Full Endoscope Research Articles

Artificial intelligence-based analysis of associations between learning curve and clinical outcomes in endoscopic and microsurgical lumbar decompression surgery.

A common spine surgery procedure involves decompression of the lumbar spine. The impact of the surgeon's learning curve on relevant clinical outcomes is currently not well examined in the literature. A variety of machine learning algorithms have been investigated in this study to determine how a surgeon's learning curve and other clinical parameters will influence prolonged lengths of stay (LOS), extended operating times (OT), and complications, as well as whether these clinical parameters can be reliably predicted. A retrospective monocentric cohort study of patients with lumbar spinal stenosis treated with microsurgical (MSD) and full-endoscopic (FED) decompression was conducted. The study included 206 patients with lumbar spinal stenosis who underwent FED (63; 30.6%) and MSD (118; 57.3%). Prolonged LOS and OT were defined as those exceeding the 75th percentile of the cohort. Furthermore, complications were assessed as a dependent variable. Using unsupervised learning, clusters were identified in the data, which helped distinguish between the early learning curve (ELC) and the late learning curve (LLC). From 15 algorithms, the top five algorithms that best fit the data were selected for each prediction task. We calculated the accuracy of prediction (Acc) and the area under the curve (AUC). The most significant predictors were determined using a feature importance analysis. For the FED group, the median number of surgeries with case surgery type at the time of surgery was 72 in the ELC group and 274 in the LLC group. FED patients did not significantly differ in outcome variables (LOS, OT, complication rate) between the ELC and LLC group. The random forest model demonstrated the highest mean accuracy and AUC across all folds for each classification task. For OT, it achieved an accuracy of 76.08% and an AUC of 0.89. For LOS, the model reached an accuracy of 83.83% and an AUC of 0.91. Lastly, in predicting complications, the random forest model attained the highest accuracy of 89.90% and an AUC of 0.94. Feature importance analysis indicated that LOS, OT, and complications were more significantly affected by patient characteristics than the surgical technique (FED versus MSD) or the surgeon's learning curve. A median of 72 cases of FED surgeries led to comparable clinical outcomes in the early learning curve phase compared to experienced surgeons. These outcomes seem to be more significantly affected by patient characteristics than the learning curve or the surgical technique. Several study variables, including the learning curve, can be used to predict whether lumbar decompression surgery will result in an increased LOS, OT, or complications. To introduce the provided prediction tools into clinics, the algorithms need to be implemented into open-source software and externally validated through large-scale randomized controlled trials.

Full-endoscopic (bi-portal or uni-portal) versus microscopic lumbar decompression laminectomy in patients with spinal stenosis: systematic review and meta-analysis.

Lumbar stenosis causes pain in the lower lumbar spine and lower extremities and reduces the patient's quality of life and walking ability. Thus, these conditions are common surgical indications for spinal stenosis. Previous reports have shown satisfactory clinical outcomes of the full-endoscopic (FE) and MI technique decompressive laminectomy for lumbar stenosis. However, they still remain controversial. We conducted a systematic review and meta-analysis to compare the postoperative outcomes between FE (bi-portal or uni-portal) and MI technique decompressive laminectomy for lumbar stenosis. We searched all comparative studies that compared postoperative outcomes (operative time, VAS for back and leg pain, ODI in 3months and last follow-up) of full-endoscopic (bi-portal or uni-portal) and microscopic technique decompressive laminectomy for lumbar stenosis from the PubMed and Scopus databases up to October 16, 2019. Nine of 1107 studies (five comparative studies and four RCT) (N = 994 patients) were eligible; all studies were included in pooling of FE and MI decompression. Five and three studies were included in pooling of bi-portal endoscopic, uni-portal endoscopic and MI decompression. All three techniques were compared in one study. Eight, nine, seven, eight, five, seven, eight and nine studies were included in pooling of VAS for back, leg, ODI in 3months and last follow-up and operative time, respectively. The UMD of VAS for back, leg, ODI in 3months and last follow-up of FE group was - 0.63 (95% CI - 1.15, - 0.12), - 0.15 (- 0.42, 0.11), - 2.06 (- 3.76, - 0.39), - 0.07 (- 0.22, 0.08), - 0.16 (- 0.29, - 0.03), - 0.20 (- 1.20, 0.81) scores and - 3.00 (- 12.25, 6.25) minutes when compared to MI in lumbar stenosis. In terms of complication, FE was lower risk of 0.62 (0.40, 0.96) times when compared to MI. After subgroup analysis, BESS had significant lower back and leg pain within 3months when compared to MI group, while uni-portal FE had significant lower leg pain in the last follow-up and complication when compared to MI group. There had no difference in ODI and operative time between two groups. FE had statistically significant lower back pain, lower leg pain and lower risk of having complications when compared to MI decompression in lumbar stenosis, while there is no difference in ODI and operative time between both groups. Comparing to MI, BESS had better early postoperative back pain while uni-portal FE had better leg pain and risk of having complications. Larger, prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient. III.

