Percutaneous Endoscopic Spine Surgery Research Articles

A Multi-Element Identification System Based on Deep Learning for the Visual Field of Percutaneous Endoscopic Spine Surgery.

Lumbar disc herniation is a common degenerative lumbar disease with an increasing incidence. Percutaneous endoscopic lumbar discectomy can treat lumbar disc herniation safely and effectively with a minimally invasive procedure. However, the learning curve of this technology is steep, which means that initial learners are often not sufficiently proficient in endoscopic operations, which can easily lead to iatrogenic damage. At present, the application of computer deep learning technology to clinical diagnosis, treatment, and surgical navigation has achieved satisfactory results. The objective of our team is to develop a multi-element identification system for the visual field of endoscopic spine surgery using deep learning algorithms and to evaluate the feasibility of this system. We established an image database by collecting surgical videos of 48 patients diagnosed with lumbar disc herniation, which was labeled by two spinal surgeons. We selected 6000 images of the visual field of percutaneous endoscopic spine surgery (including various tissue structures and surgical instruments), divided into the training data, validation data, and test data according to 2:1:2. We developed convolutional neural network models based on instance segmentation-Solov2, CondInst, Mask R-CNN and Yolact, and set the four network model backbone as ResNet101 and ResNet50 respectively. Mean average precision (mAP) and frames per second (FPS) were used to measure the performance of each model for classification, localization and recognition in real time, and AP (average) is used to evaluate how easily an element is detected by neural networks based on computer deep learning. Comprehensively comparing mAP and FSP of each model for bounding box test and segmentation task for the test set of images, we found that Solov2 (ResNet101) (mAP = 73.5%, FPS = 28.9), Mask R-CNN (ResNet101) (mAP = 72.8%, FPS = 28.5) models are the most stable, with higher precision and faster image processing speed. Combining the average precision of the elements in the bounding box test and segmentation tasks in each network, the AP(average) was highest for tool 3 (bbox-0.85, segm-0.89) and lowest for tool 5 (bbox-0.63, segm-0.72) in the instrumentation, whereas in the anatomical tissue elements, the fibrosus annulus (bbox-0.68, segm-0.69) and ligamentum flavum (bbox-0.65, segm-0.62) had higher AP(average),while extra-dural fat (bbox-0.42, segm-0.44) was lowest. Our team has developed a multi-element identification system for the visual field of percutaneous endoscopic spine surgery adapted to the interlaminar and foraminal approaches, which can identify and track anatomical tissue (nerve, ligamentum flavum, nucleus pulposus, etc.) and surgical instruments (endoscopic forceps, an high-speed diamond burr, etc.), which can be used in the future as a virtual educational tool or applied to the intraoperative real-time assistance system for spinal endoscopic operation.

Percutaneous full-endoscopic uniportal decompression for the treatment of symptomatic idiopathic lumbar spinal epidural lipomatosis: Technical note.

BackgroundLumbar spinal epidural lipomatosis (SEL) is a rare condition characterized by an excessive accumulation of adipose tissue within the spinal canal, compressing the dura sac and/or nerve roots. When conservative treatments fail and clinical symptoms progress quickly and seriously, surgical decompression should be considered. With the rapid development of endoscopic armamentaria and techniques, the pathological scope that can be treated by percutaneous endoscopic spine surgery is ever expanding.ObjectiveIn this paper, the authors describe a patient with lumbar spinal epidural lipomatosis who was treated with a percutaneous full-endoscopic uniportal decompression surgery successfully. This article aims to validate the feasibility of percutaneous full-endoscopic uniportal decompression for the treatment of symptomatic idiopathic spinal epidural lipomatosis via interlaminar approach.MethodsWe describe a case of a 69-year-old man with a 10-year history of low back pain, intermittent claudication, and bilateral leg neuropathic pain. He was diagnosed with lumbar epidural lipomatosis, which did not respond to conservative therapy. After a comprehensive evaluation, he underwent percutaneous endoscopic spine surgery to remove hyperplastic adipose tissue and decompress nerve roots and dura sac.ResultsThe patient was treated with a percutaneous full-endoscopic uniportal decompression surgery successfully. After the procedure, his leg pain decreased and his walking capacity improved. There were no surgery-related complications, such as cerebrospinal fluid leakage, incision infection, etc.ConclusionsThe case with SEL was successfully treated with a percutaneous full-endoscopic uniportal surgery, which has the advantages of excellent presentation of anatomical structures, expanded field of vision, less surgical-related trauma, and bleeding. The key point of the procedure is to release and cut off the bands which divide the epidural space into small rooms filled with excess adipose tissue.

