Percutaneous lumbar diskectomy using a new aspiration probe

An in vitro comparison of three nucleus pulposus removal techniques for partial intervertebral disc replacement: An ultra-high resolution MRI study

Background

Nuclectomy, also known as nucleotomy, is a percutaneous surgical procedure performed to remove nucleus material from the center of the disc. Multiple techniques have been considered to perform a nuclectomy, however, the advantages and disadvantages of each are not well understood.

Aims

This in vitro biomechanical investigation on human cadaveric specimens aimed to quantitatively compare three nuclectomy techniques performed using an automated shaver, rongeurs, and laser.

Material & Methods

Comparisons were made in terms of mass, volume and location of material removal, changes in disc height, and stiffness. Fifteen vertebra-disc-vertebra lumbar specimens were acquired from six donors (40 ± 13 years) and split into three groups. Before and after nucleotomy axial mechanical tests were performed and T2-weighted 9.4T MRIs were acquired for each specimen.

Results

When using the automated shaver and rongeurs similar volumes of disc material were removed (2.51 ± 1.10% and 2.76 ± 1.39% of the total disc volume, respectively), while considerably less material was removed using the laser (0.12 ± 0.07%). Nuclectomy using the automated shaver and rongeurs significantly reduced the toe-region stiffness (p = 0.036), while the reduction in the linear region stiffness was significant only for the rongeurs group (p = 0.011). Post-nuclectomy, 60% of the rongeurs group specimens showed changes in the endplate profile while 40% from the laser group showed subchondral marrow changes.

Discussion

From the MRIs, homogeneous cavities were seen in the center of the disc when using the automated shaver. When using rongeurs, material was removed non-homogeneously both from the nucleus and annulus regions. Laser ablation formed small and localized cavities suggesting that the technique is not suitable to remove large volumes of material unless it is developed and optimized for this application.

Conclusion

The results demonstrate that both rongeurs and automated shavers can be used to remove large volumes of NP material but the reduced risk of collateral damage to surrounding tissues suggests that the automated shaver may be more suitable.

Extraforaminal Full-Endoscopic Approach for the Treatment of Lateral Compressive Diseases of the Lumbar Spine

Background: The authors conducted a 2-year retrospective follow-up to investigate the efficiency of an extraforaminal full-endoscopic approach with foraminoplasty used to treat lateral compressive diseases of the lumbar spine in 247 patients. Methods: The visual analogue scale (VAS), Oswestry disability index (ODI), and MacNab scale were used to analyze the results collected during the preoperative and postoperative periods. Results: The most common diagnosis was disk herniation with lateral recess stenosis, and the most common surgical level among patients was between L4 and L5 on the left side. Pain decreased over time, as determined during sessions held to evaluate pain in the lumbar, gluteal, led, and foot regions. The ODI demonstrated significant enhancement over the evaluation period and the MacNab scale classified the surgery as good or excellent. The most common complication was dysesthesia. Conclusions: An extraforaminal full-endoscopic approach with foraminoplasty can be recommended in cases of lateral herniation or stenosis for patients with symptoms of radiculopathy, and for those who have not responded to conventional rehabilitation treatment or chronic pain management. Few complications arose as a result of this approach, and most of them were treated clinically.

Eight Surgical Interventions for Lumbar Disc Herniation: A Network Meta-Analysis on Complications

Objective: Therapeutic options for lumbar disc surgery (LDH) have been rapidly evolved worldwide. Conventional pair meta-analysis has shown inconsistent results of the safety of different surgical interventions for LDH. A network pooling evaluation of randomized controlled trials (RCT) was conducted to compare eight surgical interventions on complications for patients with LDH. Methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCT from inception to June 2020, with registration in PROSPERO (CRD42020176821). This study is conducted in accordance with Cochrane guidelines. Primary outcomes include intraoperative, post-operative, and overall complications, reoperation, operation time, and blood loss. Results: A total of 27 RCT with 2,948 participants and eight interventions, including automated percutaneous lumbar discectomy (APLD), chemonucleolysis (CN), microdiscectomy (MD), micro-endoscopic discectomy (MED), open discectomy (OD), percutaneous endoscopic lumbar discectomy (PELD), percutaneous laser disc decompression (PLDD), and tubular discectomy (TD) were enrolled. The pooling results suggested that PELD and PLDD are with lower intraoperative and post-operative complication rates, respectively. TD, PELD, PLDD, and MED were the safest procedures for LDH according to complications, reoperation, operation time, and blood loss. Conclusion: The results of this study provided evidence that PELD and PLDD were with lower intraoperative and post-operative complication rates, respectively. TD, PELD, PLDD, and MED were the safest procedures for LDH according to complications, reoperation, operation time, and blood loss. Systematic Review Registration: PROSPERO, identifier CRD42020176821.

Degenerative Lumbar Disc Disease: A Questionnaire Survey of Management Practice in India and Review of Literature

Objective  To identify the current management modalities practiced by neurosurgeons in India for degenerative lumbar disc disease.

Materials and Methods  Survey questionnaires were prepared in Google forms. It covered the following aspects of managing the lumbar disc pathology: (1) Demographic, institutional details, experience of surgeons, (2)choice of surgical procedures, (3) use of endoscopy and minimally invasive techniques, and (4) pre- and postoperative care. Responses obtained were entered in SPSS datasheet and analyzed.

Results  Of the 300 surveys sent, 80 were returned and response rate was 26.6%. But four surveys were highly incomplete and were discarded from the analysis. So, the study content is from the analysis of practices of 76 spinal surgeons working in different parts of the country. Majority of the spine surgeons ( n = 70) were neurosurgeons, while 6 were orthopaedic surgeons. Fifty-four were from urban area, 12 from semiurban area, and 10 from rural area. Forty-seven spine surgeons practiced in a teaching hospital. Total 73.6% of spine surgeons opted initial medical management. Sixty-three percent preferred microlumbar discectomy (MLD) and only eight neurosurgeons preferred minimally invasive techniques. None of the respondents used in situ fusion. Fifty-three percent of spine surgeons preferred early mobilization (first postoperative day). Fifty-nine percent preferred to follow-up patients clinically and opted for magnetic resonance imaging only when recurrence or infection was suspected. The institutional nature (government teaching, government nonteaching, private teaching, and private nonteaching) and location of the hospital (urban/semiurban/rural) were found to be influencing the preferred surgical technique, trial of medical management, or postoperative care and complications. Considerable practice variations exist for medical and perioperative management.

Conclusion  The preferred treatment of choice of majority was MLD, although laminectomy and discectomy were still used by many. Consensus lacks in the operative, perioperative, and postoperative management of degenerative disc disease. Present survey points toward the importance of making management guidelines for this common spinal surgical entity.

Feasibility of Unilateral Approach for Bilateral Decompressive Endoscopic Spinal Surgery for Lumbar Stenosis to Improve Back and Leg Pain: A Consecutive Single-Center Series of 60 Patients

Introduction: Endoscopic surgery is one of the methods that achieve the goal of decompression while minimizing collateral tissue damage. Its efficacy and safety have been supported by numerous studies. There is a plethora of studies on lumbar stenosis regarding the outcomes and related issues in endoscopic spine surgery. However, few studies evaluated the outcome of the decompressive lumbar spine surgery. The present study aims to analyze the outcome of a unilateral approach to endoscopic surgery for lumbar stenosis using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and MacNab's criteria.

Methods: This is a retrospective study (level IV) conducted between January 2009 and December 2013 on 60 patients who underwent endoscopic interlaminar decompressive spine surgery (Destandau method) for lumbar degenerative spinal stenosis in the Hospital Universiti Sains Malaysia. The clinical outcome was measured pre-operatively and post-operatively for VAS: for back and leg pain, motor and sensory grading, the ODI, and MacNab's criteria. A paired t-test was used for statistical analysis.

Results: The mean age of patients was 60.82 years comprising 23 males (38.3%) and 37 females (61.7%). The mean follow-up period was 30.1 months (range = 17.2–43 months). The mean operation time was 183.6 min (ranging from 124.8 to 242.4 min), and the mean blood loss was 150.18 mL (ranging from 30.82 to 269.54 mL). Post-operatively, mean hospital stay was 2.45 days (ranging from 1.34 to 3.56 days). The most frequently involved level was L4/L5 in 51 patients (52.6%), followed by L3/L4 in 19 patients (19.6%), L5/S1 in 24 patients (24.7%), and L2/L3 in three patients (3.1%). Improvement in the post-operative VAS for back and leg pain and the ODI for pre-operation and post-operation was statistically significant (p < 0.001). Conversely, the reduction in neurological status was statistically insignificant. Based on MacNab's criteria, 88.4% showed excellent to good outcomes.

Conclusion: To summarize, unilateral percutaneous endoscopic spine surgery to achieve the bilateral decompression in lumbar stenosis provides excellent yet safe and effective outcomes. It improves back and leg pain and patients' function significantly.

The Evolution of Transforaminal Endoscopic Spine Surgery

Transforaminal endoscopic spine surgery (T-ESS) has become a well-accepted technique. The first attempts at percutaneous discectomy by Kambin and Hijikata opened a new chapter of endoscopic spine surgery. By the last quarter of the twentieth century, spine surgeons had begun to adopt this novel technique. Many researchers helped advance endoscopic spine surgery, but the turning point was the description of a safe transforaminal triangle of safety by Parviz Kambin. Since then, the indications for T-ESS have increased as a result of the description of different surgical approaches such as inside-out, outside-in, and half-and-half. We present a review of crucial historical advancements in T-ESS and also discuss the evolution of endoscopes, the techniques used, development of endoscopic instruments and equipment, transforaminal thoracic endoscopy, transforaminal endoscopic interbody fusions, the growth of extended indications, and the future direction of T-ESS. This review provides a detailed description of key historical moments and a bird's-eye view of the vast scope of T-ESS.

