Transforaminal Endoscopy Research Articles

Preliminary Study of Transforaminal Endoscope in the Treatment of Spinal Metastasis

Objective: To investigate the therapeutic effect of transforaminal endoscope in patients with spinal metastases. Methods: Clinical data of 28 patients with spinal metastases admitted to our hospital from May 2015 to May 2019 were retrospectively collected. According to different surgical methods, they were divided into control group (20 cases) and experimental group (8 cases), among which control group was treated with traditional open palliative decompression, while the experimental group was treated with transforaminal endoscopic decompression. The surgery and recovery indicators were compared between the two groups, including surgery time, incision length, postoperative drainage volume, out of bed activity time, length of hospital stay, the Japanese Orthopaedic Association (JOA) scores of 7 days after surgery, pain degree, complications (wound infection, transient reduction of muscle strength, hypoproteinemia with wound drainage and delayed healing), and activity of daily living. Results: The surgery time, incision length, postoperative drainage volume, out of bed activity time, and postoperative length of hospital stay of the experimental group were all less than those of the control group, and the JOA score of 7 days after surgery was higher than that of the control group, showing statistically significant differences (P < 0.05). VAS scores of the experimental group on the day 1 and day 7 after surgery were lower than those of the control group, with statistically significant differences (P < 0.05). The incidence of complications in the experimental group was slightly lower than that in the control group, but the difference was not significant (P > 0.05). Conclusions: Transforaminal endoscope used in suitable patients with spinal metastases can greatly reduce the incision length, soft tissue and bone tissue damages, and postoperative drainage, promote early mobilization and early discharge, and reduce a series of complications due to hemorrhage and hypoproteinemia, which has a better early clinical effect in comparison with the traditional open palliative decompression.

Minimal Clinically Important Difference in Patient-Reported Outcome Measures with the Transforaminal Endoscopic Decompression for Lateral Recess and Foraminal Stenosis.

Patient-reported outcome measures (PROMs) have become widely used to better measure patients' judgment of treatment benefits from surgical spine care. The concept of determining the minimal clinically important differences (MCIDs) of PROMs is aimed at assessing the benefits of lumbar spine care that are meaningful to the patient. The goal of this study was to validate the utility of MCIDs of the visual analog score (VAS) and Oswestry Disability Index (ODI) in patients with sciatica-type low back and leg pain due to lateral recess and foraminal stenosis who were treated with directly visualized transforaminal outpatient endoscopic decompression. The retrospective study population consisted of 406 patients on whom PROMs were obtained preoperatively, and again postoperatively at final follow-up. Employing an anchor-based approach with a patient satisfaction index based on the modified Macnab criteria, a receiver operating characteristics (ROC) and area under the curve (AUC) analysis was performed using IBM SPSS 25.0 to define the optimal MCID in VAS and ODI with the transforaminal endoscopy using the top-left-corner criteria and the Youden index. Improvements in walking endurance were recorded as an additional parameter of patient functioning and correlated with PROMs to test for statistical significance. The patients' average age was 41.08 years, ranging from 30 to 84 years. The mean follow-up was 33.59 months, ranging from 24 to 85 months, with a standard deviation of 12.79. The MCIDs for VAS and ODI were 2.5 to 3.5 and 15 to 16.5, respectively. Patients were dichotomized as improved (377/406; 92.9%) if they reported excellent (224/406; 55.2%), good (112/406; 27.6%), and fair (41/406; 10.1%) Macnab outcomes. Patients were dichotomized as failed if they reported poor (29/406; 7.1%) Macnab outcomes. Preoperatively, only 32.5% (132/406) of patients had unlimited walking endurance compared to 77.6% (315/406) of patients postoperatively. The ROC and AUC analysis showed better accuracy with the single-integer VAS score (0.926) than with the 10-item ODI score (0.751). Transforaminal outpatient endoscopic decompression for symptomatic foraminal and lateral recess stenosis is an effective surgical treatment to alleviate sciatica-type and back symptoms in 92.9% of patients. Of the PROMs analyzed, the VAS provided a more meaningful and accurate reflection of patients' interpretation of outcome with the transforaminal endoscopic spinal decompression procedure than ODI. Understanding which patient expectations drive these MCIDs may aid in replacing open surgeries for sciatica-type low back and leg pain currently preferred by traditional spine surgeons with a personalized early-staged transforaminal endoscopic hybrid decompressive/ablative procedures favored by the authors. These may prove more cost effective by focusing on significant pain generators validated with a diagnostic interventional workup instead of employing image-based indication criteria for surgery.

