International Journal of Spine Surgery最新文献

Introduction: Recurrent lumbar disc herniation (rLDH) remains a challenge in spinal surgery. This systematic review analyzes the use of transforaminal endoscopic discectomy (TFED) for the treatment of rLDH.

Methods: A comprehensive search of 4 electronic databases, including PubMed, Google Scholar, Science Direct, and Cochrane, was conducted. Studies that analyzed the use of TFED to manage rLDH were included in the review. The primary outcomes assessed in these studies encompassed postoperative complications, length of surgery, blood loss, duration of hospitalization, pain scores, and recurrence rates.

Results: Six studies met the inclusion criteria, comprising 405 patients. The mean duration of surgery was 24 to 158.74 minutes with intraoperative estimated blood loss of 0 to 34.8 mL. The mean recurrence rate was 4.4% with a 0.7% progression to fusion during the follow-up period. Durotomy was seen in 2.7% of cases. There was a 0.1% incidence of temporary nerve irritation with no permanent nerve injuries reported.

Conclusions: TFED for the management of rLDH is a lateral minimally invasive technique that avoids going through scar tissue, hence associated with a short duration of surgery, minimal to no measurable blood loss, and a very low complication rate. The few studies in the literature seem to suggest that TFED should be considered in patients with rLDH without segmental instability who meet the criteria for surgery.

Level of evidence: 5:

Background: The effects of epidural steroid (ES) administration following open or minimally invasive surgery lumbar discectomy have been extensively studied. However, no research has investigated the impact of steroids following the unilateral biportal technique endoscopic lumbar discectomy (UBE-D) for lumbar disc herniation. This study aims to evaluate the efficacy of ES administration in controlling postoperative pain and disability scores following UBE-D for single-level lumbar disc herniation.

Methods: This double-blind, randomized, placebo-controlled trial was conducted between June 2021 and June 2023. Eighty-two patients were assessed, and 60 were eligible and randomized to receive either ES (n = 30) or saline (placebo; n = 30) after UBE-D. The Outcome measures included visual analog scale scores for pain, Oswestry Disability Index scores, morphine consumption over 24 hours, serum C-reactive protein levels, and the occurrence of complications over a 6-month follow-up period.

Results: The baseline characteristics were comparable between the 2 groups, with no significant differences observed. Analysis of visual analog scale scores for back and leg pain, as well as Oswestry Disability Index scores, at various postoperative time points (6 hours, 12 hours, 24 hours, 2 weeks, 6 weeks, 3 months, and 6 months), showed no statistically significant differences between the ES and placebo groups (P values ranged from 0.47-0.94). Additionally, no significant differences were found in morphine consumption within the first 24 hours postoperatively (P = 0.85), length of hospital stay (P = 0.36), or C-reactive protein levels at 24 hours and 3 weeks postoperatively (P values ranged from 0.54-0.79) between the 2 groups. Importantly, no postoperative or steroid-related complications were reported in either group within the 6-month follow-up period.

Conclusions: ES administration after UBE-D did not significantly reduce postoperative pain, disability scores, or morphine consumption compared with placebo. The findings suggest that routine use of ESs in this context may not provide additional benefits.

Clinical relevance: Clinicians should reconsider the use of epidural steroids as part of standard postoperative management after UBE-D, as the lack of significant improvement in patient outcomes indicates that alternative pain management strategies may be more effective.

Level of evidence: 1:

Background: Endoscopic unilateral laminectomy for bilateral decompression (ULBD) is gaining attention as a minimally invasive procedure for treating spinal stenosis. However, comprehensive studies on its outcomes remain limited.

Purpose: This study aims to evaluate the changes in radiologic parameters and clinical outcomes associated with endoscopic ULBD for treating spinal stenosis.

Methods: A retrospective study was conducted on 53 patients with central lumbar spinal stenosis who underwent endoscopic ULBD decompression surgery. Pre- and postoperative visual analog scale and Oswestry Disability Index scores were collected to assess the impact on activities of daily living. Parameters such as operation time, intraoperative blood loss, postoperative drainage volumes (first and second day), total hospital stay, and postoperative hospital stay were recorded. Additionally, pre- and postoperative imaging changes were documented, and MacNab functional scores were evaluated at 6 months postoperatively to assess clinical efficacy.

Results: No nerve injuries occurred during the operation. Two cases of cerebrospinal fluid leakage were successfully treated with pressure dressings, and no postoperative complications such as incision infection or dehiscence were observed. At 6-month follow-up, postoperative visual analog scale scores and Oswestry Disability Index showed significant improvement compared with preoperative levels (P < 0.05). Postoperative lumbar computed tomography images revealed a statistically significant enlargement in the anterior-posterior diameter of the spinal canal and the diameter of the bilateral lateral recesses (P < 0.05). All patients experienced either improvement or resolution of clinical symptoms. The MacNab functional scores at the 6-month follow-up indicated excellent outcomes in 37 cases, good in 15 cases, and fair in 1 case, resulting in an overall good rate of 98.11%.

Conclusions: This study demonstrates that endoscopic ULBD can provide favorable outcomes for single-segment central lumbar spinal stenosis under local anesthesia at a relatively low cost.

