Interlaminar Approach Research Articles

Treatment of L₄,₅ lumbar disc herniation with percutaneous endoscopic lumbar discectomy through two different approaches

To analyze the clinical efficacy, indications and operative points of transforaminal approach and interlaminar approach in the treatment of L₄,₅ lumbar disc herniation. A retrospective analysis was performed on 48 patients with L₄,₅ lumbar disc herniation treated by percutaneous endoscopic lumbar discectomy from November 2016 to June 2018. Among them, 32 patients underwent percutaneous endoscopic transforaminal discectomy(PETD), including 17 males and 15 females, with an average age of (60.22±16.55) years, and the course of disease was(2.18±2.68) months;16 patients underwent percutaneous endoscopic interlaminar discectomy(PEID), including 7 males and 9 females, with an average age of (42.25±15.89) years, and the course of disease was(2.90±3.02) months. VAS, ODI of two groups before operation, 3 days, 3 months, and 6 months after operation were analyzed, and modified Macnab standard was used to evaluate the clinical effects. All the 48 patients successfully completed the surgical treatment, and all patients were followed up. There was no significant difference in gender, course of disease and follow-up time between two groups (P>0.05). The age of PETD group was(60.22±16.55) years and PEID group was (42.25±15.89) years, there was statistical difference between two groups (P<0.05 ). In the PETD group, there were 10 patients with advanced age, non-free type(24 cases) was more than free type(8 cases), and shoulder type(27 cases) more than axillary type(1 case) and ventral type(4 cases). PETD was used in 5 patients with lateral type and 2 patients with extreme lateral type. In PEID group, the axillary type(8 cases) was more than the shoulder type(2 cases) and the ventral type(6 cases), PEID was used in 4 patients with high prolapse free type(I and IIregions). VAS scores and ODI of patients in two groups at each postoperative follow-up point were significantly improved compared with those before surgery(P<0.05). According to modified Macnab standard to evaluate the clinical effect, in PETD group, 24 cases obtained excellent results, 5 good, 2 fair, 1 poor, while in PEID group, 12 excellent, 3 good, 0 fair, 1 poor. Both two surgical approachs can achieve satisfactory efficacy in treating L₄,₅ lumbar disc herniation, but PETD is more suitable for elderly patients, non-free type, lateral type, extremely lateral type and shoulder type of lumbar disc herniation. High prolapse(I and II regions) and axillary type lumbar prominent should select PEID.

Percutaneously full endoscopic decompressive laminectomy with precise localization for the treatment of lumbar spinal stenosis

To explore the feasibility of full endoscopic fenestration (FE-FE) via interlaminar approach for the treatment of lumbar spinal stenosis (LSS), and meanwhile, to analyze the related practicability and clinical outcome. Referring to the traditional laminectomy and decompression, the lumbar spinal canal decompression was performed by using the water-medium spinal endoscopy (named FE-FE technique). Thirty-seven patients with LSS treated by FE-FE technique were retrospectively analyzed. There were 19 males and 18 females, aged from 55 to 83 years old with an average of (67.1±18.9) years. Visual analogue scale(VAS), Japanese Orthopaedic Association Scores(JOA), Oswestry Disability Index (ODI) and 36-Item Short-Form Health Survey (SF-36) were recorded. The patient's conscious pain and recovery of neurological function were observed, and the clinical efficacy was evaluated according to the improvement rate of JOA score. All 37 patients were followed up for 8 to 24 months with an average of (13.7±6.1) months. The postoperative follow-up and clinical evaluation for conscious pain and neurological function recovery showed that VAS, JOA, ODI and SF-36 scores were significantly improved compared with those before surgery(P<0.05). According to the improvement rate of JOA score to evaluate the clinical effects, at 6 months after opertion, the results were excellent in 17 cases, good in 13 cases, fair in 5 cases, and poor in 2 cases;and the last follow-up, the results were excellent in 19 cases, good in 13 cases, fair in 4 cases, and poor in 1 case. Postoperative imaging showed significant expansion of spine canal volume, and the followed-up clinical symptoms were improved satisfactorily, with the relief of lumbago and leg pain, improvement of daily life quality, and increased adaptability to social activities and no serious complications. Precise localization is the key to complete the canal decompression under full endoscopic surgery. FE-FE technique can effectively enlarge the narrow lumbar canal with less trauma, positive efficacy, safety and reliability. FE-FE has a broad application prospect though large cases and multi-center studies need to be further carried out.

