Minimally Invasive Spine Surgery Research Articles

How I do it: biportal endoscopic spinal surgery for revision of adjacent segment disease after instrumented lumbar fusion.

Lumbar fusion with rigid fixation can be complicated by adjacent segment degeneration, which may cause neurological deficits and back pain, and occasionally necessitates revision surgery. This type of revision surgery is difficult to perform in a minimally invasive manner because it requires the revision of the original internal fixation instruments. We describe a biportal endoscopic spinal surgery (BESS) procedure for revision surgery due to adjacent segment disease after lumbar fusion with rigid fixation instruments. The radiological images and complete surgical procedure are presented. BESS effectively enabled nerve decompression, intervertebral fusion, and revision of lumbar fusion with fixation instruments in a minimally invasive manner.

Lumbosacral Interbody Fusion Using a Biportal Endoscopic Technique for Patients with Multilevel Severe Degenerative Lumbosacral Spondylosis: Technical Note and Case Presentations.

Open decompression and posterior interbody fusion are standard surgical interventions for multilevel degenerative lumbosacral spondylosis (DLS). Despite their clinical efficacy, intraoperative and postoperative complications have led to the demand for a minimally invasive approach. A biportal endoscopic approach is an advanced minimally invasive surgical option. The data of two patients with multilevel DLS who had undergone biportal endoscopic spine surgery (BESS) were retrospectively analyzed. Parameters such as surgical difficulty, duration of operation, blood loss, length of hospital stay, and postoperative complications were reviewed. Pain and functionality were assessed using the visual analog scale (VAS) and the Oswestry Disability Index (ODI), respectively. Both patients were women and aged 75 and 73 years; they complained of back pain, claudication, pain and weakness in the lower extremities, and gait disturbance. The symptoms lasted 5 and 8 years, respectively. The multilevel BESS approach was applied bilaterally. Dissection, laminofacetectomy, decompression, excision, cage insertion, and screw implantation were performed. The operation durations were 170 and 160 minutes with blood loss of 500 and 650 mL, respectively. Back pain, leg pain, and ODI scores significantly improved; no pseudoarthrosis or additional neurologic deficits were noted on follow-up. The presented BESS technique is a minimally invasive treatment option for patients with multilevel DLS, which typically requires a complicated surgical approach. Randomized controlled studies with larger sample sizes and longer follow-up periods are needed to verify the superiority of this operation.

Minimally invasive mini-hemilaminectomy-corpectomy in cadaveric dogs: evaluation of the accuracy and safety of a three-dimensionally printed patient-specific surgical guide

BackgroundAs the frequency of spine surgery increases in the veterinary field, many studies have been conducted on minimally invasive spine surgery (MISS). Although many studies have been conducted on the thoracolumbar spine about MISS in animals, several problems and limitations have emerged regarding this method. Therefore, we developed a three-dimensional (3D) printed patient-specific surgical guide (3DPSSG) using 3D printing technology to overcome these problems. We aimed to evaluate the accuracy and safety of the 3DPSSG in minimally invasive mini-hemilaminectomy-corpectomy (MI-MHC).MI-MHC using 3DPSSG and an endoscopic system was performed at L1–L2 in 15 cadaveric dogs. The procedure of fixing the surgical guide to the vertebral body through screws and the surgical procedure using the guide were performed by two surgeons with different experiences. Postoperative computed tomography was used to measure planned and postoperative screw trajectories (angle, protruding from the far cortex) and to create 3D rendering images of vertebrae to evaluate the direction of bone window formation, corpectomy slot length, depth, and height ratio.ResultsThe two groups which performed by two surgeons with different experiences did not differ in terms of screw angle deviation and length of the screw protruded from the far cortex. The corpectomy slot-length ratio was not different between the two groups; however, the slot-depth and height ratios were different.ConclusionsNo differences were detected in screw trajectory and corpectomy slot-length ratio between the two groups. The 3DPSSG for MI-MHC is classified as accurate and safe; therefore, it can be an alternative to the conventional technique in dogs.

Biportal endoscopic spine surgery for cervical disk herniation: A technical notes and preliminary report.

