Recent Trends and Changes in the Endoscopic Spinal Surgery

In recent years, endoscopic spine surgeries have advanced dramatically. Endoscopic spine surgeries are expanding to not only the lumbar spine, but also thoracic and cervical spines. Indications for spinal endoscopic surgery have also been expanded. Central stenosis, lateral recess stenosis, and foraminal stenosis were included in surgical indications of endoscopy. Finally, endoscopic lumbar interbody fusion surgeries have been attempted

Comparative Analysis With Modified Inclined Technique for Posterior Endoscopic Cervical Foraminotomy in Treating Cervical Osseous Foraminal Stenosis: Radiological and Midterm Clinical Outcomes

Objective We compared the midterm clinical and radiological outcomes between 2 types of full endoscopic posterior cervical foraminotomy, including conventional posterior endoscopic cervical foraminotomy (PECF) and modified inclined technique for PECF. Methods One of the 2 types of PECF surgery was performed for defined cervical foraminal stenosis. The foraminal expansion ratio and facet resection rate and foraminal stenosis grade were measured using magnetic resonance imaging. Visual analogue scale (VAS) scores for neck and arm pain, neck disability index, MacNab criteria, operation time, hospital stay, and complications, including postoperative dysesthesia, were assessed. Clinical and radiological parameters were compared between the 2 surgical groups. Results There were 49 and 46 patients in the PECF and modified-PECF groups, respectively. The modified-PECF group showed significantly higher expansion of distal foraminal diameter and foraminal height, and a lower facet resection rate compared to PECF group (in all, p<0.001). The modified-PECF group displayed significantly lower VAS score for neck pain at 1 day and 1 week after surgery and lower arm pain VAS score after 6-month follow-up (p=0.002, p=0.001, p=0.002, respectively). Conclusion Compared with the PECF, the modified inclined technique has radiologic benefits, including enhanced facet joint preservation, restoration of the natural course of nerve roots, and prevention of restenosis by expanding the superior articular process base, especially in grade 2 foraminal stenosis. Furthermore, the modified inclined technique significantly improved the postoperative VAS score for neck pain within the 1-week follow-up and that of arm pain after 6-month follow-up

Usefulness of Oblique Lumbar Magnetic Resonance Imaging for Nerve Root Anomalies and Extraforaminal Entrapment Lesions

Study Design A retrospective review of prospectively evaluated magnetic resonance (MR) images. Purpose Routine lumbar axial and sagittal MR images may not clearly demonstrate nerve root anomalies and entrapments in the extraforaminal region. Thus, lumbar extraforaminal lesions or nerve root anomalies may be underdiagnosed because of unfamiliar radiological anatomy. We aimed to investigate the clinical efficacy of our oblique magnetic resonance imaging (MRI) technique for diagnosing nerve root anomalies and entrapment lesions. Overview of Literature Evaluation of clinical usefulness of oblique lumbar MRI for nerve root anomalies and extraforaminal entrapment lesions. Methods In total, 162 patients (60 males and 102 females; mean age, 59.8±17.8 years) with suspected nerve root anomalies and entrapments in routine axial and sagittal MR images underwent unilateral or bilateral oblique lumbar T2-weighted MRI. The axial angle of the oblique image was parallel to the foramen. The oblique MRI findings of the symptomatic side were compared with those of the asymptomatic side in cases with unilateral pathologic lesions. Interobserver agreement was analyzed using kappa statistics. Results The following abnormal findings were obtained: nerve root entrapment due to foraminal stenosis in 82 cases; extraforaminal disk herniation in 29; conjoined nerve root in six; and foraminal bony cyst in one. Forty-three of the 46 patients experienced unilateral lateralizing symptoms, unilateral nerve root entrapment due to foraminal stenosis, herniated disk, and extraforaminal bony cyst compared with the asymptomatic contralateral side (p <0.05). Conclusions Our results suggest that oblique lumbar MRI is a simple and valuable modality for diagnosing anomalous lumbar nerve root lesions and entrapment

