Traditional Posterior Approach Research Articles

Early Postoperative Outcomes of the Direct Superior Approach versus the Posterior Approach in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

Background/Objectives: The direct superior approach (DSA) is a tissue-sparing alternative to the traditional posterior approach (PA) in total hip arthroplasty (THA), potentially offering improved recovery and fewer complications. This study compares perioperative parameters, radiological and functional outcomes, and complications between the DSA and the PA in primary THA. Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. Databases searched included MEDLINE/PubMed, Cochrane Library, Embase, and Scopus. Studies comparing the DSA and the PA in primary THA were included based on predefined criteria. Data extraction and quality assessment were performed independently by two authors. Statistical analyses included calculating standardized mean differences (SMD), odds ratios (OR), and 95% confidence intervals (CI). Heterogeneity was assessed using the χ2 test, I2 statistics, and sensitivity analyses. Results: Out of 126 identified articles, 10 studies were included, which encompassed 28,063 patients (DSA: 1464; PA: 26,599). Significant advantages of the DSA over the PA were observed in blood loss (SMD −0.26, p < 0.01), transfusion rate (OR 0.59, p = 0.03), length of stay (SMD −0.59, p < 0.01), discharge to home rates (OR 2.32, p < 0.01), and incision length (SMD −2.75, p < 0.01). No significant differences were found in radiological outcomes or most functional scores, although the DSA showed higher Harris Hip Scores at 1 month (SMD 0.77, p < 0.01). Conclusions: The DSA offers significant perioperative advantages over the PA, including reduced blood loss, transfusion rates, LOS, incision length, and improved early functional recovery with higher discharge to home rates. Comparable complication rates and radiological outcomes support the DSA’s safety and efficacy for quicker recovery in THA.

A Systematic Review and Meta-Analysis of Supercapsular Percutaneously Assisted Total Hip Arthroplasty Versus Standard Posterior Approach for Femoral Neck Fracture in Elderly Patients.

This meta-analysis aimed to evaluate the efficacy and safety of the supercapsular percutaneously assisted total hip arthroplasty (SuperPATH) and the standard posterior approach in hip arthroplasty in treating femoral neck fractures in elderly patients. A systematic search was conducted for studies from 2012 to December 2022. Meta-analysis was conducted using Review Manager 5.3 on surgical time, intraoperative blood loss, Harris hip scores, and visual analog scale scores. A total of 26 studies involving 2,236 patients with femoral neck fractures were included. The SuperPATH group performed better than traditional posterior approach group in reducing intraoperative blood loss (in ml), shortening incision length (in cm), length of hospitalization period (in days) and improving Harris Hip score (HHS). The operation time took longer than the traditional posterior approach, with statistically significant differences. The VAS scores at 1 week and 3 months after surgery in the SuperPATH group were lower than those of the traditional posterior approach, with statistically significant differences. There was no statistical significance between the two groups in VAS scores 2 weeks and 1 month after surgery. The SuperPATH group resulted in better effects in reducing intraoperative blood loss (in ml), shortening incision length (in cm), length of hospitalization period (in days), and improving Harris hip score (HHS), which is conducive to the rapid postoperative recovery of patients.

Transforaminal Versus Lateral Interbody Fusions for Treatment of Adjacent Segment Disease in the Lumbar Spine.

Retrospective comparative study. This study compared outcomes for patients managed with a lateral approach to interbody fusion [lateral (LLIF) or oblique (OLIF)] versus a posterior (PLIF) or transforaminal interbody fusion (TLIF) for treatment of adjacent segment disease (ASD) above or below a prior lumbar fusion construct. No study has compared outcomes of lateral approaches to more traditional posterior approaches for the treatment of ASD. Retrospective review was performed of patients who underwent single-level lateral or posterior approaches for lumbar interbody fusion for symptomatic ASD between January 2010 and December 2021. Exclusion criteria included skeletal immaturity (age below 18y old) and surgery indication for malignancy or infection. Patient demographics, medical comorbidities, operative details, postoperative complications, and revision surgery profiles were collected for all patients. Standard descriptive statistics were used to summarize data. Comparative statistical analyses were performed using Statistical Package for the Social Sciences (Version 28.0.1.0; Chicago, IL). A total of 152 patients (65±10y) were included in the study with a mean duration of follow-up of 1.6±1.4 years. The cohort included 123 PLIF/TLIF (81%), 18 LLIF (12%), 11 OLIF (7%). TLIF/PLIF experienced greater mean operative time (210±62min vs. 184±80 OLIF/105±64 LLIF, P<0.001) and estimated blood loss (414±254mL vs. 49±29 OLIF/36±33 LLIF, P<0.001). No significant difference in rate of postoperative complications. Postoperative radicular pain was significantly greater in OLIF (7, 64%) and LLIF (7, 39%) compared with PLIF/TLIF (16, 13%), P<0.001. No statistically significant difference in health care utilization was noted between the groups. Lateral fusions to treat ASD demonstrated no significantly different risk of complication compared with posterior approaches. Our study demonstrated significantly increased operative time and estimated blood loss for the posterior approach and an increased risk of radicular pain from manipulation/retraction of psoas following lateral approaches. Level III.

