Microendoscopy-assisted extraforaminal lumbar interbody fusion for treating single-level spondylodesis.

BACKGROUND: Lumbar interbody fusion is a standard technique for treating degenerative lumbar disorders involving instability. Due to its invasiveness, a minimally invasive technique, extraforaminal lumbar interbody fusion (ELIF), was introduced. On surgically approaching posterolaterally, the posterior muscles and spinal canal are barely invaded. Despite its theoretical advantage, ELIF is technically demanding and has not been popularised. Therefore, we developed a microendoscopy-assisted ELIF (mELIF) technique which was designed to be safe and less invasive. Here, we aimed to report on the surgical technique and clinical results. METHODS: Using a posterolateral approach similar to that of lateral disc herniation surgery, a tubular retractor, 16 or 18 mm in diameter, was placed at the lateral aspect of the facet joint. The facet joint was partially excised, and the disc space was cleaned. A cage and local bone graft were inserted into the disc space. All disc-related procedures were performed under microendoscopy. The spinal canal was not invaded. Bilateral percutaneous screw-rod constructs were inserted and fixed. RESULTS: Fifty-five patients underwent the procedure. The Oswestry Disability Index and visual analogue scale scores greatly improved. Over 90% of the patients obtained excellent or good results based on Macnab's criteria. There were neither major adverse clinical effects nor the need for additional surgery. CONCLUSIONS: mELIF is minimally invasive because the spinal canal and posterior muscles are barely invaded. It produces good clinical results with fewer complications. This technique can be applied in most single-level spondylodesis cases, including those involving L5/S1 disorders.

Clinical Comparison of Unilateral Biportal Endoscopic Laminectomy versus Microendoscopic Laminectomy for Single-Level Laminectomy: A Single-Center, Retrospective Analysis.

BACKGROUND: The purpose of this study was to compare clinical results of microendoscopic laminectomy (MEL) with those of unilateral biportal endoscopic laminectomy (UBEL) in patients with single-level lumbar spinal canal stenosis. METHODS: The subjects consisted of 181 patients who underwent MEL (139 cases) and UBEL (42 cases) who were followed up for at least 6 months. All patients had lumber canal stenosis for 1 level. Outcomes of the patients were assessed with the duration of surgery, the bone resection area in 3-dimensional computed tomography, the facet preservation rates in computed tomography axial imagery, Visual Analog Scale (VAS) for low back pain, the Oswestry Disability Index, and the EuroQol 5-Dimensions questionnaire. RESULTS: The bone resection area in 3-dimensional computed tomography was 1.5 for MEL versus 1.0 cm2 for UBEL (P < 0.05). The facet preservation rates on the advancing side and the opposite side were 78% versus 86% (advancing side: MEL vs. UBEL) and 85% versus 94% (opposite side) (P < 0.05). The VAS (low back pain) score, VAS (leg pain), Oswestry Disability Index, and EuroQol 5-Dimension questionnaire significantly dropped in both groups at the final period (P < 0.05), however, exhibiting no difference between the 2 groups at each period. MEL resulted in greater numbers of complications, including 5 cases of hematoma paralysis, 8 cases of dura injury, 2 cases of reoperation, as opposed to zero cases of hematoma paralysis and only 2 cases of dura injury resulting from UBEL. CONCLUSIONS: The UBEL method is a more useful technique than the MEL method as it requires a smaller bone resection area and produces fewer complications.

Postoperative Outcomes After Transsacral Epiduroscopic Laser Decompression in Japanese Patients: Denervation Therapy for Discogenic Low-Back Pain.

