Diagnostic and prognostic significance of miR-486-5p in patients who underwent minimally invasive surgery for lumbar spinal stenosis

BACKGROUND

This study aimed to investigate the expression and clinical value of microRNA miR-486-5p in diagnosing lumbar spinal stenosis (LSS) patients and predicting the clinical outcomes after minimally invasive spinal surgery (MISS) in LSS patients, and the correlation of miR-486-5p with inflammatory responses in LSS patients.

METHODS

This study included 52 LSS patients, 46 patients with lumbar intervertebral disk herniation (LDH) and 42 healthy controls. Reverse transcription quantitative PCR was used to detect miR-486-5p expression. The ability of miR-486-5p to discriminate between different groups was evaluated by receiver-operating characteristic analysis. The visual analogue scale (VAS), Oswestry Disability Index (ODI) and Japanese Orthopaedic Association (JOA) scores at 6 months postoperatively were used to reflect the clinical outcomes of LSS patients. Enzyme-linked immunosorbent assay was used to measure the levels of inflammatory factor [interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α)]. The correlation of miR-486-5p with continuous variables in LSS patients was evaluated by the Pearson correlation coefficient.

RESULTS

Expression of serum miR-486-5p was upregulated in LSS patients and had high diagnostic value to screen LSS patients. In addition, serum miR-486-5p could predict the 6-month clinical outcomes after MISS therapy in LSS patients. Moreover, serum miR-486-5p was found to be positively correlated with the levels of IL-1β and TNF-α in patients with LSS.

CONCLUSION

miR-486-5p, increased in LSS patients, can function as an indicator to diagnose LSS and a predictive indicator for the clinical outcomes after MISS therapy in LSS patients. In addition, miR-486-5p may regulate LSS progression by modulating inflammatory responses.

Ten-step minimally invasive slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation

BACKGROUND

Unilateral laminotomy for bilateral decompression (ULBD) is a MIS surgical technique that offers safe and effective decompression of lumbar spinal stenosis (LSS) with a long-term resolution of symptoms. Advantages over conventional open laminectomy include reduced expected blood loss, muscle damage, mechanical instability, and less postoperative pain. The slalom technique combined with navigation is used in multi-segmental LSS to improve the workflow and effectiveness of the procedure.

METHODS

We outline ten technical steps to achieve a slalom unilateral laminotomy for bilateral decompression (sULBD) with navigation. In a retrospective case series, we included patients with multi-segmental LSS operated in our institution using the sULBD between 2020 and 2022. The primary outcome was a reduction in pain measured by Visual Analogue Scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI).

RESULTS

In our case series (N = 7), all patients reported resolution of initial symptoms on an average follow-up of 20.71 ± 9 months. The average operative time and length of hospital stay were 196.14 min and 1.67 days, respectively. On average, VAS (back pain) was 4.71 pre-operatively and 1.50 on long-term follow-up of an average of 19.05 months. VAS (leg pain) decreased from 4.33 to 1.21. ODI was reported as 33% pre-operatively and 12% on long-term follow-up.

CONCLUSION

The sULBD with navigation is a safe and effective MIS surgical procedure and achieves the resolution of symptoms in patients presenting with multi-segmental LSS. Herein, we demonstrate the ten key steps required to perform the sULBD technique. Compared to the standard sULBD technique, the incorporation of navigation provides anatomic localization without exposure to radiation to staff for a higher safety profile along with a fast and efficient workflow.

Clinical Outcomes of Percutaneous Endoscopic Interlaminar Discectomy Using a Laminotomy Technique With Modified Stepwise Local Anesthesia

BACKGROUND

Percutaneous endoscopic interlaminar discectomy (PEID) has been widely used in minimally invasive treatment of lumbar disc herniation (LDH) but is difficult to perform because of the narrow interlaminar window and painful for the patient. Therefore, further research is needed to find a safe and effective method to facilitate the development of PEID.

METHODS

Seventy-one consecutive patients with LDH who underwent PEID using a laminotomy technique with modified stepwise local anesthesia between July 2017 and June 2020. All patients were followed up for at least 6 months. Preoperative patient demographics, perioperative outcomes, and clinical outcomes were recorded. Visual Analog Scale (VAS) scores, Oswestry Disability Index (ODI) scores, and Macnab criteria were used to assess clinical results.

RESULTS

All patients underwent successful surgery under local anesthesia with no conversions to open surgery. The mean operation time was 79.56 ± 32.78 minutes and the average hospital stay was 6.44 ± 2.98 nights. Before surgery, the mean VAS score was 5.66 ± 1.206 and the mean ODI score was 68.41 ± 6.634; the respective scores were decreased to 0.65 ± 0.635 and 7.06 ± 1.594 after 4 weeks of follow-up (P < 0.001) and to 0.56 ± 0.691 and 7.11 ± 0.176 after 6 months (P < 0.001). According to the MacNab criteria, the outcome was excellent in 60 cases and good in the remaining 11 cases.

CONCLUSIONS

PEID via a laminotomy technique with stepwise local anesthesia is safe and effective for L4-5 and L5-S1 LDH.

Clinical Outcome of Full Endoscopic Trans Kambin's Triangle Lumbar Interbody Fusion: A Systematic Review

Full-endoscopic (FE) lumbar interbody fusion (LIF) is now a widely used type of minimally invasive surgery (MIS). Although FE-LIF includes LIF with foraminoplasty via a Kambin's triangle approach (FE-KLIF) and LIF with foraminotomy via an interlaminar approach, these techniques are rarely discussed separately. This review evaluates the outcomes and complications of FE-KLIF reported in the literature. The PubMed, Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting the outcomes of FE-KLIF. Of 464 publications assessed, 11 met our inclusion criteria. Although the most frequently treated level was L4/5, L5/S1 was also treated. FE-KLIF was performed under local anesthesia and sedation or under epidural anesthesia without general anesthesia. Visual analog scale and Oswestry Disability Index scores were improved postoperatively in all uncontrolled studies; however, there was no significant difference in these scores in studies that compared FE-KLIF with posterior LIF (PLIF) or MIS-transforaminal LIF (TLIF). There was also no significant difference in the fusion rate between FE-KLIF and PLIF or MIS-TLIF. In terms of complications, although there were no reports of hematoma, dural tear and surgical site infection were reported in 1 paper each, with transient nerve disorders reported in 5 studies (frequency, 1.8%-23.5%). This review indicates that FE-KLIF is a feasible and viable surgical option for lumbar degenerative disease. However, the amount and level of evidence is low for the studies included in this review, and the data on long-term outcomes remain limited.

