Anesthesia methods for full-endoscopic lumbar discectomy: a review

Endoscopic spine surgery for obesity-related surgical challenges: a systematic review and meta-analysis of current evidence

Obesity presents significant challenges in spinal surgery, including higher rates of perioperative complications, prolonged operative times, and delayed recovery. Traditional open spine surgery often exacerbates these risks, particularly in patients with obesity, because of extensive tissue dissection and larger incisions. Endoscopic spine surgery (ESS) has emerged as a promising minimally invasive alternative, offering advantages such as reduced tissue trauma, minimal blood loss, lower infection rates, and faster recovery. This systematic review and meta-analysis aimed to evaluate the safety, efficacy, and outcomes of ESS techniques, including fully endoscopic and biportal endoscopic lumbar discectomy and decompression, in patients with obesity and lumbar spine pathologies. A comprehensive literature search of the PubMed/Medline, Embase, and Scopus databases yielded 2,975 studies published between 2000 and 2024, of which 10 met the inclusion criteria. The meta-analysis revealed significant improvements in pain relief (Visual Analog Scale) and functional outcomes (Oswestry Disability Index), with comparable results between patients with and without obesity. Patients who are obese experienced longer operative times and have a slightly higher risk of symptom recurrence; however, ESS demonstrated lower rates of wound infections, shorter hospital stays, and faster recovery than traditional surgery. These findings position ESS as a viable and effective option for managing lumbar spine conditions in patients with obesity, addressing obesity-related surgical challenges while maintaining favorable clinical outcomes. However, limitations such as study heterogeneity and the lack of randomized controlled trials highlight the need for further high-quality research to refine ESS techniques and optimize patient care in this high-risk population.

Duckbill Release Technique for the Outside-in Method in Full-Endoscopic Spine Surgery via Transforaminal Approach: A Technical Note

BACKGROUND

In full-endoscopic spine surgery via transforaminal approach (FESS-TF), the outside-in method facilitates treatment for various cases; however, the technique is difficult to perform. To facilitate this procedure, we developed a duckbill release technique. In this article, we aimed to introduce the details of this technique and investigate its effectiveness.

METHODS

Fifty patients who underwent FESS-TF for intervertebral disc herniation were divided into 2 groups: the conventional technique and the duckbill release technique groups. The time from the initiation of surgery to exposure of the bone outside the superior articular process was measured in both groups. The visual analog scale score for leg pain and the Japanese Orthopaedic Association score before and after surgery were compared in terms of clinical outcomes.

RESULTS

No significant differences were observed between the 2 groups in terms of patient background. The approach time was 252 ± 86 seconds in the conventional group, while it was 105 ± 26 seconds in the duckbill release group, which was significantly shorter (P < 0.001). In terms of clinical outcomes, the 2 groups did not significantly differ in all endpoints of the visual analog scale score for leg pain or the Japanese Orthopaedic Association score.

CONCLUSIONS

The duckbill release technique for the outside-in method in FESS-TF could be efficient because it is a simple and time-saving approach.

Comparison of Safety and Efficacy of Anesthesia Methods in Percutaneous Endoscopic Lumbar Discectomy: A Network Meta-Analysis

Background: The objective of this study was to systematically evaluate the safety and efficacy of local anesthesia, general anesthesia, and epidural anesthesia in percutaneous endoscopic lumbar discectomy (PELD). Methods: We searched PubMed, EMBASE, and OVID databases for all relevant studies. All statistical analysis was performed using STATA 17.0. Results: Fourteen studies were finally included, comprising 7 randomized controlled trials and 7 retrospective studies. The total number of subjects across these studies was 1655, with 316 undergoing general anesthesia, 789 undergoing local anesthesia, and 550 undergoing epidural anesthesia. The meta-analysis of pairwise comparisons suggests that there are no differences among epidural, general anesthesia, and local anesthesia in terms of postoperative VAS, ODI, and surgery time. Regarding complications, general anesthesia has a higher complication rate compared with local anesthesia, but there are no differences between epidural and general anesthesia or between epidural and local anesthesia. In terms of anesthesia satisfaction, both general and epidural anesthesia have higher satisfaction rates compared with local anesthesia, with no significant difference between general and epidural anesthesia. The ranking of the best probabilities shows that epidural anesthesia has the lowest postoperative VAS and highest anesthesia satisfaction. General anesthesia has the lowest ODI scores. Local anesthesia has the fewest complications and operative time. Conclusion: Local anesthesia, general anesthesia, and epidural anesthesia are all safe and effective methods for PELD. Local anesthesia has advantages in complications and operation time. Epidural anesthesia is most advantageous in anesthesia satisfaction and postoperative VAS scores. General anesthesia is most advantageous in postoperative ODI. In the future, more multicenter RCTs are needed to further compare the safety and effectiveness of different anesthesia methods in PELD.