Using a percutaneous spinal endoscopy unilateral posterior interlaminar approach to perform bilateral decompression for patients with lumbar lateral recess stenosis

To report the clinical and radiographic outcomes of 47 patients with bilateral symptomatic lumbar lateral recess stenosis (LLRS) treated with percutaneous spinal endoscopy (PSE) via a unilateral posterior interlaminar approach with bilateral decompression. Forty-seven patients with single-level LLRS and bilateral symptoms who underwent PSE using a unilateral posterior interlaminar approach to perform bilateral decompression between May 2014 and June 2016 were reviewed retrospectively. Surgical-related data were collected, and clinical efficacy was evaluated using the Visual Analogue Scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the single continuous walking distance (SCWD) without pain at preoperative and postoperative time points. Patient satisfaction was evaluated by modified MacNab criteria at the one-year postoperative time point. All patients displayed improvements in clinical symptoms after surgery and were discharged the day of surgery. The mean operation time and blood loss were 91.17±16.81min and 13.53±4.94mL, respectively. At a mean follow-up of 18.33±4.16 months, none of the patients required reoperation, while 6 of 47 patients experienced complications. VAS scores for back and leg pain, ODI, and SCWD were significantly improved at all postoperative time points compared with the preoperative values. Satisfactory (excellent or good) results were demonstrated in 44 of 47 patients (93.6%) at the one-year postoperative time point. The percutaneous spinal endoscopic technique via a unilateral posterior interlaminar approach for performing bilateral decompression is a less invasive, effective and safe surgery and can be considered an alternative option for treating patients with bilateral symptomatic LLRS.

Quantitative assessment of steroid amount in the tissue after epidural steroid injection: a new rabbit model.

BackgroundTo develop a rabbit epidural steroid injection (ESI) model for analyzing steroid retention in the tissue, and to assess the difference in steroid retention in the model according to the location and time elapsed after ESI.MethodsFluoroscopy-guided ESI was performed using the interlaminar approach between the lowest two lumbar segments in 13 female New Zealand white rabbits. Four rabbits were allocated to each of three different groups according to the time of sacrifice: 3, 7, and 15 days post-ESI; the remaining rabbit was sacrificed immediately post-ESI to obtain baseline data. After sacrifice, two segments were harvested: the lowest two lumbar vertebrae and another two lumbar vertebrae immediately above these. The residual steroid amount (RSA) and residual steroid concentration (RSC) in the collected spinal columns were analyzed. A linear mixed model was used to compare RSAs and RSCs between the injected and adjacent segments, and among the number of days until sacrifice; P < 0.05 was considered statistically significant.ResultsBoth RSA and RSC of the injected segment were significantly higher than those of the adjacent segment (P < 0.001, both). The RSA and RSC significantly decreased over time (P = 0.009 and P = 0.016, respectively).ConclusionsThe developed rabbit ESI model verified that significantly more steroid was retained at the injected segment than at the adjacent segment and the residual steroid decreased over time. This model could be useful not only for comparing current steroid medications, but also for developing new, better steroid formulations.

Incidence and pattern of epidural spread during lumbar facet joint injection: a prospective study.

