Percutaneous Endoscopic Retrieval of Intraspinal Cement Leakage: Technical Note

Biportal Endoscopic Paraspinal Decompression for Epidural Cement Leakage Removal: A Technical Note

OBJECTIVE

We aimed to preliminarily explore the efficacy and safety of unilateral biportal endoscopy for the treatment of epidural cement leaks. We report a patient who underwent epidural cement leakage removal and achieved endoscopic spinal decompression.

METHODS

A 67-year-old female patient underwent biportal endoscopic paraspinal decompression following percutaneous vertebroplasty for an osteoporotic fracture that resulted in neurologic impairment due to epidural cement leakage. A transforaminal biportal endoscopic surgery was performed to remove the leaked cement, and the left L1 and bilateral L2 nerves were decompressed.

RESULTS

The patient's postoperative clinical course was uneventful.

CONCLUSIONS

A paraspinal approach that avoids a posterior approach reduces the need to remove stabilizing facet bone, is truly minimally invasive and does not involve an instrumented fusion, maybe a helpful addition in the minimally invasive spine surgeon's armamentarium.

Current Indications for Spinal Endoscopic Surgery and Potential for Future Expansion

Endoscopic spine surgery (ESS) has evolved as a safe, effective, and efficient alternative for minimally invasive spine surgery (MISS). The innovation of full-endoscopic systems makes definitive decompression surgery through different approaches feasible. The approach can be determined according to the location of the target lesion or the surgeon's preference. During the past 2 decades, ESS has expanded its indications from lumbar to cervical spines. Except for decompression, endoscopy-assisted fusion surgery is also developing. However, ESS is still evolving and has a steep learning curve. The revolution of technologies and ESS techniques will enable surgeons to treat various spinal diseases more practically. In recent years, the application of the computer-assisted navigation system and augmented reality have reformed imaging quality and interpretation. The endoscopic rhizotomy techniques have opened a new way for MISS of chronic low back pain. This review introduces the current indications of ESS and its potential future expansion.

A Comparison between Accurate Unilateral Puncture Paths Planned by Preoperative and Conventional Unilateral Puncture Techniques in Percutaneous Vertebroplasty

Objective. Comparison of the clinical and radiological effects of precise unilateral puncture pathway prepared by preoperative CT data and traditional unilateral puncture pathway in PVP administration for the treatment of osteoporotic vertebral compression fractures. Summary of background data. PVP is a commonly used vertebral augmentation operation for the treatment of painful spinal compression fractures. A percutaneous unilateral approach is routinely used to get access to the vertebral body. PVP has had positive clinical results in a number of prior investigations. Numerous difficulties and issues, including puncture difficulty, radiation exposure, cement leakage, spinal cord or nerve damage, and intraspinal hematoma, have been described in contrast. Methods. This prospective study included 300 patients with single-level lumbar osteoporotic vertebral compression fractures, 180 females and 120 males, with an average age of 71.5 years. PVP was performed on randomized subjects using two distinct puncture procedures. The patients were separated into two groups: Preoperative planning, in which a precise unilateral puncture path was established using preoperative CT data, and Conventional planning, in which multiple puncture procedures were used. The participants were followed up on after surgery and mostly assessed on clinical and radiological results. The visual analogue scale for pain and the 36-item Short Form Health Survey (SF-36) questionnaire for health status were used to assess clinical outcomes. Radiation dosage, bone cement distribution, vertebral body height, and kyphotic angle were used to evaluate radiological results. Results. Participants remained monitored for 12 to 28 months on average. 151 individuals were treated with accurate unilateral puncture paths planned by preoperative CT data percutaneous vertebroplasty and 149 patients were treated with conventional unilateral paths percutaneous vertebroplasty. The Preoperative planning group’s operation time and radiation dose were significantly lower than the Conventional group’s; nevertheless, the volume of injected cement was significantly higher in the Preoperative steering committee than in the Conventional group. All patients in both groups had much less pain after the operations when compared to their preoperative suffering. There were no statistically significant variations between groups when the visual analogue scale and the 36-Item Short Form Health Survey were compared. Neither group showed a substantial decrease in the kyphotic angle during the follow-ups. In the Preoperative planning group, the kyphotic angle improved much more than in the Conventional group. At 1 month postoperatively, 16 patients in the Conventional group experienced apparent discomfort in the puncture sites because to facet joint violation. At the latest follow-up, all of the patients’ discomfort had vanished after receiving local block therapy. Conclusion. Both preoperatively designed precise unilateral puncture pathways and traditional unilateral puncture procedures PVP are reasonably safe and effective for individuals with painful osteoporotic spinal compression fractures. Unilateral puncture courses planned via preoperative PVP, on the other hand, absorbed less radiation and operation time, as well as a good level of deformity correction and amount of injected cement, and caused less complications than traditional unilateral PVP.