Complications of Full-Endoscopic Versus Microendoscopic Foraminotomy for Cervical Radiculopathy: A Systematic Review and Meta-Analysis

Minimally invasive surgery of posterior cervical foraminotomy (PCF) for symptomatic radiculopathy has gained popularity in the last decade. It remains to be determined whether the 2 dominant operation techniques, full-endoscopic (FE) or microendoscopic (MI), are associated with fewer complications. An electronic retrieval from PubMed, Embase, and Web of Science was performed to identify comparative or single-arm studies concerning FE-PCF and MI-PCF. The pooled incidence of complications was calculated. A total of 26 studies with 2028 patients (FE, 402; MI, 1626) were identified. The overall complication rate was 5.8% for FE-PCF and 3.5% for MI-PCF, with no significant difference (P= 0.115). The pooled complication rate for single-level radiculopathy showed no statistical difference (FE, 4.5%; MI, 3.5%; P= 0.471), either. However, constituent of complications showed apparent disparity, with transient root palsy in FE-PCF (15/19, 78.9%) and dural tear (20/47, 42.6%) in MI-PCF being the most commonly reported. As for the subgroup analysis, both incidence of dural tear (FE, 1.5%; MI, 1.8%; P= 0.672) and superficial wound infection (FE, 2.2%; MI, 1.0%; P= 0.109) showed no statistical difference. Nevertheless, transient root palsy occurred at a higher incidence in the FE group than in the MI group (FE, 4.5%; MI, 1.5%; P= 0.002). Both FE-PCF and MI-PCF can offer relatively safe treatment for cervical radiculopathy. There is no significant difference in overall complication rate between the 2 techniques. Dural tear is the most commonly reported complication of MI-PCF, whereas transient root palsy deserves to be noticed for surgeons performing FE-PCF.

Percutaneous endoscopic interlaminar discectomy of L5\u2013S1 disc herniation: a comparison between intermittent endoscopy technique and full endoscopy technique

