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Ukeba D, Nagahama K, Yamada K, Abe Y, Hyugaji Y, Endo T, Ohnishi T, Tachi H, Hasegawa Y, Sudo H, Iwasaki N. Artificial intelligence-driven 3D MRI of lumbosacral nerve root anomalies: accuracy, incidence, and clinical utility. Neuroradiology 2025; 67:1095-1101. [PMID: 40021500 DOI: 10.1007/s00234-025-03574-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2024] [Accepted: 02/16/2025] [Indexed: 03/03/2025]
Abstract
PURPOSE Lumbosacral nerve root anomalies are relatively rare but can be a risk factor for intraoperative nerve injury. However, it is often difficult to evaluate them with preoperative imaging. We developed a software that automatically generates three-dimensional (3D) nerve root images from magnetic resonance (MR) imaging using artificial intelligence (AI). This study aims to evaluate the accuracy and utility of this modality in clinical practice by conducting an epidemiological study of nerve root anomalies. METHODS The incidence and morphology of nerve root anomalies were evaluated in the 3D images of 1,500 patients. The accuracy of the images was evaluated by comparing the images generated automatically using this AI software with those created manually by conventional methods. RESULTS Of 1,500 cases, 53 (3.5%) had nerve root anomalies with total of 58 nerve root anomalies. With respect to the spinal level, 35 nerve root anomalies were found in the L5-S1 level, the most common (60.3%). As for morphology, 47 nerve roots (81.0%) were of the Neidre-MacNab classification Type 1. The images matched in 1,493 out of 1,500 cases (99.5%) between the two methods, and the remaining 7 cases all had nerve root abnormalities, which were detected as abnormal by the AI software. CONCLUSION The MR nerve root 3D imaging provided a 3D visualization and understanding of nerve root morphology, including nerve root anomalies. The AI software enables easy and precise 3D nerve root imaging, which greatly aids in the preoperative evaluation for spinal surgery.
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Affiliation(s)
| | - Ken Nagahama
- Hokkaido University Hospital, Sapporo, Japan
- Sapporo Endoscopic Spine Surgery, Sapporo, Japan
| | | | | | | | | | | | | | | | - Hideki Sudo
- Hokkaido University Hospital, Sapporo, Japan
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Ahn Y, Bae S, Jo DJ, Yoo BR. Magnetic Resonance Imaging Predictors of Surgical Difficulty in Transforaminal Endoscopic Lumbar Discectomy for Far-Lateral Disc Herniation Under Local Anesthesia. Biomedicines 2025; 13:778. [PMID: 40299343 PMCID: PMC12025250 DOI: 10.3390/biomedicines13040778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2025] [Revised: 03/16/2025] [Accepted: 03/21/2025] [Indexed: 04/30/2025] Open
Abstract
Background/Objectives: Transforaminal endoscopic lumbar discectomy (TELD) is a minimally invasive spinal surgery known for its effectiveness, lower complication rates, faster recovery, and ability to be performed under local anesthesia. However, foraminal narrowing or access pain during the transforaminal approach can delay or hinder surgery in patients with far-lateral lumbar disc herniation (LDH). The objectives of this study were to identify predictive factors from preoperative magnetic resonance imaging (MRI) findings and demographics and discuss the optimization of surgical strategies. Methods: This retrospective study included 75 patients with far-lateral LDH who underwent TELD. Preoperative demographics and MRI findings were analyzed. Surgical data, including operative time, length of hospital stay, and intraoperative pain, were recorded. Postoperative outcomes, including complications, revision surgeries, and global outcomes based on the modified Macnab criteria, were evaluated. Preoperative clinical and radiological factors affecting the operative data and results were analyzed. Results: A higher foraminal stenosis grade was significantly correlated with prolonged operative time (p < 0.01) and extended hospital stay (p < 0.01). Extraforaminal LDH was associated with more severe access pain (p < 0.01) owing to increased nerve root irritation. Access pain was significantly correlated with operative time (p < 0.01) and hospital stay (p < 0.01). Appropriate surgical techniques and intraoperative pain management can mitigate these challenges. Conclusions: Preoperative MRI findings, particularly the grade of foraminal narrowing and herniation zone, can predict surgical difficulty and outcomes in TELD for far-lateral LDH. These insights can guide tailored strategies to reduce access pain and improve procedural success under local anesthesia.
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Affiliation(s)
- Yong Ahn
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul 05278, Republic of Korea;
| | - Sungsoo Bae
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul 05278, Republic of Korea;
| | - Dae-Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul 05278, Republic of Korea;
| | - Byung-Rhae Yoo
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Republic of Korea;
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Chau DHH, Gengatharan D, Wong WSY. Augmenting Endoscopic Transforaminal Spinal Decompression Surgery (Full Endoscopic Spine Surgery) Using Stimulated Electromyography Neuromonitoring Dilators. Int J Spine Surg 2025; 19:57-62. [PMID: 39643277 PMCID: PMC12053123 DOI: 10.14444/8692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2024] Open
Abstract
BACKGROUND Full endoscopic spine surgery via a transforaminal approach (FESS-TFA) offers a minimally invasive approach for spinal decompression. However, it carries a risk of nerve root irritation or injury. Existing intraoperative neuromonitoring primarily provides retrospective warnings of potential nerve disturbance. OBJECTIVE To introduce the use of stimulated electromyography neuromonitoring dilators in FESS-TFA for proactive nerve protection, enhanced localization, and potential reduction in radiation exposure. METHODS This technical note describes the first use of neuromonitoring dilators in FESS-TFA. A 6-mm dilator tipped with a stimulation electrode is introduced to provide real-time directional feedback regarding nerve proximity, allowing the surgeon to actively avoid accidental injury to the exiting nerve root. With the creation of a safe tract, subsequent introduction of working instruments would theoretically reduce the risk of neural injury. RESULTS The technique was successfully applied in a case of T11/T12 severe spinal stenosis, facilitating safe instrument passage and nerve localization. We describe the surgical technique and provide illustrative intraoperative details. CONCLUSION Neuromonitoring dilators represent a promising innovation in FESS-TFA with the potential to enhance patient safety and possibly streamline the procedure. Larger-scale studies are warranted to quantify the true impact of this technique on complication rates, operative time, and radiation exposure. CLINICAL RELEVANCE This technique highlights a significant advancement in reducing neural complications during minimally invasive spinal surgeries. By proactively preventing nerve irritation or injury and reducing radiation exposure, it contributes to optimizing surgical workflows and improving patient outcomes. LEVEL OF EVIDENCE: 5
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Affiliation(s)
- Dickson Hong Him Chau
- Department of Orthopedic Surgery, Sengkang General Hospital, Sengkang, Singapore
- Department of Orthopaedics, SingHealth Duke-NUS Musculoskeletal Sciences, Academic Clinical Programme, Boulevard, Singapore
| | | | - Walter-Soon-Yaw Wong
- Department of Orthopedic Surgery, Sengkang General Hospital, Sengkang, Singapore
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Wu K, Yun Z, Suvithayasiri S, Liang Y, Setiawan DR, Kotheeranurak V, Jitpakdee K, Giordan E, Liu Q, Kim JS. Evolving Paradigms in Spinal Surgery: A Systematic Review of the Learning Curves in Minimally Invasive Spine Techniques. Neurospine 2024; 21:1251-1275. [PMID: 39765270 PMCID: PMC11744536 DOI: 10.14245/ns.2448838.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/22/2024] [Accepted: 10/01/2024] [Indexed: 01/23/2025] Open
Abstract
Our research examines the learning curves of various minimally invasive lumbar surgeries to determine the benefits and challenges they pose to both surgeons and patients. The advent of microsurgical techniques since the 1960s, including advances in fluoroscopic navigation and intraoperative computed tomography, has significantly shifted spinal surgery from open to minimally invasive methods. This study critically evaluates surgical duration, intraoperative conversions to open surgery, and complications as primary parameters to gauge these learning curves. Through a comprehensive literature search up to March 2024, involving databases PubMed, Cochrane Library, and Web of Science, this paper identifies a steep learning curve associated with these surgeries. Despite their proven advantages in reducing recovery time and surgical trauma, these procedures require surgeons to master advanced technology and equipment, which can directly impact patient outcomes. The study underscores the need for well-defined learning curves to facilitate efficient training and enhance surgical proficiency, especially for novice surgeons. Moreover, it addresses the implications of technology on surgical accuracy and the subsequent effects on complication rates, providing insights into the complex dynamics of adopting new surgical innovations in spinal health care.
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Affiliation(s)
- Kun Wu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Zhihe Yun
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Siravich Suvithayasiri
- Department of Orthopedics, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand
- Bone and Joint Excellence Center, Thonburi Hospital, Bangkok, Thailand
| | - Yihao Liang
- Department of Orthopedics, The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | | | - Vit Kotheeranurak
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Khanathip Jitpakdee
- Department of Orthopedics, Thai Red Cross Society, Queen Savang Vadhana Memorial Hospital, Sriracha, Thailand
| | - Enrico Giordan
- Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Italy
| | - Qinyi Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Jin-Sung Kim
- Department of Neurosurgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Chuang HC, Hsu YC, Liu YF, Chang CJ, Hsiao YM, Huang YH, Liu KC, Chen CM, Kim HS, Lin CL. Reducing Postoperative Neurological Complications in Uniportal Full-Endoscopic Lumbar Interbody Fusion: Efficacy of the GUARD Technique Combined With Delayed Ligamentum Flavectomy. Neurospine 2024; 21:1199-1209. [PMID: 39765265 PMCID: PMC11744540 DOI: 10.14245/ns.2448656.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 08/11/2024] [Accepted: 08/19/2024] [Indexed: 01/23/2025] Open
Abstract
OBJECTIVE Uniportal full-endoscopic transforaminal lumbar interbody fusion (FE-TLIF) carries a unique risk of nerve traction and abrasion injury during cage insertion. This study aims to evaluate the clinical efficacy of the GUARD technique and delayed ligamentum flavectomy in reducing postoperative radicular pain and neurapraxia in patients undergoing uniportal FE-TLIF. METHODS A retrospective analysis was conducted on 45 patients with an average age of 53.9±12.4 years who underwent either FE facet-sparing TLIF (FE fs-TLIF) or FE facet-resecting TLIF (FE fr-TLIF). Patients were divided into 2 groups: the sentinel group (21 patients) using traditional sentinel pin techniques, and the GUARD group (24 patients) using the GUARD technique with delayed ligamentum flavectomy. Patient-reported outcomes included the visual analogue scale (VAS) for leg and back pain, and Oswestry Disability Index. Complication rates, including incidental durotomy, postoperative neurapraxia, and hematoma, were also documented. RESULTS Postoperative radicular pain in the legs was significantly reduced at 6 weeks in the GUARD group compared to the sentinel group (VAS: 2.201 vs. 3.267, p=0.021). The incidence of postoperative neurapraxia was markedly lower in the GUARD group (0% vs. 19%, p=0.047). Both groups showed similar improvements in disc height, segmental lordosis, and lumbar lordosis at the 1-year follow-up, with no significant differences in endplate injury or fusion rates. CONCLUSION The GUARD technique and delayed ligamentum flavectomy significantly enhance patient safety by reducing postoperative radicular pain and neurapraxia without incurring additional costs. These techniques are easy to learn and integrate into existing surgical workflows, offering a valuable improvement for surgeons performing FE-TLIF procedures.
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Affiliation(s)
- Hao-Chun Chuang
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chia Hsu
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Fu Liu
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chao-Jui Chang
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
- Department of Orthopaedics, Dou-Liou Branch of National Cheng Kung University Hospital, Yunlin, Taiwan
| | - Yu-Meng Hsiao
- Department of Orthopedics, Tainan Municipal An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Yi-Hung Huang
- Department of Orthopedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Keng-Chang Liu
- Department of Orthopedic Surgery, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Biomedical Sciences, National Chung Cheng University, Chiayi, Taiwan
| | - Hyeun Sung Kim
- Department of Neurosurgery, Harrison Spinartus Hospital Chungdam, Seoul, Korea
| | - Cheng-Li Lin
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Ahn Y, Choi JE, Lee S. Access Pain During Transforaminal Endoscopic Lumbar Discectomy for Foraminal or Extraforaminal Disc Herniation. Diagnostics (Basel) 2024; 14:2337. [PMID: 39451660 PMCID: PMC11508188 DOI: 10.3390/diagnostics14202337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Revised: 10/15/2024] [Accepted: 10/18/2024] [Indexed: 10/26/2024] Open
Abstract
BACKGROUND/OBJECTIVES Transforaminal endoscopic lumbar discectomy (TELD) under local anesthesia is a promising minimally invasive surgical option for intractable lumbar disc herniation (LDH). However, our understanding of access pain prediction during foraminal pathological procedures is limited. To our knowledge, no predictive rules for access pain have been established during TELD for foraminal or extraforaminal LDH. This study, with its potential for predicting access pain during TELD and discussing strategies for pain prevention and management, could significantly benefit the field of endoscopic spine surgery. METHODS This observational study included 73 consecutive patients who underwent TELD for foraminal or extraforaminal LDH between January 2017 and December 2022. Preoperative clinical and radiographic factors affecting significant access pain and the impact of access pain on clinical outcomes were evaluated. RESULTS The rate of significant access pain was 13.70% (10 of 73 patients). Extraforaminal LDH tended to cause more severe pain than did foraminal LDH during TELD under local anesthesia (p < 0.05). Although the degree of access pain was not related to global clinical outcomes, increased pain was strongly associated with prolonged operative time and length of hospital stay (p < 0.05). CONCLUSIONS TELD could be an effective surgical option for foraminal or extraforaminal LDH under local anesthesia. More access pain might develop during TELD for extraforaminal LDH. The extraforaminal component of LDH could narrow the safe working zone. Significant access pain might prolong the duration of surgery and hospitalization. Thus, a specialized technique is required for the clinical success of TELD.