BackgroundIn clinical practice, we have often observed contrast material spreading into the epidural space during lumbar facet joint injection. However, the exact incidence of epidural spread and contrast pattern have not been reported.PurposeTo evaluate the incidence and pattern of epidural spread in lumbar facet joint injection.Material and MethodsOne hundred consecutive patients (38 men, 62 women; mean age 68 years; age range 20–88 years) who underwent lumbar facet joint injection at two sites between April 2014 and June 2014 were investigated in this prospective study. Initial oblique, final anteroposterior, and lateral fluoroscopic images were obtained and evaluated for the presence of epidural spread and its contrast pattern (based on direction and extent) with the consensus of three radiologists. The relationship between epidural spread and its potential predictors was analyzed using the chi-squared test, Fisher’s exact test, and the t-test.ResultsThe incidence of epidural spread during lumbar facet joint injection was 64.6% (n=64) in 99 patients and 49.5% (n=95) in 192 procedures; ventral spread occurred in 29.2% and foraminal spread in 18.8%. When epidural spread occurred, the most commonly identified distributions were unilateral (73.7%), dorsal (92.6%), and cephalad (92.6%). Epidural spread increased significantly in the caudocephalic direction ( P &lt; 0.0001), in men (relative risk [RR]=1.478), in the adjacency of posterior fusion level (RR=1.545), in patients with spondylolisthesis (RR=1.454), and when there was no other leakage (RR=0.334).ConclusionEpidural spread occurred at about half the number of lumbar facet joint injections and showed a contrast pattern similar to that seen with the interlaminar approach.

Current techniques of endoscopic decompression in spine surgery.

Endoscopic spine surgery has become a practical, minimally invasive technique for decompression in patients with spinal disc herniation or stenosis. This review aimed to summarize the current techniques of endoscopic decompression technique in spine surgery and to discuss the benefits, limitations, and future perspectives of this minimally invasive technique. Endoscopic spine decompression surgery can be categorized according to the endoscopic property: percutaneous endoscopic (full-endoscopic), microendoscopic, and biportal endoscopic. It can also be classified based on the approach: transforaminal, interlaminar, anterior, posterior, and caudal approaches. Theoretically, each technique can be applied in the lumbar, cervical, and thoracic spine. The various endoscopic spine surgery techniques should be appropriately conducted according to the disease entities, level, and zone of pathologies. Although the current level of evidence is relatively low and the relevance of the technique is controversial, recent clinical results and the critical concept are promising. Development in optics, instruments, and approach will improve its safety and reduce technical complexity. In the meantime, high-quality clinical studies, including randomized trials and meta-analyses, are due for publication. Eventually, endoscopic spine surgery is expected to become the golden standard for spinal surgery.

Treatment of L5 - S1 intervertebral disc herniation with posterior percutaneous full-endoscopic discectomy by grafting tubes at various positions via an interlaminar approach

BackgroundDepending on the location of the herniated disc at the shoulder, axilla, or ventral side of the compression nerve root, various puncture sites and channel entrances were selected so that the goal of targeted removal of the herniated disc could be achieved by a full-endoscopic technique. Achieving good clinical therapeutic efficacy through the natural gap of bones can maximally avoid related access complications, and the necessary techniques and relevant anatomical factors were analyzed.MethodsBetween August 2012 and August 2014, 98 patients with L5 - S1 intervertebral disc herniation were treated with posterior percutaneous full-endoscopic discectomy (PPFED) by grafting tubes at various positions via the interlaminar approach. The visual analog scale (VAS) and the Oswestry disability index (ODI) were used to assess the patients’ back and leg pain and the improvements in daily function, and the modified Macnab standard was used to evaluate the treatment efficacy.ResultsAll 98 patients successfully completed the surgery, 84 patients got out of bed and walked on the first postoperative day, and 14 patients got out of bed and walked on the second postoperative day. The preoperative ODI (56.032 ± 3.625) was significantly higher than the ODI score (8.147 ± 1.398) (F = 5343.054, P ≤ 0.001) 48 months after surgery. The preoperative VAS score (7.193 ± 0.875) was significantly higher than the postoperative VAS score (0.914 ± 0.500 points) (F = 1656.173, P ≤ 0.001). The differences in ODI and VAS scores before and after surgery were statistically significant (P < 0.05). Follow-up was conducted 1, 6, 12 and 48 months postoperatively, and the modified Macnab standard was used during the last follow-up to evaluate the efficacy: 67 cases were excellent, 20 cases were good, 7 cases were fair, and 0 cases were poor; the proportion of excellent and good cases was 92.6%.ConclusionsThe treatment of L5 - S1 intervertebral disc herniation with PPFED by grafting tubes at various positions via an interlaminar approach is a safe, effective, and minimally invasive surgical method. Reaching the location of a disc herniation directly through the natural gap in the bones can maximally avoid collateral injury from spine surgery.Trial registrationThe registration number of this clinical study is ChiCTR1800014588; it has been retrospectively registered with a registration date of 05/01/2018.

