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SURGICAL TECHNIQUE

Instruments and implants approved by the AO Foundation.This publication is not intended for distribution in the USA.

Anterior lumbar intervertebral spacer

VISIOS

PRODUCT OBSOLETED – 31 March 2018

DSEM/SPN/0814/0160(2)

Image intensifier control

WarningThis description alone does not provide sufficient background for direct use of DePuy Synthes products. Instruction by a surgeon experienced in handling these products is highly recommended.

Processing, Reprocessing, Care and MaintenanceFor general guidelines, function control and dismantling of multi-part instruments, as well as processing guidelines for implants, please contact your local sales representative or refer to:http://emea.depuysynthes.com/hcp/reprocessing-care-maintenanceFor general information about reprocessing, care and maintenance of Synthes reusable devices, instrument trays and cases, as well as processing of Synthes non-sterile implants, please consult the Important Information leaflet (SE_023827) or refer to: http://emea.depuysynthes.com/hcp/reprocessing-care-maintenance

Visios Surgical Technique DePuy Synthes 1

TABLE OF CONTENTS

INDICATIONS AND CONTRAINDICATIONS 2

AO SPINE PRINCIPLES 3

IMPLANTS 4

SURGICAL TECHNIQUE 5

ADDITIONAL POSTERIOR FIXATION POSTOPERATIVE MANAGEMENT 12

BIBLIOGRAPHY 13

2 DePuy Synthes Visios Surgical Technique

INDICATIONS AND CONTRAINDICATIONS

Visios is a system of implants and instruments designed for anterior lumbar interbody fusion (ALIF). The system was developed to achieve the following objectives:

• To distract the disc space and restore normal disc height and physiological lordosis, thereby also widening the foramina

• To preserve the integrity of the vertebral body endplates

• To provide an optimal implant/endplate interface, thus considerably limiting the risk of subsidence into the adjacent vertebrae

• To stabilise the pathologically unstable segment• To support bone growth through the implant

Indications

Lumbar and lumbosacral pathologies for which segmental spondylodesis is indicated, for example:

• Degenerative disc diseases and spinal instabilities• Primary procedures for certain advanced disc diseases• Revision procedures for post-discectomy syndrome• Pseudarthrosis or failed spondylodesis• Degenerative spondylolisthesis• Isthmic spondylolisthesis

Contraindications

• Vertebral body fractures• Spinal tumours• Serious spinal instabilities• Primary spinal deformities

coronalaxial

sagittal


Copyright © 2012 by AOSpine

The four principles to be considered as the foundation for proper spine patient management underpin the design and delivery of the Curriculum: Stability – Alignment – Biology – Function.1,2

FunctionPreservations and restora-tion of function to prevent disability

StabilityStabilization to achieve a specific therapeutic out-come

AlignmentBalancing the spine in three dimensions

BiologyEtiology, pathogenesis, neural protection, and tissue healing

AO SPINE PRINCIPLES

1 Aebi et al (1998)2 Aebi et al (2007)

ImplantateImplantateImplantateImplantate


IMPLANTS

The Visios cages are radiolucent with three X-ray mark-ers for location purposes (marked red in the illustrations). The two posterior markers are shorter than the anterior marker.

Two cage designs are available:

• Visios cages with 0°/90° grooves for anterior and lateral approaches

• Visios cages with 45° grooves for the anterolateral approach

In both designs the Visios Cages are 30 mm wide and 24 mm deep. The overall height ranges between 9 and 19 mm with 2 mm increments.

Visios for anterior and lateral approaches

lateral view

Visios for anterolateral approach

AP view


The following surgical technique is described using the example of an anterior approach to L5/S1.

1Determine approach and size of Visios cage

The approach will depend on the part of the spine to be treated and the surgeon’s preference. The cage can be inserted from the anterior, anterolateral or lateral direc-tions. The insertion technique is identical for both cage designs and all three approaches.

