Oblique Lateral Lumbar Interbody Fusion at L2-L5: Proposal of a New CT-based Preoperative Assessment to Minimize Risks

Objective Oblique anterior to psoas (ATP) interbody lumbar fusion is associated with advantages such as sufficient indirect decompression and restoration of lordosis. Therefore, a comprehensive preoperative assessment that includes the location of entry into the disc space, a feasible trajectory to complete the intervertebral space procedure, and the possible retraction of the psoas muscle is necessary to correctly and safely perform the technique. Methods From January 2019 to January 2020, 160 lumbar CT scans were evaluated. Only 124 images from the L2-L3, L3-L4, and L4-L5 levels met the inclusion criteria. The length of the anterior vertebral line (AVL) and the middle-third of the disc in the anteroposterior axis were measured to localize the entry point (EP). The distance between the anterior arterial vessel (AV) and the EP was also measured. The trajectory commonly used to set the surgical instruments into the disc space was called α, and a new proposed trajectory termed β was calculated. The psoas cross-sectional area anterior to the β angle trajectory was measured to determine any possible retraction using this parameter. Results The EP-AVL distances were L2-L3 11.49 ± 0.89 mm, L3-L4 11.54 ± 0.88 mm, and L4-L5 11.57 ± 0.87 mm. The EP-AV lengths were 17.64 ± 5.62 mm, 19.36 ± 5.49 mm, and 16.48 ± 6.47 mm at L2-L3, L3-L4, and L4-L5, respectively. The average α and β trajectory angles reported were 39.91º and 14.48º, respectively. Psoas muscle retraction was primarily noted at the L4-L5 level. Conclusion This article's proposed parameters represent a routine preoperative safety assessment in patients previously selected for oblique ATP lumbar interbody fusion

Melanoma maligno primario del sistema nervioso central: un reto diagnóstico

ResumenAntecedentesLa rara incidencia del melanoma maligno primario del sistema nervioso central y su capacidad de mimetizar por imagen otros tumores melanocíticos lo hacen ser un reto diagnóstico para el neurocirujano.Caso clínicoPresentamos el caso de una paciente femenina de 51 años de edad, con un tumor localizado en el área calloso forniceal derecha. Se realizó exéresis quirúrgica total, y el resultado histopatológico fue compatible con el diagnóstico de melanoma maligno primario del sistema nervioso central, habiéndose descartado lesiones extracraneales y extrarraquídeas mucotegumentarias melanocíticas.ConclusionesEl melanoma maligno primario del sistema nervioso central es extremadamente raro. Existen características en imagen de resonancia magnética que incrementan la sospecha diagnóstica. Sin embargo, hay otros tumores más prevalentes que comparten algunas de esas características por imagen. No hay un estándar terapéutico establecido. Su pronóstico es desalentador.AbstractBackgroundThe rare incidence of primary malignant melanoma of the central nervous system and its ability to mimic other melanocytic tumors on images makes it a diagnostic challenge for the neurosurgeon.Clinical caseA 51-year-old patient, with a tumor located in the right forniceal callosum area. Total surgical excision was performed. Histopathological result was consistent with the diagnosis of primary malignant melanoma of the central nervous system, after ruling out extra cranial and extra spinal melanocytic lesions.ConclusionsThe primary malignant melanoma of the central nervous system is extremely rare. There are features in magnetic resonance imaging that increase the diagnostic suspicion; nevertheless there are other tumors with more prevalence that share some of these features through image. Since there is not an established therapeutic standard its prognosis is discouragin

Large Retroperitoneal Hematoma and Lumbosacral Plexopathy Following Microsurgical Decompression via the Wiltse Paraspinal Approach: A Case Report