Intrathecal administration of nusinersen in adult and adolescent patients with spinal muscular atrophy and scoliosis: Transforaminal versus conventional approach

Spinal deformities and surgical correction of scoliosis can make intrathecal delivery of nusinersen very challenging. We aim to evaluate the feasibility and safety of intrathecal administration of nusinersen either via interlaminar or transforaminal approach in a cohort of adult and adolescent patients with spinal muscular atrophy (SMA). Twelve patients were treated with nusinersen in our center under CT-guidance; after a CT scan of the lumbar column, we identified a safe virtual trajectory for the needle and defined patients to address to the transforaminal approach (seven patients) or the interlaminar approach (five patients). Out of 47 procedures, all injections but one were successful. There was one adverse event (post-lumbar puncture syndrome) in the interlaminar approach group (out of 20 procedures) and four adverse events in TFA group (out of 27 procedures) including one serious adverse event, a subarachnoid hemorrhage that required hospitalization. Transforaminal approach can be considered an effective option for nusinersen administration but potentially associated with serious complications, therefore it should be recommended in very selected patients.

Clinical observation of the low back pain and posterior thigh pain in the early stage after percutaneous endoscopic lumbar discectomy

Objective: To evaluate the incidence, causes and prognosis of the low back pain and posterior thigh pain in the early stage after percutaneous endoscopic lumbar discectomy (PELD). Methods: A total of 88 patients who underwent PELD from December 2017 to June 2018 in the First Affiliated Hospital of Anhui Medical University were enrolled in this study. PELD was performed by posterior-lateral approach and the interlaminar approach in 44 cases, respectively. During the 3-month of follow-up post PELD, the number of cases who suffered low back pain and posterior thigh pain, complications and postoperative treatments were all followed and evaluated. Results: All the 88 cases underwent PELD successfully. Twelve cases (27.3%) suffered low back pain after PELD by posterior-lateral approach totally, 4 patients (9.1%) were new cases and the low back pain aggravated after PELD in the other 8 cases (18.2%). The posterior thigh pain occurred in 9 cases (20.4%) after PELD in posterior-lateral approach group, of them, 5 patients (11.4%) were new cases and it was aggravated in 4(9.1%) cases after the surgery. As for the low back pain after PELD performed by the interlaminar approach, 7(15.9%) cases suffered low back pain and 1 case (2.3%) occurred after surgery. The posterior thigh pain happened in 5 cases (11.4%) after PELD in the interlaminar approach group, 2 cases (4.6%) were new cases and the pain was aggravated in 3 cases (6.8%) after surgery. According the classification of MacNab, 42 of 88 cases were classified excellent, 25 cases good, 17 cases fair and 4 cases poor after PELD. Totally 18 cases were classified into fair and poor because of the low back pain or the posterior thigh pain during the follow-up. Furthermore, none of 88 cases had infection or nerve root injury after surgery. All cases suffering the low back pain or the posterior thigh pain treated conservatively and no one needed surgery again. Conclusions: The pain in low back or posterior thigh may be one of the complications after PELD, and it can be treated conservatively. Incidence of the low back pain or the posterior thigh pain after PELD with posterior-lateral approach is higher than that in patients with interlaminar approach, and it may affect the efficacy of PELD.

