Transforaminal endoscopic thoracic discectomy with foraminoplasty for the treatment of thoracic disc herniation.

BACKGROUND: Symptomatic thoracic disc herniation (TDH) is a rare clinical entity and surgical intervention for it is even more uncommon. Despite several surgical techniques being described for thoracic discectomy, considering the unique surgical challenges, none of them have been accepted universally. Minimally invasive techniques have brought in a paradigm shift in the management of cervical/lumbar spinal disorders and similar techniques have been extrapolated to the thoracic region too. The purpose of this paper is to describe our technique, surgical experience, and the clinical results of transforaminal endoscopic thoracic discectomy (TETD). METHODS: Consecutive patients who underwent TETD (2001-2018) were reviewed. Patients who had a minimum of 6 months of follow-up, and without cervical and lumbar spine surgery or trauma during the follow-up period were included in the study. TETD was performed in patients who presented with symptomatic disc herniation of the thoracic spine and did not respond to conservative treatments. Patients with calcified disc herniation or concomitant ossification of the posterior longitudinal ligament (OPLL) were excluded. Under local anesthesia and intravenous sedation, a 4.7-mm endoscope (TESSYS, Joimax GmbH, Germany) was introduced via transforaminal approach with foraminoplasty using reamer. Patient outcome was evaluated using visual analogue scale (VAS) and Oswestry disability index (ODI) scores. Patient satisfaction was measured using Macnab's criteria. RESULTS: Ninety-two consecutive patients (mean age was 48.9 years, 57 males) who underwent TETD from 2001 to 2018 met the inclusion criteria. Patients underwent surgery at different levels: 16 patients for T2-3 to T5-6 level, 41 cases for T6-7 to T8-9, and 35 patients for T9-10 to T12-L1. During follow-up for an average of 38.4 months, all patients showed a significant improvement of pain (7.6 to 1.6 in VAS and 68.2 vs. 13.2 for ODI, P<0.05 for both). There was one patient who had transient motor weakness. CONCLUSIONS: TETD for soft, paramedian or lateral symptomatic TDH is a feasible and effective minimally invasive treatment option with favorable clinical results.

Percutaneous Endoscopic Thoracic Discectomy in the Upper and Midthoracic Spine: A Technical Note.

Despite the successful application of percutaneous endoscopic thoracic discectomy (PETD), its technical feasibility and outcomes for symptomatic upper and midthoracic disc herniation have not been reported yet. The purpose of this article was to evaluate the feasibility of the percutaneous transforaminal endoscopic approach to remove disc herniations in the upper and midthoracic spine. Fourteen consecutive patients (mean age, 42.4 years; 12 males, 2 females) who underwent PETD were included in the analysis. The procedure was performed under local anesthesia and intravenous sedation using the standard endoscopy instrument set. The transforaminal approach combined with foraminoplasty was used to access the herniated areas. Treatment outcomes were evaluated using visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified MacNab criteria. Four discectomies were performed at T2-3, 5 at T3-4, and 5 at T5-6. The mean follow-up period was 43.4 months, and all patients showed statistically significant postoperative improvement (VAS: 7.3 to 2.3, ODI: 53.5 to 16.9, p<0.05 for all). No serious complications were reported during follow-up. PETD for upper and midthoracic disc herniation is a feasible and effective minimally invasive treatment option with favorable clinical results.

Microscopic Anterior Neural Decompression Combined with Oblique Lumbar Interbody Fusion-A Technical Note.

BACKGROUND: Minimally invasive oblique lumbar interbody fusion (OLIF) techniques generally rely on deformity correction to achieve indirect neural decompression. However, indirect neural decompression will not always be sufficient. Thus, a second procedure, such as posterior direct decompression, will be added for full decompression, increasing the surgical morbidity and healthcare costs. We have described a technique of direct anterior microscopic neural decompression combined with OLIF. METHODS: We report our surgical technique of anterior lumbar neural microscopic decompression with OLIF with patients in the lateral position. We also report the cases of 3 patients treated from March 2018 to June 2018. RESULTS: Three patients underwent anterior microscopic neural decompression combined with OLIF in the lateral position. All 3 patients achieved clinically and radiologically significant neural decompression and deformity correction. No perioperative complications developed. CONCLUSION: Direct anterior microscopic neural decompression is feasible and safe in selected patients undergoing OLIF.

Cervical Myelopathy Secondary to Combined Ossification of Ligamentum Flavum and Posterior Longitudinal Ligament-A Case Report.

In the cervical spine, the combined ossification of the ligamentum flavum (OLF) and posterior longitudinal ligament is rarely seen. Patients are usually treated with cervical laminectomy or laminoplasty with OLF resection. In most of the cases, OLF is adhered to the dura and there is a risk of dural tear or cerebrospinal fluid (CSF) leakage during its resection. In this case report, the authors present results of laminectomy with debulking instead of complete excision of OLF for spinal cord decompression in a cervical myelopathy case in which OLF was adhered to the dura. A 69-year-old man presented with insidious onset weakness in bilateral lower limbs and unsteady gait, which he had experienced 1 month. He has a history of neck pain with left upper limb radiation for the last 2 years. Magnetic resonance imaging showed C5-6 severe central canal stenosis with underlying myelomalacia. Computed tomography showed ossification posterior longitudinal ligament and OLF contributing to severe central canal stenosis at the C5-6 level. The patient underwent C4-C6 laminectomy, debulking of OLF, posterior instrumentation, and fusion with autogenous bone graft from C3 to C6. A histological specimen showed osseous tissue within the ligamentum flavum. After surgery the patient's symptoms improved and no recurrence was observed at 4 years after surgery. The symptoms of myelopathy were successfully treated with debulking instead of complete excision of OLF, thus reducing the risk of dural tear or CSF leakage.

