Robotic-assisted minimally invasive repair surgery for progressive spondylolysis in a young athlete: a technical note.

Presently, the invasiveness of direct repair surgery for lumbar spondylolysis is relatively high. Thus, high school and junior high school students who play sports often cannot return to sports before graduation because of the invasiveness. The use of a robotic system enabled an accurate and minimally invasive procedure. Robotic-assisted minimally invasive direct pars repair surgery is useful for young patients with progressive spondylolysis.


Morphological Evaluation of Lumbar Facet Joints in Professional Baseball Players.

The facet joints of professional baseball players were enlarged asymmetrically, with different tendencies observed between pitchers and fielders. Although pitching and batting are movements that transmit the rotation from the lower limbs to the upper limbs, the effects of rotation and lateral flexion were associated significantly with facet joint hypertrophy.


Clinical Outcome of Full Endoscopic Trans Kambin's Triangle Lumbar Interbody Fusion: A Systematic Review.

Full-endoscopic (FE) lumbar interbody fusion (LIF) is now a widely used type of minimally invasive surgery (MIS). Although FE-LIF includes LIF with foraminoplasty via a Kambin's triangle approach (FE-KLIF) and LIF with foraminotomy via an interlaminar approach, these techniques are rarely discussed separately. This review evaluates the outcomes and complications of FE-KLIF reported in the literature. The PubMed, Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting the outcomes of FE-KLIF. Of 464 publications assessed, 11 met our inclusion criteria. Although the most frequently treated level was L4/5, L5/S1 was also treated. FE-KLIF was performed under local anesthesia and sedation or under epidural anesthesia without general anesthesia. Visual analog scale and Oswestry Disability Index scores were improved postoperatively in all uncontrolled studies; however, there was no significant difference in these scores in studies that compared FE-KLIF with posterior LIF (PLIF) or MIS-transforaminal LIF (TLIF). There was also no significant difference in the fusion rate between FE-KLIF and PLIF or MIS-TLIF. In terms of complications, although there were no reports of hematoma, dural tear and surgical site infection were reported in 1 paper each, with transient nerve disorders reported in 5 studies (frequency, 1.8%-23.5%). This review indicates that FE-KLIF is a feasible and viable surgical option for lumbar degenerative disease. However, the amount and level of evidence is low for the studies included in this review, and the data on long-term outcomes remain limited.


Facet Joint Morphology and Tropism in Adolescents: Association with Lumbar Disc Herniation and Spondylolysis.

Facet tropism in adolescents is similar in the axial and sagittal planes. Facet tropism and specific morphology may be related to lumbar disc herniation and spondylolysis in this age group.

The orientation of all lumbar facet joints was measured in the bidirectional planes on computed tomographic images for 191 patients with low back pain. The patients were divided into four groups according to age (<15 or ≥15 y) and sex. The facet joint angle and tropism rate were compared among the groups. Facet tropism was defined as a difference in bilateral angle of >10° in the axial plane and >5° in the sagittal plane. Facet joint orientation was compared among groups using one-way analysis of variance and Tukey's honestly significant difference test or Games-Howell post hoc test and the incidence of facet tropism using the Kruskal-Wallis test with Bonferroni correction. The association of facet tropism with disease was investigated further by analyzing facet joint orientation and the incidence of facet tropism in 116 patients with single-level lumbar disease.


Advantages of Full-endoscopic Trans-Kambin's Triangle Lumbar Interbody Fusion for Degenerative Spondylolisthesis: Illustrative Cases.

Various approaches to lumbar interbody fusion have been described. The usefulness of full-endoscopic trans-Kambin's triangle lumbar interbody fusion has recently been reported. This technique has several advantages in patients with degenerative spondylolisthesis, including the ability to improve symptoms without decompression surgery. Moreover, given that the entire procedure is performed percutaneously, it can be performed without increasing the operation time or surgical invasiveness, even in obese patients. In this article, we discuss these advantages and illustrate them with representative cases.


Low Back Pain and Lumbar Degeneration in Japanese Professional Baseball Players.

Among professional baseball players in their 20s, lumbar degeneration was less common, and they most frequently developed diseases less related to degeneration, such as LDH. However, among players in their 30s, lumbar degeneration was more advanced, and degenerative diseases such as discogenic pain occurred more frequently. Research on training methods could lead to the prevention of LBP. Our data may be applicable to other professional athletes and will contribute to diagnosis and treatment.


Full-Endoscopic Trans-Kambin Triangle Lumbar Interbody Fusion: Surgical Technique and Nomenclature.

Kambin's triangle lies immediately behind the psoas major. Therefore, we consider KLIF as a lateral LIF procedure comparable with oblique or extreme LIF. However, unlike oblique or extreme LIF, there are no major vessels and organs in the surgical field; therefore, KLIF is the safest type of lateral LIF. Furthermore, using the endoscope, we can perform decompression directly using the facetectomy technique.