Clinical application of a modified wiltse approach in middle and lower thoracic vertebrae: a case-control study of thoracic fracture patients

BackgroundThe Wiltse approach has been extensively employed in thoracolumbar surgeries due to its minimal muscle damage. However, in the middle and lower thoracic spine, the conventional Wiltse approach necessitates the severance of the latissimus dorsi and trapezius muscles, potentially leading to muscular injury. Consequently, we propose a modified Wiltse approach for the middle and lower thoracic vertebrae, which may further mitigate muscular damage.MethodsFrom May 2018 to April 2022, 60 patients with spinal fractures in the middle and lower thoracic vertebrae (T5-12) were enrolled in this study. Thirty patients underwent surgery using the modified Wiltse approach (Group A), while the remaining 30 patients received traditional posterior surgery (Group B). The observation indices included operation time, intraoperative blood loss, incision length, number of C-arm exposures, postoperative drainage, postoperative ambulation time, discharge time, as well as preoperative and postoperative Cobb’s angle, percentage of anterior vertebral body height (PAVBH), visual analog scale (VAS) Score, and Oswestry disability index (ODI).ResultsCompared to the traditional posterior approach, the modified Wiltse approach demonstrated significant advantages in operation time, intraoperative blood loss, length of incision, postoperative ambulation time, postoperative drainage, and discharge time, as well as postoperative VAS and ODI scores. No significant differences were observed between the two groups in terms of number of C-arm exposures, postoperative Cobb’s angle, or postoperative PAVBH.ConclusionWe propose a modification of the Wiltse approach for the middle and lower thoracic vertebral regions, which may further minimize muscular damage and facilitate the recovery of patients who have undergone surgery in the middle and lower thoracic vertebrae.

Advances in study of surgical approaches and MRI evaluation of total hip arthroplasty

To review the research on different surgical approaches and MRI evaluation of total hip arthroplasty (THA), to clarify the possible muscle damage caused by different approaches, and to help clinicians avoid intraoperative muscle damage and identify the causes of certain muscle-related complications after operation. The research literature on different surgical approaches and MRI evaluation of THA at home and abroad was extensively reviewed to summarize the MRI performance of the posterior approach, modified direct lateral approach, direct anterior approach, and minimally invasive anterolateral approach (also called Orthopadische Chirurgie Munchen approach). The traditional posterior approach mainly damages the short external rotator muscle group and increases the incidence of postoperative dislocation; the piriformis-keeping posterior approach significantly improves the quality of the pyriformis tendon in the postoperative period, but it may lead to damage to the intrapelvic portion of the piriformis muscle. The modified direct lateral approach mainly damages the gluteus medius muscle, which increases the risk of postoperative claudication. The direct anterior approach mainly damages the vastus tensoris muscle and may result in damage to the short external rotator muscle group and the muscles around the incision. The minimally invasive anterolateral approach primarily damages the superior gluteal nerve, which subsequently leads to denervation of the broad fascial tensor fasciae latae, and this approach may also result in injury to the gluteus medius and gluteus minimus muscles. The muscle damage status significantly affects prognosis, and the minimally invasive approach is more suitable for elderly patients. MRI can clarify the different types of muscle damage caused by different surgical approaches. Minimally invasive approaches can reduce muscle damage and improve postoperative function compared with traditional approaches, and can benefit elderly patients more, but due to the small field, forcing to expand the surgical field will lead to unintended muscle damage and reduce postoperative function.

Access to the Lumbosacral Spine: A Current View.

