Reoperation Rates According to Surgical Approach After Operation for Degenerative Cervical Pathology in Patients With Athetoid Cerebral Palsy: A Nationwide Cohort Study.

STUDY DESIGN: National population-based cohort study. OBJECTIVE: The overall complication rate for patients with athetoid cerebral palsy (CP) undergoing cervical surgery is significantly higher than that of patients without CP. The study was conducted to compare the reoperation and complication rates of anterior fusion, posterior fusion, combined fusion, and laminoplasty for degenerative cervical myelopathy/radiculopathy in patients with athetoid cerebral palsy. METHODS: The Korean Health Insurance Review and Assessment Service national database was used for analysis. Data from patients diagnosed with athetoid CP who underwent cervical spine operations for degenerative causes between 2002 and 2020 were reviewed. Patients were categorized into four groups for comparison: anterior fusion, posterior fusion, combined fusion, and laminoplasty. RESULTS: A total of 672 patients were included in the study. The overall revision rate was 21.0% (141/672). The revision rate was highest in the anterior fusion group (42.7%). The revision rates of combined fusion (11.1%; hazard ratio [HR], .335; P = .002), posterior fusion (13.8%; HR, .533; P = .030) were significantly lower than that of anterior fusion. Revision rate of laminoplasty (13.1%; HR, .541; P = .240) was also lower than anterior fusion although the result did not demonstrate statistical significance. CONCLUSION: Anterior fusion presented the highest reoperation risk after cervical spine surgery reaching 42.7% in patients with athetoid CP. Therefore, anterior-only fusion in patients with athetoid CP should be avoided or reserved for strictly selected patients. Combined fusion, with the lowest revision risk at 11.1%, could be safely applied to patients with athetoid CP.

Corrigendum to "The Association of Body Mass Index and Waist Circumference with the Risk of Achilles Tendon Problems: A Nationwide Population-Based Longitudinal Cohort Study".

[This corrects the article on p. 488 in vol. 15, PMID: 37274500.].

Transpedicular injection of rhBMP-2 with ß-tricalcium phosphate to reduce the proximal junctional kyphosis after adult spinal deformity correction: preliminary study.

The aim of this preliminary study was to assess the impact of injecting recombinant human bone morphogenetic protein-2 (rhBMP-2) with ß-tricalcium phosphate (ß-TCP) carrier into the uppermost instrumented vertebra (UIV) during surgery to prevent the development of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). The 25 patients from study group had received 0.5 mg rhBMP-2 mixed with 1.5 g ß-TCP paste injection into the UIV during surgery. The control group consisted of 75 patients who underwent surgery immediately before the start of the study. The incidences of PJK and PJF were analyzed as primary outcomes. Spinopelvic parameters and patient-reported outcomes were analyzed as secondary outcomes. Hounsfield unit (HU) measurements were performed to confirm the effect of rhBMP-2 with ß-TCP on bone formation at preoperative and postoperative at computed tomography. PJK and PJF was more occurred in control group than study group (p = 0.02, 0.29, respectively). The HU of the UIV significantly increased 6 months after surgery. And the increment at the UIV was also significantly greater than that at the UIV-1 6 months after surgery. Injection of rhBMP-2 with ß-TCP into the UIV reduced PJK and PJF rates 6 months after surgery with new bone formation.

Comparison of supramalleolar and inframalleolar correction for Takakura stage IIIB ankle arthritis in a single patient.

A man in his early 60s with bilateral Takakura stage IIIB varus ankle arthritis underwent calcaneal osteotomy on the right side and supramalleolar osteotomy (SMO) with fibular osteotomy on the left side. Both sides underwent identical procedures, including multiple drilling of the denuded talar dome and gutter, deltoid ligament release, anterior talofibular ligament (ATFL) reconstruction and posterior tibial tendon (PTT) lengthening. This aimed to minimise patient-related factors when assessing correction efficacy. Both procedures demonstrated a similar degree of improvement in talar tilt. Supramalleolar correction contributed more significantly to lateralising the talar centre, while greater improvement in preoperative hindfoot varus was achieved through inframalleolar correction.

c-MET-positive circulating tumor cells and cell-free DNA as independent prognostic factors in hormone receptor-positive/HER2-negative metastatic breast cancer.

