Search

Background: Delamination of cuff tendons has a negative impact on outcomes following arthroscopic rotator cuff repair (RCR). The purpose of this study is to compare en masse repair (EMR) and separate double-layer repair (SDLR) for delaminated rotator cuff tears. Methods: A systematic literature search was conducted on major databases (MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus) until 1 June 2023. Comparative studies with a minimum 24-month follow-up of patients undergoing arthroscopic RCR for delaminated tears were included. The outcomes assessed retear rates and functional outcomes. Results: Five eligible studies involving 325 cases were analyzed. The meta-analysis showed no significant difference in retear rates between SDLR and EMR for delaminated tears (OR = 0.73, 95% CI: 0.35–1.49). However, the meta-analysis demonstrated a significant intergroup difference in favor of the SDLR for the total Constant score (SMD = 0.68, 95% CI: 0.35 to 1.02), SST score (SMD = 0.37, 95% CI: 0.02 to 0.71), and postoperative range of abduction (SMD = 0.34, 95% CI: 0.03 to 0.64). Conclusion: The evidence suggests that the SDLR in arthroscopic RCR for delaminated rotator cuff tears leads to improved short-term functional outcomes and range of motion compared to EMR. However, there is no significant difference in retear risk between the two approaches. [ABSTRACT FROM AUTHOR]

(1) Background: Addressing large to massive rotator cuff tears (LMRCTs) poses complex challenges. This systematic review investigated outcomes of superior capsular reconstruction (SCR) with the long head of the biceps tendon (LHBT) compared to conventional rotator cuff repair (RCR) for LMRCTs. (2) Methods: A systematic search across the MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus databases until 1 October 2023 identified studies that directly compared SCR with LHBT with conventional RCR in patients with LMRCTs and included a minimum of a 12-month follow-up period. The assessed outcome measures encompassed retear rates, functional outcomes, range of motion (ROM), and acromiohumeral interval (AHI). Risk of bias assessment was conducted via the Robins-I tool. (3) Results: In six studies with 456 cases (210 SCR using LHBT and 246 using RCR), SCR with LHBT significantly reduced retear rates (OR = 0.21; 95% CI, 0.12–0.36; p < 0.01; I2 = 0%). Furthermore, SCR with LHBT showed significant improvement in range of forward flexion (SMD 0.32, 95% CI: 0.09–0.55, p < 0.01, I2 = 39%) and AHI (SMD 0.61, 95% CI: 0.31–0.92, p < 0.01, I2 = 0%) postoperatively. (4) Conclusion: SCR with LHBT is a safe and effective treatment for LMRCTs, reducing retear rates, maintaining greater postoperative AHI, and improving ROM compared to conventional RCR. Additional high-quality interventional studies are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Background/Objectives: The direct superior approach (DSA) is a tissue-sparing alternative to the traditional posterior approach (PA) in total hip arthroplasty (THA), potentially offering improved recovery and fewer complications. This study compares perioperative parameters, radiological and functional outcomes, and complications between the DSA and the PA in primary THA. Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines. Databases searched included MEDLINE/PubMed, Cochrane Library, Embase, and Scopus. Studies comparing the DSA and the PA in primary THA were included based on predefined criteria. Data extraction and quality assessment were performed independently by two authors. Statistical analyses included calculating standardized mean differences (SMD), odds ratios (OR), and 95% confidence intervals (CI). Heterogeneity was assessed using the χ2 test, I2 statistics, and sensitivity analyses. Results: Out of 126 identified articles, 10 studies were included, which encompassed 28,063 patients (DSA: 1464; PA: 26,599). Significant advantages of the DSA over the PA were observed in blood loss (SMD −0.26, p < 0.01), transfusion rate (OR 0.59, p = 0.03), length of stay (SMD −0.59, p < 0.01), discharge to home rates (OR 2.32, p < 0.01), and incision length (SMD −2.75, p < 0.01). No significant differences were found in radiological outcomes or most functional scores, although the DSA showed higher Harris Hip Scores at 1 month (SMD 0.77, p < 0.01). Conclusions: The DSA offers significant perioperative advantages over the PA, including reduced blood loss, transfusion rates, LOS, incision length, and improved early functional recovery with higher discharge to home rates. Comparable complication rates and radiological outcomes support the DSA's safety and efficacy for quicker recovery in THA. [ABSTRACT FROM AUTHOR]

Objective This study is aimed to comprehensively assess the prevalence and distribution of thoracic disc herniation (TDH) or thoracic hypertrophied ligamentum flavum causing stenosis (HLFS) by magnetic resonance image (MRI) in patients with back or leg pain. Methods The study participants included 2212 patients who underwent MRI evaluation for back or leg pain. The prevalence and distribution of TDH or thoracic HLFS were assessed using lumbar MRI with cervicothoracic sagittal images. The presence of TDH or HLFS and the clinical parameters such as age, sex, lumbar surgical need, and thoracic operation were retrospectively reviewed. Logistic regression analysis of the data was followed. Results The prevalence rates of TDH and thoracic HLFS in all patients were 6.5% (145/2212) and 19.0% (421/2212), respectively. The prevalence of TDH was demonstrated as a relatively even distribution across age groups, higher in male participants (8.0%) than in female participants, and more frequent in patients with lumbar surgical lesions (8.2%) than without surgical lesions. Whereas, the prevalence of thoracic HLFS tended to increase with age, was higher in female participants (21.6%) than in male participants, and had no association with presence of lumbar surgical lesions. The most frequently involved segments of TDH and HLFS were T8/9 and T10/11, respectively. Six of 145 patients with TDH and 15 of 421 patients with HLFS underwent surgery. Conclusions The prevalence of TDH had a significant association with the presence of lumbar surgical lesions and no association with age. The prevalence of thoracic HLFS had a strong association with age and no association with lumbar surgical lesions. Highlights • Prevalence of thoracic disc herniation in patients with back or leg pain was 6.5%. • Prevalence of thoracic disc herniation was evenly distributed across age groups. • Prevalence of thoracic disc herniation was high in patients with lumbar surgical lesions. • Degenerative lumbar spinal disease has high prevalence of incidental thoracic lesions. [ABSTRACT FROM AUTHOR]

Background: Comorbid chronic obstructive pulmonary disease (COPD) is increasingly common and may have an adverse impact on outcomes in patients undergoing total joint arthroplasty (TJA) of lower extremity. The purpose of this meta-analysis is to compare the postoperative complications between COPD and non-COPD patients undergoing primary TJA including total hip and knee arthroplasty. Methods: PubMed, EMBASE, and Cochrane Library were systematically searched for relevant studies published before December 2021. Postoperative outcomes were compared between patients with COPD versus those without COPD as controls. The outcomes were mortality, re-admission, pulmonary, cardiac, renal, thromboembolic complications, surgical site infection (SSI), periprosthetic joint infection (PJI), and sepsis. Results: A total of 1,002,779 patients from nine studies were finally included in this meta-analysis. Patients with COPD had an increased risk of mortality (OR [odds ratio] = 1.69, 95% confidence interval [CI] 1.42–2.02), re-admission (OR = 1.54, 95% CI 1.38–1.71), pulmonary complications (OR = 2.73, 95% CI 2.26–3.30), cardiac complications (OR = 1.40, 95% CI 1.15–1.69), thromboembolic complications (OR = 1.21, 95% CI 1.15–1.28), renal complications (OR = 1.50, 95% CI 1.14–1.26), SSI (OR = 1.23, 95% CI 1.18–1.30), PJI (OR = 1.26, 95% CI 1.15–1.38), and sepsis (OR = 1.36, 95% CI 1.22–1.52). Conclusion: Patients with comorbid COPD showed an increased risk of mortality and postoperative complications following TJA compared with patients without COPD. Therefore, orthopedic surgeons can use the study to adequately educate these potential complications when obtaining informed consent. Furthermore, preoperative evaluation and medical optimization are crucial to minimizing postoperative complications from arising in this difficult-to-treat population. Level of evidence: Level III. Registration: None. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

In the first phase of development of lumbar endoscopic spine surgery, the focus was on removal of soft disc material through the working corridor of Kambin’s triangle using transforaminal endoscopic lumbar discectomy. With the introduction of the interlaminar approach and increased interest from both industry and surgeons , there has been an exponential development of endoscopic surgical equipment and a corresponding expansion of endoscopic techniques. Endoscopic treatment strategies are applied to conditions ranging from contained prolapsed intervertebral discs to noncontained migrated herniated discs, hard calcified discs, spinal stenosis in the central or lateral recess and the foraminal and extraforaminal region, and other combinations of degenerative conditions requiring decompression or fusion surgery. The further expansion of endoscopic surgical management involving complicated spinal cases and the final quartet of trauma, infections, tumors, and possibly deformities could be the future stage of endoscopic spine surgery development. This article covers the full range of current treatment strategies and presents possible future developments of endoscopic spine surgery for the management of lumbar spinal conditions. [ABSTRACT FROM AUTHOR]

