Minimally Invasive Spine Surgery Research Articles

Commentary on "The Role and Clinical Outcomes of Endoscopic Spine Surgery of Treating Spinal Metastases; Outcomes of 29 Cases From 8 Countries".

Commentary on "The Role and Clinical Outcomes of Endoscopic Spine Surgery of Treating Spinal Metastases; Outcomes of 29 Cases From 8 Countries".

MINIMALLY INVASIVE SPINE SURGERY FOR POST-TRAUMATIC KYPHOSIS: A SYSTEMIC LITERATURE REVIEW AND RETROSPECTIVE CASE ANALYSIS

Study Design: Retrospective case analysis and systematic literature review. Objective: To comprehensively review minimally invasive surgery (MIS) for post-traumatic kyphosis. Methods: A systematic PubMed search was conducted for MIS and kyphotic deformities were published between 2012 and 2022. Sixteen patients between 2017 and 2021 met the criteria. Demographic data, surgical characteristics, and full-length radiographic parameters were collected pre- and post-operatively, and at final follow-up. Results: Twenty-three articles were included. The mean age was 67 years, and the mean follow-up was 17 months. The mean operative time was 331 min and blood loss was 252 ml. Pre-operative radiographic outcomes were as follows: Lumbar lordosis (LL), 16.84± 26.40[Formula: see text]; pelvic incidence (PI), 48.95± 14.34[Formula: see text]; PI-LL mismatch, 32.11± 31.92[Formula: see text]; pelvic tilt (PT), 32.74± 10.41[Formula: see text]; and sagittal vertical axis (SVA), 95.33± 59.62 mm. At the final follow-up, LL was 19.98± 16.16[Formula: see text] ([Formula: see text] = 0.51229), PI was 50.82± 10.19[Formula: see text] ([Formula: see text] = 0.61438), PI-LL mismatch was 30.84± 17.18[Formula: see text] ([Formula: see text] = 0.74696), PT was 27.14± 10.28[Formula: see text] ([Formula: see text] = 0.00386), and SVA was 49.73± 25.51 mm ( [Formula: see text] = 0.00465). The mean ODI and VAS scores for back pain at baseline and at 96 months follow-up were 33.2–19.7 and 8.4–2.5, respectively. Conclusion: Age-adjusted MIS provides correction of sagittal alignment for posttraumatic kyphosis that satisfies patient demand.

(010) A Novel Collaborative Protocol for Successful Management of PGAD/GPD Mediated by Tarlov Cyst-induced Radiculopathy of Sacral Spinal Nerve Roots in the Cauda Equina

Abstract Introduction In 2012, Komisaruk et al introduced the concept that neurologic-based women’s sexual health issues, genito-pelvic dysesthesia (GPD), could be caused by radiculopathy of sacral spinal nerve roots within the cauda equina. Over the last 4 years, to more effectively manage patients with suspected cauda equina pathology, a robust collaboration among sexual medicine, spine surgery and neurophysiology disciplines has been established. Objectives The aim of this study is to review the collaborative experience in managing patients with genito-pelvic dysesthesia. Methods We defined GPD in the broadest sense to include both unwanted, unrelenting, distressing arousal, pain and/or itching symptoms >6 mo (hyperfunction), and also persistent degrees of genital anesthesia leading to orgasmic dysfunction >6 mo (hypofunction). Charts from 2015 to 2019 of GPD patients presenting to our sexual medicine facility where neurogenital testing results were consistent with radiculopathy of sacral spinal nerve roots within the cauda equina were reviewed retrospectively. Lumbar and sacral MRIs were obtained and reviewed simultaneously in collaborative bi-monthly meetings and identified as having or not having treatable spinal abnormalities, subdivided into subtle or obvious. When appropriate, a transforaminal epidural spinal injection (TFESI) or caudal block with anesthetic agent and/or steroid was administered and the outcome measured by Patient Global Impression of Improvement (PGI-I). Those with clinically significant symptom reduction were considered for minimally invasive spine surgery (MISS). Results 734 patients (586 women; 80%; mean age 47 +/− 24) met criteria for this retrospective chart review. 637 lumbar and/or sacral MRIs were reviewed. A total of 112 TFESI were performed, 90 of which showed positive responses with more than 60% improvement on PGI-I of 1,2. 57 surgeries were performed. 17 patients (71% women) with PGAD underwent MISS for herniated nucleus pulposus and or annular tear. 76% declared post-op clinical improvement with PGI-I 1,2,3 with mean follow-up of 12 months (4 - 30 months). Conclusions Cauda equina pathology can cause unwanted, unrelenting, distressing neurologic-based GPD from radiculopathy of sacral spinal nerve roots. In selected cases these GPDs may be reversed by MISS. There are management benefits from collaboration among sexual medicine, spine surgery and neurophysiology specialists. Disclosure No.

