1 35 th Annual Meeting of the International Society for Minimal Intervention in Spinal Surgery (ISMISS) January 18-20, 2017 Swissôtel, Chicago, IL Presented by the International Society for Minimal Intervention in Spinal Surgery and the North American Spine Society in collaboration with the World Federation of Neurosurgical Societies I N T E R N A T I O N A L S O C IE T Y F O R M IN I M A L I N T E R V E N T I O N I N S P IN A L S U R G E R Y
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35th Annual Meeting of the
International Society for Minimal Intervention in Spinal Surgery (ISMISS)January 18-20, 2017Swissôtel, Chicago, IL
Presented by the International Society for Minimal Intervention in Spinal Surgery and the North American Spine Societyin collaboration with the World Federation of Neurosurgical Societies
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OCIETY FOR MINIMAL INTERV
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SPINAL SURGERY
35th Annual Meeting of the
International Society for Minimal Intervention in Spinal Surgery (ISMISS)January 18-20, 2017Swissôtel, Chicago, IL
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It will be your kind of town this week as MIS professionals from around the world convene to present, discuss, collaborate, learn and network.
Chicago is a great destination to hold the 35th Annual Meeting of the International Society for Minimal Intervention in Spinal Surgery. World class restaurants, shopping on the Magnifi cent Mile and cultural attractions are yours to enjoy during your free time.
ISMISS 2017 presents the latest developments in MIS featuring a hands-on cadaver course addressing current techniques; plenary sessions including peer-reviewed abstracts, debates, and case presentations and discussions; as well as exhibits showcasing the latest MIS tools and technology.
Wednesday’s full-day cadaver course focuses on minimally invasive surgical techniques ranging from transforaminal discectomy to MIS decompression of stenosis and lumbar fusion, in addition to cervical discectomy.
Don’t miss the Welcome Reception on Wednesday night. It’s the perfect opportunity to network and collaborate with world-renowned experts in MIS, develop new relationships or reconnect with colleagues. Also take advantage of the ample networking breaks throughout the meeting.
Symposia present the various minimally invasive surgical approaches available for lumbar disc herniation, lumbar spinal stenosis and lumbar fusion; the minimally invasive surgical options for the treatment of cervical radiculopathy and disc herniation; and minimally invasive surgical strategies for managing spinal trauma, spinal column tumors, spinal cord tumors, and adult degenerative scoliosis.
Case-based debates provide critical comparisons of the minimally invasive surgical approaches to lumbar disc herniation, lumbar spinal stenosis and lumbar degenerative spondylolisthesis in addition to the various minimally invasive surgical treatments for cervical radiculopathy, intradural spinal tumors and adult spinal deformity.
Four abstract presentation sessions are interspersed throughout the meeting to complete the comprehensive minimally invasive educational agenda.
LEARNING OBJECTIVESUpon completion of this meeting, participants should gain strategies to:• Promote discussion of new scientific developments and best
practices in minimally invasive spine care;• Demonstrate the application of current MIS techniques,
procedures and research;• Practice evidence- and value-based medicine relative to
minimally invasive spine care.
ANNUAL MEETING CONTINUING MEDICAL EDUCATION (CME) CREDITThis activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME). The North American Spine Society is accredited by the ACCME to provide continuing medical education for physicians and takes responsibility for the content, quality and scientific integrity of this CME activity.
The North American Spine Society designates this live activity for a maximum of 12 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The American Medical Association has determined that physicians not licensed in the U.S. to participate in this CME activity are eligible for AMA PRA Category 1 Credits™.
Additional credit may be obtained by attending the ticketed Hands-on Cadaver Course in Current Techniques in Minimally Invasive Spine Surgery.
EVALUATION AND EDUCATIONAL CERTIFICATESAfter the meeting, evaluations will be submitted electronically and CME certificates will be printed directly from our website. Visit spine.org/CME to claim education credit and to print CME certificates. Contact [email protected] with questions.
EDUCATION INFORMATION
DISCLAIMERThe material presented at the 35th Annual Meeting is made available by ISMISS/NASS for educational purposes only. The material is not intended to represent the only, nor necessarily the best, method or procedure appropriate for the medical situations discussed; rather, it is intended to present an approach, view, statement or opinion of the faculty which may be helpful to others who face similar situations.
ISMISS/NASS disclaims any and all liability for injury or other damages to any individual attending the meeting and for all claims which may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by physicians or any other person.
This Final Program contains confirmed program content, faculty and presenters as of December 7, 2016. Any further changes from the published Final Program will be announced at the beginning of each session.
2017 PROGRAM COMMITTEEISMISS/NASS would like to thank the following members for their valued time, effort and dedication in planning the educational content for this year’s meeting:
Richard G. Fessler, MD, PhDMeeting Chair and ISMISS President-Elect
John E. O’Toole, MD, MS Scientific Program Chair
Gun Choi, MD, PhDPil S. Choi, MDHansjörg Leu, MDJose Antonio Soriano-Sanchez, MDMichael Y. Wang, MDProgram Committee Members
2017 ABSTRACT REVIEWERSISMISS/NASS thank the following volunteers who spent numerous hours reviewing abstracts:Hansjörg Leu, MDJohn E. O’Toole, MD, MS Jose Antonio Soriano-Sanchez, MDMichael Y. Wang, MD
CORPORATE SUPPORTISMISS/NASS would like to thank the following companies for their generous support of the Hands-on Cadaver Course in Current Techniques in Minimally Invasive Spine Surgery:Globus MedicaljoimaxK2M, Inc.Karl StorzRichard Wolf Medical Instruments
Visit the Technical Exhibition to complement the educational sessions by evaluating first-hand the latest developments in equipment, supplies and services that are relevant to spine care. Networking coffee breaks and lunch will be available in the exhibit area.
WELCOME RECEPTION Open to All Attendees and ExhibitorsEdelweiss
Wednesday, January 186:00–8:00 p.m.
Ready to meet a few new faces at this year’s meeting or just reconnect with your colleagues? The Welcome Reception is the perfect opportunity to do so! This great networking event takes place before the conference begins, so you have time to grab a bite, have a drink and chat, before heading off to dinner. Please note that your meeting badge is required for entry.
NETWORKING COFFEE BREAKSZurich ABC
Grab a beverage and have a conversation during the Networking Coffee Breaks. Beverage services also are held in the Technical Exhibition.
Located in the Technical Exhibition, the breaks are scheduled: Thursday, January 19 . . . . . . 10:30–11:00 a.m.; 2:30–2:45 p.m.Friday, January 20 . . . . . . . . .10:35–11:00 a.m.; 2:30–3:00 p.m.
LUNCHZurich ABC
Lunch is open to all attendees and exhibitors in the Technical Exhibition from 12:00–1:00 p.m. on Thursday and Friday.
SPEAKER INFORMATION CENTERZurich Foyer
There is no Speaker Ready Room at this meeting. Presenters may upload or amend presentations by visiting the Speaker Information Center in the Zurich Foyer, near the Registration Area. Speakers are not permitted to use their own laptops for their presentations. No exceptions will be made.
Chicago offers a distinctive mix of global attractions and local charm that make this city the perfect location for ISMISS 2017. There’s shopping on the Magnificent Mile, experiencing world-class museums and viewing the truly unique architectural wonders. And don’t forget the outstanding restaurants, music venues and comedy clubs. Following are a few of the many locations to visit while in Chicago.
RESTAURANTSThe dining scene is unparalleled, serving up everything from tasty cheap eats to avant-garde cuisine.
Grace $$$$ American652 W. Randolph St.
Next Restaurant $$$$ Eclectic953 W. Fulton Market St.
Tru $$$$ French676 N. St. Clair St.
Swift & Sons $$$$ Steakhouse 1000 W Fulton Market St.
Avec Restaurant $$$ Mediterranean 615 W. Randolph St.
The Aviary $$$ Bar 955 W. Fulton Market St.
Blackbird Restaurant $$$ American 619 W. Randolph St.
The Boarding House $$$ American 720 N. Wells St.
Gibson’s Bar & Steakhouse $$$ Steak/Seafood 1028 N. Rush St.
Girl & the Goat $$$ American/Seafood 809 W. Randolph St.
Chicago Chop House $$$ Steakhouse 60 W. Ontario St.
GT Fish & Oyster $$$ Seafood 531 N. Wells St.
Joe’s Seafood, Prime Steak & Snow Crab $$$ Seafood/Steak 60 E. Grand Ave.
CHICAGO ATTRACTIONS
MK $$$ American 868 N. Franklin St.
Carmine’s $$ Italian 1043 N. Rush St.
RPM Italian $$ Italian/Steak 52 W. Illinois St.
Duck Duck Goat $$ Chinese 857 W. Fulton Market St.
MUSICLegendary blues and jazz can be heard nightly in venues throughout the city.
Andy’s Jazz Club 11 E. Hubbard St.
Blue Chicago 534 N. Clark St.
Buddy Guy’s Legends 700 S. Wabash Ave.
Rosa’s Lounge 3420 W. Armitage Ave.
The Green Mill 4802 N. Broadway St.
The Redhead Piano Bar 16 W. Ontario St.
COMEDYThe comedy scene ranges from traditional stand-up to competitive improv to sketch.
8:00 a.m. Hands-on Course Shuttle DepartsSwissôtel Event Center Entrance (Located just past the front desk, before the escalators leading to the Zurich Ballroom)
9:00 a.m.–2:00 p.m. Ticketed Session: Hands-on Cadaver Course in Current Techniques in Minimally Invasive Spine SurgerySpecialty Education & Research Center (SERC)
3:00–6:00 p.m. RegistrationZurich Foyer
6:00–8:00 p.m. Welcome Reception Open to All Attendees and ExhibitorsEdelweiss
8:00 a.m.Attendee shuttle departs for Hands-on Cadaver Course in Current Techniques in Minimally Invasive Spine Surgery Ticketed SessionSwissôtel Event Center Entrance (Located just past the front desk, before the escalators that lead to the Zurich Ballroom)
9:00 a.m.–2:00 p.m.Ticketed Session: Hands-on Cadaver Course in Current Techniques in Minimally Invasive Spine SurgerySpecialty Education & Research Center (SERC)
This hands-on cadaver course will focus on the major currently available minimally invasive surgical techniques, including transforaminal discectomy, lateral transforaminal fusion, cervical microendoscopic discectomy, lumbar microendoscopic discectomy, transforaminal lumbar interbody fusion, and lateral lumbar interbody fusion. Using a state-of-the-art facility, these techniques will be taught by the world’s experts in each of these techniques.
Upon completion of the course, participants will gain strategies to:• Utilize transforaminal lumbar interbody fusion (TLIF)
and other advanced minimally invasive spine surgery procedures.
• Perform challenging cases that include multilevel decompression and instrumentation as well as challenging levels to access.
• Identify postoperative complications and their management.
NASS designates this live activity for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
3:00–6:00 p.m.RegistrationZurich Foyer
6:00-8:00 p.m.Welcome Reception Open to All Attendees and ExhibitorsEdelweiss
This session will review the various minimally invasive surgical approaches available for lumbar disc herniation, lumbar spinal stenosis and lumbar fusion.
Upon completion of this session, participants will gain strategies to:• Select the optimal surgical procedure for lumbar disc
herniation;• Inform patients of the results and complications of surgery
for lumbar spinal stenosis;• Utilize different surgical techniques for lumbar fusion.
MIS Surgery for Lumbar Disc Herniation8:30–8:45 a.m.
8:45–9:00 a.m. Tubular Approach: Anatomy, Techniques, Results, Complications Alfred T. Ogden, MD
MIS Surgery for Lumbar Stenosis 9:00–9:15 a.m.
Endoscopic Decompression: Technique and Results Stefan Hellinger, MD
9:15–9:30 a.m. Tubular Decompression: Technique and ResultsRobert E. Isaacs, MD
DETAILED PROGRAM SCHEDULE
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9:30–9:45 a.m. Complications and RevisionsRichard G. Fessler, MD, PhD
MIS Surgery for Lumbar Fusion9:45–10:00 a.m.
Endoscopic Interbody Fusion: Technique and ResultsMichael Y. Wang, MD
10:00–10:15 a.m. Tubular Posterior Interbody Fusion: Technique and ResultsJose A. Soriano-Sanchez, MD
10:15–10:30 a.m. Lateral Interbody Fusion: Technique and ResultsAdam S. Kanter, MD
10:30–11:00 a.m.Networking Coffee BreakZurich ABC
11:00 a.m.–12:00 p.m.Plenary Session II: Abstract PresentationsZurich DEFGModerator: Michael Y. Wang, MD
11:00–11:06 a.m.1. Multiexpandable Cages for Minimally Invasive Posterior/Transforaminal Lumbar Interbody Fusion: A Preliminary ReportDonald Kucharzyk, DO1; Jeffrey D. Coe, MD2; Kornelis A. Poelstra, MD, PhD3; Joshua M. Ammerman, MD4; Sandeep Kunwar, MD5
1Orthopaedic, Pediatric & Spine Institute, Crown Point, IN, US; 2Silicon Valley Spine Institute, Campbell, CA, US; 3The Spine Institute on the Emerald Coast, Destin, FL, US; 4Washington Neurosurgical Associates, Washington, District of Columbia, US; 5Fremont, CA, US
11:06–11:12 a.m.2. In-vivo Endoscopic Visualization of Pain Generators in the Lumbar SpineAnthony T. Yeung, MDDesert Institute for Spine Care, Phoenix, AZ, US
11:12–11:18 a.m.3. Initial Experience with a Novel Robotically Operated Videoscope in Lumbar Decompression Procedures using the METRx tube systemThomas M. Doers, MD1; Sarika Walia, MD2; Maharaj Singh, PhD3
1Aurora Healthcare, Milwaukee, WI, US; 2Aurora Neurosciences Innovation Institute, Milwaukee, WI, US; 3Aurora Research Institute, Milwaukee, WI, US
11:18–11:24 a.m.4. A Comparative Clinical Study of Full-endoscopic Interlaminar Discectomy for L4/L5 versus L5/S1 Lumbar Disc HerniationYawei Li, MD, PhDThe 2nd Xiangya Hospital, Central South University, Changsha, China
11:24–11:30 a.m.5. Contralateral Radiculopathy following Minimally Invasive Transforaminal Lumbar Interbody FusionLimin Rong, MD, PhDThe 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
11:30–11:36 a.m.6. Modified Cervical Micro Endoscopic Laminoplasty for Patients with Cervical Spondylotic MyelopathyChunlin Zhang, MDThe First Affiliated Hospital of Zhengzhou University, Zhengzhou , Henan, China
11:36–11:42 a.m.7. World Federation of Neurosurgical Societies Special Presentation: Burst Stimulation with Penta Electrode for Failed Back Surgery Syndrome (FBSS)Enrique Osorio, MD
11:42 a.m.–12:00 p.m.Discussion
12:00–1:00 p.m.LunchZurich ABC
1:00–2:30 p.m.Plenary Session III: Abstract PresentationsZurich DEFGModerator: Alfred T. Ogden, MD
1:00–1:06 p.m.8. Minimally Invasive Correction of Adult Degenerative Deformity: Preliminary Follow-up and EOS StudyPei Yu, MD; Wenjian Wu, MD; Liang Yu, MD
Shanghai Ruijin Hospital, Shanghai, China
1:06–1:12 p.m.9. Treatment of Symptomatic Spinal Stenosis with the Transforaminal Endoscopic Approach Anthony T. Yeung, MDDesert Institute for Spine Care, Phoenix, AZ, US
1:18–1:24 p.m.11. Alternative to Fusion with a Hybrid Minimally Invasive Foraminal Decompression and Endoscopic Rhizolysis ProcedureAnthony T. Yeung, MDDesert Institute for Spine Care, Phoenix, AZ, US
1:24–1:30 p.m.12. The Application of Lateral Recess Partition Method in Spinal Endoscopic Transforaminal Approach to Treat the Lumbar Lateral Recess StenosisQingquan Kong, MDWest China Hospital of Sichuan University, Chengdu, Sichaun, China
1:30–1:45 p.m.Discussion
1:45–1:51 p.m.13. Posterior Dynamic Stabilization with Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel SurgeryQingquan Kong, MDWest China Hospital of Sichuan University, Chengdu, Sichaun, China
1:51–1:57 p.m.14. Percutaneous Endoscopic Decompression for the Lumbar Canal StenosesFujio Ito, MD, PhDAichi Spine Institute, Niwa-gun, Aichi-ken, Japan
1:57–2:03 p.m.15. A Biomechanical Analysis of Lateral Interbody Implants and Supplemental Fixation in Adjacent Segment DiseaseNikhil Jain, MBBS, MD1; Craig McMains, MD2; Alan Litsky, MD, ScD1; Emily Cerier, BS1; Elizabeth Yu, MD1
1The Ohio State University Wexner Medical Center, Columbus, OH, US; 2Stanford University, Redwood City, CA, US
2:03–2:09 p.m.16. Complication Risks of the Transforaminal Approach to the Lumbar Spine: An Anatomic and Pathoanatomic Risk Assessment Anthony T. Yeung, MDDesert Institute for Spine Care, Phoenix, AZ, US
2:09–2:15 p.m.17. MIS-TLIF for the Treatment of Mild to Moderate Isthmic Spondylolisthesis: Is Direct Decompression of Exiting Nerve Necessary?Wenjian Wu, MD; Liang Yu, M2
Shanghai Ruijin Hospital, Shanghai, China
2:15–2:30 p.m.Discussion
2:30-2:45 p.m.Networking Coffee BreakZurich ABC
2:45-3:00 p.m.History of EndoscopyFriedrich TieberZurich DEFG
3:00–4:35 p.m.Plenary Session IV: Case-based DebatesZurich DEFGModerator: Adam S. Kanter, MD
This session will provide critical comparisons of the minimally invasive surgical approaches to lumbar disc herniation, lumbar spinal stenosis and lumbar degenerative spondylolisthesis.
Upon completion of this session, participants will gain strategies to:• Contrast the advantages and disadvantages of surgical
approaches for lumbar disc herniation, lumbar stenosis and lumbar fusion;
• Explain to patients the rationale behind the selection of surgical technique for lumbar disc herniation, lumbar stenosis and lumbar fusion;
• Improve complication avoidance and management after surgical techniques for lumbar disc herniation, lumbar stenosis and lumbar fusion.
Lumbar Disc Herniation: Transforaminal versus Tubular Discectomy 3:00–3:10 p.m.
TransforaminalAnthony T. Yeung, MD
3:10–3:20 p.m. TubularKevin T. Foley, MD, FACS
3:20–3:25 p.m. Rebuttal/Discussion
DETAILED PROGRAM SCHEDULE
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Lumbar Stenosis: Endoscopic versus Tubular Decompression3:30–3:40 p.m.
TransforaminalPil Sun Choi, MD
3:40–3:50 p.m. TubularLarry T. Khoo, MD
3:50–3:55 p.m. Rebuttal/Discussion
Lumbar Stenosis and Degenerative Spondylolisthesis: Endoscopic versus Tubular versus Lateral4:00–4:10 p.m.
Endoscopic Fusion Jeffrey L. Katzell, MD
4:10–4:20 p.m. Tubular TLIFFaheem Sandhu, MD
4:20–4:30 p.m. MIS Lateral Interbody FusionLuiz Pimenta, MD, PhD
This session will review the minimally invasive surgical options for the treatment of cervical radiculopathy and disc herniation. The session also will present minimally invasive surgical strategies for managing spinal trauma, spinal column tumors, spinal cord tumors, and adult degenerative scoliosis.
Upon completion of this session, participants will gain strategies to:• Select the optimal surgical procedure for cervical
radiculopathy and disc herniation;• Improve complication rates and perioperative variables in
the surgical treatment of spinal trauma;• Provide patients with spinal tumors surgical procedures with
reduced morbidity.
MIS Surgery for Cervical Radiculopathy8:30–8:45 a.m.
Posterior Endoscopic Cervical Discectomy: Technique and ResultsJames J. Yue, MD
8:45–9:00 a.m. Post-tubular Cervical Discectomy: Technique and ResultsMick J. Perez-Cruet, MD
9:00–9:15 a.m. The Endoscopic Microsurgery to Treat the Degenerative Conditions of the Cervical Spine: An Advantage in Spinal SurgeryAndrea Fontanella, MD
Advanced MIS Surgical Applications 9:15–9:35 a.m.
MIS Surgery for Spinal Trauma: Technique and Results Sheeraz A. Qureshi, MD, MBA
9:35-9:55 a.m. MIS Surgery for Vertebral Body Tumors: Technique and ResultsJohn E. O’Toole, MD, MS
9:55-10:15 a.m. MIS Surgery for Intradural Tumors: Technique and ResultsTrent L. Tredway, MD
10:15-10:35 a.m. Adult Degenerative Scoliosis Correction: Technique and ResultsPaul Park, MD
11:00–11:06 a.m.18. EVOLVE: A Prospective and Multicenter Evaluation of Outcomes for Quality of Life, Pain and Activities of Daily Living following Balloon Kyphoplasty Treatment of Medicare Eligible Subjects with Vertebral Compression Fractures Melissa Chambers, MD, DVM1; Douglas P. Beall, MD2; John W. Amburgy, MD3; Devin Datta, MD4; Richard W. Easton, MD5; Bradly S. Goodman, MD6; Douglas A. Linville II, MD7; Sanjay Talati, MD8
1University of Alabama at Birmingham, Birmingham, AL, US; 2Clinical Radiology of Oklahoma, Edmond, OK, US; 3University of Alabama at Birmingham, PGY5, Department of Neurological Surgery, Birmingham, AL, US; 4The Back Center, Melbourne, FL, US; 5Beaumont Health System, Troy, MI, US; 6Alabama Ortho & Spine Center, Birmingham, AL, US; 7Scoliosis & Spine Surgery Clinic of Memphis, PLLC, Memphis, TN, US; 8Advanced Diagnostic Imaging PC, Saginaw, MI, US
11:06–11:12 a.m.19. Evaluation of Transforaminal Endoscopic Discectomy in the Treatment of Obese Patients with Lumbar Disc HerniationWei Zhang, MD, PhDDepartment of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang City, China
11:12–11:18 a.m.20. Isocentric Navigation Improves the Learning Curve of Transforamimal Percutaneous Endoscopic Lumbar DiscectomyGuoxin Fan, MD; Shisheng He, MDShanghai Tenth People’s Hospital, Shanghai, China
11:18–11:24 a.m.21. Surgical Posterior Only Treatment of Dumbbell-type Thoracic Cord Tumor versus Combined Laminectomy and Thoracoscopic SurgeryYawei Li, MD, PhDThe 2nd Xiangya Hospital, Central South University, Changsha, China
11:24–11:30 a.m.22. Radiation Reduction of Minimally Invasive Transforaminal Lumbar Interbody Fusion in Overweight Patients: A Prospective Control StudyGuoxin Fan, MD; Shisheng He, MD
Shanghai Tenth People’s Hospital, Shanghai, China
11:30–11:36 a.m.23. Application of Navigation Rod for the Location and Puncture of Percutaneous Endoscopic Lumbar DiscectomyTan Haitao; Huang Shengbin, MDGuigang City People’s Hospital, Guigang, China
11:36–11:42 a.m.24. The Role of Lumbar Facet Arthrosis in Minimal Invasive Spine SurgeryVolodymyr Radchenko Sr., MD, PhDSytenko Institute of Spine, Kharkiv, Ukraine
11:42–11:48 a.m.25. Relapsed Hernias After Open Surgery, Treated by Percutaneous Endoscopic SurgeryDaniel Gastambide, MD1; Fréderic Jacquot2
1GIEDA Inter Rachis, Paris, France; 2Hopital Saint Antoine, Department of Orthopedic Surgery, Paris, France
11:48 a.m.–12:00 p.m.Discussion
12:00–1:00 p.m.LunchZurich ABC
1:00–2:30 p.m.Plenary Session VII: Abstract PresentationsZurich DEFGModerator: Paul Park, MD
1:00–1:06 p.m.26. Failed Back Surgery Syndrome: Endoscopic Documentation of Common Causes by Visualization of Painful Pathoanatomy in the Hidden Zone of the Axilla Containing the Dorsal Root Ganglion and Salvage Treatment of Neuropathic Pain with DRG NeuromodulationAnthony T. Yeung, MDDesert Institute for Spine Care, Phoenix, AZ, US
DETAILED PROGRAM SCHEDULE
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1:06–1:12 p.m.27. Percutaneous Endoscopic Surgery for Stenosis (PESS): Laser-assisted Uniportal Full-endoscopic Decompression of Central and Lateral Recess Lumbar Spinal StenosisTagGeun Jung, MDNasaret International Hospital, Incheon, Republic of Korea
1:12–1:18 p.m.28. Comparison of Kyphoplasty Outcomes between Unilateral and Bilateral Approach for Treatment of Osteoporotic Vertebral Compression FractureXingkai Zhang, MD
The 3rd Affiliated Hospital of SUN Yat-sen University, Guangzhou, GuangDong, China
1:24–1:30 p.m.30. Radiographic Evaluation of Percutaneous Pedicle Screw Constructs Including Minimally Invasive Facet Fusions for Unstable Spinal Column Injuries Daniel L. Cavanaugh, MD1; Tristan B. Weir, BS2; Kelley E. Banagan, MD3; Eugene Y. Koh, MD, PhD4; Daniel E. Gelb, MD5; Steven C. Ludwig, MD6
1University of North Carolina Hospitals, Chapel Hill, NC, US; 2University of Maryland School of Medicine, Baltimore, MD, US; 3University of Maryland Medical System, Baltimore, MD, US; 4University of Maryland, Baltimore, MD, US; 5University of Maryland Orthopaedic Associates, Baltimore, MD, US; 6University of Maryland Medical Center, Baltimore, MD, US
1:30–1:45 p.m.Discussion
1:45–1:51 p.m.31. Early Evaluation of Value-based Ambulatory Endoscopic Spine SurgerySandeep Sherlekar, MD; Atif B. Malik, MD; John Thorpe
American Spine, Germantown, MD, US
1:51–1:57 p.m.32. Treatment of Cervical Spinal Stenosis with Percutaneous Full-endoscopic Cervical Partial Laminectomy Under Local AnesthesiaBo Zhu, MD1; Jianwei Du, MD2
1The General Hospital of the People’s Liberation Army, Beijing, Beijing, China; 2Yangzhou NO.1 People’s Hospital, Yangzhou, Jiangsu, China
1:57–2:03 p.m.33. A Novel Tubular Endoscopic System via the Posterior Approach for Lumbar Interbody Fusion Technical Feasibility and Initial Surgical OutcomeYue Zhou, MD, PhDXinqiao Hospital of the Third Military Medical University, Chongqing, China
2:03–2:09 p.m.34. Transiliac Approach Intervertebral Endoscopic Discectomy for L5/S1 Intervertebral Disc HerniationWei Zhang, MD, PhDDepartment of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang City, China
This session will critically compare the various minimally invasive surgical treatments for cervical radiculopathy, intradural spinal tumors and adult spinal deformity.
