PE-YOLO: An efficient segmentation algorithm for surgical instruments in percutaneous spinal endoscopic surgery

PurposeTo evaluate the application value of percutaneous endoscopic spinal surgery for young patients with discogenic low back pain (DLBP) and to judge its clinical efficacy.MethodsWe retrospectively analyzed young patients with single-segment discogenic lumbago from July 2018 to June 2020 in our department who underwent percutaneous endoscopic surgery according to the inclusion and exclusion criteria. We finally enrolled 20 patients. The follow-up time was 6–30 months. In all patients, we recorded the visual analog scale (VAS) score for waist pain and the Oswestry Disability Index (ODI) preoperatively, immediately postoperatively and at the last follow-up. We used the modified MacNab criteria to assess the curative effect at the last follow-up.ResultsAll 20 patients underwent successful operations without complications. No recurrence was observed during follow-up. The VAS score of low back pain was 5.05±1.19 points before surgery, 1.50±051 points immediately after surgery, and 1.10±0.72 points at the last follow-up (P < 0.05 preoperative vs both postoperative). At the last follow-up, the VAS scores of all 20 patients were ≤2, and 4 patients had no pain. The ODI was 46.66±7.03% before surgery, 9.78±4.05% immediately after surgery, and 4.11±3.18% at the last (P < 0.05, preoperative vs both postoperative). According to the evaluation under the modified MacNab standard, the good–excellent rate of clinical efficacy at the last follow-up was 95%.ConclusionPercutaneous endoscopic spinal surgery can significantly improve the symptoms and dysfunction of young patients with DLBP and has little effect on the biomechanical stability of the lumbar spine. This surgery has great clinical application value.

Biportal endoscopic spinal surgery (BESS) is a minimally invasive spinal surgery, which is basically similar to microscopic spinal surgery in terms of the use of floating technique and technically similar to conventional percutaneous endoscopic spinal surgery in terms of the use of endoscopic or arthroscopic instruments. Using two independent portals (viewing and working) and maintaining a certain distance from the bony and neural structures allow closer access to the target lesion through a panoramic view by free handling of the scope and instruments rather than through a fixed view by docking into the Kambin’s triangle. Minimally invasive surgery allows for reduced dissection and inevitable muscle injury, preserving stability and reducing risks of restabilization. The purpose of fusion surgery is the same as that of the three surgical techniques stated above. Its wider range of view helps to overcome limitations of conventional endoscopic spinal surgery and to supplement the weak points of microscopic spinal surgery, such as limited working space in a tubular retractor and difficulty in accessing the contralateral area. This technique provides an alternative to unilateral or bilateral decompression of lumbar central spinal stenosis, foraminal stenosis, low-grade spondylolisthesis, and adjacent segment degeneration. Early clinical outcomes are promising despite potential for complications, such as dural tearing and postoperative epidural hematoma, similar to other procedures. Merits of BESS include decreased postoperative infection rate due to continuous irrigation throughout the procedure and decreased need for fusion surgery for one- or two-level lumbar stenosis by wide sublaminar and foraminal decompression with minimal sacrifice of stabilizing structures.