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Affiliation(s)
- Yong Ahn
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul 05278, Republic of Korea
| | - Ji-Eun Choi
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Republic of Korea;
| | - Sol Lee
- Basgenbio Research Institute, Seoul 04167, Republic of Korea;
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Hsu YC, Liu YF, Chang CJ, Hsiao YM, Huang YH, Liu KC, Chen CM, Kim HS, Lin CL. How to Prevent Nerve Root Injury in Uniportal Full Endoscopic Lumbar Fusion Surgery? Insights From a Cadaveric Anatomic Study With Simulation Surgery. Spine (Phila Pa 1976) 2024; 49:1301-1310. [PMID: 38872241 DOI: 10.1097/brs.0000000000005066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/25/2024] [Indexed: 06/15/2024]
Abstract
STUDY DESIGN The study included 2 fresh-frozen cadavers. OBJECTIVE To elucidate the positional relationship between surgical instruments and nerve roots during full endoscopic facet-sparing (FE fs-TLIF) and full endoscopic facet-resecting (FE fr-TLIF) transforaminal lumbar interbody fusion and propose safe instrumentation insertion procedures and recommend cage glider designs aimed at protecting nerve roots. BACKGROUND Endoscopic surgical techniques are increasingly used for minimally invasive lumbar fusion surgery, with FE fr-TLIF and FE fs-TLIF being common approaches. However, the risk of nerve root injury remains a significant concern during these procedures. PATIENTS AND METHODS Eight experienced endoscopic spine surgeons performed uniportal FE fr-TLIF and FE fs-TLIF on cadaveric lumbar spines, totaling 16 surgeries. Postoperation, soft tissues were removed to assess the positional relationship between the cage entry point and nerve roots. Distances between the cage entry point, traversing nerve root, and exiting nerve root were measured. Safe instrumentation design and insertion procedures were determined. RESULTS In FE fr-TLIF, the mean distance between the cage entry point and traversing nerve root was significantly shorter compared with FE fs-TLIF (3.30 ± 1.35 vs . 8.58 ± 2.47 mm, respectively; P < 0.0001). Conversely, the mean distance between the cage entry point and the exiting nerve root was significantly shorter in FE fs-TLIF compared with FE fr-TLIF (3.73 ± 1.97 vs . 6.90 ± 1.36 mm, respectively; P < 0.0001). For FE fr-TLIF, prioritizing the protection of the traversing root using a 2-bevel tip cage glider was crucial. In contrast, for FE fs-TLIF, a single-bevel tip cage glider placed in the caudal location was recommended. CONCLUSION This study elucidates the anatomic relationship between cage entry points and nerve roots in uniportal endoscopic lumbar fusion surgery. Protection strategies should prioritize the traversing root in FE fr-TLIF and the exiting root in FE fs-TLIF, with corresponding variations in surgical techniques. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Yu-Chia Hsu
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuan-Fu Liu
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chao-Jui Chang
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Meng Hsiao
- Department of Orthopedics, Tainan Municipal An-Nan Hospital, China Medical University, Tainan
| | - Yi-Hung Huang
- Department of Orthopedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Keng-Chang Liu
- Department of Orthopedic Surgery, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
- Department of Biomedical Sciences, National Chung Cheng University, Chiayi, Taiwan
| | - Hyeun-Sung Kim
- Department of Spine Surgery, Nanoori Gangnam Hospital, Seoul, Korea
| | - Cheng-Li Lin
- Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Nakajima Y, Dezawa A, Lim KT, Wu PH. Full-Endoscopic Posterior Lumbar Interbody Fusion: A Review and Technical Note. World Neurosurg 2024; 189:418-427.e3. [PMID: 38960311 DOI: 10.1016/j.wneu.2024.06.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024]
Abstract
Remarkable innovations in spinal endoscopic surgery have broadened its applications over the past 20 years. Full-endoscopic fusions have been widely reported, and several full-endoscopic approaches for interbody fusion have been published. In general, full-endoscopic lumbar interbody fusion (LIF) is called Endo-LIF, and facet-preserving Endo-LIF through the transforaminal route is called trans-Kambin's triangle LIF, which has a relatively longer history than facet-sacrificing Endo-LIF via the posterolateral route. Both approaches can reduce intraoperative and postoperative bleeding. However, there is a higher risk of subsidence and exit nerve root injury. There is no direct decompression in either of the interbody fusions, and additional decompression is required if there is severe lumbar bony canal stenosis. However, the posterior interlaminar approach, which is a well-known standard in full-endoscopic spine surgery, has rarely been applied in the field of endoscopic lumbar fusion surgery. Full-endoscopic posterior LIF (FE-PLIF) via an interlaminar approach can accomplish direct decompression of bony canal stenosis and safe interbody fusion. FE-PLIF via an interlaminar approach demonstrated a longer operation time, less blood loss, and shorter hospitalization duration than minimally invasive transforaminal LIF. FE-PLIF, which can accomplish direct decompression for bony spinal canal stenosis, is superior to other Endo-LIFs. However, FE-PLIF requires technical dexterity to improve efficiency and reduce technical complexity.
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Affiliation(s)
| | - Akira Dezawa
- Dezawa Akira PED Clinic, Kawasaki, Kanagawa, Japan
| | - Kang-Teak Lim
- Department of Neurosurgery, Good Doctor Teun Teun Hospital, Anyang, South Korea
| | - Pang Hung Wu
- Achieve Spine And Orthopaedic Centre, Mount Elizabeth Hospital, Singapore, Singapore; National University Health Systems, Juronghealth Campus, Orthopaedic Surgery, Singapore, Singapore
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Chen Y, Lin W, Lei S, You Y, Zhang X, Ma Y, Wang D. Comparing the Efficacy and Safety of Unilateral Biportal Endoscopic Decompression with Percutaneous Endoscopic Lumbar Decompression for Lumbar Degenerative Diseases: A Meta-Analysis. World Neurosurg 2024; 187:e383-e398. [PMID: 38657790 DOI: 10.1016/j.wneu.2024.04.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE Unilateral biportal endoscopic decompression (UBED) offers the advantages of minimal tissue damage, operational flexibility, and clear visualization, positioning it as an innovative and minimally invasive endoscopic technique. Nevertheless, the clinical evidence supporting the use of UBED in the treatment of degenerative lumbar diseases is limited and conflicting. METHODS As of October 1, 2023, a comprehensive search was conducted across databases including Web of Science, PubMed, Embase, and the Cochrane Library to identify all published studies on minimally invasive UBED for the treatment of degenerative lumbar diseases. Data pertaining to patient demographics, fluoroscopy time, operative duration, intraoperative hemorrhage, hospitalization length, visual analog scale (VAS) score for back and leg pain, MacNab criteria, Oswestry Disability Index (ODI), and complication rates were extracted. The Newcastle-Ottawa scale was utilized to assess the quality. RESULTS Twelve articles were included, involving 816 patients. The back VAS score (95% confidence interval [CI]: -0.09-0.07, P = 0.75), MacNab criteria (95% CI: 0.52-2.3, P = 0.82), fluoroscopy time (95% CI: -7.03 to -0.4, P = 0.08), and the incidence of complications (95% CI: 0.5-1.73, P = 0.82) were not significantly different, while the leg VAS score (95% CI: 0.01-0.18, P = 0.03), ODI score (95% CI: -1.03 to -0.09, P = 0.02), operation time (95% CI: 5.76-20.62, P = 0.0005), hospitalization length (95% CI: 0.41-2.76, P = 0.008), and intraoperative hemorrhage (95% CI: 21.92-72.44, P = 0.0003) were significantly different. CONCLUSIONS UBED offers superiority in ODI, flexibility, and visual field clarity. Conversely, percutaneous endoscopic lumbar decompression presents advantages in terms of operation duration, blood loss, hospitalization length, and leg VAS score. These factors should be thoroughly considered when selecting a surgical approach.
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Affiliation(s)
- Yuxian Chen
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Wei Lin
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Shenglin Lei
- Shenzhen Clinical Medical School of Guangzhou University of Chinese Medicine, Shenzhen, Guangdong, China
| | - Yawen You
- The Fifth Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xiaoqing Zhang
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yingfei Ma
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Dongping Wang
- The First Clinical Medical School of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China.
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Huang X, Luo Q, Liang C, Wang Y, Jia D, Li S, Guo X. Utilization of a novel patient-specific 3D-printing template for percutaneous endoscopic transforaminal discectomy: results from a randomized controlled trial. Front Neurosci 2024; 18:1323262. [PMID: 38680448 PMCID: PMC11047121 DOI: 10.3389/fnins.2024.1323262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/25/2024] [Indexed: 05/01/2024] Open
Abstract
Background The learning curve for percutaneous endoscopic transforaminal discectomy (PETD) is steep, especially for the puncturing and localization procedures. The implementation of 3D printing technology may solve this problem. Methods A novel individualized 3D-printing template (3D-PT) was designed and utilized in PETD. A prospective randomized controlled trial was performed. A total of 28 patients with lumbar disc herniation treated with PETD were analyzed. Of these, 14 patients were treated with the assistance of 3D printing technology (3D-PT group) in conjunction with fluoroscopy, while the remaining 14 patients were treated exclusively under the guidance of C-arm fluoroscopy (control group). Results The number of puncture attempts in the 3D-PT group was significantly less than in the control group (1.36 ± 0.63 vs. 6.07 ± 3.08, p = 0.000). The 3D-PT group exhibited a significant reduction in both intraoperative puncture fluoroscopies (2.71 ± 1.27 vs. 12.14 ± 6.15, p = 0.000) and the overall number of fluoroscopies (2.71 ± 1.27 vs. 17.43 ± 6.27, p = 0.000). In the 3D-PT group, there was a significant reduction in both the puncture time (5.77 ± 1.82 vs. 13.99 ± 4.36, p = 0.000) and the total operation time (60.39 ± 9.78 vs. 76.25 ± 17.78, p = 0.007). Complications were not observed in either group. Conclusion The application of the novel individualized 3D-PT for PETD is effective and safe. The technique has substantial potential and is worth widely promoting.
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Affiliation(s)
- Xin Huang
- Department of Pain Medicine, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Qipeng Luo
- Department of Pain Medicine, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Chen Liang
- Department of Pain Medicine, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Yixuan Wang
- Department of Pain Medicine, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Donglin Jia
- Department of Pain Medicine, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Shuiqing Li
- Department of Pain Medicine, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
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Terkelsen JH, Hundsholt T, Bjarkam CR. Lumbar percutaneous transforaminal endoscopic discectomy: a retrospective survey on the first 172 adult patients treated in Denmark. Acta Neurochir (Wien) 2024; 166:155. [PMID: 38538955 PMCID: PMC10973006 DOI: 10.1007/s00701-024-06038-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/15/2024] [Indexed: 01/06/2025]
Abstract
PURPOSE To evaluate patient demographics, surgery characteristics, and patient-reported clinical outcomes related to the implementation of lumbar PTED in Denmark by surgeons novice to the PTED technique. METHODS All adult patients treated with a lumbar PTED from our first surgery in October 2020 to December 2021 were included. Data was generated by journal audit and telephone interview. RESULTS A total of 172 adult patients underwent lumbar PTED. Surgery duration was a median of 45.0 (35.0-60.0) minutes and patients were discharged a median of 0 (0-1.0) days after. Per operatively one procedure was converted to open microdiscectomy due to profuse bleeding. Post operatively one patient complained of persistent headache (suggestive of a dural tear), two patients developed new L5 paresthesia, and three patients had a newly developed dorsal flexion paresis (suggestive of a root lesion). Sixteen patients did not complete follow-up and 24 (14.0%) underwent reoperation of which 54.2% were due to residual disk material. Among the remaining 132 patients, lower back and leg pain decreased from 7.0 (5.0-8.5) to 2.5 (1.0-4.5) and from 8.0 (6.0-9.1) to 2.0 (0-3.6) at follow-up, respectively (p < 0.001). Additionally, 93.4% returned to work and 78.8% used less analgesics. Post hoc analysis comparing the early half of cases with the latter half did not find any significant change in surgery time, complication and reoperation rates, nor in pain relief, return to work, or analgesia use. CONCLUSION Clinical improvements after lumbar PTED performed by surgeons novel to the technique are satisfactory, although the reoperation rate is high, severe complications may occur, and the learning curve can be longer than expected.
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Affiliation(s)
- Jacob Holmen Terkelsen
- School of Medicine and Health, Aalborg University, Selma Lagerløfs Vej 249, 9260, Gistrup, Denmark
- Department of Neurosurgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark
| | - Torben Hundsholt
- Department of Neurosurgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark
| | - Carsten Reidies Bjarkam
- Department of Neurosurgery, Aalborg University Hospital, Hobrovej 18-22, 9000, Aalborg, Denmark.
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Bardeesi A, Tabarestani TQ, Bergin SM, Huang CC, Shaffrey CI, Wiggins WF, Abd-El-Barr MM. Using Augmented Reality Technology to Optimize Transfacet Lumbar Interbody Fusion: A Case Report. J Clin Med 2024; 13:1513. [PMID: 38592365 PMCID: PMC10934424 DOI: 10.3390/jcm13051513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
The transfacet minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a novel approach available for the management of lumbar spondylolisthesis. It avoids the need to manipulate either of the exiting or traversing nerve roots, both protected by the bony boundaries of the approach. With the advancement in operative technologies such as navigation, mapping, segmentation, and augmented reality (AR), surgeons are prompted to utilize these technologies to enhance their surgical outcomes. A 36-year-old male patient was complaining of chronic progressive lower back pain. He was found to have grade 2 L4/5 spondylolisthesis. We studied the feasibility of a trans-Kambin or a transfacet MIS-TLIF, and decided to proceed with the latter given the wider corridor it provides. Preoperative trajectory planning and level segmentation in addition to intraoperative navigation and image merging were all utilized to provide an AR model to guide us through the surgery. The use of AR can build on the safety and learning of novel surgical approaches to spine pathologies. However, larger high-quality studies are needed to further objectively analyze its impact on surgical outcomes and to expand on its application.