Feasibility of Endoscopic Transforaminal Lumbar Interbody Fusion (eTLIF) Through the Posterior Paraspinal Approach: Technical Note and Preliminary Result

Objective The implement of endoscopic spinal surgery has minimized the requirement of fusion procedures. However, certain patients still require fusion surgery such as instability. We performed a full-endoscopic transforaminal lumbar interbody fusion (eTLIF) through a conventional paraspinal approach. Methods eighteen consecutive patients with degenerative lumbar disease underwent eTLIF through paraspinal approach. Their clinical outcomes were evaluated with visual analog scale (VAS), Oswestry Disability Index (ODI) and the MacNab's criteria; radiological outcome measured with segmental lordosis (SLA), global lumbar lordosis (LLA), disc height (DH) on plain radiograph and percentage of potential fusion mass on CT scan at pre-operative, post-operative and final follow up period. intra operative and post-operative complications noted. Results Mean age was 63. 71 years and Mean follow-up periods was 7.78 months. In the X-ray result, mean SLA improved in pre-operative/post-operative/follow-up period 9.87±2.740/11.79±3.74 0/10.56±3.690 (p>0.01); mean LLA improved 37.1±7.040/39.2±7.130/35.7±7.250 (p>0.01). Mean DH improved from 8.97±1.49 mm/12.34±1.39 mm/11.44±1.98 mm(p<0.01). In the CT result, Average percentage of fusion mass was 42.61%. VAS was improved, 7.67/3.39/2.5 and ODI was improved, 74.9/34.56/27.76 by each preoperative/postoperative/final follow-up. In the clinical result, excellent was 5 cases and good was 13 cases. Conclusion eTLIF was competent and viable surgical procedure. The results were excellent in the form of endplate preservation, disc height restoration, minimal post-operative pain with early mobilization. The fusion volume occupies 40% to 50% of disc space is expected to give sufficient fusion

Safe Extraforaminal Docking and Floating Technique in Transforaminal Endoscopic Discectomy for Thoracolumbar Junction for Calcified Disc Herniation: A Case Report and Technical Review Junction for Calcified Disc Herniation

Objective Thoracolumbar disc herniation is an uncommon disabling spine condition. Methods There is relatively large dura expansion to lateral recess in the thoracolumbar junction leading to potential hazard in docking and execution of endoscopic transforaminal discectomy. Mobile outside in technique had been executed successfully in lumbar disc herniation, we modified the technique to allow safe docking and execution of discectomy in thoracolumbar junction. Herein, we report a case of thoracic twelve lumbar one disc paracentral disc herniation treated with floating transforaminal endoscopic discectomy under local anesthesia. Results A 46-year-old man with a 3-months of severe back and radicular pain on the right groin. A diagnosis of right T12/L1 paracentral disc herniation was made, based on clinical and radiological investigations. He underwent percutaneous transforaminal endoscopic thoracolumbar discectomy with floating technique. Over a follow-up of 6 months, a favorable outcome was noted. Conclusion Floating technique of transforaminal endoscopic thoracolumbar junction discectomy is a safe and an effective surgical approach for the treatment of thoracolumbar disc herniation. In patients with thoracolumbar disc herniation, careful patient selection and evaluation neural elements anatomy in relation to bony anatomy is important in preparation for endoscopic decompression

Endoscopic Resection of Symptomatic Degenerative Repetitive Stress Related Fracture of the Tip of Superior Articular Process. An Unusual Cause of Severe Back Pain: Report of 2 Cases and Technical Note

