Advantages of the Combination of Conscious Sedation Epidural Anesthesia Under Fluoroscopy Guidance in Lumbar Spine Surgery.

BACKGROUND: With the increase in life expectancy seen throughout the world, the prevalence of degenerative spinal pathology and surgery to treat it has increased. Spinal surgery under general anesthesia leads to various problems and complications, especially in patients with numerous medical comorbidities or elderly patients. For this reason, there is a need for safer anesthetic methods applicable to unhealthy, elderly patients undergoing spinal surgery. PURPOSE: To report our experience with utilizing fluoroscopy-guided epidural anesthesia in conjunction with conscious sedation in spinal surgery. PATIENTS AND METHODS: We performed a retrospective review of 111 patients at our institution that received fluoroscopy-guided epidural anesthesia for lumbar surgery from February to September 2018. Patients' records were evaluated to evaluate patient demographics, American Society of Anesthesiology Physical Classification System (ASA) class, and pain numerical rating scores (NRS) preoperatively and throughout their recovery postoperatively. Intraoperative data including volume of epidural anesthetic used, extent of epidural spread, and inadvertent subdural injection was collected. Postoperative recovery time was also collected. RESULTS: The mean age of our patients was 60 years old with a range between 31 and 83 years old. All patients experienced decreases in postoperative pain with no significant differences based on age or ASA class. There was no association between ASA class and time to recovery postoperatively. Older patients (age 70 years or greater) had a significantly longer recovery time when compared to younger patients. Recovery also was longer for patients who received higher volumes of epidural anesthesia. For every 1 mL increase of epidural anesthetic given, there was an increase in the extent of spread of 1.8 spinal levels. CONCLUSION: We demonstrate the safety and feasibility of utilizing conscious sedation in conjunction with fluoroscopy-guided epidural anesthesia in the lumbar spinal surgery.

Percutaneous Endoscopic Transforaminal Approach for Far Lateral Lumbar Discectomy: 2-Dimensional Operative Video.

The conventional surgical approach to far lateral lumbar disk herniations is a paraspinal Wiltse approach. During the Wiltse approach, it is sometimes necessary to resect some of the facet or pars interarticularis to achieve an adequate exposure. The endoscopic transforaminal route can be of benefit in far lateral disk herniations due to direct access to the epidural space through Kambin's triangle, without the need for any bony removal or nerve retraction. In this video, we describe a percutaneous endoscopic transforaminal approach for far lateral discectomy in a patient presenting with a left L4 radiculopathy due to a far lateral L4-5 disk herniation. We describe Kambin's triangle anatomy and its relevance to the transforaminal route. The steps of the procedure are then described: dissection of soft tissue and removal of free disk fragments on the inferior aspect of the foramen far from the compressed exiting nerve route above to decrease the risk of retraction injury, gentle maneuvering of endoscope superiorly with removal of further compressive disk fragments, exposure of the exiting nerve root superiorly after adequate decompression is achieved and removal of any remaining fragments in close proximity to the nerve, and finally evaluation of traversing nerve root for any compressive lesions. The presentation ends with postoperative imaging confirming decompression of the far lateral disk herniation.

Percutaneous Endoscopic Contralateral Lumbar Foraminal Decompression via an Interlaminar Approach: 2-Dimensional Operative Video.

Nerve root compression by foraminal pathology is challenging for a surgeon to decompress without violating the facet joint, which may necessitate a fusion procedure. One nonfusion approach to foraminal pathology is a combination intracanal approach for a laminotomy/foraminotomy followed by a paraspinal Wiltse approach for far lateral decompression. Unfortunately, even with the combination approach, it continues to be difficult to achieve adequate decompression without violating much of the facet joint overlying the nerve root. Spine endoscopy offers the ability to decompress the foraminal portion of the nerve without significant violation of the facet joint. We present a surgical video describing the technique for performing a percutaneous endoscopic contralateral L5-S1 foraminal decompression via an interlaminar approach, for a patient presenting with a left L5 radiculopathy due to L5-S1 foraminal stenosis. We explain the differences in the endoscopic channel docking point between ipsilateral and contralateral interlaminar approaches. The steps of an endoscopic foraminotomy are then described: dissect soft tissue and ligamentum flavum off the medial left S1 lamina and superior articulating process (SAP), undercut the superior articulating process of S1 and the inferior articulating process (IAP) of L5 with a drill, resect lateral ligamentum flavum off SAP and IAP exposing epidural fat, and finally dissect the left L5 nerve root and remove compressive lesions throughout its course in the lateral recess, foramen, and laterally. The presentation ends with an intraoperative photograph showing a decompressed L5 nerve root and postoperative imaging confirming this decompression. Appropriate patient consent was obtained.

X-rays and scans can fail to differentiate hip pathology from lumbar spinal stenosis: Two case reports.

