Biportal Endoscopic Radiofrequency Ablation of the Sacroiliac Joint Complex in the Treatment of Chronic Low Back Pain: A Technical Note with 1-Year Follow-Up.

BACKGROUND: Sacroiliac joint (SIJ) pain is a common source of low back pain. Previously reported management strategies for this pain include conservative treatment, SIJ injection, radiofrequency denervation ablation, and SIJ fusion. Herein, we describe the use of biportal endoscopic radiofrequency ablation (BERA) to treat patients with low back pain. METHODS: We included 16 patients who underwent BERA from April 2018 to June 2020. We marked the S1, S2, and S3 foramina and the SIJ line under fluoroscopy. Skin entry points were positioned at 0.5 cm medial to the SIJ line and at the level of the S1 and S2 foramina. Under local anesthesia, we introduced a 30° arthroscope with a 4 mm diameter through the viewing portal; surgical instruments were inserted through another caudal working portal. We ablated the lateral branches of the S1-S3 foramina and L5 dorsal ramus, which were the sources of SIJ pain. RESULTS: Clinically relevant improvements in both visual analog scale and Oswestry Disability Index scores were noted at 1-, 6-, and 12-month follow-up time points after surgery. The overall patient satisfaction score was 89.1%. CONCLUSIONS: BERA for SIJ pain treatment has the advantage of directly identifying and ablating the innervating nerve to the joint. Through this technique, an expanded working angle can be obtained compared with traditional single-port endoscopy. Our study demonstrated promising preliminary results.

Use artificial neural network to recommend the lumbar spinal endoscopic surgical corridor.

Objectives: The transforaminal and interlaminar approaches are the two main surgical corridors of full endoscopic lumbar surgery. However, there are no quantifying methods for assessing the best surgical approach for each patient. This study aimed to establish an artificial intelligence (AI) model using an artificial neural network (ANN). Materials and Methods: Patients who underwent full endoscopic lumbar spinal surgery were enrolled in this research. Fourteen pre-operative factors were fed into the ANN. A three-layer deep neural network was constructed. Patient data were divided into the training, validation, and testing datasets. Results: There were 899 patients enrolled. The accuracy of the training, validation, and test datasets were 87.3%, 85.5%, and 85.0%, respectively. The positive predictive values for the transforaminal and interlaminar approaches were 85.1% and 89.1%, respectively. The area under the curve of the receiver operating characteristic was 0.91. The SHapley Additive exPlanations algorithm was utilized to explain the relative importance of each factor. The surgical lumbar level was the most important factor, followed by herniated disc localization and migrating disc zone level. Conclusion: ANN can effectively learn from the choice of an experienced spinal endoscopic surgeon and can accurately predict the appropriate surgical approach.

Ultrasound Guidance for Full Endoscopic Spinal Surgery: A Technical Note.

BACKGROUND: The use of intraoperative ultrasound (IOU) has proven to be useful in spinal surgery. In this study, we present the techniques of applying IOU in cervical, thoracic, and lumbar full-endoscopic spine surgery (FESS). METHODS: For applying IOU in cervical FESS, first, we localize the surgical level by identifying the unique shape of C6 and C7 under ultrasound and then identify the cervical level subsequently. For the anterior approach, the endoscope passes through the cervical fascia between the carotid sheath and trachea/esophagus, which can be identified under ultrasound, and for the posterior approach, the endoscope docks on the facet joint under ultrasound. For applying IOU in thoracic FESS, we localize the surgical level by counting the ribs. The endoscope is advanced to the neural foramen under ultrasound without entering the pleural cavity. For applying IOU in lumbar FESS, we identify the surgical level by counting the interlaminar window from the sacrum. The endoscopic sheath is advanced to the neural foramen under ultrasound without entering the peritoneal cavity. RESULTS: The use of IOU in FESS has the potential to reduce radiation exposure, reach a higher successful puncture rate, and decrease the operation time. Furthermore, IOU prevents radiolucent organs from damage during FESS. CONCLUSIONS: We present the techniques of applying IOU in cervical, thoracic, and lumbar endoscopic spine surgery and hope that this will be helpful for physicians to master the IOU techniques.

Surgical outcomes of full endoscopic spinal surgery for lumbar disc herniation over a 10-year period: A retrospective study.