BACKGROUND: Endocrine therapy resistance in hormone receptor-positive/HER2-negative (HR+/HER2-) breast cancer (BC) is a significant clinical challenge that poses several unmet needs in the management of the disease. This study aimed to investigate the prognostic value of c-MET-positive circulating tumor cells (cMET+ CTCs), ESR1/PIK3CA mutations, and cell-free DNA (cfDNA) concentrations in patients with hormone receptor-positive (HR+) metastatic breast cancer (mBC). METHODS: Ninety-seven patients with HR+ mBC were prospectively enrolled during standard treatment at Samsung Medical Center. CTCs were isolated from blood using GenoCTC® and EpCAM or c-MET CTC isolation kits. PIK3CA and ESR1 hotspot mutations were analyzed using droplet digital PCR. CfDNA concentrations were calculated using internal control copies from the ESR1 mutation test. Immunocytochemistry was performed to compare c-MET overexpression between primary and metastatic sites. RESULTS: The proportion of c-MET overexpression was significantly higher in metastatic sites than in primary sites (p = 0.00002). Survival analysis showed that c-MET+ CTC, cfDNA concentration, and ESR1 mutations were significantly associated with poor prognosis (p = 0.0026, 0.0021, and 0.0064, respectively) in HR+/HER2- mBC. By contrast, EpCAM-positive CTC (EpCAM+ CTC) and PIK3CA mutations were not associated with progression-free survival (PFS) in HR+/HER2- mBC. Multivariate analyses revealed that c-MET+ CTCs and cfDNA concentration were independent predictors of PFS in HR+/HER2- mBC. CONCLUSIONS: Monitoring c-MET+ CTC, rather than assessing c-MET expression in the primary BC site, could provide valuable information for predicting disease progression, as c-MET expression can change during treatment. The c-MET+ CTC count and cfDNA concentration could provide complementary information on disease progression in HR+ /HER2- mBC, highlighting the importance of integrated liquid biopsy.

The association between refractory plantar fasciitis and insertional Achilles tendinopathy and peripheral spondyloarthritis: a report of human leukocyte antigen B-27 investigation and treatment outcome.

PURPOSE: This study aimed to determine the presence of peripheral spondyloarthritis and investigate the clinical characteristics of patients with concurrent peripheral spondyloarthritis in those presenting with refractory plantar fasciitis and Achilles tendinopathy by conducting human leukocyte antigen B-27 (HLA-B27) testing. METHODS: This retrospective study aimed to investigate patients who complained of persistent pain and significant limitations in daily activities due to their respective foot pain, despite receiving conservative treatment for over one year under the diagnosis of plantar fasciitis or insertional Achilles tendinopathy. The study included 63 patients who underwent HLA-B27 testing. The patients were classified into two groups based on the presence or absence of HLA-B27 positivity. The Mann-Whitney U test assessed significant relationships between continuous variables, and the chi-square test was used to compare categorical variables. RESULTS: Among the 63 included patients, HLA-B27 positivity was confirmed in 11 patients (17.5%), which was significantly associated with a lower average age (22.8 years versus 31.7 years, P = 0.01) and a substantially lower proportion of females compared to HLA-B27-negative patients (9.1% vs. 25.0%, P = 0.001). Ten of the 11 patients initiated treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) combined with oral steroids as the first-line medication after being diagnosed as HLA-B27 positive. Six patients experienced pain relief with the first-line medication (60%). Four patients who did not achieve pain control with the first-line medication received tumour necrosis factor-alpha inhibitors as the second-line medication. Two patients experienced pain relief, while two experienced reduced but persistent pain. CONCLUSIONS: Among the patients with "refractory" plantar fasciitis and insertional Achilles tendinopathy, 17.5% were diagnosed with peripheral spondyloarthritis. Patients diagnosed with peripheral spondyloarthritis had a higher proportion of men and relatively younger mean age compared to those without the diagnosis. Approximately 70% of these patients achieved symptom improvement in foot and ankle joints by taking conventional synthetic DMARDs, TNF-α inhibitors, or both appropriate for spondyloarthritis.

