Leg Pain Research Articles

Robot‐Assisted Positioning for Percutaneous Endoscopic Interlaminar Discectomy

ABSTRACTObjectiveDuring percutaneous endoscopic interlaminar discectomy (PEID), a range of technologies including medical robotics, visual navigation, and spatial registration have been proposed to expand the application scope and success rate of minimally invasive surgery. The use of robotic technology in surgery is conducive to improving accuracy and reducing risk. This study aims to introduce a precise and efficient targeting method tailored for robot‐assisted positioning under C‐arm fluoroscopy inPEID.MethodsThis study conducted a retrospective analysis of 107 patients with lumbar disc herniation (LDH) who underwent surgical treatment at our hospital from February 2023 to February 2024 (average age: 43.3 ± 13.3 years; 61 males and 43 females). The method entails constructing a specialized end‐effector capable of simultaneous fluoroscopy calibration and robot‐to‐image‐space registration. The average time of the surgical procedure and the average number of fluoroscopy exposures were collected. Preoperative and postoperative follow‐up data were collected, including assessment scores from the Japanese Orthopedic Association (JOA) and Visual Analog Scale (VAS). Paired t‐tests were employed to compare differences in each clinical outcome between the preoperative and follow‐up time.ResultsThese techniques effectively reduce both radiation exposure and operation time. Clinical data reveals that the average time for robot‐assisted positioning stands at 2.5 ± 0.7 min, with anteroposterior and lateral radiographs demonstrating accuracies of 2.4 ± 2.8 mm and 3.1 ± 3.7 mm, respectively, during robot‐assisted positioning. Postoperative VAS scores for back pain and leg pain were significantly lower than preoperative scores (1.2 ± 1.8 vs. 4.1 ± 2.3, 0.9 ± 2.0 vs. 5.9 ± 1.8; p < 0.05, p < 0.05, respectively). Postoperative JOA scores were significantly higher than preoperative scores (26.1 ± 3.5 vs. 14.5 ± 4.9; p < 0.05).ConclusionsThrough the evaluation of the system in robot‐assisted positioning during PEID, this study substantiates the accuracy and reliability of the proposed method in clinical applications.

Clinical and radiological outcomes of lumbar endoscopic decompression for treating lumbar spinal stenosis and degenerative lumbar scoliosis: a retrospective study at mean 4.4 years follow-up

PurposeTo assess the clinical and radiological outcomes of lumbar endoscopic decompression for the treatment of lumbar spinal stenosis (LSS) with concurrent degenerative lumbar scoliosis (DLS).MethodsThis study retrospectively reviewed 97 patients with LSS and DLS who underwent lumbar endoscopic decompression between 2016 and 2021. The average follow-up duration was 52.9 months. Another 97 LSS patients without DLS were selected as the control group. The pre- and postoperative visual analog score (VAS) and the Oswestry disability index (ODI) were recorded and analyzed to compare clinical outcomes. Radiological findings, such as coronal balance and intervertebral disc height, have also been reported.ResultsBoth groups' mean VAS scores for back pain, leg pain, and ODI were significantly improved two weeks after surgery and at the final follow-up (p < 0.001). There was no significant difference in the prevalence of surgical complications or patient satisfaction rates. However, patients in the DLS group reported more severe back pain at the final follow-up than those in the LSS group (p = 0.039). Radiological follow-up revealed no significant deterioration in coronal imbalance or loss of disc height in either group.ConclusionLumbar endoscopic decompression can be a safe and effective surgical technique for treating LSS with DLS, particularly in elderly patients with poor general conditions.

Cost-Utility of Lumbar Interbody Fusion Surgery: A Systematic Review.

