A New Suction Instrument for Spinal Surgery

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A New Suction Instrument for Spinal Surgery
  Forum A New Suction Instrument for Spinal Surgery Joaquim L. Reis  1,2  , Márcia Tizziani  1 , Alfonso Velasco  1   OBJECTIVE:  Spinal surgical procedures share the technical difficulty of having to preserve the integrity of the dura mater in a surgical field with different degreesof hemorrhage. This difficulty is particularly evident in the surgery of degenerative diseases.   METHODS:  We have developed a new surgical sucker that allows an easy dissection of the dural sac fromadjacent structures and improves the overall surgicalmanipulation during degenerative lumbar spinal proce-dures. The present technical note describes this newlydeveloped suction device that comprises a slightly ovalspatula positioned at an angle of 30° to the bore of thesuction tube.   RESULTS AND CONCLUSION:  Attending to the com-bination of a spatula and a suction device, it offersseveral advantages when compared to the instruments that are currently available. Namely, it facilitates thedissection of the ligamentum flavum from the subjacentdura mater, separating and holding this ligamentum from the dura mater; it also allows a slight retraction of thedural sac without direct suction and a better illuminationof the surgical field through light reflected from thespatula.Peer-Review Article OBJECTIVE Clinical conditions that require spine surgery are diverse, but they share the requirement of neural structure decompression(1-3, 5, 15). Surgical procedures to treat lumbar spine degenera-tivediseasesarequitecommoninspinalsurgeries(8,14,17).The prevalence of disk protrusion in patients with back pain and/orsciatica disorders, identified by medical imaging, varies between30.3% and 45.3%, and for nerve root canal stenosis it variesbetween 27.9% and 52.8% (16). Preserving the dural integrity duringthedecompressionofnervousstructuresinsidethespinalcanal or in the vertebral foramen is a goal of all surgeries of degenerative spine (6, 9, 10, 13).To overcome dural expansion during decompression of a degenerative lumbar spinal canal, we have developed a new surgical sucker that combines a dissector and a retractor that allows better identification and control of dural positioning. Ouraiminthisbriefcommunicationistointroducethissimpledevicethat has been a reliable improvement in our neurosurgicalpractice. METHODS Weproposeanewsurgicalsuckerwithaslightlyovalspatulathat is placed at the opening of the suction tube at an angle of 30°( Figures1 and 2 ).Theshaftofthesuctiontoolis160mmlongandit forms an angle of 60° with the handle. The handle is 75 mmlong, has a 4-mm internal diameter, and is associated with aclassicalconicshapeconnectortothesuctionsystem( Figure1D ).The tip of the sucker has an opening that is 2.5 mm in diameterand is associated with a spatula that is 4.3 mm long and 4 mm wide ( Figures 1B, 1C , and  2 ). RESULTS Theslightlyovalspatulacombinedwiththeclassicsuctiontoolof the surgical field allows to dissect the ligamentum flavum fromthe dura mater. Furthermore, it allows the retraction of the dura Key words   Dissector   Lumbar spine   Spinal surgery   Sucker   Retractor From the   1  Department of Neurosurgery, Santo António General Hospital, Porto,Portugal;   2  Department of Anatomy, Abel Salazar Institute for Biomedical Sciences, ICBAS, UMIB, University of Porto, Porto, Portugal To whom correspondence should be addressed: Joaquim L. Reis, M.D., Ph.D.[E-mail:  jlreis@icbas.up.pt ] Citation: World Neurosurg. (2011) 75, 1:15-19.DOI: 10.1016/j.wneu.2010.05.004 Journal homepage:   www.WORLDNEUROSURGERY.org  Available online :   www.sciencedirect.com  1878-8750/$ - see front matter © 2011 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY  75 [1]: 15-19, J ANUARY  2011 www.WORLDNEUROSURGERY.org  15  mater during the fenestration procedures, and the slightly ovalconfiguration of the spatula affords better dissection and separa-tion of the dural sac from the internal pedicle surface (recess)owing to a narrower transverse diameter. We have initially devel-oped and used this sucker for posterior decompression in thesurgical treatment of lumbar canal stenosis. For a wide flavec-tomy, it is required to ensure an adequate exposure and decom-pression of the dural sac; the ligamentum flavum is removed by aKerrison punch, while the spatula of the suction instrument protectstheduramaterandcleansthefield( Figure3 ).Ingeneral,after opening the ligamentum flavum and observing the duramater, the ligamentum is dissected and pulled away from thedura mater between the sucker hole and the spatula; then, thissame ligament undergoes upper retraction with the Kerrisonpunch and, before cutting and