Okay, our next talk, Juan Uribe, will be talking for Adam Cantor, Sagittal Imbalance Correction, Lateral ALL Release vs. PSO. Thank you. So I'm calling for Adam Cantor, which we believe on this procedure a lot. So the ACR procedure basically is the probably best minimal invasive way to provide lordosis in patients that need somehow better sagittal alignment. So basically the ALL release is with the patient on the lateral position, get a less invasive axis, get in front of the ALL, cut it, and then make like a fish mouth, kind of the A leaf on 5'1", and then place a hyperlordoric implant. So the trick with this procedure is that no matter what, you have to make sure that this is a lengthening procedure, because if you just wedge the patient like this, and you don't get any posterior height, then you create a really bad foraminal stenosis in a patient that probably already have a foraminal diameter compromise. So you want to really get first in the decompression and then open it up. So the type of cages that we use, they're like this. As you see, they are 20 and 30 degrees implants, but then you have to set some height on the back. Minimal 6 millimeter in the height posteriorly, and then you go from there. So for example, when you call a cage 6 millimeter, it means 6 millimeter posterior height. On the front it may be 14, 15. It's just depending on if you keep 20 or 30 degrees. So this is kind of how they look like, and it's very interesting. Every time you do an ALL release, an ACR procedure, you need to make sure that you use a screw to fix the cage into the vertebra. And the reason is because once you lose the anterior longitudinal ligament, the lead-resistant pathway is anteriorly, and you don't want this cage falling behind the vessels into the peritoneal cavity. So you have to have somehow fixation. So this screw is more for fixation, not for stabilization or something like that. So you just run a small screw, keep the cage from falling anteriorly to the peritoneal. So this is a little bit of the fluoroscopic view of a case. You see here these levels. Once you cut the ALL and put the hyperlordotic implant, this is kind of the image that you have. So you see it's a dramatic lordosis without the need to do any osteotomies posteriorly. But this is very interesting. When we start doing this procedure, we start finding that the amount of lordosis that we were providing was not exactly matching the lordosis of the cages. It means like a 20-degree cage doesn't give you 20 degrees lordosis. And then we find out that not only that, but if you start resecting posterior elements, doing facetectomies or doing Smith-Peterson osteotomies or even full-blown posterior element disruption, then you start having way more lordosis. So that one was kind of a learning process. And because of that, we end up having actually, believe it or not, we have a classification in how to deal with the anterior colon release. And what we did, so make it easier for everybody, actually we combined it. We combined with the Schwab classification. And actually this paper is getting published in the next two months on the White Journal. And hopefully we put it together just to have a common language so we can communicate. So when you do an ACR, if you tell me I did an ACR, for example, grade 2 means like you cut the anterior longitudinal ligament, then you did a complete facetectomy posterior, then we know that that case is going to give us more lordosis than one that is just cutting the ligament. So that way finally I think we're going to be able to not only speak the same language, but also to have a finer idea how much lordosis you provide depending on how much posterior resection. So I'm going to show you a little bit fast one by one. So the simple ACR, as we call it, you just go lateral, cut the anterior longitudinal ligament, put the hyperlordotic implant, something like this, and then you see in this case, for example, that we didn't put any screws posteriorly, you get some lordosis. Obviously this is the less aggressive form of the ACR. And in average you put a 20 or 30 degree case, you get maybe 10 degrees maximum, 12 degrees maximum lordosis per level. Then once you pass this level, you go to the grade one. The grade one is basically resect the ligament, take the facets. So it's the Schwab one and the ACR. And this is kind of the case like that. As you see here, you start getting more lordosis than the previous example. So this is a little bit of a cartoon showing that. So you take the facets out and then you do the ALL release and put your hyperlordotic case. Another example in here, you see how every time you see these little screws in here, it means like we did an ACR because you're holding the case. And then the grade two, now it starts getting more interesting. You do basically a complete Schwab to osteotomy, which means facets, yellow ligament, and then you start doing and getting more efficient in providing lordosis. An example like that you see here. So in cases more dramatic, you see here on the top, we did a facetectomy, a complete ACR in the lower one also. So that way you can get even more lordosis. And then the grade three and four are very interesting. Actually, if we combine the regular PSOs with an ACR, you make an amazing lordosis at that segment. So you're getting the 20, 30 degrees that you get from the PSO, but then you have the 5, 10 degrees that you get with the ACR. So this is a very powerful procedure. Obviously, we're using a very limited situation, for example, like this one, a patient with a huge kyphoric gangulations. So we go, we do the ACR, and then we do the PCO just below, and then you can get a lot of lordosis. So this is obviously cases that are very selective. You see all the posterior elements out, anterior longitudinal ligament out in here. Similar to the extended PSO that Dr. Lencky described, but the difference is we don't do a T-LIFT. We actually do a lateral, and we resect the ligament from the front. Then this is another example in here. You see this patient that actually go out of the cassette. You cannot even take the, because there's much kyphosis, you need to make something very dramatic, as you see here. So no posterior elements, ACR, and then a PCO, a PSO below that. And then, obviously, the last one is the corpectum is that you just use it when you have to do VCRs. And this is also fixed kyphoric deformities, and is a very efficient way to do it. So you can do it from the front, and then you can combine it from the back, and loosen it up. So this is one example. And then, how much more time do we have still? We're still on time. Okay, so how we do it. So I'm going to give you a little bit of surgical tips. This is a very short video, you know, it's a very simplified way. This video will demonstrate the medially invasive anterior cone release and