Background: Transsacral epiduroscopic laser decompression (SELD) is a very noninvasive surgery, so it is effective for elderly patients and athletes and is a new and minimally invasive therapeutic technique that may be useful in many patients with discogenic low-back pain (LBP) having high signal intensity zone (HIZ) in magnetic resonance imaging (MRI). We investigated the clinical outcomes of SELD in Japanese patients with discogenic LBP having HIZ as a first trial. Methods: The subjects consisted of 52 patients who underwent SELD and were followed up for at least 6 months. All patients with LBP with HIZ were operative using the SELD technique. Outcomes of the patients were assessed with visual analogue scale (VAS) for LBP, the Oswestry disability index (ODI), and the EuroQol 5 dimension (EQ-5D). Statistical analyses were carried out using a paired t-test. A p-value of <0.05 was considered significant. For statistical analysis, we used the SPSS software program. Results: At 12 months after the procedure, the average VAS score for LBP fell to 1.2 from 5.6 (p-value <0.05). The ODI score also dropped from the preoperative level of 22.3 to 8.8. The EQ-5D score also significantly increased from the preoperative level of 0.865 (SD 0.10) to 0.950 (SD 0.05). Eight cases of intraoperative cervical pain were observed as complications with no cases of hematomas, infections, and postoperative neurosis was observed. Conclusions: SELD provides a novel minimally invasive technique capable of performing multilevel intervertebral surgery. We believe that SELD is an effective method of treating discogenic LBP due to HIZs.

Step-by-Step Sublaminar Approach With a Newly-Designed Spinal Endoscope for Unilateral-Approach Bilateral Decompression in Spinal Stenosis.

OBJECTIVE: Spinal stenosis is increasingly common due to population aging. In elderly patients with lumbar central canal stenosis (LCCS), minimizing muscle damage and bone resection is particularly important. We performed a step-by-step operation with a newly designed spinal endoscope to obtain adequate decompression in patients with spinal stenosis. METHODS: From April 2015 to August 2016, 78 patients (48 males, 30 females) with LCCS (91 segments) underwent endoscopic decompression using a newly designed endoscope system. The inclusion criteria were: (1) neurogenic intermittent claudication with or without radiculopathy, (2) LCCS, and (3) having exhausted conservative treatment (>3 months). The exclusion criteria were: (1) >10° of instability, (2) spondylolisthesis grade II or greater according to the Meyerding criteria, (3) foraminal stenosis, (4) vascular intermittent claudication, (5) infection, and (6) stenosis combined with malignancy. We performed a step-by-step procedure using a newly designed endoscope system for unilateral-approach bilateral decompression. We used the same incision for 2-3 segments, only moving the skin. RESULTS: The mean follow-up was 2.3±1.3 years. Excellent or good results were found according to the MacNab criteria in 85.9% of cases (67 of 78). The visual analogue scale, Japanese Orthopedic Association score, and Oswestry Disability Index showed significant decreases at 1 month, persisting until the 2-year follow-up. Dural tear occurred in 4 cases (5.1%), and patch repair was performed under endoscopy. No patients experienced aggravated instability requiring surgery. CONCLUSION: We obtained good results with endoscopic decompression surgery using a newly designed instrument that minimized muscle and bone damage in elderly patients with spinal stenosis.

A New Angled Chisel for Microendoscopic Decompressive Laminotomy.

STUDY DESIGN: A retrospective comparative series study. OBJECTIVE: The aim of the study was to describe a new angled chisel (NAC) that facilitates the osteotomy in microendoscopic decompressive laminotomy (MEDL), and to analyze the clinical and radiologic outcomes using the tool. SUMMARY OF BACKGROUND DATA: MEDL for lumbar spinal stenosis is a minimally invasive surgery. The paraspinous unilateral approach for bilateral decompression can preserve the posterior structure better than other methods. However, the resection of the medial facet on the approach side is technically difficult because the working space is limited and the retractor is difficult to place properly. Because of these limitations, either the inferior articular process on the approach side tends to be resected excessively, which can lead to facet fracture and instability, or the superior articular process tends to be resected insufficiently, which can result in residual symptoms. The ideal decompression of the medial facet consists of sufficient resection to the deep portion, especially lateral recess of the spinal canal, and adequate facet preservation. Special curved devices to obtain optimal resection have been developed, but these devices have not effectively improved the osteotomy. We developed an NAC to allow an osteotomy at the desired angle. MATERIALS AND METHODS: Forty patients underwent MEDL with the use of NAC (NAC group) and 40 patients underwent the same procedure without the NAC (control group). The osteotomy angle of the medial facet on the approach side and Visual Analogue Scale score were analyzed. RESULTS: The average osteotomy angle of the medial facet was significantly smaller in the NAC group. The radiologic and clinical results were significantly better in the NAC group. CONCLUSIONS: The NAC was a useful tool that sharpens the osteotomy angle of the medial facet and thereby improved the clinical course.

