Applications of the ultrasonic bone cutter in spinal surgery – our preliminary experience

Application of Piezosurgery in Revision Surgery through Posterior Approach for Infection after Percutaneous Vertebral Augmentation: Technique Note with Case Series

OBJECTIVES

Pyogenic spondylitis after vertebral augmentation (PSVA) is a severe complication and even threatens the life of patients. How to deal with infectious bone cement is a big problem for surgeons. The application of piezosurgery has advantages in removal the infectious bone cement in limb bone and spinal laminectomy, but it is rarely used in PSVA. So, the present study aimed to introduce the application of piezosurgery in revision surgery for PSVA and report the preliminary radiological and clinical results.

METHODS

The data of nine patients with PSVA who had undergone revision surgery were retrospectively reviewed between May 2017 and January 2023 in our hospital. The technique of removal of infectious bone cement and lesion by piezosurgery and the reconstruction of the spinal stability were described, and the operation time and intraoperative blood loss were recorded. Postoperatively, radiographs and computed tomography scans were reviewed to evaluate the condition of bone cement removal, control of infection, and bone fusion. Oswestry disability index (ODI) and visual analog scale (VAS) were assessed pre- and postoperatively, and clinical outcomes were assessed using Odom's criteria.

RESULTS

All patients achieved satisfactory tainted bone cement cleaning and restoration of spinal alignment. The surgical time was 258.8 ± 63.2 (160-360) min, and the intraoperative blood loss was 613.3 ± 223.8 (300-900) mL. The VAS score decreased from 7.0 (6-8) points preoperatively to 2.4 (1-4) points postoperatively. The ODI index decreased from 71% (65%-80%) preoperatively to 20% (10%-30%) postoperatively. The patient's VAS and NDI scores after operation were significantly improved compared with those before surgery (p ≤ 0.05). Odom's outcomes were good for all patients in the last follow-up, and all patients reported satisfactory results.

CONCLUSIONS

Piezosurgery can effectively remove large blocks of infectious bone cement through a posterior approach while avoiding nerve and spinal cord damage. We cautiously suggest that a one-stage posterior approach using piezosurgery is an alternative option for surgical treatment of PSVA.

Ultrasonic Bone Scalpel versus Conventional Technique for Thoracolumbar Spinal Decompression: A Prospective Randomized Controlled Trial

Objective  The purpose of the present study is to compare intraoperative blood loss, operating time, laminectomy time, hospital length of stay, and complications in thoracolumbar spinal decompression using ultrasonic bone scalpels (UBSs) with conventional procedures. Methods  Forty-two patients who underwent decompressive laminectomy and pedicular screw fusion with a surgical level of 1-5 levels between February 1, 2020, and June 30, 2022, in a single institution were evaluated for eligibility, and 11 were excluded due to a history of spinal surgery ( n  = 3), spinal tumor ( n  = 3), and spinal infection ( n  = 5). A total of 31 patients were randomly divided into the UBS group ( n =15) and the conventional group ( n =16). Intraoperative blood loss, operating time, laminectomy time, hospital length of stay, and complications were recorded. Results  Intraoperative blood loss and laminectomy time were significantly lower in the UBS group (656.0 ± 167.6 ml, 54.5 ± 27.4 minutes, respectively) than in the conventional group (936.9 ± 413.2 ml, 73.4 ± 28.1 minutes, respectively). Overall operation time, hospital length of stay, and complications were all similar between the groups. Conclusion  The UBS is a useful instrument for procedures performed near the dura mater or other neural tissue without excessive heat or mechanical injury. This device is recommended for various spinal surgeries in addition to high-speed burrs and Kerrison rongeurs.

Ultrasonic bone scalpel in spine surgery

Background

Spine surgery has always been considered technically demanding even in the hands of the most experienced surgeon on account of close proximity of vital soft tissue structures. Technical advancements over the last few decades have been crucial for the progress of this complex speciality which not only increased the surgical accuracy, but patient safety as well. Ultrasonic devices are one such innovation based on piezoelectric vibrations, patented by Fernando Bianchetti, Domenico Vercellotti, and Tomaso Vercellotti in 1988.

Methods

We did an extensive literature search on ultrasonic devices and their applications in the field of spine surgery.

Results

We present the various ultrasonic bone devices available including their physical, technologic and clinical aspects in spine surgery. We also attempt to cover the limitations and future advances of Ultrasonic bone scalpel (UBS) in particular, which would be interesting and informative for any spine surgeon who is novice in this field.

Conclusion

UBS has been found to be safe and effective in all forms of spine surgeries offering distinct advantages over conventional instruments, although limited by an inherent learning curve.

Craniectomies for dogs with skull multilobular osteochondrosarcoma using the Misonix bone scalpel: cadaveric evaluation and retrospective case series

OBJECTIVES

To evaluate the Misonix bone scalpel (MBS) for craniotomies in dogs and describe clinical findings and surgical experience in three dogs with large multilobular osteochondrosarcoma (MLO) of the skull.

STUDY DESIGN

Cadaver evaluation and retrospective case series.

ANIMALS

One canine cadaver; three client-owned dogs.

METHODS

Craniotomies of different sizes and at different locations were performed with MBS. Dural tear and bone discoloration were recorded. Clinical, imaging, and surgical findings of dogs diagnosed with MLO and where MBS was used for craniectomies were retrospectively included.

RESULTS

Cadaveric evaluation identified MBS as an efficient tool for rapid craniectomies (> 5minutes) albeit dural tears and some small foci of bone discoloration were observed. Craniectomies could be performed without complications in three dogs with MLO without dural tear or bone discoloration. .Excision was in complete in all cases. The short-term outcome was good, and the long-term outcome was fair to good.

CONCLUSION

Piezoelectric bone surgery with the Misonix bone scalpel is an alternative technology to perform craniectomies in dogs. It was not associated with complications in 3 dogs diagnosed and surgically treated for MLO. Dural tears and suspected bone necrosis can occur. Great care should be taken when using CT to establish disease free surgical osteotomy.

Analysis of the curative effect of cervical spondylotic radiculopathy with osseous foraminal stenosis using ultrasonic osteotome in anterior cervical surgery

PURPOSE

To explore the clinical efficacy and operation points of cervical radiculopathy with osseous foraminal stenosis treated with ultrasonic osteotome in anterior cervical surgery.

