Minimally Invasive Surgery Transpedicular Intrabody Cage Technique for the Management of Kummell Disease.

BACKGROUND: The treatment of Kummell disease remains controversial, with a wide variety of options proposed in the literature. This study aims to introduce a unique and minimally invasive approach for the treatment of Kummell disease and present the clinical results of this technique. METHODS: Twenty patients underwent surgery using the minimally invasive surgery transpedicular intrabody cage (MISTIC) technique from 2014 to 2016. Postoperatively, patients were seen at 3, 6, and 12 months after surgery. Visual analog scale and Oswestry Disability Index scores were collected, and patient outcomes were graded according to the modified MacNab's criteria. Radiological outcomes were assessed through measurements of the anterior vertebral height (AH), mean vertebral body height (BH), and segmental angle (SA) on standing lateral radiographs pre- and postoperatively. RESULTS: There was significant improvement in the SA, AH, and BH postoperatively. The SA improved from 15.2 ± 8.7° of kyphosis to 1.2 ± 5.2° (P < 0.01) in the immediate postoperative period. The AH increased from 13.3 ± 14.6 to 22.6 ± 12.2 mm (P < 0.01), and at the final follow-up, it was 21.9 ± 12.6 mm (P < 0.01). Similarly, the BH increased from 18.5 ± 6.8 to 25.6 ± 7.6 mm (P < 0.01) postsurgery, and at the final follow-up, it was 23.6 ± 4.4 mm (P < 0.01). CONCLUSIONS: The MISTIC technique offers significant correction of kyphosis and restoration of the vertebral anatomy following surgery. These results were maintained at 12 months postoperation, with a 100% union rate of the fractures. Additionally, patients experienced significant pain relief and improvement in their ODI scores that were maintained at 12 months.

Idiopathic spinal cord herniation with postoperative paraplegia-A case report.

Key clinical message: Spinal cord herniation is an uncommon diagnosis. There should be a high index of suspicion to diagnose spinal cord herniation when a patient presents with incomplete neurological deficits. Surgical repair of the hernia can have postoperative complications with new neurological deficits and they should be considered during the treatment. Abstract: A 37-year-old male presented with insidious onset upper back pain and altered sensations of pain and temperature over the right half of the body below the nipple for 2 months. MRI of the thoracic spine showed an anterolateral defect (left) at the level of T2-T3 vertebra. The defect was covered by a dural graft and the wound was closed with a drain On the 3rd postoperative day, neurological weakness progressed to paraplegia. Patient was treated by exploration and decompression of the hematoma. The deficits were completely recovered at one-month follow-up. Patients with spinal cord herniation and neurologic deficits when treated timely have good outcomes.

Cirrhosis in intrahepatic cholangiocarcinoma: prognostic importance and impact on survival.

CONTEXT: Cholangiocarcinoma (CCA), a malignancy of the biliary tract epithelium is of increasing importance due to its rising incidence worldwide. There is a lack of data on cirrhosis in intrahepatic CCA (iCCA) and how it affects overall survival and prognosis. OBJECTIVES: The primary objective of this study was to examine if there were differences in survival outcomes between iCCA patients with concomitant cirrhosis and those without cirrhosis. METHODS: The National Cancer Database (NCDB) was used to identify and study patients with iCCA from 2004 to 2017. The presence of cirrhosis was defined using CS Site-Specific Factor 2 where 000 indicated no cirrhosis and 001 indicated the presence of cirrhosis. Descriptive statistics were utilized for patient demographics, disease staging, tumor, and treatment characteristics. Kaplan-Meier (KM) method with log-rank test and a multivariate logistic regression model was used to assess if the presence of cirrhosis in iCCA was associated with survival status and long-term survival (60 or more months after diagnosis). RESULTS: There were 33,160 patients with CCA in NCDB (2004-2017), of which 3644 patients were diagnosed with iCCA. One thousand fifty-two patients (28.9%) had cirrhosis as defined by Ishak Fibrosis score 5-6 on biopsy and 2592 patients (71.1%) did not meet the definition for cirrhosis. Although in univariate analyses using KM/log-rank tests showed a survival advantage for non-cirrhotic patients, there was no statistically significant association found between cirrhosis and survival status (OR = 0.82, p = 0.405) or long-term survival (OR = 0.98, p = 0.933) when multivariate analysis was used. iCCA patients with cirrhosis and Stage 1 tumor had the highest median OS (132 months) vs 73.7 months in the non-cirrhotic arm, while patients with stage IV disease who had cirrhosis had half the survival time of those without. Our data thus indicates that the presence of cirrhosis is not an independent prognostic factor for survival.

