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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 Background Benign spinal cysts are relatively common, but can cause significant pain. However, consensus regarding the best method for treating these cysts has not been established. We aimed to examine the usefulness of epiduroscopic neural laser decompression (ENLD), a novel percutaneous treatment, for treating lumbo-sacral cysts. Methods Ten patients (6 men, 4 women; mean age 45.5 years) with benign lumbo-sacral cysts underwent ENLD. The lumbo-sacral cysts were caused by multiple pathophysiologies and displayed different characteristics. Cysts were evaluated using a recorded epiduroscopic procedure video, magnetic resonance imaging (MRI), and electronic medical records. In all patients, MRI identified cysts with well-defined margins that were compressing the nerves in the lumbo-sacral region and were associated with the pain symptoms of the patients. Retrospectively, we reviewed a series of consecutive patients who underwent surgery (two with discal cysts, four with facet cysts, and four with Tarlov cysts). Low back/leg pain was evaluated using a 1–10 visual analog scale. Functional improvement was evaluated using Oswestry Disability Index scores. Outcomes were evaluated pre- and post-operatively and 1 year post-surgery. Results Patients were examined between May 2016 and August 2017. Average pain scores improved from 4.7 pre-surgery to 1.8 post-surgery (low back; p

Abstract Background The unilateral biportal endoscopic (UBE) technique is a minimally invasive procedure for spinal surgery, while open microscopic discectomy is the most common surgical treatment for ruptured or herniated discs of the lumbar spine. A new endoscopic technique that uses a UBE approach has been applied to conventional arthroscopic systems for the treatment of spinal disease. In this study, we aimed to compare and evaluate the perioperative parameters and clinical outcomes, including recovery from surgery, pain and life quality modification, patient’s satisfaction, and complications, between UBE and open lumbar microdiscectomy (OLM) for single-level discectomy procedures. Methods This study included 141 patients with degenerative disc disease requiring discectomy at a single level from L2–L3 to L5–S1. A total of 60 and 81 patients underwent UBE and OLM, respectively. Analysis was based on comparison of perioperative metrics, operation time (OT); estimated blood loss (EBL); length of hospital stay (HS); clinical outcomes, including assessment using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI); patient satisfaction (the MacNab score); and the incidence of reoperation and complications. Results The study cohort was 56.7% women, and the mean patient age was 50.98 ± 18.23 years. The mean VAS (the back and leg), MacNab score, and ODI improved significantly from the preoperative period to the last follow-up (12.92 ± 3.92) in both groups (p

After the completion of an endoscopic spinal surgery fellowship, the next challenge for the newly minted consultant is to set up a viable and sustainable endoscopic practice. A successful practice of endoscopic spine surgery is dependent on several factors, such as anesthetic support; surgical expertise; support for provision and maintenance of endoscopic equipment; cost of equipment; administrative and nursing support; postoperative care services to optimize patients' outcome and satisfaction; patients' ideas, concerns, and expectations, as well as continuing medical education. In this article, a perspective is given on the early career challenges that a fellowship-trained endoscopic surgeon may encounter in the period leading to first successful endoscopic spinal surgery. [ABSTRACT FROM AUTHOR]

Lumbar burst fractures (complete or incomplete) of L5 have a low incidence, accounting for 1.2% of all spinal burst fractures. Treatment for these fractures remains controversial. Decompression of neural elements and stabilization of the spine to preserve lordosis and avoid kyphotic deformity are recommended when a patient has a neurological deficit and an unstable fracture. Otherwise, the fracture could be managed conservatively. We report a detailed step-by-step unilateral biportal endoscopy technique used in a patient with an L5 incomplete burst fracture and neurological deficit. The patient had an acceptable immediate postoperative course; lower back pain and radicular symptoms improved significantly after surgery. Our unilateral biportal endoscopy technique for L5 incomplete burst fractures offers the capability to perform enough decompression of neural elements and assist other procedure-related maneuvers under direct endoscopic visualization. This technique could be considered another minimally invasive spine surgery option for treating selected patients with L5 incomplete burst fractures. [ABSTRACT FROM AUTHOR]

Identifying the histopathological diagnosis of a spinal tumor is the necessary step prior to pursuing subsequent treatment. Both minimally invasive and open spinal procedures have been described as useful methods of obtaining tumor tissue for diagnosis but differ by their limitations. Minimally invasive techniques, such as computed tomography–guided biopsies, can expose the patient to radiation, and the tissue obtained may be nondiagnostic. Tubular and open procedures require collateral soft-tissue damage and may require bony removal leading to iatrogenic injury. Endoscopic approaches to the spine can be employed to avoid treatment delay in diagnosis, decrease length of stay, and provide adequate tissue for diagnosis. We describe the surgical planning, tumor localization, and transforaminal endoscopic approach for tissue diagnosis of a lumbar spinal mass in a patient with a known history of Hodgkin lymphoma and non-Hodgkin lymphoma after a nondiagnostic computed tomography– guided biopsy. Final histopathological diagnosis of the lumbar spinal mass was consistent with large B-cell non-Hodgkin lymphoma. We demonstrate the application of an endoscopic transforaminal approach in spine oncology. We also describe our technique on how we use a beveled working channel to obtain a large tissue core sample for definitive diagnosis. [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]

The authors discuss the recent advances in the understanding and management of spondylolisthesis. The two most common kinds of spondylolisthesis - Degenerative and Spondylolytic types have been elaborated in this paper, with the understanding that similar management principles can be applied to the other lesser common varieties. The impetus has been on application of minimally invasive techniques in the treatment as well as renewed interest in stand-alone decompression in degenerative spondylolisthesis. [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]

