Full-endoscopic versus microscopic spinal decompression for lumbar spinal stenosis: a systematic review & meta-analysis.

BACKGROUND CONTEXT: Symptomatic lumbar spinal stenosis is routinely treated with spinal decompression surgery, with an increasing trend towards minimally invasive techniques. Endoscopic decompression has emerged as a technique which minimizes approach-related morbidity while achieving similar clinical outcomes to conventional open or microscopic approaches. PURPOSE: To assess the safety and efficacy of endoscopic versus microscopic decompression for treatment of lumbar spinal stenosis. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review on randomized and nonrandomized studies comparing endoscopic versus microscopic decompression was conducted, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Treatment effects were computed using pairwise random-effects meta-analysis. Risk of bias was assessed using the Cochrane Risk-of-bias and ROBINS-I tools for randomized and nonrandomized trials respectively. Quality of the overall body of evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS: A total of 19 primary references comprising 1,997 patients and 2,132 spinal levels were included. Endoscopic decompression was associated with significantly reduced intraoperative blood-loss (weighted mean differences [WMD]=-33.29 mL, 95% CI:-51.80 to -14.78, p=.0032), shorter duration of hospital stay (WMD=-1.79 days, 95% CI: -2.63 to 0.95, p=.001), rates of incidental durotomy (RR = 0.63, 95% CI: 0.43 to 0.91, p=.0184) and surgical site infections (RR=0.23, 95% CI: 0.10 to-0.51, p=.001), and a nonsignificant trend towards less back pain, leg pain, and better functional outcomes compared to its microscopic counterpart up to 2-year follow up. CONCLUSIONS: Endoscopic and microscopic decompression are safe and effective techniques for treatment of symptomatic lumbar spinal stenosis. Prospective studies of larger power considering medium to long-term outcomes and rates of iatrogenic instability are warranted to compare potential alignment changes and destabilization from either techniques.

Narrative Review of Uniportal Posterior Endoscopic Cervical Foraminotomy.

Cervical radiculopathy is a common and disabling cervical condition characterized by symptoms including axial neck pain, radicular pain, weakness, and numbness in one or both arms. Common causes include herniated discs and foraminal stenosis, often accompanied by varying degrees of degenerative disc disease and uncovertebral joint hypertrophy. In the treatment of cervical radiculopathy, there is an increasing preference for posterior foraminotomy over anterior cervical discectomy and fusion due to the avoidance of fusion-related complications. As endoscopic spine surgery techniques continue to evolve, there is a rising interest in posterior endoscopic cervical foraminotomy and posterior endoscopic cervical discectomy as effective treatments for cervical radiculopathy. Because these procedures can performed through a single subcentimeter incision with minimal soft tissue damage, they can often be carried out as ambulatory procedures. In this narrative review, we examined current literature addressing the indications, surgical techniques, outcomes, and potential complications associated with posterior cervical endoscopic approaches.

Clinical and Radiological Outcomes of a Comparative Study of Anterior Cervical Decompression and Fusion with Partial Pediculotomy, Partial Vertebrotomy (PPPV) Posterior Endoscopic Cervical Decompression (PECD) for Cervical Foraminal Pathology.