Foraminoplasty affects the clinical outcomes of discectomy during percutaneous transforaminal endoscopy: a two-year follow-up retrospective study on 64 patients

Objective: The aim of this study was to assess the significance of how the degree of injury of the facet joint affects clinical outcomes in foraminoplasty.Methods: We retrospectively enrolled 64 patients treated with percutaneous endoscopic transforaminal discectomy with foraminoplasty (PETDF) from January of 2015 to December of 2016. The patients were divided into two groups depending on whether the articular surface of the facet joint was damaged. Preoperative, perioperative, demographic data, and radiographic parameters for these two groups were extracted and compared.Results: There were no significant differences between the two groups in terms of the duration of operation (p = 0.331), intraoperative blood loss volume (p = 0.631), the weight of disc (p = 0.274) or cut bone (p = 0.526). There were no significant differences between the two groups for VAS or ODI at the same time point (p > 0.05). There were significant differences in the VAS scores of low-back pain at 24 h and 24 months after surgery in the injured group. There were significant differences in ISH, ISA, rate of lumbar instability, recurrent herniation, and Macnab scores between the two groups at 24 months after surgery (p < 0.05). The regression equation between ISA and ISH was Y = 4.237 + 0.565x (where Y denotes an increase of ISA; X, reduction of ISH; F = 6.219, p = 0.015). The Poisson ratio was 0.363 (p = 0.003).Conclusions: PETDF is effective and safe for the treatment of lumbar disc herniation. However, when foraminoplasty destroys the articular surface of the facet joint, there may be increases in lumbar instability and recurrence rate post-operation.

Auxiliary analgesic effect of wrist-ankle acupuncture on patients undergoing transforaminal endoscope surgery

To observe the auxiliary analgesic effect of wrist-ankle acupuncture on patients undergoing transforaminal endoscope surgery. A total of 64 patients with lumbar disc herniation who underwent percutaneous lateral transforaminal endoscope surgery were randomly divided into an observation group and a control group, 32 cases in each group. The patients in the control group were treated with injection of 1% lidocaine for routine local infiltration anesthesia. The patients in the observation group were treated with wrist-ankle acupuncture at lower 5 area and lower 6 area for 30 min, 5 min before routine local infiltration anesthesia; immediately, 15 min, 30 min after insertion the left-right technique, up-down technique, and rotation technique were applied for six times, respectively. The mean arterial pressure (MAP), heart rate (HR), blood oxygen saturation (SpO2) and pain visual analogue scale (VAS) were compared between the two groups at the time points of intraoperative puncture (T1), circular saw grinding (T2), and placement of working channel (T3). The intention of reoperation was recorded immediately after operation and 24 h after operation. The expectation and treatment credibility scale (ETCS) was used to evaluate the relationship between patients' expectation and efficacy 5 min before operation and immediately after operation. At T2 and T3 during the operation, the MAP and HR in the obserrvation group were lower than those in the control group, while SpO2 was higher than that in the control group (P<0.05). At T1, there was no significant difference of MAP, HR and SpO2 between the two groups (P>0.05). At T2, the peak VAS and average VAS in the observation group were lower than those in the control group (P<0.05), but there was no significant difference at T1 and T3 (P>0.05). The intention of reoperation in the observation group was higher than that in the control group both immediately after operation and 24 h after operation (P<0.05). In the observation group, the scores of each item in ETCS immediately after operation were higher than those 5 min before operation (P<0.05), while in the control group there was no significant difference between immediately after operation and 5 min before operation (P>0.05). The scores of ETCS1, ETCS2 and ETCS3 immediately after operation in the observation group were higher than those in the control group (P<0.05). The wrist-ankle acupuncture has positive auxiliary analgesic effect on lumbago during transforaminal endoscope surgery, and strengthens the patients' confidence on the operation effect.

