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The conventional location methods for minimally invasive spinal surgery (MISS) were mainly based on repeated fluoroscopy in a trial-and-error manner preoperatively and intraoperatively. Localization system mainly consisted of preoperative applied radiopaque frame and intraoperative guiding device, which has the potential to minimize fluoroscopy repetition in MISS. The study aimed to evaluate the efficacy of a novel lumbar localization system in reducing radiation exposure to patients.Included patients underwent minimally invasive transforaminal lumbar interbody fusion (MISTLIF) or percutaneous transforaminal endoscopic discectomy (PTED). Patients treated with novel localization system were regarded as Group A, and patients treated without novel localization system were regarded as Group B.For PTED, The estimated effective dose was 0.41 ± 0.13 mSv in Group A and 0.57 ± 0.14 mSv in Group B (P < .001); the fluoroscopy exposure time of PTED was 22.18 ± 7.30 seconds in Group A and 30.53 ± 7.56 seconds in Group B (P < .001); The estimated cancer risk of radiation exposure was 22.68 ± 7.38 (10) in Group A and 31.20 ± 7.96 (10) in Group B (P < .001). For MISTLIF, the estimated effective dose was 0.45 ± 0.09 mSv in Group A and 0.58 ± 0.09 mSv in Group B (P < .001); The fluoroscopy exposure time was 25.41 ± 5.52 seconds in Group A and 32.82 ± 5.03 seconds in Group B (P < .001); The estimated cancer risk was 24.90 ± 5.15 (10) in Group A and 31.96 ± 5.04 (10) in Group B (P < .001). There were also significant differences in localization time and operation time between the 2 groups either for MISTLIF or PTED.The lumbar localization system could be a potential protection strategy for minimizing radiation hazards.

Background: Transforaminal percutaneous endoscopic lumbar discectomy (tPELD) poses great challenges for junior surgeons. Beginners often require repeated attempts using fluoroscopy causing more punctures, which may significantly undermine their confidence and increase the radiation exposure to medical staff and patients. Moreover, the impact of an accurate location on the learning curve of tPELD has not been defined., Objective: The study aimed to investigate the impact of an accurate preoperative location method on learning difficulty and fluoroscopy time of tPELD., Study Design: Retrospective evaluation., Setting: Patients receiving tPELD by one surgeon with a novel accurate preoperative location method were regarded as Group A, and those receiving tPELD by another surgeon with a conventional fluoroscopy method were regarded as Group B., Methods: From January 2012 to August 2014, we retrospectively reviewed the first 80 tPELD cases conducted by 2 junior surgeons. The operation time, fluoroscopy times, preoperative location time, and puncture-channel time were thoroughly analyzed., Results: The operation time of the first 20 patients were 99.75 ± 10.38 minutes in Group A and 115.7 ± 16.46 minutes in Group B, while the operation time of all 80 patients was 88.36 ± 11.56 minutes in Group A and 98.26 ± 14.90 minutes in Group B. Significant differences were detected in operation time between the 2 groups, both for the first 20 patients and total 80 patients (P < 0.05). The fluoroscopy times were 26.78 ± 4.17 in Group A and 33.98 ± 2.69 in Group B (P < 0.001). The preoperative location time was 3.43 ± 0.61 minutes in Group A and 5.59 ± 1.46 minutes in Group B (P < 0.001). The puncture-channel time was 27.20 ± 4.49 minutes in Group A and 34.64 ± 8.35 minutes in Group B (P < 0.001). There was a moderate correlation between preoperative location time and puncture-channel time (r = 0.408, P < 0.001), and a moderate correlation between preoperative location time and fluoroscopy times (r = 0.441, P < 0.001). Mild correlations were also observed between preoperative location time and operation time (r = 0.270, P = 0.001). There were no significant differences in preoperative back visual analogue scale (VAS) score, postoperative back VAS, preoperative leg VAS, postoperative leg VAS, preoperative Japanese Orthopaedic Association (JOA) score, postoperative JOA, preoperative Oswestry disability score (ODI), or postoperative ODI (P > 0.05). However, significant differences were all detected between preoperative abovementioned scores and postoperative scores (P < 0.05). Moreover, there was no significant differences in Macnab satisfaction between the 2 groups (P = 0.179). There were 2 patients with recurrence in Group A and 3 patients in Group B. Twelve patients with postoperative disc remnants were identified in Group A and 9 patients in Group B. No significant difference was identified between the 2 groups (P = 0.718)., Limitations: The preoperative lumbar location method is just a tiny step in tPELD, junior surgeons still need to focus on their subjective feelings during punctures and accumulating their experience in endoscopic discectomy., Conclusions: The accurate preoperative location method lowered the learning difficulty and reduced the fluoroscopy time of tPELD, which was also associated with lower preoperative location time and puncture-channel time. Key words: Learning difficulty, fluoroscopy reduction, transforamimal percutaneous endoscopic lumbar discectomy, preoperative locationLearning difficulty, fluoroscopy reduction, transforamimal percutaneous endoscopic lumbar discectomy, preoperative location.

