Unilateral Biportal Endoscopy for L5-S1 Extraforaminal Stenosis (Far Out Syndrome) - Technical Note with Literature Review.

Introduction: Extraforaminal stenosis in L5-S1, or far-out syndrome (FOS), is defined as L5 nerve compression by the transverse process (TP) of the L5 and the ala of the sacrum and disc bulging with/without osteophytes and/or the thickened lumbosacral and extraforaminal ligament. This study aims to describe the unilateral biportal endoscopic decompression technique of the extraforaminal stenosis at L5-S1 or far out syndrome and evaluate its clinical results with a literature review. Case Report: A 44-year-old male presented with severe right sharp shooting pain in the buttock, thigh, leg, foot, and/or toes with numbness in the foot and toes (Visual Analog Scale [VAS] 8/10) for six months with an Oswestry disability index (ODI) score of 70%. Her pain aggravated when bending forward and performing daily routine activities. He also complained of exaggeration of pain in daily regular activities. On physical examination, power in the right lower limbs was 5/5 as per the Medical Research Council (MRC) grading, and deep tendon reflexes were normal. Pre-operative X-ray and CT scan showed no instability or calcified disc osteophyte, and magnetic resonance imaging showed extraforaminal stenosis due to disc herniation at L5-S1 in Figure 1. We performed UBE-L5-S1extraforaminal discectomy surgery to resolve his symptoms. The operative time was 68 min; blood loss was 30 mL. After surgery, the patient was followed up at one week, six weeks, three months, six months, 12 months, and two years. The pain and tingling sensation in the legs improved at the 1-week follow-up, with a VAS score of 0/10 and an ODI score of 10% at the 2-year follow-up. Patient satisfaction was surveyed using Macnab's criteria at the final follow-up visit of 2 years and was found to be excellent. Post-operative imaging showed a good extraforaminal decompression at L5-S. Conclusion: Unilateral biportal endoscopy technique has brought a paradigm shift in the treatment of spinal pathologies and has served as another treatment option for the past two decades. The UBE decompression technique for extraforaminal stenosis at L5-S1 has the advantages of minimally invasive spine surgery; it is a safe and effective treatment option for treating extraforaminal stenosis at L5-S1.

Philosophies and Surgical Techniques for High-Grade Spondylolisthesis Treatment with Literature Review.

Introduction: High-grade spondylolisthesis is defined as cases with more than 50% displacement and spondylolisthesis with Meyerding grade III and higher. The surgical management of high-grade spondylolisthesis is highly controversial. Many surgical methods have been reported such as posterior in situ fusion, instrumented posterior fusion with or without reduction, combined anterior and posterior procedures, spondylectomy with reduction of L4 to the sacrum (for spondyloptosis), and posterior interbody fusion with trans-sacral fixation. The literature has recently mentioned minimally invasive transforaminal lumbar interbody fusion for high-grade spondylolisthesis. This study aimed to review the recent literature that describes the surgical outcomes associated with various surgical techniques used for high-grade spondylolisthesis. Materials and Methods: Recent articles were searched on search engines such as PubMed and Google Scholar using keywords such as "high-grade spondylolisthesis," "surgical techniques," and "complications." Discussion: The surgical management of high-grade spondylolisthesis is an area of significant controversy. The literature is replete with regards to the need for reduction, decompression, levels of fusion, the nature of instrumentation, surgical approaches including open, minimally invasive, and "mini-open" procedures, and various techniques for reducing the slip and fusion strategy. The three basic options of high-grade spondylolisthesis include in-situ fusion, partial reduction and fusion, and complete reduction. Conclusion: Various techniques have been described for high-grade spondylolisthesis. Spine deformity study group classification gives guidelines about balanced and unbalanced pelvis and advises reduction and fusion in case of unbalanced pelvis for correction of biomechanical and global sagittal alignment. Each of the surgical techniques has its advantages and disadvantages. However, individual authors' experience, skill levels, and anatomic reduction with fusion techniques have yielded encouraging results.

Use of Navigable Ablation Decompression Treatment (L-DISQ) for Contained Cervical Disc Herniation - Technical Note and Literature Review.

