Foraminal Disc Research Articles

Contralateral Sublaminar Approach in Lumbar Spine With Unilateral Biportal Endoscopy

Unilateral biportal endoscopy (UBE) can be used to treat common lumbar pathologies, such as synovial facet cysts, foraminal disc herniations, and foraminal stenosis via a contralateral sublaminar approach. Due to the ultra-minimally invasive technique, UBE can reduce damage to anatomical structures, thereby reducing postoperative pain and allowing faster recovery. The patient is placed prone on a Wilson frame or bolsters. Fluoroscopy is used to identify the midline and medial pedicle line in the anterior-posterior projection. Spinal needles can aid to identifying portals’ trajectory in the lateral fluoroscopic projection. The procedure is performed via 2 separate portal incisions. The endoscope is introduced through the viewing portal and the surgical instruments through the working portal. Soft tissue dissector is used to create a working area over the spinous process-lamina junction. Bony shaving and drilling start at the target area and continue medially underneath the base of the spinous process until the midline and contralateral ligamentum flavum are identified. Contralateral ligamentum flavum is excised, exposing thecontralateral thecal sac, traversing nerve root, and lateral recess. The contralateral disc space, annulus, and superior articulating process are then identified and the offending pathology can be addressed under direct visualization. Meticulous hemostasis and close attention to outflow should be maintained to reduce the risk of complications. The steps of this procedure closely resemble those of traditional microscopic “over-the-top” techniques, including the surgical instruments used through the working portal. In this video, authors present the surgical technique of the contralateral sublaminar approach in the lumbar spine with UBE.

Comparative Analysis of the Clinical Effects of General Anesthesia and Intraspinal Anesthesia in Percutaneous Endoscopic Foraminal Disc Removal

Comparative Analysis of the Clinical Effects of General Anesthesia and Intraspinal Anesthesia in Percutaneous Endoscopic Foraminal Disc Removal

Treatment Concept and Technical Considerations of Biportal Endoscopic Spine Surgery for Lumbar Spinal Stenosis.

Decompression is a major component of surgical procedures for degenerative lumbar spinal stenosis (LSS). In addition to sufficient decompression to guarantee the relief of neurological pain, compensating surgical instability after wider laminectomy and foraminotomy and instrumentation with caging and fusion with grafting are performed to secure or restore the foraminal dimension and correct coronal/sagittal imbalance for longer survival of the adjacent segment. Endoscopic spinal surgery (ESS) has been developed under the flag of successful decompression while preserving structural integrity as much as possible with the help of magnification and illumination. ESS provides a technical possibility and feasibility for solving LSS by decompression alone. Recently, many endoscopic trials have been conducted to overcome conventional surgical treatment that requires wider dissection, escape inevitable complications from surgical damage, and compensate for the fusion technique. However, biportal ESS has some technical limitations, including clinical difficulties in accessibility for more moderate to severe stenosis and challenges for complicated conditions with segmental ventral slip, isthmic defect, stenosis combined with foraminal stenosis or foraminal disk rupture, or degenerative segmental scoliosis with disk height collapsing and endplate fatigue fracture. Because decompression alone is a skill for eliminating pathologies, there is no function of preserving degenerative structure or stopping the recurrence of disk degeneration or subsidence. This review of clinical reports investigated the possibility of biportal ESS for treating degenerative lumbar disorders by sufficient decompression and adequate elimination of various pathologies and decreasing technical complications. The results of this study may help develop better innovative spinal surgical techniques in the near future.

Full Endoscopic Posterior Cervical Laminoforaminotomy and Discectomy: A Technical Note

Cervical disc herniations affects different age groups especially the young population with habits of a sedentary lifestyle, long working hours over the computer, and poor neck postures who present with acute disc herniations. Cervical radiculopathy commonly presents with pain, paresthesia and motor weakness. Traditional surgical options available are anterior Cervical Discectomy and Fusion (ACDF) and Posterior Cervical Foraminotomy (PCF). However both the procedures have some disadvantages. With evolution of endoscopy in recent times provide better opportunity. Here we mention Full Endoscopic posterior cervical laminoforaminotomy and discectomy technique. It is the most advanced technique for single-level lateral and foraminal disc prolapses causing monoradiculopathy, we found this procedure is safe and effective minimally invasive technique for lateral soft herniations and foraminal stenosis. It has lesser complications and better post-op recovery.

