Background: The present video article describes transforaminal lumbar interbody fusion (TLIF), a common spine procedure, performed with use of a less common technique-utilizing a biportal endoscopic spine surgery (BESS) approach. This procedure is performed for the treatment of degenerative spondylolisthesis.
Description: The procedure is performed with the patient in the supine position. An endoscopic portal and a working portal are developed at the level of interest. Fluid is pumped into the working space with use of a standard arthroscopy tower. Using the camera endoscope to visualize; shavers, burrs, and a Kerrison rongeur are passed through the working portal to clear the disc and to create space for insertion of an interbody device. Trial TLIF cages are placed through the disc defect, which can be observed both directly and on radiograph. An appropriate final implant is placed, and percutaneous pedicle screws are typically placed at the instrumented level.
Alternatives: Alternatives include nonoperative treatment with physical therapy, weight loss, and/or corticosteroid injection. Surgical options for degenerative spondylolisthesis include lumbar decompression and instrumented fusion. Interbody fusion can provide indirect decompression and increase fusion success rates.
Rationale: This procedure utilizes a minimally invasive endoscopic approach with small incisions, resulting in decreased muscle trauma, which has been shown to reduce postoperative pain and recovery time.
Expected outcomes: Outcomes of the biportal endoscopic technique are similar to those reported for open or conventional TLIF, with the benefit of improved postoperative pain compared with those procedures.
Important tips: Position the patient on a Jackson frame with hip and thigh pads to maintain lordosis for the fusion procedure.Utilize fluoroscopic guidance when determining starting points. The goal is for the portals to be centered over the ipsilateral pedicles of the targeted level.It is best to maintain the camera portal in your non-dominant hand and the working portal in your dominant hand.Stand on the side that the patient reports has worse pain.When dissecting, there is no need to go to the lateral edge of the facet; going further can result in excessive bleeding and decreased visualization.
Acronyms and abbreviations: BESS = biportal endoscopic spine surgeryTLIF = transforaminal lumbar interbody fusionMRI = Magnetic Resonance ImagingPEEK = polyetheretherketoneK-wire = Kirschner wireCT = computed tomographyPROM = patient-reported outcome measureVAS = visual analog scaleODI = Oswestry Disability Index.
Background: Endoscopic decompression of lumbar spinal stenosis has been gaining popularity as the least invasive of several minimally invasive surgical treatment options. This procedure offers similar outcomes to those of conventional open procedures; however, endoscopic procedures are technically demanding and involve a substantial learning curve. The typical endoscopic approach is a "uni-portal" approach that utilizes a special spinal endoscope and endoscopic instruments. However, a "bi-portal" approach has been developed more recently, which utilizes a regular arthroscope and the same type of instruments that are utilized in open spine surgery.
Description: The patient is placed in a prone position under general anesthesia with electromyographic neuromonitoring. The primary portal is made at the interlaminar space with use of an obturator and a working cannula. The side of the approach is chosen according to the side of symptoms and radiographic compression. A 15°-angle, 10-mm external diameter spinal endoscope is introduced through the cannula, and the interlaminar space is exposed with use of a radiofrequency bipolar probe. Cranial and caudal laminectomies are performed with use of a 5-mm endoscopic high-speed burr or endoscopic osteotomes. A 5- to 7-mm accessory portal can be created 2 to 2.5 cm caudally (for the left side) or cranially (for the right side) on the same line as the primary portal in order to enable use of a short-distance dissector, curets, and/or osteotomes. Decompression is performed at the central and ipsilateral lateral recess with use of an endoscopic drill, various sizes of Kerrison rongeurs, and curets. Finally, the contralateral lateral recess is accessed by tilting the working cannula, and decompression is performed until the contralateral traversing nerve root and medial border of the caudal pedicle are exposed.
Alternatives: Alternative surgical treatments include conventional open microscopic laminectomy and decompression and other minimally invasive surgical options involving the use of a tubular retractor or similar minimally invasive retractor systems.
