Muscle-splitting Approach Research Articles

Comparison of biportal endoscopic and microscopic tubular paraspinal approach for foraminal and extraforaminal lumbar disc herniation.

Foraminal and extraforaminal lumbar disc herniation (FELDH) is an important pathological condition that can lead to lumbar radiculopathy. The paraspinal muscle-splitting approach introduced by Reulen and Wiltse is a reasonable surgical technique. Minimally invasive procedures using a tubular retractor system have also been introduced. However, surgical treatment is considered more challenging for FELDH than for central or subarticular lumbar disc herniations (LDHs). Some researchers have proposed uniportal extraforaminal endoscopic lumbar discectomy through a posterolateral approach as an alternative for FELDH, but heterogeneous clinical results have been reported. Recently, the biportal endoscopic (BE) paraspinal approach has been suggested as an alternative. The aim of this study was to compare the clinical outcomes of BE and microscopic tubular (MT) paraspinal approaches for decompressive foraminotomy and lumbar discectomy (paraLD) in patients with FELDH. Ninety-one consecutive patients with unilateral lumbar radiculopathy and FELDH underwent paraLD. Demographic and perioperative data were collected. Clinical outcomes were evaluated using the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI) for spinal disability, and the modified Macnab criteria for patient satisfaction. Postoperative complications and reoperation rates were also evaluated. In total, 76 patients were included in the final analysis. Among them, 43 underwent BE paraLD (group A) and the remaining 33 underwent MT paraLD (group B). The demographic and preoperative data were not statistically different between the groups. All patients showed significant improvements in VAS back, VAS leg, and ODI scores compared with baseline values (p < 0.05). The improvement in VAS back scores was significantly better in group A than in group B on postoperative day 2 (p < 0.001). However, all clinical parameters were comparable between the two groups after postoperative year 1 (p > 0.05). According to the modified Macnab criteria, 86.1% and 72.7% of the patients had excellent or good outcomes in groups A and B, respectively. No intergroup differences were observed (p = 0.367). In addition, there were no differences in the total operation time or amount of surgical drainage. Postoperative complications were not significantly different between the two groups (p = 0.301); however, reoperation rates were significantly higher in group B (p = 0.035). BE paraLD is an effective treatment for FELDH and is an alternative to MT paraLD. In particular, BE paraLD has advantages of early improvement in postoperative back pain and low reoperation rates.

The direct posterior gluteal muscle splitting approach for posterior access to acetabular fractures: Surgical technique and case series

We present a minimally invasive direct posterior, gluteal muscle splitting approach (PMS) as an alternative to the traditional Kocher-Langenbeck (KL) approach for posterior access to acetabular fractures. We believe it offers significant advantages and provides improved access while maximizing the range of fracture patterns that can be addressed through a posterior approach.One hundred and eighty-four consecutive patients treated with this approach by the senior author (RMS) between 2001 and 2018 were reviewed. The most common individual fracture pattern addressed was a posterior wall (66/36%) but more complex combination fracture types were the dominant group (106/58%), and included transverse with posterior wall, posterior wall / posterior column, and T types. A radiographically congruent reduction was consistently obtained at surgery, without any operative sciatic nerve palsies and a comparable heterotopic bone formation rate to previous reports. We have reviewed all 120 patients who were followed beyond 6 months and noted the hip replacement conversion rates to be different with each fracture type. The rate was highest with Transverse/ posterior wall injuries (36%), 16% of the posterior wall injuries were converted, a history of dislocation was not specifically associated with conversion.We believe this approach improves the posterior access to the acetabulum, but this study also confirms the poor prognosis of specific groups of higher energy multi-fragmentary, posterior acetabular injuries and suggests the need for a classification system that better predicts the prognosis for the hip joint. Level of Evidence4

The intra-muscular course and distribution of the anterior interosseous nerve within pronator quadratus: An anatomical study

BackgroundThe anterior interosseous nerve (AIN) is a terminal motor branch of the median nerve innervating the following three muscles from proximal to distal: Flexor pollicis longus (FPL), the radial half of flexor digitorum profundus (FDP), and the pronator quadratus (PQ). The aim of this study was to define the course of the AIN within the PQ to aid surgeons performing distal radial procedures. MethodsTen embalmed cadaveric forearms were dissected to identify the path of the AIN within PQ. An en-bloc excision of the PQ with its supplying AIN and vasculature was performed to identify a safe zone where PQ can be elevated without damaging AIN. A scoping literature search was performed to identify other studies reporting the path of AIN through PQ. ResultsThe mean distance from the radial border of the radius perpendicular to the point at which the AIN enters the PQ was 22.3 mm (range 21–24 mm). The mean distance from the distal wrist crease to the AIN entering PQ was 74.3 mm (range 59–84 mm). The mean number of nerve branches to PQ was 5.2 (range 3–8). In all specimens, the AIN was found to lie on the radial side of the anterior interosseous artery (AIA). ConclusionsThe AIN courses on the deep surface of the PQ in a longitudinal proximal to distal direction. A ‘safe zone’ was identified within 20 mm of the radial border of the distal radius, which may be utilised by surgeons in a muscle-splitting approach to the distal radius.

