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Beck J, Westin O, Klingenstierna M, Baranto A. Full-Endoscopic Lumbar Discectomy vs Standard Discectomy: A Noninferiority Study on Clinically Relevant Changes. Int J Spine Surg 2023:8458. [PMID: 37315994 DOI: 10.14444/8458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Surgery for lumbar disc herniation (LDH) has had a remarkable technological development during the past 20 years. Microscopic discectomy has traditionally been the gold standard method to treat symptomatic LDH before the introduction of full-endoscopic lumbar discectomy (FELD). The FELD procedure allows unsurpassed magnification and visualization and is currently the most minimally invasive surgical technique. In this study, FELD was compared with standard surgery for LDH, with a focus on medically relevant changes in patient-reported outcome measures (PROMs). PURPOSE The purpose of this study was to investigate whether FELD is noninferior to other surgical methods for LDH surgery in the most common PROMs, including postoperative leg pain and disability, while still reaching the necessary thresholds for relevant clinical and medical improvements. METHODS Patients undergoing a FELD procedure at the Sahlgrenska University Hospital, Gothenburg, Sweden, between 2013 to 2018 were included. A total of 80 (41 men and 39 women) patients were enrolled. The FELD patients were matched 1:5 to controls from the Swedish spine register (Swespine) who had a standard microscopic or mini-open discectomy surgery. PROMs, including the Oswestry Disability Index (ODI) and the Numerical Rating Scale (NRS), as well as the patient acceptable symptom states (PASS) and the minimal important change (MIC), were used to compare the efficacy of the 2 surgical approaches. RESULTS The FELD group achieved medically relevant and significant improvements noninferior to standard surgery within the predefined thresholds of MIC and PASS. No differences could be found in disability measured by ODI FELD -28.4 (SD 19.2) vs standard surgery -28.7 (SD 18.9) or leg pain NRSLeg FELD -4.35 (SD 2.93) vs standard surgery -4.99 (SD 3.12). All intragroup score changes were significant. CONCLUSIONS The FELD results are not inferior to standard surgery 1 year postoperatively after LDH surgery. There were no medically significant differences regarding MIC achieved or final PASS in any of the measured PROMs, including leg pain, back pain, or disability (ODI) between the surgical methods. CLINICAL RELEVANCE The present study highlights that FELD is noninferior to standard surgery in clinically relevant PROMs. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Joel Beck
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olof Westin
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Klingenstierna
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Adad Baranto
- Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
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Ramola M, Aggarwal A, Singh R. A simple new cost-effective retractor system for exposure in lumbar microdiscectomy:1 year outcome analysis. World Neurosurg 2022; 165:133-140. [PMID: 35760328 DOI: 10.1016/j.wneu.2022.06.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 06/18/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE A new technique for retraction in lumbar microdiscectomy called as Rubber band technique (RT) is introduced and its 1year clinical outcomes results are compared to standard microdiscectomy (SM). METHODS This study was retrospective analysis of 81 consecutive patients who underwent lumbar microdiscectomy by Rubber band technique (RT group) and standard microdiscectomy (SM) group for single level lumbar disc herniation. The primary outcome was Oswestry Disability Index (ODI) score after 1 year of surgery. Secondary outcomes included were Short form health survey Physical function (SF 36-PF), Short- form health survey bodily pain (SF36-BP), visual analogue scale (VAS) for back pain and leg pain. Other parameters included were operative time, hospital stay, skin incision, complications, and redo surgery. RESULTS Of the total 81 patients, 93% (76 patients) had complete database up to 1 year follow up. RT group comprised 39 patients (20 males, 19 females) and standard microdiscectomy (SM Group, 37 patients, 19 males 18 females). Primary & secondary outcomes like ODI score, SF 36- PF, SF 36 -BP score, VAS score back and leg pain, complications & redo surgery did not differ significantly between the treatment groups at follow-up periods (p>0.05). Skin incision was smaller in RT as compared to SM group (p=.0001). CONCLUSIONS Over the 1year follow-up period, clinical outcome of patients treated with Rubber band technique (RT) was comparable to patients treated with standard microdiscectomy group (SM). RT appears to provide alternative safe, effective, and economical approach for lumbar microdiscectomy.
