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Albert E. Telfeian, Gabriele P. Jasper, Adetokunbo A. Oyelese and Ziya L. Gokaslan

OBJECTIVE

In this study the authors describe the technical considerations and feasibility of transforaminal discectomy and foraminoplasty for the treatment of lumbar radiculopathy in patients who have herniated discs at the thoracolumbar junction.

METHODS

After institutional review board approval, charts from 3 consecutive patients with lumbar radiculopathy and T12–L1 herniated discs who underwent endoscopic procedures between 2006 and 2014 were reviewed.

RESULTS

Consecutive cases (n = 1316) were reviewed to determine the incidence and success of surgery performed at the T12–L1 level. Only 3 patients (0.23%) treated with endoscopic surgery for their herniated discs had T12–L1 herniated discs; the rest were lumbar or lumbosacral herniations. For patients with T12–L1 disc herniations, the average preoperative visual analog scale score was 8.3 (indicated in the questionnaire as describing severe and constant pain). The average 1-year postoperative visual analog scale score was 1.7 (indicated in the questionnaire as mild and intermittent pain).

CONCLUSIONS

Transforaminal endoscopic discectomy and foraminotomy can be used as a safe yet minimally invasive technique for the treatment of lumbar radiculopathy in the setting of a thoracolumbar disc herniation.

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Ralf Wagner, Menno Iprenburg and Albert E. Telfeian

The proposed advantages of total disc replacement (TDR) over fusion in the lumbar spine are the preservation of motion and the avoidance of adjacent-level disease. One of the complications inherent in TDR is the possibility of vertebral body fracture due to trauma or a malpositioned implant. The resulting dilemma is that posterior decompression of the displaced bone fragment could then have a destabilizing effect and possibly require fusion, thus obviating the benefit of an arthroplasty procedure. In this study, the authors describe the technical considerations and feasibility of the treatment of a postoperative L-5 paresis that resulted from a dislocated bone fragment at L4–5 during a 2-level lumbar TDR.

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Sean M. Barber, Jonathan Nakhla, Sanjay Konakondla, Jared S. Fridley, Adetokunbo A. Oyelese, Ziya L. Gokaslan and Albert E. Telfeian

OBJECTIVE

Endoscopic discectomy (ED) has been advocated as a less-invasive alternative to open microdiscectomy (OM) and tubular microdiscectomy (TM) for lumbar disc herniations, with the potential to decrease postoperative pain and shorten recovery times. Large-scale, objective comparisons of outcomes between ED, OM, and TM, however, are lacking. The authors’ objective in this study was to conduct a meta-analysis comparing outcomes of ED, OM, and TM.

METHODS

The PubMed database was searched for articles published as of February 1, 2019, for comparative studies reporting outcomes of some combination of ED, OM, and TM. A meta-analysis of outcome parameters was performed assuming random effects.

RESULTS

Twenty-six studies describing the outcomes of 2577 patients were included. Estimated blood loss was significantly higher with OM than with both TM (p = 0.01) and ED (p < 0.00001). Length of stay was significantly longer with OM than with ED (p < 0.00001). Return to work time was significantly longer in OM than with ED (p = 0.001). Postoperative leg (p = 0.02) and back (p = 0.01) VAS scores, and Oswestry Disability Index scores (p = 0.006) at latest follow-up were significantly higher for OM than for ED. Serum creatine phosphokinase (p = 0.02) and C-reactive protein (p < 0.00001) levels on postoperative day 1 were significantly higher with OM than with ED.

CONCLUSIONS

Outcomes of TM and OM for lumbar disc herniations are largely equivalent. While this analysis demonstrated that several clinical variables were significantly improved in patients undergoing ED when compared with OM, the magnitude of many of these differences was small and of uncertain clinical relevance, and several of the included studies were retrospective and subject to a high risk of bias. Further high-quality prospective studies are needed before definitive conclusions can be drawn regarding the comparative efficacy of the various surgical treatments for lumbar disc herniations.

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Sean M. Barber, Jonathan Nakhla, Sanjay Konakondla, Jared S. Fridley, Adetokunbo A. Oyelese, Ziya L. Gokaslan and Albert E. Telfeian

OBJECTIVE

Endoscopic discectomy (ED) has been advocated as a less-invasive alternative to open microdiscectomy (OM) and tubular microdiscectomy (TM) for lumbar disc herniations, with the potential to decrease postoperative pain and shorten recovery times. Large-scale, objective comparisons of outcomes between ED, OM, and TM, however, are lacking. The authors’ objective in this study was to conduct a meta-analysis comparing outcomes of ED, OM, and TM.

METHODS

The PubMed database was searched for articles published as of February 1, 2019, for comparative studies reporting outcomes of some combination of ED, OM, and TM. A meta-analysis of outcome parameters was performed assuming random effects.

RESULTS

Twenty-six studies describing the outcomes of 2577 patients were included. Estimated blood loss was significantly higher with OM than with both TM (p = 0.01) and ED (p < 0.00001). Length of stay was significantly longer with OM than with ED (p < 0.00001). Return to work time was significantly longer in OM than with ED (p = 0.001). Postoperative leg (p = 0.02) and back (p = 0.01) VAS scores, and Oswestry Disability Index scores (p = 0.006) at latest follow-up were significantly higher for OM than for ED. Serum creatine phosphokinase (p = 0.02) and C-reactive protein (p < 0.00001) levels on postoperative day 1 were significantly higher with OM than with ED.