Primary Open Latarjet Procedure Results in Functional Differences but No Structural Changes in Subscapularis Muscle Quality vs the Healthy Contralateral Shoulder at Long-term Follow-up

Background: There are concerns that the Latarjet procedure results in loss of glenohumeral rotation and strength and in subscapularis dysfunction. The long-term effects of this procedure on subscapularis quality, glenohumeral rotation, and strength are unknown. Purpose/Hypothesis: To analyze the long-term effect of the primary open Latarjet procedure using a muscle-splitting approach on internal and external rotation and strength, as well as subscapularis muscle quality as compared with the healthy contralateral side. We hypothesized that the primary open Latarjet procedure is associated with a reduction of long-term shoulder strength and function and decreased subscapularis quality. Study Design: Case series; Level of evidence, 4. Methods: A total of 42 patients who underwent a primary open Latarjet procedure for recurrent anterior shoulder instability at a mean age of 26 years (range, 18-36) were reviewed after a mean follow-up of 8.4 years (range, 5-12). The subscapularis muscle volume and fat fraction of both shoulders were assessed. Bilateral active internal rotation (IR) and external rotation (ER), as well as IR and ER strength, were assessed by isokinetic testing (concentric, eccentric, and fatigability). Results: Active IR (0.6-point difference, P < .001) and ER (4° difference, P = .010) were significantly greater in healthy contralateral shoulders. The IR strength of the operated shoulder was significantly less than that of the healthy shoulder in concentric and eccentric testing (range of deficit, 4%-6%; P < .05). Also, the ER strength of the operated shoulder was significantly less than that of the healthy shoulder in concentric testing (11% deficit, P < .05). Subscapularis muscle volume was significantly greater in the operated shoulder (4% difference, P = .022), and there was no significant difference in fat fraction (P = .114). Conclusions: The primary open Latarjet procedure was associated with significantly decreased active IR and ER and strength when compared with the healthy contralateral shoulder. The clinical influence of these findings is yet to be defined. There was no increased subscapularis muscle fatty degeneration but a minimal hypertrophy on the operated side at long-term follow-up.

Channel-assisted fixation and interbody fusion in treating recurrent lumbar disc herniation by muscle-splitting approach