BackgroundPercutaneous endoscopic laminar discectomy is a typical minimally invasive discectomy operation that is classified into the percutaneous endoscopic transforaminal discectomy and the percutaneous endoscopic interlaminar discectomy. Based on whether the surgeon chooses to deal with the ligamentum flavum under endoscope guidance, percutaneous endoscopic discectomy by the interlaminar approach can be performed with a full endoscope technique with the intermittent endoscope technique. To our knowledge, there is no study comparing these two techniques in regard to their surgical effects and advantages. Therefore, we conducted this study to compare the cost, safety, and efficacy between the intermittent endoscopy technique and full endoscopy technique of endoscopic interlaminar lumbar discectomy at the L5–S1 level.MethodsFrom September 2014 to March 2015, a total of 126 patients with radiculopathy due to L5–S1 disc herniation who were treated by a full endoscopy technique (65 patients) or intermittent endoscopy technique (61 patients) were included. Relevant data, such as duration time of the operation, hospitalization expenses, postoperative bed rest time, length of hospitalization, and complication rates, were recorded. Clinical outcomes were assessed by the visual analog scale score, modified MacNab criteria, and Oswestry disability index.ResultsIn the full endoscope (FE) group, the mean duration time of surgery was 75.0 ± 11.9 min. The postoperative bed rest time was 6.5 ± 1.1 h, length of hospitalization was 3.8 ± 1.1 days, and complication rate was 7.69%. In the intermittent endoscopy (IE) group, the mean duration time of surgery was 43.0 ± 16.4 min. The postoperative bed rest time was 5.0 ± 1.1 h, length of hospitalization was 3.6 ± 1.2 days, and complication rate was 6.60%. The average hospitalization expenses of the FE group and IE group, respectively, were 32,069 ± 1086 RMB and 22,665 ± 899 RMB. There were significant differences in the surgical duration and hospitalization expenses (P < 0.01), but no differences between the two groups in postoperative bed rest time, length of hospitalization, or complication rates (P > 0.05). The postoperative Oswestry disability index and VAS were clearly improved in both groups compared with those of preoperation (P < 0.01). These two procedures have the same clinical outcomes (P > 0.05).ConclusionsBoth the full endoscopy technique and intermittent endoscopy technique achieved good outcomes, whereas the intermittent endoscopy technique is a more effective option for a shorter duration surgery and lower hospitalization expenses.

Full-Endoscopic Procedures Versus Traditional Discectomy Surgery for Discectomy: A Systematic Review and Meta-analysis of Current Global Clinical Trials

Background: Traditional discectomy surgery (TDS) provides good or excellent results in clinical surgical discectomy but may induce neural adhesion, spinal structural damage, instability, and other complications. The potential advantages of full-endoscopic (FE) procedures over standard TDS include less blood loss, less postoperative pain, shorter hospitalization, and an earlier return to work. However, more evidence is needed to support this new technology in clinical applications. Objective: The aim of this systematic review and meta-analysis was to compare the safety and efficacy of FE and TDS. Study Design: Comprehensive systematic review and meta-analysis of the literature. Methods: Electronic databases, including PubMed, EMBASE, SinoMed, and Cochrane Library, were searched to identify clinical therapeutic trials comparing FE to TDS for discectomy. Results: Six trials comprising 730 patients were included, and the overall quality of the literature was moderate, including 4 Grade I levels of evidence (4 randomized controlled trials, [RCTs]) and 2 Grade II levels (2 non-RCTs). The pooled data revealed no difference in reoperation rates between FE and TDS (P = 0.94), but the complication rate was significantly lower in the FE group (3.86%) than in the TDS group (11.4%). Perioperative parameters (operation time, blood loss, hospitalization time, and return to work days) were significantly lower in the FE group (P &lt; 0.05 for all groups using either score). Postoperative pain and neurology score assessments were conducted at 4 different time points at 3 months, 6 months, 12 months, and 24 months. Significant differences were detected in the following: lumbar North American Spine Society (NASS) pain at 6 months (P = 0.008); cervical NASS neurology at 6 months (P = 0.03); visual analog scale (VAS) score in leg at 3 months (P &lt; 0.001); VAS score in arm at 24 months (P = 0.002); VAS score in neck at 3 months, 6 months, and 12 months after therapy (P = 0.003, P = 0.004, P = 0.01); and VAS score in neck at 3 months and 6 months (P = 0.01, P = 0.004). Moreover, the pooled data revealed no statistically significant differences in improvements in the Oswestry disability index (ODI), instability (X-ray), and Hilibrand criteria (P &gt; 0.05 for all groups). Limitations: Only 6 studies were included, 4 of which had the same authors. Between-study heterogeneity due to differences in socioeconomic factors, nutrition, and matching criteria is difficult to avoid. Conclusions: Based on this meta-analysis of 24 months of clinical results, we conclude that the FE procedure is as effective as TDS but has the additional benefits of lower complication rates and superior perioperative parameters. In addition, patients may experience less pain with FE techniques due to a smaller incision and less operative injury. However, large-volume, well-designed RCTs with extensive follow-up are needed to confirm and update the findings of this analysis. Key words: Full-endoscopic, minimally invasive, discectomy, meta-analysis

Learning curve of full-endoscopic technique through interlaminar approach for L5/S1 disk herniations.

