Publications by authors named "Il-Tae Jang"

88 Publications

Anatomical Importance Between Neural Structure and Bony Landmark: Clinical Importance for Posterior Endoscopic Cervical Foraminotomy.

Neurospine 2021 03 31;18(1):139-146. Epub 2021 Mar 31.

Department of Neurosurgery, Nanoori Gangnam Hospital, Seoul, Korea.

Objective: Posterior endoscopic cervical foraminotomy (PECF) is a well-established, minimally invasive surgery for cervical radiculopathy, but have the more chances of neural structure damage due to the limited visibility and steeper learning curve. So, the anatomical understanding of the nerve associated with the bony structure will be an essential surgical guideline.

Methods: We measured the distance between the bilateral dura lateral edge and bilateral V-point on axial cuts of cervical magnetic resonance imaging and 3-dimensional spine computed tomography imaging, respectively, from 80 patients. We then calculate the distance and position between the dura lateral edge and the V-point as surgically critical width (SCW). Transverse interdural distance (TIDW), transverse inter-V-point distance, and anatomical facet joint width were measured.

Results: The mean TIDW decreased as the levels down in the 40s-60s but increased at the C4-5, C5-6, and C6-7 levels in the 70s. Statistically significant difference was shown at the C6-7 level between the 40s and the 70s. The mean anatomical inter-V-point distance markedly decreased at C5-6 and continued till the C7-Tl level at all age groups. Moreover, a statistically significant difference was shown at the C3-4 and C4-5 level between the 40s and the 70s. The mean negative values of SCW increased from the 40s to 70s at the C5-6 and C6-7 levels (C5-6: -0.60 ± 1.10 mm to -1.63 ± 1.56 mm; C6-7: -0.90 ± 0.74 mm to -2.18 ± 1.25 mm). There were statistically significant differences between the 2 aged groups at the C3-4, C4-5, C5-6, and C6-7 levels.

Conclusion: A prediction of the correlated position between the lateral dura edge and the V-point is essential for the PECF not to injure the neural structure. In the case of a performing the PECF at the C5-6 and C6-7 level in the old-aged patient, it should be considered the laterally moved dura edge, and more extended bony remove is needed for less neural structure damage.
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http://dx.doi.org/10.14245/ns.2040440.220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021826PMC
March 2021

The Novel Technique of Uniportal Endoscopic Interlaminar Contralateral Approach for Coexisting L5-S1 Lateral Recess, Foraminal, and Extraforaminal Stenosis and Its Clinical Outcomes.

J Clin Med 2021 Mar 26;10(7). Epub 2021 Mar 26.

Department of Neurosurgery, Spine Center, Nanoori Gangnam Hospital, Seoul 06048, Korea.

Background: Multifocal intra-and-extraspinal lumbar stenotic lesions could be decompressed with one endoscopic surgical approach, which has the advantages of functional structure preservation, technical efficacy, and safety.

Methods: A retrospective study was performed on 48 patients who underwent uniportal endoscopic contralateral approach due to coexisting lateral recess, foraminal, and extraforaminal stenosis at the L5-S1 level. Foraminal stenosis grade and postoperative dysesthesia (POD) were analyzed. Visual analog scale (VAS) pain scores, modified Oswestry Disability Index (ODI) scores, and MacNab criteria for evaluating pain disability and response were analyzed.

Results: The foraminal stenosis grade of the treated spinal levels was grade 1 ( = 16, 33%), grade 2 ( = 20, 42%), and grade 3 ( = 12, 25%). The rate of occurrence of POD grade 2 and above, which may be related to intraoperative dorsal root ganglion (DRG) retraction injury, was revealed to be 4.2% (two with grade 2, none with grade 3). The patients showed favorable clinical outcomes.

Conclusions: Uniportal endoscopic interlaminar contralateral approach is an effective procedure to resolve combined stenosis (lateral recess, foraminal, and extraforaminal region) with one surgical approach at the L5-S1 level. It may be a minimal DRG retracting and facet joint preserving procedure in foraminal and extraforaminal decompression.
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http://dx.doi.org/10.3390/jcm10071364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037803PMC
March 2021

How I do it? Full endoscopic transforaminal approach for lumbar disc herniation that migrated bilaterally to four corners.

Acta Neurochir (Wien) 2021 04 17;163(4):1199-1203. Epub 2021 Feb 17.

Neurosurgery, Nanoori Hospital Gangnam, 731, Eonju-ro, Seoul, South Korea.

Background: Despite of the evolution of endoscopic surgery, the literature on technique uniportal transforaminal endoscopic lumbar discectomy (TELD) for bilateral lesions is scarce.

Methods: Unilateral TELD was performed in a patient with bilateral superior and inferior migrated, broad-based disc herniation presenting with an impaired neurological state. The key surgical steps focus on free mobility in Kambin triangle with the mobile outside-in technique and accessibility to contralateral lesions with an extensive annular resection procedure.

Conclusion: TELD can be a surgical option for treating bilateral multiple direction migrated lumbar disc herniation with benefits of minimal neural retraction and facet joint preservation.
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http://dx.doi.org/10.1007/s00701-021-04760-zDOI Listing
April 2021

An abrupt-onset shoulder joint subluxation and pseudoparalysis caused by intraarticular pigmented villonodular synovitis: A case report.

Jt Dis Relat Surg 2021 6;32(1):258-261. Epub 2021 Jan 6.

Department of Orthopedic Surgery, Nanoori Hospital Gangnam, 63-8 Nonhyun-Dong, Gangnam-gu, Seoul 06048, Republic of Korea.