To explore the clinical value and safety of unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation and interbody fusion by muscle-splitting approach treatment of recurrent lumbar disc herniation. The clinical data of 51 patients with recurrent lumbar disc herniation treated from June 2012 to December 2017 were retrospectively analyzed. There were 32 males and 19 females, aged 34 to 64 years with an average of (51.11± 7.28) years. Lesions invoved L4,5 in 38 cases and L5S1 in 13 cases. All patients had a history of lower back pain and radiation pain of lower limbs(3 bilateral and 48 unilateral)and underwent unilateral pedicle screw combined with contralateral translaminar facet screw fixation and interbody fusion, among which 24 patients were treated through median incision approach (median incision group);other 27 patients were treated through muscle-splitting approach with channel-assisted exposure(muscle-splitting approach group). Operation time, intraoperative blood loss, postoperative drainage and incision length of the two groups were recorded. Visual analogue scale (VAS) was used to score the pain of lumbar incision at 72 h after operation, and JOA low back pain scoring system was used to evaluate the lumbar function preoperatively and at final follow-up. Imaging data were analyzed, including the changes in the height of intervertebral space of diseased segment before operation, 3 to 5 days after operation, and at final follow-up;Cobb angle changes in the coronal and sagittal planes of lumbar spine preoperatively and at final follow-up;multifidus area and multifidus fatty tissue deposition grade before and 12 months after operation; postoperative pedicle screw and laminar process screw position and intervertebral fusion condition. The complications of the two groups were compared. There was no statistical difference in operation time between two groups (P>0.05). Muscle-splitting approach group was better than median incision group in light of incision length, intraoperative blood loss and postoperative drainage volume (P<0.05). VAS score of lumbar incision pain at 72 h after operation was 1.61±0.54 in median incision group and 0.76±0.28 in muscle-splitting approach group(P<0.05). All patients were followed up for 12 to 84 (43.50±15.84) months. At final follow-up, the JOA scores of the two groups were significantly improved compared with those before operation(P<0.05). The rate of pedicle screw malposition was 6.25%(3/48) in medianincision group and 9.26%(5/54) in muscle-splitting approach group, there was no statistically significant difference between two groups (P>0.05). Rate of translaminar facet screw malposition in median incision group (12.50%) was significant less than the muscle-splitting approach group (18.52%)(P< 0.05). The height of the intervertebral space of the two groups was significantly restored 3 to 5 days after operation (P<0.05), and there was also a significant loss of height at final follow-up (P<0.05). At final follow-up, the balance of lumbar coronal plane and sagittal plane in two groups were improved very well (P<0.05). The comparison of the area and grade of the multifidus muscle in two groups 12 months after operation showed that obvious damage to the multifidus muscle were present in the median incision, while the multifidus muscle was less damaged by muscle-splitting approach (P<0.05). The fusion rate was 91.7%(22/24) in the median incision group and 92.6%(25/27) in muscle-splitting approach group(P>0.05). In median incision group, there were 1 case of intraoperative pedicle entry point fracture, 1 case of intraoperative dural tear and 1 case of postoperative nerve root injury;in muscle-splitting approach group, there were 1 case of intraoperative pedicle entry point fracture, 2 cases of intraoperative dural tear, 1 case of postoperative nerve root injury, 2 cases of incision epidermal necrosis and 1 case of poor incision healing. Nerve root injuries in the two groups were caused by incorrect positions of pedicle screws, the screws were immediately adjusted upon discovery. The nerve root symptoms were completely recovered 3 and 6 months after surgery. No incision infection was occurred in two groups. During the follow-up, no pedicle screw and laminar facet screw were loosened, displaced, broken, or intervertebral fusion cage moved forward and backward. The complication rate of 25.93% in muscle-splitting approach group was higher than 12.50% in the median incision group (P<0.05). Muscle-splitting approach is feasible for thetreatment of recurrent lumbar disc herniation with pedicle screw fixation combined with contralateral translaminar facet screw fixation and interbody fusion. Compared with the median incision approach, the muscle-splitting approach has the advantages of small incision, less trauma, less bleeding, rapid recovery. Also it can protect multifidus and do not increase the incidence of serious complications. Thus, it can be used as a choice for fixation and fusion of recurrent lumbar disc herniation.

Comparative Analysis of Radiologic and Clinical Outcomes Between Conventional Open and Minimally Invasive Scoliosis Surgery for Adolescent Idiopathic Scoliosis

To compare radiologic and clinical outcomes between conventional open scoliosis surgery (COSS) and minimally invasive scoliosis surgery (MISS) for adolescent idiopathic scoliosis (AIS). Forty-nine AIS patients who underwent scoliosis surgery were retrospectively analyzed in 2 groups: the COSS (n= 25) and MISS (n= 24) groups. COSS procedures used monoaxial screws with a rod derotation (RD) maneuver through a long linear incision. In the MISS group, the technique was applied via 2 or 3 incisions of about 3 cm in length, and a muscle-splitting approach and correction were performed using polyaxial screws with an RD maneuver. In the analysis of the coronal (Cobb angle of the main curve) and sagittal planes (thoracic kyphosis and lumbar lordosis), correction was significantly superior in the COSS group (all P values >0.05). However, in the coronal balance and spinal vertical axis, which are global balance factors, there were no significant differences between the groups (P= 0.331 and P= 0.750). There were significant differences between the COSS and MISS groups in terms of mean hospital stay duration (P < 0.001), operative time (P < 0.001), estimated blood loss (P < 0.001), and scar length (P < 0.001). There was no significant difference in the various Scoliosis Research Society-22 questionnaire scores between the groups. Although COSS for AIS was superior for correcting the main curve, MISS was associated with shorter hospitalization, less blood loss, and superior cosmesis as well as providing adequate correction in both the coronal and sagittal planes.

Ulnar Collateral Ligament Reconstruction With the Modified Jobe Technique in Baseball Pitchers.

