Alternative Dorsal Root Ganglion Neuromodulation Electrode Implantation: A Report of 2 Cases with 3 Different Techniques

Background and Study Aims The traditional percutaneous placement of dorsal root ganglion (DRG) electrodes may not be eligible for every patient. In this tertiary spine surgery and interventional pain therapy center, alternative neurostimulation implantation techniques were developed and applied where standard percutaneous approaches failed or were contraindicated. Case presentation Three alternative implantation techniques can be used: (1) open surgical placement of DRG leads, (2) two-lead insertion via a lateral to medial transforaminal approach (level L3), and (3) percutaneous approach with two leads close to the spinal nerves L4 (peripheral nerve stimulation). Results The placement of the leads occurred without complications and resulted in similar expected outcomes as with the common percutaneous technique with long-term stable pain suppression at 7 months and 1 year. Conclusions In patients in whom the DRG cannot be approached by the standard percutaneous approach, at least three alternatives may be used in experienced hands resulting in stable pain suppression of similar magnitude.

Rigid endoscopic surgery of brainstem cavernous malformation on the cerebral aqueduct. Case report

Cavernous angiomas (malformations) of the brain occur in 0.5% of the population. Most of them are asymptomatic, but due to their anatomical features, namely escape of blood into surrounding tissues, significant neurological symptoms can occur. The deep location of cavernous angiomas in the area of cerebral aqueduct makes surgical intervention difficult. Microsurgical approaches are the gold standard in removal of cavernous angiomas, but they are associated with certain surgical risks in the formation of the surgical corridor. Cavernous malformations in the cerebral aqueduct are a rare subtype. Due to anatomical localization and concomitant obstructive hydrocephalus ІІІ and lateral ventricles, they can be removed by endoscopic frontal transcortical transventricular approach. A 59-year-old patient was diagnosed with cavernous angioma of the brainstem (in the area of cerebral aqueduct) with hemorrhage and the formation of obstructive hydrocephalus ІІІ and lateral ventricles. The operation was performed: removal of the cavernous angioma in the area of cerebral aqueduct by endoscopic frontal transcortical transventricular approach on the right. Additionally, a triventriculocisternostomy was performed. Osteoplastic trepanation with centering at the Kocher’s point in size of 4 × 4 cm and the formation of a free bone flap was performed. The dura mater is cut in an H-shape. Approach to the anterior horn of the right lateral ventricle was performed. An intracerebral retractor was inserted into the anterior horn of the right lateral ventricle. Transforaminal approach to the tuber cinereum was performed - a triventriculocisternostomy was performed. Transforaminal approach to the cerebral aqueduct was performed and the cavernous angioma of the brainstem was removed. In the postoperative period, the patient had a slight deterioration in short-term memory, which regressed 2 weeks after surgery, an increase in oculomotor disorders, in particular persistent diplopia due to moderate paresis of the left oculomotor nerve. Three months after the operation, magnetic resonance imaging of the brain with intravenous contrast enhancement was performed. There are no signs of cavernous angioma. After the operation of frontal transcortical transventricular removal of cavernous angioma in the area of cerebral aqueduct, the compression of the latter was eliminated. Occlusive hydrocephalus regressed, the size of the ventricles decreased. Endoscopic frontal transcortical transventricular approach allows reaching the area of cerebral aqueduct in a less traumatic and minimally invasive manner. This technique is effective due to the low risk of surgical approach complications.

Utilizing pre-operative MR imaging and adapting optimal needle puncture approach to improve radiofrequency ablation fraction of thoracic dorsal root ganglia

