Full endoscopic surgery for thoracic pathology: an assessment of supportive evidence.

In the last five years, surgeons have applied endoscopic transforaminal surgical techniques mastered in the lumbar spine to the treatment of thoracic pathology.The aim of this systematic review was to collate the available literature to determine the place and efficacy of full endoscopic approaches used in the treatment of thoracic disc prolapse and stenosis.An electronic literature search of PubMed, Embase, the Cochrane database and Google Scholar was performed as suggested by the Preferred Reporting Items for Systematic Review and Meta-analysis statements. Included were any full-text articles referring to full endoscopic thoracic surgical procedures in any language.We identified 17 patient series, one cohort study and 13 case reports with single or of up to three patients.Although the majority included disc pathology, 11 papers related cord compression in a proportion of cases to ossification of the ligamentum flavum or posterior longitudinal ligament. Two studies described the treatment of discitis and one reported the use of endoscopy for tumour resection.Where reported, excellent or good outcomes were achieved for full endoscopic procedures in a mean of 81% of patients (range 46-100%) with a complication rate of 8% (range 0-15%), comparing favourably with rates reported after open discectomy (anterior, posterolateral and thoracoscopic) or by endoscopic tubular assisted approaches. Twenty-one of the 31 author groups reported use of local anaesthesia plus sedation rather than general anaesthesia, providing 'self-neuromonitoring' by allowing patients to respond to cord and/or nerve stimuli. Cite this article: EFORT Open Rev 2021;6:50-60. DOI: 10.1302/2058-5241.6.200080.

Multi-level spine endoscopy: A review of available evidence and case report.

In the last ten years, there has been an exponential increase in endoscopic spinal surgery practice.With improvements in equipment quality and the availability of high definition camera systems, cervical endoscopic disc resection is now a viable alternative to anterior cervical decompression and fusion (ACDF) or disc arthroplasty for the treatment of disc prolapse and low grade stenosis.Based on the current literature, there is now strong evidence to support the use of transforaminal endoscopic approaches for the treatment of thoracic disc prolapse.There is now level I evidence to show that outcomes following transforaminal endoscopic discectomy (TED) are at least equivalent to those after open microdiscectomy, with an expected shorter operating time, lesser requirement for analgesia, reduced duration of post-operative disability, more rapid rehabilitation and lower costs of care. However, it should be recognised that there is a significant learning curve for TED.New endoscopic techniques with interlaminar approaches allow the decompression of central and lateral recess stenosis. Future developments will facilitate vision and access to the spine with 3D imaging and robotics at the forefront.We present a case report of whole spine endoscopic decompression to illustrate the potential of endoscopic surgery at all spinal levels. Cite this article: EFORT Open Rev 2017;2:317-323. DOI: 10.1302/2058-5241.2.160087.

Long-Term Follow-up of Arthrodesis vs Total Joint Arthroplasty for Hallux Rigidus.

BACKGROUND: The optimal operative management of hallux rigidus is still a matter for debate among surgeons. Despite arthrodesis widely considered to be the gold standard treatment, many surgeons advocate arthroplasty as a suitable alternative. There are, however, few long-term or high-quality studies evaluating these modalities. We present the 15-year follow-up of a randomized controlled trial. METHODS: This data is the follow-up to the original study published in 2005. In the original study, 63 patients (77 toes) were recruited to and randomized to have either metatarsophalangeal joint (MTPJ) arthrodesis or arthroplasty. The primary outcome measure was a decrease in pain on a visual analog scale (VAS) at 24 months. In the present study, data were available for all surviving patients (52 patients, 66 toes). Data were collected in the form of satisfaction scores, VAS for pain, the VAS foot and ankle and survivorship data. RESULTS: The results of the original study demonstrated that pain relief was greater following arthrodesis at 2 years. At 15 years, patients with an arthrodesis experienced less pain and were more satisfied compared to those with an arthroplasty. No functional differences were seen between these 2 groups. There were more revisions in the arthroplasty group. CONCLUSION: Despite the hope of better function, less pain, and greater satisfaction from MTPJ replacement, this was not found in our patient population. The long-term results of our study showed that arthrodesis outperformed arthroplasty. If an arthroplasty failed, then salvage was likely to be technically difficult, with significant potential for complications. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Cost-effectiveness of steroid (methylprednisolone) injections versus anaesthetic alone for the treatment of Morton's neuroma: economic evaluation alongside a randomised controlled trial (MortISE trial).

