Initial learning curve after switching to uniportal endoscopic discectomy for lumbar disc herniations.

PURPOSE: The purpose was to investigate the learning curve for elective endoscopic discectomy performed by a single surgeon who made a complete switch to uniportal endoscopic surgery for lumbar disc herniations in an ambulatory surgery center and determine the minimum case number required to safely overcome the initial learning curve. METHODS: Electronic medical records (EMR) of the first 90 patients receiving endoscopic discectomy by the senior author in an ambulatory surgery center were reviewed. Cases were divided by approach, transforaminal (46) versus interlaminar (44). Patient-reported outcome measures (visual-analog-score (VAS) and the Oswestry disability index (ODI)) were recorded preoperatively and at 2-week, 6-week, 3-month, and 6-month appointments. Operative times, complications, time to discharge from PACU, postoperative narcotic use, return to work, and reoperations were compiled. RESULTS: Median operative time decreased approximately 50% for the first 50 patients then plateaued for both approaches (mean: 65 min). No difference in reoperation rate observed during the learning curve. Mean time to reoperation was 10 weeks, with 7(7.8%) reoperations. The interlaminar and transforaminal median operative times were 52 versus 73 min, respectively (p = 0.03). Median time to discharge from PACU was 80 min for interlaminar approaches and 60 min for transforaminal (p < 0.001). Mean VAS and ODI scores 6 weeks and 6 months postoperatively were statistically and clinically improved from preoperatively. The duration of postoperative narcotic use and narcotics need significantly decreased during the learning curve as the senior author realized that narcotics were not needed. No differences were apparent between groups in other metrics. CONCLUSIONS: Endoscopic discectomy was shown to be safe and effective for symptomatic disc herniations in an ambulatory setting. Median operative time decreases by half over the first 50 patients in our learning curve, while reoperation rates remained similar without the need for hospital transfer or conversion to an open procedure in an ambulatory setting. LEVEL OF EVIDENCE: Level III, prospective cohort.

Correction and Maintenance of Cervical Alignment: 3-Level ACDF Versus Corpectomy-ACDF "Hybrid" Procedures.

STUDY DESIGN: Longitudinal observational comparative cohorts. OBJECTIVE: The objective of this study is to compare 3 and 12-month radiographic sagittal parameters and patient-reported outcomes (PROs) in patients who underwent 3-level ACDF or a hybrid procedure. SUMMARY OF BACKGROUND DATA: Anterior Cervical Discectomy and Fusion (ACDF), Anterior Cervical Corpectomy and Fusion (ACCF), and hybrids (combination ACCF-ACDF) are common procedures used to treat symptomatic cervical spondylosis. Although there is a relative abundance of literature comparing 1-level ACCF versus 2-level ACDF and 2-level ACCF versus 3-level ACDF, detailed comparisons of 3-level ACDF versus hybrid procedures have not been extensively addressed. METHODS: Patients who underwent a 3-Level ACDF (3L-ACDF, N=47) or 1-Level Corpectomy/1-Level ACDF (Hybrid, N=52) with at least a 12-month post-op data available were identified. Standard demographic, surgical and PROs were collected in addition to preoperative and postoperative radiographic data, including C2 plumb line (C2PL), C2-C7 lordosis (CL), segmental lordosis (SL), and T1 slope (T1S). RESULTS: The 2 cohorts were similar in terms of demographics. At 3 months post-op, CL (9.04° vs. -2.12°, P =0.00) and SL (6.06° vs. -2.26°, P =0.003) were significantly greater in the 3L-ACDF group versus the HYBRID group. This significant difference was maintained at 12 months postoperative for CL [(6.62° vs. -0.60°, P =0.015) but not for SL (2.36° vs. -1.09°, P =0.199)]. There were no differences in PROs between the 2 groups before surgery, at 3 months postoperative or 12 months postoperative. Seven patients required revision surgery in the 1-year study period (1 in the 3L-ACDF, and 6 in the Hybrid P <0.001). CONCLUSIONS: Three level ACDF resulted in greater C2-C7 lordosis and segmental lordosis postoperatively, which was maintained at 1 year for cervical lordosis. While PROs were similar between the groups, patients with hybrid instrumentation required significantly more revision surgeries than those treated with 3-level ACDF.

Postoperative Epidural Hematoma.

Symptomatic postoperative epidural hematomas are rare, with an incidence of 0.10% to 0.69%. Risk factors have varied in the literature, but multiple studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors for hematoma. The role of pharmacologic anticoagulation after spine surgery remains unclear, but multiple studies suggest it can be done safely with a low risk of epidural hematoma. Prophylactic suction drains have not been found to lower hematoma incidence. Most symptomatic postoperative epidural hematomas present within the first 24 to 48 hours after surgery but can present later. Diagnosis of a symptomatic hematoma requires correlation of clinical signs and symptoms with a compressive hematoma on MRI. Patients will usually first complain of a marked increase in axial pain, followed by radicular symptoms in the extremities, followed by motor weakness and sphincter dysfunction. An MRI should be obtained emergently, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation.