Percutaneous thoracolumbar decompression combined with percutaneous pedicle screw fixation and fusion: a method for treating spinal degenerative pain in a biplane angiography suite with the avoidance of general anesthesia

Abstract

Background: Spondylytic degeneration of the axial lumbar spine is a major cause of pain and disability. Recent advances in spinal surgical instrumentation, including percutaneous access and fusion techniques, have made possible the performance of instrumented fusion through small incisions. By blending strategies of interventional pain management, neuroradiology, and conventional spine surgery, it is now feasible to treat spinal axial pain using permanent fixation techniques and local anesthesia in the setting of a fluoroscopy suite using mild sedation and local anesthesia.

Methods: The author presents a series of percutaneous thoracolumbar fusion procedures performed in a biplane neuroangiographic suite and without general anesthesia for the treatment of spondylytic pain. All procedures utilized pedicle screw fixation, harvesting of local bone autograft, and application of bone fusion material.

Results: In this series of 13 patients, a statistically significant reduction of pain was seen at both the 2-week post-operative timepoint, as well as at the time of longest follow-up (mean 40 weeks).

Discussion: The advanced and rapid imaging capabilities afforded by a neuroangiographic suite can be safely combined with percutaneous fusion techniques so as to allow for fusion therapies to be applied to patients where the avoidance of general anesthesia is desirable.

Keywords: Spondylosis; biplane suite; fusion; pedicle screw; sedation.

Figure 1

Work flow sequence as seen in fluoroscopic images. (A) Access cannula for mild decompression docked at the L5 laminar level, reverse oblique view. An epidural needle is present at S1 through which contrast has been injected to achieve an epidurogram; (B) bone sculptor in use to resect laminar edge and medial facet. The epidural contrast layer provides a depth guide deep to which the instrument should not pass; (C) insertion of L5 pedicle screw after completion of S1 screw placement; (D) passage of rod through S1 skin and fascial slit. At this point, most of the epidural contrast has dissipated; (E) decortication of facet surface and preparation of fusion bed through the use of a curette with a sharpened tip.

Figure 2

Insertion of pedicle screw over K wire. At this phase of the case, the anterior-posterior (“A” plane) fluoroscopic tube has been parked cephalad and out of the field so as to allow sufficient working room for the instrumentation and operator’s hands. The lateral (“B” plane) fluoroscopic tube is seen in the working position, providing real-time high-resolution imaging.

Figure 3

Images from case 5, a 94-year-old male who underwent left L3-L4 mild decompression and pedicle screw fusion. (A) Final construct image from the biplane angiographic suite; (B) axial CT image at L4 level obtained 14 months after procedure. Note solid fusion mass medial to screw head; (C) axial CT image at L3 level, demonstrating fusion mass medial to instrumentation.