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BACKGROUND Multiple options exist for thoracic disc herniation (TDH). However, when a specific technique is chosen, the goal is to avoid the manipulation of the spinal cord, which is already compressed. OBJECTIVE To describe a hybrid endoscopic technique for intracanal TDH by combining an oblique paraspinal approach (OPA) and transforaminal full-endoscopic discectomy. METHODS We describe the step-by-step operative technique and present the clinical and radiological outcomes of a case series of hybrid endoscopic thoracic discectomy. RESULTS A total of 3 patients were treated. We observed the usefulness of an OPA to enlarge the intervertebral foramen through the rigid tubular retractor and the feasibility of a full-endoscopic transforaminal approach to reach intracanal TDHs. CONCLUSION Early experience with the hybrid endoscopic technique for TDHs demonstrated acceptable clinical and radiological outcomes in the 3 patients treated; however, a larger sample size and a methodologically advantageous study to compare this procedure with conventional options are necessary to probe the full benefits of the hybrid technique.

Foraminal and far lateral disc herniations are rarer cause of nerve root compression. There are reports regarding the outcome, however long-term follow-up results of surgically treated patients are few. The purpose of this retrospective study is to analyze the clinical characteristics and long-term surgical outcomes of the foraminal and far lateral disc herniations.The 114 patients who underwent an operation for foraminal and far lateral disc herniaitions were reviewed. Visual analogue scale of back and leg pain, the ocurrence of motor deficit and sensory dysesthesia before and after operations were used to compare the results of early and long-term outcome.A total of 114 telephone interviews were conducted. The mean follow up was 134 months. Complete relief of symptoms were reported by 77 patients (67.1%). The average VAS of radicular leg pain was 7.5 Post-operatively the average VAS of radicular pain decreased to 2.2. Preoperatively, 9 patients (7.6%) had motor deficit and 17 (14.4%) patients had sensory dysesthesia. Post-operatively 9 (100%) of the patients showed motor, and 12 (70.6%) of the patients showed sensory improvement. In 17 patients with hypoesthesia the complaints continued during 2 weeks to 6 months. They were given gabapentin as medical treatment, however 5 of these patients still have sensory dysesthesia. The outcome was: 67.1% excellent (77 patients), 26.3% good (30 patients), 6.1% fair (7 patients).The far lateral approach is a minimally invasive and safe procedure with low complication rates.

Lumbar foraminal stenosis has been identified as a common cause of radicular symptoms and can lead to persistent pain after prolonged treatment. A facet-preserving microdecompression technique using a paraspinal approach has been considered the gold standard for the surgical treatment of lumbar foraminal or far lateral stenosis but has been associated with postoperative leg pain or dysesthesia. More recently, authors have reported the use of a technique known as endoscopic foraminal discectomy with or without foraminotomy for the treatment of foraminal stenosis. Recent advancement in endoscopic devices as well as the use of a side-firing, holmium:yttrium-aluminum-garnet (Ho:YAG) laser has further the surgeon to treat foraminal stenosis more quickly and with less complications.

Disc herniation that is confined to the neural foramen area is called foraminal lumbar disc herniation (FLDH). Herniated discs arising outwardly of the neural foramen constitute extraforaminal lumbar disc herniation (EFLDH). Microscopic lumbar discectomy via the paraspinal approach is considered the gold standard for surgical treatment of FLDH and EFLDH. However, there is a possibility of postoperative complications due to the complex anatomical structures, narrow surgical field, excessive neural retraction, and incomplete decompression. Lumbar microdiscectomy via the paraspinal approach for FLDH and EFLDH using a carbon dioxide (CO2) laser can minimize spinal nerve traction and tissue damage. In this chapter, we describe the surgical method of lumbar microdiscectomy via the paraspinal approach for FLDH and EFLDH using a CO2 laser and discuss the usefulness of CO2 use.

Various methods via anterior or posterior approach with or without spinal stabilization have been performed in decompression surgery of thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL). Decompression surgery for thoracic OPLL is challenging, however, posterior approach can relatively familiar in neurosurgery. After introduction of MR and 3D CT, detection of thoracic intra-canal lesions is not difficult, and faster. So relatively small size OPLLs’ have been found not so rarely. Some of them, not all of them, are definitely symptomatic. But their severity of symptoms is not enough to bear the sequelae of big surgeries. To overcome this mismatch, posterolateral oblique paraspinal approach (OPA) was used. OPA has been used in the case of calcified thoracic disc herniation or herniation with bony spur. But some modification was needed to get more coronal and sagittal access.