Pigmented villonodular synovitis (PVNS) occurs most frequently in the knee and hand joints and is extremely rare in the shoulder joints. A 27-year-old women was admitted to our outpatient clinic with an abrupt-onset pain and limited range of motion of the left shoulder. On arthroscopic examination, localized PVNS surrounding the reactive synovitis in the posterior aspect of the subscapularis within the shoulder joint cavity. The mass was removed using a grasper and shaver. Symptomatic relief was achieved following surgical removal. In conclusion, although rare, localized PVNS of the shoulder joint should be kept in mind in patients with a sudden-onset shoulder joint subluxation and pseudoparalysis.
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http://dx.doi.org/10.5606/ehc.2021.75437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073445PMC
May 2021

A large palmar lipoma arising from flexor tenosynovium of the hand causing digital nerve compression: A case report.

Jt Dis Relat Surg 2021 6;32(1):230-233. Epub 2021 Jan 6.

Nanoori 2bko R&D Institute, Nanoori Hospital Suwon, 295, Jungbu-daero, Yeongtong-gu, Gyeonggi-Do, Republic of Korea.

Lipoma is a common benign soft tissue tumor which rarely occurs in the hand. Lipomas of the hand seldomly cause pain or other symptoms. However, in certain areas, the mass effect from the lipoma may cause clinical symptoms. It rarely involves the deep areas such as synovial membrane and muscle and, sometimes, pressure on the peripheral nerves can cause pain and neurological symptoms. The treatment is surgical resection with a low rate of recurrence. However, the rate of recurrence is high in deep and infiltrating lipomas which preclude complete resection. In this article, we report a case of a large palmar lipoma arising from the flexor tenosynovium of the hand causing digital nerve compression.
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http://dx.doi.org/10.5606/ehc.2021.75678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073440PMC
May 2021

Effect of Dorsal Root Ganglion Retraction in Endoscopic Lumbar Decompressive Surgery for Foraminal Pathology: A Retrospective Cohort Study of Interlaminar Contralateral Endoscopic Lumbar Foraminotomy and Discectomy versus Transforaminal Endoscopic Lumbar Foraminotomy and Discectomy.

World Neurosurg 2021 Apr 11;148:e101-e114. Epub 2021 Jan 11.

Nanoori Gangnam Hospital, Seoul, Spine Surgery, Republic of South Korea.

Objective: Postoperative dysesthesia (POD) is a common complication in surgery involving foraminal diseases, including lumbar foraminal or extraforaminal herniated nucleus pulposus (HNP). Minimal dorsal root ganglion (DRG) retraction is key to preventing POD. We compared the clinical results, safety, and efficacy between the paraspinal transforaminal approach requiring DRG retraction and the interlaminar contralateral approach without DRG retraction for foraminal and extraforaminal diseases.

Methods: A retrospective cohort study was performed of 50 patients who underwent uniportal transforaminal endoscopic lumbar foraminotomy and discectomy (TELD) and 50 patients who underwent anuniportal interlaminar contralateral endoscopic lumbar foraminotomy and discectomy (ICELF) because of lumbar foraminal HNP. The operated levels, combined degenerative diseases, postoperative complications, and POD were analyzed. The visual analog scale (VAS) pain scores, modified Oswestry Disability Index, and MacNab criteria for evaluating pain disability and response were analyzed.

Results: In the ICELF group (total, n = 7, 14%), there were 5 (10%) and 2 (4%) patients with POD grade 1 and 2, respectively. In the TELD group (total, n = 13, 26%), there were 7 (14%), 5 (10%), and 1 (2%) patients with POD grade 1, 2, and 3, respectively. The overall occurrence rate of grade 2 and greater POD was higher in the TELD group (n = 6, 12%) than in the ICELF group (n = 2, 4%). In the ICELF group, 3 of 9 patients (33%) with combined canal structure deforming diseases had POD, of whom none had POD of grade 2 and greater. In the TELD group, 4 of 7 patients (57%) with combined canal structure deforming diseases had POD, of whom all had POD of grade 2 and greater. Two surgical groups showed favorable clinical outcomes with the visual analog scale, Oswestry Disability Index, and MacNab criteria.

Conclusions: Both TELD and ICELF were found to treat foraminal or extraforaminal HNP with good clinical outcomes. ICELF might have a lower POD rate in complicated cases such as adjacent segment disease, degenerative spondylolisthesis, and isthmic spondylolisthesis. This surgical procedure could be an alternative in complicated cases or in patients with an anatomically limited L5-S1 level. However, the procedure is technically challenging to perform.
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http://dx.doi.org/10.1016/j.wneu.2020.12.176DOI Listing
April 2021

Reprint of: Safe Route for Cervical Approach: Partial Pediculotomy, Partial Vertebrotomy Approach for Posterior Endoscopic Cervical Foraminotomy and Discectomy.

World Neurosurg 2021 01 17;145:621-630. Epub 2020 Nov 17.

Spine Surgery Center, Nanoori Gangnam Hospital, Seoul, Republic of Korea.

Background: Cervical radiculopathy is a common cervical spine condition. However, a paucity of data is available on the effect of partial pediculotomy and partial vertebrotomy (PPPV) for posterior endoscopic cervical foraminotomy (PECF) to treat cervical radiculopathy. We investigated the radiological and clinical outcomes of this approach.

Methods: We performed a retrospective evaluation of 30 patients with cervical radiculopathy who had undergone PPPV PECF. Pre- and postoperative radiographs were performed to evaluate for stability, and computed tomography (CT) was used to evaluate the foraminal dimensions and area in the sagittal view. Three-dimensional reconstruction of the area of decompression was also performed. The clinical outcomes were evaluated using the visual analog scale, Oswestry disability index, and the MacNab criteria.

