Review of safety in endoscopic laser foraminoplasty for the management of back pain

Complications and Management of Endoscopic Spinal Surgery

In the past, the use of endoscopic spine surgery was limited to intervertebral discectomy; however, it has recently become possible to treat various spinal degenerative diseases, such as spinal stenosis and foraminal stenosis, and the treatment range has also expanded from the lumbar spine to the cervical and thoracic regions. However, as endoscopic spine surgery develops and its indications widen, more diverse and advanced surgical techniques are being introduced, and the complications of endoscopic spine surgery are also increasing accordingly. We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and key words were set as “endoscopic spinal surgery,” “endoscopic cervical foramoinotomy,” “PECD,” “percutaneous transforaminal discectomy,” “percutaneous endoscopic interlaminar discectomy,” “PELD,” “PETD,” “PEID,” “YESS” and “TESSYS.” We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic lumbar surgery was divided into full endoscopic interlaminar and transforaminal approaches and a unilateral biportal approach. We performed a comprehensive review of available literature on complications of endoscopic spinal surgery. This study particularly focused on the prevention of complications. Regardless of the surgical methods, the most common complications related to endoscopic spinal surgery include dural tears and perioperative hematoma. transient dysesthesia, nerve root injury and recurrence. However, Endoscopic spinal surgery, including full endoscopic transforaminal and interlaminar and unilateral biportal approaches, is a safe and effective a treatment for lumbar as well as cervical and thoracic spinal diseases such as disc herniation, lumbar spinal stenosis, foraminal stenosis and recurrent disc herniation.

Identification of the Magna Radicular Artery Entry Foramen and Adamkiewicz System: Patient Selection for Open versus Full-Endoscopic Thoracic Spinal Decompression Surgery

BACKGROUND

Casually cauterizing the radicular magna during routine thoracic discectomy may have dire consequences.

METHODS

We performed a retrospective observational cohort study on patients scheduled for decompression of symptomatic thoracic herniated discs and spinal stenosis who underwent a preoperative computed tomography angiography (CTA) to assess the surgical risks by anatomically defining the foraminal entry level of the magna radicularis artery into the thoracic spinal cord and its relationship to the surgical level.

RESULTS

Fifteen patients aged 58.53 ± 19.57, ranging from 31 to 89 years, with an average follow-up of 30.13 ± 13.42 months, were enrolled in this observational cohort study. The mean preoperative VAS for axial back pain was VAS of 8.53 ± 2.06 and reduced to a postoperative VAS of 1.60 ± 0.92 (p < 0.0001) at the final follow-up. The Adamkiewicz was most frequently found at T10/11 (15.4%), T11/12 (23.1%), and T9/10 (30.8%). There were eight patients where the painful pathology was found far from the AKA foraminal entry-level (type 1), three patients with near location (type 2), and another four patients needing decompression at the foraminal (type 3) entry-level. In five of the fifteen patients, the magna radicularis entered the spinal canal on the ventral surface of the exiting nerve root through the neuroforamen at the surgical level requiring a change of surgical strategy to prevent injury to this important contributor to the spinal cord's blood supply.

CONCLUSIONS

The authors recommend stratifying patients according to the proximity of the magna radicularis artery to the compressive pathology with CTA to assess the surgical risk with targeted thoracic discectomy methods.

Transforaminal endoscopic lumbar discectomy with targeted puncture and foraminotomy for very highly migrated disc herniation: A technique note with case series

Background

Transforaminal endoscopic lumbar discectomy (TELD) has been widely used for lumbar disc herniation. However, in some challenging cases such as very highly migrated disc herniation (VHMDH), traditional TELD is difficult to access the pathology.

Methods

From January 2016 to December 2019, 63 patients with single-level VHMDH underwent TELD using targeted puncture and foraminotomy techniques were included. All patients were followed up for 26.5 months on average (range, 24–48 months). Operative time, length of hospital stay, visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab criteria and surgical complications were evaluated.

Results

The operative time was 40–120 min (56.8 on average). The length of hospitalization was 2.5 days (range, 2–4 d). VAS score decreased significantly from 5.5 ± 1.3 preoperatively to 1.9 ± 1.30 (p < 0.001) 1 day postoperatively, and to 0.9 ± 0.8 (p < 0.001) at the final follow-up. ODI score improved significantly from 23.5 ± 3.2 preoperatively to 13.4 ± 3.0 (p < 0.001) 1 day postoperatively; and 3.1 ± 1.2 (p < 0.001) at the final follow-up. According to the modified MacNab criteria, 40 patients (63.5%) showed excellent results, 20 patients (31.7%) were rated as good, 2 patients (3.2%) were rated as fine, and 1 patient (1.6%) was rated as bad at the final follow-up. No residual fragments, nerve root or cauda equina injury was shown in this series. One recurrent case was resolved by open surgery.

Conclusions

With modified targeted puncture and foraminotomy techniques, VHMDH can be accessed safely and effectively, and satisfactory clinical outcomes can be obtained for these patients.

Patient selection criteria for percutaneous anterior cervical laser versus endoscopic discectomy

BACKGROUND

Percutaneous anterior laser and anterior endoscopic cervical spine surgery are associated with less approach trauma than conventional open cervical spine surgery. The literature illustrating their appropriate use corroborated with objective outcome evidence is scarce. The authors were interested in comparing the clinical outcomes following percutaneous laser disc decompression (PLDD) versus percutaneous endoscopic disc decompression (PEDD). © 2021 Wiley Periodicals LLC.

MATERIALS AND METHODS

Thirty patients with soft contained symptomatic cervical disc herniations and an average age of 50.5 years (range 26 - 68 years; 16 males and 14 females) were prospectively enrolled in 2 groups of 15 patients to be either treated with PLDD or PEDD. All patients underwent PLDD or PEDD under local anesthesia and sedation. Clinical outcomes were assessed with the Macnab criteria VAS score for arm pain. Complications and reoperations were recorded.