METHODS

From January 2018 to June 2021，a retrospective analysis of 23 patients with cervical radiculopathy with bony foraminal stenosis during this period was retrospectively analyzed. Anterior Cervical Discectomy and Fusion (ACDF) was used for all cases in this group. Intraoperative use of ultrasonic osteotome to decompress the nerve in the intervertebral foramina. The operation time, intraoperative blood loss and complication rate were recorded in this group of patients. Interbody fusion was evaluated using Brantigan criteria. The IC-PACS imaging system was used to measure the intervertebral foramen area (IFA) before and after surgery to evaluate the range of decompression. The VAS (Visual Analogue Scale, VAS) score and NDI (Neck Disability Index, NDI) score before and after surgery were recorded to evaluate the clinical efficacy.

RESULTS

All enrolled patients were followed up regularly for 1 year or more. The mean operative time was 61.5 ± 8.0 minutes. The average intraoperative blood loss was 88.3 ± 12.8 ml, and the average hospital stay was 8.1 ± 1.7d. Twenty one cases of successful fusion were followed up 1 year after operation, and the fusion rate was 91.3%. IFA expanded from 25.1 ± 4.0 mm2 before operation to 57.9 ± 3.4 mm2 at 1 year after operation, and the difference was statistically significant (P < 0.001). The VAS score and NDI score of patients 3 days after surgery, 3 months after surgery, and 1 year after surgery were significantly lower than those before surgery (P < 0.001). There was 1 case of dysphagia and 1 case of Cage subsidence after operation, and the complication rate was 8.6%.

CONCLUSION

Anterior cervical surgery using ultrasonic osteotome in the treatment of cervical radiculopathy with bony foraminal stenosis has reliable clinical efficacy and high safety, and is worthy of clinical promotion.

Clinical effect of channel assisted cervical key hole technology combined with ultrasonic bone osteotome in the treatment of single segment cervical spondylotic radiculopathy

OBJECTIVE

To explore the clinical effect and operating skills of channel assisted Cervical Key Hole technology combined with Ultrasonic Bone Osteotome (CKH-UBO) in the treatment of single segment cervical spondylotic radiculopathy (CSR).

METHODS

From June 2018 to June 2020, 14 patients diagnosed with CSR and treated with channel assisted CKH-UBO were collected. The duration of the disease, the length of the incision, the operation time, the amount of bleeding during the operation, the length of hospitalization and the complications were recorded. The Range Of Motion (ROM) and the stability of the surgical segment were recorded before and after the operation. Visual analog scale (VAS), neck disability index (NDI) and modified macnab efficacy evaluation criteria were used to evaluate the surgical efficacy.

RESULTS

The operative segments of the enrolled patients were all lower cervical vertebrae. The average incision length was 2.0 ± 0.1 cm, the operation time was 42.2 ± 5.7 min, the intraoperative bleeding volume was 32.7 ± 4.1 ml, and the hospital stay was 5.6 ± 1.2 days. There was no difference in ROM between preoperative and 3 months and 1 year after operation (P > 0.05), and all patients did not have segmental instability. The VAS scores of neck pain before surgery, 3 days after surgery, 3 months after surgery, and 1 year after surgery were 5.6 ± 1.2, 1.6 ± 0.6, 1.1 ± 0.7, 0.6 ± 0.5, and the VAS scores of upper limb pain were 6.2 ± 1.2, 1.7 ± 0.7, 1.1 ± 0.6, 0.6 ± 0.5. The NDI scores of upper limb pain before surgery, 3 days after surgery, 3 months after surgery, and 1 year after surgery were 36.7 ± 3.5, 9.8 ± 2.4, and 3.9 ± 1.5, 1.8 ± 1.0, The VAS and NDI scores at all follow-up time points after operation were significantly lower than those before operation (P < 0.001). One year after operation, the curative effect was evaluated according to the modified macnab evaluation standard, and the excellent and good rate was 100%. The complication rate was 6.25%.

CONCLUSION

Channel assisted CKH-UBO for single segment CSR has the advantages of short operation time, reliable clinical effect, high safety and low complication rate, which is worthy of clinical promotion.

Percutaneous endoscopic interlaminar discectomy for L5-S1 calcified lumbar disc herniation: A retrospective study

Background

Calcified lumbar disc herniation (CLDH) is considered to be a special type of lumbar disc herniation (LDH). Percutaneous endoscopic interlaminar discectomy (PEID), with safety and efficacy, has been proved to be a minimally invasive surgery for LDH. However, there are few studies on PEID in the treatment of CLDH at the L5-S1 level. This study aimed to analyze the clinical efficacy of PEID for L5-S1 CLDH.

Methods

From August 2016 to April 2020, we retrospectively analyzed 28 consecutive patients (17 males and 11 females) with L5-S1 CLDH treated with PEID at our institution. All the patients were monitored for more than 1 year postoperatively. The demographic characteristics, surgical results, and clinical outcomes estimated by the visual analog scale (VAS) for leg pain, the Oswestry disability index (ODI), and the modified MacNab criteria were collected.

Results

All patients successfully underwent PEID. The mean operative time and intraoperative blood loss were 65.36 ± 5.26 min and 13.21 ± 4.35 ml, respectively. The VAS for leg pain and ODI scores improved remarkably from 7.54 ± 0.96 to 1.50 ± 0.51 (P &lt; 0.05) and from 69.29 ± 9.91 to 17.43 ± 3.69 (P &lt; 0.05) a year after operation, respectively. According to the modified MacNab criteria of the last follow-up, the excellent and good rates are 92.86%. Two of the patients had complications, one had nerve root injury and the other had postoperative dysesthesia.

Conclusions

PEID achieved good clinical outcomes in the treatment of L5-S1 CLDH, and it was a safe and effective minimally invasive surgery for L5-S1 CLDH.