Journal of Neurological Surgery. Part A, Central European Neurosurgery


Association of spinal anomalies with spondylolysis and spina bifida occulta

To investigate the association of spinal anomalies with lumbar spondylolysis and spina bifida occulta (SBO). A total of 1190 patients with thoracic, abdominal, and pelvic computed tomography scans available were categorized according to the number of presacral (thoracic and lumbar) mobile vertebrae and the presence or absence of lumbosacral transitional vertebrae (LSTV). The prevalence of spondylolysis and SBO and the association of spinal anomalies with these disorders were evaluated. Normal morphology (17 mobile vertebra with no LSTV) was found in 607 men (86.5%) and 419 women (85.9%) and about 14% of patients had anomalies. Spondylolysis was found in 74 patients (6.2%), comprising 54 men (7.7%) and 20 women (4.1%). SBO involving the lumbar spine was found in 9 men (1.3%) and 2 women (0.4%). Spondylolysis was significantly more common in men with 18 vertebrae without LSTV (21.1%) than in those with 17 vertebrae without LSTV (7.2%) (p = 0.002). The prevalence of spinal anomalies was 55.6% in men and 50.0% in women with SBO that included a lumbar level was significantly higher than in both men (13.5%, p < 0.001) and women (4.8%, p = 0.003) without SBO. These findings indicate that there is a relationship between spinal anomalies and both spondylolysis and SBO, which may lead to elucidation of the mechanism of onset of spondylolysis and improve its treatment and prognosis. Awareness that patients with SBO involving the lumbar spine have an increased likelihood of a spinal anomaly may help to prevent level errors during spinal surgery.


Successful treatment of intractable pseudomeningocele with FXIII deficiency by surgery and FXIII replacement therapy: A case report.

Pseudomeningocele is an extradural cystic collection of cerebrospinal fluid (CSF) and is rare and typically asymptomatic. However, pseudomeningocele is sometimes associated with symptoms. Whether symptomatic pseudomeningocele is best treated conservatively or surgically remains controversial. Factor XIII (FXIII) is a blood coagulation factor that also promotes fibroblast proliferation during wound healing. Although treatment of postsurgical CSF leakage with FXIII has been reported, there have been no reports on surgical treatment and FXIII replacement therapy of pseudomeningocele with FXIII deficiency. We report a case of pseudomeningocele with FXIII deficiency that was successfully treated by surgery and FXIII replacement therapy. The patient presented with symptoms of intracranial hypotension syndrome that had started a few months after laminectomy for thoracic ossification of the ligamentum flavum 2 years earlier. Magnetic resonance imaging and delayed computed tomography myelography confirmed a diagnosis of pseudomeningocele. Epidural blood patch treatment was performed twice but did not result in improvement. Furthermore, the FXIII level decreased to 56%, so the patient was also diagnosed as having acquired FXIII deficiency. We elected to treat the patient by surgery with FXIII replacement therapy. The dural injury was repaired using an artificial dura mater patch, fibrin glue, and polyglycolic acid sheets. The FXIII level was 74%-135% during the perioperative period. The patient had a good postoperative course. Postoperative magnetic resonance images showed resolution of the pseudomeningocele. There was no recurrence during 6 months of follow-up. Perioperative FXIII replacement may be a useful treatment for pseudomeningocele with FXIII deficiency.

International Journal of Surgery Case Reports


Comparison between O-arm Navigation and Conventional Fluoroscopic Guidance in Corrective Posterior Fixation for Cervical Spinal Injury.

Purpose : To compare the effectiveness of O-arm navigation with that of conventional fluoroscopic guidance in corrective posterior fixation for cervical spinal injury. Methods : This retrospective comparative study involved 11 consecutive patients who underwent corrective posterior fixation using O-arm navigation or conventional fluoroscopy for cervical spinal injury between February 2016 and May 2021. Patient-specific characteristics (age and sex), number of screws, number of pedicle screws, accuracy of pedicle screw insertion, number of vertebral bodies fixed, operating time, and length of hospital stay were analyzed using the t-test. A P-value < 0.05 was considered statistically significant. Results : Corrective posterior fixation was performed under O-arm navigation in 5 patients and under conventional fluoroscopic guidance in 6. A significantly greater number of pedicle screws was used in the O-arm group (6.4 vs 2.7, P = 0.046). According to the Neo classification for pedicle screw placement, there were no grade 2 or 3 breaches. No other items showed a significant difference between the groups (P > 0.05). Conclusion : O-arm navigation can improve the accuracy of cervical pedicle screw insertion. Its introduction could expand the indications for use of pedicle screws in posterior fixation of cervical spinal injury beyond those that are possible using conventional fluoroscopy. J. Med. Invest. 69 : 273-277, August, 2022.

The Journal of Medical Investigation : JMI


Role of growth plate (apophyseal ring fracture) in causing modic type changes in pediatric low back pain patients.

Diagnostic: individual l cross-sectional studies with consistently applied reference standard and blinding.

A total of 368 MRI obtained for 240 male and 128 female patients under the age of 18 years with complaints of low back/leg pain were retrospectively examined. All changes in signal intensity in the vertebral endplate and subchondral bone on MRI were defined as MCs. We investigated the relationship between MCs and underlying diseases, including lumbar spondylolysis/spondylolisthesis, and conditions of the growth plate in cases with MCs. The degree of disc degeneration in patients with MCs was evaluated using the Pfirrmann grading system.


Transitional vertebrae and numerical variants of the spine : prevalence and relationship to low back pain or degenerative spondylolisthesis.

Overall, 24% of subjects had anomalies in the thoracolumbar region: the type of anomaly differed between males and females, which could have significant implications for spinal surgery. A decreased number of vertebrae was associated with DS: numerical variants may potentially be a clinical problem. Cite this article:


Successful Full Endoscopic Surgery for L5 Radiculopathy Due to L4-5 Discal Cyst and Disc Herniation in a Professional Baseball Player.