RESULTS

There were significant reductions in the VAS score for arm pain from preoperative 8.4 ± 2.5 to 3.1 ± 1.2 in the PLDD group (P < 0.03), and from preoperative 8.6 ± 2.7 to 2.4 ± 1.1 (P < 0.01) in the PEDD group. In the PLDD group, Macnab outcomes were excellent in 21% of patients, good in 44%, fair in 21%, and poor in 14%. In the PEDD group, Macnab outcomes were excellent in 14% of patients, good in 32%, fair in 12%, and poor in the remaining 12%. There were no statistically significant differences in clinical outcomes between the PLDD and the PEDD group. There were no approach-related or surgical complications.

CONCLUSIONS

Tissue trauma is significantly reduced with laser and endoscopic surgery techniques. PLDD and PEDD are both suitable for the specific indication of soft, symptomatic contained cervical disc herniations. The authors' small prospective cohort study indicates that PLDD and PEDD are options for cervical decompression surgery when medical comorbidities or preferences by patients and surgeons dictate more minimally invasive strategies.

Endoscopic Transforaminal Lumbar Foraminotomy: A Systematic Review and Meta-Analysis

INTRODUCTION

Spinal endoscopic techniques have recently been applied to complex degenerative conditions or failed back surgery syndrome. We performed a systematic review and meta-analysis to assess transforaminal endoscopic lumbar foraminotomy (TELF) outcomes and adverse event rates. We also analyzed the effectiveness of the technique for chronic pain after arthrodesis or previous spinal surgery.

METHODS

Multiple databases were searched for studies published in the English language, involving patients > 18 years old who underwent endoscopic foraminotomy. Outcomes included the rate of patients who showed "excellent" and "good" postoperative improvement, decreased leg pain, and improved Oswestry Disability Index (ODI) scores. Adverse events considered in the analysis included nerve root damage and intraoperative dural tear, the proportion of patients requiring revision surgery or recurrences, and infections.

RESULTS

A total of 14 studies, encompassing 600 patients, were identified. Approximately 85% of patients improved significantly after TELF, without significant differences among different groups (85% vs. 78%, respectively). Mean leg pain decreased an average of 5.2 points, and ODI scores improved by 41.2%. Patients with previous spine surgery or failed back surgery syndrome had higher postoperative leg dysesthesia rates after TELF (14% vs. 1%, respectively).

CONCLUSION

TELF is a useful and safe method to achieve decompression in foraminal stenosis. This technique is indicated in the elderly or patients with comorbidities. Preoperative planning is paramount in determining the foraminal size and endoscope trajectory. A diamond burr is recommended because it has an advantage over the regular endoscopic shaver in bleeding control and complication avoidance.

Predictive Scoring and Risk Factors of Early Recurrence after Percutaneous Endoscopic Lumbar Discectomy

Purpose

To predict the early recurrence after full endoscopic lumbar discectomy, we analyzed factors related to demographic factor anatomical factors, operative method, and postoperative management, and predicted the possibility of recurrence according to the scoring system.

Materials and Methods

In this prospective study, we enrolled 300 patients who underwent 1 out of 3 surgical procedures. The patients were randomized into one of the following groups: group A (n = 100), transforaminal inside-out approach; group B (n = 100), transforaminal outside-in approach; and group C (n = 100), interlaminar approach. The clinical results were evaluated by a visual analogue scale (VAS). Related factors evaluated with points of (A) demographic factors: (1) age, (2) gender, (3) BMI, (B) anatomical factors: (4) disc degeneration scale, (5) modic change, (6) number of involved disc herniation, (7) history of discectomy (first, recurred), (8) herniated disc level, (9) disc height, (10) segmental dynamic motion, (11) disc location, (C) operation factors: (12) annulus preservation along the disc protrusion, (13) approach method (transforaminal inside-out, transforaminal outside-in, interlaminar); (D) postoperative care factors: (14) early ambulation, (15) spinal orthosis (corset) application. Among these, we analyzed statistically significant recurrence risk factors after PELD in all patients and early recurrence predicting score ratio was obtained.

Results

The overall recurrence rate was 9.33%. The recurrence rate was 11%, 10%, and 7% for groups A, B, and C, respectively. Average early recurrence time was 3.26 months. The change in preoperative and postoperative VAS score was from 8.07 to 1.39, 8.34 to 1.34, and 8.14 to 1.86 in groups A, B, and C, respectively. The recurrence rate based on the (1) age was <40 years: 5.22% (6/115), 41–60 years: 16.1% (20/124), and >61 years: 3.07% (2/65); (2) gender was male: 13/139 (9.35%), female: 15/161 (9.32%); (3) BMI was obese: 17.57% (13/74), overweight: 11.6% (9/77), underweight: 6.35% (4/63), and normal weight: 2.33% (2/86); (4) degeneration scale was grades 1–2: 2% (1/50), grade 3: 7.4% (10/135), and grades 4–5: 14.8% (17/115); (5) modic change was type I: 25% (3/12), type II: 14.3% (1/7), type III: 33% (1/3), and no modic change: 8.27% (23/278); (6) number of involved disc herniation was 1 level: 3.9% (5/128), 2 level: 10.4% (13/125), 3 levels: 18.9% (7/37), and 4 levels: 30% (3/10); (7) history of discectomy was first: 8.83% (25/283) and repeated: 17.65% (3/17); (8) herniated disc level was L1–L2/L2–L3/L3–L4: 3.95% (3/76) and L4–L5: 14.6% (18/123); (9) disc height was <80%: 17.14% (6/35), 81%–100%: 8.16% (12/147), and >101%: 8.5% (10/118); (10) segmental dynamic motion was 1–10°: 8.58% (20/233) and 11–20° : 11.9% (8/67); (11) disc location was central: 7.41% (2/27), foraminal: 3.03% (2/66), and inferior/superior/paracentral: 11.59% (24/207); (12) radical annulotomy was 8.05% (7/87) vs. 9.86% (21/213); (13) approach method was transforaminal (inside-out): 11% (11/100), transforaminal (outside-in): 10% (10/100), and interlaminar: 7% (7/100); (14) early ambulation was 16.42% (23/140) vs. 3.13% (5/160); and (15) spinal orthosis application was 7.35% (10/136) vs. 10.98% (18/164). According to the above results, after summation of all scores, the early recurrence predicting score: recurrence rate ratio was 1–4: 0% (0/23), 5–8: 7.1% (13/183), 9–12: 8% (6/75) and 13–16 100% (10/10).

