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   Table of Contents - Current issue
October-December 2022
Volume 9 | Issue 4
Page Nos. 185-242

Online since Friday, December 30, 2022

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From the Desk of Editor in Chief p. 185
J K.B.C. Parthiban
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Expanding horizons of cervical endoscopic spine surgery: Important surgical landmarks and technical pearls p. 186
Jayesh Sardhara, Ashutosh Kumar
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Endoscopic techniques for lumbar degenerative disc disease: The problem of plenty! p. 193
Chandrashekhar Gendle, Sivashanmugam Dhandapani
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Full endoscopic anterior cervical discectomy and interbody fusion in patients with cervical spondylotic myelopathy p. 195
Kang Taek Lim
Background: For the surgical treatment of cervical spondylotic myelopathy (CSM), anterior decompression with fusion or posterior decompression using microscopy has been used widely as the standard procedure, depending on the location of pathology and the surgeon's preference. Endoscopic anterior cervical discectomy and interbody fusion (E-ACDF) is a minimally invasive, effective surgical option for the management of CSM. The advantages of using endoscopy for anterior cervical discectomy and interbody fusion (ACDF) are better visualization of the operative field with the possibility of changing the angle of the endoscope. This reduces the damage to the normal anatomical structure. Although long-term follow-up results are needed to evaluate fusion rate and complication, this appears to be a safe and feasible alternative to conventional ACDF for CSM. In this article, we have described the surgical technique, summarized the endoscopic process to discuss its operative strategies, and reviewed the radiographic records, pre- and postoperatively. Material and Methods: This retrospective review study included 36 cases aged 37 to 65 years, with CSM at one segment. All of them underwent full E-ACDF from January 2018 to April 2021. All patients were followed up for 12 months after the procedure by outpatient interviews. The clinical outcomes were evaluated based on the Visual Analog Scale (VAS) of the arm, and Japanese Orthopedic Association (JOA) score with clinical data at preoperative, 3, and 12 months after the operation. Hirabayashi method was used to assess the neurological recovery after 12 months of operation. Radiological outcomes were evaluated using plain radiography and magnetic resonance imaging, computed tomography scan to evaluate disc height, cervical lordosis (Cobb's angle), and solid fusion. Results: The mean operation time was 150 min (range 120–170 min) and the average length of hospital stay was 2 ± 3 days. There was one case of immediate postoperative anterior neck hematoma, which required open revision surgery. There was no case of infection or damage to the anterior visceral organ. The mean VAS scores for arm pain and mean JOA scores after endoscopic ACDF were significantly improved compared with before the operation during the follow-up period. The recovery rate, which was evaluated by the Hirabayashi method, looked good enough to indicate well recovered postoperatively. The disc height changed from 5.2 mm preoperatively to 6.2 mm after immediate postoperative and 5.9 mm after 6 months (P < 0.01). Cervical lordosis as Cobb's angle between C2 and C7 was significantly improved compared to the preoperative one during the follow-up periods also. The bone fusion rate was 100% at 6 months after the operation, and there was no segmental instability. Conclusions: The present study demonstrates that E-ACDF is a minimally invasive and effective surgical option for the surgical management of CSM. Based on the present study, E-ACDF may potentially enable the avoidance of various shortcomings related to surgical approaches. Through a sort of preliminary investigation, the authors confirmed the feasibility of E-ACDF and presented comparable outcome results, which might dispel the safety concern because of only one complication of wound hematoma. Better-designed randomized controlled studies with larger sample sizes in longer-term follow-ups are strongly warranted.
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Interlaminar full-endoscopic discectomy for L5-S1 disc herniations: Surgical technique and early outcomes during the learning curve p. 205
Umesh Srikantha, Yadhu K Lokanath, Akshay Hari, BS Deepak
Background: Interlaminar full endoscopic discectomy has been the least invasive and preferred route to treat disc herniations at L5-S1 and are being increasingly accepted and adopted in many centres. Compared to transforaminal approach, it offers the advantage of a familiar posterior approach with presumably easier transition for surgeons who have been doing another form of minimally invasive spine surgery. Objective: The article describes the surgical steps and early outcomes along the initial learning curve of Interlaminar Endoscopic discectomy for herniated disc at L5-S1 level. Material and Methods: This retrospective study included the first 20 patients who underwent Interlaminar Endoscopic Lumbar Discectomy (IELD) at our center. Patients with unilateral symptoms, failed conservative treatment, and good interlaminar window were selected for IELD. Visual Analog Scale (VAS) score s and McNab criteria were used to assess the outcome. Postoperative magnetic resonance imaging (MRI) was done in the majority of patients to assess and correlate the adequacy of root decompression and extent of discectomy. Results: The mean age of the 20 patients was 41 years (17 to 60 yr) with a male: female ratio of 3:2. The median surgical time was 80 min (40 to 150 min). The mean VAS scores for leg pain reduced from 8.2 preoperatively to 2.1 in the postoperative period. All patients had a minimum follow-up for 6 months. Postoperative MRI was done in 14 patients, which showed complete fragment removal with the good decompression of the nerve root in 12 patients. There was no early recurrence of radicular symptoms in any patient. According to Modified McNab criteria, 8 patients had excellent outcome, 9 patients had good outcome, and 3 patients did fairly well. Conclusion: IELD offers an excellent alternative to tubular surgeries for treating disc pathologies at L5-S1. This series represents the early reports from the first 20 cases at the author's center who have been performing tubular surgeries for more than a decade. With the learning curve been overcome, the technique could be used in a wider array of lumbar spine pathologies henceforth.
