in height. However, regardless of the type of expandable cage used, it is crucial to avoid applying excessive force to achieve greater disc height or lordosis, as this may contribute to subsidence and a possible reduction in lordotic alignment restoration. Long-term results are needed to evaluate the clinical outcome, fusion rate, and maintenance of the sagittal alignment.
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Affiliation(s)
- Khanathip Jitpakdee
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
- Department of Orthopedics, Queen Savang Vadhana Memorial Hospital, Chonburi, Thailand
| | - Fabian Sommer
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
| | - Edna Gouveia
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
- Department of Neurosurgery, Clinica Sagrada Esperança-Ilha, Luanda, Angola
| | - Catherine Mykolajtchuk
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
| | - Blake Boadi
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
| | - Jessica Berger
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
| | - Ibrahim Hussain
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
| | - Roger Härtl
- Weill Cornell Medicine-Department of Neurosurgery, New York-Presbyterian Hospital – Och Spine, New York, NY, USA
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Sommer F, Hussain I, Kirnaz S, Goldberg JL, Navarro-Ramirez R, McGrath Jr LB, Schmidt FA, Medary B, Gadjradj PS, Härtl R. Augmented Reality to Improve Surgical Workflow in Minimally Invasive Transforaminal Lumbar Interbody Fusion - A Feasibility Study With Case Series. Neurospine 2022; 19:574-585. [PMID: 36203284 PMCID: PMC9537847 DOI: 10.14245/ns.2244134.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/28/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a highly reproducible procedure for the fusion of spinal segments. We recently introduced the concept of "total navigation" to improve workflow and eliminate fluoroscopy. Imageguided surgery incorporating augmented reality (AR) may further facilitate workflow. In this study, we developed and evaluated a protocol to integrate AR into the workflow of MISTLIF. METHODS A case series of 10 patients was the basis for the evaluation of a protocol to facilitate tubular MIS-TLIF by the application of AR. Surgical TLIF landmarks were marked on a preoperative computed tomography (CT)-scan using dedicated software. This marked CT scan was fused intraoperatively with the low-dose navigation CT scan using elastic image fusion, and the markers were transferred to the intraoperative scan. Our experience with this workflow and the surgical outcomes were collected. RESULTS Our AR protocol was safely implemented in all cases. The TLIF landmarks could be preoperatively planned and transferred to the intraoperative imaging. Of the 10 cases, 1 case had additionally a synovial cyst resection and in 2 cases an additional bony decompression was performed due to central stenosis. The average procedure time was 160.6 ± 31.9 minutes. The AR implementation added 1.72 ± 0.37 minutes to the overall procedure time. No complications occurred. CONCLUSION Our findings support the idea that total navigation with AR may further facilitate the workflow, especially in cases with more complex anatomy and for teaching and training purposes. More work is needed to simplify the software and make AR integration more user-friendly.
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Affiliation(s)
- Fabian Sommer
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Jacob L. Goldberg
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Lynn B. McGrath Jr
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Franziska A. Schmidt
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Branden Medary
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Pravesh Shankar Gadjradj
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital/Och Spine, New York, NY, USA,Corresponding Author Roger Härtl Department of Neurological Surgery, New York-Presbyterian Hospital, 525 E 68th Street, Box 99, New York, New York 10065, USA