Lumbar interbody fusion (LIF) is a common surgical intervention for treating lumbar degenerative disorders. Increasing demand has contributed to ever-increasing healthcare expenditure and economic burden. To address this, cost-utility analyses (CUAs) compare value in the context of patient outcomes. CUAs quantify health improvements using quality-adjusted life years (QALYs), allowing decision-makers to determine procedure value. While there is a growing body of literature assessing LIF value, a comprehensive synthesis of LIF CUAs is lacking. This systematic review aims to address this gap by assessing all available CUAs of LIF techniques, to support evidence-based practices that improve outcomes and promote efficient resource use. Systematic Review STUDY SAMPLE: This study sample consisted of adult patients with lumbar degenerative conditions specifically treated with lumbar interbody fusion, including grade I or II degenerative spondylolisthesis, lumbar spinal stenosis, disc degeneration, and spondylosis, with or without low back and/or leg pain. List here the types of patients included? Adult, only degenerative conditions, etc. OUTCOME MEASURES: Direct (healthcare) and indirect (non-healthcare) costs, cost sources and calculation methods, utility scores, QALY gain, cost-utility, incremental cost-effectiveness ratios, and willingness-to-pay thresholds. Outcomes were reported as median and interquartile ranges (IQR). A systematic review was conducted following PRISMA guidelines. PubMed, Web of Science, and Embase were searched from inception to October 23, 2023, for CUAs reporting QALYs and costs of LIF procedures. Relevant studies were selected and data extracted. Subgroup analyses compared minimally invasive versus open surgery and anterior versus posterior approaches. Study quality was assessed using the CHEC-Extended tool. Quantitative meta-analysis was not performed due to methodological heterogeneity. Out of 2047 identified studies, 14 met inclusion criteria. The mean CHEC-Extended score was 72.1%. Most studies reported on TLIF (n=11) and utilized EQ-5D questionnaire to calculate utility (n=9). Direct costs were sourced from institutional databases, Medicare, DRGs, Redbook, and a variety of other sources. Most indirect costs were estimated from productivity loss. TLIF demonstrated the highest median QALY gain over one year (0.43, IQR 0.121-0.705), while PLIF was highest over two years (1.33). ALIF was most favorable over one year ($30901/QALY) and OLIF was most favorable over two years ($11187/QALY). PLIF, TLIF, and LLIF exhibited similar cost-utility over two years ($44383, $45628, $48576/QALY). MIS was substantially favorable to OS at one year ($42635 vs. $226304), though similar at two years ($48576 vs. $45628/QALY). Anterior approach was favorable to posterior approach at one year ($30901.5 vs. $81038) and two years ($29881.9 vs. $44383). Cost-utility comparisons substantially varied and were sensitive to utility measures, study methodology, cost sourcing, and follow-up duration. This is the first systematic review to comprehensively assess CUAs of all LIF approaches in the existing literature. While certain approaches, such as ALIF and OLIF, may demonstrate favorable outcomes, these conclusions are limited by high methodological heterogeneity and a limited study pool. By addressing existing gaps in study design and reporting, future comparative cost-utility research can better inform evidence-based decision-making and optimize the value of spinal surgical care.

Awake, endoscopic lumbar interbody spinal fusion: 10 years of experience with the first 400 cases.

Awake, endoscopic spinal fusion has been utilized as an ultra-minimally invasive surgery technique to accomplish the goals of spinal fixation, fusion, and disc height restoration. While many techniques exist for this approach, this series represents a single institution's experience with a large cohort and the evolution of this method. The medical records of a consecutive series of 400 patients treated over a 10-year period were retrospectively reviewed. Endoscopic decompression, expandable intervertebral spacer deployment, and percutaneous screws were combined with liposomal bupivacaine to allow for the surgery to be performed without general endotracheal anesthesia (GETA) in the vast majority of cases. Clinical and radiographic postoperative results were reviewed with special attention to surgical complications, in particular dorsal root ganglion (DRG) irritation. All patients underwent surgery successfully without conversion to an open operation. Their mean age was 69.1 ± 10.4 years, and 42% of the patients were male. A total of 509 levels were fused, with the most common indication being spondylolisthesis (67.5%). The mean operative time was 84.6 ± 31.4 minutes, the mean intraoperative blood loss was 98 ± 63 ml, and the mean hospital length of stay was 1.93 ± 1.1 nights. Overall, 4.3% of the patients underwent planned GETA due to comorbidities, and 2% were converted to GETA intraoperatively. Eighty percent of the patients experienced > 75% improvement in leg pain, and 52% experienced > 75% improvement in axial back pain. Complications included transient DRG irritation (23%), adjacent-level disease requiring reoperation (3.5%), inadequate decompression (2.3%), and nonunion (1.8%). This large case series demonstrates that awake, endoscopic spinal fusion is a viable option with acceptable clinical and radiographic results in a select patient population. Meticulous attention to detail is required to limit the rate of DRG irritation, achieve interbody height restoration, and mitigate nonunions.

Comparison of Clinical and Radiological Outcomes of Three-Column Lumbar Osteotomies with and without Interbody Cages for Adult Spinal Deformity.

