Objective Transforaminal lumbar interbody fusion (TLIF) has become a mainstay technique for interbody fusion, allowing for large contact area between implant and endplate, and providing increased stability and greater area for fusion. The development of 3-dimensional (3D)-expandable implants that provide multidimensional (3D) expansion has shown to provide better height restoration and clinical outcomes when compared to static implants. Comparison of the endplate coverage between 3D-expandable and static TLIF implants has yet to be studied. This study compares endplate coverage achieved with static TLIF, 3D-expandable TLIF, and anterior lumbar interbody fusion (ALIF) implants.
Methods A retrospective review of patients undergoing interbody fusion with either static TLIF, 3D-expandable TLIF, or ALIF between the years 2014 and 2022 was conducted. Postoperative computed tomography (CT) imaging was used to measure endplate and implant dimensions. 3D-expandable TLIF interbody device areas were calculated using diameter measurements on postoperative CT. The coverage ratio was defined as the ratio of twice the area of the implant and the sum of the superior and inferior endplate areas at the operative level.
Results A total of 53 patients per cohort were included. The average endplate coverage ratios for static TLIF, 3D-expandable TLIF, and ALIF implants were 0.19±0.04, 0.35±0.06, and 0.46±0.13, respectively. Subgroup analysis showed comparable coverage of 3D-expandable TLIF to ALIF implants at L3–4 and L4–5, while ALIF remained superior at L5–S1.
Conclusion 3D-expandable TLIF interbody devices provide greater endplate coverage when compared to static TLIF devices and approach comparable coverage to ALIF implants.
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Objective This study aimed to compare the clinical outcomes of patients with AOSpine A3 or A4 thoracolumbar fractures presenting with neurological deficits treated with endoscopic decompression combined with percutaneous pedicle screws fixation (endoscopic minimally invasive surgery, EMIS) or conventional open surgery (OS).
Methods Data of patients with AOSpine A3 or A4 thoracolumbar fractures with neurological deficits who were treated with EMIS or OS between June 2019 and July 2021 were extracted from the electronic database. Various clinical outcomes were compared between the 2 cohorts.
Results Among the 231 patients who were followed up for more than 2 years, 107 were in the EMIS cohort and 124 were in the OS cohort. Compared with the OS cohort, the EMIS cohort had longer operative time (p<0.05), but the intraoperative blood loss, incision length and hospital stay were significantly reduced (p<0.05). At both postoperative and final follow-up assessments, the EMIS cohort demonstrated significantly better visual analogue scale and Oswestry Disability Index outcomes compared to the OS cohort (p<0.05). Both cohorts maintained similar correction of spinal canal erosion rate, percentage of anterior vertebral height and sagittal Cobb angle after surgery and at the last follow-up (p>0.05). According to American Spinal Injury Association classification, the 2 cohorts had similar neurological recovery at the last follow-up (p>0.05).
Conclusion In comparison to OS, EMIS treatment for AOSpine A3 or A4 thoracolumbar fractures with neurological deficits has shown comparable clinical efficacy while significantly reducing surgical trauma.
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The main objective of this case and video is to demonstrate the surgical technique of navigated full-endoscopic decompression and sequestrectomy at the C7–T1 level to alleviate C8 nerve root compression and manage cervicobrachialgia. Cervicobrachialgia resulting from C7–T1 disc herniation is a quite rare yet painful condition that can significantly impair motor function in the upper limb. Traditionally, open surgeries can be invasive, with prolonged recovery times and/or fusion of the level with adjacent segment disease. Posterior full-endoscopic approach offers a minimally invasive alternative that allows for quicker recovery, less postoperative pain, and improved outcomes. By preserving motion, it also prevents adjacent segment disease. A 72-year-old female presented with sudden-onset cervicobrachial pain radiating to the ulnar side of the right arm, coupled with paresthesia and weakness of the flexors/interosseous muscles (Medical Research Council=M3). Magnetic resonance imaging confirmed a large right-sided C7–T1 disc herniation compressing the C8 nerve root. A full-endoscopic C7–T1 posterior foraminotomy and sequestrectomy was performed with navigation. The patient experienced immediate relief from pain and improved motor function in the right hand postoperatively. Posterior full-endoscopic foraminotomy and sequestrectomy of the C7–T1 disc herniation is effective for treating cervicobrachialgia due to C8 nerve compression. The minimally invasive approach demonstrated in this video highlights the technique and stresses the advantage of navigation in the lower cervical spine.