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Kulkarni AG, Rajamani PA, Tapashetti S, Kunder TS. Multimodal Applications of 3D-Navigation in Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion: Impacts on Precision, Accuracy, Complications, and Radiation Exposure. Int J Spine Surg 2022; 16:8294. [PMID: 35835566 PMCID: PMC9421208 DOI: 10.14444/8294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Three-dimensional (3D)-navigation in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is an evolving procedure. It is used not only for its accuracy of pedicle screw fixation but also for other major steps in transforaminal lumbar interbody fusion. Multimodal outcomes of this procedure are very limited in the literature. The purpose of this study was to examine the application of 3D-navigation in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). METHODS Patients who underwent single-level MI-TLIF using 3D-navigation between January 2017 and July 2019 were evaluated for navigation setting time, radiation exposure, volume of nucleus pulposus excised, cage placement, accuracy of pedicle screw placement, and cranial facet-joint violation. RESULTS One hundred and two patients with a mean age of 60.2 years met the inclusion criteria. The mean presetting time of navigation was 46.65 ± 9.45 minutes. Radiation exposure, fluoroscopy use, and fluoroscopy time were 15.54 ± 0.65 mGy, 4.43 ± 0.87 Gy.cm², and 97.6 ± 11.67 seconds, respectively. The mean amount of nucleus pulposus excised from all quadrants was quantified. The cage was centrally placed in 87 patients, with 95.4% showing a Grade 0 pedicle breach and 94.6% showing Grade 0 cranial facet-joint violation. CONCLUSION Registration and setting up 3D-navigation takes additional time. The amount of exposure to the patient is much less compared to routine computed tomography, and, importantly, the operating team is protected from radiation. Navigated MI-TLIF has high rates of accuracy with regard to placement of percutaneous pedicle screws and cages with the added advantage of protection of the cranial facet-joint. LEVEL OF EVIDENCE: 5
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Affiliation(s)
- Arvind G Kulkarni
- Mumbai Spine Scoliosis and Disc Replacement Centre, Saifee Hospital, Mumbai, India
| | - Pritem A Rajamani
- Mumbai Spine Scoliosis and Disc Replacement Centre, Saifee Hospital, Mumbai, India
| | - Sandeep Tapashetti
- Mumbai Spine Scoliosis and Disc Replacement Centre, Saifee Hospital, Mumbai, India
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Schmidt FA, Lekuya HM, Kirnaz S, Hernandez RN, Hussain I, Chang L, Navarro-Ramirez R, Wipplinger C, Rawanduzy C, Härtl R. Novel MIS 3D NAV Single Step Pedicle Screw System (SSPSS): Workflow, Accuracy and Initial Clinical Experience. Global Spine J 2022; 12:1098-1108. [PMID: 33430625 PMCID: PMC9210221 DOI: 10.1177/2192568220976393] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Prospective case series. OBJECTIVE SSPSS (single step pedicle screw system) was developed for minimally invasive spine surgery. We performed this study to report on safety, workflow, and our initial clinical experience with this novel technique. METHODS The prospective study was conducted on patients who underwent pedicle screw fixation between October 2017 and April 2018 using a novel single step 3D navigated pedicle screw system for MIS. Outcome measurements were obtained from intraoperative computerized tomography. The images were evaluated to determine pedicle wall penetration. We used a grading system to assess the severity of the pedicle wall penetration. Breaches were classified as grade 1 (<2 mm), grade 2 (2-4 mm), or grade 3 (<4 mm),1 and as cranial, caudal, medial, and lateral. RESULTS Our study includes 135 screws in 24 patients. SSPSS eliminated K-wires and multiple steps traditionally necessary for MIS pedicle screw insertion. The median time per screw was 2.45 minutes. 3 screws were corrected intraoperatively. Pedicle wall penetration occurred in 14 screws (10%). Grade 1 breaches occurred in 4 screws (3%) and grade 2 breaches occurred in 10 screws (7%). Lateral breaches were observed more often than medial breaches. The accuracy rate in our study was 90% (Grade 0 breach). No revision surgeries were needed and no complications occurred. CONCLUSIONS Our study suggests that SSPSS could be a safe, accurate, and efficient tool. Our accuracy rate is comparable to that found in the literature.
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Affiliation(s)
- Franziska A. Schmidt
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA.,Franziska A. Schmidt, Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, 525 East 68th Street, Box 99, New York, NY 10065, USA.