deformity correction in the lateral trans psoas retroperitoneal approach by Dr. Joshua Hathaway and Juan Esribe. It's an extremely advanced technique, but you can only be performed with those two actors in both lungs. Lumbar plexus is identified with correctional trigger EMT. The retractor is appropriately positioned and connected to the arm. Once the arm is locked, a shim is placed down the posterior blade into the disk space to prevent posterior migration from the retractor into the spinal canal. The retractor blades are then up and into the arm. This is an endoscopy. For anal cysts seen on AP phalloscopy. Next, we use the two materials to remove any previous material. Note the handheld instrument placed anterior to prevent soft tissue from migrating into our fillet. Next, the end plates are prepared with different end material curates. I have two materials to choose once again to clear any previous fragments. Now, we begin dissecting the anterior hand into the hand. Special care has to be taken to assure you are in the correct thing. AP phalloscopy should be used generously as major vessel damage can occur at this stage. So, you see, there's very little resistance. It's actually equivalent of the one that you see on the x-rays. Here, the dissector is in its final position. The anterior longitudinal ligament is a dent. What we do is we cut the ligament from anterior to posterior, and then we fish mouth. This is a schematic diagram showing the interrelated antennae. Let me see if we move a little more faster. So, notice in here, we go with the knife. This is the most dangerous portion of the operation. We go little by little. As you see here, the knife is going close to the contralateral pedicle. And once we get there, then we put up our distractor, and then we do out the entire space. And this is kind of when you cut it, you expect it to have this. You know, obviously, this is a very risky maneuver. It has a lot of risk. You're going to get a big vessel. You can have complications. But you see here, once you open this distractor, open the space a lot, then you can put your hyperlodotic cage. This is just showing here the space. And we use an endoscopic view in here just for the academic illustration. You know, usually we go with your loop. And then you put your hyperlodotic cage. And as you see here, once the case gets there, you have your nice lordosis. You put your screws fixating the segment so the case is not going to move anterior. And then when the case is clean and nice, you should be something like that. You see, you're getting out. And so you start getting close. And then you leave the retoplatonium and the abdominal muscles. And usually the response is something like this. So very nice lordosis of the segment. So then this is a very short one. I want to show you what can happen when you do it wrong. Okay? So this is the case. This surgeon is trying to dissect the anterior longitudinal ligament. Again, the same thing that you saw before. You dissect the ligament. Then you're ready to cut. So you come with the blade. You're going to slide through this little center ridge, as you will see here. And you see it seems like we're in the right plane. There is no problems. And then you see here, you go with the knife. And then you have to get prepared because this thing can happen to you when you start doing these cases. And you have to have a really good idea of what's happening. Yeah? So you get there. You get the vessel. You have the blade. In this case, obviously, it was not one of the big vessels. It's probably some part of the average segment. There is some pressure. You stop it up. But you have to get prepared when you do these cases to have a really good, the access surgeon has to know what's going on and make sure that you have someone close because if you get one of the big vessels, your plan B is not very good. Are we done with the time? Can I go? Okay. So just to close, I'm going to show you a case where, actually, I like this case because I was combining the best of the open world with the best of the minimally invasive world. So this case, you see here, somebody fuses flat, 4-5-5-1, where definitely there is no sagittal balance. This patient, images I'm using here, they managed to have a really good fusion of these segments. So they did two level T-lifts. Unfortunately, end up with a kyphotic kind of flat back. And then some surgeon offered a lateral stand-alone at the level above and unfortunately subsided. And then it became actually kyphotic. So the less invasive procedure actually made the procedure worse. And this is the kind of the cases that Chris Shaffrey and Lenkyo, those guys, shows all the time. They said the minimally invasive surgeon, this is what they do. But I'm going to show you this case, how we handle it. And then, obviously, he end up developing a next adjacent segment at the top of the instrumentation. So in my world, this patient needs a lot of lordosis. He was needing at least more than 30 degrees. So in my world, this patient needs a PSO and also what about if I combine it with an ACR. So you see here, this is the MRI pre-op. These are the images. So what I did in the first stage, what I did is I just opened like a regular standard surgery on the lower part. I did removal of the previous instrumentation. I did a PSO at that level. In this case, it was an L5 PSO. And then as you see here, and I left all these screws, modulars, waiting for the second stage. So the first day, what I did is using here on PSO, I did like a satellite style, like a Monish Gupta or Chris Ames papers. And then you go for the second stage and you do an ACR when you put the patient lateral. And you see here, you start doing the ischectomy. And take a look how when you start opening the level, it open up a lot. Then you can have some lordosis at that level that was kyphotic plus the PSO below. And you see this kind of the picture of what you do. So you open this area only for your PSO. You do all this area percutaneous. You do the ACR from the side. And then you don't need to do this big surgery that opening the entire thing just to do one PSO. And then we use this computerized way to pass the road on the top of the previous PSO. You're following me? So this is what the open part. Then we pass this road percutaneous. And using this computerized system, we can ride above the previous open osteotomy. And then this is what you have at the end. So this is a good example of combining open and minimally invasive techniques. So the point here is there is no competition between ACR and standard osteotomies. This actually one is a compliment of the other ones. So this is what I want to show you today for Adam Cantor. And thanks very much. >>[Applause.]

video

Dr. Juan Uribe

sagittal imbalance correction

anterior longitudinal ligament release

hyperlordotic implants