Feasibility of enlarging the ventral space by using a drill under spinal endoscopy in the treatment of severe free lumbar disc herniation / 中国骨伤

OBJECTIVE@#To evaluate the clinical efficacy of spinal endoscopy in the treatment of severe free lumbar disc herniation and explore the feasibility and application of microscopic drills to expand ventral space.@*METHODS@#Thirty patients with severe free lumbar intervertebral disc herniation treated by spinal endoscopic technique from April 2019 to March 2021 were collected, including 19 males and 11 females;aged from 19 to 76 years with an average of (44.03±16.92) years old. All patients had a single segmental lesion with prolapse of the nucleus pulposus. Among them, there were 3 cases on L2,3, 3 cases on L3,4, 15 cases on L4,5, and 9 cases on L5S1. During operation, posterior bone of vertebral body and pedicle notch were removed by a drill under the endoscope to enlarge the ventral space. And the free nucleus pulposus was exposed and completely removed. The intraoperative blood loss, operation time, hospital stay and postoperative neurological complications were recorded, and Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI) and visual analogue scale (VAS) were compared before operation, 2 days, 3 months and 1 year after operation, and Macnab standard was used to evaluate clinical efficacy.@*RESULTS@#All operations were successful and the free nucleus pulposus was completely removed. Pain in the lower back and legs was significantly relieved on the day after operation. Two patients experienced transient pain and numbness in lower limbs after operation, and no serious nerve injury complications occurred. ODI and VAS at each time point after surgery were significantly lower than those before surgery (P<0.01), and JOA score was significantly higher than before surgery (P<0.01). The excellent and good rates of Macnab were 66.67% (20/30), 83.33% (25/30) and 90.00% (27/30) on 2 days, 3 months and 1 year after operation, respectively.@*CONCLUSION@#For severe free lumbar intervertebral disc herniation, using of a drill under endoscope to expand the ventral space can smoothly remove the free nucleus pulposus and avoid nerve damage.

Comparison of clinical efficacy between percutaneous endoscopic transforaminal discectomy and coblation nucleoplasty in the treatment of inclusive lumbar disc herniation / 中国骨伤

OBJECTIVE@#To observe clinical efficacy of percutaneous endoscopic transforaminal discectomy (PETD) and target radioffrequency thermal coblation nucleoplasty(CN) on inclusive lumbar disc herniation(LDH) in different age groups, and provide a basis for clinical formulation of precise and individualized treatments.@*METHODS@#A retrospective analysis of 219 patients with lumbar disc herniation treated with PETD and CN between January 2018 and June 2021 was performed, in which 107 patients were treated with PETD and 112 with CN. Patients were stratified by age into young group(≤45 years old), middle-aged group(>45 years old and <60 years old) and older group(≥60 years old). Before treatment, 3 days, 1 month and 6 months after treatment, visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) score, infrared thermal imaging temperature difference (△T) and lumbar range of motion (ROM) were evaluated and clinical efficacy were compared in the different age groups between two treatment methods.@*RESULTS@#①VAS and JOA score outcomes, in the same age group and the same treatment method, the VAS and JOA scores at different time points postoperatively were obviously improved (P<0.05). For the same age group and the different treatment methods, the older group had lower VAS and higher JOA scores after PETD than after CN (P<0.05), and there was no significant difference between the young group and middle-aged group (P>0.05). There was no significant difference in VAS and JOA scores at the same time between age groups by PETD treatment (P>0.05). The VAS was higher and the JOA score was lower in older group than in young group and middle-aged group at 1, 6 months after CN treatment(P<0.05). ②△T and ROM outcomes, in the same age group and same treatment method, postoperative △T and ROM at different time points were obviously improved(P<0.05). There was no significant difference in △T between two methods of PETD and CN at the same age(P>0.05), there was no significant difference in ROM between young group and middle-aged group(P>0.05), ROM was higher after PETD treatment than after CN treatment(P<0.05). There was no significant difference in △T and ROM at the same time between age groups by PETD treatment(P>0.05). There was no significant difference in △T between age groups by CN treatment, but the ROM was smaller in older group than in young group and middle-aged group after CN treatment(P<0.05).@*CONCLUSION@#Both PETD and CN for inclusive LDH have good efficacy, the curative benefit for older patients receiving PETD within 6 months after surgery more than CN, and CN is more appropriate for young and middle-aged patients.