Results: No complications or recurrence developed in our PPPV PECF cohort during the study period. At the preoperative, 1-week postoperative, 3-month postoperative, and final follow-up examinations, the mean visual analog scale scores and mean Oswestry disability index showed significant improvement (score, 7.6, 3.0, 2.1, and 1.7, respectively; P < 0.05; and score, 73.9, 28.1, 23.3, and 21.5, respectively; P < 0.05). All the patients scored good to excellent using the MacNab criteria. The radiological findings showed that PPPV PECF resulted in a significant increase in decompression in the foramen area for all CT-measured parameters compared with the mean preoperative values: 1) the sagittal area increased 60.1 ± 23.1 mm; 2) the craniocaudal length increased 4.0 ± 1.54 mm; and 3) the ventrodorsal length increased 4.0 ± 1.97 mm; Also, the 3-dimensional CT scan reconstruction decompression area had increased 996 ± 266 mm (P < 0.05).

Conclusion: PPPV PECF is a safe route for decompression of the cervical spine with good clinical and radiological outcomes.
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http://dx.doi.org/10.1016/j.wneu.2020.10.158DOI Listing
January 2021

Generation Change of Practice in Spinal Surgery: Can Endoscopic Spine Surgery Expand its Indications to Fill in the Role of Conventional Open Spine Surgery in Most of Degenerative Spinal Diseases and Disc Herniations: A Study of 616 Spinal Cases 3 Years.

Neurol India 2020 Sep-Oct;68(5):1157-1165

Department of Neurosurgery, Spine Surgery, Nanoori Gangnam Hospital, Seoul, Republic of Korea.

Background: A paucity of literature on the effect of spinal endoscopic surgery replacing a large percentage of open and microscopic minimally invasive surgery on outcomes in patients.

Objective: Evaluation of the effect of endoscopic practice expansion in degenerative spinal conditions and disc herniations on patients' outcome as we shifted from first-generation endoscopic discectomy to second-generation decompression and finally third generation of endoscopic spinal fusion practice.

Subjects And Methods: Retrospective cohort study on surgical treatment of degenerative spinal conditions for 616 spinal cases. Basic demographics, preoperative, postoperative 1 week, 6 months, and final follow-up of patients' clinical outcomes in terms of pain score, Oswestry disability index, and MacNab's criteria for pain score were evaluated.

Results: 75%, 91%, and 97% of the surgeries with complications rate of 8.2%, 9%, and 3.4% were found in Generation 1, 2, and 3 of endoscopic surgery, respectively. Compared to preoperative scores, each generation VAS and ODI scores all statistically significantly improved. In the final follow-up, compared to preoperative state, the mean VAS improvement was 4.75 ± 1.7, 5.49 ± 1.66, and 5.37 ± 1.70, mean ODI improvement was 45.99 ± 11.8, 48.93 ± 11.2, and 48.43 ± 11.41, and MacNab's criteria showed a trend of upward improvement of 87.3%, 96.0%, and 98.7% cases, which showed good-to-excellent outcome, in Generation 1, 2, and 3, respectively.

Conclusions: Generation change of increasing percentage of endoscopic surgeries and expansion of endoscopic spinal indications over open surgeries in degenerative spinal conditions and disc herniations are possible as a surgeon gets more experience with endoscopic spine surgery producing a good clinical outcome.
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http://dx.doi.org/10.4103/0028-3886.299145DOI Listing
October 2020

Development of a Machine-Learning Model of Short-Term Prognostic Prediction for Spinal Stenosis Surgery in Korean Patients.

Brain Sci 2020 Oct 22;10(11). Epub 2020 Oct 22.

Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul 06048, Korea.

Background: In this study, based on machine-learning technology, we aim to develop a predictive model of the short-term prognosis of Korean patients who received spinal stenosis surgery.

Methods: Using the data obtained from 112 patients with spinal stenosis admitted at N hospital from February to November, 2019, a predictive analysis was conducted for the pain index, reoperation, and surgery time.

Results: Results show that the predicted area under the curve was 0.803, 0.887, and 0.896 for the pain index, reoperation, and surgery time, respectively, thereby indicating the accuracy of the model.

Conclusion: This study verified that the individual characteristics of the patient and treatment characteristics during surgery enable a prediction of the patient prognosis and validate the accuracy of the approach. Further studies should be conducted to extend the scope of this research by incorporating a larger and more accurate dataset.
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http://dx.doi.org/10.3390/brainsci10110764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690438PMC
October 2020

Posterior endoscopic cervical foramiotomy and discectomy: clinical and radiological computer tomography evaluation on the bony effect of decompression with 2 years follow-up.

Eur Spine J 2021 02 19;30(2):534-546. Epub 2020 Oct 19.

Department of Neurosurgery, Nanoori Hospital Gangnam, 731, Eonju-ro, Gangnam-gu, Seoul, Republic of Korea.

Purpose: Cervical radiculopathy is a common disabling cervical spine condition. Open anterior and posterior approaches are the conventional surgical treatment approaches with good clinical outcomes. However, the soft tissue damage in these procedures can lead to increase perioperative morbidity. Endoscopic spine surgery provides more soft tissue preservation than conventional approaches. We investigate the radiological and clinical outcomes of posterior endoscopic cervical foraminotomy and discectomy.

Methods: A prospective clinical and radiological study with retrospective evaluation were done for 25 patients with 29 levels of cervical radiculopathy who underwent posterior endoscopic cervical discectomy from November 2016 to December 2018. Clinical outcomes of Visual Analogue Scale, Neck Disability Index and MacNab's score were evaluated at pre-operative, post-operative 1 week, 3 months and final follow-up. Preoperative and post-operative final follow-up flexion and extension roentgenogram were evaluated for cervical stability assessment. Pre-operative and post-operative computer tomography cervical spine evaluation of foraminal length in ventro-dorsal, cephalad-caudal dimensions, sagittal foraminal area and using 3D CT reconstruction coronal decompression area were done.

