Long-term Clinical Outcomes Following Endoscopic Foraminoplasty for Patients With Single-Level Foraminal Stenosis of the Lumbar Spine.

BACKGROUND: The aim of this study is to evaluate the safety and long-term clinical outcomes of transforaminal endoscopic foraminoplasty using local anesthesia and total intravenous analgesia (TIVA) in patients with single-level lumbar foraminal stenosis and unilateral leg pain. METHODS: Postoperative pain relief was self-evaluated by 46 consecutive patients using a visual analog scale (VAS) and Oswestry Disability Index (ODI). Patient scores were obtained before the procedure and at 6, 12, 24, and 60 months after surgery. RESULTS: Pain reduction of at least 50% in the VAS score and a decrease of at least 50% or more in ODI score was achieved in 37 of 46 patients throughout the follow-up period. Median VAS score decreased from 7.5 preoperatively to 2.5 postoperatively. Median ODI score decreased from 62% preoperatively to 15% postoperatively. All patients reached 24-month follow-up and 37 patients reached 60-month follow-up. There were no surgery-related complications. CONCLUSION: Transforaminal endoscopic foraminoplasty performed under local anesthesia and TIVA produces sustained reduction in pain and improves functionality in patients with single-level lumbar foraminal stenosis without complications even in patients with comorbidities. CLINICAL RELEVANCE: Endoscopic foraminoplasty may be a useful adjunct to open micro decompressive surgery for patients with foraminal stenosis of the lumbar spine LEVEL OF EVIDENCE: 4.

Five-Year Outcomes After Transforaminal Endoscopic Foraminotomy and Discectomy for Soft and Calcified Thoracic Disc Herniations.

BACKGROUND: The aim of this study was to evaluate the safety and long-term clinical outcomes of transforaminal full endoscopic discectomy and foraminotomy performed with manual reamers under local anesthesia on soft and calcified herniated discs in the mid and lower thoracic spine. METHODS: Postoperative pain relief was self-evaluated by 16 patients using a visual analog scale (VAS) and Oswestry Disability Index (ODI). Patients were scored at 6, 12, 24, and 60 months after surgery. RESULTS: Significant pain reduction of more than 50% in the VAS score was achieved in 15 out of 16 patients at all review points throughout this study. Similarly, a decrease of more than 50% in ODI scores was achieved in 15 out of 16 patients in all 4 review points. There were no surgical complications. Good postoperative results were achieved in patients regardless of the consistency of the disc herniation. CONCLUSIONS: Transforaminal full endoscopic discectomy and foraminotomy with manual reamers performed under local anesthesia produces sustained reduction in pain and improves functionality in patients with mid and lower thoracic spine soft and calcified disc herniations. The surgery is safe and straightforward to perform with the correct training. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Thoracic transforaminal endoscopic discectomy and foraminotomy, performed in TIVA, may be a useful adjunct for treatment of patients with soft and calcified disc herniations in thoracic spine.

Transforaminal Endoscopic Discectomy for Large, Two Level Calcified, Thoracic Disc Herniations With 5-Year Follow-up.

To describe technical details and benefits of transforaminal endoscopic discectomy for treatment of patients with large, dorsomedial, calcified thoracic disc herniations at 2 levels and to report on their clinical outcomes in long follow-up period of 5 years using 4 different outcome tools. We present 2 patients with large, calcified disc herniations at 2 levels in mid and lower thoracic spine treated endoscopically in local anesthesia. Clinical outcomes were analyzed using verbal numeric scale (VNS), Roland-Morris low back pain and disability questionnaire (RMQ), Oswestry Disability Index (ODI), and modified MacNab criteria at 6-, 12-, 24-, 60-month follow-up. After transforaminal endoscopic discectomy, both patients had significant postoperative reduction of back pain using VNS and significant outcome improvement using ODI, RMQ score, and modified MacNab criteria. These results did not change during all 4 follow-up periods. Transforaminal percutaneous full-endoscopic discectomy and hand reamers foraminotomy in local anesthesia is feasible and effective surgical technique for patients with large, calcified thoracic disc herniations at 2 levels even in long follow-up period of 5 years using 4 different outcome measuring tools. All 3 outcome measuring tools correlated well with pain reduction using VNS.

[Clinical predictors correlated to outcome of war missile penetrating brain injury]. / Klinicki pokazatelji u.spjesnosti lijecenja ratnih penetrirajucih ozljeda mozga.

