Minimally invasive direct lateral, retroperitoneal transforaminal approach for large L1-2 disc herniations with intraoperative CT navigational assistance: technical note and report of 3 cases

Biplane Ultrasound Versus Fluoroscopy for Guidance of Percutaneous Lumbar Intervertebral Foramen Insertion : A Randomized Controlled Clinical Trial

STUDY DESIGN

A randomized controlled study.

OBJECTIVE

The aim of this study was to develop a clinical process of biplane ultrasound (US) guided percutaneous lumbar intervertebral foramen insertion (PLIFI) and to verify that biplane US can improve accuracy and reduce number of fluoroscopies.

SUMMARY OF BACKGROUND DATA

PLIFI is crucial for drug injection and establishment of transforaminal surgical channel. The traditional fluoroscopy guidance involves radiation and requires practical experience.

METHODS

Patients with lumbar disc herniation scheduled for an epidural steroid injection or percutaneous endoscopic lumbar discectomy were randomized to the biplane US and fluoroscopy groups. The biplane US group was divided into training and proficiency stages using a learning curve fitted by cumulative sum analysis. All punctures were performed by a junior spine surgeon and a junior sonographer. The primary outcomes were the first success rate, number of punctures and radiographs, puncture time, and confidence score.

RESULTS

Sixty-eight patients (age 51.4±15.4 yr, 36 males) were divided into the biplane US and fluoroscopy groups. According to the 12th turning point of a learning curve, the biplane US group was divided into training and proficiency periods. The first-attempt success rate was achieved in 61% using biplane US at the proficiency period, compared with 32% using fluoroscopy [ P =0.033, RR: 1.634]. The number of radiographies [1 (IQR 1-2) vs . 2 (IQR 2-3), P =0.001] was significantly smaller, and puncture time [120 s (IQR 57-210) vs. 197 s (IQR 159-341), P =0.001] was significantly faster using biplane US at the proficiency period.

CONCLUSION

Biplane US provides an accurate, safe, and convenient approach for PLIFI. With further clinical practice, biplane US would be conducive to rapid skill acquisition for novices and has the potential to achieve a completely radiation-free puncture process.

Percutaneous Endoscopic Discectomy Via a Transforaminal Approach for L5/S1 Far-Lateral Disc Herniation Assisted by Intraoperative Computed Tomography

OBJECTIVE

To examine the clinical outcomes of a percutaneous lumbar transforaminal endoscopic discectomy (PTED) with intraoperative computed tomography (iCT) navigation for the treatment of L5-S1 far-lateral lumbar disc herniation (LDH).

METHODS

A total of 30 patients with L5-S1 far-lateral LDH who underwent PTED with iCT navigation from September 2016 to October 2020 were enrolled in this study. Outcomes were assessed using the visual analog scale pain score, the Oswestry Disability Index, the Japanese Orthopedic Association score, the EQ-5D-5 L and the modified Macnab criteria. Preoperative and postoperative complications were recorded.

RESULTS

The mean visual analog scale score for leg pain improved from 8.1 at baseline to 2.3, 0.9, 0.7 and 0.9 at 1 day, 1 week, 6 months, and 12 months postoperatively, respectively (P < 0.01). The mean Oswestry Disability Index improved from 78.1% at baseline to 45.5%, 21.9%, 12.6%, and 11.7% at 1 week, 1 month, 6 months, and 12 months postoperatively, respectively (P < 0.01); and the mean Japanese Orthopedic Association score improved from 8.6 at baseline to 14.2, 20.2, 24.4, and 25.6 at 1 day, 1 week, 6 months, and 12 months postoperatively, respectively (P < 0.01). At 12 months postoperatively, the EQ-5D-5 L value significantly increased, from -0.061 ± 0.138 to 0.903 ± 0.064. The rate of a good or excellent modified Macnab result was 93% (26/28) at 12 months postoperatively. In the present study, combined L5-S1 foraminal stenosis tended to lead poor outcomes, which required more postsurgical treatments.

CONCLUSIONS

With iCT navigation, PTED is a feasible and effective minimally invasive surgery for L5-S1 far-lateral LDH.

Potential Application of MR-MR-US Fusion Imaging Navigation with Needle Tail Intelligent Positioning in Guiding Puncture in Percutaneous Transforaminal Endoscopic Discectomy

This study sought to investigate the feasibility of using magnetic resonance-magnetic resonance-ultrasound (MR-MR-US) fusion imaging navigation (FIN) with needle tail intelligent positioning (NTIP) to guide puncture in percutaneous transforaminal endoscopic discectomy (PTED). First, in a pig experiment, we found that puncture errors in lumbar intervertebral foramen (LIF) puncture using magnetic resonance-magnetic resonance-ultrasound (MR-MR-US) FIN with NTIP for experienced and novice operators were 2.00 ± 1.00 and 2.57 ± 0.98 mm, respectively (p = 0.231), suggesting this technique was minimally dependent on experience. Then, two experienced surgeons agreed (inter-observer agreement к=0.801) that the quality of MR-MR fusion images was good or sufficient. Finally, we performed PTED in eight patients using MR-MR-US FIN with NTIP, and no significant complications were reported during LIF puncture. Overall, MR-MR-US FIN with NTIP may be a potential application for guiding puncture in PTED, but more clinical studies with a larger sample size are required to further evaluate the advantages of MR-MR-US FIN with NTIP.