Biportal endoscopic spine surgery (BESS) for cervical disk herniation (CDH) has been rarely reported. The aim of the article is to describe a novel BESS as a posterior approach for CDH and report the preliminary outcomes and complications. This single-centered retrospective chart review included 109 consecutive patients who underwent BESS for symptomatic single-level CDH. Working and viewing portals were created in each unilateral paravertebral area at the target disk level. Endoscopic exploration allowed for effective and minimally invasive decompression via safe access to the medial foramen with minimal laminectomy and facetectomy. Clinical outcomes, including the visual analog scale, neck disability index, Macnab criteria, and the motor function of the involved arm, were evaluated at 4, 8, 12, and 24 postoperative weeks. Visual analog scale and neck disability index improved significantly at 24 weeks postoperatively (P < .01). According to the Macnab criteria, “excellent,” “good,” and “fair” results were obtained for 55.9%, 30.3%, and 13.8% of patients, respectively. The post 24-week distribution of the involved upper extremity strength grade was significantly improved compared to the initial value (P = .02). One patient had a motor weakness with a decreased grade over 4 weeks from excessive irrigation. The posterior approach of BESS was efficient and feasible for the treatment of CDH.

Minimally Invasive Surgery for Spinal Metastases

The incidence of metastatic spine disease (MSD) is on the rise and is currently present in 70% of patients presenting with systemic cancer. The majority of patients with MSD present with clinical symptoms such as neurological deficit, pathological fracture causing pain and spinal instability. Management of MSD is a multidisciplinary endeavor that involves surgery, radiotherapy (RT), and chemotherapy. The conventional open spine surgery approach has evolved into a less invasive surgery model categorized as minimally invasive spine surgery (MISS) or minimal access spine surgery. This evolution was brought about to address the complications associated with open surgery such as longer hospital stays and wound-related problems. MISS has been now widely explored in MSD due to lower wound-related complications, decreasing operative time, less neurological complications, and shorter hospital stays. Decompression and stabilization still remain the core concepts in MISS. Kyphoplasty/vertebroplasty, percutaneous pedicle screw fixation, separation surgery, and radiofrequency ablation are some of the minimally invasive techniques and procedures for surgical management of MSD. MISS is used in conjunction with other modern techniques like intraoperative neuromonitoring to help identify any adverse neurological events. MIS techniques will evolve with time, extending their application for the management of hypervascular tumors with significant anterior cord compression and recurrent tumors in which the open surgery currently remains the choice of approach.

Effectiveness and outcome of spinal decompression surgery in overweight and obese patients

Objectives: Minimal invasive spinal surgery (MISS) is a relatively new surgical approach that minimizes tissue damage, reduces blood loss, and promises faster post-operative recovery compared to the traditional open approach. The current retrospective study aimed to assess and compare the surgical time, blood loss during the procedures, post-operative mobility, hospital stay, post-operative pain, and post-surgery patient satisfaction between the two groups. Methods: Forty patients who underwent decompression procedures at our institute were included in this retrospective study. The patients were interviewed by a phone call by a single coinvestigator 1 year after surgery to survey their satisfaction. Results: Thirteen patients (32.5%) underwent MISS and 27 (67.5%) underwent traditional surgery. The mean operative time and blood loss volume for MISS and traditional surgery were found to be 166.08 ± 44.75 min and 193.14 ± 58.67 min, and 69.23 ± 25.31 mL and 367 ± 451.5, respectively. The hospital stay was 3.62 ± 1.38 days for the MISS and 6.48 ± 4.57 days for the traditional surgery. Post-operative mobilization was found to be the 1st day for MISS and the 1.78th day for the traditional surgery group. Statistical significance difference (P &lt; 0.05) was observed in blood loss volume, hospitalization time, post-operative mobilization, and pain level after surgery in favor of MISS. Conclusion: MISS in obese patients was found superior to traditional (open) surgery in blood loss, operative time, post-operative mobilization, and post-operative pain.

