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Transcending Minimally Invasive Lateral Spine Surgery

Juan Uribe

July 15, 2020

Transcript

- Hello, ladies and gentlemen, thank you for joining us for another session of the virtual operating room from the neurosurgical Atlas. Our guest this evening is Dr. Juan Uribe from Barrow Neurological Institute. Truly one of the most innovative neurosurgeons, spine surgeons of our time. It's truly a pleasure to listen to him to talk about minimally invasive lateral spine surgery, something that he has pioneered and refined further. So with that Juan, I'm very excited to have you and please proceed.

- Thanks very much, Aaron, welcome to this presentation to our audience today. So what I want to transmit and tell you today is that at the end of this talk, I want to make sure that if you're doing lateral surgery or you're planning on doing lateral surgery, you will get so much motivated that, or you will move your experience one notch up and they start doing more complex application of lateral surgery. Or if you've never done it, you will feel enough motivation to go and do it. And the reason is because to me, the lateral surgery on the spine is actually now so important that if you're a spine surgeon and you're not offering to your patients, the lateral surgery as an option, I think you are not a complete spine surgeon. And you will see why I'm saying that. So these are my conflicts, which we received support for grants. And then we also perform on innovate with new products in order to advance the field. And some of the parts of the talk, obviously will get the bias because I use these products to make happen some of the surgeries that you would see. So the first question is that comes to everybody is why lateral surgery on the spine? Why if the posterior approaches and the anterior approaches seems to respond good, what is the need to do a lateral surgery? So we have to go back to the principles of a spine surgery, and traditionally we say, if a procedure can decompress, align, fuse, and provide good anterior column support, then it will be actually feeling the build and it will be doing it. So when we look at the lateral spine surgery, so it decompress, but what is very interesting is, just not by performing laminectomies or direct decompression, actually decompress by doing indirect decompression. So basically you see this image by restoring the disc height, moving the better up as you see here, actually, you're able to perform a good indirect decompression without the need to do in a laminectomy. Also aligned. If you're looking here, when this cages go lateral is you're looking here in this CT on the left, just the cages getting into disc spaces naturally, as you see on the right start aligning the spine. So it actually aligned what we want. Next is fusion. So since we're using the interbody space to provoke the fusion and we placed in these cages from one diaphysis to the other one, actually you can not have a better environment to fuse like the interbody going from this side. And for example, you compare with the anterior lateral anterior approaches like ALIF. Still the ALIF cannot go from one diaphysis to the other one, they still have a little limitation. So all this area is ready to have a fusion. And then obviously as we seen here, provide anterior column support, which is very important for multiple reasons, why? And the most important is that they share the load on the posterior elements. So for example, you put a screws on it. You put any of the posterior instrumentation, actually the fact that you have anterior column support with these wide cages, then you share the load of that structure so that you see the MIS lateral actually fits the bill because actually the comprise, align, fuse and also keep support. So is actually as any other solution. So that's why it's actually a really good alternative for the patients. So from here, I'm gonna show you a couple of examples. When we have been showing the lateral surgery actually, have a good application on the spine. The first one is what I think is one of the best applications is for the spondylolisthesis. And I going to show you a couple of manuscripts and research that we doing through the years. And if you want to go deeper on this, I think these manuscripts can give you a little more granularity if you want to go into deep. But which is important is each of these applications, actually, we were able to document it and then Bulletproof with the peer-to-peer revisions. So we see, for example, this case we see here is a male with our grade one spondylolisthesis at L4 L5. And as you see here, this patient is a sagittal balance. But however, as you see on the images, there is a dominant area with the degeneration of the disc, loss of this height, anterolisthesis of the vertebrae and compression of the neural elements. And on the actual views using here very clear, the foraminal stenosis sound centralist stenosis. So the idea was to go from this side to restore the disc height and move the better route. We should be unreduced the as foraminal stenosis. So as you're looking here, this is interoperative images. As you've seen here, once you place the cage, which is in the center image, you start reducing the spondylolisthesis and also the foramin, it start opening. You're looking here the size of this foramin compared to the size of this foramin. And you see how much it's increasing just by placing this cage that actually increase and restore the size. And then with the pedicle screws. You do the last part, which is moving forward the last part of the spondylolisthesis, and then getting a total reduction. But which is more impressive because you can, right now you can asking yourself, well, that's an interoperative pictures. How do I know that the neural elements are distracted and there is any decompression? So you're looking here, these are the x-rays post-op, which showed a good sagittal balance. But then what I want you to see in here is you will see CT pre-op and MRI pre-op and then you see how the disc height increase before and after on the CT. And then on the MRI, you will see how actually, you were able to get a good decompression. So I want you to put your eyes exactly right here. You see before this pointing here, and you see after this point. Had you seen here, actually, we're able to open this the entire canal without the need of doing any laminectomies. So we didn't