Conventional Image-Guided Procedures for Painful Spine.

This article reviews image-guided approaches for the treatment of common spine pain generators. The following treatment targets are discussed: epidural space (interlaminar and transforaminal approaches), facet joint, sacroiliac joint, and synovial cysts.

Intradural lumbar disc herniation after full-endoscopic lumbar discectomy using the interlaminar approach: case report

Intradural lumbar disc herniation after full-endoscopic lumbar discectomy using the interlaminar approach: case report

Full-Endoscopic Interlaminar Lumbar Discectomy: Retrospective Review of Clinical Results and Complications in 545 International Patients

Minimally invasive techniques have been developed to provide access to the disc with better visualization while causing less muscle trauma and its consequences. This study was aimed at evaluating the clinical outcomes and complications of the fully endoscopic lumbar discectomy interlaminar approach in a large number of patients. Patients diagnosed with lumbar herniated nucleus pulposus who underwent fully endoscopic interlaminar lumbar discectomy between 2011 and 2016 were reviewed. Perioperative data, preoperative and postoperative Oswestry Disability Index (ODI) scores, visual analog scale (VAS) back pain scores, VAS leg pain scores, and complications were evaluated and recorded at 1 week and 3 and 6 months postoperatively and each year thereafter. The study cohort comprised 545 patients (average age, 46.43 years; 34.31% female). The affected levels were L2-3 in 1.47%, L3-4 in 6.96%, L4-5 in 49.45%, andL5-S1 in 44.69%. Mean preoperative ODI, VAS back pain score, and VAS leg pain score were 43.00%, 5.00, and5.69,respectively. Postoperative ODI at 1 month wasreduced to15.59% and remained within a range of 14.83%18.32%throughout follow-up. Postoperative VAS back and leg pain score results at 1 week were decreased to 1.66 and 1.79, respectively, and remained at 1.89-3.14 and 1.59-2.66, respectively, throughout follow-up. Sixty-six recurrences (12.11%) were diagnosed. Intraoperative complications were nerve root-related (n= 3) and dural tear (n= 1). Postoperative complications included numbness (n= 18), weakness (n= 5), and residual disc (n=1). No infections or hematomas were reported. Fully endoscopic interlaminar lumbar discectomy is a safe, effective option for treating lumbar disc herniation, with a long recurrence-free recovery.

Symptomatic Lumbar Juxtafacet Cyst Treated by Full Endoscopic Surgery

Juxtafacet cysts (JFCs) include both synovial and ganglion cysts adjacent to a spinal facet joint or arising from the ligamentum flavum of the spinal facet joints. Various treatments have been proposed; however, a surgical approach appears to be most effective. The aim of this study was to review patients with lumbar JFCs treated using a full endoscopic approach and elaborate the details of the surgical routes and techniques and their merits and pitfalls. All patients with lumbar JFCs underwent complete endoscopic cyst removal. Muscle power, visual analog scale score, modified MacNab criteria score, and magnetic resonance imaging were assessed during follow-up. The study enrolled 8 patients. Five patients received an interlaminar approach, 2 patients received a transforaminal approach, and 1 patient received a transfacet approach. Visual analog scale scores decreased from a mean of 7.75 (range, 5-10) before surgery to 0.625 (range, 0-2) after surgery, and modified MacNab criteria score ranged from good to excellent after surgery. No neurologic injuries were observed. JFCs could be effectively treated by full endoscopic surgery. The type of approach should be based on the anatomic site of the lesion and the condition of the patient. The interlaminar approach is appropriate for cysts located in the lower segment with larger interlaminar space. The transforaminal or transfacet approach is preferred for patients for whom general anesthesia is a high risk.