Paraspinal approaches are associated with fewer complications and better outcomes than midline approaches. However, most surgeons are not conversant with the surgical anatomy in these approaches, especially at the lumbosacral junction, where the anatomy is more complex. This paper reports a case of concomitant vascular and neurological complication following the use of the microscopic Wiltse approach. A 71-year-old woman presented with symptoms of spinal stenosis and right L5 radiculopathy. She underwent microsurgical decompression of a foraminal stenosis at the lumbosacral junction via the Wiltse approach, and a midline decompression from L3 to L5. The tubular retractor was docked inappropriately, being too deep and lateral. It directly punctured through the intertransverse membrane and injured the retroperitoneal segmental vessel and lumbosacral plexus. Postoperatively, she developed a large retroperitoneal hematoma and lumbosacral plexopathy, which were treated with surgery and intensive rehabilitation. This report highlights the importance of accurate retractor docking, familiarity with the surgical anatomy, and recognition of the potential complications of this technique

THE ACADEMIC IMPACT OF THE SYMPOSIUM ON ENDOSCOPY AND MINIMALLY INVASIVE SPINE SURGERY OF THE MEXICAN ASSOCIATION OF SPINE SURGEONS – AMCICO

ABSTRACT Introduction: The interest in spinal endoscopy is rising, particularly among younger spine surgeons. Formalized postgraduate training programs for endoscopic spinal surgery techniques are lacking behind. Methods: The authors performed a retrospective survey study amongst participants of the 2022 AMCICO endoscopic surgery symposium. Descriptive and correlative statistics were done on the surgeon’s responses recorded in multiple-choice questions. In addition, surgeons were asked about their clinical experience and preferences with spinal endoscopy, training background, the types of lumbar endoscopic decompression they perform by approach, and future training requirements. SPSS (version 27) statistical software package was used for data analysis. Descriptive statistic measures were used to count responses and calculate the mean, range, standard deviation, and percentages. In addition, chi-square statistics were used to determine the strength of the association between factors. Results: The online survey was accessed by 321 surgeons, of which 92 completed it (53.4%). Demographic data showed the majority of responding surgeons being orthopedic surgeons (73.6%) and under the age of 50 (69.2%), with over half (51.1%) having less than three months of formalized training in endoscopic spinal surgery techniques. Most surgeons practiced uni-portal (58.9%) versus bi-portal (3.4%) spinal endoscopy. The transforaminal approach (65.5%) was preferred over the interlaminar method (34.4%). The bi-portal technique was indicated almost exclusively for the lumbar spine (94.8%). For endoscopically assisted spinal fusions, a uni-portal approach was preferred by 72% of surgeons over a bi-portal procedure (24.5%). 84.1% of respondents were interested in navigation, of which 30.7% preferred optical over electromagnetic technology (18.2%). Robotics was of interest to 51.1% of survey participants. Respondents’ bias was estimated with course attendance assessments, with 37% of surgeons having attended all three days, 27.2% two days, and 16.3% one day. One-fifth of responding spine surgeons did not participate in any curriculum activities but completed the survey. The academic impact of the AMCICO endoscopy symposium was high, with 68.1% of respondents indicating interest in continued training and 61.1% of trainees ready to apply their newly acquired knowledge base to clinical practice. Conclusion: The interest in spinal endoscopy surgery techniques and protocols is high among AMCICO members. Many surgeons are interested in learning advanced endoscopic surgical techniques to integrate the technology into their surgical procedure portfolio to address common painful conditions of the degenerative spine beyond herniated discs and foraminal stenosis. The authors concluded that its academic impact was high based on the responses given by the participating surgeons. Level of evidence III; Retrospective study

A 30-Year Worldwide Research Productivity of Scientific Publication in Full-Endoscopic Decompression Spine Surgery: Quantitative and Qualitative Analysis

