Spinal endoscopy: evidence, techniques, global trends, and future projections

Transforaminal Contrast Injection Before Computed Tomography-Guided Lateral Endoscopic Lumbar Diskectomy Improves Visualization of Exiting Nerve Root

BACKGROUND AND OBJECTIVES

Percutaneous endoscopic lumbar diskectomy (PELD) is an effective, minimally invasive method for removal of lateral lumbar disk herniations. This minimally invasive technique can be applied with high success and lead to faster recovery than traditional methods. Unfortunately, adoption of these techniques in the United States has been slow. A significant barrier to using this technique is often an inability to completely visualize relevant anatomy and increased operative times. In this article, we describe a technique using computed tomography (CT) guidance in conjunction with a neurogram to perform a PELD. We detail the steps in the technique and its advantages to the surgeon performing it.

METHODS

After a patient is placed supine on a table, a transforaminal injection of contrast is performed under fluoroscopic guidance. Then, after sterilizing and draping in a normal fashion, an intraoperative CT scan is taken with a reference frame in place. During the procedure, this allows for the CT guidance to have the exiting nerve root clearly outlined.

RESULTS

This procedure was successfully performed in a single patient, allowing greater visualization of the exiting nerve root during a difficult revision PELD case. No complications were experienced.

CONCLUSION

A novel technique using a neurogram with CT guidance during a PELD was used to assist with identification of anatomy and decompression of the exiting nerve root. This technique was used without complications.

A novel endoscope-port unit for lumbar microendoscopic surgery: a single-center case series review

Minimally invasive spinal surgery has shown benefits not only from a clinical standpoint but also in some cost-effectiveness metrics. Microendoscopic procedures combine optical advantages of endoscopy with the preservation of bimanual surgical maneuvers that are not feasible with full percutaneous endoscopic procedures. TELIGEN is a new endoscopic platform designed to optimize these operations. Our aim was to present a retrospective review of surgical data from the first consecutive cases applying this device in our institution and describe some of its technical details. 25 patients have underwent procedures using this device at our institution to the date, with a mean follow-up of 341.7 ± 45.1 days. 17 decompression-only procedures, including microendoscopic discectomies (MED) and decompression of stenosis (MEDS), with or without foraminotomies (± MEF) and 8 microendoscopic transforaminal lumbar interbody fusions (ME-TLIF) were performed. Mean age and body mass index (BMI) were respectively 58.8 ± 17.4 years and 27.6 ± 5.3 kg/m2. Estimated blood loss (13 ± 4.8, 12.8 ± 6.98 and 76.3 ± 35.02 mL), postoperative length of hospital stay (11.2 ± 21.74, 22.1 ± 26.85 and 80.7 ± 44.60 h), operative time (130.3 ± 58.53, 121 ± 33.90 and 241.5 ± 45.27 min) and cumulative intraprocedural radiation dose (14.2 ± 6.36, 15.4 ± 12.17 and 72.8 ± 12.26 mGy) are reported in this paper for MED ± MEF, MEDS ± MEF and ME-TLIF, respectively. TELIGEN affords an expanded surgical field of view with unique engineered benefits that provide a promissing platform to enhance minimally invasive spine surgery.

Unilateral biportal endoscopic decompression versus anterior cervical decompression and fusion for unilateral cervical radiculopathy or coexisting cervical myelopathy: a prospective, randomized, controlled, noninferiority trial

BACKGROUND

Cervical spondylosis (CS), including myelopathy and radiculopathy, is the most common degenerative cervical spine disease. This study aims to evaluate the clinical outcomes of unilateral biportal endoscopy (UBE) compared to those of conventional anterior cervical decompression and fusion (ACDF) for treating unilateral cervical radiculopathy or coexisting cervical myelopathy induced by unilateral cervical herniated discs.

METHODS

A prospective, randomized, controlled, noninferiority trial was conducted. The sample consisted of 131 patients who underwent UBE or ACDF was conducted between September 2021 and September 2022. Patients with cervical nerve roots or coexisting spinal cord compression symptoms and imaging-defined unilateral cervical radiculopathy or coexisting cervical myelopathy induced by unilateral cervical herniated discs were randomized into two groups: a UBE group (n = 63) and an ACDF group (n = 68). The operative time, blood loss, length of hospital stay after surgery, and perioperative complications were recorded. Preoperative and postoperative modified Japanese Orthopaedic Association (mJOA) scale scores, visual analog scale (VAS) scores, neck disability index (NDI) scores, and recovery rate (RR) of the mJOA were utilized to evaluate clinical outcomes.

RESULTS

The hospital stay after surgery was significantly shorter in patients treated with UBE than in those treated with ACDF (p < 0.05). There were no significant differences in the neck or arm VAS score, NDI score, mJOA score, or mean RR of the mJOA between the two groups (p < 0.05). Only mild complications were observed in both groups, with no significant difference (p = 0.30).

CONCLUSION

UBE can significantly relieve pain and disability without severe complications, and most patients are satisfied with this technique. Consequently, this procedure can be used safely and effectively as an alternative to ACDF for treating unilateral cervical radiculopathy or coexisting cervical myelopathy induced by unilateral cervical herniated discs.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry on 02/08/2023 ( http://www.chictr.org.cn , #ChiCTR2300074273).

Global utilization of biportal spinal endoscopy: Case series on management of lumbar pathology in Soddo, Ethiopia

INTRODUCTION

Biportal spinal endoscopy is a safe and cost-effective methodology for the management of lumbar pathology in rural underserved hospitals that have standard orthopaedic arthroscopic equipment, but lack access to microscopy.

METHODS

This is a case series noting 1-year outcomes from 5 patients managed with biportal spinal endoscopy during an 11-day mission trip to Soddo, Ethiopia in November 2022. Surgical complications, postoperative assessments, and patient-reported outcomes (PROs) were retrospectively collected and analyzed. Surgical techniques and equipment utilized were shared with residents and faculty at the hospital.

RESULTS

Five Ethiopian patients (4:1, female:male) with no prior spine surgery history elected to undergo biportal surgery for the diagnoses of lumbar stenosis and disc herniation, averaging 31 years of age with Body-Mass-Indices (BMI) <35. Two patients underwent endoscopic discectomy, and three patients underwent endoscopic unilateral laminotomy and bilateral decompression (ULBD). There were no complications. No postoperative functional deficits, infections, readmissions, revisions, or wound dehiscences were noted at 12 months follow-up. VAS-back and VAS-leg scores improved to <2/10 for 80 % of patients. All patients returned to work/activities of daily living. No patients required postoperative pain management beyond the 2-week post-operative follow-up.

CONCLUSION

With these five patients, we found that biportal spinal endoscopy can be safely applied in rural hospital settings with limited resources. This supports biportal spinal endoscopy as a viable minimally invasive modality for the management of lumbar pathology. For hospitals with limited resources, but access to arthroscopic equipment, biportal spinal endoscopy is a feasible option.

LEVEL OF EVIDENCE

IV.

Percutaneous Endoscopic Suprapedicular Decompression in the Treatment of Down-Migrated Lumbar DiscHerniation

OBJECTIVE

This study aimed to investigate the clinical efficacy of percutaneous endoscopic suprapedicular decompression in treatment of down-migrated lumbar disc herniation.