Upon completion of this session, participants will gain strategies to:• Implement the most effective surgical treatment for cervical
radiculopathy;• Improve surgical decision-making in the treatment of spinal
cord tumors;• Augment surgical options in the treatment of adult spinal
deformity.
DETAILED PROGRAM SCHEDULE
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Cervical Surgery3:00-3:15 p.m.
Posterior Endoscopic Foraminotomy is BestJoachim Oertel, MD
3:15-3:30 p.m. Posterior Tubular Foraminotomy is BestZachary A. Smith, MD
3:30-3:40 p.m. Rebuttal/Discussion
Intradural Spinal Tumors 3:40-3:50 p.m.
MIS Approaches Are Best Nader S. Dahdaleh, MD
3:50-4:00 p.m. Open Approaches Are BestJohn C. Liu, MD
4:00-4:10 p.m. Rebuttal/Discussion
DETAILED PROGRAM SCHEDULE
Adult Spinal Deformity4:10 -4:20 p.m.
Circumferential MIS Approaches Are BestRichard G. Fessler, MD, PhD
4:20-4:30 p.m. Open Approaches Are BestTyler R. Koski, MD
4:30-4:40 p.m. Rebuttal/Discussion
4:40 p.m.Meeting Adjourns
COME TO THE 13TH ANNUAL
EVIDENCE & TECHNOLOGY SPINE SUMMITFebruary 22-25, 2017Canyons Village, Park City, UT
www.spine.org/ETSS
Participate in open forum dialogues on critical spine issues and controversies and enjoy the recreational activitiesat Canyons Village
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Posters may be viewed in the Zurich Ballroom Lobby on Thursday and Friday, January 19-20.
P1. Minimally Invasive Surgery in the Treatment of Spinal Infection: A Case Report and Literature ReviewLuiz H. Sandon, MD
Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
P2. Intraoperative Myelography in Extreme Lateral Interbody Fusion for Degenerative Lumbar Spinal StenosisLimin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
P3. Radiation Safety AlertAnthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
P4. Early Clinical Results of Genipin Crosslinking Treatment for Low Back PainHarwant Singh, MD, PhD1; Tom Hedman, PhD2; John Racadio, MD3
1Country Heights, Malaysia; 2Orthopeutics, L.P., Lexington, KY, US; 3Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, US
P5. The Feasibility of a Novel Hydrogel Intradiscal Implant for Nucleus AugmentationAnthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
P6. Application of Computer Navigation in the Treatment of Spinal Tuberculosis in the Extreme Lateral Interbody FusionTan Haitao; Li Ying, MD
Guigang City Hospital Guangxi China, Guigang, Guangxi, China
P7. Associations between Modic Changes and Cervical Degenerative DiseaseGeun S. Song, MD, PhD
Pusan Nat’l Univ Yangsan Hospital, Yangsan, Gyeongnam, Republic of Korea
P8. Relationship between Radiological Outcomes and BMD Based on Lumbar Vertebrae in Single-level Anterior Cervical Discectomy and FusionJun Seok Lee, BA
Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
P9. The Effect of Uncinate Process Resection on the Subsidence in Anterior Cervical Discectomy and FusionSu Hun Lee, MS
Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Republic of Korea
P10. Intradiscal Therapy for Discogenic Pain from Toxic Annular TearsAnthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
P11. Intradiscal Therapy and Transforaminal Endoscopic Decompression: Opportunities and Challenges for the FutureAnthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
P12. Learning Curve of Microendoscopy-assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: 65 Consecutive Cases of One SurgeonLimin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
P13. Hidden Hemorrhage Following Minimally Invasive and Open Transforaminal Lumbar Interbody FusionYang Yang, MD; Limin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
Far-Eastern Memorial Hospital, New Taipei, Taiwan, Taiwan
P15. Mini-Open Anterior Lumbar Interbody Fusion for the Treatment of Symptomatic Adjacent-segment Degeneration After Lumbar FusionYawei Li, MD, PhD
The 2nd Xiangya Hospital, Central South University, Changsha, China
P16. Complication and Treatment of the Lumbar Intervertebral Disc Herniation Using Percutaneous Endoscopic Lumbar DiscectomyBo Zhu, MD
The General Hospital of the People’s Liberation Army, Beijing, Beijing, China
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P17. Short-term Effectiveness of Percutaneous Endoscopic Spine Surgery for Treatment of Lumbar Disc Herniation with Posterior Ring Apophysis Separation Qingquan Kong, MD
West China Hospital of Sichuan University, Chengdu, Sichaun, China
P18. Treatment of Cauda Equina Syndrome Caused by Lumbar Disc Herniation with Percutaneous Endoscopic Lumbar DiscectomyQingquan Kong, MD
West China Hospital of Sichuan University, Chengdu, Sichaun, China
P19. Minimally Invasive Transpedicular Approach for the Treatment of Herniated Thoracic Disc Disease: A Technical Note and Comparison to Open Transpedicular DiscectomyJonathan P. Nakhla, MD; Rafael De la Garza Ramos, MD; Merritt Kinon, MD; Ajit Jada; Rani Nasser, MD; Neil Haranhalli, MD; Reza Yassari, MD, MSc
Montefiore Spine Center, Department of Neurosurgery, Spine Research Group, Bronx, NY, US
P20. Systemic Review and Personal Experience for Preventing Complications of Percutaneous Transforaminal Endoscopic Lumbar Discectomy in Learning Curve PhaseKeyi Yu, MD
Peking Union Medical College Hospital, Beijing, China
P21. Lumbar Disc Endoscopic Surgery Through the Transforaminal ApproachArman Hakobyan, MD, PhD
NAIRI Medical Center, Yerevan, Armenia
P22. Surgical Treatment of Cervical and Lumbar Parts of Spine with Percutaneous Plasma NucleoplastySh.Sh. Shatursunov¹, S.M. Saliev¹, Kh.S. Rajabov²
¹Research Institute of Traumatology and Orthopedics, MoH of Uzbekistan, Uzbekistan; ²JSC Medical Center, “Profmedservice” Tashkent, Uzbekistan
P23. Surgical Treatment of Aggressive Hemangiomas of the Spine with Percutaneous VertebroplastySh.Sh. Shatursunov¹, K.H. Karakulov¹, R.S. Musaev¹, S.M. Saliev¹, A.O. Kabilov²
¹Research Institute of Traumatology and Orthopedics, MoH of Uzbekistan, Uzbekistan; ²National Rehabilitation and Prosthetics Center of Disabled Patients of the MoH of Uzbekistan, Uzbekistan
Thursday, January 19, 201711:00 a.m.–12:00 p.m.Plenary Session II: Abstract Presentations
1. Multiexpandable Cages for Minimally Invasive Posterior/Transforaminal Lumbar Interbody Fusion: A Preliminary Report
Donald Kucharzyk, DO1; Jeffrey D. Coe, MD2; Kornelis A. Poelstra, MD, PhD3; Joshua M. Ammerman, MD4; Sandeep Kunwar, MD5
1Orthopaedic, Pediatric & Spine Institute, Crown Point, IN, US; 2Silicon Valley Spine Institute, Campbell, CA, US; 3The Spine Institute on the Emerald Coast, Destin, FL, US; 4Washington Neurosurgical Associates, Washington, District of Columbia, US; 5Fremont, CA, US
BACKGROUND CONTEXT: A significant drawback of posterior or transforaminal lumbar interbody fusion (P/TLIF) is the smaller-sized cage (compared to ALIF/LLIF) that must be used because of the narrow access corridor. This shortcoming often limits placement of bone graft, potentially increasing risk of pseudoarthrosis or cage subsidence/migration. Furthermore, degenerative conditions such as disc collapse and spondylolisthesis can make insertion of a static posterior cage challenging.PURPOSE: The purpose of this study is to evaluate early clinical outcomes with a multi-dimensional expandable ~25 mm diameter footprint interbody device (MDE-IBD) that may be placed without impaction via a 6-8 mm cannula.METHODS: A medical chart review study to evaluate a multi-center series having MDE-IBD P/TLIF was initiated by the authors and is currently ongoing. It was hypothesized that patients would demonstrate decreased pain and improved radiological findings. All MDE-IBD were placed using minimally-invasive P/TLIF.RESULTS: To date, 30 patients (15 males; 30-81 years) with 6-month follow-up are included. Principal diagnoses included spinal stenosis (n=26), spondylolisthesis (n=18), radiculopathy (n=18) and herniated disc (n=13). Eighteen (60%) patients had a single-level procedure while the rest had multiple-level fusion, with the MDE-IBD placed at two levels or in conjunction with other fusion techniques. Complications included one small dural tear without CSF leak which required no repair; no neurologic or other complications were seen. At 6 months, back and leg pain were reduced, with MCID achieved by 90% of patients. In 11 patients with available ODI scores, 7 (64%) were improved >12 points. Radiculopathy was resolved in 21/22 patients and neurologic deficit in 13/17 (+3 improving) patients who presented with these conditions preoperatively. At the first postoperative visit (~2 weeks), 29 MDE-IBD levels showed improvements of 4.8+/-2.9 mm for average disc height and 4.5+/-8.7 degrees for local disc angle. Mean (+/-SD) change at 3 and 6 months, respectively, for average disc height were 4.2+/-2.7 mm and 5.6+/-3.5 mm, and for local disc angle were 3.6+/-3.7 degrees and 3.8+/-5.0 degrees. Regional lumbar lordosis was preserved (+/-10 degrees) or improved (>10 degrees;) in 24/28 (86%) and 22/25 (88%) patients at 3 and 6 months, respectively. CONCLUSIONS: A key advantage of a multi-expandable cage is that an anterior-sized cage footprint can be delivered through a narrow posterior surgical corridor. Early experience with MDE-IBD in minimally-invasive P/TLIF is demonstrating encouraging outcomes, including absence of nerve retraction injuries and restoration of disc height and local disc angle along with preservation or restoration of regional lumbar lordosis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
2. In-vivo Endoscopic Visualization of Pain Generators in the Lumbar Spine
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: Surgeons have had difficulty correlating the pathophysiology of pain with the pathoanatomy that they decompress and ultimately stabilize to eliminate the motion of the painful spine segment. With the spine endoscopic we are able to correlate pain with the images visualized. PURPOSE: Interventional pain management provide temporary relief that depend on natural healing to mitigate pain. Visualizing the pathoanatomy 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. New instrumentation, techniques, specially configured endoscopes, 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. When a surgeon combines interventional techniques with endoscopic visualization, additional effective steps in the treatment algorithm are available. The purpose of this study is to demonstrate that the physiology of pain can be visualized as a pain generator.STUDY DESIGN/SETTING: Collection of images correlating pathophysiology with pathoanatomy and spinal probing with the patient awake, and responsive to probing under local anesthesiaPatient Sample: Endoscopic visualization of endoscopic images in over 10,000 procedures from a personal documented databaseOUTCOME MEASURES: VAS, Oswestry, Modified MacNab, patient satisfaction questionnaireMETHODS: Endoscopic foraminal surgery (The YESS) technique, is utilized: 1. Needle and cannula placement for optimal instrument placement is calculated from coordinate lines drawn on the skin from the C-Arm image. The needle trajectory is utilized for diagnostic and therapeutic injections as a precursor to endoscopic surgical intervention. 2. Injection of non-ionic radio-opaque contrast will create a foraminal epidural gram and produce epidural patterns that outline foraminal pathoanatomy such as HNP, central and lateral recess stenosis. 3. Evocative chromo-discography is performed to confirm 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). 6. Diagnostic surgical exploration of the epidural space. 7. Probe the hidden zone of Mac Nab under local anesthesia. 8. Using the biportal technique for inside-out removal of extruded and sequestered nucleus pulposus. 9. Dorsal 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 for foraminal 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
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tears 6. Visualizing the pain generators responsible for FBSS.CONCLUSIONS: New surgical skills are needed for spine surgeons to incorporate endoscopic spine surgery in their practice. Incorporating interventional pain management techniques as a surgical rather than just a diagnostic procedure confirmed by treatment of the pathoanatomy under local anesthesia helps marry the basic science of micro-anatomy brings additional clinical information that facilitate surgical intervention. New surgical procedures focusing on intradiscal therapy, disc augmentation, biologics, annular modulation, and 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 will bring make this technology mainstream.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
3. Initial Experience with a Novel Robotically Operated Videoscope in Lumbar Decompression Procedures using the METRx tube system
Thomas M. Doers, MD1; Sarika Walia, MD2; Maharaj Singh, PhD3
1Aurora Healthcare, Milwaukee, WI, US; 2Aurora Neurosciences Innovation Institute, Milwaukee, WI, US; 3Aurora Research Institute, Milwaukee, WI, US
BACKGROUND CONTEXT: For decades, the conventional stereoscopic microscope (CS-m) and loupe magnification have been the favored optical platforms among surgeons in lumbar spine surgery. Incidental durotomy is a well-known intraoperative complication of those lumbar spine surgeries. Recent introduction of a novel Robotically Operated Videoscope (ROV) (Synaptive Medical, Toronto, Ontario, Canada) has been introduced and used in lumbar spine surgery, in particular in lumbar decompression procedures with the METRx Medtronic, Minneapolis, MN) tube system. PURPOSE: To describe the first clinical experience and series of Minimally Invasive Spine surgery with ROV. It is our hypothesis that a significant number of dural tears can be attributed to decreased visualization of the critical anatomy in the operative field. Our aim was to evaluate the impact of a system with greater optical power. Therefore, in this study, we aim to demonstrate the use of a high-definition optical platform, with the collaborative use of a METRx tube system, in decreasing the rate of incidental durotomy in lumbar decompressive surgery. METHODS: The records of 222 consecutive MIS cases with the use of both ROV (82 cases) and CS-m (140 cases) were investigated retrospectively from the period of January1, 2014 to September 1, 2016. The patients were from a single surgeons practice. Incidental Durotomy (ID) was used as a measure of intraoperative complications and was recorded for each procedure. RESULTS: The two groups had no statistical difference in age or gender. The cases included both primary and revision surgeries. The overall incidence of ID in the investigated group of CS-m was 11.4%, and 3.7 % with use of the ROV (p=.02). In the last 43 ROV cases, no durotomies were obtained.CONCLUSIONS: With the recent release of a novel ROV system we present the first and largest known clinical series of its type. It shows the potential to significantly decrease a known cause of increased cost and patient morbidities. Enhanced intraoperative visualization, through an improved light source and resolution provide an increased field of view, depth of field and volume of view when compared to the CS-m (manuscript in preparation). These factors along with the added
value of ergonomic function with adaptive positional movement clearly demonstrates improvement in surgical performance, by means of incidental durotomy rates with the use of this optical technology and indicating significant advantages in the spine surgery paradigm.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
4. A Comparative Clinical Study of Full-endoscopic Interlaminar Discectomy for L4/L5 versus L5/S1 Lumbar Disc Herniation
Yawei Li, MD, PhD
The 2nd Xiangya Hospital, Central South University, Changsha, China
BACKGROUND CONTEXT: Full-endoscopic interlaminar (FEID) approach is a minimally invasive technique for the surgical treatment of L5/S1 disc herniations. Its efficacy and safety at L4/5 level, however, is still unascertained.PURPOSE: To compare the clinic outcome of full-endoscopic interlaminar discectomy (FEID) between L4/L5 and L5/S1 lumbar disc herniationSTUDY DESIGN/SETTING: A comparable retrospective studyPATIENT SAMPLE: A total of 576 cases were enrolled who had undergone FEID between August 2008 and December 2013.Outcome Measures: Clinic outcomes included the Visual Analog Scale (VAS) of low back and leg pain, the Oswestry Disability Index (ODI), and modified MacNab criteria.METHODS: A retrospective review was performed on all patients who had undergone FEID between August 2008 and December 2013. Clinic data was collected. Clinic outcomes including the Visual Analog Scale (VAS) of low back and leg pain, the Oswestry Disability Index (ODI), and modified MacNab criteria were measured and statistically analyzed.RESULTS: A total of 576 cases were enrolled. Mean follow-up time was 45.5 ± 16.8 months (ranging from 32~ 86 months). There were 180 cases performed FEID in L4/L5and 396 cases in L5/S1. There are no statistic differences between L4/L5and L5/S1 in bleeding, ambulation time and hospital stay (P>0.05). However, the mean operation time in L4/L5 group was longer than that of L5/S1 group (P<0.05). There were 12 cases converted to open surgery in L4/L5 group, compared 15 cases in L5/S1. Statistically significant differences could be found in VAS and ODI between preoperative and that at 3 months, 2-year and the final follow-up postoperatively in both groups (P<0.01). There were no statistically significant differences between that at the final follow-up and that at 3 months and 2-year postoperatively (P>0.05). At the final follow-up, good to excellent rate was 86.2% in L4/L5 and 88.4% in L5/S1 according to the modified MacNab criteria. Recurrences occurred 16 in L4/L5 and 11 of them performed open reoperation, compared 18 in L5-S1 and 10 open reoperations (P<0.05).CONCLUSIONS: Satisfied outcome of FEID could be obtained for L4/L5 and L5/S1 disc herniation. However, compared to L5/S1, operation time, the rate of converted to open operation and reoperation in L4/L5 were higher.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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5. Contralateral Radiculopathy following Minimally Invasive Transforaminal Lumbar Interbody Fusion
Limin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
BACKGROUND CONTEXT: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has been gaining more popularities because of various advantages, however, contralateral radiculopathy or its aggravation following surgery can adversely affect surgical outcome, but few literatures have systematically analyzed its causes, prophylaxis and managements.PURPOSE: To elucidate the incidence of contralateral radiculopathy or its aggravation following MIS-TLIF; to analyze its association with canal decompression method and investigate its main etiologies, prophylactic methods as well as treatment.STUDY DESIGN/SETTING: A retrospective study.PATIENT SAMPLE: A total of 102 cases were included.METHODS: Among those 102 cases, 72 cases received bilateral canal decompression through unilateral route and the remaining 30 cases underwent ipsilateral canal decompression through unilateral route. There were 49 males and 53 females with the average age of (58.5 ± 12.9) years (ranging from 39 to 85 years). For those revealing contralateral radiculopathy or its aggravation postoperatively, lumbar computed tomography (CT) scan and conservative treatment, including non-steroidal anti-inflammatory drug (NSAID), muscle relaxant, mecobalamine and methylprednisolone were applied immediately, and those who had been resistant to conservative treatment for consecutive four weeks underwent revision surgery. Incidence of this complication between bilateral and ipsilateral canal decompression through unilateral route were calculated and compared. Based on visual analogue scale (VAS), their pain intensity of the contralateral limb at the beginning and final follow-up was evaluated and compared statistically.RESULTS: Twelve cases showed contralateral radiculopathy or its aggravation postoperatively (nine and three cases for bilateral or ipsilateral canal decompression through unilateral route respectively), and ten of them showed this complication immediately, while the remaining two patients revealed it at postoperative three weeks and seven months respectively, thus its incidence was 11.8% in this series. Based on lumbar CT scan image, nine patients were mainly considered contralateral nerve root canal and (or) foramen stenosis worsening and received successful conservative treatments, while three remaining patients had contralateral disc extrusion combined with no restoration of intervertebral height at surgical level and underwent revision operations (foraminoplasty, nerve root canal or spinal canal decompression by percutaneous transforaminal endoscopy or microendoscopy). Incidence of this complication following bilateral and ipsilateral canal decompression through unilateral route were 12.5% and 10% respectively, showing no statistically significant difference (P>0.05). All of them were followed up for an average of 27.9 months after final discharge. Mean VAS value of contralateral lower limb at the start or worsening of symptom was (5.9 ± 1.4) (ranging from 4 to 8), while it decreased to (1.2 ± 1.0) at final follow-up (ranging from 0 to 3), demonstrating significant difference (P<0.05).CONCLUSIONS: Contralateral radiculopathy or its aggravation following MIS-TLIF is mainly contributed to disc extrusion, no restoration of intervertebral height at surgical level, stenosis worsening of nerve root canal and foramen, while it is not associated with canal decompression method. Immediate conservative treatments should be given to treat this complication. Most sufferers can acquire satisfactory recovery, while those refractory to conservative methods need revision surgery.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
6. Modified Cervical Micro Endoscopic Laminoplasty for Patients with Cervical Spondylotic Myelopathy
Chunlin Zhang, MD
The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
BACKGROUND CONTEXT: We published a new surgical treatment named cervical microendoscopic laminoplasty (CMEL) for CSM, which provides stable reconstruction of an expanded laminar arch and causes less damage to the spinous process-ligament complex and the deep extensor muscles than conventional surgical approaches. In order to improve the operability, we improved the mini plate on the basis of the original CMEL. The original sockets for screws fixation were modified to sliding way type.PURPOSE: The aim of this study was to evaluate the clinical effect of modified cervical microendoscopic laminoplasty (mCMEL) for patients with cervical spondylotic myelopathy (CSM).STUDY DESIGN/SETTING: Prospective clinical seriesPATIENT SAMPLE: 34OUTCOME MEASURES: JOA scores, VAS, CCI and ROMMETHODS: A total of 34 patients with multi-level CSM in received modified CMEL (mCMEL) between 2013 March and 2015 June in First Affiliated Hospital of Zhengzhou University. There were 21 men and 13 women, with a mean age of 51 years (range 37–77 years). Effects and axial symptoms were evaluated according to the Japanese Orthopedic Association (JOA) scores for neurological condition and visual analog scales (VAS) for axial neck pain, respectively. Cervical curvature index (CCI) and ROM were evaluated by X-ray. Computerized tomography imaging scans evaluated canal expansion.RESULTS: In total 157 involved levels received mCMEL. The duration of surgery averaged 102 minutes. Average blood loss was 175 mL. Follow-up ranged from 12 to 36 months. Mean JOA scores improved from 8.3±2.6 preoperatively to 13.3±1.7 at last follow up (P < 0.05). The VAS scores of axial pain significantly improved to 2.2±1.9 at the final follow-up compared with 4.5±2.4 preoperatively (P < 0.05). Sagittal spinal canal diameter increased by 1 to 3 mm. There were no differences in the pre- and postoperative CCI and ROM. There were no serious complications in any patient. CONCLUSIONS: The mCMEL could effectively expand the volume of the spinal canal, and achieve satisfactory treatment results. Compared with primary method, mCMEL could significantly improve the operability and then reduce the amount of bleeding and shorten the operation period. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
7. Burst Stimulation with Penta Electrode for Failed Back Surgery Syndrome (FBSS)
Enrique Osorio, MD
BACKGROUND CONTEXT: The FBSS corresponds patients who have experienced one or more surgeries on his spine without benefits, and with chronic pain. This type of pain is very difficult to treat. Purpose: The present study shows the results in patients who underwent spinal stimulation using a Penta (St. Jude) electrode and a Progidy (St. Jude) battery, with which Tonic and Burst stimulation were performed. With the latter it is possible to stimulate both the lateral
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and medial pathways of pain. The purpose was to compare the results in the control of axial and neuropathic pain of patients with FBSS, when using tonic vs Burst medular stimulation with Penta electrode.PATIENT SAMPLE: 11 patients with FBSS. Under local anesthesia they were implanted with a Penta electrode in the epidural space between T8 and T10 in FBSS lumbar and between C1 and C2 in cervical FBSS. Follow-up: 1 and 6 months. METHODS: Using the Visual Analogue Scale (VAS) and the satisfaction levels, the results were bought when stimulated either Tonic or Burst.RESULTS: All the patients had significant decrease in pain (VAS) over baseline pain and greater improvement with Burst versus Tonic stimulation, covering both axial and neuropathic pain. With Tonic stimulation 40% were very satisfied, 40% satisfied and 20% unsatisfied Whit Burst Stimulation 50% were very satisfied an 50% satisfied 100% patients prefer Burs stimulation over Tonic stimulation 27% patients whit Burst st. presented paresthesias100% patients with Tonic st. presented paresthesiasCONCLUSIONS: The Burst stimulation with Penta electrode in patients with FBSS, Improved pain reduction (VAS). Reduced patient attention to their pain (PVAQ) and reduced paresthesia. The Penta electrode achieves wider coverage pain, especially when there is axial pain.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Thursday, January 19, 20171:00–2:30 p.m.Plenary Session III: Abstract Presentations
8. Minimally Invasive Correction of Adult Degenerative Deformity: Preliminary Follow-up and EOS Study
Pei Yu, MD; Wenjian Wu, MD; Liang Yu, MD
Shanghai Ruijin Hospital, Shanghai, China
BACKGROUND CONTEXT: Open surgery for adult degenerative scoliosis is the well accepted treatment which has been proven to be effective to release neurological compression and to correct spinal deformity and imbalance. However, open surgery is associated with more blood loss and complications. Nowadays, minimally invasive surgery (MIS) is gaining in popularity, which can decrease surgical morbidity and complications, But the effect and the approach of minimally invasive correction of adult degenerative scoliosis was controversial.PURPOSE: The purpose of this study was to evaluate radiographic and clinical outcomes in the treatment of adult degenerative scoliosis using direct lateral interbody fusion (DLIF) and staged minimally invasive posterior spinal fusion (MISPSF).STUDY DESIGN/SETTING: 1) evaluate the effects of minimally invasive surgery to ASD on both sagittal and coronal plane,2) study the clinical significance of staged MIS procedure,3) question the current algorithm of MIS treatment to the ASD,4) have preliminary EOS study data.PATIENT SAMPLE: This study included 18 consecutive patients with adult degenerative scoliosis (mean age 69.76, range 56-82, M: F=3:15) who underwent DLIF and staged percutaneous posterior instrumented fusion in our hospital between May, 2014 and Nov, 2015. All patients were followed up for a minimal of 1 year and were subjected to the analysis. OUTCOME MEASURES: Evaluation Data collection included operation time, estimated blood loss, the change of hemoglobin, length of
hospital stay, complications (wound infections, vascular injuries, neurologic deficit, deep venous thrombosis, pulmonary embolism, cardiac events, delayed wound healing and etc), clinical outcomes and radiological outcomes. Clinical outcomes Clinical outcomes were evaluated by using Visual Analog Score (VAS) for the degree of low back pain and leg pain, and using Oswestry Disability Index (ODI) for patient function preoperatively and postoperatively. Radiological analysis Standing preoperative and postoperative radiographs were evaluated using low-dose biplanar stereoradiographic imaging EOS imaging system from head to feet. The protocol for image acquisition called for a weight-bearing, free-standing position with arms flexed at 45° in order to avoid superimposition with the spine. The coronal radiographic parameters included global coronal malalignment (C7 plumb line relative to S1), thoracic scoliosis curve (Cobb angle between superior endplate of T2 and inferior endplate of T12), lumbar scoliosis curve (Cobb angle between superior endplate of L1 and superior endplate of S1), and pelvic obliquity. The sagittal radiographic parameters included thoracic kyphosis (TK; T2–T12, Cobb angle between superior endplate of T2 and inferior endplate of T12), lumbar lordosis (LL; Cobb angle between superior endplate of L1 and superior endplate of S1), and sagittal vertical axis (SVA; C7 plumb line relative to S1). Pelvic alignment included pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and the mismatch between pelvic incidence (PI) and lumbar lordosis (PI–LL mismatch).METHODS: A retrospective analysis of 18 adult degenerative scoliosis patients treated with staged surgery, which were performed DLIF at first stage and posterior spine fixation secondly. The interval between two surgical procedures was from 7 to 42 days (mean 15 days). Preoperative and postoperative standing anteroposterior and lateral lumbar radiographs were obtained by EOS image system in all patients for measurement of sagittal and coronal plane alignment. All patients were available for at least 12 months’ follow-up (mean 15 months).RESULTS: According to MISDEF Classification, 13cases were consistent with MISDEF Class 3 and 5cases with MISDEF Class 2. After one-stage DLIF, all patients’ classification changed with class 3 to class 2 and class 2 to class 1 by EOS reassessment. The mean global sagittal alignment (sagittal vertical axis) was 9.96cm preoperatively, and SVA was 5.25cm after one-stage DLIF (p<0.001) and 2.97cm after two-stage MISPSF (p<0.001). In the Spino-pelvic parameter, the mean PT (Pelvic Tilt) decreased from 24.72° to 18.42° after DLIF (p<0.001) and from 18.42° to 15.28° after MIS PSF (p<0.01). PI-LL mismatch decreased from 29.27° to 15.70° after DLIF and from 15.70° to 9.07° after PSF (p<0.001). In the coronal plane, the mean Cobb angle of curves was 23.78° preoperatively, and it was 7.37° after one-stage DLIF (p<0.001) and 2.66° after two-stage MIS PSF (p<0.001). Mean blood loss was 253 mL for one-stage DLIF surgery and 326 mL for two-stage MIS PSF surgery in Class 3 patients and mean blood loss was 125 mL for one-stage surgery and 150 mL for two-stage surgery in Class 2 patients. No patient received allogenic blood transfusion. Mean operative time was 231 minutes for DLIF in Class 3 patients and 155 minutes for two-stage surgery and mean operative time was 152 minutes for DLIF in Class 2 patients and 104 minutes for two-stage surgery. At the last follow-up, back pain improved from 7.67to 1.89(p<0.001) and leg pain improved from 5to 2.76(p<0.001) on VAS (Visional Analogue Score); and ODI scores decreased from 62.7 to 9.8(p<0.001). No Complications and revisions occurred.CONCLUSIONS: DLIF (direct lateral interbody fusion) significantly improves segmental and coronal plane alignment in patients with degenerative lumbar scoliosis, and secondary posterior spinal fusion can provide fixation and further correction. Staged minimally invasive correction of adult reduced operational morbidity and complications.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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9. Treatment of Symptomatic Spinal Stenosis with the Transforaminal Endoscopic Approach