Introduction: A new navigable percutaneous disc decompressor (L'DISQ-C, U&I Co., Uijeongbu, Korea), introduced in 2012, is designed to allow direct access to herniated disc material. The L'DISQ device can be curved by rotating a control wheel, directed into disc herniation treats, and decompresses contained herniated discs with minimal collateral thermal damage. This study reports the case of contained central disc herniation in a 34-year-old male with a 2-year follow-up successfully treated with navigable ablation decompression treatment (L-DISQ). Case Report: A 34-year-old man presented to the outpatient department with a 6-month history of neck pain and bilateral upper limb radiation. His neck pain had increased progressively. At the time of presentation, his neck pain visual analog scale score was 7/10, and his neck disability index score was 30. The magnetic resonance images showed a single fluid-containing lesion with a hyperintense zone at the C4-5 levels with central disc herniation. The patient was successfully treated with the navigable ablation decompression treatment (L-DISQ) procedure. Conclusion: The navigable ablation decompression treatment (L-DISQ) is a valuable technique in treating contained cervical disc herniation with rapid pain relief and improvements in functional outcomes without any significant injury to surrounding structures. It is safe, precise, and effective in the treatment of symptomatic cervical disc herniations. Large, randomized, and multicenter trials are needed to explore the potential of the same technique further.

Trans sacral Endoscopic laser Decompression- a case report, technical note and literature review.

Introduction: The concept of sacral epiduroscopic laser decompression (SELD) is based on the introduction of a steerable catheter in the sacral hiatus followed by the insertion of a fiberoptic laser system into the ventral side of the epidural disc space with an epiduroscope. This procedure enables the direct decompression of the ruptured annulus as the laser vaporizes the bulging disc in the herniated part, cauterization of the sinuvertebral nerve, adhesiolysis of structures nearby the nerve root, and irrigation of inflammation with saline and steroids. Case Report: A 44-year-old man presented to the outpatient department with a 12-month history of low back pain. His back pain had increased progressively. At the time of presentation, his back pain VAS score was 7/10 and his ODI score was 44. He had received non-steroidal anti-inflammatories for more than 6 months and an epidural injection elsewhere with minimal relief from symptoms. On physical examination, power in the lower limbs was 5/5 as per the MRC grading, and deep tendon reflexes were normal. Conclusion: The procedure is a useful technique in treating lumbar disc herniation with rapid pain relief and improvements in functional outcomes without any injury to paraspinal muscles or any resection of the ligaments and bony structures. SELD is safe, precise, and effective in the treatment of symptomatic lumbar lesions. Improvements in the optics and visuals with advancements in lasers' ability to ablate tissue could be beneficial. Large, randomized, and multicenter trials are needed to further explore the potential of SELD.

Biportal Endoscopic Posterior Cervical Foraminotomy for Adjacent 2-Level Foraminal Lesions Using a Single Approach (Sliding Technique).

OBJECTIVE: Endoscopic posterior cervical foraminotomy (PCF) using uniportal or biportal endoscopic approach has been performed for cervical foraminal stenosis or foraminal disc herniation. Two-level PCF is possible using a single biportal endoscopic approach. The purpose of this study was to present a technique of biportal endoscopic PCF for contiguous 2-level foraminal lesions using a single approach and its clinical results. METHODS: Patients who received 2-level PCF using a single biportal endoscopic approach were enrolled in this study. We analyzed their clinical data including age, sex, complications, and Neck Disability Index (NDI), and visual analogue scale (VAS) of neck and arm. Postoperative magnetic resonance image was taken on the first postoperative day to determine whether there was sufficient decompression. RESULTS: We successfully performed biportal endoscopic PCF for adjacent 2-level foraminal lesions using a single approach (sliding technique) in all 12 patients. There were cervical foraminal disc herniation with foraminal stenosis (5 cases) and 2-level foraminal stenosis (7 cases). Preoperative mean NDI and VAS of arm and neck significantly decreased at 12 months after surgery. Postoperative clinical outcomes were excellent in 5 patients, good in 6 patients, and fair in 1 patient. There was no major complication. CONCLUSION: Two-level PCF could be performed using a single approach biportal endoscopic surgery with only 2 skin incisions. Clinical outcomes are favorable. This sliding PCF technique using biportal endoscopic approach might be an alternative surgical treatment for contiguous 2-level cervical foraminal pathologic lesions.