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Objective To avoid the most offending surgical instrument for dural tears, we develop a “no-punch” decompression technique for unilateral biportal endoscopic (UBE) spine surgery.
Methods This retrospective study enrolled 68 consecutive patients with degenerative lumbar spinal stenosis segments. The treatment results were evaluated using the visual analogue scale (VAS) for low back and leg pain, the Japanese Orthopaedic Association (JOA) scores, and the Oswestry Disability Index (ODI). Radiological outcomes were evaluated using the preoperative and postoperative magnetic resonance imaging.
Results This study included 36 male and 32 female patients who received 109 segments of decompression, with an average age of 68.7 (37–90 years). The average operation time was 52.2 minutes. The average hospital stay was 3.1 days. There were no dural tears but 3 minor surgical complications, all treated conservatively. The VAS for low back and leg pain improved from 4.6 and 7.0 to 0.8 and 1.2. The JOA score improved from 16.2 to 26.8, with an improvement rate of 82.0%. The ODI improved from 50.1 to 18.7. All these improvements were statistically significant. The cross-sectional dural area improved from 61.1 to 151.3 mm2, with an average increase of 90.2 mm2 and 205.3%. 87.1% of the ipsilateral facet joints and 84.7% of the contralateral facet joints were preserved. In 61% of the decompressed segments, the ipsilateral facet joints were preserved better than the contralateral facet joints.
Conclusion The UBE “no-punch” decompression technique effectively avoids the dural tears. It provides effective neural decompression, excellent facet joint preservation, and good treatment outcomes.
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Objective To compare the early radiographic and clinical outcomes of expandable uniplanar versus biplanar interbody cages used for single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).
Methods A retrospective review of 1-level MIS-TLIFs performed with uniplanar and biplanar polyetheretherketone cages was performed. Radiographic measurements were performed on radiographs taken preoperatively, at 6-week follow-up, and 1-year follow-up. Oswestry Disability Index (ODI) and visual analogue scale (VAS) for back and leg at 3-month and 1-year follow-up.
Results A total of 93 patients (41 uniplanar, 52 biplanar) were included. Both cage types provided significant postoperative improvements in anterior disc height, posterior disc height, and segmental lordosis at 1 year. No significant differences in cage subsidence rates were found between uniplanar (21.9%) and biplanar devices (32.7%) at 6 weeks (odds ratio, 2.015; 95% confidence interval, 0.651–6.235; p = 0.249) with no additional instances of subsidence at 1 year. No significant differences in the magnitude of improvements based on ODI, VAS back, or VAS leg at 3-month or 1-year follow-up between groups and the proportion of patients achieving the minimal clinically important difference in ODI, VAS back, or VAS leg at 1 year were not statistically significantly different (p > 0.05). Finally, there were no significant differences in complication rates (p = 0.283), 90-day readmission rates (p = 1.00), revision surgical procedures (p = 0.423), or fusion rates at 1 year (p = 0.457) between groups.
Conclusion Biplanar and uniplanar expandable cages offer a safe and effective means of improving anterior disc height, posterior disc height, segmental lordosis, and patient-reported outcome measures at 1 year postoperatively. No significant differences in radiographic outcomes, subsidence rates, mean subsidence distance, 1-year patient-reported outcomes, and postoperative complications were noted between groups.
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Objective To describe the surgical techniques and the treatment outcomes of biportal endoscopic transforaminal lumbar interbody fusion (BETLIF) using double cages.
Methods This study included 89 patients with 114 fusion segments between July 2019 and May 2021. One pure polyetheretherketone (PEEK) cage and 1 composite titanium-PEEK cage were used for interbody fusion. Clinical outcomes measures included visual analogue scale (VAS) scores for lower back pain and leg pain, Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) scores. Computed tomography (CT) of the lumbar spine 1 year postoperatively was used to evaluate the Bridwell interbody fusion grades.