• Spinal epidural lipomatosis can occur and progress rapidly after endoscopic spine surgery. • As in our case, focally progressed SEL anterior to the dural sac could be misdiagnosed for disc herniation. • SEL should be recognized as a rare complication of endoscopic spine surgery. Spinal epidural lipomatosis (SEL) is well known but uncommon complication of endoscopic spine surgery. Here, we present a case of SEL that progressed focally and rapidly after endoscopic spinal surgery. A 67-year-old man presented with back and Lt. leg radiating pain. MRI of the lumbar spine demonstrated severe foraminal stenosis at Lt. L4/5/S1. He underwent endoscopic posterior foraminotomy at Lt. L4/5/S1. After surgery, his leg pain disappeared. A month after surgery, the patient developed Lt. leg pain again. MR images showed focally progressed epidural fat posterior to the L5 body. After removal of lipomatosis via endoscopic posterior decompression at L3/4/5, his symptoms improved. Mostly, the epidural fat accumulates insidiously, and distributes widely across several levels. And the increased accumulation of fat is predominantly posterior and posterolateral within the spinal canal. As in this case, focally progressed SEL anterior to the dural sac is rare. And focally progressed SEL can be misdiagnosed for disc herniation. SEL should be recognized as a rare complication of endoscopic spine surgery. [ABSTRACT FROM AUTHOR]

Lumbar disk herniation can be successfully treated by lumbar endoscopic spinal procedures. However, one of the most important disadvantages of the endoscopic methods used is radiation exposure. There are multiple endoscopic spinal procedures and this study aims to compare unilateral biportal endoscopic diskectomy (UBED), percutaneous endoscopic lumbar diskectomy (PELD), and microendoscopic diskectomy (MED) methods in terms of radiation exposure. A total of 75 people were included in this prospective and multicenter study. The demographic characteristics, operating times (minutes), levels of surgery, lumbar disk herniation types, radiation exposures (dose area product [DAP]), and fluoroscopy times (seconds) of the groups were compared. Mean DAP values were 1.39 Gy·cm2 in the UBED group, 2.46 Gy·cm2 in the PELD group, and 1.01 Gy·cm2 in the MED group. The UBED group had no statistically significant difference with the MED and PELD groups in terms of DAP (P = 0.281 and P = 0.058, respectively), whereas the PELD group had statistically significantly higher DAP values than the MED group (P = 0.016). The maximum mean duration of fluoroscopy usage time was 34.9 seconds in the PELD group, 19.3 seconds in the UBED group, and 4.6 seconds in the MED group. The differences between the groups were significant (P ≤ 0.001). The more the level of invasiveness is reduced in spinal surgery, the greater the exposure to radiation. In this study, the groups are listed as PELD > UBED > MED according to the duration and level of radiation exposure. [ABSTRACT FROM AUTHOR]

Lumbar disc herniation (LDH) comprises one of the most common causes of low back pain. 35%–72% of LDH is associated with disc fragment migration. The migration of the disc fragments can be high-grade up, low-grade up, high-grade down, and low-grade down. Spine surgeons deal with unique challenges during surgical management of migrated discs. Operational challenges with open surgery include extensive lamina excision, pars excision, and potential for iatrogenic instability without fixation. In contrast, rigid instruments and poor visualization are the challenges with transforaminal endoscopic spine surgery (ESS). Hence interlaminar approach with ESS is an excellent choice with these migrated LDH. The creation of a translaminar crater in the cranial lamina without dealing with the interlaminar window or ligamentum flavum could be an excellent option to deal with these herniations face front. The lamina is the only anatomical barrier between the endoscope and the migrated disc fragment. Hence with a translaminar approach, unnecessary flavectomy can be avoided. In this technical report and video, we demonstrate the surgical technique of performing the translaminar ESS for highly upmigrated LDH with the preservation of optimal natural anatomy. [ABSTRACT FROM AUTHOR]

Minimally invasive endoscopic spine surgery is useful for the treatment of various spinal conditions. Although surgery-related complications such as dural injury, exiting nerve root injury, incomplete decompression, and hematoma have been reported, there are few reports of late complications after endoscopic surgery. A 51-year-old man complained of radiating pain to the right leg. The patient underwent endoscopic foraminal decompression under the diagnosis of foraminal stenosis with isthmic type spondylolisthesis (L5-S1). The lower extremity radiating pain was improved after surgery. Six weeks after surgery, the patient's symptoms recurred. The patient experienced a sudden onset of severe low back pain, which was aggravated by any motion of the lumbar spine. Computed tomography scan and magnetic resonance imaging revealed a fracture line with a sclerotic margin at the base of the right pedicle at the L5 level. Because the symptoms significantly interfered with his normal activities of daily living, the patient was treated with a total laminectomy, followed by posterior instrumented fusion. As the indication for endoscopic spinal surgery is widening, endoscopic decompression surgery is being performed for patients with low-grade lumbar spondylolisthesis, regardless of the presence of advanced spinal instability. However, endoscopic decompression surgery may cause damage to the posterior facet joint, which may have worsened the instability and lead to late complications such as progression of spondylolisthesis and pedicle stress fracture. The surgeon should carefully review risk factors such as isthmic type spondylolisthesis before planning spine surgery and minimize facet joint damage during endoscopic decompression. [ABSTRACT FROM AUTHOR]

An epidural nerve block injection is the most common modality of treatment for control of low backache associated with radiating pain. Epidural catheter injections are also widely used by pain physicians to control cancer pain. Epidural catheters could be associated with procedure-related complications, such as epidural hematoma, epidural abscess, and post-dural puncture headache, and rare complications, such as shearing or breakage of the catheter tip. In this report, we describe the full-endoscopic removal of a sheared epidural catheter fragment. A man aged 24 years presented with low backache radiating to his left leg with numbness and weakness. Left-sided L4-L5 disc herniation was diagnosed on magnetic resonance imaging, and the patient was posted for an epidural nerve block. The epidural catheter broke during removal, and a 4-cm fragment was retained in the epidural space. We performed an interlaminar full-endoscopic removal of the sheared epidural catheter. Postoperatively, the patient reported excellent clinical outcome. Interlaminar full-endoscopic procedure could be used for the removal of the retained epidural catheter as a practical option. [ABSTRACT FROM AUTHOR]

