Minimally invasive approach to the cervical spine: a proposal

Accuracy and evaluation of irradiation of novel localization devices with unique three-dimensional structures in microendoscopic spine surgery

BACKGROUND

Although many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery, the accurate localization of the correct spinal level remains problematic. At the same time, surgeons are also required to reduce radiation exposure to patients and operating room personnel. To solve these problems, we developed and used specially designed marking devices with a unique three-dimensional structure.

PURPOSE

To evaluate the accuracy of our novel devices for localization of the spinal level to prevent wrong-level surgery and reduce the amount and time of radiation exposure during surgery.

STUDY DESIGN

This was a retrospective cohort study.

METHODS

In 8240 consecutive patients who underwent microendoscopic spine surgery between 1993 and 2012, the incidence of wrong-level surgery was studied. In addition, the amount of radiation exposure and total fluoroscopy time were measured in recent 100 consecutive patients using a digital dosimeter attached to the fluoroscope.

RESULTS

Eight (0.097 %) patients had undergone wrong-level surgery. The average radiation exposure was 0.26 mGy (range 0.10-1.15 mGy), and the average total fluoroscopy time was 3.1 s (range 1-7 s).

CONCLUSIONS

Our novel localization devices and technique for their use in spine surgery are reliable and accurate for identifying the target level and contributed to reductions in preoperative localization error and radiation exposure to patients and operating room personnel.

Retrospective evaluation of efficiency and safety of an anterior percutaneous approach for cervical discectomy

Study Design

Retrospective case series.

Purpose

The purpose of the study was to evaluate the efficiency and complication rate of a percutaneous anterior approach to herniated cervical disks with or without concomitant foraminal stenosis and/or spondylosis.

Overview of Literature

Recent publications reflect that minimally invasive procedures gain in importance in patients and spine surgeons as they are generally associated with less tissue damage and shorter recovery times. However, for anterior percutaneous cervical discectomy, very little data is available for relevant patient populations.

Methods

Charts from patients with herniated cervical disc confirmed by magnetic resonance imaging, mainly radicular symptoms and irresponsive to conservative treatment who underwent anterior percutaneous discectomy were evaluated retrospectively. All patients were asked to return questionnaires that included visual analogue scores (VAS), MacNab score as well as subjective satisfaction data 2 years after surgery.

Results

Ninety-five patients were included. There were no neurological or vascular complications; only one patient suffered from transient hoarseness. During the two years after surgery, 9 patients underwent reoperation. 90.5% of the patients returned the questionnaire at 2 years' follow-up. 87.7% of them reported excellent or good outcome, 11.1% rated results as fair and 1.2% as unsatisfactory. On average, arm and neck pain improved significantly by 6.1 points and 5.8 points respectively on a ten point VAS. 94.5% stated that they would choose the same procedure again.

Conclusions

This procedure has proved a safe and sufficient option for symptomatic cervical disk herniations with or without concomitant spondylosis and/or foraminal stenosis.

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.

Anterior cervical discectomy and interbody fusion by endoscopic approach: a preliminary report

OBJECT

The authors report the short-term results of anterior cervical discectomy and interbody fusion performed via an endoscopic approach.

METHODS

Thirty-six patients who underwent anterior cervical discectomy and fusion (ACDF) performed using endoscopic surgery were selected for this study. The indications for surgery were cervical disc herniation caused by neck injury, spondylotic myelopathy, cervical radiculopathy, and solitary ossification of the posterior longitudinal ligament (OPLL). The involved levels included C3-4, C4-5, C5-6, and C6-7. The working channel was inserted through a 20-mm transverse incision, the protruding discs or area of OPLL were excised for complete decompression, and then an appropriate intervertebral polyetheretherketone fusion cage was implanted.

RESULTS

The time spent in surgery was 120 minutes on average (range 50-150 minutes), and the mean blood loss was 55 ml (range 20-140 ml). There were no intraoperative complications and no symptoms of irritation in the laryngopharynx after surgery. However, postoperative hemorrhage of the incision occurred in 1 case. The follow-up period ranged from 26-50 months (mean 38.5 months). Postoperative Japanese Orthopaedic Association and visual analog scale scores improved significantly.