Biportal Endoscopic Posterior Cervical Foraminotomy for Adjacent 2-Level Foraminal Lesions Using a Single Approach (Sliding Technique).

Endoscopic posterior cervical foraminotomy (PCF) using uniportal or biportal endoscopic approach has been performed for cervical foraminal stenosis or foraminal disc herniation. Two-level PCF is possible using a single biportal endoscopic approach. The purpose of this study was to present a technique of biportal endoscopic PCF for contiguous 2-level foraminal lesions using a single approach and its clinical results. Patients who received 2-level PCF using a single biportal endoscopic approach were enrolled in this study. We analyzed their clinical data including age, sex, complications, and Neck Disability Index (NDI), and visual analogue scale (VAS) of neck and arm. Postoperative magnetic resonance image was taken on the first postoperative day to determine whether there was sufficient decompression. We successfully performed biportal endoscopic PCF for adjacent 2-level foraminal lesions using a single approach (sliding technique) in all 12 patients. There were cervical foraminal disc herniation with foraminal stenosis (5 cases) and 2-level foraminal stenosis (7 cases). Preoperative mean NDI and VAS of arm and neck significantly decreased at 12 months after surgery. Postoperative clinical outcomes were excellent in 5 patients, good in 6 patients, and fair in 1 patient. There was no major complication. Two-level PCF could be performed using a single approach biportal endoscopic surgery with only 2 skin incisions. Clinical outcomes are favorable. This sliding PCF technique using biportal endoscopic approach might be an alternative surgical treatment for contiguous 2-level cervical foraminal pathologic lesions.

Magnetic resonance imaging features of canine intradural/extramedullary intervertebral disc extrusion in seven cases

Intervertebral disc disease, including intervertebral disc extrusions and protrusions, is the most common spinal cord disorder in dogs. Atypical and uncommon intervertebral disc herniations include intradural/intramedullary disc extrusion, intervertebral foraminal disc extrusion and intervertebral disc herniation (Schmorl's node). Intradural/extramedullary disc extrusion is the least common type of intervertebral disc herniation in veterinary medicine, characterized by extruded disc material within the intradural space. To date, only one study has been published in veterinary medicine reporting intradural/extramedullary disc extrusions. In this study, low field MRI was used, and the authors could not find any MRI features to diagnose with confidence an intradural/extramedullary disc location of the extruded disc material. The aim of this study was to describe the high field (1.5T) MRI characteristics of surgically confirmed intradural/extramedullary disc extrusions. This is a retrospective, multicentric and descriptive study. Inclusion criteria was surgical confirmation of intradural/extramedullary disc extrusion by durotomy and complete MRI study of the spine. Seven cases were included. Images were reviewed by a radiology resident and a certified radiologist, with emphasis on the following signs: “Golf-tee sign” (widening of the subarachnoid space cranial and caudal to the lesion), “Beak sign” (pointed and sharp compressive lesion) and “Y sign” (division of the dura and arachnoid layers). MRI showed a “Y sign” in all the cases (7/7) seen from the T2-weighted sagittal views, while “Golf-tee sign” was not recognized in any of the cases (0/7). Additionally, “beak sign” was present in half of the cases (4/7). “Y sign” maybe a reliable MRI feature for identifying intradural/medullary disc extrusions from the MRI study. As the arachnoid is peeled from the dura by the disc herniation there is a splitting of the arachnoid mater and the ventral dura. The intradural disc material will be surrounded by CSF signal intensity margin, giving the appearance of a Y, which can be identified from the T2-weighted sagittal images.