A longitudinal-torsional mode ultrasonic needle for deep penetration into bone

This work presents a longitudinal-torsional (L-T) composite mode ultrasonic needle device for deep bone penetration. The L-T needle is a geometrically modified version of an L-mode needle whose efficacy as a prototype ultrasonic bone biopsy device has been previously demonstrated by the authors. Finite element analysis (FEA) aided in the design of the L-T needle, with the aim of maximising the achievable torsional displacement while matching the longitudinal displacement achieved by the L-mode needle. Experimental modal analysis (EMA) of the fabricated ultrasonic device was used to identify the modal parameters and validate the FEA model. Harmonic analysis then provided an insight into how the inherent nonlinearities of the high-power transducer are affected by incorporating the geometrical features that degenerate the L mode into an L-T mode. High power characterisation shows that the longitudinal displacement amplitude of the L-T mode needle is larger than that of the L-mode needle. Comparative penetration tests in fresh Wistar rat skull were evaluated by investigating cell death and cell survival. The region of statistically significant cell death was small for both devices, with the combined axial and shear motion of the L-T device causing increased osteocyte necrosis within this region. Nevertheless, the results suggest a promising environment for post-operative healing. It is shown how this technology offers a potential technique for a surgical approach to the petrous apex, an application that requires a deep penetration into bone.

Safety and Effectiveness of Modified Expansive Open-door Laminoplasty Using a Ultrasonic Bone Scalpel Compared With a High-speed Drill

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

Our study aimed to compare the effectiveness and safety of ultrasonic bone scalpel (UBS) and high-speed drill (HSD) in modified expansive open-door laminoplasty.

SUMMARY OF BACKGROUND DATA

The traditional methods of decompression mostly use HSD and laminectomy forceps to lift the lamina. As a new type of bone cutting instrument, UBS has the advantages of good tissue selectivity, bone cutting accuracy, good hemostasis, cold cutting, and easy operation, leading to its popular use in surgery.

MATERIALS AND METHODS

Forty-two patients who underwent modified expansive open-door laminoplasty for multilevel cervical spondylotic myelopathy were included in this study. They were divided into HSD and UBS groups (n=18 and 24, respectively). Data on demographics, operation duration, blood loss, postoperative drainage, extubation time, length of stay, cost of hospitalization, and complications were collected and compared. Modified Japanese Orthopedic Association score, visual analog scale, Neck Disability Index, and axial symptoms were also recorded and analyzed.

RESULTS

The blood loss in the UBS group was 255.4±217.5 mL, which was lower than that in the HSD group (490.6±389.4 mL, P=0.030). The cost of hospitalization was similar between the 2 groups. The operative time and postoperative drainage did not significantly differ (P>0.05). The modified Japanese Orthopedic Association score, visual analog scale score, and Neck Disability Index score after surgery were better than those before surgery (P<0.05), but no significant difference existed between the 2 groups in each period (P>0.05). No significant difference existed in the incidence of axial symptoms and other complications (P>0.05).

CONCLUSION

The application of the UBS to modified open-door laminoplasty resulted in a safe and effective decompression effect and reduced blood loss without increasing cost benefit.

Surgical Resection of a Parietal Osteoma in a Domestic Ferret Using Advanced Neurosurgical Techniques

A 3.5 yr old male neutered ferret presented with progressive enlargement of a right dorsocaudal skull mass that had occurred over 18 mo. Computed tomography imaging revealed a large (2.4 × 2.7 cm), well-defined, pedunculated osseous mass arising from the right parietal bone. Cytology was inconclusive, and surgical biopsy was consistent with an osteoma. Further enlargement of the mass occurred over the next 3 mo, at which time surgical intervention was pursued. The patient recovered well, despite the persistence of a bony defect at the former mass site, and no mass regrowth occurred in the 14 mo following the surgical resection. This is one of only two reports in the literature to document the surgical removal of an osteoma in a ferret, and this is the sole case in which a custom apparatus was fabricated for head stabilization, a multiaxis adjustable surgical table was used to improve access to the surgical site, and an ultrasonic scalpel was used for the mass resection.

Incorporating direct metal laser sintered complex shaped Ti-6Al-4V components in ultrasonic surgical devices

Additive manufacturing (AM) offers opportunities to design more complex shapes of the Ti-6Al-4V parts commonly used in high-power ultrasonic surgical devices. Moreover, AM metal printing will be essential to the realization of miniature ultrasonic devices incorporating internal structures for minimally invasive surgical procedures. However, it is necessary first to verify the ultrasonic vibrational behavior of devices with three-dimensional (3D) printed metal parts. Therefore, two different prototype devices are fabricated, with CNC machined mill annealed and 3D printed Ti-6Al-4V parts. Both devices, an ultrasonic bone needle and a miniature ultrasonic scalpel, incorporate complex geometries but can be manufactured using subtractive processes so that the comparative effects of 3D printing on the vibrational performance of the devices can be elucidated. The metal microstructure is investigated through measurements of longitudinal and shear acoustic velocities and scanning electron microscopy. Comparisons of electrical impedance, frequency and modal responses, and the vibrational response at increasing levels of excitation enable evaluation of the efficacy of incorporating 3D printed Ti-6Al-4V parts. Results show that whereas the bone needle exhibited comparable vibrational responses for the measurement techniques used, the 3D printed bone cutting device exhibited a more dense modal response and developed cracks at high excitation levels.

Robot-assisted laminectomy in spinal surgery: a systematic review

This study aimed to summarize the current progress in the field of robot-assisted laminectomy in spinal surgery. A systematic search of the Institute of Electrical and Electronics Engineers (IEEE) Xplore, PubMed, Embase, Web of science, The Cochrane Library, Wanfang Data, China National Knowledge Infrastructure (CNKI), and Chinese Biomedicine Literature Database (CBM-SinoMed) was performed for papers related to robotic-assisted laminectomy. A total of 27 articles were selected for inclusion in our study. Among the articles, 10 robotic system, 2 bone cutting strategies, 6 state recognition strategies were founded. The most commonly adopted type of robot system was the Nathoo A type (6/10). Bone cutting strategies were mainly formulated based on force information and medical image information, and state recognition was based on a variety of factors, including force, sound, vibration, medical images, current or a combination of parameters. Early research on robot-assisted laminectomy did not reflect good continuity, and the studies mainly focused on the type of robotic system. In recent years, more researchers have chosen the Nathoo A as the robot system type, and the focus of research has gradually shifted to laminectomy path planning and safety control strategies, such as state recognition. Although these studies have been able to perform laminectomy without penetrating the inner cortex of the lamina, most experiments have been performed in vitro, and clinical application is still untested.

