[Comparative analysis of the results of microdiscectomy and minimally invasive transforaminal lumbar interbody fusion in the treatment of adjacent-level intervertebral disc herniations with lumbosacral transitional vertebra in elderly patients.]

The purpose of the study was a comparative analysis the effectiveness of microsurgical discectomy and minimally invasive transforaminal lumbar interbody fusion in the treatment of disk herniation adjacent to the anomaly of the lumbosacral junction segment in elderly patients. The study included 80 elderly patients (over 60 years old), divided into two groups: the 1st-(n=39) who underwent microsurgical discectomy; the 2nd- patients (n=41) operated on using minimally invasive transforaminal interbody fusion and percutaneous transpedicular stabilization (MI-TLIF). For the comparative analysis, we used gender characteristics (gender, age), constitutional characteristics (BMI), degree of physical status according to ASA, intraoperative parameters of interventions and the specificity of postoperative patient management, clinical data, and the presence of complications. Long-term outcomes were assessed at a minimum follow-up of 3 years. As a result, it was found that the use of MI-TLIF allows achieving better long-term clinical outcomes, fewer major complications in comparison with the microsurgical discectomy technique in the treatment of disc herniation adjacent to the anomaly of the lumbosacral junction segment in elderly patients.

The use of a minimally invasive integrated endoscopic system to perform hemilaminectomies in chondrodystrophic dogs with thoracolumbar intervertebral disc extrusions.

Introduction: The objective was to evaluate the use of a minimally invasive surgical (MIS) approach to perform hemilaminectomies in chondrodystrophic dogs with thoracolumbar intervertebral disc extrusions (IVDE). Additionally, we aimed to evaluate the degree of soft tissue trauma using the endoscopic procedure compared to the standard open approach. Methods: Eight client-owned dogs presented to the Colorado State University Veterinary Teaching Hospital with acute onset thoracolumbar IVDE were included in this study. This was a prospective, randomized case-series. Patients were assigned to undergo an endoscopic (group 1; n = 4) or a standard open approach (group 2; n = 4) for a hemilaminectomy. A post-operative MRI was performed in all cases. Results: Conversion to an open approach was not necessary for any case in group 1. All cases had adequate spinal cord decompression on post-operative MRI. There was no significant difference in soft tissue changes noted on post-operative MRI between the two groups. Discussion: The MIS approach to hemilaminectomies in chondrodystrophic dogs with thoracolumbar IVDE can successfully be performed to decompress the neural tissue and appears to lead to similar clinical outcomes in the early postoperative period compared to the standard open approach. Larger studies are needed to determine the potential advantages of the MIS technique compared to the standard open approach in veterinary medicine.

Diagnostic and prognostic significance of miR-486-5p in patients who underwent minimally invasive surgery for lumbar spinal stenosis.

BACKGROUND: This study aimed to investigate the expression and clinical value of microRNA miR-486-5p in diagnosing lumbar spinal stenosis (LSS) patients and predicting the clinical outcomes after minimally invasive spinal surgery (MISS) in LSS patients, and the correlation of miR-486-5p with inflammatory responses in LSS patients. METHODS: This study included 52 LSS patients, 46 patients with lumbar intervertebral disk herniation (LDH) and 42 healthy controls. Reverse transcription quantitative PCR was used to detect miR-486-5p expression. The ability of miR-486-5p to discriminate between different groups was evaluated by receiver-operating characteristic analysis. The visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scores at 6 months postoperatively were used to reflect the clinical outcomes of LSS patients. Enzyme-linked immunosorbent assay was used to measure the levels of inflammatory factor [interleukin-1ß (IL-1ß) and tumor necrosis factor-α (TNF-α)]. The correlation of miR-486-5p with continuous variables in LSS patients was evaluated by the Pearson correlation coefficient. RESULTS: Expression of serum miR-486-5p was upregulated in LSS patients and had high diagnostic value to screen LSS patients. In addition, serum miR-486-5p could predict the 6-month clinical outcomes after MISS therapy in LSS patients. Moreover, serum miR-486-5p was found to be positively correlated with the levels of IL-1ß and TNF-α in patients with LSS. CONCLUSION: miR-486-5p, increased in LSS patients, can function as an indicator to diagnose LSS and a predictive indicator for the clinical outcomes after MISS therapy in LSS patients. In addition, miR-486-5p may regulate LSS progression by modulating inflammatory responses.