Learning Curve of Microendoscopic Discectomy in Single-Level Prolapsed Intervertebral Disc in 120 Patients

STUDY DESIGN

Retrospective study of prospectively collected data.

OBJECTIVE

To evaluate learning curve of tubular microendoscopic discectomy (MED) in lumbar prolapsed intervertebral disc (PIVD) patients based on surgical and clinical parameters and delineate the challenges faced in early cases while practicing MED in large series of patients.

METHODS

This study was an institutional review board-approved retrospective study of the first 125 consecutive patients with single-level lumbar PIVD managed with tubular MED from 2008 to 2016 with a minimum 2-year follow-up. A total of 120 patients available at final follow-up were divided into quartiles (30 each) as per the date of surgery, with each consecutive group serving as a control for the previous group. Preoperatively and postoperatively clinical parameters (pain scores [Visual Analogue Scale; VAS], functional disability [Oswestry Disability Index; ODI] score, modified MacNab criteria), perioperative parameters (operative time, blood loss, hospital stay), technical issues (guide wire migration, tube docking-related problems, dural tear), and postoperative complications (postoperative leg pain, neural injury, infection, recurrence) were evaluated. Statistical analysis-logarithm curve-fit regression analysis and ANOVA test.

RESULTS

The sample consisted of 75 males and 45 females (mean age: 42.54 years) with no significant difference among the quartiles. There was significant difference (P < .005) noted in mean operative time (quartile 1, 87.33 minutes; quartile 2, 58.5 minutes) and mean blood loss (quartile 1, 76.33 mL; quartile 2, 32.66 mL) between quartile 1 and quartile 2, with no further significant reduction in quartile 3 and quartile 4. Significant difference (P < .005) in clinical parameters (VAS preoperative/postoperative 5.28/0.99; ODI preoperative/postoperative 32.18/12.08) were noted but was not associated with surgical experience. Overall, 90% (108 out of 120) of the patients had good to excellent results according to the modified MacNab criteria. The mean hospital stay did not show any significant difference among the quartiles. Guide wire migrated issues, neural injury, dural tear, and tube docking-related problems were significantly reduced after quartile 1. However, recurrence occurred at any phase. Infection occurred in one patient in quartile 1. Although blood loss and operative time showed a declining trend, it was not significant after quartile 2. So asymptote lay in quartile 1 and we recommend that novice surgeon should perform 25 to 30 cases to achieve mastery in this technique.

CONCLUSION

For mastering the art of tubular MED for lumbar PIVD and to reduce its learning curve, novice surgeons can avoid the challenges and problems faced during initial cases with improvement in surgical skills by practicing on cadavers, wet labs, and bone-saw models following certain recommendations that we have after achieving asymptote. Familiarity with instrumentation, communication between surgical team, and defined expectations from radiology technicians are key to reduce the learning curve.

Effect of Percutaneous Endoscopic Lumbar Foraminoplasty of Different Facet Joint Portions on Lumbar Biomechanics: A Finite Element Analysis

Objective

To evaluate the influence of percutaneous endoscopic lumbar foraminoplasty of different facet joint portions on segmental range of motion (ROM) and intradiscal pressure (IDP) of L₃/L₄ and L₄/L₅ motion segments by establishing three dimensional finite element (FE) model.

Method

Computed tomography images of a male adult volunteer of appropriate age and in good condition both mentally and physically. Obtained data was used in this study from July 2020 to December 2020, and an intact L_3–5 three dimensional finite element model was successfully constructed using ANSYS and MIMICS software (model M1). The M1 was modified to simulate the foraminoplasty of different facet joint portions, with unilateral cylindrical excision (diameter = 0.75 cm) performed on the tip (model M2) and the base (model M3) of right L₅ superior facet elements along with surrounding capsular ligaments, respectively. Under the same loading conditions, the ROM and IDP of L₃/₄ and L₄/L₅ segments in states of forward flexion, backward extension, left lateral bending, right lateral bending, left axial rotation and right axial rotation were all compared.

Result

Compared with the intact model in backward extension, M2 increased the ROM of L_4/5 segment by 9.4% and IDP by 11.7%, while the ROM and IDP of M3 changed only slightly. In right axial rotation, M2 and M3 increased the ROM of L_4/5 segment by 17.9% and by 3.6%, respectively. In left axial rotation, M2 and M3 increased the ROM of L₄/L₅ segment by 7.14% and 3.6%, respectively. As for other states including forward flexion, left lateral bending, right lateral bending, the ROM and IDP were not significantly distinct between these two models. While focusing on L₃/L₄ segment, obviously changes in the ROM and IDP have not been presented and neither M2 nor M3 changed in any loading condition.

Conclusion

This study provides evidence that the base‐facet foraminoplasty of L₅ superior facet provided a higher segmental stability compared with the tip‐facet foraminoplasty in flexion and axial rotation. Meanwhile, it also shows the two types of foraminoplasty make few differences to the L_4/5 segmental biomechanics. Besides, it does not appear to impact the stability of L₃/L₄ in six states of forward flexion, backward extension, left lateral bending, right lateral bending, left axial rotation and right axial rotation when superior facet of L₅ was partially removed. These findings might be useful in understanding biomechanics of the lumbar spine after foraminoplasty performed on different portions of the facet, thus providing endoscopic surgeons a better reference for operational approach to maintain the function and mobility of the spine.

AOSpine Consensus Paper on Nomenclature for Working-Channel Endoscopic Spinal Procedures

STUDY DESIGN

International consensus paper on a unified nomenclature for full-endoscopic spine surgery.

OBJECTIVES

Minimally invasive endoscopic spinal procedures have undergone rapid development during the past decade. Evolution of working-channel endoscopes and surgical instruments as well as innovation in surgical techniques have expanded the types of spinal pathology that can be addressed. However, there is in the literature a heterogeneous nomenclature defining approach corridors and procedures, and this lack of common language has hampered communication between endoscopic spine surgeons, patients, hospitals, and insurance providers.

METHODS

The current report summarizes the nomenclature reported for working-channel endoscopic procedures that address cervical, thoracic, and lumbar spinal pathology.

RESULTS

We propose a uniform system that defines the working-channel endoscope (full-endoscopic), approach corridor (anterior, posterior, interlaminar, transforaminal), spinal segment (cervical, thoracic, lumbar), and procedure performed (eg, discectomy, foraminotomy). We suggest the following nomenclature for the most common full-endoscopic procedures: posterior endoscopic cervical foraminotomy (PECF), transforaminal endoscopic thoracic discectomy (TETD), transforaminal endoscopic lumbar discectomy (TELD), transforaminal lumbar foraminotomy (TELF), interlaminar endoscopic lumbar discectomy (IELD), interlaminar endoscopic lateral recess decompression (IE-LRD), and lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD).

CONCLUSIONS

We believe that it is critical to delineate a consensus nomenclature to facilitate uniformity of working-channel endoscopic procedures within academic scholarship. This will hopefully facilitate development, standardization of procedures, teaching, and widespread acceptance of full-endoscopic spinal procedures.

A review of discogenic pain management by interventional techniques

This review article describes the various image guided interventional techniques used for treating chronic backache attributed to disc related pathologies. With the aim of minimum invasion and maximum relief, these procedures comprise predominantly of annuloplasty and disc decompression via different mechanisms. Newer therapies are discussed in this review article with the objective of restoring disc height and its biomechanical function by substitution of biochemical constituents, regeneration of cartilaginous end plate and finally artificial disc implantation.

Operative Approaches for Lumbar Disc Herniation: A Systematic Review and Multiple Treatment Meta-Analysis of Conventional and Minimally Invasive Surgeries

BACKGROUND

Minimally invasive surgery (MIS) techniques have emerged as viable and safe alternatives for lumbar disc herniation, including percutaneous discectomy, percutaneous endoscopic discectomy, and tubulardiscectomy (TD). We present here a systematic review and a multiple-treatment meta-analysis evaluating the operative outcomes and patient-reported outcomes of open/microdiscectomy (OD/MD) and all MIS approaches for lumbar disc herniation.

METHODS

The PICO approach and PRISMA (i.e., Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to query existing online databases since their inception to 2016, which yielded 14 studies after we applied the inclusion/exclusion criteria. The Cochrane Collaboration's tool for assessing risk of bias in randomized trials was used to assess the risk of bias in each study was used to assess the risk of bias in each study. Each outcome was assessed across all studies with the GRADE (i.e., Grading of Recommendations, Assessment, Development and Evaluations) criteria.

RESULTS

There were 1707 patients analyzed, with 782 (45.81%) undergoing OD/MD, 491 (28.76%) undergoing TD, 199 (11.65%) undergoing percutaneous endoscopic discectomy, and 235 (13.76%) patients undergoing percutaneous discectomy. TD was found to be associated with significantly worse Oswestry Disability Index scores (mean difference 1.17, P = 0.03) whereas OD/MD was associated with worse Oswestry Disability Index scores compared with all other approaches (mean difference 2.61, P = 0.03), significantly longer duration of stay (mean difference 2.96, P = 0.04), and more blood loss (mean difference 30.53, P < 0.001). In terms of complications, TD was found to be associated with a greater rate of overall complications (odds ratio [OR] 1.49, P = 0.002), greater incidence of dural tears (OR 1.72 P = 0.04), and recurrent herniation (OR 2.09, P = 0.0007). Finally, OD/MD was associated with significantly lower incidence of revision surgery (OR 0.53, P = 0.0007).

