Clinical Outcomes of Percutaneous Transforaminal Endoscopic Discectomy Assisted with Selective Nerve Root Block for Treating Radicular Pain with Diagnostic Uncertainty in the Elderly.

Purpose: To investigate the clinical outcomes of percutaneous transforaminal endoscopic discectomy assisted with selective nerve root block for treating radicular pain with diagnostic uncertainty in the elderly. Methods: A total number of 36 elderly patients were included in the study. Clinical outcomes collected for analysis include operative time, hospital stay time, Visual Analog Scale, and Oswestry Disability Index before and after the surgery, the global outcome based on the Macnab outcome criteria. Results: Seventeen males and nineteen females with a mean age of 73.72 ± 7.15 were included in this study. Radicular pain was the main complaint of all the patients with the least symptom duration of two months. Radiological findings showed that 80.6% of the patients with multilevel disc herniation, 16.7% received lumbar fusion surgery before, and 8.3% with degenerative scoliosis. Besides, 69.4% of the patients have at least one comorbidity. 85.4% of the patients showed a positive response to selective nerve root block, and 91.6% of the patients reported a favorable outcome at the last follow-up. The mean value of pre-operative leg pain was 7.56 ± 0.74 and dramatically decreased after surgery (2.47 ± 0.81, P < 0.001). Besides, the mean value of Oswestry Disability Index decreased from 43.03 ± 4.43 to 5.92 ± 5.24 (P < 0.001) one year after the surgery. Conclusion: Multilevel degeneration of the lumbar spine is common in elderly patients. Identifying the responsible segment and decompressing the nerve root through minimally invasive surgery can provide a satisfactory clinical outcome for those with radicular pain as their primary complaint. And selective nerve root block is a reliable diagnostic tool for those with an ambiguous diagnosis.

Comparison of the clinical outcomes of VBE-TLIF versus MIS-TLIF for single-level degenerative lumbar diseases.

OBJECTIVE: This research aims to compare the clinical outcomes of VBE-TLIF and MIS-TLIF for the treatment of patients with single-level degenerative lumbar diseases. METHODS: Ninety patients were enrolled in this study. The estimated blood loss, operation time, postoperative hospitalization days, time to functional exercise, amount of surgical drain and inflammatory index were recorded. The visual analog scale, Oswestry dysfunction index and modified MacNab criteria were used to assessed the patient's back and leg pain, functional status and clinical satisfaction rates. RESULTS: The average operation time of the VBE-TLIF group was longer than that of the MIS-TLIF group. The time for functional exercise, length of hospital stay, estimated blood loss and amount of surgical drain in the VBE-TLIF group were relative shorter than those in the MIS-TLIF group. Additionally, the levels of CRP, neutrophil, IL-6 and CPK in the VBE-TLIF group were significantly lower than those in the MIS-TLIF group at postoperative days 1 and 3, respectively (P < 0.001). Patients undergoing VBE-TLIF had significantly lower back VAS scores than those in the MIS-TLIF group on postoperative days 1 and 3 (P < 0.001). No significant differences were found in the clinical satisfaction rates (95.83 vs. 95.24%, P = 0.458) or interbody fusion rate (97.92 vs. 95.24%, P = 0.730) between these two surgical procedures. CONCLUSIONS: Both VBE-TLIF and MIS-TLIF are safe and effective surgical procedures for patients with lumbar diseases, but VBE-TLIF technique is a preferred surgical procedure with merits of reduced surgical trauma and quicker recovery.

Minimally invasive transforaminal lumbar interbody fusion by a novel two-medium compatible bichannel endoscopy system, technique note and preliminary clinical results.

PURPOSE: Our team designed a novel two-medium compatible bichannel endoscopy system for spinal surgery, V-shape bichannel endoscopy (VBE) system. Hereby, this study will introduce minimally invasive transforaminal lumbar interbody fusion (TLIF) with VBE system and report its preliminary clinical results. METHODS: Fifty-two participants, who accepted VBE-assisted TLIF surgery (VBE-TLIF) in our hospital were included in this study. The duration of operation, off-bed time, and days of hospitalization were recorded. Besides, the patient's preoperative and postoperative pain were evaluated via visual analog scale (VAS), the functional status was evaluated via Oswestry dysfunction index (ODI) and modified MacNab criteria. Patients were asked to follow-up in the outpatient department at the 3rd, 6th, 12th, and 24th month after surgery. X-ray or CT was examined to evaluate the internal fixation position and interbody fusion result. RESULTS: All patients received unilateral decompression with an average operation duration of 178.49 ± 27.49 min. After the surgery, their VAS score of leg pain and back pain reduced significantly. At the last follow-up, the VAS score of leg pain and back pain was 0.80 ± 0.69 and 0.86 ± 0.75 separately. The difference shows statistically significant with p < 0.05. At the last follow-up, the ODI was 15.20 ± 5.75. According to modified MacNab criteria, 39 patients rated their function as excellent, and 10 patients were good. The overall satisfaction rate reached 94%. CONCLUSION: The VBE system reported in the current study can complete TLIF surgery safely and effectively.