| | - Hervé M. Lekuya
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Robert Nick Hernandez
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Louis Chang
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Christoph Wipplinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Cameron Rawanduzy
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA
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Charles YP, Cazzato RL, Nachabe R, Chatterjea A, Steib JP, Gangi A. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Augmented Reality Surgical Navigation for Percutaneous Pedicle Screw Placement. Clin Spine Surg 2021; 34:E415-E424. [PMID: 33560011 DOI: 10.1097/bsd.0000000000001132] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective observational study. OBJECTIVE The aim of this study was to evaluate the accuracy of percutaneous pedicle screw placement using augmented reality surgical navigation during minimally invasive transforaminal lumbar interbody fusion (TLIF). SUMMARY OF BACKGROUND DATA Augmented reality-based navigation is a new type of computer-assisted navigation where video cameras are used instead of infrared cameras to track the operated patients and surgical instruments. This technology has not so far been clinically evaluated for percutaneous pedicle screw placement. MATERIALS AND METHODS The study assessed percutaneous pedicle screw placement in 20 consecutive patients who underwent single-level minimally invasive TLIF using augmented reality surgical navigation. Facet joint violation and depression by the inserted pedicle screws were evaluated. Secondary outcome such as radiation dose exposure, fluoroscopy time, and operative time were collected for 3 phases of surgery: preparation phase, pedicle screw placement, and decompression with cage placement. RESULTS A clinical accuracy for screw placement within the pedicle (Gertzbein 0 or 1) of 94% was achieved. One screw violated the facet joint with a transarticular pathway. The screw head did not depress the facet in 54%. The use of fluoroscopy during navigation correlated with patient body-mass index (r=0.68, P<0.0001). The pedicle screw placement time corresponded to 36±5% of the total operative time of 117±11 minutes. A statistically significant decrease of 10 minutes in operative time was observed between the first and last 10 procedures which corresponded to the pedicle screw placement time decrease (48±9 vs. 38±7 min, P=0.0142). The learning curve model suggests an ultimate operative time decrease to 97 minutes. CONCLUSION Augmented reality surgical navigation can be clinically used to place percutaneous screws during minimally invasive TLIF. However, the lack of tracking of the location of the device requires intraoperative fluoroscopy to monitor screw insertion depth especially in obese patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Roberto L Cazzato
- Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France
| | - Rami Nachabe
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, The Netherlands
| | - Anindita Chatterjea
- Department of Image Guided Therapy Systems, Philips Healthcare, Best, The Netherlands
| | | | - Afshin Gangi
- Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France
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Accuracy and technical limits of percutaneous pedicle screw placement in the thoracolumbar spine. Surg Radiol Anat 2021; 43:843-853. [PMID: 33449140 DOI: 10.1007/s00276-020-02673-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The two-dimensional fluoroscopic method of percutaneous pedicle screw instrumentation has been clinically described as reliable method in the caudal thoracic and lumbosacral spine. Its accuracy has not been clearly reported in the cranial thoracic spine. The aim of this in vitro study was to investigate percutaneous pedicle screw placement accuracy according to pedicle dimensions and vertebral levels. METHODS Six fresh-frozen human specimens were instrumented with 216 screws from T1 to S1. Pedicle isthmus widths, heights, transversal pedicles and screws were measured on computed tomography. Pedicle cortex violation ≥ 2 mm was defined as screw malposition. RESULTS The narrowest pedicles were at T3-T5. A large variability between transversal pedicle axes and percutaneous pedicle screw was present, depending on the spinal level. Screw malposition rates were 36.1% in the cranial thoracic spine (T1-T6), 16.7% in the caudal thoracic spine (T7-T12), and 6.9% in the lumbosacral spine (L1-S1). The risk for screw malposition was significantly higher at cranial thoracic levels compared to caudal thoracic (p = 0.006) and lumbosacral (p < 0.0001) levels. Cortex violation ≥ 2 mm was constantly present if the pedicle width was < 4.8 mm. CONCLUSION Percutaneous pedicle screw placement appears safe in the caudal thoracic and lumbosacral spine. The two-dimensional fluoroscopic method has a limited reliability above T7 because of smaller pedicle dimensions, difficulties in visualizing radiographic pedicle landmarks and kyphosis.
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Hussain I, Fu KM, Uribe JS, Chou D, Mummaneni PV. State of the art advances in minimally invasive surgery for adult spinal deformity. Spine Deform 2020; 8:1143-1158. [PMID: 32761477 DOI: 10.1007/s43390-020-00180-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022]
Abstract
Adult spinal deformity (ASD) can be associated with substantial suffering due to pain and disability. Surgical intervention for achieving neural decompression and restoring physiological spinal alignment has shown to result in significant improvement in pain and disability through patient-reported outcomes. Traditional open approaches involving posterior osteotomy techniques and instrumentation are effective based on clinical outcomes but associated with high complication rates, even in the hands of the most experienced surgeons. Minimally invasive techniques may offer benefit while decreasing associated morbidity. Minimally invasive surgery (MIS) for ASD has evolved over the past 20 years, driven by improved understanding of open procedures along with novel technique development and technologic advancements. Early efforts were hindered due to suboptimal outcomes resulting from high pseudarthrosis, inadequate correction, and fixation failure rates. To address this, multi-center collaborative groups have been established to study large numbers of ASD patients which have been vital to understanding optimal patient selection and individualized management strategies. Different MIS decision-making algorithms have been described to better define appropriate candidates and interbody selection approaches in ASD. The purpose of this state of the review is to describe the evolution of MIS surgery for adult deformity with emphasis on landmark papers, and to discuss specific MIS technology for ASD, including percutaneous pedicle screw instrumentation, hyperlordotic grafts, three-dimensional navigation, and robotics.