Clinical Features and Management of Seizure After Percutaneous Endoscopic Spine Surgery: A Retrospective Case Series Analysis

To describe the perioperative clinical features, management, and outcomes of patients with seizure after percutaneous endoscopic spine surgery (PESS). Patients who experienced seizure after PESS in a tertiary orthopedic hospital between January 2016 and June 2022 were retrospectively recruited, and patient charts were reviewed. Twenty-nine patients were recruited, and the incidence of seizure after PESS was 0.52%. The operation time was 110.0 minutes (interquartile range [IQR], 82.5-235.0 minutes) and the irrigation speed was 109.0 mL/minute (IQR, 86.5-145.5 mL/minute). Definitive dural tears were reported in 15 patients (51.7%). In addition to agitation and myotonia, significant increased respiratory rate (29.9 ± 6.5 breaths/minute), tachycardia (112.1 ± 20.6 beats/minute), and hypertension (systolic, 189.5 ± 21.9 mm Hg; diastolic, 98.3 ± 10.6 mm Hg) were observed. Arterial blood gas analysis showed hypocapnia, metabolic acidosis, and hyperlactatemia. All patients received analgesia and sedation as well as hyperosmolar therapy. The estimated duration of seizure was 3.0 hours (IQR, 2.5-4.0 hours) and the postoperative length of hospital stay was 3.0 (IQR, 3.0-5.5) days. The Japanese Orthopaedic Association score and visual analog scale score improved markedly within 6 months after surgery. Despite the low incidence and short duration, seizure after PESS should be considered a critical and urgent syndrome. Management strategies for seizure mainly involve intensive care, securing the airway, analgesia and sedation, hyperosmolar therapy, and negative fluid balance. No significant adverse effects of seizure on clinical outcomes were observed during 6 months of follow-up.

Efficacy Analysis of Percutaneous Endoscopic Spinal Surgery for Young Patients with Discogenic Low Back Pain.

PurposeTo evaluate the application value of percutaneous endoscopic spinal surgery for young patients with discogenic low back pain (DLBP) and to judge its clinical efficacy.MethodsWe retrospectively analyzed young patients with single-segment discogenic lumbago from July 2018 to June 2020 in our department who underwent percutaneous endoscopic surgery according to the inclusion and exclusion criteria. We finally enrolled 20 patients. The follow-up time was 6–30 months. In all patients, we recorded the visual analog scale (VAS) score for waist pain and the Oswestry Disability Index (ODI) preoperatively, immediately postoperatively and at the last follow-up. We used the modified MacNab criteria to assess the curative effect at the last follow-up.ResultsAll 20 patients underwent successful operations without complications. No recurrence was observed during follow-up. The VAS score of low back pain was 5.05±1.19 points before surgery, 1.50±051 points immediately after surgery, and 1.10±0.72 points at the last follow-up (P < 0.05 preoperative vs both postoperative). At the last follow-up, the VAS scores of all 20 patients were ≤2, and 4 patients had no pain. The ODI was 46.66±7.03% before surgery, 9.78±4.05% immediately after surgery, and 4.11±3.18% at the last (P < 0.05, preoperative vs both postoperative). According to the evaluation under the modified MacNab standard, the good–excellent rate of clinical efficacy at the last follow-up was 95%.ConclusionPercutaneous endoscopic spinal surgery can significantly improve the symptoms and dysfunction of young patients with DLBP and has little effect on the biomechanical stability of the lumbar spine. This surgery has great clinical application value.

