Early experience with endoscopic revision of lumbar spinal fusions

Abstract

Approximately half a million spinal fusion procedures are performed annually in the US. It is estimated that up to one-third of arthrodesis constructs require revision surgeries. In this study the authors present endoscopic treatment strategies targeting 3 types of complications following arthrodesis surgery: 1) adjacent-level foraminal stenosis; 2) foraminal stenosis at an arthrodesis segment; and 3) stenosis caused by a displaced interbody cage. A retrospective chart review of 11 patients with a mean age of 68 ± 15 years was performed (continuous variables are shown as the mean ± SEM). All patients had a history of lumbar arthrodesis surgery and suffered from unilateral radiculopathy. Endoscopic revision surgeries were done as outpatient procedures, and there were no intraoperative or perioperative complications. The cohort included 3 patients with foraminal stenosis at the level of previous arthrodesis. They presented with unilateral radicular leg pain (visual analog scale [VAS] score: 7.3 ± 2.1) and were severely disabled, as evidenced by an Oswestry Disability Index (ODI) of 46 ± 4.9. Transforaminal endoscopic foraminotomies were performed, and at a mean follow-up time of 9.0 ± 2.5 months VAS was reduced by an average of 6.3. The cohort also includes 7 patients suffering unilateral radiculopathy due to adjacent-level foraminal stenosis. Preoperative VAS for leg pain of the symptomatic side was 6.0 ± 1.6, VAS for back pain was 5.2 ± 1.7, and ODI was 40 ± 6.33. Endoscopic decompression led to reduction of the ipsilateral leg VAS score by an average of 5, resulting in leg pain of 1 ± 0.5 at an average of 8 months of follow-up. The severity of back pain remained stable (VAS 4.2 ± 1.4). Two of these patients required revision surgery for recurrent symptoms. Finally, this study includes 1 patient who presented with weakness and pain due to retropulsion of an L5/S1 interbody spacer. The patient underwent an endoscopic interlaminar approach with partial resection of the interbody cage, which resulted in complete resolution of her radicular symptoms. Endoscopic surgery may be a useful adjunct for management of certain arthrodesis-related complications. Endoscopic foraminal decompression of previously fused segments and resection of displaced interbody cages appears to have excellent outcomes, whereas decompression of adjacent segments remains challenging and requires further investigation.

Keywords: ODI = Oswestry Disability Index; PEEK = polyetheretherketone; TLIF = transforaminal lumbar interbody fusion; VAS = visual analog scale; arthrodesis surgery; endoscopic spine surgery; revision.