Ralstonia mannitolilytica as a rare cause of spondylodiscitis following endoscopic lumbar discectomy- A report of two cases

Ralstonia mannitolilytica is a low-virulence, gram-negative bacillus which causes opportunistic infections in immunosuppressed patients. Postoperative spondylodiscitis by R. mannitolilytica has not been reported so far. We report the management of two cases of postoperative spondylodiscitis caused by Ralstonia mannitolilytica presenting to our center within a span of one month following endoscopic lumbar discectomy at a different center. They were managed successfully by surgical debridement and appropriate antibiotics. In these two cases of R.mannitolilytica spondylodiscitis, prompt detection, and intensive treatment resulted in satisfactory outcomes in terms of fulfilling the purpose of the original surgery.

Ultrasound guidance for transforaminal percutaneous endoscopic lumbar discectomy may prevent radiation exposure: A case report

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) has become a mature and mainstream minimally invasive surgical technique for treating lumbar disc herniation (LDH). Repeated fluoroscopy, with more than 30 shots on average, is inevitable to ensure its accuracy and safety. However, exposure to X-rays may pose a threat to human health. We herein report a case of ultrasound (US)-assisted PELD in two levels of LDH to explore a new possibility that can reduce the radiation dose during puncture and cannulation in PELD.

CASE SUMMARY

A 38-year-old man with low back pain and left leg pain for more than 7 years came to our clinic, his symptoms had aggravated for 1 month, and he was diagnosed with L3-4 and L4-5 disc herniations. He received US-guided PELD with good results: His straight leg elevation increased from 40 to 90 degrees after PELD, and his visual analog scale (VAS) and Oswestry Disability Index scores both significantly decreased immediately and 6 mo after PELD. With the guidance of US, he received only two shots of fluoroscopy (fluoroscopic time: 4.4 s; radiation dose: 3.98 mGy). To our knowledge, this is the first case of US-guided puncture and cannulation of PELD for LDH at two levels.

CONCLUSION

US could be used to guide PELD and has the potential to largely reduce radiation than traditional X-ray guidance.

[Biomechanics changes of lumbar spine caused by foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy]

Objective: To analyze the biomechanics changes of lumbar spine caused by foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy using the finite element method. Methods: Three healthy adult males (aged 35.6 to 42.3 years) without spinal diseases were enrolled in this study and 3D-CT scans were carried out to obtain the parameters of lumbar spine. Mimics software was applied to build a 3D finite element model of lumbar spine. Graded resections (1/4, 2/4, 3/4 and 4/4) of the left superior articular process of L(5) were done via percutaneous transforaminal endoscopic lumbar discectomy. Then, the pressure of the L(4/5) right facets, the pressure of the L(4/5) intervertebral disc and the motion of lumbar spine were recorded after simulating the normal flexion and extension, lateral flexion and rotation of the lumbar spine model during different resections. The data were compared among groups with analysis of variance. Results: Comparing with the normal group, after 1/4 resection of the left superior articular process of L(5), the pressure of the L(4/5) right facets showed significant differences during left lateral flexion and rotation of lumbar spine (q=8.823, 8.248, both P<0.05); and the pressure of L(4/5) intervertebral disc also changed significantly during extension and right rotation of lumbar spine (q=6.918, 6.438, both P<0.05); the motion of lumbar spine showed obvious differences during right lateral flexion and rotation (q=6.845, 7.772, 13.58, all P<0.05). Comparing with the normal group, after 2/4 resection of the left superior articular process of L(5), the pressure of the L(4/5) right facets presented significant differences during all conditions (q=5.670-17.830, all P<0.05); the pressure of L(4/5) intervertebral disc changed significantly during flexion, extension, lateral flexion and right rotation (q=5.260, 17.150, 5.727, 8.890, 15.660, all P<0.05); the motion of lumbar spine also existed differences during extension, lateral flexion and rotation (q=9.106, 5.431, 12.060, 11.160, 17.260, all P<0.05). However, after 3/4 resections, the pressure of the L(4/5) right facets, the pressure of the L(4/5) intervertebral disc and the motion of lumbar spine presented differences during all conditions when compared with those in normal group (q=6.303-25.48, all P<0.05). After 4/4 resections, the pressure of the L(4/5) right facets and the pressure of the L(4/5) intervertebral disc and the motion of lumbar spine showed significant differences during all conditions when compared with those in normal group (q=8.065-45.70, all P<0.05). Conclusions: The biomechanics and the stability of lumbar spine changed partly after 1/4 resection of the superior articular process and obviously after more than 2/4 is resected. The superior articular process should be paid more attention during foraminotomy via percutaneous transforaminal endoscopic lumbar discectomy.