Challenges Hindering Widespread Adoption of Minimally Invasive Spinal Surgery

Minimally invasive spinal surgery (MISS) techniques offer several beneficial prospects and are being increasingly requested by patients. However, these techniques have not been uniformly adopted by spinal surgeons, and they remain controversial among some. Several barriers have prevented widespread adoption of MISS. These include concerns regarding high start-up costs, limited evidence base, and lack of surgeon training. In addition, the unique approaches involved in MISS expose spinal surgeons to unfamiliar anatomy. Further, while MISS can address a growing spectrum of spinal pathology, some conditions, as well as complications encountered during MISS procedures, require open surgery. This requires surgeons to not only acquire the new and specialized MISS skillset but also maintain their ability to perform open surgery. These factors present challenges common to developing and innovative surgical techniques. Here, we review the barriers preventing wider adoption of MISS and present a framework to promote the safe and effective growth of MISS.

Minimally Invasive Spine Surgery: An Overview

Spinal surgery is undergoing a major transformation toward a minimally invasive paradigm. This shift is being driven by multiple factors, including the need to address spinal problems in an older and sicker population, as well as changes in patient preferences and reimbursement patterns. Increasingly, minimally invasive surgical techniques are being used in place of traditional open approaches due to significant advancements and implementation of intraoperative imaging and navigation technologies. However, in some patients, due to specific anatomic or pathologic factors, minimally invasive techniques are not always possible. Numerous algorithms have been described, and additional efforts are underway to better optimize patient selection for minimally invasive spinal surgery (MISS) procedures in order to achieve optimal outcomes. Numerous unique MISS approaches and techniques have been described, and several have become fundamental. Investigators are evaluating combinations of MISS techniques to further enhance the surgical workflow, patient safety, and efficiency.

The Future of Minimally Invasive Spinal Surgery

Strong forces are pushing minimally invasive spinal surgery (MISS) to the forefront of spine care. Less-invasive surgical techniques have been enabled by a variety of technical advances. Despite the promise of MISS, however, several factors, including few training opportunities, perception of a steep learning curve, and high upfront costs, have limited the adoption of these techniques. The "6T's" is a framework highlighting key factors that must be accounted for to ensure safe and effective MISS as techniques continually evolve. Further, technological advancement in endoscopy, robotics, and augmented/virtual reality is enhancing minimally invasive surgeries to make them even less invasive and safer for patients. The evolution of these new techniques and technologies is driving the future of MISS.

NATIONWIDE SURVEY ON INCIDENTAL DURAL TEARS DURING ENDOSCOPIC SPINE SURGERY IN JAPAN

Purpose: The Japanese Orthopedic Association has conducted a nationwide survey on the status of endoscopic spine surgery in Japan every year since 2006. This study aimed to analyze incidental dural tear. Method:We sent questionnaires to all spine surgery hospitals in Japan and received responses from an average of 1296 hospitals (974–1746) each year. The average response rate for the questionnaire was 63.7% (45.2–85.8). Results:The average number of facilities performing endoscopic spine surgery was 314 (222–415). The percentage of facilities performing endoscopic procures was 24.3% (20.3–27.3%). Incidental dural tear accounted for 65.4% (3113/4758) of all complications, which was significantly higher than nerve root injuries, cauda equina injuries (4.6%), and hematomas (10.0%). The number of accidents resulting in harm to patients was 154 (3.6%) for incidental dural tear which was significantly less than that for hematoma (75.5%) and for nerve root cauda equina injury (49.5%). Conclusion:As the number of endoscopic procedures increased, the number of complications increased year by year. However, the rate of complications has remained constant, with incidental durotomy tending to be the most common endoscopic lumbar laminectomy for lumbar spinal canal stenosis.

Incidence of discitis in endoscopic spine surgery

Aim of the study was to retrospectively evaluate the incidence of discitis amongst patients undergoing endoscopic spine surgery. Material and Methods: A total of 116 patients were included in the study which underwent endoscopic discectomy. Patients were followed up in postoperative period for any backpain. They were evaluated clinically and were subjected to laboratory and radiological investigations to establish the diagnosis of postoperative discitis. Patients were given IV antibiotics initially for 4 weeks and those not responding to treatment were treated by surgical intervention. All the patients were followed up clinically, by laboratory investigations and MRI. RESULTS: Out of 116,two patients suffered from postoperative discitis. One of them responded to medical management whereas the other one required surgical debridement. CONCLUSION: Discitis following endoscopic discectomy is although a rare complication .But whenever encountered should be treated aggressively with appropriate IV antibiotics and if needed surgical intervention should be resorted to as well.