Prospective Randomized Comparison of Minimally Invasive Tlif versus Open Tlif: Clinical Effectiveness and Restoration of Working Capacity in Railway Workers.

STUDY DESIGN: Randomized Clinical Trial. OBJECTIVE: To compare the clinical efficacy and restoration of working capacity after MI (minimally invasive)-TLIF and O (open)-TLIF in railway workers with lumbar degenerative disease. METHODS: 83 patients, who were indicated for two-level lumbar decompression and fusion were randomly assigned to one of two groups: group 1 (n = 44) had MI-TLIF procedure and group 2 (n = 39) had O-TLIF procedure. The functional status was assessed using SF-36, ODI and VAS for back and leg pain, preoperatively, at discharge, and at 3, 6, and 12 months postoperatively. MRI and CT were obtained 1-year follow-up. The percentage of patients who returned to work at 1-year, work intensity and the time to return to work post-operatively were analyzed. RESULTS: At 1-year follow-up, the MI-TLIF group had significantly better ODI, VAS and SF-36 scores compared to the O-TLIF group. The postoperative MRIs revealed a statistically significantly less multifidus muscle atrophy in the MI group compared to the Open group. At 1-year follow-up, a comparable fusion ratio between MI group and Open group was recorded. After MI-TLIF procedure, depending on the workload, patients had a statistically significantly earlier return to work (P < .05) and statistically significantly higher return to work rate compared with the O-TLIF group (P < .05). CONCLUSIONS: The use of two-level MI-TLIF in railway workers has made it possible to significantly improve long-term clinical results, reduce the risk of surgical complications, muscle atrophy and time to return to work compared to O-TLIF.

Influence of various pilot hole profiles on pedicle screw fixation strength in minimally invasive and traditional spinal surgery: a comparative biomechanical study.

Despite advancements in pedicle screw design and surgical techniques, the standard steps for inserting pedicle screws still need to follow a set of fixed procedures. The first step, known as establishing a pilot hole, also referred to as a pre-drilled hole, is crucial for ensuring screw insertion accuracy. In different surgical approaches, such as minimally invasive or traditional surgery, the method of creating pilot holes varies, resulting in different pilot hole profiles, including variations in size and shape. The aim of this study is to evaluate the biomechanical properties of different pilot hole profiles corresponding to various surgical approaches. Commercially available synthetic L4 vertebrae with a density of 0.16 g/cc were utilized as substitutes for human bone. Four different pilot hole profiles were created using a 3.0 mm cylindrical bone biopsy needle, 3.6 mm cylindrical drill, 3.2-5.0 mm conical drill, and 3.2-5.0 mm conical curette for simulating various minimally invasive and traditional spinal surgeries. Two frequently employed screw shapes, namely, cylindrical and conical, were selected. Following specimen preparation, screw pullout tests were performed using a material test machine, and statistical analysis was applied to compare the mean maximal pullout strength of each configuration. Conical and cylindrical screws in these four pilot hole configurations showed similar trends, with the mean maximal pullout strength ranking from high to low as follows: 3.0 mm cylindrical biopsy needle, 3.6 mm cylindrical drill bit, 3.2-5.0 mm conical curette, and 3.2-5.0 mm conical drill bit. Conical screws generally exhibited a greater mean maximal pullout strength than cylindrical screws in three of the four different pilot hole configurations. In the groups with conical pilot holes, created with a 3.2-5.0 mm drill bit and 3.2-5.0 mm curette, both conical screws exhibited a greater mean maximal pullout strength than did cylindrical screws. The strength of this study lies in its comprehensive comparison of the impact of various pilot hole profiles commonly used in clinical procedures on screw fixation stability, a topic rarely reported in the literature. Our results demonstrated that pilot holes created for minimally invasive surgery using image-guided techniques exhibit superior pullout strength compared to those utilized in traditional surgery. Therefore, we recommend prioritizing minimally invasive surgery when screw implantation is anticipated to be difficult or there is a specific need for stronger screw fixation. When opting for traditional surgery, image-guided methods may help establish smaller pilot holes and increase screw fixation strength.