This study aimed to categorize contrast media images associated with epidural, subdural, and combined epidural–subdural anesthesia in patients who had undergone fluoroscopy-guided epidural anesthesia using contrast media combined with monitored anesthesia care (MAC) targeted at deep sedation, incorporating capnography over 5 years. Additionally, a correlation was established between the anesthetic effects and radiographic findings according to the categorized imaging appearances. This study included 628 patients who underwent endoscopic, open, or fusion surgery under epidural anesthesia at Nanoori Hospital in Gangnam between March 2018 and September 2023. Fluoroscopy-guided epidural anesthesia using contrast media combined with MAC and capnography was used. The dataset included detailed radiographic imaging, nursing, and anesthesia records. Distinct patterns of anesthesia administration were observed, with 49%, 19.6%, and 31% of patients receiving epidural, subdural, and combined epidural–subdural anesthesia, respectively. The incidence and duration of motor block were significantly different among the three groups. Additionally, subdural anesthesia displayed a higher incidence of motor block and a prolonged motor deficit duration than epidural anesthesia. Fluoroscopic guidance using a contrast medium for epidural and subdural anesthesia ensures precise space identification and prevents serious anesthetic complications. Our findings suggest the potential to achieve stable anesthesia, particularly using subdural and combined epidural–subdural anesthesia. [ABSTRACT FROM AUTHOR]

Background: Evolution of endoscopic surgery provides equivalent results to open surgery with advantages of minimal invasive surgery. The literature on technique Uniportal Full endoscopic contralateral approach is scarce. Methods: The endoscopic contralateral approach technique applies for patients presenting with double crush syndrome with foraminal and extraforminal stenosis. The key steps focus on contralateral ventral overriding superior articular process decompression, foraminal and extraforaminal discectomy, and lateral vertebral syndesmophyte decompression leading to enlargement of the contralateral foramen and extraforamen size. Conclusion: The Uniportal Full endoscopic contralateral approach is a good alternative to open surgery or minimally invasive microscopic surgery through direct endoscopic visualization of the entire route of exiting nerve with no neural retraction allowing both lateral recess and foraminal and extraforaminal decompression all in one approach. [ABSTRACT FROM AUTHOR]

Cervical radiculopathy is a common and disabling cervical condition characterized by symptoms including axial neck pain, radicular pain, weakness, and numbness in one or both arms. Common causes include herniated discs and foraminal stenosis, often accompanied by varying degrees of degenerative disc disease and uncovertebral joint hypertrophy. In the treatment of cervical radiculopathy, there is an increasing preference for posterior foraminotomy over anterior cervical discectomy and fusion due to the avoidance of fusion-related complications. As endoscopic spine surgery techniques continue to evolve, there is a rising interest in posterior endoscopic cervical foraminotomy and posterior endoscopic cervical discectomy as effective treatments for cervical radiculopathy. Because these procedures can performed through a single subcentimeter incision with minimal soft tissue damage, they can often be carried out as ambulatory procedures. In this narrative review, we examined current literature addressing the indications, surgical techniques, outcomes, and potential complications associated with posterior cervical endoscopic approaches. [ABSTRACT FROM AUTHOR]

Background With advances in techniques and instruments, percutaneous endoscopic transforaminal lumbar diskectomy (PETLD) is now widely used for lumbar disk herniation. Although the indication for PETLD is expanding, the technique still has limitations. To overcome them, we performed the epidural catheter-assisted PETLD described here. Methods A 49-year-old woman had severe radiating pain in a left L5 dermatomal distribution. Magnetic resonance imaging (MRI) revealed left paramedial disk herniation at L4–L5 and a small downward-migrated disk fragment. We performed epidural catheter-assisted PETLD. Mechanical outward pushing and normal saline injection through the epidural catheter were performed for removal of hidden disk remnants. In the second case, a 26-year-old man presented with severe radiating pain in the L5–S1 dermatoms on both sides. MRI revealed massive disk herniation at L4–L5. A unilateral approach was used, and the ruptured disk could be moved using an epidural catheter. Results The patients' pain improved immediately after the procedures. With this method, neural decompression can be performed more easily and effectively. Conclusions Epidural catheter-assisted PETLD has several advantages and can overcome the limitations of conventional PETLD. [ABSTRACT FROM AUTHOR]

Objective Treatment of severely canal compromising lumbar disk herniations (LDH), occupying more than 50% of the canal area, are associated with technical difficulty and worse outcomes. This study aimed to describe new techniques of transforaminal endoscopic lumbar diskectomy (TELD) with less neural retraction, and total annular resection for broad-based severely canal compromising disk herniation. We also evaluated the feasibility and safety of the techniques, and analyzed the clinical and radiologic outcomes of 32 patients presenting with neurologic deficits. Methods A retrospective cohort study was performed with 32 consecutive patients who underwent TELD for broad-based severely canal compromising LDH between January 2018 and January 2020. We removed the LDH using two novel techniques: (1) the "mobile outside-in" approach and total annular resection method and (2) internal decompression and subsequent pushdown method of the migrated fragment. The cross-sectional area (CSA) on magnetic resonance image was evaluated preoperatively and compared with the postoperative image within 7 days and between 6 months and 1 year. The visual analog scale (VAS) for back and leg pain, Oswestry disability index (ODI), MacNab's criteria, and motor power of the involved lower extremities were evaluated pre- and postoperatively. Results A total of 32 patients, with an average age of 37.5 years (range: 17–66), underwent surgery. The mean VAS score for back pain improved from 7.84 ± 1.02 to 1.31 ± 0.54 and the ODI score improved from 74.3 ± 7.82 to 20.4 ± 3.71 at final follow-up. According to MacNab's criteria, 23 patients had excellent and 9 patients had good outcomes at final follow-up. All patients operated on at the L4–L5 level had great toe/ankle dorsiflexion and/or ankle plantar flexion weakness; knee extension weakness was found at the L2–L3 and L3–L4 levels. Motor function improved significantly; the mean values and range preoperatively, and at 1 month, 3 months, and final follow-up, were 3.41 ± 0.95 (1–4), 4.56 ± 0.56 (3–5), 4.88 ± 0.34 (4–5), and 4.97 ± 0.18 (4–5), respectively (p < 0.001, at all follow-up). The mean values and range of the preserved CSA proportion, preoperatively and within 1 week after surgery, and at final follow-up were 34.9 ± 10.9 (15–61), 81.06 ± 10.24 (63–97), and 93.03 ± 5.37 (76–99), respectively (p < 0.001, at all follow-up). Conclusion The transforaminal endoscopic approach for broad-based severely canal compromising LDH can be considered a feasible surgical option for an experienced surgeon. With total annular resection and pushdown of migrated fragments, safe and complete removal of LDH was possible in patients with a neurologic deficit. Total annular resection may increase the overall but not the early recurrence rate. [ABSTRACT FROM AUTHOR]

Objective: There is a lack of literature on indirect decompression in uniportal endoscopic posterolateral transforaminal lumbar interbody fusion (EPTLIF). Our aim is to evaluate the dimensions of the spinal canal and contralateral foramen before and after EPTLIF. Methods: This is a retrospective study of patients who underwent EPTLIF in a tertiary spine centre over a 2-year period. The cross-sectional area of the spinal canal and the contralateral foramen at the level of fusion were measured on magnetic resonance imaging scan at 1-day postoperation and at the final follow-up. Patients were grouped according to the decompression performed as per the clinician's judgement. Results: One hundred fifty-two levels of fusion were performed in 120 patients. There was a statistically significant clinical improvement in visual analogue scale and Oswestry Disability Index scores postoperation. The measurements of the spinal canal area were 106.0 mm2, 138.8 mm2, and 195.5 mm2; while contralateral foraminal area were 73.2 mm2, 104.4 mm2, and 120.7 mm2 at preoperation, 1-day postoperation, and at the final follow-up, respectively (p < 0.001). For the subgroup analyses, spinal canal area measurements for the bilateral decompression cohort (n = 35) were 57.0 mm2, 123.9 mm2, and 191.8 mm2; for the ipsilateral decompression cohort (n = 42) were 89.3 mm2, 128.9 mm2, 183.3 mm2; and for the cohort without any decompression and only cage inserted (n = 75) were 138.3 mm2, 151.2 mm2, and 204.1 mm2 (p < 0.001). Contralateral foraminal area measurements were 73.3 mm2, 106.4 mm2 and 120.4 mm2 in the bilateral decompression cohort; 69.5 mm2, 99.0 mm2, 116.9 mm2 in the ipsilateral decompression cohort; and 75.1 mm2, 106.5 mm2, 122.9 mm2 in the cohort without any decompression (p < 0.001). Conclusion: Indirect decompression of both the spinal canal and the contralateral foramen can be achieved via EPTLIF. Decompression on an asymptomatic contralateral side is not necessary. [ABSTRACT FROM AUTHOR]