Efficacy and prognosis of transforaminal endoscopy in the treatment of lumbar disc herniation in patients infected with human immunodeficiency virus: a nonrandomized, controlled, 2-year follow-up clinical study

Background and objective: Transforaminal endoscopy has certain advantages over traditional surgeries (e.g., intervertebral disc fusion) in the treatment of lumbar disc herniation, as it is associated with minimal trauma, clear surgical vision, and lower degree of bleeding. However, the therapeutic effects of transforaminal endoscopy on lumbar disc herniation in human immunodeficiency virus (HIV)-infected patients are poorly understood. The purposes of this study are to indicate the efficacy of transforaminal endoscopy in the treatment of lumber disc herniation in HIV-infected patients and compare the efficacy between transforaminal endoscopy and conventional lumbar disc fusion based on 2-year follow-up and prognosis turnover. Subjects and Methods: This is a prospective, single-center, non-randomized, controlled, 2-year follow-up clinical study. Sixty HIV-infected patients with lumbar disc herniation who will receive treatment in the Shanghai Public Health Clinical Center will be included in this study. These patients will be divided into two groups according to the surgical treatment. Patients in the experimental group (n = 30) will undergo nucleus pulposus enucleation under an intervertebral foramen endoscope, while patients in the control group (n = 30) will undergo intervertebral disc fusion. All patients will be followed up postoperatively at 6, 12, and 24 months. This study was approved by the Institutional Ethics Committee of Shanghai Public Health Clinical Center of China (approval No. [2020]2020-S122-02) on July 28, 2020. All participants will be informed about the study protocol and will be asked to provide written informed consent. This study was designed on November 30, 2018. Patient recruitment will be performed in the period between October 30, 2020 and April 30, 2021. The study outcomes will be analyzed between May 1, 2023 and May 30, 2023. The study will be terminated on June 30, 2023. The primary outcome measure of this study is the change in the symptom improvement rate evaluated by the Japanese Orthopedic Association score at 24 months after the surgery. The secondary outcome measures include the changes in the symptom improvement rate evaluated by the Japanese Orthopedic Association score at 6 and 12 months after the surgery; pain improvement rate evaluated by the Visual Analogue Scale, and improvement in the quality of life evaluated by 36-Item Short Form Health Survey (SF-36) at 6, 12, and 24 months, as well as the recurrence rate of lumbar disc herniation and the incidence of postoperative adverse reactions at 6, 12, and 24 months after the surgery. Results: In our preliminary study ongoing between January 2016 and January 2018, 86 patients were included and divided into two groups, i.e., the experimental group (n = 48; nucleus pulposus enucleation under intervertebral foramen endoscope) and the control group (n = 38; intervertebral disc fusion). Six-month follow-up results revealed that the mortality of the experimental and control groups was 0 during and 6 months after the surgery, and no deaths occurred due to intervertebral foramen endoscope surgery or postoperative adverse reactions. Six-month follow-up results revealed that the improvement rate of the Japanese Orthopedic Association score and recurrence rate were comparable between the experimental and control groups, and no adverse reactions occurred. However, the improvement rate of the Visual Analogue Scale in the experimental group was higher than that in the control group (P Conclusion: The results of this study can be used to indicate whether transforaminal endoscopy with minimal trauma in the treatment of lumbar disc herniation in HIV-infected patients is associated with better medium- and long-term surgical effects and prognosis as well as turnover than intervertebral disc fusion. The innovation of this study lies in a fact that the subjects are HIV-infected patients with lumbar disc herniation. Trial registration: This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR2000037464) on August 28, 2020. Study protocol: 1.0.

Radiographic and clinical outcomes of huge lumbar disc herniations treated by transforaminal endoscopic discectomy

