Journal of Spine

Fusion of the anterior column with placement of interbody fusion cages is commonly employed in the treatment of instability-related degenerative disc disease that has been proven refractory in non-operative treatment. Interbody fusion cages aid in the containment of bone graft, promotion of more reliable fusion, and restoration of neuroforaminal height. The VariLift^® Interbody Fusion System (VariLift^® system) has been developed as a standalone solution to address subsidence and migration problems seen with traditional lumbar interbody fusion cages that require posterior supplemental transpedicular screw fixation for improved stability. This series of 24 consecutive patients describes patient selection criteria and the technical aspects of this novel endoscopic transforaminal lumbar interbody fusion technique in a step-by-step fashion. The transforaminal endoscopically assisted interbody fusion with the standalone expandable VariLift^® system represents a simplified alternative to other pedicle screw-based spinal fusion.

Spinal cord injury without radiographic abnormality (SCIWORA) is rare in adults. It is of considerable importance owing to the potential problem of management inherent in the diagnosis.

We report a rare case of young female who developed quadriplegia as an outcome of accidental hanging. Her initial radiological investigation were normal but subsequent magnetic resonance imaging revealed intramedullary signal changes from C2 vertebral body level extending up to C3 level without vertebral or ligamental involvement. The patient was recuperated near completely with traditionalist treatment measures including bed rest and methylprednisolone. Routine radiographs and sometimes even computerized tomography can miss this injury and SCIWORA ought to be suspected in these instances of spinal damage giving neurological deficit.

We report a case of 42-year-old male traumatic paraplegic (D9 level, ASIA A) with inability to sit in the bed and wheelchair which interfered in his rehabilitation because of myositis ossificans at bilateral hips which was confirmed clinically and radiologically. He underwent excision arthroplasty bilateral hips following which his sitting restored and patient independently used wheelchair and successfully earned his livelihood.

Objective: To evaluate the feasibility and clinical effect of endoscopic foraminoplasty and neuro-ventral decompression for the treatment of lumbar disc herniation combining with lateral recess stenosis.

Method: From June 2015 to August 2016, thirty patients with typical radicular symptoms and neurogenic intermittent claudication were treated. There were 17 cases with lumbar disc herniation with lateral recess stenosis at L4/L5 and 13 cases at L5/S1. The mean course of disease was 10.6 ± 6.1 months. The preoperative and postoperative visual analogue scales (VAS) were used to assess the intensity of pain. The outcomes were evaluated by Oswestry disability index (ODI) and Japanese Orthopaedic Association Scores (JOA). Clinical signs were observed and compared before and after the operation. These patients had undergone the normalized endoscopic foraminoplasty for spinal canal decompression and discectomy to decompress the traversing and exiting nerve.

Result: Based on MacNab's criteria assessment, 17 patients (56.7%) showed excellent, 9 (30.0%) good, 4 (10%) fair, and 0 (0%) poor results. Our results demonstrated that normalized endoscopic foraminoplasty for the treatment of lumbar disc herniation combined with lateral recess stenosis can significantly improve the VAS, ODI and JOA score at each time point postoperatively compared with preoperative parameters (P<0.05). There were no significant differences in the VAS, ODI and JOA scores at each postoperative time point compared with immediate postoperative assessment.

Conclusion: The endoscopic foraminoplasty and neuro-ventral decompression is safe, and efficacious for the treatment of lumbar disc herniation with concomitant lateral recess stenosis. Careful selection of surgical indication, and normalized, skilled surgical techniques are the key to the successful clinical outcome.

The Practice of Medicine will always be an art based on science. The human body is more complex and not like a mathematical formula. History has shown that concepts in medicine, judged by “key opinion” leaders, currently depend on scientific publications that affect medical treatment through the medical literature. Strict adherence to Cochrane criteria and old “evidence based” concepts are used for scientific dissemination and publication, but also used for insurance reimbursement in the United States. Health care is becoming more and more supported by government subsidy and payment is dependent on guidelines established by each payer. The ability of innovative and valuable level five expert EBM opinions to get published for dissemination to the scientific community can be difficult for researchers because institutional support or NIH funding is the usual pathway. If there is no institutional support, researchers must pay fees to get their work published in open access Journals. It may be the time to consider “innovative disruption” as a form of evidence based medicine to mitigate the unsustainable increasing cost of health care for spine treatment. Endoscopic spine surgery fits consideration as an innovative disruptive procedure. Patients seeking advice from their chosen physician or health care provider for their physical complaints are for conditions that are based on the Physiology and Patho-anatomy causing their symptoms. In spinal conditions, while most patients are not taken seriously until they complain of “debilitating” pain, symptomatic conditions that can be resolved with tincture of time and/or supportive modalities are supported by allopathic as well as homeopathic and naturopathic physicians. Surgical or invasive procedures are usually reserved for more specific allopathic conditions. These conditions may cause not just pain, but numbness, a change in sensation, weakness, or only intermittent debilitation. The symptoms may also reflect separate and concomitant symptoms that can be confusing when the physician focuses on a single source of the symptom. Extensive experience and perseverance with techniques that work for the clinician is valuable when there is a database large enough to be studied and mined, to demonstrate statistical significance. Such is the case with procedures that can be validated by endoscopic imaging to evaluate, and validate the complaint by the ultimate result: symptom resolution. Traditional radiologic Imaging by itself, however, is inadequate to explain complaints of symptoms that may or may not be debilitating in the physician’s judgment, and the patient may be simply dismissed or prescribed a drug to mitigate the complaint. This has, in many ways, contributed to the myriad of pharma solutions to every symptom complaint in allopathic medicine. A myriad of Naturo-pathic remedies are also marketed and sold over the counter, supported by millions of symptom sufferers who do not expect insurance reimbursement. There are also allopathic means to diagnose and treat symptomatic conditions in the spine, especially in the lumbar spine that currently garners third party reimbursement. The role and future of endoscopic spine surgery is supported here as an innovative disruption to our current means for scientific validation. Performed expertly and properly, a “warrantee” can be provided.