What is the effect of preoperative depression on outcomes after minimally invasive surgery for adult spinal deformity? A prospective cohort analysis.

OBJECTIVE: Depression has been implicated with worse immediate postoperative outcomes in adult spinal deformity (ASD) correction, yet the specific impact of depression on those patients undergoing minimally invasive surgery (MIS) requires further clarity. This study aimed to evaluate the role of depression in the recovery of patients with ASD after undergoing MIS. METHODS: Patients who underwent MIS for ASD with a minimum postoperative follow-up of 1 year were included from a prospectively collected, multicenter registry. Two cohorts of patients were identified that consisted of either those affirming or denying depression on preoperative assessment. The patient-reported outcome measures (PROMs) compared included scores on the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society Outcomes Questionnaire (SRS-22), SF-36 physical component summary, SF-36 mental component summary (MCS), EQ-5D, and EQ-5D visual analog scale. RESULTS: Twenty-seven of 147 (18.4%) patients screened positive for preoperative depression. The nondepressed cohort had an average of 4.83 levels fused, and the depressed cohort had 5.56 levels fused per patient (p = 0.267). At 1-year follow-up, 10 patients still reported depression, representing a 63% decrease. Postoperatively, both cohorts demonstrated improvement in their PROMs; however, at 1-year follow-up, those without depression had statistically better outcomes based on the EQ-5D, MCS, and SRS-22 scores (p < 0.05). Patients with depression continued to experience higher NRS leg scores at 1-year follow-up (3.63 vs 2.22, p = 0.018). After controlling for covariates, the authors found that depression significantly impacted only 1-year follow-up MCS scores (ß = 8.490, p < 0.05). CONCLUSIONS: Depressed and nondepressed patients reported similar improvements after MIS surgery, except MCS scores were more likely to improve in nondepressed patients.

Trends in surgical management of spinal metastases in a Singaporean tertiary referral center: a 17-year retrospective review.

Introduction: Surgical treatment is increasingly the treatment of choice in cancer patients with epidural spinal cord compression and spinal instability. There has also been an evolution in surgical treatment with the advent of minimally invasive surgical (MIS) techniques and separation surgery. This paper aims to investigate the changes in epidemiology, surgical technique, outcomes and complications in the last 17 years in a tertiary referral center in Singapore. Methods: This is a retrospective study of 383 patients with surgically treated spinal metastases treated between January 2005 to January 2022. Patients were divided into 3 groups, patients treated between 2005 - 2010, 2011-2016, and 2017- 2021. Demographic, oncological, surgical, patient outcome and survival data were collected. Statistical analysis with univariate analysis was performed to compare the groups. Results: There was an increase in surgical treatment (87 vs 105 vs 191). Lung, Breast and prostate cancer were the most common tumor types respectively. There was a significant increase in MIS(p<0.001) and Separation surgery (p<0.001). There was also a significant decrease in mean blood loss (1061ml vs 664 ml vs 594ml) (p<0.001) and total transfusion (562ml vs 349ml vs 239ml) (p<0.001). Group 3 patients were more likely to have improved or normal neurology (p=<0.001) and independent ambulatory status(p=0.012). There was no significant change in overall survival. Conclusion: There has been a significant change in our surgical practice with decreased blood loss, transfusion and improved neurological and functional outcomes. Patients should be managed in a multidisciplinary manner and surgical treatment should be recommended when indicated.