Background:Tearing and insufficiency of the ulnar collateral ligament (UCL) of the elbow result in valgus instability, which can lead to pain while throwing and decline in performance in overhead athletes.Purpose:To assess the clinical results of a modified UCL reconstruction technique using 1 bone hole in the ulna and 1 bone tunnel in the humerus in baseball players.Study Design:Case series; Level of evidence, 4.Methods:The inclusion criteria were medial elbow pain preventing effective playing, clinically medial elbow laxity, and magnetic resonance imaging results consistent with UCL injury. Patients who were engaged in other sports and in other positions in baseball except pitchers were excluded from this study. Our modified Tommy John procedure was performed via a muscle-splitting approach and an original single-bone-tunnel technique, using a suture anchor. After a minimum of 24 months, patients were evaluated using the Conway scale and the Timmerman-Andrews score.Results:Of 31 patients, 20 baseball pitchers (20 male: 5 high school, 5 collegiate, 8 nonprofessional, and 2 professional pitchers) were reviewed. The mean patient age at the time of operation was 21.9 years, and the mean postoperative follow-up period was 35.1 months (range, 24-66 months). The mean Timmerman-Andrews subjective score improved significantly from pre- to postoperatively (from 68.3 to 98.3; P < .05); the objective score also improved significantly (from 81.1 to 96.4; P = .01). No complications were detected at the latest follow-up. Overall, 19 patients were able to return to their preinjury level of sports or higher.Conclusion:UCL reconstruction with 1 bone hole in the ulna and 1 bone tunnel in the humerus demonstrated satisfactory results in baseball pitchers. Our modified technique was safe and achieved satisfactory clinical results, with a 95% rate of return to sports.

Single-dermatome single-incision laparoscopic right hemicolectomy.

We describe a novel single-incision laparoscopy right hemicolectomy technique using a single-dermatomal, muscle-splitting approach through a 4-cm incision located between the right anterior superior iliac spine and pubic tubercle. This new technique may be superior to traditional single-incision laparoscopy colectomy with the potential benefits of less post-operative pain, lower opioid requirements, lower risk of incisional hernia and better cosmesis but requires further validation.

Medial elbow exposure: an anatomic comparison of 5 approaches

Several surgical approaches to the medial elbow are described; however, it remains unclear which exposure provides the optimal view of relevant medial elbow structures. The purpose of this anatomic study was to determine the visible surface area of the coronoid process, distal humerus, and radial head through 5 approaches to the medial elbow. Eight fresh-frozen cadaveric upper extremity specimens were dissected. Five surgical approaches were performed on each specimen. The Smith muscle-splitting approach to the ulnar collateral ligament was performed first (Smith), followed by the Hotchkiss medial "Over the top" approach (Hotchkiss), the extended medial elbow approach (EMEA), the flexor carpi ulnaris splitting approach (FCU-Split), and the Taylor and Scham approach (T&S). Bony visualization was determined using laser surface scanning (Artec Space Spider; Artec 3D). The scans were segmented using commercially available digital software (Geomagic Wrap; 3D Systems Corporation), and the surface area visualized was determined. A descriptive analysis of the joint areas visible using the medial collateral ligament (MCL) as a clinical landmark was performed. The EMEA visualized the highest proportion of the total elbow joint from the medial side showing 13.9 ± 6.0 cm2, or 15% ± 4% of the joint. It also provided the best visualization of the coronoid (3.2 ± 1.7 cm2 of surface area, or 26% ± 9%) and distal humerus (9.9 ± 4.3 cm2, or 15% ± 4%). The Hotchkiss approach was best at visualizing the radial head (0.8 ± 0.3 cm2, or 7% ± 3%). The EMEA, Hotchkiss, and Smith approaches showed primarily the anterior bundle of the MCL, its insertion, and the regions anterior to it, whereas the FCU-Split showed the anterior bundle of the MCL and regions both anterior and posterior to it. The T&S showed primarily the areas posterior to the anterior bundle of the MCL; the anterior regions were not visible. The FCU-Split and the T&S allowed visualization of the posterior bundle of the MCL. The intraclass correlation coefficients (ICCs) for intraobserver reliability were 0.997, 0.992, and 0.974 for the test distal humerus, test coronoid, and test radial head, respectively. The ICCs for interobserver reliability were 0.915 for the test distal humerus, 0.66 for the coronoid, and 0.583 for the radial head. The EMEA provides the most visualization of the coronoid and distal humerus, whereas the Hotchkiss showed the most radial head. However, these approaches mainly visualize structures anterior to the MCL. If exposure of structures posterior to the MCL is required, the FCU-Split and T&S approaches are more appropriate.

Early Results of Single-plug Autologous Osteochondral Grafting for Osteochondritis Dissecans of the Capitellum in Adolescents.