METHODS

The clinical data of 43 patients with down-migrated lumbar disc herniation treated with endoscopic surgery at our hospital between January 2022 and January 2023 were retrospectively analyzed. Twenty-two and 21 patients underwent percutaneous endoscopic decompression using the suprapedicular and transforaminal endoscopic surgical system approaches, respectively. The perioperative, follow-up, and imaging data of the groups were compared.

RESULTS

Surgery was uneventful in both groups. The number of intraoperative fluoroscopies and duration of surgery were significantly lower in the suprapedicular group (P < 0.05). The patients in both groups were followed up for at least 12 months. At the last follow-up, lumbar pain and leg pain visual analog scale, Oswestry Disability Index, and 36-Item Short Form Health Survey scores were significantly improved in both groups compared with preoperative values (P < 0.05); the differences in these indexes between the 2 groups were not significant preoperatively (P > 0.05). However, at the last postoperative follow-up, lumbar pain visual analog scale scores were significantly better in the suprapedicular group (0.83 ± 0.85 vs. 2.54 ± 1.32, P < 0.05). There was no significant change in intervertebral space height or lumbar lordotic angle compared with preoperative values in either group at the last follow-up (P > 0.05). However, the spinal canal cross-sectional area significantly increased (P < 0.05).

CONCLUSIONS

The treatment of down-migrated lumbar disc herniation via a suprapedicular approach enabled the incision of the superior margin of the pedicle as needed under direct vision, involved less fluoroscopy while preserving facet joint stability, and enabled targeted removal of the herniated nucleus pulposus, thus greatly reducing residual nucleus pulposus. This surgical procedure was safe, rapid, and showed satisfactory therapeutic efficacy.

Validity of A Novel Simulator for Percutaneous Transforaminal Endoscopic Discectomy

BACKGROUND

Percutaneous transforaminal endoscopic discectomy (PTED) has steep learning curves and a high incidence of complications, but currently, efficient and economical training methods are lacking. This study aimed to validate a novel simulator for PTED.

METHODS

The simulated PTED included puncturing and establishing the working channel (PEWC) and endoscopic discectomy, with the PEWC being the tested module. Eleven experts and 21 novices were included and introduced to the simulator and tasks; all participants completed the PEWC. Outcomes included: total operation time, number of fluoroscopy for positioning the working sheath, number of spinal risk region invasion, Global Rating Scale (GRS) and a modified GRS, etc. The Mann-Whitney U test was used to compare 2 groups. Spearman's correlation coefficient analyzed continuous variables.

RESULTS

Experts outperformed novices in total operation time (P = 0.001), requiring fewer number of fluoroscopies for positioning the working sheath (P = 0.003). Additionally, experts had a lower number of spinal risk region invasions (P = 0.016) and higher scores on both the GRS (P < 0.001) and modified GRS (P < 0.001). PTED experience correlated with GRS scores (P = 0.001) and modified GRS (P < 0.001). The overall realism scored a median of 4 (3.75-5), and educational value had a median of 4 (range 3-5).

CONCLUSIONS

This study demonstrates the validity of the novel simulator, revealing significant associations between PTED experience and performance metrics in a simulated PEWC setting. Furthermore, the PEWC module also offers a good realistic design and high education value according to experts.

Comparing the Efficacy and Safety of Unilateral Biportal Endoscopic Decompression with Percutaneous Endoscopic Lumbar Decompression for Lumbar Degenerative Diseases: A Meta-Analysis

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.

A new technique for low back pain in lumbar disc herniation: percutaneous endoscopic lumbar discectomy combined with sinuvertebral nerve ablation

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has demonstrated efficacy in alleviating leg pain among patients with lumbar disc herniation. Nonetheless, residual back pain persists as a troubling issue for surgeons following the procedure. In the treatment of discogenic back pain, sinuvertebral nerve radiofrequency ablation has shown promising results. Nevertheless, the potential benefit of simultaneously implementing sinuvertebral nerve radiofrequency ablation during PELD surgery to address residual back pain has not been thoroughly investigated in current literature.

METHODS

This retrospective study reviewed Lumbar disc herniation (LDH) patients with low back pain who underwent combined PELD and sinuvertebral nerve ablation in our department between January 2021 and September 2023. Residual low back pain post-surgery was assessed and compared with existing literature.

RESULTS

A total of 80 patients, including 53 males and 27 females, were included in the study. Following surgical intervention, patients demonstrated remarkable improvements in pain and functional parameters. One month post-operatively, the VAS score for low back pain exhibited a 75% reduction (6.45 ± 1.3 to 1.61 ± 1.67), while the VAS score for leg pain decreased by 85% (7.89 ± 1.15 to 1.18 ± 1.26). Notably, the JOA score increased from 12.89 ± 5.48 to 25.35 ± 4.96, and the ODI score decreased form 59.48 ± 9.58 to 20.3 ± 5.37. These improvements were sustained at three months post-operatively. According to the modified Mac Nab criteria, the excellent and good rate was 88.75%. Residual low back pain is observed to be comparatively reduced compared to the findings documented in earlier literature.

CONCLUSION

The combination of percutaneous endoscopic lumbar discectomy and sinuvertebral nerve ablation demonstrates effective improvement in low back pain for LDH patients.

Advances and Challenges in Minimally Invasive Spine Surgery

Minimally invasive spine surgery continues to grow and develop. Over the past 50 years, there has been immense growth within this subspecialty of neurosurgery. A deep understanding of the historical context and future directions of this subspecialty is imperative to developing safe adoption and targeted innovation. This review aims to describe the advancements, and challenges that we face today in minimally invasive spine surgery.

Transforaminal Endoscopic Ventral Stenosis Decompression in Calcified Lumbar Disc Herniation: A Long Term Outcome in 79 Patients

BACKGROUND

Calcified lumbar disc herniations (CLDH) causing calcified ventral stenosis pose a therapeutic challenge to the treating surgeon due to their neural adhesions, location, and hardness.

METHODS

This retrospective study analyzed all the cases of CLDH/calcified ventral stenosis managed by transforaminal endoscopic lumbar discectomy with a minimum follow-up of 24 months. The preoperative images were analyzed for the level, migration; and grade (Lee's migration zones), and location (Michigan State University classification). Detailed surgical technique and intraoperative parameters including the duration of surgery and complications have been recorded. The clinical parameters including visual analog scale (VAS), Oswestry disability index (ODI), length of stay in hospital, days of return to basic work, and patient satisfaction index were analyzed. Postoperatively the images were analyzed for the adequacy of decompression.

RESULTS

The mean VAS for back pain and leg pain was 4.7 ± 2.6 (0-9), and 7.45 ± 2.2 (1-10), respectively. The mean preoperative ODI was 78.2 ± 13.2 (63.2-95.6). Nineteen patients (24%) had neurological deficits preoperatively. The mean duration of surgery was 90.5 ± 15.8 (58-131) minutes. Postoperative magnetic resonance imaging revealed adequate decompression in 97.5% (n = 77). The mean duration of hospital stay was 1.05 ± 0.22 (1-2) days, and the postoperative back and leg pain VAS was 1.14 ± 1.2 (0-3) (P < 0.05) and 1.7 ± 0.5 (0-6) (P < 0.05), respectively. The ODI at final follow-up was 6.5 ± 3.7 (2.2-18) (P < 0.05). Neurological recovery occurred in 17 (89.5%) patients and they returned to basic work/jobs in 19.5 ± 3.3 (14-26) days. The mean patient satisfaction index was 1.18 ± 0.47 (1-2) at a mean follow-up of 5.52 ± 2.91 (2-12.75) years.

