Early results of full-endoscopic decompression of lumbar central canal stenosis by outside-in technique: A clinical and radiographic study.

ABSTRACT: Retrospective cohort study.Full-endoscopic decompression of lumbar spinal canal stenosis is being performed by endoscopic surgeons as an alternative to micro-lumbar decompression in the recent years. The outcomes of the procedure are reported by few authors only. The aim of this paper is to report the clinical and radiographic outcomes of full endoscopic lumbar decompression of central canal stenosis by outside-in technique at 1-year follow-up.We reviewed patients operated for lumbar central canal stenosis by full endoscopic decompression from May 2018 to November 2018. We analyzed the visual analogue scale scores for back and leg pain and Oswestry disability index at pre-op, post-op, and 1-year follow-up. At the same periods, we also evaluated disc height, segmental lordosis, whole lumbar lordosis on standing X-rays and canal cross sectional area at the affected level and at the adjacent levels on magnetic resonance imaging and the facet length and facet cross-sectional area on computed tomography scans. The degree of stenosis was judged by Schizas grading and the outcome at final follow-up was evaluated by MacNab criteria.We analyzed 32 patients with 43 levels (M:F = 14:18) with an average age of 63 (±11) years. The visual analogue scale back and leg improved from 5.4 (±1.3) and 7.8 (±2.3) to 1.6 (±0.5) and 1.4 (±1.2), respectively, and Oswestry disability index improved from 58.9 (±11.2) to 28 (±5.4) at 1-year follow-up. The average operative time per level was 50 (±16.2) minutes. The canal cross sectional area, on magnetic resonance imaging, improved from 85.78 mm2 (±28.45) to 150.5 mm2 (±38.66). The lumbar lordosis and segmental lordosis also improved significantly. The disc height was maintained in the postoperative period. All the radiographic improvements were maintained at 1-year follow-up. The MacNab criteria was excellent in 18 (56%), good in 11 (34%), and fair in 3 (9%) patients. None of the patients required conversion to open surgery or a revision surgery at follow-up. There was 1 patient with dural tear that was sealed with fibrin sealant patch endoscopically. There were 10 patients who had grade I stable listhesis preoperatively that did not progress at follow-up. No other complications like infection, hematoma formations etc. were observed in any patient.Full endoscopic outside-in decompression method is a safe and effective option for lumbar central canal stenosis with advantages of minimal invasive technique.

Incidental Durotomy During Endoscopic Stenosis Lumbar Decompression: Incidence, Classification, and Proposed Management Strategies.

OBJECTIVE: We sought to review the types of incidental durotomies (IDs) that occurred during the endoscopic stenosis lumbar decompression through interlaminar approach (ESLD) and discuss the management strategies according to our classification. METHODS: A retrospective evaluation was performed for patients with spinal stenosis who underwent ESLD. Out of 330 patients, 27 patients of ID were clinically evaluated preoperatively and postoperatively on the basis of a visual analog scale score, Oswestry Disability Index, and MacNab's criteria. ID patterns are classified according to the size, location, and involvement of neural elements. Intraoperative and postoperative surgical management was evaluated. RESULTS: Intraoperative incidence of ID was 8.2%. According to lumbar levels, 11 (40.7%) occurred at L3-4, 12 (44.4%) at L4-5, and 4 (14.8%) at L5-S1 ID cases. IDs were divided into 4 types: 29.6% are type 1, 70% are type 2, 7.4% are type 3, and 3.7% are type 4. Overall for mean and standard deviation preoperative, 1 week postoperative, 3 months, and final follow-up for visual analog scale are 7.6 ± 1.4, 3.3 ± 1.1, 2.6 ± 1.1, and 1.9 ± 1.3, and for Oswestry Disability Index are 74.5 ± 9.0, 32.3 ± 9.4, 27.3 ± 7.2, and 24.4 ± 6.5 after patch blocking dura repair of ID. CONCLUSIONS: ID is a more common surgical complication in ESLD compared with the transforaminal approach. The endoscopic patch blocking dura repair technique should be considered in type 1 to type 3A of dura tear with good prognosis and clinical outcome. Consideration is made for conversion to open repair in types 3B, 3C and 4 dura tears with fair to poor outcome.

