BACKGROUND: In recent developments, full endoscopic and unilateral biportal endoscopic (UBE) spine surgery have emerged to aid the transforaminal lumbar interbody fusion (TLIF) procedure. Yet, both approaches present a challenge due to limited space for cage insertion, potentially leading to complications such as cage subsidence or nonfusion in long-term assessments. Utilizing double cages may mitigate these concerns. This paper presents a unique case in which a patient successfully underwent computed tomography (CT) navigation-guided UBE-TLIF with 2 converging cages, highlighting the potential benefits and feasibility of this innovative approach.
METHODS: A 59-year-old female diagnosed with degenerative spondylolisthesis at the L4-5 level underwent a UBE-TLIF. The operation is detailed step by step and supported by illustrative figures and surgical videos. Postsurgery results revealed a significant improvement in the patient\'s condition, with the visual analog scale score decreasing from 7 to 3 on the first day, leading to a satisfaction rate of 90% at the last follow-up.
CONCLUSIONS: Utilizing endoscopic visualization complemented by contrast medium has substantially elevated the quality of disc preparation. From their observations, the authors affirm that the integration of intraoperative CT navigation systems significantly augments safety and pinpoint accuracy in UBE-TLIF procedures. The strategy of employing 2 converging cages through a unilateral technique stands as a practical solution, potentially optimizing the fusion outcomes of UBE-TLIF surgery. https://thejns.org/doi/10.3171/CASE23512.

Minimally invasive spinal surgery has shown benefits not only from a clinical standpoint but also in some cost-effectiveness metrics. Microendoscopic procedures combine optical advantages of endoscopy with the preservation of bimanual surgical maneuvers that are not feasible with full percutaneous endoscopic procedures. TELIGEN is a new endoscopic platform designed to optimize these operations. Our aim was to present a retrospective review of surgical data from the first consecutive cases applying this device in our institution and describe some of its technical details. 25 patients have underwent procedures using this device at our institution to the date, with a mean follow-up of 341.7 ± 45.1 days. 17 decompression-only procedures, including microendoscopic discectomies (MED) and decompression of stenosis (MEDS), with or without foraminotomies (± MEF) and 8 microendoscopic transforaminal lumbar interbody fusions (ME-TLIF) were performed. Mean age and body mass index (BMI) were respectively 58.8 ± 17.4 years and 27.6 ± 5.3 kg/m2. Estimated blood loss (13 ± 4.8, 12.8 ± 6.98 and 76.3 ± 35.02 mL), postoperative length of hospital stay (11.2 ± 21.74, 22.1 ± 26.85 and 80.7 ± 44.60 h), operative time (130.3 ± 58.53, 121 ± 33.90 and 241.5 ± 45.27 min) and cumulative intraprocedural radiation dose (14.2 ± 6.36, 15.4 ± 12.17 and 72.8 ± 12.26 mGy) are reported in this paper for MED ± MEF, MEDS ± MEF and ME-TLIF, respectively. TELIGEN affords an expanded surgical field of view with unique engineered benefits that provide a promissing platform to enhance minimally invasive spine surgery.

Minimally invasive surgical approaches to the spine that leverage indirect decompression are gaining increasing popularity. While there is excellent literature on the value of indirect decompression, there are limitations to this procedure. Specifically, in patients with severe stenosis and neurogenic claudication, there is a concern among many surgeons regarding the adequacy of indirect decompression alone. In these cases, the lateral approach is often abandoned in favor of an open posterior or posterior minimally invasive approach. Unfortunately, some of the distinct benefits of the direct lateral approach are then lost. Here, we present the case of a 58-year-old male who underwent an L4-L5 lateral interbody fusion with an endoscopic ipsi-contra decompression to achieve both direct and indirect treatment of severe neuroforaminal and central stenosis. From this strategy, this patient had complete pre-operative symptom resolution and was able to return to work immediately after surgery without significant restriction. Combining the benefits of direct and indirect using an ultra-minimally invasive decompressive approach offers a potential solution.

