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BACKGROUND: Various approaches are used for decompressive surgeries in the thoracic spine depending on the location and consistency of the pathology, always avoiding manipulation of the thoracic spinal cord. Recently, there has been an effort to achieve adequate results and reduce morbidity with minimally invasive surgeries. Good outcomes and the advantages of full endoscopic spine surgery (FESS) have been proven for surgerical correction of herniated discs and stenoses in the lumbar and cervical spine. Similar evidence has recently been described for the thoracic spine, but it has not previously been reported in Brazil. Although the transforaminal approach is already established for the thoracic spine, the newly described interlaminar approach is equally efficient, and both techniques must be considered when treating thoracic spine diseases. The objective of the present article was to present the full endoscopic interlaminar and transforaminal techniques in patients with symptomatic disc herniation of the thoracic spine, discuss the rationality for implementing FESS in thoracic spine, and discuss the rationality in choosing between both approaches. METHODS: Two patients were submitted to thoracic FESS. A transforaminal approach was chosen for a T10-T11 foraminal disc herniation; an interlaminar approach was selected for a paramedian T7-T8 disc extrusion. Data regarding operating time, intraoperative images, hospital stay, visual analog scales before and after FESS, course of recovery, and surgery satisfaction were evaluated. RESULTS: The patients had eventless surgeries, improved from preoperative pain without morbidity. Both were satisfied and recovered well. Hospital stay was less than 6 hours after surgery. CONCLUSIONS: Transforaminal and interlaminar FESS for thoracic disc herniation are safe, efficient, and minimally invasive alternatives. CLINICAL RELEVANCE: Despite being an innovative technique with evident advantages, it should be carefully considered along with conventional technique for the treatment of thoracic spine diseases, since its clinical relevance is yet to be determined.

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Introducción: La Discectomía Endoscópica Lumbar Percutánea (DELP) es una técnica mínimamente invasiva que se usa en distintos países desde finales de los ochenta para el tratamiento de las Hernias Discales. Objetivo: El propósito del presente artículo es presentar los resultados de la evolución clínica de 110 pacientes operados de distintas hernias discales lumbares por técnica endoscópica percutánea, con seis meses de seguimiento. Asimismo, describir la técnica realizada y los aspectos más relevantes del planning preoperatorio, entre ellos el punto de ingreso percutáneo. Materiales y Métodos: En un grupo de 110 pacientes y 141 discos operados entre abril de 2016 y octubre de 2019, se recogieron datos como la edad, el sexo, la clínica, las imágenes de RMN y el planning del ingreso (Skin Entry Point) con target en el fragmento discal herniado. Se realizó en todos los casos una fragmentectomía dirigida, y luego se complementó con técnica In-Out. Se registró, como dato principal, la diferencia en los puntajes de Oswestry (ODI) pre y postquirúrgico a los 6 meses del procedimiento. También se constató la duración de la operación, el tiempo de hospitalización, y la necesidad de reintervención. Todos los pacientes se operaron despiertos, recibiendo anestesia peridural y sedación. Resultados: Se operaron 110 pacientes y 141 hernias discales. El promedio de reducción en ODI a los 6 meses fue 47,5 puntos (SD=5,7), representando un porcentaje medio de reducción de 85% (SD=9,5). Desde el punto de vista técnico se logró promediar la distancia de línea media al ingreso o Skin Entry Point, según el nivel operado y el abordaje elegido. Conclusión: a la luz de los resultados en nuestra serie de 110 pacientes con hernias discales lumbares, operados despiertos por endoscopía percutánea, se obtuvieron mejorías en el dolor promedio del 85% a seis meses. La técnica endoscópica puede ser considerada como un procedimiento efectivo para pacientes con hernias foraminales, extraforaminales y centrales en los niveles L3L4, L4L5 y L5S1.

