Hybrid Interlaminar Endoscopic Lumbar Decompression in Disc Herniation Combined With Spinal Stenosis.

BACKGROUND: Endoscopic spine surgery is an alternative to the traditional treatment of lumbar disc herniation. However, the traditional technique of interlaminar endoscopic approach is challenging and risky in patients with concomitant spinal stenosis. OBJECTIVE: To report a modified technique called hybrid interlaminar endoscopic lumbar decompression as an effective treatment. METHODS: Patients with combined lumbar disc herniation and lateral recess stenosis undergoing full-endoscopic interlaminar lumbar discectomy were retrospectively studied. The hybrid interlaminar endoscopic discectomy technique, as well as the use of 2 endoscopes with different diameters, is described in detail. The large endoscope is used for the laminotomy procedure, while the small endoscope is used for the discectomy procedure. The demographics and clinical outcomes of the patients are presented. RESULTS: A total of 19 patients were included in this study. The mean age was 46.7 yr. The visual analog scale for back and leg pain improved from 5.6 ± 3.4 and 7.5 ± 2.3 to 1.8 ± 1.3 and 1.8 ± 1.6, respectively (P < .001). The mean Oswestry Disability Index improved from 59.9 ± 21.2 preoperatively to 18.2 ± 8.5 postoperatively (P < .001). The follow-up was 8.2 mo on average. No major complications occurred, but 2 patients reported mild postoperative paresthesia. One patient had an early recurrence and underwent repeat endoscopic discectomy. CONCLUSION: Full-endoscopic lumbar discectomy provides excellent access to the intracanalicular herniation site of an intervertebral disc. By using the endoscopic technique presented here, surgeons can safely and efficiently achieve adequate decompression in patients with lumbar disc herniation combined with spinal stenosis.

The evolution of interlaminar endoscopic spine surgery.

Due to the aging population, patients required spinal surgery for degenerative spondylopathy is increasing. With the advent of surgical instruments and techniques, minimally invasive spine surgery is prevalent worldwide. Besides microscopic techniques, endoscopic spine surgery has gotten attention gradually in this surgical field for the past two decades. There are two essential approaches developed currently, including transforaminal and interlaminar approach. These innovative equipment and skills promote the progression of endoscopic surgery from discectomy to decompression of spinal stenosis. Meanwhile, they also opened up the application of endoscopic surgery in a complicated situation. From the perspective of emerging technologies and techniques, the authors will review the evolution and describe the prospects of the interlaminar endoscopic spine surgery (IESS).

Minimally Invasive Transforaminal Lumbar Interbody Fusion With Intraoperative Fluoroscopy for Disc Space Preparation: Analysis of Fusion Rate and Clinical Results.

BACKGROUND: Meticulous disc space preparation is an important step toward ensuring arthrodesis in the interbody fusion procedure. Although minimally invasive techniques are becoming increasingly advanced in lumbar interbody fusion, concerns exist regarding adequate discectomy and sufficient endplate preparation from a transforaminal lumbar approach. OBJECTIVE: To describe the radiographic and clinical outcomes of single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) using the intraoperative fluoroscopy-guided method for disc space preparation. METHODS: This is a retrospective study of 25 patients operated between June 2016 and Dec 2017. The radiographic outcomes included the intraoperative percentage of disc space preparation, fusion, and subsidence. Percentage of disc space preparation was calculated through intraoperative fluoroscopic imaging. Clinical outcomes included visual analog scale (VAS), Oswestry Disability Index (ODI), and satisfaction rate. RESULTS: Mean age of patients was 62.9 yr. The mean follow-up period was 22 mo. Mean extents of disc space preparation were 61.5% in the anteroposterior view and 80.3% in the lateral view. Fusion rates were 86% and 92% at 6 and 12-mo postoperatively, respectively. All patients showed clinical improvement according to VAS and ODI. CONCLUSION: MI-TLIF with intraoperative fluoroscopy-guided disc space preparation is shown to lead to potentially improved fusion rate. It is a safe and effective surgical method for degenerative lumbar disease. Additionally, in cases of cage subsidence caused by the endplate violation during disc space preparation, thorough sufficient bone grafting of the defect region avoids pseudoarthrosis.

Comparative Analysis of 2 Different Types of Titanium Mesh Cage for Single-level Anterior Cervical Corpectomy and Fusion in Terms of Postoperative Subsidence and Sagittal Alignment.

STUDY DESIGN: This was a retrospective observatory analysis study. OBJECTIVE: The objective of this study was to compare the differences in clinical and radiologic outcomes among patients who underwent anterior cervical corpectomy and fusion (ACCF) using titanium mesh cage (TMC) with end-caps and patients who underwent ACCF using TMC without end-cap. SUMMARY OF BACKGROUND DATA: TMC has been widely used as an effective treatment option for ACCF. However, the subsidence of TMC has been observed frequently in the early postoperative period in some cases, resulting in related clinical complications. MATERIALS AND METHODS: Patients who underwent single-level ACCF using TMC from September 2008 to June 2014 at our institute were retrospectively reviewed. Patients treated with TMC with end-cap were classified as an end-cap group, while patients treated with TMC without end-cap classified as a control group. The round press-fit-type end-caps with 2.5-degree angulation were used at both ends of the cage for the end-cap group. Patients were followed postoperatively for a minimum of 36 months with radiologic evaluation. RESULTS: The subsidence was lower in the end-cap group (4.3±3.6 vs. 4.8±3.0, P<0.01), with lower rates of severe subsidence (≥3 mm) than the control group (34.2% vs. 52.1%, P<0.01). Visual analogue scale (VAS) scores for neck pain and Neck Disability Index (NDI) was reported significantly less in the study group, which showed a positive correlation with lesser severe subsidence. Also, the characteristics of subsidence differed between the 2 groups. In the end-cap group, slippage type subsidence occurred, resulting in better sagittal alignment than that in the control group. CONCLUSIONS: For patients undergoing single-level ACCF, using TMC with end-cap provided better clinical results and similar fusion rate, compared with using TMC without end-cap. The end-cap decreased the severity of postoperative subsidence and related neck pain. Also, sagittal alignment was well preserved, suggesting it may contribute to cervical lordosis.