Minimally Invasive Decompression With Noninstrumented Facet Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Stenosis Associated With Grade 1 Lumbar Degenerative Spondylolisthesis.

Retrospective matched cohort study. With a growing interest in minimally invasive spine surgery (MIS), the question of which technique is the most advantageous for patients with low-grade degenerative lumbar spondylolisthesis (DLS) still remains unclear. To compare patient-reported outcomes, perioperative morbidity, and rates of reoperation between MIS decompression with either unilateral noninstrumented facet fusion (MIS-F) or with transforaminal interbody fusion (MIS-T) for grade 1 DLS. Twenty patients who underwent MIS-T and 20 patients with MIS-F were matched based on age, sex, and preoperative ODI, VAS back, and VAS leg. All patients had DLS with at least 4 millimeters of translation on standing radiographs. Exclusion criteria included prior level surgery, multilevel instability, disk impinging on the exiting nerve root, spondylolisthesis from significant facet arthropathy, or foraminal compromise from disk collapse. ODI, VAS back, VAS leg, and patient satisfaction measured by the North American Spine Society questionnaire were tracked at 3, 6, 12, and 24 months postoperatively. Minimum clinically important differences and substantial clinical benefits were calculated. MIS-F and MIS-T resulted in decreased ODI at 3, 6, and 12 months following the index procedure. Sixty percent of MIS-F and 83% of MIS-T patients reached minimum clinically important difference at 1 year postoperatively; however, using the threshold of 30% ODI reduction from baseline, 67% of MIS-F and 83% MIS-T ( P = 0.25) achieved this goal. Forty-three percent of MIS-F and 59% of MIS-T patients met substantial clinical benefits. Satisfaction at 1 year, measured by a score of 1 or 2 on the North American Spine Society questionnaire, was 64% for MIS-F and 83% for MIS-T. MIS-F and MIS-T are effective treatment options for spinal stenosis associated with low-grade DLS. Both techniques result in comparable patient-reported outcomes and satisfaction up to 2 years and have similar long-term reoperation rates. More evidence is required to delineate optimal selection characteristics for MIS-F versus MIS-T.

Efficacy of the erector spinae plane block with sedation for unilateral biportal endoscopic spine surgery and comparison with other anesthetic methods.

Erector spinae plane block (ESPB) is a new regional anesthesia. Unilateral biportal endoscopic (UBE) spine surgery, a minimal invasive technique, has been performed under not only general anesthesia (GA) but regional anesthesia including spinal anesthesia (SA). The aims of this study were to evaluate the efficacy of ESPB with sedation for UBE lumbar decompression and compare it with GA and SA. A retrospective age matched case-control study design was performed. Three groups (20 patients in each group) of patients who underwent UBE lumbar decompressions under each anesthetic method (GA, SA, or ESPB) were formed. The total anesthesia time excluding operation time, postoperative analgesia effects, hospital days, and complications related to anesthetic methods were evaluated. In the ESPB group, all the operations were performed without change of anesthetic methods and without anesthetic complications. But there were no anesthetic effects in the epidural space, which resulted in additional intravenous fentanyl usage. The mean of time from initiation of anesthesia to completion of surgical preparation was 23.3 ± 4.7min in the ESPB group, which was shorter than 32.3 ± 10.8min in the GA (p value = 0.001) or 33.3 ± 6.7min in the SA group (p < 0.001). The proportion of patients requiring first rescue analgesia within 30min was 30% in the ESPB group, which was lower than 85% in the GA (p < 0.001), but no significant different with 10% in the SA (p = 0.11). The mean of total hospital days in the ESPB was 3.0 ± 0.8, shorter than 3.7 ± 1.8 in the GA (p = 0.02) or 3.8 ± 1.1 in the SA group (p = 0.01). There was no case of postoperative nausea and vomiting in the ESBB even without prophylactic antiemesis. ESPB with sedation is a viable anesthetic option for UBE lumbar decompression.

