Mid-long-term effect of only placed expandable Interbody fusion cage in the treatment of lumbar spinal Stenosis with vertebral instability using micro-endoscopic Discectomy system / 中国组织工程研究

BACKGROUND: The incidence of lumbar spinal stenosis with vertebral instability is increasing year by year, which can cause symptoms such as waist and leg pain, lower limbs feeling numbness and intermittent claudication. In recent years, scholars have tried various minimally invasive treatment methods to further reduce the trauma and complications of surgery. The improvement of the clinical effect of minimally invasive surgery for lumbar spinal stenosis with vertebral instability is an important issue to be solved. OBJECTIVE: To evaluate the mid-long-term effect of only placed expandable interbody fusion cage in the treatment of lumbar spinal stenosis with vertebral instability using micro-endoscopic discectomy system. METHODS: A retrospective, self-control clinical trial was conducted in the First Affiliated Hospital of Zhengzhou University from 2012 to 2014. Totally 35 patients with lumbar spinal stenosis combined with vertebral instability were treated by only placed expandable interbody fusion cage using micro-endoscopic discectomy system. This study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University. RESULTS AND CONCLUSION: (1) All 35 patients were followed-up for 60-85 months, mean (70.17±5.40) months. Among these patients, lumbar interbody fusion in 1 segment, 2 segments and 3 segments was performed in 6, 20 and 9 cases, respectively. A total of 73 intervertebral spaces were fused. (2) The mean operation time was 53.49±9.13 minutes (range, 35-75 minutes). The mean blood loss was 114.86±54.23 mL (range, 50-250 mL). (3) Dural rupture occurred in one case during operation and then hypotensive cranial pressure headache occurred after operation. Headache gradually eased after the patient received rehydration and analgesic treatment for 3 days. Poor incision healing occurred in one case after operation and then healed well after one-week vacuum sealing drainage technique. (4) The Visual Analogue Scale scores, Oswestry Disability Index, and height of intervertebral space were significantly decreased at 1 week, 6 months, 1 year, 2 years after surgery and the final follow-up compared to the preoperative ones. At 6 months after the operation, 31(42.5%) intervertebral spaces reached a strong fusion, 25(34.2%) possible fusion, and 17(23.3%) did not reach fusion. At 1 year after surgery, 51(69.9%) intervertebral spaces achieved a strong fusion and 22(30.1%) achieved possible fusion. At 2 years after surgery, 57(78.1%) intervertebral spaces achieved a strong fusion and 16(21.9%) achieved possible fusion. During final follow-up, 62(84.9%) intervertebral spaces achieved a strong fusion and 11(15.1%) achieved possible fusion. (5) At the last follow-up, cage migration was found in one case. The patient was not treated because of symptomless. (6) Unilateral approach only placed expandable interbody fusion cage by using micro-endoscopic discectomy system is a safe and reliable minimally surgical method, which has a good mid-long-term effect on lumbar spinal stenosis with vertebral instability.

Percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for lumbar spinal stenosis / 中国修复重建外科杂志

Objective: To design the surgical strategy of percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral lumbar spinal stenosis (LSS) and to evaluate the effectiveness. Methods: The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for bilateral LSS was designed according to the pathological features of LSS. The technique was used to treat 42 patients with LSS between January 2016 and January 2018. There were 18 males and 24 females with an average age of 61.7 years (range, 46-81 years). The duration of symptoms was 1-20 years, with an average of 9.7 years. The surgical segment at L 4, 5 were 27 cases, at L 5, S 1 were 15 cases. The operation time and perioperative complications were recorded. Lumbar X-ray, CT, and MRI examinations were performed at 1 week, 3 months, and 1 year after operation. Visual analogue scale (VAS) score was used to evaluate the low back pain and leg pain, Oswestry disability index (ODI) was used to evaluate the lumbar function, and single continuous walking distance (SCWD) was used to evaluate lower extremity nerve function. The clinical efficacy was evaluated by MacNab criteria at 1 year after operation. Results: All patients underwent surgery successfully. The operation time was 68-141 minutes with an average of 98.2 minutes. All 42 patients were followed up 12-24 months with an average of 18.8 months. There were 2 cases of dural tears during operation, and 1 case of transient dysfunction of the lower limbs of the decompression channel after operation. All of them were cured after corresponding treatment. No serious complications such as death, major bleeding, or irreversible nerve injury occurred during follow-up. No segmental instability was found according to postoperative lumbar hyperextension and flexion X-ray films, and postoperative CT and MRI imaging showed that the stenotic lumbar spinal canal was significantly enlarged, and the compression of the nerve root was sufficient. The VAS score of low back pain and leg pain, ODI score, and SCWD at each time point after operation were significantly improved when compared with those before operation ( P<0.05); the indexes were significantly improved over time after operation, and the differences were significantly ( P<0.05). The clinical efficacy was evaluated by MacNab standard at 1 year after operation, and the results were excellent in 18 cases, good in 20 cases, fair in 3 cases, and poor in 1 case. The excellent and good rate was 90.5%. Conclusion: The percutaneous full-endoscopic bilateral decompression via unilateral posterior approach for LSS is a safe and effective procedure. A well-designed surgical strategy and mastery of its technical points are important guarantees for successful operation and satisfactory results.

