Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 intervertebral disc herniation

Transforaminal lumbar endoscopic discectomy: should we abandon it for L5-S1 foraminal and extraforaminal lumbar disc herniations? A prospective non-randomised study and literature review

PURPOSE

The aim of this study is to investigate the clinical outcomes of transforaminal lumbar endoscopic discectomy (TLED) in patients with L5-S1 lumbar disc herniation (LDH).

MATERIALS AND METHODS

Seventy-five consecutive individuals with diagnosed foraminal/extraforaminal L5-S1 LDH were included in this study. All patients underwent TLED, being subsequently evaluated in a 2-year follow-up period. Assessment was performed preoperatively and at 6 weeks and 3, 6, 12 and 24 months postoperatively. Visual Analogue Scale (distinctly applied for lower limb - VAS-LP and low back - VAS-BP pain) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire were implemented to assess pain and health-related quality of life (HRQoL) of enrolled individuals, respectively.

RESULTS

No major perioperative complications were observed. Recorded values of all studied indices were demonstrated to feature a clinically and statistically significant amelioration at 6 weeks, presenting lesser improvement at 3 months with subsequent stabilisation. VAS-LP and VAS-BP values were displayed to reach a plateau in 6 months postoperatively, whereas all parameters of SF-36 continued to present a statistically significant improvement until the end of follow-up at 2 years.

CONCLUSIONS

TLED represent a safe and efficient technique in terms of diminishing perceived pain and improving HRQoL in patients with L5-S1 LDHs. However, specific patient- and technique-related circumstances on the ground of low surgical experience may limit its effectiveness in these patients.

Limited Intervention in Adult Scoliosis-A Systematic Review

BACKGROUND/OBJECTIVES

Adult scoliosis is traditionally treated with long-segment fusion, which provides strong radiographic correction and significant improvements in health-related quality of life but comes at a high morbidity cost. This systematic review seeks to examine the literature behind limited interventions in adult scoliosis patients and examine the best approaches to treatment.

METHODS

This is a MEDLINE- and PubMed-based literature search that ultimately included 49 articles with a total of 21,836 subjects.

RESULTS

Our search found that long-segment interventions had strong radiographic corrections but also resulted in high perioperative morbidity. Limited interventions were best suited to patients with compensated deformity, with decompression best for neurologic symptoms and fusion needed to treat neurological symptoms secondary to up-down stenosis and to provide stability across unstable segments. Decompression can consist of discectomy, laminotomy, and/or foraminotomy, all of which are shown to provide symptomatic relief of neurologic pain. Short-segment fusion has been shown to provide improvements in patient outcomes, albeit with higher rates of adjacent segment disease and concerns for correctional loss. Interbody devices can provide decompression without posterior element manipulation. Future directions include short-segment fusion in uncompensated deformity and dynamic stabilization constructs.

CONCLUSIONS

Limited interventions can provide symptomatic relief to adult spine deformity patients, with indications mostly in patients with balanced deformities and neurological pain.

Full-Endoscopic Lumbar Discectomy Approach Selection: A Systematic Review and Proposed Algorithm

STUDY DESIGN

A systematic review of the literature to develop an algorithm formulated by key opinion leaders.

OBJECTIVE

This study aimed to analyze currently available data and propose a decision-making algorithm for full-endoscopic lumbar discectomy for treating lumbar disc herniation (LDH) to help surgeons choose the most appropriate approach [transforaminal endoscopic lumbar discectomy (TELD) or interlaminar endoscopic lumbar discectomy (IELD)] for patients.

SUMMARY OF BACKGROUND DATA

Full-endoscopic discectomy has gained popularity in recent decades. To our knowledge, an algorithm for choosing the proper surgical approach has never been proposed.

MATERIALS AND METHODS

A systematic review of the literature using PubMed and MeSH terms was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Patient samples included patients with LDH treated with full-endoscopic discectomy. The inclusion criteria were interventional research (randomized and nonrandomized trials) and observation research (cohort, case-control, case series). Exclusion criteria were case series and technical reports. The criteria used for selecting patients were grouped and analyzed. Then, an algorithm was generated based on these findings with support and reconfirmation from key expert opinions. Data on overall complications were collected. Outcome measures included zone of herniation, level of herniation, and approach (TELD or IELD).

RESULTS

In total, 474 articles met the initial screening criteria. The detailed analysis identified the 80 best-matching articles; after applying the inclusion and exclusion criteria, 53 articles remained for this review.

