An Expanded Surgical Corridor of Oblique Lateral Interbody Fusion at L4–5: A Magnetic Resonance Imaging Study

Worawat Limthongkul,Pakawas Praisarnti,Teerachat Tanasansomboon,Natavut Prasertkul,Vit Kotheeranurak,Wicharn Yingsakmongkol,Weerasak Singhatanadgige 대한척추신경외과학회 2023 Neurospine Vol.20 No.4

Objective: We introduced a new preoperative method, the “expanded surgical corridor,” to evaluate the actual safety corridor, which may expand the possibility of performing oblique lateral interbody fusion (OLIF). Methods: Axial T2-weighted magnetic resonance images at the L4–5 disc level of 511 lumbar degenerative disease patients was evaluated. The distance between the medial edge of the left-sided psoas muscle and the major artery was measured as the conventional surgical corridor (CSc). The distance between the major vein and lumbar plexus was measured as the expanded surgical corridor (ESc). Results: The mean CSc and ESc were 13.9 ± 8.20 and 37.43 ± 10.1 mm, respectively. No surgical corridor was found in 7.05% of CSc and 1.76% of ESc, small corridor ( ≤ 1 cm) was found in 27.40% of CSc and 0.59% of ESc, moderate corridor (1–2 cm) was found in 42.07% of CSc and 1.96% of ESc, and large corridor ( > 2 cm) was found in 23.48% of CSc and 95.69% of ESc. A total of 33.83% (45 of 133) of whom were preoperatively categorized as having a limited surgical corridor by conventional measurement, underwent OLIF L4–5 successfully. Conclusion: By using the ESc, only 2.35% were categorized as having a limited surgical corridor. The other 97.65% of the patients had an approachable corridor that could be successfully operated by experienced spine surgeons who employ meticulous surgical dissection and thorough understanding of the anatomical structures. The ESc may represent true accessibility to the disc space for OLIF, particularly at the L4–5 level.

Is Direct Decompression Necessary for Lateral Lumbar Interbody Fusion (LLIF)? A Randomized Controlled Trial Comparing Direct and Indirect Decompression With LLIF in Selected Patients

Worawat Limthongkul,Chayapong Thanapura,Khanathip Jitpakdee,Pakawas Praisarnti,Vit Kotheeranurak,Wicharn Yingsakmongkol,Teerachat Tanasansomboon,Weerasak Singhatanadgige 대한척추신경외과학회 2024 Neurospine Vol.21 No.1

Objective: To compare the clinical and radiographic outcomes following lateral lumbar interbody fusion (LLIF) between direct and indirect decompression in the treatment of patients with degenerative lumbar diseases. Methods: Patients who underwent single-level LLIF were randomized into 2 groups: direct decompression (group D) and indirect decompression (group I). Clinical outcomes including the Oswestry Disability index and visual analogue scale of back and leg pain were collected. Radiographic outcomes including cross-sectional area (CSA) of thecal sac, disc height, foraminal height, foraminal area, fusion rate, segmental, and lumbar lordosis were measured. Results: Twenty-eight patients who met the inclusion criteria were eligible for the analysis, with a distribution of 14 subjects in each group. The average age was 66.1 years. Postoperatively, significant improvements were observed in all clinical parameters. However, these improvements did not show significant difference between both groups at all follow-up periods. All radiographic outcomes were not different between both groups, except for the increase in CSA which was significantly greater in group D (77.73 ± 20.26 mm2 vs. 54.32 ± 35.70 mm2 , p = 0.042). Group I demonstrated significantly lower blood loss (68.13 ± 32.06 mL vs. 210.00 ± 110.05 mL, p < 0.005), as well as shorter operative time (136.35 ± 28.07 minutes vs. 182.18 ± 42.67 minutes, p = 0.002). Overall complication rate was not different. Conclusion: Indirect decompression through LLIF results in comparable clinical improvement to LLIF with additional direct decompression over 1-year follow-up period. These findings suggest that, for an appropriate candidate, direct decompression in LLIF might not be necessary since the ligamentotaxis effect achieved through indirect decompression appears sufficient to relieve symptoms while diminishing blood loss and operative time.