Study Design: The clinical study was conducted on 145 patients who received either a novel guidance method or a conventional fluoroscopic method for the percutaneous pedicle screw placement in the lumbar spine., Objective: The aim of this study was to introduce a novel guidance method for percutaneous pedicle screw placement and to compare it with the conventional fluoroscopic method., Summary of Background Data: Conventional fluoroscopic method was associated with a long screw placement and a more fluoroscopy time. The novel guidance system effectively minimized the insertion and the radiation exposure times., Methods: A total of 145 patients were divided into 2 groups. A total of 65 patients (group A) underwent 152 percutaneous pedicle screw fixation by conventional fluoroscopic method. A total of 80 patients (group B) underwent 185 percutaneous pedicle screw fixation by a novel guidance method. Age, body mass index, and sex ratio were comparable between the 2 groups (P>0.05). The time of insertion, radiation exposure, and accuracy of the screw placement between the 2 groups were compared., Results: The mean time for a single pedicle screw placement was found to be 15.11±3.32 minutes in group A and 10.35±2.82 minutes in group B, respectively. The average radiation exposure was 9.06±2.15 s in group B and 13.07±3.06 s in group A, respectively. The differences were statistically significant for both screw placement and radiation exposure times (P<0.05). A total of 131 screws (86.2%) in group A and 163 screws (88.1%) in group B were perfectly located within the pedicle. The statistical difference was not significant (χ=0.277, P=0.598)., Conclusions: The novel guidance system significantly reduced the insertion time and radiation exposure, provided the screw placement was accurately performed when compared with the conventional method.

Study Design: A prospective study., Objective: To further investigate the implication of our surface locator and intradermal locator to reduce the radiation exposure to surgeons in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) surgery., Summary of Background Data: Our previous studies published in the journal have introduced our novel spinal locators effectively minimizing fluoroscopic time during minimally invasive spinal surgery., Methods: Twenty patients underwent MIS-TLIF surgery with G-arm fluoroscopy from January 2013 to June 2013. There were 10 patients in group A who underwent standard MIS-TLIF using our spinal locators, and the other 10 in group B underwent conventional MIS-TLIF without spinal locators. The radiation dosages to the arm, the finger, the whole body, thyroid gland, gonad gland, and the eye of the surgeon were measured by thermoluminescence badges for both groups., Results: All 20 patients (9 male, 11 female), aged from 48 to 77 years old, successfully underwent the surgery. The operation time was 171.20±10.28 minutes for group A and 189.80±11.99 minutes for group B. The fluoroscopy time was 49.60±7.32 seconds for group A and 68.40±7.62 seconds for group B, hence a reduction of 27.49% was observed. There was no correlation between operation time and exposure time for group A or group B. The radiation reduction was 35.28% for the arm, 17.95% for the finger, 45.23% for the whole body, 53.62% for the thyroid gland (protected), 52.44% for the thyroid gland (unprotected), 44% for gonad gland (protected), 36.42% for the gonad gland (unprotected), 59.42% for the eye (protected), and 59.70% for the eye (unprotected)., Conclusion: The study indicated that radiation exposure to the surgeon would be effectively reduced in MIS-TLIF using our surface locator and intradermal locator, and it could be another practical choice for radiation-minimizing strategy.