CONCLUSIONS

The proposed algorithm suggests a TELD for LDH located in the foraminal or extraforaminal zones at upper and lower levels and for central and subarticular discs at the upper levels considering the anatomic foraminal features and the craniocaudal pathology location. An IELD is preferred for LDH in the central or subarticular zones at L4/L5 and L5/S1, especially if a high iliac crest or high-grade migration is found.

Current Status and research hotspots in the field of full endoscopic spine surgery: A bibliometric analysis

Purpose

We aimed to comprehensively analyze the current status, hotspots, and trends in full endoscopic spine surgery (FESS) research using bibliometric analysis and knowledge domain mapping.

Methods

The Web of Science database was used to screen FESS-related articles published between January 1, 1993 and June 10, 2022. The evaluation involved the following criteria: total number of articles; H-index; and contributions from countries/regions, institutions, journals, and authors.

Results

A total of 1,064 articles were included. Since 2016, there have been a significant number of publications in the field of FESS. The country/region contributing the largest number of articles was China (37.8%), followed by South Korea (24%), the United States (16.1%), Japan (5.7%), and Germany (5.1%). South Korea (35) had the highest H-index, followed by the United States (27), China (22), Japan (21), and Germany (20). World Neurosurgery (15.7%) published the largest number of FESS-related articles. However, among the top 10 most cited articles, six were published in Spine. The author who contributed the most was S.H. Lee (5.4%), and the largest number of contributions in this field originated from Wooridul Spine Hospital (South Korea; 6.1%). Notably, six of the 10 most published authors in this field were from South Korea. Of the top five productive institutions, three were from South Korea. The keywords with the strongest citation bursts in the field of FESS were “lumbar spine,” “discectomy,” “interlaminar,” “surgical technique,” “follow-up,” “excision,” “thoracic spine,” and “endoscopic surgery.” The 10 clusters generated in this study were: “endoscopic discectomy” (#0), “thoracic myelopathy” (#1), “recurrent lumbar disc herniation” (#2), “low back pain” (#3), “cervical vertebrae” (#4), “lumbar spinal stenosis” (#5), “transforaminal lumbar interbody fusion” (#6), “radiation exposure” (#7), “management” (#8), and “lumbar spine” (#9).

Conclusion

Global research on FESS is mostly concentrated in a few countries/regions and authors. South Korea has made the largest contribution to the field of FESS. Based on the most cited keyword bursts and clusters, the focus of FESS research was found to include its indications, management, and applications.

Application of a targeted and quantificational foraminoplasty device in percutaneous transforaminal endoscopic discectomy for L5-S1 disc herniation: preliminary clinical outcomes

OBJECTIVE

Percutaneous transforaminal endoscopic discectomy (PTED) is minimally invasive and has been widely used to treat patients with lumbar disc herniation (LDH) due to its safety and efficiency. However, due to the unique anatomy of the L5-S1 level, the PTED procedure is often difficult to perform in the region. ZESSYS, a targeted and quantificational foraminoplasty device, may help to overcome these anatomical limitations. In this study, we assessed the efficiency and the short-term effects of PTED with ZESSYS at the L5-S1 level.

METHODS

Between January and August of 2018, fifty-six patients with lumbar disc herniation at the single level of L5-S1 and who underwent percutaneous transforaminal endoscopic discectomy were enrolled in this retrospective cohort study. They were segregated into the transforaminal endoscopic surgical system (TESSYS) group and the ZESSYS group. The puncture time, foraminoplasty time, decompression time, and fluoroscopy time were evaluated for operation efficiency. Clinical outcomes were assessed by the visual analog scale (VAS) score and Oswestry Disability Index (ODI) score. The MacNab criteria were used to evaluate patient subjective satisfaction at 12-month follow-up postoperatively.

RESULTS

The average puncture time (5.29 ± 2.05 min), foraminoplasty time (12.82 ± 2.52 min), and fluoroscopy time (26.29 ± 5.96 s) were all significantly shorter in the ZESSYS group than in the TESSYS group (average puncture time 8.07 ± 3.13 min, p < 0.01; foraminoplasty time, 17.18 ± 2.92 min, p < 0.01; fluoroscopy time, 34.73 ± 6.86 s; p < 0.01). No significant differences were observed between the 2 groups in the decompression time (p = 0.057). The VAS score of low back pain and leg pain, as well as the ODI score, improved at all time points postoperatively compared with preoperative, in both the TESSYS group and the ZESSYS group (P < 0.05). There were no significant differences in the VAS score of low back pain, VAS score of leg pain, and ODI score between the TESSYS group and the ZESSYS group at the same time points (P > 0.05). According to the MacNab criteria, the excellent and good rate at 12-month follow-up postoperatively was 85.7% in the TESSYS group and 89.3% in the ZESSYS group (P > 0.05).

