A Comparative Study of Endoscopic versus Percutaneous Epidural Neuroplasty in Lower Back Pain: Outcomes at Six-Month Follow Up.

Background and Objectives: Endoscopic epidural neuroplasty (EEN) facilitates adhesiolysis through direct epiduroscopic visualization, offering more precise neural decompression than that exhibited by percutaneous epidural neuroplasty (PEN). We aimed to compare the effects of EEN and PEN for 6 months after treatment with lower back and radicular pain in patients. Methods: This retrospective study compared the visual analog scale (VAS) and Oswestry disability index (ODI) scores in patients with low back and radicular pain who underwent EEN or PEN with a steering catheter. The medical records of 107 patients were analyzed, with 73 and 34 undergoing EEN and PEN, respectively. Results: The VAS and ODI scores decreased at all time points after EEN and PEN. VAS and ODI scores decreased more in the EEN group than those in the PEN group at 1 day and 1- and 6-months post-procedure, indicating superior pain relief for both lower back and radicular pain through EEN. Conclusions: EEN is a superior treatment of pain control than PEN in lower back and radicular pain patients.

Personalized Interventional Surgery of the Lumbar Spine: A Perspective on Minimally Invasive and Neuroendoscopic Decompression for Spinal Stenosis.

Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.

The Changing Environment in Postgraduate Education in Orthopedic Surgery and Neurosurgery and Its Impact on Technology-Driven Targeted Interventional and Surgical Pain Management: Perspectives from Europe, Latin America, Asia, and The United States.

Personalized care models are dominating modern medicine. These models are rooted in teaching future physicians the skill set to keep up with innovation. In orthopedic surgery and neurosurgery, education is increasingly influenced by augmented reality, simulation, navigation, robotics, and in some cases, artificial intelligence. The postpandemic learning environment has also changed, emphasizing online learning and skill- and competency-based teaching models incorporating clinical and bench-top research. Attempts to improve work-life balance and minimize physician burnout have led to work-hour restrictions in postgraduate training programs. These restrictions have made it particularly challenging for orthopedic and neurosurgery residents to acquire the knowledge and skill set to meet the requirements for certification. The fast-paced flow of information and the rapid implementation of innovation require higher efficiencies in the modern postgraduate training environment. However, what is taught typically lags several years behind. Examples include minimally invasive tissue-sparing techniques through tubular small-bladed retractor systems, robotic and navigation, endoscopic, patient-specific implants made possible by advances in imaging technology and 3D printing, and regenerative strategies. Currently, the traditional roles of mentee and mentor are being redefined. The future orthopedic surgeons and neurosurgeons involved in personalized surgical pain management will need to be versed in several disciplines ranging from bioengineering, basic research, computer, social and health sciences, clinical study, trial design, public health policy development, and economic accountability. Solutions to the fast-paced innovation cycle in orthopedic surgery and neurosurgery include adaptive learning skills to seize opportunities for innovation with execution and implementation by facilitating translational research and clinical program development across traditional boundaries between clinical and nonclinical specialties. Preparing the future generation of surgeons to have the aptitude to keep up with the rapid technological advances is challenging for postgraduate residency programs and accreditation agencies. However, implementing clinical protocol change when the entrepreneur-investigator surgeon substantiates it with high-grade clinical evidence is at the heart of personalized surgical pain management.

Inside-Out Approach of Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: A Detailed Technical Description, Rationale and Outcomes.

Although lumbar stenosis was recognized as a contraindication for endoscopic spine surgery in the past, the advancement in endoscopic system design and development of approach techniques and strategies now enabled the endoscopic spine surgeons to manage all types of lumbar stenosis safely and more effectively. A full-endoscopic lumbar technique for surgical management of spinal canal stenosis is now used today in many advanced spine centers around the world as one of their standard procedures which can be done under general, regional, local anesthesia with sedation. In this technical report, we described in detail the inside-out approach of performing lumbar endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD) and retrospectively reviewed hospital records of 127 patients who underwent the approach from December 2018 to March 2019 to address 1 level lumbar spinal stenosis and determined its outcome after 12-month follow-up period. Perioperative outcomes, operation time, length of hospital stay, and surgical complications were recorded and analyzed. The cross-sectional area of the thecal sac at the operated level was measured. The visual analogue scale (VAS) was assessed preoperatively, 1 month, and 12 months as well as the Oswestry Disability Index (ODI). The data were statistically analyzed (using SPSS ver. 17.0). The inside-out approach LE-ULBD was shown to effect statistically significant improvement in the VAS of leg and back pain as well as the ODI. It is a familiar, safe, and effective way of performing spinal stenosis decompression with good reproducible outcomes.

Percutaneous Stenoscopic Lumbar Decompression with Paramedian Approach for Foraminal/Extraforaminal Lesions.

The lumbar foramen is affected by different degenerative diseases, including extraforaminal disc herniation, foraminal stenosis (FS), and degenerative or spondylolytic spondylolisthesis. The purpose of this study was to describe percutaneous stenoscopic lumbar decompression with a paramedian approach (para-PSLD) for foraminal/extraforaminal lesions. All operative procedures were performed using a complete uniportal endoscopic instrument system. The para-PSLD can be easily applied to patients with FS and narrow disc space or facet joint hypertrophy. The anatomical view of a para-PSLD is similar to that of a conventional open surgery and allows for good visualization of the foraminal/extraforaminal areas. We suggest that para-PSLD is an alternative and minimally invasive procedure to treat degenerative lumbar foraminal/extraforaminal stenoses.