The surgical approach to the lumbosacral spine has been the subject of experimental and scientific anatomical studies since the Hippocratic era. However, it was in the 20th century that, with the evolution of asepsis and antibiotic therapy, spine surgery began to evolve at breakneck speed, and the various possibilities of access roads became objects of development and discussion. As a result, pathologies of the lumbosacral spine can be accessed in different ways and positions, from the traditional posterior approach in the prone position to the anterior, oblique, lateral, and endoscopic approaches. The current article brings state-of-the-art access routes to the lumbosacral spine. This article objective is to elucidate the possibilities of accesses the lumbar spine for any purposes, as decompression, fusion, tumour resections, reconstruction or deformity correction, despites type of implants or implants positioning.

Posterior Transdural Approach for Thoracic Corpectomies in the Setting of Complex Spine Deformity Reconstruction.

There are many surgical approaches for execution of a thoracic corpectomy. In cases of challenging deformity, traditional posterior approaches might not be sufficient to complete the resection of the vertebral body. In this technical note, we describe indications and technique for a transdural multilevel high thoracic corpectomy. A 25-year-old man with a history of neurofibromatosis type 1 presented with instrumentation failure after a previous T1-T12 posterior spinal fusion, extensive laminectomy, and tumor resection. The patient presented with progressive back pain, had broad dural ectasia, and a progressive kyphotic rotational and anteriorly translated spinal deformity. To resect the medial-most aspect of the vertebral body, a bilateral extracavitary approach was attempted, but was found insufficient. A transdural approach was subsequently performed. A left paramedian durotomy was made, followed by generous arachnoid dissection, bilateral dentate ligament division, and T4 rootlet sacrifice to mobilize the spinal cord. A ventral durotomy was then made and the ventral dura was reflected over the spinal cord to protect it while drilling. The corpectomy was then completed. The ventral and dorsal durotomies were closed primarily and reinforced with fibrin glue and fibrin sealant patch. The corpectomy defect was filled with nonstructural autograft. The focal kyphosis was corrected with a combination of rod contouring, compression, and in situ bending. During the surgery, the patient had stable neuromonitoring data, and postoperatively had no neurological deficits. On follow-up until 1 year, the patient presented with no signs of cerebrospinal spinal leaks, no motor or sensory deficits, minimal incisional pain, and significantly improved posture. Complex high thoracic (T3-5) ventral pathology inaccessible via a bilateral extracavitary approach may be accessed via a transdural approach as opposed to an anterior/lateral transthoracic approach that requires mobilization of cardiovascular structures or scapula.

A Comparison of Hidden Blood Loss Between Multilevel Posterior Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion in Adult Spinal Deformity Patients.

Retrospective cohort study. This study aimed to compare transfusion and blood loss volumes, particularly hidden blood loss volume, in adult spinal deformity patients undergoing lateral lumbar interbody fusion (LLIF) and posterior lumbar interbody fusion (PLIF). Corrective surgery for adults with spinal deformity patients can be performed via the traditional posterior approach (PLIF) or minimally invasive lateral approach (LLIF). LLIF is associated with longer or comparable operation times and lower intraoperative blood loss. However, hidden blood loss has not been compared between the two procedures. We compared hidden blood loss and other blood loss volumes, transfusion volume, operation time, and radiographic surgical outcomes between LLIF patients (n = 71) and PLIF patients (n = 33) who underwent surgery in our institution from September 2011 to June 2018. All patients provided informed consent in accordance with the Declaration of Helsinki. Institutional ethics committee conducted this study approval was obtained. Transfusion volume and intraoperative and total blood loss volumes were significantly higher in the PLIF group. Operation time and HBL did not significantly differ. The hidden blood loss-to-intraoperative blood loss ratio was significantly higher in the LLIF group (113% vs 60%; P = .004). Radiographic measures of outcome were significantly better after surgery than before in both groups. Although intraoperative blood loss was less with LLIF than PLIF, HBL was similar between the approaches. Patients undergoing LLIF should be followed closely for postoperative anemia even if intraoperative blood loss is low.