ObjectivesLarge Central disc herniations (occupying more than 50% of canal area) are notorious as they are generally associated with worse outcomes and are technically difficult to manage. Transforaminal endoscopy (TELD) has evolved to become an interesting alternative for lumbar disc herniations. The aim of the paper is to review our technique of transforaminal endoscopy in large central disc herniations and describe the clinical and radiographic results. We also describe an innovative technique of intraoperative epidurography to assess the adequacy of decompression in some cases with severe canal compromise. Patients and methodsWe performed a retrospective analysis of all the patients undergoing TELD from December 2012 to October 2018 for huge central lumbar disc herniations. The procedure was done under local anaesthesia and required a more horizontal approach angle, undercutting of superior articular process and posterior annular release to reach the herniated fragment in the epidural space. In severe cases, a radiopaque dye was introduced via trans-sacral catheter to check the adequacy of decompression. The disc height, lumbar lordosis, segmental lordotic angle on standing radiographs and Canal cross sectional area(CSA) on MRI were evaluated preoperatively and compared with postoperative images at the end of 1 year/final follow-up. The Visual analogue scale(VAS) for Back and Leg pain and Oswestry disability index (ODI), MacNab criteria, return to daily activities, return to work, patient satisfaction rate and recommendation to others were the clinical outcomes evaluated. The percentage of patients achieving the Minimal clinically important difference (MCID) of 3 points for VAS and 12 points for ODI was calculated. ResultsA total of 18 patients, with an average age of 35.1years (range 20–61), were operated. The mean VAS back improved from 5.7(±1.77) to 1(±0.77) and VAS leg improved from 7.3(±1.37) to 1.1(±1.09). The ODI improved from 49.88(±11.42) to 13.88(±7.28) at final follow-up. According to MacNab criteria, 17 patients had excellent and 1 had good outcome at final follow-up. The patient satisfaction rate was 90.5%, with 94% patient recommendation rate. All the patients returned to daily activities and work/modified work within a median of 5 weeks. There was 1 patient who required conversion to open surgery due to incidental dural tear, 1 patient who had a remnant disc required a revision tubular discectomy and 1 patient who had recurrence at 6 weeks and again at 2 years which was treated by repeat TELD. Five patients had impending cauda equina. All the patients achieved the MCID for VAS and ODI within a median period of 6 weeks and 3 months, respectively. The recovery rate was 90.1%. Five patients had grade 4 weakness of great toe/ankle dorsiflexion, one also had ankle flexion weakness preoperatively which improved after surgery. The CSA improved from a preoperative mean of 62.26(±30.3)mm2 to 122.16(±56.5)mm2 postoperatively. The CSA improved to 141.05(±63.86)mm2 at 1 year followup. The average disc height which was 9.71 mm(±2.4) was maintained at follow-up of one year which was 9.21 mm(±2.4). The lumbar lordosis and segmental lordotic angle changed from 27.08°(±15.9) and 2.82°(±5.7) to 35.8°(±8.56) and 4.85°(±4.39) respectively. ConclusionTELD may be considered as an alternative to microdiscectomy or fusion procedures for huge central disc herniations with favourable outcomes. However, sufficient expertise with the procedure is necessary. Intraoperative decompression may be confirmed with intraoperative epidurography. The patient acceptability of the procedure is good and causes minimal disruption of the normal anatomy.

How I do it? Transforaminal endoscopic decompression of intraspinal facet cyst.

Transforaminal endoscopic surgery provides equivalent results to open surgery with added advantages of feasibility under local anesthesia, no injury to posterior elements, preservation of the ligamentum flavum, ease of revision surgery, and cost-effectiveness. The technique of transforaminal endoscopic excision of cysts of facet or zygapophyseal joints is scarcely described in literature. The transforaminal endoscopy is applicable to cyst lying in the extraforaminal, foraminal, and intraspinal regions. The "mobile" outside-in technique combined with osteotomy of the tip of the superior articular process facilitates intraspinal access for complete decompression. Transforaminal endoscopic removal of the facet cyst is a viable alternative to traditional open surgery with added advantages of a minimal access procedure.

Short- and long-term results of percutaneous full-endoscopic and microsurgical lumbar discectomy: prospective cohort study

Objective. To analyze immediate and long-term results of percutaneous endoscopic and microsurgical discectomy.Material and Methods. A prospective cohort study in two groups of patients was conducted in 2015–2018. The observation period was 6–42 months. Group 1 included 110 patients who underwent percutaneous endoscopic lumbar discectomy, and Group 2 – 331 patients who underwent microdiscectomy. Efficiency was assessed using NRS-11, ODI, SF-36, and MacNab questionnaires.Results. The operating time, bed day number, and disability period were shorter in Group 1 (p &lt; 0.001). The average effective dose of radiation exposure to the patient was 4.4 mSv in transforaminal endoscopy, and 0.8 mSv in interlaminar and microsurgical discectomy. There were no significant intergroup differences in frequency and types of complications and reoperations. The portion of symptomatic hernia recurrence in Group 1 was 10 %, in Group 2 – 4.8 %. Significant differences in neurological outcomes and quality of life were not revealed. Good and excellent outcomes according to MacNab criteria were noted in 78.2 % and 84.9 %, in Groups 1 and 2, respectively.Conclusion. The percutaneous endoscopic discectomy allows reducing hospital stay length and disability period, while having clinical efficacy equal to that of other disectomy methods. A statistically insignificant increase in the risk of hernia recurrence after percutaneous endoscopic discectomy was noted.

Risk of bleeding in patients with continued dual antiplatelet therapy during orthopedic surgery.

