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Biomedical subjects

Richard G Fessler

Publications and source records attributed to Richard G Fessler.

35 records · Page 2Linked to original sources
PubMed2004

Thoracic microendoscopic discectomy.

OBJECT: Various approaches exist for the treatment of thoracic disc herniation. Anterior approaches facilitate ventral exposure but place the intrathoracic contents at risk. Posterolateral approaches require extensive muscle dissection that adds to the risk of postoperative morbidity. The authors have developed a novel posterolateral, minimally invasive thoracic microendoscopic discectomy (TMED) technique that provides an approach to the thoracic spine which is associated with less morbidity. METHODS: Seven patients 23 to 54 years old with nine disc herniations underwent TMED. All lesions were soft lateral or midline thoracic disc herniations. Under fluoroscopic guidance with the patient positioned prone, the authors used a muscle dilation approach and the procedure was performed with endoscopic visualization through a tubular retractor. Based on a modified Prolo Scale, five patients experienced excellent results, one good, and one fair. No case required conversion to an open procedure. The mean operative time was 1.7 hours per level, and estimated blood loss was 111 ml per level. Hospital stays were short, and no complications occurred. CONCLUSIONS: The TMED is safe, effective, and provides a minimally invasive posterolateral alternative for treatment of thoracic disc herniation without the morbidity associated with traditional approaches.

Adult↗
PubMed2003

Microendoscopic discectomy for recurrent disc herniations.

OBJECT: The use of microendoscopic discectomy (MED) for the treatment of primary lumbar disc herniations has become fairly well accepted; its role in recurrent disc herniations is less clear. The reluctance of many surgeons to use this technique stems, in part, from the concern of undertaking an endoscopic discectomy in a patient in whom the anatomy is distorted from a previous operation. It appears counterintuitive to operate through a limited working area when the traditional open approach for recurrence favors wider exposure of the surgical field. Given that operating on previously exposed tissue can be associated with even greater morbidity than on virginal tissue, the authors describe their experience with performing MED for recurrent disc herniation. METHODS: Unilateral MED was performed in patients with classic symptoms of lumbar radiculopathy, a previous operation at that level, and findings of recurrent disc herniation on magnetic resonance imaging. The approach was similar to a standard MED. Aided by fluoroscopic guidance, a working cannula was docked on the laminofacet junction at the level of the nerve root, with care taken to ensure a slightly more lateral initial trajectory. A good decompression of the nerve root could then be achieved through the use of the endoscope with preservation of the paraspinous musculature and much of the remaining facet capsule. Ten consecutive patients undergoing the procedure were analyzed prospectively and compared with the previous 25 who underwent routine single-level MED. Use of the MED technique provided excellent visualization and decompression of the nerve root; no conversions to open procedures were necessary in either group. The average operative time in the experimental group was 98.5 minutes, with a mean blood loss of 33 ml and an approximate hospital stay of 7.3 hours. In this respect, there was no statistical difference between the two groups (analysis of variance, p = 0.39, 0.68, and 0.51, respectively). There was one cerebrospinal fluid leak in each group. CONCLUSIONS: Microendoscopic discectomy for recurrent disc herniation can be safely performed without an increase in surgery related morbidity.

Adult↗
PubMed2003

Clinical outcomes after minimal-access surgery for recurrent lumbar disc herniation.

OBJECT: Experience with minimal-access surgical approaches for revision lumbar surgery has not been previously reported. METHODS: During a 7-month period, 10 consecutive patients with recurrent disc herniations underwent revision operations in which microendoscopic discectomy (MED) was performed. Perioperative data and clinical outcomes (according to Macnab criteria) were compared with those obtained in 25 consecutive patients who underwent routine single-level MED as well as with previously published data. Overall, outcome of the MED-treated revision group was excellent or good in 90% during a mean follow-up period of 18.5 months (minimum 12 months). Operative blood loss, duration, complications, and length of hospital stay were not significantly different between the revision and primary MED-treated groups. CONCLUSIONS: Analysis of these early data suggests equivalent or superior results are obtained when performing MED compared with historical controls in which conventional surgery was conducted for recurrent disc surgery. The procedure appears to be a safe and effective alternative in cases in which recurrent lumbar disc herniation causes radiculopathy.

