STANDARD OPEN MICRODISCECTOMY VERSUS MINIMAL ACCESS TROCAR MICRODISCECTOMY

Abstract OBJECTIVE Minimal access surgery as a less invasive alternative to standard macro- and microsurgical approaches is becoming increasingly popular in the management of traumatic and degenerative spine diseases. However, data is lacking if minimal access spine surgery is indeed beneficial. This prospective randomized study was conducted to compare efficiency, safety, and outcome of standard open microsurgical discectomy (SOMD) for lumbar disc herniation with microsurgical discectomy using an 11.5 mm trocar system for minimal access to the spine. METHODS Sixty patients were randomized to two groups of 30 patients each. Group 1 was treated by SOMD, and Group 2 was treated by minimal access microsurgical discectomy (MAMD). Perioperative parameters and pre- and postoperative clinical findings including sensory or motor deficits and pain according to the visual analog scale, Oswestry Disability Index scores, and Short Form-36 results were assessed. All patients were followed for at least 6 months postoperatively (mean, 16 mo). RESULTS Preoperatively, no statistically significant intergroup differences could be detected proving the comparability of both groups. Postoperatively, significant improvement of neurological symptoms and pain as measured by the visual analog scale, Oswestry Disability Index, and Short Form-36 scores could be achieved in both groups. In regard to operative time, intraoperative blood loss, and complication rate, slightly better results were observed in the MAMD group. CONCLUSION SOMD and MAMD allow achievement of significant improvement of pain and neurological deficits in patients with lumbar disc herniations. Differences in operative time, blood loss, and complication rates were statistically not significant in MAMD compared with SOMD, indicating that, at least in lumbar disc surgery, minimal access trocar techniques are a viable alternative to standard spinal approaches.

Download Full-text

Failure of Percutaneous Remodeling of the Ligamentum Flavum and Lamina for Neurogenic Claudication

Neurosurgery ◽

10.1227/neu.0b013e31825356f5 ◽

2012 ◽

Vol 71 (1) ◽

pp. 86-92 ◽

Cited By ~ 20

Author(s):

Jeffrey S. Wilkinson ◽

Daryl R. Fourney

Keyword(s):

Analysis Of Variance ◽

Visual Analog Scale ◽

Oswestry Disability Index ◽

Ligamentum Flavum ◽

Short Form ◽

Visual Analog Scale Score ◽

Surgical Instruments ◽

Neurogenic Claudication ◽

Imaging Studies ◽

Analog Scale

Abstract BACKGROUND: Percutaneous remodeling of the ligamentum flavum and lamina (PRLL), commercially known as minimally invasive lumbar decompression (mild technique), relies on fluoroscopy and epidural contrast to direct surgical instruments via a 6-mm cannula. OBJECTIVE: To evaluate the safety and efficacy of PRLL and present, to our knowledge, the first reported imaging findings after PRLL. METHODS: We performed a prospective study of PRLL for neurogenic claudication. Primary outcomes were Oswestry Disability Index, Short-Form 12 version 2.0 health survey, and visual analog scale for pain at 26 weeks. Analgesic use was also assessed. Postoperative magnetic resonance imaging was performed at 12 weeks. Long-term failure, defined as the poststudy need for secondary surgery, was assessed up to 18 months. RESULTS: Ten subjects with an average age of 64 years (range, 41–81 years) were treated between September 2008 and January 2009. There were no major adverse events. Mean postoperative visual analog scale score remained significantly reduced throughout 26 weeks (P =.015, analysis of variance). Mean postoperative Oswestry Disability Index was also improved by 1 week and remained significant throughout 26 weeks (P = .024; analysis of variance). However, there was a trend toward increased reliance on narcotic type medications postoperatively. Imaging studies did not show significant decompression of the spinal canal in any patient. In the poststudy period, recurrent claudication requiring laminectomy developed in 6 patients (60%). CONCLUSION: Throughout 26 weeks, pain and disability scores were decreased; however, PRLL did not improve the degree of stenosis on imaging studies. Although PRLL appears to be safe in this small cohort of patients, poststudy outcomes indicate that the failure rate is unacceptably high.