CONCLUSIONS

Transforaminal endoscopic lumbar discectomy is a complete, safe, and efficacious procedure in patients with CLDH with earlier recovery considering the surgery is performed with the patient being awake.

Evolution, Current Trends, and Latest Advances of Endoscopic Spine Surgery

Background: The aging of the population in developing and developed countries has led to a significant increase in the health burden of spinal diseases. These elderly patients often have a number of medical comorbidities due to aging. The need for minimally invasive techniques to address spinal disorders in this elderly population group cannot be stressed enough. Minimally invasive spine surgery (MISS) has several proven benefits, such as minimal muscle trauma, minimal bony resection, lesser postoperative pain, decreased infection rate, and shorter hospital stay. Methods: A comprehensive search of the literature was performed using PubMed. Results: Over the past 40 years, constant efforts have been made to develop newer techniques of spine surgery. Endoscopic spine surgery is one such subset of MISS, which has all the benefits of modern MISS. Endoscopic spine surgery was initially limited only to the treatment of lumbar disc herniation. With improvements in optics, endoscopes, endoscopic drills and shavers, and irrigation pumps, there has been a paradigm shift. Endoscopic spine surgery can now be performed with high magnification, thus allowing its application not only to lumbar spinal stenosis but also to spinal fusion surgeries and cervical and thoracic pathology as well. There has been increasing evidence in support of these newer techniques of spine surgery. Conclusions: For this report, we studied the currently available literature and outlined the historical evolution of endoscopic spine surgery, the various endoscopic systems and techniques available, and the current applications of endoscopic techniques as an alternative to traditional spinal surgery.

Efficacy of PE-PLIF with a novel ULBD approach for lumbar degeneration diseases: a large-channel endoscopic retrospective study

PURPOSE

This study aims to assess the effectiveness of Percutaneous Endoscopic Posterior Lumbar Interbody Fusion (PE-PLIF) combined with a novel Unilateral Laminotomy for Bilateral Decompression (ULBD) approach using a large-channel endoscope in treating Lumbar Degenerative Diseases (LDD).

METHODS

This retrospective analysis evaluates 41 LDD patients treated with PE-PLIF and ULBD from January 2021 to June 2023. A novel ULBD approach, called 'Non-touch Over-Top' technique, was utilized in this study. We compared preoperative and postoperative metrics such as demographic data, Visual Analogue Scale (VAS) for pain, Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) score, surgical details, and radiographic changes.

RESULTS

The average follow-up duration was 14.41 ± 2.86 months. Notable improvements were observed postoperatively in VAS scores for back and leg pain (from 5.56 ± 0.20 and 6.95 ± 0.24 to 0.20 ± 0.06 and 0.12 ± 0.05), ODI (from 58.68 ± 0.80% to 8.10 ± 0.49%), and JOA scores (from 9.37 ± 0.37 to 25.07 ± 0.38). Radiographic measurements showed significant improvements in lumbar and segmental lordosis angles, disc height, and spinal canal area. A high fusion rate (97.56% at 6 months, 100% at 12 months) and a low cage subsidence rate (2.44%) were noted.

CONCLUSIONS

PE-PLIF combined with the novel ULBD technique via a large-channel endoscope offers significant short-term benefits for LDD management. The procedure effectively expands spinal canal volume, decompresses nerve structures, improves lumbar alignment, and stabilizes the spine. Notably, it improves patients' quality of life and minimizes complications, highlighting its potential as a promising LDD treatment option.

Composition of the editorial staff of major spinal journals based on geo-economic background: A survey analysis

Background

The widespread absence of papers originating in low and middle income economies (LAMIE) across various scholarly disciplines has been widely acknowledged. One potential reason for this could be editorial biases against submissions from LAMIE. Although this bias has been observed in different academic areas, its extent in spinal research remains largely uninvestigated. This research endeavored to investigate the composition of editorial staff members (ESM) within major spinal journals and scrutinize the degree of international diversity represented among the ESM.

Methods

We pinpointed ten major spinal journals by referencing their presence in the Journal Citation Reports of 2021. Countries of the ESM affiliated with these journals were categorized according to World Bank classifications. Following this, we conducted a thorough analysis of the ESM compositions.

Results

A total of 982 ESM from 50 countries were identified. The United States exhibited the highest representation among ESM (395, 40.22%), followed by South Korea (57, 5.80%), Switzerland (53, 5.40%). When segmented by geographical regions, North America emerged with the highest representation, constituting 43.38% of ESM at 426, trailed by Europe & Central Asia at 31.16% (306), East Asia & Pacific at 17.92% (175). The majority of ESM, amounting to 87.98%, hailed from high income economies (HIE). There was an absence of ESM representation of low income economies. The relationship regarding the quantity of ESM in each country and its population failed to demonstrate significance (p = 0.274, r = 0.281). However, a notable positive correlation emerged when exploring the connection between ESM numbers and gross domestic product (p = 0.033, r = 0.517).

Conclusions

Major spinal journals exhibit a notable absence of international representation within their editorial boards, predominantly comprising members from HIE. This underscores a substantial underrepresentation of ESM originating from LAMIE within the sphere of spinal investigation.

Morphometric Evaluation of Thoracolumbar Spinal Canal and Cord by Magnetic Resonance Imaging in Normal Small-Breed Dogs

Thoracolumbar intervertebral disc disease (IVDD) is the most common cause of spinal injury in dogs. MRI has been considered the gold standard for neurologic diagnosis, but studies focusing on the thoracolumbar spinal canal and spinal cord using MRI in small-breed dogs are limited. Therefore, this study aimed to establish an MRI reference range for the spinal cord and canal measurements (height, width, cord-to-canal ratio of height, width, cross-sectional area (CSA)) of each intervertebral disc level from T11 to L5 (total of seven levels) on transverse T2-weighted images in normal small-breed dogs. We hypothesized that the spinal cord and spinal canal measurements might vary according to the body weight and age. The width and height of the spinal cord and canal increased as the body weight increased at all levels (p < 0.05). The cord-to-canal ratio of the width showed a negative correlation to the body weight at all levels. The cord-to-canal ratio of the height did not show any correlation to the body weight at all levels. All measurements (height, width, cord-to-canal ratio of height, width, CSA) did not show any statistical correlation between the groups subdivided by age. These measurements could serve as a morphometric baseline for thoracolumbar spinal diseases and clinical research in small-breed dogs.

Advances and Challenges of Endoscopic Spine Surgery

The purpose of this paper is to review the data supporting current endoscopic surgical techniques for the spine and the potential challenges and future of the field. The origins of endoscopic spine surgery can be traced back many decades, with many important innovations throughout its development. It can be applied to all levels of the spine, with many robust trials supporting its clinical outcomes. Continued clinical research is needed to explore its expanding indications. Although the limitations of starting an endoscopic program can be justified by its cost effectiveness and positive societal impact, challenges facing its widespread adoption are still present. As more residency and fellowship programs include endoscopy as part of their spine training, it will become more prevalent in hospitals in the United States. Technological advancements in spine surgery will further propel and enhance endoscopic techniques as they become an integral part of a spine surgeon's repertoire.

