Applications in Spine Surgery and Surgical Technique Guide

UltraSonic Bone Dissector: Applications in Spine Surgery and Surgical Technique Guide Peyman Pakzaban, MD, FAANS Houston MicroNeurosurgery - Houston, TX Abstract The Misonix BoneScalpel is a novel ultrasonic surgical device that cuts bone and spares soft tissues. This relative selectivity for bone ablation makes BoneScalpel ideally suited for spine applications where bone must be cut adjacent to dura and neural structures. Extensive clinical experience with this device confirms its safety and efficacy in spine surgery. The aim of this report is to describe BoneScalpel’s mechanism of action and the basis for its tissue selectivity, review the expanding clinical experience with BoneScalpel (including the author’s personal experience), and provide a few recommendations and recipes for en bloc bone removal with this revolutionary device. 1 Introduction Mechanism of Action The advent of ultrasonic bone dissection is as Ultrasound is a wave of mechanical energy significant to spine surgery today as the adoption of propagated through a medium such as air, water, or pneumatic drill was several decades ago. Power drills tissue at a specific frequency range. The frequency is liberated spine surgeons from the slow, repetitive, typically above 20,000 oscillations per second fatigue inducing, and occasionally dangerous (20 kHz) and exceeds the audible frequency range, maneuvers that are characteristic of manually hence the name ultrasound. In surgical applications, operated rongeurs. Now ultrasonic dissection with this ultrasonic energy is transferred from a blade to BoneScalpel empowers the surgeon to cut bone with tissue molecules, which begin to vibrate in response. an accuracy and safety that surpasses that of the Whether tissue molecules can tolerate this energy power drill. transfer or be destroyed by it depends on the density of the tissue and the frequency of oscillation. Dense The greater accuracy of BoneScalpel is a result of tissues, such as bone, are ablated by frequencies in the the back-and-forth micro-motion of BoneScalpel’s low ultrasonic range. thin blade as opposed to the rotary macro-motion of a drill’s burr. This permits fine and precise bone cuts not The BoneScalpel assembly consists of an ultrasonic afforded by a drill. In addition, BoneScalpel has two generator/irrigation console that connects to a attributes that provide greater safety. First, elimination hand-piece bearing a disposable cutting tip (Fig.1). of rotary motion avoids many of the risks associated The cutting tip oscillates back and forth a very with the drill, such as slipping off the cutting surface small distance at rate of 22,500 times per second (a and entrapping important soft tissues. Second, frequency in the low ultrasonic range). The cutting BoneScalpel cuts bone better than soft tissue. This tip comes in two main varieties (additional ones are tissue selectivity, which may seem counter-intuitive at being developed): the blade and the shaver tip (Fig. 2). first glance, is extremely useful in spine surgery where The blade behaves like an ultrasonic micro-osteotome the surgeon is routinely faced with the task of cutting to make well-defined cuts in bone and is used for en bone adjacent to dura. bloc removal of large pieces of bone. The shaver tip behaves like a non-rotating burr to selectively ablate bone in a small area. The integrated irrigation feature helps remove bone debris and cool the cutting tip. The BoneScalpel blade’s mechanism of action is best understood by analogy to an osteotome (Fig. 3). When an osteotome is struck by a mallet, the energy that is transmitted down the shaft of the osteotome is focused along its narrow tip. This focused energy is then transferred from the tip to a very narrow band of bone, which disintegrates in response, thus creating the leading edge of a cleavage plane in bone. Much like an osteotome, the blade of BoneScalpel moves forward (and backward) (Fig. 4). However, the amplitude of this movement is much smaller than that of an osteotome (35-300 microns), thus transferring only a small amount of energy to bone with each impact. The very high frequency at which the blade moves back and forth to impact the bone (22.5 kHz) compensates for the small energy of each individual impact, thus resulting in a large transfer of energy to bone at the point of contact. Again, this energy disintegrates a narrow sliver of bone and develops a cleavage plane. 2 En block Precise Bone Dissection Bone Ablation Figure 2. Two bone cutting tips and techniques: Figure 3. Osteotome mechanism of action. The blade (left) is used for en bloc bone removal while the shaver tip (right) is used for precise bone ablation. s (max) s (0) s (min) Frequency = 22,500 cycles / sec Amplitude = 35-300 pm Figure 4. Back-and-forth micro-movement of BoneScalpel blade occurs at 22,500 cycles per second. 