Uniportal interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) aims to achieve decompression of lumbar spinal stenosis in the contralateral lateral recess and foraminal and extraforaminal regions of the same segment. This technique is performed under normal saline irrigation using an endoscope with optical lens magnification close to the targeted stenotic segment and has the potential of lower incidence of exiting nerve root dorsal root ganglion irritation. A systematic review of the ICELF technique was conducted from March 2000 to March 2022. Articles were selected with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eligibility of studies was independently determined by 2 reviewers, and disagreements were resolved by a third author. Eight retrospective cohort studies comprising 194 patients with foraminal stenosis who underwent uniportal ICELF were selected for systematic review. Mean age range was 62–79 years, and surgical duration was 48–73.5 minutes. There was significant improvement in Oswestry Disability Index and visual analog scale leg pain score in the included studies. Four studies met the minimum clinically significant difference for leg pain, with visual analog scale improved >5 points and Oswestry Disability Index improved >8.2 points. Four studies reported a majority of the operated patients with good or excellent outcomes following surgery, with a low rate of complications in the studies selected. There is low-level evidence that ICELF when performed by an experienced spinal endoscopic surgeon is effective in providing pain relief and improved function with low rate of complications in select patients. [ABSTRACT FROM AUTHOR]

Bilateral chylothorax following anterior cervical spine surgery is very rare. This report documents the first case of chylothorax after anterior cervical spine surgery through a right-side surgical approach. Unidentified chyle leakage can easily remain unrecognized and, thus, is difficult to treat. For early diagnosis and treatment, it is very important to consider the possibility of chylothorax following anterior cervical spine surgery, even when using a right-side surgical approach. [ABSTRACT FROM AUTHOR]

Objective: Limited literature on the effect on clinical and radiological outcomes in cervical endoscopic spine surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients for cervical disc herniations and foraminal pathologies. Methods: Retrospective comparative cohort study of two periods of 2015 to 2017 (first generation) is compared to 2018–2020 (second generation) on surgical treatment of degenerative cervical spinal conditions for 132 spinal cases. Basic demographics, preoperative, post-operative 1 week, 3 months and final follow-up of patients' clinical outcomes in terms of Visual Analog Scale Pain Score, Neck Disability Index, Japanese Orthopaedic Association Score and MacNab's Criteria were evaluated. Results: In the first generation, 50 cases of cervical disc herniation and foraminal stenosis with 70% open anterior cervical discectomy fusion or disc replacement 30% of the cases underwent posterior cervical endoscopic procedures with complication rate of 2%. In the second generation, 82 cases of cervical disc herniation and foraminal stenosis with 7% open anterior cervical discectomy fusion or disc replacement 93% of the cases underwent posterior cervical endoscopic procedures with complication rate of 6%. Compared to preoperative score, motor, JOA, VAS and NDI scores all statistically significant improved within the individual cohort. Compared to the first generation, the second generation has statistically significant improved VAS of 0.326+/−0.146 at 3 months and 0.648+/−0.163 at final follow-up and statistically significant improved NDI of 2.81+/−1.15 at final follow-up, p < 0.05. Conclusions: Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing good clinical outcomes. [ABSTRACT FROM AUTHOR]

Objective: There is limited literature on repetitive postoperative MRI and clinical evaluation after Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. Methods: Clinical visual analog scale, Oswestry Disability Index, McNab's criteria evaluation and MRI evaluation of the axial cut spinal canal area of the upper end plate, mid disc and lower end plate were performed for patients who underwent single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. From the evaluation of the axial cut MRI, four types of patterns of remodeling were identified: type A: continuous expanded spinal canal, type B: restenosis with delayed expansion, type C: progressive expansion and type D: restenosis. Result: A total of 126 patients with single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression were recruited with a minimum follow-up of 26 months. Thirty-six type A, fifty type B, thirty type C and ten type D patterns of spinal canal remodeling were observed. All four types of patterns of remodeling had statistically significant improvement in VAS at final follow-up compared to the preoperative state with type A (5.59 ± 1.58), B (5.58 ± 1.71), C (5.58 ± 1.71) and D (5.27 ± 1.68), p < 0.05. ODI was significantly improved at final follow-up with type A (49.19 ± 10.51), B (50.00 ± 11.29), C (45.60 ± 10.58) and D (45.60 ± 10.58), p < 0.05. A significant MRI axial cut increment of the spinal canal area was found at the upper endplate at postoperative day one and one year with type A (39.16 ± 22.73; 28.00 ± 42.57) mm2, B (47.42 ± 18.77; 42.38 ± 19.29) mm2, C (51.45 ± 18.16; 49.49 ± 18.41) mm2 and D (49.10 ± 23.05; 38.18 ± 18.94) mm2, respectively, p < 0.05. Similar significant increment was found at the mid-disc at postoperative day one, 6 months and one year with type A (55.16 ± 27.51; 37.23 ± 25.88; 44.86 ± 25.73) mm2, B (72.83 ± 23.87; 49.79 ± 21.93; 62.94 ± 24.43) mm2, C (66.85 ± 34.48; 54.92 ± 30.70; 64.33 ± 31.82) mm2 and D (71.65 ± 16.87; 41.55 ± 12.92; 49.83 ± 13.31) mm2 and the lower endplate at postoperative day one and one year with type A (49.89 ± 34.50; 41.04 ± 28.56) mm2, B (63.63 ± 23.70; 54.72 ± 24.29) mm2, C (58.50 ± 24.27; 55.32 ± 22.49) mm2 and D (81.43 ± 16.81; 58.40 ± 18.05) mm2 at postoperative day one and one year, respectively, p < 0.05. Conclusions: After full endoscopic lumbar decompression, despite achieving sufficient decompression immediately postoperatively, varying severity of asymptomatic restenosis was found in postoperative six months MRI without clinical significance. Further remodeling with a varying degree of increment of the spinal canal area occurs at postoperative one year with overall good clinical outcomes. [ABSTRACT FROM AUTHOR]

With advances and refinements in endoscopic lumbar spine surgery showing effective and satisfactory results, the need for simple yet effective anesthetic techniques for minimally invasive endoscopic spine surgery has increased. The aim of this study was to compare feasibility and postoperative outcomes of fluoroscopy-guided epidural anesthesia with general anesthesia in patients undergoing endoscopic lumbar decompression surgery (≤3 levels). Patients who underwent 1–3 levels of endoscopic lumbar decompression surgery under either fluoroscopy-guided epidural or general anesthesia between January 2019 and October 2020 were retrospectively reviewed. Postoperative pain intensity and use of rescue analgesics for up to 48 hours were compared between the epidural and general anesthesia groups. Intraoperative anesthetic data and postoperative recovery profiles were also analyzed. Postoperative pain scores were significantly lower in the epidural anesthesia group compared with the general anesthesia group at 10 minutes after recovery room admission (2.1 ± 1.8 vs. 5.7 ± 1.9, P < 0.001), 24 hours postoperatively (3.3 ± 1.0 vs. 5.4 ± 1.8, P < 0.001), and 48 hours postoperatively (3.2 ± 0.6 vs. 4.4 ± 1.4, P < 0.001). The proportion of patients requiring rescue analgesics in the recovery room was significantly lower in the epidural anesthesia group (1.9% vs. 20.5%, P = 0.027). The median 15-item Quality of Recovery score on postoperative day 1 was significantly higher in the epidural anesthesia group (118.0 [113.5–123.0] vs. 82.0 [73.5–111.5], P < 0.001). Occurrence of nausea, vomiting, and voiding difficulty up to 48 hours postoperatively did not differ between groups. Compared with general anesthesia, epidural anesthesia provided better analgesia and recovery characteristics during the early postoperative period in endoscopic lumbar decompression surgery. [ABSTRACT FROM AUTHOR]

Objectives The aim of this retrospective case study was to analyze the outcomes of minimal nerve root retraction in patients with impending neurologic deficit in degenerative lumbar spine disease using the full-endoscopic spine surgery. Materials and Methods Thirty-seven consecutive patients with impending neurologic deficit underwent endoscopic spine surgery through either the transforaminal or the interlaminar approach. Their clinical outcomes were evaluated with visual analog scale (VAS) leg pain score, Oswestry Disability Index (ODI), and MacNab's criteria. The outcome of motor deficitis was evaluated with the Medical Research Council (MRC) grade. Completeness of decompression was documented with a postoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan. Results A total of 40 lumbar levels of 37 patients were operated, VAS score of the leg improved from 7.7 ± 1 to 1.9 ± 0.6 (p < 0.0001). ODI score improved from 74.7 ± 6.5 to 25.4 ± 3.49 (p < 0.0001). Motor weakness improved significantly immediately after surgery. The mean MRC grade increased to 1.97, 3.65, 4.41, and 4.76 preoperatively, at 1 week, at 3 months, and at the final follow-up, respectively, and all the patients with foot drop and cauda equina syndrome symptom recovered completely. One patient with great toe drop recovered partially to MRC grade 3. Mean follow-up of the study was 13.3 ± 6.1 months. According to MacNab's criteria, 30 patients (80.1%) had good and 7 patients (18.9%) had excellent results. Three patients required revision surgery. Conclusions Minimal nerve root retraction during full-endoscopic spine surgery is safe and effective for treatment of the impending neurologic deficit. We could achieve a thorough decompression of the affected nerve root with acceptable clinical outcome and minimal postoperative morbidity. [ABSTRACT FROM AUTHOR]

