Abstracts - Doctor Luis Lombardi

Abstracts – Doctor Luis Lombardi

PARAMEDIAN, NON-TRAUMATIC APPROACH THROUGH THE LIGAMENTUM FLAVUM FOR EXTRUDED DISC HERNIATIONS IN THE LUMBAR SPINE

INTRODUCTION

With typical laminotomy/discectomy, including the so-called minimally invasive techniques, bone and ligamentum flavum need to be removed in order to access the spinal canal and the pathology. Depending on the size and location of the extruded fragment/s, the amount of bone removal ranges from a conservative laminotomy to a wider laminectomy with or without hemi-facetectomy. In either case, once the normal anatomy has been altered the possibility of failed back surgical syndrome increases dramatically.

We use a non-traumatic access small tubular system, that allows dilation without cutting through the muscle fibers and the ligamentum flavum, giving access to the spinal canal while having excellent visualization via working-channel scope. The lack of bleeding that such system produces explain the lack of scar tissue formation we observe.

METHODS

We performed a retrospective analysis since 2009 until the present. Results are reported utilizing the MacNab criteria. Population included 77 patients with Lumbar extruded disc fragments, 25% women and 75% men, from 20 to 66 years of age. The average follow-up was 6 wks.

RESULTS

Statistical analysis showed the following results: Excellent: 81.81% (n=63), Good: 14.28% (n=11), and Poor: 3.89% (n=3). The overall success rate was 96.10%. One patient developed a “rare” discal cyst in the postoperative that became symptomatic 4 wks after surgery. The discal cyst was diagnosed by discography and successfully treated with a second non-traumatic approach through the ligamentum flavum

CONCLUSSIONS

This method achieves better success rates and avoids the potentially deleterious long term ill effects of trauma that occur with typical procedures.

Endoscopic Anterior Cervical Discectomy Without Fusion Through a Two Millimeter Opening

Source: ISASS Annual Meeting, May 2014.

David A. Ditsworth, M.D., Luis A. Lombardi, M.D., Michel Levesque M.D.
INTRODUCTION

The anatomical and biomechanical characteristics of the degenerative cervical intervertebral disc may make it more prone to instability after conventional discectomy. The addition of fusion, with or without instrumentation, is a logical solution to such a problem; however, it produces long term overload of adjacent cervical levels which in turn, increases the incidence of disc degeneration and/or the development of disc herniations. The following abstract describes the results of an anterior cervical focalized discectomy through a tiny “nano”- approach.

METHODS

In 2011 and 2012, 21 patients were treated. 66% were males, 34% were women, from 23 to 73 years old, with an average of 50 years old. Only 29% of the cases presented with pure disc herniations and 71% were accompanied by osteophytes, all with radiculopathy and without myelopathy. The average follow-up was 8 wks. Technique: Under general anesthesia, a 2 mm-skin opening is made and a guide wire is introduced medial to the vessel and lateral to the esophagus. Dilating cannulas (2 mm) are introduced. Using fluoroscopy and endoscopic visualization, focal discectomy is manually performed with micro-instruments targeting the causative pathology.

RESULTS

The success rate was 95% following the MacNab criteria. Excellent 47.5% (n=10), Good 47.5% (n=10), Fair 5% (n=1) and Poor none. There was one case of negative pressure pulmonary hypertension, a complication unrelated to the surgery itself. This was resolved without sequelae.

CONCLUSIONS

Focal anterior cervical discectomy without fusion through a “nano” approach is a very effective and safe way to treat cervical disc herniations with or without osteophytic components. The limited disc resection does not produce instability or the need for fusion and preserves underlying bio-mechanical function.

Multifactorial Lumbar Stenosis Treated Successfully with Primary Factor Treatment Only

Source: The 2012 AANS/CNS Section on Disorders of the Spine and Peripheral Nerve Annual Meeting , Mar 2012. Orlando Florida.

David A. Ditsworth M.D.; Luis Lombardi M.D.
INTRODUCTION

Multifactorial Spinal stenosis, whether central, lateral or foraminal, affects millions of Americans. The clinical presentation ranges from asymptomatic (radiological finding) to neurological claudication and radicular pain.

After exhausting conservative methods of treatment, most surgical solutions entail generous bone, ligament flavum, articular facet and disc removal. This in turn could generate, in a high percentage of cases, spinal instability which leads to fusion and possibly to failed back surgery syndrome.

The present abstract deals with the treatment of multifactorial spinal stenosis by treating one of the factors, the disc, with a focused lumbar discectomy.