Endoscopic Rescue Technique for Iatrogenic Sacroiliac Joint Syndrome Caused by Sextant Percutaneous Pedicle Screw Fixation System.

BACKGROUND: The Sextant percutaneous pedicle screw fixation system is a commonly used technique. In this system, the pedicle screw and the sharp rod are placed through stab incisions. The unique mechanism of action of this system may cause unprecedented adverse effects, such as iatrogenic sacroiliac (SI) joint syndrome. CASE DESCRIPTION: A patient presented with iatrogenic SI joint syndrome caused by the rod of the Sextant system at the L4-L6 level causing ilium irritation and dynamic SI joint instability. The patient was treated with an endoscopy-based technique. This is the first report of endoscopic treatment for iatrogenic SI joint syndrome as an adverse effect resulting from use of the Sextant system. CONCLUSIONS: Surgeons need to be aware of iatrogenic SI joint syndrome using the Sextant system when performing percutaneous pedicle screw fixation. An endoscopy-based technique may be an effective alternative to conventional corrective surgery when treating iatrogenic SI joint syndrome using the Sextant system.

Therapeutic Feasibility of Full Endoscopic Decompression in One- to Three-Level Lumbar Canal Stenosis via a Single Skin Port Using a New Endoscopic System, Percutaneous Stenoscopic Lumbar Decompression.

STUDY DESIGN: This retrospective study involved 450 consecutive cases of degenerative lumbar stenosis treated with percutaneous stenoscopic lumbar decompression (PSLD). PURPOSE: We determined the feasibility of PSLD for lumbar stenosis at single and multiple levels (minimum 1-year follow-up) by image analysis to observe postoperative widening of the vertebral canal in the area. OVERVIEW OF LITERATURE: The decision not to perform an endoscopic decompression might be due to the surgeon being uncomfortable with conventional microscopic decompression or unfamiliar with endoscopic techniques or the unavailability of relevant surgical tools to completely decompress the spinal stenosis. METHODS: The decompressed canal was compared between preoperative controls and postoperative treated cases. Data on operative results, including length of stay, operative time, and surgical complications, were analyzed. Patients were assessed clinically on the basis of the Visual Analog Scale (VAS) score for the back and legs and using the Oswestry Disability Index (ODI). RESULTS: Postoperative magnetic resonance imaging revealed that PSLD increased the canal cross-sectional area by 52.0% compared with the preoperative area at the index segment (p<0.001) and demonstrated minimal damage to the normal soft tissues including muscles and the extent of removed normal bony tissues. Mean improvements in VAS score and ODI were 4.0 (p<0.001) and 40% (p<0.001), respectively. CONCLUSIONS: PSLD could be an alternative to microscopic or microendoscopic decompression with various advantages in the surgical management of lumbar stenosis.

Double-Layer TachoSil Packing for Management of Incidental Durotomy During Percutaneous Stenoscopic Lumbar Decompression.

BACKGROUND: Incidental durotomy (ID) during surgery for lumbar herniated disks or lumbar spinal stenosis is a serious complication that requires immediate recognition and repair. The incidence of ID during percutaneous endoscopic lumbar decompression has increased along with the demand for endoscopic spinal surgery. The management of ID during endoscopic surgery is more complicated and difficult than management during open surgery. A hemostatic agent, TachoSil (Nycomed, Linz, Austria), is used for control of local bleeding in several types of surgery, but its use in dural repair in endoscopic spinal surgery has not been described. CASE DESCRIPTION: We present 3 cases in which the double-layer TachoSil packing technique was used in the management of ID during percutaneous stenoscopic lumbar decompression. CONCLUSIONS: This case report reconfirms the efficacy and utility of TachoSil for IDs that occur during endoscopic spinal surgery and minimally invasive surgery. To our knowledge, this is the first report on the use and effectiveness of TachoSil for managing IDs during endoscopic spinal surgery. We hope that other surgeons will find this technique helpful in managing IDs.

Trans-Sacral Epiduroscopic Laser Decompression for Symptomatic Lumbar Disc Herniation: A Preliminary Case Series.

OBJECTIVE: The purpose of this study was to investigate the effect of trans-sacral epiduroscopic laser decompression (SELD) in patients with a herniated lumbar disc. METHODS: This prospective case series study was designed to determine the outcomes of SELD with regard to reducing pain and improving the functional status in patients with low back pain (LBP) and radiculopathy caused by definitive neural compression confirmed by MRI. A total of 250 patients with LBP and simultaneous radiculopathy underwent SELD by applying a Ho:YAG laser. Clinical outcomes were evaluated using the visual analogue scale (VAS) score for LBP, and radiculopathy and functional status were measured using the Oswestry Disability Index (ODI). RESULTS: At 2 weeks after the procedure, the average VAS score for leg pain decreased to 3.6 from 7.1 (p < 0.01), and the average VAS score for back pain decreased to 4.1 from 5.9 (p < 0.01). At 3 months, the average VAS scores for leg and back pain decreased to 2.6 and 2.7, respectively. The mean ODI improved from 50 to 19 at 2 weeks postoperatively and further decreased to 12 at 3 months postoperatively. CONCLUSIONS: The VAS score and ODI significantly improved after SELD in herniated nucleus pulposus (HNP) patients with LBP and radiculopathy. Postoperative MRI showed a notable decrease in the HNP size and a reduction in neural compression. SELD is suggested to be an effective therapeutic modality for patients with symptomatic HNP.