Experimental Model for Interlaminar Endoscopic Spine Procedures

Endoscopic spinal surgery is becoming quite popular, and the pursuit of a training model to improve surgeons' skills is imperative to overcome the limited availability of human cadavers. Our goal was to determine whether the porcine spine could be a representative model for learning and practicing interlaminar percutaneous endoscopic lumbar procedures (IL-PELPs). Lumbar and cervical segments of the porcine cadaver spine were used for the IL-PELP. We have described the technical notes on the difficulties of the procedure and the relevant anatomical features. To endorse the porcine cadaver for this procedure, 5 neurosurgeons underwent 1 day of training and completed a survey. The porcine lumbar spine has small interlaminar windows, and laminectomy is necessary, mimicking the translaminar approaches for higher human lumbar spine levels. The porcine cervical spine has wide and high interlaminar windows and mimics the human L5-S1 interlaminar approach. Entering the spinal canal with the working sheath and endoscope and training the rotation maneuver to access the disc space is only possible in the lumbar segment. It was possible to perform flavectomy and to identify and dissect the dural sac and nerve root in both the lumbar and cervical spine. The neurosurgeons considered the porcine model of good operability and, although different, possible to apply in humans. The porcine spine is an effective and representative model for learning and practicing IL-PELPs. Although the described anatomical differences should be known, they did not interfere in performing the main surgical steps and maneuvers for IL-PELPs in the porcine model.

Full-Endoscopic Decompression for Lumbar Lateral Recess Stenosis via an Interlaminar Approach versus a Transforaminal Approach

To compare the results of full-endoscopic decompression (FED) in lumbar lateral recess stenosis via an interlaminar or transforaminal approach. A total of 102 patients with lumbar lateral recess stenosis who underwent FED from February 2015 to June 2016 in our hospital were enrolled. A total of 58 patients underwent interlaminar FED (IL-FED) and 44 patients underwent transforaminal FED (TF-FED). The intraoperative radiation and operation time, length of hospital stay, time to return to work, and complications were compared between both groups. The surgical effectiveness was assessed according to the visual analog scale, Oswestry Disability Index, and modified MacNab criteria. In the IL-FED group, the mean operation time was 59.4 ± 8.5 minutes, and the intraoperative radiation time was 0.50 ± 0.16 seconds. In the TF-FED group, the mean operation time was 64.1 ± 10.2 minutes, and the intraoperative radiation time was 7.50 ± 1.25 seconds. There were significant differences in the operation and radiation time between the 2 groups (P < 0.01). There was no significant difference in the visual analog scale and Oswestry Disability Index scoring between both groups either in the pre- or postoperation (P > 0.05). Based on the modified MacNab scores at the final follow-up, the satisfactory rate in the IL-FED group was 91.4% and that in the TF-FED group was 88.6%, no significant difference was observed between the 2 groups (P > 0.05). FED could provide satisfactory clinical outcomes for lumbar lateral recess stenosis. However, the IL-FED procedure demonstrated shorter operation time and lesser radiation exposure, but higher risk for anesthetic when compared with the TF-FED procedure.

Retrospective study of the interlaminar approach for percutaneous endoscopic lumbar discectomy with the guidance of pre-operative magnetic resonance neurography.

