Download Final Program - North American Spine Society

35th Annual Meeting of the
International Society for Minimal Intervention in
Spinal Surgery (ISMISS)
January 18-20, 2017
Swissôtel, Chicago, IL
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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
IN A
L SUR GE
RY
1
2
WELCOME TO ISMISS 2017 IN CHICAGO
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 Magnificent 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 peerreviewed 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.
Enjoy the meeting and all Chicago has to offer.
Richard G. Fessler, MD, PhD
Meeting Chair
John E. O’Toole, MD, MS
Scientific Program Chair
TABLE OF CONTENTS
Education Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Meeting Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chicago Attractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Meeting-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Detailed Program Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Posters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Proceedings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Disclosure Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
Technical Exhibition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
ISMISS and NASS Boards of Directors . . . . . . . . . . . . . . . . . . .49
ISMISS and NASS Membership Applications . . . . . . . . . . . . . . 51
3
EDUCATION INFORMATION
LEARNING OBJECTIVES
Upon 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) CREDIT
This 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
CERTIFICATES
After 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.
DISCLAIMER
The 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 COMMITTEE
ISMISS/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, PhD
Meeting Chair and ISMISS President-Elect
John E. O’Toole, MD, MS
Scientific Program Chair
Gun Choi, MD, PhD
Pil S. Choi, MD
Hansjörg Leu, MD
Jose Antonio Soriano-Sanchez, MD
Michael Y. Wang, MD
Program Committee Members
2017 ABSTRACT REVIEWERS
ISMISS/NASS thank the following volunteers who spent
numerous hours reviewing abstracts:
Hansjörg Leu, MD
John E. O’Toole, MD, MS
Jose Antonio Soriano-Sanchez, MD
Michael Y. Wang, MD
CORPORATE SUPPORT
ISMISS/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 Medical
joimax
K2M, Inc.
Karl Storz
Richard Wolf Medical Instruments
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MEETING INFORMATION
REGISTRATION
Zurich Foyer
NETWORKING COFFEE BREAKS
Zurich ABC
Registration hours:
Wednesday, January 18. . . . . . 7:00–8:00 a.m.; 3:00–6:00 p.m.
Thursday, January 19 . . . . . . . . . . . . . . . . . . 7:00 a.m.–5:00 p.m.
Friday, January 20. . . . . . . . . . . . . . . . . . . . . 7:00 a.m.–5:00 p.m.
Grab a beverage and have a conversation during the
Networking Coffee Breaks. Beverage services also are held in
the Technical Exhibition.
TECHNICAL EXHIBITION
Zurich ABC
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.
Technical Exhibition hours:
Thursday, January 19 . . . . . . . . . . . . . . . . . . 8:00 a.m.–5:00 p.m.
Friday, January 20. . . . . . . . . . . . . . . . . . . . . 8:00 a.m.–3:00 p.m.
LUNCH
Zurich 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 CENTER
Zurich 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.
WELCOME RECEPTION
Open to All Attendees and Exhibitors
Edelweiss
Wednesday, January 18
6:00–8:00 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.
Plenary Sessions
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.
Speaker Information Center hours:
Thursday, January 19 . . . . . . . . . . . . . . . . . . . 7:30 a.m.–5:00 p.m.
Friday, January 20. . . . . . . . . . . . . . . . . . . . . . 7:30 a.m.–4:30 p.m.
Technical
Exhibition/
Lunch
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CHICAGO ATTRACTIONS
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 worldclass 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.
RESTAURANTS
The dining scene is unparalleled, serving up everything from
tasty cheap eats to avant-garde cuisine.
Grace $$$$ American
652 W. Randolph St.
Next Restaurant $$$$ Eclectic
953 W. Fulton Market St.
Tru $$$$ French
676 N. St. Clair St.
Swift & Sons $$$$ Steakhouse
1000 W Fulton Market St.
Avec Restaurant $$$ Mediterranean
615 W. Randolph St.
The Aviary $$$ Bar
955 W. Fulton Market St.
Blackbird Restaurant $$$ American
619 W. Randolph St.
The Boarding House $$$ American
720 N. Wells St.
MK $$$ American
868 N. Franklin St.
Carmine’s $$ Italian
1043 N. Rush St.
RPM Italian $$ Italian/Steak
52 W. Illinois St.
Duck Duck Goat $$ Chinese
857 W. Fulton Market St.
MUSIC
Legendary blues and jazz can be heard nightly in venues
throughout the city.
Andy’s Jazz Club
11 E. Hubbard St.
Blue Chicago
534 N. Clark St.
Buddy Guy’s Legends
700 S. Wabash Ave.
Rosa’s Lounge
3420 W. Armitage Ave.
The Green Mill
4802 N. Broadway St.
The Redhead Piano Bar
16 W. Ontario St.
Gibson’s Bar & Steakhouse $$$ Steak/Seafood
1028 N. Rush St.
COMEDY
The comedy scene ranges from traditional stand-up to
competitive improv to sketch.
Girl & the Goat $$$ American/Seafood
809 W. Randolph St.
Zanies Comedy Night Club
1548 N. Wells St.
Chicago Chop House $$$ 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.
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The Second City
1616 N. Wells St.
Laugh Factory
3175 N. Broadway St.
The Comedy Bar
500 N. LaSalle St.
MEETING-AT-A-GLANCE
WEDNESDAY, JANUARY 18
FRIDAY, JANUARY 20
7:00–8:00 a.m.
Hands-on Course Registration
Zurich Foyer
7:00 a.m.–5:00 p.m.
Registration
Zurich Foyer
8:00 a.m.
Hands-on Course Shuttle Departs
Swissôtel Event Center Entrance (Located
just past the front desk, before the
escalators leading to the Zurich Ballroom)
8:00 a.m.–3:00 p.m.