Diagnostic value of dysregulated microribonucleic acids in the placenta and circulating exosomes in gestational diabetes mellitus

Aims/Introduction

Differentially expressed microribonucleic acids (miRNAs) in the placenta and circulating exosomes are of diagnostic value for gestational diabetes mellitus (GDM). In a cross‐sectional study, we identified miRNAs expressed both in the placenta and circulating exosomes of pregnant women with GDM, and estimated their diagnostic value.

Materials and Methods

Next‐generation sequencing was used to identify miRNAs in the placenta that were differentially expressed between GDM and normal glucose tolerance pregnancies. Quantitative polymerase chain reaction was used to validate the identified targets. Western blot and transmission electron microscopy were used to validate exosomes. Univariate logistic regression analysis was used to establish diagnostic models based on miRNAs expression, and the diagnostic value was estimated using the receiver operator characteristic curve.

Results

We identified 157 dysregulated miRNAs in the placental tissue obtained from GDM pregnancies. Of these, miRNA‐125b was downregulated (P < 0.001), whereas miRNA‐144 was upregulated (P < 0.001). The patterns of these two miRNAs remained the same in circulating exosomes from GDM pregnancies (all P < 0.001). miRNA‐144 levels in the circulating exosomes negatively correlated with body mass index both before pregnancy (P = 0.018) and before delivery (P = 0.039), and positively correlated with blood glucose at 1 h, estimated using the oral glucose tolerance test (P = 0.044). The area under curve for the established diagnostic model was 0.898, which was higher than blood glucose levels at 0 h.

Conclusions

These findings suggest that miRNA‐125b and miRNA‐144 are consistently dysregulated in circulating exosomes and the placenta from GDM pregnancies, and are of excellent diagnostic value for GDM.

Resection of Spinal Meningioma Using Ultrasonic BoneScalpel Microshaver: Cases, Technique, and Review of the Literature

BACKGROUND

Meningiomas of the spinal canal comprise up to 40% of all spinal tumors. The standard management of these tumors is gross total resection. The outcome and extent of resection depends on location, size, patient's neurologic status, and experience of the surgeon. Heavily calcified spinal meningiomas often pose a challenge for achieving gross total resection without cord injury.

OBJECTIVE

To report our experience with the BoneScalpel Micro-shaver to resect heavily calcified areas of spinal meningiomas adherent to the spinal cord without significant cord manipulation, achieving gross total resection and outstanding clinical results.

METHODS

Seventy-nine and 82-yr-old females presented with progressive leg weakness, paresthesias, and gait instability. Magnetic resonance imaging of the thoracic spine showed a homogenous enhancing intradural extramedullary mass with mass effect on the spinal cord. Midline bilateral laminectomy was performed, and the dura was open in midline. The lateral portion of the tumor away from the spinal cord was resected with Cavitron Ultrasonic Surgical Aspirator while the BoneScalpel Micro-shaver (power level 5 and 30% irrigation) was brought into the field for the calcified portion of the tumor adherent to the spinal cord.

RESULTS

Gross total resection was achieved for both cases. At the 2-wk postoperative visit, both patients reported complete recovery of their leg weakness with significant improvement in paresthesias and ataxia.

CONCLUSION

The ultrasonic osteotome equipped with a microhook tip appears to be a safe surgical instrument allowing for effective resection of spinal meningiomas or other heavily calcified spinal masses not easily removed by usual surgical instrumentation.

Primary lumbar decompression using ultrasonic bone curette compared to conventional technique

PURPOSE

The ultrasonic bone curette (Bone Scalpel) is a novel technique in neurosurgery for bony dissection. This study aimed to evaluate its use against conventional techniques for primary lumbar decompression.

MATERIALS AND METHODS

This study was a retrospective cohort comparison, using Spine Tango Registry data. All patients undergoing a primary procedure for lumbar decompression secondary to degenerative disease during a 2-year period (2014-2016) were identified, split into age and gender matched cohorts utilising either bone scalpel or conventional techniques intra-operatively.

RESULTS

Ninety-three patients were identified within each cohort, which did not differ significantly in terms of age, gender, BMI, number of operative vertebral levels or seniority of the principal surgeon. The incidence of intra-operative blood loss >100 ml was significantly reduced within the bone scalpel cohort (16.1% bone scalpel, 34.4% conventional, p = 0.04). There was no difference in the incidence of iatrogenic dural breach (9.7% bone scalpel, 16.1% conventional, p = 0.27). There was no significant difference in pre-operative Core Outcomes Measures Index (COMI) between the cohorts (7.91 bone scalpel, 8.02 conventional, p = 0.67) and both cohorts demonstrated a significant reduction in mean COMI at 24 months (bone scalpel p = 0.004, conventional p = <0.001). No difference in mean COMI existed between either cohort at any point across the 24-month post-operative period (p = 0.18).

CONCLUSIONS

The use of ultrasonic bone curette for primary lumbar decompression is associated with reduced intra-operative blood loss compared to conventional techniques, alongside a comparable safety profile and equivalent patient reported outcomes.

The Effectiveness and Safety of Ultrasonic Bone Scalpel Versus Conventional Method in Cervical Laminectomy: A Retrospective Study of 311 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The aim of this study was to compare the results of cervical laminectomy (CL) performed with ultrasonic bone scalpel (UBS) or conventional method (CM).

METHOD

This study comprised 311 CL performed by a single surgeon between January 2004 and December 2017. Group A (GpA) comprised 124 cases of CL performed using UBS, while Group B (GpB) comprised 187 cases of CL performed using CM. These 2 groups were compared in terms of demographic characteristics of patients, duration of surgery, estimated blood loss, and surgical complications.