Introduction: Introduction: PELD is a minimally invasive technique that has been used in different countries since the late 1980s for the treatment of Herniated Discs. Objective: to describe the surgical method from the Approach point of view and PELD results in a series of 110 patients. Materials and Methods: In a group of 110 patients who together had 141 discs operated on between April 2016 and October 2019, data were collected on patients age and gender, clinical presentation, MRI abnormalities and Skin Entry Point (SEP) with target in the herniated disc fragment. A focused fragmentectomy was performed in all cases, and then it was complemented with an In-Out technique. The main result was the difference in the pre and postoperative Oswestry Disability Index (ODI) scores 6 months after the procedure. The operation duration, the lenght of hospitalization, and the need for reoperation were also recorded. All patients underwent surgery awake, receiving epidural anesthesia and sedation. Results: Respecting the SEP of the endoscope according to the MRI planning focused in the herniated fragment, the evolution of the patients was very favorable. The average reduction in ODI at 6 months was 47.5 points (SD = 5.7), representing an average percentage reduction of 85% (SD = 9.5). The average surgery time was 58 minutes, and the hospitalization time 8.5 hours. Conclusions: In our series of surgical patients with lumbar disc herniations, PELD with focused fragmentectomy in awake patients proved to be a technique with very good results, especially with prior planning of the SEP to achieve effective root decompression

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Objective To evaluate the clinical and functional results of transforaminal endoscopic lumbar discectomy. Materials and Methods From August 2015 to January 2017, 101 patients with lumbar disc hernia refractory to clinical treatment underwent endoscopic discectomy. Through clinical evaluation by the Visual Analogue Scale and functional evaluation by the Oswestry Disability Index questionnaire, the patients were analyzed in the preoperative period, the immediate postoperative period, at 1 month, 3 months, 6 months and 1 year after surgery. Results The mean age of the participants was 48.1 years. The most affected disc levels were L4-L5 and L5-S1. A total of 29 patients were treated at 2 disc levels. After 1 month of postoperative follow-up, the mean scores on the questionnaires (VAS and ODI) decreased significantly ( p < 0.001). Conclusion Transforaminal endoscopic Lumbar discectomy has been shown to be a safe, effective and minimally-invasive alternative for the treatment of lumbar disc herniation. The procedure has advantages, such as short hospital stay, surgery performed under local anesthesia and sedation, early return to daily activities, and low rate of complications.

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Abstract Objective To evaluate the clinical and functional results of transforaminal endoscopic lumbar discectomy. Materials and Methods From August 2015 to January 2017, 101 patients with lumbar disc hernia refractory to clinical treatment underwent endoscopic discectomy. Through clinical evaluation by the Visual Analogue Scale and functional evaluation by the Oswestry Disability Index questionnaire, the patients were analyzed in the preoperative period, the immediate postoperative period, at 1 month, 3 months, 6 months and 1 year after surgery. Results The mean age of the participants was 48.1 years. The most affected disc levels were L4-L5 and L5-S1. A total of 29 patients were treated at 2 disc levels. After 1 month of postoperative follow-up, the mean scores on the questionnaires (VAS and ODI) decreased significantly (p < 0.001). Conclusion Transforaminal endoscopic Lumbar discectomy has been shown to be a safe, effective and minimally-invasive alternative for the treatment of lumbar disc herniation. The procedure has advantages, such as short hospital stay, surgery performed under local anesthesia and sedation, early return to daily activities, and low rate of complications.

Resumo Objetivo Avaliar os resultados clínicos e funcionais da discectomia endoscópica transforaminal lombar. Materiais e Métodos De agosto de 2015 a janeiro de 2017, 101 pacientes portadores de hérnia de disco lombar refratária ao tratamento clínico foram submetidos a discectomia endoscópica. Por meio de avaliação clínica pela Escala Visual Analógica e análise funcional pelo questionário Oswestry Disability Index, os pacientes foram analisados no período pré-operatório, no pós-operatório imediato, com 1 mês, 3 meses, 6 meses e 1 ano após a cirurgia. Resultados A média de idade dos participantes foi de 48.1 anos. Os níveis discais mais acometidos foram L4-L5, seguidos de L5-S1. Um total de 29 pacientes foram abordados em 2 níveis discais. Após 1 mês de seguimento pós-operatório, a média das pontuações nos questionários (EVA e ODI) diminuiu significativamente (p < 0.001). Conclusão A discectomia endoscópica transforaminal lombar mostrou ser uma alternativa segura, eficaz e minimamente invasiva para o tratamento de hérnia de disco lombar. O procedimento tem vantagens, como curto período de internação hospitalar, cirurgia realizada sob anestesia local e sedação, retorno precoce às atividades diárias, e baixa taxa de complicações.