Neglected stress related fracture of superior articular process fracture leading to disability is not commonly reported. Intravertebral foraminal ligament attachment to superior articular process is well described but its repetitive stress related avulsion injury was not reported. The presence of abundant sensory and nociceptive nerve endings around the facet joint can cause significant symptoms in this uncommon condition. We hereby present 2 cases of superior articular process tip fracture. First case is a 53 years old business who presented with intractable chronic back and right gluteal pain for many years worsened with golf games with the diagnosis of nonunion of right L2 superior articular facet and second case is a 74 years old lady who had intractable left buttock and left calf radicular pain with neglected left L5 superior articular facet tip fracture after vertebroplasty treatment on L4 compression fracture; both underwent uniportal endoscopic contralateral approach for decompression and resection of the Superior Articular Process, SAP tip fragment with its attached foraminal ligament with good symptoms relief on one year follow up. Consideration can be made for endoscopic decompression SAP tip fracture in comparison to open decompression or fusion surgery in these symptomatic patients

Elevated red cell distribution width is associated with advanced fibrosis in NAFLD

Background/AimsThe red-blood-cell distribution width (RDW) is a newly recognized risk marker in patients with cardiovascular disease, but its role in nonalcoholic fatty liver disease (NAFLD) has not been well defined. The aim of the present study was to determine the association between RDW values and the level of fibrosis in NAFLD according to BARD and FIB-4 scores.MethodsThis study included 24,547 subjects who had been diagnosed with NAFLD based on abdominal ultrasonography and questionnaires about alcohol consumption. The degree of liver fibrosis was determined according to BARD and FIB-4 scores. The association between RDW values and the degree of fibrosis in NAFLD was analyzed retrospectively.ResultsAfter adjusting for age, hemoglobin level, mean corpuscular volume, history of hypertension, history of diabetes, and high-sensitivity C-reactive protein, the RDW values were 12.61±0.41% (mean±SD), 12.70±0.70%, 12.77±0.62%, 12.87±0.82%, and 13.25±0.90% for those with BARD scores of 0, 1, 2, 3, and 4, respectively, and 12.71±0.72%, 12.79±0.66%, and 13.23±1.52% for those with FIB-4 scores of <1.30, 1.31-2.66, and ≥2.67, respectively (P<0.05). The prevalence of advanced fibrosis (BARD score of 24 and FIB-4 score of ≥1.3) increased with the RDW [BARD score: 51.1% in quartile 1 (Q1) vs. 63.6% in Q4; FIB-4 score: 6.9% in Q1 vs. 10.5% in Q4; P<0.001]. After adjustments, the odds ratio of having advanced fibrosis for those in Q4 compared to Q1 were 1.76 (95%CI=1.55-2.00, P<0.001) relative to BARD score and 1.69 (95%CI=1.52-1.98, P<0.001) relative to FIB-4 score.ConclusionsElevated RDW is independently associated with advanced fibrosis in NAFLD

The Use of Dual Direction Expandable Titanium Cage With Biportal Endoscopic Transforaminal Lumbar Interbody Fusion: A Technical Consideration With Preliminary Results.

ObjectiveExpandable cage technology has emerged for lumbar interbody fusion to restore intervertebral disc space height and alignment through a narrow surgical corridor. The purpose of this study is to present the technique of biportal endoscopic transforaminal lumbar interbody fusion (TLIF) using dual direction expandable cage and provide early clinical results.MethodsWe performed the biportal endoscopic TLIF using a dual direction expandable titanium cage for height restoration and a larger footprint in 10 patients. Clinical parameters including Oswestry Disability Index (ODI), visual analogue scale (VAS), and complications were retrospectively analyzed. Also, we investigated radiologic parameters using preoperative and postoperative x-ray images.ResultsWe successfully inserted dual direction expandable cages during biportal endoscopic TLIF. There was no significant subsidence or collapse of the expandable cages during the 6-month follow-up period. Lumbar lordosis and disc height were significantly increased after surgery. ODI and VAS scores were significantly improved at 6 months after surgery.ConclusionIn this report, we describe the first use of a dual direction expandable interbody TLIF cage that expands in both width and height in biportal endoscopic TLIF surgery. Early clinical and radiographic outcomes of this TLIF technique may be favorable in early 6-month follow-up