OBJECTIVE: Full endoscopic lumbar discectomy (FELD) for lumbar disc herniation (LDH) has become popular in recent years. Previous studies have proven the efficacy, but few have discussed the possible risk factors of poor outcome. In this study, we reviewed patients who underwent FELD at Changhua Christian Hospital in the past 10 years and sought to identify factors associated with poor surgical outcomes and re-operations. METHODS: We retrospectively reviewed records from mid-2009 to mid-2018. Patients had undergone FELD and follow-up for ≥1 year were included. Factors included in the outcome evaluations were age, sex, surgical time, body mass index, surgical methods, disc herniation type, extension of herniation, degree of canal compromised, disc degenerative grade, smoking and alcohol use, surgical lumbar level, symptom duration, Oswestry low back disability index, and visual analog scale score. We had evolved from inside-out methods to outside-in methods after 2016, thus, we included this factor in the analysis. The primary outcomes of interest were poor/fair MacNab score and re-operation. RESULTS: From mid-2009 to mid-2018, 521 patients met our criteria and were analyzed. The median follow-up was 1685 days (range, 523-3923 days). Thirty-one (6.0%) patients had poor surgical outcomes (fair/poor MacNab score) and 45 (8.6%) patients required re-operation. Prolapsed herniated disc (P < 0.001), higher disc degenerative grade (P = 0.047), higher lumbar level (P = 0.026), longer preoperative symptoms (P < 0.001), and surgery before 2017 (outside-in technique, P = 0.020) were significant factors associated with poor outcomes in univariate analyses. In multivariate analyses, prolapsed herniated disc (P < 0.001), higher disc degenerative grade (P = 0.030), and higher lumbar level (P = 0.046) were statistically significant. The most common adverse symptom was numbness. Factors possibly associated with higher re-operation rate were older age (P = 0.045), alcohol use (P = 0.073) and higher lumbar level (P = 0.069). Only alcohol use showed statistically significant re-operation rates in multivariate analyses (P = 0.035). CONCLUSIONS: For treating LDH by FELD, we concluded that prolapsed disc, higher disc degenerative grade, higher lumbar level, and longer preoperative symptom duration were possibly associated with unsatisfactory surgical outcomes (poor/fair MacNab score). The outside-in technique might be superior to the inside-out technique. Older age and alcohol use might be associated with a higher re-operation rate.

Symptomatic Lumbar Juxtafacet Cyst Treated by Full Endoscopic Surgery.

BACKGROUND: Juxtafacet cysts (JFCs) include both synovial and ganglion cysts adjacent to a spinal facet joint or arising from the ligamentum flavum of the spinal facet joints. Various treatments have been proposed; however, a surgical approach appears to be most effective. The aim of this study was to review patients with lumbar JFCs treated using a full endoscopic approach and elaborate the details of the surgical routes and techniques and their merits and pitfalls. METHODS: All patients with lumbar JFCs underwent complete endoscopic cyst removal. Muscle power, visual analog scale score, modified MacNab criteria score, and magnetic resonance imaging were assessed during follow-up. RESULTS: The study enrolled 8 patients. Five patients received an interlaminar approach, 2 patients received a transforaminal approach, and 1 patient received a transfacet approach. Visual analog scale scores decreased from a mean of 7.75 (range, 5-10) before surgery to 0.625 (range, 0-2) after surgery, and modified MacNab criteria score ranged from good to excellent after surgery. No neurologic injuries were observed. CONCLUSIONS: JFCs could be effectively treated by full endoscopic surgery. The type of approach should be based on the anatomic site of the lesion and the condition of the patient. The interlaminar approach is appropriate for cysts located in the lower segment with larger interlaminar space. The transforaminal or transfacet approach is preferred for patients for whom general anesthesia is a high risk.

Brain metastases in resected non-small cell lung cancer: The impact of different tyrosine kinase inhibitors.