Sagittal alignment of the cervical spine: radiographic analysis of 111 asymptomatic adolescents, a retrospective observational study.

PURPOSE: To describe the cervical spine morphology and explore its relationship to global sagittal alignment parameters in the asymptomatic adolescent population.  METHODS: A total of 111 adolescent subjects were included. Sagittal alignment parameters, including C7 Slope, C2-C7 Cobb, C2-7 plumb line (PL), C2-S1 Sagittal Vertical Axis (SVA), C7-S1 SVA, T5-12 Cobb, T10-L2 Cobb, L1-S1 Cobb, pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS), were obtained from lateral radiographs.  RESULTS: Forty-four males and sixty-seven females with a mean age of 16.12 ± 2.40 years were included in this study. The mean values of C7 Slope, C2-7 Cobb and C2-7PL were 20.45 ± 8.88°, -7.72 ± 12.10°, and 13.53 ± 11.63 mm, respectively. C2-7 Cobb, C7 Slope showed significant differences between the male and female groups. Correlation analysis showed that C7 slope was significantly correlated with C2-7 Cobb (r = -0.544, P < 0.001), C2-S1 SVA (r = 0.335, P < 0.001), and C7-S1 SVA (r = 0.310, P = 0.001), but not lumbosacral parameters(L5-S1 Cobb, PI, PT, SS). Using a modified method of Toyama to describe the cervical spine morphology, there were 37 cases (33.3%) in the Lordotic group, and C7 slope, C2-7 Cobb and C2-7PL showed significant differences between groups. According to C2-C7 Cobb, there were 80 Lordotic cases (72.1%). C7 slope and C2-7PL were significantly different between the two groups. CONCLUSION: The cervical spine morphology of asymptomatic adolescents varies widely, from lordotic to kyphotic. Combining different classification methods provides a better understanding of the morphology of the cervical spine. C7 slope is an important predictor of global sagittal balance and C2-7PL is a key parameter for restoring cervical lordosis, which should be considered pre-operatively and for conservative treatment. Cervical regional sagittal alignment parameters are not correlated with lumbosacral parameters, and C2-7 Cobb, C7 Slope showed significant differences between males and females.

Percutaneous Endoscopic Lumbar Discectomy via Transforaminal Approach Combined with Interlaminar Approach for L4/5 and L5/S1 Two-Level Disc Herniation.

OBJECTIVE: The purpose of the present study was to discuss a new surgical strategy that combines percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) for L4/5 and L5/S1 two-level disc herniation. METHODS: This was a retrospective study. A total of 19 patients with L4/5 and L5/S1 two-level lumbar disc herniation (LDH) who underwent percutaneous endoscopic lumbar discectomy (PELD) in our hospital from January 2015 to June 2016 were retrospectively examined. The average age of these 19 patients was 42.21 ± 14.88 years old, including 12 men and 7 women. One experienced surgeon who had carried out more than 3000 lumbar surgeries performed PELD for these patients. During the PELD surgery, the transforaminal approach was adopted for L4/5 level disc herniation and the interlaminar approach was adopted for L5/S1 level disc herniation. The demographic data, operation time (min), fluoroscopy times, hospital stay (days), and complications were recorded and analyzed. The visual analogue scale (VAS), Oswestry disability index (ODI) scores, and the modified MacNab criteria were used to evaluate the surgical outcomes. MRI was conducted to evaluate the radiographic improvement. RESULTS: All patients underwent PELD via the transforaminal approach combined with the interlaminar approach successfully and achieved satisfactory efficacy. The follow-up points were 3, 12, and 18 months. The average hospital stay (days) and the average follow up (months) were 3.32 ± 0.98 and 18.63 ± 3.84, respectively. The operation time and fluoroscopy times were 85.79 ± 12.90 min and 39.05 ± 4.59 times, respectively. The fluoroscopy times (frequency) for L4/5 and L5/S1 were 26.95 ± 6.41 and 12.11 ± 3.49 (t = 7.00, P < 0.05). Furthermore, there was no significant difference for fluoroscopy times between male and female patients (t = 0.89, P = 0.99). The preoperative back pain (VAS-Back) and the last follow-up VAS-Back were 5.58 ± 2.01 and 2.37 ± 1.01, respectively (t = 7.14, P < 0.05). The preoperative leg pain (VAS-Leg) and the last follow-up VAS-Leg were 7.00 ± 1.56 and 1.63 ± 1.01, respectively (t = 20.97, P < 0.05). There were significant differences between preoperative VAS-Back and the last follow-up VAS-Back in men (t = 4.61, P < 0.05) and women (t = 6.57, P < 0.05). In addition, there was significant differences between preoperative VAS-Leg and the last follow-up VAS-Leg in men (t = 13.48, P < 0.05) and women (t = 26.87, P < 0.05). There were significant differences between preoperative ODI scores (44.84 ± 10.82%) and the last follow-up ODI scores (11.12 ± 5.80%) (t = 10.92, P < 0.05). Preoperative ODI scores and the last follow-up ODI scores were significantly different for men (t = 8.80, P < 0.05) and women (t = 6.63, P < 0.05). All patients received significant pain relief and functional improvement after the surgery. Except for two cases of postoperative dysesthesia and one dural tear, no severe complications occurred. The dysesthesia symptoms of these two patients disappeared within 1 week with the application of dexamethasone and neurotrophic drugs and the dural tear case also recovered well as the dural laceration was small. No poor results were reported and 89.47% of patients achieved excellent or good recovery. CONCLUSION: Percutaneous endoscopic lumbar discectomy via the transforaminal approach combined with the interlaminar approach under epidural anesthesia can treat L4/5 and L5/S1 two-level disc herniation safely and effectively.