CONCLUSIONS

Outcomes of TM and OM for lumbar disc herniations are largely equivalent. While this analysis demonstrated that several clinical variables were significantly improved in patients undergoing ED when compared with OM, the magnitude of many of these differences was small and of uncertain clinical relevance, and several of the included studies were retrospective and subject to a high risk of bias. Further high-quality prospective studies are needed before definitive conclusions can be drawn regarding the comparative efficacy of the various surgical treatments for lumbar disc herniations.

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Sean M. Barber, Sanjay Konakondla, Jonathan Nakhla, Jared S. Fridley, Jimmy Xia, Adetokunbo A. Oyelese, Albert E. Telfeian and Ziya L. Gokaslan

OBJECTIVE

Oncological outcomes for many malignant primary spinal tumors and isolated spinal metastases have been shown to correlate with extent of resection. For tumors with dural involvement, some authors have described spinal dural resection at the time of tumor resection in the interest of improving oncological outcomes. The complication profile associated with resection of the spinal dura for oncological purposes, however, and the relative influence of resecting tumor-involved dura on progression-free survival are not well defined. The authors performed a systematic review of the literature and identified cases in which the spinal dura was resected for oncological purposes in the interest of better understanding the associated risks and outcomes of this technique.

METHODS

Electronic databases (PubMed/MEDLINE, Scopus) were systematically searched to identify studies that reported clinical and/or oncological outcomes of patients with malignant spinal neoplasms undergoing resection of tumor-involved dura at the time of surgical intervention.

RESULTS

Ten articles describing 15 patients were included in the analysis. The most common tumor histologies were chordoma (3/15, 20%), giant cell tumor (3/15, 20%), epithelioid sarcoma (2/15, 13.3%), osteosarcoma (2/15, 13.3%), and metastasis (2/15, 13.3%). Procedure-related complications were reported in 40% of patients. A trend was seen toward an increased complication rate in redo (66.7%) versus index (16.7%) operations, but this trend did not reach statistical significance (p = 0.24). New, unexpected postoperative neurological deficits were seen in 3 patients (of 14 reporting, 21.4%). A single patient experienced a profound, unexpected neurological deterioration (paraparesis/paraplegia) after surgery, which reportedly improved considerably at latest follow-up. Tumor recurrence was seen in 3 cases (of 12 reporting, 25%) at a mean of 28.34 ± 21.1 months postoperatively. The overall mean radiographic follow-up period was 49.6 ± 36.5 months.

CONCLUSIONS

Resection of the spinal dura for oncological purposes is rarely performed, although a limited number of reports and small series have demonstrated that it is feasible. Spinal dural resection is primarily performed in patients with isolated, primary spinal neoplasms with an intent to cure. The risk associated with spinal dura resection is nontrivial and the complication profile is significant. The influence of dural resection on oncological outcomes is not well defined, and further study is needed before definitive conclusions may be drawn regarding the oncological benefit of dural resection for any particular patient or pathology.

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Sean M. Barber, Sanjay Konakondla, Jonathan Nakhla, Jared S. Fridley, Jimmy Xia, Adetokunbo A. Oyelese, Albert E. Telfeian and Ziya L. Gokaslan

OBJECTIVE

While resection of the dural attachment has been shown by Simpson and others to reduce recurrence rates for intracranial meningiomas, the oncological benefit of dural resection for spinal meningiomas is less clear. The authors performed a systematic analysis of the literature, comparing recurrence rates for patients undergoing various Simpson grade resections of spinal meningiomas to better understand the role of dural resection on outcomes after resection of spinal meningiomas.

METHODS

The PubMed/Medline database was systematically searched to identify studies describing oncological and clinical outcomes after Simpson grade I, II, III, or IV resections of spinal meningiomas.

RESULTS

Thirty-two studies describing the outcomes of 896 patients were included in the analysis. Simpson grade I, grade II, and grade III/IV resections were performed in 27.5%, 64.6%, and 7.9% of cases, respectively. The risk of procedure-related complications (OR 4.75, 95% CI 1.27–17.8, p = 0.021) and new, unexpected postoperative neurological deficits (OR ∞, 95% CI NaN–∞, p = 0.009) were both significantly greater for patients undergoing Simpson grade I resections when compared with those undergoing Simpson grade II resections. Tumor recurrence was seen in 2.8%, 4.1%, and 39.4% of patients undergoing Simpson grade I, grade II, and grade III/IV resections over a mean radiographic follow-up period of 99.3 ± 46.4 months, 95.4 ± 57.1 months, and 82.4 ± 49.3 months, respectively. No significant difference was detected between the recurrence rates for Simpson grade I versus Simpson grade II resections (OR 1.43, 95% CI 0.61–3.39, p = 0.43). A meta-analysis of 7 studies directly comparing recurrence rates for Simpson grade I and II resections demonstrated a trend toward a decreased likelihood of recurrence after Simpson grade I resection when compared with Simpson grade II resection, although this trend did not reach statistical significance (OR 0.56, 95% CI 0.23–1.36, p = 0.20).

CONCLUSIONS

The results of this analysis suggest with a low level of confidence that the rates of complications and new, unexpected neurological deficits after Simpson grade I resection of spinal meningiomas are greater than those seen with Simpson grade II resections, and that the recurrence rates for Simpson grade I and grade II resections are equivalent, although additional, long-term studies are needed before reliable conclusions may be drawn.