Introduction: Epidural steroid injection is commonly used for treatment of sciatica. Traditionally these have been administered through a needle inserted in the posterior mid line via an interlaminar (IL) route. However, in recent years the transforaminal (TF) route of administration has become popular. Potential advantages of the TF route include greater accuracy of injection (with radiological confirmation) and placement of the needle tip closer to the point at which the nerve is compressed. Methods: Consecutive patients from the practices of 2 surgeons that use an IL technique were compared with those from the practices of 2 other surgeons that use a TF technique. Inclusion criteria were leg pain accompanied by a radiological diagnosis of nerve root compression. Both patients with disc prolapse and spinal stenosis were included. Treatment outcome was measured using the Roland-Morris (RM) Score, the Sciatica Frequency and Bothersome Index (SFBI) and the Euroqol (EQ-5D) questionnaire obtained at recruitment and three months after the epidural steroid injection. A global assessment (GA) of outcome; where patients were asked whether they were. much better,. better,. un changed or. worse after treatment; was obtained at 3 months. Patients were also asked the duration of any relief obtained. Statistical methods utilized included the two tailed t-test, the Wilcoxon Rank Sum test, Odds ratio (OR) and the Chi Squared Test. Results: 39 patients received an interlaminar epidural steroid injection and 25 received a transforaminal epidural steroid injection (total 64 patients). Follow-up was achieved for 36/39 (92.3%) and 25 (100%) patients respectively. The median pre-test RM score was 11 (range 3–11) for both groups. Post test RM score was 12(6–16) for the IL group and 3 (6–10.5) for the TF group (p=0.01). Median pre-test SFBI was 25 (0–46) and 26 (4–46) for the IL and TF groups respectively. Post test SFBI was 22 (0–46) and 18 (0–41) for the IL and TF groups respectively (p=0.003). Median pre- test EQ-5D was 0.54 for both groups (range 0.06–0.72 for the IL group and 0.08–0.72 for the TF group). Post test EQ-5D was 0.55 (0.06–1) for the IL group and 0.66 (0.06–1) (p=0.21). According to their GA, 11.1% felt much better, 33.3% felt better and 55.6% felt unchanged at 3 months in the IL group. 64% felt much better, 34% better and 12% felt unchanged in the transforaminal group. The proportion of patients having relief for 3 months or more after the injections was 3/36 (8.3%) for the IL group and 10/25 (40%) for the TF group. The transforaminal injection was 7 times more likely to result in pain relief at 3 months. (OR 7.3 95% CI 1.5 – 45.8, p=0.003). Discussion: Epidural steroid injection by the transforaminal route is more effective then by the interlaminar route in the short term relief of sciatica

Introduction. In daily clinical practice, progression of spinal fusion is typically monitored during clinical follow-up using conventional radiography and Computed Tomography scans. However, recent research has demonstrated the potential of implant load monitoring to assess posterolateral spinal fusion in an in-vivo sheep model. The question arises to whether such a strain sensing system could be used to monitor bone fusion following lumbar interbody fusion surgery, where the intervertebral space is supported by a cage. Therefore, the aim of this study was to test human cadaveric lumbar spines in two states: after a transforaminal lumbar interbody fusion (TLIF) procedure combined with a pedicle-screw-rod-construct (PSR) and subsequently after simulating bone fusion. The study hypothesized that the load on the posterior instrumentation decreases as the segment stiffens due to simulated fusion. Method. A TLIF procedure with PSR was performed on eight human cadaveric spines at level L4-L5. Strain sensors were attached bilaterally to the rods to derive implant load changes during unconstrained flexion-extension (FE), lateral bending (LB) and axial rotation (AR) loads up to ±7.5Nm. The specimens were retested after simulating bone fusion between vertebrae L4-L5. In addition, the range of motion (ROM) was measured during each loading mode. Result. The ROM decreased in the simulated bone fusion state in all loading directions (p≤0.002). In both states, the measured strain on the posterior instrumentation was highest during LB motion. Furthermore, the sensors detected a significant decrease in the load induced rod strain (p≤0.002) between TLIF+PSR and simulated bone fusion state in LB. Conclusion. Implant load measured via rod strain sensors can be used to monitor the progression of fusion after a TLIF procedure when measured during LB of the lumbar spine. However, further research is needed to investigate the influence of daily loading scenarios expected in-vivo on the overall change in implant load

Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons. Pseudarthrosis, cage migration, subsidence or infection can occur, with subsequent failed surgery, persistent pain and patient’ bad quality of life. The goal of revision fusion surgery is to correct any previous technical errors avoiding surgical complications. The most safe and effective way is to choose a naive approach to the disc. Therefore, the anterior approach represents a suitable technique as a salvage operation. The aim of this study is to underline the technical advantages of the anterior retroperitoneal approach as a salvage procedure in failed PLIF/TLIF analyzing a series of 32 consecutive patients. Materials and Methods. We performed a retrospective analysis of patients’ data in patients who underwent ALIF as a salvage procedure after failed PLIF/TLIF between April 2014 to December 2019. We recorded all peri-operative data. In all patients the index level was exposed with a minimally invasive anterior retroperitoneal approach. Results. Thirty-two patients (average age: 46.4 years, median age 46.5, ranging from 21 to 74 years hold- 16 male and 16 female) underwent salvage ALIF procedure after failed PLIF/TLIF were included in the study. A minimally invasive anterior retroperitoneal approach to the lumbar spine was performed in all patients. In 6 cases (18.7%) (2 infection and 4 pseudarthrosis after stand-alone IF) only anterior revision surgery was performed. A posterior approach was necessary in 26 cases (81.3%). In most of cases (26/32, 81%) the posterior instrumentation was overpowered by the anterior cage without a previous revision. Three (9%) intraoperative minor complications after anterior approach were recorded: 1 dural tear, 1 ALIF cage subsidence and 1 small peritoneal tear. None vascular injuries occurred. Most of patients (90.6%) experienced an improvement of their clinical condition and at the last follow-up no mechanical complication occurred. Conclusions. According to our results, we can suggest that a favourable clinical outcome can firstly depend from technical reasons an then from radiological results. The removal of the mobilized cage, the accurate endplate and disc space preparation and the cage implant eliminate the primary source of pain reducing significantly the axial pain, helping to realise an optimal bony surface for fusion and enhancing primary stability. The powerful disc distraction given by the anterior approach allows inserting large and lordotic cages improving the optimal segmental lordosis restoration

To compare outcomes and costs of transforaminal endoscopic surgical discectomy (TES) with those of microdiscectomy (Micro). 48 patients with a primary lumbar disc prolapse were randomly allocated by computer to surgery. Assessments were made of leg and back pain (VAS), Oswestry Disability index (ODI), and SF-36 as primary outcomes. Cost data was collated. 25 TES and 23 Micro patients are reported with similar age, sex, smoking status and affected disc levels (14 v.17 L5/S1). Three months following surgery leg pain scores had decreased by 55 and 65% in the two groups. Patient satisfaction ratings were equal. ODI had decreased 15 points in both groups by 1yr and this improvement was maintained to 2 years (final scores: 7±3 TES v.14±13 Micro - means ±SD; p<0.05). Similar changes were noted in SF36-P. Mean bed stay was lower in the TES group (16 v. 40 hours). Other post-operative costs were similar. There were no immediate complications. One revision was required at 12 months (TES) and one at 18 months (Micro). Two patients presented with a disc prolapse at a different level and side (both TES). Results at up to two years follow-up are similar following the two interventions. Recovery was more rapid in those patients undergoing endoscopic surgery