Analgesic Effect of Intravenous Nefopam for Postoperative Pain in Minimally Invasive Spine Surgery: A Randomized Prospective Study

Chalermkitpanit Pornpan,Limthongkul Worawat,Yingsakmongkol Wicharn,Thepsoparn Marvin,Pannangpetch Patt,Tangchitcharoen Nattapat,Tanasansomboon Teerachat,Singhatanadgige Weerasak 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.5

Study Design: Randomized double-blind control study.Purpose: To evaluate the effects of nefopam on reducing morphine consumption and postoperative pain in patients undergoing minimally invasive spine surgery (MISS) and to evaluate its effects on enhanced recovery after spine surgery.Overview of Literature: Enhanced recovery after surgery (ERAS) has become a major goal for spine surgery. Multimodal pain management combining non-opioid analgesics is a key element of this. However, there is little evidence regarding the use of nefopam in spine surgery as part of an ERAS protocol.Methods: One hundred patients undergoing MISS were randomized into two groups. Patients in the nefopam group received 20 mg of intravenous nefopam diluted in 100 mL of normal saline intraoperatively, followed by 80 mg of nefopam diluted in 500 mL of normal saline, given as a continuous infusion postoperatively for 24 hours. The control group received an identical volume of normal saline. Postoperative pain was managed by patient-controlled analgesia in the form of intravenous morphine. Morphine consumption in the first 24 hours was recorded as a primary outcome. Secondary outcomes regarding ERAS were also collected.Results: There were no significant differences in either total morphine consumption or postoperative pain score in the first 24 hours postoperatively between patients receiving nefopam and the control group. Morphine consumption in patients receiving nefopam was 13.54±10.64 mg compared with 15.86±16.2 mg in the control group (<i>p</i>=0.41). Time to postanesthetic care unit discharge, times to first sitting and walking, length of hospital stay, as well as duration of Foley catheter use and time until drain removal were also similar. There were no serious adverse effects of nefopam compared with normal saline.Conclusions: Nefopam did not significantly reduce opioid consumption or postoperative pain score. Adding nefopam as part of multimodal analgesia did not show beneficial effects for enhancing recovery after spine surgery.

Utilization of Spinal Navigation to Facilitate Hassle-Free Rod Placement during Minimally-Invasive Long-Construct Posterior Instrumentation

Arun-Kumar Kaliya-Perumal,Worawat Limthongkul,Jacob Yoong-Leong Oh 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.3

During minimally-invasive long-construct posterior instrumentation, it may be challenging to contour and place the rod as the screw heads are not visualized. To overcome this, we utilized the image data merging (IDM) facility of our spinal navigation system to visualize a coherent whole image of the construct throughout the procedure. Here, we describe this technique that was used for a patient in whom L1–L5 posterior instrumentation was performed. Using an IDM facility, screws are color coded and after placement, the final image is saved. Saved images of all previous screws are displayed and observed while placing the subsequent screws. Therefore, the entry point, depth, and mediolateral alignment of subsequent screws can be adjusted to fall in line with previous screws such that the rod can be placed without hassle. Moreover, final adjustments to the construct are kept to a minimum. The possibility of screw pullout due to force engaging the rod on poorly aligned screws is thus avoided.

Perioperative Intravenous Nefopam on Pain Management and Ambulation after Open Spine Surgery: A Randomized Double-Blind Controlled Study

Chalermkitpanit Pornpan,Yingsakmongkol Wicharn,Limthongkul Worawat,Tanasansomboon Teerachat,Pannangpetch Patt,Tangchitcharoen Nattapat,Singhatanadgige Weerasak 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.4

Study Design: This was a randomized double-blind controlled study. Purpose: This study was designed to evaluate the effects of intravenous nefopam regarding its ability to reduce morphine consumption and postoperative pain and improve recovery in patients undergoing open spine surgery. Overview of Literature: Multimodal analgesia, including nonopioid medications, is essential for pain management in spine surgery. Evidence regarding the use of intravenous nefopam in open spine surgery as part of enhanced recovery after surgery is lacking. Methods: In this study, 100 patients undergoing lumbar decompressive laminectomy with fusion were randomized into two groups. The nefopam group received 20-mg intravenous nefopam diluted in 100-mL normal saline intraoperatively, followed by 80-mg nefopam diluted in 500-mL normal saline, administered as a continuous infusion postoperatively for 24 hours. The control group received an identical volume of normal saline. Postoperative pain was managed using intravenous morphine via patient-controlled analgesia. Morphine consumption in the first 24 hours was recorded as the primary outcome. Secondary outcomes, including postoperative pain score, postoperative function, and length of hospital stay (LOS), were assessed. Results: No statistically significant differences in the total morphine consumption and postoperative pain score in the first 24 hours postoperatively between the two groups. At the post-anesthesia care unit (PACU), the nefopam group demonstrated lower pain scores while at rest (p=0.03) and upon movement (p=0.02) than the normal saline group. However, the severity of postoperative pain between the two groups was similar from postoperative day 1 to day 3. LOS was significantly shorter in the nefopam group than in the control group (p<0.01). The time to first sitting and walking and PACU discharge between the two groups were comparable. Conclusions: Perioperative intravenous nefopam demonstrated significant pain reduction during the early postoperative period and shortened LOS. Nefopam is considered safe and effective as a part of multimodal analgesia in open spine surgery.