Posterior Fixation with Transforaminal Lumbar Interbody Fusion for Single Level Isthmic and Degenerative Lumbar Spondylolisthesis in Adults Causes Less Complication

BACKGROUND
 Lumbar interbody fusion has long been considered the "gold standard" technique for surgical treatment of adult spondylolisthesis. Superior results have subsequently been reported with interbody fusion with cages and posterior instrumentation. The objectives of the study were to determine the functional outcome after one year following surgery and evaluate the fusion rate.
 METHODS
 In this prospective, non-randomised study, 26 patients (average age 37.1 yrs) with isthmic spondylolisthesis (IS), who suffered for an average of 12.08 months and 14 patients with degenerative spondylolisthesis (DS) (average age 58.6 yrs), who suffered for 13.2 months on average were collected in out-patient department basis. They underwent an interbody fusion with cages with posterior instrumentation (TLIF or PLIF). Clinical outcome was measured using VAS and Oswestry Disability Index. Foraminal dimensions and disc heights were measured in standard digital radiographs. Radiographic fusion was confirmed with CT scans at 1 year.
 RESULTS
 In the IS group, a mean spondylolisthesis slip of 33.3 % was reduced to 6.7 % at 1 year. Vertical foraminal distance(C) was improved from 11.2 mm to 12.0 mm. The fusion rate was 78.2 % with TLIF and 66.7 % with PLIF. In the DS group, a mean spondylolisthesis slip of 32.7 % was reduced to 7.4 % at 1 year. C distance was improved from 11.8 mm to 13.2 mm. The fusion rate was 66.7 % with TLIF and 100 % with PLIF. The mean ODI scores at baseline and 1 year, were improved from 48 to 9.8 and from 49.5 to 18.4 in the IS and DS groups respectively. VAS score was improved from 6.4 to 0.8 and from 6.6 to 2.5 in IS and DS groups respectively.
 CONCLUSIONS
 Interbody fusion for low-grade spondylolisthesis requiring reduction results in excellent to good functional outcomes in 90 % of patients with a good fusion rate. TLIF procedure of spinal fusion requires less time, causes less bleeding, and has less chance of damage to the neural structures than PLIF.

Full Endoscopic Thoracic Discectomy: Is the Interlaminar Approach an Alternative to the Transforaminal Approach? A Technical Note.

Various approaches are used for decompressive surgeries in the thoracic spine depending on the location and consistency of the pathology, always avoiding manipulation of the thoracic spinal cord. Recently, there has been an effort to achieve adequate results and reduce morbidity with minimally invasive surgeries. Good outcomes and the advantages of full endoscopic spine surgery (FESS) have been proven for surgerical correction of herniated discs and stenoses in the lumbar and cervical spine. Similar evidence has recently been described for the thoracic spine, but it has not previously been reported in Brazil. Although the transforaminal approach is already established for the thoracic spine, the newly described interlaminar approach is equally efficient, and both techniques must be considered when treating thoracic spine diseases. The objective of the present article was to present the full endoscopic interlaminar and transforaminal techniques in patients with symptomatic disc herniation of the thoracic spine, discuss the rationality for implementing FESS in thoracic spine, and discuss the rationality in choosing between both approaches. Two patients were submitted to thoracic FESS. A transforaminal approach was chosen for a T10-T11 foraminal disc herniation; an interlaminar approach was selected for a paramedian T7-T8 disc extrusion. Data regarding operating time, intraoperative images, hospital stay, visual analog scales before and after FESS, course of recovery, and surgery satisfaction were evaluated. The patients had eventless surgeries, improved from preoperative pain without morbidity. Both were satisfied and recovered well. Hospital stay was less than 6 hours after surgery. Transforaminal and interlaminar FESS for thoracic disc herniation are safe, efficient, and minimally invasive alternatives. Despite being an innovative technique with evident advantages, it should be carefully considered along with conventional technique for the treatment of thoracic spine diseases, since its clinical relevance is yet to be determined.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy presenting as severe herniated nucleus pulposus: A case report