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: Translaminar decompression for spinal stenosis is the accepted “gold standard” for symptomatic central stenosis of the lumbar spine. Some patients, however, continues to suffer from residual sciatica because the translaminar approach cannot always adequately decompress the lateral recess lateral to the subarticular zone. This “hidden” foraminal zone is not visualized by traditional surgeons, but readily visualized using transforaminal endoscopic decompressive techniques, as most surgeons feel that they have adequately decompressed the lateral recess by using probes and curretesPURPOSE: to demonstrate how symptomatic lateral recess stenosis is effectively diagnosed and treated with transforaminal endoscopic decompressionSTUDY DESIGN/SETTING: review of 8,000 endoscopically documented cases when foraminoplasty was adoptedPATIENT SAMPLE: 20 consecutive patients with imaging evidence to lateral recess stenosis opting for transforaminal decompression over traditional translaminar decompression and two-years follow-upOUTCOME MEASURES: Vas, Oswestry, Modified MacNab CriteriaMETHODS: An endoscopic foraminal decompression technique, is made much easier with the development of an articulated burr by Richard Wolf and the routine use of a HO: yag laser. New endoscopic surgical tools by other endoscopic companies have also helped transforaminal decompression of the lateral recess become a routine foraminal decompression procedure. From experience visualizing foraminal anatomy, foraminal shoulder osteophytes, and unrecognized lateral foraminal stenosis, patients with residual sciatica and radiculitis were offered foraminal decompression under local anesthesia. Patient selection was based on the patient having at least 70% relief of their residual sciatica following transforaminal diagnostic and therapeutic block by the operating surgeon. A retrospective review of 20 consecutive patients with two years follow-up opting for endoscopic foraminal decompression over an open translaminar approach served as the rationale to offer this decompressive procedure for patients with primary lateral recess stenosis and central stenosis these patients also had evidence of a bulging disc associated with central stenosis.RESULTS: All patients improved with satisfactory resolution of their radicular symptoms. 3 patients (15%) experienced post-op temporary dysesthesia that resolved with gabapentin or post-op transforaminal therapeutic and sympathetic blocks. Unanticipated findings from foraminal decompression include incidental synovial cysts, and anomalous furcal nerves in the foramen adjacent to the foraminal ligament. Although endoscopic lateral recess decompression has been performed with trephines and lasers since 1995, its use was limited in favor of more traditional translaminar decompression due to the lack of good mechanical tools and the realization that there is a difference with simple foraminotomy versus foraminoplasty, decompression of both the exiting and traversing nerve in the Axilla for the spinal segment. Automated diamond burrs helped endoscopic decompression evolve further, but recently articulated burrs made it a routine procedure for decompression of the lateral and subarticular recess that can also reach the inlet of the lateral recess and the central spinal canal. With new articulated burrs, transforaminal decompression of spinal stenosis with significant lateral recess stenosis became routine for experienced endoscopic surgeons. The ability to reach the inlet of the lateral canal where translaminar decompression is now routine with the articulating burr, making transforaminal
decompression a very viable and desirable MIS procedure as a primary MIS procedure for foraminal stenosis. Lateral stenosis decompression is appropriate for spinal stenosis in association with disc protrusions, even in the face of axial back pain from associated lumbar spondylosis and facet arthrosis. New articulated diamond burrs will make the procedure even more safe and effectiveCONCLUSIONS: Transforaminal Lateral Recess Endoscopic decompression is a true minimally invasive procedure performed under local anesthesia. It is predictable and very successful when transforaminal epidural blocks provide excellent pain relief. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
10. Percutaneous Endoscopic Surgery to Manage Lumbar Highly Grade Migrated Disc Herniation
BACKGROUND CONTEXT: The Highly migrated disc herniations, when approached by conventional posterior laminotomy, need extensive resection of the lamina and may destabilize the motion segment aggravating back pain and increasing postoperative morbidity.PURPOSE: To evaluate the safety and effect of percutaneous endoscopic surgery to management lumbar highly grade migrated disc herniationsSTUDY DESIGN/SETTING: Between Jan 2006 to Jan 2010, sixty-eight patients with highly migrated lumbar disc herniations were performed with percutaneous endoscopic discectomy procedures by transforaminal and interlaminal approach.PATIENT SAMPLE: There were on case affecting L12 level, 4 cases involving L23 level, 6 cases involving L34, 46 cases involving L45, 11 cases involving L5S1.OUTCOME MEASURES: VAS score, Oswestry disability index, Modified MacNab criteria.METHODS: The transforaminal approach was applied for L1-4 upward and downward migrated discs and L45 upward migrated discs. The interlaminal approach was applied for L45 downward and L5S1 upward and downward migrated discs. Two patients were performed with L45 and L5S1 bi-portal interminal approach. RESULTS: The mean follow up time is 38 months. Mean Vas score for radicular pain improve from 8.21 to 1.62 and the mean Oswestry disability index improve from 68.2 to 10.86. Based on modified MacNab criteria, 92.6% (63/68) of patients experienced satisfactory outcome. One patient underwent repeat PELD next day and the other L45 downward migrated case change approach from transforaminal to interlaminal approach on the same surgery. One patient underwent open discectomy one week later. These three cases were relieved of symptom. Two patients have recurrent disc herniation at the same level after 6 months. one patient underwent repeat PELD and the other underwent open discectomy. Both patients have good results.CONCLUSIONS: Percutaneous full-endoscopic lumbar surgery is safe and effective procedure for manage lumbar highly grade migrated disc herniation and can get same result as open discectomy.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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11. Alternative to Fusion with a Hybrid Minimally Invasive Foraminal Decompression and Endoscopic Rhizolysis Procedure
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: Introduction: Surgical Treatment of chronic Low Back pain syndrome from an aging spine often focuses on fusion due to the concept of instability, deformity, and sagittal alignment when back a pain and sciatica are equally debilitating. Spine surgeons are battling an economic crisis of escalating cost and affordability when fusion authorization is requested from payers as the ultimate solution. Comparative cost effectiveness QUALY studies are the new recent focus, but surgical and implant costs, even when instrumented fusion is considered the “gold standard,” are still considered economically unsustainable by payers and denials for surgical authorization and payment are frequently denied. PURPOSE: Introduce MIS endoscopic foraminal decompression and rhizolysis as alternatives to fusion where there is deformity and instability from the aging processSTUDY DESIGN/SETTING: An endoscopic transforaminal decompressive technique that does not contribute to spinal instability has evolved into a reliable, and effective technique for surgically addressing chronic back and leg pain. It is an effective alternative to early fusion, especially if staged, reserving fusion as a “salvage” procedure. The procedure incorporates intradiscal and foraminal decompression, targeting nerves that innervate the disc and posterior column through endoscopic rhizolysis.PATIENT SAMPLE: 85 patients 2-10 year follow-upOUTCOME MEASURES: VAS, Oswestry, Modified Mac Nab criteriaMETHODS: An endoscopic transforaminal decompressive technique that does not contribute to spinal instability has evolved into a reliable, and effective technique for surgically addressing chronic back and leg pain. It is an effective alternative to early fusion, especially if staged, reserving fusion as a “salvage” procedure. The procedure incorporates intradiscal and foraminal decompression, targeting nerves that innervate the disc and posterior column through endoscopic rhizolysis.RESULTS: Average pre-operative VAS and ODI and Oswestry scores as well as patient satisfaction, all demonstrate significant and lasting improvement in a 10 year follow review from a personal electronic database of 85 patients as compared with a published and historical statistical database. Endoscopic foraminoplasty allowed for endoscopic visual stimulation of pain, and elimination of pain following foraminal decompression of the for pain generators in the disc and foramen in an awake patient that combines disc decompression foraminoplasty, and electro thermal of laser closure of “toxic” annular tears. The traversing and exiting nerve in the axilla forming the “hidden zone” of MacNab is specifically targeted for decompression. When axial back pain is significant, dorsal rhizotomy is added as a hybrid procedure. The surgical procedure is documented in an awake patient under only local anesthesia with minimal sedation serving as “immediate” surgically, and clinically based evidence. Discussion: This technique has evolved and culminated in predictable clinical results, supported by results predicted by diagnostic and therapeutic injections. Surgical decompression creates minimal surgical morbidity when operations are by highly experienced endoscopic surgeons. The procedure has evolved over 25 years, backed by a personal database of over 10,000 surgical cases correlating imaging studies with visualized painful pathoanatomy. This clinical observation is supported by peer reviewed publications. Also, no publications have refuted the documented results. Modifications of the surgical technique over the years is aided by improved instrumentation endoscopic translaminar
and transforaminal surgical techniques so that a “full endoscopic technique or combined surgical technique is possible. Level I evidence for endoscopic spine surgery under local is difficult and not likely for blinded comparison, so other evidence such as direct visualization of the surgical treatment of the pain generator may need to be substituted for evidence based scientific validation. CONCLUSIONS: Hybrid endoscopic transforaminal decompression, combined with dorsal rhizotomy will open the door for early cost effective surgical solutions for painful degenerative conditions of the lumbar spine that warrant further study and adoption by surgeons trained adequately in this techniqueFDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
12. The Application of Lateral Recess Partition Method in Spinal Endoscopic Transforaminal Approach to Treat the Lumbar Lateral Recess Stenosis
Qingquan Kong, MD
West China Hospital of Sichuan University, Chengdu, Sichaun, China
BACKGROUND CONTEXT: there are several methods to divide the lumbar spinal canal stenosis into different types. According to the anatomic structure type, it can be divided into three types: Central, Lateral recess, and intervertebral foramen. The Lateral recess stenosis here refers to the nerve root canal’s stenosis (except vertebral Canal stenosis), which specifically includes the disk-flava ligament space, the ditch next to the superior articular process (the upper part of the lateral recess bony channel) and the channel under the vertebral pedicle (the lower part of the lateral recess bony channel). The lateral recess stenosis is the common clinical type, whose manifestations are usually involving single side and accompanying single nerve root symptoms. This type of lumbar spinal stenosis, if not merge with segmental instability and severe spondylolisthesis or scoliosis deformity which lead to sagittal or Coronal plane imbalance, usually can get good clinical results, operated the unilateral decompression. Currently, spinal endoscopy can achieve lateral recess stenosis area’s decompression completely. Using endoscopy to treat the spinal lumbar lateral recess stenosis, for different location and type, can reduce the pressure through the transforaminal or interlaminar approach.PURPOSE: to retrospectively analyze the surgery parameters and treatment effects of the percutaneous spinal endoscopic technique through transforaminal approach to treat the Lumbar lateral spinal stenosis; to comparatively analyze the pertaining radiographic indices before and after the surgery; to summarize the main points and traps of this technology’s the clinical application.METHODS: Through the retrospective analysis of the qualified lumbar lateral recess stenosis patients using the percutaneous spinal endoscopic technique from January 2013 to January 2016. According to the anatomy, the lateral recess area can be divided into the following areas: the disk-flava ligament space (A zone), the ditch next to the superior articular process which is the upper part of the lateral recess bony channel (zone B, from the upper edge of the lower vertebral to the pedicle middle level) and the channel under the vertebral pedicle which is the lower part of the lateral recess bony channel (C region, from the middle level to the lower edge of the pedicle level.) The Inclusion criteria are as followings: Using the percutaneous endoscopic treatment of the spine; The type of the lateral recess stenosis (Located in A, B, C area ); Not complicated by the central tube or foraminal stenosis; Only single segment Involved with unilateral symptoms ; Not associated with lumbar segmental instability or moderate to severe lumbar spondylolisthesis, as well as the sagittal or coronal imbalance
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of spinal deformity; Followed up over 6 months, providing completed information of lumbar lateral X-ray films and lumbar MRI before and after 6 months; Summarizing the operation time and postoperative complications ; Through the VAS score to analyze the improvement of leg and low back pain before and after surgery; Evaluating the postoperative clinical curative effect by the MacNab criteria; Through the lumbar mobility analysis of patients before and after surgery, comparing and analyzing the impact to spinal stability of part front facet resection; Analyzing lumbar MRI of 3 months after operation to evaluate the effect of the spinal decompressionRESULTS: From January 2013 to January 2016, there were 938 cases of lumbar degenerative disease accepting transforaminal approach spinal endoscopic surgery. Among them, 156 cases were diagnosed as the lumbar lateral recess stenosis, 84 cases of male and 72 females; Median age 56 years (19 - 86 years old); 2 cases of L3/4 segment, 118 cases of L4/5 segment, 36 cases of L5/S1 segment. There were 124 patients who met the inclusion criteria, 73 males and 51 females; Median age 57 years (34-79 years old); 2 patients of L3/4 segment, 93 patients of L4/5 segment, 29 patients of L5/S1 segment. The classified features of this group’s patients of lateral recess stenosis were concluded: 68 cases of lateral recess stenosis type A, 11 cases of type B, 45 cases of type A + B. All patients’ leg pain VAS score before surgery was 5.7 ± 1.4, back pain VAS score was 1.5 ± 1.3; Six months after the operation, the patients’ leg pain VAS score was 0.6 ± 1.2, back pain VAS score was 1.7 ± 1.4; The preoperative and postoperative low back pain or leg pain VAS scores both show significantly different (P <0.05). And there was no clinically significant difference of lumbar spine motion range between the post operation and after six months’ evaluation (P > 0.05). All patients were evaluated according to MacNab postoperative standard, the results were as followings: excellent in 56 cases, good in 63 cases, fine in 5 cases, the rate of good up to 96%; There were no reoperation within 6 months after surgery. X-ray examinations’ frequency reach to 11 ± 6 times, the puncture completion time of foramen shaping operation was 13 ± 6 minutes, the endoscopic surgery time was 35 ± 20 minutes; 6 months after, lumbar MRI showed that the reduced target area A, or area B or area A + B, both of them have achieved complete bony and soft tissue’s decompression. 2 cases of intraoperative had gone through the dural rupture, but none of them had cauda equina or nerve root injury. For typeA, typeB, and type A + B, their surgical satisfaction rate, which was calculated by postoperation VAS score of low back pain, leg pain VAS score and MacNab index, showed no significant difference.CONCLUSIONS: According to the anatomy characteristic , this method of dividing the lateral recess stenosis lumbar spinal area into the disk-flava ligament space(A zone), the ditch next to the superior articular process which is the upper part of the lateral recess bony channel ( zone B, from the upper edge of the lower vertebral to the pedicle middle level) and the channel under the vertebral pedicle which is the lower part of the lateral recess bony channel(C region, from the middle level to the lower edge of the pedicle level.) is more conducive to the exchange of clinical experience and the choose of clinical treatment scheme. For type A, B or A + B lateral recess stenosis, using foraminal approach can achieve completely decompression of the nerve roots in these regions. It can get reliable clinical effects, but for different types, the methods are different. And the difficulty degree is different, the difficulty of A+B type’s decompression shows slightly larger compared with the others.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
13. Posterior Dynamic Stabilization with Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery
Qingquan Kong, MD
West China Hospital of Sichuan University, Chengdu, Sichaun, China
BACKGROUND CONTEXT: Surgical treatment of lumbar spondylolysis has yielded relatively good results. However, there are still many limitations of the current surgical methods, including, adjacent level degeneration, restricted indications, and soft tissue damage.PURPOSE: The aim of this study was to investigate the effectiveness of posterior ISOBAR TTL stabilization of the lumbar spine with direct pars repair using Wiltse approach for the treatment of lumbar spondylolysis with or without slight spondylolisthesis and discuss the indications of this surgery.STUDY DESIGN/SETTING: A retrospective study to evaluate the clinical outcomes of a novel surgical method for treating patients with lumbar spondylolysis.METHODS: Between August 2010 and January 2013, 13 (9 males and 4 females; mean age: 28.2 yrs), patients with lumbar spondylolysis with or without slight spondylolisthesis underwent posterior ISOBAR TTL stabilization of the lumbar spine, with direct pars repair via Wiltse approach. All patients were followed up for at least 24 months at outpatient visits or telephonically. Pre-operative and postoperative radiological assessments included anteroposterior, lateral and flexion extension radiographs, 3-dimensional reconstruction computed tomography(CT), and magnetic resonance imaging (MRI). Data pertaining to intraoperative blood loss, duration of operation, visual analog score (VAS), Oswestry disability index (ODI) scores, and other assessments were collected.RESULTS: The median follow-up duration was 36 months (range, 24–53 months). Surgery was successful in all patients with no complications; bony fusion of pars was confirmed on CT scan at postoperative 2 years. Significant pain relief was achieved in all patients including those with discogenic pain, those >30 years of age, and those with severe disc degeneration (P<0.01).CONCLUSIONS: We evaluated a new surgical technique for the treatment of patients with spondylolysis with or without slight spondylolisthesis. Besides the good clinical results, the indications for this new surgery are much wider and can potentially overcome the limitations of earlier techniques.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
14. Percutaneous Endoscopic Decompression for the Lumbar Canal Stenoses
Fujio Ito, MD, PhD
Aichi Spine Institute, Niwa-gun, Aichi-ken, Japan
PURPOSE: The decompression surgeries for the lumbar stenoses (A. lateral recess stenosis, B. central canal stenosis, C. foraminal stenosis) evolved from open decompression, to the microscope, followed by Microendoscopic decompression. Recently, we have developed a less invasive method, “Percutaneous Endoscopic Decompression”. We started this clinical study in 2013.METHODS: There are three major types of lumbar stenosis. Case numbers of performed surgerieswere131 lateral recess stenoses, 201 central canal stenoses, 64 foraminal stenoses. We chose hemi-decompression method with a unilateral approach on lateral recess stenosis, bilateral decompression method with a unilateral approach on central canal stenosis, and a unilateral foraminotomy on foraminal
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stenosis. A, B) Under continuous water irrigation, and 8mm outer sheath was inserted from the affected side of the interlaminar space for lateral recess stenosis and central canal stenosis. Superficial yellow ligament was resected with a punch and forceps, and the deep ligament was detached from the lamina using a 3.5 mm diamond drill. The ipsilateral nerve root was decompressed under trumpet shaped hemi-laminotomy. When necessary, the basis of the spinous process was shaved, allowing the sheath to be inserted toward the contralateral side, where the contralateral root was easily decompressed. C) For foraminal stenosis, the upper and lower transverse processes (or sacral ala at L5/S1) and superior articular facet were shaved, and transforaminal ligament or lumbo-sacral ligament (at L5/S1) detached. A drainage tube was set in place for 48 hours in all cases.RESULTS: Average operation time was 89±33 minutes. In the late period of the learning curve, operation time was shortened by 1/3. Adverse incidences were 13 insufficient-decompressions (re-decompressed by the same method), six dural tears (repaired by bicryl patch technique), two post-operative hematoma (removed by the same method a few days later), and 14 cases of residual numbness (treated with conservative therapy). Finally, 3.3%, 11 cases of the total 396 remained unsatisfactory. Both their JOA scores and intermittent claudication improved month by month. The blood loss during the procedure was unable to be calculated because of the continuous water irrigation. Postoperative blood volume in the port pack was 27±15cc.CONCLUSIONS: Percutaneous Endoscopic Decompression is the least invasive decompression technique for lumbar stenosis. Operation times were a little longer and few applicable tools were available, but those times can and will be shortened going forward. The most important thing is that the amount of muscle and bone damaged in the procedure must be limited to a small area.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
15. A Biomechanical Analysis of Lateral Interbody Implants and Supplemental Fixation in Adjacent Segment Disease
Nikhil Jain, MBBS, MD1; Craig McMains, MD2; Alan Litsky, MD, ScD1; Emily Cerier, BS1; Elizabeth Yu, MD1
1The Ohio State University Wexner Medical Center, Columbus, OH, US; 2Stanford University, Redwood City, CA, US
BACKGROUND CONTEXT: Adjacent segment disease (ASD) in the lumbar spine is being encountered more frequently given the increasing number of lumbar fusions being performed. The appropriate management of which however, remains unclear. The minimally invasive technique of lateral lumbar interbody fusion (LLIF) is becoming increasingly popular for a number of indications. This procedure helps reduce surgical dissection, decrease risk of vascular complications, and allows placement of a large implant to obtain fusion. There are various supplemental fixation options available, but which construct provides maximum stability with the least magnitude of surgery is unclear. There are no studies to the author’s knowledge that have analyzed stability of LLIF constructs in a cadaveric ASD model.PURPOSE: The purpose of this study was to analyze the stability of LLIF and compare various methods of supplemental fixation in Adjacent Segment Disease.STUDY DESIGN/SETTING: A biomechanical analysis of LLIF constructs was done in a human cadaveric model. The L4-L5 level was secured with an interbody spacer and pedicle screws to simulate a fused segment. Flexibility testing of the adjacent segment (L3-L4) was
performed by loading the specimens in 4-point bending using linearly-ramped load control on a servo hydraulic material test frame (Bionix 858, MTS, Eden Prairie, MN) to 150 N at 50 N/min for 4 cycles with 30 seconds recovery in between cycles. Load and displacement were measured continuously; the data reported is from the fourth loading cycle. PATIENT SAMPLE: Four human cadaveric lumbar spines (L1 - Sacrum) dissected from fresh-frozen cadavers were used.OUTCOME MEASURES: Mean displacement in millimeters was calculated from the four specimens on flexibility testing in Extension, Flexion, and Lateral bending. METHODS: Specimens were stressed in Extension, Flexion, and Lateral bending with continuous measurement of load and displacement. Each adjacent segment (L3-L4) was evaluated with flexibility testing under the following conditions in chronological order: Native disc (Control), LLIF Interbody Spacer only, Spacer with lateral plate, Plate removed and pedicle screws with Z–rod to previous fusion placed, and Z-rod removed and Single rod placed. The displacements on Extension, Flexion, and Lateral bending for Native disc (Control) and the four construct types were recorded in all specimens. The difference in mean displacements between groups was studied by the analysis of variance (ANOVA) and post-hoc Tukey test.RESULTS: Mean displacements (mm) on averaging Extension, Flexion and Lateral bending, i.e Overall motion testing were – 0.741 for Native disc, 0.273 for Interbody spacer only, 0.183 for Interbody spacer with Plate, 0.086 for Z-rod construct, and 0.106 for the Single rod construct. In the Extension, Flexion, and Overall motion analysis, all the four constructs displaced significantly less (p<0.001) as compared to Native disc (Control). Pairwise analysis among the four constructs did not reveal any superiority as the mean displacements were not significantly different from each other.CONCLUSIONS: This biomechanical cadaveric study suggests that an XLIF with and without supplemental fixation reduces motion significantly at the adjacent segment as compared to intact disc. There was a trend towards increasing rigidity with supplemental fixation (plate and pedicle screw constructs) however, no superiority was found. Further biomechanical studies with larger sample sizes are needed to identify XLIF constructs that can be placed with least surgical morbidity and are stable enough to be used in ASD. FDA DEVICE/DRUG STATUS: NuVasive XLIF System (Approved for this indication)
16. Complication Risks of the Transforaminal Approach to the Lumbar Spine: An Anatomic and Pathoanatomic Risk Assessment
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: Introduction: Minimally Invasive surgery has the same complication risks of traditional surgery, but morbidity is less. It has ranged in the 3-3.5 % range for all complications, in spite of pitfalls from operating near the dorsal root ganglion. With foraminal endoscopic surgery, documentation and visualization of pathoanatomy has also identified additional, but lesser known causes of sciatica and post-operative dysesthesia. PURPOSE: To identify the risks of foraminal endoscopic surgery and compare the risks from traditional translaminar surgerySTUDY DESIGN/SETTING: Inflammatory conditions and pathoanatomy identified with the endoscope during transforaminal endoscopic surgery, recorded in vivo of over 10,000 cases serves as the data base this study.
