Tag: minimally invasive

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Combined “Hybrid” Open and Minimally Invasive Surgical Correction of Adult Thoracolumbar Scoliosis: A Retrospective Cohort Study

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Neurosurgery 72:151–159, 2013

Surgery for scoliosis requires extensive exposure, resulting in significant tissue injury and longer recovery times. To minimize morbidity in scoliosis surgery, several studies have shown successful application of a combination of minimally invasive techniques; however, the extent of scoliosis treated has been modest.

OBJECTIVE: To achieve some of the benefits of minimally invasive surgery and yet treat curves of greater degree, we have used a combined approach, incorporating both open and minimally invasive techniques.

METHODS: We analyzed a prospectively acquired database in addition to reviewing electronic records of patients undergoing hybrid surgery for thoracolumbar scoliosis. Nine patients were identified. The minimally invasive portion involved the lumbar region in all cases. Pain was assessed by the visual analog scale and disability was measured by the Oswestry Disability Index.

RESULTS: Mean preoperative scoliosis was 47.8 degrees, which was corrected to a mean 15.2 degrees. An average of 7.8 spinal levels was treated. Estimated blood loss averaged 1094.4 mL, and length of hospital stay averaged 7.2 days. Acute complications occurred in 2 patients. Longer term complications occurred in 2 patients, consisting of adjacent segment disease. The mean improvement in the visual analog scale score was 3.7 and the mean improvement on the Oswestry Disability Index was 30.5. Average follow-up was 29.2 months.

CONCLUSION: The hybrid approach for the treatment of scoliosis results in acceptable radiographic and clinical outcomes. Complications did not appear increased compared with those expected with scoliosis surgery. Although decreased adjacent tissue injury was achieved with the minimally invasive component of the procedure, a larger comparative study is required to determine magnitude of this benefit.

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

Neurosurgery 71:86–92, 2012 DOI: 10.1227/NEU.0b013e31825356f5

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.

 

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Tubular Diskectomy vs Conventional Microdiskectomy for the Treatment of Lumbar Disk Herniation: 2-Year Results of a Double-Blind Randomized Controlled Trial

Neurosurgery 69:135–144, 2011 DOI: 10.1227/NEU.0b013e318214a98c

Transmuscular tubular diskectomy has been introduced to increase the rate of recovery, although evidence is lacking.

OBJECTIVE: To evaluate the 2-year results of tubular diskectomy compared with conventional microdiskectomy.

METHODS: Three hundred twenty-eight patients with persistent leg pain caused by lumbar disk herniation were randomly assigned to undergo tubular diskectomy (167 patients) or conventional microdiskectomy (161 patients). Main outcome measures were scores from Roland-Morris Disability Questionnaire for Sciatica, Visual Analog Scale for leg pain and low-back pain, and Likert self-rating scale of global perceived recovery.

RESULTS: On the basis of intention-to-treat analysis, there was no significant difference between tubular diskectomy and conventional microdiskectomy in Roland-Morris Disability Questionnaire for Sciatica scores during 2 years after surgery (between-group mean difference [∆] = 0.6; 95% confidence interval [CI], 20.3-1.6). Patients treated with tubular diskectomy reported more leg pain (∆ = 3.3 mm; 95% CI, 0.2-6.2) and more lowback pain (∆ = 3.0 mm; 95% CI, 20.2-6.3) than those patients treated with conventional microdiskectomy. At 2 years, 71% of patients assigned to tubular diskectomy documented a good recovery vs 77% of patients assigned to conventional microdiskectomy (odds ratio, 0.76; 95% CI, 0.45-1.28; P = .35). Repeated surgery rates within 2 years after tubular diskectomy and conventional microdiskectomy were 15% and 10%, respectively (P = .22).

CONCLUSION: Tubular diskectomy and conventional microdiskectomy resulted in similar functional and clinical outcomes. Patients treated with tubular diskectomy reported more leg pain and low-back pain, although the differences were small and not clinically relevant.

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Minimally Invasive Lumbar Interbody Fusion in Patients Older Than 70 Years of Age: Analysis of Peri- and Postoperative Complications

Neurosurgery 68:897–902, 2011 DOI: 10.1227/NEU.0b013e3182098bfa

The number of spine operations performed in the elderly population is rising.

OBJECTIVE: To identify and describe perioperative and postoperative complications in patients 70 years and older who have undergone minimally invasive lumbar interbody spine fusion.

METHODS: A retrospective analysis was performed on 66 consecutive patients aged 70 years or older who underwent a minimally invasive interbody lumbar fusion. Electronic medical records were analyzed for patient demographics, procedures, and perioperative and postoperative complications.

RESULTS: Between 2000 and 2009, 66 patients with an average age of 74.9 years (range, 70-86 years) underwent 68 lumbar interbody fusions procedures. The mean follow-up was 14.7 months (range, 1.5-50 months). The minimally invasive approaches included 41 cases of extreme lateral interbody fusion and 27 minimally invasive transforaminal lumbar interbody fusions. We observed 5 major (7.4%) and 17 minor (25%) complications. The 5 major complications consisted of 4 cases of interbody graft subsidence and 1 adjacent level disease. There were no intraoperative medical complications. There were no myocardial infarctions, pulmonary embolisms, hardware complications requiring removal, wound infections, major visceral, vascular, neural injuries, or death in the study period.

CONCLUSION: Minimally invasive interbody fusions can be performed in the elderly (ages 70 years and older) with an overall low rate of major complications. Graft subsidence in this population when not supplemented with posterior instrumentation is a concern. Age should not be a deterrent to performing complex minimally invasive interbody fusions in the elderly.