Results: Twenty-nine levels of cervical radiculopathy underwent posterior endoscopic cervical decompression. The mean follow-up was 29.6 months, and the most common levels affected were C5/6 and C6/7. There was a complication rate of 12% with 2 cases of neurapraxia and one case of recurrent of prolapsed disc. There was no revision surgery in our series. There was significant clinical improvement in Visual Analogue Scale and Neck Disability Index. Prospective comparative study between preoperative and final follow-up mean improvement in VAS score was 5.08 ± 1.75, and NDI was 45.1 ± 13.3. Ninety-two percent of the patients achieved good and excellent results as per MacNab's criteria. Retrospective evaluation of the radiological data showed significant increments of foraminal dimensions: (1) sagittal area increased 21.4 ± 11.2 mm, (2) CT Cranio Caudal length increased 1.21 ± 1.30 mm and (3) CT ventro-dorsal length increased 2.09 ± 1.35 mm and (4) 3D CT scan reconstruction coronal decompression area increased 536 ± 176 mm, p < 0.05.

Conclusion: Uniportal posterior endoscopic cervical foraminotomy and discectomy are safe, efficient and precise choreographed set of technique in the treatment of cervical radiculopathy. It significantly improved clinical outcomes and achieved the objective of increasing in the cervical foramen size in our cohort of patients.
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http://dx.doi.org/10.1007/s00586-020-06637-8DOI Listing
February 2021

Anaplastic lymphoma receptor tyrosine kinase-negative inflammatory myofibroblastic tumor of triceps brachii: Case report.

Jt Dis Relat Surg 2020 ;31(3):605-609

Nanoori 2bko R&D Institute, Nanoori Hospital Suwon, 295, Jungbu-daero, Yeongtong-gu, 16503 Gyeonggi-Do, Republic of Korea.

Inflammatory myofibroblastic tumor (IMT) is a non-neoplastic benign lesion comprising various inflammatory cells, including myofibroblasts and vascular tissues. It is a rare tumor that sometimes shows similar signs and progression as malignant tumors. The anatomical sites of IMTs include the lungs, liver, orbit, skin, mesentery, and maxillary sinus, but they rarely occur in the limb musculoskeletal system. To our knowledge, no case of neurological symptoms caused by the tumor in the triceps brachii muscle has been reported. In this article, we report the case of a 42-year-old male patient with an IMT that grew rapidly in the triceps brachii muscle and consequently caused symptoms of ulnar nerve lesion owing to its increasing size. The patient showed no ulnar nerve lesion symptoms after undergoing wide excision and was diagnosed with anaplastic lymphoma receptor tyrosine kinase- negative IMT.
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http://dx.doi.org/10.5606/ehc.2020.74662DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607928PMC
February 2021

Current and Future of Endoscopic Spine Surgery: What are the Common Procedures we Have Now and What Lies Ahead?

World Neurosurg 2020 08;140:642-653

Department of Spine Surgery, Nanoori Gangnam Hospital, Seoul, Republic of South Korea.

The aging population around the world leads to increasing incidence of degenerative spinal conditions. There is a need for a minimally invasive technique in treatment for spinal conditions to meet the medical complexity and comorbidities that comes with aging. Principles of endoscopy are similar to minimally invasive surgery, which is to decrease pressure on soft tissue crushing from prolonged retraction, avoid soft tissue stripping and dissection, and bone and ligamentous preservation for optimal decompression without excessive destruction. Endoscopic spine surgery techniques started slowly in development in the 1970s to 2000s, with a rapid phase of development since the turn of the 21st century with endoscopic solutions developing in cervical, thoracic, and lumbar conditions with increasing complexity in nature of operation. Technological enhancement with progressively supportive literature is pushing boundaries of endoscopy from the early days of soft tissue procedure to current fusion procedures, endoscopic spine surgery techniques is covering more areas of spine than ever previously possible with good clinical results. We present a review on the current techniques available and postulated near future development for endoscopic spine surgery.
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http://dx.doi.org/10.1016/j.wneu.2020.03.111DOI Listing
August 2020

Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression Outside-In Approach: A Proctorship Guideline With 12 Steps of Effectiveness and Safety.

Neurospine 2020 Jul 31;17(Suppl 1):S99-S109. Epub 2020 Jul 31.

Nanoori Gangnam Hospital, Spine Surgery, Seoul, Korea.

Minimally invasive spinal surgery in particular lumbar endoscopic unilateral laminotomy with bilateral decompression becomes popular as it can be performed with regional anesthesia, soft tissue damages are minimized as endoscopic visualization and instruments can be brought close to operating area bypassing much of the intervening soft tissues for sufficient spinal decompression with ligamentum flavum resection despite less bony resection compared to open surgery. Overall, when well executed, it preserves spinal stability. Outside-in technique of decompression is also known as over the top decompression in minimally invasive literature. It involves maintaining deep layer of ligamentum flavum integrity till satisfactory bony decompression is achieved. Deep layer of ligamentum flavum is removed as final step of decompression. Preservation of the deep layer of ligamentum flavum protects the neural elements, allowing drills and sharp equipment to be used safely to perform bony decompression.In this study, we demonstrate the technical details of outside-in approach lumbar endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD). LE-ULBD Outside-in Technique is an effective and safe procedure in relieving lumbar spinal stenosis with favorable results with a follow-up for more than 1 year.
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http://dx.doi.org/10.14245/ns.2040078.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410378PMC
July 2020

A Narrative Review of Development of Full-Endoscopic Lumbar Spine Surgery.