Successful Criteria for Indirect Decompression With Lateral Lumbar Interbody Fusion

Wicharn Yingsakmongkol,Khanathip Jitpakdee,Stephen Kerr,Worawat Limthongkul,Vit Kotheeranurak,Weerasak Singhatanadgige 대한척추신경외과학회 2022 Neurospine Vol.19 No.3

Objective: No consensus criteria have been established regarding ideal candidates for indirect decompression with lateral lumbar interbody fusion (LLIF), and contributing factors of indirect decompression failure were rarely reported. We aim to investigate the success rate of indirect decompression by LLIF with proposed selection criteria and identify risk factors associated with indirect decompression failure, defined as persistent pain requiring revision with direct decompression. Methods: Data from 191 patients undergoing LLIF were retrospectively reviewed. All the following criteria must be fulfilled: (1) dynamic clinical symptoms (pain relief in supine position), (2) presence of reducible disc height (recovered disc height in supine position), (3) no profound weakness, and (4) no static stenosis. The success rate of indirect decompression with LLIF and results after at least 1 year of follow-up were collected. Preoperative, procedure-related, and postoperative factors were assessed for their relationship with failure. Results: Of 191 patients,13 patients (6.8%) required additional direct decompression due to persistent pain, giving a criteria success rate of 93.2%. Factors associated with indirect decompression failure included low bone mineral density (T-score < 2.1), low reducible disc height (<13%), low postoperative disc height (< 10 mm), high-grade cage subsidence, and use of plate fixation. Conclusion: We proposed patient selection criteria for indirect decompression with LLIF which had a satisfactory success rate and identified factors associated with the need for additional direct decompression. Our proposed criteria may assist selection of patients likely to achieve good results following indirect decompression with LLIF, and optimize selection based on risk factors of failure.

Clinical and Radiographic Comparisons among Minimally Invasive Lumbar Interbody Fusion: A Comparison with Three-Way Matching

Yingsakmongkol Wicharn,Jitpakdee Khanathip,Varakornpipat Panapol,Choentrakool Chitapoom,Tanasansomboon Teerachat,Limthongkul Worawat,Singhatanadgige Weerasak,Kotheeranurak Vit 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.5

Study Design: Retrospective cohort study.Purpose: To compare clinical and radiographic outcomes among minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), extreme lateral lumbar interbody fusion (XLIF), and oblique lateral lumbar interbody fusion (OLIF) techniques.Overview of Literature: To date, there are many reports comparing outcomes between MIS-TLIF and XLIF, MIS-TLIF and OLIF, or XLIF and OLIF procedures. However, there are no previous studies comparing clinical and radiographic outcomes among all these three techniques.Methods: Data from patients who underwent minimally invasive (MI) fusion surgery for lumbar degenerative diseases at L4–L5 level was analyzed. Thirty patients each from MIS-TLIF, XLIF, and OLIF groups were recruited for propensity score matching. Visual Analog Scale (VAS) of the back and legs and Oswestry Disability Index (ODI) were evaluated preoperatively and at 1, 3, and 6 months and 1 year postoperatively. Radiographic outcomes were also compared. The fusion rate was evaluated at 1 year after surgeries.Results: The clinical outcomes were significantly improved in all groups. The disk height was significantly restored in all groups postoperatively, which was significantly more improved in XLIF and OLIF than MIS-TLIF group (<i>p</i><0.001). The axial canal area was significantly increased more in MIS-TLIF versus XLIF and OLIF (<i>p</i><0.001). The correction of lumbar lordotic angle and segmental sagittal angle were similar among these techniques. OLIF and XLIF groups showed less blood loss and shorter hospital stays than MIS-TLIF group (<i>p</i><0.001). There was no significant difference in fusion rate among all groups.Conclusions: MIS-TLIF, XLIF, and OLIF facilitated safe and effective MI procedures for treating lumbar degenerative diseases. XLIF and OLIF can achieve clinical outcomes equivalent to MIS-TLIF by indirect decompression. XLIF and OLIF showed less blood loss, shorter hospital stays, and better disk and foraminal height restorations. In single-level L4–5, the restoration of sagittal alignment was similar between these three techniques.