Objective The ever-growing number of articles related to full-endoscopic spine surgery published in the last few decades presents a challenge which is perplexing and time-consuming in identifying the current research status. The study aims to identify and analyze the most cited works related to full-endoscopic decompression spine surgery, compare the articles published by different publishers and area, and show the current publication status of full-endoscopic research. Methods Using Bibliometrix, CiteSpace, and VOSviewer, we analyzed the bibliometric data selected from the Web of Science database between 1992 and 2022. Spine has the highest H-index with the most-cited journal in the field of full-endoscopic decompression spine surgery. China ranked as the most productive country, whereas the most cited with high H-index papers came from South Korea. For the author analysis, Yeung AT, Ruetten S, Hoogland T, Ahn Y, Choi G, and Mayer HM were the most impactful authors in the global and local citations. The most productive organization is Wooridul Spine Hospital. Conclusion The bibliometric study showed a growing trend of research on full-endoscopic decompression spine surgery over the past 30 years. It has demonstrated that there is a significant increase in the number of authors, institutions, and internationally collaborated countries. However, the quality of studies is still low, and the lack of high-quality clinical evidence and the trend of general journal submissions has somewhat affected the quality of endoscopy journals in recent years

MINIMALLY INVASIVE SINGLE-DOOR PLATE LAMINOPLASTY WITH LATERAL MASS SCREW FIXATION FOR THE UNSTABLE SEGMENT. REPORT OF TWO CASES WITH LONG FOLLOW-UP

ABSTRACT Objective: To report two cases of multilevel cervical spondylotic myelopathy with monosegmental instability, in which we performed a minimally invasive microsurgical transmuscular approach with tubular retractors to create a single-door plate laminoplasty combined with fixation of the unstable segment with lateral mass screws. Methods: The surgical procedures were performed by the senior author. In both patients, the follow-up was performed using the Oswestry Disability Index (ODI), the Visual Analogue Scale for neck and radicular pain (radVAS, neckVAS), the Neck Disability Index (NDI) and the Short Form 36 (SF-36), in the preoperative (preop) and postoperative (postop) periods, and at 1, 3, 6, 12, 18 and 24 months. A radiological evaluation also was performed, which included AP, lateral and flexion-extension films at 6, 12 and 24 months and CT-scan at 12 months. Results: Case 1 - preop ODI: 40%, 24 months postop ODI: 4%; preop radVAS: 7, 24 months radVAS: 0; preop neckVAS: 8, postop 24 months neckVAS: 0; preopNDI: 43%, 24 months PostopNDI: 8%; SF-36 - preop Physical Functioning (PF): 40, preop Vitality (VT): 40, preop Emotional role functioning (RE): 33.3, Bodily pain (BP): 51, General Health (GH): 57, Social Functioning (SF): 75; postop PF: 95, VT: 95, RE: 100, BP: 74, GH: 87, SF: 100. Case 2 - preopODI: 46%, 24 months postopODI: 10%; preop radVAS: 7, 24m radVAS: 0; preop neckVAS: 9, postop 24 months neckVAS: 0; preopNDI: 56%, 24 months PostopNDI: 15%; SF-36 - preop PF: 39, VT: 45, RE: 33.3, BP: 50, GH: 49, SF: 70; postop PF: 90, VT: 100, RE: 100, BP: 82, GH: 87, SF: 100. No complications, cervical instability or signs of failed surgery were found trough and at final follow-up at 24 months. We found significant clinical improvement in both patients. Conclusions: Minimally invasive cervical laminoplasty combined with lateral mass screw fixation for the unstable segment is a useful technique in cases with multilevel cervical spondylotic myelopathy associated with monosegmental instability. Additional comparative studies are needed to establish its efficacy

MICROSURGICAL LANDMARKS IN MINIMALLY INVASIVE TRANSFORAMINAL LUMBAR INTERBODY FUSION

Microsurgical landmarks of the facet joint complex were defined to provide guidance and security within the tubular retractor during transforaminal surgery. A retrospective observational study was performed in segments L4-L5 by the left side approach. Microsurgical relevant photos, anatomical models and drawing were used to expose the suggested landmarks. The MI-TLIF technique has advantages compared with conventional open TLIF technique, however minimally invasive technique implies lack of security for the surgeon due to the lack of defined microanatomical landmarks compared to open spine surgery, and disorientation within the tubular retractor, the reason why to have precise microsurgical references and its recognition within the surgical field provide speed and safety when performing minimally invasive technique