Visual trephine arthroplasty assisted percutaneous transforaminal endoscopic discectomy for lumbar disc herniation / 中国骨伤

OBJECTIVE@#To compare the clinical efficacy between visual trephine arthroplasty assisted percutaneous transforaminal endoscopic discectomy (VPTED) and traditional percutaneous transforaminal endoscopic discectomy(PTED) in the treatment of lumbar disc herniation.@*METHODS@#The clinical data of 60 patients with lumbar disc herniation admitted from June 2019 to December, 2020 was retrospectively analyzed. There were 38 males and 22 females, aged from 26 to 58 years old with an average of (43.63±8.48) years, 47 cases were on L4,5 segment and 13 cases were on L5S1 segment. Among them, 32 were treated with VPTED (group A) and 28 were treated with traditional PTED (group B). The general conditions of all the patients were recorded, including intraoperative fluoroscopy times, operation time, hospital stay and surgical complications during follow-up. The arthroplasty area ratio was observed by sagittal CT at the middle level of the intervertebral foramen. Visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score of low back pain, Oswestry disability index (ODI) were used to evaluate the clinical efficacy between two groups.@*RESULTS@#All patients were followed up from 9 to 15 months with an average of (12.10±1.16) months. There was no statistical difference of preoperative general data between two groups. The operation time, fluoroscopy times and hospital stay were (70.47±5.87) min, (13.66±1.34) times and (6.31±0.69) d in group A, and (90.71±7.66) min, (22.82±2.48) times and (6.54±0.92) d in group B. The operation time and intraoperative fluoroscopy times in group A were lower than those in group B(P<0.05). There was no significant difference in hospital stay between two groups (P>0.05). No obvious surgical complications were found during the follow-up in both groups. The arthroplasty area ratio in group A was (29.72±2.84)% and (29.57±2.20)% in group B, respectively, with no significant difference (P>0.05). There was no significant difference in VAS, ODI and JOA score between two groups before operation and at the final follow-up(P>0.05), but the final follow-up was significantly improved(P<0.05).@*CONCLUSION@#The two surgical methods have definite clinical efficacy in the treatment of lumbar disc herniation. Visual trephine arthroplasty assisted percutaneous transforaminal endoscopic discectomy has the advantages of high efficiency and rapidity when establishing the channel, and can significantly reduce the operation time and intraoperative fluoroscopy times.

Treatment of degenerative lumbar lateral recess stenosis with full endoscopic lamina fenestration discectomy / 中国骨伤

OBJECTIVE@#To compare the clinical efficacy of full endoscopic lamina fenestration discectomy (Endo-LOVE) with full endoscopic transforaminal approach discectomy in the treatment of degenerative lumbar lateral recess stenosis.@*METHODS@#A retrospective analysis of 48 patients with degenerative lumbar lateral recess stenosis between March 2018 and March 2019 was performed. There were 32 males and 16 females, aged from 60 to 83 years old with an average of (72.9±6.5) years, course of disease ranged from 5 to 16 years with an average of (8.0±2.8) years. The patients were divided into observation group and control group according to surgical approaches. There were 28 cases in observation group, underwent Endo-LOVE surgery;and 20 cases in control group, underwent full endoscopic foraminal approach discectomy. The operation time, intraoperative blood loss, hospitalization day and complications were observed between two groups. Visual analgue scale (VAS), Japanese Orthopaedic Association(JOA), Oswestry Disability Index(ODI), lateral crypt angle were compared between two groups. And clinical effects were evaluated by modified Macnab standard.@*RESULTS@#There was no significant difference in follow-up and operation time between two groups (P>0.05). Intraoperative blood loss was from 5 to 15 ml with an average of (8.4±3.6) ml in observation group and 5 to 25 ml with an average of (11.5±5.4) ml in control group. The hospitalization day was from 5 to 8 days with an average of (6.0±1.0) days in observation group and 6 to 9 days with an average (7.2±1.1) days in control group. Intraoperative blood loss and hospitalization day were significantly lower in observation group(P<0.05). There were no serious complications in both groups. The VAS, JOA scores, and ODI at 3-month and final follow-up were significantly improved in both groups (P<0.05), and observation group was significantly better than control group (P<0.05). The skeletal lateral crypt angle and soft lateral crypt angle were significantly greater than the preoperative angle at 3 days postoperatively(P<0.05), and observation group was significantly better than control group(P<0.05). At the final follow-up, the modified Macnab criteria was used to assess clinical efficacy, in observation group, 22 patients obtained excellent results, 5 good and 1 fair;while 11 excellent, 4 good and 5 fair in control group;the clinical efficacy of observation group was significantly better than that of control group(P<0.05).@*CONCLUSION@#Both surgical methods are performed under direct vision, with high safety and good clinical efficacy. However, Endo-LOVE enlarged the lateral crypt more fully.

Pain intensity and functionality after percutaneous endoscopic discectomy: a retrospective cohort study / Intensidade de dor e funcionalidade após discectomia endoscópica percutânea: estudo de coorte retrospectivo / Intensidad del dolor y funcionalidad después de la discectomía endoscópica percutánea: un estudio de cohorte retrospectivo

ABSTRACT Objectives To evaluate pain intensity and functional status before and 30 days following percutaneous lumbar endoscopic discectomy. Methods A retrospective cohort study that included patients who underwent percutaneous endoscopic discectomy from January 2019 to October 2020 at the Irmandade Santa Casa de Misericórdia Hospital, in Porto Alegre. The data were collected from the electronic medical records of the patients by two independent physicians. Clinical outcomes were assessed using visual analog scale (VAS) and Oswestry Disability Index (ODI) scores. Results Forty-six patients with a mean age of 52.6 ± 15.8 years, 27 of whom (58.7%) were male, were evaluated. Regarding clinical outcomes, a statistically significant improvement was observed in the comparison between the pre- and 30-day postoperative VAS and ODI scores, with no significant difference in relation to sex. No peri- or postoperative complications were observed. All patients successfully completed surgery and were discharged after recovery from anesthesia. Conclusion There was a significant improvement in pain and functional status 30 days after percutaneous endoscopic discectomy performed to correct lumbar disc herniation, with no difference in relation to sex. In addition, no peri- or postoperative complications were observed. Future studies, with longer follow-up times, comparing clinical outcomes from the various techniques of percutaneous endoscopic discectomy are necessary. Level of evidence III; Retrospective comparative study.

RESUMO Objetivos Avaliar a intensidade da dor e o estado funcional antes da cirurgia e em 30 dias de pós-operatório de discectomia endoscópica lombar percutânea. Métodos Estudo de coorte retrospectivo. Foram incluídos pacientes tratados com discectomia endoscópica percutânea, de janeiro de 2019 a outubro de 2020, no complexo hospitalar Irmandade Santa Casa de Misericórdia de Porto Alegre. Os dados foram coletados do prontuário eletrônico dos pacientes por dois médicos independentes. Os desfechos clínicos foram avaliados pela pontuação da Escala Visual Analógica (EVA) e do Índice de Incapacidade Oswestry (ODI). Resultados Foram incluídos 46 pacientes no estudo, com média de idade de 52,6 ± 15,8 anos, sendo 27 (58,7%), do sexo masculino. Quanto aos desfechos clínicos, observou-se melhora estatisticamente significativa com relação às escalas de EVA e ODI na comparação entre pré-operatório e 30 dias depois da cirurgia, sem diferença significativa com relação ao sexo. Não foram observadas complicações peri e pós-operatórias. Todos os pacientes completaram a cirurgia com sucesso e receberam alta após recuperação da anestesia. Conclusão Observou-se melhora significativa da dor e do estado funcional 30 dias depois da discectomia endoscópica percutânea realizada para correção da hérnia de disco lombar, sem diferença com relação ao sexo. Além disso, não foram observadas complicações peri e pós-operatórias, assim como não houve necessidade de internação hospitalar. Futuros estudos, com maior tempo de seguimento, que comparem os desfechos clínicos através das diversas técnicas de discectomia endoscópica percutânea fazem-se necessários. Nível de evidência III; Estudo retrospectivo comparativo

RESUMEN Objetivo Evaluar la intensidad del dolor y el estado funcional antes de la cirugía y 30 días después de la discectomía endoscópica lumbar percutánea. Métodos Estudio de cohorte retrospectivo. Se incluyeron pacientes tratados mediante discectomía endoscópica percutánea, de enero de 2019 a octubre de 2020, en el complejo hospitalario Hermandad Santa Casa de Misericordia de Porto Alegre. Los datos fueron recolectados de los registros médicos electrónicos de los pacientes por dos médicos independientes. Los resultados clínicos se evaluaron mediante la puntuación de la Escala Visual Analógica (EVA) y del Índice de Discapacidad de Oswestry (ODI). Resultados Se incluyeron 46 pacientes en el estudio, con una edad promedio de 52,6 ± 15,8 años, de los cuales 27 (58,7%) eran del sexo masculino. En cuanto a los resultados clínicos, hubo una mejoría estadísticamente significativa en relación a las escalas EVA y ODI al comparar el preoperatorio y 30 días después de la cirugía sin diferencia significativa en cuanto al sexo. No se observaron complicaciones perioperatorias y postoperatorias. Todos los pacientes completaron con éxito la cirugía e fueron dados de alta después de recuperarse de la anestesia, sin casos de reingreso hospitalario. Conclusión Hubo una mejoría significativa del dolor y del estado funcional luego de 30 días de discectomía endoscópica percutánea, realizada para corregir la hernia de disco lumbar, sin diferencias en cuanto al sexo. Además, no hubo complicaciones perioperatorias y postoperatorias, así como tampoco hubo necesidad de hospitalización. Son necesarios estudios futuros, con un período de seguimiento más largo, que comparen los resultados clínicos a través de las diferentes técnicas de discectomía endoscópica percutánea. Nivel de evidencia III; Estudio comparativo retrospectivo.