Postoperative dysesthesia (POD) is a common complication in surgery involving foraminal diseases, including lumbar foraminal or extraforaminal herniated nucleus pulposus (HNP). Minimal dorsal root ganglion (DRG) retraction is key to preventing POD. We compared the clinical results, safety, and efficacy between the paraspinal transforaminal approach requiring DRG retraction and the interlaminar contralateral approach without DRG retraction for foraminal and extraforaminal diseases. A retrospective cohort study was performed of 50 patients who underwent uniportal transforaminal endoscopic lumbar foraminotomy and discectomy (TELD) and 50 patients who underwent anuniportal interlaminar contralateral endoscopic lumbar foraminotomy and discectomy (ICELF) because of lumbar foraminal HNP. The operated levels, combined degenerative diseases, postoperative complications, and POD were analyzed. The visual analog scale (VAS) pain scores, modified Oswestry Disability Index, and MacNab criteria for evaluating pain disability and response were analyzed. In the ICELF group (total, n = 7, 14%), there were 5 (10%) and 2 (4%) patients with POD grade 1 and 2, respectively. In the TELD group (total, n = 13, 26%), there were 7 (14%), 5 (10%), and 1 (2%) patients with POD grade 1, 2, and 3, respectively. The overall occurrence rate of grade 2 and greater POD was higher in the TELD group (n = 6, 12%) than in the ICELF group (n = 2, 4%). In the ICELF group, 3 of 9 patients (33%) with combined canal structure deforming diseases had POD, of whom none had POD of grade 2 and greater. In the TELD group, 4 of 7 patients (57%) with combined canal structure deforming diseases had POD, of whom all had POD of grade 2 and greater. Two surgical groups showed favorable clinical outcomes with the visual analog scale, Oswestry Disability Index, and MacNab criteria. Both TELD and ICELF were found to treat foraminal or extraforaminal HNP with good clinical outcomes. ICELF might have a lower POD rate in complicated cases such as adjacent segment disease, degenerative spondylolisthesis, and isthmic spondylolisthesis. This surgical procedure could be an alternative in complicated cases or in patients with an anatomically limited L5-S1 level. However, the procedure is technically challenging to perform. [ABSTRACT FROM AUTHOR]

Background: Despite of the evolution of endoscopic surgery, the literature on technique uniportal transforaminal endoscopic lumbar discectomy (TELD) for bilateral lesions is scarce. Methods: Unilateral TELD was performed in a patient with bilateral superior and inferior migrated, broad-based disc herniation presenting with an impaired neurological state. The key surgical steps focus on free mobility in Kambin triangle with the mobile outside-in technique and accessibility to contralateral lesions with an extensive annular resection procedure. Conclusion: TELD can be a surgical option for treating bilateral multiple direction migrated lumbar disc herniation with benefits of minimal neural retraction and facet joint preservation. [ABSTRACT FROM AUTHOR]

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases. [ABSTRACT FROM AUTHOR]

Purpose: Cervical radiculopathy is a common disabling cervical spine condition. Open anterior and posterior approaches are the conventional surgical treatment approaches with good clinical outcomes. However, the soft tissue damage in these procedures can lead to increase perioperative morbidity. Endoscopic spine surgery provides more soft tissue preservation than conventional approaches. We investigate the radiological and clinical outcomes of posterior endoscopic cervical foraminotomy and discectomy. Methods: A prospective clinical and radiological study with retrospective evaluation were done for 25 patients with 29 levels of cervical radiculopathy who underwent posterior endoscopic cervical discectomy from November 2016 to December 2018. Clinical outcomes of Visual Analogue Scale, Neck Disability Index and MacNab's score were evaluated at pre-operative, post-operative 1 week, 3 months and final follow-up. Preoperative and post-operative final follow-up flexion and extension roentgenogram were evaluated for cervical stability assessment. Pre-operative and post-operative computer tomography cervical spine evaluation of foraminal length in ventro-dorsal, cephalad-caudal dimensions, sagittal foraminal area and using 3D CT reconstruction coronal decompression area were done. Results: Twenty-nine levels of cervical radiculopathy underwent posterior endoscopic cervical decompression. The mean follow-up was 29.6 months, and the most common levels affected were C5/6 and C6/7. There was a complication rate of 12% with 2 cases of neurapraxia and one case of recurrent of prolapsed disc. There was no revision surgery in our series. There was significant clinical improvement in Visual Analogue Scale and Neck Disability Index. Prospective comparative study between preoperative and final follow-up mean improvement in VAS score was 5.08 ± 1.75, and NDI was 45.1 ± 13.3. Ninety-two percent of the patients achieved good and excellent results as per MacNab's criteria. Retrospective evaluation of the radiological data showed significant increments of foraminal dimensions: (1) sagittal area increased 21.4 ± 11.2 mm2, (2) CT Cranio Caudal length increased 1.21 ± 1.30 mm and (3) CT ventro-dorsal length increased 2.09 ± 1.35 mm and (4) 3D CT scan reconstruction coronal decompression area increased 536 ± 176 mm2, p < 0.05. Conclusion: Uniportal posterior endoscopic cervical foraminotomy and discectomy are safe, efficient and precise choreographed set of technique in the treatment of cervical radiculopathy. It significantly improved clinical outcomes and achieved the objective of increasing in the cervical foramen size in our cohort of patients. [ABSTRACT FROM AUTHOR]

Cervical radiculopathy is a common cervical spine condition. However, a paucity of data is available on the effect of partial pediculotomy and partial vertebrotomy (PPPV) for posterior endoscopic cervical foraminotomy (PECF) to treat cervical radiculopathy. We investigated the radiological and clinical outcomes of this approach. We performed a retrospective evaluation of 30 patients with cervical radiculopathy who had undergone PPPV PECF. Pre- and postoperative radiographs were performed to evaluate for stability, and computed tomography (CT) was used to evaluate the foraminal dimensions and area in the sagittal view. Three-dimensional reconstruction of the area of decompression was also performed. The clinical outcomes were evaluated using the visual analog scale, Oswestry disability index, and the MacNab criteria. No complications or recurrence developed in our PPPV PECF cohort during the study period. At the preoperative, 1-week postoperative, 3-month postoperative, and final follow-up examinations, the mean visual analog scale scores and mean Oswestry disability index showed significant improvement (score, 7.6, 3.0, 2.1, and 1.7, respectively; P < 0.05; and score, 73.9, 28.1, 23.3, and 21.5, respectively; P < 0.05). All the patients scored good to excellent using the MacNab criteria. The radiological findings showed that PPPV PECF resulted in a significant increase in decompression in the foramen area for all CT-measured parameters compared with the mean preoperative values: 1) the sagittal area increased 60.1 ± 23.1 mm2; 2) the craniocaudal length increased 4.0 ± 1.54 mm; and 3) the ventrodorsal length increased 4.0 ± 1.97 mm; Also, the 3-dimensional CT scan reconstruction decompression area had increased 996 ± 266 mm2 (P < 0.05). PPPV PECF is a safe route for decompression of the cervical spine with good clinical and radiological outcomes. [ABSTRACT FROM AUTHOR]

Uniportal endoscopic posterolateral lumbar interbody fusion (Endo-TLIF) provides one of the least invasive forms of minimally invasive surgery, allowing large size cages which are commercially available for open and tubular microscopic transforaminal lumbar interbody fusion (TLIF) to be inserted through this approach. We studied the effect of such a technique on a series of patients with low-grade degenerative scoliosis. Endo-TLIF was applied to patients who had 10°–40° of degenerative adult scoliosis. Pre- and postoperative 1-week, 3-month, and final follow-up clinical status of visual analog scale, Oswestry Disability Index, perioperative complications, and Macnab criteria were collected. Roentgenogram to assess changes in Cobb angles was done. There was statistically significant improvement of preoperative, 1-week postoperative, 3-month postoperative, and final follow-up mean of visual analog scale scores with 7.72 (5–10), 3.68 (3–6), 2.88 (2–4), and 1.96 (1–3), respectively, and with Oswestry Disability Index mean of 70.4 (52–86), 35.12 (26–56), 27.68 (24–38), and 24 (20–28), respectively (P < 0.05). In terms of Macnab criteria, 100% had good to excellent result. In terms of scoliosis measured by Cobb angle, there was statistically significant improvement. Endo-TLIF is a safe and effective procedure in mild to moderate degenerative scoliosis with good early clinical results and improvement in coronal Cobb angle. It can be considered as an option if a short segment(s) fusion is planned for adult degenerative scoliosis. [ABSTRACT FROM AUTHOR]

