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Zappi K, Giantini-Larsen A, Yan J, Konate M, Garton ALA, Knopman J, Stieg PE, Salama G, Park JK. Innovations in the Treatment of Spinal Cerebrospinal Fluid Leaks. World Neurosurg 2024; 187:304-312. [PMID: 38970201 DOI: 10.1016/j.wneu.2024.03.112] [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: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 07/08/2024]
Abstract
Spontaneous spinal cerebrospinal fluid (CSF) leaks are uncommon but can be neurologically debilitating. When initial treatments fail, definitive repair or closure of the leak is indicated. Depending upon the type of leak present, innovative strategies for their treatment have been developed. Among them are open surgical techniques using a transdural approach for the closure of ventral CSF leaks, minimally invasive tubular techniques for the reduction and repair of lateral meningeal diverticula, and endovascular embolization of CSF-venous fistulas. Illustrative cases demonstrating the indications for and implementation of these techniques are provided.
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Affiliation(s)
- Kyle Zappi
- Weill Cornell Medical College, New York, New York, USA
| | - Alexandra Giantini-Larsen
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Jenny Yan
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Mawa Konate
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Andrew L A Garton
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Jared Knopman
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Philip E Stieg
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - Gayle Salama
- Department of Radiology, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA
| | - John K Park
- Department of Neurological Surgery, NewYork-Presbyterian Weill Cornell Medicine, New York, New York, USA; Department of Neurological Surgery, NewYork-Presbyterian Queens Hospital, Queens, New York, USA.
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Melcher C, Hussain I, Kirnaz S, Goldberg JL, Sommer F, Navarro-Ramirez R, Medary B, Härtl R. Use of a High-Fidelity Training Simulator for Minimally Invasive Lumbar Decompression Increases Working Knowledge and Technical Skills Among Orthopedic and Neurosurgical Trainees. Global Spine J 2023; 13:2182-2192. [PMID: 35225716 PMCID: PMC10538343 DOI: 10.1177/21925682221076044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Prospective comparative study. OBJECTIVE To quantify the educational benefit to surgical trainees of using a high-fidelity simulator to perform minimally invasive (MIS) unilateral laminotomy for bilateral decompression (ULBD) for lumbar stenosis. METHODS Twelve orthopedic and neurologic surgery residents performed three MIS ULBD procedures over 2 weeks on a simulator guided by established AO Spine metrics. Video recording of each surgery was rated by three blinded, independent experts using a global rating scale. The learning curve was evaluated with attention to technical skills, skipped steps, occurrence of errors, and timing. A knowledge gap analysis evaluating participants' current vs desired ability was performed after each trial. RESULTS From trial 1 to 3, there was a decrease in average procedural time by 31.7 minutes. The cumulative number of skipped steps and surgical errors decreased from 25 to 6 and 24 to 6, respectively. Overall surgical proficiency improved as indicated by video rating of efficiency and smoothness of surgical maneuvers, most notably with knowledge and handling of instruments. The greatest changes were noted in junior rather than senior residents. Average knowledge gap analysis significantly decreased by 30% from the first to last trial (P = .001), signifying trainees performed closer to their desired technical goal. CONCLUSION Procedural metrics for minimally invasive ULBD in combination with a realistic surgical simulator can be used to improve the skills and confidence of trainees. Surgical simulation may offer an important educational complement to traditional methods of skill acquisition and should be explored further with other MIS techniques.
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Affiliation(s)
- Carolin Melcher
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital Munich, Munich, Germany
| | - Ibrahim Hussain
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Sertac Kirnaz
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Jacob L. Goldberg
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Fabian Sommer
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Branden Medary
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
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Oyama R, Arizono T, Inokuchi A, Imamura R, Hamada T, Bekki H. Comparison of Microendoscopic Laminotomy (MEL) Versus Spinous Process-Splitting Laminotomy (SPSL) for Multi Segmental Lumbar Spinal Stenosis. Cureus 2022; 14:e22067. [PMID: 35295365 PMCID: PMC8916905 DOI: 10.7759/cureus.22067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/05/2022] Open
Abstract
Aims This study was aimed to compare the perioperative and postoperative outcomes of patients who underwent posterior decompression for multi-segmental lumbar spinal stenosis by microendoscopic laminotomy (MEL) versus spinous process-splitting laminotomy (SPSL) retrospectively. Methods We retrospectively reviewed 73 consecutive patients who underwent two or three levels MEL (n=51) or SPSL (n=22) for lumbar spinal stenosis between 2012 and 2018. The perioperative outcomes were operative time, intraoperative blood loss, length of postoperative hospital stay, complications, and reoperation rate. The postoperative outcomes were evaluated using a visual analog scale (VAS) and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores at one year postoperatively. Results The mean follow-up time was 26.6 months in MEL and 35.6 months in SPSL. The mean operative time was significantly longer in MEL than SPSL (two levels, 183.6 ± 43.2 versus 134.8 ± 26.7 min, respectively; three levels: 241.6 ± 47.8 versus 179.9 ± 28.8 min, respectively). MEL's mean postoperative hospital stay was significantly shorter than SPSL (12.3 ± 5.9 versus 15.5 ± 7.2 days, respectively). There was no significant difference in the mean intraoperative blood loss, complication rate, reoperation rate, and postoperative outcomes between the two groups. Conclusions This study suggests that both techniques are effective in treating multi-segmental lumbar spinal stenosis. There was no significant difference between the two procedures in intraoperative blood loss (IBL), complications rate, reoperation rate, or improvement in VAS and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) scores. MEL had an advantage in the postoperative hospital stay.