Results There were significant improvement in VAS for lower back pain from 5.2 ± 3.1 to 1.7 ± 2.1, VAS for leg pain from 6.3 ± 2.5 to 1.7 ± 2.0, ODI from 46.7 ± 17.0 to 12.7 ± 16.1, and JOA score from 15.6 ± 6.3 to 26.4 ± 3.2. The p-values were all < 0.001. The average hospital stay was 5.7 ± 1.1 days. The CT studies available for 60 fusion segments showed successful fusion (Bridwell grade I or grade II) in 56 segments (93.3%). Significant cage subsidence of more than 2 mm was only noted in 3 segments (5.0%). Complications included 1 dural tear, 2 pedicle screws malposition, and 2 epidural hematomas, in which 2 patients required reoperations.
Conclusion BETLIF with double cages provided good neural decompression and a sound environment for interbody fusion with a big cage footprint, a large amount of bone graft, endplate preservation, and segmental stability.
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Objective Surgical resection of benign intradural extramedullary tumors (BIETs) is effective for appropriately selected patients. Minimally invasive surgical (MIS) techniques have been described for successful resection of BIET while minimizing soft tissue injury. Augmented reality (AR) is a promising new technology that can accurately allow for intraoperative localization from skin through the intradural compartment. We present a case series evaluating the timing, steps, and accuracy at which this technology is able to enhance BIET resection.
Methods A protocol for MIS and open AR-guided BIET resection was developed and applied to determine the feasibility. The tumor is marked on diagnostic magnetic resonance imaging (MRI) using AR software. Intraoperatively, the planning MRI is fused with the intraoperative computed tomography. The position and size of the tumor is projected into the surgical microscope and directly into the surgeon's field of view. Intraoperative orientation is performed exclusively via navigation and AR projection. Demographic and perioperative factors were collected.
Results Eight patients were enrolled. The average operative time for MIS cases was 128 ± 8 minutes and for open cases 206 ± 55 minutes. The estimated intraoperative blood loss was 97 ± 77 mL in MIS and 240 ± 206 mL in open procedures. AR tumor location and margins were considered sufficiently precise by the surgeon in every case. Neither correction of the approach trajectory nor ultrasound assistance to localize the tumor were necessary in any case. No intraoperative complications were observed.
Conclusion Current findings suggest that AR may be a feasible technique for tumor localization in the MIS and open resection of benign spinal extramedullary tumors.
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Objective The American Society of Anesthesiologists (ASA) physical status classification has been used to risk stratify surgical candidates. Our study compares outcomes of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) procedures based on preoperative ASA physical status classification.
Methods A surgical registry was reviewed for primary, single-level MIS TLIF patients. Patients were categorized by preoperative ASA physical status classification: ASA I, ASA II, ASA III+. Perioperative complications were compared among groups. Patient-reported outcome measures (PROMs) for back pain, leg pain, physical function, and disability were recorded preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. PROM improvement from baseline (ΔPROM) and minimum clinically important difference (MCID) achievement was calculated for each timepoint and compared among groups. MCID achievement was determined as ΔPROMs that surpassed previously established MCID values.
Results Of the 487 patients, 64 had an ASA classification of I, whereas 336 had an ASA of II, and 87 had an ASA of III or greater. Rates of complications were not associated with ASA classification (all p > 0.050). Neither mean PROM scores nor ΔPROM scores were significantly associated with ASA classification at any timepoint (all p > 0.050). MCID achievement was significantly associated with ASA classification for back pain at 1 year only (p = 0.041). Overall MCID achievement was not significantly associated with ASA classification for any PROM (p > 0.050).
Conclusion While ASA classification has been commonly used to risk stratify surgical candidates for spinal procedures, patients with an ASA of III or greater may be able to achieve similar long-term outcomes following MIS TLIF given proper selection criteria.
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Objective Long-segment fusion in adult spinal deformity (ASD) is often needed, but more focal surgeries may provide significant relief with less morbidity. The minimally invasive spinal deformity surgery (MISDEF2) algorithm guides minimally invasive ASD surgery, but it may be useful in open ASD surgery. We classified ASD patients undergoing focal decompression, limited decompression and fusion, and full correction according to MISDEF2 and correlated outcomes.
