Decompression Technique Research Articles

Surgical Treatment of Patients with Acute Pancreatitis in Sterile Stage 
 and in Biliary Etiology of the Disease

The main indication for surgical treatment in acute pancreatitis (AP) is infected necrosis in the late phase of the disease. However, some patients require surgery in the sterile stage including the earliest period. In sterile necrosis interventions are associated with the risk of infection and increased mortality, being the responsibility of a surgeon. Patients with biliary AP often require early interventions and specific tactic regarding the pathology of the biliary tract. The review analyses recent studies and modern practical recommendations on the surgical treatment of patients with AP in the sterile stage and in biliary etiology. Obstruction of bile duct and cholangitis, enzymatic peritonitis, abdominal compartment syndrome caused by ineffective conservative measures, massive pancreatogenic accumulations with the threat of a rupture into the abdominal cavity, pain syndrome, compression of the adjacent organs often resulted from the disconnected pancreatic duct syndrome require invasive interventions to prevent the development of infectious necrosis. A number of questions have an ambiguous solution. The threshold level of intra-abdominal pressure, the rate of its increase, or other apparent criteria for the implementation of surgical decompression and the choice of decompression technique for abdominal compartment syndrome have not been stated. The optimal timing and the priority method of drainage in the disconnected pancreatic duct syndrome remain uncertain. The management of patients with biliary acute pancreatitis regarding prophylactic endoscopic papillotomy is controversial. Further, well-designed research studies involving surgical treatment of patients with acute pancreatitis are needed.

Microendoscopic Lumbar Posterior Decompression Surgery for Lumbar Spinal Stenosis: Literature Review.

Lumbar spinal stenosis (LSS) is a common disease in the elderly, mostly due to degenerative changes in the lumbar spinal complex. Decompression surgery is the standard surgical treatment for LSS. Classically, total laminectomy—which involves resection of the spinous process, entire laminae and medial facet—has been the standard decompression technique; however, it can cause post-surgical instability. To overcome this disadvantage, various minimally invasive techniques that preserve the stabilization structures of the spine have been developed, and surgeons have begun to re-evaluate decompression surgery from the standpoint of reduced invasiveness and cost. More than two decades have passed since the introduction of microendoscopic spine surgery, and studies continue to shed light on its advantages and limitations as new knowledge becomes available. This article is a narrative review of the available literature, along with authors’ experience, regarding the indications, surgical techniques, clinical outcomes, and limitations/complications of microendoscopic decompression for LSS.

Technique of Microvascular Decompression for Hemifacial Spasm Based on Surgical Anatomy

This article describes the anatomical approach and operative points of microvascular decompression for hemifacial spasm based on the author's personal experience with 1,000 cases. As vascular compression of the facial nerve is often quite caudal, it is necessary to ensure that the compressing arteries in this area are moved. Neither the vessels nor the prosthesis used to move them should not touch the root exit zone of the nerve(vascular transposition nerve isolation technique). It should also be emphasized that every effort should be made to avoid complications such as hearing impairment and postoperative subcutaneous spinal fluid accumulation.

Endoscopic Sciatic Neurolysis for Deep Gluteal Space Syndrome

Background: Deep gluteal syndrome (DGS) encompasses a spectrum of pathologies causing symptomatic sciatic nerve compression deep to the gluteus maximus muscle. Endoscopic sciatic neurolysis is an option for management of DGS when conservative treatment fails. Indications: Endoscopic sciatic neurolysis is indicated for retro-trochanteric pain, sciatica-like burning in the posterior thigh, and sitting discomfort that is reproducible on physical examination after failing conservative management. Technical Description: The technique presented here introduces a standard endoscopic sciatic neurolysis technique with an accessory posterolateral portal placed distally and in line with the sciatic nerve. Use of a switching stick through an accessory distal posterolateral portal can allow for in-line protection and retraction of the sciatic nerve while it is carefully released from compressive fibrous bands using an arthroscopic shaver. It is important that the accessory portal be placed under direct visualization with caution not to injure the sciatic nerve. An arthroscopic radiofrequency device can be used for hemostasis and further release of fibrous bands. At the end of the procedure, the sciatic nerve should be visualized fully released and freely mobile from the piriformis muscle to the level of the lesser trochanter. Results: In properly selected patients, the procedure is very successful. In a series of 35 cases, the procedure reduced sitting pain (present in 97% of patients preoperative, 17% of patients postoperative), reduced narcotic use, improved visual analog scale (VAS) pain scores, and improved modified Harris hip scores without major complications. Discussion: Although rare following hip arthroscopy, postoperative scarring and fibrous bands are a common cause of DGS which can be effectively treated by endoscopic sciatic nerve decompression. Results of endoscopic sciatic neurolysis have thus far been encouraging with improvements in patient reported outcome scores and high rates of satisfaction. However, complications do occur and can result in neurologic deficits. Nevertheless, with careful patient selection and meticulous sciatic nerve dissection, endoscopic sciatic neurolysis for DGS is a safe and effective technique for decompression of fibrous bands and adhesions that can lead to sciatic neuralgia.

