Early return to activity after minimally invasive full endoscopic decompression surgery in medical doctors

Transforaminal Full-Endoscopic Ventral Facetectomy: Midterm Results and Factors Associated with Poor Surgical Outcomes

BACKGROUND

 Full-endoscopic spine surgery (FESS) is a well-established procedure for herniated nucleus pulposus. It is a minimally invasive surgery that can be performed under local anesthesia through only an 8-mm skin incision. With improvements in surgical equipment such as high-speed drills, the indications for FESS have expanded to include lumbar spinal stenosis (LSS). We perform a transforaminal full-endoscopic ventral facetectomy (TF-FEVF) for unilateral nerve root-type lateral recess stenosis (LRS) using a transforaminal approach under local anesthesia.The aim of this study was to examine the postoperative results of TF-FEVF for LRS and to identify factors associated with poor surgical outcomes. 85 patients who underwent TF-FEVF for LRS under local anesthesia. Clinical outcomes were determined by visual analog scale (VAS) and the modified MacNab criteria. Evaluation was performed using magnetic resonance imaging (MRI), computed tomography (CT), and flexion-extension radiographs.

METHODS

 This study involved 85 patients (47 males and 38 females) who underwent TF-FEVF for LRS. The mean age was 70.5 years and the mean follow-up duration was 14.8 months. Data were collected on sex, age, level of operation, diagnosis, history of spine surgery at the same level, and duration of follow-up. The diagnosis was categorized as LSS with or without disk bulging. Clinical evaluation was performed using the VAS and modified MacNab criteria. MRI was used to evaluate the degree of disk degeneration, vertebral endplate degeneration, disk height, thickening of the ligamentum flavum, and stenosis. Bony stenosis was evaluated using CT. Sagittal translation and sagittal angulation were also measured by flexion-extension radiographs, and the Cobb angle was measured using a standing front view radiograph. All variables were compared between patients with excellent/good outcomes (E/G group) and those with fair/poor outcomes (F/P group) using the modified MacNab criteria.

RESULTS

 Postoperative VAS showed that leg pain decreased from 59.0 ± 28.6 preoperatively to 17.9 ± 27.2 at the final follow-up (p < 0.01) and that lower back pain also decreased from 60.7 ± 26.6 preoperatively to 27.3 ± 28.6 at final follow-up (p < 0.01). According to the modified MacNab criteria, the results during the final follow-up were excellent in 39 cases, good in 21 cases, fair in 13 cases, and poor in 12 cases. There were no significant differences in sex, age, diagnosis, history of spine surgery, and duration of follow-up periods between the 60 cases (70.6%) in the E/G group and the 25 cases (29.4%) in the F/P group. Imaging evaluation revealed statistically significant differences between the E/G group and the F/P group in intervertebral angle flexion (3.2 vs. 0.4 degrees; p < 0.05), sagittal angulation (4.3 vs. 8.1 degrees; p < 0.05), slip in flexion (0.9 vs. 2.8 mm; p < 0.05), sagittal translation (0.7 vs. 1.6 mm; p < 0.05), and Cobb angle (-0.5 vs. -1.9 degrees; p < 0.05).

CONCLUSION

 Midterm results of TF-FEVF were generally favorable; factors contributing to good or poor TF-FEVF outcomes were large sagittal angulation, large sagittal translation, and concave side.

Awake transforaminal endoscopic lumbar discectomy in an ambulatory surgery center: early clinical outcomes and complications of 100 patients

PURPOSE

Transforaminal endoscopic discectomy has been found to have equivalent outcomes to traditional discectomy techniques. Controversy exists concerning whether this should be performed under general anesthetic with neuromonitoring or can be safely performed on awake patients without neuromonitoring. This study aimed to evaluate the safety and effectiveness of awake transforaminal endoscopic discectomy in an ambulatory setting.