take the lamina. We didn't take nothing of that. So you see here indirect decompression works very good, and you don't have to go in the back, disrupt the posterior elements, and you can put your screws percutaneous and having a really good resource. Again, this is another case is a little more extreme. It's a grade two spondylolisthesis are we seeing here and four, five, then you see here, they might just stop. And then you see how good it looks at the end. So if you're looking here, we have missing one with the images. And then and another, and another example is the adjacent segment failure. So you see this patient had a previous fusion of four five. Unfortunately, a patient didn't have the adequate lordosis to correct the problem. And then the belly up, of the adjacent segment failure at three or four with some anterolisthesis at that level. So in this case, again, we go from the side and you see here, we can run the video you see here, this is intraoperative fluoroscopy. They can look one, we put the cages and take a look on that video you seen here. The case is basically taken more than 90% on the AP and on the lateral images, having a good reduction and then go to next slide. So, and then we see here in that case, we are able to place the cage that we saw and then minimally invasively, we can also pass a percutane rod, having that really good indirect decompression again, you see in the circles before and after how good by it, we started at this height. So this is the important thing, restoring the disc height, you see, we get a really good height restoration. Then you have a really good in the decompression and alignment without losing the stability of the spine. You see here, the CT pre- and after, you see the size of the cages. So basically we're going, taking almost 90% of the case as a grafting. So we based in the clays from here to here and we've regained in this height, getting in direct decompression. And then when you look on the back, you actually can pass the percutane rod, attach it to the previous instrumentation, using a very minimal footprint and keeping that part of spinal muscles intact. You see here, some images post-op you see how you're able to connect percutaneously to the previous instrumentation and extend it to a level on the top. Okay, we going on more applications, one of the best application, I would say the most elegant application doing lateral surgery is what we call extending indication of lateral, going into the chest. And as we know, as the spine surgeons, treatment of a thoracic disc herniations and thoracic calcified disc, it's a very challenging surgical situation and doing the access using the mini open lateral access actually has a really good option. And you can do a limited, as we see here, on the left you see is the classic incision that we also like called the shark bite incision. So we don't want, you know, these monster incision, we call it a sharp bite incision instead of doing that. What about, yeah, this is more incision and actually you didn't die in that doing the same job. So, it's a little bit of a joke on the left, but that's why the reason we call it the sharp bite, because you basically go, the entire flank is totally dissected. And then you end up doing the same procedure. So I gonna show you here in the next picture and we can, moving here, you see here in this case, this patient has a significant calcified mid-thoracic disc herniation which is important, interesting on this case is I want you to pay attention that the disc is more towards the left of the herniation. And in this case, as we see here, actually we have the aorta basically on the approach. So the question is, how can you get lateral? What is the best approach to take this fragment that is actually pushing on the spinal cord without affecting the big vessels, without taking all these spinal muscles out or without going from all the way, one side to the other one, which is very hard because if the dura is intact right here, how you access to here? So you see here, which one of the beautiful things of the lesson basically with spine surgery is that actually you can sequentially dilate and this anatomical structures move. So I want you to see here on the post-op images, you obtain a full resection of the herniation. And as you've seen here, the aorta that was on the way, actually, by doing sequential dilation, you can place your to, your dilator, exact exactly where you need, and you do your job. You take the paycol out, you take the head of the rib out, you take the fragment that was calcified out. And then actually you get out of there with not even putting a single screw or destabilizing the patient. So this is, as you see, is a really good elegant way to treat a very complicated procedures. See again, pre-operative images and post-operative images, but I'll show you in this video, you can run it. This is a good example, but here, what I'm trying to highlight is on a patient with a significant disc herniation, again on the mid thoracic area, how come and how you can do a, using a small incision, a mini-open approach, going exactly behind the pleura, and perform retro pleura approach without compromising the other structures. Okay, so you're seeing here, you see the herniation, which is right there centered pushing on the spinal cord. So in this case, the approach will be a lateral retro pleura and the video, kind of highlight how to dissect the pleura. So you're seeing here now is the patient in the lateral position. You see how you decide your incision, usually is at six centimeters incision, and then you start dissecting taking the part of the rib and they're not seeing here on the bottom of your screen is posterior. The top of your screen is anterior. The right of your screen is the head and the legs on the left of your screen. You're seeing here how little by little finding this plane that is between the pleura and the medial part of the ribs that is called the endodontic fascia using here with these dilate or little by little dissecting, the pleura until you get to the head of the rib and he's using here, I'm using in this case, a ultrasonic bonus scalpel you can use an osteotomy if you want, but I found very useful using these ultrasonic bone cutters to cut the head the rib. So you see one, your head of the rib is cut, basically is the pedicle that was exposed. And it's the first target that we want. We take some of the pedicle down in order to