Background: The implement of endoscopic spinal surgery into degenerative spinal disease has minimized the requirement of fusion procedures. However, it is still necessary to develop endoscopic spine surgery in certain patients requiring fusion such as instability. We performed a full-endoscopic transforaminal lumbar interbody fusion(eTLIF) through a conventional paraspinal approach. The feasibility of procedure and early outcome were evaluated.Materials and Methods: eighteen consecutive patients with degenerative lumbar disease underwent eTLIF through a conventional paraspinal approach. Their clinical outcomes were evaluated with visual analog scale(VAS) leg pain score, Oswestry Disability Index(ODI) and the MacNab's criteria; radiological outcome measured with segmental lordosis, global lumbar lordosis, disc height on plain radiograph and percentage of potential fusion mass on CT scan at pre-operative, post-operative and final follow up period. intra operative and post-operative complications noted.Results: Mean age was 63. 71 years and Mean follow-up periods was 7.78 months. According to the level, L2-3 (1 case), L3-4 (4 cases), L4-5 (13 cases) and L5-S1 (2 cases). In the X-ray result, mean segmental lordosis angle(SLA) improved in pre-operative/post-operative/follow-up period 9.87±2.74 degree/ 11.79±3.74 degree/ 10.56±3.69 degree (p > 0.01); mean lumbar lordosis angle(LLA) improved 37.1±7.04 degree/ 39.2±7.13 degree/ 35.7±7.25 degree(p > 0.01). Mean preoperative disc height(DH) improved from 8.97±1.49 mm/ 12.34±1.39 mm/ 11.44±1.98 mm (p < 0.01). In the CT result, Average percentage of fusion mass was 42.61%. VAS was improved significantly, 7.67 / 3.39 / 2.5 and ODI was improved significantly, 74.9 / 34.56 / 27.76 by each preoperative / postoperative / final follow-up. In the clinical result, excellent was 5 cases and good was 13 cases. Conclusion: According to the results of this study, eTLIF was competent enough to perform as open TLIF. and good results were obtained in the form of endplate preservation, disc height restoration, minimal blood loss and post-operative pain with early mobilization. In addition, the fusion volume including the cage and the bone graft material occupies 40% to 50% of disc space is expected to give sufficient fusion by using 3D printed cages which gives the high fusion rate. In conclusion, eTLIF is considered to be a viable surgical procedure.

Background: To evaluate the clinical efficacy of the Wiltse paraspinal approach and percutaneous pedicle screw placement under O-arm navigation for the treatment of thoracolumbar fracture.Methods: We enrolled a total of 54 patients with neurologically intact thoracolumbar fracture who received minimally invasive treatment. Among these, 28 patients were treated with pedicle screw fixation through the Wiltse paraspinal approach (WPSF), and another 26 were received percutaneous pedicle screw fixation under O-arm navigation (OPSF). Statistical methods were used to perform a detailed comparison of clinical outcomes, radiologic findings and complications between the two groups obtained preoperatively, postoperatively and at last follow-up.Results: There were no significant differences between the two groups in terms of the intraoperative bleeding, length of incision, postoperative hospitalization durations or accuracy rate of pedicle screw placement (p>0.05). Visual analog scale (VAS) scores, Oswestry disability in­dex (ODI) scores, local Cobb angle (LCA), vertebral wedge angle (VWA) and R value were notably improved after surgery, though no clear discrepancy between the groups at each time point (p>0.05). However, the OPSF group had a longer operation time and greater surgical expenditure than the WPSF group (p

Objective To report and describe a modified posterior-only approach (paraspinal approach) for total en bloc spondylectomy (TES) of lumbar spinal tumors. Methods From February 2013 to June 2014, 5 patients with lumbar spinal tumors who underwent TES through a posterior-only paraspinal approach were studied retrospectively; operative time, blood loss, complications, neurologic outcomes, and degree of resection were recorded to evaluate the efficacy of this surgical method. Results Patients included 3 men and 2 women with a mean age of 48.4 years (range, 46–52 years). Two lesions were located in L2, 2 lesions were located in L3, and 1 lesion was located in L4. Three patients had solitary metastatic tumors (lung cancer in 2 cases, breast cancer in 1 case), and 2 patients had primary tumors (osteosarcoma and plasma cell tumor). According to the surgical classification of spinal tumors by Tomita et al., 4 cases were type 4 and 1 case was type 1. Mean operative time was 464 minutes (range, 420–510 minutes), and mean blood loss was 1280 mL (range, 1000–1500 mL). One patient had cerebrospinal fluid leakage, and 1 had transient motor weakness because of nerve root traction. Mean follow-up time was 20.6 months (range, 12–30 months), and all patients had improved or stable neurologic function. No local recurrence was observed at last follow-up. Conclusions The posterior-only paraspinal approach is a valid alternative for TES of lumbar spinal tumors, especially for overweight or muscular patients.