Efficacy and safety of percutaneous transforaminal endoscopic discectomy in the treatment of lumbar spinal stenosis combined with osteoporosis

SUMMARY OBJECTIVE: To investigate the efficacy and safety of percutaneous transforaminal endoscopic discectomy (PTED) in the treatment of lumbar spinal stenosis (LSS) combined with osteoporosis. METHODS: Eighty patients with LSS combined with osteoporosis were divided into a control and PTED group, which received conventional transforaminal lumbar interbody fusion and PTED, respectively. The surgical indications, incision visual analogue scale (VAS), lumbar and leg pain VAS, lumbar Japanese Orthopaedic Association (JOA) and Oswestry disability index (ODI) scores, bone mineral density (BMD), and adverse reactions were observed. RESULTS: Compared with the control group, in the PTED group, the operation time, bleeding loss and hospitalization duration, incision VAS scores at postoperative 12, 24 and 48 h and lumbar and leg pain VAS and lumbar ODI scores on postoperative 6 months were significantly decreased (P < 0.01), and the lumbar JOA score on postoperative 6 months was significantly increased (P < 0.05). There was no significant difference in BMD between two groups (P > 0.05). Compared with the control group, in the PTED group, the total effective rate was significantly higher (P < 0.05), and the incidence of adverse reactions was significantly lower (P < 0.05). CONCLUSIONS: PTED is safe and effective in the treatment of LSS combined with osteoporosis.

RESUMO: OBJETIVO: Investigar a eficácia e segurança da discectomia endoscópica percutânea transforaminal (DEPT) no tratamento da estenose lombar (EL) combinada à osteoporose. MÉTODOS: Oitenta pacientes com EL combinada à osteoporose foram divididos entre um grupo de controle e um grupo de DEPT, que receberam tratamento convencional com fusão intersomática lombar transforaminal e DEPT, respectivamente. As indicações cirúrgicas, a escala analógica visual (VAS) da incisão e de dor lombar e nas pernas, os escores lombares de acordo com a Associação Ortopédica Japonesa (JOA) e o Oswestry Disability Index (ODI), a densidade mineral óssea (DMO) e possíveis reações adversas foram observados. RESULTADOS: Em comparação com o grupo de controle, no grupo de DEPT o tempo de operação, a perda de sangue e duração de internação, os escores VAS da incisão no pós-operatório após 12, 24 e 48 h, o VAS para dor lombar e nas pernas e os escores ODI lombares após 6 meses de pós-operatório foram significativamente menores (P < 0,01); já o escore JOA lombar após 6 meses de pós-operatório foi significativamente maior (P < 0,05). Não houve diferença significativa na densidade mineral óssea entre os dois grupos (P > 0,05). Em comparação com o grupo de controle, o grupo de DEPT teve uma taxa efetiva total significativamente maior (P < 0,05), e a incidência de reações adversas foi significativamente menor (P < 0,05). CONCLUSÕES: A discectomia endoscópica percutânea transforaminal é segura e eficaz no tratamento de EL combinada à osteoporose.

Radiation Exposure during Percutaneous Endoscopic Lumbar Discectomy: Interlaminar versus Transforaminal

Objective Percutaneous endoscopic lumbar discectomy (PELD) relies heavily on fluoroscopy guidance; therefore, medical staff exposure to radiation has become an important issue. The purpose of this study was to determine the radiation dose and the amount of time to which the surgeons are exposed during PELD and to compare both parameters in the transforaminal (TF) and interlaminar (IL) approaches. Although they are considerably different, they may be wrongly considered together. Methods A retrospective evaluation of the last 20 PELD performed by the authors is presented. Patients were distributed in 2 groups. Six (1F, 5M) patients were submitted to IL-PELD and 14 (6F, 8M) to TF-PELD. Fluoroscopy reports were obtained from patients' records, all performed with the same C-Arm device and software mode. Groups were compared using unpaired t-test. Results The IL group showed an average radiation exposure of 8.37 4.21 mGy and duration of 11.1 5.45 seconds, while the TF group showed an average radiation exposure of 28.92 7.56 mGy and duration of 42 16.64 seconds. The p-value for radiation was 0.0000036, and for time it was 0.00027. Conclusions Interlaminar PELD requires a lower radiation dose and a shorter amount of exposure than TF-PELD. Studies that concern radiation required for minimallyinvasive spine surgeries should consider the PELD approaches separately.