find the dura media to the pedicle because we think that the safest way to find the dura is taking some of the pedicle down. Then once you know exactly where it's the anterior canal, again, using the ultrasonic bolt cutter as you see here, we make a osteotomy in the front of the anterior longitudinal ligament. So knowing a hundred percent sure that we've not hitting the dora and the neural elements. And then we start drilling little by little using these extended coarse diamond drills, which are not very harmful with the dura. We start working above and below the disc space. Notice in here that this space is basically located from here to here, the dura runs this way. So using here, we are moving these fragments, trying to move it anterior on these areas that we created. And you see here, we start pushing little by little, the fragment. Now we can see the dura, that whitish area, that show up. And then finally you start removing the fragments out the neural canal. And again, you'll see the dura mater is from here to here. This is the, and then you see once you take the fragment, then you have a really good decompression of the dura. And then as you've seen here is totally decompress. And then using here, we took the pedicle out, decompress the neural elements. And then it's more incision is most foot print. And you see there's the pre-op MRI. And I want you to see the post-op MRI. So you're seeing here, there is absolutely decompression. So as you see is a very elegant and amazing way to go over the thoracic disc herniation, which is a very complicated solution. Especially when you go from posterior approaches, you have to make a huge mobilizations of tissues, and you're still working indirectly. You're not having a contact direct mission. So we go to the next one, please. Okay, so this is a little bit of close-up of that, you've seen here, how nice was before and take a look, how nice is the posterior approach? And the good thing is you see, you create these little small corpectomy on the front, partial corpectomy to move the fragments this way, that way you don't violate the neural elements and the dura is intact and you don't have any injuries on the spinal cord. So it's a very elegant way to treat that. So we keep going on an IRA application. This is actually another great application on the lateral surgery, which is when you use surgery, lateral minimally invasive lateral approach, actually for treating a aorta spinal deformity. And this is some of the publication that we have using a less invasive techniques, which is in a group with the ISSG, where we show the, actually that the lateral surgeries, basically the workhorse of the treatment of minimally invasive spine surgery for deformity. And the biggest maneuver that we do on the lateral for deformity is actually what we call the ACR that basically the Anterior Column Release, basically cutting the anterior longitudinal ligament with the lateral axis and a small incision, and then creating a fish mouth opening anterior to the disc, similar with the ALIF where we'd have lateral on a levels that you cannot abscess with the ALIF and then creating lordosis, which is interesting is we can combine it with posterial osteotomies and actually making a very good an attractive coration definitive plan. As you see here is a little bit of a fast version of the anterior column release for treatment of a deformity cases. So in this video, okay, so we've got to show in here a case, a patient that it has some sagittal imbalance, and as you've seen here, he's missing approximately 15, 20 degrees lordosis. And you see before and after you go on the, I know the full gain was approximately, you know, 20 something degrees of lordosis by doing this. So basically the procedure is, after you find where the lumbar plexus is, make sure that you're retracting it the correct way from anterior to posterior. You place your retractor on it. And as you see here this through percutaneous technique, we're not using any didactic, disorganization. Everything has been using by using electromyography with a discrete readings and the directionality. And then you get, and you put your retractor in front of the lumbar plexus. So that way you don't injure. And then you get your diskectomy using here on the top of your screens. Anterior, we start a taking the disc first, and then once the disc is partially remove, notice that we start a doing a preparation of the end plates. And now we're going to start dissecting little by little, the anterior into a ligament. You see on the insert on the right, how we advance this retractor in front of the anterior longitudinal ligament using here, getting into the anterior longitudinal ligament. And then the next plan is, you'll see the ALL exposing here. We basically cut the ALL this way from anterior to posterior. And then, and then we, we provoke a, a good diskectomy without compromising the other level. So you're seeing here, you get the diskectomy. And then the plan is one that ligament is dissected. You cut the ligament. As you've seen here, the anterior longitudinal ligament from anterior to posterior. So in front of these dilator, there are the big vessels which are protected by that dissector. And he's using here, we are showing how you cut it. Once you have the entire ligament section, then the next step is to start opening the interspace. You're seeing here with this device, sequentially, you keep opening and opening until you basically fish mouth the entire segment. As you see here, once the disc space is is totally prepared and the ligament is open, here. We put in an, a template, as you've seen here with the hyperlordosis we talking about cages of 20, 30 degrees, then you can get the lordosis that you want it. And then you actually can affect the sagittal plane. They're using here when closing the cage, which again is 20, 30 degrees. And then we fix the cage to a vertebra, that way the cage that not migrate into the retroperitonium. And then as you seen here, as long as you don't violate anatomical structure, the bases are intact. You'll see the footprint of this procedure is very small. You see how you leave the source? Now you live the retroperitonium. Now we've got dominant muscles. And then basically you perform a significant amount of lordosis procedure that usually only the uptake reconstruction sternotomy can give you these, which we know that is a morbid procedure. So that's why we justified taking the risk