Contralateral Keyhole Biportal Endoscopic Surgery for Ruptured Lumbar Herniated Disc: A Technical Feasibility and Early Clinical Outcomes.

OBJECTIVE: Spinal endoscopic surgery is increasingly adapted as a minimal invasive technique, however, significant facet joint violation may be developed after ipsilateral laminectomy. The aim of this study is to introduce surgical technique of contralateral keyhole biportal endoscopic surgery (CKES) for ruptured lumbar disc and report it is early surgical outcomes with facet joint violation. METHODS: Between January to December 2019, 27 patients with ruptured lumbar disc were underwent CKES. Simple radiographs were obtained to investigate development of iatrogenic instability or spondylolisthesis. Magnetic resonance imaging scan was checked about 8 hours after surgery to evaluate successful removal of ruptured disc and existence of facet joint violation. Clinical outcomes were assessed by modified MacNab criteria, visual analogue scale (VAS) scores of back and radicular pain. RESULTS: The mean age of the patients was 62.8 ± 12.48 years. The average operative time and mean follow-up period were 57.1 ± 21.36 minutes and 8.1 ± 3.78 months, respectively. Compared to preoperative scores, the VAS scores of back and radicular pain were significantly improved. Modified MacNab outcome grade was good to excellent in 96.3% (26 out of 27 patients) of patients. The reduction rate of facet joint plane was about 4.9% after contralateral approach. CONCLUSION: CKES may be considered as an excellent surgical option to treat ruptured lumbar disc without the development of iatrogenic instability. Low rate of facet joint reduction, good visualization of lateral recess, and identification of accurate midline of central spinal canal are advantages of the procedure.

Full Endoscopic Technique for High-Grade Up-Migrated Lumbar Disk Herniation via a Translaminar Keyhole Approach: Preliminary Series and Technical Note.

BACKGROUND AND STUDY AIMS: Technically and anatomically, accessing a high-grade migrated lumbar disk herniation (LDH) using traditional full endoscopic lumbar diskectomy (FELD) approaches (either transforaminal or interlaminar) is challenging. The objective of this study was to present an effective and safe surgical approach for high-grade up-migrated LDH by translaminar FELD. PATIENTS AND METHODS: Thirteen patients with soft high-grade up-migrated LDH treated with a translaminar FELD between May 2015 and July 2018 were reviewed in this study. Five of these patients had very high-grade up-migration. Clinical outcomes were assessed including preoperative and postoperative visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and MacNab criteria. RESULTS: Overall, 7 of the 13 patients had disk-fragment migration at L4-L5: three at L5-S1, two at L3-L4, and the remaining one at L2-L3. In all cases, the highly up-migrated LDH was removed successfully through the translaminar approach, as confirmed by postoperative magnetic resonance imaging. The improvements of VAS for back and leg pain were 4.5 ± 0.9 to 1.3 ± 1.3 and 7.1 ± 1.0 to 1.6 ± 0.7, respectively (both p < 0.05). The ODI decreased from preoperative 41.9 ± 6.0 to postoperative 13.0 ± 4.1 (p < 0.05). According to the MacNab criteria, the satisfaction rate was 92.3% (excellent or good outcomes). None of the patients experienced any perioperative complications or recurrence during the follow-up period. CONCLUSION: Although full endoscopic technique via the translaminar keyhole route may not be used as a routine surgical approach, it could serve as a feasible alternative method for patients with highly up-migrated disk herniation.

The Feasibility and Perioperative Results of Bi-Portal Endoscopic Resection of a Facet Cyst Along With Minimizing Facet Joint Resection in the Degenerative Lumbar Spine.