BACKGROUND: Morton's neuroma is a common foot condition affecting health-related quality of life. Though its management frequently includes steroid injections, evidence of cost-effectiveness is sparse. So, we aimed to evaluate whether steroid injection is cost-effective in treating Morton's neuroma compared with anaesthetic injection alone. METHODS: We undertook incremental cost-effectiveness and cost-utility analyses from the perspective of the National Health Service, alongside a patient-blinded pragmatic randomised trial in hospital-based orthopaedic outpatient clinics in Edinburgh, UK. Of the original randomised sample of 131 participants with Morton's neuroma (including 67 controls), economic analysis focused on 109 (including 55 controls). Both groups received injections guided by ultrasound. We estimated the incremental cost per point improvement in the area under the curve of the Foot Health Thermometer (FHT-AUC) until three months after injection. We also conducted cost-utility analyses using European Quality of life-5 Dimensions-3 Levels (EQ-5D-3L), enhanced by the Foot Health Thermometer (FHT), to estimate utility and thus quality-adjusted life years (QALYs). RESULTS: The unit cost of an ultrasound-guided steroid injection was £149. Over the three months of follow-up, the mean cost of National Health Service resources was £280 for intervention participants and £202 for control participants - a difference of £79 [bootstrapped 95% confidence interval (CI): £18 to £152]. The corresponding estimated incremental cost-effectiveness ratio was £32 per point improvement in the FHT-AUC (bootstrapped 95% CI: £7 to £100). If decision makers value improvement of one point at £100 (the upper limit of this CI), there is 97.5% probability that steroid injection is cost-effective. As EQ-5D-3L seems unresponsive to changes in foot health, we based secondary cost-utility analysis on the FHT-enhanced EQ-5D. This estimated the corresponding incremental cost-effectiveness ratio as £6,400 per QALY. Over the recommended UK threshold, ranging from £20,000 to £30,000 per QALY, there is 80%-85% probability that steroid injection is cost-effective. CONCLUSIONS: Steroid injections are effective and cost-effective in relieving foot pain measured by the FHT for three months. However, cost-utility analysis was initially inconclusive because the EQ-5D-3L is less responsive than the FHT to changes in foot health. By using the FHT to enhance the EQ-5D, we inferred that injections yield good value in cost per QALY. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13668166.

Decompression and paraspinous tension band: a novel treatment method for patients with lumbar spinal stenosis and degenerative spondylolisthesis.