Augmented Reality in Minimally Invasive Spinal Surgery: A Narrative Review of Available Technology

INTRODUCTION

Spine surgery has undergone significant changes in approach and technique. With the adoption of intraoperative navigation, minimally invasive spinal surgery (MISS) has arguably become the gold standard. Augmented reality (AR) has now emerged as a front-runner in anatomical visualization and narrower operative corridors. In effect, AR is poised to revolutionize surgical training and operative outcomes. Our study examines the current literature on AR-assisted MISS, synthesizes findings, and creates a narrative highlighting the history and future of AR in spine surgery.

MATERIAL AND METHODS

Relevant literature was gathered using the PubMed (Medline) database from 1975 to 2023. Pedicle screw placement models were the primary intervention in AR. These were compared to the outcomes of traditional MISS RESULTS: We found that AR devices on the market show promising clinical outcomes in preoperative training and intraoperative use. Three prominent systems were as follows: XVision, HoloLens, and ImmersiveTouch. In the studies, surgeons, residents, and medical students had opportunities to operate AR systems, showcasing their educational potential across each phase of learning. Specifically, one facet described training with cadaver models to gauge accuracy in pedicle screw placement. AR-MISS exceeded free-hand methods without unique complications or contraindications.

CONCLUSIONS

While still in its infancy, AR has already proven beneficial for educational training and intraoperative MISS applications. We believe that with continued research and advancement of this technology, AR is poised to become a dominant player within the fundamentals of surgical education and MISS operative technique.

Posterolateral full-endoscopic debridement and irrigation is effective in treating thoraco-lumbar pyogenic spondylodiscitis, except in cases with large abscess cavities

PURPOSE

To determine the efficacy and poor prognostic factors of posterolateral full-endoscopic debridement and irrigation (PEDI) surgery for thoraco-lumbar pyogenic spondylodiscitis.

METHODS

We included 64 patients (46 men, 18 women; average age: 63.7 years) with thoracic/lumbar pyogenic spondylodiscitis who had undergone PEDI treatment and were followed up for more than 2 years. Clinical outcomes after PEDI surgery were retrospectively investigated to analyze the incidence and risk factors for prolonged and recurrent infection.

RESULTS

Of 64 patients, 53 (82.8%) were cured of infection after PEDI surgery, and nine (17.2%) had prolonged or recurrent infection. Multivariate analysis demonstrated that significant risk factors for poor prognosis included a large intervertebral abscess cavity (P = 0.02) and multilevel intervertebral infections (P < 0.05).

CONCLUSION

PEDI treatment is an effective, minimally invasive procedure for pyogenic spondylodiscitis. However, a large intervertebral abscess space could cause instability at the infected spinal column, leading to prolonged or recurrent infection after PEDI. In cases with a large abscess cavity with or without vertebral bone destruction, endoscopic drainage alone may have a poor prognosis, and spinal fixation surgery could be considered.

Virtual and Augmented Reality in Spine Surgery: A Systematic Review

BACKGROUND

Augmented reality (AR) and virtual reality (VR) implementation in spinal surgery has expanded rapidly over the past decade. This systematic review summarizes the use of AR/VR technology in surgical education, preoperative planning, and intraoperative guidance.

METHODS

A search query for AR/VR technology in spine surgery was conducted through PubMed, Embase, and Scopus. After exclusions, 48 studies were included. Included studies were then grouped into relevant subsections. Categorization into subsections yielded 12 surgical training studies, 5 preoperative planning, 24 intraoperative usage, and 10 radiation exposure.

RESULTS

VR-assisted training significantly reduced penetration rates or increased accuracy rates compared to lecture-based groups in 5 studies. Preoperative VR planning significantly influenced surgical recommendations and reduced radiation exposure, operating time, and estimated blood loss. For 3 patient studies, AR-assisted pedicle screw placement accuracy ranged from 95.77% to 100% using the Gertzbein grading scale. Head-mounted display was the most common interface used intraoperatively followed by AR microscope and projector. AR/VR also had applications in tumor resection, vertebroplasty, bone biopsy, and rod bending. Four studies reported significantly reduced radiation exposure in AR group compared to fluoroscopy group.

CONCLUSIONS

AR/VR technologies have the potential to usher in a paradigm shift in spine surgery. However, the current evidence indicates there is still a need for 1) defined quality and technical requirements for AR/VR devices, 2) more intraoperative studies that explore usage outside of pedicle screw placement, and 3) technological advancements to overcome registration errors via the development of an automatic registration method.

Full-endoscopic spine surgery diminishes surgical site infections - a propensity score-matched analysis

BACKGROUND CONTEXT

Surgical site infections (SSI) are one the most frequent and costly complications following spinal surgery. The SSI rates of different surgical approaches need to be analyzed to successfully minimize SSI occurrence.

PURPOSE

The purpose of this study was to define the rate of SSIs in patients undergoing full-endoscopic spine surgery (FESS) and then to compare this rate against a propensity score-matched cohort from the National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

This is a retrospective multicenter cohort study using a propensity score-matched analysis of prospectively maintained databases.

PATIENT SAMPLE

One thousand two hundred seventy-seven non-instrumented FESS cases between 2015 and 2021 were selected for analysis. In the nonendoscopic NSQIP cohort we selected data of 55,882 patients.

OUTCOME MEASURES

The occurrence of any SSI was the primary outcome. We also collected any other perioperative complications, demographic data, comorbidities, operative details, history of smoking, and chronic steroid intake.