Background:To prevent risk of life-threatening stent thrombosis, all patients need to undergo dual antiplatelet therapy (DAPT) for at least 6 weeks to 12 months after stent implantation. If DAPT is continued during noncardiac surgery, there is a risk of severe bleeding at the surgical site. Our study was to assess the risk of bleeding in patients with continued DAPT during orthopedic surgery.Methods:The clinical data of 78 patients with coronary heart disease who underwent orthopedic surgery from February 2006 to July 2018 were retrospectively analyzed. Prior to orthopedic surgery, DAPT was continued in 16 patients (group I), 24 patients were treated with single antiplatelet therapy (group II), and 26 patients received low-molecular-weight heparin therapy for more than 5 days after the discontinuation of all antiplatelet therapies (group III). Twelve patients were excluded, as they had undergone minimally invasive surgery such as transforaminal endoscopy and vertebroplasty. The perioperative blood loss of each patient was calculated using Nadler's formula and Gross’ formula. The intraoperative bleeding volume, total volume of intraoperative bleeding in addition to postoperative drainage, and total blood loss were compared between groups. The level of significance was set at P < 0.05.Results:There were no significant differences between the three groups in age, intraoperative bleeding volume, total volume of intraoperative bleeding in addition to postoperative drainage, and total perioperative blood loss calculated by Nadler's formula and Gross’ formula (all P > 0.05). Six patients experienced postoperative cardiovascular complications due to the delayed restart of antiplatelet therapy; one of these patients in group III died from myocardial infarction.Conclusions:Continued DAPT or single antiplatelet treatment during orthopedic surgery does not increase the total intraoperative and perioperative bleeding compared with switching from antiplatelet therapy to low-molecular-weight heparin. However, the discontinuation of antiplatelet therapy increases the risk of serious cardiac complications.

Application progress of percutaneous transforaminal endoscopic discectomy in the treatment of lumbar intervertebral disc herniation

Lumbar intervertebral disc herniation (LDH) is a syndrome caused by various reasons such as nucleus pulposus protrusion, compression of nerve root and herniation of nucleus pulposus, and stimulation of nerve root and cauda equina nerve. It is one of the most common diseases in orthopedics. There are a variety of surgical treatments for this disease, including traditional open surgery and minimally invasive techniques. At present, the minimally invasive technique represented by percutaneous transforaminal endoscopy has gradually replaced the traditional open surgery as the mainstream because of its advantages of less trauma, faster recovery and fewer complications. This article will systematically expound the application and progress of percutaneous lumbar intervertebral foraminoscopy in the treatment of lumbar disc herniation from the development course, indications, operation skills, matters needing attention, curative effect analysis, complications and so on. Key words: Lumbar vertebrae/SU; Intervertebral disk displacement/SU; Diskectomy, percutaneous; Endoscopy; Review

Comparative evaluation of percutaneous endoscopic and microsurgical lumbar discectomy

The results of percutaneous endoscopic and microsurgical discectomy have been compared. It was established that the operative intervention time, bed-day medians and disability period were significantly shorter (p0,001) in the percutaneous endoscopy group. The average effective dose of radiation exposure for a patient during transforaminal endoscopy was 4,4 mSv, for interlaminar endoscopic techniques and microsurgery - 0,8 mSv. The proportions of complications and repeated operations in both groups were comparable. The risk of recurrence was 10% for the endoscopic group, 4,8% for the microsurgical group. Significant differences in terms of local and radicular pain, quality of life and the physical component of health have not been established. The mental component of health was the best in the endoscopic group. Good and excellent results on the MacNab treatment satisfaction scale in the endoscopy group were observed in 78,2% of cases, after microdiscectomy - in84,9%. Lower invasiveness of percutaneous endoscopy affected the reduction in the period of hospitalization and disability. The effectiveness of percutaneous endoscopic discectomy methods was comparable to standard microsurgical techniques. A statistically insignificant increase in the risk of hernia recurrence after percutaneous endoscopic discectomy was noted. Infectious complications were not typical for percutaneous endoscopic discectomy. Differences in the frequency of complications and reoperations between percutaneous endoscopic and microsurgical lumbar discectomy are also not confirmed.

Effect and effectiveness analysis of different approaches of transforaminal endoscope on extirpation amount of nuclues pulposus

