Biportal endoscopic bone graft repair and percutaneous screw fixation for lumbar spondylolysis-technical note and clinical outcomes

BACKGROUND

Lumbar spondylolysis involves a bony defect in the vertebral pars interarticularis, predominantly affecting the lower lumbar spine. This condition is a significant etiological factor in lumbar instability and recurrent lower back pain, particularly in young individuals. While conservative treatments are the primary intervention, they often fail to provide relief, necessitating surgical approaches. Notwithstanding, executing bone grafting and fixation in the pars interarticularis defect simultaneously through minimally invasive surgery remains challenging.

METHOD

This study elucidates the biportal endoscopic spinal surgery (BESS) technique, innovatively applied for bone graft repair and percutaneous cannulated screw fixation in a patient with lumbar spondylolysis. We offer a detailed walkthrough of the technical procedures supplemented with follow-up radiographic evidence.

RESULTS

The BESS technique facilitated meticulous clearance of the defect site, coupled with bone grafting and cannulated screw fixation, effectively addressing lumbar spondylolysis through a minimally invasive approach. This method holds promise for achieving substantial osseous fusion at the vertebral pars interarticularis defect site.

CONCLUSION

The BESS procedure for lumbar spondylolysis ensures a clean and prepared defect site for grafting and encourages successful osseous fusion, spotlighting its potential as a viable surgical strategy in managing this condition.

Comparison of biportal endoscopic technique and uniportal endoscopic technique in Unilateral Laminectomy for Bilateral Decomprssion (ULBD) for lumbar spinal stenosis

OBJECTIVE

Unilateral laminotomy for bilateral decompression (ULBD) has been adopted widely to treat lumbar spinal stenosis (LSS). The objective of the study is to investigate clinical and radiological outcomes of the biportal endoscopic ULBD (BE-ULBD) and uniportal endoscopic ULBD (UE-ULBD).

METHODS

We collected retrospectively 65 patients' data who met the inclusion criteria (July 2019-June 2021). 33 patients underwent BE-ULBD surgery, and 32 patients underwent the UE-ULBD surgery, and were followed up for at least 1 year. The following preoperative and postoperative outcomes were compared between groups: the visual analog scale (VAS) for pain, the Oswestry disability index (ODI) for nerve function, and modified Macnab criteria for satisfaction, the cross-sectional area of the dural sac (DSCSA), the mean angle of facetectomy.

RESULTS

Age, BMI, gender, levels of involvement and duration of symptoms were not significantly different at baseline in this study. Clinical data showed that postoperative ODI, VAS scores and Modified Macnab Criteria were not statistically different between the two groups. The BE-ULBD group had a shorter operation time than the UE-ULBD group (P < 0.001). Patients in the BE-ULBD group had a larger postoperative expansion of DSCSA expansion postoperatively (85.58 ± 3.16 mm2 VS 71.43 ± 3.35 mm2, P < 0.001) and a larger contralateral facetectomy angle (63.95 ± 3.34° vs 57.80 ± 3.43°, P < 0.001) compared with patients in the UE-ULBD group. There were no statistical differences in the incidence of postoperative complications between the two groups.

CONCLUSION

Both the BE-ULBD and the UE-ULBD yielded clinical improvement in terms of pain and stenosis symptoms. The BE-ULBD technique has the advantages of the shorter operation time, larger DSCSA expansion and larger contralateral facetectomy angle.

Temperature change of epidural space by radiofrequency use in biportal endoscopic lumbar surgery: safety evaluation of radiofrequency

PURPOSE

Articles evaluating radiofrequency (RF) safety are insufficient. Thus, the purpose of this study was to investigate RF safety during biportal endoscopic lumbar decompressive laminotomy by measuring epidural temperature after RF use.

METHODS

Both in vitro cadaveric study and in vivo study were performed. The epidural temperature was measured at epidural space after RF use in three cadavers. The epidural temperature was measured and analysed according to RF mode, RF power, RF usage time, and saline irrigation patency. In the in vivo study, the epidural temperature was measured after biportal endoscopic surgery. Epidural temperatures were measured around ipsilateral and contralateral traversing nerve roots after 1-s use of RF.