Background Data: Percutaneous screws fixation became popular as it depends on minimal muscle destruction and no para-spinal muscle stripping. However, there is a lot of disadvantages of percutaneous fixation technique including the high radiation exposure. Complications reported in conventional midline approach including muscle stripping from lamina and spinous processes and long-term postoperative pain and muscle weakness led the spine surgeon to rediscover minimally invasive technique to manage spinal fractures through posterior approach. One of these techniques is Wiltse technique which access the pedicle through blunt dissection between the longissimus muscle and multifidus muscle. Purpose: This study aims to compare pedicle screw fixation via Wiltse approach, and the traditional posterior midline approach outcome. Study Design: Prospective comparative study. Patients and Methods: A total of 36 patients of single-level thoracolumbar fractures without neurologic injury underwent pedicle screw fixation using two different approaches. Twenty patients were treated using conventional technique (Group 1 ), and 16 patients were operated using Wiltse technique (Group 2 ). Screw placement accuracy rate, operative time, blood loss, postoperative hospitalization time, radiation exposure time, postoperative improvement of Cobb angle for regional kyphosis, functional disability index using Oswestry Disability Index, and Visual Analogue Scale (VAS) of the two groups were compared. Results: There were no significant differences in the accuracy rate of pedicle screw placement, radiation exposure and Cobb angle improvement between the two groups. However, the Wiltse technique had obvious advantages over the conventional technique in operative time, blood loss, hospitalization time, ODI improvement and postoperative short-term improvement in VAS. Conclusion: Our data suggest that pedicle screw insertion using Wiltse technique for treatment of thoracolumbar fracture has the advantages of less tissue trauma, short operative and rehabilitative time on the premise of guaranteed accuracy rate and no significant increased radiation exposure. (2018ESJ160)

Introduction Technical developments in spinal surgery have reduced the number of surgical incisions and of the length of time for the procedure. Objective Describe topographical landmarks, anatomy and characteristics of the Wiltse access, a paraspinal approach to the lumbar spine. Methods A review of the literature was performed using as databases: PubMed, Embase, Science Direct, the Cochran Database and Google Scholar. Total 22 papers met the inclusion criteria, and they were all published between 1959 and 2016. Discussion The Wiltse approach is performed by median skin incision with lateral muscle dissection between the multifidus and the longissimus muscles, in a natural pathway. This approach allows access to the pedicles and to the lateral recess, enabling the performance of posterior spinal fusion and decompression and minimally invasive discectomy techniques. This access is less traumatic than the median approach, and it is ideal for lower levels, like L4–5 and L5-S1. Conclusion The authors strongly encourage this approach because they believe that, when well-indicated, the benefits outweigh the disadvantages and complications due to the fact that it is a less invasive procedure.

With technical development and evolution of endoscopic instruments, endoscopic spine surgery (ESS) has been developed as an effective and minimally invasive surgical treatment for degenerative spinal diseases. Endoscopic spinal approaches are said to have many merits such as less postoperative pain, short hospital stay and early return to normal life due to it’s minimal invasiveness. Endoscopic paraspinal approach, which follows the same anatomical principle of classic Wiltse approach, provides thorough decompression of whole length of exiting nerve root from pedicle to extraforaminal area with such advantages from ESS. Although endoscopic paraspinal approach has some limitations, such as technical difficulties and steep learning curves, compared to conventional techniques, which can be overcame with surgical experiences and skilled operative technique. Endoscopic paraspinal approach consists of many essential skills to manage different endoscopic anatomical structures of the spine. From the perspective of surgical completion and safety, the authors will describe the whole concept and practical details of this procedure, and discuss few issues related with technical considerations in endoscopic paraspinal approach for lumbar foraminal stenosis.