Download Full-text

COMPARATIVE STUDY OF UNILATERAL AND BILATERAL CAGES WITH RESPECT TO CLINICAL OUTCOMES AND STABILITY IN INSTRUMENTED POSTERIOR LUMBAR INTERBODY FUSION

Neurosurgery ◽

10.1227/01.neu.0000335077.62599.f0 ◽

2008 ◽

Vol 63 (1) ◽

pp. 109-114 ◽

Cited By ~ 13

Author(s):

Ji-Ho Lee ◽

Jae Hyup Lee ◽

Kang-Sup Yoon ◽

Seung-Baik Kang ◽

Chris H. Jo

Keyword(s):

Blood Loss ◽

Visual Analog Scale ◽

Oswestry Disability Index ◽

Lumbar Lordosis ◽

Interbody Fusion ◽

Posterior Lumbar Interbody Fusion ◽

Postoperative Blood Loss ◽

Lumbar Interbody Fusion ◽

Analog Scale ◽

Fusion Level

ABSTRACT OBJECTIVE We sought to compare the clinical and radiological results of instrumented posterior lumbar interbody fusion (PLIF) using unilateral or bilateral polyetheretherketone cages and pedicle screws. METHODS One hundred eighty-seven cases of degenerative spine that had been followed for at least 18 months were reviewed retrospectively. In 88 cases (147 levels), one cage was inserted, and in 99 cases (152 levels), two cages were inserted. Visual analog scale, Oswestry disability index, and functional rating indices were measured. Lumbar lordosis, lumbar scoliotic and fusion level scoliotic angles, and stable fixation were determined before surgery and 12 months postoperatively on standing x-rays. Amounts of intra- and postoperative blood loss, total quantities transfused, and operation times were also evaluated. RESULTS No significant differences were found between the two groups in terms of visual analog scale, Oswestry disability index, functional rating indices, lumbar lordosis, lumbar scoliotic angles, fusion level scoliotic angles, or fixation stabilities. However, the amounts of postoperative blood loss, total blood loss, and total transfusion for two-level PLIF using a unilateral cage were statistically smaller than those for two-level PLIF using bilateral cages. Times required for PLIF using a unilateral cage were also significantly shorter than those for PLIF using bilateral cages. CONCLUSION Unilateral cage and bilateral pedicle screw insertion may be a good alternative surgical option because it provides adequate alignment, balance, and mechanical stability in addition to reducing operative time, blood loss, and transfusion requirements.

Download Full-text

Percutaneous endoscopic transforaminal discectomy precedes interlaminar discectomy in the efficacy and safety for lumbar disc herniation

Bioscience Reports ◽

10.1042/bsr20181866 ◽

2019 ◽

Vol 39 (2) ◽

Cited By ~ 4

Author(s):

Peng Chen ◽

Yihe Hu ◽

Zhanzhan Li

Keyword(s):

Blood Loss ◽

Hospital Stay ◽

Lumbar Disc Herniation ◽

Disc Herniation ◽

Operative Time ◽

Lumbar Disc ◽

Final Analysis ◽

Quality Data ◽

Complication Rates ◽

Short Term

Abstract We searched several databases from the times of their inception to 20 December 2018. Randomized controlled trials and cohort studies that compared percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) were identified. We used a random-effects model to calculate the relative risks (RRs) of, and standardized mean differences (SMDs) between the two techniques, with 95% confidence intervals (CIs). Twenty-six studies with 3294 patients were included in the final analysis. Compared with PEID, PETD reduced the short-term (SMD −0.68; 95% CI −1.01, −0.34; P=0.000) and long-term (SMD −0.47; 95% CI −0.82, −0.12; P=0.000) visual analog scale scores, blood loss (SMD −4.75; 95% CI −5.80, −3.71; P=0.000), duration of hospital stay (SMD −1.86; 95% CI −2.36, −1.37; P=0.000), and length of incision (SMD −3.93; 95% CI −5.23, −2.62; P=0.000). However, PEID was associated with a lower recurrence rate (P=0.035) and a shorter operative time (P=0.014). PETD and PEID afforded comparable excellent- and good-quality data, long- and short-term Oswestry disability index (ODI) scores, and complication rates. PETD treated lumbar disc herniation (LDH) more effectively than PEID. Although PETD required a longer operative time, PETD was as safe as PEID, and was associated with less blood loss, a shorter hospital stay, and a shorter incision. PETD is the best option for patients with LDH.

Download Full-text

Early outcomes and safety of the minimally invasive, lateral retroperitoneal transpsoas approach for adult degenerative scoliosis

Neurosurgical FOCUS ◽

10.3171/2010.1.focus09282 ◽

2010 ◽

Vol 28 (3) ◽

pp. E8 ◽

Cited By ~ 244

Author(s):

Elias Dakwar ◽

Rafael F. Cardona ◽

Donald A. Smith ◽

Juan S. Uribe

Keyword(s):