Collagen Matrix Inlay Graft for Management of Incidental Durotomy During Full-Endoscopic Lumbar Spine Surgery: Technique and Case Series.

Endoscopic spine surgery (ESS) has a reduced rate of incidental durotomy (ID) compared with open spine surgery. However, there are unique challenges regarding the management of ID in ESS due to the single, deep, narrow working corridor and aqueous environment. Here, we present a collagen matrix inlay graft technique for the management of ID encountered during ESS. Three patients were identified via medical record review of full ESS where an intraoperative ID was encountered. These were all addressed endoscopically. All surgeries were performed by a single surgeon in the years 2019 to 2023. Patient, operative, and postoperative details, including patient-reported outcomes, were recorded. Briefly, the collagen matrix inlay graft technique included introducing a segment of collagen matrix into the surgical field and manipulating the collagen matrix so that it passed through the durotomy and resided within the dura, plugging the hole. Three IDs were identified out of a total of 295 eligible cases (1.02%). The IDs measured 2 to 2.5 mm in length. For these 3 patients, the duration of hospital stay ranged from 172 to 1,068 minutes. No patients exhibited signs or symptoms of cerebrospinal fluid leak at any postoperative timepoint. At the 6-week postoperative visit, all patients had achieved the minimum clinically important difference in Oswestry Disability Index, and all patients with available visual analog scale scores for leg and low back pain had achieved the cutoff for the minimum clinically important difference. We presented 3 cases of ID during uniportal full ESS who were repaired using a collagen matrix inlay technique. Prolonged bed rest was avoided, and all patients achieved excellent clinical outcomes without further complication. This technique may also be appropriate for other minimally invasive spine surgery techniques. ID is a common and undesirable complication of degenerative lumbar spine surgery. Endoscopic ID repair techniques provide an option to avoid conversion to open or tubular surgery for the management of ID.

Riding the Wave of Innovation: Endoscopic Spine Surgery Is Here to Stay.

Riding the Wave of Innovation: Endoscopic Spine Surgery Is Here to Stay.

Durotomy- and Irrigation-Related Serious Adverse Events During Spinal Endoscopy: Illustrative Case Series and International Surgeon Survey.

Durotomy during endoscopic spine surgery can cause a patient's neurological or cardiovascular status to deteriorate unexpectedly intra- or postoperatively. There is currently limited literature regarding appropriate fluid management strategies, irrigation-related risk factors, and clinical consequences of incidental durotomy during spinal endoscopy, and no validated irrigation protocol exists for endoscopic spine surgery. Thus, the present article sought to (1) describe 3 cases of durotomy, (2) investigate standard epidural pressure measurements, and (3) survey endoscopic spine surgeons on the incidence of adverse effects believed to result from durotomy. The authors first reviewed clinical outcomes and analyzed complications in 3 patients with intraoperatively recognized incidental durotomy. Second, the authors conducted a small case series with intraoperative epidural pressure measurements during gravity-assisted irrigated video endoscopy of the lumbar spine. Measurements were conducted on 12 patients with a transducer assembly that was introduced through the endoscopic working channel of the RIWOSpine Panoview Plus and Vertebris endoscope to the decompression site in the spine. Third, the authors conducted a retrospective, multiple-choice survey of endoscopic spine surgeons to better understand the frequency and seriousness of problems they attributed to irrigation fluid escaping from the surgical decompression site into the spinal canal and neural axis. Descriptive and correlative statistical analyses were performed on the surgeons' responses. In the first part of this study, durotomy-related complications during irrigated spinal endoscopy were observed in 3 patients. Postoperative head computed tomographic (CT) images revealed massive blood in the intracranial subarachnoid space, the basal cisterns, the III and IV ventricle, and the lateral ventricles characteristic of an arterial fisher grade IV subarachnoid hemorrhage, and hydrocephalus without evidence of aneurysms or angiomas. Two additional patients developed intraoperative seizures, cardiac arrhythmia, and hypotension. The head CT image in 1 of these 2 patients had intracranial air entrapment.In the second part, epidural pressure measurements in 12 patients who underwent uneventful routine lumbar interlaminar decompression for L4-L5 and L5-S1 disc herniation showed an average epidural pressure of 24.5 mm Hg.In the third part, the online survey was accessed by 766 spine surgeons worldwide and had a response rate of 43.6%. Irrigation-related problems were reported by 38% of responding surgeons. Only 11.8% used irrigation pumps, with 90% running the pump above 40 mm Hg. Headaches (4.5%) and neck pain (4.9%) were observed by nearly a 10th (9.4%) of surgeons. Seizures in combination with headaches, neck and abdominal pain, soft tissue edema, and nerve root injury were reported by another 5 surgeons. One surgeon reported a delirious patient. Another 14 surgeons thought that they had patients with neurological deficits ranging from nerve root injury to cauda equina syndrome related to irrigation fluid. Autonomic dysreflexia associated with hypertension was attributed by 19 of the 244 responding surgeons to the noxious stimulus of escaped irrigation fluid that migrated from the decompression site in the spinal canal. Two of these 19 surgeons reported 1 case associated with a recognized incidental durotomy and another with postoperative paralysis. Patients should be educated preoperatively about the risk of irrigated spinal endoscopy. Although rare, intracranial blood, hydrocephalus, headaches, neck pain, seizures, and more severe complications, including life-threatening autonomic dysreflexia with hypertension, may arise if irrigation fluid enters the spinal canal or the dural sac and migrates from the endoscopic site along the neural axis rostrally. Experienced endoscopic spine surgeons suspect a correlation between durotomy and irrigation-related extra- and intradural pressure equalization that could be problematic if associated with high volumes of irrigation fluid LEVEL OF EVIDENCE: 3.