Technical Exhibition
Zurich ABC
8:25–8:30 a.m.
Welcome/Announcements
Zurich DEFG
8:30–10:35 a.m.
Plenary Session V:
NASS Symposium
Zurich DEFG
10:35–11:00 a.m.
Networking Coffee Break
Zurich ABC
9:00 a.m.–2:00 p.m.
Ticketed Session: Hands-on Cadaver
Course in Current Techniques in
Minimally Invasive Spine Surgery
Specialty Education & Research Center
(SERC)
3:00–6:00 p.m.
Registration
Zurich Foyer
6:00–8:00 p.m.
Welcome Reception
Open to All Attendees and Exhibitors
Edelweiss
11:00 a.m.–12:00 p.m. Plenary Session VI:
Abstract Presentations
Zurich DEFG
12:00–1:00 p.m.
Lunch
Zurich ABC
1:00–2:30 p.m.
Plenary Session VII:
Abstract Presentations
Zurich DEFG
THURSDAY, JANUARY 19
7:00 a.m.–5:00 p.m.
Registration
Zurich Foyer
8:00 a.m.–5:00 p.m.
Technical Exhibition
Zurich ABC
2:30–3:00 p.m.
8:25–8:30 a.m.
Welcome/Announcements
Zurich DEFG
Networking Coffee Break
Zurich ABC
3:00–4:40 p.m.
8:30–10:30 a.m.
Plenary Session I:
ISMISS Symposium
Zurich DEFG
Plenary Session VIII:
Case-based Debates
Zurich DEFG
4:40 p.m.
Meeting Adjourns
10:30–11:00 a.m.
Networking Coffee Break
Zurich ABC
11:00 a.m.–12:00 p.m. Plenary Session II:
Abstract Presentations
Zurich DEFG
12:00–1:00 p.m.
Lunch
Zurich ABC
1:00–2:30 p.m.
Plenary Session III:
Abstract Presentations
Zurich DEFG
2:30–2:45 p.m.
Networking Coffee Break
Zurich ABC
2:45–3:00 p.m.
History of Endoscopy
Zurich DEFG
3:00–4:35 p.m.
Plenary Session IV:
Case-based Debates
Zurich DEFG
7
DETAILED PROGRAM SCHEDULE
WEDNESDAY, JANUARY 18, 2017
THURSDAY, JANUARY 19, 2017
7:00–8:00 a.m.
Hands-on Course Registration
Zurich Foyer
7:00 a.m.–5:00 p.m.
Registration
Zurich Foyer
8:00 a.m.
Attendee shuttle departs for Hands-on Cadaver Course in
Current Techniques in Minimally Invasive Spine Surgery
Ticketed Session
Swissôtel Event Center Entrance (Located just past the front
desk, before the escalators that lead to the Zurich Ballroom)
8:00 a.m.–5:00 p.m.
Technical Exhibition
Zurich ABC
9:00 a.m.–2:00 p.m.
Ticketed Session:
Hands-on Cadaver Course in Current Techniques in
Minimally Invasive Spine Surgery
Specialty 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.
Registration
Zurich Foyer
6:00-8:00 p.m.
Welcome Reception
Open to All Attendees and Exhibitors
Edelweiss
8
8:25–8:30 a.m.
Welcome/Announcements
Zurich DEFG
8:30–10:30 a.m.
Plenary Session I:
ISMISS Symposium
Zurich DEFG
Moderator: Faheem Sandhu, MD
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 Herniation
8:30–8:45 a.m.
Endoscopic Transforaminal Approach: Anatomy,
Techniques, Results, Complications
Hansjörg Leu, MD
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 Results
Robert E. Isaacs, MD
DETAILED PROGRAM SCHEDULE
9:30–9:45 a.m.
Complications and Revisions
Richard G. Fessler, MD, PhD
11:18–11:24 a.m.
4. A Comparative Clinical Study of Full-endoscopic
Interlaminar Discectomy for L4/L5 versus L5/S1 Lumbar
Disc Herniation
MIS Surgery for Lumbar Fusion
9:45–10:00 a.m.
Endoscopic Interbody Fusion: Technique and Results
Michael Y. Wang, MD
Yawei Li, MD, PhD
10:00–10:15 a.m.
Tubular Posterior Interbody Fusion: Technique and
Results
Jose A. Soriano-Sanchez, MD
10:15–10:30 a.m.
Lateral Interbody Fusion: Technique and Results
Adam S. Kanter, MD
10:30–11:00 a.m.
Networking Coffee Break
Zurich ABC
The 2nd Xiangya Hospital, Central South University, Changsha, China
11:24–11:30 a.m.
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
11:30–11:36 a.m.
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
11:00 a.m.–12:00 p.m.
Plenary Session II:
Abstract Presentations
Zurich DEFG
Moderator: Michael Y. Wang, MD
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)
11:00–11:06 a.m.
1. Multiexpandable Cages for Minimally Invasive
Posterior/Transforaminal Lumbar Interbody Fusion: A
Preliminary Report
11:42 a.m.–12:00 p.m.
Discussion
Enrique Osorio, MD
1
12:00–1:00 p.m.
Lunch
Zurich ABC
11:06–11:12 a.m.
2. In-vivo Endoscopic Visualization of Pain Generators in
the Lumbar Spine
1:00–2:30 p.m.
Plenary Session III:
Abstract Presentations
Zurich DEFG
Moderator: Alfred T. Ogden, MD
Donald Kucharzyk, DO1; Jeffrey D. Coe, MD2; Kornelis A. Poelstra, MD,
PhD3; Joshua M. Ammerman, MD4; Sandeep Kunwar, MD5
Orthopaedic, 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
Anthony T. Yeung, MD
Desert 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 system
Thomas M. Doers, MD1; Sarika Walia, MD2; Maharaj Singh, PhD3
Aurora Healthcare, Milwaukee, WI, US; 2Aurora Neurosciences Innovation
Institute, Milwaukee, WI, US; 3Aurora Research Institute, Milwaukee, WI, US
1
1:00–1:06 p.m.
