Name:
10.3171/2024.1.FOCVID23208
Description:
10.3171/2024.1.FOCVID23208
Thumbnail URL:
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Duration:
T00H09M32S
Embed URL:
https://stream.cadmore.media/player/efd6267e-6225-4007-ab5d-9d9ac9815b16
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/efd6267e-6225-4007-ab5d-9d9ac9815b16/7. 23-208.mp4?sv=2019-02-02&sr=c&sig=N4i%2FW9kyx1SHFGGFuzIZJi0G%2Fydfofb2yKWiPala3DY%3D&st=2026-05-13T19%3A05%3A25Z&se=2026-05-13T21%3A10%3A25Z&sp=r
Upload Date:
2024-03-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SANJAY KONAKONDLA: This case demonstrates the application of full endoscopic uni-portal spine techniques to remove bilateral synovial cysts in the lumbar spine. I'm Sanjay Konakondla, and I'll review the key points in the patient workup, technical nuances, and intraoperative considerations, which are all necessary for a successful surgical result. The patient is a 63-year-old male with a BMI of 41 and a complex past medical history significant for chronic kidney disease, coronary artery disease, myocardial infarction, status post-stenting, diabetes, hypertension, and obesity.
SANJAY KONAKONDLA: He presented with a more than 1-year history of chronic low back pain, weakness, and bilateral lower extremity pain, which matched clinically with a bilateral L5 radiculopathy. On examination, the patient exhibited bilateral ankle dorsiflexion weakness graded 4+ out of 5 bilaterally. The patient had a notable antalgic gait and used a wheelchair to mobilize due to the pain intensity.
SANJAY KONAKONDLA: The patient failed all conservative management, which included physical therapy, pain medications, and injections. Initial imaging available for review included an MRI of the lumbar spine, which revealed transitional anatomy, lumbar spondylosis, and an L4–5 grade 1 spondylolisthesis. At the level of L4–5 bilateral synovial cysts, right greater than left, were identified with resultant significant cauda equina nerve root compression.
SANJAY KONAKONDLA: A SPECT-CT was completed and revealed significant radiotracer uptake at the bilateral L4–5 joints. Standing neutral and flexion/extension x-rays, however, did not reveal significant dynamic instability. Due to the patient's severe symptoms, clinical examination, and exam findings, the patient was deemed appropriate for resection of the bilateral synovial cysts. The goal was to decompress the neural elements, halt the progression of neurologic impairment, and to improve his quality of life.
SANJAY KONAKONDLA: The recommendation of a fusion procedure can also be considered in this patient with bilateral synovial cysts and advanced facet degeneration and could be supported by the literature. Due to the patient's comorbidities, stable flexion/extension x-rays and our goals to avoid significant collateral damage, we elected to attempt only a decompression first. A full endoscopic surgical procedure was chosen to accomplish these goals under direct visualization.
SANJAY KONAKONDLA: Given the patient's past medical history, our aim was to minimize surgical invasiveness, avoid instrumented fixation and fusion, and to reduce postoperative narcotic consumption. After full written and informed consent, the patient was scheduled electively for this procedure. Intraoperative positioning, included an open Jackson table with a Wilson frame. The patient was induced under general endotracheal anesthesia without complication and positioned prone onto the operating table.
SANJAY KONAKONDLA: All pressure points were accounted for and padded, intraoperative neuromonitoring was used throughout the case. Screens were opposite the surgeon for comfort. It is important to note that typically the surgeon and the assistant are on the same side of the pathology when the pathology is unilateral. In this case, an over-the-top approach was necessary to complete the successful resection of the bilateral synovial cysts.
SANJAY KONAKONDLA: With this in mind, the approach was from the side of the smaller left cyst for better off-axis view of the larger cyst when traveling contralaterally, as highlighted by the green arrows. Intraoperative fluoroscopy is used to identify specific landmarks. After the appropriate level is identified, lines are drawn at the midline and at the disc level, which are represented by the purple dashed lines.