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Nolte MT, Parrish JM, Jenkins NW, Cha EDK, Lynch CP, Mohan S, Geoghegan CE, Jadczak CN, Hrynewycz NM, Singh K. The Influence of Comorbidity on Postoperative Outcomes Following Lumbar Decompression. Clin Spine Surg 2021; 34:E390-E396. [PMID: 33560010 DOI: 10.1097/bsd.0000000000001133] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 12/22/2020] [Indexed: 01/05/2023]
Abstract
STUDY DESIGN Retrospective. OBJECTIVE Evaluate the association between comorbidity burden and reaching minimum clinically important difference (MCID) following lumbar decompression (LD). SUMMARY OF BACKGROUND DATA There is limited research on the influence of preoperative comorbidity burden on patient-reported outcome improvement following LD. METHODS A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries between 2015 and 2019. Inclusion criteria were primary, single, or multilevel LD. Patients were excluded for missing preoperative patient-reported outcome surveys. Stratification was based on Charlson Comorbidity Index (CCI) score: 0 points (no comorbidities), 1-2 points (low CCI), ≥3 points (high CCI). Demographics and perioperative characteristics were evaluated for differences. Linear regression assessed postoperative improvement for visual analogue scale (VAS) back, VAS leg, Oswestry disability index (ODI), Short Form-12 Physical Composite Score (SF-12 PCS), and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) scores through 1 year. Achievement rate of MCID was compared between groups and evaluated for significant predictors. RESULTS Three hundred fourteen patients were included (123 no comorbidities, 100 low CCI, 91 high CCI). Higher CCI patients were older, more likely to smoke, and have comorbid diseases (all P<0.001). Perioperative differences included increased operative time, levels decompressed, length of stay, and discharge day in the CCI≥3 group. No differences in the rate of achieving MCID for VAS back, VAS leg, and ODI. CCI≥3 subgroup had a lower rate of reaching MCID at 6 months for SF-12 PCS, at 6 weeks for PROMIS-PF, and the overall rate for both SF-12 PCS and PROMIS-PF (all P<0.05). Multilevel procedures was a predictor for MCID achievement for ODI. CONCLUSIONS Patients with increased comorbidities undergoing LD had an equivalent MCID achievement rate for pain and disability metrics through 1 year. High CCI patients did, however, have a lower rate of achieving MCID for their physical function surveys which suggests that comorbidity burden influences improvement in physical function following LD.
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Affiliation(s)
- Michael T Nolte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Chung AS, Ballatori A, Ortega B, Min E, Formanek B, Liu J, Hsieh P, Hah R, Wang JC, Buser Z. Is Less Really More? Economic Evaluation of Minimally Invasive Surgery. Global Spine J 2021; 11:30S-36S. [PMID: 32975446 PMCID: PMC8076812 DOI: 10.1177/2192568220958403] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
STUDY DESIGN Review. OBJECTIVE A comparative overview of cost-effectiveness between minimally invasive versus and equivalent open spinal surgeries. METHODS A literature search using PubMed was performed to identify articles of interest. To maximize the capture of studies in our initial search, we combined variants of the terms "cost," "minimally invasive," "spine," "spinal fusion," "decompression" as either keywords or MeSH terms. PearlDiver database was queried for open and minimally invasive surgery (MIS; endoscopic or percutaneous) reimbursements between Q3 2015 and Q2 2018. RESULTS In general, MIS techniques appeared to decrease blood loss, shorten hospital lengths of stay, mitigate complications, decrease perioperative pain, and enable quicker return to daily activities when compared to equivalent open surgical techniques. With regard to cost, primarily as a result of these latter benefits, MIS was associated with lower costs of care when compared to equivalent open techniques. However, cost reporting was sparse, and relevant methodology was inconsistent throughout the spine literature. Within the PearlDiver data sets, MIS approaches had lower reimbursements than open approaches for both lumbar posterior fusion and discectomy. CONCLUSIONS Current data suggests that overall cost-savings may be incurred with use of MIS techniques. However, data reporting on costs lacks in uniformity, making it difficult to formulate any firm conclusions regarding any incremental improvements in cost-effectiveness that may be incurred when utilizing MIS techniques when compared to equivalent open techniques.
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Affiliation(s)
| | | | | | - Elliot Min
- University of Southern California, Los Angeles, CA, USA
| | | | - John Liu
- University of Southern California, Los Angeles, CA, USA
| | - Patrick Hsieh
- University of Southern California, Los Angeles, CA, USA
| | - Raymond Hah
- University of Southern California, Los Angeles, CA, USA
| | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA,Zorica Buser, Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA 90033, USA.
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Yolcu YU, Helal A, Alexander AY, Bhatti AU, Alvi MA, Abode-Iyamah K, Bydon M. Minimally Invasive Versus Open Surgery for Degenerative Spine Disorders for Elderly Patients: Experiences from a Single Institution. World Neurosurg 2020; 146:e1262-e1269. [PMID: 33276177 DOI: 10.1016/j.wneu.2020.11.145] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) of the spine has been associated with lower complication rates and improved patient-reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients. METHODS Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with a nondegenerative cause such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics and associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications. RESULTS A total of 107 elderly patients were identified for this study, with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded an MIS group with significantly lower EBL (P < 0.001), operative time (P < 0.001), and LOS (P < 0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (P = 0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement also favored the MIS group and although they were not found to be significantly different between the 2 groups on univariate and multivariable analysis, the results trended toward significance. CONCLUSIONS These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose a lower risk of associated perioperative and postoperative complications with faster recovery time.
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Affiliation(s)
- Yagiz U Yolcu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed Helal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Alex Y Alexander
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA
| | - Atiq U Bhatti
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammed A Alvi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA.
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Chiu RG, Patel S, Zhu A, Aguilar E, Mehta AI. Endoscopic Versus Open Laminectomy for Lumbar Spinal Stenosis: An International, Multi-Institutional Analysis of Outcomes and Adverse Events. Global Spine J 2020; 10:720-728. [PMID: 32707015 PMCID: PMC7383785 DOI: 10.1177/2192568219872157] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study and systematic review. OBJECTIVES Endoscopic decompression offers a minimally invasive alternative to traditional, open laminectomy. However, comparison of these surgical techniques has been largely limited to small, single-center studies. In this study, we perform the first international, multicenter comparison of both with regard to their associated rates of mortality, complications, readmissions, and reoperations. METHODS The 2017 American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database, containing data from over 650 hospitals internationally, was queried to evaluate the effect of endoscopic guidance on adverse events. Operative time, length of stay, readmission and reoperation rates, as well as the incidence of peri- and postoperative complications, were compared between endoscopic and open groups. The PubMed/MEDLINE database was queried for studies comparing the techniques. RESULTS A total of 10 726 single-level lumbar decompression patients were identified and included in this study, 34 (0.32%) of whom were operated upon endoscopically. Apart from 2 (5.88%) readmissions, among which only 1 was unplanned, there were no reported surgical complications within the endoscopic group. The mean length of stay for these patients was 0.86 ± 1.44 days, with procedures lasting an average of 91.89 ± 46.72 minutes. However, these endpoints did not differ significantly from the open group. On literature review, 16 studies met the inclusion criteria, and largely consisted of single-center, retrospective analyses. CONCLUSIONS Endoscopically guided approaches to single-level lumbar decompression did not reduce the incidence of adverse events, length of stay or operative time, perhaps due to advances among certain nonendoscopic techniques, such as microsurgery.