Percutaneous Endoscopic Lumbar Discectomy (PELD) via a Transforaminal and Interlaminar Combined Approach for Very Highly Migrated Lumbar Disc Herniation (LDH) Between L4/5 and L5/S1 Level.

BACKGROUND Percutaneous endoscopic lumbar discectomy (PELD) has become one of the most popular minimally invasive surgeries for lumbar disc herniation (LDH), however, very highly migrated LDH is still a tricky issue for PELD. This study reported a new endoscopic discectomy strategy for the treatment of very highly migrated LDH between the L4/5 and L5/S1 level. MATERIAL AND METHODS The current study retrospectively analyzed 12 patients who accepted PELD for very highly migrated LDH between the L4/5 and L5/S1 level. Under local anesthesia, the transforaminal approach was chosen for the L4/5 level and the interlaminar approach was chosen for the L5/S1 level. The 10-point visual analogue scale (VAS) was used to assess back pain (VAS-Back) and leg pain (VAS-Leg). Oswestry disability index (ODI) and Modified Mac Nab Criteria were adopted as the functional evaluation methods. All patients were followed in the outpatient department for at least 12 months after their operation. RESULTS Our study showed that very highly migrated disc between L4/5 and L5/S1 level could be removed completely by this strategy. Except for 1 case of postoperative dysesthesia and 1 case of dural tear, no severe complication occurred. At the last follow-up, the average VAS-Back score of the study patients was reduced from 5.17±2.12 to 2.08±1.08 (P<0.05) and the average VAS-Leg score was reduced from 7.25±1.48 to 1.33±0.89 (P<0.05). The average ODI scores improved from 48.50±10.59 to 13.00±2.76 (P<0.05). According to the Modified Mac Nab Criteria, 83.33% of patients (10 out of 12 patients) received an excellent or good recovery and no poor result was reported. No recurrence was observed during follow up. CONCLUSIONS PELD via a transforaminal and interlaminar combined approach provides an alternative option for select patients with very highly migrated LDH between the L4/5 and L5/S1 level.

Epidural Spinal Cord Stimulation Promotes Motor Functional Recovery by Enhancing Oligodendrocyte Survival and Differentiation and by Protecting Myelin after Spinal Cord Injury in Rats.

Epidural spinal cord stimulation (ESCS) markedly improves motor and sensory function after spinal cord injury (SCI), but the underlying mechanisms are unclear. Here, we investigated whether ESCS affects oligodendrocyte differentiation and its cellular and molecular mechanisms in rats with SCI. ESCS improved hindlimb motor function at 7 days, 14 days, 21 days, and 28 days after SCI. ESCS also significantly increased the myelinated area at 28 days, and reduced the number of apoptotic cells in the spinal white matter at 7 days. SCI decreased the expression of 2',3'-cyclic-nucleotide 3'-phosphodiesterase (CNPase, an oligodendrocyte marker) at 7 days and that of myelin basic protein at 28 days. ESCS significantly upregulated these markers and increased the percentage of Sox2/CNPase/DAPI-positive cells (newly differentiated oligodendrocytes) at 7 days. Recombinant human bone morphogenetic protein 4 (rhBMP4) markedly downregulated these factors after ESCS. Furthermore, ESCS significantly decreased BMP4 and p-Smad1/5/9 expression after SCI, and rhBMP4 reduced this effect of ESCS. These findings indicate that ESCS enhances the survival and differentiation of oligodendrocytes, protects myelin, and promotes motor functional recovery by inhibiting the BMP4-Smad1/5/9 signaling pathway after SCI.