SANJAY KONAKONDLA: The C-arm on the AP view is optimized to open the interspinous distance over the disk space. This distance is represented by the yellow bidirectional arrows. An initial dilator is placed at the medial edge of the inferior articulating process of L4, sequential dilators are passed, a tubular retractor is passed over the dilators and a fluoroscopic image is completed to reveal appropriate trajectory.
SANJAY KONAKONDLA: This is shown on the right-sided fluoroscopic image. The green circle marks the docking point. The green arrows represent the possible trajectories traveling in between the spinous processes to reach the contralateral side. This offers the possibility of minimizing extensive bony resection when trying to reach contralaterally. The endoscope was introduced into the tubular retractor. A high-speed round course diamond tip drill was used to undermine the lamina.
SANJAY KONAKONDLA: As any typical interlaminar endoscopic approach, the ligamentum flavum was identified and removed using graspers. The system used in this case was the joimax iLESSYS Pro set, which has a tubular retractor inner and outer diameter of 7.5 and 8.5 mm, respectively. This allows for the passage of an endoscope with a 4.7-mm working channel diameter and facilitates Kerrison instruments up to 4 mm and a round diamond drill of a 4.5-mm diameter.
SANJAY KONAKONDLA: The drilling seen here is of the L4 inferior articulating process and the superior portion of the L5 lamina. The first sight of the contralateral larger synovial cyst can be seen and is identified by the black asterisk, and the compressed dura is represented by the blue arrow. The white asterisk represents the ipsilateral synovial cyst components.
SANJAY KONAKONDLA: The working channel on the endoscope returned to identify the ipsilateral ligamentum flavum, which is removed with Kerrison punches to uncover the ipsilateral synovial cyst. The bipolar is used to release and visualize the cyst dural plane of the ipsilateral side. This is represented by the blue arrow. A ball-tipped bipolar device is used as a dissector to identify the cyst dural plane and the full extent of the contralateral cyst.
SANJAY KONAKONDLA: Epidural veins and bony bleeders are carefully cauterized. The ipsilateral inferior articulating process is further removed with a diamond drill bit. A first glimpse of the ipsilateral traversing nerve root identified by the black asterisk, and fat can be seen on the lateral side of the ipsilateral cyst, indicating adequate ipsilateral exposure.
SANJAY KONAKONDLA: Attention was placed on the ipsilateral cyst and the cyst wall was removed with Kerrison punches and pituitary graspers of varying sizes. Throughout the case, the ball-tipped bipolar device was used as a dissector and to obtain hemostasis. After removal of the ipsilateral cyst, the area was inspected from top to bottom.
SANJAY KONAKONDLA: The contralateral cyst and the cyst wall were removed with Kerrison punches and pituitary graspers of varying sizes. Careful technique should always be emphasized to slide along the dorsal dural surface and to only travel into inviting planes.
SANJAY KONAKONDLA: The cyst wall and ligamentum flavum ventral to the contralateral L5 superior articulating process is removed. After adequate cyst removal, the contralateral traversing nerve root can now be visualized, demonstrated by the white asterisk. A now decompressed thecal sack is appreciated after removal of both cysts.
SANJAY KONAKONDLA: The contralateral reaches again demonstrated with fluoroscopic imaging and a curved instrument can be seen traveling dorsal to the dura to the exiting and traversing nerve root cranially and caudally, respectively. The surgery was completed without any peri- or intraoperative complications. After meticulous hemostasis, the 8-mm incision was closed with absorbable sutures and glue.
SANJAY KONAKONDLA: Surgery time was 273 minutes. Given the bilateral nature of the pathology and difficult cyst wall to dural plains, significant time was taken to ensure maximal safe resection of the compressive cyst components to avoid complications. We do believe with equipment and device innovations, the operative time may be reduced substantially. The patient reported immediate pain relief and was discharged home on postoperative day 1 without any issues.
SANJAY KONAKONDLA: It should be noted that these cases are challenging and specific consideration should be given to preoperative planning. These considerations specifically include pathology characteristics and approach trajectories. Comprehensive training and full endoscopic spine procedures, clinical experience, and surgical volume of endoscopic spine procedures are necessary for successful surgical outcomes.
SANJAY KONAKONDLA:
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