Full Endoscopic Thoracic Discectomy: Is the Interlaminar Approach an Alternative to the Transforaminal Approach? A Technical Note.

BACKGROUND: Various approaches are used for decompressive surgeries in the thoracic spine depending on the location and consistency of the pathology, always avoiding manipulation of the thoracic spinal cord. Recently, there has been an effort to achieve adequate results and reduce morbidity with minimally invasive surgeries. Good outcomes and the advantages of full endoscopic spine surgery (FESS) have been proven for surgerical correction of herniated discs and stenoses in the lumbar and cervical spine. Similar evidence has recently been described for the thoracic spine, but it has not previously been reported in Brazil. Although the transforaminal approach is already established for the thoracic spine, the newly described interlaminar approach is equally efficient, and both techniques must be considered when treating thoracic spine diseases. The objective of the present article was to present the full endoscopic interlaminar and transforaminal techniques in patients with symptomatic disc herniation of the thoracic spine, discuss the rationality for implementing FESS in thoracic spine, and discuss the rationality in choosing between both approaches. METHODS: Two patients were submitted to thoracic FESS. A transforaminal approach was chosen for a T10-T11 foraminal disc herniation; an interlaminar approach was selected for a paramedian T7-T8 disc extrusion. Data regarding operating time, intraoperative images, hospital stay, visual analog scales before and after FESS, course of recovery, and surgery satisfaction were evaluated. RESULTS: The patients had eventless surgeries, improved from preoperative pain without morbidity. Both were satisfied and recovered well. Hospital stay was less than 6 hours after surgery. CONCLUSIONS: Transforaminal and interlaminar FESS for thoracic disc herniation are safe, efficient, and minimally invasive alternatives. CLINICAL RELEVANCE: Despite being an innovative technique with evident advantages, it should be carefully considered along with conventional technique for the treatment of thoracic spine diseases, since its clinical relevance is yet to be determined.

Functional Evolution after Percutaneous Endoscopic Lumbar Discectomy, an Earlier Evaluation of 32 Cases.

Objective To determine time period for hospital discharge and pain and function improvement in patients submitted to percutaneous endoscopic lumbar discectomy (PELD). Methods Retrospective evaluation of length of stay and visual analog scale (VAS), Oswestry disability index (ODI), and Roland-Morris questionnaire results in 32 patients undergoing PELD at the preoperative period and at 2 days and 1, 2, 4, 6 and 12 postoperative weeks. Results All patients were discharged in less than 6 hours. There was a statistically significant improvement between the results obtained before the procedure and 2 days postsurgery: the mean VAS for axial pain went from 6.63 to 3.31, the VAS for irradiated pain went from 6.66 to 2.75, the Oswestry score went from 44.59 to 33.17%, and the Roland-Morris score went from 14.03 to 10.34. This difference progressively improved up to 12 weeks in all questionnaires. Regarding the Oswestry score, minimum disability values (19.39%) were observed at 6 weeks. Conclusion All 32 patients were discharged within 6 hours. Pain and function improved significantly after 48 hours, with further significant and progressive improvement until the 3 rd month.

Functional Evolution after Percutaneous Endoscopic Lumbar Discectomy, an Earlier Evaluation of 32 Cases / Evolução funcional após discectomia endoscópica lombar, uma avaliação mais precoce de 32 casos

Abstract Objective To determine time period for hospital discharge and pain and function improvement in patients submitted to percutaneous endoscopic lumbar discectomy (PELD). Methods Retrospective evaluation of length of stay and visual analog scale (VAS), Oswestry disability index (ODI), and Roland-Morris questionnaire results in 32 patients undergoing PELD at the preoperative period and at 2 days and 1, 2, 4, 6 and 12 postoperative weeks. Results All patients were discharged in less than 6 hours. There was a statistically significant improvement between the results obtained before the procedure and 2 days postsurgery: the mean VAS for axial pain went from 6.63 to 3.31, the VAS for irradiated pain went from 6.66 to 2.75, the Oswestry score went from 44.59 to 33.17%, and the Roland-Morris score went from 14.03 to 10.34. This difference progressively improved up to 12 weeks in all questionnaires. Regarding the Oswestry score, minimum disability values (19.39%) were observed at 6 weeks. Conclusion All 32 patients were discharged within 6 hours. Pain and function improved significantly after 48 hours, with further significant and progressive improvement until the 3rd month.