Oblique lateral interbody fusion combined with lateral plate fixation for the treatment of degenerative diseases of the lumbar spine: A retrospective study.

Oblique lateral interbody fusion (OLIF) is a minimally invasive decompression technique used in the treatment of lumbar degenerative diseases (LDDs). It is usually combined with posterior pedicle screw fixation to decrease perioperative complications. Few studies have reported the efficacy of OLIF combined with lateral plate instrumentation (OLIF-LP) for the treatment of LDDs.The purpose of this retrospective study was to evaluate the clinical efficacy of OLIF combined with lateral plate instrumentation for the treatment of LDDs.From May 2020 to September 2020, the clinical data of 52 patients who underwent OLIF-LP were analyzed. The operation time, blood loss, and complications were recorded. The radiological parameters, visual analog scale score, and Oswestry Disability Index were evaluated.The average operation time, blood loss, and length of hospital stay were 75.41 ± 11.53 minutes, 39.57 ± 9.22 mL, and 7.22 ± 1.85 days, respectively. The visual analog scale score and Oswestry Disability Index both improved significantly after surgery (7.23 ± 1.26 vs 2.15 ± 0.87; 60.27 ± 7.91 vs 21.80 ± 6.32, P < .01). The postoperative disk height was 13.02 ± 8.83 mm, which was much greater than the preoperative value. The postoperative foraminal height improved significantly (16.18 ± 3.49 vs 21.54 ± 2.12 mm, P < .01), and the cross-sectional area improved from 88.95 ± 14.79 to 126.53 ± 8.83 mm2 (P < .001). The radiological fusion rate was 88% at the last follow-up. No major complications, such as ureteral injury, vascular injury, or vertebral body fracture, occurred.Use of the OLIF-LP technique can help avoid lumbar posterior surgery and minimize the operative time and blood loss. OLIF-LP can achieve 1-stage intervertebral fusion and instrumentation through a single small incision.

Standard incision and median nerve external neurolysis for recalcitrant carpal tunnel syndrome

Purpose: Failed carpal tunnel surgery poses a challenge for the attending surgeon(s). Numerous revision techniques have been reported in the literature, with evidence of long-term improvement. However, studies exploring how early could symptomatic improvement be detected are scarce. The objective of this study was to identify the speed of symptom(s) recovery after a repeated decompression technique using an open standard incision and median external nerve neurolysis with no supplemental procedures.Methods: Nine patients who underwent revision carpal tunnel surgery involving standard incision, external median neurolysis, and no supplemental techniques between June 2017 and June 2020, were included. Data regarding the preoperative Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score, Disabilities of the Arm, Shoulder and Hand score, visual analogue score, and grip strength were collected and compared with evaluation results at 3 months postoperatively. Results: In all patients, severe adhesion of the median nerve with the surrounding soft tissue was confirmed intraoperatively. Compared with preoperative findings, 3-month evaluation of patients demonstrated a statistically significant improvement in the BCTQ symptoms score and pain score. All nine patients were satisfied with the procedure. Conclusion: Standard incision and median nerve external neurolysis can be a good option for recalcitrant carpal tunnel syndrome patient who has an adhesion of the median nerve with surrounding soft tissue.