Clinical Features and Management of Seizure Following Percutaneous Endoscopic Spine Surgery: A Retrospective Case Series Analysis

Clinical Features and Management of Seizure Following Percutaneous Endoscopic Spine Surgery: A Retrospective Case Series Analysis

Consideration on progressive expanding the indications of percutaneous endoscopic spine surgery

Consideration on progressive expanding the indications of percutaneous endoscopic spine surgery

Full-Endoscopic Decompression with the Application of an Endoscopic-Matched Ultrasonic Osteotome for Removal of Ossification of the Thoracic Ligamentum Flavum

Resection of the ossification of the thoracic ligamentum flavum (OTLF) with a high-speed burr may cause a high rate of perioperative complications, such as dural laceration and/or iatrogenic spinal cord injury. The aim of this study was to investigate the safety and feasibility of the endoscopic-matched ultrasonic osteotome in full-endoscopic spinal surgery for direct removal of OTLF. Retrospective study. All data were from Honghui Hospital in Xi'an. This study conducted between December 2017 and December 2018, included 27 consecutive patients who met the study criteria, had single-level OTLF, and underwent full-endoscopic decompression under local anesthesia. The postoperative follow-up was scheduled at 1, 3, 6, and 12 months postoperatively. Outcomes evaluations included the Visual Analog Scale (VAS) score for lower extremity pain and the modified Japanese Orthopaedic Association (mJOA) score and improvement rate for the assessment of thoracic myelopathy. Removal of OTLF was measured by comparing the pre- and postoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans. The operation was completed in all patients without conversion to open surgery. The operation time ranged from 65 to 125 minutes (average, 83.7 ± 12.3 minutes). All patients were followed up for 12 to 18 months, with an average follow-up of 14.3 ± 1.3 months. Satisfactory neurologic decompression was confirmed by postoperative CT and MRI, and no revision surgery was required. The VAS and mJOA scores showed statistically higher improvement at the 1-month follow-up and the last follow-up compared with the preoperative assessment (P < 0.05). According to the improvement rate at the final follow-up, 20 cases were classified as good, 6 cases were fair, and 1 case remained unchanged. A single-center, noncontrol study. The endoscopic-matched ultrasonic osteotome can be considered quite safe and feasible for direct removal of OTLF during full-endoscopic spinal surgery in strictly selected patients, as this allows for effective direct decompression of OTLF while minimizing trauma and instability. In addition, because of the design characteristics of the ultrasonic osteotome, surgical complications, especially dural tears and spinal cord injury, can also be effectively controlled.

Feasibility of Unilateral Approach for Bilateral Decompressive Endoscopic Spinal Surgery for Lumbar Stenosis to Improve Back and Leg Pain: A Consecutive Single-Center Series of 60 Patients.

Introduction: Endoscopic surgery is one of the methods that achieve the goal of decompression while minimizing collateral tissue damage. Its efficacy and safety have been supported by numerous studies. There is a plethora of studies on lumbar stenosis regarding the outcomes and related issues in endoscopic spine surgery. However, few studies evaluated the outcome of the decompressive lumbar spine surgery. The present study aims to analyze the outcome of a unilateral approach to endoscopic surgery for lumbar stenosis using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and MacNab's criteria.Methods: This is a retrospective study (level IV) conducted between January 2009 and December 2013 on 60 patients who underwent endoscopic interlaminar decompressive spine surgery (Destandau method) for lumbar degenerative spinal stenosis in the Hospital Universiti Sains Malaysia. The clinical outcome was measured pre-operatively and post-operatively for VAS: for back and leg pain, motor and sensory grading, the ODI, and MacNab's criteria. A paired t-test was used for statistical analysis.Results: The mean age of patients was 60.82 years comprising 23 males (38.3%) and 37 females (61.7%). The mean follow-up period was 30.1 months (range = 17.2–43 months). The mean operation time was 183.6 min (ranging from 124.8 to 242.4 min), and the mean blood loss was 150.18 mL (ranging from 30.82 to 269.54 mL). Post-operatively, mean hospital stay was 2.45 days (ranging from 1.34 to 3.56 days). The most frequently involved level was L4/L5 in 51 patients (52.6%), followed by L3/L4 in 19 patients (19.6%), L5/S1 in 24 patients (24.7%), and L2/L3 in three patients (3.1%). Improvement in the post-operative VAS for back and leg pain and the ODI for pre-operation and post-operation was statistically significant (p < 0.001). Conversely, the reduction in neurological status was statistically insignificant. Based on MacNab's criteria, 88.4% showed excellent to good outcomes.Conclusion: To summarize, unilateral percutaneous endoscopic spine surgery to achieve the bilateral decompression in lumbar stenosis provides excellent yet safe and effective outcomes. It improves back and leg pain and patients' function significantly.