Transforaminal lumbar interbody fusion (TLIF) using an implanted cage is the gold standard surgical treatment for disc diseases such as disc collapse and spinal cord compression, when more conservative medical therapy fails. Titanium (Ti) alloys are widely used implant materials due to their superior biocompatibility and corrosion resistance. A new Ti-6Al-4V TLIF cage concept featuring an I-beam cross-section was recently proposed, with the intent to allow bone graft to be introduced secondary to cage implantation. In designing this cage, we desire a clear pathway for bone graft to be injected into the implant, and perfused into the surrounding intervertebral space as much as possible. Therefore, we have employed shape optimization to maximize this pathway, subject to maintaining stresses below the thresholds for fatigue or yielding. The TLIF I-beam cage (Fig. 1(a)) with an irregular shape was parametrically designed considering a lumbar lordotic angle of 10°, and an insertion angle of 45° through the left or right Kambin's triangles with respect to the sagittal plane. The overall cage dimensions of 30 mm in length, 11 mm in width and 13 mm in height were chosen based on the dimensions of other commercially available cages. The lengths (la, lp) and widths (wa, wp) of the anterior and posterior beams determine the sizes of the cage's middle and posterior windows for bone graft injection and perfusion, so they were considered as the design variables for shape optimization. Five dynamic tests (extension/flexion bending, lateral bending, torsion, compression and shear compression, as shown in Fig. 2(b)) for assessing long term cage durability (10. 7. cycles), as described in ASTM F2077, were simulated in ANSYS 15.0. The multiaxial stress state in the cage was converted to an equivalent uniaxial stress state using the Manson-Mcknight approach, in order to test the cage based on uniaxial fatigue testing data of Ti-6Al-4V. A fatigue factor (K) and a critical stress (σcr) was introduced by slightly modifying Goodman's equation and von Mises yield criterion, such that a cage design within the safety design region on a Haigh diagram (Fig. 2) must satisfy K ≤ 1 and σcr ≤ SY = 875 MPa (Ti-6Al-4V yield strength) simultaneously. After shape optimization, a final design with la = 2.30 mm, lp = 4.33 mm, wa = 1.20 mm, wp = 2.50 mm, was converged upon, which maximized the sizes of the cage's windows, as well as satisfying the fatigue and yield strength requirements. In terms of the strength of the optimal cage design, the fatigue factor (K) under dynamic torsion approaches 1 and the critical stress (σcr) under dynamic lateral bending approaches the yield strength (SY = 875 MPa), indicating that these two loading scenarios are the most dangerous (Table 1). Future work should further validate whether or not the resulting cage design has reached the true global optimum in the feasible design space. Experimental validation of the candidate TLIF I-beam cage design will be a future focus. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Purpose: Circumferential arthrodesis of the lumbar spine is necessary in certain selected situations (lumbar stenosis with instability and preserved disc height or spondylolisthesis). Posterior lumbar interbody fusion (PLIF) raises the risk of significant bleeding and fibrosis around the roots as well as neurological complications. Transforaminal lumbar interbody fusion (TLIF) can avoid excessive bleeding and root displacement. The cages are inserted via a unilateral approach. Material and methods: This prospective single-centre study included twenty patients (nine men and eleven women), mean age 49 years. Indications for lumbar surgery were degenerative spondylolisthesis in nine patients and discal lumbar pain with foraminal stenosis in five. The clinical status was assessed with the Oswestry score, SF-36 and a visual analogue scale (VAS). Radiological assessment was based on inter-body fusion, segmentary lordosis, and lumbopelvic parameters. TLIF was associated with a posterior approach for insertion of titanium pedicular screws (CDH, Medtronic Sofamor Danek). Temporary unilateral distraction opened the foramen. Unilateral arthrectomy enabled a lateral approach to the disc without involving the roots and avoiding any movement of the dural sac. The disc was resected and the body endplates were prepared before introducing two cages (pyramesh) filled with macroporous ceramic granules (BCP) mixed with autologous bone marrow. Installation to two contourned rods enabled segmentary compression to stabilise the cages in association with posterolateral fusion. Results: Mean operative time was three hours. Mean blood loss was 400 ml. The patients were verticalised on day three without a corset. Mean follow-up was six months with retrospective evaluation of the Oswestry score, SF-36, and VAS. Postoperative pain resolved rapidly. Two patients developed transient incomplete L5 deficit. Bony bridges around the cases and posterolaterally were identified on the six-month x-rays. Spine view confirmed the quality of the fusion and lumbopelvic parameters revealed restoration of segmentary lordosis. Conclusion: The unilateral approach for TLIF is a reliable technique which does not compromise the roots. It enables very reliable primary stability and recovery of local segmentary lordosis. We are developing a minimally invasive percutaneous technique for this procedure

The purpose of this study was to investigate the efficacy and fusion rates of a unilateral pedicle screw construct supplemented with a translaminar screw in transforaminal lumbar interbody fusion (TLIF). The construct was used with an aim of providing suitable spine stiffness with minimal implant load for spinal fusion. Nineteen consecutive patients who underwent single level TLIF were included in the study. All patients had posterior spinal instrumentation using a unilateral pedicle screw construct with a contralateral translaminar screw. Patients were assessed preoperatively and at two, six, twelve and twenty-four weeks following surgery and at the end of one and two years. At every visit Oswestry disability index score,Visual analogue scale for pain and a pain diagram were recorded. A radiographic exam was also conducted and CT scan was done if there was concern about fusion. The average follow up was twenty-four months. There were twelve males and seven females with an average age of forty-eight years. All patients went on to clinical and radiographic union. Sixteen of nineteen patients had significant clinical improvement on VAS for pain, Oswestry scores and pain medication. Three patients had recurrence of radicular pain on the side of the TLIF leading to reexploration. In all three patients solid fusion was observed but scar tissue was evident and symptoms resolved following redecompression of the foramen. The biomechanical competence of a construct is evidenced by successful fusion. With the advent of minimally invasive techniques to achieve spinal fusion the goal is to use minimal instrumentation without compromising on the final stiffness of the spine. The construct of unilateral pedicle screws supplemented with a trans-laminar screw led to fusion in all our cases. It requires lesser soft tissue dissection and the posterior implants are 56% cheaper

Study design. Prospective randomized study. Objective. Primary aim of this study was to compare clinical and radiological results of transforaminal lumbar interbody fusion (TLIF) with posterolateral (interlaminar) instrumented lumbar fusion (PLF) in adult low grade (Meyerding 1 & 2) spondylolisthesis patients. Background data. Theoretically, TLIF has better radiological result than PLF in spondylolisthesis in most of the studies. Method. 24 patients of low grade adult spondylolisthesis were randomly allocated to one of the two groups: group 1- PLF and group 2-TLIF. Study period was between August 2010 to March 2013. All patients were operated by a single surgeon (CN). Posterior decompression was performed in all patients. Average follow up period was 18.4 months. Quality of life was accessed with Visual analogue scale and Oswestry Low Back Pain Disability Index. Fusion was assessed radiologically by CT scan and X-ray. Result. Though fusion was significantly better in TLIF group, clinical outcome including relief of back pain and neurogenic claudication were better in PLF group. Rate of complication was also lower in PLF group. Conclusion. Considering the low complication rate and similar or better clinical results, posterolateral instrumented lumbar fusion is the better option in low grade adult spondylolisthesis