Background: A paucity of literature on the effect of spinal endoscopic surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients.Objective: Evaluation of the effect of endoscopic practice expansion in degenerative spinal conditions and disc herniations on patients' outcome as we shifted from first-generation endoscopic discectomy to second-generation decompression and finally third generation of endoscopic spinal fusion practice.Subjects and Methods: Retrospective cohort study on surgical treatment of degenerative spinal conditions for 616 spinal cases. Basic demographics, preoperative, postoperative 1 week, 6 months, and final follow-up of patients' clinical outcomes in terms of pain score, Oswestry disability index, and MacNab's criteria for pain score were evaluated.Results: 75%, 91%, and 97% of the surgeries with complications rate of 8.2%, 9%, and 3.4% were found in Generation 1, 2, and 3 of endoscopic surgery, respectively. Compared to preoperative scores, each generation VAS and ODI scores all statistically significantly improved. In the final follow-up, compared to preoperative state, the mean VAS improvement was 4.75 ± 1.7, 5.49 ± 1.66, and 5.37 ± 1.70, mean ODI improvement was 45.99 ± 11.8, 48.93 ± 11.2, and 48.43 ± 11.41, and MacNab's criteria showed a trend of upward improvement of 87.3%, 96.0%, and 98.7% cases, which showed good-to-excellent outcome, in Generation 1, 2, and 3, respectively.Conclusions: Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing a good clinical outcome. [ABSTRACT FROM AUTHOR]

Cervical radiculopathy is a common cervical spine condition. There is a paucity of literature discussing the effect of partial pediculotomy and partial vertebrotomy for posterior endoscopic cervical foraminotomy (PPPV PECF) on cervical radiculopathy. We investigated the radiologic and clinical outcomes of this approach. This was a retrospective evaluation of 30 cases with cervical radiculopathy who underwent PPPV PECF. Preoperative, postoperative roentgenogram for evaluation of stability, computed tomography (CT) evaluation of foraminal dimensions, and area in sagittal view was performed. Three-dimensional reconstruction area of decompression evaluation was performed. Clinical outcomes of the visual analog scale, Oswestry Disability Index, and Macnab score were evaluated. There was no complication and recurrence in our PPPV PECF cohort during the study period. At preoperative, 1 week postoperative, and 3 months postoperative and final follow-up, the mean visual analog scale score had significant improvement, with scores of 7.6, 3.0, 2.1, and 1.7, respectively, P < 0.05, and also the mean Oswestry Disability Index, with scores of 73.9, 28.1, 23.3, and 21.5 respectively, P < 0.05. Macnab criteria showed all patients scoring good and excellent. Radiologic results showed PPPV PECF had a significant increase in decompression in the foramen area in all CT-measured parameters, as compared with the mean preoperative values; 1) sagittal area increased 60.1 ± 23.1 mm2, 2) CT craniocaudal length increased 4.0 ± 1.54 mm, 3) CT ventrodorsal length increased 4.0 ± 1.97 mm, and 4) 3-dimensional CT scan reconstruction decompression area increased 996 ± 266 mm2, P < 0.05. PPPV PECF is a safe route of decompression of cervical spine with good clinical and radiologic outcome. [ABSTRACT FROM AUTHOR]

We sought to review the types of incidental durotomies (IDs) that occurred during the endoscopic stenosis lumbar decompression through interlaminar approach (ESLD) and discuss the management strategies according to our classification. A retrospective evaluation was performed for patients with spinal stenosis who underwent ESLD. Out of 330 patients, 27 patients of ID were clinically evaluated preoperatively and postoperatively on the basis of a visual analog scale score, Oswestry Disability Index, and MacNab's criteria. ID patterns are classified according to the size, location, and involvement of neural elements. Intraoperative and postoperative surgical management was evaluated. Intraoperative incidence of ID was 8.2%. According to lumbar levels, 11 (40.7%) occurred at L3-4, 12 (44.4%) at L4-5, and 4 (14.8%) at L5-S1 ID cases. IDs were divided into 4 types: 29.6% are type 1, 70% are type 2, 7.4% are type 3, and 3.7% are type 4. Overall for mean and standard deviation preoperative, 1 week postoperative, 3 months, and final follow-up for visual analog scale are 7.6 ± 1.4, 3.3 ± 1.1, 2.6 ± 1.1, and 1.9 ± 1.3, and for Oswestry Disability Index are 74.5 ± 9.0, 32.3 ± 9.4, 27.3 ± 7.2, and 24.4 ± 6.5 after patch blocking dura repair of ID. ID is a more common surgical complication in ESLD compared with the transforaminal approach. The endoscopic patch blocking dura repair technique should be considered in type 1 to type 3A of dura tear with good prognosis and clinical outcome. Consideration is made for conversion to open repair in types 3B, 3C and 4 dura tears with fair to poor outcome. [ABSTRACT FROM AUTHOR]

Background: Schmorls node (SN) are mostly asymptomatic and incidental findings on MRI. However, sometimes they present like acute onset low back pain or acute exacerbation of chronic back pain after minor trauma.Case Presentation: We present rare case of symptomatic infected SN in 67 years female patient presented with complains of low back pain radiating to right buttock. After initial conservative treatment failed subsequent imaging showed significant increase in size of lesion with focal signal changes in disc space gave suspicion of underlying secondary pathology. Patient operated for complete excision of lesion. Histopathological report was suggestive of pyogenic vertebral osteomyelitis. Patient improved well postoperatively.Conclusion: Most of the time acute SN responds well to conservative treatment; however rapid deterioration of symptoms or persistent severe pain should give suspicion of underlying secondary pathology. [ABSTRACT FROM AUTHOR]

Degenerative disc disease is a leading cause of chronic back pain in the aging population in the world. Sinuvertebral nerve and basivertebral nerve are postulated to be associated with the pain pathway as a result of neurotization. Our goal is to perform a prospective study using radiofrequency ablation on sinuvertebral nerve and basivertebral nerve; evaluating its short and long term effect on pain score, disability score and patients' outcome. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain with bulging degenerative intervertebral disc or spinal stenosis underwent Uniportal Full Endoscopic Radiofrequency Ablation application through either Transforaminal or Interlaminar Endoscopic Approaches. Their preoperative characteristics are recorded and prospective data was collected for Visualized Analogue Scale, Oswestry Disability Index and MacNab Criteria for pain were evaluated. There was statistically significant Visual Analogue Scale improvement from preoperative state at post-operative 1wk, 6 months and final follow up were 4.4 ± 1.0, 5.5 ± 1.2 and 5.7 ± 1.3, respectively, p < 0.0001. Oswestery Disability Index improvement from preoperative state at 1week, 6 months and final follow up were 45.8 ± 8.7, 50.4 ± 8.2 and 52.7 ± 10.3, p < 0.0001. MacNab criteria showed excellent outcomes in 17 cases, good outcomes in 11 cases and fair outcomes in 2 cases Sinuvertebral Nerve and Basivertebral Nerve Radiofrequency Ablation is effective in improving the patients' pain, disability status and patient outcome in our study. [ABSTRACT FROM AUTHOR]

Discal cyst has been recognized as a distinct cause of back pain and radiculopathy. The clinical features are similar to other pathologies as disc prolapse and stenosis. Various treatment modalities have been described, ranging from nerve blocks to surgical excision. There are scarce reports on the endoscopic appearance of discal cysts. The present paper based on two cases operated by transforaminal and interlaminar endoscopy at our institute demonstrates the explicit intraoperative view and different pathological components of discal cysts. [ABSTRACT FROM AUTHOR]