Usefulness of Contralateral Indirect Decompression through Minimally Invasive Unilateral Transforaminal Lumbar Interbody Fusion

STUDY DESIGN: Retrospective study. PURPOSE: This study aims to investigate the clinical and radiological results of contralateral indirect decompression through minimally invasive unilateral transforaminal lumbar interbody fusion (MI-TLIF). OVERVIEW OF LITERATURE: Several studies have proposed that blood loss and operation time could be reduced through a unilateral approach, although many surgeons have forecast that satisfactory foraminal decompression is difficult to achieve through a unilateral approach. METHODS: The study included 30 subjects who had undergone single-level MI-TLIF. Visual analogue scale (VAS) and Oswestry disability index (ODI) were analyzed for clinical assessment. Disc height, segmental lordosis, and lumbar lordosis angle were examined for radiological assessment. The degree of contralateral indirect decompression was evaluated through a comparative analysis, with a magnetic resonance imaging (MRI) performed preoperatively and at one year postoperatively. RESULTS: Intraoperative blood loss volume was 308.75 mL in the unilateral approach group (UAP), and 575.00 mL in the bilateral approach group (BAP), showing a statistically significant difference. Operation time was 139.50 minutes in the UAP group, and 189.00 minutes in the BAP group, exhibiting a statistically significant difference (p0.05). CONCLUSIONS: Satisfactory results were acquired with MI-TLIF conducted through the unilateral approach of contralateral indirect decompression, in alignment with the bilateral approach. Therefore, contralateral indirect decompression is thought to be a useful procedure in reducing the operation time and volume of blood loss.

Management of Thoracal and Lumbar Schwannomas Using a Unilateral Approach without Instability: An Analysis of 15 Cases

STUDY DESIGN: Retrospective case series. PURPOSE: The objectives of this study were to determine and discuss the surgical planning of patients who underwent operations following diagnoses of thoracal and lumbar spinal schwannomas. We also aimed to discuss the application of unilateral hemilaminectomy for the microsurgery of schwannomas. OVERVIEW OF LITERATURE: Schwannomas are located in different regions and sites. These differences require several surgical approaches. Unilateral laminectomy without stabilization of the spine provides a more minimally invasive removal of the tumor. METHODS: In this retrospective study, 15 patients with spinal schwannomas were evaluated with regards to age, sex, onset history, neurological findings, tumor locations, McCormick scale, surgical procedure, and operational results. The lateral approach provides exposure of intradural structures and posterior paraspinal regions. Extensions of tumors cause problem for the surgeon in terms of approach, resectability of the tumor, and stability of the spine. Gross total resection was achieved in all cases, and none of the patients necessary required a fusion procedure. RESULTS: Five patients were males and 10 were females. The age interval was 29-65 years. The tumor was located in the lumbar region in 9 patients, in the thoracic region in 2 patients, and in the thoracolumbar junction in 4 patients. The intradural lesions were removed by laminectomy and the extradural lesions were resected with hemilaminectomy. The paramedian route was used to explore the extraspinal part of the tumor. Costotransversectomy was for the thoracic region. Subtotal resection was performed in 1 patient. Patient symptoms recovered gradually in the postoperative period. CONCLUSIONS: Resection of giant schwannomas is challenging and usually requires a different approach. We describe the complete resection of complex dumbbell or paraspinal schwannomas of the thoracic and lumbar spine by unilateral hemilaminectomy.