Injuries to the Peripheral Blood Vessels

Contributions from the armed conflicts of the 20th century have defined the standards for vessel ligation or repair of arterial and venous injuries. Since the Vietnam War, there has been considerable modernization in the battlefield medical environment, and forward surgical capability, expeditious evacuation and new and effective resuscitation strategies have provided the foundation for innovation and progress. Lessons learned during current US military operations continue to advance the practice of vascular trauma surgery, and these techniques are directly translated to surgical practices in trauma centers around the world. This review covers mechanisms and sites of extremity vascular injury, initial assessment, management, and special considerations. Figures show an avulsion injury, in which an artery is stretched, an algorithm for the workup of a patient with a potential extremity vascular injury, an algorithm for the management of complex extremity trauma, exposure of the axillary artery, exposure of the brachial artery, exposure of the femoral artery, medial exposure of the proximal and distal popliteal arteries, the two-incision technique for lower leg decompression in compartment syndrome, and incisions for forearm decompression in compartment syndrome. This review contains 11 figures, 6 tables, and 84 references

Injuries to the Peripheral Blood Vessels

Contributions from the armed conflicts of the 20th century have defined the standards for vessel ligation or repair of arterial and venous injuries. Since the Vietnam War, there has been considerable modernization in the battlefield medical environment, and forward surgical capability, expeditious evacuation and new and effective resuscitation strategies have provided the foundation for innovation and progress. Lessons learned during current US military operations continue to advance the practice of vascular trauma surgery, and these techniques are directly translated to surgical practices in trauma centers around the world. This review covers mechanisms and sites of extremity vascular injury, initial assessment, management, and special considerations. Figures show an avulsion injury, in which an artery is stretched, an algorithm for the workup of a patient with a potential extremity vascular injury, an algorithm for the management of complex extremity trauma, exposure of the axillary artery, exposure of the brachial artery, exposure of the femoral artery, medial exposure of the proximal and distal popliteal arteries, the two-incision technique for lower leg decompression in compartment syndrome, and incisions for forearm decompression in compartment syndrome. This review contains 11 figures, 6 tables, and 84 references

Lateral Transtumoral Transforaminal Removal of Cervical Dumbbell Tumors

Abstract Background Cervical dumbbell tumors constitute 15% of cervical nerve sheath tumors. These tumors occupy intraspinal, foraminal, and extraspinal compartments. Laminectomy, laminectomy and facetectomy and anterolateral partial vertebrectomy are the approaches used to address these multicompartment tumors. Laminectomy leads to incomplete tumor removal. Other approaches ensure complete tumor excision but involve more extensive bone work. Objective We describe our surgical technique and clinical experiences of six patients treated through single lateral approach, addressing all compartments (transforaminal approach) with minimal or no bony resection. Methods Six patients with cervical dumbbell tumors underwent minimally invasive transforaminal approach and tumor excision. The cohort consisted of four women and two men. All patients underwent complete tumor excision Technique Intraoperative X-ray and ultrasound are used to localize the respective foramen. Skin is entered from the lateral side and sequential dilatation is done through muscles. The dilators and port are docked to the lateral surface of articular facets. Standard technique of capsule dissection, internal decompression and capsule mobilization is done to remove the tumor. Arachnoid is seen at the end. Tumor cavity is obliterated with fat graft. Results Total excision of tumor was documented in all patients with postoperative MRI scan. The mean blood loss was 100 mL. The patients could be discharged on second or third postoperative day. Mean follow-up is of 48 months (18–70 months) and all patients had resolution in features of myelopathy. Conclusions Endoportal transforaminal approach is technically feasible and minimally invasive option to remove the dumbbell schwannomas.

Management of periapical lesion with persistent exsudate

This case describes the treatment and follow-up of a mandibular molar in an 18-year-old female with a periapical cyst. Thus, it becomes important to know which options should we take when faced with a clinical situation that we cannot resolve through conventional methods, and which techniques and approaches we have to achieve treatment success. This case showed the treatment plan and follow-up, by the use of CBCT images, from a previously treated mandibular molar with a large periapical abscess and cystic lesion, in which, the first treatment plan approach was to make the endodontic retreatment. During the chemo-mechanical preparation the presence of permanent intracanal purulent exudate made it impossible to dry the canals, impeding obturation of the root canal system. Due to this clinical situation, a surgical approach was performed with the intention of reduce this permanent exudate and to execute a decompression technique. Clinical findings, periapical radiographs and cone beam computed tomographic, indicated almost complete resolution of the radiolucency, after a one-year follow-up.