OBJECTIVES: The purpose of this study was to examine the impact of epidermal growth factor receptor (EGFR) mutation status and tyrosine kinase inhibitors (TKIs) on the survival of brain metastases (BM) in patients with surgically resected non-small cell lung cancer (NSCLC). METHODS: We selected the patients who had developed metastatic NSCLC; analyzed the differences between brain metastases and other sites of metastases, including patient characteristics, EGFR status, and survival; and selected the patients who had BM for further investigation. We also compared the treatment effects of first-generation TKIs with those of second-/third-generation TKIs. RESULTS: A total of 785 cases of stage I-IIIa NSCLC were reviewed. Thirty-six (4.6%) patients were identified as having BM. Among them, 14 patients had a mutated EGFR status. No association between EGFR mutation and the incidence of BM was observed (p = 0.199). Patients with mutated EGFRs had significantly longer overall survival and post-recurrence survival than patients with wild-type EGFR mutation (p = 0.001 for both). However, there was no survival difference between patients with exon 19 and exon 21 mutations (p = 0.426). Furthermore, patients who received the second- and/or third-generation EGFR-TKIs had better survival than patients who only received first-generation EGFR-TKIs (p = 0.031). A multivariate analysis indicated that the next-generation TKIs (HR, 0.007; 95% CI, 0.000 to 0.556; p = 0.026) and a longer interval before BM development (HR, 0.848; 95% CI, 0.733 to 0.980; p = 0.025) were significant factors in longer survival. CONCLUSIONS: EGFR-TKIs were effective in treating NSCLC patients with BM after curative pulmonary surgery, especially in those patients harboring EGFR mutations. Furthermore, the second-/third-generation EGFR-TKIs showed more promising results than the first-generation EGFR-TKIs in treating those particular patients, though larger studies needed to further prove the results.

Spinal intramedullary tuberculoma following pulmonary tuberculosis: A case report and literature review.

RATIONALE: Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis. We presented a case with pulmonary tuberculosis and concurrent IMTB at C3 to C5 level and reviewed the recent case series and discussed the diagnosis, treatment, and outcome. PATIENT CONCERNS: A 33-year-old male had concurrent pulmonary TB and IMTB at the C3 to C5 level. He had quadriplegia (muscle power 0 at 4 limbs) and sensory loss below C5 level. He also had incontinence, anal tone loss, and paradoxical respiratory pattern. DIAGNOSIS: Spinal magnetic resonance imaging (MRI) showed a 25 11mm intramedullary lesion at C3/C4 level. Under the impression of IMTB, he underwent surgery. INTERVENTION: We performed C3 to C5 laminectomy and en bloc removal of the tumor. The patient kept receiving anti-TB medications after the surgery. OUTCOME: His 4 limbs muscle power had improved but could not be liberated from the endotracheal tube, so tracheostomy was performed. Muscle power gradually increased to 3 points in his upper limbs and to 2 points in his lower limbs. Sensation in his 4 limbs gradually improved as well. LESSONS: IMTB is a rare disease that should be treated with a combination of medication and surgery. For patients with prominent spinal cord compression and neurological symptoms, early operation to remove the tumor is necessary.

Treating intracranial dural arteriovenous fistulas with gamma knife radiosurgery: A single-center experience.

OBJECTIVE: We evaluated the effectiveness and safety of gamma knife radiosurgery (GKRS) for the treatment of intracranial dural arteriovenous fistulas (dural AVFs) over the past 10 years. MATERIALS AND METHODS: The records of 21 patients diagnosed with dural AVFs between 2004 and 2014 and treated with GKRS were reviewed retrospectively. Complete obliteration (CO) was defined as total symptom relief plus confirmation through magnetic resonance imaging or conventional angiography. RESULTS: The median follow-up was 70.5 months (range 3-136 months). Five patients underwent embolization (2 after GKRS). One patient underwent GKRS twice. The CO rate was 47%, and partial to CO rate was 88%. The complete symptom resolution rate was 77%, and all patients achieved partial to complete symptom resolution. The CO rates for Borden Type I and Type II/III dural AVFs were 66.7% and 25% (P = 0.153), respectively, and complete symptom-free rates were 76.9% and 75.0% (P = 1.000%), respectively. The median duration between initial GKRS and complete symptom resolution was 14.3 months. The median treatment to image-free durations for Borden Type I and Type II/III dural AVFs were 25.9 and 60.4 months (P = 0.028), respectively, and treatment to symptom-free durations were 10.6 and 36.7 months (P = 0.103), respectively. One patient had a recurrent hemorrhage. Two patients experienced brain edema after stereotactic radiosurgery and one patient experienced cystic formation after GKRS. The morbidity rate was 19% (four patients) and there was no mortality. CONCLUSION: Treatment with GKRS for dural AVFs offers a favorable rate of obliteration. Patients with dural AVFs that are refractory or not amenable to endovascular or surgical therapy may be safely and effectively treated using GKRS.