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Affiliation(s)
- Anas Bardeesi
- Department of Neurosurgery, Duke University Hospital, Durham, NC 27710, USA
| | | | - Stephen M. Bergin
- Department of Neurosurgery, Duke University Hospital, Durham, NC 27710, USA
| | - Chuan-Ching Huang
- Department of Neurosurgery, Duke University Hospital, Durham, NC 27710, USA
| | | | - Walter F. Wiggins
- Department of Radiology, Duke University Hospital, Durham, NC 27710, USA
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Kishima K, Yagi K, Yamashita K, Tezuka F, Morimoto M, Takata Y, Sakai T, Maeda T, Sairyo K. Transforaminal Full-Endoscopic Ventral Facetectomy: Midterm Results and Factors Associated with Poor Surgical Outcomes. J Neurol Surg A Cent Eur Neurosurg 2024; 85:155-163. [PMID: 36482000 DOI: 10.1055/a-1995-1772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Full-endoscopic spine surgery (FESS) is a well-established procedure for herniated nucleus pulposus. It is a minimally invasive surgery that can be performed under local anesthesia through only an 8-mm skin incision. With improvements in surgical equipment such as high-speed drills, the indications for FESS have expanded to include lumbar spinal stenosis (LSS). We perform a transforaminal full-endoscopic ventral facetectomy (TF-FEVF) for unilateral nerve root-type lateral recess stenosis (LRS) using a transforaminal approach under local anesthesia.The aim of this study was to examine the postoperative results of TF-FEVF for LRS and to identify factors associated with poor surgical outcomes. 85 patients who underwent TF-FEVF for LRS under local anesthesia. Clinical outcomes were determined by visual analog scale (VAS) and the modified MacNab criteria. Evaluation was performed using magnetic resonance imaging (MRI), computed tomography (CT), and flexion-extension radiographs. METHODS This study involved 85 patients (47 males and 38 females) who underwent TF-FEVF for LRS. The mean age was 70.5 years and the mean follow-up duration was 14.8 months. Data were collected on sex, age, level of operation, diagnosis, history of spine surgery at the same level, and duration of follow-up. The diagnosis was categorized as LSS with or without disk bulging. Clinical evaluation was performed using the VAS and modified MacNab criteria. MRI was used to evaluate the degree of disk degeneration, vertebral endplate degeneration, disk height, thickening of the ligamentum flavum, and stenosis. Bony stenosis was evaluated using CT. Sagittal translation and sagittal angulation were also measured by flexion-extension radiographs, and the Cobb angle was measured using a standing front view radiograph. All variables were compared between patients with excellent/good outcomes (E/G group) and those with fair/poor outcomes (F/P group) using the modified MacNab criteria. RESULTS Postoperative VAS showed that leg pain decreased from 59.0 ± 28.6 preoperatively to 17.9 ± 27.2 at the final follow-up (p < 0.01) and that lower back pain also decreased from 60.7 ± 26.6 preoperatively to 27.3 ± 28.6 at final follow-up (p < 0.01). According to the modified MacNab criteria, the results during the final follow-up were excellent in 39 cases, good in 21 cases, fair in 13 cases, and poor in 12 cases. There were no significant differences in sex, age, diagnosis, history of spine surgery, and duration of follow-up periods between the 60 cases (70.6%) in the E/G group and the 25 cases (29.4%) in the F/P group. Imaging evaluation revealed statistically significant differences between the E/G group and the F/P group in intervertebral angle flexion (3.2 vs. 0.4 degrees; p < 0.05), sagittal angulation (4.3 vs. 8.1 degrees; p < 0.05), slip in flexion (0.9 vs. 2.8 mm; p < 0.05), sagittal translation (0.7 vs. 1.6 mm; p < 0.05), and Cobb angle (-0.5 vs. -1.9 degrees; p < 0.05). CONCLUSION Midterm results of TF-FEVF were generally favorable; factors contributing to good or poor TF-FEVF outcomes were large sagittal angulation, large sagittal translation, and concave side.
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Affiliation(s)
- Kazuya Kishima
- Department of Orthopaedics, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Kiyoshi Yagi
- Department of Orthopaedic, Nagoya City University, Nagoya, Aichi, Japan
| | - Kazuta Yamashita
- Department of Orthopedics, Tokushima University Hospital, Tokushima, Japan
| | - Fumitake Tezuka
- Department of Orthopedics, Tokushima University Hospital, Tokushima, Japan
| | - Masatoshi Morimoto
- Department of Orthopedics, Tokushima University Hospital, Tokushima, Japan
| | - Yoichiro Takata
- Department of Orthopedics, Tokushima University Hospital, Tokushima, Japan
| | - Toshinori Sakai
- Department of Orthopedics, Tokushima University Hospital, Tokushima, Japan
| | - Toru Maeda
- Department of Orthopedics, Tokushima University Hospital, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Tokushima University Hospital, Tokushima, Japan
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Reddy A, Barik AK, Bhatia N, Jain K. Ultrasound-guided erector spinae plane block for awake spine surgery: A case report and review of the literature. Saudi J Anaesth 2024; 18:126-128. [PMID: 38313734 PMCID: PMC10833031 DOI: 10.4103/sja.sja_548_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 02/06/2024] Open
Abstract
Percutaneous endoscopic lumbar discectomy is increasingly gaining recognition as an alternative to open microdiscectomy for the treatment of intervertebral disk herniation. Apart from the neuraxial blockade, and general anesthesia, there is literature demonstrating the performance of endoscopic lumbar discectomy under sole local anesthesia infiltration. This is particularly advantageous as an awake patient assists the surgeon by verbalizing and preventing any inadvertent nerve root damage. However, marked pain has been reported during key steps such as endoscope port installation and radiculolysis. The erector spinae plane (ESP) block is an interfascial paraspinal block that soaks the spinal nerve roots with epidural spread providing superior analgesia for endoscopic discectomy. The utility of ESP block as a perioperative analgesic technique following spine surgery is well established; there are no reports of successful endoscopic discectomy performed using this block. This article emphasizes the utility of ESP block as the sole anesthetic technique for minimally invasive spine surgery in the awake state.
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Affiliation(s)
- Ashwini Reddy
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amiya K. Barik
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Bhatia
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kajal Jain
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mooney J, Erickson N, Laskay N, Salehani A, Mahavadi A, Ilyas A, Mainali B, Godzik J. Epidural Versus Local Anesthesia for Percutaneous Endoscopic Lumbar Discectomy: A Systematic Review and Meta-Analysis. Clin Spine Surg 2023; 36:458-469. [PMID: 37348062 DOI: 10.1097/bsd.0000000000001476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 05/09/2023] [Indexed: 06/24/2023]
Abstract
STUDY DESIGNS Systematic Review. OBJECTIVE To examine the impact of anesthesia type on patient-reported outcomes (PROs) and complications after percutaneous endoscopic lumbar discectomy (PELD). SUMMARY OF BACKGROUND DATA A significant advantage of PELD involves the option to use alternative sedation to general anesthesia (GA). Two options include local anesthesia (LA) and epidural anesthesia (EA). While EA is more involved, it may yield improved pain control and surgical results compared with LA. However, few studies have directly examined outcomes for PELD after LA versus EA, and it remains unknown which technique results in superior outcomes. MATERIALS AND METHODS A systematic review and meta-analysis of the PubMed, EMBASE, and SCOPUS databases examining PELD performed with LA or EA from inception to August 16, 2021 were conducted. All studies reported greater than 6 months of follow-up in addition to PRO data. PROs, including visual analog scale (VAS)-leg/back, and Oswestry Disability Index (ODI) scores were collected. Complications, recurrent disk herniation, durotomy, and reoperation rates, as well as surgical data, were recorded. All outcomes were compared between pooled studies examining LA or EA. RESULTS Fifty-six studies consisting of 4465 patients (366 EA, 4099 LA) were included. Overall complication rate, durotomy rate, length of stay, recurrent disk herniation, and reoperation rates were similar between groups. VAS back/leg and ODI scores were all significantly improved at the first and last follow-up appointments in the LA group. VAS leg and ODI scores were significantly improved at the first and last follow-up appointments in the EA group, but VAS back was not. CONCLUSIONS EA can be a safe and feasible alternative to LA, potentially minimizing patient discomfort during PELD. Conclusions are limited by a high level of study bias and heterogeneity. Further investigation is necessary to determine if PELD under EA may have greater short-term PRO benefits compared with LA.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, AL
| | | | - Nicholas Laskay
- Department of Neurosurgery, University of Alabama at Birmingham, AL
| | | | - Anil Mahavadi
- Department of Neurosurgery, University of Alabama at Birmingham, AL
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, AL
| | - Bipul Mainali
- School of Medicine, University of Alabama at Birmingham, AL
| | - Jake Godzik
- Department of Neurosurgery, University of Alabama at Birmingham, AL
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Abel F, Fiore J, Belanger M, Sneag DB, Lebl DR, Tan ET. Lumbar dorsal root ganglion displacement between supine and prone positions evaluated with 3D MRI. Magn Reson Imaging 2023; 104:29-38. [PMID: 37769881 DOI: 10.1016/j.mri.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE Pre-operative lumbar spine MRI is usually acquired with the patient supine, whereas lumbar spine surgery is most commonly performed prone. For MRI to be used reliably and safely for intra-operative navigation for foraminal and extraforaminal decompression, the magnitude of dorsal root ganglion (DRG) displacement between supine and prone positions needs to be understood. METHODS A prospective study of a degenerative lumbar spine cohort of 18 subjects indicated for lumbar spine surgery. Three-dimensional T2-weighted fast spin echo and T1-weighted spoiled gradient echo sequences were acquired at 3 T. Displacement and cross-sectional area (CSA) of the bilateral DRGs at 5 motion levels (L1-2 to L5-S1) were determined via 3D segmentation by 2 independent evaluators. Wilcoxon rank-sum tests without correction for multiple comparison were performed against hypothesized 1-mm absolute displacement and corresponding 24% CSA change. RESULTS DRG mean absolute displacement was <1 mm (p > 0.99, mean = 0.707 mm, 95% confidence interval (CI) = 0.659 to 0.755 mm), with the largest directional displacement in the dorsal-to-ventral direction from supine to prone (mean = 0.141 mm, 95% CI = 0.082 to 0.200 mm). Directional displacements caudal-to-cephalad were 0.087 mm (95% CI = 0.022 to 0.151 mm), and left-right were -0.030 mm (95%CI = -0.059 to -0.001 mm). Mean CSA change was within 24% (p > 0.99, mean = -8.30%, 95% CI = -10.5 to -6.09%). Mean absolute displacement was largest for the L1 (mean = 0.811 mm) and L2 (mean = 0.829 mm) DRGs. CONCLUSIONS Minimal, non-statistically significant soft tissue displacement and morphological area differences were demonstrated between supine and prone positions during 3D lumbar spine MRI.
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Affiliation(s)
- Frederik Abel
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA; Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jake Fiore
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Marianne Belanger
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Darren R Lebl
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Ek T Tan
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA.
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Huang X, Liu X, Zhu B, Hou X, Hai B, Li S, Yu D, Zheng W, Li R, Pan J, Yao Y, Dai Z, Zeng H. Evaluation of Augmented Reality Surgical Navigation in Percutaneous Endoscopic Lumbar Discectomy: Clinical Study. Bioengineering (Basel) 2023; 10:1297. [PMID: 38002421 PMCID: PMC10669401 DOI: 10.3390/bioengineering10111297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The puncture procedure in percutaneous endoscopic lumbar discectomy (PELD) is non-visual, and the learning curve for PELD is steep. METHODS An augmented reality surgical navigation (ARSN) system was designed and utilized in PELD. The system possesses three core functionalities: augmented reality (AR) radiograph overlay, AR puncture needle real-time tracking, and AR navigation. We conducted a prospective randomized controlled trial to evaluate its feasibility and effectiveness. A total of 20 patients with lumbar disc herniation treated with PELD were analyzed. Of these, 10 patients were treated with the guidance of ARSN (ARSN group). The remaining 10 patients were treated using C-arm fluoroscopy guidance (control group). RESULTS The AR radiographs and AR puncture needle were successfully superimposed on the intraoperative videos. The anteroposterior and lateral AR tracking distance errors were 1.55 ± 0.17 mm and 1.78 ± 0.21 mm. The ARSN group exhibited a significant reduction in both the number of puncture attempts (2.0 ± 0.4 vs. 6.9 ± 0.5, p = 0.000) and the number of fluoroscopies (10.6 ± 0.9 vs. 18.5 ± 1.6, p = 0.000) compared with the control group. Complications were not observed in either group. CONCLUSIONS The results indicate that the clinical application of the ARSN system in PELD is effective and feasible.
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Affiliation(s)
- Xin Huang
- Pain Medicine Center, Peking University Third Hospital, Beijing 100191, China; (X.H.)
| | - Xiaoguang Liu
- Pain Medicine Center, Peking University Third Hospital, Beijing 100191, China; (X.H.)