Biportal Endoscopic Posterior Thoracic Laminectomy for Thoracic Spondylotic Myelopathy Caused by Ossification of the Ligamentum Flavum: Technical Developments and Outcomes.

OBJECTIVE: Advanced biportal endoscopic surgery techniques can be used to treat thoracic myelopathy secondary to ossification of the ligamentum flavum (OLF). This case series elaborates on a feasible biportal endoscopic technique for thoracic OLF removal and evaluates clinical and radiological outcomes. METHODS: A biportal endoscopic posterior thoracic laminectomy was performed to remove the thoracic OLF. Surgical techniques have evolved from inside-out piecemeal removal methods to outside-in en bloc removal methods. Preoperative computed tomography was performed to analyze dural ossification and OLF types. Intraoperative videos were reviewed to observe dural ossification and to determine the surgical method. Neurological outcomes were assessed using the Japanese Orthopaedic Association (JOA) score. RESULTS: Clinical symptoms and neurological function improved markedly after surgery (JOA score, preoperative: 12.6 ± 1.0, final follow-up: 15.6 ± 1.2). The mean operation time per segment was not short (106.6 ± 38 minutes). At early experience stages, inside-out piecemeal decompression was used and it caused intraoperative spinal cord injury. However, outside-in en bloc decompression technique did not induce neural complications. Postoperative segmental instability and correlated mechanical back pain were not observed. CONCLUSION: The biportal endoscopic posterior thoracic approach is an attractive surgical option to treat thoracic spondylotic myelopathy secondary to OLF. Piecemeal inside-out decompression can induce irreversible spinal cord injury, especially in the early experience stages. Outside-in decompression is more efficient and safer than inside-out pattern procedures by minimizing dural manipulation. Nonetheless, this technique is technically demanding and should only be performed in selected patients after acquiring abundant experience with endoscopic spine surgeries.

Unilateral Biportal Endoscopic Approach for Symptomatic Adjacent Segment Disease: Case Report and Technical Note.

Introduction: Recently, lumbar degenerative disease has been treated using unilateral biportal endoscopic (UBE) lumbar interbody fusion. However, the use of the UBE approach for symptomatic ASD following lumbar interbody fusion surgery isn't illustrated widely in the literature. This case report and technical note describe the use of the UBE approach for symptomatic ASD. Case Report: A 72-year-old female who underwent conventional fusion surgery elsewhere twelve years ago at the L5-S1 level presented with severe back pain (VAS 8/10) and radicular pain in both legs (left > right) (left VAS 7/10, right VAS 7/10) for 1 year with an ODI score of 70%. Preoperative X-ray and MRI showed dynamic instability with spondylolisthesis at L4-5. We performed an upper-level extension using UBE FES techniques to resolve ASD. The operative time was 132 minutes, blood loss was 40 ml. After surgery, the patient was followed up at 1 week, 6 weeks, 3 months, 6 months, 12 months, and 2 years. The pain and tingling sensation in the legs got better at the 1-week follow-up itself with a VAS score of 0/10 and an ODI score of 10% at the 2-year follow-up. Patient satisfaction was surveyed using Odom's criteria at each follow-up visit (at 1 week, 6 weeks,3 months, 6 months, and 2 years) and found to be excellent. Postoperative imaging showed a good reduction and canal decompression at L4-5. Conclusion: The UBE fusion extension technique for ASD is a safe, less invasive, and effective treatment option for lumbar interbody fusion extension and posterior pedicle screw revision with less morbidity and early recovery.

The Past, Present, and Future of Unilateral Biportal Endoscopy with a Technical Note on Novel Endoscopic Visualization Pedicle Screw Insertion Technique and UBE-transforaminal Lumbar Interbody Fusion Technique with Literature Review.