Purpose of the study: Revision surgery for scoliosis in adults is a technical challenge. Indications include flat back, non-union, and syndromes adjacent to the instrumentation The purpose of this work was to evaluate the pertinence of the transforaminal lumbar interbody fusion (TLIF) method for revision surgery for scoliosis in adults. Material and methods: In our spinal surgery unit, 23 patients underwent revision surgery for thoracolumbar and lumbar scoliosis. A unique posterior approach was used. The TLIF was performed systematically at the lumbosacral level, at the non-union when it was present, and at the level of the Smith-Petersen osteotomies, as well as the levels above and below a transpedicular osteotomy. Seventeen patients presented flat back, ten non-union, five degenerative disease distal to the instrumentation and one degeneration proximal to the instrumentation. Nine patients had several indications for surgical revision. Five transpedicular osteotomies were performed in five patients. Results: Mean follow-up was 30 months (range 18–48). On average 2.3 levels (range 1–4) were involved in the TLIF. The fusion was extended to the sacrum in 22 patients. The mean operative time was 5h50m (range 3–8 hours). Mean blood loss was 2100ml (400–4500). Postoperative lumbar lordosis (L1S1) was 53.5°, giving an improvement of 23° copared with the preoperative lordosis. Among the postoperative complications, there was one neurological complications which recovered partially at last follow-up one case of deep infection of the operative site which require partial removal of the implants and one case of recurrent non-union. There was no loss of correction in the frontal or sagittal planes with the exception of one patient who developed an infection. None of the patients in the series required complementary anterior surgery. Conclusion: For revision surgery of scoliosis in the adult, a circumferential arthrodeis is needed to maintain the fusion. The TLIF method has the advantage of allowing intersomatic fusion via the posterior approach alone without opening the spinal canal. We consider that the TLIF technique is an alternative to two-phase procedures for revision surgery for scoliosis in adults. This method has given a good percentage of fusion in our series with little loss of correction

Introduction Circumferential fusion is becoming increasingly popular and has been advocated by many authors to improve the fusion rates and clinical outcomes of the degenerative lumbosacral spine. Anterior lumbar interbody fusion (ALIF) with posterolateral fusion does provide direct access to the disc via a separate incision/ approach but has inherent neurovascular risks. Posterior lumbar interbody fusion (PLIF) with posterolateral fusion mandates bilateral exposure with significant retraction of neural elements with higher incidence of postoperative radiculitis. PLIF also reduces surface area for fusion and disrupts the posterior tension band. TLIF allows for a circumferential fusion through a single posterior incision with only slight retraction of the thecal sac and nerve roots, with much less morbidity and costs as compared to traditional PLIF and ALIF techniques. To our knowledge, there are no studies that report radiographic and clinical results of using recombinant human bone morphogenic protein (rhBMP-2) and allograft in a TLIF setting. The purpose of this study was to assess clinical & radiographic outcomes of patients treated with one or two level instrumented transforaminal lumbar interbody fusions (TLIF) performed with allograft and rh-BMP2 for treatment of symptomatic spondylolisthesis or degenerative disc disease. Methods During a consecutive 13 month period, 77 patients underwent TLIF procedures utilizing rhBMP-2 by one spine surgeon for lumbosacral degenerative and deformity conditions with simultaneous posterolateral fusions with allograft. Pedicle screw instrumentation (Monarch, DePuy Spine) provided distraction and a carbon-fiber curvilinear cage (Leopard, Depuy Spine) packed with rhBMP-2 (Large II Kit, total graft volume 8ml onto 77.4 sq. cm collagen sponge; Infuse: Medtronic Sofamor Danek) was placed into the disk space after hemifacetectomy and discectomy. The patients were followed at two weeks and three, six, 12 and 24 months after surgery patients were followed with several functional parameters such as the visual analog scale (VAS), SF-36 and Oswestry Disability Index (ODI) questionnaires. Fusion was assessed by static and dynamic radiographs at 6, 12, and 24 months as well as CT scans at 24 months. Results 71 patients were available for follow-up (92%) evaluation (mean 16 months; range 6–24 months). At 24 months, 85 percent and 81 percent of patients had improvement over preoperative ODI and SF-36 measures respectively. At 24 months, 70% of patients had good to excellent outcomes by both ODI and SF-36. We achieved 94% fusion rate with only four pseudarthroses. There was one wound infection treated with hardware removal and intravenous antibiotics. One patient had excessive bone growth into the foramen, necessitating surgical decompression with subsequent excellent clinical outcome. Ten patients had paresthesias on the side of the TLIF, all of which resolved by three weeks. There were no permanent neurologic deficits. Discussion The use of rhBMP-2 inside the cage, in combination with posterolateral allograft, can provide a high fusion rate and good clinical outcomes in a TLIF setting. The morbidity associated with iliac crest bone graft is avoided, with fusion rates approaching that of a true anterior/posterior circumferential fusion. Complications were few, with no significant neurologic sequelae from the placement of a structural graft into the anterior column through a posterior approach. Overgrowth of bone into the neural foramen, likely related to the residue of rhBMP-2 at the TLIF entry site, can occur. Care must be taken to place the TLIF cage device and the contained rhBMP-2 into the anterior half of the disk space to minimize the risk of this complication