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Bin Zhu
- Department of Orthopedics, Beijing Friendship Hospital, Beijing 100052, China
| | - Xiangyu Hou
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Bao Hai
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
| | - Shuiqing Li
- Pain Medicine Center, Peking University Third Hospital, Beijing 100191, China; (X.H.)
| | - Dongfang Yu
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China
| | - Wenhao Zheng
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China
| | - Ranyang Li
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China
| | - Junjun Pan
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China
| | - Youjie Yao
- Smart Learning Institute, Beijing Normal University, Beijing 100875, China
| | - Zailin Dai
- Smart Learning Institute, Beijing Normal University, Beijing 100875, China
| | - Haijun Zeng
- Smart Learning Institute, Beijing Normal University, Beijing 100875, China
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18
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Zhong D, Wang Y, Lin L, Cheng S, Zhao GS, Wang LY, Liu Y, Ke ZY. Development and Validation of a Nomogram to Predict the Risk of Recurrent Lower Extremity Radiating Pain Within 1 Week Following Full-Endoscopic Lumbar Discectomy. World Neurosurg 2023; 179:e348-e358. [PMID: 37634669 DOI: 10.1016/j.wneu.2023.08.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Accurately predicting the risk of lower extremity (LE) radiating pain after surgery is an important endeavor for spinal surgeons. Our study aimed to identify risk factors for LE radiating pain after decompression with full-endoscopic lumbar discectomy (FELD) and develop a nomogram. METHODS We retrospectively reviewed the medical data of patients with lumbar disc herniation who underwent FELD. Two hundred thirty-five patients diagnosed at our hospital from January 2015 to December 2020 were used for model development. The independent risk factors for LE radiating pain after surgery were determined by least absolute shrinkage and selection operator logistic regression and multivariate logistic regression analysis. A nomogram was developed to predict the risk of LE radiating pain based on independent risk factors. Receiver operating characteristic curve, calibration curve, and decision curve analyses were used to evaluate the predictive performance. The nomogram was further verified by an independent cohort. RESULTS Three hundred seventy-five patients were enrolled in this study, with 102 patients in the training cohort reporting LE radiating pain after FELD, while 133 patients did not. In the validation cohort, 57 patients reported LE radiating pain after FELD, while 83 patients did not. The model was established by multivariate logistic regression analysis. The risk factors included a higher Michigan State University classification of herniated discs, increased disease course, increased time of surgery, reduced lateral recess width, and an interlaminar surgical approach, compared to transforaminal approach. The C-indices and the area under the receiver operating characteristic curve of the predictive model demonstrated good discrimination. Good predictive performance and accuracy were also observed in the validation cohort. CONCLUSIONS A novel nomogram for predicting recurrent LE radiating pain within 1 week after FELD was established and validated. More aggressive pain management strategies should be considered for patients at high risk of LE radiating pain after surgery, as predicted by this model.
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Affiliation(s)
- Dian Zhong
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Wang
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Lu Lin
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Si Cheng
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guo Sheng Zhao
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Yuan Wang
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Liu
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen Yong Ke
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Dannebrock FA, Zardo EDA, Ziegler MS, Vialle E, Soder RB, Schwanke CHA. Lumbar safety triangle: comparative study of coronal and coronal oblique planes in 3.0-T magnetic resonance imaging. Radiol Bras 2023; 56:327-335. [PMID: 38504808 PMCID: PMC10948153 DOI: 10.1590/0100-3984.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/31/2023] [Accepted: 09/26/2023] [Indexed: 03/21/2024] Open
Abstract
Objective To compare the measurements of the lumbar safety triangle (Kambin's triangle) and the invasion of the dorsal root ganglion in the triangle in coronal and coronal oblique planes. Materials and Methods A cross-sectional study, in which 210 3.0-T magnetic resonance images of L2-L5 were analyzed in coronal and coronal oblique planes. Exams with lumbar spine anomalies were excluded. Demographic (sex and age) and radiological variables were recorded by a single evaluator. Results Most sample was female (57.1%), mean age 45.5 ± 13.3 (18-98 years). The measurements average, as well as the areas, gradually increased from L2 to L5. The dorsal root ganglion invaded the triangle in all images. The safety triangle average area was smaller in the coronal oblique plane than in the coronal plane. Of the seven dimensions of safety triangle obtained for each level of the lumbar spine, six were significantly smaller in the coronal oblique plane than in the coronal plane. The only dimension that showed no difference was the smallest ganglion dimension. Conclusion The dimensions and areas investigated were smaller in coronal oblique plane, especially the area (difference > 1 mm). The analysis of the triangular zone in this plane becomes important in the preoperative assessment of minimally invasive procedures.
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Affiliation(s)
| | - Erasmo de Abreu Zardo
- Pontifícia Universidade Católica do Rio Grande do Sul
(PUCRS), Porto Alegre, RS, Brazil
- Instituto Gaúcho de Cirurgia da Coluna Vertebral, Porto
Alegre, RS, Brazil
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20
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Huang X, Liu X, Zhu B, Hou X, Hai B, Yu D, Zheng W, Li R, Pan J, Yao Y, Dai Z, Zeng H. Augmented Reality Surgical Navigation in Minimally Invasive Spine Surgery: A Preclinical Study. Bioengineering (Basel) 2023; 10:1094. [PMID: 37760196 PMCID: PMC10525156 DOI: 10.3390/bioengineering10091094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND In minimally invasive spine surgery (MISS), where the surgeon cannot directly see the patient's internal anatomical structure, the implementation of augmented reality (AR) technology may solve this problem. METHODS We combined AR, artificial intelligence, and optical tracking to enhance the augmented reality minimally invasive spine surgery (AR-MISS) system. The system has three functions: AR radiograph superimposition, AR real-time puncture needle tracking, and AR intraoperative navigation. The three functions of the system were evaluated through beagle animal experiments. RESULTS The AR radiographs were successfully superimposed on the real intraoperative videos. The anteroposterior (AP) and lateral errors of superimposed AR radiographs were 0.74 ± 0.21 mm and 1.13 ± 0.40 mm, respectively. The puncture needles could be tracked by the AR-MISS system in real time. The AP and lateral errors of the real-time AR needle tracking were 1.26 ± 0.20 mm and 1.22 ± 0.25 mm, respectively. With the help of AR radiographs and AR puncture needles, the puncture procedure could be guided visually by the system in real-time. The anteroposterior and lateral errors of AR-guided puncture were 2.47 ± 0.86 mm and 2.85 ± 1.17 mm, respectively. CONCLUSIONS The results indicate that the AR-MISS system is accurate and applicable.
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Affiliation(s)
- Xin Huang
- Pain Medicine Center, Peking University Third Hospital, Beijing 100191, China;
| | - Xiaoguang Liu
- Pain Medicine Center, Peking University Third Hospital, Beijing 100191, China;
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China; (X.H.); (B.H.)
| | - Bin Zhu
- Department of Orthopedics, Beijing Friendship Hospital, Beijing 100052, China;
| | - Xiangyu Hou
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China; (X.H.); (B.H.)
| | - Bao Hai
- Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China; (X.H.); (B.H.)
| | - Dongfang Yu
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China; (D.Y.); (R.L.)
| | - Wenhao Zheng
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China; (D.Y.); (R.L.)
| | - Ranyang Li
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China; (D.Y.); (R.L.)
| | - Junjun Pan
- State Key Laboratory of Virtual Reality Technology and Systems, Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing 100191, China; (D.Y.); (R.L.)
| | - Youjie Yao
- Smart Learning Institute, Beijing Normal University, Beijing 100875, China
| | - Zailin Dai
- Smart Learning Institute, Beijing Normal University, Beijing 100875, China
| | - Haijun Zeng
- Smart Learning Institute, Beijing Normal University, Beijing 100875, China
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21
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Tabarestani TQ, Sykes DAW, Kouam RW, Salven DS, Wang TY, Mehta VA, Shaffrey CI, Wiggins WF, Chi JH, Abd-El-Barr MM. Novel Approach to Percutaneous Lumbar Surgeries via Kambin's Triangle-Radiographic and Surgical Planning Analysis with Nerve Segmentation Technology. World Neurosurg 2023; 177:e385-e396. [PMID: 37355168 DOI: 10.1016/j.wneu.2023.06.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE While Kambin's Triangle has become an ever more important anatomic window given its proximity to the exiting nerve root, there have been limited studies examining the effect of disease on the corridor. Our goal was to better understand how pathology can affect Kambin's Triangle, thereby altering the laterality of approach for percutaneous lumbar interbody fusion (percLIF). METHODS The authors performed a single-center retrospective review of patients evaluated for percLIF. The areas of Kambin's Triangle were measured without and with nerve segmentation. For the latter, the lumbosacral nerve roots on 3-dimensional T2 magnetic resonance imaging were manually segmented. Next, the borders of Kambin's Triangle were delineated, ensuring no overlap between the area and nerve above. RESULTS Fifteen patients (67.5 ± 9.7 years, 46.7% female) were retrospectively reviewed. We measured 150 Kambin's Triangles. The mean areas from L1-S1 were 50.0 ± 12.3 mm2, 73.8 ± 12.5 mm2, 83.8 ± 12.2 mm2, 88.5 ± 19.0 mm2, and 116 ± 29.3 mm2, respectively. When pathology was present, the areas significantly decreased at L4-L5 (P = 0.046) and L5-S1 (P = 0.049). Higher spondylolisthesis and smaller posterior disk heights were linked with decreased areas via linear regression analysis (P < 0.05). When nerve segmentation was used, the areas were significantly smaller from L1-L5 (P < 0.05). Among 11 patients who underwent surgery, none suffered from postoperative neuropathies. CONCLUSIONS These results illustrate the feasibility of preoperatively segmenting lumbosacral nerves and measuring Kambin's Triangle to help guide surgical planning and determine the ideal laterality of approach for percLIF.
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Affiliation(s)
| | - David A W Sykes
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Romaric W Kouam
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina, USA
| | - David S Salven
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Timothy Y Wang
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Vikram A Mehta
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | | | - Walter F Wiggins
- Department of Radiology, Duke University Hospital, Durham, North Carolina, USA
| | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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22
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Mooney J, Laskay N, Erickson N, Salehani A, Mahavadi A, Ilyas A, Mainali B, Nowak B, Godzik J. General vs Local Anesthesia for Percutaneous Endoscopic Lumbar Discectomy (PELD): A Systematic Review and Meta-Analysis. Global Spine J 2023; 13:1671-1688. [PMID: 36564907 PMCID: PMC10448082 DOI: 10.1177/21925682221147868] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES It remains unknown whether general anesthesia (GA) or local ± epidural anesthesia (LA) results in superior outcomes with percutaneous endoscopic lumbar discectomy (PELD). The present study sought to examine the impact of anesthesia type on patient-reported outcomes (PROs) and complications with PELD. METHODS Systematic review and meta-analysis examining PELD performed under GA or LA was conducted. Patient-reported outcomes including Visual Analog Scale (VAS)-leg/back, and Oswestry Disability Index (ODI) scores were collected. Complication, recurrent disc herniation, durotomy, and reoperation rates as well as surgical data were recorded. All outcomes were compared between pooled studies examining GA or LA. RESULTS Sixty-eight studies consisting of 5269 patients (724 GA, 4465 LA) were included in the meta-analysis. Overall complication rate was significantly higher in the GA group (9% vs 4%, P = .003). Durotomy rates, length of stay, recurrent disc herniation and reoperation rates were similar between groups. At the first follow-up timepoint, the LA group demonstrated significant improvements in VAS back and ODI scores (P < .05) while the GA group did not (P > .05). At the final follow-up (> 6 months), the percent of patients achieving an excellent McNab score was significantly higher in the GA vs LA group (P < .001). CONCLUSIONS Percutaneous endoscopic lumbar discectomy with LA may be associated with greater short-term improvement in VAS back pain and ODI scores. General anesthesia may be associated with more durable pain relief but a higher complication rate. Further systematic investigation is necessary to determine what short and long term benefits are associated with PELD performed under LA and GA.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicholas Laskay
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nicholas Erickson
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anil Mahavadi
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bipul Mainali
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Błażej Nowak
- Department of Neurosurgery, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
| | - Jake Godzik
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
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23
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Greil ME, Ogunlade JI, Bergquist J, Williams JR, Kashlan ON, Hofstetter CP. Full-endoscopic trans-pars interarticularis approach for far lateral lumbar discectomy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07698-1. [PMID: 37166550 DOI: 10.1007/s00586-023-07698-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Surgical management of far lateral disc herniations remains challenging. Current transforaminal full-endoscopic approaches require non-visualized docking in the Kambin's triangle and have been associated with significant risk of inadvertent nerve injury. We develop a full-endoscopic approach based on reliable bony landmarks allowing for visualization of the exiting nerve root prior to the far lateral discectomy. METHODS The surgical details of a full-endoscopic trans-pars interarticularis approach for far lateral discectomy are described. These descriptions include high quality intraoperative images and important surgical pearls. A small patient cohort is presented to demonstrate feasibility and safety of the procedure. RESULTS We demonstrate the feasibility of this approach in 14 patients with a mean age of 59.5 ± 14.7 years. At a mean follow up of 21.9 ± 6.8 months, improvement of the visual analogue scale (VAS) for leg pain was 4.3 ± 1.0 resulting in minimally clinically important difference in 78.6% of the patients. The mean improvement in VAS for the back pain was 2.6 ± 0.8 and for Oswestry disability index (ODI) was 20.6 ± 5.3. Nuances of the trans-pars surgical techniques are presented in a patient with a right-sided L4-5 far lateral disc herniation. Preoperative imaging studies, steps of the surgical progression, and intraoperative views are described in detail. CONCLUSION Using the pars interarticularis as the bony target area allows for safe visualized access to the extraforaminal compartment of the exiting nerve root. This novel surgical technique has the potential benefit of decreasing inadvertent neural injury and subsequent postoperative dysesthesias.
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Affiliation(s)
- Madeline E Greil
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - John I Ogunlade
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Julia Bergquist
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - John R Williams
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - Osama N Kashlan
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christoph P Hofstetter
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA.
