Endoscopic Techniques for the Management of Spinal Trauma

What's New in Spine Surgery.

A paucity of literature on the effect of spinal endoscopic surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients. Evaluation of the effect of endoscopic practice expansion in degenerative spinal conditions and disc herniations on patients' outcome as we shifted from first-generation endoscopic discectomy to second-generation decompression and finally third generation of endoscopic spinal fusion practice. Retrospective cohort study on surgical treatment of degenerative spinal conditions for 616 spinal cases. Basic demographics, preoperative, postoperative 1 week, 6 months, and final follow-up of patients' clinical outcomes in terms of pain score, Oswestry disability index, and MacNab's criteria for pain score were evaluated. 75%, 91%, and 97% of the surgeries with complications rate of 8.2%, 9%, and 3.4% were found in Generation 1, 2, and 3 of endoscopic surgery, respectively. Compared to preoperative scores, each generation VAS and ODI scores all statistically significantly improved. In the final follow-up, compared to preoperative state, the mean VAS improvement was 4.75 ± 1.7, 5.49 ± 1.66, and 5.37 ± 1.70, mean ODI improvement was 45.99 ± 11.8, 48.93 ± 11.2, and 48.43 ± 11.41, and MacNab's criteria showed a trend of upward improvement of 87.3%, 96.0%, and 98.7% cases, which showed good-to-excellent outcome, in Generation 1, 2, and 3, respectively. Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing a good clinical outcome.

The Japan Orthopedic Association has led the way with endoscopic surgery for the spine and has developed its own training course and technical authorization system. Endoscopic surgery can be classified roughly as an anterior procedure from the pleural or peritoneal cavity or as a posterior procedure from the posterior interlaminar space in spine endoscopic surgeries. A representative technique of the endoscopic posterior spine surgery, which uses the posterior method, is microendoscopic discectomy (MED). While MED was initially utilized for lumbar herniotomy, it has recently been used for lumbar spinal canal stenosis and cervical spine disease. Therefore, all the posterior operative procedures are generally used with an MED system and they are referred to as MED. Thus, MED accounts for 98.7% of spine endoscopic operations performed in Japan (2006). There is little soft tissue damage with this approach and the lamina can be reached between the muscles for lumbar disc herniation. In the MED, radiographic control is indispensable for localization of the tube retractor, and it is necessary to resect the yellow ligament little by little to divide the superficial layer and the deep layer. MED is superior in visual safety for retraction of the nerve root to herniotomy. As for issues with MED, there is a substantial learning curve, the operation requires a long time, expensive instrumentation, there is the lack of haploscopic vision, the visual field to operate is limited, there is a tendency to become disoriented, and the lack of sensation of palpating an organ. Additional approaches include video-assisted thoracoscopic spine surgery (VATS) and endoscopic anterior lumbar spine surgery via the peritoneal or retroperitoneal cavity, but they do not lead to global operations.

PurposeWe aimed to comprehensively analyze the current status, hotspots, and trends in full endoscopic spine surgery (FESS) research using bibliometric analysis and knowledge domain mapping.MethodsThe Web of Science database was used to screen FESS-related articles published between January 1, 1993 and June 10, 2022. The evaluation involved the following criteria: total number of articles; H-index; and contributions from countries/regions, institutions, journals, and authors.ResultsA total of 1,064 articles were included. Since 2016, there have been a significant number of publications in the field of FESS. The country/region contributing the largest number of articles was China (37.8%), followed by South Korea (24%), the United States (16.1%), Japan (5.7%), and Germany (5.1%). South Korea (35) had the highest H-index, followed by the United States (27), China (22), Japan (21), and Germany (20). World Neurosurgery (15.7%) published the largest number of FESS-related articles. However, among the top 10 most cited articles, six were published in Spine. The author who contributed the most was S.H. Lee (5.4%), and the largest number of contributions in this field originated from Wooridul Spine Hospital (South Korea; 6.1%). Notably, six of the 10 most published authors in this field were from South Korea. Of the top five productive institutions, three were from South Korea. The keywords with the strongest citation bursts in the field of FESS were “lumbar spine,” “discectomy,” “interlaminar,” “surgical technique,” “follow-up,” “excision,” “thoracic spine,” and “endoscopic surgery.” The 10 clusters generated in this study were: “endoscopic discectomy” (#0), “thoracic myelopathy” (#1), “recurrent lumbar disc herniation” (#2), “low back pain” (#3), “cervical vertebrae” (#4), “lumbar spinal stenosis” (#5), “transforaminal lumbar interbody fusion” (#6), “radiation exposure” (#7), “management” (#8), and “lumbar spine” (#9).ConclusionGlobal research on FESS is mostly concentrated in a few countries/regions and authors. South Korea has made the largest contribution to the field of FESS. Based on the most cited keyword bursts and clusters, the focus of FESS research was found to include its indications, management, and applications.