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Awake spinal fusion - Endoscopic facet sparing transforaminal lumbar interbody fusion under caudal epidural: A game changer p. 212
Rahul Ahluwalia
Background: Trans-Kambin fusion offers the advantage of providing reduced morbidity and awake surgery allowing for patient's own neuromonitoring during the procedure, along with reduced hospital stay, early mobilization, reduced blood loss, and reduced operative time, while maintaining the standard of fusion that can be achieved with open/MISS transforaminal lumbar interbody fusion. Objective: Spinal fusions done under GA have restrictions when it comes to patients with OSA/COPD/Cardiac dysfunction, etc. Awake Endoscopic Spinal fusion surgeries can provide a novel solution to such patients. Material and Methods: EKLIF was performed in total of 19 patients with 17 single-level and 02 patients with multilevel lumbar discopathy and/or degenerative spondylolisthesis resulting in axial back pain and claudication, pseudoradicular, or radicular symptoms. Endoscopic discectomy and interbody cage insertion were performed through a 1 cm lateral incision used for transforaminal access, followed by percutaneous pedicle screw-rod fixation. Clinical outcome was assessed by early postoperative pain scores (visual analog score [VAS]). Fusion rates were assessed by X-rays at 6 months. Clinical outcome, time in the operating room, intraoperative blood loss, VAS at preoperative, immediate postoperative, and after 6 months were determined. Results: Excellent and good clinical results were obtained in 16 (84%) out of 19 patients at 6 months. The mean time spent in the operating room 71 min and no patient required a blood transfusion. The mean hospital stay was 2.8 days, with one patient having a prolonged stay of 8 days due to an intraoperative dural tear that was managed conservatively. There was no morbidity related to instrumentation. Postoperative stay was reduced with all patients mobilized on the next day of surgery. Fusion was visible in all patients on follow-up imaging at 6 months. The mean VAS of the study group before surgery was 6.63 with a significant change to 2.94 in the immediate postoperative period. At 6-month follow-up, the mean VAS was 1.3. Conclusions: EKLIF allows for safe and efficient minimally invasive treatment of single and multilevel degenerative lumbar instability with good clinical results. Further prospective studies investigating long-term functional results are required to assess the definitive merits of trans-Kambin fusion of the lumbar spine.
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Endoscopic transcervical approach for single-stage anterior decompression and stabilization for atlantoaxial dislocation p. 218
Shailendra Ratre, Yad Ram Yadav, Jitin Bajaj, Narayan M Swamy, Vijay Singh Parihar, Mallika Sinha, Ketan Hedaoo, Jitendra Shakya
Background: Anterior and posterior approaches are used for the management of atlantoaxial dislocation (AAD). Anterior decompression is required in some patients in whom the C1–2 dislocation is not properly reduced by the posterior approach. It can be done using transnasal, transoral, or transcervical approaches. The endoscopic transcervical approach can be used for single-stage decompression and stabilization that includes an odontoidectomy and anterior fusion. Objective: To determine the surgical outcomes of endoscopic transcervical approach for single-stage decompression and fixation for atlantoaxial dislocation. Material and Methods: This was a prospective observational study done at a tertiary center specialized for endoscopic neurosurgery during the period from 2015 to 2021. All surgeries were performed under endoscopic control. Data were collected for the extent of decompression, amount of blood loss, operative time, need for conversion to microscopy, and complications. Results: The age ranged from 5 to 68 years, and follow-up from 12 to 84 months (average = 46 months). Preoperatively, 54 patients were in the Ranawat Grade 3b, 43 in the Ranawat Grade 3a, and 5 in Grade 2. A total of 42 patients needed odontoidectomy with median C2 corpectomy. Conversion to a microscopic approach was not required in any case. Of 102 patients, 90 improved to Ranawat Grade 1, 7 patients to Grade 2, and 5 patients to Grade 3a. The blood loss was between 25 and 100 ml (average = 68 ml). Two patients suffered from screw pull-out. One patient had re-dislocation and was managed with redo surgery. There was no mortality. Conclusion: Endoscopic transcervical single-stage decompression and stabilization is a safe and effective technique for AAD.
