2nd - ismiss turkey
Transkript
2nd - ismiss turkey
2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Contents Welcome Message by Hansjoerg F. Leu ................................................................ 2 Welcome Message by Tolgay Satana ..................................................................... 3 ISMISS Officers .......................................................................................................4 Organizing Committee ............................................................................................ 5 Faculty .................................................................................................................... 6 Scientific Program ........................................................................................... 7 - 15 Chairpersons ................................................................................................. 16 - 36 Lectures ....................................................................................................... 37 - 103 Poster Presentations .................................................................................. 104 - 111 1 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Since its foundation in 1989, the International Society for Minimal Invasive Spinal Surgery (ISMISS / www.ismiss.com affiliated to SICOT) aims for well controlled information and methodical instruction in the rapidly evolving field of spinal surgery. So starting in the US and central Europe in the eighties, since the nineties a rapid growth was to observe in Korea and Japan, in the young 21th century also in China. Respectively interested groups of active spinal surgeons brought up the new techniques and their experiences to periodically organized meetings under the auspices of ISMISS. The goal remains to allow first hand information on new techniques, their concepts with well defined indications, limits and results. As in other fields of surgery, minimal invasive techniques challenge today former golden standards and sollicitate our critical evaluation and responsibility for well defined respective clinical practice. So all over the world several courses are now organized under the auspices of ISMISS under this commitment. Beside technical and operative aspects also clinical analysis of indications, learningcurves and follow-up criteria deserve our interest in worldwide economically restricted conditions and an evident need for outcome quality control. So also a need is evident for ISMISS to define common sense definitions and guidelines, helping so all active partners in the field of minimal invasive spinal surgery to orient themselves in the rapid evolution in this field. So in the nearby 20 years tradition of ISMISS, also this first specific meeting under the auspices if ISMISS in Turkey shall reflect an up-date on already done proven steps in this field, the actual state of the art and ongoing innovative developments in this continuously evolving branch of spinal surgery. We thank Dr. S. Tolgay from Istanbul and his group for the superb organization of this meeting. It is with great pleasure that we see the large interest of our colleges in Turkey. We are convinced that such an exchange between local and international pioneers and experts sharing the course faculty promise to contribute to a vivid and collegial atmosphere of this first turkish meeting and making many new friendships and bridges with this amazing country. Hansjoerg F. Leu, M.D. President Elect ISMISS 2008-2011 2 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional 'Primum nil nocere' (Never harm) principle has been the primary principle of medicine since the Hypocrates era. As surgical treatment methods in general evolve towards less invasive procedures, former invasive spinal surgery also climbs up rapidly an analogous ladder of evolution. Although minimal invasive spinal surgery has become more popular along with the improving optic systems in the last two decades, it has always prevailed in throughout the past century. Beside ISMISS, other spinal societies hosted the early platforms for exchanging information. owever, their meetings often underperformed innovative expectations. Sometimes minimal invasive interventions were just lost among glorious implants and material intensive surgery. That is why various local branches of ISMISS, e.g. Swiss branch organized 25 annual meetings in Zurich/Switzerland, focussing mainly on minimal invasive spinal interventions. Where in conventional spine meetings in the last decade present, minimal invasive spinal surgery has been included into the programs with individual presentations. Now for the first time in Turkey, this meeting will be dedicated in its program to the entire range of today's minimal invasive spinal interventions. Furthermore, our goal is to allow all physicians interested in minimal invasive surgery to get in contact with renowned international experts in order to exchange information and share best practices. On behalf of International Organizing Committee Tolgay SATANA, MD National Representative of ISMISS 3 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ISMISS OFFICERS PRESIDENT Hj. Leu, M.D., Switzerland PRESIDENT ELECT S-H. Lee, M.D., South Korea VICE PRESIDENT V. Radchenko, M.D., Ukraine PAST PRESIDENT J. Chiu, M.D., United States SECRETARY American Branch J. Chiu, M.D., United States European Branch V. Radchenko, M.D., Ukraine Asian Branch S. Nakai, M.D., Japan TREASURER European Section Hj. Leu, M.D., Switzerland American Section J. Chiu, M.D., United States NATIONAL REPRESENTATIVE Australia China Germany Italy Korea Spain Turkey United Kingdom : G. Speck, M.D. : Z. Zheng, M.D. : C. Birkenmaier, M.D. : A. Fontanella, M.D. : S-H. Lee, M.D. : C. Algara Lemagniere, M.D. : S. Tolgay, M.D. : L. Wilson, M.D. Brazil : Pil-Sun Choi, M.D. France : D. Gastambide, M.D. Hong Kong : K. Fung, M.D. Japan : A. Dezawa, M.D. Russia : L. Sak, M.D. Switzerland : M. Rühli, M.D. Ukraine : E. Pedachenko, M.D. United States : J. Chiu, M.D. SICOT REPRESENTATIVE M. Hinsenkamp M.D. 4 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ORGANIZING COMMITTEE Honorary Presidents Parviz Kambin (USA) Hansjoerg Leu ( Switzerland) Co-President Erol Yalnız (Turkey) Mehmet Zileli (Turkey) Course Coordinator Tolgay Şatana (Turkey) Secretary Murat Bezer (Turkey) Oğuz Karaeminoğulları (Turkey) Alpaslan Şenköylü (Turkey) Treasurer Mehmet Altuğ (Turkey) Murat Ergüven (Turkey) 5 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional FACULTY Salahadin Abdi (USA) Abdul Gaffar Shaikh Ahmed (Bahrain) Gülseren Akyüz (Turkey) Vitalli Alexandrovski (Ukraine) Mehmet Altuğ (Turkey) Mustafa Anter (Turkey) Figen Yağmur Aslan (Turkey) Yair Barzilay (Israel) Murat Bezer (Turkey) Christof Birkenmaier (Germany) Alexander Brekhov (Russia) Josip Buric (Italy) John Chiu (USA) Gun Choi (Korea) Bayram Çırak (Turkey) Bambang Darwono (Indonesia) Jean Destandeu (France) Akira Dezawa (Japan) Devanand A. Dominique (USA) Serdar Erdine (Turkey) Murat Ergüven (Turkey) Andrea Fontanella (Italy) Daniel Gastambide (France) Lex Giltaij (USA) Krzok Guntram (Germany) Nils Haberland (Germany) Azmi Hamzaoğlu (Turkey) Mitchell Hardenbrook (USA) Stefan Hellinger (Germany) Thomas Hoogland (Germany) Fujio Ito (Japan) Sudeep Jain (India) Chang Il Ju (Korea) Serdar Kabataş (Turkey) Parviz Kambin (USA) Solomon Kamson (USA) Sri Kantha (USA) H.Selim Karabekir (Turkey) Bülent Fahri Kılınçoğlu (Turkey) Panagiotis Korovessis (Greece) Banu Kuran (Turkey) Sang Ho Lee (Korea) Hansjoerg Leu (Switzerland) Alexandre Levshin (Ukraine) Nuket Göçmen Mas (Turkey) Paolo Menchetti (Italy) Ahmet Menku (Turkey) Christian W. Müler (Germany) Semih Özdemir (Turkey) Burak Özgür (USA) Çağatay Öztürk (Turkey) Chan Wearn Benedict Peng (Singapore) Andrey Popov (Ukraine) Konstantin Popsuishapka (Ukraine) Vladimir A. Radchenko (Ukraine) Wolfgang Rauschning (Sweden) Sebastian Ruetten (Germany) Jan Peter Schilling (Germany) Jalal Jalal Shokouhi (Iran) Arsen Shpigelman (Israel) Artem Skidanov (Ukraine) Tariq Sinan (Kuwait) Dilşat Sindel (Turkey) Alexander Sirenko (Ukraine) Ufuk Soylu (Turkey) Kayıhan Şahinoğlu (Turkey) Tolgay Şatana (Turkey) Mehmet Şenoğlu (Turkey) Mehmet Ali Tümöz (Turkey) Ahmet Usta (Turkey) Füsun Uysal (Turkey) İlker Yağcı (Turkey) Anthony Yeung (USA) Kemal Yücesoy (Turkey) Park Kyung-Woo (Korea) Mehmet Zileli (Turkey) 6 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Scientific Programme 7 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 3, 2009 J. Destandau - S. Hellinger T. Satana 08:30 - 13:00 Live Surgery on " Endoscopic and Cervical Discectomy" 09:00 Posterior Endoscopic Discectomy (Destandau Tecnique) 10:00 Percutaneous Endoscopic Lumbar Discectomy S. Hellinger 11:00 Percutaneous Endoscopic Lumbar Discectomy G. Krzok 12:00 Thorasic Discectomy 14:00 - 17.00 Pre-Congress Cadaver Hands-on Workshop on “Foraminal and endoscopic spinal anatomy” 10min Foraminal and endescopic spinal anatomy 10min Basic Principles of miss techniques J. Destandau J. Chiu K. Sahinoglu - T. Satana K. Sahinoglu T. Satana Hands on workshop with cadavra: Percutan endescopic lumbar discectomy - Endoscopic thorasic discectomy - Percutan endescopic cervical discectomy April 4, 2009 J. Chiu - S. Hellinger G. Krzok - S.H.Lee - H. Leu T. Satana 08.00 - 08:05 Welcome Adress Mehmet Zileli 08.05 - 08:10 Presidential greeting address of ISMISS Hansjoerg Leu Panel 1 - Basic Principles Hansjoerg Leu Mahmet Zileli 08:10 - 08:18 History of Minimal Invasive Spinal Surgery Mehmet Ali Tümöz 08:18 - 08: 26 Definition of MISS procedures and regulations in Turkey 08:26 - 08:34 Outcome measures in low back pain 08:34 - 08:42 Back pain in children and adolescent 08:42 - 08:50 Digital Technology Convergence and Control System: Minimally Invasive Spine Surgeon’s (MISS) Perspective and Technological Consideration 08:50 - 08:58 Thoracoscopic Management of Spine Tumors 08:58 - 09:06 Biological-functional considerations regarding the treatment of lumbar DDD. 09:06 - 09:14 Intervertebral Foramen from the Anatomic Approach 09:14 - 09:20 Discussion 8 Tolgay Satana L-1 Fusun Uysal L-2 John Chiu L-3 Ahmet Usta L-4 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 4, 2009 Master lecture John Chiu 09:20 - 09:35 Full-endoscopic operations of the lumbar, thoracic and cervical spine 09:35 - 09:50 Minimalinvasive Procedures on the cervical spine - From the Nonendoscopic Percutanoues Laserdiscdecompression to the selective Percutaneous Endoscopic Cervical Decompression and Discectomy 09:50 - 09:55 Discussion 09:55 - 10:15 Coffee Break Sebastian Ruetten ML - 1 Stefan Hellinger ML - 2 Master lecture Sang Ho Lee 10:15 - 10:30 Complication risks of the foraminal approach to the lumbar spine: It’s corellation with foraminal anatomy, variations, and anomalous structures in the “hidden” zone” Antony Yeung ML - 3 10:30 - 10:45 Endoscopic Surgery of Lumbar Spinal Stenosis. About 145 cases. Jean Destandeu ML - 4 10:45 - 10:50 Discussion Panel 2: Endescopic Spine Techniques Sang Ho Lee 10:50 - 10:58 Posterior Lateral Thoracic Endoscopic Microdiscectomy 10:58 - 11:06 Endoscopic Approaches to Degenerative Cervical Deseases. 11:06 - 11:14 Transforaminal Endoscopic Microdecompression for Herniated Lumbar Discs and Spinal Stenosis and Tissue Modulation Technology - Update 11:14 - 11:22 PECD for Noncontained HCD 11:22 - 11:30 Endoscopic lumbar disc surgery : up-date 2009 11:30 - 11:38 The endoscopic resection for Juxta-facet cysts – a new promising technique 11:38 - 11:46 XMR assisted PELD 11:46 - 11:54 Full-endoscopic posterior operation of cervical lateral disc herniations – Prospective, randomized comparison to anterior cervical decompression and fusion (ACDF) 11:54 - 12:02 Clinical outcomes of percutaneous endoscopic discectomy (peld) 12:02 -12:10 Discussion 12:10 - 13:00 Lunch 12:10 - 13:00 Luncheon Meeting of General Assambly of ISMISS Turkey co joined ISMISS Board. 9 John Chiu L-5 Jean Destandeu L-6 John Chiu L-7 Sang Ho Lee L-8 Hansjoerg Leu L-9 Stefan Hellinger L - 10 Sang Ho Lee L - 11 Semih Özdemir L - 12 Fujio ITO L - 13 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 4, 2009 Stefan Hellinger Burak Özgür Program Lectures 13:00 - 13:08 Percutaneous endoscopic discectomy in lumbar disc herniation combined with spinal stenosis having severe unilateral radiculopathic leg pain caused by dominant root compression : Transforaminal suprapedicular approach 13:08 - 13:16 Comparative study of efficiency of Destandau endoscopic discectomy and open microsurgical discectomy for lumbar disc herniation. 13:16 - 13:24 Transforaminal endescopic extradiscal vs intradiscal access in lumbar disc herniation 13:24 - 13:32 Minimally invasive approach to lesions located in spinal canal 13:32 - 13:40 Clinical and Radiological outcomes of Minimally Invasive versus open transforaminal lumbar interbody fusion 13:40 - 13:48 Prophylactic of relapses of facet joint syndrome after their’s denervation 13:48 - 13.56 Rigid Interspinous Spacer with Tension Band (ILF) 13:56 - 14:04 Inter-spinous Process Fixation for Degenerative Pathology of the Lumbar Spine 14.04 - 14:12 Analysis of Cervical RF nucleopasty as a minimal invasive procedure with 2-3 years follow-up 14:12 - 14:20 Discussion Chang Il Ju L - 14 Guntram Krzok L - 15 Chan Wearn Benedict Peng L - 16 Alexander Sirenko L - 17 Sang Ho Lee L - 18 Mitchell Hardenbrook L - 19 Hamit Selim Karabekir L - 20 Salahadin Abdi Pier Paolo Menchetti Master lecture 14:20 - 14:35 Intradiscal Therapies Serdar Erdine ML - 5 14:35 - 14.50 Identifying the pain generators in the lumbar spine: Bridging the Gap between Interventional Pain Management and Traditional Spine Surgery Antony Yeung ML - 6 14:50 - 15:05 Endoscopic transforaminal discectomy for recurrent lumbar disc herniation Thomas Hoogland ML - 7 15:05 - 15:10 Discussion 15:10 - 15:30 Coffee Break 10 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 4, 2009 MAINHALL Panel 3 - Intradiscal Therapies and Pain Management Serdar Erdine 15:30 - 15:38 Cervical Facet Denervation Serdar Erdine L - 21 15:38 - 15:46 Paraspinal mapping in lumbar spinal stenosis İlker Yağcı L - 22 15:46 - 15.54 Interventional causalgia treatment "image guided" Jalal Jalal Shokouhi L - 23 15:54 - 16:02 Advances in the treatment of discogenic back pain Salahadin Abdi L - 24 16:02 - 16:10 Is Success Rate of Lumbar Epidural Steroid Injection Predictable? 16:10 - 16:18 Controversies surrounding epidural steroid injections Salahadin Abdi L - 25 16:18 - 16:26 Intraoperative alcohol injection for the treatment of a sacral spinal epidural hemangioma. Technical note. Ahmet Menku L - 26 16:26 - 16:34 Percutaneous automatic discectomy of cervical and lumbar spine Konstantin Popsuishapka L - 27 16:34 - 16: 42 Lumbar and Cervical Facet Joint Denervation with Laser Sri Kantha L - 28 16:42 - 16:50 Fluoroscopically guided transforaminal epidural steroid injections for lumbar spinal stenosis and lumbar discogenic pain Serdar Kabataş L - 29 16:50 - 16:55 Discussion Program Lectures Pier Paolo Menchetti 16:55 - 17:03 Minimal-invasive approach to the surgical treatment of lumbar spinal canal stenosis. 17:03 - 17:11 Minimal Invasive Surgery (Balloon Kyphoplasty plus Short posterior Instrumentation) for Acute Lumbar Fractures. 17:11 - 17:19 Preliminary report on Percutaneous Transpediculr Screw instrumentation combined with Minimal ALIF approach 17:19 - 17:27 270 degrees fusion with TLIF technique: Tricks to avoid complications 17:27 - 17:35 Panagiotis Korovessis Josip Buric L - 30 Two years follow-up results of over 400 lumbar nucleoplasty cases Kemal Yucesoy L - 31 17:35 - 17:43 Adult stem cell treatment in spinal cord injury - technique and first clinical results Nils Haberland L - 32 17:43 - 17:51 Percutaneous Transsacral Lumbar Interbody Fusion (Axialif) 17:51 - 17:59 Percutaneous Interspinous Spacers in Degenerative Lumbar Spinal Stenosis. Indications and Results at more than 1 year. 17:59 - 18:07 Diam device for low back pain in degenerative disc disease Josip Buric L - 33 11 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 4, 2009 18:07 - 18:15 Hyperosmolar Dextrose Solution Injection on Lumbosacral medial branch and Bilateral Sacroiliac Joint for Remnant Buttock Pain after Vertebral Augmentation Procedures 18:15 - 18:20 Discussion Chang Il Ju L - 34 April 5, 2009 Tolgay Satana Vladimir Radchenko Program Lectures 08:00 - 08:08 In-Space (Percutaenous Intarspinous spacer) Treatment of Canal stenosis Tariq Sinan L -35 08:08 - 08:16 Endoscopic excision of synovial cyst of facet joint 08:16 - 08:24 Osteoid Osteoma of the Spine: Geiger Guided Resection. 5 cases from our department. Arsen Shpigelman L - 36 08:24 - 08:32 Cervical Laminoplasty as a Minimal Invasive Technique in Spondylotic Myelopathy 08:32 - 08:40 Is it really safe to perform Percutaneous Interventions for beginners around Neural Foramens? 08:40 - 08:48 Percutaneous iliosacral screw fixation in Sacral fractures and iliosacral seperation 08:48 - 08:56 Lumbar spine degenerative diseases - treatment using dynamic spinal stabilization systems 08:56 - 09:04 Interspinous fixation with coflex and diam implants in surgical treatment of lumbar spine degenerative disease 09:04 - 09:12 Interspinous Dynamic Spacer (COFLEX) insertion, our experience and surgical technique. Arsen Shpigelman L - 37 09:12 - 09:20 “Coflex” experience Alexandre Levshin L - 38 09:20 - 09:28 Flexis - System - A interspinous device study of 90 cases 09:28 - 09:36 High anterior cervical approach to the upper cervical spine: A Quantitative Anatomical and Morphometric Evaluation Mehmet Senoglu L - 39 09:36 - 09:44 Syringomyelia: retrospective clinical analysis & review of the surgical treatment options Bayram Cirak L - 40 Nuket Gocmen Mas L - 41 Figen Yağmur Aslan L - 42 Figen Yağmur Aslan L - 43 09:44 - 09:52 09:52 - 10:00 10:00 - 10:08 Significans of morphometric evaluation of lumbar vertebral bodies for corpectomy reconstruction: A stereological study A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Lumbar Disc Herniation (Hole Approach) and video presantation A Novel Technigue Of Microsurgical Approach Through Laminofacet Articular Junction For Foraminal Stenosis And Spondylolisthesis (Hole Approach) And video presantation 10:08 - 10:15 Discussion 10:15 - 10:35 Coffee Break 12 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 5, 2009 Christof Birkenmaier Kemal Yucesoy Master lecture 10:35 - 10:50 The Lumbar Facet Sydrome Vladimir Radchenko ML - 8 10:50 - 11:05 Clinical results for lateral lumbar disc herniations with PELD,10-syringe discectomy and retroperitoneoscopy Akira Dezawa ML - 9 11:05 - 11:20 Lumbar dynamic segmental restabilization : the DYNESYSR experience 1999-2009 Hansjoerg Leu ML - 10 11:20 - 11:35 Endoscopic Microdecompressive Cervical Discectomy and Foraminal Decompression over 2000 Patients John Chiu ML - 11 11:35 -11:45 Discussion 11:45 - 12:45 Debate Session - Round Table : Tolgay Satana Microscopic discectomy versus Percutaneous discectomy Percutaneous discectomy versus Microscopic discectomy Sebastian Ruetten, Sang Ho Lee, Antony Yeung, Fahir Özer, Hansjoerg Leu, Thomas Hoogland, Mehmet Zileli, Stefan Hellinger, Jean Destandeu, John Chiu 12:45 - 13:30 Lunch Yair Barzilay Akira Dezawa Program Lectures 13:30 - 13.38 Kyphoplasty- patient selection, advantages and pitfalls 13:38 - 13:46 Stand-Alone Kyphoplasty of the Thoracolumbar Junction – Potential for Severe Complications 13:46 - 13:54 Vesselplasty using SrHA New cement ( Osteo-G ) 13.54 - 14:02 Percutaneous vertebroplasty of osteoporotic fractures of thoracal and lumbar spine with various compositive materials 14:02 - 14:10 Percutaneous vertebroplasty 14:10 - 14:18 Complications of vertebroplasty 14:18 - 14.26 Design rationale and preliminary clinical results of NuNec, a PEEK-on-PEEK cervical arthroplasty system. 14:26 - 14:34 Long term results of lumbar restabilization using the B-Twin device for lumbar segmental insufficiency. Report on 350 cases. 14:34 - 14:42 Total disc replacement compared to lumbar fusion. A randomised controlled trial with two-year follow up 14:42 - 14:50 Discussion 13 Christof Birkenmaier L - 44 Bambang Darwono L - 45 Andrey Popov L - 46 Kemal Yucesoy L - 47 A.R. Giltaij L - 48 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 5, 2009 MAINHALL Nils Haberland Anthony Yeung Master lectures 14:50 - 15:05 Percutaneous Laser Discectomy. State of the art. Long term results. Pier Paolo Menchetti ML - 12 15:05 - 15:20 Robotic assisted spine surgery - a breakthrough or a surgical toy? Yair Barzilay ML - 13 15:20 - 15:35 Minimally Invasive Lateral Trans-Psoas Approach to Treating Thoracic and Lumbar Spinal Disease Burak Özgür ML - 14 15:35 - 15:40 Discussion 15:40 - 16:00 Coffee Break Figen Yağmur Aslan Daniel Gastambide Panel 4- Less Invasiv 16:00 - 16:08 The Clinical Use of Unilateral Minimal Access TLIF surgery 16:08 - 16:16 Aperius™ Interspinous spacer vs open surgery in degenerative lumbar spinal stenosis.Retrospective multicentric experience. 16:16 - 16:24 Minimally Invasive Trans-Sacral Approach to the Lumbo-Sacral Spine 16:24 - 16:32 Endescopy and percutaneous arthrodesis in relapsed discl hernias 16:32 - 16:40 Influence of facet joints asymmetry on the development of lateral recess stenosis 16:40 - 16:48 16:48 - 16:56 Tubular Microsurgery for Lumbar Discectomies and Laminectomies in Obese Patients: Operative Results and Outcome Conventional posterior lumbar interbody fusion Versus Mini-open posterior lumbar interbody fusion Using the New Percutaneously Inserted Spinal transpedicular screwing System 16:56 - 17:04 Discussion 17:04 - 17:15 Closing Lecture 14 Pier Paolo Menchetti L - 49 Burak Özgür L - 50 Daniel Gastambide L - 51 Artem Skidanov L - 52 Chang Il Ju L - 53 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional April 5, 2009 08:30 - 10:30 POSTER DISCUSSION SESSION Percutaneous vertebroplasty(pvp): an effective and economically viable perspective from a developing country for vertebral collapse fractures(vcf's) of various etiologies Screw reinforcing Percutaneous Short Segment Transpedicular Screwing for Unstable Thoracolumbar Burst Fractures Sudeep Jain P-1 Chang Il Ju P-2 Chang Il Ju P-3 Far Lateral Extraforaminal Synovial Cyst Not Connecting Facet Joint Ahmet Menku P-4 Non-traumatic acute monoplegia associated with intradural cervical disc herniation: a case report Ahmet Menku P-5 Nikolaos Syrmos P-6 Sudeep Jain P-7 Bone Cement Augmentation of Short Segment Fixation for Unstable Burst Fracture in Severe Osteoporosis Fractures of the thoracolumbar spine Selective nerve root injections in lumbar radiculopathy: A prospective clinical outcome study as a minimally invasive alternative to surgery. A five year followup 15 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Chairpersons 16 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Salahadin Abdi, MD, PhD Salahadin Abdi, MD, PhD, is currently a Professor of Clinical Anesthesiology and Chief of Pain Medicine at the University of Miami Pain Center. He joined his current position after serving as the Director of the Massachusetts General Hospital, Harvard Pain Center. Prior to that he served as the Director of the Fellowship Program in Pain Medicine at MGH, Harvard. Dr. Abdi obtained his degrees from the University of Muenster in Germany. He completed his residencies in Anesthesiology both at the University of Muenster Medical Center in Germany and at the Massachusetts General Hospital, Harvard Medical School, Boston, MA. Dr. Abdi also completed his fellowship at the Shriners Burns Institute and University of Texas Medical Branch in Galveston, TX. Dr. Abdi has been an active member in various national and international medical societies including ASA, APS, ASIPP, IASP, ASRA etc.. He was a Section Editor for the journal of “Current Opinion in Anaesthesiology - Pain Medicine” and has been appointed to the editorial board of the journal of minimally invasive surgery and Pain Physician (official journal of American Society of Interventional Pain Physicians) where he is currently serving as Associate Editor. Dr. Abdi has attended several National and International meetings as an invited Speaker. Furthermore, Dr. Abdi has authored and coauthored over 120 peer-reviewed articles, book chapters and the popular handbook, “The Massachusetts General Hospital Handbook of Pain Management”. He is a reviewer for Anesthesiology, Current Opinion in Anesthesiology, Emerging Drugs, Pain Physician, Clinical Journal of Pain and Spine to name a few. Dr.Abdi’s current areas of research interest include: basic science and clinical investigations in the areas of back pain, neuropathic pain, and cancer pain. Finally, Dr. Abdi has been listed as “Florida Super Doctors” in 2008 and 2009. 17 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Dr. Figen Yağmur Aslan Education Publications Attended Congresses Attended Courses 1985- 1991:Akdeniz University (Antalya, Türkiye);General practitioner \ School of Medicine 1993 - 2001:Akdeniz University (Antalya, Türkiye);Medical Doctor \ School of Medicine, Specialist Training Programme of Neurosurgery 2001- 2008:: General Hospital Antalya, Türkiye; Neurosurgeon \ Department of Neurosurgery *“Traumatic Cerebrospinal Liquid Rhionere”, Journal of Turkish Neurosurgery, April, 1995. “Post Operative Angiography in intracranialAneurysm”, Journal of Turkish Neurosurgery, May,2000. *“A Case Report on Cysthydatic in The Fifth Cervical Vertebrae”, The 14th Scientific Congress of NeurosurgicalSociety, Antalya, Türkiye, May, 2000. *“The Effect of Screw Malposition in The Late Period of Stabilization”, The 15th Scientific CongressofNeurosurgicalSociety,Antalya,Türkiye,May,2001. Acta Neurochir (Wien). 2003 Nov;145(11):949-54; discussion 954-5. *“The Treatment of Toracolomber Traumas, The Value of Transpedicular Screw Fixation”, M.D. Thesis, Akdeniz University, SchoolofMedicine, Department of Neurosurgery, June, 2001. *Transarticular medial approach with partial facetectomy for lomber disc hernia and forforaminalstenosis:andspondylolisthesis. -The 17th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2003. (Disc Hernia). -The 18th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2004. (Foraminalstenosis) -The 19th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2005. (Disc hernia,foraminalstenosis). *Transarticular medial approach with partial facetectomy for lomber disc hernia and for foraminal foraminal stenosis:and spondylolisthesis, Euro Spine Congress, İstanbul, Türkiye, April, 2006. *A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Lumbar Disc Herniation (Hole Approach),The 4th İnternational World Spine Congress, İstanbul, Türkiye, June, 2007. *A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Foraminal Stenosis, And Spondylolisthesis (Hole Approach ) ,The 4th İnternational World Spine Congress, İstanbul, Türkiye, June, 2007. *A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Foraminal Stenosis, And Spondylolisthesis (Hole Approach ) ,The 10th international Spine Congress collobration with World Spine Society, Alexandre, Egypt, March, 2008 (İnvitedSpeaker). *ANovel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Lumbar Disc Herniation (Hole Approach) ‘’Video Presentation ‘’ The 1th İnternational African Neurological Society, Egypt Neurosurgical Society, Egypt Spine Society, Sharm ElShake, Egypt, February, 2009 (İnvitedSpeaker). *A Novel Technique Of Microsurgical Approach Through Laminofacet Articular Junction For Foraminal Stenosis, And Spondylolisthesis (Hole Approach ) ‘’Video Presentation’’ ,The 1th İnternational African Neurological Society, Egypt Neurosurgical Society, Egypt Spine Society, Sharm El-Shake, Egypt, February,2009, ( İnvited Speaker). *The9th Scientific Congress of Neurosurgical Society, İzmir, Türkiye, April 9-14, 1995. *The11th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May 9-11, 1997. *The12th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May 15-19, 1998. *The13th Scientific Congress of Neurosurgical Society, İstanbul, Türkiye, May 17-19, 1999. The*14thScientificCongressofNeurosurgicalSociety,Antalya,Türkiye,May17-21,2000. *The15thScientificCongressofneurosurgicalSociety,Antalya,Türkiye,May22-26,2001. *Symposium of Lomber Degenerative Disc Disease, Antalya, Türkiye, October 6-7, 2000. *The 17th Scientific Congress of Neurosurgical Society, Antalya, Türkiye, May , 2003. *8th Turkish spinal surgery groups meeting,Antalya,Türkiye,November,2008 -Workshop on Spinal Surgery, Ege University, School of Medicine, İzmir, Türkiye, November 25-26,2000. -Spinal Surgery ( as a fellow) Ege University, School of Medicine, İzmir, Turkey, at six 18 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Yair Barzilay, MD Date of Birth: March 20, 1968 Place of Birth: Jerusalem, Israel Current Address: 90/5 Hachayil St. Jerusalem, 97891, Israel Cell phone: + (972) 508-573279 E-mail: dbar@hadassah.org.il Martial Status: Married + 3 Children Current post: Consultant Orthopaedic and Spine surgeon, Spine unit, Department of Orthopaedic Surgery, Hadassah Hebrew-University Medical Center, Jerusalem, Israel Selected Publications Book Chapters: Y. Barzilay, L. Kaplan, M. Liebergall. Miniature robotic guidance for spine surgery. In Medical Robots; Vanja Bozociv(ed.) pp 219-232. Advanced Robotic Systems International & Pro Verlag 2008. Journal Publications (Peer Reviewed) Bhatia CK, Barzilay Y, Pollock R, Krishna M. Cement Leakage in percutaneous vertebroplasty; effect of pre-injection gelfoam embolization – Spine. 