Management of Super-refractory Postoperative Lumbar Cerebrospinal Fluid Leak: A Case Report and Review of the Literature.

One well-documented risk of spinal surgery is cerebrospinal fluid (CSF) leak in the immediate postoperative period. While the majority of CSF leaks occur due to an obvious intraoperative dural tear, several reports have documented delayed CSF leakage from occult intraoperative dural tears. There is a paucity of published literature regarding the true incidence of dural tears in minimally invasive spinal surgery. Furthermore, the types of dural tears that require closure are poorly understood. According to the limited existing literature available, the recommended treatment of dural tears includes primary repair, subarachnoid drainage catheters, and blood patches. However, there are no distinct treatment guidelines between the different etiologies of CSF leakage. The most important aspect in the management of CSF leakage is prevention, including preoperative risk assessment and meticulous intraoperative manipulation. One emerging treatment strategy is to alter the pressure gradient in a manner that stops CSF leakage. This method is based on one of two mechanisms: direct suture or augmented closure with dural substitute material and either reducing the subarachnoid fluid pressure or increasing the epidural space pressure. Bed rest is a key element in the treatment of persistent CSF leaks, as it can reduce the lumbar CSF pressure, thereby preventing CSF leakage. We describe the challenging case of a persistent CSF leak despite multiple attempts at direct repair, as well as our management strategies. Understanding the proper positioning techniques to reduce leakage is crucial for proper management, and orthopedic surgeons, neurosurgeons, and neurointensivists may consider being more aggressive in treating persistent CSF leaks.

A spatial registration method based on 2D-3D registration for an augmented reality spinal surgery navigation system.

BACKGROUND: In order to provide accurate and reliable image guidance for augmented reality (AR) spinal surgery navigation, a spatial registration method has been proposed. METHODS: In the AR spinal surgery navigation system, grayscale-based 2D/3D registration technology has been used to register preoperative computed tomography images with intraoperative X-ray images to complete the spatial registration, and then the fusion of virtual image and real spine has been realised. RESULTS: In the image registration experiment, the success rate of spine model registration was 90%. In the spinal model verification experiment, the surface registration error of the spinal model ranged from 0.361 to 0.612 mm, and the total average surface registration error was 0.501 mm. CONCLUSION: The spatial registration method based on 2D/3D registration technology can be used in AR spinal surgery navigation systems and is highly accurate and minimally invasive.

Ten-step minimally invasive slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation.

BACKGROUND: Unilateral laminotomy for bilateral decompression (ULBD) is a MIS surgical technique that offers safe and effective decompression of lumbar spinal stenosis (LSS) with a long-term resolution of symptoms. Advantages over conventional open laminectomy include reduced expected blood loss, muscle damage, mechanical instability, and less postoperative pain. The slalom technique combined with navigation is used in multi-segmental LSS to improve the workflow and effectiveness of the procedure. METHODS: We outline ten technical steps to achieve a slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation. In a retrospective case series, we included patients with multi-segmental LSS operated in our institution using the sULBD between 2020 and 2022. The primary outcome was a reduction in pain measured by Visual Analogue Scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI). RESULTS: In our case series (N = 7), all patients reported resolution of initial symptoms on an average follow-up of 20.71 ± 9 months. The average operative time and length of hospital stay were 196.14 min and 1.67 days, respectively. On average, VAS (back pain) was 4.71 pre-operatively and 1.50 on long-term follow-up of an average of 19.05 months. VAS (leg pain) decreased from 4.33 to 1.21. ODI was reported as 33% pre-operatively and 12% on long-term follow-up. CONCLUSION: The sULBD with navigation is a safe and effective MIS surgical procedure and achieves the resolution of symptoms in patients presenting with multi-segmental LSS. Herein, we demonstrate the ten key steps required to perform the sULBD technique. Compared to the standard sULBD technique, the incorporation of navigation provides anatomic localization without exposure to radiation to staff for a higher safety profile along with a fast and efficient workflow.

