European Spine Journal最新文献

Background: The Hoffmann (H-) reflex is a monosynaptic electrophysiological response that reflects S1-root integrity. Although widely used in experimental and in clinical outpatient neurophysiological testing, its intra-operative application during endoscopic lumbar surgery is rarely reported. We present the first real-time documentation of H-reflex normalization immediately after endoscopic decompression of an acute L5-S1 disc herniation.

Case description: A 49-year-old woman presented with acute right-sided S1 radiculopathy (ankle dorsiflexion/plantar-flexion MRC grade III; hallux extension grade I). MRI showed a large, right sub-articular L5-S1 disc extrusion compressing the S1 nerve root. Unilateral biportal endoscopic discectomy was performed under general anesthesia with multimodal intra-operative neuromonitoring (MEPs, free-run EMG, and continuous tibial-nerve H-reflex). Baseline recordings revealed marked side-to-side asymmetry: right-leg MEP amplitudes were depressed, and the right H-reflex was low and unstable. During foraminoplasty and fragment removal, a sudden, sustained 100% surge in right H-reflex amplitude occurred, coincidence with root decompression, while MEPs remained unchanged. Free-run EMG discharges abated after the H-reflex improved. Post-operative recovery was uneventful. At 2 months the patient demonstrated near-complete motor recovery (MRC IV-V) and full pain relief.

Conclusion: Continuous H-reflex monitoring provided an immediate, sensitive marker of S1-root decompression when conventional MEPs failed to reflect functional recovery. This single-case experience supports the feasibility and potential prognostic value of adding H-reflex surveillance to the neuromonitoring toolkit for endoscopic lumbar surgery. Prospective studies in larger cohorts are warranted to validate threshold criteria, refine stimulation parameters, and determine cost-effectiveness.

Purpose: Endoscopic spine surgery (ESS) may reduce perioperative risks traditionally associated with obesity in open lumbar procedures. This study evaluated 90-day complications, healthcare utilization, and insurer-payments in obese versus non-obese patients undergoing endoscopic lumbar decompression.

Methods: A national administrative database was queried for adults undergoing endoscopic lumbar decompression from January 2017 to April 2023. Patients with trauma, neoplasm, or infection within 90-days preoperatively or < 90-day follow-up postoperatively were excluded. Cohorts were stratified by obesity (body mass index > 30 kg/m²). Demographics, 90-day complications (any, severe, minor), and healthcare utilization (emergency department visits, readmissions, physical therapy) were compared using univariable tests and multivariable logistic regression adjusting for age, sex, Elixhauser Comorbidity Index, smoking, type 2 diabetes, hypertension, obstructive sleep apnea, and surgical indication (stenosis vs. disc herniation). Ninety-day insurer payments were compared using a Wilcoxon rank-sum test.

Results: A total of 1,989 patients met criteria (1618 non-obese; 371 obese). On univariable and multivariable analysis, obesity was not associated with increased odds of any 90-day complication or healthcare-utilization outcome. Median (25th quartile, 75th quartile) 90-day insurer-payments were $2563 ($1074, 5124) for non-obese patients and $3310 ($1572, 5784) for obese patients (p = 0.0003).

Conclusion: This study demonstrated obesity was not associated with increased odds of 90-day complications or healthcare utilization in the adjusted models. However, obese patients incurred higher insurer-paid costs, underscoring important clinical and policy considerations. As ESS becomes increasingly utilized, future work should examine patient-reported outcomes, longer-term complications, and reoperation-free survival in obese patients as well as in populations with other comorbidities.