Computer Guided Spinal Navigation (FULL PROCEDURE)!!

Hi my name is Dr. Antonio Webb. I'm an orthopedic spine surgeon here in San Antonio, Texas. Today we're going to be doing a lumbar laminectomy with posterior instrumentation. This is for a gentleman who I've been a physician for who's had problems with his back and his leg for a long time now. We're about to get started. I just met him in the pre-operative area. We talked about the risks of the surgery, the benefits, and answered all those questions so should be a good case. These are the patient's MRI images here. This view here is called the sagittal view. You can see that this patient has multi-level disc degeneration disease. These discs here, they're dark. They're supposed to be kind of whitish color here. This is the spinal cord where it ends and turns into the cauda equina or fecal sac and you can see that there's quite a pressure here or stenosis which means this patient has pressure on his spinal canal and nerves. He also has a large cyst. We call it a facet cyst and this cyst is contributing to some of his leg pain. These are the facet joints right here and you can see that there's fluid in the facet joints which should not be there. That tells me that there's some movement at that level and every time that he moves, extends, flexes his back there's pressure on those nerves. We're actually going to use the o-arm which is navigation similar to navigation that's in your car, GPS that's in your car. I'll be looking at the computer screen while I'm placing his pedicle screws so that it goes into a really accurate and precise manner and position. That's called computer guided navigation. We'll take a CAT scan while he's asleep to obtain those images so should be a good case. My patient just got to the holding area, the pre-operative area. I'm about to go meet him and see if he has any last minute questions before surgery. Hey, how are you? Good. All right, you ready? I'm ready. I'm excited. I've actually watched some other videos and stuff of the actual procedure but you're going to use computer assisted? Yeah, so one part of the surgery is decompression or your spinal canal is severely tight so we're going to open that up and take the pressure off of it. The part that we have to put the screws in I'm going to use computer guided navigation. All right, I'll see you back there, okay? Take care. Hang tight. So this is the posterior back portion of the spine. It's also called the dorsal side of the spine. This is the ventral portion of the spine. So we'll be operating posteriorly. This is the spinous process at every level here. That's the bones that you can fill on your back right in the midline and this is the lamina on both sides. So we're doing a laminectomy which means we remove that lamina that's causing pressure to remove the pressure that's pushing on his spinal canal. Once we have the decompression, take the pressure off the nerves and also the spinal canal at this level, we'll place pedicle screws and these screws, they go into the bone here and they end up into what's called the vertebral body and that will hold the spine in place so that it fuses together. All right, right now we're just getting the room set up for the case. There's a lot of different people that will be in the operating room. Anesthesiologist, there's an operating room technician. I have a nurse practitioner who will be assisting me during the case. We have medical sales reps. We have the x-ray technician, the anesthesiologist assistant who helps get everything set up. So a lot of moving parts, a lot of different people. There's a lot of behind the scenes things that go on to successfully complete a surgery. These are very gratifying surgeries just because he has severe compression of his spinal canal. You know, it's very fun and gratifying to see that the spinal canal kind of inflate. If you think of the spinal canal in the fecal sac as like a balloon that has water in it and you have compression from like a large disherniation or from ligamentum hypertrophy, which is a ligament that is into the spine that can cause some stenosis or tightening, or if there's a bone piece that's pushing on the spinal canal, it's squeezing like a balloon. So in surgery, I have to remove those compressile elements and then and watch it expand and it's really cool to just watch it expand. So the patient just rolled into the room. I'm just getting set up. Everybody's in position and when we think about surgery, it's kind of like going to the orchestra. Everybody has a really important role. We all work together to take care of the patient and make for a successful operation. So yeah, should be a good surgery. All right, about to get scrubbed in here. Patient's off to sleep. Nice and comfortable. During these surgeries, the patient doesn't feel anything. They don't remember anything, so he'll be nice and comfortable. Surgery like this will probably take about three hours or so. 30 minutes, 20-30 minutes for exposure, which means we have to open up his back, pull off the muscles off of the back to actually get down to the spine. Another 30-45 minutes for screws, maybe 30 minutes or so, and then 45 minutes to an hour for decompression. So a question that I get all the time from students, people that are trying to get into the medical field is, do you get nervous before these big surgeries? And just like professional athletes, you know, you have these little bubble guts and you get somewhat nervous, but I think a little level of being nervous is good. It helps you prepare and be successful. So I prepare for these surgeries or we prepare for these surgeries sometimes weeks in advance. So reviewing their imaging studies, talking to the patient multiple times, talking to other surgeons, getting feedback and suggestions, recommendations. So it takes a lot of planning, preparation to actually get to this point where we're at today. And then, would you mind putting the Sertrum on the board for me, please? All right, that's incision there. Right now, we're dissecting down, trying to get part of the spine where we can see his bony architecture. So we're pulling off the muscles off of the back. This is a ronger here. This is used to grab objects. I'm using it to grab the soft tissue. Usually