Clinical Outcome of Full Endoscopic Trans Kambin's Triangle Lumbar Interbody Fusion: A Systematic Review.

Full-endoscopic (FE) lumbar interbody fusion (LIF) is now a widely used type of minimally invasive surgery (MIS). Although FE-LIF includes LIF with foraminoplasty via a Kambin's triangle approach (FE-KLIF) and LIF with foraminotomy via an interlaminar approach, these techniques are rarely discussed separately. This review evaluates the outcomes and complications of FE-KLIF reported in the literature. The PubMed, Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting the outcomes of FE-KLIF. Of 464 publications assessed, 11 met our inclusion criteria. Although the most frequently treated level was L4/5, L5/S1 was also treated. FE-KLIF was performed under local anesthesia and sedation or under epidural anesthesia without general anesthesia. Visual analog scale and Oswestry Disability Index scores were improved postoperatively in all uncontrolled studies; however, there was no significant difference in these scores in studies that compared FE-KLIF with posterior LIF (PLIF) or MIS-transforaminal LIF (TLIF). There was also no significant difference in the fusion rate between FE-KLIF and PLIF or MIS-TLIF. In terms of complications, although there were no reports of hematoma, dural tear and surgical site infection were reported in 1 paper each, with transient nerve disorders reported in 5 studies (frequency, 1.8%-23.5%). This review indicates that FE-KLIF is a feasible and viable surgical option for lumbar degenerative disease. However, the amount and level of evidence is low for the studies included in this review, and the data on long-term outcomes remain limited.

Clinical Outcomes of Percutaneous Endoscopic Interlaminar Discectomy Using a Laminotomy Technique With Modified Stepwise Local Anesthesia.

BACKGROUND: Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in minimally invasive treatment of lumbar disc herniation (LDH) but is difficult to perform because of the narrow interlaminar window and painful for the patient. Therefore, further research is needed to find a safe and effective method to facilitate the development of PEID. METHODS: Seventy-one consecutive patients with LDH who underwent PEID using a laminotomy technique with modified stepwise local anesthesia between July 2017 and June 2020. All patients were followed up for at least 6 months. Preoperative patient demographics, perioperative outcomes, and clinical outcomes were recorded. Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and Macnab criteria were used to assess clinical results. RESULTS: All patients underwent successful surgery under local anesthesia with no conversions to open surgery. The mean operation time was 79.56 ± 32.78 minutes and the average hospital stay was 6.44 ± 2.98 nights. Before surgery, the mean VAS score was 5.66 ± 1.206 and the mean ODI score was 68.41 ± 6.634; the respective scores were decreased to 0.65 ± 0.635 and 7.06 ± 1.594 after 4 weeks of follow-up (P < 0.001) and to 0.56 ± 0.691 and 7.11 ± 0.176 after 6 months (P < 0.001). According to the MacNab criteria, the outcome was excellent in 60 cases and good in the remaining 11 cases. CONCLUSIONS: PEID via a laminotomy technique with stepwise local anesthesia is safe and effective for L4-5 and L5-S1 LDH.

Augmented Reality in Minimally Invasive Spinal Surgery: A Narrative Review of Available Technology.

INTRODUCTION: Spine surgery has undergone significant changes in approach and technique. With the adoption of intraoperative navigation, minimally invasive spinal surgery (MISS) has arguably become the gold standard. Augmented reality (AR) has now emerged as a front-runner in anatomical visualization and narrower operative corridors. In effect, AR is poised to revolutionize surgical training and operative outcomes. Our study examines the current literature on AR-assisted MISS, synthesizes findings, and creates a narrative highlighting the history and future of AR in spine surgery. MATERIAL AND METHODS: Relevant literature was gathered using the PubMed (Medline) database from 1975 to 2023. Pedicle screw placement models were the primary intervention in AR. These were compared to the outcomes of traditional MISS RESULTS: We found that AR devices on the market show promising clinical outcomes in preoperative training and intraoperative use. Three prominent systems were as follows: XVision, HoloLens, and ImmersiveTouch. In the studies, surgeons, residents, and medical students had opportunities to operate AR systems, showcasing their educational potential across each phase of learning. Specifically, one facet described training with cadaver models to gauge accuracy in pedicle screw placement. AR-MISS exceeded free-hand methods without unique complications or contraindications. CONCLUSIONS: While still in its infancy, AR has already proven beneficial for educational training and intraoperative MISS applications. We believe that with continued research and advancement of this technology, AR is poised to become a dominant player within the fundamentals of surgical education and MISS operative technique.