BACKGROUND: Occasionally, hip pathologies may present alone or combined with lumbar spine pathology, especially lumbar stenosis. Although the history and clinical examination may help differentiate between the two, hip X-rays alone without accompanying magnetic resonance imaging (MRI) studies may prove unreliable. CASE DESCRIPTIONS: Case 1 - A 72-year-old male presented with the sudden onset of severe back and left posterior thigh pain. Straight leg raising test was positive at 70° (right) and 60° (left), and he had left lower extremity numbness and weakness. The lumbar MRI showed L5-S1 spinal stenosis. Although X-rays of both hips were negative, the MRI showed bilateral femoral neck fractures. He underwent screw fixation of the hip fractures and later underwent endoscopic decompression of the spinal stenosis. Case 2 - A 35-year-old male presented with low backache and right hip pain of 1 month's duration. The neurological examination was normal, except for positive straight leg raising bilaterally at 60°. The spine MRI was normal. However, despite negative X-ray of both hips, the hip MRI revealed avascular necrosis (AVN) of both femoral heads requiring subsequent orthopedic management. CONCLUSION: Hip pathology may mimic lumbar spinal stenosis. In the two cases presented, plain X-rays failed to document hip fractures (case 1) and AVN (case 2), respectively, both of which were later diagnosed on MRI studies.

Evolution of Spinal Endoscopic Surgery.

Innovations in the development of endoscopic spinal surgery were classified into different generations and reviewed. Future developments and directions for endoscopic spinal surgery were discussed. Surgical therapy for spinal disease has been gradually changing from traditional open surgery to minimally invasive spinal surgery. Recently, endoscopic spinal surgery, which initially was limited to the treatment of soft tissue lesions, has expanded to include other aspects of spinal disease and good clinical results have been reported. As the paradigm of spinal surgery shifts from open surgery to endoscopic surgery, we discussed the evolution of endoscopic spine surgery in our literature review. Through this description, we presented possibilities of future developments and directions in endoscopic spine surgery.

Percutaneous Transforaminal Endoscopic Radiofrequency Ablation of the Sinuvertebral Nerve in an Olympian with a Left L5 Pedicle/Pars Interarticularis Fracture-Associated Left L5-S1 Disk Desiccation.

BACKGROUND: Irritation of the sinuvertebral nerve by a posterior or posterolateral disk desiccation can cause somatic referred pain that can mimic a lumbar radiculopathy. We present a case of a patient presenting with this condition and the positive result in pain improvement after endoscopic radiofrequency ablation of the sinuvertebral nerve. CASE DESCRIPTION: An 18-year-old Olympic runner presented to our clinic with back pain and left leg pain in a clear L5 distribution. He did not have a history of trauma. His imaging did not demonstrate any lesion causing compression of the left L5 nerve root as expected. He was found to have a left healing L5 pedicle fracture and ipsilateral chronic L5 pars interarticularis fracture. He was also found to have an ipsilateral minor left L5-S1 disk desiccation. His visual analog scale (VAS) score was 7. After a positive provocative diskogram, the patient underwent percutaneous transforaminal endoscopic radiofrequency ablation of the left L5 sinuvertebral nerve, which was irritated by the left L5-S1 disk desiccation. At his 6-month follow-up visit, the patient's VAS score was 1. CONCLUSIONS: It is important for clinicians to remember that back-associated leg pain can be caused by somatic referred pain because of irritation of the sinuvertebral nerve. Endoscopic radiofrequency of this nerve can be beneficial in pain control, but further randomized prospective trials are needed to study these techniques further.

Radiographic outcomes of endoscopic decompression for lumbar spinal stenosis.

OBJECTIVELumbar central stenosis can theoretically be decompressed with minimal bone removal via an endoscopic approach. Although multiple studies have demonstrated an adequate radiographic decompression, none has quantified the volume of bone removal after endoscopic decompression. The objective of this study was to quantify the 3D volume of bone removed from the lamina and facet joints during endoscopic decompression for lumbar central and lateral recess stenosis.METHODSThis retrospective study included adults with lumbar spinal stenosis who underwent endoscopic decompression of a single level or 2 noncontiguous lumbar levels. Central stenosis on MRI was graded preoperatively and postoperatively using the Schizas scale. A computer program was developed in MATLAB to semiautomatically perform a 3D volumetric analysis of preoperative and postoperative lumbar CT scans. The volumetric percentage of bone removed from the lamina and facet joints ipsilateral and contralateral to the side of approach was quantified.RESULTSNineteen patients with 21 treated lumbar levels were included in the study. Preoperatively, the number of levels with Schizas stenosis grades B, C, and D were 5, 12, and 4, respectively. Stenosis grades improved postoperatively to grades A, B, C, and D for 17, 3, 1, and 0 levels, respectively. All levels improved by at least 1 stenosis grade. The volumetric percentage of laminar bone removed was 15.5% (95% CI 11.2%-19.8%, p < 0.001) from the ipsilateral lamina and 8.8% (95% CI 5.7%-11.8%, p < 0.001) from the contralateral lamina. The percentage of facet joint resection was 5.3% (95% CI 4.2%-6.4%, p < 0.001) and 4.3% (95% CI 2.2%-6.4%, p < 0.001) for the ipsilateral and contralateral facet joints, respectively. Average pain scores, as measured by the visual analog scale, improved from 7.9 preoperatively to 2.2 by 3-10 months postoperatively (p < 0.001).CONCLUSIONSEndoscopic lumbar decompression achieves improvement in the radiographic grade of lumbar central stenosis with minimal bone removal from the lamina and facet joints. Future prospective studies are needed to validate the findings of this study with more comprehensive clinical outcomes.