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INTRODUCTION: Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive technique that has been used in different countries since the late eighties for the treatment of herniated discs. OBJECTIVE: The objective of this study was to describe the results of PELD in a series of awake patients, treated with epidural anesthesia and mild sedation. MATERIALS AND METHODS: In a group of 60 patients, who together had 77 discs operated on between April 2016 and March 2018, data were collected on patient age and gender, clinical presentation, and MRI abnormalities. The main outcome of interest was the difference between preoperative and postoperative Oswestry (Oswestry disability index [ODI]) scores 8 weeks after the procedure. Macnab criteria, operation duration, length of hospitalization, surgical complications, and the need for reoperation were other outcomes evaluated. All patients received epidural anesthesia and mild sedation. RESULTS: The average reduction in ODI at 8 weeks was 48 points (standard deviation [SD] = 5), representing an average percentage reduction of 85% (SD = 8). By Macnab's criteria, 85% of patients experienced either an excellent or good result, while 10% and 5% had a fair and poor result, respectively. Average surgery time was 50 min and in-hospitalization stay 8.6 h. CONCLUSIONS: In our series of surgical patients with lumbar disc herniations, PELD yielded very good results, manifest as significantly reduced pain, brief procedural durations, no complications, and short hospital stays. Patients accepted the option of being awake and immediately ambulatory, and the approach proved highly feasible to execute.

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Introducción: La DELP es una técnica mínimamente invasiva que se usa en distintos países desde finales de los años ochenta para el tratamiento de las hernias discales. Nuestro objetivo es describir los resultados de las DELP en una serie de pacientes despiertos, con anestesia peridural y sedación. Materiales y Métodos: En un grupo de 60 pacientes y 77 hernias de discos operados entre abril de 2016 y marzo de 2018, se recogieron datos como la edad, el sexo, la imagen clínica y las anomalías de imágenes mediante MRI. El resultado principal fue la diferencia en los puntajes de Oswestry (ODI) pre y postquirúrgico a las 8 semanas del procedimiento. También se evaluaron los criterios de Macnab, la duración de la operación, el tiempo de hospitalización, las complicaciones quirúrgicas y la necesidad de reintervención. Los pacientes recibieron anestesia peridural y sedación. Resultados: Se operaron 60 pacientes y 77 hernias discales. El promedio de reducción en ODI a las 8 semanas fue 48 puntos (SD=5), representando un porcentaje medio de reducción de 85%(SD=8). Según los criterios de Macnab, tuvieron excelente o buena evolución el 85% de los pacientes, regular 10% y mala evolución 5%. El tiempo de cirugía promedio fue de 50 minutos y el de hospitalización 8,6 horas. Conclusiones: En nuestra serie de pacientes quirúrgicos con hernias discales lumbares la DELP resultó ser una técnica con muy buenos resultados en la reducción del dolor, de corta duración quirúrgica, sin complicaciones y breve estadía hospitalaria. La opción del paciente despierto y la modalidad ambulatoria fueron muy aceptadas por los pacientes y resultaron de factible ejecución.

Introduction: Percutaneous endoscopic lumbar discectomy (PELD) is a minimally-invasive technique that has been used in different countries since the late eighties for the treatment of herniated discs. Objective: To describe the results of PELD in a series of awake patients, treated with epidural anesthesia and mild sedation. Methods and Materials: In a group of 60 patients, who together had 77 discs operated upon between April 2016 and March 2018, data were collected on patient age and gender, clinical presentation, and MRI abnormalities. The main outcome of interest was the difference between preoperative and postoperative Oswestry (ODI) scores eight weeks after the procedure. Macnab criteria, operation duration, length of hospitalization, surgical complications, and the need for reoperation were other outcomes evaluated. All patients received epidural anesthesia and mild sedation. Results: The average reduction in ODI at 8 weeks was 48 points (SD = 5), representing an average percentage reduction of 85% (SD = 8). By Macnab's criteria, 85% of patients experienced either an excellent or good result, while 10% and 5% had a fair and poor result, respectively. Average surgery time was 50 minutes and in-hospitalization stay 8.6 hours. Conclusions: In our series of surgical patients with lumbar disc herniations, PELD yielded very good results, manifest as significantly reduced pain, brief procedural durations, no complications, and short hospital stays. Patients accepted the option of being awake and immediately ambulatory, and the approach proved highly feasible to execute.