Under microscope bilateral decompression via unilateral approach for the treatment of lumbar stenosis / 中华显微外科杂志

Objective To evaluate the characteristics and efficacy of microscope-assisted bilateral decompression via unilateral approach for the treatment of lumbar stenosis. Methods From June 2007 to June 2010, Sixty case lumbar stenosis with bilateral decompression were treated via unilateral approach under microscopy. Patients were followed up from 6 to 24 months, average (12 ± 4.7) months. Results The pain level of each patient was assessed both before and after the opeartion, using a visual analogue scale (VAS). Intermittent claudication was completely relieved in 57 out of 60 cases, moderately relieved in 3 cases. VAS score decreased from pre-operational 9.08 ± 0.76 to post-operational 2.33 ± 1.43, and there was significantly difference between them. There was no recurrent case during the whole follow-up. Conclusion Bilateral decompression via unilateral approach under microscope is proved to be an effective and safe procedure for the treatment of lumbar stenosis, and have the advantages of minimal invasion, less pain, quick recovery, better effect, little influence on the spinal stability.

Comparative Study of Posterior Lumbar Interbody Fusion via Unilateral and Bilateral Approaches in Patients with Unilateral Leg Symptoms

OBJECTIVE: We investigated the clinical and radiological advantages of unilateral laminectomy in posterior lumbar interbody fusion (PLIF) procedure comparing with bilateral laminectomy, under the same procedural condition including bilateral instrumentation and insertion of two cages, in patients with degenerative lumbar disease with unilateral leg symptoms. METHODS: We retrospectively reviewed 124 consecutive cases of PLIF via unilateral or bilateral approach between January 2006 and April 2010. In 80 cases (bilateral group), two cages were inserted via bilateral laminectomy, and in 44 cases (unilateral group), via unilateral laminectomy. The average follow-up duration was 29.5 months. The clinical outcomes were evaluated with the Visual Analogue Scale (VAS) and the Oswestry disability index (ODI). The fusion rates and disc space heights were determined by dynamic standing radiographs and/or computed tomography. Operative times, intra-operative and post-operative blood losses and hospitalization periods were also evaluated. RESULTS: In clinical evaluation, the VAS and ODI scores showed excellent outcomes in both groups. There were no significant differences in term of fusion rate, but the perioperative blood loss and the operative time of the unilateral group were lower than that of the bilateral group. CONCLUSION: Unilateral laminectomy can minimize the operative time and perioperative blood loss in PLIF procedure. However, the different preoperative disc height between two groups is a limitation of this study. Despite this limitation, solid fusion and satisfactory symptomatic improvement could be achieved uniquely by our surgical method. This surgical method can be an alternative surgical technique in patients with unilateral leg pain.

Minimally Invasive Transforaminal Lumbar Interbody Fusion in Patients with Low Grade Spondylolisthesis: Comparison of the Unilateral and Bilateral Approaches / 대한정형외과학회잡지

PURPOSE: We wanted to analyze the clinical and radiological results of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) in patients with low grade spondylolisthesis, and we also compared the unilateral and bilateral approaches. MATERIALS AND METHODS: This study examined a consecutive series of 27 patients who underwent one-level MI-TLIF (16 cases of the unilateral approach and 11 cases of the bilateral approach) and the follow-up data was compared with a minimum 1-year follow-up. The amount of intraoperative blood loss, the postoperative drainage, the transfusion requirement and the surgery time were investigated. The clinical outcomes were analyzed using the visual analogue scale (VAS), the Oswestry disability index (ODI) and the SF-36 Physical Composite Score (SF-36). The preoperative, postoperative and last follow-up changes in the height of the disc, the degree of the slipping and the slip angle in the fused segments were radiologically analyzed. RESULTS: There were no significant differences between the two groups in terms of the clinical and radiological results at the last follow-up. But the unilateral approach-group was found to have less blood loss, less postoperative drainage, a lesser requirement for transfusion and a shorter duration of surgery. During the reduction process in 1 patient among the cases that had the unilateral approach used, the pedicle screw fixed to the vertebral body fell out. CONCLUSION: The unilateral MI-TLIF can shorten the operation time and reduce the blood loss as compared to the bilateral approa

Minimal Invasive Unilateral Transforaminal Lumbar Interbody Fusion by Sublaminar Decompression: Comparison to Bilateral Approach / 대한정형외과학회잡지