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
1:06–1:12 p.m.
9. Treatment of Symptomatic Spinal Stenosis with the
Transforaminal Endoscopic Approach
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
9
DETAILED PROGRAM SCHEDULE
1:12–1:18 p.m.
10. Percutaneous Endoscopic Surgery to Manage Lumbar
Highly Grade Migrated Disc Herniation
Shaokeh Hsu, MD
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?
Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
Wenjian Wu, MD; Liang Yu, M2
Shanghai Ruijin Hospital, Shanghai, China
1:18–1:24 p.m.
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
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 Stenosis
Qingquan Kong, MD
West 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 Surgery
Qingquan Kong, MD
West China Hospital of Sichuan University, Chengdu, Sichaun, China
1:51–1:57 p.m.
14. Percutaneous Endoscopic Decompression for the
Lumbar Canal Stenoses
Fujio Ito, MD, PhD
Aichi 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
Disease
Nikhil Jain, MBBS, MD1; Craig McMains, MD2; Alan Litsky, MD, ScD1; Emily
Cerier, BS1; Elizabeth Yu, MD1
The Ohio State University Wexner Medical Center, Columbus, OH, US;
2
Stanford University, Redwood City, CA, US
1
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, MD
Desert Institute for Spine Care, Phoenix, AZ, US
10
2:15–2:30 p.m.
Discussion
2:30-2:45 p.m.
Networking Coffee Break
Zurich ABC
2:45-3:00 p.m.
History of Endoscopy
Friedrich Tieber
Zurich DEFG
3:00–4:35 p.m.
Plenary Session IV:
Case-based Debates
Zurich DEFG
Moderator: 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.
Transforaminal
Anthony T. Yeung, MD
3:10–3:20 p.m.
Tubular
Kevin T. Foley, MD, FACS
3:20–3:25 p.m.
Rebuttal/Discussion
DETAILED PROGRAM SCHEDULE
Lumbar Stenosis: Endoscopic versus Tubular
Decompression
3:30–3:40 p.m.
Transforaminal
Pil Sun Choi, MD
3:40–3:50 p.m.
Tubular
Larry T. Khoo, MD
3:50–3:55 p.m.
Rebuttal/Discussion
Lumbar Stenosis and Degenerative Spondylolisthesis:
Endoscopic versus Tubular versus Lateral
4:00–4:10 p.m.
Endoscopic Fusion
Jeffrey L. Katzell, MD
4:10–4:20 p.m.
Tubular TLIF
Faheem Sandhu, MD
4:20–4:30 p.m.
MIS Lateral Interbody Fusion
Luiz Pimenta, MD, PhD
4:30–4:35 p.m.
Rebuttal/Discussion
FRIDAY, JANUARY 20, 2017
7:00 a.m.–5:00 p.m.
Registration
Zurich Foyer
8:00 a.m.–3:00 p.m.
Technical Exhibition
Zurich ABC
8:25–8:30 a.m.
Welcome/Announcements
Zurich DEFG
8:30–10:35 a.m.
Plenary Session V:
NASS Symposium
Zurich DEFG
Moderator: Zachary A. Smith, MD
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 Radiculopathy
8:30–8:45 a.m.
Posterior Endoscopic Cervical Discectomy: Technique
and Results
James J. Yue, MD
8:45–9:00 a.m.
Post-tubular Cervical Discectomy: Technique and Results
Mick 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 Surgery
Andrea 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
Results
John E. O’Toole, MD, MS
9:55-10:15 a.m.
MIS Surgery for Intradural Tumors: Technique and
Results
Trent L. Tredway, MD
10:15-10:35 a.m.
Adult Degenerative Scoliosis Correction: Technique
and Results
Paul Park, MD
11
DETAILED PROGRAM SCHEDULE
10:35–11:00 a.m.
Networking Coffee Break
Zurich ABC
11:00 a.m.–12:00 p.m.
Plenary Session VI:
Abstract Presentations
Zurich DEFG
Moderator: Nader S. Dahdaleh, 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
University 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;
7
Scoliosis & Spine Surgery Clinic of Memphis, PLLC, Memphis, TN, US;
8
Advanced Diagnostic Imaging PC, Saginaw, MI, US
11:24–11:30 a.m.
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
11:30–11:36 a.m.
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
11:36–11:42 a.m.
24. The Role of Lumbar Facet Arthrosis in Minimal
Invasive Spine Surgery
Volodymyr Radchenko Sr., MD, PhD
Sytenko Institute of Spine, Kharkiv, Ukraine
1
11:06–11:12 a.m.
19. Evaluation of Transforaminal Endoscopic Discectomy
in the Treatment of Obese Patients with Lumbar Disc
Herniation
11:42–11:48 a.m.
25. Relapsed Hernias After Open Surgery, Treated by
Percutaneous Endoscopic Surgery
Daniel Gastambide, MD1; Fréderic Jacquot2
GIEDA Inter Rachis, Paris, France; 2Hopital Saint Antoine, Department of
Orthopedic Surgery, Paris, France
1
11:48 a.m.–12:00 p.m.
Discussion
Wei Zhang, MD, PhD
Department 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
Discectomy
Guoxin Fan, MD; Shisheng He, MD
Shanghai 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 Surgery
Yawei Li, MD, PhD
The 2nd Xiangya Hospital, Central South University, Changsha, China
12:00–1:00 p.m.
Lunch
Zurich ABC
1:00–2:30 p.m.