Modified anterior approach versus traditional posterior approach for ultrasound-guided superior laryngeal nerve block in awake endotracheal intubation: a randomized non-inferiority clinical trial

Study objective This study was undertaken to compare the effect of the modified ultrasound-guided anterior superior laryngeal nerve block (SLNB) with the traditional ultrasound-guided posterior SLNB in providing intubation conditions during awake tracheal intubation (ATI) in patients without difficult airway. Design Randomized, assessor-blind. Registration number: ChiCTR2200058086. Setting West China Hospital of Sichuan University, Chengdu, China. Patients 104 patients aged 18–65 years, of American Society of Anesthesiologists status I-III, posted for elective general surgery with general endotracheal anesthesia. Interventions The patients were randomized into two groups (modified group, n = 52; traditional group, n = 52). Modified anterior SLNB or traditional posterior SLNB was performed under ultrasound guidance. Measurements The primary outcome was the proportion of acceptable intubation condition (AIC), which was analyzed in both per-protocol (PP) and intention-to-treat (ITT) populations. The prespecified non-inferiority margin was −4.8%. Secondary outcomes included intubation success rate on the first attempt, hemodynamic parameters during ATI, time taken for airway anesthesia and intubation, recall of intubation, patient perception of comfort, and incidence and severity of postoperative complications. Main results In the PP population, the proportion of AIC in the modified group was 49/49 (100%) and that in the traditional group was 49/49 (100%), absolute difference 0, lower limit of 1-sided 95% CI, −0.3%. In the ITT population, the primary outcomes in the modified and traditional group were 52/52 (100%) and 51/52 (98.1%), respectively, with an absolute difference of 1.9% and a lower limit of 1-sided 95% CI of −1.2%. The non-inferiority of modified ultrasound-guided anterior SLNB was confirmed in both populations. Conclusions Among adults without difficult airways during videolaryngoscope-assisted ATI, the modified ultrasound-guided anterior SLNB, compared to the traditional posterior approach, showed a statistically non-inferior effect in terms of providing AIC.

Lumbar lateral interbody fusion: step-by-step surgical technique and clinical experience.

Lateral lumbar interbody fusion (LLIF) is a minimally invasive surgical approach used to treat a variety of degenerative and deformity conditions of the lumbar spine such as advanced degenerative disease, degenerative scoliosis, foraminal and central stenosis. It has emerged as an alternative to the traditional posterior and anterior lumbar approaches with some potential benefits such as lower blood loss and shorter hospital stay. In this article, we provide our single institutional surgical experience including main indications and contraindications, a step-by-step surgical technique description, a detailed preoperative imaging assessment with a focus on magnetic resonance imaging (MRI) psoas anatomy, operative room (OR) setup and patient positioning. A descriptive surgical technical note of the following steps is provided: positioning and fluoroscopic confirmation, incision and intraoperative level confirmation, discectomy and endplate preparation, implant size selection and insertion and final fluoroscopic control, hemostasis check and wound closure along with an instructional surgical video with tips and pearls, postoperative patient care recommendations, common approach-related complications, along with our historical clinical institutional group experience. Finally, we summarize our research experience in this surgical approach with a focus on LLIF as a standalone procedure. Based on our experience, LLIF can be considered an effective surgical technique to treat degenerative lumbar spine conditions. Proper patient selection is mandatory to achieve good outcomes. Our institutional experience shows higher fusion rates with good clinical outcomes and a relatively low rate of complications.

Clinical Efficacy and Imaging Observation of Three Surgical Approaches in Treatment of Thoracolumbar Fractures.

To observe the efficacy and imaging of surgical treatment of thoracolumbar fractures via the paravertebral muscle space approach. A retrospective analysis was conducted on patients with thoracolumbar fractures receiving surgery in Baoding First Central Hospital from January 2019 to December 2020. According to different surgical approaches, they were divided into paravertebral approach group, posterior median approach group and minimally invasive percutaneous approach group. They received surgery via the paravertebral muscle space approach, posterior median approach and minimally invasive percutaneous approach, respectively. Statistically significant differences were found in surgical duration, intraoperative bleeding volume, intraoperative fluoroscopy frequency, postoperative drainage volume and hospital stay among the three groups. One year after surgery, the VAS, ADL and JOA scores of the paravertebral approach group and the minimally invasive percutaneous approach group had statistically significant differences from the posterior median approach group (P < 0.05). For the surgical treatment of thoracolumbar fractures, the clinical efficacy of the paravertebral muscle space approach is superior to that of the traditional posterior median approach, and the clinical efficacy of the minimally invasive percutaneous approach is similar to that of the posterior median approach. All the three approaches can effectively improve the postoperative function and pain symptoms of patients without increasing the incidence of complications. Compared with the posterior median approach, the surgery via the paravertebral muscle space and minimally invasive percutaneous approaches presents shorter surgical duration, less bleeding and shorter hospital stay, which is more conducive to postoperative recovery of patients.