Evaluation of the efficacy and safety of conventional and interlaminar full-endoscopic decompressive laminectomy to treat lumbar spinal stenosis (ENDO-F trial): Protocol for a prospective, randomized, multicenter trial.

Lumbar spinal stenosis is a common spinal degenerative condition. Minimally invasive interlaminar full-endoscopic decompressive laminectomy provides greater patient satisfaction and faster recovery than open decompressive laminectomy. The aim of our randomized controlled trial will be to compare the safety and efficacy of interlaminar full-endoscopic laminectomy and open decompressive laminectomy. Our trial will include 120 participants (60 per group) who will undergo surgical treatment for lumbar spinal stenosis. The primary outcome will be the Oswestry Disability Index measured at 12 months postoperatively. Secondary patient-reported outcomes will include back and radicular leg pain measured via a visual analog scale; the Oswestry Disability Index; the Euro-QOL-5 Dimensions score measured at 2 weeks and at 3, 6, and 12 months postoperatively; and patient satisfaction. The functional measures will include time to return to daily activities postoperatively and walking distance/time. The surgical outcomes will include postoperative drainage, operation time, duration of hospital stay, postoperative creatine kinase (an indicator of muscle injury) level, and postoperative surgical scarring. Magnetic resonance and computed tomography images and simple radiographs will be obtained for all patients. The safety outcomes will include surgery-related complications and adverse effects. All evaluations will be performed by a single assessor at each participating hospital who will be blinded to group allocation. The evaluations will be conducted preoperatively and at 2 weeks and 3, 6, and 12 months postoperatively. The randomized, multicenter design of the trial, blinding, and justification of the sample size will reduce the risk of bias in our trial. The results of the trial will provide data regarding the use of interlaminar full-endoscopic laminectomy as an alternative to open decompressive laminectomy that results in similar surgical findings with less invasiveness. Trial registration: This trial is registered at cris.nih.go.kr. (KCT0006198; protocol version 1; 27 May 2021).

Risk factors for ninety-day readmissions following full-endoscopic transforaminal lumbar discectomy for 1542 patients in the biggest spine institutes in Korea.

INTRODUCTION: Endoscopic techniques are becoming popular among spine surgeons because of their advantages. Though the advantages of endoscopic spine surgery are evident and patients can be discharged home within hours of surgery, readmissions can be sought for incomplete relief of leg pain, recurrent disc herniation, and recurrent leg pain. We aim to find out the factors related to the readmission of patients treated for lumbar pathologies. MATERIALS AND METHODS: This is a retrospective analysis of the data between the time duration of 2012 and 2022. Patients in the age group of 18-85 years, with lumbar disc herniation treated by transforaminal endoscopic lumbar procedures, were included. The patients who were readmitted within 90 days were included in the R Group and those who were not were included in the NR group. Univariable and multivariable logistic regression analyses were used to find the risk factors for 90-day readmission. RESULTS: There were a total of 1542 patients enrolled in this study. Sex, number of episodes before admission, hypertension, smoking, BMI, migration, disc height, disc height index, spondylolisthesis, instability, pelvic tilt (PT), and disc cross-sectional area (CSA) were found significant on univariable analysis. Age, spondylolisthesis, instability and muscle CSA were the only variables that were found to be statistically significant on multivariable analysis. CONCLUSIONS: This study shows that the elderly age group, presence of spondylolisthesis, segmental instability and decreased muscle cross-sectional area are independent risk factors for 90-day hospital readmissions. Patients having the above risk factors should be carefully counseled regarding the possibility of readmission in the future.

