Unilateral Biportal Percutaneous Transforaminal Endoscopic Lumbar Foraminal Decompression and Discectomy: A Technical Note.

Background and Introduction: Minimally invasive spine surgery (MISS) is a set of techniques and procedures that reduces the local tissue injury while achieving the same results through traditional open surgery. The techniques for the treatment of lumbar disc herniation and degenerative canal stenosis have evolved from tubular discectomy to endoscopic discectomy. This helps in preserving spine function. Good clinical outcomes have been reported with the use of an endoscope for degenerative lumbar disc disease. Objective: In this video abstract, we present a case lumbar foraminal stenosis in an elderly man that was treated successfully using unilateral biportal endoscopic spine surgery. (UBESS). Surgical Technique: A 70-year-old man presented with progressive neurogenic claudication and left L4 numbness and paresthesias. His claudication distance was 200 m. His MRI Lumbosacral spine showed severe left L4-5 foraminal stenosis due to a disc prolapse. The patient underwent a left-sided unilateral biportal endoscopic transforaminal decompression and discectomy at L4-5 successfully. Postoperative period was uneventful and the patient had significant relief in his symptoms. Postoperative MRI Lumbosacral spine showed no muscle damage with adequate decompression at left L4-5 level. Results: The patient had an uneventful recovery. Conclusion: Biportal percutaneous transforaminal endoscopic discectomy/decompression is an ideal alternative to the uniportal endoscopic and minimal invasive microsurgery for foraminal and paracentral disc herniations and lateral recess and foraminal stenosis.

Challenges to the orthopedic resident workforce during the first wave of COVID-19 pandemic: Lessons learnt from a global cross-sectional survey.

BACKGROUND: The COVID-19 pandemic has caused unprecedented concerns on the safety, well-being, quality of life(QOL), and training of the orthopedic resident physician workforce worldwide. Although orthopedic residency programs across the globe have attempted to redefine resident roles, educational priorities, and teaching methods, the global orthopedic residents' perspective with regards to their safety, well-being, QOL, and training, taking into account regional variances remains unknown. METHODS: A 56-item-questionnaire-based cross-sectional survey was conducted online during the COVID-19 pandemic involving 1193 orthopedic residents from 29 countries across six geographical regions to investigate the impact of the COVID-19 pandemic on the well-being, safety, and training of orthopedic residents at a global level, as well as to analyze the challenges confronted by orthopedic residency programs around the world to safeguard and train their resident workforce during this period. RESULTS: The total response rate was 90.3%(1077/1193). Time spent on residency-training activities decreased by 24.7 h/week (95% CI, -26.5 to -22.9,p < 0.001), with 50.2% (n = 541) residents performing duties outside their residency curriculum. 80.5% (n = 869) residents had no prior experience working in infectious outbreaks. A greater percentage of residents from Middle East, Asia and Europe were redeployed to the COVID-19 frontlines, p < 0.001. Only 46.5% (n = 491) and 58.4% (n = 600) of residents underwent training in critical care or PPE (Personal Protective equipment) usage, respectively; 28.5% (n = 302) residents (majority from Africa, Middle East, South America) reported lack of institutional guidelines to handle infectious outbreaks; 15.4% (n = 160) residents (majority from Africa, Asia, Europe) had concerns regarding availability of PPE and risk of infection. An increase in technology-based virtual teaching modalities was observed. The most significant stressor for residents was the concern for their family's health. Residents' QOL significantly decreased from 80/100 (IQR 70-90) to 65/100 (IQR 50-80) before and during the pandemic, p < 0.001. CONCLUSIONS: The COVID-19 pandemic has significantly impacted the safety, well-being, QOL, and training of the global orthopedic resident physician workforce to different extents across geographical regions. The findings of this study will aid educators, program leaderships, and policy makers globally in formulating flexible, generalizable, and sustainable strategies to ensure resident safety, well-being, and training, while maintaining patient care.

Delayed unrelated presentation of a lumbar burst fracture consequent to a remote episode of a single convulsive seizure: A diagnostic challenge.

Non-traumatic vertebral fractures occurring as a sole consequence of the violent muscle forces generated during the first episode of a GTCS(generalized tonic clonic seizure) in a previously healthy non-epileptic individual are very rare. Being clinically asymptomatic they are easily overseen at the time of initial presentation due to their rarity of occurrence and the presence of potentially distracting factors in the post-ictal phase. We present a 52-year-old healthy non-epileptic male who presented with unrelenting back pain and neurodeficit secondary to a four-month-old unstable burst fracture of the first lumbar vertebra sustained during an isolated single episode of a witnessed GTCS. A detailed inquiry revealed no history of a significant traumatic event either during the convulsive episode or thereafter. A meticulous history taking, a thorough clinical and neurological examination combined with a comprehensive radiological evaluation established the unusual etiology of the fracture and the presence of a thoracolumbar kyphotic deformity with compression of conus medullaris. A detailed neurological, and laboratory work-up, confirmed no attributable organic or metabolic cause for the seizure. His BMD(Bone Mineral Density) was normal. Patient was managed with posterior instrumented deformity correction by a posterior column shortening osteotomy, neural decompression and fusion of D12-L1 facets. Patient had complete neurological recovery with good clinical and functional outcomes at 28-months follow-up. A few cases of seizure-induced non-traumatic spinal fractures have been published in literature. A majority of these fractures occurred in individuals with either seizure-provoking risk factors (epileptics with recurrent seizures, brain tumors, drug overdose/withdrawal, metabolic disorders, or electrolyte imbalance) or in those with an increased susceptibility to fracture due to decreased BMD. This case demonstrates the rare occurrence of a non-traumatic vertebral fracture during the first episode of a GTCS in an otherwise healthy non-epileptic individual with normal BMD and no seizure-provoking risk factors. This is the first case report of a delayed unrelated presentation of a non-traumatic lumbar vertebral fracture with complications (spinal deformity and neurodeficit) consequent to a remote episode of a single convulsive seizure. It emphasizes the need for a high index of clinical suspicion,a meticulous history taking, thorough musculoskeletal and neurological examination in any individual presenting with a seemingly benign back pain following a remote isolated episode of seizure, even in the absence of overt trauma. A detailed radiological evaluation guided by a meticulous history taking and detailed clinical examination is essential to rule out a fracture unless proven otherwise. It also shows that a single convulsive seizure can result in a potentially unstable fracture that when neglected, can result in devastating complications like spinal deformity and neurodeficit. LEVEL OF EVIDENCE: Level IV.