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Study Design: A cost-utility analysis (CUA)., Objective: The aim of this study was to evaluate the cost-effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) techniques for the treatment of L5-S1 lumbar disc herniation (LDH)., Summary of Background Data: The annual cost of treatment for lumbar disc herniation is staggering. As the two major approaches of percutaneous endoscopic lumbar discectomy (PELD): percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) have gained recognition for the treatment of L5-S1 lumbar disc herniation (LDH) and showed similar clinical outcome. ost-utility analysis (CUA) can help clinicians make appropriate decisions about optimal health care for L5-S1 LDH., Methods: Fifty and 25 patients were included in the PETD and PEID groups of the study. Patients' basic characteristics, health care costs, and clinical outcome of PETD and PEID group were collected and analyzed. Quality-adjusted life-years (QALYs) were calculated and validated by EuroQol five-dimensional (EQ-5D) questionnaire. Cost-effectiveness was determined by the incremental cost per QALY gained., Results: The mean total cost of the PETD group was $5275.58 ± 292.98 and the PEID group was $5494.45 ± 749.24. No significant differences were observed in hospitalization expenses, laboratory and radiographic evaluations expenses, surgical expenses, and drug costs. Surgical equipment and materials costs, and anesthesia expense in the PEID group were significantly higher than in the PETD group (P < 0.001). Clinical outcomes, including Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores, and Japanese Orthopaedic Association (JOA), also showed no significant differences between the two groups. The cost-effectiveness ratio of PETD and PEID were $6816.05 ± 717.90/QALY and $7073.30 ± 1081.44/QALY, respectively. The incremental cost-effectiveness ratios (ICERs) of PEID over PETD was $21887.00/QALY., Conclusion: Observed costs per QALY gained for L5-S1 LDH with PETD or PEID were similar for patients, demonstrating that the two different approaches of PELD are equally cost-effective and valuable interventions., Level of Evidence: 5.

Aim: To conduct a scientometric assessment of the research activities of spinal fusion in various subspecialties carried out by different surgeons., Material and Methods: All articles regarding spinal fusion research on Web of Science from the year 1994 to 2015 were identified and analyzed in the following aspects: year of publication, publication journal, number of times cited, Hirsch index (H-index), spine surgeon specialty, and country/territory., Results: A total of 15060 articles were identified, and the research productivity of spinal fusion has grown steadily over the last two decades. The average research productivity of spinal fusion each year was 109.09 ± 23.26 articles for cervical spine, 90.09 ± 52.56 articles for thoracic spine, and 304.91 ± 181.63 articles for lumbar. The research productivity of spinal fusion by neurosurgeons was 9474 articles published, while the orthopedic surgeons published 8263 articles. The average number of citations for spinal fusion articles was 19.61 times for neurosurgeons, and 20.36 times for orthopedic surgeons. In most countries neurosurgoens published more spinal fusion articles than orthopedic surgeons or at least the same amount, but orthopedic surgeons in China and Germany published far more spinal fusion articles ( > 100) than neurosurgeons. The United States published the greatest number of articles (6819/15060, 45.28%), followed by China (1280/15060, 8.50%) and Germany (1252/15060, 8.31%), and had the highest total citations (164378) and H-index (144)., Conclusion: Neurosurgeons tend to publish more articles regarding spinal fusion, but orthopedic surgeons seem to have higher citations. North America, West Europe and East Asia were the most productive regions in spinal fusion research, and the United States made the most academic contributions to this area.

Retrospectively study.The purpose of this study was to compare the effects of intraoperative epidural steroids and single dose intravenous steroids following a percutaneous endoscopic lumbar discectomy (PELD).Inflammatory irritation of dorsal root ganglia or sensory nerve roots may cause postoperative pain. Epidural steroids have been applied after a lumbar discectomy for more than 20 years. Epidural steroid application after a PELD is easier to perform and safer because the operations are under observation of the scope.We retrospectively reviewed the medical records of patients with lumbar intervertebral disc herniation who had undergone transforaminal PELD at our department. There are 60 patients in epidural steroid group, intravenous steroid group, and control group, respectively. Visual analog scores (VAS) and the Oswestry Disability Index (ODI) were collected. Successful pain control is defined as 50% or more reduction in back and leg pain (VAS scores).VAS scores (back and leg) and ODI showed a significant decrease in all groups when comparing pre- and postoperatively. Epidural steroid group had a significant improvement in successful pain control compared with the control group at 2 weeks of follow-up. VAS scores (leg) in the epidural steroid group showed a significant decrease compared with the intravenous steroids group at 1, 3, and 7 days after the surgery, but this difference had no statistical significance at 1, 6, and 12 months of follow-up. All groups did not show a significant difference in ODI at 1, 6, and 12 months follow-up.Epidural application of steroid has a better effect on controlling the postoperative pain of PELD in the short term. The epidural application of steroid did not show a tendency to cause infection.