To investigate the effect and effectiveness analysis of different approaches of transforaminal endoscope on extirpation amount of nuclues pulposus. Between August 2011 and December 2014, a total of 165 patients with lumbar disc herniation were retrospectively enrolled and were treated with nucleus pulposus discectomy through transforaminal endoscope. The patients were randomly divided into 4 groups according to different approach of transforaminal endoscope. The posterolateral approach (Yeung's technology) was used in group A (42 cases), transforaminal endoscopic spine system (TESSYS) technology was used in group B (40 cases), improved transforaminal endoscopic access (ITEA) technology was used in group C (43 cases), and interlaminar approach (40 cases) was used in group D (40 cases). There was no significant difference in gender, age, disease duration, symptomatic side, and segments among 4 groups ( P>0.05). The extirpation amount of nuclues pulposus was calculated and compared among 4 groups; the effectiveness was evaluated by pre- and post-operative visual analogue scale (VAS) score, Oswestry disability index (ODI), lumbar curvature index (LCI), and intervertebral height. The discectomy amount of nucleus pulposus was (3.7±0.8), (3.6±0.7), (4.5±1.1), and (3.0±0.8) cm 3 in groups A, B, C, and D, respectively. The amount of group C was significantly larger than that of the other 3 groups ( P<0.05), and the amount of group D was significantly smaller than that of the other 3 groups ( P<0.05); no significant difference was found between groups A and B ( P>0.05). Cerebrospinal fluid leakage was found in 1 case; no other postoperative complications including intervertebral space infection and epidural hematoma was found. All the incisions healed by first intension. All the patients were followed up 12-24 months (mean, 18 months), and no typical symptoms of recurrence was found during the follow-up period. There was no significant difference in preoperative lower back pain VAS score, lower extremities VAS score, and ODI scores among 4 groups ( P>0.05). The above scores at last follow-up were significantly improved when compared with preoperative ones in each group ( P<0.05), but no significant difference of above scores and recovery values was found among 4 groups ( P>0.05). The difference in LCI and intervertebral height at preoperation and at last follow-up were not significant between 4 groups ( P>0.05). The difference in LCI and intervertebral height of each group between at preoperation and last follow-up were not significant ( P>0.05). And the recovery value of LCI and the lost of height at last follow-up also showed no significant differences between 4 groups ( P>0.05). The ITEA technology can give a wider field of view than other technologies. It is more convenient to find and remove the nucleus pulposus. However, the appropriate operative approaches should be chosen according to the symptoms and characteristics of lumbar disc herniation.

Transforaminal Endoscopic Discectomy for Treatment of Central Disc Herniation: Surgical Techniques and Clinical Outcome

Background: Though transforaminal endoscopic discectomy has achieved a satisfactory clinical outcome in the treatment of paracentral disc herniation, it has a high failure rate for treating central disc herniation. Objective: To explore the surgical techniques of transforaminal endoscopic discectomy in treating central disc herniation and the clinical outcome based on 2-year follow-up. Study Design: A retrospective study. Setting: The Department of Spinal Surgery at the Third Hospital of Hebei Medical University in China. Methods: Sixty-nine consecutive patients (male:female = 14:9, mean age 38.8 ± 10.5 years) were enrolled in the study, all of whom underwent transforaminal endoscopic discectomy due to central disc herniation. The rod adjustment technique, apex technique, and posterior longitudinal ligament detection technique were adopted for intraoperative individualization. All of the patients were followed up for 24 months to assess the visual analog scale (VAS), Japanese Orthopaedic Association (JOA), and Oswestry Disability Index (ODI) scores. The postoperative segmental instability and recurrence were observed during the follow-up period as well. MacNab criteria scores were recorded both intraoperatively and at the final follow-up; postoperative complications and the surgical outcome and safety were also evaluated. Results: The herniated disc tissues were successfully removed for all patients, without revision by open surgery. Twenty-one cases (30.43%) were rated excellent, 44 (63.77%) good, 4 (5.80%) fair, and 0 (0.00%) poor upon the final follow-up, with an overall excellent-to-good rate of 86.96%. The VAS scores of low back and leg pain were all significantly lower at 3, 6, 12, and 24 months postoperatively compared to preoperatively (all P &lt; 0.05). The JOA scores at the 3-month and 24-month postoperative follow-ups were significantly higher than the preoperative values (all P &lt; 0.05). The ODI evaluation was significantly lower at 3 and 24 months postoperatively than preoperatively (all P &lt; 0.05). Limitations: The retrospective nature of this study is a limitation, as well as the small sample size and short observation time. Conclusion: The application of novel surgical techniques can help improve the safety and efficacy of transforaminal endoscopic discectomy in treating central disc herniations. Intraoperative individualized application of rod adjustment technique, apex technique, or posterior longitudinal ligament detection technique is the key to satisfactory clinical outcome. Key words: Central disc herniation, rod adjustment technique, transforaminal endoscopy, minimal invasion, complication

Percutaneous transforaminal endoscopic discectomy and drainage for spondylodiscitis: A technical note and review of literature