Extradural benign cysts located in close proximity to the facet joints are called juxtafacetal cysts. Only about 3.5% of such cysts occur in the cervical spine. To our knowledge, there has been no published article on the endoscopic resection of a cervical facet cyst, and this is the first report. A 48-year-old male presented with a chief complaint of severe axial neck pain (visual analog scale score 9) and right scapular pain. The patient had no related radiculopathy or myelopathy, and neurologic status was intact. There was severe limitation of cervical spine movements. Plain radiographs indicated age-related degenerative changes with typical features of ankylosing spondylitis with a bamboo spine appearance and gross fusion of all the vertebrae. The only mobile cervical spinal level was C6-C7. Axial magnetic resonance imaging revealed a right-sided juxtafacetal lesion at C6-C7 level that was hyperintense on T2 and hypointense on T1 imaging. A percutaneous endoscopic posterior cervical foraminotomy at right-sided C7-T1 was performed under general anesthesia. The cyst was removed, and adequate decompression of the C7 root was achieved. Postoperative magnetic resonance imaging and computed tomography scan showed adequate foraminotomy and decompression of the neural structures. The patient had gross relief of neck pain (visual analog scale score 2). The findings suggest that ankylosing spondylitis may cause formation of a juxtafacetal cyst at the mobile levels in a relatively less mobile cervical spine. The endoscopic resection of such cysts is a minimally invasive novel procedure that can cure such patients successfully without unwanted fusion surgery. [ABSTRACT FROM AUTHOR]

Intraspinal epidural lymphangioma of cauda equina are extremely rare, only three cases have been reported in the past. We report a 63-year-old female with lymphangioma at S1–S2 level which was resected under epidural anesthesia using a percutaneous full endoscope with no evidence of recurrence at 19 months follow-up. [ABSTRACT FROM AUTHOR]

Background Tuberculosis (TB) of the posterior spinal element is an uncommon condition. In a developed country its diagnosis is becoming difficult due to low incidence. Case Description A 60-year-old lady presented with low back pain and right leg pain for 6 months. On examination there was tenderness over L4 and L5, a positive straight leg raise test at 70 degrees on the right side and free on the left, and sensory involvement on the right L5 dermatome. Initial magnetic resonance imaging (MRI) showed an L4-5 ligamentum flavum cyst, high signal intensity in the right pedicle and facet joint. It was considered to be a degenerative spinal disorder. Later MRI showed increased size of the cyst, and computed tomography revealed erosion of the right pedicle of the L5 vertebrae, which raised the suspicion of the tubercular pathology. Initially the patient was managed for a degenerative spinal disorder. Later, when tubercular pathology was suspected, she underwent full endoscopic uniportal stenosis decompression and excision biopsy of the cyst. The histology of the cyst revealed chronic granulomatous inflammation with central necrosis. The diagnosis of a TB cyst was confirmed, and antitubercular therapy was started. Conclusion TB of the posterior elements of the spine is a diagnostic challenge in developed parts of the world. We describe the first likely case of tubercular ligamentum flavum cyst, which was managed by a full endoscopic uniportal approach. [ABSTRACT FROM AUTHOR]

Background Kummell disease is defined as avascular necrosis of vertebra, occurs after the delayed posttraumatic osteoporotic vertebral collapse, and mainly occurs in adults older than 50 years of age. We report the first case of refracture of Kummell disease and epidural hematoma followed by paraparesis. Case Description A 67-year-old woman with a known case of osteoporotic T12 fracture (3 months back) visited our outpatient clinic complaining of persistent back pain and paraparesis after jerking while getting up from the bed. Her neurology worsened suddenly in the next 2 days. A physical examination revealed grade 3 power in lower extremities with a lower extremity paresthesia and diminished bilateral knee and ankle reflexes. Urinary retention was also present. A plain radiographic examination of her thoracolumbar spine revealed osteoporotic compression fractures with almost 50% reduction in height of the 12th thoracic vertebra. Magnetic resonance imaging showed dorsal epidural soft tissue mass that caused posterior compression of the spinal cord at the T12-L3 levels. We performed thoracic lateral retropleural corpectomy and cage insertion at T12. Bone cement−augmented pedicle screw fixation was performed at the T10, T11, and L1 levels with laminectomy and decompression of hematoma at the T12, L1, L2, and L3 levels as a stage 1 procedure. Conclusions Although rare, the possibility of refracture of Kummell disease and spinal epidural hematoma should be kept in mind in patients with osteoporotic fractures. Periodic follow-up and treatment are essential for preventing tragic neurologic impairment. Highlights • Paraparesis caused by spinal epidural hematoma associated with refracture of Kummell disease is extremely rare. • In literature, only 2 such cases have been reported. • We succeeded with a single-stage anterior corpectomy, posterior decompression, and percutaneous pedicle screw fixation. • In Kummell disease, a periodic follow-up and treatment are essential for preventing tragic neurologic impairment. [ABSTRACT FROM AUTHOR]

Background Intradural disk herniation is a rare entity with <0.3%−1% of all disk herniations and at an L2-L3 level even rarer. The dural defects repairs on ventral aspect are technically challenging and may not be possible after durotomy, so many authors have placed fascia, muscle, or plugging by the hemostatic material. The surgical treatment of intradural disk herniation is usually posterior open surgery with formal durotomy to remove the disk fragments with good to fair results. Poorer outcome occurs in late-presenting cases. Case Report We report on a 78-year-old man who presented with spontaneous low back pain and bilateral buttock pain aggravated for 1 month with severe walking difficulty without bowel and bladder symptoms. Magnetic resonance imaging revealed disk herniation at the L2-L3 level. He underwent a transforaminal endoscopic removal of intradural disk fragments via the original rent in the anterolateral aspect of the dura, and sealing was performed with dural patch and Gelfoam without any lumbar drain. The patient's symptom significantly improved postoperatively with muscle power improved to grade 5 on day 1 with no cerebrospinal fluid leakage, and he was mobilized with a lumbar orthosis on the first postoperative day. Postoperative and at 6-month follow-up, magnetic resonance imaging revealed adequate decompression and successful sealing of the ventral dural defect. Conclusions To our knowledge, this is the first case of transforaminal endoscopic treatment of intradural disk herniation at an L2-L3 level in which good clinical outcomes were obtained and maintained until recent follow-up of 8 months. Highlights • Transforaminal endoscopic treatment of intradural disk herniation at L2-L3 had a good outcome until the 8-month follow-up. • This technique avoids the need for dorsal durotomy to remove herniated disk materials. • The ventral defect in the dura can be sealed. • Despite a steep learning curve, this technique may negate the need for open surgery in intradural disk herniation. [ABSTRACT FROM AUTHOR]

Background Partially calcified lumbar herniated nucleus pulposus (HNP) can cause severe radiating pain and neurologic symptoms requiring surgical treatment. As it is not safe to enforce conventional endoscopic lumbar discectomy using trephine or burr to remove the partially calcified disc, we report a calcification floating technique using a working channel for the treatment of these cases. Methods We retrospectively analyzed 31 patients who underwent full endoscopic discectomy using this technique for partially calcified lumbar HNP between April 2009 and June 2013. Calcification floating technique was performed by inserting the working channel around the partially calcified HNP and then rotating the working channel around it to remove the lesion. We analyzed the outcomes with a Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and complication rate. Results The mean follow-up period was 26.58 ± 11.2 months. The interlaminar approach was used in 15 cases, and the transforaminal approach was used in 16 cases. The mean VAS of 8.19 ± 0.65 before surgery was decreased to 1.29 ± 0.69 at the last follow-up. The mean ODI score before surgery was decreased at the last follow-up, from 41.32 ± 2.87 to 9.87 ± 3.47. Mean operative duration was 45 ± 12 minutes per level. None of the patients required revision surgery or developed any major complication. Conclusions Calcification floating technique is a safe and effective method for the treatment of partially calcified lumbar HNP. Highlights • Partially calcified lumbar HNP can cause severe radiating pain and neurologic symptoms requiring surgical treatment. • It is not safe to enforce conventional endoscopic discectomy using trephine or burr to remove the partially calcified disc. • The calcification floating technique is safe and complete decompression of neural structures is possible with it. [ABSTRACT FROM AUTHOR]