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Affiliation(s)
- Ryan G. Chiu
- University of Illinois at Chicago, Chicago, IL, USA
| | - Saavan Patel
- University of Illinois at Chicago, Chicago, IL, USA
| | - Amy Zhu
- University of Illinois at Chicago, Chicago, IL, USA
| | - Eddy Aguilar
- University of Illinois at Chicago, Chicago, IL, USA
| | - Ankit I. Mehta
- University of Illinois at Chicago, Chicago, IL, USA,Ankit I. Mehta, Department of Neurosurgery, University of Illinois at Chicago, 912 South Wood Street, 4 N NPI, Chicago, IL 60612, USA.
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Barber SM, Fridley JS, Konakondla S, Nakhla J, Oyelese AA, Telfeian AE, Gokaslan ZL. Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:217. [PMID: 31297382 DOI: 10.21037/atm.2019.01.04] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.
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Affiliation(s)
- Sean M Barber
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jonathan Nakhla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
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Phan K, Mobbs RJ. Minimally Invasive Versus Open Laminectomy for Lumbar Stenosis: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2016; 41:E91-E100. [PMID: 26555839 DOI: 10.1097/brs.0000000000001161] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review with meta-analysis. OBJECTIVE To assess the relative merits of minimally invasive unilateral laminectomy for bilateral decompression (ULBD) versus open laminectomy, a systematic review and meta-analysis of all available evidence was performed. SUMMARY OF BACKGROUND DATA Lumbar spinal stenosis is one of the most common pathologies in the increasingly elderly population that results in claudication, back and leg pain, and disability. The conventional approach for decompression is open laminectomy. In recent years, there has been a surge in microendoscopic procedures, which aim to minimize invasiveness. Despite the increasing use of these minimally invasive techniques, few studies have directly compared the safety, efficacy, and outcomes of these procedures with conventional laminectomy. There is a lack of robust clinical evidence, with most reports limited to single-center, inadequately powered, noncomparative studies. METHODS Relevant articles were identified from six electronic databases. Predefined endpoints were extracted and meta-analyzed from the identified studies. RESULTS Satisfaction rates were significantly higher in the minimally invasive group (84% vs. 75.4%; P = 0.03), whereas back pain Visual Analog Scale scores were lower (P < 0.00001). Minimally invasive laminectomy operative duration was 11 minutes longer than the open approach (P = 0.001), however this may not have clinical significance. However, there was less blood loss (P < 0.00001) and shorter hospital stay (2.1 days; P < 0.0001). Dural injuries and cerebrospinal fluid leaks were comparable, but reoperation rates were lower in the minimally invasive cohort (1.6% vs. 5.8%; P = 0.02); however this was not significant when only randomized evidence was considered. CONCLUSION The pooled evidence suggests ULBD may be associated with less blood loss and shorter stay, with similar complication profiles to the open approach. These findings warrant verification in large prospective registries and randomized trials. LEVEL OF EVIDENCE 1.
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Affiliation(s)
- Kevin Phan
- *Department of Neurosurgery, University of New South Wales, High Street, Randwick, New South Wales, Australia†Neuro Spine Clinic, Prince of Wales Private Hospital, Randwick, New South Wales, Australia‡Neuro Spine Surgery Research Group, Sydney, Australia
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Soliman HM. Irrigation endoscopic decompressive laminotomy. A new endoscopic approach for spinal stenosis decompression. Spine J 2015; 15:2282-9. [PMID: 26165475 DOI: 10.1016/j.spinee.2015.07.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 06/07/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The classic surgical treatment of spinal stenosis involves bilateral dissection of paraspinal muscles to expose all the involved levels, wide laminectomy, and medial facetectomy and foraminotomy. The surgical morbidity of the procedure is further magnified by being more common in elderly with associated medical comorbidities and being usually global involving multiple levels. To address this problem, several less invasive techniques have been introduced over the past decade including the microendoscopic decompression. PURPOSE The aim was to describe and evaluate a new endoscopic technique for lumbar spinal canal decompression named irrigation endoscopic decompressive laminotomy. STUDY DESIGN This was a technical report. PATIENT SAMPLE One hundred four consecutive patients suffering from neurogenic claudication and resistant to 3 months of conservative management were included in the study. Grade I degenerative spondylolisthesis and degenerative scoliosis were not considered a contraindication. Patients with segmental instability and predominant low back pain were excluded. OUTCOME MEASURES Primary outcome measures included the final functional outcome using modified Macnab criteria and the Oswestry Disability Index (ODI). In addition, the operative time and complication rate have been evaluated. Secondary outcome measures included the evaluation of the early postoperative course using visual analog scale for postoperative incisional pain, time for ambulation, and length of hospital stay. METHODS Two 0.5-cm portals were used, one for the endoscope and the other for instruments. For every additional level, one portal is added. The endoscope and instruments are directly placed over the surface of lamina without any dissection, and saline under pump pressure is used to open a potential working space. Unilateral laminotomy/laminectomy is performed according to the severity of stenosis, followed by bilateral decompression beneath the midline structures. RESULTS Mean follow-up period was 28 months. The final outcome was excellent in 63%, good in 24%, fair in 9%, and poor in 4%. The preoperative ODI dropped from a mean of 64.2±10.0 to 23.1±20.8 postoperatively. Complications were limited to six cases of dural tear, which required no open conversion. CONCLUSIONS Irrigation endoscopic decompressive laminotomy allows the surgeon to safely perform effective central and foraminal decompression resulting in satisfactory midterm clinical results. Substituting long surgical incisions with 0.5-cm stabs and direct placement of instruments without dissection or dilatation could result in an improved postoperative course, shortened time for hospitalization, and reduced infection rate. However, still multicenter studies and randomized trials are needed before making final conclusions.