BACKGROUND: Presentation of degenerative facet cysts (FC) as radicular pain in patients is well established. The traditional treatment of FCs has been decompressive laminectomy with a medial facetectomy and cyst excision. A major disadvantage of open procedures with medial facetectomy is predisposition to further instability. OBJECTIVE: To describe a contralateral bi-portal endoscopic excision of FC along with minimizing facet joint resection. METHODS: Thirteen patients between March 2016 and December 2017 were evaluated retrospectively for clinical, radiological, and morphometric outcomes. Patients with complaints of unilateral radiculopathy with associated neurogenic claudication from degenerative lumbar FC were included. Clinical evaluation was by NRS leg pain and ODI scores, radiological evaluation was by MRI. For morphometric analysis, cross-sectional area of facet joint (CSA-FJ) was measured on MRI in square millimeters. RESULTS: Thirteen FCs were decompressed (no adverse events) NRS leg pain and ODI improved from 6.85 ± 0.69 and 65.08 ± 7.95 preoperatively to 1 ± 0.91 and 13.46 ± 5.19 at 1-yr follow-up, respectively. CSA-FJ remained relatively well preserved from 212.83 ± 58.05 to 189.77 ± 62.93 post decompression (statistically insignificant, P = .3412). CONCLUSION: Bi-portal endoscopic decompression of FC can be performed with good clinical and radiological outcomes. This surgical technique may be recommended for further evaluation as an addition in the armamentarium of a spine surgeon for treatment of degenerative lumbar FC.

A Systematic Review of Unilateral Biportal Endoscopic Spinal Surgery: Preliminary Clinical Results and Complications.

OBJECTIVE: Unilateral biportal endoscopic spine surgery (UBE) for the treatment of lumbar spinal diseases has achieved favorable results. In this systematic review, the technical nuances, surgical outcomes, and complications of UBE are summarized. METHODS: A systematic review of the literature published to June 2018 was performed. Reported studies related to UBE were identified through searching the PubMed database. The outcomes measured included operative time, hospital stay, complications, visual analog scale (VAS), Oswestry Disability Index, and the Macnab criteria. RESULTS: A total of 556 patients and 679 levels were collected from the selected 11 studies. The mean follow-up was 15.2 months, the mean operative time was 81.3 minutes, and the mean length of hospital stay was 4.4 days. The mean overall complication rate was 6.7% (range, 0%-13.8%). The mean VAS score for leg pain decreased from preoperative 7.9 to 1.9 at final follow-up visit and the mean VAS score for back pain decreased from 5.7 to 1.8. The mean Oswestry Disability Index significantly improved from preoperative 63.7 to 18.6 at the final follow-up. The average satisfied outcome (excellent/good; based on the Macnab criteria) was 84.3% (range, 75.35%-95%). There were similar results between UBE for the treatment of lumbar disc herniation and stenosis, including operative time, length of hospital stay, complications, and satisfaction rate. CONCLUSIONS: Although the existing studies are limited to small cohorts and short-term follow-up, based on the given preliminary results and experiences of current studies, UBE may be a feasible option for lumbar spinal surgery.

Biportal Endoscopic Decompression of Exiting and Traversing Nerve Roots Through a Single Interlaminar Window Using a Contralateral Approach: Technical Feasibilities and Morphometric Changes of the Lumbar Canal and Foramen.

BACKGROUND: Endoscopic surgery for lumbar stenosis is gaining acceptance because of the minimal muscle damage, short recovery times, reduced blood loss, and good clinical results. We report a novel technique of decompressing contralateral traversing and exiting nerve roots through a single interlaminar window, avoiding separate incision for foraminal decompression with minimal damage to facet joints and comparing morphometric changes after decompression. METHODS: Between March and December 2017, 30 patients were evaluated retrospectively for clinical, radiologic, and morphometric outcomes. Patients with unilateral radiculopathy and magnetic resonance imaging (MRI) showing spinal stenosis at 2 levels (lateral recess and cranial level foraminal compression) were included. Clinical evaluation used a numerical rating scale (NRS) for leg pain and Oswestry Disability Index (ODI) scores, and radiologic evaluation used MRI. For morphometric analysis, the cross-sectional area of the intervertebral foramen (CSA-IVF), spinal canal (CSAC), and facet joint (CSA-FJ) was measured on MRI. RESULTS: Thirty levels were decompressed (no adverse events). NRS leg pain and ODI scores improved from 7.5 ± 0.86 and 67.9 ± 9.7 preoperatively to 1.53 ± 0.86 and 15.7 ± 6.6 at last follow-up, respectively. CSAC improved from 99.34 ± 34.01 to 186.83 ± 41.41, indicating good canal decompression. CSA-IVF improved from 56.40 ± 19.28 to 97.60 ± 28.46, indicating good foraminal decompression. CSA-FJ improved from 231.37 ± 62.53 to 194.96 ± 50.56, indicating good foraminal decompression with less damage to facet joint. Morphometric changes were statistically significant (P < 0.05). CONCLUSIONS: Biportal endoscopic decompression of the lateral recess and cranial foramen through a single interlaminar window can be performed using a contralateral approach. In view of the good clinical and radiologic outcomes of patients, with notable improvements in morphometric measurements at stenosed segments, this surgical technique is worthy of further evaluation and application.