Plenary Session VII:
Abstract Presentations
Zurich DEFG
Moderator: 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
Neuromodulation
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
12
DETAILED PROGRAM SCHEDULE
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 Stenosis
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 Outcome
TagGeun Jung, MD
Xinqiao Hospital of the Third Military Medical University, Chongqing,
China
Nasaret International Hospital, Incheon, Republic of Korea
Yue Zhou, MD, PhD
1:12–1:18 p.m.
28. Comparison of Kyphoplasty Outcomes between
Unilateral and Bilateral Approach for Treatment of
Osteoporotic Vertebral Compression Fracture
2:03–2:09 p.m.
34. Transiliac Approach Intervertebral Endoscopic
Discectomy for L5/S1 Intervertebral Disc Herniation
Xingkai Zhang, MD
Department of Spinal Surgery, The Third Hospital of Hebei Medical
University, Shijiazhuang City, China
Wei Zhang, MD, PhD
1:18–1:24 p.m.
29. Microendoscopy-assisted Minimally Invasive
Transforaminal Lumbar Interbody Fusion for Lumbar
Degenerative Disease: Short-term and Medium-term
Outcomes
2:09–2:15 p.m.
35. Minimally Invasive Full-endoscopic Posterior Cervical
Foraminotomy: Preliminary Clinical Results
Yang Yang, MD; Limin Rong, MD, PhD
Xinqiao Hospital, Chong Qing, China
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
1
University 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 Surgery
Sandeep 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 Anesthesia
Chao Zhang, MD, PhD
2:15–2:30 p.m.
Discussion
2:30–3:00 p.m.
Networking Coffee Break
Zurich ABC
3:00-4:40 p.m.
Plenary Session VIII:
Case-based Debates
Zurich DEFG
Moderator: Trent Tredway, MD
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.
Bo Zhu, MD1; Jianwei Du, MD2
1
The General Hospital of the People’s Liberation Army, Beijing, Beijing,
China; 2Yangzhou NO.1 People’s Hospital, Yangzhou, Jiangsu, China
13
DETAILED PROGRAM SCHEDULE
Cervical Surgery
3:00-3:15 p.m.
Posterior Endoscopic Foraminotomy is Best
Joachim Oertel, MD
Adult Spinal Deformity
4:10 -4:20 p.m.
Circumferential MIS Approaches Are Best
Richard G. Fessler, MD, PhD
3:15-3:30 p.m.
Posterior Tubular Foraminotomy is Best
Zachary A. Smith, MD
4:20-4:30 p.m.
Open Approaches Are Best
Tyler R. Koski, MD
3:30-3:40 p.m.
Rebuttal/Discussion
4:30-4:40 p.m.
Rebuttal/Discussion
Intradural Spinal Tumors
3:40-3:50 p.m.
MIS Approaches Are Best Nader S. Dahdaleh, MD
4:40 p.m.
Meeting Adjourns
3:50-4:00 p.m.
Open Approaches Are Best
John C. Liu, MD
4:00-4:10 p.m.
Rebuttal/Discussion
Participate in open forum dialogues on
critical spine issues and controversies
and enjoy the recreational activities
at Canyons Village
CO M E TO T H E 13 T H A N NUA L
EVIDENCE & TECHNOLOGY SPINE SUMMIT
February 22-25, 2017
Canyons Village, Park City, UT
www.spine.org/ETSS
14
POSTERS
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 Review
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
Luiz 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 Stenosis
Limin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou,
GuangDong, China
P3. Radiation Safety Alert
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
P4. Early Clinical Results of Genipin Crosslinking
Treatment for Low Back Pain
Harwant Singh, MD, PhD1; Tom Hedman, PhD2; John Racadio, MD3
Country Heights, Malaysia; 2Orthopeutics, L.P., Lexington, KY, US;
3
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, US
1
P5. The Feasibility of a Novel Hydrogel Intradiscal Implant
for Nucleus Augmentation
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
P10. Intradiscal Therapy for Discogenic Pain from Toxic
Annular Tears
Anthony T. Yeung, MD
Desert Institute for Spine Care, Phoenix, AZ, US
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
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
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
P6. Application of Computer Navigation in the Treatment
of Spinal Tuberculosis in the Extreme Lateral Interbody
Fusion
P14. Intermuscular Approach for Mini-Open
Transforaminal Lumbar Interbody Fusion
Tan Haitao; Li Ying, MD
Far-Eastern Memorial Hospital, New Taipei, Taiwan, Taiwan
Jwo-Luen Pao, MD
Guigang City Hospital Guangxi China, Guigang, Guangxi, China
P7. Associations between Modic Changes and Cervical
Degenerative Disease
P15. Mini-Open Anterior Lumbar Interbody Fusion for
the Treatment of Symptomatic Adjacent-segment
Degeneration After Lumbar Fusion
Geun S. Song, MD, PhD
Yawei Li, MD, PhD
Pusan Nat’l Univ Yangsan Hospital, Yangsan, Gyeongnam, Republic of
Korea
The 2nd Xiangya Hospital, Central South University, Changsha, China
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
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
15
POSTERS/AUTHOR INDEX
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 Discectomy
Qingquan 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
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
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
P21. Lumbar Disc Endoscopic Surgery Through the
Transforaminal Approach
Arman Hakobyan, MD, PhD
NAIRI Medical Center, Yerevan, Armenia
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
P23. Surgical Treatment of Aggressive Hemangiomas of
the Spine with Percutaneous Vertebroplasty
Sh.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
16
AUTHOR INDEX
Amburgy, John W.: 18
Ammerman, Joshua M.: 1
Banagan, Kelley E.: 30
Beall, Douglas P.: 18
Brown, Luke: 30
Cavanaugh, Daniel L.: 30
Cerier, Emily: 15
Chambers, Melissa: 18
Coe, Jeffrey D.: 1
De la Garza Ramos, Rafael: P19
Doers, Thomas M.: 3
Du, Jianwei: 32
Fan, Guoxin: 20, 22
Gastambide, Daniel: 25
Gelb, Daniel E.: 30
Goodman, Bradly S.: 18
Haitao, Tan: 23, P6
Hakobyan, Arman: P21
Haranhalli, Neil: P19
