Clinical study on real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YANG Yang ,  DONG Jianwen , LIU Zhongyu , CHEN Ruiqiang , CHEN Zihao , ZHAI Zhengjia , QI Jiakun , RONG Limin

Department of Spine Surgery, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou Guangdong, 510630, P. R. China;

Corresponding author：

DONG Jianwen, Email: dongjw@mail.sysu.edu.cn

Keywords：

Real-time navigation; three-dimensional CT; spine endoscopic surgery; transforaminal apporoach; lumbar interbody fusion

DOI：

10.7507/1002-1892.202202092

Video：

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Objective To analyze the technical notes, effectiveness, and current issues of real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion. Methods Between April 2020 and October 2021, a total of 27 patients received real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion. There were 18 males and 9 females with an average age of 63.2 years (range, 48-84 years). There were 6 cases of lumbar spinal stenosis, 1 case of lumbar instability, 9 cases of lumbar spinal stenosis with instability, 3 cases of degenerative spondylolisthesis, 6 cases of isthmus spondylolisthesis, and 2 cases of recurrent lumbar disc herniation. All patients showed neurological symptoms before operation (ipsilateral symptom for 15 cases and bilateral symptom for 12 cases). The symptom duration was 1-300 months (median, 24 months). The operations were performed via transforaminal approach in 8 cases, trans-facet joint approach in 18 cases, and combined approaches in 1 case. A total of 32 levels were fused, including 23 single-level cases, 3 two-level cases, and 1 three-level case. Lumbar fusion segment was L_{2, 3} in 1 case, L_{3, 4} in 4 cases, L_{4, 5} in 20 cases, and L₅, S₁ in 7 cases. The operation time, intraoperative estimated blood loss (IEBL), and perioperative complications were recorded. The improvement of intervertebral space height at fusion level was measured, and the accuracy of percutaneous pedicle screw (PPS) and Cage placement was also evaluated based on CT images performed at 1 week postoperatively. Visual analogue scale (VAS) score for both low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, and Oswestry disability index (ODI) were evaluated before operation, at 1 week postoperatively, and at last follow-up. Satisfaction to effectivenss were assessed by patients using modified MacNab criteria at last follow-up. Results The operation time was ranged from 255 to 805 minutes (mean, 424.9 minutes). IEBL was 150-290 mL (mean, 219.3 mL). All patients received follow-up with the duration from 4 to 22 months (mean, 12.4 months). At 1 week postoperatively and last follow-up, VAS scores of low back pain and leg pain, JOA score, and ODI were significantly improved when compared with those before operation (P<0.05). At last follow-up, the clinical indicators were similar in comparison with those at 1 week postoperatively (P>0.05). There were 26 patients and 1 patient who respectively ranked excellent and mild in terms of effectiveness according to the modified MacNab criteria, with the excellent and good rate of 96.3%. There was 1 patient who suffered from incomplete injury of L₅ nerve root and partial neurological function recovered after 3-month conservative treatments. There were 118 implanted PPSs, and 116 of them were implanted under navigation. There were 33 Cages that were implanted under navigation. The accuracy of PPS and Cage placement was 99.1% and 97.0% respectively based on CT performed at 1 week postoperatively. The postoperative intervertebral space height was significantly increased in comparison with that before operation (P<0.05). During follow-up, mild Cage subsidence was observed in 1 patient, whereas no fixation loosing was found. Conclusion Real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion has great safety and effectiveness with satisfactory preliminary clinical results. Design and further improvement of surgical equipment and instruments are expected to resolve the current technical difficulties.