To measure the direct effects of pre-operative magnetic resonance neurography (MRN), and analyze the procedure and clinical outcomes of the percutaneous endoscopic interlaminar discectomy, in order to demonstrate the feasibility and safety of the interlaminar approach. In this study, 127 patients who underwent percutaneous endoscopic lumbar discectomy (PELD) and were followed up by more than 12 months, were retrospectively evaluated. The pre-operative demographic data were collected. In addition, the coronal scan and the reconstruction of the lumbosacral plexus were examined to measure the distance between the nerve root and the dural sac at the coronal plane. Furthermore, the post-operative and pre-operative visual analog scale (VAS) scores and Oswestry Disability Index (ODI) were compared. The mean and minimum values of distance T between the nerve root and dural sac of L5/S1 to L2/3 on the operation side of the MRN images were all larger than 7.3 mm which is the diameter of the working canal. During the follow-up, VAS and ODI data improved significantly compared with their corresponding pre-operative scores (P<0.01). Regarding the post-operative complications, there were 2 (1.57%) cases of hypesthesia and 3 (2.36%) cases of neuropathic pain, which were transient and alleviated in 3 months. In addition, there was 1 (0.79%) case of intervertebral space infection and 1 (0.79%) dural tear. No relapse of disc herniation and iatrogenic instability occurred by the end of the last follow-up. The MRN indicates that the incidence of herniated disc impingement increases over the distance between the nerve root and the dural sac, thus making the interlaminar approach more suitable for the treatment of herniation. The procedures and clinical outcomes of the IL-PELD demonstrate the safety and advantages of the interlaminar approach.

Unilateral Epidural Blockade for Lower Limb Fracture Surgery: Parasagittal Epidural Versus Midline Epidural Anesthesia.

Objective:To compare the efficacy of parasagittal interlaminar (PIL) and midline interlaminar (MIL) approaches for epidural block in patients with lower limb orthopedic surgery. Methods:This double-blind randomized clinical trial was performed on 40 patients undergoing tibial shaft fracture surgery. In PIL group, an 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L2-3 or L3-4 intervertebral spaces and pushed forward in a posteroanterior (PA) direction vertical to the body surface. After determining the most lateral place for needle arrival in an anteroposterior (AP) view, needle was pushed forward into the epidural space. For the MIL group, needle was pushed forward from the midline interspinous space with the same method. After confirmation of needle position, 1 mL of contrast was injected to confirm the epidural space distribution and then 15 ml lidocaine 2% was injected. The sensory and motor block level, onset, duration, heart rate (HR), mean arterial pressure (MAP), and arterial oxygen saturation (SPO2), and success rate were recorded. Results:Mean patients’ baseline characteristics showed no statistically significant difference between the two groups.p>0.05). Outcome measures were statistically different and significantly higher in PIL group (p-values for sensory block level <0.001, motor block level <0.001, duration of sensory block: <0.001 and duration of motor block <0.001 and success rate: <0.001). Hemodynamic variables didn’t show statistically significant difference between the two groups (p-values for Systolic pressure: 0.997, diastolic pressure:0.579, MAP:0.585, HR:0.710).Conclusion:Epidural anesthesia with parasagittal interlaminar approach provide deep motor block, high sensory level block, and hemodynamic stability.Clinical trial registry: IRCT2017041615515N2

Using Percutaneous Endoscopic Outside-In Technique to Treat Selected Patients with Refractory Discogenic Low Back Pain