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Affiliation(s)
- Hesham Magdi Soliman
- Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, 21A Abdelaziz Al Seoud, Manial-EL Roda, Cairo, Egypt.
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Ramesh A, Lyons F, Kelleher M. Aperius interspinous device for degenerative lumbar spinal stenosis: a review. Neurosurg Rev 2015; 39:197-205; discussion 205. [PMID: 26324829 DOI: 10.1007/s10143-015-0664-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 06/27/2015] [Indexed: 11/26/2022]
Abstract
With an aging population, degenerative lumbar spinal stenosis (DLSS) leading to neurogenic intermittent claudication (NIC) is a growing problem. For patients suffering from this condition, interspinous process distraction devices (IPDs) offer an effective and cheap alternative to conservative or decompressive surgery. Aperius is one such device that has been gaining popularity for its percutaneous insertion under local anesthetic, short operative time, and low risk of complications. The main objective of this review was to carry out a comprehensive search of the literature to evaluate the effectiveness and potential complications of Aperius. A database search, including PubMed, Clinical trials.gov, Cochrane (CENTRAL), MEDLINE, CINAHL, EMBASE, and Scopus, was carried out to identify relevant articles written in English reporting on complications with a minimum 12-month follow-up. The literature search resulted in six eligible studies; two nonrandomized comparative and four prospective case series were available. The analysis revealed that in total, 433 patients underwent treatment with Aperius, with all studies demonstrating an improvement in outcome measures. The average follow-up was 17 months with an overall complication rate of 10.62%. Overall, the quality of evidence is low, suggesting that currently, the evidence is not compelling and further prospective randomized trials including cost-effectiveness studies are required.
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Affiliation(s)
- Ashwanth Ramesh
- RCSI, Department of Anatomy, St. Stephens Green, Dublin 2, Ireland.
| | - Frank Lyons
- Cappagh National Orthopaedic Hospital, Dublin, Ireland
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12
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[Influencing factors on the length of stay in lumbar spine surgery : analysis of the German spine registry]. DER ORTHOPADE 2015; 43:1043-51. [PMID: 25371016 DOI: 10.1007/s00132-014-3033-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Spinal disc herniation, lumbar spinal stenosis and spondylolisthesis are known to be leading causes of lumbar back pain. The cost of low back pain management and related operations are continuously increasing in the healthcare sector. There are many studies regarding complications after spine surgery but little is known about the factors predicting the length of stay in hospital. The purpose of this study was to identify these factors in lumbar spine surgery in order to adapt the postoperative treatment. MATERIAL AND METHODS The current study was carried out as a post hoc analysis on the basis of the German spine registry. Patients who underwent lumbar spine surgery by posterior surgical access and with posterior fusion and/or rigid stabilization, whereby procedures with dynamic stabilization were excluded. Patient characteristics were tested for association with length of stay (LOS) using bivariate and multivariate analyses. RESULTS A total of 356 patients met the inclusion criteria. The average age of all patients was 64.6 years and the mean LOS was 11.9 ± 6.0 days with a range of 2-44 days. Independent factors that were influencing LOS were increased age at the time of surgery, higher body mass index, male gender, blood transfusion of 1-2 erythrocyte concentrates and the presence of surgical complications. CONCLUSION Identification of predictive factors for prolonged LOS may allow for estimation of patient hospitalization time and for optimization of postoperative care. In individual cases this may result of a reduction in the LOS.
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Overdevest G, Vleggeert-Lankamp C, Jacobs W, Thomé C, Gunzburg R, Peul W. Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis. 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 2015; 24:2244-63. [PMID: 26184719 DOI: 10.1007/s00586-015-4098-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/27/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare the effectiveness of techniques of posterior decompression that limit the extent of bony decompression or to avoid removal of posterior midline structures of the lumbar spine versus conventional facet-preserving laminectomy for the treatment of patients with degenerative lumbar stenosis. METHODS A comprehensive electronic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, and the clinical trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform was conducted for relevant literature up to June 2014. RESULTS A total of four high-quality RCTs and six low-quality RCTs met the search criteria of this review. These studies included a total of 733 participants. Three different techniques that avoid removal of posterior midline structures are compared to conventional laminectomy; unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy. Evidence of low or very low quality suggests that different techniques of posterior decompression and conventional laminectomy have similar effects on functional disability and leg pain. Only perceived recovery at final follow-up was better in patients that underwent bilateral laminotomy compared with conventional laminectomy. Unilateral laminotomy for bilateral decompression and bilateral laminotomy resulted in numerically fewer cases of iatrogenic instability, although in both cases, the incidence of instability was low. The difference in severity of postoperative low back pain following bilateral laminotomy and split-spinous process laminotomy was significantly less, but was too small to be clinically important. We found no evidence to show that the incidence of complications, length of the procedure, length of hospital stay and postoperative walking distance differed between techniques of posterior decompression. CONCLUSION The evidence provided by this systematic review for the effects of unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy compared with conventional laminectomy on functional disability, perceived recovery and leg pain is of low or very low quality. Therefore, further research is necessary to establish whether these techniques provide a safe and effective alternative for conventional laminectomy. Proposed advantages of these techniques regarding the incidence of iatrogenic instability and postoperative back pain are plausible, but definitive conclusions are limited by poor methodology and poor reporting of outcome measures among included studies.
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Affiliation(s)
- Gijsbert Overdevest
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands.