Objective: To evaluate short-term efficacy and safety of percutaneous transforaminal endoscopic discectomy (PTED) in treatment of symptomatic adjacent segment disease (ASD) after lumbar fusion in elderly patients >65 years old., Methods: Patients >65 years old who underwent PTED for ASD after lumbar fusion between January 2013 and September 2016 were retrospectively evaluated. Demographics and perioperative clinical data were collected from medical records. MacNab classification, visual analog scale, Oswestry Disability Index, and Japanese Orthopaedic Association scores as well as 36-Item Short-Form Health Survey were used to assess the efficacy of PTED., Results: We evaluated 25 consecutive patients >65 years old with ASD (11 men, 14 women; mean age 74.65 ± 9.61 years). Mean follow-up time was 37.14 ± 11.60 months. Of patients, 84.0% (21/25) had excellent or good clinical outcomes, 12.0% (3/25) had fair outcomes, and 4.0% (1/25) had poor outcomes. Complications included 1 dural laceration, 1 postoperative dysesthesia, and 1 recurrence. For patient-reported outcomes, significant improvements were observed postoperatively compared with preoperatively in visual analog scale (P < 0.05), Oswestry Disability Index (P < 0.05), Japanese Orthopaedic Association (P < 0.05), and 36-Item Short-Form Health Survey (P < 0.05)., Conclusions: PTED demonstrated satisfactory short-term efficacy and safety in management of ASD after lumbar fusion in patients >65 years old. PTED may be an alternative choice for elderly patients with ASD after lumbar fusion., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Local anesthesia (LA) is recommended for percutaneous transforaminal endoscopic discectomy (PTED) but clinical practice indicates that LA cannot achieve satisfactory pain management during PTED., Objectives: The study aimed to investigate the comparisons between LA and EA for PTED in elderly population over 65 years old., Methods: We performed a retrospective analysis of patients over 65 years old received PTED from May 2013 to December 2014. And patients were divided into two groups according to the anesthesia method. The data collected for analysis including operative time, fluoroscopy time, postoperative bed time, visual analog scale (VAS), Oswestry Back Pain Disability Index (ODI), the global outcome based on the Macnab outcome criteria, satisfaction rate of anesthesia, and complications., Results: A total of 132 consecutive patients were enrolled in this study. There were 65 patients in LA group and 67 patients in EA group. Compared to LA group, EA group had longer operative time (P < 0.001) and postoperative bed time (P < 0.001) but shorter fluoroscopy time, (P < 0.001), smaller VAS score of lumbar pain intraoperatively (P < 0.001), 1-h postoperatively (P < 0.001) and 1-week postoperatively (P < 0.001). Similarly, EA group had lower VAS score of leg pain intraoperatively (P < 0.001) and 1-h postoperatively (P < 0.001). In additions, higher satisfaction rate of anesthesia was observed in EA group (P = 0.029)., Conclusions: EA and LA for PTED achieved comparable clinical outcomes in elderly population over 65 years old. However, compared to LA for PTED, EA had a better performance in pain management., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

MINI: The time trend for the number of minimally invasive spine surgery articles showed a significant increase over time with an average of 93.23 articles per year. Among all related journals, Spine published the largest number of articles in minimally invasive spine surgery research and was the most popular one in the top five countries., Study Design: Bibliometric analysis., Objective: This study aimed to reveal the characteristics of world productivity in the field of minimally invasive spine surgery (MISS) research and to provide a general picture for surgeons and researchers., Summary of Background Data: Significant growth has been observed in the field of MISS research in recent years. However, bibliometric studies concerning the quantity and quality of articles published in MISS journals are scarce., Methods: All the data concerning MISS in this study originate from the Web of Science (Thomson Reuters, New York, NY) without restrictions. All selected literates were evaluated in the following aspects: publication year, publication journals, author, times cited, Web of Science category, countries/territories., Results: A total number of 2051 articles were published worldwide. The articles published during 2000 to 2015 are more than 11.28 times when compared to those published before 2000. The United States published the largest number of articles (855/2051, 41.7%), followed by Germany (245/2051, 11.9%), South Korea (160/2051, 7.8%), China (147/2051, 7.2%), and Japan (108/2051, 5.2%) and had the highest total citations (16,626). Additionally, the United States had the highest average citations per article (12.14), followed by Japan (11.98), Germany (11.19), South Korea (11.04), and China (10.95). High-income countries published 98.73% of articles, upper-middle-income countries published 0.24% of articles, and middle-income countries published 1.03% of articles., Conclusion: The time trend for the number of MISS articles showed a significant increase over time with an average of 93.23 articles per year. The United States was the most productive country and had the highest average citations per article. Among related journals, Spine published the largest number of articles in MISS research and was the most popular one in the top five countries., Level of Evidence: 5.