Background: Controversy is not uncommon in the diagnosis of discogenic low back pain (DLBP) and in the identification of the location of the pain source for the symptomatic disc in patients with DLBP. Various techniques, from minimally invasive procedures to fusion surgery, are used to treat chronic DLBP, but the clinical outcomes are variable. Percutaneous endoscopic discectomy by transforaminal or interlaminar approach is considered to be an effective method to treat DLBP, but the evidence is limited; the lack of clear evidence may be associated with patient selection and surgical technique. Objectives: The purpose of this study is to evaluate the clinical results of percutaneous endoscopic treatment for annular tear in selected patients with DLBP by using the outside-in technique. Study Design: A prospective study and retrospective observations were performed on 24 consecutive patients with a minimum 2 years of follow-up. This study was approved by the Institutional Review Board (IRB) of Buddhist Dalin Tzu-Chi General Hospital Foundation (IRB number: 10504004) and written informed consent was obtained from all patients. Setting: This research took place within an interventional pain management and spine practice. Methods: Twenty-four consecutive patients with single-level DLBP diagnosed by positive highintensity zone on magnetic resonance imaging, positive provocative discography, and block test underwent a percutaneous endoscopic procedure from January 2014 to December 2015. The transforaminal approach or interlaminar approach was selected according to the location of the annular tear. The torn lesions were visualized directly and treated by puncture and debridement of the inflammatory tissues from the outer annulus fibrosus to the inner nucleus using the outsidein technique. The Visual Analog Scale (VAS) score and Oswestry Disability Index (ODI) score were evaluated before and after surgery. The clinical global outcomes were assessed on the basis of modified MacNab criteria. Results: These patients included 13 men and 11 women with a mean age of 43.8 years (range, 32-55 yrs). There were 15 lesion levels at L4/L5 and 9 lesion levels at L5/S1. Among them, 15 levels were accessed by transforaminal approach and 9 levels by interlaminar approach. No serious complications were observed during the follow-up periods. All except 2 patients experienced significant symptomatic and functional improvements at the 2-year follow-up with a success rate of 91.7%. Limitations: Significant limitations include nonrandom format and small sample size. Future research may focus on controlled prospective studies with larger sample sizes and long-term followup to examine the validity of this protocol. Conclusions: The percutaneous endoscopic procedure provides a safe and effective treatment for selected patients with DLBP. The outside-in technique allows the surgeons to visualize and treat the torn or inflammatory lesions directly, and the success rate is high at 2 years follow-up. Key words: Transforaminal, interlaminar, outside-in technique, endoscopic discectomy, discogenic low back pain

Dispersal Pattern of Injectate After Cervical Epidural Steroid Injection Evaluated With Magnetic Resonance Imaging

Study Design:Prospective, nonrandomized, clinical study.Objective:Epidural steroid injections (ESIs) are an important diagnostic and treatment modality for spine pathology. The success of these injections has been attributed to the anatomic location reached by the injectate. This study evaluates injectate dispersal patterns after cervical interlaminar ESI using magnetic resonance imaging (MRI).Methods:Patients between the ages of 18 and 85 years with cervical radiculopathy were identified. After obtaining consent for study participation, a gadolinium-enhanced cervical ESI was administered via an interlaminar approach under fluoroscopic guidance. Study participants underwent a cervical spine MRI within 15 minutes of administering the injection. Craniocaudal dispersal and the presence or absence of circumferential dispersal was assessed.Results:The injectate dispersed a mean of 8.11 cm in the cranial direction, 6.63 cm in the caudal direction, and 360° circumferentially. No adverse events related to the ESI were reported.Conclusions:Fluoroscopy-guided cervical interlaminar ESI resulted in nearly uniform circumferential dispersal within the epidural space with multilevel migration in the cranial and caudal directions. MRI is a safe and accurate tool to evaluate spinal injectate dispersal.

A Novel Biportal Full Endoscopy Technique for Lumbar Lateral Recess Stenosis: Technical Report.

Full endoscopy spine surgery is one of the minimally invasive procedures for lumbar spine disease and is especially popular in East Asia. As for the interlaminar approach, lumbar recess stenosis can be manipulated through a uniportal bigger diameter working channel spinal endoscope or a smaller one, or a biportal arthroscope. Each kind of procedure has its advantages and shortcomings. Here, a novel experience in biportal interlaminar approach for lumbar recess stenosis is presented. A smaller uniportal spinal endoscope is adopted for biportal procedures rather than the arthroscope. Briefly, 2 spinal endoscope working tubes are placed onto the interlaminar window of the target segment. Both of the 2 working tubes can serve as either a viewing or working channel, which means that more flexible visual fields and instrument manipulation can be used during the procedures. Bigger surgical instruments can be used directly through one working tube, and the visual field can be provided by the spinal endoscope in the other working tube. Smaller surgical instruments can be used at the same time through the working channel of the endoscope. The 2 working tubes can change their roles according to the surgeon's needs. This paper will describe the surgical technique and perioperative management.