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PATIENT SAMPLE: 10,000 consecutive cases documented in a single spine group practiceOUTCOME MEASURES: VAS, Oswestry, Modified MacNab Criteria, patient satisfaction questionnaireMETHODS: Method: Patients with minor and major adverse effects undergoing endoscopic foraminal surgery are prospectively studied and retrospectively reviewed. Inflammatory conditions and pathoanatomy identified with the endoscope recorded in vivo of over 10,000 cases serves as the data base this study. RESULTS: Findings: Postoperative dysesthesia occurred an average of 8-15% of the time in a periodic review spanning over 10,000 consecutive procedures for herniated lumbar discs and painful degenerative conditions of the lumbar spine from 1991-2016. Findings of “anomalous” nerves, synovial cysts, inflammatory membranes and increased vasculature in the foraminal zone are routinely seen, even when presented in the literature as a complication risk. Foraminal branches of dorsal ramus, the spinal traversing or exiting nerve (furcal nerves) contribute significantly to the pre-and postoperative symptom complex. Furcal nerves may be difficult to differentiate from a conjoined nerve or the foraminal ligament. Autonomic nerves confirmed by endoscopic excisional biopsy, have also been identified. The most common pathologic endoscopic finding was inflammatory and granulation tissue in the foramen, annulus, and disc. The presence of inflammation in “normal” tissue is correlated with pain. This endoscopic finding correlated well with severe back pain and sciatica produced by evocative discography. Its severity post-operatively may be correlated with the extent of thermal annulopasty of the annulus and the presence of anomalous and furcal nerves in the foramen. Dysesthesia is a “complication” that is an unavoidable consequence of surgical access through the foramen, even when no adverse event is anticipated and when the surgery goes well. Surgeons working in the foramen through a paramedian posterior approach encounters the same surgical risk. Working near the Dorsal Root Ganglion is a known risk by itself, transforaminal surgery. Judicious ablation or removal of nerves in the inflammatory membrane, however, results in a satisfactory surgical outcome of overall pain relief of axial back pain and sciatica, but may also produce a temporary side effect of dysesthesia of varied severity. Furcal nerves, when identified, but are correlated with temporary dysesthesia if ablated and small in size. Dysesthesia is usually mild, self-limited, and temporary, but a major concern to patients who gets it severely post-operatively. Permanent residuals are rare, usually self-limited, but may result in residual numbness and extremity weakness. Post-operative dysesthesia responds well to gabapentin or pre gabapentin, foraminal nerve blocks, and lumbar sympathetic blocks. Co-morbidities such as peripheral neuropathy, and seizure disorders are additional risk factors. CONCLUSIONS: Postoperative neuropathic pain staying the same or worsening may not be able to be completely eliminated, and is a risk of the endoscopic procedure. Preoperative Consent should include neuropathic pain, usually transient, but with a possibility of permanent numbness or weakness. A thorough discussion of the risks associated with foraminal surgery must be explained to any patient undergoing open or endoscopic foraminal surgery. Knowledge of the effect of foraminal epidural injections intra-operatively, post-operatively, and in the management of post-operative dysesthesia will decrease this adverse side effect of foraminal surgery. The overall risks and surgical morbidity are still less than posterior trans-canal surgeryFDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
17. MIS-TLIF for the Treatment of Mild to Moderate Isthmic Spondylolisthesis: Is Direct Decompression of Exiting Nerve Necessary?
Wenjian Wu, MD; Liang Yu, M2
Shanghai Ruijin Hospital, Shanghai, China
BACKGROUND CONTEXT: The surgical treatment for isthmic spondylolisthesis is still controversial, regarding the reduction for spondylolisthesis and the decompression for exiting nerve root. Purpose: The purpose of the present study is to investigate the clinical and radiological outcome of the MIS-TLIF in the treatment of grade I-II isthmic spondylolisthesis without direct decompression for exiting nerve root.STUDY DESIGN/SETTING: prospective cohort study.PATIENT SAMPLE: From Jan 2011 to Jan 2014, 26 consecutive cases of grade I-II isthmic spondylolisthesis were treated with minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).OUTCOME MEASURES: Radiographic evaluation of the percentage of the slippage, segmental lordosis (SL) and lumbar lordosis (LL), presence fusion, hardware-related problems. Clinical evaluation with ODI and VAS.METHODS: From Jan 2011 to Jan 2014, 26 consecutive cases of grade I-II isthmic spondylolisthesis were treated with minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Radiographs were obtained before and after surgery, 3 months postoperatively, and at the final follow-up to determine the percentage of the slippage, segmental lordosis (SL) and lumbar lordosis (LL), presence of fusion, hardware-related problems. The Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) score of back pain and radicular pain were evaluated before and after surgery, and at the final follow-up. The intra-operative data and perioperative complications were recorded. RESULTS: Mean follow-up period was 41 months (range 24-58 months). 18 cases got complete reduction, 7 cases got partial reduction and 1 case no reduction. The mean SL was 3.2opreoperatively and 15.3opostoperatively. The mean LL was 49.3opreoperatively and 51.5opostoperatively, both SL and LL were significantly improved after surgery (P<0.05). There were 23 cases got fusion at the final follow-up (88.2%). The mean ODI was 49.9% before surgery and significantly improved to 21.2% at the final follow-up. There was 1 patient got transient radicular pain after surgery and was recover after conservative treatment.CONCLUSIONS: MIS-TLIF is safe and effective for the treatment of grade I-II isthmic spondylolisthesis. For carefully selected patient, direct decompression of exiting nerve is not necessary. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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Friday, January 20, 201711:00 a.m–12:00 p.m.Plenary Session VI: Abstract Presentations
18. EVOLVE: A Prospective and Multicenter Evaluation of Outcomes for Quality of Life, Pain and Activities of Daily Living following Balloon Kyphoplasty Treatment of Medicare Eligible Subjects with Vertebral Compression Fractures
Melissa Chambers, MD, DVM1; Douglas P. Beall, MD2; John W. Amburgy, MD3; Devin Datta, MD4; Richard W. Easton, MD5; Bradly S. Goodman, MD6; Douglas A. Linville II, MD7; Sanjay Talati, MD8
1University of Alabama at Birmingham, Birmingham, AL, US; 2Clinical Radiology of Oklahoma, Edmond, OK, US; 3University of Alabama at Birmingham, PGY5, Department of Neurological Surgery, Birmingham, AL, US; 4The Back Center, Melbourne, FL, US; 5Beaumont Health System, Troy, MI, US; 6Alabama Ortho & Spine Center, Birmingham, AL, US; 7Scoliosis & Spine Surgery Clinic of Memphis, PLLC, Memphis, TN, US; 8Advanced Diagnostic Imaging PC, Saginaw, MI, US
BACKGROUND CONTEXT: Vertebral compression fractures (VCF) resulting from osteoporosis or cancer are common and painful. Worldwide, osteoporosis causes more than 8.9 million fractures annually. Quality of life is threatened and mortality and morbidity rates increase following a VCF. Kyphoplasty is a minimally invasive procedure to restore vertebral body height when possible, stabilize the fracture, reduce pain, and improve quality of life and mobility.PURPOSE: The primary objective was to assess for statistically significant improvement in four co-primary endpoints at 3 months.STUDY DESIGN/SETTING: National prospective clinical outcomes trialPATIENT SAMPLE: 354 Medicare eligible subjects with painful, acute or subacute vertebral compression fractures.OUTCOME MEASURES: These included the short form 36 question physical component summary (SF-36v2 PCS) and Euroqol-5-domain (EQ-5D) quality of life assessments, the numeric rating scale (NRS) for back pain and the Oswestry disability index (ODI).METHODS: 354 Medicare eligible subjects with painful, acute or subacute VCF were prospectively enrolled at 24 sites in the United States with 343 undergoing kyphoplasty. The study protocol identified four co-primary endpoints at 3 months. These included the short form 36 question physical component summary (SF-36v2 PCS) and Euroqol-5-domain (EQ-5D) quality of life assessments, the numeric rating scale (NRS) for back pain and the Oswestry disability index (ODI). The primary objective was to assess for statistically significant improvement in four co-primary endpoints at 3 months. Data was collected at baseline and at 1, 3, 6 and 12 months.RESULTS: The SF-36 PCS average baseline score of 24.2 points (scale 0 to 100) improved to 36.6 and EQ-5D had an average baseline score of 0.383 (scale 0 to 1), which improved to 0.746 at the 3-month time point (p < 0.001 for each). Similarly, back pain with an average baseline NRS score of 8.7 (scale 0 to 10) improved to 2.7 and ODI with an average baseline score of 63.4 (scale 0 to 100) improved to 27.1 at the 3-month time point (p < 0.001 for each). The four co-primary endpoints showed significant improvement at each interval throughout the study and each measure improved further at 12 months. With statistically significant improvement from baseline in the four co-primary endpoints at 3 months, the primary objective of the study was met. There were five reported device-related or procedure-related adverse events (AE). These included one of each of the following: asymptomatic balloon rupture, transient rib pain, aspiration pneumonia, a new VCF 25 days’ post-procedure, and myocardial infarction 105 days’ post-procedure. All symptoms associated with reported AE resolved with appropriate treatment.
CONCLUSIONS: This large, prospective, multicenter trial demonstrates that kyphoplasty is a safe, very effective and durable procedure for treating Medicare patients with VCF due to osteoporosis or cancer.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
19. Evaluation of Transforaminal Endoscopic Discectomy in the Treatment of Obese Patients with Lumbar Disc Herniation
Wei Zhang, MD, PhD
Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang City, China
BACKGROUND CONTEXT: With the booming development of minimally invasive spine surgery, the technique of spinal endoscopy has made revolutionary progress, especially for percutaneous transforaminal endoscopic discectomy (PTED). PTED also shed light on the treatment of obese patients with LDH. However, few studies were carried out to specifically aim at the effect of transforaminal endoscopic discectomy (TED) on the treatment of obese patients, which safety and effectiveness still do not clear. PURPOSE: This study aimed to evaluate the efficacy of transforaminal endoscopic discectomy (TED) in the treatment of obese patients with lumbar disc herniation (LDH).STUDY DESIGN/SETTING: Retrospective studyPATIENT SAMPLE: 69OUTCOME MEASURES: VAS JOA MacNab score METHODS: A total of 69 obese patients with LDH (35 males and 34 females; age range, 24 to 43 years; median age, 34 years) were included in this study. These patients had undergone TED from March 2011 to December 2015 in The Third Hospital of Hebei Medical University. Their clinical and follow-up data were prospectively analyzed. The degree of pain and disability were measured on the basis of the Visual Analog Scale (VAS) on 1 day before surgery, immediately after surgery and 3 months after surgery. Neurologic functions were measured on the basis of Japanese Orthopaedic Association (JOA) on 1 day before surgery and 3 months after surgery. Patients’ MacNab score of last follow-up was recorded to evaluate the early clinical efficacy. Complications during the operation and after the operation were recorded to evaluate the safety of surgery. RESULTS: Two patients experienced abnormal sensation in export nerve root zone postoperatively, which disappeared after three days of treatment with dehydration and administration of hormone(dexamethasone). Three cases of recurrence were observed on postoperative six months, seven months and nine months, respectively. They were scheduled to receive total laminectomy combined with bone grafting internal fixation. A total of67 patients were followed up for 3-23 months and mean follow-up was 11.8 months. The VAS scores at postoperative 3 months and one year significantly reduced compared to that of pre-operation, with significant differences between them (t=43.072, P<0.05; t=43.139, P<0.05). The JOA scores at last follow-up postoperatively was significantly higher than that before surgery (t=-60.312, P<0.05). For the last follow-up, 17 cases (25.3%) had excellent outcomes, 39 (58.2%) good, 7 (10.4%) fair, and 4 (5.9%) poor. Overall excellent and good rate was 83.5%. CONCLUSIONS: The early efficacy of TED is relatively good and safe for the selected obese patients with LDH in this study. Large sample studies with long term and follow-up are required to detect the safety and effectiveness of TEDFDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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20. Isocentric Navigation Improves the Learning Curve of Transforaminal Percutaneous Endoscopic Lumbar Discectomy
Guoxin Fan, MD; Shisheng He, MD
Shanghai Tenth People’s Hospital, Shanghai, China
BACKGROUND CONTEXT: Beginners usually need increased punctures and dozens of fluoroscopy in learning transforaminal percutaneous endoscopic lumbar discectomy (tPELD), which result in longer operation time and higher radiation exposure. Navigator-assisted spinal surgery (NASS) was a novel technique that could induce a definite trajectory with isocentric navigation. However, the impact of definite trajectory on learning curve of tPELD is not defined.PURPOSE: The study aimed to investigate the impact of a definite trajectory by HELLO system on the learning curve of tPELD.STUDY DESIGN/SETTING: Retrospective study.PATIENT SAMPLE: A total of 120 patients with symptomatic lumbar disc herniation who received tPELD between 2012 and 2014.OUTCOME MEASURES: Operation time, preoperative location time, fluoroscopy time, puncture-channel time, hospital stay, patient-reported outcomes, and complications of the two groups were compared and analyzed.METHODS: Patients receiving tPELD with NASS technique by one surgeon were regarded as Group A, and those receiving conventional methods by another surgeon were regarded as Group B. Each group was divided into three subgroups (case 1-20, case 21-40, case 41-60).RESULTS: The fluoroscopy times were 22.62±3.80 in Group A and 34.32±4.78 in Group B (P<0.001). The preoperative location time was 3.56±0.60 min in Group A and 5.49±1.48 min in Group B (P<0.001). The puncture-channel time was 21.85±4.31 min in Group A and 34.20±8.88 min in Group B (P<0.001). The operation time was 84.62±9.20 min in Group A and 101.97±14.92 min in Group B (P<0.001), and the learning curve of tPELD in Group A was steeper than that in Group B. No significant differences were detected in patient-reported outcomes, hospital stay, patient satisfaction, and complication rate between the two groups (p>0.05).CONCLUSIONS: Definite trajectory by isocentric navigation significantly reduced the operation time, preoperative location time, puncture-channel time and fluoroscopy times of tPELD by beginners, and thus reshaped the learning curve of tPELD and minimized the radiation exposure.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
21. Surgical Posterior Only Treatment of Dumbbell-type Thoracic Cord Tumor versus Combined Laminectomy and Thoracoscopic Surgery
Yawei Li, MD, PhD
The 2nd Xiangya Hospital, Central South University, Changsha, China
BACKGROUND CONTEXT: Surgical removal of dumbbell tumors is challenging because of the well-separated intraspinal and anterior paraspinal components, which are connected through an intervertebral foramen. The different surgical approaches to thoracic dumbbell tumors includes a single posterior only approach with laminectomy, costotransversectomy, or a combined posterior and anterior approach via separate incisions; these different surgical approaches, however, remain controversial.PURPOSE: To compare the clinical outcomes of posterior only surgical treatment and combined laminectomy and thoracoscopic surgery for treating dumbbell-type thoracic cord tumors.
STUDY DESIGN/SETTING: A comparable retrospective study.PATIENT SAMPLE: We retrospectively analyzed 32 cases of dumbbell-type thoracic cord tumor treated by two surgical procedures in our center from February 2003 to July 2013.OUTCOME MEASURES: The operation time, blood loss, hospitalization, recovery of neurological function and complications were collected and statistically analyzed between the two different proceduresMETHODS: The patients were divided into two groups depending on the type of surgery: Group A (n = 12) cases underwent posterior only approach followed by laminectomy, costotransversectomy and instrumentation, while Group B cases (n = 20) underwent posterior laminectomy and anterior video-assisted thoracoscopic surgery in a single-stage procedure. The operation time, blood loss, hospitalization, recovery of neurological function and complications were compared between the two groups.RESULTS: Complete surgical excision was achieved in both groups. All patients were followed up for an average of 7.4 ± 2.8 (range, 3–13) years. At the final follow-up visit, there was no recurrence of tumor and no differences in the neurological results between the two groups (P > 0.05). However, the average operative duration, blood loss, hospitalization, and rate of complications were significantly lower in Group A than in Group B (P < 0.05).CONCLUSIONS: Both the posterior only approach and the posterior approach combined with anterior thoracoscopic surgery could effectively remove dumbbell-type thoracic cord tumor. Nevertheless, the posterior only approach was associated with reduced operative duration and rate of complications than the latter approach.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
22. Radiation Reduction of Minimally Invasive Transforaminal Lumbar Interbody Fusion in Overweight Patients: A Prospective Control Study
Guoxin Fan, MD; Shisheng He, MD
Shanghai Tenth People’s Hospital, Shanghai, China
BACKGROUND CONTEXT: Minimally invasive transforaminal lumbar interbody fusion (MITLIF) has been well validated in overweight or even obese patients, which has been indicated to be correlated with higher radiation exposure.PURPOSE: This prospective study aimed to investigate the efficacy of a novel lumbar localization system for MITLIF in overweight patients.STUDY DESIGN/SETTING: Prospective multicenter study.PATIENT SAMPLE: A total of 62 overweight patients were assigned as Group A, and another 64 patients were assigned as Group B.OUTCOME MEASURES: The primary outcomes were the effective radiation dosage to the surgeon and the exposure time.METHODS: The novel localization system mainly consists of self-made preoperative locator and screw-assisted device. Patients in Group A received localization system, while those in Group B underwent conventional methods.RESULTS: The effective dosage was 0.0217±0.0079mSv in Group A and 0.0383±0.0104mSv in Group B (p<0.001). The fluoroscopy exposure time was 26.42±5.91s in Group A and 40.67±8.18s in Group B (P<0.001). The operation time was 175.56±32.23min and 206.08±30.15min (P<0.001). The preoperative localization time was 4.73±0.84min in Group A and 7.03±1.51min in Group B (P<0.001). The screw placement time was 47.37±10.43min in Group A and 67.86±14.15min in Group B (P<0.001). Moreover, the pedicle screw violation rate was 0.35% (1/283) in Group A and 2.79% (8/287) in Group B (p=0.020).
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CONCLUSIONS: The study indicated that the localization system could effectively reduce radiation exposure, exposure time, operation time, preoperative localization time, and screw placement time in overweight patients undergoing MIS-TLIF, which could be another practical option for minimizing potential radiation hazards.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
23. Application of Navigation Rod for the Location and Puncture of Percutaneous Endoscopic Lumbar Discectomy
Tan Haitao; Huang Shengbin, MD
Guigang City People’s Hospital, Guigang, China
BACKGROUND CONTEXT: Location and puncture is the critical step in percutaneous endoscopic lumbar discectomy. Now we face some problems. The number of punctures made was more, the time taken for puncture was long, surgeon and patient received much too X-ray.PURPOSE: To discuss the application of navigation rod for the location and puncture of percutaneous endoscopic lumbar discectomy (PELD) and analyze its feasibility and value in clinical application.STUDY DESIGN/SETTING: 60 patients undergoing PELD were included in this retrospective study. Patients were divided in two groups. Those who received navigation rod (our invention) to locate the puncture position for lumbar discectomy were considered as “navigation group”, and those who received the traditional C-arm fluoroscopy were considered as “traditional group”. PATIENT SAMPLE: 60 patients undergoing PELD were included in this retrospective study. Patients were divided in two groups. Those who received navigation rod (our invention) to locate the puncture position for lumbar discectomy were considered as “navigation group”, and those who received the traditional C-arm fluoroscopy were considered as “traditional group”.OUTCOME MEASURES: The average number of punctures made was (1.10+0.31) in the navigation group, and (10.53+5.55) in the traditional group (P<0.001). The average fluoroscopic exposure times was (8.30+1.24) in the navigation group, and (60+15.15) in the traditional group (P<0.001). The average time taken for the puncture was (5.05+2.01 min) in the navigation group, and (34.80+6.32 min) in traditional group (P<0.001).METHODS: 60 patients undergoing PELD were included in this retrospective study. Patients were divided in two groups. Those who received navigation rod (our invention) to locate the puncture position for lumbar discectomy were considered as “navigation group”, and those who received the traditional C-arm fluoroscopy were considered as “traditional group”. There were 30 cases in the navigation group, 18 cases of L4-5 discectomy, 12 cases of L5-S1 discectomy, and 30 cases in the traditional group, 16 cases of L4-5 discectomy, 14 cases of L5-S1 discectomy. Comparisons were made between the 2 groups for the number of punctures made; the number of times of fluoroscopy exposure; and the total time taken to do the puncture.RESULTS: The average number of punctures made was (1.10+0.31) in the navigation group, and (10.53+5.55) in the traditional group (P<0.001). The average fluoroscopic exposure times was (8.30+1.24) in the navigation group, and (60+15.15) in the traditional group (P<0.001). The average time taken for the puncture was (5.05+2.01 min) in the navigation group, and (34.80+6.32 min) in traditional group (P<0.001). There were no serious complications in both groups.CONCLUSIONS: Using the navigation rod can solve the bottleneck problem of PELD, and improve the success rate of puncture; reduce the number of punctures made thereby avoiding injury; reduce the time taken for puncture; greatly reduce the X-ray exposure to the surgeon
and patient; and improve the curative effect. Therefore it is worthy of consideration for clinical application.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
24. The Role of Lumbar Facet Arthrosis in Minimal Invasive Spine Surgery
Volodymyr Radchenko Sr., MD, PhD
Sytenko Institute of Spine, Kharkiv, Ukraine
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
25. Relapsed Hernias After Open Surgery, Treated by Percutaneous Endoscopic Surgery
Daniel Gastambide, MD1; Fréderic Jacquot2
1GIEDA Inter Rachis, Paris, France; 2Hopital Saint Antoine, Department of Orthopedic Surgery, Paris, France
BACKGROUND CONTEXT: Relapsed lombosciaticas provoked by a recurrent discal hernia previously operated on are the most worrying for both the patient and the surgeon. The rate is from 5 to 16% and increases with the follow-up in the observed series. The aim of this study is to show the updated indications of secondary surgery, by endoscopic transforaminal discectomy (ETD), or by posterolateral arthrodesis (PLIF), after an experience of more than 1500 endoscopic discectomies.METHODS: We will present relapses in simple cases and in complex cases, then relapses on hinge disks, and finally relapses on stenosis. In the simple cases, with a strict inclusion criterion, we percutaneously operated on 12 patients (sex ratio 10/2), selected during a period of three years. These patients presented a relapse of a discal hernia after an open discectomy, after a free period of mainly 3,58 years, on levels L4L5 and L5S1 in 9 cases. The complex cases are more numerous after the relapse of open surgery and received percutaneous discectomy and/or a percutaneous or open arthrodesis. There are 8 relapses on a hinge above a previous arthrodesis on one or two levels. There were 7 relapses on stenosis, for patients aged from 22 to 74.RESULTS: The results of a relapse on a one level hernia operated on using the endoscopic technique are good in 8 cases, fair in 2 and poor in 2. The complex cases had several procedures, particularly a percutaneous or an open arthrodesis, with poor and fair results. For the hinge disks, we made an extension of the arthrodesis in all cases except one with fair and good results. In the relapsed hernias on a stenosis, the results of a laminectomy and of an arthrodesis were fair and good.CONCLUSIONS: Tom Hoogland obtained 4,62% in cases all under local anesthesia (Spine, 2008). Fessler had 16 successful operations without any failures (J. Spinal Disord Tech. 2010, Feb. 23 (1): 30-4). Eugene Carragee (Spine, 2009) had 10% of relapse in the first two hernias. With open reoperation, he had 10% recurrence, reduction of the disc height (26%). Our indications are: if the disc is merely degenerated (less than one third of loss in intersomatic height): ETD, rarely conventional open surgery; if the disc is degenerated, as it is most often the case: (1) if there is an associated foraminal stenosis, or if there is a Modic 1 and/or 2, and without important radicular adhesions, indication of percutaneous arthrodesis with Europa cages; (2) if a surgical exposure with exploration is necessary, PLIF, keeping in mind that our previous series of terminal PLIF has only 62,8% good results after two years on 36 personal cases operated on between 1999 and 2003. Since
