Is Asia truly a hotspot of contemporary minimally invasive and endoscopic spinal surgery?

Transforaminal Contrast Injection Before Computed Tomography-Guided Lateral Endoscopic Lumbar Diskectomy Improves Visualization of Exiting Nerve Root

BACKGROUND AND OBJECTIVES

Percutaneous endoscopic lumbar diskectomy (PELD) is an effective, minimally invasive method for removal of lateral lumbar disk herniations. This minimally invasive technique can be applied with high success and lead to faster recovery than traditional methods. Unfortunately, adoption of these techniques in the United States has been slow. A significant barrier to using this technique is often an inability to completely visualize relevant anatomy and increased operative times. In this article, we describe a technique using computed tomography (CT) guidance in conjunction with a neurogram to perform a PELD. We detail the steps in the technique and its advantages to the surgeon performing it.

METHODS

After a patient is placed supine on a table, a transforaminal injection of contrast is performed under fluoroscopic guidance. Then, after sterilizing and draping in a normal fashion, an intraoperative CT scan is taken with a reference frame in place. During the procedure, this allows for the CT guidance to have the exiting nerve root clearly outlined.

RESULTS

This procedure was successfully performed in a single patient, allowing greater visualization of the exiting nerve root during a difficult revision PELD case. No complications were experienced.

CONCLUSION

A novel technique using a neurogram with CT guidance during a PELD was used to assist with identification of anatomy and decompression of the exiting nerve root. This technique was used without complications.

Screw Insertional Torque Measurement in Spine Surgery: Correlation With Bone Mineral Density and Hounsfield Unit

OBJECTIVE

Achieving successful fusion during spine surgery is dependent on rigid pedicle screw fixation. To assess fixation strength, the insertional torque can be measured during intraoperative screw fixation. This study aimed to explore the technical feasibility of measuring the insertional torque of a pedicle screw, while investigating its relationship with bone density.

METHODS

Thoraco-lumbar screw fixation fusion surgery was performed on 53 patients (mean age, 65.5 ± 9.8 years). The insertional torque of 284 screws was measured at the point passing through the pedicle using a calibrated torque wrench, with a specially designed connector to the spine screw system. The Hounsfield units (HU) value was determined by assessing the trabecular portion of the index vertebral body on sagittal computed tomography images. We analyzed the relationship between the measured insertional torque and the following bone strength parameters: bone mineral density (BMD) and HU of the vertebral body.

RESULTS

The mean insertion torque was 105.55 ± 58.08 N∙cm and T-score value (BMD) was -1.14 ± 1.49. Mean HU value was 136.37 ± 57.59. Screw insertion torque was positively correlated with BMD and HU in whole patients. However, in cases of osteopenia, all variables showed very weak correlations with insertional torque. In patients with osteoporosis, there was no statistically significant correlation between BMD and torque strength; HU showed a significant correlation.

CONCLUSION

The insertional torque of screw fixation significantly correlated with bone density (BMD and HU). HU measurements showed greater clinical significance than did BMD values in patients with osteoporosis.

Australian Spine Surgeon's Perspectives on Endoscopic Spine Surgery: An In-depth Analysis

OBJECTIVE

Endoscopic spine surgery (ESS) is a minimally invasive approach with reduced tissue trauma, shorter hospital stays, and faster recovery times. It employs advanced endoscopic instruments and imaging technologies to address a wide range of spinal pathologies with minimal disruption to surrounding tissues. As ESS continues to evolve, this article aims to gather insights into the opinions and perspectives of the key stakeholders involved, and highlight strategies to improve implementation.

METHODS

A cross-sectional survey was distributed to collect data on Australian spine surgeons' perspectives of ESS. The survey questionnaire was distributed electronically to a diverse group of spine surgeons who are members of the Spine Society of Australia.

RESULTS

Of responders, 46.8% were already integrating ESS into practice, or had the sufficient training to commence ESS. A further 29.8% were contemplating introduction of ESS techniques, while just under one quarter of respondents (23.4%) were not interested in implementing minimally invasive techniques. Primary motivators for implementation included skill development and improved patient outcomes. Primary barriers included lack of training opportunities, length of time to develop competency and lack of current supporting evidence.

CONCLUSION

The study contributes to the existing body of knowledge on ESS by providing a comprehensive analysis of surgeon opinions and experiences. The results highlight the growing interest in endoscopic techniques, while recognizing the challenges that need to be addressed to make this more widely utilised and available. The findings can guide future research, training programs, clinical practice and ultimately improve health and financial outcomes to patients and the wider health system.