| | - Carmen Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - Wilco Jacobs
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - Claudius Thomé
- Department of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria
| | - Robert Gunzburg
- Department of Orthopaedics, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
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Overdevest GM, Jacobs W, Vleggeert-Lankamp C, Thomé C, Gunzburg R, Peul W. Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis. Cochrane Database Syst Rev 2015:CD010036. [PMID: 25760812 DOI: 10.1002/14651858.cd010036.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The gold standard treatment for symptomatic lumbar stenosis refractory to conservative management is a facet-preserving laminectomy. New techniques of posterior decompression have been developed to preserve spinal integrity and to minimise tissue damage by limiting bony decompression and avoiding removal of the midline structures (i.e. spinous process, vertebral arch and interspinous and supraspinous ligaments). OBJECTIVES To compare the effectiveness of techniques of posterior decompression that limit the extent of bony decompression or avoid removal of posterior midline structures of the lumbar spine versus conventional facet-preserving laminectomy for the treatment of patients with degenerative lumbar stenosis. SEARCH METHODS An experienced librarian conducted a comprehensive electronic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and the clinical trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) for relevant literature up to June 2014. SELECTION CRITERIA We included prospective controlled studies comparing conventional facet-preserving laminectomy versus a posterior decompressive technique that avoids removal of posterior midline structures or a technique involving only partial resection of the vertebral arch. We excluded studies describing techniques of decompression by means of interspinous process devices or concomitant (instrumented) fusion procedures. Participants included individuals with symptomatic degenerative lumbar stenosis only. DATA COLLECTION AND ANALYSIS Two review authors independently assessed risk of bias using the Cochrane Back Review Group criteria for randomised controlled trials (RCTs) and the Newcastle-Ottawa Scale for non-randomised studies. We extracted data regarding demographics, intervention details and outcome measures. MAIN RESULTS A total of four high-quality RCTs and six low-quality RCTs met the search criteria of this review. These studies included a total of 733 participants. Investigators compared three different posterior decompression techniques versus conventional laminectomy. Three studies (173 participants) compared unilateral laminotomy for bilateral decompression versus conventional laminectomy. Four studies (382 participants) compared bilateral laminotomy versus conventional laminectomy (one study included three treatment groups and compared unilateral and bilateral laminotomy vs conventional laminectomy). Finally, four studies (218 participants) compared a split-spinous process laminotomy versus conventional laminectomy.Evidence of low or very low quality suggests that different techniques of posterior decompression and conventional laminectomy have similar effects on functional disability and leg pain. Only perceived recovery at final follow-up was better in people who underwent bilateral laminotomy compared with conventional laminectomy (two RCTs, 223 participants, odds ratio 5.69, 95% confidence interval (CI) 2.55 to 12.71).Among the secondary outcome measures, unilateral laminotomy for bilateral decompression and bilateral laminotomy resulted in numerically fewer cases of iatrogenic instability, although in both cases, the incidence of instability was low (three RCTs, 166 participants, odds ratio 0.28, 95% CI 0.07 to 1.15; three RCTs, 294 participants, odds ratio 0.10, 95% CI 0.02 to 0.55, respectively). The difference in severity of postoperative low back pain following bilateral laminotomy (two RCTs, 223 participants, mean difference -0.51, 95% CI -0.80 to -0.23) and split-spinous process laminotomy compared with conventional laminectomy (two RCTs, 97 participants, mean difference -1.07, 95% CI -2.15 to -0.00) was significantly less, but was too small to be clinically important. A quantitative comparison between unilateral laminotomy and conventional laminectomy was not possible because of different reporting of outcome measures. We found no evidence to show that the incidence of complications, length of the procedure, length of hospital stay and postoperative walking distance differed between techniques of posterior decompression. AUTHORS' CONCLUSIONS The evidence provided by this systematic review for the effects of unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy compared with conventional laminectomy on functional disability, perceived recovery and leg pain is of low or very low quality. Therefore, further research is necessary to establish whether these techniques provide a safe and effective alternative for conventional laminectomy. Proposed advantages of these techniques regarding the incidence of iatrogenic instability and postoperative back pain are plausible, but definitive conclusions are limited by poor methodology and poor reporting of outcome measures among included studies. Future research is necessary to establish the incidence of iatrogenic instability using standardised definitions of radiological and clinical instability at comparable follow-up intervals. Long-term results with these techniques are currently lacking.
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Affiliation(s)
- Gijsbert M Overdevest
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, Leiden, Netherlands, 2300 RC
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Scheer JK, Harvey MJ, Dahdaleh NS, Smith ZA, Fessler RG. K-Wire fracture during minimally invasive transforaminal lumbar interbody fusion: Report of six cases and recommendations for avoidance and management. Surg Neurol Int 2015; 5:S520-2. [PMID: 25593770 PMCID: PMC4287903 DOI: 10.4103/2152-7806.148009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/13/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Although rare, minimally invasive spine techniques do have the risk of intraoperative device failure. Kirschner wire (K-wire) fractures during minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) have not been previously reported. This report focuses on the incidence of k-wire fractures following MI-TLIF and describes techniques to help avoid and treat these fractures when they occur. METHODS INCLUSION CRITERIA (i) patients underwent 1, 2, or 3 level MI-TLIF over a 10-year period and (ii) had a k-wire fracture leading to a retained fragment. Exclusion criteria included: >10° coronal curves, significant sagittal malalignment, infection, and preoperative instrumentation failure. RESULTS Of 513 patients undergoing MI-TLIF, 6 (1.2%) sustained k-wire fracture (3 males, 3 females, mean age 43 ± 13 years). Complications included k-wire fracture alone (4 patients), cerebrospinal fluid (CSF) leak (1 patient), and both ileus and revision for hardware removal (1 patient). All six patients went home postoperatively. The mean follow-up duration was 27.7 ± 37.4 months. All retained k-wire fragments were located in the vertebral bodies at the tip of the pedicle screws; none breached the anterior cortex of the vertebral bodies. None of the k-wires migrated at final follow-up 7.8 years (93.7 months) postoperatively. Furthermore, no complications were attributed to retained k-wires. CONCLUSIONS K-wire fractures during MI-TLIF are rare (incidence of 1.2%) and retained k-wire segments led to no postoperative complications (e.g. no migration).
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Affiliation(s)
- Justin K Scheer
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, USA
| | - Michael J Harvey
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, 676 N. St. Clair Street, Suite 2210, USA
| | - Richard G Fessler
- Department of Neurological Surgery, Rush University School of Medicine, Chicago, IL, 60611, USA
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Complications of minimally invasive, tubular access surgery for cervical, thoracic, and lumbar surgery. Minim Invasive Surg 2014; 2014:451637. [PMID: 25097785 PMCID: PMC4109131 DOI: 10.1155/2014/451637] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 06/23/2014] [Indexed: 11/17/2022] Open
Abstract
The object of the study was to review the author's large series of minimally invasive spine surgeries for complication rates. The author reviewed a personal operative database for minimally access spine surgeries done through nonexpandable tubular retractors for extradural, nonfusion procedures. Consecutive cases (n = 1231) were reviewed for complications. There were no wound infections. Durotomy occurred in 33 cases (2.7% overall or 3.4% of lumbar cases). There were no external or symptomatic internal cerebrospinal fluid leaks or pseudomeningoceles requiring additional treatment. The only motor injuries were 3 C5 root palsies, 2 of which resolved. Minimally invasive spine surgery performed through tubular retractors can result in a low wound infection rate when compared to open surgery. Durotomy is no more common than open procedures and does not often result in the need for secondary procedures. New neurologic deficits are uncommon, with most observed at the C5 root. Minimally invasive spine surgery, even without benefits such as less pain or shorter hospital stays, can result in considerably lower complication rates than open surgery.