METHODS

All FESS cases from a multi-institutional group that underwent surgery from 2015 to 2021 were identified for analysis. A cohort of cases for comparison was identified from the NSQIP database using Current Procedural Terminology of nonendoscopic cervical, thoracic, and lumbar procedures from 2015 to 2019. Trauma cases as well as arthrodesis procedures, surgeries to treat pathologies affecting more than 4 levels or spine tumors that required surgical treatment were excluded. In addition, nonelective cases, and patients with wounds worse than class 1 were also not included. Patient demographics, comorbidities, and operative details were analyzed for propensity matching.

RESULTS

In the non-propensity-matched dataset, the endoscopic cohort had a significantly higher incidence of medical comorbidities. The SSI rates for nonendoscopic and endoscopic patients were 1.2% and 0.001%, respectively, in the nonpropensity match cohort (p-value <.011). Propensity score matching yielded 5936 nonendoscopic patients with excellent matching (standard mean difference of 0.007). The SSI rate in the matched population was 1.1%, compared to 0.001% in endoscopic patients with an odds ratio 0.063 (95% confidence interval (CI) 0.009-0.461, p=.006) favoring FESS.

CONCLUSIONS

FESS compares favorably for risk reduction in SSI following spinal decompression surgeries with similar operative characteristics. As a consequence, FESS may be considered the optimal strategy for minimizing SSI morbidity.

Minimally invasive trans-superior articular process percutaneous endoscopic lumbar discectomy with robot assistance

BACKGROUND

To compare the clinical outcomes of patients with lumbar disc herniation treated with robot-assisted percutaneous endoscopic lumbar discectomy (r-PELD) or conventional PELD under fluoroscopy guidance (f-PELD).

METHODS

Our study group included 55 patients, 22 in the r-PELD group and 33 in the f-PELD group. The following clinical and surgical outcomes were compared between the two groups: the visual analog scale for radiculopathy pain; Oswestry Disability Index; intraoperative volume of blood loss; frequency of fluoroscopy used during the procedure; and MacNab classification. The follow-up period was 6-8 months.

RESULTS

Compared with f-PELD, r-PELD was associated with a lower volume of intraoperative blood loss and frequency of fluoroscopy (p < 0.01). There were no differences in complications, MacNab classification, postoperative disability and leg pain, and duration of hospitalization between the two groups.

CONCLUSION

Based on our findings, r-PELD provides a safe and effective alternative to conventional PELD for the treatment of lumbar disc herniations, with the accuracy for placement of punctures lowering radiation exposure.

Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF) Compared with Open TLIF for Acute Cauda Equina Syndrome: A Retrospective Single-Center Study with Long-Term Follow-Up

OBJECTIVES

In a retrospective study, we sought to compare the clinical efficacy and postoperative magnetic resonance imaging (MRI) scans of minimally invasive (MI) and open (O) transforaminal lumbar interbody fusion (TLIF) in the treatment of cauda equina syndrome (CES) caused by lumbar disc herniation.

METHODS

In total, 116 patients with CES associated with disc herniation underwent decompression and stabilization surgery from January 2005 to January 2020 in a single-center study, and data were collected and retrospectively analyzed. The patients were divided into the O-TLIF and the MI-TLIF group. The perioperative clinical data and MRI assessment were used to assess the efficacy of the respective surgical methods preoperatively and with a minimum follow-up of 30 months.

RESULTS

As expected, the O-TLIF group had statistically significantly longer surgery times and hospital stay, more bleeding, and perioperative surgical complications than the MI-TLIF group. At a minimum follow-up period of 30 months, the MI-TLIF group had significantly better Oswestry Disability Index, visual analog scale, and Short-Form-36, and neurologic CES symptoms than the O-TLIF group. The postoperative MRIs revealed a statistically significant difference in the multifidus muscle area in MI group compared with the O group.

CONCLUSIONS

In patients with acute CES caused by disc herniation, MI-TLIF, with decreased disruption of paravertebral tissues and postoperative pain syndrome, results in earlier mobilization and rehabilitation with better long-term clinical outcomes compared with O-TLIF.

Challenges Hindering Widespread Adoption of Minimally Invasive Spinal Surgery

Minimally invasive spinal surgery (MISS) techniques offer several beneficial prospects and are being increasingly requested by patients. However, these techniques have not been uniformly adopted by spinal surgeons, and they remain controversial among some. Several barriers have prevented widespread adoption of MISS. These include concerns regarding high start-up costs, limited evidence base, and lack of surgeon training. In addition, the unique approaches involved in MISS expose spinal surgeons to unfamiliar anatomy. Further, while MISS can address a growing spectrum of spinal pathology, some conditions, as well as complications encountered during MISS procedures, require open surgery. This requires surgeons to not only acquire the new and specialized MISS skillset but also maintain their ability to perform open surgery. These factors present challenges common to developing and innovative surgical techniques. Here, we review the barriers preventing wider adoption of MISS and present a framework to promote the safe and effective growth of MISS.

A pilot study of endoscope-assisted MITLIF with fluoroscopy-guided technique: intraoperative objective and subjective evaluation of disc space preparation

BACKGROUND

Adequate discectomy and endplate preparation are extremely crucial steps for spinal interbody fusion. Minimally invasive transforaminal lumbar interbody fusion MITLIF technique is safe and effective. However, concerns exist regarding sufficient disc space preparation from unilateral access. The purpose of this study, was to demonstrate our preliminary experience in objective and subjective evaluation of disc space preparation intraoperatively during endoscope-assisted MITLIF with fluoroscopy-guided, describing some of its possible advantages, and analyzing its safety and feasibility.

METHODS

From March 2018 to July 2019, three patients with degenerative spinal stenosis with radiculopathy and instability underwent endoscope-assisted MITLIF with fluoroscopy-guided. Patients' demographic data, clinical parameters, subsidence, and fusion were collected.