Conclusions

Early recurrence after PELD is associated with several risk factors such as BMI, degeneration scale, combined HNP, and early ambulation. If we use the predicting score, we can postulate the occurrence of early recurrence after PELD. Knowing the predictive factors prior to surgical intervention will allow us to decrease the early recurrence rate after PELD.

Transforaminal endoscopic discectomy versus conventional microdiscectomy for lumbar discherniation: a systematic review and meta-analysis

BACKGROUND

The open microdiscectomy is the most common surgical procedure for the decompression of radiculopathy caused by lumbar disk herniation. To date, a variety of minimally invasive (MI) techniques have been developed. In the last decades, endoscopic techniques have been developed to perform discectomy. The transforaminal endoscopic discectomy (TED) with posterolateral access evolved out of the development of endoscopic techniques.

METHODS

A systematic literature search was performed using the PubMed, EMBASE, and Cochrane Library databases for trials written in English. The randomized trials and observational studies that met our inclusion criteria were subsequently included. Two reviewers respectively extracted data and estimated the risk of bias. All statistical analyses were performed using Review Manager 5.3.

RESULTS

Five prospective and four retrospective studies involving 1527 patients were included. The results of the meta-analysis indicated that there were significant differences between the two groups in length of hospital stay (MD = - 8.41, 95% CI - 10.26, - 6.56; p value < 0.00001). However, there were no significant differences in the leg visual analog scale (VAS) scores, the Oswestry Disability Index (ODI) scores, and the incidence of complications and recurrence.

CONCLUSIONS

The transforaminal endoscopic discectomy is superior to open microdiscectomy in the length of hospital stay. However, there were no differences in leg pain, functional recovery, and incidence of complications between TED and MD in treating LDH.

Lumbar Scoliosis Combined Lumbar Spinal Stenosis and Herniation Diagnosed Patient Was Treated with "U" Route Transforaminal Percutaneous Endoscopic Lumbar Discectomy

The objective was to report a case of a 63-year-old man with a history of low back pain (LBP) and left leg pain for 2 years, and the symptom became more serious in the past 5 months. The patient was diagnosed with lumbar scoliosis combined with lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH) at the level of L4-5 that was confirmed using Computerized Topography and Magnetic Resonance Imaging. The surgical team preformed a novel technique, “U” route transforaminal percutaneous endoscopic lumbar discectomy (PELD), which led to substantial, long-term success in reduction of pain intensity and disability. After removing the osteophyte mass posterior to the thecal sac at L4-5, the working channel direction was changed to the gap between posterior longitudinal ligament and thecal sac, and we also removed the herniation and osteophyte at L3-4 with “U” route PELD. The patient's symptoms were improved immediately after the surgical intervention; low back pain intensity decreased from preoperative 9 to postoperative 2 on a visual analog scale (VAS) recorded at 1 month postoperatively. The success of the intervention suggests that “U” route PELD may be a feasible alternative to treat lumbar scoliosis with LSS and LDH patients.

A brief history of endoscopic spine surgery

Few neurosurgeons practicing today have had training in the field of endoscopic spine surgery during residency or fellowship. Nevertheless, over the past 40 years individual spine surgeons from around the world have worked to create a subfield of minimally invasive spine surgery that takes the point of visualization away from the surgeon's eye or the lens of a microscope and puts it directly at the point of spine pathology. What follows is an attempt to describe the story of how endoscopic spine surgery developed and to credit some of those who have been the biggest contributors to its development.

Sedation for Percutaneous Endoscopic Lumbar Discectomy

Although anesthetic requirements for minimally invasive neurosurgical techniques have been described in detail and applied successfully since the early 2000s, most of the literature on this subject has dealt with cranial cases that were operated on in the supine or sitting positions. However, spinal surgery has also used minimally invasive techniques that were performed in prone position for more than 30 years to date. Although procedures in both these neurosurgical techniques require the patient to be awake for a certain period of time, the main surgical difference with minimally invasive spinal surgery is that the patients are in the prone position, which may result in increased requirement of airway management because of deep sedation. In addition, although minimally invasive spinal surgery progresses slowly and different techniques are used with no agreement on the terminology used to describe these techniques thus far, the anesthetist needs to understand the surgical and anesthetic requirements for each type of intervention in order to take necessary precautions. This paper reviews the literature on this topic and discusses the anesthetic necessities for percutaneous endoscopic laser surgery.

Outcomes of percutaneous endoscopic lumbar discectomy via a translaminar approach, especially for soft, highly down-migrated lumbar disc herniation

PURPOSE

This study reports a new approach for percutaneous endoscopic lumbar iscectomy (PELD), especially for soft, highly down-migrated lumbar disc herniation.

METHODS

Seven patients with soft, highly down-migrated lumbar disc herniation who underwent PELD via a translaminar approach under local anaesthesia from January 2013 to June 2015, including five patients who underwent failed PELD in other hospitals, were retrospectively analyzed. Clinical outcomes were evaluated according to pre-operative and post-operative visual analogue scale (VAS) scores, Oswestry disability index (ODI) scores and post-operative magnetic resonance imaging (MRI).

