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Van Isseldyk F, Padilla-Lichtenberger F, Guiroy A, Asghar J, Quillo-Olvera J, Quillo-Reséndiz J, Hagel V. Endoscopic Treatment of Lumbar Degenerative Disc Disease: A Narrative Review of Full-Endoscopic and Unilateral Biportal Endoscopic Spine Surgery. World Neurosurg 2024; 188:e93-e107. [PMID: 38754549 DOI: 10.1016/j.wneu.2024.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Degenerative lumbar spine disease is the leading cause of disability and work absenteeism worldwide. Lumbar microdiscectomy became the standard treatment for herniated discs and stenotic disease. With the evolution of different techniques, endoscopic spinal surgery emerged to minimize the surgical footprint while providing at least non-inferior results. Currently, two different types of endoscopic spine procedures are dominating the surgical scenario: "Full-Endoscopic" (FE) and Unilateral Biportal Endoscopic" (UBE) Spine Surgery. The aim of this study is to describe and analyze their indications, their technical characteristicswithitsadvantagesanddisadvantagesofbothtechniquesandtheirfuture trends. METHODS We performed a narrative review of the most relevant articles published up to August 2023 through a Pub Med search. The search terms " FE Spine Surgery" and " UBE Spine Surgery" were used. The articles selected, were independently reviewed by 3 authors and 55 full text articles were reviewed. RESULTS The FE and UBE Spine Surgery techniques were described. The FE technique is performed with a monoportal access under constant saline irrigation. The FE comprises the transforaminal and the interlaminar approaches, and the indication depends from the pathology to treat, and still remains controversial. UBE can approach also the spine from a posterior, postero lateral,and para spinal route. It uses two different ports addressed to a target with continuous irrigation. The process of establishing these two portals is called triangulation. CONCLUSIONS FE and UBE spine surgery have demonstrated outcomes comparable to open surgery, minimizing complications and surgical footprint.
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Affiliation(s)
- Facundo Van Isseldyk
- Hospital Privado de Rosario, Universidad de Rosario, Rosario City, Santa Fe, Argentina
| | | | - Alfredo Guiroy
- Elite Spine Health and Wellness, Mendoza City, Mendoza, Argentina
| | - Jahangir Asghar
- Elite Spine Health and Wellness, Mendoza City, Mendoza, Argentina
| | - Javier Quillo-Olvera
- Hospital Angeles Centro Sur, Neurosurgery Unit, Spine Center, Queretaro City, Mexico
| | | | - Vincent Hagel
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Spine Center, Asklepios Hospital Lindau, Lindau, Germany
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Tabarestani TQ, Drossopoulos PN, Huang CC, Bartlett AM, Paturu MR, Shaffrey CI, Chi JH, Ray WZ, Goodwin CR, Amrhein TJ, Abd-El-Barr MM. The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology. World Neurosurg 2024; 188:e247-e258. [PMID: 38777315 DOI: 10.1016/j.wneu.2024.05.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space. METHODS In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded. RESULTS A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, body mass index 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (P < 0.001). CONCLUSIONS Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.
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Affiliation(s)
- Troy Q Tabarestani
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Peter N Drossopoulos
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Chuan-Ching Huang
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Alyssa M Bartlett
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mounica R Paturu
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | | | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, North Carolina, USA
| | - Wilson Z Ray
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Timothy J Amrhein
- Department of Radiology, Duke University Hospital, Durham, North Carolina, USA
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Schievink WI, Maya MM, Tay ASMS, Taché RB, Prasad RS, Wadhwa V, Nuño M. Lateral Spinal CSF Leaks in Patients with Spontaneous Intracranial Hypotension: Radiologic-Anatomic Study of Different Variants. AJNR Am J Neuroradiol 2024; 45:951-956. [PMID: 38871369 DOI: 10.3174/ajnr.a8261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/15/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND AND PURPOSE Spinal CSF leaks cause spontaneous intracranial hypotension. Several types of leaks have been identified, and one of these types is the lateral dural tear. Performing myelography with the patient in the decubitus position allows precise characterization of these leaks. The purpose of the current study was to describe the different variants of spontaneous lateral CSF leaks. MATERIALS AND METHODS This retrospective cohort study included a consecutive group of patients with spontaneous intracranial hypotension and lateral CSF leaks who underwent digital subtraction myelography in the decubitus position and underwent surgery to repair the CSF leak between July 2018 and June 2023. RESULTS The mean age of the 53 patients (37 women and 16 men) was 35.5 years. Three different variants of lateral CSF leak could be identified. Forty-nine patients (92.5%) had a lateral dural tear associated with the nerve root sleeve. The dural tear was at the axilla of the nerve root sleeve in 36 patients (67.9%) and at the shoulder in 13 patients (24.5%). Four patients (7.5%) had a lateral dural tear at the level of the pedicle that was not associated with the nerve root sleeve. Findings on digital subtraction myelography were concordant with intraoperative findings in all patients. An extradural CSF collection was seen in all patients with a lateral dural tear associated with the nerve root sleeve but in only 2 of the 4 patients with the pedicular variant of a lateral dural tear. CONCLUSIONS We identified 3 variants of spontaneous lateral dural tears. Most lateral dural tears are associated with extradural CSF collections and arise from either the axilla (67.9%) or the shoulder (24.5%) of the nerve root sleeve. Lateral dural tears at the level of the pedicle (7.5%) not associated with the nerve root sleeve are uncommon and may require specialized imaging for their detection.