Objective The purpose of this study was to present the outcome of the microsurgical foraminotomy via Wiltse paraspinal approach for foraminal or extraforaminal (FEF) stenosis at L5–S1 level. We investigated risk factors associated with poor outcome of microsurgical foraminotomy at L5–S1 level. Methods We analyzed 21 patients who underwent the microsurgical foraminotomy for FEF stenosis at L5–S1 level. To investigate risk factors associated with poor outcome, patients were classified into two groups (success and failure in foraminotomy). Clinical outcomes were assessed by the visual analogue scale (VAS) scores of back and leg pain and Oswestry disability index (ODI). Radiographic parameters including existence of spondylolisthesis, existence and degree of coronal wedging, disc height, foramen height, segmental lordotic angle (SLA) on neutral and dynamic view, segmental range of motion, and global lumbar lordotic angle were investigated. Results Postoperative VAS score and ODI improved after foraminotomy. However, there were 7 patients (33%) who had persistent or recurrent leg pain. SLA on neutral and extension radiographic films were significantly associated with the failure in foraminotomy (p17.3°) and extension radiographic films (>24°).

Purpose: To examine the hidden blood loss (HBL) in treatment of AO type A1-A3 thoracolumbar fractures with three different approaches and to explore the influential factors of HBL among patients after the surgery of internal fixation for thoracolumbar fractures. Methods: We retrospectively studied 85 patients in treatment of thoracolumbar fractures: 25 patients via percutaneous approach (Group A), 33 patients via paraspinal approach (Group B), and 27 patients via conventional open approach (Group C). The demographic information of the patients was collected. Each patient's preoperative and postoperative hematocrit were recorded and used for calculating the blood loss according to the Gross's formula. The difference of blood loss between the three groups was measured by ANOVA. And influential factors were further analyzed by multivariate linear regression analysis in each group. Results: The average HBL was 240.0 ± 65.1 mL in Group A, 313.7 ± 138.1 mL in Group B, and 382 ± 153.8 mL in Group C. There was statistical difference in the HBL between three groups (P = 0.000). However, multivariate linear regression analysis revealed that HBL of three approaches was not associated with age, gender, body mass index (BMI), percentage of height loss, percentage of height restoration, fracture type, or operation time. Conclusion: There was a substantial HBL in the treatment of thoracolumbar fractures, which was neglected by surgeons. Further investigation is necessary to study the risk factors for surgery on HBL in treatment of thoracolumbar fractures.

The authors present a new minimally invasive posterior thoracic and upper lumbar spinal approach, using midline-staged incision with bilateral dissection via the natural muscular cleavage plane between the spinalis and longissimus muscles for pedicle fixation. The aim was to clarify anatomy and compare results between this technique and the conventional paraspinal approach. An anatomic MRI study determined the position of the superficial aponeurosis of the spinalis-longissimus intermuscular cleavage plane with respect to the midline. The surgical procedure is described. A radiological and clinical study evaluated 24 patients divided into two comparative groups, operated on via the medial intermuscular or the paraspinal approach, for isolated A3 and B2 Magerl fracture between T2 and L2, without neurologic involvement. Pain, postoperative complications, reduction quality and esthetic satisfaction were assessed. MRI located the cleavage plane, which was consistently 11.01±0.9mm (range, 9.4-12.3mm) from the midline. In the "medial approach" group, hospital stay was significantly shorter, by 3 days, at 4±1.9 (range, 2-8 days) (p: 0.005); pain on VAS was 2 points lower at postoperative day 1 (2.1±1.4; range,≤1-4; p:0.032), and lower at discharge (0.3±0.6; range, 0-1; p: 0.001). The scar was considered esthetically very satisfactory. This easily performed and reproducible medial intermuscular approach showed low iatrogenesis, significantly improving postoperative course.

Thoracolumbar fractures are usually treated by open posterior pedicle screw fixation. However, this procedure involves massive paraspinal muscle stripping, inflicting surgical trauma, and prolonged X-ray exposure. In this study, we observed 127 patients with single-segment injury thoracolumbar fractures. Thirty-six patients were treated by the modified Wiltse's paraspinal approach with minimally invasive channel system, while 91 patients were treated via traditional posterior approach. Operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, screw placement accuracy, visual analogue scale score, and Cobb's angle of two groups were compared. The X-ray exposure times were notably reduced (4.2±1.6) in the new approach group (P

Summary Discectomy for lumbar discal herniation is the most commonly performed spinal surgery. The basic principle of the various techniques is to relieve the nerve root compression induced by the herniation. Initially, the approach was a unilateral posterior 5-cm incision: the multifidus was detached from the vertebra, giving access through an interlaminar space in case of posterolateral herniation; an alternative paraspinal approach was used for extraforaminal herniation. Over the past 30 years, many technical improvements have decreased operative trauma by reducing incision size, thereby reducing postoperative pain and hospital stay and time off work, while improving clinical outcome. Magnification and illumination systems by microscope and endoscope have been introduced to enable minimally invasive techniques. Several comparative studies have analyzed the clinical results of these various techniques. Although the methodology of most of these studies is debatable, all approaches seem to provide clinical outcomes of similar quality. At all events, minimally invasive techniques reduce hospital stay. While technical proficiency is essential, the final result depends on strict compliance with a prerequisite for surgical indication: close correlation between clinical symptoms and radiological findings. It is essential to discuss the risk/benefit ratio and explain the pros and cons of the recommended technique to the patient.