of dissecting the vessels and the ligament, because we know that the content part, which is the pay reconstruction sternotomy is a totally different game here. So next, next slide. So we keep going there. I want you to show you one more case. You go to the next one. Oh, it's me. Okay, so you're looking here. This another good application, and this is actually how we start pushing these A lateral so due to the next level. And I'm going to show you for surgeons that are right now in these presentation. And they think that they haven't seen something novel. So I'm going to show you from now on a new application on lateral that I think is actually a really good option and can feed multiple types. You see this patient again? adjacent segment failure patient has a previous fusion on four, five developing an unstable three, four segment. As we see here on flexing extension x-rays. So make sure that are not show you cases, that you think that the patient will not even need surgery. So it's very clear, it's an unstable is symptomatic. You look on the MRI, definitely is approximately the stenosis. And even he has these curling signs in here that we know that is a significant stenosis and compression of the neural elements. And then on this same patient, we look at the CT pre-op and then as we seen here, we start in this case, we go lateral, but I want you to see the different, in this case, we localize the level as H level, but then notice in this case, actually, we're doing the lateral with the patient in prone position. So we not doing it with the patient, a lateral position. And the reason is because we have a significant time savings. If you have to perform a posterior manipulation somehow. And also, as we know, placing screws on prone position is much easier than any other position. And then we took about touch of the lateral position to place the best interbody position possible device. And you seen here in this case, because the patient has so much stenosis, we decided that the patient needed also posterior decompression, which is very fascinating on this case. You see what I'm doing? The latter axis actually my fellows or the other surgeon is actually performing the posterior surgery at the same time. So this one goes into savings of time. And not only that, but also morbidity for the patient. We try to reduce the OR time as you see here, when you keep doing the lateral axis, the posterior exposure can be done at the same time. Can you move that video? So you see here, once I place the retractor, I will be ready to start performing the lateral interbody fusion. Then we just go next, basically we pack the posterior incision. Go to the next one, please. And then as you see here, this is the retractor place at the level. And then once we start working for lateral, this is the view from the retractor on the patient on prone lateral. At the end, you see these two areas of a retroperitonium fat getting into a retractor blades. Varying here is actually the analysis of that L3 or four level as we see here on the insert, that's the view that we have. And then when we moved this video, please, and then you looking here, once you put the retractor and we working through that, now we do exactly the same routine that we do with the patient on lateral which is cleaning the end plates, take the disc out. And then once you do this, then the next step is actually right away without the need to reposition the patient. We start placing the screws as you see here, taking the oldest screws out in this case, performing the laminectomies. And then with the result and gaining of time and efficiency in the OR using here really good posterior surgery and a really good lateral surgery. So we provide a safe configuration access to a spine with a, using the best implants that we can put in an interior space. Just imagine the size of this implant compared to a TLIF implant, for example, is three times this size or doing an ALIF at L3 L4. We know that is not easy technically, and you have to put the patient on then on supine and on prone or if you do, in this case, on the lateral position, doing the compression and placing the screws on the lateral position is not a friendly as you do in posterior. You know, obviously at the end is dealer choice, but I think is a really good option. You're seeing here pre and post-op MRI. We show a good decompression and using here the case in a good position, and we don't compromise the balance of the patient. We keep it on sagittal balance with no problem. So we're going to a next example. This is a 52, 42 year old male. And this case is a patient that we see every day in our practices is a grade one is spondylolisthesis. And in this case also, in order to save times and be more efficient again, we doing the lateral up surgery in prone position. So see again, this patient, a very significant and a stable level, the MRI, the classic MRI of a spondylolisthesis, the CT shows a part defect at L4 L5, significant loss of fight. You know, the grade one, almost grade two anterolisthesis on four five. And then you see here again, patient in proposition, we marked incision. So you see here, the fluoroscopy we marked incision there which is interesting is on the top. We have the target that we see here. This is the target of the level. This is where we opening the incision. So it becomes very useful that we know that if we dissect the retroperitoneal until we hit these cross, we going to be on the level that we want to go. Next slide please, so here we see, we cut the skin and then we start doing a dilation of the abdominal muscles, make sure that we don't really cut the nerves that run on the abdominal muscle, which is the heliohypogastric on the ilioinguinal nerves. So once you do that dissection go next, please. So then once you get there, now we start monitoring using directionality using here, trying to find out, make sure that we are the lumbar plexus is actually posterior to the dilator. So that's what we want. So once we find out that we are in front of the lumbar plexus and the dilator is in a good position, then we use directionality, which is very important. We want to make sure that we in front of the lumbar plexus, then the next step go next, please. Then we place the retractor, next. And then we start doing extractormy. You see the same sequence called one M plate, then box cutters. Then we start putting the implant in this time. As you've seen here, we use in our load, this