Conservative treatment outcome for Achilles tendon re-rupture occurring in the subacute phase after primary repair.

INTRODUCTION: Until now, a treatment protocol for Achilles tendon re-rupture (ATRR) occurring in the postoperative period 5-12 weeks following primary Achilles tendon repair has not been established. We refer to this time frame as the subacute postoperative phase, and the objective of this study was to assess the efficacy of conservative treatment for subacute ATRR in this phase. MATERIALS AND METHODS: We conducted a retrospective review of 390 cases (385 patients) who had undergone primary Achilles tendon repair using the 4-strand Krachow method between January 2010 and August 2021. All patients were subjected to more than 12 months of follow-up and were categorized into two groups based on the presence of subacute ATRR: Group 1 comprised 370 cases without ATRR, while Group 2 comprised 20 cases with ATRR. Following confirmation of ATRR, we immediately applied a below-knee cast in an ankle plantar flexed position (25°-30°), followed by bracing according to the same rehabilitation plan used for the primary repair. After administering conservative treatment to the patients with ATRR, we compared several outcome parameters between the two groups, including isokinetic plantar flexion power measured using a dynamometer, time required for a single heel raise (t-SHR), time needed for ten repetitive SHRs (t-SHR10), Achilles Tendon Total Rupture Score (ATRS), and Foot and Ankle Ability Measure (FAAM) scores. The baseline timepoints for Groups 1 and 2 were the dates of the primary repair and the re-injury event. RESULTS: After primary Achilles tendon repair, subacute ATRR occurred in 5.1% of patients. There were no significant differences between the groups in terms of t-SHR and t-SHR10 (P = 0.281, 0.486). Similarly, the isokinetic dynamometer measurements revealed no significant differences in peak torque for plantar flexion at angular velocities of 30°/s and 120°/s, both in absolute values and as a percentage of the contralateral side, between the groups (P > 0.05 for each). However, ATRSs were significantly lower in Group 2 compared to Group 1 before 6 months (P < 0.05), as were FAAM-Activities of Daily Living scores at 6 months (P < 0.05). After 12 months, there were no significant differences in these scores between the two groups (both P > 0.05). CONCLUSION: Conservative treatment for subacute ATRR following primary Achilles tendon repair yields clinical outcomes comparable to those without ATRR. Therefore, we recommend that surgeons consider relying on the patient's natural healing capabilities rather than opting for aggressive surgical interventions, as expediting such operations may be unnecessary for subacute injuries.

Visualizing mast cell migration to tumor sites using sodium iodide symporter of nuclear medicine reporter gene.

PURPOSE: Owing to the close relationship between mast cells and cancer progression, an imaging technique that can be applied in a clinical setting to explore the biological behavior of mast cells in the tumor microenvironment is needed. In this study, we visualized mast cell migration to lung tumor lesions in live mice using sodium iodide symporter (NIS) as a nuclear medicine reporter gene. EXPERIMENTAL DESIGN: The murine mast cell line MC-9 was infected with retrovirus including NIS, luciferase (as a surrogate marker for NIS), and Thy1.1 to generate MC-9/NFT cells. Radioiodine uptake was measured in MC-9/NFT cells, and an inhibition assay of radioiodine uptake using KCLO4 was also performed. Cell proliferation and FcεRI expression was examined in MC-9 and MC-9/NFT cells. The effect of mast cell-conditioned media (CM) on the proliferation of Lewis lung cancer (LLC) cells was examined. The migration level of MC-9/NFT cells was confirmed in the presence of serum-free media (SFM) and CM of cancer cells. After intravenous injection of MC-9/NFT cells into mice with an LLC tumor, I-124 PET/CT and biodistribution analysis was performed. RESULTS: MC-9/NFT cells exhibited higher radioiodine avidity compared to parental MC-9 cells; this increased radioiodine avidity in MC-9/NFT cells was reduced to basal level by KCLO4. Levels of FcεRI expression and cell proliferation were not different in parental MC-9 cell and MC-9/ NFT cells. The CM of MC-9/NFT cells increased cancer cell proliferation relative to that of the SFM. The migration level of MC-9/NFT cells was higher in the CM than the SFM of LLC cells. PET/CT imaging with I-124 clearly showed infiltration of reporter mast cells in lung tumor at 24 h after transfer, which was consistent with the findings of the biodistribution examination. CONCLUSION: These findings suggest that the sodium iodide symporter can serve as a reliable nuclear medicine reporter gene for non-invasively imaging the biological activity of mast cells in mice with lung tumors. Visualizing mast cells in the tumor microenvironment via a nuclear medicine reporter gene would provide valuable insights into their biological functions.