Background, techniques, applications, current trends, and future directions of minimally invasive endoscopic spine surgery: A review of literature

Across many of the surgical specialties, the use of minimally invasive techniques that utilize indirect visualization has been increasingly replacing traditional techniques which utilize direct visualization. Arthroscopic surgery of the appendicular skeleton has evolved dramatically and become an integral part of musculoskeletal surgery over the last several decades, allowing surgeons to achieve similar or better outcomes, while reducing cost and recovery time. However, to date, the axial skeleton, with its close proximity to critical neural and vascular structures, has not adopted endoscopic techniques at as rapid of a rate. Over the past decade, increased patient demand for less invasive spine surgery combined with surgeon desire to meet these demands has driven significant evolution and innovation in endoscopic spine surgery. In addition, there has been an enormous advancement in technologies that assist in navigation and automation that help surgeons circumvent limitations of direct visualization inherent to less invasive techniques. There are currently a multitude of endoscopic techniques and approaches that can be utilized in the treatment of spine disorders, many of which are evolving rapidly. Here we present a review of the field of endoscopic spine surgery, including the background, techniques, applications, current trends, and future directions, to help providers gain a better understanding of this growing modality in spine surgery.

Unilateral Modified Posterior Lumbar Interbody Fusion Combined With Contralateral Lamina Fenestration Treating Severe Lumbarspinal Stenosis: A Retrospective Clinical Study

Study design: Retrospective study. Objectives: The traditional PLIF is routinely utilized in severe lumbar spinal stenosis to relief the nerve compression. Nevertheless, the removal of posterior tension-band structure and the denervation and atrophy of the paraspinal muscle affect the clinical efficacy. Therefore, unilateral modified PLIF combined with contralateral fenestration was performed to overcome above-mentioned drawbacks. Methods: 32 modified PLIF and 33 traditional PLIF cases were retrospectively included. Operation time, length of stay (LOS) and blood loss were recorded. VAS of low back pain and leg pain, ODI and Sf-36 score including physical function and body pain were assessed. Fusion rate, lumbar lordosis (LL), intervertebral angle (IVA) and intervertebral height index (IHI) were evaluated radiologically. Results: Modified group possessed less blood loss, shorter operation time and less LOS. Compared with traditional group, the VAS of back pain was lower at 6 months postoperatively (P < .05) and the ODI score was lower at 3 months postoperatively (P < .05) in modified group. Modified group exhibited better physical function 3 months postoperatively and lower body pain 6 months postoperatively in Sf-36 score (P < .05). No statistic difference in LL, IVA, IHI and fusion rate were observed between both groups. Conclusions: Our modified PLIF combining with contralateral fenestration procedure exhibited particular advantages in comparison to traditional PLIF. The preservation of posterior tension-band structure facilitates to less low back pain, low complication rate and early functional recovery.

Effectiveness of Multimodal Chiropractic Care Featuring Spinal Manipulation for Persistent Spinal Pain Syndrome Following Lumbar Spine Surgery: Retrospective Chart Review of 31 Adults in Hong Kong

BACKGROUND The term "persistent spinal pain syndrome type 2" (PSPS-2) has been proposed by the International Association for the Study of Pain to replace the term "failed back surgery syndrome". This retrospective study aimed to evaluate effectiveness of multimodal care featuring chiropractic spinal manipulation (CSMT) in 31 adults in Hong Kong with PSPS-2. MATERIAL AND METHODS We identified new adult patients with PSPS-2 receiving CSMT from 2016 to 2018. Demographic and clinical data and baseline/follow-up numeric pain rating scale (NPRS) and Oswestry Disability Index (ODI) scores were extracted. Multiple linear regression was used to examine posttreatment NPRS and ODI reduction, with clinical variables as covariates. RESULTS Of 6589 patients with low back pain, 31 met criteria (mean age 52.2±13.7 years). Surgeries included laminectomy (81%), discectomy (13%), and fusion (6%). Mean baseline NRPS was 6.6±1.9; ODI was 43.8±15.1%. Patients received CSMT (100%), drop technique (81%), passive modalities (65%), soft tissue manipulation (13%), flexion-distraction (13%), and mechanical traction (13%). Mean posttreatment NPRS was 0.6±1.0; ODI was 2.4±3.3%. All patients had a minimum clinically important difference for NPRS (≥2/10) and ODI (≥30%). One year after treatment, 48% maintained improvement, 42% experienced recurrence; in 10%, follow-up was unavailable. Regression analysis identified younger age, shorter symptom duration, and greater baseline NPRS as predictors of NPRS reduction; and greater baseline ODI as a predictor of ODI reduction (all P<0.05). CONCLUSIONS Patients with PSPS-2 improved with multimodal care featuring CSMT, which was more effective in patients with younger age, shorter symptom duration, and higher baseline pain or disability levels.

