Application And Clinical Evaluation Of Minimally Invasive Spinal Endoscopic Surgery For Lumbar Degenerative Diseases

Background:Lumbar degenerative disorder is the most common spinal diseases among middle-aged people.Lumbar disc herniation,spinal stenosis,spondylolisthesis are the main causes which can lead to low back pain,lower extremity pain,sensory and/or motor deficits,and have a bad effect on middle-aged population.When patients were typical radicular pain with a lack of response to extensive conservative treatment,surgery would be the efficient means to relieve compression of nerve and modify symptoms quickly.Traditional open surgery of spine requires direct visualization of anatomic landmarks with significant muscular dissection.the damage to the lumbar musculature was directly related to the retraction pressure and duration during surgery,which may be associated with some postoperative complications or remain back pain.With the development of modern spinal surgery technique,minimally invasive,intelligentize,digitization and precise surgery technique have been the main evolution in the future.Compared with traditional open or MIS-baffle type lumbar procedures,minimally invasive spine endoscopic procedure use serial dilators to create a muscle-sparing surgical corridor and achieve accurate positioning and decompression with amplifying and clearly endoscopic vision.According to the disease of patients,we can select solely nerve decompression or interbody fusion procedure with endoscopy.Although lessening the approach related morbidity is a primary aim of minimally invasive spine surgery,this must be accomplished without compromising the efficacy of the procedure.As with any new surgical technique,there is a learning curve that must be defeated before technical proficiency can be achieved.Minimally invasive endoscopic tubular TLIF is more technically demanding because of the smaller working area,the need for longer and bayoneted surgical instruments,and the eye-hand coordination capability.Despite the accumulated data that have begun to demonstrate specific techniques and clinical situations in which MIS may be preferable to open surgery,the overall evidence base has relied heavily on retrospective studies with a relatively small number of patients and surgeons involved.A greater emphasis on prospective and comparative studies is required going forward as we seek to firmly establish the role of MIS in spinal surgery in the future.Part one: Applied research of Cone endoscopic channel system(VISTA)in posterior lumbar fusion surgeryPurpose:The objective of this article was to demonstrate the clinical feasibility and efficiency of the cone endoscopic system via the posterior approach in lumbar interbody fusion technique for degenerative diseases.And then compare the clinical outcomes and characteristics of VISTA system versus Quadrant system and open lumbar interbody fusion.Methods: A total of 152 prospective consecutive patients who underwent the minimally invasive TLIF procedure using tubular endoscopic system(MetrxVISTA,Medtronic Sofamor Danek,Memphis,TN)between April 2015 and May 2016 were included in this series.The electronic medical records and images studies were reviewed.Clinical outcomes such as visual analog scale(VAS)scores of low back pain,lower extremity pain,Japanese Orthopedic Association(JOA)scores,Oswestry disability index(ODI)scores,fusion rates,and Macnab criteria were assessed.Operation parameters such as surgical time,hospitalization cost,and postoperative hospitalization days were also recorded.The concentration of WBC,IL-6,IL-8,TNF-a and CPK-MM of the enrolled patients were measured in preoperation and first,third,fifth day after surgery.Multifidus muscle edema and atrophy were evaluated by MRI T2 weighted image at three different time points(preoperative,postoperative and two-year follow-up).Postoperative complications and symptom re-recurrence requiring reoperation were assessed through review of medical record documentation and/or telephone interviews with patients.Results:1.There were no significant differences between VISTA and Quadrant group in regards to incision length,blood loss,time to ambulation and postoperative hospitalization,while these factors of both groups were significant less than open group.There were significances among three groups about postoperative drainage volume,which was least in VISTA group,secondly in Quadrant group and most in open group.There was no significant difference between VISTA and Quadrant group about hospitalization cost,which was much less in open group.The operation time of Quadrant group was less than VISTA group and had no significant difference compared with open group.2.The concentration level of CPK-MM and CRP was lower in VISTA group compared with Quadrant and open group,and there was no significant difference between Quadrant and open group.The concentration level of WBC was higher in open group compared with the others,and no significant difference was found between VISTA and Quadrant group.There were no significant differences with respect to IL-6,IL-8 and TNF-a among the 3 groups.3.MRI T2 signal intensity ratio of multifidus muscle was higher in open group compared with the other groups after surgery,and no significant difference was found between VISTA and Quadrant group.There were significances among three groups at two-year follow up about MRI T2 signal intensity ratio of multifidus muscle,which was least in VISTA group,secondly in Quadrant group and most in open group.4.The VAS scores for low back pain,leg pain improved significantly in both groups after surgery,as did the JOA and ODI scores.However,there were no significant differences among the three groups in regards to the preoperative and final follow-up VAS,JOA,ODI scores,fusion rates and the distribution of the Macnab criteria.Conclusion: Our results show that the novel Endoscopic System via the Posterior Approach for Lumbar Interbody Fusion is a sufficient and safe technique supplement and comparable to conventional procedures.What's more,the concentration level of CPK-MM,CRP shown that the novel special endoscopic system would minimize deep muscles injury compared with Quadrant and open group.Comparing with the other groups,the vista group had significantly less blood loss and less drainage volume at the second day postoperatively.The operation time and hospitalization cost was significantly higher in VSITA group.Part two: Analysis of the characteristics and clinical outcomes of percutaneous endoscopic lumbar discectomy for upper lumbar disc herniationPurpose: The objective of this study was to evaluate the characteristics,clinical presentation,and outcomes of patients who underwent percutaneous endoscopic lumbar discectomy at L1-L2 and L2-L3,compared with those who underwent PELD at L3-L4.Methods: We retrospectively evaluated the clinical data from 55 patients who underwent PELD for single-level lumbar disc herniation between 2008 and 2014,at a mean follow-up of 29.9±16.4 months(12 month minimum,effective rate was 89.1%).Surgical time,postoperative hospital stay,hospitalization cost,rates of recurrence,Macnab criteria assessment,visual analogue scale score of back pain,sciatica and lower extremity numbness,Japanese Orthopedic Association low back pain score,and Oswestry disability index(ODI)before and after surgery were evaluated.Results: In the L1-L3 group,76.9% of the patients had positive femoral stretch test,compared with only 42.8% of those in the L3-L4 group(p<0.05).Of the 49 patients with adequate follow-up,17(34.7%)had excellent,23(46.9%)had good,and 6(12.2%)had fair improvement according to Macnab criteria.The VAS for back pain,leg pain,and numbness decreased significantly postoperatively in both groups,as did all other outcomes measures(p<0.05).Conclusion: PELD is a safe and effective treatment for upper lumbar disc herniation and may compare favorably to the same procedure for lower lumbar disc herniation.Additionally,the positive femoral stretch test was a relatively good diagnostic method for disc herniation at L1-L2 and L2-L3,compared to L3-L4.