Citation： YANG Yang, DONG Jianwen, LIU Zhongyu, CHEN Ruiqiang, CHEN Zihao, ZHAI Zhengjia, QI Jiakun, RONG Limin. Clinical study on real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(6): 665-671. doi: 10.7507/1002-1892.202202092 Copy

1.	Arif S, Brady Z, Enchev Y, et al. Minimising radiation exposure to the surgeon in minimally invasive spine surgeries: A systematic review of 15 studies. Orthop Traumatol Surg Res, 2021, 107(7): 102795. doi: 10.1016/j.otsr.2020.102795.
2.	Carl B, Bopp M, Saß B, et al. Reliable navigation registration in cranial and spine surgery based on intraoperative computed tomography. Neurosurg Focus, 2019, 47(6): E11. doi: 10.3171/2019.8.FOCUS19621.
3.	Klingler JH, Scholz C, Hohenhaus M, et al. Radiation exposure to scrub nurse, assistant surgeon, and anesthetist in minimally invasive spinal fusion surgery comparing 2D conventional fluoroscopy with 3D fluoroscopy-based navigation: A randomized controlled trial. Clin Spine Surg, 2021, 34(4): E211-E215.
4.	Konieczny MR, Krauspe R. Navigation versus fluoroscopy in multilevel MIS pedicle screw insertion: Separate analysis of exposure to radiation of the surgeon and of the patients. Clin Spine Surg, 2019, 32(5): E258-E265.
5.	Vaishnav AS, Merrill RK, Sandhu H, et al. A review of techniques, time demand, radiation exposure, and outcomes of skin-anchored intraoperative 3D navigation in minimally invasive lumbar spinal surgery. Spine (Phila Pa 1976), 2020, 45(8): E465-E476.
6.	Khanna R, McDevitt JL, Abecassis ZA, et al. An outcome and cost analysis comparing single-level minimally invasive transforaminal lumbar interbody fusion using intraoperative fluoroscopy versus computed tomography-guided navigation. World Neurosurg, 2016, 94: 255-260.
7.	Lian X, Navarro-Ramirez R, Berlin C, et al. Total 3D Airo^® navigation for minimally invasive transforaminal lumbar interbody fusion. Biomed Res Int, 2016, 2016: 5027340. doi: 10.1155/2016/5027340.
8.	Wu MH, Dubey NK, Li YY, et al. Comparison of minimally invasive spine surgery using intraoperative computed tomography integrated navigation, fluoroscopy, and conventional open surgery for lumbar spondylolisthesis: a prospective registry-based cohort study. Spine J, 2017, 17(8): 1082-1090.
9.	Zhang Y, Xu C, Zhou Y, et al. Minimally invasive computer navigation-assisted endoscopic transforaminal interbody fusion with bilateral decompression via a unilateral approach: Initial clinical experience at one-year follow-up. World Neurosurg, 2017, 106: 291-299.
10.	Shin Y, Sunada H, Shiraishi Y, et al. Navigation-assisted full-endoscopic spine surgery: a technical note. J Spine Surg, 2020, 6(2): 513-520.
11.	Hahn BS, Park JY. Incorporating new technologies to overcome the limitations of endoscopic spine surgery: Navigation, robotics, and visualization. World Neurosurg, 2021, 145: 712-721.