Objectives: Lumbar lateral transpsoas interbody fusion is a powerful technique for addressing various spinal pathologies, enabling effective anterior column reconstruction. A critical decision in performing this procedure is selecting the appropriate side for the approach to the lumbar spine, whether in the prone or lateral decubitus position. This article outlines a decision-making framework to assist surgeons in deciding the optimal approach for direct lateral surgery to achieve the desired surgical outcome.

Study design: Technical note for lateral spinal fusion approaches.

Methods: The article explores anatomical considerations, surgical indications, and patient-specific factors relevant to the choice of approach in lateral lumbar transpsoas fusions. Through case examples, various factors influencing side selection are discussed.

Results: While many traditionally learn and perform direct transpsoas fusions through left-sided approaches, it is essential to consider pertinent anatomical features or variations, surgical pathologies, and patient-specific symptoms. The optimal side of the approach may vary based on these factors and remain key considerations for a holistic decision.

Conclusions: A thoughtful assessment of the factors highlighted here can significantly improve the likelihood of a successful prone or lateral transpsoas fusions. Although comprehensive studies are needed to better guide decisions between right- and left-sided approaches, surgeons currently rely on their clinical judgment and expertise to navigate these choices to maximize safety and efficacy for each patient.

Clinical relevance: This study highlights minimizing surgical risk through holistic patient-centered decision-making.

Level of evidence: 4:

Background: Full endoscopic spine surgery (FESS) champions a rapid recovery and a low rate of overall complications. However, its efficacy in geriatric patients that might yield additional benefits from minimized invasiveness remains underexplored.

Methods: A multi-institutional prospective cohort study was conducted involving patients undergoing elective lumbar FESS. Participants were categorized into nongeriatric (18-69 years old) and geriatric (≥70 years old) groups. Studied variables included demographics, medical comorbidities, operative details, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI). A mobile application was leveraged to collect real-time data pre- and postoperatively.

Results: One hundred and sixty-four patients were included and divided into nongeriatric (N = 125) and geriatric (N = 39) cohorts. No group differences were observed between sex (P = 0.404), body mass index (P = 0.372), procedure duration (P = 0.350), or blood loss (P = 0.384). Nongeriatric patients received discectomy more frequently (P < 0.001), while older patients underwent more decompressive procedures (P < 0.001). Characterization of pain and functional outcome revealed that nongeriatric and geriatric patients follow a similar recovery trajectory and both appreciate significant improvements from baseline to 3 months postoperatively (P < 0.001 for VAS back, VAS leg, and ODI). There were no differences in the rate of improvement between age groups at any time point (P > 0.05 for VAS back, VAS leg, and ODI).

Conclusions: FESS significantly improves pain and function in both geriatric and nongeriatric adults with degenerative lumbar conditions, with no difference in the degree of improvement between groups.

Clinical relevance: These findings underscore the efficacy of FESS as a minimally invasive surgical option for elderly patients. Mobile application technology is useful for collecting patient-reported data in spine surgery clinical research.

Level of evidence: 3:

Background: Direct vertebral rotation (DVR) effectiveness in improving scoliosis correction outcomes remains unclear and requires further investigation.

Purpose: This study aimed to evaluate the effectiveness of short and extended fusion techniques using en-bloc DVR in correcting adolescent idiopathic scoliosis (AIS) classified as Lenke 5 curve (5C).

Materials and methods: This retrospective study included 90 randomly selected AIS patients with Lenke 5C who underwent posterior spinal instrumentation surgery using en-bloc DVR between 2014 and 2021. Patients were divided into 2 groups: (1) extended fusion, Group A (n = 40): upper instrumented vertebra = upper-end vertebra +1 or +2 or (2) short fusion, Group B (n = 50): upper instrumented vertebra = upper-end vertebra. Radiographic parameters were compared preoperatively and at postoperative follow-ups of 6 months, 3 years, and more.

Results: The mean follow-up duration was 37.5 ± 6 months for Group A and 40.0 ± 8 months for Group B (P = 0.596). The coronal balance correction rate was comparable between the 2 groups, with no significant differences observed at the final follow-up. Significant differences were noted in the fused segment, with Group A having an average fusion rate of 6.8 ± 0 compared with 6.3 ± 0 in Group B (P = 0.001). TK and lumbar lordosis measurements at the final follow-up did not show significant differences between the groups. However, substantial differences were observed in rib hump correction, with Group A demonstrating a better correction rate than Group B at both 6 months and the last follow-up (P = 0.001 for both time points).

Conclusion: Selective DVR spinal instrumentation effectively corrects AIS Lenke 5C. However, extended fusion demonstrates more efficient correction and greater improvement in the patient's cosmetic appearance, including better thoracic curve correction, rib hump correction, and shoulder balance, compared with short-level fusion.

Background: Despite its clinical importance, osteoporosis remains underdiagnosed, particularly in spinal surgery patients, where bone quality affects surgical outcomes. Existing screening methods are often costly or inaccessible, highlighting the need for a simpler alternative.