Discal cysts are rare intraspinal extradural cysts that communicate with the corresponding intervertebral discs, and the diagnosis is difficult to distinguish from other causes of low back pain and radiculopathy. Optimal management for this type of cyst has not been determined because of its rarity. Here, we report successful treatment of a discal cyst and lumbar disc herniation using full endoscopic surgery in a professional baseball player with a chief complaint of weakness in his left lower leg. He had been treated conservatively but symptoms did not improve. Discography helped us to differentially diagnose discal cyst from other cystic lesions. Conventional surgical treatment would have resulted in considerable loss of baseball playing time for the patient. We opted to perform minimally invasive transforaminal full endoscopic surgery under local anesthesia to treat the discal cyst and lumbar disc herniation simultaneously without resection of bone and ligament handling. We removed the discal cyst and disc herniation, which released tension on the left nerve root at the L5 level, and then performed thermal annuloplasty to avoid recurrence. Postoperative course was good and he returned to play baseball at his original competitive level 3 months later. To our knowledge, there have been no previous reports of successful full endoscopic surgery for discal cyst and lumbar disc herniation performed simultaneously in a professional baseball player. It can be difficult to decide on the proper treatment for discal cysts, but full endoscopic surgery for symptomatic discal cyst might be one good option especially for elite athletes.


Prompt Return to Work after Bilateral Transforaminal Full-endoscopic Lateral Recess Decompression under Local Anesthesia: A Case Report.

Transforaminal full-endoscopic lumbar diskectomy became established early in the 21st century. It can be performed under local anesthesia and requires only an 8-mm skin incision, making it the least invasive disk surgery method available. The full-endoscopic technique has recently been used to treat lumbar spinal canal stenosis. Here, we describe the outcome of simultaneous bilateral decompression of lumbar lateral recess stenosis via a transforaminal approach under local anesthesia in a 60-year-old man. The patient presented with a complaint of bilateral leg pain that was preventing him from standing and walking, and he had been able to continue his work as a dentist by treating patients while seated. Imaging studies revealed bilateral lumbar lateral recess stenosis with central herniated nucleus pulposus at L4/5. We performed simultaneous bilateral transforaminal full-endoscopic lumbar lateral recess decompression (TE-LRD) under local anesthesia. Both decompression and diskectomy were successfully completed without complications. Five days after TE-LRD, he was able to return to work, and 3 months after the surgery, he resumed playing golf. Full-endoscopic surgery under local anesthesia can be very effective in patients who need to return to work as soon as possible after surgery.

Journal of Neurological Surgery. Part A, Central European Neurosurgery


Risk Factor for Additional Intravenous Medication during Transforaminal Full-endoscopic Lumbar Discectomy under Local Anesthesia.

Transforaminal full-endoscopic lumbar discectomy (TELD) can be performed under local anesthesia. However, there have been no reports on risk factors for a change in vital signs or the need for additional medications to maintain adequate analgesia during this procedure. The purpose of this study was to identify risk factors for additional intravenous medication during TELD under local anesthesia. The following factors were retrospectively evaluated in 113 consecutive patients who underwent TELD under local anesthesia at our institution: demographic characteristics, radiological features at the intervertebral disc level, distance between the superior articular process and the exiting nerve root, height of the intervertebral disc, height of the bulging disc, height of the intervertebral foramen, and distance from the insertion site to the spinous process on magnetic resonance imaging (MRI) and computed tomography (CT) scans of the lumbar spine. Logistic regression analysis was performed to determine factors associated with the need for additional drugs. In all, 23 cases (20.4%) required additional intraoperative medications because of hypertension, hypotension, bradycardia, or pain. Logistic regression analysis revealed that age (partial regression coefficient 0.05, p = 0.02) and bulging disc height (partial regression coefficient -0.7, p = 0.003) influenced the need for additional drugs. There were significant associations of need for additional intravenous medication with older age (>62 years) and a smaller bulging disc height (<8.2 mm). Patients with these factors require close monitoring for changes in vital signs or increasing pain when performing TELD under local anesthesia and may need additional intravenous medication.


Bone Formation During Correction of Vertebral Rounding Deformity in a Rat Model of Pediatric Spondylolisthesis.

Correction of vertebral rounding deformity was associated with improvement of chondrocyte differentiation; furthermore, there is possible involvement of a third mechanism, namely transchondroid bone ossification.Level of Evidence: N/A.


Return to the Original Work Activity Following the Full-endoscopic Lumbar Surgery under the Local Anesthesia.

Transforaminal full-endoscopic spine (TF-FES) surgery is minimally invasive and can be performed under local anesthesia. Thus, it is expected that the patient can return to work (RTW) quickly. However, information in the literature regarding this is sparse. The purpose of this study is to review the timing of RTW after TF-FES surgery. This study involved 50 patients (14 women, 36 men; mean age 44.5 years, age range: 20-65 years) who underwent TF-FES surgery between January 2016 and April 2018. All the patients were active workers. Occupations varied widely (e.g., physician, nurse, helper, clerk, construction worker, chef, and schoolteacher). There were no surgery-related complications. Median time to RTW was 21 days. More than half of the patients could RTW within 21 days. In all, 12 cases (24%) could have RTW within 7 days. Occupations of 12 patients who achieved RTW within 7 days included physician, company owner, and restaurant owner, with 11 in the Light work, 1 was in the Medium work, and none in the Heavy work. All 12 had a quick RTW because their work was Light and they could not take prolonged sick leave. Prompt RTW is possible with TF-FES surgery. The biggest merit of TF-FES surgery is minimal invasiveness to the muscles of the back. Also, it can be performed under local anesthesia. Our findings reveal quicker RTW after surgery, depending on occupational type.