Circumferential Decompression Technique of Posterior Endoscopic Cervical Foraminotomy.

Objective Cervical osseous foraminal stenosis (COFS) results from the uncinate process and facet hyperostosis. Currently, the optimal surgical technique for the treatment of COFS remains controversial. Materials and Methods Patients with COFS presenting radiculopathy underwent posterior endoscopic cervical foraminotomy by the circumferential decompression technique. The neck disability index (NDI), the visual analogue scale (VAS), and the modified MacNab criteria were used to evaluate the outcomes. In addition, the range of motion (ROM) and the slippage distance between the operated vertebrae in flexion-extension position were measured to evaluate the stability of the cervical spine. Results There were 24 consecutive patients in the study. The mean follow-up period was 16.2 months (range: 12-26 months). The NDI and VAS scores for arm/neck pain improved significantly from preoperatively to the last follow-up. The satisfaction rate by modified MacNab criteria was 91.7% on the third postoperative day and 100% on the day of final follow-up. There were no significant differences in intervertebral ROM or slippage distance between the last follow-up and preoperatively (P = 0.968, P = 0.394). Arm pain occurred in one patient, and sustained fingers numbness in two patients, but these symptoms resolved at the last follow-up. Conclusions Posterior endoscopic cervical foraminotomy by the circumferential decompression technique is a safe and effective treatment for COFS. Moreover, it preserves the stability and physiological mobility of the cervical spine.

Microsurgical decompression of the peroneal nerve in treatment of fibular tunnel syndrome

Fibular tunnel syndrome (FTS) is the most common neuropathy of the lower extremity. Compression of the peroneal nerve leads to movement and sensory disorders, which is manifested by weakness of the muscles that normally provide dorsiflexion of the foot and toes, gait disturbance and loss of sensitivity. Our study involved 30 patients with symptoms of FTS. All underwent microsurgical two-level decompression of the peroneal nerve. In the postoperative period, the results of the operation were assessed by changes in sensory and motor neurological deficits according to the British Medical Research Council Scale (BMRCS). It has been proven that the peroneal nerve decompression technique is an effective way to treat primary and secondary FTS. In this case, the restoration of sensitive fibers occurs earlier than motor ones. Taking into account the similarity of clinical manifestations with proximal lesions and the structural features of the canal, it is necessary to develop a clinic-diagnostic algorithm to determine the therapeutic tactics and the volume of surgical intervention.

Spinal decompression with patient-specific guides

BACKGROUND CONTEXTPatient-specific instruments (PSI) have been well established in spine surgery for pedicle screw placement. However, its utility in spinal decompression surgery is yet to be investigated. PURPOSEThe purpose of this study was to investigate the feasibility and utility of PSI in spinal decompression surgery compared with conventional freehand (FH) technique for both expert and novice surgeons. STUDY DESIGNHuman cadaver study. METHODSThirty-two midline decompressions were performed on 4 fresh-frozen human cadavers. An expert spine surgeon and an orthopedic resident (novice) each performed 8 FH and 8 PSI-guided decompressions. Surgical time for each decompression method was measured. Postoperative decompression area, cranial decompression extent in relation to the intervertebral disc, and lateral recess bony overhang were measured on postoperative CT-scans. In the PSI-group, the decompression area and osteotomy accuracy were evaluated. RESULTSThe surgical time was similar in both techniques, with 07:25 min (PSI) versus 06:53 min (FH) for the expert surgeon and 12:36 min (PSI) vs. 11:54 (FH) for the novice surgeon. The postoperative cranial decompression extent and the lateral recess bony overhang did not differ between both techniques and surgeons. Further, the postoperative decompression area was significantly larger with the PSI than with the FH for the novice surgeon (477 vs. 305 mm2; p=.01), but no significant difference was found between both techniques for the expert surgeon. The execution of the decompression differed from the preoperative plan in the decompression area by 5%, and the osteotomy planes had an accuracy of 1–3 mm. CONCLUSIONPSI-guided decompression is feasible and accurate with similar procedure time to the standard FH technique in a cadaver model, which warrants further investigation in vivo. In comparison to the FH technique, a more extensive decompression was achieved with PSI in the novice surgeon's hands in this study. CLINICAL SIGNIFICANCEThe PSI-guided spinal decompression technique may be a useful alternative to FH decompression in certain situations. A special potential of the PSI technique could lie in the technical aid for novice surgeons and in situations with unconventional anatomy or pathologies such as deformity or tumor. This study serves as a starting point toward PSI-guided spinal decompression, but further in vivo investigations are necessary.

