Clinical and Radiological Outcomes of a Comparative Study of Anterior Cervical Decompression and Fusion with Partial Pediculotomy, Partial Vertebrotomy (PPPV) Posterior Endoscopic Cervical Decompression (PECD) for Cervical Foraminal Pathology.

Background and Objectives: The purpose was to compaSre medium-term clinical and radiological outcomes of Partial Pediculotomy, Partial Vertebrotomy (PPPV) Posterior Endoscopic Cervical Decompression (PECD) surgery versus Anterior Cervical Discectomy and Fusion (ACDF) for patients with cervical disc herniations and foraminal pathologies. Materials and Methods: A prospective registry of patients who had undergone either PPPV PECD surgery or ACDF surgery for cervical disc herniation or foraminal pathologies under a single fellowship-trained spine surgeon was performed. The baseline characteristics and operative details including complications were recorded for all included patients. The clinical outcomes evaluated include VAS, MJOA, motor score, and NDI and MacNab's score. The radiological parameters in neutral-measured facet length, facet area, disc height, C2-C7 angle, neck tilt angle, T1 slope and thoracic inlet angle were also evaluated. Results: A total of 55 patients (29 PPPV PECD, 26 ACDF) were included, with mean follow-up periods of 21.9 and 32.3 months, respectively. Each cohort was noted to have a single case of surgical complication. Statistically significant changes of facet area (49.05 ± 14.50%) and facet length (52.71 ± 15.11%) were noted in the PPPV PECD group. At neutral alignment of the neck on a lateral X-ray, compared to ACDF, PPPV PECD had a statistically significant change in neck tilt angle (-11.68 ± 17.35°) and T1 slope angle (-11.69 ± 19.58°). Whilst both PPPV PECD and ACDF had significant improvements in VAS, MJOA and NDI postoperatively, PPPV PECD was found to be superior across all above scores at various follow-up timepoints compared to its ACDF counterparts. Conclusions: PPPV PECD surgery achieved a satisfactory radiological correction of neck alignment and significantly improved clinical outcomes at medium-term follow-up for our cohort of patients, highlighting its feasibility in treating patients with cervical disc herniations and foraminal pathologies.

Posterior endoscopic cervical foramiotomy and discectomy: clinical and radiological computer tomography evaluation on the bony effect of decompression with 2 years follow-up.

PURPOSE: Cervical radiculopathy is a common disabling cervical spine condition. Open anterior and posterior approaches are the conventional surgical treatment approaches with good clinical outcomes. However, the soft tissue damage in these procedures can lead to increase perioperative morbidity. Endoscopic spine surgery provides more soft tissue preservation than conventional approaches. We investigate the radiological and clinical outcomes of posterior endoscopic cervical foraminotomy and discectomy. METHODS: A prospective clinical and radiological study with retrospective evaluation were done for 25 patients with 29 levels of cervical radiculopathy who underwent posterior endoscopic cervical discectomy from November 2016 to December 2018. Clinical outcomes of Visual Analogue Scale, Neck Disability Index and MacNab's score were evaluated at pre-operative, post-operative 1 week, 3 months and final follow-up. Preoperative and post-operative final follow-up flexion and extension roentgenogram were evaluated for cervical stability assessment. Pre-operative and post-operative computer tomography cervical spine evaluation of foraminal length in ventro-dorsal, cephalad-caudal dimensions, sagittal foraminal area and using 3D CT reconstruction coronal decompression area were done. RESULTS: Twenty-nine levels of cervical radiculopathy underwent posterior endoscopic cervical decompression. The mean follow-up was 29.6 months, and the most common levels affected were C5/6 and C6/7. There was a complication rate of 12% with 2 cases of neurapraxia and one case of recurrent of prolapsed disc. There was no revision surgery in our series. There was significant clinical improvement in Visual Analogue Scale and Neck Disability Index. Prospective comparative study between preoperative and final follow-up mean improvement in VAS score was 5.08 ± 1.75, and NDI was 45.1 ± 13.3. Ninety-two percent of the patients achieved good and excellent results as per MacNab's criteria. Retrospective evaluation of the radiological data showed significant increments of foraminal dimensions: (1) sagittal area increased 21.4 ± 11.2 mm2, (2) CT Cranio Caudal length increased 1.21 ± 1.30 mm and (3) CT ventro-dorsal length increased 2.09 ± 1.35 mm and (4) 3D CT scan reconstruction coronal decompression area increased 536 ± 176 mm2, p < 0.05. CONCLUSION: Uniportal posterior endoscopic cervical foraminotomy and discectomy are safe, efficient and precise choreographed set of technique in the treatment of cervical radiculopathy. It significantly improved clinical outcomes and achieved the objective of increasing in the cervical foramen size in our cohort of patients.