Neurospine 2020 Jul 31;17(Suppl 1):S20-S33. Epub 2020 Jul 31.

Nanoori Gangnam Hospital, Spine Surgery, Seoul, Korea.

In the first phase of development of lumbar endoscopic spine surgery, the focus was on removal of soft disc material through the working corridor of Kambin's triangle using transforaminal endoscopic lumbar discectomy. With the introduction of the interlaminar approach and increased interest from both industry and surgeons, there has been an exponential development of endoscopic surgical equipment and a corresponding expansion of endoscopic techniques. Endoscopic treatment strategies are applied to conditions ranging from contained prolapsed intervertebral discs to noncontained migrated herniated discs, hard calcified discs, spinal stenosis in the central or lateral recess and the foraminal and extraforaminal region, and other combinations of degenerative conditions requiring decompression or fusion surgery. The further expansion of endoscopic surgical management involving complicated spinal cases and the final quartet of trauma, infections, tumors, and possibly deformities could be the future stage of endoscopic spine surgery development. This article covers the full range of current treatment strategies and presents possible future developments of endoscopic spine surgery for the management of lumbar spinal conditions.
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http://dx.doi.org/10.14245/ns.2040116.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410380PMC
July 2020

Evolution of endoscopic transforaminal lumbar approach for degenerative lumbar disease.

J Spine Surg 2020 Jun;6(2):424-437

Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, Republic of Korea.

Endoscopic spine surgery has evolved dramatically in last 30 years; with the development of new improved endoscopic optics and instrumentation limitation of endoscopic spine surgery has significantly reduced. The transforaminal approach has been limited in its indications due to its optimized approach and obstacles of bony or neural structures. As the initial transforaminal approach is based on the inside out technique, there were many limitations on the indications. Outside-in approach has been developed to address these limitations. However, the outside-in approach was not free from anatomical obstacles. The mobile outside-in approach technique has advantage of both inside-out and outside-in technique. It is equally safe as inside-out technique and provides an easy handling of structures, while it is equally versatile as outside-in technique in managing different types of disc prolapse such as central, paracentral, foraminal, far lateral, and up and down migration, and in high-canal compromise cases. The mobile outside in technique, however, demands a longer learning curve and beginners need to be patient while learning the technique.
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http://dx.doi.org/10.21037/jss.2019.11.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340818PMC
June 2020

Epidural Catheter-Assisted Percutaneous Transforaminal Endoscopic Diskectomy: A Technical Note.

J Neurol Surg A Cent Eur Neurosurg 2020 Sep 22;81(5):472-474. Epub 2020 Jun 22.

Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, Republic of Korea.

Background:  With advances in techniques and instruments, percutaneous endoscopic transforaminal lumbar diskectomy (PETLD) is now widely used for lumbar disk herniation. Although the indication for PETLD is expanding, the technique still has limitations. To overcome them, we performed the epidural catheter-assisted PETLD described here.

Methods:  A 49-year-old woman had severe radiating pain in a left L5 dermatomal distribution. Magnetic resonance imaging (MRI) revealed left paramedial disk herniation at L4-L5 and a small downward-migrated disk fragment. We performed epidural catheter-assisted PETLD. Mechanical outward pushing and normal saline injection through the epidural catheter were performed for removal of hidden disk remnants. In the second case, a 26-year-old man presented with severe radiating pain in the L5-S1 dermatoms on both sides. MRI revealed massive disk herniation at L4-L5. A unilateral approach was used, and the ruptured disk could be moved using an epidural catheter.

Results:  The patients' pain improved immediately after the procedures. With this method, neural decompression can be performed more easily and effectively.

Conclusions:  Epidural catheter-assisted PETLD has several advantages and can overcome the limitations of conventional PETLD.
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http://dx.doi.org/10.1055/s-0040-1701636DOI Listing
September 2020

Uniportal Full Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion with Endoscopic Disc Drilling Preparation Technique for Symptomatic Foraminal Stenosis Secondary to Severe Collapsed Disc Space: A Clinical and Computer Tomographic Study with Technical Note.

Brain Sci 2020 Jun 15;10(6). Epub 2020 Jun 15.

Spine Surgery, Nanoori Gangnam Hospital, Seoul 06048, Korea.

Background: Severe collapsed disc secondary to degenerative spinal conditions leads to significant foraminal stenosis. We hypothesized that uniportal posterolateral transforaminal lumbar interbody fusion with endoscopic disc drilling technique could be safely applied to the collapsed disc space to improve patients' pain score, restore disc height, and correct the segmental angular parameters.

Methods: We included patients who met the indication criteria for lumbar fusion and underwent uniportal full endoscopic posterolateral transforaminal lumbar interbody fusion with pre-operative Computer Tomography mid disc height of less than or equal to 5 mm and MRI of Grade 3 Foraminal Stenosis. Visual analogue scale and computer tomography pre-operative and post-operative sagittal disc height in the anterior, middle and posterior part of the disc; sagittal focal segmental angle; mid coronal disc height and coronal wedge angles were evaluated.

Results: 30 levels of Endo-TLIF were included, with a mean follow up of 12 months. The mean improvement in decreasing pain score was 2.5 ± 1.1, 3.2 ± 0.9 and 4.3 ± 1.0 at 1 week post operation, 3 months post operation and at final follow up, respectively, p < 0.05. There was significant increase in mid sagittal computer tomographic anterior, middle and posterior disc height of 6.99 ± 2.30, 6.28 ± 1.44, 5.12 ± 1.79 mm respectively, p < 0.05. CT mid coronal disc height showed an increase of 7.13 ± 1.90 mm, p < 0.05. There was a significant improvement in the CT coronal wedge angle of 2.35 ± 4.73 and the CT segmental focal sagittal angle of 1.98 ± 4.69, p < 0.05.