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Yamada K, Nagahama K, Abe Y, Hyugaji Y, Ukeba D, Endo T, Ohnishi T, Ura K, Sudo H, Iwasaki N, Takahata M. Evaluation of Surgical Indications for Full Endoscopic Discectomy at Lumbosacral Disc Levels Using Three-Dimensional Magnetic Resonance/Computed Tomography Fusion Images Created with Artificial Intelligence. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050860. [PMID: 37241092 DOI: 10.3390/medicina59050860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Although full endoscopic lumbar discectomy with the transforaminal approach (FED-TF) is a minimally invasive spinal surgery for lumbar disc herniation, the lumbosacral levels present anatomical challenges when performing FED-TF surgery due to the presence of the iliac bone. Materials and Methods: In this study, we simulated whether FED-TF surgery could be safely performed on a total of 52 consecutive cases with L5-S1 or L5-L6 disc herniation using fused three-dimensional (3D) images of the lumbar nerve root on magnetic resonance imaging (MRI) created with artificial intelligence and of the lumbosacral spine and iliac on computed tomography (CT) images. Results: Thirteen of the fifty-two cases were deemed operable according to simulated FED-TF surgery without foraminoplasty using the 3D MRI/CT fusion images. All 13 cases underwent FED-TF surgery without neurological complications, and their clinical symptoms significantly improved. Conclusions: Three-dimensional simulation may allow for the assessment from multiple angles of the endoscope entry and path, as well as the insertion angle. FED-TF surgery simulation using 3D MRI/CT fusion images could be useful in determining the indications for full endoscopic surgery for lumbosacral disc herniation.
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Affiliation(s)
- Katsuhisa Yamada
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Ken Nagahama
- Department of Orthopaedic Surgery, Sapporo Endoscopic Spine Surgery Clinic, North-16, East-16, Higashi-ku, Sapporo 065-0016, Hokkaido, Japan
| | - Yuichiro Abe
- Department of Orthopaedic Surgery, Eniwa Hospital, Eniwa 061-1449, Hokkaido, Japan
| | - Yoshinori Hyugaji
- Department of Orthopaedic Surgery, Sapporo Endoscopic Spine Surgery Clinic, North-16, East-16, Higashi-ku, Sapporo 065-0016, Hokkaido, Japan
| | - Daisuke Ukeba
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Tsutomu Endo
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Takashi Ohnishi
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Katsuro Ura
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Hideki Sudo
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
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Tang K, Goldman S, Avrumova F, Lebl DR. Background, techniques, applications, current trends, and future directions of minimally invasive endoscopic spine surgery: A review of literature. World J Orthop 2023; 14:197-206. [PMID: 37155511 PMCID: PMC10122780 DOI: 10.5312/wjo.v14.i4.197] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/02/2023] [Accepted: 04/12/2023] [Indexed: 04/18/2023] Open
Abstract
Across many of the surgical specialties, the use of minimally invasive techniques that utilize indirect visualization has been increasingly replacing traditional techniques which utilize direct visualization. Arthroscopic surgery of the appendicular skeleton has evolved dramatically and become an integral part of musculoskeletal surgery over the last several decades, allowing surgeons to achieve similar or better outcomes, while reducing cost and recovery time. However, to date, the axial skeleton, with its close proximity to critical neural and vascular structures, has not adopted endoscopic techniques at as rapid of a rate. Over the past decade, increased patient demand for less invasive spine surgery combined with surgeon desire to meet these demands has driven significant evolution and innovation in endoscopic spine surgery. In addition, there has been an enormous advancement in technologies that assist in navigation and automation that help surgeons circumvent limitations of direct visualization inherent to less invasive techniques. There are currently a multitude of endoscopic techniques and approaches that can be utilized in the treatment of spine disorders, many of which are evolving rapidly. Here we present a review of the field of endoscopic spine surgery, including the background, techniques, applications, current trends, and future directions, to help providers gain a better understanding of this growing modality in spine surgery.
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Affiliation(s)
- Kevin Tang
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY 10021, United States
| | - Samuel Goldman
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY 10021, United States
| | - Fedan Avrumova
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY 10021, United States
| | - Darren R Lebl
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY 10021, United States
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Hara T, Ohara Y. Perioperative Management for Full-Endoscopic Lumbar Discectomy: Consideration From the Perspective of Preventing Complication. Neurospine 2023; 20:28-32. [PMID: 37016851 PMCID: PMC10080411 DOI: 10.14245/ns.2346056.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/02/2023] [Indexed: 04/03/2023] Open
Abstract
In recent years, full-endoscopic discectomy (FED) has expanded its range of indications with the development of devices and various techniques. The advantage of FED over conventional surgery is that it is a minimally invasive procedure. However, intraoperative and postoperative precautions must be taken to prevent complications. It is necessary to avoid complications that could compromise the outcome of the procedure. Effective perioperative management is necessary to avoid complications; however, there is no set view for perioperative management in FED. In this study, we perform a literature review to examine the effectiveness of perioperative management methods for FED. The key to ensuring the efficacy and minimal invasiveness of FED is prevention of complications. Based on the result and literature review, we believe that the most manageable postoperative management after FED is prevention of recurrent disc herniation and hematoma formation. A drain should be placed to prevent postoperative hematoma formation. It is advisable to evaluate the patient’s symptoms and monitor C-reactive protein and erythrocyte sedimentation rate levels during the first week after surgery. Postoperative antibiotics were administered for 1 day.
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Affiliation(s)
- Takeshi Hara
- Spine and Spinal Cord Center, Juntendo University, Tokyo, Japan
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
- Corresponding Author Takeshi Hara Department of Neurosurgery, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Yukoh Ohara
- Spine and Spinal Cord Center, Juntendo University, Tokyo, Japan
- Department of Neurosurgery, Juntendo University, Tokyo, Japan
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27
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Neurological Safety of Endoscopic Transforaminal Lumbar Interbody Fusion: A Magnetic Resonance Neurography Study. Spine (Phila Pa 1976) 2023; 48:344-349. [PMID: 36191017 DOI: 10.1097/brs.0000000000004496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/17/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE A magnetic resonance neurography (MRN) study was conducted to assess the neurological safety of endoscopic transforaminal lumbar intervertebral fusion (endo-TLIF). MATERIALS AND METHODS A total of 56 healthy volunteers (29 men, 27 women; average age, 44 yr; age range, 21-60 yr) were included in the study. Coronal MRN images were collected from L2/L3 to L5/S1. The working triangle, modified working zone, and safest working zone areas, as well as the vertical and horizontal safe operation diameters, were measured. Linear regression analyses were conducted to explore the correlations between general characteristics (sex, age, height, body mass index) and the measured radiographic indicators. RESULTS MRN can effectively evaluate the operation zone of endo-TLIF. The safest working zone, modified working zone, and working triangle areas were largest at L4/L5 (92.4±23.4, 136±35.6, and 197±41.7 mm 2 , respectively) and smallest at L2/L3 (45.5±12.9, 68.1±19.5, and 92.6±24.4 mm 2 , respectively). The vertical safe operation diameter was large at L4/L5 and L2/L3 (5.34±0.8 and 5.42±0.9 mm, respectively) and smallest at L5/S1 (2.94±0.9 mm). The horizontal safe operation diameter was large at L4/L5 (7.28±1.2 mm) and smaller at L5/S1 and L2/L3 (4.28±1.0 and 4.77±0.8 mm, respectively). CONCLUSIONS L4/L5 has the lowest risk of nerve injury, and may be the safest level for beginners initiating endo-TLIF in their practice. We recommend that coronal MRN is routinely performed before endo-TLIF to minimize the risk of neurological injury.
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28
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Tabarestani TQ, Sykes DAW, Maquoit G, Wang TY, Ayoub CM, Shaffrey CI, Wiggins WF, Abd-El-Barr MM. Novel Merging of CT and MRI to Allow for Safe Navigation into Kambin's Triangle for Percutaneous Lumbar Interbody Fusion-Initial Case Series Investigating Safety and Efficacy. Oper Neurosurg (Hagerstown) 2023; 24:331-340. [PMID: 36701664 DOI: 10.1227/ons.0000000000000531] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 09/18/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND For percutaneous lumbar fusion (percLIF), magnetic resonance imaging and computed tomography are critical to defining surgical corridors. Currently, these scans are performed separately, and surgeons then use fluoroscopy or neuromonitoring to guide instruments through Kambin's triangle. However, anatomic variations and intraoperative positional changes are possible, meaning that safely accessing Kambin's triangle remains a challenge because nerveroot visualization without endoscopes has not been thoroughly described. OBJECTIVE To overcome the known challenges of percLIF and reduce the likelihood of iatrogenic injuries by showing real-time locations of neural and bony anatomy. METHODS The authors demonstrate an intraoperative navigational platform that applies nerve root segmentation and image fusion to assist with percLIF. Five patients from a single institution were included. RESULTS Of the 5 patients, the mean age was 71 ± 8 years and 3 patients (60%) were female. One patient had general anesthesia while the remaining 4 patients underwent awake surgery with spinal anesthesia. The mean area for the L4-L5 Kambin's triangle was 76.1 ± 14.5 mm 2 . A case example is shown where the side of approach was based on the fact that Kambin's triangle was larger on one side compared with the other. The mean operative time was 170 ± 17 minutes, the mean blood loss was 32 ± 16 mL, and the mean hospital length of stay was 19.6 ± 8.3 hours. No patients developed postoperative complications. CONCLUSION This case series demonstrates the successful and safe application of nerve segmentation using magnetic resonance imaging/computed tomography fusion to perform percLIF and provide positive patient outcomes.
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Affiliation(s)
- Troy Q Tabarestani
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David A W Sykes
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gisselle Maquoit
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina, USA
| | - Timothy Y Wang
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Chakib M Ayoub
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina, USA
| | | | - Walter F Wiggins
- Department of Radiology, Duke University Hospital, Durham, North Carolina, USA
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Wagner R, Hu J, Hofstetter CP. Trans-Superior Articular Process Endoscopic Lumbar Approach. ENDOSCOPY OF THE SPINE 2023:313-322. [DOI: 10.1007/978-981-19-7761-9_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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Waguia Kouam R, Tabarestani TQ, Sykes DAW, Gupta N, Futch BG, Kakmou E, Goodwin CR, Foster NA, Than KD, Wiggins WF, Abd-El-Barr MM. How dimensions can guide surgical planning and training: a systematic review of Kambin's triangle. Neurosurg Focus 2023; 54:E6. [PMID: 36587400 DOI: 10.3171/2022.10.focus22606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/17/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The authors sought to analyze the current literature to determine dimensional trends across the lumbar levels of Kambin's triangle, clarify the role of imaging techniques for preoperative planning, and understand the effect of inclusion of the superior articular process (SAP). This compiled knowledge of the triangle is needed to perform successful procedures, reduce nerve root injuries, and help guide surgeons in training. METHODS The authors performed a search of multiple databases using combinations of keywords: Kambin's triangle, size, measurement, safe triangle, and bony triangle. Articles were included if their main findings included measurement of Kambin's triangle. The PubMed, Scopus, Ovid, Cochrane, Embase, and Medline databases were systematically searched for English-language articles with no time frame restrictions through July 2022. RESULTS Eight studies comprising 132 patients or cadavers were included in the study. The mean ± SD age was 66.69 ± 9.6 years, and 53% of patients were male. Overall, the size of Kambin's triangle increased in area moving down vertebral levels, with L5-S1 being the largest (133.59 ± 4.36 mm2). This trend followed a linear regression model when SAP was kept (p = 0.008) and removed (p = 0.003). There was also a considerable increase in the size of Kambin's triangle if the SAP was removed. CONCLUSIONS Here, the authors have provided the first reported systematic review of the literature of Kambin's triangle, its measurements at each lumbar level, and key areas of debate related to the definition of the working safe zone. These findings indicate that CT is heavily utilized for imaging of the safe zone, the area of Kambin's triangle tends to increase caudally, and variation exists between patients. Future studies should focus on using advanced imaging techniques for preoperative planning and establishing guidelines for surgeons.
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Affiliation(s)
| | | | | | - Nithin Gupta
- 1Campbell University School of Osteopathic Medicine, Lillington
| | | | - Elisabeth Kakmou
- 3Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - C Rory Goodwin
- 3Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - Norah A Foster
- 4Department of Orthopedic Surgery, Miami Valley Hospital, Centerville, Ohio; and
| | - Khoi D Than
- 3Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - Walter F Wiggins
- 5Department of Radiology, Duke University Hospital, Durham, North Carolina
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Yusof MI, Salim AA, Johari J, Rajagopal AR. Determination of the Entry Point for Lower Lumbar Intradiscal Procedure Using Transforaminal Technique: Cross-Sectional Study Using Magnetic Resonance Imaging. Spine Surg Relat Res 2022; 6:689-695. [PMID: 36561161 PMCID: PMC9747223 DOI: 10.22603/ssrr.2021-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/20/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Triangular working area otherwise known as the Kambin triangle is designated as a safe place to position the instrument during the operation, with minimal risk to exiting nerves. This study aims to improve understanding and increase the safety of various transforaminal intradiscal procedures at L3/L4, L4/L5, and L5/S1 levels. Methods A cross-sectional analysis involving 102 MRIs that met the inclusion criteria was obtained and analyzed at the L3/L4, L4/L5, and L5/S1 discs level. For each level, the Kambin triangle was measured. By evaluating those measurements, the viability of this method was determined. Results Safe working zone approach angles were consistently getting wider from L3 to S1 levels. It was statistically significant to be wider for the left side for the mean angle of lateral nucleus trajectory at the L4/L5 level and L5/S1. The entry point is at 32, 45, and 55-60 mm from the midline, and the instrument should be directed at 12°, 20°, and 27° medially for the lateral nucleus at L3/L4, L4/L5, and L5/S1, respectively. The center of the nucleus pulposus entry point is at 64, 77, and 85 mm from the midline with a medial inclination of 40°, 47°, and 52°, respectively, for L3/L4, L4/L5, and L5/S1. For the posterior nucleus pulposus, the skin should be pierced 90, 140, and 180 mm from the midline and directed medially at 53°, 61°, and 68°, respectively, for L3/L4, L4/L5, and L5/S1. The posterior annulus fibrosis entry point is 172, 355, and 450 mm with a medial inclination of 69°, 80°, and 84° at L3/L4, L4/L5, and L5/S1, respectively. The sagittal inclination is 3° cephalad at L3/L4, 10° caudally at L4/L5, and 27° caudally at L5/S1. Conclusions Preoperative MRI assessment is important to determine the angle of trajectory for the safe entry point for intradiscal procedure via transforaminal approach.