Adult↗
PubMed2003

Bone grafting.

In recent years our understanding of spinal fusion biology has improved. This includes the continued elucidation of the step-by-step cellular and molecular events involved in the prototypic bone induction cascade, as well as the identification and characterization of the various critical growth factors governing the process of bone formation and bone graft incorporation. Based on these fundamental principles, growth factor technology has been exploited in an attempt to improve rates of spinal fusion, and promising results have been realized in preclinical animal studies and initial clinical human studies. In this article the authors review the recent advances in the biology of bone fusion and provide a perspective on the future of spinal fusion, a future that will very likely include increased graft fusion rates and improved patient outcome as a result of the successful translation of fundamental bone fusion principles to the bedside.

Animals↗
PubMed2002

A minimally invasive technique for decompression of the lumbar spine.

STUDY DESIGN: The technical feasibility of percutaneous microendoscopic bilateral decompression of lumbar stenosis via a unilateral approach was evaluated in a human cadaver model. OBJECTIVES: The purpose of this study was to determine the feasibility of using a microendoscopic laminotomy technique to treat spinal stenosis. SUMMARY AND BACKGROUND DATA: Minimally invasive surgery is an important means of reducing tissue trauma and patient morbidity. This may prove to be essential in improving pain and in reducing postoperative stress responses and delayed sequelae that can lead to unfortunate complications after otherwise uneventful procedures. To date, minimally invasive lumbar endoscopic techniques have not been used to decompress the lumbar spinal canal. METHODS: In each of four cadavers, the laminae of L1 through L4 were subjected to one of four procedures consisting of unilateral microendoscopic laminotomy, bilateral microendoscopic laminotomy, unilateral open laminotomy, and bilateral open laminotomy. Every procedure was performed once at all levels. Computed tomography was performed before and after laminotomy to establish the extent of decompression of the spinal canal, and measurements of the midsagittal, interpedicular, and decompression diameters were taken. RESULTS: The four procedures were successfully performed at every level. Satisfactory decompression of the spinal canal was achieved regardless of the approach used. The exiting nerve roots were well visualized when any one of these techniques was used. Complications, including dural tears and facet complex instability, were independent of the procedure performed. CONCLUSION: Microendoscopic laminotomy can be used to decompress the spinal canal as effectively as an open laminotomy and may prove to be beneficial in decreasing the complications and morbidity of standard treatments for lumbar stenosis.

Cadaver↗
PubMed2002

Review: complications of minimally invasive spinal surgery.

Complications of minimally invasive spinal surgery can be related to anesthesia, patient positioning, and surgical technique. The performance of successful minimally invasive spinal surgery is beset with several technical challenges, including the limited tactile feedback, two-dimensional video image quality of three-dimensional anatomy, and the manual dexterity needed to manipulate instruments through small working channels, which all account for a very steep learning curve. Knowledge of possible complications associated with particular minimally invasive spinal procedures can aid in their avoidance. This article reviews complications associated with minimally invasive spinal surgery in the cervical, thoracic, and lumbar spine by reviewing reported data of sufficient detail or with sufficient numbers of patients. In addition, possible complications associated with anesthesia use, patient positioning, and surgical techniques during thoracoscopic and laparoscopic spinal procedures are reviewed.

Endoscopes↗
PubMed2002

Minimally invasive cervical microendoscopic foraminotomy: an initial clinical experience.

