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Clinical results of percutaneous biportal endoscopic lumbar interbody fusion with application of enhanced recovery after surgery

Dong Hwa Heo and Choon Keun Park

OBJECTIVE

The aims of enhanced recovery after surgery (ERAS) are to improve surgical outcomes, shorten hospital stays, and reduce complications. The objective of this study was to introduce ERAS with biportal endoscopic transforaminal lumbar interbody fusion (TLIF) and to investigate the clinical results.

METHODS

Patients were divided into two groups based on the fusion procedures. Patients who received microscopic TLIF without ERAS were classified as the non-ERAS group, whereas those who received percutaneous biportal endoscopic TLIF with ERAS were classified as the ERAS group. The mean Oswestry Disability Index (ODI) and visual analog scale (VAS) scores were compared between the two groups. In addition, demographic characteristics, diagnosis, mean operative time, estimated blood loss (EBL), fusion rate, readmissions, and complications were investigated and compared.

RESULTS

Forty-six patients were grouped into the non-ERAS group (microscopic TLIF without ERAS) and 23 patients into the ERAS group (biportal endoscopic TLIF with ERAS). The VAS score for preoperative back pain on days 1 and 2 was significantly higher in the non-ERAS group than in the ERAS group (p < 0.05). The mean operative duration was significantly higher in the ERAS group than in the non-ERAS group, while the mean EBL was significantly lower in the ERAS group than in the non-ERAS group (p < 0.05). There was no significant difference in fusion rate between the two groups (p > 0.05). Readmission was required in 2 patients who were from the non-ERAS group. Postoperative complications occurred in 6 cases in the non-ERAS group and in 2 cases in the ERAS group.

CONCLUSIONS

Percutaneous biportal endoscopic TLIF with an ERAS pathway may have good aspects in reducing bleeding and postoperative pain. Endoscopic fusion surgery along with the ERAS concept may help to accelerate recovery after surgery.

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Bone loss of vertebral bodies at the operative segment after cervical arthroplasty: a potential complication?

Dong Hwa Heo, Dong Chan Lee, Jong Yang Oh, and Choon Keun Park

OBJECTIVE

Bony overgrowth and spontaneous fusion are complications of cervical arthroplasty. In contrast, bone loss or bone remodeling of vertebral bodies at the operation segment after cervical arthroplasty has also been observed. The purpose of this study is to investigate a potential complication—bone loss of the anterior portion of the vertebral bodies at the surgically treated segment after cervical total disc replacement (TDR)—and discuss the clinical significance.

METHODS

All enrolled patients underwent follow-up for more than 24 months after cervical arthroplasty using the Baguera C disc. Clinical evaluations included recording demographic data and measuring the visual analog scale and Neck Disability Index scores. Radiographic evaluations included measurements of the functional spinal unit's range of motion and changes such as bone loss and bone remodeling. The grading of the bone loss of the operative segment was classified as follows: Grade 1, disappearance of the anterior osteophyte or small minor bone loss; Grade 2, bone loss of the anterior portion of the vertebral bodies at the operation segment without exposure of the artificial disc; or Grade 3, significant bone loss with exposure of the anterior portion of the artificial disc.

RESULTS

Forty-eight patients were enrolled in this study. Among them, bone loss developed in 29 patients (Grade 1 in 15 patients, Grade 2 in 6 patients, and Grade 3 in 8 patients). Grade 3 bone loss was significantly associated with postoperative neck pain (p < 0.05). Bone loss was related to the motion preservation effect of the operative segment after cervical arthroplasty in contrast to heterotopic ossification.

CONCLUSIONS

Bone loss may be a potential complication of cervical TDR and affect early postoperative neck pain. However, it did not affect mid- to long-term clinical outcomes or prosthetic failure at the last follow-up. Also, this phenomenon may result in the motion preservation effect in the operative segment after cervical TDR.