Comparative Analysis of ABM/P-15, Bone Morphogenic Protein and Demineralized Bone Matrix after Instrumented Lumbar Interbody Fusion.

OBJECTIVE: ABM/P-15 (anorganic bone matrix/15-amino acid peptide fragment) is a commercially available synthetically manufactured P-15 collagen peptide fragment, that is adsorbed on ABM. This study was done to investigate the efficacy of ABM/ P-15 in achieving fusion in the lumbar spine and comparing it with that of recombinant bone morphogenic protein-2 (rhBMP-2) and demineralized bone matrix (DBM). METHODS: A retrospective observational study of prospectively collected data of 140 patients who underwent lumbar spinal fusion surgeries in a single specialty spine hospital between 2016 and 2020, with a minimum 6-month follow-up was conducted. Based on the material used for the augmentation of the bone graft at the fusion site, the patients were divided into three categories namely ABM/P-15, rhBMP-2, and DBM group. RESULTS: ABM/P-15, rhBMP-2, and DBM were used in 46, 44, and 50 patients, respectively. Patient characteristics like age, gender, bone mineral density, smoking history, and presence of diabetes mellitus were comparable amongst the three groups. Average follow-up was 16.0±5.2, 17.9±9.8, and 26.2±14.9 months, respectively in ABM/P-15, rhBMP-2, and DBM groups. The fusion was achieved in 97.9%, 93.2%, and 98% patients while the average time-to-union was 4.05±2.01, 10±4.28, and 9.44±3.49 months (p<0.001), respectively for ABM/P-15, rhBMP-2, and DBM groups. The average pre-operative Visual analogue scale score was 6.93±2.42, 7.14±1.97, 7.01±2.14 (p=0.900) for ABM/P-15, rhBMP-2 and DBM groups, respectively, which reduced to 1.02±0.80, 1.21±0.96, and 0.54±0.70 (p=0.112), respectively at the last follow up. Pre-operative Oswestry disability index scores were 52.7±18.02, 55.4±16.8, and 53.56±19.6 (p=0.751) in ABM/P-15, rhBMP-2, and DBM groups, which post-operatively reduced to 33.77±15.52, 39.42±16.47, and 38.3±15.89 (p=0.412) and further to 15.74±8.3, 17.41±10.45, and 16.76±9.81 (p=0.603), respectively at the last follow-up. CONCLUSION: ABM/P-15 appears to achieve union significantly earlier than rhBMP-2 and DBM in lumbar spinal fusion cases while maintaining a comparable clinical and complication profile.

Comparative study of the efficacy and safety of minimally invasive interlaminar full-endoscopic discectomy versus conventional microscopic discectomy in single-level lumbar herniated intervertebral disc (ENDO-F Trial): a multicenter, prospective, randomized controlled trial protocol.