OBJECTIVE: We have previously reported the feasibility of using the microendoscopic foraminotomy (MEF) technique in a cadaveric study. We now report our initial clinical experience with this novel technique. METHODS: From March 1998 to January 2001, we prospectively used the MEF technique in 25 patients with cervical root compression from either foraminal stenosis or disc herniation. The patients' demographic, clinical presentation, surgical, and outcome data were recorded. Another 26 patients treated via open cervical laminoforaminotomy were used for comparison. RESULTS: MEF cases involved less blood loss (138 versus 246 ml per level). MEF patients recovered more rapidly, had a shorter postoperative stay (20 versus 68 hours), and needed fewer narcotics (11 versus 40 equivalents). There were two durotomies after MEF. Overall, our initial experience with the MEF procedure yielded symptomatic improvement for approximately 87 to 92% of patients, depending on which symptom was analyzed. After MEF (mean follow-up, 16 mo; minimum follow-up, 1 year), patients with radiculopathy experienced resolution of their symptoms in 54%, improvement in 38%, and no change in 8% of cases. For open surgery, radiculopathy resolved in 48%, improved in 40%, and remained unchanged in 12%. For neck pain, the MEF results were 40% resolved, 47% improved, and 13% unchanged. Open results for neck pain were 33% resolved, 56% improved, and 11% unchanged. Overall, there was no significant difference in outcomes between the groups. CONCLUSION: The MEF technique yielded clinical results equivalent to those of the open surgical group as well as to those described in the literature. MEF patients, however, had less blood loss, shorter hospitalizations, and a much lower postoperative pain medication requirement.

Adult↗
PubMed2002

Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction.

OBJECTIVE: We describe a series of seven consecutive patients treated with endoscopically assisted transoral surgery for decompression of high cervical and clival abnormalities. METHODS: Seven endoscopically assisted transoral procedures were performed at the University of Florida from September 1999 to April 2000 for irreducible compression at the cervicomedullary junction. The abnormalities encountered were primary basilar invagination from congenital craniovertebral junction malformation (two cases), irreducible rheumatoid cranial settling (one case), secondary basilar invagination caused by migration of odontoid fracture fragments (one case), pseudogout granulation mass (one case), clivus chordoma (one case), and Chiari malformation with associated basilar invagination (one case). RESULTS: Successful decompression was achieved in all seven patients. There were no adverse neurological sequelae. One patient died from a perioperative myocardial infarction. At a mean clinical follow-up of 6.16 months, neurological status was noted to be stable or improved in all remaining patients. CONCLUSION: Endoscopically assisted transoral surgery represents an emerging alternative to standard microsurgical techniques for transoral approaches to the anterior cervicomedullary junction. Used in conjunction with intraoperative fluoroscopy, it provides a safe method for anterior decompression of the cervicomedullary junction without the need for extensive soft palate splitting, hard palate resection, or extended maxillotomy. Experience is required with greater numbers of patients and long-term follow-up to further validate this promising technique.

Adult↗
PubMed2002

Vertebroplasty for osteoporotic compression fractures: current practice and evolving techniques.

Perutaneous vertebroplasty was developed in France by Deramond et al., who provided initial reports of the procedure in 1987. This minimally invasive procedure uses a large-bore bone-cutting needle to percutaneously access a vertebral body, inject bone cement, and thereby stabilize and reinforce the remaining bone structure. The procedure was used initially to treat aggressive hemangiomas, but it then was extended to the treatment of osteolytic metastases and myeloma and currently osteoporotic compression fractures refractory to medical therapy. In this article, we review the current technique and its indications along with emerging devices and areas of current research.

Aged↗
PubMed2002

Microendoscopic lumbar discectomy: technical note.