Endoscopic decompression for lumbar spinal canal stenosis

Laminectomy and fusion were surgical options to decompress neural structures and provide more space for the spinal cord in a stenosis patient with severe leg pain and progressive neurologic signs, such as numbness and weakness. The evolution of endoscopic spinal surgery techniques has created advantages for patients who require a laminectomy. The authors present a unique technique for endoscopic access to the central and lateral recess pathology as a minimally invasive procedure, which provides a good visualization. We performed two cases of endoscopic spinal surgery for single-level and consecutive three-level lumbar spinal canal stenosis using an 8 mm outer diameter, 5.5 mm working channel, 10° angled lens spinal endoscopic system (percutaneous stenoscopic lumbar decompression, MaxMore Spine Company, Unterföhring, Germany). Optimized endoscopic drills, forceps, and Kerrison punch were used to remove bony pathology and ligamentum flavum under direct endoscopic visualization. The first case had a narrow canal space in the L4/L5 segment with severe numbness at the same dermatome and did not respond with adequate conventional treatment. The second case had three-level canal stenosis with severe back pain and leg weakness. The purpose of this paper is to describe the technique, the efficacy, and feasibility of unilateral endoscopic laminectomy and bilateral decompression via posterior approach in lumbar spinal canal stenosis. Moreover, in this article, we present the technical details on endoscopic procedures and the prevention of complications and management during operation for spinal canal stenosis.

Эндоскопическое лечение дегенеративного стеноза позвоночного канала

Microsurgical decompression technique has been regarded as the standard surgical method in degenerative spinal diseases to date. The conventional method may lead to instability and lead to chronic lower back pain due to injury of facet joints, posterior ligamentous complex, as well as paraspinal muscles. To avoid these complications, the new biportal endoscopic technique has been introduced in our clinical practice. Since 2019, we have been widely using this technique and for the first time in Russia we have accumulated unique experience that allowed us to complete this article. The aim of this study is to demonstrate a new biportal endoscopic spinal surgical technique’s possibility in treatment of degenerative lumbar spine diseases and to report the results of using this technique in our clinic. Study design: retrospective study. One hundred two patients who were suffering from neurologic symptoms by degenerative lumbar spine diseases were included in study. All patients were divided into 3 groups according to the clinical condition: 1st group — patients with degenerative central spinal stenosis who underwent biportal endoscopic bilateral decompression using a unilateral approach, 2nd group — patients with foraminal spinal stenosis who underwent biportal endoscopic foraminotomy using a extraforaminal approach, 3rd group — patients with degenerative monosegmental instability, degenerative or isthmic spondylolisthesis who underwent biportal endoscopic lumbar interbody fusion. Clinical outcomes were analyzed in accordance with modified-Macnab criteria, Oswestry Disability Index (ODI), Numeral rating scale (NRS), also postoperative complications were analyzed. There was a significant improvement in the dynamics of pain syndrome, ODI scale in all 3 groups. According to the McNab scale, no unsatisfactory results were observed in any group. There were 4 cases of durotomy. In all cases, the durotomy did not exceed 3 mm and did not require further treatment. No cases of infectious complications were identified. Biportal endoscopic surgery can be considered an alternative to the traditional microsurgical technique of spinal decompression and spinal fusion in the lumbar spine. The use of this technique can significantly reduce muscle trauma, achieve sufficient decompression, and reduce the frequency of infectious complications.