How I do it? Full endoscopic transforaminal approach for lumbar disc herniation that migrated bilaterally to four corners.

BACKGROUND: Despite of the evolution of endoscopic surgery, the literature on technique uniportal transforaminal endoscopic lumbar discectomy (TELD) for bilateral lesions is scarce. METHODS: Unilateral TELD was performed in a patient with bilateral superior and inferior migrated, broad-based disc herniation presenting with an impaired neurological state. The key surgical steps focus on free mobility in Kambin triangle with the mobile outside-in technique and accessibility to contralateral lesions with an extensive annular resection procedure. CONCLUSION: TELD can be a surgical option for treating bilateral multiple direction migrated lumbar disc herniation with benefits of minimal neural retraction and facet joint preservation.

Infected Schmorl's node: a case report.

BACKGROUND: Schmorls node (SN) are mostly asymptomatic and incidental findings on MRI. However, sometimes they present like acute onset low back pain or acute exacerbation of chronic back pain after minor trauma. CASE PRESENTATION: We present rare case of symptomatic infected SN in 67 years female patient presented with complains of low back pain radiating to right buttock. After initial conservative treatment failed subsequent imaging showed significant increase in size of lesion with focal signal changes in disc space gave suspicion of underlying secondary pathology. Patient operated for complete excision of lesion. Histopathological report was suggestive of pyogenic vertebral osteomyelitis. Patient improved well postoperatively. CONCLUSION: Most of the time acute SN responds well to conservative treatment; however rapid deterioration of symptoms or persistent severe pain should give suspicion of underlying secondary pathology.

How I do it? Uniportal full endoscopic contralateral approach for lumbar foraminal stenosis with double crush syndrome.

BACKGROUND: Evolution of endoscopic surgery provides equivalent results to open surgery with advantages of minimal invasive surgery. The literature on technique Uniportal Full endoscopic contralateral approach is scarce. METHODS: The endoscopic contralateral approach technique applies for patients presenting with double crush syndrome with foraminal and extraforminal stenosis. The key steps focus on contralateral ventral overriding superior articular process decompression, foraminal and extraforaminal discectomy, and lateral vertebral syndesmophyte decompression leading to enlargement of the contralateral foramen and extraforamen size. CONCLUSION: The Uniportal Full endoscopic contralateral approach is a good alternative to open surgery or minimally invasive microscopic surgery through direct endoscopic visualization of the entire route of exiting nerve with no neural retraction allowing both lateral recess and foraminal and extraforaminal decompression all in one approach.

Percutaneous full endoscopic treatment of cystic lymphangioma of cauda equina: a case report.

Intraspinal epidural lymphangioma of cauda equina are extremely rare, only three cases have been reported in the past. We report a 63-year-old female with lymphangioma at S1-S2 level which was resected under epidural anesthesia using a percutaneous full endoscope with no evidence of recurrence at 19 months follow-up.

Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease.

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.