He, Shisheng: 20, 22
Hedman, Tom: P4
Hsu, Shaokeh: 10
Ito, Fujio: 14
Jacquot, Fréderic: 25
Jada, Ajit: P19
Jain, Nikhil: 15
Jung, TagGeun: 27
Kabilov, A.O.: P23
Karakulov, K.H.: P23
Kinon, Merritt: P19
Koh, Eugene Y.: 30
Kong, Qingquan: 12, 13, P17, P18
Kucharzyk, Donald: 1
Kunwar, Sandeep: 1
Lee, Jun Seok: P8
Lee, Su Hun: P9
Li, Yawei: 21, 4, P15
Litsky, Alan: 15
Ludwig, Steven C.: 30
Malik, Atif B.: 31
McMains, Craig: 15
Musaev, R.S.: P23
Nakhla, Jonathan P.: P19
Nasser, Rani: P19
Osorio, Enrique: 7
Pao, Jwo-Luen: P14
Poelstra, Kornelis A.: 1
Racadio, John: P4
Radchenko, Volodymyr: 24
Rajabov, Kh.S.: P22
Rong, Limin: 29, 5, P2, P12, P13
Saliev, S.M.: P22, P23
Sandon, Luiz H.: P1
Shatursunov, Sh.Sh.: P22, P23
Shengbin, Huang: 23
Sherlekar, Sandeep: 31
Singh, Harwant: P4
Singh, Maharaj: 3
Son, Dong Wuk: P7, P8, P9
Song, Geun S.: P7
Thorpe, John: 31
Walia, Sarika: 3
Weir, Tristan B.: 30
Wu, Junlong: 33
Wu, Wenjian: 17, 8
Yang, Yang: 29, P13
Yassari, Reza: P19
Yeung, Anthony T.: 2, 9, 11, 16,
26, P3, P5, P10, P11
Ying, Li: P6
Yu, Elizabeth: 15
Yu, Keyi: P20
Yu, Liang: 17, 8
Yu, Pei: 8
Zhang, Chao: 35
Zhang, Chunlin: 6
Zhang, Wei: 19, 34
Zhang, Xingkai: 28
Zhou, Yue: 33
Zhu, Bo: 32, P16
PROCEEDINGS
Thursday, January 19, 2017
11:00 a.m.–12:00 p.m.
Plenary Session II: Abstract Presentations
2. In-vivo Endoscopic Visualization of Pain Generators in the
Lumbar Spine
1. Multiexpandable Cages for Minimally Invasive Posterior/
Transforaminal Lumbar Interbody Fusion: A Preliminary
Report
Desert Institute for Spine Care, Phoenix, AZ, US
Donald Kucharzyk, DO1; Jeffrey D. Coe, MD2; Kornelis A. Poelstra, MD,
PhD3; Joshua M. Ammerman, MD4; Sandeep Kunwar, MD5
Orthopaedic, 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
1
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 multicenter 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.
Anthony T. Yeung, MD
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 anesthesia
Patient Sample: Endoscopic visualization of endoscopic images in over
10,000 procedures from a personal documented database
OUTCOME MEASURES: VAS, Oswestry, Modified MacNab, patient
satisfaction questionnaire
METHODS: 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
17
PROCEEDINGS
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
1
Aurora 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 highdefinition 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
18
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
herniation
STUDY DESIGN/SETTING: A comparable retrospective study
PATIENT 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.
PROCEEDINGS
5. Contralateral Radiculopathy following Minimally Invasive
Transforaminal Lumbar Interbody Fusion
FDA DEVICE/DRUG STATUS: This abstract does not discuss or
include any applicable devices or drugs.
Limin Rong, MD, PhD
The 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou,
GuangDong, China
6. Modified Cervical Micro Endoscopic Laminoplasty for
Patients with Cervical Spondylotic Myelopathy
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.
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 series
PATIENT SAMPLE: 34
OUTCOME MEASURES: JOA scores, VAS, CCI and ROM
METHODS: 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
19
PROCEEDINGS
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 paresthesias
100% patients with Tonic st. presented paresthesias
CONCLUSIONS: 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, 2017
1:00–2:30 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
20
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 twostage 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.
PROCEEDINGS
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 curretes
PURPOSE: to demonstrate how symptomatic lateral recess stenosis
is effectively diagnosed and treated with transforaminal endoscopic
decompression
STUDY DESIGN/SETTING: review of 8,000 endoscopically
documented cases when foraminoplasty was adopted
PATIENT SAMPLE: 20 consecutive patients with imaging evidence to
lateral recess stenosis opting for transforaminal decompression over
traditional translaminar decompression and two-years follow-up
OUTCOME MEASURES: Vas, Oswestry, Modified MacNab Criteria
METHODS: 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 effective
CONCLUSIONS: 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
Shaokeh Hsu, MD
Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan
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
herniations
STUDY DESIGN/SETTING: Between Jan 2006 to Jan 2010, sixtyeight 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.
21
PROCEEDINGS
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 process
STUDY 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-up
OUTCOME MEASURES: VAS, Oswestry, Modified Mac Nab criteria
METHODS: 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
22
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 technique
FDA 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
PROCEEDINGS
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 decompression
RESULTS: 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 hemidecompression 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
23
PROCEEDINGS
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 (redecompressed 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
The Ohio State University Wexner Medical Center, Columbus, OH, US;
Stanford University, Redwood City, CA, US
1
2
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
24
performed by loading the specimens in 4-point bending using linearlyramped 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 surgery
STUDY 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.