This experimental study evaluates the location of thoracic dorsal root ganglions (DRGs) through magnetic resonance imaging (MRI) scans, and evaluates the radiofrequency ablation (RFA) fraction of different puncture approaches on distinct DRG locations. Eight normal adult corpse specimens were used as thoracic spine specimens. An MRI examination was performed on each specimen using the following MRI sequences: STIR T2WI, fs-FRFSE T2WI, and 3D FIESTA-c. Then thoracic spine specimens (n = 14) were divided into three groups for RFA: Group A, using a transforaminal approach irrespective of DRG location; Group B, using a transforaminal, trans-lateral-zygapophysial or translaminar approach according to the DRG location; and Group C using a combination of puncture approaches. The quality of visualization of thoracic DRGs on STIR T2WI, fs-FRFSE T2WI, and 3D FIESTA-c scans were 53.5% (77/144), 88.2% (127/144), and 93.1% (134/144), respectively. In group A, the RFA fractions of the extraforaminal DRGs (N = 29), intraforaminal DRGs (N = 12) and intraspinal DRGs (N = 7) via a transforaminal approach were 72.6 ± 18.9%, 54.2 ± 24.8% and 32.9 ± 28.1% respectively. In group B, RFA of extraforaminal DRGs via a transforaminal approach (N = 43) or a trans-lateral zygapophysial approach (N = 45) led to ablation fractions of 71.9 ± 15.2% and 72.0 ± 17.9%, respectively; RFA of intraforaminal DRGs via a transforaminal approach (N = 14) or a translaminar approach (N = 16) led to ablation fractions of 57.1 ± 18.0% and 52.5 ± 20.6%, respectively; RFA of intraspinal DRGs via a transforaminal approach (N = 12) or a translaminar approach (N = 14) led to ablation fractions of 34.8 ± 24.6% and 71.8 ± 16.0%, respectively. In group C, the combined approach led to an ablation fraction for extraforaminal DRGs (N = 69) of 82.5 ± 14.1%, for intraforaminal DRGs (N = 39) of 81.5 ± 11.8%, and for intraspinal DRGs (N = 36) of 80.8 ± 13.3%. MRI can accurately assess DRG location before RFA. Adopting different and combined puncturing approaches tailored to different DRG locations can significantly increase the DRG RFA fraction.

Comparative Study of the Percutaneous Endoscopic Interlaminar Approach and Transforaminal Approach in the Treatment of Calcified Lumbar Disc Herniation

Background: Percutaneous endoscopic lumbar discectomy (PELD) is a relatively safe and effective minimally invasive surgery in the treatment of calcified lumbar disc herniation (CLDH). However, studies on percutaneous endoscopic interlaminar discectomy (PEID) and percutaneous endoscopic transforaminal discectomy (PETD) for CLDH have rarely been reported. This research aimed to compare the clinical efficacy of PEID and PETD for L5-S1 CLDH.Methods: We retrospectively analyzed 42 consecutive patients with L5-S1 CLDH treated with PELD at our institution from August 2016 to December 2019. Patients were divided into PEID group (n = 24) and PETD (n = 18) group according to the surgical methods. The demographic characteristics and surgical results of the two groups were compared. Clinical outcomes were estimated by the visual analog scale (VAS) for leg pain, Oswestry disability index (ODI) and modified MacNab criteria.Results: All patients were successfully operated on by PEID or PETD. No significant differences in the demographic characteristics, intraoperative blood loss, postoperative hospital stay and complication rate were noted between the PEID and PETD groups (P > 0.05). The excellent and good rates in the PEID group were similar to those in the PETD group (91.67% vs 88.89%, P > 0.05), whereas the PEID group exhibited superior results for operative time (m) (64.58 ± 5.88 vs 85.56 ± 9.06, P < 0.05) and fluoroscopy times (n) (2.96 ± 0.96 vs 13.33 ± 2.64, P < 0.05) compared with the PETD group.Conclusions: PEID had achieved good clinical efficacy as PETD for L5-S1 CLDH. Compared with PETD, PEID had the advantages of shorter operative time and a reduced number of fluoroscopy times in the treatment of CLDH.

Percutaneous Transforaminal Endoscopic Decompression for Lumbar Lateral Recess Stenosis

Objective: The aim of this study was to evaluate the treatment efficacy of lateral spinal stenosis through the decompression of the nerve root under a multiple planar endoscope.Methods: From January 2017 to March 2019, 52 patients with lumbar spinal stenosis or lumbar spinal stenosis combined with intervertebral disc herniation had been treated via transforaminal approach spinal endoscopy. Our study retrospectively analyzed the treatment outcome. All patients experienced complications with different degrees of facet joint hyperplasia and ligamentum flavum hyperplasia and hypertrophy. Some patients suffered disc herniation. All patients were treated with percutaneous transforaminal approach multiple planar endoscopic decompression. The visual analog scale (VAS) and the Oswestry Disability Index (ODI) were compared before and after the operation, as were the horizontal foramen areas of the medial margins of the upper and lower pedicles of the vertebral arch. The treatment effectiveness was evaluated.Results: VAS and ODI scores were significantly improved at postoperative 3 days, 3 months, 6 months, and the last follow-up (P &lt; 0.05). The area of the intervertebral foramen was 422.5 ± 159.2 mm2 preoperatively and 890.8 ± 367.7 mm2 postoperatively, the difference was statistically significant (P &lt; 0.05).Conclusion: Percutaneous transforaminal approach multiple planar endoscopic decompression could achieve an accurate and effective decompression of the lumbar lateral spinal canal. This procedure has good short-term effects, and is especially suitable for elderly patients.