CLINICAL RESULTS OF EVOLUTIONAL CHANGE OF PRACTICE FROM OPEN TO ENDOSCOPIC SURGERY FOR CERVICAL DISC HERNIATION AND FORAMINAL STENOSIS

Objective: Limited literature on the effect on clinical and radiological outcomes in cervical endoscopic spine surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients for cervical disc herniations and foraminal pathologies. Methods: Retrospective comparative cohort study of two periods of 2015 to 2017 (first generation) is compared to 2018–2020 (second generation) on surgical treatment of degenerative cervical spinal conditions for 132 spinal cases. Basic demographics, preoperative, post-operative 1 week, 3 months and final follow-up of patients’ clinical outcomes in terms of Visual Analog Scale Pain Score, Neck Disability Index, Japanese Orthopaedic Association Score and MacNab’s Criteria were evaluated. Results: In the first generation, 50 cases of cervical disc herniation and foraminal stenosis with 70% open anterior cervical discectomy fusion or disc replacement 30% of the cases underwent posterior cervical endoscopic procedures with complication rate of 2%. In the second generation, 82 cases of cervical disc herniation and foraminal stenosis with 7% open anterior cervical discectomy fusion or disc replacement 93% of the cases underwent posterior cervical endoscopic procedures with complication rate of 6%. Compared to preoperative score, motor, JOA, VAS and NDI scores all statistically significant improved within the individual cohort. Compared to the first generation, the second generation has statistically significant improved VAS of 0.326+/−0.146 at 3 months and 0.648+/−0.163 at final follow-up and statistically significant improved NDI of 2.81+/−1.15 at final follow-up, p &lt; 0.05. Conclusions: Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing good clinical outcomes.

Full Endoscopic Surgery for Thoracic Pathology: Next Step after Mastering Lumbar and Cervical Endoscopic Spine Surgery?

Thoracic disc herniation and stenosis are relatively rare, and various symptoms make them difficult to diagnose. Due to the complexity of neural and vascular structure, surgical treatment of thoracic pathology is challenging. Endoscopic spine surgery is an emerging minimally invasive surgical option. Based on wide experience on the cervical and lumbar spine, an endoscopic approach for the thoracic pathology can be performed beyond the learning curve. Transforaminal approach for thoracic disc herniation, endoscopic unilateral approach, and bilateral decompression for thoracic stenosis have been reported as favorable and safe surgical options. In the present study, the authors described the detailed surgical procedure as well as tips and tricks.

MP21-10 WHEN GENITO-PELVIC DYSESTHESIA DOES NOT ORIGINATE IN THE GENITO-PELVIC REGION: MANAGEMENT OF PATIENTS WITH SACRAL RADICULOPATHY

