Faculty Bibliography

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:Full-endoscopic surgery is increasingly used for treating lumbar foraminal pathologies, though the specific indications remain unclear. This study aims to evaluate patient-reported outcomes after transforaminal full-endoscopic spine surgery for various lumbar foraminal conditions. METHODS:Multicenter cohort study of patients with intervertebral lumbar foraminal pathology who underwent full-endoscopic decompression at four medical centers. Postoperative patient-reported outcomes, including low back and leg pain as well as Oswestry Disability Index (ODI) scores, were prospectively tracked using a mobile app for 6 months. Six-month outcome measures (patient-reported outcome measures) were used as the primary outcome variable to determine treatment effectiveness regarding various foraminal pathologies. RESULTS:A total of 83 patients with a mean age of 57.04 ± 1.63 years were included. The most common operative levels were L4/5 for transforaminal endoscopic discectomies (59.6%) and L5/S1 for endoscopic foraminotomies (58.1%). Endoscopic discectomies resulted in significant improvements in Visual Analog Scale scores for low back pain (from 5.85 ± 0.43 to 3.02 ± 0.41; P < .001), leg pain (from 6.66 ± 0.34 to 3.12 ± 0.57; P < .001), and ODI scores (from 24.39 ± 1.35 to 12.32 ± 176; P < .001). Endoscopic foraminotomies also resulted in significant improvements in Visual Analog Scale scores for low back pain (from 5.58 ± 0.53 to 3.68 ± 0.58; P < .001) and leg pain (from 6.42 ± 0.47 to 4.21 ± 0.58; P < .001), as well as ODI scores (from 19.28 ± 1.41 to 14.67 ± 2.03; P < .01). The amount of improvement was independent of the severity of foraminal stenosis, as determined on preoperative MRI. However, vertical foraminal stenosis was associated with the lowest treatment response rate. CONCLUSION/CONCLUSIONS:Endoscopic foraminotomies result in clinically meaningful symptomatic improvement for most lumbar foraminal pathologies. However, the effectiveness of decompression surgery for vertical foraminal stenosis is limited and requires further investigation.

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 AND OBJECTIVES/OBJECTIVE:Surgical treatment for symptomatic thoracic disc herniations (TDH) involves invasive open surgical approaches with relatively high complication rates and prolonged hospital stays. Although advantages of full endoscopic spine surgery (FESS) are well-established in lumbar disc herniations, data are limited for the endoscopic treatment of TDH despite potential benefits regarding surgical invasiveness. The aim of this study was to provide a comprehensive evaluation of potential benefits of FESS for the treatment of TDH. METHODS:PubMed, MEDLINE, EMBASE, and Scopus were systematically searched for the term "thoracic disc herniation" up to March 2023 and study quality appraised with a subsequent meta-analysis. Primary outcomes were perioperative complications, need for instrumentation, and reoperations. Simultaneously, we performed a multicenter retrospective evaluation of outcomes in patients undergoing full endoscopic thoracic discectomy. RESULTS:We identified 3190 patients from 108 studies for the traditional thoracic discectomy meta-analysis. Pooled incidence rates of complications were 25% (95% CI 0.22-0.29) for perioperative complications and 7% (95% CI 0.05-0.09) for reoperation. In this cohort, 37% (95% CI 0.26-0.49) of patients underwent instrumentation. The pooled mean for estimated blood loss for traditional approaches was 570 mL (95% CI 477.3-664.1) and 7.0 days (95% CI 5.91-8.14) for length of stay. For FESS, 41 patients from multiple institutions were retrospectively reviewed, perioperative complications were reported in 4 patients (9.7%), 4 (9.7%) required revision surgery, and 6 (14.6%) required instrumentation. Median blood loss was 5 mL (IQR 5-10), and length of stay was 0.43 days (IQR 0-1.23). CONCLUSION/CONCLUSIONS:The results suggest that full endoscopic thoracic discectomy is a safe and effective treatment option for patients with symptomatic TDH. When compared with open surgical approaches, FESS dramatically diminishes invasiveness, the rate of complications, and need for prolonged hospitalizations. Full endoscopic spine surgery has the capacity to alter the standard of care for TDH treatment toward an elective outpatient surgery.