Biportal endoscopic discectomy versus tubular microscopic discectomy for treating single-level lumbar disc herniation in obese patients: a multicenter, retrospective analysis.

PURPOSE: In microscopic lumbar discectomy in obese patients, a correlation is found between the operation time and increase in estimated blood loss according to the increase in body mass index; however, no studies have investigated the outcomes of biportal endoscopic lumbar discectomy in obese patients. Therefore, this study aimed to compare the clinical and radiographic outcomes of microscopic and endoscopic discectomy in obese patients with lumbar herniated discs. METHODS: In this multicenter, retrospective study, clinical and radiological data were compared and analyzed in 73 obese patients with a body mass index of > 30 kg/m2 who underwent microscopic or biportal endoscopic lumbar discectomy. Clinical data on the visual analog scale (VAS), Oswestry disability index (ODI), and EuroQol-5D (EQ-5D) scores were measured, and radiological data were obtained using magnetic resonance imaging (MRI). RESULTS: This study enrolled 43 patients who underwent microscopic discectomy and 30 who underwent biportal endoscopic discectomy. The VAS, ODI, and EQ-5D scores in both groups improved after surgery compared with those before surgery, although there was no difference between the two groups. Although there was a difference in the incidence of recurrent disc herniation confirmed by MRI after surgery, no difference was found in the number of patients requiring surgery between the two groups. CONCLUSION: In obese patients with lumbar disc herniation that was not improved with conservative treatment, no significant clinical or radiological differences in outcomes were noted between microscopic and biportal endoscopic surgery methods. In contrast, minor complications were less common in the biportal group.

The Association of Body Mass Index and Waist Circumference with the Risk of Achilles Tendon Problems: A Nationwide Population-Based Longitudinal Cohort Study.

Background: The purpose of this study was to evaluate the association of body mass index (BMI) and waist circumference (WC) with the risk of Achilles tendinopathy (AT) or Achilles tendon rupture (ATR), using data from a nationwide population-based cohort. We hypothesized that higher BMI and WC would be independently associated with the increased risk of AT or ATR. In addition, a higher WC may potentiate the association between BMI and the risk of Achilles tendon problems. Methods: We used the National Health Insurance database that covers the entire South Korean population to follow up subjects who participated in the National Health Screening Program (NHSP) from January 2009 to December 2010. The NHSP data include subjects' BMI, WC, blood test results, blood pressure, and information about lifestyle. Among the subjects, those who were newly diagnosed as having AT or ATR before December 31, 2017, were selected. To examine the association of the variables with the risk of AT or ATR and determine whether the effect of higher BMI varied according to WC, multivariate Cox proportional hazards regression was used. Results: Among a total of 16,830,532 subjects, 125,814 and 31,424 developed AT and ATR, respectively. A higher BMI showed a greater association with the increased risk of ATR than AT (adjusted hazard ratio [HR], 3.49 vs. 1.96). A higher WC was associated with the increased risk of AT (adjusted HR, 1.22), but not ATR. In a separate analysis, the association between BMI and the risk of AT was higher when subjects had higher WC as compared to those with lower WC, being most significant in individuals with both higher BMI and higher WC. Conclusions: Higher BMI was more associated with the increased risk of ATR than AT. Moreover, a high central fat distribution played an independent and potentiating role in the development of AT. This implies the greater importance of a high central fat distribution contributing to the development of AT in obese people.