PROCEEDINGS
PATIENT SAMPLE: 10,000 consecutive cases documented in a single
spine group practice
OUTCOME MEASURES: VAS, Oswestry, Modified MacNab Criteria,
patient satisfaction questionnaire
METHODS: 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 surgery
FDA 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, hardwarerelated 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 intraoperative data and perioperative complications were recorded.
RESULTS: Mean follow-up period was 41 months (range 2458 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.
25
PROCEEDINGS
Friday, January 20, 2017
11:00 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
University 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
1
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 trial
PATIENT 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’ postprocedure. All symptoms associated with reported AE resolved with
appropriate treatment.
26
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 study
PATIENT SAMPLE: 69
OUTCOME 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 TED
FDA DEVICE/DRUG STATUS: This abstract does not discuss or
include any applicable devices or drugs.
PROCEEDINGS
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. Navigatorassisted 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, patientreported 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 dumbbelltype 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 procedures
METHODS: 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).
27
PROCEEDINGS
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
28
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
1
GIEDA 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
PROCEEDINGS
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, 2017
1:00–2:30 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 nerve
STUDY DESIGN/SETTING: Transforaminal endoscopic surgery
provides surgical options using mechanical decompression as well as
DRG neuromodulation for FBSS
PATIENT SAMPLE: Consecutive patients with FBSS following
translaminar decompression and fusion from a personal database of
transforaminal endoscopic cases from 1991-2016
OUTCOME MEASURES: vas
METHODS: 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 fullendoscopic 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 report
PATIENT 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
29
PROCEEDINGS
months(2-11months). The VAS-B decreased from 6.7 +/-1.3(59) 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(3.711.2mm) 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 fracture
STUDY 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 months
METHODS: 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 recollapse of fractured vertebra.
CONCLUSIONS: Kyphoplasty through a unilateral extrapedicular
approach can achieve convergent and proper cement filling in the
30
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 microendoscopyassisted 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.
PROCEEDINGS
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
University 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
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 inclusionexclusion criteria and were excluded, 26 of the 55 for not having followup 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 removal
METHODS: 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 female
OUTCOME 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 postoperative 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.
31
PROCEEDINGS
32. Treatment of Cervical Spinal Stenosis with Percutaneous
Full-endoscopic Cervical Partial Laminectomy Under Local
Anesthesia
Bo Zhu, MD1; Jianwei Du, MD2
1
The 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 report
PATIENT 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 followup. 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
32
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 report
PATIENT 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 longterm 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.
34. Transiliac Approach Intervertebral Endoscopic
Discectomy for L5/S1 Intervertebral Disc Herniation
Wei Zhang, MD, PhD
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.
PROCEEDINGS
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 study
PATIENT SAMPLE: 57
OUTCOME MEASURES: operative time, intraoperative fluoroscopy
times, VAS scores, The MacNab score
METHODS: 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 preoperation 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.
35. Minimally Invasive Full-endoscopic Posterior Cervical
Foraminotomy: Preliminary Clinical Results
Chao Zhang, MD, PhD
Xinqiao Hospital, Chong Qing, China
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 Review
PATIENT 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
33
PROCEEDINGS
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 weeks
METHODS: 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
34
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 disorders
FDA DEVICE/DRUG STATUS: This abstract does not discuss or
include any applicable devices or drugs.
PROCEEDINGS
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
Country Heights, Malaysia; 2Orthopeutics, L.P., Lexington, KY, US;
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, US
1
3
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 procedurespecific 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
35
PROCEEDINGS
pain and disability at 1 and 3 months. Secondary efficacy endpoints
included a metric of device functionality – reduction of flexionextension 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 used
RESULTS: 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 electrothermal 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
36
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-up
PATIENT SAMPLE: 188 + 30 (two separate pilot studies)
OUTCOME MEASURES: VAS, Oswestry, and patient satisfaction
METHODS: 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 threeyear 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.
PROCEEDINGS
P6. Application of Computer Navigation in the Treatment of
Spinal Tuberculosis in the Extreme Lateral Interbody Fusion
FDA DEVICE/DRUG STATUS: This abstract does not discuss or
include any applicable devices or drugs.
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&lt;0.05). Intraoperative C arm fluoroscopy cumulative
exposure time was navigation group 31 + 14S, control group 96 + 38S,
the difference was statistically significant (p&lt;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.
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 study
METHODS: 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 study
METHODS: 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 ra­diological evaluation. Global
cervical lordosis (GCL), fused segment angle (FSA), fused segment
height (FSH), and disc space height (DSH) were measured and
analyzed.
37
PROCEEDINGS
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 study
METHODS: 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 preoperative 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.
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 2004
OUTCOME MEASURES: Modified MacNab Criteria, VAS, patient
satisfaction questionnaire
METHODS: 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
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
38
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
PROCEEDINGS
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 followup 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 pathoanatomy
OUTCOME MEASURES: VAS, Oswestry, Modified Mac Nab Criteria,
patient satisfaction
METHODS: Transforaminal Endoscopic Technique, described as YESS
endoscopic surgery in the literature
RESULTS: 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
patients
PATIENT 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.
39
PROCEEDINGS
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
40
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. Thirtyfour 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
PROCEEDINGS
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 miniopen 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
complications
FDA 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
41
PROCEEDINGS
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.
42
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 postoperative 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.
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 reoperation, 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 [13]. 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
Sh.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
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
43
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.