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Patient characteristics associated with increased postoperative length of stay and readmission after elective laminectomy for lumbar spinal stenosis. Spine (Phila Pa 1976) 2014; 39:833-40. [PMID: 24525996 PMCID: PMC4006290 DOI: 10.1097/brs.0000000000000276] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To identify factors that were independently associated with increased postoperative length of stay (LOS) and readmission in patients who underwent elective laminectomy for lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA Lumbar spinal stenosis is a common pathology that is traditionally treated with decompressive laminectomy. Risk factors associated with increased LOS and readmission have not been fully characterized for laminectomy. METHODS Patients who underwent laminectomy for lumbar spinal stenosis during 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patient characteristics were tested for association with LOS and readmission using bivariate and multivariate analyses. Patients with LOS more than 10 days were excluded from the readmission analysis as the American College of Surgeons National Surgical Quality Improvement Program only captures readmissions within 30 postoperative days, and the window for potential readmission was deemed too short for patients staying longer than 10 days. RESULTS A total of 2358 patients who underwent laminectomy met inclusion criteria. The average age was 66.4 ± 11.7 years (mean ± standard deviation). Average postoperative LOS was 2.1 ± 2.6 days. Of those meeting criteria for readmission analysis, 3.7% of patients (86 of 2339) were readmitted within 30 days postoperatively.Independent risk factors for prolonged LOS were increased age (P < 0.001), increased body mass index (P = 0.004), American Society of Anesthesiologists class 3-4 (P = 0.005), and preoperative hematocrit less than 36.0 (P = 0.001). Independent risk factors for readmission were increased age (P = 0.013), increased body mass index (P = 0.040), American Society of Anesthesiologists class 3-4 (P < 0.001), and steroid use (P = 0.001). The most common reason for readmission was surgical site-related infections (25.0% of patients readmitted in 2012). CONCLUSION The identified factors associated with LOS and readmission after lumbar laminectomy may be useful for optimizing patient care.
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Stadler JA, Wong AP, Graham RB, Liu JC. Complications Associated with Posterior Approaches in Minimally Invasive Spine Decompression. Neurosurg Clin N Am 2014; 25:233-45. [DOI: 10.1016/j.nec.2013.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Wong AP, Smith ZA, Stadler JA, Hu XY, Yan JZ, Li XF, Lee JH, Khoo LT. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): surgical technique, long-term 4-year prospective outcomes, and complications compared with an open TLIF cohort. Neurosurg Clin N Am 2014; 25:279-304. [PMID: 24703447 DOI: 10.1016/j.nec.2013.12.007] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Transforaminal lumbar interbody fusion (TLIF) is an important surgical option for the treatment of back pain and radiculopathy. The minimally invasive TLIF (MI-TLIF) technique is increasingly used to achieve neural element decompression, restoration of segmental alignment and lordosis, and bony fusion. This article reviews the surgical technique, outcomes, and complications in a series of 144 consecutive 1- and 2-level MI-TLIFs in comparison with an institutional control group of 54 open traditional TLIF procedures with a mean of 46 months' follow-up. The evidence base suggests that MI-TLIF can be performed safely with excellent long-term outcomes.
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Affiliation(s)
- Albert P Wong
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 St. Clair, Suite 2210, Chicago, IL 60611, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 St. Clair, Suite 2210, Chicago, IL 60611, USA
| | - James A Stadler
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, 676 St. Clair, Suite 2210, Chicago, IL 60611, USA
| | - Xue Yu Hu
- Department of Orthopaedics, Xijing Hospital, The Fourth Military Medical University, 127 Changle West Road, Xi'an, Shaanxi 710032, China
| | - Jia Zhi Yan
- Department of Orthopaedics, Beijing Tiantan Hospital, The Capital Medical University, Beijing 100050, People's Republic of China
| | - Xin Feng Li
- Department of Orthopaedic Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, People's Republic of China
| | - Ji Hyun Lee
- The Spine Clinic of Los Angeles, Good Samaritan Hospital, University of Southern California, 1245 Wilshire Blvd, Suite 717, Los Angeles, CA 90117, USA
| | - Larry T Khoo
- The Spine Clinic of Los Angeles, Good Samaritan Hospital, University of Southern California, 1245 Wilshire Blvd, Suite 717, Los Angeles, CA 90117, USA.
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Cervical microendoscopic discectomy and fusion: does it affect the postoperative course and the complication rate? A blinded randomized controlled trial. Spine (Phila Pa 1976) 2013; 38:2064-70. [PMID: 24026156 DOI: 10.1097/01.brs.0000435030.96058.bf] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A blinded randomized controlled trial. OBJECTIVE The purpose of this study was to evaluate the cervical microendoscopic discectomy and fusion. SUMMARY OF BACKGROUND DATA Minimally invasive treatment of spinal disorders allows surgeons to have direct access to the pathology with a reduced surgical morbidity, which is reflected over the improved postoperative course. Minimally invasive techniques for cervical discectomy including the posterior microendoscopic discectomy and the percutaneous endoscopic discectomy have a high success rate but are limited by the narrow range of indications. Lately, preliminary reports about cervical microendoscopic discectomy and fusion (CMEDF) showed high success rates without restrictions in the indications. METHODS Seventy consecutive patients were randomly assigned in 2 equal groups, the first operated by the "gold standard" anterior cervical discectomy and fusion and the second by CMEDF. Blinding included the patient-until dressing removal, the evaluating physician, and the radiologist throughout the entire study. The mean follow-up period was 28 months and outcome has been assessed using the Japanese Orthopaedic Association score, Odom criteria and the visual analogue scale. In addition, the operative time, complication rate, hospitalization, and the postoperative analgesic doses were recorded. RESULTS The functional outcome of the CMEDF at the final follow-up was 91% good to excellent. Results in the open group were very similar. Meanwhile, CMEDF demonstrated improved cosmesis, reduced laryngopharyngeal complication rate, postoperative analgesics, and hospital stay. CONCLUSION The results of the CMEDF are very promising. However, a much larger patient series from multicenter studies is still required for drawing up a final conclusion. LEVEL OF EVIDENCE 1.
