To compare the clinical efficacy of interlaminar endoscopic surgical system delta (iLESSYS-Delta) discectomy with that of classical fenestration discectomy for treating lumbar disc herniation. Patients who underwent iLESSYS-Delta or fenestration discectomy were enrolled in this study. Baseline information and clinical indicators were collected. The baseline data were matched using propensity score matching. Fifty-two patients were in each group. In the iLESSYS-Delta cohort, the volume of intraoperative bleeding was 18.17 ± 4.20 ml, the length of postoperative hospital stay was 4.16 ± 2.29 days, and the length of postoperative off-bed activity was 1.58 ± 0.88 days. In contrast, in the fenestration group, the volume of intraoperative bleeding was 32.50 ± 17.13 ml, the length of postoperative hospital stay was 6.66 ± 2.44 days, and the length of postoperative off-bed activity was 3.18 ± 1.28 days. The difference between the two groups was statistically significant (P < 0.05). The operation time was 88.90 ± 19.14 min in the iLESSYS-Delta group and 67.63 ± 19.32 min in the fenestration group, and the difference between the two groups was statistically significant (P < 0.05). Regarding the pain visual analogue scale scores at 24, 48, and 72 h after surgery, patients in the iLESSYS-Delta group had less pain than did those in the fenestration group (P < 0.05). The Oswestry disability indices of postoperative patients in both groups significantly improved at 3 months after surgery and at the last follow-up (P < 0.05); however, there was no statistically significant difference in the postoperative ODI scores between the two surgery groups (P > 0.05). The two groups showed no significant differences in clinical effects, postoperative recurrence rates, or perioperative complications. iLESSYS-Delta can cause less intraoperative bleeding and faster recovery than fenestration discectomy.

BACKGROUND: Non-contiguous two-level Anterior Cervical Discectomy and Fusion (ACDF) may be a viable option for patients with degenerative cervical myelopathy and imaging-evident spine and radicular compression at two non-contiguous cervical levels. The risk of hastening degeneration and triggering Adjacent Segment Disease at the spine levels located between the fused levels is a putative adverse event, which was assessed in a few studies. The aim of this study is to investigate the clinical outcomes of patients undergoing non-contiguous two levels ACDF and to assess biomechanical modifications at non-fused segments.
METHODS: We retrospectively reviewed all patients with noncontiguous two-level spine and radicular compression, who underwent simultaneous noncontiguous two-level ACDF at our center. We analyzed clinical and radiological outcomes and investigated the rate of adjacent segment disease. Radiographic parameters were calculated on pre- and postoperative images.
RESULTS: Thirty-two patients underwent simultaneous noncontiguous two-level ACDF for cervical myelo-radiculopathy between 2015 and 2021 and were followed up for a mean period of 43.3 months. For all patients, the mJOA score significantly improved from 14.57 ± 2.3 to 16.5 ± 2.1 (p<0.01) and the NDI score significantly decreased from 21.45 ± 4.3 to 12.8 ± 2.3 (p<0.01) postoperatively. Cervical lordosis increased after surgery (from 9.65° ±9.47 to 15.12° ± 6.09); intermediate disc height decreased (5.68 mm ± 0.57 to 5.27 mm ±0.98); the ROMs of intermediate (from 12.45 ± 2.33 to 14.77 ± 1.98), cranial (from 14.63 ± 1.59 to 15.71 ± 1.02), and caudal (from 11.58 ± 2.32 to 13.33 ± 2.67) segments slightly increased. During follow-up assessment, in one patient the myelopathy worsened due to spine compression at the intermediate level.
CONCLUSIONS: Simultaneous and non-contiguous two-level ACDF is a safe and effective procedure. The occurrence of postoperative adjacent and intermediate segment disease is rare.