31(8):915-919, April 15, 2006 4;4 Y. Barzilay, M. Liebergall, A. Fridlander, N. Knoller. Miniature robotic guidance for spine surgery – Introduction of a novel system and analysis of challenges encountered during the clinical development phase in two spine centers. IJMRCAS Volume 2, Issue 2, June 2006, Pages: 146-153 3;2 L Kaplan, Y Bronstein, Y Barzilay, A Hasharoni, JA Finkelstein. Canal expansive laminoplasty in the management of cervical spondylotic myelopathy. IMAJ 2006: 8: August: 548-552. 0 Aharony S, Milgrom C, Wolf T, Barzilay Y, Applbaum YH, Schindel Y, Finestone A, Liram N. Magnetic resonance imaging showed no signs of overuse or permanent injury to the lumbar sacral spine during a Special Forces training course. Spine J. 2008 Jul-Aug;8(4):578-83. Epub 2007 Mar 2. 0 Barzilay Y, Kaplan L, Liebergall M. Robotic assisted spine surgery – a breakthrough or a surgical toy? Int. J. Med Robot. 2008 Sep;4(3):195-6. 0 Ongoing research projects * Objective assessment of outcome in various medical conditions using a new objective tool * Protection of spinal cord injury in the rabbit model * Miniature robotics and navigation systems * New non operative treatment of non specific low back pain 19 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Christof Birkvenmaier, MD Department of Orthopedic Surgery Grosshadern Medical Center University of Munich Marchioninistr. 15 D - 81377 Munich Ph.: +49-89-7095 0 Fax: +49-89-7095 5814 cbirkenm@med.uni-muenchen.de CLINICAL POSITIONS 2006 – cont. Faculty, Dept. of Orthopedic Surgery, Großhadern Medical Center, University Head of Spine Team, Head of Osteology Clinics 2004 – 2006 Junior Faculty, Dept. of Orthopedic Surgery, Großhadern Medical Center, University of Munich 2001 - 2004 Resident, Dept. of Orthopedic Surgery, Großhadern Medical Center, University of Munich 1999 - 2001 Resident, Dept. of Orthopedic Surgery, Medical Center rechts der Isar, Technical University Munich 1995 - 1998 Resident, Dept. of Surgery, Medical Center rechts der Isar, Technical University Munich 1993 - 1995 Resident, Dept. of Surgery, University of California, San Francisco, CA, USA 1989 - 1990 House Officer, Departments of Orthopedics and General Surgery, Royal Free Hospital, London, UK of Munich RESEARCH 2006 - ongoing Study of Epidural Pain Medications in a Fibroblast Cell Culture Modell, B. Braun Foundation research grant 2006 - ongoing Characterization of Cryolesions Used in Interventional Pain Therapy 2004 - 2006 Randomized Placebo-Controlled Multicenter Trial on the Efficacy of the Racz Epidural Catheter Therapy 2002 - 2006 Prospective Clinical Trial on Percutaneous Cryodenervation of Lumbar Facet Joints 1990 - 1993 Postdoctoral Research Fellowship at the Department of Surgery, University of California, San Francisco, CA, USA. Deutsche Forschungsgemeinschaft postdoctoral grant. Topic: ”Immunological Consequences of Trauma” EDUCATION 1982 - 1989 MD at the University of the Saarland, Homburg, Germany INTERNATIONAL ELECTIVES 1986, Aug. - Oct. Pediatrics, University Department of Child Health at Mater Children's Hospital, University of Queensland, Brisbane, Australia 1988, Feb. - May General Surgery and Orthopedics, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland PROFESSIONAL LICENSES 2008, Oktober Orthopedic Traumatology Board Certfication – M. Board of Bavaria 2004, February Orthopedic Board Certification - Medical Board of Bavaria 2000, May Surgical Board Certification - Medical Board of Bavaria 1994, October California Medical License 1992 German Medical License 1993, June FLEX (Score 84) 1989, January FMGEMS PROFESSIONAL SOCIETIES AOSPINE Member since 2005 BVO Berufsverband der Fachärzte für Orthopädie DGOOC Deutsche Gesellschaft für Orthopädie & Orthopädische Chirurgie ISMISS International Society for Minimal Intervention in Spinal Surgery (ass. with SICOT) FELLOWSHIPS 2009 designated AO Spine Fellow to the Centre For Spinal Studies & Surgery, University Hospital, Queen’s Medical Centre, Nottingham, UK AO TRAINING 2004 Interactive Spine Course I, Davos 2003 Advances in Operative Fracture Treatment, Davos 2002 Principles of Operative Fracture Treatment, Davos TEACHING CREDENTIALS 2005 – 2008 Musculoskeletal Tutor for the revised Medical Curriculum at the University of Munich (MECUM) 2002 – 2004 Tutor of the Musculoskeletal Course, Munich – Harvard International Alliance for Medical Education LANGUAGE SKILLS German mother tongue English excellent (speech & writing) French good (speech & writing) Portuguese good (speech) Spanish basics (speech) 20 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional John Chiu, MD Medical Director, California Center for Minimally Invasive Spinal Surgery and California Spine Institute Medical Center. Dr. John C. Chiu is a pioneer in the field of endoscopic spinal surgery. He is the President of California Spine Institute Medical Center and the founding chairman of American Academy of Minimally Invasive Spinal Surgery and Medicine (AAMISMS)._ With extensive experience in minimally invasive spine surgery (MISS), he is actively involved in MISS clinical research, development and education. He received a D.Sc. degree in surgical research on Tissue Modulation Technology and was appointed a Professor of Minimally Invasive Spinal Surgery in Neurosurgery, and subsequently as the Provost of the American International University and President, ISMISS/SICOT (International Society of Minimally Invasive Spinal Surgery) in January 2007. Dr. Chiu is an adjunct Professor in Spine Surgery, Orthopaedic Surgery Dept. Faculty of Medicine, both at Ain Shams University, Cairo, Egypt, and at Hunan Medical University of TCM, and a Clinical Professor, The First Affiliated Hospital of Hunan University of TCM, Changsha, Hunan, China. Dr. Chiu was involved in micro vascular neurosurgery and microspine surgery, before dedicating his practice to the advancement of minimally invasive spinal surgery and endoscopic spine surgery._ He has been involved in the development of robotic surgery, telesurgery, OR of the Future, tissue modulation technology including laser thermodiskoplasty, and the use of radiofrequency and bipolar technology. He is an active advocate of redefining the algorhythm for the treatment of degenerative spinal disorders and spinal segmental motion preservation with MISS. He has served as a spinal consultant to eight companies related to MISS products and digital technology. He also served on a spinal advisory committee of one of the largest health care insurance companies, and as a special advisor / consultant to a State Department of Labor and Work Force Development. Recently he conducted the first interactive live Webcast on endoscopic MISS, with nearly 1,000 global participants and viewed by 3,000, and participated in a global tele-video web conference involving 3 continents (UCLA, USA, North America; Bordeaux, France, Europe; Korea, Asia). He is the Editor in Chief for “The Internet Journal of Minimally Invasive Spinal Technology” and is a co-editor of the textbook “Practice of Minimally Invasive Spinal Technique” (2000 and 2005 editions) and on the editorial board of the journals “Surgical Technology International” and the “Journal of Minimally Invasive Spine Technique,”_Dr. Chiu has authored numerous articles in peer review journal and 45 textbook chapters and other publications on MISS and related topics._ He is a recipient of various honors and awards from professional societies, medical universities, and governmental entities, globally and in the US. Dr. Chiu has lectured and performed spine surgeries throughout the world. He has held visiting professorships at universities worldwide and has served as course director for numerous spine surgery seminars and workshops both in the United States and abroad._ He has written or presented over 800 papers (peer reviewed) at national and international scientific conferences, including North American Spine Society, American Academy of Neurological Surgeons, Congress of Neurological Surgeons, World Spine, World Congress of Neurosurgery, AAMISMS, ISMISS/SICOT and other meetings. He also has demonstrated and performed numerous live endoscopic spine surgeries at major medical centers and university hospitals around the world._ His patients have included international VIP’s, leading medical professionals (neurosurgeons, spine surgeons, and others), top government officials, generals and even a head of state. He has been invited as a lecturer,_visiting professor, chairman of various conferences and keynote speaker on endoscopic MISS in numerous university medical centers, and in numerous conferences in countries including China, Hong Kong, India, Iran, Korea, Singapore, Taiwan, England, France, Germany, Greece, Italy, Luxembourg, Spain, Switzerland, Russia, Ukraine, Israel, Jordan, the Kingdom of Saudi Arabia, Marrakesh, Morocco, United Arab Emirates, Egypt, Brazil, Colombia, Mexico, Venezuela, Uruguay and others._ Internationally, Dr. Chiu also has served as the honorary President of the Mexican Minimally Invasive Spine Surgery and Orthopedic and Trauma Society, Cochairman of the 1st Chinese International Minimally Invasive Spine Surgery Congress, MISS China, 2007 and others. Born in Fukien China, he received his medical degree from Baylor University College of Medicine and Neurosurgical training at the Mayo School of Medicine._ Further training and fellowship were undertaken at the State University of New York, University of Zurich and the University of Lund in Sweden. Dr. Chiu is certified by the American Board of Neurological Surgery. Has served as an advisor/consultant for American Medical Foundation for Peer Review and Education for major teaching hospitals and medical staff to establish proper peer review and credentialing process. His outside interests include playing the Chinese classical musical instrument, Guzheng (Zither) and practice of martial arts and its philosophy, as a grand master in kung fu, ninjitsu, and jujitsu. He participated in the International Martial Arts Tournament, St. Petersburg, Russia and is the recipient of the Martial Arts Lifetime Achievement Award, and the Martial Arts Pioneer Award as well as other awards, and an invited speaker for the Humanitarian Award in Martial Arts, U.S.A. International Black Belt Hall of Fame. 21 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Jean Destandau Address : 145 Rue de la Pelouse de Douet , 33000 , Bordeaux , France. Tel. : (33) 0556515160 Fax : (33) 0556986710 e-mail : docteur.destandau@orange.fr * Date of Birth : August 23, 1953 * Family Status : married with two children EDUCATION * 1970 : Passed Baccalaureat Examination * 1970-72 : Preparatory classes for competitive examination for Special Engineering University * 1972-1979 : Medical School of the University of Bordeaux, Bordeaux 2, Rue Leo Saignat, 33000, Bordeaux. Passed final examination to become Resident. * 1979-1983 : Resident with orientation towards neurosurgery and anatomy at Bordeaux University Hospital, Bordeaux 2, Rue Leo Saignat, 33000, Bordeaux. * 1981 : Certification in General Anatomy (Medical School of University of Bordeaux - Prof. Videau).` * 1982 : Certification in Neuro-Anatomy (Medical School of University of Montpellier - Prof. J. Bossy). * 1982 : Masters in Human Biology and Anatomy, Bordeaux 2. * 1985 : Diploma in Research in Human Biology and Anatomy (Medical School of University of Montpellier - Prof. Rabischong). *1985 : Certification in Neurosurgery PROFESSIONAL ACTIVITY - 1980-1983 : University Instructor in Anatomy, Medical School of University of Bordeaux. - 1983-1987 : Assistant Professor in Anatomy Neurosurgeon at Bordeaux University Hospital - 1987-Present : Neurosurgeon in private practice en Bordeaux. My special interest is the surgery of brain tumors and disc herniations and the reduction of operative trauma in their treatment. In this objective, I have developed an endoscopic tehchnique, and its necessary material, for the surgery of lumbar disc prolapses. Since 1993, I have operated on over 5000 patients with a rate of cure superior to 90% and a postoperatory period of convalescence greatly inferior to the normal. By 1998, the success of this treatment aroused a certain interest in the medical community and the Storz Company undertook the production and the comercialization of the material as well as the publication and spreading of the technique. As a result, I have been invited to demonstrate this procedure in many countries including the United States, China, Egypt and Korea. PROFESSIONAL ASSOCIATIONS - Member of “la Société Française de Neurochirurgie”. - Member of “la Société de Neurochirurgie de Langue Francaise” - Member of “la Société Francophone de Neurochirurgie du Rachis” - Member of the American Academy of Minimally Invasive Spinal Medecine and Surgery Extra -curricular activities - Skiing - Golf - Theatre 22 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Serdar Erdine, MD, FIPP Personal Born in Turkey; 19.10.1954 Personal Address: Department of Algology, Medical Faculty of Istanbul, 34390, Capa Klinikleri, Istanbul, Turkey Email; algomed@superonline.com Professional - Graduated from Cerrahpasa Medical Faculty of Istanbul University in 1978 - Completed residency in the Department of Anesthesiology and Reanimation of Medical Faculty of Istanbul, Istanbul University in 1982 - Associate Professor in Anesthesiology in 1986 - Professor of Anesthesiology and Algology in 1991 - Professor and Founder and Chairman of Department of Algology since 1990 Scientific - Member of IASP since 1981 - Founder and President of Turkish Society of Algology - Founder and Former President of Turkish Society of Regional Anesthesia - Former Turkish Representative in European Society of Regional Anesthesia - Former Member of the executive Board of Neuromodulation Society - Treasurer of EFIC ,1996-1999 - Honorary Secretary of EFIC, 1999-2002 - President Elect of EFIC, 2002-2005 - President of EFIC, 2005-2008 - Founding member of World Institute of Pain-WIP,1994 - General Secretary of WIP,1994-1999 - Vice President of WIP,1999-2002 - President Elect of WIP, 2005-2008 - President of WIP ,2008-2011 - Chair of Board of Examination – WIP,2005-2008 - Member of the WHO Advisory Expert Panel on Drug Dependence.2007-2011 - Member of the editorial Board of European Journal of Pain - Member of the editorial board of Pain Practice - Member of the editorial board of Pain Physician - Editor of Turkish Journal of Pain-cited in index medicus - Awarded as the Young leader in medicine/Turkish Jaysees,1991 - Invited speaker in 120 lectures on international level - Invited speaker in 200 lectures on national level - Author of 25 books in Turkish - Editor-co editor of 7 books in English - Author of 200 articles in international or national level mainly on interventional pain management. - Organizer of 15 National Congresses on Pain Medicine in Turkey - Organizer of World Congress of World Society of Pain Clinicians ,Đstanbul,1996 - Organizer of the Annual Congress of European Society of Regional Anesthesia , Đstanbul,1999 - Organizer of 3rd World Congress of World Institute of Pain, Đstanbul,2001 - Organizer of the Pain in Europe V, triennial Congress of EFIC, Đstanbul,2006 23 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Daniel Gastambide, MD Born: September 7th, 1942 (France) Nationality: French Medical University of Paris: 1960 -1967 Internship Paris: 1969-1973 Residency Paris (Chef de Clinique à la Faculté de Médecine de Paris, Assistant des Hôpitaux de Paris) : 1973-1975 Medical Doctor : 1974 Orthopedic Surgeon : 1975 Orthopaedic Department Chief : Nemours 1975-1978 Blois : 1978-1991 Private Practice in Paris since 1992: spine surgery 95% Founder Member of the International Group for Study of Intervertebral Approaches (GIEDA INTER RACHIS: Groupe International d’Etude Des Abords INTERvertébraux du RACHIS) and took part in the organization of its 21 annual congresses in Europe (Blois 1988, Brussels 1989, Bordeaux 1990, Paris 1991 to 2007, Brussels 2008), and of 4 workshops about endoscopic techniques. President of this group in 2002 Delegate to the internet site: www.gieda.com, treasurer of the GIEDA since 2007 Multiple presentations about endoscopic techniques for treatment of lumbar and cervical hernias, and with the use of laser Ho-YAG. Member of the ISMISS since 1990, delegate for France since 2008 Member of SOFCOT since 1977, SICOT since 1989, IITS since 1993, NASS since 1999, IMLAS since 2004 24 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Nils Haberland, MD Date of birth: Place of birth: Nationality: Marital Status: School education: 16.10.1957 Luckau German Married 1964 – 1972 Elementary School / Upper School 1972 – 1976 Grammar School Practical training: 01.09.1976 – 27.10.1976 male nurse at a hospital in Neuenhagen near by Berlin Military service: 1979 – 1979 in the health service University: 1979 – 1985 Study of human medicine at the Humboldt-University in Berlin, receiving a university-degree rated “good” Diploma: 21.05.1985 Receiving a diploma rated “good” at the Humboldt-University in Berlin Qualification: 01.02.1986 in Berlin Promotion: 02.02.1987 Promotion rated “cum laude” at the Humboldt-University in Berlin Vocational experience: 01.02.1986 beginning of occupation as an assistant doctor in the field of Neurosurgery at the medical academy in Erfurt. 01.01.1990 recognition of specialist in Neurosurgery 01.01.1994 – 14.5.1994 assistant medical director at the neurosurgical hospital in Erfurt 15.05.1994 – 28.02.2000 assistant medical director at the neurosurgical hospital of the Friedrich-Schiller-University in Jena 01.03.2000 beginning of occupation as locum of the senior consultant at the Trauma & Accident Center in Frankfurt 01.09.2004 Chief of Neurosurgical Department, Trauma & Accident Center (BGU Hospital)Frankfurt am Main 01.10.2007 Chairman of the International Spine Center Cairo and Consultant Neurosurgeon of the XCell-Center Düsseldorf, Germany Member of the tumor-center in Erfurt since 1992, member of the German society of neurosurgery since 1996, member of German society of spine since 1997 Prof.Dr.Dr.h.c. Nils Haberland Chairman International Spine Center Cairo – ISCC EgyptAir Hospital www.egyptairhospital.com NDHaberland@aol.com Tel.: 0020108745692 Fax: 0020227576895 Consultant Neurosurgeon XCell-Center Düsseldorf GERMANY www.xcell-center.com 25 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Stefan Hellinger, MD Geb. 16.10.1962 German Present position: Klinik Spec.: Prof. Address: Orthopaedic surgeon in privat practice and as consultant in Isar Spine and jointsurgery, Rheumatology, Pain therapy Windenmacherstr.2 80333 München Prof. Qualifications: 1993 MD for medicine Universität Erlangen Postgrad. Qualifications: 01/1994 Intern at surgical departement 06/1994 Kreiskrankenhaus Auerbach. 07/.1994 Resident surgical department des StädtischenKrankenhaus Rothenburg o.d.T. 07/1995 Resident in orthopaedic practice 09/1995 in Munich 10/1995Resident in der Orthopädischen Abteilung des 03/2000 Kreiskrankenhaus Rheinfelden 10/1999 certification as orthopaedic surgeon 04/2000Staff surgeon Orthopädischen Abteilung 12/2000 des Dreifaltigkeitshospital Lippstadt 02/2001 Degree for special orthopaedic surgery 01/2001different Fellowships, 06/2001 spine fellow Zurich, Schulthess Clinic Prof. Grob since07/2001 Orthopaedic and spine surgeon in own practice and as consultant for the Isar clinic munich sprec. on spine surgery, development of different minimal invasive procedures, spinal endoscopy Director of Institute for clinical research, consulting and expertise 26 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Sang Ho Lee, MD, PhD Chairman, Wooridul Spine Hospital, Seoul, Korea Education 1968-1975 : Pusan National University College of Medicine, MD 1975-1980 : Intern & Resident, Dept of Neurosurgery, National medical center, Seoul Korea 1980-1981 : Korea, Army Major & Head of Neurosurgery department in 103 field hospital, 1976-1985 : Yonsei University College of Medicine, Master and PhD 1985-1986 : Clinical fellow, UFR Biomedicale Laboratoire D'anatomie, Academie de Paris Universite Rene Descartes Paris France Training Experience (Spine Training Courses) 1988 : School of Medicine, University of California, San Francisco, U.S.A. 1989 : School of Medicine, University of Washington, Seattle, U.S.A. 1990 : Uniformed Service, National Institute of Health(NIH) 1992 : Arthroscopic Microdiscectomy, The University of Pennsylvania School of Medicine, Berwyn, Pennsylvania, U.S.A. 1993 : Laser Medical Institute, Houston, Texas, U.S.A. 1995 : Medical School, University of Zurich, Zurich, Switzerland 1995 : Pitié-Salpêtrière, Universite Pierre et Marie Curie : Paris 6 Current Position Clinical Professor, Yonsei University College of Medicine, Dept. of Anatomy Clinical Professor, Dong-A University College of Medicine, Dept. of Neurosurgery Clinical Professor, Catholic University College of Medicine, Dept. of Neurosurgery President, World Congress of Minimally Invasive Spinal Surgery & Techniques (WCMMIST) President-Elect, Intl. Society for Minimal Intervention in Spinal Surgery (ISMISS) President, International Musculoskeletal Laser-Society (IMLAS) President, Asian Academy of Minimally Invasive Spinal Surgery (AAMISS) Honorary President, Korean Musculoskeletal Laser and Radiofrequency Society (KOMULARS) Executive Chairman, Korean Society for Laser Medicine and Surgery (KSLMS) President, International Intradiscal Therapy Society (IITS) Past President, Korean Neurosurgical Society Seoul, Gyunggi, Inchon Branch International member, American Association of Neurological Surgeons (AANS) Active member, Congress of Neurological Surgeons (CNS) Active member, North American Spine Society (NASS) Chairman, Wooridul Spine Hospital, Korea President, Wooridul Spine Health, Seoul Korea 27 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Hansjoerg Leu, MD, PD Date of birth Studies 1979 1993 January 5, 1954, Zurich/Switzerland Swiss Federal Examination, Medical Degree Habilitation/Venia Legendi as Private Docent for Orthop. Surgery, Med. Faculty, Zurich University Professional Activities 1980/1982 Department for General Surgery and Traumatology, Aargovian Cantonal Hospital, Aarau/Switzerland. Chairman: Prof.Dr.F.Deucher 1982/1985 Sct. for Orthopaedics, Thurgovian Cant. Hospital, Frauenfeld/Switzerland. Chief: Dr.U.Romer 1985/1995 Department for Orthopaedic Surgery Balgrist, Medical School, University of Zurich/Switzerland Chairman : Prof. Dr. A.Schreiber 1988 Speciality Degree in Orthopaedic Surgery FMH 1989 - 1995 Clinical Lecturer and Senior Clinician, Balgrist Univ.Clinic since 1993 Private Docent in Orthopaedics with instructional duties 1994-2000 PD-Representative for Orthopaedics, Faculty Group of Surgical Disciplines, University of Zurich/Switzerland 1992 - 31.3.1995 Senior Surgeon for Spinal Surgery, Balgrist Univ. Clinic Zurich 4.1995 – 10.2004 Consultant Orthop. Surgeon, Neumunster Hospital Zurich since 10/2004 Consultant Orthopaedic Spine Surgeon, Bethania Clinicum Bethania Spine Base, Zurich, Switzerland Grants & merits 1991 1992 2002 ASG-Fellowship of the Austro/Swiss/German Orthopaedic Societies (ASG-Travelling Studies GB/USA 1992) Georg-Schmorl Award by the German Society for Spine Research, Frankfurt/Germany Doctor honoris causa, Sytenko Institute, Medical Faculty, University of Charkov, Ukraine Memberships numerous memberships in national and international spine Societies - International Society for Minimal Intervention in Spinal Surgery (ISMISS, since 1990) President in charge for 2008/2011 Family married since 1985 to Jutta-Maria, born Überle, (Christoph 1986, Martin 1988, Isabelle 1990) 28 3 children 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Pier Paolo Menchetti, MD, FRCS Pier Paolo Maria Menchetti, M.D., FRCS (US) Born in Neaples (Italy) on 9th April 1968 Residency: Florence (Italy) - 50132, J. Nardi 15 Orthopedic Surgeon Professor Florence University - Italy Professor Spine Surgery Unit, La Sapienza University, Rome, Italy Professor Spine Surgery Unit,Palermo University, Italy Fellow Royal College of Physicians and Surgeons of United States of America Fellow American Board Minimally Invasive Spine Medicine and Surgery Member American Academy Minimally Invasive Spine Medicine and Surgery (AAMISMS) ISLASS (International Society Laser Assisted Spine Surgery) President Office: Florence - Cherubini Clinic Rome - Rome American Hospital Milan - Milan City Clinic 29 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Burak Özgür, MD. Director of Minimally Invasive Spine Surgery Assistant Professor of Neurosurgery Cedars-Sinai Medical Center Department of Neuro surgery 8631 W. Third Street, Suite 800E Los Angeles, CA. 90048 Office #: (310) 423-7900 FAX #: (310) 423-0810 Burak.Ozgur@cshs.org _____________________________________________________________________________ EMPLOYMENT Cedars-Sinai Medical Center Department of Neurosurgery Attending (Faculty) Neurosurgeon October 2007- present University of California, Irvine Medical Center Department of Neurological Surgery Assistant Professor of Clinical Neurosurgery Director of Spinal Neurosurgery Co-Director of the Multidisciplinary Spine Program July 2006– October 2007 EDUCATION University of California, San Diego Me dical Center NeurosurgeryChief Resident June 2005– June 2006 University of California, San Diego Medical Center Neurosurgery Spine Fellowship July 2004– December 2004: Neurosurgery Spine (Dr. LF Marshall, Dr. WR Taylor) January 2005– June 2005: Orth opedic Spine (Dr. SR Garfin, Dr. C. Kim) University of California, San Diego Medical Center General Surgery Internship Neurosurgery & Residency June1999– June 2005 University of Vermont College of Medicine, Class of 1999 MD degree awarded May 1999 University of California, Irvine Biological Sciences major Bachelor of Science degree 1994 30 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Vladimir Radchenko Date of birth 1956, Ukraine Head od Department of Spine surgery, Vice-Director of Sytenko Institute of Spine and Joint Pathology,Kharkov,Ukraine Professor of Orthopaedicsdan Traumathology, Professor of Academia of Postgraduate Education,Kharkov Merited Statesman of Science and Technique Presidents Award of Science and Technique Parlaments Award Work Experience Since 1979– General Surgeon in Dneepropetrovsk clinic 1980-1984Department of Orthopaedics and Traumatology, Emergency Hospital Dneeprodzerginsk Since 1984- Sytenko Institute of Spine and Joint Pathology – Department of Spine Surgery Spine Society Ukrainian Society of Orthopaedics and Traumatology (vice -president) International Society of Minimal Intervention in Spinal Surgery ISMISS (vice-president, European Branch secretary); Society of Orthopedics and Traumatology SICOT (since 1994) AO Spine International 31 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Prof.Dr. Kayıhan ŞAHİNOĞLU 32 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Tolgay Satana, MD. He was born in Ankara/Turkey in October 14, 1968. He completed primary, intermediate and high school education in Ankara. He received MD degree from the University of Ankara Faculty of Medicine in 1991. Dr. Satana had worked in Tuzluca/Igdir as a Medical Practitioner from 1991 to 1992 . He completed the residency in Orthopaedic Surgery and Traumatology at University of Gazi, Faculty of Medicine Ankara/Turkey in 1997. He was appointed to Ankara Etimesgut Hospital as an Orthopedic Surgeon in 1997. Dr Satana completed a military service obligation in Maresal Cakmak Military Hospital, Erzurum in 1998. After the military service he went to USA and_ attended postgraduate education as an visitor professor in Pediatric spine surgery in University of Michigan in 2000. He came back to Turkey at the end of 2000 and be appointed to Gaziantep Hospital. He worked as an Orthopaedic surgeon about a year Gaziantep Hospital and resigned in 2002. He set up the Orthopaedic Clinic and worked in Gaziantep American Hospital in 2002. In 2003 He appointed to Ankara Research Hospital and Middle East University Medical Center and worked about five year as an Orthopaedic and trauma surgeon. He is minimally invasive spine surgery performer since 2002 and member of IMLAS,_ AAMISS and ISLAS. He observed and be trained by most of MISS surgeon around world short time period. He is national representative of Ismiss and AAMISS since 2004 and WALA. Now on He is working _Acibadem Beylikduzu Medical Center Istanbul_ since 2008 as a full-time staff. He is aiming to create miss conducted surgeon society in Turkey He is married and has a daugther and a son. 33 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Anthony Yeung, MD. Orthopedic and Minimally Invasive Endoscopic Spine Surgeon Desert Institute for Spine Care Phoenix, Arizona Voluntary Associate Clinical Professor University of California San Diego School of Medicine Department of Orthopedi cs Dr Yeung is a board certified orthopedic spine surgeon subspecializ ing in endoscopic surgery of the lumbar spine . He developed theFDA , allowing for approvedYeung Endoscopic Spine System (YESS™) surgical decompression of the disc, spinal canal, and lumbar foramen . Through this development, offering “no hype, just results, painful ” degenerative condtions of the Lumbar spine are now able to be treated through Dr Yeung’s patents, technologic developments, and innovations. Dr Yeung is recognized internationally for hiscontributions to minimally , receivingbest of meetingawards for invasive/endoscopic spine surgery his Podium presentations andosters. P He is also a recipient of honorary titles fromNational andInternationalOrthopedic andSpine Societiesfor his innovative work. He is the co-editor ofthe two volumes ofPractice of Minimally Invasive Spinal Technique,2000 and 2003, and the author ofover 60 peer reviewedscientificarticles, publications, and book chapters on endoscopic spine surgery and related topics. He is a reviewer for Spine, Spine Arthroplasty Journal, the Indian Journal of Orthopedics. Dr Yeung has trainedacademicspine faculty andspine fellows from the United States,China, and various countries in North and South America, Asia, Australia,Europe, and Africa. Dr Yeung is currently the executive director of the International served as President and Intradiscal Therapy Society, having also Director of Medical Education. Dr Yeung is also a Past Presidentof the MaricopaCounty Medical Society , the Arizona Orthopedic Society, The Western Orthopedic Society and Chinese American Medical Society, Arizona Chapter, as well sa the board of the Arizona Medical Association. He has served on the Professional Liability Committee of the American Academy of Orthopedic Surgery , is past chairmanof the surgical care committee . Locally, Dr Yeung has been honored by the Business Journal as a “Health Care Hero” and awarded the Arizona Medical Association’ s Humanitarian a nd National leadership Award. 