We aimed to describe the surgical technique and clinical outcomes of paraspinal-approach reduction and fixation (PARF) in a group of patients with Denis type B thoracolumbar burst fracture (TLBF) with neurological deficiencies. A total of 62 patients with Denis B TLBF with neurological deficiencies were included in this study between January 2009 and December 2011. Clinical evaluations including the Frankel scale, pain visual analog scale (VAS) and radiological assessment (CT scans for fragment reduction and X-ray for the Cobb angle, adjacent superior and inferior intervertebral disc height, and vertebral canal diameter) were performed preoperatively and at 3 days, 6 months, and 1 and 2 years postoperatively. All patients underwent successful PARF, and were followed-up for at least 2 years. Average surgical time, blood loss and incision length were recorded. The sagittal vertebral canal diameter was significantly enlarged. The canal stenosis index was also improved. Kyphosis was corrected and remained at 8.6±1.4o (P>0.05) 1 year postoperatively. Adjacent disc heights remained constant. Average Frankel grades were significantly improved at the end of follow-up. All 62 patients were neurologically assessed. Pain scores decreased at 6 months postoperatively, compared to before surgery (P

Objective Lumbar foraminal or extraforaminal disc herniations (FEFDH) have unusual clinical features and higher incidence in elderly patients compared to usual intraspinal canal disc herniations. We evaluated the efficacy of microdiscectomy via paramedian approach for lumbar FEFDH in elderly patients over the age of 65. Methods Retrospective study was performed in 68 patients over the age of 65 (23 male and 45 female patients; 71.46±3.87 years) who underwent microdiscectomy via paramedian approach for unilateral lumbar FEFDH causing sciatica. The radiological factors including degree of slippage, presence of instability, disc height, and degree of disc degeneration; pain and functional status by the means of visual analogue scale score, Oswestry Disability Index score, and Macnab classification were analyzed preoperatively and during the postoperative follow-up period of 3 years to evaluate the efficacy of the surgical treatment. Results Pain and functional status improved according to short- and long-term follow-up evaluations after surgery. Radiological changes following surgery, which can be understood as structural deteriorations and deformations, did not represent patient condition. Nine patients underwent additional surgery due to sustained or recurring leg pain of aggravation of back pain, and fusion surgery was required for 3 patients. Degree of preoperative slippage was the only statistically significant factor related to additional surgery (p Conclusion Microdiscectomy via paramedian approach for FEFDH may be a good surgical alternative in elderly patients. Radiological changes after surgery did not show a concordance with patients' actual functional status. The excessive preoperative slippage tended to lead to unfavorable result after surgery and was associated with additional surgery.

OBJECTIVE: This prospective randomized controlled study compared the efficacy and safety of two paraspinal muscle-sparing surgical approaches for the management of neurologically intact patients with thoracolumbar burst fractures and posterior ligamentous complex injuries. METHODS: Patients were randomized to undergo either percutaneous ( n = 31) or paraspinal ( n = 30) fluoroscopically-guided pedicle screw—rod fixation, and were followed for ≥ 3 years. Preoperative postural reduction was attempted in all patients. RESULTS: The percutaneous approach was associated with significantly less intraoperative blood loss and shorter duration of surgery and hospitalization, as well as less pain and better functional recovery at 3 months after surgery compared with the paraspinal approach. Paraspinal surgery resulted in significantly better correction of kyphosis and restoration of vertebral height compared with percutaneous surgery. There were no differences in long-term clinical outcomes between the two groups. CONCLUSIONS: The minimally invasive percutaneous approach appears to be better in cases of successful postural reduction. The paraspinal approach results in better surgical correction and is, therefore, recommended for patients without successful postural reduction.