Rationale: The development of endoscopic spine surgery has expanded indications from simple lumbar discectomy to lumbar central, foraminal, and extraforaminal stenosis, as well as revision surgery. However, the endoscopic approach to lumbar spinal stenosis is challenging and has not been widely adopted because of the steep learning curve and technical difficulty. A fully endoscopic, uni-portal approach is the least invasive option for lumbar decompression because all access and decompression procedures are performed within the limited space inside the working cannula. However, this "full-endoscopic" approach may limit the access angle to the surgical field because the working channel is fixed by the trajectory of the endoscope. Also, spinal endoscope-specific, long, small-di
Background: Broström-Gould surgery is the gold standard operative treatment of chronic lateral ankle instability. In cases of failed nonoperative treatment, the Broström-Gould repair aims to improve lateral ankle stability via anatomic repair and the overlapping of the anterior talofibular ligament (ATFL) and calcaneofibular ligament, with reinforcement of the ATFL by the extensor retinaculum1-3. Lateral ankle ligament injuries typically present with additional pathologies, including hindfoot varus, peroneal tendon lesions, and tarsal coalition4,9. Previous studies have hypothesized that treatment of ligamentous injuries with concurrent osteotomy of the calcaneus can correct altered stress loading, aiding in the prevention of future injuries and complications4,9,10. The presently described technique is a modification of the Broström-Gould technique that allows the addition of a calcaneal osteotomy without additional incisions.
Description: Patients are positioned supine with a foam bump under the torso on the ipsilateral side and bone foam to elevate and pronate the operative foot. The incision begins 4 cm proximal to the tip of the lateral malleolus, posterior to the peroneal tendons, and ends 1 cm proximal to the base of the fifth metatarsal. Subcutaneous tissues are bluntly dissected, and neurovasculature is protected. Tenosynovectomy of the peroneus longus and brevis is performed. During the tenosynovectomy, care must be taken to avoid damaging the sural nerve, which is posterior to the tendon sheath. Hohmann retractors are utilized to better visualize the lateral calcaneus. Calcaneal osteotomy is performed with use of a micro saw for the lateral two-thirds and with use of an osteotome for the medial third. In the example case, a single 7.0-mm cancellous screw was utilized for fixation; however, 2 screws can be utilized to provide greater rotational stability. The ATFL is elevated from the talus and lateral malleolus. The lateral malleolus is freed of periosteum with use of a rongeur. Two 3.5-mm suture anchors (each with 4 needles) with number-0 FiberWire (Arthrex) are inserted through the tip of the lateral malleolus. The suture material is passed through the ATFL and calcaneofibular ligament to tighten the ligaments. The superior extensor retinaculum is advanced over, and sutured to, the ATFL. The incision is closed in layers, and a short leg splint is applied with the foot in slight eversion and dorsiflexion. Patients are transitioned from the splint to a short leg non-weight-bearing cast or boot for 6 weeks. At 6 weeks postoperatively, the patient is transitioned to a walking boot for progressive weight-bearing per a physical therapy protocol.
Alternatives: Nonoperative treatment of chronic ankle instability involves rest and physical therapy with bracing or the use of orthotics. Operative treatments are performed when nonoperative treatment
Background: Fibrovascular bands are currently considered the most relevant cause of deep gluteal pain syndrome, according to various reports1-6. This condition often exists concurrently with hypertrophic bursae in the peritrochanteric space due to the same inflammatory process because of the anatomical continuity between both spaces7-10. In such cases, we perform bursectomy of the lateral space and resection of fibrovascular bands in the posterior space. Our technique has shown good results, without requiring a piriformis tenotomy11. In the present video article, we demonstrate our endoscopic technique with modified portals, which addresses both spaces providing complete management of the pathology.