Biportal Endoscopic Excision of Facetal Cyst in the Far Lateral Region of L5S1: 2-Dimensional Operative Video.

Unilateral biportal endoscopy (UBE) is a recently introduced technique that utilizes 2 portals, one for endoscopy and one as a working portal, in contrast to full endoscopy, which utilizes a single portal. The advantages are a favorable learning curve and free mobility of instruments in the operative field. UBE is successful in addressing cervical and lumbar disc herniations, lumbar stenosis, and foraminal/extraforaminal pathologies, such as herniations and foraminal stenosis. However, there is no report of UBE for a far-lateral L5S1 facet cyst. The patient was an 85-yr-old female with a left lower limb radicular pain with magnetic resonance imaging evidence of the facet cyst compressing the L5 nerve root. Conventional treatment of such a condition would either be an L5S1 fusion procedure or a standalone decompression via the Wiltse paramedian approach. Because the patient had no instability, we decided to do a standalone decompression using the UBE technique. The UBE technique has the advantages of any minimal access procedure, including small incisions, minimal tissue dissection, good magnification, and preservation of anatomic structures. A written informed consent was obtained from the patient before the procedure. The procedure was done under general anesthesia using a 30° endoscope, a radiofrequency probe, and standard lumbar spine surgery instruments. The initial landing point of the endoscope and instruments is via triangulation at the lateral border of the isthmus of L5. The postoperative clinical and radiological outcomes were satisfactory (VAS Back and Leg, 0; Oswestry disability index, 15 at 3 mo).

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

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

Full-Endoscopic Resection of Ligamentum Flavum Cyst in Lumbar Spine.

BACKGROUND: Cysts of the ligamentum flavum (LF) are rare occurrences, with only a few cases reported in literature. They are a result of age-related degenerative changes in the LF. The cyst compresses the neural elements and causes neurogenic symptoms. Endoscopic resection of the LF cyst has not been described in literature. In this report, we describe our experience with endoscopic resection of an LF cyst in the L3-L4 region. CASE DESCRIPTION: A 54-year-old female patient presented with claudication in both lower limbs and evidence on magnetic resonance imaging of a LF cyst in the L3-L4 region compressing the neural elements. The patient underwent full endoscopic resection of the LF cyst through the interlaminar approach from the left side with preservation of facet joints. The postoperative clinical outcomes improved significantly, and postoperative magnetic resonance imaging revealed a complete removal of the cyst. CONCLUSIONS: Full-endoscopic resection may be considered as a viable option for treatment of LF cyst in the lumbar region.

How I do it? Oblique lumbar interbody fusion at L5S1(OLIF51).

BACKGROUND: OLIF51 retains the advantages of traditional ALIF procedure with good fusion rates and improvement in radiographic parameters and reduces its drawbacks. It has the added advantage of being a minimal access technique. METHODS: Preoperative analysis of the vascular anatomy using CT angiography is mandatory. OLIF51 is done in right lateral position using specialized retractor blades and Thompson retractor system. The procedure is similar to OLIF at other levels except for the differences described here. The instruments are specialized for OLIF at L5S1. CONCLUSION: OLIF51 provides an excellent alternative to traditional ALIF.

A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations.

Thoracic disc herniation (TDH) is a rare, but technically challenging, disorder. Apart from their unfamiliarity with this condition, surgeons are often posed with challenges regarding the diverse methods available to address TDH, the neurological disturbances accompanying the disorder, the prospect of iatrogenic cord damage during surgical procedures, and the complications associated with various surgical approaches. In today's era, when minimally invasive surgery has been incorporated into almost every aspect of managing spine disorders, it is necessary for surgeons to be aware of the various minimally invasive techniques available for the management of these rare and difficult conditions. In this review article, we provide a synopsis of the epidemiology, clinical features, and technical aspects of TDH, starting from level identification to intraoperative neuromonitoring and including important steps and guidance for all the minimally invasive approaches to TDH. We conclude the review by providing insights into the clinical decision-making process and outline the specific aspects of "giant" thoracic discs and indications for fusion in certain conditions. Outcomes of minimally invasive surgery for these conditions are generally favorable. The location of herniation is an important factor for surgical planning.