Clinical, Radiographic and Fusion Comparison of Oblique Lumbar Interbody Fusion (OLIF) stand-alone and OLIF with posterior pedicle screw fixation in patients with degenerative spondylolisthesis.

PURPOSE: To compare the outcomes and characteristics of oblique lumbar interbody fusion stand-alone (OLIF-SA) and OLIF with posterior pedicle screw fixation (OLIF-PPS) in the treatment of Grade I or Grade II degenerative lumbar spondylolisthesis. PATIENTS AND METHODS: Between January 2019 and May 2022, 139 patients with degenerative spondylolisthesis were treated with OLIF-SA (n = 85) or OLIF-PPS (n = 54). The clinical and radiographic records were reviewed. RESULTS: The clinical and radiographic outcomes were similar in both groups. The operative time and intraoperative blood loss in the OLIF-SA group were lower than those in the OLIF-PPS group (P < 0.05). However, the OLIF-PPS group had significantly better disc height (DH) and postoperative forward spondylolisthesis distance (FSD) improvement at 6 months (P < 0.05). The OLIF-PPS group had a significantly lower cage subsidence value than the OLIF-SA group (P < 0.05). Improvement of the lumbar lordotic angle (LA) and fusion segmental lordotic angle (FSA) in the OLIF-PPS group was significantly better than that in the OLIF-SA group (P < 0.05). In terms of fusion types, the OLIF-SA group tended to undergo fusion from the edge of the vertebral body. Fusion in the OLIF-PPS group began more often in the bone graft area of the central cage of the vertebral body. The fusion speed of the OLIF-SA group was faster than that of the OLIF-PPS group. CONCLUSION: OLIF-SA has the advantages of a short operative time, less intraoperative blood loss, and reduced financial burden, while PPS has incomparable advantages in the reduction of spondylolisthesis, restoration of lumbar physiological curvature, and long-term maintenance of intervertebral DH. In addition, the SA group had a unique vertebral edge fusion method and faster fusion speed.

Analysis of the Screw Accuracy and Postoperative Efficacy of Screw Placement in Single Position and Bipedal Position in Robot-Assisted Oblique Lumbar Interbody Fusion: Preliminary Results of Mazor X Stealth Usage.

OBJECTIVE: Traditional manual OLIF combined with pedicle screw implantation has many problems of manual percutaneous screw implantation, such as high difficulty of screw placement, many fluoroscopies, long operation time, and many adjustments, resulting in greater trauma. The robot can perform various types of screw placement in the lateral recumbent position, which allows OLIF combined with posterior screw placement surgery to be completed in a single position. To compare the screw accuracy and initial postoperative results of oblique anterior lumbar fusion with robot-assisted screw placement in the lateral position and screw placement in the prone position for the treatment of lumbar spondylolisthesis. METHODS: From May to June 2022, 45 patients with single-segment lumbar spondylolisthesis underwent Mazor X-assisted oblique lumbar fusion in one position and Renaissance-assisted surgery in two different positions, and screw accuracy was assessed on computed tomography scans according to a modified Gertzbein-Robbins classification. Patients were divided into a single position group and a bipedal position group (the lateral position for complete oblique lumbar fusion and then changed to the prone position for posterior screw placement), and the perioperative parameters, including operative time, number of fluoroscopies, and operative complications, were recorded separately. The results of the clinical indicators, such as the visual analog scale (VAS) for back and leg pain and the Oswestry Disability Index (ODI) score, were obtained. RESULTS: There were no significant differences in the patients' demographic data between the two groups. The single position group had a shorter operative time and fewer fluoroscopies than the bipedal position group; the single position group had a higher percentage of screw accuracy at the A level than the bipedal position group, but there was no statistically significant difference between the two groups at the acceptable level (A + B) (p > 0.05). The single-position group had better outcomes at the 1-week postoperative follow-up back pain VAS scores (p < 0.05). There was no statistically significant difference in the postoperative leg pain VAS scores or the ODI scores when compared to the control group. CONCLUSION: Robot-assisted lateral position oblique lumbar interbody fusion with pedicle screw placement has the same accuracy as prone positioning. Single position surgery can significantly shorten the operation time and reduce the fluoroscopy. There was no significant difference in the long-term efficacy between the two groups.