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Affiliation(s)
- Wouter I Schievink
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Marcel M Maya
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
- Department of Imaging (M.M.M., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Angelique Sao-Mai S Tay
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Rachelle B Taché
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Ravi S Prasad
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
- Department of Imaging (M.M.M., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Vikram Wadhwa
- From the Department of Neurosurgery (W.I.S., M.M.M., A.S.-M., S.T., R.B.T., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
- Department of Imaging (M.M.M., R.S.P., V.W.), Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuño
- Department of Public Health Sciences (M.N.), University of California, Davis, California
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Drossopoulos PN, Ononogbu-uche FC, Tabarestani TQ, Huang CC, Paturu M, Bardeesi A, Ray WZ, Shaffrey CI, Goodwin CR, Erickson M, Chi JH, Abd-El-Barr MM. Evolution of the Transforaminal Lumbar Interbody Fusion (TLIF): From Open to Percutaneous to Patient-Specific. J Clin Med 2024; 13:2271. [PMID: 38673544 PMCID: PMC11051479 DOI: 10.3390/jcm13082271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
The transforaminal lumbar interbody fusion (TLIF) has seen significant evolution since its early inception, reflecting advancements in surgical techniques, patient safety, and outcomes. Originally described as an improvement over the posterior lumbar interbody fusion (PLIF), the TLIF began as an open surgical procedure, that notably reduced the need for the extensive neural retractation that hindered the PLIF. In line with the broader practice of surgery, trending toward minimally invasive access, the TLIF was followed by the development of the minimally invasive TLIF (MIS-TLIF), a technique that further decreased tissue trauma and postoperative complications. Subsequent advancements, including Trans-Kambin's Triangle TLIF (percLIF) and transfacet LIF, have continued to refine surgical access, minimize surgical footprint, and reduce the risk of injury to the patient. The latest evolution, as we will describe it, the patient-specific TLIF, is a culmination of the aforementioned adaptations and incorporates advanced imaging and segmentation technologies into perioperative planning, allowing surgeons to tailor approaches based on individual patient anatomy and pathology. These developments signify a shift towards more precise methods in spine surgery. The ongoing evolution of the TLIF technique illustrates the dynamic nature of surgery and emphasizes the need for continued adaptation and refinement.
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Affiliation(s)
- Peter N. Drossopoulos
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - Favour C. Ononogbu-uche
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - Troy Q. Tabarestani
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - Chuan-Ching Huang
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - Mounica Paturu
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - Anas Bardeesi
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - Wilson Z. Ray
- Department of Neurological Surgery, Washington University, St Louis, MO 63110, USA
| | - Christopher I. Shaffrey
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - C. Rory Goodwin
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
| | - Melissa Erickson
- Division of Spine, Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - John H. Chi
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Muhammad M. Abd-El-Barr
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC 27710, USA (T.Q.T.); (M.M.A.-E.-B.)
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Tabarestani TQ, Salven DS, Sykes DAW, Bardeesi AM, Bartlett AM, Wang TY, Paturu MR, Dibble CF, Shaffrey CI, Ray WZ, Chi JH, Wiggins WF, Abd-El-Barr MM. Using Novel Segmentation Technology to Define Safe Corridors for Minimally Invasive Posterior Lumbar Interbody Fusion. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-01010. [PMID: 38149852 DOI: 10.1227/ons.0000000000001046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/15/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There has been a rise in minimally invasive methods to access the intervertebral disk space posteriorly given their decreased tissue destruction, lower blood loss, and earlier return to work. Two such options include the percutaneous lumbar interbody fusion through the Kambin triangle and the endoscopic transfacet approach. However, without accurate preoperative visualization, these approaches carry risks of damaging surrounding structures, especially the nerve roots. Using novel segmentation technology, our goal was to analyze the anatomic borders and relative sizes of the safe triangle, trans-Kambin, and the transfacet corridors to assist surgeons in planning a safe approach and determining cannula diameters. METHODS The areas of the safe triangle, Kambin, and transfacet corridors were measured using commercially available software (BrainLab, Munich, Germany). For each approach, the exiting nerve root, traversing nerve roots, theca, disk, and vertebrae were manually segmented on 3-dimensional T2-SPACE magnetic resonance imaging using a region-growing algorithm. The triangles' borders were delineated ensuring no overlap between the area and the nerves. RESULTS A total of 11 patients (65.4 ± 12.5 years, 33.3% female) were retrospectively reviewed. The Kambin, safe, and transfacet corridors were measured bilaterally at the operative level. The mean area (124.1 ± 19.7 mm2 vs 83.0 ± 11.7 mm2 vs 49.5 ± 11.4 mm2) and maximum permissible cannula diameter (9.9 ± 0.7 mm vs 6.8 ± 0.5 mm vs 6.05 ± 0.7 mm) for the transfacet triangles were significantly larger than Kambin and the traditional safe triangles, respectively (P < .001). CONCLUSION We identified, in 3-dimensional, the borders for the transfacet corridor: the traversing nerve root extending inferiorly until the caudal pedicle, the theca medially, and the exiting nerve root superiorly. These results illustrate the utility of preoperatively segmenting anatomic landmarks, specifically the nerve roots, to help guide decision-making when selecting the optimal operative approach.
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Affiliation(s)
- Troy Q Tabarestani
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David S Salven
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David A W Sykes
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anas M Bardeesi
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Alyssa M Bartlett
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Timothy Y Wang
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Mounica R Paturu
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Christopher F Dibble
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | | | - Wilson Z Ray
- Department of Neurosurgery, Washington University, St. Louis, Missouri, USA
| | - John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter F Wiggins
- Department of Radiology, Duke University Hospital, Durham, North Carolina, USA
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Chen C, Liu C, Wu Z, Su J. How I do it? Uniportal full-endoscopic transforaminal lumbar interbody fusion with a complete reduction for L5 isthmic grade 2 spondylolisthesis. Acta Neurochir (Wien) 2023; 165:3969-3974. [PMID: 37946000 DOI: 10.1007/s00701-023-05886-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Endoscopic transforaminal lumbar interbody fusion (endo-TLIF) with bilateral percutaneous pedicle screw fixation is an emerging option for low-grade spondylolisthesis. However, uniportal full endo-TLIF with a complete reduction for high-grade spondylolisthesis is challenging. METHODS We attempted uniportal endo-TLIF for L5 isthmic grade 2 spondylolisthesis with a complete reduction, and have described the procedures, with a discussion of the indications, limitations, potential complications, and ways to avoid complications. CONCLUSION We had successfully completed a perfect reduction of L5 isthmic grade 2 spondylolisthesis via uniportal endo-TLIF with bilateral pedicle screw fixation. Uniportal endo-TLIF is suitable for isthmic grade 2 spondylolisthesis.
