Technical feasibility of combined uniportal unilateral laminotomy with bilateral decompression and interlaminar lumbar discectomy surgery for cauda equina syndrome due to lower lumbar disc herniation.

Background: Traditionally, open wide laminectomy and discectomy have been advocated for the treatment of cauda equina syndrome caused by lumbar disc herniation. We aimed to evaluate the technical feasibility of uniportal interlaminar endoscopy in treating cauda equina syndrome. Methods: Nine patients with cauda equina syndrome underwent uniportal endoscopic decompression and discectomy from December 2020 to December 2022. Data were collected retrospectively. Patients diagnosed with cauda equina syndrome were operated on within 6 hours of presentation to the hospital. The visual analogue score (VAS), Oswestry disability index (ODI), and bladder/bowel score were used to measure the outcome. Results: Analysis showed that VAS scores for leg pain and back pain significantly decreased from preoperative scores of 8.22±0.79 and 4.67±1.76 to postoperative day 1 scores of 0.67±0.67 and 2.56±1.42 (p<.05). The ODI scores improved from preoperative 52.33±11.93 to postoperative (day 1) 14±6.80. Eight patients had early recovery (1 week) of bladder and bowel functions, and one had delayed recovery at 8 months. None of the patients had a residual bowel/bladder deficit. Macnab's criteria outcomes were excellent in all patients at the final follow-up. Conclusions: Uniportal endoscopic lumbar endoscopic unilateral laminotomy with bilateral decompression and subsequent interlaminar endoscopic lumbar discectomy is a safe and effective minimally invasive course of treatment for cauda equina syndrome as an alternative to open laminectomy in our cohort of patients.

Letter to editor regarding "The Efficacy and Safety of Topical Saline Irrigation with Tranexamic Acid on Perioperative Blood Loss in Patients Treated with PELD".

Letter: We have read the recent article published by Zhang et al titled "The Efficacy and Safety of Topical Saline Irrigation with Tranexamic Acid on Perioperative Blood Loss in Patients Treated with Percutaneous Endoscopic Interlaminar Diskectomy: A Retrospective Study". In this retrospective study, authors performed interlaminar endoscopic lumbar discectomy (IELD) for L5-S1 disc herniations, categorizing patients into two groups. One group underwent IELD with saline irrigation fluid containing 0.33 gm of tranexamic acid (TXA) per 1L of saline, while the other group received only saline irrigation fluid. We appreciate the authors' efforts in shedding light on the use of TXA in irrigation fluid, which currently has limited literature available. However, we wish to highlight several points of concern that, in our view, warrant further discussion. Upon reviewing the manuscript, our initial concern centers on the reported amount of blood loss, a crucial outcome in this study. The blood loss figures presented in this study appear significantly higher compared to the existing literature. In both study groups, the authors indicate total blood loss (TBL) exceeding 300 ml and intraoperative blood loss (IBL) surpassing 40 ml. In contrast, a systematic review and meta-analysis by Jitpakdee et al. (1) reported a range of blood loss from 10.9 ml to 23.35 ml for interlaminar endoscopic discectomy without any systemic or local use of tranexamic acid. Accurately assessing blood loss in endoscopic spine surgery poses a challenge, and the accuracy of indirect calculation methods is questionable, particularly when bleeding is minimal. Endoscopic discectomy has been proven benefits by minimal tissue damage and negligible blood loss. Another significant concern we would like to address is related to the safety and efficacy of topical tranexamic acid (TXA) use in endoscopic spine surgery. The existing literature generally accepts the safety profile and efficacy of use of intravenous TXA in open spine surgery where the blood loss incurred is substantial (2, 3). However, when it comes to the safety of topical TXA, it is important to note that TXA is known to have neurotoxic and epileptogenic properties when applied to central nervous system (CNS) tissue (5, 6). This is due to its interference with central GABAA receptors and glycine receptors (7). In endoscopic spine surgeries, small dural tears can sometimes go unnoticed due to continuous irrigation fluid pressure. In such cases, the potential CNS side effects associated with topical TXA could pose a real danger. Furthermore, even when dural tears are identified during surgery, it can be challenging to completely washout all the irrigation fluid containing TXA from the surgical field. The accumulation of excessive epidural or intrathecal TXA, especially after a dural tear, can lead to life-threatening conditions such as seizures or arrhythmias, significantly increasing morbidity and mortality in what is often intended as a day-care procedure. Moreover, the authors have not mentioned any exclusion criteria for patients with conditions that are suspected to elevate risk of developing TXA-related side effects, such as a history of thromboembolic events and/or coagulopathy, convulsive disorders and dural disruption. Lastly, in terms of the efficacy of TXA, there are limited studies demonstrating the use of local TXA in spine surgeries to reduce blood loss. For example, Krohn et al(4) used topical TXA irrigation in open instrumented spinal fusion surgery before wound closure. Their study showed a reduction in postoperative blood loss, with drain output decreasing from 525 ml in the non-TXA group to 252 ml in the TXA group. However, it had no significant effect on intraoperative blood loss. We would like to raise a pertinent question regarding endoscopic discectomy procedures, which are characterized by minimal blood loss and are often conducted as day-care surgeries. It becomes a matter of concern whether the potential advantages of using topical TXA in reducing blood loss outweigh the associated risks of neurological damage to the central nervous system (CNS) and other potentially life-threatening complications.

