Patient radiation exposure during transforaminal lumbar endoscopic spine surgery: a prospective study.

OBJECTIVE The aim of this study was to describe patient radiation exposure during single-level transforaminal endoscopic lumbar discectomy procedures at levels L2-5 and L5-S1. METHODS Radiation exposure was monitored in 151 consecutive patients undergoing single-level transforaminal endoscopic lumbar discectomy procedures. Two groups were studied: patients undergoing procedures at the L4-5 level or above and those undergoing an L5-S1 procedure. RESULTS For the discectomy procedures at L4-5 and above, the average duration of fluoroscopy was 38.4 seconds and the mean calculated patient radiation exposure dose was 1.5 mSv. For the L5-S1 procedures, average fluoroscopy time was 54.6 seconds and the mean calculated radiation exposure dose was 2.1 mSv. The average patient radiation exposure dose among these cases represents a 3.5-fold decrease compared with the senior surgeon's first 100 cases. CONCLUSIONS Transforaminal lumbar endoscopic discectomy can be used as a minimally invasive technique for the treatment of lumbar radiculopathy in the setting of a herniated lumbar disc without the significant concern of exposing the patient to harmful doses of radiation. One caveat is that both the surgeon and the patient are likely to be exposed to higher doses of radiation during a surgeon's early experience in minimally invasive endoscopic spine surgery.

Transforaminal endoscopic decompression of a postoperative dislocated bone fragment after a 2-level lumbar total disc replacement: case report.

The proposed advantages of total disc replacement (TDR) over fusion in the lumbar spine are the preservation of motion and the avoidance of adjacent-level disease. One of the complications inherent in TDR is the possibility of vertebral body fracture due to trauma or a malpositioned implant. The resulting dilemma is that posterior decompression of the displaced bone fragment could then have a destabilizing effect and possibly require fusion, thus obviating the benefit of an arthroplasty procedure. In this study, the authors describe the technical considerations and feasibility of the treatment of a postoperative L-5 paresis that resulted from a dislocated bone fragment at L4-5 during a 2-level lumbar TDR.

Transforaminal endoscopic spinal surgery: the future 'gold standard' for discectomy? - A review.

BACKGROUND: Lumbar disc prolapse is common and the primary method of care in most centres is still open discectomy facilitated by microscope or loupe magnification and illumination. Hospitalisation may be less than 24 h, but post-operative pain usually requires an overnight stay. This review describes transforaminal endoscopic spinal surgery (TESS) using HD-video technology, that is generally performed as a day case procedure under sedation or light general anaesthesia, and collates the evidence comparing the technique to microdiscectomy. METHODS: The method of TESS is described and an electronic literature search performed to identify papers reporting clinical outcomes. International data were translated where necessary and proceedings' abstracts included. In addition, papers held by the authors and colleagues in personal libraries were carefully cross-referenced to the obtained database. RESULTS: Analysis of the data supports the use of a transforaminal endoscopic approach to the lumbar intervertebral disc and suggests that outcomes following surgery are at least equivalent to those following microdiscectomy. Significant cost-savings in terms of in-patient stay may be generated. In addition, there is also some evidence supporting endoscopic surgery for relief of foraminal stenosis. CONCLUSION: Based on current evidence there are good arguments supporting a more wide-spread adoption of transforaminal endoscopic surgery for the treatment of lumbar disc prolapse with or without foraminal stenosis.

Endoscopic Surgical Technique for Treating Sacral Radiculopathy Secondary to S1 Nerve Compression After Minimally Invasive Sacroiliac Joint Fusion: Technical Note.

BACKGROUND: Sacroiliac (SI) joint fusion is considered for the treatment of degenerative sacroiliitis. The procedure has increased in popularity for patients who have exhausted less invasive treatment options since the development of percutaneous SI joint fusion systems. One possible complication of the procedure is a sacral radiculopathy that can result from compression of the S1 nerve by the SI joint fusion implant. Others have described revising the implant by removing it and replacing it with a shorter implant. METHODS: Here we describe a minimally invasive endoscopic S1 nerve root decompression that does not require removing or revising the SI fusion implant. RESULTS: The postoperative course was uneventful, and the patient's radicular pain improved immediately after surgery. Six months after his endoscopic procedure, the patient had no clinical symptoms related to the S1 nerve root compression and was symptomatically improved from her sacroiliac pain. CONCLUSIONS: This technical note is for others to consider as a possible minimally invasive solution for the treatment of lumbar radiculopathy after a minimally invasive SI joint fusion procedure.