BACKGROUND: Advances in minimally invasive surgery have expanded the indications for interlaminar full-endoscopic discectomy. Although the clinical outcomes for this approach may be equivalent to those of conventional microscopic discectomy, the supporting evidence is still based on small, single-center, prospective, and retrospective studies. Therefore, a multicenter randomized controlled trial is warranted. METHODS: This will be a prospective, multicenter, randomized controlled trial comparing the efficacy and safety of interlaminar full-endoscopic discectomy to those of conventional microscopic discectomy. The trial will enroll 100 participants with a lumbar disc herniation, 50 in each group. The primary outcome will be the Oswestry Disability Index (ODI) score at 12 months post-surgery. Secondary outcomes will be back and leg pain (visual analog scale); the ODI; the EuroQol-5-dimension score; patient satisfaction; and walking distance/time and time to return to daily activities post-surgery. Surgical outcomes will include postoperative drainage, operative time, duration of hospital stay, postoperative creatine kinase level as an indicator of muscle injury, and postoperative scarring. Postoperative magnetic resonance imaging, computed tomography, and simple radiography will be performed to evaluate radiographic outcomes between the two surgical approaches. Surgery-related complications and adverse effects will be evaluated as safety outcomes. A single assessor at each participating hospital, blinded to group allocation, will assess the enrolled participants at baseline, at 2 weeks, and at 3, 6, and 12 months postoperatively. DISCUSSION: This trial is designed to determine whether interlaminar full-endoscopic discectomy is clinically comparable to microscopic discectomy to treat lumbar disc herniations. All efforts will be made to reduce bias, including adequate sample size, blinded analyses, and multicenter prospective registration. The outcomes will inform practice, providing the evidence needed for using interlaminar full-endoscopic over microscopic discectomy by confirming the potential of this technique to improve patient satisfaction and clinical outcomes. TRIAL REGISTRATION: Clinical Research Information Service; cris.nih.go.kr. (KCT0006277); protocol version (v1, June 8, 2021).

Spinal subdural hematoma after interlaminar full-endoscopic decompression of lumbar spinal stenosis: a case report and literature review.

The use of full-endoscopic decompression for lumbar spinal stenosis has been increasing recently. It is a minimally invasive surgical procedure that has few complications. Spinal subdural hematoma (SSH) following endoscopic surgery has never been reported. Previously described SSHs have occurred spontaneously or due to surgery-related iatrogenic injury. We describe the first case of SSH after endoscopic decompression. A 68-year-old woman presented with bilateral radiating pain and neurological claudication due to lumbar spinal stenosis at the L4-5 level. Full-endoscopic interlaminar decompression was performed without intraoperative complications. Preoperative leg pain improved after endoscopic decompression. However, two days after the index surgery, the patient complained of severe radiating pain in her right leg with urinary retention. The radiologic evaluation showed compressive subdural fluid collection at the index level. Open microscopic decompression was performed. No dural injury was observed. After durotomy, xanthochromic fluid gushed out at a high pressure. We found that the arachnoid was also intact. The patient recovered completely after surgical hematoma evacuation. Although SSH after endoscopic decompression is a very rare event, it is a reminder that suspicion and urgent imaging and intervention are necessary during the postoperative period upon development of unexpected, progressive neurological deterioration regardless of intraoperative problems. Additionally, early surgical decompression is necessary for optimal neurological recovery.

Novel Simultaneous Decompression Through Single-stage Mini-thoracotomy for Concurrent Ossification of the Posterior Longitudinal Ligament and Ossification of the Ligamentum Flavum at the Same Thoracic Level: A Technical Report and Literature Review.

STUDY DESIGN: Technical case report. OBJECTIVE: To describe a novel technique of decompression through single-stage mini-thoracotomy for removing concurrent ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF) at the same thoracic level simultaneously. SUMMARY OF BACKGROUND DATA: Concurrent OPLL and OLF at the same thoracic level is not common. Because these conditions lead to severe thoracic myelopathy, however, they require surgical decompression.To date, several cases with concurrent OPLL and OLF at the same thoracic level and surgical methods to treat these conditions have been described. However, no consensus on the surgical methods for the treatment these conditions has been established and these surgical methods have been also reported to be linked with the incidence of complication like neurological deterioration and the requirement of bone grafting and instrumentation. METHODS: Three consecutive patients who presented with thoracic myelopathy caused by concurrent OPLL and OLF at the same thoracic level were treated by our novel surgical technique of decompression through single-stage mini-thoracotomy. RESULTS: Simultaneous complete removal of OPLL and OLF through single-stage mini-thoracotomy was performed successfully in the three patients. All patients' preoperative symptoms gradually improved during the follow-up period, and no additional complications were associated with removal of OLF through thoracotomy. And there was no kyphotic change or instability in the thoracic spine after more than a year of follow-up although both bone grafting and instrumentation were not performed. CONCLUSION: This novel surgical technique is considered to be able to be a safe and effective alternative to the conventional treatment of selective cases of thoracic myelopathy caused by concurrent OPLL and OLF at the same thoracic level.Level of Evidence: 4.