Reduced Radiation Exposure and Puncture Time of Percutaneous Transpedicular Puncture with Real-Time Ultrasound Volume Navigation.

OBJECTIVES: The present study introduced ultrasound volume navigation (UVN) to reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP). METHODS: We retrospectively reviewed the medical records of patients with osteoporotic vertebral compression fracture who had undergone PVP or PKP guided by UVN or fluoroscopy from September 2017 to December 2017. RESULTS: We enrolled 10 patients (6 women, 4 men) with 24 pedicles involved in the present study. Significant reductions in fluoroscopy frequency (2.58 vs. 17.42; P < 0.01), exposure time (2.36 vs. 15.69 seconds; P < 0.01), and puncture time (4.13 vs. 19.21 minutes; P < 0.01) for each pedicle were observed in the UVN group compared with the fluoroscopy group. Obvious correlations among fluoroscopy frequency, exposure time, and puncture time for each pedicle were observed (P < 0.01). The visual analog scale scores and Oswestry Disability Index were both significantly improved after the procedures. All patients achieved excellent or good clinical outcomes. No complications were observed in any patient. CONCLUSIONS: UVN could obviously reduce the radiation exposure and puncture time of percutaneous transpedicular puncture in PVP and PKP.

Guided Punctures with Ultrasound Volume Navigation in Percutaneous Transforaminal Endoscopic Discectomy: A Technical Note.

OBJECTIVE: Ultrasound volume navigation (UVN) has been widely used for accurate guidance and decreased radiation exposure. However, few studies have focused on the clinical significance of UVN in guiding percutaneous puncture in percutaneous transforaminal endoscopic discectomy (PTED). We evaluated UVN to guide percutaneous puncture in PTED. METHODS: We retrospectively reviewed the medical records of 12 patients (8 men and 4 women), who had undergone PTED with the help of UVN or fluoroscopic guidance for lumbar disc herniation from November 2017 to December 2017. RESULTS: The age of these 12 patients range was 26-71 years, and the body mass index range was 18.19-26.91 kg/m2. Of the 12 patients, 6 were in UVN group and 6 were in fluoroscopy group. The mean number of punctures was 1.00 in UVN group and 3.83 in fluoroscopy group. The mean exposure time was 3.60 and 13.80 seconds in UVN and fluoroscopy groups, respectively. The mean operation time was 48.17 minutes and 61.33 minutes in UVN and fluoroscopy groups, respectively. A positive relationship was found between operation time and exposure time (P < 0.05). All patients achieved excellent or good clinical outcomes. The Oswestry Disability Index and visual analog scales for leg pain and back pain all showed significant improvement after the procedure (P < 0.05). None of patients experienced a complication. CONCLUSIONS: UVN decreased the number of puncture attempts, radiation exposure, and operation time compared with fluoroscopic guidance in PTED. Therefore, UVN is a feasible and efficient method for guiding percutaneous puncture in PTED.

Comparison of 3 Anesthetic Methods for Percutaneous Transforaminal Endoscopic Discectomy: A Prospective Study.

BACKGROUND: Percutaneous transforaminal endoscopic discectomy (PTED) under local anesthesia (LA) is growing popular in recent years because of its safety, effectiveness and increased patient demands for minimally invasive procedures. To avoid neural injuries, local anesthesia that can keep the patient conscious is recommended. However, many patients complain about the severe pain during surgery. Epidural anesthesia (EA) is an alternative choice. We put forward an anesthetic method that combined preemptive analgesia (PA) and local anesthesia. OBJECTIVES: The study aimed to assess the effectiveness of 3 methods of anesthesia for PTED, LA, EA and PA. STUDY DESIGN: A prospective study. METHODS: Three groups of patients were treated with standard PTED under LA, PA or EA, respectively. The data collected for analysis were operative time, x-ray exposure time, postoperative bed time, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI), the global outcome based on the Macnab outcome criteria, satisfaction rate of anesthesia, and complications. RESULTS: A total of 240 consecutive patients were enrolled in this study from January 2014 to December 2016. Among 3 groups, 1-week postoperatively VAS (back and leg) and ODI were improved compared with preoperative data, and the excellent/good rates were all above 90%. However, satisfaction rate of anesthesia showed significant differences among the 3 groups. PA and EA showed significantly better performance in pain management intraoperatively and 1 hour postoperatively. The operation time of group PA was the shortest and group EA was the longest. No severe neural injuries occurred in any of the 3 groups. Transient paresis of lower limbs occurred in all 3 groups and showed no significant differences. Decreased muscle strength of lower limbs postoperatively occurred in 2 patients in group EA. The incidence of nausea and vomiting postoperatively was significantly higher in group PA (6 cases, 7.50%). There were 3 cases of dysuria postoperatively in group EA (3.75%). LIMITATION: First, this is a single center study. Second, this study investigated the effects of anesthesia on perioperative period and the follow-up time was relatively short. Third, we choose morphine in group PA and there are other types of anesthetics which may be used in preemptive analgesia in further study. CONCLUSION: All 3 of these anesthetic methods are safe to avoid neural injuries. EA and PA showed better performance in pain management but had more anesthesia-related complications. KEY WORDS: Percutaneous transforaminal endoscopic discectomy (PTED), local anesthesia, epidural anesthesia, preemptive analgesia, morphine, ropivacaine, pain management, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI).