Endoscopic Revision Strategies and Outcomes for Recurrent L4/5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy.

Objective: We explore the endoscopic revision and surgical techniques for L4/5 recurrent disc herniation (rLDH) after percutaneous endoscopic transforaminal discectomy (PETD). Methods: A retrospective study was conducted. From January 2016 to September 2022, 96 patients who underwent percutaneous endoscopic lumbar discectomy for L4/5 rLDH after PETD were enrolled in the study. Based on the revision approach, the patients were divided into PETD group (57 cases) and percutaneous endoscopic interlaminar discectomy (PEID) group (39 cases). Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and modified MacNab standard were recorded to evaluate the clinical outcomes. Results: No significant differences were found in the demographic data and intraoperative blood loss between the two groups (P>0.05), but the time of operation and intraoperative X-ray fluoroscopy exposures in the PEID group were significantly less than that in the PETD group (P<0.05). The patients' postoperative clinical indexes gradually improved, and the VAS score, ODI index, and JOA score of the patients in both groups showed significant improvement compared with the preoperative period at the 1-week, 1-month, and 6-month postoperative follow-ups (P < 0.05). There was no serious complication observed during the follow-up. Conclusion: For recurrent LDH after PETD of L4/5 segments, percutaneous endoscopic revision can achieve satisfactory results. Among them, PEID has a shorter operative and fluoroscopy time and allows avoidance of the scar that forms after the initial surgery, so it can be considered preferred when both procedures can remove the disk well. However, for some specific types of herniation, a detailed surgical strategy is required.

Surgical Strategy and Outcomes of Full Endoscopic Lumbar Discectomy for Recurrent Lumbar Disk Herniation Following a Previous Full Endoscopic Lumbar Discectomy.

OBJECTIVE: Recurrent lumbar disc herniation (RLDH) cannot be prevented after full endoscopic lumbar discectomy (FELD), and the optimal surgical treatment for RLDH after FELD remains controversial. The aim of the study was to suggest a surgical strategy for FELD to treat RLDH following a previous FELD and to present surgical outcomes. METHODS: Between February 2015 and March 2022, 68 patients with RLDH were surgically treated with FELD retrospectively. An original approach was suggested for the treatment of early recurrence (24 h-2 weeks). The full endoscopic transforaminal technique (FETD) was considered for patients requiring local anesthesia, and in RLDH with FETD indications or FEID technological difficulties. The full endoscopic interlaminar technique (FEID) was chosen in RLDH with FEID indications. Both FEID and FETD were suitable if no FEID or FETD technological difficulties existed. Clinical efficacy was evaluated using the visual analog scale (VAS) score, Oswestry disability index (ODI), and modified MacNab criteria. Postoperative follow-up data at 24 h, 3 months, and final-follow-up were recorded. Operation time and clinical outcomes were assessed with t test. p-value < 0.05 was considered statistically significant. RESULTS: All 68 patients had an average follow-up time of 23.8 months (range, 6-76 months). In the 13 cases of early recurrence, the operation time (32.30 ± 9.67 vs. 58.00 ± 6.16 min) in the original surgical approach group was shorter than that in the changing surgical approach group (p < 0.05). In the 28 cases of L4/5 FETD recurrence (>2 weeks), the operation time (66.17 ± 12.18 vs. 53.60 ± 5.45 min) in the FETD group was more than that in the FEID group (p < 0.05). In the 22 cases of L5S1 recurrence (>2 weeks), the operation time (55.75 ± 8.79 vs. 79.33 ± 6.65 min) in the FEID group was shorter than in the FETD group (p < 0.05). The postoperative VAS and ODI scores at 24 h, 3 months, and final-follow up were all significantly improved, compared with their preoperative counterparts (p < 0.05). Based on the modified MacNab criteria, 88.23% of patients showed excellent or good results. Re-recurrence occurred in three patients at 3 months. No surgical complications were observed in any of the 68 cases. CONCLUSION: FELD is a safe and effective treatment option for RLDH with previous FELD. For early recurrence, the original approach was suggested. Both FEID and FETD were effective and safe for recurrence (>2 weeks), but FEID seemed more efficient for L4/5 RLDH after previous FETD and for L5S1 RLDH.

