A new surgical method to treat intracanal lumbar disc herniation using the unilateral biportal endoscopic transforaminal approach: patient series.

BACKGROUND: Unilateral biportal endoscopic lumbar discectomy (UBELD) is a new minimally invasive spine surgery. The purpose of this study is to describe a new surgical method to treat intracanal lumbar disc herniation (LDH) using the unilateral biportal endoscopic transforaminal approach (UBE-TFA). The first 15 patients who had undergone UBELD for single-level LDH were included in this study. Operative time, intraoperative blood loss, postoperative stay, and intraoperative complications were recorded. The Oswestry Disability Index (ODI), numeric rating scale (NRS) score for leg pain, and modified MacNab criteria were assessed at 3 months postoperatively. OBSERVATIONS: The mean operative time was 52.0 ± 13.8 minutes. The mean intraoperative blood loss was 10.5 ± 10.2 mL. The mean postoperative stay was 1.1 ± 0.3 days. There were no complications. The postoperative mean ODI was significantly improved from 44.9 ± 14.4 to 7.7 ± 11.2 at the final follow-up (p < 0.001). There was a significant decrease in the postoperative mean NRS score for leg pain, from 6.1 ± 1.9 to 0.8 ± 1.3 at the final follow-up (p < 0.001). Based on the modified MacNab criteria, good to excellent results were obtained in 86.7% of the patients. LESSONS: We considered UBELD-TFA as not only one of the promising surgical methods for UBELD, but also a new surgical implementation of the TFA.

Intracranial subarachnoid hemorrhage caused by an aneurysm at the thoracic spinal region: case report and literature review.

Background: The most common cause of intracranial subarachnoid hemorrhage (SAH) is an intracranial aneurysm or other vascular lesion; however, spinal lesions have also been implicated. Furthermore, vascular lesions rarely occur in the thoracolumbar region. We herein presented a case of intracranial SAH caused by an isolated aneurysm in the thoracic spinal artery.Case presentation: A 79-year-old woman developed the sudden onset of headaches in the parietal and occipital regions followed by vomiting. Head computed tomography (CT) scans showed SAH in the basal cistern and around the parietal lobe cortex. Cerebral angiography detected no aneurysm or vascular malformation. Spinal CT on day 1 showed extensive SAH at the posterior surface of the spinal cord, which was the most prominent at the level of T9/10, and spinal angiography subsequently revealed an aneurysm fed by the T10 radicular artery. The aneurysm was resected by T8-10 laminectomy, and the patient recovered with no long-term neurological deficit.Conclusions: A literature review revealed 17 cases of intracranial SAH from thoracolumbar vascular lesions. Most cases resulted in poor functional outcomes, which occurred in the later phase of the disease and may have been avoided with earlier diagnoses and interventions. We suggest whole spine CT as a useful tool for rapid screening of this rare lesion, and is recommended when an initial survey for intracranial lesions does not detect any likely lesions. Furthermore, ventricular reflux on head CT may lead to an accurate diagnosis in the absence of spinal symptoms.

Advantages and disadvantages of posterolateral approach for percutaneous endoscopic lumbar discectomy.

BACKGROUND: Percutaneous endoscopic lumbar discectomy (PELD) is one of the less invasive treatments for lumbar disc herniation (LDH), and has 3 different operative approaches. This study focused on the posterolateral approach (PLA) and investigated the appropriate operative indication. METHODS: PLA was performed in 29 patients with foraminal and extraforaminal LDH. The height and width of the foramen, LDH type, and positional relationship between LDH and the foramen were radiologically evaluated. Foraminoplasty was also performed in 12 cases including those combined with intra-canal LDH or osseous foraminal stenosis. Pre- and postoperative status was evaluated using Numerical Rating Scale (NRS) scores. RESULTS: Patient mean age was 56.8 years; there was single-level involvement at L3/4 (13 cases) and at L4/5 (13 cases). The mean pre- and postoperative NRS scores were 6.1 and 1.8, respectively. Early recurrence developed in a patient who was found to have local scoliosis at the corresponding vertebral level. CONCLUSIONS: PLA can be safely used to treat foraminal and extraforaminal LDH with foraminal height ≥13 mm and foraminal width ≥7 mm. The procedure is effective for preserving the facet joint; however, we should carefully consider the indications when local scoliosis and/or instability are present.

Surgical complications associated with spinal decompression surgery in a Japanese cohort.

The aim of the present study was to identify risk factors for perioperative complications associated with spinal surgery for cervical, thoracic, and lumber spinal stenosis in a Japanese cohort. Patients with spinal stenosis who underwent spinal surgery between 2008 and 2012 were included. Neurological and/or surgical site complications within 30 days of index surgery were retrospectively collected, and the rates of complications were calculated. Using univariate and multivariate logistic regression analyses, risk factors for complications were identified. A total of 364 patients underwent 407 spinal surgeries. Of the 407 surgeries performed, 236 were cervical, 28 were thoracic, and 143 were lumbar surgeries. Ossification of the ligamentum flavum was the most common diagnosis in patients with thoracic stenosis (85%), whereas spinal degenerative stenosis and disc herniation were the two most common diagnoses in patients with cervical and lumbar stenosis. Laminoplasty and laminectomy alone were the two most frequently performed procedures. The rate of complications was greater in patients with thoracic stenosis (36%) than in those with cervical (16%) or lumbar stenosis (13%, p=0.013). After a multivariate analysis, only thoracic stenosis (odds ratio 2.87) remained an independent risk factor for surgical complications. The novel result of the present study was that the level of stenosis in the spine had a significant impact on complications after spinal surgery in a Japanese cohort. The result can be explained by the fact that challenging ossified lesions are a common cause of thoracic stenosis in eastern Asia.

Superficial siderosis: bleeding from the bone marrow after laminectomy for spinal tumor removal.

Superficial siderosis of the CNS is a rare disease characterized by the deposition of hemosiderin in the subpial layers of the CNS as the result of chronic subarachnoid bleeding. The arrest of bleeding is important for preventing the progression of this disease; however, the exact source of bleeding remains unknown in most cases because of a lack of objective surgical data. The authors of this report have described a unique case of superficial siderosis following cervical laminectomy and autograft fusion for the removal of a spinal schwannoma; the bleeding source was verified by intraoperative and histopathological findings. The patient exhibited no obvious neurological deficits, such as hearing loss or cerebellar ataxia, when the superficial siderosis was diagnosed, although there were the social impairments associated with schizophrenia. During repair surgery, the bleeding source was revealed as the bone marrow vasculature of the remaining vertebral arch, and not the fragile vessels at the dural defect or the residual tumor. Chronic bleeding was stopped before the onset of irreversible neurological deficits in this case. Bone marrow exposed to the intrathecal space may represent a chronic bleeding source in patients with superficial siderosis following CNS surgery including laminectomy or craniotomy. The following recommendations have been proposed for superficial siderosis of the CNS from both a preventative and a therapeutic perspective: 1) During CNS surgery, neurosurgeons should make every effort to prevent exposing bone marrow to the intrathecal space to avoid the risk of chronic subarachnoid bleeding. 2) In the case of a large dural defect and pseudomeningocele following CNS surgery, bone marrow around the dural defect should be considered as the bleeding source of superficial siderosis, and such cases should undergo revision surgery before the progression of this disease.