Cases Of Dural Tear Research Articles

One-hole split endoscopy technique versus unilateral biportal endoscopy technique for L5-S1 lumbar disk herniation: analysis of clinical and radiologic outcomes

BackgroundLumbar disk herniation (LDH) is one of the most common diseases of the spine, especially occurring in L4-5 and L5-S1 intervertebral disks, and surgery is a choice when conservative treatment is ineffective. The purpose of this study is to investigate the clinical efficacy and radiologic outcomes of one-hole split endoscopy (OSE) technique versus unilateral biportal endoscopy (UBE) technique in the treatment of L5-S1 lumbar disk herniation (LDH).MethodsA total of 133 patients of a single center surgically treated for L5-S1 LDH between 2019 and 2021 were retrospectively included in this study, of which 70 were treated by UBE technique and the rest were treated by OSE technique. Hospitalization time, operative time, intraoperative blood loss, fluoroscopy times, incision length and related complications were recorded. Bone resection area (BRA), articular process resection rate, range of motion (ROM), sagittal translation (ST), disk height (DH), Visual Analog Score (VAS), Oswestry Disability Index (ODI) and Macnab criteria were used to evaluated the clinical efficacy.ResultsThere was no statistically significant difference in hospitalization time or fluoroscopy times between the two groups. The operation time was shorter in the UBE group than that in the OSE group; however, the incision length was longer. Intraoperative blood loss and BRA were larger in the UBE group than in the OSE group. There was no significant difference in ROM, ST, DH, or postoperative facet resection rate between the two groups. There was no significant difference in ROM, ST, or postoperative facet resection rate compared with preoperative indicators in each group, but there was a significant difference in DH among distinct groups. At any time point, the lower back and leg VAS and ODI in each group were significantly improved compared to those before the operation, with no significant difference between the two groups. There was one case of dural tear in the UBE group. One case of transient hypoesthesia occurred in each of the two groups. The excellent–good rates of the UBE group and the OSE group were 88.6% and 90.5%, respectively.ConclusionThe OSE technique is an effective minimally invasive surgical option as well as the UBE technique in the treatment of L5-S1 LDH.

Posterior endoscopic decompression combined with anterior cervical discectomy and fusion versus posterior laminectomy and fusion for multilevel cervical spondylotic myelopathy: a retrospective case-control study

ObjectiveTo compare the clinical efficacy of surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) between the hybrid procedure, posterior endoscopic decompression (PED) combined with anterior cervical discectomy fusion (ACDF), and posterior cervical laminectomy and fusion (PCLF).MethodsA retrospective analysis was performed on 38 patients who received surgical treatment for MCSM from January 2018 to December 2021, including 19 cases in hybrid procedure group (13 males and 6 females), followed up for 10 to 22 (12.8 ± 10.3) months, and 19 cases in PCLF group (15 males and 4 females), followed up for 10 to 21 (11.7 ± 8.9) months. Perioperative information, including operation time, intraoperative blood loss, length of hospitalization, and complications, were compared between two groups. Visual analogue scale (VAS) of pain, neck disability index (NDI) and Japanese Orthopaedic Association (JOA) score were recorded to evaluate clinical efficacy. Cervical lordosis was calculated by radiographic examination.ResultsIntraoperative blood loss, length of hospital stay were less in hybrid group than PCLF group, while operation time is longer in hybrid group, with a statistically significant difference (p < 0.05). Increased lordosis was better in hybrid group. There was no significant difference in preoperative VAS, JOA and NDI at pre-operation and final follow-up between two groups. But at post-operation and final follow-up, VAS was less in hybrid group than PCLF group (p < 0.05). There were 2 cases of neurostimulation symptoms in hybrid group, 2 cases of C5 nerve root palsy, 2 cases of subcutaneous fat necrosis and 1 case of dural tear in PCLF group, and all patients relieved with symptomatic treatment.ConclusionThe hybrid procedure of PED combined with ACDF showed satisfied clinical outcome, with less intraoperative blood loss, shorter length of hospitalization and lower post-operative neck pain than PCLF. It is an effective surgical treatment for MCSM.

CT-based radiographic measurements and effectiveness estimates of full-endoscopic surgery in thoracic myelopathy caused by ossification of ligamentum flavum