Introduction: Over the past two decades, unilateral biportal endoscopy (UBE) has brought a new paradigm shift in the surgical treatment of spinal disorders with its innovative technique. This study aims to review the development of the UBE technique with a technical note on the novel endoscopic visualization pedicle screw (EVPS) insertion technique and UBE-transforaminal lumbar interbody fusion technique (UBE-TLIF). Case Report: A 66-year-old female presented with severe back pain (Visual Analog Scale [VAS] 8/10) and radicular pain in both legs (left > right) (left VAS 7/10 and right VAS 7/10) for one year with an Oswestry disability index (ODI) score of 70%. Her pain aggravated when bending forward and performing daily routine activities. She also complained of severe intermittent neurological claudication at a distance of <50 m. On physical examination, power in the lower limbs was 5/5 as per the Medical Research Council grading, and deep tendon reflexes were normal. She had a known case of diabetes mellitus and hypertension and was on treatment with oral medications. Pre-operative X-ray and magnetic resonance imaging showed dynamic instability with spondylolisthesis at L4-5. We performed UBE-TLIF with the EVPS insertion technique to resolve her symptoms. The operative time was 122 min; blood loss was 40 mL. After surgery, the patient was followed up at one week, six weeks, three months, six months, 12 months, and two years. The pain and tingling sensation in the legs improved at the 1-week follow-up, with a VAS score of 0/10 and an ODI score of 10% at the 2-year follow-up. Patient satisfaction was surveyed using Macnab's criteria at the final follow-up visit of 2 years and was found to be excellent. Post-operative imaging showed a good reduction and canal decompression at L4-5. Conclusion: The novel EVPS insertion technique and UBE-TLIF have the advantages of minimally invasive spine surgery; they are a safe and effective treatment option for treating lumbar spine pathologies.

Repair of Incidental Durotomy Using Sutureless Nonpenetrating Clips via Biportal Endoscopic Surgery.

STUDY DESIGN: Technical report. OBJECTIVES: Dural tear is one of the most common complications of endoscopic spine surgery. Although endoscopic dural repair of the durotomy area may be difficult, we successfully repaired the dural tear area using nonpenetrating clips during biportal endoscopic surgery. We introduce the surgical technique of dural repair using nonpenetrating titanium clips in biportal endoscopic spine surgery and report its clinical outcome. METHODS: We retrospectively reviewed and analyzed 5 patients who were treated via primary dural repair using nonpenetrating titanium clips during biportal endoscopic lumbar surgery. The 2 methods of dural clipping and repair include 2 or 3 portals. We analyzed radiological parameters such as cerebrospinal fluid collection as well as clinical parameters, including postoperative clinical outcomes. RESULTS: Five patients underwent biportal endoscopic dural repair using nonpenetrating clips. Incidental durotomy was successfully repaired using nonpenetrating titanium clips in all 5 patients. No cerebrospinal fluid collection was detected in the postoperative magnetic resonance images. Clinically, preoperative symptoms improved significantly after surgery (P < .05). CONCLUSIONS: We repaired the dural tear area completely using nonpenetrating titanium vascular anastomosis clips in biportal endoscopic lumbar surgery. Dural repair via clipping method may be an effective alternative for incidental durotomy.

Does androgen-deprivation therapy increase the risk of ischemic cardiovascular and cerebrovascular diseases in patients with prostate cancer? A nationwide population-based cohort study.

PURPOSE: We investigated whether ADT use was associated with the risk of ischemic cardiovascular diseases (CVD) and cerebrovascular diseases (CrVD) in a nationwide population-based cohort. METHODS: Claims data of the Health Insurance and Review Assessment system in South Korea were used. In total, 195,308 men with newly diagnosed prostate cancer between January 1, 2008 and December 31, 2017 were identified. After applying the exclusion criteria, 131,189 men were enrolled. The study cohort was divided into ADT and non-ADT groups. Study outcomes were newly developed CVD, cardiovascular intervention (CVI), and CrVD. To control for potential confounders, various cardiovascular risk factors were balanced between groups. Cox proportional hazard regression models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of events. RESULTS: Univariable analysis revealed that ADT was significantly associated with an increased risk of CVD and CrVD. Multivariable analysis did not reveal this association. In the propensity score matched cohort (n = 61,722), multivariable analysis demonstrated that ADT independently reduced the risk of CVD (HR 0.890; 95% CI 0.846-0.936; p < 0.0001), CVI (HR 0.873; 95% CI 0.770-0.991; p = 0.0352), and CrVD (HR 0.869; 95% CI 0.824-0.917; p < 0.0001). CVD risk was significantly decreased in patients using ADT for over 2 years. CVI and CrVD risks were significantly lower in men using ADT for over 3 years. CONCLUSION: This study demonstrated that ADT may reduce the risk of CVD, CVI, and CrVD, and ADT duration is associated with this risk reduction.