Progression and clinical application in unilateral biportal endoscopic

With the advantages of less operative injury and quicker postoperative recovery time, percutaneous endoscopic spine surgery system is currently one of the most widely used minimal invasive spine surgery techniques in China. However, this technique usually requires surgeon to operate in a single cannula, which brings much inconvenience such as limited vision, small range of motion and low efficiency. Meanwhile, the increasingly popular technique of unilateral biportal endoscopic (UBE) surgery possesses the advantages of better operation visual field, more flexible in operation, shorter learning curve period, handier surgical instruments for spine surgeon, and minimize radiation dosage caused by intraoperative fluoroscopy when comparing with single cannula endoscopic technique, since UBE requires an additional portal for surgical instruments while the anther portal is placed for arthroscope and pressure pump irrigation system. This technique has been applied to the treatment of degenerative diseases of cervical and lumbar spine, facet cyst, spinal epidural lipomatosis and abscess, and has achieved satisfactory clinical results.

Therapeutic Effectiveness of Percutaneous Endoscopic Spinal Surgery for Intraspinal Cement Leakage Following Percutaneous Vertebroplasty: An Early Clinical Study of 12 Cases

Intraspinal cement leakage is a catastrophic complication of percutaneous vertebroplasty (PVP). Percutaneous endoscopic spinal surgery (PESS) for intraspinal cement leakage has rarely been reported. To evaluate the therapeutic effectiveness of PESS for intraspinal cement leakage following PVP. This was a retrospective study approved by the ethics committee of our institution. Department of Orthopedics from an affiliated hospital. Twelve patients with neurologic impairments resulting from intraspinal cement leakage after PVP were treated with PESS for spinal decompression from May 2014 to June 2018. Computed tomography and 3-dimensional reconstruction were used to confirm the vertebral level of cement leakage. The surgical index, neurologic function, and clinical results were recorded in this study. The leaked cement of all patients was successfully removed under PESS, and no severe intraoperative complications were reported in our study. The operation time ranged from 43 to 119 minutes (mean, 65.5 minutes). The amount of intraoperative blood loss was 64.25 ± 9.62 mL. The lengths of postoperative hospital stays were 5.25 ± 2.53 days. The follow-up rate was 83.3% (10/12). The follow-up time ranged from 14 to 30 months (mean, 22 months). The Visual Analog Scale scores of foraminal leaks improved from 6.50 ± 0.93 preoperatively to 1.75 ± 0.71 at the last follow-up (P < 0.05). Neurologic function was evaluated by Japanese Orthopaedic Association 29 scores, which improved from 18.75 ± 1.06 to 22.70 ± 1.64 (P < 0.0001). The good and excellent rates were 80% according to the modified Macnab criteria. This study is limited by the volume of patients and the deep learning curve needed for PESS. PESS, as a minimally invasive technique, can achieve targeted spinal cord decompression and may be a safe and effective alternative approach to conventional procedures for cement leakage after PVP. Endoscopes, cement leakage, minimally invasive surgery, percutaneous vertebroplasty.