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy is the most common inherited cerebral microangiopathy. Its clinical features include recurrent central nervous system symptoms—including lacunar stroke, migraine, psychiatric disturbance, acute reversible encephalopathy, and cognitive impairment. We report a case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy in a patient presenting with severe low back pain and a herniated nucleus pulposus. A 45-year-old female patient with a prior history of right-sided sciatic pain, hypoesthesia, and paresthesia in the right S1 sensory dermatome was referred after back surgery because of persistent low back pain and a spastic gait abnormality. Imaging revealed a right protruding disc herniation of L5/S1 with right S1 nerve root compression and right posterior disc bulging at L4/5 with foraminal stenosis and disc degeneration, for which she underwent surgery. After surgery, she experienced mild sciatica, an antalgic limping gait with foot-dragging, and progressive motor weakness. Her family history was significant for a parent and sibling affected by stroke. The diagnosis of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy was established by polymerase chain reaction sequencing, which showed a mutated exon 11 of NOTCH3 on chromosome 19. Clinicians should assess patients with non-specific extra-central nervous system symptoms or atypical courses for potential underlying diseases.

Spinal surgery for gallstones disease - Case report of a rare differential diagnosis.

Introduction and importanceAbdominal pain in the right upper quadrant is very common for patients to present in the emergency department. Finding the correct diagnosis seems straightforward in most cases but can be challenging.Case presentationWe present the case of a 75-year-old male with a rare differential diagnosis for right upper quadrant and back pain, initially diagnosed as symptomatic cholelithiasis. After referral to an abdominal surgeon, detailed history taking prior to planned cholecystectomy revealed a record of back pain due to spinal degeneration and fusion surgery, as well as a bulb of the right abdominal wall with hypesthesia in a dermatomal area in the right upper quadrant. Considering these “new” facts, a spinal surgeon was consulted and a foraminal disc hernia of the thoracic vertebrae 11/12 was identified as the cause of symptoms. Instead of the initially planned cholecystectomy, a right-sided facetectomy Th11/12, sequestrectomy and unilateral transpedicular stabilization to decompress the nerve root was successfully performed.Clinical discussionAlthough, symptomatic cholelithiasis is one of the most common diagnoses for patients presenting with right upper quadrant pain in the presence of gallstones, other differential diagnoses have to be considered. Thoracic disc herniations can present with atypical symptoms that mimic other non-spinal causes and may pose a diagnostic challenge, sometimes even leading to unnecessary surgery.ConclusionThis case highlights a rare differential diagnosis for one of the most common diseases seen by emergency physicians. It emphasizes the risk of working under time pressure, especially in an emergency setting, which may lead to premature diagnostic error and treatment, endangering patient's care and safety.

A Novel Technique of the Full Endoscopic Interlaminar Contralateral Approach for Symptomatic Extraforaminal Juxtafacet Cysts

Objective: Extraforaminal juxtafacet cyst is rare and present a surgical challenge due to its anatomical location. This study aimed to introduce the surgical technique of interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) for extraforaminal juxtafacet cyst removal and reveal its approach-related benefits.Method: The endoscope was docked on the ipsilateral spinolaminar junction and access the contralateral foraminal area through the contralateral sublaminar space created by the fine drilling. As the foraminal was enlarged by foraminal ligament removal and the superior articular process drilling, the endoscope was introduced deeper to the extraforaminal area without violation of the foraminal disc. Combined foraminal stenosis was also resolved while exploring the foraminal space. Subsequently, the extraforaminal cyst was safely and entirely removed while exposing the cyst-nerve root adhesion site with an endoscopic view looking up obliquely.Results: Radiating pain in the right leg, back pain, leg hypesthesia, and ankle weakness improved. Conclusion: ICELF for the treatment of extraforaminal JFC can be an alternative surgical method to resolve symptomatic foraminal stenosis and the cyst simultaneously. The endoscopic system moves parallel to the exiting nerve root during ICELF, facilitating clear visualization of the cranial-dorsally or cranial-ventrally located extraforaminal JFCs. The entire cyst contour and the site of cyst-nerve root adhesion can be detected without nerve root retraction, and meticulous dissection is possible without violating the cystic wall.