3 Tissue Selectivity When performing the third step, the BoneScalpel’s The relative selectivity of BoneScalpel for bone cutting relative selectivity for bone cutting provides a good has to do with the relative rigidity of bone compared margin of safety, allowing the surgeon to contact to soft tissues (Fig. 5). When the blade of BoneScalpel the underlying dura. However, it is important for the comes in contact with rigid bone, the bone does not surgeon to avoid the following pitfalls. First, one must bend, deform, or move away from the tip. As a result, a not plunge into the dura. As with any other surgical tool, large amount of energy is transferred to a small amount such plunging may cut the dura and result in neural of bone at the point of contact, resulting in destruction injury. Second, one should not linger over of that bone. In contrast, soft tissue structures (such as the dura so as to avoid excessive heat development and ligamentum avum, posterior longitudinal ligament, and a thermal lesion. Once the inner cortex is penetrated, dura) can bend, deform, move away, and vibrate upon the blade is withdrawn and moved to an adjacent contact with the blade, thus dampening the energy location. Third, one should avoid using this device transfer and protecting the tissue from destruction. when dura is likely to be adherent to the inner bone cortex (e.g. in presence of epidural scar or in ossification It is important to note that this selectivity is not of posterior longitudinal ligament). In these settings, absolute. With sufficient time and pressure, soft tissues the dura is at risk, since it cannot move away from the will be cut. Safe and efficient use of BoneScalpel in blade of BoneScalpel after the latter en bloc penetrates spine surgery depends on development of a tactile the inner cortex. Furthermore, even if the bone is cut “feel” for penetrating the inner cortex of bone. After this uneventfully, elevating it from the underlying adherent penetration occurs, the blade should come in contact dura is likely to result in dural laceration. Alternatively, with underlying tissues for a limited time with limited one can cut a slice of bone adjacent to the region of pressure. epidural scarring, dissect the adherent dura from the undersurface of the adjacent bone, cut another slice of Bone Cutting Technique bone in the dissected area and repeat these steps until The analogy to a micro-osteotome whose blade moves the desired amount of bone is removed. back and forth will help the surgeon understand that BoneScalpel cuts more efficiently with downward (axial) Unlike the drill, safe and ef cient use of BoneScalpel pressure rather than side-to-side (lateral) movements. has a surprisingly short learning curve. When teaching In the author’s experience, a useful strategy for cutting this technique to other surgeons, the author makes the bicortical bone consists of the following 3 steps: following recommendations: • Develop a tactile “feel” for BoneScalpel by practicing 1. Lateral movement with little axial pressure to score on a bone specimen. It is important not only the outer cortex of bone to be cut (Fig. 6A). to develop a feel for when the inner cortex is 2. Axial pressure and liberal lateral sweeps to cut penetrated, but also to familiarize oneself with the through the cancellous mid-portion of the bone amount of axial pressure that is required to cut (Fig. 6B). through bone efficiently. 3. Controlled cyclical forward/backward movement • Palpate with BoneScalpel off. If unsure of whether with short lateral sweeps to penetrate the inner the inner bone cortex has been penetrated, bone cortex (Fig. 6C). This step primarily involves momentarily stop the bone scalpel and “palpate” the the use of controlled axial (downward) pressure. residual bone with the BoneScalpel blade. Once the surgeon palpates the intended breach • Plan the cuts to be made. Unlike manual rongeurs of the inner cortex, he withdraws the blade or power drills, BoneScalpel removes bone en bloc. slightly, moves slightly to one side and repeats the It is, therefore, imperative that one plans in advance sequence. It is important to note that one generally and de nes the boundaries of the bone to be cut. At cannot visualize the underlying soft tissues through the end of this article, several cutting “recipes” for the thin trough that is created and must rely on various spine projects are provided. tactile feedback. If unsure of having penetrated • Divide the project into smaller pieces. Although it the cortex, the surgeon can momentarily stop the may appear counter-intuitive, it is often more ef ultrasonic action, palpate the inner cortex with the cient to divide a large bone cutting project (e.g. BoneScalpel blade, and then resume cutting. removing a whole lumber lamina) into two or three smaller pieces. Doing so will improve visualization of the thicker or deeper portions of the bone to be cut and will facilitate elevation of cut bone blocks from the underlying ligaments.

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