Minimally Invasive Muscle Sparing Transmuscular Microdiscectomy : Technique and Comparison with Conventional Subperiosteal Microdiscectomy during the Early Postoperative Period

[Effectiveness of simultaneous and staged minimally invasive dorsal decompression-stabilization procedures in patients with lumbar spine degenerative diseases]

Minimally invasive procedures reduce the trauma of spine surgery. However, they are associated with high complexity of manipulations, long learning curve, need for expensive equipment for intraoperative navigation and significant irradiation. Various options for surgical approaches are being developed to reduce irradiation of medical staff and patients, surgery time and the number of drugs administered for general anesthesia. Simultaneous surgical interventions (SiSI) is one of these options.

OBJECTIVE

To compare the effectiveness of simultaneous and staged minimally invasive dorsal decompression-stabilization procedures in patients with lumbar spine degenerative diseases.

MATERIAL AND METHODS

A prospective study included 67 patients (41 men and 26 women) aged 48 (34; 56) years who underwent a single-level minimally invasive spinal root decompression and transforaminal interbody fusion via Wiltse posterior-lateral approach. Two study groups were distinguished: group I (simultaneous surgical interventions, SiSI) (n=29), in which guide spokes and transpedicular screws were installed simultaneously by two surgeons within one x-ray session from two sides; group II (staged surgical interventions, StSI) (n=38), in which staged transpedicular stabilization was performed (decompression side followed by contralateral side). Mean follow-up was 14 months in group I and 20 months in group II. We considered intraoperative fluoroscopy and irradiation dose, duration of surgery and anesthesia with calculation of doses of opioid drugs, blood loss, time of activation, hospital-stay and perioperative morbidity. Clinical outcomes were studied in long-term postoperative period.

RESULTS

Simultaneous approach ensured less time of intraoperative fluoroscopy (p=0.029) and irradiation dose (p=0.035), duration of surgery (p=0.01) and anesthesia (p=0.02), amount of opioid drugs during anesthesia (p=0.017). Blood loss, duration of activation and hospitals-stay were similar in both groups (p=0.35, p=0.12 and p=0.57, respectively). There was comparable improvement in VAS score of pain in the lumbar spine and lower extremities in both groups (p=0.63 and p=0.31, respectively). According to SF-36 questionnaire, there was no between-group difference in physical and psychological components (p=0.44 and p=0.72, respectively). There was significantly greater number of adverse effects of anesthesia in the StSI group (26.2% vs. 6.8%, p=0.003). At the same time, the number of surgical postoperative complications was similar in both groups (3.4% vs. 5.3%, p=0.62).

CONCLUSION

Simultaneous minimally invasive dorsal decompression-stabilization procedures have some significant advantages over staged approach regarding intraoperative parameters and adverse effects of anesthesia in patients with lumbar spine degenerative diseases. Nevertheless, there were similar clinical data and small incidence of surgical perioperative complications.

Does Percutaneous Lumbosacral Pedicle Screw Instrumentation Prevent Long-Term Adjacent Segment Disease after Lumbar Fusion?

STUDY DESIGN

Retrospective cohort study.

PURPOSE

To assess long-term clinical outcomes of adjacent segment disease (ASD) in patients who underwent lumbar interbody fusion with percutaneous pedicle screw (PS) instrumentation.

OVERVIEW OF LITERATURE

ASD is a well-known sequela of spinal fusion, and is reported to occur at a rate of 2%-3% per year. There is debate as to whether ASD is a result of the instrumentation and fusion method or is the natural history of the patient's disease. Minimally invasive percutaneous PS augmentation of lumbar interbody fusion aims to prevent the disruption of posterior soft tissue stabilizers.

METHODS

From 2004-2014, 419 consecutive patients underwent anterior, lateral, or minimally invasive transforaminal lumbar interbody fusion with percutaneous PS placement at a single institution. The mean follow-up was 4.5 years. The primary outcome measure was reoperation due to ASD. Patients were divided into two cohorts: those who underwent revision surgery secondary to ASD and those who did not require further surgery. Radiographic parameters were performed using postoperative radiographs. Patients with a pelvic incidence-lumbar lordosis (PI-LL) mismatch >10° were noted.