Blood Loss ◽

Minimally Invasive ◽

Visual Analog Scale ◽

Oswestry Disability Index ◽

Anterior Column ◽

Analog Scale ◽

Degenerative Scoliosis ◽

Transpsoas Approach ◽

Anterior Column Support

Object The object of this study was to evaluate an alternative surgical approach to degenerative thoracolumbar deformity in adults. The authors present their early experience with the minimally invasive, lateral retroperitoneal transpsoas approach for placing interbody grafts and providing anterior column support for adult degenerative deformity. Methods The authors retrospectively reviewed a prospectively acquired database of all patients with adult thoracolumbar degenerative deformity treated with the minimally invasive, lateral retroperitoneal transpsoas approach at our institution. All patient data were recorded including demographics, preoperative evaluation, procedure used, postoperative follow-up, operative time, blood loss, length of hospital stay, and complications. The Oswestry Disability Index and visual analog scale (for pain) were also administered pre- and postoperatively as early outcome measures. All patients were scheduled for follow-up postoperatively at weeks 2, 6, 12, and 24, and at 1 year. Results The authors identified 25 patients with adult degenerative deformity who were treated using the minimally invasive, lateral retroperitoneal transpsoas approach. All patients underwent discectomy and lateral interbody graft placement for anterior column support and interbody fusion. The mean total blood loss was 53 ml per level. The average length of stay in the hospital was 6.2 days. Mean follow-up was 11 months (range 3–20 months). A mean improvement of 5.7 points on visual analog scale scores and 23.7% on the Oswestry Disability Index was observed. Perioperative complications include 1 patient with rhabdomyolysis requiring temporary hemodialysis, 1 patient with subsidence, and 1 patient with hardware failure. Three patients (12%) experienced transient postoperative anterior thigh numbness, ipsilateral to the side of approach. In this series, 20 patients (80%) were identified who had more than 6 months of follow-up and radiographic evidence of fusion. The minimally invasive, lateral retroperitoneal transpsoas approach, without the use of osteotomies, did not correct the sagittal balance in approximately one-third of the patients. Conclusions Degenerative scoliosis of the adult spine is secondary to asymmetrical degeneration of the discs. Surgical decompression and correction of the deformity can be performed from an anterior, posterior, or combined approach. These procedures are often associated with long operative times and a high incidence of complications. The authors' experience with the minimally invasive, lateral retroperitoneal transpsoas approach for placement of a large interbody graft for anterior column support, restoration of disc height, arthrodesis, and realignment is a feasible alternative to these procedures.

Download Full-text

The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve

Journal of Neurosurgery Spine ◽

10.3171/2019.7.spine19656 ◽

2020 ◽

Vol 32 (2) ◽

pp. 207-220 ◽

Cited By ~ 4

Author(s):

Darryl Lau ◽

Vedat Deviren ◽

Christopher P. Ames

Keyword(s):

Blood Loss ◽

Operative Time ◽

Surgical Complication ◽

Perioperative Complications ◽

Adult Spinal Deformity ◽

Neurological Deficits ◽

Complication Rates ◽

Years Of Experience ◽

Surgeon Experience ◽

Operative Measures

OBJECTIVEPosterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.METHODSA retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.RESULTSA total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.CONCLUSIONSSurgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

Download Full-text

Burst Spinal Cord Stimulation

Neurosurgery ◽

10.1227/01.neu.0000368153.44883.b3 ◽

2010 ◽

Vol 66 (5) ◽

pp. 986-990 ◽

Cited By ~ 201

Author(s):

Dirk De Ridder ◽

Sven Vanneste ◽

Mark Plazier ◽

Elsa van der Loo ◽

Tomas Menovsky

Keyword(s):

Spinal Cord ◽

Neuropathic Pain ◽

Visual Analog Scale ◽

Spinal Cord Stimulation ◽

Short Form ◽

Burst Stimulation ◽

Analog Scale ◽

Tonic Stimulation ◽

Better Than

Abstract INTRODUCTION Spinal cord stimulation is commonly used for neuropathic pain modulation. The major side effect is the onset of paresthesia. The authors describe a new stimulation design that suppresses pain as well as, or even better than, the currently used stimulation, but without creating paresthesia. METHODS A spinal cord electrode (Lamitrode) for neuropathic pain was implanted in 12 patients via laminectomy: 4 at the C2 level and 7 at the T8–T9 level for cervicobrachialgia and lumboischialgia, respectively (1 at T11 at another center). During external stimulation, the patients received the classic tonic stimulation (40 or 50 Hz) and the new burst stimulation (40-Hz burst with 5 spikes at 500 Hz per burst). RESULTS Pain scores were measured using a visual analog scale and the McGill Short Form preoperatively and during tonic and burst stimulation. Paresthesia was scored as present or not present. Burst stimulation was significantly better for pain suppression, by both the visual analog scale score and the McGill Short Form score. Paresthesia was present in 92% of patients during tonic stimulation, and in only 17% during burst stimulation. Average follow-up was 20.5 months. CONCLUSION The authors present a new method of spinal cord stimulation using bursts that suppress neuropathic pain without the mandatory paresthesia. Pain suppression seems as good as or potentially better than that achieved with the currently used stimulation. Average follow-up after nearly 2 years (20.5 months) suggests that this stimulation design is stable.