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Resumen: Introducción: La nucleotomía percutánea es una técnica de descompresión discal aprobada por la FDA que ha mostrado ser útil para mejorar el dolor causado por hernia discal. No obstante, su práctica se encuentra en discusión debido a que los beneficios de la técnica son controversiales. Objetivos: Describir los resultados de la evolución clínica de los pacientes con hernia discal lumbar baja (L4-L5, L5-S1) tratada mediante cirugía percutánea a un año de operados y mostrar que es una opción quirúrgica útil para el alivio de la sintomatología causada por esta entidad patológica. Material y métodos: Estudio de cohorte; presentamos la evolución clínica de 21 individuos con hernia discal lumbar tratados con nucleotomía percutánea manual durante Marzo 2011-Noviembre 2013. La evaluación fue hecha antes de la cirugía y a los cuatro, 30, 180 y 365 días después de operados mediante la escala numérica del dolor (END), índice de discapacidad funcional de Oswestry (IDO) y criterios de MacNab. Utilizamos estadística inferencial no paramétrica (Wilcoxon) para diferencias. Resultados: n = 21: seis (28.57%) hombres, 15 (71.42%) mujeres; edad promedio: 37.95 años (14-56), ± 10.60; el nivel vertebral más afectado: L4-L5, en 12 (57.14%) sujetos. La END preoperatoria promedio: 7.75 (5-9) ± 1.12; a los 365 días: promedio 2.14 (0-7) ± 2.37. El IDO preoperatorio promedio: 37% (28-40%) ± 3.06 y a los 365 días: 9.52% (0-40%) ± 13.92. El pronóstico (IDO) en el prequirúrgico fue bueno en cero (0%) personas y en 15 (71.42%) a los 365 días, regular en cinco (23.80%) y malo en una (4.78%) (p = 0.000 IC 95% 0.00-0.13, Wilcoxon); de acuerdo con los criterios de MacNab, en 15 (71.42%) casos fueron excelentes y buenos, pobres en cuatro (19.04%) y malos en dos (9.52%) (p = 0.00). Conclusiones: La nucleotomía percutánea ofrece buenos resultados para el tratamiento de las hernias discales lumbares (L4-L5, L5-S1) a los 365 días de operados los pacientes.

Abstract: Introduction: Percutaneous discectomy is a disc decompression technique approved by the FDA that is useful to improve pain caused by a herniated disc. However, its practice is under discussion because the benefits of the technique are controversial. Objectives: To describe the clinical course of patients with low lumbar disc herniation (L4-L5, L5-S1) treated by percutaneous surgery within one year of surgery and prove that it is a useful surgical option for the relief of symptoms caused by this pathological entity. Material and methods: Cohort study; the clinical course of 21 patients with lumbar disc herniation treated with percutaneous discectomy manually during March 2011-November 2013, is presented. The evaluation was made before surgery and at four, 30, 180 and 365 days after surgery by numerical pain scale (NPS), Oswestry (IDO) and MacNab criteria. We used nonparametric inferential statistics (Wilcoxon) for differences in proportions. Results: n = 21, six (28.57%) men, 15 (71.42%) women; average age: 37.95, (14-56) ± 10.60 years; the most affected vertebral level was L4-L5 in 57.14% of the patients; the NPS preoperative average was 7.75 (5-9) ± 1.12; at 365 days: average 2.14 (0-7) ± 2.37. The IDO preoperative average was 37% (28-40%) ± 3.06, and at 365 days: 9.52% (0-40%) ± 13.92. The prognosis (IDO) in the presurgical was good to zero (0%) patients and in 15 (71.42%) at 365 days, regular in five (23.80%) and poor in one (4.78%) (p = 0.00, CI 95% 0.00 to 0.13, Wilcoxon); according to MacNab criteria, in 15 (71.42%) patients were excellent and good, poor in four (19.04%) and bad in two (9.52%) (p = 0.00). Conclusions: Percutaneous discectomy provides good results for the treatment of lumbar disc herniation (L4-L5, L5-S1) at 365 days after surgery.