Characterizing and Improving Nomenclature for Reporting Lumbar Interbody Fusion Techniques.

OBJECTIVE: Lumbar interbody fusion (LIF) techniques have seen impressive innovation in recent years, leading to an expansion of the LIF lexicon. This study systematically analyzes LIF nomenclature in contemporary literature and proposes a standardized classification system for reporting LIF terminology. METHODS: A search query was conducted through the PubMed database using "lumbar fusion OR lumbar interbody fusion." A total of 1455 articles were identified, and 605 references to LIF were recorded. Following a systematic review of the terminology, we developed a LIF reporting guidelines that capture the existing LIF nomenclature while avoiding redundant or ambiguous terminology. RESULTS: The most referenced anatomical approaches were transforaminal (43.0%), followed by posterior (25.0%), lateral (19.7%), and anterior (10.9%). Overall, there were 72 unique ways to describe LIF. Unique prefixes were recorded by approach (posterior: 26; lateral: 13; anterior: 3). Forty unique prefixes/suffixes overlapped in their usage. "MI" (14.4%), "MIS" (38.1%), and "MISS" (0.6%) all referenced a minimally invasive approach. "O" (12.5%), "CO" (1.3%), and "TO" (1.3%) all described open techniques. "Endo" (0.6%), "Endoscopic-assisted" (1.3%), and "PE" (1.9%) all referenced endoscopic-assisted procedures. CONCLUSIONS: The current LIF nomenclature contains many unique LIF terms that were found to be inconsistently defined, redundant, or ambiguous. We propose the standardization of a 4-part naming system which highlights the crucial parts of LIF: (1) intraoperative repositioning, (2) patient position, (3) anatomical approach, and (4) orientation of the surgical corridor to the psoas muscles.

Pure endoscopic minimally invasive surgery with a non­expandable tubular retractor for intradural extramedullary spinal tumors.

Minimally invasive spinal surgery (MISS) for intradural extramedullary (IDEM) spinal tumors is a safe and effective surgical strategy. Currently, various tubular retractors are widely used in the MISS of IDEM spinal tumors, primarily relying on microscopic visualization. To the best of the authors' knowledge, there is no report of pure endoscopic surgery with parallel non-expandable tubular retractors for IDEM spinal lesions. The present study reports a case series of IDEM spinal tumors that were treated via pure endoscopic MISS with a parallel non-expandable tubular retractor. The extent of tumor resection was evaluated by comparing preoperative and postoperative magnetic resonance imaging (MRI). The initial and follow-up clinical conditions were assessed according to the visual analog scale for pain and the modified McCormick scale for neurological status. Postoperative MRI demonstrated that all cases had achieved a gross total resection. After the operation, the clinical symptoms of all patients were significantly improved and there were no serious postoperative complications. At the initial follow-up, the pain experienced by the patients was significantly reduced or had even disappeared, and the neurological deficit was improved by at least one grade on the modified McCormick scale. The present report indicates that pure endoscopic MISS with a parallel non-expandable tubular retractor may be an effective and safe surgical strategy for IDEM spinal tumor resection.

Virtual and Augmented Reality in Spine Surgery: A Systematic Review.