Background and Objectives: The purpose was to compaSre medium-term clinical and radiological outcomes of Partial Pediculotomy, Partial Vertebrotomy (PPPV) Posterior Endoscopic Cervical Decompression (PECD) surgery versus Anterior Cervical Discectomy and Fusion (ACDF) for patients with cervical disc herniations and foraminal pathologies. Materials and Methods: A prospective registry of patients who had undergone either PPPV PECD surgery or ACDF surgery for cervical disc herniation or foraminal pathologies under a single fellowship-trained spine surgeon was performed. The baseline characteristics and operative details including complications were recorded for all included patients. The clinical outcomes evaluated include VAS, MJOA, motor score, and NDI and MacNab's score. The radiological parameters in neutral-measured facet length, facet area, disc height, C2-C7 angle, neck tilt angle, T1 slope and thoracic inlet angle were also evaluated. Results: A total of 55 patients (29 PPPV PECD, 26 ACDF) were included, with mean follow-up periods of 21.9 and 32.3 months, respectively. Each cohort was noted to have a single case of surgical complication. Statistically significant changes of facet area (49.05 ± 14.50%) and facet length (52.71 ± 15.11%) were noted in the PPPV PECD group. At neutral alignment of the neck on a lateral X-ray, compared to ACDF, PPPV PECD had a statistically significant change in neck tilt angle (-11.68 ± 17.35°) and T1 slope angle (-11.69 ± 19.58°). Whilst both PPPV PECD and ACDF had significant improvements in VAS, MJOA and NDI postoperatively, PPPV PECD was found to be superior across all above scores at various follow-up timepoints compared to its ACDF counterparts. Conclusions: PPPV PECD surgery achieved a satisfactory radiological correction of neck alignment and significantly improved clinical outcomes at medium-term follow-up for our cohort of patients, highlighting its feasibility in treating patients with cervical disc herniations and foraminal pathologies.

Uniportal Thoracic Endoscopic Unilateral Laminotomy with Bilateral Decompression of Thoracic Ossification of Ligamentum Flavum: A Systematic Review of Current Literature.

BACKGROUND: Thoracic ossification of ligamentum flavum (TOLF) is a rare disease that often results in worsening neurologic sequelae if left untreated. Although the gold standard treatment for TOLF is open posterior laminectomy, it is often accompanied by high rates of complications and perioperative morbidity. There have been studies looking into feasibility of endoscopic posterior decompression for TOLF, citing potential for lower perioperative morbidity and achieving similar functional outcomes to its open laminectomy counterparts. We provide an up-to-date systematic review of clinical outcomes after endoscopic posterior decompression for TOLF from the latest assemblage of evidence. METHODS: A systematic review of the technique was conducted from May 2000 to May 2023. Articles were selected based on PRISMA guidelines. Eligibility of studies was independently by 2 reviewers, with disagreements resolved by a third author. RESULTS: Nineteen primary references comprising 337 patients with TOLF who underwent endoscopic posterior decompression were included in the systematic review. Mean follow-up time across all studies ranged from 8.9 to 65.3 months. Mean age ranged from 51.2 to 63 years, with mean intraoperative blood loss ranging from 15 to 62 mL. There is significant improvement in visual analog scale (VAS) score, VAS back, VAS leg, modified Japanese Orthopaedic Association score, and Oswestry Disability Index compared with preoperative recorded values across all studies, with low rates of complications reported. CONCLUSIONS: Endoscopic posterior spinal decompression is a safe and effective technique for treatment of TOLF, with a low rate of complications and improvement in pain and function.

Spinal Canal Remodeling and Indirect Decompression of Contralateral Foraminal Stenosis After Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: There is a lack of literature on indirect decompression in uniportal endoscopic posterolateral transforaminal lumbar interbody fusion (EPTLIF). Our aim is to evaluate the dimensions of the spinal canal and contralateral foramen before and after EPTLIF. METHODS: This is a retrospective study of patients who underwent EPTLIF in a tertiary spine centre over a 2-year period. The cross-sectional area of the spinal canal and the contralateral foramen at the level of fusion were measured on magnetic resonance imaging scan at 1-day postoperation and at the final follow-up. Patients were grouped according to the decompression performed as per the clinician's judgement. RESULTS: One hundred fifty-two levels of fusion were performed in 120 patients. There was a statistically significant clinical improvement in visual analogue scale and Oswestry Disability Index scores postoperation. The measurements of the spinal canal area were 106.0 mm2, 138.8 mm2, and 195.5 mm2; while contralateral foraminal area were 73.2 mm2, 104.4 mm2, and 120.7 mm2 at preoperation, 1-day postoperation, and at the final follow-up, respectively (p < 0.001). For the subgroup analyses, spinal canal area measurements for the bilateral decompression cohort (n = 35) were 57.0 mm2, 123.9 mm2, and 191.8 mm2; for the ipsilateral decompression cohort (n = 42) were 89.3 mm2, 128.9 mm2, 183.3 mm2; and for the cohort without any decompression and only cage inserted (n = 75) were 138.3 mm2, 151.2 mm2, and 204.1 mm2 (p < 0.001). Contralateral foraminal area measurements were 73.3 mm2, 106.4 mm2 and 120.4 mm2 in the bilateral decompression cohort; 69.5 mm2, 99.0 mm2, 116.9 mm2 in the ipsilateral decompression cohort; and 75.1 mm2, 106.5 mm2, 122.9 mm2 in the cohort without any decompression (p < 0.001). CONCLUSION: Indirect decompression of both the spinal canal and the contralateral foramen can be achieved via EPTLIF. Decompression on an asymptomatic contralateral side is not necessary.