Preoperative and postoperative ultrasound elastography findings of the sciatic nerve in patients with unilateral lumbar foraminal disc herniation: a pre-test and post-test design.

The aim of this study was to compare preoperative and postoperative findings of the sciatic nerve by using B-mode ultrasound, strain elastography (SE), and shear wave elastography (SWE) in patients with unilateral lumbar foraminal disc herniation. In this prospective study group, patients with complaints of foraminal disc herniation due to one level (L4-5 or L5-S1) were included. Preoperative and postoperative (one month after surgery) B-mode ultrasound, SE, and SWE findings of the affected sciatic nerve in patients who underwent unilateral spinal decompression surgery were compared. Evaluations were performed on the axial plane from the gluteal region using a convex probe of 5-9L MHz. The reference method used to assess nerve root compression was 1.5-T Magnetic Resonance Imaging (MRI). A total of 20 patients (9 males, 11 females) with a mean age of 46.2±13.1 years were included. The cross-sectional area (CSA), diameter, SWE values of the sciatic nerve were significantly higher in the affected side compared to those of the non-affected side (all for p<0.05). Blue and blue-green were the most common color codes in the affected side while green and green-yellow-red were the most common color codes in the non-affected side. The CSA, diameter, and SWE values of the sciatic nerve decreased after the surgery in the affected side (all for p<0.05), nonetheless. those did not differ in the non-affected side (all for p>0.05). Lumbar decompression surgery decreases the sciatic nerve diameter, CSA, and stiffness of the sciatic nerve.

Percutaneous Full-Endoscopic versus Biportal Endoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Foraminal Disc Disease.

The biportal endoscopic technique (BE) is a fast-growing surgical modality that can be applied to posterior cervical foraminotomy (PCF), as well as lumbar discectomy and decompressive laminectomy. It has several technical differences from the percutaneous full-endoscopic technique (PE), which has been standardized as the representative endoscopic spinal surgery technique. The purpose of this study was to compare the short-term clinical outcomes between BE-PCF and PE-PCF. A retrospective review was conducted on 66 patients who had single-level unilateral cervical foraminal disc disease (UCFD). All patients underwent PE- or BE-PCF. Clinical outcomes including visual analog scale (VAS)-arm, VAS-neck, and Neck Disability Index (NDI) were evaluated. Perioperative data including operation time, length of hospital stay (LOS), amount of surgical drain, postoperative complications, and reoperation were collected. Serum creatine phosphokinase (CPK) and C-reactive protein (CRP) levels were recorded. A total of 65 patients were included in the final analysis: 32 with PE-PCF and 33 with BE-PCF. There was no statistically significant difference in demographic and preoperative data between the two groups. All patients had significant improvement in VAS-arm, VAS-neck, and NDI compared to the baseline value. The improvement of all parameters was comparable between the two groups at each point for 1 year after surgery (p > 0.05), except for the significantly lower VAS-neck at postoperative 2 days in PE-PCF (p = 0.005). The total operation time was significantly shorter in BE-PCF (p = 0.036). There were no statistically significant differences between the two groups in regard to LOS, amount of surgical drain, and serum CPK and CRP levels (p > 0.05). Reoperation and complications between the two groups were comparable (p > 0.05). The 1-year postoperative clinical outcomes of PE-PCF and BE-PCF for cervical pain and disability caused by UCFD were good and comparable. PE-PCF resulted in significantly less immediate postoperative neck pain, but BE-PCF required shorter total operation time.