Influence of the facet joint angle on facet joint degeneration following pedicle screw fixation without fusion in thoracolumbar fractures.

Posterior approach pedicle screw fixation without fusion is widely used in the treatment of neurologically intact type A3 thoracolumbar fractures. To analyze the influence of the facet joint (FJ) angle on FJ degeneration following posterior approach pedicle screw fixation without fusion in neurologically intact type A3 thoracolumbar fractures. Fifty-eight patients who underwent pedicle screw fixation via the traditional posterior approach (n= 28) or the Wiltse approach (n= 30) were enrolled. A CT scan was performed before fixation and before fixation removal (Within 1.5 to 2 years after fixation) to evaluate the FJs parameters, including FJ inclination (FJI), FJ tropism (FJT), FJ violation, and FJ degeneration grade (FJDG), of three fixed segments and the adjacent segment below the fixed segments. There was no significant difference in FJ violation rate, FJDG deterioration, or FJ angle between the two groups (P> 0.05). FJDG deterioration showed a weak positive correlation with FJI and FJT before fixation, and the angular change in FJI (P< 0.05); and FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration (P< 0.01). The Wiltse approach did not increase the rate of FJDG deterioration and FJs angle changes. However, the FJT before fixation and the angular change in FJI were risk factors for FJDG deterioration.

Occipital interhemispheric transtentorial approach in pediatric patients for lesions of the superomedial cerebellum: operative findings and results.

The occipital interhemispheric transtentorial (OITT) approach is frequently used for accessing the pineal region. There are scarce reports of using the OITT to access superior cerebellar lesions. This approach affords the patient several advantages over traditional posterior fossa approaches. This study is to describe and evaluate clinical outcomes in a single surgeon case series of the OITT approach for pediatric patients with lesions of the superior cerebellum. All pediatric patients who underwent an OITT craniotomy for a superior cerebellar lesion by a single surgeon over a 5-year period were included in this retrospective analysis. Patient demographics and clinical data were collected. Thirteen pediatric patients were identified. Cases included twelve tumors and one arteriovenous malformation. Gross total resection was achieved in 92% of cases. No patients developed posterior fossa syndrome. Two patients had transient homonymous hemianopsia that resolved by 1month post-operatively. There were no permanent neurological deficits. For superomedial cerebellar lesions presenting to the tentorial surface of the superior cerebellum in patients with normal to steep tentorial angles, the OITT approach is effective and safe. This approach has a low risk of posterior fossa syndrome and permanent visual deficits when applied appropriately. Patient selection is critical for maximizing the advantages of the OITT for superior cerebellar lesions.

Paramedian Wiltse Approach for Giant Paraspinal Lumbar Schwannoma: Technical Note and Alternative Approaches.

Paraspinal lumbar schwannomas are primarily located outside of the spinal canal with minimal extension into the neural foramen. Approaching these tumors through a traditional posterior approach can be challenging given their lateral location to the spine and is likely to require extensive bony removal and potential destabilization of the spine. Alternatives approaches have been identified that may circumvent the need for extensive bony removal. To examine the use of the paramedian Wiltse approach for giant extraspinal tumors and compare the approach with other nonposterior approaches. We present 2 cases in which the paramedian Wiltse approach is used to effectively approach large paraspinal schwannomas and achieve complete tumor resection without destabilization of the spine. The paramedian Wiltse approach along with expandable retractors systems were able to achieve complete resection of the giant paraspinal schwannomas. Neural preservation was able to be achieved in one case which was facilitated by the exposure achieved through the posterior paramedian corridor that allowed for visualization of the proximal and distal ends of the tumor. The paramedian Wiltse approach is an ideal approach to target large extraspinal schwannomas for complete resection and potential neural preservation without the need for destabilization of the spine.

Techniques for psoas navigation in lateral lumbar interbody fusion

Lateral Lumbar Interbody Fusion (LLIF) is a minimally-invasive, retroperitoneal surgical technique utilized as an alternative to direct anterior and traditional posterior approaches. LLIF can be performed as a trans-psoas or psoas-sparing approach. The majority of LLIF systems utilize neuromonitoring to minimize nerve root injury. The purpose of this manuscript is to review the methods of neuromonitoring and navigation employed in LLIF, and discuss potential advances on the horizon.