BACKGROUND: Augmented reality (AR) and virtual reality (VR) implementation in spinal surgery has expanded rapidly over the past decade. This systematic review summarizes the use of AR/VR technology in surgical education, preoperative planning, and intraoperative guidance. METHODS: A search query for AR/VR technology in spine surgery was conducted through PubMed, Embase, and Scopus. After exclusions, 48 studies were included. Included studies were then grouped into relevant subsections. Categorization into subsections yielded 12 surgical training studies, 5 preoperative planning, 24 intraoperative usage, and 10 radiation exposure. RESULTS: VR-assisted training significantly reduced penetration rates or increased accuracy rates compared to lecture-based groups in 5 studies. Preoperative VR planning significantly influenced surgical recommendations and reduced radiation exposure, operating time, and estimated blood loss. For 3 patient studies, AR-assisted pedicle screw placement accuracy ranged from 95.77% to 100% using the Gertzbein grading scale. Head-mounted display was the most common interface used intraoperatively followed by AR microscope and projector. AR/VR also had applications in tumor resection, vertebroplasty, bone biopsy, and rod bending. Four studies reported significantly reduced radiation exposure in AR group compared to fluoroscopy group. CONCLUSIONS: AR/VR technologies have the potential to usher in a paradigm shift in spine surgery. However, the current evidence indicates there is still a need for 1) defined quality and technical requirements for AR/VR devices, 2) more intraoperative studies that explore usage outside of pedicle screw placement, and 3) technological advancements to overcome registration errors via the development of an automatic registration method.

Training and Credentialing Standards for Minimally Invasive Spinal Surgery Techniques: Results of a Survey.

BACKGROUND: BACKGROUND: The controversy continues on how to best become proficient in contemporary minimally invasive spinal surgery techniques (MISST). Postgraduate training programs typically lag behind the innovation. Other subspecialty spine care providers often compete with spine surgeons particularly when they do not offer the treatments needed by their patients. The public debate centers around who should be taught and credentialed in providing surgical spine care. OBJECTIVES: The purpose of this study was to conduct an opinion survey amongst spine care providers regarding the learning curve of MISST and which credentialing standards should be established. SETTING: Surgeon online opinion survey sent by email, and chat groups in social media networks, including WeChat, WhatsApp, and LinkedIn. METHODS: Surgeons were asked the following questions: 1) Do you think MISS is harder to learn compared to open surgery? 2) Do you perform MISS? 3) What type of MISS do you perform? 4) If you perform endoscopic surgery, which approach(es)/technique(s) do you employ? 5) In your opinion, where does the innovation take place? 6) Where should MISST be taught? 7) Do you think mastering the MISST learning curve and surgeon skill level affect patient outcomes? 8) Which credentialing criteria do you recommend? Demographic data of responding surgeons, including age, postgraduate training and years from graduation, and practice setting, were also obtained. Descriptive statistics were employed to count the responses and compared to the surgeon's training using statistical package SPSS Version 27.0 (IBM Corporation, Armonk, NY). RESULTS: The online survey was viewed by 806 surgeons, started by 487, and completed by 272, yielding a completion rate of 55.9%. Orthopedic surgeons comprised 52.6% (143/272) of respondents, followed by 46.7% (127/272) neurosurgeons, and 0.7% pain management physicians (2/272). On average, respondents had graduated from a postgraduate training program 15.43 ± 10.13 years. Nearly all respondents employed MISST (252/272; 92.8%) and thought that proficiency in MISST affects patients' outcomes (270/272; 98.2%). Some 54.1% (146/270) opined that MISS is more challenging to learn than traditional open spine surgery. Preferred credentialing criteria were 1) number of MISST cases (87.5%; 238/272), b) skill level (69.9%; 190/272), and c) proficiency assessment (59.9%; 163/272). A case log review (42.3%; 116/272) or an oral examination (26.1%; 71/272) was not favored by surgeons. Surgeons reported academia (43.4%; 116/267) and private practice (41.2%; 110/267) as the centers of innovation. Only 15.4% (41/267) of respondents opined that industry was the main driver over innovation. LIMITATIONS: Geographical and cultural biases may impact the opinions of responding surgeons. CONCLUSIONS: Respondents preferred case volume, skill level, and proficiency assessment as credentialing criteria. Surgeons expect academic university programs and specialty societies to provide the necessary training in novel MISST while working with governing boards to update the certification programs.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis.

