DLIF

Question 1

EMG Monitoring

Answer 1

Leads placed by neurophysiologist to make sure surgeon has visualization on disc space

Question 2

Patient Positioning

Answer 2

Patient is placed in a lateral decubitus position (left side up) on a breakaway table. flex legs to an almost fetal position to relax psoas muscle (decrease complications).

Question 3

Prep

Answer 3

Surgeon confirms correct level with c-arm and then marks incision site with sterile marker. Taped to the bed at the hip, chest, and across the legs. Prep and drape. Loban sticker is placed

Question 4

Incision

Answer 4

A small transverse incision is made with a 15 blade in a true lateral approach

Question 5

exposure

Answer 5

Blunt finger dissection is performed

Question 6

Probe

Answer 6

The surgeon inserts the first dilator through psoas muscle to the lateral aspect of disc space. The dilator helps the surgeon to navigate the nerves and leave them undamaged Use c-arm periodically.

Question 7

Neuro Monitoring

Answer 7

Once there has been clearance through the nerves and proper annultomy site is confirmed.

Question 8

K-wire

Answer 8

k-wire is placed through the dilator and is advanced midway through the disc to secure the position

Question 9

Sequential Dilators

Answer 9

A series of sequential dilators are introduced increasing in size until an adequate working space is achieved. This carefully expands the incision reducing irritation.

Question 10

Retractor Blade Length

Answer 10

Appropriate retractor blade length is confirmed by depth marks on the largest dilator

Question 11

Retractor Assembly and intro

Answer 11

Retractor is assembled and placed over the largest dilator. It is gently pushed down to retract the muscle tissues and provide access to the spine. Dilator tubes are removed.

Question 12

Retractor secured

Answer 12

Retractor is fixed to the table to prevent movement. It is docked to the vertebral body with a shim pin.

Question 13

Annulotomy

Answer 13

surgeon uses a long 11 blade to create an incision into the disc. Pituitary rongeur is used to remove soft tissue.

Question 14

Contralateral release

Answer 14

A wide Cobb elevator is introduced into the disc space and advanced through to the contralateral side to release the annulus fibrosis from the endplate. This allows for greater distraction. (do not disrupt ALL)

Question 15

Discectomy

Answer 15

Shavers curettes and pituitary rongeurs are used to remove disc material

Question 16

Endplate Prep

Answer 16

Endplates are prepped using scraper like rakes and rasps to create good bleeding bone.

Question 17

Trials

Answer 17

A series of trials are used with a inserter and mallet to create a good footprint (good, height, width, length and lordosis.) It should span from apophyseal ring to apohyseal ring to maximize support and decrease subsidence. c-arm

Question 18

Final implant

Answer 18

Attach Cage to inserter and pack with biologics. Using c-arm/fluoro, gently mallet into disc space

Question 19

expandable cage

Answer 19

If surgeon chooses an expandable cage, then implant and expand to correct height. Surgeon with backfill cage with biologics

Question 20

Standalone

Answer 20

If Standalone cage is used, awl, drill guide and drill to advance 2 screws into the lateral vertebral bodies.

Question 21

Final Steps

Answer 21

Confirm with x-ray, irrigate, disconnect retractors and pull retractor out, Close