Unilateral biportal endoscopic spine surgery for lumbar spinal stenosis: a systematic review and meta-analysis.

Lumbar spinal stenosis is the most common spinal degenerative disease in patients over 60 years, and the unilateral biportal endoscopic (UBE) spine surgery treatment of lumbar spinal stenosis (LSS) has achieved preliminary clinical results. This systematic review and meta-analysis aimed to reveal the clinical efficacy of UBE for LSS and provide evidence for clinical practice. PubMed, Embase, Web of Science, and Cochrane databases were searched for literature. The papers selected were those published from inception till October 2021. The selected pieces of literature were graded for evidence using the Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009). Outcomes measures were operation time, blood loss, complication rate, admission period, Visual Analogue Scale (VAS)-back, VAS-leg, and Oswestry Disability Index (ODI) score, and radiological outcomes. The mean comparisons were based on VAS and ODI scores. A total of 823 patients with a single LSS segment were included from the selected nine studies. There were nine studies comparing UBE clinical outcomes and micro-endoscopic unilateral laminotomy for bilateral decompression (M-ULBD). The meta-analysis revealed that the UBE group had better VAS-leg and -back scores in the first week postoperatively [total: mean difference (MD) = -0.96, 95% confidence interval (CI): -1.19, -0.74, p < 0.00001; total: MD = -1.69, 95% CI: -1.93, -1.45, p < 0.00001], 1st month postoperatively (total: MD = -0.35, 95% CI: -0.61, -0.08, p = 0.01; total: MD = -0.40, 95% CI: -0.68, -0.12, p = 0.005), 6th month postoperatively (total: MD = -0.22, 95% CI: -0.35, -0.08, p = 0.002; total: MD = -0.24, 95% CI: -0.40, -0.07, p = 0.005), and UBE group also performed better in ODI score at 1st month postoperatively (total: MD = -3.36, 95% CI: -4.26, -2.46, p < 0.00001). There was no significant difference in VAS-leg and -back scores between both groups at the 3rd and 12th month postoperatively, and ODI scores did not significantly differ between both groups at 3, 6, and 12 months postoperatively (all p > 0.05). UBE has achieved good preliminary clinical results and may be a minimally invasive alternative surgery for patients with single segmental LSS.

Outcome of Transforaminal Endoscopic Discectomy in Rural India in a Single-Level Lumbar Disc Prolapse Under Local Anesthesia.