You have accessJournal of UrologyCME1 May 2022MP21-10 WHEN GENITO-PELVIC DYSESTHESIA DOES NOT ORIGINATE IN THE GENITO-PELVIC REGION: MANAGEMENT OF PATIENTS WITH SACRAL RADICULOPATHY Irwin Goldstein, Choll Kim, Sue Goldstein, Maria Uloko, Noel Kim, and Barry Komisaruk Irwin GoldsteinIrwin Goldstein More articles by this author , Choll KimCholl Kim More articles by this author , Sue GoldsteinSue Goldstein More articles by this author , Maria UlokoMaria Uloko More articles by this author , Noel KimNoel Kim More articles by this author , and Barry KomisarukBarry Komisaruk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002554.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urologists encounter both women and men who experience unwanted persistent, distressing, atypical sensations such as arousal (including erection, burning, itching, pain in the clitoris/penis and other genito-pelvic regions (e.g. vulva/scrotum, pelvic floor, bladder, urethra, perineal/perianal region, prostate). Genito-pelvic dysesthesia (GPD) is usually thought to emanate from pathology in the end organ (e.g., clitoris/penis) or pelvis/perineum (e.g., pelvic floor or pudendal nerve). Recently GPD has been shown to be associated with sacral radiculopathy from annular tear lumbosacral disc pathology impacting the cauda equina. In such cases, the GPD may be a result of nerve root irritation in the cauda equina producing sensations perceived as originating in the peripheral genito-pelvic region. This is analogous to sciatica where pain is perceived in the lower extremities but is commonly the result of “upstream” cauda equina pathology. We utilized a novel management algorithm to identify GPD patients with sacral radiculopathy from annular tear lumbosacral disc disease who underwent spine surgery and evaluated their long-term outcome. METHODS: A chart review of patients with GPD who underwent spine surgery between 2016 and 2019 was performed. The management algorithm involved ruling out pathology in the genito-pelvic regions; identifying pathology in the cauda equina on lumbosacral MRI; finding abnormal neurogenital testing of the pudendal/sciatic nerves; having a positive diagnostic response to a transforaminal epidural spinal injection; and undergoing lumbar endoscopic spine surgery. All patients had at least 1 year follow-up post-spine surgery. Treatment outcome was based on the Patient Global Impression of Improvement (PGI-I), measured every 3 months post-operatively. RESULTS: A total of 15 women and 5 men (mean age 40.3 16.8) with GPD underwent spine surgery and were discharged the same day. Lumbosacral disc pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Patients were followed for an average of 20 months (range 12-37 months). 80% (16/20 patients) reported improvement on the PGI-I. There were no serious surgical complications. CONCLUSIONS: When assessing GPD the urologist should look beyond the genito-pelvic region. GPD can be a result of sacral radiculopathy from lumbosacral disc disease. Long-term alleviation of GPD symptoms is achievable with spine surgery. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e330 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Irwin Goldstein More articles by this author Choll Kim More articles by this author Sue Goldstein More articles by this author Maria Uloko More articles by this author Noel Kim More articles by this author Barry Komisaruk More articles by this author Expand All Advertisement PDF DownloadLoading ...

A novel management algorithm and long-term treatment outcome of men with unusual sexual dysfunctions

ABSTRACT Introduction The most commonly treated sexual dysfunctions in men are erectile dysfunction, Peyronie's disease, premature and delayed ejaculation, and decreased sexual desire. While urologists have expertise treating these sexual dysfunctions, there are unusual sexual health concerns in men that can prove a management quandary to many clinicians. These include persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal, and severe ejaculatory pain, which may be secondary to a radiculopathy of the sacral spinal nerve roots (SSNR). Men with these unusual problems often experience despair, emotional lability, catastrophization, and/or suicidality. Objective The objective was to examine the management of men presenting to our multidisciplinary sexual medicine clinic with unusual sexual dysfunctions including persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal and severe ejaculatory pain, using a novel diagnostic and treatment algorithm. Methods We performed a retrospective chart review of men who presented to our clinic from 2015 through 2020 with a history of an unusual sexual dysfunction lasting for more than 3 months and had, at minimum, a follow-up of one year post treatment. All were managed using the novel algorithm, which included a sex therapy evaluation, neurogenital sensory testing of both the pudendal and sciatic nerves, measurement of the bulbocavernosus reflex latency, regional dorsal and pudendal nerve diagnostic anesthesia testing, lumbosacral MRI, and diagnostic transforaminal epidural spinal injection (TFESI) with an anesthetic. If the unusual sexual dysfunction was suspected to be secondary to SSNR radiculopathy, lumbar endoscopic spine surgery (LESS) was performed. Results 5 patients (mean age at presentation 26, range 17 – 38 years) meeting the criteria had the following symptoms: persistent genital arousal (3/5), distressing penile pain with arousal (3/5), spontaneous ejaculation/orgasm (2/5), and/or severe ejaculatory pain (2/5). Significant psychological distress was noted including suicidal ideation in 3/5 of patients. Neurogenital testing was abnormal in all. Mean perception of finger/glans vibration, cold and heat were 4/11 volts; 21.2/15.8° and 31 /37° respectively. Mean perception of finger/buttock vibration, posterior thighs and posterior calf were 4/14.3 volts. Mean value of bulbocavernosus reflex latency testing was 93 msec (normal 30-50 msec). Regional dorsal and pudendal nerve diagnostic anesthesia tests failed to temporarily resolve unusual sexual dysfunction symptoms in 100%. MRI findings showed annular tears in 5/5: L5-S1 (2/5), L4-L5 (4/5). Diagnostic TFESI resulted in clinically significant symptom reduction in 5/5. Based on these results, sexual dysfunctions were highly suspected to be secondary to SSNR radiculopathy. All patients underwent LESS, were discharged the same day, and had no surgical complications. All reported improvement on Patient Global Impression of Improvement of very much better (2/5) or much better (3/5). Mean follow-up was 21.6 months post-LESS treatment. Conclusions Unusual sexual dysfunctions can be a management challenge to urologists. Although persistent genital arousal, spontaneous ejaculation/orgasm, penile pain with arousal, and severe ejaculatory pain are perceived to be in the genitals, in this patient population these unusual sexual dysfunctions were actually caused by an upstream mechanical/inflammatory SSNR radiculopathy from lumbosacral annular tears. Symptom alleviation was achieved by LESS in all patients. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Elliquence, Lumenis).