Osteochondral autologous transplantation surgery (OATS) has been advocated for unstable osetochondritis dissecans (OCD) lesions of the adolescent capitellum, though limited information is available regarding clinical and radiographic results in North American patients. We hypothesize that single-plug OATS is safe and effective in alleviating pain and restoring function in unstable OCD. Twenty-eight patients with unstable OCD treated with single-plug OATS were evaluated. Mean age at surgery was 14.2 years; there were 14 males. Etiology of OCD was presumed to be sports participation, including baseball (n=5) and gymnastics (n=11). Indications for surgery included unstable, deep OCD lesions; 2 lesions were uncontained, and 3 patients (11%) had OATS after failed prior surgery. OATS was performed by an anconeus muscle-splitting approach; donor grafts were harvested from the lateral femoral condyle by small arthrotomy. Functional outcomes were quantified using the Timmerman instrument. Median clinical and radiographic follow-up was 6.3 months (range, 5.0 to 27.0 mo) and 5.7 months (range, 5.0 to 26.7 mo), respectively. Furthermore, all patients returned functional questionnaires at a median of 9 months postoperatively (range, 5 to 27 mo). Of the 26 patients who reported preoperative tenderness, 19 (73%) patients had no tenderness at most recent clinical follow-up (P=0.02). Of 18 patients with restricted elbow motion preoperatively, 13 had achieved full range of motion (P=0.10). Both elbow flexion and extension improved significantly [flexion: median change (interquartile range)=10 degrees (0 to 10 degrees), P=0.009; extension: 0 degree (-5 to 0 degrees), P <0.001). On postoperative magnetic resonance imaging, 86% (P<0.001) of elbows had restoration of articular congruity and 93% had complete graft incorporation. Objective [median change (interquartile range)=5 degrees (0 to 15 degrees)], subjective [25 degrees (15 to 40 degrees)], and overall [35 degrees (15 to 45 degrees)] Timmerman scores improved significantly (P=0.001, <0.001, and <0.001, respectively). Of the 13 patients with >6 months follow-up, 9 patients (69%) had returned to their primary sport (P=0.27) and 100% had returned to general sports participation. There were no postoperative complications. At final follow-up, all donor knees were asymptomatic with full motion and strength. Single-plug OATS is safe and effective in improving pain and elbow function in adolescents with unstable OCD, with high return to sports rates and little donor-site morbidity. Level IV-case series.

Fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures using a sliding hip screw system: can we trust a two-hole side plate construct? A review of the literature.

Trochanteric femur fractures are frequently fixed with a four-hole side plate sliding hip screw device, but in recent decades two-hole side plates have been used in an attempt to minimize operative time, surgical dissection, blood loss and post-operative pain.The aim of this review was to determine whether two-hole sliding hip screw constructs are an acceptable option for fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures.An electronic MEDLINE® database search was performed using PubMed®, and articles were included in this review if they were reporting historical, biomechanical, clinical or outcome data on trochanteric fracture fixation using a two-hole sliding hip screw device.A two-hole dynamic hip screw with a minimally invasive muscle-splitting approach is recommended for fixation of AO-OTA 31-A1 simple trochanteric fractures; this implant is biomechanically safe, and allows the use of a minimally invasive muscle-splitting approach which potentially provides better clinical outcome, such as decreased surgical trauma, shorter operative time, less blood loss, decreased analgesics use, and shorter incision length. As the majority of reviewed publications relate to the dynamic hip screw, it is not clear whether the above recommendations can be extended to any other sliding hip screw device.An intramedullary device is recommended for all other extra-capsular proximal femoral fractures.Cite this article: EFORT Open Rev 2020;5:118-125. DOI: 10.1302/2058-5241.5.190020

Safety and effectiveness of minimally invasive scoliosis surgery for adolescent idiopathic scoliosis: a retrospective case series of 84 patients.

The aim of this study was to retrospectively evaluate a prospective series of patients with adolescent idiopathic scoliosis (AIS) who were treated with minimally invasive scoliosis surgery (MISS) technique with a minimum follow-up more than 1year. We retrospectively analyzed the prospectively collected data of 84 patients with AIS treated with MIS technique using two or three coin hole size incisions and a muscle-splitting approach. The clinical and radiological data such as the correction of deformity, coronal and sagittal profile and record of the perioperative morbidity of the patients were analyzed. The mean primary Cobb angle was corrected from 59.8° preoperatively to 18.6° postoperatively with a mean correction of 68.9% (p < 0.001). The mean kyphosis at T2 to T12 was maintained within normal range with an increase from 31.2° preoperatively to 35.3° postoperatively (p < 0.001). The 30-day perioperative complication rate was 7.14% with one deep infection and five cases of hemothorax. The mean operation time was 312.8min; mean estimated blood loss was 846.6ml (range 420-2800); and mean length of stay was 8.5days (range 5 to 14). All data of postoperative SRS-22 questionnaire were significantly improved (p < 0.001). MISS used for AIS provides adequate correction in both planes and acceptable rate of perioperative complications, with a low estimated blood loss and short length of stay. Considering all the positives, the application of MISS technique for AIS seems meaningful and can become a valid alternative to posterior approach in the routine use. These slides can be retrieved under Electronic Supplementary Material.