RESULTS

In the in vivo study, epidural space temperature was increased by 0.31 ± 0.16 °C ipsilaterally and 0.29 ± 0.09° contralaterally after RF use in coagulation mode 1. The epidural temperature of epidural space was increased by 0.21 ± 0.13 °C ipsilaterally and 0.15 ± 0.21 °C contralaterally after RF use in high mode 2. In the in vitro study, epidural temperature was significantly increased with a long duration of RF use and a poor patency of irrigation fluid.

CONCLUSION

The use of RF in biportal endoscopic spine surgery might be safe. In order to reduce indirect thermal injuries caused by RF use, it might be necessary to reduce RF use time and maintain continuous saline irrigation patency well.

How I do it: biportal endoscopic spinal surgery for revision of adjacent segment disease after instrumented lumbar fusion

BACKGROUND

Lumbar fusion with rigid fixation can be complicated by adjacent segment degeneration, which may cause neurological deficits and back pain, and occasionally necessitates revision surgery. This type of revision surgery is difficult to perform in a minimally invasive manner because it requires the revision of the original internal fixation instruments.

METHOD

We describe a biportal endoscopic spinal surgery (BESS) procedure for revision surgery due to adjacent segment disease after lumbar fusion with rigid fixation instruments. The radiological images and complete surgical procedure are presented.

CONCLUSIONS

BESS effectively enabled nerve decompression, intervertebral fusion, and revision of lumbar fusion with fixation instruments in a minimally invasive manner.

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

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

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

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

Current and Future of Endoscopic Spine Surgery: What are the Common Procedures we Have Now and What Lies Ahead?

The aging population around the world leads to increasing incidence of degenerative spinal conditions. There is a need for a minimally invasive technique in treatment for spinal conditions to meet the medical complexity and comorbidities that comes with aging. Principles of endoscopy are similar to minimally invasive surgery, which is to decrease pressure on soft tissue crushing from prolonged retraction, avoid soft tissue stripping and dissection, and bone and ligamentous preservation for optimal decompression without excessive destruction. Endoscopic spine surgery techniques started slowly in development in the 1970s to 2000s, with a rapid phase of development since the turn of the 21st century with endoscopic solutions developing in cervical, thoracic, and lumbar conditions with increasing complexity in nature of operation. Technological enhancement with progressively supportive literature is pushing boundaries of endoscopy from the early days of soft tissue procedure to current fusion procedures, endoscopic spine surgery techniques is covering more areas of spine than ever previously possible with good clinical results. We present a review on the current techniques available and postulated near future development for endoscopic spine surgery.

Contralateral Keyhole Biportal Endoscopic Surgery for Ruptured Lumbar Herniated Disc: A Technical Feasibility and Early Clinical Outcomes

OBJECTIVE

Spinal endoscopic surgery is increasingly adapted as a minimal invasive technique, however, significant facet joint violation may be developed after ipsilateral laminectomy. The aim of this study is to introduce surgical technique of contralateral keyhole biportal endoscopic surgery (CKES) for ruptured lumbar disc and report it is early surgical outcomes with facet joint violation.

METHODS

Between January to December 2019, 27 patients with ruptured lumbar disc were underwent CKES. Simple radiographs were obtained to investigate development of iatrogenic instability or spondylolisthesis. Magnetic resonance imaging scan was checked about 8 hours after surgery to evaluate successful removal of ruptured disc and existence of facet joint violation. Clinical outcomes were assessed by modified MacNab criteria, visual analogue scale (VAS) scores of back and radicular pain.

RESULTS

The mean age of the patients was 62.8 ± 12.48 years. The average operative time and mean follow-up period were 57.1 ± 21.36 minutes and 8.1 ± 3.78 months, respectively. Compared to preoperative scores, the VAS scores of back and radicular pain were significantly improved. Modified MacNab outcome grade was good to excellent in 96.3% (26 out of 27 patients) of patients. The reduction rate of facet joint plane was about 4.9% after contralateral approach.

CONCLUSION

CKES may be considered as an excellent surgical option to treat ruptured lumbar disc without the development of iatrogenic instability. Low rate of facet joint reduction, good visualization of lateral recess, and identification of accurate midline of central spinal canal are advantages of the procedure.