new titanium, 3D coded implants, and you see here, the lateral makes a partial reduction of the spondylolisthesis, but then right away on the proposition, we played the percutaneous spake on this screws. And we make the last reduction of the spondylolisthesis, having a complete anatomical reduction of the case with the advantage of having the patient in prone position and not compromised with the surgical balance. You've seen here, MRI pre-op and MRI post-op really good indeed, the decompression, good anatomical reduction. As you see here, how nice it's more, this goes compared to this one where we are hearing, the vertebrae instead of having this nice reduction. So you see a CT before and after good disc height, good reduction of the spondylolisthesis. Really good placement of the pedicle screws as you see here in the middle of the pay cause with no problem. And then we have a really happy patient. So then we're going to show you a one more case. And this case is a patient with a previous laminectomy and then a instability at L4 L5 and a retrolisthesis at L3 L4. And then you have an L5 S1 laminectomy posterially. So you don't want to feel this segment and this segment and leave this one without laminectomy, because we will fall apart. So we decided this patient needs this level, this level and this level fused. And as we seen here, again, in this case, we start with the SLIF with the ALIF with the patient on lateral position. So patient is in lateral position, this is the left side up, legs are this way. The head is this way. And then as you see here we are on the lateral position. We go to L5 S1, we perform on an ALIF on L5 S1, then without taking the patient out of the table, what we do is we go lateral and we do L4 L5 and L3 L4. And then we perform the placement of the pedicle screws with the patient on lateral, as we're seeing here. And that way we perform also a really good procedure without taking the patient out of the table. Having what I think is good results in the leg, decompression, or you see at these three levels, this is the C post-op not compromising the sagittal balance with the gain of gaining some time. Now we're going to go a little bit on the more, a complex case, which is in here patient with ALL the spinal deformity with a minor, sagittal imbalance, but significant coronal imbalance that we here. See if I can write this line straight, well, not easy, but patient is definitely sagittal imbalance and coronary imbalance, they're not using here is disc and disc collapse of L4 L5 significant agnation at L3 or L4, bone in bone, bone in bone, bone in bone at each of these levels. So in this case, also, we decided to perform the procedure in the prone lateral as you've seen here, there also a patient has significant allostasis. So you're seeing here, which the lateral is a great tool for all these theses as you see later on. So in these images, when you see this, when I see these images, actually, instead of me getting afraid to get axed at lateral, actually I know that once I put the patient on the table, I can have access to the level. And then I suggest showing that the patient has a good bone quality. We put the patient on the prone position. Then we start marking all the levels. Then we dissect the abdominal muscles. We place our dilators, and then we go level by level. This is the level with allothesis that we see here. Find a way to place the wire through it. The dilators using the real time, ENG monitoring, then you place your retractor at a level, you put your interbody, same sequence. Then you go to the next level, find a way to get there. Then you go to a third level, which is a very collapsed on a kyphotic level. We place in this case, we dilate, dilate until we cut the anterior longitudinal ligament. And then we use a hyperlordotic cage. And then actually we can provide really good lordosis at this segment is using here. The segment basically was flat. We create some nice harmonious lordosis at that level. So this is with the patient in prone right away. In this case, we use navigation for claimants of the screws. We obtain the interpreter, CT, and then with the patient in the same position with the gaining of time, then we start placing the percutaneous pedicle screws at each level, as you're seeing here with these are results. But then if you're looking here, the CT pre-op CT post-op. So you're seeing here the gain is we gained almost 20 degrees of lordosis by doing these interlevels. As you've seen here, then really good position of the screws will even stay 'cause they have a small size. By the using of navigation and the prone position And then I want you to pay attention, to see how good the allostesis. Actually get corrected without the need of doing an open procedure, taking laminas, taking facets, making the procedure more complicated, and then MRI pre and post. You see the good indirect decompression you seeing here, these bumps, without the need of doing any laminectomies. So you see here is a really good option. This is the next level of the lateral surgery. And as you see here, the patient is still very good aligned. Remember the scoliosis at this level and the patient was so worse the left side. You see how actually the patient keep good corner balance, good lordosis, and you don't need to do this massive posterior laminectomy, facetectomy, you name it on the anterior procedure. So as you see here, the lateral surgeries are really good option. And I, as I mentioned before, if you're a lateral surgeon, I want you to feel motivated to start going to the next level and start tackling surgeries, more complex like thoracic disc, or even start considering doing this surgery with the patient in prone, patient on lateral, single concision. So you're seeing here now the lateral access to a spine, it's actually a pallet of offers. So you can do it with the patient on lateral, with the patient on prone. And you can do also the L5 as one level with the patient, not only in supine, if you're doing an ALIF, but also lateral with the gain, so having single what we call single position surgery. So, as I mentioned, the modern spine surgeon should be able to sit in front of the patients and be able to offer any type of surgery to a patient, open, MIS, lateral, posterior or you name it, but you don't want to be that surgeon in that situation. So I think that's the end of the slide. And I willing to take any questions at this point. Thanks very much.