Objective: The purpose of the present study was to assess the canal bone ratio (CBR) as a predictive tool for bone mineral density (BMD) in patients with lumbar degenerative diseases and establish a specific cutoff value for diagnosing osteoporosis.

Methods: A retrospective analysis was conducted of 102 patients older than 50 years who underwent lumbar spine surgery at our institution from 2016 to 2024. Eligible patients underwent dual-energy x-ray absorptiometry (DXA), full-spine x-ray imaging, and computed tomography within 3 months before their surgery. CBR measurements were obtained by analyzing x-ray images for the inner and outer diameters of the femoral shaft 7 cm below the lesser trochanter. The Youden index based on T score thresholds from DXA scans determined the optimal cutoff value for diagnosing osteoporosis using CBR.

Results: The cutoff value for CBR was 0.501, which was identified by analyzing BMD data from the lumbar spine and femoral neck regions. This cutoff demonstrated a strong correlation with low BMD scores, exhibiting a sensitivity of 0.656 and a specificity of 0.671 for identifying osteoporosis among the included patients. Additionally, CBR values negatively correlated with T scores and computed tomography-based Hounsfield units values obtained from lumbar and femoral regions, reinforcing its validity as a screening tool.

Conclusion: CBR correlates with T scores from DXA and Hounsfield units values, establishing itself as a feasible and practical screening tool for osteoporosis in patients with lumbar degenerative disease.

Clinical relevance: CBR facilitates early intervention and improves management in populations at high risk for bone fragility.

Level of evidence: 3:

Background: Lumbar interbody fusion with screw fixation is a standard treatment for lumbar degenerative diseases. While full-endoscopic lumbar interbody fusion is minimally invasive, it utilizes smaller cages compared with the oblique lateral interbody fusion (OLIF) technique, which offers superior biomechanical support. To merge full-endoscopic lumbar interbody fusion minimal invasiveness with OLIF's advantages, we developed a novel instrument, the Single Beak Adjustable Cage Glider, to facilitate OLIF cage insertion via the full-endoscopic trans-Kambin triangle approach. This note and case report introduce this alternative solution.

Case presentation: In a case of L4 to L5 spondylolisthesis, we performed fluoroscopy-guided uniportal facet-preserving trans-Kambin endoscopic fusion surgery. We initially installed percutaneous pedicle screws and rods to correct the anterolisthesis, then established the endoscopic trans-Kambin approach. After releasing the disc-endplate junction, the nerve root was mobilized and protected by the beak of the cage glider. The disc space was cleared, and a 22 × 40 × 12 mm interbody device was inserted through the cage glider under fluoroscopic guidance. The integrity of the exiting nerve root was confirmed with an endoscope.

Results: Postoperatively, the patient experienced significant improvements in both low back pain and bilateral lower limb numbness. Muscle strength in both lower limbs returned to baseline, and the patient was able to walk independently without assistive devices. Follow-up radiographs and computed tomography scans showed a well-reduced regional lordotic angle, and the axial computed tomography view confirmed adequate decompression of the spinal canal while preserving the facet joints.

Conclusions: The Single Beak Adjustable Cage Glider enables precise positioning of the OLIF cage through the Kambin triangle lumbar interbody fusion approach, avoiding nerve root injury and preserving facet joints. This technique reduces surgical trauma and maintains spine biomechanics, potentially improving patient outcomes.

Clinical relevance: This technique potentially reduces the cage subsidence rate.

Level of evidence: 5:

Background: Surgeons' reliance on intraoperative fluoroscopy during vertebroplasty procedures has raised concerns regarding the level of patient and surgeon radiation. Navigation systems have shown a potential to reduce the overall patient and medical staff exposure during dose exposure studies. The main objective of this study was to determine whether the Surgivisio platform (eCential Robotics, France), a unified imaging and navigation platform, lowers the patient dose during routine clinical usage as compared with published fluoroscopy and other navigation options that are published in the literature.

Methods: To accomplish this, we evaluated the radiation exposure dose during routine vertebroplasty procedures in which the surgeon was not trying to limit radiation and then compared the results to best-case dose assessment studies. Since a decreased radiation dose can lead to decreased image quality, we also quantified the surgeon's perception of image quality and ease of use. Two hundred and seventy-four Surgivisio-assisted vertebral augmentations were pooled from a broader 1694-patient protocol (not focusing on radiation outcomes) and analyzed.

Results: We measured a median dose-area product and effective dose equal to 3.47 Gy.cm² and 0.81 mSv. The 3-dimensional image acquisitions contributed to 56.3% of the total dose-area product. When screening the literature, fluoroscopy dose levels (8.37-15.1 Gy.cm²) and navigation dose levels (9.12-9.83 Gy.cm²) were generally higher than those delivered with the Surgivisio protocol. Surgeon satisfaction for image quality and overall system experience was 95.8% and 85% for ease of use.

Conclusions: The Surgivisio platform provided surgeons with high-quality images and ease of use. Since the surgeon is out of the room during the 3-dimensional image acquisition, this also substantially decreased their radiation exposure. This study demonstrates the efficiency of the Surgivisio platform to assist surgeons during vertebral augmentations, as the reported radiation levels are reduced in routine cases compared with published scenarios reported for other guidance methods.