RESULTS

Revision proportion secondary to ASD was 4.77% (n=20). Mean time to revision surgery was 2.5 years. Revision rate secondary to ASD was 1.1% per year. Patients who developed ASD were younger than those who did not (50.5 vs. 56.9 years, p=0.015). There was no difference in number of levels fused between cohorts. Revision proportion secondary to ASD was similar between approaches (anterior, lateral, minimally invasive). There was no significant difference in PI-LL mismatch between those who underwent revision for ASD and those who did not (22.2% vs. 18.8%, p=0.758).

CONCLUSIONS

ASD rates in patients who underwent percutaneous PS placement were lower than those previously published after open PS placement, possibly related to greater preservation of the posterior stabilizing elements of the lumbar spine.

Radiologic Efficacy and Patient Satisfaction after Minimally Invasive Unilateral Laminotomy and Bilateral Decompression in Patients with Lumbar Spinal Stenosis: A Retrospective Analysis

BACKGROUND AND STUDY AIMS

 Lumbar spinal stenosis (LSS) is the most common spinal disease in older adults. Although surgical modalities are recommended in patients who are unresponsive to conservative treatment, the most appropriate minimally invasive surgical procedure for patients with LSS remains controversial. Moreover, few previous studies have focused on patient-centered outcomes with radiologic correlation. In the present study, we aimed to investigate radiologic efficacy and patient satisfaction following bilateral decompression via unilateral laminotomy.

MATERIALS AND METHODS

 We performed a retrospective analysis of radiologic efficacy and patient satisfaction in a series of surgical patients treated at our institution. We classified patients into two groups based on the primary pathology (i.e., central or lateral recess stenosis). Medical records were analyzed retrospectively for radiologic outcomes and clinical parameters including pain and changes in quality of life. Data related to outcomes were collected at 2 weeks, 3 months, and 12 months after surgery in the outpatient clinic.

RESULTS

 Among the 122 patients enrolled in this study, 51 had central spinal stenosis; 71 had lateral recess stenosis. Radiologically, we observed significant improvements in the anteroposterior diameter and cross-sectional area of the dural sac (central stenosis) and the lateral width of the central canal and depth of the lateral recess (lateral recess stenosis). Two weeks and 12 months after the surgical procedure, we observed significant improvements in the extent of symptoms, patient satisfaction, and quality of life (including physical function).

CONCLUSION

 Our findings suggest that bilateral decompression via a unilateral approach shows improved radiologic outcomes, varying based on the type of stenosis. Furthermore, patient satisfaction significantly improved regardless of the type of disease.

Comparing the Incidence of Index Level Fusion Following Minimally Invasive Versus Open Lumbar Microdiscectomy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine the incidence of index level fusion following open or minimally invasive lumbar microdiscectomy.

METHODS

We conducted a retrospective review of 174 patients with a symptomatic single-level lumbar herniated nucleus pulposus who underwent microdiscectomy via a mini-open approach (MIS; 39) or through a minimally invasive dilator tube (135). Outcomes of interest included revision microdiscectomy and the ultimate need for index level fusion. Continuous variables were analyzed with independent sample t test, and χ² analysis was used for categorical data. A multivariate regression analysis was performed to identify predictive factors for patients that required index level fusion after lumbar microdiscectomy.

RESULTS

There was no difference in patient demographics in the open and MIS groups aside from length of follow-up (60.4 vs 40.03 months, P < .0001) and body mass index (24.72 vs 27.21, P = .03). The rate of revision microdiscectomy was not statistically significant between open and MIS approaches (10.3% vs 10.4%, P = .90). The rate of patients who ultimately required index level fusion approached significance, but was not statistically different between open and MIS approaches (10.3% vs 4.4%, P = .17). Multivariate regression analysis indicated that the need for eventual index level fusion after lumbar microdiscectomy was statistically predicted in smokers and those patients who underwent revision microdiscectomy (P < .05) in both open and MIS groups.

CONCLUSIONS

Our results suggest a low likelihood of patients ultimately requiring fusion following microdiscectomy with predictors including smoking status and a history of revision microdiscectomy.