Extraosseous Signal Changes on Magnetic Resonance Imaging in Pediatric Patients with Early-Stage Lumbar Spondylolysis.

Purpose : To analyze extraosseous signal changes (ESCs) on magnetic resonance imaging (MRI) in pediatric patients with stress fractures occurring in the lamina. Methods : This study was a retrospective review of 69 consecutive pediatric patients with stress fractures occurring in the lamina. We analyzed MRI scans obtained at the first presentation. Results : We used mainly axial short tau inversion recovery images acquired through the pedicle of these 84 fracture sites to identify the ESCs. These were then divided into three groups: "invisible" when no ESC was detected, "periosteal" for ESC seen on only the dorsal side of the lamina, and "perimuscular" for ESC distinctly spread around / in the paravertebral muscles. In total, 78 (92.9%) fracture sites showed ESCs on the dorsal side of the lamina among which 72 ESCs were located on only the "dorsal" side, while 6 ESCs were on the ventral side against the transverse process. Conclusion : ESCs on MRI were detected in more than 90% of patients before stress fracture became apparent in the lamina, which was considered similar to findings of periosteal thickening / edema detected at the onset of stress fracture in long bone. J. Med. Invest. 68 : 136-139, February, 2021.

The Journal of Medical Investigation : JMI


Full-endoscopic Decompression of Foraminal Stenosis Caused by Facet Hypertrophy Contralateral to the Dominant Hand in a Baseball Pitcher: A Case Report.

Back pain and lower extremity pain have various causes and occasionally occur simultaneously, creating diagnostic difficulties. In addition, athletes require special consideration in terms of treatment. Here, we report a case of foraminal stenosis as a result of lumbar disc prolapse combined with facet hypertrophy contralateral to the dominant hand in a baseball pitcher that was successfully treated by minimally invasive full-endoscopic surgery. A 31-year-old left-handed male baseball pitcher presented with complaints of low back pain and right buttock pain while pitching. A diagnosis of foraminal stenosis caused by a disc bulge combined with facet hypertrophy contralateral to the dominant hand was made on the basis of physical and radiological findings. His symptoms improved immediately after transforaminal full-endoscopic lumbar discectomy and foraminoplasty under local anesthesia. He returned to play 3 months after surgery. Foraminal stenosis due to facet hypertrophy may occur in the side contralateral to the throwing arm in pitchers. Minimally invasive decompression using a full-endoscopic procedure is required for high-level athletes at this position.


Spontaneous Laminar Fracture during Successful Conservative Treatment of Lumbar Spondylolysis at the Adjacent Spinal Level: A Case Report.

Although lumbar spondylolysis (LS) is regarded as a stress fracture, the underlying pathomechanism has yet to be fully elucidated. Here, we present a case that casts doubt on the notion that LS is truly a stress fracture. An 11-year-old female basketball player was brought to our clinic with a 2-week history of persistent low back pain. Magnetic resonance imaging with short TI inversion recovery (STIR-MRI) showed high signal intensity changes at the L4 pedicles bilaterally. Computed tomography (CT) revealed a faint fracture line at the left pars interarticularis. We made a diagnosis of stress fracture and recommended conservative treatment, including cessation of sports activities and wearing of a hard brace. Compliance with treatment was excellent. As expected, the STIR-MRI findings at L4 gradually resolved and bone healing was achieved. However, a follow-up STIR-MRI scan 10 weeks later revealed high signal intensity at the left L5 pedicle. Conservative treatment was continued for the findings at L5, which were considered to indicate a stress fracture (spondylolysis). Five weeks later, CT revealed a bony defect in the lamina at L5 on the left and bone union at L4. Although LS is generally considered to be a stress fracture, there have been several reports of familial occurrence and genetic predisposition. This patient's mother had also been treated for spondylolysis at L5. These observations suggest an underlying genetic etiology in this case.


Morphometric Analysis of Subaxial Cervical Spine with Myelopathy: A Comparison with the Normal Population.

The morphometry of the sagittal diameter of the spinal canal, sagittal-transverse ratio, and canal-body ratio on axial reconstructive CT images appears useful for distinguishing cervical spinal canal stenosis involving myelopathy.


Debridement for Infectious Spondylodiscitis in a 9-year-old Girl Using Full-Endoscopic Discectomy System : a Case Report and literature review.

Objective : Infectious spondylodiscitis (IS) is rarely seen in healthy elementary school age children. Conservative treatment with antibiotics is usually preferable but sometimes fails because of the low identification rate of the pathogen by percutaneous needle biopsy. When surgical treatment is indicated, selecting the appropriate procedure is crucial in terms of invasiveness for such young children. Case report : We present the case of a 9-year-old otherwise healthy girl with IS who successfully underwent debridement and identification of the causative pathogen using full endoscopic discectomy (FED) system. Methicillin-susceptible Staphylococcus aureus was identified on several cultures of samples. Immediately after the surgery, the LBP was significantly decreased and the remittent fever resolved dramatically. At the 1-year follow-up, she had no symptoms and plain radiographs showed bony fusion. Conclusion : This is the first report on IS in elementary school-age children treated with the FED system. Debridement using this system could provide minimally invasive and effective curettage of the infected disc space and can be helpful in identifying the pathogen even for small children. J. Med. Invest. 67 : 351-354, August, 2020.