PURPOSE: This is a comparison of the unilateral and bilateral approaches for minimal invasive transforaminal lumbar interbody fusion (TLIF), and we did so by measuring the clinical and radiological results. MATERIALS AND METHODS: This study examined a consecutive series of 47 patients who underwent one-level TLIF (26 cases of the unilateral approach and 21 cases of the bilateral approach to the lumbar spine) and the follow-up data was compared with a minimum 1-year follow-up. Sublaminar decompression and contralateral foraminectomy were done in all the case of using the unilateral approach. The age of each patient, the amount of intraoperative blood loss, the postoperative drainage, the transfusion requirement and the surgery time were investigated. The clinical outcomes were analyzed using the visual analogue scale, the SF-36 Physical Composite Score (PCS) and the Oswestry disability index (ODI). The preoperative, postoperative & last follow-up changes in the height and angles of the disc in the fused segments and the lumbar lordotic angles were radiologically analyzed. RESULTS: There was no statistical difference between the two groups in terms of the clinical and radiographic results at the last follow-up. But the unilateral approach-group was found to have a less blood loss, less postoperative drainage, a lesser requirement for transfusion and a shorter surgery time. CONCLUSION: This study confirms that the unilateral approach can be the better way if the technical problems are solved.

Mini-invasive unilateral transforaminal lumbar interbody fusion and pedicle screw fixation / 한양의대학술지

Posterior lumbar interbody fusion can simultaneously achieve spinal stabilization, anterior-column support, and direct neural decompression via a posterior approach. Unilateral transforaminal lumbar interbody fusion (TLIF) has several advantages such as less invasive and less retraction of neural components compared with conventional interbody fusion. But standard posterior spinal fusion with instrumentation requires a moderate amount of paraspinal musculoligamentous dissection. This dissection causes muscle denervation and atrophy that increases risk for failed back syndrome. Therefore, the authors performed a minimally invasive unilateral TLIF with a tubular retractor system combined with pedicle screw fixation to minimize the iatrogenic tissue injury. Although a less invasive unilateral approach was used, the early and longterm outcomes were as good as those on many reported series of posterior interbody fusion. More comfortness during the early postoperative period, small operation scar and less blood loss were the beneficial points compared with other conventional procedures. In the cases of instability of one-motion segment, pedicle screw fixation and TLIF with the tubular retractor system, minimally invasively, can reduce unnecessary trauma to the lumbar supporting structures while still accomplishing sufficient decompression and effective stabilization.

Outcomes of Unilateral Approach for Bilateral Decompression of Lumbar Spinal Stenosis: Comparison between Younger and Geriatric Patients

OBJECTIVE: The purpose of our retrospective study is to evaluate the surgical outcome of patients who underwent unila- teral approach for bilateral decompression surgery for lumbar spinal stenosis and to compare outcomes between geriatric and younger patients. METHODS: We reviewed records of 85 patients with an average age of 64 years at the time of surgery after the unilateral laminotomy for bilateral decompression of degenerative lumbar spinal stenosis between 2005 and 2007. To compare clinical and functional outcomes between younger and geriatric patients, they were divided by age into 2 groups: Group A included patients 65 years of age or older and Group B contained patients younger than 65 years. The study parameters were set to ensure a follow-up period of at least 3 months and hospital records and phone-call review were analyzed for patients' clinical and demographic data, co-morbidity, type of stenosis, clinical and functional outcomes. Clinical outcomes were measured using the scale of Finneson and Cooper and the visual analog scale score for leg and back pain. Functional outcome was assessed with change of walking distance of patients. RESULTS: Follow-up was completed in 80(94.1%) of 85 patients and Group A included 44 patients and Group B did 36 patients. The number of decompressed level showed 2.26 with similar results in both groups(group A, 2.25; Group B, 2.28). The number of co-morbidity was significantly higher incidence of 2.36 in geriatric patients than that of 1.67 in younger individuals. Other demographic data and type of stenosis were similar between two groups. For each back and leg pain, 86.3%(Group A: 86.4%; Group B, 80.6%) and 83.8%(Group A: 90.9%; Group B: 80.6%) had an excellent-to-fair operative result under the scale of Finneson and Cooper. Improvement rate of walking distance was 81.5% of patients and higher in group B(89.3%) than in group A(75.6%), however, there was not statistical significance. Three major complications were occurred in all patient groups, the first patient with chronic renal failure suffered from immediately postoperative epidural hematoma and the second patient had wound dehiscence. The third patient with no improvement was operated with fusion surgery at the other hospital nonetheless she had not improved until now. CONCLUSIONS: The ULBD allowed sufficient and safe decompression of the neural structures and adequate preservation of vertebral stability with acceptable complication rates. This technique could provide a minimally invasive approach for LSS in elderly patients frequently having comorbidities as well as younger one.