BackgroundEvaluate the effectiveness of posterior percutaneous full-endoscopic technique for patients with thoracic myelopathy caused by ossification of ligamentum flavum (TOLF).MethodsA prospective study was conducted for 16 patients with TOLF, who were treated with posterior endoscopic technique from 2017 to 2019. The sagittal and cross-sectional CT images are used to measure the area of ossified ligamentum and evaluate the decompression of surgery, respectively. The effectiveness was evaluated with visual analog scale (VAS), modified Japanese Orthopedic Association scale (mJOA), The Oswestry Disability Index (ODI), and Macnab efficacy evaluation.ResultsThe average area of TOLF on sagittal and cross-sectional CT images in the 16 patients was (116.62 ± 32.72) mm2 and (141.59 ± 27.25) mm2 preoperatively, (15.99 ± 12.54) mm2 and (11.72 ± 8.64) mm2 at 3 days after the operation, (16.78 ± 11.49) mm2 and (10.82 ± 7.57) mm2 postoperative 1 year, respectively. The invasive proportion of spinal canal at preoperative sagittal and cross-sectional CT images was (48.10 ± 10.04) % and (57.58 ± 11.37) %, which decreased to (6.83 ± 4.48) % and (4.40 ± 3.01) % at the final follow-up. The average score of mJOA, VAS and ODI improved. The excellent and good rate was 87.50% according to Macnab evaluation. Compared with preoperative, differences in areas of TOLF, proportions of spinal canal, and clinical assessments of postoperative 3 days and 1 year were all statistically significant. Two cases of dural tear were observed.ConclusionEndoscopic surgery has a good clinical effect on TOLF, which has the advantage of less trauma to the paraspinal muscles and no impact on the spinal structure. The CT-based radiographic measurements can quantitatively evaluate the degree of spinal canal stenosis in TOLF.

Comparison of mid-term effectiveness of unilateral biportal endoscopy-transforaminal lumbar interbody fusion with minimally invasive surgery-transforaminal lumbar interbody fusion assisted with three-dimensional microscope in treating lumbar spondylolisthesis

To compare the mid-term effectiveness of unilateral biportal endoscopy (UBE)-transforaminal lumbar interbody fusion (TLIF) and minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) assisted with three-dimensional microscope in the treatment of single-level lumbar spondylolisthesis. A total of 41 single level lumbar spondylolisthesis patients who met the selection criteria were retrospectively collected between June 2018 and September 2019. Twenty-three patients were treated with UBE-TLIF (study group) and 18 with MIS-TLIF assisted with three-dimensional microscope (control group). There was no significant difference in gender, age, Meyerding degree of slippage, type of spondylolisthesis, lesion segment, course of disease, and preoperative hemoglobin (Hb) level, visual analogue scale (VAS) score, Oswestry disability index (ODI), lumbar lordosis (LL), and disc height (DH) between the two groups (P>0.05). The operation time, hospitalization time, intraoperative blood loss, Hb level between preoperative and postoperative at 1 day, and complications were compared between the two groups. The recovery of clinical sign and symptom was evaluated by VAS score and ODI before operation, and at 1 month, 3 months, 1 year, and 3 years after operation. The LL and DH were measured by radiography before operation and at last follow-up, and the fusion rate was calculated according to Suk grade at last follow-up. All the operations were successfully completed. There was no significant difference in operation time between the two groups (P>0.05); the hospitalization time, intraoperative blood loss, and Hb difference between pre- and post-operation in the study group were significantly less than those in the control group (P<0.05). Both groups were followed up 36-48 months, with an average of 39.2 months. In the study group, 1 case of dural tear and 2 cases of Cage subsidence occurred, without postoperative infection and epidural hematoma; in the control group, infection occurred in 1 case, dural tear in 2 cases, Cage subsidence in 1 case, and no epidural hematoma occurred; there was no significant difference in the incidence of complications between the two groups (13.04% vs. 22.22%) (χ2=0.601, P=0.438). The VAS score and ODI at each time point after operation in both groups significantly improved when compared with those before operation, and further improved with time (P<0.05). There was no significant difference in VAS scores between the two groups at each time point after operation (P>0.05); the ODI of the study group was significantly lower than that of the control group at 1 and 3 months after operation (P<0.05), and there was no significant difference between the two groups at other time points (P>0.05). The imaging test showed that the intervertebral fusion rates were 95.7% in the study group and 94.4% in the control group at last follow-up, with no significant difference (χ2=0.032, P=0.859). At last follow-up, LL and DH in the two groups significantly improved when compared with those before operation (P<0.05), and the difference between before and after operation showed no significant difference between the two groups (P>0.05). Both UBE-TLIF and MIS-TLIF assisted with three-dimensional microscope have the advantages of clear intraoperative field and high surgical efficiency in treating lumbar spondylolisthesis, and can obtain satisfactory mid-term effectiveness. Compared with MIS-TLIF assisted with three-dimensional microscope, UBE-TLIF has the advantages of less bleeding and faster recovery.