Objective: To assess a new intradermal locator device for percutaneous placement of lumbar pedicle screws., Material and Methods: Patients were alternately assigned to two groups. The locator group underwent lumbar pedicle screw placement using the intradermal locator. The control group was aided by traditional fluoroscopy. Baseline demographics, visual analog scale (VAS) pain scores, operation time, intraoperative fluoroscopy time and guidewire insertion time were recorded. All postoperative CT scans were reviewed by an independent spine surgeon to grade screw placement accuracy., Results: Thirty-six patients (180 screws) were assigned to the locator group and 30 patients (128 screws) to the control group. The locator device could significantly reduce the fluoroscopy time [3.9 sec (SD = 1.9) vs. 9.6 sec (SD = 5.8), p < 0.001] and guidewire insertion time [2.69 min (SD = 0.67) vs. 4.49 min (SD = 1.96), p < 0.001] compared with the conventional method for each pedicle screw. The whole operation time of the locator group was shorter than that of the control group [2-segment: 243.2 min (SD = 16.9) vs. 301.7 min (SD = 14.9), p < 0.001; 1-segment: 154.5 min (SD = 14.3) vs. 194.6 min (SD = 19.3), p < 0.001]. As for the rates of pedicle breaches, postoperative VAS scores, no significant difference was found between the two groups., Conclusion: The intradermal locator device could help reduce the radiation exposure in percutaneous pedicle screw placement while maintaining the accuracy.

Background. Percutaneous endoscopic transforaminal discectomy (PETD) is usually chosen for lumbar disc herniation due to its obvious advantages such as small incision and absence of nerve or muscular traction. However, learning PETD is a great challenge for inexperienced surgeons. Objective. The study aimed to investigate whether isocentric navigation would be beneficial in PETD training. Methods. A total of 117 inexperienced surgeons were trained with PETD at L2/3, L3/4, L4/5, and L5/S1 on the cadavers without (Group A n=58) or with (Group B n=59) isocentric navigation. Puncture times, fluoroscopy times, exposure time, and radiation dose were recorded and analyzed. Questionnaires were conducted before and after the training program. Result. Isocentric navigation could improve young surgeons’ satisfaction with the training program and decrease the puncture times, fluoroscopy times, exposure time, and radiation dose significantly (P<0.001). Conclusion. Isocentric navigation contributes to the training of PETD and may improve its standardization, homogenization, and generalization. [ABSTRACT FROM AUTHOR]

Purpose: Beginners usually need increased punctures and dozens of fluoroscopy in learning transforamimal percutaneous endoscopic lumbar discectomy (tPELD). Navigator-assisted spinal surgery (NASS) is a novel technique that could induce a definite trajectory. The retrospective study aimed to investigate the impact of a definite trajectory on the learning curve of tPELD.Methods: A total of 120 patients with symptomatic lumbar disc herniation who received tPELD between 2012 and 2014. Patients receiving tPELD with NASS technique by one surgeon were regarded as group A, and those receiving conventional methods by another surgeon were regarded as group B. Each group was divided into three subgroups (case 1-20, case 21-40, case 41-60).Results: The fluoroscopy times were 22.62 ± 3.80 in group A and 34.32 ± 4.78 in group B (P < 0.001). The pre-operative location time was 3.56 ± 0.60 minutes in group A and 5.49 ± 1.48 minutes in group B (P < 0.001). The puncture-channel time was 21.85 ± 4.31 minutes in group A and 34.20 ± 8.88 minutes in group B (P < 0.001). The operation time was 84.62 ± 9.20 minutes in group A and 101.97 ± 14.92 minutes in group B (P < 0.001), and the learning curve of tPELD in group A was steeper than that in group B. No significant differences were detected in patient-reported outcomes, hospital stay, patient satisfaction, and complication rate between the two groups (p > 0.05).Conclusions: Definite trajectory significantly reduced the operation time, preoperative location time, puncture-channel time, and fluoroscopy times of tPELD by beginners, and thus reshaped the learning curve of tPELD and minimized the radiation exposure. [ABSTRACT FROM AUTHOR]

The aim of this study was to directly compare the clinical outcomes of posterior lumbar interbody fusion (PLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in three-level lumbar spinal stenosis. This retrospective study involved a total of 60 patients with three-level degenerative lumbar spinal stenosis who underwent MIS-TLIF or PLIF from January 2010 to February 2012. Back and leg visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) scale were used to assess the pain, disability, and health status before surgery and postoperatively. In addition, the operating time, estimated blood loss, and hospital stay were also recorded. There were no significant differences in back VAS, leg VAS, ODI, SF-36, fusion condition, and complications at 12-month follow-up between the two groups (P>0.05). However, significantly less blood loss and shorter hospital stay were observed in MIS-TLIF group (P<0.05). Moreover, patients undergoing MIS-TLIF had significantly lower back VAS than those in PLIF group at 6-month follow-up (P<0.05). Compared with PLIF, MIS-TLIF might be a prior option because of noninferior efficacy as well as merits of less blood loss and quicker recovery in treating three-level lumbar spinal stenosis. [ABSTRACT FROM AUTHOR]