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Affiliation(s)
- Changxian Chen
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China
| | - Chunhua Liu
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China.
| | - Zhiqiang Wu
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China
| | - Jinzhi Su
- Department of Spinal Surgery, Quanzhou Orthopedic-Traumatological Hospital, Quanzhou, Fujian Province, China
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Wu W, Yu R, Hao H, Yang K, Jiao G, Liu H. Visible trephine-based foraminoplasty in PTED leads to asymmetrical stress changes and instability in the surgical and adjacent segments: a finite element analysis. J Orthop Surg Res 2023; 18:431. [PMID: 37312161 DOI: 10.1186/s13018-023-03916-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023] Open
Abstract
This study aimed to construct a multi-segment lumbar finite element model (FEM) of PTED surgery to analyze the changes in stress and ROM after visible trephine-based foraminoplasty. The CT scans of a 35-year-old healthy male were used to develop a multi-segment lumbar FEM with Mimic, Geomagic Studio, Hypermesh and MSC.Patran. Different foraminoplasty was performed on the model, and these were grouped into normal group (A), the ventral resection group (B), the apex resection group (C), the ventral + apex + isthmus resection group (D), and the SAP + isthmus + lateral recess resection group (E). A vertical load of 500N and a torque of 10N·M were applied to the upper surface of the L3 vertebral body to simulate the biomechanical characteristics under the motion of flexion, extension, lateral bending, and rotation. The von Mises stress maps of the intervertebral f, vertebral body, facet joints, and the ROM of the L3-S1 intervertebral disk were calculated and analyzed. The changes of peak stress on the vertebral body for each group were not significant in the same motion state. Significant stress differences were observed in the L4/5 intervertebral disks, while no obvious stress changes were observed for the L3/4 and L5/S1 intervertebral disks. The stress of the L3/4 and L5/S1 facet joints decreased after L4/5 foraminoplasty, while the stress of L4/5 facet joints displayed an overall increasing trend. Significant asymmetrical stress changes of bilateral facet joints were observed in all three segments, particularly during bilateral rotation movements. The ROM of L3-S1 gradually increased from Group A to Group E, especially during flexion, left lateral bending, and right rotation, with the highest elevation observed for the L45 ROM. Our FEM indicated that enlarged resection and exposure of the articular surface could lead to significant asymmetrical stress changes in the bilateral facet joints and ROM instability of the surgical and adjacent segments. These findings suggested that unnecessary and excessive resection should be avoided in PTED to reduce the incidence of low back pain and the risk of postsurgical degeneration.
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Affiliation(s)
- Wenliang Wu
- Department of Spine Surgery, Qilu Hospital of Shandong University, Wenhuaxi Road No.107, Jinan, 250012, People's Republic of China
- Department of Physician Training, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Ruixuan Yu
- Department of Spine Surgery, Qilu Hospital of Shandong University, Wenhuaxi Road No.107, Jinan, 250012, People's Republic of China
| | - Hongkai Hao
- Department of Spine Surgery, Qilu Hospital of Shandong University, Wenhuaxi Road No.107, Jinan, 250012, People's Republic of China
| | - Kaiyun Yang
- Institute of Stomatology, Qilu Hospital of Shandong University, Jinan, 250012, People's Republic of China
| | - Guangjun Jiao
- Department of Spine Surgery, Qilu Hospital of Shandong University, Wenhuaxi Road No.107, Jinan, 250012, People's Republic of China
| | - Haichun Liu
- Department of Spine Surgery, Qilu Hospital of Shandong University, Wenhuaxi Road No.107, Jinan, 250012, People's Republic of China.
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Greil ME, Ogunlade JI, Bergquist J, Williams JR, Kashlan ON, Hofstetter CP. Full-endoscopic trans-pars interarticularis approach for far lateral lumbar discectomy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023:10.1007/s00586-023-07698-1. [PMID: 37166550 DOI: 10.1007/s00586-023-07698-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Surgical management of far lateral disc herniations remains challenging. Current transforaminal full-endoscopic approaches require non-visualized docking in the Kambin's triangle and have been associated with significant risk of inadvertent nerve injury. We develop a full-endoscopic approach based on reliable bony landmarks allowing for visualization of the exiting nerve root prior to the far lateral discectomy. METHODS The surgical details of a full-endoscopic trans-pars interarticularis approach for far lateral discectomy are described. These descriptions include high quality intraoperative images and important surgical pearls. A small patient cohort is presented to demonstrate feasibility and safety of the procedure. RESULTS We demonstrate the feasibility of this approach in 14 patients with a mean age of 59.5 ± 14.7 years. At a mean follow up of 21.9 ± 6.8 months, improvement of the visual analogue scale (VAS) for leg pain was 4.3 ± 1.0 resulting in minimally clinically important difference in 78.6% of the patients. The mean improvement in VAS for the back pain was 2.6 ± 0.8 and for Oswestry disability index (ODI) was 20.6 ± 5.3. Nuances of the trans-pars surgical techniques are presented in a patient with a right-sided L4-5 far lateral disc herniation. Preoperative imaging studies, steps of the surgical progression, and intraoperative views are described in detail. CONCLUSION Using the pars interarticularis as the bony target area allows for safe visualized access to the extraforaminal compartment of the exiting nerve root. This novel surgical technique has the potential benefit of decreasing inadvertent neural injury and subsequent postoperative dysesthesias.
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Affiliation(s)
- Madeline E Greil
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - John I Ogunlade
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Julia Bergquist
- Stritch School of Medicine, Loyola University of Chicago, Maywood, IL, USA
| | - John R Williams
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA
| | - Osama N Kashlan
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christoph P Hofstetter
- Harborview Medical Center, Department of Neurological Surgery, University of Washington, 325 Ninth AVE, Seattle, WA, 98104, USA.
