Faculty Bibliography

BACKGROUND:Thoracic disc herniations (TDHs) are rare, comprising <1% of all disc herniations, but when symptomatic can cause severe neurological dysfunction. Traditional open and mini-open approaches allow for ventral canal decompression but are associated with high morbidity, including pulmonary complications, chest tube placement, and frequent need for fusion. Full-endoscopic thoracic discectomy has emerged as an ultra-minimally invasive alternative with reduced complications and faster recovery, but its application to midline or calcified thoracic discs remains technically demanding. CASE PRESENTATION/METHODS:We report the case of a 54-year-old man with progressive chest wall pain and lower-extremity hyperreflexia who was found to have a T6 to T7 central disc herniation with mild calcification and spinal cord signal change. The patient underwent an outpatient right-sided full-endoscopic transforaminal discectomy. Complete decompression was achieved without spinal cord retraction or manipulation. The patient had complete resolution of his preoperative pain and was discharged home within 2 hours. DISCUSSION/CONCLUSIONS:Compared with open thoracic discectomy, endoscopic approaches significantly lower complication rates, blood loss, hospital stay, and cost while preserving motion segments. Our case highlights strategies for addressing technically challenging central TDHs, including lateralized access, controlled bony resection, and angled instrumentation. These methods align with growing evidence demonstrating the safety and efficacy of endoscopy in thoracic pathology, though the technique requires advanced endoscopic expertise and careful patient selection. CONCLUSION/CONCLUSIONS:Full-endoscopic transforaminal discectomy provides a safe, effective, and minimally invasive option for central TDHs in selected cases. With proper planning and advanced technical execution, endoscopic surgery can achieve decompression comparable to open surgery while minimizing morbidity and expediting recovery.

BACKGROUND:Lateral lumbar interbody fusion is a widely used technique to address degenerative lumbar conditions but can be associated with injury to the psoas, lumbar plexus, and abdominal wall owing to retractor usage. We describe a minimally invasive endoscopic lateral lumbar interbody fusion (ELLIF) procedure that aims to reduce these complications by avoiding prolonged muscle retraction, preparing the disc space under direct endoscopic vision, and shortening the surgical time. METHODS:Between 2019 and 2024, 35 patients underwent ELLIF at a single center. Discectomy, endplate preparation, and iliac crest harvest were done via a working-channel endoscope without expandable retractors. Neurophysiological monitoring was used to minimize nerve injury. Outcomes included complications, visual analog scale scores for pain, and Oswestry Disability Index (ODI). RESULTS:< 0.001). By the 3-year follow-up in 9 patients, ODI scores remained near normal, and visual analog scale was reduced by 93% from baseline. CLINICAL RELEVANCE/CONCLUSIONS:We present a minimally invasive, ELLIF, and decompression technique that provides patients with minimal complications and excellent functional recovery. CONCLUSION/CONCLUSIONS:ELLIF offers a safe, minimally invasive alternative for patients with lumbar degenerative disease. This technique minimizes direct retraction on the psoas and lumbar plexus, resulting in a low complication rate and substantial functional recovery at short- and medium-term follow-up.

OBJECTIVE:The role of prophylactic musculocutaneous flap closure following posterior spine surgery remains under-characterized. This study presents a single-institution experience with paraspinous-only musculocutaneous flap reconstruction among high-risk patients following spine surgery. Associations between risk factors, surgical indication, intraoperative characteristics, and postoperative wound complications are explored. METHODS:A retrospective chart review identified all cases of prophylactic paraspinous flap reconstruction following posterior spine over an 11-year period. Patients who had uncomplicated postoperative courses were compared to those who developed wound complications. Multivariate logistic regression characterized associations among risk factors, surgical indication, and wound complications. RESULTS:Two hundred fifty-seven patients underwent primary prophylactic closure using paraspinous musculocutaneous flaps only. 49.4% female, with a mean age of 60.7±13.9 years. Surgical indications included degenerative disease (n=124, 48.2%), tumor (n=78, 30.4%), deformity (n=22, 8.6%), congenital anomaly (n=18, 7.0%), and trauma (n=15, 5.8%). This population exhibited high-risk features, including diabetes (19.5%), history of smoking (53.3%), prior spine surgery (58.8%); mean body mass index was 30.1±6.9. Wound complications occurred in 37 patients (14.4%). Postoperative complications coincided with greater number of incised levels, higher degree of instrumentation, and longer closure length. CONCLUSIONS:Prophylactic flap closure was associated with wound complication rates consistent with the literature in cohorts with substantial comorbidity burden. Outcomes were predominantly influenced by procedural factors rather than baseline patient characteristics. The findings support the feasibility of prophylactic flap closure in high-risk patients across the spectrum of spinal indications. Controlled studies are necessary to evaluate effectiveness.