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the invention of endoscopic surgery and since we began using a percutaneous intersomatic arthrodesis called Europa, the therapeutic indications for the treatment of recurrent discal hernias have become more various, more targeted and less invasive. FBSS prevention takes place during early mini-invasive surgery, particularly by percutaneous intersomatic arthrodesis. Further studies will be necessary to confirm these recent indications in mini-invasive surgery.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Friday, January 20, 20171:00–2:30 p.m.Plenary Session VII: Abstract Presentations
26. Failed Back Surgery Syndrome: Endoscopic Documentation of Common Causes by Visualization of Painful Pathoanatomy in the Hidden Zone of the Axilla Containing the Dorsal Root Ganglion and Salvage Treatment of Neuropathic Pain with DRG Neuromodulation
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: Introduction: Failed back surgery syndrome is a very loose term that has different meanings to different providers and specialists treating chronic lumbar pain. Surgeons label the term following failure to obtain their projected surgical results following traditional decompression and fusion. Non-surgeons focus on spinal cord, DRG, or percutaneous neuromodulation to block neuropathic pain. The divergent specialties depend on divergent treatments without additional knowledge on the more specific reasons for surgical failure. Endoscopic visualization using transforaminal endoscopic approaches can identify and treat FBSS by isolating the source of pain with diagnostic and therapeutic injections, then surgically addressing the pain generator, performed with the patient awake with decompression and ablation. The patient is able to provide symptom feedback during surgery. If there is neuropathic pain from a “battered” nerve root, injured by the degenerative or traumatic process, a salvage treatment by wireless neuromodulation, now FDA approved is available for clinical use. PURPOSE: To demonstrate pathoanatomy identified transforaminally and decompressed with an endoscope that can visualize the hidden zone between the traversing and exiting nerveSTUDY DESIGN/SETTING: Transforaminal endoscopic surgery provides surgical options using mechanical decompression as well as DRG neuromodulation for FBSSPATIENT SAMPLE: Consecutive patients with FBSS following translaminar decompression and fusion from a personal database of transforaminal endoscopic cases from 1991-2016OUTCOME MEASURES: vasMETHODS: Transforaminal endoscopic visualization of painful pathoanatomy followed by decompression and ablation in a personal data base of over 10,000 procedure serves as the basis for treating FBSS at the DRG. In addition, a pilot study of a wireless neuromodulation device and the author’s method patent resulting on visualization of pathoanatomy from endoscopic experience, resulted in a pilot study sponsored by Stimwave. This study demonstrated favorable results for patients with residual neuropathic pain failing traditional surgical decompression. Five FBSS patients with multiple procedure histories, dissatisfactory back and leg pain following fusion or lumbar discectomy, were implanted with a wirelessly powered, SNS
system percutaneously that was remotely powered and monitored. FDA approval followed.RESULTS: All five patients reported successful stimulation as defined by at least 80% reduction in pain and 80% paresthesia coverage of the pre-operative pain distribution. Baseline VAS pain scores averaged 8.5. VAS at the end of the trial period averaged 2.3. The transforaminal endoscopic technique also allows surgical access to the lumbar spine for treatment of a wide spectrum of painful conditions in patients who had residual pain following a variety of traditional spine surgeries. Visualizing the pain generators responsible for FBSS are supported by case examples collected from a personal database of over 10,000 surgical cases over 25 years. Good surgical results are obtained with intradiscal therapy and direct endoscopic decompression with feedback from the patient during surgery.CONCLUSIONS: Visualizing the pathoanatomy with an endoscope targeting the pathoanatomy by interventional needle trajectories, has opened the door for surgical decompression and ablation of the pain generators not seen by traditional surgical techniques. As a supplement to endoscopic decompression of residual pathoanatomy, a wirelessly powered SNS fully implanted lead without an implantable pulse generator, or hermetically sealed RF receiver; enables direct a transforaminal implantation technique to be placed directly at pain generator locations to achieve pain relief in chronic FBSS patients with neuropathic pain. Wireless SNS is a practical and simplified therapy that may provide a viable treatment option for chronic low back and/or leg pain from FBSS due to uncorrected, unrecognized pain in the region of the Dorsal Root Ganglion, or as a pain management modality utilized by both specialties. It can even be combined as a Hybrid procedure.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
27. Percutaneous Endoscopic Surgery for Stenosis (PESS): Laser-assisted Uniportal Full-endoscopic Decompression of Central and Lateral Recess Lumbar Spinal Stenosis
TagGeun Jung, MD
Nasaret International Hospital, Incheon, Republic of Korea
BACKGROUND CONTEXT: As the practice of minimally invasive spine surgery advances, one of the last frontiers for the percutaneous spine surgery to cover will be its applicability in the management of lumbar stenosis.PURPOSE: This study evaluated the outcome of percutaneous endoscopic stenosis surgery(PESS), a laser assisted uniportal full-endoscopic interlaminar approach for decompression of lumbar spinal stenosis under monitored anesthesia care(MAC) and also presented a technical report of the procedure.STUDY DESIGN/SETTING: A retrospective study and technical reportPATIENT SAMPLE: From August, 2015 to January, 2016, 30 patients (34 vertebral levels) with lumbar stenosis that underwent PESS procedure were retrospectively reviewed.OUTCOME MEASURES: For clinical outcome, we used visual analogue scale (VAS) score and Oswestry Disability Index(ODI) and MacNab’s criteria for clinical result pre-/postoperatively and for radiological result, used T2-weighted axial MRI: axial midline anterior-posterior thecal sac diameter(MAP-TSd).METHODS: All patients ‘s characteristics were reviewed by clinical records and evaluated at final follow-up by VAS score for back and leg pain and ODI score and MacNab’s criteria. The radiological evaluation was done by measuring the midline anterior-posterior thecal sac diameter on T2-WI MRI.RESULTS: The overall successful outcome by MacNab’s criteria was 96.6% on the last follow-up. Mean follow-up periods was 4.4
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months(2-11months). The VAS-B decreased from 6.7 +/-1.3(5-9) to 1.9+/-0.6(1-3). VAS-L decreased from 8.3+/-0.7(7-9) to 1.3+/-0.6(0-3). The MAP-TSd increased from 6.5+/-2.1mm(3.7-11.2mm) to 10.4+/-1.4mm(8.5-13.7mm) and the ODI decreased from 34.1+/-3.8(27-41) to 15.6 +/- 3.3(12-25). It was statistically significant(P=0.05). The complications were four cases (one case of incidental durotomy and one case of numbness of leg and foot, both resolved spontaneously over 3-5 days, and two cases of epidural hematoma that needed no surgical intervention.CONCLUSIONS: PESS under MAC can be an alternative to standard open lumbar microsurgical unilateral laminectomy with bilateral decompression under general anesthesia.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
28. Comparison of Kyphoplasty Outcomes between Unilateral and Bilateral Approach for Treatment of Osteoporotic Vertebral Compression Fracture
Xingkai Zhang, MD
BACKGROUND CONTEXT: Kyphoplasty is broadly used for treatment of osteoporotic vertebral compression fracture, it is a minimal invasive technique, can relieve pain, partially restore height of fracture vertebral body, avoid complication caused by spinal deformity and long term immobilization. Unilateral extrapedicular approach can save operation time, reduce X-ray exposure, but its effectiveness remains controversy.PURPOSE: To compare effectiveness of kyphoplasty using unilateral extrapedical approach with bilateral approach to treat osteoporotic vertebral fractureSTUDY DESIGN/SETTING: Retrospective study on 107 patients with osteoporotic vertebral compression fractures underwent percutaneous kyphoplasty between July 2010 and July 2013. PATIENT SAMPLE: 33 cases were male, 74 were female, 40 cases were via a unilateral extrapedicular approach, 67 were via bilateral approach. Average patient age was 65.7 years. OUTCOME MEASURES: Pain relief, kyphosis correction bone cement volume and collapse rate of the fractured vertebrae were compared between 2 groups using the visual analog scale and radiographs. Mean follow-up was 9.5 monthsMETHODS: All affected vertebrae were identified via physical examination, magnetic resonance imaging, and radiographs. One group received unilateral approach kyphoplasty and other group received bilateral approach.RESULTS: The operation was successful in all patients. Visual analog scale pain score improving rate was 90.7% in unilateral group and was 93.7 in bilateral group; kyphosis correction rate was 18.7% in unilateral and 18.5% in bilateral group. Average injected bone cement volume was 5.5 ml in unilateral group and was 5.3ml in bilateral group. There is no significant difference between two groups in all above observing results. The collapse rate was 10% in unilateral group and 4.5% in bilateral group, there is significant difference between the two groups. No lateral wedging was found in the coronal alignment of the treated vertebrae. Re-collapse of the fractured vertebrae after vertebral augmentation were multi-factorial, including bone density, anti-osteoporosis therapy after surgery and approaches. Unilateral extrapedicular approach had some limitation in maintain vertebral height, but can obviously improve the symptoms caused by vertebral fracture. Combined use of anti-osteoporosis therapy would reduce re-collapse of fractured vertebra. CONCLUSIONS: Kyphoplasty through a unilateral extrapedicular approach can achieve convergent and proper cement filling in the
affected vertebrae to effectively restore stiffness, relieve pain, and correct kyphosis in fractured vertebrae.FDA DEVICE/DRUG STATUS: kyphon (Approved for this indication)
29. Microendoscopy-assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: Short-term and Medium-term Outcomes
Yang Yang, MD; Limin Rong, MD, PhD
The 3rd Affiliated Hospital of SUN Yat-sen University, Guangzhou, GuangDong, China
BACKGROUND CONTEXT: Microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has advantages of decreased iatrogenic injury, reduced pain and quicker recovery, however, its short-term and medium-term clinical outcomes have not been well compared with open TLIF.PURPOSE: To evaluate short-term and medium-term outcomes of microendoscopy-assisted MIS-TLIF and open TLIF for lumbar degenerative disease.STUDY DESIGN/SETTING: A prospective, randomized control study.PATIENT SAMPLE: A total of 100 patients were included. Fifty cases received microendoscopy-assisted MIS-TLIF (MIS group), while another well-matched 50 cases accepted open TLIF (open group).METHODS: Parameters between MIS group and open group, including surgical duration, intraoperative blood loss and radiologic exposure, postoperative analgesic usage and ambulatory time, visual analogue scale (VAS) for back and leg, functional scores, self-evaluation of surgical outcome (modified MacNab criteria), interbody fusion rate, adjacent segment degeneration (ASD) rate, as well as complication incidence were compared at 1 month and 24 months postoperatively. RESULTS: Intraoperative blood loss and postoperative analgesic usage were significantly reduced in MIS group (206.0 ml versus 491.1 ml, 46.1 mg versus 78.1 mg. P<0.05). Patients undergoing microendoscopy-assisted MIS-TLIF were able to ambulate earlier postoperatively than those receiving open TLIF (2.3 days versus 4.0 days, P<0.05). However, it showed prolonged surgical duration and enhanced radiologic exposure in MIS group (188.7 minutes versus 145.1 minutes, 19.4 mGy versus 7.6 mGy, P<0.05). At 1 month postoperatively, MIS group was associated with more improvement of VAS and functional scores compared with open group (P<0.05). While at 24 months postoperatively, both groups revealed similar VAS and functional scores (P>0.05). Excellent and perfect scale rating by modified MacNab criteria, interbody fusion rate, ASD rate and complication incidence between both groups were nearly the same (96% versus 92%, 88% versus 90%, 12% versus 18%, 10% versus 8%, P>0.05).CONCLUSIONS: Microendoscopy-assisted MIS-TLIF owns advantages of less iatrogenic injury, decreased blood loss, reduced analgesic usage and earlier rehabilitation, while it has drawbacks of more surgical duration and radiologic exposure. It is superior than open TLIF in terms of short-term clinical outcomes and has similar medium-term clinical outcomes.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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30. Radiographic Evaluation of Percutaneous Pedicle Screw Constructs Including Minimally Invasive Facet Fusions for Unstable Spinal Column Injuries
Daniel L. Cavanaugh, MD1; Tristan B. Weir, BS2; Kelley E. Banagan, MD3; Eugene Y. Koh, MD, PhD4; Daniel E. Gelb, MD5; Steven C. Ludwig, MD6
1University of North Carolina Hospitals, Chapel Hill, NC, US; 2University of Maryland School of Medicine, Baltimore, MD, US; 3University of Maryland Medical System, Baltimore, MD, US; 4University of Maryland, Baltimore, MD, US; 5University of Maryland Orthopaedic Associates, Baltimore, MD, US; 6University of Maryland Medical Center, Baltimore, MD, US
BACKGROUND CONTEXT: Open pedicle screw fixation and fusion has been the traditional treatment for operative spine fractures, but several recent studies have challenged the need for fusion in the setting of adequate fixation, demonstrating comparable radiographic and functional results without fusion. Percutaneous treatment of spine fractures has been demonstrated to have decreased blood loss, operative time, and post-operative pain, but fixation of traumatic injuries without fusion raises the concern for failure of the instrumentation secondary to stress fatigue. Treatment of these unstable injuries with minimally invasive facet fusion using a tubular system in addition to percutaneous instrumentation represents an alternative strategy that may reduce morbidity, while promoting long term construct stability. PURPOSE: The purpose of this study is to compare the maintenance of correction of unstable, operative spine fractures that underwent percutaneous fixation with and without facet fusion. A secondary outcome was to critically evaluate the hardware constructs for loosening and failure during a short-term follow-up period.STUDY DESIGN/SETTING: Retrospective chart review from a single tertiary care institution with a level one trauma center. PATIENT SAMPLE: Through use of our institutions billing codes, 141 were identified to be screened. 55 subjects did not meet inclusion-exclusion criteria and were excluded, 26 of the 55 for not having follow-up images.OUTCOME MEASURES: Outcome measures listed below were compared between facet fusion(FF) with bone morphogenetic protein(BMP), FF without BMP, and no FF. Change in degree of kyphosis Implant breakage Screw loosening Level of loosening Implant removalMETHODS: Using CPT codes, we conducted a retrospective review of all operative thoracic and lumbar spine fractures using our institutional billing and coding database from 2006 to 2013. One-hundred and forty-one cases were obtained from the database. Fifty-five cases were excluded for lack of post-operative radiographs and comorbidities. Eighty-seven had radiographs and operative reports available for review. Maintenance of correction was the primary outcome. One-week postoperative radiographs and all available follow-up radiographs were analyzed for the Cobb angle (lateral view) using the vertebral levels at the apices of the construct to evaluate for progressive kyphosis and loss of correction. We also examined each radiograph for instrumentation fracture, loosening (greater than 2 mm of radiolucency around any screw), or screw pullout.RESULTS: The mean follow-up of for all patients was 33 weeks. There average amount of kyphotic progression was 3.2 degrees. There were no cases of instrumentation fracture during this follow-op period. Overall, the rate of screw loosening was 24%. There was no significant difference in the rate of loosening or progression of kyphosis in patients with facet fusion (with or without bone morphogenetic protein [BMP]) and without facet fusion. There was no difference in the percentage of screw pullout between groups. A total of 19 patients (22%) eventually underwent instrumentation removal, of which, only 2 constructs were loose (10.5%).
CONCLUSIONS: We did not demonstrate a significant difference in the progression of kyphosis postoperatively between patients with and without facet fusion. Additionally, no difference in kyphotic progression was noted when facet fusions were performed with or without BMP. In thoracic and lumbar spinal column injuries, where percutaneous fixation is indicated, the addition of facet fusion may be superfluous. Interestingly, we found a significantly higher rate of screw loosening (24%) than previously reported for percutaneous cases, but loosening was not significantly different between fused and non-fused groups. The clinical significance of this instrumentation loosening remains unclear, as only 2 of 19 instrumentation removals had loosening, and further clinical follow-up is needed.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
31. Early Evaluation of Value-based Ambulatory Endoscopic Spine Surgery
Sandeep Sherlekar, MD; Atif B. Malik, MD; John Thorpe
American Spine, Germantown, MD, US
BACKGROUND CONTEXT: Traditionally hospital surgeries were the main choice when dealing with spinal procedures. They typically are costlier and overall less efficient for certain procedures. Other factors include increase in length of stay and risk of infection.PURPOSE: To demonstrate the ability of an ambulatory setting endoscopic spinal and other MIS procedures. By nature, this reduces overall cost, leads to expedient discharges (same day), and reduced risk of infection.STUDY DESIGN/SETTING: This study is a retrospective chart review coupled with patient interview. PATIENT SAMPLE: A total of 280 patients: average age was 47.7 years, 156 male/ 124 femaleOUTCOME MEASURES: VAS and ODI were used to access patients.METHODS: All patients underwent MIS surgery with general anesthesia under fluoroscopic control. Neuro-monitoring was used in all cases. Procedures included endoscopic discectomy and endoscopic decompression with fusion. Evaluations were done pre-op, three months, six months, and at one year.RESULTS: ASSC charges 34.3% of what a typical hospital would charge for the same procedures. For PELDs and LINDIFF/OLLIF Pre-op leg pain was 8.7/10 and post-op 2.9/10. The VAS for back pain went from 7.1 to 1.9. Six patients (2.1%) suffered post-op dysesthesia, four (1.4%) had hardware failure following falls, and four (1.4%) were admitted to hospital for pain control.CONCLUSIONS: ASSC was able to perform a variety of MIS procedures at all levels of the spine. All patients were discharged same day. Follow ups conclude a very high level of post-op pain control with no infections this cohort. The overall cost on average was a third of hospital costs for similar procedures. The MIS procedures performed had minimal post-operative morbidity. All patients were able to be immediately mobilized. There were no cases reported of intra-operative neurological damage as surgeons had extensive experience with techniques used.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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32. Treatment of Cervical Spinal Stenosis with Percutaneous Full-endoscopic Cervical Partial Laminectomy Under Local Anesthesia
Bo Zhu, MD1; Jianwei Du, MD2
1The General Hospital of the People’s Liberation Army, Beijing, Beijing, China; 2Yangzhou NO.1 People’s Hospital, Yangzhou, Jiangsu, China
BACKGROUND CONTEXT: Posterior percutaneous spine endoscopy has been successfully applied to treat the cervical spondylotic radiculopathy. Treatment of cervical spinal stenosis with posterior percutaneous endoscopic approach for partial laminectomy has not been reported. PURPOSE: To assess the early clinical outcome, surgical techniques and postoperative complications of percutaneous full-endoscopic cervical partial laminectomy in treating cervical spinal stenosis. STUDY DESIGN/SETTING: to introduce this method by case reportPATIENT SAMPLE: 4 cases of cervical spinal stenosis admitted in our hospital between October 2015 and January 2016 underwent percutaneous full-endoscopic cervical partial laminectomy under local anesthesia. All patients have cervical disc herniation and hypertrophic ligamentum flavum. 3 patients underwent a single segmental decompression and one underwent three segments decompression. Para-midline incision at the lesion side was made, and decompression was performed at the lower edge of the upper lamina, upper edge of the lower lamina under endoscopy. Limited recessive decompression was performed at the bottom of spinous process and contralateral lamina, followed by resection of ligamentum flavum.OUTCOME MEASURES: Japanese Orthopaedic Association (JOA) score was used to assess the spinal cord function and VSA pain score was used to assess the axial neck pain. METHODS: to measure this method by compare the patients’ outcomes before and after surgery.RESULTS: All 4 patients underwent percutaneous full-endoscopic cervical partial laminectomy under local anesthesia. The average age of patients was 62.5 ± 14.7 years. Duration of the follow-up was 7.75 ± 1.5 months. The average JOA score was elevated from 10.25 ± 2.2 preoperatively to 15.5 ± 1.3 at the latest follow-up, with recovery rate of 30.9 ± 8.8%. VSA pain score of all patients was 0 at the latest follow-up. There were no complications including dural sac tear and C5 nerve root palsy.CONCLUSIONS: This study reported satisfactory results and this technique had several advantages. (1) Unilateral approach and bilateral decompression with sufficient decompression range. (2) It is more minimally invasive compared to traditional partial laminectomy and could reduce the incidence of postoperative axial neck pain and kyphosis. (3) Local anesthesia facilitates intraoperative monitoring. The short-term results indicate that the percutaneous full-endoscopic cervical partial laminectomy is a sufficient and safe supplement and alternative to conventional procedures when the indication criteria are fulfilled.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
33. A Novel Tubular Endoscopic System via the Posterior Approach for Lumbar Interbody Fusion Technical Feasibility and Initial Surgical Outcome
Yue Zhou, MD, PhD
Xinqiao Hospital of the Third Military Medical University, Chongqing, China
BACKGROUND CONTEXT: The classic surgical technique such as transforaminal lumbar interbody fusion (TLIF) based on Quadrant or
pedicle-screw-based retractor system was accomplished under direct visualization without microscope or micro-endoscope. Both techniques needed to excessively disconnect the deep paraspinal muscles, while the iatrogenic injury may also result in increased postoperative pain and lengthened recovery time. The novel tubular endoscopic system which was originated from micro-endoscopic technique could achieve minimally invasive endoscopic decompression and fusion integration. What’s more, the special X-tube which was designed with larger outside and smaller inside caliber would minimize back muscles injury.PURPOSE: The purpose was to evaluate the feasibility and initial results of the novel tubular Endoscopic System via the posterior approach associated with Lumbar Interbody Fusion technique for lumbar degenerative diseases.STUDY DESIGN/SETTING: Technical reportPATIENT SAMPLE: Twenty-five patients OUTCOME MEASURES: The functional outcome using modified MacNab criteria, the Oswestry Disability Index (ODI) and Japanese Orthopedic Association (JOA) low back pain score. The 10-point visual analog scale for back pain and leg pain, length of operation time, intraoperative and postoperative blood loss were recorded. Radiologic fusion was determined with flexion-extension radiographs.Methods: Twenty-five patients (M:F=8:17; mean age, 56±12y) underwent Tubular Endoscopic System via the Posterior Approach for Lumbar Interbody Fusion from April 2015 to April 2016.The level operated was in L4-L5 (21) and L5-S1 (4).RESULTS: The follow up period was range 4.2 to 16.4 months. The final outcome was excellent in 18, good in 6. No poor results and major complications were reported. And the mean operating times were 219.3±56.5 minutes, the intraoperative and postoperative blood loss was 168.7±75.6 ml and 59.31 ±34.29 ml. The preoperative ODI dropped from a mean of 43.36±2.57 to 12.55±7.69 postoperatively, VAS for back pain from 7.20±0.63 to 0.82±1.01 and leg pain from 5.82±0.91 to 0.18±0.40. Improvements in average JOA (preoperative to last follow-up) scores were 12.14±12.62 to 24.05±3.12. At final follow-up, twenty-one patients had solid fusions by radiographic criteria. CONCLUSIONS: The clinical results show that Tubular Endoscopic System via the Posterior Approach for Lumbar Interbody Fusion was a sufficient and safe technique supplement and alternative to conventional procedures when the indication criteria were fulfilled. At the same time, it offered the advantages of minimally invasive intervention. However, multicenter studies, large sample size and long-term follow-up would be needed before making final conclusions. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Department of Spinal Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang City, China
BACKGROUND CONTEXT: With the development of minimally invasive spine surgery, percutaneous transforaminal endoscopic discectomy (PTED) is widely used in the treatment of lumbar disc herniation now and obtain a good curative effect. But there is a big difficulty for some patients with high iliac crest, especially in the segments L5~S1, since the iliac crest can block operation. Therefore, the patients took intervertebral endoscopic surgery was a thorny problem faced by spine surgeons.