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Yamada K, Nagahama K, Abe Y, Hyugaji Y, Ukeba D, Endo T, Ohnishi T, Ura K, Sudo H, Iwasaki N, Takahata M. Evaluation of Surgical Indications for Full Endoscopic Discectomy at Lumbosacral Disc Levels Using Three-Dimensional Magnetic Resonance/Computed Tomography Fusion Images Created with Artificial Intelligence. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050860. [PMID: 37241092 DOI: 10.3390/medicina59050860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Although full endoscopic lumbar discectomy with the transforaminal approach (FED-TF) is a minimally invasive spinal surgery for lumbar disc herniation, the lumbosacral levels present anatomical challenges when performing FED-TF surgery due to the presence of the iliac bone. Materials and Methods: In this study, we simulated whether FED-TF surgery could be safely performed on a total of 52 consecutive cases with L5-S1 or L5-L6 disc herniation using fused three-dimensional (3D) images of the lumbar nerve root on magnetic resonance imaging (MRI) created with artificial intelligence and of the lumbosacral spine and iliac on computed tomography (CT) images. Results: Thirteen of the fifty-two cases were deemed operable according to simulated FED-TF surgery without foraminoplasty using the 3D MRI/CT fusion images. All 13 cases underwent FED-TF surgery without neurological complications, and their clinical symptoms significantly improved. Conclusions: Three-dimensional simulation may allow for the assessment from multiple angles of the endoscope entry and path, as well as the insertion angle. FED-TF surgery simulation using 3D MRI/CT fusion images could be useful in determining the indications for full endoscopic surgery for lumbosacral disc herniation.
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Affiliation(s)
- Katsuhisa Yamada
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Ken Nagahama
- Department of Orthopaedic Surgery, Sapporo Endoscopic Spine Surgery Clinic, North-16, East-16, Higashi-ku, Sapporo 065-0016, Hokkaido, Japan
| | - Yuichiro Abe
- Department of Orthopaedic Surgery, Eniwa Hospital, Eniwa 061-1449, Hokkaido, Japan
| | - Yoshinori Hyugaji
- Department of Orthopaedic Surgery, Sapporo Endoscopic Spine Surgery Clinic, North-16, East-16, Higashi-ku, Sapporo 065-0016, Hokkaido, Japan
| | - Daisuke Ukeba
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Tsutomu Endo
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Takashi Ohnishi
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Katsuro Ura
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Hideki Sudo
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo 060-8638, Hokkaido, Japan
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Neurological Safety of Endoscopic Transforaminal Lumbar Interbody Fusion: A Magnetic Resonance Neurography Study. Spine (Phila Pa 1976) 2023; 48:344-349. [PMID: 36191017 DOI: 10.1097/brs.0000000000004496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/17/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE A magnetic resonance neurography (MRN) study was conducted to assess the neurological safety of endoscopic transforaminal lumbar intervertebral fusion (endo-TLIF). MATERIALS AND METHODS A total of 56 healthy volunteers (29 men, 27 women; average age, 44 yr; age range, 21-60 yr) were included in the study. Coronal MRN images were collected from L2/L3 to L5/S1. The working triangle, modified working zone, and safest working zone areas, as well as the vertical and horizontal safe operation diameters, were measured. Linear regression analyses were conducted to explore the correlations between general characteristics (sex, age, height, body mass index) and the measured radiographic indicators. RESULTS MRN can effectively evaluate the operation zone of endo-TLIF. The safest working zone, modified working zone, and working triangle areas were largest at L4/L5 (92.4±23.4, 136±35.6, and 197±41.7 mm 2 , respectively) and smallest at L2/L3 (45.5±12.9, 68.1±19.5, and 92.6±24.4 mm 2 , respectively). The vertical safe operation diameter was large at L4/L5 and L2/L3 (5.34±0.8 and 5.42±0.9 mm, respectively) and smallest at L5/S1 (2.94±0.9 mm). The horizontal safe operation diameter was large at L4/L5 (7.28±1.2 mm) and smaller at L5/S1 and L2/L3 (4.28±1.0 and 4.77±0.8 mm, respectively). CONCLUSIONS L4/L5 has the lowest risk of nerve injury, and may be the safest level for beginners initiating endo-TLIF in their practice. We recommend that coronal MRN is routinely performed before endo-TLIF to minimize the risk of neurological injury.
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Tabarestani TQ, Sykes DAW, Maquoit G, Wang TY, Ayoub CM, Shaffrey CI, Wiggins WF, Abd-El-Barr MM. Novel Merging of CT and MRI to Allow for Safe Navigation into Kambin's Triangle for Percutaneous Lumbar Interbody Fusion-Initial Case Series Investigating Safety and Efficacy. Oper Neurosurg (Hagerstown) 2023; 24:331-340. [PMID: 36701664 DOI: 10.1227/ons.0000000000000531] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 09/18/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND For percutaneous lumbar fusion (percLIF), magnetic resonance imaging and computed tomography are critical to defining surgical corridors. Currently, these scans are performed separately, and surgeons then use fluoroscopy or neuromonitoring to guide instruments through Kambin's triangle. However, anatomic variations and intraoperative positional changes are possible, meaning that safely accessing Kambin's triangle remains a challenge because nerveroot visualization without endoscopes has not been thoroughly described. OBJECTIVE To overcome the known challenges of percLIF and reduce the likelihood of iatrogenic injuries by showing real-time locations of neural and bony anatomy. METHODS The authors demonstrate an intraoperative navigational platform that applies nerve root segmentation and image fusion to assist with percLIF. Five patients from a single institution were included. RESULTS Of the 5 patients, the mean age was 71 ± 8 years and 3 patients (60%) were female. One patient had general anesthesia while the remaining 4 patients underwent awake surgery with spinal anesthesia. The mean area for the L4-L5 Kambin's triangle was 76.1 ± 14.5 mm 2 . A case example is shown where the side of approach was based on the fact that Kambin's triangle was larger on one side compared with the other. The mean operative time was 170 ± 17 minutes, the mean blood loss was 32 ± 16 mL, and the mean hospital length of stay was 19.6 ± 8.3 hours. No patients developed postoperative complications. CONCLUSION This case series demonstrates the successful and safe application of nerve segmentation using magnetic resonance imaging/computed tomography fusion to perform percLIF and provide positive patient outcomes.