BACKGROUND: Cervical spondylosis in the warfighter is a common musculoskeletal problem and can be career-ending especially if it requires fusion. Head-mounted equipment and increased biomechanical forces on the cervical spine have resulted in accelerated cervical spine degeneration. Current surgical gold standard is anterior cervical discectomy and fusion (ACDF). Posterior cervical foraminotomy (PCF) is a nonfusion surgical alternative, and this can be effective in alleviating radiculopathy from foraminal stenosis caused by disc-osteophyte complex. Biomechanical studies have not been done to analyze motion associated with military aircrew personnel following PCF. The aim of this study was to compare the biomechanical responses of the effects of ACDF and PCF with different grades of facet resection under simulated military aircrew conditions using range of motion, disc pressure, and facet loads at the index and adjacent levels.
METHODS: A validated 3D finite element model of the human cervical spinal column was used to simulate various graded PCF and ACDF. All surgical simulations were performed at the most commonly operated level (C5-C6) in warfighters. Pure moment loading under flexion, extension, and lateral bending, and in vivo follower force of 75 N were applied to the intact spine. Hybrid loading protocol was used to achieve 134 degrees of combined flexion-extension and 83 degrees of lateral bending in intact and surgical models to reflect military loading conditions. Segmental motions, disc pressure, and facet load were obtained and normalized with respect to the intact model to quantify the biomechanical effect.
RESULTS: Anterior cervical discectomy and fusion decreased range of motion at the index and increased motion at the adjacent levels, while all graded PCF responses had an opposite trend: increased motion at the index and decreased motion at adjacent levels. The magnitude of changes depended on the level of resection, spinal level, and loading mode. Disc pressure increased at the index level and decreased at the adjacent levels after PCF. These changes were exaggerated with increasing extent of facet resection. Facet load increased at the index level after PCF especially with extension and right (contralateral) lateral bending. Complete facetectomy led to facet load increases greater than ACDF at the adjacent levels in both flexion and extension.
CONCLUSIONS: Posterior cervical foraminotomy is a motion-preserving implant-free surgical alternative to ACDF for warfighters with cervical radiculopathy after failure of conservative management. The treating surgeon must pay close attention to the extent of facet resection to avoid potential spinal instability and future disc and facet degeneration after PCF. Posterior cervical foraminotomy can be more advantageous than ACDF in terms of adjacent segment degeneration, motion preservation, reoperation rate, surgical cost, and retention of warfighters.

BACKGROUND: The number of surgical trials is increasing but such trials can be complex to deliver and pose specific challenges. A multi-centre, Phase III, RCT comparing Posterior Cervical Foraminotomy versus Anterior Cervical Discectomy and Fusion in the Treatment of Cervical Brachialgia (FORVAD Trial) was unable to recruit to target. A rapid qualitative study was conducted during trial closedown to understand the experiences of healthcare professionals who participated in the FORVAD Trial, with the aim of informing future research in this area.
METHODS: Semi-structured interviews were conducted with 18 healthcare professionals who had participated in the FORVAD Trial. Interviews explored participants\' experiences of the FORVAD trial. A rapid qualitative analysis was conducted, informed by Normalisation Process Theory.
RESULTS: Four main themes were generated in the data analysis: (1) individual vs. community equipoise; (2) trial set-up and delivery; (3) identifying and approaching patients; and (4) timing of randomisation. The objectives of the FORVAD trial made sense to participants and they supported the idea that there was clinical or collective equipoise regarding the two FORVAD interventions; however, many surgeons had treatment preferences and lacked individual equipoise. The site which had most recruitment success had adopted a more structured process for identification and recruitment of patients, whereas other sites that adopted more \"ad hoc\" screening strategies struggled to identify patients. Randomisation on the day of surgery caused both medico-legal and practical concerns at some sites.
CONCLUSIONS: Organisation and implementation of a surgical trial in neurosurgery is complex and presents many challenges. Sites often reported low recruitment and discussed the logistical issues of conducting a complex surgical RCT. Future trials in neurosurgery may need to offer more flexibility and time during set-up to maximise opportunities for larger recruitment numbers. Rapid qualitative analysis informed by Normalisation Process Theory was able to quickly identify key issues with trial implementation so rapid qualitative analysis may be a useful approach for teams conducting qualitative research in trials.
BACKGROUND: ISRCTN, ISRCTN reference: 10,133,661. Registered 23rd November 2018.