Spondylodiscitis is on rise due to increasing elderly population and immunocompromised people and now gets early detected due to early imaging. Percutaneous Transforaminal Endoscopic Discectomy and Drainage (PTELDD), is simple procedure that yields high culture wihich helps in specific targeted antimicrobial bombardment. Dr. Satishchandra Gore has been pioneer in introducing transforaminal endoscopy in India way back in 1999. His persistent efforts has made inroads into traditional spine care treatments and endoscopy bandwagon is flying high and many surgeons are able to give results with the technique all over India. The available english literature of transforaminal endoscopy in spondylodiscitis is reviewed here with technical note of this simplistic procedure. The reported outcome in literature is excellent in majority of cases. Authors unpublished report of 16 cases is also comparable with literature. PTELDD is a simplistic most minimalist minimally invasive procedure that gives very positive outcome in early cases of spondylodiscitis.

Rami Communicans Block Prior to Transforaminal Endoscopic Discectomy relieves Procedure Pain Significantly and adds Safety: A Case–control Study

Background: The ability to isolate and visualize thepain generators in the foramen and treat persistent pain by visualizing inflammation and compression of nerves serves as the basis for transforaminal endoscopic (TFE) surgery.It provides a least invasive basic access to the disc. One of the important steps is the insertion of dilator and working sleeve followed by introduction of endoscope. Often this step is carried out with the help of a hammer, which is agonizing for the patients undergoing surgery. This study aims at analyzing the efficacy of the rami communicans nerve block in reducing the intraoperative pain in patients undergoing TFE discectomy. Materials and methods: A total of 48 patients undergoing TFE discectomy were assigned into two groups. Group I (case, n = 27) received rami communicans block prior to endoscopic discectomy a nd f or g roup II (control, n= 2 1), n o r ami c ommunicans block was given. Under all aseptic precautions, the rami communicans block was given to group I patients after identification of corresponding level. After proper placement of block, lumbar TFE discectomy was performed using the insideout approach. Pain was assessed using numerical rating scale (NRS) at different time intervals. Statistical analysis was carried out using independent Student's t-test, chi-squared test, and Mann–Whitney U test. Results: While comparing NRS, group I showed significantly lower NRS when compared with group II and it was highly significant (p-value < 0.0001). The need for rescue analgesia was also compared and this difference was also found to be highly significant (p-value <0.0001). Conclusion: The rami communicans block is highly effective in reducing the intraoperative pain in patients undergoing TFE discectomy and thus, reduces the total dose of anesthetics and analgesics intraoperatively.

Feasibility of interlaminar lumbar discectomy through percutaneous transforaminal endoscopy and blunt perforation of the ligamentum flavum.

To determine the efficacy, safety, and clinical value of a novel surgical procedure involving the blunt perforation of the ligamentum flavum (LF) during endoscopic interlaminar lumbar discectomy. This was a prospective study of 50 patients (27 males, 17-51 years of age) undergoing lumbar discectomy for single segment L4/L5 or L5/S1 disk herniation were grouped into the control (cutting of the LF; n=28) and test (blunt perforation; n=22) groups. Intraoperative injury to the LF was evaluated by electrophysiological monitoring. The time required for perforation, total surgical time, and proportion of epidural sac and nerve root injury were assessed. Among the enrolled patients, 90% showed herniation of the L4/5 segment and 10% of the L5/S1 segment. The success rate for the perforation of the LF was 93%. The intraoperative observation showed mild self-closing injury to the LF tissue. The test group showed shorter overall surgical time (43 vs. 56 min) and shorter duration to go through the LF (1 vs. 13 min, p 0.001). No dural sac or nerve root injury resulting from blunt perforation of the LF was observed. Compared to cutting, blunt perforation of the LF could reduce surgical time and injury to LF and surrounding tissues. Thus, it could be a safe and efficient surgical technique for patients undergoing intralaminar lumbar discectomy.