The Journal of Medical Investigation : JMI


Successful full-endoscopic decompression surgery under local anesthesia for L5 radiculopathy caused by L5-Sforaminal stenosis and L4-5 lateral recess stenosis : A case report.

In this report, we presented a 65 year-old male case having right leg pain due to L5 radiculopathy. Based on the radiological examination including CT, MRI and radiculography, double crash impingement of L5 nerve root due to L4-5 lateral recess and L5-S foraminal stenosis was diagnosed. Because of the strong pain, he could not work anymore. His job was a general manager of big hospital, he needed to return to job as soon as possible. We decided to conduct the full-endoscopic decompression surgery of ventral facetectomy (FEVF) for L4-5 lateral recess stenosis and foraminoplasty (FELF) for L5-S foraminal stenosis. The technique can be done under the local anesthesia with only 8 mm skin incision; thus, it must be the least invasive spine surgery. Soon after the surgery, he could return to the original job as a general manager. In conclusion, the full-endoscopic decompression surgery for the spinal canal stenosis such as FELF and FEVF would be minimally invasive procedure and it enable patients the quick return to the original activity. J. Med. Invest. 67 : 192-196, February, 2020.


Distribution of the Spinal Arteries in Adult Patients with Lumbar Spondylolysis.

INTRODUCTION : The pathology of lumbar spondylolysis is generally thought to begin with a stress fracture in adolescence. Stress fractures of the lower extremities occur in watershed areas with a poor vascular supply because of an inability to respond to stress and heal. This pathology has not been well researched in the lumbar spine. The aim of this study was to evaluate the distribution of the spinal arteries in patients with lumbar spondylolysis. METHODS : The extraosseous distribution of the arteries around the pars interarticularis was retrospectively investigated in 14 patients with colon cancer who underwent abdominal contrast-enhanced computed tomography (CE-CT) as part of a preoperative assessment at our hospital and were found to have spondylolysis at L5. RESULTS : All patients were found to have terminal-stage spondylolysis at L5 (1 unilateral, 13 bilateral). L5 segmental artery was absent in all cases. However, separate spinal arteries supplying the pars interarticularis at L5 were found above and below the transverse process at this level. CONCLUSION : All the patients had two separate arteries originating from the cranial and caudal sides that distributed to the superior and inferior articular processes, suggesting that the pars interarticularis is a posterior element containing a vascular watershed area. J. Med. Invest. 67 : 62-66, February, 2020.


Operating Costs of Full-endoscopic Lumbar Spine Surgery in Japan.

For full-endoscopic lumbar discectomy, operating costs are also important because expensive equipment are necessary. We surveyed the operating costs of surgical equipment necessary for full-endoscopic surgery together with surgical procedure reimbursement fees. A total of 295 cases of full-endoscopic surgery via a transforaminal approach were retrospectively analyzed. We calculated the frequency of damage and the unit purchase price of devices such as endoscopes, and surgical instruments such as grasping forceps for nucleotomy, high-speed drill bar, and bipolar forceps, and examined the operating costs in Japanese yen against the procedure fee per case. Endoscope breakage occurred seven times, and a payment of ¥760,000 was necessary for trade-in and purchase of a new endoscope. The total breakage number of grasping forceps was 58, and the purchase price per unit was ¥116,000. Therefore, a total of ¥12,020,000 was required for the 295 cases, and the calculated operating cost that accompanies equipment breakage was ¥40,000 per case. In addition, about ¥118,000 was required for disposable bipolar forceps and high-speed drill bar to be used intraoperatively for each case. Thus, for one case it is calculated that total ¥158,000 is utilized for equipment from the surgical reimbursement fee per case specified by the Japanese Ministry of Health being ¥303,900. Minimally invasive procedures provide great benefit to patients; however, the eventual contribution to hospital profits is small and may not be sufficient. To resolve this issue, the cost of surgical equipment should be lowered and/or the surgical reimbursement fee of the full-endoscopic surgery should be raised.


Early return to activity after minimally invasive full endoscopic decompression surgery in medical doctors.

Full endoscopic surgery including discectomy (FED) and ventral facetectomy (FEVF) is a minimally invasive lumbar decompression surgery that only requires an 8 mm skin incision and can be done under the local anesthesia and sedation. Six male medical doctors underwent the endoscopic decompression (FED/FEVF) for common degenerative lumbar spine problems. Their age ranged from 27 to 63 years of age with a mean of 40 years. Five doctors underwent FED surgery for herniated nucleus pulposus (HNP), and the remaining one physician had FEVF for lumbar lateral recess stenosis. There were no surgery related complications. Postoperatively, 5 out of the 6 physician patients returned the original job within a week because they had clinical duties. The shortest duration to return to work was reported by a 63-year-old orthopedic surgeon resumed working in his clinic 2 days after the FEVF surgery. The longest duration to return to work occurred in general medicine resident who took almost 2 weeks for the sick leave because he did not have clinical duties. The mean duration for the returning to work was 5.8 days after the surgery. At final follow-up ranging from 6 to 30 months, all physician patients were working without any residual pain. In the hands of the authors, the full endoscopic transforaminal decompression surgery is the preferred surgical option and allowed early return to work-an observation that is not the norm in Japan.