Neurological safety of spinal surgery for nucleus pulposus removal under spinal endoscopic imaging guided by inter laminar spine

Original Article Bin Chen1, Zengfeng Du2 ABSTRACTObjective: To explore the technical points, approach selection and short-term clinical efficacy of PELD through the intervertebral foramina or interlaminar approach in the treatment of highly shifted LDH. Methods: From September 2018 to June 2020, 19 patients with highly shifted LDH were treated with PELD in The First Hospital of Yulin. It included, 10 males and 9 females; aged 34 to 69 years, with an average of 48 years. Thirteen cases were shifted to the caudal side, and six cases were shifted to the head side. The responsible segments included L3/41 cases, L4/511 cases, and L5/S17 cases. All patients had symptoms of low back and leg pain. The Sowerby dysfunction index (ODI) was 63.5%±10.7% before surgery. The visual analogue scale of pain (VAS) was low back pain (5.2±2.1) and leg pain (7.1±2.4). 14 cases used transforaminal approach, and 5 cases used translaminar approach. Results: All cases completed the operation successfully, the operation time was 60~110min, with an average of 70 minutes. The follow-up time ranged from 6 to 42 months, with an average of 20.8 months. At the last follow-up, ODI was 10.8%±6.8%, VAS back pain score (2.1±1.1) and leg pain score (1.8±0.9). Compared with preoperative, ODI and VAS scores were significantly decreased (P<0.05). The results of Mac Nab method were 14 excellent, four good, and one fair. During the follow-up period, one patient’s leg pain symptoms recurred seven days after operation. No further hernia was found under intervertebral foramen. The symptoms disappeared after two weeks of symptomatic treatment such as swelling and analgesia, and he was discharged. No perioperative complications such as infection and nerve root injury occurred. Conclusion: When PELD is used to treat high-displacement LDH, the choice of transforaminal approach or interlaminar approach needs to be personalized according to the LDH segment and the direction of displacement. KEYWORDS: Spinal Surgery, Spinal Endoscopic Imaging, Inter Laminar Spine, Nucleus Pulposus Removal. doi: https://doi.org/10.12669/pjms.37.6-WIT.4880How to cite this:Chen B, Du Z. Neurological safety of spinal surgery for nucleus pulposus removal under spinal endoscopic imaging guided by inter laminar spine. Pak J Med Sci. 2021;37(6):1667-1671. doi: https://doi.org/10.12669/pjms.37.6-WIT.4880 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A comparative evaluation of kambin’s triangle approach versus safe triangle approach for lumbar transforaminal epidural injection in patients with lumbar radiculopathy - A prospective, randomized, double blind study

Background: Epidural injection of steroid and local anaesthetic is a common modality for management of radicular pain. Transforaminal approach is preferred for epidural injection in case of radiculopathy. Aims and Objectives: To compare the effect of the Kambin’s triangle and subpedicular approaches of transforaminal epidural injection (TFEI) in patients of lumbar radiculopathy. Materials and Methods: Forty patients with lumbar radicular pain were enrolled and randomly assigned to each group (Group K for Kambin’s triangle approach and Group S for subpedicular approach). All procedures were performed under fluroscopic guidance. The frequency of complications during the procedure and the effect of TFEI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual Analog scale (VAS). Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors and the therapeutic effect. Result: VAS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups. There were no statistical differences in changes of VAS between these two groups. Spinal nerve pricking occurred in one case of the subpedicular and in none of the cases of the Kambin’s triangle approach (p<0.05). Conclusion: Kambin’s triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages (i.e., less spinal nerve pricking during procedure). So, Kambin’s triangle approach may be an alternative method for TFEI in cases where needle tip positioning in the anterior epidural space is difficult.