BACKGROUND CONTEXT: Prior studies have demonstrated the superiority of decompression and fusion over decompression alone for the treatment of lumbar degenerative spondylolisthesis with spinal stenosis. More recent studies have investigated whether nonfusion stabilization could provide durable clinical improvement after decompression and fusion. PURPOSE: To examine the clinical safety and effectiveness of decompression and implantation of a novel flexion restricting paraspinous tension band (PTB) for patients with degenerative spondylolisthesis. STUDY DESIGN: A prospective clinical study. PATIENT SAMPLE: Forty-one patients (7 men and 34 women) aged 45 to 83 years (68.2 ± 9.0) were recruited with symptomatic spinal stenosis and Meyerding Grade 1 or 2 degenerative spondylolisthesis at L3-L4 (8) or L4-L5 (33). OUTCOME MEASURES: Self-reported measures included visual analog scale (VAS) for leg, back, and hip pain and the Oswestry Disability Index (ODI). Physiologic measures included quantitative and qualitative radiographic analysis performed by an independent core laboratory. METHODS: Patients with lumbar degenerative spondylolisthesis and stenosis were prospectively enrolled at four European spine centers with independent monitoring of data. Clinical and radiographic outcome data collected preoperatively were compared with data collected at 3, 6, 12, and 24 months after surgery. This study was sponsored by the PTB manufacturer (Simpirica Spine, Inc., San Carlos, CA, USA), including institutional research support grants to the participating centers totaling approximately US $172,000. RESULTS: Statistically significant improvements and clinically important effect sizes were seen for all pain and disability measurements. At 24 months follow-up, ODI scores were reduced by an average of 25.4 points (59%) and maximum leg pain on VAS by 48.1 mm (65%). Back pain VAS scores improved from 54.1 by an average of 28.5 points (53%). There was one postoperative wound infection (2.4%) and an overall reoperation rate of 12%. Eighty-two percent patients available for 24 months follow-up with a PTB in situ had a reduction in ODI of greater than 15 points and 74% had a reduction in maximum leg pain VAS of greater than 20 mm. According to Odom criteria, most of these patients (82%) had an excellent or good outcome with all except one patient satisfied with surgery. As measured by the independent core laboratory, there was no significant increase in spondylolisthesis, segmental flexion-extension range of motion, or translation and no loss of lordosis in the patients with PTB at the 2 years follow-up. CONCLUSIONS: Patients with degenerative spondylolisthesis and spinal stenosis treated with decompression and PTB demonstrated no progressive instability at 2 years follow-up. Excellent/good outcomes and significant improvements in patient-reported pain and disability scores were still observed at 2 years, with no evidence of implant failure or migration. Further study of this treatment method is warranted to validate these findings.

Creation of an ovine model of progressive structural lordo-scoliosis using a unilateral laminar tether.

PURPOSE: To characterise changes in vertebral dimension in an ovine model of scoliosis and determine whether a reproducible curvature could be created that would be suitable for future testing of curve modifying surgical implants. METHODS: At a mean age of 5 weeks, 28 Scottish blackface sheep were anaesthetised. A 4 mm braided synthetic tape was laid under the left lamina of T5 and L1 and tightened to 'hand' tension. A scoliosis was then created by binding the six lowest ribs on the same side just distal to their rib angles and resecting a segment from each of the opposite ribs. Radiographs were taken at 4 weekly intervals, and CT images at 2, 5 and 7 months post tethering, to determine multi-planar curve progression. 20 animals were assessed at age 3 months, 12 at 41 weeks and 10 at 1 year with comparisons to five control animals. RESULTS: A significant bi-planar deformity was produced in all animals (scoliosis 32 ± 13º and lordosis 53 ± 21º 2 months post tethering; mean ± SD, n = 22). During the next 5 months the scoliosis decreased slightly (p = 0.08) but the sagittal deformity remained static: 21 ± 18° and 53 ± 19°, respectively (n = 12). The values at 7 months were associated with a mean 6 ± 4º rotational deformity. There was approximately twice as much growth in the right anterior aspects of the apical vertebrae as in the left posterior. CONCLUSIONS: With appropriate care it was possible to obtain a reproducible curvature in immature sheep. The methods described are suitable for use in studies of growth modulation and other spinal devices.

Modulation of spinal shape with growth following implantation of a novel surgical implant.