The Learning Curve of Unilateral Biportal Endoscopic (UBE) Spinal Surgery by CUSUM Analysis.

ObjectiveTo assess the learning curve of the unilateral biportal endoscopic (UBE) technique for the treatment of single-level lumbar disc herniation by cumulative summation (CUSUM) method analysis.MethodsA retrospective analysis was conducted to assess 97 patients' general condition, operation time, complications, and curative effect of single segmental UBE surgery performed by a spinal surgeon in his early stage of this technique. The learning curve of operation time was studied using a CUSUM method, and the cut-off point of the learning curve was obtained.ResultsThe operation time was 30 – 241(97.9 ± 34.7) min. The visual analog scale score of lower limb pain decreased from 5.75 ± 0.81 before the operation to 0.39 ± 0.28 at the last follow-up (P < 0.05). The Oswestry disability index score decreased from 66.48 ± 4.43 before the operation to 14.57 ± 3.99 at the last follow-up (P < 0.05). The CUSUM assessment of operation time revealed the learning curve was the highest in 24 cases. In the learning stage (1–24 cases), the operation time was 120.3 ± 43.8 min. In the skilled stage (25–97 cases), the operation time was 90.5 ± 27.8 min.ConclusionsAbout 24 cases of single segmental UBE operation are needed to master the UBE technique.

End-points of Decompression of in Lumbar Transforaminal Endoscopic Spine Surgery: A Narrative Review of Objective and Subjective Criteria to Prevent Failures

Objective: Executions of indications/extended indications are associated with higher than normal rates of symptomatic recurrences and treatment failures, especially for novice surgeons incorporating Percutaneous Transforaminal endoscopic lumbar discectomy/decompression (PTELD) techniques. Causes of failures can be manifold and can occur because of a residual or a complete fragment causing persistent compression or associated unaddressed stenosis. To prevent this problem, proper training, multiple instrument inventory, variable techniques are needed with progressive learning. Authors aim to suggest objective and subjective criteria to define end-points/adequacy of decompression (EPD).Methods: PubMed database search was limited to locate only adequacy of decompression of PTELD and thus included specific keywords: “ENDPOINT” OR “ADEQUATE” AND “DECOMPRESSION” AND “TRANSFORAMINAL” AND “ENDOSCOPY”. Authors added their experience to refine and define multiple EPD.Results: In the search we found 12 articles total. Upon reviewing these, we found 7 articles matching our criteria. Cross references of included articles were searched, 5 additional articles were included. EPD were described in only 9 articles. Author’s experience with other relevant references were added to complete the viewpoint (EPD, n=29). Direct observed/ provoked EPD and inferred EPD were defined separately. Videos, illustrations and descriptions of each EPD are illustrated to provide the ideation.Conclusion: EPD are variable and not all signs may be elicited in every case and may change with surgeon experience. The ability to recognize EPD is the crux for successful outcomes and maximum possible EPD’s should be aimed in every surgery to avoid failures.