Prior to surgery, estimate the appropriate size of the cage. This initial estimate can be made by comparing the preoperative planning template (X000008) with the ad-jacent intervertebral discs on a lateral radiograph. With the segment fully distracted, the cage must fit tightly and accurately between the endplates. Use the tallest possible cage so as to maximise segment stability through tension between the longitudinal ligament and the annulus fibrosus.

2Position patient

The position of the patient will depend on the selected approach. For the management of indications affecting the lower lumbar spine via an anterior approach, the pa-tient is placed in the Trendelenburg position. If the Visios cage is to be inserted via an anterolateral approach – for example for indications affecting a higher part of the lumbar spine – the patient must be placed in a supine or lateral position.

SURGICAL TECHNIQUE

4


3Expose disc

For the anterior approach, expose the disc so as to pro-duce an opening on either side of the midline (sagittal plane) corresponding to half the width of the Visios cage. If the blood vessels and/or tissues cannot be re-tracted sufficiently, an anterolateral or lateral approach may be indicated.

4Cut window

For the anterior approach, cut a rectangular window, matching the width of the Visios cage in the anterior longitudinal ligament and the annulus fibrosus.

For the anterolateral or lateral approaches, cut a corre-sponding window in the annulus fibrosus.

A Visios Trial Implant (396.441–446, 396.451–456) can be used to measure the width of the window.

Preserve as much of these structures as possible since they are important for the stability of the operated seg-ment.

Surgical technique


5Prepare disc space

Via the window in the annulus fibrosus, excise the disc ma terial and remove the cartilaginous layers from the endplates until bleeding bone is attained. Adequate cleaning of the endplate is important for the vascular supply to the bone graft. Excessive cleaning, however, may weaken the endplates due to removal of the denser bone of the endplates. If possible prepare the endplates so that their curvature matches that of the Visios cage.

Note: Remove sufficient material from the disc space so as to ensure that no disc material is pushed back during insertion of the Visios trial implant and the cage.

6Distract segment

Instrument

SFW650R Prodisc-L Spreader Forceps, curved

Distraction of the segment is essential for restoration of the disc height, widening of the foramina and the stabil-ity of the Visios cage.

Use Prodisc-L Spreader Forceps (SFW650R) for spreading the disc space. Prior to distraction ensure that the posi-tion of the spreader forceps posterior is adequately deep. Check the lateral position using the image intensi-fier.

Note: The disc space can also be distracted with the Visios trial implants and/or a vertebral body spreader.

7


7Select Visios trial implant and mount on holder

The following Visios Trial Implants are available for the anterior and lateral approaches (396.441–396.446) and for the anterolateral approach (396.451–396.456):

Height 0°/90° 45° (anterior and lateral) (anterolateral)

9 mm 396.441 396.451

11 mm 396.442 396.452

13 mm 396.443 396.453

15 mm 396.444 396.454

17 mm 396.445 396.455

19 mm 396.446 396.456

Select the trial implant corresponding to the preopera-tively determined cage size and approach, mount on the Holder (397.089) according to the particular approach and secure by fully tightening the knurled nut.

8Insert Visios trial implant

It is a general insertion with slight hammering and insert into the disc space.

If a tight fit is not achieved, try the next larger size. If the trial implant cannot be inserted, try the next smaller size. With the segment fully distracted, the trial implant must fit tightly and accurately between the endplates so that the disc height is preserved.

When the correct size of the Visios cage has been deter-mined, the distraction can be released temporarily.

Note: The trial implants are not for implantation and must be removed before insertion of the cage.

for anterior approach

for lateral approach

for anterolateral approach

Surgical technique


9Select Visios cage and mount on holder

The following Visios cages are available for the anterior and lateral approaches (889.961–889.966) and for the anterolateral approach (889.971–889.976):

Height 0°/90° 45° (anterior and lateral) (anterolateral)

9 mm 889.961 889.971

11 mm 889.962 889.972

13 mm 889.963 889.973

15 mm 889.964 889.974

17 mm 889.965 889.975

19 mm 889.966 889.976

Select the cage corresponding to the trial implant, mount on the holder according to the particular ap-proach and secure by fully tightening the knurled nut.