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Affiliation(s)
- Mohd Imran Yusof
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia,Department of Orthopaedics, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Azizul Akram Salim
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia,Department of Orthopaedics, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Joehaimey Johari
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia,Department of Orthopaedics, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
| | - Allan Ravi Rajagopal
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia,Department of Orthopaedics, Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
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Usefulness of 3D CT/MRI Fusion Imaging for the Evaluation of Lumbar Disc Herniation and Kambin's Triangle. Diagnostics (Basel) 2022; 12:diagnostics12040956. [PMID: 35454004 PMCID: PMC9031438 DOI: 10.3390/diagnostics12040956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/03/2022] [Accepted: 04/10/2022] [Indexed: 02/04/2023] Open
Abstract
Study design: Prospective study. Objective: The aim of this study is to visualize the morphology of a lumbar herniated disc and Kambin’s triangle in three dimensions (3D) based on preoperative CT/MRI fusion images. Methods: CT/MRI fusion images of 23 patients (10 males and 13 females; mean age 58.2 years) were used to evaluate Kambin’s triangle, which is created between the superior articular process (SAP), exiting nerve root (ENR), inferiorly by the superior endplate of the lower lumbar vertebra and dural canal medially at 60 degree and 45 degree endoscopic approach angles. The percentage of the safe usage of transforaminal endoscopic approach was evaluated to utilize a 5 mm dilater without partial facet resection in the fusion image. The 3D lumbar nerve root sleeve angulation (3DNRA), which is the angle between the axis of the thecal sac and the nerve root sleeve, was calculated. The herniated discs were also visualized in the CT/MRI fusion image. Results: The 3DNRA became smaller from L2 to S1. The L2 3DNRA was statistically larger than those of the other root, and the S1 3DNRA was significantly smaller than the others (p < 0.05). (L2, 41.0°; L3, 35.6°; L4, 36.4°; L5, 33.9°; and S1, 23.2°). The SAP-ENR distance at 60° was greatest at L4/5 (5.9 mm). Possible needle passages at 60° to each disc level were 89.1% at L2/3, 87.0% at L3/4 and 84.8% at L4/5. However, the safe 5 mm dilater passage at 60° without bony resection to each disc level were 8.7% at L2/3, 28.3% at L3/4 and 37.0% at L4/5. The 60° corridor at L2/3 was the narrowest (p < 0.01). All herniated discs were visualized in the fusion image and the root compression site was clearly demonstrated especially with foraminal/extraforaminal herniations. Conclusion: The 3D lumbar CT/MRI fusion image enabled a combined nerve-bony assessment of Kambin’s triangle and herniated disc. A fully endoscopic 5 mm dilater may retract the exiting nerve root in more than 60% of total cases. This new imaging technique could prove to be very useful for the safety of endoscopic lumbar disc surgery.
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Hussain I, Yeung AT, Wang MY. Challenges in Spinal Endoscopy. World Neurosurg 2022; 160:132-137. [DOI: 10.1016/j.wneu.2021.11.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 10/18/2022]
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Ahn Y, Lee SG. Percutaneous endoscopic lumbar foraminotomy: how I do it. Acta Neurochir (Wien) 2022; 164:933-936. [PMID: 35020086 DOI: 10.1007/s00701-022-05114-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/02/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Percutaneous endoscopic lumbar foraminotomy (PELF) is a good alternative for foraminal stenosis. The steep learning curve and lack of a practical manual can make this technique challenging. METHOD We describe a step-by-step technique based on the literature review and our experience in actual practice: (1) posterolateral foraminal landing, (2) bony unroofing of the superior articular process, and (3) full-scale soft tissue decompression. Technical tips for preventing complications are also discussed. CONCLUSION PELF may be effective and minimally invasive. Standardized surgical techniques are essential for clinical success.
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Affiliation(s)
- Yong Ahn
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, South Korea.
| | - Sang Gu Lee
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, South Korea
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Hu B, Li L, Wang H, Ma T, Fu Z, Kang X, Feng Z. Determining the Minimum Effective Concentration of Ropivacaine in Epidural Anesthesia for Tolerable Pain in Transforaminal Percutaneous Endoscopic Lumbar Discectomy to Avoid Nerve Injury: A Double-Blind Study Using a Biased-Coin Design. Drug Des Devel Ther 2022; 16:315-323. [PMID: 35173415 PMCID: PMC8841299 DOI: 10.2147/dddt.s334605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/21/2021] [Indexed: 01/09/2023] Open
Abstract
Purpose Epidural anesthesia (EA) is the main anesthesia method for transforaminal percutaneous endoscopic lumbar discectomy (PELD). Reducing the concentration of ropivacaine can help preserve tactile sensation, allowing patients to provide timely feedback to the surgeons when a nerve root is contacted to avoid nerve injury. Therefore, a 90% effective concentration (EC90) that allows for mild pain [visual analog scale (VAS) score ≤3] while maximizing tactile sensation must be identified. Methods The concentration of ropivacaine for EA was varied for consecutive patients in this study using a two-stage biased-coin design (BCD) according to the response of the previous patient; the concentration used for the first patient was 0.2%. When the previous patient had a negative response (VAS score >3), the concentration used for the next one was increased by 0.015%. When the previous patient had a positive response (VAS score ≤3), the concentration used for the next one had an 89% probability of remaining the same and an 11% probability of being reduced by 0.015%. The EC90 of ropivacaine was estimated using isotonic regression, and the 95% confidence interval (CI) was estimated using the bootstrapping method in R. Results A total of 58 patients were included in the study. The calculated EC90 was 0.294% [95% CI (0.271%, 0.303%)]. Among 13 patients who reported unintended nerve root contact during the operation, none were found to have irreversible nerve injury after the operation. Conclusion To preserve maximum tactile sensation, the EC90 of ropivacaine was 0.294% for patients with allowed mild pain. This concentration could allow for timely feedback when the nerve root is contacted, to avoid nerve injury.
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Affiliation(s)
- Bingwei Hu
- Department of Pain, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Liang Li
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Hongwei Wang
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Tingting Ma
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Zhimei Fu
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang, People’s Republic of China
| | - Xianhui Kang
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
| | - Zhiying Feng
- Department of Pain, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People’s Republic of China
- Correspondence: Zhiying Feng; Xianhui Kang, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People’s Republic of China, Email ;
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Cao J, Xie P, Feng F, Li K, Tan L, Chen Z, Ren J, Zheng R, Rong L. Potential Application of MR-MR-US Fusion Imaging Navigation with Needle Tail Intelligent Positioning in Guiding Puncture in Percutaneous Transforaminal Endoscopic Discectomy. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3458-3469. [PMID: 34593278 DOI: 10.1016/j.ultrasmedbio.2021.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 06/13/2023]
Abstract
This study sought to investigate the feasibility of using magnetic resonance-magnetic resonance-ultrasound (MR-MR-US) fusion imaging navigation (FIN) with needle tail intelligent positioning (NTIP) to guide puncture in percutaneous transforaminal endoscopic discectomy (PTED). First, in a pig experiment, we found that puncture errors in lumbar intervertebral foramen (LIF) puncture using magnetic resonance-magnetic resonance-ultrasound (MR-MR-US) FIN with NTIP for experienced and novice operators were 2.00 ± 1.00 and 2.57 ± 0.98 mm, respectively (p = 0.231), suggesting this technique was minimally dependent on experience. Then, two experienced surgeons agreed (inter-observer agreement к=0.801) that the quality of MR-MR fusion images was good or sufficient. Finally, we performed PTED in eight patients using MR-MR-US FIN with NTIP, and no significant complications were reported during LIF puncture. Overall, MR-MR-US FIN with NTIP may be a potential application for guiding puncture in PTED, but more clinical studies with a larger sample size are required to further evaluate the advantages of MR-MR-US FIN with NTIP.
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Affiliation(s)
- Junyan Cao
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Key Laboratory of Liver Research, Guangzhou, China
| | - Peigen Xie
- Department of Spine Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Feng Feng
- Department of Spine Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Kai Li
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Key Laboratory of Liver Research, Guangzhou, China
| | - Lei Tan
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Key Laboratory of Liver Research, Guangzhou, China
| | - Zihao Chen
- Department of Spine Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China
| | - Jie Ren
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Key Laboratory of Liver Research, Guangzhou, China
| | - Rongqin Zheng
- Department of Ultrasound, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Key Laboratory of Liver Research, Guangzhou, China.
| | - Limin Rong
- Department of Spine Surgery, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Quality Control of Minimally Invasive Spine Surgery, Guangzhou, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Center for Engineering and Technology Research of Minimally Invasive Spine Surgery, Guangzhou, China.
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Lewandrowski KU, Telfeian AE, Hellinger S, Jorge Felipe Ramírez León, Paulo Sérgio Teixeira de Carvalho, Ramos MRF, Kim HS, Hanson DW, Salari N, Yeung A. Difficulties, Challenges, and the Learning Curve of Avoiding Complications in Lumbar Endoscopic Spine Surgery. Int J Spine Surg 2021; 15:S21-S37. [PMID: 34974418 PMCID: PMC9421222 DOI: 10.14444/8161] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Spinal endoscopy has the stigma of being reserved for only a few surgeons who can figure out how to master the steep learning curve and develop clinical practice settings where endoscopic spine surgery can thrive. In essence, endoscopic treatment of herniated discs specifically and nerve root compression in the lumbar spine in general amounts to replacing traditional open spine surgery protocols with spinal endoscopic surgery techniques. In doing so, the endoscopic spine surgeon must be confident that the degenerative spine's common painful problems can be handled with endoscopic spinal surgery techniques with at least comparable clinical results and complication rates. In this review article, the authors illustrate the difficulties and challenges of the endoscopic lumbar decompression procedure. In addition, they shed light on how to master the learning curve by systematically looking at all sides of the problem, ranging from the ergonomic aspects of the endoscopic platform and its instruments, surgical access planning, challenging clinical scenarios, complications, and sequelae, as well as the training gaps after postgraduate residency and fellowship programs.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Staff Orthopaedic Spine Surgeon Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tuscon, Arizona
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá, D.C., Colombia
- Department of Orthopedics, Hospital Universitário Gaffre e Guinle, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Stefan Hellinger
- Department of Orthopedic Surgery, Arabellaklinik, Munich, Germany
| | - Jorge Felipe Ramírez León
- Centro de Columna - Cirugía Mínima Invasiva, Clínica Reina Sofía - Clínica Colsanitas, Bogotá, D.C., Colombia
- Fundación Universitaria Sanitas. Bogotá, D.C., Colombia
| | - Paulo Sérgio Teixeira de Carvalho
- Federal University of the State of Rio de Janeiro UNIRIO, Rio de Janeiro, Brazil
- Gaffre e Guinle University Hospital, Rio de Janeiro, Brazil
| | - Max R F Ramos
- Federal University of the State of Rio de Janeiro UNIRIO, Rio de Janeiro, Brazil
- Gaffre e Guinle University Hospital, Rio de Janeiro, Brazil
| | - Hyeun Sung Kim
- Department of Neurosurgery, Nanoori Hospital, Seoul City, Republic of Korea
| | | | - Nimar Salari
- Desert Institute for Spine Care, Phoenix, Arizona
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Xue YD, Diao WB, Ma C, Li J. Lumbar degenerative disease treated by percutaneous endoscopic transforaminal lumbar interbody fusion or minimally invasive surgery-transforaminal lumbar interbody fusion: a case-matched comparative study. J Orthop Surg Res 2021; 16:696. [PMID: 34838078 PMCID: PMC8626985 DOI: 10.1186/s13018-021-02841-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/12/2021] [Indexed: 12/20/2022] Open
Abstract
Purpose This study aimed to evaluate the clinical efficacy and imaging results of percutaneous endoscopic transforaminal lumbar interbody fusion (PETLIF) through comparing it with minimally invasive surgery-transforaminal lumbar interbody fusion (MISTLIF). Materials and methods We performed a retrospective analysis on patients with lumbar degenerative disease treated by PETLIF or MISTLIF from September 2017 to January 2019, and the patients were divided into two groups: the PETLIF group and the MISTLIF group. The clinical and imaging parameters of the two groups were evaluated. Results There was no significant difference between the two groups in complication rate. The operative time in the PETLIF group was significantly less than that in the MISTLIF group. Compared with those before operation, the postoperative VAS-L and VAS-B scores were significantly improved after operation in the both groups. In addition, the postoperative VAS-B score of the PETLIF group was significantly lower than that of the MISTLIF group. At the last follow-up, there was no significant difference between the two groups in the VAS-L score, VAS-B score, ODI score, and bony fusion rate. Conclusions Both PETLIF and MISTLIF could achieve satisfactory clinical outcomes in the treatment of lumbar degenerative disease, but our study suggested that PETLIF had less damage, rapid recovery after operation, and short discharge time. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-021-02841-4.