319. Minimally invasive surgery for neuromuscular scoliosis: a case control study of 140 consecutive patients

BACKGROUND CONTEXT Minimally invasive surgery (MIS) has been shown to have benefits in adolescent idiopathic scoliosis (AIS) and adult scoliosis with regards to estimated blood loss (EBL), transfusion rate, pain, narcotic usage and hospital stay. These benefits are ideal for neuromuscular scoliosis (NMS) patients, who generally have larger and stiffer curves which are at risk of progression, even with bracing. PURPOSE The purpose of this study was to report a consecutive case series of NMS patients undergoing MIS or standard PSF. STUDY DESIGN/SETTING Retrospective chart review. PATIENT SAMPLE A total of 37 NMS patients treated with MIS and 103 NMS patients treated with PSF. OUTCOME MEASURES Pre- and postoperative Cobb angle, pre- and postoperative kyphosis, pre- and postoperative pelvic obliquity, perioperative complications, surgery time, EBL, transfusion rates, ICU length of stay, hospital length of stay. METHODS We retrospectively collected data of 37 consecutive patients with neuromuscular scoliosis treated with MIS using 1 incision and a muscle-splitting approach by 2 senior surgeons from 2013-2018. 103 NMS patients treated with standard PSF and pedicle screw constructs were retrospectively reviewed in comparison. RESULTS In the MIS group, respectively the control group, the mean Cobb angle was corrected from 69.9° vs 67.7° to 29.4° vs 25.4° with a mean correction of 59% vs 63%, (p CONCLUSIONS The use of MIS for patients with neuromuscular scoliosis results in a significant correction of spinal deformity, with a low EBL, a significantly lower rate of need for allogenic blood transfusion, and a shorter LOS. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Platysma sparing approach to anterior cervical spine surgery: A less exposure surgery technique

IntroductionAuthors aim to demonstrate the surgical technique and outcomes of using a platysma sparing approach to anterior cervical spine surgery. MethodsMedical records of 496 prospective patients, group 1 (259 patients) with an outpatient platysma muscle-sparing approach. Group 2 (237 patients) with inpatient standard muscle-splitting approach. ResultsIntergroup comparison showed statistical significant improvement in VAS neck and NDI scores p = 0.009 and p = 0.012 and surgical operative time and estimated blood loss, p = 0.003 and p = 0.006 respectively. ConclusionThis anatomy sparing technique demonstrates a safe, effective and reproducible approach to cervical spine surgery which is a goal of less exposure surgery philosophy.

Paper # 7 - Safety of posterior endoscopic distal biceps repairs

Background: A prerequisite to restoring preinjury supination strength following a distal biceps rupture is tendon re-attachment to its footprint. 1 Schmidt C.C. Brown B.T. Qvick L.M. Stacowicz R.Z. Latona C.R. Miller M.C. Factors that determine supination strength following distal biceps repair. J Bone Joint Surg. 2016; 98: 1153-1160http://dx.doi.org/10.2106/JBJS.15.01025 Crossref PubMed Scopus (33) Google Scholar An ECU / supinator muscle splitting approach reliability exposes the footprint, but iatrogenic injury to the supinator has been associated with decreased strength. 1 Schmidt C.C. Brown B.T. Qvick L.M. Stacowicz R.Z. Latona C.R. Miller M.C. Factors that determine supination strength following distal biceps repair. J Bone Joint Surg. 2016; 98: 1153-1160http://dx.doi.org/10.2106/JBJS.15.01025 Crossref PubMed Scopus (33) Google Scholar Repairing the distal biceps tendon using endoscopy is a unique technique that minimizes supinator injury while providing the visualization required for an anatomic repair (Fig. 1). 2 Schmidt C.C. Savoie 3rd, F.H. Steinmann S.P. Hausman M. Voloshin I. Morrey B.F. et al. Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting-2015. J Shoulder Elbow Surg. 2016; 25 (Epub 2016 Aug 10): 1717-1730http://dx.doi.org/10.1016/j.jse.2016.05.025 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar The goal of this study is to determine safe posterior endoscopy portals for distal biceps repair.

Muscle-splitting approach to thoracoacromial vein for superdrainage in deep inferior epigastric artery perforator flap breast reconstruction.

