Interlaminar Endoscopic Lumbar Discectomy Using a New 8.4-mm Endoscope and Nerve Root Retractor.

STUDY DESIGN: Surgical technique. OBJECTIVE: Using an 8.4-mm endoscope and endoscopic nerve root retractor, the interlaminar endoscopic lumbar discectomy (IELD) technique is introduced for lumbosacral levels. SUMMARY OF BACKGROUND DATA: Although spine surgeons are familiar with IELD, this technique is only used for L5-S1 disk herniations and requires a wide interlaminar space. METHODS: Using an 8.4 mm-endoscope, high-speed drill, and endoscopic Kerrison punches, a nerve-root retractor facilitated the simultaneous medial retraction of the nerve root and removal of the disk fragment by the instrument's cannula. Clinical parameters such the visual analog scale scores for back and leg pain, modified Macnab criteria, and Oswestry Disability Index were analyzed. RESULTS: A total of 101 patients were enrolled. The visual analog scale scores for back and leg pain significantly decreased from 6.8±2.1 and 7.8±1.5 to 2.0±0.6 and 1.78±1.1, respectively, at the 1-year follow up (P<0.01). The Oswestry Disability Index score significantly improved from 28.6±11.7 to 7.4±2.9 (P<0.01). Ninety-nine patients (97.1%) showed good outcomes. CONCLUSIONS: A new IELD technique and instruments can overcome the drawbacks of existing IELD with adequate bone work and control of the affected nerve root.

Cost-effectiveness of microdiscectomy versus endoscopic discectomy for lumbar disc herniation.

BACKGROUND CONTEXT: Microdiscectomy is a standard technique for the surgical treatment of lumbar disc herniation (LDH). Endoscopic discectomy (ED) is another surgical option that has become popular owing to reports of shorter hospitalization and earlier return to work. No study has evaluated health care costs associated with lumbar discectomy techniques and compared cost-effectiveness. PURPOSE: To assess the cost-effectiveness of four surgical techniques for LDH: microdiscectomy (MD), transforaminal endoscopic lumbar discectomy (TELD), interlaminar endoscopic lumbar discectomy (IELD), and unilateral biportal endoscopic discectomy (UBED). STUDY DESIGN AND SETTING: Retrospective analysis. PATIENT SAMPLE: Patients who underwent either MD or ED for primary LDH with 1-year follow-up between the ages of 20 and 60 years old. OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER). METHODS: Five hundred sixty-five patients aged 20-60 years who underwent treatment using one of the four surgical techniques with at least 1-year follow-up were reviewed. Health care costs were defined as the sum of direct and indirect costs. The former included the covered and uncovered costs of the National Health Insurance from operation to 1-year follow-up; indirect costs included costs incurred by work loss. Direct and indirect costs were evaluated separately. ICER was determined using cost/quality-adjusted life year (QALY). Health care costs and ICER were compared statistically among the four surgical groups. Cost-effectiveness was compared statistically between MD and ED. RESULTS: One hundred fifty-seven patients who underwent TELD, 132 for IELD, 140 for UBED, and 136 for MD were enrolled. The direct costs of TELD, IELD, UBED, and MD were $3,452.2±1,211.5, $3,907.3±895.3, $4,049.2±1,134.6, and $4,302.1±1,028.9, respectively (p<.01). The indirect costs of TELD, IELD, UBED, and MD were $574.5±495.9, $587.8±488.3, $647.4±455.6, and $759.7±491.7, respectively (p<.01). The 1-year QALY gains were 0.208 for TELD, 0.211 for IELD, 0.194 for UBED, and 0.186 for MD. ICER (costs/QALY) was the highest for MD ($34,840.4±25,477.9, p<.01). Compared with MD, ED saved an additional net of $8,064 per QALY (p<.01). There was no significant difference in the ICERs among the three endoscopic techniques. CONCLUSIONS: ED was more cost-effective compared with MD at 1-year follow up.

Comparative study on the period of absolute bed rest of vertebral compression fracture.

OBJECTIVE: As a conservative treatment of compression fractures, absolute bed rest (ABR) for a certain period has been recommended, but no guideline on the period has yet been established. Considering that a long ABR period may adversely affect patients, the difference in prognosis according to the ABR period was investigated in this study. METHODS: A prospective study was conducted who were diagnosed with compression fracture. Groups A and B were put on ABR (one week for group A and two weeks for group B). X-ray images at baseline, 1, 2, 4, and 8 weeks were obtained from both groups, for assessment purposes. RESULTS: The compression rates of both groups were no significant difference at baseline, 1, 2, 4, and 8 weeks. The conditions of 25.9% and 21.2% of the subjects deteriorated in groups A and B, showing no significant difference. Between the groups of age and bone mineral densities (BMD), no significant difference was observed in the incidence of deterioration. In terms of complications development including constipation and other Gastrointestinal problems, voiding difficulty, etc., group A reported 57.4%, and group B, 84.8%, showing a significant difference (p-value=0.001). CONCLUSION: No significant difference in the conservative period was observed between the groups. Group B, however, reported a higher complications development rate than group A. Therefore, a short ABR period may be helpful in the early stage of conservative treatment.

Spinal epidural hematoma related to intracranial hypotension.

A 45-year-old female patient visited the hospital complaining of severe sudden headache and posterior neck pain. The patient did not have any traumatic history or abnormal neurologic finding. The patient had sudden quadriplegia and sensory loss. Cervical spine MRI scan was taken, and the compatible findings to acute epidural hematoma were shown. The emergency operation was performed. After the operation, the patient recovered all motor and senses. As there was CSF leakage in the postoperative wound, this was confirmed by cervical spinal computed tomography (CT). Then lumbar drainage was thus performed. The opening pressure upon lumbar puncture was not measured as it was very low. As a result of continous CSF leakage, dural repair was performed. After the operation, the patient had been discharged without neurologic deficits. In this case, it is sensible to suspect intracranial hypotension as a possible cause of spinal EDH.