Unilateral Biportal Endoscopic Translaminar Keyhole Approach to Treat High-grade Up-migrated Lumbar Disc Herniation: Technical Note

The incidence of lumbar disc fragment migration is approximately 35%–72% of which 34% are high-grade up-migrated discs. Translaminar keyhole approach is a minimally invasive and true tissue sparing technique which has been applied to approach migrated disc herniation. The unilateral biportal endoscopic approach is an emerging technique among endoscopic spine surgery that combines the advantages of microscopic surgery with endoscopic surgery. In this technical report we demonstrate the surgical technique of performing the translaminar keyhole approach with unilateral biportal endoscopic spine surgery to treat high-grade up-migrated discs. As far as we know, this is the first technical report of unilateral biportal endoscopy with translaminar keyhole approach to treat high-grade up migrated lumbar disc herniation.

Endoscopic lumbar spinal hybrid surgery in the treatment of multiple-level lumbar degenerative spondylolisthesis and spinal stenosis

BackgroundElderly patients frequently suffer from multi-level degenerative lumbar spondylolisthesis/stenosis, particularly heavy labor workers, farmers, and obese individuals. The gold standard of treatment is surgical fusion following failure of conservative management; however, long-segment fusion wounds can cause premature adjacent segment disease. Owing to improved techniques and equipment, endoscopic spine surgery, lumbar spine fusion, laminectomy, or discectomy can be performed with a single or biportal spinal endoscope. We attempted to use these endoscopic techniques to decrease the fusion level in long-segment degenerative lumbar spines. Our strategy was to only fuse the most severe central and foraminal spondylolisthesis levels and arrange for endoscopic decompression only (without fusion) in other central stenosis spondylolisthesis levels. MethodsFrom September 2019 to May 2021, we enrolled 14 patients (average age 72 [9 females, 5 males]) with long-segment (>3 segments) low-grade spondylolisthesis and spinal stenosis who required spinal fusion after failed conservative treatment. We performed anterior lumbar interbody fusion or endoscopic-transforaminal lumbar interbody fusion for spondylolisthesis with central and foraminal stenosis levels only, particularly those involving the lowest segment; the endoscopic unilateral approach and bilateral decompressions were performed for other cephalic spondylolisthesis with central stenosis levels. ResultsAt the 1-year after hybrid operation, the patient’s daily function and neurologic pain have significant improvement. No major complications occurred during follow-up. There was no significant lumbar lordosis change, vertebral slip distance progression or range of motion change, even in vertebrae adjacent to the fusion level. ConclusionsPerforming multiple levels of endoscopic decompression above the fusion level is a reliable alternative technique that does not negatively impact spine structural stability.

Comparison of Microscopic Decompression and Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Canal Stenosis and Herniated Disc: A One-year Follow-up

Backgrounds. Microscopic decompression (MD) has been widely used as an alternative to open decompression. Lately, biportal endoscopic spinal surgery (BESS) - a new approach in minimal-invasive spinal surgery – has also been used with good results. Although both groups can achieve adequate lumbar decompression, there is still a lack of evidence regarding their comparison. We aim to compare the outcomes of both techniques in a one-year follow-up.&#x0D; Methods. This is a retrospective study in 100 consecutive patients with symptomatic lumbar spine compression due to herniated nucleus pulposus (HNP) and lumbar canal stenosis (LCS) that was treated by either BESS or MD. Clinical evaluations using Visual Analog Score (VAS), Oswestry Disability Index (ODI), and SF-36 questionnaire were obtained. Objective data such as surgery duration, amount of postoperative drain production, and hospital length of stay were collected. Complications were noted throughout the follow-up time.&#x0D; Results. The BESS group had a significantly lesser surgical duration, drain production, and length of stay. At one year follow-up, both groups achieved significant improvement in VAS, ODI, and SF-36 compared to the preoperative condition. Complications were not observed in the BESS group.&#x0D; Conclusions. Both procedures were comparably effective to treat lumbar stenosis. Although this study shows superiority with BESS technique in immediate and long-term follow-up, the final choice may depend on the surgeon's preference