Lumbar Degenerative Disease Part 1: Anatomy and Pathophysiology of Intervertebral Discogenic Pain and Radiofrequency Ablation of Basivertebral and Sinuvertebral Nerve Treatment for Chronic Discogenic Back Pain: A Prospective Case Series and Review of Literature.

Degenerative disc disease is a leading cause of chronic back pain in the aging population in the world. Sinuvertebral nerve and basivertebral nerve are postulated to be associated with the pain pathway as a result of neurotization. Our goal is to perform a prospective study using radiofrequency ablation on sinuvertebral nerve and basivertebral nerve; evaluating its short and long term effect on pain score, disability score and patients' outcome. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain with bulging degenerative intervertebral disc or spinal stenosis underwent Uniportal Full Endoscopic Radiofrequency Ablation application through either Transforaminal or Interlaminar Endoscopic Approaches. Their preoperative characteristics are recorded and prospective data was collected for Visualized Analogue Scale, Oswestry Disability Index and MacNab Criteria for pain were evaluated. There was statistically significant Visual Analogue Scale improvement from preoperative state at post-operative 1wk, 6 months and final follow up were 4.4 ± 1.0, 5.5 ± 1.2 and 5.7 ± 1.3, respectively, p < 0.0001. Oswestery Disability Index improvement from preoperative state at 1week, 6 months and final follow up were 45.8 ± 8.7, 50.4 ± 8.2 and 52.7 ± 10.3, p < 0.0001. MacNab criteria showed excellent outcomes in 17 cases, good outcomes in 11 cases and fair outcomes in 2 cases Sinuvertebral Nerve and Basivertebral Nerve Radiofrequency Ablation is effective in improving the patients' pain, disability status and patient outcome in our study.

Bilateral chylothorax following anterior cervical spine surgery.

Bilateral chylothorax following anterior cervical spine surgery is very rare. This report documents the first case of chylothorax after anterior cervical spine surgery through a right-side surgical approach. Unidentified chyle leakage can easily remain unrecognized and, thus, is difficult to treat. For early diagnosis and treatment, it is very important to consider the possibility of chylothorax following anterior cervical spine surgery, even when using a right-side surgical approach.

Comparison of En Masse Repair versus Separate Double-Layer Repair for Delaminated Rotator Cuff Tears: A Systematic Review and Meta-Analysis.

BACKGROUND: Delamination of cuff tendons has a negative impact on outcomes following arthroscopic rotator cuff repair (RCR). The purpose of this study is to compare en masse repair (EMR) and separate double-layer repair (SDLR) for delaminated rotator cuff tears. METHODS: A systematic literature search was conducted on major databases (MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus) until 1 June 2023. Comparative studies with a minimum 24-month follow-up of patients undergoing arthroscopic RCR for delaminated tears were included. The outcomes assessed retear rates and functional outcomes. RESULTS: Five eligible studies involving 325 cases were analyzed. The meta-analysis showed no significant difference in retear rates between SDLR and EMR for delaminated tears (OR = 0.73, 95% CI: 0.35-1.49). However, the meta-analysis demonstrated a significant intergroup difference in favor of the SDLR for the total Constant score (SMD = 0.68, 95% CI: 0.35 to 1.02), SST score (SMD = 0.37, 95% CI: 0.02 to 0.71), and postoperative range of abduction (SMD = 0.34, 95% CI: 0.03 to 0.64). CONCLUSION: The evidence suggests that the SDLR in arthroscopic RCR for delaminated rotator cuff tears leads to improved short-term functional outcomes and range of motion compared to EMR. However, there is no significant difference in retear risk between the two approaches.

Outcomes of Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon in Large to Massive Rotator Cuff Tears: A Meta-Analysis and Systematic Review.