Severe Symptomatic Epidural Hematoma Following Percutaneous Endoscopic Unilateral Laminectomy for Bilateral Decompression (Endo-ULBD)-Series Report and Management Strategies.

OBJECTIVES: Severe symptomatic epidural hematoma (SSEH) is one of the most severe complications following percutaneous endoscopic unilateral laminectomy for bilateral decompression (Endo-ULBD). Considering that this technique has been performed for a short time, no detailed reports have been recently published. Thus, it is critical to gain a better understanding of SSEH occurring in its postoperative period with regard to its incidence, possible causes, outcome, etc., in order to identify relevant management strategies. METHODS: Patients with spinal stenosis who had undergone Endo-ULBD in our department from May 2019 to May 2022 were retrospectively analyzed. Of which, patients with postoperative epidural hematoma were followed-up. The preoperative and postoperative physical conditions of each patient were recorded, and the information related to hematoma removal surgery was recorded in detail. Clinical outcomes were assessed using the visual analogue scale (VAS) and Oswestry disability index (ODI), and the results were classified into "excellent," "good," "fair," or "poor" based on the modified MacNab criteria. The incidence of hematoma with different factors was calculated, and a bar graph was used to compare the difference of the indexes related to hematoma removal between cases, and a line graph was used to reflect the trend of the outcome of each patient within 6 months to evaluate the effect of the treatment. RESULTS: A total of 461 patients with spinal stenosis who underwent Endo-ULBD were enrolled in the study. SSEH occurred in four cases, with an incidence rate of 0.87% (4/461). All these four patients underwent decompression of multiple segments, and three of them had a history of hypertension comorbid with diabetes. Notably, one patient had a past history of hypertension and coronary artery disease and was on postoperative low molecular heparin due to lower extremity venous thrombosis. According to the conditions of the four patients, three types of treatment were used. And with timely treatment, all patients recovered well. CONCLUSION: Despite being a minimally invasive technique, postoperative epidural hematoma remains a severe complication of Endo-ULBD. Therefore, during percutaneous endoscopic surgery, it is essential to enhance the comprehensive perioperative management of patients with Endo-ULBD. Signs related to postoperative hematoma must be recognized and promptly managed. If necessary, satisfactory results can be achieved by using percutaneous endoscopy along the original surgical channel to remove the hematoma.

Fully Endoscopic 360° Decompression for Central Lumbar Spinal Stenosis Combined with Disc Herniation: Technical Note and Preliminary Outcomes of 39 Cases.

Purpose: To evaluate the outcomes, feasibility, and safety of endoscopic unilateral laminectomy, bilateral decompression and discectomy (Endo-ULBDD) for central lumbar spinal stenosis (CLSS) combined with disc herniation (DH). Methods: This study includes 39 patients diagnosed with CLSS combined with DH who met the inclusion criteria and underwent surgery for Endo-ULBDD from April 2020 to March 2021. The mean age of the patients, operation time, hospitalization time, time in bed, and complications were recorded. Patients were followed up for at least 12 months. Visual analog scale (VAS) scores for low-back and lower-limb pain and Oswestry Disability Index (ODI) scores were evaluated preoperatively, before discharge, and at 3, 6, and 12 months postoperatively. To evaluate clinical effectiveness 12 months postoperatively, the modified MacNab criteria were used. Results: The mean age of the patients was 59.9 years, the mean operation time was 82.1 minutes, the mean hospitalization time was 3.7 days, and the mean time in bed was 20.9 hours. The mean VAS scores of low-back and lower-limb pain improved from 5.9 and 7.2 to 2.0 and 1.6, respectively (P < 0.05). The ODI score improved from 56.0 to 16.7 (P < 0.05). The overall excellent-good rate of the modified MacNab criteria was 89.7%. Two kinds of complications occurred in 4 patients (10.3%), including 1 patient whose inferior articular process was excessively removed and 3 patients who suffered from postoperative dysesthesia. No other severe complications were noted. Conclusion: Endo-ULBDD is a safe, feasible, efficient, and minimally invasive approach to treating CLSS combined with DH.