Learning curve analysis of unilateral biportal endoscopic lumbar interbody fusion

To analyze the learning curve of unilateral biportal endoscopic lumbar interbody fusion (UBE-LIF). Fifty-five patients with single-segment lumbar degenerative disease treated with UBE-LIF between December 2020 and February 2022 were selected as the research subjects. The patients were grouped according to the operation sequence, the first 27 cases were in the early group, and the last 28 cases were in the late group. There was no significant difference between the two groups in age, gender, disease type, and surgical segment distribution ( P>0.05). The operation time, the amount of hemoglobin loss (the difference between 1 day before operation and 3 days after operation), the hospital stay after operation, and the incidence of perioperative complications were recorded; the learning curve of UBE-LIF was analyzed by log-curve regression analysis. All the operations were successfully completed without changing to other operations. The operation time, the amount of hemoglobin loss, and hospital stay in the early group were significantly more than those in the late group ( P<0.05). Complications occurred in 2 cases (7.4%) in the early group, including 1 case of dural tear during operation and 1 case of epidural hematoma after operation, and 1 case (3.6%) with transient radiculitis in the late group. There was no significant difference in the incidence of complications between the two groups ( P=0.518) . The log-curve regression analysis showed that the operation time decreased significantly with the increase of the number of patients ( P<0.05). The operation time tended to be stable after the surgeon completed 17 cases. For single-level lumbar degenerative disease, the operation time of UBE-LIF can decrease gradually with the increase of the number of patients, and tend to be stable after 17 cases.

Impact of sarcopenia on effectiveness of lumbar decompression surgery in patients with lumbar spinal stenosis

To investigate the impact of sarcopenia on effectiveness of lumbar decompression surgery in patients with lumbar spinal stenosis. The clinical data of 50 patients with lumbar spinal stenosis who met the selection criteria between August 2017 and December 2020 were retrospectively analyzed. According to the diagnostic criteria of the European Working Group on Sarcopenia in Older People (EWGSOP), based on the calculation of the skeletal muscle index (SMI) at the L 3 level, SMI<45.4 cm 2/m 2 (men) and SMI<34.4 cm 2/m 2 (women) were used as the diagnostic threshold, the patients were divided into sarcopenia group (25 cases) and non-sarcopenia group (25 cases). There was no significant difference in gender, age, disease duration, level of lumbar spinal stenosis, surgical fusion level, and comorbidity between the two groups ( P>0.05); the body mass index in sarcopenia group was significantly lower than that in non-sarcopenia group ( t=-3.198, P=0.002). Clinical data of the two groups were recorded and compared, including operation time, intraoperative blood loss, postoperative drainage volume, hospitalization stay, and complications. The visual analogue scale (VAS) scores of low back pain and sciatica and Oswestry disability index (ODI) scores were recorded preoperatively and at last follow-up. The effectiveness was evaluated according to modified MacNab standard. There was no significant difference between the two groups in terms of operation time, intraoperative blood loss, and postoperative drainage volume ( P>0.05). However, the hospitalization stay in sarcopenia group was significantly longer than that in non-sarcopenia group ( t=2.105, P=0.044). The patients were followed up 7-36 months (mean, 29.7 months). In sarcopenia group, 1 case of dural tear and cerebrospinal fluid leakage occurred during operation, as well as 1 case of internal fixator loosening during follow-up; 1 case of incision exudation and poor healing occurred in each of the two groups, and no adjacent segment degeneration and deep vein thrombosis of lower extremity occurred in the two groups during follow-up. There was no significant difference in the incidence of complications (12% vs. 4%) between the two groups ( χ 2=1.333, P=0.513). VAS scores in low back pain and sciatica as well as ODI scores in two groups significantly improved when compared with preoperative results at last follow-up ( P<0.05). The differences of VAS scores in low back pain and ODI scores before and after operation in sarcopenia group were significantly lower than that in non-sarcopenia group ( P<0.05). However, there was no significant difference of that in VAS scores of sciatica between the two groups ( t=-1.494, P=0.144). According to the modified MacNab standard, the excellent and good rate of the sarcopenia group was 92%, and that of the non-sarcopenia group was 96%, showing no significant difference between the two groups ( χ 2 =1.201, P=0.753). Patients with sarcopenia and lumbar spinal stenosis may have longer postoperative recovery time, and the effectiveness is worse than that of non-sarcopenic patients. Therefore, for elderly patients with lumbar spine disease, it is suggested to improve preoperative assessment of sarcopenia, which can help to identify patients with sarcopenia at risk of poor surgical prognosis in advance, so as to provide rehabilitation guidance and nutritional intervention in the perioperative period.

Percutaneous endoscopic stenosis surgery under local anaesthesia

A retrospective study including 50 cases of lumbar canal stenosis patients who underwent percutaneous endoscopic stenosis decompression surgery through unilateral/bilateral transforaminal approach under local anaesthesia. Clinical outcomes such as back and leg VAS, the Macnab criteria were evaluated. Surgical results including operative time, postoperative hospital stay, recurrence, and surgical complications were also studied.Results: All 50 patients were followed up. The average operation time was 73 +/- 22.8min. The mean VAS of leg and back pain improved from 7.06 +/-1 to 2.2 +/-1. According to the Macnab criteria, 97.7% of patients achieved excellent and good results. There was 1 case of dural tear and 3 cases of transient postoperative dysthesia.Conclusions: Except for the main pathogenic factors on the dorsal side of the dural sac namely bony canal stenosis, percutaneous endoscopic decompression through a unilateral/bilateral transforaminal approach is sufficient for Lumbar canal stenosis and affords better foraminal decompression than an open approach. It is a feasible, safe, and clinically effective minimally invasive procedure.