Balloon Kyphoplasty using a Unilateral Approach for the Treatment of Osteoporotic Vertebral Compression Fractures / 대한정형외과학회잡지

PURPOSE: To evaluate the clinical results of a unilateral balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures (VCFs). MATERIALS AND METHODS: Twenty patients, 23 cases of osteoporotic VCFs who failed to respond to nonoperative treatments and who were confirmed by a consultant radiologist, were enrolled in this study. Times between injury and operation varied from 2 weeks to 2 months. All patients except two (18 female, 2 male patients), were female, and mean patient age was 71.7 (58-82) years. Follow-ups were conducted at least 12 months (12-27, mean 18.3). All patients underwent unilateral balloon kyphoplasty. Roentgenographic assessments were perform to evaluate fractured vertebra restoration and reduction loss. A ten-point visual analogue scale was used to measure pre- and postoperative pain severity. RESULTS: Preoperative anterior, middle and posterior heights of vertebra bodies were 57.8%, 66.1% and 85.3% of normal at presentation and these increased to 76.2%, 80.1%, 88.7% respectively at immediately after operation and at last follow-up, heights of each portion were 74.4%, 78.6%, 87.3%. Mean preoperative kyphotic angles of 17.6 degrees at presentation improved to 8.9 degrees at immediately after operations and to 9.1 degrees at last follow-ups. Loss of reduction was 1.8%, 1.5%, 1.4% and 0.2 degrees. Mean pain scores were 8.5 before surgery, 2.5 immediately after operations and 2.7 at last follow-ups. Statistical analysis showed a significant decrease in kyphotic angle (p=0.03) but VAS scores were no different (p=0.056). Anterior, middle and posterior body height was decreased with a statistical significance between two period (p<0.001). PMMA leakage occurred in 3 cases, but they did not cause neurologic deficits. CONSLUSION: Balloon kyphoplasty using a unilateral approach is a good treatment method for osteoporotic vertebral compression fractures and an alternative to the substitute bilateral approach.

Posterior Lumbar Interbody Fusion via a Unilateral Approach

This study sought to determine the outcomes of posterior lumbar interbody fusion (PLIF), via a unilateral approach, in selected patients who presented with unilateral leg pain and segmental instability of the lumbar spine. Patients with a single level of a herniated disc disease in the lumbar spine, unilateral leg pain, chronic disabling lower back pain (LBP), and a failed conservative treatment, were considered for the procedure. A total of 41 patients underwent a single-level PLIF using two PEEK(TM) (Poly-Ether-Ether-Ketone) cages filled with iliac bone, via a unilateral approach. The patients comprised 21 women and 20 men with a mean age of 41 years (range: 22 to 63 years). Two cages were inserted using a unilateral medial facetectomy and a partial hemilaminectomy. At follow-up, the outcomes were assessed using the Prolo Scale. The success of the fusion was determined by dynamic lumbar radiography and/or computerized tomography scanning. All the patients safely underwent surgery without severe complications. During a mean follow-up period of 26 months, 1 patient underwent percutaneous pedicle screw fixation due to persistent LBP. A posterior displacement of the cage was found in one patient. At the last follow up, 90% of the patients demonstrated satisfactory results. An osseous fusion was present in 85% of the patients. A PLIF, via a unilateral approach, enables a solid union with satisfactory clinical results. This preserves part of the posterior elements of the lumbar spine in selected patients with single level instability and unilateral leg pain.

Posterior Lumbar Interbody Fusion via a Unilateral Approach

This study sought to determine the outcomes of posterior lumbar interbody fusion (PLIF), via a unilateral approach, in selected patients who presented with unilateral leg pain and segmental instability of the lumbar spine. Patients with a single level of a herniated disc disease in the lumbar spine, unilateral leg pain, chronic disabling lower back pain (LBP), and a failed conservative treatment, were considered for the procedure. A total of 41 patients underwent a single-level PLIF using two PEEK(TM) (Poly-Ether-Ether-Ketone) cages filled with iliac bone, via a unilateral approach. The patients comprised 21 women and 20 men with a mean age of 41 years (range: 22 to 63 years). Two cages were inserted using a unilateral medial facetectomy and a partial hemilaminectomy. At follow-up, the outcomes were assessed using the Prolo Scale. The success of the fusion was determined by dynamic lumbar radiography and/or computerized tomography scanning. All the patients safely underwent surgery without severe complications. During a mean follow-up period of 26 months, 1 patient underwent percutaneous pedicle screw fixation due to persistent LBP. A posterior displacement of the cage was found in one patient. At the last follow up, 90% of the patients demonstrated satisfactory results. An osseous fusion was present in 85% of the patients. A PLIF, via a unilateral approach, enables a solid union with satisfactory clinical results. This preserves part of the posterior elements of the lumbar spine in selected patients with single level instability and unilateral leg pain.