Background In cases of Kümmell disease without neurologic deficit, percutaneous vertebroplasty or kyphoplasty has achieved short-term favorable outcomes. In the long term, recollapse of the augmented vertebral body and aggravation of kyphosis at the index level is often reported. Owing to medical comorbidities, elderly patients are often unsuited for extensive open spine surgery under general anesthesia. Case Description A 95-year-old man presented with a 1-month history of intractable back pain and gait disturbance. Magnetic resonance imaging revealed intravertebral avascular necrosis with fluid collection at the L4 vertebra. After postural reduction using a pillow in the supine position for 2 days, percutaneous pedicle screw fixation with bone cement augmentation was performed at the L3-5 level including L4 fracture under epidural anesthesia. Additional posterior column compression was performed to achieve restoration of spinal canal and lumbar lordosis. Severe back pain was reduced after surgery, and the patient was able to walk the day after surgery. Conclusions To our knowledge, this is the first case of Kümmell disease in an extremely elderly patient in whom good clinical result was obtained after postural reduction, vertebral augmentation, and short segment percutaneous pedicle screw fixation under epidural anesthesia. Highlights • A case of Kümmell disease in an extremely elderly patient had a good clinical result after PPSF under epidural anesthesia. • This case suggests that active intervention should be an option even in advanced age. • Risks, benefits, and expectations after surgery should be addressed before surgery. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective analysis of functional limitations due to stiffness after long-level spinal instrumented fusion surgery to correct lumbar degenerative flat back was performed.Objective: To analysis the functional limitations in patients treated surgically for adult lumbar degenerative flat back (ALDFB) with long-level instrumented fusion to the sacrum or pelvis.Summary Of Background Data: Long-level instrumented fusion for ALDFB decreases back pain and spinal deformity. On the contrary, this surgery considerably eliminates spinal range of motion. This may have the potential to impair function and ability to perform activities of daily living (ADLs).Methods: Consecutive 44 patients who underwent long-level instrumented fusion to the sacrum or pelvis for ALDFB were retrospectively included in this study. All patients were followed up for a minimum of 13 months. The Lumbar Stiffness Disability Index for Korean Lifestyle and Oswestry Disability Index were administered and analyzed to assess the impact of spinal stiffness on daily living. Cohorts were defined based on the upper instrumented vertebrae (above T10 [group 1] or below L1 [group 2]) and lower instrumented vertebrae (S1 pedicle screw [group S] or iliac bolt screw [group I]).Results: All patients showed deteriorated postoperative ADLs compared to preoperative values. Group 1 showed deterioration postoperatively compared to group 2. Group 1 showed deteriorated postoperative ADLs compared to preoperative values. In group 2, question 5 and 7 showed deterioration postoperatively compared to preoperative values, and question 2 and 10 showed improvement postoperatively compared to preoperative values. Group I showed deterioration postoperatively compared to group S.Conclusion: This study will hopefully allow surgeons to provide patients with ALDFB with a more informed explanation of expected surgery effects on specific ADLs.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Extraosseous Ewing sarcoma (EES) arising from peripheral nerves is extremely rare with only 11 cases mentioned in the literature. It poses a diagnostic challenge to the clinicians due to its nonspecific presentation and rare occurrence. Case Description A 56-year-old woman came with a history of low back pain and intractable right leg pain. Physical examination revealed the normal motor power of both lower limbs with decreased sensation along the lateral aspect of the foot with decreased ankle reflex. There was no improvement with conservative management. It was a diagnostic challenge due to its presentation like a lumbar radiculopathy, which was further endorsed by magnetic resonance imaging findings of foraminal stenosis. Due to red flags such as unrelenting pain at rest and history of thyroid tumor, we proceeded with magnetic resonance imaging of the hip, which was suggestive of right sciatic nerve sheath tumor. Excisional biopsy was confirmed as EES, and the patient was subsequently started on chemoradiotherapy. Conclusion A high index of suspicion is required for early diagnosis of EES. It can present as lumbar radiculopathy and mimic benign nerve sheath tumor on imaging. These sarcomas must be managed with a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Thoracic ossification of ligamentum flavum (TOLF) is a rare disease that often results in worsening neurologic sequelae if left untreated. Although the gold standard treatment for TOLF is open posterior laminectomy, it is often accompanied by high rates of complications and perioperative morbidity. There have been studies looking into feasibility of endoscopic posterior decompression for TOLF, citing potential for lower perioperative morbidity and achieving similar functional outcomes to its open laminectomy counterparts. We provide an up-to-date systematic review of clinical outcomes after endoscopic posterior decompression for TOLF from the latest assemblage of evidence. A systematic review of the technique was conducted from May 2000 to May 2023. Articles were selected based on PRISMA guidelines. Eligibility of studies was independently by 2 reviewers, with disagreements resolved by a third author. Nineteen primary references comprising 337 patients with TOLF who underwent endoscopic posterior decompression were included in the systematic review. Mean follow-up time across all studies ranged from 8.9 to 65.3 months. Mean age ranged from 51.2 to 63 years, with mean intraoperative blood loss ranging from 15 to 62 mL. There is significant improvement in visual analog scale (VAS) score, VAS back, VAS leg, modified Japanese Orthopaedic Association score, and Oswestry Disability Index compared with preoperative recorded values across all studies, with low rates of complications reported. Endoscopic posterior spinal decompression is a safe and effective technique for treatment of TOLF, with a low rate of complications and improvement in pain and function. [ABSTRACT FROM AUTHOR]

Background Acute bilateral isolated foot drop due to lumbar disk prolapse with canal stenosis is rare with only 3 cases reported in literature. Our patient was managed using the percutaneous full endoscopic technique. This is mainly to highlight the ease of access and patient outcome with preoperative and postoperative images to support our minimally invasive treatment for this rare condition. Case Description A 46-year-old male presented with sudden-onset severe back pain with bilateral foot drop. Clinical examination showed a bilateral L5 radiculopathy with normal perianal sensation. Investigations excluded other causes of bilateral foot drop. A magnetic resonance imaging scan showed disk herniation at the right L4-L5 (inferior migrated) and L5-S1 level (paracentral and extraforaminal) with spinal canal stenosis at the L2-L3 and L5-S1 levels due to ligamentum flavum hypertrophy. The patient underwent percutaneous endoscopic stenosis lumbar decompression at the L2-L3 and L5-S1 level. At the right L4-L5, L5-S1 level, transforaminal endoscopic diskectomy was done using the conventional percutaneous approach. The inferior migrated disk of the L4-L5 level was removed using a left L5-S1 contralateral approach. The patient recovered with favorable outcome and added benefits of minimally invasive surgery. Conclusion Lumbar disk prolapse with canal stenosis should be considered in patients presenting with bilateral isolated foot drop. To our best knowledge, this is the first report of percutaneous endoscopic treatment to address multiple-lumbar-level pathology for this rare condition of acute bilateral isolated foot drop. [ABSTRACT FROM AUTHOR]

Background The causes of chronic diskogenic back pain have not yet been clearly identified. Neural ingrowth around the annulus is widely considered to be one of the possible cause. However, neuropathy around the annulus has yet to be observed visually. We report a case of a hotspot that was observed in an epiduroscopic view, but not in imaging findings. Case Description A 46-year-old woman was admitted with pain in the back, left buttock, and posterior thigh for 2 years. A straight leg raising test was positive on the left side, and left great toe dorsiflexion was decreased to grade 3/5. The Visual Analog Scale pain score was 7/10. On the basis of her symptoms, epidural block, medial branch block, sacroiliac joint block, piriformis muscle injection, physical therapy, and medication were attempted, but no improvement in symptoms was observed. A provocation test was performed at the L3-L4, L4-L5, and L5-S1 intervertebral disks, and severe pain was induced in the L5-S1 intervertebral disk, which was not suspicious on magnetic resonance imaging. We performed transforaminal epiduroscopic laser ablation on L5-S1 and found a hotspot on L5-S1 during the procedure. During laser provocation of the hotspot, the patient complained of severe pain in her lower back and legs, and her pain decreased after ablation of hotspot with laser and improvement in motor weakness was noticed. Conclusion In this study, we observed annulus hotspots, which have not been observed in imaging studies such as computed tomography or magnetic resonance imaging in patients with chronic back pain and leg pain, and observed remarkable symptom improvement after transforaminal epiduroscopic laser ablation. [ABSTRACT FROM AUTHOR]

Purpose. To evaluate the efficacy of suprapedicular circumferential opening technique (SCOT) of percutaneous endoscopic transforaminal lumbar discectomy (PETLD) for high grade inferiorly migrated lumbar disc herniation. Material and Methods. Eighteen consecutive patients who presented with back and leg pain with a single-level high grade inferiorly migrated lumbar disc herniation were included. High grade inferiorly migrated disc was removed by the SCOT through PETLD approach. Outcome evaluation was done with visual analog scale (VAS) and Mac Nab’s criteria. Result. There were 14 males and 4 females. The mean age of patients was 53.3±14.12 years. One, 4, and 13 patients had disc herniation at L1-2, L3-4, and L4-5 levels, respectively, on MRI, which correlated with clinical findings. The mean follow-up duration was 8.4±4.31 months. According to Mac Nab’s criteria, 9 patients (50%) reported excellent and the remaining 9 patients (50%) reported good outcomes. The mean preoperative and postoperative VAS for leg pain were 7.36±0.73 and 1.45±0.60, respectively (p<0.001). Improvement in outcomes was maintained even at final follow-up. There was no complication. Conclusion. In this preliminary study we achieved good to excellent clinical results using the SCOT of PETLD for high grade inferiorly migrated lumbar disc herniation. [ABSTRACT FROM AUTHOR]