CONCLUSIONS

Our meta-analysis revealed that tubular-discectomy and percutaneous-endoscopic-discectomy, the most commonly employed MIS techniques for discectomy, can be used as safe alternatives for open discectomy depending on the preference of the operating surgeon.

Anatomical considerations of the iliac crest on percutaneous endoscopic discectomy using a transforaminal approach

BACKGROUND CONTEXT

Percutaneous endoscopic discectomy is a minimally invasive procedure for the surgical treatment of lumbar disc herniation (LDH). It can be performed under local anesthesia and requires a skin incision of only 8 mm, with minimal disruption of the spinal structures including ligaments and muscles. However, performing percutaneous endoscopic discectomy with a transforaminal approach (TF-PED) for the lower lumbar spine is associated with some anatomical problems, such as interference from the iliac crest. This study sought to assess the operability of TF-PED for the lower lumbar spine.

PURPOSE

The purpose of this study was to assess a three-dimensional relationship between the trajectory of TF-PED and the iliac crest, and the operability of TF-PED at the lower lumbar disc levels (L4-L5 and L5-S1) using CT images.

STUDY DESIGN

This is a retrospective study using 323 multiplanar abdominal computed tomography (CT) scans.

PATIENT SAMPLE

We retrospectively reviewed contrast-enhanced multiplanar abdominal CT scans of 323 consecutive patients (203 male and 120 female) in our hospital from April 2009 to March 2013. The mean age was 66.5 (range 15-89) years old.

OUTCOME MEASURES

The operability of the TF-PED was the outcome measure.

MATERIALS AND METHODS

We defined the tangent line in the iliac crest and the superior articular process of the caudal spine as the trajectory line of TF-PED, and evaluated the maximum inclination angle of the trajectory of the TF-PED (α angle) at the L4-L5 and the L5-S1 disc levels. Assuming the use of an oblique viewing endoscope at 25°, we defined α angle≥65° as the operability of TF-PED.

RESULTS

(1) Relationship between iliac crest and disc level: The trajectory of the TF-PED interfered with the iliac crest at L4-L5 in 40.2% (right) and 54.5% (left) of the subjects, and at L5-S1 in 99.7% and 100% of the subjects. (2) The maximum inclination angle of the trajectory of TF-PED: the α angles were 84.3° and 82.3° at the L4-L5, and 56.8° and 55.2° at L5-S1. (3) Laterality of the α angle: At both disc levels, the mean age of the subjects with a laterality of ≥10° was significantly higher than that of subjects with a laterality of <10°. (4) Operability of TF-PED: At L4-L5, TF-PED could be performed in 94.4% and 90.4% of the subjects. In contrast, at L5-S1 the procedure could be performed in 24.1% and 19.2% of the subjects (male: 15.8% and 10.8%, female: 38.3% and 33.3%).

CONCLUSIONS

From the results of this study, the trajectory of TF-PED can be limited by the surrounding anatomical structures. The maximum inclination angle indicated that treatment for the central type of LDH at the L5-S1 disc level was considered more difficult than that at the L4-L5 disc level because of the iliac crest. In the clinical setting, such anatomical particularities can be overcome by using a more perpendicular approach (hand-down technique) with the possible addition of a foraminoplasty. Moreover, we found that we must consider the laterality of the trajectory of TF-PED in terms of the patients' age or sex.

Endoscopic Spine Surgery

Surgical treatment of the degenerative disc disease has evolved from traditional open spine surgery to minimally invasive spine surgery including endoscopic spine surgery. Constant improvement in the imaging modality especially with introduction of the magnetic resonance imaging, it is possible to identify culprit degenerated disc segment and again with the discography it is possible to diagnose the pain generator and pathological degenerated disc very precisely and its treatment with minimally invasive approach. With improvements in the optics, high resolution camera, light source, high speed burr, irrigation pump etc, minimally invasive spine surgeries can be performed with various endoscopic techniques for lumbar, cervical and thoracic regions. Advantages of endoscopic spine surgeries are less tissue dissection and muscle trauma, reduced blood loss, less damage to the epidural blood supply and consequent epidural fibrosis and scarring, reduced hospital stay, early functional recovery and improvement in the quality of life & better cosmesis. With precise indication, proper diagnosis and good training, the endoscopic spine surgery can give equally good result as open spine surgery. Initially, endoscopic technique was restricted to the lumbar region but now it also can be used for cervical and thoracic disc herniations. Previously endoscopy was used for disc herniations which were contained without migration but now days it is used for highly up and down migrated disc herniations as well. Use of endoscopic technique in lumbar region was restricted to disc herniations but gradually it is also used for spinal canal stenosis and endoscopic assisted fusion surgeries. Endoscopic spine surgery can play important role in the treatment of adolescent disc herniations especially for the persons who engage in the competitive sports and the athletes where less tissue trauma, cosmesis and early functional recovery is desirable. From simple chemonucleolysis to current day endoscopic procedures the history of minimally invasive spine surgery is interesting. Appropriate indications, clear imaging prior to surgery and preplanning are keys to successful outcome. In this article basic procedures of percutaneous endoscopic lumbar discectomy through transforaminal and interlaminar routes, percutaneous endoscopic cervical discectomy, percutaneous endoscopic posterior cervical foraminotomy and percutaneous endoscopic thoracic discectomy are discussed.

Multi-level spine endoscopy: A review of available evidence and case report

In the last ten years, there has been an exponential increase in endoscopic spinal surgery practice.

With improvements in equipment quality and the availability of high definition camera systems, cervical endoscopic disc resection is now a viable alternative to anterior cervical decompression and fusion (ACDF) or disc arthroplasty for the treatment of disc prolapse and low grade stenosis.

Based on the current literature, there is now strong evidence to support the use of transforaminal endoscopic approaches for the treatment of thoracic disc prolapse.

There is now level I evidence to show that outcomes following transforaminal endoscopic discectomy (TED) are at least equivalent to those after open microdiscectomy, with an expected shorter operating time, lesser requirement for analgesia, reduced duration of post-operative disability, more rapid rehabilitation and lower costs of care. However, it should be recognised that there is a significant learning curve for TED.

New endoscopic techniques with interlaminar approaches allow the decompression of central and lateral recess stenosis. Future developments will facilitate vision and access to the spine with 3D imaging and robotics at the forefront.

We present a case report of whole spine endoscopic decompression to illustrate the potential of endoscopic surgery at all spinal levels.

Cite this article: EFORT Open Rev 2017;2:317-323. DOI: 10.1302/2058-5241.2.160087

Illumination in Spinal Surgery Depending on Different Approaches and Light Sources

BACKGROUND

Sufficient visualization of the operating field is crucial for success in surgery and is important especially concerning minimally invasive and deep approaches in spine surgery.

METHODS

The spinal microsurgical approach was imitated using an isolated box that was accessed with different devices. Different light sources and auxiliary devices were analyzed and compared. Light sources used were a microscope, a standard operating room lamp, and a headlamp. The auxiliary devices included different tubes with and without optical light fibers, different retractors, and an endoscope.

RESULTS

We demonstrated that different combinations of light sources and auxiliary devices provide significantly different illumination in the artificial operating field. A tube with optical fibers seems to be superior for nonmicroscopic approaches. The smaller these tubes are in diameter, the higher the illuminance on the surgical focus.

CONCLUSIONS

The combination of tube and microscope seems to be the best choice for deep approaches in microsurgical spinal surgery. An endoscope supplies illuminance comparable to a surgical microscope.

The visualization of the surgical field in tubular assisted spine surgery: Is there a difference between HD-endoscopy and microscopy?

OBJECTIVE

Expert spinal surgeons criticized endoscopic procedures for poor image quality, in comparison to microscopic visualization. The recent introduction of high definition (HD) digital cameras has shown good results in spinal endoscopy. The aim of this study was to assess endoscopic HD image quality in comparison with microscopic visualization.

PATIENTS AND METHODS

All posterior lumbar and cervical spinal surgeries of this study were performed with the EasyGO-system in HD resolution. For each comparison, anatomical structures were predefined intraoperatively. A junior resident was randomly required to enter the operating theatre and to identify those structures either using HD-endoscopic or microscopic visualization through the endoscopic working sheath.

RESULTS

Thirteen lumbar and three cervical procedures were performed. Thirty-four comparisons with a total of 214 predefined anatomical structures were analyzed. The number of predefined structures ranged from 5 to 9 per surgical field. Out of 214 predefined structures, 124 structures (65.8%) were correctly identified under endoscopic view and 88 (41.1%) under microscopic view (p=0.001). Subjective impression of visualization quality were rated 1.25 (very good) for endopscopic images and 1.6 (very good to good) for microscopic view (p=0.02).

CONCLUSIONS

When using a working trocar and live images, endoscopic HD camera imaging accounted for significantly more reliable identifications of anatomical structures compared to the microscopic view. The subjective impression of video quality is significantly better with HD-optics. The goal of further studies should be to evalute if these findings results in improved surgical outcome.

Anatomic Considerations of Intervertebral Disc Perspective in Lumbar Posterolateral Approach via Kambin's Triangle: Cadaveric Study

Study Design

Anatomical study.

Purpose

To evaluate the anatomy of intervertebral disc (IVD) area in the triangular working zone of the lumbar spine based on cadaveric measurements.

Overview of Literature

The posterolateral percutaneous approach to the lumbar spine has been widely used as a minimally invasive spinal surgery. However, to our knowledge, the actual perspective of disc boundaries and areas through posterolateral endoscopic approach are not well defined.

Methods

Ninety-six measurements for areas and dimensions of IVD in Kambin's triangle on bilateral sides of L1–S1 in 5 fresh human cadavers were studied.