INTRODUCTION/UNASSIGNED:Endoscopic spine surgery (ESS) has evolved considerably, yet there remains a lack of consensus on patient selection, technical specifications, and outcome reporting. This heterogeneity hinders collaborative efforts to establish comprehensive evidence-based practices. RESEARCH QUESTION/UNASSIGNED:To develop core outcome sets (COS) and reporting guidelines for ESS for disc disease through an international consensus. MATERIAL AND METHODS/UNASSIGNED:We established a multidisciplinary, international expert panel through literature review and peer-to-peer recruitment. Between January and April 2025, we employed a three-round modified Delphi technique. Items spanned three domains: patient characteristics, practices and outcomes. Propositions endorsed by ≥ 75 % of participants were classified as 'strong' and included in the COS. Those with 50-75 % were reconsidered in the subsequent round, requiring ≥66 % for inclusion as 'moderate'. RESULTS/UNASSIGNED:The panel consisted of 77 spine surgeons from Europe (61 %), Asia (14 %), and North America (13 %), with 58 completing all three rounds. Of 183 items (165 initially provided, 18 participant add-ons), agreement was reached on 99 items (82 strongly and 17 moderately). Key consensus elements included demographics, comorbidities, clinical complaints, imaging findings, surgical indications, technical parameters, and outcome measures such as pain scores, functional outcomes, and complications. DISCUSSION AND CONCLUSION/UNASSIGNED:We established the Neurocore-SENSED framework, comprising COS and reporting guidelines for ESS for disc disease. This consensus addresses fundamental heterogeneity in ESS research, complementing existing nomenclature and indication-specific guidelines. By enhancing consistency, comparability, and quality of ESS research, this framework aims to accelerate the development of evidence-based practices that optimize patient outcomes in this rapidly advancing field.

Hemorrhagic facet cysts are a rare condition including both synovial and ganglion cysts. Here, the authors present the first-ever reported case of a hemorrhagic ganglion cyst of the facet joint at L1 to L2 causing cauda equina syndrome. In this report, a 72-year-old woman presented with symptoms of cauda equina syndrome requiring urgent surgical consideration. Magnetic resonance imaging and computed tomography showed an extradural mass at the L1 to L2 level. Due to the giant size of the cyst, there was severe compression of the thecal sac and nerve roots. The patient underwent interlaminar contralateral decompression and cystectomy using a uniportal endoscopic approach. The patient had a quick postoperative recovery, with postoperative magnetic resonance imaging of the lumbar spine showing recovery of the facet cyst with no sign of recurrence or stenosis. This case demonstrates the successful surgical technique of interlaminar endoscopic contralateral decompression combined with cystectomy, showing that a hemorrhagic ganglion cyst at the facet at L1 to L2 can be removed completely under endoscopic view.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Emergency department (ED) utilization and readmission rates after spine surgery are common quality of care measures. Limited data exist on the evaluation of quality indicators after full-endoscopic spine surgery (FESS). The objective of this study was to detect rates, causes, and risk factors for unplanned postoperative clinic utilization after FESS. METHODS:This retrospective multicenter analysis assessed ED utilization and clinic readmission rates after FESS performed between 01/2014 and 04/2023 for degenerative spinal pathologies. Outcome measures were ED utilizations, hospital readmissions, and revision surgeries within 90 days postsurgery. RESULTS:Our cohort includes 821 patients averaging 59 years of age, who underwent FESS. Most procedures targeted the lumbar or sacral spine (85.75%) while a small fraction involved the cervical spine (10.11%). The most common procedures were lumbar unilateral laminotomies for bilateral decompression (40.56%) and lumbar transforaminal discectomies (25.58%). Within 90 days postsurgery, 8.0% of patients revisited the ED for surgical complications. A total of 2.2% of patients were readmitted to a hospital of which 1.9% required revision surgery. Primary reasons for ED visits and clinic readmissions were postoperative pain exacerbation, transient neurogenic bladder dysfunction, and recurrent disk herniations. Our multivariate regression analysis revealed that female patients had a significantly higher likelihood of using the ED ( P = .046; odds ratio: 1.77, 95% CI 1.01-3.1 5.69% vs 10.33%). Factors such as age, American Society of Anesthesiologists class, body mass index, comorbidities, and spanned spinal levels did not significantly predict postoperative ED utilization. CONCLUSION/CONCLUSIONS:This analysis demonstrates the safety of FESS, as evidenced by acceptable rates of ED utilization, clinic readmission, and revision surgery. Future studies are needed to further elucidate the safety profile of FESS in comparison with traditional spinal procedures.