Transforaminal endoscopic thoracic discectomy with foraminoplasty for the treatment of thoracic disc herniation.

BACKGROUND: Symptomatic thoracic disc herniation (TDH) is a rare clinical entity and surgical intervention for it is even more uncommon. Despite several surgical techniques being described for thoracic discectomy, considering the unique surgical challenges, none of them have been accepted universally. Minimally invasive techniques have brought in a paradigm shift in the management of cervical/lumbar spinal disorders and similar techniques have been extrapolated to the thoracic region too. The purpose of this paper is to describe our technique, surgical experience, and the clinical results of transforaminal endoscopic thoracic discectomy (TETD). METHODS: Consecutive patients who underwent TETD (2001-2018) were reviewed. Patients who had a minimum of 6 months of follow-up, and without cervical and lumbar spine surgery or trauma during the follow-up period were included in the study. TETD was performed in patients who presented with symptomatic disc herniation of the thoracic spine and did not respond to conservative treatments. Patients with calcified disc herniation or concomitant ossification of the posterior longitudinal ligament (OPLL) were excluded. Under local anesthesia and intravenous sedation, a 4.7-mm endoscope (TESSYS, Joimax GmbH, Germany) was introduced via transforaminal approach with foraminoplasty using reamer. Patient outcome was evaluated using visual analogue scale (VAS) and Oswestry disability index (ODI) scores. Patient satisfaction was measured using Macnab's criteria. RESULTS: Ninety-two consecutive patients (mean age was 48.9 years, 57 males) who underwent TETD from 2001 to 2018 met the inclusion criteria. Patients underwent surgery at different levels: 16 patients for T2-3 to T5-6 level, 41 cases for T6-7 to T8-9, and 35 patients for T9-10 to T12-L1. During follow-up for an average of 38.4 months, all patients showed a significant improvement of pain (7.6 to 1.6 in VAS and 68.2 vs. 13.2 for ODI, P<0.05 for both). There was one patient who had transient motor weakness. CONCLUSIONS: TETD for soft, paramedian or lateral symptomatic TDH is a feasible and effective minimally invasive treatment option with favorable clinical results.

Transforaminal Endoscopic Discectomy for Hard or Calcified Lumbar Disc Herniation: A New Surgical Technique and Clinical Outcomes.

OBJECTIVE: Hard or calcified discs are often adherent to surrounding nerve tissue. The whole herniated disc is difficult to remove by pulling part of the hernia mass, which makes obtaining good results through endoscopic treatment difficult. The purpose of this study was to describe the details of the transforaminal endoscopic lumbar discectomy technique for a hard or calcified disc and report the clinical results. METHODS: From October 2016 to June 2019, 43 consecutive cases diagnosed as hard or calcified lumbar disc herniation at our institution and treated with transforaminal endoscopic discectomy were evaluated. Endoscopic decompression was performed in patients with hard or calcified lumbar disc herniation. RESULTS: The preoperative visual analog scale score for leg pain (mean ± standard deviation) was 7.09 ± 1.74. The score improved to 2.55 ± 1.35 at 1 week postoperatively, 1.88 ± 1.29 at 4 weeks postoperatively, and 1.58 ± 1.0 at 26 weeks postoperatively (P < 0.01 for all). The preoperative Oswestry Disability Index (mean ± standard deviation) was 55.4 ± 23.04, which improved to 30.89 ± 13.64 at 1 week postoperatively, 23.08 ± 11.64 at 4 weeks postoperatively, and 16.42 ± 9.76 at 26 weeks postoperatively (P < 0.01 for all). Two patients developed a dural laceration. Both patients were discharged after several hours of observation. None of the patients had postoperative infection, epidural hematoma, or delayed neurological deterioration. CONCLUSIONS: Transforaminal endoscopic discectomy could be an effective treatment method for a selected group of patients with hard or calcified lumbar disc herniation.