34 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Kemal Yucesoy, MD. Dr.Kemal Yücesoy was born in Ankara, 1963, and received his MD degree from Ege University Medical Faculty, İzmir. He trained in Neurosurgery at Dokuz Eylül University, İzmir and after completion of his residency (1996), he continued his carrier at the same clinic as a specialist, an assistant professor (1997), and associate professor (2003). Dr.Yücesoy especially interested in spine surgery, and he worked with Prof.Sonntag (BNI, Pheonix, 1999, 2005), and Prof.Crockard (NHNN, London, 2000). He has authored over 100 scientific papers and book chapters, and presented over 200 papers and lectures at meetings. He is also educator in Spine Section of Medtronic and Arthrocare Company. 35 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Mehmet Zileli, MD. Dr.Mehmet Zileli is the Professor of Neurosurgery and Head of the Spine Section of Neurosurgery Department in Ege University, Izmir, Turkey. He is a faculty member since 1989. Between 1987-1988 he has worked as a Research Fellow in the Dept of Neurosurgery, University of Erlangen-Nürnberg, Germany (Prof.J.Schramm). He is the founder and first president of the Spine Section of Turkish Neurosurgical Association, (1995-1999), Ex-Committee Member of the World Spine Society (2003Present), and member of many national (11) and international (13) societies. He is the program chairman of the World Spine IV Meeting which was held in Istanbul between July 29 and August 1, 2007. He is the First Vise Chairman of the World Spine Society. He has served as the President of the Turkish Neurosurgical Society between 2006-2008. He has important contributions to education and training in spine surgery in Turkey. Since 1997 he organizes hands-on practical courses on spine surgery, and has organized a cadaver course in 2003 and 2005 in colloboration with Cleveland Clinic, USA and World Spine Society. He is the chief of a spine fellowship program that served many national and international fellows. He has also been the host of the “Travelling Fellowship of Spine Society of Europe” in 2002, 2003 and 2004. He is the author or co-author of 39 international, and 70 national scientific papers, editor of 4 books, author of 13 international book chapters and 74 national book chapters. He has presented and given talks in international (154) and national (249) scientific meetings. He is also reviewer or editorial board member of international (4) and national (9) scientific journals. He speaks English and German. He is merried, and father of two children Address: Department of Neurosurgery Ege University Faculty of Medicine Bornova, Izmir 35100 TURKEY Phone: +90-232-3903380 / 006 Fax: +90-232-4637751 E-Mail: mehmet.zileli@ege.edu.tr 36 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Lectures 37 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-1 MISS Regulations in Turkey Tolgay SATANA It would not be wrong to say that the emergence of minimal invasive surgery and its introduction to our country date back to our master, Hippocrates, who lived in these lands. However, subsequent advancements in this geographic area resulted in the evolution, development, and appropriation of Hippocrates and his principles throughout western civilization. We generally tend to emulate the rules and regulations from abroad even when it is not necessary just like we import knowledge when we should develop it ourselves. This time, we tried to do the opposite by using Asclepius’s healing baton against Poseidon’s wind. What was the situation in the World? The International Musculoskeletal Laser Society (IMLAS) had published successful studies on spinal endoscopy, an innovative area of surgery. Şahap Atik, the prominent figure in laser joint surgery in our country, helped us kick off the MISS journey, starting with use of laser in spinal endoscopy. The introduction of MISS got under way immediately as part of the Osteo meetings, the studies on Bone and Joint Decay and Osteoporosis of which, was arranged by the Turkish Joint Diseases Foundation, or TEVAK. In addition to the great success achieved with the Osteo Congress, MISS was now being discussed as a subject matter. It was in 2005 when the Journal of Joint Diseases and Related, in parallel with relocation of the IMLAS meeting to Turkey, was published as a special report, hence breaking new ground throughout the world and in Turkey. We succeeded in introducing the Minimal Invasive concept. Now, it was time characteristics. Characterization began to occur in the minds of fellows who resort to classical surgery techniques as we tried to explain that minimal invasive surgery did not mean downsizing incisions but rather working in a less traumatic manner. At this stage it was necessary to move from the introduction stage to the characterization stage. We were supposed to engrave the defined processes into the minds by ensuring they corresponded to the originals. We started with those dealing with spinal surgery. Azmi Hamzaoğlu, the foremost figure in modern spinal surgery in Turkey, helped us go through introductory stage very rapidly due to his position as the Chair of the Association. We embarked on our studies, under Mr. Hamzaoğlu’s leadership. Tolgay Şatana simultaneously performed the first Percutaneous Endoscopic Lumbar Discectomy. Tolgay Şatana introduced the surgery to the public with the first televised broadcast. We took part in this time, with IMLAS, the studies of the ISMISS Association, which specializes on the Spine. We presented our limited experience at the ISMISS meetings and at other local meetings. We were able to practise on only private patients, not even in the universities and public hospitals despite our readiness to bring the device from outside. An application was submitted to the new chair of the Spinal Association, Ufuk Aydınlı. In the meantime, we made another application to TTB. Now the characterization stage was completed too. For the new initiatives were referred to the wise men committee of the bureaucracy. Our individual application in 2005 was not successful because we were not a legal entity and was thus forgotten. So, we had to become an association, but it was impossible to achieve that without first forming a society. Patients approached the operation decisions with doubt. The surgeons practising classical surgery mercilessly used the phrase “charlatan.” A discussion carried out in the e-mail groups under the leadership of Ufuk Aydınlı gave us the chance to categorize MISS operations. The operations then were explained to a distinguished group of attendants at the Bursa AO meeting. It bore a result: Drafts, brought up by Neurosurgery and Spinal Association, were being discussed now. But the split in the Spinal Association’s new governing body interrupted this process. ISMISS had better come to Turkey and contribute to the formation of a new society. Contacts were made with Spinal Association, Neurosurgery Association, Physical Treatment and Pain Association. The first ISMISS meeting was held subsequent to harvesting the necessary support. The world’s leading authorities defined the initiatives at this gathering. Scientific conclusions showed surgery served the public interest. But the training part of the meeting was obstructed and participant satisfaction waned because the cadaver course was not conducted. While the persons responsible for this situation were removed a new association was set up, and formation of a society is still in the works. But the association was comprised of those who did not practice MISS techniques or those who did so only to a limited extent. Moreover, it maintained the division regarding the management of the Spinal Association. Thus, the ones blocking the first ISMISS meeting took the lead. Rather than working for the needs of the country, the newly established association preferred to exchange correspondence with outside institutions that did not recognize ISMISS’s national representation. The ISMISS meeting was immediately relocated from Ankara to Istanbul. It won Istanbul University’s backing. Favourable conditions were provided thanks to the cadaver courses. When the only existing textbook on MISS needed to be translated into Turkish, the members of this group failed to do so and thus the association failed to serve the public interest. In addition, the year 2008 passed without any regulatory demands and the global crisis had a deep impact on the second ISMISS meeting. It was apparent that ISMISS had to launch a new cooperation. An offer of combined efforts made at the first ISMISS get-together was reiterated to the governing body of Turkish Society of Orthopaedics and Traumatology (TOTBID). Nevertheless, as TOTBID stated it did not recognize ISMISS and so another association was established. The first thing International Society for Minimal Intervention in Spinal Surgery (ISMISS – Turkish OMID), did was to apply to the Turkish Medical Association (TTB) with an official statement, which said that the use of MISS was not defined and that this did not serve the public interest. After classification, OMID informed the other concerned associations and the Ministry of Health. OMID evaluates the past amendments to the laws related to the individual applications. The Ministry of Health formed the Social Security Institution (SGK) system by implementing the general health system. This system analyzes classifications that are not compatible with the TTB’s private practice application manual by referring to the medical practice regulation (SUT). All the MISS applications can be shown as IDET and Nucleotomy in the SUT and TTB manuals. Endoscopy applications can be priced by adding 600 units to classical surgery for TTB. This is contrary to MISS’s cost reduction goal. It makes it difficult for the insurance companies to support the initiative. In fact, MISS is the most low-cost system within the insurance, hospital and doctor triangle. OMID is working to improve this situation. 38 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-3 Digital Technology Convergence and Control System: Minimally Invasive Spine Surgeon’s (MISS) Perspective and Technological Consideration John C. Chiu, M.D., FRCS, D.Sc, Director, Neurospine Surgery Problems and challenges facing minimally invasive spinal surgery: Degenerated spinal disc and spinal stenosis are common problems requiring decompressive spinal surgery. Open spinal discectomy is associated with significant morbidity, long-term convalescence, prolonged general anesthesia and wide dissection of tissues that can cause bleeding, scarring and eventual destabilization of spinal segments. The evolving less traumatic minimally invasive endoscopic lumbar decompression procedure is free from these potential complications. Therefore the pursuit of minimally invasive spine surgery (MISS) began. Current and future trends of spinal surgery are toward minimally or less invasive and biologic material. This endoscopic spine surgical procedure, its surgical indications (for treatment of herniated lumbar discs, post fusion junctional disc herniation, neural compression, osteophytes, spinal stenosis, vertebral compression fractures, spinal tumor, synovial cysts and etc.), its operative techniques (both transforaminal endoscopic approach and interlamina endoscopic assisted approach) including tissue modulation technology (i.e. laser and radiofrequency surgical application), requires preoperative planning, intraoperative monitoring, control and image data collection and utilization. Additional problems and challenges facing MISS include large number of surgical personal for each case, slow turn over time, preoperative review of numerous medical records, imaging and X-rays studies, no biometric confirmation of the surgical patient, many multiple scattered intraoperative data monitors/displays, lack of adequate bio sensors and warning systems, lack of organized educational and training displays for MISS etc. Answer: With increased utilization of complex high tech and digital technologies, and instruments in the DOR, it requires seamless connectivity and control to perform the surgical procedures, in a precise and orchestrated manner. The SurgMatix® prototype, a new integrated DOR, image-data based convergence and control system has been developed and utilized to facilitate MISS. This system is designed to promote seamless integration of all aspects related to the surgical procedure and to reduce surgical time and personal requirement significantly. This ease to use SurgMatix® system creates an organized control instead of organized chaos is needed. In addition, it can provide training of other spinal surgeons to perform the minimally invasive spinal surgery. Seamless integrated digital OR is needed to provide effective, safer and higher quality in spinal surgical patient treatment. 39 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-4 INTERVERTEBRAL FORAMEN FROM THE ANATOMIC APPROACH PROF.DR. AHMET USTA, M.D. During this small lecture, we will try to understand how the incisura becomes a foramen, what the relation between the foramen and a spinal nerve. Additionally, the structures around a foramen. 40 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 1 Full-endoscopic operations of the lumbar, thoracic and cervical spine - State of the art and outlook in disc herniations and stenosis Sebastian Ruetten The therapy of degenerative diseases of the lumbar spine involves both medical and socioeconomic problems. A surgical procedure may be necessary if conservative measures have been exhausted and states of exacerbated pain or neurological deficits persist. Despite good therapeutic results with conventional operations, there may be consecutive damage due to traumatization. Thus, it is important to continuously improve these procedures. Taking existing quality standards into account, the objectives must be to minimize operation-induced traumatization and negative long-term sequelae. Current research results and technical innovations must be critically applied in order to guarantee the best-possible treatment strategies. Minimal-invasive techniques can reduce tissue damage and its consequences. Endoscopic operations under continuous fluid flow bring advantages which raise these procedures in many areas to the standard level. New optics have been developed with a wide working channel for spinal surgery which enable sufficient bone resection using burrs under visual control. These days, there are various full-endoscopic techniques available which can supplement each other: for the lumbar spine there is the posterolateral to lateral transforaminal as well as the interlaminar access; for the thoracic spine, the postererolateral transforaminal and the interlaminar access; for the cervical spine, the anterior transdiscal and the posterior access. There are specific advantages and disadvantages for all of these techniques. The transforaminal access can be preferred, since it can be performed atraumatically. Nonetheless, mobility problems may arise. Here, the interlaminar procedure can expand the spectrum and enable operation of all disc herniations and lateral spinal stenosis, and in the thoracic spine special lateral disc herniations. In the cervical spine, the dorsal access enables therapy of all lateral disc herniations and foraminal stenosis. Unlike the anterior transdiscal procedure, which is the only treatment available for medial pathologies, the disc is not damaged and mobility is expanded. Considering the indication criteria, now the combination of full-endoscopic approaches with the new developed endoscopes and instruments provides sufficient decompression under visual control of lumbar, cervical and thoracic disc herniations and spinal stenosis. The results are equal to that of conventional procedures, but with all the advantages of a truly minimally-invasive procedure. In addition due to the possibility of resect bone in a sufficient way the indication is broadened with respect to techniques for spinal canal decompression. However, total avoidance of known problems in spinal surgery can hardly be imagined. In addition, open procedures will remain as indispensable in the future as they currently are. At the moment the full-endoscopic procedures are estimated as a sufficient supplementation and alternative inside the complete spectrum of spine surgery. 41 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 2 Minimalinvasive Procedures on the cervical spine From the Nonendoscopic Percutanoues Laserdiscdecompression to the selective Percutaneous Endoscopic Cervical Decompression and Discectomy Dr. Med. Stefan Hellinger There is a high incidence of cervical discogenic pain symptoms in the population. It is estimated that one person in five in Germany who visits an orthopedist presents with the symptoms of a cervical disc syndrome. The treatment of cervical discogenic diseases makes high demands in terms of both diagnostics and therapy. Diagnostics has been made easier by improved imaging and the enhancement of neurological measuring methods. Consequently, there is now interdisciplinary consensus that the principal pathologic causes can be reliably identified. With the aid of appropriate conservative therapy, approximately 80 percent of all cervical syndromes can be cured. Only once all the conservative and semi-invasive procedures have been exhausted should surgery be considered. The first step in the interventional treatement of cervical syndroms is in our opinion the nonendoscopic decompression and nucleotomy by Laser introduced 1990 by J. Hellinger. The technique is simple and will be demonstrated. As a bridge between open and percutaneous therapy, endoscopy of the cervical spine started to be used at the beginning of the 1990s, following good experiences on the lumbar spine. The principle of microsurgery is combined with the minimally invasive principles by bringing the optical level to the forefront of pathology. Access morbidity has been significantly reduced by the percutaneous access technique. Furthermore, a large proportion of the intervertebral disc, in particular most of the fibrous ring, is preserved. The pathology is only removed selectively in the area of the nucleus pulposus and on the dorsal fibrous ring. This preserves the remaining biomechanical function of the degenerated intervertebral disc. By means of tried and tested minimally invasive methods under vision, such as the use of a laser or radiofrequency to ablate and shrink tissue, the risk of complications has been further reduced, at the same time as enhancing efficiency. Meanwhile segmental fusions if necessary are by the endoscopic technique performed. The indications for both procedures are neck pain radiating into the arm (radicular pain), symptoms of segmental dysesthesia, and motor deficits matching the pathologic segment, conservative therapyresistant vertebrogenic headache with reliable imaging, disc herniation confirmed by MRI or CT, with associated clinical picture, damage in adjoining segments after preceding fusion, with corresponding clinical picture, and multisegment disc herniations. This method cannot be used in cases of serious cervical spinal stenosis, migrated free sequestra, pronounced spondylosis with large osteophytes, and calcifications of the posterior spinal ligament. The results of this methods display a success rate of 80% - 95% for good to very good outcomes. This includes various work techniques of endoscopic cervical decompression, such as laser. Our experience also confirms this success rate. The complication rate of percutaneous cervical decompression is extremely small, as is the case with nonendoscopic percutaneous procedures. Inadequate decompression when using the nonendoscopic or the endoscopic technique will be reflected in the incidence of secondary operations. Summary: The nonendoscopic percutanoues Leserdiscdecompression and nucleotomy as well as the selective percutaneous endoscopic decompression and nucleotomy are safe and efficient alternatives to conventional anterior cervical discectomy, with or without fusion, for the treatment of discogenic syndromes of the cervical spine. It entails less surgical trauma, and considerably reduces surgeryrelated stress for the patient, while also shortening the period of hospitalization and the operating time. With the new devices for this procedure we got further possibillities in the current treatement of cervical disc desease and for develepement of new opportunities. 42 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 3 COMPLICATION RISKS OF THE FORAMINAL APPROACH TO THE LUMBAR SPINE: IT’S CORELLATION WITH FORAMINAL ANATOMY, VARIATIONS, AND ANOMALOUS STRUCTURES IN THE “HIDDEN” ZONE” ANTHONY T. YEUNG, M.D. ARIZONA INSTITUTE FOR MINIMALLY INVASIVE SPINE CARE, PHOENIX, ARIZONA Purpose: The trans-foraminal approach to the lumbar spine is an excellent minimally invasive portal to the spine that has gained interest in recent years as an approach for interbody fusion and far lateral disc herniations. This approach, however, traverses the “hidden zone” of MacNab, and is still unfamiliar territory for many traditional spine surgeons. With the recent development of endoscopic surgery, pitfalls of the foraminal approach are important to surgeons in order to avoid adverse clinical outcomes. This is best learned from the experience of endoscopic spinal surgeons and a through knowledge of the normal, variant, and patho-anatomy of the foramen. Method: Complications and adverse side effects encountered in over 3,000 patients and 8,000 lumbar discs undergoing endoscopic decompression for painful degenerative conditions of the lumbar spine are retrospectively reviewed. Painful patho-anatomy was confirmed by spinal probing, and recorded in vivo on analog video and DVD. Discogenic pain reproduction was correlated intra-operatively by evocative chromodiscography™. Pain reproduction was correlated with abnormal discogram patterns that was compared with Mri findings. Indigocarmine dye was mixed 1:10 with Isovue 300 to stain the degenerated nucleus and adjacent structures in the path of the injectate. Extraforaminal, foraminal, and intradiscal normal and patho-anatomy, included routine visualization of the annulus, the traversing and exiting nerves at each operative level , and the epidural space. Findings: The most common endoscopic finding was degenerative nucleus and inflammatory tissue in the disc and annulus, a common finding in painful disc herniations. Inflammation, granulation tissue, and an inflammatory membrane denote chronicity. An inflammatory membrane in the annulus was associated with severe back pain produced by low pressure low volume discography. The pain is not always concordant, but usually severe, just from distending the disc annulus. Foraminal osteophytes could be seen tethering and irritating the exiting nerve, producing perineural scar tissue that is difficult to see with open approaches. “Anomalous” nerves in the “hidden zone” of MacNab identified pain generators in-vivo that have not been emphasized in the literature. Foraminal branches of either the traversing or exiting nerve (furcal nerves) are contributed to the symptom complex. Furcal nerves are difficult to differentiate from a conjoined nerve. Autonomic nerves are also present, confirmed by endoscopic biopsy. Results: Working near the Dorsal Root Ganglion is a risk by itself, a known risk factor in any foraminal surgery. Ablation or removal of nerves in the inflammatory membrane results in decreased axial back pain and sciatica, but may also produce a side effect of dysesthesia of varied severity. Dysesthesia occurs between 5-15% of the time, depending on the patho genesis of the painful condition. It is usually very mild and completely self limited and temporary. Discussion: Dysesthesia responds to Lyrica or Neurontin, foraminal nerve blocks, and lumbar sympathetic blocks. It can be associated with motor weakness that usually resolves, unless there is significant comorbidity such as peripheral neuropathy, and seizure disorders. Pre-operative Consent should include usually transient neuropathic pain. Post Operative Neuropathic pain staying the same or worsening may not be able to be completely eliminated, and is a risk of the endoscopic procedure, even with neuromonitoring utilizing continuous EMG. Conclusion: A through discussion of the risks associated with foraminal endoscopic surgery must be explained to any patient undergoing foraminal endoscopic surgery. It is similar to the risk of trans-canal surgery. It has unique risks due to variations in foraminalnormal and patho-anatomy. The use of foraminal epidural injections intra-operatively, post-operatively, and in the management of post-operative dysesthesia will decrease this adverse side effect of foraminal surgery to approximately 1% of patients with mild permanent sensory or motor residuals. The overall risks and surgical morbidity are still less than posterior trans-canal surgery 43 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 4 ENDOSCOPIC SURGERY OF LUMBAR SPINAL STENOSIS. ABOUT 145 CASES. JEAN DESTANDAU Study Design: Endoscopic technique has been used by the author since 1993 for lumbar discectomy and since 2001 for spinal stenosis. The technique is discribed and the results of 145 patients are presented Material and Methods: The device (Endospine, Karl Storz GmbH, Tuttlingen, Germany) is composed of three tubes: one for the endoscope, one for suction and the largest one for classical surgical instruments. Since 2001 this endoscopic technique has been used in spinal stenosis performing a bilatéral décompression through a posterior approach from the left side or from the side of prédominant signs. From February 2001 to September 2007, 145 patients have been operated on with this technique. In 83% surgery was a single level décompression and in 16% there was an associated spondylolisthesis. Prolo’s criteria were used. Results: 104 questionnaires (72%) were returned showing excellent results in 94 cases (90%) and poor in 9 (8,7%). With an average delay of 3 weeks, 94 patients (90%) returned to a normal life. Four patients (4%) needed a second operation with an average delay of 5 months. The complications observed were: dural tear in 12 (8,3%); nerve root lesion in 3 (2%); resection of articular process in 7 4,8%); wrong level décompression in 2 (1,4%); and 1 compressive hematoma. In answer to the questions on global satisfaction and on the accuracy of the information given before surgery, 97% responded as satisfied and 95% felt the information given to be accurate. Conclusions: This minimally invasive technique is mainly used in single level spinal stenosis even with associated spondylolisthesis, but can be also used in several levels décompression. The good results and the fast resumption of normal activities explain that this endoscopic technique could become the gold standard in spinal stenosis, pathology that will increase with the lifespan extension 44 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-5 POSTERIOR LATERAL THORACIC ENDOSCOPIC MICRODISCECTOMY JOHN C. CHIU, M.D., FRCS, D.SC, DIRECTOR, NEUROSPINE SURGERY CALIFORNIA SPINE INSTITUTE MEDICAL CENTER, THOUSAND OAKS, CA 91360, USA Purpose: To demonstrate the safety and efficacy of outpatient based endoscopic thoracic discectomy with laser thermodiskoplasty performed for symptomatic thoracic herniated nucleus pulposus. Materials and Methods: Since February 1996, 420 patients’ (525 discs) with symptomatic thoracic discs without myelopathy, who failed at least 12 weeks of conservative care, were treated. The technique of percutaneous microdecompressive endoscopic thoracic discectomy (with laser thermodiskoplasty) by posterolateral approach is described. The thoracic disc levels were T1 to T12. All patients demonstrated a contained soft thoracic disc herniation on MRI or CT scans. Intraoperative thoracic discogram and pain provocative tests were positive and confirmed the disc involved. Results: Preliminary postoperative follow-up demonstrates 96% of all patients had good to excellent symptomatic relief. Two patients demonstrated persistent, though reduced thoracic pain and paresthesia. The average time to return to work was ten days for the non-workers' compensation patients. Most of the patients received non-ablative lower laser energy application for thoracic disc shrinkage or tightening. Conclusion: Percutaneous microdecompressive endoscopic thoracic discectomy with added application of non-ablative lower Holmium laser energy for disc shrinkage (laser thermodiskoplasty) appears to be easy, safe and efficacious. This less traumatic, easier outpatient treatment leads to excellent results, faster recovery, and significant economic savings 45 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-6 ENDOSCOPIC APPROACHES TO DEGENERATIVE CERVICAL DESEASES JEAN DESTANDAU The degenerative cervical pathology entails radicular, medullar or radiculo-medullar compression. Soft cervical hernia occurs on young patients in their forties, whereas osteophyticcompressions, either radicular or medullar, occur on old and thus more fragile patients. ENDOSPINE can be used for three types of operations: • posterior endoscopic foraminotomy • anterior endoscopic foraminotomy following Jho’s technique • anterior endoscopic foraminotomy and partial vertebrectomy also following Jho’s technique Posterior endoscopic foraminotomy: Its main indication is the soft cervical hernia which occurs at C7-T1 or T1-T2 levels, which are difficult to approach anteriorly. Using a posterior approach, the ENDOSPINE operating tube is inserted along the spine, positioned on the facets after fluoroscopic control and we realise a posterior lamino-foraminotomy either with little Kerrison forceps or with the help of a drill. The relief is immediate, the postoperative course extremely simple, and there are no special precautions to take during the postoperative period. Anterior endoscopic foraminotomy following Jho’s technique: It is indicated for soft and/ or hard foraminal hernia. The technique consists of a classical antero-lateral approach sliding between the vascular bundle outside and the visceral bundle inside and exposing the level wanted. We leave the longus colli aponeurosis intact in order to avoid a sympathetic lesion, but we remove the medial side of the muscle a little above the disc level. With the ENDOSPINE, we perform a complete anterior foraminotomy with the use of a drill which exposes the nerve root from the spinal canal until its passing behind the vertebral artery. Once again, the relief is immediate and the post-operative course extremely simple without any particular post-operative precautions. Anterior endoscopic foraminotomy and partial vertebrectomy following Jho’s technique: In case of cervicarthroscopic myelopathy, in elderly patients with pinched or inexistent disc, the anterior endoscopic foraminotomy with the ENDOSPINE can easily be extended to the opposite side where the foramen begins and can be done at several levels if needed. 