Background: Percutaneous transforaminal endoscopic discectomy (PTED) usually requires numerous punctures under X-ray fluoroscopy. Repeated puncture will lead to more radiation exposure and reduce the beginners' confidence. Objective: This cadaver study aimed to investigate the efficacy of HE’s Lumbar Location (HELLO) system in puncture reduction of PTED. Study design: Cadaver study. Setting: Comparative groups. Methods: HELLO system consists of self-made surface locator and puncture locator. One senior surgeon conducted the puncture procedure of PTED on the left side of 20 cadavers at L4/L5 and L5/S1 level with the assistance of HELLO system (Group A). Additionally, the senior surgeon conducted the puncture procedure of PTED on the right side of the cadavers at L4/L5 and L5/S1 level with traditional methods (Group B). On the other hand, an inexperienced surgeon conducted the puncture procedure of PTED on the left side of the cadavers at L4/L5 and L5/S1 level with the assistance of our HELLO system (Group C). Results: At L4/L5 level, there was significant difference in puncture times between Group A and Group B (P<0.001), but no significant difference was observed between Group A and Group C (P = 0.811). Similarly at L5/S1 level, there was significant difference in puncture times between Group A and Group B (P<0.001), but no significant difference was observed between Group A and Group C (P = 0.981). At L4/L5 level, there was significant difference in fluoroscopy time between Group A and Group B (P<0.001), but no significant difference was observed between Group A and Group C (P = 0.290). Similarly at L5/S1 level, there was significant difference in fluoroscopy time between Group A and Group B (P<0.001), but no significant difference was observed between Group A and Group C (P = 0.523). As for radiation exposure, HELLO system reduced 39%-45% radiation dosage when comparing Group A and Group B, but there was no significant difference in radiation exposure between Group A and Group C whatever at L4/L5 level or L5/S1 level (P>0.05). There was no difference in location time between Group A and Group B or Group A and Group C either at L4/L5 level or L5/S1 level (P>0.05). Limitations: Small-sample preclinical study. Conclusion: HELLO system was effective in reducing puncture times, fluoroscopy time and radiation exposure, as well as the difficulty of learning PTED. (2015-RES-127) [ABSTRACT FROM AUTHOR]

Objective Ultrasound volume navigation (UVN) has been widely used for accurate guidance and decreased radiation exposure. However, few studies have focused on the clinical significance of UVN in guiding percutaneous puncture in percutaneous transforaminal endoscopic discectomy (PTED). We evaluated UVN to guide percutaneous puncture in PTED. Methods We retrospectively reviewed the medical records of 12 patients (8 men and 4 women), who had undergone PTED with the help of UVN or fluoroscopic guidance for lumbar disc herniation from November 2017 to December 2017. Results The age of these 12 patients range was 26–71 years, and the body mass index range was 18.19–26.91 kg/m2. Of the 12 patients, 6 were in UVN group and 6 were in fluoroscopy group. The mean number of punctures was 1.00 in UVN group and 3.83 in fluoroscopy group. The mean exposure time was 3.60 and 13.80 seconds in UVN and fluoroscopy groups, respectively. The mean operation time was 48.17 minutes and 61.33 minutes in UVN and fluoroscopy groups, respectively. A positive relationship was found between operation time and exposure time (P < 0.05). All patients achieved excellent or good clinical outcomes. The Oswestry Disability Index and visual analog scales for leg pain and back pain all showed significant improvement after the procedure (P < 0.05). None of patients experienced a complication. Conclusions UVN decreased the number of puncture attempts, radiation exposure, and operation time compared with fluoroscopic guidance in PTED. Therefore, UVN is a feasible and efficient method for guiding percutaneous puncture in PTED. Highlights • The present study introduced UVN for guiding the percutaneous puncture in PTED. • UVN reduced the puncture time, radiation exposure, and operation time during PTED. • UVN could be a helpful tool during PTED. [ABSTRACT FROM AUTHOR]