Comparison of one-hole split endoscopic discectomy and microendoscopic discectomy in the treatment of lumbar disk herniation: a one-year retrospective cohort study

BACKGROUND

We aim to compare and assess the surgical parameters and follow-up information of one-hole split endoscopic discectomy (OSE) and microendoscopic discectomy (MED) in the treatment of LDH.

METHODS

This study included 154 patients with degenerative lumbar disk disease. Sixty-eight patients underwent OSE and 86 patients MED. The VAS score for lower back and lower limb radiation pain, ODI score, modified MacNab score, estimated blood loss (EBL), length of the incision, amount of C-reactive protein, and recurrence and complication rates were examined as indicators for clinical outcomes and adverse events.

RESULTS

After surgery, the VAS and ODI scores in the two groups significantly decreased. On the third day after surgery, the VAS and ODI scores of the OSE group were significantly better than those of the MED group. The VAS and ODI scores preoperatively and at 1 month, 3 months, 6 months, and 12 months following the procedure did not substantially vary between the two groups. There was less EBL and a shorter incision with OSE than with MED. There was no significant difference in the rate of complications between the two groups.

CONCLUSION

Compared with MED, OSE is a new alternative option for LDH that can achieve similar and satisfactory clinical outcomes. Furthermore, OSE has many advantages, including less EBL and a smaller incision. Further clinical studies are needed to confirm the effectiveness of OSE.

The Evolution of Spinal Endoscopy: Design and Image Analysis of a Single-Use Digital Endoscope Versus Traditional Optic Endoscope

Spinal endoscopy has evolved significantly since its inception, offering minimally invasive solutions for various spinal pathologies. This study introduces a promising innovation in spinal endoscopy-a single-use digital endoscope designed to overcome the drawbacks of traditional optic endoscopes. Traditional endoscopes, despite their utility, present challenges such as fragility, complex disinfection processes, weight issues, and susceptibility to mechanical malfunctions. The digital endoscope, with its disposable nature, lighter weight, and improved image quality, aims to enhance surgical procedures and patient safety. The digital endoscope system comprises a 30-degree 1000 × 1000 pixel resolution camera sensor with a 4.3 mm working channel, and LED light sources replacing optical fibers. The all-in-one touch screen tablet serves as the host computer, providing portability and simplified operation. Image comparisons between the digital and optic endoscopes revealed advantages in the form of increased field of view, lesser distortion, greater close-range resolution, and enhanced luminance. The single-use digital endoscope demonstrates great potential for revolutionizing spine endoscopic surgeries, offering convenience, safety, and superior imaging capabilities compared to traditional optic endoscopes.

Near infrared imaging system for preventing blood vision obstruction in endoscopy

Spinal endoscopy procedure is commonly used in the diagnosis and treatment of various health problems and is effective. Bleeding is one of the most common complications of spinal endoscopy procedures. Blood vision obstruction (BVO), that is, obstruction of the endoscopic camera lens caused by the accumulation of blood in the surgical field, is a serious problem in endoscopic procedures. This study presents what we believe to be a new approach to addressing BVO with external multispectral imaging. The study was completed using a BVO simulation model, and the results reveal that this technology can be used to effectively overcome BVO and provide clear images of the anatomy, enabling more effective diagnosis and treatment. This technique may enable improvement of the outcomes of endoscopic procedures and could have far-reaching implications in the field of endoscopy.

Endoscopic Anterior Lumbar Interbody Fusion: Systematic Review and Meta-Analysis

Laparoscopic anterior lumbar interbody fusion (L-ALIF), which employs laparoscopic cameras to facilitate a less invasive approach, originally gained traction during the 1990s but has subsequently fallen out of favor. As the envelope for endoscopic approaches continues to be pushed, a recurrence of interest in laparoscopic and/or endoscopic anterior approaches seems possible. Therefore, evaluating the current evidence base in regard to this approach is of much clinical relevance. To this end, a systematic literature search was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following keywords: "(laparoscopic OR endoscopic) AND (anterior AND lumbar)." Out of the 441 articles retrieved, 22 were selected for quantitative analysis. The primary outcome of interest was the radiographic fusion rate. The secondary outcome was the incidence of perioperative complications. Meta-analysis was performed using RStudio's "metafor" package. Of the 1,079 included patients (mean age, 41.8±2.9 years), 481 were males (44.6%). The most common indication for L-ALIF surgery was degenerative disk disease (reported by 18 studies, 81.8%). The mean follow-up duration was 18.8±11.2 months (range, 6-43 months). The pooled fusion rate was 78.9% (95% confidence interval [CI], 68.9-90.4). Complications occurred in 19.2% (95% CI, 13.4-27.4) of L-ALIF cases. Additionally, 7.2% (95% CI, 4.6-11.4) of patients required conversion from L-ALIF to open surgery. Although L-ALIF does not appear to be supported by studies available in the literature, it is important to consider the context from which these results have been obtained. Even if these results are taken at face value, the failure of endoscopy to have a role in the ALIF approach does not mean that it should not be incorporated in posterior approaches.

Hybrid Minimally Invasive Endoscopic Approach for Gaseous Protrusion Causing L5 Radiculopathy

We present an illustrative case of a hybrid approach between minimally invasive and endoscopic spine surgery techniques. We utilized this hybrid approach for the first 3 cases to help diminish the learning curve as we started a spinal endoscopy program. The patient is an 85-year-old woman with a prior history of arthrodesis at L3-5. She presented with severe leg pain and imaging evidence of degenerative disk disease with disk protrusion in the extraforaminal zone at L5-S1. Computed tomography imaging shows the disk protrusion to be gaseous in nature. Given failure of conservative management and patient refusal for extension of her prior fusion, she was offered a combined minimally invasive navigated technique and endoscopic approach for far lateral diskectomy. After obtaining the correct trajectory, with confirmation by intraoperative fluoroscopy, microscopic visualization was used to identify the protruded disk and the exiting nerve root (Video 1). Given the difficult visualization, a 30-degree endoscopic probe was used, which enabled real-time visualization of the gaseous protrusion being released in the liquid medium. After decompression, microscopic visualization was used for confirmation, with the patient obtaining a good surgical outcome and complete relief of her presenting pain. This case illustrates the synergism between endoscopic and minimally invasive spine surgery techniques and the unique advantages of enabling visualization of spinal anatomy through a liquid medium with the use of an endoscope.1-3.

Interlaminar Endoscopic Lumbar Discectomy Versus Microscopic Lumbar Discectomy: A Preliminary Analysis of L5-S1 Lumbar Disc Herniation Outcomes in Prospective Randomized Controlled Trials

OBJECTIVE

A preliminary report from a single institution, noninferiority, prospective randomized controlled trial is conducted to determine the effectiveness of interlaminar endoscopic lumbar discectomy (IELD) versus microscopic lumbar discectomy (MLD) for the treatment of L5-S1 lumbar disc herniation (LDH).