Обзор возможностей проведения симультанных операций с целью хирургической реабилитации пациентов с эндокринной офтальмопатией

The importance of revising the traditional multi-stage approach to the surgical rehabilitation of patients with thyroid eye disease is supported by multiple reasons, such as high operation costs, anesthesia-related increase in a burden for patients, and repeated surgical incisions associated with a delayed healing of surgical wounds. Over the past two decades, the orbital surgeons have attempted to solve the problem by combining several operations into a single-stage procedure. The article reviews the results of studies elucidating various simultaneous surgical techniques for orbital decompression, because the surgical treatment of exophthalmos is a "cornerstone" in solving functional problems arising from Graves’ orbitopathy. Moreover, the optimal planning depends on the severity of aesthetic problems in the periorbital region and the associated changes of eyelids and midface. Thus, it is necessary to consider multiple potential solutions within a single anesthesia exposure, the availability of surgeons with the appropriate skills or the involvement of a multidisciplinary team. In conclusion, the authors, referring to their own experience and the latest articles in international editions, propose anatomical and physiological criteria for selecting candidates for simultaneous orbit decompression surgery and for predicting surgical treatment outcomes in such patients. Keywords: orbital decompression, eyelid retraction, simultaneous operations, restrictive strabismus, thyroid eye disease, canthoplasty, exophthalmos. For citation: Atarshchikov D.S., Korchemkina E.Yu. Review of potential simultaneous operations for the surgical rehabilitation of patients with thyroid eye disease. Russian Journal of Clinical Ophthalmology. 2022;22(3):187–190 (in Russ.). DOI: 10.32364/2311-7729-2022-22-3-187-190

Unilateral Biportal Endoscopy for Decompression of Extraforaminal Stenosis at the Lumbosacral Junction: Surgical Techniques and Clinical Outcomes.

ObjectiveThe aims of this study were to describe the unilateral biportal endoscopic (UBE) technique for decompression of extraforaminal stenosis at L5–S1 and evaluate 1-year clinical outcomes. Especially, we evaluated compression factors of extraforaminal stenosis at L5–S1 and described the surgical technique for decompression in detail. MethodsThirty-five patients who underwent UBE decompression for extraforaminal stenosis at L5–S1 between March 2018 and February 2019 were enrolled. Clinical results were analyzed using the MacNab criteria, the visual analogue scale (VAS) for back and leg pain, and the Oswestry Disability Index (ODI). Compression factors evaluated pseudoarthrosis within the transverse process of L5 and ala of sacrum, disc bulging with or without osteophytes, and the thickened lumbosacral and extraforaminal ligament. ResultsThe mean back VAS was 3.7±1.8 before surgery, which dropped to 2.3±0.8 at 1-year postoperative follow-up (p<0.001). There was a significant drop in postoperative mean VAS for leg pain from 7.2±1.1 to 2.3±1.2 at 1 year (p<0.001). The ODI was 61.5 before surgery and 28.6 (p<0.001). Pseudoarthrosis between the transverse process and the ala was noted in all cases (35 of 35, 100%). Pure disc bulging was seen in 12 patients (34.3%), and disc bulging with osteophytes was demonstrated in 23 patients. The thickened lumbosacral and extraforaminal ligament were identified in 19 cases (51.4%). No complications occurred in any of the patients. ConclusionIn the current study, good surgical outcomes without complications were achieved after UBE decompression for extraforaminal stenosis at L5–S1.

Double Dome Laminoplasty: A Novel Technique for C2 Decompression.

ObjectiveTo introduce a new surgical technique - double dome laminoplasty for decompression of the entire C2 lamina and preservation of an extensor muscle insertion. MethodsEleven consecutive cervical myelopathy patients due to ossification of the posterior longitudinal ligament involving the Axis (C2) area were contained at this study. Direct decompression was evaluated as an increasing rate in space available cord (%) and posterior cord shift (mm) at C2 level. The Japanese Orthopaedic Association (JOA) score, visual analogue scale, and C2–7 Cobb angle in a neutral lateral x-ray were analyzed. ResultsThe mean increase in space available for spinal cord at the C2 level, average posterior cord shift, and JOA recovery rate were 69.7%, 5.3±0.15 mm, and 58.0%, respectively. Cervical lordotic angle was maintained in all patients. One patient reported neck pain (visual analogue scale 6) postoperatively. No specific complications such as C2 laminar fracture or insufficient decompression were observed. ConclusionWe recommend double dome laminoplasty for treating patients with cervical myelopathy involving the C2 area to avoid C2 laminectomy, reduce postoperative neck pain, and maintain lordotic cervical spine alignment.