METHODS

27 cases were obtained from a retrospective chart review from 2009 up to date. We included cases of patients older than 50 years of age with multifactorial spinal stenosis diagnosed by MRI and CT scan, interpreted by independent radiologists. All patients underwent CT scan after discography and were treated with a focused lumbar discectomy. Ages ranged from 50 to 86; 41% females and 59% males. 70 % of patients presented with a combination of central, recess and foraminal stenosis; 78% with radicular symptoms, 11% with lumbago and 11 % with neurological claudication, the latter in combination with radicular presentation. Average follow up was 8 wks.

RESULTS

Utilizing the MacNabb criteria the results were as follows: 41 % (n=11) excellent, 52% (n=14) good and 7% (n=2) Fair with a success rate of 93%. No complications were reported.

CONCLUSIONS

The treatment of multifactorial spinal stenosis with solely a primary factor approach lumbar discectomy is very effective and safe. At the same time it does not preclude the use of other more invasive surgical options should this approach be insufficient

“Lumbar Fusion Candidates” Avoid Fusion: Long Term Follow-up.

Source: The Congress of Neurological Surgeons 2011 Annual Meeting, Oct 2011.
INTRODUCTION

Lumbar fusion rates have steadily increased since the 1990’s. However, after lumbar fusion approximately 40% of patients remain unchanged or become even worse as measured by Oswestry at two year follow-up. Our analysis group represents those patients treated here who had fusion recommended, by outside surgeons, but the patients chose our smaller access out-patient discectomy instead. This procedure is a focused, precision discectomy. Our retrospective analysis goal was to determine whether these patients had undergone a later fusion. Our success is defined as those patients that have avoided fusion (90%). METHODS

59 patients were available for follow-up. 35 % were women (n=21) and 65 % men (n=38) with an average age of 42 years old, ranging from 21 to 70 years of age. 16% of patients presented with primarily low back pain and 77% had objective signs of radiculitis. The average follow-up was 43 months.

CONCLUSIONS

Fusion should only be done after a careful evaluation of the individual case taking into consideration all factors involved, including whether much smaller procedures may be sufficient. The use of the smaller access discectomy technique was shown above to be a valuable tool in avoiding fusion of the lumbar spine, even in cases where associated factors beyond the discopathy were not surgically treated.

RESULTS

There were 9 patients who underwent a reoperation: 6 fusions, 1 disc decompression, 1 laminectomy/foraminotomy and 1 minimally invasive discectomy. Therefore, our success rate for avoiding fusion was 90 % and for avoiding any further procedure was 85%. Of the 6 patients that required fusion: 1 had 2 previous lumbar operations, 1 had concomitant multiple sclerosis, 1 had a previous fusion one segment below and one had spondylolysthesis. All but 1 re-operated case presented with hard disks. 70 % of patients showed excellent and good clinical results. No complications were reported.

NON-TRAUMATIC, TRANS-LIGAMENTUM FLAVUM APPROACH FOR L5/S1 EXTRUDED DISC HERNIATIONS

Source: Annual Meeting of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves, Feb 2010.

David A. Ditsworth M.D.; Luis Lombardi M.D., Irina Bogacheva Ph.D.
INTRODUCTION

The use of a non-traumatic, small-sized, access tubular system allows for excellent visualization via scope viewing and working simultaneously in order to part through the ligamentum flavum. There is no internal cutting, bone or joint removal. Lack of bleeding virtually eliminates the risk of new scar tissue.

METHODS

A retrospective analysis from 2002 through the present was performed. The results are reported utilizing the Ma cNab criteria. The study population includes 111 patients with L5/S1 extruded disc herniations/free fragments into the spinal canal; 74% males and 26% females, ages ranging from 17 to 58 years old. The mean follow up was 6 weeks.

RESULTS

Statistical analysis showed the following results: Excellent: 57.65% (n=64), Good: 35.13% (n=39), Fair: 3.60% (n=4) and Poor: 3.60% (n=4). The overall success rate was 93%, or if the Fair result group is also included with modified MacNab criteria, it is 96%. One COMPLICATION was a small dural sac leak which occurred indirectly after removal of free fragments that were plastered against the dura. This was successfully treated with an epidural blood patch placed by the anesthesiologist; this patient was not hospitalized, had headaches with standing for two days that disappeared completely with the blood patch and the patient had an excellent outcome..

CONCLUSIONS

This method achieves better success rates and avoids the potentially deleterious long term ill effects of trauma that occur with typical procedures.