[Percutaneous endoscopic discectomy in the treatment of patients with degenerative diseases of the lumbosacral spine]

Modern surgery uses a variety of treatments for spine pathology. Endoscopic techniques have become particularly popular across the world over the past decade. In this article, we summarize our experience and analyze the immediate and long-term results of surgical treatment of lumbar disc herniation using a percutaneous fully endoscopic technique for removing the herniated intervertebral disc, which is new for Russian medical practice.

OBJECTIVE

to evaluate the efficacy of percutaneous endoscopic discectomy in the treatment of herniated lumbar discs in patients with radicular pain syndrome.

MATERIAL AND METHODS

We conducted a cohort retrospective study that included 69 patients who underwent herniated disc removal using the percutaneous endoscopic technique. Surgery was performed through two approaches: the intralaminar approach was used in 44 patients, and the transforaminal approach was used in 25 patients. To assess the efficacy of surgery, we used a visual analogue scale (VAS) of pain: the intensity of local pain (VAS1) and the intensity of radicular pain (VAS2). Changes in the quality of life and ability to work were assessed by using the Oswestry scale; patient satisfaction with treatment was assessed by using the MacNab scale.

RESULTS

The mean follow-up period after surgery was 24 months. An analysis of changes in the pain syndrome (VAS1 and VAS2) before surgery and in the early postoperative period demonstrated a significant regression of pain regardless of the approach type (r=0.25). Patients' survey (MacNab scale) in the long-term postoperative period revealed no unsatisfactory results; excellent, good, and satisfactory results were observed in 21 (30%), 32 (46%), and 16 (24%) patients, respectively.

CONCLUSION

Percutaneous endoscopic discectomy is an effective surgical treatment for degenerative diseases of the lumbosacral spine, providing excellent and good treatment outcomes in most operated patients.

What is the rate of lumbar adjacent segment disease after percutaneous versus open fusion?

OBJECTIVE

Adjacent segment disease (ASD) requiring treatment or re-operation is a common problem after surgery on the lumbar spine. The hypothesis of this retrospective study was that ASD occurs less often following lumbar spine fusion in patients who undergo percutaneous minimally invasive (MIS) instrumentation than in those in whom open instrumentation is used.

METHODS

A case-control study was performed on consecutive patients who had undergone staged single or two level anterior lumbar interbody fusion for degenerative conditions followed by open or MIS instrumentation from 2002 to 2005 in our institution. ASD was defined as that necessitating additional procedures for new symptoms related to an adjacent lumbar dermatome.

RESULTS

One hundred and seventeen patients met the inclusion criteria. Of these, 53 had been followed up by chart or medical record review for longer than one year. There were 23 patients in the MIS group and 30 in the open group. Of the 30 patients in the open group, 9 had developed ASD (30%). Of the 23 patients in the MIS group, 7 had developed ASD (30%). This difference is not statistically significant (P = 1.00).

CONCLUSION

Contrary to our hypothesis, there was no significant difference in incidence of ASD in patients who had underwent open versus percutaneous instrumentation following anterior lumbar interbody fusion.

Adjacent segment disease in the lumbar spine following different treatment interventions

BACKGROUND CONTEXT

Adjacent segment disease (ASD) is symptomatic deterioration of spinal levels adjacent to the site of a previous fusion. A critical issue related to ASD is whether deterioration of spinal segments adjacent to a fusion is due to the spinal intervention or due to the natural history of spinal degenerative disease.

PURPOSE

The purpose of this review is to summarize the recent clinical literature on adjacent segment disease in light of the natural history, patient-modifiable risk factors, surgical risk factors, sagittal balance, and new technology.

STUDY DESIGN

This review will evaluate the recent literature on genetic and hereditary components of spinal degenerative disease and potential links to the development of ASD.

METHODS

After a meticulous search of Medline for relevant articles pertaining to our review, we summarized the recent literature on the rate of ASD and the effect of various interventions, including motion preservation, sagittal imbalance, arthroplasty, and minimally invasive surgery.

RESULTS

The reported rate of ASD after decompression and stabilization procedures is approximately 2% to 3% per year. The factors that are consistently associated with adjacent segment disease include laminectomy adjacent to a fusion and a sagittal imbalance.

CONCLUSIONS

Spinal surgical interventions have been associated with ASD. However, whether such interventions may lead to an acceleration of the natural history of the disease remains questionable.