Ambulatory uniportal versus biportal endoscopic unilateral laminotomy with bilateral decompression for lumbar spinal stenosis-cohort study using a prospective registry.

BACKGROUND: Endoscopic spine surgery has been established as a practical, minimally invasive technique for decompression in patients with lumbar spinal stenosis. However, there remains a paucity of studies prospective cohort study comparing uniportal lumbar endoscopic unilateral laminotomy with bilateral decompression and unilateral biportal endoscopic unilateral laminotomy with bilateral decompression with open spinal decompression-both viable techniques with satisfactory clinical outcomes in the treatment of lumbar spinal stenosis. OBJECTIVE/AIM: To compare the efficacy of UPE and BPE lumbar decompression surgery for patients with lumbar spinal stenosis. METHODS: A prospective registry of patients who had undergone spinal decompression for lumbar stenosis via UPE or BPE under a single fellowship trained spine surgeon was studied. Baseline characteristics, initial clinical presentation, and operative details including complications were recorded for all included patients. Clinical outcomes, such as visual analogue scale and Oswestry Disability Index, were recorded at preoperative, immediate postoperative, 2-week, 3-, 6-, and 12-month follow-up periods. RESULTS: A total of 62 patients underwent endoscopic decompression surgery for lumbar spinal stenosis (29 UPE, 33 BPE). No significant baseline differences were found between uniportal and biportal decompression, when comparing operative duration (130 vs. 140 min; p = 0.30), intraoperative blood loss (5.4 vs. 6mLs; p = 0.05), and length of hospital stay (23.6 vs. 20.3 h; p = 0.35). Two patients (7%) who underwent uniportal endoscopic decompression required conversion to open surgery due to inadequate decompression. Intraoperative complication rates were significantly higher in the UPE group (13.4% vs. 0%, p < 0.05). VAS score (leg & back) and ODI improved significantly (p < 0.001) in both endoscopic decompression groups across all follow-up time points, with no appreciable statistical differences between both groups. CONCLUSION: UPE has the same efficacy as BPE in the treatment of lumbar spinal stenosis. While UPE surgery enjoys added aesthetic benefits of only one wound, BPE had potentially lower risks of intraoperative complication, inadequate decompression, and conversion to open surgery during early period of learning curve.

Prospective Cohort Study with a 2-Year Follow-up of Clinical Results, Fusion Rate, and Muscle Bulk for Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. PURPOSE: Postoperative evaluation of the cross-sectional area of paraspinal muscle and clinical findings in patients who had interlaminar route uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion (EPTLIF) after 2 years. OVERVIEW OF LITERATURE: There are limited short-term follow-up studies on efficacy, safety, and physiological changes with a 2-year follow-up. There is no study on paraspinal muscle cross-sectional area change in patients who had undergone uniportal EPTLIF. METHODS: We evaluated patients who underwent EPTLIF with a minimum 24-month follow-up. Clinical parameters of the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured at the preoperative, 1-week postoperative mark, postoperative 3-month mark, and final follow-up. Preoperative and 1-year postoperative magnetic resonance imaging measurement of preoperative and postoperative Kjaer grade, right and left psoas muscle mass area, and right and left paraspinal muscle mass area was performed. RESULTS: EPTLIF with a minimum 24-month follow-up of 35 levels was included. The complication rate was 6%, and the mean Bridwell's fusion grade was 1.37 (1-2). There was statistically significant improvement at 1 week, 3 months, and 2 years in VAS (4.11±1.23, 4.94±1.30, and 5.46±1.29) and in ODI (40.34±10.06, 46.69±9.14, and 49.63±8.68), respectively (p <0.05). Successful operation rate with excellent and good MacNab's criteria at 2 years was 97%. There was an increment of statistically significant bilateral psoas muscle cross-sectional area, right side (70.03±149.1 mm²) and left side (67.59±113.2 mm²) (p <0.05). CONCLUSIONS: Uniportal EPTLIF achieved good fusion and improved clinical outcomes with favorable paraspinal musculature bulk at the 2-year follow-up.

