Clinical problem

Transforaminal lumbar interbody fusion (TLIF) is a common surgical technique performed via a posterior approach with favorable fusion rates [1]. Open TLIF, however, can present clinical challenges, including greater soft-tissue disruption [1], increased complication risk [2−5], slower recovery [6, 7], and variable long-term outcomes, such as greater back pain and disability [7].

The MIS-TLIF techniques have evolved to reduce complications seen with open TLIF [1]; however, they may be linked with certain limitations, such as lack of consistent visualization and steep learning curve [8], and occupational hazards to the surgeon [9,10].

Solution

TELIGEN™ System is a technology platform that facilitates MIS-TLIF procedures through digital tools for visualization and access. Its first clinical application is a beginning-to-end procedural solution for MIS-TLIF surgery (DePuy Synthes VueLIF™-T Procedure). Other enabling technologies, like neuromonitoring and navigation, can be integrated into the workflow.

TELIGEN™ System overview/instruments

The system components are centrally controlled from the TELIGEN Digital Control Center (tower). Included in the tower are the monitor, the camera control system (CSS), the camera wash box with foot pedal control, and the vacuum pump for discectomy (Fig 1).

The TELIGEN HD CCS operates the TELIGEN™ Camera, which is used for illumination and visualization of the surgical site. The image collected at the TELIGEN™ Camera is transferred to the CCS and then displayed on the monitor.

The TELIGEN™ Camera provides an opportunity to see beyond the boundaries of the port. Placing the camera at the distal end of the port enables line of sight past the edge of the port, expanding the field of view of the surgical site. Visual interference from the surgical instruments is reduced compared to traditional visualization methods (eg, surgical microscope, loupes, exoscope). The camera has a field of view (FOV) of 70°, direction of view (DOV) of 22.5°, and a depth of field (DOF) of 8−120 mm (Fig 2).

Two LEDs located near the tip of the camera provide light across the field of view. The camera is self-retained in the channel of the port allowing for hands-free use. The camera cable is held by the cable wing of the port holder, securing the camera’s position, and preventing interference within the surgical workspace. This allows for bimanual control of instruments during the procedure.

The camera view can be rotated around the access port axis during the procedure. After the camera is rotated within the patient, pressing the corresponding clock position on the CCS’s user interface will match the on-screen orientation (Fig 3).

The TELIGEN™ Camera Wash Box assists the surgeon in maintaining a clear visual field during endoscopic spine surgery by cleaning the lens of the camera. The camera lens and surgical site can be irrigated in-situ without removal from the working channel. The cleaning cycle is activated by foot pedal or from the CCS touchscreen.

TELIGEN™ comes with a disposable procedure kit and a set of reusable instruments. The contents of each of these sets may vary in some markets. These components are designed to facilitate the entire procedure beginning to end introducing procedural efficiencies along with features that are complimented using the TELIGEN™ camera.

VueLIF-T™ Procedure Kit contains sterile, single-use instruments to allow for access, visualization, discectomy, and graft delivery. It includes the camera, ports, and port holder, TELIGEN™ Clear (MIS discectomy device, former CONCORDE Clear), soft-tissue retractor, port cutter cartridge, and bone graft delivery instruments (Fig 4).

The set of reusable instruments include table mounting instruments, dilators, port adjuster and port cutter, graft delivery cannula, suction tubes, and Kerrisons, etc (Fig 5).

The head-up display allows surgeons to maintain ergonomic posture during procedures (Fig 6) [11]. This may help avoid significant musculoskeletal pain commonly reported by spine surgeons, especially low back and neck pain [12,13].

(Case provided by Michael Y Wang, MD, University of Miami Hospital and Sasha Vaziri, MD, Sarasota, Florida, USA)

• A 73-year-old woman
• Severe and worsening low back pain, left lower extremity numbness, and radiculopathy
• Failed multiple rounds of conservative management including epidural steroid injections, physical therapy, and medications
• Imaging revealed L4/L5 spondylolisthesis and a left-sided synovial cyst (Fig 8)
• Diagnosis: lumbar spondylolisthesis and radiculopathy
  

Surgical treatment

• Left L4/L5 VueLIF™ Procedure utilizing the TELIGEN™ System
• Patient-mounted TELIGEN™ tubular access system using a MIS-TLIF approach (Fig 9)
• Discectomy with TELIGEN™ Clear
• VIPER PRIME™ Screws and CONCORDE™ Bullet Interbody Cage (Fig 10)

Outcomes

• The patient did well and stayed one night at the hospital.
• At the 6-week postoperative follow-up she was pain free.