Correcting sagittal malalignment in adult spinal deformity (ASD) is a challenging task, often requiring complex surgical interventions like pedicle subtraction osteotomies (PSOs). Different types of three-column osteotomies (3COs), including Schwab 3, Schwab 4, Schwab 4 with interbody cages, and the "sandwich" technique, aim to optimize alignment and fusion outcomes. The role of interbody cages in enhancing fusion and segmental correction remains unclear. This study aimed to compare outcomes among these 4 3CO techniques, evaluating the impact of cage use at the osteotomy site on postoperative radiographic imaging and clinical outcomes. This is a multicenter retrospective study utilizing data from a prospective multicenter database of patients undergoing complex ASD surgery. Ninety-seven patients who underwent 1 of 4 3CO techniques for thoracolumbar ASD correction with at least 2 years of follow-up were included. The sample consisted of 29 patients who underwent Schwab 3 osteotomy, 20 Schwab 4, 28 Schwab 4 with interbody cages, and 20 who underwent "sandwich" osteotomy. The Scoliosis Research Society-22 revised (SRS22r) questionnaire evaluating pain, activity, appearance, mental health, and satisfaction was used to evaluate patient reported outcomes and radiographic measures including segmental lordosis and fusion rates determined by 3 blinded reviewers were used to evaluate physiologic outcomes. This study analyzed demographic data, radiographic outcomes, patient-reported outcomes, complications, and fusion rates over a 2-year follow-up period. Fusion status was determined via serial radiographs and evaluated independently by 3 blinded reviewers. Univariate and multivariate statistical analyses were performed to assess differences among the groups and the impact of interbody cage use on outcomes. Patients undergoing "sandwich" osteotomy exhibited worse preoperative leg pain scores and lower SRS22r activity (P=0.015), appearance (P=0.007), and mental health domain scores (P=0.0015). No differences in complications were found among groups (P>0.05). Patients who underwent osteotomy with a cage were more likely to have had previous spine fusion (91.7% vs. 71.4%, P=0.010). Additionally, these patients had lower preoperative SRS22r mental domain (2.9±1 vs. 3.5±1, P=0.009), satisfaction (2.3±1 vs. 2.7±1.2, P=0.034), and SRS22r total scores (2.3±0.6 vs. 2.6±0.6, P=0.0026) but demonstrated the greatest improvement in the mental health domain (0.9±0.7 vs. 0.3±0.9, P=0.002). Cage use was associated with a larger mean change in segmental lordosis at the osteotomy site (32.9±9.6 vs. 28.7±9.5, P=0.038). Fusion rates were significantly higher in the cage group (79.2% vs. 55.1%, P=0.0012). Regression analysis identified cage use as an independent predictor for fusion (odds ratio, 3.338; 95% confidence interval, 1.108-10.054, P=0.032). Interbody cage use at the osteotomy site during 3COs for ASD correction was associated with improved fusion rates and greater segmental lordosis without increasing complication rates. Incorporating cages may provide enhanced alignment and fusion outcomes in complex ASD surgeries.

Comparing Patient-Reported Outcomes of Lateral to Paramedian Lumbar Disc Herniation: A Propensity-Score Matched Observational Study.

The aim of this study was to investigate patient-reported outcomes (PROs) following lumbar discectomy on patients with lateral lumbar disc herniation (LDH) compared to patients with paramedian LDH. Surgery for disc herniation is one of the most common procedures of the lumbar spine. LDHs can be divided into median, paramedian, foraminal and extraforaminal types based on the anatomical site of the lesion. Lateral (foraminal and extraforaminal) LDH surgery is considered challenging compared to paramedian LDH surgery. Data on patients with lateral and paramedian LDH, operated between 2017 and 2020 at a single public spine unit, was extracted from the National Danish Spine Registry, DaneSpine. A propensity score-matched, case-control analysis was conducted to compare the two groups. Subgroup analysis was made by further dividing the lateral LDHs into a foraminal and extraforaminal group. Patient demographics, Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) of leg and back pain (0-100), EuroQol-5D questionnaire (EQ-5D), measures of patient improvement and satisfaction were collected at baseline and 1-year postoperatively. Of 887 eligible patients, baseline and 1-year follow-up data was available on 525 paramedian and 68 lateral LDH patients. Following propensity-score matching the two groups were similar in terms of all baseline characteristics (P>0.05). There was no significant difference between the paramedian and lateral LDH group in ODI, VAS leg pain, VAS back pain and EQ-5D 1-year postoperatively. Both groups improved in all outcomes from inclusion to follow-up (P<0.001). Subgroup analysis showed that patients with foraminal LDH, compared to extraforaminal LDH, had a significantly greater improvement in VAS leg pain (x vs x, P = 0.016) with a larger number of patients with clinically significant leg pain improvement (x vs x, P = 0.03). Lateral and paramedian LDH patients reported similar postsurgical outcomes. Spine surgeons should be less hesitant to operate patients with lateral LDH. Extraforaminal LDH patients experienced the least relief of leg pain.

