Transforaminal endoscopy in lumbar burst fracture: A case report

Transdural reduction of a bone fragment protruding into the spinal canal during surgical treatment of lumbar burst fracture: A case report

Background:

There have been many reports on the clinical, radiographic, and surgical management of thoracolumbar burst fractures attributed to high-energy trauma. Interestingly, few reports have described how to extract bone fragments associated with these injuries protruding into the spinal canal contributing to significant neurological deficits.

Methods:

An 18-year-old male presented with a severe L3-level paraparesis (i.e., loss of motor/sensory function below L3 lower extremity hyporeflexia, and sphincter dysfunction: American Spinal Injury Association [ASIA] Impairment Scale B) following a high-speed crash. The computed tomography and magnetic resonance studies revealed a L3 burst fracture with bone fragments protruding into the spinal canal causing marked cauda equina compression. Following a L3-L4 laminectomy, and opening of the dorsal dura, the bone fragments were ventrally impacted into the fractured L3 vertebral body a pedicle/screw L1-L5 fusion was then completed.

Results:

One month later, the patient recovered to an ASIA Scale of C, (i.e., residual proximal 3/5 and distal 2/5 motor deficits, with partial sensory sparing).

Conclusion:

Transdural ventral impaction of protruded bone fragments attributed to high speed lumbar burst fractures contributing to significant cauda equina compression can be safely/effectively accomplished.

Percutaneous pedicle screw fixation combined with selective transforaminal endoscopic decompression for the treatment of thoracolumbar burst fracture

Background

The objective of this study was to evaluate the feasibility, safety, efficacy, and indications of percutaneous pedicle screw fixation (PPSF) combined with selective transforaminal endoscopic decompression (TED) in the treatment of thoracolumbar burst fracture (TBLF).

Methods

From August 2015 to October 2018, a total of 41 patients with single-segment TLBF (28 men and 13 women) were enrolled in this study. X-ray and computed tomography were obtained before surgery, 1 week after surgery, and 1 year after surgery to evaluate spinal recovery. In addition, we used the visual analog scale (VAS), the Oswestry Disability Index (ODI), the Japanese Orthopedic Association score (JOA), and the Frankel classification of neurological deficits to evaluate the effectiveness of the treatments.

Results

The average follow-up time was 22.02 ± 8.28 months. The postoperative Cobb angle, vertebral body compression ratio, vertebral wedge angle, mid-sagittal canal diameter compression ratio, and Frankel grade were significantly improved. There were also significant improvements in the VAS (7.61 ± 1.41 vs. 1.17 ± 0.80, P < 0.001), ODI (89.82 ± 7.44 vs. 15.71 ± 13.50, P < 0.001), and JOA (6.90 ± 2.91 vs. 24.90 ± 3.03, P < 0.001).

Conclusions

Our results showed that PPSF combined with selective TED in the treatment of TLBF had excellent efficacy, high safety, less secondary injury than other treatments, and a wide range of indications and that it could accurately distinguish patients who did not need spinal canal decompression after posterior fixation. PPSF combined with selective TED is therefore a good choice for the treatment of TLBF.

Percutaneous pedicle screw fixation combined with transforaminal endoscopic spinal canal decompression for the treatment of thoracolumbar burst fracture with severe neurologic deficit: A case report

RATIONALE

The most common fractures of the spine are associated with the thoracolumbar junction (T10-L2). And burst fractures make up 15% of all traumatic thoracolumbar fractures, which are often accompanied by neurological deficits and require open surgeries. Common surgeries include either anterior, posterior or a combination of these approaches. Here, we report the first attempt to treat thoracolumbar burst fracture (TLBF) with severe neurologic deficits by percutaneous pedicle screw fixation (PPSF) and transforaminal endoscopic spinal canal decompression (TESCD).

