Asian Spine Journal最新文献

Study design: Retrospective study.

Purpose: To compare the clinical and radiographic outcomes of unilateral biportal endoscopy-assisted extraforaminal lumbar interbody fusion (BE-ELIF) and oblique lateral interbody fusion (OLIF).

Overview of literature: OLIF is widely recognized for its strong realignment capability, achieved through placing a large interbody cage, and its favorable clinical outcomes with indirect decompression. ELIF, similar to OLIF, does not entail exposure of the spinal canal. At our hospital, BE-ELIF involves removing the superior articular processes on both sides, inserting two expandable cages, and performing indirect canal decompression. BE-ELIF is a lumbar interbody fusion technique that provides indirect decompression similar to OLIF. However, no studies have compared the efficacy of ELIF performed under unilateral biportal endoscopy with that of OLIF.

Methods: Forty-nine adults who underwent single-level L4/5 interbody fusion for degenerative spondylolisthesis were divided into BE-ELIF (n=27) and OLIF (n=22) groups based on the surgical approach used. Clinical outcomes were assessed using the Visual Analog Scale and the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). Radiographic parameters, including distance of spondylolisthesis, disc height, segmental lordosis, lumbar lordosis, pelvic tilt, and sagittal vertical axis, were evaluated preoperatively and at final follow-up.

Results: OLIF provided significantly better relief of pain in lower limbs and buttocks at 1-year follow-up. No significant between-group differences were observed in JOABPEQ domains. BE-ELIF resulted in greater improvements in spondylolisthesis distance and disc height, while other parameters did not differ significantly between the two groups.

Conclusions: For L4/5 degenerative spondylolisthesis, BE-ELIF demonstrated superior spondylolisthesis reduction and disc height improvement than OLIF. Although BE-ELIF was associated with some inferior clinical outcomes, it provided satisfactory results, effective realignment, and a low complication risk.

Unilateral biportal endoscopy (UBE) has revolutionized minimally invasive spinal surgery, offering enhanced visualization and reduced recovery times. However, the steep learning curve and technical complexity require a structured training framework. This narrative review proposes a 10-tier difficulty progression framework for UBE designed to guide novice surgeons through incremental skill acquisition. Each tier corresponds to specific procedures with escalating challenges spanning lumbar, cervical, and thoracic pathologies. The proposed framework begins with foundational lumbar procedures, such as ipsilateral recess decompression and discectomy, and advances to more intricate techniques, such as transforaminal lumbar interbody fusion. Transitioning to the cervical and thoracic regions requires mastery of earlier tiers, emphasizing precision in handling delicate anatomical structures. These challenges include achieving proficiency in mobilizing nerve roots, minimizing spinal cord manipulation, and mastering advanced decompression techniques. Evidence from learning curve analyses, including cumulative sum methodologies, underscores the importance of tailored training to reduce complications and optimize outcomes. By standardizing the progression of UBE procedures, this framework aims to enhance surgical safety, improve patient outcomes, and facilitate their widespread adoption. Future research should focus on validating this framework by using clinical trials, training feedback, and long-term patient data. Ultimately, this 10-tiered approach provides a roadmap for mastering UBE, addressing the growing demand for minimally invasive spinal surgery with precision and confidence.

Study design: Retrospective analysis of a prospective study.

Purpose: The study aimed to evaluate and compare the clinical results of three surgical techniques for the resection of the hypertrophic ligamentum flavum in patients with lumbar stenosis.

Overview of literature: Lumbar spinal stenosis is a common degenerative condition. Biportal endoscopic surgery is a modern technique that has gained popularity in recent years. Although various techniques have been proposed for resecting the ligament, no studies have identified the most superior method.

Methods: This retrospective study enrolled patients with severe lumbar canal stenosis who underwent biportal endoscopic "Z" technique decompression between 2021 and 2023. Patients with any clinical or radiological signs of spondylolisthesis were excluded. The resection of the ligamentum flavum was classified into piecemeal resection, one-piece "butterfly" resection, and the novel variant "two-wings" or two-piece resection. Several demographic and clinical statistical variables were collected, with a specific focus on surgical time, postoperative complications, and clinical outcomes.

Results: Ninety lumbar decompression surgeries were performed on 70 patients. The patients were divided into the butterfly group (en bloc) with 27 levels, "two-wings" group with 35 levels, and "piecemeal" group with 28 levels. No significant differences in demographics or clinical variables were found among the three groups. However, piecemeal resection was associated with a higher incidence of dural tears and a longer surgical time (p<0.05). In contrast, en bloc resection, particularly in the two-wing group, demonstrated the best surgical times without an increase in complication rates.

Conclusions: The results revealed that removing the ligamentum flavum en bloc (either in two pieces or one) may reduce the surgical time and incidence of dural tears. Randomized and prospective studies are warranted to establish definitive conclusions.

Study design: Retrospective study.

