Diário da Espinha

Objective: Ultrasonographic evaluation of the anatomy of the intervertebral discs, vertebral canal of the cervical spine in practically healthy adolescents.

Materials and methods: The study included 72 healthy children with normal neurologic status, 35 of them aged 13-15 years, 37-16-18 years old. Ultrasonography (USG) was performed at the level of disks C2-C3, C3-C4, C4-C5, C5-C6, C6-C7, C7-Тh1 in longitudinal and transverse projections. In the longitudinal projection, the height of the intervertebral discs (IVD) and vertebral bodies (V), their ratio (IVD/V), and in the transverse projection - the sagittal size of the IVD, the spinal canal (SC), their sagittal size ratio IVD/SC, the width of spinal nerve canals (NC), the yellow ligament thickness, the sagittal size of the anterior dural space (ADS), their ratio of the ADS and SC (ADS/ SC). In addition to the quantitative parameters of the IVD and SC, the echo structure of the nucleus pulpous (NP) and fibrous ring (FR) was also studied.

Results: The highest sagittal size IVD and SC in the age groups 13-15 (15.6 ± 0.8 mm and 16.4 ± 0.9 mm) and 16-18 years (16.9 ± 0.7 mm and 17.3 ± 0.8 mm) was recorded at the level of C2-C3. Only in the age group 16-18 years were no significant differences (p<0.05) compared with the level of C7-Th1 (17.3 ± 0.8 mm in front of 15.2 ± 0.7 mm). In both age groups, the height of the IVD was also the highest at C2-C3 (4.2 ± 0.23 mm and 4.5 ± 0.37 mm), but no significant differences compared with the levels of C2-C3 and C7-Th1 has not been revealed.

SC area was calculated from the linear dimensions and on the perimeter. At the level of C2-C3 in 13-15 years, these figures were 188 ± 11 mm2 and 287 ± 14 mm2, aged 16-18 years - and 195 ± 12 mm2 312 ± 14 mm2. At the level of C7-Th1 these figures were 152 ± 8 mm2 (p<0.05), 158 ± 7 mm2 (p<0.01), 236 ± 12 mm2 (p<0.001), 248 ± 9 mm2 (p<0.001).

The thickness of the yellow ligament (YL (TAR-reject) increases from top to bottom, it was the highest level of C6- C7 in the age group 16-18 years and was 2.8 ± 0.24 mm significantly (p<0.05) higher than at the level of C2 C3 (2.1 ± 0.15 mm).

Sagittal size anterior dural space (ADS) in all children at all levels of IVD profit lower than the rear PDS index ADS/PDS was lowest at C4-C5 and was 0.82 ± 0.03.

Conclusion: In adolescents, the sagittal size of the intervertebral disc and spinal canal, the height of the IVD, the frontal size, the area of the SC, the width of the spinal nerve canals, the dural spaces have the largest value at the C2-C3 level, the smallest at the C6-C7 and C7-Th1 levels. The smallest ratio of IVD/SC is observed at the level of C2- C3. The maximum thickness of the yellow ligament is recorded at the level of C6-C7, the smallest sagittal dimension of the anterior dural space is determined at the level of C6-C7 and C7-Th1.

Introduction: Traditional interventional pain management only provides temporary relief that depend on the patient’s natural healing to mitigate pain. Visualizing the patho-anatomy with an endoscope targeting the pathoanatomy by interventional needle trajectories, however, has opened the door for surgical decompression and ablation of the pain generators. Endoscopic spine surgery is effective using mobile cannulas to target the pain source facilitated by surgical visualization and decompression and ablation using an endoscope. New instrumentation, techniques, specially configured endoscopes, access cannulas, RF and laser modalities all facilitate effective surgical treatment of the pain generator. While traditional translaminar surgical approaches provide open access to spinal pathology, there are conditions better suited for an endoscopic approach, especially when the surgeon can add intradiscal therapy using the transforaminal or translaminar approach. When a surgeon combines interventional techniques with endoscopic visualization, additional effective steps in the treatment algorithm are available. The purpose of this paper is to demonstrate that the physiology of pain can be visualized, and treated surgically as the path-anatomy of a pain generator.

