Ki Joon Kim

Full Endoscopic Lumbar Discectomy using the Calcification Floating Technique for Symptomatic Partially Calcified Lumbar Herniated Nucleus Pulposus

BACKGROUND Partially calcified lumbar herniated nucleus pulposus (HNP) can cause severe radiating pain and neurologic symptoms requiring surgical treatment. As it is not safe to enforce conventional endoscopic lumbar discectomy using trephine or burr to remove the partially calcified disc, we report a calcification floating technique using a working channel for the treatment of these cases. METHODS We retrospectively analyzed 31 patients who underwent full endoscopic discectomy using this technique for partially calcified lumbar HNP between April 2009 and June 2013. Calcification floating technique was performed by inserting the working channel around the partially calcified HNP and then rotating the working channel around it to remove the lesion. We analyzed the outcomes with a Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and complication rate. RESULTS The mean follow-up period was 26.58 ± 11.2 months. The interlaminar approach was used in 15 cases, and the transforaminal approach was used in 16 cases. The mean VAS of 8.19 ± 0.65 before surgery was decreased to 1.29 ± 0.69 at the last follow-up. The mean ODI score before surgery was decreased at the last follow-up, from 41.32 ± 2.87 to 9.87 ± 3.47. Mean operative duration was 45 ± 12 minutes per level. None of the patients required revision surgery or developed any major complication. CONCLUSIONS Calcification floating technique is a safe and effective method for the treatment of partially calcified lumbar HNP.

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.

Feasibility of Full Endoscopic Spine Surgery in Patients Over the Age of 70 Years With Degenerative Lumbar Spine Disease

Background/Aims Degenerative spine disease, encompassing disc prolapse and stenosis, is a common ailment in old age. This prospective study was undertaken to evaluate the role of endoscopic spine surgery in elderly patients (above 70 years of age) with clinical and radiological follow-up. Methods In this study, a retrospective analysis was conducted of 53 patients with lumbar disc prolapse or spinal stenosis who were treated with percutaneous endoscopic discectomy or decompression from November 2015 to June 2017. Clinical follow-up was done at 1 week, 3 months, and 1 year, and at yearly intervals thereafter. The outcomes were assessed using the modified Macnab criteria, a visual analogue scale, and the Oswestry Disability Index. Results Of the 53 patients, 21 were men and 32 were women. Their mean age was 76±4 years. The mean follow-up period was 17 months. Percutaneous endoscopic discectomy was performed in 24 patients and endoscopic decompression in 24 patients, while 5 patients underwent combined surgery. An excellent outcome in terms of the MacNab criteria was observed in 9 patients (16.98%), a good outcome in 38 patients (71.7%), and a poor outcome in 6 patients (11.3%). Of the 6 patients with a poor outcome, 5 (9.4%, 5 of 53) developed recurrent disc prolapse, and 1 developed hematoma with motor weakness. All 6 of these cases required revision surgery. Conclusion Managing degenerative spine disease in elderly patients with multiple comorbidities is a challenging task. Percutaneous endoscopic spine surgery is pivotal for addressing this concern. The authors have shown that optimal results can be achieved with various types of disc prolapse and stenosis with favorable long-term outcomes.

Extreme lateral and interlaminar approach for intra-canal and foraminal double disc herniation at lumbosacral level

INTRODUCTION AND OBJECTIVES There are several approaches for double disc herniation consisting of an intracanal and foraminal lesion. Of several approaches, we introduced extreme lateral and interlaminar approach (ELIA). And we aimed to compare the approach with the conventional combined interlaminar and paraisthmic approach (CIPA). PATIENTS AND METHODS The authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level between March 2012 and February 2016 and patients who underwent CIPA or ELIA were selected. For preoperative testing, simple X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans were performed. For postoperative outcomes, the Korean version of the Oswestry Disability Index (K-ODI) and Numeric Rating Scale (NRS) at one, two, and three months post-operation were checked. RESULTS Eleven patients were given ELIA and twenty-four patients were involved in CIPA. The mean pre K-ODI was 34.1 (±13.9) and 32.4 (±4.0) at each group. 1st, 2nd and 3rd month post-operative K-ODI was 8.2 (±4.1), 6.4 (±2.1) and 5.3 (±2.4) in ELIA and 8.1 (±3.2), 7.1 (±3.5) and 8.4 (±6.4) in CIPA. Post-operative 3rd month K-ODI showed significant difference between two groups (p: 0.005). The mean pre NRS was 8 (±0.9) and 8.6 (±1.0). 1st, 2nd and 3rd month post-operative NRS was 2.4 (±1.5), 2.2 (±1.5) and 2.0 (±0.9) in ELIA and 3.3 (±1.4), 3.3 (±1.6) and 3.7 (±1.9). Post-operative 3rd month NRS showed significant difference between two groups as well (p: 0.001). There were four (19.0%) recurrence cases in CIPA patients group, otherwise there was no recurrence case in ELIA group. CONCLUSIONS In the treatment of L5-S1 double disc herniation, the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation.

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc-outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 ± 16 years and the male/female ratio was 2:1. The mean follow-up was 19 ± 6 months. A total of 190 lumbar levels were operated on (L1-L2: n = 4, L2-L3: n = 17, L3-L4: n = 27, L4-5: n = 123, and L5-S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 ± 12 (25 - 56) min and the mean hospital stay was 1.2 ± 0.5 (1-3) days. The VAS score for leg pain improved from 7.5 ± 1 to 1.7 ± 0.9. The ODI improved from 70 ± 8.3 to 23 ± 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

Percutaneous Endoscopic Interlaminar Unilateral Ventral Dural Approach for Symptomatic Bilateral L5–S1 Herniated Nucleus Pulposus: Technical Note

Background Percutaneous endoscopic lumbar diskectomy is a good treatment modality for lumbar disk herniation. However, when a patient complains of bilateral lower limb radicular pain with severe disk protrusion at the L5‐S1 level, the transforaminal approach is often unable to resolve both lesions owing to anatomical limitations. It is also very difficult to resolve both lesions in an ipsilateral direction using the percutaneous interlaminar approach. We report our surgical technique and clinical results using a ventral dural approach of percutaneous endoscopic interlaminar lumbar diskectomy for L5‐S1 herniated nucleus pulposus (HNP) in patients with bilateral radiculopathy due to a severe disk protrusion. Methods Twenty‐seven patients with severe L5‐S1 HNP complaining of back pain and bilateral lower limb pain were included in the study. The unilateral ventral dural approach of percutaneous full endoscopic interlaminar lumbar diskectomy technique was used. The visual analog scale (VAS) and Macnab criteria were used for clinical evaluation. All assessments were completed 1 day before surgery, 1 week after surgery, 6 months after surgery, and at final follow‐up after surgery. Results The mean preoperative back and leg pain VAS scores decreased from 5.67 ± 0.78 and 7.81 ± 0.83 to 2.44 ± 0.58 and 2.26 ± 0.53 at 1 week, 1.78 ± 0.51 and 1.52 ± 0.58 at 6 months, and 1.56 ± 0.70 and 1.67 ± 0.96, respectively, at the final follow‐up after surgery. With respect to the Macnab criteria, 51.85% of the results were excellent, 44.44% were good, and 3.70% were fair. Four cases recurred: three patients underwent conservative treatment and one patient operated with percutaneous endoscopic interlaminar lumbar diskectomy. Conclusion According to the results of this study, the ventral dural approach of percutaneous full endoscopic interlaminar lumbar diskectomy in patients with L5‐S1 HNP associated with bilateral lower limb pain due to a severely protruded HNP is a good option for a minimally invasive surgical approach.

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.