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Affiliation(s)
- You-Di Xue
- Department of Orthopaedics, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou Clinical College of Nanjing Medical University, 199 Jiefang South Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China
| | - Wen-Bo Diao
- Department of Orthopaedics, Zhoukou Orthopedic Hospital, Zhoukou, 466000, Henan, People's Republic of China
| | - Chao Ma
- Department of Orthopaedics, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou Clinical College of Nanjing Medical University, 199 Jiefang South Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China
| | - Jie Li
- Department of Orthopaedics, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University, Xuzhou Clinical College of Nanjing Medical University, 199 Jiefang South Road, Xuzhou, 221009, Jiangsu Province, People's Republic of China.
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Ahn Y, Yoo BR, Jung JM. The irony of the transforaminal approach: A comparative cohort study of transforaminal endoscopic lumbar discectomy for foraminal versus paramedian lumbar disc herniation. Medicine (Baltimore) 2021; 100:e27412. [PMID: 34622848 PMCID: PMC8500638 DOI: 10.1097/md.0000000000027412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/17/2021] [Indexed: 01/05/2023] Open
Abstract
Transforaminal endoscopic lumbar discectomy (TELD) is useful for soft lumbar disc herniation (LDH). Although the transforaminal approach can reach the foraminal disc zone, the risk of exiting nerve root irritation along the path is considerable. Few studies have assessed the difficulties of TELD for foraminal LDH. The objective of this study is to compare the clinical results of TELD between foraminal or far-lateral LDH and paramedian LDH.Between June 2016 and July 2017, 135 consecutive patients with single-level LDH were treated with TELD for 2 years. Among them, 25 patients had foraminal or far-lateral LDH (foraminal group), and the remaining 110 patients had central or subarticular LDH (paramedian group). Perioperative data and clinical outcomes were evaluated using the visual analog pain scale, Oswestry Disability Index, and modified Macnab criteria.The foraminal group showed a higher rate of significant access pain (24.00% vs 8.19%, P < .05). The foraminal group also had a longer duration of surgery, length of hospital stay, and return to work (all P < .05). Pain scores and functional status were significantly improved in both groups. Although there were no differences in the outcomes at 2 years postoperatively, early pain and disability at 6 weeks were higher in the foraminal group.Ironically, the early clinical results of TELD for foraminal LDH may be less favorable than those for paramedian LDH. Therefore, great care should be taken during TELD for foraminal or far-lateral LDH.
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Morphological analysis of Kambin's triangle using 3D CT/MRI fusion imaging of lumbar nerve root created automatically with artificial intelligence. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2191-2199. [PMID: 34216235 DOI: 10.1007/s00586-021-06916-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/04/2021] [Accepted: 06/26/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE We developed a software program that automatically extracts a three-dimensional (3D) lumbar nerve root image from magnetic resonance imaging (MRI) lumbar nerve volume data using artificial intelligence. The aim of this study is to evaluate the morphology of Kambin's triangle in three dimensions based on an actual endoscopic transforaminal surgical approach using three-dimensional (3D) computed tomography (CT)/ magnetic resonance imaging (MRI) fusion images of the lumbar spine and nerve tissue. METHODS Three-dimensional lumbar spine/nerve images of 100 patients (31 males and 69 females; mean age, 66.8 years) were used to evaluate the relationship between the superior articular process (SAP), exiting nerve root (ENR), and dural canal at the L2/3, L3/4, and L4/5 levels at 45° and 60° approach angles. RESULTS The SAP-ENR distance at 60° was the greatest at L4/5 and was significantly greater at L2/3 and L4/5 than at L3/4 (P < 0.01, P < 0.01, respectively). The SAP-ENR distance at 45° was the greatest at L2/3, and it was larger in L2/3 and L4/5 than in L3/4 (P < 0.01, P < 0.01, respectively). The SAP-ENR distances at L4/5 were significantly greater at 60° than at 45° (P < 0.01). The dural canal was located within Kambin's triangle on the plane of the upper endplate of the lower vertebra at L2/3 in 41.5% of the cases and at L3/4 in 14% of the cases at 60° but not at L4/5. CONCLUSION The 3D lumbar spine/nerve image enabled a combined assessment of the positional relationship between the SAP, ENR, and dural canal to quantify the safety zone of practical endoscopic spinal surgery using a transforaminal approach. Three-dimensional lumbar spine/nerve images could be useful for examining parameters, including bones and nerves, to ensure the safety of surgery.
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Pruttikul P, Chobchai W, Pluemvitayaporn T, Kunakornsawat S, Piyaskulkaew C, Kittithamvongs P. Comparison of post-operative wound pain between interlaminar and transforaminal endoscopic spine surgery: which is superior? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:909-914. [PMID: 34169355 DOI: 10.1007/s00590-021-03065-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Prospective cohort study PURPOSE: The objective is to compare post-operative wound pain in patients treated by endoscopic surgery between interlaminar and transforaminal approach at lumbar region. OVERVIEW OF LITERATURE There are two common approaches for endoscopic lumbar spine surgery, interlaminar and transforaminal approach. The wound size of these two approaches is about the same. However, post-operative wound pain may differ according to the entrance area. METHODS We conducted a prospectively cohort study including all patients underwent full endoscopic lumbar spine surgery by single surgeon between January 2016 to October 2019. Wound pain using visual analog scale (VAS) at post-operative day 1 and day 14 were collected. VAS back pain, VAS leg pain, Oswestry Disability Index (ODI), modified McNab criteria and complications were also collected. RESULTS There were 313 patients included in the study. There was no significant difference in VAS wound pain between interlaminar and transforaminal group. Interestingly, subgroup analysis in interlaminar group found statistically significant higher VAS for wound pain at post-operative day 1 when significant bone resection was done by power burr. VAS back-leg pain and ODI have improved significantly between pre-operative and last follow up in both approaches. CONCLUSIONS Wound pain from endoscopic spine surgery is minimal. This study found no difference in wound pain between endoscopic interlaminar and transforaminal approach. Both approaches show favorable clinical outcomes with few serious complications rate. Further study with long term follow up is needed.
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Affiliation(s)
- Pritsanai Pruttikul
- Spine Unit, Institute of Orthopedics, Lerdsin Hospital, Department of Orthopedic Surgery, College of Medicine, Rangsit University, 190 Silom Road, Bangkok, 10500, Thailand
| | - Wichayan Chobchai
- Spine Unit, Institute of Orthopedics, Lerdsin Hospital, Department of Orthopedic Surgery, College of Medicine, Rangsit University, 190 Silom Road, Bangkok, 10500, Thailand
| | - Tinnakorn Pluemvitayaporn
- Spine Unit, Institute of Orthopedics, Lerdsin Hospital, Department of Orthopedic Surgery, College of Medicine, Rangsit University, 190 Silom Road, Bangkok, 10500, Thailand.
| | - Sombat Kunakornsawat
- Spine Unit, Institute of Orthopedics, Lerdsin Hospital, Department of Orthopedic Surgery, College of Medicine, Rangsit University, 190 Silom Road, Bangkok, 10500, Thailand
| | - Chaiwat Piyaskulkaew
- Spine Unit, Institute of Orthopedics, Lerdsin Hospital, Department of Orthopedic Surgery, College of Medicine, Rangsit University, 190 Silom Road, Bangkok, 10500, Thailand
| | - Piyabuth Kittithamvongs
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopedics, Lerdsin Hospital, Department of Orthopedic Surgery, College of Medicine, Rangsit University, 190 Silom Road, Bangkok, 10500, Thailand
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Application of a targeted and quantificational foraminoplasty device in percutaneous transforaminal endoscopic discectomy for L5-S1 disc herniation: preliminary clinical outcomes. J Orthop Surg Res 2021; 16:398. [PMID: 34158087 PMCID: PMC8218444 DOI: 10.1186/s13018-021-02533-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/08/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Percutaneous transforaminal endoscopic discectomy (PTED) is minimally invasive and has been widely used to treat patients with lumbar disc herniation (LDH) due to its safety and efficiency. However, due to the unique anatomy of the L5-S1 level, the PTED procedure is often difficult to perform in the region. ZESSYS, a targeted and quantificational foraminoplasty device, may help to overcome these anatomical limitations. In this study, we assessed the efficiency and the short-term effects of PTED with ZESSYS at the L5-S1 level. METHODS Between January and August of 2018, fifty-six patients with lumbar disc herniation at the single level of L5-S1 and who underwent percutaneous transforaminal endoscopic discectomy were enrolled in this retrospective cohort study. They were segregated into the transforaminal endoscopic surgical system (TESSYS) group and the ZESSYS group. The puncture time, foraminoplasty time, decompression time, and fluoroscopy time were evaluated for operation efficiency. Clinical outcomes were assessed by the visual analog scale (VAS) score and Oswestry Disability Index (ODI) score. The MacNab criteria were used to evaluate patient subjective satisfaction at 12-month follow-up postoperatively. RESULTS The average puncture time (5.29 ± 2.05 min), foraminoplasty time (12.82 ± 2.52 min), and fluoroscopy time (26.29 ± 5.96 s) were all significantly shorter in the ZESSYS group than in the TESSYS group (average puncture time 8.07 ± 3.13 min, p < 0.01; foraminoplasty time, 17.18 ± 2.92 min, p < 0.01; fluoroscopy time, 34.73 ± 6.86 s; p < 0.01). No significant differences were observed between the 2 groups in the decompression time (p = 0.057). The VAS score of low back pain and leg pain, as well as the ODI score, improved at all time points postoperatively compared with preoperative, in both the TESSYS group and the ZESSYS group (P < 0.05). There were no significant differences in the VAS score of low back pain, VAS score of leg pain, and ODI score between the TESSYS group and the ZESSYS group at the same time points (P > 0.05). According to the MacNab criteria, the excellent and good rate at 12-month follow-up postoperatively was 85.7% in the TESSYS group and 89.3% in the ZESSYS group (P > 0.05). CONCLUSION The targeted and quantificational foraminoplasty device named ZESSYS was more efficient in the puncture and foraminoplasty procedures, effectively protecting the exiting nerve and minimizing the level of radiation exposure. The device is efficient and safe for PTED in treating lumbar disc herniation at the L5-S1 level.
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Hasan S, White-Dzuro B, Barber JK, Wagner R, Hofstetter CP. The Endoscopic Trans-Superior Articular Process Approach: A Novel Minimally Invasive Surgical Corridor to the Lateral Recess. Oper Neurosurg (Hagerstown) 2021; 19:E1-E10. [PMID: 32281629 DOI: 10.1093/ons/opaa054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/01/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Transforaminal approaches to the lumbar spine are typically performed utilizing Kambin's triangle as approach corridor; however, degenerative changes can distort anatomy and expose the exiting nerve root to inadvertent injury. OBJECTIVE To describe the surgical technique of a novel full-endoscopic approach to access the lateral recess and report clinical outcomes. METHODS The trans-superior articular process (SAP) approach involves partial resection of the SAP, allowing access to the lateral recess both ventral and dorsal to the traversing nerve root. A retrospective review of 40 patients who had undergone a trans-SAP approach for decompression of lateral recess pathology was conducted. Outcomes were measured using visual analog scores (VAS) and Oswestry Disability Index (ODI) at 2 wk, 3 mo, and at last follow-up. RESULTS At a mean follow-up of 24 mo, patients experienced statistically significant improvement of the VAS for ipsilateral leg pain, VAS for back pain, and ODI when comparing preoperative values to all postoperative time points. The percentage of patients reaching a minimally clinically important difference for VAS leg pain and ODI was approximately 90% and 88%, respectively. The complication profile was favorable with no dural tears and no postoperative motor or sensory deficits. One patient required revision, with a total reoperation rate of 3%. CONCLUSION The trans-SAP approach is a novel approach that utilizes a safe surgical corridor via the SAP to access lateral recess pathology. Our initial clinical experience suggests that the trans-SAP approach allows for treatment of lateral recess and foraminal pathology with low complication rates.
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Affiliation(s)
- Saqib Hasan
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
| | - Brie White-Dzuro
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
| | - Jason K Barber
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
| | - Ralf Wagner
- Ligamenta Spine Center, Frankfurt am Main, Germany
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Yu H, Zhu B, Song Q, Liu X. Evaluation of full-endoscopic lumbar discectomy in the treatment of obese adolescents with lumbar disc herniation: a retrospective study. BMC Musculoskelet Disord 2021; 22:562. [PMID: 34147091 PMCID: PMC8214765 DOI: 10.1186/s12891-021-04449-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/08/2021] [Indexed: 02/07/2023] Open
Abstract
Background Obese patients are at risk of complications after spinal surgery. Full-endoscopic lumbar discectomy (FELD) has advantages over conventional open surgery in the treatment of obese adult patients with lumbar disc herniation (LDH) because it can decrease perioperative complications and enhance the degree of patient satisfaction. However, no clinical studies have evaluated the efficacy of FELD in obese adolescents with LDH (ALDH). This study aimed to evaluate the efficacy of FELD for the treatment of obese ALDH. Methods We retrospectively collected clinical data from 208 patients with single-segment ALDH who underwent FELD in our hospital between January 2015 and December 2019. According to the WHO classification of obesity, the patients were divided into obese (BMI ≥30 kg/m2) and non-obese (BMI < 30 kg/m2) groups (control group). Based on the preoperative baseline data of the two groups, propensity score matching was performed to select patients from these groups for a comparative study. Perioperative data included operative time, intraoperative blood loss, and length of postoperative hospitalization. The visual analog scale (VAS), Oswestry disability index (ODI), and modified MacNab criteria were recorded as the main indicators of the surgical outcome. Recurrence rate and incidence of complications were recorded as minor indicators. Results Twenty-eight patients and 80 patients were included in the obese and non-obese groups, respectively, after 1:4 propensity score matching. Both groups showed improvements in VAS and ODI scores after surgery and at each follow-up time point (p < 0.05). However, there was no significant statistical difference in the surgical outcomes between the two groups at each follow-up time point (p > 0.05). The differences in operative time, intraoperative blood loss, and length of postoperative hospitalization were not statistically significant between the two groups (p > 0.05). Conclusion FELD is a safe and effective minimally invasive technique for treating obese patients with ALDH. The efficacy of FELD in obese and non-obese patients with ALDH was comparable.