Experimental model for transforaminal endoscopic spine

Abstract Purpose: To validate the porcine spine as a model for learning and practicing transforaminal percutaneous endoscopic lumbar procedures (TF-PELP). Methods: TF-PELP was performed in three porcine cadaver lumbar spine levels. Anatomical features of the current cadaver were compared to human and porcine spines. Performance and documentation of endoscopic procedures were described. Results: This study shows that this representative animal model reflects anatomical characteristics of the human spine. Transforaminal approaches were successfully completed. Although lower disc heights make disc puncture more difficult, the outside-in technique is feasible and more useful to identify anatomical parameters and to practice different surgical steps and maneuvers. Conclusion: This is an effective and representative model for learning and practicing this procedure. Difficulties of the procedure, as well as the differences compared to the human spine, were described.

Lumbar herniated disc treatment with percutaneous hydrodiscectomy

SUMMARY Lumbar herniated disc are common manifestations of degenerative spine diseases, the main cause of radiated lower back pain. This guideline followed standard of a systematic review with recovery of evidence based on the movement of evidence-based medicine. We used the structured method for formulating the question synthesized by the acronym p.I.C.O., In which the p corresponds to the lumbar herniated disc, i to the treatment intervention with percutaneous hydrodiscectomy, c comparing with other treatment modalities, o the outcome of clinical evolution and complications. From the structured question, we identify the descriptors which constituted the evidence search base in the medline-pubmed databases (636 papers) and therefore, after the eligibility criteria (inclusion and exclusion), eight papers were selected to answer to clinical question. The details of the methodology and the results of this guideline are exposed in annex i.

RESUMO Hérnias discais lombares são manifestações comuns das doenças degenerativas da coluna, sendo a principal causa de dor lombar irradiada. Esta diretriz seguiu padrão de uma revisão sistemática com recuperação de evidências com base no movimento da Medicina Baseada em Evidências. Utilizamos a forma estruturada de formular a pergunta sintetizada pelo acrônimo P.I.C.O., em que o P corresponde à Hérnia de disco lombar, I à intervenção Tratamento com hidrodiscectomia percutânea, C comparando com Outras modalidades de tratamento, O de desfecho de Evolução clínica e complicações. A partir da pergunta estruturada, identificamos os descritores que constituíram a base da busca da evidência nas bases de dados Medline-PubMed (636 trabalhos) e, assim, após os critérios de elegibilidade (inclusão e exclusão), oito trabalhos foram selecionados para responder à dúvida clínica. Os detalhes da metodologia e dos resultados desta diretriz estão expostos no Anexo I.

Randomized clinical trial comparing lumbar percutaneous hydrodiscectomy with lumbar open microdiscectomy for the treatment of lumbar disc protrusions and herniations

OBJECTIVES: Hydrodiscectomy is a new technique used for percutaneous spinal discectomy that employs a high-intensity stream of water for herniated disc ablation and tissue aspiration. No previous clinical study has examined the effects of percutaneous hydrodiscectomy. The aim of this study is to evaluate the outcomes of hydrodiscectomy compared to open microdiscectomy regarding pain, function, satisfaction, complications and recurrence rates. METHODS: In this randomized clinical trial, patients referred to our tertiary hospital for lumbar back pain were recruited and included in the study if they had disc protrusion or small herniation in only one level, without neurological deficits and with no resolution after six weeks of conservative treatment. One group underwent open microdiscectomy, and the other group underwent percutaneous microdiscectomy via hydrosurgery. Function was evaluated using the Oswestry Disability Index and pain was assessed using a visual analog scale. Evaluations were performed preoperatively, and then during the first week and at one, three, six and twelve months postoperatively. Personal satisfaction was verified. Clinicaltrials.gov: NCT01367860. RESULTS: During the study period, 20 patients were included in each arm and 39 completed one-year of follow-up (one patient died of unrelated causes). Both groups exhibited equal improvement on the visual analog scale and Oswestry evaluations after treatment, without any significant differences. The improvement in the lumbar visual analog scale score was not significant in the hydrodiscectomy group (p=0.138). The rates of infection, pain, recurrence and satisfaction were similar between the two groups. CONCLUSION: Percutaneous hydrodiscectomy was demonstrated to be as effective as open microdiscectomy for reducing pain. The rates of complications and recurrence of herniation were similar between groups. Patient satisfaction with the treatment was also similar between groups.