The treatment of acute thoracolumbar fractures is a demanding and fine surgical challenge. Conventional procedures are not always satisfactory enough because of postoperative complications of failure of posterior instrumentation or lumbodorsal pain etc. This prospective outcome study was undertaken to investigate the improvement of the surgical treatment effect on acute thoracolumbar fractures by performing modified surgeries. Nineteen patients with acute thoracolumbar fractures and associated incomplete neurologic deficit, subjected to the methods of transpedicular intracorporeal hydroxyapatite grafting and pedicle screw fixation through paraspinal approach, were reviewed after a minimum follow-up of 2 years. Nineteen patients all suffered from a single thoracolumbar fracture. The mean preoperative ratio of the height of the anterior border was 57.2%, kyphosis degree was 21.6°, and occupancy of canales spinalis was 30.5%. The radiographic parameters were evaluated, and clinical records were reviewed. The average operating time was 112.4 min, and the mean blood loss was 123.7 ml. The neurologic function of all 19 patients was improved by at least one American Spine Injury Association grade, with 17 (89.5%) having complete neurologic recovery. The mean height of injured spine was corrected from 57.2% to 88.4% at the most recent follow-up, and the kyphosis was corrected from 21.6° to 4.8°. There was only one patient (5.3%) who complained that the operative area was a little painful, and the remaining patients did not claim pain in waist and back. Transpedicular intracorporeal hydroxyapatite grafting and pedicle screw fixation through paraspinal approach could provide reliable neurologic improvement in patients with incomplete neurologic deficit, and could prevent the development of kyphosis. Furthermore, it has the obvious advantages of less invasion and blood loss, and decreases the risks of postoperative lumbodorsal pain.

ObjectForaminal stenosis is a common cause of lumbar radicular symptoms. Recognition of the dynamic pathology, as well as the static anatomical changes, is important to achieving successful surgical outcomes. Excessive facet and anulus removal leads to subsequent disc space narrowing and/or segmental instability, which can cause poor results after decompressive surgery. The objective of this study was to evaluate the efficacy of the paraspinalapproach transforaminal lumbar interbody fusion (TLIF) in the treatment of lumbar foraminal stenosis.MethodsTwenty levels of lumbar foraminal stenosis in 16 patients were treated using an instrumented paraspinal-approach TLIF. There were 12 single-level and 4 two-level cases. Pathologies included foraminal stenosis at 13 levels and lateral disc herniation with disc space narrowing at 7.ResultsIn all patients, preoperative radicular symptoms and mechanical low-back pain were resolved immediately after the operation and leg weakness improved gradually. The recovery rate using the Japanese Orthopaedic Association score was 89.1%. Bony union was achieved within 6 months after the operation in all cases. Postoperative MR imaging showed minimal changes in the paraspinal muscles in the single-level cases.ConclusionsThe paraspinal-approach TLIF is a minimally invasive, safe, and secure procedure for treating lumbar foraminal lesions. Direct visualization and decompression for the foraminal lesion, distraction of the collapsed disc space, and stabilization of the unstable segments can be achieved simultaneously through the paraspinal approach, which produces successful clinical and radiological results.

Tuberculosis is highly prevalent in developing country and with rising incidence of HIV, incidence of tuberculosis is further rising. Spine is most common site of osseous involvement of tuberculosis and the psoas abscess one of its common complication. We encountered a rare case of bilateral tubercular psoas abscess having aneurysm of abdominal aorta. While performing aspiration of abscess through posterior paraspinal approach for diagnostic work up, we land up in fatal complication of aortic aneurysm rupture. The case was further managed by injecting glue, so could avoid life threatening complication.

Background The influence of approach on outcomes of posterior nonfusion stabilization has not been described. This paper analyzes the influence of surgical approach on functional outcome with nonfusion stabilization. Methods We performed a prospective consecutive cohort outcome analysis of 88 patients who had undergone posterior nonfusion stabilization of the lumbar spine at 178 levels using the Dynesys system (Zimmer Spine, Inc, Warsaw, Indiana). Patients needing decompression (n = 42) were operated through a midline approach using microscopic laminotomy/foraminotomy with or without discectomy, followed by posterior nonfusion stabilization with Dynesys. None of the patients had a complete laminectomy. Patients not needing decompression (n = 46) underwent the procedure via the bilateral paraspinal muscle-sparing approach and were subsequently stabilized. Clinical and functional outcomes data were collected using the visual analog scale (VAS), Treatment Intensity Score (TIS), Oswestry Disability Index (ODI), and SF-36. Average follow-up was 18 months (range, 12–36 mo). Results All outcome measures in both groups showed significant improvement at last follow-up. Between the groups a significant difference was apparent in the reduction of the TIS when measured at 1 week and 6 weeks. The preoperative, 1-week, and 6-week values were 66, 48, and 40, respectively (P < 0.05), for the midline group and 80, 32, and 28 (P < 0.05) for the paraspinal group. This trend continued through 3 to 6 months after the procedure but did not reach statistical significance. In the paraspinal group, pain scores showed a nonsignificant trend toward lower values in the first month, compared with values in the midline group. Patients reported excellent to fair results, with the exception of three patients in the midline group and two in the paraspinal group, who rated the procedure as fair. Conclusions Significantly fewer patients required postoperative narcotics in the paraspinal group than in the midline group. This improvement in early outcomes suggests a significant early benefit to the less tissue-destructive muscle-sparing approach in posterior nonfusion stabilization procedures.