Background and Aims. Transforaminal epidurals (TFEs) have been widely used as a treatment for lumbar radicular pain since its introduction by Krempen and Smith in 1974. 1. Originally used as a diagnostic tool, it is now becoming increasingly recognised as a definitive treatment. 2. This study investigates the use of TFEs by a single surgeon over 4 years. We hoped that the study would add to our understanding and the discussion of the actual benefit of therapeutic steroid and local anaesthetic injections by this route. 3. . Methods and Results. A total of 181 patients were identified. At injection 10mls 0.25% Marcaine and 40mg Depomedrone was injected under fluoroscopic guidance. Clinic notes and MRI reports for all patients were reviewed. Of the 176 patients included in the study, 127 showed a symptomatic improvement. Of these patients, 59 proceeded to surgical decompression. For 50 patients, TFE was the definitive treatment. 13 patients were offered but declined surgery. 5 patients were too frail to proceed to surgery. 49 patients showed no symptomatic improvement. Of this group, 34 were deemed unsuitable for surgical intervention. 15 patients did proceed to surgery. Conclusions and Discussion. These results are comparable to other similar case series. Vad et al. 3. demonstrated that 78% of patients studied were satisfied with the outcome of TFE. Riew et al. 2. showed that 53% of their study group avoided surgery due to positive long term effect of TFE. The operative notes of the 15 patients who proceeded to surgery despite a negative TFE outcome are being reviewed and will be presented. Conflicts of Interest. None. Source of Funding. None

Introduction: A far lateral access is required in fullen-doscopic operations of sequestered lumbar disc herniations to achieve a sufficient decompression of the ventral epidural space. The conventional endoscopes and instruments had very narrow limits especially in the mobility and possibility to resect hard tissue and to clean the intervertebral space sufficiently. The aim of this prospective study was to investigate the extended possibilities of the new endoscopes and instruments with regard to the efficacy of decompression, the advantages and problems of this technique in comparison to previous data. Methods: 368 patients with lumbar disc herniations have been treated in 2002 and 2003 in a full endoscopic transforaminal technique using a lateral access. A 7-mm endoscope with 4 mm-working canal and new designed instruments were used. Follow-up lasted at least 12 months. 298 patients (81%) could be followed. Results: No intraoperative complication occurred. 6 patients reported a transient dysaesthesia postoperatively. The average operation time was 28 minutes. A sufficient decompression could be achieved in all cases. 244 patients (82%) reported no more leg pain after surgery, 42 patients (14%) had transient persistence in the first 6 weeks. 8 patients (2,7%) showed a recurrent herniation, 7 of those were reoperated in the same technique. Discussion/Conclusion: As a minimally invasive technique wich efficacy of decompression is equal to an open procedure we see advantages over conventional operations of lumbar disc herniations. Within the inclusion criterias of indication this technique is sufficient and safe. The technical developments on endoscopes and instruments lead to a decrease of recurrence, increase of mobility as well as the possibility of resection of hard tissue and sufficient cleaning of the intervertebral space. The combination of a far lateral access with other approaches extends the spectrum of indications with regard to full endoscopic bony decompression and fusion

Purpose: To review the sagittal lumbar and clinical profile of the two surgical procedures: TLIF (transforaminal lumbar interbody fusion and ALIF (anterior lumbar interbody fusion).

Materials and methods: We carried out a retrospective study of 46 patients who underwent circumferential fusion in 2000–2001. TLIF was used in the first group (21) and ALIF in the second (25). The posterior approach with pedicle instrumentation was used in all patients. Lateral radiographs of the lumbar spine in neutral position and bipedestation were used for evaluation before and after surgery and during follow-up. The results were compared statistically using the Wilcoxon matched pairs test.