Conclusion: Application of Uniportal Endoscopic Posterolateral Lumbar Interbody Fusion in patients with severe foraminal stenosis secondary to severe collapsed disc space significantly relieved patients' pain and restored disc height without early subsidence or exiting nerve root dysesthesia in our cohort of patients.
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http://dx.doi.org/10.3390/brainsci10060373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348812PMC
June 2020

Technical Considerations of Uniportal Endoscopic Posterolateral Lumbar Interbody Fusion: A Review of Its Early Clinical Results in Application in Adult Degenerative Scoliosis.

World Neurosurg 2021 01 9;145:682-692. Epub 2020 Jun 9.

Department of Spine Surgery, Nanoori Gangnam Hospital, Seoul, Republic of South Korea.

Background: Uniportal endoscopic posterolateral lumbar interbody fusion (Endo-TLIF) provides one of the least invasive forms of minimally invasive surgery, allowing large size cages which are commercially available for open and tubular microscopic transforaminal lumbar interbody fusion (TLIF) to be inserted through this approach. We studied the effect of such a technique on a series of patients with low-grade degenerative scoliosis.

Methods: Endo-TLIF was applied to patients who had 10°-40° of degenerative adult scoliosis. Pre- and postoperative 1-week, 3-month, and final follow-up clinical status of visual analog scale, Oswestry Disability Index, perioperative complications, and Macnab criteria were collected. Roentgenogram to assess changes in Cobb angles was done.

Results: There was statistically significant improvement of preoperative, 1-week postoperative, 3-month postoperative, and final follow-up mean of visual analog scale scores with 7.72 (5-10), 3.68 (3-6), 2.88 (2-4), and 1.96 (1-3), respectively, and with Oswestry Disability Index mean of 70.4 (52-86), 35.12 (26-56), 27.68 (24-38), and 24 (20-28), respectively (P < 0.05). In terms of Macnab criteria, 100% had good to excellent result. In terms of scoliosis measured by Cobb angle, there was statistically significant improvement.

Conclusions: Endo-TLIF is a safe and effective procedure in mild to moderate degenerative scoliosis with good early clinical results and improvement in coronal Cobb angle. It can be considered as an option if a short segment(s) fusion is planned for adult degenerative scoliosis.
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http://dx.doi.org/10.1016/j.wneu.2020.05.239DOI Listing
January 2021

Safe Route for Cervical Approach: Partial Pediculotomy, Partial Vertebrotomy Approach for Posterior Endoscopic Cervical Foraminotomy and Discectomy.

World Neurosurg 2020 08 11;140:e273-e282. Epub 2020 May 11.

Nanoori Gangnam Hospital, Spine Surgery, Seoul, Republic of South Korea.

Introduction: Cervical radiculopathy is a common cervical spine condition. There is a paucity of literature discussing the effect of partial pediculotomy and partial vertebrotomy for posterior endoscopic cervical foraminotomy (PPPV PECF) on cervical radiculopathy. We investigated the radiologic and clinical outcomes of this approach.

Methods: This was a retrospective evaluation of 30 cases with cervical radiculopathy who underwent PPPV PECF. Preoperative, postoperative roentgenogram for evaluation of stability, computed tomography (CT) evaluation of foraminal dimensions, and area in sagittal view was performed. Three-dimensional reconstruction area of decompression evaluation was performed. Clinical outcomes of the visual analog scale, Oswestry Disability Index, and Macnab score were evaluated.

Results: There was no complication and recurrence in our PPPV PECF cohort during the study period. At preoperative, 1 week postoperative, and 3 months postoperative and final follow-up, the mean visual analog scale score had significant improvement, with scores of 7.6, 3.0, 2.1, and 1.7, respectively, P < 0.05, and also the mean Oswestry Disability Index, with scores of 73.9, 28.1, 23.3, and 21.5 respectively, P < 0.05. Macnab criteria showed all patients scoring good and excellent. Radiologic results showed PPPV PECF had a significant increase in decompression in the foramen area in all CT-measured parameters, as compared with the mean preoperative values; 1) sagittal area increased 60.1 ± 23.1 mm, 2) CT craniocaudal length increased 4.0 ± 1.54 mm, 3) CT ventrodorsal length increased 4.0 ± 1.97 mm, and 4) 3-dimensional CT scan reconstruction decompression area increased 996 ± 266 mm, P < 0.05.

Conclusions: PPPV PECF is a safe route of decompression of cervical spine with good clinical and radiologic outcome.
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http://dx.doi.org/10.1016/j.wneu.2020.05.033DOI Listing
August 2020

Infected Schmorl's node: a case report.

BMC Musculoskelet Disord 2020 May 2;21(1):280. Epub 2020 May 2.

Department of Neurosurgery, Nanoori Hospital Gangnam, 731, Eonju-ro, Gangnam-gu, Seoul, 06048, Republic of Korea.

Background: Schmorls node (SN) are mostly asymptomatic and incidental findings on MRI. However, sometimes they present like acute onset low back pain or acute exacerbation of chronic back pain after minor trauma.

Case Presentation: We present rare case of symptomatic infected SN in 67 years female patient presented with complains of low back pain radiating to right buttock. After initial conservative treatment failed subsequent imaging showed significant increase in size of lesion with focal signal changes in disc space gave suspicion of underlying secondary pathology. Patient operated for complete excision of lesion. Histopathological report was suggestive of pyogenic vertebral osteomyelitis. Patient improved well postoperatively.