Double Approach Small Endoscopic Discectomy in L/4-L5 & L5/S1 True Central Disc Herniations: No Access Surgical Trauma, Better Results

Source: IITS 2009, Phoenix

Abstract:
Access to L4/L5 & L5/S1 true central disc herniations is very limited. In conventional open surgery (including microscopic approaches), important bone and soft tissue removal must occur in order to access the pathology, more so than in other locations. This, in turn, increases the likelihood of long-term spinal instability and post-surgical failed back syndrome.

The use of a small working channel scope with a double access approach is another way to treat this pathology. This approach allows precise, focused treatment, with no bone or soft tissue removal and minimal invasiveness. Pre-operative CT mapping, including full thickness “wide views” is essential.

A retrospective analysis of the years 2002 and 2003 was performed by one of the authors and the results were reported utilizing the MacNab criteria. The study population included 33 patients (66% single level), 29% females and 71% males with an age range between 13 and 83 years (mean = 36 years). There were 19 L4/L5 and 14 L5/S1 herniations. 78.78% of the herniations were contained and 21.21% uncontained. The mean follow-up time was 2.5 months (1-8).

No limitations to the double access were found in the wide view CT scans. The analysis showed the following results: Excellent: 33.33% (n = 11), Good: 57.57% (n = 19), Fair: 6.06% (n = 2) and Poor: 3.03% (n = 1). The overall success rate was 90.90%. No complications were reported. There was a statistically significant difference between the success rates of herniations at L4/5 (94.72%) and L5/S1 (85.71%) and also between uncontained (100%) vs. contained (87.56%) herniations.

Small endoscopic double access of L4/L5 & L5/S1 central herniations is not just a viable alternative to open surgery but has proven to be highly successful, avoiding the deleterious long-term effects of considerable bone removal and soft tissue resection and retraction. This minimally invasive technique is also extremely safe.

Treatment of central and paracentral lumbar disc herniations with a transforaminal double access non-traumatic discectomy: safe and with better results.

WCMISST, June 2008

Purpose: Access to central and paracentral disc herniations is very limited. In conventional open surgery, important bone removal and soft tissue resection must occur in order to access the pathology. This increases the likelihood of long-term spinal instability and post-surgical failed back syndrome. The purpose of the following study is to demonstrate that the use of a small working channel scope with a double access approach allows precise, focused treatment, with no bone or soft tissue removal and no muscle cutting, showing statistical results that are better than with open, invasive approaches.

Methods: A retrospective analysis from 2002 through 2007 was performed. Cases with an L5/S1 paracentral free fragment/s was/were no included in the present study since they can be better treated with an intralaminar approach. The results were reported utilizing the MacNab criteria. The study population included 184 patients, 66% males and 34% females; age range between 13 and 83 years (mean=36 years). The levels affected the most were: L4/L5 (54%), L5/S1 (43%) and L3/L4 (3%). The mean follow-up time was 6 months.

Results: The analysis showed the following results: Excellent: 42.93% (n=78), Good: 48.36% (n=89), Fair: 7.06% (n=13), Poor: 2.17% (n=4). The overall success rate was: 90.75%. No complications were reported.

Conclusions: No-access-trauma double approach lumbar spine surgery for central and paracentral herniations is not just a viable alternative to open surgery, but has proven to be highly successful, avoiding the deleterious long-term effects of considerable bone removal and soft tissue resection and retraction.

7 cases with previous surgeries and free fragments: 100% success with average of 16 weeks follow-up.

Source: IITS 2007 France
INTRODUCTION

Success rates reports in endoscopically treated recurrent disc herniations are rare to find in the literature. The purpose of the present abstract is to report 7 cases of uncontained recurrent disc herniations treated with a non-traumatic endoscopic approach.

MATERIAL AND METHODS

7 cases of patients with recurrent disc herniations and free fragments were randomly selected from our data bank. 29% were females and 71 % were males with ages ranging from 21 to 60 years old (average 40 years old). All patients had a previous laminectomy at the same level and on the same side of the current presentation. 43 % of the herniations were located at the L4/L5 level and 57 % at L5/S1 level. 4 cases were treated with a double approach, 2 with a single approach and 1 with a paramedian access. The patients were followed up on an average of 16 weeks post-surgically.

RESULTS

Utilizing the MacNab criteria results were as follows: EXCELLENT: 58% (n:4), GOOD: 42% (n:3). The SUCCESS RATE was 100%. No complications were reported.