(1) Background: Addressing large to massive rotator cuff tears (LMRCTs) poses complex challenges. This systematic review investigated outcomes of superior capsular reconstruction (SCR) with the long head of the biceps tendon (LHBT) compared to conventional rotator cuff repair (RCR) for LMRCTs. (2) Methods: A systematic search across the MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus databases until 1 October 2023 identified studies that directly compared SCR with LHBT with conventional RCR in patients with LMRCTs and included a minimum of a 12-month follow-up period. The assessed outcome measures encompassed retear rates, functional outcomes, range of motion (ROM), and acromiohumeral interval (AHI). Risk of bias assessment was conducted via the Robins-I tool. (3) Results: In six studies with 456 cases (210 SCR using LHBT and 246 using RCR), SCR with LHBT significantly reduced retear rates (OR = 0.21; 95% CI, 0.12-0.36; p < 0.01; I2 = 0%). Furthermore, SCR with LHBT showed significant improvement in range of forward flexion (SMD 0.32, 95% CI: 0.09-0.55, p < 0.01, I2 = 39%) and AHI (SMD 0.61, 95% CI: 0.31-0.92, p < 0.01, I2 = 0%) postoperatively. (4) Conclusion: SCR with LHBT is a safe and effective treatment for LMRCTs, reducing retear rates, maintaining greater postoperative AHI, and improving ROM compared to conventional RCR. Additional high-quality interventional studies are needed to confirm these results.

Effect of Bone Marrow Stimulation on Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis.

Background: Arthroscopic rotator cuff repair (RCR) is a common orthopaedic procedure, but it has a high rate of retears that can negatively affect the functional outcomes. Bone marrow stimulation (BMS) has been suggested as an additional treatment to improve the outcomes of RCR. Purpose: To compare the effectiveness of the BMS procedure during RCR with conventional RCR. Study Design: Systematic review; Level of evidence, 2. Methods: A systematic literature search was conducted in MEDLINE/PubMed, Embase, Cochrane Library, and Scopus, on March 1, 2023, for studies comparing postoperative retear rates and functional outcomes between patients who underwent primary arthroscopic RCR with and without the BMS procedure. Only level 1 and 2 randomized controlled trials with a minimum 12-month follow-up were included. The primary outcomes were retear rates and functional outcomes as measured by the Constant; American Shoulder and Elbow Surgeons (ASES); and University of California, Los Angeles (UCLA) scores and by postoperative range of motion. Subgroup analyses were performed based on repair technique (single-row repair vs double-row or suture-bridge repair). The standardized mean difference (SMD) and odds ratio (OR) were utilized to synthesize continuous and dichotomous outcomes, respectively. Homogeneity was evaluated using the chi-square test and I2 statistic. Results: The literature search yielded 661 articles, of which 6 studies (522 patients; 261 with BMS, 261 without BMS) met the eligibility criteria. The combined analysis showed no significant decrease in retear rates with the utilization of the BMS procedure during RCR (OR, 0.60; 95% CI, 0.35 to 1.03; P = .07; I2 = 24%). There was no significant intergroup difference in functional outcomes (Constant score: SMD, 0.13; 95% CI, -0.04 to 0.31; P = .13; I2 = 0%; ASES score: SMD, 0.04; 95% CI, -0.20 to 0.28; P = .73; I2 = 0%; UCLA score: SMD, -0.13; 95% CI, -0.50 to 0.23; P = .47; I2 = 0%). Subgroup analyses revealed no significant differences in postoperative retear risk or total Constant score according to the repair technique. Conclusion: Based on the available evidence, this systematic review did not find a significant benefit of the BMS procedure at the footprint during arthroscopic RCR compared with conventional RCR in terms of retear rates and functional outcomes at short-term follow-up.

Narrative Review of Uniportal Posterior Endoscopic Cervical Foraminotomy.

