Faculty Bibliography

BACKGROUND:Transforaminal endoscopic discectomy and foraminotomy is a well-described minimally invasive technique for surgically treating lumbar radiculopathy caused by a herniated disc and foraminal narrowing. OBJECTIVE:To describe the technique and feasibility of transforaminal foraminoplasty for the treatment of lumbar radiculopathy in patients who have already undergone instrumented spinal fusion. STUDY DESIGN/METHODS:Retrospective study. SETTING/METHODS:Hospital and ambulatory surgery center METHODS:After Institutional Review Board approval, charts from 18 consecutive patients with lumbar radiculopathy and instrumented spinal fusions who underwent endoscopic procedures between 2008 and 2013 were reviewed. RESULTS:The average pain relief one year postoperatively was reported to be 67.0%, good results as defined by MacNab. The average preoperative VAS score was 9.14, indicated in our questionnaire as severe and constant pain. The average one year postoperative VAS score was 3.00, indicated in our questionnaire as mild and intermittent pain. LIMITATIONS/CONCLUSIONS:This is a retrospective study and only offers one year follow-up data for patients with instrumented fusions who have undergone endoscopic spine surgery. CONCLUSION/CONCLUSIONS:Transforaminal endoscopic discectomy and foraminotomy could be used as a safe, yet, minimally invasive and innovative technique for the treatment of lumbar radiculopathy in the setting of previous instrumented lumbar fusion. IRB approval: Meridian Health: IRB Study # 201206071J

BACKGROUND:Transforaminal lumbar interbody fusion (TLIF) is a well-accepted fusion technique that uses unilateral facet removal as an oblique corridor for inserting an interbody spacer. This manuscript focused on five cases of endoscopic foraminotomy for patients presenting with recurrent radiculopathy after TLIF procedures. METHODS:After Institutional Review Board approval, charts from five patients with lumbar radiculopathy and instrumented TLIF procedures who underwent subsequent endoscopic procedures between 2011 and 2013 were reviewed. RESULTS:The average pain relief 1 year postoperatively was reported to be 63.8%, good results as defined by MacNab. The average preoperative visual analog scale (VAS) score was 9.5, indicated in our questionnaire as severe and constant pain. The average 1 year postoperative VAS score was 3.5, indicated in our questionnaire as mild and intermittent pain. CONCLUSION/CONCLUSIONS:Transforaminal endoscopic discectomy and foraminotomy could be used as a safe, yet, minimally invasive and innovative technique for the treatment of lumbar radiculopathy in the setting of previous instrumented lumbar fusion. IRB APPROVAL/UNASSIGNED:Lifespan: IRB Study # 600415.

BACKGROUND:Endoscopic discectomy is an ultra- minimally invasive outpatient surgical option for the treatment of lumbar herniated discs. The purpose of this study was to assess the benefit of tranforaminal versus interlaminar endoscopic discectomy in patients with single level Lumbar 5-Sacral 1(L5-S1) disc herniations and lumbar radiculopathy. METHODS:After Institutional Review Board Approval, charts from 41 consecutive patients with complaints of lower back and radicular pain and an L5-S1 herniated disc who underwent an endoscopic procedure between 2007 and 2012 were reviewed. The transforaminal approach was used for patients with far lateral, foraminal, and paracentral disc herniations and the intralaminar approach was used for herniations that were more central. RESULTS:The average pain relief 1-year postoperatively was 75.9% for the transforaminal group and 75.3% for the interlaminar group, both excellent results as defined by MacNab. The average preoperative visual analogue scale (VAS) scores were 8.2 and 8.4 for the transforaminal and interlaminar groups respectively, indicated in our questionnaire as severe and constant pain. The average 1-year postoperative VAS scores were 1.7 and 2.1, indicated in our questionnaire as mild and intermittent pain. There were no complications in the series of patients treated. CONCLUSIONS:The 1-year follow-up data presented here for transforaminal and intralaminar approaches to L5-S1 disc herniations appears to indicate that either approach can be used as determined to best suit the pathology without sacrificing the probability of postoperative pain improvement.

BACKGROUND:Lumbar degenerative spondylolisthesis is a common entity and occurs mainly in elderly patients. The trend in surgery has been to offer decompression with instrumented fusion based on patient-based outcome data and the inherent instability of the condition. OBJECTIVES/OBJECTIVE:Transforaminal endoscopic discectomy and foraminotomy is an ultra-minimally invasive outpatient surgical option available to patients that does not require general anesthesia and does not involve the same amount of destabilizing facet joint removal as a traditional laminectomy and medial facetectomy. The purpose of this study was to assess the benefit of tranforaminal endoscopic discectomy and foraminotomy in patients with lumbar 4-5 (L4-L5) and lumbar 5-sacral 1 (L5-S1) spondylolisthesis and lumbar radiculopathy. METHODS:After Institutional Review Board Approval, charts from 21 consecutive patients with L4-L5 or L5-S1 spondylolisthesis and complaints of lower back and radicular pain who underwent endoscopic procedures between 2007 and 2012 were reviewed. RESULTS:The average pain relief one year postoperatively was reported to be 71.9%, good results as defined by MacNab. The average pre-operative VAS score was 8.48, indicated in our questionnaire as severe and constant pain. The average one year postoperative VAS score was 2.30, indicated in our questionnaire as mild and intermittent pain. LIMITATIONS/CONCLUSIONS:This is a retrospective study and only offers one year follow-up data for patients with spondylolisthesis undergoing endoscopic spine surgery for treatment of lumbar radiculopathy. CONCLUSIONS:Endoscopic discectomy is a safe and effective alternative to open back surgery. The one year follow-up data presented here appears to indicate that an ultra-minimally invasive approach to the treatment of lumbar radiculopathy in the setting of spondylolisthesis that has a low complication rate, avoids general anesthesia, and is outpatient might be worth studying in a prospective, longer term way. IRB approval: Meridian Health: IRB Study # 201206071J.