Complications of Surgical Treatment of Adult Scoliosis

Introduction: With the increase in global life expectancy, the number of patients presenting with progressive spinal deformities is also on rise. The increasing frequency of surgical intervention as a treatment of this group of patients is associated with many complications and also with increasing rate of reoperation.&#x0D; Methodology: Seventy-two cases of adult scoliosis were treated surgically in Ain Shams spine unit with a minimum follow-up of five years (average, 76 months). Preoperative clinical and radiological evaluation was done, with special emphasis on the degree of pains (back and leg), Oswestry Disability Index (ODI), scoliosis angle, lumbar lordosis, any instability, and the level of spinal canal stenosis needing decompression. The pelvic incidence was measured preoperatively to plan the amount of lordosis needed to be restored.&#x0D; Result: The mean preoperative scoliosis angle was 22 ± 10.4º (16 to 34º) and the mean preoperative lordosis angle was 20.3 ± 12.7º (–15 to –28º). The mean preoperative ODI score was 54.7 ± 5.5, and the mean postoperative scoliosis angle improved to 7.4 ± 3.3. The mean postoperative lordosis angle became 37.3 ± 8.6, and the mean postoperative ODI score was 21.3 ± 3.8.&#x0D; Conclusion: The list of complications included seven cases of pseudoarthrosis and screw loosening, adjacent segment fracture in nine cases, and one case of spondylodiscitis at a level just proximal to the fused level. These 17 cases needed reoperations (24%). Additionally, there were five cases of dural tear, prolonged graft side pain in one case, and two cases of superficial wound infections.

Degenerative central lumbar spinal stenosis: is endoscopic decompression through bilateral transforaminal approach sufficient?

BackgroundAt present, few reports of percutaneous endoscopic transforaminal decompression surgery have been reported to solve central lumbar spinal stenosis (CLSS). Is endoscopic decompression through bilateral transforaminal approach decompression sufficient for degenerative CLSS?MethodsThis retrospective study included 47 cases of CLSS patients who underwent percutaneous endoscopic decompression through bilateral transforaminal approach. Clinical outcomes such as ODI, back and leg VAS, the Macnab criteria were evaluated. Surgical results including operative time, postoperative hospital stay, recurrence, and surgical complications were also studied. Radiologically, lumbar stability was assessed and lumbar dural sac dimension was compared preoperatively and postoperatively.ResultsAll 47 patients were followed up. The average follow-up period was 24.5 months. The average operation time was 116 min. The mean VAS of leg and back pain, and the mean ODI improved from 7.81, 2.53, and 77.03% at baseline to a final 1.94 (P = 0.00), 2.47 (P = 0.71), and 19.40% (P = 0.00), respectively. According to the Macnab criteria, 97.9% of patients achieved excellent and good results. There were 2 cases of dural tear and 3 cases of transient postoperative dysthesia. The cross-sectional area of the dural sac was significant enlargement at the last fellow up (74.28 ± 13.08 mm2 vs.104.91 ± 12.40 mm2, P = 0.00).ConclusionsExcept for the main pathogenic factors on the dorsal side of the dural sac, percutaneous endoscopic decompression through a bilateral transforaminal approach is sufficient for CLSS. It is a feasible, safe, and clinically effective minimally invasive procedure.

Posterior Minimally Invasive Transpedicular Approach for Giant Calcified Thoracic Disc Herniation.

Study Design:Retrospective case series.Objective:Posterior surgery for thoracic disc herniation was associated with increased morbidity and mortality and new minimally invasive approaches have been recommended for soft disc herniation but not for calcified central disc. The objective of this study is to describe a posterolateral microscopic transpedicular approach for central thoracic disc herniation.Methods:This is a single center retrospective review of all the cases of giant thoracic calcified disc herniation as defined by Hott et al. Presence of myelopathy, percentage of canal compromise, T2 hypersignal, ASIA score, and ambulatory status were recorded. This posterolateral technique using a tubular retractor was thoroughly described.Results:Eight patients were operated upon with a mean follow-up of 16 months. Mean canal compromise was 61%. Mean operative time was 228 minutes and mean operative bleeding was 250 mL. There were no cases of dural tear or neurologic degradation.Conclusion:This is the first report of posterior minimally invasive transpedicular approach for giant calcified disc herniation. There were neither cases of neurological deterioration nor increased rate of dural tears. This technique is thus safe and could be recommended for treatment of this rare disease.