RESULTS

GpA included 112 males and 12 females, mean age being 61.18 years. GpB comprised 166 males and 21 females, mean age being 62.04 years. Mean duration of surgery, estimated blood loss, and length of hospital stay was 65.52/70.87 minutes, 90.24/98.40 mL, and 4.80/4.87 days in GpA and GpB, respectively. Six patients were reported to have dural injuries in each group. In GpA, 2 cases of C5 palsy and 1 nerve root injury was observed, while in GpB, 3 cases of C5 palsy and no nerve root injury was reported. One patient had developed transient neurological deterioration postsurgery in GpA as against 11 patients in GpB.

CONCLUSION

Neurological complications observed in CM leads to intensive care unit admission, additional morbidity, and additional expenditure, whereas UBS provides a safe, rapid, and effective means of performing CL, thereby decreasing the rate of surgical complications and postoperative morbidity.

Efficacy and Safety Analysis of Ultrasonic Bone Curette in the Treatment of Thoracic Spinal Stenosis

Objective

To investigate the efficacy and safety of ultrasonic bone curette in treating thoracic spinal stenosis.

Methods

A total of 30 patients of thoracic spinal stenosis who underwent posterior thoracic decompression in the hospital from December 2015 to 2017 were enrolled. Of these, 18 patients (group A) underwent posterior thoracic decompression using ultrasonic bone curette; and 12 patients underwent the treatment using a high‐speed drill (group B). The time of laminectomy, amount of intraoperative blood loss, presence or absence of cerebrospinal fluid leakage, and nerve root injury were recorded. All patients underwent X‐ray, computed tomography with three‐dimensional reconstruction, and magnetic resonance imaging before and after surgery. The Frankel classification and the Japanese Orthopaedic Association (JOA) scores were used to assess the neurological function and neurological recovery in patients. The measured data were statistically processed and analyzed using SPSS21.0 software, and the measurement data were expressed as mean ± SD.

Results

In groups A and B, the average time for single‐segment laminectomy was 3.3 ± 1.2 min and 6.0 ± 1.8 min and the mean bleeding volume was 105.5 ± 43.3 mL and 177.4 ± 54.7 mL, respectively, with a statistically significant difference between the groups. The difference in JOA scores before and after surgery in groups A and B was statistically significant. No significant difference was found between the groups, in group A, the improvement rate of nerve function at the last follow‐up was 71% and in group B, the improvement rate at the last follow‐up was 70%. In group A, at last follow‐up, two patients had Frankel grade B injury, one had grade C injury, seven had grade D injury, and eight had grade E injury. In group B, at last follow‐up, one patient had Frankel grade B injury, one had grade C injury, five had grade D injury, and five had grade E injury. The Frankel classification of both groups A and B significantly improved. Four patients experienced cerebrospinal fluid leakage in group A and five in group B, with no significant difference between the groups. There was no nerve root injury in both groups, and no complications, such as pulmonary infection and urinary tract infection, occurred after operation.

Conclusions

With the use of ultrasonic bone curette in posterior thoracic decompression, the decompression surgery could be completed relatively safely and quickly. It effectively reduced the amount of intraoperative blood loss.

Removal of calcified lumbar disc herniation with endoscopic-matched ultrasonic osteotome - Our preliminary experience

Objective: To evaluate the clinical efficacy, practicability, and safety of an ultrasonic osteotome for percutaneous transforaminal endoscopic discectomy (PTED) in patients with calcified lumbar disc herniation (CLDH).Methods: A total of 25 CLDH patients who underwent PTED at our department between December 2017 and August 2018 were analyzed retrospectively. Post-operative lumbar spine CT was used to evaluate residual calcification. Efficacy was evaluated by pre- and post-operative with the pain visual analog scale (VAS), Oswestry disability index (ODI), and the Modified MacNab Scale; the incidence of intra- and postoperative complications was also analyzed.Results: All procedures were successfully completed and none of the patients was lost to follow-up. Postoperative CT verified the successful removal of calcified protrusions. VAS and ODI scores improved significantly after surgery. Based on the Modified MacNab scale, >90% patients achieved good or excellent outcomes. There were no complications such as dural tear and infection. Seven patients had varying degrees of postoperative dysesthesia. One patient experienced recurrence of herniation within 1 week after operation; successful recovery was achieved after repeat PTED.Conclusions: Use of this ultrasonic osteotome for PTED facilitated effective removal of calcified disc protrusion, relieved nerve compression, and protected the adjacent neurovascular tissues. The instrument may help expand the indications for endoscopic surgery and avoid open surgery for some CLDH patients.

3D Real-Time Image-Guided Navigation Spine Corpectomy with Ultrasonic Bone Cutter: Technical Note

BACKGROUND

Surgical interventions for congenital scoliosis are challenging for spine surgeons. The coordination of 3-dimensional (3D), real-time, image-guided navigation with an ultrasonic bone cutter allows surgeons to localize the affected area of the spine accurately and remove the lesion without damaging soft tissue structures. The goal of this technical paper is to report a previously undescribed method of hemivertebrectomy that combines 3D, real-time, image-guided navigation and an ultrasonic bone cutter. We highlight the feasibility and safety of this method in spinal surgery.

METHODS

Three patients with congenital scoliosis were treated with this technique. We present three illustrative cases comprising hemivertebrectomies for congenital scoliosis. Intraoperative photos demonstrating the technique are also provided.

RESULTS

All surgeries were completed without complications. The hemivertebrae were completely removed, and marked correction of congenital scoliosis was noted.

CONCLUSIONS

We believe that the combination of 3D, real-time image navigation and an ultrasonic bone cutter improves hemivertebrectomy by increasing accuracy and avoiding dura laceration, major organ damage, or potential vessel damage.

The Efficacy of Ultrasonic Bone Scalpel for Unilateral Cervical Open-Door Laminoplasty: A Randomized Controlled Trial

BACKGROUND

In cervical open-door laminoplasty for cervical myelopathy, a high-speed rotatory drill and rongeurs are used to make unicortical troughs and bicortical openings in the laminae. The lamina is reflected at the trough to enlarge the spinal canal, followed by bone healing on the hinge side to stabilize laminoplasty. The ultrasonic bone scalpel (UBS) has been used due to theoretical advantages including a better hinge union rate, less soft tissue trauma, less neurological injury, and shorter operative time.

OBJECTIVE

To assess the superiority of UBS for hinge union compared to the drill through randomized controlled trial.