Assessment of vertebral bone mineral density and stand-alone oblique lumbar interbody fusion for adjacent segment disease and primary lumbar degenerative diseases.

To evaluate the vertebral bone mineral density and the value of stand-alone oblique lumbar interbody fusion (SA OLIF) for the management of single-level adjacent segment disease (ASD) and primary lumbar degenerative diseases. Seventy-eight patients undergoing single-level SA OLIF was divided into index surgery group (n = 36) or revision surgery group (n = 42) at single center. The vertebral body Hounsfield units (HU) value was measured to assess bone mineral density of operated level by the preoperative CT. The following data were retrospectively collected and compared between the two groups: demographic, surgical data, clinical results, and complications. No differences were found between the two groups in surgical data. The fusion segment HU values in the revision group were significantly higher than that in the index group (147.4 ± 35.3 vs 129.2 ± 38.4 p = .033). There were significant differences while comparing fusion segment HU values to L1-L4 horizontal plane (147.4 ± 35.3 vs 126.1 ± 28.4, p = .000) and L1 (147.4 ± 35.3 vs 126.8 ± 26.2, p = .000) in revision group, meanwhile, no statistically significant difference was observed in index group (p > .05). The cage subsidence was observed in the revision group (n = 2) and index group (n = 9) (p = .045). The patients with cage subsidence had significantly lower vertebral HU values. SA OLIF is valid alternative to the traditional posterior approach in the management of ASD with good clinical outcomes at short-term follow-up. Increased HU values of fusion segment may play a role in the management of ASD by SA OLIF.

Analysis of the Advantages of Wiltse Approach Ligamentotaxis Method for Thoracolumbar Fractures

The Wiltse approach ligamentotaxis (WALT) is a combination of paravertebral muscle natural gap access and posterior longitudinal ligament tension, which can achieve good fracture repositioning and indirect spinal canal decompression, thus avoiding the disadvantages of traditional posterior direct decompression approach. This paper provides a detailed explanation and analysis of WALT through clinical cases.

Effect of percutaneous minimally invasive pedicle screw internal fixation in the treatment of thoracolumbar vertebral fractures and its impact on quality of life.

ABSTRACTObjectives:To investigate and analyze the effect of percutaneous minimally invasive pedicle screw internal fixation in the treatment of thoracolumbar vertebral fractures and its impact on quality of life.Methods:Fifty patients with thoracolumbar vertebral fracture admitted to our hospital from January 2015 to December 2018 were selected and divided into two groups according to different treatment regimens. The observation group was treated with minimally invasive percutaneous pedicle screw internal fixation, while the control group was treated with traditional posterior approach open pedicle screw internal fixation. The surgery time, incision length, intraoperative blood loss, postoperative drainage, hospitalization time, ambulation time, fracture healing time and postoperative VAS scores were compared between the two groups. In addition, the cobb angle, the sagittal plane index, and the anterior vertebral height were compared between the two groups before and after surgery, as were the Oswestry Disability Index (ODI) at 1d, 3 months, and 6 months postoperatively.Results:The surgery time, incision length, postoperative pain level, postoperative drainage and intraoperative blood loss of the observation group were less than those of the control group (P<0.05). The postoperative Cobb angle of the two groups decreased, the sagittal plane index as well as the anterior vertebral height increased (P<0.05). The Oswestry index of the observation group was better than that of the control group at one day and three months postoperatively, with a statistical significance between the two groups (P<0.05). The complication rate of the observation group was significantly lower than that of the control group (P<0.05).Conclusion:Percutaneous minimally invasive pedicle screw internal fixation is safer than the traditional open pedicle screw internal fixation, and it is more worthy of clinical promotion.

Minimally Invasive Posterior Cervical Discectomy: 2-Dimensional Operative Video.