Nucleoplasty as a therapeutic option for lumbar disc degeneration related pain: a retrospective study of 396 cases / Nucleoplastia como opção terapêutica para dor relacionada à degeneração do disco lombar: um estudo retrospectivo de 396 casos

OBJECTIVES: To make a retrospective analysis and evaluate a clinical response to the control of disc degeneration related pain of 396 patients submitted to percutaneous lumbar nucleoplasty; and to make a record of visual analogical scale (VAS) up to a three-year follow-up after the surgical procedure. METHODS: Analysis of VAS score in 396 patients with lumbar disc degeneration related pain, according to anamnesis, clinical examination and magnetic resonance imaging (MRI), without improvement of previous clinical treatment, submitted to percutaneous nucleoplasty. RESULTS: A total of 26% of the patients presented 100% remission of pain or paresthesia, of whom 75% showed at least 50% of pain improvement. The median VAS pain improvement was about 67%. CONCLUSIONS: The median VAS improvement in inferior disc levels was higher than four points. The VAS showed improvement of the pain and paresthesia up to a three-year follow up after the surgical procedure.

OBJETIVOS: Analisar retrospectivamente a resposta clínica no controle da dor relacionada à degeneração discal em 396 pacientes submetidos à nucleoplastia percutânea lombar; e fazer um registro da escala analógica visual (EAV) com seguimento de três anos após a cirurgia. MÉTODOS: Análise da EAV de 396 pacientes com diagnóstico de hérnia de disco, de acordo com anamnese, exame clínico e imagens por meio de ressonância magnética (RM), sendo que nenhum deles apresentou melhora com tratamento clínico prévio. Estes pacientes foram submetidos à nucleoplastia percutânea. O estudo utilizou, para avaliação, o registro de escala analógica visual (EAV) durante seguimento de até três anos após o procedimento cirúrgico. RESULTADOS: Um total de 26% apresentou 100% de remissão da dor ou parestesia; 75% apresentaram pelo menos 50% de melhora da dor. A mediana da EAV de melhora da dor foi de aproximadamente 67%. CONCLUSÕES: Houve melhora da EAV, com mediana maior do que quatro pontos nos pacientes com acometimento nos níveis discais inferiores. A EAV mostrou melhora da dor e parestesia num período de seguimento de até três anos após o procedimento cirúrgico.

Nucleotomía percutánea automatizada: experiencia personal 1998-2002 / Automated percutaneous nucleotomy: personal experience 1998-2002

La hernia del núcleo pulposo como etiología de una radiculopatía fue señalada por primera vez en 1934, solo en década del 50 se planteó por primera vez un tratamiento quirúrgico. En 1984 Onik describió la nucleotomía percutánea autoimatizada como alternativa a la disquectomía convencional o microquirúrgica. El trabajo muestra la experiencia en 74 pacientes, entre las edades de 18 y 63 años, intervenidos quirúrgicamente por el autor, con la técnica de nucleotomía percutánea automatizada, 89 discos fueron operados, con un seguimiento de 3 a 42 meses, de los cuales 81 fueron lumbares y 8 cervicales. La tasa de éxito a largo plazo fue de 95,9 por ciento, con una morbilidad del 8 por ciento, la cual fue transitoria y no incidió en el resultado final de la cirugía. El porcentaje de recidiva en esta serie fue de 4,1 por ciento. No se registró mortalidad. Se hace énfasis en la selección de los pacientes desde el punto de vista clínico e imagenológico, dándole importancia a la integridad del ánulo fibroso discal, en una hernia protuída, usándose la resonancia magnética nuclear como examen de elección. Se destaca lo simple, lo poco invasivo y seguro del procedimiento quirúrgico, la corta hospitalización y la rápida reintegración laboral de los pacientes intervenidos.

