Suprapedicular Retrocorporeal Technique of Transforaminal Full-Endoscopic Lumbar Discectomy for Highly Downward-Migrated Disc Herniation.

OBJECTIVE: Anatomical barriers (e.g., pedicles, narrow foramina) can hinder direct access to, and removal of, disc fragments that have migrated far downward. Using transforaminal full-endoscopic lumbar discectomy (FELD), we devised a modified technique, the suprapedicular retrocorporeal approach, for herniations in which the disc has migrated to the axilla of the traversing nerve roots. In the present report, we have described our preliminary results. METHODS: Soft, highly downward-migrated disc herniation was treated with transforaminal FELD through the suprapedicular retrocorporeal approach in 22 patients from June 2017 to May 2019. The clinical outcomes were evaluated, including the preoperative and postoperative visual analog scale scores for the back and leg, Oswestry disability index, and MacNab criteria for surgical success. RESULTS: The affected discs were at L4-L5 in 14 patients, L3-L4 in 6 patients, and L5-S1 in 2 patients. In each case, the affected disc was successfully removed using the suprapedicular retrocorporeal approach. The mean follow-up was 18.1 ± 5.7 months. The mean visual analog scale scores for back and leg pain improved significantly (P < 0.05 for both). The mean Oswestry disability index had decreased from 62.5 ± 14.2 preoperatively to 10.5 ± 5.9 postoperatively (P < 0.05). Using the MacNab criteria, 13 patients reported excellent outcomes and 9, good outcomes. No complications or recurrence developed during follow-up. CONCLUSIONS: The suprapedicular retrocorporeal technique is a feasible and effective surgical option in transforaminal FELD for the treatment of herniation in which the disc has migrated to the axilla of the traversing nerve roots.

Symptomatic Lumbar Juxtafacet Cyst Treated by Full Endoscopic Surgery.

BACKGROUND: Juxtafacet cysts (JFCs) include both synovial and ganglion cysts adjacent to a spinal facet joint or arising from the ligamentum flavum of the spinal facet joints. Various treatments have been proposed; however, a surgical approach appears to be most effective. The aim of this study was to review patients with lumbar JFCs treated using a full endoscopic approach and elaborate the details of the surgical routes and techniques and their merits and pitfalls. METHODS: All patients with lumbar JFCs underwent complete endoscopic cyst removal. Muscle power, visual analog scale score, modified MacNab criteria score, and magnetic resonance imaging were assessed during follow-up. RESULTS: The study enrolled 8 patients. Five patients received an interlaminar approach, 2 patients received a transforaminal approach, and 1 patient received a transfacet approach. Visual analog scale scores decreased from a mean of 7.75 (range, 5-10) before surgery to 0.625 (range, 0-2) after surgery, and modified MacNab criteria score ranged from good to excellent after surgery. No neurologic injuries were observed. CONCLUSIONS: JFCs could be effectively treated by full endoscopic surgery. The type of approach should be based on the anatomic site of the lesion and the condition of the patient. The interlaminar approach is appropriate for cysts located in the lower segment with larger interlaminar space. The transforaminal or transfacet approach is preferred for patients for whom general anesthesia is a high risk.

Full Endoscopic Discectomy, Debridement, and Drainage for High-Risk Patients with Spondylodiscitis.