Surgical Outcomes for Upper Lumbar Disc Herniations: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To conduct a literature review on outcomes of discectomy for upper lumbar disc herniations (ULDH), estimate pooled rates of satisfactory outcomes, compare open laminectomy/microdiscectomy (OLM) versus minimally invasive surgical (MIS) techniques, and compare results of disc herniations at L1-3 versus L3-4.

METHODS

A systematic review of articles reporting outcomes of nonfusion surgical treatment of L1-2, L2-3, and/or L3-4 disc herniations was performed. The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of 20 articles were included in the quantitative meta-analysis. Pooled proportion of satisfactory outcome (95% CI) was 0.77 (0.70, 0.83) for MIS and 0.82 (0.78, 0.84) for OLM. There was no significant improvement with MIS techniques compared with standard OLM, odds ratio (OR) = 0.86, 95% CI (0.42, 1.74), P = .66. Separating results by levels revealed a trend of higher satisfaction with L3-4 versus L1-3 with OLM surgery, OR = 0.46, 95% CI (0.19, 1.12), P = .08.

CONCLUSION

Our analysis reveals that discectomy for ULDH has an overall success rate of approximately 80% and has not improved with MIS. Discectomy for herniations at L3-4 trends toward better outcomes compared with L1-2 and L2-3, but was not significant.

Intraoperative Computed Tomography-Based Navigation with Augmented Reality for Lateral Approaches to the Spine

Background. Lateral approaches to the spine have gained increased popularity due to enabling minimally invasive access to the spine, less blood loss, decreased operative time, and less postoperative pain. The objective of the study was to analyze the use of intraoperative computed tomography with navigation and the implementation of augmented reality in facilitating a lateral approach to the spine. Methods. We prospectively analyzed all patients who underwent surgery with a lateral approach to the spine from September 2016 to January 2021 using intraoperative CT applying a 32-slice movable CT scanner, which was used for automatic navigation registration. Sixteen patients, with a median age of 64.3 years, were operated on using a lateral approach to the thoracic and lumbar spine and using intraoperative CT with navigation. Indications included a herniated disc (six patients), tumors (seven), instability following the fracture of the thoracic or lumbar vertebra (two), and spondylodiscitis (one). Results. Automatic registration, applying intraoperative CT, resulted in high accuracy (target registration error: 0.84 ± 0.10 mm). The effective radiation dose of the registration CT scans was 6.16 ± 3.91 mSv. In seven patients, a control iCT scan was performed for resection and implant control, with an ED of 4.51 ± 2.48 mSv. Augmented reality (AR) was used to support surgery in 11 cases, by visualizing the tumor outline, pedicle screws, herniated discs, and surrounding structures. Of the 16 patients, corpectomy was performed in six patients with the implantation of an expandable cage, and one patient underwent discectomy using the XLIF technique. One patient experienced perioperative complications. One patient died in the early postoperative course due to severe cardiorespiratory failure. Ten patients had improved and five had unchanged neurological status at the 3-month follow up. Conclusions. Intraoperative computed tomography with navigation facilitates the application of lateral approaches to the spine for a variety of indications, including fusion procedures, tumor resection, and herniated disc surgery.

Navigation-assisted full-endoscopic spine surgery: a technical note

Background

Full-endoscopic spine surgery (FESS) necessitates the use of X-ray fluoroscopy for intraoperative guidance and orientation. However, the two-dimensional X-ray fluoroscopic images do not provide real-time guidance. The authors developed a new real-time three-dimensional (3D) navigation technique for FESS that entails the use of intraoperative cone beam computed tomography (CBCT) in a hybrid operating room (OR).

Methods

A total of 23 patients undergoing FESS using real-time 3D navigation system were enrolled. Preoperative and intraoperative CBCT data were registered in the navigation system. The 3D navigation was used to intraoperatively determine the trajectory and obtain position information. The feasibility and usefulness of the navigation system were retrospectively analyzed.

Results

Twenty patients had lumbar spine disease, whereas three patients had cervical spine disease. The 3D navigation was successfully used for intraoperative guidance and provided accurate information in all patients. X-ray fluoroscopy was not required in any of the patients. No complications associated with the use of 3D navigation system were encountered.

Conclusions

The use of real-time 3D navigation system in the hybrid OR was found to be safe and effective in providing intraoperative guidance for FESS.

Percutaneous Endoscopic Transforaminal Discectomy versus Conventional Open Lumbar Discectomy for Upper Lumbar Disc Herniation: A Comparative Cohort Study

Background

Percutaneous endoscopic transforaminal discectomy (PETD) is regarded as a viable alternative option for upper lumbar disc herniation (LDH). However, few studies have evaluated PETD for upper LDH, and no study has compared the advantages of endoscopic procedures versus conventional surgery. The present study was aimed at comparing the surgical outcome and safety of PETD versus conventional open lumbar discectomy in the treatment of upper LDH.