Background The paraspinal, posterolateral, or Wiltse approach is an old technique that observes the principles of an MIS procedure. The aim of this study was to provide a step-by-step description from the literature of the Wiltse paraspinal approach and analyze its main advantages and limitations. Methods Here, we provide a step-by-step description of the Wiltse approach. Utilizing PubMed and Lilacs and the Mesh terms "Wiltse approach," "paraspinal approach," "muscle sparing approach," and "lumbar spine," we identified 10 papers. We then put together, based on these publications, a step-by-step analysis of the preparation, patient positioning, skin incision, fascial opening, dissection, bone identification, retractors, deperiostization, decompression, discectomy, instrumentation, arthrodesis, and closure for the Wiltse technique. Results Most papers underscored the minimally invasive aspects of the typical Wiltse approach. Advantages included minimal intraoperative bleeding, a shorter hospital length of stay, and a low infection rate. Conclusion The classical approach described by Wiltse is essentially minimally invasive, sparing both the muscle planes and soft tissues, allowing for ample far lateral lumbar decompression, including discectomy and fusion, with a low complication rate.

We treated 8 cases (5 males and 3 females) with lateral lumbar disc herniation surgically since 1995, and the intralateral approach, in which intralamina fenestration was performed in addition to a paraspinal approach, was conducted in 5 cases. We operated on the cases that had not been efective for conservative treatments, and chose the intralateral approach for the cases that was thought difficult for only medial fenestration. The purpose of this study is evaluate postoperative clinical improvement the in JOA score with procedure.The average age at the time of surgery was 63.4 years (range; 56 to 76 years). The follow-up period averaged 1 year 9 months. The level was L2/3 in 1 case, L3/4 in 1, L4/5 in 3, L5/S1 in 3. Depending on the case intralateral approach, Love's method, or partial laminectomy was conducted without facetectomy.The results were as follows: the mean JOA scores before treatment were 11.8/29 for the intralateral approach (5 cases), 17/29 in Love's method (1 case), 12.5/29 in partial laminectomy (2 cases), and 14/29 for the conservative group. The mean JOA scores after treatments were 24.2/29 for the intralateral approach, 26/29 for the Love's method, 26.0/29 for the partial laminectomy, and 25.4/29 for the conservative group. The mean percentage of clinical improvement was 71.9%, 75%, 82.2%, and 75.6% respectively. All patients evaluated their degree of satisfaction were excellent or good.

In this independent review, at an average of 5.5 years after surgical excision of a lateral zone disc herniation using a paraspinal approach, 51 of 60 patients (85%) were satisfied with the results. Pain was eliminated in 36 (60%) and reduced in all but 3 (5%). Two-thirds of patients had no residual weakness or numbness. Thirty patients (50%) developed some new low-grade back pain, 17 (28%) developed some radicular pain, 9 (19%) developed some degree of radiographic instability, and 9 (15%) required further operative procedures. Based on this information, surgeons should be able to provide realistic expectations for their patients regarding outcomes. Based on our review of the literature, results using the paraspinal window appear similar, but not superior, to other available techniques, and the choice of approach should be based on the comfort of the surgeon.

The paraspinal posterior approach to the lumbar spine initially was described for spinal fusion, particularly for treatment of lumbosacral spondylolisthesis. Despite the technical details described by Wiltse et al, the exact location of the sacrospinalis muscle that must be split remains unclear. We sought to clarify the anatomic description of the paraspinal posterior approach to the lumbar spine, and to provide topographic landmarks for facilitating this surgical approach. Fifty cadavers were dissected using an anatomic transmuscular paraspinal approach. The level of the natural cleavage plane between the multifidus and the longissimus parts of the sacrospinalis muscle was noted, and measurements were taken between this level and the midline at the level of the spinous process of L4. A natural cleavage plane between the multifidus and the longissimus parts of the sacrospinalis muscle was present in all specimens. There was a fibrous separation between the two muscular parts in 88 of 100 cases. The mean distance between the level of the cleavage plane and the midline was 4.04 cm (range, 2.4-7 cm). Small arteries and veins were present at the level of the cleavage plane in all specimens. These vascular landmarks make it easier to locate the muscular cleavage plane and reach the articular and transverse processes during the paraspinal approach.