12.	Chen KT, Song MS, Kim JS. How I do it? Interlaminar contralateral endoscopic lumbar foraminotomy assisted with the O-arm navigation Acta Neurochir (Wien), 2020, 162(1): 121-125.
13.	Ao S, Wu J, Tang Y, et al. Percutaneous endoscopic lumbar discectomy assisted by O-arm-based navigation improves the learning curve. Biomed Res Int, 2019, 2019: 6509409. doi: 10.1155/2019/6509409.
14.	Heo DH, Lee DC, Kim HS, et al. Clinical results and complications of endoscopic lumbar interbody fusion for lumbar degenerative disease: A meta-analysis. World Neurosurg, 2021, 145: 396-404.
15.	Kou Y, Chang J, Guan X, et al. Endoscopic lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases: A systematic review and meta-analysis. World Neurosurg, 2021, 152: e352-e368.
16.	Stone CE, Myers BL, Gupta S, et al. Surgical outcomes after single-level endoscopic transforaminal lumbar interbody fusion: A systematic review and meta-analysis. Cureus, 2020, 12(10): e11052. doi: 10.7759/cureus.11052.
17.	Rao G, Brodke DS, Rondina M, et al. Comparison of computerized tomography and direct visualization in thoracic pedicle screw placement. J Neurosurg, 2002, 97(2 Suppl): 223-226.
18.	Frane N, Megas A, Stapleton E, et al. Radiation exposure in orthopaedics. JBJS Rev, 2020, 8(1): e0060. doi: 10.2106/JBJS.RVW.19.00060.
19.	Osman SG. Endoscopic transforaminal decompression, interbody fusion, and percutaneous pedicle screw implantation of the lumbar spine: A case series report. Int J Spine Surg, 2012, 6: 157-166.
20.	Jacquot F, Gastambide D. Percutaneous endoscopic transforaminal lumbar interbody fusion: is it worth it? Int Orthop, 2013, 37(8): 1507-1510.
21.	Ao S, Zheng W, Wu J, et al. Comparison of preliminary clinical outcomes between percutaneous endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases in a tertiary hospital: Is percutaneous endoscopic procedure superior to MIS-TLIF? A prospective cohort study. Int J Surg, 2020, 76: 136-143.
22.	Zhao XB, Ma HJ, Geng B, et al. Early clinical evaluation of percutaneous full-endoscopic transforaminal lumbar interbody fusion with pedicle screw insertion for treating degenerative lumbar spinal stenosis. Orthop Surg, 2021, 13(1): 328-337.
23.	Jin M, Zhang J, Shao H, et al. Percutaneous transforaminal endoscopic lumbar interbody fusion for degenerative lumbar diseases: A consecutive case series with mean 2-year follow-up. Pain Physician, 2020, 23(2): 165-174.
24.	Brusko GD, Wang MY. Endoscopic lumbar interbody fusion. Neurosurg Clin N Am, 2020, 31(1): 17-24.
25.	Liounakos JI, Wang MY. Lumbar 3-lumbar 5 robotic-assisted endoscopic transforaminal lumbar interbody fusion: 2-dimensional operative video. Oper Neurosurg (Hagerstown), 2020, 19(1): E73-E74.