Study Design: Retrospective database analysis., Objective of the Study: The objective of the study was to quantify the incidence of dysphagia and dysphonia and assess the associated risk factors after multilevel cervical anterior operation., Summary of Background Data: Anterior approach for multilevel cervical spondylotic myelopathy has been developed and obtained favorable outcomes. As number of fused levels increased, the operation difficulty, invasiveness and operative risks are higher. Meanwhile, the 2 most common postoperative complications described in the literature are dysphonia and dysphagia., Materials and Methods: Two hundred thirty-six multilevel cervical spondylotic myelopathy patients between October 2004 and June 2012 were included in the study. All patients undergoing anterior operation, and incidences of dysphagia were identified. Risk factors were assessed using logistic regression., Results: At a minimum of 1 year after operation, 70.6% (n=156) were 3-level anterior operation and 29.4% (n=65) were 4-level anterior operation. The overall dysphagia rate was 23.1% (51 patients). The overall dysphonia rate was 28.5% (63 patients). Logistic regression analysis demonstrated that risk factors for dysphagia included age, operation time and lack of tracheal traction exercise. Age, operation time were 2 factors significantly related to dysphonia., Conclusions: The incidence of postoperative dysphagia and dysphonia is relative higher after multilevel anterior operation. Age and operation time carry a greater risk of postoperative dysphagia and dysphonia. Tracheal traction exercise might help patients reduce postoperative dysphagia. Sufficient preoperative preparation and evaluation combining with proficient and precise operation technique are suggested when multilevel anterior fusion is performed.

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

This retrospective study aimed to compare the patient-reported outcomes and radiographic assessment of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative spondylolisthesis with reduction versus in situ fusion. Patients receiving MI-TLIF with reduction were assigned as Group A, and those without reduction were assigned as Group B. Radiographic fusion was assessed using Bridwell's grading criteria. Preoperative and postoperative patient-reported outcomes including visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) scale and improvement rate were analyzed. There were 41 patients in Group A and 37 patients in Group B. The mean follow-up was 30.78±14.15months in Group A and 28.95±10.75months in Group B (p=0.525). There were no significant differences in hospital stay (p=0.261), estimated blood loss (p=0.639), blood transfusion (p=0.336), operation time (p=0.762) and complications (p=1.00) between the two groups. Radiographic fusion rate was 92.68% (38/41) in Group A, and 81.08% (30/37) in Group B (p=0.110). Significant differences were observed in either 3-month or last follow-up JOA, VAS, and ODI compared with preoperative JOA, VAS, and ODI, respectively (p<0.05). However, there were no significant differences in JOA, VAS, and ODI between the two groups whenever preoperatively, or 3-month postoperatively, or at the last follow-up (p>0.05). According to MacNab criteria, the excellent and good rate was 85.37% in Group A and 86.49% in Group B (p=0.983). MI-TLIF is an effective and satisfactory surgical technique to manage degenerative spondylolisthesis regardless of reduction or not, so routine reduction may not be a requirement in MI-TLIF for degenerative spondylolisthesis., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: The study aimed to compare the clinical outcomes of reduction versus in situ fusion with minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for isthmic spondylolisthesis., Methods: Demographic, preoperative, and postoperative data were collected from the medical records. Radiographic fusion was assessed by use of the grading criteria of Bridwell. Preoperative and postoperative patient-reported outcomes including visual analog scale, Oswestry Disability Index, Japanese Orthopedic Association scale and improvement rate were calculated. Patient satisfaction was assessed with the criteria of Macnab (excellent, good, fair, poor)., Results: There were 24 patients (11 male) in the reduction group and 21 patients (10 male) in the in situ fusion group. The average follow-up was 34.75 ± 8.06 months in reduction group and 31.05 ± 6.52 months in the in situ fusion group (P = 0.101). There were no significant differences in hospital stay, estimated blood loss, blood transfusion, operation time, fusion grading, and complications between the 2 groups (P > 0.05). Spinal fusion rate was 91.67% (22/24) in the reduction group and 85.71% (18/21) in the in situ group (P = 0.835). There were no significant differences in Japanese Orthopedic Association scale, visual analog scale, and Oswestry Disability Index score between the 2 groups whenever preoperatively, 3-month postoperatively, or at the last follow-up (P > 0.05). According to the criteria of Macnab, the rate of excellent and good was 83.33% in reduction group and 80.95% in the in situ group (P = 0.899)., Conclusions: MIS-TLIF with reduction did not induce significantly better patient-reported outcomes, spinal fusion rate, perioperative outcomes, or fewer complications in isthmic spondylolisthesis. Intentional reduction may not be a requirement in MIS-TLIF for isthmic spondylolisthesis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aim: We conducted a novel classification system of degenerative lumbar spinal stenosis (DLSS) based on clinical manifestations and imaging (computed tomography and magnetic resonance imaging) features. We chose different minimally invasive surgical procedures according to our system. Clinical parameters and radiological findings will be assessed in the article., Material and Methods: A retrospective study was conducted on 96 patients undergoing minimally invasive surgery for DLSS. We chose different surgical procedures according to our novel classification system based on clinical manifestations, imaging features, and concurrence with other spinal diseases. Clinical parameters and radiological findings were assessed pre- and postoperatively., Results: The mean follow up period was 24 months (range, 15~36 months). There was a statistically significant improvement in the Visual Analogue Scale (VAS) score of low back pain and leg pain after surgery (p < 0.05). According to the Japanese Orthopaedic Association (JOA) scores, the operation efficacy was excellent in 57 cases, good in 36 cases, and fair in 3 cases. According to Bridwell's criterion, the fusion rate was 96% (48/50) in patients who underwent fusion surgery. There were no cages or pedicle screws related complications., Conclusion: Minimally invasive surgical treatment of DLSS has satisfactory outcomes according to the novel classification, but further long-term, prospective, randomized controlled studies involving a larger study group are needed to validate the long-term efficacy.