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Wang YT, Wu XT, Chen H, Wang C. Endoscopy-assisted posterior lumbar interbody fusion in a single segment. J Clin Neurosci 2013; 21:287-92. [PMID: 24238828 DOI: 10.1016/j.jocn.2013.04.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/16/2013] [Accepted: 04/19/2013] [Indexed: 11/26/2022]
Abstract
Posterior lumbar interbody fusion (PLIF) has been routinely performed for the treatment of lumbar segmental lesions. However, traditional PLIF procedures can result in a variety of approach-related morbidities. The purpose of this study was to determine the efficacy of endoscopy-assisted PLIF in lumbar arthrodesis. From July 2005 to May 2007, a total of 56 patients underwent PLIF, including 24 endoscopy-assisted operations (endoscopic group) and 32 traditional open operations (open group). The perioperative data, clinical outcomes and radiographic results were compared. The intraoperative bleeding volume, postoperative drainage volume, intraoperative and postoperative allogeneic blood transfusion volumes, values for C-reactive protein and erythrocyte sedimentation rate on postoperative day 3 and postoperative hospitalization days were decreased in the endoscopic group (p<0.05), while the operative time was longer than that of the open group (p=0.026). According to the Visual Analog Scale for pain, the postoperative low back pain score in the endoscopic group was lower than that observed in the open group (p<0.05). In the endoscopic group, the excellent and good outcome rate was 87.5%, the incidence of complications was 8.3%, and the intervertebral fusion rate was 100%. There were no significant differences for these outcomes when compared with the open group (p>0.05). Endoscopy-assisted PLIF can achieve a clinical efficacy similar to that of traditional open operations while minimizing destruction to adjacent tissues. This technique is safe and is characterized by less bleeding, less tissue trauma, decreased postoperative pain, rapid recovery, and a shorter postoperative hospital stay.
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Affiliation(s)
- Yun-Tao Wang
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu Province 210009, People's Republic of China.
| | - Xiao-Tao Wu
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu Province 210009, People's Republic of China
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu Province 210009, People's Republic of China
| | - Chen Wang
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu Province 210009, People's Republic of China
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Wong AP, Shih P, Smith TR, Slimack NP, Dahdaleh NS, Aoun SG, El Ahmadieh TY, Smith ZA, Scheer JK, Koski TR, Liu JC, Fessler RG. Comparison of symptomatic cerebral spinal fluid leak between patients undergoing minimally invasive versus open lumbar foraminotomy, discectomy, or laminectomy. World Neurosurg 2013; 81:634-40. [PMID: 24239738 DOI: 10.1016/j.wneu.2013.11.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/21/2013] [Accepted: 11/07/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Minimally invasive spine surgery (MISS) techniques have similar long-term outcomes compared to open surgery for patients undergoing 1- or 2-level discectomy, foraminotomy, or laminectomy. However, the rate of cerebrospinal fluid (CSF) leaks with both techniques has not been well established in the literature. This study sought to compare the rate and clinical impact of CSF leak in open lumbar foraminotomy, discectomy, or laminectomy with comparable MISS approaches. METHODS A total of 863 patients undergoing 1- or 2-level discectomy, foraminotomy, or laminectomy by either MISS an open technique were evaluated for CSF leaks. Variables assessed included operative time, blood loss, CSF leaks, hospital stay, days with lumbar drain, days of postoperative flat bed rest, and postoperative intervention. Statistical analyses include univariate analysis (Student t test, analysis of variance, odds ratio, χ(2)) and bivariate analysis (logistic regression). RESULTS In the MISS group there were 15 CSF leaks (4.7%), and 49 CSF leaks (9.0%) in the open group. Eight patients in the open group required lumbar drainage, compared to zero patients in the MISS group. Twelve patients required reoperation for persistent CSF leak in the open group, compared to zero patients in the MISS group. Patients undergoing open spine surgery were 2 times more likely to have a CSF leak (odds ratio = 2.3, 95% confidence interval = 1.2 to 3.7, P = .01). Patients undergoing MISS had significantly lower reoperation rates for CSF leak repairs (open = 25% of open CSF leak cases, MISS = 0%, P < .01). CONCLUSIONS In this study, there was a statistically significant decreased rate of CSF leak between an MISS approach and an open surgical approach. Furthermore, CSF leaks in open surgery have a higher probability of requiring lumbar drainage or reoperation to repair the durotomy.
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Affiliation(s)
- Albert P Wong
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick Shih
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Timothy R Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nicholas P Slimack
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Salah G Aoun
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Zachary A Smith
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Justin K Scheer
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tyler R Koski
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John C Liu
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Richard G Fessler
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Minimally invasive surgery through endoscopic laminotomy and foraminotomy for the treatment of lumbar spinal stenosis. J Orthop 2013; 10:13-6. [PMID: 24403742 DOI: 10.1016/j.jor.2013.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 01/01/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Lumbar spinal stenosis is a common cause of radicular and generalized back pain among older adults. Endoscopic minimally invasive surgery, in contrast to open decompression, may provide the opportunity for a less invasive surgical intervention. Thus, the purpose of this study is to evaluate the safety (operative complications, estimated blood loss, operative room time) and effectiveness (pre- versus postoperative level of disability and pain severity) of minimally invasive surgery using endoscopic laminotomy and foraminotomy among a large sample of patients with lumbar spinal stenosis. METHODS This study is composed of 320 consecutive patients with lumbar spinal stenosis who underwent posterior lumbar laminotomy and foraminotomy between 2008 and 2011. Outcome measures consisted of perioperative complications, estimated blood loss, operative room time, level of disability, and pain severity. Pain severity and level of disability were prospectively analyzed to an average of 18 months (12-36 months) post-surgery. RESULTS There was an average estimated blood loss of 39.3 cc and a mean operative room time of 74 min. Seven patients experienced minor operative complications. All patients were discharged the same day as surgery and reported a significantly lower level of disability (p = 0.00) and pain severity (p = 0.00) postoperative compared to preoperative. CONCLUSIONS Minimally invasive surgery using endoscopy for the treatment of lumbar spinal stenosis has a short operative time, a low operative complication rate, and minimal estimated blood loss. This study also indicates that MIS for the treatment of LSS can significantly reduce pain and disability level. Thus, minimally invasive surgery using endoscopic laminotomy and foraminotomy appears to be a safe and effective alternative surgical treatment for open decompression surgery in adult patients with lumbar spinal stenosis.