Remodeling of Epidural Fluid Hematoma after Uniportal Lumbar Endoscopic Unilateral Laminotomy with Bilateral Decompression: Comparative Clinical and Radiological Outcomes with a Minimum Follow-up of 2 Years.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To evaluate the clinical and radiological effects of epidural fluid hematoma in the medium term after lumbar endoscopic decompression. OVERVIEW OF LITERATURE: There is limited literature comparing the effect of postoperative epidural fluid hematoma after uniportal endoscopic decompression. METHODS: Magnetic resonance imaging (MRI) and clinical evaluation were performed for patients with single-level uniportal endoscopic lumbar decompression with a minimum follow-up of 2 years. RESULTS: A total of 126 patients were recruited with a minimum follow-up of 26 months. The incidence of epidural fluid hematoma was 27%. Postoperative MRI revealed a significant improvement in the postoperative dura sac area at postoperative day 1 and at the upper endplate at 6 months in the hematoma cohort (39.69±15.72 and 26.89±16.58 mm2) as compared with the nonhematoma cohort (48.92±21.36 and 35.1±20.44 mm2), respectively (p <0.05); and at the lower endplate on postoperative 1 day in the hematoma cohort (51.18±24.69 mm2) compared to the nonhematoma cohort (63.91±27.92 mm2) (p <0.05). No significant difference was observed in the dura sac area at postoperative 1 year in both cohorts. The hematoma cohort had statistically significant higher postoperative 1-week Visual Analog Scale (VAS; 3.32±0.68) pain and Oswestry Disability Index (ODI; 32.65±5.56) scores than the nonhematoma cohort (2.99±0.50 and 30.02±4.84, respectively; p <0.05). No significant difference was found at the final follow-up VAS, ODI, and MRI dura sac area. CONCLUSIONS: Epidural fluid hematoma is a common early postoperative MRI finding in lumbar endoscopic unilateral laminotomy with bilateral decompression. Conservative management is the preferred treatment option for patients who do not have a neurological deficit. Symptoms last only a few days and are self-limiting. A common endpoint is a remodeled fluid hematoma and the subsequent expansion of the dura sac area.

Narrative Review of Pathophysiology and Endoscopic Management of Basivertebral and Sinuvertebral Neuropathy for Chronic Back Pain.

Chronic lower back pain is a leading cause of disability in musculoskeletal system. Degenerative disc disease is one of the main contributing factor of chronic back pain in the aging population in the world. It is postulated that sinuvertebral nerve and basivertebral nerve main mediator of the nociceptive response in degenerative disc disease as a result of neurotization of sinuvertebral and basivertebral nerve. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain and management strategy is discussed in this review to aid understanding of sinuvertebral and basivertebral neuropathy treatment strategies.