Percutaneous Endoscopic Lumbar Discectomy (PELD) via a Transforaminal and Interlaminar Combined Approach for Very Highly Migrated Lumbar Disc Herniation (LDH) Between L4/5 and L5/S1 Level.

BackgroundPercutaneous endoscopic lumbar discectomy (PELD) has become one of the most popular minimally invasive surgeries for lumbar disc herniation (LDH), however, very highly migrated LDH is still a tricky issue for PELD. This study reported a new endoscopic discectomy strategy for the treatment of very highly migrated LDH between the L4/5 and L5/S1 level.Material/MethodsThe current study retrospectively analyzed 12 patients who accepted PELD for very highly migrated LDH between the L4/5 and L5/S1 level. Under local anesthesia, the transforaminal approach was chosen for the L4/5 level and the interlaminar approach was chosen for the L5/S1 level. The 10-point visual analogue scale (VAS) was used to assess back pain (VAS-Back) and leg pain (VAS-Leg). Oswestry disability index (ODI) and Modified Mac Nab Criteria were adopted as the functional evaluation methods. All patients were followed in the outpatient department for at least 12 months after their operation.ResultsOur study showed that very highly migrated disc between L4/5 and L5/S1 level could be removed completely by this strategy. Except for 1 case of postoperative dysesthesia and 1 case of dural tear, no severe complication occurred. At the last follow-up, the average VAS-Back score of the study patients was reduced from 5.17±2.12 to 2.08±1.08 (P<0.05) and the average VAS-Leg score was reduced from 7.25±1.48 to 1.33±0.89 (P<0.05). The average ODI scores improved from 48.50±10.59 to 13.00±2.76 (P<0.05). According to the Modified Mac Nab Criteria, 83.33% of patients (10 out of 12 patients) received an excellent or good recovery and no poor result was reported. No recurrence was observed during follow up.ConclusionsPELD via a transforaminal and interlaminar combined approach provides an alternative option for select patients with very highly migrated LDH between the L4/5 and L5/S1 level.

Degree of satisfaction following full-endoscopic cervical foraminotomy.

Foraminotomy has been reported to be effective for the treatment of cervical radiculopathy (CR). Foraminotomy has been performed by an open approach or minimally invasive approach using a microscope or endoscope. A review of the literature has revealed that both the open and minimally invasive approach provide good clinical results. Since the introduction of full-endoscopic cervical foraminotomy (FECF) followed by microendoscopic cervical foraminotomy, we adopted FECF in 2016. The purpose of this study was to evaluate the degree of satisfaction following FECF for CR. A total of 109 consecutive patients underwent FECF for CR. All operations were performed at Iwai Orthopaedic Medical Hospital. Patient background information and operative data were collected. The numerical rating scale (NRS) score for the arm was assessed preoperatively and postoperatively at the time of discharge from the hospital. The satisfaction score was also recorded at discharge and the 3 months after the operation. In total 109 patients, the mean age was 51.3 years; 22.9% were female and 77.1% were male. The cervical level most frequently operated on was C6/7, followed by C5/6. The mean hospital stay was 4.7 days. The mean operation time was 61.7 minutes. The estimated blood loss was 0 to 10 mg in all cases. One patient exhibited temporary postoperative muscle weakness, although he recovered within 1 year. There was one case of dural tear, and no cases of nerve root injury or surgical site infection. There was one case of reoperation by microendoscopic surgery in 3 months due to insufficient improvement. Preoperative NRS scores for the arm was 4.6 and it improved significantly postoperatively to 2.1 for the entire study group. The mean satisfaction score at discharge was 7.5. The mean score at 3 months after the operations was 7.4. Degree of satisfaction following FECF for CR was high 3 months after the operation.

Revision decompression with fusion as a treatment for same level restenosis after laminotomy for lumbar spinal stenosis

Background/Purpose: Laminotomy is an established procedure to relieve symptoms of lumbar spinal stenosis. However, there is a group of patients with symptomatic recurrence. Re-decompression and fusion could be an effective salvage procedure but the results are seldom found in the literature. In this study, we focused on investigating the clinical outcomes and complication rates of revision decompression with fusion in this patient group. Methods: A retrospective study including patients who had undergone revision decompression with fusion for recurrent symptoms due to same level restenosis after primary laminotomy for lumbar spinal stenosis was performed. Patients with recurrent symptoms due to prolapsed intervertebral disc, trauma, infection, and neoplasm were excluded. Demographics, clinical outcomes, and complications were retrieved. Results: Twenty-eight patients with a total number of 42 levels of revision decompression and fusion were included. With a mean follow-up time of 27 months after revision surgery, there were statistically significant improvement of 63, 49, and 13% in Japanese Orthopaedic Association score, visual analog scale for leg pain, and Roland-Morris disability questionnaire score, respectively. There were 6(21%), 2(7%), 0(0%), and 2(7%) cases of dural tear, infection requiring reoperation, new neurological deficit, and other complications, respectively, in these revision cases. Conclusion: Bearing potential complications in mind, re-decompression with fusion is a viable option with reasonable clinical outcomes for patients with recurrent symptoms after laminotomy for lumbar spinal stenosis. As a treatment option for symptomatic lumbar spinal stenosis, primary laminotomy could have the potential benefit of lower complication rates in revision surgery.