a lot of soft tissue and fat sitting over the bone. I have to remove all of that so we can see what we're doing. Have a kerosene ronger under the lamina. We're localizing our level. Make sure we're at the right level. So many different levels in the spine. Go north a little bit, please. Just a tad bit. Right there. So I'm under the five lamina there. Okay. All right. Go north. All right. We're going to take one more film. X-ray. All right. Save that. Table back down, please. We have the other bovie. Yep. Cut to 45, please. Yep. All right. Let's get those big gelfies, please. We'll take two crops. Ronger, please. Get a section down the hole there so you can see. So fat and soft tissue that I'm removing from the bone there, especially when we're trying to fuse the bone. We want all that soft tissue kind of gone. Otherwise, the bone won't fuse. All right. Let's get some Raytec, please. I'm stuffing these in the wound to help with bleeding. So it provides a little pressure, a little hemostasis. So I'm facing over to the bone called the spinous process, and this is how we will acquire our images and connect the navigation after we get a CAT scan here shortly. Just making sure that's really tight. All right. So this is an interoperative O-arm here from Medtronic. We're going to take a couple scout shots to get an AP and lateral of the patient's spine. And then while the patient's asleep, we're going to get some interoperative O-arm CT scan. We'll upload those images to our self-navigation system here and then use that to place our instrumentation. Okay. Four, five. Yeah. Go back that way. Okay. I like that. All right. So we're doing a high definition? Yep. Okay. All right. We're going to exit the room. Can we hold respirations, please? Yeah. So we have to step out of the operating room when we're getting the CAT scan because of the radiation. But the advantage of using navigation for a case like this is there's a lot less radiation exposure to the OR staff and also to the surgeon. So if we're replacing screws into the spine, we use fluoroscopy, which is C-arm or x-ray. In surgery, there's a lot of images that are taken. So it's a lot of x-ray exposure, especially over time. But this, we take one or two shots at the beginning with x-ray. And then navigation, we really don't have to take any more shots. So it saves down, cuts down on the radiation exposure. So we're going to go back in and look at the CAT scan here shortly. And Adam, would you scroll through this for me? So we're just scrolling through the CAT scan, just making sure we have all of our levels that we want to see, and which everything looks good. This is axial view and also sagittal view, coronal view. So it looks like we're good. It's called a gear shift here. This is where I'm going to find my starting point for the screw that we're going to put in. And I'm looking on the monitor there. So using this navigation here, I can see, we can measure what size screw and also the length of the screw instead of just guessing or... That's a 7.5? 7.5. So this is the pedicle screw here that we're going to put at this level. This is a 7.5 by 45 millimeter screw. Hold that for a second. Can I have a filler, please? So the screw is going into the pedicle of the bone. I'm going to just tap or fill and make sure that I don't have any breaches. And it feels really nicely. I feel laws all around that pedicle. This is a high-speed drill right here. So I'm using a foot pedal. This cuts and takes away bone here. Here's some bone for you. So this is all good bone here. It's autograft. I take it from the facet joint. We're going to use that to help his spine fuse together. I'm just taking his own bone. That's called autograft. That's the best bone that we can use to get a fusion. I'm coming around. Turn the lights on, please. Go ahead and drape your seat on. Yep, we need to drape that. We're going to pull it in in a second. There's more bone that we're taking away from the facet joints that we're going to fuse. Yeah, start with AP. Shoot. All right, save that. All right, you can go north, please. So now we have our pedicle screws in place. We got x-rays that looks like the screws are in a good position. So we're going to do our decompression at this point. So for a time reference, we've been going for about a little bit, hour and 10 minutes or so, or 20 minutes. So we have our screws in. We did our exposure. This is the decompression site right here. This is the spinous process, that bone right there. This is the other spinous process. Those are our pedicle screws. Get a clobber, Amanda. So those little green tabs there are tulips for our pedicle screws. Get a little bit deeper so we can see them. Right between them. There you go. So those little tabs there, those are our pedicle screws that are placed into the spine and this side here. We're going to decompress his spine at this point. Take away the remaining portion of that bone. I'll take a drill, please. So this is the bone graft that's going into what's called the posterolateral gutter outside of the screws to get it to fuse together. So it's really soft. This will form or turn into bone. So it's called allograft. We mixed it with his own bone, which is the autograft, and all of this graft here will get it to fuse together. We're using some DBM also, demineralized bone matrix. That's a synthetic bone graft. All right. All right. So these are the postoperative x-rays. These are the pedicle screws that are going into his spine here. This is the AP view and also the lateral view. So his spine is not unstable anymore. It's not moving, shifting backwards and forwards. And yeah, I think he'll have a good outcome. All right. So we just finished the laminectomy and decompression, laminectomy, decompression, and fusion. Really hard case because his cyst was actually stuck to the spinal canal. When that happens, it makes it very challenging to take the pressure off the spinal canal and open it up, decompress it, but kind of really good decompression, wide decompression, and also put the screws in. X-rays look really good. He's off to recovery at this point, and hopefully he wakes up and has some resolution of his back and leg pain. This is Dr. Webb. Thank you for watching, and we'll see you in the next one. Bye.