Two Cases of Iatrogenic Lumbar Foraminal Disc Herniations

Objective We report two cases of iatrogenic deterioration of lumbar foraminal disc herniations following lumbar disc injections. Summary of Background Data. Complications associated with discography were reported. However, only a few reports have thus far referred to the iatrogenic deterioration of lumbar foraminal disc herniations. Cases 60-year-old and 74-year-old men were treated with MR images of L4-5 foraminal disc herniations without fragment in the spinal canal. The patients underwent discography and disc block for its diagnosis and treatment. After disc injections, both patients complained of deterioration of L4 radiculopathy. Results On disco-CT or reexamined MR images after disc injections, herniated fragment was migrated from neural foramen to cranial central spinal canal with was not shown in previous MR images. The herniated fragments were extirpated by means of osteoplastic laminoplasty or transforaminal lumbar interbody fusion with facetectomy. The herniated fragments were migrated from neural foramen to cranial central spinal canal. Conclusions The injection of liquid medicine into the nucleus led the intradiscal pressure increased, and the disc fragment might prolapsed through the raptured region of annulus fibrosus and migrated to cranial central spinal canal by anatomical reason. The disc injection may have a risk for deterioration of foraminal disc herniation. Our report is instructive for the management of discography for the diagnosis of foraminal disc herniations.

Contralateral retrodiscal transforaminal approach for percutaneous epidural adhesiolysis: A technical description and retrospective comparative study.

Retrodiscal transforaminal (RdTF) epidural steroid injection (ESI) is clinically comparable to conventional transforaminal ESI and can avoid catastrophic complications. However, it poses a risk of inadvertent intradiscal, intravascular, and intrathecal injections. Therefore, we aimed to evaluate the feasibility of percutaneous epidural adhesiolysis (PEA) using the contralateral (Contra)-RdTF approach. The electronic medical records of 332 patients with unilateral lumbar radiculopathy due to foraminal disk pathology were reviewed. Patients were categorized into two groups: Group A (ESI using the RdTF approach) and Group B (PEA using the Contra-RdTF approach). Effective pain relief (EPR; ≥50% pain relief from baseline) in patients was evaluated using the visual analog scale (VAS) at 4 and 12weeks after the procedure. The presence of unintended fluoroscopic findings and complications was recorded. A total of 119 patients were enrolled in the final analysis: 81 in Group A and 38 in Group B. Both groups showed lesser VAS scores after 4 and 12weeks than at baseline (p<0.05). However, the proportion of patients with EPR was significantly greater in Group B after 12weeks (p=0.015). No complications, including intrathecal injection, infectious discitis, and neurologic deterioration, were reported. However, inadvertent intradiscal and intravascular injections were reported to be significantly higher in Group A than in Group B (14.8% and 0%, respectively; p=0.009). Although applications of this study are limited by its retrospective design, the results suggest that PEA using the Contra-RdTF approach is feasible because it can achieve EPR and avoid unintended fluoroscopic findings.

Postoperative outcome of robot-assisted transforaminal lumbar interbody fusion: A pilot study

Introduction:Transforaminal lumbar interbody fusion (TLIF) surgery is well established for the treatment of discopathy, foraminal disc herniation, and recurrent disc herniation. At the Amiens university medical center, we have been using a robot-assisted technique for performing the TLIF. The purpose of this study is to evaluate the radiological and clinical outcome, specifically pain, of patients having undergone robot-assisted TLIF.Materials and Methods:We performed a retrospective analysis of prospectively collected data of patients having undergone minimally invasive (MI) robot-assisted TLIF between November 2014 and July 2018 in a French university medical center. In clinical consultations at 6 weeks, 12 months, and 24 months posttreatment, patients were assessed for back and leg pain (on a visual analog scale), breached screws, and sagittal parameters.Results:A total of 136 pedicle screws were inserted with robot guidance into 32 patients. Four of the patients required laminectomy before fusion. No pedicle breach occurred for 94% of the screws, and no joint violation was observed for 90%. Lordosis was improved in 78% of the cases.Conclusions:The robot provides valuable assistance during MI arthrodesis; it facilitates the surgical procedure by preplanning the trajectory, providing instantaneous navigation and tracking, and thus assure the accuracy of screw positioning.