Retrospective Case Control Study: Clinical and Computer Tomographic Fusion and Subsidence Evaluation for Single Level Uniportal Endoscopic Posterolateral Approach Transforaminal Lumbar Interbody Fusion Versus Microscopic Minimally Invasive Transforaminal Interbody Fusion.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: Assessment of difference in clinical and computer tomographic outcomes between the 2 cohorts. METHODS: Computer tomographic evaluation by Bridwell's grade, Kim's stage, Kim's subsidence grade and clinical evaluation by VAS, ODI and McNab's criteria on both cohorts. RESULTS: 33 levels of Endo-TLIF and 22 levels of TLIF were included, with a mean follow up of 14.3 (10-24) and 22.9 (13-30) months respectively. Both Endo-TLIF and TLIF achieved significant improvement of pain and ODI at post-operative 4 week, 3 months and at final follow up with VAS 4.39 ± 0.92, 5.27 ± 1.16 and 5.73 ± 1.21in Endo-TLIF and 4.55 ± 1.16, 5.05 ± 1.11 and 5.50 ± 1.20 in TLIF respectively and ODI at post-operative 1 week, 3 months and final follow up were 43.15 ± 6.57, 49.27 ± 8.24 and 51.73 ± 9.09 in Endo-TLIF and 41.73 ± 7.98, 46.18± 8.46 and 49.09 ± 8.98 in TLIF respectively, P < 0.05. Compared to TLIF, Endo-TLIF achieved better VAS with 0.727 ± 0.235 at 3 months and 0.727 ± 0.252 at final follow up and better ODI with 3.88 ± 1.50 at 3months and 3.42 ± 1.63 at final follow up, P < 0.05. At 6 months radiological evaluation comparison of the Endo-TLIF and TLIF showed significant with more favorable fusion rate in Endo-TLIF of -0.61 ± 0.12 at 6 months and -0.49 ± 0.12 at 1 year in Bridwell's grading and 0.70 ± 0.15 at 6 months and 0.56 ± 0.14 at 1 year in Kim's stage.There is less subsidence of 0.606 ± 0.18 at 6 months and -0.561 ± 0.20 at 1 year of Kim's subsidence grade, P < 0.05. CONCLUSION: Application of single level uniportal endoscopic posterolateral lumbar interbody fusion achieved better clinical outcomes and fusion rate with less subsidence than microscopic minimally invasive transforaminal lumbar interbody fusion in mid-term evaluation for our cohorts of patients.

Systematic Review of Current Literature on Clinical Outcomes of Uniportal Interlaminar Contralateral Endoscopic Lumbar Foraminotomy for Foraminal Stenosis.

BACKGROUND: Uniportal interlaminar contralateral endoscopic lumbar foraminotomy (ICELF) aims to achieve decompression of lumbar spinal stenosis in the contralateral lateral recess and foraminal and extraforaminal regions of the same segment. This technique is performed under normal saline irrigation using an endoscope with optical lens magnification close to the targeted stenotic segment and has the potential of lower incidence of exiting nerve root dorsal root ganglion irritation. METHODS: A systematic review of the ICELF technique was conducted from March 2000 to March 2022. Articles were selected with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eligibility of studies was independently determined by 2 reviewers, and disagreements were resolved by a third author. RESULTS: Eight retrospective cohort studies comprising 194 patients with foraminal stenosis who underwent uniportal ICELF were selected for systematic review. Mean age range was 62-79 years, and surgical duration was 48-73.5 minutes. There was significant improvement in Oswestry Disability Index and visual analog scale leg pain score in the included studies. Four studies met the minimum clinically significant difference for leg pain, with visual analog scale improved >5 points and Oswestry Disability Index improved >8.2 points. Four studies reported a majority of the operated patients with good or excellent outcomes following surgery, with a low rate of complications in the studies selected. CONCLUSIONS: There is low-level evidence that ICELF when performed by an experienced spinal endoscopic surgeon is effective in providing pain relief and improved function with low rate of complications in select patients.

Spinal arachnoid cysts: A case series & systematic review of the literature.