Conclusion: Most of the time acute SN responds well to conservative treatment; however rapid deterioration of symptoms or persistent severe pain should give suspicion of underlying secondary pathology.
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http://dx.doi.org/10.1186/s12891-020-03276-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196219PMC
May 2020

Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease.

Int J Mol Sci 2020 Mar 20;21(6). Epub 2020 Mar 20.

Spine Surgery, Nanoori Gangnam Hospital, Seoul 06048, Korea.

With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.
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http://dx.doi.org/10.3390/ijms21062135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139690PMC
March 2020

Endoscopic spine surgery in Republic of Korea.

J Spine Surg 2020 Jan;6(Suppl 1):S40-S44

Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, Republic of Korea.

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http://dx.doi.org/10.21037/jss.2019.09.30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063316PMC
January 2020

Lumbar Degenerative Disease Part 1: Anatomy and Pathophysiology of Intervertebral Discogenic Pain and Radiofrequency Ablation of Basivertebral and Sinuvertebral Nerve Treatment for Chronic Discogenic Back Pain: A Prospective Case Series and Review of Literature.

Int J Mol Sci 2020 Feb 21;21(4). Epub 2020 Feb 21.

Nanoori Gangnam Hospital, Seoul, Spine Surgery, Seoul 06048, Korea.

Degenerative disc disease is a leading cause of chronic back pain in the aging population in the world. Sinuvertebral nerve and basivertebral nerve are postulated to be associated with the pain pathway as a result of neurotization. Our goal is to perform a prospective study using radiofrequency ablation on sinuvertebral nerve and basivertebral nerve; evaluating its short and long term effect on pain score, disability score and patients' outcome. A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain with bulging degenerative intervertebral disc or spinal stenosis underwent Uniportal Full Endoscopic Radiofrequency Ablation application through either Transforaminal or Interlaminar Endoscopic Approaches. Their preoperative characteristics are recorded and prospective data was collected for Visualized Analogue Scale, Oswestry Disability Index and MacNab Criteria for pain were evaluated. There was statistically significant Visual Analogue Scale improvement from preoperative state at post-operative 1wk, 6 months and final follow up were 4.4 ± 1.0, 5.5 ± 1.2 and 5.7 ± 1.3, respectively, < 0.0001. Oswestery Disability Index improvement from preoperative state at 1week, 6 months and final follow up were 45.8 ± 8.7, 50.4 ± 8.2 and 52.7 ± 10.3, < 0.0001. MacNab criteria showed excellent outcomes in 17 cases, good outcomes in 11 cases and fair outcomes in 2 cases Sinuvertebral Nerve and Basivertebral Nerve Radiofrequency Ablation is effective in improving the patients' pain, disability status and patient outcome in our study.
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http://dx.doi.org/10.3390/ijms21041483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073116PMC
February 2020

Incidental Durotomy During Endoscopic Stenosis Lumbar Decompression: Incidence, Classification, and Proposed Management Strategies.

World Neurosurg 2020 07 12;139:e13-e22. Epub 2020 Feb 12.

Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, Republic of Korea.

Objective: We sought to review the types of incidental durotomies (IDs) that occurred during the endoscopic stenosis lumbar decompression through interlaminar approach (ESLD) and discuss the management strategies according to our classification.

Methods: A retrospective evaluation was performed for patients with spinal stenosis who underwent ESLD. Out of 330 patients, 27 patients of ID were clinically evaluated preoperatively and postoperatively on the basis of a visual analog scale score, Oswestry Disability Index, and MacNab's criteria. ID patterns are classified according to the size, location, and involvement of neural elements. Intraoperative and postoperative surgical management was evaluated.

Results: Intraoperative incidence of ID was 8.2%. According to lumbar levels, 11 (40.7%) occurred at L3-4, 12 (44.4%) at L4-5, and 4 (14.8%) at L5-S1 ID cases. IDs were divided into 4 types: 29.6% are type 1, 70% are type 2, 7.4% are type 3, and 3.7% are type 4. Overall for mean and standard deviation preoperative, 1 week postoperative, 3 months, and final follow-up for visual analog scale are 7.6 ± 1.4, 3.3 ± 1.1, 2.6 ± 1.1, and 1.9 ± 1.3, and for Oswestry Disability Index are 74.5 ± 9.0, 32.3 ± 9.4, 27.3 ± 7.2, and 24.4 ± 6.5 after patch blocking dura repair of ID.

Conclusions: ID is a more common surgical complication in ESLD compared with the transforaminal approach. The endoscopic patch blocking dura repair technique should be considered in type 1 to type 3A of dura tear with good prognosis and clinical outcome. Consideration is made for conversion to open repair in types 3B, 3C and 4 dura tears with fair to poor outcome.
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http://dx.doi.org/10.1016/j.wneu.2020.01.242DOI Listing
July 2020

Advantages of the Combination of Conscious Sedation Epidural Anesthesia Under Fluoroscopy Guidance in Lumbar Spine Surgery.

J Pain Res 2020 21;13:211-219. Epub 2020 Jan 21.

Department of Neurosurgery, Nanoori Hospital Bupyeong, Incheon, Republic of Korea.

Background: With the increase in life expectancy seen throughout the world, the prevalence of degenerative spinal pathology and surgery to treat it has increased. Spinal surgery under general anesthesia leads to various problems and complications, especially in patients with numerous medical comorbidities or elderly patients. For this reason, there is a need for safer anesthetic methods applicable to unhealthy, elderly patients undergoing spinal surgery.

Purpose: To report our experience with utilizing fluoroscopy-guided epidural anesthesia in conjunction with conscious sedation in spinal surgery.