BACKGROUND:Atlantoaxial pseudoarticulation is a rare condition characterized by atypical joint formation at C1-2, potentially causing severe neck pain and progressive cervical myelopathy due to spinal cord compression. Traditional treatments often involve decompression with or without fusion and can lead to significant tissue disruption and extended recovery time. Here, the authors describe a novel, minimally invasive full endoscopic technique for resecting atlantoaxial pseudoarticulation, achieving successful spinal decompression. OBSERVATIONS/METHODS:A 44-year-old female patient presented with 6 months of progressive cervical myelopathy, including gait instability, right-sided weakness, and numbness. Imaging confirmed a C1-2 pseudoarticulation causing severe spinal cord compression. A paraspinal endoscopic approach was used, avoiding the need for instrumented fusion. Postoperatively, the patient's condition rapidly improved, with complete symptom resolution at 6 months and only mild intermittent hand numbness at 18 months. Imaging confirmed stable, effective decompression without complications. LESSONS/CONCLUSIONS:This case represents the first documented application of a full endoscopic approach for atlantoaxial pseudoarticulation, achieving effective decompression while preserving spinal integrity and reducing recovery time. This technique offers a promising, minimally invasive alternative for complex cervical pathologies, supporting a shift toward less invasive, tissue-sparing spinal surgery. https://thejns.org/doi/10.3171/CASE24766.

BACKGROUND AND CONTEXT/BACKGROUND:Unplanned readmission within 30 days following elective spine surgery is a key indicator of quality of care, as readmissions often signal early complications or poor recovery. The Hospital Readmission Reduction Program (HRRP) and the Centers for Medicare and Medicaid Services (CMS) utilizes this metric to assess hospital and surgeon performance. PURPOSE/OBJECTIVE:Here we aim to delineate quality of care metrics for full-endoscopic spine surgery (FESS) compared to traditional spine surgery. DESIGN/METHODS:The study was a retrospective multicenter analysis comparing outcomes of propensity matched cohorts. PATIENT SAMPLE/METHODS:The study included 908 FESS patients operated between 2014 and 2023 and a matched cohort of 73,906 non-FESS patients. OUTCOME MEASURES/METHODS:Our primary outcome measures were postoperative 30-day hospital readmissions and revision surgery. Furthermore, demographic data, hospitalization, surgical details and comorbidities were included. METHODS:Data were collected from 6 participating institutions. Patients older than 18 years undergoing noninstrumented FESS spine surgeries for degenerative lumbar spinal pathologies from 2016 to 2023 were included. A matched non-FESS cohort was identified in the ACS-NSQIP database (2015-2019). Propensity-score matching was used to compare the cohorts. RESULTS:Before matching, the 30-day readmission rate was significantly lower in the FESS cohort (1.1% vs 4.4%, p<.001), which remained consistent after matching (1.1% vs 4.5%, p<.001). The rate of 30-day surgical revisions was similar between cohorts (1.0% vs 1.1%, p=.63). Multivariate analysis indicated a significant correlation between FESS and reduced 30-day readmissions (odds ratio [OR] 0.28, 95% CI 0.14-0.57, p<.001). CONCLUSION/CONCLUSIONS:This study is the first to compare 30-day hospital readmissions between FESS and nonendoscopic surgeries in a large, matched multicenter cohort. FESS significantly reduces both the length of postoperative hospital stay and 30-day readmission rates compared to nonendoscopic approaches, underscoring the safety and effectiveness of outpatient FESS. Future studies are needed to define the role of FESS in more complex spine procedures.