Robot assisted procedures have evolved during the last years, today many surgical, units perform laparoscopic procedures with DaVinci on a regular Basis. The major advantages of Robot assisted procedures comprise technical factors and improved visualization. In Spinal surgery endoscopic stabilization of fractures has become a Standard for many. We have employed DaVinci as an access tool for a retroperitoneal lumbar approach followed by a DaVinci assisted corpectomy and cage implantation to treat a fracture of L3. A single operation as proof of concept and demonstration of the method was performed. The whole procedure was video recorded. Time factors and clinical outcome were documented. The procedure was performed safely with no complications. The operating time was longer than usual but within reasonable limits. The postoperatrive outcome did not differ from the usual procedure. The visualization of critical structure during preparation of the vertebral body was superior along with superior soft tissue management with DaVinci. An endoscopic robotic instrument can be used for endoscopic access surgery. Despite major advantages in visualization and handling of the endoscopic instruments all bone and cartilage preparation must be performed in a traditional endoscpic way because no appropriate instruments are available at present. In order to perform full robotic assisted procedures, new instruments need to be developed. [ABSTRACT FROM AUTHOR]

We sought to evaluate the feasibility for awake, endoscopic treatment of lumbar pseudarthrosis after a transforaminal lumbar interbody fusion (TLIF). A 71-year-old male with severe cardiac disease, determined to be high risk for general anesthesia, presented with mechanical back pain and a L3-4 pseudarthrosis and L3 pedicle screw loosening after a L3-5 TLIF. An awake, transforaminal endoscopic redo diskectomy and TLIF procedure were performed by removing residual disk material adjacent to the previous "PEEK" (polyetheretherketone) interbody spacer and placing allograft, bone morphogenetic protein, and an expandable titanium interbody device adjacent to the PEEK cage. At 1-year follow-up, preoperative visual analog scale for back pain and Oswestry disability index improved from 7 and 38% to 1 and 2%. The 1-year follow-up radiograph showed stable interbody placement and no further screw loosening. A minimally invasive, awake procedure is presented for the treatment of pseudarthrosis after TLIF. [ABSTRACT FROM AUTHOR]

To evaluate the incidence and outcomes of incidental durotomy in transforaminal endoscopic spine surgery. Transforaminal lumbar endoscopic procedures were performed by 2 surgeons in 907 patients over a period of 4 years from 2014 to 2018. Patient data were evaluated retrospectively in these patients with a minimum follow-up of 1 year. In 907 patients over 4 years there were 5 durotomies: 4 incidental and 1 intentional. The rate for incidental durotomy was therefore 0.4%. There were no adverse outcomes from the incidental durotomies, and only 1 patient noted a headache. Incidental durotomy is a rare complication of transforaminal lumbar endoscopic spine surgery and appears to occur more likely in patients who have undergone previous spine surgery at the site of the endoscopic procedure, not unexpectantly. Glues, patches, and bedrest were among the various methods used after durotomy. In this series there were no cases of symptomatic spinal fluid leakage or pseudomeningocele seen. Only 20% of patients who had durotomies noted a headache in the immediate postoperative period. [ABSTRACT FROM AUTHOR]

Lumbar facet cysts are commonly seen in degenerative lumbar conditions causing stenosis and radiculopathy. Extraforaminal lumbar facet cysts are a rare entity and present a surgical challenge because of their location. Transforaminal endoscopic spine surgery is an emerging technique in spine surgery but has never been described as a treatment option for lumbar radiculopathy in the setting of extraforaminal lumbar facet cyst. A technique for the transforaminal endoscopic treatment of an extraforaminal lumbar facet cyst is presented in 2 patients. We retrospectively reviewed 321 cases of patients who underwent transforaminal endoscopic surgery in a 4-year period with a minimum follow-up of 2 years. A series of 2 patients who underwent transforaminal endoscopic foraminotomy and cyst resection procedures for extraforaminal lumbar facet cysts between 2014 and 2017 is presented: A 51-year-old woman with a right L4-5 extraforaminal cyst improved from a preoperative visual analog scale (VAS) of 7 and Oswestry disability index (ODI) of 26 to a 1-year postoperative VAS score of 2 and ODI of 4; and a 71-year-old woman with a left L5-S1 extraforaminal cyst improved from a preoperative VAS of 7 and ODI of 30 to a 1-year postoperative VAS score of 2 and ODI of 6. Transforaminal endoscopic surgery for a lumbar radiculopathy in the setting of an extraforaminal lumbar facet cyst is presented as a unique minimally invasive approach for the treatment of extraforaminal lumbar facet cyst that avoids facet resection and fusion. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the quantity and quality of articles in the field of full-endoscopic spine surgery (FESS) from different countries and assess characteristics of worldwide research productivity.Methods: Articles published from 1997 to July 23, 2018, were screened using the Web of Science database. All studies were assessed for the following parameters: the number of total publications, h-index, contribution of countries, authors, journals, and institutions.Results: A total of 408 articles were identified between 1997 and 2018. Between 1997 and 2017, the number of published articles tended to increase by 41 times. The largest number of articles was from China (30.15%), followed by South Korea (28.68%), the USA (13.97%), Germany (9.31%), and Japan (4.90%). The highest h-index was found for articles from South Korea (23), followed by the USA (18), Germany (16), China (11), and Japan (7). The highest number of articles was published in World Neurosurgery (12.50%), followed by Pain Physician (10.29%), Spine (6.62%), European Spine Journal (4.66%), and Journal of Neurosurgery: Spine (4.17%). Wooridul Spine Hospital published the largest number of articles (10.29%), followed by Tongji University (5.88%), University of Witten/Herdecke (5.39%), Brown University (5.15%), and Third Military Medical University (3.43%).Conclusions: The number of articles published in the field of FESS has increased rapidly in the past 20 years. In terms of quantity, China is the most contributive country based on the number of publications. High-quality papers as measured by h-index and the large quantity is from South Korea (second only to China). These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Posterior cervical foraminotomy is a commonly performed procedure to address cervical radiculopathy through direct decompression of the neural foramen by partially resecting the dorsal aspect of the facet joint. The procedure is an alternative to anterior cervical approaches such as anterior cervical discectomy and fusion and cervical disc arthroplasty, which require complete discectomy to address foraminal stenosis that cause cervical radiculopathy. The procedure has evolved from open to minimally invasive techniques including endoscopic methods, which has recently increased in interest by spine surgeons. This review discusses the currently existing endoscopic techniques for cervical posterior foraminotomy and synthesizes the existing literature. [ABSTRACT FROM AUTHOR]