A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients.

INTRODUCTION: Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients. MATERIALS AND METHODS: This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65 years (group 1, 13 patients) and < 65 years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position. RESULTS: The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively. CONCLUSION: We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.

Operative outcome of mucous cyst of lesser toes: A comparison between cyst excision with osteophytectomy and distal interphalangeal fusion.

BACKGROUND: To date, the optimal operative treatment for mucous cysts of the lesser toes (MCLT) has not been discussed in detail, although many previous studies have focused on treating finger lesions. Therefore, we evaluated the operative outcomes of two different procedures for MCLT: cyst excision with osteophytectomy and cyst excision with distal interphalangeal (DIP) fusion. METHODS: We retrospectively reviewed and compared the clinico-radiographic outcomes of patients who underwent cyst excision with osteophytectomy (group 1, 22 cases) or cyst excision with DIP fusion (group 2, 16 cases) for MCLT between January 2010 and August 2021. The minimum follow-up duration for inclusion in the study was 12 months. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) lesser toes metatarsophalangeal-interphalangeal scale and the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale. We also collected information on postoperative recurrence and operation-related complications. RESULTS: The preoperative and postoperative AOFAS and FAAM-ADL scores were not significantly different between the two groups (P > 0.05, each). However, the postoperative recurrence rate was 31.8 % in group 1 (7 of 22 cases), whereas no recurrence was observed in group 2. Every recurrence occurred within 8 postoperative weeks (mean, 4.8 weeks; range, 3-8 weeks). Nonunion of the fusion site was observed in one patient (6.3 %). CONCLUSION: We confirmed that postoperative recurrence was significantly lower in the case of cyst excision with DIP fusion than in cyst excision with osteophytectomy for the treatment of MCLT. Clinical outcomes were not significantly different between the two procedures. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Prevalence of chronic low back pain and its associated factors in the general population of South Korea: a cross-sectional study using the National Health and Nutrition Examination Surveys.

BACKGROUND: Many factors associated with chronic low back pain (CLBP) have been proposed, including individual, psychosocial, and physical factors. However, these associated factors are still controversial. PURPOSE: (1) To determine the prevalence of CLBP and (2) to analyze factors associated with CLBP in the general population using a nationally representative sample of South Koreans. STUDY DESIGN: Cross-sectional study. PATIENT SAMPLE: Data from versions IV-1, -2, and -3 of the Korea National Health and Nutrition Examination Survey (KNHANES), which were performed in 2007, 2008, and 2009, respectively (n = 24,871). OUTCOME MEASURES: Multiple logistic regression analysis was performed to determine the association between several factors (age, gender, alcohol consumption, household income, education level, mid-intensity physical activity, depressive symptoms, vitamin D level, and comorbidities [stroke, ischemic heart disease, knee osteoarthritis, asthma, COPD, cancer history]) and CLBP. METHODS: CLBP status was surveyed using a self-reported questionnaire. Demographic, socioeconomic status, comorbidities, and other factors were evaluated from health questionnaires, health and physical examinations, and laboratory tests. To analyze the association between these factors and CLBP, we used multiple logistic regression analysis. RESULTS: Data from 17,038 participants were included in the final analysis, including 2,693 with CLBP and 14,345 without. The prevalence of CLBP was 15.8% in South Korean subjects, with a prevalence of 11.8% in men and 24.5% in women. After regression analysis, we found advanced age, female gender, mid-intensity physical activity, depressive symptoms, stroke, ischemic heart disease, knee arthritis, asthma, COPD, and cancer history were positively associated with CLBP. In contrast, alcohol consumption ≥ 1 drink per month, increased household income, higher education level, and vitamin D insufficiency were negatively associated with CLBP. CONCLUSIONS: Our study showed that CLBP was most common in the elderly and women in the general South Korean population. Several individual, socioeconomic, lifestyle, and health-related factors were associated with CLBP. These results demonstrate the influence of these factors on CLBP in the general population and suggest that consideration of these factors may improve the management of CLBP.