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Affiliation(s)
- Mahesh Ramola
- Department of Neurosurgery, SGRR Institute of Medical & Health Sciences, Dehradun, Uttarakhand. India.
| | - Amulya Aggarwal
- Department of Surgery, SGRR Institute of Medical & Health Sciences, Dehradun, Uttarakhand. India
| | - Ritu Singh
- Department of Community medicine, SGRR Institute of Medical & Health Sciences, Dehradun, Uttarakhand. India, Current affiliation of Dr. Ritu Singh - Community health center, Raipur, Dehradun, Uttarakhand. India
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Soriano Sánchez JA, Lewandrowski KU, Franco Jímenez JA, Soto Garcia ME, Solís SS, García MR, Escandón OS, Rangel R, Israel JA. Minimally Invasive Posterior Tubular Microsurgical Approach for the Management of Symptomatic Synovial Cysts of the Lumbar and Cervical Spine. Int J Spine Surg 2021; 15:1014-1024. [PMID: 34551923 DOI: 10.14444/8134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Synovial cysts are commonly associated with instability. Whether to fuse patients is a matter of controversy. Simple resection may offer favorable clinical outcomes but may come at the expense of recurrence rate. We describe our experience with the minimally invasive management of these lesions using microsurgical dissection through a tubular retractor system. MATERIALS A retrospective cohort study of symptomatic patients with synovial cysts treated by a minimally invasive tubular approach from 2001 to 2018 was performed. We evaluated variables such as preexisting spinal pathology, previous surgery, radiological findings, comorbidities, and secondary surgery requiring fusion. We used the visual analog scale (VAS), the Oswestry disability index (ODI), and the Macnab scale for clinical evaluation. RESULTS There were 35 patients with a mean age of 63 years. The mean duration of symptoms before surgery was 195 weeks. Axial pain was present in 77.1% of cases; radiculopathy was the main symptom in 94.3% of cases. The most frequent site was L4-L5 (62.8%). Presenting comorbidities were lumbar stenosis (28.6% of patients), spondylolisthesis (8.6%), and facet hypertrophy (31.4%). Mean surgical time was 143 minutes (range, 55-360 minutes). The mean hospital stay was 2 days, ranging from 1 to 5 days. No complications were encountered as a consequence of the surgical procedure. All patients showed neurophysiological improvement after surgical intervention. A total of 34 patients (97.14%) showed clinical improvement at the end of follow-up, averaging 17 months and ranging from 1 to 60 months, 28 patients (80%) had good to excellent Macnab outcomes, 6 patients (17.14%) were rated as fair, and 1 (2.86%) patient had a poor Macnab outcome. Radicular VAS significantly changed (P < .05) from a preoperative mean of 8.23 ± 1.24 to a postoperative mean of 2.23 ± 1.94. ODI significantly decreased (P < .05) from a preoperative of mean of 41.02 ± 12.56 to a postoperative of mean of 11.82 ± 10.56. We performed fusion at initial surgery in 37.1% of cases; however, 3 more patients required secondary fusion at follow-up. CONCLUSION Our series corroborates the prior literature with a low incidence of synovial cysts in the cervical spine and none in the thoracic spine. The present work shows the efficacy of minimally invasive surgery in the treatment of these lesions. Synovial cysts were associated with instability, ultimately requiring fusion in the majority of patients. The authors' study includes a large patient series with minimally invasive microsurgical decompression performed through a tubular retractor to date. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | - Kai Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Tucson, Arizona.,Department of Orthopaedics at UNIRIO, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Alfonso Franco Jímenez
- Spine Clinic, The American-British Cowdray Medical Center I.A.P., Campus Santa Fe, Mexico City, Mexico.,Pediatric Neurosurgery, Children's Hospital, Federico Gómez, Mexico City, Mexico
| | | | - Sergio Soriano Solís
- Spine Clinic, The American-British Cowdray Medical Center I.A.P., Campus Santa Fe, Mexico City, Mexico
| | - Manuel Rodríguez García
- Spine Clinic, The American-British Cowdray Medical Center I.A.P., Campus Santa Fe, Mexico City, Mexico
| | - Oscar Sanchéz Escandón
- Spine Clinic, The American-British Cowdray Medical Center I.A.P., Campus Santa Fe, Mexico City, Mexico
| | | | - José Alberto Israel
- Spine Clinic, The American-British Cowdray Medical Center I.A.P., Campus Santa Fe, Mexico City, Mexico.,Regional General Hospital #25 of the National Institute of Social Security, Mexico City, Mexico.,University of Sonora, Sonora, Mexico
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Grasso G, Paolini S, Sallì M, Torregrossa F. Lumbar Spinal Fixation Removal by a Minimal Invasive Microscope-Assisted Technique. Case Report with Technical Description. Neurol India 2020; 68:1211-1213. [PMID: 33109879 DOI: 10.4103/0028-3886.299148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The concept of minimally invasive spine surgery (MISS) has gained increasing popularity in the last decades. While MISS holds promise for faster patient recovery, and shorter hospital stays, the removal of the surgical fixation, when required, is still performed by an extensive approach often resulting in disabling pain and discomfort. We describe a novel minimal invasive microscope-assisted technique for lumbar spinal fixation removal. This technique has been successfully applied in a 35-year-old man, affected by back pain despite a previous posterior dynamic MISS L4-S1 fixation. The previous skin incisions were opened and under microscopic vision, the screws and the roads were dissected from the scars and removed. The patient was discharged on postoperative day-1. He reported a progressive improvement of the symptoms with a satisfactory cosmetic result. Minimal invasive microscope-assisted technique for spinal fixation removal offers a simple and effective surgical alternative to the traditional open surgery.