METHODS

100 consecutive patients with lumbar disc herniations treated with transforaminal endoscopic discectomy by a single surgeon were enrolled in the study. All procedures were performed under conscious sedation with local anesthetic. Preoperative and postoperative visual analog scale (VAS) scores were recorded and compared. Time spent in recovery prior to discharge home and complications were also recorded.

RESULTS

Average VAS score improved from a mean of 6.85 to 0.74 (median 7 to 0) immediately postoperatively. The average time spent in Post Anesthesia Care Unit (PACU) prior to discharge was 56.7 min. Average VAS score at 2 weeks was 3.07 (median 2.5). Complication rates were commensurate with published results in the literature. The most common complication was radiculitis, which appears to be more likely with foraminal/extraforaminal herniations at a rate of 20.7%, versus 2.6% for central/paracentral herniations. There were no cases that required conversion to general anesthetic or transfer to a hospital and no permanent nerve injuries in this cohort.

CONCLUSIONS

Endoscopic discectomy can safely and successfully be performed in an ambulatory surgery center under conscious sedation and local anesthetic without neuromonitoring. This procedure leads to rapid recovery in the PACU and significantly improved VAS scores postoperatively.

LEVEL OF EVIDENCE

Level IV.

Recovery Kinetics After Commonly Performed Minimally Invasive Spine Surgery Procedures

STUDY DESIGN

Single-center, multisurgeon, retrospective review.

OBJECTIVE

To evaluate the timing of return to commonly performed activities following minimally invasive spine surgery. Identify preoperative factors associated with these outcomes.

SUMMARY OF BACKGROUND DATA

Studies have reported return to activities with open techniques, but the precise timing of when patients return to these activities after minimally invasive surgery remains uncertain.

MATERIALS AND METHODS

Patients who underwent either minimally invasive lumbar laminectomy (MI-L) or minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) were included. Patient-reported outcome measures, return to drive, return to work, and discontinuation of opioids data were reviewed. Regression was conducted to identify factors associated with return to driving by 15 days, return to work by 30 days, and for discontinuing opioids by 15 days. A composite group analysis was also performed for patients who returned to all three activities by 30 days.

RESULTS

In total, 123 MI-L patients and 107 MI-TLIF patients were included. Overall, 88.8% of MI-L patients and 96.4% of MI-TLIF patients returned to driving in 11 and 18.5 days, respectively. In all, 91.9% of MI-L patients and 85.7% of MI-TLIF patients returned to work in 14 and 25 days. In all, 88.7% of MI-L patients and 92.6% of MI-TLIF patients discontinued opioids in a median of seven and 11 days. Overall, 96.2% of MI-L patients and 100% of MI-TLIF patients returned to all three activities, with a median of 27 and 31 days, respectively. Male sex [odds ratio (OR)=3.57] and preoperative 12-Item Short Form Physical Component Score (OR=1.08) are associated with return to driving by 15 days. Male sex (OR=3.23) and preoperative 12-Item Short Form Physical Component Score (OR=1.07) are associated with return to work by 30 days. Preoperative Visual Analog Scale back was associated with decreased odds of discontinuing opioids by 15 days (OR=0.84).

CONCLUSION

Most patients return to activity following MI-L and MI-TLIF. These findings serve as an important compass for preoperative counseling.

Planned Four-stage Transforaminal Full-endoscopic Lumbar Decompression under Local Anesthesia in a Patient with Severe Comorbidity

A 74-year-old man presented with symptoms of intermittent claudication. A diagnosis of lumbar spinal canal stenosis (LSS) at L3/4 and L4/5 was made based on the clinical and radiological findings. Bilateral lateral recess stenosis was detected at both these levels on magnetic resonance imaging (MRI) and on computed tomography (CT) scans obtained after myelography. Four nerve roots were impinged bilaterally at L4 and L5. The initial plan was to perform conventional laminectomy at L3/4 and L4/5 under general anesthesia. However, the neurologists pointed out that the patient had comorbidities of parkinsonism and severe carotid artery stenosis, meaning that an increase or decrease in blood pressure during general anesthesia could cause a stroke. Therefore, we changed the surgical plan to four-stage full-endoscopic ventral facetectomy at L3/4 and L4/5 bilaterally under local anesthesia. There were no surgery-related complications after any of the four operations. The patient's symptoms improved after the final operation and the modified MacNab criteria indicated a good clinical outcome. Full-endoscopic lumbar decompression surgery under local anesthesia may be effective in elderly patients who are in poor general health.