Aim  The aim of this study was to undertake a clinical study to evaluate the outcomes of transforaminal endoscopic discectomy under local anesthesia and to study the complication rate. Study Design  It is a prospective study. Methods  We prospectively analyzed outcomes of 60 patients with a single-level lumbar disc prolapse in rural India from December 2018 to April 2020 who underwent endoscopic discectomy under local anesthesia. Follow-up was done using the visual analogue score (VAS) and Oswestry Disability Index (ODI) scoring systems with a minimum follow-up up to 1 year postoperatively. Results  In our study of 60 patients, there was 38 cases of L4-L5 disc pathology, 13 L5-S1 discs, and 9 L3-L4 discs. Our study showed a significant clinical reduction in mean VAS score that was 7.07/10 preoperatively and reduced to 3.88/10 at the third month and 3.64/10 at 1 year of follow-up ( p -value < 0.05) showing clinical significance. The ODI scoring done preoperatively was an average mean of 57.37% pointing to how crippled the patients were with lumbar disc prolapse and showed a significant reduction to 29.32% postoperatively at 1 year ( p -value < 0.05) showing clinical significance. This reduction in ODI directly corelates to how almost all patients returned to normal life coping to all activities and were completely pain free at 1 year of follow-up. Conclusion  Endoscopic spine surgery in lumbar disc prolapse is highly effective and can deliver a good functional outcome if done with correct preoperative planning and approach.

Transforaminal endoscopic thoracic discectomy: surgical technique.

The major challenge inherent to the surgical treatment of thoracic disc herniations is that the disc herniation is often ventral to the spinal cord. Posterior approaches are difficult and dangerous due to the morbidity associated with retraction of the thoracic spinal cord. A ventral approach is not feasible due to the thoracic viscera. A lateral transcavitary approach is the standard for treating ventral thoracic disc pathology but is also quite morbid. Transforaminal endoscopic spine surgery has emerged as a minimally invasive technique for treating thoracic disc pathology and it can be performed in the outpatient setting even with the patient awake. Advances in endoscopic camera technologies as well as the availability of specialty instruments that can be used down a working channel endoscope has now made a myriad of spine pathologies accessible to the minimally invasive spine surgeon. The transforaminal approach and the angled endoscopic camera are an ideal combination for creating a technical advantage to accessing thoracic disc pathology in a minimally invasive fashion. The principal challenges to the approach are needle targeting and understanding the endoscopic visual anatomy. Many surgeons interested in pursuing this technique are often deterred by the burden of the cost and time it takes to become adept and performing the technique. Detailed here are the authors' step-by-step technique and illustrative video that demonstrate transforaminal endoscopic thoracic discectomy (TETD).

Analysis of the efficacy of percutaneous spinal endoscopic surgery in the treatment of lumbar spinal stenosis.

Analysis of the efficacy of percutaneous spinal endoscopic surgery in the treatment of lumbar spinal stenosis.

Enhancing endoscopic foraminal decompression in adult isthmic spondylolisthesis: the potential influence of lateral recess isthmic spur and our case series of an innovative craniocaudal interlaminar approach via unilateral biportal endoscopic spinal surgery

BackgroundThe NASS guideline cannot recommend any of the surgical treatment options toward adult isthmic spondylolisthesis (AIS) since 2014. After the introduction of endoscopic decompression, instead of treating the spondylolysis itself, treatment can specifically target the refractory radicular pain developed during the degeneration progress without devastating the peripheral soft tissue. However, we noticed that endoscopic transforaminal decompression seems to be less effective in AIS compared to other types of degenerative spondylolisthesis. Thus, we came up with a novel craniocaudal interlaminar approach, utilizing the proximal adjacent interlaminar space to perform bilateral decompression and observed the pathoanatomy of pars defect directly and tried to identify the cause of decompression failure.MethodsFrom January 2022 to June 2022, 13 patients with AIS underwent endoscopic decompression via the endoscopic craniocaudal interlaminar approach and were followed up for at least 6 months. Visual Analogue Scale, Oswestry Disability Index and MacNab scores were recorded to monitor patients’ clinical recovery. All endoscopic procedures were recorded and reviewed to illustrate the pathoanatomy.ResultsFour patients required minor revision via the same technique. One of them required it due to incomplete isthmic spur resection, two due to neglected disc protrusion, and the other due to root subpedicular kinking in higher grade anterolisthesis. All patients’ clinical condition improved significantly subsequently. After reviewing the endoscopic video, we have observed that the hook-like, ragged spur originating from the isthmic defect extends beyond the region around the foramen. Instead, it extends proximally into the adjacent lateral recess, resulting in impingement along the fracture edge above the index foramen and, in some cases, even in the extraforaminal area.ConclusionsThe broad spanning isthmic spur extending to the proximal adjacent lateral recess might be the reason why the transforaminal approach yielded less satisfactory results due to the incomplete decompression result from approach related restriction. Our study demonstrated an optimistic outcome by applying decompression from the upper level. Therefore, we propose that the craniocaudal interlaminar approach might be a better route for decompression in adult isthmic spondylolisthesis.