[Clinical study of single-level cervical disc herniation treated by full-endoscopic decompression via anterior transcorporeal approach]

OBJECTIVE

To investigate the clinical feasibility of full-endoscopic decompression for the treatment of single-level cervical disc herniation via anterior transcorporeal approach.

METHODS

According to the inclusion and exclusion criteria, 21 patients with cervical disc herniation who received full-endoscopic decompression via anterior transcorporeal approach between September 2014 and March 2016 were retrospectively analyzed. There were 12 males and 9 females with an age ranged from 32 to 65 years, with an average of 48.5 years. The duration of symptoms ranged from 6 to 18 weeks, with an average of 10.5 weeks. According to the Nurick grading of spinal cord symptoms, there were 2 cases with grade 1, 7 cases with grade 2, and 12 cases with grade 3. Operative segment was C 3, 4 in 2 cases, C 4, 5 in 8 cases, C 5, 6 in 9 cases, and C 6, 7 in 2 cases. The operation time and related complications were recorded. The central vertical height of the vertebral body and the diseased segment space were measured on the cervical X-ray film. The neck and shoulder pain were evaluated by visual analogue scale (VAS) score; Japanese Orthopaedic Association (JOA) score was used to evaluate the improvement of neurological function in patients. The MRI of cervical spine was reexamined at 3 months after operation, and the CT of cervical spine was reexamined at 12 months after operation. The decompression of spinal cord and the healing of bone canal in the vertebral body were further evaluated.

RESULTS

Full-endoscopic decompression via anterior transcorporeal approach were achieved at all 21 patients. The operation time was 85-135 minutes, with an average of 96.5 minutes. All patients were followed up 24-27 months, with an average of 24.5 months. There was no complication such as residual nucleus pulposus, spinal cord injury, large esophageal vessels injury, pleural effusion, endplate collapse, intraspinal hematoma, cervical spine instability, protrusion of disc in the same segment, or kyphosis. Both VAS scores of neck and shoulder pain and JOA scores were significantly improved at 12 months after operation ( P<0.05). At 3 months after operation, it was confirmed by the cervical MRI that neural decompression was sufficient and the abnormal signal was also degraded in the patients with intramedullary high signal at T2-weighted image. The cervical CT showed that bone healing were achieved in the surgical vertebral bodies of all patients at 12 months after operation. At 24 months after operation, the central vertical height of the diseased segment space significantly decreased compared with preoperative one ( t=2.043, P=0.035); but there was no significant difference in the central vertical height of the vertebral body between pre- and post-operation ( t=0.881, P=0.421).

CONCLUSION

Full-endoscopic decompression via anterior transcorporeal approach, integrating the advantages of the endoscopic surgery and the transcorporeal approach, provide an ideal and thorough decompression of the ventral spinal cord with satisfactory clinical and radiographic results.