METHODS

This prospective, noncrossover, randomized controlled trials was conducted at a single neurosurgical center. Patients with symptomatic radiculopathy or intermittent neurogenic claudication caused by LDH were enrolled from July 2016 to July 2021. The study compared the effectiveness of microscopic and full-endoscopic discectomy procedures. Outcome measures included visual analogue scale (VAS) scores for back and leg pain, Oswestry Disability Index scores, radiologic measurements, endurance time of walking, and satisfaction rate.

RESULTS

Of 37 assessed patients, both IELD and MLD groups demonstrated significant improvements in VAS scores for pain over time, with no significant difference between them. For secondary outcomes, the IELD group had a shorter hospital stay and reduced blood loss but a longer operation time than the MLD group. Radiographic evaluations showed no change compared to preoperative data. Patient satisfaction and recovery rates were slightly higher for the MLD group, but both groups were comparable in most evaluations, with complications being minimal.

CONCLUSION

The IELD was noninferior in improving the intensity of back and leg pain and functional disability, compared to the MLD. Additionally, the IELD showed no difference in clinical outcomes for patients in terms of radiographic results and patient satisfaction rates. The results of this research preliminarily demonstrate that the IELD could be considered an effective alternative to MLD for L5-S1 central or paracentral LDH.

A Beginner's Perspective on Biportal Endoscopic Spine Surgery in Single-Level Lumbar Decompression: A Comparative Study with a Microscopic Surgery

Background

The application of biportal endoscopic spinal surgery (BESS) in spine surgery is increasing. However, the clinical results of related studies have been inconsistent. In this study, the perioperative and clinical outcomes of two techniques in single-level lumbar decompression surgery were compared using the perspective of a spine surgeon experienced in microscopic surgery but inexperienced in BESS.

Methods

This is a retrospective study performed with prospectively collected data. From April 2019, 50 consecutive patients who underwent a single-level lumbar decompression surgery with BESS were evaluated. Additionally, the data of 150 consecutive patients who underwent the same microscopic surgery before April 2019 were collected. We performed 1 : 1 ratio propensity score matching for these two groups to adjust for baseline variables. The postoperative patient-reported outcome measures included the Oswestry Disability Index (ODI) and numeric rating scale for the back and leg preoperatively and at 6 months after surgery. The laboratory data (C-reactive protein [CRP, mg/L] and hemoglobin [Hb, g/dL]) were measured preoperatively and 3 times (1, 2, and 3 or 4 days) postoperatively. In these periods, the peak and lowest CRP and Hb concentrations were evaluated. The perioperative outcomes, operation time (from skin incision to dressing), length of hospital stay, drainage (for 24 hours after surgery), and surgery-related complications were also evaluated.

Results

Forty-seven patients (27 men and 20 women) were included in each group. The postoperative 6-month ODI was significantly lower in the BESS group than in the microscope group (6.90 ± 5.98 vs. 11.54 ± 9.70). The peak CRP concentration (16.63 ± 19.41 vs. 42.40 ± 37.73, p < 0.001) and CRP increment (peak CRP minus preoperative CRP, 14.69 ± 19.47 vs. 40.71 ± 37.32, p < 0.001) were significantly higher in the microscope group. Operation time (83.72 ± 35.71 vs. 70.27 ± 23.24, p = 0.047) was significantly longer in the BESS group. Surgery-related complications were found in 6 and 3 cases in the BESS group (3 revisions, 2 dural tears, and 1 conversion to open surgery) and microscope group (2 revisions and 1 hematoma), respectively.

Conclusions

BESS as a new technique resulted in satisfying short-term outcomes. It was a well-tolerated option for surgical treatment of single-level lumbar degenerative disease. The relatively high incidence of recurrence at the index level and incidental dural tears should be considered for surgeons new to BESS; however, these were manageable complications.

Endoscopic image classification algorithm based on Poolformer

Image desmoking is a significant aspect of endoscopic image processing, effectively mitigating visual field obstructions without the need for additional surgical interventions. However, current smoke removal techniques tend to apply comprehensive video enhancement to all frames, encompassing both smoke-free and smoke-affected images, which not only escalates computational costs but also introduces potential noise during the enhancement of smoke-free images. In response to this challenge, this paper introduces an approach for classifying images that contain surgical smoke within endoscopic scenes. This classification method provides crucial target frame information for enhancing surgical smoke removal, improving the scientific robustness, and enhancing the real-time processing capabilities of image-based smoke removal method. The proposed endoscopic smoke image classification algorithm based on the improved Poolformer model, augments the model's capacity for endoscopic image feature extraction. This enhancement is achieved by transforming the Token Mixer within the encoder into a multi-branch structure akin to ConvNeXt, a pure convolutional neural network. Moreover, the conversion to a single-path topology during the prediction phase elevates processing speed. Experiments use the endoscopic dataset sourced from the Hamlyn Centre Laparoscopic/Endoscopic Video Dataset, augmented by Blender software rendering. The dataset comprises 3,800 training images and 1,200 test images, distributed in a 4:1 ratio of smoke-free to smoke-containing images. The outcomes affirm the superior performance of this paper's approach across multiple parameters. Comparative assessments against existing models, such as mobilenet_v3, efficientnet_b7, and ViT-B/16, substantiate that the proposed method excels in accuracy, sensitivity, and inference speed. Notably, when contrasted with the Poolformer_s12 network, the proposed method achieves a 2.3% enhancement in accuracy, an 8.2% boost in sensitivity, while incurring a mere 6.4 frames per second reduction in processing speed, maintaining 87 frames per second. The results authenticate the improved performance of the refined Poolformer model in endoscopic smoke image classification tasks. This advancement presents a lightweight yet effective solution for the automatic detection of smoke-containing images in endoscopy. This approach strikes a balance between the accuracy and real-time processing requirements of endoscopic image analysis, offering valuable insights for targeted desmoking process.

Clinical outcomes and complications after biportal endoscopic spine surgery: a comprehensive systematic review and meta-analysis of 3673 cases

PURPOSE

Current literature suggests that biportal spinal endoscopy is safe and effective in treating lumbar spine pathology such as lumbar disc herniation, lumbar stenosis, and degenerative spondylolisthesis. No prior study has investigated the postoperative outcomes or complication profile of the technique as a whole. This study serves as the first comprehensive systematic review and meta-analysis of biportal spinal endoscopy in the lumbar spine.

METHODS

A PubMed literature search provided over 100 studies. 42 papers were reviewed and 3673 cases were identified with average follow-up time of 12.5 months. Preoperative diagnoses consisted of acute disc herniation (1098), lumbar stenosis (2432), and degenerative spondylolisthesis (229). Demographics, operative details, complications, and perioperative outcome and satisfaction scores were analyzed.

RESULTS

Average age was 61.32 years, 48% male. 2402 decompressions, 1056 discectomies, and 261 transforaminal lumbar Interbody fusions (TLIFs) were performed. Surgery was performed on 4376 lumbar levels, with L4-5 being most common(61.3%). 290 total complications occurred, 2.23% durotomies, 1.29% inadequate decompressions, 3.79% epidural hematomas, and < 1% transient nerve root injuries, infections, and iatrogenic instability. Significant improvement in VAS-Back, VAS-Leg, ODI, and Macnab Scores were seen across the cohort.