Explorations of percutaneous endoscopic spine surgery

Explorations of percutaneous endoscopic spine surgery

Complications and limitations of endoscopic spine surgery and percutaneous instrumentation

Endoscopic spine surgery has started replacing conventional microdiscectomy in various centers across the globe. With development in the field of optics and instrumentation, the field of percutaneous endoscopic spine surgery has evolved immensely. With increasing experience, endoscopic spine surgeons have expanded the indications not only to lumbar paramedian disc herniations but also to central disc herniations, high-grade migrated disc herniations, sequestered herniations, thoracic and cervical disc herniations, and more recently, lumbar canal stenosis. With broadening indications, unexpected adverse events are bound to increase. Hence, it is essential for the endoscopic spine surgeons to be aware of the potential hazards and unexpected complications of the procedure so that appropriate care is taken to avoid adverse events as much as possible. In this article, we summarize all the complications of transforaminal endoscopic discectomy reported in the literature. We have classified the complications into intraoperative, immediate postoperative, and late postoperative complications. The senior author has also suggested the tips to avoid these complications and carry out the procedure as safely as possible. As percutaneous instrumentation, particularly, percutaneous pedicular screws, is also becoming common with the development of minimally invasive spine surgery, we have also summarized its complications and limitations. An insight into these complications will help the endoscopic surgeons to take special precautions when performing the procedure.

Biportal Endoscopic Spinal Surgery for Lumbar Spinal Stenosis.

Biportal endoscopic spinal surgery (BESS) is a minimally invasive spinal surgery, which is basically similar to microscopic spinal surgery in terms of the use of floating technique and technically similar to conventional percutaneous endoscopic spinal surgery in terms of the use of endoscopic or arthroscopic instruments. Using two independent portals (viewing and working) and maintaining a certain distance from the bony and neural structures allow closer access to the target lesion through a panoramic view by free handling of the scope and instruments rather than through a fixed view by docking into the Kambin’s triangle. Minimally invasive surgery allows for reduced dissection and inevitable muscle injury, preserving stability and reducing risks of restabilization. The purpose of fusion surgery is the same as that of the three surgical techniques stated above. Its wider range of view helps to overcome limitations of conventional endoscopic spinal surgery and to supplement the weak points of microscopic spinal surgery, such as limited working space in a tubular retractor and difficulty in accessing the contralateral area. This technique provides an alternative to unilateral or bilateral decompression of lumbar central spinal stenosis, foraminal stenosis, low-grade spondylolisthesis, and adjacent segment degeneration. Early clinical outcomes are promising despite potential for complications, such as dural tearing and postoperative epidural hematoma, similar to other procedures. Merits of BESS include decreased postoperative infection rate due to continuous irrigation throughout the procedure and decreased need for fusion surgery for one- or two-level lumbar stenosis by wide sublaminar and foraminal decompression with minimal sacrifice of stabilizing structures.

Percutaneous endoscopic spinal surgery for lumbar disc prolapse in Erbil city of Iraq: A study on 60 patients

Background: As an alternative to back surgeries, endoscopic spinal operations is the most effective and safe procedure that does not impose the fear reaction to the patients. Objective: In this study the results, complications, and outcomes of 60 patients complaining from prolapsed lumbar inter-vertebral discs who experienced prolapsed endoscopic lumbar discectomy (PELD) were reported. Patients and Methods: This is a prospective study conducted in three sentinel hospitals over a period of 3 years (2013-2015) in Erbil city of Iraq. Clinical findings in addition to pre-operative MRI were the main diagnostic methods used for including patients who were suffering from lumbar disc herniation at different levels. Clinical appraisal was done utilizing the modified Macnab criteria. The Storz lens spinoscope was utilized to perform PELD. Results: Sixty patients (37 males and 23 females) with lumbar disc herniation were included in the study. The mean operative time was 50 minutes. Patients were discharged during 1st 24 hours post-operatively. After surgery, patients were followed up for two months to three years with a mean of 18 months. Seven (11.7%) patients developed complications including one (1.7%) instance of shallow nerve injury, three (5%) with dural tears, two (3.3%) instances of intermittent delayed disc prolapse and one patient (1.7%) had post-operative discitis. Modified Macnab criteria (excluding patients with long dural tear) showed excellence results for 36 patients, while good results were observed for 17 patients, reasonable results for 3 patients and poor results for 2 patients. The achievement rate was 91.4% . Conclusion:Although endoscopic spinal discectomy is a compelling procedure for management of lumbar disc prolapse, and although its final outcome is reasonable it is not devoid from complications.