OBJECTIVE: To explore the feasibility of applying CT Hounsfield Units (HUs) for the assessment of preoperative paraspinal muscle fat infiltration (FI) in different segments in patients who underwent anterior cervical discectomy and fusion (ACDF). To compare the consistency of preoperative paraspinal muscle FI evaluations using MRI and those via CT HUs in patients who underwent ACDF surgery.
METHODS: Ninety-five patients (45 males and 50 females, aged 37‒71 years) who received CT and MRI examinations and underwent ACDF surgery were retrospectively analyzed. In the axial T2-weighted MR images at the median level of the C3/4, C4/5, and C5/6 segments, regions of interests (ROIs) were delineated along the boundaries of the cervical multifidus (MF) and semispinalis cervicis (Scer) muscles. Using the threshold tool in ImageJ software, areas of fat tissue and intermuscular septa within the ROI were quantified. The effective cross-sectional area (ECSA) for each side was obtained by subtracting the areas of fat tissue and intermuscular septa from the total ROI area. The ratio of the fat tissue area to the CSA was then calculated to determine the initial FI value. The depth of subcutaneous fat from the midline spinous process to the epidermis at the median plane of the C4/5 intervertebral disc was measured. The initial FI values were then divided by the depth of fat to determine the post-correction FI value. Using the Picture Archiving and Communication System (PACS), at identical segments and planes, ROIs were delineated using the same method as in MRI under a standard soft tissue window (width of 500 HU, level of 60 HU). The CT HU values were measured within these defined areas. The CT HU values from both sides are summed to obtain the total HU value for the segment. According to whether the measurement results of two sets of data follow a normal distribution, Pearson\'s test or Sperman\'s test was used to analyze the correlation.
RESULTS: On MRI, a statistically significant difference was observed in the post-correction FI only at the C3/4 segment compared to the other two segments (P < 0.05). No significant difference in the post-correction FI between the C4/5 and C5/6 segments was noted (P > 0.05). The CT HU results showed a substantial discrepancy between C3/4 and C4/5 segments and between C3/4 and C5/6 segments (P < 0.05), whereas no statistically significant difference was found in the CT HU value between the C4/5 and C5/6 segments (P > 0.05). The consistency analysis revealed a relatively strong correlation between the post-correction FI and CT HU values of the C3/4 and C4/5 segments. Furthermore, a strong correlation was detected in the variations in the measurement outcomes at the C5/6 segment.
CONCLUSIONS: Patients requiring surgical treatment for the cervical spine exhibit varying degrees of FI in paraspinal muscles across different locations and segments. Evaluating the degree of FI in the paraspinal muscles of the cervical spine through CT HU values is feasible. There is considerable consistency between the post-correction FI assessed under MRI and the measurements of CT HU values in evaluating the FI of paraspinal muscles in the cervical spine.

BACKGROUND: Gabapentin supplementation may have some potential in pain control after lumbar laminectomy and discectomy, and this meta-analysis aims to explore the impact of gabapentin supplementation on postoperative pain management for lumbar laminectomy and discectomy.
METHODS: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched, and we included randomized controlled trials assessing the effect of gabapentin supplementation on the pain control of lumbar laminectomy and discectomy.
RESULTS: Five randomized controlled trials were finally included in the meta-analysis. Overall, compared with control intervention for lumbar laminectomy and discectomy, gabapentin supplementation was associated with significantly lower pain scores at 2 hours (MD = -2.75; 95% CI = -3.09 to -2.41; P < .00001), pain scores at 4 hours (MD = -2.28; 95% CI = -3.36 to -1.20; P < .0001), pain scores at 24 hours (MD = -0.70; 95% CI = -0.86 to -0.55; P < .00001) and anxiety score compared to control intervention (MD = -1.32; 95% CI = -1.53 to -1.11; P < .00001), but showed no obvious impact on pain scores at 12 hours (MD = -0.58; 95% CI = -1.39 to 0.22; P = .16). In addition, gabapentin supplementation could significantly decrease the incidence of vomiting in relative to control intervention (OR = 0.31; 95% CI = 0.12-0.81; P = .02), but they had similar incidence of nausea (OR = 0.51; 95% CI = 0.15-1.73; P = .28).
CONCLUSIONS: Gabapentin supplementation benefits to pain control after lumbar laminectomy and discectomy.