CONCLUSION

The targeted and quantificational foraminoplasty device named ZESSYS was more efficient in the puncture and foraminoplasty procedures, effectively protecting the exiting nerve and minimizing the level of radiation exposure. The device is efficient and safe for PTED in treating lumbar disc herniation at the L5-S1 level.

Preoperative Simulation of the Trajectory for L5/S1 Percutaneous Endoscopic Transforaminal Discectomy: A Novel Approach for Decision-Making

OBJECTIVE

We simulated the trajectory for an L5/S1 percutaneous endoscopic transforaminal discectomy (PETD) to guide decision-making for the surgery approach.

METHODS

Twenty-three patients with L5/S1 lumbar disc herniation were included in the study. The patients all underwent thin-section computed tomography scans, after which data were collected for 3-dimensional reconstruction. Simulations of the trajectory for the L5/S1 PETDs were generated and the hindrance of surrounding anatomic structures was evaluated.

RESULTS

Preoperative simulation showed that 14 patients were considered suitable for lumbar PETD. Nine patients were not considered suitable for PETD surgery according to the simulation. Factors affecting the trajectory included high iliac crest in 5 patients, L5 transverse process in 3 patients, and hypertrophic L5-S1 facet joint in 1 patient.

CONCLUSIONS

Preoperative simulation of the trajectory for L5/S1 PETD was helpful in the decision-making for the surgical approach.

Deep learning-based lumbosacral reconstruction for difficulty prediction of percutaneous endoscopic transforaminal discectomy at L5/S1 level: A retrospective cohort study

BACKGROUND

Deep learning has been validated as a promising technique for automatic segmentation and rapid three-dimensional (3D) reconstruction of lumbosacral structures on CT. Simulated foraminoplasty of percutaneous endoscopic transforaminal discectomy (PETD) through the Kambin triangle may benefit viability assessment of PETD at L5/S1 level.

MATERIAL AND METHODS

Medical records and radiographic data of patients with L5/S1 lumbar disc herniation (LDH) who received a single-level PETD from March 2013 to February 2018 were retrospectively collected and analyzed. Deep learning was adopted to achieve semantic segmentation of lumbosacral structures (nerve, bone, disc) on CT, and the segmented masks on reconstructed 3D models. Two observers measured the area of the Kambin triangle on 6 selected deep learning-derived 3D (DL-3D) models and ground truth-derived 3D (GT-3D) models, and intraclass correlation coefficient (ICC) was calculated to assess the test-retest and interobserver reliability. Foraminoplasty of PETD was simulated on L5/S1 lumbosacral 3D models. Patients with extended foraminoplasty or stuck canula occurs on simulations were predicted as PETD-difficult cases (Group A). The remaining patients were regarded as PETD-normal cases (Group B). Clinical information and outcomes were compared between the two groups.

RESULTS

Deep learning-derived 3D models of lumbosacral structures (nerves, bones, and disc) from thin-layer CT were reliable. The area of the Kambin triangle was 161.27 ± 40.10 mm² on DL-3D models and 153.57 ± 32.37 mm² on GT-3D models (p = 0.206). Reliability test revealed strong test-retest reliability (ICC between 0.947 and 0.971) and interobserver reliability of multiple measurements (ICC between 0.866 and 0.961). The average operation time was 99.62 ± 17.39 min in Group A and 88.93 ± 21.87 min in Group B (P = 0.025). No significant differences in patient-reported outcomes or complications were observed between the two groups (P > 0.05).

CONCLUSION

Deep learning achieved accurate and rapid segmentations of lumbosacral structures on CT, and deep learning-based 3D reconstructions were efficacious and reliable. Foraminoplasty simulation with deep learning-based lumbosacral reconstructions may benefit surgical difficulty prediction of PETD at L5/S1 level.

Treatment of high-iliac-crest L5-S1 lumbar disc herniation via a transverse process endoscopic transforaminal approach

OBJECTIVE

To investigate the clinical efficacy of transverse process endoscopic transforaminal discectomy for the treatment of high-iliac-crest L5-S1 lumbar disc herniation.

METHODS

Seventeen patients with high-iliac-crest L5-S1 lumbar disc herniation who were treated with transforaminal endoscopy from April 2016 to January 2019 in the Department of Neurosurgery of Xuanwu Hospital were selected. The visual analog scale (VAS) and Oswestry disability index (ODI) were used to evaluate the efficacy of the procedure.