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PURPOSE: To discuss the technical points and the short-term curative effect of bore puncture for the treatment of L5/S1 intervertebral disc herniation with transiliac approach intervertebral endoscopic discectomy.STUDY DESIGN/SETTING: Retrospective studyPATIENT SAMPLE: 57OUTCOME MEASURES: operative time, intraoperative fluoroscopy times, VAS scores, The MacNab scoreMETHODS: Nineteen patients from March 2014 to September 2015 were diagnosed as L5 /S1 disc herniation, and accepted nucleus pulposus excision treatment through approach endoscopic discectomy (transiliac approach group, group I). At same times, 20 patients were diagnosed as non-L5/S1 disc herniation, and underwent conventional approach endoscopic discectomy (conventional approach group, group R). The operation time and intraoperative fluoroscopy times of the two groups were analyzed and compared. The leg pain was evaluated by visual analogue scale (VAS) at preoperatively, immediately postoperatively and 12 months postoperatively, respectively. MacNab Ratings of last follow-up were recorded to evaluate early clinical efficacy, and postoperative complications were recorded to evaluate surgical safety. The imaging changes of the patients with 3 months after surgery were observed.RESULTS: One case in group I who felt abnormal in nerve root exit zone took dehydration, hormone and other symptomatic treatment, and the abnormalities disappeared 3 days after treatment. There were no obvious complications in the rest patients, and all patients received outpatient followed up for 12 months. There was no obvious statistical significance in operative time and intraoperative fluoroscopy times between group I and R (p > 0.05), but group I had a higher tendency. The VAS scores of post-operation were significantly lower than pre-operation in the two groups (p <0.05), but the difference between groups were not statistically significant (p > 0.05). The MacNab score of the last follow-up showed excellent and good rate of 94.7% (18/19) and 90% (18/20) in group I and group R, respectively.CONCLUSIONS: Bone puncture combined transiliac approach intervertebral endoscopic surgery could locate iliac puncture point individually, and this contributed to establish a good iliac channel. The therapy of L5/S1 disc herniation is a safe, effective, and minimally invasive treatment.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
PURPOSE: The surgical treatment of cervical radiculopathy includes the traditional laminectomy, laminoplasty and minimally invasive foraminotomy. Full-endoscopic posterior cervical foraminotomy has been described as a safe, effective and minimally invasive method for patients with a foraminal disk herniation. In this study, authors describe the surgical indications, technique, preliminary clinical outcomes and also the change in radiological outcomes such as cervical curvature and segmental angle in a series of patients who underwent the single level full-endoscopic posterior cervical foraminotomy procedure.METHODS: Thirty consecutive patients (19 men, 11 women; mean age, 44.9 ±8.2 years) who had single-level foraminal disk herniation at our institution were retrospectively reviewed. Radicular arm pain was the most common presenting symptom in patients. All patients
underwent full-endoscopic posterior cervical foraminotomy. The clinical parameters and radiological parameters included cervical curvature(CA), segmental angle(SA) and range of motion(ROM) preoperatively and last follow up were assessed.RESULTS: The mean follow up for the patients was 8.3 months (range 6 to 20). There were no perioperative complications. Excellent outcomes were achieved in 22 out of 30 patients and good in 6. Postoperative CA and CA-ROM were improved but not significantly changed. The SA became more lordotic postoperatively (4.5 to -0.6 degree, p < 0.05). By multivariate analysis of the clinical factors, patients with a history less than 3 month had a better outcome than patients with history ≥3 month (excellent, 90.91% vs 42.11).CONCLUSIONS: The results show that the full endoscopic posterior foraminotomy is a safe and effective option for cervical radiculopathy with the advantages of a minimally invasive method.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
Posters
P1. Minimally Invasive Surgery in the Treatment of Spinal Infection: A Case Report and Literature Review
Luiz H. Sandon, MD
Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
BACKGROUND CONTEXT: We should consider the possibility of pyogenic infectious discitis whenever a patient present with pain and other inflammatory signs associated with blood inflammatory markers. The most commonly found bacterium is Staphylococcus aureus, mainly in post-operative infections; however, many patients are infected by other pathogens. Additionally, in the case of patients with arthrodesis and screws, there is not necessarily a need for the instrumentation to be removed, but antibiotics should be maintained for a long period. Conservative treatment is always the first choice; however, in cases with aggravating factors such as those with major bone deterioration, those with severe or progressive deformity, or those without improvement with antibiotic treatment, we should opt for surgical debridement of the affected area and consider spinal fusion in cases of instability. Minimally invasive techniques are already consolidated and accepted as an option for spine surgery. Nevertheless, not much is known about the use of these techniques in the treatment of surgical complications. There are some reports of minimally invasive surgery (MIS) for the treatment of postoperative infection, such as those of Yu et al. or Gill and Blumenthal in the mid-1990s. Both reports described transpedicular techniques, with satisfactory results but in small cohorts.PURPOSE: We further discuss minimally invasive surgery as a new tool for treating classical spine pathologies and resolving complications and increasingly complex cases.STUDY DESIGN/SETTING: Case Report and Literature ReviewPATIENT SAMPLE: A 73-year-old man, without previous relevant morbidities, who underwent transforaminal lumbar interbody fusion at another spinal surgery center in November 2014 complained of having pain in his right leg since May 2015, 1 month prior to presenting for initial attendance at our outpatient clinic at Pohang Wooridul Hospital. On the first examination, the patient complained of lumbar pain irradiating to the buttocks and both the lower limbs, with positive Lasegue signs on both sides and crural paraparesis (strength grade 4). After the examination he was properly informed about his clinical condition and the surgery procedure. The patient provided informed
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consent for the full disclosure of the data to the scientific community for medical purposes. Magnetic resonance imaging of the lumbar spine revealed inflammation in the soft tissue at the L3 and L4 levels and CT-Scan with severe lytic infection at the L3 vertebra (osseous sclerosis, edema, and destruction of the end plate) The protrusion of the posterior wall of L3 to the spinal canal and inflammation affected the lumbar roots in the region considering the advanced severity of the patient’s general condition, surgery via percutaneous biopsy and the placement of catheters on both sides for continuous irrigation and drainage was opted for. Simultaneously, a dosage of 1 g/day of vancomycin was initiated.OUTCOME MEASURES: As described previously by Hanaoka et al. in 2006, we used a surgical approach similar to that of percutaneous discectomy for a herniated disc. In the operating room, the patient underwent local anesthesia with 1% lidocaine and conscious sedation (with a bolus dose of 50 μg fentanyl [0.8 μg/kg] + repeated 3–5 minute doses until a total dose of 150 μg); he was then placed in the prone position on a radiotransparent table. The entry points for the punctures (approximately 12 cm from the midline on each side) were determined by studying preoperative MRI and computed tomography images. Standard preparation of the skin was performed by using aseptic and antiseptic iodine. Next, the intervertebral space was punctured, and micro forceps and micro curettes were placed under direct c-arm fluoroscopic guidance. The affected vertebral disc (L3/L4) as well as the end plates of the adjacent vertebrae (L3 and L4) was curetted in order to remove as much material as possible; then, a 3.2-mm silicone catheter was inserted into the intervertebral space under c-arm fluoroscopic guidance. After that, the same procedure was performed contralaterally, and finally, a 3.2-mm silicone catheter was inserted in the epidural space. The intervertebral space and surrounding areas were cleansed with 3000 mL of physiological saline, confirming the drainage of the opposite side of the infusion. A continuous irrigation and drainage system was then installed. All the curetted material was sent for biopsy, histopathological analysis, and culturing. The patient was transferred from the operating room to the wards for therapeutic follow-up and rehabilitation (stimulating mobilization and early ambulation) Standard spine radiography and MRI and measurements of inflammatory markers (C-reactive protein level, erythrocyte sedimentation rate, and white blood cell count) showed that the patient had significant improvement. On the 6th postoperative day, Candida parapsilosis was identified on the culture of the curetted material. On the 8th postoperative day, the antibiotics were changed according to the antibiogram for 200 mg/day of intravenous (IV) fluconazole + 1 g bid of IV cefotiam, with continuous irrigation with fluconazole. Nevertheless, the patient continued to complain of lumbar back pain that irradiated to the buttocks and legs, although with less intensity than at the initial examination, and he still had difficulty walking. On the 15th postoperative day, the catheters for continuous irrigation and drainage were removed and the intravenous medication regimen continued. On the 26th postoperative day, the patient still experienced pain, and although there was improvement in the infection, we performed lumbar arthrodesis with L2-L5 fusion. On April 24, 6 weeks after initiating antibiotic treatment, the patient was discharged with a final diagnosis of fungal discitis set after culture results from percutaneous biopsy were obtained, with remission of the irradiated pain to the lower limbs, with little remaining lumbar back pain, and without neurological deficits; he was to the oral intake of 200 mg/day fluconazole for 12 weeksMETHODS: Pyogenic spondylodiscitis is an uncommon diagnosis, corresponding to only 3–5% of all cases of osteomyelitis. The global incidence of spine infections is only 0.02–2 cases for every 100,000 persons,1 and the incidence of spine surgical site infections is 0.7–12%. There are less than 40 cases of vertebral spine osteomyelitis caused
by C. parapsilosis, and of these, only 3 were isolated in culture, with most cases in patients who were much more clinically debilitated than were our patient. The initial step in treating pyogenic spondylodiscitis is to diagnose and isolate the causative agent. In this way, obtaining samples of the infected tissue is indispensable for culturing and obtaining a clear identification of the agent; that is, biopsy of the site is the gold standard for the diagnosis and the primary guide for the subsequent treatment. We know that puncture biopsy guided by imaging is usually quite specific but only moderately sensitive for identifying the causative agent; therefore, it is an examination technique with a good positive predictive value but not very good negative predictive value.14 When surgery is indicated, most studies recommend the removal of the infected and/or devitalized tissue (which enables histopathological analysis) along with fusion of the affected spine to guarantee local stabilization, either by autologous grafts or by instrumentation.RESULTS: Using the described minimally invasive technique, we could obtain satisfactory local decompression in addition to directly obtaining samples of the lesion, thereby permitting biopsy and culture of the material and increasing the probabilities of identifying the causative agent. Additionally, it also allowed us to infuse the antibiotic/antifungal agent at the infection site, so that adequate local concentration was achieved, regardless of the ability of the drug to translocate through the blood or surrounding tissue. As this method is not as invasive as open surgery, it does not require general anesthesia. Therefore, it can be used in patients with poor clinical status or with multiple comorbidities. In addition, it ensures greater recovery of agility, with almost immediate relief of symptoms (pain), thus allowing early ambulation and rehabilitation (favoring the outcome for the patient and decreasing perioperative complications). However, MIS still has limited applications, as it is restricted to infections focused in only one location, with a limited affected area, and is contraindicated in cases of serious bone deterioration and advanced or progressive localized deformity. As there is no direct visualization of the affected area, it is possible that there can be insufficient removal of the material or unsatisfactory decompression, which sometimes makes it necessary to repeat the approach and/or resort to conventional open surgery; in addition, there are inherent risks of nerve or vascular injury with the procedure. Although we have other case series describing the treatment of spinal infection with minimally invasive techniques, they still represent a small portion of all cases. Moreover, this is the first reported case of a fungal infection treated with this procedure.CONCLUSIONS: MIS was a great valuable tool for this patient, allowing rapid, accurate diagnosis, ensuring precise treatment, and promoting early rehabilitation. The technique offers little morbidity for the patient and allows administration of suitable doses of antibiotics/antifungal agent, in addition to promoting significant improvement in pain symptoms and allowing early ambulation. The findings of this case should be used to advance the technical development of MIS in such a way that it can be used as an additional tool in the treatment of complex cases of spinal disordersFDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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P2. Intraoperative Myelography in Extreme Lateral Interbody Fusion for Degenerative Lumbar Spinal Stenosis
Limin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
BACKGROUND CONTEXT: Extreme lateral interbody fusion (XLIF) has become an increasingly popular minimally invasive procedure for degenerative lumbar spinal stenosis. However, concern remains about how to determine the adequacy of spinal canal decompression when performing XLIF.PURPOSE: To address feasibility and effectiveness of intraoperative myelography in determining adequacy of indirect canal decompression when performing XLIF for degenerative lumbar spinal stenosis (DLSS).STUDY DESIGN/SETTING: Retrospective analysis of prospectively collected data.PATIENT SAMPLE: Seven patients suffering from DLSS received XLIF.METHODS: Seven patients received intraoperative myelography following interbody cage placement. Any remaining filling defect in intraoperative myelogram was identified and resolved by additional microendoscopic canal decompression (MECD). “Stenosis ratio” (SR) is defined as ratio of dural sac width in operated level with mean dural sac width. Preoperative and postoperative SR in both anterior-posterior and lateral positions were calculated and compared. Dural sac area of operated level was measured in transverse computed tomography (CT) images and compared between preoperation and postoperation. Visual analogue scale (VAS) for back and leg, Japanese Orthopaedic Association score (JOA) and Oswestry disability index (ODI) before and after surgery, as well as one year postoperatively were also compared.RESULTS: All seven patients underwent XLIF safely and demonstrated significant improvement of neurological symptom postoperatively. Four of them showed adequate intraoperative canal decompression, while three remaining patients revealed inadequate canal decompression intraoperatively, following additional MECD, their residual stenosis was resolved. Postoperative anterior-posterior and lateral SR (84.2%, 81.1%), as well as dural sac area of operated level (1.41 cm2) were increased statistically compared with preoperation (26.1%, 33.1%, 0.65 cm2, P<0.05). At both two weeks and one year postoperatively, VAS for back (1.9, 1.9), VAS for leg (1.7, 1.6), JOA (24.9, 25.1) and ODI (31.7%, 29.0%) of all seven patients were also significantly improved in comparison with preoperation (5.0, 6.1, 14.7, 50.6%, P<0.05).CONCLUSIONS: Intraoperative myelography during XLIF is able to assess adequacy of its indirect canal decompression for DLSS, thus promising favorable clinical outcomes.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P3. Radiation Safety Alert
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: With the trend toward percutaneous minimally invasive procedures becoming an integral part of spine procedures, there is a growing concern on radiation safety. Awareness of the biological effects of ionizing radiation is more important than ever. What are the effects of ionizing radiation on the surgeon and staff? What measures can be taken to minimize exposure during surgery and pain procedures? What are the lesser known effects of ionizing radiation?METHODS: With a 25-year career in percutaneous transforaminal endoscopic surgery with over 10,000 procedures, One Endoscopic
Surgeon’s simple steps used in his operating suites and the use of radiation protection that may be lacking globally is demonstrated and discussed. The methods start with protection in the operating room utilizing lead shielding of the operating table and patient positioning frames. Overhead mounted lead shields and the awareness of radiation scatter after it passes though the patient can be minimized appropriate table shielding. A study in 2010 on the use of lead gloves in vivo under operating conditions is re-visited. Involvement in image guidance equipment and robotics rounds out the platform for reducing radiation exposure.RESULTS: Answers to questions: 1. What shielding and protective resources will decrease patient and staff exposure to X-rays? 2. What measures can be taken to minimize the surgeon’s exposure? 3. What basic knowledge is needed by the surgeon on the effects of ionizing radiation that may not be obvious? 4. What general principles during the training process are needed to protect trainees and ourselves? 5. What technologies are being developed for endoscopic decompressive techniques other than hardware insertion?CONCLUSIONS: In addition to the obvious simple steps of Radiation Protection discussed, new equipment for image guidance and robotics may be another answer to minimizing exposure for surgical procedures relying more on percutaneous and intra-operative imaging. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P4. Early Clinical Results of Genipin Crosslinking Treatment for Low Back Pain
Harwant Singh, MD, PhD1; Tom Hedman, PhD2; John Racadio, MD3
1Country Heights, Malaysia; 2Orthopeutics, L.P., Lexington, KY, US; 3Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, US
BACKGROUND CONTEXT: Chronic low back pain (CLBP) is a leading cause of disability worldwide, imposing a substantial economic burden through healthcare costs and decreased worker productivity. A large proportion of CLBP sufferers experience discogenic pain, thought to be associated with disc degeneration. Micro-invasive exogenous crosslinking, a new, injectable approach for the treatment of chronic discogenic low back pain, is in the clinical trial phase of development. The technology is based on the injection of a protein crosslinking reagent into the pathologic disc annulus to restore or augment its mechanical properties, reduce neural compression, and stabilize the intervertebral joint. PURPOSE: To evaluate the ability of the Genepin to reduce symptoms of back pain; and to evaluate its safety in humans.STUDY DESIGN/SETTING: A prospective, single center, single arm five-patient clinical study.PATIENT SAMPLE: Four patients met the selection criteria; and enrolled to study. The average pretreatment VAS was 5.9 (5-7), and the average pretreatment ODI was 51% (42%-56%).OUTCOME MEASURES: VAS and ODI: and clinical adverse reactions.METHODS: Fluoroscopic image-guidance was used to deliver two posterolateral injections of up to 1.0 ml GP reagent to each symptomatic disc using a 21 Ga Chiba needle. The injectate contained 50% contrast agent (Iopamiro 370) plus a buffer solution with 50 mM 4-(2-Hydroxyethyl)-1-piperazinepropanesulfonic acid (EPPS), 50 mM phosphate (pH 9), and 48mM GP. All injections were made by the same orthopaedic surgeon in a single day. The surgeon received procedure-specific training and had considerable experience with micro-invasive treatment of spinal discs (1000s of cases) prior to these procedures. The study primary safety endpoint was serious adverse events at 30 days, and the primary efficacy endpoint was set at reduction of
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pain and disability at 1 and 3 months. Secondary efficacy endpoints included a metric of device functionality – reduction of flexion-extension instability via imaging (to be analyzed after the 3-month time-point), patient satisfaction, and reduction of pain medications. Due to the small number of patients in this first-in-human study, descriptive statistics were usedRESULTS: All four patients underwent successful delivery of the device with 2 posterolateral injections of GP reagent delivered to each targeted symptomatic disc under fluoroscopic guidance. A total of 6 discs were treated in these 4 patients, 3 L4/L5 and 3 L5/S1 discs. Patient ages ranged from 24 to 43 years. The patients represented 3 different ethnic groups. The first patient’s 2-level procedure took over 1 hour, while each of the other three procedures were complete within 20 minutes, including one patient with treatment at 2-levels. Following the procedure, all patients had temporary central pain of varying intensity associated with increased fluid content in the treated discs. This procedure related pain dissipated slowly while the patient remained in a supine position, but dissipated rapidly with time spent in an erect posture and by walking. By the 2-week (± 1 week) post-procedure time-point (see Figure 1), average VAS (pain) scores had dropped 94% to 0.375 (range 0-1), and average ODI (disability) had decreased 85% to an average of 7.5% (range 0-18%), a 43.5 percentage point drop. One patient had an onset of neuritic pain in the left leg 3-days post procedure corresponding to extravasation of the injectate in the vicinity of the nerve root at the time of the procedure. The leg pain subsided with time and was successfully managed with pregabaline (Lyrica). This patient experienced an elimination of back pain, with both VAS and ODI scores of 0. All four patients were happy with results of the procedure at 2 weeks. After 1-month average VAS scores were decreased 92% compared to baseline to an average pain score of 0.5, and average ODI had decreased 88% compared to baseline to an average disability score of 6%. Three of the four patients reported pain and disability scores of zero. The other patient was the patient that received the smallest volume of GP reagent. All four patients had returned to work and strenuous activities. All four patients were happy with results of procedure at 1 month.CONCLUSIONS: This study presents compelling initial clinical data associated with a GP-based injectable device designed to reduce back pain and prevent ongoing disc degeneration through immediate and lasting tissue strengthening and joint stabilization.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P5. The Feasibility of a Novel Hydrogel Intradiscal Implant for Nucleus Augmentation
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: Nonoperative treatments often fail to achieve effective relief in chronic, discogenic back pain. Surgical options range from endoscopic intradiscal therapy with electro-thermal or laser therapy to lumbar fusion. Discectomy is a surgical treatment when discogenic pain progresses to disc herniation caused by failure of the annulus fibrosis, validated by the SPORT study. Transforaminal surgical decompression with thermal annuloplasty is the current most effective treatment, especially if endoscopically visualized.PURPOSE: To neutralize the acidity and offer hydraulic support of the degenerative disc in the treatment of a painful disc. After discectomy, the disc loses hydraulic support and degeneration is accelerated. Discogenic pain from painful annular tears are from the inflammation created by cytokines leaking to the annular tears. The biomimetic
hypothesis is to use Hydrogel implants sticks to hydrate the desiccated disc and to neutralize the acidic degenerative nucleus.STUDY DESIGN/SETTING: Polyacylonitril (Hypan-90) is a hydrogel that is a bio-compatible Material that was used in European pilot studies with more than 3-year follow-up. It was first tested by implantation in degenerative discs that were positive for concordant pain following diagnostic evocative discography, then used to provide hydraulic support to degenerative discs and foraminal stenosis after foraminoplasty in a pilot study with over 3-year follow-upPATIENT SAMPLE: 188 + 30 (two separate pilot studies)OUTCOME MEASURES: VAS, Oswestry, and patient satisfactionMETHODS: Materials and Method: A polyacryonitril (Hypan-90) hydrogel nucleus augmentation is an implant with a CE mark that focuses on providing hydraulic support to the nucleus rather than nucleus replacement or just decompression and ablation. The nucleus is augmented through an implant inserted through a thin walled18 gauge needle in patients with discogenic pain confirmed by evocative discography. The desiccated, spaghetti shaped hydrogel “sticks” expand 4-5 times in volume with hydration that neutralizes the acidic pH of the disc and provides hydraulic support. In 188 cases with three-year follow-up, hydrogel implants were also inserted into desiccated discs in patients with stenosis needing foraminoplasty. Results were better than foraminoplasty alone.RESULTS: Results: Overall favorable results for pilot studies, performed in Spain, England, Germany, and Asia, demonstrate its efficacy and safety with results better than discectomy alone as measured by VAS, Oswestry, and patient satisfaction. The studies demonstrate very high clinical efficacy rate with few known extrusions or procedure related complications. The soft, spaghetti like hydrated implants resist extrusion in an intact annulus provides immediate hydraulic support, and elevation of the Ph in the acidic degenerative disc. Chronic lumbar discogenic pain is a difficult condition to treat, because its pathogenesis is multifactorial and only partially understood. Non-operative therapeutic methods often fail to achieve sufficient pain relief because chemical irritants emanate from the degenerating disc and irritate the spinal nerves and DRG through annular tears. Epidural steroids may be effective in the temporary relief of back pain and sciatica, but are less successful long term in resolving low back pain. Surgical options vary greatly, ranging from surgical disc decompression (Sport study) to 360° fusion. Surgical morbidity associated with all fusion techniques, however, while more thoroughly studied, is significant when considering only 65 – 80 % of patients obtain satisfactory longer term clinical results. The morbidity of fusion for back pain often creates more problems with adjacent level degeneration or when the procedure fails. Chymopapain, the only intradiscal procedure to be validated by Level 1 evidence based medicine is no longer available due to abandonment by industry. Profitability and liability issues, including transverse myelitis and anaphylactic shock, caused manufacturers to cease manufacturing this effective intradiscal “drug”, regulated as such by the FDA. The current trend in Endoscopic MIS Spine are surgical procedures focusing on intradiscal therapy. Other intradiscal therapies have emerged, but all have focused on the elimination of pain in a degenerating disc by decompression, ablation, irrigation, or oxidation, but not nucleus augmentation.CONCLUSIONS: Pilot studies on intradiscal augmentation demonstrate very high clinical efficacy rate with almost no complications. The Gelstik nucleus augmentation option is a procedure focused on replacing and augmenting the nucleus with and without endoscopic decompression. Favorable results in preliminary pilot cases warrant further study.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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P6. Application of Computer Navigation in the Treatment of Spinal Tuberculosis in the Extreme Lateral Interbody Fusion
Tan Haitao; Li Ying, MD
Guigang City Hospital Guangxi China, Guigang, Guangxi, China
BACKGROUND CONTEXT: In recent years, computer assisted navigation system has been gradually applied in spinal surgery, using the X-ray technology, CT data, combined with computer technology, spatial positioning technology and clinical operation, can show the dynamic relative position of surgical instruments and the structure of the human body during operation, play the role of guide and assistant operation. XLIF was using to cure spinal tuberculosis operation in recent years. in the aspect of reducing surgical trauma than traditional surgery has certain advantages, but the technique of X-ray fluoroscopy dependence. How to ensure the operation effect and reduce the radiation of nurses and patients in the operation, shorten the operation time is the surgeon’s concern.PURPOSE: Discussion of computer navigation in the XLIF (extreme lateral interbody fusion) of thoracolumbar and lumbar tuberculosis with debridement, internal fixation and bone grafting.STUDY DESIGN/SETTING: From June 2013 to October 2014, cure 46 cases of thoracolumbar or lumbar tuberculosis patients in the XLIF. Patients were randomly divided into navigation Group (male 16 cases, female 7 cases) and control group (male 14 cases, female 9 cases), 23 cases in each group. The average age of navigation (37.7 + 16.7) years old, the average age of the control group (39.2 + 18.4) years old. 17 cases with nerve dysfunction (navigation group 7 cases, control group 10 cases), ASIA grade: navigation group 5 cases of grade C, 2 cases of grade D, the control group 6 cases of grade C, 4 cases of grade D. Postoperative outpatient follow-up records of erythrocyte sedimentation rate, bone fusion time, VAS, ASIA score and Cobb angle lesions.PATIENT SAMPLE: Patients were randomly divided into navigation Group (male 16 cases, female 7 cases) and control group (male 14 cases, female 9 cases), 23 cases in each group. The average age of navigation (37.7 + 16.7) years old, the average age of the control group (39.2 + 18.4) years old.17 cases with nerve dysfunction (navigation group 7 cases, control group 10 cases), ASIA grade: navigation group 5 cases of grade C, 2 cases of grade D, the control group 6 cases of grade C, 4 cases of grade D. Postoperative outpatient follow-up records of erythrocyte sedimentation rate, bone fusion time, VAS, ASIA score and Cobb angle lesions.OUTCOME MEASURES: the navigation group and control group in the postoperative recovery time of erythrocyte sedimentation rate, VAS score, kyphosis angle (Cobb angle), operation time, bone fusion time were no significant difference between the two groups. The navigation group of intraoperative bleeding was 447 + 139ml, the control group of intraoperative bleeding was 627 + 251ml, the difference has statistical significance (p<0.05). Intraoperative C arm fluoroscopy cumulative exposure time was navigation group 31 + 14S, control group 96 + 38S, the difference was statistically significant (p<0.05).The control group of 10 cases have preoperative symptoms of spinal cord injury, 6 cases of grade C patients after surgery in 3 cases recovered to grade D, 3 cases recovered to E grade.4 grade D patients recovered to grade E. Symptoms of spinal cord injury were 7 cases of preoperative patients with navigation group, 5 cases of grade C patients after operation 3 cases recovered to grade D, 2 cases recovered to E grade.2 grade D patients recovered to E grade. CONCLUSIONS: Thoracolumbar and lumbar tuberculosis debridement internal fixation and bone grafting in XLIF applicate computer navigation and conventional fluoroscopy were not statistically significant between the two groups, but computer navigation can reduce the surgery time and trauma, reduce the patients and medical staff of intraoperative radiation exposure.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P7. Associations between Modic Changes and Cervical Degenerative Disease
Geun S. Song, MD, PhD
Pusan Nat’l University Yangsan Hospital, Yangsan, Gyeongnam, Republic of Korea
BACKGROUND CONTEXT: Modic changes are signal intensity changes in adjacent vertebral bone marrow on magnetic resonance imaging (MRI). Few studies have investigated these changes with regard to the cervical spine. Therefore, this study aimed to determine cervical spine degenerative diseases associated with Modic changes.STUDY DESIGN/SETTING: retrospective studyMETHODS: We conducted a retrospective collection of radiological data in patients with neck pain at our hospital from January 2010 to December 2014. A total of 733 patients were included in this study. Disc herniation grade and disc space height for each cervical segment were evaluated. If Modic changes were present, we recorded the Modic change type based on the literature, vertebral level, age, sex, and surgical requirement.RESULTS: MRI scans of the 733 patients were reviewed, 99 patients exhibited Modic changes in the cervical spine (13.5%). Out of these 99 patients, Modic change type II (87 patients, 87.9%)and C5–6 vertebral level (41 patients, 41.4%)were the most predominant categories. Patients with Modic change showed worse outcomes in regard to disc herniation grade and disc space height than patients without (p<0.01). Among 733 patients, 38 patients had undergone anterior cervical discectomy with fusion (ACDF). Patients with Modic changes (13/99 patients, 13.1%) had a greater probability of undergoing ACDF than those without (25/634 patients, 3.9%; p<0.01).CONCLUSIONS: Modic changes may be an important indication of disc degeneration requiring surgery.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P8. Relationship between Radiological Outcomes and BMD Based on Lumbar Vertebrae in Single-level Anterior Cervical Discectomy and Fusion
Jun Seok Lee, BA
Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
BACKGROUND CONTEXT: Bone mineral density (BMD) is important in predicting mechanical strength of cage subsidence in increasing aging population. However, BMD based on cervical vertebrae is not routinely measured for cervical degenerative diseases. This study determined the association of the subsidence in anterior cervical discectomy and fusion (ACDF) and BMD data based on lumbar vertebrae.STUDY DESIGN/SETTING: retrospective studyMETHODS: Radiological data of patients who underwent ACDF for one-level disc disease at our hospital were retrospectively collected from January 2012 to December 2014. Radiography and computed tomography scans were performed for ra diological evaluation. Global cervical lordosis (GCL), fused segment angle (FSA), fused segment height (FSH), and disc space height (DSH) were measured and analyzed.