Percutaneous Endoscopic Cervical Discectomy Versus Anterior Cervical Discectomy and Fusion: A Comparative Cohort Study with a Five-Year Follow-Up.

Percutaneous endoscopic cervical discectomy (PECD) is an effective minimally invasive surgery for soft cervical disc herniation in properly selected cases. The current gold standard is anterior cervical discectomy and fusion (ACDF). However, few studies have evaluated the outcome of PECD compared with ACDF. We compared the surgical results of PECD and ACDF. Data from patients treated with single-level PECD (n = 51) or ACDF (n = 64) were analyzed. Patients were prospectively entered into the clinical database and their records were retrospectively reviewed. Perioperative data and clinical outcomes were evaluated using the visual analogue scale (VAS), Neck Disability Index (NDI), and modified Macnab criteria. VAS and NDI results significantly improved in both groups. The rates of excellent or good results were 88.24% and 90.63% in the PECD and ACDF group, respectively. The revision rates were 3.92% and 1.56% in the PECD and ACDF group, respectively. Operative time, hospital stay, and time to return to work were reduced in the PECD group compared to the ACDF group (p < 0.001). The five-year outcomes of PECD were comparable to those of conventional ACDF. PECD provided the typical benefits of minimally invasive surgery and may be an effective alternative for treating soft cervical disc herniation.

Laser-assisted endoscopic lumbar foraminotomy for failed back surgery syndrome in elderly patients.

Elderly patients with failed back surgery syndrome (FBSS) or post-laminectomy foraminal stenosis have a higher risk of perioperative morbidity with extensive revision surgery. Thus, there is a need for safer and less invasive surgical options, such as laser-assisted endoscopic lumbar foraminotomy (ELF). A pin-point laser beam can allow precise tissue ablation and dissection in fibrotic adhesion tissues while preventing normal tissue injury. The present study aimed to describe the surgical technique of laser-assisted ELF and to evaluate the clinical outcomes of elderly patients with FBSS. Two-year follow-up data were collected from 26 consecutive patients aged 65 years or older who were treated with laser-assisted ELF for FBSS. Full-endoscopic foraminal decompression was performed using a side-firing laser and mechanical instruments. The average age of the patients was 70.2 years (range, 65-83 years). The mean visual analog pain score for leg pain improved from 8.58 at baseline to 3.35 at 6 weeks, 2.19 at 1 year, and 2.35 at 2 years after ELF (P < 0.001). The mean Oswestry disability index improved from 65.93 at baseline to 31.41 at 6 weeks, 21.77 at 1 year, and 20.64 at 2 years after ELF (P < 0.001). Based on the modified Macnab criteria, excellent or good results were obtained in 84.6% patients and symptomatic improvements were obtained in 92.3%. Extensive revision surgery in elderly patients might cause significant surgical morbidities. Laser-assisted ELF under local anesthesia could be a safe and effective surgical alternative for such patients at risk.

Brown-Séquard Syndrome Caused by Acute Traumatic Cervical Disc Herniation.

Brown-Séquard syndrome (BSS) is an incomplete spinal cord injury caused by damage to one-half of the spinal cord. Most cases of BSS result from penetrating trauma or tumors, and acute cervical disc herniation is a relatively rare cause of BSS. In this case, a 34-year-old man with a sudden onset posterior neck pain and left side motor weakness was admitted to the local spine hospital. Pain and temperature sensation of pain was decreased below the right C4 dermatome. The left arm and leg motor grade was 0. Magnetic resonance imaging (MRI) showed a huge trans-ligamentous herniated disc rupture from the center to the left at the level of C3-4, and anterior cervical discectomy and fusion were performed. After emergency surgery, left arm and leg motor grade recovered to 2, and normal voiding function returned. MRI verified complete removal of the cervical herniated disc. This case describes the approach to rapid diagnosis in a patient with characteristic clinical symptoms of BSS and radiological findings of a herniated cervical disc. Rapid and accurate diagnosis and immediate decompressive surgery increased the possibility of a good surgical outcome, even if the neurologic deficits are grave at the time of admission.