METHODS

In 190 randomly allocated cervical myelopathy patients, the trough and opening at the lamina were made using either the drill (n = 95) or UBS (n = 95) during 2015 to 2018. The primary outcome was the hinge union rate on 6-mo postoperative computed tomography. Secondary outcomes included the hinge union rate at 12 mo, the operative time, intraoperative/postoperative bleeding, neurological injury, complications, and clinical outcomes over a 24-mo follow-up.

RESULTS

Hinge union in all laminae was achieved in 60.0% (drill) and 43.9% (UBS) of patients at 6 mo (intention-to-treat analysis; P = .02; odds ratio, 2.1) and in 91.9% (drill) and 86.5% (UBS) at 12 mo. Dural injury only occurred in the drill group (2.1%), and the UBS group showed significantly less intraoperative bleeding (P < .01). The other secondary outcomes did not differ between groups.

CONCLUSION

The hinge union rate was inferior in the UBS group at 6 mo postoperatively, but UBS was efficacious in reducing dural injuries and bleeding.

Effects of Combined Use of Ultrasonic Bone Scalpel and Hemostatic Matrix on Perioperative Blood Loss and Surgical Duration in Degenerative Thoracolumbar Spine Surgery

How to decrease intraoperative bleeding, shorten surgical time, and increase safety in spinal surgery is an important issue. Ultrasonic bone removers and FloSeal have been proven to increase safety, reduce the surgical duration, and decrease intraoperative bleeding in skull base surgery. Therefore, we aimed to compare the surgical duration, blood loss, and complications during spinal surgery with or without the use of FloSeal and an ultrasonic bone scalpel. Therefore, we retrospectively reviewed 293 patients who underwent thoracolumbar spinal surgery with decompression and instrumented fusion performed by a single surgeon. We divided these patients into three groups, including nonuse of FloSeal nor a bone scalpel (group A), use of FloSeal only (group B), and use of FloSeal and a bone scalpel (group C) intraoperatively after pairing in terms of age, sex, and surgical level. The surgical duration, blood loss, and occurrence of complications were all recorded. The mean surgical duration in group A was 160 mins, in group B it was 167 mins, and in group C it was 134 mins. The mean blood loss was 700 ml in group A, 682 ml in group B, and 383 ml in group C. Six patients sustained intraoperative dura injuries in total, 3 in group A, 2 in group B, and 1 in group C. No postoperative neurologic defects or occurrences of hematoma were recorded. According to our results, we concluded that combined use of FloSeal and bone scalpels is recommended during primary thoracolumbar spinal surgery to reduce the intraoperative blood loss and shorten the surgical duration.

Three-dimensional navigation (O-arm) versus fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone curette: A retrospective comparative study

Three-dimensional intraoperative navigation (O-arm) has been used for many years in spinal surgeries and has significantly improved its precision and safety. This retrospective study compared the efficacy and safety of spinal cord decompression surgeries performed with O-arm navigation and fluoroscopy. The clinical data of 56 patients with thoracic spinal stenosis treated from March 2015 to April 2017 were retrospectively analyzed. Spinal decompression was performed with O-arm navigation and ultrasonic bone curette in 29 patients, and with ultrasonic bone curette and fluoroscopy in 27 patients. Patients were followed-up at postoperative 1 month, 3 months, and the last clinic visit. The neurologic functions were assessed using the Japanese Orthopaedic Association (JOA) Back Pain Evaluation Questionnaire. The accuracy of screw placement was examined using three-dimensional computed tomography (CT) on postoperative day 5. There was no significant difference in the incidences of intraoperative dural tear, nerve root injury, and spinal cord injury between the two groups. The two groups showed no significant difference in postoperative JOA scores (P > .05). The O-arm navigation group had significantly higher screw placement accuracy than the fluoroscopy group (P < .05). O-arm navigation is superior to fluoroscopy in the treatment of thoracic spinal stenosis with ultrasonic bone curette in terms of screw placement accuracy. However, the two surgical modes have similar rates of intraoperative complications and postoperative neurologic functions.

Ultrasonic bone scalpel: utility in cervical corpectomy. A technical note

PURPOSE

Anterior cervical corpectomy and fusion (ACCF) is a technically challenging surgery. Use of conventional instruments like high-speed burr and kerrison rongeurs is associated with high complication rates such as increased blood loss and incidental durotomy. Use of ultrasonic bone scalpel (UBS) in cervical corpectomy helps to minimize such adverse events.

METHODS

We performed a retrospective study based on the data of 101 consecutive patients who underwent cervical corpectomies with UBS for different cervical spine pathologies from December 2014 to December 2016. Total duration of surgery, time taken for corpectomy, estimated blood loss, and incidental durotomies were noted.

RESULTS

Total surgical time was 30-80 min (59.36 ± 13.21 min) for single-level ACCF and 60-120 min (92.74 ± 21.04 min) for double-level ACCF. Time taken for single-level corpectomy was 2 min 11  ± 10 s and 3 min 41  ± 20 s for double-level corpectomy. Estimated blood loss ranged from 20-150 ml (52.07 ± 29.86 ml) in single level and 40-200 ml (73.22 ± 41.64 ml) in double level. Four (3.96%) inadvertent dural tears were noted, two during single-level corpectomy and other two during double-level corpectomy.

CONCLUSIONS

Use of UBS is likely to provide a safe, rapid, and effective surgery when compared to conventional rongeurs and high-speed burr. The advantages such as lower blood loss and lower intra-operative incidental dural tears were noted with the use of UBS.

[The application of ultrasonic bone curette in laminoplasty of spinal canal after resection of intraspinal tumors]

Objective

To explore the practicability and safety of ultrasonic bone curette in the laminoplasty of spinal canal after resection of intraspinal tumors.

