Name:
10.3171/2024.1.FOCVID23228
Description:
10.3171/2024.1.FOCVID23228
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/2bc5b2f2-ffeb-482b-8222-2896b0e21958/thumbnails/2bc5b2f2-ffeb-482b-8222-2896b0e21958.jpeg
Duration:
T00H07M07S
Embed URL:
https://stream.cadmore.media/player/2bc5b2f2-ffeb-482b-8222-2896b0e21958
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/2bc5b2f2-ffeb-482b-8222-2896b0e21958/13. 23-228.mp4?sv=2019-02-02&sr=c&sig=0xpA9eiSNbR%2Fg3KcnA7hD7qbQk1j7dzUIUZkoRfSJvE%3D&st=2026-04-26T09%3A59%3A03Z&se=2026-04-26T12%3A04%3A03Z&sp=r
Upload Date:
2026-04-26T10:04:03.8853289Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: In this video article, we
SPEAKER: will examine a case of tethered cord release using a minimally invasive spinal surgery technique called biportal endoscopic approach, which has become increasingly popular in recent years. Our patient is a 24-year-old female who has been experiencing severe back pain radiating to the buttocks with episodic attacks for the past 8 years. She occasionally reports numbness in her inner thighs.
SPEAKER: There are no active complaints related to urinary or fecal incontinence. During the physical examination, no motor deficits were observed. But there is mild hypoesthesia in the sacral dermatomes. Deep tendon reflexes are normal. And inspection reveals increased fat accumulation and hairiness in the sacral region disproportionate to the patient's weight.
SPEAKER: Preoperative radiological examinations revealed a midline fusion defect at the L5 level. On MRI examination, the conus medullaris terminates at the L3 level. And a short, thick, and fat filum terminale with a hyperintense appearance is noted on the T1 sequence. For the surgical approach, a classic unilateral biportal endoscopic approach was chosen. Triangulation was performed at the left L5 spinal laminar junction.
SPEAKER: A 3-mm cranial incision was made at the level of the L5 pedicle to create a viewing port. And a trocar was introduced through this port. A 1-cm skin incision was made at the level of the left S1 pedicle to create a working port. And a working channel was established using thickened dilators.
SPEAKER: The dilators in the working port were removed. And the surgery proceeded through the free skin. After completing the triangulation phase, level control was confirmed with lateral and anteroposterior fluoroscopic images. After the verification of the triangulation level with fluoroscopy, saline irrigation is started. And landmarks, such as lamina facet are defined. Starting from the left L5 spinal laminar junction, a minimal partial laminectomy was performed using a spherical arthroscopic burr and Kerrison rongeur.
SPEAKER: The ligamentum flavum was dissected from the dura with a nerve hook. Then flavectomy was performed with a Kerrison. Since the level is L5–S1, the ATA ligament in the midline is separated from the dura with sharp dissection to avoid irregular dural tier.
SPEAKER: Durotomy is started from the midline with a scalpel. Then approximately 8- mm to durotomy completed with a microscissors. Both edges of the durotomy hanged with 8-0 Prolene sutures.
SPEAKER: Since our approach is unilateral, the purpose of suturing the contralateral dural leaf is not to increase exposure. By elevating both dural leaves, we reduce the migration of the sacral rootlets toward the extradural space and prevent them from interfering with the filum terminale dissection. Filum terminale and rootlets are stimulated through electrophysiological study.
SPEAKER: Working in saline here did not interfere with neuromonitoring. Firstly, we stimulated neural tissue, and the electrophysiological study proved that it was the sacral rootlet which innervates the anal sphincter. Then, we stimulated the filum at three different locations, and there was no response at the neuromonitor. The vascular structures of the filum terminale are coagulated using bipolar electrocautery, and the filum is cut with microscissors.
SPEAKER: The neural tissues adhered to the filum terminale are dissected from it with a microdissector and microhook. The single remaining vascular structure is coagulated with bipolar and then severed.
SPEAKER: It is observed that the free ends of the filum move away from each other in both cranial and caudal directions. The rootlets herniated outside the dura are carefully reinserted into the dura with a dissector at the end of the operation. Then the approximately 2-hour- long surgical procedure terminated. As we planned a minimal dermatome, 6 to 8 mm, and utilized the advantages of the endoscopy technique, there was no muscle dissection and, consequently, no potential dead space.
SPEAKER: This approach eliminated the expectation of complications such as pseudo meningocele and CSF fistula. Consequently, dural repair was deemed unnecessary. A postoperative radiological examination confirmed the separation of the cranial and caudal ends of the filum terminale on T1-weighted MRI images. On postoperative CT examination, a minimal bone defect is observed at the left L5 spinal laminar junction. The major advantage of this approach is the successful execution of the surgery with minimal bone excision without the need for total laminectomy.
SPEAKER: In conclusion, the patient was mobilized 24 hours after the surgery, and there were no cerebrospinal fluid fistula or neurological deficits in the postoperative period. The patient was discharged 72 hours after the surgery. The patient's low-back pain, which affected her daily life, showed a dramatic improvement in the early postoperative period. In the postoperative control examination, the patient described that she could hold her urine for a longer period of time and urinate a higher volume at a time.
SPEAKER: Therefore, it was evaluated that the patient had an unrecognized urinary dysfunction, which was improved postoperatively. The postoperative first month MRI showed no evidence of pseudo meningocele and CSF fistula.
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