Safe Electromyography Stimulation Thresholds Within Kambin's Triangle During Endoscopic Transforaminal Lumbar Interbody Fusion

Full-Percutaneous Trans-Kambin Lumbar Interbody Fusion With a Large-Footprint Interbody Cage

STUDY DESIGN

Exploratory prospective observational cohort.

OBJECTIVES

Aim of this study was to evaluate clinical and radiologic outcome, and surgical efficiency of a novel universal delivery system that allows full-percutaneous extraforaminal, trans-Kambin lumbar interbody fusion with a large-footprint lumbar interbody cage using only fluoroscopic imaging and open-surgery instrumentation.

METHODS

We prospectively evaluated patients that underwent elective trans-Kambin TLIF surgery with a large-footprint interbody cage using a novel universal delivery system. Clinical follow-up was evaluated pre-and post-operatively with Visual Analogic Scale (VAS) and Oswestry Disability Index (ODI) scores, while radiologic follow-up was performed with a computed tomography scan and standing films post-operatively at hospital discharge and 1 year follow-up.

RESULTS

A total of 47 patients were evaluated. Clinically, post-operative VAS and ODI scores significantly (P < 0.001) improved compared to pre-operative scores and 29.4 months mean follow-up. Radiologic evaluation yielded an intervertebral fusion rate of 90% of the operated levels and a significant increase in segmental lordosis by 3.7°. Median surgical time for interbody cage insertion per level was 28 minutes. Complications included 14 (29%) cases with transitory post-operative radiculitis, 4 (8%) cases with partial muscle weakness and 2 (4%) cases that required revision surgery. Post-operative ambulation started at a median 5 hours and median hospital length of stay was 28 hours.

CONCLUSIONS

A new universal delivery system allows overcoming most limitations of current full-endoscopic trans-Kambin fusion as it allows a time- efficient full-percutaneous insertion of a large-footprint interbody cage under fluoroscopy imaging only, with standard open-surgery instruments and optional endoscopic visualization.

Full-endoscopic lumbar spine surgery using working-channel endoscopes: technical tips for practical effectiveness

INTRODUCTION

Full-endoscopic spine surgery (FESS) has emerged as an effective and minimally invasive option for the surgical treatment of degenerative lumbar spine disease. FESS can be characterized as endoscopic spine surgery conducted via the percutaneous uniportal approach using working-channel endoscopes under continuous saline irrigation. Despite available evidence, the clinical application of this endoscopic procedure may require more work for standard spine surgeons. Therefore, this review aims to provide comprehensive technical tips to ensure the practical effectiveness of FESS.

AREA COVERED

FESS of the thoracolumbar spine can be performed through the transforaminal and interlaminar approaches according to direction and passing window. Published literature on technical tips and learning were reviewed narratively, after which practical technical pearls were demonstrated specific to the properties of working-channel endoscopes.

EXPERT OPINION

Currently, FESS remains a reliable option for achieving successful surgical outcomes in cases of lumbar disk herniation and spinal stenosis, with few complications and rapid recovery. A comprehensive understanding of the core features of working-channel endoscopes is crucial for expediting the learning process. Importantly, the development of specific instruments, surgical approaches, and optics is a continuous process that is necessary for establishing FESS as the standard technique for degenerative lumbar spine disease.