Objective Percutaneous endoscopic contralateral interlaminar lumbar foraminotomy (PECILF) for lumbar degenerative spinal stenosis is an established procedure. Better preservation of contralateral facet joint compared with that of the approach side has been shown with uniportal bilateral decompression. The aim of this retrospective case series was to analyze the early clinical and radiologic outcomes of stand-alone contralateral foraminotomy and lateral recess decompression using PECILF. Methods Twenty-six consecutive patients with unilateral lower limb radiculopathy underwent contralateral foraminotomy and lateral recess decompression using PECILF. Their clinical outcomes were evaluated with visual analog scale leg pain score, Oswestry Disability Index, and the MacNab criteria. Completeness of decompression was documented with a postoperative magnetic resonance imaging. Results Mean age for the study group was 62.9 ± 9.2 years and the male/female ratio was 4:9. A total of 30 levels were decompressed, with 18 patients (60%) undergoing decompression at L4-L5, 9 at L5-S1 (30%), 2 at L3-L4 (6.7%), and 1 at L2-L3 (3.3%). Mean estimated blood loss was 27 ± 15 mL per level. Mean operative duration was 48 ± 12 minutes/level. Visual analog scale leg score improved from 7.7 ± 1 to 1.8 ± 0.8 ( P < 0.0001). Oswestry Disability Index improved from 64.4 ± 5.8 to 21 ± 4.5 ( P < 0.0001). Mean follow-up of the study was 13.7 ± 2.7 months. According to the MacNab criteria, 10 patients (38.5%) had good results, 14 patients (53.8%) had excellent results, and 2 patients (7.7%) had fair results. One patient required revision surgery. Conclusions Facet-preserving contralateral foraminotomy and lateral recess decompression with PECILF is effective for treatment of lateral recess and foraminal stenosis. Thorough decompression with acceptable early clinical outcomes and minimal perioperative morbidity can be obtained with the contralateral endoscopic approach. [ABSTRACT FROM AUTHOR]

Objective To determine the optimal proximal fusion level after long instrumented fusion to the sacrum for lumbar degenerative flat back. Methods Data from 70 patients with lumbar degenerative flat back were reviewed retrospectively. Three groups were designated according to the upper instrumented vertebrae (UIV): group 1 (UIV = T10 or above), group 2 (UIV = T11-12), and group 3 (UIV = L1 or below). Pre- and postoperative pelvic parameters, degree of correction, and prevalence of proximal junctional kyphosis (PJK) and its risk factors were evaluated. Results The prevalence of PJK was 27.1% (average 35.5 months of follow-up). Preoperative pelvic incidence (PI) and sacral slope (SS) in group 1 were higher in the PJK group than in the non-PJK group ( P = 0.03 and P = 0.001, respectively). Preoperative thoracolumbar (TL) in group 3 was higher in the PJK group than in the non-PJK group ( P = 0.01). Postoperative pelvic tilt (PT) was lower (<20°) in the non-PJK group than in the PJK group ( P = 0.025 in group 3). Postoperative TL in group 3 was lower than in the non-PJK group ( P = 0.024). Conclusions If the PI is ≥50°, TL kyphosis is ≥5°, and SS is ≥20°, the UIV should be raised above T10 up to the midthoracic level. If the PI is ≥50°, SS is ≤20°, and thoracic kyphosis (TK) is normal despite TL kyphosis, the UIV should be at T10. Even if the PI is ≥50°, TK is normal, and there is no TL kyphosis, the UIV should be set at L1 or below. Regardless of the UIV, the postoperative PT should be ≤20°. [ABSTRACT FROM AUTHOR]

Objective Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) can be performed by using foraminal, intervertebral, and suprapedicular routes. The aim of this study was to assess clinical results of three different routes of PETLD. Methods One hundred eleven patients who underwent PETLD between January 2016 and October 2016 were included in this study. PETLD was performed using the foraminal (group A), intervertebral (group B), and suprapedicular (group C) routes in 32, 46, and 33 patients, respectively. Outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and MacNab criteria. Results Seventy-one men and 40 were women (mean age 53.33 ± 14.12 years). The mean follow-up period was 6.44 ± 3.26 months. The preoperative VAS score decreased significantly ( P < 0.01) in all 3 groups, but the postoperative VAS score was higher for the foraminal route than for the intervertebral ( P = 0.001) and suprapedicular routes ( P < 0.001). Excellent outcome grade according to MacNab criteria was less in foraminal route (18.7%) than in intervertebral (52.2%) and suprapedicular (56.7%) routes. ODI improved significantly ( P < 0.01) in all 3 groups. Conclusion All 3 routes of PETLD resulted in good to excellent clinical results. Nevertheless, the postoperative VAS score was higher for the foraminal route than for the intervertebral and suprapedicular routes, probably not because of the surgery but because of the neurologic characteristics of the disk location. The surgeon should consider this problem to alleviate pain postoperatively and counsel to patient well before surgery. [ABSTRACT FROM AUTHOR]

Background When considering various risk factors such as age, comorbidities, and complications related to the surgical procedure itself, open surgery in degenerative spinal stenosis is likely to cause more complications. Here, we report the surgical procedure and preliminary clinical results of percutaneous endoscopic stenosis lumbar decompression (PESLD) technique using a uniportal-contralateral approach for bilateral decompression of degenerative spinal stenosis. Materials and Methods Electronic medical records of 48 consecutive patients who were treated between January 2016 and August 2016 were reviewed retrospectively. All patient received PESLD through the uniportal–contralateral approach. We analyzed the outcomes using the visual analogue scale, Macnab criteria, Oswestry Disability Index, and complication rate. Results There were 48 cases (15 men, 33 women). Mean age of patients was 62.44 ± 8.68 years. Mean symptom duration was 20.13 ± 16.87 months. Neurogenic intermittent claudication was 550 m on average. Follow-up period was 7.75 ± 2.28 months (range, 5–13 months). Visual analogue scale and Oswestry Disability Index decreased significantly ( P < 0.001) and decreased by 1.073 and 5.795 odds ratio, respectively, in contralateral foraminotomy cases. Macnab outcome grade was good to excellent in 96% of patients. Dural tear occurred in 3 cases (6.25%), and 2 cases (4.17%) required transforaminal lumbar interbody fusion operation after this procedure. Conclusions The preliminary result of this uniportal–contralateral PESLD technique is encouraging (96% demonstrated a good-to-excellent outcome), and the procedure is safe. However, we need long-term follow-up and a more detailed study for more accurate results of this technique. [ABSTRACT FROM AUTHOR]

Objective The aim of this article was to analyze risk factors for secondary new vertebral compression fractures (SNVCFs) after percutaneous vertebroplasty in patients with osteoporosis. Methods We investigated medical records and radiologic images of patients undergoing percutaneous vertebroplasty for osteoporotic vertebral compression fracture between October 2009 and September 2014. We assessed patients' age, past medical history, and bone mineral content using computed tomography. Procedure-specific outcomes were assessed, including ratio of injected bone cement to vertebral body volume, bone cement distribution in the vertebral body (to identify degree of consistency in bone cement injection), presence of bone cement leakage into adjacent disc space, segmental kyphosis, and time interval between first and second fracture events. Results Percutaneous vertebroplasty was performed in 293 patients (60 men and 233 women) with 336 affected levels. Of this cohort, 34 (14.6%) patients sustained SNVCFs. We compared patients in 2 groups: patients who experienced SNVCFs, and patients who did not experience fractures. Significant differences were identified in bone mineral content ( P = 0.000) and bone cement distribution ( P = 0.000). Patients exhibiting bone cement leakage into disc space revealed a higher incidence of SNVCF than patients without leakage ( P = 0.039). Conclusions Poor bone mineral content can be a predictive factor of SNVCFs. To prevent SNVCFs, bone cement should be injected as evenly as possible into the vertebral body. Bone cement leakage into the disc space should be avoided. [ABSTRACT FROM AUTHOR]

Objective. Structures such as ligamentum flavum, annulus, and lamina play an important role in the segmental function. We proposed the surgical technique for achieving the sufficient preservation of segmental structures, in spite of sufficient removal of pathologic disc in the L5-S1 using the ligamentum flavum splitting and sealing technique. Methods. We retrospectively analyzed 80 cases that underwent percutaneous endoscopic lumbar discectomy for L5-S1 herniated nucleus pulposus, using the ligamentum flavum splitting and sealing technique between January 2011 and June 2013. Outcomes were assessed using VAS (leg, back), MacNab’s criteria, and the immediate postoperative MRI for all patients. Structural preservation was classified as complete, sufficient, and incomplete. Results. The surgical results are as follows: 65 cases were complete, 15 cases were sufficient, and 0 cases were incomplete. The VAS was decreased at the last follow-up (leg: from 7.91±0.73 to 1.15±0.62; back: from 5.15±0.71 to 1.19±0.75). A favorable outcome (excellent or good outcome by MacNab’s criteria) was achieved in 77 patients (96.25%). During the follow-up period, 2 cases (2.5%) of recurrence have occurred. Conclusion. According to the result, we could obtain the favorable clinical and radiological outcomes while simultaneously removing pathologic discs using the ligamentum flavum splitting and annular fissure sealing technique. [ABSTRACT FROM AUTHOR]