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Affiliation(s)
- Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Saverio Paolini
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Marcello Sallì
- Department of Neurosensory and Motor Surgery, University of Palermo, Palermo, Italy
| | - Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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Krishnan A, Kohli R, Degulmadi D, Mayi S, Ranjan R, Dave B. Cauda Equina Syndrome: A Review of 15 Patients Who Underwent Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD) Under Local Anaesthesia. Malays Orthop J 2020; 14:101-110. [PMID: 32983384 PMCID: PMC7513651 DOI: 10.5704/moj.2007.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 04/19/2020] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION To analyse the results of Cauda Equina Syndrome (CES) operated by Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD). MATERIAL AND METHODS The study is a retrospective series of 15 patients operated by PTELD. Bladder dysfunction was classified as incomplete CES (CESI) and complete CES retention (CESR). Bladder / motor recovery rate and its timing, Oswestry Disability Index (ODI), Visual Analogue Score (VAS), patient satisfaction index, and sexual dysfunction were used to measure the outcome objectively. Additionally, in CESR patients, post-void residual (PVR) urine was measured by sonography. Complications and technical problems were noted. RESULTS There were ten patients of CESI and five patients of CESR. The average follow-up was 20.33(12.05) months. Bladder symptoms recovery was 100%, and motor recovery was 80%. VAS for back pain recovered to 0.53(0.52) from 8(2.39). VAS for leg pain recovered to 0.13(0.35) from 9.20(1.32). ODI improved to 6.07(2.85) from 77.52(13.20). The time to the recovery of bladder function was 1.47(1.55) days. All CESR patient's abnormal PVR urine was normalised at five weeks post-operative. No complications were reported. However, five technical executional problems occurred. CONCLUSION PTELD can be considered for CES treatment due to its substantial and quick recovery advantages. However, more evidence support is needed to make it a practice recommendation.
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Affiliation(s)
- A Krishnan
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - R Kohli
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - D Degulmadi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - S Mayi
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - R Ranjan
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
| | - B Dave
- Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, India
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Gautschi OP, Stienen MN, Corniola MV, Schaller K. [Minimal invasive surgery: historical review, current status and perspective]. Praxis (Bern 1994) 2014; 103:1323-1329. [PMID: 25351695 DOI: 10.1024/1661-8157/a001832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Lumbar spine surgery has been performed for decades using the so-called «dorsal open approach». Although established as a safe and effective procedure, it is associated to some extent with extensive collateral damage in the area of the operative field. For over ten years, minimal-invasive spine surgery (MISS) techniques, which are considerably less destructive and less traumatic, have earned their place as valuable and at times superior to the established dorsal open approach. Advantages include smaller skin incisions, less soft tissue and muscle damage, less peri-operative blood loss, lower infection rates, earlier postoperative return to function or work as well as shorter hospital stays. All these advantages, however, have to be carefully balanced against the potential disadvantages of MISS techniques, notably reduced orientation, steep learning curves, and increased radiation exposure from repeated imaging for guidance. This article gives an overview about the evolution and current role of MISS in lumbar spine surgery.
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Affiliation(s)
- Oliver P Gautschi
- Service de Neurochirurgie, Hôpitaux Universitaires de Genève et Faculté de Médecine, Université de Genève, Genève
| | | | - Marco V Corniola
- Service de Neurochirurgie, Hôpitaux Universitaires de Genève et Faculté de Médecine, Université de Genève, Genève
| | - Karl Schaller
- Service de Neurochirurgie, Hôpitaux Universitaires de Genève et Faculté de Médecine, Université de Genève, Genève
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Abstract
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.
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Affiliation(s)
- Arvind G Kulkarni
- Department of Orthopaedics, Bombay Hospital, Mumbai, Maharashtra, India,Address for correspondence: Dr. Arvind G. Kulkarni, Consultant Spine Surgeon, Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Room No 206, 2nd Floor MRC, 12, New Marine Lines - 400 020, Mumbai, Maharashtra, India. E-mail:
| | - Anupreet Bassi
- Department of Orthopaedics, Bombay Hospital, Mumbai, Maharashtra, India
| | - Abhilash Dhruv
- Department of Orthopaedics, Bombay Hospital, Mumbai, Maharashtra, India
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