Early Career Challenges in Setting Up an Endoscopic Spine Surgery Practice

Applications of navigation in full-endoscopic spine surgery

PURPOSE

Advancement in all surgery continues to progress towards more minimally invasive surgical (MIS) approaches. One of the platform technologies which has helped drive this trend within spine surgery is the development of endoscopy; however, the limited anatomic view experienced when performing endoscopic spine surgery requires a significant learning curve. The use of intraoperative navigation has been adapted for endoscopic spine surgery, as this provides computer-reconstructed visual data presented in three dimensions, which can increase feasibility of this technique to more surgeons.

METHODS

This paper will describe the principles, technical considerations, and applications of stereotactic navigation-guided endoscopic spine surgery.

RESULTS

Full-endoscopic spine surgery has advanced in recent years such that it can be utilized in both decompressive and fusion surgeries. One of the major pitfalls to any minimally invasive surgery (including endoscopic) is that the limited surgical view can often complicate the surgery or confuse the surgeon, leading to longer operative times, higher risks, among others. This is the real utility to using navigation in conjunction with the endoscope-when registered correctly and utilized appropriately, navigated endoscopic spine surgery can take some of the guesswork out of the minimally invasive approach.

CONCLUSIONS

Using navigation with endoscopy in spine surgery can potentially expand this technique to surgeons who have yet to master endoscopy as the assistance provided by the navigation can alleviate some of the complexities with anatomic understanding and surgical planning.

Ambulatory uniportal versus biportal endoscopic unilateral laminotomy with bilateral decompression for lumbar spinal stenosis-cohort study using a prospective registry

BACKGROUND

Endoscopic spine surgery has been established as a practical, minimally invasive technique for decompression in patients with lumbar spinal stenosis. However, there remains a paucity of studies prospective cohort study comparing uniportal lumbar endoscopic unilateral laminotomy with bilateral decompression and unilateral biportal endoscopic unilateral laminotomy with bilateral decompression with open spinal decompression-both viable techniques with satisfactory clinical outcomes in the treatment of lumbar spinal stenosis.

OBJECTIVE/AIM

To compare the efficacy of UPE and BPE lumbar decompression surgery for patients with lumbar spinal stenosis.

METHODS

A prospective registry of patients who had undergone spinal decompression for lumbar stenosis via UPE or BPE under a single fellowship trained spine surgeon was studied. Baseline characteristics, initial clinical presentation, and operative details including complications were recorded for all included patients. Clinical outcomes, such as visual analogue scale and Oswestry Disability Index, were recorded at preoperative, immediate postoperative, 2-week, 3-, 6-, and 12-month follow-up periods.

RESULTS

A total of 62 patients underwent endoscopic decompression surgery for lumbar spinal stenosis (29 UPE, 33 BPE). No significant baseline differences were found between uniportal and biportal decompression, when comparing operative duration (130 vs. 140 min; p = 0.30), intraoperative blood loss (5.4 vs. 6mLs; p = 0.05), and length of hospital stay (23.6 vs. 20.3 h; p = 0.35). Two patients (7%) who underwent uniportal endoscopic decompression required conversion to open surgery due to inadequate decompression. Intraoperative complication rates were significantly higher in the UPE group (13.4% vs. 0%, p < 0.05). VAS score (leg & back) and ODI improved significantly (p < 0.001) in both endoscopic decompression groups across all follow-up time points, with no appreciable statistical differences between both groups.

CONCLUSION

UPE has the same efficacy as BPE in the treatment of lumbar spinal stenosis. While UPE surgery enjoys added aesthetic benefits of only one wound, BPE had potentially lower risks of intraoperative complication, inadequate decompression, and conversion to open surgery during early period of learning curve.

Development of an Endoscopic Spine Surgery Program: Overview and Basic Considerations for Implementation

Endoscopic spine surgery (ESS) is an innovative technique allowing for minimally invasive, direct visualization of spinal abnormalities. The growth of ESS in the United States has been stunted by high start-up costs, low reimbursement rates, and the steep learning curve associated with mastering endoscopic techniques. Hergrae, we describe the current state and future direction of ESS and provide key action items for ESS program implementation.