Wiltse has described in 1968 an intermuscular lumbar approach with two vertical incisions made at 30 mm each on both sides of the midline. Since 1988, Wiltse recommends to practice a single median incision because of aesthetic arguments and because it avoids potential difficulties in case of iterative surgery. In this paper, the goal of authors was to determine the advantages of two lateral incisions, particularly in term of cutaneous vascularization. This cadaveric study concerned ten specimens. Colored latex was injected into the lumbar segmentary arteries before taking a cutaneous flap. We calculated the mean of the number of vessels injected and cut on the midline, then all the 10 mm on both sides. The goal was to establish a cutaneous cartography, and to determine a zone of less vascular sacrifice. The lumbar skin was vascularized by an arteriolar network which spreads out from the midline. At 30 mm from the midline, the number of cut vessels is statistically less than in the others areas (P < 0.05). At this distance, the small arteries are superficial, fine, and the subcutaneous tissue appears poorly vascularized. The two lateral incisions have the advantage compared to a single median incision of being short, and of allowing a direct access to the muscular plan of cleavage without subcutaneous detachment, with a less pressure retraction. We think that an incision at 30 mm from spinous processes is less noxious for the skin because it is located at the border of two vascular territories, which depend of a median network for one, and a lateral network for the other. These incisions generate technical difficulties, however, when the approach is prolonged with the top of L2/L3, when a lateral and/or central canalar decompression is considered, and finally, in the event of iterative surgery.

Forty-two patients underwent surgery for far-lateral disc herniations. Average patient age was 45.1 years, 28 patients were male and 14 female. The level concerned most was L4-5 disc (55%). A paramedian muscle-splitting intertransverse approach is described for this type of disc herniation. This method allows direct visualization of the disc and root involved and does not provide bone resection and important surgical manipulation. Ninety-one percent of the patients reported excellent or good results according to Macnab outcome criteria with an average follow-up of 32.5 months (range 1–5 years). Twelve patients (28.6%) developed postoperative transient radicular pain that disappeared in 15–21 days after analgesic therapy. There were no recurrences or spinal instability.

Background Complications in posterior pedicle screw fixation using a conventional posterior approach for thoracolumbar fractures include vertebral height loss, kyphosis relapse and breakage, or loosening of instrumentation. The purpose of this study was to evaluate the clinical effects of transpedicular bone grafting and pedicle screw fixation in injured vertebrae using a paraspinal approach for thoracolumbar fractures. Methods We retrospectively analyzed 50 patients with thoracolumbar fractures treated with transpedicular bone grafting and pedicle screw fixation in injured vertebrae using a paraspinal approach. Operative time, blood loss, visual analog scale (VAS) scores for back pain, and the relative height and Cobb angle of the fractured vertebrae were measured. Results The average operative time was 71.8 min, and the blood loss was 155 ml. Postoperative VAS scores were significantly lower than preoperative scores (P = 0.08), but there was no difference between 1 week and 1 year postoperatively (P = 0.18). The postoperative relative heights of the fractured vertebrae were higher than the preoperative heights (P = 0.001, 0.005, 0.001), but there were no differences between 1 week and 1 or 2 years postoperatively (P = 0.24/0.16). The postoperative Cobb angles were larger than the preoperative angles (P = 0.002, 0.007, 0.001), but there were no differences between 1 week and 1 or 2 years postoperatively (P = 0.19/0.23). Conclusions Transpedicular bone grafting and pedicle screw fixation in injured vertebrae using a paraspinal approach for thoracolumbar fractures achieved satisfactory results and can restore vertebral height, increase the stability of the anterior and middle columns of injured vertebrae, and decrease the risk of back pain.

There are 2 fairly common types of spondylolisthesis in children - dysplastic and isthmic. The dysplastic type is secondary to congenital defects at the lumbosacral joint. The isthmic is usually due to a fatigue fracture of the pars interarticularis but there is also an hereditary element in this type. Most children with spondylolisthesis never develop significant symptoms and even of those who do, the vast majority can be treated without surgery. If symptoms persist or if further olisthesis is occurring, a one-level spinal fusion done through a paraspinal approach is recommended. It is most important not to allow olisthesis to develop to the point that the child shows the cosmetically undesirable stigmata characteristic of the condition. Solid fusion can be obtained in every case and will stop further slip.