Methods

The clinical data of 17 patients with thoracolumbar intraspinal tumors treated with ultrasonic bone curette after resection of intraspinal tumors between December 2015 and April 2017 were retrospectively analyzed. All patients were male, aged 42-73 years with an average of 57.4 years. The disease duration was 2-47 months with an average of 21.1 months. Among them, there were 4 cases of thoracic intrathoracic tumors (T ₁₀ in 1, T ₁₂ in 3) and 13 cases of lumbar intrathoracic tumors (L ₁ in 5, L ₂ in 4, L ₃ in 2, and L ₄ in 2). Postoperative pathological diagnosis showed that 8 cases were schwannoma, 4 cases were meningioma, 2 cases were neurofibroma, 2 cases were dermoid cyst, and 1 case was ependymoma. Spinal nerve function was evaluated preoperatively according to Frankel classification criteria, with 2 cases of grade B, 7 cases of grade C, and 8 cases of grade D. During the operation, the time of single segmental vertebral canal posterior wall incision, the overall operation time, intraoperative blood loss, intraoperative dural injury, and cerebrospinal fluid leakage, spinal cord and nerve root injury were recorded. At 3-6 months after operation, the tumor and bone healing were observed according to MRI and CT three-dimensional reconstruction, and the spinal nerve function was evaluated by Frankel classification.

Results

The time of ultrasonic osteotomy for the posterior wall of a single segmental vertebral canal was 3.4-5.7 minutes, with an average of 4.1 minutes. The overall operation time was 135-182 minutes, with an average of 157.3 minutes. The intraoperative blood loss was 300-500 mL, with an average of 342.6 mL. There was no accidental dural injury, and cerebrospinal fluid leakage, nerve root injury, or spinal cord injury. The incision healed by first intention after operation. All the 17 patients were followed up 9-18 months, with an average of 12.7 months. MRI examination showed no tumor recurrence, and CT three-dimensional reconstruction showed good bone healing in all patients. During the follow-up, there was no loosening or rupture of the internal fixator and there was no re-compression of the spinal cord. At last follow-up, according to Frankel classification, there were 1 case as grade B, 5 cases as grade C, 7 cases as grade D, and 4 cases as grade E.

Conclusion

The application of ultrasonic bone curette in laminoplasty of spinal canal after resection of intraspinal tumors can preserve the integrity of the bone ligament structure of posterior column, maintain the volume of vertebral canal, and has high safety, practicability, and good postoperative effectiveness.

Use of image-guided bone scalpel for resection of spine tumors: technical note

In the literature, the use of navigation for spine tumor surgery has largely centered on implant placement. We describe the cases of two patients with spinal tumors on whom we utilized our resection technique of registering an ultrasonic bone scalpel (UBS) to a navigation system. In both cases, we achieved a satisfactory tumor resection with negative margins and excellent neurologic outcomes. We feel that using the navigation-registered UBS is a valuable tool to increase the operator's ability to achieve desired resections while minimizing the neurologic deficits and operative morbidity associated with these challenging surgical cases.

Suitability of Administrative Databases for Durotomy Incidence Assessment: Comparison to the Incidence Associated With Bone-Removal Devices, Calculated Using a Systemic Literature Review and Clinical Data

Background

Durotomy is a major complication of spinal surgery, potentially leading to additional clinical complications, longer hospitalization, and increased costs. A reference durotomy incidence rate is useful for the evaluation of the safety of different surgical aspects. However, the literature offers a wide range of incidence rates, complicating this comparison. Theoretically, a reference incidence value can be extracted from administrative databases, containing a large number of procedures. However, it is suspected that these databases suffer from underreporting of complications. This study aims to evaluate durotomy incidence using several large-scale databases and to assess the ability to use it as a reference by comparison to durotomy incidences directly associated with 4 bone removal devices, including the commonly used high-speed drill.

Methods

Durotomy overall incidence was estimated from several administrative databases using different methods in order to achieve minimal and maximal estimations. Durotomy incidences for 3 bone removal devices were derived using literature meta-analysis, and the incidence for the fourth device was calculated using clinical data.

Results

The incidence range of durotomy according to the databases was 2.8-3.5%. The calculated incidence of durotomy for the studied devices was 0.4-2.91%. The highest rate, 2.91%, is associated with the commonly used high-speed drill combined with Kerrison Rongeur and bone punches. Since bone-removal devices are just one of the possible causes of dural tears, the general incidence is expected to be higher than the incidence associated with the devices, yet even the maximal estimation, 3.5%, was only slightly higher, suggesting that the speculation of underreporting of dural tears to these databases is probably true, as also supported by the mostly higher incidences reported in the literature.

Conclusions

Hospital administrative databases seem to show a lower-than-reasonable incidence of durotomy, suggesting possible underreporting. Researchers should therefore use this tool with caution. Reduction of the absolute durotomy incidence by approximately 2.5% can be achieved by improving the safety of bone-removal devices.

Microendoscopic Surgery with an Ultrasonic Bone Curette for a Patient with Intraforaminal Stenosis of the Lumbar Spine Due to an Ossification Lesion: A Technical Case Report

Introduction:

We present a rare case with radiculopathy resulting from intraforaminal stenosis of the lumbar spine due to an ossification lesion. Microendoscopic surgery was chosen because of two strong advantages. One was the ease to reach the nerve foramen and ossification lesion and the other was the non-invasiveness at the posterior supporting structures of the spine. Moreover, an ultrasonic bone curette developed for microendoscopic spine surgery was applied. This is the first detailed case report of microendoscopic surgery using an ultrasonic bone curette for a patient with radiculopathy due to intraforaminal free ossification.

Case Report:

A 49-year-old woman born in Japan had complained of severe left leg pain for over 7 months in spite of conservative treatment including selective nerve root block. There was no lumbago, muscle weakness, or loss of sensation in her leg. Plain radiography revealed spondylolytic spondylolisthesis classified as Grade II at L4-L5, but there was no instability on dynamic assessment. Computed tomography (CT) showed a free ossification lesion in the foramen at L4-L5. Considering a diagnosis of left L4 radiculopathy due to the free ossification, ossification resection and nerve decompression were performed with posterior spinal microendoscopic surgery using an ultrasonic bone curette. A tubular retractor was introduced into the extraforaminal zone using Wiltse approach. After a part of the ossification lesion and the nerve root were exposed, an ultrasonic bone curette was applied to remove the ossification mass. After decompression, the nerve root was found to be relaxed. The surgical time was 83 min, and blood loss was 5 g. According to the Japanese Orthopedic Association scoring system, her score improved from 21/29 preoperatively to 29/29 postoperatively, and the full score was maintained at the final observation. Post-operative CT revealed the absence of an ossification lesion.