Endoscopic Spine Surgery: Distance Patients Will Travel for Minimally Invasive Spine Surgery.

BACKGROUND: Transforaminal lumbar endoscopic discectomy is a minimally invasive spine surgery procedure performed principally for the treatment of lumbar herniated discs. Endoscopic spine surgeons around the world have noted how far patients will travel to undergo this minimally invasive spine surgery, but the actual distance patients travel has never been investigated. OBJECTIVE: We present here our analysis of how far patients will travel for endoscopic spine surgery by studying the referral patterns of patients to 3 centers in 3 different countries. STUDY DESIGN: Retrospective chart review of de-identified patient data was performed to analyze the distance patients travel for spine surgery. METHODS: Patient demographic data was analyzed for patients undergoing transforaminal lumbar endoscopic discectomy procedures over the same 8 month period in 2015 at centers in the United States (U.S.), Netherlands, and Germany. RESULTS: Travel distances for patients were determined for 327 patients. The average distance traveled for the U.S. center was 91 miles, the Dutch center was 287 miles, and the German center was 103 miles. For the U.S. center 16% of patients traveled out of state for surgery and for the European centers combined, 4% of patients traveled out of the country for surgery. LIMITATIONS: The period of data analyzed was less than one year and the data collected was analyzed retrospectively. CONCLUSIONS: Quality metrics in health care tend to be focused on how health care is delivered. Another health care metric that focuses more on what patients desire is presented here: how far patients will travel for innovative spine care.Key words: Endoscopic spine surgery, transforaminal, minimally invasive, travel, lumbar disc herniation.

Minimally invasive fully endoscopic two-level posterior cervical foraminotomy: technical note.

Posterior cervical foraminotomy is an effective surgical treatment method for relieving radicular symptoms that result from cervical nerve root compression. Minimally invasive techniques and tubular retractor systems are available to minimize tissue retraction, but minimally invasive approaches can carry with them the surgical challenge of trying to pass instruments through a long narrow retractor that is also the port for visualizing the surgical pathology. Herein, the authors present a case of a 65-year-old man who presented with symptoms of a left C6 and C7 radiculopathy and left C5-6 and left C6-7 foraminal narrowing on MRI. A minimally-invasive fully endoscopic left C5-6 and C6-7 posterior foraminotomy was performed through a 1cm outer diameter working channel endoscopic with a 6 mm working channel. Clinicians should be aware that new minimally invasive non-fusion approaches for the treatment of cervical radiculopathy that utilize endoscopic visualization are now coming into use in clinical practice.

Transforaminal Endoscopic Decompression for Displaced End Plate Fracture After Lateral Lumbar Interbody Fusion: Technical Note.

Lateral lumbar interbody fusion is a minimally invasive approach to anterior spinal column fusion, deformity correction, and indirect decompression of the lumbar spine. A rarely reported possible complication of the procedure is end plate fracture, which has the potential for nerve root compression. Here we present a case of end plate fracture and nerve compression after stand-alone lateral lumbar interbody fusion, its diagnosis, and its subsequent successful treatment with transforaminal endoscopic spine surgery. The case highlights the possible role for minimally invasive endoscopic surgery as a rescue procedure after fusion complication.

Contralateral facet-sparing sublaminar endoscopic foraminotomy for the treatment of lumbar lateral recess stenosis: technical note.

Lumbar lateral recess stenosis that results from a degenerative bulging of the disc and overgrowth of the facet is a very common cause for lumbar radiculopathy in the elderly. The standard surgical treatment for symptomatic lumbar lateral recess stenosis often requires a laminectomy or hemi-laminectomy and medial facetectomy which can further destabilize a pathological motion segment. The authors present here a novel technique for contralateral endoscopic access to the lateral recess pathology that is truly minimally invasive and spares most of the facet joint complex: 6 patient cases are described where lateral recess stenosis pathology was accessed from a contralateral sublaminar endoscopic approach.

Transpedicular endoscopic surgery for lumbar spinal synovial cyst-report of two cases.