OBJECTIVE: The microendoscopic discectomy (MED) technique was initially developed in 1997 to treat herniated lumbar disc disease. Since then, thousands of cases have been successfully performed at more than 500 institutions. This article discusses the technical aspects of this procedure and presents a consecutive case series. METHODS: A total of 150 consecutive patients underwent MED. MED is performed by a muscle-splitting approach using a series of tubular dilators with consecutively increasing diameters. A tubular retractor is then inserted over the final dilator, and a specially designed endoscope is placed inside the tubular retractor. The microdiscectomy is performed endoscopically while the surgeon views the procedure on a video monitor. RESULTS: Clinical outcomes were determined using a modified MacNab criteria, which revealed that 77% of patients had excellent, 17% had good, 3% had fair, and 3% had poor outcomes. The average hospital stay was 7.7 hours. The average return to work period was 17 days. Complications primarily included dural tears, which occurred in 8 patients (5%) and were seen early on in the patient series. Complication rates diminished as the surgeon's experience with this technique increased. CONCLUSION: MED for lumbar herniated disc disease can be performed safely and effectively, resulting in a shortened hospital stay and faster return to work; however, there is a learning curve to this procedure.

Adult↗
PubMed2002

Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis.

OBJECTIVE: By modifying existing microendoscopic discectomy techniques, we previously developed a novel surgical treatment of lumbar stenosis and validated its ability to achieve a thorough decompression in a cadaveric study. We now describe our clinical experience with this new, minimally invasive microendoscopic decompressive laminotomy (MEDL) technique. METHODS: A MEDL was performed in 25 patients with classic features of lumbar stenosis. By use of a fluoroscopically guided percutaneous technique, the working portal was docked on the lamina with minimal soft-tissue injury. With the angle of the endoscope combined with an oblique entry, a bilateral bony and ligamentous decompression was achieved under the midline, thereby preserving the supraspinous-interspinous ligaments and contralateral musculature. A second group of 25 patients treated with open decompression was used for comparison. RESULTS: Effective circumferential decompression was achieved in the majority of patients. The results for the MEDL group were as follows: operative time, 109 minutes per single level; blood loss, 68 ml; and postoperative stay, 42 hours. The results for the open-surgery group were as follows: operative time, 88 minutes; blood loss, 193 ml; and postoperative stay, 94 hours. The MEDL group needed significantly less narcotic medication after surgery. Overall, 16% of the MEDL patients reported resolution of their back pain, 68% improved symptomatically, and 16% remained unchanged. The outcome of the open group was very similar. CONCLUSION: Compared with an equivalent open technique, MEDL appears to offer a similar short-term clinical outcome with a significant reduction in operative blood loss, postoperative stay, and use of narcotics. This lower surgical stress, decreased tissue trauma, and quicker recovery are particularly important in this elderly population of patients.

Adult↗
PubMed2002

Minimally invasive percutaneous posterior lumbar interbody fusion.

OBJECTIVE: The wide exposure required for a standard posterior lumbar interbody fusion (PLIF) can cause unnecessary trauma to the lumbar musculoligamentous complex. By combining existing microendoscopic, percutaneous instrumentation and interbody technologies, a novel, minimally invasive, percutaneous PLIF technique was developed to minimize such iatrogenic tissue injury (MIP-PLIF). METHODS: The MIP-PLIF technique was validated in three cadaveric torsos with six motion segments decompressed and fused. Preoperative variables measured from imaging included interpedicular distance, pedicular height and width, interspinous distance, lordosis, intervertebral height, Cobb angle, and foraminal height and volume. Using the METRx and MD spinal access systems (Medtronic Sofamor Danek, Memphis, TN), bilateral laminotomies were performed using a hybrid of microsurgical and microendoscopic techniques. The intervertebral disc spaces were then distracted and prepared with the Tangent (Medtronic Sofamor Danek) interbody instruments. Either a 10 or 12 by 22 mm interbody graft was then placed. Using the Sextant (Medtronic Sofamor Danek) system, percutaneous pedicle screw-rod fixation of the motion segment was completed. We then applied MIP-PLIF in three patients. RESULTS: For segments with preoperative intervertebral/foraminal height loss, MIP-PLIF was effective in restoring both heights in all cases. The amount of improvement (9.7 to 38% disc height increase; 7.7 to 29.9% foraminal height increase) varied directly with the size of the graft used and the original degree of disc and foraminal height loss. Segmental lordosis improved by 29% on average. Graft and screw placement was accurate in the cadavers, except for a single Grade 1 screw violation of one pedicle. The average operative time was 3.5 hours per level. In our three clinical cases, the MIP-PLIF procedure required a mean of 5.4 hours, estimated blood loss was 185 ml, and inpatient stay was 2.8 days, with no intravenous narcotic use after 2 days in any of the patients. All screw and graft placements were confirmed. CONCLUSION: A complete PLIF procedure can be safely and effectively performed using minimally invasive techniques, thereby potentially reducing the pain and morbidity associated with standard open surgery. Prospective, randomized outcome studies will be required to validate the efficacy of this exciting new surgical technique.

Aged↗
PubMedDate not supplied

Cervical juxtafacet cysts: case report and literature review.

BACKGROUND: Juxtafacet cysts of the cervical and thoracic spine are rare and often present with myelopathy. Juxtafacet cysts are well recognized entities found commonly in the lumbar spine but are unusual in the cervical and thoracic spine. We present a case of a patient with gait disturbance and early myelopathy who was found to have a juxtafacet cyst at the cervico-thoracic junction. We further review the literature. PURPOSE: To describe a case of a cervico-thoracic juxtafacet cyst and review the literature. STUDY DESIGN: Case report and subject review. METHODS: One patient presenting with early myelopathy and pain underwent surgery for resection of the lesion. Pathologic analysis revealed a juxtafacet cyst. RESULTS: The patient recovered uneventfully with relief of his pain. Pubmed review revealed less than 30 similar cases in the literature. CONCLUSION: Juxtafacet cysts of the cervical spine are rare entities. These lesions comprise both synovial cysts and ganglion cysts. The benign lesions present with myelopathy and should be considered in patients with cystic lesions in the cervical spinal canal.

Aged↗
PubMedDate not supplied

A surgical revisitation of Pott distemper of the spine.

BACKGROUND CONTEXT: Pott disease and tuberculosis have been with humans for countless millennia. Before the mid-twentieth century, the treatment of tuberculous spondylitis was primarily supportive and typically resulted in dismal neurological, functional and cosmetic outcomes. The contemporary development of effective antituberculous medications, imaging modalities, anesthesia, operative techniques and spinal instrumentation resulted in quantum improvements in the diagnosis, management and outcome of spinal tuberculosis. With the successful treatment of tuberculosis worldwide, interest in Pott disease has faded from the surgical forefront over the last 20 years. With the recent unchecked global pandemic of human immunodeficiency virus, the number of tuberculosis and secondary spondylitis cases is again increasing at an alarming rate. A surgical revisitation of Pott disease is thus essential to prepare spinal surgeons for this impending resurgence of tuberculosis. PURPOSE: To revisit the numerous treatment modalities for Pott disease and their outcomes. From this information, a critical reappraisal of surgical nuances with regard to decision making, timing, operative approach, graft types and the use of instrumentation were conducted. STUDY DESIGN: A concise review of the diagnosis, management and surgical treatment of Pott disease. METHODS: A broad review of the literature was conducted with a particular focus on the different surgical treatment modalities for Pott disease and their outcomes regarding neurological deficit, kyphosis and spinal stability. RESULTS: Whereas a variety of management schemes have been used for the debridement and reconstruction of tuberculous spondylitis, there has also been a spectrum of outcomes regarding neurological function and deformity. Medical treatment alone remains the cornerstone of therapy for the majority of Pott disease cases. Surgical intervention should be limited primarily to cases of severe or progressive deformity and/or neurological deficit. Based on the available evidence, radical ventral debridement and grafting appears to provide reproducibly good long-term neurological outcomes. Furthermore, recurrence of infection is lowest with such techniques. Posterior operative techniques are most effective in the reduction and prevention of spinal deformity. CONCLUSIONS: Unlike historical times, effective medical and surgical management of tuberculous spondyitis is now possible. Proper selection of drug therapy and operative modalities, however, is needed to optimize functional outcomes for each individual case of Pott disease.

Antitubercular Agents↗