Background and Objectives: Minimally invasive spine surgery (MISS) under monitored anesthesia care (MAC) has emerged as a treatment modality for spinal radiculopathy. It is essential to secure the airway and guarantee spontaneous respiration without endotracheal intubation during MISS in a prone position. Materials and Methods: To evaluate the feasibility and safety of MAC with dexmedetomidine during MISS, we retrospectively reviewed clinical cases. A retrospective review of medical records was conducted between September 2015 and June 2016. A total of 17 patients undergoing MISS were included. Vital signs were analyzed every 15 min. The depth of sedation was assessed using the bispectral index (BIS) and the frequency of rescue sedatives. Adverse events during anesthesia, including bradycardia, hypotension, respiratory depression, postoperative nausea, and vomiting, were evaluated. Results: All cases were completed without the occurrence of airway-related complications. None of the patients needed conversion to general anesthesia. The median maintenance dosage of dexmedetomidine for adequate sedation was 0.40 (IQR 0.40-0.60) mcg/kg/hr with a median loading dose of 0.70 (IQR 0.67-0.82) mcg/kg. The mean BIS during the main procedure was 76.46 ± 10.75. Rescue sedatives were administered in four cases (23.6%) with a mean of 1.5 mg intravenous midazolam. After dexmedetomidine administration, hypotension and bradycardia developed in six (35.3%) and three (17.6%) of the seventeen patients, respectively. Conclusions: MAC using dexmedetomidine is a feasible anesthetic method for MISS in a prone position. Hypotension and bradycardia should be monitored carefully during dexmedetomidine administration.

UNASSIGNED: Percutaneous transforaminal endoscopic discectomy (PTED) has become popular over the years due to its safety and low invasiveness. This surgery can be performed with different anesthesia techniques; however, the extent to which the surgeon and patient are satisfied with the analgesia is debatable.
UNASSIGNED: This study investigated the efficiency of the S1 transforaminal epidural block.
UNASSIGNED: This retrospective study was conducted on 60 patients with L4 - L5 lumbar disc herniation who underwent PTED under the S1 transforaminal epidural block. All patients had clinical symptoms associated with unilateral radiculopathy and were candidates for surgery. Percutaneous transforaminal endoscopy and S1 epidural block were performed by a surgeon for all patients.
UNASSIGNED: Of the 60 evaluated cases, 61.7% and 38.3% were female and male, respectively, with a mean age of 42.98 ± 10.79 years. The mean pain score before surgery was 7.83 ± 0.69, which decreased to 2.58 ± 0.65 during surgery and 0.50 ± 0.50 48 hours after surgery (P < 0.001). The mean duration of operation in these patients was 58.58 ± 16.95 minutes, and the mean onset time was 10.08 ± 3.12 minutes. Moreover, the mean bleeding was 124.17 ± 25.20 cc.
UNASSIGNED: The PTED with S1 epidural anesthesia is a simple, safe, and effective method that causes good analgesia during the operation and cooperates well with the surgeon in neurological monitoring due to patient consciousness.

OBJECTIVE: The goal of this study was to describe the indirect and partial correction of spine kyphotic deformities (secondary to various pathologies) achieved by minimally invasive posterolateral extracavitary approach (MIS PLECA) for corpectomy.
METHODS: The authors retrospectively reviewed a consecutive case series of 12 patients undergoing MIS PLECA in a single institution. Perioperative data were collected and follow-up computed tomographies and radiographs were reviewed to assess for interbody arthrodesis.
RESULTS: The mean age was 60.7 ± 20.8 years (58.4% males). The etiologies of deformity included pathological fracture (41.6%), acute trauma (30%), and infection. An expandable cage was used in 66.7% of patients for anterior reconstruction. The mean total estimated blood loss was 764.1 ± 332.9 ml. The mean operative time was 413.3 ± 98.8 minutes. The average length of hospital stay was 5.8 ± 2.5 days. A consistent degree of focal correction of sagittal alignment was seen in all patients with a mean correction of sagittal angle of 7.4 ± 4.3° (P < 0.0001). The mean duration of rehabilitation was 8.5 ± 6.7 days. All patients remained neurologically stable at the last follow-up with a mean follow-up period of 20.1 ± 12.8 months. Successful fusion was achieved in 91.7% at the last follow-up.
CONCLUSIONS: MIS PLECA for corpectomy appears to be a feasible, safe, and effective MIS technique for select patients, particularly those who cannot tolerate the traditional open approach. Additionally, a focal sagittal deformity correction can be achieved using MIS corpectomy.