To evaluate the feasibility, safety, and early effectiveness of percutaneous endoscopic thoracic spine surgery via the trench technique for ventral decompression in central calcified thoracic disc herniation (CCTDH) and thoracic ossification of the posterior longitudinal ligament (T-OPLL). Seven patients with single-segment CCTDH or T-OPLL admitted between June 2017 and May 2020 and meeting the selection criteria were retrospectively analyzed. There were 3 males and 4 females with an average age of 51.7 years ranging from 41 to 62 years. There were 2 patients with T-OPLL (T 1, 2 in 2 cases) and 5 patients with CCTDH (T 1, 2 in 1 case, T 7, 8 in 1 case, T 10, 11 in 2 cases, T 11, 12 in 1 case). Five patients with thoracic axial pain and intercostal neuralgia had a preoperative visual analogue scale (VAS) score of 6.0 (5.0, 6.5), and 7 patients had a preoperative Japanese Orthopaedic Association (JOA) score of 21 (21.0, 22.0). Transforaminal approach was used in 4 cases and transpedicular approach in 3 cases. Ventral decompression of thoracic spinal cord was performed by thoracic endoscopy combined with trench technique. The operation time, intraoperative blood loss, postoperative hospital stay, and postoperative complications were recorded. Thoracic spine CT and MRI were performed preoperatively and postoperatively to evaluate the surgical decompression, VAS score was used to evaluate the pain of thoracic back and lower limbs, and JOA score was used to evaluate the functional recovery. Modified MacNab criteria was used to evaluate the effectiveness. All surgeries were successfully completed. The operation time ranged from 60 to 100 minutes, with an average of 80.4 minutes; the intraoperative blood loss ranged from 40 to 75 mL, with an average of 57.1 mL; the postoperative hospital stay ranged from 4 to 7 days, with an average of 5.4 days. CT and MRI examinations indicated that the decompression was adequate. All 7 patients were followed up 3-22 months, with an average of 13.3 months. One case developed postoperative wound infection, and 1 case developed pneumonia; the remaining patients did not have any complications such as wound infection or cerebrospinal fluid leakage. Five patients with thoracic axial pain and intercostal neuralgia had VAS scores of 2.0 (1.5, 2.5) at 1 day after operation and 2.0 (1.0, 2.0) at last follow-up, both of which were significantly lower than the preoperative scores ( P<0.05). At 1 day after operation, the JOA scores for all 7 patients were 22.0 (21.0, 24.0), which showed no significant difference compared to the preoperative score ( P>0.05); however, at last follow-up, the score improved to 24.0 (24.0, 26.0), which was significant compared to the preoperative scores ( P<0.05). At last follow-up, the effectiveness was assessed using the modified MacNab criteria, the results were excellent in 2 cases, good in 3 cases, fair in 2 cases, and the excellent and good rate was 71.4%. Using the trench technique, percutaneous endoscopic thoracic spine surgery can achieve the ventral decompression in CCTDH and T-OPLL, providing a new approach for surgical treatment of CCTDH and T-OPLL.

To explore the factors influencing the short-term efficacy of percutaneous transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation is the main objective. 100 patients with lumbar disc herniation who were treated in our hospital from February 2017 to February 2019 were selected as the control group (n=85, effective) and observation group (n=15, ineffective), the effective rate of treatment was statistically analyzed. Visual analogue scale and Japanese orthopaedic association scores were compared before surgery, 3 mo after surgery and 6 mo after surgery. The influencing factors of lumbar disc herniation treatment effect were analyzed. The effective rate of lumbar disc herniation patients treated by percutaneous transforaminal endoscopic lumbar discectomy surgery was 85.00 %. Compared with that before surgery, the visual analogue scale score of lumbar disc herniation patients was significantly decreased 3 mo after surgery and 6 mo after surgery, but the Japanese orthopaedic association score was significantly increased (p<0.05). In logistics regression analysis, it was found that the course of disease, history of trauma and degree of lumbago were the main factors affecting the therapeutic efficacy of percutaneous transforaminal endoscopic surgery in patients with lumbar disc herniation. There are many factors influencing the efficacy of percutaneous transforaminal endoscopic surgery for lumbar disc herniation patients and the relationship between them and the therapeutic effect should be comprehensively analyzed.

New Trends in Instrumentation and Complex Techniques in Spine Surgery.