CONCLUSION

Biportal spinal endoscopy is a novel method to address pathology in the lumbar spine with direct visualization through an endoscopic approach. Complications are comparable to previously published rates. Clinical outcomes demonstrate effectiveness. Prospective studies are required to assess the efficacy of the technique as compared to traditional techniques. This study demonstrates that the technique can be successful in the lumbar spine.

Development of an Endoscopic Spine Surgery Program: Overview and Basic Considerations for Implementation

Endoscopic spine surgery (ESS) is an innovative technique allowing for minimally invasive, direct visualization of spinal abnormalities. The growth of ESS in the United States has been stunted by high start-up costs, low reimbursement rates, and the steep learning curve associated with mastering endoscopic techniques. Hergrae, we describe the current state and future direction of ESS and provide key action items for ESS program implementation.

Fully Endoscopic Spine Separation Surgery in Metastatic Disease-Case Series, Technical Notes, and Preliminary Findings

Objective: This report aims to describe the surgical methodology and potential effectiveness of endoscopic separation surgery (ESS) in patients with metastatic spine disease. This concept may reduce the invasiveness of the procedure, which can potentially speed up the wound healing process and, thus, the possibility of faster application of radiotherapy. Materials and Methods: In this study, separation surgery for preparing patients for stereotactic body radiotherapy (SBRT) was performed with fully endoscopic spine surgery (FESS) followed by percutaneous screw fixation (PSF). Results: Three patients with metastatic spine disease in the thoracic spine were treated with fully endoscopic spine separation surgery. The first case resulted in the progression of paresis symptoms that resulted in disqualification from further oncological treatment. The remaining two patients achieved satisfactory clinical and radiological effects and were referred for additional radiotherapy. Conclusions: With advancements in medical technology, such as endoscopic visualization, and new tools for coagulation, we can treat more and more spine diseases. Until now, spine metastasis was not an indication for the use of endoscopy. This method is very technically challenging and risky, especially at such an early stage of application, due to variations in the patient's condition, morphological diversity, and the nature of metastatic lesions in the spine. Further trials are needed to determine whether this new approach to treating patients with spine metastases is a promising breakthrough or a dead end.

Background, techniques, applications, current trends, and future directions of minimally invasive endoscopic spine surgery: A review of literature

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.

Advancing Education in Endoscopic Spinal Navigation: Novel Methods and Technical Note

This report aims to demonstrate how to teach anatomy and understanding of spinal endoscopic vision and navigation using mnemonics. The authors present a new surgical technique for teaching endoscopic spinal navigation in a didactic manner with tips such as the "rule of the hand" and decomposition of the endoscopic navigation movement. We demonstrate how the surgery is seen and illustrate how images are projected onto the screen, then divide the navigation into spatial orientation and self-navigation. The article describes the proper puncture technique, how to introduce the working portal, and how to assimilate this new anatomical vision using the "rule of the hand." The surgeon projects their hand on the video screen to guide themselves when starting the navigation and uses the same technique to localize regions of interest during surgery. Finally, the authors break down the navigational movement into three components: forceps positioning, triangulation, and joystick motion. One of the biggest challenges when learning spinal endoscopic surgery is understanding the anatomy seen through the endoscope. By decomposing movements required for navigation, one can understand how to make proper use of the equipment as well as improve their knowledge of this "new anatomy." The learning methods taught in this article have the potential to decrease the learning curve and radiation exposure to those that are still acquainting themselves to spinal endoscopic navigation. We recommend that further studies measure and quantify the impact of these methods on surgical practice.

Learning curve for biportal endoscopic posterior cervical foraminotomy determined using the cumulative summation test

BACKGROUND

Learning curves describe the rate of performance improvements corresponding to the surgeon's caseload, followed by a plateau where limited further improvements are observed. This study aimed to determine the learning curve for biportal full-endoscopic posterior cervical foraminotomy (BE-PCF) for the unilateral cervical foraminal disc.

METHODS

The learning curve was evaluated using a learning curve cumulative summation test (LC-CUSUM). The goal for the operation time was set to 78 min, which is the mean operation time (mOT) of percutaneous full-endoscopic posterior cervical foraminotomy (PE-PCF) performed by a senior surgeon. Moreover, clinical outcomes and post-operative complications were compared between the early and late learning periods 1 year post-operatively.

RESULTS

This study enrolled the first 50 patients who underwent single-level BE-PCF, performed by a single surgeon. The LC-CUSUM signalled competency for surgery at the 20th operation, indicating that sufficient evidence was obtained to prove that the surgeon was competent. The mOT was 71.29 ± 11.69 min in BE-PCF, 71.84 ± 12.61 min in the early learning period, and 67.83 ± 10.31 min in the late learning period (p = 0.254). There was no statistical difference in clinical outcomes, visual analogue scale scores, and neck disability index between both periods (p > 0.05). Four complications were recorded throughout the whole period, with three in the early period and one in the late period (p = 0.285).

CONCLUSION

Our study shows that BE-PCF has a learning curve of 20 caseloads to achieve 90% proficiency, and it significantly reduces the operation time based on the performance of a senior surgeon proficient in PE-PCF.

Predictors for failure after surgery for lumbar spinal stenosis: a prospective observational study

BACKGROUND/CONTEXT

Some patients do not improve after surgery for lumbar spinal stenosis (LSS), and surgical treatment implies a risk for complications and deterioration. Patient selection is of paramount importance to improve the overall clinical results and identifying predictive factors for failure is central in this work.

PURPOSE

We aimed to explore predictive factors for failure and worsening after surgery for LSS.

STUDY DESIGN /SETTING

Retrospective observational study on prospectively collected data from a national spine registry with a 12-month follow-up.

PATIENT SAMPLE

We analyzed 11,873 patients operated for LSS between 2007 and 2017 in Norway, included in the Norwegian registry for spine surgery (NORspine). Twelve months after surgery, 8919 (75.1%) had responded.

OUTCOME MEASURES

Oswestry Disability Index (ODI) 12 months after surgery.

METHODS

Predictors were assessed with uni- and multivariate logistic regression, using backward conditional stepwise selection and a significance level of 0.01. Failure (ODI>31) and worsening (ODI>39) were used as dependent variables.

RESULTS

Mean (95%CI) age was 66.6 (66.4-66.9) years, and 52.1% were females. The mean (95%CI) preoperative ODI score was 39.8 (39.4-40.1). All patients had decompression, and 1494 (12.6%) had an additional fusion procedure. Twelve months after surgery, the mean (95%CI) ODI score was 23.9 (23.5-24.2), and 2950 patients (33.2%) were classified as failures and 1921 (21.6%) as worse. The strongest predictors for failure were duration of back pain > 12 months (OR [95%CI]=2.24 [1.93-2.60]; p<.001), former spinal surgery (OR [95%CI]=2.21 [1.94-2.52]; p<.001) and age>70 years (OR (95%CI)=1.97 (1.69-2.30); p<.001). Socioeconomic variables increased the odds of failure (ORs between 1.36 and 1.62). The strongest predictors for worsening were former spinal surgery (OR [95%CI]=2.04 [1.77-2.36]; p<.001), duration of back pain >12 months (OR [95%CI]=1.83 [1.45-2.32]; p<.001) and age >70 years (OR [95%CI]=1.79 [1.49-2.14]; p<.001). Socioeconomic variables increased the odds of worsening (ORs between 1.33-1.67).