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OBJECTIVES: Hydrodiscectomy is a new technique used for percutaneous spinal discectomy that employs a high-intensity stream of water for herniated disc ablation and tissue aspiration. No previous clinical study has examined the effects of percutaneous hydrodiscectomy. The aim of this study is to evaluate the outcomes of hydrodiscectomy compared to open microdiscectomy regarding pain, function, satisfaction, complications and recurrence rates. METHODS: In this randomized clinical trial, patients referred to our tertiary hospital for lumbar back pain were recruited and included in the study if they had disc protrusion or small herniation in only one level, without neurological deficits and with no resolution after six weeks of conservative treatment. One group underwent open microdiscectomy, and the other group underwent percutaneous microdiscectomy via hydrosurgery. Function was evaluated using the Oswestry Disability Index and pain was assessed using a visual analog scale. Evaluations were performed preoperatively, and then during the first week and at one, three, six and twelve months postoperatively. Personal satisfaction was verified. Clinicaltrials.gov: NCT01367860. RESULTS: During the study period, 20 patients were included in each arm and 39 completed one-year of follow-up (one patient died of unrelated causes). Both groups exhibited equal improvement on the visual analog scale and Oswestry evaluations after treatment, without any significant differences. The improvement in the lumbar visual analog scale score was not significant in the hydrodiscectomy group (p=0.138). The rates of infection, pain, recurrence and satisfaction were similar between the two groups. CONCLUSION: Percutaneous hydrodiscectomy was demonstrated to be as effective as open microdiscectomy for reducing pain. The rates of complications and recurrence of herniation were similar between groups. Patient satisfaction with the treatment was also similar between groups.

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Objectives Vertebrae, when looked at in x-rays with oblique incidence (45°), seem similar in shape to a Scottish Terrier dog. The "Scotty Dog" incidence is commonly used in spinal pain treatments such as radiofrequency and transforaminal blockages for correct insertion of the needle, because it allows complete visualization of the pedicle. The objective is to describe a series of cases of spinal surgery using the "Scotty Dog" monitoring technique and to evaluate safety. Methods In this study, we describe all consecutive patients operated by the same surgeon from August 2011 to August 2012 using the "Scotty Dog" technique of fluoroscopic monitoring. Patients were operated for spondylolisthesis, lumbar canal stenosis, spinal disc herniations, and fractures. All patients underwent computed tomography (CT) after surgery to confirm the correct positioning of screws. Results During the study period, 42 patients with a mean age of 64.5 years underwent operation, most of them for spinal disc herniation correction. In all cases, visualization of the pedicle was possible in all its length and no case of foramen invasion was registered. Surgical time was 98 minutes on average, with no need for transfusion or complications requiring admission to the ICU. There was one case of infection. Conclusions The Scotty Dog technique for imaging monitoring of the spine provides easy visualization of the whole pedicle, allowing a safe screw insertion. In this case series, there was no case of foramen invasion.

Objetivos As vértebras, visualizadas pela incidência oblíqua (45°) nos raios-X, têm o formato de um cão da raça Scottish Terrier. A incidência Scotty Dog é usada em tratamentos de dor na coluna, como radiofrequência e bloqueios transforaminais, para correta inserção da agulha, porque permite completa visualização do pedículo. O objetivo deste trabalho é descrever uma série de casos de cirurgia de coluna usando a técnica de monitoramento Scotty Dog e avaliar segurança. Métodos Todos os pacientes consecutivos operados pelo mesmo cirurgião de agosto de 2011 a agosto de 2012 usando a técnica Scotty Dog de monitoramento fluoroscópico foram descritos. Pacientes foram operados devido a espondilolistese, estenose do canal vertebral, hérnias e fraturas. Todos os pacientes foram submetidos a tomografia computadorizada após a cirurgia para confirmação do correto posicionamento dos parafusos. Resultados No período do estudo, 42 pacientes foramoperados, commédia de idade de 64,5 anos, a maioria para correção de hérnia de disco. Em todos os casos, a visualização do pedículo foi possível emtoda a sua extensão e não foi registrado caso de invasão do forame. O tempo de cirurgia foi de 98 minutos em média, sem necessidade de transfusões ou complicações exigindo internação em unidade de terapia intensiva. Houve um caso de infecção. Conclusões A técnica Scotty Dog de monitoramento por imagem da coluna permite fácil visualização de todo o pedículo e inserção do parafuso com segurança, com nenhum caso de invasão foraminal nesta série de casos.