Intracanalicular Osteochondroma in the Lumbar Spine.

resection of the osteochondroma with the ligamentum flavum relieved the symptoms. Spinal osteochondroma occurs relatively frequently in elderly individuals compared with peripheral lesions and mimics a degenerative spinal disorder. Careful physical examination and imaging evaluation can reveal this tumor and surgery is effective for relieving the symptoms.


Imaging Features of Non-Isthmic Spondylolysis: A Case Report.


Transforaminal full-endoscopic lumbar discectomy under local anesthesia in awake and aware conditions: the inside-out and outside-in techniques.

Initially, TELD was performed as the "inside-out" technique but was associated with reports of postoperative dysesthesia due to exiting nerve injury. Recently, the "outside-in" technique after foraminoplasty was proposed for safer insertion of the cannula into the disc. Foraminoplasty can widen the narrow foramen, thereby allowing the 8-mm cannula to pass through easily and safely, and thus injury to the exiting nerve root can be theoretically avoided. We described two types of the TELD in this review. Surgeons should be familiar with the inside-out and outside-in techniques for TELD; therefore, we can select appropriate technique for each case.

Current Reviews in Musculoskeletal Medicine


Ⅱ各種疾患に対する治療法・モダリティ 腰部脊柱管狭窄症に対する局所麻酔下の全内視鏡手術

整形・災害外科 4月臨時増刊号 脊椎脊髄外科の最近の進歩

整形・災害外科 4月臨時増刊号 脊椎脊髄外科の最近の進歩


Low Back Pain in Adolescent Athletes: Comparison of Diagnoses Made by General Orthopedic Surgeons and Spine Surgeons.

In adolescent athletes, the rate of NSLBP diagnosed by general orthopedic surgeons decreased markedly when the diagnosis was made by spine surgeons. A thorough medical interview, careful physical examination, appropriate diagnostic imaging, and selective nerve block examination can effectively identify the cause of low back pain.


Identification of abnormalities in the lumbar nerve tract using diffusion-weighted magnetic resonance neurography.

Abnormalities of the lumbar nerve tract caused by congenital variations or high nerve root take-off angles are difficult to visualize. Diffusion-weighted magnetic resonance neurography (DW-MRN) has recently been introduced for imaging of the lumbosacral region. The aims of this study were to identify lumbar nerve tract abnormalities caused by congenital variation or a high nerve root take-off angle using DW-MRN and to assess the diagnostic value of this imaging modality.

Congenital variations were identified in 8 patients (9 nerve roots, 1.6%). The most commonly identified variation was in the sacral nerve root (n = 5) followed by the L4 (n = 3) and L5 (n = 1) nerve roots. All variations identified were on the left side. There were 3 cases of type 1a variation, 1 of type 1b, 1 of type 2, and 4 of type 3. In total, 210 (36.6%) of the magnetic resonance images showed high nerve root take-off angles at the intervertebral foramen that was caused by disk herniation, spondylolisthesis, or osteophytes with degeneration. Patients with high nerve root take-off angles were significantly older than those without (P < 0.05). These slides can be retrieved under Electronic Supplementary Material.


Thermal Annuloplasty Using Percutaneous Endoscopic Discectomy for Elite Athletes with Discogenic Low Back Pain.

The purpose of this study was to assess the usefulness of radiofrequency thermal annuloplasty (TA) using percutaneous endoscopic discectomy/TA (PED/TA) in elite athletes with discogenic low back pain. Twelve patients (11 men, 1 woman; mean age 27.9 years) underwent PED/TA under local anesthesia. Clinical data for these patients (17 affected intervertebral discs), including type of sport played, average duration of low back pain, disc level affected, presence or absence of a high signal intensity zone on magnetic resonance imaging, and whether the patient returned to playing competitive sport, were retrospectively reviewed. The most common sport played by the patient was baseball (n = 8), followed by cycling (n = 2), tennis (n = 1), and hammer throw (n = 1). The average duration of low back pain was 24.3 months. The intervertebral disc levels affected were L4/5 (n = 11) and L5/S1 (n = 6). A high signal intensity zone was detected in nine discs. Although two patients required additional surgery, all patients were able to return to their original competitive level of play. Duration for the return to play was 2.8 months after surgery except the two revision cases. PED/TA for discogenic pain enables an early return to competitive sports, and so is particularly useful for elite athletes.


Age-related changes in axial and sagittal orientation of the facet joints: Comparison with changes in degenerative spondylolisthesis.

Despite facet joints being three-dimensional structures, previous computed tomography and magnetic resonance imaging studies have evaluated facet joint orientation in only the axial plane. Facet joint orientation in the sagittal plane has rarely been studied using these imaging techniques. The aim of this study was to elucidate facet joint orientation in both the axial and sagittal planes on computed tomography. A total of 568 patients (343 men, 225 women) (excluding orthopedic outpatients) for whom abdominal and pelvic computed tomography scans were obtained at our hospital between September 2010 and October 2012 were included. Mean age was 63 (range 21-90) years. Patients were divided into a degenerative spondylolisthesis group (67 patients; 30 men, 37 women) and a control group (313 patients; 313 men, 188 women). Facet joint orientation was evaluated in the control group according to patient age (≤50, 51-60, 61-70, or ≥71 years). The findings in the control group were then compared with those in the degenerative spondylolisthesis group. The orientation of the lumbar facet joints at each level was measured in the axial and sagittal planes on computed tomography images. Facet joint angles decreased with age at L4/5 and L5/S1 in women in the axial plane and at L4/5 in men and L3/4 and L4/5 in women in the sagittal plane. The variation in facet joint angle was greatest at L4/5 in women. Patients with degenerative spondylolisthesis showed more sagittally and horizontally oriented facet joints in the axial and sagittal planes; facet tropism showed an association with degenerative spondylolisthesis in the axial plane. The axial and sagittal orientation of facet joints in the lower lumbar vertebra, especially L4/5, was negatively correlated with age. This finding could help to explain why older people are more prone to degenerative spondylolisthesis.