Comparison of bilateral versus unilateral decompression incision of minimally invasive transforaminal lumbar interbody fusion in two-level degenerative lumbar diseases.

PURPOSE: To compare the efficacy and safety of two different surgical incisions for minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the management of two-level degenerative lumbar diseases. METHODS: We conducted a retrospective study of 129 patients, who underwent two-level MIS-TLIF for degenerative lumbar diseases from September 2014 to December 2015. Sixty-two patients underwent MIS-TLIF with unilateral long decompression incision (group A) and 67 patients underwent MIS-TLIF with bilateral short decompression incision (group B). Demographics and peri-operative clinical data were collected from medical records. Radiographic fusion, visual analog scale for leg pain (VAS-LP), back pain (VAS-BP), the Oswestry Disability Index (ODI), and MacNab satisfaction were compared between two groups. RESULTS: Patients in group A experienced significantly longer operative time (P = 0.019), more estimated blood loss (P = 0.002), and radiation exposure (P < 0.001) than those in group B. However, no statistical differences were detected between two groups in blood transfusion (P = 0.845) or hospital stay (P = 0.690). Besides, VAS-BP, VAS-LP, and ODI significantly improved in both groups after the surgery, but no significant differences were observed between two groups pre-operatively, three day post-operatively, or at the last follow-up. Moreover, there were no distinct differences between two groups in total complication rate (P = 0.653), fusion rate (P = 0.822), or MacNab satisfaction (P = 1.000) at the last follow-up. CONCLUSIONS: In two-level degenerative lumbar diseases, based on the bilateral decompression via unilateral approach technique, MIS-TLIF with bilateral short decompression incision could significantly reduce radiation exposure, shorten operative time, decrease blood loss, and achieve comparable clinical outcomes when compared to unilateral long decompression incision.

Percutaneous Transforaminal Endoscopic Discectomy for Adjacent Segment Disease After Lumbar Fusion in Elderly Patients Over 65 Years Old.

OBJECTIVE: To evaluate short-term efficacy and safety of percutaneous transforaminal endoscopic discectomy (PTED) in treatment of symptomatic adjacent segment disease (ASD) after lumbar fusion in elderly patients >65 years old. METHODS: Patients >65 years old who underwent PTED for ASD after lumbar fusion between January 2013 and September 2016 were retrospectively evaluated. Demographics and perioperative clinical data were collected from medical records. MacNab classification, visual analog scale, Oswestry Disability Index, and Japanese Orthopaedic Association scores as well as 36-Item Short-Form Health Survey were used to assess the efficacy of PTED. RESULTS: We evaluated 25 consecutive patients >65 years old with ASD (11 men, 14 women; mean age 74.65 ± 9.61 years). Mean follow-up time was 37.14 ± 11.60 months. Of patients, 84.0% (21/25) had excellent or good clinical outcomes, 12.0% (3/25) had fair outcomes, and 4.0% (1/25) had poor outcomes. Complications included 1 dural laceration, 1 postoperative dysesthesia, and 1 recurrence. For patient-reported outcomes, significant improvements were observed postoperatively compared with preoperatively in visual analog scale (P < 0.05), Oswestry Disability Index (P < 0.05), Japanese Orthopaedic Association (P < 0.05), and 36-Item Short-Form Health Survey (P < 0.05). CONCLUSIONS: PTED demonstrated satisfactory short-term efficacy and safety in management of ASD after lumbar fusion in patients >65 years old. PTED may be an alternative choice for elderly patients with ASD after lumbar fusion.

Comparison of the effects of local anesthesia and epidural anesthesia for percutaneous transforaminal endoscopic discectomy in elderly patients over 65 years old.