Materials and method: In endoscopic transforaminal surgery, the Yeung Endoscopic Spine SurgeryTM (YESSTM) technique, is utilized: 1. Needle and cannula placement for optimal instrument placement is calculated from skin marking drawn on the skin from the PA and Lateral C-arm image. A similar needle trajectory is utilized for diagnostic and therapeutic injections as a diagnostic precursor that helps predict the success of transforaminal endoscopic surgical intervention. 2. Injection of non-ionic radio-opaque contrast will create a foraminal epidural gram and produce epidural patterns that outline foraminal patho-anatomy such as HNP; central and lateral recess stenosis, and other pathologies from the epiduralgram pattern. 3. Evocative chromo-discographyTM is performed to provide a normal or abnormal discogram pattern that helps correlate the patho-anatomy of discogenic pain. Disc and foraminal decompression is aided by vital tissue staining. 5. Endoscopic foraminoplasty decompresses the lateral recess and visualizes the exiting and traversing nerve in the axilla containing the Dorsal Root Ganglion (DRG), In addition, other anomalous path-anatomy not suspected or identified by traditional imaging can be visualized with the endoscope. 6. Surgical exploration of the epidural space. 7. Probe the “hidden zone” of Mac Nab under local anesthesia with a capability for the patient to provide back to the surgeon during surgery while mildly sedated or without sedation under local anesthesia. 8. Using a biportal or multiple portal techniques for out-side in or inside-out removal of extruded and sequestered nucleus pulposus and other patho-anatomy. 9. Dorsal and foraminal visualized rhizotomy of the branches of the dorsal ramus to denervate the facet joint. A database of over 10,000 surgical cases utilizing jpeg and MP4 video imaging illustrate the painful conditions most suitable and also possible with endoscopic surgery.

Results: The transforaminal endoscopic technique will allow surgical access to the lumbar spine for treatment of a wide spectrum of painful degenerative conditions. There are, moreover, conditions where the endoscopic foraminal approach has advantages over traditional surgical approaches. These conditions are: 1. Discitis 2. Far lateral foraminal and extraforaminal HNP, especially at L5-S1, 3. Upper lumbar HNP 4. Lateral foraminal stenosis. 5. Discogenic pain from toxic annular tears 6. Visualizing the pain generators responsible for failed back surgery syndrome (FBSS). 7. When anomalous nerves such as furcal nerves are visualized, judgment must be used to determine whether the nerves can be avoided or ablated. Avoiding the nerves my cause failed back surgery syndrome by failing to remove the source of pain in the “hidden zone”, or ablation can resolve the cause of pain from these branches of spinal nerves, also described as conjoined nerves. If the nerve does not hurt on probing or thermal stimulation, it is usually safe to ablate the nerve, with the risk of temporary dysesthesia requiring time to resolve, or the use of transforaminal steroid blocks and sympathetic blocks. Repeat surgical attempts to further decompress the foramen is discouraged as the symptoms and any effect of weakness may worsen or become permanent.

Conclusion: New surgical skills are needed for spine surgeons to incorporate endoscopic spine surgery in their practice. Incorporating interventional pain management techniques as a surgical as well, and not just as a diagnostic procedure confirmed by the results of rational treatment of the patho-anatomy under local anesthesia helps marry the basic science of surgical micro-anatomy with surgical results. This provides additional clinical information that facilitates surgical intervention. New surgical procedures focusing on intradiscal therapy, disc augmentation, biologics, annular modulation, and tissue neuromodulation are all well suited for the minimally invasive approach. Endoscopic foraminal access to the lumbar spine will open the door to for true minimally invasive access to the lumbar spine without affecting and destabilizing the dorsal muscle column. Formal training or mentorship is needed to make this technology mainstream. New evolving technology facilitated by robotics and biologics will help evolve this procedure in the near future.

Background: Adjacent Segment Disease (ASD) is a notable complication following lumbar fusion surgery. Clinicians use various surgical techniques to correct the progression of spine deterioration and reduce the risk of continued ASD. The aim of this retrospective case series is to describe patient outcomes following posterior lumbar interbody fusion (PLIF) using the VariLift® standalone interbody device (without supplemental fixation) for the treatment of ASD.

Methods: Nine consecutive patients who underwent a single-level PLIF for the treatment of ASD were reviewed. Outcome measures included patient demographics, comorbidities, surgical complications, time to fusion, Visual Analog Scales for Pain (VAS), and overall patient reported recovery of symptoms. Nine patients (8 males, 1 female) with a mean age of 62.3 (42 to 72) years underwent a single-level procedure. The standalone VariLift interbody fusion system was used in all 9 sequential patients, regardless of the type of fusion/fixation instrumentation previously used. Surgical technique consisted of discectomy and generous bilateral laminotomies with medial facetectomies preserving midline ligamentous structures.