Seizure After Percutaneous Endoscopic Surgery-Incidence, Risk Factors, Prevention, and Management

BACKGROUND

Percutaneous endoscopic surgery is a popular surgery to treat lumbar spinal disorders. However, seizure after percutaneous endoscopic surgery is an unpredictable complication. The only prodromal sign for seizure currently known is neck pain. We reviewed the incidence of, and risk factors for, seizure during percutaneous endoscopic surgery and present the cases of 3 patients with seizure and our management.

CASE DESCRIPTION

From October 2006 to March 2019, 3 of 816 patients (0.34%) with thoracic lumbar disorders who had undergone percutaneous endoscopic surgery experienced a seizure episode. The cases of those 3 patients were carefully reviewed. Studies of the risk factors for seizure after spinal procedures reported before June 13, 2019 were identified through a PubMed search. We found that infusion fluid containing cefazolin, the infusion rate, a prolonged operative time, the occurrence of a dural tear, and sevoflurane anesthesia might be associated with seizure, both described in the reported data and found in our experience. Three patients who experienced a seizure episode had had general anesthesia with sevoflurane, and the surgical approach used was interlaminar for a herniated disc in L5-S1. We noted a "red flag sign," namely an uncontrollable hypertension episode combined with a decreasing pulse rate, in all 3 patients who had experienced a seizure, which was not observed in the other patients. All 3 patients had received antihypertensive medication (labetalol) ≥3 times without response.

CONCLUSION

Seizure after percutaneous endoscopic surgery is rare, but lethal. Although its cause remains unknown, all risk factors for seizure should be checked and corrected immediately when a red flag sign, uncontrolled hypertension, appears.

Foraminoplasty at the Tip or Base of the Superior Articular Process for Lateral Recess Stenosis in Percutaneous Endoscopic Lumbar Discectomy: A Multicenter, Retrospective, Controlled Study with 2-Year Follow-Up

Objective

To compare the clinical efficacy and complications which obtained foraminoplasty at the tip or base of the superior articular process (SAP) for the patients with lateral recess stenosis treated by percutaneous endoscopic lumbar discectomy (PELD).

Methods

Between January 2015 and January 2016, 156 patients of lumbar disc herniation accompanying with lateral recess stenosis were treated with PELD in five tertiary hospitals and fulfilled the 2-year follow-up. Among them, 78 patients obtained a foraminoplasty at the tip of SAP (group A), and foraminoplasty at the base of SAP was performed in the other 78 cases (group B). Clinical efficacy was evaluated using the visual analog scale (VAS) score for back and leg pain, Oswestry Disability Index (ODI), and 36-item Short-Form Health Survey (SF-36) score. The intervals of follow-up were scheduled at 1 month, 3 months, 6 months, 1 year, and 2 years after surgery.

Results

Mean operative duration is shorter in group B (55 versus 61 min, P = 0.047). Only one case belonged to group A could not tolerate the neural irritation and required conversion to an open procedure. During the surgery, no dura tears, cauda equina syndrome, or infections were observed. 5 patients experienced transient dysesthesia located at the exiting nerve in group A, while no cases complained dysesthesia in group B. 2 cases who suffered temporary motor weakness all belonged to group A. A total of 5 cases obtained a revision surgery after recurrence in the follow-up, in which 3 patients belonged to group A. Compared to the preoperative data, significant improvements in VAS scores of low back pain and sciatica, ODI, and SF-36 PCS and MC were observed in the follow-up, respectively (P < 0.05, respectively). However, no statistical difference was observed at all time-points after surgery between these two groups (P > 0.05, respectively).

Conclusions

For the patients of LDH accompanying with lateral recess stenosis, compared with the routine foraminoplasty at the tip of SAP, our modified foraminoplastic technique does not only change place of foraminoplasty to the base of SAP but also simplified puncture process in transforaminal PELD. Although there was no significant difference in symptom relief, the modified foraminoplasty showed the advantages in decreasing the incidence of postoperative neural dysfunction and reducing operation time.