Purpose: With the dramatic growth of mobile phone usage, concerns have been raised with regard to the adverse health effects of mobile phone on spinal posture. The aim of this study was to determine the head and cervical postures by photogrammetry when viewing the mobile phone screen, compared with those in neutral standing posture., Methods: A total of 186 subjects (81 females and 105 males) aged from 17 to 31 years old participated in this study. Subjects were instructed to stand neutrally and using mobile phone as in daily life. Using a photographic method, the sagittal head and cervical postures were assessed by head tilt angle, neck tilt angle, forward head shift and gaze angle., Results: The photographic method showed a high intra-rater and inter-rater reliability in measuring the sagittal posture of cervical spine and gaze angle (ICCs ranged from 0.80 to 0.99). When looking at mobile phone, the head tilt angle significantly increased (from 74.55° to 95.22°, p = 0.000) and the neck angle decreased (from 54.68° to 38.77°, p = 0.000). The forward head posture was also confirmed by the significantly increased head shift (from 10.90 to 13.85 cm, p = 0.000). The posture assumed in mobile phone use was significantly correlated with neutral posture (p < 0.05). Males displayed a more forward head posture than females (p < 0.05). The head tilt angle was positively correlated with the gaze angle (r = 0.616, p = 0.000), while the neck tilt angle was negatively correlated with the gaze angle (r = -0.628, p = 0.000)., Conclusions: Photogrammetry is a reliable, quantitative method to evaluate the head and cervical posture during mobile phone use. Compared to neutral standing, subjects display a more forward head posture when viewing the mobile phone screen, which is correlated with neutral posture, gaze angle and gender. Future studies will be needed to investigate a dose-response relationship between mobile phone use and assumed posture.