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Affiliation(s)
- Ibrahim Hussain
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, Box 99, New York, NY, USA.
| | - Juan S Uribe
- Department of Neurological Surgery, Barrow Neurologic Institute, Phoenix, AZ, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Peh S, Chatterjea A, Pfarr J, Schäfer JP, Weuster M, Klüter T, Seekamp A, Lippross S. Accuracy of augmented reality surgical navigation for minimally invasive pedicle screw insertion in the thoracic and lumbar spine with a new tracking device. Spine J 2020; 20:629-637. [PMID: 31863933 DOI: 10.1016/j.spinee.2019.12.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive approaches are increasingly used in spine surgery. The purpose of navigation systems is to guide the surgeon and to reduce intraoperative x-ray exposure. PURPOSE This study aimed to determine the feasibility and clinical accuracy of a navigation technology based on augmented reality surgical navigation (ARSN) for minimally invasive thoracic and lumbar pedicle screw instrumentation compared with standard fluoroscopy-guided minimally invasive technique. STUDY DESIGN/SETTING Cadaveric laboratory study. METHODS ARSN was installed in a hybrid operating room, consisting of a flat panel detector c-arm with two dimensional/three dimensional imaging capabilities and four integrated cameras in its frame. The surface-referenced navigation device does not require a bony reference but uses video cameras and optical markers applied to the patient's skin for tracking. In four cadavers, a total of 136 pedicle screws were inserted in thoracic and lumbar vertebrae. The accuracy was assessed by three independent raters in postoperative conventional computed tomography. RESULTS The overall accuracy of ARSN was 94% compared with an accuracy of 88% for fluoroscopy. The difference was not statistically significant. In the thoracic region, accuracy with ARSN was 92% compared with 83% with fluoroscopy. With fluoroscopy, unsafe screws were observed in three normal cadavers and one with scoliosis. Using ARSN, unsafe screws were only observed in the scoliotic spine. No significant difference in the median of time for K-wire placement was recorded. As no intraoperative fluoroscopy was necessary in ARSN, the performing surgeon was not exposed to radiation. CONCLUSIONS In this limited cadaveric study minimally invasive screw placement using ARSN was demonstrated to be feasible and as accurate as fluoroscopy. It did not require any additional navigation time or use of any intraoperative x-ray imaging, thereby potentially permitting surgery in a protective lead garment-free environment. A well-powered clinical study is needed to demonstrate a significant difference in the accuracy between the two methods. CLINICAL SIGNIFICANCE ARSN offers real-time imaging of planned insertion paths, instrument tracking, and overlay of three dimensional bony anatomy and surface topography. The referencing procedure, by optical recognition of several skin markers is easy and does not require a solid bony reference as necessary for conventional navigation which saves time. Additionally, ARSN may foster the reduction of intraoperative x-ray exposure to spinal surgeons.
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Affiliation(s)
- Simon Peh
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany.
| | - Anindita Chatterjea
- Image Guided Therapy Systems, Philips Healthcare, Veenpluis 4-6, 5684 PC, Best, the Netherlands
| | - Julian Pfarr
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Jost Philipp Schäfer
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Matthias Weuster
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Tim Klüter
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Andreas Seekamp
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
| | - Sebastian Lippross
- Department of Orthopedics and Trauma Surgery, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105 Kiel, Germany
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Hussain I, Cosar M, Kirnaz S, Schmidt FA, Wipplinger C, Wong T, Härtl R. Evolving Navigation, Robotics, and Augmented Reality in Minimally Invasive Spine Surgery. Global Spine J 2020; 10:22S-33S. [PMID: 32528803 PMCID: PMC7263339 DOI: 10.1177/2192568220907896] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Innovative technology and techniques have revolutionized minimally invasive spine surgery (MIS) within the past decade. The introduction of navigation and image-guided surgery has greatly affected spinal surgery and will continue to make surgery safer and more efficient. Eventually, it is conceivable that fluoroscopy will be completely replaced with image guidance. These advancements, among others such as robotics and virtual and augmented reality technology, will continue to drive the value of 3-dimensional navigation in MIS. In this review, we cover pertinent features of navigation in MIS and explore their evolution over time. Moreover, we aim to discuss the key features germane to surgical advancement, including technique and technology development, accuracy, overall health care costs, operating room time efficiency, and radiation exposure.
