Minimally-Invasive versus Conventional Repair of Spondylolysis in Athletes: A Review of Outcomes and Return to Play

Spondylolysis from pars fracture is a common injury among young athletes, which can limit activity and cause chronic back pain. While current literature has examined the relative benefits of surgical and conservative management of these injuries, no study has yet compared outcomes between conventional direct repair of pars defects and modern minimally invasive procedures. The goals of surgery are pain resolution, return to play at previous levels of activity, and a shorter course of recovery. In this review, the authors have attempted to quantify any differences in outcome between patients treated with conventional or minimally invasive techniques. A literature search was performed of the PubMed database for relevant articles, excluding articles describing conservative management, traumatic injury, or high-grade spondylolisthesis. Articles included for review involved young athletes treated for symptomatic spondylolysis with either conventional or minimally invasive surgery. Two independent reviewers conducted the literature search and judged articles for inclusion. All studies were classified according to the North American Spine Society standards. Of the 116 results of our initial search, 16 articles were included with a total of 150 patients. Due to a paucity of operative details in older studies and inconsistencies in both clinical methods and reporting among most articles, little quantitative analysis was possible. However, patients in the minimally invasive group did have significantly higher rates of pain resolution (p<0.001). Short recovery times were also noted in this group. Both groups experienced low complication rates, and the majority of patients returned to previous levels of activity. Surgical repair of spondylolysis in young athletes is a safe and practical therapy. Current literature suggests that while conventional repair remains effective, minimally invasive procedures better clinical outcomes. We await further data to conduct a more thorough quantitative analysis of these techniques

Endoscopic Treatment of Thoracic Discitis with Robotic Access: A Case Report Merging Two Cutting-Edge Technologies

Emerging technologies in minimally invasive spinal surgery include surgical robots for navigation and spinal endoscopy. We applied these technologies in concert to treat a critically ill patient with thoracic discitis. The patient was an 83-year old woman with extensive medical comorbidities. In 2016, she was admitted from her skilled nursing facility with chest pain radiating to her left arm. Following a negative cardiac workup, computed tomography imaging revealed a right paramediastinal thoracic collection with endplate erosion at the T4 and T5 levels. Subsequent magnetic resonance imaging was consistent with spondylodiscitis. We developed a preoperative trajectory with targeting software to the target levels. Following positioning and calibration in the operating room, we used the robot to establish our planned trajectory along the T4-T5 transpedicular route on the left side. We established a working channel and docked the endoscope through the T4-T5 annulus. Frank pus extruded on entering the disc, which we immediately sampled and sent for culture. We next advanced the endoscope into the disc space, allowing us to clean the endplates with microcurettes and copious irrigation. The patient tolerated the procedure well and was sent to the intensive care unit in light of her general medical status. She recovered well and was discharged from our hospital on postoperative day 11 after a course of intravenous antibiotics. This case represents a novel endoscopic-robotic hybrid spine surgery that we believe will find further applications in spinal surgery

Working Channel Endoscopic Interlaminar Microdiscectomy: 2-Dimensional Operative Video

Abstract This video demonstrates a working channel interlaminar microdiscectomy performed in a patient with significant back and leg pain due to a persistent disc herniation. We describe this technique in detail, describing the endoscopic anatomy and illustrating key steps to safely perform this operation. Due to the limited soft tissue destruction required to access the disc space with this approach, the patient was able to leave the hospital on the day of surgery, and required no pain medication by short-term follow-up a few weeks postoperatively. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient gave direct consent for the use of the endoscopic footage and associated information from this surgery for the making of this video

Novel Application of a New Lateral System for Adjacent-level Revision Surgery: A Case Report

In recent years, lateral lumbar interbody fusion (LLIF) has grown in popularity as a minimally invasive spine surgery (MISS) approach that can be offered to patients with prior surgeries from a posterior approach. In this report, we present a patient with a focal disease and a history of multiple posterior lumbar surgeries who underwent LLIF with a novel application of the Duo system (Spineology Inc., MN, USA) adjacent to prior surgical levels and without posterior instrumentation. At one year postoperatively, she continued to have no back pain or complaints relating to her lumbar pathology. The case demonstrates the novel use of a new MISS LLIF system that requires minimal exposure as compared to current LLIF systems to treat a patient with adjacent segment disease and progressive symptoms following multiple posterior decompressive surgeries

Endoscopic transforaminal lumbar interbody fusion without general anesthesia: technical innovations and outcomes

Innovations in surgical techniques and technologies have enabled spine surgeons to offer patients less morbid alternatives to traditional spine procedures. This review will explore the development of the endoscopic transforaminal lumbar interbody fusion (TLIF) without general endotracheal anesthesia (GETA) and discuss the technical refinements and innovations learned from experiences with this technique. The Awake TLIF employs several key technological innovations: (I) conscious sedation; (II) endoscopic visualization; (III) an expandable interbody device; (IV) recombinant human bone morphogenetic protein; (V) long-acting local analgesia; and (VI) percutaneous instrumentation. Technical refinements, including premedication for prophylaxis against nausea, vomiting, and epistaxis, were made as a result of early experiences with this technique. Results from the first 100 patients to undergo the Awake TLIF demonstrated durable clinical benefit beyond one year postoperatively. Operating time, blood loss, and hospital length of stay averages well below those generally seen with conventional MIS TLIF. Patients achieved a significant reduction in Oswestry Disability Index from baseline of -12.3 points (P<0.0001). In this initial 100 patient cohort, four conversions to GETA were required and four complications resulted, three of which occurred during the first 50 cases. To date, over 200 Awake TLIF cases and the first three-level procedure have been performed. Endoscopic TLIF without the use of general anesthesia is a novel but promising approach for short-segment lumbar fusion. Continued technical innovations will likely afford greater improvements in outcomes, both in the acute and long-term recovery periods

Just the Tip: Resection of a Narcotic Catheter-Tip Granuloma: 2-Dimensional Operative Video

Abstract The catheter tip “granuloma” is a rare inflammatory mass that forms in about 3% of patients with an intradural catheter, most commonly from a morphine pump. It has also been seen with other narcotic pumps, narcotic-non-narcotic combinations, and baclofen pumps. Mass formation is associated with increased opioid dose and concentration. It typically presents with increasing pain requiring increasing doses of medication, with minimal improvement, although it may present with neurologic deficits or be asymptomatic. On MRI, it appears as a round, rim-enhancing lesion that is low intensity with a hypointense rim on both T1 and T2. In the absence of neurologic deficits, there are many treatment options, ranging from a temporary stopping of the pump to catheter replacement. When the lesion presents with neurologic deficits, surgical intervention, beyond catheter replacement or repositioning, is indicated. A laminectomy is performed, with intradural exploration and careful resection of the mass, which is likely adherent to the spinal cord. Postoperative worsening of symptoms is common due to the mass being densely adherent to the spinal cord, requiring spinal cord manipulation. This worsening is usually temporary, and many patients make excellent recoveries. We present a case of a hydromorphone pump inflammatory mass, which initially presented with increasing pain, then progressive neurologic deficits, requiring referral and mass resection. We achieved only a partial resection due to the lesion's adherent nature. This surgical video demonstrates our intradural technique for resection of this rare and technically difficult mass, with 6-mo patient follow-up. The patient has consented to this case report