OBJECTIVE: To evaluate the efficacy and clinical results of full endoscopic debridement and drainage (FEDD) for high-risk patients with spondylodiscitis. METHODS: Fourteen patients who underwent FEDD at our institution between November 2015 and September 2017 were retrospectively reviewed. All patients had single-level infectious spondylodiscitis and were high-risk candidates for surgery. Their general condition was evaluated according to the American Society of Anesthesiologists grading system. The Charlson Comorbidity Index was used for comprehensive assessment of comorbidity status. Outcomes were evaluated by numeric rating scale (NRS) pain score, Oswestry Disability Index, modified Macnab criteria, and radiographic images at follow-up. RESULTS: All 14 patients experienced immediate relief of back pain after FEDD, with no procedure-related complications. The causative bacteria were identified in 10 of the 14 patients (71.5%). Half of the 14 patients had an American Society of Anesthesiologists score of ≥3. The average Charlson Comorbidity Index was 5.1 ± 1.6 points. Compared with the preoperative NRS score of 8.2 ± 0.9, the NRS scores at 1 week and 12 months after surgery were 3.4 ± 1.1 and 1.4 ± 1.2, respectively. A significant improvement in Oswestry Disability Index was observed after surgery (preoperative, 30.1 ± 3.9; 12 months postoperatively, 17.6 ± 6.2; P < 0.05). Satisfaction rate was 85.7% based on the Macnab criteria (excellent or good outcome). None of the patients developed any significant kyphotic deformity after FEDD. CONCLUSIONS: FEDD may be an effective alternative to extensive open surgery in patients with infectious spondylodiscitis, especially those who are high-risk candidates for surgery (elderly patients with multiple comorbidities and patients in poor general condition).

Percutaneous Endoscopic Lumbar Surgery via the Transfacet Approach for Lumbar Synovial Cyst.

BACKGROUND: There are currently no high-quality studies on the optimal therapeutic approach for juxtafacet cyst, as treatment guidelines have not been developed. Herein, a novel technique in which we used an endoscopic transfacet approach to treat a patient with symptomatic lumbar synovial cyst is presented. CASE DESCRIPTION: An 87-year-old man presented with severe dull pain in the right anterior thigh. Lumbar magnetic resonance imaging revealed disc extrusion over the central canal zone at the L2-L3 and L4-L5 levels and an ovoid lesion with a hyperintense center plus a hypointense rim on the T2-weighted image. The lesion was located over the medial side of the right juxtafacet region at the L2-L3 level, causing thecal sac compression. After the operation, the visual analog pain scale improved with a value of 0-1/10, and straight leg raise test was negative. Microscopically, cystic fibrous tissue with focal myxoid degeneration, fibrin exudate, and scant synovial-like lining was observed. These findings were consistent with clinical synovial cyst. Three months later, lumbar magnetic resonance imaging was performed, and no evidence of cyst was disclosed. Lumbar computed tomography revealed the upper part of left L2-L3 facet joint was removed. The patient did not report any radicular pain during the 6-month follow-up period. CONCLUSIONS: Percutaneous endoscopic lumbar surgery could be a new option for the management of lumbar synovial cysts, especially when general anesthesia is not appropriate for the patient.

Full Endoscopic Interlaminar Approach for Nerve Root Decompression of Sacral Metastatic Tumor.

BACKGROUND: Endoscopic surgery has been successfully applied in treatment of degenerative spinal disease, but few studies have assessed its use in treating sacral metastasis. We report a successful full endoscopic interlaminar approach for sacral nerve root decompression of a sacral metastatic tumor. CASE DESCRIPTION: An 80-year-old man with a history of hepatocellular carcinoma presented with buttock pain with radiation to the right lower leg for 1 week. There was also decreased muscle power of the right lower extremity. Lumbosacral magnetic resonance imaging revealed metastasis of the sacral spine and right iliac bone with S1 exiting nerve root compression. S1 nerve root decompression via a full endoscopic interlaminar approach under local anesthesia was performed. Under fluorescence guidance, a working sleeve with a beveled opening was placed in the interlaminar space of L5-S1. We entered the sacral canal and identified the S1 exiting nerve root. A laminotomy was performed from the internal edge of the right sacral laminae toward the lateral recess. During decompression of the nerve root, buttock and leg pain improved gradually. There was almost complete resolution of leg pain after surgery, and the patient recovered the ability to walk. Visual analog scale score for pain decreased from 8 to 2 after 3 months of follow-up. CONCLUSIONS: For patients with sacral metastasis without spinal instability or difficulty lying in prone position under local anesthesia, the full endoscopic interlaminar approach for nerve root decompression of sacral metastasis may be a suitable method.