Results: Lumbar lordosis was achieved with both techniques: TLIF+PF(posterior fusion) −33° (preoperative), −46° (postoperative) and ALIF+ PF −49° (preoperative), −54° (postoperative). However the height of the disc improved significantly with the anterior approach: TLIF+ PF 0.62 (preoperative), 1.35 (postoperative) and ALIF+PF 1 (preoperative), 4.65 (postoperative).

The duration of surgery, blood loss and hospital stay were greater with ALIF+PF than with TLIF+PF.

Conclusions: TLIF+PF has clinical and economic advantages over ALIF+PF. Lumbar lordosis and the area of instrumented lordosis was achieved with both circumferential fusion procedures and the only radiographic difference was the restoration of the disc height with ALIF.

Aims. People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). Methods. An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. Results. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). Conclusion. This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK. Cite this article: Bone Jt Open 2024;5(7):612–620

Lumbar fusion surgery is an established procedure for the treatment of several spinal pathologies. Despite numerous techniques and existing devices, common surgical trends in lumbar fusion surgery are scarcely investigated. The purpose of this Canada-based study was to provide a descriptive portrait of current surgeons’ practice and implant preferences in lumbar fusion surgery while comparing findings to similar investigations performed in the United Kingdom. Canadian Spine Society (CSS) members were sampled using an online questionnaire which was based on previous investigations performed in the United Kingdom. Fifteen questions addressed the various aspects of surgeons’ practice: fusion techniques, implant preferences, and bone grafting procedures. Responses were analyzed by means of descriptive statistics. Of 139 eligible CSS members, 41 spinal surgeons completed the survey (29.5%). The most common fusion approach was via transforaminal lumber interbody fusion (TLIF) with 87.8% performing at least one procedure in the previous year. In keeping with this, 24 surgeons (58.5%) had performed 11 to 50 cases in that time frame. Eighty-six percent had performed no lumbar artificial disc replacements over their last year of practice. There was clear consistency on the relevance of a patient specific management (73.2%) on the preferred fusion approach. The most preferred method was pedicle screw fixation (78%). The use of stand-alone cages was not supported by any respondents. With regards to the cage material, titanium cages were the most used (41.5%). Published clinical outcome data was the most important variable in dictating implant choice (87.8%). Cage thickness was considered the most important aspect of cage geometry and hyperlordotic cages were preferred at the lower lumbar levels. Autograft bone graft was most commonly preferred (61.0%). Amongst the synthetic options, DBX/DBM graft (64.1%) in injectable paste form (47.5%) was preferred. In conclusion, findings from this study are in partial agreement with previous work from the United Kingdom, but highlight the variance of practice within Canada and the need for large-scale clinical studies aimed to set specific guidelines for certain pathologies or patient categories

Aim. To identify a means to reduce the duration and radiation dose coupled with fluoroscopic guided nerve root blocks (NRB). Method. Consecutive prospective two cohort comparative study. A similar method performed during CT guided NRBs was employed to guide needle placement for transforaminal nerve root injections with the aid of static MR images and fluoroscopy. Axial MR images at the level of the target nerve root were used. An angle of inclination of 60 degrees was created from the nerve root to the skin of the back, the apex of this to represent the site of needle introduction. Triangulation on the MRI enabled the lateral entry point to be determined. The transforaminal injections were then performed with the simple expedient of a skin marker line at the appropriate lateral distance from the midline for needle entry. The radiation dose and fluoroscopic time as measured by the image intensifier were recorded. This method was performed for 20 patients and compared to the same parameters for 23 previous patients in whom the transforaminal injections were performed without such a technique. Results. 20 patients in the navigated arm (group 1) and 23 in the non-navigated (group 2). Average fluoroscopic time (seconds) was 17.7 seconds (range 8-40) for group 1 and 16.4 seconds (range 6-45) for group 2 (P value 0.625). Radiation dose measured was 79.76 cgycm. 2. (range 8-212) for group 1 and 63.05 cgycm. 2. (range 8-260) for group 2 (P value 0.247). Conclusion. This method of navigating nerve root blocks via fluoroscopy did not appear to reduce the duration of the procedure or radiation dose involved on objective data. Subjectively it was found to be a useful training aid for triangulation for those new to the technique but the available objective evidence was not obtained