Methods A retrospective study of ASD patients treated by 2 surgeons at our hospital was performed. Inclusion criteria were: age > 50, minimum 2-year follow-up, and open ASD surgery. Tumor, trauma, and infections were excluded. Patients had open surgery including focal decompression, short segment fusion, or full scoliosis correction. All patients were categorized by MISDEF2 into 4 classes based upon spinopelvic parameters. Perioperative metrics were assessed. Radiographic correction, complications and reoperation were recorded.
Results A total of 136 patients met inclusion criteria. Mean follow-up was 46 ± 15.8 months (range, 24–118 months). Forty-seven underwent full deformity correction, 71 underwent short segment fusion, and 18 underwent decompression alone. There were 24 cases of class I, 66 cases of class II, 23 cases of class III, and 23 cases of class IV patients. Patients in class I and II had perioperative complication rates of 0% and 16.7% and revision rates of 8% and 21.2% when undergoing focal decompression or limited fusion. However, class II patients undergoing full correction had higher perioperative complications rate (p = 0.03) and revision surgery rates (p = 0.047). This difference was not seen in class III patients (p > 0.05). All class IV patients underwent full correction, but they had higher perioperative complication rates (p < 0.019), comparable revision surgery rates (p = 0.27), and better radiographic realignment (p < 0.001). In addition, full deformity correction was associated with longer length of stay, increased blood loss, and longer operative time (p < 0.001).
Conclusion The MISDEF2 algorithm may help guide ASD surgical decision making even in open surgery, with focal treatment used in class I and II patients as a viable alternative and full correction implemented in class IV patients because of severe malalignment. However, class II patients with ASD undergoing full deformity correction do have higher complication rates.
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Objective While visual analogue score (VAS) metrics are among the most universally adopted patient-reported outcome measures (PROMs), there is limited research on the influence of back and leg pain on the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores. Here we assess the association of VAS back and VAS leg scores with PROMIS PF in the setting of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Secondarily, we determine if PROMIS PF is more influenced by back or leg pain.
Methods A prospective surgical registry was reviewed from May 2015 to November 2018. Inclusion criteria were primary, single-level MIS TLIFs. We excluded multilevel procedures and patients without preoperative PROMs. Pre- and postoperative PROMIS PF, VAS back, and VAS leg scores were recorded at 6 weeks, 12 weeks, 6 months, and 1 year. A Pearson correlation evaluated PROMIS PF association with VAS back and VAS leg scores. A Fisher z-test compared correlations. Linear regression evaluated PROMIS with VAS back and VAS leg scores.
Results Our cohort was comprised of 146 subjects. 40.4% were female and the average age of 51 years. VAS back demonstrated a stronger correlation than VAS leg with PROMIS PF at all timepoints. PROMIS PF scores were negatively associated with both VAS back and VAS leg at all timepoints. Fisher z-test revealed VAS back to have a stronger correlation with PROMIS PF (p = 0.025) than VAS leg.
Conclusion In the setting of MIS TLIF, physical function as evaluated by PROMIS PF, had a stronger correlation with VAS back than VAS leg at 6 months. This suggests that postoperative PROMIS PF scores may be more influenced by back pain than with leg pain.
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Biportal endoscopic transforaminal lumbar interbody fusion (TLIF) may have advantages of minimally invasive fusion surgery as well as those of endoscopic surgery. The purpose of this study was to present the biportal endoscopic TLIF technique along with video presentations and a review of the literature on this technique. Basically, the biportal endoscopic TLIF technique is similar to minimally invasive TLIF with a tubular retractor. There were 2 options in the biportal endoscopic TLIF procedures. The first was the insertion of one long TLIF cage and the other was the insertion of 2 short posterior lumbar interbody fusion (PLIF) cages. After the interbody fusion procedures, percutaneous pedicles screw fixation was performed. Biportal endoscopic TLIF achieved complete neural decompression through laminectomy and facetectomy like conventional TLIF. Endplate preparation was performed completely under a clear and magnified endoscopic view. It was also feasible to insert a large TLIF cage or 2 cages for PLIF without exiting nerve root injury. Biportal endoscopic TLIF might have the advantages of endoscopic surgery as well as minimally invasive fusion surgery. Direct neural decompression, endplate preparation under endoscopic guidance, and the insertion of a large TLIF cage or 2 PLIF cages may be the merits of biportal endoscopic lumbar fusion procedures.