Thoracoacromial vein (TAv) is seldomly considered as a secondary outflow recipient option when venous congestion of deep inferior epigastric artery perforator (DIEP) flap is encountered. The purpose of this study was to present a computed tomography (CT)-based anatomy and a method of approaching TAv in performing superdrainage using superficial inferior epigastric vein (SIEV) in DIEP flap breast reconstruction. For CT-based anatomical study, 42 thoracoacromial vessels (TAV) of 21 patients who underwent DIEP flap breast reconstruction were analyzed. From November 2016 to May 2018, pectoralis major (PM) muscle splitting approach to TAv in the first intercostal space was applied to 7 patients who required superdrainage via SIEV. TAVs at mid-first intercostal space (ICS) were located 83.5 ± 9.8 mm lateral to the sternal border (H), 41.5 ± 12.9 mm below the clavicle (V), and 11.7 ± 3.2 mm deep to the outer surface of PM muscle (D). Mean oblique distances from TAV to internal mammary vessels in the 2nd and 3rd ICS were 75.7 ± 9.7 mm and 98.2 ± 10.9 mm, respectively. Seven DIEP flaps presenting intraoperative venous congestion were successfully salvaged intraoperatively with superdrainge procedure. TAvs were harvested without cutting the PM muscle in any patient. Their mean size at anastomosis was 1.61 ± 3.2 mm (range, 0.9-2.5 mm). All flaps survived without perfusion-related complications including fat necrosis. Harvest of TAv by muscle-splitting approach is an alternative option when additional venous anastomosis using SIEV is mandated for managing venous congestion of DIEP flap.

Splitting of the semispinalis capitis muscle as a less invasive approach for atlantoaxial fusion – A technical note

PurposeAtlantoxial fusion with screw rod constructs traditionally requires subperiostal dissection of the C1/C2 muscle attachments, which may lead to postoperative axial neck pain and intraoperative blood loss. We evaluate a potentially less invasive, muscle splitting approach for atlantoaxial fusion in a cadaver model. MethodsA technical feasibility study was performed in a human cadaveric specimen with standard surgical instruments and an operating microscope. Surgically relevant anatomical structures as well as final exposure of the C1, C1/C2 and C2 screw entry points are demonstrated. ResultsFollowing a midline skin incision, blunt mobilization and downward retraction of the trapezius and splenius capitis muscle is followed by a longitudinal split of the semispinalis capitis muscle. At the lower border of the rectus capitis posterior major and the obliquus capitis inferior muscle the entry points for C1 lateral mass, C1/C2 transarticular and C2 pedicle screw are exposed. ConclusionMinimal invasive splitting of the semispinalis capitis muscle allows adequate exposure of the screw entry points of C1, C1/C2 and C2 while preserving the intrinsic muscles of the back at the craniocervical junction.

Short-term effects of combined pedicle/facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach for the treatment of degenerative lumbar spine diseases in the elderly

Objective To examine the feasibility and early effects of unilateral pedicle screw fixation in combination with contralateral translaminar facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach for the treatment of degenerative lumbar spine diseases in elderly patients. Methods A total of 82 elderly patients with degenerative lumbar spine diseases received treatment between January 2015 and June 2016.Of these patients, 25 had lumbar spinal stenosis, 42 had degenerative lumbar instability, 13 had giant lumbar disc herniation, and two had recurrent lumbar disc herniation; There were 69 cases of single segment and 13 cases of double segment lesions.Perioperative evaluation, imaging evaluation, and clinical evaluation were performed, and surgical complications were analyzed. Results The average length of incision was (2.6±0.4) cm in cases of single segment lesions and (4.4±0.5) cm in cases of two segment lesions.The mean operation time was (98.3±19.6) minutes and peri-operation blood loss was (232.2±25.8) ml.The post-operation height of the intervertebral disc space significantly increased at the last follow-up(P<0.05); the height of the intervertebral disc space was restored and well maintained with internal fixation showing no loosening, breakage or Cage shift.The post-operation lumbar coronal Cobb angle decreased(P<0.05)while the sagittal Cobb angle increased(P<0.05)at the last follow-up.There was no significant difference in the area and grade of the multifidus muscle on MRI 12 months after operation.Seventy-two patients were followed up for 12-18 months(mean=16.8 months), and there were 67 cases of intervertebral fusion(93.1%). The last follow-up showed a Japanese Orthopaedic Association(JOA)score of (25.8±1.7), which was significantly higher than the pre-operation score(10.6±1.3), with an excellence rate of 88.9%.The Oswestry Disability Index score was significantly reduced, from (50.9±21.6) at pre-operation to (9.6±4.8) at the last follow-up.There were 78 patients with primary wound healing, three cases of superficial wound necrosis, one case of dural tear, and one case of nerve root injury.No cardiovascular or cerebrovascular incident was observed during or after operation. Conclusions Combined pedicle/facet screw fixation plus interbody fusion through the channel-assisted muscle-splitting approach shows satisfactory short-term effects when used for the treatment of degenerative lumbar spine diseases in the elderly and possesses advantages such as minimal invasiveness, limited bleeding, quick recovery, high fusion rates and significantly improved clinical outcomes.However, further clinical studies are required to assess its medium-and long-term efficacy. Key words: Spinal fusion; Surgical procedures minimally invasive; Arthritis, degenerative