OBJECTIVE: Three-level hybrid surgery (HS) consisting of cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) has been partly used for the treatment of multi-level cervical degenerative disc disease (CDDD). The complications related to the implants and the collapse of the surgical vertebral bodies had been reported in multi-level anterior cervical spine surgery. Thus, this study aimed to explore the biomechanical effects on the prostheses and vertebrae in three-level HS.
METHODS: A FE model of cervical spine (C0-T1) was constructed. Five surgical models were developed. They were FAF model (ACDF-CDA-ACDF), AFA model (CDA-ACDF-CDA), FFF model (three-level ACDF), SF model (single-level ACDF), and SA model (single-level CDA). A 75-N follower load and 1.0-N·m moment was applied to produce flexion, extension, lateral bending, and axial rotation.
RESULTS: Compared with the intact model, the range of motion (ROM) of total cervical spine in FAF model decreased by 34.54%, 54.48%, 31.76%, and 27.14%, respectively, in flexion, extension, lateral bending, and axial rotation, which were lower than those in FFF model and higher than those in AFA model. The ROMs of CDA segments in FAF and AFA models were similar to the intact model and SA model. Compared with the intact model, the ROMs at C3/4 segment in FFF model increased from 5.71% to 7.85%, and increased from 5.31% to 6.81% at C7/T1 segment, following by FAF model, then the FAF model. The maximum interface pressures of the Prestige-LP in FAF model were similar to SA model, however the corresponding values were increased in AFA model. The maximum interface pressures of the Zero-P were increased in FAF and AFA model compared with those in SF and FFF models. The stress was mainly distributed on the screws. In AFA model, the maximum pressures of the ball and trough articulation in superior and inferior Prestige-LP were all increased compared with those in SA and FAF model. In FFF model, the maximum pressures of the vertebrae were higher than those in other models. The stress was mainly distributed on the anterior area of the vertebral bodies.
CONCLUSIONS: HS seemed to be more suitable than ACDF for the surgical treatment of three-level CDDD in consideration of the biomechanical effects, especially for the two-level CDA and one-level ACDF construct. But a more appropriate CDA prosthesis should be explored in the future.

OBJECTIVE: To report our institutional experience with full-endoscopic lumbar discectomy (FELD) and analyzed the pertinent literature.
METHODS: We retrospectively enrolled 100 patients who had undergone full-endoscopic discectomy for lumbar disc herniation using either an interlaminar (IL) or transforaminal (TF) approach. All patients underwent pre-operative imaging. Before and after surgery, patients\' pain and disability levels were measured using visual analog scale (VAS) and Oswestry disability index (ODI) respectively. Clinical outcomes were assessed using the modified MacNab criteria. Patients were divided into two groups, Group 1 (cases 1-50) and Group 2 (cases 51-100), and their learning curve factors were compared using a Student\'s t-test.
RESULTS: Sixtynine cases were operated via an IL approach and the remaining 31 cases using a TF approach. There were 4 early conversions in microdiscectomy. The mean operative time of the 96 procedures was 57 min. In Group 1, the mean operative time was 61.7 minutes (range: 35-110); in Group 2, it was 52.3 minutes (range: 25-75). The difference between the two groups was statistically significant (p=0.009). No significant differences were found in conversions, early operations, and recurrences between Groups 1 and 2. Both groups experienced a significant reduction in postoperative VAS and ODI compared to preoperative scores.
CONCLUSIONS: The findings support previously reported information on the safety and effectiveness of the FELD. Herein, we share some practical tips and tricks based on our initial experience and on the review of the available literature, which could facilitate new users. In experienced hands endoscopic techniques make treatment of herniated discs feasible independently of patient age, anatomy, and/or targeted pathology features. Conversely, thoughtful patient selection and careful preoperative planning are highly recommended for new users.

