Awake spinal fusion - Endoscopic facet sparing transforaminal lumbar interbody fusion under caudal epidural: A game changer

Abstract

Background: Trans-Kambin fusion offers the advantage of providing reduced morbidity and awake surgery allowing for patient's own neuromonitoring during the procedure, along with reduced hospital stay, early mobilization, reduced blood loss, and reduced operative time, while maintaining the standard of fusion that can be achieved with open/MISS transforaminal lumbar interbody fusion.Objective: Spinal fusions done under GA have restrictions when it comes to patients with OSA/COPD/Cardiac dysfunction, etc. Awake Endoscopic Spinal fusion surgeries can provide a novel solution to such patients.Material and Methods: EKLIF was performed in total of 19 patients with 17 single-level and 02 patients with multilevel lumbar discopathy and/or degenerative spondylolisthesis resulting in axial back pain and claudication, pseudoradicular, or radicular symptoms. Endoscopic discectomy and interbody cage insertion were performed through a 1 cm lateral incision used for transforaminal access, followed by percutaneous pedicle screw-rod fixation. Clinical outcome was assessed by early postoperative pain scores (visual analog score [VAS]). Fusion rates were assessed by X-rays at 6 months. Clinical outcome, time in the operating room, intraoperative blood loss, VAS at preoperative, immediate postoperative, and after 6 months were determined.Results: Excellent and good clinical results were obtained in 16 (84%) out of 19 patients at 6 months. The mean time spent in the operating room 71 min and no patient required a blood transfusion. The mean hospital stay was 2.8 days, with one patient having a prolonged stay of 8 days due to an intraoperative dural tear that was managed conservatively. There was no morbidity related to instrumentation. Postoperative stay was reduced with all patients mobilized on the next day of surgery. Fusion was visible in all patients on follow-up imaging at 6 months. The mean VAS of the study group before surgery was 6.63 with a significant change to 2.94 in the immediate postoperative period. At 6-month follow-up, the mean VAS was 1.3.Conclusions: EKLIF allows for safe and efficient minimally invasive treatment of single and multilevel degenerative lumbar instability with good clinical results. Further prospective studies investigating long-term functional results are required to assess the definitive merits of trans-Kambin fusion of the lumbar spine.