CONCLUSIONS

Non-traumatic endoscopic approach in recurrent disc herniations with free fragments, previously treated with more invasive and traumatic surgical procedures, is a safe and very effective method of treatment. The presence of scar tissue from a previous procedure doesn’t seem to have an impact on the outcome. However, a larger population should be studied before getting to a more definitive conclusion.

“Lumbar Fusion Candidates” Avoid Fusion (Long Term Follow-up).

Source: Minimally Invasive Surgery of the Spine 2007, San Diego
Lumbar fusion rates have increased steadily since the 1990’s and accelerated after 1996 since the approval of the fusion cages. In 2001, 122,000 fusions were performed in the US, which represented an increase of 220 % from 1990. Despite the increasing use of fusion techniques in the lumbar spine, the re-operation rates have not been reduced and the patient overall ranking of results satisfaction does not exceed 60 %. Even though improvement has been demonstrated in approximately 60 % of the patients, approximately 40 % of patients’ condition after lumbar fusion remained unchanged or became even worse measured by LBP, leg pain and Oswestry at two year follow-up.

Our group represents those patients treated at the Back Institute in the past 5 years who had fusion recommended, and in most cases scheduled, by outside surgeons, but the patient decided to undergo our non-traumatic access out-patient discectomy instead. This procedure is a focused, precision discectomy. Our retrospective analysis goal was to determine whether these patients had undergone a later fusion. Our success is defined as those patients that have avoided fusion (94%).

33 patients were available for long term follow up and all were contacted directly by phone. 24 % were women (n=8) and 76 % men (n=25) with an average age of 48 years old, ranging from 28 to 63 years of age. All had significant lumbar disc protrusion/herniations pre-operatively. The average follow-up was 30 months.

4 patients underwent re-operation: 2 fusions, 1 disc decompression and 1 laminectomy/foraminotomy. Therefore, our success rate in this “fusion group” for avoiding fusion was 94 % and for avoiding any further procedure was 88%. Of the 4 patients that required further procedures all of them presented with tough (medium to hard) discs and bony foraminal stenosis. 67 % of the 33 patients showed excellent or good long term clinical results, which is superior to the results for fusion in general. Taking into consideration the presence of other pathological conditions, namely: osteophytosis, ligamentous hypertrophy, bony canal stenosis and bony foraminal stenosis, 56 % of the 29 non-reoperation patients presented with 2 or more of these factors in addition to the disc pathology, showing that these factors were not contra-indications to a pure discectomy. No complications occurred.

Fusion should only be considered after a careful evaluation of each individual case taking into consideration all factors involved, especially in view of the above results

Outpatient Small Non Traumatic Discectomy In L4/5 Lateral Recess Lumbar Disc Herniations: Successful And Surgically Conservative.

Source: 2005 March
INTRODUCTION The possibility of developing failed back surgery syndrome, which may be related to the size of the access pathway to the pathology, is a major concern. When the herniation lies at the L4-L5 level (the most common level in our experience) the particular anatomical dimensions and confined space create a requirement for greater access trauma, when typical surgical approaches are used.

METHODS Utilizing a small working channel endoscope through a double postero-lateral approach provides a better alternative to open surgery, by addressing the problem with minimal surgical trauma. This method substantially reduces the likelihood of developing post-surgical long-term complications. 43 patients from 2002 and 2003 were retrospectively analyzed. 11.63% (n= 5) were females and 88.37% (n= 38) were males (average age 38.55 years) (19-60). The results were tabulated utilizing the Mac Nab criteria. 70% of the herniations were contained and 30% uncontained. No limitations to access were found on wide view CT scans. All patients had two small postero-lateral approaches made to the L4/L5 disc pathology

RESULTS EXCELLENT: 25.58% (n=11), GOOD: 67.44% (n=29), FAIR: 4.65% (n=2) and POOR: 2.32% (n= 1). Overall SUCCESS RATE was 93.02%. No complications. Follow-up averaged 3 months. The success rate in uncontained herniations was better than in contained herniations: 100% vs. 90% respectively.

CONCLUSIONS In L4-L5 lateral recess herniations, the traditional surgical approach increases the probability of the development of surgical failed back syndrome. Whereas, in this group, the small outpatient double-access endoscopic approach is highly successful, extremely safe and more surgical conservative.