Desbridación percutánea de la espondilo-disquitis piógena con el nucleotomo / Nucleotome percutaneous debridement for pyogenic spondylo-discitis

Se estudiaron 22 pacientes con espondilo-disquitis piógena de columna lumbar, siendo 15 hombres y 7 mujeres con edad promedio de 54 aÏos. En sólo 2/3 partes se encontró el foco de infección con predominio de: Salmonella, Brucella, y cocos Gram +. El nivel m s afectado fue L3-4 y clínicamente todos tuvieron una lumbociatalgia sistematizada a algún dermatoma y los estudios de Rx mostraron un proceso óseo destructivo en plataformas con reacción esclerosa, espículas óseas, compresión neurológica por el absceso e inestabilidad segmentaria. Tradicionalmente existen 2 tipos de tratamiento: el conservador, con antibioticos y reposo en cama hasta por 9 meses; y el quirúrgico, con un riesgo alto de morbimortalidad. Nosotros proponemos otra alternativa viable de tratamiento, con el uso del Nucleotomo, para la desbridación percutánea del absceso por ser no invasivo y proporcionar muestra para estudio bacteriológico e histopatológico. Con la desbridación percutánea del absceso, se descomprimen las estructuras neurológicas y la lumbociatálgia remitió de 1-5 días con recuperación neurológica progresiva de 1-4 semanas en el 95 por ciento de los casos. Al drenar el absceso se observó una pronta reparación del defecto óseo y una fusión intersomática espontánea de 4-5 meses en los 22 casos, estabilizando la columna.

Free disc fragment: a retrospective case analysis.

Preoperative diagnosis of free disc fragment is important in order to avoid treatment by chymopapain and percutaneous method of disc removal or anterior discectomy. This retrospective case analysis was to study the cause, physical findings and appropriate investigation to identify free disc fragment before surgery. One hundred and thirteen operative patients of herniated lumbar disc were studied. Of these, eleven patients (9.7%) were diagnosed with free disc fragment. The results revealed that one patient was diagnosed preoperatively with free disc fragment by myelography and MRI and three other patients using MRI alone. We concluded that preoperative diagnosis of free disc fragment can be made through identification of a large myelographic defect and/or sagittal scan MRI showing migration of disc material from native disc space.

Disquectomía torácoca usando toracoscopía vídeo-asistida: trabajo experimental: informe de 33 disquectomías / Thoracic discectomy by video-assisted thoracoscopy: experimental trial: report of 33 discectomies

La aplicabilidad del uso de la toracoscopía vídeo-asistida (TVA) para resecar discos torácicos fue investigada. Fue un estudio de laboratorio llevado a cabo usando 10 puercos vivos y un perro vivo como especímenes. Un total de treinta y tres niveles fueron descomprimidos. El objetivo fue estudiar la eficacia de realizar las resecciones torácicas usando TVA. La TVA ha sido usada por los cirujanos torácicos desde 1991 para enfermedades pleuropulmonares y desde 1994 en indicaciones ortopédicas. Se hicieron resecciones quirúrgicas de 33 en 11 animales anestesiados, en todos los casos se usó la TVA para realizar el procedimiento y visualizar el sitio quirúrgico. Se evacuaron adecuadamente 30 de 33 espacios, esto fue confirmado por la visualización de las placas terminales y el ligamento común anterior en cada espacio. La media de tiempo operatorio fue de 2.7 horas (con un rango de 1.5 horas a 4 horas). La posición de decúbito lateral (DL), fue usada en 6 animales y la decúbito prono (DP) en 5, comparándolas. Cuando el cuerpo fue colocado en DP la orientación topográfica fue más rápida y mejor, y el efecto de las leyes de la gravedad protege a las estructuras viscerales y vasculares alejándolas del campo operatorio. Ocurrió un episodio de laceración vascular (vena ácigos) y la ruptura de la punta de un instrumento (Cuchilla). La técnica de TVA mejora el acceso a la columna torácica anterior y es una manera útil de realizar las disquectomías. No fueron necesarias incisiones largas para toracotomía. Al minimizar el tamaño de la incisión muchos de los riesgos de esta operación pueden ser evitados. La TVA parece una alternativa razonable para las disquectomías torácicas

Disectomía percutánea manual lumbar / Percutaneous manual lumbar disectomy

Se presenta un análisis de 25 casos operados de patología discal lumbar a nivel L3L4, L4L5 y L5S1. En 21 pacientes (84 porciento) se objetivó una HNP, en 4 pacientes (16 porciento) una protrusión discal sintomática. En el 100 porciento se realizó discografía. El interés de la disectomía percutánea manual (DPM) consiste en evitar la vía intraraquídea. Sus ventajas son el uso de anestesia local, gesto poco traumatizante, disminución de riesgos de fibrosis peridural, corto período de hospitalización y menor costo. Los resultados obtenidos son satisfactorios en el 80 porciento de los casos a 2 años de seguimiento

Biopsia de pleura visceral: un nuevo método diagnóstico percutáneo, cerrado y ciego en enfermedad pleural