RESULTS

Patients were successfully treated by endoscope-assisted MITLIF with fluoroscopy-guided at single-level or two-level. Symptoms improved postoperatively in all patients, and no complications occurred during follow-up. No cage subsidence was observed. At 6-month postoperatively, there was bony fusion observed on computed tomography in two patients.

CONCLUSION

Endoscope-assisted MITLIF with fluoroscopy-guided is a safe and feasible technique to improve visualization during discectomy and endplate preparation objectively and subjectively, possibly increasing fusion rate and early time to fusion.

Original Designed Uniportal-Bichannel Spinal Endoscopic System (UBiSES) for Foraminoplasty in Percutaneous Endoscopic Transforaminal Discectomy

OBJECTIVE

The study introduced uniportal-bichannel spinal endoscopic system (UBiSES) and explored the feasibility of applying UBiSES to conduct lumbar foraminoplasty in percutaneous endoscopic transforaminal discectomy (PETD).

METHODS

This is a cohort study. 36 patients confirmed as L5/S1 lumbar disc herniation (LDH) in our hospital from March, 2019 to November, 2019 were enrolled. 36 patients were divided into two groups named the UBiSES group (n = 18, male: female = 8:10) and the TESSYS group (n = 18, male: female = 10:8). The average age of the UBiSES group and the TESSYS group were 40.94 ± 12.39 years old and 39.78 ± 13.02 years old respectively. PETD via uniportal-bichannel foraminoplasty assisted by UBiSES was adopted on the UBiSES group while PETD via conventional foraminoplasty was performed on the TESSYS group. One experienced surgeon with more than 4000 cases of lumbar surgery performed PETD on all patients. The demographic data, the duration of working cannula placement (minutes), decompression time (minutes), radiation exposure time (seconds), complications, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) scores and modified MacNab criteria were recorded and analyzed. The magnetic resonance imaging (MRI) and computed tomography (CT) were conducted to evaluate the radiographic improvement.

RESULTS

PETD via lumbar foraminoplasty was successfully performed in all cases. The follow-up points were 3 months, 6 months, and 12 months. The average follow-up period of all patients was 15.78 ± 2.29 months. There was no statistic difference in age (P = 0.81), sex (P = 0.51) and follow-up (P = 0.14) between two groups. The duration of working cannula placement was 19.08 ± 2.30 min in the UBiSES group and 24.90 ± 4.71 min in the TESSYS group and there was significant difference between two groups (P < 0.05). There was no statistic difference in decompression time between the UBiSES group (44.18 ± 5.70 min) and the TESSYS group (47.46 ± 5.96 min) (P = 1.70). The radiation exposure time was 28.00 ± 4.70 s in the UBiSES group and 40.50 ± 5.73 s in the TESSYS group respectively, and has significant difference between two groups (P < 0.05). Furthermore, there was significant different in the duration of working cannula placement and radiation exposure time in male or female between the UBiSES group and the TESSYS group (P < 0.05). For male or female, no difference observed in decompression time and follow-up period between two groups. Postoperative VAS of low back and leg at every follow-up point (1 day, 3 months, 6 months, 12 months) was improved significantly in both groups compared with their preoperative VAS (P < 0.05). The postoperative ODI (3 months, 6 months, 12 months) has decreased significantly in both the UBiSES group and the TESSYS group compared with their preoperative ODI (P < 0.05). 94.44% patients received an excellent or good recovery in the UBiSES group and 88.89% for the TESSYS group. There was no poor result reported in both groups. The radiographic images showed satisfactory foraminoplasty and sufficient decompression of nerve in both groups. No postoperative complications were observed during follow-ups in the UBiSES group. Two patients in the TESSYS group experienced postoperative dysesthesia and the symptom was disappeared in 5 days and 7 days respectively with dexamethasone and neurotrophic drugs treatment.

CONCLUSIONS

The original designed UBiSES could effectively and safely enlarge the foramen with an extensive surgical view and space under full-time and real-time visualization and get satisfactory efficacy.

Clinical outcomes of minimally invasive transforaminal lumbar interbody fusion via a novel tubular retractor

Objective

To assess the feasibility and clinical results of microscopic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) using a novel tapered tubular retractor that preserves the multifidus.

Method

A total of 122 patients underwent MIS-TLIF using a tapered tubular retractor system from March 2016 to August 2017. Perioperative parameters and follow-up outcomes were reviewed.

Results

The follow-up period was 23.95 ± 1.43 months. The operative time averaged 130.48 ± 34.44 minutes. The estimated blood loss was 114.10 ± 96.70 mL. The mean time until ambulation was 16.33 ± 6.29 hours. The average visual analogue scale (leg/waist) and Oswestry Disability Index scores (preoperative to last follow-up) improved from 4.93 ± 2.68/3.74 ± 2.28 to 0.34 ± 0.77/0.64 ± 0.74 and from 59.09% ± 22.34 to 17.04% ± 8.49, respectively. At the last follow-up, 98.36% of the patients achieved solid fusion. Cerebrospinal fluid leakage occurred in two cases. The asymptote of the surgeon’s learning curve occurred at the 25th case. There were no significant differences between the preoperative qualitative and quantitative analyses of multifidus muscle fatty infiltration and those at the final follow-up.

Conclusion

MIS-TLIF can be performed safely and effectively using this tapered tubular retractor system, which helps preserve the multifidus.

A matched comparison of outcomes between percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for the treatment of lumbar disc herniation: a 2-year retrospective cohort study

BACKGROUND CONTEXT

Although open lumbar microdiscectomy (OLMD) is considered to be the gold standard method for discectomy, recent progress in endoscopic spinal surgery has increased the popularity of percutaneous endoscopic lumbar discectomy (PELD) for this indication. However, one of the main drawbacks of PELD is incomplete decompression, especially at the start of the surgeon's learning curve. The functional outcomes of PELD and OLMD in patients matched for age, hernia level, and hernia location have not previously been compared.

PURPOSE

To compare OLMD with PELD in terms of the clinical outcome and the time to recovery.