With the ongoing development of Unilateral Biportal Endoscopic (UBE) spine surgery, it has become standard of care at many centers across the globe for lumbar decompressions and discectomies due to minimal muscle damage, minimal postoperative back pain and early recovery. In UBE, the separation of viewing portal and working portal allows greater freedom of movement for the surgical instruments as the camera and instruments move independently providing unrestricted vision. Moreover, the continuous irrigation fluid pressure decreases bleeding and helps to irrigate out the bone debris. Hence, UBE spine surgery has become quite popular and has expanded its indications to lumbar spinal fusion. The adoption of UBE for conventional spine surgeons into their routine practice is relatively easier than uniportal endoscopy because of use of standard arthroscopic lenses, familiar view of anatomy, and use of conventional open spinal instruments. In this article, we review the current literature and discuss the indications, contraindications, clinical outcomes, complications and compare it with existing minimally invasive transforaminal lumbar interbody fusion. [ABSTRACT FROM AUTHOR]

Spine surgery has witnessed significant advancements in endoscopic techniques over the past several decades. Compared to open approaches, endoscopic spine surgery allows for minimal tissue dissection, blood loss, and hospital stay, while optimizing early functional recovery. Recent improvements in instrumentation have enabled endoscopic techniques to address a larger range of degenerative pathology. However, regulatory barriers and specialized training are thought to underlie the purportedly steep learning curve, which hinders the widespread implementation of endoscopy in clinical practice. This review aims to provide an overview of endoscopic spine surgery and discuss its learning curve relative to other minimally invasive techniques. [ABSTRACT FROM AUTHOR]

Surgical treatment of extremely migrated caudal and rostral lumbar disk herniations is technically challenging. Traditional open technique often requires more bone resection, which can lead to rare but significant complications such as pars fracture or instability requiring fusion surgery. Endoscopic diskectomy is a safe alternative to traditional open surgery with acceptable complication rates. 1-4 Endoscopic diskectomy provides the advantage of excellent visualization and maneuverability while minimizing soft tissue trauma and bony resection, which can result in less postoperative pain, less opioid consumption, and quicker recovery. 5 We present a surgical technique guide (Video 1) for endoscopic diskectomy of 2 patients with very high rostral (grade 1) and caudal (grade 6) lumbar disk herniations as graded by Ahn's modification of the Lee-Kim grading classification. 6,7 Risks, benefits, and alternatives to surgery were discussed with the patients, and they consented to the procedure. This video is not a replacement for hands-on training. [ABSTRACT FROM AUTHOR]

Objective: There is limited literature comparing the uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion outside-in approach (ETLIF (O)) with the inside-out approach (ETLIF (I)). Methods: Radiological evaluation was performed on disc height restoration and coronal wedging angle, and operation time (inferior articular process resection time/total operation time) and clinical evaluation were made. Result: 48 cases of inside-out and 38 cases of outside-in cases were included. Compared to inside-out, the outside-in approach had significantly less operative time required to resect inferior articular process: 36.55 ± 10.37, and total operative time: 87.45 ± 20.14 min compared to 49.83 ± 23.97 and 102.56 ± 36.53 min, respectively, for the inside-out approach, p < 0.05. Compared to the preoperative state, both cohorts achieved significant improvement of VAS and ODI at post-operative 1 week, 3 months and at final follow up. Both cohorts achieved statistically significant increased disc height with 5.00 ± 2.87 mm, 5.49 ± 2.33 mm and statistically significant improvement in coronal wedge angle with 1.76 ± 1.63°, 3.24 ± 2.92° in the inside-out and outside-in approaches respectively. Conclusions: Complete removal of inferior articular process is the key part of endoscopic fusion with two methods that can be applied: an inside-out approach or an outside-in approach. Comparing both techniques, the outside-in approach has a shorter operative time required for inferior articular process resection and total length of operation with similar good clinical and radiological outcomes.

Objective: Questions regarding anticipated pain improvement and functional recovery postsurgery are frequently posed in preoperative consultations. However, a lack of data characterizing outcomes for the first postoperative days only allows for anecdotal answers. Hence, the assessment of ultra-early patient-reported outcome measures (PROMs) is essential for patient-provider communication and patient satisfaction. The aim of this study was to elucidate this research gap by assessing and characterizing PROMs for the first days after full endoscopic spine surgery (FESS)., Methods: This multicenter study included patients undergoing lumbar FESS from March 2021 to July 2023. After informed consent was provided, data were collected prospectively through a smartphone application. Patients underwent either discectomy or decompression. Analyzed parameters included demographics, surgical details, visual analog scale scores for both back and leg pain, and the Oswestry Disability Index (ODI) score. Data were acquired daily for the 1st postoperative week, as well as after 2 weeks, 3 months, and 6 months., Results: A total of 182 patients were included, of whom 102 underwent FESS discectomy and 80 underwent FESS decompression. Significant differences between the discectomy and decompression groups were found for age (mean 50.45 ± 15.28 years and 63.85 ± 13.25 years, p < 0.001; respectively), sex (p = 0.007), and surgery duration (73.45 ± 45.23 minutes vs 98.05 ± 46.47 minutes, p < 0.001; respectively). Patients in both groups reported a significant amelioration of leg pain on the 1st postoperative day (discectomy group VAS score: 6.2 ± 2.6 vs 2.4 ± 2.9, p < 0.001; decompression group: 5.3 ± 2.8 vs 1.9 ± 2.2, p < 0.001) and of back pain within the 1st postoperative week (discectomy group VAS score: 5.5 ± 2.8 vs 2.8 ± 2.2, p < 0.001; decompression group: 5.2 ± 2.7 vs 3.1 ± 2.4, p < 0.001). ODI score improvement was most pronounced at the 3-month time point (discectomy group: 21.7 ± 9.1 vs 9.3 ± 9.1, p < 0.001; decompression group: 19.3 ± 7.8 vs 9.9 ± 8.3, p < 0.001). For both groups, pain improvement within the 1st week after surgery was highly predictive of later benefits., Conclusions: Ultra-early PROMs reveal an immediate pain improvement after FESS. While the benefits in pain reduction plateaued within the 1st postoperative week for both groups, functional improvements developed over a more extended period. These results illustrate a biphasic rehabilitation process wherein initial pain alleviation transitions into functional improvement over time.