RESULTS

The highly down-migrated lumbar disc herniation was completely removed by PELD via a translaminar approach in seven patients, as confirmed by post-operative MRI. Leg pain was eased after removal of the disc migrations. The mean follow-up duration was 9.8 (range, 6-14) months. The mean pre-operative VAS was 7.6 ± 0.8 (range, 6-9), which decreased to 3.1 ± 1.5 (range, 2-5) at one week post-operatively and to 1.3 ± 0.8 (range, 0-3) by the last follow-up visit. The mean pre-operative ODI was 61.6 (range, 46-84), which decreased to 16.3 (range, 10-28) at the one month post-operative follow-up and to 8.4 (range, 0-14) by the last follow-up visit. No recurrence was observed in any of the seven patients during the follow-up period.

CONCLUSION

PELD via a translaminar approach could be a good alternative option for the treatment of soft, highly down-migrated lumbar disc herniation.

Foraminoplastic Superior Vertebral Notch Approach with Reamers in Percutaneous Endoscopic Lumbar Discectomy : Technical Note and Clinical Outcome in Limited Indications of Percutaneous Endoscopic Lumbar Discectomy

To describe the details of the foraminoplastic superior vertebral notch approach (FSVNA) with reamers in percutaneous endoscopic lumbar discectomy (PELD) and to demonstrate the clinical outcomes in limited indications of PELD. Retrospective data were collected from 64 patients who underwent PELD with FSVNA from August 2012 to April 2014. Inclusion criteria were high grade migrated disc, high canal compromised disc, and disc protrusion combined with foraminal stenosis. The clinical outcomes were assessed using by the visual analogue scale (VAS), Oswestry Disability Index (ODI) and modified MacNab criteria. Complications related to the surgery were reviewed. The procedure used a unique approach, using the superior vertebral notch as the target and performing foraminoplasty with only reamers under C-arm control. The mean age of the 55 female and 32 male patients was 52.73 years. The mean F/U period was 12.2±4.2 months. Preoperative VAS (8.24±1.25) and ODI (67.8±15.4) score improved significantly at the last follow-up (VAS, 1.93±1.78; ODI, 17.14±15.7). Based on the modified MacNab criteria, excellent or good results were obtained in 95.3% of the patients. Postoperative transient dysthesia (n=2) and reoperation (n=1) due to recurred disc were reported. PELD with FSVNA could be a good method for treating lumbar disc herniation. This procedure may offer safe and efficacious results, especially in the relatively limited indications for PELD.

A meta-analysis of endoscopic discectomy versus open discectomy for symptomatic lumbar disk herniation

PURPOSE

The purpose of this study was to systematically compare the effectiveness and safety of endoscopic discectomy (ED) with open discectomy (OD) for the treatment of symptomatic lumbar disc herniation (LDH).

METHODS

A highly sensitive search strategy was used to identify all published randomized controlled trials up to August 2014. A criteria list taken from Koes et al. was used to evaluate the risk of bias of the included studies. The five questions that were recommended by the Cochrane Back Review Group were used to evaluate the clinical relevance. Cochrane methodology was used for the results of this meta-analysis.

RESULTS

Nine relevant RCTs involving 1,092 patients were identified. Compared with OD, ED results in slightly better clinical outcomes which were evaluated by the Macnab criteria without clinical significance (ED group: 95.76 %; OD group: 80 %; OR: 3.72, 95 % CI: [0.76, 18.14], P = 0.10), a significantly greater patient satisfaction rate (ED group: 93.21 %; OD group: 86.57 %; OR: 2.19; 95 % CI: [1.09, 4.40]; P = 0.03), lower intraoperative blood loss volume (WMD: -123.71, 95 % CI: [-173.47, -73.95], P < 0.00001), and shorter length of hospital stay (WMD: -Table 2144.45, 95 % CI: [-239.54, -49.37], P = 0.003).

CONCLUSIONS

From the existing outcomes, ED surgery could be viewed as a sufficient and safe supplementation and alternative to standard open discectomy. The cost-effectiveness analyses still remain unproved from the existing data. More independent high-quality RCTs using sufficiently large sample sizes with cost-effectiveness analyses are needed.

Endoscopic foraminal decompression for failed back surgery syndrome under local anesthesia

BACKGROUND

The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.(1-6) The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.(7.)

METHODS

Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the "hidden zone" of Macnab (Figure 2).(8, 9) The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI. Fig. 1A diagnostic and therapeutic epidural gram may help identify unrecognized lateral recess stenosis underestimated by MRI. An excellent result from a therapeutic block lends excellent prognosis for a more lasting and "permanent" result from transforaminal endoscopic lateral recess decompression.Fig. 2Kambin's Triangle provides access to the "hidden zone" of Macnab by foraminoplasty. The foramen and lateral recess is decompressed by removing the ventral aspect and tip of the superior articular process to gain access to the axilla between the traversing and exiting nerve. FBSS contains patho-anatomy in the axilla between the traversing and exiting nerve that hides the pain generators of FBSS.

RESULTS

The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid "open" decompression or fusion surgery.

CONCLUSIONS / LEVEL OF EVIDENCE 3

The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.(10) The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.(11) It also avoids going through the previous surgical site.

CLINICAL RELEVANCE

Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.(12) Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not "burn bridges" for a more conventional approach and it adds to the surgical armamentarium of FBSS. Fig. 3Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.

Transforaminal endoscopic lumbar decompression & foraminoplasty: a 10 year prospective survivability outcome study of the treatment of foraminal stenosis and failed back surgery

Background

Conventional diagnosis between axial and foraminal stenosis is suboptimal and long-term outcomes limited to posterior decompression. Aware state Transforaminal Endoscopic Lumbar Decompression and Foraminoplasty (TELDF) offers a direct aware state means of localizing and treating neuro-claudicant back pain, referred pain and weakness associated with stenosis failing to respond to conventional rehabilitation, pain management or surgery. This prospective survivability study examines the outcomes 10 years after TELDF in patients with foraminal stenosis arising from degeneration or failed back surgery.