Early Experience, Setup, Learning Curve, Benefits, and Complications Associated with Exoscope and Three-Dimensional 4K Hybrid Digital Visualizations in Minimally Invasive Spine Surgery.

Study DesignProspective observational study (n=74).PurposeTo evaluate the learning curve for exoscope and three-dimensional (3D) 4K hybrid visualization in terms of operating time, advantages, disadvantages, and surgical complications in tubular-access minimally invasive spine surgery (MISS) and to assess surgeon satisfaction with image quality, ergonomics, and ability to perform target site treatment.Overview of LiteratureWorking through tubular retractors poses a challenge. The extreme angulations during microsurgical decompression, especially contralateral decompression, require surgeons to work non-ergonomically. An exoscope allows surgeons to work ergonomically and independently of the microscope oculars as visualizations are now provided by large 3D 4K monitors. However, the value and efficacy of solely depending on an exoscope and 3D 4K monitors during microsurgical work are still unknown.MethodsSeventy-four patients (99 levels) underwent trans-tubular MISS between March 2018 and January 2019. Five patients were excluded: one had pyogenic discitis, two had revisions, and two were trans-tubular transoral. In total, we analyzed 69 for operating time, blood loss, and complications. The learning curve graph was plotted using the surgical time for each procedure. Surgeons were asked to rate their satisfaction with image quality, ability to maintain ergonomic posture, and efficient target site treatment.ResultsFor tubular microdiscectomy, the operating time plateaued after six cases, and for tubular decompression and minimally invasive transforaminal lumbar interbody fusion, the operating time plateaued after nine cases. Mean operating time was significantly reduced after the plateau. Complications included four cases of dural tear. All patients improved symptomatically, and there were no postoperative neurological deficits.ConclusionsUse of the exoscope has a short learning curve. Surgeons benefit from improved ergonomic posture during surgery, and resident teaching appears to be good. The only drawback is the need to rearrange the operating table setup. Complications were comparable to those when using the surgical microscope. An exoscope with hybrid digital visualization provides excellent visualization, depth perception, clarity, and precision target site treatment.

Percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for lumbar spinal stenosis

To design the surgical strategy of percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral lumbar spinal stenosis (LSS) and to evaluate the effectiveness. The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral LSS was designed according to the pathological features of LSS. The technique was used to treat 42 patients with LSS between January 2016 and January 2018. There were 18 males and 24 females with an average age of 61.7 years (range, 46-81 years). The duration of symptoms was 1-20 years, with an average of 9.7 years. The surgical segment at L 4, 5 were 27 cases, at L 5, S 1 were 15 cases. The operation time and perioperative complications were recorded. Lumbar X-ray, CT, and MRI examinations were performed at 1 week, 3 months, and 1 year after operation. Visual analogue scale (VAS) score was used to evaluate the low back pain and leg pain, Oswestry disability index (ODI) was used to evaluate the lumbar function, and single continuous walking distance (SCWD) was used to evaluate lower extremity nerve function. The clinical efficacy was evaluated by MacNab criteria at 1 year after operation. All patients underwent surgery successfully. The operation time was 68-141 minutes with an average of 98.2 minutes. All 42 patients were followed up 12-24 months with an average of 18.8 months. There were 2 cases of dural tears during operation, and 1 case of transient dysfunction of the lower limbs of the decompression channel after operation. All of them were cured after corresponding treatment. No serious complications such as death, major bleeding, or irreversible nerve injury occurred during follow-up. No segmental instability was found according to postoperative lumbar hyperextension and flexion X-ray films, and postoperative CT and MRI imaging showed that the stenotic lumbar spinal canal was significantly enlarged, and the compression of the nerve root was sufficient. The VAS score of low back pain and leg pain, ODI score, and SCWD at each time point after operation were significantly improved when compared with those before operation ( P<0.05); the indexes were significantly improved over time after operation, and the differences were significantly ( P<0.05). The clinical efficacy was evaluated by MacNab standard at 1 year after operation, and the results were excellent in 18 cases, good in 20 cases, fair in 3 cases, and poor in 1 case. The excellent and good rate was 90.5%. The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for LSS is a safe and effective procedure. A well-designed surgical strategy and mastery of its technical points are important guarantees for successful operation and satisfactory results.