Pedicle screw insertion is a common procedure in spine surgery, and freehand, fluoroscopic, and robotic-assisted techniques all are used. These are indirect methods that use fluoroscopy, and direct visualization of canal involvement has not been possible. However, owing to the development of high-definition imaging modalities, delicate procedures that use endoscopy are possible. A 47-year-old man presented with severe radiating pain in his leg after undergoing L5-S1 level endoscopic transforaminal lumbar interbody fusion and percutaneous pedicular screw fixation. The patient then underwent an endoscopy-assisted technique for violated spinal canal and screw revision in which the misplaced screw was directly visualized using endoscopy and the trajectory of the misplaced screw was changed. With 30° endoscopy, we directly visualized the screw thread and root compression. Then with 0° endoscopy, we changed the screw trajectory inside the pedicle with an anatomic landmark. The patient's radiating pain was completely relieved after revision of the malpositioned screw. Postoperative imaging showed the revised screw trajectory inside the pedicle. Endoscopy-assisted pedicle screw insertion does not require an additional incision, and early recovery after the procedure is possible. Accurate diagnosis of canal pathology and treatment are possible with direct visualization using endoscopy. [ABSTRACT FROM AUTHOR]

Pneumocephalus is a rare complication after an elective lumbar spine surgery. Full endoscopic lumbar diskectomy (FELD) is an evolving minimally invasive surgical procedure gaining its popularity in the past decade. Although seizure was recognized as a possible complication, organic injury to the central nervous system such as pneumocephalus has not yet been reported after FELD. A 63-year-old man with L3-4 intervertebral disk herniation received FELD via the transforaminal approach under general anesthesia. A small dural tear about 2 mm was encountered. After the operation, the patient was unable to recover from anesthesia and failed to be extubated due to tachypnea and generalized tonic-clonic seizures. Emergent brain computed tomography (CT) revealed pneumocephalus in the subdural and subarachnoid space. Pure oxygen was given, and hyperbaric oxygen therapy (HBO 2) was arranged immediately. Fortunately, he started to regain his consciousness 8 hours after the operation and had full recovery of consciousness on the next day. Follow-up brain CT showed nearly complete resolution of the pneumocephalus. He had no neurologic deficits at final follow-up. This case report highlights the risk of pneumocephalus with conscious disturbance when a dural tear occurs during FELD under general anesthesia. FELD is safer when performed under local anesthesia because the patient is awake to report his discomfort and thus possible to prevent serious neurologic sequels. An emergent brain CT is critical to obtain a prompt diagnosis and HBO 2 is probably helpful for resolving the mass effect caused by the pneumocephalus. [ABSTRACT FROM AUTHOR]

Cysts of the ligamentum flavum (LF) are rare occurrences, with only a few cases reported in literature. They are a result of age-related degenerative changes in the LF. The cyst compresses the neural elements and causes neurogenic symptoms. Endoscopic resection of the LF cyst has not been described in literature. In this report, we describe our experience with endoscopic resection of an LF cyst in the L3–L4 region. A 54-year-old female patient presented with claudication in both lower limbs and evidence on magnetic resonance imaging of a LF cyst in the L3–L4 region compressing the neural elements. The patient underwent full endoscopic resection of the LF cyst through the interlaminar approach from the left side with preservation of facet joints. The postoperative clinical outcomes improved significantly, and postoperative magnetic resonance imaging revealed a complete removal of the cyst. Full-endoscopic resection may be considered as a viable option for treatment of LF cyst in the lumbar region. [ABSTRACT FROM AUTHOR]

Perineural cysts are a benign spine pathology but, when they become symptomatic and require surgical treatment, represent a significant challenge to the spine surgeon. Here we describe our experience with a novel endoscopic approach to the biopsy, drainage, resection of the cyst wall, and direct cyst fenestration to the subarachnoid space. A transforaminal endoscopic approach to a large lumbar 2−3 perineural cyst is presented here in a 25-year-old patient. A step-by-step technique for the biopsy, drainage, and resection of the cyst wall is presented. The patient underwent cyst resection and fenestration into the subarachnoid space without complication, with immediate relief of his preoperative symptoms and after 1 year remains symptom-free. Surgical treatment of perineural cysts in the spine represent a significant challenge to the surgeon, principally due to the risk of spinal fluid leak in the postoperative period. Transforaminal endoscopic surgical access to this disease pathology is a novel minimally invasive surgical approach presented here that allows diagnosis and treatment of a perineural cyst and can be performed in an awake patient. [ABSTRACT FROM AUTHOR]

This study was aimed to provide a brief historical perspective to facilitate appreciation of current techniques, describe outcomes of endoscopic lumbar surgery relative to those of existing techniques, and identify topics in need of study and future directions for the field of endoscopic lumbar surgery. Using the PubMed database, a comprehensive search was conducted to identify peer-reviewed English language articles pertaining to endoscopic lumbar surgery. Lack of focus on pertinent techniques or lack of outcome measures constituted exclusion criteria. A majority of included articles were published from 2015-2019. A context with which to appreciate the application of endoscopic lumbar techniques is established. An abundance of case series and several recent comparison studies have documented the benefits and potential pitfalls of these methods in the past two decades. The advantages of endoscopic lumbar spine surgery are widely touted to include reduced perioperative morbidity, including blood loss, operative time and immediate postoperative recovery, minimal structural trauma resulting from surgery, generally positive patient report outcome scores and the potential to contain costs. Additional high-quality research assessing outcomes of endoscopic lumbar surgery are certainly needed and currently expected given the rapid expansion of the field in recent years. [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: Severe collapsed disc secondary to degenerative spinal conditions leads to significant foraminal stenosis. We hypothesized that uniportal posterolateral transforaminal lumbar interbody fusion with endoscopic disc drilling technique could be safely applied to the collapsed disc space to improve patients’ pain score, restore disc height, and correct the segmental angular parameters. Methods: We included patients who met the indication criteria for lumbar fusion and underwent uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion with pre-operative Computer Tomography mid disc height of less than or equal to 5 mm and MRI of Grade 3 Foraminal Stenosis. Visual analogue scale and computer tomography pre-operative and post-operative sagittal disc height in the anterior, middle and posterior part of the disc; sagittal focal segmental angle; mid coronal disc height and coronal wedge angles were evaluated. Results: 30 levels of Endo-TLIF were included, with a mean follow up of 12 months. The mean improvement in decreasing pain score was 2.5 ± 1.1, 3.2 ± 0.9 and 4.3 ± 1.0 at 1 week post operation, 3 months post operation and at final follow up, respectively, p < 0.05. There was significant increase in mid sagittal computer tomographic anterior, middle and posterior disc height of 6.99 ± 2.30, 6.28 ± 1.44, 5.12 ± 1.79 mm respectively, p < 0.05. CT mid coronal disc height showed an increase of 7.13 ± 1.90 mm, p < 0.05. There was a significant improvement in the CT coronal wedge angle of 2.35 ± 4.73 and the CT segmental focal sagittal angle of 1.98 ± 4.69, p < 0.05. Conclusion: Application of Uniportal Endoscopic Posterolateral Lumbar Interbody Fusion in patients with severe foraminal stenosis secondary to severe collapsed disc space significantly relieved patients’ pain and restored disc height without early subsidence or exiting nerve root dysesthesia in our cohort of patients.