46 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-7 TRANSFORAMINAL ENDOSCOPIC MICRODECOMPRESSION FOR HERNIATED LUMBAR DISCS WITH SPINAL STENOSIS AND TISSUE MODULATION TECHNOLOGY – UPDATE JOHN C. CHIU, M.D., FRCS, D.SC, DIRECTOR, NEUROSPINE SURGERY CALIFORNIA SPINE INSTITUTE MEDICAL CENTER, THOUSAND OAKS, CA 91320, USA Purpose: To demonstrate effective transforaminal endoscopic microdecompression for herniated lumbar discs with spinal stenosis, for very large protruded discs, recurrent discs with scar tissue and bony spurs or spondylitic bars compressing the lumbar nerve root. This is to be accomplished with endoscopic micro spinal instruments, laser application, and newly developed endoscopic decompression instruments (including tubular retractors, large cannulae, more aggressive trephines, curettes, rasps, and ronguers), in addition to laser thermodiskoplasty for disc shrinkage. Materials and Methods: Since 1993, 3421 herniated lumbar discs in 2000 patients with lumbar stenosis. Average age of 44.2 (24 to 92) with symptomatic lumbar single and multiple herniated intervertebral discs with lumbar stenosis. Males: 1010 - Females: 990. Each failed at least 12 weeks of conservative care. Post operative follow up 6mos to 72mos (average 42mos). Progressive series of different diameters endoscopic assisted tubular retractors, with appropriate sized dilators and more aggressive saw-toothed trephines, and laser are utilized to perform transforaminal endoscopic microdecompression for herniated lumbar discs and spinal stenosis, in addition to the posteriorlateral foraminoscope and endoscopic assisted spinal operating systems. Some tubular retractors have extensions like a duckbill on one side that can be oriented toward the nerve root to retract and protect it. The microdecompressive endoscopic assisted discectomy (MEAD) system and/or SMART Endolumbar System are used for dorso-medial spinal decompression/laminotomy and laminoplasty. Laser application is included for laser thermodiskoplasty. Results: There was no postoperative mortality, and had morbidity of less than 1%, in 2000 patients. For single level, 94% of patients had good or excellent results, 6% had some residual symptoms though improved overall, and 3% of patients did not improve significantly. A newly devised larger and more aggressive decompressive discectomy instrument set, safely and efficaciously allow wider and more complete removal of large or recurrent disc protrusions, scar tissue and bony spurs that cause nerve root compression, while protecting the adjacent nerve root. The MEAD system and or SMART Endo-lumbar System allows a minimal approach to laminotomy for spinal stenosis decompression and laminoplasty. Laser thermodiskoplasty reshapes and tightened disc tissue further for decompression. Conclusion: Transforaminal endoscopic laser microdecompression can effectively decompress herniated lumbar discs with spinal stenosis, and perform foraminoplasty for lateral and central spinal stenosis. This minimally invasive endoscopic technique aided by new instruments and laser application, provides a safe and effective modality to achieve results in effective decompression of lumbar discs with spinal stenosis, preserves spinal motion and creates a channel for spinal arthroplasty. 47 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-8 PERCUTANEOUS ENDOSCOPIC CERVICAL DISCECTOMY FOR NONCONTAINED CERVICAL DISC HERNIATION: MINIMUM 3 YEARS FOLLOW-UP SANG-HO LEE, MD, PHD, JUNE-HO LEE, MD, SUNG MIN HUR, MD WOORIDUL SPINE HOSPITAL (WSH), SEOUL, KOREA Introduction: Although percutaneous endoscopic cervical discectomy (PECD) has been an effective procedure for soft disc herniation, the conventional technique has the risk of spinal cord injury because of the relatively blind approach and straight-firing laser and the difficulty of removal of remnants, especially foraminal fragment. The aim of this study is to present the surgical technique and clinical outcome of PECD using a working channel scope (WSH endoscopy set, Storz, Germany) and a side-firing laser for noncontained cervical disc herniation. Methods: Between March 2002 and January 2005, 108 of 114 patients underwent PECD using a WSH endoscopy set were available for follow-up. The inclusion criteria were cervical radiculopathy due to foraminal, noncontained HCD as demonstrated on CT/MRI scan not responding to at least 6 weeks of conservative therapy. Under the conscious sedation, the patient was placed in supine position with neck extension. After pushing esophagus and trachea to the opposite side, an 18G needle was inserted into the disc space under C-arm guidance. The tract was dilated using a serial dilators, and the working channel scope was inserted into disc space. Under the direct visualization, ruptured disc fragment was removed by a microforceps and vaporized by a side-firing Ho:YAG laser through the working channel. The clinical outcomes were assessed by the Visual Analogue Scale (VAS) and the Neck Disability Index (NDI). Results: The mean follow-up period was 42 (range, 24–68) months. There were 66 males (57.9%) and 48 females (42.1%) with a mean age of 48.3 (range 26–68) years. The mean VAS score for neck pain dropped from 7.7 to 3.1. The NDI improved from 36 to 4%. There were 6 cases requiring revisional surgery at the affected levels. There was no associated complication such as infection, hoarseness, esopageal injury or intraoperative neural injury. Conclusion: PECD using a WSH working channel scope provided a safer and effective alternative for the treatment of noncontained cervical disc herniation. The WSH working channel scope had several advantages, such as a high quality of optics, a bigger working channel, and a side-firing laser. 48 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L-9 ENDOSCOPIC LUMBAR DISC SURGERY : UP-DATE 2009 HANSJOERG LEU, PD DR.MED. BETHANIA SPINE BASE, ORTHOPAEDIC SPINAL SURGERY, PRIVATKLINIKUM BETHANIEN CH-8044 ZÜRICH / SWITZERLAND – BETHANIA-SPINE@BLUEWIN.CH Coming up from Japanese Hijikata’s uniportal percutaneous technique of closed percutaneous nucleotomy introduced in 1979, in 1982 intradiscal biportal endoscopy was introduced in Zurich for visually controlled intervertebral tissue elaboration. Beside decompressive indications, in 1987/88, in combination with percutaneous external pedicular fixation, endoscopy controlled interbody fusion was introduced. After a first decade in clinical experience with this biportal applications, the idea arised to combine simultaneous endoscopic control with direct extradiscal tissue elaboration across an uniportal approach in the later eighties. Experiments with modified urologic workings-scopes designed for cystoscopic applications demonstrated in 1990, that endoscopic applications are possible also in non-preformed anatomical spaces when some hyperpressive irrigation was used for local atraumatic tissue spacing. After respective technical adaptations we introduced endoscopic coaxial foraminoscopy clinically for the first time in February 1991 for the treatment of a foraminal sequestrated herniation. A first publication on the early series was published in 1996*. Since then the technology with improved endoscopic tools and irrigation systems as well as high-frequency coagulation under irrigation became almost standardized for this specific range of indication. The posterolateral approach from 9-12 cm from the midline follows the same criteria as for intradiscal applications, but the working cannula is directed to the foraminal sequestrum, which is extracted under endoscopic control then with a special working scope. After a steep learning curve today the optimal indications and contraindications are clearly defined. Our first clinically controlled series of 200 standardized cases brought successful primary results in 164 cases, including the learning courve. Here the results trend to "black or white": or the sequester is removed or not. Relatively freshly sequestrated fragments without local scar-adhesions are easier to remove. Anatomical limits can occur in L5/S1 when high iliac crests can impair flat approach to medioforaminally located sequestra. For preop evaluation a 3d-CT offering clear bony analysis of accessible trajectories can trace the access precisely. Detailed knowledge of foraminal anatomy is mandatory. Hospital stay could be reduced to 2 to 3 days, out-patient care is possible nowadays as well. Other pioneering authors as Ruetten in Germany broungt up the interlaminar endoscopic lumbar decompression, what definitely extende the range of this minimal endoscopic approach also to more medilateral forms of lumbar disc herniation. So the available complementary endoscopic techniques today challenge in well trained hands more and more the conventional golden standards as microdiscectomy. * Reverence : Leu Hj., Hauser R.: Die perkutan posterolaterale Foraminoskopie : Prinzip, Technik und Erfahrungen seit 1991. Arthroskopie 9(1996)26-31 49 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 10 The endoscopic resection for Juxta-facet cysts – a new promising technique Stefan Hellinger, ISAR Clinic Munich Extradural expensive lesions in the spinal channel can lead to a compression of the nerve root, the myelon or the cauda equina with related symptoms. Most common are disc herniations or bony/ligamentous constrictions. Very rare the symptoms are caused by clinical relevant cysts from the intervertebral joint. The terminus Juxta.facet caysts has been founded by Kao et al. 1974. This includes the different forms of cysts by the interveertebral joints. We are finding synovial cysts by degenerative articular joints or ganglions by mucoid degeneration of the periarticular tissue. Meanwhile synovial cysts are connected to the joint and have a good response of conservative treatement, the ganglions are without any connection to the articular space and have a bad tendency for regression. Especially here is the surgical decompression necessary. Mostly for the surgical treatement the open microsurgical removal of the cyst and a part of the intervertebral joint is the standard procedure. Her we are experiencing the same problems as by microsurgical spine procedures. Especially the potentially induced instability by a partly resection of the intervertebral joint leads to a recommendation of a concomitant fusion. The endoscopic interlaminar accses allows a minimalisation of the approach related demages. Beside the disc surgery the endoscopic decompression of facet cysts has shown a good alternative for surgical treatement of these pathology. Methods: The surgical technique is an endoscopic approach to the interlaminar foramen with a 7mm tube. The flavum and the lamina is partly removed over the cyst in a limited area. After release of adhesions between the cyst and the neurological structures the cysts is solely removed by preserving the facet joint. The Patients had been evaluated preoperativley and 6 weeks postoperatively. Results: Until now we treated 3 patients with this techique. The neurological radicular symptoms recovered in all in all cases. One patient remained local back pain by facett arthrosis and treated further by rhizotomy. No complications had been exoerienced. The recovery time was by approximately 2 days. Conclusion: The endoscopic technique gives us an new option for the minimal aggressive removal of clinical relavant cysts by the intervertebral joints. The results are comparable to an open procedure. Cause of the limited account of cases is a statistical evaluation of the outcome difficult. The decision of the inervention is by unsuccesful conservativ treatement or by verification of a ganglion. For the patient this technique is less harming and gives a fast recovery. 50 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 11 X-MR assisted Percutaneous Endoscopic Lumbar Dicectomy Sang-Ho Lee, MD, PhD, Gun Choi, MD, PhD, Tae-Joon Ahn, MD Wooridul Spine Hospital (WSH), Seoul, Korea Introduction: Although percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniations shows satisfactory outcomes, there have been cases in which the PELD has failed because of the incomplete removal of disc fragments. The hybrid magnetic resonance/X-ray suite (X-MR) is a recently introduced imaging solution that provides intraoperative images. Preoperatively X-MR images were taken without changing prone position during the procedure to determine a precise skin entry point and evaluate any change in size or location of herniated disc. Before the finishing the procedure, X-MR was checked. The purpose of this study is to present our experience in X-MR assisted PELD during 2 year follow-up. Methods: A retrospective analysis was performed in 50 patients who underwent X-MR assisted PELD between Jan. 2006 and Dec. 2006 at our institution are followed retrospectively. We obtained intraoperative X-MR by placing skin markers on patient’s back. Postperatively, X-MR was repeated for doubtful remnant fragments. When remnants were found, procedure was continued until the fragments were removed completely. Results: The mean follow-up period was 26 months. Three patients repeated PELD for remnant disc. Based on the modified Macnab criteria, 93.9 % (out of 50 patients) showed excellent or good outcomes. The mean visual analogue scale score for leg and back symptom dropped from 7.7 to 1.7 (p<.05) and 6.8 to 1.8, respectively (p<.05). And the oswestry disability index decreased from 62.4 to 14.0% (p<0.05). Three patients underwent repeated PELD for remnant disc by the X-MR. Two patients demonstrated the progression of disc herniation in preoperative MRI. One patient repeated PELD due to hematoma. And one patient needed open lumbar discectomy after PELD due to recurrent disc herniation. Conclusions: According to progression or migration of herniated fragment since the 1st preop MRI and duration of conservative treatment more than 6 weeks, the X-MR assisted PELD facilitates in locating precise skin entry point and confirm complete removal of disc fragment intraoperatively, thereby increasing the success rate. 51 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 12 Full-endoscopic posterior operation of cervical lateral disc herniations – Prospective, randomized comparison to anterior cervical decompression and fusion (ACDF) Semih Oezdemir Background: There are various techniques for the operation of cervical disc herniations. The most common today appears to be ventral decompression and fusion. It brings good results, but requires more major surgery with loss of segment mobility. Dorsal "keyhole foraminotomy" is also been used without fusion. This operation is now possible in a full-endoscopic technique. Objective: The objective of the prospective randomized study was to compare ventral decompression and fusion (Group 1) to full-endoscopic dorsal decompression (Group 2) in lateral, soft disc herniations. Patients and methods: 70 patients were operated (35 per group). Inclusion criteria were: monosegmental mediolateral and lateral soft disc herniation, radicular pain. In Group 1, the operation was performed in known technique using a PEEK cage without plating. In Group 2, the operation was performed using 5.8-mm endoscopes with a 3.2-mm intraendoscopic working canal under continuous lavage. The follow-up lasted 24 months. 62 patients (88 %) were followed. Results: The mean operation time in Group 1 was 75 minutes., in Group 2 35 minutes There were no measurable blood loss and serious complications in either group. In Group 1, 2 patients had transient difficulty swallowing. In Group 2, transient numbness occurred twice. There was no operation-related neck pain in Group 2 after wound healing. One patient in Group 2 suffered recurrence. CT-examinations showed resection of less than 1/4 of the facettes in Group 2. There was no increasing instability or kyphosing in Group 2, in Group 1 no adjacent instability. 57 patients subjectively attained a satisfactory result. This corresponded to the significantly constant improvement recorded by the validated measuring instruments. There were no significant differences between the groups. Conclusion: Full-endoscopic dorsal foraminotomy is technically feasible and a potential alternative to ventral decompression and fusion. It enables a selective procedure with direct visualization, decompression is rapid, sufficient and the complication rate is low. Traumatization of the access pathway and the structures of the spinal canal is reduced due to the minimallyinvasive technique. Strict attention must be paid to the indication for lateral and soft disc herniation. Recurrences cannot be ruled out. 52 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 13 CLINICAL OUTCOMES OF PERCUTANEOUS ENDOSCOPIC DISCECTOMY (PELD) Fujio ITO Objective: Percutaneous Endoscopic Lumbar Discectomy (PELD) is an overnightstay operation that makes a 7 mm incision under local anesthesia. We discuss about the indications and results of transforaminal (TF) , interlaminar(IL) and extraforaminal (EF) approach. Materials and methods: The TF approach was used in 241 cases in L2/3 ~ L5/S1, IL was 129 in only L5/S1 and EF was 52. Total cases were 422 composed of 320 males and 102 females, their average age 45.9. Patients with both upward and downward migrations of 10 mm or more, instability found, any lateral recess less than 3 mm, or osseous proliferation of spondylolysis were excluded from the subjects. Results: JOA (Japanese Orthopaedic Association) scores before operation and 1 month, 3 months, and 6 months later were 11.0 (N=365), 20.0 (N=290), 22.1 (N=183), and 22.3 (N=113), respectively. The VAS (visual analogue scales) for buttock and lower limb were 7.1, 2.4, 1.8, and 1.5, respectively. Open surgery was performed in two cases with canal stenosis. 11remnants and 6 impossible insertion cases were operated on by MED, 12 recurrences and 1 level mistook case were operated on by the same methods, 2 instabilities were operated on by fusion. One root damage caused a drop foot, 15 pain residual cases were under self-control. Conclusion: PELD has indications for a large majority of lumbar disc herniation not complicated by bone lesions and is a minimally invasive spine surgery which allows the patient to walk and leave the next morning. 53 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 14 PERCUTANEOUS ENDOSCOPIC DISCECTOMY IN LUMBAR DISC HERNIATION COMBINED WITH SPINAL STENOSIS HAVING SEVERE UNILATERAL RADICULOPATHIC LEG PAIN CAUSED BY DOMINANT ROOT COMPRESSION : TRANSFORAMINAL SUPRAPEDICULAR APPROACH CHANG IL JU, M.D., HYEUN SUNG KIM, M.D., SEOK WON KIM, M.D., SEUNG MYUNG LEE, M.D., HO SHIN, M.D. DEPARTMENT OF NEUROSURGERY, DEPARTMENT OF NEUROSURGERY, CHOSUN UNIVERSITY, Objective. Endoscopic discectomy for lumbar disc herniation combined spinal stenosis have been considered as contraindication. But, we could have obtained satisfactory results from the cases of lumbar disc herniation combined with spinal stenosis that have symptoms of severe radiculopathic leg pain with or without back pain caused by compression traversing nerve root in lateral recess by applying percutaneous endoscopic discectomy. hence, the outcome is reported here. Materials and Methods. At our hospital, from October 2006 to December 2007, The subjects were 26 patients with lumbar disc herniation combined with spinal stenosis. All patients had severe unilateral leg radiating pain and/or back pain symptoms caused by dominantly herniated disc compressing the nerve root. Preoperative MR T2 weighted axial images show spinal stenotic findings that more than 4mm thickened ligament flavum and evident protruded disc to compress the traversing nerve root. We had performed percutaneous transforaminal decompressive discectomy and then decompressed traversing root by suprapedicular approach with semi-rigid flexible curved probe. Results. There were 26 patients, 7 male and 19 female patients. One patient was in her 20's, one patient in their 30's, four patients in their 40's, seven patients were in their 50's and eight patients were in their 60's, five patients were in their 70's. Mean follow-up was 6.37 month. The mean visual analogue scale (VAS) of the patients prior to surgery was 8.08, and the mean postoperative VAS was 2.08. According to Macnab's criteria, patients who showed excellent result were 6 cases and good result were 17 cases, fair results were 2 cases, poor result was 1 case and thus satisfactory results were obtained in 88.46 % cases. Conclusion. Generally, the lumbar disc herniation combined with spinal stenosis is known as contraindication of endoscopic discectomy. But, If main symptoms was caused by herniated disc compression traversing nerve root in the lateral recess, percutaneous lumbar discectomy could effective methods to decompress the traversing root by transforaminal suprapedicular approach. 54 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 15 Transforaminal endoscopic extradiscal vs. intradiscal access in lumbar disc herniation Guntram Krzok Orthopaedic Centre Waltershausen We want to report about our experience after more than 800 transforaminal endoscopic surgeries in lumbar disc herniation. From 1999 until 2003 we used the intradiscal access with the YESS-technique in 300 cases with lumbar disc herniation. This technique was easy and safe, but the indication is limited. The access to level L5-S1 was nearly impossible in cases with high iliac crest and/or narror foramen. The removing of sequestered disc material from the spinal canal was mostly impossible. From 2003 until today we used the extradiscal access with the TESSYS-technique in more than 500 cases. This technique is useable in nearly all cases of lumbar disc herniation and allows the direct access to the herniation by stepwise reaming and enlarging of the foramen. The results can be improved by the combination of herniotomy and foraminoplasty. Disadvantage of the method is the long learning curve. Most complications are recuccences (6,5%)and bleedings (1%). Nerve damages are rare (0,6%)and mostly after trouble with aneathesia. 55 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 16 CLINICAL AND RADIOLOGICAL OUTCOMES OF MINIMALLY INVASIVE VERSUS OPEN TRANSFORAMINAL LUMBAR INTERBODY FUSION CWB PENG, WM YUE, SB TAN Singapore General Hospital, Singapore, Singapore CLINICAL AND RADIOLOGICAL OUTCOMES OF MINIMALLY INVASIVE VERSUS OPEN TRANSFORAMINAL LUMBAR INTERBODY FUSION CHAN WB PENG MD (PRESENTING AUTHOUR), WAI M YUE MD, SEANG B TAN MD Department of Orthopedic Surgery, Singapore General Hospital, Outram Road, Singapore 169608. Fax: +65 62262684, Tel: +65 91261586, Email: bencwpeng@gmail.com Study Design: Prospective study Objective: Comparison of clinical and radiological outcomes of minimally invasive (MIS) versus open transforaminal lumbar interbody fusion (TLIF). Summary of Background Data: Open TLIF has been performed for many years with good results. MIS TLIF techniques have recently been introduced with the aim of smaller wounds and faster recovery. Methods: From 2004 - 2006, 29 MIS TLIF were matched paired with 29 Open TLIF. Patient demographics and operative data were collected. Clinical assessment in terms of NASS, SF-36 and VAS scores were performed preoperatively, 6 month and 2 year postoperatively. Fusion rates based on Bridwell grading were assessed at 2 years. Results: The mean age for MIS and Open procedures were 54.1 and 52.5 years respectively. There were 24 females and 5 males in both groups. Fluoroscopic time (MIS: 105.5 seconds, Open: 35.2 seconds, p<0.05) and operative time (MIS: 216.4 minutes, Open: 170.5 minutes, p<0.05) were longer in MIS cases. There was less blood loss in MIS (150ml) versus Open (681ml) procedures (p<0.05). The total morphine used for MIS cases (17.4mg) was less compared to Open (35.7mg, p<0.05). MIS (4 days) patients have shorter hospitalisation compared to Open (6.7 days, p<0.05). Both MIS and Open groups showed significant improvement in back pain and lower limb symptoms (NASS and VAS scores, p<0.05) and Quality of Life scores (SF-36, p<0.05) at 6 months and 2 years but there was no significant difference between the two groups. 