Patients And Methods: We performed a retrospective review of 111 patients at our institution that received fluoroscopy-guided epidural anesthesia for lumbar surgery from February to September 2018. Patients' records were evaluated to evaluate patient demographics, American Society of Anesthesiology Physical Classification System (ASA) class, and pain numerical rating scores (NRS) preoperatively and throughout their recovery postoperatively. Intraoperative data including volume of epidural anesthetic used, extent of epidural spread, and inadvertent subdural injection was collected. Postoperative recovery time was also collected.

Results: The mean age of our patients was 60 years old with a range between 31 and 83 years old. All patients experienced decreases in postoperative pain with no significant differences based on age or ASA class. There was no association between ASA class and time to recovery postoperatively. Older patients (age 70 years or greater) had a significantly longer recovery time when compared to younger patients. Recovery also was longer for patients who received higher volumes of epidural anesthesia. For every 1 mL increase of epidural anesthetic given, there was an increase in the extent of spread of 1.8 spinal levels.

Conclusion: We demonstrate the safety and feasibility of utilizing conscious sedation in conjunction with fluoroscopy-guided epidural anesthesia in the lumbar spinal surgery.
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http://dx.doi.org/10.2147/JPR.S227212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982434PMC
January 2020

Arthroscopic Suprapectoral Biceps Tenodesis: The "Double Secure Loop Technique" Using an All-Suture Anchor and an Arthroscopic Suture Passer.

Arthrosc Tech 2019 Dec 21;8(12):e1511-e1515. Epub 2019 Nov 21.

Department of Orthopedic Surgery, Nanoori Suwon Hospital, Suwon, Republic of Korea.

Although the long head of the biceps tendon is known to resist superior movement of the humeral head in the shoulder joint and assist flexion and supination of the elbow joint, its exact function remains unclear. Moreover, the ideal treatment of lesions of the long head of the biceps tendon such as tendinitis, subluxation, dislocation, and partial or complete rupture remains controversial. Various tenodesis methods have been introduced by many authors. This technique-based article aims to discuss tenodesis as an option for biceps tendon fixation.
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http://dx.doi.org/10.1016/j.eats.2019.07.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928365PMC
December 2019

How I do it? Uniportal full endoscopic contralateral approach for lumbar foraminal stenosis with double crush syndrome.

Acta Neurochir (Wien) 2020 02 10;162(2):305-310. Epub 2019 Dec 10.

Department of Neurosurgery, Nanoori Gangnam Hospital, 731, Eonju-ro, Gangnam-gu, Seoul, Republic of South Korea.

Background: Evolution of endoscopic surgery provides equivalent results to open surgery with advantages of minimal invasive surgery. The literature on technique Uniportal Full endoscopic contralateral approach is scarce.

Methods: The endoscopic contralateral approach technique applies for patients presenting with double crush syndrome with foraminal and extraforminal stenosis. The key steps focus on contralateral ventral overriding superior articular process decompression, foraminal and extraforaminal discectomy, and lateral vertebral syndesmophyte decompression leading to enlargement of the contralateral foramen and extraforamen size.

Conclusion: The Uniportal Full endoscopic contralateral approach is a good alternative to open surgery or minimally invasive microscopic surgery through direct endoscopic visualization of the entire route of exiting nerve with no neural retraction allowing both lateral recess and foraminal and extraforaminal decompression all in one approach.
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http://dx.doi.org/10.1007/s00701-019-04157-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982631PMC
February 2020

Rod Fracture Causing Relief of Back Pain That Developed After Adult Lumbar Degenerative Flat-Back Correction Surgery: A Case Report.

Neurospine 2019 Dec 9;16(4):789-792. Epub 2019 Dec 9.

Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, Korea.

A 73-year-old woman underwent deformity correction surgery (anterior lumbar interbody fusion of L2-L3-L4-L5-S1, pedicle subtraction osteotomy at L4, and posterior screw fixation from T10 to the pelvis) due to lumbar degenerative flat-back. Following the operation, the patient experienced pain in her back and buttocks, for which she regularly took medications. She reported frequently feeling a heavy and stretched sensation of pain after the operation in those areas, which made her regret undergoing the operation. However, at 33 months postoperatively, she reported that one day, while getting up from a chair, she felt a crack in her back, which was followed by an improvement in her back and buttock pain; thereafter, she stopped taking pain medications. Follow-up radiography revealed a bilateral rod fracture at the L4-5 level on the right side and at the L3-4 level on the left side. The overall pelvic parameters, except pelvic incidence, slightly changed after the rod fracture. Therefore, the broken rod was replaced and another rod was added to the broken rod area; however, the changed pelvic parameters were not corrected further during the reoperation. Following the reoperation, the patient showed improvements and she no longer required pain medication.
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http://dx.doi.org/10.14245/ns.1836198.099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6944985PMC
December 2019

Cervical instability following artificial disc replacement.

Surg Neurol Int 2019 20;10:183. Epub 2019 Sep 20.

Department of Neurosurgery, Nanoori Hospital Gangnam, Seoul, South Korea.

Background: Although there has been increased interest in utilizing artificial disc replacement (ADR) techniques to treat cervical degenerative disease, few reports have focused on their postoperative complication and reoperation rates.

Case Description: A 52-year-old male underwent the uneventful placement of a C5-C6 cervical ADR for disc disease and foraminal stenosis. One year later, he experienced the onset of severe neck pain attributed to instability of the ADR construct. This required removal of the C5-6 ADR and subsequent fusion.

Conclusion: Strict adherence to appropriate criteria is critical for choosing when to place a cervical ADR. This requires documenting; adequate surgical indications, careful selection of the appropriate ADR device, meticulous surgical technique, proper preservation of the supporting structures, and sufficient neural decompression.
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http://dx.doi.org/10.25259/SNI_431_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778327PMC
September 2019