Introduction: Spinal arachnoid cysts (SACs) are rare lesions with challenging and controversial management. Research question: We analyzed our experiences from a case series and provide a systematic review to determine 1) Demographic and clinical features of SACs, 2) Optimal imaging for diagnosis and operative planning, 3) Optimal management of SACs, and 4) Clinical outcomes following surgery. Materials and methods: A single-institution, ambispective analysis of patients with symptomatic SACs surgically managed between May 2005 and May 2019 was performed. Data were collected as per local ethics committee stipulations. A systematic review of SACs in adults was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and a preapproved protocol. Results: Our series consisted of 11 patients, M:F 8:3, mean age 47.8 years (range 18-73 years). Mean follow-up was 19 months (range 5-36 months). SACs were excised or marsupialised (7), fenestrated (3) or partially excised (1). Eight patients had expansile duroplasty, 3 primary dural closure. One patient had a cystoperitoneal shunt. All patients were AIS D preoperatively; 4 remained unchanged and 7 improved to AIS E at follow-up. Our systematic search retrieved 725 citations. Fourteen case series met the inclusion criteria. There was no evidence to support superiority of one surgical strategy over another. Surgery for symptomatic patients resulted in positive clinical outcomes. Discussion and conclusions: Symptomatic SACs require surgical intervention. Limited evidence suggests that decompressing the cord, breakdown of arachnoid adhesions, and establishing CSF flow by consideration of expansile duroplasty are important for positive outcomes.

Remodeling Pattern of Spinal Canal after Full Endoscopic Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: One Year Repetitive MRI and Clinical Follow-Up Evaluation.

Objective: There is limited literature on repetitive postoperative MRI and clinical evaluation after Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. Methods: Clinical visual analog scale, Oswestry Disability Index, McNab's criteria evaluation and MRI evaluation of the axial cut spinal canal area of the upper end plate, mid disc and lower end plate were performed for patients who underwent single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression. From the evaluation of the axial cut MRI, four types of patterns of remodeling were identified: type A: continuous expanded spinal canal, type B: restenosis with delayed expansion, type C: progressive expansion and type D: restenosis. Result: A total of 126 patients with single-level Uniportal Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression were recruited with a minimum follow-up of 26 months. Thirty-six type A, fifty type B, thirty type C and ten type D patterns of spinal canal remodeling were observed. All four types of patterns of remodeling had statistically significant improvement in VAS at final follow-up compared to the preoperative state with type A (5.59 ± 1.58), B (5.58 ± 1.71), C (5.58 ± 1.71) and D (5.27 ± 1.68), p < 0.05. ODI was significantly improved at final follow-up with type A (49.19 ± 10.51), B (50.00 ± 11.29), C (45.60 ± 10.58) and D (45.60 ± 10.58), p < 0.05. A significant MRI axial cut increment of the spinal canal area was found at the upper endplate at postoperative day one and one year with type A (39.16 ± 22.73; 28.00 ± 42.57) mm2, B (47.42 ± 18.77; 42.38 ± 19.29) mm2, C (51.45 ± 18.16; 49.49 ± 18.41) mm2 and D (49.10 ± 23.05; 38.18 ± 18.94) mm2, respectively, p < 0.05. Similar significant increment was found at the mid-disc at postoperative day one, 6 months and one year with type A (55.16 ± 27.51; 37.23 ± 25.88; 44.86 ± 25.73) mm2, B (72.83 ± 23.87; 49.79 ± 21.93; 62.94 ± 24.43) mm2, C (66.85 ± 34.48; 54.92 ± 30.70; 64.33 ± 31.82) mm2 and D (71.65 ± 16.87; 41.55 ± 12.92; 49.83 ± 13.31) mm2 and the lower endplate at postoperative day one and one year with type A (49.89 ± 34.50; 41.04 ± 28.56) mm2, B (63.63 ± 23.70; 54.72 ± 24.29) mm2, C (58.50 ± 24.27; 55.32 ± 22.49) mm2 and D (81.43 ± 16.81; 58.40 ± 18.05) mm2 at postoperative day one and one year, respectively, p < 0.05. Conclusions: After full endoscopic lumbar decompression, despite achieving sufficient decompression immediately postoperatively, varying severity of asymptomatic restenosis was found in postoperative six months MRI without clinical significance. Further remodeling with a varying degree of increment of the spinal canal area occurs at postoperative one year with overall good clinical outcomes.

Comparative Clinical and Radiographic Cohort Study: Uniportal Thoracic Endoscopic Laminotomy With Bilateral Decompression by Using the 1-Block Resection Technique and Thoracic Open Laminotomy With Bilateral Decompression for Thoracic Ossified Ligamentum Flavum.