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Comparative analysis of three types of minimally invasive decompressive surgery for lumbar central stenosis: biportal endoscopy, uniportal endoscopy, and microsurgery

Dong Hwa Heo, Dong Chan Lee, and Choon Keun Park

OBJECTIVE

Recently, minimally invasive unilateral laminotomy with bilateral decompression (ULBD) has been performed for lumbar stenosis using endoscopic approaches. The object of this retrospective study was to compare the clinical and radiological outcomes of three types of minimally invasive decompressive surgery: microsurgery, percutaneous uniportal endoscopic surgery, and percutaneous biportal endoscopic surgery.

METHODS

In the period from March 2016 to December 2017, minimally invasive ULBD was performed using microscopy, a uniportal endoscopic approach, or a biportal endoscopic approach to treat lumbar canal stenosis. Patients were classified into three groups based on the surgery they had undergone. The angle of medial facetectomy area and postoperative dural expansion were measured using MR images. The visual analog scale (VAS) score for leg and back pain, Oswestry Disability Index (ODI), operation time, and complications were assessed. Clinical and radiological parameters were compared among the three groups.

RESULTS

There were 33 patients in the microscopy group, 37 in the biportal endoscopy group, and 27 in the uniportal endoscopy group. Preoperatively stenotic dural areas were significantly expanded in each of the three groups after surgery (p < 0.05). Mean dural expansion in the uniportal endoscopy group was significantly lower than that in the microscopy or biportal endoscopy group (p < 0.05). The mean angle of the facetectomy in the biportal endoscopic group was significantly lower than that in the microscopic group or uniportal endoscopic group (p < 0.05). On the 1st day after surgery, the VAS score for back pain was significantly higher in the microscopic group than in the uniportal or biportal endoscopic group (p < 0.05). However, there were no significant differences in the VAS score for back pain, VAS score for leg pain, or ODI at the final follow-up among the three groups (p > 0.05).

CONCLUSIONS

Although radiological results were different among the three groups of patients, postoperative clinical outcomes were significantly improved after each type of surgery. The percutaneous biportal or uniportal endoscopic approach offers the advantage of reduced immediate postoperative pain. A percutaneous uniportal or biportal endoscopic lumbar approach may be effective for the treatment of lumbar central stenosis and an alternative to conventional microsurgical decompression.

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Fully endoscopic lumbar interbody fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results

Dong Hwa Heo, Sang Kyu Son, Jin Hwa Eum, and Choon Keun Park

OBJECTIVE

Minimally invasive spine surgery can minimize damage to normal anatomical structures. Recently, fully endoscopic spine surgeries have been attempted for lumbar fusion surgery. In this study, the authors performed a percutaneous unilateral biportal endoscopic (UBE) technique as a minimally invasive surgery for lumbar fusion. The purpose of this study is to present the UBE technique of fully endoscopic lumbar interbody fusion (LIF) and to analyze the clinical results.

METHODS

Patients who were to undergo single-level fusion surgery from L3–4 to L5–S1 were enrolled. Two channels (endoscopic portal and working portal) were used for endoscopic lumbar fusion surgery. All patients underwent follow-up for more than 12 months. Demographic characteristics, diagnosis, operative time, and estimated blood loss were evaluated. MRI was performed on postoperative Day 2. Clinical evaluations (visual analog scale [VAS] for the leg and Oswestry Disability Index [ODI] scores) were performed preoperatively and during the follow-up period.

RESULTS

A total of 69 patients (24 men and 45 women) were enrolled in this study. The mean follow-up period was 13.5 months. Postoperative MRI revealed optimal direct neural decompression after fully endoscopic fusion surgery. VAS and ODI scores significantly improved after the surgery. There was no postoperative neurological deterioration.

CONCLUSIONS

Fully endoscopic LIF using the UBE technique may represent an alternative minimally invasive LIF surgery for the treatment of degenerative lumbar disease. Long-term follow-up and larger clinical studies are needed to validate the clinical and radiological results of this surgery.