Surgeon Recommendation and Outcomes of Decompression With vs Without Fusion in Patients With Degenerative Spondylolisthesis

The ability of surgeons to choose the right patient for fusion in addition to decompression when operating for degenerative spondylolisthesis with symptomatic spinal stenosis is debated. The addition of fusion increases risk, morbidity, and costs but has been claimed to give better results for selected patients. To investigate whether following surgeons' opinions regarding fusion was associated with clinical outcomes. This cohort study was conducted alongside the Norwegian Degenerative Spondylolisthesis and Spinal Stenosis randomized clinical trial, which showed noninferiority for decompression alone compared with decompression with fusion. From February 12, 2014, to December 18, 2017, trial surgeons from 16 Norwegian departments denoted their preferred treatment for 222 of 267 patients with symptomatic spinal stenosis and degenerative spondylolisthesis. For this analysis, the clinical outcomes of the patients who were and were not randomized to the recommended treatment were compared. The primary outcome was a reduction of at least 30% from baseline to 2 years after surgery on the Oswestry Disability Index, ranging from 0 (no impairment) to 100 (maximum impairment). Secondary outcomes included the Zürich Claudication Questionnaire, leg and back pain scores, and the EuroQol 5-Dimension score. Among 222 patients (155 [70%] female; mean [SD] age, 66.2 [7.7] years), decompression alone was recommended for 112 patients, of whom 59 received only decompression, and additional fusion for 110 patients, of whom 57 received fusion. At 2-year follow-up, 87 of 116 patients (75%) who received surgery in agreement with the surgeons' recommendations and 77 of 106 (73%) who received surgery in disagreement with the surgeons' recommendations reached the primary outcome (difference, 2.4 percentage points; 95% CI, -9.1 to 13.9 percentage points). All secondary outcomes were in the same direction as the primary outcome. In this cohort study of 222 patients with degenerative spondylolisthesis who participated in a randomized clinical trial, surgeons' recommendations were not associated with better outcomes than a random allocation when deciding between decompression alone and decompression with instrumented fusion. The results suggest that surgeons performing degenerative spondylolisthesis surgery could rely safely on evidence of operating with decompression alone, despite the conflict of expert opinion.

Modified single-incision MIS-TLIF with expandable tubular assistance for degenerative lumbar spine diseases

ObjectiveEvaluating the clinical value of the modified single-incision posterior median approach with expandable tubular assistance for lumbar interbody fusion in managing degenerative lumbar spine diseases.MethodA retrospective analysis was conducted on 121 patients with single-level degenerative lumbar spine disease treated in our spine surgery department from January 2017 to December 2021. Of these, 72 patients underwent a modified single-incision posterior median approach with expandable tubular assistance lumbar interbody fusion (single-incision MIS-TLIF group), while 49 patients received the classic open posterior median incision P-TLIF (open surgery group). We collected basic demographic data including age, gender, BMI, and surgical level. Surgical-related indicators such as operation time, intraoperative blood loss, postoperative drainage, length of hospital stay, hospital costs, and complication rates were compared between the two groups. Laboratory results [whole blood C-reactive protein (CRP), serum creatine kinase (CK)] and clinical outcomes [VAS scores for low back and leg pain, Oswestry Disability Index (ODI), excellent and good rate according to the modified MacNab criteria, and interbody fusion rate according to the Brantigan criteria] were also evaluated.ResultThere were no significant differences in the basic demographics between the two groups. The operation time, postoperative hospital stay, and hospital costs were also similar between the groups. However, significant differences were observed in intraoperative blood loss, postoperative drainage, and complication rates. On postoperative days 1 and 3, whole blood CRP and CK levels showed marked differences between the groups. At 3, 6, and 12 months postoperatively, the single-incision MIS-TLIF group had lower ODI scores and VAS scores for back pain compared to the open surgery group. The excellent and good rate according to the MacNab criteria was higher in the single-incision MIS-TLIF group. There were no significant differences in leg pain VAS scores and interbody fusion rates at 12 months postoperatively between the groups.ConclusionThe modified single-incision posterior median approach with expandable tubular assistance lumbar interbody fusion is highly effective in treating degenerative lumbar spine diseases. It results in less postoperative pain, faster recovery, and significant improvement in postoperative functional outcomes, making it a valuable treatment option.

Disability and pain after lumbar surgery-group-based trajectory analysis.

Previous studies in lumbar spine surgery have mainly studied functioning and pain by comparing average scores from Patient Reported Outcome Measures (PROMs) at different time points. Less is known about these changes in different subgroups. It is self-evident that, while most patients may demonstrate trajectories of these changes close to the average one, some groups may follow more or less different trends. Also, it is unclear which preoperative factors may affect the probability of being classified into groups with different development trajectories of surgical outcome. The objective of this study was to identify groups exhibiting distinct trajectories within the broader cohort of patients undergoing lumbar spine surgery and to determine whether certain factors may be associated with a probability of being classified into a particular group. This was a register-based study of 1,451 patients undergoing lumbar spine surgery. The group-based trajectory analysis was used separately for leg pain, for back pain, and for functioning. The probability of group membership was calculated based on sex, age, leg and back pain duration before surgery, and obesity. Two kinds of group-based trajectories were identified for each of three-factor variables: a long-term and a short-term improvement group. Sex and age were not associated with being classified into short-term improvement groups, but obesity was associated for all three-factor variables with relative risk ratios (RRR) varying from 1.26 (95% CI 1.02 to 1.56) to 1.45 (95% CI 1.10 to 1.90). Preoperative leg and back pain duration was significantly associated solely with back pain severity with an RRR of 1.28 (95% CI 1.01 to 1.61). The results of this study suggest that most of the patients may experience pain relief and improved functioning within three months after lumbar surgery, and this effect may last, at least, for two years. Higher BMI and worse preoperative pain and disability were associated with the inferior outcome of surgery. When considering surgery, planning pre- and postoperative rehabilitation, or forecasting the use of pain medications, a higher probability of worse outcome could be expected for overweight and initially more painful patients with higher level of disability.