1. Arif S, Brady Z, Enchev Y, et al. Minimising radiation exposure to the surgeon in minimally invasive spine surgeries: A systematic review of 15 studies. Orthop Traumatol Surg Res, 2021, 107(7): 102795. doi: 10.1016/j.otsr.2020.102795.
2. Carl B, Bopp M, Saß B, et al. Reliable navigation registration in cranial and spine surgery based on intraoperative computed tomography. Neurosurg Focus, 2019, 47(6): E11. doi: 10.3171/2019.8.FOCUS19621.
3. Klingler JH, Scholz C, Hohenhaus M, et al. Radiation exposure to scrub nurse, assistant surgeon, and anesthetist in minimally invasive spinal fusion surgery comparing 2D conventional fluoroscopy with 3D fluoroscopy-based navigation: A randomized controlled trial. Clin Spine Surg, 2021, 34(4): E211-E215.
4. Konieczny MR, Krauspe R. Navigation versus fluoroscopy in multilevel MIS pedicle screw insertion: Separate analysis of exposure to radiation of the surgeon and of the patients. Clin Spine Surg, 2019, 32(5): E258-E265.
5. Vaishnav AS, Merrill RK, Sandhu H, et al. A review of techniques, time demand, radiation exposure, and outcomes of skin-anchored intraoperative 3D navigation in minimally invasive lumbar spinal surgery. Spine (Phila Pa 1976), 2020, 45(8): E465-E476.
6. Khanna R, McDevitt JL, Abecassis ZA, et al. An outcome and cost analysis comparing single-level minimally invasive transforaminal lumbar interbody fusion using intraoperative fluoroscopy versus computed tomography-guided navigation. World Neurosurg, 2016, 94: 255-260.
7. Lian X, Navarro-Ramirez R, Berlin C, et al. Total 3D Airo^® navigation for minimally invasive transforaminal lumbar interbody fusion. Biomed Res Int, 2016, 2016: 5027340. doi: 10.1155/2016/5027340.
8. Wu MH, Dubey NK, Li YY, et al. Comparison of minimally invasive spine surgery using intraoperative computed tomography integrated navigation, fluoroscopy, and conventional open surgery for lumbar spondylolisthesis: a prospective registry-based cohort study. Spine J, 2017, 17(8): 1082-1090.
9. Zhang Y, Xu C, Zhou Y, et al. Minimally invasive computer navigation-assisted endoscopic transforaminal interbody fusion with bilateral decompression via a unilateral approach: Initial clinical experience at one-year follow-up. World Neurosurg, 2017, 106: 291-299.
10. Shin Y, Sunada H, Shiraishi Y, et al. Navigation-assisted full-endoscopic spine surgery: a technical note. J Spine Surg, 2020, 6(2): 513-520.
11. Hahn BS, Park JY. Incorporating new technologies to overcome the limitations of endoscopic spine surgery: Navigation, robotics, and visualization. World Neurosurg, 2021, 145: 712-721.
12. Chen KT, Song MS, Kim JS. How I do it? Interlaminar contralateral endoscopic lumbar foraminotomy assisted with the O-arm navigation Acta Neurochir (Wien), 2020, 162(1): 121-125.
13. Ao S, Wu J, Tang Y, et al. Percutaneous endoscopic lumbar discectomy assisted by O-arm-based navigation improves the learning curve. Biomed Res Int, 2019, 2019: 6509409. doi: 10.1155/2019/6509409.
14. Heo DH, Lee DC, Kim HS, et al. Clinical results and complications of endoscopic lumbar interbody fusion for lumbar degenerative disease: A meta-analysis. World Neurosurg, 2021, 145: 396-404.
15. Kou Y, Chang J, Guan X, et al. Endoscopic lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion for the treatment of lumbar degenerative diseases: A systematic review and meta-analysis. World Neurosurg, 2021, 152: e352-e368.
16. Stone CE, Myers BL, Gupta S, et al. Surgical outcomes after single-level endoscopic transforaminal lumbar interbody fusion: A systematic review and meta-analysis. Cureus, 2020, 12(10): e11052. doi: 10.7759/cureus.11052.
17. Rao G, Brodke DS, Rondina M, et al. Comparison of computerized tomography and direct visualization in thoracic pedicle screw placement. J Neurosurg, 2002, 97(2 Suppl): 223-226.
18. Frane N, Megas A, Stapleton E, et al. Radiation exposure in orthopaedics. JBJS Rev, 2020, 8(1): e0060. doi: 10.2106/JBJS.RVW.19.00060.
19. Osman SG. Endoscopic transforaminal decompression, interbody fusion, and percutaneous pedicle screw implantation of the lumbar spine: A case series report. Int J Spine Surg, 2012, 6: 157-166.
20. Jacquot F, Gastambide D. Percutaneous endoscopic transforaminal lumbar interbody fusion: is it worth it? Int Orthop, 2013, 37(8): 1507-1510.
21. Ao S, Zheng W, Wu J, et al. Comparison of preliminary clinical outcomes between percutaneous endoscopic and minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative diseases in a tertiary hospital: Is percutaneous endoscopic procedure superior to MIS-TLIF? A prospective cohort study. Int J Surg, 2020, 76: 136-143.
22. Zhao XB, Ma HJ, Geng B, et al. Early clinical evaluation of percutaneous full-endoscopic transforaminal lumbar interbody fusion with pedicle screw insertion for treating degenerative lumbar spinal stenosis. Orthop Surg, 2021, 13(1): 328-337.
23. Jin M, Zhang J, Shao H, et al. Percutaneous transforaminal endoscopic lumbar interbody fusion for degenerative lumbar diseases: A consecutive case series with mean 2-year follow-up. Pain Physician, 2020, 23(2): 165-174.
24. Brusko GD, Wang MY. Endoscopic lumbar interbody fusion. Neurosurg Clin N Am, 2020, 31(1): 17-24.
25. Liounakos JI, Wang MY. Lumbar 3-lumbar 5 robotic-assisted endoscopic transforaminal lumbar interbody fusion: 2-dimensional operative video. Oper Neurosurg (Hagerstown), 2020, 19(1): E73-E74.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical study on real-time three-dimensional CT navigation-guided full-endoscopic lumbar interbody fusion

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