CONCLUSIONS

After surgery for LSS, 33% of the patients reported failure, and 22% reported worsening as assessed by ODI. Preoperative duration of back pain for longer than 12 months, former spinal surgery, and age above 70 years were the strongest predictors for increased odds of failure and worsening after surgery.

Training to be a spinal endoscopic surgeon: What matters?

Objective

Spinal endoscopic surgery has been promoted rapidly in the past decade, attracting an increasing number of young, dedicated surgeons. However, it has long been denounced for its long learning curve as a factor impeding the development of this state-of-the-art technique. The aim of the present study was to discover what really matters in the educational process of becoming a spinal endoscopic surgeon.

Methods

An online survey consisting of 14 compulsory questions was distributed in April and May 2022 through the First Chinese Spinal Endoscopic Surgeons Skills Competition. Reminders were sent to increase response rates.

Results

Of the 893 emails that were sent, we received 637 responses. A total of 375 (76.7%) surgeons most frequently used endoscopic techniques in their practices. Regardless of their different backgrounds, 284 (75.7%) surgeons thought it would be necessary for a young spinal endoscopic surgeon to perform 300 cases independently in order to become proficient, followed by 500 (n=43, 11.5%), 100 (n=40, 10.7%), and 1,000 (n=8, 2.1%) cases. According to the surgeons, the most difficult aspect of mastering the endoscopic technique is a disparate surgical view (n=255, 68%), followed by adaption to new instruments (n=86, 22.9%) and hand-eye coordination (n=34, 9.1%). The most helpful training method for helping the spinal endoscopic surgeons of younger generations improve is operating on simulation models or cadaver courses (n=216, 57.6%), followed by online or offline theoretical courses (n=67, 17.9%), acquiring opportunities during surgeries (n=51, 13.6%), and frequently participating in surgeries as an assistant (n=41, 10.9%).

Conclusion

From the perspective of surgeons, to be skilled in spinal endoscopic surgery means overcoming a steep learning curve. However, training systems should be given more attention to make them more accessible to younger surgeons so they can work on simulation models or take cadaver courses.

Contralateral inclinatory approach for decompression of the lateral recess and same-level foraminal lesions using unilateral biportal endoscopy: A technical report

Objective

Unilateral biportal endoscopic (UBE)surgery is being increasingly adopted as a minimally invasive technique. The purpose of the current study was to introduce a novel surgical technique for lateral recess and same-level foraminal decompression by the contralateral inclinatory approach with unilateral biportal endoscopy(CIA-UBE) at the lumbar level.

Methods

Between January 2020 and February 2022, 10 patients suffering from lateral recess and same-level foraminal stenosis at the lumbar level underwent UBE surgery by contralateral inclinatory approach (CIA-UBE). Magnetic resonance imaging (MRI) scans were examined after surgery to measure the cross-sectional area (CSA) of the spinal canal (CSA-SC), the CSA of the intervertebral foramen (CSA-IVF), and the CSA of the facet joint (CSA-FJ). Postoperative radiologic images using computed tomography (CT) were obtained to investigate the existence of facet joint violation. Clinical outcomes were assessed using Oswestry Disability Index (ODI) scores and visual analogue scale (VAS) scores for buttock and radicular pain.

Results

Ten levels were decompressed, and the mean age of the patients was 56.92 ± 13.26 years. The mean follow-up period was 7.60 ± 4.47 months. The average operative time was 85.14 ± 25.65 min. Postoperative CT and MRI revealed ideal neural decompression of the treated segments in all patients. CSA-IVF and CSA-FJ improved significantly, indicating good foraminal and lateral recess decompression with less damage to facet joints. Preoperative VAS and ODI scores improved significantly after surgery.

Conclusion

CIA-UBE may be an effective surgical treatment of the lateral recess and same-level foraminal stenosis at the lumbar level, which provides successful surgical decompression for traversing and exiting nerve roots with a better operative view and easier surgical manipulation. This approach may also help to maximize the preservation of the facet joint.

[Brief history, global trends, and Chinese mission of unilateral biportal endoscopy technique]

The current unilateral biportal endoscopy (UBE) technique was originated from Argentina and developed in South Korea, which was rapidly growing and popularizing in China. The adoption of spinal endoscopy, using small cameras placed inside body with continuous water irrigation, providing better surgical field with less tissue dissection and quicker recovery for patients. As with other disciplines, the use of spinal endoscopy in spinal surgery will become increasingly widespread. UBE technique will promote the popularization of spinal endoscopy in China with monoportal endoscopy technique. At the same time, biportal endoscopy has better expansibility, the application of accessory incision may provide solution for more complicated spinal disease. Chinese spine surgeon should better understand the trends in spinal endoscopy, seize the opportunity of the rapidly evolving in spinal healthcare, and to promote the popularization of UBE across the globe.

Unilateral biportal endoscopic lumbar interbody fusion assisted by intraoperative O-arm total navigation for lumbar degenerative disease: A retrospective study

Background

Recently, unilateral biportal endoscopic lumbar interbody fusion (BE-LIF) has been successfully applied for degenerative diseases of the lumbar spine, with good clinical results reported. However, the drawbacks include radiation exposure, limited field of view, and steep learning curves.

Objective

This retrospective study aimed to compare the results between navigation and non-navigation groups and explore the benefits of BE-LIF assisted by intraoperative O-arm total navigation.

Methods

A total of 44 patients were retrospectively analyzed from August 2020 to June 2021. Perioperative data were collected, including operative time, estimated intraoperative blood loss, postoperative drainage, postoperative hospital stay, radiation dose, and duration of radiation exposure. In addition, clinical outcomes were evaluated using postoperative data, such as the Oswestry Disability Index (ODI), visual analog scale (VAS), modified MacNab criteria, Postoperative complications and fusion rate.

Results

The non-navigation and navigation groups included 23 and 21 patients, respectively. All the patients were followed up for at least 12 months. No significant differences were noted in the estimated intraoperative blood loss, postoperative drainage, postoperative hospital stay, fusion rate, or perioperative complications between the two groups. The radiation dose was significantly lower in the navigation group than in the non-navigation group. The average total operation time in the navigation group was lower than that in the non-navigation group (P < 0.01). All clinical outcomes showed improvement at different time points postoperatively, with no significant difference noted between the two groups (P > 0.05).

Conclusions

Compared with the non-navigation approach, O-arm total navigation assistive BE-LIF technology not only has similar clinical results, but also can provide accurate intraoperative guidance and help spinal surgeons achieve accurate decompression. Furthermore, it can reduce radiation exposure to surgeons and operation time, which improve the efficiency and safety of surgery.

Endoscope-Assisted Retroperitoneal Prepsoas Approach to Lumbar Intervertebral Disk Decompression. Technical Note

BACKGROUND

Increasingly there is an impetus on the part of surgeons to find more minimally invasive approaches to treat spinal pathologies. Retroperitoneal prepsoas and transpsoas approaches to the lumbar spine are one such example gaining increased attention. Endoscope-assisted approaches may help further reduce soft tissue dissection.

