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Lumbar vacuum disc, vertical instability, standalone endoscopic interbody fusion, and other treatments: an opinion based survey among minimally invasive spinal surgeons.

ABSTRACT: Background:A diseased lumbar intervertebral vacuum disc void of any structurally intact tissue may be vertically unstable. A primary standalone endoscopic decompression and interbody fusion surgery in the treatment of vertical instability in patients with a vacuum disc may be a more reliable treatment than decompression alone. Methods:The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups on social media networks, including Facebook, WeChat, WhatsApp, and Linkedin. Descriptive and correlative statistics were employed to count the responses and compare the surgeon's responses recorded on a Likert scale from 1 (disagree) to 10 (agree) or in multiple-choice questions. Surgeons were asked about their familiarity with the concept of vacuum disc and vertical instability and how they would treat such patients. Kappa statistics and linear regression analysis of agreement of incoming responses were performed. Results:A total of 1,165 surgeons accessed the survey. The completion rate was 22.78. The majority surgeons were very familiar with the concept of a "vacuum disc" as a sign of end-stage lumbar degenerative disc disease and a collapsing lumbar motion segment (182/273; 66.7%; Likert score 6.53). The majority of surgeons also thought that vertical instability precedes anterolateral lumbar instability (187/273; 68.5%; Likert score 6.64) and that a vacuum disc may cause vertical instability with symptomatic dynamic foraminal & lateral recess stenosis (222/273; 81%; Likert score 7.48), mechanical back pain (201/273; 73.1%; Likert score 7.48), and may cause sciatica-type low back and leg pain (179/273; 66.3%; Likert score 6.59). The majority of surgeons indicated that vacuum phenomenon on radiographic studies is associated with vertical instability and collapse resulting in dynamic foraminal and lateral recess stenosis and should be treated surgically (199/266; 73.7%; 7 missing responses; Likert score 6.86). Preferred treatments were decompression alone without fusion (P<0.014). There was consensus in support of fusion by TLIF or PLIF with a Likert score of 6.68 (184/266; 69.2%; 7 missing responses). There was no consensus on standalone fusion. Conclusions:Vacuum phenomenon on radiographic studies is associated with a vertical instability and collapse, resulting in dynamic foraminal and lateral recess stenosis that should be treated surgically. Preferred surgical treatments were decompression alone, decompression with interbody fusion using just bone graft, and fusion employing TLIF or PLIF. Further research into the clinical significance of lumbar vacuum disc, vertical instability and its most appropriate surgical treatments if any is necessary.

SUBMITTER: Lewandrowski KU

PROVIDER: S-EPMC7063324 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Lumbar vacuum disc, vertical instability, standalone endoscopic interbody fusion, and other treatments: an opinion based survey among minimally invasive spinal surgeons.

Lewandrowski Kai-Uwe KU Zhang Xifeng X Ramírez León Jorge Felipe JF de Carvalho Paulo Sérgio Teixeira PST Hellinger Stefan S Yeung Anthony A

Journal of spine surgery (Hong Kong) 20200101 Suppl 1

<h4>Background</h4>A diseased lumbar intervertebral vacuum disc void of any structurally intact tissue may be vertically unstable. A primary standalone endoscopic decompression and interbody fusion surgery in the treatment of vertical instability in patients with a vacuum disc may be a more reliable treatment than decompression alone.<h4>Methods</h4>The authors solicited responses to an online survey sent to spine surgeons by email, and chat groups on social media networks, including Facebook, W ...[more]