BACKGROUND: Lumbar facet cysts are a benign, degenerative, and fairly uncommon cause for lumbar radiculopathy. The standard surgical treatment for lumbar facet cysts often requires a laminectomy and medial facetectomy which can further destabilize a pathological motion segment. The authors present here a novel technique for transpedicular endoscopic access to the pathology that obviates the need to violate the lamina or facet. METHODS: Two patient cases are described where the lumbar 4-5 facet cysts arise medial to the pedicle. Percutaneous access to the cysts was established by drilling through the adjacent pedicle creating a 7-mm corridor to establish access for the endoscopic tubular retractor and the working channel endoscope. Straight and bendable forceps were used to remove the cysts under direct visualization. RESULTS: Following surgery, the patients' symptoms showed immediate regression with complete relief of one patient's foot drop by 6 months. CONCLUSIONS: Transpedicular endoscopic access is described as novel minimally invasive surgical option in the awake patient for lumbar facet cysts adjacent to the Lumbar 4 or 5 pedicle.

Transpedicular Lumbar Endoscopic Surgery for Highly Migrated Disk Extrusions: Preliminary Series and Surgical Technique.

OBJECTIVE: Endoscopic surgery for highly migrated lumbar disk extrusions is a challenge even for spine surgeons who are familiar with using endoscopic techniques. Because of the anatomic constraints involved in transforaminal access in endoscopic surgery, an incomplete removal of a highly migrated disk extrusion can result in some cases. Here the authors describe a new technique for accessing extruded lumbar disks that have migrated into the canal directly through a transpedicular approach. METHODS: A technique for the endoscopic treatment of highly migrated lumbar disk extrusions is presented. Retrospectively, we reviewed a series of 21 consecutive patients operated on with lumbar 3-4, lumbar 4-5, and lumbar 5-sacral 1 highly migrated disk extrusions: preoperative and postoperative clinical data with 1-year follow-up. RESULTS: A preliminary series of 11 male and 10 female patients with an average age of 56.9 years (from 33-78 years old) who underwent transpedicular endoscopic retrieval of an extruded lumbar disk between 2012 and 2015 is presented. Two patients required revision to transforaminal access, 1 at the same sitting and the other 4 weeks later. The mean visual analog scale score for radicular pain improved from an average pain score before surgery of 8.1-1.7 one year after surgery. No pedicle fractures were encountered. CONCLUSIONS: Transpedicular endoscopic access to highly migrated lumbar herniated disk extrusions is presented as a unique minimally invasive approach to extruded lumbar herniated disks, especially at L3-4, L4-5, and L5-S1.

Transforaminal Endoscopic Solution to a Kyphoplasty Complication: Technical Note.

Kyphoplasty is a minimally invasive spine surgical procedure performed to stabilize and treat the pain caused by a spine compression fracture. Complications are rare with kyphoplasty and include cement extrusion into the vertebral canal leading to spinal cord or nerve root compression. Herein, the authors present a case of a 72-year-old woman who presented with symptoms of a right L2 radiculopathy after a kyphoplasty procedure. Computed tomography imaging showed leakage of the kyphoplasty cement into the neural foramen above and medial to the right L2 pedicle. A transforaminal endoscopic surgical approach was used to remove the cement and decompress the L2 nerve. The patient's postoperative clinical course was uneventful. Clinicians should be aware that for the treatment of complications to vertebroplasty and kyphoplasty procedures, minimally invasive transforaminal endoscopic surgery is one option to avoid the destabilizing effects of laminectomy and facetectomy.

Transforaminal Endoscopic Foraminoplasty and Discectomy for the Treatment of a Thoracic Disc Herniation.

Transforaminal endoscopic spine surgery has emerged internationally as a minimally invasive technique that can be performed in an awake patient in the outpatient setting. Advances in high-definition endoscopic camera technologies as well as the availability of specialty graspers, reamers, drills, and other instruments that can be used down a working channel endoscope have made a myriad of spine diseases accessible to the minimally invasive spine surgeon. The major challenge inherent in the surgical treatment of thoracic disc disease is that the disc herniation is often ventral to the spinal cord. The transforaminal approach and the angled endoscopic camera are an ideal combination for creating a technical advantage to accessing thoracic disc disease.