Cervical radiculopathy is a common and disabling cervical condition characterized by symptoms including axial neck pain, radicular pain, weakness, and numbness in one or both arms. Common causes include herniated discs and foraminal stenosis, often accompanied by varying degrees of degenerative disc disease and uncovertebral joint hypertrophy. In the treatment of cervical radiculopathy, there is an increasing preference for posterior foraminotomy over anterior cervical discectomy and fusion due to the avoidance of fusion-related complications. As endoscopic spine surgery techniques continue to evolve, there is a rising interest in posterior endoscopic cervical foraminotomy and posterior endoscopic cervical discectomy as effective treatments for cervical radiculopathy. Because these procedures can performed through a single subcentimeter incision with minimal soft tissue damage, they can often be carried out as ambulatory procedures. In this narrative review, we examined current literature addressing the indications, surgical techniques, outcomes, and potential complications associated with posterior cervical endoscopic approaches.

Serratus Anterior Plane Block: A Better Modality of Pain Control after Pectus Excavatum Repair.

Background: Postoperative pain management following minimally invasive repair of pectus excavatum (MIRPE) remains a critical concern due to severe post-procedural pain. Promising results have been reported for cryoanalgesia following MIRPE; however, its invasiveness, single-lung ventilation, and additional instrumentation requirements remain obstacles. Serratus anterior plane block (SAPB) is a regional block technique capable of covering the anterior chest wall at the T2-9 levels, which are affected by MIRPE. We hypothesized that SAPB would be a superior alternative pain control modality that reduces postoperative pain more effectively than conventional methods. Methods: We conducted a retrospective study of patients who underwent MIRPE between March 2022 and August 2023. The efficacy of pain control was compared between group N (conventional pain management, n=24) and group S (SAPB, n=26). Group N received intravenous patient-controlled analgesia (IV-PCA) and subcutaneous local anesthetic infusion. Group S received bilateral continuous SAPB with 0.3% ropivacaine after a bilateral bolus injection of 30 mL of 0.25% ropivacaine with baseline IV-PCA. Pain levels were evaluated using a Visual Analog Scale (VAS) at 1, 3, 6, 12, 24, 48, and 72 hours postoperatively and total intravenous rescue analgesic consumption by morphine milligram equivalents (MME). Results: Mean VAS scores were significantly lower in group S than in group N throughout the 72-hour postoperative period (p<0.01). Group S showed significantly lower MME at postoperative 72 hours (group N: 108.53, group S: 16.61; p<0.01). Conclusion: SAPB improved immediate postoperative pain control in both the resting and dynamic states and reduced opioid consumption compared to conventional management.

Epidural, Inadvertent Subdural, and Combined Epidural-Subdural Anesthesia in Lumbar Spine Surgery: A Retrospective Analysis.

This study aimed to categorize contrast media images associated with epidural, subdural, and combined epidural-subdural anesthesia in patients who had undergone fluoroscopy-guided epidural anesthesia using contrast media combined with monitored anesthesia care (MAC) targeted at deep sedation, incorporating capnography over 5 years. Additionally, a correlation was established between the anesthetic effects and radiographic findings according to the categorized imaging appearances. This study included 628 patients who underwent endoscopic, open, or fusion surgery under epidural anesthesia at Nanoori Hospital in Gangnam between March 2018 and September 2023. Fluoroscopy-guided epidural anesthesia using contrast media combined with MAC and capnography was used. The dataset included detailed radiographic imaging, nursing, and anesthesia records. Distinct patterns of anesthesia administration were observed, with 49%, 19.6%, and 31% of patients receiving epidural, subdural, and combined epidural-subdural anesthesia, respectively. The incidence and duration of motor block were significantly different among the three groups. Additionally, subdural anesthesia displayed a higher incidence of motor block and a prolonged motor deficit duration than epidural anesthesia. Fluoroscopic guidance using a contrast medium for epidural and subdural anesthesia ensures precise space identification and prevents serious anesthetic complications. Our findings suggest the potential to achieve stable anesthesia, particularly using subdural and combined epidural-subdural anesthesia.

Narrative Review of Pathophysiology and Endoscopic Management of Basivertebral and Sinuvertebral Neuropathy for Chronic Back Pain.