Background: Biportal spinal endoscopy is increasingly utilized for lumbar disc herniations and lumbar stenosis. The objective was to investigate the safety and effectiveness of the technique in the outpatient vs inpatient setting., Methods: This is a comparative study of consecutive patients who underwent biportal spinal endoscopy by a single surgeon at a single institution. Demographics, surgical complications, and patient-reported outcomes were prospectively collected and retrospectively analyzed. Statistics were calculated among treatment groups using unpaired t test and χ 2 analysis where appropriate. Statistical significance was determined as P < 0.05., Results: Eighty-four patients were included, 58 (69.0%) as outpatient, 26 (31.0%) as inpatient. Mean follow-up was 7.5 months. Statistically significant differences in age, American Society of Anesthesiologists classification, and Charleston Comorbidity Index scores were reported between cohorts, with younger and healthier patients undergoing outpatient surgery ( P < 0.0001). Outpatients were more likely to have discectomies while inpatients were more likely to have decompressions for stenosis. No significant differences in postoperative complications were found between groups.Both cohorts demonstrated significant improvement in visual analog scale (VAS) back and leg pain scores and Oswestry Disability Index scores ( P < 0.001). Outpatients had significantly lower postoperative VAS back pain ( P = 0.001) and Oswestry Disability Index scores ( P = 0.004) at 5-8 weeks compared with inpatients, but there was no significant difference for VAS leg pain scores at all time points between the cohorts., Conclusions: Early results demonstrate that biportal spinal endoscopy can safely and effectively be performed in both inpatient and outpatient settings., Clinical Relevance: Outpatient biportal spinal endoscopy can be performed successfully in well selected patients, which may reduce the financial burden of spine surgery to the U.S. healthcare system., Competing Interests: Declaration of Conflicting Interests : The first author, D.Y.P., is a strategic board member for Amplify Surgical, Inc., which manufactures the biportal endoscopic equipment used in this study. Other conflicts of interest for D.Y.P. include being a consultant for Alphatec, Nuvasive, and Seaspine in the past 36 months. The remaining authors have no conflicts of interest., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2023 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Study Design: Retrospective Study., Objectives: Minimally invasive endoscopic spinal surgery is gaining popularity, but our understanding of the lumbar spine's microvascular geometry relies heavily on cadaver studies and textbook illustrations. Additionally, inconsistent nomenclature of vessels in the literature hampers effective communication among surgeons. This study aims to improve the clarity and comprehensibility of the lumbar spinal microvascular geometry under endoscopic view., Methods: The study included 400 patients who underwent endoscopic spinal surgery for lumbar spinal canal stenosis and foraminal stenosis. The surgeries were performed by an experienced surgeon using either the interlaminar or transforaminal approach. Endoscopic video recordings were further analyzed to map the microvascular geometry and common bleeding foci. The observed results were cross-referenced with existing literature to reconstruct a comprehensive view of the vascular anatomy., Results: The transforaminal approach commonly encounters bleeding foci originating from the major branches of the segmental lumbar artery and the emissary veins within the foramen. The interlaminar approach primarily encounters bleeding foci from the muscle vessels in the dorsal lamina, which are believed to be located near the ends of the three main branches. In the intracanal region, epidural vessels form a rotary loop above the disc, which can contribute to most of the bleeding during discectomy., Conclusions: This study provides a comprehensive understanding of the microvascular anatomy in the lumbar spine during endoscopic spinal surgery. Recognizing the geometry will help surgeons anticipate and control bleeding, reducing the risk of complications. The findings contribute to the improvement of surgical techniques and patient safety in endoscopic spinal surgery., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Spinal epidural abscess is a rare but serious infectious disease that can rapidly develop into a life-threatening condition. Therefore, the appropriate treatment is indispensable. Although conservative treatment is justifiable in certain cases, surgical treatment needs to be considered as an alternative early on because of complications such as (progressive) neurological deficits or sepsis. However, traditional surgical techniques usually include destructive approaches up to (multilevel) laminectomies. Such excessive approaches do have biomechanical effects potentially affecting the long-term outcomes. Therefore, minimally invasive approaches have been described as alternative strategies, including endoscopic approaches., Observations: The authors describe a surgical technique involving a combination of two minimally invasive approaches (endoscopic and microsurgical) to drain a multisegmental (thoracolumbar) abscess using the physical phenomenon of continuous pressure difference to minimize collateral tissue damage., Lessons: The combination of minimally invasive approaches, including the endoscopic technique, may be an alternative in draining selected epidural abscesses while achieving a similar amount of abscess removal and causing less collateral approach damage in comparison with more traditional techniques.