Clinical and Immunological Implications of Frameshift Mutations in Lung Cancer.

INTRODUCTION: Presently, programmed death ligand 1 is the most commonly used biomarker to predict response to immune checkpoint inhibitors (ICIs) in NSCLC. Owing to its several limitations, there is continuous search for more precise and reliable markers. Frameshift mutations by insertion or deletion (fsindels) are suggested to induce more immunogenic tumor-specific neoantigens, conferring better response to ICIs. Positive correlation of fsindels with ICI response has been studied in melanoma and renal cell carcinoma. We investigated the implication of fsindels in the clinical outcomes and immune landscape of patients with NSCLC treated with ICIs. METHODS: We utilized The Cancer Genome Atlas data set to analyze tumor mutational burden, neoantigen burden, and immune landscape in relation to fsindel status. In addition, utilizing the clinical data from 122 patients treated with ICIs, we evaluated the influence of fsindels on disease response rates and survival outcomes. RESULTS: A positive correlation between fsindel burden and tumor mutational burden and activated CD4/CD8 T-cell infiltration was shown. Presence of fsindels was also associated with significant prolongation of progression-free survival in patients treated with ICIs (median 6.2 versus 2.7 months [p = 0.01]). In addition, significant differences in the overall response rates (26% versus 12% [p = 0.04]) and disease control rates (68% versus 48% [p = 0.02]) were observed in patients with fsindels. CONCLUSION: Our findings suggest that fsindels may have a predictive role for ICI response in NSCLC.

Percutaneous Endoscopic Thoracic Discectomy in the Upper and Midthoracic Spine: A Technical Note.

Despite the successful application of percutaneous endoscopic thoracic discectomy (PETD), its technical feasibility and outcomes for symptomatic upper and midthoracic disc herniation have not been reported yet. The purpose of this article was to evaluate the feasibility of the percutaneous transforaminal endoscopic approach to remove disc herniations in the upper and midthoracic spine. Fourteen consecutive patients (mean age, 42.4 years; 12 males, 2 females) who underwent PETD were included in the analysis. The procedure was performed under local anesthesia and intravenous sedation using the standard endoscopy instrument set. The transforaminal approach combined with foraminoplasty was used to access the herniated areas. Treatment outcomes were evaluated using visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified MacNab criteria. Four discectomies were performed at T2-3, 5 at T3-4, and 5 at T5-6. The mean follow-up period was 43.4 months, and all patients showed statistically significant postoperative improvement (VAS: 7.3 to 2.3, ODI: 53.5 to 16.9, p<0.05 for all). No serious complications were reported during follow-up. PETD for upper and midthoracic disc herniation is a feasible and effective minimally invasive treatment option with favorable clinical results.

Microscopic Anterior Neural Decompression Combined with Oblique Lumbar Interbody Fusion-A Technical Note.

BACKGROUND: Minimally invasive oblique lumbar interbody fusion (OLIF) techniques generally rely on deformity correction to achieve indirect neural decompression. However, indirect neural decompression will not always be sufficient. Thus, a second procedure, such as posterior direct decompression, will be added for full decompression, increasing the surgical morbidity and healthcare costs. We have described a technique of direct anterior microscopic neural decompression combined with OLIF. METHODS: We report our surgical technique of anterior lumbar neural microscopic decompression with OLIF with patients in the lateral position. We also report the cases of 3 patients treated from March 2018 to June 2018. RESULTS: Three patients underwent anterior microscopic neural decompression combined with OLIF in the lateral position. All 3 patients achieved clinically and radiologically significant neural decompression and deformity correction. No perioperative complications developed. CONCLUSION: Direct anterior microscopic neural decompression is feasible and safe in selected patients undergoing OLIF.