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Role of microendoscopic discectomy for the treatment of recurrent lumbar disc herniation: A retrospective review p. 224
Rakeshkumar C Luhana, Jinil N Doshi, Ankit Khodifad
Background: Recurrent herniation following lumbar disc excision has been reported in 5–11% of patients. There are very few studies on role and outcomes of minimally invasive techniques for the treatment of recurrent disc herniation. Study Design: A retrospective analytical study of 22 patients with recurrent lumbar disc herniation treated with minimally invasive techniques. Objectives: To analyze the role and scope of minimally invasive surgical techniques and consequent outcome in various cases of recurrent lumbar disc herniation. Method: Total 22 patients with recurrent lumbar disc herniations who underwent operations in the form of microendoscopic discectomy (MED) were studied for a period of 1 year. These cases of recurrent lumbar disc herniation with the perioperative data and clinical outcomes (according to modified Macnab criteria) upto 1 year follow up were compared with the previously published data. Results: Overall, the clinical outcomes were significantly excellent or good during and at 1 year follow-up. No case had to be converted to open procedure. Complications occurred in three cases including one incidental durotomy and two patients had recurrent disc herniation. No other significant morbidity including wound infection, neural injury or residual instability occurred till last follow-up. Operative duration, blood loss, complication rate and overall outcomes were statistically comparable to the previously published data. Conclusions: This study suggests that outcomes of minimally invasive techniques for treating recurrent lumbar disc herniation are equivalent to or even superior in some cases in which conventional open surgery was considered. The operative time, blood loss and complications of patients treated with revision MED were comparable to the previously published data. The procedure appears to be a safe and effective alternative with significant improvement in pain, disability, and faster return to work in case of recurrent lumbar disc herniation.
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Endoscopic transforaminal lumbar interbody fusion: Technical note p. 231
Sukumar Sura, K Mahesha, Gaurav Chamle, Abhinandan Reddy Mallepally, Ajaykumar Allamwar, Naresh Kumar Pagidimarry
With recent advanced tools in hands, spine surgery is leaping towards the whole new era, conventional open spine surgeries are being replaced by the minimally invasive endoscopic spine procedures. With evolution of endoscopy, long list of objectives is possible to achieve like minimize the trauma of surgery and the reductions of surgical blood loss, hospital stay, and complication rates. Traditional open lumbar fusion surgery and in last decade minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) have become the standard treatment for the lumbar spine disorders. However, MIS-TLIF techniques still require an access through musculature for tube placement with considerable trauma to the musculature and bone resection. Thus, MIS-TLIF represents an incremental but not revolutionary advancement over the existing open surgical methods. With endoscopy-assisted transforaminal/transkambian Interbody fusion with MIS spine fixation provides a better and minimally invasive way of TLIF. In this article, we will discuss the technique of Endo TLIF, pearls, and pitfalls.
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Technical note: A modified wiltse technique for minimally invasive surgery transforaminal lumbar interbody fusion p. 236
Mohit Goyal, Asheesh Tandon, Alok Agrawal
Background: Conventional midline dorsal approach to spine leads to excessive muscle retraction and hence muscular injury, denervation, atrophy, or ischemic necrosis. Wiltse paraspinal approach prevents these complications. We present a modified Wiltse approach using minimally invasive surgery techniques for fixation of lumbar spinal instability patients. Methods: Here, we provide a step wise description of the modified Wiltse approach. We then put together, a step wise analysis of the preparation, patient positioning, skin incision, fascial opening, dissection, bone identification, retractors, deprioritization, decompression, discectomy, instrumentation, arthrodesis, and closure for the Wiltse technique. Conclusion: The classical approach described by Wiltse is essentially minimally invasive, sparing both the muscle planes and soft tissues. Adding a modification with tubular retractor system gives an additional advantage of muscle-sparing discectomy and fusion with a very low complication rate.
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Commentary on “Endoscopic Transforaminal Lumbar Interbody Fusion – Technical note” p. 240
Junseok Bae
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Publication comments on the manuscript titled “Awake Spinal Fusion-endoscopic Facet Sparing Transforaminal Interbody Fusion under Caudal Epidural, a Game Changer” p. 242
Jun Ho Lee
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