Although minimally invasive full-endoscopic (FE) spine surgery through the interlaminar approach has proved safe and effective for surgical treatment of lumbar disk herniation, the learning curve of the procedure has not been sufficiently established. The purpose of this study is to determine the learning curve for the FE surgery through interlaminar approach for treating the L5/S1 disk herniation. Thirty-six patients with lumbar disk herniation (L5/S1 segment) who underwent FE lumbar discectomy through the interlaminar approach between March 2011 and March 2012 were equally divided into Group A, B, and C by the study time of the surgeons. Clinical evaluation data included perioperative parameters (operative duration, intraoperative blood loss, and the amount of intraoperative bone and ligament excision), clinical curative effect index [visual analog scale (VAS) score for leg and back pain], complications, and the rate of conversion to open surgery. The operation duration, intraoperative bleeding, and the amount of bone and ligament excision were gradually and significantly reduced in the Groups A, B, and C (P < 0.01) and reflected in steep curves of proficiency suggesting that the rate of learning was fast. The VAS scores of leg and back pain were significantly improved (P < 0.01) and no symptomatic recurrence was noticed during the follow-up period (1-1.5 years). The outcomes the three groups were not significantly different. The clinical outcomes of the minimally invasive surgery for the treatment of L5/S1 segment disk herniation through the interlaminar approach were excellent suggesting of a satisfactory curative effect. The steep learning curves of perioperative parameters plotted against the number of surgeries conducted suggest that proficiency can be reached reasonably fast.

Full-endoscopic interlaminar approach for the surgical treatment of lumbar disc herniation: the causes and prophylaxis of conversion to open

Retrospective case series. To analyze the causes of conversion to open for the surgical treatment of lumbar disc herniation with use of full endoscopic (FE) technique, and prophylaxis of conversion to open also proposed. 50 patients with lumbar disc herniation underwent discectomy using unilateral portal FE interlaminar approach collected from August 2008 to August 2010. All FE operations were performed under general anesthesia and endotracheal intubation. According to the level incision of the ligament flavum, the starting point of nerve root at the dura under endoscopic view was classified as: Type I (starting point of the nerve root was higher than the incision) and Type II (the starting point of nerve root was lower than the incision). The causes and effective prophylactic measurements for cases of conversion to open were analyzed. There were 47 cases classified as Type I for a rate of 94 %, and Type II in 3 cases for a rate of 6 %. Five cases were converted to open surgery, and the conversion rate was 10 %. There were three males and two females with a mean age of 36.2 (29-44) years, the average duration of symptoms was 58.4 (35-105) days. The level was L5-S1 in four cases and L4-5 in one, lateral extrusion in three cases, paracentral extrusion in one, and sequestration in one. Leg pain resolved in three cases and improved in two after open surgery. Of five cases of conversion to open, misplacement of the working portal occurred in one case (Type I). Difficult dissection of nerve root and hemostasis resulting in open conversion occurred in one case (Type II); this patient sustained a dural injury. The nerve root could not be exposed in three cases (Type II), the FE changed to open finally. During the open procedure with Type II, we found that the location of origin of the nerve root was caudal to the inferior laminar edge. Therefore, partial removal of bony structures along lateral recess was necessary in order to visualize the nerve root. Misplacement of working portal during the exposure of the ligament flavum and difficulty in indentifying anatomy are potential causes for conversion to open in the initial adoption of FE technique. However, uncommon conditions such as variation of the nerve root origin can also result in conversion to open in experienced hands. Endoscopic experience, proper patient selection and specific radiographic examination are needed to obtain optimal outcomes using a full endoscopic technique for microdiscectomies.

