Byapak Paudel

Percutaneous Full Endoscopic Bilateral Lumbar Decompression of Spinal Stenosis Through Uniportal-Contralateral Approach: Techniques and Preliminary Results

BACKGROUND When considering various risk factors such as age, comorbidities, and complications related to the surgical procedure itself, open surgery in degenerative spinal stenosis is likely to cause more complications. Here, we report the surgical procedure and preliminary clinical results of percutaneous endoscopic stenosis lumbar decompression (PESLD) technique using a uniportal-contralateral approach for bilateral decompression of degenerative spinal stenosis. MATERIALS AND METHODS Electronic medical records of 48 consecutive patients who were treated between January 2016 and August 2016 were reviewed retrospectively. All patient received PESLD through the uniportal-contralateral approach. We analyzed the outcomes using the visual analogue scale, Macnab criteria, Oswestry Disability Index, and complication rate. RESULTS There were 48 cases (15 men, 33 women). Mean age of patients was 62.44 ± 8.68 years. Mean symptom duration was 20.13 ± 16.87 months. Neurogenic intermittent claudication was 550 m on average. Follow-up period was 7.75 ± 2.28 months (range, 5-13 months). Visual analogue scale and Oswestry Disability Index decreased significantly (P < 0.001) and decreased by 1.073 and 5.795 odds ratio, respectively, in contralateral foraminotomy cases. Macnab outcome grade was good to excellent in 96% of patients. Dural tear occurred in 3 cases (6.25%), and 2 cases (4.17%) required transforaminal lumbar interbody fusion operation after this procedure. CONCLUSIONS The preliminary result of this uniportal-contralateral PESLD technique is encouraging (96% demonstrated a good-to-excellent outcome), and the procedure is safe. However, we need long-term follow-up and a more detailed study for more accurate results of this technique.

Percutaneous Full Endoscopic Treatment of Bertolotti Syndrome: A Report of Three Cases with Technical Note

Background Bertolotti syndrome is characterized by an abnormal enlargement of the transverse process of the most caudal lumbar vertebra. Most of the time it is asymptomatic, but when it is symptomatic it is associated with low back pain, radiating leg pain, or both. There is no consensus regarding management of this pathology. Open to minimal invasive tubular resection techniques are described in the literature, but a full endoscopic resection technique has not yet been described. Endoscopic technique is a less invasive target‐oriented iliolumbar ligament preserving technique. We report our percutaneous full endoscopic technique for the treatment of symptomatic Bertolotti syndrome. Method We have treated three symptomatic cases of Bertolotti syndrome with the percutaneous endoscopic technique. We review the feasibility of this technique and the outcomes. Result Full endoscopic resection of Bertolotti syndrome is feasible and safe with comparable good outcomes and the added benefits of minimal invasive surgery. Conclusion We believe this novel percutaneous full endoscopic technique will yield good results in the hands of expert endoscopic spine surgeons and can be an alternative treatment method in cases of symptomatic Bertolotti syndrome. To our knowledge this is the first report of percutaneous full endoscopic treatment of Bertolotti syndrome in the world.

Transforaminal Epiduroscopic Basivertebral Nerve Laser Ablation for Chronic Low Back Pain Associated with Modic Changes: A Preliminary Open-Label Study

Background Chronic low back pain (CLBP) arising from degenerative disc disease continues to be a challenging clinical and diagnostic problem whether treated with nonsurgical, pain intervention, or motion-preserving stabilization and arthrodesis. Methods Fourteen patients with CLBP, greater than 6 months, unresponsive to at least 4 months of conservative care were enrolled. All patients were treated successfully following screening using MRI findings of Modic type I or II changes and positive confirmatory provocative discography to determine the affected levels. All patients underwent ablation of the basivertebral nerve (BVN) using 1414 nm Nd:YAG laser-assisted energy guided in a transforaminal epiduroscopic approach. Macnabs criteria and visual analog scale (VAS) score were collected retrospectively at each follow-up interval. Results The mean age was 46 ± 9.95 years. The mean symptoms duration was 21.21 ± 21.87 months. The mean follow-up was 15.3 ± 2.67 months. The preoperative VAS score of 7.79 ± 0.97 changed to 1.92 ± 1.38, postoperatively (P < 0.01). As per Macnabs criteria, seven patients (50%) had excellent, six patients (42.85%) had good, and one patient (7.14%) had fair outcomes. Conclusion The transforaminal epiduroscopic basivertebral nerve laser ablation (TEBLA) appears to be a promising option in carefully selected patients with CLBP associated with the Modic changes.

Suprapedicular Circumferential Opening Technique of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for High Grade Inferiorly Migrated Lumbar Disc Herniation

Purpose To evaluate the efficacy of suprapedicular circumferential opening technique (SCOT) of percutaneous endoscopic transforaminal lumbar discectomy (PETLD) for high grade inferiorly migrated lumbar disc herniation. Material and Methods Eighteen consecutive patients who presented with back and leg pain with a single-level high grade inferiorly migrated lumbar disc herniation were included. High grade inferiorly migrated disc was removed by the SCOT through PETLD approach. Outcome evaluation was done with visual analog scale (VAS) and Mac Nabs criteria. Result There were 14 males and 4 females. The mean age of patients was 53.3 ± 14.12 years. One, 4, and 13 patients had disc herniation at L1-2, L3-4, and L4-5 levels, respectively, on MRI, which correlated with clinical findings. The mean follow-up duration was 8.4 ± 4.31 months. According to Mac Nabs criteria, 9 patients (50%) reported excellent and the remaining 9 patients (50%) reported good outcomes. The mean preoperative and postoperative VAS for leg pain were 7.36 ± 0.73 and 1.45 ± 0.60, respectively (p < 0.001). Improvement in outcomes was maintained even at final follow-up. There was no complication. Conclusion In this preliminary study we achieved good to excellent clinical results using the SCOT of PETLD for high grade inferiorly migrated lumbar disc herniation.

Transforaminal Epiduroscopic Laser Ablation of Sinuvertebral Nerve in Patients with Chronic Diskogenic Back Pain: Technical Note and Preliminary Result

Background Diskogenic back pain is an unsolved mystery and accounts for a large number of patients with chronic low back pain. Various treatment modalities have been described, but treatment is still a matter of debate. We evaluated transforaminal epiduroscopic laser ablation (TELA) focusing on sinuvertebral nerve laser ablation for chronic diskogenic back pain. To our knowledge this is the first treatment described for diskogenic back pain that directly targets the sensitized sinuvertebral nerve extradiskally through a transforaminal approach. Methods A total of 52 patients with a diagnosis of chronic diskogenic back pain and treated with TELA between September 2015 and June 2016 were analyzed. Outcome was measured with the visual analog scale (VAS), Macnab criteria, and Oswestry Disability Index (ODI). Results Of the 52 patients, 55.8% were female, and the mean age was 42.40 ± 11.99 years. Pfirrmann disk degeneration grade was mostly grade IV (63.5%) and involved spinal levels L4‐L5 and L5‐S1. The average follow‐up period was 15.88 ± 1.79 months. VAS decreased significantly after TELA (p < 0.001). Improvement in ODI was also significant (p < 0.001). Good to excellent outcome was 96.1% according to the Macnab criteria. Four patients had transient motor weakness. Conclusion TELA targeting to the sinuvertebral nerve was effective in 96.1% with good to excellent results and an immediate decrease in chronic diskogenic back pain. The sinuvertebral nerve may play an important role in chronic diskogenic back pain.