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Rhee J, Anaizi AN, Sandhu FA, Voyadzis JM. Minimally invasive resection of lumbar synovial cysts from a contralateral approach. J Neurosurg Spine 2012; 17:453-8. [DOI: 10.3171/2012.8.spine12101] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Synovial cysts of the lumbar spine result from degeneration of the facet capsule and often mimic symptoms commonly seen with herniated intervertebral discs. In symptomatic patients, the prevalence of synovial cysts may be as high as 10%. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for lumbar synovial cyst resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption. The authors report 2 cases of a minimally invasive synovial cyst resection via a contralateral laminotomy. In both cases, complete resection of the cyst was achieved while sparing the facet joint.
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Wong AP, Smith ZA, Lall RR, Bresnahan LE, Fessler RG. The microendoscopic decompression of lumbar stenosis: a review of the current literature and clinical results. Minim Invasive Surg 2012; 2012:325095. [PMID: 22900163 PMCID: PMC3415081 DOI: 10.1155/2012/325095] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 06/07/2012] [Indexed: 01/19/2023] Open
Abstract
Lumbar stenosis is a well-defined pathologic condition with excellent surgical outcomes. Empiric evidence as well as randomized, prospective trials has demonstrated the superior efficacy of surgery compared to medical management for lumbar stenosis. Traditionally, lumbar stenosis is decompressed with open laminectomies. This involves removal of the spinous process, lamina, and the posterior musculoligamentous complex (posterior tension band). This approach provides excellent improvement in symptoms, but is also associated with potential postoperative spinal instability. This may result in subsequent need for spinal fusion. Advances in technology have enabled the application of minimally invasive spine surgery (MISS) as an acceptable alternative to open lumbar decompression. Recent studies have shown similar to improved perioperative outcomes when comparing MISS to open decompression for lumbar stenosis. A literature review of MISS for decompression of lumbar stenosis with tubular retractors was performed to evaluate the outcomes of this modern surgical technique. In addition, a discussion of the advantages and limitations of this technique is provided.
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Affiliation(s)
- Albert P. Wong
- Department of Neurological Surgery, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611, USA
| | - Zachary A. Smith
- Department of Neurological Surgery, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611, USA
| | - Rohan R. Lall
- Department of Neurological Surgery, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611, USA
| | - Lacey E. Bresnahan
- Department of Neurological Surgery, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611, USA
| | - Richard G. Fessler
- Department of Neurological Surgery, Northwestern University, 676 N. St. Clair Street, Suite 2210, Chicago, IL 60611, USA
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Abstract
Minimally invasive spine surgery (MISS) techniques were developed to address morbidities associated with open spinal surgery approaches. MISS was initially applied for indications such as the microendoscopic decompression of stenosis (MEDS)-an operation that has become widely implemented in modern spine surgery practice. Minimally invasive surgery for MEDS is an excellent example of how an MISS technique has improved outcomes compared with the use of traditional open surgical procedures. In parallel with reports of surgeon experience, accumulating clinical evidence suggests that MISS is favoured over open surgery, and one could argue that the role of MISS techniques will continue to expand. As the field of minimally invasive surgery has developed, MISS has been implemented for the treatment of increasingly difficult and complex pathologies, including trauma, spinal malignancies and spinal deformity in adults. In this Review, we present the accumulating evidence in support of minimally invasive techniques for established MISS indications, such as lumbar stenosis, and discuss the need for additional level I and level II data to demonstrate the benefit of MISS over traditional open surgery. The expanding utility of MISS techniques to address an increasingly broad range of spinal pathologies is also highlighted.
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Percutaneous intradiscal treatments for discogenic pain. ACTA ACUST UNITED AC 2012; 50:25-8. [DOI: 10.1016/j.aat.2012.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 01/03/2012] [Accepted: 01/06/2012] [Indexed: 11/18/2022]
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Epstein NE. Spine surgery in geriatric patients: Sometimes unnecessary, too much, or too little. Surg Neurol Int 2011; 2:188. [PMID: 22276241 PMCID: PMC3263001 DOI: 10.4103/2152-7806.91408] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Accepted: 11/21/2011] [Indexed: 11/08/2022] Open
Abstract
Background: Although the frequency of spinal surgical procedures has been increasing, particularly in patients of age 65 and over (geriatric), multiple overlapping comorbidities increase their risk/complication rates. Nevertheless, sometimes these high-risk geriatric patients are considered for “unnecessary”, too much (instrumented fusions), or too little [minimally invasive surgery (MIS)] spine surgery. Methods: In a review of the literature and reanalysis of data from prior studies, attention was focused on the increasing number of operations offered to geriatric patients, their increased comorbidities, and the offers for “unnecessary” spine fusions, including both major open and MIS procedures. Results: In the literature, the frequency of spine operations, particularly instrumented fusions, has markedly increased in patients of age 65 and older. Specifically, in a 2010 report, a 28-fold increase in anterior discectomy and fusion was observed for geriatric patients. Geriatric patients with more comorbid factors, including diabetes, hypertension, coronary artery disease (prior procedures), depression, and obesity, experience higher postoperative complication rates and costs. Sometimes “unnecessary”, too much (instrumented fusions), and too little (MIS spine) surgeries were offered to geriatric patients, which increased the morbidity. One study observed a 10% complication rate for decompression alone (average age 76.4), a 40% complication rate for decompression/limited fusion (average age 70.4), and a 56% complication rate for full curve fusions (average age 62.5). Conclusions: Increasingly, spine operations in geriatric patients with multiple comorbidities are sometimes “unnecessary”, offer too much surgery (instrumentation), or too little surgery (MIS).
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Affiliation(s)
- Nancy E Epstein
- Department of Neurological Surgery, The Albert Einstein College of Medicine, Bronx, NY, 10461, and Winthrop University Hospital, Mineola, NY 11501, USA
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