Spinal Anesthesia for Awake Spine Surgery: A Paradigm Shift for Enhanced Recovery after Surgery

Awake surgery has been applied for various surgical procedures with positive outcomes; however, in neurosurgery, the technique has traditionally been reserved for cranial surgery. Awake surgery for the spine (ASFS) is an alternative to general anesthesia (GA). As early studies report promising results, ASFS is progressively gaining more interest from spine surgeons. The history defining the range of adverse events facing patients undergoing GA has been well described. Adverse reactions resulting from GA can include postoperative nausea and vomiting, hemodynamic instability and cardiac complications, acute kidney injury or renal insufficiency, atelectasis, pulmonary emboli, postoperative cognitive dysfunction, or malignant hyperthermia and other direct drug reactions. For this reason, many high-risk populations who have typically been poor candidates under classifications for GA could benefit from the many advantages of ASFS. This narrative review will discuss the significant historical components related to ASFS, pertinent mechanisms of action, protocol overview, and the current trajectory of spine surgery with ASFS.

Case report of minimally invasive spinal endoscopic debridement and pedicle screw fixation for severe spinal infection of the lumbosacral spine

Background

Surgical treatment of spinal infections, refractory to medical treatments, is increasing in incidence. Here, we present a unique case of discitis secondary to an iatrogenic cause, spinal steroid injection, that resulted in acute neurology, ventral phlegmon, and osteomyelitis requiring multiple surgical interventions for treatment.

Case Description

With the adoption of minimally invasive spinal surgery, the patient underwent full endoscopic debridement and decompression at our hospital. The endoscopic technique offers a unique avenue to the anatomically difficult ventral phlegmon for surgical excision, cultures, and pathogen identification. The endoscopic debridement was paired with percutaneous pedicle screw fixation to stabilize the spine from the worsening bone destruction.

Outcome

The patient recovered well postoperatively, with the resolution of her neurological symptoms and improved mobility.

Conclusions

Full endoscopic spinal debridement and decompression is a powerful tool to manage severe spinal discitis and preliminary studies encourage its adoption in surgical practices.

Observation on the Analgesic Effect of Different Doses of a Combination of Esketamine and Dexmedetomidine Administered for Percutaneous Endoscopic Transforaminal Discectomy: A Randomized, Double-Blind Controlled Trial

BACKGROUND

Percutaneous endoscopic transforaminal discectomy (PETD) is an effective method for treating lumbar disc herniation, and is typically performed under local anesthesia. However, inadequate analgesia during the procedure remains a concern, prompting the search for a medication that can provide optimal pain control with minimal impact on the respiratory and circulatory systems.

OBJECTIVES

The aim of this study was to observe the effects of different doses of esketamine combined with dexmedetomidine on reducing visual analog scale (VAS) scores during surgical interventions.

METHODS

One hundred two patients who underwent PETD were randomly divided into a control group (group C: normal saline + dexmedetomidine), an E1 group (0.1 mg kg-1 esketamine + dexmedetomidine), and an E2 group (0.2 mg kg-1 esketamine + dexmedetomidine). The primary outcome was the maximum visual analogue scale (VAS) (score: 0 = no pain and 10 = worst pain) at six time points. The secondary outcomes included the Assessment of Alertness/Sedation Scale (OAA/S) score and mean arterial pressure (BP), heart rate (HR), respiratory rate (RR), and oxygen saturation (SpO2) at 11 time points. The incidence of adverse reactions during and 24 h after the operation and patient satisfaction with the anesthesia were also recorded.

RESULTS

Compared with those in group C, the VAS scores of patients in groups E1 and E2 were lower at T6, T7, and T9 (P < 0.05). From T4 to T10, the OAA/S scores of the E1 and E2 groups were both lower than those of group C (P < 0.05), and at the T4-T6 time points, the OAA/S score of the E2 group was lower than that of group E1 (P < 0.05). At T4 and T5, the HR and BP of patients in groups E1 and E2 were greater than those in group C (P < 0.05). Compared with those in group C, the incidences of intraoperative illusion, floating sensation, postoperative dizziness, and hyperalgesia in groups E1 and E2 were significantly greater (P < 0.01). There was no significant difference in patient RR, SpO2, or postoperative satisfaction with anesthesia among the three groups (P > 0.05).

CONCLUSION

The combination of esketamine and dexmedetomidine can reduce VAS scores during certain stages of this type of surgery; it has minimal impact on respiration and circulation. However, this approach is associated with increased incidences of postoperative dizziness and psychiatric side effects, which may also affect patients' compliance with surgical instructions from medical staff. Patient satisfaction was not greater with dexmedetomidine combined with esketamine than with dexmedetomidine alone.

TRIAL REGISTRATION

http://www.chictr.org.cn . Identifier: ChiCTR2300068206. Date of registration: 10 February 2023.