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ENHANCED DISCOGRAPHY (PRE-OPERATIVE MAPPING): A PRELUDE TO SMALL GUIDED LUMBAR ENDOSCOPIC DISCECTOMY

Source: IITS 2005, San Diego

Abstract:
Thorough planning for a precise small-guided endoscopic approach to lumbar disc pathology is of the utmost importance. To achieve this, Enhanced Discography of the affected levels is performed. A CT scan is done which includes focal cuts at the affected levels as well as full thickness abdominal cuts called “wide views” with the presence of different metallic markers.

This combined clinical-radiological study allows determining the size and location of the herniation and the presence of fissures usually with greater accuracy than the MRI. It also provides a route map for the guide-wire passage.

A retrospective analysis of 122 preoperative mappings performed in the past two years was done. A Radiologist independent from the surgical team, performed the radiological evaluation.

The patient population was comprised as follows: 91 males (75%) and 31 females (25%) with an age range from 15 to 65 years and an average 38.86 years. 93 % and 88 % of the patients presented to consult with lower back pain and radiculitis symptoms respectively. The physical examination showed objective sings of radiculopathy in 76 % of the cases.

Internal disc derangement and fissuring was shown in 70% of the cases of post-contrast CT, which were not noted on MRI. When comparing Enhanced Discography with MRI, the size and location of the herniation was demonstrated with greater accuracy in 48% of the cases. The lumbar disc analysis provided important additional information in all cases.

Conclusion: Enhanced Discography provided more accurate information than MRI in 78% of the population regarding disc herniation characteristics and disc derangement/ fissuring. This clinical-radiological study is essential to the pre-operative planning and decision process in order to provide precise treatment of the specific pathology through small-guided lumbar endoscopic discectomy.

Double Approach Small Endoscopic Discectomy in L/4-L5 & L5/S1 True Central Disc Herniations: No Access Surgical Trauma, Better Results

Source: CNS 2004 San Francisco, California

Paramedian Small Endoscopic L5-S1 Discectomy

Source: CNS 2002 Philadelphia

Abstract:
Introduction: Outpatient endoscopic discectomies were performed for thirty patients with large L5-S1 free fragments, during the past three years, using an atraumatic small, soft, scope (fragment delivery) technique.

Methods: The scope was fully flexible to beyond 90 degrees, as shown in Surgical Neurology, June 1998, pages 588-598. A 5 mm skin opening, just large enough for the scope, was made 1 cm off midline. Local anesthesia and IV sedation was used. The approach was made between the lamina and dilated up to use a 4.2 mm outer cannula, with the fiber-optic working channel plastic endoscope telescoping through the cannula. Micro-tools were used through the 2.5 mm scope lumen. The 30 patients ranged in age from 29 to 61, 19 males and 11 females. All had sizeable free fragments in the spinal canal at L5-S1 ruptured lateral to the dura. Open microdiscectomy/laminotomy had already been recommended in all cases. All had persistent radicular pain, numbness and/or weakness consistent with the herniation.

Results: Results were tabulated with the Macnab criteria: 26 excellent (no symptoms, no restriction of activity) 3 good (occasional symptoms), 1 poor (no improvement, required further surgery); for an overall success rate of 97%. The only ill effect was that one patient (an early case) developed a small area of mildly increased skin sensitivity which resolved in one week.

Conclusions: This technique provides a direct and non-traumatic approach for reaching and physically removing free fragments at L5-S1 without the access disruption of muscle detachment, ligament and bone removal.

Preparative Analysis for Precision Lumbar Endoscopic Disc Surgery

Source: CNS 2001 San Diego, California

Abstract:
Introduction: Thirty patient files, from the past two years, were randomly selected for review. These were all patients who subsequently underwent an endoscopic discectomy for herniated disc, as well as specific intradiscal thermal treatment, where indicated.

Methods: Contrast was placed into the disc through an 18 gauge needle. Access positional analysis and subsequent CT scanning with markers provided mapping data. The radiologic evaluation was done independently from the surgical team. Patient ages varied from 16 to 63, with 18 male and 12 female. Sixteen patients had primary signs and symptoms on the right and fourteen on the left side. In all cases, the patients symptoms were reproduced with the procedure.

Results: In twenty-two of the thirty patients, the disc herniation was shown better than on MRI; and in twenty-one of the thirty, fissuring and internal disc changes (potentially treatable endoscopically) were demonstrated which were not noted on MRI; twenty-six of the thirty had either the disc herniation shown better or fissuring and internal changes shown better.

Conclusions: Contrast analysis provided important additional information in all cases. In 86.67% of the cases reviewed (26 of the 30), contrast analysis and mapping were essential to the pre-operative planning and decision process needed for precise, focused treatment of the specific pathology.