Diário da Espinha

Endoscopic spine surgery is receiving intense interest as minimally invasive techniques, robotics and biologics are the latest focus in spine care that is embraced by a myriad of providers, all touting their area of expertise as the answer to treating painful conditions of the spine. All stakeholders agree that if non-surgical methods of treatment are effective, the natural adaptation of painful degenerative conditions will eventually be mitigated or resolved with some modification of work or activities of daily living that avoids aggravating the clinical condition or delays a rapid advancement to a painful condition.

Each stakeholder in the treatment spectrum is touting, and marketing their areas of expertise, but few stakeholders work together in a truly multidisciplinary and cooperative agenda. Procedural or surgical interventions are easiest to market and to measure its efficacy and cost effectiveness. The cumulative cost of spinal care is, however, becoming less affordable as spinal care does not follow the economics of a free market since increased consumption and availability does not result in decreased cost as an economic model.

There is a need for cooperation and a focus on the diagnosis and treatment of common painful conditions of an aging spine, starting with common back pain that affects tens of millions of patients. Back pain is one of the most costly and debilitating conditions universally affecting work productivity.

In the United States and in industrialized countries, new procedures for back pain tend to “follow the money” aided by industry. In Asian and OUS countries, there is more acceptance of traditional non-surgical treatment from thousands of years of medical treatment history. New and non-traditional treatments based on evolving science, are being made readily available in the information highway by Open Access Journals where researchers can publish their Level V evidenced based concepts for interested parties and other scientists.

Anthony T. Yeung’s work focuses on the surgical treatment of the pain generator in the lumbar spine. Patient selection is aided by using diagnostic and therapeutic injections, to identify the likelihood of surgical success when the pain source is targeted. This article focuses on the details of Yeung’s 27 years’ experience on identifying and treating the pain generators in the lumbar spine by an endoscope and combined with an endoscopic system that he has trademarked the Yeung Endoscopic Spine System (YESSTM).

Anthony T. Yeung M.D., has reported his 5-10-year results in a preliminary review of endoscopic transforaminal of isthmic and degenerative spondylolisthesis decompression causing sciatica and back pain at international spine meetings. Fifty-five patients from January 2002-December 2012 served as the database for the clinical presentation in patients who specifically chose to stage Yeung’s endoscopic transforaminal decompressive procedure over fusion. The patients were specifically evaluated for endoscopic spine surgery in a shared clinical decision.

This more focused article is subdivided with stratified indications to degenerative spondylolisthesis only, omitting isthmic spondylolisthesis since isthmic spondylolisthesis is traditionally the surgical option of choice for patients who elected to undergo surgical intervention as the standard surgical option versus continuing with non-surgical care. Disc protrusions associated with degenerative spondylolisthesis, disc herniation, patients with concomitant stenosis, who did well with the first study on both degenerative and isthmic spondylolisthesis were analyzed from the first database and stratified for degenerative spondylolisthesis. The patients of the original 10-year follow-up study were 100% satisfied with their decision to try the endoscopic surgery first, even when they subsequently opted for fusion since it would not interfere with a fusion as a secondary staged procedure. There was no attempt to stratify the first patient group who wanted to stage their surgical options, even if fusion became necessary for their pain and activity requirements.

In this 10-year study 33% eventually opted to undergo fusion in order to get more symptom relief. Transforaminal foraminoplasty also provided some unanticipated back pain relief as well. When dorsal endoscopic ablation of the medial branch of the dorsal ramus was later added to the endoscopic procedure to address axial back pain, even better clinical outcomes were obtained by this focused study on degenerative spondylolisthesis, with or without disc protrusion and stenosis.

The standard treatment for lumbar pyogenic spondylodiscitis is an intravenous antibiotic. If conservative treatment fails, surgery is indicated. However, many patients suffer from residual lumbago after prolonged conservative treatment, and invasive surgery is problematic in poorly conditioned patients. We developed a new treatment in which intravenous antibiotics are supplemented by multiple injections of antibiotic directly into the infected disc. Here we report our experience with twenty adult patients. Shortly after infection was diagnosed, we performed the needle biopsy that we reported followed by direct antibiotic injection into the infected disc. Antibiotic was injected twice weekly until inflammation subsided. The average number of injections was 6.8. Infection was eradicated in all cases. Surgery was needed in two cases (10%): one because of acute paralysis and one because of residual sciatica. We observed no adverse effects. Excluding two cases who died of cancer, we obtained excellent (n=12) or good (n=3) results (83%) in a total of 18 patients evaluated according to Macnab's lumbago criteria at an average of 27.5 months follow-up. The disc height was retained in ten cases during the initial two months of treatment: nine of these patients showed excellent results on Macnab's lumbago scale. We conclude that supplementing standard systemic antibiotic therapy with multiple injections of antibiotic directly into the infected disc provides a safe and effective method of eradicating lumbar pyogenic spondylodiscitis. This treatment also provides an excellent chance of maintaining the disc height, which leads to less residual lumbago.

Introduction: Although cervical arthroplasties have been widely used with some success over the last decade, long terms results are missing, particularly for the latest designed implants such as semi constrained prostheses.

Material and methods: 89 patients were enrolled in an observational study evaluating long term safety and potential complications related to the use of the cervical prosthesis Baguera® C. All patients had been treated at one or two levels between June 2009 and June 2011.

At the 5 years FU visit, the patients were evaluated clinically and neurologically, and with self-assessment questionnaires (NDI, SF12). Radiological examination was performed by lateral X-rays in neutral, flexion and extension positions.

Results: There were no reoperations at the arthroplasty level, no fracture of system components, no loss of fixation, and no migration nor subsidence. 17 patients had signs of adjacent level(s) degeneration.

The performance related to Baguera®C usage, was evaluated at 5+ Y. PO by three parameters: Range of Motion (ROM), NDI and SF-12 scores. ROM at the treated level was 8.6° ± 5.0°. 87.7% of the treated levels showed preserved motion.

NDI score was 19.5% ± 14.1%. 92% of the subjects reported NDI scores over 50%, and 74.2% of the subjects reported NDI scores under 30% and 45% of the subjects reported NDI scores under 10%.

The QOL Index and Patient Satisfaction (SF-12 scores) reached 48.5 ± 8.6 for the PCS physical score and 48.0 ± 10.5 for the MCS Mental score. Both SF-12 components, physical and mental, were close to a normal health status (50%).

Conclusion: Cervical disc replacement with the Baguera®C prosthesis shows excellent safety, clinical results and long-term motion preservation. There was no index or adjacent level reoperation after 5 years. Radiological progression of adjacent level degeneration was seen in a significant minority of cases, but without clinical expression.