BACKGROUND: Local anesthesia (LA) is recommended for percutaneous transforaminal endoscopic discectomy (PTED) but clinical practice indicates that LA cannot achieve satisfactory pain management during PTED. OBJECTIVES: The study aimed to investigate the comparisons between LA and EA for PTED in elderly population over 65 years old. METHODS: We performed a retrospective analysis of patients over 65 years old received PTED from May 2013 to December 2014. And patients were divided into two groups according to the anesthesia method. The data collected for analysis including operative time, fluoroscopy time, postoperative bed time, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI), the global outcome based on the Macnab outcome criteria, satisfaction rate of anesthesia, and complications. RESULTS: A total of 132 consecutive patients were enrolled in this study. There were 65 patients in LA group and 67 patients in EA group. Compared to LA group, EA group had longer operative time (P < 0.001) and postoperative bed time (P < 0.001) but shorter fluoroscopy time, (P < 0.001), smaller VAS score of lumbar pain intraoperatively (P < 0.001), 1-h postoperatively (P < 0.001) and 1-week postoperatively (P < 0.001). Similarly, EA group had lower VAS score of leg pain intraoperatively (P < 0.001) and 1-h postoperatively (P < 0.001). In additions, higher satisfaction rate of anesthesia was observed in EA group (P = 0.029). CONCLUSIONS: EA and LA for PTED achieved comparable clinical outcomes in elderly population over 65 years old. However, compared to LA for PTED, EA had a better performance in pain management.

The effect of preoperative administration of morphine in alleviating intraoperative pain of percutaneous transforaminal endoscopic discectomy under local anesthesia: A STROBE compliant study.

Local anesthesia is routinely recommended for percutaneous transforaminal endoscopic discectomy (PTED). However, the intense intraoperative pain remains a serious problem. The purpose of the current study is to find a safe and effective method to alleviate the intense pain during PTED for lumbar disc herniation (LDH) under local anesthesia.This study retrospectively analyzed 63 LDH patients who accepted PTED under local anesthesia. Thirty-one patients received intramuscular injection of morphine before PTED, while the other 32 were not. The 10 points visual analogue scale (VAS) was used to assess the patients' maximum leg and back pain. Patients were asked to grade their experiences of surgery and anesthesia on a 5-point Likert-type scale after the surgery. Modified Mac Nab Criteria were used to evaluate the surgical outcomes after 3-month follow-up.The intraoperative VAS scores of patients who accepted preoperative intervention decreased significantly. The postoperative VAS scores of both groups showed no significance. Patients who received preoperative intervention reported a higher subjective satisfaction rate with the surgery experience. According to the Modified Mac Nab criteria, the surgical outcomes of both groups were similar through the 3-month follow-up. After injection of morphine, 4 patients complained nausea and 2 patients experienced vomiting.Preoperative intramuscular injection of morphine could reduce the patients' pain during the PTED surgery and improve the patients' satisfaction without affecting the surgical outcome. Except for a higher incidence of nausea and vomiting, this method is relatively safe and convenient.

Clinical Outcome and Postoperative CT Measurements of Microendoscopic Decompression for Lumbar Spinal Stenosis.

STUDY DESIGN: This was a retrospective case series. OBJECTIVE: To retrospectively evaluate the clinical outcome of microendoscopic decompression for lumbar spinal stenosis (LSS) including an evaluation of the extent of decompression using computed tomography. SUMMARY OF BACKGROUND DATA: Microendoscopic decompression has been a widely applied procedure to treat LSS with satisfactory outcomes and comparatively fewer complications and revision. However, few reports showed computed tomography (CT) measurements of the lumbar spine to assess the postoperative decompression. METHODS: This study included 103 patients (55 males and 48 females; mean age, 69 y) who underwent microendoscopic decompression for treatment of LSS between January 2009 and January 2011. All patients underwent preoperative CT and postoperative CT at 6 months and 2 years of follow-up to measure the vertebral canal area and the sagittal diameter of the lateral recess at the outer rim. The Japanese Orthopedic Association (JOA) scale, Oswestry Disability Index, and Visual Analogue Scale were used to evaluate clinical efficacy. RESULTS: The mean vertebral canal area and sagittal diameter of the lateral recess were significantly larger at 6 months and 2 years after surgery compared with 1 day before surgery (P<0.001). The mean JOA scale scores were significantly higher at 6 and 24 months following surgery compared with before surgery (P<0.001). The mean Oswestry Disability Index scores and Visual Analogue Scale scores at 6 months and 2 years after surgery were significantly lower compared with before surgery (both P<0.001). The mean JOA recovery rates at 6 months and 2 years of follow-up were 61% and 64.3%, respectively. CONCLUSIONS: The results confirm that microendoscopic decompression for LSS is safe and effective. This study is one of the first to obtain CT measurements of the lumbar spine to assess the postoperative decompression of this procedure.