Purpose: This study aimed to introduce biportal endoscopic lumbar interbody fusion (BELIF) using a large polyetheretherketone (PEEK) cage, describe the surgical technique, and evaluate its clinical and radiological outcomes.

Overview of literature: Biportal endoscopic techniques have emerged as a promising approach in spine surgery, and BELIF is reported to have good surgical outcomes. The use of large PEEK cage in lumbar interbody fusion has gained attention owing to their potential biomechanical advantages. Despite the potential benefits of BELIF with large PEEK cages, studies on its effectiveness and safety are lacking.

Methods: Twelve consecutive patients underwent single-level BELIF for lumbar degenerative disease. The technique involves two small portals, one each for endoscopy and instruments. A large PEEK cage was inserted through a posterolateral approach. Clinical outcomes, including a Visual Analog Scale for back and leg pain, the Oswestry Disability Index, and the European Quality of Life-5 Dimensions, were assessed preoperatively and at 3, 6, and 12 months postoperatively. Fusion status was evaluated using computed tomography (CT) at 12 months.

Results: The mean patient age was 69.1±7.2 years, with operations predominantly at the L4-5 level (83%). The mean operation time was 149.7±37.4 minutes, and the average surgical drainage was 201.4±59.7 mL. All clinical outcome measures showed significant improvement at 12 months (p<0.05). Fusion was achieved in 83.3% of patients. Cage subsidence (>1 mm) occurred in one patient (8.3%). Complications included one case each of incidental durotomy, wrong-site surgery, and wound dehiscence and three cases of asymptomatic hematoma.

Conclusions: BELIF using a large PEEK cage demonstrated promising clinical outcomes and fusion rates. The technique offers enhanced visualization and enables direct neural decompression while minimizing tissue trauma. The use of a large PEEK cage may contribute to improved stability and reduced subsidence risk.

This study introduces a novel biportal endoscopic foraminal decompression technique that minimizes bone removal while ensuring safe and effective nerve root decompression. Leveraging the accessory process as a key surgical landmark, this technique enables precise navigation and controlled turn-down of the ligamentum flavum (LF). A key advantage of this technique is its reduced requirement for bone resection, differing from traditional microscopic or uniportal endoscopic surgeries that often necessitate resection of the lateral isthmus or superior articular process. This technique is particularly beneficial for foraminal and extraforaminal herniated nucleus pulposus cases, where bony decompression needs are relatively lower compared to foraminal stenosis. Using the accessory process as a landmark also enhances surgical precision and reduces the risk of nerve root injury, providing a valuable advantage for less experienced surgeons. Despite these advantages, challenges exist, particularly at the L5-S1 level, where the less prominent accessory process and limited workspace due to anatomical constraints can pose difficulties. In cases of severe bony compression, additional bone removal may be necessary to achieve adequate decompression. In conclusion, the Non-facetectomy LF turn-down technique (non-facetectomy foraminal decompression) offers a safe and effective minimally invasive alternative for treating various foraminal pathologies.

Biportal endoscopic spinal surgery (BESS) with interbody fusion is a relatively novel minimally invasive technique that was developed to reduce soft tissue trauma and intraoperative blood loss and shorten recovery time while achieving comparable clinical outcomes for lumbar degenerative diseases. Despite the growing interest in BESS, a comprehensive analysis of its effectiveness, complication rates, and long-term outcomes remains lacking. This systematic review evaluated the clinical outcomes, surgical efficacy, and complication rates of BESS with interbody fusion for lumbar degenerative diseases. Recent literature on endoscopic lumbar interbody fusion was included to expand the scope and gain new perspectives, thereby, providing a comparative analysis that highlighted the advantages, limitations, and emerging trends in minimally invasive spine surgery. This review synthesized current evidence to guide future research and clinical applications. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and using a combination of MeSH (Medical Subject Headings) terms and relevant keywords, PubMed/Medline and Scopus databases were systematically searched for studies published between January 2000 and September 2024. The studies were assessed using the ROBINS-I (Risk of Bias in Nonrandomized Studies of Interventions) tool to determine the risk of bias. From the 12 studies that provided clinical evidence, the data extracted were patient demographics; operative time; blood loss; clinical outcomes, such as Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores and fusion rates; and complications. The mean operative time ranged from 98 to 206 minutes, with fusion rates between 70% and 95%. Most studies reported significant improvements in VAS scores for back and leg pain and ODI scores. Complications, including dural tears (2.9%-6.4%) and hematomas (1.4%-4.3%), were infrequent but notable. BESS with interbody fusion demonstrated excellent clinical outcomes, high fusion rates, and few complications. Although these results are promising, more randomized controlled trials and long-term studies are required to confirm the broader applicability, particularly in more complex or multilevel spinal pathologies.

Study design: A retrospective study.

Purpose: To evaluate the clinical efficacy of uniportal endoscopic decompression and debridement (UEDD) in treating infectious diseases of the spine (IDS) with neurological deficits.