Results: Radiographic ASD was confirmed in all cases. Each patient had a history of a lumbar fusion. Preoperatively, 89% of patients reported 9-10 VAS back pain levels. All patients experienced symptomatic improvement. By 12 months postoperatively, average VAS back pain score was 2, a significant improvement from baseline (p<0.05). Solid interbody fusion without implant failure was observed in all cases with averaged time to fusion at 346 days (min=181 days).

Conclusion/level of evidence: Posterior lumbar interbody fusion using the VariLift device to treat symptomatic ASD offers significant clinical success and solid fusion rates without the need for supplemental fixation or extension of previous supplemental fixation. Level of evidence IV.

Clinical relevance: This stand-alone fusion device produced high fusion rates and symptomatic improvement in a sample of patients with severe back pain and ASD.

Introduction: Thoracic disc herniations causing unrelenting neuralgia are relatively rare, especially cephalad to T-10 because the rib cage provides enough stability to offer relief with non-surgical methods over time. A transforaminal percutaneous endoscopic thoracic approach (PETD) however, is a feasible minimally invasive option for decompressing and removing the herniation without resorting to a more invasive and surgically more morbid open approach requiring thoracotomy and removal of the rib head through the thoracic cavity.

Method: The application of three-dimensional printing of individualized anatomic models, improves the accuracy and safety of this less invasive percutaneous operation that allows for surgical performance under local anesthesia. With the data provided by preoperative three-dimensional reconstructive CT scans, an individualized 3-D thoracic model is established by using medical mimics’ software, produced with a 3-D laser printer. A more exact trajectory with a calculated skin entry point provides extra safety for a percutaneous postero-lateral approach.

A 16-year-old male, with a thoracic disc herniation and unrelenting neuralgia, is diagnosed by CT scans and magnetic resonance imaging. Non-surgical methods failed to help his severe intercostal neuralgia. Following a preoperative evaluation, a percutaneous decompression was performed, aided by 3-D printing of the thoracic spine. PETD was performed under local anesthesia.

Result: The patient had immediate resolution of his pre-operative radiating pain with no operative surgical morbidity. Extra safety is provided by operating with the patient awake.

Conclusion: Thoracic disc herniations can be decompressed safely and effectively under local anesthesia by percutaneous endoscopic thoracic decompression (PETD). 3 D printing reconstructing the individual’s anatomy at the herniation level provides an additional method for trajectory guidance. Accuracy in a trans-foraminal approach for thoracic disc herniations is critical because of the close proximity of the spinal cord and the chest cavity.

Spinal arachnoid cysts are uncommon benign lesions that occur in the spinal axis, and can cause spinal cord or nerve roots compression and may become clinically relevant. The authors report a 49-year-old woman who presented progressive onset of cervical pain with distal paraesthesia of the upper limbs associated to an intramedullary arachnoid cyst in the mid-cervical spine diagnosed by MRI. From the literature review, only six cases in patients over 18-year-old were found, all with thoracic location and one with cervical extension, and all were submitted to decompressive surgery. The authors described the first intramedullary arachnoid cyst with a wait and scan approach.

Background: This study was to find out that whether the lumbar disc prolapse at different level influence the functional outcome of patients after discectomy. Present study is of 50 adult cases admitted at D. Y Patil Medical College. Common age group involved was between 40-60 years.

Aims: To assess whether there is any difference in functional outcome of patients with disc prolapse at different levels in the lumbar spine after performing discectomy Objectives: To compare pre-operative and post-operative:

• Leg pain and back pain by Visual Analog Scale Score

• Functional outcome by Modified Oswestry Disability index score of the selected patients.

Materials and methods: This study was a comparative study, conducted for a period of about two years, July 2014 to September 2016 in dr. D. Y. Patil Medical College, Hospital & Research Centre, only patients who were scrutinized for exclusion criteria and also abiding to inclusion criteria were included. Period required for data collection: 2 years. Period required for data analysis and reporting: - 6 months. We prospectively followed 50 consecutive patients with unilateral lumbar herniation either at L2-L3, L3-L4, L4-L5 or L5-S1 levels requiring surgery. The procedure performed was Micro lumbar discectomy in all patients. Results: A total of 50 patients were included in our study of which 4 (8%) patients had prolapsed intervertebral disc at L2-L3 level and 10 (20%) patients had disc prolapsed at L3-L4 level. These 14 patients were included in upper lumbar level disc herniation group referred hereafter as Group 1 (28%). 22 (44%) patients had disc prolapsed at L4-L5 level and 14 (28%) patients had disc prolapsed at L5-S1 level, these 36 patients were included in lower lumbar level disc herniation group who are referred hereafter as Group 2 (72%). On comparing the results after discectomy of prolapsed intervertebral disc at different levels in the lumbar spine we found no significant difference in the end result and functional outcome of the patients. Conclusion: The aim of this study was to find out that whether the lumbar disc prolapse at different levels influence the functional outcome of patients. According to the observations of this study and after reviewing various similar studies done in the past we conclude that after discectomy, level of disc prolapse per se has no significant bearing on functional outcome of the patients.