Percutaneous Endoscopic Spine Surgery for Extruded Lumbar Disc Herniation

The conventional open discectomy is the gold standard for treating extruded lumbar disc herniation, especially in highly migrated lumbar disc herniation. Endoscopic spine surgery is known to be very challenging and technically demanding, in particular for highly migrated disc herniation. However, several studies have reported numerous effective techniques with results approximatively equal to conventional open surgeries or mini-open surgery. In the last few years, an increased number of endoscopic spine surgical techniques have been proposed in order to overcome various issues encountered in traditional endoscopic spine surgery. Nevertheless, surgical approach selection for treating extruded lumbar disc herniation is based on aspects such as anatomical structures, availability of surgical instruments, surgeon’s experience, and the disc herniation location. Advances in endoscopic visualization and instrumentation, as well as an increased demand for minimally invasive procedures, have led to the popularity of Percutaneous Endoscopic Lumbar Discectomy (PELD). PELD is a recent and advanced technique among other minimally invasive spine surgeries (MIS). It includes various kinds of surgical techniques to treat lumbar disc herniation and aims to offer a safe, less invasive surgical procedure for lumbar disc space decompression and removal of nucleus pulposus.

Percutaneous Endoscopic Retrieval of Intraspinal Cement Leakage: Technical Note

We sought to preliminarily explore the efficacy and safety of percutaneous endoscopic spinal surgery for epidural cement leakage. We report a case series of patients who underwent percutaneous retrieval of leaked epidural cement and achieved spinal decompression under endoscopy. Five patients with neurologic impairment due to epidural cement leakage after percutaneous vertebroplasty were treated with percutaneous endoscopic spinal decompression. Computed tomography reconstruction and 3-dimensional imaging were used to evaluate the extruded material. During follow-up at 3, 6, and 12 months postoperatively, all patients were advised to undergo plain radiograph and computed tomography examinations. The leaked epidural cement was successfully removed in all patients under percutaneous endoscopy through a unilateral or bilateral approach. At the 12-month follow-up, the visual analog scale score of all patients improved. In addition, the neurologic function of each patient improved to at least 1 grade level, as evaluated using the American Spinal Injury Association. According to the modified MacNab criteria, 2 patients had excellent recovery, whereas the other 3 patients had good recovery. We described a novel and minimally invasive procedure to ameliorate intractable epidural cement extrusion. As an alternative to conventional laminectomy, percutaneous endoscopic retrieval achieved the targeted decompression without damaging the posterior lamina. Moreover, the whole operation was performed under regional anesthesia accompanied with dexmedetomidine sedation, allowed real-time neural function evaluation, and had lower risks of anesthesia-related complications, compared with general anesthesia.

Feasibility of Full Endoscopic Spine Surgery in Patients Over the Age of 70 Years With Degenerative Lumbar Spine Disease.

Background/AimsDegenerative spine disease, encompassing disc prolapse and stenosis, is a common ailment in old age. This prospective study was undertaken to evaluate the role of endoscopic spine surgery in elderly patients (above 70 years of age) with clinical and radiological follow-up. MethodsIn this study, a retrospective analysis was conducted of 53 patients with lumbar disc prolapse or spinal stenosis who were treated with percutaneous endoscopic discectomy or decompression from November 2015 to June 2017. Clinical follow-up was done at 1 week, 3 months, and 1 year, and at yearly intervals thereafter. The outcomes were assessed using the modified Macnab criteria, a visual analogue scale, and the Oswestry Disability Index. ResultsOf the 53 patients, 21 were men and 32 were women. Their mean age was 76±4 years. The mean follow-up period was 17 months. Percutaneous endoscopic discectomy was performed in 24 patients and endoscopic decompression in 24 patients, while 5 patients underwent combined surgery. An excellent outcome in terms of the MacNab criteria was observed in 9 patients (16.98%), a good outcome in 38 patients (71.7%), and a poor outcome in 6 patients (11.3%). Of the 6 patients with a poor outcome, 5 (9.4%, 5 of 53) developed recurrent disc prolapse, and 1 developed hematoma with motor weakness. All 6 of these cases required revision surgery. ConclusionManaging degenerative spine disease in elderly patients with multiple comorbidities is a challenging task. Percutaneous endoscopic spine surgery is pivotal for addressing this concern. The authors have shown that optimal results can be achieved with various types of disc prolapse and stenosis with favorable long-term outcomes.