How I do it? Interlaminar contralateral endoscopic lumbar foraminotomy assisted with the O-arm navigation.

BACKGROUND: The interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) provides access to the foraminal pathology with less violation to facet than the ipsilateral approach. However, it is technically challenging even for an experienced surgeon. METHODS: We introduce the step-by-step workflow of the interlaminar contralateral endoscopic lumbar foraminotomy assisted with O-arm navigation system. CONCLUSION: The ICELF assisted with O-arm navigation is safe, accurate, and efficient for the treatment of lumbar foraminal stenosis. The CT-based navigation reshapes the learning curve of the advanced endoscopic technique, reducing the risk of facet joint violation, and minimizes radiation exposure to surgeons.

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.

The Clinical Usefulness of Preoperative Imaging Studies to Select Pathologic Level in Cervical Spondylotic Myelopathy: Comparative Analysis of Three-Position MRI and Post-Myelographic CT.

AIM: To compare the accuracy of determining pathologic segment between three-position MRI (3P-MRI) and post-myelographic CT (PMCT) in cervical spondylotic myelopathy (CSM) by assessing the degree of inter-observer and intra-observer agreement. MATERIAL AND METHODS: We retrospectively reviewed 3P-MRI and PMCT for the diagnosis of multilevel CSM in 136 patients who underwent surgery. Using an assessment scale, 8 blind observers with various clinical experiences examined 5 parameters: spinal canal narrowing, foraminal stenosis, bony abnormality, intervertebral disc herniation, and nerve root compression. Spinal canal, neural foraminal, spinal cord and disc protrusion diameters were measured. Intra-observer and inter-observer agreement of each image was analyzed. RESULTS: Spinal canal width and foraminal diameter was found to be significantly smaller in 3P-MRI compared to PMCT. No significant differences of cervical cord diameter and the size of disc protrusion measured in 3P-MRI compared to PMCT were observed. Comparing between 3P-MRI and PMCT, disc abnormality and nerve root compression showed better agreement on 3P-MRI, whereas foraminal stenosis and bony lesion showed better agreement on PMCT. CONCLUSION: In the present study, PMCT was still useful in diagnosis of the foraminal stenosis and bony lesion compared to 3P-MRI but showed limitation in disc abnormality and nerve root compression. Even though PMCT may provide valuable additional information in difficult or ambiguous cases, universal standard of 3P-MRI showed higher reliability in detecting pathologic levels in CSM patients.

Ponticulus posticus: Morphometric analysis and Its anatomical Implications for occipito-cervical fusion.

OBJECTIVE: The purpose of this study was to evaluate the morphometric characteristics of ponticulus posticus (PP) and determine the impact of two promising high cervical operations (posterior arch to lateral mass screw fixation (PALMSF) and occipital condyle fixation (OCF)). PATIENTS AND METHODS: We evaluated retrospective data from a total of 2628 head and neck 3-dimensional CT-angiographies (3D-CTA) that did not have bony or vascular abnormalities. The PP anomaly cases were confirmed, then we measured vertebral artery groove height (VAGH), arch to vertebral artery distance (AVD) and posterior arch height (PAH) for PALMSF. We also measured the vertebral artery to occipital bone distance (VOD) for OCF. RESULTS: In 186 patients (7.1%), 227 PP (complete or near complete) were identified and this anomaly was more common in males and on the left side. The mean VAGH and PAH values ranged from 5.0 to 6.0mm and from 7.0 to 8.8mm, respectively. The VAGH value was not statistically different, regardless of the presence of PP, and the feasibility (>4mm) of a safe PALMSF (range, 87.7-100%) was not influenced by PP anomalies. The mean value of VOD in the anomaly side (range, 6.0-8.0mm) was much higher than for normal side (range, 4.2-5.7mm) and the proportion of patients that had a safe OCF (>3.5mm) was also much higher (range, 90.8-96.9%) than for the normal side. CONCLUSIONS: A PP anomaly might have some anatomical feasibility and advantage during PALMSF and OCF, due to the relatively sufficient bony (VAGH) and spatial regions (VOD). However, there are gender differences in anatomical dimensions (VAGH, VOD and AVD); therefore, surgery in female patients should be approached more cautiously in the future.

Effect of unstable surface training on walking ability in stroke patients.

[Purpose] The purpose of this study was to determine the effects of unstable surface training (UST) on walking ability in chronic stroke patients. [Subjects] The subjects were 12 stroke patients who were randomly divided into experimental (n1=6) and control (n2=6) groups. [Methods] The Subjects in both groups performed treadmill training for 30 minutes. The Subjects in the experimental group also performed UST after treadmill training, with the UST being performed for 10 minutes, five times per week, for four weeks. All subjects were evaluated with a 10-meter walk test, Timed Up and Go test and 6-minute walk test. The pared t-test was performed to test the significant differences between before and after the intervention. The independent t-test was conducted to test the significant differences between groups. [Results] Following the intervention, the experimental group showed significant differences in the Timed Up and Go test and 6-minute walk test. [Conclusion] The results of the study suggest that UST is an effective method for improvement of walking ability in chronic stroke patients.