Outcome of colon cancer initially presenting as colon perforation and obstruction.

BACKGROUND: Emergency complications of colon cancer include perforation and obstruction which were recognized as poor prognostic factors. Few studies have directly compared the outcomes of these two groups. In this study, we evaluated mortality and morbidity in patients with colon cancer initially presenting as perforation and obstruction. METHODS: Newly diagnosed colon cancer cases initially presenting with perforation or obstruction at Tzu Chi General Hospital, Hualien, Taiwan, between 2009 and 2015 were included. Cases of iatrogenic perforation or perforation sites far away from the tumor sites and rectal (< 15 cm from the anal verge) cancer were excluded. Progression-free survival, local recurrence rate, distant metastasis rate, and overall survival were the evaluated outcomes. RESULTS: Eighty-one patients met the selection criteria; 23 and 58 patients had perforation and obstruction, respectively, as the initial symptom. The median age was 72 years. The median tumor stage was stage IIIB. The 1-year and 3-year survival rates were 83.7 and 59.7%, respectively. The perforation group (PRG) and obstruction group (OBG) did not differ significantly in intensive care unit (ICU) stay rate (p = 0.147), sex (p = 0.45), comorbidities (heart, liver, and renal diseases and diabetes mellitus), median stage (p = 0.198), and overall survival (p = 0.328). However, PRG had a higher age at diagnosis (74 vs. 64 years, p = 0.037), a higher APACHE II score (12 vs. 7, p = 0.002), lower disease-free survival (p = 0.001), a higher recurrence rate (56.5 vs. 19%, p = 0.002), a higher distant metastasis rate (39.1 vs. 13.8%, p = 0.015), and a higher local recurrence rate (43.5 vs. 5.2%, p < 0.001) than did OBG. OBG had a higher two-stage operation rate (46.6 vs. 17.4%, p = 0.022). After adjustment for the tumor stage, comorbidity (chronic renal disease), body mass index (BMI), and adjuvant chemotherapy or radiotherapy in multivariate statistics, PRG had lower disease-free survival (p = 0.005) than OBG but overall survival was identical. CONCLUSION: For colon cancer initially presenting as perforation or obstruction, the PRG had poorer progression-free survival, a higher local recurrence rate, and a higher distant metastasis rate than did OBG. Overall survival did not differ between these two groups.

Effect of an Anterior Cingulotomy on Pain, Cognition, and Sensory Pathways.

BACKGROUND: Anterior cingulotomy (AC) was originally used to treat patients with a psychiatric disorder, but it is also useful for treating patients with chronic intractable pain. We reviewed 24 patients at our hospital who underwent AC for chronic intractable pain to determine whether surgery influenced patient cognition and the pain circuit. METHODS: A visual analog scale (VAS) was used to evaluate patients' pain scale preoperatively, at 1 month and 3-6 months postoperatively, and at the final follow-up. Mini-Mental State Examination (MMSE) and Cognitive Abilities Screening Instrument (CASI) were used to evaluate postoperative cognitive function. The latencies of peaks P20 and P37 of the somatosensory evoked potential (SSEP) conductive time were used to evaluate the intactness of the thalamocortical tract after AC. RESULTS: The median preoperative VAS score was 8, MMSE score was 27, and CASI score was 86.8. Six patients underwent a reoperation because of recurrent pain. Pain was significantly reduced after AC, and the median VAS score at the last follow-up was 5. There was no significant pain improvement in patients who underwent a reoperation. There were no significant changes in MMSE and CASI scores or SSEP after cingulotomy. There were no operation-related complications in the patients. CONCLUSIONS: A stereotactic AC was safe and effective in resolving chronic refractory pain. It did not affect patient cognition or the sensory conductive pathway. However, patients who had recurrent intractable pain after a cingulotomy did not respond well to the reoperation.