Endoscopic Posterior Cervical Decompression for Ossified Posterior Longitudinal Ligament: A Technical Note.

Ossification of the posterior longitudinal ligament (OPLL) may cause cervical myelopathy. In its multilevel form, it may not be easy to manage. Minimally invasive endoscopic posterior cervical decompression may be an alternative to traditional laminectomy surgery. Thirteen patients with multilevel OPLL and symptomatic cervical myelopathy were treated with endoscopic spine surgery from January 2019 to June 2020. In this consecutive observational cohort study, pre- and postoperative Japanese Orthopaedic Association (JOA) score and Neck Disability Index (NDI) were analyzed at a final follow-up of 2 years postoperatively. There were 13 patients consisting of 3 women and 10 men. The patient's average age was 51.15 years. At the final 2-year follow-up, the JOA score improved from a preoperative value of 10.85 ± 2.91 to 14.77 ± 2.13 postoperatively (P < 0.001). The corresponding NDI scores decreased from 26.61 ± 12.88 to 11.12 ± 10.85 (P < 0.001). There were no infections, wound complications, or reoperations. Direct posterior endoscopic decompression for multilevel OPLL is feasible in symptomatic patients when executed at a high skill level. While 2-year outcomes were encouraging and on par with historic data obtained with traditional laminectomy, future studies will need to show whether any long-term shortcomings exist.

Patient Perceptions of Paramedian Minimally Invasive Spine Skin Incisions.

In clinical outcome studies, patient input into the factors that drive higher satisfaction with lumbar minimally invasive spinal surgery (MISS) is rare. The skin incision is often the only visible consequence of surgery that patients can assess. The authors were interested in patients' opinions about the type of lumbar paramedian minimally invasive spinal (MIS) skin incision employed during MISS and how novel skin incisions could impact patients' interpretation of the outcome. The authors wanted to compare traditional lumbar stab incisions to three novel lumbar paramedian (MIS) skin incisions to determine if further study is indicated. The primary objective was to examine patient satisfaction and perceptions regarding lumbar paramedian MIS skin incisions. We reviewed the literature and conducted a patient opinion survey. Responses were solicited from back pain patients from a single chiropractic office. Survey questions regarding novel skin incisions for minimally invasive spine surgery (NSIMISS) were conceptualized. The three novel skin incisions were designed using Langer's lines to reduce the total number of incisions; improve patient satisfaction; increase ease of surgical approach/fixation; and reduce operative time/radiation exposure. One hundred and six participants were surveyed. When shown traditional lumbar paramedian MIS skin stab incisions, 76% of respondents indicated negative responses, n = 65. The majority of patients chose traditional stab incisions (n = 41) followed by novel larger intersecting incisions (n = 37). The least popular incisions were the novel horizontal (n = 20) and the novel mini oblique (n = 5) incisions. Female patients worried more than male patients about how their incision looked. However, there was no statistically significant difference (p value of 0.0418 via Mann-Whitney U one-tailed test and p value of 0.0836 via Mann-Whitney U two-tailed test). Patients less than or equal to 50 years of age worried more than patients over 51 years of age, which was statistically significant (p value of 0.0104 via Mann-Whitney U one-tailed test and p value of 0.0208 via Mann-Whitney U two-tailed test). Patients do have opinions on the type of lumbar paramedian MIS skin incision used. It appears that younger patients and female patients worry most about how the incision on their back looks after surgery. A larger population of patients across many demographics is needed to validate these findings.

Study of functional outcome of dorsolumbar spine fractures treated with minimal invasive spine surgery

Spinal trauma is a common problem in modern Orthopedics. Spine surgery has recently been transformed significantly by the growth of minimally invasive surgery (MIS). Easily acceptable to patients as less invasive with smaller incisions, MIS is often perceived as superior to traditional open spine surgery. This study aims to study the functional outcome of minimally invasive surgery (MIS) in posterior thoracolumbar instrumentation in spine fractures. Present study was prospective in nature conducted among 35 patients. All patients fulfilling inclusion criteria and exclusion criteria were taken up for the study. Study was carried out over a period of 1.5 years. Majority of the patients was in the age group of 30-50 years and most of them were male. Mean VAS score &amp; ODI functional outcome scores significantly reduced after MIS. Incidence of complications after MIS was 5.71%. 86% patients had excellent to good outcome after MIS according to McNab criteria. Minimal invasive surgery is safe and effective procedure with minimal complications and good post-operative outcome.