Remodeling of Epidural Fluid Hematoma after Uniportal Lumbar Endoscopic Unilateral Laminotomy with Bilateral Decompression: Comparative Clinical and Radiological Outcomes with a Minimum Follow-up of 2 Years

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To evaluate the clinical and radiological effects of epidural fluid hematoma in the medium term after lumbar endoscopic decompression.

OVERVIEW OF LITERATURE

There is limited literature comparing the effect of postoperative epidural fluid hematoma after uniportal endoscopic decompression.

METHODS

Magnetic resonance imaging (MRI) and clinical evaluation were performed for patients with single-level uniportal endoscopic lumbar decompression with a minimum follow-up of 2 years.

RESULTS

A total of 126 patients were recruited with a minimum follow-up of 26 months. The incidence of epidural fluid hematoma was 27%. Postoperative MRI revealed a significant improvement in the postoperative dura sac area at postoperative day 1 and at the upper endplate at 6 months in the hematoma cohort (39.69±15.72 and 26.89±16.58 mm2) as compared with the nonhematoma cohort (48.92±21.36 and 35.1±20.44 mm2), respectively (p <0.05); and at the lower endplate on postoperative 1 day in the hematoma cohort (51.18±24.69 mm2) compared to the nonhematoma cohort (63.91±27.92 mm2) (p <0.05). No significant difference was observed in the dura sac area at postoperative 1 year in both cohorts. The hematoma cohort had statistically significant higher postoperative 1-week Visual Analog Scale (VAS; 3.32±0.68) pain and Oswestry Disability Index (ODI; 32.65±5.56) scores than the nonhematoma cohort (2.99±0.50 and 30.02±4.84, respectively; p <0.05). No significant difference was found at the final follow-up VAS, ODI, and MRI dura sac area.

CONCLUSIONS

Epidural fluid hematoma is a common early postoperative MRI finding in lumbar endoscopic unilateral laminotomy with bilateral decompression. Conservative management is the preferred treatment option for patients who do not have a neurological deficit. Symptoms last only a few days and are self-limiting. A common endpoint is a remodeled fluid hematoma and the subsequent expansion of the dura sac area.

Comparative Clinical and Radiographic Cohort Study: Uniportal Thoracic Endoscopic Laminotomy With Bilateral Decompression by Using the 1-Block Resection Technique and Thoracic Open Laminotomy With Bilateral Decompression for Thoracic Ossified Ligamentum Flavum

BACKGROUND

Symptomatic thoracic myelopathy secondary to thoracic ossified ligamentum flavum (OLF) often requires decompression spinal surgery.

OBJECTIVE

To compare clinical and radiological outcomes in uniportal endoscopic vs open thoracic decompression for thoracic OLF.

METHODS

Retrospective evaluation of patients who underwent uniportal thoracic endoscopic unilateral laminotomy with bilateral decompression (TE-ULBD) by using the one-block resection technique compared with thoracic open laminotomy (TOL) with bilateral decompression. Radiological outcomes in MRI scan and clinical charts were evaluated.

RESULTS

Thirty-five levels of TE-ULBD were compared with 24 levels of TOL. The overall complication rate of TOL was 15% while TE-ULBD was 6.5%. Both TOL and TE-ULBD cohort had significantly improved their visual analog scale (VAS), Oswestry Disability Index, and Japanese Orthopaedic Association (JOA) myelopathy score after operation. Comparative analysis of TE-ULBD performed statistically and significantly better than TOL in improvement of final VAS and JOA scores. The mean difference ± standard deviation of VAS and JOA improvement in final follow-up when compared with preoperative state of TE-ULBD and TOL was 0.717 ± 0.131 and 1.03 ± 0.2, respectively, P < .05. The mean Hirabayashi recovery rates were 94.5% (TE-ULBD) and 56.8% (TOL). There was no statistical difference in change in preoperative and final Oswestry Disability Index and MRI volume at upper endplate, middisk, and lower endplate canal cross-sectional area.

CONCLUSION

Uniportal TE-ULBD achieved significantly improved pain and neurological recovery with sufficient spinal canal decompression, as compared with thoracic open laminectomy for patients with myelopathy secondary to OLF in our cohort.

Remodeling Pattern of Spinal Canal after Full Endoscopic Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: One Year Repetitive MRI and Clinical Follow-Up Evaluation

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.