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Affiliation(s)
- Troy Q Tabarestani
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - David A W Sykes
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gisselle Maquoit
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina, USA
| | - Timothy Y Wang
- Department of Neurosurgery, Duke University Hospital, Durham, North Carolina, USA
| | - Chakib M Ayoub
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina, USA
| | | | - Walter F Wiggins
- Department of Radiology, Duke University Hospital, Durham, North Carolina, USA
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12
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Waguia Kouam R, Tabarestani TQ, Sykes DAW, Gupta N, Futch BG, Kakmou E, Goodwin CR, Foster NA, Than KD, Wiggins WF, Abd-El-Barr MM. How dimensions can guide surgical planning and training: a systematic review of Kambin's triangle. Neurosurg Focus 2023; 54:E6. [PMID: 36587400 DOI: 10.3171/2022.10.focus22606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/17/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The authors sought to analyze the current literature to determine dimensional trends across the lumbar levels of Kambin's triangle, clarify the role of imaging techniques for preoperative planning, and understand the effect of inclusion of the superior articular process (SAP). This compiled knowledge of the triangle is needed to perform successful procedures, reduce nerve root injuries, and help guide surgeons in training. METHODS The authors performed a search of multiple databases using combinations of keywords: Kambin's triangle, size, measurement, safe triangle, and bony triangle. Articles were included if their main findings included measurement of Kambin's triangle. The PubMed, Scopus, Ovid, Cochrane, Embase, and Medline databases were systematically searched for English-language articles with no time frame restrictions through July 2022. RESULTS Eight studies comprising 132 patients or cadavers were included in the study. The mean ± SD age was 66.69 ± 9.6 years, and 53% of patients were male. Overall, the size of Kambin's triangle increased in area moving down vertebral levels, with L5-S1 being the largest (133.59 ± 4.36 mm2). This trend followed a linear regression model when SAP was kept (p = 0.008) and removed (p = 0.003). There was also a considerable increase in the size of Kambin's triangle if the SAP was removed. CONCLUSIONS Here, the authors have provided the first reported systematic review of the literature of Kambin's triangle, its measurements at each lumbar level, and key areas of debate related to the definition of the working safe zone. These findings indicate that CT is heavily utilized for imaging of the safe zone, the area of Kambin's triangle tends to increase caudally, and variation exists between patients. Future studies should focus on using advanced imaging techniques for preoperative planning and establishing guidelines for surgeons.
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Affiliation(s)
| | | | | | - Nithin Gupta
- 1Campbell University School of Osteopathic Medicine, Lillington
| | | | - Elisabeth Kakmou
- 3Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - C Rory Goodwin
- 3Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - Norah A Foster
- 4Department of Orthopedic Surgery, Miami Valley Hospital, Centerville, Ohio; and
| | - Khoi D Than
- 3Department of Neurosurgery, Duke University Hospital, Durham, North Carolina
| | - Walter F Wiggins
- 5Department of Radiology, Duke University Hospital, Durham, North Carolina
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13
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Yan BC, Fan YF, Tian QH, Wang T, Huang ZL, Song HM, Li Y, Jiao L, Wu CG. Efficacy and Safety of the Safe Triangular Working Zone Approach in Percutaneous Vertebroplasty for Spinal Metastasis. Korean J Radiol 2022; 23:901-910. [PMID: 35926840 PMCID: PMC9434739 DOI: 10.3348/kjr.2021.0914] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 06/09/2022] [Accepted: 06/19/2022] [Indexed: 12/05/2022] Open
Abstract
Objective This study aimed to assess the technical feasibility, efficacy, and safety of the safe triangular working zone (STWZ) approach applied in percutaneous vertebroplasty (PV) for spinal metastases involving the posterior part of the vertebral body. Materials and Methods We prospectively enrolled 87 patients who underwent PV for spinal metastasis involving the posterior part of the vertebral body, with or without the STWZ approach, from January 2019 to April 2022. Forty-nine patients (27 females and 22 males; mean age ± standard deviation [SD], 57.2 ± 11.6 years; age range, 31–76 years) were included in group A (with STWZ approach), accounting for 54 vertebrae. Thirty-eight patients (18 females and 20 males; 59.1 ± 10.9 years; 29–81 years) were included in group B (without STWZ approach), accounting for 57 vertebrae. Patient demographics, procedure-related variables, and pain relief as assessed using the visual analog scale (VAS) were collected at different time points. Tumor recurrence in the vertebrae after PV was analyzed using Kaplan–Meier curves. Results The STWZ approach was successful from T1 to L5 without severe complications. Cement filling was satisfactory in 47/54 (87.0%) and 25/57 (43.9%) vertebrae in groups A and B, respectively (p < 0.001). Cement leakage was not significantly different between groups A and B (p = 1.000). Mean VAS score ± SD before and 1 week and 1, 3, 6, 9, and 12 months after PV were 7.6 ± 1.8, 4.2 ± 2.0, 2.7 ± 1.9, 1.9 ± 1.5, 1.7 ± 1.4, 1.7 ± 1.1, and 1.6 ± 1.3, respectively, in group A and 7.2 ± 1.7, 4.0 ± 1.3, 3.4 ± 1.6, 2.4 ± 1.2, 1.8 ± 1.0, 1.4 ± 0.5, and 1.7 ± 0.9, respectively, in group B. Kaplan–Meier analysis showed a lower tumor recurrence rate in group A than in group B (p = 0.001). Conclusion The STWZ approach may represent a new, safe, alternative/auxiliary approach to target the posterior part of the vertebral body in the PV for spinal metastases.