Minimally invasive lumbar decompression surgery offers many advantages including reduced patient morbidity and quicker return to normal life. Endoscopic lumbar spine surgery, sometimes termed "ultra" minimally invasive, further pushes the envelope on reducing operative time, blood loss, and recovery time. Endoscopy offers the additional advantage to the surgeon of placing the surgeon's eye not 50 cm away through the lens of loupes or a microscope, but right at the spine pathology in high definition. Uniportal approach involves a single incision through which the endoscope and instruments are passed. Biportal approach involves two incisions, one for the endoscope and one for the instruments. In what follows we review the indications and efficacy of these procedures with case examples.

BACKGROUND CONTEXT/BACKGROUND:Return to work (RTW) after spinal surgery is a crucial postoperative outcome influencing patients' lives. Endoscopic spinal surgery (ESS) is an ultra-minimally invasive technique for the treatment of spinal pathology, and some ESS procedures have been shown to improve RTW dynamics following spinal surgery. PURPOSE/OBJECTIVE:The aim of this study is to investigate RTW within ninety days following various lumbar ESS procedures in the United States (US) and compare differences in RTW between patient occupational activity levels and ESS procedural types. STUDY DESIGN/SETTING/METHODS:Prospectively collected data provided by patients via the SPINEHealthie mobile health application. PATIENT SAMPLE/METHODS:Patients with a status of employed who received lumbar ESS (n=192). OUTCOME MEASURES/METHODS:Back pain, leg pain, ODI, and return to work after spine surgery. METHODS:The SPINEHealthie project dataset was used for this study. The SPINEHealthie project is a multicenter, multisurgeon prospectively collected dataset for endoscopic spine surgery in which patients utilize a mobile health application to report critical outcome measures. One hundred ninety-two patients met the inclusion criteria for this study. The primary outcome was patient reported time to RTW. Kaplan Meier survival analysis and Cox proportional hazard models were performed to analyze RTW after lumbar ESS. RESULTS:Average age was 52.0 years, and 59.4% of the sample were male. The cumulative incidence in RTW was 83.6% with a median of patients returning to work at or before 16.0 days after any type of lumbar ESS. Patients with labor-intensive occupations returned to work significantly later than patients with sedentary occupations (p=.014). Surgical procedure was also associated with RTW (p=.043); a median of patients returned to work at or before 13.0 days after interlaminar discectomy or unilateral decompression, 20.0 days after far lateral approaches for discectomy or decompression, and 40.0 days after interlaminar unilateral laminotomy for bilateral decompression. CONCLUSIONS:Patients who received lumbar ESS return to work relatively rapidly compared to the literature on traditional open lumbar procedures. The type of ESS (as dictated by the underlying pathology), as well as patient occupational physical activity requirements impact postoperative RTW.

Full endoscopic spine surgery (FESS) offers an ultra-minimally invasive solution for addressing many different degenerative spine pathologies. While FESS has demonstrated strong evidence for faster recovery, reduced hospital stays, fewer complications, and potentially lower overall costs, FESS remains underutilized in low-income countries (LICs). This narrative review synthesizes the existing literature to evaluate access to FESS in LICs, highlighting challenges such as a lack of trained neurosurgeons and orthopedic surgeons, insufficient access to specialized equipment, capital costs, and limited representation in research. A systematic literature search identified only a handful of relevant studies, underscoring the scarcity of data on FESS in LICs. Findings reveal stark disparities in training opportunities and equipment availability, with less than 25% of LIC facilities equipped with the essential tools. This review advocates for international collaboration, increased funding, cost reduction, and targeted research to bridge these gaps. Innovative solutions such as virtual training platforms may help overcome current limitations. Addressing these challenges is essential to leveraging FESS's potential to mitigate the burden of spinal disorders in LICs and advance global health equity.

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.