PURPOSE: First, to determine whether scoliosis development could be limited or reversed by growth when a novel modular hinged implant was fixed to the convexity of a scoliosis created by contralateral rib and laminar tethering and unilateral rib resection in a sheep model. Second, to assess the effect and performance of the implant in normal non-tethered sheep. METHODS: At 5 weeks, 20 Scottish Blackface lambs underwent surgery to create a right sided scoliosis by (i) tethering the left lamina of T5-L1 and the left lower six ribs and (ii) resecting a segment of their right lower six ribs [1, 2]. Twelve weeks later, through an antero-lateral thoracotomy, a mobile bi-planar hinged implant was inserted onto the right side of the spine of eight animals (group 1). For comparison, 12 sheep were tethered only but had no implant insertion (group 2). In addition, seven had no tethering but were implanted (group 3) and normal growth patterns were observed in five that had no surgery (group 4). Curve progression was assessed by plain radiography and CT over a 1-year period. RESULTS: Before implant insertion the trial animals had a scoliosis of 35º ± 16º and a lordosis of 44º ± 20º (n = 8, mean ± SD). Surgery immediately reduced these values to 25º ± 14º, p < 0.01 and 35º ± 18º, p < 0.001, with scoliosis continuing to decrease during the next three months. Spinal flexibility was retained. In the un-tethered sheep, a scoliosis of 10º ± 6º was created on the opposite side to the implant (p < 0.05) with no significant change in alignment in the sagittal plane (1º ± 6º). The implant did not cause any adverse effect on growth or affect neurological function. CONCLUSIONS: In the un-tethered animals the effect of the implant was to create a scoliotic deformity and in the tethered to improve deformity while maintaining spinal motion. We believe that the results are promising and that devices of similar construct may be of use in children with scoliosis, potentially changing current methods of clinical care.

Methylprednisolone injections for the treatment of Morton neuroma: a patient-blinded randomized trial.

BACKGROUND: Morton neuroma is a common cause of neuralgia affecting the web spaces of the toes. Corticosteroid injections are commonly administered as a first-line therapy, but the evidence for their effectiveness is weak. Our primary research aim was to determine whether corticosteroid injection is an effective treatment for Morton neuroma compared with an anesthetic injection as a placebo control. METHODS: We performed a pragmatic, patient-blinded randomized trial set within hospital orthopaedic outpatient clinics in Edinburgh, United Kingdom. One hundred and thirty-one participants with Morton neuroma (mean age, fifty-three years; 111 [85%] female) were randomized to receive either corticosteroid and anesthetic (1 mL methylprednisolone [40 mg] and 1 mL 2% lignocaine) or anesthetic alone (2 mL 1% lignocaine). An ultrasonographic image was obtained before treatment, and injections were performed with the needle placed under ultrasonographic guidance. The primary outcome was the difference in patient global assessment of foot health between the two groups at three months after injection. This was measured with use of a 100-unit visual analog scale (VAS) anchored by "best imaginable health state" and "worst imaginable health state." RESULTS: Compared with the control group, global assessment of foot health in the corticosteroid group was significantly better at three months (mean difference, 14.1 scale points [95% confidence interval, 5.5 to 22.8 points]; p = 0.002). The difference between the groups was also significant at one month. Significant and nonsignificant improvements associated with the corticosteroid injection were observed for measures of pain, function, and patient global assessment of general health at one and three months after injection. The size of the neuroma as determined by ultrasonography did not significantly influence the treatment effect. CONCLUSIONS: Corticosteroid injections for Morton neuroma can be of symptomatic benefit for at least three months.

Transforaminal endoscopic spinal surgery: the future 'gold standard' for discectomy? - A review.

BACKGROUND: Lumbar disc prolapse is common and the primary method of care in most centres is still open discectomy facilitated by microscope or loupe magnification and illumination. Hospitalisation may be less than 24 h, but post-operative pain usually requires an overnight stay. This review describes transforaminal endoscopic spinal surgery (TESS) using HD-video technology, that is generally performed as a day case procedure under sedation or light general anaesthesia, and collates the evidence comparing the technique to microdiscectomy. METHODS: The method of TESS is described and an electronic literature search performed to identify papers reporting clinical outcomes. International data were translated where necessary and proceedings' abstracts included. In addition, papers held by the authors and colleagues in personal libraries were carefully cross-referenced to the obtained database. RESULTS: Analysis of the data supports the use of a transforaminal endoscopic approach to the lumbar intervertebral disc and suggests that outcomes following surgery are at least equivalent to those following microdiscectomy. Significant cost-savings in terms of in-patient stay may be generated. In addition, there is also some evidence supporting endoscopic surgery for relief of foraminal stenosis. CONCLUSION: Based on current evidence there are good arguments supporting a more wide-spread adoption of transforaminal endoscopic surgery for the treatment of lumbar disc prolapse with or without foraminal stenosis.