Methods

For 10 years prospective data were collected on 114 consecutive patients with multilevel spondylosis and neuro-claudicant back pain, referred pain and weakness with or without failed back surgery whose symptoms had failed to respond to conventional rehabilitation and pain management and who underwent TELDF. The level responsible for the predominant presenting symptoms of foraminal stenosis, determined on clinical grounds, MRI and or CT scans, was confirmed by transforaminal probing and discography. Patients underwent TELDF at the spinal segment at which the predominant presenting symptoms were reproduced. Those that required treatment at an additional segment were excluded. Outcomes were assessed by postal questionnaire with failures being examined by the independent authors using the Visual Analogue Pain Scale (VAPS), the Oswestry Disability Index (ODI) and the Prolo Activity Score.

Results

Cohort integrity was 69%. 79 patients were available for evaluation after removal of the deceased (12), untraceable (17) and decliners (6) from the cohort.

VAP scores improved from a pre-operative mean of 7.3 to 2.4 at year 10. The ODI improved from a mean of 58.5 at baseline to 17.5 at year 10. 72% of reviewed patients fulfilled the definition of an “Excellent” or “Good Clinical Impact” at review using the Spinal Foundation Outcome Score. Based on the Prolo scale, 61 patients (77%) were able to return and continue in full or part-time work or retirement activity post-TELDF. Complications of TELDF were limited to transient nerve irritation, which affected 19% of the cohort for 2 – 4 weeks. TELDF was equally beneficial in those with failed back surgery.

Conclusions

TELDF is a beneficial intervention for the long-term treatment of severely disabled patients with neuro-claudicant symptoms arising from spinal or foraminal stenosis with a dural diameter of more than 3mm, who have failed to respond to conventional rehabilitation or chronic pain management. It results in considerable improvements in symptoms and function sustained 10 years later despite co-morbidity, ageing or the presence of failed back surgery.

Clinical Relevance

The long term outcome of TELDF in severely disabled patients with neuro-claudicant symptoms arising from foraminal stenosis which had failed to respond to conventional rehabilitation, surgery or chronic pain management suggests that foraminal pathology is a major cause of lumbar axial and referred pain and that TELDF should be offered as primary treatment for these conditions even in the elderly and infirm. The application of TELDF at multiple levels may further widen the benefits of this technique.

The "inside out" transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature

Surgical management of back and leg pain is evolving and changing due to a better understanding of the patho-anatomy well correlated with its pathophysiology. Pain is better understood with in vivo visualization and probing of the pain generators using an endoscopic access rather than just relying on symptoms diagram and image correlation. This has resulted in a shared decision making involving patient and surgeon, focused on a broader spectrum of surgical as well as non-surgical treatments, and not just masking the pain generator. It has moved away from decisions based on diagnostic images alone, that, while noting the image alterations, cannot explain the pain experienced by each individual as images do not always show variations in nerve supply and patho-anatomy. The ability to isolate and visualize "pain" generators in the foramen and treating persistent pain by visualizing inflammation and compression of nerves, serves as the basis for transforaminal endoscopic (TFE) surgery. This has also resulted in better pre surgical planning with more specific and defined goals in mind. The "Inside out" philosophy of TFE surgery is safe and precise. It provides basic access to the disc and foramen to cover a large spectrum of painful pathologies.

Exiting root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety

PURPOSE

To evaluate the clinical and radiological risk factors for exiting root injuries during transforaminal endoscopic discectomy.

METHODS

We retrospectively examined cohort data from 233 patients who underwent percutaneous endoscopic lumbar discectomy for lumbar disc herniation between January 1st, 2010 and December 31st, 2011. We divided the patients into the two groups: those who presented a postoperative exiting root injury, such as postoperative dysesthesia or motor weakness (Group A, n = 20), and those who did not suffer from a root injury (Group B, n = 213). We examined the clinical and radiological factors relating exiting root injuries. We measured the active working zone with the exiting root to the upper facet distance (Distance A), the exiting root to disc surface distance at the lower facet line (Distance B) and the exiting root to the lower facet distance (Distance C) in magnetic resonance imaging (MRI).

RESULTS

Group A exhibited a shorter Distance C (6.4 ± 1.5 versus 4.4 ± 0.8 mm, p < 0.001) and a longer operation time (67.9 ± 21.8 versus 80.3 ± 23.7 min, p = 0.017) relative to Group B. The complication rate decreased by 23% per each 1-mm increase in Distance C (p = 0.000). In addition, the complication rate increased 1.027-fold per each 1-min increase in the operation time (p = 0.027).

CONCLUSION

We recommend measuring the distance from the exiting root to the facet at the lower disc level according to a preoperative MRI scan. If the distance is narrow, an alternative surgical method, such as microdiscectomy or conventional open discectomy, should be considered.

Cervical Deuk Laser Disc Repair(®): A novel, full-endoscopic surgical technique for the treatment of symptomatic cervical disc disease

Background:

Cervical Deuk Laser Disc Repair^® is a novel full-endoscopic, anterior cervical, trans-discal, motion preserving, laser assisted, nonfusion, outpatient surgical procedure to safely treat symptomatic cervical disc diseases including herniation, spondylosis, stenosis, and annular tears. Here we describe a new endoscopic approach to cervical disc disease that allows direct visualization of the posterior longitudinal ligament, posterior vertebral endplates, annulus, neuroforamina, and herniated disc fragments. All patients treated with Deuk Laser Disc Repair were also candidates for anterior cervical discectomy and fusion (ACDF).

Methods:

A total of 142 consecutive adult patients with symptomatic cervical disc disease underwent Deuk Laser Disc Repair during a 4-year period. This novel procedure incorporates a full-endoscopic selective partial decompressive discectomy, foraminoplasty, and posterior annular debridement. Postoperative complications and average volume of herniated disc fragments removed are reported.