Chronic lower back pain is a leading cause of disability in musculoskeletal system. Degenerative disc disease is one of the main contributing factor of chronic back pain in the aging population in the world. It is postulated that sinuvertebral nerve and basivertebral nerve main mediator of the nociceptive response in degenerative disc disease as a result of neurotization of sinuvertebral and basivertebral nerve. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain and management strategy is discussed in this review to aid understanding of sinuvertebral and basivertebral neuropathy treatment strategies.

ALiGN: Attention based Line Guided Network for Vertebral Comprssion Fracture Detection.

Vertebral Compression Fracture (VCF) is one of the common fractures, especially for elderlies. As it affects postural deformation that may cause secondary disorders in the respiratory or digestive system if not treated in time, diagnosis of VCF is crucial. Using deep learning model based detection technology in diagnosis can reduce the workload of healthcare workers and misdiagnosis. Hence in this work, we propose ALiGN, a compression fracture detection model in the lumbar vertebra based on a deep convolutional neural network (CNN). Specifically, we take the location of each vertebral body into account via a feature pyramid network with an attention mechanism. Our proposed model outperforms the earlier works with a sensitivity 0.9729, specificity 0.9914, and mAP 0.7882.

Impact of Chronic Obstructive Pulmonary Disease on Outcomes After Total Joint Arthroplasty: A Meta-analysis and Systematic Review.

Background: Comorbid chronic obstructive pulmonary disease (COPD) is increasingly common and may have an adverse impact on outcomes in patients undergoing total joint arthroplasty (TJA) of lower extremity. The purpose of this meta-analysis is to compare the postoperative complications between COPD and non-COPD patients undergoing primary TJA including total hip and knee arthroplasty. Methods: PubMed, EMBASE, and Cochrane Library were systematically searched for relevant studies published before December 2021. Postoperative outcomes were compared between patients with COPD versus those without COPD as controls. The outcomes were mortality, re-admission, pulmonary, cardiac, renal, thromboembolic complications, surgical site infection (SSI), periprosthetic joint infection (PJI), and sepsis. Results: A total of 1,002,779 patients from nine studies were finally included in this meta-analysis. Patients with COPD had an increased risk of mortality (OR [odds ratio] = 1.69, 95% confidence interval [CI] 1.42-2.02), re-admission (OR = 1.54, 95% CI 1.38-1.71), pulmonary complications (OR = 2.73, 95% CI 2.26-3.30), cardiac complications (OR = 1.40, 95% CI 1.15-1.69), thromboembolic complications (OR = 1.21, 95% CI 1.15-1.28), renal complications (OR = 1.50, 95% CI 1.14-1.26), SSI (OR = 1.23, 95% CI 1.18-1.30), PJI (OR = 1.26, 95% CI 1.15-1.38), and sepsis (OR = 1.36, 95% CI 1.22-1.52). Conclusion: Patients with comorbid COPD showed an increased risk of mortality and postoperative complications following TJA compared with patients without COPD. Therefore, orthopedic surgeons can use the study to adequately educate these potential complications when obtaining informed consent. Furthermore, preoperative evaluation and medical optimization are crucial to minimizing postoperative complications from arising in this difficult-to-treat population. Level of evidence: Level III. Registration: None. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-022-00794-2.

Uniportal Thoracic Endoscopic Unilateral Laminotomy with Bilateral Decompression of Thoracic Ossification of Ligamentum Flavum: A Systematic Review of Current Literature.