19. Anterior lumbar interbody fusion with porous titanium interbody cages is associated with equivalent fusion rates and patient reported outcomes as bone morphogenetic protein-2

<h3>BACKGROUND CONTEXT</h3> Although frequently used for anterior lumbar interbody fusion (ALIF), concerns regarding the use of recombinant human bone morphogenetic protein 2 (BMP-2) include off-label use, elevated cost and adverse outcomes such as osteolysis. The growing evolution of porous implant technology in promoting osseous integration via ingrowth provides an opportunity for a paradigm shift by relying less on biologic-assisted through-growth and leveraging implant on-growth and in-growth in similar fashion to porous metallic implants used in other orthopedic settings such as hip arthroplasty. <h3>PURPOSE</h3> This study compared perioperative clinical and radiographic outcomes between patients undergoing ALIF with the assistance of BMP-2 in a nonporous, traditional window interbody cage vs those with no biologic using a minimal-window porous titanium interbody cage. <h3>STUDY DESIGN/SETTING</h3> Retrospective clinical. <h3>PATIENT SAMPLE</h3> This study retrospectively examined 75 consecutive patients who underwent 1- or 2-level ALIF between 2014 and 2020 with the use of BMP-2 in a nonporous PEEK cage vs a porous titanium interbody cage and no biologic. All patients had surgery with the senior surgeon and were followed for a minimum follow-up of 6-months postoperatively. <h3>OUTCOME MEASURES</h3> Patient demographics, comorbidities, postoperative complications, and preoperative, immediate and final postoperative patient-reported outcomes (PROs) were assessed. Rates of reoperation were recorded, and arthrodesis was evaluated using Bridwell radiographic criteria and CT when available. Pre- and postoperative radiographic parameters were evaluated for differences in spinopelvic alignment and correction. <h3>METHODS</h3> Statistical methods included student's t-test and chi-square for continuous and categorical variables, respectively. Continuous variables were reported as means and standard deviations, and categorical variables as proportions. The threshold for statistical significance was set to p < .05. <h3>RESULTS</h3> Forty-three (13 female, 30 male) and 32 (19 female, 13 male) patients were assessed in the BMP-2 and titanium cage cohorts, respectively. On PRO assessment, baseline VAS leg among BMP-2 patients (6.87, SD: 1.96 vs 5.16, SD: 2.41; p = .023) while the titanium cage group reported worse VAS back scores (6.23, SD: 2.39 vs 7.82, SD: 1.40; p = .023). However, there were no significant differences recorded in postoperative PRO surveys between groups. Correction of spinopelvic alignment was equally maintained between groups at final follow-up when compared to immediate postoperative radiographs. Similarly, disc spaces were equivalently upheld across cohorts, with the exception of greater degeneration among BMP-2 patients at the L4-L5 anterior (-1.78, SD: 3.00 vs -0.07, SD: 2.63; p = .039) and foraminal (-2.34, SD: 3.11 vs -0.07, SD: 2.06; p = .006) disc spaces. Interbody subsidence was similar at the superior (1.13, SD: 0.84 vs 1.28, SD: 0.88; p = .458) and inferior endplates (0.55, SD: 0.79 vs 0.91, SD: 1.27; p = .154), and radiographic evidence of fusion was observed at equivalent rates (90% vs 90.9%, p = .776). There were no differences in the rates of secondary surgeries for adjacent segment disease (ASD) (4.6% vs 0%, p = .222) or index-level revisions (9.1% vs 18.8%, p = .219). <h3>CONCLUSIONS</h3> Porous titanium interbody cages for ALIF may be equivalent to BMP-2 in nonporous PEEK in achieving arthrodesis, alignment durability and reoperation rates. Although long-term follow-up is necessary, the use of porous titanium implants without external biologics is an intriguing paradigm change which may produce similar outcomes at lower costs. <h3>FDA DEVICE/DRUG STATUS</h3> Alphatec Identiti Cage (Approved for this indication), Recombinant Human Bone Morphogenetic Protein-2 (Approved for this indication)