BACKGROUND: Symptomatic thoracic myelopathy secondary to thoracic ossified ligamentum flavum (OLF) often requires decompression spinal surgery. OBJECTIVE: To compare clinical and radiological outcomes in uniportal endoscopic vs open thoracic decompression for thoracic OLF. METHODS: Retrospective evaluation of patients who underwent uniportal thoracic endoscopic unilateral laminotomy with bilateral decompression (TE-ULBD) by using the one-block resection technique compared with thoracic open laminotomy (TOL) with bilateral decompression. Radiological outcomes in MRI scan and clinical charts were evaluated. RESULTS: Thirty-five levels of TE-ULBD were compared with 24 levels of TOL. The overall complication rate of TOL was 15% while TE-ULBD was 6.5%. Both TOL and TE-ULBD cohort had significantly improved their visual analog scale (VAS), Oswestry Disability Index, and Japanese Orthopaedic Association (JOA) myelopathy score after operation. Comparative analysis of TE-ULBD performed statistically and significantly better than TOL in improvement of final VAS and JOA scores. The mean difference ± standard deviation of VAS and JOA improvement in final follow-up when compared with preoperative state of TE-ULBD and TOL was 0.717 ± 0.131 and 1.03 ± 0.2, respectively, P < .05. The mean Hirabayashi recovery rates were 94.5% (TE-ULBD) and 56.8% (TOL). There was no statistical difference in change in preoperative and final Oswestry Disability Index and MRI volume at upper endplate, middisk, and lower endplate canal cross-sectional area. CONCLUSION: Uniportal TE-ULBD achieved significantly improved pain and neurological recovery with sufficient spinal canal decompression, as compared with thoracic open laminectomy for patients with myelopathy secondary to OLF in our cohort.

Full-Endoscopic Lumbar Decompression with Minimal Nerve Root Retraction for Impending Neurologic Deficit in Degenerative Lumbar Spine Diseases.

OBJECTIVES: The aim of this retrospective case study was to analyze the outcomes of minimal nerve root retraction in patients with impending neurologic deficit in degenerative lumbar spine disease using the full-endoscopic spine surgery. MATERIALS AND METHODS: Thirty-seven consecutive patients with impending neurologic deficit underwent endoscopic spine surgery through either the transforaminal or the interlaminar approach. Their clinical outcomes were evaluated with visual analog scale (VAS) leg pain score, Oswestry Disability Index (ODI), and MacNab's criteria. The outcome of motor deficitis was evaluated with the Medical Research Council (MRC) grade. Completeness of decompression was documented with a postoperative magnetic resonance imaging (MRI) and computed tomography (CT) scan. RESULTS: A total of 40 lumbar levels of 37 patients were operated, VAS score of the leg improved from 7.7 ± 1 to 1.9 ± 0.6 (p < 0.0001). ODI score improved from 74.7 ± 6.5 to 25.4 ± 3.49 (p < 0.0001). Motor weakness improved significantly immediately after surgery. The mean MRC grade increased to 1.97, 3.65, 4.41, and 4.76 preoperatively, at 1 week, at 3 months, and at the final follow-up, respectively, and all the patients with foot drop and cauda equina syndrome symptom recovered completely. One patient with great toe drop recovered partially to MRC grade 3. Mean follow-up of the study was 13.3 ± 6.1 months. According to MacNab's criteria, 30 patients (80.1%) had good and 7 patients (18.9%) had excellent results. Three patients required revision surgery. CONCLUSIONS: Minimal nerve root retraction during full-endoscopic spine surgery is safe and effective for treatment of the impending neurologic deficit. We could achieve a thorough decompression of the affected nerve root with acceptable clinical outcome and minimal postoperative morbidity.

Evaluation of Two Methods (Inside-Out/Outside-In) Inferior Articular Process Resection for Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion: Technical Note.