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Affiliation(s)
- Ibrahim Hussain
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
- Ibrahim Hussain and Murat Cosar are equal contributors to this study
| | - Murat Cosar
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
- Ibrahim Hussain and Murat Cosar are equal contributors to this study
| | - Sertac Kirnaz
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Franziska A. Schmidt
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Christoph Wipplinger
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Taylor Wong
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
| | - Roger Härtl
- Weill Cornell Medical College, New York–Presbyterian Hospital, New York, NY, USA
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Lener S, Wipplinger C, Hernandez RN, Hussain I, Kirnaz S, Navarro-Ramirez R, Schmidt FA, Kim E, Härtl R. Defining the MIS-TLIF: A Systematic Review of Techniques and Technologies Used by Surgeons Worldwide. Global Spine J 2020; 10:151S-167S. [PMID: 32528800 PMCID: PMC7263344 DOI: 10.1177/2192568219882346] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To date there is no consensus among surgeons as to what defines an MIS-TLIF (transforaminal lumbar interbody fusion using minimally invasive spine surgery) compared to an open or mini-open TLIF. This systematic review aimed to examine the MIS-TLIF techniques reported in the recent body of literature to help provide a definition of what constitutes the MIS-TLIF, based on the consensus of the majority of surgeons. METHODS We created a database of articles published about MIS-TLIF between 2010 and 2018. We evaluated the technical components of the MIS-TLIF including instruments and incisions used as well the order in which key steps are performed. RESULTS We could identify several patterns for MIS-TLIF performance that seemed agreed upon by the majority of MIS surgeons: use of paramedian incisions; use of a tubular retractor to perform a total facetectomy, decompression, and interbody cage implantation; and percutaneous insertion of the pedicle-screw rod constructs with intraoperative imaging. CONCLUSION Based on this review of the literature, the key features used by surgeons performing MIS TLIF include the use of nonexpandable or expandable tubular retractors, a paramedian or lateral incision, and the use of a microscope or endoscope for visualization. Approaches using expandable nontubular retractors, those that require extensive subperiosteal dissection from the midline laterally, or specular-based retractors with wide pedicle to pedicle exposure are far less likely to be promoted as an MIS-based approach. A definition is necessary to improve the communication among spine surgeons in research as well as patient education.
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Affiliation(s)
- Sara Lener
- Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
- Medical University of Innsbruck, Innsbruck, Austria
- These authors contributed equally to this work
| | - Christoph Wipplinger
- Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
- Medical University of Innsbruck, Innsbruck, Austria
- These authors contributed equally to this work
| | - R Nick Hernandez
- Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
- These authors contributed equally to this work
| | - Ibrahim Hussain
- Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
| | - Sertac Kirnaz
- Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
| | | | | | - Eliana Kim
- Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA
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Namboothiri S, Gore S, Veerasekhar G. Treatment of Low Back Pain by Treating the Annular High Intensity Zone (HIZ) Lesions Using Percutaneous Transforaminal Endoscopic Disc Surgery. Int J Spine Surg 2018; 12:388-392. [PMID: 30276096 DOI: 10.14444/5045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The study design was a retrospective case series. The objective was to find the clinical success rate of percutaneous transforaminal endoscopic disc surgery in patients suffering from discogenic chronic low back pain who were showing high intensity zone (HIZ) with degenerated disc as the only abnormality in the magnetic resonance imaging (MRI). The HIZ in the posterior annulus in degenerated disc is recognized as a pain generator. There are only a few studies available in the literature addressing the effect of identification and treatment of HIZ in the chronic low back pain patient. Methods We retrospectively evaluated the case records of all the patients who were treated by percutaneous endoscopic disc surgery for relief of symptoms as determined by visual analog scale (VAS) score, Oswestry Disability Index (ODI), Mac Nab criteria, and the consumption of analgesics, who had the predominant symptom of chronic low back pain, and whose lumbar spine MRI showed degenerated disc with HIZ and no other cause of back pain, like facet joint arthritis or sacroiliac joint arthritis. Results A total of 23 patients were identified to include in the study. Mean preoperative duration of low back pain was 13.1 months. Mean follow up after the procedure was 29 months. At final follow up, 69.6% of the patients were not taking any pain medicines, 17.36% were on frequent analgesic medicines, 13.04% were on occasional analgesics. There was statistically significant reduction in VAS at 6 weeks postop and final follow up after surgery and the ODI at final follow up; 82.6% of patients had an excellent/good outcome as per Mac Nab criteria. There were no complications or reoperations in any of the patients. Conclusions Visualization and ablation of the chronic annular pathology in HIZ may give an effective and minimally invasive treatment for one of the back pain causes.