PMID: 32195425

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Project description:We report a case of subsidence induced recurrence of unilateral L5 and S1 radiculopathy six months following a successful staged two-level endoscopic standalone lumbar interbody fusion using the VARILIF-L™ device. The patient was a 64-year-old female who first underwent outpatient endoscopic fusion L4/5 for failed non-operative care of Grade I spondylolisthesis. Within 11 months from the L4/5 index procedure, she developed symptomatic adjacent segment disease stemming from the L5/S1 level. A preoperative computed tomography before the planned L5/S1 endoscopic standalone VARILIF™ fusion 15 months following her L4/5 VARILIF™ procedure revealed fusion at the L4/5 level with minimal subsidence of the VARILIF-L™ implant, and advanced degeneration of the L5/S1 motion segment with lateral recess and foraminal stenosis, reduced posterior disc height, and vacuum disc. The patient underwent uneventful L5/S1 endoscopic standalone fusion using the VARILIF-L™ implant with successful clinical outcome and resolution of back and leg symptoms. Six months after the second endoscopic L5/S1 VARILIF™ procedure she developed recurrent L5 and S1 radiculopathy. Computed tomography showed significant implant subsidence and formation of a large soft tissue bulge on the approach side behind the interbody fusion cage. The subsidence induced subsidence and loss of posterior disc height and the associated recurrence of nerve root compression of the traversing S1 and exiting L5 nerve root. The recurrent radiculopathy was eventually treated with another transforaminal endoscopic decompression which included a more generous foraminoplasty with resection of the remaining superior articular process including a partial S1 pediculectomy and additional resection of the posterior annulus as well as scar and bony tissue that had formed within the axillary hidden zone of Macnab. We concluded that recurrent radiculopathy might occur after standalone lumbar transforaminal endoscopic interbody fusion with an expandable threaded cylindrical cage as a result of vertical and angular subsidence.

Project description:BackgroundMinimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and oblique lateral interbody fusion (OLIF) are widely used in the treatment of lumbar degenerative diseases. In the present study, a meta-analysis was conducted to compare the clinical and radiographic efficacy of these two procedures.MethodsA systematic literature review was performed, and the quality of retrieved studies was evaluated with the Newcastle-Ottawa Scale (NOS). Clinical outcomes, including operation time, intraoperative blood loss, improvement in Visual Analogue Scale (VAS), improvement in Oswestry Disability Index (ODI), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) effectiveness rate and complications, in addition to radiographic outcomes, including restoration of disc height, disc angle, overall lumbar lordosis, fusion rate and subsidence, were extracted and input into a fixed or random effect model to compare the efficacy of MIS-TLIF and OLIF.ResultsSeven qualified studies were included. Clinically, OLIF resulted in less intraoperative blood loss and shorter operation time than MIS-TLIF. Improvement of VAS for leg pain was more obvious in the OLIF group (P < 0.0001), whereas improvement of VAS for back pain (P = 0.08) and ODI (P = 0.98) as well as JOABPEQ effectiveness rate (P = 0.18) were similar in the two groups. Radiographically, OLIF was more effective in restoring disc height (P = 0.01) and equivalent in improving the disc angle (P = 0.18) and lumbar lordosis (P = 0.48) compared with MIS-TLIF. The fusion rate (P = 0.11) was similar in both groups, while the subsidence was more severe in the MIS-TLIF group (P < 0.00001).ConclusionsThe above evidence suggests that OLIF is associated with a shorter operation time (with supplementary fixation in the prone position) and less intraoperative blood loss than MIS-TLIF and can lead to better leg pain alleviation, disc height restoration and subsidence resistance. No differences regarding back pain relief, functional recovery, complications, disc angle restoration, lumbar lordosis restoration and fusion rate were found. However, due to the limited number of studies, our results should be confirmed with high-level studies to fully compare the therapeutic efficacy of MIS-TLIF and OLIF.Trial registrationPROSPERO ID: CRD42020201903 .

Dataset Information

Lumbar vacuum disc, vertical instability, standalone endoscopic interbody fusion, and other treatments: an opinion based survey among minimally invasive spinal surgeons.

Publications

Lumbar vacuum disc, vertical instability, standalone endoscopic interbody fusion, and other treatments: an opinion based survey among minimally invasive spinal surgeons.

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