Resumo Objetivo Determinar o tempo de alta hospitalar e o período de melhora funcional e da dor dos pacientes submetidos a discectomia endoscópica percutânea lombar (DEPL). Métodos Avaliação retrospectiva do tempo de internação e dos questionários escala visual análoga (EVA), índice de incapacidade Oswestry (IIO), e Roland-Morris de 32 pacientes submetidos a DEPL nos períodos pré-operatório e com 2 dias, e 1, 2, 4, 6, e 12 semanas pós-operatórias. Resultados Todos os pacientes receberam alta em menos de 6 horas houve melhora estatística entre o período pré-operatório e 2 dias pós-operatório , sendo o valor médio do questionário EVA axial de 6,63 para 3,31, do EVA irradiado de 6,66 para 2,75, do IIO de 44,59% para 33,17% e do Roland-Morris de 14,03 para 10,34. Tal diferença apresentou melhora progressiva até 12 semanas em todos os questionários. O IIO atingiu valores de incapacidade mínima (19,39%) com 6 semanas de avaliação. Conclusão Todos os 32 pacientes receberam alta hospitalar em até 6 horas. Houve melhora significativa dos sintomas funcionais e de dor já com 48 horas, apresentando ainda melhora adicional significativa e progressiva até o 3º mês.

Experimental Model for Interlaminar Endoscopic Spine Procedures.

BACKGROUND: Endoscopic spinal surgery is becoming quite popular, and the pursuit of a training model to improve surgeons' skills is imperative to overcome the limited availability of human cadavers. Our goal was to determine whether the porcine spine could be a representative model for learning and practicing interlaminar percutaneous endoscopic lumbar procedures (IL-PELPs). METHODS: Lumbar and cervical segments of the porcine cadaver spine were used for the IL-PELP. We have described the technical notes on the difficulties of the procedure and the relevant anatomical features. To endorse the porcine cadaver for this procedure, 5 neurosurgeons underwent 1 day of training and completed a survey. RESULTS: The porcine lumbar spine has small interlaminar windows, and laminectomy is necessary, mimicking the translaminar approaches for higher human lumbar spine levels. The porcine cervical spine has wide and high interlaminar windows and mimics the human L5-S1 interlaminar approach. Entering the spinal canal with the working sheath and endoscope and training the rotation maneuver to access the disc space is only possible in the lumbar segment. It was possible to perform flavectomy and to identify and dissect the dural sac and nerve root in both the lumbar and cervical spine. The neurosurgeons considered the porcine model of good operability and, although different, possible to apply in humans. CONCLUSIONS: The porcine spine is an effective and representative model for learning and practicing IL-PELPs. Although the described anatomical differences should be known, they did not interfere in performing the main surgical steps and maneuvers for IL-PELPs in the porcine model.

Radiation Exposure during Percutaneous Endoscopic Lumbar Discectomy: Interlaminar versus Transforaminal

Objective Percutaneous endoscopic lumbar discectomy (PELD) relies heavily on fluoroscopy guidance; therefore, medical staff exposure to radiation has become an important issue. The purpose of this study was to determine the radiation dose and the amount of time to which the surgeons are exposed during PELD and to compare both parameters in the transforaminal (TF) and interlaminar (IL) approaches. Although they are considerably different, they may be wrongly considered together. Methods A retrospective evaluation of the last 20 PELD performed by the authors is presented. Patients were distributed in 2 groups. Six (1F, 5M) patients were submitted to IL-PELD and 14 (6F, 8M) to TF-PELD. Fluoroscopy reports were obtained from patients' records, all performed with the same C-Arm device and software mode. Groups were compared using unpaired t-test. Results The IL group showed an average radiation exposure of 8.37 4.21 mGy and duration of 11.1 5.45 seconds, while the TF group showed an average radiation exposure of 28.92 7.56 mGy and duration of 42 16.64 seconds. The p-value for radiation was 0.0000036, and for time it was 0.00027. Conclusions Interlaminar PELD requires a lower radiation dose and a shorter amount of exposure than TF-PELD. Studies that concern radiation required for minimallyinvasive spine surgeries should consider the PELD approaches separately.