(040) A Case Report of Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia Secondary to Lumbar Facet Cyst-Induced Sacral Radiculopathy Treated by Lumbar Endoscopic Spine Surgery

Abstract Introduction Persistent genital arousal disorder/genito-pelvic dysesthesia (PGAD/GPD), characterized by distressing, abnormal genito-pelvic sensations, especially unwanted genital arousal, may be triggered by pathology in Region 3, the cauda equina. Sacral radiculopathy is an inflammatory irritation of the S2-S3 nerve roots in the cauda equina, formed by convergence of pelvic, pudendal, and sciatic nerves and clinical symptoms that involve the sensory fields of these nerves. In a subgroup of patients, both cauda equina Tarlov cyst-induced sacral radiculopathy and lumbosacral annular tear-induced sacral radiculopathy have been reported to trigger PGAD/GPD, and in both conditions, endoscopic spine surgery has been shown safe and effective. Lumbar facet cysts, most common at the L4-L5 level, arise from lumbar zygapophyseal joints and can cause sacral radiculopathy. Thus, it is possible that lumbar facet cyst-induced sacral radiculopathy may be a trigger for PGAD/GPD. Objective To report one case of PGAD/GPD secondary to lumbar facet cyst-induced sacral radiculopathy, successfully treated with lumbar endoscopic spine surgery (LESS). Methods A 55-year old woman with a long history of PGAD/GPD presented to our spine-sexual medicine program for biopsychosocial assessment and treatment using our multidisciplinary management algorithm: Step A) detailed psychosocial and medical history; Step B) non-invasive assessments for sacral radiculopathy; Step C) targeted diagnostic transforaminal epidural spinal injection (TFESI) resulting in temporary clinically significant reduction of PGAD/GPD symptoms; Step D) surgical intervention with LESS and post-operative multidisciplinary follow-up. The patient was diagnosed with PGAD/GPD from lumbar facet cyst-induced sacral radiculopathy and underwent LESS for an L4-5 facet cyst. Results This 55 year old cisgendered woman had multiple painful spontaneous orgasms, shooting sharp pains that felt “like a bruise” going up the inside of her vagina, hypersensitivity of her vulva, clitoris, vagina, urethra and anus, along with constant symptoms of arousal and urinary urgency. These began in 2008 after her second childbirth. Her PGAD symptoms worsened over the last 2 years. She experienced sensations of pins and needles in her right buttocks, front of her left thigh, and down both legs into feet and toes. She also had severe constipation and restless leg syndrome. Neurogenital testing, including quantitative sensory testing, sacral dermatome testing and bulbocavernosus reflex latency testing, were all abnormal consistent with sacral radiculopathy. Region 1 anesthesia testing for vestibular pain showed persistent PGAD/GPD symptoms despite numbness on vestibular cotton swab testing. Pudendal nerve testing was negative. It was thus hypothesized that her PGAD/GPD trigger was closer to the central nervous system. Her MRI showed an L4-5 facet cyst. A TFESI with anesthetic was positive with temporary symptom reduction. She underwent LESS to excise the facet cyst and was discharged the same day. At early post-operative follow-up, she is PGAD-free. She no longer has irritative bladder symptoms, sciatica, restless leg syndrome, or pins and needles, and her constipation symptoms have improved. Conclusions Of the many recognized triggers for PGAD/GPD, we report for the first time a patient diagnosed with lumbar facet cyst-induced sacral radiculopathy after a multidisciplinary step-care management algorithm evaluation. She experienced marked improvement with lumbar endoscopic spine surgery. Disclosure No

Treatment of lumbar intervertebral disc herniation - a review of the latest therapeutic methods