The microendoscopic approach for far lateral lumbar disc herniation: a preliminary series of 33 patients

BackgroundFar lateral lumbar disc herniation (FLLDH) compresses the nerve root at the same level. The laterally herniated disc fragment typically could not be exposed by the standard posterior hemi-laminectomy technique, and a total facetectomy including wide bone removal is usually mandatory for good exposure and removal of the herniation but simultaneously increasing the risk of instability.ObjectiveIn the present study, the author presents his initial 4-year experience and surgical outcome in treatment of far lateral lumbar disc herniation with a posterior endoscopic approach.MethodsThis study was carried out in the period between February 2011 and January 2015, where 33 consecutive patients with symptomatic FLLDHs underwent a posterior endoscopic lateral approach for resection of the herniation. The mean age was 39.3 years, range 26–59 years. Patients were followed up for 4 years (mean follow-up was 19.9 months, range 3–47 months). Patients had their clinical outcomes reviewed and evaluated in terms of pain by visual analog scale (VAS) and in terms of functional outcome by modified Macnab criteria (MMC).ResultsMean operative time was 91 min (range 55–166 min). At initial follow-up, according to MMC (3 months postoperative), 86% of patients were pain-free (28/33) and considered their postoperative status as excellent and 14% as good (5/33), and no patients reported a fair or poor outcome. There were no new postoperative neurological deficits or major complications. There were three cases of accidental medial facetectomy due to excess bony work, a single case of dural tear, and a single case that had a transient postoperative neuralgia that persisted for 2 weeks.ConclusionsFLLDH can be treated adequately with the reported microendoscopic approach. The technique is associated with marked improvement in back pain and lower limb symptoms, as well as a short length of hospitalization and other benefits of minimal invasiveness. Although a transitory learning curve is necessary, the endoscope in general was safe in handling bimanually and allowed adequate mobility and visualization.

Short-term effects of combined pedicle/facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach for the treatment of degenerative lumbar spine diseases in the elderly

Objective To examine the feasibility and early effects of unilateral pedicle screw fixation in combination with contralateral translaminar facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach for the treatment of degenerative lumbar spine diseases in elderly patients. Methods A total of 82 elderly patients with degenerative lumbar spine diseases received treatment between January 2015 and June 2016.Of these patients, 25 had lumbar spinal stenosis, 42 had degenerative lumbar instability, 13 had giant lumbar disc herniation, and two had recurrent lumbar disc herniation; There were 69 cases of single segment and 13 cases of double segment lesions.Perioperative evaluation, imaging evaluation, and clinical evaluation were performed, and surgical complications were analyzed. Results The average length of incision was (2.6±0.4) cm in cases of single segment lesions and (4.4±0.5) cm in cases of two segment lesions.The mean operation time was (98.3±19.6) minutes and peri-operation blood loss was (232.2±25.8) ml.The post-operation height of the intervertebral disc space significantly increased at the last follow-up(P<0.05); the height of the intervertebral disc space was restored and well maintained with internal fixation showing no loosening, breakage or Cage shift.The post-operation lumbar coronal Cobb angle decreased(P<0.05)while the sagittal Cobb angle increased(P<0.05)at the last follow-up.There was no significant difference in the area and grade of the multifidus muscle on MRI 12 months after operation.Seventy-two patients were followed up for 12-18 months(mean=16.8 months), and there were 67 cases of intervertebral fusion(93.1%). The last follow-up showed a Japanese Orthopaedic Association(JOA)score of (25.8±1.7), which was significantly higher than the pre-operation score(10.6±1.3), with an excellence rate of 88.9%.The Oswestry Disability Index score was significantly reduced, from (50.9±21.6) at pre-operation to (9.6±4.8) at the last follow-up.There were 78 patients with primary wound healing, three cases of superficial wound necrosis, one case of dural tear, and one case of nerve root injury.No cardiovascular or cerebrovascular incident was observed during or after operation. Conclusions Combined pedicle/facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach shows satisfactory short-term effects when used for the treatment of degenerative lumbar spine diseases in the elderly and possesses advantages such as minimal invasiveness, limited bleeding, quick recovery, high fusion rates and significantly improved clinical outcomes.However, further clinical studies are required to assess its medium-and long-term efficacy. Key words: Spinal fusion; Surgical procedures minimally invasive; Arthritis, degenerative

Percutaneous endoscopic lumbar discectomy and minimally invasive transforaminal lumbar interbody fusion for massive lumbar disc herniation