Background: The purpose of this study is to investigate the differences of the clinical results and imaging findings among three different bilateral decompression via unilateral approach with a minimum 2-year follow-up period.

Methods: Thirty consecutive patients with lumbar spinal canal stenosis who had undergone bilateral decompression via 3 different unilateral paraspinous approaches with a minimum 2-year follow-up period were chosen retrospectively for groups A (conventional open surgery), B (mini open surgery), and C (micro-endoscopic surgery). The clinical results and imaging findings of these three groups were then investigated.

Results: A significant difference in length of incision and intraoperative blood loss per level decompressed was seen with group A>B>C. Operative time per level decompressed was longer in group C than in groups A or B. Japanese Orthopaedic Association (JOA) score recovery rate was lower in group B than in group C. The change ratios of cross-sectional area (CSA) of the ipsilateral and contralateral multifidus were smaller in group A than in groups B or C. Ipsilateral facet joint preservation was less in group A than group C, and contralateral facet joint preservation was less in group A than in groups B or C. The difference in change in slippage was greater in group A than in group C.

Conclusion: This study revealed that bilateral decompression via a unilateral approach using mini open or microendoscopic procedures could be better surgical interventions compared to a conventional unilateral open approach for paravertebral muscle and facet joint preservation for at least 2 years.

The purpose of this study is to evaluate mutual influence of selected postural parameters onto movement of the line of the human body gravity point with use of noncontact optical tool (photogrammetry based). This study constitutes a part of the wider observational cross-sectional study of body posture of healthy people. A specially designed measurement set-up was developed to determine the 3D location of selected characteristic points of the human body. The photogrammetry tool was applied to calculate (x, y, z) coordinates of the points marked on the examined body, e.g., processus mastoideus and angulus superior scapulae. With these assumptions postural parameters in the sagittal and coronal planes can be determined, respectively. The 3D coordinates were used to evaluate the correlation between position of the examined body points and movement of the line of the examined’ body gravity point. It can be seen that it is impossible to determine the correlation of the absolute values of the angles of rotation as simple subject to analysis. To demonstrate the interdependence, it is necessary to take into account the sign of the angle of rotation. In the presented study, this factor can be analyzed. Obtained results suggest the usefulness of presented system in physiotherapy of body posture.

Background: Lumber disc prolapse accounts for only 5% of all low back pain problems but is the most common cause of radiating nerve root pain which called sciatica. In the 20th century, techniques were developed to remove the herniated disc with minimal invasiveness, with these minimally invasive techniques; authors demonstrated decreased soft tissue manipulation, operative time, blood loss, and hospital stay, allowing early recovery.

Patients and methods: This is a prospective study carried in Sulaimaniyah Teaching hospital for 111 patients (72 male and 39 female) complained from lumber disc prolapse from May 2010 till May 2015. Two different surgical discectomy procedures were done to these patients as follows: 1. Fenestration discectomy was performed to 53 patients through 2-5 cm skin incision. 2. Hemilaminectomy and discectomy had done to 58 patients through skin incision 4-7 cm. 3. The patients were evaluated preoperatively and 6 months postoperatively by PROLO score.

Results: 111 patients (72 male and 39 females with ratio 1.8:1) underwent surgical discectomy. The mean age of the patient was 36.2 + 6.2 years.

Fenestration discectomy group: 53 patients (47.7%) underwent fenestration discectomy. The operation time was ranging from 48–92 min with mean operative duration 69.13 ± 8.96 min. The mean hospital stay was 1.31 ± 0.73 days ranging from 16 hours to 3 days. According to PROLO score, fair results were reported in four (7%) patients while good result obtained in 12 patients (23%) and 37 patients (70%) showed excellent result. No patient expressed poor result.

Hemilaminectomy and discectomy group: 58 patients (52.3%) underwent hemilaminectomy and discectomy. The operation time was ranging from 56–103 min with mean operative time 78.66 ± 10.31 min. The mean hospital stay was 2.46 ± 1.42 days ranging from 1 day to 10 days. According to PROLO score, 9 patients (16%) obtained fair results while reliable results obtained in 15 patients (26%) and excellent results founded in 34 patients (58%). No patient showed poor results.