Description: The patient is placed in the supine position with the operative limb placed freely on the operative field for easy manipulation. The distance between the anterior and posterior borders of the greater trochanter at the level of the vastus tuberosity is demarcated. This distance is projected lengthwise onto the posterior third of the femur, delineating the proximal posterolateral accessory (PPLA) and distal posterolateral accessory (DPLA) portals. Under direct visualization, the DPLA portal is made, followed by the PPLA portal. A wide bursectomy in the peritrochanteric space is performed, followed by a partial tenotomy of the distal insertion of the gluteus maximus. Once in the subgluteal space, fibrovascular adhesions in the piriformis branch of the inferior gluteal artery are carefully released. Once the nerve has been identified, resection of the fibrovascular bands is performed in the subgluteal space, and the recovery of epineural circulation and free excursion of the nerve are evaluated.
Alternatives: Nonoperative treatment is a valid alternative as the initial management of deep gluteal pain syndrome. If there is a poor response to nonoperative treatment or a chronic pathology of both compartments, surgical treatment should be considered. Open procedures have been described, which are more invasive and could generate a greater inflammatory response3. Several reports have described the difficulty of endoscopic treatment in both the peritrochanteric and subgluteal spaces, which necessitates the use of accessory portals for management of hypertrophic bursae and release of the sciatic nerve12,14,17,18. Routine piriformis tenotomy has also been described for use alongside resection of fibrovascular bands4,12-16.
Rationale: This endoscopic technique allows access to the peritrochanteric and subgluteal spaces through 2 portals. The locations of, and method for, using these portals have been previously established in cadaveric studies. We observed the presence of fibrovascular bands in all of the specimens under study. In our medium-term clinical study, resection of the fibrosis from the l
Background: Shoulder internal rotation contracture is one of the most common problems observed in patients with residual brachial plexus birth injury1,2. Minimally invasive subscapularis release is a simple extra-articular procedure that involves the release of the subscapularis origin from the undersurface of the scapula. This procedure addresses the contracture and has been shown to result in remodeling of the glenohumeral joint when concomitant conjoined tendon transfer is performed3.
Description: The procedure is performed with the patient in the lateral decubitus position. The procedure is initiated by elevating the medial border of the scapula by performing internal rotation and forward flexion of the arm. A 1-cm incision is made at the junction of the upper one-third and lower two-thirds of the medial border of the scapula, and space for insertion of a periosteal elevator is made with a hemostat. Sequentially, 5-mm and 10-mm periosteal elevators are inserted and are slid in a clockwise direction to release the muscle fibers from their origin on the undersurface of the scapula. After circumferential release, the internal rotators and the anterior shoulder joint capsule are stretched with gentle and progressive external rotation of the shoulder joint. A postoperative shoulder spica is applied with the shoulder in the corrected position.
Alternatives: Operative alternatives to this technique include anterior open reduction of the glenohumeral joint with release of the pectoralis and subscapularis at their humeral insertions4,5. Arthroscopic subscapularis and anterior capsular release has also been described. Other extra-articular techniques, such as an open subscapularis slide from the lateral scapular border, have been described6,7.
Rationale: Losing strength of internal rotation at the shoulder is the main concern when releasing the subscapularis from its insertion. Internal rotation strength is maintained following this technique because the muscle-tendon unit ratio is unchanged. Benefits of performing this technique from the medial border include easier access to the tight superomedial septae of the subscapularis and reduced likelihood of iatrogenic injury to circumflex scapular neurovascular pedicle.
Expected outcomes: Significant improvement in shoulder abduction and external rotation range (both passive and active) can be expected postoperatively. In a published series of 45 patients, the mean improvements in passive and active external rotation were 80° and 43°, respectively. Mean shoulder abduction improved from 101° preoperatively to 142° postoperatively. The aggregate 5-point Mallet Score improved from 12.8 points preoperatively to 18.5 points postoperatively. Glenohumeral remodeling can be expected in young children with Waters type-IV glenohumeral joint changes. Older pediatri
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