Targeting IL-20 alleviates inflammatory mechanical allodynia and reduces epidural fibrosis in post-laminectomy syndrome rat model.

Post-laminectomy syndrome (PLS) manifests as recurrent chronic back pain, with or without radiating leg pain, affecting 10-40% of patients following laminectomy. While surgical interventions can alleviate recurrent disc herniation or joint instability, medical management of PLS remains challenging due to unsatisfactory outcomes. Epidural fibrosis is a frequent cause of PLS, leading to nerve root tethering and dural sac compression. This study aimed to investigate the role of interleukin-20 (IL-20) in the development of epidural fibrosis and the pathogenesis of PLS. A rat model of PLS was used to investigate IL-20 production and its impact on downstream fibrotic biomarkers. Spinal tissues from L1-2 segments were analyzed for cytokine and fibrotic marker expression. Primary fibroblasts were isolated from PLS rats and cultured to assess IL-20 receptor expression. The functional effects of IL-20 on fibroblasts were evaluated, including its impact on cytokine production, fibrotic marker expression, and cell proliferation. Additionally, the efficacy of IL-20 inhibition using the anti-IL-20 monoclonal antibody (mAb) was investigated in relation to epidural fibrosis and the severity of PLS. A significant increase in IL-20 production was observed along with increased expression of TGF-β, IL-1β, MCP-1, collagen-1, and fibronectin-1 in the L1-2 spinal segments of PLS rats. Treatment with the anti-IL-20 mAb significantly reduced epidural fibrosis and improved functional outcomes in the PLS rat model. Mechanistically, primary fibroblasts from PLS rats expressed IL-20 receptors, and IL-20 stimulation significantly increased IL-1β, TNF-α, and TGF-β levels, along with upregulated fibrotic markers, including fibronectin-1 and collagen-1. IL-20 also enhanced fibroblast proliferation and α-SMA production but did not alter MCP-1 levels. IL-20 is implicated in promoting epidural fibrosis and may contribute to the pathogenesis of PLS through the modulation of fibroblast function. Targeting IL-20 could represent a potential therapeutic approach for managing PLS. This study demonstrates that blocking IL-20 with an anti-IL-20 mAb significantly reduces epidural fibrosis and improves pain-related outcomes in a rat model of PLS. These findings suggest that targeting IL-20 could represent a promising new therapeutic strategy for alleviating PLS symptoms and improving recovery.

Full-Endoscopic Midline Foraminoplasty: An Alternative Method for Treating Lumbar Foraminal Stenosis

Objective: To describe the full-endoscopic lumbar foraminoplasty with midline skin incision (FEFM) and lateral recess decompression procedure and to report its clinical outcomes at the 1-year follow-up.Methods: Consecutive patients with lumbar foraminal and/or lateral recess stenosis who underwent FEFM procedures were retrospectively reviewed. Clinical outcomes were evaluated with a visual analogue scale (VAS) of back and leg pain and Oswestry Disability Index (ODI) up to 1 year postoperatively. The complications and recurrence rate were also recorded.Results: A total of 30 cases (51 levels) were included (L3–4, 6 cases [11.8%]; L4–5, 23 [45.1%]; L5–S1, 22 cases [43.1%]). VAS scores collected at preoperative, postoperative day 1, 3 months, 6 months, and 1 year were 9.16, 1.7, 1.36, 1.3, and 1.43, respectively. The ODI scores collected at preoperative, postoperative 3 months, 6 months, and 1 year were 46.63, 11.5, 10.66, and 10.46, respectively (p&lt;0.05). The mean operation time was 88.7 minutes (range, 45–152 minutes). The length of hospital stay was 1.21 days (range, 1–3 days). No immediate complications were identified, and no patients experienced a recurrence of symptoms requiring revision surgery.Conclusion: FEFM is an effective procedure for treating foraminal and/or lateral recess stenosis. It demonstrates the capability to decompress both bilateral foraminal and lateral recess stenosis through a single-entry point.

The safety and efficacy of anti-inflammatory-impregnated gelatin sponge in spine surgery: a systematic review and meta-analysis.