Demographic Predictors of Treatment and Complications for Adult Spinal Deformity: An Analysis of the National Inpatient Sample

PURPOSE

To examine the role of demographics on surgical management and inpatient complications in patients with spinal deformity between 2010 and 2014 via retrospective analysis.

METHODS

Data were obtained from the National Inpatient Sample (NIS). International Classification of Diseases 9th revision codes were used to identify patients with a primary diagnosis of adult spinal deformity (ASD). Multivariable Poisson regression analyses were used to determine whether any individual demographic variables were predictive of surgical management, surgical complexity, postoperative complications and revision operations.

RESULTS

17,433 patients were identified for analysis. Surgical intervention was performed for 94.5% of patients with a primary diagnosis of ASD. Patients at urban teaching hospitals were the most likely to receive surgery (OR= 2.13; 95% CI 1.51-2.95; p < 0.001) relative to rural patients. Female patients were the majority undergoing surgery and were more likely to receive a complication or require a revision when controlling for surgical complexity. Medicare patients were the least likely to undergo surgery and the most likely to receive complex fusion when undergoing an operation. Medicare patients were the least likely to experience complications (OR=0.89; 95% CI 0.80-0.98; p = 0.022) after adjusting for surgical complexity. With regards to race and ethnicity, Hispanics had a decreased likelihood of receiving a revision surgery.

CONCLUSION

There were substantial differences in rates of surgical management, postoperative complications, and revisions among individuals of different demographics including sex, insurance status, ethnicity and hospital teaching status. Further research evaluating the effect of demographics in spine surgery is warranted to fully understand their influence on patient outcomes.

Microendoscopic Decompression for Lumbar Disc Herniations: An Analysis of Short and Long Term Patient Reported Outcome Measures

INTRODUCTION

Endoscopic spine surgery is increasingly being used, and techniques, platforms, and applications are rapidly evolving. Despite substantial enthusiasm surrounding these techniques, there is a dearth of longer term patient-reported clinical outcomes. Within the United States in particular, there are yet to be reported large cohort studies with a notable follow-up. We sought to characterize the clinical outcomes of patients undergoing microendoscopic decompression (MED) for lumbar disk herniations.

METHODS

The records of patients with symptomatic lumbar disk herniations who underwent MED from May 2018 to February 2021 within a single practice were reviewed. Paired outcomes scores were evaluated using Patient-Reported Outcomes Measurement Information System parameters. Basic perioperative data including length of stay, estimated blood loss, mean opioid use, complication rate, and rate of revision were tabulated. Paired sample Student t-tests and paired Wilcoxon sign tests were used to compare normally distributed and nonparametric data, respectively.

RESULTS

Thirty-five patients with complete paired patient-reported outcome measures data and a minimum 6-month follow-up were included; 65.7% of the patients were male with a mean age of 47.1 years (SE 1.8). The mean follow-up was 590.6 days (SE 47.7). In total, 34 of the 35 patients (97.1%) were discharged on the day of their procedure. The estimated blood loss was <25 mL for each procedure. The mean opioid use after extubation and before discharge was 10.4 morphine milligram equivalents. At the 2-week follow-up, there were notable improvements in pain metrics and global health components. At the final follow-up, nearly all parameters showed notable improvement that exceeded minimally clinical important difference values. For most parameters, preoperative values outside of the "normal" range were within normal limits on postoperative testing.

DISCUSSION

MED resulted in sustained notable improvement in patient-reported outcome measures that exceeded minimally clinical important difference values at the average follow-up approximating 2 years. These findings substantiate the utility of this technique and additional investment in endoscopic spine technology.

DATA AVAILABILITY

Not publicly available; available upon request.