Introduction and purpose: The aim of this study is to provide a comprehensive description of intervertebral disc herniation, with a focus on the lumbar spine, including the current conservative and modern surgical treatment options such as minimally invasive procedures.&#x0D; State of Knowledge: Spinal pain is a prevalent cause of disability in developed countries, with an increasing number of people affected by this condition. Intervertebral disc herniation resulting from degenerative changes is a common pathology, particularly in the lumbar and cervical spine. This condition involves the protrusion of the nucleus pulposus, which exerts pressure on the spinal roots, causing irritation. While the prognosis for herniated nucleus pulposus is usually positive and many patients can undergo conservative treatment, some may require a surgery.  Due to advancements in technology, the current goal is to minimize tissue trauma during hernia repair procedures.&#x0D; Conclusions: Due to advances in treatment of lumbar intervertebral disc herniation, patients can achieve better clinical outcomes and improved quality of life. Conservative treatment should be considered as the first line treatment in a majority of cases. Surgery is usually a last resort when conservative treatment proves insufficient. No surgical method seems to be unequivocally superior to the others, so its choice is tailored to the individual patient's needs and depends on the surgeon's preferences and experience. Recent advances in endoscopic spine surgery are providing new insights into disc surgery and pain management strategies.

Full endoscopic spine surgery

BackgroundWith a dramatic increase in elderly population worldwide, the prevalence of degenerative spine disease is steadily rising. Even though the entire spinal column is affected the problem is more commonly seen in the lumbar, cervical spine and to some extent the thoracic spine. The treatment of symptomatic lumbar disc or stenosis is primarily conservative with analgesics, epidural steroids and physiotherapy. Surgery is advised only if conservative treatment is ineffective. Conventional open microscopic procedures even though are still a gold standard, have the disadvantages of excessive muscle damage and bone resection, epidural scarring along with prolonged hospital stay and increased need of postoperative analgesics. Minimal access spine surgeries minimize surgical access related injury by minimizing soft tissue and muscle damage and also bony resection thus preventing iatrogenic instability and unnecessary fusions. This leads to good functional preservation of the spine and enhances early postoperative recovery and early return to work. Full endoscopic spine surgeries are one of the more sophisticated and advanced form of MIS surgeries. PurposeFull endoscopy has definitive benefits over conventional microsurgical techniques. These include better and clear vision of the pathology due to presence of irrigation fluid channel, minimal soft tissue and bone trauma, better and relatively easy approach to deep seated pathologies like thoracic disc herniations and a possibility to avoid fusion surgeries. The purpose of this article is to describe these benefits, give an overview of the two main approaches - transforaminal and interlaminar, their indications, contraindications and their limitations. The article also describes about the challenges in overcoming the learning curve and its future prospectives. ConclusionFull endoscopic spine surgery is one of the fastest growing technique in the field of modern spine surgery. Better intraoperative visualization of the pathology, lesser incidence of complications, faster recovery time, less postoperative pain, better relief of symptoms and early return to activity are the main reasons behind this rapid growth. With better patient outcomes and reduced medical costs, the procedure is going to be more accepted, relevant and popular procedure in future.

Clinical outcomes and complications after biportal endoscopic spine surgery: a comprehensive systematic review and meta-analysis of 3673 cases.

Current literature suggests that biportal spinal endoscopy is safe and effective in treating lumbar spine pathology such as lumbar disc herniation, lumbar stenosis, and degenerative spondylolisthesis. No prior study has investigated the postoperative outcomes or complication profile of the technique as a whole. This study serves as the first comprehensive systematic review and meta-analysis of biportal spinal endoscopy in the lumbar spine. A PubMed literature search provided over 100 studies. 42 papers were reviewed and 3673 cases were identified with average follow-up time of 12.5months. Preoperative diagnoses consisted of acute disc herniation (1098), lumbar stenosis (2432), and degenerative spondylolisthesis (229). Demographics, operative details, complications, and perioperative outcome and satisfaction scores were analyzed. Average age was 61.32years, 48% male. 2402 decompressions, 1056 discectomies, and 261 transforaminal lumbar Interbody fusions (TLIFs) were performed. Surgery was performed on 4376 lumbar levels, with L4-5 being most common(61.3%). 290 total complications occurred, 2.23% durotomies, 1.29% inadequate decompressions, 3.79% epidural hematomas, and < 1% transient nerve root injuries, infections, and iatrogenic instability. Significant improvement in VAS-Back, VAS-Leg, ODI, and Macnab Scores were seen across the cohort. Biportal spinal endoscopy is a novel method to address pathology in the lumbar spine with direct visualization through an endoscopic approach. Complications are comparable to previously published rates. Clinical outcomes demonstrate effectiveness. Prospective studies are required to assess the efficacy of the technique as compared to traditional techniques. This study demonstrates that the technique can be successful in the lumbar spine.