Return to the Original Work Activity Following the Full-endoscopic Lumbar Surgery under the Local Anesthesia

Transforaminal full-endoscopic spine (TF-FES) surgery is minimally invasive and can be performed under local anesthesia. Thus, it is expected that the patient can return to work (RTW) quickly. However, information in the literature regarding this is sparse. The purpose of this study is to review the timing of RTW after TF-FES surgery. This study involved 50 patients (14 women, 36 men; mean age 44.5 years, age range: 20-65 years) who underwent TF-FES surgery between January 2016 and April 2018. All the patients were active workers. Occupations varied widely (e.g., physician, nurse, helper, clerk, construction worker, chef, and schoolteacher). There were no surgery-related complications. Median time to RTW was 21 days. More than half of the patients could RTW within 21 days. In all, 12 cases (24%) could have RTW within 7 days. Occupations of 12 patients who achieved RTW within 7 days included physician, company owner, and restaurant owner, with 11 in the Light work, 1 was in the Medium work, and none in the Heavy work. All 12 had a quick RTW because their work was Light and they could not take prolonged sick leave. Prompt RTW is possible with TF-FES surgery. The biggest merit of TF-FES surgery is minimal invasiveness to the muscles of the back. Also, it can be performed under local anesthesia. Our findings reveal quicker RTW after surgery, depending on occupational type.

Feasibility of Deep Learning Algorithms for Reporting in Routine Spine Magnetic Resonance Imaging

BACKGROUND

Artificial intelligence is gaining traction in automated medical imaging analysis. Development of more accurate magnetic resonance imaging (MRI) predictors of successful clinical outcomes is necessary to better define indications for surgery, improve clinical outcomes with targeted minimally invasive and endoscopic procedures, and realize cost savings by avoiding more invasive spine care.

OBJECTIVE

To demonstrate the ability for deep learning neural network models to identify features in MRI DICOM datasets that represent varying intensities or severities of common spinal pathologies and injuries and to demonstrate the feasibility of generating automated verbal MRI reports comparable to those produced by reading radiologists.

METHODS

A 3-dimensional (3D) anatomical model of the lumbar spine was fitted to each of the patient's MRIs by a team of technicians. MRI T1, T2, sagittal, axial, and transverse reconstruction image series were used to train segmentation models by the intersection of the 3D model through these image sequences. Class definitions were extracted from the radiologist report for the central canal: (0) no disc bulge/protrusion/canal stenosis, (1) disc bulge without canal stenosis, (2) disc bulge resulting in canal stenosis, and (3) disc herniation/protrusion/extrusion resulting in canal stenosis. Both the left and right neural foramina were assessed with either (0) neural foraminal stenosis absent, or (1) neural foramina stenosis present. Reporting criteria for the pathologies at each disc level and, when available, the grading of severity were extracted, and a natural language processing model was used to generate a verbal and written report. These data were then used to train a set of very deep convolutional neural network models, optimizing for minimal binary cross-entropy for each classification.

RESULTS

The initial prediction validation of the implemented deep learning algorithm was done on 20% of the dataset, which was not used for artificial intelligence training. Of the 17,800 total disc locations for which MRI images and radiology reports were available, 14,720 were used to train the model, and 3560 were used to validate against. The convergence of validation accuracy achieved with the deep learning algorithm for the foraminal stenosis detector was 81% (sensitivity = 72.4.4%, specificity = 83.1%) after 25 complete iterations through the entire training dataset (epoch). The accuracy was 86.2% (sensitivity = 91.1%, specificity = 82.5%) for the central stenosis detector and 85.2% (sensitivity = 81.8%, specificity = 87.4%) for the disc herniation detector.