80% of MIS and 86.7% of Open TLIF levels achieved Grade 1 fusion (p>0.05). Conclusion: MIS TLIF has similar good long term clinical outcomes and high fusion rates of OPEN TLIF with the additional benefits of less initial postoperative pain, early rehabilitation, shorter hospitalization and fewer complications. Curriculum Vitae Name: Chan Wearn Benedict Peng Sex: Male Qualification FRCS (Orthopaedics) (Edinburgh) 2006 MMed (Orthopaedics) 2002 MB ChB (Honours) 1996 Education University of Leeds Medical School 1991 - 1996 Hwa Chong Junior College 1989 - 1990 The Chinese High School 1985 - 1988 St. Andrew's Primary School 1979 - 1984 Medical Training Clinical Spine Fellowship - Hospital for Joint Diseases (New York, USA) 2007 Spine Fellowship (Observer) - Hospital for Special Surgery (New York, USA) 2007 Advanced Surgical Trainee (Orthopaedics) 2002-2006 Basic Surgical Trainee - 2000-2002 Awards AO Spine Traveling Fellowship 2007 SGH Service with A Heart Award 2006 Garland Prize in Clinical Neurology 1996 Tetley and Lupton Scholarship (University of Leeds) 1991-96 Medical Insurance Agency Charity Award - for Elective Programme 1995 Lady Moynihan Award for Elective Research 1995 Infirmary Prize - for Best Performance in 2nd MB 1993 Biochemistry Prize - for Best Performance in Biochemistry 1993 Shuttleworth Prize - for Best Performance in Anatomy 1993 Crabtree Prize - for Outstanding Academic Performance 1992 Academic Position Clinical Tutor - National University of Singapore Clinical Supervisor - Singapore General Hospital Orthopaedic Department Professional Affiliations Member of North American Spine Society Since 2006 Member of AOSpine Since 2006 Member of Asia-Pacific Orthopaedic Association Since 2006 Member of Singapore Orthopaedic Association Since 2006 Member of Singapore Medical Association Since 1997 56 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 17 PROPHYLACTIC OF RELAPSES OF FACET JOINT SYNDROME AFTER THEIR’S DENERVATION ALEXANDER SIRENKO 57 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 18 RIGID INTERSPINOUS SPACER WITH TENSION BAND SANG-HO LEE, MD, PHD, EWY-RYONG CHUNG, MD, PHD, OON KI BAEK, MD WOORIDUL SPINE HOSPITAL (WSH), SEOUL, SOUTH KOREA BACKGROUND CONTEXT: Degenerative lumbar spinal stenosis is a common condition in elderly patients and many of these patients are candidates for decompressive surgery. The purpose of study is to evaluate the efficacy of the interspinous stabilizing device, Locker after microdecompression as an alternative to the fusion for the treatment of lumbar stenosis with mild degree of instability in the elderly patients. METHODS: 51 patients (20 male, 31 female) with the minimum age of 65 years and symptomatic spinal stenosis who underwent Interspinous Locker Fixation (ILF) after microdecompression between 2004 and 2007 at our institution are followed retrospectively. And the mean age of 70.8 years, mean follow-up period was 2 years 4 months. RESULTS: The mean Visual Analogue Scale (VAS) score for leg and back symptom dropped from 7.0 to 3.1 and 5.9 to 3.2, respectively (p < 0.05). The Oswestry Disability Index (ODI) improved from 58.9 to 32.4 (p < 0.05). There was one case requiring revisional surgery at the affected levels. There was no associated complication such as infection or intraoperative neural injury. Satisfaction rate was 73.56%. CONCLUSIONS: This less invasive and bloodless, non-fusion technique in the management of spinal stenosis has been developed to decrease the morbidity and mortality associated with large laminectomy with or without lumbar fusion in elderly patients. 58 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 19 Inter-spinous Process Fixation for Degenerative Pathology of the Lumbar Spine Mitchell Hardenbrook Fusion has been an accepted surgical treatment for degenerative pathology of the lumbar spine. This has traditionally been enhanced through the use of pedicle screw and rod instrumentation. Though this instrumentation has improved the rate of fusion, it has also resulted in numerous adverse outcomes. Placement of pedicle screw requires a wide surgical exposure with intraoperative muscle stripping resulting in significant morbidity. Additionally, the pedicle is in close proximity of the adjacent un-fused facet joint. Placement of pedicle screws often results in iatrogenic injury of the adjacent facet at the cephalad of the construct. This fact combined with the rigidity of the screw-rod construct has lead to accelerated degeneration of the adjacent levels. This has been reported as high as 30% incident. This raises a number of questions. First, can alternative fixation be utilized to avoid the pedicle? This would reduce the need for a wide surgical exposure and reduce the risk of iatrogenic injury to the adjacent facet. Second, would a less rigid construct reduce the rate of adjacent segment degeneration while providing enough stability to enhance surgery? Inter-spinous process fixation allows for posterior fixation as an adjunct to lumbar fusion. It has the benefit of providing fixation with only minimal midline muscle dissection. Biomechanical testing shows inter-spinous fixation to be equal in stiffness to pedicle screw/rod fixation when paired with anterior interbody fusion in flexion and extension. However, there is less rigidity in lateral bending and rotation in the inter-spinous process fixation. Biomechanical testing of the adjacent level to inter-spinous process more closely matches the intact disc when compared to the adjacent level of the rod-screw construct. Early evaluation has demonstrated improved perioperative clinical outcomes. 59 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 20 ANALYSIS OF CERVICAL NUCLEOPLASTY OUTCOMES USING COBLATION TECHNOLOGY H.Selim Karabekir, Kocatepe University School of Medicine,Neurosurgery Department Background: Nucleoplasty is a minimally invasive procedure for managing chronic discogenic cervical pain. Although there’s some reports of nucleoplasty outcome rates, few have dissected the detailed factors affecting those outcomes. Purpose: To evaluate outcomes of chronic cervical discogenic pains treated with nucleoplasty and success of it. Material & Methods: Data were gathered on the basis of records from 08 January 2005 to 08 January 2006. Thirty-six cases treated at a single or double levels with disc protrusion ≤2 mm, without motor deficities and annular tearing and positive discogram were studied. Minimum follow-up period was 24 months. All assessments included visual analog score (VAS) and at 6,12,24 and 36 months post-procedure. VAS was evaluated by a 10-point numeric rating scale, ranging from no aggravated pain “0” to the worst aggravated pain “10”. Results: The improvement of pain with VAS displayed moderate changes at 6, 12,24 and 36 months and patients ability of daily life were good. Conclusion: Good classified patients with cervical disc degeneration without annular tearings and motor deficities have a good prognosis managing with minimal invasive procedure, nucleoplasty. Key words: Cervical degenerative disc, nucleoplasty, ablation, coagulation, 60 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 5 Intradiscal Therapies Prof. Serdar Erdine, MD,FIPP Department of Algology , Medical Faculty of Istanbul, Turkey The pathological basis for some low back pain may be due to internally disrupted intervertebral discs and in particular ,sensitized annular tears.Besides surgical interventions like total disc excision and artrhrodesis,percutaneous intradiscal therapies may also be considered. These intradiscal techniques are 1. annuloplasty a. intradiscal electrothermal therapy (IDET) b. Radiofrequency posterior annuloplasty (RFA) c. Biaculoplasty 2. Percutaneous disc decompression a. Laser discectomy b. Radiofrequency coblation c. Mechanical disc decompresson(decompressor) d. Manual percutaneous lumbar discectomy (PLD) 3. Endoscopic percutaneous discectomy. Most of these intradiscal therapies are in application more than a decade and long tem follow ups with each technique are emerging in the literature. These therapise attempt to reduce pain rather than repair the degenerated disc.Despite anectodal statements of success,long term results thus far have found their use to be of little direct benefit. In this lecture , long term results of these techniques will be presented and discussed. Reference;Raj.P; Intervertebral Disc;Anatomy-Physiology- PathophysiologyTreatment. Pain Practice;vol 8,issue 1. 2008,18-44 61 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 6 Identifying the pain generators in the lumbar spine: Bridging the Gap between Interventional Pain Management and Traditional Spine Surgery: Anthony T. Yeung, M.D., Introduction: Interventional pain management physicians attempt to find pain generators with injection techniques. This usually only provides temporary pain relief, anticipating that the injection will mitigate the pain. The ability to place a needle in the vicinity of the pain source, however, and then visualize patho-anatomy with the endoscope has opened the door for access to the lumbar spine from T-10 to S-1. Endoscopic Spine Surgery is therefore possible with evolving modalities and techniques to address the patho-anatomy of pain. While traditional approaches provide standard proven and optimal access to spinal pathology, there are conditions better suited for the foraminal endoscopic approach. When a surgeon combines interventional techniques with endoscopic visualization, additional steps in the treatment algorhythm are available. Materials and Method: A standardized method for endoscopic foraminal surgery (the YESS technique) is utilized: 1. A protocol for optimal instrument placement is calculated by lines drawn on the skin from the C-Arm image. This facilitates needle and cannula placement for endoscopic surgery. This same trajectory is utilized for diagnostic and therapeutic injections as a precursor to endoscopic surgical intervention. 2. Injection of non-ionic radio-opaque contrast will result in a foraminal epiduralgram will produce foraminal epidural patterns that provide information on foraminal patho-anatomy such as HNP, and central and lateral spinal stenosis. 3. Evocative chromo-discography. ™ is performed to confirm discogenic pain and tissue removal is aided by the vital tissue staining. 5. Endoscopic foraminoplasty can be performed if needed. 6. Diagnostic and surgical exploration of the epidural space. 7. Probe the hidden zone of MacNab containing the exiting nerve, DRG, and axilla of the traversing and exiting nerve. 8. Using the biportal technique for inside-out removal of extruded and sequestered nucleus pulposus. Results: The foraminal endoscopic technique will allow surgical access to the lumbar spine for treatment of a wide spectrum of painful degenerative conditions. There are, however, conditions where the endoscopic foraminal approach is advantageous over traditional surgical approaches. These conditions are 1. Discitis 2. Far lateral extraforaminal HNP, especially at L5-S1. 3. Upper lumbar HNP 4. Lateral foraminal stenosis 5. Discogenic pain from annular tears. 6. Visualized endoscopic medial branch Rhizotomy. Case examples utilizing jpeg and mpeg imaging illustrate the painful conditions most suitable for foraminal endoscopic surgery. Conclusion: New surgical skills will become desirable and necessary for the spine surgeon to incorporate endoscopic spine surgery in their practice. Incorporating Interventional pain management helps bring additional clinical information that facilitates patient selection. New spinal procedures such as nucleus replacement, annular repair, annular reinforcement, and biologics are well suited for the foraminal minimally invasive approach. Endoscopic foraminal access to the lumbar spine will open the door for true minimally invasive access to the lumbar spine without affecting and destabilizing the dorsal muscle column. 62 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 7 ENDOSCOPIC TRANSFORAMINAL DISCECTOMY FOR RECURRENT LUMBAR DISC HERNIATION T. Hoogland; M. Schubert; K. Brekel-Dijkstra; B. Miklitz ALPHA-KLINIK, Munich, Effnerstr38, 81925 München- Germany Purpose Recurrent disc herniation is a significant problem as scar formation and progressive disc degeneration may lead to increased morbidity with re-operation. The advantage of the ETD is that there is no need to go through the old scar tissue. The disadvantage may be a long learning curve for the surgeon. Purpose of this prospective study was to review complications and results of the Endoscopic Transforaminal Discectomy (ETD) for recurrent herniated discs. Material and Methods 262 consecutive patients over a four year period with a MRI proven recurrent discherniation in the lumbar spine with primarily radicular symptoms who did not respond satisfactory to conservative treatment over were included in this prospective clinical study. From a lateral approach first the intervertebral foramen was enlarged and a working cannula was inserted into the spinal canal. The prolapsed or extruded part was removed under endoscopic view with special forceps’s. With a special reamer the inferior endplate was perforated, abraded and all loose intradiscal fragments were removed. Results 3 months post-operative all patients underwent a clinical evaluation and at two years post-operative 90.8% returned an extensive questionnaire including VAS Scores, MacNab Score as well as subjective satisfaction assessment. At two years 85.7% of the patients rated the result of the surgery as excellent or good. 9.7 % reported a fair and 4.6 % patients an unsatisfactory result. Patients recorded an average improvement of their leg pain of 5.9 points and 5.7 points of their back pain on the VAS scale (1-10). According to Mac Nab criteria 30.7% of the patients felt fully regenerated, 50 % felt their efficiency to be slightly restricted, 16.8% felt their efficiency noticeably restricted and 2.5% felt unaltered. All patients had a 3-month follow-up where possible complications were registered. 3 transient nerve root irritations and 6 (2.3%) early recurrent herniations (<3 months) were reported. There was no case of infection or discitis. 11 patients have been re-operated for recurrence, after 3 months and within 2 years (4.6%). Conclusion Endoscopic Transforaminal Discectomy appears to be an effective treatment for recurrent disc herniation with only few complications and a high patient satisfaction. 63 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 21 Cervical Facet Denervation S. Erdine,MD,FIPP Dept. of Algology,Med Fac of IstanbulTurkey The causes of facet pain in the cervical region are; Degenerative disease,Postural abnormalities and Trauma.If medication or physical therapy does not sustain pain relif there may be an indication of cervical facet denervation. The indications for cervical facet denervation are;Duration (pain) > 3 months,no causal therapy,transient response to local anesthetic injection and no neurological deficit. The contraindications RF-lesions are central pain syndrome, use of anticoagulants,or abnormal response to test block. The procedure has to be performed under fluoroscopy.Recently for cervical region pulsed rf is more preferred due to less complications. The complications are;Local pain,dizziness,ataxia,sympathetic block,injury of the vertebral artery or ventral ramus,local anesthetic injection into the vertebral artery,convulsion,air injection into the vertebral artery,serious neurological sequele,excess amount of local anesthetic passing to the epidural and subarachnoid space and advancing the needle penetrating to the epidural,subdural and subarachnoid space. Techniques in cervical region should be performed by experts and not recommended for beginners. Reference; Erdine S. Targets and optimal imaging for cervical spine and head blocks. Tecniques in Regional Anesthesia and Pain Management 2007; 11(2): 263-72. 64 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 22 PARASPINAL MAPPING IN LUMBAR SPINAL STENOSIS İLKER YAĞCI, MD, PHYSIATRIST Lumbar spinal stenosis (LSS) is a clinical syndrome of buttock or lower extremity pain, which may occur with or without back pain, associated with diminished space available for the neural and vascular elements in the lumbar spine. LSS is a prevalent condition, with an estimated 13% to 14% of those patients who seek help from a specialty physician and 3% to 4% who see a general practitioner for low back pain diagnosed with LSS. LSS is a well known source of significant disability among the elderly and a common cause for back surgery which is likely to increase in prevalence as society ages. The differential diagnosis of spinal stenosis includes numerous disorders ranging from mechanical back pain to vascular disease to polyneuropathy. The diagnosis is generally based on clinical findings and supported by radiographic evidence. Magnetic resonance imaging (MRI) is commonly used to assess lumbar spine. MRI can demonstrate the presence and size of a lesion. However there is no relationship between the radiologic measurements and symptomatology in LSS. Additionally, there are many studies addressing high rates of radiologic LSS in asymptomatic persons. The false positive diagnosis can lead to misdiagnosis and also mistreatments in patient who has a different condition that mimics LSS. Even in symptomatic LSS defined by AP spinal canal diameter is not significantly associated with location or severity of clinical symptoms. However the therapeutic interventions such as selection of roots in transforaminal epidural injections are performed based on MRI. The rationale behind performing electrodiagnosis in patients who may have lumbar spinal stenosis is to evaluate real-time electrophysiological function of nerves and rule out diagnoses with similar presentations such as peripheral neuropathy and motor neuron disease. Beside differential diagnosis needle electromyography can demonstrate the nerve root functions. In recent years the quantification and standardization of paraspinal EMG have been developed which was known as paraspinal mapping (PSM) technique. It was demonstrated that PSM had higher sensitivity than MRI in asymptomatic patients. According to our unpublished data the technique is very useful to differ radiological LSS from the symptomatic patients. The technique can additionally demonstrate the root functions successfully in symptomatic patients. This feature may guide the treatment approaches but the prognostic value of PSM is needed to clarify with further investigations. 65 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 23 INTERVENTIONAL CAUSALGIA TREATMENT "IMAGE GUIDED" JALAL JALAL SHOKOUHI JAMEJAM MEDICAL CENTER,IRANIAN SOCIETY OF RADIOLOGY InterventIonal causalgIa treatment "Image guIded" CausalgIa, complex regIonal paIn syndrome or reflex sympathetIc dystrophy treated In war Injured patIents. In 1905 fIrst sympathetIc trunk block made by SelheIm and followed later wIth blocks by Lawen, KappIs and FInsterer. The common sympathetIc ganglIon blocks Include: 1. Stellate ganglIon block for upper extremIty and lower facIal and neck paIn. 2. CelIac ganglIon block for paIn of the upper abdomen. 3. Lumbar sympathetIc block for paIn related to the lower extremItIes. 4. Impar ganglIon block for paIn In the lower pelvIs and perIneal regIons. Lumbar sympathetIc block or blockage and ethanol sympatectomy may be helpful In cases of lower extremIty reflex sympathetIc dystrophy or causalgIa of war Injured patIents. The lumbar sympathetIc plexus extends from L2 down to L5. The best target Is anterIor of L2 vertebrae. A postero-anterIor approach, slIghtly off mIdlIne Is made In all patIents. InjectIon of IodIne contrast medIum (AIr bubble In hypersensItIve patIents) confIrms safety of InjectIon sIte (to save Aorta, IVC and ureter In the retroperItoneum). All patIents guIded by X-ray CT Scan. 68 Adult patIents treated by thIs methods, 18 persons was operated before by surgIcal sympatectomy methods and vascular surgeons for many tImes but paIn recurred agaIn. In orthopedIc surgIcal and InterventIonal procedures: LInson,Leffert and Todd reported use of lIdocaIn and CortIcosteroId wIth 89% paIn lessenIng In causalgIa and 80% treatment In other dystrophIc varIants. They used sequentIonal sympathetIc blocks. All our patIents had gunshot wounds or metallIc fragments from explosIve army materIals. WIth hIgh velocIty InjurIes spontaneous paIn recovery takes longer tIme (3-9 months for slow velocIty InjurIes). After thIs prIod there Is IndIcatIon for surgery or InterventIon. We used BupIvIcaIn 0.5% (20 cc) and Ethanol 65% (10-16 cc). PaIn reductIon gaIned In all patIents about 85%. All of patIents treated by sImple procedure except few patIents wIth subsequent Ethanol sympatectomy after successful BupIvIcaIn or MarcaIn sympathetIc block. Speaker: Jalal ShokouhI Jalal-M.D.* FatehI MansourM.D.* AmerI AlIakbar-M.D.* +98-9121137884 +98-21-88317260 jalaljalalshokouhI@hotmaIl.com *IranIan socIety of radIology,Tehran,Iran 66 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 24 ADVANCES IN THE TREATMENT OF DISCOGENIC BACK PAIN SALAHADIN ABDI, MD, PHD Diagnosis and treatment of lumbar discogenic pain due to internal disc disruption (IDD) remains a challenge. It accounts for 39% of patients with low back pain. The mechanism of discogenic pain remains unclear and its clinical presentation is atypical. Magnetic resonance imaging (MRI) can find high-intensity zone as an indirect indication of IDD. However, relative low sensitivity (26.7% to 59%) and high false positive (24%) and falsenegative (38%) rates reduce the value of MRI in screening for the existence of painful IDD. Provocative discography can provide unique information about the pain source and the morphology of the disc. It may also provide information for selecting appropriate treatment for the painful annular tear. Adjunctive therapies, including nonsteroidal antiinflammatory drugs, physical therapy, rehabilitation, antidepressants, antiepileptics, and acupuncture, have been used for low back pain. The value of these treatments for discogenic pain is yet to be established. Intradiscal steroid injection has not been proved to provide long-term benefits. Intradiscal electrothermal therapy may offer some pain relief for a group of well-selected patients. No benefits have been found for the intradiscal radiofrequency thermocoagulation. In this presentation, I will discuss about L2 spinal nerve block as this may interfere with the transition of painful information from the discs to the central nervous system. Furthermore, I will discuss disc cell transplantation which is in the experimental stage and has the potential to become a useful option for the prevention and treatment of discogenic back pain. However, more basic science and clinical studies are needed to establish its clinical value. References: Aprill C et al. Br J Radiol. 1992;65:361–369. Bogduk N et al. J Anat 132:39-56,1981 Bogduk et al.: Spine J 2002;2:343–350. Brisby et al.: Orthop Clin North Am 2004;35:85–93. Cassinelli eta al.: Spine J 2001;1:205–214. Coppes MH et al. Spine 22:2342-50,1997 Freemont et al.: Lancet 1997;350:178–181. Groen et al. Am J Anat 188:282-296,1990 Horton WC, Spine 1992;17:S164–S171. Kitano T et al. Clin Orthop 293, 372-377,1993 Nakamura et al.: J Bone Joint Surg [Br] 1996;78-B:606-612. Pauza et al.: Spine J 2004;4:27–35. Schwarzer AC, et al.: Spine 1995;20:1878–1883 Zhou and Abdi, Clin J pain 2006; 22(5):468-81. Zucherman J, Spine 1988;13:1355–1359. 67 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 25 CONTROVERSIES SURROUNDING EPIDURAL STEROID INJECTIONS SALAHADIN ABDI, MD, PHD EpIdural steroId InjectIon Is a commonly performed procedure In managIng chronIc back paIn. However, Its effectIveness contInues to be a subject of controversy. Thus, thIs presentatIon wIll cover the followIng: I. DIscuss the pathology and pathophysIology of dIsc hernIatIon II. RevIew the lIterature and present the evIdence of: - Caudal ESI - InterlamInar ESI - TransforamInal ESI III. DIscuss the controversIes surroundIng ESI IV. ConclusIons and future dIrectIons References: AbdI et al. PaIn PhysIcIan 2007; (10):185-212 Armon et al Neurology 2007; 68(10):723-729 Cannon DT, et al Arch Phys Med Rehab 2000; 81 (S):87-97 Carette et al. NEJM 1997; 336:1634-40. Devor, M et al; PaIn, 1992, 48:261-268 KawakamI M et al SpIne 19:1780-1794,1994 KIrkaldy-WIllIs WH SpIne 9:49-55,1984 Koes BW et al. PaIn 1995; 63:279-288 Lee HM et al SpIne 23:1191-1196,1998 Nygaard et al. SpIne 1997; 22:2484-8 68 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 26 INTRAOPERATIVE ALCOHOL INJECTION FOR THE TREATMENT OF A SACRAL SPINAL EPIDURAL HEMANGIOMA. TECHNICAL NOTE. AHMET MENKU Vertebral hemangiomas are not true neoplasms but congenital vascular malformations. Spinal hemangiomas can also be epidural without vertebral body involvement; these are extremely rare with few reported cases in the sacral epidural spinal location. Because of the high vascularization of hemangiomas, preoperative misinterpretation may result in unexpected intraoperative hemorrhage and incomplete resection, which results in the persistence of clinical symptoms or recurrence. Reoperation for remnant or recurrent epidural hemangioma is very difficult because of peridural or periradicular adhesion and unclear tumor margins; as a result, complete resection cannot be guaranteed in reoperation. Therefore, proper preoperative planning and complete resection in the first operation is essential. The authors present a detailed characterization of a sacral spinal epidural hemangioma in a 38-year-old woman who presented with complaints of gradual onset of low-back pain that worsened over 1 year. The MR imaging findings indicated a large L5-S2 epidural spinal mass causing thecal sac compression. The patient underwent an S1 hemilaminectomy, and a vascular extradural mass was noted on the posterior aspect of the dura mater. Total resection of the tumor was achieved using intraoperative alcohal injection and microscopic dissection. The postoperative MR imaging findings and clinical outcome were excellent. The authors also review treatment modalities and demonstrate the utility and effectiveness of intraoperative alcohal injection in grosstotal resection of large difficult spinal epidural hemangiomas. 69 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 27 PERCUTANEOUS AUTOMATIC DISCECTOMY OF CERVICAL AND LUMBAR SPINE KONSTANTIN POPSUISHAPKA 70 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 28 LUMBAR AND CERVICAL FACET JOINT DENERVATION WITH LASER SRI KANTHA, M.D. Facet joint arthritis is a common cause of disabling neck and low back pain. Currently the treatment options include facet joint blocks, radiofrequency and laser facet rhizotomy, and spinal fusion in severe cases. The results of facet joint blocks with steroids and local analgesics are temporary. Radiofrequency rhizotomy of cervical and lumbar facet joints has been implemented over the past 25 years. From my clinical experience, the results of radiofrequency facet rhizotomy are variable from 9-83%. Lasers have been used in disc decompression since 1991 with excellent results. This has prompted us to use laser on intractable cervical and lumbar facet joint arthritis pain and facet joint mediated pain post discectomy. Laser is widely employed in various surgical specialties for its precision in thermocoagulation. Laser has the advantage that a relatively larger area in the vicinity of the probe undergoes thermocoagulation in contrast to a radiofrequency probe. We have used this procedure on patients with intractable facet joint mediated pain since 1993. Many of our patients had multiple open spinal surgeries and also endoscopic discectomies. Their radiculopathy had improved, but these patients continued to experience paraspinal neck and back pain, and referred pain including headaches, suprascapular discomfort, and pain radiating to the posterior thigh. Some patients who had failed or experienced short lasting relief following radiofrequency denervation, underwent laser facet joint denervation, with complete and long lasting relief. Percutaneous laser facet joint denervation is a technique which can be used in intractable pain secondary to cervical and lumbar facet joint arthritis, and post-discectomies. This is a minimally invasive procedure with good to excellent success rate. Cervical and lumbar facet joint denervation by laser-assisted technique is performed using a cannula to approach the facet joints. A HO:YAG laser straight firing probe is inserted through the cannula and laser heat is applied at 10 Hz, 5 watts to selectively denervate the facet joint. Every effort is made to denervate the joint yet preserve the capsule of the joint. From my personal experience, the results of laser denervation are more rewarding than radiofrequency lesioning for denervation of cervical and lumbar facet joints causing mechanical neck and low back pain. 71 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 29 FLUOROSCOPICALLY GUIDED TRANSFORAMINAL EPIDURAL STEROID INJECTIONS FOR LUMBAR SPINAL STENOSIS AND LUMBAR DISCOGENIC PAIN SERDAR KABATAS Introduction: Epidural steroid injections (ESIs) have been used in the treatment of chronic low back pain (CLBP) with success. We therefore analysed the efficacy of fluoroscopically guided transforaminal ESI in patients with lomber spinal stenosis (LSS) and lumbar discogenic pain (LDP) with radiculopathy. Methods: We retrospectively analyzed the prospectively collected data of all patients with a diagnosis of CLBP performed fluoroscopically guided transforaminal ESI between February 2008 and December 2008. Twenty-nine patients with neuroradiological evidence of disc pathology with radiculopathy and LSS were included. All patients received at least one fluoroscopically guided transforaminal epidural injection with 80 mg methylprednisolone acetate and 2 cc of bupivacaine HCl 0.5%. Collected follow-up information included Visual Numeric Pain Scale (VNPS) and North American Spine Society (NASS) patient satisfaction scores. Results: Ages of patients ranged from 34 to 83 years old (mean,56.1±1.2 years old). Among them, 22 are women (75.86%), and 7 are men (24.14%). 68.96 % of patients were determined to have a successful outcome and 31.04% were deemed failures, respectively. Successes were found to differ significantly from failures in pre-injection pain scores and patient satisfaction (p<0.05). Conclusion: Fluoroscopically guided transforaminal ESIs have reliable results to perform in patients with LSS and LDP with radiculopathy. 