Video-Assisted Thoracic Surgery Core Needle Biopsy for Pulmonary Nodules in Patients with Impaired Lung Function: Is It Feasible and Safe?

Background: The number of patients with incidentally identified pulmonary nodules is increasing. This study attempted to confirm the usefulness and safety of video-assisted thoracic surgery (VATS) core needle biopsy of pulmonary nodules. Methods: Data from 18 patients diagnosed with pulmonary nodules who underwent VATS core need biopsy were retrospectively reviewed. Results: Of the 18 patients, 15 had malignancies (primary lung cancer, n=14; metastatic lung cancer, n=1), and 3 had benign nodules. Mortality and pleural metastasis did not occur during the follow-up period. Conclusion: In patients with solitary pulmonary nodules that require tissue confirmation, computed tomography-guided percutaneous cutting needle biopsy or diagnostic pulmonary resection sometimes may not be feasible choices due to the location of the solitary pulmonary nodule or the patient's impaired pulmonary function, VATS core needle biopsy may be performed in these patients as an alternative method.

Operative outcomes of a high-grade talar neck fracture - Lessons from 20 years' clinical experience in a single, tertiary hospital.

BACKGROUND: The operative treatment of high-grade talar neck fractures remains challenging, despite numerous previous reports. Our goal was to determine long-term outcomes and to establish a plan for management of postoperative complications (especially, avascular necrosis [AVN] of talar body) after high-grade talar neck fractures. We hypothesized that not every case with AVN of talar body require secondary surgical interventions. METHODS: We retrospectively reviewed the radiographic and clinical findings of 14 patients who underwent operative treatment for high-grade talar neck fractures (modified Hawkins type III and IV) between January 2000 and December 2017. The minimum follow-up duration for inclusion was 3 years. Using radiographs during follow-up, we assessed the development of AVN of the talar body, malunion, nonunion, and posttraumatic osteoarthritis. Information about the secondary operations and their outcomes were also investigated using visual analogue scale (VAS) and American orthopaedic foot and ankle society (AOFAS) ankle-hindfoot scale at the final follow-up. RESULTS: In 10 of 14 patients (71.4 %), talar body AVN developed during follow-up. However, secondary operation was required in only 30.0 % (3 of 10 patients). In the remaining 7 patients who did not undergo secondary operation, the symptoms were tolerable with a maximum of 89 months follow-up; although the talar body presented sclerotic changes, but without talar dome collapse. The rates of malunion and post-traumatic subtalar osteoarthritis were 21.4 % and 14.3 %, respectively. No patients presented with fracture site nonunion. After a mean of 55.86 ± 14.45 months (range, 37-89) follow-up, the final mean VAS and AOFAS scores were 3.07 ± 0.73 (range, 2-4) and 80.43 ± 3.11 (range, 75-85), respectively. CONCLUSION: We recommend leaving talar body AVN untouched, unless the patient's symptoms become intolerable. In our clinical practice, postoperative AVN could be stably maintained without talar dome collapse for more than 7 years, although the sclerotic change persisted. Despite the small number of patients, our clinical experience may benefit patients with high-grade talar neck fractures and surgeons who treat such rare, serious, and challenging foot injuries. LEVEL OF EVIDENCE: Level IV, Case series.

Biportal endoscopic versus microscopic discectomy for lumbar herniated disc: a randomized controlled trial.