Results:

All patients were successfully treated with cervical Deuk Laser Disc Repair. There were no postoperative complications. Average volume of herniated disc material removed was 0.09 ml.

Conclusions:

Potential benefits of Deuk Laser Disc Repair for symptomatic cervical disc disease include lower cost, smaller incision, nonfusion, preservation of segmental motion, outpatient, faster recovery, less postoperative analgesic use, fewer complications, no hardware failure, no pseudoarthrosis, no postoperative dysphagia, and no increased risk of adjacent segment disease as seen with fusion.

Transforaminal endoscopic spinal surgery: the future 'gold standard' for discectomy? - A review

BACKGROUND

Lumbar disc prolapse is common and the primary method of care in most centres is still open discectomy facilitated by microscope or loupe magnification and illumination. Hospitalisation may be less than 24 h, but post-operative pain usually requires an overnight stay. This review describes transforaminal endoscopic spinal surgery (TESS) using HD-video technology, that is generally performed as a day case procedure under sedation or light general anaesthesia, and collates the evidence comparing the technique to microdiscectomy.

METHODS

The method of TESS is described and an electronic literature search performed to identify papers reporting clinical outcomes. International data were translated where necessary and proceedings' abstracts included. In addition, papers held by the authors and colleagues in personal libraries were carefully cross-referenced to the obtained database.

RESULTS

Analysis of the data supports the use of a transforaminal endoscopic approach to the lumbar intervertebral disc and suggests that outcomes following surgery are at least equivalent to those following microdiscectomy. Significant cost-savings in terms of in-patient stay may be generated. In addition, there is also some evidence supporting endoscopic surgery for relief of foraminal stenosis.

CONCLUSION

Based on current evidence there are good arguments supporting a more wide-spread adoption of transforaminal endoscopic surgery for the treatment of lumbar disc prolapse with or without foraminal stenosis.

Foraminoplastic ventral epidural approach for removal of extruded herniated fragment at the L5-S1 level

The 'foraminoplastic' ventral epidural approach and its advantages in the treatment of extruded disk herniation at the L5-S1 level are described. Percutaneous endoscopic lumbar discectomy is a minimally invasive procedure applicable to various types of lumbar disk herniation, but the L5-S1 disk space is still challenging to access due to anatomic limitations such as high iliac crest or severely narrowed foramen. The 'foraminoplastic' ventral epidural approach was performed in 25 patients with herniated disk radiculopathy at L5-S1 from March 2003 to May 2004. Their mean age was 39.2 years (range 20-67 years) and the mean follow-up duration was 32.5 months (range 28-42 months). During the procedure, 'foraminoplasty' was performed by undercutting the hypertrophic superior facet with the endoscopic bone cutter under C-arm guidance. The clinical result was assessed according to the visual analogue scale (VAS) and Oswestry disability index (ODI). Preoperative mean VAS score of 7.4 for leg pain fell to 1.6 postoperatively and mean preoperative ODI of 55.5% improved to 16.9% postoperatively, both showing significant improvements (p < 0.001). Mean hospital stay was 14.2 hours. Twenty-two patients had the favorable outcomes. Two patients required conversion to open microdiscectomy due to incomplete decompression and recurrent disk herniation. The 'foraminoplastic' approach is a safe and efficient surgical option for L5-S1 disk herniation even in patients with high iliac crest and narrow foramen.

Revisional percutaneous full endoscopic disc surgery for recurrent herniation of previous open lumbar discectomy

Study Design

A retrospective study.

Purpose

To determine the feasibility and effectiveness of revisional percutaneous full endoscopic discectomy for recurrent herniation after conventional open disc surgery.

Overview of the Literature

Repeated open discectomy with or without fusion has been the most common procedure for recurrent lumbar disc herniation. Percutaneous endoscopic lumbar discectomy for recurrent herniation has been thought of as an impossible procedure. Despite good results with open revisional surgery, major problems may be caused by injuries to the posterior stabilized structures. Our team did revisional full endoscopic lumbar disc surgery on the basis of our experience doing primary full endoscopic disc surgery.

Methods

Between February 2004 and August 2009 a total of 41 patients in our hospital underwent revisional percutaneous endoscopic lumbar discectomy using a YESS endoscopic system and a micro-osteotome (designed by the authors). Indications for surgery were recurrent disc herniation following conventional open discectomy; with compression of the nerve root revealed by Gadolinium-enhanced magnetic resonance imaging; corresponding radiating pain which was not alleviated after conservative management over 6 weeks. Patients with severe neurologic deficits and isolated back pain were excluded.

Results

The mean follow-up period was 16 months (range, 13 to 42 months). The visual analog scale for pain in the leg and back showed significant post-treatment improvement (p < 0.001). Based on a modified version of MacNab's criteria, 90.2% showed excellent or good outcomes. There was no measurable blood loss. There were two cases of recurrence of and four cases with complications.

Conclusions

Percutaneous full-endoscopic revisional disc surgery without additional structural damage is feasible and effective in terms of there being less chance of fusion and bleeding. This technique can be an alternative to conventional repeated discectomy.

Transforaminal endoscopic surgery for lumbar stenosis: a systematic review

Transforaminal endoscopic techniques have become increasingly popular in surgery of patients with lumbar stenosis. The literature has not yet been systematically reviewed. A comprehensive systematic literature review up to November 2009 to assess the effectiveness of transforaminal endoscopic surgery in patients with symptomatic lumbar stenosis was made. Two reviewers independently checked all retrieved titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality, and relevant data, including outcomes, were extracted by two reviewers independently. No randomized controlled trials were identified, but seven observational studies. The studies were of poor methodological quality and heterogeneous regarding patient selection, indications, operation techniques, follow-up period and outcome measures. Overall, 69-83% reported the outcome as satisfactory and a complication rate of 0-8.3%. The reported re-operation rate varied from 0 to 20%. At present, there is no valid evidence from randomized controlled trials on the effectiveness of transforaminal endoscopic surgery for lumbar stenosis. Randomized controlled trials comparing transforaminal endoscopic surgery with other surgical techniques are direly needed.

Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature

The study design includes a systematic literature review. The objective of the study was to evaluate the effectiveness of transforaminal endoscopic surgery and to compare this with open microdiscectomy in patients with symptomatic lumbar disc herniations. Transforaminal endoscopic techniques for patients with symptomatic lumbar disc herniations have become increasingly popular. The literature has not yet been systematically reviewed. A comprehensive systematic literature search of the MEDLINE and EMBASE databases was performed up to May 2008. Two reviewers independently checked all retrieved titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality and outcomes were extracted by the two reviewers independently. One randomized controlled trial, 7 non-randomized controlled trials and 31 observational studies were identified. Studies were heterogeneous regarding patient selection, indications, operation techniques, follow-up period and outcome measures and the methodological quality of these studies was poor. The eight trials did not find any statistically significant differences in leg pain reduction between the transforaminal endoscopic surgery group (89%) and the open microdiscectomy group (87%); overall improvement (84 vs. 78%), re-operation rate (6.8 vs. 4.7%) and complication rate (1.5 vs. 1%), respectively. In conclusion, current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide valid information to either support or refute using this type of surgery in patients with symptomatic lumbar disc herniations. High-quality randomized controlled trials with sufficiently large sample sizes are direly needed to evaluate if transforaminal endoscopic surgery is more effective than open microdiscectomy.

Learning curve for percutaneous endoscopic lumbar discectomy

Percutaneous endoscopic lumbar discectomy (PELD) is one of the surgical options for soft lumbar disk herniation, but the learning curve is perceived to be steep. The first 51 PELD cases performed for single-level intracanalicular lumbar disk herniation causing radiculopathy by the same surgeon were prospectively studied. The patients were divided into 3 groups of 17 patients, and the PELD learning curve was assessed by evaluating operating time, failure rate, complication rate, and 1-year reherniation rate. One-year clinical success rate was assessed by telephone interviews. The herniated disk was successfully removed by PELD in 47 patients. Four patients required subsequent open discectomy due to PELD failure. There were 2 minor complications. One year after surgery, clinical success was achieved in 42 of the 47 patients in whom PELD was initially successful, and reherniation developed in 5 patients. A significant reduction in operating time was observed after 17 patients had been treated (p = 0.0004). No significant differences were observed in terms of either failure rate or complication rate between the 3 groups. No significant differences were observed in terms of either the clinical success rate or the reherniation rate at 1 year after surgery. The PELD learning curve seems to be stable and acceptable with proper pre-PELD training.

Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope

STUDY DESIGN

A retrospective analysis of 59 patients operated for excision of soft highly migrated intracanal lumbar disc herniations by percutaneous endoscopic foraminoplasty.

OBJECTIVE

To describe a safe and effective percutaneous endoscopic technique for removal of migrated herniations and report the results on the basis of modified MacNab criteria.

SUMMARY OF BACKGROUND DATA

Migrated herniations pose a great challenge even for experienced endoscopic surgeons. These herniations are hidden from the endoscopic view by anatomic barriers like hypertrophied facet, inferior pedicle and foraminal ligaments rendering percutaneous endoscopic transforaminal lumbar discectomy (PELD) by conventional approach, difficult with high failure rate. Foraminoplasty, which means enlargement of foramen by undercutting ventral part of superior-facet, upper border of inferior pedicle along with ablation of foraminal ligament, can help us to address this issue.

METHODS

Fifty-nine patients with soft highly migrated herniations who underwent PELD with foraminoplasty under local anesthesia from January 2002 to June 2006 were analyzed retrospectively. Patients were evaluated by postoperative Visual Analog Scale for leg pain and Oswestry Disability Index scores. Outcomes were graded according to modified MacNab criteria.

RESULTS

Mean follow-up was 25.4 months. Mean visual analog scale score for radicular pain improved from 8.01 to 1.56, and mean Oswestry disability Index improved from 61.6 to 10.76. Based on modified MacNab criteria, 91.4% of patients experienced satisfactory outcome. Three patients had persistent leg pain after surgery. One patient underwent a repeat-PELD on next day and the other after 1 month. Both were relieved of symptoms. Third patient was subjected to open discectomy after 25 weeks from the first operation and showed improvement. Two patients had recurrent herniation at same level after 6 months; 1 patient underwent repeat PELD, and the other underwent open discectomy. Both patients had good results.

CONCLUSION

Foraminoplastic-PELD is safe and effective procedure for surgical treatment of soft migrated herniations. The results are comparable to results of open discectomy.

Papel de la cirugía en la enfermedad degenerativa espinal. Análisis de revisiones sistemáticas sobre tratamientos quirúrgicos y conservadores desde el punto de vista de la medicina basada en la evidencia

INTRODUCTION

The lifetime prevalence of invalidating back pain in general population caused by Spinal Degenerative Disease (SDD) is about 70-80%. Global costs related to this disease are enormous (1-2% gross domestic product). From an Evidence-based point of view, there is a striking discrepancy between the use of many available surgical techniques (especially for spinal fusion) and the lack of scientific support.

METHODS

The authors carefully reviewed all published metaanalysis on SDD therapies up to December 2003. Treatment recommendations were classified according to levels of evidence (strong, moderate, mild or lack of evidence) for both surgical and conservative measures.

RESULTS

Forty-four metaanalysis were selected (nine on lumbar surgery, three on cervical surgery and thirty-two on other therapies). Relating surgery, there is strong evidence favouring early laminectomy in cauda equina syndrome secondary to lumbar disc herniation; discectomy or microdiscectomy are superior to chemo-nucleolysis in lumbar prolapse and spondylosis; and fusion surgery (probably noninstrumented) in adult isthmic spondylolysthesis or degenerative spondylolysthesis with spinal stenosis. In cervical spondylosis and radiculomyelopathy, discectomy seems as effective as discectomy plus fusion, which does not seem to be better than untreated SDD beyond 24 months. Preoperative antibiotics seem to prevent infection in spinal surgery. No benefit of surgery is demonstrated in discogenic pain. None of conservative therapies are supported by strong evidence. Antidepressants improve pain perception but do not influence the functional status.