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Minimally invasive percutaneous transpedicular screw fixation: increased accuracy and reduced radiation exposure by means of a novel electromagnetic navigation system

Acta Neurochir (2011) 153:589–596. DOI 10.1007/s00701-010-0882-4

Minimally invasive percutaneous pedicle screw instrumentation methods may increase the need for intraoperative fluoroscopy, resulting in excessive radiation exposure for the patient, surgeon, and support staff. Electromagnetic field (EMF)-based navigation may aid more accurate placement of percutaneous pedicle screws while reducing fluoroscopic exposure. We compared the accuracy, time of insertion, and radiation exposure of EMF with traditional fluoroscopic percutaneous pedicle screw placement.

Methods Minimally invasive pedicle screw placement in T8 to S1 pedicles of eight fresh-frozen human cadaveric torsos was guided with EMF or standard fluoroscopy. Setup, insertion, and fluoroscopic times and radiation exposure and accuracy (measured with post-procedural computed tomography) were analyzed in each group.

Results Sixty-two pedicle screws were placed under fluoroscopic guidance and 60 under EMF guidance. Ideal trajectories were achieved more frequently with EMF over all segments (62.7% vs. 40%; p=0.01). Greatest EMF accuracy was achieved in the lumbar spine, with significant improvements in both ideal trajectory and reduction of pedicle breaches over fluoroscopically guided placement (64.9% vs. 40%, p=0.03, and 16.2% vs. 42.5%, p=0.01, respectively). Fluoroscopy time was reduced 77% with the use of EMF (22 s vs. 5 s per level; p<0.0001) over all spinal segments. Radiation exposure at the hand and body was reduced 60% (p=0.058) and 32% (p=0.073), respectively. Time for insertion did not vary between the two techniques.

Conclusions Minimally invasive pedicle screw placement with the aid of EMF image guidance reduces fluoroscopy time and increases placement accuracy when compared with traditional fluoroscopic guidance while adding no additional time to the procedure.

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Endoscopic endonasal transclival resection of chordomas: operative technique, clinical outcome, and review of the literature

J Neurosurg 112:1061–1069, 2010. DOI: 10.3171/2009.7.JNS081504

Transcranial approaches to clival chordomas provide a circuitous route to the site of origin of the tumor often involving extensive bone drilling and brain retraction, which places critical neurovascular structures between the surgeon and pathology. For certain chordomas, the endonasal endoscopic transclival approach is a novel minimal access, but it is an equally aggressive alternative providing the most direct route to the tumor epicenter.

Methods. The authors present a consecutive series of patients undergoing endonasal endoscopic resection of clival chordomas. Extent of resection was determined by postoperative volumetric MR imaging and divided into > 95% and < 95%.

Results. Seven patients underwent 10 operations. Preoperative cranial neuropathies were present in 4. The mean patient age was 52.0 years. The mean tumor volume was 34.9 cm3. Intraoperative lumbar drainage was used in 1 patient, and the tumors extended intradurally in 3. One patient underwent 2 intentionally palliative procedures for subtotal debulking. Greater than 95% resection was achieved in 7 of 8 operations in which radical resection was the goal (87%). All tumors with volumes < 50 cm3 had > 95% resection (p = 0.05). The overall mean follow-up was 18.0 months. Cranial neuropathies resolved in all 3 patients with cranial nerve VI palsies. One patient with recurrent nasopharyngeal chordoma died of disease progression; another experienced 2 recurrences before receiving radiation therapy. All surviving patients remain progression free. There were no intraoperative complications; however, 1 patient developed a pulmonary embolus postoperatively. There were no postoperative CSF leaks.

Conclusions. The endonasal endoscopic transclival approach represents a less invasive and more direct approach than a transcranial approach to treat certain moderate-sized midline skull base chordomas. Longer follow-up is necessary to determine comparability to transcranial approaches for long-term control. Large tumors with significant extension lateral to the carotid artery may not be suitable for this approach.

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Posterior Lumbar Interbody Fusion: Comparison of Single Intervertebral Cage and Single Side Pedicle Screw Fixation versus Bilateral Cages and Screw Fixation

Minim Invas Neurosurg 2009; 52: 132 – 136. DOI 10.1055/s-0029-1224097

Introduction: The efficacy and economy of an alternative sparing method for posterior lumbar interbody fusion (PLIF) using a single cage fixed with pedicle screws placed on a single side (SS group, n = 22) was compared to that of a standard bilateral protocol using two cages and pedicle screws placed bilaterally (BL group, n = 15).

Methods: All PLIFs were non-compensation cases done at a single level by a single surgeon and were similar in most background characteristics. Significant differences were not found between the two groups in fusion rates, complications or in 2-year prospectively collected outcomes including percent improvement in back and leg pain (visual analog scales) and the Oswestry disability index.

Results: Perioperative results significantly favored the SS group: BL patients lost 81 % more blood, used 74 % more time for surgery, stayed in hospital 1.7 days longer, and the hospital-related cost per procedure was twice as high. Currently, the SS procedure typically averages less than 1 hand blood loss less than 50 mL. In summary, the BL and SS groups had similar outcomes while the SS procedure provided substantially superior efficiency and economy.

Conclusion: In conclusion, the results of this retrospective comparative level III study warrant further studies on the SS protocol which may lead to the adoption of this minimally invasive protocol in the standard practice of PLIF in selected cases.

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