CONCLUSIONS

Endoscopic surgery for ACDF can produce satisfactory results in patients with cervical disc herniation, cervical myelopathy, or radiculopathy. The optimal levels for this procedure are C4-5 and C5-6. Compared with a traditional approach, this technique has great advantages in terms of cosmetic results, intraoperative visualization, and postoperative recovery course. Nevertheless, every precaution should be taken to avoid possible complications, such as postoperative hemorrhage.

Endoscopic Thyroidectomy Using a Gasless Axillary Approach

PURPOSE

We have recently developed an endoscopic thyroidectomy using a gasless axillary approach and report the surgical outcome of the procedure.

MATERIALS AND METHODS

The gasless axillary approach was performed through a 3-cm axillary incision using a retractor instead of carbon dioxide insufflation. We performed a total of 35 thyroidectomies using this technique in patients with benign thyroid nodules.

RESULTS

Thirty-four cases were successfully completed with the gasless axillary approach; one case had to be converted to a conventional technique after intraoperative frozen section revealed papillary carcinoma. The mean operative time and mean hospital stay were 180.6 +/- 54.5 minutes and 7.1 +/- 0.9 days, respectively. The mean tumor size was 2.9 +/- 1.4 cm. There were three minor postoperative complications: one case each of wound seroma, transient voice change, and persistent wound pain. All patients were satisfied with the cosmetic result. The axillary scars were not visible when the ipsilateral arms were in their natural position.

CONCLUSION

Endoscopic thyroidectomy using a gasless axillary approach is a safe procedure that offers a good cosmetic result and has the merits of minimal invasiveness even in patients with a large thyroid mass. It is a safe and feasible alternative to traditional thyroid surgery, especially in young female patients with a large thyroid mass.

Cirugía cervical endoscópica

The beginning of cervicoscopy dates back to the first laparoscopic parathyroidectomy in 1996. This operation, with its distinct variants, has today become a valid therapeutic option in many well-regarded centers. Later on endoscopic or video-assisted thyroidectomy was introduced, despite the limits imposed by the large size of the gland on its removal. Consequently, this technique is indicated in a small number of patients but both parathyroidectomy and thyroidectomy provide significant advantages over conventional surgery, which have been demonstrated in prospective studies. The main advantages are a better cosmetic outcome and a less distressing postoperative course. Both approaches have been proved to be safe and feasible in any surgical background and their complication rate is similar to that of traditional open surgery of the neck. Videoscopic access to neck lymph nodes (central and lateral compartments) seems to be highly promising, whereas other fields of application such as carotid artery surgery and spine surgery are still the object of experimental studies. Consequently, cervicoscopy should be considered an important surgical tool which already shows great possibilities but which could be further improved.

Multiple parallel skin markers for minimal incision lumbar disc surgery; a technical note

BACKGROUND

Spinal surgery depends on accurate localization to prevent incorrect surgical approaches. The trend towards minimally invasive surgery that minimizes surgical exposure and reduces postoperative pain increasingly requires surgeons to accurately determine the operative level before an incision is made. Preoperative localization with a C-arm image intensifier is popular, but the exposure of both patients and theatre staff to radiation is a disadvantage, as well as being time-consuming.

METHODS

We describe a simple surgical tool developed to help localize exact spinal levels in conjunction with a simple AP X-ray film immediately before surgery. Multiple parallel skin markers were made using a circular oven rack comprising multiple 1.5 cm spaced parallel wires attached to a circular outside rim. The longest line was placed on the line of the postero-superior iliac spine (PSIS) over the junction of the L5-S1 region.

RESULTS AND CONCLUSIONS

Based on the film taken, the incision can be accurately made at the intended level. The incision wound can be minimized to 3.0 cm even when using conventional disc surgery instruments.

Endoscopic thyroid surgery today: a diversity of surgical strategies

The advancement of video-assisted minimally invasive surgery in this decade fostered the successful attempt at endoscopic thyroidectomy in 1997. This technically demanding surgery is now being evaluated in a small number of specialized centers. The procedure earned the most attention in Japan and is performed in more than 20 centers; a conference dedicated to the technique was held in Japan in 2001. By retrieving information from published or presented articles and direct personal communications, we report on the multitude of surgical strategies designed by different experts to enable relocalization of the surgical wounds to optimize cosmesis to the patient while complying with the gold standard of thyroid surgery.