72 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 30 PRELIMINARY REPORT ON PERCUTANEOUS TRANSPEDICULR SCREW INSTRUMENTATION COMBINED WITH MINIMAL ALIF APPROACH JOSIP BURIC*, DOMENICO BOMBARDIERI*, LUCA CORÒ° Objective: This study was performed to compare the minimally invasive circumferential fusion to standard open circumferential fusion for low back pain in lumbar degenerative disc disease. Background: Standard open circumferential fusion is associated with better clinical and radiological results than PLIF or TLIF fusion procedures but has a higher degree of intraoperative and post-operative complications. Minimally invasive ALIF combined with percutaneous trenaspedicular screw instrumentation has the potential of reducing the disadvantages of the procedure. Methods: Eighteen patients affected by low back and leg pain due to degenerative disc disease from L3 to S1 levels were submitted to the operation during 2007 year using this minimally invasive approach. Posterior part of the procedure was performed using the percutaneous transpedicular screws (Pathfinder, Abbott Spine) while the ALIF was performed in a minimally invasive retroperitoneal way implanting anterior full-body cage (Perimeter, Medtronic). Results: All of 18 patients improved upon surgery. The mean improvement was of 5,7 points on VAS scale and 7 points on the Roland Morris Disability Quetionnaire. The mean operating time for the posterior part of the procedure (skin to skin) was as follows: 50 minutes for one level and 80 minutes for two levels. The mean operating time for the anterior approach was 90 minutes for one level and 110 minutes for two levels. The total amount of time for both approaches, including the turn-up time for patient repositioning ranged from 160 minutes for one level till 300 minutes for double level. No major complications due to vascular rupture or peritoneal damage were encountered. As well, a nerve root damage was ever found. The mean blood loss per surgery was approximately 250 milliliters and in no patient blood transfusion was indicated. Surgical wound drainage was never used. All the patients were raised from the bed between 12 to 18 hours after the surgery. The longets hospital stay was 6 days. As compared to standard circumferential fusion, the reported post-operative pain was 3-fold less and the use of post-operative opioids and pain killers was 60% less. No wound or systemic infection was ever encountered. There were no complicatioins observed due to pulmonary embolism. Conclusion: Minimally invasive ALIF combined with posterior percutaneous transpedicular screw instrumentation seems an equally usefull system as compared to standard open circumferential fusion with the advantage of less blood loss, fewer complication rate, shorter operation time and shorter hospital stay. Longer follow-up is mandatory to verify clinical and radiological results. 73 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 31 TWO YEARS FOLLOW-UP RESULTS OF OVER 400 LUMBAR NUCLEOPLASTY CASES KEMAL YÜCESOY, MD Objective: To evaluate long term follow-up period results of lumbar disc nucleoplasty for the treatment of degenerative disc disease. Methods: We presented four hundred and two cases. All patients were evaluated with visual analogue scores and Oswestry back pain questionnaire results. Preoperative, early postoperative, first, third, and sixth month, one, and two year follow-up results were discussed. Results: 494 levels were treated by percutaneous disc nucleoplasty using coblation technique in four hundred and thirty six cases. 327 of these patients were female, and mean age was found 42.7 (14-64 years old). One level coblation was performed in 378 cases, and two level in fifty-eight (L5-S1 level in eighty-six, L4-5 level in three hundred and thirty-eight, L3-4 level in sixty-two, L2-3 level in five, L1-2 level in two, and T12-L1 level in one) without any complications. 34 of these cases dismissed during one and two years control follow-up examination, and we presented as late results of 402 cases. Mean visual analogue score was detected preoperatively, postoperatively, at one, three and sixth month, one, and two year follow-up controls and, 8.30, 1.02, 2.37, 1.55, 1.36, 1.48, and 1.64 was found, respectively. Also Oswestry back pain questionnaire scores were detected as 53.69, 16.18, 12.19, 7.18, 4.52, 6.38, and 8.04 at the same examinations. During the follow-up period second disc nucleoplasty was performed at same level in thirteen cases, and open surgery was performed in twenty-two. Conclusion: We can conclude that successful results are directly related to patient selection, physical examination and changing of life style. 74 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 32 ADULT STEM CELL TREATMENT IN SPINAL CORD INJURY – TECHNIQUE INDICATION AND FIRST CLINICAL RESULTS NILS HABERLAND, The adult stem cell therapy is nowadays established in the treatment of blood cancer and heart attack. New is the application of adult stem cells for neurological diseases and in brain and spinal cord injury. The aim of the study was to achieve first results in cases of spinal cord injury for the evaluation of the efficiency of the adult stem cell therapy. Method: We used bone marrow material from the iliac crest for the isolation and separation of the adult stem cells (CD34+). The reinjection of the stem cells we perform via lumbar puncture. We treated 100 patients with incomplete and complete spinal cord injury and evaluated 40 patients with a minimal follow up time of 3 months. Result: In 57.5% of the examined patients we saw an improvement of the neurological deficit. A deterioration of the neurological symptoms was not found and we observed not a specific complication regarding the adult stem cells. Conclusion: The first clinical results of the adult stem cell treatment are encouragering in cases of spinal cord injury. In our study the treatment was effective and safe. Prospective randomised studies are necessary for a scientific evaluation of this kind of stem cell treatment. 75 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 33 DIAM DEVICE FOR LOW BACK PAIN IN DEGENERATIVE DISC DISEASE J BURIC; M PULIDORI Objective: To evaluate the usefulness of the DIAM device in patients affected by low back pain due to degenerative disc disease. Background: Recently a number of interspinous devices for dynamic interspinous distraction-stabilization have entered the clinical practice in Europe. All of these devices have a common property of acting on the posterior part of the functional spinal unit by distracting the spinous processes and avoiding extension of the treated segment. Consequently, these systems seem to improve the cross-sectional area of the thecal sac and enlarge the diameter of the intervertebral foramina. What was found as a collateral observatin after implantation of these devices was that those patients affected by low back pain, improved significantly in their pain level. Methods and Materials: Fifty-two consecutive patients were included in the study. There were 29 females and 23 males, aged between 29 and 77 years (mean 49.4 ± s.d.12.4). The preoperative symptom duration ranged from 6 to 84 months (mean 31.8 ± s.d.20.2, median 24 months).The following diagnositic measures were prformed in each patients: MRI, dynamic x-rays and provocative discography positive for pain reproduction. The patients were followed for pain by VAS and for functional status by self-reported Roland-Morris Disability Questionnaire. The minimum follow-up was 24 months (24 to 36). The intermediate follow-up at six, twelve and eighteen months was tested for, too. Results: To determine the number of improved patients we have arbitrarly selected a cut-off criteria based on a 30³% of improvement as calculated on the Roland Morris Disability Questionnaire scale comparing the 24 months values to the baseline values. Fourthy-six patients (88%) were considered as success and 2 (4%) were considered as failure. No long-term complications were observed. Conclusions: This preliminary report indicates that the DIAM device colud possibly be usefull in the treatment of LBP due to DDD. Further research with RCT is necessary to confirm these preliminary results. Keywords – low back pain, degenerative disc disease, interspinous spacers, spine instrumentation 76 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 34 HYPEROSMOLAR DEXTROSE SOLUTION INJECTION ON LUMBOSACRAL MEDIAL BRANCH AND BILATERAL SACROILIAC JOINT FOR REMNANT BUTTOCK PAIN AFTER VERTEBRAL AUGMENTATION PROCEDURES CHANG IL JU, M.D. Background: Osteoporotic vertebral compression fractures (VCFs) in the elderly patient can cause significant pain and lead to restrict their daily life activities. Augmentation procedures (Vertebroplasty(VP) and kyphoplasty(KP)) have reported as a standard treatment of VCFs in cases of not responding to conservative treatment. However, the patients who have remnant pain after augmentation procedures are challenges to doctors and require the definite treatment. We have tried to inject hyperosmolar dextrose solution into the lumbosacral medial branch and bilateral sacroiliac joint for remnants buttock pain and report our results. Methods: Thirty six patients with remnant pain after augmentation procedures of 321 patients were surveyed. We judged the remnant pain when patients complained the pain after postoperative 2 days. The patients were performed bilateral lumbosacral (L4, L5, S1) medial branch injection and bilateral sacroiliac joint injection using hyperosmolar dextrose solution. Injection was given after 3-5 days VP and KP procedures. All remnant pain patients were evaluated at interval of 1-2 weeks and added injection if they had pain. Results: Total number of injection was 2.31. Pain intensity using VAS (visual analog scale) was decreased, from 8.78 before augmentation procedures to 4.33 after augmentation procedures to 2.67 after the first injection procedure and 1.97 after the second injection procedure. Successful outcome was determined if pain reduction exceeded 50% relief than post-augmented buttock pain state. 5 of the 36 patients (13.9%) did not respond favorably to injection (pain reduction less than 50%), and 31 patients (86.1%) showed successful responses. Conclusions: The hyperosmolar dextrose solution injection into the lumbosacral medial branch and bilateral sacroiliac joint to the patient who has a remnant pain after augmentation procedures in the patients with VCFs is the one of the methods that decreases the symptoms. 77 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 35 IN-SPACE (PERCUTAENOUS INTARSPINOUS SPACER) TREATMENT OF CANAL STENOSIS. T. SINAN, A. OBAID Intraspinous spacers have become an accepted minimally invasive method for treating Dynamic spinal canal stenosis. We present our experience using the INSPACE (Percutaenous Intraspinous spacer) in treating Dynamic canal stenosis in Kuwait. Material and method: Prospective study of 30 patients presenting with neurological claudication with dynamic canal stenosis on MRI. All patients were aged 50 +. IN-SPACE was used in these entire patients under fluoroscopy. Follow up was made at 1 week, 1 month, 3 month and some patients 6 months. VAS score was compared before and after procedure. Complications rate and patient satisfaction were noted. Results: > 70 % patients had significant improvement with no complications. We also describe the procedure. 78 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 36 OSTEOID OSTEOMA OF THE SPINE: GEIGER GUIDED RESECTION. ARSEN SHPIGELMAN, MD Background: It is often difficult to accurately localize the Nidus of Osteoid Osteoma ( OO ) during the operation. There has been a tendency to extensively excise the lesion with surrounding sclerotic bone to avoid recurrence due to presence of residual Nidus. We describe method of Geiger guided Resection of Osteoid Osteoma of the spine in 5 cases from our department. Method: We localized intraoperatively the Nidus with preoperatively injected technetium labeled methylene diphosphonate and a sterile wrapped Geiger counter. The radioactive agent was injected 12 hours before operation. The tissue around the Nidus reduce radioactivity 12 hours after injection of radioactive Technetium. Results: 5 cases of Block Resection of Osteoid Osteoma from the pedicle and facet area were proceeding. Technetium labeled methylene diphosphonate was injected 12 hours preoperative. We localized the Nidus of OO with Geiger counter intraoperative. Pain relive after operation in all cases. Clear Bone scan – without uptake – in the operative region half year after operation. Without local recurrence of the disease. Conclusion: We describe the simple and clear method to identify of Osteoid Osteoma of the Spine: * Before operation. * Intraoperative. We recommended to inject a radioactive agent 12 hours before operation for reduce of false negative identification of the tissue around the Nidus. We recommended to use of this method for identify and resection of Osteoid Osteoma from the pedicles of the vertebras. 79 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 37 INTERSPINOUS DYNAMIC SPACER (COFLEX) INSERTION, OUR EXPERIENCE AND SURGICAL TECHNIQUE. A.P.SHPIGELMAN, M.D., K.ASLAN, M.D., D.ANGEL, M.D. “BNAI ZION” MEDICAL CENTER, HAIFA, ISRAEL. Background: -More than 60% of the population suffer from low back pain at some time in their lives. -Low back pain is the primary cause of disability in individuals younger than 50 years. Subsequent interspinous process devices have been designed for longer-term implantation for managing various conditions, including spinal stenosis, disk herniation, segmental instability, and degenerative disk disease. Method: -We localized the surgical level with intraoperative X-Ray. -Limited incision approach was performed: 3 cm’ to one level disease and up to 5 cm’ to two level pathology. -Semilunate incision of the fascia was opened to the side of the foramenal stenosis or disc herniation. -Full removal of the Interspinous Ligament. -Spreading of the vertebras with laminar spreader. -Insertion of the Interspinous Spacer and fixation of the Spacer to the spinous processes. Results: -Radicular and Low Back Pain relief immediately after the surgery. -Minimal postoperative wound pain due to Less Invasive Surgery. -Early patient’s mobilization after the surgery. -On the postoperative and follow-up examinations and imaging – preserve of the Intervertebral Disc Space and Foramenal Diameter, natural motions in the segment. Conclusion: -We describe the simple and clear technique of Back Pain Treatment. -Motion Preservation by Dynamic Interspinous Spacer insertion. -Limited Incision Procedure was performed to insertion of the Spacer. 80 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 38 “COFLEX” EXPERIENCE ALEXANDRE LEVSHIN 81 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 39 HIGH ANTERIOR CERVICAL APPROACH TO THE UPPER CERVICAL SPINE: A QUANTITATIVE ANATOMICAL AND MORPHOMETRIC EVALUATION MEHMET SENOGLU 1, DAVUT OZBAG 2, YAKUP GUMUSALAN 2 Abstract Object Knowledge of the quantitative anatomy of the C2 spine is essential to safely perform anterior plate-screw fixation of the C2 spine. Injury to the spinal cord during drill or screw placement is the most feared complication of this procedure. Therefore, proper screw length is the most important issue for safety of vertebral body screw placement. Obviously, understanding the safety distance between the entry point of screw insertion and the posterior cortex of the vertebral body is essential. In this study, we analyze the anatomy of the C2 body relevant to C2 anterior plate-screw fixation. Materials and Methods Eighty-six dried C2 spines were evaluated directly for this study. Measurements were made on the C2 body width and midsagittal anteroposterior (AP) depth as well as AP parasagittal depth 5 mm lateral to the midline on the inferior endplates, in addition to on the middle body. Measurements also were made on AP parasagittal vertebral depth with both medial and lateral inclination of 10 degrees, with respect to the parasagittal plane of the vertebral body. Results The ideal maximum screw length and trajectory was found to be AP medial parasagittal depth of inferior surface of the C2 body [Right: 13.7±1.4 mm (11.0-17.9), Left: 13.6±1.5 mm (10.7-17.8)]. Conclusions We report the measurements of the vertebral body of the C2. We think these measurements provide guidelines for conducting operations on the anterior C2 spine, and enhance the confidence interval of the surgeon. Key Words: anterior plate, screw, corpus, C2, axis. 82 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 40 SYRINGOMYELIA: RETROSPECTIVE CLINICAL ANALYSIS & REVIEW OF THE SURGICAL TREATMENT OPTIONS BAYRAM CIRAK, ACAR F, COSKUN E, SITTI I. DEPARTMENT OF NEUROSURGERY, PAMUKKALE UNIVERSITY, MEDICAL SCHOOL SYRINGOMYELIA: RETROSPECTIVE CLINICAL ANALYSIS & REVIEW OF THE SURGICAL TREATMENT OPTIONS Sitti I, Cirak B, Acar F, Coskun E Syringomyelia is a progressive and degenerative disease characterized by longitudinal cystic cavities all along the spinal cord. Cervical spinal cord being the most commonly affected part. Magnetic Resonance İmaging study is the gold standart for the diagnosis. Although diagnosis is easy there is a controversy about the treatment. There are different types of surgical treatment some of which are, simple drainage by either percutaneous or open surgical route, posterior fossa and foramen magnum decompression and dural decompression in case of tonsillar herniation and syringomyelia, cysto-pleural (or cysto peritoneal, or cystosubarachnod) shunting. In these study, we retrospectively analysed the surgical treatment results of patients admitted to our clinic with the diagnosis of syringomyelia. All the cases have been evaluated with respect to type of surgical treatment. In between 2005 and 2008 19 patients have been admitted and operated on with the diagnosis of syringomyelia. Mean age was 33 (r:3-64), male / female ratio was 8/11, All the patients were diagnosed with the evaluation of MRI. 19 patients have undergone 28 operations. Mean follow up was 13 months. Neurological condition and status of all the patients were evaluated before and after the surgery and during follow up. 83 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 41 SIGNIFICANS OF MORPHOMETRIC AND VOLUMETRIC EVALUATION OF LUMBAR VERTEBRAL BODIES FOR CORPECTOMY RECONSTRUCTIONS: A STEREOLOGICAL STUDY NUKET MAS MD PHD ASSIST PROF., SELIM KARABEKIR MD ASSIST PROF., TOLGA ERTEKIN PHD, METE EDIZER MD PHD ASSIST PROF., YAZICI CANAN PHD ASSIST PROF. Objectives The use of technologies for the treatment of degenerative spinal diseases has undergone rapid clinical and scientific development. It has been extensively studied in combination with various techniques for spinal stabilization from both anterior and posterior approach. Anterior access to the L1-L5 disc space can be technically challenging, frequently requiring the use of an approach surgeon for adequate exposure. For a successful surgery and a suitable instrumental design via screw, adequate morphometric knowledge about body of lumbar vertebra and standardized volumetric data is also required. There are some reports about the relationships between the surgical manifestations and the vertebral body morphology in patients with degenerative spinal disease, traumatic and non-traumatic fractures and vertebral malignities. Delineating the normal lumbar vertebra volume and its neurosurgical importance interested in both the anatomists and the spinal surgeons. In the present study, we aimed to evaluate the lumbal vertebra using a stereological technique. determine the morphometric mesurements of the bodies depending on gender. Materials and methods Randomly selected individuals (11 males, 10 females) aged between 25– 85 years who have normal lumbar MR and CT were enclosed in the study. Volumetric lumbal vertebras were evaluated via stereological method on the magnetic resonance (MR) images of healthy subjects. We evaluated volumetric measurements of the body of lumbar vertebrae using a CT scan and MR via stereological technique. The shape and volumetry of the L1-L5 vertebra, vertebral body length, vertebral body width, and also height were analyzed selected axial and sagittal slices that passed through the upper part of the body of all lumbar vertebras and another one that passed through the lower part of them with comparing each other. The data set were analyzed by two factor repeated measure analysis. Results The lumbal vertebra volumes were evaluated comparing with each other according to gender.. Body of vertebra measurements were evaluated. Conclusions The stereological evaluation of lumbar vertebral analysis in humans correlate with gender is of importance for both clinicians and anatomists. The stereological volume analysis technique is simple, reliable, unbiased and inexpensive. Further studies are needed with larger samples in order to support the data. Keywords Lumbar vertebra, body, morphometry, volumetry, stereology, magnetic resonance imaging,computed tomography 84 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 42 A NOVEL TECHNIQUE OF MICROSURGICAL APPROACH THROUGH LAMINOFACET ARTICULAR JUNCTION FOR LUMBAR DISC HERNIATION (HOLE APPROACH) AND VIDEO PRESENTATION FIGEN YAGMUR ASLAN Objects: Hole approach has not been described in lumbar disc herniation, previously. We aim to give details and results of a new operation technique, used in 516 patients with different localization and types of disc herniation. Methods: Between March 2001 to 2007, 516 patients with lumbar disc herniation underwent Hole approach. In this procedure, in order to expose facets of the inferior articular edge superior and inferior facets were removed minimally by high-speed drill. The facet capsule left intact and opened a hole (as large as a thumb nail) in the junction between the facets and the lamina. After the root was found, the disc was removed, yellow ligament opened minimally. Also the residue disc may be taken out from contralateral side by using this technique. Same side and controlateral side disc may be cleaned at the one side operation in this technique. Patients data included; leg and back pain, return time to daily activity, Oswestry pain score, and final outcome. Patients were evaluated with post operative spiral CT and three dimensional reconstruction CT to show the amount of bone removing. Results: Following the operation no one had leg or back pain. All patients were able to mobilize at ½ to 4 hours, returned to daily activities at 5 to 7 days postoperatively. When compared with preoperative Oswestry pain score (46 ± 3,3), postoperative score (3,1 ± 0,9) was significantly decreased (p<0,001). Conclusion: The goal of this approach were to protect to the facet articular joint, to used procedure in every type and size of disc herniation, to open the yellow ligament minimally, and return the daily activity and work early. Hole approach is a very safe and effective by means of treatment for back pain and sciatica pain caused by same side and controlateral side disc herniation. 85 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 43 A NOVEL TECHNIGUE OF MICROSURGICAL APPROACH TROUGH LAMINOFACET ARTICULAR JUNCTION FOR FORAMINAL STENOSIS AND SPONDYLOLISTHESIS (HOLE APROAACH) AND VIDEO PRESENTATION FIGEN YAGMUR ASLAN Objectives: Hole approach on the foraminal stenosis and spondylolisthesis has not been described previously. In this study, we aim to give details and results of a new operation technique, used in 136 patients with foraminal stenosis and spondylolisthesis. Patients and Methods: Between March 2001 and 2007, 93 patients with foraminal stenosis and 43 patients with spondylolisthesis, who had conservative treatment before, were operated with hole approach. During operation a hole 0,5-1 cm was opened articular joint edge and conjunction between facet and lamina. At this approach minimaly inferomedial edge of the superior facet and superomedial edge of the inferior facet were drilled away by Anspach. Facet capsule leave intact. By guidance of the disc space, the portions and osteofit anteriorly, and medial face of the facet posteriorly were cleaned. Inferior and superior root conjunctions were exposed and interapophyseal space was released. Any instrumentation system and fusion were not used. Patients data included; leg pain, paresthesia, and weakness, return time to daily activity and Oswestry pain score and final outcome. Patients were evaluated with post operative spiral CT and three dimensional reconstruction CT to show the amount of bone removing. Results: All patients were mobilized within 4-6 hr, discharged within 24-48 hr, sat down within 8-12 days, returned to daily activities and works within 15-25 days. Postoperative Oswestry pain score (3,4±1,7) was significantly decreased when compared with the preoperative pain scores (38,8±5,01) in the patients with foraminal stenosis (p<0.001). Conclusion: Hole approacch may be considered as a safe and effective a new procedure for the patients with foraminal stenosis and spondylolisthesis. This approach will be use multilevel segment and any instrumentatition system were not used . 86 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 8 THE LUMBAR FACET SYNDROME RADCHENKO V., M.D. SYTENKO INSTITUTE OF SPINE AND JOINT PATHOLOGY 61024, KHARKOV, UKRAINE Introduction. The lumbar facet syndrome is encountered most frequently, it follows that possible ways of its treatment are particularly important. Purpose Estimation of possibilities of diagnostics and treatment of patients with a lumbar facet syndrome Materials and methods We used morphological material of 56 facet joints of the lumbar spine taken in the course of the operation of the posterior lumbar interbody fusion on levels L4-5 and L5-S1 for various structural and functional disorders of the lumbar spine; 52 arthrograms of the facet joints. Results of intraarticular blocades (518 patients), data about 428 patients having lumbar facet syndrome which underwent mini-invasive surgical treatment including denervation and percutaneous arthrodesis. 201 patients were treated by way of denervation through electrocoagulation (1-st group) and 211 by way of cryodestruction (2-nd group). Percuteneous arthrodesis was performed in 16 patients. The results were evaluated by Oswestry scale. Results Morphological investigation demonstrated the whole range of changes characteristic for the sinovial joints. By data of the articular arthrography the picture peculiar to instability, severe arthrosis was determined. In 3 cases diverticuli of the upper turn of the facet joint markedly influencing the formation of clinical symptoms were identified. The results of the intraarticular blocades in the intraarticular group were good - 65%, satisfactory - 33%, unsatisfactory - 2% . In the paraarticular group they were good 58%, sutisfactory – 35%, unsatisfactory - 7%. In the course of comparative analysis of the results in first and second group facet denervation we could find significant difference in favour of cryodestruction. Among the patients with the percutaneous arthrodesis performad 15 patients had good result and in 1 patient the condition was not changed. Conclusion Variable changes of the facet joints of the lumbar spine play a significant role in the formation of pain syndrome and their diagnostics and treatment demand a special consideration. Application of active tactics in the treatment of the lumbar facet syndrome makes it possible to achieve good results. 87 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 9 CLINICAL RESULTS FOR LATERAL LUMBAR DISC HERNIATIONS WITH PELD, 10-SYRINGE DISCECTOMY AND RETROPERITONEOSCOPY AKIRA DEZAWA Purpose The object of this study was to introduce the transforaminal Percutaneous Endoscopic Lumbar Discectomy (PELD) and retroperitoneal laparoscopic (retroperitoneoscopic) lateral approach. Techniques and to assess the safety and efficacy of treating patients with far-lateral and foraminal disc herniations via a percutaneous transforaminal endoscopic approach. The incidence of a lumbar disc herniation lateral to the facet has been reported to be between 0.7 and 11.7% over all sites of a lumbar disc herniation. Methods From May 1997 to December 2007 we operated 39cases of PED (20cases) and 10syringe discectomy (16) and retroperitoneal laparoscopic lateral approach (3) for far lateral and foraminal lumbar disc herniations. A retrospective analysis was performed of 39consecutive patients who underwent surgery via this approach. All procedures were performed after induction of a local anesthetic on an outpatient basis. Surgical indication was intractable leg pain regardless of symptom period, which was resistant to conservative treatment including selective root block. Results Outcome was measured with Macnab criteria and by determining a patient's return-toprevious work. The median follow-up period was 15months (range 10-33 months). Excellent or good outcome was obtained in 31 (79.5%) of 39 patients. Of the 39patients playing sports and working before the onset of symptoms, 32 (82.1%) returned to previous work and sports. One patient (2.5%) experienced poor outcomes and subsequently underwent open procedures at the same level. There were no complications. Conclusions RLLA 10-syringe discectomy provide adequate exposure necessary for extraforaminal exploration, discectomy and nerve root decompression. PELD is sufficient for minimally invasive treatment of extreme lateral lumbar herniation. 