Download Full-text

A Prospective Study on the Role of Neurophysiological Studies in Predicting Functional Outcome After Lumbar Discectomy

Iranian Journal of Neurosurgery ◽

10.32598/irjns.5.3.6 ◽

2020 ◽

Vol 5 (3 And 4) ◽

pp. 133-140

Author(s):

Shanti Lal Sankhla ◽

◽

Anshul Dahuja ◽

Rashmeet Kaur ◽

Jagdeep Singh ◽

...

Keyword(s):

Visual Analog Scale ◽

Lumbar Disc ◽

Intervertebral Discs ◽

Clinical Findings ◽

X Rays ◽

Analog Scale ◽

Disability Score ◽

Refractory Pain ◽

Operative Outcomes ◽

Neurophysiological Studies

Background and Aim: Lumbar intervertebral discs are complex anatomical structures essential for the mobility of intervertebral joints. There is general consensus for some indications for surgery, including acute or progressive neurological deficit(s), cauda equine syndrome, or refractory pain unresponsive to conservative treatments. However, controversy exists regarding the optimal management of cases with the disparity between radiological and clinical findings, which includes a great proportion of patients. This study examines whether neurophysiological studies can be used to identify subgroups with improved post-operative outcomes. Methods and Materials/Patients: This prospective cohort study was conducted on 60 patients with clinical and imaging evidence in favor of Lumbar Disc Herniation (LDH). The pre-operative radiological assessment was the lateral X-rays in flexion and extension positions, and lumbar spine Magnetic Resonance Imaging (MRI). Pre-operative clinical assessment was done by the Oswestry Low Back Pain Disability Questionnaire and Visual Analog Scale (VAS). Neurophysiological studies were done at least one month after the onset of radiculopathy. Surgery was performed at the level suggested by neuroimaging. In all patients, we found an abnormal disc, which was removed along with any loose disc material. The patients were followed up for 1 year with intervals of 3 months for post-operative assessments. Results: In the two study arms with abnormal or normal pre-operative electrodiagnostic studies, a significant decrease was observed in the percentages of visual analog scale reduction (73.69% and 95.59%, respectively) and Oswestry disability score (65.3% and 76.2%, respectively) at the month 12 post-operative (P=0.993 to 0.002 and P=0.200 to 0.037, respectively). Conclusion: Neurophysiological studies could be regarded as helpful adjuncts to distinguish a subgroup of patients with LDH, who may experience a favorable outcome after surgical intervention.

Download Full-text

Spinal cord stimulation for chronic intractable trunk or limb pain: study protocol for a Chinese multicenter randomized withdrawal trial (CITRIP study)

10.21203/rs.2.20185/v2 ◽

2020 ◽

Author(s):

Yang Lu ◽

Peng Mao ◽

Guihuai Wang ◽

Wei Tao ◽

Donglin Xiong ◽

...

Keyword(s):

Spinal Cord ◽

Visual Analog Scale ◽

Spinal Cord Stimulation ◽

Pulse Generator ◽

Short Form ◽

Control Group ◽

Withdrawal Period ◽

Analog Scale ◽

Limb Pain ◽

Vas Score

Abstract Background: Although effective results of many studies support the use of spinal cord stimulation in the chronic pain patients, no randomized controlled trial has been undertaken in China to date. CITRIP is a multicenter, prospective, randomized, withdrawal study designed to evaluate the clinical effectiveness and safety of spinal cord stimulation plus remote programming management in patients with intractable trunk or limb pain.Method：Participants will be recruited in approximately 10 centers across China. Eligible participants with intractable trunk or limb and an average Visual Analog Scale (VAS) score ≥ 5 will undergo spinal cord stimulation test. Participants with VAS score reduction ≥ 50% could move forward to receive implantation of an implanted pulse generator. In the withdrawal period at 3-months follow-up visit, participants randomized to the experimental group (EG) will undergo continuous stimulation while ceasing the stimulation in the control group (CG). The outcome assessment will occur at baseline and at 1, 3 (pre and post randomization) and 6 months. The primary outcome is the difference of maximal visual analog scale (VAS) score between EG and CG in the withdrawal period compared with baseline before the withdrawal period. Additional outcomes include VAS score change at 1, 3 and 6-month follow-ups, responder rate (VAS score improving by 50%), achievement rate of a desirable pain state (VAS score ≤ 4), awake times during sleep, Beck Depression Inventory for depression evaluation, short-form 36 for quality of life evaluation, drug usage, satisfaction rating of the device. Adverse events will be collected. The primary analysis will follow the intention-to-treat principle. Discussion：The CITRIP study seeks to evaluate the effectiveness and safety of a randomized withdrawal trial of spinal cord stimulation for patients with intractable trunk or limb pain.Trial registration: NCT03858790, clinicaltrials.gov, registered on March 1st, 2019, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03858790

Download Full-text