Experimental model for transforaminal endoscopic spine

Abstract Purpose: To validate the porcine spine as a model for learning and practicing transforaminal percutaneous endoscopic lumbar procedures (TF-PELP). Methods: TF-PELP was performed in three porcine cadaver lumbar spine levels. Anatomical features of the current cadaver were compared to human and porcine spines. Performance and documentation of endoscopic procedures were described. Results: This study shows that this representative animal model reflects anatomical characteristics of the human spine. Transforaminal approaches were successfully completed. Although lower disc heights make disc puncture more difficult, the outside-in technique is feasible and more useful to identify anatomical parameters and to practice different surgical steps and maneuvers. Conclusion: This is an effective and representative model for learning and practicing this procedure. Difficulties of the procedure, as well as the differences compared to the human spine, were described.

Experimental model for transforaminal endoscopic spine.

PURPOSE: To validate the porcine spine as a model for learning and practicing transforaminal percutaneous endoscopic lumbar procedures (TF-PELP). METHODS: TF-PELP was performed in three porcine cadaver lumbar spine levels. Anatomical features of the current cadaver were compared to human and porcine spines. Performance and documentation of endoscopic procedures were described. RESULTS: This study shows that this representative animal model reflects anatomical characteristics of the human spine. Transforaminal approaches were successfully completed. Although lower disc heights make disc puncture more difficult, the outside-in technique is feasible and more useful to identify anatomical parameters and to practice different surgical steps and maneuvers. CONCLUSION: This is an effective and representative model for learning and practicing this procedure. Difficulties of the procedure, as well as the differences compared to the human spine, were described.

Avaliação estética e funcional do tratamento cirúrgico do torcicolo congênito com a técnica de liberação distal do músculo esternocleidomastoideo / Evaluación estética y funcional del tratamiento quirúrgico del tortícolis congénito con la técnica de liberación distal del músculo esternocleidomastoideo / Aesthetic and functional evaluation of the surgical treatment of congenital muscular torticollis applying the technique of the lower liberation of the sternocleidomastoid contracture

OBJETIVO: realizar uma avaliação estética e funcional do tratamento cirúrgico do torcicolo congênito por meio da técnica de liberação distal do músculo esternocleidomastoideo. MÉTODOS: foi realizada análise cirúrgica retrospectiva em 21 pacientes portadores de torcicolo congênito submetidos à liberação distal da contratura do músculo esternocleidomastoideo no período de Setembro de 1986 a Setembro de 2003 no Departamento de Ortopedia e Traumatologia da Faculdade de Ciências Médicas da Santa Casa de São Paulo, avaliados pelo protocolo de Cheng e Tang. RESULTADOS: a média do tempo de seguimento foi de 55 meses (variando de 6 meses a 17 anos). Este estudo revelou que 20 pacientes (95 por cento) apresentaram um resultado estético-funcional bom ou excelente com poucas complicações inerentes ao procedimento. CONCLUSÕES: na presente casuística, observou-se um resultado estético-funcional satisfatório no tratamento cirúrgico do torcicolo muscular congênito.

OBJECTIVE: to evaluate the treatment outcome of surgical treatment of congenital torcicollis through distal liberation of sternocleidomastoid muscle. METHODS: the result of the surgical treatment of 21 patients bearing congenital muscular torticollis, submitted to the lower liberation of the sternocleidomastoid muscle's contracture, from September of 1986 through September of 2003, at the Department of Orthopedics and Traumatology of the Faculdade de Ciências Médicas of the Santa Casa de São Paulo, was retrospectively evaluated using Cheng and Tang's protocol. RESULTS: with an average of 55 months of follow-up (ranging from 6 months to 17 years), this study revealed that 20 patients (95 percent) showed good or even excellent aesthetic-functional results, with few complications due to the procedure. CONCLUSIONS: in the present experience, the surgical treatment of the congenital muscular torticollis showed good or even excellent aesthetic-functional results.