removing it with the punch, thesucker positioning is changed and the dura mater is pulled downslightlywiththeinferiorsurfaceofthesuckertocheckonceagainthat the dura mater is out of the range of the punch ( Figure 4 ).Furthermore, the anterior portion of the spatula being made of stainless steel allows a better penetration of the microscope light into the surgical field as a result of light reflecting from thespatula ( Figure 4B ). During lumbar disk herniation surgical pro-cedures, we have also used this new sucker for the fenestrationand also for medial retraction of the dura mater of the nerve root during the diskectomy phase. This additional use of the suctiondevice allows direct aspiration of the dura mater, with a lowersuction intensity, between the sucker hole and the 30° angledspatula that allows retraction and, if necessary, elevation of thedura mater that surrounds the root with the purpose of obtaininga wider access to the intervertebral disk ( Figure 5 ).We have made a retrospective analysis of the last 36 cases of degenerative spine surgery operated by the first author of thispaper before and after introducing this new device. The totalnumber of surgical procedures in each group was equally dividedfor different types of surgical techniques. There were 12 consec-utive cases of lumbar disk herniation or one- and two-level de-compressive fenestrations. The number of dural tears was thesame in surgeries whether the new tool was used or not, that is,twoineachgroup;thedurationoftheproceduresforlumbardisk herniation was also quite similar in both groups; for lumbarstenotic channels submitted to decompressive large fenestra-tions, the surgical procedures with this new tool appeared tobe faster although these differences were not statistically signif-icant ( t   test) ( Figure 6 ). We have also a few additional cases of spondylolisthesis operated through a transforaminal approach( Figure 5 ). DISCUSSION This new device is designed to help the surgeon who workssimultaneously with a Kerrison punch and an aspirator duringfenestration. The slightly oval spatula on the aspirator providesseveral simple and unique practical advantages:1. dissection of the ligamentum flavum from the dura mater;2. gentle temporary dural retraction without direct suction of thetissue during the posterior approach;3. better illumination of the surgical field under the vertebral lam-ina, since the oval retractor permits some mirror effect;4. the angled sucker entrance, which can also be used as a duramater retractor, to gently aspirate with a low intensity and to Figure 1.  Photograph showing a sideview of the sucker-dissector  (A) . Thedevice comprises a handle portion(arrow) connected to the suctionsystem, a curved shaft (dotted arrow),and the tip with a spatula (oval area).The sucker tip  (B)  is formed by thesuction opening associated with aslightly oval spatula at an acute angleof 30°; a higher view of the sucker tip (C) ; the connector system of thesucker with a classic conical shape  (D) . Figure 2.  This figure presents a schematic drawing of the sucker with adetailed representation in different views of the sucker tip with an ovalspatula. F ORUM JOAQUIM L. REIS ET AL. NEW SUCTION INSTRUMENT FOR SPINAL SURGERY 16  www.SCIENCEDIRECT.com  WORLD NEUROSURGERY , DOI:10.1016/j.wneu.2010.05.004  hold the dura mater of thelumbar sac or the nerveroot, although there areother devices already de-scribed with this goal(18);5. additionally, it can holdthe ligamentum flavum toallow better separationfrom the underlying duramater.A literature search regard-ingtheuseofsuctiontoolsinspinal surgery showed sev-eral devices with additionalfunctions with different pro-posals,suchasthenerveroot retractor (18) with a small posterior platform adjacent to the sucker tip to hold thedura mater; a reversible dis-sector(4)forminga90°angle  with the tip of the sucker that  was conceived for brain sur-gery; a sucker with side aper-tures covered by film halves with the purpose of causingless damage to the tissues(11); a tubular portion slid- ablypositionedoversaidsuc-tion tube and wherein thespatula is curved radially away from the suction tube with 1 cm for retracting thenerve root (12); a suction tube with a series of smallholes on its proximal end al-lowing precise control of suctionpressureduringami-crosurgical procedure (7). Our newly developed de- vice clearly differs from thepreviously available ones andhas more applications in thefield of spine surgery. Thenew suction instrument, with a 30° spatula, has a new configuration that permitsdissection and retraction of the dura mater with the samedevice. As a dural retractor,its chief and novel advantageis its ability to pull away thedura mater over the caudaequina, allowing safe fenes- Figure 3.  