Preperitoneal Suction Technique to Secure the Proper Mesh Position During Laparoscopic Herniorrhaphy.

PURPOSE: Dislocation of the mesh is 1 cause of recurrence after laparoscopic inguinal hernia repair (LIHR). Here, we propose a new procedure, the "preperitoneal cavity suction technique," to confirm mesh position during LIHR under a transabdominal preperitoneal approach (TAPP). PATIENTS AND METHODS: We developed the "preperitoneal cavity suction technique" during LIHR by TAPP, visualizing the mesh through the closed peritoneum by vacuuming up the carbon dioxide and effusion at the preperitoneal cavity using a suction tube inserted through the tunnel from a laterally placed trocar into the preperitoneal space. We applied this technique in adults with inguinal hernias who were scheduled to undergo elective surgery in our hospital between April 2013 and March 2015. RESULTS: In total, 84 lesions were treated in 74 consecutive LIHRs by TAPP. The "preperitoneal cavity suction technique" was applied to 83 lesions. We confirmed appropriate positioning of the mesh for 82 of the 83 lesions (98.8%), with dislocation of the mesh detected in 1 case. In that case, we reopened the peritoneal flap and repositioned the mesh correctly during the operation. No patients complained of pain or a sense of discomfort, and no hematoma was identified around the dissected area or anterior superior iliac spine on the affected side. Mean duration of hospitalization was 2.5 days. No cases of hernia recurrence were observed during follow-up (range, 7 to 31 mo; median, 15 mo). CONCLUSIONS: The "preperitoneal suction technique" seems useful to detect mesh dislocation and has potential to reduce TAPP-related complications.

[Pancreatic Adenosquamous Carcinoma That Developed after Resection of IPMA in the Pancreatic Tail].

Pancreatic adenosquamous carcinoma coexisting with intraductal papillary mucinous neoplasm(IPMN)is extremely rare. We report a rare case of pancreatic adenosquamous carcinoma that developed after resection of intraductal papillary mucinous adenoma(IPMA). A 67-year-old man was suspected of having a pancreatic cystic lesion. MRCP demonstrated a cystic lesion measuring 25mm in the pancreatic tail, which had an enhanced nodule. We therefore diagnosed branch duct type IPMN of the pancreas. Although pancreatic juice cytology did not indicate malignancy, we performed laparoscope-assisted distal pancreatectomy. The reason why the IPMN lesion had an enhanced nodule. The histopathological diagnosis was IPMA without malignancy. One year and 5 months after surgery, blood analysis showed an elevated tumor marker level, and abdominal CT demonstrated a pancreatic head tumor with lymphadenopathy. EUS-FNA was performed and the patient was diagnosed with pancreatic adenosquamous carcinoma based on immunohistochemical staining. We administered chemotherapy with gemcitabine and S-1. After 3 courses of this chemotherapy, the size of the pancreatic tumor and the tumor marker level decreased. The patient achieved a partial response. He is still receiving chemotherapy after 7 courses.

Upper thoracic extralobar pulmonary sequestration with anomalous blood supply from the subclavian artery.

The authors report on a newborn boy with extralobar pulmonary sequestration in the right upper thoracic region. Preoperative angiography showed an anomalous large vessel from the right subclavian artery, supplying the sequestrated lobe. Right thoracotomy was performed to resect the sequestrated lobe, which was diagnosed as extralobar form. This is an extremely rare case of extralobar pulmonary sequestration in which anomalous blood supply from the subclavian artery was seen preoperatively on radiographs. The authors recommend angiographic examination, particularly in case of diagnostic difficulty.

Colonic atresia and Hirschsprung's disease: importance of histologic examination of the distal bowel.

Hirschsprung's disease associated with colonic atresia is rare. A boy with colonic atresia at the hepatic flexure who had a colostomy in the neonatal period suffered from severe constipation after definitive colocolostomy. Hirschsprung's disease was diagnosed with anorectal manometry and rectal mucosal biopsy, and a Duhamel-Ikeda's pull-through procedure was performed. Aganglionosis of the entire distal colon was seen, and intrauterine torsion of the dilated proximal colon followed by necrosis and absorption was suspected as the cause of colonic atresia. Colonic atresia should be generally screened for Hirschsprung's disease with a rectal biopsy. J