Ipsilateral Pedicle Stress Fracture After Endoscopic Foraminal Decompression for Patient with Isthmic Spondylolisthesis

MRI = magnetic resonance imagingRF = radiofrequencyAP = anteroposterior.

History of endoscopic spine surgery: where did it all begin? Development of indications and techniques.

To evaluate the techniques of minimally invasive single- and multilevel corpectomy and reconstruction of the thoracic and thoracolumbar spine using expandable vertebral body replacement (VBR) cages and ventrolateral plate fixation (VPF) via anterolateral retropleural (ALRA) and combined thoracoabdominal approaches. 38 patients with spondylitis, traumatic or metastatic lesions of thoracic or thoracolumbar vertebrae T4 to L2 underwent spinal decompression and ventral column reconstruction with correction of spinal deformity by VBR and VPF via ALRA or a combined lateral extrapleural/extraperitoneal (extracoelomic) thoracolumbar approach (CLETA). Overall clinical and neurological outcome, operative time, blood loss, reduction of deformity, and postoperative pain were assessed during a mean follow-up period of 22.8 months. VBR and VPF were carried out successfully without conversion to conventional approaches in all patients. Mean operative time (ALRA, 163 +/- 33 min; CLETA, 175 +/- 39 min), mean blood loss (ALRA, 280 +/- 160 ml; CLETA, 420 +/- 250 ml), average correction (19.3 degrees), loss of correction of sagittal deformity (0.9 degrees), and clinical outcome compare favorably to the results reported for open and endoscopic techniques. Postoperative pain levels (mean visual analog scale score at 24 h, 2.7 +/- 0.9) and the incidence of postoperative pulmonary dysfunction (three out of 38 patients) were low. The average length of stay was 7.4 days. ALRA and CLETA obviate routine chest tube insertion, thus allowing for early postoperative ambulation (average, 1.1 d). Minimally invasive VBR and VPF conducted via minimally invasive approaches (ALRA or CLETA) yields favorable clinical results at least equal to conventional open surgery, with significant reductions in perioperative morbidity and pain, expedited ambulation, and early discharge from the hospital.

# 01.1.1: Surgery versus standardized nonoperative care for the treatment of lumbar disc herniations: a Canadian trial {#article-title-2} The beneficial treatment effect surgery demonstrates over conservative care for radiculopathy secondary to acute lumbar disc herniation (LDH), occurs in the

New Trends in Instrumentation and Complex Techniques in Spine Surgery.

Transforaminal Endoscopic Decompression in the Setting of Lateral Lumbar Spondylolisthesis

# Presentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spine {#article-title-2} Regular corticosteroid has become standard for slowing disease progression in Duchenne muscular dystrophy (DMD). However, patients must contend with the insidious side effect of osteopenia and