OBJECTIVE: Cervical alignment and range of motion (ROM) changes after cervical spine surgery are related to cervical biomechanical and functions. Few studies compared these parameters between posterior laminoplasty and anterior 3-level hybrid surgery incorporating anterior cervical discectomy and fusion (ACDF) with cervical disc replacement (CDR). This study is aimed to detect the differences of cervical alignment and ROM changes of the two surgeries in a matched-cohort study.
METHODS: From January 2018 and May 2020, 51 patients who underwent 3-level hybrid surgery incorporating ACDF with ACDR were included. A 1:1 match of the patients who underwent cervical laminoplasty based on age, gender, duration of symptoms, body mass index, and cervical alignment type was utilized as control group. General data (operative time, blood loss, etc.), Japanese Orthopaedic Association (JOA) score, VAS (Visual Analog Score), NDI (The Neck Disability Index), cervical sagittal alignment, and cervical range of motion (ROM) were recorded and compared.
RESULTS: Both groups gained significant improvement in JOA, VAS, NDI scores postoperatively (p < 0.05). Cervical alignment significantly increased in hybrid group and decreased in control group after surgeries (p < 0.001). ROM decrease was similar in two groups. For cervical lordosis, though cervical alignment angle in control group decreased, the final follow-up cervical alignment and cervical alignment changes were not significantly different between hybrid and control groups. For cervical non-lordosis, cervical alignment decreased in control group while increased in hybrid group. At final follow-up, cervical alignment and the changes between the two groups were significantly different. Both control group and hybrid group had similar ROM decrease after the surgery no matter whether there was cervical lordosis or non-lordosis. Hybrid surgery showed cervical alignments significantly improved and similar ROM preservation compared with control group at final follow-up both for 1-level and 2-level disc replacement subgroups.
CONCLUSIONS: The hybrid surgery demonstrated advantages of preserving cervical alignment and gaining similar cervical ROM preservation compared with cervical laminoplasty, especially for cervical non-lordosis. Given the importance of restoring lordotic cervical alignment, hybrid surgery may be preferred over laminoplasty to treat multilevel cervical disc herniation.

OBJECTIVE: For cervical nerve root compression, anterior cervical discectomy with fusion (anterior surgery) or posterior foraminotomy (posterior surgery) are safe and effective options. Posterior surgery might have a more beneficial economic profile compared to anterior surgery. The purpose of this study was to analyse if posterior surgery is cost-effective compared to anterior surgery.
METHODS: An economic evaluation was performed as part of a multicentre, noninferiority randomised clinical trial (Foraminotomy ACDF Cost-effectiveness Trial) with a follow-up of 2 years. Primary outcomes were cost-effectiveness based on arm pain (Visual Analogue Scale (VAS; 0-100)) and cost-utility (quality adjusted life years (QALYs)). Missing values were estimated with multiple imputations and bootstrap simulations were used to obtain confidence intervals (CIs).
RESULTS: In total, 265 patients were randomised and 243 included in the analyses. The pooled mean decrease in VAS arm at 2-year follow-up was 44.2 in the posterior and 40.0 in the anterior group (mean difference, 4.2; 95% CI, - 4.7 to 12.9). Pooled mean QALYs were 1.58 (posterior) and 1.56 (anterior) (mean difference, 0.02; 95% CI, - 0.05 to 0.08). Societal costs were €28,046 for posterior and €30,086 for the anterior group, with lower health care costs for posterior (€12,248) versus anterior (€16,055). Bootstrapped results demonstrated similar effectiveness between groups with in general lower costs associated with posterior surgery.
CONCLUSIONS: In patients with cervical radiculopathy, arm pain and QALYs were similar between posterior and anterior surgery. Posterior surgery was associated with lower costs and is therefore likely to be cost-effective compared with anterior surgery.