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Affiliation(s)
- Sreedharan Namboothiri
- Department of Orthopaedics and Spine Surgery, Kovai Medical Center and Hospitals, Coimbatore, Tamilnadu, India
| | | | - Ganesh Veerasekhar
- Department of Orthopaedics and Spine Surgery, Kovai Medical Center and Hospitals, Coimbatore, Tamilnadu, India
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12
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Janssen I, Lang G, Navarro-Ramirez R, Jada A, Berlin C, Hilis A, Zubkov M, Gandevia L, Härtl R. Can Fan-Beam Interactive Computed Tomography Accurately Predict Indirect Decompression in Minimally Invasive Spine Surgery Fusion Procedures? World Neurosurg 2017; 107:322-333. [DOI: 10.1016/j.wneu.2017.07.167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/25/2017] [Accepted: 07/27/2017] [Indexed: 12/29/2022]
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13
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Tsuang FY, Chen CH, Kuo YJ, Tseng WL, Chen YS, Lin CJ, Liao CJ, Lin FH, Chiang CJ. Percutaneous pedicle screw placement under single dimensional fluoroscopy with a designed pedicle finder-a technical note and case series. Spine J 2017. [PMID: 28645672 DOI: 10.1016/j.spinee.2017.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive spine surgery has become increasingly popular in clinical practice, and it offers patients the potential benefits of reduced blood loss, wound pain, and infection risk, and it also diminishes the loss of working time and length of hospital stay. However, surgeons require more intraoperative fluoroscopy and ionizing radiation exposure during minimally invasive spine surgery for localization, especially for guidance in instrumentation placement. In addition, computer navigation is not accessible in some facility-limited institutions. PURPOSE This study aimed to demonstrate a method for percutaneous screws placement using only the anterior-posterior (AP) trajectory of intraoperative fluoroscopy. STUDY DESIGN A technical report (a retrospective and prospective case series) was carried out. PATIENT SAMPLE Patients who received posterior fixation with percutaneous pedicle screws for thoracolumbar degenerative disease or trauma comprised the patient sample. METHOD We retrospectively reviewed the charts of consecutive 670 patients who received 4,072 pedicle screws between December 2010 and August 2015. Another case series study was conducted prospectively in three additional hospitals, and 88 consecutive patients with 413 pedicle screws were enrolled from February 2014 to July 2016. The fluoroscopy shot number and radiation dose were recorded. In the prospective study, 78 patients with 371 screws received computed tomography at 3 months postoperatively to evaluate the fusion condition and screw positions. RESULTS In the retrospective series, the placement of a percutaneous screw required 5.1 shots (2-14, standard deviation [SD]=2.366) of AP fluoroscopy. One screw was revised because of a medialwall breach of the pedicle. In the prospective series, 5.8 shots (2-16, SD=2.669) were required forone percutaneous pedicle screw placement. There were two screws with a Grade 1 breach (8.6%), both at the lateral wall of the pedicle, out of 23 screws placed at the thoracic spine at T9-T12. Forthe lumbar and sacral areas, there were 15 Grade 1 breaches (4.3%), 1 Grade 2 breach (0.3%), and 1 Grade 3 breach (0.3%). No revision surgery was necessary. CONCLUSION This method avoids lateral shots of fluoroscopy during screw placement and thus decreases the operation time and exposes surgeons to less radiation. At the same time, compared with the computer-navigated procedure, it is less facility-demanding, and provides satisfactory reliability and accuracy.