BACKGROUND CONTEXT: Biportal endoscopic discectomy has been frequently performed in recent years and has shown acceptable clinical outcomes. However, evidence regarding its efficacy and safety remains limited. PURPOSE: This study aimed to compare the clinical efficacy and safety of biportal endoscopic with that of open microscopic discectomy in patients with single-level herniated lumbar discs. STUDY DESIGN: Prospective, randomized, multicenter, open-label, assessor-blind, non-inferiority controlled trial. PATIENT SAMPLE: Sixty-four participants suffering from low back and leg pain with a single-level herniated lumbar disc and required discectomy. OUTCOME MEASURES: Outcomes were assessed with the use of patient-reported outcome measures (PROMs), visual analog scale (VAS) pain score for surgical site, low back and lower extremity, Oswestry Disability Index (ODI) for lumbar disabilities, European Quality of Life-5 Dimensions value for quality of life, and painDETECT for neuropathic pain. Surgery-related outcomes such as hospital stay, operation time, and opioid usage were collected. Adverse events occurring during the follow-up period were also noted. METHODS: All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic (biportal group) or microscopic discectomy (microscopy group). The primary outcome was the difference in ODI scores at 12-months post surgically based on a modified intention-to-treat strategy, with a non-inferiority margin of 12.8 points. The secondary outcomes included PROMs, surgery-related outcomes, and adverse events. RESULTS: The ODI score at the 12-month follow-up was 11.97 in the microscopy group and 13.89 in the biportal group (mean difference, 1.92; 95% confidence interval [CI], -3.50 to 7.34), showing the non-inferiority of biportal group. The results for the secondary outcomes were similar to those for the primary outcome. Creatinine phosphokinase ratios were low in the biportal group. Early surgical site pain was slightly lower in the biportal group (mean difference of VAS pain score at 48-hr, -0.98; 95% CI, -1.77 to -0.19). Adverse events including reoperation showed no significant difference between the groups. CONCLUSION: Biportal endoscopic discectomy was non-inferior to microscopic discectomy over a 12 month period. Biportal endoscopic discectomy is suggested to be a relatively safe and effective surgical technique with the slight advantage of reduced muscle damage. However, the clinical implications of surgical site pain should be carefully considered.

Recent Updates on Minimally Invasive Spine Surgery: Techniques, Technologies, and Indications.

A number of minimally invasive spine surgeries (MISSs) have been developed to address the drawbacks of open spine surgery. Their advantages include small skin incisions, reduction in tissue damage, quick recovery, and short hospital stay. However, the clinical outcomes are comparable to open surgery. There was a cap on the number of indications that could be set for all spinal illnesses. The indications for MISSs have been expanding owing to mechanical and technological advances in medical equipment. Thus, this review presents the various MISSs developed to date, surgical indications, surgical techniques, and their advantages and disadvantages.

Clinical and radiologic outcomes of biportal endoscopic lumbar discectomy in obese patients: a retrospective case-control study.

BACKGROUND: Obese patients have a higher risk of complications during spinal surgery than non-obese patients. To the best of our knowledge, no studies have examined the differences in clinical and radiological outcomes after biportal endoscopic lumbar discectomy (BELD) between obese and non-obese patients. The study evaluated the association between obesity and outcomes after BELD in patients with lumbar disc herniation. METHODS: This was a retrospective case-control study conducted from March 2017 to March 2021 at two hospitals with 360 patients who underwent BELD after showing no improvement with conservative treatment. Clinical and radiologic outcomes were retrospectively analyzed after BELD in the non-obese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2) groups. Demographic data and surgery-related factors were compared between the two groups. Clinical outcomes were followed up for 12 months after surgery and analyzed for differences. RESULTS: A total of 211 patients were enrolled in this study, and through case-control matching, the data of 115 patients (29, obese group; 86, non-obese group) were analyzed. The two groups showed no significant differences in Oswestry Disability Index, European Quality of Life-5 Dimensions (EQ-5D), and visual analog scale scores measured immediately after BELD and 12 months after surgery. After surgery, back pain, radiating leg pain, and EQ-5D scores improved. However, there was no significant difference in improvement, residual herniated disc, hematoma, or recurrence between the groups. CONCLUSIONS: Obese patients who underwent BELD for lumbar disc herniation showed no significant difference in clinical and radiologic outcomes compared with non-obese patients.

