Browsing by Author "Wiggins, Walter F"

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    ItemOpen Access
    A Novel Approach to Percutaneous Lumbar Surgeries via Kambin's Triangle - A Radiographic and Surgical Planning Analysis with Nerve Segmentation Technology.
    (World neurosurgery, 2023-06) Tabarestani, Troy Q; Sykes, David AW; Kouam, Romaric W; Salven, David S; Wang, Timothy Y; Mehta, Vikram A; Shaffrey, Christopher I; Wiggins, Walter F; Chi, John H; Abd-El-Barr, Muhammad M

    Objective

    While Kambin's triangle has become an ever more important anatomic window given its proximity to the exiting nerve root, there have been limited studies examining the effect of disease on the corridor. Our goal was to better understand how pathology can affect Kambin's triangle thereby altering laterality of approach for percutaneous lumbar interbody fusion (percLIF).

    Methods

    The authors performed a single-center retrospective review of patients evaluated for percLIF. The areas of Kambin's triangle were measured without and with nerve segmentation. For the latter, the lumbosacral nerve roots on 3D T2 MRI were manually segmented. Next, the borders of Kambin's triangle were delineated ensuring no overlap between the area and the nerve above.

    Results

    15 patients (67.5 ± 9.7 years, 46.7% female) were retrospectively reviewed. 150 Kambin's triangles were measured. The mean areas from L1-S1 were 50.0 ± 12.3 mm2, 73.8 ± 12.5 mm2, 83.8 ± 12.2 mm2, 88.5 ± 19.0 mm2, and 116 ± 29.3 mm2, respectively. When pathology was present, the areas significantly decreased at L4-L5 (p = 0.046) and L5-S1 (p = 0.049). Higher spondylolisthesis and smaller posterior disc heights were linked with decreased areas via linear regression analysis (p < 0.05). When nerve segmentation was used, the areas were significantly smaller from L1-L5 (p < 0.05). Among 11 patients who underwent surgery, none suffered from postoperative neuropathies.

    Conclusion

    These results illustrate the feasibility of pre-operatively segmenting lumbosacral nerves and measuring Kambin's triangle to help guide surgical planning and determine the ideal laterality of approach for percLIF.
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    ItemOpen Access
    Novel Merging of CT and MRI to Allow for Safe Navigation into Kambin's Triangle for Percutaneous Lumbar Interbody Fusion-Initial Case Series Investigating Safety and Efficacy.
    (Operative neurosurgery (Hagerstown, Md.), 2023-03) Tabarestani, Troy Q; Sykes, David AW; Sykes, David AW; Maquoit, Gisselle; Wang, Timothy Y; Ayoub, Chakib M; Shaffrey, Christopher I; Wiggins, Walter F; Abd-El-Barr, Muhammad M

    Background

    For percutaneous lumbar fusion (percLIF), magnetic resonance imaging and computed tomography are critical to defining surgical corridors. Currently, these scans are performed separately, and surgeons then use fluoroscopy or neuromonitoring to guide instruments through Kambin's triangle. However, anatomic variations and intraoperative positional changes are possible, meaning that safely accessing Kambin's triangle remains a challenge because nerveroot visualization without endoscopes has not been thoroughly described.

    Objective

    To overcome the known challenges of percLIF and reduce the likelihood of iatrogenic injuries by showing real-time locations of neural and bony anatomy.

    Methods

    The authors demonstrate an intraoperative navigational platform that applies nerve root segmentation and image fusion to assist with percLIF. Five patients from a single institution were included.

    Results

    Of the 5 patients, the mean age was 71 ± 8 years and 3 patients (60%) were female. One patient had general anesthesia while the remaining 4 patients underwent awake surgery with spinal anesthesia. The mean area for the L4-L5 Kambin's triangle was 76.1 ± 14.5 mm 2 . A case example is shown where the side of approach was based on the fact that Kambin's triangle was larger on one side compared with the other. The mean operative time was 170 ± 17 minutes, the mean blood loss was 32 ± 16 mL, and the mean hospital length of stay was 19.6 ± 8.3 hours. No patients developed postoperative complications.

    Conclusion

    This case series demonstrates the successful and safe application of nerve segmentation using magnetic resonance imaging/computed tomography fusion to perform percLIF and provide positive patient outcomes.
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    ItemOpen Access
    Two-Year Clinical and Radiographic Outcomes for Percutaneous Lumbar Interbody Fusion With an Expandable Titanium Cage Through Kambin's Triangle Without Facetectomy.
    (International journal of spine surgery, 2023-12) Tabarestani, Troy Q; Wang, Timothy Y; Sykes, David AW; Mehta, Vikram A; Yang, Lexie Z; Chow, Shein-Chung; Shaffrey, Christopher I; Wiggins, Walter F; Chi, John H; Abd-El-Barr, Muhammad M

    Background

    There has been heightened interest in performing percutaneous lumbar interbody fusions (percLIFs) through Kambin's triangle, an anatomic corridor allowing entrance into the disc space. However, due to its novelty, there are limited data regarding the long-term benefits of this procedure. Our objective was to determine the long-term efficacy and durability of the percutaneous insertion of an expandable titanium cage through Kambin's triangle without facetectomy.