DISCUSSION

Although lumbar instrumented surgery has nearly doubled over two decades and the annual growth is about 20%, clinical results do not seem to have improved, not even global fusion rates. The increasing use of fusion surgery for cases other than spinal deformities, spondylolysthesis or spinal stenosis plus lysthesis may be related to multiple technical and clinical-epidemiological factors where huge financial and commercial interests must be considered. It is crucial to differentiate subsets of patients prone to benefit from surgery. It is discussed whether randomized trials incorporating sham operations are ethically justifiable, because of the lack of sound evidence for many spinal procedures. The efficacy of most conservative treatments is mild or moderate (mainly transient) and they should be probably used in combination. CONCLUSIONS. There is no strong evidence favouring most of surgical procedures for SDD from an evidence-based approach. It seems necessary that scientific organizations studying SDD create clinical guidelines relating its multidisciplinary and integral management, recognizing that, up to now, few interventions positively modify in the long-term the natural history of the disease.

Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases

STUDY DESIGN

A retrospective study of 43 consecutive patients who underwent percutaneous endoscopic lumbar discectomy for recurrent disc herniation.

OBJECTIVES

To evaluate the efficacy of endoscopic discectomy for recurrent disc herniations and to determine the prognostic factors affecting surgical outcome.

SUMMARY OF BACKGROUND DATA

Repeated open discectomy with or without fusion has been the most common procedure for a recurrent lumbar disc herniation. There have been no reports published on the feasibility and prognostic factors of the endoscopic discectomy for recurrent disc herniation.

METHODS

The inclusion criteria were recurrent disc herniations at the same level, regardless of side, with a pain-free interval longer than 6 months after the conventional open discectomy. Posterolateral endoscopic laser-assisted disc excisions were performed under local anesthesia.

RESULTS

The mean follow-up period was 31 months (24-39 months). Based on the MacNab criteria, 81.4% showed excellent or good outcomes. The mean visual analog scale decreased from 8.72 +/- 1.20 to 2.58 +/- 1.55 (P <0.0001). In our series, better outcomes were obtained in patients younger than 40 years (P = 0.035), patients with duration of symptoms of less than 3 months (P = 0.028), and patients without concurrent lateral recess stenosis (P = 0.007).

CONCLUSIONS

Percutaneous endoscopic lumbar discectomy is effective for recurrent disc herniation in selected cases. The posterolateral approach through unscarred virgin tissue can prevent nerve injury and could preserve the spinal stability. Both foraminal and intracanalicular portions can be decompressed simultaneously.

Posterolateral percutaneous endoscopic lumbar foraminotomy for L5-S1 foraminal or lateral exit zone stenosis. Technical note

The purpose of this study was to determine the efficacy and feasibility of posterolateral percutaneous endoscopic lumbar foraminotomy (PELF) for foraminal or lateral exit zone stenosis of the L5-S1 level in the awake patient. Twelve consecutive patients with L5-S1 foraminal stenosis and associated leg pain underwent PELF between May 2001 and July 2002. Under fluoroscopic guidance, posterolateral endoscopic foraminal decompression was performed using a bone reamer, endoscopic forceps, and a laser. Using this new technique, the authors removed part of the hypertrophied superior facet, thickened ligamentum flavum, and protruded disc compressing the exiting (L-5) nerve root. Clinical outcome was measured using the Macnab criteria. The mean follow-up period was 12.9 months. All the patients were discharged within 24 hours. Satisfactory (excellent or good) results were demonstrated in 10 patients. There was no complication. The PELF procedure provides a simple alternative for treating lumbar foraminal or lateral exit zone stenosis in selected cases. The authors found that the posterolateral endoscopic approach to the L5-S1 foramen was usually possible and that using a bone reamer to undercut the superior facet was effective.

Management of isthmic spondylolisthesis with posterolateral endoscopic foraminal decompression

STUDY DESIGN

Prospective evaluation of 24 consecutive patients with isthmic spondylolisthesis with chronic back, buttock, and leg pain treated by endoscopic foraminal decompression and followed for a minimum of 2 years.

OBJECTIVES

To assess the efficacy of endoscopic foraminal decompression and mobilization of the exiting and transiting nerves, discectomy, ablation of osteophytes, and impinging pars as a means of treatment by the posterolateral approach.

SUMMARY OF BACKGROUND DATA

Open decompression with or without fusion is a commonly accepted procedure for symptomatic isthmic spondylolytic spondylolisthesis in patients who fail to respond to conservative treatment. There is no published data on the outcome of endoscopic procedures for this condition.

METHODS

Endoscopic foraminal decompression achieved with laser-assisted bone and soft-tissue ablation was performed on 12 males and 12 females with an average age of 42.4 years (36-72 years) followed for an average period of 34 months (28-46 months). The average preoperative duration of symptoms was 6.1 years (3-9 years).

RESULTS

One hundred percent cohort integrity was maintained at the final follow-up. Results were analyzed using the percentage change in Oswestry Disability Scores and in Visual Analogue Pain scores. Using a percentage change in Oswestry Disability Score of 50 or more plus VAP scores of 50 or more to determine good and excellent outcomes, 79% (19 out of 24) exceeded this value.

CONCLUSION

Laser-assisted endoscopic foraminal decompression provides a minimalist means of exploring the extraforaminal zone, the isthmic defect, the foramen and its contents, the disc and the epidural space. It allows adequate resection with decompression and discectomy, without the need for open decompression and fusion, and targets the symptomatic level effectively in patients with Grade I-III isthmic spondylolisthesis.