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Affiliation(s)
- Fon-Yih Tsuang
- Institute of Biomedical Engineering, National Taiwan University, Taipei City, Taiwan No. 1, Sec. 1, Jen-Ai Road, Taipei City, 100, Taiwan; Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan No. 7, Chung-Shan South Road, Taipei City 100, Taiwan; Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan No. 579, Yun-Lin Road, Diou-Liu City, Yun-Lin County, 640, Taiwan; Kinmen Hospital, Ministry of Health and Welfare, Kinmen County, Taiwan No. 2, Fu-Xing Road, Kin-Hu Township, Kin-Men County, 891, Taiwan
| | - Chia-Hsien Chen
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan No. 291, Zhongzheng Rd, Zhonghe District, New Taipei City, 23561, Taiwan
| | - Yi-Jie Kuo
- Department of Orthopedics, Taipei Medical University Hospital, Taipei City, Taiwan No. 252, Wu-Xing Street, Taipei City, 110, Taiwan; Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan No. 250, Wu-Xing Street, Taipei City, 110, Taiwan
| | - Wei-Lung Tseng
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan No. 7, Chung-Shan South Road, Taipei City 100, Taiwan; Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan No. 579, Yun-Lin Road, Diou-Liu City, Yun-Lin County, 640, Taiwan
| | - Yuan-Shen Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan No. 579, Yun-Lin Road, Diou-Liu City, Yun-Lin County, 640, Taiwan
| | - Chin-Jung Lin
- Kinmen Hospital, Ministry of Health and Welfare, Kinmen County, Taiwan No. 2, Fu-Xing Road, Kin-Hu Township, Kin-Men County, 891, Taiwan
| | - Chun-Jen Liao
- Industry Technology Research Institute, Hsinchu County, Taiwan No. 195, Sec. 4, Chung-Hsing Road., Chutung, Hsinchu County, 310, Taiwan
| | - Feng-Huei Lin
- Institute of Biomedical Engineering, National Taiwan University, Taipei City, Taiwan No. 1, Sec. 1, Jen-Ai Road, Taipei City, 100, Taiwan; Division of Medical Engineering, National Health Research Institute, Miaoli County, Taiwan No. 35, Keyan Road, Zhunan, Miaoli County, 35053, Taiwan
| | - Chang-Jung Chiang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan No. 291, Zhongzheng Rd, Zhonghe District, New Taipei City, 23561, Taiwan; Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan No. 250, Wu-Xing Street, Taipei City, 110, Taiwan.
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Zhu W, Sun W, Xu L, Sun X, Liu Z, Qiu Y, Zhu Z. Minimally invasive scoliosis surgery assisted by O-arm navigation for Lenke Type 5C adolescent idiopathic scoliosis: a comparison with standard open approach spinal instrumentation. J Neurosurg Pediatr 2017; 19:472-478. [PMID: 28186473 DOI: 10.3171/2016.11.peds16412] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recently, minimally invasive scoliosis surgery (MISS) was introduced for the correction of adult scoliosis. Multiple benefits including a good deformity correction rate and fewer complications have been demonstrated. However, few studies have reported on the use of MISS for the management of adolescent idiopathic scoliosis (AIS). The purpose of this study was to investigate the outcome of posterior MISS assisted by O-arm navigation for the correction of Lenke Type 5C AIS. METHODS The authors searched a database for all patients with AIS who had been treated with either MISS or PSF between November 2012 and January 2014. Levels of fusion, density of implants, operation time, and estimated blood loss (EBL) were recorded. Coronal and sagittal parameters were evaluated before surgery, immediately after surgery, and at the last follow-up. The accuracy of pedicle screw placement was assessed according to postoperative axial CT images in both groups. The 22-item Scoliosis Research Society questionnaire (SRS-22) results and complications were collected during follow-up. RESULTS The authors retrospectively reviewed the records of 45 patients with Lenke Type 5C AIS, 15 who underwent posterior MISS under O-arm navigation and 30 who underwent posterior spinal fusion (PSF). The 2 treatment groups were matched in terms of baseline characteristics. Comparison of radiographic parameters revealed no obvious difference between the 2 groups immediately after surgery or at the final follow-up; however, the MISS patients had significantly less EBL (p < 0.001) and longer operation times (p = 0.002). The evaluation of pain and self-image using the SRS-22 showed significantly higher scores in the MISS group (p = 0.013 and 0.046, respectively) than in the PSF group. Postoperative CT showed high accuracy in pedicle placement in both groups. No deep wound infection, pseudarthrosis, additional surgery, implant failure, or neurological complications were recorded in either group. CONCLUSIONS Minimally invasive scoliosis surgery is an effective and safe alternative to open surgery for patients with Lenke Type 5C AIS. Compared with results of the open approach, the outcomes of MISS are promising, with reduced morbidity. Before the routine use of MISS, however, long-term data are needed.