Surgical Treatment of Lumbar Herniated Nucleus Pulposus Combined with Residual Bony Fragment of Apophyseal Ring Fracture in High-Level Athletes : A Report of Two Cases.

In this paper, we present 2 cases of herniated nucleus pulposus (HNP) combined with the residual bony fragment of apophyseal ring fracture. HNP typically exists at the narrow lateral recess formed by the bony fragment, and so it has been reported that symptoms may persist. Case 1 was a 22-year-old man, a high-level javelin thrower and Paralympic athlete. He had a history of persistent pain for 4 years due to HNP, and so we performed surgical removal. Case 2 was a 23-year-old male professional baseball player. He was referred to us only 17 days after the onset of pain and presented with muscle weakness, a feature which may prolong the clinical course in addition other features such as pain. Thus, we performed a comparatively quick intervention of surgical removal. In both cases, we had excellent clinical outcomes and better function and performance. In conclusion, in cases with HNP and apophyseal ring separation, surgical intervention in the comparatively early phase can be recommended, particularly if the patients desire quick return to their original level of activity. J. Med. Invest. 66 : 358-361, August, 2019.

The Journal of Medical Investigation : JMI


Minimally invasive cervical micro-endoscopic foraminotomy for C6 radiculopathy with overlooked scapular winging - A case report.

A 73-year-old woman complained of right medial side of scapular pain associated with winged scapula to miss without observing the back in minute detail. Additional treatment was required due to overlooking caused by insufficient examination. We performed micro-endoscopic foraminotomy that provided the disappearance of scapular pain and improvement of winged scapula in relatively early. It was commonly said that winged scapula is an extremely rare condition that causes dysfunction of the upper extremities. We suggest that there are the meaning of winged scapula in diagnosis and the importance of physical examination. Further studies should be required to research the morbidity of winged scapula associated with cervical disease. By sharing our experience of this attention arousing case, we provide information not to repeat the same mistakes. J. Med. Invest. 66 : 340-343, August, 2019.


A semi-rigid thoracolumbar orthosis fitted immediately after spinal surgery : stabilizing effects and patient satisfaction.

Purpose : To evaluate the stabilizing effects of a Fit Cure-Spine® semi-rigid thoracolumbar orthosis and wearer satisfaction after lumbar surgery. Methods : In study 1, the spinal angle, spinal motion angle, and distribution of load were measured in 8 adult male volunteers when the orthosis was worn (1) with no custom-made stay (CMS), (2) with a CMS in the prone position (P-CMS), and (3) with a CMS in the prone position and decreased lordosis (DP-CMS). In study 2, pain scale scores and responses to a questionnaire were recorded in 40 consecutive patients who underwent lumbar spinal surgery in our hospital. Results : In study 1, the mean lumbar lordosis when standing was similar to that in the prone position. When the trunk was bent forward, loads on the back support in P-CMS and DP-CMS were concentrated at the center of the CMS, unlike those for No-CMS. In study 2, there was a significant decrease in postoperative wound pain after wearing the Fit Cure-Spine orthosis for 2 weeks. Most patients who wore the orthosis were satisfied with their pain outcome. Conclusion : Adjustment to lumbar lordosis and the prone position was restricted in volunteers wearing the Fit Cure-Spine with a CMS. J. Med. Invest. 66 : 275-279, August, 2019.


Accurate diagnosis of low back pain in adult elite athletes.

Background : There is few reports evaluated accurately the pain generator of low back pain in elite athletes. The purpose of this report was to show case series and to investigate the cause of unidentified low back pain of elite athletes. Methods : Twenty-three adult elite athletes consulted our sports spine clinic to seek a second opinion for low back pain between April 2013 and March 2016. Their cause of low back pain had not been identified by nearby doctor. Spine surgeons had diagnosed using diagnostic injection and STIR-MRI and the final diagnosis made by the spine surgeon were collected. Results : The mean age of 23 patients (16 male, 7 female) was 30.4 years. The most common sport played was baseball. The final diagnosis made by a spine surgeon was as follows : disc related low back pain (n = 12), facet joint arthritis (n = 5), vertebral endplate injury (n = 4), early-stage lumbar spondylolysis (n = 1), supraspinous ligament injury (n = 1). Conclusions : A thorough medical interview, careful physical examination, appropriate diagnostic imaging, and injection block examination can effectively identify the cause of low back pain. J. Med. Invest. 66 : 252-257, August, 2019.


A novel surgical concept of transforaminal full-endoscopic lumbar undercutting laminectomy (TE-LUL) for central canal stenosis of the lumbar spine with local anesthesia : A case report and literature review.