Transforaminal endoscopy through interlaminar approach for inferior lumbar disc herniation

Objective To study the efficacy of transforaminal endoscopy through interlaminar approach for intervertebral disc herniation (LDH) at L4/L5 and L5/S1. Methods Between January 2013 and September 2014, 76 patients with LDH at L4/L5 and L5/S1 were treated at our department through the posterior interlaminar approach between the facet process and dural sac clearance. They were 46 men and 30 women, 22 to 78 years of age (56.2 years) . The responsible level was at L4/L5 in 34 cases and L5/S1 in 42 ones. All the patients were assessed preoperation, 1 week, 1 and 3 months postoperation using visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) scoring in terms of pain, numbness, muscular strength and motion. Results All surgeries succeeded with no injury to nerve root, dural sac disruption, or spondylodiscitis. All wounds healed primarily. The patients obtained an average follow-up of 14 months (range, from 12 to 18 months) . No relapse was found during the follow-ups. There were significant differences in VAS and JOA scores between preoperation and all the time points postoperation in all the patients (P 0.05). Conclusion Transforaminal endoscopy through interlaminar approach for LDH at L4/L5 and L5/S1, if its indications are strictly followed, can have the advantages of high safety, limited invasion, little bleeding, few complications and quick recovery. Key words: Lumbar vertebrae; Prolapsed disk; Endoscopes

Ligament, nerve, and blood vessel anatomy of the lateral zone of the lumbar intervertebral foramina.

To provide an anatomical basis for intrusive treatment using an approach through the lateral zones of the lumbar intervertebral foramina (LIF), especially for acupotomology lysis, percutaneous transforaminal endoscopy, and lumbar nerve root block. Blood vessels, ligaments, nerves, and adjacent structures of ten cadavers were exposed through the L1-2 to L5-S1 intervertebral foramina and examined. The lateral zones of the LIF were almost filled by ligaments, nerves, and blood vessels, which were separated into compartments by superior/inferior transforaminal ligaments and corporotransverse superior/inferior ligaments. Two zones relatively lacking in blood vessels and nerves (triangular working zones) were found beside the lamina of the vertebral arch and on the root of the transverse processus. Both the ascending lumbar vein and branches of the intervetebral vein were observed in 12 Kambin's triangles, and in only seven Kambin's triangles were without any veins. Nerves and blood vessels are fixed and protected by transforaminal ligaments and/or corporotransverse ligaments. It is necessary to distinguish the ligaments from nerves using transforaminal endoscopy so that the ligaments can be cut without damaging nerves. Care needs to be taken in intrusive operations because of the veins running through Kambin's triangle. We recommend injecting into the lamina of the vertebral arch and the midpoint between the adjacent roots of the transverse processus when administering nerve root block. Blind percutaneous incision and acupotomology lysis is dangerous in the lateral zones of the LIF, as they are filled with nerves and blood vessels.

The "inside out" transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature.

Surgical management of back and leg pain is evolving and changing due to a better understanding of the patho-anatomy well correlated with its pathophysiology. Pain is better understood with in vivo visualization and probing of the pain generators using an endoscopic access rather than just relying on symptoms diagram and image correlation. This has resulted in a shared decision making involving patient and surgeon, focused on a broader spectrum of surgical as well as non-surgical treatments, and not just masking the pain generator. It has moved away from decisions based on diagnostic images alone, that, while noting the image alterations, cannot explain the pain experienced by each individual as images do not always show variations in nerve supply and patho-anatomy.The ability to isolate and visualize “pain” generators in the foramen and treating persistent pain by visualizing inflammation and compression of nerves, serves as the basis for transforaminal endoscopic (TFE) surgery. This has also resulted in better pre surgical planning with more specific and defined goals in mind. The “Inside out” philosophy of TFE surgery is safe and precise. It provides basic access to the disc and foramen to cover a large spectrum of painful pathologies.

Reliving refractory pain of spinal metastasis patients with radiofrequency ablation through transforaminal endoscopy

To explore the short-term outcomes of radiofrequency ablation treatment of bone metastasis. Between November 2011 and November 2012, a total of 18 cases were retrospectively reviewed. They underwent resection of bone metastasis with radiofrequency ablation through transforaminal endoscopic spine system. According to the Tomita classification system, the classifications were type 5 (n = 8), type 6 (n = 4) and type 7 (n = 6). There were 8 males and 10 females with a median age of 52.1 (32-76) years. The primary lesions were breast cancer (n = 5), carcinoma of prostate (n = 3), digestive cancer (n = 4), thyroid carcinoma (n = 2)and lung cancer (n = 4). And two cases had pathologic fracture. The operative duration was 118 (90-180) min and blood loss volume 30.6 (10-60) ml. All incisions achieved excellent healing.One case of pneumonia recovered with antibiotic. The postoperative visual analogue scale (VAS) scores were 2.4 ± 0.4, 2.6 ± 0.6, 3.0 ± 0.3 and 2.8 ± 0.7. Radiofrequency ablation through transforaminal endoscopy may be a safe and efficacious option for refractory pain with bone metastasis, especially for those with uncontrolled pain. This procedure is mini-invasive and causes less bleeding.