Unilateral biportal endoscopic supralaminar, posterior spinous process sparing approach for en bloc cervical laminectomy in case of cervical osteochondroma causing myelopathy: A case report.

Background Context: Cervical osteochondroma is a rare cause of myelopathy. Traditional treatment is open laminectomy with or without fusion. There is limited literature on unilateral bi-portal endoscopic en-bloc resection of cervical osteochondroma. Study Design: We describe a case of a 39-year-old male diagnosed with cervical compressive myelopathy. The pathologic site is located on the ventral surface of C4 lamina. Herein we describe a step-by-step method of unilateral biportal endoscopy (UBE) en-bloc resection of extra-dural sublaminar osteochondroma for patient who had cervical myeloradiculopathy. Spinous process sparing osteotomy was performed to conserve the spinous process and supraspinous ligament.. Outcome Measures: The patient was successfully treated via UBE and the operative time was 50 minutes with no intra-operative complications. Patient symptoms improved in the immediate postoperative period and by 3 months he regained fine motor functions of hand. Conclusions: Unilateral biportal endoscopic en bloc cervical laminectomy can effectively decompress cervical spine and remove posterior benign cervical tumor. UBE preserves musculature and posterior ligamentous complex and thus reduces postoperative neck pain and postlaminectomy kyphosis.

In Vertebral Hemangiomas with Neurological Deficit, Is a Less Extensive Approach Adequate.

STUDY DESIGN: This was a retrospective study. PURPOSE: To analyze the surgical and neurological outcomes following surgical decompression in patients with aggressive vertebral hemangioma (AVH) presenting with neurological deficit and to determine whether a less extensive approach is appropriate. OVERVIEW OF LITERATURE: AVHs are a rare subset of benign vascular tumors frequently presenting with neurological deficit because of spinal cord compression. Though the results of surgical management have improved over time, there is a lack of consensus on the ideal management in this group of patients. METHODS: Twenty-one patients who underwent surgery for AVH between 2009 and 2018 were analyzed. Demographic and clinical details of patients were retrieved from hospital information system. Imaging information (i.e., radiography, computed tomography, magnetic resonance imaging) of all patients was accessed and analyzed in picture archiving and communication system. Tumor staging was performed using Enneking and Weinstein-Boriani-Biagini classifications and Spinal Instability Neoplastic Score. At followup, neurological and radiological evaluations were performed. RESULTS: Twenty-one patients (13 [61.9%] females and 8 [38.1%] males) were included with a mean age of 44.29 years (range, 14-72 years). All patients in the study had neurological deficit. Back pain was present in 80.9% of patients. Mean duration of symptoms was 4.6 months (range, 1 day to 10 months). Most common lesion location was thoracic spine (n=12), followed by thoracolumbar (D11- L2; n=7) and lumbar (n=2) regions. Ten patients had multiple level lesions. All patients underwent preoperative embolization. Nine patients underwent intralesional spondylectomy with reconstruction; another nine patients underwent stabilization, decompression, and vertebroplasty; three patients underwent decompression and stabilization. Neurology improved in all patients, and only one case of recurrence was noted in a mean follow-up of 55.78±25 months (range, 24-96 months). CONCLUSIONS: In AVH, good clinical and neurological outcomes with low recurrence rates can be achieved using less extensive procedures, such as posterior instrumented decompression with vertebroplasty and intralesional tumor resection.

Efficacy of Non-Fusion Surgeries in the Management of AO Type C Injuries of the Thoracic and Thoracolumbar Spine: A Retrospective Study.