88 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 10 LUMBAR DYNAMIC SEGMENTAL RESTABILIZATION : THE DYNESYS® EXPERIENCE 1999-2009 LEU HJ., PD DR.MED., PRESIDENT ISMISS 2008-2011 BETHANIA SPINE BASE, ORTHOPAEDIC SPINAL SURGERY, KLINIKUM BETHANIEN CH-8044 ZÜRICH / SWITZERLAND – BETHANIA-SPINE@BLUEWIN.CH In modern western societies, degenerative disc disease is an increasing therapeutic and economic problem in modern societies and afflicts over 80% op population at least once in lifetime. The reasons ground in changed live stile with more sitting working position, long sitting schooling periods in decisive adolescent skeletal maturation phase of life. Beside changes in physical behavior also some nutritional aspects in post-agricultural societies may play a relevant role. While in an early stage lumbar disc failures as protrusion and herniation prevales, in a later stage segmental instability deserves our diagnostic and therapeutic interest. Segmental instability has become a controversially defined and treated vertebral pathology with considerable impact also on tt costs. From asymptomatic hypermobility up to instability covers a larger field of different combined pathologies that need well differentiated treatments. In cases without neurologic implication a physical therapy with isometric circumferential stabilization remains the golden standard. Where this fails, treatment options are to consider following the structures to treat. For diagnostics, beside clinical examination various imaging techniques help to determine the concerned level. First is conventional functional x-ray, the classic lumbar functional myelography and where available dynamic MR-imaging. This newest technique nevertheless has its methodical limits in symptomatic patients due to up to unbearable pain with motion-artefacts during still relatively long exposure time. In cases with isolated mono- or bisegmental instability of the ventral pillar including alsp posterior facet disease, interbody restabilization with fusion or total disc replacement (TDR) are available; in cases with isolated inborn defects of the posterior facet pillar - such as spondylolysis – an interbody fusion (PLIF) remains the golden standard. TDR is fine in cases with untreatable dysfunction of the disc with intact mid/posterior pillar structures. Due to persisting facet problems where preoperatively present and potential problems due to its anterior operative approach (e.g. lesions of the plexus hyposgastricus with potential sexual dysfunctions), its indication remains narrow and its outcome controversial. Where instability is due to spondylolysis, local isthmic repair hardly brings reproducible results in larger series. In degenerative facet disease without pseudolisthesis less then grade II, a dynamic restabilization with pedicular anchorage (e.g. DYNESYS® developed by Dubois in France 1994)) is our treatment of choice since its clinical introduction in 1999. In mayor pseudolisthesis segmental instrumented fusion remains the tt of choice. Interspinal implants can be a favorable option in an elderly patient without considerable all-day demands and restricted systemic options for mayor surgery. In an younger active patient, beside lost of correction due to spinal process arrosion and other risks as their limited lateral bending stability can maintain facet irritation symptoms. As degenerative instability is often combined with soft (ligamentary) stenosis, combined treatment is mandatory and deserves our individual evaluation for specific operative adaptations. Since 1999 to 2007 over 572 cases with lumbar posterior facet disease and lumbar soft stenosis were treated with a combination of interlaminar decompression in combination with a pedicular based posterior bilateral dynamic stabilization device. A selscted group of 224 cases with over 5 year decourse and some specific problems as screw-loosening, spontaneous interfacet fusion and seldom reported late infection of its textile cable components are presented. The clinical overall outcome reached a score of 7.6 while a control group of 100 cases with conventional fusion reached 6.8 in the Balgrist-score. As the indications of Dynesys involve less advanced pathologies, the slightly better score is not significant. The same is to consider for the slightly lower rate of adjacent level degeneration over 5 years. The main advantages remain its less invasive operative procedure and the easier muscular rehabilitation. 89 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 11 ENDOSCOPIC MICRODECOMPRESSIVE CERVICAL DISCECTOMY AND FORAMINAL DECOMPRESSION OVER 2000 PATIENTS CHIU, JOHN C., M.D., FRCS, D.SC, DIRECTOR, NEUROSPINE SURGERY CALIFORNIA SPINE INSTITUTE MEDICAL CENTER, THOUSAND OAKS, CA 91320, USA Purpose: To demonstrate outpatient endoscopic microdecompressive cervical discectomy and foraminal decompression, with mechanical decompression and lower level non-ablative Holmium laser for disc shrinking and tightening effect (laser thermodiskoplasty), performed for treatment of symptomatic herniated cervical disc to be efficacious and safe, and preserves spinal motion. Materials and Methods: Since 1995, 2100 patients (3875 Discs), who failed at least 12 weeks of conservative care were treated. Levels were C2 to C7, inclusive. All patients demonstrated unilateral radicular pain of a specific dermatome, single level or multiple levels, confirmed with EMG/NCV. MRI or CT scans demonstrated the herniated cervical disc. Anterior endoscopic microdecompressive cervical discectomy and foraminal decompression technique is described. Non-ablative lower Holmium laser energy was added for disc shrinkage. Results: Average time to return to work was ten to fourteen days. At an average follow-up of 48 months. For single level, 94% had good to excellent symptomatic relief and spinal motion preservation. There were no intraoperative complications. Postoperatively, one patient with transient Horner’s syndrome and one transient hoarseness voice were noted. 6% of patients had persistent neck and upper extremity pain associated with parasthesia, after surgery. Conclusion: This endoscopic microdecompressive cervical discectomy and foraminal decompression with mechanical decompression and lower level non-ablative Holmium laser for disc shrinking and tightening effect (laser thermodiskoplasty), has proven to be safe, less traumatic, easier, and efficacious with significant economic savings. It preserves spinal motion and provides a channel for spinal arthroplasty. It is an effective alternative or replacement for conventional open cervical spinal surgery for discectomy, and can decompress stenosis, in degenerative spine disease. 90 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 44 STAND-ALONE KYPHOPLASTY OF THE THORACOLUMBAR JUNCTION – POTENTIAL FOR SEVERE COMPLICATIONS C. BIRKENMAIER1, T. SEIDL2, B. WEGENER1, V. JANSSON1 AND H. TROUILLIER2 Introduction: Kyphoplasty is a popular therapy for osteoporotic vertebral fractures (OVF), based on an easyto-learn technique and few perioperative complications. Good reimbursement and intense advertisement by the industry also play a role. The technique is not exclusively being performed by surgeons with experience in the treatment of traumatic spinal fractures. The PMMA-bonecement that is employed for the procedure is much stiffer than osteoporotic cancellous bone, it does not biologically integrate into bone and there is no secondary stabilization around the tamp. Methods: Analysis of 9 cases referred to our departments from 2006 through 2008. All patients had received kyphoplasty of the thoracolumbar junction or the thoracic spine at other institutions and were subsequently referred to our departments. After initial improvement, all patients experienced renewed pain and immobilization within weeks, several patients suffered neurological deficits. Presented is an analysis of the radiographic features of these fractures, their biomechanics, how these relate to the AO fracture classification and what the implications for the primary stability of these fractures are. Results: In all 9 cases, gross instability was found around the cement tamp, in several cases with advanced destruction of neighboring vertebrae and in several cases with subtotal spinal canal occlusion. 1 case had an infected bone tamp in addition. Analysis of the preoperative imaging studies gave evidence to unstable burst fractures, pedicle root discontinuity or disc-withendplate avulsion. The low contrast of severely osteoporotic vertebrae in CT combined with thick slices and incomplete multiplanar reconstructions may have been contributing to misjudging these fractures. 8 patients required multisegment posterior instrumentation, some with vertebral body replacement for anterior support. 1 patient died from complications of immobilization prior to the scheduled stabilization. Discussion and Conclusion: Performing kyphoplasty in unstable OVF may cause complications that far exceed the original problem. Correct fracture analysis is of paramount importance and a high-resolution, thin-slice CT scan with multiplanar reconstructions is required. Fractures of the thoracolumbar junction are demanding to treat and stand-alone kyphoplasty in this region carries significant risks. If, based on thorough fracture analysis, kyphoplasty cannot with certainty achieve adequate primary stability, additional pedicle screw stabilization should be used. Because of the osteoporosis, pedicle screw augmentation with PMMA may be needed in order to avoid screw cut-out. Alternatively, conservative treatment with a custom cast brace may be considered. 91 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 45 VESSELPLASTY USING SRHA NEW CEMENT (OSTEO-G®). A PRELIMINARY REPORT. DARWONO A. BAMBANG, M.D. DEPARTMENT OF ORTHOPAEDIC SURGERY, GADING PLUIT HOSPITAL, JAKARTA, INDONESIA. Object. Vesselplasty system, was percutaneous Osteoplasty technique (moulding the bone) to treat the symptomatic vertebral compression fractures (VCFs), by injection of bone filler materials (BFMs) : polymethyl metacrylate (PMMA), other kinds of bone cement, or different kind of osteoinductive / osteoconductive materials. Since 2004 over two hundreds vesselplasty were done using a mixture of PMMA 70% + Ca sulfate 30% + radioopaque dye in viscous condition. The point of this mixture is to reduce the heat, extend the setting time longer, and the visibility of cement during the procedure through Carm imaging. The viscous condition is used as a hydrostatic pressure to restore the vertebral body’s height while injecting inside the vessel container. In certain condition the vesselplasty was performed in bilateral or unilateral through transpedicle or extra-pedicle routes, and through a proper procedure this system is able to prevent risk of leakage of BFMs. A New SrHA cement (Osteo-G®) from A-Spine Holding Co was used as BFMs in vesselplasty. The purpose of this study was to review the advantage of SrHA cement compare to the previous mixture of PMMA and Ca sulfate cement. Methods. A non randomized prospective study of vesselplasty using new SrHA cement was done either bilateral, unilateral, through trans- or extra-pedicle routes. The heat, viscosity, setting time of the cement, the short term, mid- and long term result inside the vertebra of the patients were evaluated by X-ray and Ct-scan. Results. 8 cases of VCFs that have been treated using vesselplasty and new SrHA cement. Two cases dropped and only 6 cases can be evaluated and reported. Conclusions. The results of Vesselplasty technique are excellent. This technique allows the stabilization and restoration of vertebral body height of VCFs, with the advantage in controlling the volume of the injected BFMs , the pressure inside BFC, also preventing the leakage of BFMs, and left as an implant body expander. The preliminary results of new SrHA cement show that the heat, viscosity, and setting time of the cement are ideal for vesselplasty, but to evaluate the result inside the vertebra in short-, mid- and long term need longer follow up and bigger number of samples. Key Words : 92 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 46 PERCUTANEOUS VERTEBROPLASTY OF OSTEOPOROTIC FRACTURES OF THORACAL AND LUMBAR SPINE WITH VARIOUS COMPOSITIVE MATERIALS ANDREY POPOV 93 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 47 COMPLICATIONS OF VERTEBROPLASTY KEMAL YUCESOY Objective: The aim of this study is to vertebroplasty in pathological fractures. evaluate the complications of percutaneous Introduction: Complications related with vertebroplasty have become the subject of clinical studies with the increasing number of procedures. There can be puncture associated complications such as wrong needle path leading to fracture of the pedicle or mechanical irritation of the nerve root, pneumotorax , thecal injury and epidural bleeding. Cement leakage can also be an important complication during the procedure. Since polymethymethacrylate is injected as liquid, microfractures at the margins of the vertebral bodies or filling of intraosseous veins can lead to extravasation. Methods: Vertebroplasty technique was applied on 101 patients and 122 levels with the diagnosis of vertebral fractures. Procedure was undertaken under local anesthesia with the aim of a x-arm device. Complications of the surgical procedure along with the clinical and radiological properties of the cases were evaluated. Etiological factors were secondary to trauma in 41 cases, osteoporotic compression fracture in 39, compression secondary to metastatic tumor in 16 cases, hemangioma in 3 cases and solitary plasmasytoma in 2 cases. 79 cases were treated at one level and 22 cases at 2 levels.( 1 case of T3, 1 case of T4, 3 cases of T7, 2 cases of T8, 2 cases of T9, 5 cases of T10, 6 cases of T11, 32 cases of T12, 36 cases of L1, 15 cases of L2, 7 cases of L3 , 7 cases of L4 and 5 cases of L5). All patients were evaluated with visual analogue scores and Oswestry back pain questionnaire results. Results: The major problem experienced in our series was complications related with cement leakage. Minor leakage was detected in 25 cases; leakage into intervertebral disc space (14 cases), vascular leakage (3 cases), extravasation beneath ALL (8 cases). Major leakage was detected in 3 cases as leakage into the neural canal. We applied open surgery in all of these 3 cases. First case was belongs to our late (three hour later) procedures because of slowly progressive neurological deficit and, insufficient viewing on C-arm. She was treated with hemilaminectomy to decompress the neural structures but resulted in paraplegia. Others were operated on with a very quick manner with total laminectomy and removal of the extravasated PMMA and were all deficit-free (Figure 1). Long-term follow-up of our cases revealed that 5 cases were re-operated because of adjacent segment fractures. Four of these cases suffered from leakage into the intervertebral disc space in the first procedure. We experienced no complications related with the puncture of the needle, nor allergic reactions in our series. Conclusion: In general, PVP is quick, safe and easy but complications can be severe and should not be underestimated. Excellent fluoroscopy technique is mandatory to optimize the anatomic orientation and awareness of cement leakage or puncture associated situations. All PVP procedures must be done in operating room in order to access to the neural canal with open surgery in cases of major complications. Sedation can also be superior to general anesthesia as patients can be aware of symptoms such as radicular pain or paresthesis and can warn the clinicians for the possibility of complication. 94 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 48 DESIGN RATIONALE AND PRELIMINARY CLINICAL RESULTS OF NUNEC, A PEEK-ON-PEEK CERVICAL ARTHROPLASTY SYSTEM. A.R. GILTAIJ Introduction Fusion has been the gold standard as the surgical treatment for DDD, but disc arthroplasty is gaining more popularity based on motion-preserving characteristics and theoretically, preventing accelerated disc degeneration at adjacent levels. NuNec is a novel cervical device developed to maintain motion, while not interfering with MRI/ CT and incorporating a fixation system that does not require overdistraction or keel cutting of bone. Design Similar to most cervical disc arthroplasty devices, NuNec has an inner ball/socket articulation. The device is manufactured from PEEK-OPTIMA with hydroxyapatitecoated outer surfaces and is fixated by a unique CAM interference screw locking mechanism. Fixation strength was tested with bench-top pullout testing and bony ingrowth was examined in a pilot study with an in-vivo caprine model. Wear testing of the device was conducted following ASTM/ISO recommendations. Most cervical arthroplasty devices are of metal-on-metal or metal-on-UHMWPE, resulting in strong MRI/CT artifacts prohibiting accurate future diagnosis on the index level. NuNec is made from radiolucent PEEK and will not interfere with MRI and CT. For fixation of the endplates to the adjacent vertebrae, most devices use keels, flangescrews or spikes. Keel designs have the potential risk of spinal cord injury during keel cutting and splitting of the vertebral body, especially for multi-level disc arthroplasty. Spikes need overdistraction for implantation of the device. Also most devices have roughened, plasma-sprayed metallic surfaces to enhance by bone ingrowth. The CAM design of NuNec offers implantation with zero profile and fixation by rotating interference CAM’s into the endplates. Bench-top pullout testing has shown this CAM design has a fixation force higher than most keel and flange-screw designs. The hydroxyapatite coating does not affect the chemical and mechanical properties of the device; 3-month results from an in-vivo caprine model have shown excellent bony apposition to the coating/PEEK with no adverse histological response. Wear testing shows a wear rate comparable to other devices. Conclusion NuNec is the first articulating radiolucent cervical arthroplasty device in combination with a unique, instinctive mechanical fixation with a hydroxyapatite coating. These design benefits have been demonstrated through preclinical testing and have allowed for advancement to the clinical stage. 95 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 12 PERCUTANEOUS LASER DISCECTOMY. STATE OF THE ART. LONG TERM RESULTS. PIER PAOLO MENCHETTI 96 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 13 MINIATURE ROBOTIC SPINE SURGERY – A SURGICAL TOY OR A BREAK-THROUGH? Y. BARZILAY, M. LIEBERGALL, L. KAPLAN SPINE UNIT, DEPARTMENT OF ORTHOPEDIC SURGERY, HADASSAH HEBREWUNIVERSITY MEDICAL CENTER, JERUSALEM, ISRAEL Instrumentation has become an integral part in traumatic, infected, neoplastic and degenerative spinal conditions. Misplacement of implants may result in immediate catastrophic events, or may lead to inferior mechanical properties of the construct and may lead to late sequel such as adjacent level degeneration. Many efforts have been made to increase the safety of instrumentation. Factors affecting misplacement include: surgical experience, the area of the spine operated on, factors affecting anatomy (deformity, severe degeneration, previous surgery, etc.). Fluoroscopy guided implantation increases the accuracy, however, lumbar pedicle screw misplacement may reach 30%, thoracic misplacement may reach 50% and cervical screws misplacement may reach 70%. The rate of clinical consequences, although much lower, harbors medical, legal and financial issues. The need for navigated systems in the aid of spinal instrumentation is quite intuitive, however until efficacy and cost-effectiveness are proven their routine use is not expected. Computer assisted navigation systems have been introduced in the 1990's, however none gained enough popularity, and most are sitting in the corridors of the operating theaters serving as "white elephants". The reasons for failure may include high cost, cumbersome procedures, the need for extra-staff and the need for a direct line of sight. Miniature robotic spine surgery is a new concept for aiming instrumentation in various spinal procedures. The basic steps in its use include: 1. A high resolution CT scan 2. Pre-operative planning based on 3-plane 2-D reconstructions of the CT imported to the software 3. Connection of one of the three robotic platforms to the patient 4. Acquisition of 2-plane fluoroscopy images with a target connected to the robotic platform 5. Connection of the robot to the platform and execution of the surgical plan. Studies performed on cadavers have demonstrated its accuracy and reliability, together with a short learning curve and a significant reduction in the need for image control and the exposure of the OR staff to irradiation. Robotic guidance has been used in several centers around the world in the introduction of pedicle screws, trans- laminar screws, vertebral augmentation needles and biopsy needles. It was also used in deformity surgery and to locate and excise small lesion such as osteoid osteoma. Between 9/2006 and 1/2009 robotic guidance was used in 65 patients in our institution. Mean patient's age was 61.7 (14-84), 39 were fames and 29 were males. In 51 patients pedicle screws were inserted with robotic guidance, while 11 patients underwent vertebral body augmentation with cement or core needle biopsy and 1 patient underwent excision of an osteoid osteoma. Mean surgical time was 196 minutes (47-435), off which 34 minutes (14-95) were needed for robotic guidance. 245 trajectories were planned (1 to 8, mean 3.8 per case). Misplaced entry points and trajectories were recorded in slightly over 4% (10 trajectories), however, these were detected before the vertebra was instrumented and therefore no harm was done to the patient. Two critical steps prevent better results at the moment – errors of planning and technical errors causing an unstable connection between the robot's platform and the patient's body. Omitting all cases were technical errors were encountered (Malfunction of the system or mounting the platform in an unstable manner) – the system was found to have an accuracy of 97%. 97 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional ML - 14 MINIMALLY INVASIVE LATERAL TRANS-PSOAS APPROACH TO TREATING THORACIC AND LUMBAR SPINAL DISEASE BURAK M. OZGUR MD. Purpose: The purpose of this study is to demonstrate the versatility and effectiveness of the minimally invasive lateral trans-psoas approach (XLIF). Introduction: This approach can be used in accessing the lumbar spine above L5 and the lower thoracic spine. We have used it repeatedly, safely, and effectively for common single level degenerative disc disease as well as multilevel adult degenerative scoliosis. It affords minimally side-effects and lend itself to much of the spine disease population. Patients tend to recovery very quickly and soft tissue is preserved especially in comparison to traditional open spine surgery. Methods: We aim to demonstrate five key representative cases in which we have used technique to access the spine from the lower thoracic spine to L5. A retrospective data and imaging analysis has been performed. Results: Our results confirm the safe and effective use of the XLIF procedure in accessing the spine from the thoracic spine down to L5. Complications are rare. The results are reproducible. Conclusions: The minimally invasive lateral trans-psoas approach to the spine is a safe and effective technique used more and more by the spine surgeon. The advantages of minimally invasive surgery are appreciated and the outcomes are thusfar at least equivalent to traditional spine surgery. 98 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 49 PERCUTANEOUS LASER DISCECTOMY. STATE OF THE ART. LONG TERM RESULTS. PIER PAOLO MENCHETTI 99 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 50 MINIMALLY INVASIVE TRANS-SACRAL APPROACH TO THE LUMBOSACRAL SPINE BURAK M. OZGUR MD. Purpose: The purpose of this study is to demonstrate the versatility and effectiveness of the minimally invasive trans-sacral approach to the lumbo-sacral spine (AxiaLIF). Introduction: This approach can be used in accessing the L5-S1 lumbar spine and in select cases may afford access to L4-S1. We have used it repeatedly, safely, and effectively for single level degenerative disc disease as well as 2-level disease in some patients with appropriate anatomy. It affords minimally sideeffects. Patients tend to recovery very quickly and soft tissue is preserved especially in comparison to traditional open spine surgery. Methods: We aim to demonstrate five key representative cases in which we have used technique to access the L5-S1 or L4-S1 spine levels. A retrospective data and imaging analysis has been performed. Results: Our results confirm the safe and effective use of the AxiaLIF procedure in accessing the lumbo-sacral spine. Complications are rare. The results are reproducible. Conclusions: The minimally invasive trans-sacral approach to the spine is a safe and effective technique used more and more by the spine surgeon. The advantages of minimally invasive surgery are appreciated and the outcomes are thusfar at least equivalent to traditional spine surgery. 100 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 51 ENDOSCOPY AND PERCUTANEOUS ARTHRODESIS IN RELAPSED DISCAL HERNIAS DANIEL GASTAMBIDE (PARIS), PIERRE FINIELS (NIMES), PATRICE MOREAU (BOURSAY) Relapsed lombosciaticas provoked by recurrence of a discal hernia previously operated on are the most worrying for the patient and the surgeon together. The rate is from 5 to 16% and is increasing with the follow-up of the observed series. The aim of this study is to show the updated indications of secondary surgery, by endoscopic transforaminal discectomy (ETD), by percutaneous intersomatic arthrodesis by percutaneous cages (Europa) under local anesthesia and sedation, and by open posterolateral arthrodesis (PLIF). The story of several series amongst our patients is complex: 52 suffered from relapsed lumbosciatica due to discal hernia at the same level. The following graphic shows the different kinds of last operations according to the first operations: Last OP type according to 1st OP type of same level FIRST OP last OP 21 open surgery 14 ETD 19 ETD 9 ETD 8 open surgery 2 ETD then ETD 3 RF or laser 1 CNL 5 Europa 5 Europa 6 Europa 1 1 4 PLIF 1 3 ETD 1 Two other patients suffered from a relapsed hernia at another level, 8 patients suffered from a new hernia on a hinge disc after arthrodesis due to relapsed discal hernia, and 7 recurrences of discal hernia were associated with a central stenosis. In all cases, there is often an associated foraminal stenosis or a flare of the end plates of Modic type, which can be symptomatic or predominant Our indications are: -if the disc is little degenerated (less than one third of loss of intersomatic height): ETD , rarely conventional open surgery; -if the disc is degenerated, as it is most often the case: − if there is an associated foraminal stenosis, or if there is a Modic 1 and/or 2, and without important radicular adhesions, indication of percutaneous arthrodesis by Europa cages; − if a surgical exposure with exploration is necessary, PLIF, keeping in mind that our previous series of terminal PLIF has only 62,8% of good results after two years on 36 personal cases operated on between 1999 and 2003. Since endoscopical surgery appeared and since we begun the percutaneous intersomatic arthrodesis that we call Europa, therapeutical indications for treatment of recurrence of discal hernia have become more various, more targeted, and less invasive. FBSS prevention is passing by early mini-invasive surgery, particularly by percutaneous intersomatic arthrodesis. Further studies are necessary to confirm these recent indications of mini-invasive surgery. 