Interlaminar Percutaneous Endoscopic Lumbar Discectomy: Rotate and Retract Technique.

BACKGROUND: Interlaminar percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique to treat soft disc herniation. However, the currently used single working channel does not allow for safe nerve root retraction. This study aims to describe the rotate and retract technique for safe nerve root retraction during L5-S1 interlaminar PELD. METHODS: A total of 17 patients who underwent interlaminar PELD with the rotate and retract technique between November 2016 and August 2017 were retrospectively evaluated. Both pre- and postoperative visual analog scale (VAS) scores (back and leg) and Oswestry Disability Index (ODI) scores were used for clinical assessment. RESULTS: The mean preoperative VAS scores for back and leg pain were 3.84 ± 1.15 (range, 2-6) and 8.7 ± 0.2 (range, 8-10), respectively. The mean preoperative ODI score was 64.2 ± 13.2 (range, 48-90). The mean VAS scores for back and leg pain decreased to 1.24 ± 1.34 (range, 0-6) and 1.15 ± 0.65 (range, 0-4), respectively, at the last follow-up (P < 0.001). The mean ODI score also improved to 13.2 ± 5.1 (range, 9-29) at the last follow-up (P < 0.001). CONCLUSIONS: The rotate and retract technique for interlaminar PELD is an effective maneuver for the treatment of L5-S1 disc herniations in selected patients if performed by experienced surgeons.

Correction to: Cervical pedicle screw instrumentation is more reliable with O-arm-based 3D navigation: analysis of cervical pedicle screw placement accuracy with O-arm-based 3D navigation.

Unfortunately, the second author name of the above-mentioned article was incorrectly published in original publication. The complete correct name is given below: Hamid Rahmatullah Bin Abd Razak. The original article has been corrected.

Cervical pedicle screw instrumentation is more reliable with O-arm-based 3D navigation: analysis of cervical pedicle screw placement accuracy with O-arm-based 3D navigation.

PURPOSE: Despite proven biomechanical superiority and resultant superior clinical outcomes, pedicle instrumentation in cervical spine is not widely practiced due to technical difficulties, steep learning curve, and possible potential catastrophic complications due to screw misplacement. This study was undertaken with the purpose to evaluate the feasibility, accuracy, and complications of cervical pedicle screw instrumentation solely using O-arm-based 3D navigation technology. METHODS: Prospectively maintained data from a single-surgeon case series were retrospectively analyzed. All the patients had undergone cervical pedicle instrumentation under O-arm 3D navigation. Screw placement accuracy was analyzed and compared among different vertebral levels and also between different patient groups. RESULTS: A total of 241 cervical pedicle screws were inserted in 44 patients. Out of the 241 screws, 197 (81.74%) were inserted at the level of C3-C6 vertebrae with nearly equal distribution among the 4 vertebrae, followed by 32 (13.28%) and 12 (4.98%) screws at C2 and C7 vertebrae, respectively. After the analysis of screw placement as per Gertzbein classification, the overall breach rates were found to be 7.05% (17 screws) with 52.94% (10 screws) Grade I, 47.06% (7 screws) Grade II, and nil Grade III screw breaches. CONCLUSION: The use of O-arm-based intra-operative 3D scans for navigation can make cervical pedicle screw placement reliable. High accuracy and better intra-operative control can increase surgeon's confidence in using cervical pedicle instrumentation on more regular basis. These slides can be retrieved under Electronic Supplementary Material.

Extradural hemangioma mimicking a dumbbell nerve sheath tumor in the thoracolumbar spine: Case report.

BACKGROUND: Extradural hemangiomas are rare, have varied and challenging clinical presentations, and require special considerations from the management point of view. CASE DESCRIPTION: A 70-year-old female presented with back pain that was ultimately attributed to a thoracolumbar extra-dural "dumbbell" hemangioma. Following surgical resection, the patient did well. CONCLUSION: Extradural hemangiomas may present as spinal extradural soft tissue masses that must be differentiated from dumbbell neurofibroma.

Ultrasound monitoring of fracture healing: is this the end of radiography in fracture follow-ups?

OBJECTIVE: To compare the efficacy of ultrasonography (US) versus radiography (XR) in monitoring fracture healing. DESIGN: Prospective diagnostic follow-up study. SETTING: Department of Orthopaedics, Level II trauma center. PATIENTS: Forty-eight acute closed tibial mid diaphysis fracture (OTA 42-A and B) treated by closed reduction and internal fixation with a reamed statically locked tibial interlocking nail between October 2011 and October 2012. INTERVENTION: Evaluation of fracture healing using both US and XR at 2 week intervals. MAIN OUTCOME MEASUREMENTS: Ultrasonographic criterion for fracture healing was set as progressive appearance of periosteal callus along with progressive decrease in visibility of nail. Radiographic criterion for fracture union was set as the appearance of bridging callus across all 4 cortices. RESULTS: Thirty-eight of 48 fractures achieved union, 6 developed a delayed union, whereas 4 went onto nonunion. It was observed that using the above-stated criteria, fracture union was diagnosed at an average of 2 weeks earlier with US as compared with XR. Four of the 6 delayed unions and all nonunions declared themselves much earlier on US versus XR. CONCLUSIONS: Ultrasonography can provide valuable early information about union and predict delayed and nonunions at an earlier time interval than standard plain radiographs. LEVEL OF EVIDENCE: Diagnostic level II. See Instructions for authors for a complete description of levels of evidence.