Results

The trapezoidal IVD area (mean±standard deviation) for true working space was 63.65±14.70 mm² at L1–2, 70.79±21.88 mm² at L2–3, 99.03±15.83 mm² at L3–4, 116.22±20.93 mm² at L4–5, and 92.18±23.63 mm² at L5–S1. The average dimension of calculated largest ellipsoidal cannula that could be placed in IVD area was 5.83×11.02 mm at L1–2, 6.97×10.78 mm at L2–3, 9.30×10.67 mm at L3–4, 8.84×13.15 mm at L4–5, and 6.61×14.07 mm at L5–S1.

Conclusions

The trapezoidal perspective of working zone of IVD in Kambin's triangle is important and limited. This should be taken into consideration when developing the tools and instruments for posterolateral endoscopic lumbar spine surgery.

Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation Via an Interlaminar Approach Versus a Transforaminal Approach: A Prospective Randomized Controlled Study With 2-Year Follow Up

STUDY DESIGN

A prospective, randomized controlled study of patients with L5-S1 lumbar disc herniations, operated with endoscopic discectomy through an interlaminar or transforaminal approach.

OBJECTIVE

To compare the results of percutaneous endoscopic lumbar discectomy in L5-S1 disc herniation through an interlaminar or transforaminal approach.

SUMMARY OF BACKGROUND DATA

The transforaminal and interlaminar techniques are both acceptable approaches for L5-S1 disc herniation. This is the first study to compare these two approaches in terms of their surgical effects and advantages.

METHODS

From January 2010 to June 2010, 60 patients with L5-S1 disc herniation were randomly recruited into two groups; one group underwent percutaneous endoscopic interlaminar discectomy (PEID) and the other group underwent percutaneous endoscopic transforaminal discectomy (PETD). There were 30 patients in each group. The operation time, intraoperative radiation time, postoperative bed rest time, hospitalization time, and complications were compared between the groups. The surgical effectiveness was assessed according to the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and modified MacNab criteria.

RESULTS

All the patients completed follow up with a mean of 27.6 months (range, 24-37 months). In the PEID group, the mean operation time was 65.0 ± 14.9 minutes, and the intraoperative radiation time was 0.60 ± 0.24 seconds. For the PETD group, the mean operation time was 86.0 ± 15.4 minutes, and the intraoperative radiation time was 6.50 ± 1.52 seconds. There were significant differences in operation time and radiation time between the two groups (P < 0.01) but not in the postoperative bed rest time, hospitalization time, or complication rate (P > 0.05). The postoperative ODI and VAS were obviously improved in both groups when compared with preoperation (P < 0.01). According to the MacNab criteria, the satisfactory rates were 93.3% and 90.0% in the two groups, without a significant difference (P > 0.05).

CONCLUSION

PEID can escape the blockade of crista iliaca, and advantages include a faster puncture orientation, a shorter operation time, and less intraoperative radiation exposure. PETD requires higher punctuation skill and more intraoperative radiation exposure.

LEVEL OF EVIDENCE

4.

Long-Term Results of Endoscopic Lumbar Discectomy by "Destandau's Technique"

Study Design

Prospective study.

Purpose

The aim of the study was to present long-term results from a 10-year follow-up after endoscopic lumbar discectomy (ELD) by "Destandau's technique".

Overview of Literature

Endoscopic disc surgery by Destandau's technique using ENDOSPINE Karl Storz system is a relatively new technique. It was introduced in 1993. It has been gaining popularity among the spine surgeons, as it is attractive for small skin incision and allows a gentle and excellent tissue dissection with excellent visualization. Many authors have published results of their own studies; however, in all these studies the long-term follow up of the patients has not been emphasized.

Methods

A total of 21 patients selected on basis of strict inclusion criteria's underwent ELD from November 2004 to March 2005. Surgery outcome was assessed by using "Prolo's Anatomic-Functional-Economic Rating System" (1986). Patients were followed up to 10 years. In addtion, we compared the results of our study with other studies.

Results

Outcomes were excellent in 17 patients (80.95%), good in 3 (14.28%) and fair in 1 (4.78%), with no patients having a poor result. In our study, 19 patients (90.47%) were able to resume their previous works/jobs, and only 2 (9.52%) needed to change their jobs for lighter work. No patient retired from his or her previous daily routine following the operation.

Conclusions

The initial and long-term results are very good for endoscopic lumbar discectomy by Destandau's technique. In properly selected patients it is a safe and minimally invasive technique, and we recommend ELD in properly selected patients.

[Sciatica. From stretch rack to microdiscectomy]

In ancient times as well as in the Middle Ages treatment options for discogenic nerve compression syndrome were limited and usually not very specific because of low anatomical and pathophysiological knowledge. The stretch rack (scamnum Hippocratis) was particularly prominent but was widely used as a therapeutic device for very different spinal disorders. Since the beginning of the nineteenth century anatomical knowledge increased and the advances in the fields of asepsis, anesthesia and surgery resulted in an increase in surgical interventions on the spine. In 1908 the first successful lumbar discectomy was initiated and performed by the German neurologist Heinrich O. Oppenheim (1858-1919) and the surgeon Fedor Krause (1857-1937); however, neither recognized the true pathological condition of discogenic nerve compression syndrome. With the landmark report in the New England Journal of Medicine in 1934, the two American surgeons William Jason Mixter (1880-1958) and Joseph Seaton Barr (1901-1963) finally clarified the pathomechanism of lumbar disc herniation and furthermore, propagated discectomy as the standard therapy. Since then interventions on intervertebral discs rapidly increased and the treatment options for lumbar disc surgery quickly evolved. The surgical procedures changed over time and were continuously being refined. In the late 1960s the surgical microscope was introduced for spinal surgery by the work of the famous neurosurgeon Mahmut Gazi Yasargil and his colleague Wolfhard Caspar and so-called microdiscectomy was introduced. Besides open discectomy other interventional techniques were developed to overcome the side effects of surgical procedures. In 1964 the American orthopedic surgeon Lyman Smith (1912-1991) introduced chemonucleolysis, a minimally invasive technique consisting only of a cannula and the proteolytic enzyme chymopapain, which is injected into the disc compartment to dissolve the displaced disc material. In 1975 the Japanese orthopedic surgeon Sadahisa Hijikata described percutaneous discectomy for the first time, which was a further minimally invasive surgical technique. Further variants of minimally invasive surgical procedures, such as percutaneous laser discectomy in 1986 and percutaneous endoscopic microdiscectomy in 1997, were also introduced; however, open discectomy, especially microdiscectomy remains the therapeutic gold standard for lumbar disc herniation.

Interventional therapies for chronic low back pain

OBJECTIVE

Low back pain (LBP) is a highly prevalent condition and one of the leading causes of lost productivity and health-care costs. The objective of this review is to discuss the role of interventional pain procedures and evidence of their effectiveness in treatment of chronic LBP.

METHODS

This is a narrative review examining published studies on interventional procedures for LBP. The rationales, indications, technique, evidence, and complications for the interventional procedures are discussed.

RESULTS

Interventional pain procedures are used extensively in diagnosis and treatment of chronic pain. LBP is multifactorial, and while significant progress has been made in understanding its pathophysiology, this has not resulted in a proportional improvement of functional outcomes. For certain procedures, such as spinal cord stimulation, medical branch blocks and radiofrequency ablations, and epidural steroid injections for radiculopathy, safety, efficacy, and cost-effectiveness in treating LBP have been well studied. For others, such as interventions for discogenic pain, treatment successes have been modest at best.

CONCLUSIONS

Implementation of interventional pain procedures in the treatment framework of LBP has resulted in improvement of pain intensity in at least the short and medium terms, but equivocal results have been observed in functional improvement.

A history of lumbar disc herniation from Hippocrates to the 1990s

In ancient times, a supernatural understanding of the syndrome of lumbar radiculopathy often involved demonic forces vexing the individual with often crippling pain. The ancient Greeks and Egyptians began to take a more naturalistic view and, critically, suspected a relationship between lumbar spinal pathology and leg symptoms. Relatively little then changed for those with sciatica until the classic works by Cotugno and Kocher arrived in the late 18th century. Early lumbar canal explorations were performed in the late 1800s and early 1900s by MacEwen, Horsley, Krause, Taylor, Dandy, and Cushing, among others. In these cases, when compressive pathologies were found and removed, the lesions typically were (mis-)identified as enchondromas or osteochondritis dissecans. To better understand the history, learn more about the first treatments of lumbar disc herniation, and evaluate the impact of the early influences on modern spine practice, searches of PubMed and Embase were performed using the search terms discectomy, medical history, lumbar spine surgery, herniated disc, herniated nucleus pulposus, sciatica, and lumbar radiculopathy. Additional sources were identified from the reference lists of the reviewed papers. Many older and ancient sources including De Ischiade Nervosa are available in English translations and were used. When full texts were not available, English abstracts were used. The first true, intentional discectomy surgery was performed by Mixter and Barr in 1932. Early on, a transdural approach was favored. In 1938, Love described the intralaminar, extradural approach. His technique, although modified with improved lighting, magnification, and retractors, remains a staple approach to disc herniations today. Other modalities such as chymopapain have been investigated. Some remain a part of the therapeutic armamentarium, whereas others have disappeared. By the 1970s, CT scanning after myelography markedly improved the clinical evaluation of patients with lumbar disc herniation. In this era, use of discectomy surgery increased rapidly. Even patients with very early symptoms were offered surgery. Later work, especially by Weber and Hakelius, showed that many patients with lumbar disc herniation would improve without surgical intervention. In the ensuing decades, the debate over operative indications and timing continued, reaching another pivotal moment with the 2006 publication of the initial results of Spine Patient Outcomes Research Trial.