Fully endoscopic transforaminal discectomy for thoracolumbar junction disc herniation with or without calcification under general anesthesia: Technical notes and preliminary outcomes.

Objective: To evaluate the feasibility, safety, and outcomes of percutaneous endoscopic transforaminal discectomy (PETD) for thoracolumbar junction disc herniation (TLDH) with or without calcification. Methods: This study included 12 patients diagnosed with TLDH with or without calcification who met the inclusion criteria and underwent surgery for PETD from January 2019 to December 2021. The mean patient age, operation time, hospitalization time, time in bed, and complications were recorded. Patients were followed up for at least 9 months. Visual analog scale (VAS) scores for low-back and leg or thoracic radicular pain and modified Japanese Orthopedic Association score (m-JOA) scores were preoperatively evaluated, at 1 day and 3, 6, and 12 months postoperatively or at last follow-up. The modified MacNab criteria were used to evaluate clinical efficacy at 12 months postoperatively or at last follow-up. Results: The mean patient age, operation time, hospitalization time, and time in bed were 53 ± 13.9 years, 101.3 ± 9.2 min, 4.5 ± 1.3 days, and 18.0 ± 7.0 h, respectively. The mean VAS scores of low-back and leg or thoracic radicular pain improved from 5.8 ± 1.5 and 6.5 ± 1.4 to 2.0 ± 0.9 and 1.3 ± 0.5, respectively (P < 0.05). The m-JOA score improved from 7.5 ± 1.2 to 10.0 ± 0.7 (P < 0.05). The overall excellent-good rate of the modified MacNab criteria was 83.3%. No severe complications occurred. Conclusion: Fully endoscopic transforaminal discectomy and ventral decompression under general anesthesia is a safe, feasible, effective, and minimally invasive method for treating herniated discs with or without calcification at thoracolumbar junction zone.

Clinical Application of Large Channel Endoscopic Systems with Full Endoscopic Visualization Technique in Lumbar Central Spinal Stenosis: A Retrospective Cohort Study.

INTRODUCTION: Recently, large channel endoscopic systems and full endoscopic visualization technique have been used to perform unilateral laminotomy for bilateral decompression (ULBD) treatment for lumbar central spinal stenosis (LCSS). However, various endoscopic systems possess different design parameters, which may affect the technical points and treatment outcomes. The object of this retrospective study was to compare the efficiency, safety, and effectiveness of ULBD under the iLESSYS Delta system versus the Endo-Surgi Plus system. METHODS: In the period from October 2020 to April 2021, ULBD was performed using the iLESSYS Delta system or Endo-Surgi Plus system to treat LCSS. Patients were classified into two groups based on the endoscopy system employed. Patient demographics, perioperative indexes, complications, and imaging characteristics were reviewed. Clinical outcomes were quantified using back and leg visual analog scale (VAS) scores and Oswestry Disability Index (ODI) at the time points of follow-up. RESULTS: Thirty-two patients were assigned to the iLESSYS Delta system group and 37 to the Endo-Surgi Plus system group. In the comparison between the two groups, the Endo-Surgi Plus system possessed a shorter incision length and operation time (p < 0.005), and no statistical differences in other aspects were observed. The dural sacs of both groups were significantly expanded postoperatively compared to preoperatively (p < 0.001). Both groups experienced improvements in VAS and ODI scores at all time points (p < 0.001) and equally low frequency of complications. CONCLUSIONS: Current research suggests that both the Endo-Surgi Plus system and iLESSYS Delta system achieved favorable high safety and clinical outcomes in ULBD for treatment of LCSS. The use of a fully visualized trephine may have increased the efficiency of the Endo-Surgi Plus system. Moreover, the Endo-Surgi Plus system may be associated with a wider decompression range and indications.