Effectiveness of percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification

To investigate the feasibility, effectiveness, and security of percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification. Between July 2008 and June 2016, 96 patients with lumbar spine disorders (lumbar disc herniation or lumbar spinal stenosis) with intraspinal ossification were treated with percutaneous endoscopic spine surgery. There were 59 males and 37 females, aged from 13 to 57 years (mean, 29.5 years). The disease duration was 3-51 months (mean, 18.2 months). Fifty-one cases had trauma history. Ninety-two cases were single segmental unilateral symptom, 4 cases were bilateral symptom. The ossification property was posterior ring apophysis separation in 89 cases, and ossification of the fibrous ring or posterior longitudinal ligament in 7 cases. There were 32 cases of lateral type, 13 cases of central type, and 51 cases of mixed type. The pressure factors, such as nucleus pulposus, hyperplasia of the yellow ligament, joint capsule, or articular osteophyma, were removed under the microscope. Local anesthesia or continuous epidural anesthesia was performed in the transforaminal approach with 50 cases, and continuous epidural anesthesia or general anesthesia was performed in the interlaminar approach with 46 cases. The visual analogue scale (VAS) score was used to evaluate the degree of leg pain preoperatively and at last follow-up. The effectiveness was evaluated at last follow-up according to the modified Macnab criteria. All patients were successfully operated. Via transforaminal approach, the mean operation time was 53 minutes and the mean intraoperative fluoroscopy times was 8 times; and via interlaminar approach was 58 minutes and 3 times, respectively. The mean bed rest time after operation was 6.5 hours and the mean hospitalization time was 4.7 days. All patients were followed up 6-18 months (median, 11 months). Postoperative lumbar CT scan and three-dimensional reconstruction after 3 days of operation showed that ossification tissues of 26 cases were not resected, 12 cases were resected partly, and 49 cases were resected completely. Postoperative lumbar MRI after 3 months of operation showed that spinal cord and nerve root were not compressed. At last follow-up, VAS score of leg pain was 0.7±1.1, which was significantly lower than preoperative score (5.8±1.1) ( t=1.987, P=0.025). At last follow-up, according to modified Macnab criteria, the results were excellent in 87 cases, good in 5 cases, and fair in 4 cases, and the excellent and good rate was 95.8%. Percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification is an effective, safe, and minimal invasive alternative, and the short-term effectiveness is reliable. Accounting for the treatment of intraspinal ossification, comprehensive analysis should be made by combining clinical symptoms, imaging characteristics, and risk assessment.

Guidelines for percutaneous endoscopic spinal surgery

Randomized controlled trials have demonstrated equal effectiveness of the endoscopic procedures compared to the microsurgical reference procedures in cervical as well as in lumbar applications. Some of these studies also showed lower complication rates with endoscopy and none had higher complication rates with endoscopy. In these trials, spinal endoscopy generated less postoperative pain and faster rehabilitation than the microsurgical procedures. However, all these trials with one exception were performed by the same team of highly experienced endoscopic spinal surgeons. It is conceivable, that surgeons with less experience may not necessarily be able to achieve the same results. RCTs from other groups will have to prove or disprove this assumption. Sofar, no long-lasting advantages of endoscopic spine surgery over the microsurgical technique have been demonstrated. There is some experimental evidence that the effects of reduced access trauma can be measured, but interestingly, there seems to be no advantage of using a microtubular retractor system over standard microsuraical techniaue and instruments.

Percutaneous endoscopic spinal surgery for degenerative disc disease 1989-2009 : From pioneering applications to proven standards

Percutaneous endoscopic spinal surgery for degenerative disc disease 1989-2009 : From pioneering applications to proven standards