A clinical case of treatment of a patient with long-term consequences of a gunshot wound to the lumbar spine with a follow-up period of fifteen years is presented. In the last year and a half, the repeatedly recurrent retroperitoneal phlegmon associated with a foreign body of the lumbar spine has prompted a decision on the issue of surgical treatment (removal of a foreign body - a bullet). The location of the foreign body and previous experience with endoscopic foreign body removal played a decisive role in the choice of surgical tactics. Removal of the wounding projectile was performed using a percutaneous transforaminal endoscopic approach. The choice of such an approach was dictated by the peculiarity of the location of the foreign body (coaxial with the endoscopic tube in the foraminal approach), as well as sufficient experience in using the technique of percutaneous endoscopic surgery. At the same time, the conversion plan was worked out in sufficient detail with both posterolateral and anterior open approaches with the involvement of appropriate specialists. So, in case of failure, it was planned to transfer endoscopic access to open, using the already installed working tube of the endoscope as a conductor to a foreign body. In case of inefficiency, for some reason, this version of the operation was planned for the next, third stage: wound suturing, patient turning on the back with a right-hand retroperitoneal approach to the anterior-lateral surface of LI and LII bodies. Fortunately, the purpose of the operation was achieved using the most gentle version of the allowance. The given clinical case testifies that the technique of percutaneous transforaminal endoscopic surgery is not limited in indications to the treatment of degenerative-dystrophic diseases of the spine.

What's New in Spine Surgery.

ObjectiveOblique lumbar interbody fusion (OLIF) has been used to treat lumbar spine spondylolisthesis. However, it usually needs posterior pedicle screws fixation for biomechanical stability and possible posterior direct decompression for relieving neurologic symptoms. We use percutaneous transforaminal endoscopic surgery (PTES) combined with mini-incision OLIF and anterolateral screws rod fixation for surgical treatment of lumbar spondylolisthesis. The purpose of study is to evaluate the feasibility, efficacy, and safety of this method compared with minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF).MethodsFrom July 2016 to May 2018, 65 patients of lumbar spondylolisthesis (L2–4) with neurologic symptoms were treated using PTES combined with mini-incision OLIF and anterolateral screws rod fixation (31 cases, group A) or MIS-TLIF (34 cases, group B) in this study. Operative duration, blood loss, incision length, fluoroscopy frequency, and hospital stay are compared. Preoperative and postoperative visual analog scale (VAS) pain scores of back and legs, Oswestry disability index (ODI), intervertebral space height, lumbar lordotic angle, operative segmental lordotic angle, and complications are recorded. The fusion status is assessed according to Bridwell's fusion grades.ResultsThe VAS score of back and leg pain and ODI significantly dropped after surgery in both groups (p < 0.001). There was no statistical difference of back and leg VAS score and ODI between two groups except that back VAS scores in group A were significantly lower than that of group B immediately after surgery (p = 0.000). Group A had significantly more intervertebral space height and operative segmental lordotic angle than group B postoperatively (p = 0.022, p = 0.002). Twenty-three segments (74.2%) were grade I and 8 segments (25.8%) were grade II in group A; 20 segments (58.8%) were grade I and 14 segments (41.2%) were grade II in group B at a 2-year follow-up (p = 0.194). No difference was observed in the complication rate between the two groups (6.5% vs. 5.9%, p = 0.924).ConclusionThe long-term clinical efficacy and complication rates of both groups are comparable. PTES combined with mini-incision OLIF and anterolateral screws rod fixation is a good choice of minimally invasive surgery for lumbar spondylolisthesis, which hardly destroys the paraspinal muscles and bone structures.

BackgroundPercutaneous transforaminal endoscopy has been widely used to treat lumbar disc herniation (LDH), but the steep learning curve and difficulties in removing the calcified disc hinders the application of conventional endoscopy in treating calcified lumbar disc herniation (CLDH). In 2017, we first reported Percutaneous Transforaminal Endoscopic Surgery (PTES) as an easy-to-learn posterolateral transforaminal endoscopic technique to decompress the nerve root for LDH. We used our PTES technique to remove the calcified LDH and the purpose of this study is to evaluate the safety and efficacy of this technique.MethodsForty-six patients with CLDH and fifty-five patients with uncalcified lumbar disc herniation (ULDH) underwent PTES to decompress the nerve root. Visual analogue scale was collected before the surgery, immediately, one week, one month, two months, three months, six months, 12 months and 24 months after surgery. The outcomes of MacNab classification were collected 24 months after surgery. Intra- and Post-operative complications were also recorded.ResultsFor CLDH patients, the VAS score was 9 (5–10) before operation, and then dropped to 2 (1–4) after surgery. VAS score continually decreased to 0 (0–3) at 24 months after surgery. 95.65% of CLDH patients showed excellent or good outcomes. ULDH group showed similar MacNab classification (94.55%) and VAS changing curve. The therapeutic effect of PTES in treating CLDH was as good as that in treating uncalcified patients.ConclusionsPTES is an effective and safe method to treat calcified lumbar disc herniation.