    Methods

    A retrospective review of patients undergoing percLIF via Kambin's triangle using an expandable titanium cage was performed. Demographics, visual analog scale (VAS) scores, Oswestry Disability Index (ODI), radiographic measurements, perioperative variables, and complications were recorded. VAS, ODI, and radiographic measurements were compared with baseline using the generalized estimating equations assuming normally distributed data. Fusion was assessed with computed tomography (CT) at 1 and 2 years after the procedure.

    Results

    A total of 49 patients were included. Spondylolisthesis, lumbar lordosis (LL), sacral slope, pelvic tilt, and anterior/posterior disc space height were all significantly improved postoperatively at each time point of 3, 6, 12, and 24 months (P < 0.001). Pelvic incidence-LL mismatch decreased significantly at each follow-up (P < 0.001) with a mean reduction of 4° by 24 months. VAS back scores reduced by >2 points at the 6, 12, and 24 month follow-ups. ODI scores reduced by >15 points at the 12- and 24-month follow-ups. Of the patients who had 1- and 2-year CT images, fusion rates at those time points were 94.4% (17/18) and 87.5% (7/8), respectively. The mean annual rate of surgically significant adjacent segment disease was 2.74% through an average follow-up of 2.74 years.

    Conclusion

    These results highlight that percLIF, a procedure done without an endoscope or facetectomy, can be performed using an expandable titanium cage through Kambin's triangle with excellent radiographic and clinical results.

    Clinical relevance

    percLIF via Kambin's triangle is a safe and succesful procedure with long-term improvements in both clinical and radiographic outcomes.

    Level of evidence: 3

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    ItemOpen Access
    Using Augmented Reality Technology to Optimize Transfacet Lumbar Interbody Fusion: A Case Report
    (Journal of Clinical Medicine, 2024-03-01) Bardeesi, Anas; Tabarestani, Troy Q; Bergin, Stephen M; Huang, Chuan-Ching; Shaffrey, Christopher I; Wiggins, Walter F; Abd-El-Barr, Muhammad M
    The transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a novel approach available for the management of lumbar spondylolisthesis. It avoids the need to manipulate either of the exiting or traversing nerve roots, both protected by the bony boundaries of the approach. With the advancement in operative technologies such as navigation, mapping, segmentation, and augmented reality (AR), surgeons are prompted to utilize these technologies to enhance their surgical outcomes. A 36-year-old male patient was complaining of chronic progressive lower back pain. He was found to have grade 2 L4/5 spondylolisthesis. We studied the feasibility of a trans-Kambin or a transfacet MIS-TLIF, and decided to proceed with the latter given the wider corridor it provides. Preoperative trajectory planning and level segmentation in addition to intraoperative navigation and image merging were all utilized to provide an AR model to guide us through the surgery. The use of AR can build on the safety and learning of novel surgical approaches to spine pathologies. However, larger high-quality studies are needed to further objectively analyze its impact on surgical outcomes and to expand on its application.
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    ItemOpen Access
    Using Novel Segmentation Technology to Define Safe Corridors for Minimally Invasive Posterior Lumbar Interbody Fusion.
    (Operative neurosurgery (Hagerstown, Md.), 2023-12) Tabarestani, Troy Q; Salven, David S; Sykes, David AW; Bardeesi, Anas M; Bartlett, Alyssa M; Wang, Timothy Y; Paturu, Mounica R; Dibble, Christopher F; Shaffrey, Christopher I; Ray, Wilson Z; Chi, John H; Wiggins, Walter F; Abd-El-Barr, Muhammad M

    Background and objectives

    There has been a rise in minimally invasive methods to access the intervertebral disk space posteriorly given their decreased tissue destruction, lower blood loss, and earlier return to work. Two such options include the percutaneous lumbar interbody fusion through the Kambin triangle and the endoscopic transfacet approach. However, without accurate preoperative visualization, these approaches carry risks of damaging surrounding structures, especially the nerve roots. Using novel segmentation technology, our goal was to analyze the anatomic borders and relative sizes of the safe triangle, trans-Kambin, and the transfacet corridors to assist surgeons in planning a safe approach and determining cannula diameters.

    Methods

    The areas of the safe triangle, Kambin, and transfacet corridors were measured using commercially available software (BrainLab, Munich, Germany). For each approach, the exiting nerve root, traversing nerve roots, theca, disk, and vertebrae were manually segmented on 3-dimensional T2-SPACE magnetic resonance imaging using a region-growing algorithm. The triangles' borders were delineated ensuring no overlap between the area and the nerves.

    Results

    A total of 11 patients (65.4 ± 12.5 years, 33.3% female) were retrospectively reviewed. The Kambin, safe, and transfacet corridors were measured bilaterally at the operative level. The mean area (124.1 ± 19.7 mm2 vs 83.0 ± 11.7 mm2 vs 49.5 ± 11.4 mm2) and maximum permissible cannula diameter (9.9 ± 0.7 mm vs 6.8 ± 0.5 mm vs 6.05 ± 0.7 mm) for the transfacet triangles were significantly larger than Kambin and the traditional safe triangles, respectively (P < .001).

    Conclusion

    We identified, in 3-dimensional, the borders for the transfacet corridor: the traversing nerve root extending inferiorly until the caudal pedicle, the theca medially, and the exiting nerve root superiorly. These results illustrate the utility of preoperatively segmenting anatomic landmarks, specifically the nerve roots, to help guide decision-making when selecting the optimal operative approach.