RESULTS

All of the patients successfully underwent the surgical treatment. Sixteen patients (94.1 %) completed effective follow-up for more than 12 months. The VAS was 7.8 ± 1.9, 2.9 ± 1.6, 2.3 ± 1.5 and 2.2 ± 1.6 before surgery and at one day, 3 months, and the last follow-up after surgery, respectively. The ODI scores were 52.8 ± 15.2 and 16.9 ± 9.7 before surgery and 3 months after surgery, respectively, both of which were lower than before surgery (both P < 0.01).

EFFICACY EVALUATION

An excellent outcome was achieved in 13 (81.3 %) patients, a good outcome in 1 patient (6.3 %), an acceptable outcome in 1 patient (6.3 %), and a poor outcome in 1 patient (6.3 %).

CONCLUSIONS

The transverse process endoscopic transforaminal discectomy is a safe and effective surgical method for the treatment of high-iliac-crest L5-S1 lumbar disc herniation.

Preoperative Design for the Posterolateral Approach in Full-Endoscopic Spine Surgery for the Treatment of L5/S1 Lumbar Disc Herniation

OBJECTIVE

Full-endoscopic spine surgery (FESS) is a relatively less invasive treatment for lumbar disc herniation (LDH). This study investigated the optimal operative route of the posterolateral approach (PLA) of FESS for the treatment of L5/S1 LDH.

METHODS

Between June 2016 and November 2018, a total of 21 patients with leg pain due to L5/S1 LDH underwent PLA of FESS. According to the partial removal of the superior articular process (SAP) of the L5/S1 facet joint (FJ), we categorized these patients into 2 groups. LDH type, anatomical configurations (FJ, sacral ala [SA], and iliac crest [IC]), the presence or absence of spondylolysis, operation time, and operative outcome were compared between these 2 groups.

RESULTS

Although the anatomical configuration of the FJ was the most important factor for the necessity of SAP removal, the configuration of the SA and IC did not restrict endoscope insertion and subsequent LDH removal. Even in intracanal LDH, the removal of SAP was not absolutely required depending on the FJ configuration. Furthermore, the presence of spondylolysis was a factor associated with the unnecessity of SAP removal.

CONCLUSION

Detailed radiological examination of the FJ configuration is an important preoperative investigation to determine the optimal operative route for PLA of FESS.

Current concepts for lumbar disc herniation

PURPOSE

To present the pathophysiology, biology, clinical presentation, diagnosis, and current treatment options for lumbar disc herniation.

METHODS

A thorough literature search was undertaken in PubMed and Google Scholar to summarize the current knowledge and future perspectives on lumbar disc herniation.

RESULTS

Several changes in the biology of the intervertebral disc are thought to contribute to disc herniation; nevertheless, the exact inciting event leading to disc herniation is yet to be discovered. Non-operative treatments have stood the test of time as the first-line treatment for most patients with lumbar disc herniation; however, operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function.

CONCLUSIONS

The exact event leading to disc herniation remains unclear. Non-operative treatments should be the first-line treatment for most patients with lumbar disc herniation. Operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Regenerative medicine is promising.

Transforaminal Percutaneous Endoscopic Discectomy using Transforaminal Endoscopic Spine System technique: Pitfalls that a beginner should avoid

Transforaminal Percutaneous Endoscopic Discectomy (TPED) is a minimally invasive technique mainly used for the treatment of lumbar disc herniation from a lateral approach. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss, trauma, and scar tissue compared to conventional procedures. However, the procedure should be performed by a spine surgeon experienced in the specific technique and capable of recognizing or avoiding various challenging conditions. In this review, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Lumbar Disc Herniation

PURPOSE OF REVIEW

Substantial advancements have been made in the cause, diagnosis, imaging, and treatment options available for patients with lumbar disc herniation (LDH). We examined the current evidence and highlight the concepts on the frontline of discovery in LDH.

RECENT FINDINGS

There are a myriad of novel etiologies of LDH detailed in recent literature including inflammatory factors and infectious microbes. In the clinical setting, recent data focuses on improvements in computer tomography as a diagnostic tool and non-traditional injection options including tumor necrosis alpha inhibitors and platelet-rich plasma. Operative treatment outcomes have focused on minimally invasive endoscopic approaches and demonstrated robust 5-year post-operative outcomes. Advances in the molecular etiology of LDH will continue to drive novel treatment options. The role of endoscopic treatment for LDH will continue to evolve. Further research into10-year outcomes will be necessary as this surgical approach continues to gain widespread popularity.