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Minimally invasive techniques for transforaminal lumbar interbody fusion (MIS-TLIF) are advantageous because they allow for sufficient surgical exposure and fewer complications through a smaller incision than conventional TLIF. It could be difficult to maintain minimally invasive spine surgery following the unexpected complications after MIS-TLIF. Because MIS-TLIF is usually done via a paramedian small incision with posterior fusion using screws and rods, visualization of the surgical field is limited, and it is difficult to directly assess the neural structure without removing instrumentation. Unilateral biportal endoscopic decompression (UBE) is a rapidly growing surgical method using two 1-cm incisions that are 2 to 3 cm apart. We would like to suggest UBE as an option for immediate reoperation after MIS-TLIF because it has the advantages of targeting pathologic regions and a wide field of visualization through small wounds. The operation is independent of the existing incision from MIS-TLIF, enabling immediate revision surgery without the removal of the screws and rods. UBE has the advantages of targeting specific surgical regions and providing a wide visualization of the operation field through small incisions. UBE can be very useful for discectomy or decompression surgery as well as in immediate reoperation after MIS-TLIF.
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Objective The oblique lumbar interbody fusion (OLIF) can be done with either fluoroscopy or navigation. However, it is unclear how navigation affects the overall flow of the procedure. We wished to report on the accuracy of this technique using navigation and on how navigation affects surgical time and complications.
Methods A retrospective review was undertaken to evaluate patients who underwent OLIF using spinal navigation at University of California San Francisco. Data collected were demographic variables, perioperative variables, and radiographic images. Postoperative lateral radiographs were analyzed for accuracy of cage placement. The disc space was divided into 4 quadrants from anterior to posterior, zone 1 being anterior, and zone 4 being posterior. The accuracy of cage placement was assessed by placement.
Results There were 214 patients who met the inclusion criteria. A total of 350 levels were instrumented from L1 to L5 using navigation. The mean follow-up time was 17.42 months. The mean surgical time was 211 minutes, and the average surgical time per level was 129.01 minutes. After radiographic analysis, 94.86% of cages were placed within quartiles 1 to 3. One patient (0.47%) underwent revision surgery because of suboptimal cage placement. For approach-related complications, transient neurological symptoms were 10.28%, there was no vascular injury.
Conclusion The use of navigation to perform OLIF from L1 to L5 resulted in a cage placement accuracy rate of 94.86% in 214 patients.
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OBJECTIVE This retrospective study of 57 patients was performed to evaluate the therapeutic effectiveness of percutaneous endoscopic surgery by using interlaminar approach (ILA) in symptomatic lumbar disc herniation (LDH) at L5-S1. METHODS Visual analogue pain score (VAS) and Oswestry disability index (ODI) were used to assess the clinical outcome. All assessment was done on 1 day before the operation, 3 days, 3months and 12months after the operation. RESULTS The mean preoperative back and leg VAS was decreased from 5.6+/-1.4, 8.5+/-1.7 to 1.8+/-1.2, 1.5+/-1.3 at 3 days, 1.2+/-1.1, 1.8+/-1.7 at 3 months, and 1.4+/-1.7, 1.6+/-1.3 at 12 months after the operation. Mean preoperative ODI score was improved from 46.8+/-22.4% to 17.7+/-11.6% at 3 days, 15.3+/-10.1% at 3 months, and 16.2+/-9.3% at 12 months after the operation. There were 2 cases of surgical failure due to dural tearing and calcified disc. One patient presented with transient paresthesia postoperatively. Two patients showed the recurrent disc herniation at the same level and same side, and underwent second open surgery. CONCLUSION The present study revealed that percutaneous endoscopic surgery by using ILA is an effective surgical modality for the selective cases of LDH at L5-S1.
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Feasibility of Unilateral Approach for Bilateral Decompressive Endoscopic Spinal Surgery for Lumbar Stenosis to Improve Back and Leg Pain: A Consecutive Single-Center Series of 60 Patients Azizul Akram Salim, Abdul Halim Yusof, Joehaimey Johari, Mohd Imran Yusof Frontiers in Surgery.2020;[Epub] CrossRef
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