AIM OF THE STUDY: The purpose of this retrospective study was to review and discuss the outcome of surgical management and other clinical predictors influencing the prognosis of war missile penetrating brain injuries. PATIENTS AND METHODS: To determine clinical predictors that influence the prognosis of war missile penetrating brain injury, 126 surgically treated patients who had sustained such an injury during the two-year period of war in Croatia (1991-1993) were retrospectively analyzed. Investigated clinical features were: Glasgow Coma Scale (GCS) score on admission; extent of brain injury; time between injury and hospital admission; presence of intracranially retained foreign bodies or bone fragments; development of postinjury and posttraumatic complications; and Glasgow Outcome Score (GOS) at six-month follow up. The data were statistically analyzed. RESULTS: Sixty-seven patients survived penetrating missile brain injury, in most of them with GCS score above 8 on admission. The mean time interval to hospital admission in this group of patients was less than two hours. Twelve of 67 patients developed different complications. All patients recovered well according to GOS (GOS 5 and 4) at six-month follow up. Fifty-nine patients died. The wounded who were in moribund state on the hospital admission (n = 11), and those who died during surgery (n = 8) were excluded from the analysis. The remaining 40 patients who did not survive were analyzed. The majority of them had GCS score 3-8 on admission. They mostly sustained bilateral hemispheric lesion, and/or ventricular lesion, and developed brain edema. The mean time interval between injury and hospital admission was over two hours in this group of patients. Postoperative complication developed in 9 of 40 patients. DISCUSSION: The patients with GCS score exceeding 8 had by far more favorable outcome in comparison to those with GCS score less than 8. Considering the extent of injury, patients suffering unihemispheric brain wounds had a more favorable outcome than those with lesions of both hemispheres, and particularly those with transventricular lesions. The time between injury and hospital admission proved to be another important prognostic factor. The majority of patients admitted up to one hour of injury survived, while two thirds of those admitted between one and three hours of injury succumbed. The presence of intracranially retained foreign bodies and bone fragments, and postinjury and postoperative complications implied worse outcome in comparison with their absence. CONCLUSION: The state of consciousness on admission was the most sensitive criterion as far as the prognosis is concerned. The outcome also depended on the extent of brain damage since the wounds associated with a high mortality rate were predominantly bihemispheric. Concerning survival, the time between injury and hospital admission also appeared to be important, as well as intracranially retained foreign bodies and bone fragments, and development of complications. There was no relationship between the presence of retained fragments and development of infection, suggesting that it is not necessary to reoperate for retained fragments. We assume that early surgery is essential for treatment outcome, although it is not necessary to reoperate for retained fragments.

Case-control study of risk factors for lumbar intervertebral disc herniation in Croatian island populations.

AIM: To investigate the risk factors for lumbar intervertebral disc herniation (L4/L5 or L5/S1) severe enough to require surgery of the lower spine among 9 isolated populations of Croatian islands and to evaluate predictive value, sensitivity, and specificity of a simple screening test based on the understanding of the risk factors in this population. METHODS: In a sample of 1001 examinees from Croatian island populations, we identified all subjects who underwent surgery of the lower spine due to lumbar intervertebral disc herniation L4/L5 or L5/S1 and selected 4 controls matched by age, gender, and village of residence for each of them. Odds ratio was computed for the following variables: body mass index, occupation, intensity of physical labor at work, intensity of physical labor at home, smoking index, claudication index, self-assessed limitation in physical activity, level of education, socio-economic status, and family history of lumbar intervertebral disc herniation requiring surgery. RESULTS: Comparison of 67 identified cases with 268 controls revealed the highest odds ratios (OR) for positive family history (OR 4.00; 95% confidence intervals [CI], 1.89-6.11, P<0.001), intensity of physical labor at work defined as (hard) (OR 2.94; 95% CI, 1.07-4.81, P<0.001), and body mass index of 25.7 or more (OR 2.77, 95% CI, 1.05-4.49, P=0.002). A simple screening test based on the presence of any two of these three criteria has 74% sensitivity and 82% specificity to detect persons who underwent lower spine surgery due to lumbar intervertebral disc herniation in the population aged 40 years or more. CONCLUSION: Occurrence of lumbar disk herniation severe enough to require surgery of the lower spine can be predicted using a very simple set of criteria. This type of screening could reduce the need for surgery in isolated communities through prevention within primary health care.