Percutaneous endoscopic lumbar foraminotomy: an advanced surgical technique and clinical outcomes

Supplemental Digital Content is Available in the Text.

BACKGROUND:

Although several authors have reported the use of endoscopic techniques to treat lumbar foraminal stenosis, the practical application of these techniques has been limited to soft disc herniation.

OBJECTIVE:

To describe the details of the percutaneous endoscopic lumbar foraminotomy (ELF) technique for bony foraminal stenosis and to demonstrate the clinical outcomes.

METHODS:

Two years of prospective data were collected from 33 consecutive patients with lumbar foraminal stenosis who underwent ELF. The surgical outcomes were assessed using the visual analog scale, Oswestry Disability Index, and modified MacNab criteria. The procedure begins at the safer extraforaminal zone rather than the riskier intraforaminal zone. Then, a full-scale foraminal decompression can be performed using a burr and punches under endoscopic control.

RESULTS:

The mean age of the 18 female and 15 male patients was 64.2 years. The mean visual analog scale score for leg pain improved from 8.36 at baseline to 3.36 at 6 weeks, 2.03 at 1 year, and 1.97 at 2 years post-surgery (P < .001). The mean Oswestry Disability Index improved from 65.8 at baseline to 31.6 at 6 weeks, 19.7 at 1 year, and 19.3 at 2 years post-surgery (P < .001). Based on the modified MacNab criteria, excellent or good results were obtained in 81.8% of the patients, and symptomatic improvements were obtained in 93.9%.

CONCLUSION:

Percutaneous ELF under local anesthesia could be an efficacious surgical procedure for the treatment of foraminal stenosis. This procedure may offer safe and reproducible results, especially for elderly or medically compromised patients.

ABBREVIATIONS:

ELF,endoscopic lumbar foraminotomy

ODI, Oswestry Disability Index

VAS, visual analog scale

Ozone-augmented percutaneous discectomy: a novel treatment option for refractory discogenic sciatica

AIM

To assess the short and medium-term efficacy and safety of a novel, minimally invasive therapeutic option combining automated percutaneous lumbar discectomy, intradiscal ozone injection, and caudal epidural: ozone-augmented percutaneous discectomy (OPLD).

MATERIALS AND METHODS

One hundred and forty-seven patients with a clinical and radiological diagnosis of discogenic sciatica who were refractory to initial therapy were included. Fifty patients underwent OPLD whilst 97 underwent a further caudal epidural. Outcomes were evaluated using McNab's score, improvement in visual analogue score (VAS) pain score, and requirement for further intervention. Follow-up occurred at 1 and 6 months, and comparison was made between groups.

RESULTS

OPLD achieved successful outcomes in almost three-quarters of patients in the short and medium term. OPLD achieved superior outcomes at 1 and 6 months compared to caudal epidural. There was a reduced requirement for further intervention in the OPLD group. No significant complications occurred in either group.

DISCUSSION

OPLD is a safe and effective treatment for patients with refractory discogenic sciatica in the short and medium term. OPLD has the potential to offer an alternative second-line minimally invasive treatment option that could reduce the requirement for surgery in this patient cohort.

Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation

BACKGROUND

Microdiscectomy or open discectomy (MD/OD) are the standard procedures for symptomatic lumbar disc herniation and they involve removal of the portion of the intervertebral disc compressing the nerve root or spinal cord (or both) with or without the aid of a headlight loupe or microscope magnification. Potential advantages of newer minimally invasive discectomy (MID) procedures over standard MD/OD include less blood loss, less postoperative pain, shorter hospitalisation and earlier return to work.

OBJECTIVES

To compare the benefits and harms of MID versus MD/OD for management of lumbar intervertebral discopathy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (November 2013), MEDLINE (1946 to November 2013) and EMBASE (1974 to November 2013) and applied no language restrictions. We also contacted experts in the field for additional studies and reviewed reference lists of relevant studies.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-randomised controlled trials (QRCTs) that compared MD/OD with a MID (percutaneous endoscopic interlaminar or transforaminal lumbar discectomy, transmuscular tubular microdiscectomy and automated percutaneous lumbar discectomy) for treatment of adults with lumbar radiculopathy secondary to discopathy. We evaluated the following primary outcomes: pain related to sciatica or low back pain (LBP) as measured by a visual analogue scale, sciatic specific outcomes such as neurological deficit of lower extremity or bowel/urinary incontinence and functional outcomes (including daily activity or return to work). We also evaluated the following secondary outcomes: complications of surgery, duration of hospital stay, postoperative opioid use, quality of life and overall participant satisfaction. Two authors checked data abstractions and articles for inclusion. We resolved discrepancies by consensus.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. We used pre-developed forms to extract data and two authors independently assessed risk of bias. For statistical analysis, we used risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI) for each outcome.

MAIN RESULTS

We identified 11 studies (1172 participants). We assessed seven out of 11 studies as having high overall risk of bias. There was low-quality evidence that MID was associated with worse leg pain than MD/OD at follow-up ranging from six months to two years (e.g. at one year: MD 0.13, 95% CI 0.09 to 0.16), but differences were small (less than 0.5 points on a 0 to 10 scale) and did not meet standard thresholds for clinically meaningful differences. There was low-quality evidence that MID was associated with worse LBP than MD/OD at six-month follow-up (MD 0.35, 95% CI 0.19 to 0.51) and at two years (MD 0.54, 95% CI 0.29 to 0.79). There was no significant difference at one year (0 to 10 scale: MD 0.19, 95% CI -0.22 to 0.59). Statistical heterogeneity was small to high (I(2) statistic = 35% at six months, 90% at one year and 65% at two years). There were no clear differences between MID techniques and MD/OD on other primary outcomes related to functional disability (Oswestry Disability Index greater than six months postoperatively) and persistence of motor and sensory neurological deficits, though evidence on neurological deficits was limited by the small numbers of participants in the trials with neurological deficits at baseline. There was just one study for each of the sciatica-specific outcomes including the Sciatica Bothersomeness Index and the Sciatica Frequency Index, which did not need further analysis. For secondary outcomes, MID was associated with lower risk of surgical site and other infections, but higher risk of re-hospitalisation due to recurrent disc herniation. In addition, MID was associated with slightly lower quality of life (less than 5 points on a 100-point scale) on some measures of quality of life, such as some physical subclasses of the 36-item Short Form. Some trials found MID to be associated with shorter duration of hospitalisation than MD/OD, but results were inconsistent.

AUTHORS' CONCLUSIONS

MID may be inferior in terms of relief of leg pain, LBP and re-hospitalisation; however, differences in pain relief appeared to be small and may not be clinically important. Potential advantages of MID are lower risk of surgical site and other infections. MID may be associated with shorter hospital stay but the evidence was inconsistent. Given these potential advantages, more research is needed to define appropriate indications for MID as an alternative to standard MD/OD.

The technological development of minimally invasive spine surgery

Minimally invasive spine surgery has its roots in the mid-twentieth century with a few surgeons and a few techniques, but it has now developed into a large field of progressive spinal surgery. A wide range of techniques are now called "minimally invasive," and case reports are submitted constantly with new "minimally invasive" approaches to spinal pathology. As minimally invasive spine surgery has become more mainstream over the past ten years, in this paper we discuss its history and development.

Microendoscopic lumbar discectomy: Technique and results of 188 cases

BACKGROUND

Discectomy performed open or with an operating microscope remains the standard surgical management. Tubular retractor system is being increasingly used. Potential benefits include less muscle and local damage, better cosmesis, decreased pain and operative time and faster recovery after surgery. We have evaluated the outcome of micro endoscopic discectomy (MED) utilizing tubular retractors in terms of safety and efficacy of the technique.

MATERIALS AND METHODS

188 consecutive patients who underwent surgery for herniated disc using the tubular retractors between April 2007 and April 2012 are reported. All patients had a preoperative MRI (Magnetic Resonance Imaging) and were operated by a single surgeon with the METRx system (Medtronic, Sofamor-Danek, Memphis, TN) using 18 and 16 mm ports. All patients were mobilized as soon as pain subsided and discharged within 24-48 hours post surgery. The results were evaluated by using VAS (Visual Analog Scale 0-5) for back and leg pain and ODI (Oswestry Disability Index). Patients were followed up at intervals of 1 week, 6 weeks, 3 months, 6 months, 12 months and 2 years.

RESULTS

The mean age of patients was 46 years (range 16-78 years) and the sex ratio was 1.5 males to 1 female. The mean followup was 22 months (range 8-69 months). The mean VAS scale for leg pain improved from 4.14 to 0.76 (P < 0.05) and the mean VAS scale for back pain improved from 4.1 to 0.9 (P < 0.05). The mean ODI changed from 59.5 to 22.6 (P < 0.05). The mean operative time per level was about 50 minutes (range 20-90 minutes). Dural punctures occurred in 11 (5%) cases. Average blood loss was 30 ml (range 10-500 ml). A wrong level was identified and later corrected in a case of revision discectomy. Four patients with residual disc-herniation had revision MED and three patients with recurrent disc herniation later underwent fusion. One patient had wound infection which needed a debridement.

CONCLUSION

MED for herniated discs effectively achieves the goals of surgery with minimal access. The advantages of the procedure are cosmesis, early postoperative recovery and minimal postoperative morbidity.

Comparison of percutaneous vertebroplasty with and without interventional tumour removal for malignant vertebral compression fractures with symptoms of neurological compression

OBJECTIVE

To compare the efficacy of percutaneous vertebroplasty (PVP) with and without interventional tumor removal (ITR) on malignant vertebral compression fractures and symptoms of neurological compression.

