Department of Orthopedics, Tokushima University, Tokushima, Japan.
Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan.
J Neurol Surg A Cent Eur Neurosurg. 2023 Nov;84(6):528-535. doi: 10.1055/a-1877-0594. Epub 2022 Jun 15.
Revision lumbar spine surgery via a posterior approach is more challenging than primary surgery because of epidural or perineural scar tissue. It demands more extensive removal of the posterior structures to confirm intact bony landmarks and could cause iatrogenic instability; therefore, fusion surgery is often added. However, adjacent segment disease after fusion surgery could be a problem, and further exposure of the posterior muscles could result in multiple operated back syndrome. To address these problems, we now perform transforaminal full-endoscopic spine surgery (TF-FES) as revision surgery in patients who have previously undergone posterior lumbar surgery. There have been several reports on the advantages of TF-FES, which include feasibility of local anesthesia, minimal invasiveness to posterior structures, and less scar tissue with fewer adhesions. In this study, we aim to assess the clinical outcomes of revision TF-FES and its advantages.
We evaluated 48 consecutive patients with a history of posterior lumbar spine surgery who underwent revision TF-FES (at 60 levels) under local anesthesia. Intraoperative blood loss, operating time, and complication rate were evaluated. Postoperative outcomes were assessed using the modified Macnab criteria and visual analog scale (VAS) scores for leg pain, back pain, and leg numbness. We also compared the outcome of revision FES with that of primary FES.
Mean operating time was 70.5 ± 14.4 (52-106) minutes. Blood loss was unmeasurable. The clinical outcomes were rated as excellent at 16 levels (26.7%), good at 28 (46.7%), fair at 10 (16.7%), and poor at 6 (10.0%). The mean preoperative VAS score was 6.0 ± 2.6 for back pain, 6.8 ± 2.4 for leg pain, and 6.3 ± 2.8 for leg numbness. At the final follow-up, the mean postoperative VAS scores for leg pain, back pain, and leg numbness were 4.3 ± 2.5, 3.8 ± 2.6, and 4.6 ± 3.2, respectively. VAS scores for all three parameters were significantly improved ( < 0.05). There was no significant difference in operating time, intraoperative blood loss, or the complication rate between revision FES and primary FES.
Clinical outcomes of revision TF-FES in patients with a history of posterior lumbar spine surgery were acceptable (excellent and good in 73.4% of cases). TF-FES can preserve the posterior structures and avoid scar tissue and adhesions. Therefore, TF-FES could be an effective procedure for patients who have previously undergone posterior lumbar spine surgery.
经后路进行腰椎翻修手术比初次手术更具挑战性，因为存在硬膜外或神经周围瘢痕组织。这需要更广泛地切除后方结构以确认完整的骨性标志，并且可能导致医源性不稳定；因此，通常会添加融合手术。然而，融合手术后的邻近节段疾病可能是一个问题，进一步暴露后方肌肉可能会导致多发性手术后背综合征。为了解决这些问题，我们现在在先前接受过后路腰椎手术的患者中进行经椎间孔全内镜脊柱手术（TF-FES）作为翻修手术。已经有几项关于 TF-FES 优点的报告，包括局部麻醉的可行性、对后方结构的微创性以及较少的粘连和更少的疤痕组织。在这项研究中，我们旨在评估经后路腰椎翻修 TF-FES 的临床效果及其优点。
我们评估了 48 例既往接受后路腰椎手术的患者（60 个节段）接受局部麻醉下经后路腰椎翻修 TF-FES 的临床效果。评估术中出血量、手术时间和并发症发生率。使用改良的 Macnab 标准和视觉模拟评分（VAS）评估术后腿痛、腰痛和腿部麻木的评分。我们还比较了翻修 FES 与原发性 FES 的结果。
平均手术时间为 70.5±14.4 分钟（52-106 分钟）。术中出血量无法测量。临床结果评定为优 16 级（26.7%），良 28 级（46.7%），可 10 级（16.7%），差 6 级（10.0%）。术前腰痛 VAS 平均为 6.0±2.6，腿痛 VAS 平均为 6.8±2.4，腿部麻木 VAS 平均为 6.3±2.8。末次随访时，腿痛、腰痛和腿部麻木的 VAS 评分分别为 4.3±2.5、3.8±2.6 和 4.6±3.2。所有三个参数的 VAS 评分均显著改善（ < 0.05）。翻修 FES 和原发性 FES 在手术时间、术中出血量和并发症发生率方面无显著差异。
对于有后路腰椎手术史的患者，后路腰椎翻修 TF-FES 的临床效果是可以接受的（73.4%的病例为优和良）。TF-FES 可以保留后方结构，避免疤痕组织和粘连。因此，TF-FES 可能是后路腰椎手术患者的有效治疗方法。