Influence of a Preoperative Conference on Surgeons' Decision-making for Adult Spinal Disorders: A Prospective Clinical Study From a Spine Hospital.

STUDY DESIGN: This was a prospective clinical study. OBJECTIVE: The aim of this study was to evaluate the influence of a preoperative conference on spine surgeons' decision-making in the treatment of adult spinal disorders. SUMMARY AND BACKGROUND DATA: There are several factors that spine surgeons have to consider when determining a surgical plan for the treatment of spinal disorders, which include surgical approach, application of fusion or nonfusion surgery, levels to be treated, treatment of accompanying spinal conditions, the need for further preoperative imaging, and the implant type to be used. MATERIALS AND METHODS: A consecutive series of patients with a variety of adult spinal disorders at a single spine hospital were analyzed. The imaging modalities and clinical examination history of these patients were presented at a daily preoperative conference attended by staff spine surgeons and spine surgery fellows at this spine hospital. The specific surgical plan before the preoperative conference and before the surgery were compared for each patient. RESULTS: A total of 506 consecutive patients were reviewed over a 4-month period. Changes in the surgical plan following the preoperative conference occurred in 29 cases (5.7%). Seventeen of these changes were minor modifications in the same surgical level, or inclusion/exclusion of adjacent or other levels in the surgical plan, without changing the planned surgical approach. The surgical approach changed in a total of 12 cases (2.3%). Statistical analysis showed that the surgeons with experience of <10 years and orthopedic surgeons changed their surgical plan more often after the preoperative conference (P<0.05). CONCLUSIONS: Preoperative conference for the surgical treatment of adult spinal disorders influenced the surgical plan in 5.7% of surgeries. This type of daily preoperative conference seems to have only a minor impact on spine surgeons' decision-making, but, instead, it could be used to provide training and insight to better a fellow or resident's education at the spine institution. LEVEL OF EVIDENCE: Level IV.

Long-Term Minimum Clinically Important Difference in Health-Related Quality of Life Scores After Instrumented Lumbar Interbody Fusion for Low-Grade Isthmic Spondylolisthesis.

BACKGROUND: Despite its growing popularity, no comparative studies have explored the minimum clinically important difference (MCID) of health-related quality of life scores following lumbar interbody fusion (LIF) performed on a single-level adult low-grade isthmic spondylolisthesis (LGIS). OBJECTIVE: The purpose of this study is to investigate factors related to MCID of health-related quality of life scores following instrumented LIF performed on a single-level adult LGIS. METHODS: Consecutive patients who underwent instrumented LIF for single-level LGIS were reviewed. The inclusion criteria were adult patients who underwent L4-5 or L5-S1, underwent anterior lumbar interbody fusion or transforaminal lumbar interbody fusion with a posterior screw fixation, and had a minimum 36-month postoperative follow-up period. MCID was defined as having an improved score of visual analog scale (VAS) back and leg pain >3 and Oswestry Disability Index (ODI) >12. Patients were subdivided into groups named "achievement" (A) and "nonachievement" (N) depending on their postoperative MCID for each health-related quality of life score category. RESULTS: One-hundred and five patients met the inclusion criteria. The overall achievement of MCID for VAS back, leg, and ODI was 80%, 73.3%, and 82.9%. MCID-VAS leg and ODI were less achieved at the L5-S1 level than at the L4-5 level. Postoperatively, disk height was higher and segmental lordosis (SL) was lower in group A of MCID-VAS leg. SL was lower in group A of MCID-ODI. CONCLUSIONS: We postulate that excessive SL does not affect lumbar lordosis; rather, it can result in lowering posterior disk height. The decrease in posterior DH may lead to a decreased foraminal height that, in turn, can lead to nerve root compression. Proper restoration of disk height and bone fusion is more important than restoration of more segmental lordosis or slip reduction for isthmic spondylolisthesis.