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Total 3D Airo® Navigation for Minimally Invasive Transforaminal Lumbar Interbody Fusion. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5027340. [PMID: 27529069 PMCID: PMC4978816 DOI: 10.1155/2016/5027340] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/08/2016] [Indexed: 12/04/2022]
Abstract
Introduction. A new generation of iCT scanner, Airo®, has been introduced. The purpose of this study is to describe how Airo facilitates minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Method. We used the latest generation of portable iCT in all cases without the assistance of K-wires. We recorded the operation time, number of scans, and pedicle screw accuracy. Results. From January 2015 to December 2015, 33 consecutive patients consisting of 17 men and 16 women underwent single-level or two-level MIS-TLIF operations in our institution. The ages ranged from 23 years to 86 years (mean, 66.6 years). We treated all the cases in MIS fashion. In four cases, a tubular laminectomy at L1/2 was performed at the same time. The average operation time was 192.8 minutes and average time of placement per screw was 2.6 minutes. No additional fluoroscopy was used. Our screw accuracy rate was 98.6%. No complications were encountered. Conclusions. Airo iCT MIS-TLIF can be used for initial planning of the skin incision, precise screw, and cage placement, without the need for fluoroscopy. “Total navigation” (complete intraoperative 3D navigation without fluoroscopy) can be achieved by combining Airo navigation with navigated guide tubes for screw placement.
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Meng XT, Guan XF, Zhang HL, He SS. Computer navigation versus fluoroscopy-guided navigation for thoracic pedicle screw placement: a meta-analysis. Neurosurg Rev 2015; 39:385-91. [DOI: 10.1007/s10143-015-0679-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 04/25/2015] [Accepted: 08/09/2015] [Indexed: 10/22/2022]
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Helm PA, Teichman R, Hartmann SL, Simon D. Spinal Navigation and Imaging: History, Trends, and Future. IEEE TRANSACTIONS ON MEDICAL IMAGING 2015; 34:1738-46. [PMID: 25594965 DOI: 10.1109/tmi.2015.2391200] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The clinical practice of spine navigation has rapidly grown with the development of image-based guidance. In this paper, a brief history of spinal navigation is presented and a review of clinical outcomes for 12,622 pedicle screws placed using the latest technology in the sacral, lumbar and thoracic regions. The clinical evidence demonstrate that intraoperative 3D image guided surgery has a 96.8% success rate. A concluding section detailing existing barriers that limit more widespread adoption and future development efforts is presented.
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Al-Khouja L, Shweikeh F, Pashman R, Johnson JP, Kim TT, Drazin D. Economics of image guidance and navigation in spine surgery. Surg Neurol Int 2015; 6:S323-6. [PMID: 26167370 PMCID: PMC4496834 DOI: 10.4103/2152-7806.159381] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 03/06/2015] [Indexed: 12/31/2022] Open
Abstract
Background: Image-guidance and navigation in spinal surgery is becoming more widely utilized. Several studies have shown the use of this technology to increase accuracy of pedicle screw placement, decrease the rates of revision surgery, and minimize radiation exposure. In this paper, the authors analyze the economics of image-guided surgery (IGS) and navigation in spine surgery. Methods: A literature review was performed using PubMed, the CEA Registry, and the National Health Service Economic Evaluation Database. Each article was screened for inclusion and exclusion criteria, including costs, reoperation, readmission rates, operating room time, and length of stay. Results: Thirteen studies were included in the analysis. Six studies were identified to meet the inclusion criteria for reporting costs and seven met the criteria for analysis of efficacy. Average costs ranged from $17,650 to $39,643. Pedicle screw misplacement rates using IGS ranged from 1.20% to 15.07% while reoperation rates ranged from 0% to 7.42%. Conclusion: There is currently an insufficient amount of studies reporting on the economics of spinal navigation to accurately conclude on its cost-effectiveness in clinical practice. Although a few of these studies showed less costs associated with intraoperative imaging, none were able to establish a statistically significant difference. Preliminary findings drawn from this study indicate a possible cost-effectiveness advantage with IGS, but more comprehensive data on costs need to be reported in order to validate its utilization.
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Affiliation(s)
- Lutfi Al-Khouja
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Robert Pashman
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA ; Department of Neurosurgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Terrence T Kim
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Doniel Drazin
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
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