STUDY DESIGN

Retrospective, matched cohort study.

PATIENT SAMPLE

Data of all patients who underwent elective spinal surgery between January 2015 and June 2017 were extracted from the local database.

OUTCOME MEASURES

Clinical outcomes were assessed using a 0-to-10 visual analogue scale (VAS) for lower back pain (LBP) and leg pain were scored before surgery and at postoperative day 1 and at each follow-up visit (3, 12, and 24 months), the Oswestry Disability Index (ODI: 0%-100%), the length of hospital stay, time to resumption of work, recurrence of Lumbar disc herniation, procedure failures, and complications.

METHODS

The participants were matched for age, disc level, and location of the herniated disk (central and paracentral vs. far-lateral). The participants' mean±standard deviation age was 47.09±12.55 (range: 28-70). We compared the various clinical outcomes between the two groups to identify which procedure had better immediate and long-term functional outcomes. The differences in mortality and occurrence of postoperative complications were also compared in patients with PELD versus controls.

RESULTS

Fifty-eight patients were enrolled (29 with PELD and 29 with OLMD). Both groups reported significant reductions in LBP and leg pain (p<0.01) postoperatively and an improvement in the ODI at 24 months postsurgery. The intergroup difference in the VAS for LBP at 1 day and 3 months was statistically significant (1.48 vs. 3.5, and 1.62 vs. 2.72, respectively; p=0.01 and 0.026, respectively) but the intergroup difference in the ODI was not. The mean length of hospital stay and the time to resumption of work were significantly shorter in the PELD group than in the OLMD group (2.55 vs. 3.21 days, and 4.45 vs. 6.62 weeks, respectively; p=0.037 and 0.01, respectively. There were no significant intergroup differences in terms of complications, recurrence, or procedure failures.

CONCLUSIONS

Both PELD and OLMD can provide equivalent, satisfactory outcomes. However, PELD demonstrated several potential advantages, including more rapid recovery and lower LBP early on. Further large-scale, randomized studies with long-term follow-up are now warranted.

Minimally Invasive Transforaminal Lumbar Interbody Fusion With Intraoperative Fluoroscopy for Disc Space Preparation: Analysis of Fusion Rate and Clinical Results

BACKGROUND

Meticulous disc space preparation is an important step toward ensuring arthrodesis in the interbody fusion procedure. Although minimally invasive techniques are becoming increasingly advanced in lumbar interbody fusion, concerns exist regarding adequate discectomy and sufficient endplate preparation from a transforaminal lumbar approach.

OBJECTIVE

To describe the radiographic and clinical outcomes of single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) using the intraoperative fluoroscopy-guided method for disc space preparation.

METHODS

This is a retrospective study of 25 patients operated between June 2016 and Dec 2017. The radiographic outcomes included the intraoperative percentage of disc space preparation, fusion, and subsidence. Percentage of disc space preparation was calculated through intraoperative fluoroscopic imaging. Clinical outcomes included visual analog scale (VAS), Oswestry Disability Index (ODI), and satisfaction rate.

RESULTS

Mean age of patients was 62.9 yr. The mean follow-up period was 22 mo. Mean extents of disc space preparation were 61.5% in the anteroposterior view and 80.3% in the lateral view. Fusion rates were 86% and 92% at 6 and 12-mo postoperatively, respectively. All patients showed clinical improvement according to VAS and ODI.

CONCLUSION

MI-TLIF with intraoperative fluoroscopy-guided disc space preparation is shown to lead to potentially improved fusion rate. It is a safe and effective surgical method for degenerative lumbar disease. Additionally, in cases of cage subsidence caused by the endplate violation during disc space preparation, thorough sufficient bone grafting of the defect region avoids pseudoarthrosis.

Hybrid Minimally Invasive Technique for Treatment of Thoracolumbar Spondylodiscitis and Vertebral Osteomyelitis

OBJECTIVE

Spondylodiscitis and vertebral osteomyelitis cause significant morbidity and mortality, and typically occur in patients with multiple comorbidities. The use of minimally invasive spinal surgery in the previous decade has offered the advantages of reduced intraoperative blood loss and postoperative pain for patients. In the present report, we have described our experience with using a hybrid minimally invasive (HMI) technique (combining percutaneous fixation with a mini-open approach for decompression and debridement) for the treatment of thoracolumbar spondylodiscitis, reporting the patient demographics, intraoperative measures, and 12-month outcomes.

METHODS

The data from patients presenting to a tertiary referral neurosurgical center with thoracolumbar spondylodiscitis and osteomyelitis who had undergone HMI from 2016 to 2018 were retrospectively evaluated. Patient demographics, intraoperative factors, estimated blood loss, and immediate postoperative complications were recorded. The patient outcomes were evaluated using EuroQOL 5-dimension questionnaire and visual analog scale in the immediate postoperative period and at 12 months postoperatively.

RESULTS

A total of 13 patients were included in the present study, 12 with spontaneous infection and 1 with infection secondary to recent microdiscectomy at another institution. All the patients had systemic comorbidities with an American Society of Anesthesiologists class of ≥2. Of the 13 patients, 11 had pyogenic infections and 2 had spinal tuberculosis. The mean estimated blood loss was 546.2 mL. The mean time for patients to sit out of bed was 2.2 days, and the mean time to start mobilizing was 4.5 days. The EuroQOL 5-dimension questionnaire scores showed improvement in all modalities at 12 months postoperatively.

CONCLUSIONS

In our cohort, HMI was a safe and effective treatment of thoracolumbar spondylodiscitis, with the potential benefits of reduced blood loss, operative duration, and postoperative pain.

Enhanced recovery after surgery (ERAS) pathway for microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion

OBJECTIVES

Enhanced recovery after surgery (ERAS) principle and minimally invasive surgery allow patients to recover faster and better postoperatively. Due to a paucity of their integration, this retrospective study aims to assess clinical outcomes of ERAS pathway in microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).