Extra-laminar microscopic-assisted percutaneous nucleotomy (EL-MAPN) for the treatment of foraminal lumbar disc prolapse, a modified minimally invasive approach

In this work, a modification of the percutaneous surgical approach for removing the lumbar foraminal disc prolapse is introduced. A prospective study was performed. The indication for surgery was foraminal disc prolapse presenting with acute motor or persistent sensory radiculopathy. MRI and X-ray of the lumbar spine were performed. VAS and ODI were recorded. The operation was done under general anesthesia. A needle was inserted for level-localization using C-arm. A 1.5cm para-median skin incision was performed. A gradual dilatation using trocars was followed by the insertion of a tubular system. Under direct vision using the operative microscope, the lateral edge of the lamina was identified. A small, hooked probe was inserted in the foramen, and its position was documented fluoroscopically. With the help of the microscope, the triad consisting of Pedicle, Nerve root, and Prolapse "PNP" was identified. The nerve root was mobilized, and the prolapsed disc was removed. The study included 50 patients, 26 females, and 24 males. The mean follow-up was 18months. The mean operative time was 65min. The mean blood loss was 105ml. The mean VAS improved from 7.8 ± 2.3 preoperatively to 0.8 ± 0.3 after one year (p = 0.001). Mean ODI improved from 28 ± 10.4 to 4 ± 2.3 after one year (p = 0.02). A recurrent disc occurred in 2 patients and was revised in the same technique. EL-MAPN represents a minimally invasive approach for foraminal disc prolapse removal under direct visual control avoiding injury to the facet joint or pars interarticularis.

Surgical Techniques Ensuring Success in Posterior Endoscopic Cervical Foraminotomy and Discectomy at C6-7 in Patients with Prominent Shoulders and Short Necks

Introduction: There is a steep learning curve for a successful posterior endoscopic cervical foraminotomy and discectomy (PECFD), an important surgery for cervical foraminal or lateral disc herniation, and cervical radiculopathy due to a small operation field. PECFD becomes even more challenging in patients who have prominent shoulders and/or short necks with C6–7-disc herniation, because of the difficulty to localize C6–7 vertebral structure under fluoroscopy. The study objective is to prove that the PECFD can be performed safely and successfully to C6–7-disc herniation on patients with prominent shoulders and/or short necks following our novel surgical techniques under fluoroscopic guidance. Materials and Methods: PECFD was performed on a patient who had an extruded foraminal disc herniation at C6–7 on the left with left arm pain and weakness. Due to his prominent shoulders and a short neck, the C6–7 anatomic site was not visible under traditional anterior-posterior (AP) and lateral fluoroscopic views. The authors inserted a reference needle to C4–5 facets between C4 and C5 pedicles under AP and lateral fluoroscopic views. Following the reference needle, the C6–7 facets were easily located with an oblique fluoroscopic view. A large endoscopic cannula was used initially for adequate resection of C6–7 facets, followed by a small cannula for nerve root handling with minimal pressure and discectomy. Results: The novel surgical techniques resulted in a complete resection of the C6–7-disc herniation and resolution of the patient’s radiculopathy with no postoperative complications. Conclusion: PECFD can be safely and successfully applied for C6–7-disc herniation in patients with prominent shoulders and/or short necks using our novel surgical techniques.

Conservative Management of a Foraminal Lumbar Disc Herniation

A 39-year-old college professor presented to physical therapy via direct access, with a 2-month history of progressive lower back and right buttock pain. Following examination, the patient self-referred to a physiatrist, who ordered magnetic resonance imaging of the lumbar spine. Magnetic resonance imaging revealed a moderate, broad-based right foraminal disc herniation at L5-S1 encroaching on the right L5 nerve root exit. JOSPT Cases 2021;1(1):49–50. doi:10.2519/josptcases.2021.9776