Are Emergently Placed Nephrostomy Tubes Suitable for Subsequent Percutaneous Endoscopic Renal Surgery?

Contralateral Interlaminar Keyhole Percutaneous Endoscopic Lumbar Surgery in Patients with Unilateral Radiculopathy

Explorations of percutaneous endoscopic spine surgery

Percutaneous endoscopic spine surgery is popular in recent years because of its minimally invasive manner. After transforaminal approach presented by Kambin in the late 1980s, many specific methods were described to establish an accurate and feasible approach to the target disc. Among them, the techniques of Yeung[1], Hoogland[2] and Ruetten[3] are the most famous ones and each has different design and indications. However, no consensus have been made because of the debated clinical results, steep learning curves, and pitfalls that exist in each approach. Guide needle insertion and subsequent working channel building remain a challenging procedure. Poor accuracy may lead to poor safety as the nerve root and dura are at risk. Many surgeons attempted to optimize the procedure, but few researches have integrated computer-assisted navigation with tPELD (transforaminal percutaneous endoscopic lumbar discectomy). It is time to bring our surgical robot into the field.

Background: Spinal instrumentation and fusion surgery presents the anaesthesiologist with multiple issues like intraoperative blood loss, hemodynamic changes, prolonged surgery etc, but the most probing aspect is analgesia. While both ketamine and dexmedetomidine as adjuvants have shown to decrease intraoperative anaesthetics and post operative analgesic consumption but there are no comparative studies. The primary aim of this study was comparison of post-operative analgesic requirements for 1st 24 hours after surgery when either of the drugs was used as adjuvants. Methods: Adult patients aged 18-60 years, of either sex, and ASA status I or II scheduled for elective lumbar spine instrumentation (of 2 or more spinal levels) surgery were enrolled for the study. Patients were randomised into one of the 3 treatment regimens ketamine/group K (0.5mg/kg bolus followed by 250 mcg/kg/h infusion), dexmedetomidine/ group D (0.5mcg/kg bolus followed by 0.5 mcg/kg/h infusion) or the placebo/ group S (saline/placebo). The study drugs were started after turning the patient prone. Data were recorded for intraoperative hemodynamics, anesthetic consumption (inhalational agent and opioids), emergence through RAS scale (Riker sedation agitation scale), PCA (patient controlled analgesia)-fentanyl use and VAS (visual analog scale) score in the 1st 24 hours after surgery. Appropriate statistical analysis was done. Results: A total of 42 patients (14 in each group) were enrolled. The total PCA fentanyl consumed in first 24 hours of surgery was maximum with the group-S (1366.6±382.6 mcg) in compared with group- D (1035.4±391.8 mcg) and group- K (1164.9±503.6 mcg) (P=0.13). The post extubation RAS score was lower in group-K (3.7±0.6) when compared with group-D (4±0.4) and group-S (4.5±0.9) (P=.009). Total intraoperative sevoflurane and fentanyl consumption showed no difference (P=0.19 and P=0.28). VAS score at rest was higher at baseline with group-S (P=0.009). The ICU stay was comparable (group-D: 1.4±0.5 d, group-K: 1.5±0.5 d, group-S: 1.9±0.5 d) among the groups. Hospital stay was also comparable (P=0.09). Conclusion: In patients undergoing lumbar instrumentation surgery, opioid consumption, VAS scores, PCA pump bad demands, inhalational agent consumption, hospital stay were comparable when either ketamine or dexmedetomidine was used as intraoperative anesthetic adjuvants.

Envisioning the evolution of orthopedic surgery in the twenty-first century