A retrospective study of epidural and intravenous steroids after percutaneous endoscopic lumbar discectomy for large lumbar disc herniation

OBJECTIVE

To assess the early curative effect of epidural or intravenous administration of steroids during a percutaneous endoscopic lumbar discectomy (PELD).

METHODS

28 consecutive patients who underwent PELD due to large lumbar disc herniation between November 2014 and January 2016 were followed up for 6 months. These patients were divided into two groups according to the treatment they received after PELD. 14 patients (Group A) were treated by PELD and epidural steroids, while the other 14 patients (Group B) were treated by PELD and intravenous steroids. We evaluated the effectiveness by the preoperative and postoperative visual analogue scale (VAS) scores for back and leg pain, and the postoperative Oswestry disability index (ODI) at 3 weeks after surgery via the clinical charts and telephone interview. Postoperative hospital stay and time return to work were investigated as well.

RESULTS

There is a significant decrease in VAS (back, leg), ODI, and time return to work (p < 0.05). For VAS (back), Group A showed a significant decrease compared with Group B at 1 day and 1 week after surgery (p = 0.011, p = 0.017). As for VAS (leg), Group A showed a significant decrease compared with Group B at 1 day, 1 week, 3 weeks, and 3 months follow-up examinations (p = 0.002, p = 0.006, p < 0.001, p < 0.001). For ODI, Group A showed a notable decrease compared with Group B (p < 0.001). The postoperative hospital stay in two groups was not statistically different (p = 0.636). But the time return to work in Group A was significantly shorter than that in Group B (p = 0.023).

CONCLUSION

Patients who underwent PELD with epidural steroid administration for large lumbar disc herniation showed favorable curative effect compared with those who underwent PELD with intravenous steroid administration.

Endoscopic inter laminar management of lumbar disease

Discectomy for lumbar disc provides faster relief in acute attack than does conservative management. Long-term results of open, microscopy-, and endoscopy-assisted discectomy are same. Early results of endoscopy-assisted surgery are better as compared to that of open surgery in terms of better visualization, smaller incision, reduced hospital stay, better education, lower cost, less pain, early return to work, and rehabilitation. Although microscopic discectomy also has comparable advantages, endoscopic-assisted technique better addresses opposite side pathology. Inter laminar technique (ILT) and trans foraminal technique (TFT) are two main endoscopic approaches for lumbar pathologies. Endoscopy-assisted ILT can be performed in recurrent, migrated, and calcified discs. All lumbar levels including L5-S1 level, intracanalicular, foraminal disc, lumbar canal and lateral recess stenosis, multiple levels, and bilateral lesions can be managed by ILT. Migrated, calcified discs, L5-S1 pathology, lumbar canal, and lateral recess stenosis can be better approached by ILT than by TFT. Most spinal surgeons are familiar with anatomy of ILT. It can be safely performed in foramen stenosis and in uncooperative and anxious patients. There is less risk of exiting nerve root damage, especially in short pedicles and in presence of facet osteophytes as compared to TFT. On the other hand, ILT is more invasive than TFT with more chances of perforations of the dura matter, pseudomeningocele formation, and cerebrospinal fluid fistula in early learning curve. Obtaining microsurgical experience, attending workshops, and suitable patient selection can help shorten the learning curve. Once adequate skill is acquired, this procedure is safe and effective. The surgeon must be prepared to convert to an open procedure, especially in early learning curve. Spinal endoscopy is likely to achieve more roles in future. Endoscopy-assisted ILT is a safer alternative to the microscopic technique.