Obesity is an increasing public health concern associated with increased perioperative complications and expense in lumbar spine fusions. While open and mini-open fusions such as transforaminal lumbar interbody fusion (TLIF) and minimally invasive TLIF (MIS-TLIF) are more challenging in obese patients, new MIS procedures like oblique lateral lumbar interbody fusion (OLLIF) may improve perioperative outcomes in obese patients relative to TLIF and MIS-TLIF. The purpose of this study is to determine the effects of obesity on perioperative outcomes in OLLIF, MIS-TLIF, and TLIF. This is a retrospective cohort study. We included patients who underwent OLLIF, MIS-TLIF, or TLIF on three or fewer spinal levels at a single Minnesota hospital after conservative therapy had failed. Indications included in this study were degenerative disc disease, spondylolisthesis, spondylosis, herniation, stenosis, and scoliosis. We measured demographic information, body mass index (BMI), surgery time, blood loss, and hospital stay. We performed summary statistics to compare perioperative outcomes in MIS-TLIF, OLLIF, and TLIF. We performed multivariate regression to determine the effects of BMI on perioperative outcomes controlling for demographics and number of levels on which surgeries were operated. OLLIF significantly reduces surgery time, blood loss, and hospital stay compared to MIS-TLIF, and TLIF for all levels. MIS-TLIF and TLIF do not differ significantly except for a slight reduction in hospital stay for two-level procedures. On multivariate analysis, a one-point increase in BMI increased surgery time by 0.56 ± 0.47 minutes (p = 0.24) in the OLLIF group, by 2.8 ± 1.43 minutes (p = 0.06) in the MIS-TLIF group, and by 1.7 ± 0.43 minutes (p < 0.001) in the TLIF group. BMI has positive effects on blood loss for TLIF (p < 0.001) but not for OLLIF (p = 0.68) or MIS-TLIF (p = 0.67). BMI does not have significant effects on length of hospital stay for any procedure. Obesity is associated with increased surgery time and blood loss in TLIF and with increased surgery time in MIS-TLIF. Increased surgery time may be associated with increased perioperative complications and cost. In OLLIF, BMI does not affect perioperative outcomes. Therefore, OLLIF may reduce the disparity in outcomes and cost between obese and non-obese patients

With the increase in the elderly population, there is a dramatic increase in the number of spinal fusions. Spinal fusion is usually performed in cases of primary instability. However it is also performed to prevent iatrogenic instability created during surgical treatment of spinal stenosis in most cases. In literature, up to 75% of adjacent segment disease (ASD) can be seen according to the follow-up time. 1. Although ASD manifests itself with pathologies such as instability, foraminal stenosis, disc herniation or central stenosis. 1,2. There are several reports in the literature regarding lumbar percutaneous transforaminal endoscopic interventions for lumbar foraminal stenosis or disc herniations. However, to the best our knowledge, there is no report about the treatment of central stenosis in ASD. In this study, we aimed to investigate the short-term results of unilateral biportal endoscopic decompressive laminotomy (UBEDL) technique in ASD cases with symptomatic central or lateral recess stenosis. The number of patients participating in the prospective study was 8. The mean follow-up was 6.9 (ranged 6 to 11) months. The mean age of the patients was 68 (5m, 3F). The development of ASD time after fusion was 30.6 months(ranged 19 to 42). Mean fused segments were 3 (ranged 2 to 8). Preoperative instability was present in 2 of the patients which was proven by dynamic lumbar x-rays. Preoperative mean VAS-back score was 7.8, VAS Leg score was 5.6. The preoperative mean JOA (Japanese Orthopaedic Association) score was 11.25. At 6th month follow-up, the mean VAS back score of the patients was 1, and the VAS leg score was 0.5. This improvement was statistically significant (p = 0.11 and 0.016, respectively). The mean JOA score at the 6th month was 22.6 and it was also statistically significant comparing preoperative JOA score(p = 0.011). The preoperative mean dural sac area measured in MR was 0.50 cm2, and it was measured as 2.1 cm. 2. at po 6 months.(p = 0.012). There was no progress in any patient's instability during follow-up. In orthopedic surgery, when implant related problems develop in any region of body (pseudoarthrosis, infection, adjacent fracture, etc.), it is generally treated by using more implants in its final operation. This approach is also widely used in spinal surgery. 3. However, it carries more risk in terms of devoloping ASD, infection or another complications. In the literature, endoscopic procedures have almost always been used in the treatment of ventral pathologies which constitute only 10%. In ASD, disease devolops as characterized by wide facet joint arthrosis and hypertrophied ligamentum flavum in the cranial segment and it is mostly presented both lateral recess and santal stenosis symptoms (39%). In this study, we found that UBEDL provides successful results in the treatment of patients without no more muscle and ligament damage in ASD cases with spinal stenosis. One of the most important advantages of UBE is its ability to access both ventral and dorsal pathologies by minimally invasive endoscopic aproach. I think endoscopic decompression also plays an important role in the absence of additional instability at postoperatively in patients. UBE which has already been described in the literature given successful results in most of the spinal degenerative diseases besides it can also be used in the treatment of ASD. Studies with longer follow-up and higher patient numbers will provide more accurate results