OBJETIVO: realizar una evaluación estética y funcional del tratamiento quirúrgico del tortícolis congénito por medio de la técnica de liberación distal del músculo esternocleidomastoideo. MÉTODOS: los autores realizaron un análisis quirúrgico retrospectivo en 21 pacientes portadores del tortícolis congénito. Todos fueron sometidos a la liberación distal de la contractura del músculo esternocleidomastoideo en el período de Septiembre de 1986 a Septiembre de 2003, en el Departamento de Ortopedia e Traumatologia da Faculdade de Ciências Médicas da Santa Casa de São Paulo, evaluados por el protocolo de Cheng & Tang. RESULTADOS: el promedio del tiempo de seguimiento fue de 55 meses (con variación de 6 meses a 17 años). Este estudio reveló que 20 pacientes (95 por ciento) presentaron un resultado estético/funcional bueno o excelente, con pocas complicaciones inherentes al procedimiento. CONCLUSIONES: fue observado, en la presente casuística, un resultado estético/funcional satisfactorio en el tratamiento quirúrgico del tortícolis muscular congénito.

Fratura toracolombar tipo explosão: comparação do tratamento conservador em pacientes com e sem fratura do arco vertebral posterior / Thoracolumbar burst fracture: comparing conservative treatment in patients with and without fracture of the posterior vertebral arch

OBJETIVO: Comparar clínica e radiologicamente os resultados a longo prazo do tratamento conservador da fratura explosão toracolombar, em pacientes com e sem fratura do arco vertebral posterior, com o propósito de avaliar eventuais diferenças na evolução destes dois tipos de lesão. MÉTODOS: Foram avaliados, retrospectivamente, os prontuários e exames de imagem (radiografias e tomografias computadorizadas) de 25 pacientes sem déficit neurológico, com fratura toracolombar tipo explosão tratados não cirurgicamente e comparados o grau de progressão da cifose entre os casos com fratura da lâmina (grupo 1) e sem fratura posterior (grupo 2). Desses, 13 pacientes foram submetidos à avaliação comparativa por meio da escala visual analógica de dor (VAS), da escala de dor e trabalho de Denis e do questionário de qualidade de vida SF-36. RESULTADOS: Foram analisados 25 pacientes (36 por cento do grupo A e 74 por cento do grupo B) com tempo médio de seguimento de 111,64 meses. Não houve diferença em relação ao grau de progressão da cifose durante o seguimento entre os grupos A e B (5,22º x 4,63º - p = 0,650). Dos 13 pacientes analisados funcionalmente, 46 por cento eram do grupo A e 54 por cento do grupo B. Nesta avaliação, apesar da VAS pior (1,83 x 5,00 - p = 0,015) nos pacientes sem fratura posterior (grupo B), não houve diferença em relação à escala de Denis (4,00 x 5,71 - p > 0,05) e SF-36 (98,60 x 90,83 - p = 0,168) entre os dois grupos. CONCLUSÃO: A fratura do arco posterior, isoladamente, parece não ser indicativo de instabilidade ou de mau prognóstico nas fraturas toracolombares tipo explosão.

OBJECTIVE: To make a clinical and radiological comparison of long term results of the conservative treatment of thoracolumbar burst fractures, in patients with and without fracture in the posterior vertebral arch, in order to assess possible differences in the evolution of the two types of lesion. METHODS: A retrospective analysis was made of the clinical records and imaging exams (X-rays CT scans) of 25 patients without neurological deficit with thoracolumbar burst fractures treated without surgery, and a comparison was made of the degree of progression of kyphosis between the cases with fracture of the lamina (Group 1) and those without posterior fracture (Group 2). 13 of these patients were submitted to comparative evaluation using the visual analogical scale of pain (VAS), the Denis pain and work scale, and the life quality questionnaire SF-36. RESULTS: 25 patients were analyzed (36 percent in group A and 74 percent in group B) with mean follow-up of 111.64 months. There was no difference in the degree of kyphosis progression during follow-up between groups A and B (5.22º x 4.63º - p = 0.650). Of the 13 patients functionally analyzed, 46 percent were from group A and 54 percent from group B. In this assessment, despite the worse VAS (1.83 x 5.00 - p = 0.015) in patients without posterior fracture (Group B), there was no difference in the Denis scale (4.00 x 5.71 - p > 0.05 ) and SF-36 (98.60 x 90.83 - p = 0.168) between the two groups. CONCLUSION: Taken separately, the posterior arch fracture does not seem to be an indicator of instability or of poor prognosis in thoracolumbar burst fractures.