Percutaneous Full-Endoscopic versus Biportal Endoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Foraminal Disc Disease.

Background: The biportal endoscopic technique (BE) is a fast-growing surgical modality that can be applied to posterior cervical foraminotomy (PCF), as well as lumbar discectomy and decompressive laminectomy. It has several technical differences from the percutaneous full-endoscopic technique (PE), which has been standardized as the representative endoscopic spinal surgery technique. The purpose of this study was to compare the short-term clinical outcomes between BE-PCF and PE-PCF. Methods: A retrospective review was conducted on 66 patients who had single-level unilateral cervical foraminal disc disease (UCFD). All patients underwent PE- or BE-PCF. Clinical outcomes including visual analog scale (VAS)-arm, VAS-neck, and Neck Disability Index (NDI) were evaluated. Perioperative data including operation time, length of hospital stay (LOS), amount of surgical drain, postoperative complications, and reoperation were collected. Serum creatine phosphokinase (CPK) and C-reactive protein (CRP) levels were recorded. Results: A total of 65 patients were included in the final analysis: 32 with PE-PCF and 33 with BE-PCF. There was no statistically significant difference in demographic and preoperative data between the two groups. All patients had significant improvement in VAS-arm, VAS-neck, and NDI compared to the baseline value. The improvement of all parameters was comparable between the two groups at each point for 1 year after surgery (p > 0.05), except for the significantly lower VAS-neck at postoperative 2 days in PE-PCF (p = 0.005). The total operation time was significantly shorter in BE-PCF (p = 0.036). There were no statistically significant differences between the two groups in regard to LOS, amount of surgical drain, and serum CPK and CRP levels (p > 0.05). Reoperation and complications between the two groups were comparable (p > 0.05). Conclusions: The 1-year postoperative clinical outcomes of PE-PCF and BE-PCF for cervical pain and disability caused by UCFD were good and comparable. PE-PCF resulted in significantly less immediate postoperative neck pain, but BE-PCF required shorter total operation time.

Learning curve for microscopic unilateral laminectomy for bilateral decompression surgery using the cumulative summation test for learning curve.

A retrospective observational study The purpose of this study was to characterize the learning curve for a single level unilateral laminectomy and bilateral decompression in lumbar spinal stenosis using a learning curve cumulative summation test. Unilateral laminectomy and bilateral decompression for lumbar spinal stenosis proposes a potential benefit with minimizing surgery-related instability compared to traditional bilateral laminectomy, by preserving posterior stabilizing structures and contralateral facet joint and neural arch. Due to a narrow surgical corridor, it is considered to exhibit a steep learning curve as other types of minimally invasive procedures. However, there are few reports available regarding learning curve of unilateral laminectomy and bilateral decompression. The learning curve of a single surgeon performing single level unilateral laminectomy and bilateral decompression was assessed using learning curve cumulative summation test analysis. The surgeon had minimal experience in open decompressive laminectomy but no previous experience in unilateral laminectomy and bilateral decompression. Procedure success was defined as an operation time less than 75 minutes. Surgery related complications were recorded. Total 194 consecutive patients, who underwent primary single level unilateral laminectomy and bilateral decompression by a single spine surgeon, were included. The mean operative time for unilateral laminectomy and bilateral decompression was 64.6 ± 23.6 minutes. The mean operative time in the early learning period (≤29th case) was 80.6 ± 20.9 minutes, and that in the late learning period (after 29th case) was 61.8 ± 22.7 minutes, respectively. The overall complication rate was 13.9%. Majority of complications occurred in the early learning period. The learning curve cumulative summation test signaled competency for unilateral laminectomy and bilateral decompression at the 29th operation, indicating that the surgeon reached the competent level. In addition, based on the cumulative summation test, the surgeon seemed to maintain his competency for the procedure. This study showed that surgical experience reduced the operation time and surgery related complications. For inexperienced surgeon to achieve an acceptable outcome in unilateral laminectomy and bilateral decompression, minimum 30 cases of unilateral laminectomy and bilateral decompression are required to reach competent level of surgery.