Contralateral Interlaminar Keyhole Percutaneous Endoscopic Lumbar Surgery in Patients with Unilateral Radiculopathy.

OBJECTIVE: Percutaneous endoscopic surgery is increasingly used as an alternative to open microsurgery for treating lumbar spinal diseases. The purpose of this study was to determine the feasibility and efficacy of contralateral keyhole endoscopic surgery for treating unilateral radiculopathy. METHODS: We performed percutaneous endoscopic sublaminar decompression via the contralateral interlaminar approach in 14 patients with unilateral radiculopathy. All procedures were performed under epidural anesthesia. The epidural space was accessed under fluoroscopic guidance; only the tongue portion of the handmade working sheath was placed within the epidural space to prevent nerve compression injury by the instruments. The base of the spinous process, caudal edge of the upper lamina, and rostral edge of the lower lamina were partially removed using a 3.5-mm drill bit under direct endoscopic visualization. After undercutting the ventral surface of the lamina by an endoscopic drill, the ligamentum flavum was removed using a punch, rongeurs, and forceps. The lateral recess and the traversing nerve roots were completely decompressed. RESULTS: Symptoms were relieved immediately after surgery. The mean operating time was 68.2 minutes. Visual analog scale and Oswestry Disability Index scores improved significantly from 6.8 points and 61.6% preoperatively to 2 points and 22.2% at 6 months after surgery. A postoperative epidural hematoma was observed in 1 patient. No postoperative complications, such as dural tear, neurologic injury, or infection, were reported. CONCLUSIONS: Contralateral keyhole endoscopic surgery is a safe and useful technique to decompress unilateral lateral recess stenosis or facet cyst.

Minimally invasive anterior lumbar interbody fusion followed by percutaneous translaminar facet screw fixation in elderly patients.

OBJECT: The purpose of this study was to determine whether anterior lumbar interbody fusion (ALIF) followed by percutaneous translaminar facet screw fixation is effective in elderly patients with degenerative spinal disease. METHODS: Twenty-nine patients > 60 years old who underwent ALIF with percutaneous translaminar facet screw fixation from January to June 2004 were studied. The radiological and clinical data of these patients were collected and analyzed. The mean follow-up period was 14.6 months (range 12-17 months). RESULTS: The mean preoperative, immediate postoperative, and 6- and 12-month postoperative posterior disc heights were 7.1, 11.6, 9.8, and 9.8 mm, respectively. Subsidences of posterior disc height > 20% developed in 9 patients (30%). The significant risk factor for subsidence was found to be 2-level operations (p = 0.023). The mean preoperative Oswestry Disability Index score and visual analog scale scores for the back and leg were 24.4, 6.6, and 7.5, respectively, and improved postoperatively to 14.2, 1.5, and 1.8, respectively. CONCLUSIONS: Minimally invasive ALIF followed by percutaneous translaminar facet screw fixation was performed as a minimally invasive surgical technique in elderly patients. However, in certain circumstances such as multilevel operations or in patients with severe osteoporosis, significant cage subsidence can develop.

Partial disc replacement with the PDN prosthetic disc nucleus device: early clinical results.

The aim of this study was to evaluate the efficacy of the PDN prosthetic disc nucleus device for the treatment of chronic discogenic back pain caused by degenerative disc disease. Among the 48 patients who underwent nucleus replacement surgery from January 2001 through May 2002, 46 patients were followed >6 months. The mean Oswestry Disability Index score was 58.9% preoperatively, and it improved to 18% at the 1-year follow-up. Visual Analogue Pain Scale scores improved from a preoperative mean of 8.5 to 3.1 after 1 year. The mean Prolo Scale score also improved from 5.2 preoperatively to 7.2 at 1 year. Major complications included four cases of device migration, requiring revision surgery, and infection in one patient. According to MacNab's criteria, results were excellent in 5 patients (10.9%), good in 31 (67.4%), fair in 3 (6.5%), and poor in 7 (15.1%). The overall clinical success rate was 78.3%. Nucleus replacement with the PDN device seemed to be effective in treating patients with chronic discogenic back pain caused by degenerative disc disease.