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Affiliation(s)
- Bi Cong Yan
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yan Feng Fan
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qing Hua Tian
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Tao Wang
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zhi Long Huang
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hong Mei Song
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ying Li
- Department of Radiology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Lei Jiao
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Chun Gen Wu
- Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Kaya M, Keskin E, Ceylan D, Kacira T, Kitiki Kacira Ö. Surgical Treatment of Far Lateral Lumbar Disc Herniation: Outcomes of the Safe and Simple Midline Approach. Cureus 2022; 14:e27907. [PMID: 36134043 PMCID: PMC9481221 DOI: 10.7759/cureus.27907] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/25/2022] Open
Abstract
Objective Surgery for far lateral lumbar disc herniation (FLLDH) hernias is different than surgery for median and paramedian disc hernias. Our study offers a minimally invasive surgical technic for far lateral disc herniations. Methods The results of the midline surgical approach in 18 patients diagnosed with FLLDH were evaluated retrospectively. Results A total of 18 patients (7 females, 11 males), with a mean age of 57.9±9.4 years (range: 35-71 years), were included in the analyses. Three patients (16.7%) had lesions at the left L3-L4 level, six patients (33.3%) on the left L4-L5 level, five patients (27.8%) on the right L3-L4 level, and four patients (22.2%) on the right L4-L5 level. All patients had low back and leg pain. These complaints completely regressed after surgery. Conclusion This study presents a review of a consecutive series of patients who underwent minimally invasive surgery for FLLDH using a midline approach.
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15
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Tabarestani TQ, Sykes D, Murphy KR, Wang TY, Shaffrey CI, Goodwin CR, Horne P, Than KD, Abd-El-Barr MM. Beyond Placement of Pedicle Screws - New Applications for Robotics in Spine Surgery: A Multi-Surgeon, Single-Institution Experience. Front Surg 2022; 9:889906. [PMID: 35784931 PMCID: PMC9243459 DOI: 10.3389/fsurg.2022.889906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
Interest in robotic-assisted spine surgery has grown as surgeon comfort and technology has evolved to maximize benefits of time saving and precision. However, the Food and Drug Administration (FDA) has currently only approved robotics to assist in determining the ideal trajectory for pedicle screw placement after extensive research supporting its efficacy and efficiency. To be considered a durable and effective option, robotics need to expand beyond the indication of just placing pedicle screws. This article aims to illustrate a multi-surgeon, single-institution experience with unique applications of robotic technologies in spine surgery. We will explore accessing Kambin's Triangle in percutaneous transforaminal interbody fusion (percLIF), iliac fixation in metastatic cancer, and sacroiliac (SI) fusions. Each of these topics will be covered in depth with associated background information and subsequent discussion. We show that with proper understanding of its limitations, robots can help surgeons perform difficult surgeries in a safe manner.
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Affiliation(s)
- Troy Q Tabarestani
- Duke University School of Medicine, Duke University Hospital, Durham, Durham, NC
| | - David Sykes
- Duke University School of Medicine, Duke University Hospital, Durham, Durham, NC
| | - Kelly R Murphy
- Department of Neurosurgery, Duke University Hospital, Durham, Durham, NC
| | - Timothy Y Wang
- Department of Neurosurgery, Duke University Hospital, Durham, Durham, NC
| | | | - C Rory Goodwin
- Department of Neurosurgery, Duke University Hospital, Durham, Durham, NC
| | - Phillip Horne
- Department of Orthopedic Surgery, Duke University Hospital, Durham, Durham, NC
| | - Khoi D Than
- Department of Neurosurgery, Duke University Hospital, Durham, Durham, NC
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16
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Li Y, Wang MY. Safe Electromyography Stimulation Thresholds Within Kambin's Triangle During Endoscopic Transforaminal Lumbar Interbody Fusion. Neurosurgery 2022; 91:150-158. [PMID: 35383716 DOI: 10.1227/neu.0000000000001959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transforaminal endoscopic approaches through Kambin's triangle traditionally require surgery to be performed without general anesthesia to allow live patient feedback. No reliable intraoperative neuromonitoring method specific to the dorsal root ganglion (DRG), the structure most at risk during this approach, currently exists. OBJECTIVE To correlate evoked electromyography (EMG) thresholds within Kambin's triangle with new postoperative pain or sensorimotor symptoms potentially resulting from DRG irritation. METHODS Data were prospectively collected for all patients undergoing endoscopic transforaminal lumbar interbody fusion (TLIF) under general anesthesia at a single institution. A stimulation probe was inserted into Kambin's triangle under fluoroscopic and robotic guidance, before passage of endoscopic instruments. EMG thresholds required to elicit corresponding myotomal responses were measured. Postoperatively, any potential manifestations of DRG irritation were recorded. RESULTS Twenty-four patients underwent a total of 34 transforaminal lumbar interbody fusion levels during the study period, with symptoms of potential DRG irritation occurring in 5. The incidence of new onset symptoms increased with lower stimulation thresholds. Sensitivities for EMG thresholds of ≤4, ≤8, and ≤11 mA were 0.6, 0.8, and 1, respectively. Corresponding specificities were 0.90, 0.69, and 0.55, respectively. CONCLUSION We demonstrated for the first time the feasibility of direct intraoperative neuromonitoring within Kambin's triangle in transforaminal endoscopic surgery. Eight milliampere seems to be a reasonable compromise between sensitivity and specificity for this monitoring technique. In the future, larger-scale studies are required to refine safe stimulation thresholds.
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Affiliation(s)
- Yingda Li
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope LIFE Centre, Miami, Florida, USA
- Department of Neurosurgery, Westmead Hospital, Westmead, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope LIFE Centre, Miami, Florida, USA
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17
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Waguia R, Gupta N, Gamel KL, Ukachukwu A. Current and Future Applications of the Kambin’s Triangle in Lumbar Spine Surgery. Cureus 2022; 14:e25686. [PMID: 35812644 PMCID: PMC9259071 DOI: 10.7759/cureus.25686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/05/2022] Open
Abstract
Kambin’s triangle has become the anatomical location of choice when accessing the lumbar spine to treat degenerative spinal disorders. Currently, lumbar interbody fusion is the most common procedure utilizing this space; however, with the advent of the Kambin’s prism definition, advanced imaging modalities, and robotic-assisted techniques, lumbar spine surgery has become increasingly precise and less invasive. These technological and procedural advances have drastically reduced the rate of complications, improved patient outcomes, and expanded the use of the Kambin’s triangle to treat different pathologies utilizing cutting-edge techniques. In this review, the authors present the current uses of the Kambin’s triangle and the future application of this anatomical corridor in lumbar spine surgery.