101 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 52 INFLUENCE OF THE FACET JOINTS ASYMMETRY ON THE DEVELOPMENT OF LATERAL RECESS STENOSIS ARTEM SKIDANOV, VLADYMYR RADCHENKO SYTENKO INSTITUTE OF SPINE AND JOINT PATHOLOGY, KHARKOV, UKRAINE Purpose of study. To improve the diagnostics of the vertebral canal lateral arthritic stenosis with the patients suffering from degenerative diseases of the lumbar spine on the ground of the vertebral canal structure peculiarities study, back supporting complex study and disease development mechanisms study. Methods used: As the material for the clinical research we used the examination data of 110 patients suffering from the lumbar spine degenerative diseases. All the patients have been clinically examined, including neurological examination, Oswestry disability index study; roentgenometrical study of regular and functional spondylograms; rentgenocontrast ways of study, spiral computer and magnetic resonance imaging tomography of the lower lumber spine. In addition, 92 tomograms of the lower lumbar spine of the patients under the age of 20 have been analyzed. Biomechanical study of the lumbar spine has been carried out with the help of mathematical modeling using finite element method. Classical methods of statistical data manipulation has been used for analysis. Summary of findings In this thesis the authors reveal clinical, roentgenological, computer-tomographic, magnetic resonance tomographic symptoms that accompany lateral recess stenosis. Special features of the structure of the lumbar spine vertebral canal predisposing to the development of lateral recess stenosis have been ascertained and innate character of these special features has been proved. The methodology of determination of vertebrae articular processes spatial orientation has been developed, the character of the arc-shaped process joints asymmetry bringing on the development of lateral degenerative stenosis has been revealed. Mechanisms of the development of this disease have been studied with the help of mathematical modeling using the finite element method. Relationship between findings and existing knowledge: Both the innate character of the lumbar spine trefoil form and a possibility of the nervous roots arthritic compression in the lateral section of the vertebral canal have been known for a long time. Our research established the possible variants of the vertebral canal trefoil form and specific peculiarities of facet joints constitution leading to the development of the lateral recess stenosis. Overall significance of findings: The received data not only allowed to improve the diagnostics of the lateral recess lumbar stenosis but also gave rise to the further study of other degenerative spine diseases development mechanisms, and besides, figure prominently in the designing of facet joints implants. The key words: Lateral recess stenosis, vertebral canal, degenerative diseases, lumbar spine. 102 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional L - 53 CONVENTIONAL POSTERIOR LUMBAR INTERBODY FUSION VERSUS MINI-OPEN POSTERIOR LUMBAR INTERBODY FUSION USING THE NEW PERCUTANEOUSLY INSERTED SPINAL TRANSPEDICULAR SCREWING SYSTEM CHANG IL JU, M.D., HYEUN SUNG KIM, M.D., SEOK WON KIM, M.D., SEUNG MYUNG LEE, M.D., HO SHIN, M.D. DEPARTMENT OF NEUROSURGERY, CHOSUN UNIVERSITY, GWANGJU, KOREA Objectives: Between the group where the conventional posterior lumbar interbody fusion (PLIF) was performed using microscope and the open transpedicular screw fixation system and that where mini-open PLIF was performed using the newly-designed percutaneous transpedicular screw fixation system characterized by vertical axis and detachable screw extender system, the surgical outcome was compared. Thus, attempts were made to analyze the usefulness of vertical axis and detachable screw extender system. Methods: During a period ranging from January 2004 to February 2007, the surgical outcome was compared between the group where the conventional posterior lumbar interbody fusion (PLIF) was performed using microscope and the open transpedicular screw fixation system and that where mini-open PLIF was performed using the newly-designed percutaneous transpedicular screw fixation system (Apollon system, Solco medical, South Korea) characterized by vertical axis and detachable screw extender system. The number of cases in which the conventional PLIF was performed was 86 (Group A) and that of those in which the mini-open PLIF was performed was 145 (Group B). In the Group A, mean followup period was 23.7 months (6 months to 43months) and mean age was 56.3 (34 to 73) years. In regard to the level, one level was seen in 73 cases, two levels were seen in 11 cases and three levels were seen in 4 cases. In the Group B, mean follow-up period was 25.3 months (6 months to 43months) and mean age was 59.1 (23 to 78) years. In regard to the level, one level was seen in 117 cases, two levels were seen in 22 cases and three levels were seen in 6 cases. Clinical outcome was assessed using last clinical follow up Low Back Outcome Score (LBOS). We also compared the operation time, intra-operative bleeding loss, postoperative surgical scar and complications. Results: In the Group A, mean surgical time was 163.7 minutes (120-280 minutes), bleeding loss was 753 ml (350-1200ml) and average LBOS was 56.2. The levels of postoperative surgical scar were as follows: one level: 6.23 Cm, two levels: 11.28Cm and three levels: 15.26Cm. Complications include five cases (5.8%) of dural tear, four cases (4.7%) of deep wound infection and four cases (4.7%) of device failure and fusion failure. In the Group B, mean surgical time was 142.6 minutes (100240minutes), bleeding loss was 438 ml (160-850ml) and average LBOS was 63.8. The levels of postoperative surgical scar were as follows: one level: 3.71 Cm, two levels: 6.27 Cm and three levels: 8.35Cm. Complications include eight cases (5.5%) of dural tear, four cases (2.7%) of deep wound infection and five cases (3.4%) of device failure and fusion failure. Conclusions: Vertical Axis and detachable Screw Extender System makes it easier to perform rod manipulation as well as compression and distraction. As compared with conventional PLIF, it can diminish midline skin incision. It is therefore useful in reducing operation time and intra-operative bleeding loss, thus minimizing the postoperative occurrence of back pain and complication. Accordingly, a prompt recovery and a good clinical outcome can be expected. 103 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional Poster Presentations 104 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional P-1 PERCUTANEOUS VERTEBROPLASTY(PVP): AN EFFECTIVE AND ECONOMICALLY VIABLE PERSPECTIVE FROM A DEVELOPING COUNTRY FOR VERTEBRAL COLLAPSE FRACTURES(VCF'S) OF VARIOUS ETIOLOGIES DR. SUDEEP JAIN: REGISTRAR/SENIOR RESIDENT, DEPARTMENT OF ORTHOPAEDICS; ALL INDIA INSTITUTE OF MEDICAL SCIENCES(AIIMS), NEW DELHI(INDIA) ALL INDIA INSTITUTE OF MEDICAL SCIENCES(AIIMS) & VARDHMAN MAHAVIR MEDICAL COLLEGE(VMMC) & ASSOC. SAFDARJUNG HOSPITAL(SJH) INTRODUCTION: Approximately ⅓rd of patients who have clinical vertebral fractures develop chronic pain that does not respond to conservative therapy. One thoracic VCF is associated with a 9% reduction in forced vital capacity. PVP provides pain relief and minimally invasive mechanical stabilization within a vertebral body to prevent further vertebral body collapse. It is hypothesized that the exothermic reaction of cement polymerization may destroy the nociceptive receptors in the vertebra. In addition by affording strength to the VB, the biomechanics of axial loading is altered and this also contributes to the pain relief. Fractures of thoracolumbar junction (T11-L1), burst fractures, wedge anterior compression fractures with >30° of sagittal angulation, vacuum shadow in fractured body (ischemic necrosis of bone) and patients with progressive radiographic collapse are less likely to benefit from conservative treatment. Although the French developed PVP 20 years ago, it is only now beginning to gain widespread acceptance. Hence, a prospective clinico-radiological outcome study was conducted to better define the various indications, contra-indications, technique, complications, clinical outcomes and role of adjunctive imaging in PVP in a developing country set-up. AIMS & OBJECTIVES: To evaluate prospectively the effects of PVP on mobility, analgesic use, pain, kyphosis and other patient/ fracture variables in patients with painful VCFs. To formulate guidelines for PVP in a developing country set up. To discuss the role of adjunctive imaging and vertebrography in PVP. MATERIALS AND METHODS: From may 2005 to October 2006, a total of 84 patients with 135 vertebral pathologies due to various etiologies satisfying the following inclusion/ exclusion criteria were taken up for PVP. The decision to perform PVP was based on clinical and imaging evaluation. INCLUSION CRITERIA: Acute and sub-acute painful osteoporotic VCFs, Painful vertebrae due to osteolytic metastasis, Painful vertebrae due to multiple myeloma, Painful vertebrae due to Kummell's disease (vertebral osteonecrosis), Painful vertebral hemangioma and other benign lesions, Severe resistant back pain with vertebral osteoporosis, Selected post-traumatic VCFs (>3 wks old) in non-osteoporotic patients. EXCLUSION CRITERIA: active systemic/localized (spine) infection, cardiopulmonary compromise, bleeding disorders/ anticoagulant therapy, improvement on medical t/t, High energy injury, severe VB collapse (vertebra plana), neurological compromise, osteoblastic metastasis, posterior VB wall deficiency, very old fractures, pre-existing epidural extension of metastatic tumour, unstable fractures with posterior element involvement especially with facet joint disruption. Cord compression on MRI in the absence of neurological findings was considered a relative contraindication. RESULTS: Multiple vertebral involvement was quite common in our series and was seen in 45/84 cases (53.6%). A kyphotic deformity of ≥30° (Cobb's angle) was present in 30/84 patients (35.7%). Venography was performed in only 6 cases towards the initial part of the study. The distribution of iodinated contrast did not accurately predict the eventual distribution of cement and only increased the operative and fluoroscopic times. The average amount of cement injected per level was 4.4ml. There was a decrease in mean pain score of 5.47, mean analgesic score of 2.11 & mean disability score of 8.86 immediately following the procedure. A mean improvement of 0.05 in the VB compression ratio and 5.28° in the Cobb's angle was obtained immediately post-procedure. Their mean pain, analgesic and disability scores at 2 yr follow-up were 0.6, 0.4 and 4.4 respectively while their mean VB compression ratio and kyphotic angle were 0.7 and 17.4° respectively. The changes in mean pain scores, analgesic scores, disability scores, VB compression ratios and kyphotic angles both immediately post-procedure (p<0.001) and at 2 yrs following the procedure (p<0.001) were highly significant. The scores improved significantly immediate post-procedure and kept improving till 2 yrs. Asymptomatic cement extravasation was seen in 39/84 patients (46.4%) at 60/135 augmented levels (44.4%). DISCUSSION: In our own series, we noted an improvement in disability scores by a mean of 8.9 immediately after the procedure (p<0.001) and remained so at 2 yrs(p<0.001). The distribution of cases is skewed in favour of osteoporosis (50%) with much less proportion of osteoporotic + traumatic (25%) & traumatic VCFs (25%). PVP is a safe & effective alternative for the treatment of many types of painful vertebral lesions, including OVCFs, hemangiomas, or malignancy-induced pathologic vertebral fractures. Medical therapy often is limited to pain control, which may not be effective, and immobilization, which can result in dangerous deconditioning of an elderly patient. Because surgery is contraindicated frequently in persons who have OVCFs because of the high incidence of instrumentation failure, and because patients who have widespread metastatic disease often are not surgical candidates, PVP may be the only practical option available. Regardless of etiology, PVP is a safe, inexpensive, and highly efficacious procedure in appropriately selected patients; however, because of the potential for devastating complications, all efforts must be made to optimize patient safety. CONCLUSIONS: There was a highly significant improvement in mean pain, analgesic & disability scores and mean kyphotic angles & VB compression ratios immediate post-procedure which was sustained at 2 years follow-up (p value < 0.01). Minor instances of cement leak were seen in a few patients without any major clinical significance. There were no new adjacent level VB fractures seen after the 135 vertebroplasty procedures in 84 patients till the last mean follow-up of 2 years. KEY WORDS: vertebral body(vb), vertebral collapse fractures(vcf's), percutaneous vertebroplasty(pvp), polymethyl methacrylate. 105 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional P-2 SCREW REINFORCING PERCUTANEOUS SHORT SEGMENT TRANSPEDICULAR SCREWING FOR UNSTABLE THORACOLUMBAR BURST FRACTURES CHANG IL JU, M.D., HYEUN SUNG KIM, M.D., SEOK WON KIM, M.D., SEUNG MYUNG LEE, M.D., HO SHIN, M.D. DEPARTMENT OF NEUROSURGERY, CHOSUN UNIVERSITY, GWANGJU, KOREA Objective: The purpose of this study was to determine the efficacy of bone cement or hydroxyapatite reinforcing percutaneous short segment transpedicular screwing following postural reduction and present a technique for thoracolumbar burst fractures without fusion. Methods: Retrospectively, eleven consecutive patients (average age, 50.73 ± 24.6 years) who sustained thoracolumbar (T10-L3) burst fractures were included. All patients had unstable burst fractures with canal compromise, but their motor power was intact. All patients underwent bone cement or hydroxyapatite reinforcing short segment transpedicular screwing with a percutaneous screwing system (Apolon System, Solco Medical, South Korea) following postural reduction using a soft roll at the involved vertebra in cases of severely collapsed vertebrae of more than one-half their original height. The surgical procedure included postural reduction for 2 days and bone cement (with osteoporosis) or hydroxyapatite (without osteoporosis) reinforcing screw fixations at one level above, adjacent above and below level including fractured level itself. Imaging and clinical findings, including the level of the involved vertebra, vertebral height restoration, local kyphosis, clinical outcome, and complications were analyzed. Results: The mean follow-up period was 10.64 months. The operative time and blood loss averaged 76minutes and 50.9 mL, respectively. The mean pain score (visual analogue scale) prior to surgery was 8.09, which decreased to 2.36 at the last follow-up. The kyphotic angle improved significantly from 20.8° ± 8.2° before surgery to 5.7° ± 2.3° at the last follow up. The fraction of the height of the vertebra increased from 43.45% ± 8.05% to 80.73% ± 5.25% in the anterior portion of the vertebra. There was no evidence of neurologic deterioration in any case. Bone cement leakage was observed in two cases without clinical sequelae; no other complications were observed. There were no signs of hardware pull-out or aggravation of kyphotic deformities and vertebral height correction. Conclusion: In the management of unstable thoracolumbar burst fractures, if patients are neurologically intact, bone cement or hydroxyatpatite reinforcing percutaneous short segment pedicle screwing following postural reduction can be used to reduce the total levels of pedicle screwing and to correct kyphotic deformities, as well as to reduce the complication rate as occurs in open surgery. 106 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional P-3 BONE CEMENT AUGMENTATION OF SHORT SEGMENT FIXATION FOR UNSTABLE BURST FRACTURE IN SEVERE OSTEOPOROSIS CHANG IL JU, M.D., HYEUN SUNG KIM, M.D., SEOK WON KIM, M.D., SEUNG MYUNG LEE, M.D., HO SHIN, M.D. DEPARTMENT OF NEUROSURGERY, CHOSUN UNIVERSITY, GWANGJU, KOREA Objective: The purpose of this study was to determine the efficacy of short segment fixation following postural reduction for the re-expansion and stabilization of unstable burst fractures in patients with osteoporosis. Methods: Twenty patients underwent short segment fixation following postural reduction using a soft roll at the involved vertebra in cases of severely collapsed vertebrae of more than half their original height. All patients had unstable burst fracture with canal compromise, but their motor power was intact. The surgical procedure included postural reduction for 2 days and bone cement-augmented pedicle screw fixations at one level above, one level below and the fractured level itself. Imaging and clinical findings, including the level of the vertebra involved, vertebral height restoration, injected cement volume, local kyphosis, clinical outcome and complications were analyzed. Results: The mean follow-up period was 15 months. The mean pain score (visual analogue scale) prior to surgery was 8.1, which decreased to 2.8 at 7 days after surgery. The kyphotic angle improved significantly from 21.6±5.8° before surgery to 5.2±3.7° after surgery. The fraction of the height of the vertebra increased from 35% and 40% to 70% in the anterior and middle portion. There were no signs of hardware pull-out, cement leakage into the spinal canal or aggravation of kyphotic deformities. Conclusion: In the management of unstable burst fracture in patients with severe osteoporosis, short segment pedicle screw fixation with bone cement augmentation following postural reduction can be used to reduce the total levels of pedicle screw fixation and to correct kyphotic deformities. 107 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional P-4 FAR LATERAL EXTRAFORAMINAL SYNOVIAL CYST NOT CONNECTING FACET JOINT AHMET MENKU*, KAGAN KAMASAK**, CUNEYT GOCMEZ***, YURDAER DOGU*** ERCIYES UNIVERSITY*, DEPARTMENT OF NEUROSURGERY, KAYSERI/TURKEY BATMAN STATE HOSPITAL **, DEPARTMENT OF NEUROSURGERY, BATMAN,/TURKEY TEKDEN HOSPITAL *** , DEPARTMENT OF NEUROSURGERY, KAYSERI/TURKEY Synovial cysts of the spine may occur anywhere in the cervical, thoracic, and lumbar spine predominantly at L4-L5 level. Almost all symptomatic synovial cysts originate from the facet joint and usually present as intraspinal extradural masses, which compress nerve root and dural sac from posterolaterally. The authors report a case of lumbar radiculopathy caused by a synovial cyst located in the L5-S1 far lateral extraforaminal area. The patient underwent decompression of the L5 nerve root via transmuscular micro endoscopic surgery. No connection to the facet joint was observed radiographically or at operation. Postoperative recovery was uneventful, and the patient was totally pain free with no motor deficit. The clinical and radiographic features of the unusual case are discussed and a comprehensive review of the existing literature is presented. An extraforaminal synovial cyst is a highly unusual finding. To our knowledge, only 8 cases of symptomatic extraspinal synovial cysts have been described in the literature. However, in our case, the cyst developed in the far lateral extraforaminal region at the L5-S1 level of the spine and no connection to the facet joint was observed. 108 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional P-5 NON-TRAUMATIC ACUTE MONOPLEGIA ASSOCIATED WITH INTRADURAL CERVICAL DISC HERNIATION: A CASE REPORT AHMET MENKU*, KAGAN KAMASAK**, CUNEYT GOCMEZ***, YURDAER DOGU*** ERCIYES UNIVERSITY*, DEPARTMENT OF NEUROSURGERY, KAYSERI/TURKEY BATMAN STATE HOSPITAL **, DEPARTMENT OF NEUROSURGERY, BATMAN,/TURKEY TEKDEN HOSPITAL *** , DEPARTMENT OF NEUROSURGERY, KAYSERI/TURKEY Intradural disc herniation is rare, especially in the cervical spine. Most cervical intradural disc herniations occur at C5–C6 or C6–C7 levels and affect patients who are 40–50 years of age. As serious symptoms can progress rapidly, immediate surgical treatment is often a necessity We present a unique case of intradural cervical disc herniation causing only monoplegia and pain in the left lower extermity. To our knowledge, this is the first case described in the literature. Magnetic resonance imaging of the thoracic and lumbar spine was normal. However, the cervical spine revealed a disc herniation at C6–C7 with a more left-sided appearance and signal intensity was observed in the spinal cord. Microdiscectomy and anterior cervical fusion with peec cage containing otogreft was performed. After surgery, the patient was free of complaints, with her motor function immediately improving in a several weeks with rehabilitation. Our experience of this case suggests that in the diagnosis of patients with monoplegia and pain in the lower extremitiy, spinal cord compression should be explored by imaging studies not only in the thoracic and lumbar spine, but also in the cervical spine, especially at the C6–C7 level, even if the symptoms and abnormal neurological findings are absent in the upper extremities. 109 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional P-6 FRACTURES OF THE THORACOLUMBAR SPINE NIKOLAOS SYRMOS, VASILIOS VALADAKIS, KOSTANTINOS GRIGORIOU,, DIMITRIOS ARVANITAKIS NEUROSURGICAL DEPARTMENT-VENIZELEION GENERAL HOSPITALHERAKLION,GREECE INTRODUCTION Thoracolumbar fracture can be a disabling condition that requires thorough evaluation and treatment. Although most thoracolumbar spine injuries are benign myofascial strains that respond well to nonsurgical management, the spectrum of injuries is broad and includes fractures and bony instability, ligamentous instability, and neurologic compromise. Evaluation of thoracolumbar injuries requires a rapid and focused evaluation at the time of injury to rule out catastrophic and neurologically threatening injuries; a detailed history and physical examination carried out at a later point in time should be paired with appropriate imaging studies.. Spinal trauma is classified according to the mechanism of injury and the presence or absence of stability. A variety of imaging modalities, including radiography, conventional tomography, computed tomography, and magnetic resonance imaging are available for assessment of the injured spine. Acute treatment may be required and initiated at the time of injury; further treatment should be carried out once the nature and extent of the injury is fully understood. Nonoperative treatment is successful in most of the injuries. Operative treatment is applied in selected cases of structural instability or neurologic compromise MATERIAL-METHODS At our department during the period 2003-2007 years 46 patients were observed with thoracolumbar spine fractures, from were 23 - 50% - were falls, 15-32, 6% - were car accidents and the rest 8-17, 4% - were other types of injuries. 40 cases - 86,9% - were multiple traumas. Average age of patients All patients underwent the following examinations: 1.¬was 39 (16-66). RESULTS Instability fractures was mentioned in 20 cases¬x-ray, 2. C.T-scan, 3. M.R.I. - 43% - Neurological disorders in 10 - 21,7% - 28 patients - 60,8% - underwent conservative treatment. 18 patients - 39,2% - were operated-posterior In case of¬approach-deccomression-transpendicle screw fixation of segments. Good¬Neurological disorders the operation was done in the first 12 hours. ¬outcome was seen in 40 cases - 87% - with regress of neurology symptoms, Minimal rest neurological deficit in 4 cases and poor results in 2 patients 110 2nd ISMISS Congress in Turkey on INTERVENTION IN SPINAL SURGERY Treatments Affiliated with Minimal Invasive Spine Surgery and Interventional P-7 SELECTIVE NERVE ROOT INJECTIONS IN LUMBAR RADICULOPATHY: A PROSPECTIVE CLINICAL OUTCOME STUDY AS A MINIMALLY INVASIVE ALTERNATIVE TO SURGERY. A FIVE YEAR FOLLOWUP. DR. SUDEEP JAIN{Senior Resident/Registrar, Department of Orthopaedics; All India Institute of Medical Sciences(AIIMS), New Delhi(India)}. DR. SUDEEP JAIN{Senior Resident/Registrar, Department of Orthopaedics; All India Institute of Medical Sciences(AIIMS), New Delhi(India)}. TYPE OF STUDY: A prospective clinical outcome study. AIM OF STUDY: To establish selective nerve root injections in lumbar radiculopathy as an effective, minimally invasive alternative in patients either unwilling or unfit for surgery. INTRODUCTION: Treatment of lumbar radiculopathy ranges from bed rest to decompression. Many unsatisfactory results of different surgical interventions has led to reappraisal of some more conservative treatment options. Low back and sciatic pain are most likely due to a combination of mechanical compression and inflammatory changes. An autoimmune or chemical basis for lumbar radiculopathy was postulated in 1977. Recent evidence supports a neurochemical basis for pain generation. Based on these findings, epidural instillation of steroids was implicated as a treatment modality for low back and radicular pain. Studies done by using MRI done at serial intervals revealed that herniated nucleous pulposus size decreased in 66-88% patients on conservative management and this correlated with clinical outcomes. In these injections, epidural space is entered dorsally which is distant from perceived source of pain and inflammation which lies anteriorly thus large volumes must be injected which can dilute their potency. Extensive degenerative changes and altered anatomy and scarring of previous surgery also hamper this blind translaminar technique. Thus an alternative method for delivery was first described by Macnab and later by Krempen and Smith called selective nerve root injections in which under fluoroscopic guidance a needle is placed next to the affected nerve root ensuring a precise and concentrated delivery of drug. Success of injection depends on precise delivery of high concentration of drug directly to interface between herniated nucleus pulposus and ventral dura and nerve root sleeve which can only be done reliably by a fluoroscopically guided transforaminal approach with pre-injection contrast documenting flow to the target tissue. METHODS: A five year prospective clinical outcome study conducted on patients with lumbar radicular pain with disc herniation, secondary foraminal stenosis confirmed by an MRI and patients with failed previous surgery demonstrating persistent symptoms. All these patients had failed atleast 6 weeks of conservative management and were ideal candidates for surgery but had either refused or were unfit. In all 150 patients were injected with Bupivacaine and Betamethasone, 220 nerve roots were injected and 300 injections were given with a minimum followup of 5 years. We used 1 ml of betamethasone(4mg/ml) with 1 ml of 0.25% bupivacaine. All injections were performed fluoroscopically and needle placement confirmed by injecting omnipaque240. RESULTS: Of 150 patients, 80 had single level involvement and 70 had multilevel disease. 10 patients had B/L radiculopathy, rest had almost equal distribution among rt and lt lower limbs. All pts had LBP with radicular pain. Duration of LBP ranged from 3 months to 3 yrs while that of radicular pain ranged from 1-6 months. 35 patients had history of similar episodes in the past. 80% had list and 2/3rd had marked paraspinal spasm. 140 had localized tenderness. SLR restricted in all pts. While sciatic stretch test was positive in all but 5 pts.. 30 had positive cross SLR. Post injection, SLR improved in 140 out of 150, list persisted in only 25 pts while nerve tension test continued to be positive in only 15 pts. Preinjection 140 pts were severely disabled with an oswestry score between 40-60 while 10 pts were crippled with scores more then 60. Following injection, 120 out of 150 were left with only a minimum disability whereas 30 did not show much improvement. On an average, oswestry scores improved by 34% from an average of 54.1% in preinjection to 20.03% in postinjection pts. 100 pts improved with a single injection while a second injection had to be repeated after 2 wks in 10 pts. 5 pts required 3 injections for complete relief. 5 pts were improved after 2 injections but had a recurrence after 3 months for which they required a third injection. Thus out of 150 pts who were ideal candidates for surgery, 115 were able to avoid a surgery after a minimum followup period of 5 yrs. DISCUSSION: Perfect approach to management of degenerative disc disease has been controversial. When sciatic symptoms persist, it is thought that local inflammatory changes may be contributory factor. Some recent studies show that after 4 yrs, results of conservative management are same as that of surgery. Many studies have now proven the biochemical nature of radicular pain. This has led to popularity of epidural steroid injections as it is thought that pain is produced only in presence of inflammation. Blind nature of translaminar epidural steroid placement led to inconsistent results. These shortcomings led to appraisal of fluoroscopically guided transforaminal injections with reported success rates from 60-80%. In our study, 80% operative candidates were able to avoid surgery which is comparable to other studies using similar techniques. Like other studies, results were better in pts with symptom duration less then 3 months. This can be explained by development of irreversible neurophysiologic changes due to chronic inflammation. We also found that patients who had concomitant secondary foraminal stenosis responded less favourably compared to pts who had just prolapse disc as cause of their symptoms. CONCLUSION: It can be concluded that selective, fluoroscopically guided lumbar nerve root injections are current, state of the art form of local anaesthetic and steroid delivery to exact trigger site of pain with minimal complication. They may be diagnostic as well as therapeutic and may obviate need for a lumbar surgery. KEY WORDS: lumbar radiculopathy, fluoroscopically guided, transforaminal, selective nerve root injection, bupivacaine, betamethasone. 111