The purpose of this systematic review and meta-analysis is to evaluate the safety and efficacy of anti-inflammatory-impregnated gelatin sponges in spine surgeries. Gelatin sponges are increasingly used as delivery vehicles for anti-inflammatory and analgesic drugs during spine surgeries. However, concerns about their safety and efficacy persist. A comprehensive literature search was conducted to identify original research articles investigating the use of anti-inflammatory-impregnated gelatin sponges in spine surgeries from 2006 to 2024. Case reports, case series, animal studies, cadaveric studies, and abstract-only articles were excluded. The risk of bias was assessed using Cochrane Risk of Bias 2.0 (Cochrane, UK) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Meta-analysis was performed using Cochrane Review Manager Web. Thirteen studies (six RCTs, six cohort studies, and one case-control study) were included. Pooled analysis revealed a significant decrease in Visual Analog Scale (VAS) score for back pain (mean difference [MD], -0.62; 95% confidence intervals [CI], -0.78 to -0.46; p<0.00001), VAS score for leg pain (MD, -0.60; 95% CI, -0.87 to -0.34; p<0.00001), and length of hospital stay (MD, -0.99; 95% CI, -1.68 to -0.31; p=0.0004). Additionally, there was a significant increase in the Japanese Orthopedic Association score (MD, 0.98; 95% CI, 0.00 to 1.96; p=0.05). However, no significant difference was observed in the disability index (MD, -0.59; 95% CI, -1.88 to -0.70; p=0.37). The use of anti-inflammatory-impregnated gelatin sponges during spine surgeries decreases postoperative back pain and leg pain, reduces length of stay, and improves neurological function. Larger, prospective, randomized trials are required to obtain more robust evidence.

Full-Endoscopic J-Shaped Transforaminal L5 Nerve Decompression in Bertolotti Syndrome

This case report and video demonstrate the technique of full-endoscopic J-shaped transforaminal L5 exiting nerve decompression in Bertolotti syndrome. Bertolotti syndrome, characterized by a congenital lumbosacral transitional vertebra, often results in mechanical lower back pain and nerve root compression. A 69-year-old male presented with progressive radiating pain in the right leg and tingling in the L5 dermatome. Lumbar spine MRI revealed a right foraminal disc herniation at the L5–S1 level, with calcification and foraminal stenosis. The patient was also diagnosed with Castellvi type I Bertolotti syndrome, featuring a large L5 transverse process and a high iliac crest. These anatomical variations complicated the transforaminal approach, creating a narrow safety zone for conventional methods. The approach began with docking on the L5 transverse process. Endoscopic drilling was performed in a J-shaped configuration to partially resect the transverse process and alar wing, facilitating endoscope insertion into Kambin’s triangle. Foraminal decompression was achieved by removing the tip of the superior articular process (SAP), thereby decompressing the L5 exiting nerve root. Full-endoscopic spine surgery offers a safe and effective alternative to traditional open techniques for L5 nerve decompression in Bertolotti syndrome. This video presentation illustrates the intraoperative endoscopic approach, detailing the decompression techniques and highlighting the minimally invasive advantages of this method.

Reducing Postoperative Neurological Complications in Uniportal Full-Endoscopic Lumbar Interbody Fusion: Efficacy of the GUARD Technique Combined With Delayed Ligamentum Flavectomy

Objective: Uniportal full-endoscopic transforaminal lumbar interbody fusion (FE-TLIF) carries a unique risk of nerve traction and abrasion injury during cage insertion. This study aims to evaluate the clinical efficacy of the GUARD technique and delayed ligamentum flavectomy in reducing postoperative radicular pain and neurapraxia in patients undergoing uniportal FE-TLIF.Methods: A retrospective analysis was conducted on 45 patients with an average age of 53.9±12.4 years who underwent either FE facet-sparing TLIF (FE fs-TLIF) or FE facet-resecting TLIF (FE fr-TLIF). Patients were divided into 2 groups: the sentinel group (21 patients) using traditional sentinel pin techniques, and the GUARD group (24 patients) using the GUARD technique with delayed ligamentum flavectomy. Patient-reported outcomes included the visual analogue scale (VAS) for leg and back pain, and Oswestry Disability Index. Complication rates, including incidental durotomy, postoperative neurapraxia, and hematoma, were also documented.Results: Postoperative radicular pain in the legs was significantly reduced at 6 weeks in the GUARD group compared to the sentinel group (VAS: 2.201 vs. 3.267, p=0.021). The incidence of postoperative neurapraxia was markedly lower in the GUARD group (0% vs. 19%, p=0.047). Both groups showed similar improvements in disc height, segmental lordosis, and lumbar lordosis at the 1-year follow-up, with no significant differences in endplate injury or fusion rates.Conclusion: The GUARD technique and delayed ligamentum flavectomy significantly enhance patient safety by reducing postoperative radicular pain and neurapraxia without incurring additional costs. These techniques are easy to learn and integrate into existing surgical workflows, offering a valuable improvement for surgeons performing FE-TLIF procedures.