Objective: There is limited literature comparing the uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion outside-in approach (ETLIF (O)) with the inside-out approach (ETLIF (I)). Methods: Radiological evaluation was performed on disc height restoration and coronal wedging angle, and operation time (inferior articular process resection time/total operation time) and clinical evaluation were made. Result: 48 cases of inside-out and 38 cases of outside-in cases were included. Compared to inside-out, the outside-in approach had significantly less operative time required to resect inferior articular process: 36.55 ± 10.37, and total operative time: 87.45 ± 20.14 min compared to 49.83 ± 23.97 and 102.56 ± 36.53 min, respectively, for the inside-out approach, p < 0.05. Compared to the preoperative state, both cohorts achieved significant improvement of VAS and ODI at post-operative 1 week, 3 months and at final follow up. Both cohorts achieved statistically significant increased disc height with 5.00 ± 2.87 mm, 5.49 ± 2.33 mm and statistically significant improvement in coronal wedge angle with 1.76 ± 1.63°, 3.24 ± 2.92° in the inside-out and outside-in approaches respectively. Conclusions: Complete removal of inferior articular process is the key part of endoscopic fusion with two methods that can be applied: an inside-out approach or an outside-in approach. Comparing both techniques, the outside-in approach has a shorter operative time required for inferior articular process resection and total length of operation with similar good clinical and radiological outcomes.

Alleviating Paravertebral Muscle Spasm after Radiofrequency Ablation Treatment of Hypersensitive Basivertebral and Sinuvertebral Nerves for Chronic Discogenic Back Pain.

BACKGROUND: Paraspinal muscle spasm caused by pain from a lumbar degenerative disc is frequently investigated in patients with low back pain. Radiofrequency ablation (RFA) surgery could alleviate paraspinal muscle spasms. OBJECTIVES: We performed RFA surgery on the high-intensity zone (HIZ) and hypersensitive sinuvertebral and basivertebral nerves to evaluate its outcome. The paravertebral muscle cross-sectional area (CSA) was measured on magnetic resonance imaging (MRI) before and after surgery to evaluate the effect of RFA surgery on the paravertebral muscle. STUDY DESIGN: Prospective cohort study. SETTING: A single spine surgery center. METHODS: A comparative study was performed on 2 different uniportal spinal endoscopic surgery groups; 23 patients who underwent RFA surgery for chronic discogenic back pain and 45 patients who underwent posterior decompression surgery for lumbar spinal stenosis with 12 months of follow-up. Paravertebral muscle cross-sectional area, Schiza grade, Modic type, and HIZ size were measured on pre- and post-operative MRI. An endoscopic video review was performed to evaluate the presence of intraoperative twitching and grade the degree of epidural neovascularization and adhesion. Visual analog scale VAS, modified Oswestry Disability Index, ODI and MacNab's criteria were evaluated for outcome measures. RESULTS: Intraoperative endoscopic video evaluation showed neovascularization and adhesion adjacent to the disc and pedicle. In the RFA surgery group, there were 7 patients (30.43%) with grade 2 and 16 (69.57%) with grade 3 neovascularization; intraoperative twitching was observed in 19 out of 23 patients (82.61%). After performing an RFA on the sinuvertebral and basivertebral nerves for the treatment of discogenic back pain, the results showed significant improvement in pain and disability scores. The mean CSA of the paraspinal muscle in the RFA surgery group was significantly increased after surgery at the L4-L5 and L5-S1 levels (L4-L5: 3901 ± 1096.7 mm² to 4167 ± 1052.1 mm², P = 0.000; L5-S1: 3059 ± 968.5 mm² to 3323 ± 1046.2 mm², P = 0.000) compared to preoperative CSA. LIMITATIONS: This study was limited by its small sample size. CONCLUSION: Hypersensitive sinuvertebral and basivertebral nerves are strongly associated with epidural neovascularization with adhesion and the pathological pain pathway in degenerative disc disease. Epidural neovascularization with adhesion reflects aberrant neurological connections, which are associated with reflex inhibitory mechanisms of the multifidus muscle, which induces spasm. RFA treatment of the region of epidural neovascularization with adhesion effectively treated chronic discogenic back pain and could induce paraspinal muscle spasm release.