Background: Traditionally, open wide laminectomy and discectomy have been advocated for the treatment of cauda equina syndrome caused by lumbar disc herniation. We aimed to evaluate the technical feasibility of uniportal interlaminar endoscopy in treating cauda equina syndrome., Methods: Nine patients with cauda equina syndrome underwent uniportal endoscopic decompression and discectomy from December 2020 to December 2022. Data were collected retrospectively. Patients diagnosed with cauda equina syndrome were operated on within 6 hours of presentation to the hospital. The visual analogue score (VAS), Oswestry disability index (ODI), and bladder/bowel score were used to measure the outcome., Results: Analysis showed that VAS scores for leg pain and back pain significantly decreased from preoperative scores of 8.22±0.79 and 4.67±1.76 to postoperative day 1 scores of 0.67±0.67 and 2.56±1.42 (p<.05). The ODI scores improved from preoperative 52.33±11.93 to postoperative (day 1) 14±6.80. Eight patients had early recovery (1 week) of bladder and bowel functions, and one had delayed recovery at 8 months. None of the patients had a residual bowel/bladder deficit. Macnab's criteria outcomes were excellent in all patients at the final follow-up., Conclusions: Uniportal endoscopic lumbar endoscopic unilateral laminotomy with bilateral decompression and subsequent interlaminar endoscopic lumbar discectomy is a safe and effective minimally invasive course of treatment for cauda equina syndrome as an alternative to open laminectomy in our cohort of patients., Competing Interests: One or more of the authors declare financial or professional relationships on ICMJE-NASSJ disclosure forms., (© 2023 The Author(s).)

Background: As an alternative to back surgeries, endoscopic spinal operations is the most effective and safe procedure that does not impose the fear reaction to the patients. Objective: In this study the results, complications, and outcomes of 60 patients complaining from prolapsed lumbar inter-vertebral discs who experienced prolapsed endoscopic lumbar discectomy (PELD) were reported. Patients and Methods: This is a prospective study conducted in three sentinel hospitals over a period of 3 years (2013-2015) in Erbil city of Iraq. Clinical findings in addition to preoperative MRI were the main diagnostic methods used for including patients who were suffering from lumbar disc herniation at different levels. Clinical appraisal was done utilizing the modified Macnab criteria. The Storz lens spinoscope was utilized to perform PELD. Results: Sixty patients (37 males and 23 females) with lumbar disc herniation were included in the study. The mean operative time was 50 minutes. Patients were discharged during 1st 24 hours post-operatively. After surgery, patients were followed up for two months to three years with a mean of 18 months. Seven (11.7%) patients developed complications including one (1.7%) instance of shallow nerve injury, three (5%) with dural tears, two (3.3%) instances of intermittent delayed disc prolapse and one patient (1.7%) had post-operative discitis. Modified Macnab criteria (excluding patients with long dural tear) showed excellence results for 36 patients, while good results were observed for 17 patients, reasonable results for 3 patients and poor results for 2 patients. The achievement rate was 91.4% . Conclusion:Although endoscopic spinal discectomy is a compelling procedure for management of lumbar disc prolapse, and although its final outcome is reasonable it is not devoid from complications. [ABSTRACT FROM AUTHOR]

Background Sacroiliac (SI) joint fusion is considered for the treatment of degenerative sacroiliitis. The procedure has increased in popularity for patients who have exhausted less invasive treatment options since the development of percutaneous SI joint fusion systems. One possible complication of the procedure is a sacral radiculopathy that can result from compression of the S1 nerve by the SI joint fusion implant. Others have described revising the implant by removing it and replacing it with a shorter implant. Methods Here we describe a minimally invasive endoscopic S1 nerve root decompression that does not require removing or revising the SI fusion implant. Results The postoperative course was uneventful, and the patient's radicular pain improved immediately after surgery. Six months after his endoscopic procedure, the patient had no clinical symptoms related to the S1 nerve root compression and was symptomatically improved from her sacroiliac pain. Conclusions This technical note is for others to consider as a possible minimally invasive solution for the treatment of lumbar radiculopathy after a minimally invasive SI joint fusion procedure. Highlights • Sacral radiculopathy after SI joint fusion is a complex problem. • Endoscopic S1 nerve decompression is possible after SI fusion. • SI joint fusion implants can compress neural structures. [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]

Objective The incidental dural tear is a common complication in lumbar spine surgery. It has been reported that the incidence of dural tears is much greater in endoscopic procedures. Primary closure via suturing remains challenging in endoscopic procedures. The objective of this study was to conduct a literature review on the surgical technique for dural closure and repair in endoscopic spine surgery. Methods A systematic literature search was performed using the database PubMed. In total, 12 studies reported specifically about the surgical treatment for dural tear in percutaneous and tubular assisted endoscopic technique. The dural tear rate, the technique of dural closure, postoperative time of bed rest, postoperative symptoms related to cerebrospinal fluid fistula, and revision surgery were assessed. Results The overall rate of dural tears in endoscopic spinal surgery was 2.7%, with a range from 0% to 8.6%. The incidence of a dural tear was much greater in cases with lumbar stenosis (3.7%) than in lumbar disc herniation (2.1%). The greatest rate was accompanied by resecting synovial cysts. In addition, the risk of dural tear is greater in bilateral decompression procedures via a unilateral approach. There is no consensus about the ideal technique for dural closure in endoscopic procedures. Furthermore, there is a debate whether dural tear requires surgical treatment or not. Conclusions An autologous muscle or fat graft in combination with fibrin glue or a fibrin-sealed collagen sponge seems to be a good and safe method for the management of dural tear in lumbar endoscopic spine surgery. Highlights • The overall dural tear rate in endoscopic spine surgery is 2.7%. • Endoscopic closure of dural tears is feasible, and successful closure via fat and autologous muscle grafts has been reported. • Less than 2% of all cases required an open procedure after endoscopic dural tear closure. [ABSTRACT FROM AUTHOR]