Background: The initial descriptions of successful management of non-fusion surgeries in the management of unstable burst injuries of the thoracic and thoracolumbar spine (TTLS) were published by Osti in 1987 and Sanderson in 1999. These were further supported by prospective studies and meta-analyses establishing comparable results between fusion and non-fusion surgeries. However, there is a paucity of literature regarding the efficacy of non-fusion surgeries in the management of AO type C injuries. Objective, Materials and Methods: The study aims to determine the efficacy of open posterior instrumented stabilization without fusion in AO type C injuries of the TTLS. Patients with AO type C injuries of the TTLS (T4-L2 levels) with normal neurology who underwent open, posterior, long segment instrumented stabilization without fusion between January 2015 and June 2018 were included. The regional kyphotic angle, local kyphotic angle, AP (anterior and posterior wall) ratio, and cumulative loss of disc space angle were assessed on radiographs. Functional outcome was assessed using Oswestry Disability Index (ODI) and the AO Spine patient-reported outcome spine trauma (PROST) instrument. Results and Conclusion: The study included 35 patients with AO type C injury of the TTLS and a normal neurology who underwent open posterior instrumented stabilization and had a mean follow-up of 43.2 months (range 24-60 months). The mean preoperative regional kyphotic angle decreased from 19.8 ± 13.7° to 6.6 ± 11.3° after surgery but showed an increase to 9.21 ± 10.5° at final follow-up (P = 0.003). The cumulative loss of disc space angle was significant at final follow-up (2.4 ± 5° [P = 0.002]). Twenty-eight out of 35 patients had minimal while seven had moderate disability on the ODI score. The AO Spine PROST revealed that patients regained 95.7 ± 4.2% of their pre-injury functional status at final follow-up. Posterior instrumented stabilization without fusion in the management of AO type C injuries of the TTLS gives satisfactory results with acceptable functional and radiological outcomes.

Spondylolysis of the Thoracic Spine with Instability: A Rare Cause for Myelopathy.

CASE: A 51-year-old lady with multiple comorbidities presented with T11 spondylolysis in association with thoracic stenosis and myelopathy. Our patient underwent T11-T12 laminectomy, T10-L1 posterior instrumented stabilization, and T11-T12 transforaminal interbody fusion. She had a good neurological recovery, and the radiographs at 1-year follow-up showed good fusion and implant position. CONCLUSION: Spondylolysis is an anatomical defect or stress fracture of the pars interarticularis and usually reported in the lumbar region. This case of T11 spondylolysis in association with thoracic stenosis, spinal instability, and myelopathy is highlighted for its rarity and to reiterate the need for high index of suspicion among surgeons for the timely diagnosis.

Spinal Hypertrophic Pachymeningitis Causing Thoracic Myelopathy in a Patient of Takayasu Arteritis: A Case Report.

CASE: A 52-year-old man presented with thoracic myelopathy, and his magnetic resonance imaging (MRI) was suggestive of T1-T4 hypertrophic-pachymeningitis. Incidentally, circumferential thickening of the infra-renal abdominal aorta and right common iliac artery was seen, which along with the findings in a contrast computed tomography was consistent with Takayasu arteritis (TA). The patient underwent T1-T4 laminectomy, thinning of dura, biopsy, and steroid therapy. At the 1-year follow-up, he was asymptomatic and MRI revealed resolution of the lesion. CONCLUSION: This is the first report describing an association between TA and hypertrophic spinal pachymeningitis, emphasizing the unusual neurological manifestation of myelopathy and complete resolution of symptoms with timely and appropriate intervention.

Symptomatic Postsurgical Lumbar Pseudomeningocele Treated by Ultrasound-Guided Epidural Blood Patch Application.

Postsurgical pseudomeningoceles are extradural collections of cerebrospinal fluid (CSF) that results following an intraoperative dural breach. Although usually asymptomatic and self-subsiding, they may present with symptoms of postural headache, blurred vision, diplopia, photophobia, back pain, radiculopathy, and vomiting. Most of the cases recover with conservative measures such as bed rest, hydration, and pressure dressings. Symptomatic patients usually require surgical re-exploration and direct open repair of the durotomy. We report the case of a 48-year-old female who presented with lumbar pseudomeningocele following lumbar microdiscectomy treated by Ultrasound-guided (USG)-guided epidural blood patch application. She had globular swelling at the surgical site, postural headache, and left lower-limb radicular pain with normal neurology. Her magnetic resonance imaging (MRI) showed a left L4 laminar defect with pseudomeningocoele (measuring 5.5 cm × 4.2 cm × 4 cm) with intraspinal communication. USG was used to guide the aspiration of CSF from pseudomeningocele and to apply the epidural blood patch one level above and at the level of laminectomy. Postoperatively, she had marked improvement in her symptoms. At 1-year follow-up, she was completely symptom free and full resolution of pseudomeningocele was seen on 1-year follow-up MRI. This case is being reported to highlight the use of USG-guided epidural blood patch for the treatment of postoperative lumbar pseudomeningocele.