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RESULTS: Successful bone fusion was achieved at the final follow-up examination in all patients who underwent ACDF. However, loss of disc height over 3mm at the surgical level was observed in two patients in the osteoporosis group. Although all outcomes of the osteoporosis group were slightly lower than those of the normal group, there was no significant difference between the groups (p>0.05).CONCLUSIONS: BMD based on lumbar vertebrae was not a significant factor to subsidence after ACDF. To better understand the cervical bone, it may be necessary to obtain BMD of surgical levels. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P9. The Effect of Uncinate Process Resection on the Subsidence in Anterior Cervical Discectomy and Fusion
Su Hun Lee, MS
Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do, Republic of Korea
BACKGROUND CONTEXT: The effects of uncinate process resection (UPR) on cervical spine instability have a controversy according to study type; in vivo, in vitro. To estimate in vivo effects of UPR in the case of anterior cervical discectomy and fusion (ACDF), we evaluated clinical and radiological outcome after ACDF with bilateral UPR.STUDY DESIGN/SETTING: retrospective studyMETHODS: We collected a clinical and radiological data from January 2011 to June 2015, retrospectively. A total of 29 patients 41 segments were included in this study. All procedure includes bilateral UPR and anterior plate fixation by single surgeon. Coronal reformatted-CT images were used to evaluate the resection rate of uncinate processes. To reduce level induced bias, we converted the area of UPR to proportion of UPR to pre-operative vertebral body (UPR/VB) or pre-operative uncinate process (pUPR). RESULTS: The sum of bilateral pUPR (p=0.006) is closely correlated to subsidence. By simple regression analysis, the subsidence could be estimated by following formula; subsidence=0.896 + 3.980 x sum of pUPR. The subsidence rate was 34%. Comparative analysis revealed no significant difference on clinical outcomes, and fusion rate between subsidence group and non-subsidence group.CONCLUSIONS: We performed quantitative analysis of UPR, and correlation analysis with subsidence. Our finding suggests that if the sum of pUPR were more than 52.9 %, the possibility of subsidence would increase significantly. (R2=0.178, p=0.006)FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P10. Intradiscal Therapy for Discogenic Pain from Toxic Annular Tears
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: Non-operative therapeutic regimens often fail to achieve effective relief in chronic discogenic back pain. Surgical options range from intradiscal electrothermal therapy to lumbar fusion. Other percutaneous procedures, Coblation, Biacuplasty, and Disc Fx has attracted interventionalist’s interest, but endoscopic techniques in the literature favor visualized intradiscal procedures that incorporate Selective Endoscopic Discectomy with thermal annuloplasty for discogenic back pain over fluoroscopically guided procedures.PURPOSE: To illustrate that intradiscal therapy guided by endoscopic visualization of toxic annular tears is rational and effective in relieving discogenic back pain
STUDY DESIGN/SETTING: A 1997 IRB approved study of endoscopic spine surgery for painful degenerative conditions of the lumbar spine determined that thermal modulation using lasers and radiofrequency can provide back pain relief emanating from the lumbar disc. PATIENT SAMPLE: 113 consecutive patients studied retrospectively and published in Spine in 2004OUTCOME MEASURES: Modified MacNab Criteria, VAS, patient satisfaction questionnaireMETHODS: The clinical outcome of a retrospective study of 113 consecutive patients with minimal 2-year follow-up was reported in Spine, October 2004. Patient selection included positive evocative discography pre-operatively and/or intraoperatively, correlated with an abnormal discogram pattern. At surgery, chromo-discography with diluted indigo carmine dye stained the degenerative nucleus pulposus, targeting the stained degenerative tissue for removal. Tears in the annulus had interposed disc material in the annulus, preventing it from healing. The annulus was the treated by laser and radiofrequency flex probes under endoscopic visualization. Interpositional nucleus material embedded in the annulus needed to be removed for best results.RESULTS: The painful discs had inflammatory or granulation tissue adjacent to the annular tears. The degenerative nucleus pulposus is removed mechanically, with rongeurs, shavers or laser, then the granulation and inflammatory tissue adjacent to the annular tears are thermally modulated by flexible radiofrequency electrodes. The annular defects are endoscopically observed to be altered by radiofrequency treatment. From this early experience with Selective endoscopic discectomy, a less invasive 3mm fluoroscopically guided cannula was developed combining mechanical discectomy with thermal annuloplasty (Disc fx). The results mirrored visualized endoscopic discectomy and thermal annuloplasty. Visualization, however added information to determine why some tears elicited relatively minor pain while others were truly disabled by their tears.CONCLUSIONS: The treatment rationale for selective endoscopic discectomy and thermal annuloplasty includes endoscopic discectomy to decompress the disc and to remove the source of chemical sciatica from the deteriorating nucleus, but also removes the nuclear tissue embedded in the annular tear. Inflammatory tissue is thermally ablated. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P11. Intradiscal Therapy and Transforaminal Endoscopic Decompression: Opportunities and Challenges for the Future
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
BACKGROUND CONTEXT: The literature on endoscopic techniques support visualized procedures that incorporate Selective Endoscopic Discectomy and thermal annuloplasty for discogenic back pain. Foraminoplasty offers additional efficacy for stenosis and failed back surgery syndrome. Fusion is the ultimate surgical means by traditional surgeons to eliminate debilitating back pain and sciatica. Spine surgeons trained to perform fusions, with no training in endoscopic surgery, however, struggle to battle a crisis of escalating cost and affordability when using fusion as the ultimate solution.PURPOSE: To introduce endoscopic transforaminal disc and foraminal decompression (foraminoplasty vs foraminal facet decompression) as an effective minimally invasive procedure that will augment traditional translaminar decompression
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STUDY DESIGN/SETTING: A 1997 IRB approved study of endoscopic spine surgery for painful degenerative conditions of the lumbar spine provided opportunities to study intradiscal therapy, and evolved into decompressive procedures that have successfully treated stenosis, failed back surgery syndrome, and chronic lumbar pain. Over 10,000 procedures in a personal database enabled by the development of special endoscopes and instruments has made the transforaminal approach to the lumbar spine a versatile approach for a wide variety of painful lumbar conditions. The surgical technique, aided by improved instrumentation, validates outcomes with modified MacNab criteria, VAS, ODI, and patient satisfaction questionnaires. The average follow-up time, from this personal database, ranges from 2-20 years.Patient Sample: Database of over 10,000 transforaminal decompression procedures with images of the painful pathoanatomyOUTCOME MEASURES: VAS, Oswestry, Modified Mac Nab Criteria, patient satisfactionMETHODS: Transforaminal Endoscopic Technique, described as YESS endoscopic surgery in the literatureRESULTS: These procedures have evolved and culminated in predictable clinical results with minimal surgical morbidity for highly experienced endoscopic surgeons. This is backed by recent peer reviewed literature, with publications increasing since 2000. Multiple studies of patient series, reported since 2000, illustrate the validity and cost effectiveness of this endoscopic guided procedure that has withstood the test to time. Although lateral recess decompression has been performed with trephines and lasers since 1995, its use was limited in favor of more traditional translaminar decompression and the lack of good mechanical tools. Automated burrs helped endoscopic decompression evolve further, but recently articulated burrs made it a routine procedure for decompression of the lateral and subarticular recess that can also reach the inlet of the lateral recess and the central spinal canal. Visualization, decompression and ablation of painful pathoanatomy, documented in an awake patient under only local anesthesia with minimal sedation serves as the “surgical based evidence”. Level I evidence is impossible and unethical for blinded comparison, so other evidence such as direct visualization of the surgical treatment of the pain generator should be substituted for evidence based scientific validation.CONCLUSIONS: The transforaminal endoscopic approach is effective for chronic back pain and sciatica by decompressing the pathoanatomy in the axilla, called the “hidden zone of Mac Nab. The approach avoids going through the previous translaminar surgical sites. It does not “burn bridges” for a more conventional approach, and, if the approach is used as the first alternative to fusion, it will mitigate the need for fusion for 30-75% of patients who first opt for this less invasive philosophy and procedure after non-surgical treatment fails. Transforaminal Lateral Recess Endoscopic decompression is a true minimally invasive procedure performed under local anesthesia. It is predictably successful when transforaminal epidural blocks provide excellent pain relief. Endoscopic surgical techniques will open the door for cost effective surgical solutions for painful degenerative conditions of the lumbar spine, warranting further study and adoption by surgeons trained adequately in this technique.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P12. Learning Curve of Microendoscopy-assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: 65 Consecutive Cases of One Surgeon
Limin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
BACKGROUND CONTEXT: Microendoscopy-assisted minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has advantages of reduced iatrogenic injury, enhanced recovery and comparable clinical outcomes, thus gaining more popularities recently. However, its learning curve has not been well described.PURPOSE: To evaluate the learning curve of microendoscopy-assisted MI-TLIF performed by one senior surgeon.STUDY DESIGN/SETTING: Retrospective cohort study of consecutive patientsPATIENT SAMPLE: A total of 65 patients suffering from lumbar degenerative disease underwent single-level microendoscopy-assisted MI-TLIF.METHODS: Piecewise regression analysis was used to define the turning point of learning curve (early and plateau phase). Perioperative evaluations included surgical duration, intraoperative fluoroscopic time and blood loss, postoperative analgesic usage and ambulatory time. Clinical outcome assessments involved visual analogue score (VAS) for back and leg, Japanese Orthopaedics Association score (JOA), Oswestry disability index (ODI) and modified MacNab criteria. All these indicators, as well as complication incidence and interbody fusion (Birdwell classification) between both phases were compared.RESULTS: The asymptote of learning curve was reached following previous 21 cases. Comparing latter 44 cases with first 21 cases, surgical duration (178.9 minutes versus 195.5 minutes), intraoperative fluoroscopic time (53.2 seconds versus 77.5 seconds), blood loss (184.0 ml versus 205.5 ml), postoperative analgesic usage (43.0 mg versus 73.6 mg) and ambulatory time (2.1 days versus 2.6 days) revealed significant differences (P<0.05). While at 20 months postoperation, VAS-back (0.8 versus 0.8), VAS-leg (0.7 versus 0.5), JOA (25.0 versus 25.0), ODI (12.2 versus 12.0), perfect or good assessment based on modified MacNab criteria (20/21 versus 43/44) and interbody fusion rate of grade I (18/21 versus 37/44) were nearly the same (P>0.05). There were 5 complications and 10 complications at early and latter phase respectively, also showing no statistical significance (P>0.05).CONCLUSIONS: The turning point of this surgeon’s learning curve for microendoscopy- assisted MI-TLIF is achieved at the 21st case. Patients at its both phases acquire similar clinical outcomes, while latter patients can get additional advantages.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P13. Hidden Hemorrhage Following Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion
Yang Yang, MD; Limin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou, GuangDong, China
BACKGROUND CONTEXT: Hidden hemorrhage has been proved to be significant in other surgical techniques, however, when referring to lumbar interbody fusion, it is often ignored because of its invisibility.PURPOSE: To calculate and compare hidden hemorrhage following minimally invasive and open transforaminal lumbar interbody fusion (TLIF), meanwhile, to analyze its clinical significance.
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STUDY DESIGN/SETTING: A prospective cohort study.PATIENT SAMPLE: A total of 41 cases were included. Twenty-one patients underwent minimally invasive TLIF (MIS-TLIF; minimally invasive group, MIS group) and another well-matched 20 patients underwent open TLIF (open group).METHODS: For each case, total volume loss of red blood cell (RBC) was firstly calculated by “Gross” formula based on perioperative hematocrit change, then perioperative visible volume loss of RBC was calculated through hemorrhage volume and weight. After deducting it from total volume loss of RBC, hidden volume loss of RBC was obtained. Absolute amount of hidden hemorrhage and its ratio upon total hemorrhage, as well as indicators assessing clinical outcomes [visual analogue scale (VAS) of back and leg, Oswestry disability index (ODI)] were compared and analyzed.RESULTS: Mean hidden volume loss of RBC in MIS group was significantly reduced compared with open group (166.7 ml versus 245.6 ml, P=0.028). Besides, both mean total and visible volume loss of RBC in MIS group were also statistically less than those in open group (355.3 ml versus 538.6 ml, P<0.001; 188.6 ml versus 293.0 ml, P<0.001). While mean ratio of hidden hemorrhage upon total hemorrhage was 46.7% for MIS group and 44.5% for open group respectively, showing no statistical significance (P=0.626). With respect to clinical outcomes, more improvements of VAS for back and leg, as well as ODI were seen in MIS group compared with open group (MIS: 2.7, 2.8, 31.7%; open: 4.6, 3.4, 34.7%, P<0.05), meanwhile, complication rates between both groups were nearly the same (MIS: 9.5%; open: 5%, P=1.000).CONCLUSIONS: Besides reduced visible het and improved clinical outcomes, MIS-TLIF also owns the superiority of less hidden hemorrhage, offering another advantage over open TLIF.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P14. Intermuscular Approach for Mini-Open Transforaminal Lumbar Interbody Fusion
Jwo-Luen Pao, MD
Far-Eastern Memorial Hospital, New Taipei, Taiwan, Taiwan
BACKGROUND CONTEXT: The integrity of posterior stabilizing complex was considered as an important factor to prevent late adjacent segment pathology (ASP). Mini-open transforaminal lumbar interbody fusion (mini-TLIF) is a popular minimally invasive technique that causes minimal destruction to not only the posterior stabilizing complex but also the paraspinal muscles.PURPOSE: Instead of using the transmuscular approach and percutaneous transpedicle screw (TPS) system, we modified our techniques for mini-TLIF by using the intermuscular approach without the fancy and expansive TPS system. This study is to evaluate the treatment results and the impact on ASP after the spinal fusion.STUDY DESIGN/SETTING: A retrospective series study.PATIENT SAMPLE: A total of 103 patients underwent mini-TLIF for degenerative lumbar diseases during July 2011 and Dec 2012 were included in this study. They were 36 male and 67 female patients with an average age of 60 (range: 19 ~ 83). The indications for mini-TLIF were spondylolisthesis in 57 patients, degenerative disc disease in 40 patients, and segmental instability after laminectomy or discectomy in the remaining 6 patients. Seventy-five patients received 1-segment fusion (L3-4 = 4; L4-5 = 50; L5-S = 21), the other 28 patients received 2-segment fusion (L2-4 = 1; L3-5 = 17; L4-S = 10). OUTCOME MEASURES: The treatment results were evaluated with ODI and JOA questionnaire before surgery and at annual follow-up. X-ray and
MR evaluation for radiographic ASP (RASP) and clinical ASP (CASP). METHODS: Surgical techniques: We used Wiltse’s approach through two longitudinal skin incisions. The paraspinal muscles were split through the intermuscular plane between multifidus and longissimus and maintained using the Quadrant retractor system. Following unilateral total facetectomy, discectomy, and meticulous endplate preparation, moserized allograft or DBM, and a PEEK spacer was inserted through the transforaminal approach. Unilateral laminotomy for bilateral decompression was performed if indicated. The insertion of transpedicle screws was guided under the fluoroscope. Reduction of the listhesis and scoliosis was attempted as possible. Outcomes evaluation: All the patients had routine AP and dynamic flexion/extension lateral X-ray, before surgery and at annual follow-up. Thirty-four patients had follow-up MRI performed at 2 years post-operatively. RASP refers to progression of adjacent segment pathology detected by X-ray or MRI, including decreased disc height, progression of disc degeneration, anterior or retrolisthesis, buckling of ligamentum flavum, and progression of canal stenosis. CASP refers to symptomatic ASP that requires treatment or further surgical intervention. RESULTS: The average follow-up period was 39.7 months (range: 27 ~ 67). Of the 103 patients, RASP was identified in 31 patients (30.1%). Decreased disc height was noted in 15 patients, canal stenosis in 10 patients, segmental instability in 9 patients, buckling of ligamentum flavum in 4 patients, and osteophyte formation in 2 patients. In contrary to the relative high RASP rate, only 5 patients (4.9%) had CASP: adjacent vertebral compression fracture in 1 patient, lumbar spinal stenosis in 2 patients, and segmental instability in 2 patients. Of the 5 patients with CASP, only 2 patients required secondary surgery: microendoscopic decompression in 1 patient and revision mini-TLIF in the other one. The ODI was improved from 48.9 ± 21.3 to 10.6 ± 16.3; the JOA score was improved from 14.5 ± 6.5 to 25.8 ± 4.8.CONCLUSIONS: Mini-TLIF is an effective spinal fusion technique with excellent treatment results. The radiographic changes as a result of ASP seem unavoidable by adapting minimally invasive surgical techniques. However, preserving the posterior stabilizing complex and paraspinal muscle may help to maintain an intact posterior tension band, stabilize the lumbar spine, and avoid secondary surgery. The theoretical benefits of mini-TLIF with the modified intermuscular approach in preventing late ASP can only be verified by long-term clinical follow-up or comparison studies.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P15. Mini-Open Anterior Lumbar Interbody Fusion for the Treatment of Symptomatic Adjacent-segment Degeneration After Lumbar Fusion
Yawei Li, MD, PhD
The 2nd Xiangya Hospital, Central South University, Changsha, China
BACKGROUND CONTEXT: Adjacent-segment degeneration (ASD) is very common after lumbar fusion. Given a high incidence, spinal surgeons are facing a growing population of patients in need of treatment for ASD. However, most studies were only focused on the etiology and incidence, few studies involving surgical treatments had been reported. Mini-open ALIF using PEEK cages with integrated intracorporeal anchoring plates in the treatment of symptomatic ASD had not been studied.PURPOSE: The aim of this retrospective study was to evaluate the efficacy and safety of mini-open Anterior Lumbar Interbody Fusion (ALIF) using Polyetheretherketone (PEEK) cages with integrated intracorporeal anchoring plates for patients with symptomatic adjacent-segment degeneration(ASD) after lumbar fusion
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STUDY DESIGN/SETTING: A comparable retrospective study.PATIENT SAMPLE: 12 patients with symptomatic ASD underwent mini-open ALIF in the time range from Jan. 2013 to June 2014 were enrolled in this study.OUTCOME MEASURES: Clinical outcome measures included the Visual Analog Scale (VAS) of low back and leg pain, the Oswestry Disability Index (ODI), Quality of Life (SF-36), patient subjective satisfaction and analgesic drug use. Radiological outcome measures included fusion rate, cage subsidence and retrograde and disc height.METHODS: The 12 patients with symptomatic ASD underwent mini-open ALIF in the time range from Jan. 2013 to June 2014 were enrolled in this study. They presented severe low-back pain with or without radicular pain in low extremes. Perioperative data was recorded. Evaluation was performed preoperatively and postoperatively at 3, 6, 12 months and final follow-up. Clinical and radiological data was collected and statistically analyzed.RESULTS: The mean age was 54.3 years ranging from 42 years to 65 years. The mean follow-up was 32 months (24 months to 42 months). ALIF surgery was successfully performed in all patients. No serious complications could be found. During the follow-up, VAS of low back and leg pain, ODI and analgesic drug use were obviously decreased with statistically significant differences (P<0.05) while SF-36 was improved significantly (P<0.05). Anterior and posterior disc height were restored significantly (P<0.05). At the final follow-up, fusion was achieved in 11 cases (91.7%). No case with cage subsidence and retrograde.CONCLUSIONS: The study suggests that mini-open ALIF using PEEK cages with integrated intracorporeal anchoring plates for symptomatic ASD could resulting in satisfied efficiency and safety. Both clinic and radiological outcome was improved significantly without serious complicationsFDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P16. Complication and Treatment of the Lumbar Intervertebral Disc Herniation Using Percutaneous Endoscopic Lumbar Discectomy
Bo Zhu, MD
The General Hospital of the People’s Liberation Army, Beijing, Beijing, China
BACKGROUND CONTEXT: percutaneous endoscopic lumbar discectomy (PELD) has been successfully applied to treat lumbar intervertebral disc herniation. The postoperative complication and the retreatment afterment has not been reported.PURPOSE: To summarize and discuss the lapsus and the treatment of the lumbar intervertebral disc herniation using percutaneous endoscopic lumbar discectomy.STUDY DESIGN/SETTING: These cases with complications in operation and postoperation were studied retrospectively. PATIENT SAMPLE: Between July 2002 and October 2015, 3178 patients with lumbar intervertebral disc herniation treated by PELD were analyzed, including 2156 males, and 1022 females. Single lumbar intervertebral disc herniation were 3123 cases. double lumbar intervertebral disc herniation was 52; three lumbar intervertebral disc herniation were 3. Central type in 245, side central type in 1671, lateral type in 1113, extreme lateral type in 92, sequestered type in 57. OUTCOME MEASURES: VSA pain score was used to assess the pain and the complication and retreatment after surgery were used to assess the lapsus and the treatment postoperative complication and retreatment after surgery postoperative complication and retreatment after surgery
METHODS: To follow all the patients and observe the outcomes. To record the postoperative complication and retreatment after surgery. RESULTS: There were nucleus pulposus omissions in 25 patients and 11 patients underwent open resection of nucleus pulposus during operation immediately and the second operation was needed in 7 cases, 1 case with transforaminal lumbar interbody fusion (TLIF) and the others with open resection of nucleus pulposus. Seven patients had nerve root injury, but all completely recovered in 3-6 months after operation. Spinal dura mater disruption was in 7 patients, recovered after suturing of skin wound. 2985 patients were followed up for 8-162 months, mean follow-up time was 46 months. Postoperative spondylodiscitis was in 13 patients, recovery after expectant treatment in 1, percutaneous puncture irrigation and drainage for continued use of local antibiotics in 8, posterior infective lumbar discectomy in 4. Postoperative relapse was in 18 patients, operated secondly by PELD in 11 and by TLIF in 7, recovery after the second operation. Nerve root induced hyperalgesia and burning-like nerve root pain was seen in 112 patients, the symptom was improved by analgesic drug, neurotrophy drug and physiotherapy. The effect of single segment PELD was not good in 32 patients with spinal stenosis, who underwent multiple segment TLIF later. CONCLUSIONS: The complications during operation usually are nucleus pulposus omissions, nerve root injury, spinal dura mater disruption. Accordingly, the complications after operation include spondylodiscitis, recurrence, nerve root induced hyperalgesia or burning-like nerve root pain. Strict indication, aseptic technique, skilled operation and proper rehabilitation exercise are effective ways to reduce complications. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P17. Short-term Effectiveness of Percutaneous Endoscopic Spine Surgery for Treatment of Lumbar Disc Herniation with Posterior Ring Apophysis Separation
Qingquan Kong, MD
West China Hospital of Sichuan University, Chengdu, Sichaun, China
PURPOSE: To investigate the feasibility and short-term effectiveness of percutaneous endoscopic spine surgery for treatment of lumbar disc herniation with posterior ring apophysis separation.METHODS: Between July 2008 and January 2013, 57 patients with lumbar disc herniation and posterior ring apophysis separation were treated. There were 39 males and 18 females, aged from 13 to 46 years (mean, 26.7 years). Of 57 cases, 29 had a clear trauma history. All patients had single segmental unilateral lumbar disc herniation, and the location was at L4, 5 in 22 cases and at L5, S1 in 35 cases; there were 25 cases of lateral bone fragments and 32 cases of central cortical and cancellous fragments. While fracture located at posterior inferior edge of the vertebrae at L4 level in 9 cases and at L5 level in 8 cases, at posterior superior edge at L5 level in 13 cases and in S1 level in 27 cases. Percutaneous endoscopic surgeries were performed via interlaminar or transforaminal approach from unilaterally symptomatic side for discectomy of lumbar disc herniation and partial or complete resection of free bone fragments. RESULTS: Accurate positioning was obtained in all patients during operation, and no complication of nerve root injury, hematoma formation, or dural tear occurred. The operation time was 20-85 minutes; the intraoperative fluoroscopy times were 2-15 times, and the blood loss was 3-10 mL. Postoperative radiographic examination showed that bone fragment was not removed in 16 cases, was partly removed in 32 cases, and was completely removed in 9 cases. Disc was completely
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removed. All patients were followed up 10-64 months (median, 16 months). According to modified MacNab criteria for the evaluation of effectiveness, the results were excellent in 48 cases, good in 6 cases, and fair in 3 cases, and the excellent and good rate was 94.7%.CONCLUSIONS: Percutaneous endoscopic spine surgery through unilaterally symptomatic approach has advantages of small tissue damage and lumbar structure damage, less bleeding, and shorter recovery time. It has a good short-term effectiveness, but long-term effectiveness need further follow-up.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P18. Treatment of Cauda Equina Syndrome Caused by Lumbar Disc Herniation with Percutaneous Endoscopic Lumbar Discectomy
Qingquan Kong, MD
West China Hospital of Sichuan University, Chengdu, Sichaun, China
PURPOSE: To evaluate the feasibility and clinical efficacy of percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH) with cauda equina syndrome (CES).METHODS: The patients with CES produced by LDH in early and intermediate clinical stages of Shi’s classification were selected as the object of study. 16 enrolled patients underwent PELD. Clinical outcomes were assessed using the MacNab criteria and the visual analogue scale (VAS).RESULTS: The mean follow-up time of the patients was 26.2±2.2 months (range, 24–32 months). The VAS for leg pain and back pain significantly decreased (P < 0.05) from preoperative scores of 7.67±1.23 and 7.52±1.42, respectively, to postoperative scores of 1.71±0.53 and 3.18±0.72. The outcome of the 16 patients was excellent in 7 patients (43.8%), good in 6 patients (37.5%), and fair in 3 patients (18.7%). 13 individuals (81.2%) showed favorable result. Complications included one case of motor weakness (muscle power decrease from grade 4 to 2) recovered within postoperative two weeks, and one patient developed a recurrent herniation after 9-months and underwent further fusion surgery.CONCLUSIONS: PELD is a safe, effective, and minimally invasive procedure, and could be used as an alternative surgical method for the treatment of LDH presented with CES in properly selected cases. The proper/appropriate selection of the cases and the reasonable adoption of the surgical approach are vital to acquire a satisfactory outcome for LDH with CES treated by PELD technique.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P19. Minimally Invasive Transpedicular Approach for the Treatment of Herniated Thoracic Disc Disease: A Technical Note and Comparison to Open Transpedicular Discectomy
Jonathan P. Nakhla, MD; Rafael De la Garza Ramos, MD; Merritt Kinon, MD; Ajit Jada; Rani Nasser, MD; Neil Haranhalli, MD; Reza Yassari, MD, MSc
Montefiore Spine Center, Department of Neurosurgery, Spine Research Group, Bronx, NY, US
BACKGROUND CONTEXT: Thoracic disc disease is a rare entity in clinical medicine and is treated via a number of different surgical approaches circumferentially orientated around the spine, from a traditional thoracotomy to less invasive posterior and posterior-lateral approaches. Furthermore, there is a paucity of outcome results and data comparing the different approaches.
PROCEEDINGS
PURPOSE: We describe our experience at a single institution using a minimally invasive (MIS) approach via a tubular retractor system to the thoracic spine and its feasibility for transpedicular thoracic discectomies and compared our clinical results to our more traditional open transpedicular approach.STUDY DESIGN/SETTING: We performed a retrospective review of all cases performed between 2011 and 2016 comparing the results of a total of 8 patients with thoracic disc disease resulting in myelopathy with or without radicular symptoms treated surgically with an open approach (3 patients, 4 levels) or an MIS approach (6 patients, 7 levels). We then compared length of surgery, blood loss, time to ambulate, and looked at major and minor complications.RESULTS: For all MIS cases, the postoperative imaging demonstrated excellent decompression that meets the requirements and standard of what is accomplished with an open approach. There were no post-operative complications in either group. Patients who underwent an MIS approach had decreased blood loss and had an earlier time to ambulate (within 24-48 vs. >48 for all open cases). The average surgery time was longer for the MIS approach with a steep learning curve to acquire the technical fine-tuning for MIS. There were no major or minor complications in either group.CONCLUSIONS: MIS thoracic disc disease is a rare and challenging disease, much different than the lumbar or cervical spine due to the anatomy and its adjacent structures. However, similar to the MIS approach to the lumbar spine, this approach has similar benefits including decreased blood loss, shorter operative times. This approach allows patients to ambulate at an earlier stage. Overall, MIS transpedicular thoracic discectomies is a safe and feasible approach to the thoracic spine for thoracic disc herniation in selected patients.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P20. Systemic Review and Personal Experience for Preventing Complications of Percutaneous Transforaminal Endoscopic Lumbar Discectomy in Learning Curve Phase
Keyi Yu, MD
Peking Union Medical College Hospital, Beijing, China
BACKGROUND CONTEXT: Percutaneous transforaminal endoscopic lumbar discectomy (PTELD)become more and more popular in recent years, since it was considered very difficult to get through the learning curve phase, but how to decrease the complication rate in this particular time was seldom discussed in the literature. So we want to report the complications in the learning curve phase of PTELD for a surgeon who had not been previously exposed to this procedure with the first 100 cases experience and systemic review of literature.PURPOSE: To summarize the strategy for decreasing the complication rate based on personal experience and review of literature.STUDY DESIGN/SETTING: We use search strategies developed for a Cochrane systemic review in PubMed database for complications in learning curve phase in PELD. We retrospectively reviewed the author’s first 100 cases data to summarize the personal experience. Then we conclude the strategy for prevention of the complication in the learning curve phase for PTELD.PATIENT SAMPLE: The author’s (Dr. Keyi Yu) first 100 PTELD cases for lumbar disc herniation(LDH) were retrospectively reviewed from March of 2014 to June of 2016, the clinical results and complications in the learning curve phase was summarized. OUTCOME MEASURES: We use the VAS, Oswestry Disability Index (ODI) and modified MacNab criteria to evaluate the clinical result. The complications of the author’s first 100 cases were collected and analyzed.
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PROCEEDINGS
METHODS: We use search strategies developed for a Cochrane systemic review in PubMed database for complications in learning curve phase in PTELD. We include and exclude literature by the defined criteria, the characteristic of complications in learning curve phase in PTELD was summarized. The author’s (Dr. Keyi Yu) first 100 PTELD cases for lumbar disc herniation(LDH) were retrospectively reviewed from March of 2014 to June of 2016, the clinical results and complications in the learning curve phase was summarized. RESULTS: The average age of the patients was 37 years old (13-71years old). The mean reported scores on the VAS and Oswestry Disability Index (ODI) were 6.0 ±3.0 and 56.5 ±21.1 before surgery respectively, the final scores on the VAS and ODI were significantly reduced to 1.4 ±1.1 and 22.4 ±8.1 at final follow-up respectively (p < 0.05). The mean follow-up was 20.5 months (range 3 months - 2 years). Open conversion to microdiscectomy was required in two patients with suspected root irritation in one patient and excessive bleeding in another patient during the first 20 cases. Overall 93% of patients had good-to-excellent results using modified MacNab criteria, with two patients having recurrence of whom one was reoperated. The re-herniation rate was 2% and re-operation rate was 1%. Two patients had postoperative dysesthesia may due to exiting nerve injury which recovered in 3 months. Through the systemic review of the literature, we found the major complication of PTELD in the learning curve phase include conversion to open discectomy or microdiscectomy, inadequate decompression of lumbar disc, re-herniation of disc and re-operation, other complications include exiting nerve injury, pain shock et al. Good training for surgeon may decrease the complication rate of TPELD in the learning curve phase, which include cadaver operation training, observing surgery, demonstrating teaching.CONCLUSIONS: The major complications of PTELD in learning curve phase include conversion to open surgery, inadequate decompression of lumbar disc, re-herniation of disc and re-operation. Good training may help to decrease the complication rate in the learning curve phase for PTELD, especially for re-operation rate.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P21. Lumbar Disc Endoscopic Surgery Through the Transforaminal Approach
Arman Hakobyan, MD, PhD
NAIRI Medical Center, Yerevan, Armenia
BACKGROUND CONTEXT: The rapid increase of minimal invasive surgeries of intervertebral hernia was observed in the last two decades. Some authors think that endoscopic surgery has strict limits. Other authors have suggested the endoscopic surgery for any kind of intervertebral hernias of lumbar spine despite its size and location [1-3]. We think that endoscopic transforaminal disc hernia extraction can be applied in any cases, when the patient has intervertebral disc hernia on lumbar spine. This method is as effective as open microdiscectomy. METHODS: The method of endoscopic hernia surgery through transforaminal approach was performed in 520 cases during the last 5 years in our clinic. Operations were performed under general anesthesia. RESULTS: The general criteria for assessing the outcomes were pain syndrome. In 489 (94%) cases the results were excellent or good. In 7 (1,3%) cases the results were enough. In 5 (1%) cases the results were bad because of inflammatory complications. These patients took long time antibacterial treatment. In 19 (3,7%) cases the patients came back with reherniation. Those patients were re-operated and the result of the second surgery was good.