BACKGROUND CONTEXT: Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence. PURPOSE: The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database. DESIGN: This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases. PATIENT SAMPLE: A total of 1277 noninstrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients. OUTCOME MEASURES: The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake. METHODS: All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching. RESULTS: In the nonpropensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS. CONCLUSIONS: FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

The Utility of 'Minimal Access and Separation Surgery' in the Management of Metastatic Spine Disease.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To compare outcomes of percutaneous pedicle screw fixation (PPSF) to open posterior stabilization (OPS) in spinal instability patients and minimal access separation surgery (MASS) to open posterior stabilization and decompression (OPSD) in metastatic spinal cord compression (MSCC) patients. METHODS: We analysed patients who underwent surgery for thoracolumbar metastatic spine disease (MSD) from Jan 2011 to Oct 2017. Patients were divided into minimally invasive spine surgery (MISS) and open spine surgery (OSS) groups. Spinal instability patients were treated with PPSF/OPS with pedicle screws. MSCC patients were treated with MASS/OPSD. Outcomes measured included intraoperative blood loss, operative time, duration of hospital stay and ASIA-score improvement. Time to initiate radiotherapy and perioperative surgical/non-surgical complications was recorded. Propensity scoring adjustment analysis was utilised to address heterogenicity of histological tumour subtypes. RESULTS: Of 200 eligible patients, 61 underwent MISS and 139 underwent OSS for MSD. There was no significant difference in baseline characteristics between MISS and OSS groups. In the MISS group, 28 (45.9%) patients were treated for spinal instability and 33 (54.1%) patients were treated for MSCC. In the OSS group, 15 (10.8%) patients were treated for spinal instability alone and 124 (89.2%) were treated for MSCC. Patients who underwent PPSF had significantly lower blood loss (95 mL vs 564 mL; P < .001) and surgical complication rates(P < .05) with shorter length of stay approaching significance (6 vs 19 days; P = .100) when compared to the OPS group. Patients who underwent MASS had significantly lower blood loss (602 mL vs 1008 mL) and shorter length of stay (10 vs 18 days; P = .098) vs the OPSD group. CONCLUSION: This study demonstrates the benefits of PPSF and MASS over OPS and OPSD for the treatment of MSD with spinal instability and MSCC, respectively.

Posterolateral full-endoscopic debridement and irrigation is effective in treating thoraco-lumbar pyogenic spondylodiscitis, except in cases with large abscess cavities.

PURPOSE: To determine the efficacy and poor prognostic factors of posterolateral full-endoscopic debridement and irrigation (PEDI) surgery for thoraco-lumbar pyogenic spondylodiscitis. METHODS: We included 64 patients (46 men, 18 women; average age: 63.7 years) with thoracic/lumbar pyogenic spondylodiscitis who had undergone PEDI treatment and were followed up for more than 2 years. Clinical outcomes after PEDI surgery were retrospectively investigated to analyze the incidence and risk factors for prolonged and recurrent infection. RESULTS: Of 64 patients, 53 (82.8%) were cured of infection after PEDI surgery, and nine (17.2%) had prolonged or recurrent infection. Multivariate analysis demonstrated that significant risk factors for poor prognosis included a large intervertebral abscess cavity (P = 0.02) and multilevel intervertebral infections (P < 0.05). CONCLUSION: PEDI treatment is an effective, minimally invasive procedure for pyogenic spondylodiscitis. However, a large intervertebral abscess space could cause instability at the infected spinal column, leading to prolonged or recurrent infection after PEDI. In cases with a large abscess cavity with or without vertebral bone destruction, endoscopic drainage alone may have a poor prognosis, and spinal fixation surgery could be considered.