CONCLUSIONS

Deep learning algorithms may be used for routine reporting in spine MRI. There was a minimal disparity among accuracy, sensitivity, and specificity, indicating that the data were not overfitted to the training set. We concluded that variability in the training data tends to reduce overfitting and overtraining as the deep neural network models learn to focus on the common pathologies. Future studies should demonstrate the accuracy of deep neural network models and the predictive value of favorable clinical outcomes with intervention and surgery.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Feasibility, clinical teaching, and evaluation study.

Endoscopic Transforaminal Lumbar Interbody Fusion With a Single Oblique PEEK Cage and Posterior Supplemental Fixation

BACKGROUND

To demonstrate the feasibility of an endoscopically assisted minimally invasive surgery transforaminal lumbar interbody fusion (MIS-TLIF) and to study clinical outcomes with the use of a static oblique bullet-shaped cannulated poly-ether-ether-ketone (PEEK) lumbar interbody fusion cage in conjunction with platelet enriched plasma infused allograft cancellous chips and posterior supplemental fixation.

METHODS

In this retrospective study of 43 patients who underwent endoscopically assisted MIS-TLIF for spondylolisthesis (53.5%) and stenosis (46.3%), the Oswestry Disability Index, the visual analog scale (VAS) for back and leg pain, and the modified Macnab criteria were used as primary clinical outcome measures. Clinical outcomes were cross-tabulated against fusion grade using the Bridwell classification of interbody fusion.

RESULTS

The majority of patients (90.7%) had excellent (8/43; 18.6%) and good (31/43; 72.1%) Macnab outcomes. There were significant VAS back score reductions from an average preoperative values of 8.9070 to a postoperative VAS score of 3.8605, and a score of 2.7674 at final follow-up (P < .0001). The reductions in the VAS leg scores were also significant from preoperative score of 5.58 to a postoperative value of 2.16, and a final follow-up score of 1.67 (P < .0001); the Oswestry Disability Index score went from a preoperative value of 54.4 to 23.3 postoperatively and 18.5 at the final follow-up (P < .0001). The vast majority of patients (92.9%) with Bridwell grade I fusion had excellent and good Macnab outcomes (P = .027).

CONCLUSIONS

The authors recommend the use of an endoscope as an adjunct to MIS-TLIF, a minimally invasive spinal surgery technique in which many surgeons may be well versed and have a great deal of experience. Clinical outcomes with the endoscopic interbody fusion procedure with a static PEEK cage in conjunction with platelet-enriched bone allograft were favorable.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Feasibility study.

Complete resolution of chronic pain, sensory impairment, and motor dysfunction following percutaneous transforaminal endoscopic decompression in a failed back surgery syndrome patient-a case report

Failed back surgery syndrome (FBSS) is an increasingly common problem that presents a clinical challenge. Though usual treatments may improve pain for some period of time, they do not provide clinically significant recovery of subjective numbness and weakness. We describe a case of a 48-year-old female with FBSS, who presented to the pain clinic with a 29-year history of low back pain, and a 7-year history of sensory and motor dysfunction of her left lower extremity, ever since a left hemi-laminectomy. At the time of presentation, she was wheelchair bound with intense pain, 4/5 strength in her left lower extremity proximally, and 3/5 strength distally. She had previously failed conservative management including medications, physical therapy, and epidural and facet injections. During percutaneous transforaminal endoscopic decompression, her transiting left L5 nerve root was found to be encased in thick scar tissue. The entirety of this scar tissue entrapping her L5 nerve was able to be released, resulting in not only complete resolution of pain but full return of sensory and motor function; in fact, the patient was able to walk out of the post anesthesia care unit without any assistive devices. Despite long-standing damage from many years of nerve entrapment, this patient's sensory and motor function was able to be restored simply by freeing her nerve of scar tissue. Thus, if nerve entrapment in scar tissue is the cause of FBSS, transforaminal endoscopic decompression may offer not only pain relief, but also return of sensory and motor function.