PATIENTS AND METHODS

A total of 72 consecutive cases were enrolled. According to their inclusion order, the former 21 cases received microendoscopy-assisted MIS-TLIF without any ERAS approach (control group), while the latter 51 participants underwent the same surgery with ERAS protocol (observation group). Perioperative parameters, including operative duration, intraoperative estimated blood loss (EBL), length of stay, postoperative analgesic usage and ambulatory time, were recorded. Visual analogue scale (VAS, back and leg), Barthel index were obtained before and at three days, one month, six months postoperatively. Modified MacNab criteria and Bridwell grading were used to assess surgical outcome and interbody fusion at one week and two years after surgery, respectively.

RESULTS

Observation group had statistically improved perioperative parameters (operative duration, intraoperative EBL, length of stay, postoperative analgesic usage and ambulatory time) in comparison with control group. Remarkable decreases in VAS (back and leg) were observed continuously at three days, one month and six months post-surgery in both groups when compared with scores prior to the surgery. More significant improvement of VAS (back and leg) was found in observation group at both three days and one month postoperatively. Regarding Barthel index, despite its transient decrease at three days after surgery in control group, it showed statistical increase at postoperative one month when compared with preoperative values in both groups; moreover, its inter-groups comparison revealed much more improvement in patients receiving ERAS recommendations; while at final follow-up, it continued further increase in either group. Marginally higher proportion of patients in observation group showed perfect or good clinical outcome, as well as solid interbody fusion.

CONCLUSIONS

ERAS pathway in microendoscopy-assisted MIS-TLIF has advantages of decreased operative time, reduced intraoperative haemorrhage, increased initial back pain relief, decreased length of stay, lowered analgesic usage and earlier daily activity recovery and thus, benefit postoperative rehabilitation further.

[Hybrid operating room : Application in trauma surgery and orthopaedics]

BACKGROUND

For some years now, more and more hospitals in Germany have acquired so-called hybrid operating rooms. In these operating rooms it is possible to produce three-dimensional imaging during the operation. Originally developed for cardiovascular surgery, these rooms are increasingly being used for interdisciplinary purposes. Previous experiences in the use for trauma surgery and orthopedics has shown that three-dimensional imaging can have a positive effect on the success of surgery.

OBJECTIVE

Can minimally invasive operations on the spine benefit intraoperatively from three-dimensional imaging with respect to operating times and results?

METHODS

Minimally invasive operations on the spine performed at the UKSH Campus Kiel between 2015 and 2018 in the hybrid operating room were considered. These were compared to minimally invasive spinal surgery performed in conventional operating rooms.

RESULTS

As is usual with the establishment of a new procedure, there are initially longer operating times. With regular use and appropriate training and experience of the personnel, the processes can be optimized.

CONCLUSION

Due to the accuracy of the three-dimensional imaging, errors can be detected and eliminated at an early stage during the operation. Revisions are less frequent. In contrast, there is increased radiation exposure and sometimes longer operation and anesthesia times.

Surgical and Clinical Results of Minimally Invasive Spinal Fusion Surgery in an Unselected Patient Cohort of a Spinal Care Unit

OBJECTIVES

To review the surgical results and to identify possible parameters influencing the clinical outcomes in an unselected patient collective undergoing minimally invasive lumbar interbody fusion in a spinal care unit.

METHODS

A total of 229 adult patients who underwent minimally invasive lumbar spinal fusion between 2008 and 2016 were included in this retrospective analysis. Lumbar fusion was performed using transforaminal interbody fusion (TLIF) devices and posterolateral fusion. To eliminate confounding parameters, in all patients interbody fusion was indicated by lumbar degenerative pathologies, and surgery was performed using the same fusion device. Treatment efficacy was evaluated using scores describing pain (visual analogue scale [VAS]) and health impairment (EQ-5D, Oswestry Disability Index [ODI]). The influence of patient age, obesity, active smoking status, and co-morbidities on clinical outcome and perioperative complications was analyzed.

RESULTS

The patient population reviewed had improved VAS (P_{(leg pain)} ≤ 0.0001, P_{(back pain)} ≤ 0.0001), ODI (P ≤ 0.0001), EQ-VAS (P ≤ 0.0001), and EQ-5D subscales "mobility", "self-care", "pain", and "anxiety" (P_(mobility) ≤ 0.0001, P_(self-care)  = 0.41, P_(pain) ≤ 0.0001, P_(anxiety)  = 0.011) postoperatively. Neither advanced patient age, nor increased body mass index (BMI), hypertension, or active smoking status had a significantly limiting influence on the success of minimally invasive spinal surgeries (MIS). Duration of surgery strongly correlated with the number of spinal levels treated and with intraoperative blood loss (r = 0.774, P ≤ 0.0001, n = 208). Weak positive correlations were found between patient age and duration of surgery (r = 0.184, P = 0.005, n = 229), intraoperative blood loss (r = 0.165, P = 0.012, n = 229), and duration of hospitalization (r = 0.270, P ≤ 0.0001, n = 228), respectively. When compared to non-smokers, smokers were younger (P ≤ 0.0001), and had a significantly lower BMI (P = 0.001), shorter durations of surgery (P ≤ 0.0001), decreased intraoperative blood loss (P = 0.022), and shorter hospital stays (P = 0.006), respectively. Complications occurred in 17 patients (7%) and were not affected by patient age, BMI, hypertension, or active smoking status.

CONCLUSION

Minimally invasive spinal surgery is a safe and effective treatment option and may be superior to open surgery in subpopulations with significant co-morbidities and risk factors, such as elderly and obese patients as well as patients with an active smoking status.

Minimally invasive unilateral pedicle screws and a translaminar facet screw fixation and interbody fusion for treatment of single-segment lower lumbar vertebral disease: surgical technique and preliminary clinical results

Background

Conventional open transforaminal lumbar interbody fusion (TLIF) using unilateral pedicle screws and a translaminar facet screw has been performed for many years with good results. The outcomes of minimally invasive TLIF (MIS TLIF) are similar to the good outcomes of open TLIF, with the additional benefits of reducing iatrogenic injury, shortening hospital stays, and reducing the recovery duration. Instead of using small cuts on both sides, we performed MIS TLIF through a single cut using unilateral pedicle screws and a translaminar facet screw. The operative feasibility, efficacy safety, and benefits of single-level MIS TLIF of such techniques require further clarification.