Challenges of Spine Surgery in Obese Patients: A Case Report with a Review of the Literature

Introduction: Obese patients face unique challenges across all phases of spine care and surgery, including preoperative, intraoperative, and postoperative periods. Significantly higher risks are associated with spinal surgery in obese patients. This study explores the challenges of managing spinal conditions in obese patients and offers strategies to mitigate these risks. Case report: A 56-year-old female with a BMI of 42 was referred for evaluation of chronic lower back pain and radicular leg pain. Imaging results were lumbar fusion for degenerative disc disease at the L4-5 and L5-S1 levels. During surgery, the patient required a prolonged operating time due to her increased soft tissue, which made visualization more difficult. The surgical team had to use longer instruments to navigate through the deeper tissue layers. Fluoroscopy was employed to ensure accurate placement of the fusion hardware. Postoperatively, the patient developed delayed wound healing, which required close monitoring and wound care interventions. She had significant reduction in back pain and improved mobility at her 6-month follow-up. Conclusion: Obese patients present numerous challenges to spine surgeons, ie. elective and non-elective surgeries, anesthetic issues, operative challenges, post-operative issues, complications, and outcomes. To mitigate associated risks and optimize outcomes, specific precautions can be taken during the preoperative, intraoperative, and postoperative phases.

Full-Endoscopic Resection of a Lumbar Intradural Tumor (Schwannoma): Video Case Report and Description of the Surgical Technique

Endoscopic spinal surgery has gained increasing popularity over the past 10 years. Its muscle-preserving nature, reduction in postoperative pain, and lower complication rates have contributed to the growing number of surgeons adopting this technique year after year. This same progression has led to the application of the technique in oncological pathology, primarily for separation surgeries and biopsies of extradural lesions. However, reports in the literature on the use of this technique to treat intradural spinal tumors remain scarce. To present a case report of a patient with an intradural lesion, compatible with schwannoma, successfully removed using a fully endoscopic technique. A 46-year-old female patient presented with a long-standing history of low back pain and bilateral leg pain. The pain worsened over the past few months before her initial presentation. She also reported experiencing weakness in her feet and intermittent hypesthesia in her legs. Magnetic resonance imaging (MRI) showed a small intradural extramedullary tumor at the L1 level. Given the patient’s young age, the tumor location at the thoracolumbar junction, and the rather small tumor size, a full-endoscopic approach was selected and performed. A step-by-step video of the surgical technique is provided with the manuscript. The current follow-up period is 2.5 years, with the patient remaining asymptomatic. The most recent follow-up MRI, conducted 16 months after the surgery, indicated no signs of recurrence. To our knowledge, this is the first video report providing a step-by-step description of this procedure. More high-quality evidence is needed to properly evaluate the safety and outcomes of this technique.

Transforaminal Endoscopic Lumbar Foraminotomy for Iatrogenic Foraminal Stenosis Following Vertebroplasty

We present a case of iatrogenic lumbar foraminal stenosis caused by bone-cement leakage during vertebroplasty, successfully managed using transforaminal endoscopic lumbar foraminotomy (TELF). Vertebroplasty is an effective treatment for osteoporotic vertebral compression fractures (VCFs); however, complications such as bone-cement leakage can lead to vascular or neurological issues, including lumbar radiculopathy. TELF is a minimally invasive surgical option for addressing various forms of lumbar foraminal stenosis. An 82-year-old female patient presented to Gachon University Gil Medical Center with severe right inguinal pain radiating to the anterior thigh and knee. Six months prior, she had undergone vertebroplasty at the L3 level for an osteoporotic VCF at another hospital. Following the procedure, she developed radicular leg pain with a diminished knee jerk reflex, which progressively worsened despite extensive conservative treatment. Magnetic resonance imaging and computed tomography revealed right-sided L3–4 foraminal stenosis caused by bone-cement leakage from the prior vertebroplasty. TELF was performed under local anesthesia to decompress the affected area. Bone-cement fragments, along with hypertrophic bone and ligaments, were successfully removed, achieving sufficient decompression of the exiting nerve root. The patient experienced immediate postoperative pain relief. This case represents the first documented instance of endoscopic decompression for iatrogenic foraminal stenosis following vertebroplasty. TELF, performed safely under local anesthesia, demonstrates its effectiveness as a minimally invasive solution for this rare complication.