OBJECTIVE

To describe an endoscope-assisted lateral retroperitoneal prepsoas approach for lumbar diskectomy.

METHODS

Two fresh-frozen thoracolumbar cadaveric specimens were obtained and placed in the right lateral decubitus position. Using a left-sided, retroperitoneal prepsoas approach to the lumbar spine and under endoscopic visualization, diskectomies were performed at the L2/3, L3/4, L4/5, and L5/S1 intervertebral spaces. Qualitative assessment of the extent of central and contralateral foraminal decompression was performed.

RESULTS

The endoscope was found to provide effective visualization at all disk spaces and combined with the anterior retroperitoneal prepsoas approach allowed for effective decompression of all explored disk spaces. Both operators noted difficulty obtaining visualization of the ipsilateral foramen, but adequate central and contralateral foraminal decompression was achievable for central, paracentral, and contralateral far lateral disk protrusions.

CONCLUSION

Endoscope assistance may improve visualization of the lumbar intervertebral disk spaces during retroperitoneal prepsoas approaches and thereby help to expand the surgical indication for anterior and oblique lumbar interbody fusion.

The Surgical Treatment of Osteoarthritis

Osteoarthritis is a degenerative condition affecting the whole joint with the underlying bone, representing a major source of pain, disability, and socioeconomic cost worldwide. Age is considered the strongest risk factor, albeit abnormal biomechanics, morphology, congenital abnormality, deformity, malalignment, limb-length discrepancy, lifestyle, and injury may further increase the risk of the development and progression of osteoarthritis as well. Pain and loss of function are the main clinical features that lead to treatment. Although early manifestations of osteoarthritis are amenable to lifestyle modification, adequate pain management, and physical therapy, disease advancement frequently requires surgical treatment. The symptomatic progression of osteoarthritis with radiographical confirmation can be addressed either with arthroscopic interventions, (joint) preservation techniques, or bone fusion procedures, whereas (joint) replacement is preferentially reserved for severe and end-stage disease. The surgical treatment aims at alleviating pain and disability while restoring native biomechanics. Miscellaneous surgical techniques for addressing osteoarthritis exist. Advanced computer-integrated surgical concepts allow for patient personalization and optimization of surgical treatment. The scope of this article is to present an overview of the fundamentals of conventional surgical treatment options for osteoarthritis of the human skeleton, with emphasis on arthroscopy, preservation, arthrodesis, and replacement. Contemporary computer-assisted orthopaedic surgery concepts are further elucidated.

Microendoscopic Decompression for Lumbar Disc Herniations: An Analysis of Short and Long Term Patient Reported Outcome Measures

INTRODUCTION

Endoscopic spine surgery is increasingly being used, and techniques, platforms, and applications are rapidly evolving. Despite substantial enthusiasm surrounding these techniques, there is a dearth of longer term patient-reported clinical outcomes. Within the United States in particular, there are yet to be reported large cohort studies with a notable follow-up. We sought to characterize the clinical outcomes of patients undergoing microendoscopic decompression (MED) for lumbar disk herniations.

METHODS

The records of patients with symptomatic lumbar disk herniations who underwent MED from May 2018 to February 2021 within a single practice were reviewed. Paired outcomes scores were evaluated using Patient-Reported Outcomes Measurement Information System parameters. Basic perioperative data including length of stay, estimated blood loss, mean opioid use, complication rate, and rate of revision were tabulated. Paired sample Student t-tests and paired Wilcoxon sign tests were used to compare normally distributed and nonparametric data, respectively.

RESULTS

Thirty-five patients with complete paired patient-reported outcome measures data and a minimum 6-month follow-up were included; 65.7% of the patients were male with a mean age of 47.1 years (SE 1.8). The mean follow-up was 590.6 days (SE 47.7). In total, 34 of the 35 patients (97.1%) were discharged on the day of their procedure. The estimated blood loss was <25 mL for each procedure. The mean opioid use after extubation and before discharge was 10.4 morphine milligram equivalents. At the 2-week follow-up, there were notable improvements in pain metrics and global health components. At the final follow-up, nearly all parameters showed notable improvement that exceeded minimally clinical important difference values. For most parameters, preoperative values outside of the "normal" range were within normal limits on postoperative testing.

DISCUSSION

MED resulted in sustained notable improvement in patient-reported outcome measures that exceeded minimally clinical important difference values at the average follow-up approximating 2 years. These findings substantiate the utility of this technique and additional investment in endoscopic spine technology.

DATA AVAILABILITY

Not publicly available; available upon request.

Microendoscopic decompression of conjoined lumbosacral nerve roots

Nerve root morphological variability is often incompletely appreciated on preoperative imaging and can complicate intraoperative decision-making. This case demonstrates the utility of spinal endoscopy in the visualisation and manipulation of conjoined nerve roots and includes procedural images to promote better understanding and awareness of this anatomical anomaly. A woman in her 50s presented with 1 year of progressive left S1 radiculopathy refractory to non-operative modalities. History and examination were notable for S1 dermatomal paresthesias, positive ipsilateral straight leg raise and grade 4/5 gastrocnemius strength. MRI demonstrated an L5-S1 left paracentral disc herniation causing severe lateral recess stenosis. Endoscopic decompression revealed conjoined lumbosacral nerve roots. Laminotomies and discectomy provided circumferential decompression. The patient experienced immediate and sustained relief of her preoperative radiculopathy as manifested in patient-reported outcome measures. Evolving endoscopic spine platforms provide novel visualisation of nerve root anomalies yielding new insight on safe and effective decompressive techniques.

Surgeons’ Perspective, Learning Curve, Motivation, and Obstacles of Full-Endoscopic Spine Surgery in Thailand: Results From A Nationwide Survey

Objective

To report a nationwide survey of the endoscopic spine surgeons across Thailand. Furthermore, the survey will be focused on the perspective of experience, learning curve, motivations, and obstacles at the beginning of their practices.

Materials and Methods

The online survey consisting of 16 items was distributed to spine surgeons who are performing endoscopic spine surgery in Thailand via the Google forms web-based questionnaire to investigate participants' demographics, backgrounds, experience in endoscopic spine surgery, motivations, obstacles, and future perspectives. The data was recorded from January 7, 2020 to January 21, 2022. Descriptive statistics were used for analysis.

Results

A total of 42 surveys were submitted by 6 neurosurgeons (14.3%) and 36 orthopedic surgeons (85.7%). From the surgeons' perspective, the average number of cases that should be performed until one feels confident, consistently good outcomes, and has minimal complications was 27.44 ± 32.46 cases. For surgeons who starting the endoscopic spine practice, at least 3 workshop participation is needed. Personal interest (39 selected responses) and trending marketing or business purpose (25 selected responses) were the primary motivators for endoscopic spine surgery implementation. Lack of support (18 selected responses) and afraid of complications (16 selected responses) were pertinent obstacles to endoscopic spine surgery implementation.

Conclusions

The trend of endoscopic spine surgery has continued to grow in Thailand, shown by the rate of implementation of endoscopic spine surgery reported by Thai spine surgeons. The number of appropriate cases until one feels confident was around 28 cases. The primary motivator and obstacles were personal interest and lack of support.