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4

2

1

3


10Pack Visios cage with cancellous bone

The cancellous bone can be taken either from the iliac crest or, using the Instrument Set for Vertebral Body Trephine (187.280), from an adjacent vertebral body. In-sert the cage, attached to the holder (397.089), into the opened Packing Block (397.096) (1), close the packing block lid (2) and tighten the knurled nut (3). Using the Cancellous Bone Impactor (394.581) fill the cage com-pletely with the crushed bone material and press down firmly (4). The cage has to be completely filled with bone graft.

Surgical technique

13

3–4 mm


11Implant Visios cage

When the cage is ready for implantation, redistract the segment. Insert the cage into the disc space with slight hammering.

12Remove instruments

Remove the holder.

13Verify position of Visios cage

The optimal position for the cage is centred within the vertebral endplates.

Depending on the size of the vertebrae, the anterior edge of the cage will be approximately 3–4 mm behind the anterior edge of the adjacent vertebrae. Verify the AP position of the cage relative to the vertebral bodies under the image intensifier (see planning template).

Posteriore Fixation


Additional posterior fixation

Additional posterior instrumentation with translaminar or transpedicular screws considerably enhances the bio-mechanical stability of the motion segment, regardless of the design of the ALIF implant (Oxland et al., 1997). Such an additional posterior fixation is therefore recom-mended for improving the stability of the Visios cage. The fixation is performed after implan tation of the cage. See bibliography for further details of this technique.

Additional posterior fixation with pedicle screws is indi-cated for the treatment of spondylolisthesis and is per-formed prior to cage insertion.

Note: Excessive distraction of the disc space must be avoided in patients with existing posterior fixa-tion.

Postoperative management

Mobilization can begin on the first postoperative day. It is advisable for the patient to wear a corset (T.L.S.O or L.S.O) for the first three months after surgery. The pa-tient must be warned against undertaking activities that place excessive stress on the operated spinal area. Physi-cal activities and trauma with adverse effects on the af-fected vertebrae can lead to failures as a result of loos-ening and fracture of the endplates.

ADDITIONAL POSTERIOR FIXATION POSTOPERATIVE MANAGEMENT


Aebi M, Arlet V, Webb JK (2007): AOSPINE Manual (2 vols). Stuttgart. New York: Thieme

Aebi M, Thalgott J, Webb J (1998) AO/ASIF Principles in Spine Surgery. Springer, Berlin

Heggeness M, Esses S (1991) Translaminar facet joint screw fixation for lumbar and lumbosacral fusion. A clini-cal and biomechanical study. Spine 16 (6S): 266–269

Heiden E, Montesano P (1996) Translaminar facet screw fixation. In Thalgott J, Aebi M (eds.) Manual of internal fixation of the spine. Lippincott-Raven Publishers, Phila-delphia

Jacobs R, Montesano P, Jackson R (1989) Enhancement of lumbar spine fusion by use of translaminar facet joint screws. Spine 14 (1): 12–15

Müller M, Allgöwer M, Schneider R, Willenegger H (1991) Manual of internal fixation. Techniques recom-mended by the AO/ASIF group. Third edition, Springer, Berlin

Oxland T, Hoffer Z, Nydegger T, Rathonyi G, Nolte L (1997) Comparative biomechanical investigation of anterior lumbar interbody cages: Central and bilateral insertion. Proceedings of the 8th Annual Meeting of the European Spine Society, Kos, Greece: 14

Watkins R (1989) Anterior lumbar interbody fusion. Surgical technique. In Lin P, Gill K (eds) Lumbar Interbody Fusion. Aspen Publishers, Inc., Rockville, USA: 107–114

BIBLIOGRAPHY

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Synthes GmbHEimattstrasse 34436 OberdorfSwitzerlandTel: +41 61 965 61 11Fax: +41 61 965 66 00www.depuysynthes.com ©

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Not all products are currently available in all markets.

This publication is not intended for distribution in the USA.

All surgical techniques are available as PDF files at www.depuysynthes.com/ifu

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