MATERIALS AND METHODS

A total of 52 patients with malignant vertebral compression fractures and symptoms of neurological compression were selected for PVP and ITR (n = 24, group A) or PVP alone (n = 28, group B). A 14-G needle and a guidewire were inserted into the vertebral body, followed by sequential dilatation of the tract with the working cannula until the last working cannula reached the distal pedicle of the vertebral arch. ITR was performed with marrow nucleus rongeurs. Then, 5-10 mL cement was injected into the extirpated vertebral body.

RESULTS

PVP procedures with and without ITR were successful in all patients, except for one patient in group A. The clinical assessment obtained at the initial and final follow-up indicated that the rates of full recovery and improved neurological compression symptoms were significantly higher in group A than in group B (P < 0.05).

CONCLUSION

Treatment of malignant vertebral compression fractures with symptoms of neurological compression with PVP and ITR resulted in better intermediate-term clinical results in terms of improved neurological compression symptoms than the currently recommended approach of PVP.

KEY POINTS

• Percutaneous vertebroplasty (PVP) is now widely used for vertebral collapse due to malignancy • PVP can be coupled with interventional tumour removal (ITR) • PVP coupled with ITR provided better clinical results for neurological compression • PVP coupled with ITR provided better pain relief • PVP and ITR can remove tumour and helps prevent polymethyl methacrylate leakage.

Exiting root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety

PURPOSE

To evaluate the clinical and radiological risk factors for exiting root injuries during transforaminal endoscopic discectomy.

METHODS

We retrospectively examined cohort data from 233 patients who underwent percutaneous endoscopic lumbar discectomy for lumbar disc herniation between January 1st, 2010 and December 31st, 2011. We divided the patients into the two groups: those who presented a postoperative exiting root injury, such as postoperative dysesthesia or motor weakness (Group A, n = 20), and those who did not suffer from a root injury (Group B, n = 213). We examined the clinical and radiological factors relating exiting root injuries. We measured the active working zone with the exiting root to the upper facet distance (Distance A), the exiting root to disc surface distance at the lower facet line (Distance B) and the exiting root to the lower facet distance (Distance C) in magnetic resonance imaging (MRI).

RESULTS

Group A exhibited a shorter Distance C (6.4 ± 1.5 versus 4.4 ± 0.8 mm, p < 0.001) and a longer operation time (67.9 ± 21.8 versus 80.3 ± 23.7 min, p = 0.017) relative to Group B. The complication rate decreased by 23% per each 1-mm increase in Distance C (p = 0.000). In addition, the complication rate increased 1.027-fold per each 1-min increase in the operation time (p = 0.027).

CONCLUSION

We recommend measuring the distance from the exiting root to the facet at the lower disc level according to a preoperative MRI scan. If the distance is narrow, an alternative surgical method, such as microdiscectomy or conventional open discectomy, should be considered.

Comparison of MR imaging findings between extraligamentous and subligamentous disk herniations in the lumbar spine

BACKGROUND AND PURPOSE

The method of treating an HIVD in the lumbar spine may depend on the integrity of the PLL. The purpose of this study was to analyze and compare the MR imaging findings of extraligamentous and subligamentous HIVDs in the lumbar spine.

MATERIAL AND METHODS

One hundred seventeen patients (M/F = 71:46; mean age, 47 years; age range, 15-79 years) underwent lumbar spine MR imaging and disk surgery (extraligamentous/subligamentous = 66:51) from May 2003 to November 2006. Two radiologists in consensus retrospectively reviewed all MR images, focusing on 10 criteria.

RESULTS

The following 5 criteria are suggestive of extraligamentous HIVD in the lumbar spine: 1) spinal canal compromised for more than half its dimension, 2) internal signal difference in the HIVD, 3) an ill-defined margin of the HIVD, 4) disruption of the continuous low-signal-intensity line covering the HIVD, and 5) the presence of an internal dark line in the HIVD (P < .05). When we combined these 5 MR imaging criteria, the sensitivity, specificity, accuracy, and odds ratio were 77.3%, 74.5%, 76.1%, and 9.93 (P < .0001).

CONCLUSIONS

Our proposed 5 MR imaging criteria will be helpful in differentiating extraligamentous and subligamentous HIVDs in the lumbar spine.

Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse

PURPOSE

The purpose of this study is to present a new endoscopic procedure, aiming to achieve the success rate equivalent to microsurgical discectomy, while addressing the drawbacks and limitations of other percutaneous techniques.

METHODS

A series of 43 patients with uncontained lumbar disc herniation underwent surgery with irrigation endoscopic discectomy (IED). The endoscope and instruments are placed directly over the surface of the lamina through two posterior skin portals 5 mm each without any muscle retraction or dilatation. Pump irrigation is used for the opening of a potential working space. The rest of the procedure is performed endoscopically like the standard microsurgical discectomy.

RESULTS

Outcome according to modified Macnab criteria was excellent in 78%, good in 17%, and poor in 5% of patients. VAS for leg pain dropped from 78 preoperatively to 7, and the Oswestry Low-Back Pain Disability Questionnaire dropped from 76 to 19. The mean time for postoperative ambulation was 4 h, hospital stay was 8 h, and for return to work was 7 days.

CONCLUSIONS

Preliminary clinical experience with IED shows it to be as effective as microsurgical discectomy, and in comparison to other percutaneous procedures addressing noncontained herniations, a reduction in the cost, technical difficulty and surgical invasiveness has been demonstrated.

Percutaneous Disc Coagulation Therapy (PDCT) comparing with Automated Percutaneous Lumbar Discectomy (APLD) in Patients of Herniated Lumbar Disc Disease: Preliminary Report

OBJECTIVE

Percutaneous techniques are rapidly replacing traditional open surgery. This is a randomized controlled trial study of clinical outcomes of Percutaneous Plasma Disc Coagulation Therapy (PDCT) in patients with HLD(herniated lumbar disc) as a new percutaneous access in comparison with Automated Percutaneous Lumbar Discectomy (APLD) in its clinical application and usefulness as a reliable alternative method.

METHODS

The authors analyzed 25 patients who underwent PDCT randomized 1:1 to 25 who underwent APLD between June, 2010 and October, 2011. All patients had herniated lumbar disc diseases. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNab's criteria.

RESULTS

The age of the patients who underwent PDCT ranged from 29 to 88 years with a mean age of 51.8 years. The age of the APLD undergone patients' population ranged from 30 to 66 with a mean age of 46.0 years. The average preoperative VAS score in PDCT was 7.60 and 1.94 at 7months post-operatively, and in APLD was 7.32, and 3.53 at 7 months post-operatively (p<0.001). In Macnab's criteria, 20 patients (80%) had achieved favorable improvement (excellent and good) in PDCT group. In Macnab's criteria, 16 patients (64%) had achieved favorable improvement in APLD group (p<0.001).

CONCLUSION

PDCT can be considered a viable option as a new percutaneous access to herniated lumbar disc. PDCT showed to be more effective than APLD in this study, allowing stable decompression and safe minimally invasive operation to an area desired by the operator in lumbar disc herniation patients, although further long term clinical evaluations are still necessary.

Triamcinolone decreases bupivacaine toxicity to intervertebral disc cell in vitro

BACKGROUND CONTEXT

Local anesthetics combined with corticosteroids are commonly used for management of back pain in interventional spinal procedures. Several recent studies suggest cytotoxicity of bupivacaine, whereas others report protective and cytotoxic effects of corticosteroids on chondrocytes and intervertebral disc cells. Considering the frequent use of these agents in spinal interventions, it is meaningful to know how they affect intervertebral disc cells.

PURPOSE

This study was conducted to assess the effects of bupivacaine and triamcinolone, both alone and in combination, on viability of intervertebral disc cells in vitro.

STUDY DESIGN

Controlled laboratory study.

METHODS

Nucleus pulposus cells were isolated from human disc specimens from patients undergoing surgery because of disc herniation or degenerative disc disease. They were grown in three-dimensional alginate beads for 1 week to maintain their differentiated phenotypes and to allow for matrix formation before analysis. After 1 week of culture, the cells were exposed to bupivacaine (0.1%, 0.25%, 0.5%, and 1%) or bupivacaine (0.1%, 0.25%, 0.5%, and 1%) with 1 mg of triamcinolone for 1, 3, or 6 hours. Cell viability was measured using trypan blue exclusion assay and flow cytometry. Live cell/dead cell fluorescent imaging was assessed using confocal microscopy.

RESULTS

Trypan blue exclusion assays demonstrated dose- and time-dependent cytotoxic effects of bupivacaine on human nucleus pulposus cells. Similar but reduced cytotoxicity was observed after exposure to the combination of bupivacaine and 1 mg of triamcinolone. Flow cytometry showed a dose-dependent cytotoxic effect of bupivacaine on nucleus pulposus cells after 3 hours of exposure. The reduced cytotoxicity of bupivacaine combined with 1 mg of triamcinolone was also confirmed in flow cytometry. Confocal images showed that the increase in dead cells correlated with the concentration of bupivacaine. Nevertheless, fewer cells died after exposure to several different concentrations of bupivacaine combined with 1 mg of triamcinolone than did after exposure to bupivacaine alone.

CONCLUSIONS

The combination of bupivacaine and triamcinolone induced dose- and time-dependent cytotoxicity on human intervertebral disc cells in vitro, but the cytotoxicity was much weaker than that of bupivacaine alone. This study shows a potential protective influence of triamcinolone on intervertebral disc cells.