Methods

A total of 60 patients with various single-segment lower lumbar vertebral diseases were treated in our department from January 2010 to March 2013. All the patients were initially performed single-level MIS TLIF using a hybrid construction of unilateral pedicle screws and a translaminar facet screw. Patient demographics and operative data were collected. The clinical outcomes were assessed before surgery and 3, 6, 12, and 24 months after surgery using the visual analog scale (VAS) for back and leg pain and the Oswestry Disability Index (ODI). Radiologic assessment of the lumbar spine with static and dynamic plain radiographs was performed 3, 6, 12, and 24 months after surgery. The fusion rates were assessed by an independent radiologist 2 years after surgery according to the Bridwell interbody fusion grading system.

Results

No patients experienced significant postoperative complications. Excepting two cases, 58 cases were followed up for 24–38 months, averaged 29.9 ± 4.1 months. The patients’ average age was 46.6 ± 11.5 years, operative time 109.7 ± 17.8 min, intraoperative blood loss 67.3 ± 29.7 ml, length of incision 29.0 ± 3.2 mm, fluoroscopy time 31.1 ± 7.2 s, time to ambulation 20.3 ± 7.0 h, length of hospital stay 5.1 ± 1.1 days, and length of the translaminar facet screw 51.7 ± 3.4 mm. Screw position results: type I, 54 cases with 54 segments; type II, four cases with four segments. There were two (3.4%) translaminar facet screw failures, which were intraoperatively converted to a bilateral pedicle screw fixation procedure and excluded from the research. The postoperative images showed good positioning of the hybrid internal fixation, and all of the translaminar facet screws penetrated the facet joint. Two (3.6%) translaminar facet screws penetrated the lateral lamina and two (3.6%) translaminar facet screws penetrated the medial lamina without any serious neural complications. During the follow-up, there was no screw loosening or pedicle fracture observed. The VAS and ODI scores were significantly improved compared with the preoperative scores (P < 0.05), and the symptoms disappeared gradually. Fifty-one patients (87.9%) achieved grade I fusion radiographically at the final follow-up.

Conclusions

MIS TLIF using a hybrid construction of unilateral pedicle screws and a translaminar facet screw is safe and effective in the treatment of single-segment lower lumbar vertebral disease, and it can be used as an optimal choice for fixation and fusion of some single-segment lower lumbar vertebral diseases.

Microsurgery or open cervical foraminotomy for cervical radiculopathy? A systematic review

OBJECTIVE

The purpose of this article was to systematically review the clinical outcomes of microendoscopic foraminotomy compared with the traditional open cervical foraminotomy.

METHODS

A literature search of two databases was performed to identify investigations performed in the treatment of cervical foraminotomy with microsurgery or an open approach. Data including blood loss, surgical time, hospital stay, complications, clinical success rate, reduction of arm and neck pain, improvement of neurological function, and repeated surgery rate were summarized, calculated and compared. Results of clinical success were performed by calculattng effect indicators and standard errors based on a single rate to assess heterogeneity in the two groups.

RESULTS

The initial literature search resulted in 713 articles, of which, 26 were determined as relevant on abstract review. An open foraminotomy approach was performed in 16 and a microsurgery approach in ten studies. The open group demonstrated minimal to moderate heterogeneity, with I (2) value of 27 %; and microsurgery group demonstrated minimal heterogeneity, with I (2) value of 1 %. Aggregated data found that patients treated by microsurgery foraminotomy have lower blood loss by 100.1 ml (open: 149.5 ml, microsurgery: 49.4 ml, n = 1257), shorter surgical time by 24.9 minutes (open 88.7 minutes, microsurgery 63.8 minutes, n = 1423),and shorter hospital stay by 3.0 days (open 4.1 days, microsurgery 1.1 days, n = 1350), compared with patients treated by open cervical foraminotomy. The pooled clinical success rate was 89.7 % [confidence interval (CI) 87.7-91.6) in the open group versus 92.5 % (CI 89.9-95.1) in the microsurgery group, with no statistical difference (p = 0.095). Overall complication rates were not statistically significant between groups (p = 0.757). The incidence of dural tears was 1.07 %( 12/1121) in patients undergoing microsurgery versus 0.27 % (2/745) for open surgery (p = 0.091). The incidence of infection was 0.54 % (6/1121) in patients undergoing microsurgery versus 0.40 % (3/745) for open surgery (p = 0.949). The incidence of root injury was 0.80 % (9/1121) in patients undergoing microsurgery versus 1.48 % (11/745) for open surgery (p = 0.166). Revision surgery occurred in 2.32 % (27/1163) in the microsurgery group versus 3.35 % (28/835) for traditional surgery, with no statistical difference (p = 0.164). Pooled reduction in visual analogue scale for the arm (VASA) was 75.0 % (CI 66.0-84.0) in the open group and 87.1 % (CI:76.7, 97.5) in the microsurgery group, with no statistical difference (p = 0.065). Pooled reduction in VAS of the neck (VASN) was 66.2 % (CI:52.2, 80.2) in the open group and 68.1 % (CI:36.4, 99.8) in the microsurgery group, with no statistical difference(p = 0.894). Pooled improvement in neurological function was 55.3 % (CI:18.6, 91.9) in the open group and 64.9 % (CI:34.6, 95.2) in the microsurgery group, with no statistical difference (p = 0.576).

CONCLUSIONS

Although advantages of cervical microsurgery are less blood loss and shorter surgical time and hospital stay over the standard open technique, there is no significant difference in clinical success rate, complication rate, reduction of arm and neck pain and improvement of neurological function between microsurgery and open cervical foraminotomy.

