Objective This study evaluates surgical strategies based on preoperative computed tomography (CT) findings during unilateral biportal endoscopic (UBE) surgery for thoracic ossification of the ligamentum flavum (OLF) with dural ossification.
Methods This retrospective study included patients undergoing posterior thoracic laminectomy via UBE surgery to treat symptomatic thoracic stenosis due to OLF. Clinical outcomes were assessed using visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) scores, alongside analyses of preoperative CT and intraoperative videos for dural ossification characteristics.
Results A total of 34 patients participated, showing significant improvements in VAS and JOA scores postoperatively. All focal dural ossifications exhibiting the tram-track sign were effectively excised without significant dural defects. The circumferential floating technique was employed for cases with the bridge sign, whereas wide excision was warranted for those with the comma sign.
Conclusion UBE surgery effectively manages progressive thoracic OLF associated with dural ossification. Preoperative CT imaging is essential for assessing dural involvement and guiding surgical techniques. Microscopic surgery is recommended for inexperienced surgeons requiring wide dural excision.
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Objective Advanced biportal endoscopic surgery techniques can be used to treat thoracic myelopathy secondary to ossification of the ligamentum flavum (OLF). This case series elaborates on a feasible biportal endoscopic technique for thoracic OLF removal and evaluates clinical and radiological outcomes.
Methods A biportal endoscopic posterior thoracic laminectomy was performed to remove the thoracic OLF. Surgical techniques have evolved from inside-out piecemeal removal methods to outside-in en bloc removal methods. Preoperative computed tomography was performed to analyze dural ossification and OLF types. Intraoperative videos were reviewed to observe dural ossification and to determine the surgical method. Neurological outcomes were assessed using the Japanese Orthopaedic Association (JOA) score.
Results Clinical symptoms and neurological function improved markedly after surgery (JOA score, preoperative: 12.6 ± 1.0, final follow-up: 15.6 ± 1.2). The mean operation time per segment was not short (106.6 ± 38 minutes). At early experience stages, inside-out piecemeal decompression was used and it caused intraoperative spinal cord injury. However, outside-in en bloc decompression technique did not induce neural complications. Postoperative segmental instability and correlated mechanical back pain were not observed.
Conclusion The biportal endoscopic posterior thoracic approach is an attractive surgical option to treat thoracic spondylotic myelopathy secondary to OLF. Piecemeal inside-out decompression can induce irreversible spinal cord injury, especially in the early experience stages. Outside-in decompression is more efficient and safer than inside-out pattern procedures by minimizing dural manipulation. Nonetheless, this technique is technically demanding and should only be performed in selected patients after acquiring abundant experience with endoscopic spine surgeries.
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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.
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Objective The aim of this study was to compare the clinical and radiologic outcomes of 3 types of minimally invasive posterior cervical foraminotomy (PCF): uniportal endoscopic surgery, biportal endoscopic surgery, and microsurgery.
Methods Between January 2019 to January 2020, PCF was performed using 3 different approaches to treat foraminal stenosis. The foraminal expansion rate, facet resection rate, and surgical foraminal approach angle were measured using magnetic resonance imaging. Visual analogue scale (VAS) scores for neck and arm pain, neck disability index (NDI), MacNab criteria, operation time, hospital stay, and complications were assessed. Clinical and radiologic parameters were compared among the 3 surgical groups.
Results There were 38, 30, and 50 patients in the uniportal endoscopy, biportal endoscopy, and microscopy groups, respectively. Microscopy group displayed significantly higher foraminal expansion compared to uniportal endoscopy group (p = 0.001). Facet resection rates and inclination angle for facet joint undercutting were significantly different among the 3 groups. Uniportal endoscopy group had the highest inclination angle and the least facet resection. On the 6 months and final follow-up, VAS scores and NDI were significantly lower in the uniportal endoscopy group than in the microscopy group (p = 0.000).
Conclusion All 3 types of PCF displayed favorable clinical outcomes and sufficient expansion of the midforaminal area. Two endoscopy groups showed a significantly higher inclination angle for undercutting the facet joint and a lower facet resection rate than the microscopy group. Reduced facet joint resection using an inclinatory approach did not interfere with sufficient foraminal expansion and enhanced the clinical result after 6 months of follow-up.
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Objective Posterior endoscopic cervical foraminotomy (PECF) is a well-established, minimally invasive surgery for cervical radiculopathy, but have the more chances of neural structure damage due to the limited visibility and steeper learning curve. So, the anatomical understanding of the nerve associated with the bony structure will be an essential surgical guideline.
Methods We measured the distance between the bilateral dura lateral edge and bilateral V-point on axial cuts of cervical magnetic resonance imaging and 3-dimensional spine computed tomography imaging, respectively, from 80 patients. We then calculate the distance and position between the dura lateral edge and the V-point as surgically critical width (SCW). Transverse interdural distance (TIDW), transverse inter-V-point distance, and anatomical facet joint width were measured.
Results The mean TIDW decreased as the levels down in the 40s–60s but increased at the C4–5, C5–6, and C6–7 levels in the 70s. Statistically significant difference was shown at the C6–7 level between the 40s and the 70s. The mean anatomical inter-V-point distance markedly decreased at C5–6 and continued till the C7–Tl level at all age groups. Moreover, a statistically significant difference was shown at the C3–4 and C4–5 level between the 40s and the 70s. The mean negative values of SCW increased from the 40s to 70s at the C5–6 and C6–7 levels (C5–6: -0.60 ± 1.10 mm to -1.63 ± 1.56 mm; C6–7: -0.90 ± 0.74 mm to -2.18 ± 1.25 mm). There were statistically significant differences between the 2 aged groups at the C3–4, C4–5, C5–6, and C6–7 levels.
Conclusion A prediction of the correlated position between the lateral dura edge and the V-point is essential for the PECF not to injure the neural structure. In the case of a performing the PECF at the C5–6 and C6–7 level in the old-aged patient, it should be considered the laterally moved dura edge, and more extended bony remove is needed for less neural structure damage.
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