BACKGROUND:Full endoscopic spine surgery (FESS) champions a rapid recovery and a low rate of overall complications. However, its efficacy in geriatric patients that might yield additional benefits from minimized invasiveness remains underexplored. METHODS:A multi-institutional prospective cohort study was conducted involving patients undergoing elective lumbar FESS. Participants were categorized into nongeriatric (18-69 years old) and geriatric (≥70 years old) groups. Studied variables included demographics, medical comorbidities, operative details, visual analog scale (VAS) for back and leg pain, and Oswestry Disability Index (ODI). A mobile application was leveraged to collect real-time data pre- and postoperatively. RESULTS:> 0.05 for VAS back, VAS leg, and ODI). CONCLUSIONS:FESS significantly improves pain and function in both geriatric and nongeriatric adults with degenerative lumbar conditions, with no difference in the degree of improvement between groups. CLINICAL RELEVANCE/CONCLUSIONS:These findings underscore the efficacy of FESS as a minimally invasive surgical option for elderly patients. Mobile application technology is useful for collecting patient-reported data in spine surgery clinical research.

INTRODUCTION/BACKGROUND:DISTINCT is a randomized controlled trial evaluating passive recharge burst SCS compared with CMM in improving pain and pain-related physical function in patients suffering from chronic back pain without prior lumbar surgery, and for whom corrective surgery is not an option. Sub-analyses of outcome measures are presented for a subset implanted with paddle leads at both 6 and 12 months. OBJECTIVE:To investigate the treatment effect of using BurstDR-capable SCS in nonsurgical low back pain (NSLBP) patients with paddle leads. METHODS:An independent board-certified spine surgeon reviewed each case, confirming a lack of corrective surgical options. Out of 29 sites and 115 implants, 10 sites implanted 50 patients with paddle leads. Primary and secondary endpoints assessed improvements in low back pain intensity (NRS), low back pain-related disability (ODI), pain catastrophizing (PCS), and patient global impression of change (PGIC). RESULTS:Data for patients with NSLBP and implanted with paddle leads are available for 47 and 44 patients at 6 and 12 months, respectively. Patients reported significant reductions in pain relief at 6 and 12 months, decreasing from 7.8 ± 1.2 at baseline to 2.0 ± 1.6 and 2.2 ± 2.2, respectively (p < 0.0001). Disability was substantially reduced (> 20 points) from severe to mild at 6 and 12 months; ODI reduced from 54.4 ± 15.0 at baseline to 19.9 ± 14.1 and 22.1 ± 13.6, respectively (p < 0.0001). Pain catastrophizing improved to reflect the average of a non-chronic pain population; decreased from 27.6 ± 13.1 at baseline to 8.1 ± 8.2 and 7.8 ± 9.9 (p < 0.0001). 93.2% of patients reported a moderately better-much-improved outcome on PGIC. Ten complications occurred in 9 patients, 3 being severe device-related events. Two explants were required; one due to infection and one due to persistent pain at the IPG site, and one lead-related event was resolved by surgical repositioning. CONCLUSIONS:Passive recharge burst using paddle leads provides substantial relief to patients suffering from severe, debilitating, NSLBP. Patients report significant improvements in pain, function, and pain-related emotional distress. In addition, the rate of adverse events is low, supporting a favorable safety profile.