Minimally invasive posterior cervical microdiscectomy is an appropriate surgical approach for patients with foraminal stenosis from herniated disc with radicular symptoms that is not responsive to conservative management. While anterior cervical discectomy and fusion (ACDF) or arthroplasty is increasingly utilized to treat herniated disc, a posterior approach eliminates the risk of potential approach related injuries to the esophagus, carotid artery, or recurrent laryngeal nerve. Additional benefits of posterior decompression include avoidance of instrumentation, which represents an increased healthcare cost, as well as potential long-term risks of adjacent-level pathologies or device failures. A traditional open posterior cervical approach has the potential to cause significant postoperative pain due to dissection of the paraspinal musculature and the potential for disrupting the posterior tension band with inadvertent injury to the interspinous ligaments. Such disadvantages are reduced by utilizing the minimally invasive technique where a small tubular working channel is placed through a muscle splitting technique via a paramedian approach. This technique minimizes the need for muscle stripping, and thus decreases postoperative functional and structural disturbance. Discectomy in this case can also be safely performed with minimal retraction at the axilla of the nerve root. Additionally, this approach can be utilized in an ambulatory setting, which coupled with the lack of any additional instrumentation helps contribute to the overall healthcare cost savings of such a procedure. This video describes how the minimally invasive posterior cervical discectomy can be effectively and safely performed in this illustrative case. The patient consented to the procedure and publication.

The Clinical Effect of Manual Reduction Combined with Internal Fixation Through Wiltse Paraspinal Approach in the Treatment of Thoracolumbar Fracture.

ObjectiveTo evaluate the clinical outcome of manual reduction combined with pedicle fixation through Wiltse paraspinal approach (WPA) in the treatment of thoracolumbar fractures.MethodsFrom May 2017 to May 2019, 48 thoracolumbar fractures patients without neurological symptoms were enrolled in this study. Forty‐eight patients were randomly divided into two groups based on the different surgical treatment. Group 1 was manual reduction combined with pedicle screw fixation through Wiltse paraspinal approach treatment group. Group 2 was pedicle screw fixation through traditional posterior approach treatment group. The operation time (OT), intraoperative blood loss (BL), postoperative drainage (PD), time of brace (TB) and the cobb angle recovery of the injured kyphosis in the prone position were obtained and compared between the two groups, respectively. Comparison of cobb angle changes, serum creatine kinase (CK) level, pain visual analogue score (VAS), Oswestry disability index (ODI), and multifidus cross‐sectional (MCS) area changes were achieved between the two groups, respectively.ResultsForty‐eight patients were enrolled in this study and each group had 24 patients. There was no significant difference between the two groups in patient's age, height, weight, and body mass index (BMI). There were 20 males and four females in group 1. The mean age, height, weight, and BMI of patients were 61.99 ± 11.00 years (range, 42–75 years), 175.21 ± 4.49 cm, 76.71 ± 4.87 kg, and 24.98 ± 1.03 kg/m2 in group 1, respectively. Group 2 had 18 males and six females, and the mean age, height, weight, and BMI of patients were 57.95 ± 9.22 years (range, 44–77 years), 176.37 ± 4.56 cm, 77.42 ± 4.61 kg, and 24.87 ± 1.10 kg/m2 in group 2, respectively. The mean bleeding volume of group 1 was significantly less than group 2 (64.13 ± 9.77 ml and 152.13 ± 10.73 ml, respectively) (P < 0.05). The mean operation time, postoperative drainage, and time of brace were 62.95 ± 9.80 min, 66.25 ± 12.75 ml, and 3.62 ± 0.97 days in group 1, respectively, and they were significantly better than those of group 2 (69.29 ± 6.82min, 162.96 ± 14.55ml and 7.88 ± 1.94 days, respectively) (P < 0.05). The mean multifidus cross‐sectional area was significantly smaller than per‐operation after surgery in two groups (P < 0.05). The mean creatine kinase of group 1 was 403.13 ± 39.78 U/L and 292.12 ± 45.81 U/L at 1 and 3 days after surgery, respectively, which was significantly smaller than those in group 2 (654.25 ± 53.13 U/L and 467.67 ± 44.25 U/L, respectively) (P < 0.05). The Oswestry disability index of group 1 were significantly better than those in group 2 especially at 1 month and final follow‐up after surgery (P < 0.05). Moreover, group 1 also had better outcomes in postoperative Cobb angle change than those in group 2, with significant difference on intra‐operation, 1 day and 1 month post‐operation (P < 0.05).ConclusionIn short, this operation is suitable for thoracolumbar fractures without neurologic symptoms. Preoperative manual reduction had advantages of restoring the height of injured vertebrae. Wiltse intermuscular approach can reduce intraoperative blood loss, shorten operation time, and reduce paraspinal muscle damage. Using the traditional posterior approach, it is easy for surgeons to grasp this technique and it should be recommended as conforming with the minimally invasive approach of recent years.