PATIENT CONCERNS

A 46-year-old Chinese woman suffered from severe lower back pain with grade 0 muscle strength of lower limbs, without any sensory function below the injury level, with an inability to urinate or defecate after a motor vehicle accident. Imaging studies confirmed that she had Magerl type A 3.2 L1 burst fracture.

DIAGNOSES

Burst fracture at L1.

INTERVENTIONS

The patient underwent PPSF at the level of T12 to L2, but her neurological function did not fully recover after the operation. One week after the injury, we performed TESCD on her.

OUTCOMES

There was an immediate improvement in her neurological function in just 1 day after 2-stage operation. During the 6-month follow-up period, her neurological functions gradually recovered, and she was able to defecate and urinate. At the last follow-up visit, her spinal cord function was assessed to be at Frankel grade D.

LESSONS

PPSF plus TESCD can achieve complete spinal cord decompression, promote neurological recovery, and is therefore an effective method for the treating lumbar burst fractures with severe neurologic deficits.

The benefit zone of full-endoscopic spine surgery

Minimally invasive spine procedures have undergone rapid development during the last decade. Efforts to decrease muscle crush injuries during prolonged retraction, avoid significant soft tissue stripping and minimize bony resection are surgical principles that are employed to prevent iatrogenic instability and provide patients with decreased post-operative pain and disability. Full-endoscopic spine surgery represents a tool for the spine surgeon to provide targeted access to spinal pathology utilizing these principles. Endoscopic techniques have seen over 30 years of evolution and innovation, however, early iterations of these techniques largely focused on transforaminal lumbar microdiscectomies. Currently, endoscopic techniques are utilized for approaching pathology in the cervical, thoracic and lumbar spine. There has been a growing body of literature that not only confirms the efficacy of these procedures but also underscores the advantages these procedures offer with respect to less morbidity and safer complication profiles. Endoscopic decompressions have been utilized in the settings of degenerative spinal stenosis, spondylolisthesis, scoliosis, previous fusion, tumor and infection. Furthermore, endoscopic interbody fusion has also been utilized in the lumbar spine as technology continues to advance. As technological innovation continues to facilitate reproducible surgical technique and expand the indications for use, we believe that endoscopic spine surgical techniques will provide surgeons with a more powerful and less morbid approach to spinal pathology that ultimately elevates the standard of care when treating our patients. We present a brief review of the history of endoscopic spine surgery, an overview of current techniques and review current outcomes of endoscopic spine surgical procedures in the context of an invasiveness/complexity index to elucidate the benefit zone of these newer techniques.

Recurrent lumbar disc herniation recurrence after percutaneous endoscopic lumbar discectomy: A case report

RATIONALE

Lumbar disc herniation (LDH) is a degenerative disease and affects human health. Although percutaneous endoscopic lumbar discectomy (PELD) can redeem the living quality of patient with LDH rapidly, it appears weak to limit the recurrence rate of LDH.

PATIENT CONCERNS

A 52-year-old male suffered lower back pain and lower limb paralysis for 20 years. However, conservative treatment could not relieve above-mentioned symptoms after doing heavy labor.

DIAGNOSES

Computed tomography (CT) revealed a disc fragment had migrated to the inferior edge of the L5 pedicle. Magnetic resonance imaging (MRI) demonstrated a type 2 Modic change (MC) at L5 and spinal canal stenosis at L4-L5. Based on these findings, the patient was diagnosed with L4-L5 disc herniation and secondary lumbar stenosis.

INTERVENTIONS

The patient underwent surgery twice for PELD at L4-L5 in 1 month. Symptoms were not improved effectively until the conventional posterior discectomy with fusion was performed.

OUTCOMES

No signs of recurrence have been detected in 6 months of follow-up, except for mild lower back pain meeting the temperature change.

LESSONS

Rapid decompression and instant therapeutic effect do not mean extending the indications of PELD. It is unreasonable to revise the recurrent LDH or treat the primary LDH with PELD under inadequate preoperative assessment.