BACKGROUND: Thoracic ossification of ligamentum flavum (TOLF) is a rare disease that often results in worsening neurologic sequelae if left untreated. Although the gold standard treatment for TOLF is open posterior laminectomy, it is often accompanied by high rates of complications and perioperative morbidity. There have been studies looking into feasibility of endoscopic posterior decompression for TOLF, citing potential for lower perioperative morbidity and achieving similar functional outcomes to its open laminectomy counterparts. We provide an up-to-date systematic review of clinical outcomes after endoscopic posterior decompression for TOLF from the latest assemblage of evidence. METHODS: A systematic review of the technique was conducted from May 2000 to May 2023. Articles were selected based on PRISMA guidelines. Eligibility of studies was independently by 2 reviewers, with disagreements resolved by a third author. RESULTS: Nineteen primary references comprising 337 patients with TOLF who underwent endoscopic posterior decompression were included in the systematic review. Mean follow-up time across all studies ranged from 8.9 to 65.3 months. Mean age ranged from 51.2 to 63 years, with mean intraoperative blood loss ranging from 15 to 62 mL. There is significant improvement in visual analog scale (VAS) score, VAS back, VAS leg, modified Japanese Orthopaedic Association score, and Oswestry Disability Index compared with preoperative recorded values across all studies, with low rates of complications reported. CONCLUSIONS: Endoscopic posterior spinal decompression is a safe and effective technique for treatment of TOLF, with a low rate of complications and improvement in pain and function.

Minimally Neural Retractive, Total Annular Resection, Transforaminal Endoscopic (TARTE) Approach for Severely Canal Compromising Lumbar Disk Herniation Accompanied by a Neurologic Deficit.

OBJECTIVE: Treatment of severely canal compromising lumbar disk herniations (LDH), occupying more than 50% of the canal area, are associated with technical difficulty and worse outcomes. This study aimed to describe new techniques of transforaminal endoscopic lumbar diskectomy (TELD) with less neural retraction, and total annular resection for broad-based severely canal compromising disk herniation. We also evaluated the feasibility and safety of the techniques, and analyzed the clinical and radiologic outcomes of 32 patients presenting with neurologic deficits. METHODS: A retrospective cohort study was performed with 32 consecutive patients who underwent TELD for broad-based severely canal compromising LDH between January 2018 and January 2020. We removed the LDH using two novel techniques: (1) the "mobile outside-in" approach and total annular resection method and (2) internal decompression and subsequent pushdown method of the migrated fragment. The cross-sectional area (CSA) on magnetic resonance image was evaluated preoperatively and compared with the postoperative image within 7 days and between 6 months and 1 year. The visual analog scale (VAS) for back and leg pain, Oswestry disability index (ODI), MacNab's criteria, and motor power of the involved lower extremities were evaluated pre- and postoperatively. RESULTS: A total of 32 patients, with an average age of 37.5 years (range: 17-66), underwent surgery. The mean VAS score for back pain improved from 7.84 ± 1.02 to 1.31 ± 0.54 and the ODI score improved from 74.3 ± 7.82 to 20.4 ± 3.71 at final follow-up. According to MacNab's criteria, 23 patients had excellent and 9 patients had good outcomes at final follow-up. All patients operated on at the L4-L5 level had great toe/ankle dorsiflexion and/or ankle plantar flexion weakness; knee extension weakness was found at the L2-L3 and L3-L4 levels. Motor function improved significantly; the mean values and range preoperatively, and at 1 month, 3 months, and final follow-up, were 3.41 ± 0.95 (1-4), 4.56 ± 0.56 (3-5), 4.88 ± 0.34 (4-5), and 4.97 ± 0.18 (4-5), respectively (p < 0.001, at all follow-up). The mean values and range of the preserved CSA proportion, preoperatively and within 1 week after surgery, and at final follow-up were 34.9 ± 10.9 (15-61), 81.06 ± 10.24 (63-97), and 93.03 ± 5.37 (76-99), respectively (p < 0.001, at all follow-up). CONCLUSION: The transforaminal endoscopic approach for broad-based severely canal compromising LDH can be considered a feasible surgical option for an experienced surgeon. With total annular resection and pushdown of migrated fragments, safe and complete removal of LDH was possible in patients with a neurologic deficit. Total annular resection may increase the overall but not the early recurrence rate.