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Usefulness of 3D CT/MRI Fusion Imaging for the Evaluation of Lumbar Disc Herniation and Kambin's Triangle. Diagnostics (Basel) 2022; 12:diagnostics12040956. [PMID: 35454004 PMCID: PMC9031438 DOI: 10.3390/diagnostics12040956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/03/2022] [Accepted: 04/10/2022] [Indexed: 02/04/2023] Open
Abstract
Study design: Prospective study. Objective: The aim of this study is to visualize the morphology of a lumbar herniated disc and Kambin’s triangle in three dimensions (3D) based on preoperative CT/MRI fusion images. Methods: CT/MRI fusion images of 23 patients (10 males and 13 females; mean age 58.2 years) were used to evaluate Kambin’s triangle, which is created between the superior articular process (SAP), exiting nerve root (ENR), inferiorly by the superior endplate of the lower lumbar vertebra and dural canal medially at 60 degree and 45 degree endoscopic approach angles. The percentage of the safe usage of transforaminal endoscopic approach was evaluated to utilize a 5 mm dilater without partial facet resection in the fusion image. The 3D lumbar nerve root sleeve angulation (3DNRA), which is the angle between the axis of the thecal sac and the nerve root sleeve, was calculated. The herniated discs were also visualized in the CT/MRI fusion image. Results: The 3DNRA became smaller from L2 to S1. The L2 3DNRA was statistically larger than those of the other root, and the S1 3DNRA was significantly smaller than the others (p < 0.05). (L2, 41.0°; L3, 35.6°; L4, 36.4°; L5, 33.9°; and S1, 23.2°). The SAP-ENR distance at 60° was greatest at L4/5 (5.9 mm). Possible needle passages at 60° to each disc level were 89.1% at L2/3, 87.0% at L3/4 and 84.8% at L4/5. However, the safe 5 mm dilater passage at 60° without bony resection to each disc level were 8.7% at L2/3, 28.3% at L3/4 and 37.0% at L4/5. The 60° corridor at L2/3 was the narrowest (p < 0.01). All herniated discs were visualized in the fusion image and the root compression site was clearly demonstrated especially with foraminal/extraforaminal herniations. Conclusion: The 3D lumbar CT/MRI fusion image enabled a combined nerve-bony assessment of Kambin’s triangle and herniated disc. A fully endoscopic 5 mm dilater may retract the exiting nerve root in more than 60% of total cases. This new imaging technique could prove to be very useful for the safety of endoscopic lumbar disc surgery.
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Sousa JM, Ribeiro H, Silva JL, Nogueira P, Consciência JG. Clinical outcomes, complications and fusion rates in endoscopic assisted intraforaminal lumbar interbody fusion (iLIF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): systematic review and meta-analysis. Sci Rep 2022; 12:2101. [PMID: 35136081 PMCID: PMC8825843 DOI: 10.1038/s41598-022-05988-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 01/20/2022] [Indexed: 12/23/2022] Open
Abstract
This meta-analysis aims to determine the clinical outcomes, complications, and fusion rates in endoscopic assisted intra-foraminal lumbar interbody fusion (iLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative diseases. The MEDLINE, Embase, and Cochrane Library databases were searched. The inclusion criteria were: five or more consecutive patients who underwent iLIF or MI-TLIF for lumbar degenerative diseases; description of the surgical technique; clinical outcome measures, complications and imaging assessment; minimum follow-up of 12 months. Surgical time, blood loss, and length of hospital stay were extracted. Mean outcome improvements were pooled and compared with minimal clinically important differences (MCID). Pooled and direct meta-analysis were evaluated. We identified 42 eligible studies. The iLIF group had significantly lower mean intra-operative blood loss, unstandardized mean difference (UMD) 110.61 mL (95%CI 70.43; 150.80; p value < 0.0001), and significantly decreased length of hospital stay (UMD 2.36; 95%CI 1.77; 2.94; p value < 0.0001). Visual analogue scale (VAS) back, VAS leg and Oswestry disability index (ODI) baseline to last follow-up mean improvements were statistically significant (p value < 0.0001), and clinically important for both groups (MCID VAS back > 1.16; MCID VAS leg > 1.36; MCID > 12.40). There was no significant difference in complication nor fusion rates between both cohorts. Interbody fusion using either iLIF or MI-TLIF leads to significant and clinically important improvements in clinical outcomes for lumbar degenerative diseases. Both procedures provide high rates of fusion at 12 months or later, without significant difference in complication rates. iLIF is associated with significantly less intraoperative blood loss and length of hospital stay.
Study registration: PROSPERO international prospective register of systematic reviews: Registration No. CRD42020180980, accessible at https://www.crd.york.ac.uk/prospero/ April 2020.
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Affiliation(s)
- José Miguel Sousa
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal. .,Comprehensive Health Research Center, NOVA Medical School - Universidade NOVA de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
| | - Hugo Ribeiro
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal
| | - João Luís Silva
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal
| | - Paulo Nogueira
- Área Disciplinar Autónoma de Bioestatística (Laboratório de Biomatemática), Faculdade de Medicina, Instituto de Medicina Preventiva e Saúde Pública, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - José Guimarães Consciência
- Orthopaedics Department, Centro Hospitalar Lisboa Ocidental, Estrada do Forte do Alto Duque, 1449-005, Lisbon, Portugal.,Comprehensive Health Research Center, NOVA Medical School - Universidade NOVA de Lisboa, Campo Mártires da Pátria, 130, 1169-056, Lisbon, Portugal
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Panjeton GD, Brown HL, Searcy S, Meroney M, Kumar S. Endoscopic Spinal Decompression: A Retrospective Review of Pain Outcomes at an Academic Medical Center. Cureus 2021; 13:e19112. [PMID: 34858754 PMCID: PMC8614167 DOI: 10.7759/cureus.19112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Spinal stenosis is a chronic, debilitating condition that is expected to affect an increasing number of people as the population ages. Symptomatic spinal stenosis, like other spine pathologies, including disc herniation and degenerative disc disease, traditionally required an open decompressive surgical approach if more conservative approaches failed. An emerging alternative has been developed to address the needs of this population of patients in the form of endoscopic spine surgery (ESS). Advantages of ESS include minimal tissue trauma, decreased risk of damage to the neurovascular structures, minimal epidural fibrosis/scarring, reduced hospital stay, early functional recovery, and improved cosmetic outcomes. The purpose of this study was to review the outcomes of patients undergoing transforaminal endoscopic spinal decompression at an academic pain program. METHODS We conducted a retrospective review of electronic medical records with approval from the University of Florida Institutional Review Board (IRB #202001529). Twenty patients underwent successful transforaminal endoscopic lumbar spinal decompression surgery at UF Health Pain Medicine from July 1, 2019, to June 1, 2020. The majority of cases were performed at L4-5 (n = 14), followed by an equal number (n = 3) of cases at L3-4 and L5-S1. Preoperative and postoperative visual analog scale (VAS) pain scores from patients' pain clinic appointments were obtained from the electronic health records system to assess the intervention as a pain relief strategy. RESULTS Patients had an average pain reduction of 82% (SD = 31%), resulting in an average postoperative pain score of 1.8 (SD = 2.8) on a 10-point VAS. CONCLUSION This study highlights the benefits of endoscopic spine surgery for patients, including pain reduction and reduced scarring.