44
DISCLOSURE INDEX
FINANCIAL CONFLICT OF INTEREST
DISCLOSURE POLICY
NASS 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 DISCLOSURE
As 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
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FDA DISCLOSURE
If a device or drug requiring FDA approval is identified as an
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indicate the FDA status of those devices or drugs as Approved,
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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 Key
Level A. $100 to $1000
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RESOLUTION OF CONFLICT OF INTEREST IN
PRESENTATIONS
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interest, if any, have been identified and have been resolved
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45
DISCLOSURE INDEX
Ammerman, Joshua M.: Consulting: Medtronic (Amount not disclosed);
Speaking and/or teaching arrangements: Benvenue (Amount
not disclosed); Scientific Advisory Board: Benvenue (Amount not
disclosed).
Anand, Neel: Royalties: Medtronic (F), NuVasive (D), Globus Medical (C);
Stock Ownership: Globus (Amount not disclosed), Medtronic (Amount
not disclosed); Private Investments: Paradigm Spine (<1%), Bonovo
Orthopaedics (<1%), Pearl Diver (<1%), Theracell (<1%); Consulting:
NuVasive (None); Speaking and/or Teaching Arrangements: Medtronic
(B); Trips/Travel: Medtronic (Consulting disclosed); Scientific Advisory
Board: Globus Medical (None).
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).
Isaacs, Robert E.: Royalties: NuVasive (F); Stock Ownership: Villaspine
Limited (100%), Providence (<1%), Saferay Spine, LLC (Owner),
SafeWire (33334 Shares), Vertera (<1%); Private Investments:
SafeWire (30000 Shares); Consulting: NuVasive (D); Trips/Travel:
Vertera (A); Board of Directors: SafeWire (Stock ownership disclosed),
Saferay Spine, LLC (Director); Scientific Advisory Board: Providence
(B); Research Support - Staff and/or Materials: NuVasive (C, Paid
directly to institution/employer).
Jacquot, Frederic P.: Trips/Travel: Stryker (A), Vexim (A), Medtronic (B).
Kanter, Adam S.: Royalties: Lanx (F, Paid directly to institution/
employer); Consulting: NuVasive (Financial, Paid directly to
institution/employer).
46
Katzell, Jeffrey L.: Royalties: Amendia (C); Stock Ownership: Amendia
(150000 Shares); Consulting: Amendia (Stock ownership disclosed);
Speaking and/or Teaching Arrangements: Amendia (Stock ownership
disclosed); Trips/Travel: Amendia (B).
Khoo, Larry T.: Consulting: TranS1 (Amount not dislcosed); Speaking
and/or Teaching Arrangements: TranS1 (Consulting disclosed).
Koh, Eugene Y.: Consulting: Biomet (None).
Koski, Tyler R.: Royalties: NuVasive (F); Stock Ownership: NuVasive
(8000 Shares); Consulting: NuVasive (B), MB Innovations/Spine Wave
(None), Medtronic (B); Speaking and/or Teaching Arrangements:
Medtronic (Consulting disclosed); Trips/Travel: Medtronic (B),
NuVasive (A); Scientific Advisory Board: SpineCME (None); Research
Support - Staff and/or Materials: Medtronic (B, Paid directly
to institution/employer); Grants: Medtronic (C, Paid directly to
institution/employer).
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);
Stock Ownership: Theracell (.4%); Consulting: Globus Medical (A),
Pioneer Surgical (A).
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).
Poelstra, Kornelis A.: Consulting: DePuy Spine (D); Speaking and/or
teaching arrangements: K2M (C); Trips/travel: Mazor (B), Benvenue
(B).
DISCLOSURE INDEX
Qureshi, Sheeraz A.: Royalties: Zimmer Spine (A); Consulting: Stryker
Spine (B), Medtronic Spine (B), Orthofix (B); Speaking and/or
Teaching Arrangements: Globus (B), Stryker (B), Medtronic (B); Board
of Directors: MTF (B, Paid directly to institution/employer); Scientific
Advisory Board: Orthofix (None), Zimmer (None); Other Office: CSRS
(Program Committee, Survey Committee), NASS (Value Committee,
Evidence Based Guidelines Committee), AAOS (Evaluations
Committee); Grants: CSRS (C, Paid directly to institution/employer);
Fellowship Support: Globus Medical (E, Paid directly to institution/
employer).
Racadio, John: Consulting: Philips Healthcare (None).
Sandhu, Faheem: Royalties: K2M (C), SpineArt (A), Globus (A), Precision
Spine (B); Stock Ownership: Globus (450 Shares); Consulting: K2M
(B), Precision Spine (B), Facet Link (B), SpineGuard (B), VGI (B);
Speaking and/or Teaching Arrangements: K2M (B), SpineGuard (C),
SpineArt (B); Scientific Advisory Board: K2M (B), Aesculap (B).
Wang, Michael Y.: Royalties: DePuy Spine (E); Consulting: DePuy
Spine (E), Aesculap (B); Speaking and/or Teaching Arrangements:
DePuy Spine (C), K2M (B), Joimax (B); Scientific Advisory Board: ISD
(None); Grants: Department of Defense (A, Paid directly to institution/
employer).
Yassari, Reza: Private Investments: Sigma Surgical (15%); Speaking
and/or teaching arrangements: AO Spine (Travel expenses).
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).
Yue, James J.: Royalties: Alphatec Spine (B); Stock Ownership: Alphatec
Spine (<1%); Private Investments: Paradigm Spine (<1%); Consulting:
Wolf Spine (B), Aesculap Spine (B); Speaking and/or Teaching
Arrangements: Replication Medical (B).
The following participants have Nothing to Disclose:
Amburgy, John W.
Banagan, Kelley E.
Brown, Luke
Cavanaugh, Daniel L.
Cerier, Emily
Chambers, Melissa
Choi, Gun
Choi, Pil Sun Dahdaleh, Nader S.
De la Garza Ramos, Rafael
Doers, Thomas M.