ObjectivesTo compare the clinical outcomes of patients with massive lumbar disc disease undergoing percutaneous endoscopic lumbar discectomy and minimally invasive transforaminal lumbar interbody fusion at a single clinic. Patients and methodsFrom January 2008 to January 2014, 360 consecutive patients with massive lumbar disc herniation were treated with PELD(184 patients) or MIS-TLIF(176 patients). Data collected prospectively for analysis included clinical and radiographic results after revision surgery and complications. ResultsDuring the follow-up period, postoperative data between two treatment groups showed no significant difference in the mean total postoperative VAS score for leg pain, JOA and ODI scores. The recovery rate was 89.3% in the PELD and 93.4% in MIS-TLIF groups, respectively. Satisfaction rates were 86.3% in the PELD group and 92.2% in the MIS-TLIF group. Four cases of dural tear were observed in the MIS-TLIF group. Recurrence manifested in 14 patients in the PELD group, and one patient in this group also suffered permanent neurologic deficit. One case of postoperative intervertebral infection was recorded in the MIS-TLIF group. ConclusionA comparison of PELD and MIS-TLIF for treating massive lumbar disc herniation revealed that both showed favorable clinical outcomes but had different sets of complications. Compared to MIS-TLIF, PELD had the following advantages: (1) its feasibility under local anesthesia and (2) the rarity of “fusion disease,” such as ASD. However, the PELD is also revealed several problems, including a relatively lower success rate and satisfaction,a relative higher rate of postoperative long-term chronic low back pain and the possibility of recurrence, despite low opportunity. Therefore, the main difference between these two treatments was related to postoperative complications and the satisfaction and recovery rates. We suggest that, in the future, multi-center studies, recruiting a larger number of patients, should be undertaken to better understand the clinical relevance of these complications.

Clinical Outcomes of Hernia Nucleous Pulposus after Microendodiscectomy

There are several options of surgical treatment of Hernia Nucleous Pulposus (HNP) such as discectomy and micro-endodiscectomy (MED). The fundamental differences between these procedures are the size of the incision, the discectomy procedure and the volume of disc taken. However, until now, there has not been any class 1 evidences explaining the efficacy of these procedures, and there is only a few studies about its safety and factors influencing its efficacy in treating HNP, especially in Indonesia. This study is aimed to assess clinical outcomes and safety of MED in HNP patients who underwent this procedure. Patient with HNP who underwent MED were followed prospectively in a period of January 2015 until December 2016. Clinical outcomes were evaluated by using Visual Analog Score (VAS) for assessing back pain and leg, and Oswestry Disability Index (ODI). The mean of pre-treatment score was compared with the mean of post-surgical treatment score by using paired t-test. Sampel were 78 HNP patients treated surgery. The average surgery duration (± SD) was 60 ± 17.1 minutes. The pretreatment score mean on VAS and ODI were 4.88 ± 1.10 and 35.21 ± 8.24. After surgical treatment, the VAS and ODI score obtained were significantly reduced to 1.53 ± 1.14 and 5.16 ± 5.52, respectively (p&lt;0,001). A type of complication was observed, which was 5 (6.4%) cases of dural tear; no deficit in ankle dorsiflexion nor foot paresis were found. MED has been shown to be able to treat HNP with clinical outcomes similar to conventional open discectomy but with better levels of safety and effectiveness. However, this procedure still requires high quality randomized controlled trials studying about its efficacy and cost effectiveness in HNP treatment.

Accuracy of pedicle screw placement in patients with Marfan syndrome

BackgroundThere is no study concerning safety and accuracy of pedicle screw placement in Marfan syndrome. The objective of this study is to investigate accuracy and safety of pedicle screw placement in scoliosis associated with Marfan syndrome.MethodsCT scanning was performed to analyze accuracy of pedicle screw placement. Pedicle perforations were classified as medial, lateral or anterior and categorized to four grades: ≤ 2 mm as Grade 1, 2.1–4.0 mm as Grade 2, 4.1–6.0 mm as Grade 3, ≥6.1 mm as Grade 4. Fully contained screws or with medial wall perforation ≤ 2 mm or with lateral wall perforation ≤ 6 mm and without injury of visceral organs were considered acceptable, otherwise were unacceptable.Results976 pedicle screws were placed, 713 screws (73.1%) were fully contained within the cortical boundaries of the pedicle. 924 (94.7%) screws were considered as acceptable, and 52 (5.3%) as unacceptable. The perforation rate was higher using free-hand technique than O-arm navigation technique (30.8% VS. 11.4%, P < 0.05), higher in lumbar region than in thoracic region (34.1% VS. 22.3%, P < 0.05) and higher in concave side than in convex side (33.5% VS. 21.9%, P < 0.05). No injury of visceral organs especially aorta erosion was noted in the series. 7 cases of dural tear caused by misplaced screws occurred, and 4 cases developed cerebro-spinal fluid leak. Drainage and pressure dressings were applied for these patients, and no infection was observed. Leg pain was observed in 7 cases, and 2 cases simultaneously complained of leg weakness. Revision surgery was conducted to remove the misplaced screws for these 2 patients. Conservative treatment was applied for the 5 patients without leg weakness. Symptoms of leg weakness and pain resolved in all patients.ConclusionPlacement of pedicle screw in Marfan syndrome is accuracy and safe. O-arm navigation was an effective modality to ensure the safety and accuracy of screw placement. Special attention should be paid when screws were placed at the lumber spine and the concave side of spine deformity to avoid the higher rate of complications.