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Affiliation(s)
| | - Holden L Brown
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Sam Searcy
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Matthew Meroney
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
| | - Sanjeev Kumar
- Anesthesiology, University of Florida College of Medicine, Gainesville, USA
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Ahn Y, Yoo BR, Jung JM. The irony of the transforaminal approach: A comparative cohort study of transforaminal endoscopic lumbar discectomy for foraminal versus paramedian lumbar disc herniation. Medicine (Baltimore) 2021; 100:e27412. [PMID: 34622848 PMCID: PMC8500638 DOI: 10.1097/md.0000000000027412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/17/2021] [Indexed: 01/05/2023] Open
Abstract
Transforaminal endoscopic lumbar discectomy (TELD) is useful for soft lumbar disc herniation (LDH). Although the transforaminal approach can reach the foraminal disc zone, the risk of exiting nerve root irritation along the path is considerable. Few studies have assessed the difficulties of TELD for foraminal LDH. The objective of this study is to compare the clinical results of TELD between foraminal or far-lateral LDH and paramedian LDH.Between June 2016 and July 2017, 135 consecutive patients with single-level LDH were treated with TELD for 2 years. Among them, 25 patients had foraminal or far-lateral LDH (foraminal group), and the remaining 110 patients had central or subarticular LDH (paramedian group). Perioperative data and clinical outcomes were evaluated using the visual analog pain scale, Oswestry Disability Index, and modified Macnab criteria.The foraminal group showed a higher rate of significant access pain (24.00% vs 8.19%, P < .05). The foraminal group also had a longer duration of surgery, length of hospital stay, and return to work (all P < .05). Pain scores and functional status were significantly improved in both groups. Although there were no differences in the outcomes at 2 years postoperatively, early pain and disability at 6 weeks were higher in the foraminal group.Ironically, the early clinical results of TELD for foraminal LDH may be less favorable than those for paramedian LDH. Therefore, great care should be taken during TELD for foraminal or far-lateral LDH.
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Kumari C, Gupta T, Gupta R, Kumar V, Sahni D, Aggarwal A, Neelkamal. Cadaveric anatomy of the lumbar triangular safe zone of Kambin's in North West Indian population. Anat Cell Biol 2021; 54:35-41. [PMID: 33619238 PMCID: PMC8017462 DOI: 10.5115/acb.20.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 11/27/2022] Open
Abstract
A three dimensional triangular space ‘the Kambin’s triangle (KT)’ present on the dorsolateral aspect of the intervertebral disc, is considered to be a safe area for transforaminal approaches. It allows access to the exiting and traversing nerve roots, the thecal sac and to the intervertebral disc spaces. Our aim was to calculate the area of the triangle by measuring the height and base at all the intervertebral spaces bilaterally in the lumbar region in North West Indian cadavers and to assess the diameter of circle inscribed within this triangle which will correspond to the size of cannula inserted for the minimally invasive transforaminal approaches in this population. Five randomly chosen adult cadavers were used for this study. After clearing the area, the exiting nerve was identified. The height and base of the bony KTs (n=40) were measured with the help of digital Vernier’s calliper (accuracy 0.02 mm) to calculate the area of the KT. There is a steady increase in the area of the bony KT reaching maximum at the level of L4-5 intervertebral space. Statistically there were no differences in the calculated areas between right and left side. The mean diameter of inscribed circle within the triangle also showed gradual increase from 5.82 mm at L1-2 level, reaching maximum value of 7.26 mm at L4-5 level on the right side while on the left side the values were 5.66 mm and 8.16 mm respectively. Careful anatomical consideration is of utmost importance in transforaminal approaches during surgical or interventional procedures in this region. Cannula having external diameter ranging 6–8 mm is recommended for any interventional approach through Kambin’s space.
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Affiliation(s)
- Chiman Kumari
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Tulika Gupta
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Richa Gupta
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Kumar
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Daisy Sahni
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anjali Aggarwal
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelkamal
- Department of Anatomy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gray CM, Kumar S. 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. JOURNAL OF SPINE SURGERY 2020; 6:613-619. [PMID: 33102899 DOI: 10.21037/jss-20-586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Caitlin M Gray
- Department of Pain Medicine/Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sanjeev Kumar
- Department of Pain Medicine/Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
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Technical Considerations of Endoscopic Kambin's Triangle Lumbar Interbody Fusion. World Neurosurg 2020; 145:670-681. [PMID: 32485242 DOI: 10.1016/j.wneu.2020.05.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/18/2023]
Abstract
The performance of transforaminal endoscopic lumbar interbody fusion through a Kambin's triangle approach requires significant modifications when compared to a traditional transforaminal discectomy. Indeed, due to the inherently limited field of view, small working corridor, and need to deploy an adequately sized interbody graft, there are several important technical adaptations which can help improve the efficacy of this approach. In this manuscript, the technical aspects of a percutaneous, endoscopic interbody fusion are discussed in detail.
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