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Affiliation(s)
- Haijiang Yu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Bin Zhu
- Department of Orthopedics, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China
| | - Qingpeng Song
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China.
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Kou Y, Chang J, Guan X, Chang Q, Feng H. Endoscopic Lumbar Interbody Fusion and Minimally Invasive Transforaminal Lumbar Interbody Fusion for the Treatment of Lumbar Degenerative Diseases: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 152:e352-e368. [PMID: 34087465 DOI: 10.1016/j.wneu.2021.05.109] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To compare clinical efficacy and safety of endoscopic lumbar interbody fusion (Endo-LIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in treatment of lumbar degenerative diseases. METHODS A literature search was performed using PubMed, Embase, Web of Science, and Cochrane Library databases. Studies published up to November 15, 2020, that compared Endo-LIF with MIS-TLIF for treating lumbar degenerative diseases were retrieved. Data were extracted according to predefined clinical outcome measures. Primary outcomes were preoperative and postoperative visual analog scale for leg and back pain and Oswestry Disability Index scores. Secondary outcomes were operative time and intraoperative blood loss; length of hospitalization; and complication, reoperation, and fusion rates. Data analysis was conducted with statistical software. RESULTS The meta-analysis included 6 studies comprising 480 patients. Results of the merged analysis revealed similar complication, reoperation, and fusion rates and preoperative and postoperative visual analog scale for leg and back pain and Oswestry Disability Index scores (P > 0.05) for Endo-LIF and MIS-TLIF. Nevertheless, with the exception of longer operative time (P < 0.05), Endo-LIF compared favorably with MIS-TLIF, with less intraoperative blood loss, shorter hospital stay (P < 0.05), and better long-term functional outcome. CONCLUSIONS Based on the evidence provided by this study, there is no significant difference in clinical efficacy and safety between Endo-LIF and MIS-TLIF in the treatment of lumbar degenerative diseases. Although Endo-LIF has a longer operative time, it has the advantages of less tissue trauma and rapid recovery after operation.
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Affiliation(s)
- Yuanqiao Kou
- The Third Clinical Medical College of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jianjun Chang
- Department of Spinal Surgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Xiaoming Guan
- Department of Spinal Surgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Qiang Chang
- Department of Spinal Surgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, Shanxi, China
| | - Haoyu Feng
- Department of Spinal Surgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, Shanxi, China.
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Krishnan A, Kim HS, Raj A, Dave BR. Expanded Indications of Full Endoscopic Spine Sugery. JOURNAL OF MINIMALLY INVASIVE SPINE SURGERY AND TECHNIQUE 2021; 6:S130-S156. [DOI: 10.21182/jmisst.2021.00129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/07/2021] [Indexed: 12/16/2024]
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Li X, Bai J, Hong Y, Zhang J, Tang H, Lyu Z, Liu S, Chen S, Liu J. Minimum Seven-Year Follow-Up Outcomes of Percutaneous Endoscopic Lumbar Discectomy for Lumbar Degenerative Disease. Int J Gen Med 2021; 14:779-785. [PMID: 33707968 PMCID: PMC7943319 DOI: 10.2147/ijgm.s293400] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/22/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To investigate the long-term (> 7 years) clinical outcomes of percutaneous endoscopic lumbar discectomy for lumbar degenerative disease to address postoperative problems including postoperative dysesthesia (POD), residual back pain and segmental instability. Methods Inclusion and exclusion criteria were established. All patients who met the above criteria were treated by PELD using the transforaminal approach. Limited discectomy was performed to preserve the disc material in the intervertebral space as much as possible. The Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score for back pain (VAS-B) and leg pain (VAS-L) and Modified MacNab’s criterion were used for clinical evaluation. Radiographic parameters including height of intervertebral disc and segmental instability were also evaluated. Results Forty-two patients (24 men and 18 women) who met our inclusion and exclusion criteria were included in our study. The average follow-up period was 95.71±5.63 months (ranging from 87 to 105 months). There were no neurological complications associated with the operation. POD was found in 14.29% of patients, while only 2 patients (4.76%) complained of mild dysesthesia at final follow-up. Two patients (4.76%) required revision surgery during the follow-up period. The final follow-up ODI, JOA score, VAS-B and VAS-L were significantly better than preoperative values. The average disc-height ratio was 84.52±5.66% of the preoperative disc height. No instability at the operation level was noted at final follow-up. Conclusion Our study showed that PELD using the transforaminal approach can provide favorable results after a long-term follow-up period. POD is a common complication at initial prognosis. Limited discectomy can preserve the disc height well and minimize the risk of residual back pain.
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Affiliation(s)
- Xiang Li
- Department of Orthopaedics, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Jinzhu Bai
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
| | - Yi Hong
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
| | - Junwei Zhang
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
| | - Hehu Tang
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
| | - Zhen Lyu
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
| | - Shujia Liu
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
| | - Shizheng Chen
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
| | - Jiesheng Liu
- Department of Spine and Spinal Cord Surgery, Beijing Bo'ai Hospital, China Rehabilitation Research Center; School of Rehabilitation, Capital Medical University, Beijing, People's Republic of China
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Zheng Q, Ying X, Jin Y, Zhu B, Shen J, Wang Y, Zheng M, Liu F. Treatment of single-segment suppurative spondylitis with the transforaminal endoscopic focal cleaning and drainage. J Spinal Cord Med 2021; 44:267-275. [PMID: 31180827 PMCID: PMC7952067 DOI: 10.1080/10790268.2019.1617921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective: To evaluate the clinical value of the transforaminal endoscopic focal cleaning and drainage for suppurative spondylitis.Design: Retrospective study.Participants: Twenty-one patients with single-segment suppurative spondylitis.Interventions: All patients were treated with the transforaminal endoscopic focal cleaning and drainage.Outcome Measures: The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were measured before and after the operation. Visual analogue scale (VAS) was used to evaluate the relief of pain symptoms. Neurological function American Spinal Injury Association (ASIA) grade was used to evaluate the recovery of neurological function. The postoperative clinical efficacy of the patients was evaluated using the Kirkaldy-Willis functional scoring criteria. The stability of the spine and the recurrence of infection were evaluated by imaging data.Results: Postoperative bacteriological culture results showed positive in 15 cases and no bacteria growth in 6 cases. Besides, 16 cases were pathologically diagnosed. The ESR, CRP, and VAS scores at 2 weeks postoperatively and at the last follow-up were significantly improved compared with those at pre-operation. At the last follow-up, the clinical outcome was excellent in 17 cases, good in 3 cases, and fair in 1 case, according to the Kirkaldy-Willis functional scoring criteria; and the ASIA grade returned to normal. There was no significant difference in the Cobb angle between the last follow-up and the pre-operation. There was no recurrence of infection during the follow-up period.Conclusion: The transforaminal endoscopic focal cleaning and drainage is a minimally invasive, effective and safe surgical procedure for suppurative spondylitis.
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Affiliation(s)
- Qi Zheng
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China
| | - Xiaozhang Ying
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China,Correspondence to: Xiaozhang Ying, Department of Orthopedics, Hangzhou Red Cross Hospital, No. 208, Huancheng East Road, Hangzhou, Zhejiang310003, People’s Republic of China. E-mail:
| | - Yanghui Jin
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China
| | - Bo Zhu
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China
| | - Jian Shen
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China
| | - Yifan Wang
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China
| | - Mingfeng Zheng
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China
| | - Fei Liu
- Department of Orthopedics, Hangzhou Red Cross Hospital, Hangzhou, People’s Republic of China
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Yamaya S, Tezuka F, Sugiura K, Takeuchi M, Manabe H, Morimoto M, Yamashita K, Takata Y, Sakai T, Maeda T, Sairyo K. Risk Factor for Additional Intravenous Medication during Transforaminal Full-endoscopic Lumbar Discectomy under Local Anesthesia. Neurol Med Chir (Tokyo) 2021; 61:236-242. [PMID: 33504730 PMCID: PMC7966206 DOI: 10.2176/nmc.oa.2020-0275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Transforaminal full-endoscopic lumbar discectomy (TELD) can be performed under local anesthesia. However, there have been no reports on risk factors for a change in vital signs or the need for additional medications to maintain adequate analgesia during this procedure. The purpose of this study was to identify risk factors for additional intravenous medication during TELD under local anesthesia. The following factors were retrospectively evaluated in 113 consecutive patients who underwent TELD under local anesthesia at our institution: demographic characteristics, radiological features at the intervertebral disc level, distance between the superior articular process and the exiting nerve root, height of the intervertebral disc, height of the bulging disc, height of the intervertebral foramen, and distance from the insertion site to the spinous process on magnetic resonance imaging (MRI) and computed tomography (CT) scans of the lumbar spine. Logistic regression analysis was performed to determine factors associated with the need for additional drugs. In all, 23 cases (20.4%) required additional intraoperative medications because of hypertension, hypotension, bradycardia, or pain. Logistic regression analysis revealed that age (partial regression coefficient 0.05, p = 0.02) and bulging disc height (partial regression coefficient −0.7, p = 0.003) influenced the need for additional drugs. There were significant associations of need for additional intravenous medication with older age (>62 years) and a smaller bulging disc height (<8.2 mm). Patients with these factors require close monitoring for changes in vital signs or increasing pain when performing TELD under local anesthesia and may need additional intravenous medication.
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Affiliation(s)
- Seiji Yamaya
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan.,Department of Orthopaedic Surgery, Sendai Nishitaga National Hospital, Sendai, Miyagi, Japan
| | - Fumitake Tezuka
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Kosuke Sugiura
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Makoto Takeuchi
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Hiroaki Manabe
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan.,Department of Orthopedic Surgery, Tokushima Prefecture Naruto Hospital, Tokushima, Tokushima, Japan
| | - Masatoshi Morimoto
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Kazuta Yamashita
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Yoichiro Takata
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Toshinori Sakai
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Toru Maeda
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedics, Tokushima University, Tokushima, Tokushima, Japan
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Jarebi M, Awaf A, Lefranc M, Peltier J. A matched comparison of outcomes between percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for the treatment of lumbar disc herniation: a 2-year retrospective cohort study. Spine J 2021; 21:114-121. [PMID: 32683107 DOI: 10.1016/j.spinee.2020.07.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although open lumbar microdiscectomy (OLMD) is considered to be the gold standard method for discectomy, recent progress in endoscopic spinal surgery has increased the popularity of percutaneous endoscopic lumbar discectomy (PELD) for this indication. However, one of the main drawbacks of PELD is incomplete decompression, especially at the start of the surgeon's learning curve. The functional outcomes of PELD and OLMD in patients matched for age, hernia level, and hernia location have not previously been compared. PURPOSE To compare OLMD with PELD in terms of the clinical outcome and the time to recovery. STUDY DESIGN Retrospective, matched cohort study. PATIENT SAMPLE Data of all patients who underwent elective spinal surgery between January 2015 and June 2017 were extracted from the local database. OUTCOME MEASURES Clinical outcomes were assessed using a 0-to-10 visual analogue scale (VAS) for lower back pain (LBP) and leg pain were scored before surgery and at postoperative day 1 and at each follow-up visit (3, 12, and 24 months), the Oswestry Disability Index (ODI: 0%-100%), the length of hospital stay, time to resumption of work, recurrence of Lumbar disc herniation, procedure failures, and complications. METHODS The participants were matched for age, disc level, and location of the herniated disk (central and paracentral vs. far-lateral). The participants' mean±standard deviation age was 47.09±12.55 (range: 28-70). We compared the various clinical outcomes between the two groups to identify which procedure had better immediate and long-term functional outcomes. The differences in mortality and occurrence of postoperative complications were also compared in patients with PELD versus controls. RESULTS Fifty-eight patients were enrolled (29 with PELD and 29 with OLMD). Both groups reported significant reductions in LBP and leg pain (p<0.01) postoperatively and an improvement in the ODI at 24 months postsurgery. The intergroup difference in the VAS for LBP at 1 day and 3 months was statistically significant (1.48 vs. 3.5, and 1.62 vs. 2.72, respectively; p=0.01 and 0.026, respectively) but the intergroup difference in the ODI was not. The mean length of hospital stay and the time to resumption of work were significantly shorter in the PELD group than in the OLMD group (2.55 vs. 3.21 days, and 4.45 vs. 6.62 weeks, respectively; p=0.037 and 0.01, respectively. There were no significant intergroup differences in terms of complications, recurrence, or procedure failures. CONCLUSIONS Both PELD and OLMD can provide equivalent, satisfactory outcomes. However, PELD demonstrated several potential advantages, including more rapid recovery and lower LBP early on. Further large-scale, randomized studies with long-term follow-up are now warranted.
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Affiliation(s)
- Meshal Jarebi
- Department of Neurosurgery, Amiens Picardie University Hospital, Amiens, France; Department of Neurosurgery, Al jubail Royal Commission Hospital, Al jubail, Saudi Arabia.
| | - Aisha Awaf
- Department of Family Medicine, Ministry of Health, Jazan, Saudi Arabia
| | - Michel Lefranc
- Department of Neurosurgery, Amiens Picardie University Hospital, Amiens, France
| | - Johann Peltier
- Department of Neurosurgery, Amiens Picardie University Hospital, Amiens, France
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