- Thank you, Juan, really amazing work. We're all appreciative to you on how much you have done for the advancement of lateral spine surgery, which has truly proven to be so effective. There were three questions and I'll start. The first one was, what's the estimated blood loss in these surgeries compared to the open ones, the traditional ones. Has there been any data that you want to comment on please?

- Yeah, that's a really good question. So obviously we are not talking about hiring a Hollywood complication, for example, on the ACR and deformities, if you get out of your plane and you hit the cave of the aorta, I mean, I'm not even one to talk how much blood loss will be that, but as long as you're able to compare everything and to control all the structures, there is no doubt that the less invasive techniques the blood loss is minimal compared to open. So for example, when you do a percutaneous traction osteotomy in a deformity open case, I mean, it's not unusual to lose one, one and a half liters of blood per level of paracostal osteotomy. In here, you go straight forward, you can do a whole surgery with two or 300 CC's blood loss. And then also another thing that we have been able to demonstrate with less invasive surgery is like we have less risk of infection and less risk of blood loss, it's probably the only two battles that we were able to demonstrate. And it's very interesting, the question, because today, speaking to my fellows, we were like, we want to revisit these two big advantage of the minimally invasive surgery and let's look in our group, our biggest scale. What exactly is that? Our infection rates compared to the open and also our blood loss. Great question.