Microsurgery for lumbar herniated discs that require surgical intervention is a very successful and well-described technique, whether performed through more traditional "open" microsurgical retractors or through minimally-invasive "tube" retractors. Surgery for extruded lumbar disc fragments that migrate caudad or cephalad from the disc origin may typically require modifying the standard hemilaminotomy by removing additional laminar bone to retrieve the migrated fragment. Although midline and paramedian Wiltse approaches have been the standard methods for resecting herniated lumbar disc fragments, advances in neuroendoscopic techniques have expanded the potential targets for transforaminal endoscopic treatment to include extruded lumbar disc fragments. Sequestrations migrated cephalad or caudal to the disc can be removed using specialized flexible instruments. The instruments enable the surgeon to circumnavigate and reach into the epidural space and as far as the mid-vertebral body. The authors present a case of an endoscopically resected lumbar herniated disc fragment extruded caudad behind the inferior vertebral body through a transforaminal approach in an awake patient using local anesthetic. Radiographic and endoscopic visualization make it possible to access intracanal pathology. Although more traditional lumbar disc surgery is widely performed and is safe and effective, neuroendoscopic procedures may also allow a safe and effective approach for even extruded disc fragments for patients who cannot tolerate general anesthesia or are seeking the most minimally invasive option. Endoscopic discectomy is a minimally invasive alternative to open back surgery. Maintained spinal stability and absence or minimal formation of scar tissue allow for ease of subsequent surgeries, both open and minimally invasive (if needed).

BACKGROUND:The elderly population is growing in the United States. As the oldest old are projected to be the fastest growing part of the elderly population, we must consider how to best treat their degenerative spine conditions when non-operative treatment fails. OBJECTIVES/OBJECTIVE:Transforaminal endoscopic discectomy and foraminotomy is an ultra-minimally invasive outpatient surgical option that does not require general anesthesia and is available to geriatric. The purpose of this study was to assess the benefit of transforaminal endoscopic discectomy and foraminotomy in geriatric patients with single level and multi-level lumbar disc herniations and lumbar radiculopathy. STUDY DESIGN/METHODS:Retrospective study SETTING/METHODS:Outpatient surgery center. METHODS:After Institutional Review Board Approval, charts from 50 consecutive patients aged 75 and older with complaints of lower back and radicular pain who underwent one or more endoscopic procedures between 2007 and 2011 were reviewed. RESULTS:The average pain relief 6 months postoperatively was reported to be 71.8%, good results as defined by MacNab. The average pre-operative VAS score was 9.04, indicated in our questionnaire as severe and constant pain. The average 6 month post-operative VAS score was 2.63, indicated in our questionnaire as mild and intermittent pain. LIMITATIONS/CONCLUSIONS:This is a retrospective study and only offers 6 month follow-up data for geriatric patients undergoing endoscopic spine surgery. CONCLUSIONS:Endoscopic discectomy is a safe and effective alternative to open back surgery. The 6-month follow-up data presented here appears to indicate that an ultra-minimally invasive approach to the geriatric spine that has a low complication rate, avoids general anesthesia, and is outpatient might be worth studying in a prospective, longer term way. IRB approval: Meridian Health: IRB Study # 201206071J.

OBJECTIVE:Transforaminal endoscopic surgery has evolved from an intradiscal procedure to a true foraminal epidural procedure where both a targeted discectomy and foraminal decompression can be performed. The success of transforaminal decompression for radiculopathy using preoperative selective nerve root block as part of a treatment algorithm for single level and multilevel lumbar disc herniations is described here. METHODS:After Institutional Review Board Approval, charts from 195 patients with complaints of lower back and radicular pain who received one or more endoscopic discectomy procedures were reviewed. Visual Analog Scale was applied to each patient preoperatively and 6 months after the procedure. RESULTS:Patients with multi-level pathologies receiving one procedure have an average relief of 69.7% attributed to correct diagnosis of the inflicting level as opposed to 83.9% improvement in patients with a single level herniation. CONCLUSION/CONCLUSIONS:Patients with single level lumbar herniations receiving one endoscopic discectomy have excellent outcomes, but with a good response to a selective nerve root block as a preoperative adjunct, patients with multilevel disc herniations also have significant benefit from single level endoscopic discectomy.