An aid to the explanation of surgical risks and complications: the International Spinal Surgery Information Sheet.

STUDY DESIGN: Presentation and analysis of a patient information sheet. OBJECTIVE: To produce an evidence-based information sheet that will serve as an aide-memoire to the process of taking informed consent prior to spinal surgery. SUMMARY OF BACKGROUND DATA: Consent for a surgical intervention is the end of a process of discussion between the surgeon and the patient. It is essential that the patient has been provided with sufficient information to make an informed judgment as to whether the benefits of a proposed procedure will outweigh its risks. METHODS: We searched MEDLINE, the Cochrane database of systematic reviews and personal libraries for articles reporting complications of the surgical treatment of spinal diseases with particular reference to the most commonly treated conditions. A draft document was drawn up referencing the odds of specific complications. This was circulated to the National Health Service Scotland Central Legal Office for scrutiny and to an English language expert at the University of Edinburgh for translation to lay English. Finally, the document was issued to 50 patients in the outpatient clinic and scored on visual analog scales (VAS) for the ease of understanding, usefulness, and length. RESULTS: The product of this project was a two-page A4 sheet, with the front page outlining information applicable to spinal surgery "in general" and a back page detailing all common risks, relating to a headline procedure, that a Court of Law would expect a surgeon to discuss. The patients' VAS score (0-10) for "ease of understanding" was 8.8 ± 1.3 and for "usefulness" 8.9 ± 1.0 (means ± SD). Forty-three of 50 patients (86%) indicated that the length of the document was "just right" and seven (14%) of them that it was "too long." CONCLUSION: The ISSiS is user friendly and can be employed as a tool in the process of obtaining consent.

Surgical interventions for lumbar disc prolapse: updated Cochrane Review.

STUDY DESIGN: An updated Cochrane Review. OBJECTIVES: To assess the effects of surgical interventions for the treatment of lumbar disc prolapse. SUMMARY OF BACKGROUND DATA: Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions. METHODS: Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007. RESULTS: Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy. CONCLUSION: Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.

Foraminal stenosis and single-level degenerative disc disease: a randomized controlled trial comparing decompression with decompression and instrumented fusion.

STUDY DESIGN: A randomized controlled trial with 5-year outcome data. OBJECTIVE: To compare clinical outcomes following spinal decompression (Group 1) with those following decompression and instrumented posterolateral fusion (Group 2) and decompression and instrumented posterolateral fusion plus transforaminal interbody fusion (TLIF) (Group 3). SUMMARY OF BACKGROUND DATA: Decompression is frequently advocated for the relief of nerve root stenosis in the presence of degenerate disc disease. It is uncertain if spinal fusion is also necessary. MATERIALS AND METHODS: Following completion of a standardized physiotherapy program, 44 patients with single-level disc disease were randomly assigned to 1 of 3 surgical groups. In those patients undergoing instrumentation, segmental pedicle screw fixation was used to stabilize the spine. Titanium interbody cages filled with autologous bone were inserted into patients in Group 3. Spinal disability, quality of life, and pain were assessed before surgery, and then at 1, 2, and 5 years by an independent researcher. RESULTS: At 2 years, 82% of the patients were pain free or moderately improved. Disability (Low Back Outcome Score and Roland Morris index) were both better in Group 1, but only Low Back Outcome Score was better in Group 2 (P < 0.05). By 5 years, although patients in all 3 groups showed some improvements in all the ratings used (Low Back Outcome Score, SF-36 Physical Functioning, and Roland Morris score), only Group 1 patients showed significant changes in all 3 outcomes (P < 0.05). There was no difference in any score between groups (P > 0.05). Two had secondary surgery for adjacent level stenosis (Group 2 and 3). One patient (Group 1) underwent subsequent lateral mass fusion for chronic pain. No patient required revision surgery for instrumentation failure, cage displacement, or pseudarthrosis. Evidence of at least unilateral lateral mass bone graft incorporation was evident in 95% of Groups 2 and 3. CONCLUSIONS: The results are encouraging in that almost all patients had improved by 5 years. However, it is a concern that no significant additional benefit has been noted from the more complex surgery. This suggests that patients are optimally treated by decompression alone, with the proviso that further operations may be required.