Introducción: Los métodos invasivos de estudio de la pleura permiten examinar y tomar muestras de la hoja visceral. Por el contrario, los instrumentos de biopsia percutánea, menos invasivos, se limitan a la toma de material de la superficie parietal, que es afectada en forma más tardia por la enfermedad pleural. Sería deseable contar con un instrumento que reuniera las ventajas de ambos métodos al obtener por punción percutánea y hermética, muestras de pleura visceral, sin necesidad de anestesia general y de toracostomía luego del procedimiento. Objetivo: Evaluar la utilidad diagnóstica de un nuevo instrumento para la biopsia percutánea cerrada y ciega de pleura visceral en el estudio de la enfermedad pleural. Estudio de comparación entre dos métodos de toma de biopsia (biopsia visceral con el nuevo instrumento y biopsia con aguja de Abrams). Pacientes y Métodos: Pacientes con exudado pleural e indicación para biopsia que aceptaron someterse a ambos procedimiento en días diferentes. El orden de los procedimientos se seleccionó en forma aleatoria. Las muestras fueron analizadas por el mismo patólogo, sin datos acerca del método de toma de la biopsia. Los resultados se compararon con el diagnóstico final al egreso del paciente y se calculó la sensibilidad, especifidad y valores predictivos. Resultados: Se estudiaron 20 pacientes, 13 hombres y 7 mujeres, con edad promedio de 54,5 años, 75 años, 75 por ciento con exudado linfocítico, la mayoría (55 pór ciento) izquierdo, 85 por ciento libres y 50 por ciento con alteración del parénquima. Los diagnósticos finales fueron cáncer (10), tuberculosis (7) y tres pleuritis inespecíficas. La biopsia de pleura visceral diagnóstico correctamente nueve de las 10 neoplasias y cinco de las tuberculosis y la muestra pariental obtuvo diagnóstico correcto de cáncer en cinco y de tuberculosis en seis. Con cada método las muestras no fueron presentativas en dos casos. Se presentaron dos neumotórax con cada método de biopsia. La sensibilidad especifidad, valor predictivo positivo y negativo, calculados con estos datos, son similares entre los dos procedimientos. La sensibilidad de la biopsia con el nuevo método (90 por ciento) para el diagnóstico de cáncer es superior a al obtenida con la aguja de abrams (50 por ciento) y no hay otras diferencias entre ellos. Conclusión: El rendimiento diagnóstico del...

La discectomía percutánea en la hernia discal lumbar / Percutaneous discectomy in lumbar disc herniation

Se realizó un estudio descriptivo, retro y prospectivo, de 90 pacientes operados de hernia discal lumbar por el método de la discectomía percutánea posterolateral semiautomatizada, en el período comprendido de septiembre de 1991 a marzo de 1994. Los datos fueron tomados de las historias clínicas de estos pacientes, así como de entrevistas personales con ellos. Correspondieron al sexo masculino 71 pacientes y 19 al femenino. Predominó el grupo de edad comprendido entre 31 y 40 años (31,1 por ciento). De 96 espacios intervertebrales intervenidos, el nivel de herniación fue más significativo en el espacio L4-L5, con 52 casos (54.2 por ciento). Se les realizó un seguimiento posoperatorio, durante el cual se evaluó el dolor como síntoma fundamental; 47 pacientes (52,2 por ciento) obtuvieron un alivio completo de aquél. La hernia recurrente fue la complicación que más se presentó, con un total de 16 pacientes (17,7 por ciento). En el transcurso de un año, en 72 pacientes (80 por ciento) se obtuvieron resultados favorables. Sólo 18 (20 por ciento) tuvieron un resultado no favorable después de aplicada la técnica. El tiempo de recuperación de los pacientes con resultados favorables fue de sólo tres meses, aproximadamente (AU)

Availability of discographic computed tomography in automated percutaneous lumbar discectomy

Automated percutaneous lumbar discectomy (APLD) has been developed since 1984 when Gary Onik first attempted it. This procedure has many advantages and has been used widely in the treatment of protruded disc diseases. The success rate of APLD by authors from March 1988 to February 1993 when the discographic computed tomography (CT) had not been performed was 74%. In evaluating lumbar disc diseases, we have used discographic CT. According to the patterns of dye distribution in the disc, two different types of protrusion can be distinguished: broad dye base protrusion and narrow dye base protrusion. From April 1993 to July 1994, 52 patients with protruded disc diseases were performed discographic CT. 23 Patients had narrow dye base protrusion and 29 patients had broad dye base protrusion. 29 patients with a broad dye base on discographic CT were treated with APLD and evaluated. The success rate in these patients was 93% by Macnab's criteria. Thus, we suggest that it is mandatory to apply discographic CT to increase the success rate of APLD in patients with protruded disc diseases.