Transforaminal endoscopic spinal surgery: the future 'gold standard' for discectomy? - A review

BACKGROUND

Lumbar disc prolapse is common and the primary method of care in most centres is still open discectomy facilitated by microscope or loupe magnification and illumination. Hospitalisation may be less than 24 h, but post-operative pain usually requires an overnight stay. This review describes transforaminal endoscopic spinal surgery (TESS) using HD-video technology, that is generally performed as a day case procedure under sedation or light general anaesthesia, and collates the evidence comparing the technique to microdiscectomy.

METHODS

The method of TESS is described and an electronic literature search performed to identify papers reporting clinical outcomes. International data were translated where necessary and proceedings' abstracts included. In addition, papers held by the authors and colleagues in personal libraries were carefully cross-referenced to the obtained database.

RESULTS

Analysis of the data supports the use of a transforaminal endoscopic approach to the lumbar intervertebral disc and suggests that outcomes following surgery are at least equivalent to those following microdiscectomy. Significant cost-savings in terms of in-patient stay may be generated. In addition, there is also some evidence supporting endoscopic surgery for relief of foraminal stenosis.

CONCLUSION

Based on current evidence there are good arguments supporting a more wide-spread adoption of transforaminal endoscopic surgery for the treatment of lumbar disc prolapse with or without foraminal stenosis.

The obturator guiding technique in percutaneous endoscopic lumbar discectomy

In conventional percutaneous disc surgery, introducing instruments into disc space starts by inserting a guide needle into the triangular working zone. However, landing the guide needle tip on the annular window is a challenging step in endoscopic discectomy. Surgeons tend to repeat the needling procedure to reach an optimal position on the annular target. Obturator guiding technique is a modification of standard endoscopic lumbar discectomy, in which, obturator is used to access triangular working zone instead of a guide needle. Obturator guiding technique provides more vivid feedback and easy manipulation. This technique decreases the steps of inserting instruments and takes safer route from the peritoneum.

Endoscopic resection of intrathoracic tumors: experience with and long-term results for 26 patients

Object

Thoracoscopy may be used in place of thoracotomy to resect intrathoracic neoplasms such as paraspinal neurogenic tumors. Although these tumors are rare, they account for the majority of tumors arising in the posterior mediastinum.

Methods

A database was maintained of all patients undergoing thoracoscopic surgery for tumors. The authors analyzed the presenting symptoms, pathological diagnoses, and outcomes of 26 patients (7 males and 19 females, mean age 37.2 years) who were treated for intrathoracic tumors via thoracoscopy between January 1995 and May 2009. Fourteen patients were diagnosed incidentally (54%). Five patients (19%) presented with dyspnea or shortness of breath, 4 (15%) with pain, 1 (4%) with pneumonia, 1 (4%) with hoarseness, and 1 (4%) with Horner syndrome.

Results

Pathology demonstrated schwannomas in 20 patients (77%). Other diagnoses included ganglioneurofibroma, paraganglioma, epithelioid angiosarcoma, benign hemangioma, benign granular cell tumor, and infectious granuloma. One patient required conversion to open thoracotomy due to pleural scarring to the tumor. One underwent initial laminectomy due to intraspinal extension of the tumor. Gross-total resection was obtained in 25 cases (96%). The remaining patient underwent biopsy followed by radiation therapy. The mean surgical time was 2.5 hours, and the mean blood loss was 243 ml. The mean duration of chest tube insertion was 1.3 days, and the mean length of hospital stay was 3.0 days. Cases that were treated in the second half of the cohort were more often diagnosed incidentally, performed in less time, and had less blood loss than those in the first half of the cohort. There was 1 case of permanent treatment-related morbidity (mild Horner syndrome). All previously employed patients were able to return to work (mean clinical follow-up 43 months). There were no recurrences (mean imaging follow-up 54 months).

Conclusions

Endoscopic transthoracic approaches can reduce approach-related soft-tissue morbidity and facilitate recovery by preserving the normal tissues of the chest wall, by avoiding rib retraction and muscle transection, and by reducing postoperative pain. This less invasive approach thus shortens hospital stay and recovery time.

[Endoscopic nucleotomy - Renaissance of a procedure. State of the art]

Since the introduction of percutaneous nucleotomy two lines of development have been followed. On the one hand the blindly driven intradiscal tissue active methods and on the other hand endoscopically controlled minimally invasive tissue methods. The first group diminished the acceptance of intradiscal applications due to few reproducible results. Due to high resolution endoscopy with coaxial endoscopes, the second group developed into effective minimally invasive forms of surgery with well defined indications and reproducible results and challenges conventional techniques in the range of intradiscal and extradiscal indications.

Endoscopic lumbar discectomy: Experience of first 100 cases

BACKGROUND

Various modalities of treatment from standard discectomy, microdiscectomy, percutaneous discectomy, and transforaminal endoscopic discectomy have been in use for lumbar intervertebral disc prolapse. The access to spine is kept to a minimum without stripping paraspinal muscles minimizing muscle damage by posterior interlaminar endoscopic approach. The aim of this study was to evaluate technical problems, complications, and overall initial results of microendoscopic discectomy.

MATERIALS AND METHODS

First 100 consecutive cases aged 19-65 years operated by microendoscopic dissectomy between August 2002 - December 2005 are reported. All patients with single nerve root lesions including sequestrated or migrated and selected central disc at L4-5 and L5-S1 were included. The patients with bilateral radiculopathy were excluded. All patients had preoperative MRI and first 11 patients had postoperative MRI to check the adequacy of decompression. Diagnostic selective nerve root blocks were done in selective cases to isolate the single root lesion when MRI was inconclusive (n=7). All patients were operated by a single surgeon with the Metrx system (Medtronics). 97 were operated by 18-mm ports, and only three patients were operated by 16-mm ports. Postoperatively, all patients were mobilized as soon as the pain subsided and discharged within 24-48 h postsurgery. Patients were evaluated for technical problems, complications, and overall results by modified Macnab criteria. Patients were followed up at 2, 6, and 12 weeks.

RESULTS

The mean follow up was 12 months (range 3 months - 4 years). Open conversion was required in one patient with suspected root damage. Peroperatively single facet removal was done in 5 initial cases. Minor dural punctures occurred in seven cases and root damage in one case. The average surgical time was 70 min (range 25-210 min). Average blood loss was 20-30 ml. Technical difficulties encountered in initial 25 cases were insertion of guide pin, image orientation, peroperative dissection and bleeding problems, and reaching wrong levels suggestive of a definitive learning curve. Postoperative MRI (n=11) showed complete decompression. Overall 91% of patients had good-to-excellent results, with four patients having recurrence of whom three were reoperated. Four patients had postoperative discitis. One of the patients required fusion for discitis and rest were managed conservatively. One patient had root damage to L5 root that had paresthesia in L5 region even on 4 years of follow-up.

CONCLUSION

Microendoscopic discectomy is minimally invasive procedure for discectomy with early encouraging results. Once definite learning curve was over and expertise is acquired, the results of this procedure are acceptable safe and effective.

The accuracy of MRI in the detection of lumbar disc containment

BACKGROUND

MRI has proven to be an extremely valuable tool in the assessment of normal and pathological spinal anatomy. Accordingly, it is commonly used to assess containment of discal material by the outer fibers of the anulus fibrosus and posterior longitudinal ligaments. Determination of such containment is important to determine candidacy for intradiscal techniques and has prognostic significance. The accuracy of MRI in detecting containment has been insufficiently documented.

METHODS

The MRI's of fifty consecutive patients undergoing open lumbar microdiscectomy were prospectively evaluated for disc containment by a neuroradiologist and senior spinal surgeon using criteria available in the literature and the classification of Macnab/McCulloch. An independent surgeon then performed the surgery and documented the actual containment status using the same methods. Statistical evaluation of accuracy was undertaken.

RESULTS

MRI was found to be 72% sensitive, 68% specific, and 70% accurate in detecting containment status of lumbar herniated discs.

CONCLUSION

MRI may be inaccurate in assessing containment status of lumbar disc herniations in 30% of cases. Given the importance of containment for patient selection for indirect discectomy techniques and intradiscal therapies, coupled with prognostic significance; other methods to assess containment should be employed to assess containment when such alternative interventions are being considered.

Prospective evaluation of transabdominal percutaneous lumbar discectomy for L5–S1 disc herniation: initial clinical experience

Object

Anterior approaches to the lumbosacral spine have become an increasingly common procedure in spine surgery, but transabdominal percutaneous lumbar discectomy (TPLD) performed anteriorly under fluoroscopic guidance is challenging. In this study the authors describe the TPLD and evaluate its safety and early clinical results in the management of L5–S1 disc herniation.

Methods

Between January 2005 and June 2007, 30 consecutive patients with L5–S1 disc herniation were treated with L5–S1 TPLD. All procedures were performed with the patient in a state of local anesthesia. After bowel preparation, the hypogastrium was compressed to move the intestinal canal away from the puncture site. The TPLD was then performed with fluoroscopic guidance to remove herniated disc material. Patients were evaluated prospectively using the visual analog scale (VAS) and the Oswestry Disability Index (ODI) during ≤ 30 months of follow-up.

Results

The mean hospital stay was 6.7 days. Scores on the VAS for leg pain (preoperative mean score 7.10, postoperative mean score 0.93) and the ODI (preoperative mean index 62.03, postoperative mean index 10.33) were statistically significantly (p = 0.00) improved at the last follow-up examination compared with preoperative scores. All members of the study group showed favorable results. On the day after the procedure pancreatitis developed in 1 patient but was cured by fasting and intravenous nutrition with antibiotics for 7 days. No other complications occurred during the follow-up.

Conclusions

Transabdominal percutaneous lumbar discectomy is a safe, effective, and minimally invasive procedure for the treatment of disc herniations at the L5–S1 level.