De Novo Vesicoureteral Reflux Following Ureterocele Decompression in Children: A Systematic Review and Meta-Analysis Comparing Laser Puncture versus Electrosurgical Incision Techniques.

Background: The available endoscopic techniques for ureterocele decompression include laser puncture (LP), electrosurgical incision (ES), and cold-knife incision. This systematic review was performed to compare the efficacy of LP versus ES techniques with special emphasis on de novo VUR. Methods: Four databases were systematically searched by the authors. The inclusion criteria were all comparative studies in which ureterocele decompression was performed by either LP or ES endoscopic techniques. Outcomes including the incidence of de novo VUR, the need for endoscopic retreatment of the ureterocele, and the need for secondary surgical procedures were studied. Risk ratios (RR) were calculated for all outcomes and the Mantel-Haenszel method was utilized for the estimation of pooled RR. The methodological quality was assessed by the Downs and Black scale. Results: Five studies were considered for systematic review, while four of them were included in the meta-analysis. Out of 202 children, 67 developed de novo VUR. Significantly lower rates of reflux were observed in the LP group vis-a-vis ES group (RR = 0.17, 95% CI 0.09 to 0.32, p < 0.00001). Endoscopic retreatment rates (n = 20) demonstrated no significant difference among the two patient groups (RR = 0.66, 95% CI 0.26–1.68, p = 0.38). A total of 46 secondary procedures were performed in 170 children, mostly ureteral re-implantations, with a significantly lower need of secondary surgeries following LP versus ES (RR = 0.26, 95% CI 0.13–0.49, p < 0.0001). The risk of bias in the included studies was low-to-moderate. Conclusions: When compared to the ES technique, the LP technique is associated with a significantly low incidence of de novo VUR and requirement for secondary surgeries (particularly anti-reflux surgeries). Endoscopic retreatment rates showed no significant difference between the two techniques. However, due to the moderate risk of bias in two out of four included studies, randomized controlled trials are needed in the future.

No Benefit with Preservation of Midline Structures in Decompression for Lumbar Spinal Stenosis: Results From the National Swedish Spine Registry 2-Year Post-Op.

Observational cohort study. The aim of this study was to investigate whether preservation of the midline structures is associated with a better clinical outcome compared to classic central decompression for lumbar spinal stenosis (LSS). The classic surgical procedure for LSS is a central, facet joint sparing decompressive laminectomy (LE). Alternative approaches have been developed to preserve the midline structures. The effect of the alternative techniques compared to LE remains unclear. All patients >50 years of age who underwent decompression surgery for LSS without concomitant fusion in the National Swedish Spine Registry (Swespine) from December 31, 2015 until October 6, 2017 were included in this study based on surgeon-reported data and patient questionnaires before and 2 years postoperatively. Propensity score matching was used to compare decompression with preservation of midline structures with patients who underwent LE. The primary outcome was the Oswestry Disability Index (ODI) and secondary outcomes were the Numeric Rating Scale (NRS) for leg and back pain, EuroQol-5 Dimensions (EQ-5D), Global Assessment (GA), patient satisfaction and rate of subsequent surgery. Some 3339 patients completed a 2-year follow-up. Of these, 2974 (89%) had decompression with LE and 365 underwent midline preserving surgery. Baseline scores were comparable between the groups. Mean ODI improvement at follow-up was 16.6 (SD = 20.0) in the LE group and 16.9 (SD = 20.2) in the midline preserving surgery group. In the propensity score-matched analysis the difference in improved ODI was 0.53 (95% confidence interval, CI -1.71 to 2.76; P = 0.64). The proportion of patients who showed a decreased ODI score of at least our defined minimal clinically important difference (=8) was 68.3% after LE and 67.0% after preserving the midline structures (P = 0.73). No significant differences were found in the improvement of NRS for leg and back pain, EQ-5D, GA or patient satisfaction. The rate of subsequent surgery was 5.5% after LE and 4.9% after midline preserving surgery without a significant difference in the propensity score-matched analysis (hazard ratio, HR 0.87; 95% CI 0.49-1.54; P = 0.64). In this study on decompression techniques for LSS, there was no benefit in preserving the midline structures compared to LE 2 years after decompression. The conclusion is that the surgeon is free to choose the surgical method that is thought most suitable for the patient and the condition with which the patient presents.Level of Evidence: 3.