Overview of literature: IDS patients with neurological deficits often require urgent surgical decompression. However, the efficacy of UEDD in this complex patient population is not well-characterized.

Methods: This retrospective study analyzed 32 consecutive IDS patients who underwent UEDD surgery. Clinical features, laboratory data (erythrocyte sedimentation rate and C-reactive protein), and treatment outcomes were analyzed.

Results: Definite microorganisms were identified in 27 patients (84.3%), with 24 (88.9%) meeting cure criteria. The cure rate was significantly higher in the detected pathogen group compared to the undetected pathogen group (88.9% vs. 80%; χ²=19.36, p<0.0001). Metagenomic next generation sequencing (mNGS) provided faster diagnosis (41.72±6.81 hours) compared to tissue culture (95.74±35.47 hours, p<0.05). The predominant causative pathogen was Mycobacterium tuberculosis, followed by Staphylococcus aureus. Significant improvements were observed in Visual Analog Scale pain scores, from a mean of 7.9 preoperatively to 1.06 at 1 year postoperatively. The Oswestry Disability Index revealed a similar trend, showing significant improvement (p<0.05).

Conclusions: UEDD is a viable alternative to traditional open surgery for managing IDS in high-risk patients. UEDD offers a dual therapeutic-diagnostic advantage during the initial admission phase, enabling simultaneous debridement, neurological decompression, and targeted biopsy in a single intervention. Compared with traditional tissue culture, mNGS enables rapid microbiological diagnosis and extensive pathogen coverage.

Study design: Technical case report.

Purpose: To present a novel navigation-assisted transforaminal unilateral biportal endoscopy (UBE) lumbar discectomy technique for managing upper lumbar disc herniation.

Overview of literature: Upper lumbar disc herniation is significantly less common than lower lumbar disc herniation, accounting for only 1%-2% of cases. However, treatment is more challenging and is associated with worse outcomes. Anatomical differences between the upper and lower lumbar spine complicate the standard interlaminar approach using UBE, making it insufficient for complete removal of herniated discs. Integrating endoscopic spine surgery with intraoperative navigation provides three-dimensional computer-reconstructed visual data, thereby enhancing the feasibility of the technique.

Methods: The UBE approach targeted the ventral part of the superior articular process in the transforaminal UBE setup, specifically for upper lumbar disc herniation, with an approach angle of approximately 30º on the axial plane. Intraoperative navigation was employed to improve puncture accuracy for this relatively unfamiliar surgical technique. Navigation-assisted transforaminal UBE lumbar discectomy was performed on four patients presenting with back or leg discomfort due to disc herniation at the L1-L2 or L2-L3 levels.

Results: All patients experienced symptom relief and were discharged on postoperative day 2.

Conclusions: Transforaminal UBE lumbar discectomy is a viable therapeutic option for upper lumbar paracentral disc herniation, which is typically associated with poor prognosis. Integrating navigation integration into this novel approach enhances precision and safety.

Study design: Expanding upon established surgical simulation methods, we developed a fused deposition modeling three-dimensional (3D)-printed model of the C1-T1 vertebra for posterior cervical foraminotomy training that features silicone-based neural elements, polyurethane foam-based ligaments, and polyethylene terephthalate glycol vertebrae.

Purpose: This study evaluated the effectiveness of a cost-efficient 3D-printed training model designed to help neurosurgical residents acquire fundamental skills in endoscopic posterior cervical foraminotomy while addressing the technique's challenging learning curve and limited training resources.

Overview of literature: Only a few studies have investigated the efficacy of such a model.

Methods: Eight neurosurgery residents each with over 2 years of training completed four training sessions on two randomly assigned cervical spine levels using the newly developed 3D-printed model. A simple plumbing endoscope was used for real-time surgical visualization.

Results: Among the 64 completed surgical levels, left-sided procedures showed significantly higher insufficient decompression rates than did right-sided procedures (25.0% vs. 3.6%, p=0.002). However, no significant difference in overall complication rates was observed between sides (p=0.073). Surgical parameters remained consistent across sides, with no significant differences in operative duration. Brunner-Langer analysis revealed substantial improvements in operative duration (mean duration decrease from 21:42±2:15 to 6:33±0:42 minutes, p=0.004) and total complications (mean decrease from 2.1±0.8 to 0.4±0.5, p=0.007) across sessions. Although fluoroscopy timing showed marginal improvement (mean duration decrease from 2:12±1:15 to 0:55±0:23 minutes, p=0.057), the number of fluoroscopic images tended to decrease.

Conclusions: Our findings suggest that this novel 3D-printed cervical spine model could be a viable, low-cost option for neurosurgical training programs aiming to help residents develop essential endoscopic skills in a controlled setting. Facilitating early proficiency in posterior cervical foraminotomy can serve as a valuable intermediate step before transitioning to cadaveric models and clinical practice.