An evaluation of the learning curve for a complex surgical technique: the full endoscopic interlaminar approach for lumbar disc herniations

Background context Compared with conventional microsurgical technique, the full endoscopic (FE) interlaminar approach is a more minimally invasive technique for the surgical treatment of lumbar disc herniations. Its efficacy and safety have been confirmed by numerous studies. However, a steep learning curve with the use of such a complex technique is a major concern for the initial adoption of this technique. Purpose To evaluate the learning curve of using an FE interlaminar technique for the surgical treatment of lumbar disc herniation. Study design A prospective study of patients with lumbar disc herniation who underwent discectomy via interlaminar approach assisted by FE instruments. Patient sample Thirty patients with lumbar disc herniation underwent discectomy using an interlaminar endoscopic-only approach between 2008 and 2009. Methods The patients were divided into three groups of 10 sequential cases each. Group A consisted of the first 10 cases, Group B the subsequent 10 cases, and Group C the last 10 cases. The clinical evaluation data included operative time, length of hospital stay, visual analog scale (VAS) leg and back pain scores, complications, and rate of conversion to an open. Results All patients were observed prospectively for 1.61±0.22 years (range, 1.2–2.0 years). There was no measurable intraoperative bleeding and postoperative infections in the three groups. Compared with Group A, the operative time in Group B was significantly decreased (p<.001). The patients in Group C had much less operative time than in Group B (p=.002). There was no significant difference with length of hospital stay in the three groups (p=.897). The improvement of VAS leg and back pain scores in each group was similar: there was a significant improvement (p<.01) at 3 months after surgery when compared with preoperative scores, but there was no statistical difference (p>.05) in the VAS leg and back pain scores between 3 months after surgery and final follow-up. The complication rate was 12.5% for Group A, 10% for Group B, and 0% for Group C. The need for conversion to an open procedure for Group A was 20% compared with zero cases in both Groups B and C. There were no symptomatic recurrences in our study. Conclusions Excellent clinical and minimally invasive outcomes can be obtained in the surgical treatment of lumbar disc herniation via the interlaminar approach assisted by FE technique. However, attention must be paid to the steep learning curve by using this complex technique. Imprecise anatomic orientation and manipulation inside the spinal canal are key factors in the steep learning curve. Obtaining microsurgical experience, attending workshops, and suitable patient selection can help shorten the learning curve and decrease the complications.

Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique: a prospective, randomized, controlled study

Extensive decompression with laminectomy where appropriate is often still described as the method of choice in surgery for lateral recess stenosis. Nonetheless, tissue-sparing procedures are becoming more common. Endoscopic techniques have become the standard in many areas because of the advantages they offer in surgical technique and in rehabilitation. Transforaminal and interlaminar access provide 2 full-endoscopic (FE) techniques for lumbar spine surgery. The goal of this prospective randomized controlled study was to compare the surgical results for the FE technique via the interlaminar approach with those of the conventional microsurgical technique in patients with degenerative lateral recess stenosis. A total of 161 patients with FE or microsurgical decompression underwent follow-up for 2 years. In addition to general and specific parameters, the following measuring instruments were used: visual analog scale, German version of the North American Spine Society instrument, and the Oswestry low-back pain disability questionnaire. The results show that 74.5% of patients reported no longer having leg pain, and 20.5% had only occasional pain. The clinical results were the same in both groups. The rate of complications and revisions was significantly reduced in the FE group. The FE techniques brought advantages in the following areas: operation, complications, traumatization, and rehabilitation. The clinical results of the FE interlaminar technique are equal to those of the microsurgical technique. At the same time, there are advantages in the operation technique, such as reduced traumatization. The FE interlaminar spinal decompression procedure is a sufficient and safe supplement and alternative to microsurgical procedures.