Background Lateral subluxation of the vertebra is commonly seen in degenerative lumbar scoliosis. Transforaminal endoscopic spine surgery is an emerging technique in spine surgery but has never been described as a treatment option for lumbar radiculopathy in the setting of lateral lumbar spondylolisthesis. Methods A technique for endoscopic treatment of lumbar disc herniation in the setting of lateral spondylolisthesis is presented. We retrospectively reviewed 199 cases of patients who underwent transforaminal endoscopic surgery in a 3-year period with a minimum follow-up of 1 year. Results Between 2014 and 2017, 4 patients (average age, 74.8 years; range, 69–82 years) underwent transforaminal endoscopic discectomy procedures for disc herniations at the level of lateral subluxation. One patient whose lateral subluxation was above an instrumented fusion required an extension of fusion to the operated level 5 months after endoscopic surgery for a reherniation. For the other 3 patients, mean visual analog scale score for radicular pain improved from an average pain score of 8.3 before surgery to 3.0 1 year after surgery, and Oswestry Disability Index improved from 26.7 to 4.7. Conclusions Transforaminal endoscopic surgery for lumbar disc herniation in the setting of lateral subluxation of vertebral bodies is a unique minimally invasive approach for treatment of lumbar radiculopathy that might be considered as an alternative treatment to deformity correction surgery in older patients. [ABSTRACT FROM AUTHOR]

Lumbar total disk replacement is considered for the treatment of lumbar degenerative disk disease with the hope that by preserving motion, the long-term fusion complication of adjacent segment disease can be avoided. The complications of lumbar total disk replacement can be divided into approach-related and long-term complications. Little has been described about the complications and treatment for complications >10 years after the device has been implanted. Here we describe a transforaminal endoscopic diskectomy procedure for a patient presenting with foot drop 12 years after a L5-S1 total disk replacement. [ABSTRACT FROM AUTHOR]

Background: Surgical options for removing high-grade down-migrated lumbar disc herniations located medial to the pedicle include an extensive laminectomy and facetectomy. A direct percutaneous endoscopic approach through the pedicle for reaching the herniated disc without risk of iatrogenic instability is feasible.Method: The transpedicular approach consists of creating a tunnel through the pedicle. Subsequently, access to the parapedicular epidural space is obtained, and downward migrated disc can be removed.Conclusion: This technique allows to reach migrated herniations medially to the pedicle safely and effectively. [ABSTRACT FROM AUTHOR]

Transforaminal endoscopic spine surgery is an emerging technique in spine surgery, but it offers 2 distinct challenges to spine surgeons looking to adopt it: 1) targeting spine pathology and 2) understanding the endoscopic anatomy visualized through the endoscope. Intraoperative computed tomography (CT)-guided navigation is also an emerging technique in spine surgery that is becoming widely adopted for its benefits in assisting surgeons in localizing pathology and guided spine instrumentation placement. In this technical note, we describe a technique that uses intraoperative CT-guided navigation concomitantly with a transforaminal endoscopic approach to decompress a L4-L5 foraminal heterotopic bone formation after an oblique lumbar interbody fusion. The addition of intraoperative CT-guided navigation proved beneficial in targeting the pathology during the procedure and ensuring that the pathology was resolved by offering postoperative CT visualization of the decompressed neural foramen. [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 unilateral biportal endoscopic (UBE) technique is a minimally invasive procedure for spinal surgery, while open microscopic discectomy is the most common surgical treatment for ruptured or herniated discs of the lumbar spine. A new endoscopic technique that uses a UBE approach has been applied to conventional arthroscopic systems for the treatment of spinal disease. In this study, we aimed to compare and evaluate the perioperative parameters and clinical outcomes, including recovery from surgery, pain and life quality modification, patient's satisfaction, and complications, between UBE and open lumbar microdiscectomy (OLM) for single-level discectomy procedures. Methods: This study included 141 patients with degenerative disc disease requiring discectomy at a single level from L2-L3 to L5--S1. A total of 60 and 81 patients underwent UBE and OLM, respectively. Analysis was based on comparison of perioperative metrics, operation time (OT); estimated blood loss (EBL); length of hospital stay (HS); clinical outcomes, including assessment using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI); patient satisfaction (the MacNab score); and the incidence of reoperation and complications. Results: The study cohort was 56.7% women, and the mean patient age was 50.98 ± 18.23 years. The mean VAS (the back and leg), MacNab score, and ODI improved significantly from the preoperative period to the last follow-up (12.92 ± 3.92) in both groups (p < 0.001). One week after operation, the back VAS score in the UBE group showed significantly more improvement than that in the OLM group. However, the 1-week, 3-month, and 12-month VAS (the back and leg), ODI improvement, modified MacNab score, and OT were not significantly different between the two groups. In the UBE group, EBL (34.67 ± 16.92) was smaller and HS (2.77 ± 1.2) was shorter than that of the OLM group (140.05 ± 57.8, 6.37 ± 1.39). However, OT (70.15 ± 22.0) was longer in the UBE group than in the OLM group (60.38 ± 15.5), and the difference was statistically significant. Meanwhile,thedifferencesintherateofsurgicalconversion and complications between the two groups were not statistically significant. Conclusions: The UBE for single-level discectomy yielded similar clinical outcomes to OLM, including pain control, functional disability, and patient satisfaction, but incurred minimal EBL, HS, and postoperative back pain. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

Background: Trans-sacral epiduroscopic lumbar decompression (SELD) is an emerging procedure for the treatment of lumbar disc herniation (LDH), with favorable outcomes having been reported. However, the complications associated with SELD have not been comprehensively evaluated to date. Therefore, the aim of our study was to describe the incidence rate, types, and characteristics of complications following SELD and management outcomes. Methods: Retrospective analysis of the surgical and clinical outcomes for 127 patients (average age, 42.2 ± 15.2 years) who underwent SELD for LDH at L2-3, L3-4, L4-5, and/or L5-S1, performed by a single experienced spine surgeon at a single center, between January 2015 and April 2017, was conducted. Results: All procedures were successful, with a mean follow-up of 12.3 ± 2.3 months. Complications were identified in 8 patients (6.3%), including 3 cases of incomplete decompression (2.4%), 2 cases of recurrent disc herniation (1.6%), and one case each of hematoma, dural tearing, and subchondral osteonecrosis (0.8%). Among these cases with complications, only 2 cases with incomplete decompression and one case with recurrent LDH did not improve with conservative treatment and required re-operation using an open approach. The rate of complications decreased from 12.6% when considering only the first 50 cases to 2.6% for cases 51-127. Conclusions: Incomplete decompression, recurrent herniation, epidural hematoma, dural tear, and subchondral osteonecrosis were identified as complications of SELD, although the overall rate of complications was low. Practice with the procedure and careful patient selection can lower the risk of complications. [ABSTRACT FROM AUTHOR]