Early therapeutic efficacy of condoliase chemonucleolysis for lumbar disc herniation

BackgroundLow back pain is often caused by lumbar disc herniation (LDH). Treatment of LDH is possible using chemonucleolysis of the nucleus pulposus with condoliase injection. However, onset of the therapeutic effect varies among patients, with improvement from an early stage to 3 months post-injection. This study was performed to identify the characteristics of early responders to condoliase therapy.MethodsA retrospective cohort study was performed in 371 consecutive patients (259 males, 112 females; age, 49.9 ± 18.7 years; follow-up period, 13.1 ± 7.4 months) treated with condoliase injection for LDH between August 2018 and January 2024. Chemonucleolysis was performed with 1 mL of condoliase (1.25 U/mL) injected into the intervertebral nucleus pulposus. Clinical assessments were made before injection and 1 day, and 1, 4 and 12 weeks post-injection. Pain was measured on a visual analogue scale. Herniation parameters were evaluated on axial MRI. The herniated disc volume was measured on plain lumbar radiography. Demographic and clinical data were taken from medical charts. Multivariate logistic regression analysis was used to identify factors with independent relationships with treatment efficacy.ResultsImprovement of leg pain from baseline by ≥ 50% occurred in 21% of cases within one day after condoliase treatment. Patients with this improvement at 1 week post-injection were defined as early responders (n = 142, 38.3%). In multivariate analysis, age < 40 years (p = 0.022, odds ratio (OR): 1.71, 95% confidence interval (CI): 1.12–4.35), Pfirrmann Grade II or III at baseline (p = 0.032, OR: 1.86, 95% CI: 1.17–5.41), and a high intensity MRI signal in the herniation (p = 0.041, OR: 1.87, 95% CI: 1.06–5.27) were significantly associated with early improvement. No patients had anaphylactic shock or neurologic sequelae.ConclusionsThis study confirms the safety and efficacy of chemonucleolysis with condoliase for treating patients with painful LDH. Age, high-intensity MRI signals, and baseline Pfirrmann grade were significant factors associated with early improvement.

Comparing Patient-Reported Outcomes in Patients Undergoing Lumbar Fusion for Degenerative Spondylolisthesis With Predominant Back Pain Versus Predominant Leg Pain Symptoms.

Retrospective review. This study aims to compare postoperative patient-reported outcome measures (PROMs) in predominant back pain (PBP) versus predominant leg pain (PLP) patients following lumbar fusion for degenerative spondylolisthesis (DS). Prior studies comparing PROMs in patients undergoing lumbar fusion with PBP versus PLP symptoms have included heterogeneous spinal pathology and restricted analysis to posterior fusion techniques. Demographics, perioperative characteristics, complications, and PROMs from a retrospective single-surgeon database were collected for primary, elective, and single-level lumbar fusion for DS. Preoperative/postoperative PROMs included visual analog scale (VAS)-back/leg pain (VAS-BP/VAS-LP), Oswestry disability index (ODI), 12-Item Short Form Physical and Mental Composite Score (SF-12 PCS/MCS), and Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF). Preoperative VAS-BP>VAS-LP established the PBP cohort and VAS-LP>VAS-BP established the PLP cohort. The average follow-up was 23.4±2.8 months. Improvement in PROMs (ΔPROM) at 6 weeks (ΔPROM-6W) and final follow-up (ΔPROM-FF) were calculated. χ2 and the Student t test analyzed categorical and continuous variables, respectively. Postoperative PROMs, ΔPROMs, and MCID achievement rates were compared between groups with multivariate linear or logistic regression. In total, 166 patients were selected with 108 in the PBP cohort. Both cohorts saw improvements in all PROM scores over time. The PBP cohort reported significantly greater ΔPROM-6W and ΔPROM-FF for VAS-BP (P<0.003). The PLP cohort reported greater ΔPROM-6W and ΔPROM-FF for VAS-LP and ΔPROM-FF for SF-12 PCS (P<0.014). MCID achievement rates for VAS-BP were higher in the PBP cohort, and VAS-LP MCID achievement rates were higher in the PLP cohort (P<0.015). Regardless of predominant pain location, patients-reported improvements in all PROs at the final follow-up. Patients with PLP-reported greater improvement in leg pain and physical function and patients with PBP-reported greater back pain improvement.

Xanthogranulomatous osteomyelitis: multimodality imaging of a rare case involving tibial diaphysis with review of literature.

The case report discusses xanthogranulomatous osteomyelitis, a rare inflammatory bone condition that can resemble malignancy on imaging studies. The report details a case of a 42-year-old woman with left leg pain, swelling, and redness lasting 4months. Imaging revealed a lytic lesion in the left tibia with endosteal erosion, and MRI showed extraosseous soft tissue extension. An open biopsy confirmed xanthogranulomatous osteomyelitis. Following surgical curettage and bone grafting, the patient recovered well at subsequent follow-ups until 1year after surgery. The article emphasizes the importance of distinguishing xanthogranulomatous osteomyelitis from other malignancies and discusses its epidemiology, clinical presentation, diagnostic techniques, and relevant imaging features, highlighting the potential for misdiagnosis based on overlapping characteristics with conditions like lymphoma and Ewing sarcoma.