Technical Tips for Percutaneous Transforaminal Endoscopic Discectomy: A Three-step Maneuver for Puncture and Early Clinical Experience

Application of 3D visualization virtual surgery system in percutaneous transforaminal endoscopic discectomy

BackgroundPercutaneous transforaminal endoscopic discectomy (PTED) is an effective minimally invasive technique for treating lumbar disc herniation (LDH). However, precise channel establishment remains challenging. A three-dimensional visualization virtual surgery system (3DVVSS) is increasingly used in specific surgeries, yet its value in PTED remains uncertain.ObjectiveTo investigate the application of a 3DVVSS combined with a self-made intervertebral foramen positioning puncture device (IFPPD) in PTED for the treatment of LDH.MethodsThis study enrolled 120 LDH patients who underwent PTED between January 2021 and February 2022. Patients were randomly assigned to 3DVVSS combined with the IFPPD group (V group), and the traditional freehand methods group (T group). Hospitalization days, number of puncture attempts, fluoroscopy time, operation time, visual analog scale (VAS), Oswestry disability index (ODI), and complications were analyzed.ResultsAll patients completed follow-up without serious complications. Hospitalization days between the two groups were comparable (p > 0.05). However, the V group showed statistically significant advantages over the T group in puncture time, number of puncture attempts, fluoroscopy times, and operation time (p < 0.05). All patients exhibited significant improvements in VAS and ODI compared to those of preoperation (p < 0.05). Still, there was no significant difference in VAS and ODI between T and V groups (p > 0.05).Conclusion3DVVSS combined with IFPPD can significantly improve the successful puncture rate, and reduce the operation time and the fluoroscopy times, indicating its great potential in future clinical applications.

Validity of A Novel Simulator for Percutaneous Transforaminal Endoscopic Discectomy

BACKGROUND

Percutaneous transforaminal endoscopic discectomy (PTED) has steep learning curves and a high incidence of complications, but currently, efficient and economical training methods are lacking. This study aimed to validate a novel simulator for PTED.

METHODS

The simulated PTED included puncturing and establishing the working channel (PEWC) and endoscopic discectomy, with the PEWC being the tested module. Eleven experts and 21 novices were included and introduced to the simulator and tasks; all participants completed the PEWC. Outcomes included: total operation time, number of fluoroscopy for positioning the working sheath, number of spinal risk region invasion, Global Rating Scale (GRS) and a modified GRS, etc. The Mann-Whitney U test was used to compare 2 groups. Spearman's correlation coefficient analyzed continuous variables.

RESULTS

Experts outperformed novices in total operation time (P = 0.001), requiring fewer number of fluoroscopies for positioning the working sheath (P = 0.003). Additionally, experts had a lower number of spinal risk region invasions (P = 0.016) and higher scores on both the GRS (P < 0.001) and modified GRS (P < 0.001). PTED experience correlated with GRS scores (P = 0.001) and modified GRS (P < 0.001). The overall realism scored a median of 4 (3.75-5), and educational value had a median of 4 (range 3-5).

CONCLUSIONS

This study demonstrates the validity of the novel simulator, revealing significant associations between PTED experience and performance metrics in a simulated PEWC setting. Furthermore, the PEWC module also offers a good realistic design and high education value according to experts.

Three-dimensional analysis of puncture needle path through safety triangle approach PLD and design of puncture positioning guide plate

OBJECTIVE

In this study, the three-dimensional relationship between the optimal puncture needle path and the lumbar spinous process was discussed using digital technology. Additionally, the positioning guide plate was designed and 3D printed in order to simulate the surgical puncture of specimens. This plate served as an important reference for the preoperative simulation and clinical application of percutaneous laser decompression (PLD).

METHOD

The CT data were imported into the Mimics program, the 3D model was rebuilt, the ideal puncture line N and the associated central axis M were developed, and the required data were measured. All of these steps were completed. A total of five adult specimens were chosen for CT scanning; the data were imported into the Mimics program; positioning guide plates were generated and 3D printed; a simulated surgical puncture of the specimens was carried out; an X-ray inspection was carried out; and an analysis of the puncture accuracy was carried out.

RESULTS

(1) The angle between line N and line M was 42°~55°, and the angles between the line M and 3D plane were 1°~2°, 5°~12°, and 78°~84°, respectively; (2) As the level of the lumbar intervertebral disc decreases, the distance from point to line and point to surface changes regularly; (3) The positioning guide was designed with the end of the lumbar spinous process and the posterior superior iliac spine on both sides as supporting points. (4) Five specimens were punctured 40 times by using the guide to simulate surgical puncture, and the success rate was 97.5%.

CONCLUSION

By analyzing the three-dimensional relationship between the optimal puncture needle path and the lumbar spinous process, the guide plate was designed to simulate surgical puncture, and the individualized safety positioning of percutaneous puncture was obtained.

Knowledge Areas and New Trends in Lumbar Disc Herniation Research: Bibliometrics and Knowledge Mapping Analysis

OBJECTIVE

To determine the coalitions and impact of authors, countries, institutions, and journals, evaluate the knowledge base, find the hotspot trends, and identify the emerging topics in lumbar disc herniation (LDH).

METHOD

The articles related to LDH were obtained from the Web of Science Core Collection on August 21, 2021. Two scientometric software (CiteSpace 5.8.R.1 and VOSviewer 1.6.17) were used to perform bibliometric and knowledge-map analysis.

RESULTS

From the set parameters, 4642 articles were included in the literature. Although the total number of publications fluctuated between 2001 and 2020, a general trend toward increase was observed. Respectively, the most productive country and institution in the field were the United States and Wooridul Spine Hospital. The most active and cited authors were Lee and Weinstein. Spine was the most impactful and cited journal. Weinstein (JAMA 296:2441-2450, 2006) had the highest number of co-citations and Weinstein(N Engl J Med 358:794-810, 2008) had the highest number of citations. The keyword "low back pain" was ranked first for frequency and total link strength, whereas "risk factor" was ranked first for centrality. Topics including pathogenesis (disc herniation), examination methods (MRI), treatment methods (non-surgical treatment, surgical treatment), surgical options (laminectomy, discectomy), clinical observations (double-blind, efficacy, outcome, learning curve), and evaluation of efficacy (meta-analysis) of LDH have been the focus of leading-edge research in 2001-2020.

CONCLUSION

Using bibliometric methods, this study mapped the knowledge map of LDH research in the past 20 years. The study identifies existing trends to provide a framework for further research.