Lower Learning Difficulty and Fluoroscopy Reduction of Transforaminal Percutaneous Endoscopic Lumbar Discectomy with an Accurate Preoperative Location Method.

BACKGROUND: Transforaminal percutaneous endoscopic lumbar discectomy (tPELD) poses great challenges for junior surgeons. Beginners often require repeated attempts using fluoroscopy causing more punctures, which may significantly undermine their confidence and increase the radiation exposure to medical staff and patients. Moreover, the impact of an accurate location on the learning curve of tPELD has not been defined. OBJECTIVE: The study aimed to investigate the impact of an accurate preoperative location method on learning difficulty and fluoroscopy time of tPELD. STUDY DESIGN: Retrospective evaluation. SETTING: Patients receiving tPELD by one surgeon with a novel accurate preoperative location method were regarded as Group A, and those receiving tPELD by another surgeon with a conventional fluoroscopy method were regarded as Group B. METHODS: From January 2012 to August 2014, we retrospectively reviewed the first 80 tPELD cases conducted by 2 junior surgeons. The operation time, fluoroscopy times, preoperative location time, and puncture-channel time were thoroughly analyzed. RESULTS: The operation time of the first 20 patients were 99.75 ± 10.38 minutes in Group A and 115.7 ± 16.46 minutes in Group B, while the operation time of all 80 patients was 88.36 ± 11.56 minutes in Group A and 98.26 ± 14.90 minutes in Group B. Significant differences were detected in operation time between the 2 groups, both for the first 20 patients and total 80 patients (P < 0.05). The fluoroscopy times were 26.78 ± 4.17 in Group A and 33.98 ± 2.69 in Group B (P < 0.001). The preoperative location time was 3.43 ± 0.61 minutes in Group A and 5.59 ± 1.46 minutes in Group B (P < 0.001). The puncture-channel time was 27.20 ± 4.49 minutes in Group A and 34.64 ± 8.35 minutes in Group B (P < 0.001). There was a moderate correlation between preoperative location time and puncture-channel time (r = 0.408, P < 0.001), and a moderate correlation between preoperative location time and fluoroscopy times (r = 0.441, P < 0.001). Mild correlations were also observed between preoperative location time and operation time (r = 0.270, P = 0.001). There were no significant differences in preoperative back visual analogue scale (VAS) score, postoperative back VAS, preoperative leg VAS, postoperative leg VAS, preoperative Japanese Orthopaedic Association (JOA) score, postoperative JOA, preoperative Oswestry disability score (ODI), or postoperative ODI (P > 0.05). However, significant differences were all detected between preoperative abovementioned scores and postoperative scores (P < 0.05). Moreover, there was no significant differences in Macnab satisfaction between the 2 groups (P = 0.179). There were 2 patients with recurrence in Group A and 3 patients in Group B. Twelve patients with postoperative disc remnants were identified in Group A and 9 patients in Group B. No significant difference was identified between the 2 groups (P = 0.718). LIMITATIONS: The preoperative lumbar location method is just a tiny step in tPELD, junior surgeons still need to focus on their subjective feelings during punctures and accumulating their experience in endoscopic discectomy. CONCLUSIONS: The accurate preoperative location method lowered the learning difficulty and reduced the fluoroscopy time of tPELD, which was also associated with lower preoperative location time and puncture-channel time. Key words: Learning difficulty, fluoroscopy reduction, transforamimal percutaneous endoscopic lumbar discectomy, preoperative locationLearning difficulty, fluoroscopy reduction, transforamimal percutaneous endoscopic lumbar discectomy, preoperative location.

Patient-reported and radiographic outcomes of minimally invasive transforaminal lumbar interbody fusion for degenerative spondylolisthesis with or without reduction: A comparative study.

This retrospective study aimed to compare the patient-reported outcomes and radiographic assessment of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis with reduction versus in situ fusion. Patients receiving MI-TLIF with reduction were assigned as Group A, and those without reduction were assigned as Group B. Radiographic fusion was assessed using Bridwell's grading criteria. Preoperative and postoperative patient-reported outcomes including visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) scale and improvement rate were analyzed. There were 41 patients in Group A and 37 patients in Group B. The mean follow-up was 30.78±14.15months in Group A and 28.95±10.75months in Group B (p=0.525). There were no significant differences in hospital stay (p=0.261), estimated blood loss (p=0.639), blood transfusion (p=0.336), operation time (p=0.762) and complications (p=1.00) between the two groups. Radiographic fusion rate was 92.68% (38/41) in Group A, and 81.08% (30/37) in Group B (p=0.110). Significant differences were observed in either 3-month or last follow-up JOA, VAS, and ODI compared with preoperative JOA, VAS, and ODI, respectively (p<0.05). However, there were no significant differences in JOA, VAS, and ODI between the two groups whenever preoperatively, or 3-month postoperatively, or at the last follow-up (p>0.05). According to MacNab criteria, the excellent and good rate was 85.37% in Group A and 86.49% in Group B (p=0.983). MI-TLIF is an effective and satisfactory surgical technique to manage degenerative spondylolisthesis regardless of reduction or not, so routine reduction may not be a requirement in MI-TLIF for degenerative spondylolisthesis.