Bilateral pedicle screw fixation combined with interbody fusion for the treatment of lumbar spondylolisthesis (degree II or III) through muscle-splitting approach

Objective To investigate the feasibility and effectiveness of bilateral pedicle screw fixation combined with interbody fusion for the treatment of lumbar spondylolisthesis (degree II or III) through muscle-splitting approach. Methods There were 52 patients (16 males and 36 females) analyzed in our study from January 2012 to December 2015. The average age was 54.9±7.21 years (from 35 to 70 years). The history of disease was from 10 months to 15 years, with an average of 66.6±32.71 months. Diagnosis included: degenerative spondylolisthesis in 2 cases, and isthmic spondylolysis in 50 cases. The sites included L4,5 in 18 cases and L5S1 in 34 cases. The degree was II in 35 cases and III in 17 cases. 27 cases were treated by bilateral pedicle screw fixation combined with interbody fusion through median incision approach (open group) and 25 cases through muscle-splitting approach (minimally invasive group). The clinical and imaging results were observed and compared between the two groups, including operation time, intraoperative blood loss, postoperative incision drainage, VAS score of lumbar incision pain at 72h post-operative, intraoperative and postoperative complications, interbody fusion rate, multifidus muscle areas and grades at 1 year post-operative, and the improvement of ODI index. Results All the cases were operated successfully. The operation time of open group was shorter than minimally invasive group. However, the intraoperative blood loss and postoperative incision drainage of minimally invasive group was statistically less than open group. The VAS scores of postoperative 72 h were 3.25 (2 to 6) in open group and 1.62 (1 to 3) in minimally invasive group. And the difference was statistically significant. The misplacement rate of pedicle screws of minimally invasive group was lower than open group. The average follow-up time was 25.5 months (ranged from 12 to 36 months). The multifidus muscle areas and grades of minimally invasive group were superior to open group at 1 year postoperatively. Compared to preoperative, the slipping angle, slipping rate, sacral inclination angle and vertebral space height were significant improved after operation in two groups. The ODI index was improved postoperatively in both two groups, and the difference was statistically significant at the final follow-up. The interbody fusion rate was 92.6% in open group and 96% in minimally invasive group, and there was no significant difference between the two groups. No cerebrospinal fluid leak, never injury, pedicle fracture or wound infection was found after the operation in two groups. There was no pedicle screw loosening, cage shifting, or degeneration of the adjacent segment observed during follow-up. Conclusion Bilateral pedicle screw fixation combined with interbody fusion through muscle-splitting approach has advantages of small incision, less trauma, less bleeding, quick recovery and well clinical results, which can be a better choice in treating lumbar spondylolisthesis (degree II or III). Key words: Lumbar vertebrae; Spondylolysis; Surgical procedures, minimally invasive; Spinal fusion

Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach

To discuss lessons learned from an initial lateral lumbar interbody fusion (LLIF) experience with a focus on evolving surgical technique, complication avoidance, and new motor and sensory outcomes after implementation of a modified surgical approach. A retrospective analysis of a prospectively collected series of all patients undergoing LLIF by the senior author (A.D.L.) from January 2010 to January 2018 after implementation of a modified surgical mini-open technique, compared with previously reported institutional results with the originally recommended percutaneous technique. LLIF-specific complications examined included groin/thigh sensory dysfunction, flank bulge/pseudohernia, psoas-pattern weakness, and femoral nerve injury. The incidence (19%, n= 98 patients) of groin/thigh sensory dysfunction in our cohort was significantly lower than that of the historical control (60%, n= 59) (P<0.0001). The incidence of abdominal flank bulge/pseudohernia (2.0%, n= 98 patients) in our cohort was improved but not significantly lower than that of the historical control (4.2%, n= 118) (P= 0.36). The incidence of psoas-pattern weakness (3.1%, n= 98) in our cohort was significantly lower than that of the historical control (23.7%, n= 59) (P= 0.0001). The incidence of femoral nerve injury (0%, n= 98 patients) in our cohort was improved but was not significantly lower than that of the historical control (1.7%, n= 118) (P= 0.20). The adoption of an exclusive mini-open muscle-splitting approach with first-look inspection of the lumbosacral plexus nerve elements may improve motor and sensory outcomes in general and the incidence of postoperative groin/thigh sensory dysfunction and psoas-pattern weakness in particular.