Full-endoscopic spinal surgery was first developed for the lumbar herniated nucleus pulposus. Mainly, there are two types in the full-endoscopic lumbar surgery : i.e., transforaminal (TF) and interlaminar approach. The surgery can be done under the local anesthesia for the TF approach ; therefore, we need to further develop the TF approach to variety of the spinal disorders. Recently, the TF full-endoscopic surgery has been applied for the spinal canal stenosis. First, transforaminal full-endoscopic lumbar foraminoplasty for the foraminal stenosis ; then, transforaminal lumbar lateral recess decompression for the lateral recess stenosis has been developed. Finally, we have developed the surgical technique to decompress the central stenosis via TF approach under the local anesthesia. Prior to initiate the clinical case, we have attempted the lumbar undercutting laminectomy using a fresh cadaveric spine. After we technically confirmed that the transforaminal full-endoscopic lumbar undercutting laminectomy (TE-LUL) is possible, we applied the technique to the patient whose lung capacity did not allow general anesthesia. The 72 years old female patient with central canal stenosis could be improved her left leg pain and muscle weakness after TE-LUL under the local anesthesia. In this paper, we introduce the surgical technique of the TE-LUL and discuss of the efficacy of the TE-LUL. J. Med. Invest. 66 : 224-229, August, 2019.


Radiological Outcomes of Posterior Lumbar Interbody Fusion Using a Titanium-coated PEEK Cage.

INTRODUCTION Titanium (Ti) coated polyether ether ketone (PEEK) interbody cages (IBCs) have been introduced to overcome any disadvantages. The purpose of this study was to investigate the radiological outcomes of lumbar interbody fusion (LIF) surgery using the Ti-coated PEEK IBC with a minimum of 1-year of follow-up. METHODS A total of 26 intervertebral spaces in consecutive 21 patients who underwent posterior/transforaminal LIF using the Ti-coated PEEK IBC were evaluated. Rates of bone union, screw loosening, cage subsidence and bone cyst formation around the endplate were evaluated on computed tomography scans acquired at least 1 year postoperatively. RESULTS AND DISCUSSION At the 1-year follow-up, bone fusion was achieved in 23 (88.4%) of 26 intervertebral spaces. Cagesubsidence was found in 5 intervertebral spaces ; however,bone fusion was achieved in all these spaces. Bone cysts formed in 4 intervertebral spaces and 4 of 94 screws were found to be loosened. Three of the loosened screws were found in vertebral bodies adjacent to intervertebral spaces with nonunion. However, there was no association between these events. Although more scientific evidence is required to determine the advantages of Ti-coated PEEK IBCs, we believe the clinical outcomes achieved were favorable at the 1 year minimum follow-up. J. Med. Invest. 66 : 119-122, February, 2019.


Successful Endoscopic Surgery for L5 Radiculopathy Caused by Far-Lateral Disc Herniation at L5-S1 and L5 Isthmic Grade 2 Spondylolisthesis in a Professional Baseball Player.

Minimally invasive endoscopic surgery is an option for radiculopathy in very active patients who need an early return to their previous level of physical activity.


Pullout Strength of Pedicle Screws Following Redirection After Lateral or Medial Wall Breach.

Forty-seven vertebrae (T9-L5) were harvested from 8 fresh cadaveric spines. The 18 pedicle screws that breached the lateral wall were then removed and redirected using a pedicle screw of 1 mm larger in diameter. The 16 pedicle screws that had breached the medial wall were then removed and redirected using a pedicle screw of the same diameter. The other 13 pedicle screws that had breached the medial wall were then removed and redirected using a pedicle screw of 1 mm larger in diameter. The pullout strength was measured.


Kinematically and kinetically, the spinopelvic angles in Dash were considered similar to those in Shoot. Dash could cause mechanical stress at the pars interarticularis of the lumbar spine, similar to that caused by Shoot, thus leading to spondylolysis.


Bony Healing of Discontinuous Laminar Stress Fractures Due to Contralateral Pars Defect or Spina Bifida Occulta.

Contralateral pars defect remains an unfavorable factor for bony healing discontinuous laminar stress fractures.


Role of Epiligament in Ligamentum Flavum Hypertrophy in Patients with Lumbar Spinal Canal Stenosis:a Pilot Study.

Ligamentum flavum (LF) hypertrophy is one of the main factors of lumbar spinal canal stenosis (LSCS). The primary object of this study is to clarify the existence of epiligament in the LF and its role in hypertrophy, and to develop an LF hypertrophy animal model. A cadaveric spine from a 30-year-old man was used to investigate the existence of epiligament in LF. Five LF samples from LSCS patients were obtained to evaluate hypertrophied LF. To create a rat model, we destabilized the lumbar spine. Each LF was sagittally cut for histological evaluation. The epiligament was clearly evident in normal LF specimens, which stained pink on Elastica van Gieson and green on Masson Trichrome. One layer was observed on the dural side and another on the dorsal side of the LF. LSCS patients had an enlarged dorsal epiligament, at around 30 times that of the regular thin epiligament on the dural side. The destabilized rat model showed an enlarged dorsal epiligament, with a mean thickness 8-fold that of the control. LF hypertrophy may be due to enlargement of the dorsal epiligament. Mechanical loading of the LF is an important factor for inducing hypertrophy in the rat model. J. Med. Invest. 65:85-89, February, 2018.

The Journal of Medical Investigation : JMI