Global scientific production of robotic surgery in medicine: A 20-year survey of research activities.

INTRODUCTION: Robot-assisted surgery operations are being performed more frequently in the world these years. In order to have a macroscopic view of publication activities about robotic surgery, the first bibliometric analysis was conducted to investigate the publication distributions of robotic surgery. METHODS: The original articles about robotic surgery were extracted from the Science Citation Index Expanded (SCI-E) on Web of Science and analyzed concerning their distributions. We also explored the potential correlations between publications of different countries and their Gross Domestic Product (GDP). RESULTS: The total number of original articles retrieved from SCI-E was 3362 from 1994 to 2015. The number of original articles published in the last decade has a burgeoning increase of 572.87% compared with that published in the former decade. The leading country was USA who have published 1402 pieces of articles (41.701%), followed by Germany with 342 (10.173%). The journal published the highest number of original articles was Journal of Endourology with 237 (7.049%), followed by Surgical Endoscopy and Other Interventional Techniques (188, 5.592%). There was strong correlations between publication numbers and GDP of different countries (r(2) = 0.889, p < 0.001). In the different medical fields, urology has the highest number of articles (n = 878, 26.007%). DISCUSSIONS: The macroscopic view of research activities has the potential to guide future trend in the field of robotic surgery. CONCLUSIONS: There is a skyrocket trend of robotic surgery in medical research over the last two decades, and countries with high GDP tend to make more contributions to the medical field of robotic surgery.

Gender difference in mobile phone use and the impact of digital device exposure on neck posture.

This cross-sectional study aimed to identify gender differences in the cervical postures when young adults were using mobile phones, as well as the correlations between the postures and the digital devices use (computer and mobile phone). Questionnaires regarding the habits of computer and mobile phone use were administrated to 429 subjects aged from 17 to 33 years old (19.75 ± 2.58 years old). Subjects were instructed to stand habitually and use a mobile phone as in daily life; the sagittal head and cervical postures were measured by head flexion, neck flexion angle and gaze angle. Male participants had a significantly larger head flexion angle (96.41° ± 12.23° vs. 93.57° ± 12.62°, p  =  0.018) and neck flexion angle (51.92°  ±  9.55° vs. 47.09° ± 9.45°, p  <  0.001) than females. There were significant differences in head (F  =  3.62, p  =  0.014) and neck flexion (F  =  3.99, p  =  0.009) between different amounts of computer use. Practitioner Summary: We investigated possible gender differences in head and neck postures of young adults using mobile phones, as well as the potential correlations between these postures and digital device use. We found that males displayed larger head and neck flexion angles than females, which were associated with the amount of computer use.

A Novel Classification and Minimally Invasive Treatment of Degenerative Lumbar Spinal Stenosis.

AIM: We conducted a novel classification system of degenerative lumbar spinal stenosis (DLSS) based on clinical manifestations and imaging (computed tomography and magnetic resonance imaging) features. We chose different minimally invasive surgical procedures according to our system. Clinical parameters and radiological findings will be assessed in the article. MATERIAL AND METHODS: A retrospective study was conducted on 96 patients undergoing minimally invasive surgery for DLSS. We chose different surgical procedures according to our novel classification system based on clinical manifestations, imaging features, and concurrence with other spinal diseases. Clinical parameters and radiological findings were assessed pre- and postoperatively. RESULTS: The mean follow up period was 24 months (range, 15~36 months). There was a statistically significant improvement in the Visual Analogue Scale (VAS) score of low back pain and leg pain after surgery (p < 0.05). According to the Japanese Orthopaedic Association (JOA) scores, the operation efficacy was excellent in 57 cases, good in 36 cases, and fair in 3 cases. According to Bridwell's criterion, the fusion rate was 96% (48/50) in patients who underwent fusion surgery. There were no cages or pedicle screws related complications. CONCLUSION: Minimally invasive surgical treatment of DLSS has satisfactory outcomes according to the novel classification, but further long-term, prospective, randomized controlled studies involving a larger study group are needed to validate the long-term efficacy.