The drawing represents the sucker tip retracting the ligamentum flavum of the lumbar spine  (A)  duringfenestration, and a detailed configuration of the sucker tip and Kerrison punch that are used in this technicalprocedure  (B) . K, Kerrison punch; S, sucker. Figure 4.  Photographs obtained with the surgical microscope during a surgery of decompression of the stenotic lumbarchannel, with the spatula of the sucker holding the ligamentum flavum detached from the dura mater  (A) . During thelamina removal with the Kerrison punch, the sucker retracts and aspirates over the dura mater and allows better lightpenetration as a result of some mirror effect  (B) . To the right of each micrograph is a drawing showing the function of thissucker. K, Kerrison punch; S, sucker. F ORUM JOAQUIM L. REIS ET AL. NEW SUCTION INSTRUMENT FOR SPINAL SURGERY WORLD NEUROSURGERY  75 [1]: 15-19, J ANUARY  2011 www.WORLDNEUROSURGERY.org  17  tration during the posteriorapproach owing to betterpenetration of the light source. The main new advan-tages as a dissector is itssmooth oval border and theslightly larger diameter of the spatula compared withthe tip sucker hole and the30° angle that permits safedissection, retraction, andholding of the dura materfrom a posterior approach.This device is very simple tomake, and we have created it in the laboratory of our hos-pital. Nevertheless, it hassome minor disadvantages,as in some positions it can besomewhat noisy during theremoval of blood and alsotends to obstruct more fre-quently, which sometimesrequiresusingaguidewiretoclean the lumen. Addition-ally, this tool is most useful when used with the non-dominant hand of the mainsurgeon and it should beused when the dura mater isidentified after opening theligamentum flavum. Further-more, variations concerningmaterials, lengths, and angleof the associated spatula canbe easily modified for this device. Indeed, we have tried a longersucker with an angle of about 45° but we have had a betterperformance with the herein described device. Although otherfactors are also important, such as the individual characteristicsof the patients and surgeon’s experience, the results of our lim-ited experience deserves a reflection: better control of dura materpositioning allows a slightly quicker procedure; our confidencehas grown and we currently use this device in the surgery of alldegenerative spinal lumbar cases. CONCLUSION A new sucker device is presented that can also be used as duraldissector and retractor. Its main advantage is its ability to pushawaytheduralsacwithbetterlightpenetration,anditcanalsobeused to put away the nerve root. A further advantage of the new tool is that it allows an easy dissection of the flavum ligament from the dural sac, allowing a better control of dura mater posi-tioning. Figure 5.  Photographs of a minimal invasivetechnique surgery that used expandable tubes fora lumbar L4-5 istmic spondylolisthesis procedurewith the goal of decompressing the nerve roots,followed by fixation with cages and transpedicularscrews. The sucker retracts the exposed L4 at theforamen  (A)  and is also used to retract and elevatethe dural sac medially during the diskectomyphase  (B) . The drawing  (C)  represents theretraction of the dura mater obtained with theangled sucker entrance that can be applied to thedural sac or to the nerve root. R, rongeur fordiskectomy; S, sucker. Figure 6.  The graph represents the time spent during the most commonspine lumbar degenerative surgical procedures with the use of this newsucker compared with a standard one. F ORUM JOAQUIM L. REIS ET AL. NEW SUCTION INSTRUMENT FOR SPINAL SURGERY 18  www.SCIENCEDIRECT.com  WORLD NEUROSURGERY , DOI:10.1016/j.wneu.2010.05.004  REFERENCES 1. 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Worldintellectualpropertyorganization.Nerveroot retractor and sucker, patent WO/2005/058387,McKinley LM, 2005. Available at: http://www. wipo.int/pctdb/en/wo.jsp?wo  2005058387. Ac-cessed September 2, 2009. Citation: World Neurosurg. (2011) 75, 1:15-19.DOI: 10.1016/j.wneu.2010.05.004 Journal homepage:   www.WORLDNEUROSURGERY.org  Available online :   www.sciencedirect.com  1878-8750/$ - see front matter © 2011 Elsevier Inc.All rights reserved. Hubble Space Telescope. NASA astronaut Drew Feustel, STS-125 mission specialist, trains with fellow astronauts and Hubble engineers in the clean room at NASA’s GoddardSpace Flight Center. Feustel is using a computer-controlled power tool to install the Wide Field Camera 3 into a high-fidelity Hubble model. Credit: NASA F ORUM JOAQUIM L. REIS ET AL. NEW SUCTION INSTRUMENT FOR SPINAL SURGERY WORLD NEUROSURGERY  75 [1]: 15-19, J ANUARY  2011 www.WORLDNEUROSURGERY.org  19
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