Conclusions:

For a rare case with radiculopathy resulting from intraforaminal stenosis of the lumbar spine due to an ossification lesion, microendoscopic surgery with an ultrasonic bone curette was very effective. The use of ultrasonic bone curette is easy and safe in microendoscopic surgery and it helps achieve less invasiveness and ideal decompression, without injuring the nerve root.

Use of Ultrasonic Device in Cervical and Thoracic Laminectomy: a Retrospective Comparative Study and Technical Note

Multilevel severe compressive myelopathy is a challenging disorder for the surgeons, the aim of this study is to assess the efficacy and safety of a newly designed ultrasonic burr as an assistant tool to the ultrasonic scalpel in laminectomy for this disease. This is a retrospective comparative study, the included subjects were patients who received cervical and thoracic laminectomy using ultrasonic device (LUD, n = 9, 10 surgeries) and controls with the high-speed burr (LHB, n = 16). Fifteen patients (60.0%) showed severe cord occupancy and the average number of laminae operated was 3.5. Ultrasonic devices caused less blood loss (P = 0.02) and quicker operative time per level (P < 0.001) than LHB, and was associated with more operated laminae (P = 0.04). Preoperative JOA scores (P = 0.51), improvement rate (P = 0.47), and dural injury (P = 0.51) were not related to LUD. Our experience indicates ultrasonic devices are safe and effective for laminectomy treating multilevel and severe compressive myelopathy, the instrument could be used with ease especially for cases with ossified posterior longitudinal ligament and ossification of the ligamentum flavum, proper utility of the instrument is crucial to prevent complications.

Technical Aspects on the Use of Ultrasonic Bone Shaver in Spine Surgery: Experience in 307 Patients

Aim. We discuss technical points, the safety, and efficacy of ultrasonic bone shaver in various spinal surgeries within our own series. Methods. Between June 2010 and January 2014, 307 patients with various spinal diseases were operated on with the use of an ultrasonic bone curette with microhook shaver (UBShaver). Patients' data were recorded and analyzed retrospectively. The technique for the use of the device is described for each spine surgery procedure. Results. Among the 307 patients, 33 (10.7%) cases had cervical disorder, 17 (5.5%) thoracic disorder, 3 (0.9%) foramen magnum disorder, and 254 (82.7%) lumbar disorders. Various surgical techniques were performed either assisted or alone by UBShaver. The duration of the operations and the need for blood replacement were relatively low. The one-year follow-up with Neck Disability Index (NDI) and Oswestry Disability Index (ODI) scores were improved. We had 5 cases of dural tears (1.6%) in patients with lumbar spinal disease. No neurological deficit was found in any patients. Conclusion. We recommend this device as an assistant tool in various spine surgeries and as a primary tool in foraminotomies. It is a safe device in spine surgery with very low complication rate.

Long-term outcomes of ultrasonic scalpel treatment in giant cell tumor of long bones

Giant cell tumors (GCTs) are generally benign, locally aggressive lesions with the potential to metastasize and a tendency of local recurrence. The present study aimed to investigate the advantages and long-term outcomes of application of ultrasonic scalpel in the treatment of GCT of long bones. This study retrospectively analyzed 32 cases of GCT of long bones, including 24 males and eight females. The age range was from 8 to 34 years old (mean age, 23.5 years old). The 32 cases were randomly divided into an observation group (n=10) and a control group (n=22). Patients in the observation group received curettage by ultrasonic scalpel combined with local methotrexate gelfoam adjuvant treatment, and then the cavity was filled with allograft and/or homograft bone. Patients in the control group eceived curettage by local methotrexate gelfoam adjuvant treatment and bone grafting. No local recurrence or pulmonary metastases were observed among patients in the observation group, however, six patients in the control group exhibited recurrence following surgery, although none of the patients demonstrated distant metastasis (P<0.05). Additionally, all 10 patients showed good bone knitting and rehabilitation without deformity and functional issues. The segmental bone graft was perfectly incorporated without obvious immune rejection, collapse and fracture. Curettage by ultrasonic scalpel with local methotrexate gelfoam adjuvant treatment and filling the site by allograft and/or homograft bone showed satisfactory results.

Blood Loss Reduction During Surgical Correction of Adolescent Idiopathic Scoliosis Utilizing an Ultrasonic Bone Scalpel

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVES

To evaluate blood loss associated with posterior spinal fusion in adolescent idiopathic scoliosis patients performed with and without the use of an ultrasonic bone scalpel (UBS).

SUMMARY OF BACKGROUND INFORMATION

After using an ultrasonic-powered bone-cutting device with recent Food and Drug Administration approval for use in the spine, the authors perceived a reduction in bone bleeding associated with the cut boney surfaces.

METHODS

The first 20 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion using the UBS by a single surgeon were compared with 2 control groups: 1) the 20 most recent prior cases of the same surgeon before beginning use of the bone scalpel; and 2) 20 cases of the same surgeon before using the bone scalpel matched based on Cobb angle magnitudes. Both cases and controls had Ponte-type posterior apical releases; none had an anterior procedure. Patient demographic and surgical data were analyzed using analysis of variance (p < .05).

RESULTS

Preoperatively, the UBS group was similar to both control groups in terms of primary and secondary curve magnitudes, number of levels fused, number of levels with Ponte release, antifibrinolytic use, and patient age (p > .05). The UBS group had significantly less estimated blood loss (EBL) (550 ± 359 mL), Cell Saver blood transfused (94 ± 146 mL), and EBL per level fused (48 ± 30 mL) than the most recent controls (EBL: 799 ± 376 mL; Cell Saver: 184 ± 122 mL; EBL/level fused: 72 ± 28 mL) and Cobb-matched controls (EBL: 886 ± 383 mL; Cell Saver: 198 ± 115 mL; EBL/level fused: 78 ± 30 mL) (p < .05). Surgical times were equivalent and there were no dural tears in any group.

CONCLUSIONS

The use of an ultrasonic bone scalpel to perform the bone cuts associated with facetectomies and apical Ponte-type posterior releases resulted in significantly less bleeding compared with cuts made with standard osteotomes and rongeurs, limiting overall blood loss by 30% to 40%.