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INTRODUCTION: Percutaneous discectomy is a disc decompression technique approved by the FDA that is useful to improve pain caused by a herniated disc. However, its practice is under discussion because the benefits of the technique are controversial. OBJECTIVES: To describe the clinical course of patients with low lumbar disc herniation (L4-L5, L5-S1) treated by percutaneous surgery within one year of surgery and prove that it is a useful surgical option for the relief of symptoms caused by this pathological entity. MATERIAL AND METHODS: Cohort study; the clinical course of 21 patients with lumbar disc herniation treated with percutaneous discectomy manually during March 2011-November 2013, is presented. The evaluation was made before surgery and at four, 30, 180 and 365 days after surgery by numerical pain scale (NPS), Oswestry (IDO) and MacNab criteria. We used nonparametric inferential statistics (Wilcoxon) for differences in proportions. RESULTS: n = 21, six (28.57%) men, 15 (71.42%) women; average age: 37.95, (14-56) ± 10.60 years; the most affected vertebral level was L4-L5 in 57.14% of the patients; the NPS preoperative average was 7.75 (5-9) ± 1.12; at 365 days: average 2.14 (0-7) ± 2.37. The IDO preoperative average was 37% (28-40%) ± 3.06, and at 365 days: 9.52% (0-40%) ± 13.92. The prognosis (IDO) in the presurgical was good to zero (0%) patients and in 15 (71.42%) at 365 days, regular in five (23.80%) and poor in one (4.78%) (p = 0.00, CI 95% 0.00 to 0.13, Wilcoxon); according to MacNab criteria, in 15 (71.42%) patients were excellent and good, poor in four (19.04%) and bad in two (9.52%) (p = 0.00). CONCLUSIONS: Percutaneous discectomy provides good results for the treatment of lumbar disc herniation (L4-L5, L5-S1) at 365 days after surgery.

La nucleotomía percutánea es una técnica de descompresión discal aprobada por la FDA que ha mostrado ser útil para mejorar el dolor causado por hernia discal. No obstante, su práctica se encuentra en discusión debido a que los beneficios de la técnica son controversiales.

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OBJECTIVES: To make a retrospective analysis and evaluate a clinical response to the control of disc degeneration related pain of 396 patients submitted to percutaneous lumbar nucleoplasty; and to make a record of visual analogical scale (VAS) up to a three-year follow-up after the surgical procedure. METHODS: Analysis of VAS score in 396 patients with lumbar disc degeneration related pain, according to anamnesis, clinical examination and magnetic resonance imaging (MRI), without improvement of previous clinical treatment, submitted to percutaneous nucleoplasty. RESULTS: A total of 26% of the patients presented 100% remission of pain or paresthesia, of whom 75% showed at least 50% of pain improvement. The median VAS pain improvement was about 67%. CONCLUSIONS: The median VAS improvement in inferior disc levels was higher than four points. The VAS showed improvement of the pain and paresthesia up to a three-year follow up after the surgical procedure.

OBJETIVOS: Analisar retrospectivamente a resposta clínica no controle da dor relacionada à degeneração discal em 396 pacientes submetidos à nucleoplastia percutânea lombar; e fazer um registro da escala analógica visual (EAV) com seguimento de três anos após a cirurgia. MÉTODOS: Análise da EAV de 396 pacientes com diagnóstico de hérnia de disco, de acordo com anamnese, exame clínico e imagens por meio de ressonância magnética (RM), sendo que nenhum deles apresentou melhora com tratamento clínico prévio. Estes pacientes foram submetidos à nucleoplastia percutânea. O estudo utilizou, para avaliação, o registro de escala analógica visual (EAV) durante seguimento de até três anos após o procedimento cirúrgico. RESULTADOS: Um total de 26% apresentou 100% de remissão da dor ou parestesia; 75% apresentaram pelo menos 50% de melhora da dor. A mediana da EAV de melhora da dor foi de aproximadamente 67%. CONCLUSÕES: Houve melhora da EAV, com mediana maior do que quatro pontos nos pacientes com acometimento nos níveis discais inferiores. A EAV mostrou melhora da dor e parestesia num período de seguimento de até três anos após o procedimento cirúrgico.

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