BACKGROUND: Endoscopic spine surgery (ESS) has a reduced rate of incidental durotomy (ID) compared with open spine surgery. However, there are unique challenges regarding the management of ID in ESS due to the single, deep, narrow working corridor and aqueous environment. Here, we present a collagen matrix inlay graft technique for the management of ID encountered during ESS.
METHODS: Three patients were identified via medical record review of full ESS where an intraoperative ID was encountered. These were all addressed endoscopically. All surgeries were performed by a single surgeon in the years 2019 to 2023. Patient, operative, and postoperative details, including patient-reported outcomes, were recorded. Briefly, the collagen matrix inlay graft technique included introducing a segment of collagen matrix into the surgical field and manipulating the collagen matrix so that it passed through the durotomy and resided within the dura, plugging the hole.
RESULTS: Three IDs were identified out of a total of 295 eligible cases (1.02%). The IDs measured 2 to 2.5 mm in length. For these 3 patients, the duration of hospital stay ranged from 172 to 1,068 minutes. No patients exhibited signs or symptoms of cerebrospinal fluid leak at any postoperative timepoint. At the 6-week postoperative visit, all patients had achieved the minimum clinically important difference in Oswestry Disability Index, and all patients with available visual analog scale scores for leg and low back pain had achieved the cutoff for the minimum clinically important difference.
CONCLUSIONS: We presented 3 cases of ID during uniportal full ESS who were repaired using a collagen matrix inlay technique. Prolonged bed rest was avoided, and all patients achieved excellent clinical outcomes without further complication. This technique may also be appropriate for other minimally invasive spine surgery techniques.
CONCLUSIONS: ID is a common and undesirable complication of degenerative lumbar spine surgery. Endoscopic ID repair techniques provide an option to avoid conversion to open or tubular surgery for the management of ID.
METHODS:

BACKGROUND: High-energy traumatic sacral fractures, particularly U-type or AOSpine classification type C fractures, may lead to significant functional deficits. Traditionally, spinopelvic fixation for unstable sacral fractures was performed with open reduction and fixation, but robotic-assisted minimally invasive surgical methods now present new, less invasive approaches. The objective here was to present a series of patients with traumatic sacral fractures treated with robotic-assisted minimally invasive spinopelvic fixation and discuss early experience, considerations, and technical challenges.
METHODS: Between June 2022 and January 2023, 7 consecutive patients met the inclusion criteria. Intraoperative fluoroscopic images were merged with intraoperative computed tomography images using a robotic system to plan the trajectories for placement of bilateral lumbar pedicle and iliac screws. Intraoperative computed tomography was performed after pedicle and pelvic screw insertion to confirm appropriate placement before insertion of rods percutaneously without the need for a side connector.
RESULTS: The cohort consisted of 7 patients (4 female, 3 male) with ages ranging from 20 to 74. Intraoperatively, the mean blood loss was 85.7 ± 84.0 mL, and mean operative time was 178.4 ± 63.9 minutes. There were no complications in 6 patients; 1 patient experienced both a medially breached pelvic screw and a complicated rod pullout. All patients were safely discharged to their homes or an acute rehabilitation facility.
CONCLUSIONS: Our early experience reveals that robotic-assisted minimally invasive spinopelvic fixation for traumatic sacral fractures is a safe and feasible treatment option with the potential to improve outcomes and reduce complications.

BACKGROUND: Annually, hundreds of thousands of patients undergo surgery for degenerative spine disease (DSD). This represents only a fraction of patients that present for surgical consideration. Procedures are often avoided due to comorbidities that make patients poor candidates for general anesthesia (GA) and its associated risks. With increasing interest in awake surgery under spinal anesthesia (SA), the authors have observed that SA may facilitate spine surgery in patients with relative contraindications to GA. With this in mind, the authors set out to summarize the outcomes of a series of highly comorbid patients who received surgery under SA.
METHODS: Case logs of a single surgeon were reviewed, and patients undergoing spine surgery under SA were identified. Within this group, patients were identified with relative contraindications to GA, such as advanced age and medical comorbidities. For these patients, for whom surgery was facilitated by SA, the medical records were consulted to report demographic information and patient outcomes.
RESULTS: Ten highly comorbid patients were identified who received lumbar spine surgery for DSD under SA. Comorbidities included octogenarian status, obesity, and chronic health conditions such as heart disease. The cohort had a mean age of 75.5 and a mean American Society of Anesthesiologists Physical Status (ASA-PS) score of 3.1. The patients were predicted to have a 2.74-fold increase of serious complications compared to the average patient. There were no adverse events.
CONCLUSIONS: For patients with symptomatic, refractory DSD and relative contraindications to GA, SA may facilitate safe surgical intervention with excellent outcomes.

Lateral lumbar interbody fusion is an evolving procedure in spine surgery allowing for the placement of large interbody devices to achieve indirect decompression of segmental stenosis, deformity correction and high fusion rates through a minimally invasive approach. Traditionally, this technique has been performed in the lateral decubitus position. Many surgeons have adopted simultaneous posterior instrumentation in the lateral position to avoid patient repositioning; however, this technique presents several challenges and limitations. Recently, lateral interbody fusion in the prone position has been gaining in popularity due to the surgeon\'s ability to perform simultaneous posterior instrumentation as well as decompression procedures and corrective osteotomies. Furthermore, the prone position allows improved correction of sagittal plane imbalance due to increased lumbar lordosis when prone on most operative tables used for spinal surgery. In this paper, we describe the evolution of the prone lateral approach for interbody fusion and present our experience with this technique. Case examples are included for illustration.