CONCLUSIONS: Based on our studies we can sure that the possibilities of endoscopic transforaminal method are the same as open surgery (microdiscectomy). The adequate surgical approach is the general step for good outcomes. In our practice difficulties were seen in five conditions. In case of three patients the disc space was very narrow than the diameter of forceps. And in the other two cases are typical for surgery on level L5-S1 in patients with high located cresta ilica. In those cases, there is no possibility to do adequate discectomy. The surgical opportunity of the endoscopic transforaminal method is enough effective than open surgery. The results after 6-9 months in patients group, whom endoscopic or open surgery was performed, were the same. The use of endoscopic method allows us reducing time of hospitalization up to 1 day. The most important point of endoscopic surgery is correct surgical approach. It is very difficult to correct it if it is performed incorrect. The adequate discectomy helps us reduce the percent of disc reherniation. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P22. Surgical Treatment of Cervical and Lumbar Parts of Spine with Percutaneous Plasma Nucleoplasty
Sh.Sh. Shatursunov¹, S.M. Saliev¹, Kh.S. Rajabov²
¹Research Institute of Traumatology and Orthopedics, MoH of Uzbekistan, Uzbekistan; ²JSC Medical Center, “Profmedservice” Tashkent, Uzbekistan
PURPOSE: Improvement of specialized medical service to patients with degenerative diseases of spine by mini invasive high-tech treatment methods. METHODS: Cold plasma nucleoplasty was performed in 35 patients at the age of 18 to 62 years with different localization of disc herniation. Coblation in the lumbar spine was made in patients, in the cervical spine – in 10 patients. All patients before surgery received conservative treatment which did not give any effect. Preoperative examination included clinical, radiological, and MRI studies. Procedure was performed under C arm x ray control.RESULTS: MRI study was performed in all patients at 1 to 12months after nucleoplasty. It is revealed a reduction of herniation by 1.2mm–3.3 mm in 30 patients. Five patients did not present herniation reduction but a change to drop-shaped form accounted for a decrease in intradisc pressure. CONCLUSION: Conducted mini invasive nucleoplasty patients with degeneration of cervical and lumbar part of spine brings to decreasing of pain syndrome, reducing of volume of disc and dropping of intradisc pressure.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
P23. Surgical Treatment of Aggressive Hemangiomas of the Spine with Percutaneous Vertebroplasty
¹Research Institute of Traumatology and Orthopedics, MoH of Uzbekistan, Uzbekistan; ²National Rehabilitation and Prosthetics Center of Disabled Patients of the MoH of Uzbekistan, Uzbekistan
BACKGROUND CONTEXT: Spine hemangiomas occur in population with frequency of 10-11%, mean age of the disease manifestation is 30-45 years, over 2/3 of these patients are women. The thoracal part of the spine is most frequently involved (70-75 %). Associated
44
PROCEEDINGS
involvement of posterior elements is marked in 10-15 % of cases, tumor distribution in paravertebral and epidural spaces is found in 3-4 % of cases, and intervertebral disc lesion is uncommon.PURPOSE: improvement of surgical treatment of patients with aggressive hemangiomas of the spine.PATIENT SAMPLE/METHODS: Vertebroplasty procedure consisted in transpedicular injection of bone cement under fluoroscopy guidance. «Simplex» bone cement of «Stryker» company was used mainly, a volume of injected cement ranged from 3 to 8 ml. Between 2015 and 2016 78 vertebroplasties have been performed in patients with vertebral body hemangiomas of thoracolumbar spine. The patients’ age varied from 28 to 61, mean age was 48,2 years, female were 45 and male were 33. In 66 patients vertebroplasty was performed on one level, in 12 patients on two levels. 52 (66,7%) hemangiomas were localized in thoracal spine, 26 (33,3%) - in lumbar spine. Preoperative examination included an estimation of the general condition of patients, orthopedic, neurologic status, X-ray methods of diagnostics: spine plain X-ray films, MRI, CT, in some cases a densitometry was carried out. RESULTS: Intensity of a pain syndrome and an estimation of a functional condition of patients were evaluated by Watkins scale, Visual Analogue Score (VAS) and by Oswestry inability index. In all the patients, in the following 24-72 h, a successful outcome has been observed with a complete resolution of pain symptom. Cement leakage has been observed in 5 patients, without any onset of clinical radicular syndrome due to epidural diffusion. Clinical and radiological follow-up until 3 years has been performed in 54 patients and it showed stability of the treatment and absence of pain. CONCLUSIONS: Percutaneous treatment with vertebroplasty for aggressive hemangiomas is a valuable, mini-invasive, and quick method that allows a complete and enduring resolution of the painful vertebral symptoms without findings of fracture of a vertebral body adjacent to the one treated.FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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FINANCIAL CONFLICT OF INTEREST DISCLOSURE POLICYNASS recognizes that professional relationships with industry are essential for development of new spine technologies and medical advancement. According to the Committee on Ethics and Professionalism, which authored the disclosure policy, “the goal is to create an environment of scientific validity, in which learners can accurately judge whether the information they receive is objective and unbiased, and to be sure that our members are current and forthright in their dealings with one another and with their colleagues and patients.” The establishment of uniform disclosure requirements frees individuals from having to decide which relationships might influence his or her decision-making and which are irrelevant; transparent disclosure allows the audience to participate in the interpretation of the significance. All authors and faculty speaking at the Annual Meeting have been required to provide complete disclosure of all potential conflicts of interest.
COMMERCIAL SUPPORT DISCLOSUREAs a sponsor accredited by the ACCME, the North American Spine Society must ensure balance, independence, objectivity and scientific rigor in all its sponsored activities. All individuals participating in a NASS-sponsored CME activity are expected to disclose to the audience all financial interests or other relationships with any commercial interest that occurred within the past 12 months. Financial interests or other relationships may include: grants or research support, employee, consultant, major stockholder, member of the speaker’s bureau, etc. Disclosure information will be made available visually on a PowerPoint® slide before each presentation and in this Final Program. It should also be noted that audience members who volunteer questions or statements during symposia, focused discussions, or other educational events should disclose their own conflicts to the assembled group before proceeding with their comments.
PROGRAM COMMITTEE STATEMENT ON RESOLUTION OF CONFLICT OF INTEREST IN PRESENTATIONSThe intent of this disclosure is to ensure that all conflicts of interest, if any, have been identified and have been resolved prior to the speaker’s presentation. By doing so, the North American Spine Society has determined that the speaker’s or author’s interests or relationships have not influenced the presentation with regard to exposition or conclusion; nor does the Society view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the presentation.
FDA DISCLOSUREIf a device or drug requiring FDA approval is identified as an important component of a presentation, the author must indicate the FDA status of those devices or drugs as Approved, Investigational or Not Approved for distribution within the United States. The Final Program will include all FDA status information. Certain medical devices and drugs identified at the 35th ISMISS Annual Meeting may have FDA clearance for use for specific purposes only, or in restricted research settings. The FDA has stated it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use in clinical practice and to use these products in compliance with applicable law.
These disclosures are current as of November 8, 2016.
Range KeyLevel A. $100 to $1000Level B. $1,001 to $10,000Level C. $10,001 to $25,000Level D. $25,001 to $50,000Level E. $50,001 to $100,000Level F. $100,001 to $500,000Level G. $500,001 to $1MLevel H. $1,000,001 to $2.5MLevel I. Greater than $2.5M
DISCLOSURE INDEX
46
Ammerman, Joshua M.: Consulting: Medtronic (Amount not disclosed); Speaking and/or teaching arrangements: Benvenue (Amount not disclosed); Scientific Advisory Board: Benvenue (Amount not disclosed).
Beall, Douglas P.: Device or Biologic Distributorship (Physician-Owned Distributorship): Medtronic (E), Alphatec Spine (A), Synthes (B), Eli Lilly (D), Amendia (A), Benvenue (C); Stock Ownership: Spineology (20000 shares), Vexim (<1%), Amendia (2000 shares); Consulting: Medtronic (E), Eli Lilly (D), Vexim (C); Speaking and/or teaching arrangements: Medtronic (E), Eli Lilly (D); Trips/travel: Medtronic (B), Vexim (B), Benvenue (B); Board of Directors: Vexim (C); Research Support (Investigator Salary): Alphatec Spine (D); Research Support (Staff and/or Materials): Benvenue (B).
Coe, Jeffrey D.: Stock Ownership: Phygen, LLC (<1%), Implantium, LLC (3%), Alphatec (<1%); Consulting: NuVasive (None), SI Bone (None), Benvenue Medical (C); Speaking and/or teaching arrangements: NuVasive (C), Providence Medical (B); Board of Directors: California Orthopaedic Association (A); Research Support (Staff and/or Materials): Medtronic Sofamor Danek (B), SI Bone (B).
Fessler, Richard G.: Royalties: Stryker (B), DePuy (B), Medtronic (B); Private Investments: In Queue Innovations (50%); Consulting: DePuy (None).
Foley, Kevin T.: Royalties: ArthroCare (B), Medtronic (I); Stock Ownership: Medtronic (38000 Shares), NuVasive (30000 Shares); Private Investments: Discgenics (13%), SpineWave (753000 Shares), TrueVision (5%), BioD (Amount not disclosed); Consulting: Medtronic (D), NuVasive (A); Board of Directors: MERI (None), Discgenics (None), BioD (None), TrueVision (None).
Gelb, Daniel E.: Royalties: Globus Medical (A), Depuy Synthes Spine (C); Consulting: Synthes Spine (B); Speaking and/or teaching arrangements: AO Spine North America (B); Fellowship Support: Synthes Spine (E).
Goodman, Bradly S.: Stock Ownership: Mesoblast (<1%), Discgenics (<1%); Consulting: Discgenics (Amount not disclosed); Other Office: Mesoblast (Amount not disclosed, Paid directly to institution/employer), ISTO (Amount not disclosed, Paid directly to institution/employer).
Hedman, Tom: Stock Ownership: Orthopeutics, L.P. (35%), Intralink Spine, Inc. (17%); Board of Directors: Intralink Spine, Inc. (Chairman/CSO, E); Scientific Advisory Board: LMH Biotech (None); Other Office: Orthopeutics, L.P. (General Partner); Relationships Outside the One Year Requirement: University of Southern California (Royalties, None), NIH (Grant, H).
Kucharzyk, Donald: Royalties: Precision Spine (C); Consulting: Benvenue Medical (Amount not disclosed), Biomet Zimmer (Amount not disclosed), Precision Spine (Amount not disclosed); Speaking and/or teaching arrangements: Precision Spine (Amount not disclosed), Benvenue Medical (Amount not disclosed), Biomet Zimmer (Amount not disclosed); Trips/travel: Precision Spine (Amount not disclosed), Biomet Zimmer (Amount not disclosed), Benvenue Medical (Amount not disclosed); Scientific Advisory Board: Precision Spine (B); Research Support (Investigator Salary): Benvenue Medical (A).
Kunwar, Sandeep: Royalties: Nuvasive (C); Stock Ownership: Benvenue (None); Consulting: Benvenue (Amount not disclosed), Biomet (Amount not disclosed); Speaking and/or teaching arrangements: Biomet (Amount not disclosed); Other Office: Benvenue (Medical Director).
Ludwig, Steven C.: Royalties: Depuy Synthes Spine (G); Stock Ownership: ISD (4%), In-Sight Medical (18%); Private Investments: Advanced Spinal Intellectual Properties (29%); Consulting: DePuy Spine (D); Speaking and/or teaching arrangements: AO Spine (B); Board of Directors: Advanced Spinal Intellectual Properties, LLC (D); Scientific Advisory Board: Globus Medical (B); Fellowship Support: OREF Grant (E, Paid directly to institution/employer).
Osorio, Enrique: Consulting: St. Jude Medical (Travel expenses).O’Toole, John E.: Royalties: Globus Medical (A), Pioneer Surgical (D);
Park, Paul: Royalties: Globus Medical (B); Consulting: Globus Medical (B), Vertex (B), Medtronic (C), Biomet (C); Speaking and/or Teaching Arrangements: Globus Medical (C); Scientific Advisory Board: Neuralstem (A); Research Support - Investigator Salary: Blue Cross Blue Shield Foundation (A, Paid directly to institution/employer); Grants: Blue Cross Blue Shield (E, Paid directly to institution/employer), StemCells (C, Paid directly to institution/employer).
Perez-Cruet, Mick J.: Royalties: Thompson MIS (A); Stock Ownership: MI4Spine LLC (60%, President and CEO), Thompson MIS LLC (6%); Private Investments: MI4Spine LLC (60%, President and CEO), Spineology (40000 Shares); Consulting: Aesculap (C), Zimmer (None), Aesculap (None); Speaking and/or Teaching Arrangements: Stryker Spine (B), Zimmer Spine (B); Trips/Travel: Aesculap (A); Board of Directors: MI4Spine LLC (President and CEO); Scientific Advisory Board: US Spine (Medical Advisory Board).
Pimenta, Luiz: Royalties: NuVasive (G); Consulting: NuVasive (Amount not disclosed), Zyga Tech (Consulting disclosed), MDT (Biotec) (Amount not disclosed); Board of Directors: ISASS (None); Scientific Advisory Board: LASAS (Scientific reviewer).
Yeung, Anthony T.: Royalties: Richard Wolf (D), Elliquence (D), Elliquence (None); Stock Ownership: Paradigm Spine (<1%, Paid directly to institution/employer), Bonovo Orthopedics (<1%), Core Spine (<1%), Mobius (<1%), Nocimed (<1%), Ouroboros (<1%), Replication Medical (<1%), Small Bone Innovations (<1%), Stimwave (<1%), Surgitech (<1%), Vivex Biomedical (<1%); Private Investments: Ouroborous, Surgitech (20%); Consulting: Richard Wolf, Elliquence (Amount not disclosed, Paid directly to institution/employer), Aleeva Medical (Amount not disclosed), Elliquence (Amount not disclosed), Stimwave, Inc. (Amount not disclosed); Other: Arizona Recovery Care Center (Amount not disclosed), Squaw Peak Surgical Facility (Co-owner).
Yu, Elizabeth: Trips/travel: DePuy Synthes (Amount not disclosed); Grants: Nuvasive (B, Paid directly to institution/employer).
The following participants have Nothing to Disclose:
Amburgy, John W.Banagan, Kelley E. Brown, Luke Cavanaugh, Daniel L. Cerier, EmilyChambers, Melissa Choi, Gun Choi, Pil Sun Dahdaleh, Nader S.De la Garza Ramos, Rafael Doers, Thomas M. Du, JianweiFan, Guoxin Fontanella, Andrea Gastambide, Daniel Haitao, tan Hakobyan, ArmanHaranhalli, Neil He, Shisheng Hellinger, StefanHsu, Shaokeh Ito, Fujio Jada, Ajit Jain, Nikhil Jung, TagGeun Kabilov, A.O.Karakulov, K.H.Kinon, Merritt Kong, Qingquan Lee, Jun Seok Lee, Su Hun Leu, Hansjörg Li, Yawei Litsky, AlanLiu, John C.Malik, Atif B. McMains, Craig Musaev, R.S.Nakhla, Jonathan P. Nasser, Rani Oertel, Joachim Ogden, Alfred T.Pao, Jwo-Luen Radchenko, Volodymyr Rajabov, Kh.S.Rong, Limin Saliev, S.M.Sandon, Luiz H. Shatursunov, Sh.Sh.Shengbin, Huang Sherlekar, Sandeep Singh, Harwant Singh, MaharajSmith, Zachary A.Son, Dong Wuk Song, Geun S. Soriano-Sanchez, Jose A.Thorpe, John Tredway, Trent Walia, Sarika Weir, Tristan B. Wu, Junlong Wu, Wenjian
DISCLOSURE INDEX
Yang, Yang Ying, Li Yu, Keyi Yu, Liang Yu, Pei Zhang, Chao Zhang, Chunlin Zhang, Wei Zhang, Xingkai Zhou, Yue Zhu, Bo
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Back Pain Centers of Americawww.backpaincentersofamerica.com
Back Pain Centers of America (BPC) is the nation’s largest network connecting patients seeking surgical consultations for neck and back pain to highly qualified, specialty orthopedic centers. To date, BPC has helped more than 20,000 people find relief. Because patient experience and safety are top priority, BPC only accepts board-certified physicians who meet certain criteria such as having available surgical capacity. BPC is currently taking new applications from orthopedic practices in specific states and cities.
Eclipse Loupes and Productswww.eclipseloupesandproducts.com
Eclipse Loupes and products offers the highest quality, low cost loupe and light options for all surgical needs. All of our products come backed with an industry leading lifetime warranty.
elliquence, LLCwww.elliquence.com
elliquence, LLC manufactures patented Radiowave technology with innovative devices for orthopedic, neurosurgery, and pain management applications. Surgi-Max® Plus allows precision tissue preservation, non-adherent bipolar effects and surgical versatility. Cobbra™ Energized Cobb Elevator, and Disc-FX™ Discectomy System are examples of the surgical accessories offered for use with the Surgi-Max Plus energy source. elliquence focuses on sparing healthy tissue while precisely treating pathology.
Hoogland Spine Products GmbHwww.max-more.com
The Hoogland Spine Products GmbH is built upon over 35 years of experience in the field of arthroscopy, endoscopy, spine surgery and instrument engineering. The Company has a strong management team who play a vital role in the operation, business and product development as well as customer support. Our global exclusive distribution network shares in our passion and commitment to build the maxmorespine® brand, support our customers and facilitate better patient outcomes.
At Hoogland Spine Products GmbH we produce endoscopic instrumentation which enables doctors to treat lumbar spine conditions with utmost safety, precision and effectiveness. The company is committed to partnering with researchers and educators to advance the science, knowledge and performance of endoscopic spine surgery.
joimax, Inc.www.joimaxusa.com
joimax® is the leading developer and provider of complete systems for minimally invasive spine surgery. Our proven endoscopic methods allow surgeons to operate on herniated discs, spinal stenosis and other pathologies with minimal anatomical and surgical trauma, through a single 8 mm incision, under local anesthetic and on an outpatient basis. The newest EndoLIF® and Percusys® systems give the surgeon the added option of an endoscopically-assisted, minimally invasive fusion.
KARL STORZ Endoscopy America Inc.www.ksea.com
KARL STORZ Endoscopy-America, Inc., an established leader in diagnostic and operative endoscopy technologies, markets a comprehensive range of state-of-the-art products for minimally invasive spine surgery. Among our latest solutions is the SpineTIP System, a pure endoscopic system for lumbar discectomy, which combines the flexibility of three surgical approaches: transforaminal, interlaminar and posterolateral. And, our VITOM® 3D SPINE System provides exceptional depth of field, magnification, contrast and color reproduction for FULL HD image display and recording.
Misonix, Inc.www.misonix.inc
Misonix is a world leader in developing ultrasonic surgical devices for hard and soft tissue removal. The Misonix BoneScalpel is a unique ultrasonic osteotome for tissue-selective bone dissection that encourages en-bloc bone removal and refined osteotomies while sparing elastic soft tissue structures. Many leading surgeons have praised the BoneScalpel to be one of the most important advancements to enter spine surgery this decade.
Richard Wolf Medical Instruments Corp.www.richardwolfusa.com
Richard Wolf is the leader in Spine Endoscopy, working with world-renowned surgeons to pioneer a broad range of endoscopic applications including transforaminal and interlaminar discectomy, foraminoplasty, anterior and posterior cervical decompression, dorsal ramus rhizotomy, central canal decompression, and endoscopically assisted interbody fusion surgery. Customized endoscopic sets have been developed for each application and feature high definition working-channel spine endoscopes and innovative specialized instruments such as the TipControl Articulating Burr which allows for bone resection in difficult-to-reach areas, and the TipControl Articulating Nucleus Resector which permits the rapid and efficient removal of nucleus tissue.
TECHNICAL EXHIBITION
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2017 ISMISS BOARD OF DIRECTORS
R. Fessler, MDPresident 2017-2020
Y. Zhou, MDPresident-Elect
J. Oertel, MDVice President 2017-2020
V. Radchenko, MDPast President 2017-2020
J. Chiu, MDSecretary/Treasurer: American Branch
H. Leu, MDSecretary/Treasurer: European Branch
M. Yoshida, MDSecretary/Treasurer: Asian Branch
C. Rezoagli, MDNational Representative: Argentina
A. Hakobyan, MDNational Representative: Armenia
G. Speck, MDNational Representative: Australia
S. Hsu, MDNational Representative: China/ROC
Y. Zhou, MDNational Representative: China/PRC
D. Gastambide, MDNational Representative: France
C. Birkenmaier, MDNational Representative: Germany
A. Erbszt, MDNational Representative: Hungary
B. Darwono, MDNational Representative: Indonesia
A. Fontanella, MDNational Representative: Italy
A. Dezawa, MDNational Representative: Japan
C. Chung, MDNational Representative: Korea
L. Antolak, MDNational Representative: Poland
P. Pereira, MDNational Representative: Portugal
L. Sak, MDNational Representative: Russia
R. Morgenstern, MDNational Representative: Spain
M. Rühli, MDNational Representative: Switzerland
E. Yalniz, MDNational Representative: Turkey
Y. Pedachenko, MDNational Representative: Ukraine
A. Mesiwala, MDNational Representative: United States of America
S. Shatursunov, MDNational Representative: Uzbekistan
M. Hinsenkamp MDSICOT Representative
F. Jacquot, MDWCMISST Representative
E. MuehlbauerNASS Representative
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F. Todd Wetzel, MDPresident
Daniel K. Resnick, MD, MS1st Vice President
Jeffrey C. Wang, MD2nd Vice President
Christopher M. Bono, MDPast President
William J. Sullivan, MDSecretary
Eeric Truumees, MDTreasurer
David Rothman, PhDEthicist
Edward J. Dohring, MDEducation Council Director
John G. Finkenberg, MDAdvocacy Council Director
Zoher Ghogawala, MD, FACSResearch Council Director
David R. O’Brien Jr., MDHealth Policy Council Director
Charles A. Reitman, MDAdministration and Development Council Director
Joseph S. Cheng, MD, MSSection Development Chair
Charles Cho, MDEvidence Compilation and Analysis Chair
MDs and DOs (or international equivalent): Are you board certified? q Yes q No Name of Board providing your certification (required if applying for Active or Associate membership):
Percentage of professional activities dedicated to spine: q Less than 50% q 50% or Greater
My professional activities are primarily (choose one): q Clinical q Academic/Teaching q Research q Business
Have you ever had a license to practice medicine revoked or suspended in any jurisdiction, past or present? q No q Yes (If yes, please attach an explanation)
Have you ever been censured/sanctioned by another professional medical association or organization? q No q Yes (If yes, please attach an explanation of the circumstances and specify the sanction enforced)
Application RequirementsCurriculum Vitae/RésuméPlease submit a copy of your most recent curriculum vitae (CV) or résumé with this application. Your membership will remain inactive until a copy of this document is received.
Please provide your primary reason for applying for membership.q Recommendation from colleague (optional, provide colleague name: )q Career development, CME, or to receive updates on spine care issuesq To take advantage of membership discounts on educational offeringsq To access journals and publicationsq To network with colleaguesq To support and contribute to the fieldq Other:
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2017APPLICATION FOR MEMBERSHIP
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In-Training Membership Applicants Onlyq Resident q Fellow q Medical School q Other Training Program Name Date of Completion (mm/dd/yy):
Program Director Printed Name:
Program Director Signature: (or attach a letter from your program director verifying your in-training status)
Method of PaymentApplication Fee (waived for In-Training Membership applicants): $50.00
Membership Dues (from above; for the most current dues amounts, visit www.spine.org):
Total Enclosed:
q Check or money order (made payable to the North American Spine Society; in U.S. dollars)
Credit Card: q VISA q MasterCard q American Express
Card #: Expiration Date (mm/yy):
Cardholder’s Name: Signature:
Go Green! q Opt out of receiving printed copies of SpineLine q Eliminate future dues billing by signing up for automatic renewal using the credit card above.
Category of MembershipPlease choose a membership category (for a full listing of benefits, visit www.spine.org). Upon receipt of all application requirements, the Membership Committee will review all material to ensure that applicants are placed into the appropriate membership category. Membership is on a calendar-year basis (January 1 through December 31) and dues are prorated quarterly.
q Active Membership: Board-certified MDs and DOs, or PhDs (or international equivalent) who devote at least 50% of their professional activities to spine. Dues: $625*
q Associate Membership: Board-eligible MDs and DOs, or individuals who have completed a substantially equivalent program who devote at least 50% of their professional activities to spine. Dues: $625*
q In-Training Membership: Physicians, medical students, graduate students or other individuals of the medical profession, basic sciences or allied services who are enrolled in a full-time, accredited training program or postdoctoral fellowship related to spine care. Individuals who have been awarded a terminal degree and are returning for additional education unrelated to spine care are not eligible for this membership category. Dues: Complimentary*
q Affiliate Membership: Physicians and PhDs who devote less than 50% of their professional activities to spine, nurse practitioners, registered nurses, physician assistants, chiropractors, physical therapists, researchers, practice managers, coders, technical professionals or other health care professionals with an interest in spine. Dues: $325*
q International Membership: Health care professionals not residing in the United States with an interest in spine. Dues: $275* (Discounted dues of $95 are available to individuals residing in countries whose economies are classified by the World Bank as low-income or lower-middle-income.)
*The above prices represent full 2017 membership dues (from October 1, 2016 through March 31, 2017); dues are prorated on a quarterly basis. If you are applying for membership outside of these dates, visit the NASS website at www.spine.org for the most current membership dues information or to apply online. 7.75% of total dues is allocated to lobbying and is not deductible for income tax purposes.
North American Spine Society7075 Veterans Blvd. | Burr Ridge, IL 60527
Application Check ListHave you...q Attached a copy of your CV or résumé?q Remitted payment (if applicable)?
The NASS Professional Compliance Panel (PCP) exists to ensure member compliance with the NASS ethics policies as well as any other rules or regulations incumbent upon a healthcare professional. By submitting this form, you acknowledge that you are required to comply with such policies, rules and regulations, and further agree to promptly comply with all requests to provide documentation concerning PCP investigations, when it is within your legal ability to do so.