Du, Jianwei
Fan, Guoxin
Fontanella, Andrea
Gastambide, Daniel
Haitao, tan
Hakobyan, Arman
Haranhalli, Neil
He, Shisheng
Hellinger, Stefan
Hsu, 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, Alan
Liu, 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, Maharaj
Smith, 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
Yang, Yang
Ying, Li
Yu, Keyi
Yu, Liang
Yu, Pei
Zhang, Chao
Zhang, Chunlin
Zhang, Wei
Zhang, Xingkai
Zhou, Yue
Zhu, Bo
47
TECHNICAL EXHIBITION
Back Pain Centers of America
joimax, Inc.
www.backpaincentersofamerica.com
www.joimaxusa.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.
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.
Eclipse Loupes and Products
KARL STORZ Endoscopy America Inc.
www.eclipseloupesandproducts.com
www.ksea.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.
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.
elliquence, LLC
www.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 GmbH
www.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.
48
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-toreach areas, and the TipControl Articulating Nucleus Resector which
permits the rapid and efficient removal of nucleus tissue.
2017 ISMISS BOARD OF DIRECTORS
R. Fessler, MD
A. Fontanella, MD
President 2017-2020
National Representative: Italy
Y. Zhou, MD
A. Dezawa, MD
President-Elect
National Representative: Japan
J. Oertel, MD
C. Chung, MD
Vice President 2017-2020
National Representative: Korea
V. Radchenko, MD
L. Antolak, MD
Past President 2017-2020
National Representative: Poland
J. Chiu, MD
P. Pereira, MD
Secretary/Treasurer: American Branch
National Representative: Portugal
H. Leu, MD
L. Sak, MD
Secretary/Treasurer: European Branch
National Representative: Russia
M. Yoshida, MD
R. Morgenstern, MD
Secretary/Treasurer: Asian Branch
National Representative: Spain
C. Rezoagli, MD
M. Rühli, MD
National Representative: Argentina
National Representative: Switzerland
A. Hakobyan, MD
E. Yalniz, MD
National Representative: Armenia
National Representative: Turkey
G. Speck, MD
Y. Pedachenko, MD
National Representative: Australia
National Representative: Ukraine
S. Hsu, MD
A. Mesiwala, MD
National Representative: China/ROC
National Representative: United States of America
Y. Zhou, MD
S. Shatursunov, MD
National Representative: China/PRC
National Representative: Uzbekistan
D. Gastambide, MD
M. Hinsenkamp MD
National Representative: France
SICOT Representative
C. Birkenmaier, MD
F. Jacquot, MD
National Representative: Germany
WCMISST Representative
A. Erbszt, MD
E. Muehlbauer
National Representative: Hungary
NASS Representative
B. Darwono, MD
National Representative: Indonesia
49
2016-2017 NASS BOARD OF DIRECTORS
F. Todd Wetzel, MD
Joseph S. Cheng, MD, MS
President
Section Development Chair
Daniel K. Resnick, MD, MS
Charles Cho, MD
1st Vice President
Evidence Compilation and Analysis Chair
Jeffrey C. Wang, MD
Mitchel Harris, MD, FACS
2nd Vice President
Governance Committee Chair
Christopher M. Bono, MD
Alan S. Hilibrand, MD
Past President
Continuing Medical Education Chair
William J. Sullivan, MD
Scott Kreiner, MD
Secretary
Clinical Research Development Chair
Eeric Truumees, MD
Donna D. Ohnmeiss, PhD
Treasurer
Education Publishing Chair
David Rothman, PhD
Mitchell Reiter, MD
Ethicist
Payor Policy Review Chair
Edward J. Dohring, MD
Jerome Schofferman, MD
Education Council Director
Committee on Ethics & Professionalism Chair
John G. Finkenberg, MD
Norman B. Chutkan, MD, FACS
Advocacy Council Director
At Large Member
Zoher Ghogawala, MD, FACS
Matthew Smuck, MD
Research Council Director
At Large Member
David R. O’Brien Jr., MD
Eric J. Muehlbauer, MJ, CAE
Health Policy Council Director
Executive Director
Charles A. Reitman, MD
Administration and Development Council Director
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Follow us:
2017
APPLICATION FOR MEMBERSHIP
Full Name (including degrees):
Date of Birth (mm/dd/yy):
Gender: q Male q Female
Preferred Mailing Address: q Professional q Home
Professional Address (as it should be listed in the Find a Specialist directory)
Company Name:
Address:
City:
Phone:
State/Province:
Postal Code:
Fax:
Country:
Email:
Office Manager Email (to contact regarding membership information):
Home Address
Address:
City:
State/Province:
Mobile Phone:
Postal Code:
Country:
Email:
Professional Information
Specialty:
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
Primary Employer: q Hospital
q Private Practice
q Academic Institution
q Other:
Have you ever had a license to practice medicine revoked or suspended in any jurisdiction, past or present? q No
(If yes, please attach an explanation)
q Yes
Have you ever been censured/sanctioned by another professional medical association or organization?
(If yes, please attach an explanation of the circumstances and specify the sanction enforced)
q Yes
q No
Application Requirements
Curriculum Vitae/Résumé
Please 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 issues
q To take advantage of membership discounts on educational offerings
q To access journals and publications
q To network with colleagues
q To support and contribute to the field
q Other:
)
Continued on next page
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Category of Membership
Please 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.
In-Training Membership Applicants Only
q 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 Payment
Application 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 #:
Cardholder’s Name:
Expiration Date (mm/yy):
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.
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.
Application Check List
Have you...
q Attached a copy of your CV or résumé?
q Remitted payment (if applicable)?
54
North American Spine Society
7075 Veterans Blvd. | Burr Ridge, IL 60527
Phone: 630-230-3600 | Fax: 630-230-3700
www.spine.org | [email protected]
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