Intervertebral disc: anatomy-physiology-pathophysiology-treatment

This review article describes anatomy, physiology, pathophysiology and treatment of intervertebral disc. The intervertebral discs lie between the vertebral bodies, linking them together. The components of the disc are nucleus pulposus, annulus fibrosus and cartilagenous end-plates. The blood supply to the disc is only to the cartilagenous end-plates. The nerve supply is basically through the sinovertebral nerve. Biochemically, the important constituents of the disc are collagen fibers, elastin fibers and aggrecan. As the disc ages, degeneration occurs, osmotic pressure is lost in the nucleus, dehydration occurs, and the disc loses its height. During these changes, nociceptive nuclear material tracks and leaks through the outer rim of the annulus. This is the main source of discogenic pain. While this is occurring, the degenerative disc, having lost its height, effects the structures close by, such as ligamentum flavum, facet joints, and the shape of the neural foramina. This is the main cause of spinal stenosis and radicular pain due to the disc degeneration in the aged populations. Diagnosis is done by a strict protocol and treatment options are described in this review. The rationale for new therapies are to substitute the biochemical constituents, or augment nucleus pulposus or regenerate cartilaginous end-plate or finally artificial disc implantation..

STANDARD OPEN MICRODISCECTOMY VERSUS MINIMAL ACCESS TROCAR MICRODISCECTOMY

OBJECTIVE

Minimal access surgery as a less invasive alternative to standard macro- and microsurgical approaches is becoming increasingly popular in the management of traumatic and degenerative spine diseases. However, data is lacking if minimal access spine surgery is indeed beneficial. This prospective randomized study was conducted to compare efficiency, safety, and outcome of standard open microsurgical discectomy (SOMD) for lumbar disc herniation with microsurgical discectomy using an 11.5 mm trocar system for minimal access to the spine.

METHODS

Sixty patients were randomized to two groups of 30 patients each. Group 1 was treated by SOMD, and Group 2 was treated by minimal access microsurgical discectomy (MAMD). Perioperative parameters and pre- and postoperative clinical findings including sensory or motor deficits and pain according to the visual analog scale, Oswestry Disability Index scores, and Short Form-36 results were assessed. All patients were followed for at least 6 months postoperatively (mean, 16 mo).

RESULTS

Preoperatively, no statistically significant intergroup differences could be detected proving the comparability of both groups. Postoperatively, significant improvement of neurological symptoms and pain as measured by the visual analog scale, Oswestry Disability Index, and Short Form-36 scores could be achieved in both groups. In regard to operative time, intraoperative blood loss, and complication rate, slightly better results were observed in the MAMD group.

CONCLUSION

SOMD and MAMD allow achievement of significant improvement of pain and neurological deficits in patients with lumbar disc herniations. Differences in operative time, blood loss, and complication rates were statistically not significant in MAMD compared with SOMD, indicating that, at least in lumbar disc surgery, minimal access trocar techniques are a viable alternative to standard spinal approaches.

Transabdominal Percutaneous L5–S1 Lumbar Discectomy: Interventional Technique, Early Results, and Complications

PURPOSE

Anterior approaches to the lumbosacral spine have become increasingly common in spine surgery, but transabdominal percutaneous lumbar discectomy (TPLD) is challenging. This study describes TPLD and evaluates safety and early clinical results in the management of L5-S1 disc herniation.

MATERIALS AND METHODS

Between October 2001 and October 2006, 58 consecutive patients with L5-S1 disc herniations were treated with TPLD of the L5-S1 discs, and nine of the patients with L4-L5 disc herniations were treated with posterolateral percutaneous lumbar discectomy (PPLD) soon after TPLD. The patients were divided into two groups according the operator who performed the procedures. The patients were evaluated with a visual analog scale (VAS) and the Oswestry Disability Index (ODI) at 5 years of follow-up. Logistic regression was used to analyze significant risk factors for complications.

RESULTS

Mean hospital stay was 6.38 days +/- 8.48. VAS scores for leg pain and ODI scores showed significant improvement at last follow-up. All patients showed favorable results with no recurrent herniations. Major and minor complications occurred in eight (13.79%) and seven cases (12.06%), respectively, during and after the procedure. Major complications occurred in seven patients treated by operator A and one treated by operator B, a significant difference between operators (P = .044). Multivariate analysis revealed that only bowel preparation remained a significant predictor of complications (P = .040).

CONCLUSION

TPLD was a safe and effective procedure for the removal of disc herniations at the L5-S1 level when total bowel preparation was performed.

Minimally invasive techniques for the management of lumbar disc herniation

Traditionally, minimally invasive techniques for surgical discectomy have been defined as smaller incisions, tubular retractors, microscopically assisted tissue dissection, and conservative removal of only extruded or sequestered nucleus pulposus with preservation of the annulus. The first truly minimally invasive technique was chymopapain dissolution of the nucleus pulposus. Other percutaneous techniques followed; however, none were as efficacious as the gold standard of microlumbar discectomy until endoscopically visualized methods evolved to allow visualized mechanical discectomy through the foramen. In experienced hands, such a technique is as effective as microlumbar discectomy and results in less surgical morbidity for herniations that are appropriate for this minimally invasive endoscopic surgical portal that completely avoids traumatizing the normal anatomy of the dorsal musculature and ligamentous structures.

Minimally invasive spine surgery: a historical perspective

Minimally invasive spine surgery has gained considerable momentum and increased acceptance among spine surgeons throughout the years. An understanding and awareness of the development of minimally invasive spine surgery and its role in the operative treatment of various spine conditions is imperative. This article provides a succinct historical perspective of the development of spine surgery from the more traditional, open procedures to the use of more "minimal access" or minimally invasive spine surgery procedures.

Percutaneous laser disc decompression for lumbar disc hernia: indications based on Lasegue's Sign

OBJECTIVE

The present study was conducted to establish reasonable indications of patient neurological manifestations for use of percutaneous laser disc decompression (PLDD).

BACKGROUND DATA

PLDD is a less invasive surgical procedure for lumbar disc hernia, whose indications have been described on the basis of radiographical findings.

METHODS

Sixty-five consecutive patients (45 men and 20 women) with lumbar disc hernia were treated with PLDD by applying a diode laser (wavelength 805 nm). A total of 450-1,205 joules (average, 805.5 joules) were delivered per disc. All patients suffered from radicular pain. They were divided based on the presence of Lasegue's sign. The post-procedure results at 1 week and 1 year were compared between the groups.

RESULTS

PLDD was effective for patients with Lasegue's sign (80.0%), but ineffective for those without the sign.

CONCLUSION

The present study suggests that Lasegue's sign in patients is an indication of PLDD for lumbar disc hernia.

Sciatica: Treatment with Intradiscal and Intraforaminal Injections of Steroid and Oxygen-Ozone versus Steroid Only

PURPOSE

To prospectively compare the clinical effectiveness of intraforaminal and intradiscal injections of a mixture of a steroid, a local anesthetic, and oxygen-ozone (O(2)-O(3)) (chemodiscolysis) versus intraforaminal and intradiscal injections of a steroid and an anesthetic in the management of radicular pain related to acute lumbar disk herniation.

MATERIALS AND METHODS

Medical Ethical Committee approval and informed consent were obtained. One hundred fifty-nine patients (86 men, 73 women; age range, 18-71 years) were included and were randomly assigned to two groups. Seventy-seven patients (group A) underwent intradiscal and intraforaminal injections of a steroid and an anesthetic, and 82 patients (group B) underwent the same treatment with the addition of an O(2)-O(3) mixture. Procedures were performed with computed tomographic guidance. An Oswestry Low Back Pain Disability Questionnaire was administered before treatment and at intervals, the last at 6-month follow-up. Patients and clinicians were blinded as to which treatment was performed. Results were compared with the chi(2) test.

RESULTS

After 6 months, treatment was successful in 36 (47%) patients in group A and in 61 (74%) patients in group B. The difference was significant (P < .01).

CONCLUSION

Intraforaminal and intradiscal injections of a steroid, an anesthetic, and O(2)-O(3) are more effective at 6 months than injections of only a steroid and an anesthetic in the same sites.

Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations: extraforaminal targeted fragmentectomy technique using working channel endoscope

STUDY DESIGN

A retrospective analysis of 41 patients operated for excision of soft lumbar extraforaminal disc herniation (EFDH) by percutaneous endoscopic extraforaminal approach under local anesthesia by a new technique.

OBJECTIVES

To describe a new and safer percutaneous endoscopic technique for the removal of soft EFDH and report the results on the basis of a new objective criterion modified from Oswestry Disability Index (ODI).

SUMMARY OF BACKGROUND DATA

EFDHs usually occur in older patients and present with atypical symptoms. Their diagnosis and treatment are still controversial, with various authors describing open midline or paraspinal approaches using the microscope with varying amounts of success. Percutaneous endoscopic techniques have traditionally been considered unsuitable for these herniations.

METHODS

Forty-one patients with a soft EFDH were subjected to percutaneous endoscopic discectomy with the new technique. In our technique, the skin entry point is medial and the angle of approach steeper as compared with the earlier described endoscopic techniques. This might help in avoiding exiting root injury and increasing the efficacy of the procedure. The results were analyzed on the basis of percentage change in ODI as compared with preoperative values.

RESULTS

Mean follow-up was 34.1 month. Mean VAS score for radicular pain improved from 8.6 to 1.9, and mean ODI improved from 66.3 to 11.5. Overall, 92% of patients experienced satisfactory outcome. Two patients had poor outcome due to the need for subsequent open surgery.

CONCLUSION

Percutaneous endoscopic discectomy using the "extraforaminal targeted fragmentectomy" technique is an effective and safe procedure for the select group of patients with a soft EFDH.