Spinal endoscopy: evidence, techniques, global trends, and future projections

The utilization of indirect visualization during procedures has been increasingly replacing traditional forms of direct visualization across many different surgical specialties. The adoption of arthroscopy, using small cameras placed inside joints, has transformed musculoskeletal care over the last several decades, allowing surgeons to provide the same anatomic solutions with less tissue dissection, resulting in lower requirements for inpatient care, reduced costs, and expedited recovery.  For a variety of reasons, spine surgery has lagged behind other specialties in the adoption of indirect visualization.  Nonetheless, patient demand for less invasive spine procedures and surgeon drive to provide these solutions and improve care quality has driven global adoption of spinal endoscopy.  There are numerous endoscopic platforms and techniques currently utilized, and these systems are rapidly evolving.  Additionally, the variance in technology and health system incentives across the globe has generated tremendous regional heterogeneity in the utilization of spinal endoscopic procedures.  We present a consolidated review, including the background, evidence, techniques, and trends in spinal endoscopy, so that clinicians can gain a deeper understanding of this rapidly evolving domain of spinal healthcare.

Dural Tears During Lumbar Spinal Endoscopy: Surgeon Skill, Training, Incidence, Risk Factors, and Management

BACKGROUND

Incidental dural tears during lumbar endoscopy can be challenging to manage. There is limited literature on their appropriate management, risk factors, and the clinical consequences of this typically uncommon complication.

MATERIALS AND METHODS

To improve the statistical power of studying durotomy with lumbar endoscopy, we performed a retrospective survey study among endoscopic spine surgeons by email and chat groups on social media networks, including WhatsApp and WeChat. Descriptive and correlative statistics were done on the surgeons' recorded responses to multiple-choice questions. Surgeons were asked about their clinical experience with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, the decompression instruments they use, and incidental durotomy incidence with routine lumbar endoscopy.

RESULTS

There were 689 dural tears in 64 470 lumbar endoscopies, resulting in an incidental durotomy incidence of 1.07%. Seventy percent of the durotomies were reported by 20.4% of the surgeons. Eliminating these 19 outlier surgeons yielded an adjusted durotomy rate of 0.32. Endoscopic stenosis decompression (54.8%; P < .0001), rather than endoscopic discectomy (44.1%; 41/93), was significantly more associated with durotomy. Medium-sized dural tears (1-10 mm) were the most common (52.2%; 48/93). Small pinhole durotomies (less than 1 mm) were the second most common type (46.7%; 43/93). Rootlet herniations were seen by 46.2% (43/93) of responding surgeons. The posterior dural sac injury during the interlaminar approach (57%; 53/93) occurred more frequently than traversing nerve-root injuries (31.2%) or anterior dural sac (23.7%; 22/93). Exiting nerve-root injuries (10.8%;10/93) were less common. Over half of surgeons did not attempt any repair or closure (52.2%; 47/90). Forty percent (36/90) used sealants. Only 7.8% (7/90) of surgeons attempted an endoscopic repair or sutures (11.1%; 10/90). DuralSeal was the most commonly used brand of commercially available sealant used (42.7%; 35/82). However, other sealants such as Tisseal (15.9%; 13/82), Evicel (2.4%2/82), and additional no-brand sealants (38; 32/82) were also used. Nearly half of the patients (48.3%; 43/89) were treated with 24-48 hours of bed rest. The majority of participating surgeons (64%; 57/89) reported that the long-term outcome was unaffected. Only 18% of surgeons reported having seen the development of a postoperative cerebrospinal fluid (CSF)-fistula (18%;16/89). However, the absolute incidence of CSF fistula was only 0.025% (16/64 470). Severe radiculopathy with dysesthesia; sensory loss; and motor weakness in association with an incidental durotomy were reported by 12.4% (11/89), 3.4% (3/89), and 2.2% (2/89) of surgeons, respectively.

CONCLUSIONS

The incidence of dural tears with lumbar endoscopy is about 1%. The incidence of durotomy is higher with the use of power drills and the interlaminar approach. Stenosis decompression that typically requires the more aggressive use of these power instruments has a slightly higher incidence of dural tears than does endoscopic decompression for a herniated disc. Most dural tears are small and can be successfully managed with mechanical compression with Gelfoam and sealants. Two-thirds of patients with incidental dural tears had an entirely uneventful postoperative course. The remaining one-third of patients may develop a persistent CSF leak, radiculopathy with dysesthesia, sensory loss, or motor function loss. Patients should be educated preoperatively and reassured.

LEVEL OF EVIDENCE

3.

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.