Discussion: Duration of the operation and hospital stay were significantly shorter in fenestration discectomy group than hemilaminectomy and discectomy one (p-value less than 0.001). Through PROLO score both procedures showed significant improvement postoperatively in both economic and functional assessments. Most of our patients gain excellent results according to PROLO score in both surgical procedures. In this series 92% of patients treated with fenestration discectomy improved postoperatively with good or excellent score, while 85% of the patients treated with hemilaminectomy have that improvement.

Conclusion: Both fenestration discectomy and hemilaminectomy with discectomy showed the same final postoperative outcome but the fenestration discectomy is superior since the operation duration, hospital stay is less and overall improvement is relatively better.

Background/purpose: Operating under local anesthesia allows the patient to respond and provide feedback during surgery that is invaluable for patient safety and for the assessment of the pain generators and ultimately understanding of the source of pain that the surgeon is targeting. Over 10,000 case studies make up the database for information gleaned from patients reporting the pain experienced and relieved during translaminar and transforaminal endoscopic decompression. Method: The patient is provided mild sedation with versed and fentanyl unless no sedation is requested. Patients requesting no sedation are usually anesthesiologists and other spine surgeons who opt for decompressive surgery, but wanted some measure of surgical participation and control. The anesthesiologist titrates the patient with 1-2 cc of fentanyl and versed pre-op with titration during surgery. The average total amount is 4-5 cc for most procedures. 1% lidocaine is utilized for the local anesthetic. An average of 10-20 cc is used for local anesthesia, titrated as needed during surgery. Results: The results of decompression can be predicted by a combination of pain relief reported during, immediately after, and augmented by visualization of the targeted patho-anatomy. Such visualized pathology visualized includes annular tears, decompressed spinal nerves, and visualization of the axilla between the traversing and exiting nerve. Conclusion: Observations provides level 5 EBM (Expert opinion) for surgical intervention. Evidence based medicine usually starts with level 5 “expert” opinions. With the ability to evoke pain in conscious surgical patients, with endoscopic images of the patho-anatomy that correlates evoked pain production with subsequent pain resolution following visualized endoscopic decompression. Along with comparison of pre-and post op images, a new and different and level of EBM may emerge and need to be considered in addition to the traditional Levels 1-5 EBM guidelines.

Introduction: The history and development of endoscopic spine surgery (PELD) in China is reviewed. Its significance and effect is predicted to have great implications for advancing spine care in China’s working and aging population. Percutaneous spine technology was introduced simultaneously from Japan and the United states by Hijikata and Kambin in the early 1980s. It was called Arthroscopic Microdiscectomy (AMD). The access portal was called “Kambin’s Triangle, with the discectomy technique through a “safe” puncture portal through an anatomical triangular zone in the foramen bordered by the facet and foraminal ligament dorsally, the exiting nerve ventrally, and the endplate of the caudal margin of the triangle.

Method: An expanded indication for the transforaminal Kambin technique was introduced to China by Anthony Yeung in 1998, and its evolution and contribution to modern minimally invasive spine care, called the Yeung Endoscopic Spine System (YESSTM) technique, is reviewed. The percutaneous technique has been adopted by surgeons as well as non-surgeons who also undergo surgical training in their rehabilitation programs who integrate the technique through their various affiliations in China for painful degenerative conditions of the spine.

Results: The efficacy of the endoscopic technique has evolved significantly since Kambin, with additional contributions by Chinese surgeons and key opinion leaders of surgical and non-surgical Chinese associations that have co-existed, but are focused on providing treatment options for the Chinese population for centuries. Western Medicine has provided great influence on Chinese medicine, but a significant percentage of the Chinese population still cling to traditional treatment, embracing both Old and New methods. With respect to modern surgical techniques, surgeons and no surgeons are cooperative, and focus on results while working together. They recognize that with endoscopic spine surgery, it is important to maintain a success rate comparable to traditional western open surgery with less surgical morbidity utilizing the endoscope. Peer reviewed papers are emerging from China, using the EBM guidelines of Western Journals.

Conclusion: A rapidly increasing number of surgeries along with improving results will continue to drive this minimally invasive surgical method to China that bridges the gap between non-surgical pain management, physical medicine, and surgical intervention that focuses on the patho-anatomy and patho-physiology of spinal conditions of pain. This will be known as “surgical pain management, a term coined by Dr Anthony Yeung. Future developments will continue to drive the adoption of endoscopic surgery as a significant advancement for Chinese medicine and surgery.