Objectives. Juxtafacet cysts of the spine can cause radicular pain, neurological symptoms and are often associated with spinal degeneration. The mainstay of treatment of juxtafacet cysts is surgical resection with laminotomy and resection of the cyst. Other methods, including epidural steroid and facet injections are mostly temporarily effective. The aim of this study is the sufficient decompression with reduced traumatization and destabilization with the full-endoscopic interlaminar and transforaminal technique. Methods. 60 patients with unilateral, single-level juxtafacet cysts were included in this study. 30 Patients (group 1) were operated in full-endoscopic technique (22 interlaminar, 8 trans-/extraforaminal) and 30 Patients (group 2) with conventional microscopic-assisted technique. The full-endoscopic operation was performed with 6.9-mm endoscopes with 4.1-mm intra-endoscopic working canal. The follow-up was 18 months. 27 (91%) patients were followed. Additionally to general parameters validated scores were used. Results. No intraoperative complications occurred. 2 patient in group 1 and 4 patients in group 2 showed transient dysaesthesia. The mean operation time in group 1 was 32 minutes, in group 2 56 minutes. There was no measurable blood loss in group 1, and a mean blood loss of 85 ml in group 2. The follow-up showed satisfactory subjective results in 53 patients. There were no significant differences between the two groups or within group 1 between the transforaminal and interlaminar technique in the clinical results. Group 1 showed significant advantages in different clinical, technical and economical parameters. The maximum time in hospital for group 1 patients was 3 days and 6 days in group 2. No recurrence of the cyst was found in the follow up. Conclusion. The full-endoscopic operation of lumbar facet cysts with full-endoscopic technique is an alternative to the conventional microscopic-assisted procedure for sufficient decompression of juxtafacet cyst. It enables selective procedure with direct visualization, sufficient decompression and less traumatization of the access pathway and the spinal canal structures

Purpose of the study: The endoscopic transforaminal approach to the lumbar disc proposed by A.T. Yeung has achieved world-wide acceptance. The Yeung endoscopic spinal system (YESS) used with a specific instrument set enables direct magnified optical control of discectomy performed under local anesthesia and neurolepanalgesia in the outpatient setting. We began our experience in 2003 and report here the results obtained in a consecutive series of 100 patients reviewed retrospectively. Material and methods: The inclusion criteria were patients with lumbar disc herniation-related lumbosciatic or crural pain non-responsive to well conducted medical care (including epidural or periradicular injections) for at least three months. The patients also had to display a concordant clinical and radiographic picture with confirmation of the symptomatic level by discography. Exclusion criteria were: excluded herniation with a fragment which had migrated into the canal; caudia equina syndrome; lower limb paralysis with muscle force scored less than 3; advanced-stage degernerative central bony stenosis affecting the clinical expression; pregnancy. The levels treated were: L3–L4 (n=6), L4–L5 (n=72), and L5–S1 (n=22). Herniation was forminal and extraforaminal in 53 cases, posterolateral in 31, and median in 16. There was an associated constitutional central stenosis in ten cases and in thirteen others, herniation was a recurrence after conventional surgery. Results: One hundred patients were reviewed at mean 18 months (range 12–34 months) follow-up. There were no serious neurological, vascular, or infectious complications. According to the McNab criteria outcome was good for 71 cases, fair for 16 and poor for 13 with 11 requiring revision with conventional surgery. Patients with foraminal and extraforminal herniation accounted for more than half of our series and responded best to treatment (84.9% good outcome) compared with posterolateral herniation (48%) (p< 0.05). Patients with median herniation had an intermediary outcome (68% good results). The least satisfactory outcome was observed at the L5–S1 level (63% fair and poor outcome), but the difference did not reach statistical significance compared with the higher levels. In patients with recurrent herniation after conventional surgery, there were four cases of failure. Discussion: These results are less satisfactory than those found in the literature. This might be explained by the less satisfactory outcome obtained with posterolateral herniations, probably because more than halve had migrated, generally above the plane of the disc, which in our experience cannot be accessed via the transforaminal approach. In addition, comparison of our first 50 cases with the last 50 showed an improvement in outcome to a mean 82%, expressing a learning curve for this type of technique. The most frequent error early in our experience was to insert the working endoscopic canula too anteriorly compared with the disc. The point of insertion must be very lateral determined by the discography in order to enter at least 30° posterior to the posterior part of the disc. Progressive fine-tuning of patient selection also helped improve outcome. YESS improves the work of the intradiscal instruments which can be control by direct view, explaining the the better results compared with the older mechanical or automatic (blind) methods. YESS is a very effective alternative to chemonucleolysis since papaine is no longer available. Compared with other endoscopic techniques for disectomy via an interlaminar approach, YESS offers the possibility of treatment patients in an outpatient setting with a local anesthesia. In addition the quality of the visual control of the foramen is better. These methods can be used in association with intradiscal Holmium-Yag laser which can also be applied to the bony walls of the foramen for a widening foraminoplasty. This transformainal endoscopic approach also offers a way to perform an exclusively foraminoscopic spondylodesis using an intersomatic cage. Conclusion: YESS is an excellent technique for non-migrated subligament posterolateral foraminal and extraforaminal herniations where conventional access to the foramen is known to be very difficult