Effect of the percutaneous pedicle screw fixation at the fractured vertebra on the treatment of thoracolumbar fractures

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of percutaneous pedicle screw fixation at the fractured vertebra in the treatment of thoracolumbar fractures.

METHODS

Thirty-two consecutive patients were enrolled in the study. All patients received percutaneous pedicle screw fixation, and they were randomly divided into two groups to undergo either the placement of pedicle screws into the fractured vertebra (fractured group) or not (control group). The operation time and intra-operative blood loss were recorded. Oswestry disability index (ODI) questionnaire and visual analogue scale (VAS) as clinical assessments were quantified. Radiographic follow-up was defined by the vertebral body index (VBI), anterior vertebral body height (AVBH), and Cobb angle (CA).

RESULTS

No significant difference was observed in the operation time and intra-operative blood loss between the two groups. Clinical results (VAS and ODI scores) showed no significant difference during all the follow-up periods. In the fractured group, there were better correction and less loss of AVBH and VBI compared with the control group. However, post-operative correction of the CA immediately after surgery and the correction loss at the final follow-up showed no significant difference between the two groups.

CONCLUSION

Percutaneous screw fixation combined with intermediate screws at the fractured vertebra could more effectively restore and maintain fractured vertebral height, and is an acceptable, minimally invasive surgical choice for patients with type A thoracolumbar fractures.

Adult Degenerative Scoliosis with Spinal Stenosis Treated with Stand-Alone Cage via an Extreme Lateral Transpsoas Approach; a Case Report and Literature Review

We report the case of a 73-year-old female with severe degenerative scoliosis and back and leg pain that was successfully treated with stand- alone cages via an extreme lateral transpsoas approach. This patient had declined open surgery and instrumentation due to her advanced age concerns about potential side effects.

Postoperative expansion of dural sac cross-sectional area after unilateral laminotomy for bilateral decompression: correlation with clinical symptoms

OBJECTIVE

Dural sac cross-sectional area (DSCSA) is a way to measure the degree of central spinal canal compression. The objective was to investigate the correlation between the expansion ratio of DSCSA after unilateral laminotomy for bilateral decompression (ULBD) and the clinical results for lumbar spinal stenosis.

METHODS

We retrospectively reviewed the clinical data and radiographs of 103 patients who underwent ULBD for symptomatic spinal stenosis in one year. We compared preoperative and postoperative clinical data and DSCSA and evaluated the correlation between clinical and radiographic measurements.

RESULTS

There was a significant increase of DSCSA after ULBD (p=0.000) and mean expansion ratio of DSCSA was 203.7±147.2%(range -32.9-826.1%). Clinical outcomes, measured by VAS and ODI were improved significantly not only in early postoperative period, but also in the last follow-up. However, there were no statistically significant correlations between the preoperative DSCSA and clinical symptoms, Perioperative expansion ratio of DSCSA and clinical parameters were also not correlated to the improvement of clinical symptoms significantly in both early postoperative phase and last follow-up.

CONCLUSION

Our result indicates that the DSCSA itself has a definite limitation to be correlated to the clinical symptoms, and thus meticulous correlation between the clinical presentation and MRI imaging is essential in determination of surgical treatment.

[Current status of thoracoscopic surgery for thoracic and lumbar spine. Part 2: treatment of the thoracic disc hernia, spinal deformities, spinal tumors, infections and miscellaneous]

INTRODUCTION

Thoracoscopic surgery or video-assisted thoracic surgery (VATS) of the thoracic and lumbar spine has evolved greatly since it appeared less than 20 years ago. It is currently used in a large number of processes and injuries. The aim of this article, in its two parts, is to review the current status of VATS of the thoracic and lumbar spine in its entire spectrum.

DEVELOPMENT

After reviewing the current literature, we developed each of the large groups of indications where VATS takes place, one by one. This second part reviews and discusses the management, treatment and specific thoracoscopic technique in thoracic disc herniation, spinal deformities, tumour pathology, infections of the spine and other possible indications for VATS.

CONCLUSIONS

Thoracoscopic surgery is in many cases an alternative to conventional open surgery. The transdiaphragmatic approach has made endoscopic treatment of many thoracolumbar junction processes possible, thus widening the spectrum of therapeutic indications. These include the treatment of spinal deformities, spinal tumours, infections and other pathological processes, as well as the reconstruction of injured spinal segments and decompression of the spinal canal if lesion placement is favourable to antero-lateral approach. Good clinical results of thoracoscopic surgery are supported by growing experience reflected in a large number of articles. The degree of complications in thoracoscopic surgery is comparable to open surgery, with benefits in regard to morbidity of the approach and subsequent patient recovery.

[Current status of thoracoscopic surgery for thoracic and lumbar spine. Part 1: general aspects and treatment of fractures]

INTRODUCTION

Thoracoscopic surgery or video-assisted thoracic surgery (VATS) of the thoracic and lumbar spine has greatly evolved since it appeared less than 20 years ago. Nowadays, it is indicated in a large number of processes and injuries. The aim of this article, in its 2 parts, is to review the current status of VATS in treatment of the thoracic and lumbar spine in its entire spectrum.

DEVELOPMENT

After reviewing the current literature, we develop each of the large groups of indications where VATS is used, one by one. This first part contains a description of general thoracoscopic surgical technique including the necessary prerequisites, transdiaphragmatic approach, techniques and instrumentation used in spine reconstruction, as well as a review of treatment and specific techniques in the management of spinal fractures.

CONCLUSIONS

Thoracoscopic surgery is in many cases an alternative to conventional open surgery. The transdiaphragmatic approach has made endoscopic treatment of many thoracolumbar junction processes possible, thus widening the spectrum of therapeutic indications. These include the treatment of fractures and deformities, as well as the reconstruction of injured spinal segments and decompression of the spinal canal in any etiological processes if the lesion placement is favourable to antero-lateral approach. Good clinical results of thoracoscopic surgery are supported by the growing experience reflected in a large number of articles. The degree of complications in thoracoscopic surgery is comparable to open surgery, with benefits in morbidity of the approach and subsequent patient recovery.