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has become an increasingly popular method of lumbar arthrodesis. However, there are few published studies comparing the clinical outcomes between unilateral and bilateral instrumented MIS TLIF. Sixty-five patients with degenerative lumbar spine disease were enrolled in this study. Thirty-one patients were randomized to the unilateral group and 34 to the bilateral group. Recorded demographic data included sex, age, preoperative diagnosis, and degenerated segment. Operative time, blood loss, hospital stay length, complication rates, and fusion rates were also evaluated. The Oswestry Disability Index (ODI) score and Visual Analog Scale (VAS) pain score data were obtained. All patients were asked to follow-up at 3 and 6 months after surgery, and once every 6 months thereafter. The mean follow-up was 26.6 months (range 18-36 months). The two groups were similar in sex, age, preoperative diagnosis, and operated level. The unilateral group had significantly shorter operative time, lower blood loss, and shorter hospital time than the bilateral group. The average postoperative ODI and VAS scores improved significantly in each group. No significant differences were found between the two groups in relation to ODI and VAS. All patients showed evidence of fusion at 12 months postoperatively. The total fusion rate, screw failure, and general complication rate were not significantly different. Results showed that single-level MIS TLIF with unilateral pedicle screw fixation would be sufficient in the management of preoperatively stable patients with lumbar degenerative disease. It seems that MIS TLIF with unilateral pedicle screw instrumentation is a better choice for single-level degenerative lumbar spine disease., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To explore the effectiveness of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative lumbar scoliosis stenosis by expandable tubular retractor., Methods: Between April 2009 and October 2010, 39 patients with degenerative lumbar scoliosis stenosis were treated. Of 39 patients, 20 underwent MI-TLIF (group A) and 19 underwent open surgery (group B). There was no significant differences in gender, age, disease duration, range of lumbar degenerative scoliosis, Cobb angle, Oswestry disability index (ODI), and visual analogue scale (VAS) between 2 groups (P > 0.05). The operation time, intraoperative blood loss, postoperative independently turning over time, postoperative complication rate, Cobb angle, fusion rates, ODI score, and VAS score were compared between 2 groups., Results: The operation time of group A was significantly longer than that of group B (P < 0.05), and the intraoperative blood loss of group A was significantly less than that of group B (P < 0.05); no significant difference was found in postoperative independently turning over time between 2 groups (t=1.869, P=0.069). The complication rate was 20.0% (4/20) in group A and 26.3% (5/19) in group B, showing no significant difference (Chi2=0.219, P=0.640). All patients were followed up 2 years to 3 years and 6 months (mean, 2.9 years). At last follow-up, the fusion rate of bone graft was 92.9% (78/84) in group A and 95.2% (80/84) in group B, showing no significant difference (Chi2=0.425, P=0.514). According to the Macnab standard for effectiveness evaluation, the results were excellent in 12 cases, good in 6 cases, fair in 1 case, and poor in 1 case, with an excellent and good rate of 90.0% in group A; the results were excellent in 12 cases, good in 5 cases, and fair in 2 cases, with an excellent and good rate of 89.5% in group B; there was no significant difference between 2 groups (Z= -0.258, P=0.835). The postoperative VAS score, ODI score, and Cobb angle were significantly improved when compared with preoperative ones in 2 groups (P < 0.05); and there was no significant differences between 2 groups at 2 weeks after operation and last follow-up (P > 0.05)., Conclusion: MI-TLIF by expandable tubular retractor is an available clinical choice in treating degenerative lumbar scoliosis stenosis. It can obtain the same effectiveness as the open surgery.

The objective of this retrospective study was to explore, which radiographic parameters, immediately after posterior spinal fusion with pedicle screw fixation for adolescent idiopathic scoliosis (AIS), best correlate with subjacent disc wedging at a minimum of 2-year follow-up. Sixty-four consecutive AIS patients who underwent posterior pedicle screw-only instrumentation were studied. Preoperative and postoperative radiographs were obtained to measure various parameters regarding global coronal, shoulder, sagittal, and regional balance. Specific correlation of these parameters to selected 2-year postoperative disc wedging and lowest-instrumented vertebra (LIV) tilt and translation were analyzed. The average lateral disc opening changed from 4.59±4.75 preoperatively to 1.46±2.82 at 2 weeks and 2.81±6.43 at 2 years postoperatively. Two-year postoperative lateral disc opening significantly correlated with the 2-week postoperative lateral disc opening, C7 plumbline relative to the posterior-superior corner of the first sacral vertebra distance, and LIV-center sacral vertical line (CSVL) distance (r=0.7433, P<0.0001). The two-year postoperative LIV tilt significantly correlated with the 2-week postoperative LIV tilt, T12-LIV lordosis, LIV-CSVL distance, and C7-CSVL distance (r=0.8879, P<0.0001). Two-year postoperative LIV-CSVL significantly correlated with 2-week postoperative LIV-CSVL distance and lateral disc opening (r=0.6104, P<0.0001). Two-year postoperative disc wedging, LIV tilt, and LIV translation occurred most often when disc wedging and LIV deviation or obliquity existed immediately postoperatively. This study identified a potential indicator for AIS repair. Preoperative surgical planning and intraoperative correction are important for avoiding subjacent regional imbalance after scoliosis fusion.