The multidirectional stability potential of anterior, posterior, and combined instrumentations applied at L1-L3 was studied after L2 corpectomy and replacement with a carbon-fiber implant. To evaluate the biomechanical characteristics of short-segment anterior, posterior, and combined instrumentations in lumbar spine tumor vertebral body replacement surgery. The biomechanical properties of many different spinal instrumentations have been studied in various spinal injury models. Only a few studies, however, investigate the stabilization methods in spinal tumor vertebral body replacement surgery. Eight fresh frozen human cadaveric thoracolumbar spine specimens (T12-L4) were prepared for biomechanical testing. Pure moments (2.5 Nm, 5 Nm, and 7.5 Nm) of flexion-extension, left-right axial torsion, and left-right lateral bending were applied to the top vertebra in a flexibility machine, and the motions of the L1 vertebra with respect to L3 were recorded with an optoelectronic motion measurement system after reconditioning. The L2 vertebral body was resected and replaced by a carbon-fiber cage. Different fixation methods were applied to the L1 and L3 vertebrae. One anterior, two posterior, and two combined instrumentations were tested. Load-displacement curves were recorded and neutral zone and range of motion parameters were determined. The anterior instrumentation provided less potential stability than the posterior and combined instrumentations in all motion directions. The anterior instrumentation, after vertebral body replacement, showed greater motion than the intact spine, especially in axial torsion (range of motion, 10.3 degrees vs 5.5 degrees; neutral zone, 2.9 degrees vs. 0.7 degrees; P < 0.05). Posterior instrumentation provided greater rigidity than the anterior instrumentation, especially in flexion-extension (range of motion, 2.1 degrees vs. 12.6 degrees; neutral zone, 0.6 degrees vs. 6.1 degrees; P < 0.05). The combined instrumentation provided superior rigidity in all directions compared with all other instrumentations. Posterior and combined instrumentations provided greater rigidity than anterior instrumentation. Anterior instrumentation should not be used alone in vertebral body replacement.

Objective To explore the feasibility and clinical effects of transforaminal fenestration approach in lumbar spine.Methods Transforaminal fenestration approach was performed on 30 specimens of adult lumbar spine from L1 to S1 segments,with the exiting nerve root and posterior aspect of disc fully exposed.The resected structures were measured.The 3D CT was performed before and after fenestration,and the structure resected was measured.The 3D CT data of lumbar spine of 31 adult patients were collected and the resected structures were measured.Transforaminal fenestration approach was applied in 10 patients with far lateral lumbar disc herniation.Microendoscopic discectomy was performed with mobile endospine system at level of L3,4 in 2 cases,L4,5 in 4,L5S1 in 4.Results From L1 to S1,the isthmus and laminae gradually extends laterally,the transverse process gradually moves downward,and the distance between the dura sac and the lateral edge of lamina and facet increased.At the segment of L1,2,L2,3 and L3,4,only a small range of structure was resected.At the segment of L4,5 and L5S1,a large range of lamina and faceted were resected,and the dura sac can not be fully exposed.A crescentiform fenestration can preserve more connection of isthmus and lower facet.The transforaminal fenestration approach was successfully used in all the 10 patients,the herniation and sequestered nucleus was exposed fully and removed completely.The follow-up time was 12 months,excellent result was obtained in 8 patients,and good in 2 according to Macnab scale,without instability at dynamic film.Conclusion Transforaminal fenestration approach can provide enough exposition with the preservation of stable structure in lumbar spine,especially with endoscopic surgery and cresceutiform fenestration,and far lateral lumbar disc herniation can be effectively treated in this approach. Key words: Lumbar vertebrae; Intervertebral disk displacement; Anatomy; Treatment outcome

Background In unstable burst fractures of the thoracic and lumbar spine, short segmental posterior fixation has been associated with a high rate of hardware failure, with recurrence of deformity. Anterior surgical treatment allows direct decompression of the neural elements and reconstruction of the weight-bearing column with fusion of only two levels. Aim of the work The aim of this study was to evaluate the effectiveness of anterior-only surgery and locked plate fixation in the treatment of unstable burst fractures of the thoracic and lumbar spine. Study design Prospective study. Patients and methods We included 22 patients (13 men and nine women) with acute thoracolumbar burst fractures treated with anterior surgery, strut iliac graft, and fixation with a locked thoracolumbar plate. The mean age of the patients at the time of surgery was 33.2 years (range 19–55 years). Neurologically, five patients were Frankel B, 13 were Frankel C, and four were Frankel E. All patients had preoperative and postoperative radiographs and computed tomography scan. Results The 18 patients with neurological deficit showed at least one Frankel grade improvement on final observation, with 16 (88.9%) patients showing complete neurological recovery. Sagittal alignment was improved from a mean preoperative kyphosis of 19.9–6.7π at the final observation. Conclusion Through the anterior surgery of the spine and locked plate fixation, we can achieve good canal decompression, spinal column alignment, and short segment arthrodesis.