Methods

Data from 42 patients treated for upper LDH from July 2015 to July 2018 were retrospectively analyzed, including 21 patients treated with PETD (PETD group) and 21 patients treated with conventional posterior lumbar discectomy (open group). The two groups were compared regarding demographic information, physical examination, radiological evaluations, and perioperative indicators. The clinical outcomes were assessed in accordance with the Oswestry Disability Index (ODI), visual analog scale (VAS), and modified MacNab criteria.

Results

The postoperative ODI and VAS scores were significantly improved in both groups compared with the preoperative baseline values (P < 0.001), and the satisfactory rate was 90.5% in both groups in accordance with the modified MacNab criteria. There were no significant differences between the two groups in the clinical outcomes and complication rate (P < 0.001), and the satisfactory rate was 90.5% in both groups in accordance with the modified MacNab criteria. There were no significant differences between the two groups in the clinical outcomes and complication rate (P < 0.001), and the satisfactory rate was 90.5% in both groups in accordance with the modified MacNab criteria. There were no significant differences between the two groups in the clinical outcomes and complication rate (

Conclusions

PETD has a similar outcome to the conventional surgical method for the treatment of upper LDH but provides the typical advantages of minimally invasive procedures such as reduced iatrogenic injury, minimal activity restrictions, and accelerated ambulation recovery postoperatively.

Review of Risks and Complications of Extreme Lateral Interbody Fusion (XLIF)

Background

Extreme lateral interbody fusions (XLIF) and Minimally Invasive (MIS) XLIF were developed to limit the vascular injuries associated with anterior lumbar interbody fusion (ALIF), and minimize the muscular/ soft tissue trauma attributed to transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), and posterolateral lumbar fusion (PLF).

Methods

Nevertheless, XLIF/MIS XLIF pose significant additional risks and complications that include; multiple nerve injuries (e.g. lumbar plexus, ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, and subcostals (to the anterior abdominal muscles: abdominal oblique), and sympathectomy), major vascular injuries, bowel perforations/postoperative ileus, seromas, pseudarthrosis, subsidence, and reoperations.

Results

The risks of neural injury with XLIF/MIS XLIF (up to 30-40%) are substantially higher than for TLIF, PLIF, PLF, and ALIF. These neural injuries included: lumbar plexus injuries (13.28%); new sensory deficits (0-75% (21.7%-40%); permanent 62.5%); motor deficits (0.7-33.6%-40%); iliopsoas weakness (9%-31%: permanent 5%), anterior thigh/groin pain (12.5-34%), and sympathectomy (4%-12%). Additional non-neurological complications included; subsidence (10.3%-13.8%), major vascular injuries (0.4%), bowel perforations, recurrent seroma, malpositioning of the XLIF cages, a 45% risk of cage-overhang, pseudarthrosis (7.5%), and failure to adequately decompress stenosis. In one study, reviewing 20 publications and involving 1080 XLIF patients, the authors observed "Most (XLIF) studies are limited by study design, sample size, and potential conflicts of interest."

Conclusion

Many new neurological deficits and other adverse events/complications are attributed to MIS XLIF/ XLIF. Shouldn't these significant risk factors be carefully taken into consideration before choosing to perform MIS XLIF/XLIF?

Comparison of Transforaminal Percutaneous Endoscopic Lumbar Discectomy with and without Foraminoplasty for Lumbar Disc Herniation: A 2-Year Follow-Up

BACKGROUND

Both transforaminal percutaneous endoscopic lumbar discectomy with foraminoplasty (TF PELF) and transforaminal percutaneous endoscopic lumbar discectomy without foraminoplasty (TF PELD) were developed for lumbar disc herniation (LDH) patients. However, the safety and effectiveness between the TF PELF and TF PELD have not been investigated.

METHODS

Of the included 140 LDH patients, 62 patients received TF PELF (PELF group) and 78 patients received TF PELD (PELD group). The operation time, the duration of staying at the hospital, and complication incidences were recorded. All patients were followed up for 2 years, where low back and leg visual analogue scale (VAS) pain ratings and Oswestry Disability Index (ODI) were compared between the 2 groups before and after surgery. Modified Macnab criterion was estimated for all patients at postoperative 2 years.

RESULTS

There were no significant difference of the operation time, number of days staying at the hospital, and the incidence of complications between the 2 groups (P > 0.05). Two cases in the PELF group and 1 case in the PELD group received a second surgery due to unrelieved symptoms postoperatively. Low back and leg VAS and ODI scores decreased in both groups after operation (P < 0.01), respectively, but were not significant between the 2 groups over time (P > 0.05). Six patients in the PELF group and 3 patients in the PELD group did not continue the follow-up; thus, only 131 patients completed Macnab evaluation. The satisfactory rate was reported as 80.4% in the PELF group and 90.7% in the PELD group (P > 0.05).

CONCLUSIONS

This study suggested that the safety and effectiveness of TF PELF are comparable to TF PELD for LDH patients.