- Have you tried, or what do you think about using the endoscope as you get deep into some of these cases, especially lateral thoracic or other cases?

- Yeah, so I, endoscopic techniques is very good and the optics are getting better Aaron, the problem with endoscopies is that steel is very hard to do the manual part. You know, like getting big cages which requires a lot of energy on the impaction, the steel endoscopies doesn't let us do that. Endoscopy is very good, now we have 3D images, you can get there, but once you're there, how you can bring these big instruments, forget that we are the carpenters of the spine, and the neurosurgeon, in the neurosurgery, like for example, in the brain, we, as a neurosurgeons, we know that using the endoscope can get there, but you never need to go and place a cage with significant amounts of loads and trying to create this indirect decompression. So the limitation of the endoscopy is that we don't have devices that can do that. I'm a big believer that some day, they're going to be room for that, with the new expandable and all these are new options. I'm sure that that we're going to have that because the tendency is do less, getting more, and endoscopy can fit the bill.

- What are the indications of lateral plus posterior or posterior alone surgery?

- Okay, that's a very, very wide question. You know, we can spend all night here talking, but what I can tell you is in general, I'm going to tell you, what are the good indication for lateral that way maybe you help. So patients, for example, a spondylolisthesis on the lower spine, I don't see a better indication for lateral than that. Because there is two or three good points on lateral for a spondylolisthesis. One is most of the patients with spondylolisthesis has loss of disc height. Also the anterior migration with the vertebrae makes very attractive that restoring the disc height and bring in the vertebrae where it should be will decompress all the structure on the back. So a spondylolisthesis really good application. Also, you don't want to do lateral when you don't have a loss of disc height. So you want to have a loss of disc height. So what we call sometimes that the best predictor factors to create what we call indirect decompression that is actually how the lateral surgery works is, one, is loss of disc height. Secondly, is a spondylolisthesis. Third is, on the MRIs, when you see hyperintensity on the facets' area, that's a really good point also for indirect decompression. So those are really good factors that can become important on when they come to indication of lateral. Then posterior is oh, I'm still doing open decompression. So patients with short paco syndrome that you know, that no matter what, no matter what you do it's gonna be a stenotic. So you have to actually open the canal. Patients with a significant central stenosis and neurogenic claudication, without a back pain. That's a good example of patients with posterior approach.

- Excellent. What do you need to have a vacuum disc to reduce entryless theses or lateral atheses with lateral approach?

- Yeah, actually this question is coming from someone that knows what she's doing, which I appreciate it. So yeah, in general, and that's another good point vacuum phenomenon. When you see the vacuum phenomenon in the disc space, I always call that the best friend of the latter axis surgeon is the vacuum phenomenon. Every time you see vacuum phenomenon in a disc space, you know that the patient is going to do great lateral. But in a spondylolisthesis, you don't have to have it. Just the fact that the barrier rise moving anteriorly, you know, that there is some role for the lateral surgery, but back in phenomena we'll make it definitely easier than without it.

- What's the comparison of the number of days of hospitalization, of the minimally invasive approach versus the open bigger approaches?

- Oh my God, you guys are nailing today, you know, exactly today also with talking to our fellows, we need to write a paper again. We have one paper that we wrote a few years ago, and which is important is in the short term, when you do it, the lateral, the way that should be done or any less invasive procedures we can put on that group, that mini-open TLIFs, patients traditionally, for example, single level, they go home the next day. When you do it open it's hard to send these people next day home. So that's a really good option on that. The other thing is cost wise, you know? If you are able to send the people home same day or next day, actually you're saving money on the long run, no matter what and just because the trauma, the soft tissues is smaller, that's the big, attractive point of less invasive techniques. But again, I want to make sure that I'm not generalizing, still is room for open procedures. It's not like everybody has to be minimally basic, but I would say to me, a single level of spondylolisthesis, you do an open procedure. I think that's should not be the right treatment for the patient.

- You know Juan, I wanna thank you again very much. It was a very, very illuminating talk, amazing pearls of technique, truly a cutting edge set of information that I sincerely appreciate. So with that in mind, I want to really, again, thank you for being with us this evening and look forward to seeing you with us in the near future, thank you.

- So thank you Aaron for inviting me. I know that the Atlas of Neurosurgery is the place for people to learn all over the world and I'm honored to be here. You're doing an amazing job. I mean, we are very proud to have you and put this thing together. You're leaving a legacy for the people that follow us. Thanks very much.

- Same to you. Same to you, same, I appreciate your legacy. Thank you so much, Juan.

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