Surgery for degenerative lumbar spondylosis: updated Cochrane Review.

STUDY DESIGN: An updated Cochrane review. OBJECTIVE: To review current scientific evidence on the effectiveness of surgical interventions for degenerative lumbar spondylosis. SUMMARY OF BACKGROUND DATA: There is still limited scientific evidence on spinal surgery. METHODS: Use of standard Cochrane review methods to analyze all randomized controlled trials published to March 31, 2005. RESULTS: A total of 31 randomized controlled trials were identified. Most of the earlier trials reported mainly surgical outcomes; more of the recent trials also reported patient-centered outcomes of pain or disability. There is still very little information on occupational outcomes or long-term outcomes beyond 2-3 years. Seven heterogeneous trials on spondylolisthesis, spinal stenosis, and nerve compression permitted limited conclusions. There were two new trials on fusion that showed conflicting results. One trial showed that fusion gave better clinical outcomes than conventional physiotherapy, and the other showed that fusion was no better than a modern exercise and rehabilitation program. There were 8 trials that showed that instrumented fusion produces a higher fusion rate, but any improvement in clinical outcomes is probably marginal. CONCLUSIONS: No conclusions are possible about the relative effectiveness of anterior, posterior, or circumferential fusion. The preliminary results of three small trials of intradiscal electrotherapy suggest it is ineffective, except possibly in highly selected patients. Preliminary data from three trials of disc arthroplasty do not permit firm conclusions.

Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial.

BACKGROUND: Arthrodesis is the current treatment for end-stage hallux rigidus, although there are many reports advocating total joint replacement arthroplasty. The aim of this randomized controlled trial was to evaluate clinical outcomes after first metatarsophalangeal joint (MTPJ) arthrodesis and replacement arthroplasty. METHODS: Between November, 1998, and January 2001, 63 patients between the ages of 34 and 77 years, with unilateral or bilateral MTPJ arthritis were recruited and randomly selected to have either MTPJ arthrodesis or arthroplasty. Twenty-two patients (38 toes) had arthrodesis and 27 patients (39 toes) had arthroplasty. A single surgeon performed all surgery. The primary outcome measure determining successful surgery was a decrease in pain as measured on a Visual Analogue Scale (VAS). Functional outcome was assessed at 6 months and 1 and 2 years. Cost data were simultaneously collected. RESULTS: At 24 months, pain improved in both groups (p < 0.001), but there were significantly greater improvements after arthrodesis (p = 0.01). All 38 arthrodeses united at a mean dorsiflexion angle of 26 degrees, with few complications. In contrast, in the arthroplasty group, six of the 39 inserted implants had to be removed because of phalangeal component loosening. In the remainder the range of motion gained was poor, and the patients tended to bear weight on the outer border of their foot. The cost ratio was 2:1 in favor of arthrodesis. CONCLUSIONS: Outcomes after arthrodesis were better than those after arthroplasty. The results were partially attributable to an unacceptably high incidence of loosening of the phalangeal components, which resulted in removal of the implants. However, even when data from the failures were excluded, arthrodesis was clearly preferred by most patients.